Psychiatric-Mental Health Nursing
Depression
Loss of interest in life's activities, usually related to loss (job, body part, self-esteem, etc.).
Negative view of the world.
Anhedonia: Loss of pleasure in previously enjoyable activities.
Appearance:
Not well-kept.
Lack of energy.
Weight gain (mild) or weight loss (severe).
Crying spells (mild to moderate), but fewer or no tears in severe depression.
Irritability (possibly due to decreased serotonin).
Patients need help with self-care.
Assist with bathing, hair, and dressing.
Help experience accomplishment to improve self-esteem.
Be cautious with compliments; patients may focus on the negative.
Prevent isolation.
Actively involve patients in activities.
Seek out the patient.
If severely depressed, sit with the patient without demanding interaction.
Difficulty making decisions; offer options.
Assess suicide risk.
If there's any indication of suicidal thoughts, confront it directly.
Suicide risk may increase as depression lifts due to increased energy.
Sudden mood improvement may indicate a decision to commit suicide.
Elderly men are at higher risk and tend to use more lethal methods.
Delusions and hallucinations can occur, depending on the severity.
Slowed thoughts affect communication; speak slowly and allow more time for responses.
Concentration is impaired.
Sleep disturbances:
Hypersomnia (mild depression).
Insomnia (moderate to severe depression).
Difficulty falling asleep, staying asleep, or early morning awakenings.
Mania
Continuous high, emotions are labile (changing rapidly).
Flight of ideas: Difficulty staying on one subject.
Delusions:
False ideas, e.g., delusion of grandeur (feeling very important, like thinking they are Jesus).
Delusions of persecution (feeling threatened).
Do not argue about the belief, as it reinforces it.
Acknowledge the patient needs the belief, but do not endorse it; look for the underlying need (e.g., feeling safe in delusions of persecution or self-esteem needs for delusions of grandeur).
Constant motor activity can lead to exhaustion.
Interrupt the activity if necessary.
Dress inappropriately (seductively, wildly) or may not wear anything.
Maintain their integrity, cover them up, and get them back to their room and out of the environment that made them want to take their clothes off.
Cannot stop to eat; provide finger foods.
Altered sleep patterns; may not sleep at all during acute stages.
Spending sprees make them feel important.
Poor judgment, no inhibitions, hypersexual, may exploit other patients.
The nurse has to protect other people.
Manipulates and gets mad and turns if they don't get their way.
Manipulation makes them feel secure and powerful.
Set limits and provide consistent staff interactions.
Decreased attention span.
May hallucinate.
Treatment:
Decrease stimuli.
Limit group activities.
One-on-one relationships are best.
Remove hazards (manic patients can hurt themselves with anything).
Monitor smoking (give back two at a time and monitor) and stay with patient as anxiety increases.
A structured schedule makes everyone feel more secure.
Provide activity to replace aimless activity.
Brief, frequent contact with staff; avoid intense conversations.
Offer finger foods and snacks, weigh daily, and walk with patients during meals.
Prioritize caloric intake over coping mechanisms in acute stages (following Maslow's hierarchy of needs).
Don't argue with patients or try to reason with them.
Maintain dignity, as they may say or do things they wouldn't normally do.
Medications:
Haldol, Thorazine, Zyprexa, Risperdal, Lithium.
Lithium: Sodium levels must remain balanced to avoid toxicity. Take into account that there are handouts with normal drug levels of Lithium, Dig levels, Theophylline Levels, etc.
Schizophrenia
Focuses inward, creating their world; retreats from the outside world.
Degrees of the illness vary.
Inappropriate, flat, or blunted affect (e.g., laughing while describing a tragic event).
Disorganized thoughts, loose associations, interrupted connections.
Echolalia: Repeating words.
Neologisms: Making up new words; seek clarification without using the words yourself.
Concrete thinkers.
Alteration in communication is a top nursing diagnosis.
Delusions, hallucinations (auditory most common, then visual).
Childlike mannerisms.
May become preoccupied with religion.
Treatment:
Decrease stimuli.
Observe frequently without being obvious (don't peek).
Orient frequently.
Keep conversations reality-based.
Meet personal needs.
Medications available.
Pharmacology Considerations
Focus on basic medication administration principles, IV calculations, blood administration, TPN, and central line care.
Pharmacology is one component of the test; showing weakness in multiple areas is what leads to failure.
Suicide
Assess for a plan, lethality, access to the plan, and previous attempts.
Guns, car crashes, hanging and carbon monoxide are very lethal plans. Want to know if the person has access to the plan and if they have ever attempted before.
Watch for isolating behavior, writing a will, collecting harmful objects, and giving away belongings.
Elderly men are particularly at risk.
Safety is the number one priority.
Provide a safe environment and safe-proof the room.
Contract to postpone: create a contract with the patient that they will not bring harm to themselves in the next 8 - 24 hours.
Direct closed-ended statements are appropriate (e.g., "Are you having thoughts of suicide?").
Re-channel anger through exercise (punching bag rather than a long walk).
Stay calm, as anxiety is contagious.
If there's a suicide attempt on the unit, manage information carefully to prevent chaos.
Restraints: Use as a last resort, check frequently (every 15 minutes), and provide for hydration, nutrition, and elimination.
Observation:
Every 15-30 minute intervals or one-on-one if they will not contract for safety.
Paranoia
Suspiciousness without reason, responding in a way consistent with their paranoid beliefs.
Cannot explain away delusions or false beliefs.
Distrust is the number one problem.
Pathologic jealousy, hypersensitivity, cannot relax and has no humor.
They Believe that their life is unfair.
Unemotional, but craves recognition.
React with rage and can become violent.
Treatment:
Be reliable to build trust.
Brief visits and be on time.
Be careful with touch and respect their personal space; avoid whispering.
Don't mix their medicines; be matter-of-fact when administering.
Allow them to eat sealed foods, foods they fix for themselves, or foods from home; the goal is to get them eating what everyone else is eating.
Consistent nursing staff is important.
No competitive activities, can get humiliated.