psych 2

Exam 2 Review

• Important note to review the Test Breakdown for medications.

Chapters 5 & 6 Objectives

1. Importance of Culturally Relevant Care

   • Culturally relevant care is essential in psychiatric mental health nursing practice to ensure that care is tailored to the cultural background, beliefs, and values of patients, which enhances patient understanding, cooperation, and treatment outcomes.

2. Comparison of Western Nursing Practices and Diverse Cultural Practices

   • Western nursing often emphasizes biomedical models and individualism, while diverse cultures may prioritize holistic health, family involvement, and spiritual beliefs.

   • Understanding these differences can assist nurses in providing more effective, culturally competent care.

3. Culturally Sensitive Assessments

   • Develop assessments that recognize risk factors and barriers faced by culturally diverse patients, such as:

     • Language barriers

     • Socioeconomic challenges

     • Lack of access to care

     • Stigma associated with mental health

4. Ethics vs. Bioethics

   • Ethics: The study of what is right and wrong in human behavior.

   • Bioethics: A subfield that specifically addresses ethical issues arising in healthcare and biological sciences.

   • Five Principles of Bioethics:

     • Autonomy: Respecting the decision-making rights of patients.

     • Beneficence: Acting in the best interest of the patient.

     • Nonmaleficence: Avoiding harm to the patient.

     • Justice: Ensuring fair treatment and access to care.

     • Fidelity: Upholding commitments and trust in relationships.

5. Patient Rights

   • Five Important Patient Rights:

     • Right to treatment

     • Right to refuse treatment

     • Right to informed consent

     • Right to confidentiality

     • Right to participate in care decisions.

6. Actions for Suspected Negligence or Illegal Activities

   • Nurses should follow established protocols which include:

     • Reporting to a superior or appropriate authority.

     • Documenting observations and concerns thoroughly.

     • Maintaining objectivity and professional ethics in handling the situation.

7. Legal Considerations for Patient Privilege

   • Conditions under which patient confidentiality may be breached:
     a. After a patient has died, confidentiality may still be upheld depending on the jurisdiction.
     b. If the patient tests positive for HIV, disclosure may be required in certain scenarios to protect third parties (e.g., partners).
     c. If the patient's employer states a "need to know," confidentiality may be overridden but must follow legal guidelines.

8. Duty to Break Patient Confidentiality

   • Situations that warrant breaking confidentiality include:

     • Duty to report: when there is a threat of harm to the patient or others.

     • Cases of abuse or neglect.

     • In instances of imminent danger or legal requirements to disclose.

9. Patient’s Civil Rights and Restraint/Seclusion

   • Patients have civil rights that require safeguarding, particularly concerning the use of restraint and seclusion, which should be justified and documented.

10. Balance Between Patient Rights and Societal Rights

    • Relevant legal concepts in nursing:
      a. Duty to intervene: Obligation to act if a patient poses a danger to self or others.
      b. Documentation: Critical for legal protection and accurate patient care records.
      c. Confidentiality: Must be maintained while also considering public safety.

11. Legal Terminology related to Psychiatric Nursing

    • Torts: Wrongful acts that result in harm or injury and can be classified as civil rather than criminal.

    • Negligence: Failure to provide adequate care that a reasonable person would provide, resulting in harm.

    • Malpractice: Professional negligence where a healthcare provider fails to deliver the standard of care, leading to patient injury.

Chapters 13 & 25 Objectives

1. Assessment of a Patient with Mania

   • Focus on:
     a. Mood: Observe for elevated mood or irritability.
     b. Behavior: Look for hyperactivity or restlessness.
     c. Thought processes: Assess for racing thoughts or distractibility.

2. Nursing Diagnoses for Mania

   • Formulate three relevant nursing diagnoses based on collected data, such as risk of injury or ineffective coping.

3. Communication Methods for Patients with Mania

   • Explain five effective communication techniques, including:

     • Use of simple, clear language.

     • Active listening and validation of feelings.

     • Non-confrontational stance and tone.

4. Side Effects of Lithium Therapy

   • Teach key side effects like:

     • Tremors

     • Weight gain

     • Gastrointestinal upset

     • Polyuria

     • Thirst and dry mouth.

5. Lithium Toxicity Signs

   • Early signs: Nausea, mild tremors, diarrhea.

   • Severe toxicity: Ataxia, seizures, and renal failure.

6. Medication Care Plan for Lithium Carbonate

   • Five areas of patient teaching include:

     • Importance of regular blood level monitoring.

     • Signs of toxicity to report.

     • Need for adequate hydration.

7. Seclusion for Patients with Mania

   • Indications include:

     • Risk of harm to self or others.

     • Severe agitation that cannot be controlled.

8. Focus of Treatment in Mania Phases

   • Treatment differs for:

     • Acute mania: Stabilization and safety are priorities.

     • Continuation phase: Focus shifts to preventing relapse and treating ongoing symptoms.

9. Precipitating Events for Suicide Attempts

   • Identify at least three common events such as:

     • Loss of a significant relationship.

     • Changes in health status.

     • Financial or legal troubles.

10. Risk Factors for Suicide

    • Include:

      • Coexisting psychiatric disorders (e.g., depression, anxiety).

      • History of previous attempts.

      • Substance abuse issues.

11. Common Coexisting Psychiatric Disorders

    • Most frequent include:

      • Depression

      • Anxiety disorders

      • Substance use disorders.

12. Interventions for Suicide

    • Primary interventions: Preventative measures (e.g., education).

    • Secondary interventions: Crisis intervention at the hospital level.

    • Tertiary interventions: Long-term care and rehabilitation post-attempt.

13. Basic-level Interventions in Hospitals/Community

    • Focus on creating a safe environment and establishing therapeutic relationships.

14. Suicide Precautions and Safety

    • Key elements include removing harmful objects and ensuring constant monitoring.

Chapters 14, 31 & 23 Objectives

1. Major Depressive Disorder vs. Dysthymic Disorder

   • Compare:

     • Major Depressive Disorder: Characterized by persistent sadness and loss of interest/pleasure in activities, typically more severe symptoms.

     • Dysthymic Disorder (Persistent Depressive Disorder): A chronic form of depression with less severe symptoms lasting longer.

2. Assessing Depression Behaviors

   • Evaluate behaviors in relation to:
     a. Affect: Look for flat or labile mood.
     b. Thought processes: Identify negative and distorted thoughts.
     c. Feelings: Note feelings of worthlessness or hopelessness.
     d. Physical behavior: Signs of psychomotor retardation or agitation.
     e. Communication: Changes in speech patterns or lack of verbal communication.

3. Nursing Diagnoses for Depression

   • Formulate five nursing diagnoses with evaluation criteria such as:

     • Risk for suicide.

     • Disturbed sleep pattern.

4. Principles of Communication for Patients with Depression

   • Role play six key principles, including acknowledging feelings, listening actively, and providing reassurance.

5. SSRIs vs. Tricyclic Antidepressants

   • Evaluate the advantages of Selective Serotonin Reuptake Inhibitors (SSRIs), including lower side effect profile and safety in overdose compared to tricyclic antidepressants.

6. Medication Plan for Tricyclic Antidepressants

   • Outline necessary patient education on adverse effects, toxic reactions, and drug interactions that may exacerbate side effects.

7. Medication Plan for MAOIs

   • Include dietary restrictions (tyramine contraindications) and interactions with certain medications that can lead to hypertensive crisis.

8. Mental Health Disorders in Older Adults

   • Common disorders include:

     • Depression

     • Anxiety

     • Delirium

     • Dementia

     • Substance abuse.

9. Ageism’s Effect on Care

   • Discuss how negative stereotypes about aging may affect willingness to engage in treatment for older adults.

10. Clinical Picture of Delirium vs. Dementia

    • Compare:

      • Delirium: Acute onset, fluctuating attention, often reversible.

      • Dementia: Gradual onset, progressive cognitive decline, usually irreversible.

11. Nursing Diagnoses and Interventions for Delirium, Dementia, and Alzheimer's

    • Identify at least three tailored diagnoses and outcomes for nursing care, focusing on safety, orientation, and therapeutic communication.

12. Symptoms of Alzheimer's Disease Progression

    • Amnesia: Memory loss, especially short-term.

    • Apraxia: Difficulty with motor tasks despite having the desire to perform them.

    • Agnosia: Inability to recognize objects or persons.

    • Aphasia: Impairment in language abilities affecting speaking and understanding.

General Antidepressants: SSRIs and SNRIs

Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are among the most commonly prescribed antidepressants due to their generally favorable side effect profiles compared to older classes.

• Indications: Primarily used for major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and social anxiety disorder. SNRIs are also often used for chronic pain (neuropathic pain, fibromyalgia).

• Mechanism of Action:

  • SSRIs block the reuptake of serotonin (5-HT) into the presynaptic neuron, increasing serotonin concentration in the synaptic cleft.

  • SNRIs block the reuptake of both serotonin and norepinephrine, increasing the levels of both neurotransmitters.

• Side Effects:

  • Common: Nausea, diarrhea, insomnia or somnolence, headache, sexual dysfunction (very common with SSRIs), weight changes.

  • Less Common/More Serious: Serotonin syndrome (especially with other serotonergic drugs), increased risk of bleeding (due to platelet effects), hyponatremia (especially in elderly), QTc prolongation (some SSRIs/SNRIs).

• Contraindications/Interactions:

  • Contraindications: Concurrent use with MAOIs (risk of serotonin syndrome). Certain SSRIs (e.g., fluoxetine) have long half-lives. Caution in patients with seizure disorders, severe liver/renal impairment.

  • Interactions: Other serotonergic drugs (e.g., triptans, tramadol, linezolid, St. John's Wort) due to serotonin syndrome risk. NSAIDs/anticoagulants (increased bleeding risk). CYP450 inhibitors/inducers (can alter drug levels).

Tricyclic (TCA) Antidepressants

TCAs are older antidepressants with broader pharmacological actions, which contribute to both their efficacy and their less favorable side effect profile.

• Indications: MDD (especially severe or melancholic depression), neuropathic pain, migraine prophylaxis, OCD (clomipramine), insomnia.

• Mechanism of Action: Block the reuptake of norepinephrine and serotonin. They also block histamine (H1), acetylcholine (muscarinic), and alpha-1 adrenergic receptors, which accounts for many of their side effects.

• Side Effects:

  • Anticholinergic: Dry mouth, blurred vision, urinary retention, constipation, confusion (especially in elderly).

  • Antihistaminergic: Sedation, weight gain.

  • Alpha-1 blockade: Orthostatic hypotension, dizziness.

  • Cardiac: QTc prolongation, arrhythmias (risk in overdose, narrow therapeutic index).

  • Other: Seizures (lowered seizure threshold), sexual dysfunction.

• Contraindications/Interactions:

  • Contraindications: Recent myocardial infarction, severe heart block, glaucoma, prostatic hypertrophy, concurrent MAOI use.

  • Interactions: Other CNS depressants (additive sedation), anticholinergic drugs (additive effects), antihypertensives (orthostatic hypotension), CYP450 inhibitors/inducers.

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs are a potent class of antidepressants, typically reserved for treatment-resistant depression due to their strict dietary restrictions and significant drug interactions.

• Indications: Atypical depression, treatment-resistant depression, panic disorder with agoraphobia.

• Mechanism of Action: Inhibit the enzyme monoamine oxidase (MAO-A and MAO-B), which is responsible for breaking down monoamine neurotransmitters (norepinephrine, serotonin, dopamine, tyramine) in the presynaptic terminal, leading to increased levels of these neurotransmitters.

• Side Effects:

  • Common: Orthostatic hypotension, dizziness, insomnia, weight gain, sexual dysfunction.

  • Serious: Hypertensive crisis (from tyramine-containing foods or sympathomimetics), serotonin syndrome (with serotonergic drugs).

• Contraindications/Interactions:

  • Contraindications: Cerebrovascular disease, pheochromocytoma, history of recurrent headaches, concurrent use of many medications (e.g., SSRIs, SNRIs, TCAs, sympathomimetics), general anesthesia without appropriate washout period.

  • Interactions:

    • Food Interactions (Tyramine-rich foods): This is the class with many food interactions! MAOIs prevent the breakdown of tyramine, leading to a buildup that can cause a hypertensive crisis (severe headache, palpitations, stiff neck, nausea, vomiting, sweating, high blood pressure). Patients must avoid: aged cheeses, cured meats (salami, pepperoni), fermented products (sauerkraut, soy sauce, fava beans), tap beers, red wine, yeast extracts, and certain overripe fruits.

    • Drug Interactions: Any sympathomimetic (e.g., decongestants like pseudoephedrine, stimulants), SSRIs, SNRIs, TCAs, meperidine (opioid), dextromethorphan (cough suppressant) can lead to hypertensive crisis or serotonin syndrome.

Mood Stabilizers (e.g., Lithium)

Mood stabilizers are primarily used to treat bipolar disorder, aiming to reduce the intensity and frequency of mood swings.

• Indications: Bipolar I and II disorder (acute mania, mixed episodes, and maintenance treatment), adjunctive treatment for depression (especially lithium).

• Mechanism of Action (Lithium): Complex and not fully understood, but involves modulating neurotransmitter systems (serotonin, norepinephrine), second messenger systems (inositol depletion), and neurotrophic factors. It is thought to stabilize neuronal membranes.

• Side Effects (Lithium):

  • Common: Nausea, diarrhea, fine tremor, polyuria/polydipsia (nephrogenic diabetes insipidus), weight gain, cognitive dulling.

  • Serious (often related to toxicity): Coarse tremor, ataxia, slurred speech, confusion, seizures, renal impairment (long-term), hypothyroidism (monitor TSH).

• Contraindications/Interactions (Lithium):

  • Contraindications: Significant renal dysfunction, cardiovascular disease, severe dehydration, concurrent use of diuretics (especially thiazides) or NSAIDs (which can increase lithium levels and toxicity).

  • Interactions:

    • Increased Lithium Levels/Toxicity: NSAIDs (except aspirin), thiazide diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs).

    • Decreased Lithium Levels: Caffeine, theophylline.

    • Increased Risk of Serotonin Syndrome: Concurrent use with SSRIs, SNRIs (though sometimes cautiously co-prescribed).

    • Increased Risk of Neurotoxicity: Antipsychotics, calcium channel blockers.