Exam 1

Characteristics/principles of a therapeutic relationship

• Therapeutic rather than Social 

• Client Focused 

• Goal Directed 

• Objective not subjective 

• Time-Limited 

Phases of the therapeutic relationship

• Preorientation Phase 

• Orientation Phase 

• Working Phase 

• Termination Phase 

preorientation phase

• Takes place prior to meeting with the client 

• 1st gather data about the client, his or her condition, and the present situation 

• Nurse then examines his or her thoughts, feelings, perceptions, and attitudes about this particular client 

orientation phase

• The nurse-client become acquainted; build trust and rapport 

• A contract is established 

• Includes time and place for the meeting, as well as the purpose of the meetings 

• Dependability is imperative for both the nurse and the client 

• Client strengths, limitations, and problem areas are identified 

• Outcome criteria and a plan of care are established

working phase

• Orientation phase ends and working phase begins when the client takes responsibility for his or her own behavior change 

• Client shows commitment to working on issues that have caused a life disruption 

• Clients’ needs are prioritized- safety and health come first 

• RN assists the client to change problematic behaviors in a safe environment 

termination phase

• Relationship comes to a close 

• This phase begins in the orientation phase when meeting times are established- lets the client know that the relationship will come to an end 

• Avoids confusing the client who may be unable to recognized boundaries in a relationship 

• Termination occurs when the client has improved or has been discharged 

thought process

• how thoughts are formed, organized, and expressed. It involves the flow and coherence of ideas. 

• Descriptors 

  • Speed 

    • Thought blocking 

    • Flight of ideas 

      • Too many thoughts 

  • Organization (Severity from mild to severe) 

    • Circumstantial 

    • Tangential 

      • Loose associations 

    • Word salad 

thought content

• the themes, ideas, and beliefs that occupy a patient's mind. It includes the presence of any delusions, obsessions, or preoccupations. 

• Descriptors: 

  • Logical vs. illogical 

  • Abstract vs. concrete 

  • Magical thinking 

  • Obsessions 

  • Ruminations 

  • Delusions 

  • Ideas of Reference 

  • Thought Broadcasting 

  • Thought Insertion 

  • Thought Withdrawal

thought process vs content

Example for Thought Process: 

• Mr. X’s thinking was logical and goal-directed, with some circumstantiality when discussing suicidal thoughts. 

Example for Thought Content: 

• Mr. X exhibited delusions of persecution, believing that people were conspiring against him 

perception

Abnormalities in how one perceives their environment 

• Hallucinations: Perceptions without an external stimulus. 

  • Auditory (AH): Hearing sounds or voices that are not present. 

  • Visual (VH): Seeing objects or figures that are not there. 

  • Olfactory (OH): Smelling odors that are not present. 

  • Tactile (TH): Feeling sensations on the skin that are not real. 

  • Gustatory (GH): Tasting flavors that are not there. 

• Illusions: Misinterpretations of real external stimuli. 

• Depersonalization/Derealization: 

  • Depersonalization: Feeling detached from oneself, as if observing oneself outside the body. 

  • Derealization: Feeling that the external world is unreal or distorted 

Hallucinations vs Illusions vs Depersonalization

Hallucinations: 

• Mr. X reports experiencing auditory hallucinations, describing hearing voices that are not present. He also mentions occasional visual hallucinations, such as seeing shadows moving in his peripheral vision. There are no reports of olfactory, tactile, or gustatory hallucinations. 

Illusions: 

• Mr. X describes experiencing illusions, such as misinterpreting the rustling of leaves as whispers. He states that these occurrences are infrequent but distressing when they happen. 

Depersonalization/Derealization: 

• Mr. X reports feelings of depersonalization, stating, "I sometimes feel like I am watching myself from outside my body." He also describes episodes of derealization, where the world around him seems unreal or distorted 

judgement and insight

Judgment 

• Ability to assess and evaluate situations, make rational decisions, understand consequences of behavior, and take responsibility for actions. 

  • Key Questions: 

    • Can the patient make sound decisions? 

    • Do they understand the consequences of their actions? 

Insight 

• Ability to perceive and understand the cause and nature of one's own and others’ situations. 

  • Key Questions: 

    • Do they understand their illness? 

    • Do they have insight into their relationships with others? 

judgement vs insight examples

Judgment: 

• Mr. X demonstrated poor judgment during the assessment. He reported that despite knowing the potential legal consequences, he frequently drives under the influence of alcohol. He also mentioned impulsively quitting his job without securing another source of income, reflecting an inability to evaluate situations and make rational decisions. 

Insight: 

• Mr. X exhibited limited insight into his condition. When asked about his mental health, he denied having any problems despite exhibiting clear symptoms of depression and anxiety. He also showed a lack of understanding of how his substance use affects his relationships and overall well-being, indicating a significant lack of insight into his situation 

capacity

• the case of whether or not an individual is capable of making health care decisions 

• Based on if the patient has the ability to: 

  • Communicate 

  • Understand information 

  • Understand situation and its consequences 

• Rationale for treatment options 

  • Capacity is Fluid – not static 

  • Capacity can change from time to time 

• No specific psychiatric disorder automatically reduces it

  • Patients with neurocognitive disorders, psychotic disorders, etc., can have capacity depending on the state of their illness 

competency

• a legal term – determined by courts, not medical professionals 

• Adults are assumed to be competent, but a hearing may be pursued if: 

  • Significant psychiatric disorder 

  • Judgment impaired 

  • Disease that impedes an individual’s ability to reason 

• If it is deemed that an individual is unable to make a competent, informed, and voluntary decision re: treatment, courts have stated that the med determinations and treatment plans are best left to the professionals 

veracity and fidelity

Veracity 

• Definition: Being truthful and transparent with patients. 

• Example: Fully explaining risks and benefits of treatments. 

• Application: Ensure patients can make informed decisions based on accurate information. 

Fidelity 

• Definition: Loyalty and commitment to professional duties. 

• Example: Keeping promises, providing consistent care. 

• Application: Maintain trust by fulfilling professional obligations and providing reliable care 

justice

• Fair and equal treatment of individuals 

• Access to resources 

  • Equity vs. equality

    • Equity – focuses on fairness by ensuring everyone has what they need to succeed, recognizing that individuals don’t start from the same place. 

      • Same starting place 

    • Equality – treats everyone the same, which doesn’t necessarily lead to fairness when people have different starting points or challenges 

      • Same outcomes 

right to refuse

• Patients have the right to refuse medications. Even if: 

  • Psychotic 

  • Involuntary 

• “Forced medications” (MOO/FMP) require: 

  • Two physicians to agree that the medication is needed for sanctity of life 

  • Involuntary commitment 

• Forcible medications change from individual treatment to public protection when medication is used to 

  • Prevent violence to third parties 

  • To prevent suicide 

  • To preserve security 

• Forced medications should be provided in the least restrictive method. 

  • Offer oral first, if refused and safety risk remains, provide injection 

  • Identify your needs and orders before starting the shift 

informed consent

• Informed consent is a documented agreement from the provider and patient identifying that information was provided and agreed 

• Adequate information on the risks and benefits of a given treatment modality 

• Should be educated on alternative modalities 

• Assumes patient has decision-making capacity and adequate information 

• Assumes voluntary decision in regard to treatment – but patient must still be provided with risks/benefits even in the case of involuntary treatment

involuntary commitment

Criteria

• The person is unable without the care, supervision and assistance of others to satisfy his/her need for nourishment, personal or medical care, shelter or self-protection or safety and that death or serious physical debilitation would occur within 30 days unless treatment was provided 

• The person has attempted suicide, or the person has made threats to commit suicide and committed acts in furtherance of the threats 

• The person has mutilated himself/herself or the person has made threats to mutilate and committed acts in furtherance of the threats 

• Danger to others shall be shown by establishing that within the previous 30 days the person has inflicted or attempted to inflict serious bodily harm on another or has threatened serious bodily harm and has committed acts in furtherance of the threat to commit harm to another 

• Obtaining the Warrant: 

  • Subjective belief that the individual has met the criteria for a commitment 

  • Locate crisis center in counter and meet with case worker who will support call to country delegate 

  • County delegate: 24-hour service of an appointed individual’s staff that can give the power of warrant for arrest 

  • Review narrative with county delegate 

  • Approval or denial of the warrant/petition 

• Hospitalization: 

  • Petitioner must agree to keep the client's belongs secure 

  • Fax or deliver the warrant to the police who will pick up the client and take to the nearest facility for evaluation 

  • ER provider agrees with warrant (or doesn’t) and the patient is admitted 

• Post-Hospitalization 

  • Within 5 days the patient will have a hearing to determine the validity of the need for treatment based on the 302 criteria 

• Involuntary Denial 

  • If the county delegate at any time denies the petition the evidence use cannot be used for further petitions 

  • If the patient isn’t found the 302 is canceled 

    • Evidence use cannot be used for further petitions 

  • If the judge for the inpatient hearing find no safety issue with the petition the patient is allowed to leave (no 48 hours) 

    • Evidence use cannot be used for further petitions 

issues with involuntary

Details 

• Anyone can 302 anyone 

• Practitioners and providers can call delegate directly; others must use emergency centers 

Issues 

• If an individual is not found for admission the petition is ruined 

• If the petitioner does not present for the hearing 

• If the information provided in the narrative does not meet criteria for the delegate 

• Well known patients 

• Authoritarian vs Autonomy 

• Authoritarian – false imprisonment will occur if it means safety for others 

• Approved 302->303 prevents the patient from owning firearms in the future 

voluntary commitment

• To go into the psychiatric lock unit legal agreement to be in the hospital locked floor is required called a “Voluntary Agreement” (201 in PA) 

• Safety concerns are still required 

• This patient has identified themselves that they are unsafe 

• If the patient later requests discharge: 

• Patient can be held on the on the unit for up to 72 hours until evaluated for safety 

• The patient will be discharged if the provider determines that the patient is safe 

• If the provider identifies criteria leading to risk, the mental health professional can convert the admission to an involuntary. Involuntary legal process will occur after this decision is made

Maslow’s hierarchy of Needs

• Abraham Maslow 

• Encourage us to look at the whole personality—not just the weaknesses (as past theories have focused on) but also the virtues 

• His theory proposes that humans have a hierarchy of 5 basic needs which are arranged in hierarchical order 

CBT

• Aaron Beck

• Works to alter how we perceive the world to decrease a negative impact on our mood 

• most widely used therapy

• The cognitive triad is Beck’s term to identify 3 common characteristics that distort the thinking of people with depression: 

  • Negative Views of Self 

    • Self image as defective/worthless 

  • Negative views of the world 

    • Evaluation of ongoing life events negatively 

  • Negative Views of the future 

    • “future holds no promise and that current difficulties will continue” 

• These cognitive distortions occur as automatic negative thoughts 

• The cognitive techniques help clients notice their own automatic negative thoughts and the connection of those thoughts to moods and actions 

• The behavioral techniques are used to show individuals that they are capable of interrupting/reframing dysfunctional patterns 

DBT

• Marsha Linehan

• Psychotherapy to benefit characteristics of emotional distress for patient who 

• Difficult to think when affective 

• Difficulty with social situations 

• Conditioned for a chaotic environment 

• Deficit in coping skills to distress 

• Focus is on: 

• Mindfulness: Improving ability to accept and be present in the current moment. 

• Distress Tolerance: Increasing tolerance of negative emotion, rather than trying to escape from it. 

• Emotion Regulation : Skills to manage and change intense emotions 

• Interpersonal effectiveness: Techniques that improve communication in a way that is assertive, maintains self-respect, and strengthens relationships 

• Although considered an individual therapy it is recommended that it is provided in a comprehensive setting 

  • Individual therapy 

  • Group Therapy 

  • Individual psychiatry 

  • Work book homework 

  • 24-Crisis supports 

• Providing requires certification by Dr. Linehan 

interpersonal therapy

• Focus is on interpersonal problems rather than on personality reconstruction 

• Therapist identifies the nature of the problem that needs resolved 

• #1 intervention for adolescents 

• 4 problem areas have been identified: 

  • Grief

  • Role disputes 

  • Role transitions 

  • Interpersonal deficit 

• Identification of Interpersonal Issues: 

  • Identification of specific interpersonal issues/problems that are contributing to their emotional distress 

• Communication Analysis: 

  • Identification of communication styles and patterns that may be contributing to misunderstandings or conflicts in relationships 

• Role Play: 

  • Exercises to help clients practice and develop better interpersonal skills. 

  • Clients may reenact specific interpersonal situations or conversations, allowing them to gain insight into their behavior & responding. 

• Grief and Loss Work: 

  • Techniques to help process emotions and adapt to these losses. 

  • A supportive space to express grief and explore the impact of the loss on their relationships and sense of self 

mood vs affect

• Mood

  • what the patient says they are feeling. This is the only subjective part of the MSE. 

• Affect

  • the observable expression of emotion. It is what you observe 

major depressive episode symptoms

• 1. Depressed mood most of the day, nearly every day, 

• 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day 

• 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day. 

• Rule out: cancer, eating disorder, thyroid issues, T1DM 

• 4. Insomnia or hypersomnia nearly every day 

• Psychomotor agitation or retardation nearly every day 

• 6. Fatigue or loss of energy nearly every day. 

• 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day 

• 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day 

• 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide 

Major depressive disorder vs. Persistent depressive disorder (dysthymia)

• Essentially prolonged, subthreshold depressive symptoms 

• Duration 

  • 2 years in adults 

  • 1 year in children/adolescents 

• Two (or more) of the following symptoms must be present 

  • Poor appetite or overeating 

  • Insomnia or hypersomnia 

  • Low energy or fatigue 

  • Low self-esteem 

  • Poor concentration or difficulty making decisions 

  • Feelings of hopelessness 

• Does NOT need to present dysfunction 

SSRIs

examples

• Fluoxetine (Prozac) 

• Paroxetine (Paxil) 

• Strong side effect profile limits patient profile, strong meds for OCD 

• Sertraline (Zoloft) 

• Citalopram (Celexa) 

• Escitalopram (Lexapro) 

• Fluvoxamine (Luvox) – OCD only 

side effects

• Many side effects are transient – provide patient education: Due to increase in serotonin 

  • Headache 

  • Nausea, vomiting, GI distress 

  • Increases in anxiety/activation 

  • Sexual side effects may be problematic and may not resolve with time.. This is from agonizing the 5ht-2A receptor 

• Other considerations: 

  • QT interval prolongation (caution in the elderly) 

  • Increased risk for bleeding/thrombocytopenia 

  • Potential for hyponatremia 

  • Increases in suicidality – Black Box Warning for children and adolescents 

SNRI

examples

• Duloxetine (Cymbalta) 

• Used for pain as well 

• Venlafaxine (Effexor) 

• Desvenlafaxine (Pristiq) 

side effects

• Headaches (transient) 

• Nausea, vomiting, GI distress (transient) 

• Increased anxiety/activation (transient) 

• Sexual dysfunction (typically persists with therapy) 

• Increased risk for suicidality 

• Major side effect that differs from SSRIs is dose-dependent increases in blood pressure during rapid titration 

  • Must monitor blood pressure in these patients as a nursing intervention 

TCAs

Examples

• Amitriptyline (Elavil) 

• Amoxapine (Asendin) 

• Clomipramine (Anafranil) 

• Desipramine (Norpramin) 

• Dothiepin (Prothladen) 

• Doxepin (Sinequan) 

• Imipramine (Tofranil) 

• Lofepramine (Deprimyl) 

• Nortriptyline (Pamelor) 

• Protriptyline (Triptil) 

• Trimipramine (Surmontil) 

Side Effects

• Antagonists at serotonin transporter and norepinephrine transporter  

• Significant anticholinergic side effects – dry mouth, constipation, urinary retention  

• Anti-histamine properties – sedation and weight gain 

• Antagonist at alpha adrenergic 1 receptors – dizziness, sedation, hypotension  

• Risk for both cardiac arrhythmias (QTc prolongation) and seizures  

• Lethal in overdose  

MAOIs

examples

• Isocarboxazid (Marplan) 

• Phenelzine (Nardil) 

• Tranylcypromine (Parnate) 

• Selegiline (Emsam) 

  • Does come in patch form – better side effect profile 

    • CYP450 receptors exist in the small intestine, patch bypasses this 

Side effects

• significant issue with drug-food interaction, limiting patient tolerability and acceptability 

  • Tyramine must be avoided -> if consumed, can lead to hypertensive crisis 

  • Cured meats, red wine, aged cheese, beer 

  • Grapefruit 

• Other notable side effects include sedation, anticholinergic side effects, and orthostatic hypotension 

bipolar I vs bipolar II

I

• The presence of 1 MANIC episode 

• Typically, even depression is more profound and severe 

• Suicidality Risk 

  • Impulsivity associated with the diagnosis 

  • Risk of suicide is 15x greater than that of the general population 

• Rapid cycling

  • Four or more episodes in 12 months 

  • Associated with poorer outcomes 

II

• The presence of 

  • Hypomanic episode 

  • One major depressive episode 

  • A manic episode excludes this diagnosis 

• Diagnosing 

  • Very difficult to recognize, and can incorrectly be treated with SSRIs which may worsen disease trajectory 

  • Years of evaluation before eventual identification

mood stabilizers

• Lithium

• Anticonvulsants

  • Valproate (Depakote)

  • Depakote (ER, Sprinkles etc)

  • Divalproex Sodium

  • Valproic Acid

  • Lamotrigine (Lamictal)

  • Carbamazepine (Tegretol)

  • Oxcarbazepine (Trileptal)

• Medications previously thought to work for bipolar

  • Topiramate (Topamax)

  • Neurontin

lithium

• Short Term

  • Polyuria and polydipsia (nephrogenic diabetes insipidus)

  • Diarrhea, nausea, weight gain

  • Acne, rash, alopecia

  • Leukocytosis – False Positive

  • Arrhythmia

  • Toxicity - to be discussed on following slide

• Long Term

  • Goiter (euthyroid or hypothyroid)

  • Renal impairments (10+ years)

  • Hypercalcemia related to alterations of parathyroid functioning

0.6 – 1.2 mEq/L

NARROW THERAPEUTIC RANGE

• Early signs of toxicity *

  • Tremor: Can be a normal side effect

  • Ataxia,

  • Vomiting (very fine tremor may occur even at

  therapeutic levels)

• Profound signs of toxicity

  • Mental status changes,

  • Confusion,

  • Coma

valproate

side effects

• Common: Nausea, vomiting, abdominal pain, dizziness, tremor, weight gain

• Hepatotoxicity

  • Incidence: Higher in children under 2 years and patients on multiple anticonvulsants

  • Action: Monitor liver function tests, watch for symptoms like jaundice, fatigue, and abdominal pain

• DRESS Syndrome

  • Incidence: Rare but serious

  • Action: Report any signs of rash, fever, swollen lymph nodes, or other symptoms of systemic illness;

    seek immediate medical attention

• Thrombocytopenia

  • Incidence: Monitor platelet counts

  • Action: Watch for signs of bruising, bleeding, and report to a healthcare provide

Monitoring

• Liver Function: Regular liver function tests

• Platelet Count: Monitor for thrombocytopenia

• Skin Reactions: Monitor for signs of DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms)

• Caution in PCOS

lamotrigine

side effects

• Common

  • Dizziness, headache, blurred vision, coordination problems, GI disturbances

• Serious

  • Severe skin rashes (Stevens-Johnson syndrome, toxic epidermal necrolysis)

  • Multi-organ hypersensitivity reactions

  • Aseptic meningitis

• Monitoring

  • Skin Reactions: Watch for rashes, especially initially

carbamazepine and oxcarbazepine

Side Effects

• Common: Dizziness, drowsiness, nausea, vomiting, ataxia, visual disturbances

• Monitoring

  • Liver Function: Regular liver function tests

  • Sodium Levels: Monitor for hyponatremia

  • Complete Blood Count (CBC): Watch for signs of blood dyscrasias (e.g., agranulocytosis, aplastic anemia)

  • Skin Reactions: Monitor for signs of SJS/TEN and DRESS syndrome

• Blood Dyscrasias

  • Incidence: Rare but serious

  • Action: Monitor CBC; watch for signs of infection, unusual bleeding, bruising, and fatigue

• Hyponatremia

  • Incidence: More common with oxcarbazepine

  • Action: Monitor sodium levels; watch for symptoms like nausea, headache, confusion, and seizures

• Teratogenicity:

  • Risk of birth defects; contraindicated in pregnancy unless absolutely necessary

lithium tests

• Renal function tests

• Thyroid function

• Serum electrolytes with special consideration for serum calcium

• EKG

• Weight/BMI

• Beta-hCG pregnancy tests in all women of childbearing age

• Serum lithium levels

  • Draw trough just before next dose (8 to 12 hours after previous dose) → usually first thing in the AM

steven johnson syndrome

• Stevens-Johnson Syndrome (SJS)

• Incidence: Approximately 0.04% of patients

• Action: Any rash should be immediately evaluated; stop medication and seek emergency care.

• SJS Progression

  • Prodromal Phase

    • Fever >102°F

    • Flu-like symptoms

    • Photophobia

    • Mucosal lesions

  • Cutaneous Phase

    • Widespread skin rash, often starting on the face and thorax

    • Blistering and peeling of the skin

  • Recovery Phase

    • Re-epithelialization (new skin formation)