ATI Mental Health CMS

ATI Mental Health CMS Chapter 1; Basic Mental Health Nursing Concepts → Assessment Mental Status Exam (MSE) 1) Level of consciousness: - Alert - Lethargic: client can open eyes and respond but is drowsy and falls asleep quickly - Stuporous: client requires vigorous and painful stimuli to elicit brief response - Comatose: unconscious & does not respond to painful stimuli Abnormal posturing in comatose client Decorticate rigidity; flexion & internal rotation of upper extremity joints & legs Decerebrate rigidity; neck & elbow extension, wrist & finger flexion 2) Physical appearance 3) Behavior - Mood: emotion that she is feeling - Affect: objective expression of mood, such as flat affect or lack of facial expression 4) Cognitive & intellectual abilities: orientation, memory, knowledge, calculation, illness perception, judgment, speech - Immediate memory; repeat series of numbers or list - Recent memory: visitors from current day, purpose of current appt - Remote memory: fact from past, DOB, mothers name → Considerations Across The Lifespan Children & Adolescents - Assessment includes temperament social and environmental factors cultural and religious concerns and developmental level. the client should be the source of the information but with children and adolescents caregivers can also provide valuable information. - Mentally healthy children and adolescents trust others view the world as safe accurately interpret their environments master developmental tasks and use appropriate coping skills HEADSSS standardized assessment tool Home environment; Education/employment; Activities; Drug/ substance abuse; Sexuality; Suicide/depression; Safety →Mental Health Diagnoses • The Diagnostic & Statistical Manual of Mental Disorders 5th Edition (DSM-5) - Used by mental health professionals - establishes diagnostic criteria for mental health disorders - identifies expected findings for mental health disorders - used by nurses to plan implement and evaluate care for clients who have mental health disorders • Serious Mental Illness - Includes disorders classified as severe and persistent mental illnesses - Clients often have difficulty with activities of daily living - Are lifelong disorders that can have remissions and exacerbations → Therapeutic Strategies in The Mental health Setting • Counseling; using therapeutic communication skills, assisting with problem solving, crisis intervention, and stress management • Milieu therapy; orienting the client to the physical setting, identifying rules and boundaries of the setting, ensuring a safe environment for the client, and assisting the client to participate in appropriate activities • Promotion of self-care activities; helping with self-care task, allowing time for the client to complete self-care task, and setting incentives to promote client self-care • Psychobiological interventions; administering prescribed medications, providing teaching to the client and family about medications, and monitoring for adverse effects and effectiveness of pharmacological therapies • Cognitive & behavioral therapies; modeling, operant conditioning, systemic disinvitation • Health teaching; teaching social & coping skills • Health promotion & maintenance • Case management; coordinate holistic care to include medical, mental health, & social services Chapter 2; Legal & Ethical Issues → Legal rights of Clients in Mental Health Setting Same civil rights as any other citizen including; - the right to humane treatment and care - right to vote - rights r/t granting, forfeiture, or denial of driver’s license - right to due process of law including right to press charges - right to consent & refuse treatment - confidentiality written plan of care, participation, and discharge follow up right to communicate with others outside facility psychiatric advanced directive → Ethical Issues Bioethics; ethical dilemmas regarding patient care Beneficence: quality of doing good Autonomy; right to make own choices Justice; fair & equal treatment Fidelity: loyalty & faithfulness to client and own duty Veracity; honesty → Types of Admission to Mental Health Facility Criteria for involuntary admission; - presence of mental illness - danger to self or others - demonstrates severe disability or inability to meet basic needs - requires treatment but unable to seek it r/t impact of mental illness Number of physicians required to certify clients conditions varies (usually 2) Limited to 60 days Still considered competent and have the right to refuse. → Clients Rights w/ Seclusion & Restraint When a nurse has tried all other less restrictive means to prevent a client from harming self or others the following must occur in order to use seclusion or restraint; - Prescriber must prescribe seclusion or restrain in writing - Time limits based on age; 18+ (4 hr.), 9-17 (2 hr.), difficulty concentrating*, but learning and problem-solving can still occur –  HR,  RR, change in voice **somatic manifestations like headache, body ache, insomnia →NURSING; Interventions for Mild-Mod Anxiety; Use active listening, provide calm presences, evaluate past coping mechanisms, explore alternatives, encourage participation in activities such as exercise • Severe: perceptual field is greatly reduced (not able to focus on anything except relieving the anxiety) – hyperventilation, tachycardia, loud and rapid speech, aimless activity **not able to take direction from others i.e., sense of impending doom • Panic-level: SOB*, markedly disturbed behavior, lose touch with reality, severe hyperactivity or flight, dilated pupils, delusions, hallucinations →NURSING; Interventions for Severe- Panic Anxiety; Provide environment that meets physical & safety needs, remain w/ client & remain calm, provide quiet environment w/ minimal stimulation, use meds & restraint only after less restrictive interventions have failed, encourage gross motor activities, aet limits by using firm, short simple statements, direct to acknowledge reality Chapter 5; Creating & Maintaining a Therapeutic Environment → Milieu therapy; aka Therapeutic community or therapeutic environment; creates supportive, therapeutic, and safe environment Transference; pt. views nurse as similar to significant person in their life Countertransference; nurse displaces feelings relating to people in past onto pt. Phases and tasks of a therapeutic relationship: - Orientation: set the contract, establish boundaries, discuss confidentiality, build trust, develop/set goals, EXPLORE CLIENTS IDEAS/ISSUES/NEEDS, enforce limits, start the relationship with patient Working: maintain the relationship, reassess problems & goals; revise as necessary Termination: discussion, summarize goals and achievements Chapter 6; Diverse Practice Setting → Settings for Mental Health • Acute Care; provides intensive treatment & supervision in locked units for clients who have severe mental illness, who present danger to self or others • Community; primary care is provided in community based settings; i.e.. clinics, schools, day care centers, partial hospitalization programs, substance treatment, forensic settings, home health Acute Mental Health Settings; Criteria to justify admission Clear risk of the clients danger to self or others Inability to meet own basic needs Failure to meet expected outcomes of community based treatment A dangerous decline in the mental health status of client undergoing long term treatment A client w/ a medical need in addition to a mental illness Community Health Settings • Levels of Prevention - Primary; promotes health - Secondary; focuses on early detection - Tertiary; focuses on rehabilitation & prevention of further problems Community Based Mental Health Programs • Partial Hospitalization programs; provide intense short term treatment for clients who are well enough to go home every night and who have a responsible person at home to provide support and a safe environment • • • Assertive Community Treatment (ACT); includes nontraditional case management and treatment by interprofessional team for severe mental illness and are non-compliant; helps to reduce recurrence of hospitalizations & provide crisis intervention assistant with independent living & information regarding resources for support Community Mental Health Centers; provide variety of services for a ride range of community clients including educational groups medication dispensing programs and individual and family Psychosocial Rehabilitation programs; provide a structured range of programs for clients in a mental health setting including residential services and day programs for older adults Ch 7; Psychoanalysis, Psychotherapy, & Behavioral Therapies →Psychoanalysis • Classical psychoanalysis: therapeutic process of assessing unconscious thoughts and feelings, and resolving conflict by talking to a psychoanalyst – months to years - Past relationships are common focus** - Help find the cause of the anxiety** • Psychoanalysis Therapeutic Tools: - Free association: spontaneous, uncensored verbalization of whatever comes to client’s mind - Dream analysis and interpretation urges and impulses of the unconscious mind - Use of defense mechanisms - Transference →Psychotherapy; more verbal therapist to client interaction than classic psychoanalysis • Psychodynamic psychotherapy; uses same tools as psychoanalysts but focuses more on the client's present state rather than early life • Interpersonal psychotherapy (IPT); assist clients in addressing specific problems can improve interpersonal relationships communication relationship and bereavement • Cognitive Therapy: focuses on individual thoughts and behaviors to solve current problems (depression, anxiety, eating disorders, other issues that can improve by changing a client’s attitude toward life experiences) - Priority restructuring - Assertiveness training - Journal keeping - Monitoring thoughts • Behavioral Therapy: Modeling: imitates therapist to improve behavior Operant Conditioning: positive rewards for positive behavior Systematic Desensitization**: exposure to events that cause anxiety then practicing RELAXATION techniques Aversion Therapy**: pairing of a bad behavior with a punishment or unpleasant stimuli to promote change (ex. electric shock, Disulfiram for alcohol use) • Biofeedback: behavioral therapy to control pain, tension, and anxiety uses mechanical device to help gain voluntary control over autonomic such as HR, pulse, BP • Other Techniques Flooding: great deal of undesirable stimuli in attempt to turn off anxiety response Ch 8; Group & Family Therapy Types of Families • Nuclear families: Include children who reside with married parents • • • • • • Single-parent families: Include children who live with a single adult that can be related or nonrelated to the children Adoptive families: Include children who live with parents who have adopted them Blended families: Include children who live with one biological or adoptive parent and a nonrelated stepparent who are married Cohabitating families: Include children who live with one biological parent and a nonrelated adult who are cohabitating Extended families: Include children living with one biological or adoptive parent and a related adult who is not their parent (grandparent, aunt, uncle) Other families: Include children living with related or nonrelated adults who are neither biological nor adoptive parents (grandparents, adult siblings, foster parents) Dysfunctional Families - Blaming: Members blame others to shift focus away from their own inadequacies. - Manipulating: Members use dishonesty to support their own agendas. - Placating: One member takes responsibility for problems to keep peace at all costs. - Distracting: A member inserts irrelevant information during attempts at problem solving. - Generalizing: Members use overall descriptions (“always” and “never”) in describing family encounters. - Scapegoating: A member of the family with little power is blamed for problems within the family. For example, one child who has not completed their chores can be blamed for the entire family not being able to go on an outing. - Triangulation: A third party is drawn into the relationship with two members whose relationship is unstable. For example, one parent can develop an alliance with a child, leaving the other parent relatively uninvolved with both. - Multigenerational issues: These are emotional issues or themes within a family that continue for at least three generations (a pattern of substance use or addictive behavior, dysfunctional grief patterns, triangulation patterns, divorce). Ch 9; Stress Management Assessment • Acute Stress (Fight or Flight): apprehension, unhappiness/sorrow, decrease appetite, increase respiratory rate, increase heart rate, increase CO, increase bp, increase metabolism and glucose use, depressed immune system • Prolonged Stress (Maladaptive Response): chronic anxiety or panic attacks, depression, chronic pain, sleep disturbances, weight gain or loss, increase risk for MI and stroke, poor diabetes control, hypertension, fatigue, irritability, decrease ability to concentrate, increase risk for infection Stress Reduction Strategies • Cognitive techniques - Cognitive Reframing; client. Helped look at irrational cognitions (thoughts) in a more realistic light & to restructure those thoughts in a more positive way • Relaxation Techniques; - Guided imagery: The client is guided through a series of images to promote relaxation. Images vary depending on the individual. For example, one client might imagine walking on a beach, while another client might imagine themselves in a position of success. - Breathing exercises are used to decrease rapid breathing and promote relaxation. - Progressive muscle relaxation: A person trained in this method can help a client attain complete relaxation within a few minutes. - Physical exercise (yoga, walking, biking) causes release of endorphins that lower anxiety, promote relaxation, and have antidepressant effects. Ch 10; Brain Stimulation Therapies Electroconvulsive Therapy (ECT): Major depressive disorder, Schizo, Acute manic episodes, Bipolar, suicidal - THREE TIMES A WEEK, 6-12 treatments - Meds: -30 min before, give IM of Atropine (antimuscarinic) or Glycopyrrolate to decrease secretions that can cause aspiration and to counteract vagal stimulation (bradycardia) - anesthetic: Methohexital or Propofol via IV bolus - muscle relaxant: Succinylcholine – paralyze muscles/dec injury - Contra; Cardiovascular disorders, Cerebrovascular disorders → FASTING due to sedation, will become alert w/in 15min after procedure, not a cure; give oxygen, monitor vitals and mental status before and after, monitor EEG (A/E: cardiac problems), place on side to prevent aspiration – make sure gag reflex is back! A/E: HYPERTENSION, short-term memory loss and confusion, headache, muscle soreness, nausea Transcranial Magnetic Stimulation (TMS): noninvasive electromagnetic placed on scalp – alert during procedure - DAILY for 4-6weeks - Not associated with systemic adverse effects or neurological deficits Vagus Nerve Stimulation (VNS): electrical stimulation through surgically implanted device A/E: voice changes, hoarseness, throat or neck pain, dysphagia, dyspnea Education: turn off VNS during exercise or when periods of prolonged speaking Ch 11; Anxiety Disorders Anxiety Disorders • Separation anxiety disorder: excessive fear or anxiety when separated from an individual to which the client is emotionally attached. • Specific phobias: an irrational fear of a certain object or situation. Specific clinical names are used to refer to specific phobias (monophobia = phobia of being alone; zoophobia = phobia of animals; acrophobia = phobia of heights). • Agoraphobia: extreme fear of certain places (the outdoors or being on a bridge) where the client feels vulnerable or unsafe. • Social anxiety disorder (social phobia): experiences excessive fear of social or performance situations. • Generalized Anxiety Disorder: uncontrollable, excessive worry for SIX months restlessness, muscle tension, avoidance of stressful stuff, increased time and effort required to prepare for stressful stuff, procrastination in decision making, seeks repeated reassurance • Panic disorder: attacks last 15-30min - FOUR OR MORE manifestations: palpitations, SOB, choking or smothering sensation, chest pain, nausea, feelings of depersonalization, fear of dying or insanity, chills, or hot flashes Obsessive Compulsive Disorders • Obsessive compulsive disorder (OCD): intrusive thoughts of unrealistic obsessions and tries to control these thoughts with compulsive behaviors, such as repetitive cleaning of a particular object or washing of hands. • • Hoarding disorder: The client has difficulty parting with possessions, resulting in extreme stress and functional impairments. Body dysmorphic disorder: The client has a preoccupation with perceived flaws or defects in physical appearance. Medications • SSRI antidepressants, (sertraline or paroxetine); first line treatment of anxiety &obsessive- compulsive disorders. • SNRI antidepressants, (venlafaxine or duloxetine); effective in the treatment of anxiety disorders. • Antianxiety medications; helpful in treating the manifestations of anxiety disorders. - Benzodiazepines (diazepam) are indicated for short-term use - Buspirone is effective in managing anxiety and can be taken for long-term treatment of anxiety. • Other medications that can be used to treat anxiety disorders include beta blockers and antihistamines to decrease anxiety. Anticonvulsants are used as mood stabilizers for the client who is experiencing anxiety. Ch 12; Trauma & Stressor Related Disorders Specific Disorders • Acute Stress Disorder: at least THREE days but not more than ONE month • Posttraumatic stress disorder (PTSD): longer than ONE month and can last YEARS -Avoid caffeine, alcohol • Adjustment disorder: A stressor triggers a reaction causing changes in mood and/or dysfunction in performing usual activities. The stressor and effects are less severe than with ASD or PTSD. • Dissociative disorders - Depersonalization/derealization disorder: characterized by a temporary change in awareness displaying depersonalization, derealization, or both, often in response to stress Depersonalization: observe their own body from a distance – detached from own’s body Derealization: disconnected from environment – ex. furniture in room is small and far away - Dissociative amnesia: Inability to recall personal information related to traumatic or stressful events. The amnesia can be of events of a certain period of time or just certain details. - Dissociative fugue: A type of dissociative amnesia in which the client travels to a new area and is unable to remember one’s own identity and at least some of one’s past. Can last weeks to months and usually follows a traumatic event. - Dissociative identity disorder: Client displays more than one distinct personality, with a stressful event precipitating the change from one personality to another. Ch 13; Depressive Disorders Depressive Disorders • Major Depressive Disorder (MDD): at least 5 of the findings & occur almost every day for min 2 weeks and last almost all day - depressed mood, difficulty sleeping or excessive sleeping, indecisiveness, dec ability to concentrate, suicidal ideation,  or  in motor activity, inability to feel pleasure (anhedonia),  or  in weight of more than 5% of total body weight over 1 month - Psychotic features: The presence of auditory hallucinations (such as voices telling the client they are sinful) or the presence of delusions (such as the client thinking that they have a fatal disease) - • • • • • Postpartum onset: A depressive episode that begins within 4 weeks of childbirth (known as postpartum depression) and can include delusions, which can put the newborn infant at high risk of being harmed by the mother Acute phase: severe clinical findings of depression & may need hospitalization o treatment: 6-12w goal: reduction of depressive manifestations; assess suicide risk Continuation phase: increased ability to function of treatment: 4-9m goal: relapse prevention* Maintenance phase: remission of manifestations treatment: years goal: prevention of future episodes Dysthymic Disorder: mild depression, can be early onset (childhood or adolescence); TWO YEARS (adults; 1yr child) + THREE findings; can become MDD -Depression more common in females and unmarried people Seasonal affective disorder (SAD): depression that occurs seasonally, usually during winter, when there is less daylight. Light therapy is the first-line treatment for SAD. Persistent Depressive Disorder (previously known as dysrhythmic disorder): milder form of depression, usually has an early onset (in childhood or adolescence) and lasts at least 2 years for adults (1 year for children). Persistent depressive disorder contains at least three clinical findings of depression and can become major depressive disorder. Premenstrual dysphoric disorder (PMDD): depressive disorder associated with the luteal phase of the menstrual cycle. The prevalence of premenstrual dysphoric disorder is 2-6% of menstruating clients and causes problems that can be severe enough to interfere with the ability of a client to work or interact with others. -S/S; mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating; lack of energy, overeating, hyper- or insomnia, breast tenderness, aching, bloating, and weight gain. -Treatment; exercise, diet, and relaxation therapy. Substance-induced depressive disorder: Clinical findings of depression that are associated with the use of, or withdrawal from, drugs and alcohol. Ch 14; Bipolar Acute phase: acute mania & may need hospitalization goal: reduction of mania and client safety; assess suicide risk; one-to-one may be required Continuation phase: remission of manifestations treatment: 4-9m goal: relapse prevention Maintenance phase: increased ability to function treatment: years goal: prevention of future episodes Behaviors • Mania: abnormally elevated mood and hospitalization required – 1 week+ • Hypomania: less severe and lasts 4days+ plus 3+ mania manifestations, less impaired • Rapid cycling: four or more episodes within 1 year Types • • • Bipolar I: at least 1 episode of mania alternation with MDD Bipolar II: 1 or more hypomanic disorder alternating with MDD Cyclothymic: hypomanic manifestations (not an actual episode) with minor depressive episodes for 2y+ →NURSING: frequent rest periods, portable nutritious food (finger foods), high calorie drinks, decrease stimulation, seclusion sometimes necessary, step-by-step reminders for dress and hygiene monitor fluid intake, sleep, nutrition consistent client behavior expectations, offer concise explanations, establish consistent limits use firm, calm, matter of fact, specific approach with communication Ch 15; Psychotic Disorders (Schizophrenia) Schizophrenia: psychotic thinking or behavior present for at least 6 months Schizotypal personality disorder: impairments of personality (self and interpersonal) functioning; impairment not as severe as with schizophrenia. Delusional disorder: delusional thinking for at least 1 month; self or interpersonal functioning is not markedly impaired. Brief psychotic disorder: psychotic manifestations that last 1 day to 1 month in duration. Schizophreniform disorder: manifestations similar to schizophrenia, but the duration is 1 to 6 months, and social/occupational dysfunction might not be apparent. Schizoaffective: Schizo + Depressive Disorder or Bipolar disorder Expected Findings Positive symptoms: not normally present ex. hallucinations, delusions, alterations in speech, bizarre behavior Negative symptoms: Absence of things that are normally present (more difficult to treat!!!) ex. blunted or flat affect, alogia (poverty of thought or speech), anergia (lack of energy), anhedonia (lack of pleasure/joy), avolition (lack of motivation) Cognitive symptoms: problems with thinking Affective symptoms: emotions ex. hopelessness and suicidal ideation Alterations in Thoughts (Delusions): • Ideas of reference: occurrences in the environment are about or because of them - misconstrues trivial events and attaches personal significance to them (believing others are talking about him but actually talking about something else) • Persecution: someone or something wants to INTENTIONALLY HURT them - feels singled out for harm by others (being hunted down by FBI) • Grandeur: believes that she is all powerful and important (believes they’re a god) • Somatic delusions: believes body changing in unusual way (growing third arm) • Jealousy • Being controlled • Thought broadcasting; believes their thoughts are heard by others • Thought insertion; believes others’ thoughts inserted in their mind • Thought withdrawal; believes that their thoughts have been removed from mind by outside agency • Religiosity • Magical thinking*: believes their action or thoughts are able to control a situation or affect others Alterations in Speech • Flight of ideas: associative looseness. sentence after sentence but related to different topics. listener unable to follow client’s thoughts • Neologisms: made up words that have meaning only to client • Echolalia: repeat words of someone else = imitation • Clang association: rhyming (clang bang) • Word salad: words jumbled together with little meaning or significance Alterations in Speech • Auditory: Hearing voices or sounds - Command: The voice instructs the client to perform an action (to hurt self or others). • Visual: Seeing persons or things • • • Olfactory: Smelling odors Gustatory: Experiencing tastes Tactile: Feeling bodily sensations Alterations in Behavior • Extreme agitation, including pacing and rocking • Stereotyped behaviors: Motor patterns had meaning to pt. (sweep floor) but now mechanical & lack purpose • Automatic obedience: Responding in a robot-like manner • Waxy flexibility: Maintaining a specific position for an extended period of time • Stupor: Motionless for long periods of time, coma-like • Negativism: Doing the opposite of what is requested • Echopraxia: Purposeful imitation of movements made by others • Catatonia: Pronounced decrease or increase in the amount of movement. Muscular rigidity, or catalepsy, may be so severe that limbs remain in whatever position they are placed. • Motor retardation: Pronounced slowing of movement • Impaired impulse control: Reduced ability to resist impulses • Gesturing or posturing: Assuming unusual and illogical expressions • Boundary impairment: Impaired ability to see where one person’s body ends and another’s begins Screening Tools • AIMS: Abnormal Involuntary Movement Scare – monitor involuntary movements and tardive dyskinesia in pts taking antipsychotics Effective Communication - “I don’t hear anything, but you seem to be feeling frightened” but DON’T say “the voices are not real, or else we would both hear them” - “I can’t imagine that the President would have a reason to kill a citizen, but it must be frightening for you to believe that” →Okay to manage symptoms by interacting with auditory or visual hallucination and telling it to go away or stop Ch 16; Personality Disorders Defense mechanisms: repression, suppression, regression, undoing, splitting - Splitting: inability to incorporate positive and negative aspects of oneself or others into a whole image; ass. with Borderline Personality Disorder; Characterize person as all good or all bad. - Regression: dysfunctional attempt to reduce anxiety and conflict by returning to less mature behaviors that help the client better tolerate the anxiety; i.e., 5 yr. old wetting bed - Repression: unconscious removal of thoughts or memories from one’s awareness Risk factors: substance use disorder, crimes/sex offences • Cluster A (odd or eccentric traits) - Paranoid - Schizoid: may isolate themselves - Schizotypal: may isolate themselves but also have magical thinking, ideas of reference, illusions, etc. • Cluster B (dramatic, emotional, or erratic traits) - Antisocial: limit setting and consistency (for any manipulative behavior); exploitation and manipulation of others, failure to accept personal responsibility - Borderline: limit setting and consistency - Histrionic: they’re super “extra”, can be flirtatious – use assertiveness training and remodeling - Narcissistic: indecisiveness, grandiose thinking, lack of empathy, exploits others, self-centered • Cluster C (anxious or fearful traits; insecurity or inadequacy) - Avoidant: anxiety in social situations, fear of rejection - Dependent: self-assess frequently for countertransference; use assertiveness training and remodeling - Obsessive-Compulsive Case management: - Acute care facility: obtain pertinent history from providers, support reintegration with family, ensure appropriate referrals to outpatient care - Long term outpatient facility reducing hospitalization by providing resources for crisis services, enhancing social support system. Ch 17; Neurocognitive Disorders Types of Neurocognitive Disorders • Delirium: rapid over short period of time, worse at night/early morning, change in vital signs, secondary to another medical condition (infection, malnutrition, depression, etc.), change in LOC – REVERSIBLE s/s; tachycardia, elevated bp, sweating, dilated pupils, electrolyte imbalance • Mild Neurocognitive Disorder • Major Neurocognitive Disorder (Dementia): gradual over months or years, sundowning may occur - IRREVERSIBLE - Alzheimer’s Disease: neurodegenerative Defense Mechanisms • Denial • Confabulation: client makes up stories when questioned about events or activities that she doesn’t remember – for self-esteem bc doesn’t remember • Perseveration: client avoids answering questions by repeating phrases or behavior – also self-esteem →NURSING: close to windows and nurses station; clocks, calendars, pictures, familial objects – NO MIRRORS; consistent daily routine; consistent caregivers; reinforce reality, orientation to time and place, limit number of choices, minimize need for decision making and abstract thinking to avoid frustration; caution with PRNs for agitation and anxiety Medications: • Cholinesterase inhibitor: Donepezil, Rivastigmine, Galantamine MOA: increase Ach** – slows cognitive deterioration and improve cognitive function in early stages A/E: N/V, diarrhea,  HR, syncope, bronchospasm, fluid volume deficit, monitor pulse, check for heart disease →NURSING: titrate dose so start low then gradually increase; taper med; Donepezil: once daily AT BEDTIME * Caution: asthma, COPD Contra; NSAIDs • Memantine: block Ca into nerve cells and slow down brain cell death A/E: dizziness, HA, confusion, constipation →NURSING: remove rugs, put locks, water heater low, good lighting, mattress on floor, remove clutter, secure electrical cords to baseboards, cleaning supplies stored in locked cupboards, install handrails Ch 18; Substance Use & Addictive Disorder → Substance Related Disorders comprise 2 groups; • Substance- Use Disorders; addiction - A compulsive or chronic requirement, need so strong as to generate distress if unfulfilled - Substances include; including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedativehypnotics or anxiolytics, stimulants, and tobacco (nicotine) - Individuals are considered to have a substance use disorder when in interferes with the ability to fulfill role obligations that work school or home; when increasing amounts are required to produce desired effects, when characteristic withdrawal symptoms develop upon cessation or drastic decrease in use - Characterized by; compulsive substance seeking & use, substance use despite harmful consequences, tendency to relapse • Substance- Induced Disorders; intoxication, withdrawal, delirium, neurocognitive disorder, psychosis, bipolar disorder, depressive disorder, obsessive-compulsive disorder, anxiety disorder, sexual dysfunction, and sleep disorders Predisposing Factors; unknown, genetics, biochemical changes, developmental influences (punitive superego; fixation in the oral stage of psychosexual development), personality factors (low self-esteem, frequent depression, passivity, inability to relax or defer gratification, inability to communicate effectively), social learning, conditioning, & cultural & ethnic influences Ch 19; Eating Disorders Anorexia; prolonged loss of appetite Characterized by morbid fear of obesity; depression, anxiety, or irritability may be present s/s; gross distortion of body image, preoccupation with food, & refusal to eat; hypothermia, bradycardia, hypotension with orthostatic changes, peripheral edema, lanugo (fine, neonatal-like hair growth), bone fractures, acrocyanosis (bluish color to hands and feet related to poor circulation), variety of metabolic changes; Amenorrhea usually follows weight loss, may happen early Bulimia; excessive, insatiable appetite Bulimia nervosa; episodic, uncontrolled, compulsive, rapid ingestion of large amount of food over short period followed by inappropriate compensatory behaviors to get rid of the excess calories - May fast or exercise excessively - Persistent overconcern with personal appearance, mainly how others perceive them - Most are normal weight, some slightly under or overweight - Common comorbidities; Depression, anxiety, substance abuse - About 50 % have had history of anorexia Binge Eating Disorder (BED); episodes of binge eating similar to bulimia, but DOES NOT include compensatory purging; risk for substantial weight gain - Binge time period; less than 2 hours; - Often accompanied by guilt & depression - Improvement rates higher than bulimia Predisposing Factors; genetics, physiological factors, family dynamics, environmental & lifestyle factors Criteria for Acute Care Treatment - Malnutrition: Twenty percent below expected weight for height recommended for inpatient treatment; 30% below expected weight for height recommended for long-term intensive treatment - Dehydration: Assessment includes thirst, orthostatic hypotension, tachycardia, elevated sodium levels, and other symptoms - Severe electrolyte imbalance: Potassium levels below 3 mmol/L, phosphate levels below 3 mg/dL, magnesium levels below 1.4 mEq/L, calcium below 7 mg/dL - Cardiac arrhythmia: ST segment and T wave changes usually related to electrolyte imbalances - Severe bradycardia: Below 50 beats per minute - Hypothermia: Body temperature below 96.8 - Hypotension: A pattern of low blood pressure or orthostatic hypotension (20 mm Hg or greater drop in systolic blood pressure with positional changes and pulse rate increase by 20 or more beats) - Suicidal ideation Ch 20; Somatic Symptom & Related Disorders - Associated with severe anxiety; Anxiety is repressed and manifested in the form of symptoms & behavior associated w/ these disorders Somatic Symptoms Disorder (SSD): characterized by physical signs and symptoms suggesting medical disease but without demonstratable origins of pathology; Nursing care aimed at relief of discomfort of physical s/s Dissociative Disorders: a disruption in the usual integrated functions of consciousness, memory & identity Nursing care aimed at restoring normal thought processes Type of Somatic Symptom Disorders • SSD; syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long term seeking medical care • chronic disorder and anxiety, depression, and suicidal ideation often manifested • common complications include drug abuse & dependence • Personality characteristics heightened emotionality, strong dependency needs & preoccupation with self and s/s • Illness Anxiety Disorder; unrealistic or inaccurate interpretation of physical symptoms leading to preoccupation & fear of having a serious disease • Behavioral responses are exaggerated and unrealistic • Anxiety & depression are common; OCD traits often accompany • Conversion Disorder; loss or change in body function that cannot be explained by any known medical disorder - Most obvious & “classic” symptoms suggest neurological disease - Some instances may be precipitated by stress • Factitious Disorder; aka Munchausen syndrome; conscious, intentional faking of physical and/or psychological symptoms; Pretend to be ill to receive emotional care and support → Predisposing Factors Associated w/ SSD - Genetic; possible ass. w/ SSD, conversion disorder, & illness anxiety disorder - Biochemical; decreased levels of serotonin & endorphins may play role in SSD, mainly pain - Neuroanatomical; Brain dysfunction has been a factor of factitious disorder - Psychodynamic Theory; suggests illness anxiety disorder is an ego defense mechanism; physical complaints of low self-esteem & feeling of worthlessness; conversion disorder may represent emotions ass. With a traumatic event that is to unacceptable to express & converted into physical s/s - Family Dynamics; in dysfunctional families when a child becomes ill the focus shifts from the open conflict to the child’s illness; somatization brings some stability to the family & positive reinforcement to the child - Learning Theory; somatic complaints reinforced when ill person realizes they • May avoid stressful obligations or unwanted duties (primary gain) • May become focus of attention due to illness (secondary gain) • May relieve conflict within the family as concern is shifted (tertiary gain) - Transactional Model of Stress/ Adaptation; cause of SSD influenced by multiple factors Types of Dissociative Disorders • Dissociative amnesia; inability to recall important personal information that is too extensive to be explained as ordinary forgetfulness & is no due to the direct effects of substance use, a neurological disorder, or other medical conditions; Onset often follows psychosocial stress -Dissociative fugue; sudden unexpected travel away from home with inability to recall some or all of past • Dissociative Identity Disorder (DID); the existence of two or more personalities within one person; Transition from one personality to another is usually sudden, drastic, and precipitated by stress • Depersonalization-Derealization Disorder; a temporary change in the quality of self-awareness that takes the form of feelings of unreality, changes in body image, feelings of detachment from environment, sense of observing self from outside the body - Depersonalization; disturbance in self perception - Derealization; alteration in perception of external environment - s/s often accompanied by; anxiety & depression, fear on insanity, obsessive thoughts, somatic complaints, disturbance in subjective sense of time →Predisposing Factors to Dissociative Disorders - Genetics; possible ass. w/ DID; dissociative amnesia may be r/t neurophysiological dysfunction - Psychodynamic Theory; dissociate behaviors are a defense against unresolved painful issues - Psychological Trauma; the cause of DID as set of traumatic experiences that overwhelm capacity to cope by any means other than dissociation; DID is thought to be a survival strategy for children Ch 21; Medications for Anxiety & Trauma & Stressor Related Disorder Anxiety Meds • Benzodiazepines: “AM” ex. Lorazepam*, Clonazepam, Alprazolam, Diazepam*, & Chlordiazepoxide* - For anxiety, panic disorders, seizures, muscle spasms, alcohol withdraw, anesthesia MOA: increase effects of GABA (reducing neuron activity) A/E: CNS depression (SEDATION, lightheadedness, ataxia, dec cognitive function), anterograde amnesia (difficulty recalling events after dosing), dizziness - Oral Toxicity: drowsiness, lethargy, CONFUSION - IV Toxicity: RESPIRATORY DEPRESSION**, severe HYPOTENSION, cardiac arrest dependency, withdrawal (taper off) Education: only short term use (7-10days), at bedtime, takes 2 nights for effects, do not stop abruptly; avoid alcohol and hazardous activities; do not chew or crush sustained-release tablets (swallow whole)* **Antidote - Flumazenil** (=benzodiazepine receptor antagonist. Administer the medication via IV bolus, titrating doses as needed, for a maximum of 3 mg. However, the medication can precipitate seizures and might not reverse respiratory depression, so airway support may be necessary.) • Atypical anti-anxiety: Buspirone - For anxiety, panic disorder, OCD, PTSD A/E: dizziness, nausea, headache, lightheadedness, agitation Education: no dependency so can be used LONG-TERM --- taken on scheduled basis and not as PRN; can take 2-4w and up to 6w for effects **HINT: PAM has anxiety, so she takes benzos but are not long term so takes BUS to PIER for longer effect • Other Anti-anxiety meds: SSRIs, SNRIs Ch 22; Medications for Depressive Disorders SSRIs: “INE” ex. Fluoxetine* (Prozac), Paroxetine (Paxil), Sertraline* (Zoloft), Citalopram* (Celexa), Fluvoxamine (Luvox) - inhibits serotonin reuptake so increases serotonin in the body; For: anxiety, OCD, depression, PTSD A/E: nausea, fatigue, weight gain for long term treatment, sexual dysfunction (anorgasmia, impotence, decreased libido), CNS stimulation (inability to sleep, agitation, anxiety), INSOMNIA (Paroxetine only – take at morning), bruxism (use mouth guard), skin rash, SEROTONIN SYNDROME (agitation, tachycardia, hallucinations, fever, diaphoresis, tremors, seizures, diarrhea, abdominal pain, coma) **Withdrawal Syndrome: HA, nausea, visual disturbances, anxiety, dizziness, tremors Education: take in the MORNING*, with food if GI upset, tell pt. about sexual A/E (may need to reduce dose or go on medication holiday) and suicidal ideation (monitor for deepened depression), 4w+ for effects, never abruptly stop meds (need to taper to avoid withdrawal syndrome) Contra: TCAs, MAOIs, St John’s wort, NSAIDs* (take acetaminophen instead)*, Warfarin, lithium Atypical antidepressants: Bupropion**, Trazodone - For: depression, used to stop smoking MOA: inhibit norepinephrine and dopamine reuptake so increases in the body A/E: INSOMNIA**, weight LOSS*, GI distress, HA, dry mouth, constipation,  HR, nausea, restlessness, seizures - Sedation w/ Trazodone* (bedtime – used to treat insomnia) Education: appetite suppression Contra: MAOIs, seizures** TCAs: Amitriptyline**, Doxepin, Nortriptyline, Amoxapine, plus other amine - For: depression, neuropathy, fibromyalgia, anxiety, insomnia MOA: inhibit norepinephrine and serotonin reuptake so increases in the body A/E: ANTICHOLENERGIC** (dry mouth, blurry vision, photophobia, tachycardia, urinary retention/hesitancy, constipation); sedation, ORTHOSTATIC HYPOTENSION** - Toxicity*: cardiac dysrhythmias, mental confusion, agitation, seizures -  seizure threshold - Expected findings (NORMAL): excessive sweating,  appetite Education: to counteract anticholinergic then chew gum, fluids, high fiber, sunglasses; take at BEDTIME* Contra: MAOIs, SSRIs, St John’s wort, antihistamines or other anticholinergic agents, CNS depressants HINTT: AMY Trips on Things MAOIs: PIT => Phenelzine**, Isocarboxazid, Tranylcypromine - For: depression A/E: CNS stimulation (agitation, anxiety, hypomania, mania), orthostatic hypotension, HYPERTENSIVE CRISIS ( BP/HR, headache, N/V, diaphoresis, change in LOC from intake in tyramine)*** - HTN Crisis: Antidote – Phentolamine or Nifedipine Contra: TYRAMIME (red wine, aged cheese, pepperoni/salami, avocado, figs, bananas, fermented or smoked meats/fish, liver, dried or cured fish, some beers, protein dietary supplements, etc.), TCAs, SSRIS, antihypertensives, & vasopressors (coffee, chocolate, ginseng) SNRIs: Venlafaxine, Duloxetine A/E: nausea, insomnia, weight gain, diaphoresis, sexual dysfunction Contra: caution with HTN →Antidepressant Education: - full effects can take months do not suddenly discontinue - therapy continues for 6m+ assess for suicide risk Ch 23 Meds for Bipolar Disorder Lithium; Maintenance range: 0.4-1 (during mania 0.8-1.4) A/E: GI upset (nausea, diarrhea, pain - give with milk or food), FINE HAND TREMORS**, polyuria, weight gain, kidney toxicity, bradydysrhythmia, hypotension, electrolyte imbalances **Toxicity: OVER 1.5** = COARSE hand tremors, extreme polyuria, confusion, severe hypotension, tinnitus, involuntary extremity movements, jerking movement, blurred vision, ataxia, seizures monitor plasma levels, creatinine, and BUN Education: maintain diet adequate in sodium (lithium excretion decreased w/  Na), drink lots of water, avoid conditions that cause dehydration such as exercising in hot weather or diarrhea bc that can increase risk of toxicity Contra: diuretics*, NSAIDs*, anticholinergics* Antiepileptics: Carbamazepine, Valproic acid treat: bipolar, anticonvulsive (seizures) A/E: Carbamazepine: blood dyscrasias (leukopenia, anemia, thrombocytopenia)*, CNS effects (nystagmus, double vision, vertigo, staggering gait, headache), hypo-osmolality (ADH secretion -> fluid overload), skin rash (Steven Johnsons Syndrome), teratogenesis Check for any bruising and bleeding of gums, monitor for signs of infection such as sore throat or fatigue, fever, pallor, weakness; monitor sodium, edema, urine I&O, hypertension Contra: pts with myelosuppression or bleeding disorders, Warfarin, Phenytoin A/E: Valproic acid: HEPATOTOXICITY**, weight gain, GI effects, pancreatitis, thrombocytopenia, teratogenesis; monitor AST/ALT and LDH Contra: liver disorders, Phenytoin Ch 24 Meds for Psychotic disorders Antipsychotics (Schizophrenia) • First generation: Chlorpromazine*, Haloperidol*, Loxapine, Fluphenazine – POSITIVE symptoms A/E: Extrapyramidal Side Effects (EPS): dystonia (muscle spasm of tongue, face, back), Parkinsonism (bradykinesia, rigidity, shuffling gait, drooling, tremors), akathisia (pacing, agitated), tardive dyskinesia (involuntary movements of tongue and face such as lip-smacking and of arms, legs, trunk), Neuroleptic Malignant Syndrome (sudden high-grade fever, bp fluctuations, severe dysrhythmias, muscle rigidity, sweating, drooling, change in LOC), anticholinergic effects, neuroendocrine effects (gynecomastia, galactorrhea, menstrual irregularities), seizures, skin (photosensitivity), orthostatic hypotension, sedation, sexual dysfunction, agranulocytosis (watch for infection, fever, sore throat), liver impairment *treat EPS or Parkinsonism with anticholinergics (Benztropine, Diphenhydramine), benzos, or b-blockers *treat Neuroleptic Malignant Syndrome with muscle relaxants (Dantrolene) Education: sugarless gum, fiber, fluids 2-3L, get up slowly; do not cause addiction, can get IM injections Contra: anticholinergics, CNS depressants, Levodopa (Parkinson’s med) Atypicals: Clozapine*, Risperidone*, Olanzapine, Ziprasidone, Quetiapine – POSITIVE & NEGATIVE symptoms A/E: not as many and not as serious – DIABETES, WEIGHT GAIN,  CHOLESTEROL (measure cholesterol before**), orthostatic hypotension, anticholinergic effects, sexual dysfunction,  prolactin levels, AGRANULOCYTOSIS* - Monitor for infection, obtain WBC (myalgia in pt. can be sign of viral infection), monitor cholesterol, glucose, triglycerides Education: healthy low-calorie diet, exercise, monitor weight, report agitation/dizziness/sedation/sleep disruption, inform for need of blood tests; not addictive – don’t have to taper; long term Contra: avoid alcohol, immunosuppressives • Ch 25 Meds for Mental health in Children & Adolescents (ADHD) Methylphenidate Amphetamine (Adderall) A/E:  appetite (give immediately before/after a meal), CNS stimulation (restless, INSOMNIA*) Education; monitor child’s weight, GIVE AT MORNING, GIVE AFTER MEAL Ch 26 Meds for Substance Abuse Alcohol Withdrawal: symptoms can start 4-12 hrs.** after the last drink and symptoms peak at 24-48 hours** and can subside in 5-7days – ask “when was your last drink?” s/s; delirium tremens (tremors),  HR,  BP,  RR, N/V, HA, sweating, INSOMNIA, depression, irritability, seizures • Withdrawal meds: Benzodiazepines* (Chlordiazepoxide**,Lorazepam, etc.) TX seizures: Carbamazepine, Phenytoin TX diaphoresis: Clonidine (alpha 2 receptor agonist), Atenolol TX craving: Propranolol Maintain bp: Clonidine and Propranolol • Abstinence meds: Disulfiram**, Naltrexone, Acamprosate ** must ensure that the client has not had any alcohol intake for at least 12 hr. prior to administration** C/I: alcohol (including mouth wash, cough syrup, aftershave lotion, hand sanitizer, pure vanilla extract, windshield fluid) Opioid Withdrawal (Heroin, Fentanyl, Codeine, Morphine) s/s: pupillary dilation, muscle aches, diarrhea, insomnia, rhinorrhea x – Withdrawal meds; Methadone**: opioid agonist; Clonidine; Buprenorphine Opioid antidote: Naloxone (only in acute care setting for emergency severe respiratory depression – not for treatment) opioids A/E: CONSTIPATION** (can pair w/ stool softener (i.e., Docusate sodium), RESPIRATORY DEPRESSION**, urinary retention Nicotine withdrawal from tobacco use: Meds; Bupropion (be “appropriate” and don’t smoke) – can cause dry mouth Nicotine replacement therapy: nicotine gum, nicotine patch Varenicline; reduces crazing & severity of withdrawal s/s Abstinence Meds: Varenicline, Rimonabant Ch 27 Care of Clients who are Dying and/or Grieving Five Stages of Grief: DABDA 1. Denial 4. Depression 2. Anger 5. Acceptance: by 6th month 3. Bargaining Normal grief: anger, resentment, withdrawal, hopelessness, guilt Anticipatory grief: “letting go” of an object or person before the loss, as in the case of terminal illness Complicated Greif; Delayed or inhibited grief Distorted or exaggerated grief: feelings and somatic manifestations of normal grief but to exaggerated level, stay in angry stage, may develop depression Chronic or prolonged grief Disenfranchised grief; entails an experienced loss that cannot be publicly shared or is not socially accepted (suicide and abortion). Ch 28 Mental Health Issues of Children or Adolescents Depressive disorders, including major depressive disorder and persistent depressive disorder. Anxiety disorders, including separation anxiety disorder and panic disorder Trauma‐ and stressor‐related disorders, including posttraumatic stress disorder (PTSD) Substance use disorders, including alcohol use disorder, tobacco use disorder, cannabis use disorder Feeding and eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder Disruptive, impulse control, and conduct disorders, including oppositional defiant disorder, disruptive mood dysregulation disorder, and conduct disorder Conduct disorder: onset can be in child or adolescent; lack of remorse for others, bullies, threatens & intimidates, low self-esteem, signs of suicidal ideation, physical cruelty to animals or others, has used weapon that can cause serious injuries Neurodevelopmental disorders, including attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder, intellectual developmental disorder, and specific learning disorder ADHD: behaviors must be present before age 12 - inattention, hyperactivity, impulsivity – risk for injury Autism: inability to maintain eye contact, repetitive actions, and strict observance of routines x sensory integration dysfunction, sleep disorders, digestive disorders, feeding disorders, epilepsy, and/or allergies Bipolar and related disorders Schizophrenia spectrum and other psychotic disorders Nonsuicidal self-injury and suicidal behavior disorder; suicide leading cause of death for 10 – 24 yrs. Impulse control disorders, including intermittent explosive disorder - Ch 29 Crisis Management • Types of Crises Situational/External: unanticipated loss or change experienced in everyday, often unanticipated, life events ex. lost job, illness Maturational/Internal: achieving new developmental stages, which requires learning additional coping mechanisms ex. marriage, kids move away Adventitious: natural disasters, crimes, rape (not part of everyday life) • Phases of a crisis PHASE 1: Escalating anxiety from a threat activates increased defense responses. PHASE 2: Anxiety continues escalating as defense responses fail, functioning becomes disorganized, and the client resorts to trial-and-error attempts to resolve anxiety. PHASE 3: Trial-and-error methods of resolution fail, and the client’s anxiety escalates to severe or panic levels, leading to flight or withdrawal behaviors. PHASE 4: experiences overwhelming anxiety that can lead to anguish and apprehension, feelings of powerlessness and being overwhelmed, dissociative findings (depersonalization, detachment from reality), depression, confusion, and/or violence against others or self. Ch 30 Suicide Risk factors; OLDER ADULT CLIENTS (Untreated depression, Loss of employment and finances, Feelings of isolation, powerlessness, Prior attempts at suicide (older adult clients are more likely to succeed), Change in functional ability, Declining physical health, Alcohol or other substance use disorder, Loss of loved ones) Family history, Physical disorders Psychosocial (hopelessness, intense emotions, poor interpersonal relationships, developmental stressors American Indian & Alaskan native Lack of access to healthcare, unemployment s/s; Overt comment: “There is just no reason for me to go on living.” Covert comment: “Everything is looking pretty grim for me.” Ch 31 Anger Management - Preassaultive: The client begins to become angry and exhibits increasing anxiety, tension, hyperactivity, and verbal abuse. - Assaultive: The client commits an act of violence. Seclusion and physical restraints can be required. - Post assaultive: Staff reviews the incident with the client during this stage. → NURSNG; Responding quickly, Remaining calm and in control, Encouraging the client to express feelings verbally, using therapeutic communication techniques (reflective techniques, silence, active listening), Allowing the client as much personal space as possible, Maintaining eye contact and sitting or standing at the same level as the client, Communicating with honesty, sincerity, and nonaggressive stance, Avoiding accusatory or threatening statements, Describing options clearly and offering choices, Reassuring the client that staff members are present to help prevent loss of control, Setting limits for the client Ch. 32 Family and Community Violence Cycle of Violence • Tension building phase; minor episodes of anger and can be verbally abusive and responsible for some minor physical violence (pushing, shoving). • Acute battering phase; The tension becomes too much to bear, and serious abuse takes place. • Honeymoon phase; The situation is defused for a while after the violent episode.; The perpetrator becomes loving, promises to change, and is sorry for the behavior. • Periods of escalation and descalation; Usually continue with shorter and shorter periods of time between the two without intervention. Age Specific Assessments; Risk factors of child abuse: child is “different”, child under 3y • INFANTS Shaken Baby Syndrome: bulging of fontanelles, expanded head circumference, intracranial or retinal hemorrhage, respiratory distress ***Any bruising on infant 6m or younger is suspicious • Preschool/Adolescents Bruising on abdomen, back, buttocks (knees, arms, legs are common in kids so not signs of abuse) Burns covering “glove” or “stocking” areas of hands or feet; small round burns Forearm spinal fractures (twisting arm) Human bite marks Head injuries *** Report all suspected abuse Ch 33 Sexual Assault Rape; Contusions and abrasions about various parts of the body, headaches, fatigue, sleep pattern disturbances, stomach pains, nausea, and vomiting, vaginal discharge, and itching, burning on urination, rectal bleeding and pain, rage, humiliation, embarrassment, desire for revenge, and self-blame, fear of physical violence and death • Rape trauma syndrome; two emotional patterns of response that may occur within hours after a rape INITIAL emotional/Impact rxn Expressed response pattern; the survivor expresses feelings of fear, anger, and anxiety through behaviors such as crying, sobbing, restlessness, and tension Controlled response pattern; the feelings are masked or hidden and a calm, composed, or subdued affect is present Somatic reaction; can occur later where client has physical manifestations • Compound rape reaction; additional symptoms such as depression and suicide, substance abuse, and even psychotic behaviors • Silent rape reaction; survivor tells no one about the assault -