Exam 2 Lecture 3

All share symptoms of

- Sadness, emptiness, irritability, somatic (body) concerns, and impairment of thinking

All impact a person's ability to function

depressive disorders

Major depressive disorder

Others

- Disruptive mood dysregulation disorder

- Persistent depressive disorder (previously dysthymia)

- Premenstrual dysphoric disorder

- Substance/medication-induced depressive disorder

- Depressive disorder due to another medical condition

depressive disorders classified

Five (or more) of the following in 2-week period

- Weight loss and appetite changes

- Sleep disturbances

- Fatigue

- Worthlessness or guilt

- Loss of ability to concentrate

- Recurrent thoughts of death

PLUS—at least one symptom is also either

- Depressed mood or

Loss of interest or pleasure (anhedonia)

Persistent for minimum 2 weeks to 6 months

Chronic: Lasting more than 2 years

Recurrent episodes common

Symptoms cause distress or impaired function

Episode not attributed to physiological effects

Absence of a manic or hypomanic episode

major depressive disorder

Formerly known as dysthymia

Low-level depressive feelings through most of each day, for the majority of days

- At least 2 years in adults

- At least 1 year in children and adolescents

Must have two or more of the following:

- Decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness

Persistent Depressive Disorder

Symptom cluster in last week prior to onset of a woman's period; include

- Mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating

Symptoms decrease significantly or disappear with the onset of menstruation

Premenstrual Dysphoric Disorders

Substance-induced depressive disorder

- Person does not experience depressive symptoms in the absence of drug or alcohol use or withdrawal

Depressive disorder associated with another medical condition

- Can be caused by kidney failure, Parkinson's disease, and Alzheimer's disease

- Symptoms that result from medical diagnoses or certain medications are not considered major depressive disorder

Other Depressive Disorders

During intake, Jeff doesn't speak much, but his parents are able to list the following symptoms they have observed:

• Weight loss and appetite changes

• Insomnia

• Fatigue

• Worthlessness or guilt

• Loss of interest in his college classes and even the online games he usually plays with friends

"Constant sadness"

Jeff's parents have described his lack of interest in things he used to enjoy, like games with his friends, and his classes, which he used to like. This may be best described by the term

A.Inappetance

B.Anergia

C.Indolence

D. Anhedonia

D. Anhedonia

Biological factors

• Genetic

• Biochemical

-- Stressful life events

• Alterations in hormonal regulation

• Inflammatory process

• Diathesis-stress model

Psychological factors

• Cognitive theory

• Learned helplessness

etiology of depressive disorders

Assessment

• Assessment tools

• Assessment of suicide potential

Key assessment findings

• Depressed mood and anhedonia

• Anergia

• Anxiety

• Psychomotor agitation or retardation

• Vegetative signs

• Comorbidity: chronic pain

Areas to assess

• Affect

• Thought processes

• Mood

• Feelings

• Physical behavior

• Communication

• Religious beliefs and spirituality

Age considerations

• Children and adolescents

• Older adults

Self assessment

Feeling what the patient is feeling

Nursing diagnosis

• Risk for suicide—safety is always the highest priority

• Hopelessness

• Ineffective coping

• Social isolation

• Spiritual distress

• Self-care deficit

Outcomes identification

Recovery model

• Focus on patient's strengths

• Treatment goals mutually developed

• Based on patient's personal needs and values

Planning

Geared toward

• Patient's phase of depression

• Particular symptoms

Patient's personal goals

Implementation

Three phases

• Acute phase (6 to 12 weeks)

• Continuation phase (4 to 9 months)

• Maintenance phase (1 year or more)

Counseling and communication

Health teaching and health promotion

Promotion of self-care activities

Teamwork and safety

Nursing Process for depressive disorders

Which question would be a priority when assessing for symptoms of major depression?

A."Tell me about any special powers you believe you have."

B."You look really sad. Have you ever thought of harming yourself?"

C."Your family says you never stop. How much sleep do you get?"

D. Do you ever find that you don't remember where you've been or what you've done?"

B."You look really sad. Have you ever thought of harming yourself?"

Choosing an antidepressant

• Symptom profile of the patient

• Side-effect profile (e.g., sexual dysfunction, weight gain)

• Ease of administration

• History of past response

• Safety and medical considerations

Psychopharmacological Interventions for depressive disorders

Selective serotonin reuptake inhibitors (SSRIs)

- First-line therapy

- Rare risk of serotonin syndrome

Serotonin norepinephrine reuptake inhibitors (SNRIs)

- SSRIs may be tolerated better

Tricyclic antidepressants

- Anticholinergic adverse reactions

Monoamine oxidase inhibitors (MAOs)

- Effective for unconventional depression

Special Populations

- Antidepressant use by pregnant women

- Antidepressant use by children and adolescents

- Antidepressants use by older adults

Antidepressants

Jeff was just diagnosed with a major depressive disorder. Which medication is the health care provider most likely to start the patient on?

A.SSRI

B.SNRI

C.Tricyclic antidepressant

D. Monoamine oxidase inhibitor

A.SSRI

The most effective depression treatment

Psychotic illnesses = second most common indication

ECT the primary treatment in

- Severe malnutrition, exhaustion, and dehydration due to lengthy depression

- Safer than meds with certain medical conditions

- Delusional depression

- Failure of previous medication trials

- Schizophrenia with catatonia

Electroconvulsive Therapy

Noninvasive

Uses MRI-strength magnetic pulses to stimulate focal areas of the cerebral cortex

Presence of metal is the only contraindication

Adverse reactions

- Headache and lightheadedness

- No neurological deficits or memory problems

- Seizures rarely

- Most are mild and include scalp tingling and discomfort at the administration site.

Transcranial Magnetic Stimulation

Originally used to treat epilepsy

Decreases seizures and improves mood

Electrical stimulation boosts the level of neurotransmitters

Side effects

- Voice alteration (nearly 60% of patients)

- Neck pain, cough, paresthesia, and dyspnea, which tend to decrease with time

Vagus Nerve Stimulation

Surgically implanted electrodes (in the brain)

Stimulates those regions identified as underactive in depression

More invasive than VNS

- Electrodes placed directly into the brain

Deep Brain Stimulation

First-line treatment for seasonal affective disorder (SAD)

Efficacy due to influence of light on melatonin

Effective as medication for SAD

Negative effects: headache and jitteriness

Light Therapy

Flower processed into tea or tablets

Thought to increase serotonin, nerepinephrin, and dopamine in the brain

Useful in mild to moderate depression

st johns wort

Biological, social, and psychological effects

Increases serotonin availability

Dampens HPA axis (thought to be overly active in depression)

Exercise

Psychotherapy

- Cognitive-behavioral therapy (CBT)

- interpersonal therapy (IPT)

- Time-limited focused psychotherapy

- Behavior therapy

Group therapy

Advanced Practice Interventions for depressive disorders

A patient with major depression walks and moves slowly. Which term should the nurse use to document this finding?

A. Psychomotor retardation

B. Psychomotor agitation

C. Vegetative sign

D. Anhedonia

A. Psychomotor retardation

Which assessment finding in a patient with major depression represents a vegetative sign?

A.Restlessness

B.Hypersomnia

C.Feelings of guilt

D. Frequent crying

B.Hypersomnia

energy, hyperactive, hyper sexuality, paranoid delusions, rapid speech

mania

more severe, longer manic episodes (at least 7 days) depressive to full on mania

need one hpyermanic episode and depression to be considered bipolar

Anosognosia: dont recognize they have a problem

bipolar I disorder

less severe, hypomanic, like 3 days, depressive to slight manic symptoms

need one hypomanic episode and depression to be considered bipolar

bipolar II disorder

give bunch of information and go off on different topics but come back to the point

circumstantial speech

The meaningless rhyming of words, often in a forceful manner.

clang association

a disorder marked by numerous periods of hypomanic symptoms and mild depressive symptoms

Rapid cycling possible (4 episodes in 1 year)

cyclothymic disorder

false beliefs, often of persecution or grandeur, that may accompany psychotic disorders

delusions

rapidly changing or disjointed thoughts

flight of ideas

a mental state just below mania

hypomania

disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts

loose associations

Abnormal rate of speech, speaking quickly and urgently

pressured speech

the occurrence of four or more mood episodes per year

rapid cycling

a communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation

tangential speech

Substance/medication-induced bipolar and related disorder

Bipolar and related disorder due to another medical condition (hyperthyroidism - mania)

Other specified bipolar and related disorder

unspecified bipolar and related disorder

Other Bipolar Disorders

Up to 21% of patients with major depression may actually have undiagnosed bipolar disorder

Bipolar I—more common in males

Bipolar II—more common in females

Cyclothymia—usually begins in adolescence or early adulthood

bipolar - about 30 years old

Epidemiology for bipolar

Biological factors

- Genetic

- Neurobiological

- Neuroendocrine

Environmental factors

Psychological factors

risk factors for bipolar

Mood - what they tell you

Behavior - rapid speech, danger, pleasure

Thought processes and speech patterns - rapid speech, loud, tangential, flight of ideas

Cognitive functioning - altered

assessment for bipolar

Pressured speech

Circumstantial speech

Tangential speech

Loose associations

Flight of ideas

Clang associations

Speech patterns for bipolar

Grandiose delusions

Persecutory delusions

Thought content for bipolar

Manipulative

Demanding

Splitting

Impulsive

Pleasure Seeking

Manic patient symptoms

Frequent staff meetings to deal with patient behavior and staff response

Set limits consistently

Staff member actions for manic patients

Danger to self or others

Need for protection from uninhibited behaviors

Need for hospitalization

Medical status

Coexisting medical conditions

Family's understanding

Assessment Guidelines Bipolar Disorder

Risk for injury

Risk for violence

- Other-directed

- Self-directed

Ineffective coping

nursing diagnosis for bipolar

Acute phase

- Prevent injury

Continuation phase

- Relapse prevention

Maintenance phase

- Limit severity and duration of future episodes

outcomes identification for bipolar

Medical stabilization

Maintaining safety

Nursing care

- Managing medications, decreasing physical activity, increasing food and fluid intake, ensuring at least 4 to 6 hours of sleep per night, and intervening so that self-care needs are met. Seclusion, restraint, or electroconvulsive therapy (ECT) may be considered during the acute phase.

planning for bipolar

Medical stabilization

Maintaining safety

In-hospital nursing care

Seclusion, restraint, or ECT may be considered during the acute phase

planning: acute manic phase

Managing medications

Decreasing physical activity

Increasing food and fluid intake

Ensuring at least 4 to 6 hours of sleep per night

Intervening so that self-care needs are met

Nursing Care for Acute Mania (Hospitalization)

Hospitalization for suicidal, psychotic, or catatonic signs

Medication concerns about bringing on a manic phase

Depressive episodes implementation

Hospitalization for acute mania (bipolar I disorder)

Communicating challenges and strategies

high risk of suicide

Manic episodes implementation

Two main foci

- Reduce agitation

- Mood stabilization

Pharmacological Interventions for bipolar

Indications

Therapeutic and toxic levels

-- Therapeutic blood level: 0.6 to 1.2 mEq/L / 0.8 to 1.4 mEq/L

-- Maintenance blood level: 0.4 to 1.3 mEq/L

-- Toxic blood level: 1.5 mEq/L and above: HAND TREMORS, CHANGE IN LOC

Maintenance therapy

Contraindications

Lithium carbonate

Valproate (Depakote) - avoid if pt has liver issues

Carbamazepine (Tegretol)

Lamotrigine (Lamictal)

Anticonvulsant Mood Stabilizers

Olanzapine (Zyprexa)

Risperidone (Risperdal)

Aripiprazole (Abilify)

Asenaprine (Saphris)

Cariprazine (Vraylar)

Lurasidone (Latuda)

Quetiapine (Seroquel, Seroquel XR)

Ziprasidone (Geodon)

Second-Generation Antipsychotics

ECT

Teamwork and safety

Seclusion protocol

Support groups

Health teaching and health promotion

other treatments for bipolar

Cognitive-behavioral therapy (CBT)

Interpersonal and social rhythm therapy

Family-focused therapy

Advanced Practice Interventions for bipolar

Which anticonvulsant medication might be prescribed for a patient with bipolar disorder?

A.Divalproex sodium (Depakote)

B.Clonazepam (Klonopin)

C.Olanzapine (Zyprexa)

D.Lithium (Lithobid)

A.Divalproex sodium (Depakote)

Which statement made by the patient demonstrates an understanding of the effective use of newly prescribed lithium to manage bipolar mania? Select all that apply.

a. "I have to keep reminding myself to consistently drink six 12-ounce glasses of fluid every day."

b. "I discussed the diuretic my cardiologist prescribed with my psychiatric care provider."

c. "Lithium may help me lose the few extra pounds I tend to carry around."

d. "I take my lithium on an empty stomach to help with absorption."

e. "I've already made arrangements for outpatient lithium level monitoring."

a. "I have to keep reminding myself to consistently drink six 12-ounce glasses of fluid every day."

b. "I discussed the diuretic my cardiologist prescribed with my psychiatric care provider."

e. "I've already made arrangements for outpatient lithium level monitoring."

A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially?

a. Reinforce that the level is considered therapeutic.

b. Instruct the patient to hold the next dose of medication and contact the prescriber.

c. Have the patient go to the hospital emergency department immediately.

d. Alert the patient to the possibility of seizures and appropriate precautions.

b. Instruct the patient to hold the next dose of medication and contact the prescriber.

Which intervention should the nurse implement when caring for a patient demonstrating manic behavior? Select all that apply.

a. Monitor the patient's vital signs frequently.

b. Keep the patient distracted with group-oriented activities.

c. Provide the patient with frequent milkshakes and protein drinks.

d. Reduce the volume on the television and dim bright lights in the environment.

e. Use a firm but calm voice to give specific concise directions to the patient.

a. Monitor the patient's vital signs frequently.

c. Provide the patient with frequent milkshakes and protein drinks.

d. Reduce the volume on the television and dim bright lights in the environment.

e. Use a firm but calm voice to give specific concise directions to the patient.

Ted, a former executive, is now unemployed due to manic episodes at work. He was diagnosed with bipolar I disorder 8 years ago. Ted has a history of IV drug use, which resulted in hepatitis C. He is taking his lithium exactly as scheduled, a fact that both Ted's wife and his blood tests confirm. To reduce Ted's mania, the psychiatric nurse practitioner recommends:

a. Clonazepam (Klonopin)

b. Fluoxetine (Prozac)

c. Electroconvulsive therapy (ECT)

d. Lurasidone (Latuda)

c. Electroconvulsive therapy (ECT)

Substance use problems or disorders are often present in people diagnosed with bipolar disorder. Laura, a 28-year-old with a diagnosis of bipolar disorder, drinks alcohol instead of taking her prescribed medications. The nurse caring for this patient recognizes that:

a. Anxiety may be present.

b. Alcohol ingestion is a form of self-medication.

c. The patient is lacking a sufficient number of neurotransmitters.

d. The patient is using alcohol because she is depressed.

b. Alcohol ingestion is a form of self-medication.

harmful things but no matter how harmful people still want/need it

addiction

a problem in which people neglect themselves to care for, control, or try to "fix" someone else

codependence

change in body due to substance

intoxication

rapid removal of substance that causes harmful occurrences

withdrawal

gambling, sex, video games, things beside drugs

process addictions

comes into the ER do a quick screening if you suspect certain things. find motivation and want to change, then refer to treatment

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

using a substance or misusing a substance to the point where you need that substance to continue

substance use disorder

need more of the drug to have the therapeutic effect

tolerance

Symptom fall in the following categories:

Impaired control

Social impairment

Risky use

Physical effects (i.e., intoxication, tolerance, and withdrawal)

In 2023 study randomly interviewing people 12 and older determined 59% of the population in the US admitted to using Alcohol, Tobacco and/or Drugs.

Currently 50 million people in the US meet the criteria for a Substance Use Disorder

Typically peaks 18-29y/o

epidemiology for drug addiction

Genetic

Neurobiological factors

Environmental factors

etiology for drug addiction

Caffeine

Cannabis

Hallucinogen

Inhalant

Opioid

Sedative-hypnotic

Stimulant

Tobacco

Alcohol

Other: Process addiction—Gambling

Substances That Lead to Use Disorders

Most widely used psychoactive substance in the world

Can result in intoxication and withdrawal

caffeine

Most widely used illegal drug in the world

Fourth most commonly used psychoactive drug in the United States after caffeine, alcohol, and nicotine

Cannabis (Marijuana)

Cause a profound disturbance in reality

Hallucinogens

Solvents for glues and adhesives

Propellants

Thinners

Fuels

Most popular in adolescents

Inhalants

Heroin and prescription drugs

Pharmacologic treatment: Methadone, buprenorphine, and naltrexone

Opioids

Benzodiazepines

Benzodiazepine-like drugs

Carbamates

Barbiturates

Barbiturate-like hypnotics

Sedative, hypnotic, and antianxiety medications

Amphetamine-type, cocaine, or other stimulant drugs (ADHD drugs)

Second only to cannabis as the most widely used illicit substances in the United States

Stimulant

Short Term: Alertness, Increased energy, Decreased appetite, increase heart rate and b/p, Dilated Pupils

Long Term: Irregular Heartbeat, Chest Pains, Risk of heart attack, Panic attacks, Delusions, Hallucinations (bugs under skin)

Withdrawal: Depression, Fatigue, irritability, anxiety, poor concentration, psychomotor retardation, Paranoia, drug craving

Intoxication symptoms (Stimulants)

Low doses: Euphoria, mild stimulation, relaxation, lowered inhibitions

High doses: Drowsiness, slurred speech, nausea, emotional volatility, loss of coordination, visual distortions, impaired memory, loss of consciousness, respiratory arrest, seizures, coma, death

Alcohol

Wernicke-Korsakoff Syndrome: ETOH interferes with the absorption of Thiamine

Blackouts

Alcohol-induced amnesia disorder

physical and cognitive abnormalities in children caused by a pregnant woman's heavy drinking

Fetal alcohol syndrome

Peripheral neuropathy

Alcoholic myopathy and cardiomyopathy

Esophagitis, gastritis, and pancreatitis

Alcoholic hepatitis

Cirrhosis of the liver

Leukopenia

Thrombocytopenia

Cancer (head and neck)

Alcoholism: Systemic effects

6 to 8 hours after alcohol cessation: Mild to moderate alcohol withdrawal includes: Tremors, agitation, lack of appetite, nausea, vomiting, insomnia, impaired cognition, and mild perceptual changes. Both systolic and diastolic blood pressure increases, as does pulse and body temperature: Valium is typically used to reduce Withdrawal symptoms and to prevent worsening of detox symptoms

8 to 10 hours. If your patient is undergoing withdrawal to the point of psychosis, it should be considered a medical emergency because of the risks of unconsciousness, seizures, and delirium.

12 to 24 hours after alcohol cessation Withdrawal seizures may occur. These seizures are generalized and tonic-clonic. Additional seizures may occur within hours of the first seizure. Diazepam (Valium) given intravenously is a common treatment for withdrawal seizures.

Alcohol withdrawal delirium, also known as delirium tremens (DTs), is a medical emergency that can result in the death in 20% of untreated patients, usually as a result of medical problems such as pneumonia, renal disease, hepatic insufficiency, or heart failure (Sadock et al., 2015). Alcohol withdrawal delirium may happen anytime in the first 72 hours. Autonomic hyperactivity may result in tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension. Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium - ICU

alcohol withdrawal

Disulfiram (Antabuse) - GIVE NEGATIVE CONSEQUENCES TO MAKE PERSON STOP DRINKING

Naltrexone (Vivitrol—injectable, ReVia, Depade—oral)

Benzodiazepine (Diazepam) for Withdrawal

Screening tools: SBIRT, CAGE, AUDIT-C

Psychotherapy: CBT, Motivational Interviewing

Community Resources: AA, PHP, IOP, Half Way House

treatment - alcohol

Screening, brief intervention, and referral to treatment

SBIRT

Alcohol use disorders identification test

AUDIT

4 questions to identify alcohol abuse

CAGE

Same questions as CAGE but adds drug use to alcohol

CAGE-AID

Tolerance, Annoyance, Cut down, Eye-opener

T-ACE

bradycardia

hypotension

hypothermia

sedation

miosis (pinpoint pupils)

hypokinesis

slurred speech

head nodding

constipation

analgesia (pain killing effects)

opioid intoxication

tachycardia

hypertension

hyperthermia

insomnia

mydriasis (dilated pupil)

hyperreflexia

diaphoresis

piloerection

abd cramps, nausea, vomiting, diarrhea

anxiety

opioid withdrawal

Clonidine (Catapres) reduces symptoms of sympathetic nervous system being activated during detox, give for ADHD in kids as well

Suboxone (buprenorphine and naloxone) Maintenance therapy - naloxone will make them immediately withdrawal/detox so wait a good bit since last use

Sublocade (buprenorphine) once per month injection

Naltrexone (ReVia), is an opioid antagonist that prevents intoxication

Methadone (Dolophine, Methadose) is a synthetic narcotic opioid

Naloxone (Narcan), a specific opioid antagonist, very short acting overdose drug. need another dose bc half life is so short they will go right back into overdose state !!!!!!

psychopharmacology for opioid use

Assessment

- Family assessment (codependence)

- Self-assessment - prevent biases (judgement)

Diagnosis

Outcomes identification

Planning

- Identifying problem

- Setting a goal

- Determining the interventions that will accomplish the goal

Implementation

- Promoting safety and sleep: first-line interventions

- Reintroduce good nutrition and hydration

- Support for self-care (hygiene)

- Exploring harmful thoughts and spiritual distress

nursing process for substance use disorder

precontemplation, contemplation, preparation, action, maintenance

Transtheoretical stages of change theory