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Components of Mental Status Exam
- Thought Process
- Attitude, appearance, activity, affect
- Though content
- Enlightenment - Asylums
- Pre-Enlightenment: Assistance, Banishment & Confinement
Scientific Study - Major scientists Frued, Krapelin and Bleuler classified mental illness and treated patients
- Psychotripic Drugs - 1950's
- Chlorpromazine (thorazine) - psychotropic
- Imipramine - antidepressant
- Lithium - Mood stablizer
Community Mental Health - Funds shifted to community. More pt rights.
- Brain - 1990's
- Increase brain research.
Psychiatric Nursing Education
1880's - 1st psychiatric nurse Linda Richards --> school of psychiatric nursing
1920 - 1st psychiatric nursing textbook Harriet Bailey
1937 - Psychiatric nursing part of general nursing education cirriculum
1952 - 1st phsychiatric nursing theorist
Ability to recover from misfortune
- Recognize feelings
- Deal with feelings
- Learn from experiences
7 signs of mental health
- Control over behavior
- Appraisal of reality
- Effectiveness in work
- Healthy self-concept
- Satisfying Relationships
- Effective coping strategies
Studies groups of ppl with defined illnesses/symptoms.
- * Frequency of mental disorder
- * Frequency of symptoms appearing together
- * Prevalence rate of population with mental disorders.
Classifies Mental Disorders & How to Treat them
- Axis 1 - Mental Disorders
- Axis 2 - Personality Disorders & Mental Retardation
- Axis 3 - General Medical Conditions
- Axis 4 - Psychosocial & environmental problems
- Axis 5 - Global Assessment of Functioning (GAF) Scale 1-100 higher the better
Anxiety & Fear definitions
Anxiety: feeling of apprehension, uneasiness, uncertainty, or dread resulting from real or percieved threat whose acutal source is unknown or unrecognized.
Fear: Reaction to specific Danger
**These are alike in their physiological response -flight or fight-
Types of Anxiety
Normal - motivating force that provides energy to carry out tasks of living
Acute or State - Anxiety that is precipitated by imminent loss or change that threatens one's security (overwhelming feeling)
Chronic or trait - axiety that persists over time (always anxious, less productive)
Levels of Anxiety Mild and Moderate
- *Occurs in everyday living
- *Increases perception, improves
- problem solving
- *Restlessness, irritablity, mild tension relieving behaviors.
- *Escalation from normal experience
- *Descreases productivity
- *Increase HR, RR, perspiration, mild
- somatic symptoms
- Nursing actions for both
- *Open-ended statements
- *Broat openings
- *Seeking clarification
Levels of Anxiety Severe and Panic
- *Greatly reduced perceptual field
- *Learning & problem solving not
- *Erratic, uncoordinated and
- impulsive behavior.
- *Loss of reality focus
- *Disturbed behavior occurs
- *Confusion, shouting, screaming and
- Nursing Actions
- *Reduce environmental stimuli (move to quite area and remain with patient)
- *Gross motor activity to reduce tension.
- *Firm, short and simple statements.
- *Reinforce reality
- *Medications and restraints (last resort)
Help protect people from painful awareness of feelings and memories that can cause overwhelming anxiety.
Operate all the time, relatively unconscious.
- Adaptive - Healthy
- Maladaptive - Unhealthy
Healthy Defense Mechanisms
Altruism - Stressors are dealth with by meeting the needs of others.
Sublimation - Substituting an acceptable activity for impulses that are not acceptable. Ex. Agressive man - butcher
Supression - Consvious denial of disturbing feeling.
Intermediate Defense Mechanisms
Repression - Exclusion of unplesant things from conscious. Ex. forgetting an ex's name.
Displacement - Taking it out on someone else.
Reaction formation - "overcompensation" ex. guy who hates kids becomes boy scout leader
Undoing - Make up for. Ex. giving a gift
Rationalization - Jusifying illogical ideas.
Immature Defense Mechanisms
Passive Agression - Indirectly expression aggression towards others.
Acting-out Behaviors - Deals with emotions by actions rather that feelings.
Dissociation - Blocking things out of your memory.
Idealization - Attributing exaggerated posivite qualities to a person.
Splitting - Aspects of self and others are very opposite. "split personality"
Projection - Using a "scapegoat" to take feelings out on.
Denial - Ignoring reality.
Sudden onset of extreme apprehension or fear of imending doom.
Fear of losing one's mind or having a heart attack.
SOB, Chest Pain, Choking, Tingles
- Nursing Actions
- -Stay w/ pt & acknowledge discomfort
- -Remain calm, avoid touch
- -Short simple sentences
- -1 direction at a time
- -Treat hyperventilation
- -Allow to pace & cry
- -Communicate that your in control
- -Communicate that pt is safe
- -Encourage discussion of fears
Fear of being in places or situations from which escape is difficult or help is unavailable.
Feared places are avoided, restricts one's life.
Persistent, irrational fear of specific objects, activities or situations.
- Specific: response to specific objects
- Social: result of exposure to social situations or required perfomance.
Obession - Thoughts, impulses or images that persist and recur.
Compulsion - Ritualistic behaviors that individual feels driven to perform.
- Nursing Actions
- -Ensure basic needs are met
- -Provide time to perform rituals
- -Explain expectations, routines, changes
- -Convey acceptance & understanding
- -Simple activities
- -Assist to connect behavior & feelings.
Generalized Anxiety Disorder (GAD)
Excessive worry about numerous things lasting at least 6 months. "worry wart"
- -poor concentration
- -sleep disorders
Posttraumatic Stress Disorder (PTSD)
- Reexperience traumatic Event. Occurs around 3 months from incident.
- Ex. War
- Characterized by:
- -Recurrent dreams or flashbacks
- -Avoidance of stimuli associated w/ trauma
- -Numbing of responsiveness
**Can become chronic if not treated.
Acute Stress Disorder
Occurs within 1 month after exposure to traumatic event.
- Characterized by at least 3 dissociative symptoms during/after event.
- -Subjective sense of numbing
- -Reductive of awareness of surroundings
- -Dissociative Amnesia
Anxiety Caused by Medical Conditions
- Direct physiological result of medical conditions such as:
- Pulmonary Embolism
- Cardiac Dysrhythmias
- "body can tell something is wrong"
Nursing Interventions: Milieu Therapy
Used as part of treatment approach for patient w/ anxiety disorder who is hospitalized. "Group Therapy"
- What goes on?
- -Structure daily routine
- -Provide daily activities to promote interaction.
- -Provide therapeutic interactions
- -Include patient in decision making
Treatment for Anxiety Disorder
Cognitive-Behavioral Therapy (CBT)
- Therapist teaches patient to:
- -Examine assumptions
- -Redefine Fears
- -Restructure Thinking
- -Make Changes
- **What's going on and how to handle.
How Do They Work?
- Most have effect on synapse by
- -changing neurotransmitter release
- -change receptors they bind to
Exact mechanism is unknown
- Sleep, hunger, mood, pain perception
- Aggression, sexual behavior
Decrease - Anxiety, panic, phobias, obsessions and compulsions, bulimia/food cravings, depression
Increase - Anxiety
Mood, Flight or fight
Decrease - impaired attention, poor concentration, poor memory, slow info processing, psychomotor retardation, fatigue and depression
Increase - mania, anxiety, schizophrenia
Fine muscle movement, integration of emotions/thoughts, decision making, hormone release
Decrease - Depression, Parkinson's
Increase - Schizophrenia, Mania
Learning, memory, mood, aggression
Decrease - Alzheimers, Parkinson's
Increase - Depression
Types of Psychotropic Drugs
Antipsychotics - Reduce unrealistic thinking
Antidepressants - Improve Mood
Antianxiety - Calm Mood
Drugs to improve thinking, such as ones used for Alzheimer's
Antiparkinsonian drugs: correct problems caused by antipsychotic drugs
Common Meds for Anxiety Disorders
Benzo's - short-term treatment only
Buspirone - not as addictive as benzos
Selective sertonin reuptake inhibitors
Selective norepinephrine reubtake inhibitors
Tricyclic antidepressants (TCAs)
Other meds and Complementary Therapy
- Other Meds
- -B Blockers
- Complementary Therapy
- -Kava Kava
- -Valerain Root
- -Gotu kola
- -St. John's wort
Cognition: process that is intellectual and perceptual and closely integrated with individuals emotional and spiritual values.
- Amnestic Disorder
Prevalence and Comorbidity
- Prevalence: Delirium
- -present in 60% of nursing home residents 75 and older
- -80% of terminally ill people develop delirium before death
- Comorbidity: Delirium
- ALWAYS exists secondary to another condition
- Comorbidity: Amnestic Disorders
- ALWAYS secondary to another condition
- Prevalence: Dementia
- -Alzheimers Disease most common
- -5% by age 65 and 50% by age 85
- Comorbidity: Dementia
- -80% is irriversible
- -Reversible demenia can be secondary to other processes
- Short Term
- Has to be caused by something such as illness or surgery
- 2 subtypes - hypoactive & hyperactive
- -Rapid Onset
- -Anxious, fearful, bewildered
- -Abrupt disruption in perception of environment
- -Disturbance in consciousnes x3
- -Cognitive and perceptual disturbances
- (illusions and hallucinations)
- -Impaired short term memory
Care for Delirium
- -Frequent assessment
- -One to one care
- -Private Room by nurse's station
- -Camouflage tubes
- -Keep on nomral day/night schedule
- -Night light
- -Have wear assistive devices
- -Talk with pt about meaningful things
- -Use reality orientation tools clocks, calendars, family pics ect.
- Haldol (#1 choice)
Progressive deterioration in intellectual functioning, memory, ability to problem solve/learn new skills, decline in ablity to perform ADLs adn impaired judgement.
- Various types Alzheimers most common
- Early onset <65 seems to be inherited
- Late onset >65 no obvious pattern
Common Symptoms of Dementia
- Defensive behaviors in early dementia
- -Denial - attemp to hide memory deficits
- -Confabulation - make up stories
- -Perseveration - repeat phrases
- -Avoid questions
Cardinal Symptoms in Dementia
- 4 A's
- Amneisa - can't remember
- Aphasia - can't express thoughts
- Apraxia - can't recall info.
- Agnosia - inability of motor function
- Brain damage begins long before symptoms.
- What happens:
- -Buildup of protein (beta amyloid)
- -Neurofibrillary tangles
- -Granulovascular degeneration
Mild - forgetful, short term memory loss
Moderate - confusion, progressive memory loss, decline in ADL's, social withdrawl
Moderate to Severe - Ambulatory dementia, loss of ADL's, difficulty communicating, care usually needed
End Stage - bedbound, family recognition disappears, forgets how to eat swallow chew, can't ID self Institutional care needed.
Treatment for Dementia
- Mild to Moderate
- -cholinesterage inhibitors: increase availabe Ach.
- Examples: galantamine (Reminyl)
- rivastigmine (Exelon)
- donepezil (Aricept)
- N-methyl-D-aspartarte (NMDA): also makes more Ach available
- Example: Memantine (Namenda)
Cannot stop process, only slow down.
Ppl with depression experience great pain and suffering.
All ages, races and both sexes. Women more than men.
Vulnerability can be related to genetics and life stressors.
Can have comorbidity ex. cancer
Depressive Disorder Theories
- Psychodynamic factors: stress diathesis model
- -early life trauma sensitized stress pahtways to brain increase vulnerability to depression.
- Cognitive Theory - Aaron Beck
- -Automatic negative thoughts
- Learned Helplessness - Martin Seligman
- -Individual's perception of lack of control over stressful life events leads to depression.
Clinical Diagnosis of Major Depressive Episode
5 more more symptoms each day for 2 weeks
-Emotional and cognitive symptoms: depressed mood, feelings of worthlessness and guilt, anhedonia, hopelessness, decreased concentration, recurrent thoughts of death/suicide.
-Physical: weight gain or loss, insomnia or hypersomnia, increased or decreased motor activity, anergia, consipation.
- Low Energy
- Affect, Anorexia
- Trouble Sleeping
- Three D'S
Dysthymic Disorder (DD)
Chronic depressive syndrome usually present for most of the day, more days than not for 2 years.
Onset usually early adulthood or younger.
- Physical needs
- Express feelings
- Exercise & simple activities to increase
- Reduce risk for suicide
- -Milieu Therapy: structured hospital environment
-Psychotherapy - Cognitive-behavioral )CBT) and interpersonal (IPT) therapies used
-Group Therapy - Don't feel alone
Medications for Depression
- Tricyclic Antidepressants (TCAs)
- Action: inhibit reuptake of norepinephrine, dopamine and sertononin.
- Dose: start low and increase
- Side effects: SLUDGE
- 4-6 weeks to be therapeutic
- Blocks seratonin reuptake therefore increase amount of seratonin available in body.
- Side effects: agitation, anxiety, sleep disturbance, termor, sexual dysfunction, headache, weight changes impotence
- Prevent enzyme monoamine oxidase from breaking down neurotransmitters
- Side effects: sedations, hypotension, insomnia, muscle cramps, SLUDGE
- Toxic Reaction: Hypertensive crisis
- Electrolyte Therapy
- 2-3 treatments a week for 6-12 weeks