Comprehensive Nursing Notes on Psychiatric-Mental Health Nursing
Clinical Manifestations and Assessment of Bipolar Disorder and Manic States
Bipolar disorder is characterized by distinct periods of elevated mood and behavioral changes. A manic episode is defined as lasting at least week, whereas a hypomanic episode lasts at least days. A hallmark symptom is grandiose delusions, which are fixed false beliefs where the individual believes they possess extraordinary powers, identity, or abilities. Patients in a state of mania are considered a significant fall risk due to hyperactivity and impaired judgment. Their speech patterns often exhibit specific abnormalities: pressured speech constitutes talking rapidly and being unable to stop; circumstantial speech includes excessive, unnecessary details and long-windedness; tangential speech involves going off-topic or talking in circles; loose associations involve ideas shifting rapidly from one topic to another; and flight of ideas occurs when ideas form and change even more quickly between topics, though some connection remains. Clang associations are also common, where the individual links words based on sound or rhyming rather than meaning.
Nursing interventions for patients in mania prioritize physical needs and safety. Nurses must monitor vital signs and offer frequent, mobile, high-calorie foods and protein drinks (finger foods) for patients who cannot sit to eat. It is essential to avoid caffeine, reduce environmental stimulation, and encourage rest through sleep-inducing interventions. Hygiene assistance involves providing specific choices and reminders. If a patient’s agitation escalates, verbal de-escalation is the first line of intervention before considering antipsychotics. Pharmacological management typically includes mood stabilizers like Lithium or various anticonvulsants. For bipolar depression, antidepressants must never be administered alone due to the risk of triggering a manic episode; they must be used in combination with a mood stabilizer. Gastric upset from medications can be mitigated by taking them with food, though they can be taken without food if no upset occurs.
Depressive Disorders and the Diathesis-Stress Model
Seasonal Affective Disorder (SAD) is frequently observed in women between the ages of and follows a seasonal pattern related to decreased sunlight exposure. The development of depressive and other psychiatric disorders is often explained by the Diathesis-Stress Model. This model posits that a disorder develops from a combination of a diathesis (an inherited predisposition or vulnerability, such as genetic factors or prenatal trauma) and environmental stressors (such as childhood abuse, family conflict, or significant life changes). A stronger diathesis implies that less environmental stress is required to trigger the onset of the disorder. Tools like the PHQ-9 are utilized for screening, specifically assessing for suicidal ideation. Communication with severely withdrawn patients requires specific techniques, such as using observations (e.g., "You are wearing new shoes") when the patient is silent, using simple and concrete words, allowing ample time for responses, and listening for covert messages regarding suicide. Nurses must avoid platitudes like "things will get better," as these minimize the patient's feelings.
Physiological and Psychological Impact of Stress
Stress manifests in both acute and chronic forms with distinct physiological consequences. Acute stress can cause uneasiness, concern, increased energy use, increased metabolism, and heightened cardiovascular tone, while also temporarily enhancing memory and learning. Conversely, chronic stress is associated with profound negative outcomes, including immune suppression, hypertension (HTN), infertility, erectile dysfunction (ED), and anovulation. It leads to increased risks of stroke, blood clotting, anxiety, panic attacks, Major Depressive Disorder, and eating disorders like anorexia or overeating. Long-term chronic stress results in insulin resistance, diabetes, decreased libido, fatigue, irritability, and increased respiratory issues. The Social Readjustment Rating Scale (Holmes and Rahe) is used to measure stress based on recent life changes, though it is noted that not all events are perceived equally across different cultures.
Defense Mechanisms and Coping Strategies
Individuals utilize various defense mechanisms to manage anxiety. Altruism involves helping others to feel good, while compensation involves focusing on strengths to make up for weaknesses. Conversion occurs when psychological stress manifests as a physical symptom with no medical cause. Denial is the refusal to accept reality, and displacement is taking feelings out on a safer target. Dissociation involves mentally "checking out," while identification is copying another's traits. Intellectualization avoids emotions by focusing strictly on facts. Projection involves blaming others for one's own feelings, and rationalization involves making excuses. Reaction formation is acting the opposite of how one truly feels. Regression is acting in a childlike manner, while repression is the unconscious blocking of thoughts. Suppression is the conscious choice to ignore something temporarily. Splitting involves seeing things as entirely good or entirely bad. Sublimation turns negative impulses into positive actions, and undoing is an attempt to "fix" a previous bad action. Effective coping leads to anxiety reduction and a return to functional behavior, whereas ineffective coping can lead to physical or psychological illness.
Crisis Intervention and Levels of Prevention
Crisis occurs in four phases: () exposure to a stressor leads to increased anxiety and the use of coping skills; () if these fail, anxiety increases to discomfort and disorganization, prompting trial-and-error problem-solving; () if trial and error fails, anxiety reaches severe or panic levels, leading to withdrawal or fight-or-flight; () if unresolved, the individual becomes overwhelmed, leading to depression, violence, or suicidal behavior. Crisis is usually self-limiting, lasting weeks. Intervention steps include assessing lethality, establishing rapport, identifying the "last straw" problem, dealing with emotions through active listening, exploring alternatives, developing an action plan, and following up. Crises are categorized as Maturational (e.g., marriage, aging), Situational (e.g., job loss, death of a loved one), or Adventitious (e.g., natural disasters, war). Prevention is categorized into three levels: Primary (promoting mental health to reduce the incidence of crisis), Secondary (acute intervention to ensure safety), and Tertiary (long-term support and rehabilitation).
Anxiety, Obsessive-Compulsive, and Related Disorders
Peplau defines four levels of anxiety: Mild (alert and focused, learning is possible), Moderate (narrowed focus, shaky, learning is difficult), Severe (confused, no learning possible, requiring simple commands), and Panic (loss of touch with reality, terror, safety is the priority). Specific disorders include Panic Disorder (sudden intense fear/doom), Generalized Anxiety Disorder (GAD; excessive worry about everything), and Obsessive-Compulsive Disorder (OCD; obsessions driven by anxiety and compulsions performed for temporary relief). GAD symptoms include restlessness, fatigue, and muscle tension. Panic attacks may present with chest pain, shortness of breath (), sweating, and tremors. Treatment includes Cognitive Behavioral Therapy (CBT), exposure therapy, and medications such as SSRIs (Sertraline/Zoloft, Fluoxetine/Prozac) or Benzodiazepines (Lorazepam/Ativan) for short-term relief.
Schizophrenia and Psychotic Disorders
Schizophrenia onset typically occurs between ages for men and for women. Etiology involves genetics, increased dopamine, prenatal infections, and environmental toxins. Symptoms are classified as Positive (excess behaviors like delusions and hallucinations) or Negative (deficits such as anhedonia, avolition, asociality, apathy, and alogia/poverty of speech). Specific speech disruptions include word salad (jumbled words), neologisms (made-up words), and loose associations (disconnected words). In group therapy settings, concepts like universality (sharing common experiences) and altruism are emphasized.
Psychiatric Pharmacotherapy and Medical Procedures
Medication management requires careful monitoring of side effects and toxicity. Lithium is used for mania with a therapeutic range of . Toxicity (>2.0) presents as diarrhea, tremors, ataxia, and seizures; the nurse should hold the dose and push fluids. Anticonvulsants like Valproate require liver function monitoring, while Lamotrigine carries a risk for Stevens-Johnson Syndrome/TENS (presenting as a rash). First-generation antipsychotics (Haloperidol) carry a high risk for Extrapyramidal Symptoms (EPS), such as tardive dyskinesia. Second-generation antipsychotics (Risperidone, Olanzapine) are associated with metabolic syndrome and weight gain. Clozapine requires monitoring for agranulocytosis (low WBC). Neuroleptic Malignant Syndrome (NMS) is a medical emergency characterized by a high body temperature and muscle rigidity. Tricyclic Antidepressants (TCAs) like Amitriptyline are lethal in overdose due to cardiotoxicity. Monoamine Oxidase Inhibitors (MAOIs) like Phenelzine require a low-tyramine diet (avoiding aged cheeses, cured meats, and fermented foods) to prevent hypertensive crisis. Electroconvulsive Therapy (ECT) is used for treatment-resistant depression or severe mania; patients must be for hours, and the treatment may cause short-term amnesia. Serotonin Syndrome, caused by excessive serotonin, presents with flu-like symptoms, tremors, and hyperreflexia.