Mental Health Lecture Note Chapter 2

Alcoholism • The #1 psychological problem is DENIAL • How do you respond/treat to pts in denial? o Confront them by pointing out the difference b/w what they say and what they do o For instance, say something like: “Ok, you say you’re not an alcoholic but it is 10 a.m. and you’ve already had a 6 pack” … It is not the same as aggression. Don’t attack the person o Good answer has “I” … Bad answer has “YOU” o One place where denial is ok—loss and grief Stages of grief are “DABDA”—Denial, anger, bargaining, depression, acceptance The title of this section is alcoholism. However, this rule can be used for any abuse situation 1.So, what it the number 1 psychological problem in child abuse? … In gambling? … In cocaine abuse? … In spousal abuse? … In elder abuse? a. The answer is denial o So when the question is about pt in denial, pay attention to whether you are dealing with loss or abusive situation Support = Loss Confront = Abuse Dependency vs. Co-dependency • The #2 psychological problem is Dependency or Co-Dependency • Dependency: when the get the significant other to do things or make decisions for them o The abuser is dependent • Co-dependency: when the significant other derive self-esteem for doing things or making decisions for the abuser o The significant other is the co-dependent • Dependency and co-dependency has a symbiotic, yet a pathological relationship o The dependent pt get a free ride on the co-dependent o The co-defendant pt feels good from “doing stuff” for the abuser • How do you treat dependency/codependency? o Dependent pts are “abusers” … Confront them o Co-dependent pts have self-esteem issues … Teach pts how to set limits and enforce them o Agree in advance on what requests are allowed then enforce o Teach significant other to say no o Work on self-esteem on the co-dependent person Manipulation • Manipulation is when the abuser gets the significant other to do things or make decisions that are not in the best interests of the significant other o The nature of the act is dangerous and harmful to the significant other • How is manipulation like dependency? o In both situations the dependent person gets the co-dependent person to do things or make decisions o If what the significant other is being asked to do is not inherently dangerous and harmful, then this is dependency/co-dependency o However, if the significant other is being asked to do something inherently dangerous and harmful, then this is manipulation • Manipulation? Set LIMITS and Enforce them Examples Determine if either one of these situations is dependent/co-dependent problem or a manipulation problem • A 49-year-old alcoholic gets her 17-year-old son to go to the store and buy alcohol for her. o The mother is manipulating the son o This is an illegal act = Harmful o Dependency … There are 2 patients o The dependent has a denial issue o The co-dependent has a selfesteem issue • A 49-year-old alcoholic asks her 50-year-old husband to go to the store and buy alcohol for her. o This is not illegal for the husband to buy alcohol o This a dependency/co-dependency situation o Manipulation … There is 1 patient—no self-esteem issues o Easier to treat because no one like to be manipulated Wernicke (Korsakoff) Syndrome Typically, Wernicke and Korsafoff are 2 separate disorders. The NCLEX however bundles the 2 as 1 condition • Wernicke is an encephalopathy • Korsakoff is a psychosis • Wernicke and Korsafoff tend to go together Wernicke and Korsafoff • Psychosis induced by Vitamin B1, thiamine deficiency • This is a situation the pt looses touch with reality due to vit B1 deficiency • The primary S/Sx are amnesia (memory loss) and confabulation (making up stories) o Confabulation—The lies for this pts are just as real as reality How do deal with a pt with Wernicke and Korsafoff who is confabulating about going to a meeting with Barack Obama this morning? • Redirect the pt to something he can do o For instance, tell pt something along that line: “Why can we go watch TV to see what is on the news today” Characteristics of Wernicke and Korsafoff syndrome 1.Preventable … Take B1 2.Arrestable (stop it from getting worse) … Take B1 3.Irreversible (70%) … Will kill brain cells Antabuse and Revia (Disulfiram) • Antabuse—Alcohol deterrent • Revia—Antidote • Aversion (strong hatred) Therapy—a type of behavior therapy designed to make a patient give up an undesirable habit by causing them to associate it with an unpleasant effect o Works in theory better than in reality • Onset (how long it takes to start working) and duration (how long it lasts) of effectiveness of Antabuse/Revia is 2 weeks o For instance, if pt will be at a function and would like to drink, the pt must be on Antabuse/Revia at least 2 weeks prior to the event • Patient teaching o Teach pt to avoid all forms of EtOH. Not doing so may lead to symptoms of n/v, even death o Teach them to avoid the followings items as they contain alcohol … Mouth wash, cologne, perfume, aftershave, elixir, most OTC liquid medicine, insect repellant, hand sanitizer, vanilla extract (can’t have cupcake with unbaked icing) o On the exam, do not pick the Red Wine vinaigrettes … It does not have alcohol in it Overdose and Withdrawal First thing you ask in an overdose question is: Is it an Upper or a Downer? • This is because every abuse drug is either an Upper or a Downer • However, laxative abuse in the elderly is neither an Upper nor a Downer Upper Downer • Caffeine • There are over 135 drugs that are downers • Cocaine • If it is not an upper, it is a downer • PCP/LSD (psychedelics/hallucinogens) • Methamphetamines • Adderall • Memorize these five for the NCLEX Signs and Symptoms Signs and Symptoms • Things go UP! • Things go DOWN! • Euphoria, seizures, restlessness, • Lethargic, respiratory depression/arrest, irritability, hyperreflexia (3+, 4+), constipated, etc. tachycardia, increased bowels (borborygmi), diarrhea What are the highest nursing priority to anticipate in an Upper or Downer? • Upper: The highest priority to anticipate in an Upper is suctioning due to seizures • Downer: The highest priority to anticipate in a Downer is intubation/ventilation due to respiratory arrest Example One of your pt is “high on cocaine.” What is critically important to assess? • Having a RR of 12 is not a critical measurement to assess for that pt • However, assessing for reflexes (3+ or 4+), irritability, borborygmi (increased bowel sounds), or increased temperature would be more appropriate o The “ABC rule” does not apply here … In fact, the pt’s ABC in cocaine toxicity is unremarkable After you know that the drug in question is an Upper or a Downer, the second question you should ask yourself is whether it is an Overdose or a Withdrawal • Overdose and withdrawal have the opposite effects Overdose Overdose on an Upper • Too much Overdose on a Downer • Too little Withdrawal Withdrawal on an Upper • Too little • Too much Withdrawal on a Downer Question The driver of a squad car calls the ER and says he is bringing a pt who in ODed on cocaine. What do you expect to see? … Select all that apply • Pt ODed on Upper OD … Expect to se Too much o First question: Upper or a Downer? o Second question: Overdose or Withdrawal? o S/Sx would be: Irritability, 4+ reflexes, borborygmi, increased temperature, etc. Question The same pt is withdrawing from cocaine … Same question • This pt is an Upper in Withdrawal = Too little • Therefore, respiratory is under 12, pt is difficult to arouse, give them Narcan Drug Abuse in the Newborn Always assume intoxication, not withdrawal at birth, in a newborn less than 24 hours after birth. 24 hours or more after birth, you can assume the newborn is in withdrawal Question You are caring for an infant born to Quaalude addicted mother 24 hours after birth. Select all that apply • Overdose/withdrawal condition … Ask the following 2 questions o Is it an Upper or a Downer? … We don’t what it is because it is a “Quaalude” (it is likely a Downer) o Is it Overdose or Withdrawal? … 24 hours after birth (Withdrawal) o A Downer in Withdrawal = Too much o S/Sx = Difficult to console, seizure risk, shrill, high-pitched cry, exaggerated startle reflex Alcohol Withdrawal Syndrome vs. Delirium Tremens Alcohol Withdrawal Syndrome and Delirium Tremens are not the same • Every alcoholic goes through alcohol withdrawal approximately 24 hours after the person stops drinking • However, less than 20% of alcoholics in alcohol withdrawal syndrome progress to delirium tremens … Delirium tremens occurs about 72 hours after the person stop drinking • Alcohol withdrawal syndrome always precedes delirium tremens; however, delirium tremens does not always follow alcohol withdrawal syndrome Alcohol Withdrawal Syndrome • Occurs after 24 hours after drinking • Non-life threatening to self and others Delirium Tremens • Occurs after 72 hours after drinking • Life threatening to self and others Nursing Care Plan Nursing Care Plan • Regular diet • NPO (seizures) or clear liquid diet • Semiprivate room, anywhere on the unit • Private room, near nursing station • Pt is up ad lib (Pt is free to move around • Restricted bed rest (Pt is not free to move as desired) around as desired—no bathroom) • No restraints • Restraints (vest or 2-point lock letters) Note • “Up ad lib” or “up ad liberum” means pt may have activity or free to move around as desired any time • 2-point lock letters restraints: Restraints in 1 upper and the contralateral lower extremities. Release and secure upper arm first, and then release and secure the foot. Switch extremities every 2 hours • Give both anti-HTN medication, tranquilizer, multivitamin containing vit B1 Question So what two situations would respiratory arrest be a priority? • Overdose of a Downer • Withdrawal of an Upper Question Which pts would seizure be a risk for? • Overdose of an Upper • Withdrawal of a Downers Aminoglycosides (Top 5 most tested drugs) Aminoglycosides are the big guns of ABXs (antibiotics) — use them when nothing else works. Aminoglycosides are unsafe at toxic levels and safety then becomes an issue. They are the 5th most tested drugs on the NCLEX The most testeddrugs on the NCLEX are: • Top 5 o Psychiatric o Insulin o Anticoagulant o Digitalis o Aminoglycosides • Others o Steroids o Beta-blockers o Calcium channel blockers o Pain medications o Obstetrics medications “A Mean Old Mysin” = Aminoglycosides Would be used to treat serious, resistant, life-threatening, Gram negatives infections • So, treat a mean old infection with a “Mean Old Mycin” o Examples are: TB, septic peritonitis, fulminating pyelonephritis, septic shock, infection from third degree wound covering >80% of the body o However, sinusitis, otitis media, bladder infection, viral pharyngitis, and strep throat are not old mean infections and are not treated with a mean old mycin All aminoglycosides end in Mycin • Gentamycin, Vancomycin, and Clindamycin, Streptomycin, Cleomycin, Tobramycin • Not all drugs ending in mycin are aminoglycosides o Azithromycin, Clarithromycin, Erythromycin … All have THRO in the middle … So, THRO them off the “Mean Old Mycin” list What are toxic effects? • Mycin—Sounds like Mice (Think ears) … Monitor hearing (#1), balance, tinnitus (ringing of the ear, CN8 toxicity) • The human ears are shaped like a kidney so another toxic effect of aminoglycosides is nephrotoxicity (Toxic to the kidneys) o Therefore, monitor Creatinine What would be your answer if in a question, you have to choose which is 1.Creatinine = Best indicator of kidney function the best between 24-hour creatinine 2.24-hour creatinine clearance is better than Serum and serum creatinine? creatinine The figure 8 drawn inside the ear should remind you of of 2 things They are toxic to CN8 Administer them q8 hour Do not give Mean Old Mycins PO because they are not absorbed, and therefore would not have any systemic effects There are 2 cases where Mean Old Mycins are given PO • Hepatic encephalopathy (or hepatic coma) where ammonia level gets too high • Pre-op bowel surgery: to sterilize the bowel before surgery • In both cases, the ABX stays in the gut (not absorbed), sterilizes the bowel, and would not be toxic “TAP” Levels • A method to remember what is done before or after, when dealing with a medication with troughs and peaks • “TAP”—Trough, Administer, Peak • o Trough before drug administration o Peak after drug administration o Trough and Peak levels are drawn because of a drug’s narrow therapeutic window or index o Narrow therapeutic window or index means that there is a small difference in what works and what kills Which one of the following medications would “trough and peak” Note 1.Draw TAP on important? Mean Old Mycins o Smaller dose: 5 or 10 because of their • Lasix (furosemide) narrow therapeutic o Larger dose: 80 or 120 index • Digitalis (digoxin) • o Smaller dose: 0.125 o Larger dose: 0.25 o Would draw “TAP” (Trough, Administer, Peak) on digitalis When to Draw a Through and a Peak • Both Trough and Peak are not medication-dependent • The trough, it is always drawn 30 minutes before next dose • For the peak, it depends on the route o Peak SubL 5 to 10 minutes after drug is dissolved o Peak IV 15 to 30 minutes after drug is finished (bag empty) o Peak IM 30 to 60 minutes o Peak SubQ Depends on insulin (See diabetes lecture) o Peak for PO Not necessary, not tested Question You give 100 mL of a drug at 200 mL per hour (the Note drug takes 30 minutes to run). If you hang the drug at 10 a.m., it will finish running at 10:30 a.m. The same drug given by 2 different routes at the same time will have different peaks, however, 2 different drugs given at the same time and route (IV) will peak together. When will the drug peak? 1. 10:15 a.m. 2. 10:30 a.m. 10:45 a.m. 3. 4. 11:00 a.m. Answer: Two right answers—pick 11:00 a.m. In this case, play the “Price Is Right”—go with the highest time w/o going over