Comprehensive Study Guide for Psychiatric Nursing and Mental Health

Anxiety and Escalation Management

  • Fear vs. Anxiety: Fear is defined as being afraid of something that is actually present or a specific fear of performing an action. Anxiety is the feeling of dread; it is an unavoidable part of life.
  • Goal of Care: The objective is to teach clients coping skills and relaxation techniques so they are not overwhelmed when facing anxiety.
  • Signs of Agitation and Escalation: Clinical escalation often begins with anxiety. Nurses must monitor for:
    • Pacing.
    • Wringing of hands.
    • Hitting objects or slapping walls.
  • Catastrophizing: When a client feels that many things are wrong simultaneously, the nurse must address the underlying anxiety first.
  • Levels of Anxiety:
    • Mild: The client is more alert. This is the optimal time for the nurse to teach coping skills.
    • Moderate: The client is stressed. The nurse should use shorter questions and provide more directive instructions.
    • Severe or Panic: This is acute high anxiety. It is difficult to communicate with the client, and they are at significant risk for self-harm. They cannot think rationally and are prone to accidents. Teaching is not possible at this level; the priority is safety.

Pharmacological Interventions for Anxiety and Withdrawal

  • Benzodiazepines: Used for acute/severe anxiety and alcohol detoxification.
    • Examples: Alprazolam (Xanax), Lorazepam (Ativan), and Librium (chlordiazepoxide).
    • Librium: Noted for having a longer half-life, meaning it remains in the system for an extended duration.
    • Pregnancy Contraindications: Benzodiazepines are not compatible with pregnancy. Potential side effects for the infant include prematurity, low birth weight, and hypotonia (floppy muscles).
    • Risks: These drugs can be addictive. Withdrawal poses a high risk for seizures and death. They are generally not recommended for elderly populations.
  • Alcohol Withdrawal Management:
    • Signs/Symptoms: Agitation, tremors, elevated blood pressure, elevated heart rate, and diaphoresis.
    • Screening Tool: The CYBAL (Clinical Institute Withdrawal Assessment) tool is used. A higher CYBAL score indicates more severe symptoms.
    • Withdrawal Risks: Withdrawal from benzodiazepines and alcohol can lead to seizures and death. This process must be monitored by a prescriber.

Post-Traumatic Stress Disorder (PTSD) and Stress Syndromes

  • Causes: PTSD can result from military combat, extended serious illness, injury to oneself or a loved one, country displacement (refugees), or seeing a traumatic event firsthand.
  • Symptoms: Flashbacks (reliving the experience while conscious), nightmares, and triggers (similar circumstances, people, or events).
  • Grounding Techniques: These are used to help clients manage flashbacks.
  • Diagnostic Timeframe: The primary difference between Acute Stress Syndrome and PTSD is the duration. If symptoms persist for longer than 11 month, it is classified as PTSD. (Note: A duration longer than 33 months was also mentioned as a marker).
  • Therapeutic Modalities:
    • Systematic Desensitization: Gradually exposing a client to anxiety-producing triggers (e.g., spiders in arachnophobia) while exercising relaxation techniques.
    • Flooding (Exposure Therapy): Directly exposing the client to a maximum intensity anxiety-producing stimulus.
    • Cognitive Restructuring: Reframing negative thoughts into positive ones.
    • EMDR (Eye Movement Desensitization and Reprocessing): A specific trauma therapy where a client recalls events and focuses on associated thoughts/emotions while undergoing bilateral stimulation. It must be performed by a specifically trained therapist.
    • Medication: Often includes antidepressants combined with therapy.

Bipolar Disorder and Lithium Therapy

  • Mania Symptoms: Insomnia (going days without sleep), impulsiveness (gambling, excessive shopping), malnourishment (too busy to eat), rapid speech, and psychosis.
  • Cycle and Risk: Suicide risk increases after a manic episode concludes and the individual realizes the consequences of their actions (e.g., financial ruin), leading to a depressive crash.
  • Onset: Typically occurs in young adulthood or the 20s−30s20s-30s.
  • Lithium Therapy: Effective in approximately 75%75\% of clients.
  • Lithium Toxicity: Life-threatening condition. Signs include severe vomiting, diarrhea, and weakness, which can progress to seizures.
    • Precipitating Factors: Sodium imbalances and dehydration. Clients must remain hydrated.
    • Therapeutic Window: Lithium has a very narrow therapeutic range/window, making toxicity highly probable if not monitored correctly.

Depressive Disorders and Antidepressants

  • Depression Symptoms: Not bathing, hopelessness, tearfulness, guilt, worthlessness, self-blame, and drug use to numb pain.
  • Screening: The PHQ-9 tool is used.
  • SSRI (Selective Serotonin Reuptake Inhibitors):
    • Examples: Prozac (fluoxetine), Cymbalta (duloxetine), and Elavil (amitriptyline - though often categorized as a TCA, it is grouped here with antidepressants acting similarly).
    • Prozac: Has a long half-life.
    • Side Effects: Decreased sex drive, weight loss, drowsiness, dry mouth, nausea, and orthostatic hypotension.
    • Therapeutic Lag: Takes 44 to 66 weeks for full effect. The risk for suicide increases at the 22-week mark as energy improves before mood.
  • MAOIs (Monoamine Oxidase Inhibitors):
    • Dietary Restrictions: Clients must avoid tyramine-rich foods to prevent hypertensive crisis. This includes aged cheeses, aged/processed meats, wine, ripe bananas, and yogurt.
    • Examples: Nardil (phenelzine) and Selegiline (Emsam - which is administered via a skin patch).
  • Serotonin Syndrome: Caused by excessive serotonin activity (e.g., SSRIs and MAOIs taken together). Signs: Agitation, restlessness, tachycardia, high blood pressure, tremors, and high fever.
  • Bupropion (Wellbutrin/Zyban): Used for depression, smoking cessation, and weight loss. It has fewer sexual side effects. However, it lowers the seizure threshold and is contraindicated in clients with a history of seizures, anorexia, or bulimia.

Grief and Loss

  • Kübler-Ross Stages of Grieving:
    • Denial: Acting as if the loss has not occurred.
    • Anger: Hostility or outbursts toward staff or family.
    • Bargaining: Seeking more time from a higher power in exchange for specific behaviors.
    • Depression: Overwhelming sadness.
    • Acceptance: Accepting the loss to move forward.
  • Characteristics: Grieving is individual and non-linear; clients can move back and forth between stages or experience them in any order. Complicated grief occurs when a client fails to move through the stages.

Suicide Precautions in Behavioral Health

  • Warning Signs: Poor hygiene, giving away belongings, reminiscing about the past, or saying goodbye.
  • Inpatient Unit Safety:
    • Count plastic utensils before and after meals.
    • Use only paper bags (no plastic bags or containers).
    • Identify and remove ligature risks and hanging-proof surfaces.
    • Keep empty rooms locked.
    • Remove all sharps.
    • In some facilities, specific scrubs distinguish those on behavioral health watch.

Substance Abuse and Detoxification

  • Tolerance: Needing increased amounts of a substance to achieve the same effect.
  • Addiction: Can be physical or mental; cravings may persist after physical detox.
  • Alcohol Detox: Medical detox uses benzodiazepines to relieve withdrawal. Symptoms begin hours after the last drink.
  • Delirium Tremens (DTs): Severe symptoms including acute confusion, psychosis, hypertension, and cardiac dysrhythmias. Requires close monitoring (often ICU) and IV sedatives like Ativan.
  • Opioid Management:
    • ComforMeds: Medications provided to manage uncomfortable withdrawal symptoms (nausea, diarrhea, aches).
    • Methadone: A synthetic heroin used for opioid replacement. It is addictive and must be obtained from a licensed clinic. Hospital providers must verify the dose with the clinic.
  • Disulfiram (Antabuse): A deterrent for alcohol. Any alcohol consumption leads to severe vomiting, flushing, and breathing trouble.
  • Other Substances:
    • Hallucinogens (PCP/LSD): Causes illusions and feelings of being out of control. Withdrawal includes muscle stiffness, depressed breathing, and flashbacks that can last years.
    • Amphetamines (Meth/Adderall): Withdrawal involves prolonged sleep, cravings, overeating ("munchies"), and paranoia.

Schizophrenia and Psychotic Disorders

  • Positive Symptoms (Traits added to personality):
    • Hallucinations: Experiencing non-existent sights, sounds, smells, or tactile sensations.
    • Delusions: Fixed false beliefs (e.g., Grandiose - thinking one is famous; Paranoid/Persecutory - thinking others will harm them).
    • Thought/Speech Disruptions: Ideas of Reference, Word Salad (jumbled words), Neologisms (made-up words), Thought Insertion, Thought Broadcasting, and Pressured Speech.
  • Negative Symptoms (Traits taken away):
    • Anhedonia: Lack of pleasure.
    • Poverty of Speech: Lack of verbal communication.
    • Avolition: Lack of motivation.
  • Pharmacological Treatment:
    • First Generation: Higher risk of side effects and Neuroleptic Malignant Syndrome (NMS).
    • Atypical (Second Generation): Lower risk of NMS but can still cause Extrapyramidal Symptoms (EPS) and rapid weight gain.
    • Clozapine (Clozaril): Risk of agranulocytosis (lowered immune system).
    • Neuroleptic Malignant Syndrome (NMS): Fever, hypertension, tachycardia, and elevated CPK levels. Treated with Dantrolene.
    • Side Effect Management: Benadryl for emergent EPS; Cogentin (benztropine) for prophylactic management.
    • Long-Acting Injectables: Medications like Abilify Maintena (IM) help with compliance.

Personality Disorders and Defense Mechanisms

  • Borderline Personality Disorder (Cluster B):
    • Splitting: All-or-nothing thinking (loving or hating staff). Staff splitting involves playing staff against each other to avoid a "no" answer.
    • Traits: Impulsivity, dramatic behavior, and self-harm risk.
  • Defense Mechanisms:
    • Displacement: Transferring negative feelings to a different person/thing.
    • Suppression: Conscious decision to deal with emotions later.
    • Repression: Unconscious blocking of unpleasant thoughts.
    • Projection: Attributing one's own unacceptable traits to others.
    • Sublimation: Channeling unacceptable urges into productive activities.
  • Obsessive Compulsive Disorder (OCD):
    • Rituals: Handwashing, counting, or checking, performed to reduce anxiety.
    • Nursing Care: Initially, the nurse must allow the client time for rituals to prevent overwhelming anxiety. The ultimate goal is to use relaxation to reduce the time spent on rituals.

Questions & Discussion

  • Question: Why are clients at risk for harm when they have severe anxiety?
  • Response: Because they are hitting things, wringing their hands, pacing, and may act out on others. They are difficult to calm down and cannot think rationally, making them prone to accidents.
  • Question: Does a person have to actually experience an event to have PTSD?
  • Response: No. Seeing an event can also cause PTSD.
  • Question: What is the difference between acute stress syndrome and PTSD?
  • Response: The time frame. If the symptoms last longer than one month, it is PTSD.
  • Question: What are some signs and symptoms of alcohol withdrawal?
  • Response: Agitation, tremors, elevated blood pressure, elevated heart rate, and diaphoresis.
  • Question: What is one of the most important questions to ask a client with a history of heavy drinking?
  • Response: "When was your last drink, and what was it?" Additionally, ask about a history of delirium tremens (DTs) or seizures during withdrawal.
  • Interjection (Student): "Hi professor. Yuzima said she's waiting in the waiting room."
  • Response: "I'll let her in. Thank you."
  • Interjection (Personal): Discussion regarding a student's dog, a 0.50.5-year-old Frenchie.