Psychiatric Nsg Exam 01

transference: client's unconscious displacement of feelings for significant people in the past onto the nurse in the current relationship

countertransference: nurse's emotional rxn to the client based on significant relationships in the nurse's past

Freedom from Seclusion and Restraint

Right to refuse treatment

Confidentiality

Informed consent

When duty to warn and protect are mandated

When a nurse is a mandated child/elder abuse reporter

State laws requiring reporting of certain communicable diseases

State laws requiring reporting of gunshot wounds

State laws that do not give nurses "privilege" (re: disclosures made within the context of the nurse-client relationship)

if a patient has a history of physical violence known to the licensed health care provider, and the provider has a reasonable basis to believe that there is a clear and present danger the patient will harm the victim, there is a duty to warn

identify the potential victim; document all communication (patient, nurse, victim, police); keep copies of letters/receipts

monoamine

➧involved in fine muscle movement, integration of emotions and thoughts, decision-making
➧stimulates hypothalamus to release hormones (sex, thyroid, adrenal)

↓: Parkinson's disease; depression

↑: schizophrenia; mania

monoamine

➧level in brain affects mood
➧attention & arousal
➧stimulates sympathetic branch of autonomic NS for "fight or flight" in response to stress

↓: depression

↑: mania; anxiety states; schizophrenia

monoamine

➧plays a role in sleep regulation, hunger, mood states, pain perception, aggression and sexual behavior
➧hormonal activity

↓: depression

↑: anxiety states

monoamine

➧involved in alertness & inflammatory response
➧stimulates gastric secretion

↓: sedation; weight gain

amino acid

➧plays a role in inhibition, reduces aggression, excitation, anxiety
➧may play role in pain perception
➧anticonvulsant and muscle-relaxing properties
➧may impair cognition & psychomotor functioning

↓: anxiety states; schizophrenia; mania; Huntington's disease

↑: reduction of anxiety

amino acid

➧excitatory
➧AMPA plays role in learning & memory

↓NMDA: psychosis

↑NMDA: prolonged increased state can be neurotoxic; neurodegeneration in Alzheimer's

↑AMPA: improvement of cognitive performance in behavioral tasks

cholinergic

➧plays role in learning & memory
➧regulates mood: mania & sexual aggression
➧affects sexual & aggressive behavior
➧stimulates parasympathetic NS

↓: Alzheimer's; Huntington's; Parkinson's

↑: depression

neuro: CVA; MS; seizures

infections: mono; hepatitis; HIV

endocrine: Cushing's; thyroid

GI: cirrhosis; pancreatitis

CV: hypoxia; CHF

Resp: sleep apnea

nutritional: vitamin & protein deficiencies

Collagen vascular: Lupus; RA

cancer

neuro: CVA; Huntington's

infections: encephalitis; meningitis

endocrine: thyroid; hypoglycemia

metabolic: low CA, K; liver failure

CV: angina; CHF; PE

Resp: pneumothorax; asthma; emphysema

Drugs: stimulants; sedative withdrawal

lead, mercury poisoning

medical: migrane HA; Addison's; HIV; temporal lobe epilepsy; occipital tumors; encephalitis; hypothyroid

drugs: hallucinogens; alcohol withdrawal; coccaine; corticosteriods

represents a change in previous functions

>5 Sx including depressed mood and/or anhedonia (for >2wks)
➧significant weight change
➧psychomotor agitation/retardation
➧pervasive loss of energy/fatigue
➧feelings of worthlessness/excessive or inappropriate guilt
➧difficulty concentrating
➧sleep disturbance
➧recurrent thought of death/suicide

genetic/bio: inheritance; female between menarche & menopause; male before young adulthood & after middle adulthood; Black American; high levels of neuroticism; postpartum period

environment/social: poverty; lack of social support; stressful event; substance abuse; medical co-morbidity; Southern USA residence; unmarried

other: sibling relationship, neonatal stress

usually develops over days/weeks

episode is minimal 2wks

unTx lasts 6mon or more, but then remits in most cases

recovery of 8wks remission

suicidal ideation

anhedonia & anergia

psychomotor retardation/agitation

vegetative signs

sad affect

slow and/or negative thinking

hopeless, helpless, worthless feelings

poor memory, concentration

Sex, Age, Depression, Previous attempt, Ethanol use, Rational thought loss, Social supports lacking, Organized plan, No spouse, Access to lethal mass, Sickness

0-2: send home with follow up
3-4: closely follow up; consider hospitalization
5-6: strongly consider hospitalization
7-10: hospitalize or commit

family Hx; males; Hx attempts; Native American; substance abuse; White; mini epidemic in community; Hx delinquency w/o depression; firearms presence; suicidal ideation; plan; co-occurring psych/medical illness; Hx abuse; lack of social support; unemployment; recent stressful life event; hopelessness; panic attacks; feelings of shame/humiliation; impulsivity; aggressiveness; loss of cognitive function; impending incarceration; low frustration tolerance; sexual orientation issues

if no Hx, SEX + AGE trumps all factors
males: 65+yo d/t loss of spouse, retirement, illness
females: 45-64yo d/t menopause, kids leaving, etc

anxiety; decisional conflict; fatigue; grieving/dysfunctional; hopelessness; low self-esteem; risk for suicide; disturbed sleep pattern; imbalanced nutrition

1st line = psychopharmacology plus:
➧problem-solving therapy for primary care (to develop coping skills)
➧interpersonal psychotherapy (to develop upon relationships, social skills and conflicts)

2nd line = psychopharmacology plus:
➧cognitive behavioral therapy (for problem solving, sleep, activation)

reported in usage of: antidepressants, dopamine agonists, analgesics; wait 2wks after d/c MAOI & starting SSRI, wait 5-6wks when d/c SSRI & starting MAOI

associated w/: amphetamines, analgesics, antibiotics, anticonvulsants, antiemetics, antimigranine, bariatric, abuse, herbs, OTC

Sx: rapid onset of flu-like Sx = agitation, myoclonus, hyperreflexia, fever, shivering, diaphoresis, ataxia, diarrhea

Tx (moderate): d/c drugs; place on fall precautions; replace fluids

Tx (severe): admit ICU; administer cooling blankets (NOT NSAIDS) for temp; administer benzodiazepines for agitation

medication-refractory depression

psychotic depression

depression with medical complications

Hx of positive response to ECT

catatonia

mania unresponsive to medication

occurs over a 2yr period (1yr for kids), depressed mood

>2 Sx:
➧decreased/increased appetite
➧insomnia or hypersomnia
➧low energy or chronic fatigue
➧decreased self-esteem
➧poor concentration or difficulty making decision
➧feelings of hopelessness or despair

sense of responsibility to family; pregnancy; religion; satisfaction with life; positive social support; access to health care; effective coping skills; effective problem-solving skills; intact reality testing

hard method: (ex) gun, jumping, hanging, CO poisoning

soft method: (ex) cutting, natural gas inhalation, pill ingestion

lethal if proposed method is available or psychotic/command hallucinations

Sensory and motor

➧receive/ID sensory info
➧concept formation and abstraction
➧proprioception and body awareness
➧reading, math
➧right/left orientation

Thought processes

➧formulate or select goals
➧initiate, plan, terminate actions
➧decision-making
➧insight
➧motivation
➧social judgment
➧start of voluntary motor ability

Auditory

➧language comprehension
➧sound storage into memory (language, speech)
➧connects with limbic system (emotion) to allow expression of emotions

Vision

➧interprets visual images
➧visual association
➧visual memories
➧involved with language formation

Bipolar I: combo of major depression & full manic episodes

Bipolar II: combo of major depression & hypomania

mania:
➧1wk duration
➧severe impairment in functioning
➧psychotic features

hypomania:
➧4day duration
➧change in functioning
➧no psychosis

mixed episodes: both manic and depressive episodes

hypomanic episode: same as manic but <4days

secondary mania: cause by medical disorders or Tx

rapid cycling: 4 or more episodes w/i 12mon

enlarged 3rd & lateral ventricles

smaller area/vol of corpus callosum

↓intracranial & white matter vol

hyperintensities revealed by T2 (weighted MRI) esp in frontal lobe

the more frequent the psychosis = the more damage to the brain

sleep disturbance & instability of 24h rhythms continue when BD pts are not acutely ill

biological sensitivity to light is a trait marker of BD

circadian rhythms (activity, body temp, melatonin, cortisol, thyrotropin) are altered in acute episodes

characterized by intense rage episodes for up to 2-3hr in kids 5-10

Sx of BD reflect developmental level of child

often have other psychiatric d/o: ADHD, ODD

must distinguish from normal teen behavior

earlier onset = greater impairment

more neuro abnorms & cognitive disturbances

poorer prognosis b/c of comorbid medical conditions

most women experience BPD episodes in 2wks postpartum

half experience exacerbation during pregnancy

10%-25% Dx w/ postpartum psychosis

Tx prophylactically

observed: little sleep, little eating, thyroid issues, hypersexual, substance abuse

manic episode: euphoric for 1wk; great amt of energy/little need for sleep; talking fast; racing thoughts; easily distracted; inflated feeling of power; reckless behavior (money, sex, drugs); flamboyant appearance

speech: humorous, pressured, loud, dramatic

affect: euphoric, poor judgment, grand schemes

thinking: grandiose ideas, inflated self-esteem, flight of ideas

psychomotor: ↑libido, sexually indiscreet, voracious appetite, sleeps only in naps

speech: vary labile, laughing to anger, excessive use of profanities

affect: anger & irritability, acutely sensitive to criticism

thinking: persecutory/sexual/religious delusions

psychomotor: naked in public areas, too hyper to eat/sleep

speech: out of touch w/ reality, use of clang expressions, speech so pressured it's incomprehensible

affect: physically threatening, verbally abusive, enraged

thinking: vivid visual hallucinations consistent w/ mood

psychomotor: extremely agitated, motor activity so unrelenting as to necessitate sedation/restraint

Disturbed sleep pattern, sleep deprivation
Imbalanced nutrition, hypothermia, deficit fluid balance Disturbed sensory perception
Disturbed thought processes
Defensive coping
Risk for suicide Ineffective role performance
Interrupted family processes
Impaired social interaction
Impaired parenting
Compromised family coping
Risk for violence
Ineffective coping

communication: firm, calm; be neutral; consistent limits; redirect energy

structured solitary activities (w/ staff)

frequent high calorie/protein snacks

encourage rest; reduce stimulation

appearance: incapable of caring for self, poor hygiene

vegetative signs: severe psychomotor disturbances (retardation or agitation); regressive behavior

mood: extremely blunted affect; non-reponsive

thought content: nihilistic or paranoid delusions; somatic delusions of body rotting; may be secretive of delusions/suicidality

S/S appear 3wks after delivery

mood: extreme feelings of worthlessness, tearfulness, anxious

thoughts: inordinate concern w/ baby's health; delusions of baby being defective/dead; auditory hallucinations to harm baby

impulsivity: baby may be subjected to physical abuse/death

prognosis: 95% improve to premorbid state in 2-3mon w/ conventional Tx for psychotic depression

familial: genetic inheritance

environment: stress in womb, LBW, maternal infection; cannabis use

grey matter loss

↓frontal lobe activity

atrophy of amygdala, hippocampus & parahippocampus

irregular dopamine pathways

positive: hallucinations; delusions; disorganized speech; bizarre behavior

negative: blunted affect; poverty of thought (alogia); loss of motivation; inability to feel pleasure/joy (anhendonia)

cognitive: inattention/easily distracted; impaired memory; poor problem-solving; poor decision-making; illogical thinking; impaired judgement

co-occuring problem: anxiety; depression; substance abuse; suicide

what's affected: occupation; interpersonal relationships; self-care; social functioning; quality of life

during 1mon period, at least 2 of following 5 conditions:

➧positive Sx
➧negative Sx
➧1 or more areas of social/occupational limits in functioning

paranoid: paranoid delusions or hallucinations predominate

disorganized: incoherence, extreme social malfunctioning

catatonic: marked ↓ in reactivity to the enviro

undifferentiated: can't classify in just one of the above categories

residual: signs of illness present, but not as prominent as in the other types; functioning but chronically impaired

persecutory: being singled out for harm by others

delusions of reference: in which events/people have particular and unusual significance (ex. a TV commentator is mocking him)

thought broadcasting: thoughts are broadcast from one's head to the external world so that others can hear them

thought insertion: thoughts that are not one's own are being inserted in one's head

grandiose: false belief that one is a very powerful & important person

somatic: false belief that the body is changing in an usual way

auditory:
➧frequently involve voices (singular or multiple; often insulting/persecutory)
➧command hallucinations (voices that demand the person behave in a certain way)
➧occasionally sounds instead of voices

tactile: typically involve electrical, tingling or burning sensations

somatic: sensations of snakes crawling inside the abd

visual: seeing a person, object, or animal that does not exist in the environment

gustatory: tasting sensations which have no stimulus in reality

olfactory: smelling odors that are not present in the environment

VISUAL, GUSTATORY & OLFACTORY occur but with less frequency and raise the possibility or organic mental disorder or drug induced psychosis (ex. LSD or cocaine)

1. prodromal

2. active

3. residual or chronic

4. remission

first phase

onset: teen or young adult

Sx: sleep disturbance; anxiety; irritability; deterioration in role; depression; social withdrawal; poor concentration; suspiciousness; loss of motivation; perceptual disturbance; motor changes; weight loss

at risk: suicidal thoughts; self-harm; cannabis use 4x higher

Tx: low dose atypical antipsychotic; CBT

GOAL: reduce risk of transition to psychosis

second phase

onset: develops <1yr after prodromal phase; 18-25yo male, 25-35yo female

active psychosis injures the pathological processes in the brain

GOAL: reduce the morbidity of schizophrenia w/ effective initial Tx

third phase

20%-40% Tx resistant; 35% yearly relapse rate

forth phase

10yrs after 1st episode 10% will have less Sx

30yrs after 1st episode 25%-35% have minimal Sx

dependent on: age of onset; early intervention w/ meds; vocation/rehab Tx; CBT; family Tx & support; socioeconomic status; substance abuse

predictors for nonremission: noncompliance w/ antipsychotics; persistent substance use

predictors of remission: younger age; employed; living independently; early Tx w/ atypical antipsychotics; early intervention

Disturbed thought processes
Disturbed sensory perceptions
Disturbed body image
Risk of violence, suicideSelf-care deficit
Disturbed sleep pattern
Ineffective therapeutic regimen management
Imbalanced nutrition
Excess fluid volume

#1 Assertive Community Treatment
#2 Supported Employment
#3 Skills training
#4 CBT
#5 Token Economy Interventions
#6 Family Based Treatment

Support groups
Half-way or residential treatment
Partial Hospital
Psychiatric rehabilitation or Sheltered workshop
Family interventions: support groups; local and state resources; help negotiate provider system

Supported Employment Programs/Individual Placement and Support Model: Ongoing individual support provided indefinately; small caseload for employment consultant

Social Skills Training: Vocational skills; Social Milieu Training; Self-Care Activities; Communication Skills

schizophreniform disorder: <1mon, >6mon; impaired social/occupational functioning but may not develop into schizophrenia

brief psychotic disorder: sudden onset of psychosis or disorganized catatonic behavior lasting >1day and <1mon; often precipitated by stressors & return to premorbid functioning

schizoaffective disorder: MDD, manic, or mixed mood episode presenting w/ schizophrenia Sx

delusional disorder: nonbizarre delusions for 1mon; no marked impairment

shared psychotic disorder (folie a deux): one person shares delusions of someone they are close with; much smaller impairment than other person

induced or secondary psychosis: from substances or medical conditions

Cost containment dictates that the shortest possible stay would be chosen. This might be from 48 to 96 hours, but probably less than 1 week. Clients seem to fare well with brief hospitalization and rapid return to the community as long as the problems that precipitated admission can be resolved before discharge.

Nursing is the discipline primarily responsible for maintenance of a therapeutic milieu, an environment that serves as a real-life training ground for learning about self and practicing communication and coping skills in preparation for a return to the community outside the hospital.

Because the acuity level on inpatient units is high, nurses are responsible for ensuring that the environment is safe and that elopement and self-harm opportunities are minimized.

The components of the nursing diagnosis are problem, etiology, and supporting data.

holistic assessment

Central to Maslow's theory is the assumption that human beings are active rather than passive participants in life, striving for self-actualization. Maslow (1968) focuses on human need fulfillment, which he describes in six incremental stages, beginning with physiological survival needs and ending with self-transcendent needs (Figure 2-2). Although these needs are present in all human beings, the behaviors that emanate from them differ according to a person's individual biological makeup and environmental factors. This picture is broader and more holistic.

The premise underlying behavior therapy is that behavior is learned and can be modified. Behaviorists agree that behavior can be changed without insight into the underlying cause.

According to Sullivan, the purpose of all behavior is to get needs met through interpersonal interactions and decrease or avoid anxiety. He viewed anxiety as a key concept and defined it as any painful feeling or emotion arising from social insecurity or blocks to getting biological needs satisfied.

Interpersonal therapy is considered to be effective in resolving problems of grief, role disputes, role transition, and interpersonal deficit.

"What I did was stupid."

Cognitive therapists help clients identify, reality test, and correct distorted conceptualizations and dysfunctional beliefs, such as realizing that doing a stupid thing does not mean the person is stupid.

The ego develops defenses or defense mechanisms to ward off anxiety by preventing conscious awareness of threatening feelings.

Increase of gluconeogenesis stimulated by release of cortisol ensures increased amounts of glucose are available to the individual. Increased glucose levels heighten and maintain energy levels to meet the demands of a crisis or stressor.

Insulin resistance and obesity are considered long-term sequalae of the high blood glucose levels incurred when the body responds to stress.

Culture and long experience with certain remedies are the basis for many alternative and complementary therapies.

Homeopathy is listed as one of the five major domains of complementary and alternative health care by National Center for Complementary and Alternative Medicine. Other examples are oriental medicine and naturopathy.

Homeopathy attempts to stimulate the body's immune system to relieve the client's distress and uses tiny amounts of substances known to produce the symptoms from which the client is experiencing.

Beck is a cognitive theorist who developed the theory of the cognitive triad of three automatic thoughts responsible for people becoming depressed: (1) a negative, self- deprecating view of self, (2) a pessimistic view of the world, and (3) the belief that negative reinforcement will continue.

A no-suicide contract is quite straightforward in seeking a promise not to kill oneself within a specified period. When that time expires, a new contract is negotiated.

establishing trust with the client.

Maslow describes basic needs as "D-motives" or "deficiency needs," meaning that they are so basic to existence that they must be resolved to reduce the tension associated with them. These needs have the greatest strength and must be satisfied before a person turns his attention to higher-level needs.

identify that human potential and the client’s strengths are key to building nurse-client relationships.

The value of Maslow's model in nursing practice is twofold. First, the emphasis on human potential and the client's strengths is key to successful nurse-client relationships. The second value lies in establishing what is most important in sequencing of nursing actions in the nurse-client relationship.