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ragan_ashley
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2011-02-14 21:06:23
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Psychiatric Nursing
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  1. Components of Mental Status Exam
    • STA4T
    • Speech
    • Thought Process
    • Attitude, appearance, activity, affect
    • Though content
  2. 5 Benchmarks
    • 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.
  3. 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
  4. Resiliency Concept
    Ability to recover from misfortune

    • Recognize feelings
    • Deal with feelings
    • Learn from experiences
  5. 7 signs of mental health
    • Happiness
    • Control over behavior
    • Appraisal of reality
    • Effectiveness in work
    • Healthy self-concept
    • Satisfying Relationships
    • Effective coping strategies
  6. Clinical Epidemiology
    Studies groups of ppl with defined illnesses/symptoms.

    • Describes:
    • * Frequency of mental disorder
    • * Frequency of symptoms appearing together
    • * Prevalence rate of population with mental disorders.
  7. DSM-IV-TR
    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
  8. 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-
  9. 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)
  10. Levels of Anxiety Mild and Moderate
    • Mild
    • *Occurs in everyday living
    • *Increases perception, improves
    • problem solving
    • *Restlessness, irritablity, mild tension relieving behaviors.

    • Moderate
    • *Escalation from normal experience
    • *Descreases productivity
    • *Increase HR, RR, perspiration, mild
    • somatic symptoms

    • Nursing actions for both
    • *Open-ended statements
    • *Broat openings
    • *Seeking clarification
    • *Exploration
  11. Levels of Anxiety Severe and Panic
    • Severe
    • *Greatly reduced perceptual field
    • *Learning & problem solving not
    • possible
    • *Erratic, uncoordinated and
    • impulsive behavior.

    • Panic
    • *Loss of reality focus
    • *Disturbed behavior occurs
    • *Confusion, shouting, screaming and
    • withdrawl.

    • 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)
  12. Defense Mechanisms
    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
  13. 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

    Humor

    Supression - Consvious denial of disturbing feeling.
  14. 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.
  15. 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.
  16. Panic Disorders
    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
  17. Agoraphobia
    Fear of being in places or situations from which escape is difficult or help is unavailable.

    Feared places are avoided, restricts one's life.
  18. Phobia
    Persistent, irrational fear of specific objects, activities or situations.

    • Types
    • Specific: response to specific objects
    • Social: result of exposure to social situations or required perfomance.
  19. Obessive-Compulsive Disorder
    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.
  20. Generalized Anxiety Disorder (GAD)
    Excessive worry about numerous things lasting at least 6 months. "worry wart"

    • Symptoms
    • -restlessness
    • -fatigue
    • -poor concentration
    • -irritability
    • -tension
    • -sleep disorders
  21. 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.
  22. 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
    • -Derealization
    • -Depersonalization
    • -Dissociative Amnesia
  23. Anxiety Caused by Medical Conditions
    • Direct physiological result of medical conditions such as:
    • Hyperthyroidism
    • Pulmonary Embolism
    • Cardiac Dysrhythmias
    • "body can tell something is wrong"
  24. 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
  25. 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.
  26. Psych Meds
    How Do They Work?
    • Most have effect on synapse by
    • -changing neurotransmitter release
    • -change receptors they bind to

    Exact mechanism is unknown
  27. Neurotransmitters
    Sertotonin (5-HT)
    • Sleep, hunger, mood, pain perception
    • Aggression, sexual behavior

    Decrease - Anxiety, panic, phobias, obsessions and compulsions, bulimia/food cravings, depression

    Increase - Anxiety
  28. Neurotransmitters
    Norepinephrine (NE)
    Mood, Flight or fight

    Decrease - impaired attention, poor concentration, poor memory, slow info processing, psychomotor retardation, fatigue and depression

    Increase - mania, anxiety, schizophrenia
  29. Neurotransmitters
    Dopamine (DA)
    Fine muscle movement, integration of emotions/thoughts, decision making, hormone release

    Decrease - Depression, Parkinson's

    Increase - Schizophrenia, Mania
  30. Neurotransmitters
    Acetylcholine (Ach)
    Learning, memory, mood, aggression

    Decrease - Alzheimers, Parkinson's

    Increase - Depression
  31. 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
  32. 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)
  33. Other meds and Complementary Therapy
    • Other Meds
    • -B Blockers
    • -Antihistamines
    • -Anticonvulsants

    • Complementary Therapy
    • -Kava Kava
    • -Valerain Root
    • -Gotu kola
    • -St. John's wort
  34. Cognitive Disorders
    Cognition: process that is intellectual and perceptual and closely integrated with individuals emotional and spiritual values.

    • Delirium
    • Dementia
    • Amnestic Disorder
  35. Cognitive Disorders
    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
  36. Delirium
    • Short Term
    • Has to be caused by something such as illness or surgery
    • 2 subtypes - hypoactive & hyperactive

    • Symptoms
    • -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
  37. 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.

    • Meds
    • Haldol (#1 choice)
    • Risperdal
    • Zyprexa
    • Seroquel
    • Thorazine
  38. Dementia
    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
  39. Common Symptoms of Dementia
    • Defensive behaviors in early dementia
    • -Denial - attemp to hide memory deficits
    • -Confabulation - make up stories
    • -Perseveration - repeat phrases
    • -Avoid questions
  40. 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
  41. Alzheimer's Disease
    • Brain damage begins long before symptoms.
    • What happens:
    • -Buildup of protein (beta amyloid)
    • -Neurofibrillary tangles
    • -Granulovascular degeneration
  42. Alzheimer's Stages
    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.
  43. Treatment for Dementia
    Medications

    • Mild to Moderate
    • -cholinesterage inhibitors: increase availabe Ach.
    • Examples: galantamine (Reminyl)
    • rivastigmine (Exelon)
    • donepezil (Aricept)
    • Severe
    • N-methyl-D-aspartarte (NMDA): also makes more Ach available
    • Example: Memantine (Namenda)

    Cannot stop process, only slow down.
  44. Depression
    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
  45. 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.
  46. 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.
  47. Depression:
    General Assessment
    • FLA2T
    • Feelings
    • Low Energy
    • Affect, Anorexia
    • Trouble Sleeping

    • Three D'S
    • Despair
    • Dysphoric
    • Down
  48. 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.
  49. Depression Interventions

    Treatments
    • PEER
    • Physical needs
    • Express feelings
    • Exercise & simple activities to increase
    • self-esteem
    • Reduce risk for suicide

    • Treatments
    • -Milieu Therapy: structured hospital environment

    -Psychotherapy - Cognitive-behavioral )CBT) and interpersonal (IPT) therapies used

    -Group Therapy - Don't feel alone
  50. 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

    • SSRIs
    • Blocks seratonin reuptake therefore increase amount of seratonin available in body.
    • Side effects: agitation, anxiety, sleep disturbance, termor, sexual dysfunction, headache, weight changes impotence

    • MAOIs
    • 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

    Light Therapy

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