nclex-rn preparation program mental health disorders module 6, part 2 of 3
TRANSCRIPT
NCLEX-RN PREPARATION PROGRAM
MENTAL HEALTH
DISORDERS
Module 6, Part 2 of 3
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Major Mental Health DisordersPERSONALITY DISORDERS (PD)
Diagnostic criteria (Axis II, DSM-IV): “Enduring pattern of inner experience & behavior that deviates from expectations in 2 or more areas”:
Cognition Affectivity Interpersonal functioning Impulse control
Hinders one’s ability to Maintain meaningful relationships Feel fulfilled & enjoy life Adjust psychosocially (cope)
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Personality Disorder Clusters
A. Odd-eccentric Paranoid Schizoid Schizotypal
C. Anxious-Fearful Dependent Obsessive-Compulsive Avoidant
B. Dramatic-Emotionally Erratic
Borderline (BPD) Antisocial (APD) Narcissistic Histrionic
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Personality DisordersCluster A: Odd-Eccentric
A profound deficit in the ability to form personal relationships or respond to others in a meaningful way. Appear indifferent, aloof and/or unresponsive to praise or criticism. Typically have no close friends and prefer to be alone. Social detachment and consequent impairment in social & occupational functioning. Paranoid - pervasive distrust Cognitive impairment is more serious with Cluster A personality disorders than with cluster B & C disorders Most peculiar & maladaptive defensive styles Observed in families with schizophrenia, especially schizotypal
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Personality DisordersCluster B: Dramatic and Emotional
Present oriented and want immediate gratification Act without evaluating consequences (impulsive) BPD more likely to hurt self. APD more likely to
aggress outward APD commonly involved in criminal activities and
lack remorse or guilt - emotionally retarded Self-centered and manipulative Splitting (the inability to integrate the positive and
negative qualities of oneself or others into a cohesive image)
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Personality DisordersCluster C: Anxious-Fearful
Present as primarily anxious or fearful Experience impairment as
Restricted affect: problems expressing feelings Non-assertiveness, avoids conflict Unrealistic expectations of others Rely on others for support and decision-making Unable to function without a partner or family
member - stays in abusive relationship rather than be alone
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Schizoid - Orders home delivery; ingests food through mail slotSchizotypal - Eats soup using gardening equipment & chop sticksParanoid - Sits with back to the wall; spies on food prep areaAntisocial P.D. - Steals tip left by narcissistBorderline P.D. - When informed her boyfriend plans to go duck hunting, throws a drink at him, then uses glass to cut selfHistrionic - Does a belly dance in the center of the restaurantNarcissist - Expects best table without a reservationAvoidant - Tips generously for take-out serviceDependent - Vegetarian non-smoker eats veal in smoking area to please dateOCPD - Aligns cutlery & dispenses etiquette tips
Bistro of the Personality Disorders (PDs)
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Personality Disorders Interventions
Establish therapeutic relationship Control Milieu therapy
Provide experienced, consistent staff Implement a structure with rules that are
firm & consistently enforced (limit setting with consequences)
Protection from self-harm Modify impulsive behavior Incorporate behavioral strategies
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Personality Disorders Interventions (continued)
Medications have a limited role: Decrease impulsivity, mood swings, anxiety
Teach how to get needs met without manipulation
Maintain matter-of-fact but caring approach; mobilize healthy aspects of personality
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Personality DisordersGoals
Less impulsive Able to meet needs without manipulating Increased satisfaction with quality of
relationships Participates in close relationships Expresses recognition of positive
behavioral change
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A client recently released from prison for embezzlement has a history of becoming defensive and angry when criticized and blaming others for personal problems. The client has expressed no remorse or emotion about the actions that resulted in the prison term, but instead says that the embezzlement was justifiable because the employer “did not treat me fairly.” The nurse concludes these behaviors are consistent with which of the following mental health problems?
A. Narcissistic personality disorder B. Histrionic personality disorder C. Antisocial personality disorder D. Borderline personality disorder
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Which intervention strategy should the nurse routinely include in the nursing care plan for a client with antisocial personality disorder?
A. Establish clear and enforceable limits. B. Vary unit rules based on client demands. C. Vary unit rules based on staff needs. D. Let the client have a voice in when unit rules should apply.
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Anxiety Disorders DescriptionAn unrealistic fear in which the cause may or may not be identified. Symptoms: Anxiety and avoidance behavior Familial predisposition Results from
Exposure to traumatic and stressful life events Observing others experiencing trauma or behaving fearfully Vicariously through watching movies and TV
Physical symptoms occur
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Anxiety Disorders
Central Features Pervasive anxiety Feelings of inadequacy Tendency to avoid Self-defeating behavior blocks growth Can stimulate action to alter stressful situation Most symptoms of the body involved See physician vs. psychiatrist for treatment
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Anxiety DisordersAssessment
Restlessness and inability to relax Episodes of trembling and shakiness Chronic muscular tension Dizziness Inability to concentrate Fatigue and sleep problems Inability to recognize connection between anxiety and physical symptoms Focused on the physical discomfort
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Anxiety Disorders Generalized Anxiety Disorder
GAD Chronic excessive worry about a number of events
or activities for at least 6 months. History of uncontrollable & unpredictable life stress -
prone to Generalized Anxiety Disorder (GAD) Unrealistic/excessive Motor tension, autonomic hyperactivity, apprehensive
expectations, vigilance & scanning Experiences at least 3 of the following:
Restlessness, fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance
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Anxiety Disorders Panic Disorders
Panic Disorders Panic Disorder - discrete episode of intense fear
Sense of impending doom, helplessness, or being trappedPeaks within 10 minutesOccurs unexpectedly and on an intermittent basis Concern about additional attacks
Panic Disorder with agoraphobiaAvoidance of places or situations in which escape is difficult or help not available in the event of a panic attack (i.e., outside the home alone, being in a crowd…)
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Anxiety Disorders Post-traumatic Stress Disorder
PTSD Development of physiologic/behavioral symptoms
following a psychologically traumatic event A traumatic event is unavoidable (terrorist attacks, war,
rape, crime events, disasters, fires, childhood sexual abuse, kidnapping, hostages)
Before exposure did not have psychological problems Symptoms include: re-experiencing the trauma, avoiding
reminders of the trauma, numbing of affect
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Anxiety Disorders Phobic Disorders
Phobic Disorders Social phobia -
Fear of scrutiny (evaluated or judged) by others Fearful of doing something or acting in a way that will
be humiliating or embarrassing Specific Phobia
Persistent irrational fears of specific objects or situations
i.e., Animals (zoophobia), fear of closed places (claustrophobia), & fear of heights (acrophobia)
What are some other common phobias?
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Anxiety Disorders Obsessive-Compulsive Disorder
OCD
Obsessions Unwanted, persistent, & intrusive thoughts, impulses
or images that cause anxiety or distress Compulsions
Irrational impulse to act Behaviors or mental rituals performed to
neutralize/prevent the distressing thoughts or images Thoughts about dirt, contamination and danger most
common obsessions; cleaning & checking for danger most common ritual
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Anxiety Disorder Medications Buspirone (Buspar)
Minimal CNS depressant actions Does not enhance effects of alcohol, barbiturates & other
general CNS depressants. Takes several weeks to establish effectiveness.
Benzodiazpam Adverse effects:
CNS Depression Amnesia Respiratory Depression Dependence and abuse E.g. Valium, Librium, Xanax
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Anxiety Disorder Medications Beta-adrenergic blocking agents such as propranolol
(Inderal) can relieve symptoms caused by autonomic hyperactivity
Selective Serotonin Reuptake Inhibitors (Paxil, Proxac…), Tricyclic Antidepressants (Imipramine - Tofranil)
Barbituates CNS depression High abuse potential Powerful respiratory depressants with strong potential for
fatal overdose
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Anxiety Disorder Assessment
Take steps to lower anxiety level Encourage trust/calm approach Assess current feelings What happened immediately prior to onset? Client’s perspective of situation Thought processes Affect, expression, nonverbal behaviors Communication ability, thought blocking
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Anxiety Disorder Interventions Establish trusting relationship Nurses’ self-awareness Recognition of anxiety Insight into anxiety Modifying environment Encouraging activity Promote relaxation response Learn new ways to cope with stress Medication Goal: Client will demonstrate adaptive ways of coping
with stress
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A client who is hospitalized for panic disorder is experiencing increased anxiety. The client exhibits selective inattention and tells the nurse, “I’m anxious now.” The nurse determines that the degree of the client’s anxiety is:
A. Mild B. Moderate C. Severe D. Panic
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During an assessment interview, the client tells the nurse, “I can’t stop worrying about my makeup. I can’t go anywhere or do anything unless my makeup is fresh and perfect. I wash my face and put on fresh makeup at least once and sometimes twice an hour.” The nurse’s priority should be to adjust the client’s plan of care so the client will be:
A. Required to spend daytime hours out of own room
B. Given advance notice of approaching time for all group therapy sessions
C. Asked to keep a diary of feelings experienced if unable to groom self at will
D. Allowed to use own cosmetics and grooming products
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A client asks why a beta blocker (Inderal) medication has been prescribed for anxiety. When answering this question, the nurse should explain that this medication class is effective for treatment of which symptoms associated with anxiety?
A. Cognitive dissonance and confusion
B. Depression and suicidal ideations
C. Insomnia and nightmares
D. Palpitations and rapid heart beat
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Somatoform Disorders
1. Somatization Disorder2. Hypochondriasis 3. Conversion Disorder4. Pain Disorder5. Body Dysmorphic Disorder
Focus: Physical symptoms with absence of a pathophysiological problem
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Somatization Disorder Involvement of multiorgan system symptoms: pain, GI,
sexual, pseudoneurological Lack physical signs or structural abnormalities Different than hypochondriasis in that preoccupation
occurs only during episodeHypochondriasis
Preoccupation with fear of having serious illness and hypersensitive to body functions
Becomes central feature of self-image, topic of social interaction and response to life stresses
Somatoform Disorders
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Somatoform DisordersConversion Disorder
A symptom or deficit that affects motor or sensory functioning
Inappropriately unconcerned about symptoms Symptoms remit within 2 wks, recurrence common Common symptoms are blindness, deafness, paralysis
and the inability to talk
Pain Disorder Preoccupation with pain after confirmation of absence of
pathophysiologic causes
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Somatoform DisordersBody Dysmorphic Disorder
Preoccupation with an imagined/exaggerated defect in physical appearance
Crooked lip, bumpy nose, falling face Somatoform Interventions: Client education
Medications, Rx, lifestyle changes, ways to cope with anxiety & stress, relaxation training, physical activity
Goal: Client will express feelings verbally rather than through physical symptoms
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An older client with chronic low back pain receives cooking and cleaning help from her extended family. The mental health nurse anticipates that this client benefits from which of the following in this situation?
A. Primary gain
B. Secondary gain
C. Attention-seeking
D. Malingering
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What would the nurse expect a client who has a somatization disorder to reveal in the nursing history?
A. Abrupt onset of physical symptoms at menopauseB. Episodes of personality dissociationC. Ignoring physical symptoms until role performance was alteredD. Numerous physical symptoms in many organ areas
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A client treated for hypochondriasis would demonstrate understanding of the disorder by which statement to the nurse?
A. “I realize that tests and lab results cannot pick up on the seriousness of my illness.”
B. “Once my family realizes how severely ill I am, they will be more understanding.”
C. “I know that I don’t have a serious illness, even though I still worry about my symptoms.”
D. “I realize that exposure to toxins can cause significant organ damage.”
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Dissociative Disorders
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Dissociative Disorders Avoids stress by dissociating self from
core personality, characterized by sudden or gradual disruption in identity, memory or consciousness Dissociative Amnesia Dissociative Fugue Dissociative Identity Disorder Depersonalization Disorder
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Dissociative Disorders
Dissociative Amnesia Inability to recall important personal information Too extensive to be explained by ordinary
forgetfulness
Dissociative Fugue Sudden, unexpected travel away from home or work Inability to recall one’s past Confusion about personal identity (ID) or assumption
of a new ID
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Dissociative Disorders
Dissociative Identity Disorder Formally “Multiple Personality Disorder” Presence of 2 or more distinct identities that recurrently
take over behavior Inability to recall important personal info Identity fragmentation Often a history of physical &/or sexual abuse
Depersonalization Disorder Recurrent feeling of being detached from one’s mental
processes or body Intact reality testing
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Dissociative Disorders: Interventions
Development of insight Identify stressors Clarify beliefs in relationship to feelings and
behaviors Explore use of coping resources Decrease anxiety through stress management
Goal Obtain the maximum level of self-actualization to
realize potential
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The spouse of a client who is experiencing a fugue state asks the nurse if the spouse will be able to remember what happened during the time of fugue. What is the nurse’s best response?
A. “Your spouse will probably have no memory for events during the fugue.”
B. “Your spouse will be able to tell you – if you can gently encourage talking.”
C. “It is not possible to predict whether your spouse will remember the fugue state.”
D. “Avoid mentioning it, or your spouse may start alternating old and new identities.”
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Mood Disorders: Major Depressive Disorder and
Bipolar Disorders
Mood Disorder
A mood disorder is characterized by: Depressed mood or cycles of depressed and
elated mood Feelings of hopelessness and helplessness Decrease in interest or pleasure in usual activities
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Mood Disorders: Major Depressive Disorders
Depression Models of Causation Biological factors
Serotonin, norepinephrine, and acetylcholine deficiencies Effect of light on mood
Genetic factors Familial predisposition
Situational, physiological, and psychosocial stressors
Learned hopelessness and helplessness and a negative self-view
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Mood Disorders
Depression: Signs and Symptoms Cognitive: Difficulty concentrating, focusing, and problem
solving; ambivalence, confusion, sleep disturbances Loss of interest or motivation, anhedonia Decrease in personal hygiene Anxiety, worthlessness, helplessness, hopelessness Psychomotor retardation/agitation Vegetative signs: Hypersomnia, slowed bowel function Risk of harm to self or other: Suicidal ideation or
thoughts, self-destructive acts, violence, overt hostility often connected with suicidal thoughts
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Mood Disorders
Depression: Psychotrophics Selective Serotonin Reuptake Inhibitors
Rapid onset, fewer side effects, higher rate of compliance, lower overdose harm
Citalopram (Celexa) Paroxetine (Paxil) Fluoxetine (Prozac) Sertraline (Zoloft) Escitalopram (Lexapro) Fluvaxamine (Luvox)
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Mood DisordersSSRI ConsiderationsSelective Serotonin Reuptake Inhibitors
(SSRIs):
Physical assessment: renal, liver function, seizures
Agitation vs. vegetative symptoms Level of anxiety Ease of compliance Risk for suicide by overdose
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Mood DisordersSerotonin Syndrome Cause: Excess Serotonin at receptor sites Onset 3-9 days Symptoms: fever, confusion, restlessness, agitation,
hyper-reflexia, diaphoresis, shivering, diarrhea, fever, poor coordination
Triggered by high doses, concurrent MAOI, lithium or Trazadone administration
Interventions: Hold meds, notify MD, give P.O. fluids, supervise and support patient, antipyretics, cooling blanket
Resolves without specific treatment over 24 hours
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Mood Disorders
Depression: Psychotrophics Novel antidepressants:
Bupropion (Wellbutrin) Nefazadone (Serzone) Trazadone (Desyrel) Venlafaxine (Effexor) Mirtazipine (Remeron) Duloxetine (Cymbalta)
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Mood Disorders
Depression: Psychotrophics Tricyclic antidepressants
Amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor) Trimipramine (Surmontil)
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Mood Disorders
Depression: Psychotrophics Monoamine Oxidase Inhibitors
Tranylcypromine (Parnate) Phenelzine (Nardil) Isocarboxazid (Marplan) Tyramine-rich foods to avoid: aged cheese,
sausage, beer on tap, sauerkraut, soy sauce,red wine
OTC cold remedies, tricyclic antidepressants, narcotics, antihypertensives, stimulants
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Mood DisordersNursing Interventions for Depression: Maintain safety Question negative beliefs Encourage activities to increase self-esteem Encourage ADLs Encourage physical activity Medication teaching Milieu, group and/or individual therapyGoals No self-harm Resolution of negative self-image and situational insight Restoration of normal physical functioning Medication compliance, relapse prevention
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The nurse has explained to a client the biologic theories of depression. The nurse concludes that the teaching has been effective if the client says, “I now know that my depression may be caused from:
A. Excessive serotonin activity in the central nervous system (CNS).”
B. Insufficient serotonin activity in the CNS.”C. Excessive norepinephrine in the CNS.”D. Insufficient acetylcholine activity in the CNS.”E. A genetic mutation on chromosome 6.”
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A 63-year-old male client expresses feelings of hopelessness and helplessness about his spouse’s illness and anticipated death. On which of the following issues should the nurse initially assist the client to focus?
A. The nature of the spouse’s present illnessB. The client’s response to past lossesC. The dying spouse’s feelings about
impending loss and deathD. The client’s relationship with the spouse
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Mood Disorders: Bipolar Disorder
Bipolar Disorder A mood disorder, formerly known as manic
depression, characterized by recurrent and typically alternating episodes of depression and mania.
Either phase may be predominant at any given time or elements of both phases may be present simultaneously.
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Mood DisordersBipolar Disorder
Biological Factors Possible excess of norepinephrine, serotonin
and dopamine Increased intracellular sodium and calcium Neurotransmitters supersensitive to
transmission of impulses Defective feedback mechanism in limbic
system
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Mood Disorders
Bipolar Disorder: Signs and Symptoms of Mania Impulsivity: Spending money, giving away money or
possessions, hypersexual behavior Racing thoughts, hyper-social Increased activity, grandiose view of self and abilities Mood elation, progressively more hostile Speech loud, jovial, pressured Poor judgment Reduced sleep Impairment in social and occupational functioning
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Mood Disorders
Bipolar Disorder: Psychotrophics Lithium Carbonate (Carbolith, Eskalith..) Anticonvulsants
Valproate, (Depakote) Carbamazepine (Tegretol) Gabapentin (Neurontin) Topiramate (Topamax) Lamotrogene (Lamictal)
Benzodiazapines Antipsychotics such as Olanzapine (Zyprexa)
and Arpiprazole (Abilify) Electroconvulsive therapy
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Mood Disorders
Bipolar Disorder: Medical Management Lithium can have potentially harmful effects on the
kidney, thyroid gland, heart and developing fetus Pre-lithium treatment lab tests
Thyroid Function Tests (e.g. TSH), CBC (benign elevation of WBCs), BUN, serum creatinine, electrolytes Urinalysis, ECG,, pregnancy test During Lithium treatment: TSH, BUN, serum creatinine,
ECGs every 6 to 12 months
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Mood Disorders
Bipolar Disorder: Medical ManagementLithium Monitor serum levels or lithium (0.5-1.0 mEg/L) to prevent
toxicity and confirm compliance. Report sub-therapeutic or toxic levels to prescribing practitioner
Encourage adequate hydration and adequate dietary salt Therapeutic improvement takes 1-3 weeks Tremors and a metallic taste are side effectsAnticonvulsants as Mood Stabilizers Monitor serum levels every 2-4 months (liver function tests,
complete blood count, electrolytes, ECG, pregnancy test every 6-12 months)
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Mood DisordersBipolar Disorder Nursing Interventions and Goals Maintain physical safety (self harm, assault, impulse control,
exhaustion) Decrease sensory stimulation Establish normal sleep/rest cycle Establish adequate food/fluid intake Limit escalation of behavior Provide reality orientation Psychoeducation: Disease process, target symptoms, self monitoring,
alternative coping behaviors, self-care measures, medication management, medication compliance, laboratory monitoring, side effect management, community resources, relapse prevention, reinforce abstinence from drugs and alcohol
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The client has bipolar I disorder. Lithium carbonate (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:
A. “Minor hand trembling often happens for a few days after Lithium is started. It usually decreases in 1 to 2 weeks.”
B. “There’s no reason to worry about that. We won’t, unless it lasts longer than a couple of weeks.”
C. “Just in case your blood level is too high, I am not going to give you your next dose of Lithium.”
D. “I wouldn’t worry about it if I were you. It’s a small tremor that doesn’t interfere with your functioning.”
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Thought Disorders
Schizophrenia Involves disturbances in:
Reality, thought processes, perception, affect, social and occupational functioning
1.5% of the population 75% of cases diagnosed between ages 17 and 25 Causation: Heredity/genetic transmission,
psychodynamics, stress, drug abuse, excessive dopamine. CT and MRI studies show decreased brain volume, enlarged ventricles, deeper fissures, and/or underdevelopment of brain tissue
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Thought Disorders
Schizophrenia: Types
Catatonic Disorganized Paranoid Undifferentiated Residual
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Thought Disorders
Schizophrenia: Types
Catatonic Type
Catatonic stupor, evidenced by extreme psychomotor retardation and posturing, and catatonic excitement, extreme psychomotor agitation with purposeless movements that may harm self or others
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Thought Disorders
Schizophrenia: Types Disorganized Type
Flat or inappropriate affect (such as silliness or giggling), bizarre behavior and social impairment
Paranoid TypeParanoid delusions in which the individual falsely believes that others are out to harm him/her. The individual may be hostile, argumentative and aggressive
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Thought Disorders
Schizophrenia: Types
Undifferentiated TypeBizarre behavior that does not meet the criteria of other types of schizophrenia. Delusions and hallucinations are prominent
Residual Type Individual who has had one major episode of schizophrenia with prominent psychotic symptoms and who has lingering symptoms
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Thought Disorders
Schizophrenia: Diagnostic Criteria
Delusions, hallucinations, disorganized speech and/or behavior
Social and/or occupational impairment Symptoms for at least 6 months Not attributable to another disorder
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Thought Disorders
Schizophrenia: Positive and Negative Symptoms
Positive: delusions, hallucinations, bizarre behavior, agitation, pressured speech, suicidal ideation
Negative: Flat affect, poor eye contact, withdrawal, anhedonia, poverty of speech, apathy, inattention, lack of motivation
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Thought Disorders
Schizophrenia: Positive Signs and Symptoms Hallucinations: Auditory, visual, olfactory, gustatory, tactile Illusions: False interpretations of external sensory stimuli
and inappropriate responses to the perception. Alterations in thinking
Delusions - Fixed false beliefs (grandiose, persecutory, somatic…)Thought broadcasting, insertion
Ideas of reference Flight of ideas Thought/language disruption
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Thought Disorders
Schizophrenia: Co-Morbid Conditions and Effects Anxiety, depression, suicidal ideation Substance abuse Impaired occupational and interpersonal
relationships Decreased self-care Poor social functioning Lowered quality of life
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Thought Disorders
Schizophrenia: Psychotrophics
Antipsychotic medications decrease the intensity and frequency of psychotic symptoms.
Anti-Parkinsonian medications are used to counteract the extrapyramidal symptoms (EPS) associated with antipsychotic medications.
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Thought DisordersSchizophrenia: Psychotrophics Phenothiazines
Chlorpormazine (Thorazine), trifluoperazine (Stelazine), Thioridazine (Mellaril)…
Atypical Clozapine (Clozaril), Olanzapine (Zyprexa), Risperidone (Risperdal), Ziprasidone (Geodon), Arpiprazole (Abilify), Quetiapine Fumarate (Seroquel)
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Thought DisordersSchizophrenia: Psychotrophic Side Effects Acute
Dystonic reaction Ocular crisis Agranulocytosis Neuroleptic malignant syndrome
Chronic Tardive dyskinesia Pseudoparkinsonism Photo sensitivity Weight gain
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Thought Disorders
Schizophrenia: Psychotrophic Side Effects Sudden onset muscular rigidity, fever, elevated
CPK Escalates over 24-48 hours Late: hypertension, confusion-coma, gross
diaphoresis, dysphagia, tachycardia High potency neuroleptics, dosage, mood
disorders, concurrent lithium and polypharmacy
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Thought Disorders
Schizophrenia: Factors Supporting Compliance Perception of illness Risk for relapse Knowledge/involvement with treatment plan Optimism regarding positive effects Awareness of unpleasant effects when meds stopped Psychoeducation regarding psychotropic medications’
action, purpose, intended effects, management of side effects, toxic or dangerous effects and treatment for side effects
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Thought Disorders
Schizophrenia: Factors Inhibiting Compliance Delusions about medications Return of enjoyable symptoms Lack of social support regarding taking meds Side effects distressing Requires multiple changes in habits Multiple medications
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Thought DisordersSchizophrenia: Interventions Establish & maintain safe environment Establish trust Manage delusions Focus on feelings versus delusions Engage in reality testing Validate functional behaviors Anxiety management Stress reduction strategies
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The major advantage of the newer atypical antipsychotics over older phenothiazines and high potency antipsychotic medication is:
A. Less chance for agranulocytosisB. Availability as a long-lasting injectionC. Absence of EPSD. Resolution of positive and negative symptoms
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A patient with schizophrenia tells you that voices in his head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:
A. “I know these voices are very real to you, but I don't hear them.”B. “You need to get out of your room and get your mind occupied so you don't hear the voices."C. “Don't worry. You're safe in the hospital. I won't let anything happen to you.”D. “The voices are coming from your imagination.”
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Substance Abuse/Dependence Incidence
Alcohol dependence/abuse 14% Drug dependence 3% Co-morbidity common
Defense Mechanisms Rationalization, projection, denial
CNS depressants Alcohol, benzodiazapines, barbituates
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Substance Abuse Maladaptive, recurring use of substance
accompanied by repeated detrimental effects of drug
Present for one year or more Episodic binges Can occur without dependency Encounters with law, school suspension,
family/marital problems
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Maladaptive, reversible pattern of behavior Perceptual disturbances Sleep—wake cycle changes Disturbs attention, concentration, thinking,
judgment, psychomotor activity Interferes with relationships
Substance Intoxication
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Substance Dependence Craving – strong inner drive to use substance -
unsuccessful efforts to control use Tolerance – decreased effectiveness of drug over
time with need for increased doses of substance to achieve same effect
Withdrawal – unpleasant, maladaptive changes in behavior as blood/tissue concentrations of substance decline after prolonged heavy use
Much time used in obtaining substance Activities given up in lieu of substance use Continued use in spite of negative problems from
usage
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Larger amounts over longer time period than intended
Persistent desire/unsuccessful efforts to control use
Much time used in obtaining substance Activities given up in lieu of substance use Continued use in spite of negative problems
from usage
Substance Dependence
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PHASES Phase 1
Mood swings, altered emotional state Phase 2
Hangover effects, guilt about behavior Phase 3
Dependent lifestyle, control over substance is lost Phase 4
Dependency, addiction, blackouts, paranoia,helplessness
Substance Dependence
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Substance Abuse/DependencePossible long-term effects of chronic alcohol abuse
Gastritis Esophagitis Acute or chronic pancreatitis Cirrhosis Cardiac problems Neurological problems Wernicke-Korsakoff’s syndrome Osteoporosis and myopathy
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Alcohol WithdrawalAccompanied by physiologic/cognitive symptoms from reduction in prolonged substance use
Early Signs Develop within few hours after cessation/peak at
24-48 hours Anxiety, anorexia, insomnia, tremors, hyperactivity,
irritability, “shaking inside,” hallucinations, illusions, nausea/vomiting, Increased Temp, pulse, and BP
Delirium Tremens (DTs) Peak in 48-72 hours after cessation of drinking –
last 2-3 days 20% fatality rate
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Nursing Interventions: Alcohol Dependence
Medication – sedation High protein, high vitamin
diet (B/C) Replace fluid/ electrolytes
(I/O)• Diuresis with blood alcohol
level increase• Fluid retention may occur
(overhydration)
MgSO4 to increase body’s response to thiamine/raise seizure threshold
VS q hour x 12 h, then q4h
• Pulse good indicator of progress through withdrawal
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Vitamin B1 Deficiency Vitamin B1 (Thiamine) and niacin deficiency Encephalopathy and psychosis primarily in
alcoholics caused by thiamine deficiency, due to poor dietary intake and malabsorption (Wernicke-Korsakoff Syndrome)
Permanent progressive cognitive loss
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Substance Dependence: Alcohol Maintaining abstinence
Antidepressents - SSRIs and Buspirone (BuSpar) Naltrexone (ReVia), Nalmefene (Revex) -opioid
antagonists that help with alcohol dependence - reduces cravings and increases abstinence
Disulfiram (Antabuse) - Treat alcoholism. Inhibits aldehyde dehydrogenase, if alcohol ingested, causes facial flushing, tachycardia, decreased BP, nausea, vomiting, SOB, seating dizziness and confusion
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Substance Dependence: Alcohol
Relapse prevention Accept as a chronic disease Self-help groups, AA Stress management Family support
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Substance Abuse/Dependence Narcotic opiates commonly abused
Heroin, Demerol, Dilaudid, Oxycontin Treatment
Recognition of drug seeking Manage intoxication/overdose Opioid withdrawal: Naltrexone (ReVia),
Buprenophine (Buprenex), Dolophine (Methadone) Self-help groups, Narcotics Anonymous (NA) Relapse prevention
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Substance Abuse/Dependence
Types of Drugs Frequently Abused Barbiturates, antianxiety drugs, hypnotics Opioids (narcotics): heroin, morphine, meperidine, methadone,
hydromorphone Amphetamines: amphetamine, dextroamphetamine,
methamphetamine (speed), some appetite suppressants Cocaine, hydrochloride cocaine (crack) Phencyclidine (PCP) Hallucinogens: LSD, mescaline Cannabis: marijuana, hashish, THC Assessment findings and nursing interventions for overdose
vary with particular drug Polydrug abusers: Synergistic effect and additive effect
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Substance Abuse/Dependence
Reasons nurses are at high risk for substance use. Nurses see medication as solutions to problems
Access to drugs at work
Access to physicians who prescribe drugs
Compassion fatigue: Pressure and emotional pain felt at work
Anger and frustration nurses feel at work
Emotions felt at work respond to drugs– short term
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Substance Abuse/Dependence
Signs of substance abuse in nurses Change in nurse’s behavior Mood changes, irritability, isolation Change in work performance Multiple medication errors, missed deadlines, poor judgment, absenteeism Signs of drug use or withdrawal Red eyes, ataxia, anxiety, use of breath mints and perfume, slurred speech
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Substance Abuse/Dependence
Action plan if you suspect a peer
Report the peer suspected of drug abuse to a manager or supervisor to: Protect the clients from harm Protect the peer from harming clients or self Get diagnosis and treatment for impaired peers
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A client says, “I have a very small drink every morning to calm my nerves and stop my hands from trembling.” The nurse concludes that this client is describing which of the following?
A. An anxiety disorder
B. Tolerance
C. Withdrawal
D. Alcohol abuse
97
A client asks the nurse to provide information about the detoxification process and withdrawal from a benzodiazepine. The nurse should inform the client that the process will involve which of the following?
A. Rapid reduction in amount and frequency of the drug normally used
B. Abrupt discontinuation of the drug commonly used
C. Gradual downward reduction in dosage of the drug commonly used
D. Planned, progressive addition of an anti-psychotic drug
98
When the nurse is caring for a client experiencing delirium tremens, what is the most important nursing intervention?
A. Present psycho-education on the dangers of drug and alcohol use.
B. Encourage the client to develop a relapse prevention plan.
C. Administer anti-craving medications.D. Provide withdrawal care based on unit
protocol.
99
Photo Acknowledgement:All unmarked photos and clip art
contained in this module were obtained from the
2003 Microsoft Office Clip Art Gallery.