Professional Documents
Culture Documents
Mental Health
Mental Illness
Development of Psychopharmacology
• Standard I. Assessment
o The psychiatric-mental health nurse collects
health data
• Standard II. Diagnosis
o The psychiatric-mental health nurse analyzes the
data in determining diagnoses.
• Standard III. Outcome identification.
o The psychiatric-mental health nurse identifies
expected outcomes individualized to the client.
• Standard IV. Planning.
o The psychiatric-mental health nurse develops a
plan of care that prescribes interventions to attain
expected outcomes.
• Standard V. Implementation
o The psychiatric-mental health nurse implements
the interventions identified in the plan of care.
• Standard Va. Counseling
o The psychiatric-mental health nurse uses
counseling interventions to assist clients in
improving or regaining their previous coping
abilities, fostering mental health, and preventing
mental illness and disability.
• Standard Vb. Milieu Therapy
o The psychiatric-mental health nurse provides
structures, and maintains a therapeutic
environment in collaboration with the client and
other health care practitioners.
• Standard Vc. Self-care activities.
o The psychiatric-mental health nurse structures
interventions around the client’s activities of daily
living to foster self-care and mental and physical
well-being.
• Standard Vd. Psychobiologic Interventions.
o The psychiatric-mental health nurse uses
knowledge of psychobiologic interventions and
applies clinical skills to restore the client’s health
and prevent further disability.
• Standard Ve. Health teaching.
o The psychiatric-mental health nurse, through
health teaching, assists clients in achieving,
satisfying, productive, and healthy patterns of
living.
• Standard Vf. Case Management.
o The psychiatric-mental health nurse provides case
management to coordinate comprehensive health
services and ensure continuity of care.
• Standard Vg. Health promotion and maintenance.
o The psychiatric-mental health nurse employs
strategies and interventions to promote and
maintain mental health and prevent illness.
Areas of practice
• Counseling
o Interventions and communication techniques
o Problem solving
o Crisis intervention
o Stress management
o Behavior modification
• Milieu therapy
o Maintain therapeutic environment
o Teach skills
o Encourage communication between clients and
others
o Promote growth through role modeling
• Self-care activities
o Encourage independence
o Increase self-esteem
o Improve function and health
• Psychobiologic interventions
o Administer medications
o Teaching
o Observations
• Health teaching
• Case management
• Health promotion and maintenance
• Psychotherapy
• Prescriptive authority for drugs (in many states)
• Consultation
• Evaluation
Self-awareness issues
Neurotransmitters
Psychopharmacology
Antipsychotic drugs
• Also known as neuroleptics, are used to treat the
symptoms of psychosis, such as the delusions and the
hallucinations seen in schizophrenia, schizoaffective
disorder, and the manic phase of bipolar disorder.
• Antipsychotic’s work by blocking receptors of the
neurotransmitter, dopamine.
• Dopamine receptors are classified into subcategories
(D1, D2, D3, D4, and D5) and D2, D3, and D4 have
been associated with mental illness.
• The typical antipsychotic drugs are potent antagonists
(blockers) of D2, D3, and D4. This makes them effective
in treating target symptoms but also produces many
extrapyramidal side effects because of the blocking of
the D2 receptors.
• Newer, atypical antipsychotic drugs such as clozapine
(Clozaril) are relatively weak blockers of D2, which may
account for the lower incidence of extrapyramidal side
effects.
• The newer antipsychotics also inhibit the reuptake of
serotonin, increasing their effectiveness in treating the
depressive aspects of schizophrenia.
Tardive Dyskinesia
• (TD) is a syndrome of permanent involuntary
movements. This is most commonly caused by the
long-term use of antipsychotic drugs.
• There is no treatment available.
• The symptoms of TD include involuntary movements of
the tongue, facial, and neck muscles, upper and lower
extremities, and truncal musculature. Tongue thrusting
and protruding, lip smacking, blinking, grimacing, and
other excessive unnecessary facial movements are
characteristic.
• One TD has developed, it is irreversible.
Agranulocytosis
Antidepressant drugs
Stimulants
Cultural considerations
• I’m not going to go much into this. Just know that
clients from various cultures may metabolize
medication at different rates and therefore require
alterations in standard dosages.
Crisis Intervention
• Care
• Welfare
• Safety (#1!)
• Security
Anxiety:
Defensive:
• Loss of rationality.
• Nursing interventions:
o Direct approach to setting limits.
o Take away privileges.
o Give the patient some control and choices.
Tension-Reduction:
• Subsiding of energy.
• Nursing interventions:
o Establish therapeutic rapport
o Prime time to talk and teach about preventions of
behavior.
What if the patient simply refuses?
• Set limits!
• Make the limits reasonable and enforceable.
Intimidation:
Paraverbal communication
• 55% nonverbal
• 7% verbal
• 38% paraverbal it’s not what you say; it’s how you
say it!
• TVC (total voice control)
o Tone
o Volume
o Cadence
Mood disorders
• Unipolar
o Major depression
• Bipolar
o Mania
o Depression
o Period of normalcy
Treatments
Electroconvulsive therapy
Suicidal Ideation
Judgment
Self Concept
Interventions
Bipolar disorder
Drug treatment
• Lithium
o Lithium is not metabolized; rather, it is reabsorbed
by the proximal tubule and excreted in the urine.
o Thought to work in the synapse to increase
destruction of dopamine and norepinephrine;
decreases sensitivity to postsynaptic receptors
(Basically- when a person is in a manic phase, they
are synapsing super fast. Lithium helps slow this
synapsing down).
o Onset of action is 5-14 days; other drugs must be
used during the acute phases to reduce symptoms
of mania or depression.
o Maintenance lithium level is 0.5-1.0 mEq/L.
3 is toxic! Duh.
o Lithium is a salt contained in the human body. It
not only competes for salt receptor sites but also
affects calcium, potassium, and magnesium ions
as well as glucose metabolism.
MUST complete an electrolyte blood panel
(focus on Chloride).
o Having too much salt in the diet can cause the
lithium level to be too low.
o Not having enough dietary salt can cause the
lithium levels to be too high.
o Persistent thirst and diluted urine can indicate the
need to call the MD; lithium dosage may need to
be reduced.
• Anticonvulsant drugs: mechanism is unclear, but they
raise the brains threshold for dealing with stimulation;
this prevents the person from being bombarded with
external and internal stimuli.
o Tegretol
Huge concern about agranulocytosis (a
decrease in WBC).
Need serum levels monitored 12 hours after
last dose.
o Depakote
Need to monitor serum level, CBC with
platelets, liver function including ammonia
level (ammonia is a by-product of liver
metabolism)
o Klonopin
Anticonvulsant and benzodiazepine
Drug dependence can occur
Monitor CBC, liver function
Withdrawal drug slowly to prevent GI issues
Cannot be used alone to manage bipolar;
must be used in conjunction with lithium or
another mood stabilizer.
Suicide
Incidence
Physiologic responses
Anxiety disorders
• Panic disorder
• Phobic disorder
• Agoraphobia
• Obsessive-compulsive
• PTSD
• Generalized anxiety
• Anxiety related to medical conditions
• Substance-induced anxiety disorder
• Predisposing factors
o Onset: Acute or insidious (builds up)
o Precipitating event
o Chronic stressors
o Unusual behavior
o Fears disproportionate to reality
Levels of anxiety
• Mild:
o Psychological: Wide perceptional field, sharpened
senses, increased motivation, effective problem
solving, increased learning ability, irritability.
o Physiologic: Restlessness, fidgeting, “butterflies”,
difficulty sleeping, hypersensitivity to noise.
• Moderate:
o Psychological: perceptual field narrowed to
immediate task, selectively attentive, cannot
connect thoughts or events independently,
increased use of automatisms
o Physiologic: Muscle tension, diaphoresis, pounding
pulse, HA, dry mouth, high voice pitch, faster rate
of speech, GI upset, frequent urination
• Severe:
o Psychological: Perceptual field narrowed to one
detail or scattered details; cannot complete tasks;
cannot solve problems or learn effectively;
behavior geared toward anxiety relief and is
usually ineffective; doesn’t respond to redirection;
feels awe, dread, or horror; cries; ritualistic
behavior.
o Physiologic: Severe HA, N/V, diarrhea, rigid stance,
vertigo, pale, tachycardia, chest pain.
• Panic:
o Psychological: Perceptual field reduced to focus on
self; cannot process any environmental stimuli;
distorted perceptions; loss of rational thought;
doesn’t recognize potential danger; can’t
communicate verbally; possible delusions or
hallucinations; may be suicidal.
o Physiologic: May bolt and run OR totally immobile
and mute; dilated pupils, increased blood pressure
and pulse; flight, fright, or freeze.
• Alarm reaction
o Physiologic response
o Body prepares to defend itself
• Resistance stage
o Body will defend by flight or fight
o If the stress is gone; body relaxes
• Exhaustion stage
o Negative response to anxiety and stress
o Body stores are depleted
Panic disorders
Treatment
• Psychotherapy
o Positive reframing
o Assertiveness training
• Psychopharmacology
o SSRIs
o Anxiolytics
o Antidepressants
o MAOIs
Phobias
• An illogical, intense, persistent fear of a specific object
or social situation that causes extreme distress and
interferes with having a normal life.
• Treatment for phobias:
o Psychopharmacology
Anxiolytics
Benzodiazepines
SSRIs
Beta Blockers
o Psychotherapy
Behavioral therapy
Systemic desensitization
“Flooding” Getting rid of fear all at one
time
Substance abuse
Withdrawal
• Two purposes:
o Safe withdrawal with medication
Suppress symptoms of abstinence
Around the clock schedule and PRN
Never, ever go cold turkey.
o Prevent relapse
May need to go to AA for rest of life.
Cognitive disorders
Delirium
Causes of Delirium
• Metabolic
• Infection—UTI
• Low sodium
o Normal is 135-145 mEq/L
o Always check electrolytes!
• Drug related
o Or, withdrawal from drugs and alcohol
o Sedatives and benzodiazepines cause confusion
• Effects of anesthesia
Dementia
Dementia
• Mild:
o Forgetfulness
o Difficulty finding words
o Frequently loses objects and experiences anxiety
about these losses.
o Occupational and social settings are less
enjoyable, and the person may avoid them.
• Moderate:
o Confusion is present along with memory loss
o The person cannot complete complex tasks but
remains oriented to person and place.
o Still recognizes familiar people.
o Some assistance with care
o Executive functioning suffers (especially with
ADLs)
• Severe:
o Personality and emotional changes occur
o May be delusional, wander at night, forget the
names of spouse and children and require
assistance in ADLs.
o Most live in ECF.
Causes of Dementia
Culture
• Underlying cause
o Example: Vascular dementia can be helped by
diet, exercise, control of hypertension or diabetes.
• Psychopharmacology
o Cognex and Aricept are cholinesterase inhibitors
and have shown therapeutic effects; slow the
progress of dementia. They do not reverse
damage already done.
Must have liver function tests done with
Cognex.
Flu-like symptoms, diarrhea, sleep
disturbances are common.
o Tegretol and Depakote help stabilize mood and
diminish aggressive outbursts.
These doses are often ½-2/3 less lower than
prescribed for seizures, therefore, does not
need to be in the “therapeutic level” for
blood work.
o Benzodiazepines may cause delirium and can
worsen already compromised cognitive abilities.
• History
o Remember, interview family
• Motor behavior and general appearance
o Display aphasia
o Conversation repetitive
o Apraxia (such as combing hair)
o Gait disturbance
o Uninhibited behavior; never have displayed these
behaviors before.
• Mood and Affect
o Grieve at first
o Emotional outbursts are common
o Pattern of withdrawal; lethargic, apathetic, look
dazed and listless.
• Thought process and content
o Executive functioning impaired
o Have to stop working
o Client may accuse others of stealing lost objects
• Sensorium and Intellectual Processes
o First affects recent and immediate memory,
eventually impairs the ability to recognize family
members and oneself.
o Confabulation: clients make up answers to fill in
memory gaps; often inappropriate words or
fabricated ideas (SCREW YOU, ASSHOLE).
o Visual hallucinations are common.
• Judgment and insight
o Underestimate risk
• Self concept
o Initially grieve, and then slowly lose sense of self.
• Roles and Relationships
• Physiologic and self-care considerations
o Altered sleep-wake cycle
o Some clients ignore internal cues such as hunger
or thirst
o Neglect bathing and grooming; become
incontinent.
Schizophrenia
Types of schizophrenia
• Paranoid schizophrenia
o Suspiciousness
o Hostility
o Delusions
o Auditory hallucinations
o Anxiety and anger
o Aloofness
o Persecutory schemes
o Violence
• Disorganized schizophrenia
o Extreme social withdrawal
o Disorganized speech or behavior
o Flat or inappropriate affect
o Silliness unrelated to speech
o Stereotyped behaviors
o Grimacing mannerisms
o Inability to perform activities of daily living
• Catatonic schizophrenia
o Significant psychomotor disturbances
o Immobility
o Stupor
o Waxy flexibility
o Excessive purposeless motor activity
o Echolalia
o Automatic obedience
o Stereotyped or repetitive behavior
• Undifferentiated schizophrenia
o Undifferentiated schizophrenia does not meet the
criteria for paranoid, disorganized, or catatonic
schizophrenia
o Delusions and hallucinations
o Disorganized speech
o Disorganized or catatonic behavior
o Flat affect
o Social withdrawal
• Residual schizophrenia
o Diagnosed as schizophrenic in the past
o Time limited between attacks but may last for
many years
o The client exhibits considerable social isolation
and withdrawal and impaired role functioning
Interventions
Mental retardation
Adolescent depression
• Some issues are due to background and family issues
• Transition into adulthood often very difficult
• Depression is almost always due to a combination of
factors
• Boys are more successful in committing suicide; more
violent in attempts
o Acetaminophen affects liver
o Ibuprophen affects kidneys
• Presents as “classic” symptoms in girls
• In boys, depression is more likely to be “acted out” with
aggressive behavior such as risk taking, substance
abuse, confrontations with authority.
o Drinking in teenage years (ages 15-17) stops
emotional growth. Kids that grow into adults are
stuck in this stage (Identity vs. Role confusion).
They learn that drinking is the way to cope. This is
not awesome.
• First major episode are during adolescent years; often
between the ages of 15-19
• Manic depression
o Teens may be sad and gloomy one day and excited
and elevated the next
o Mood stabilizers are important in decreasing mood
swings
Lithium (check blood levels!)
Depakote
Tegretol
Neurontin
• In depression, one of the first cues is a large drop in
school performance
• Other symptoms disguised:
o Drug/alcohol abuse
o Lack of concentration
o Restlessness or hyperactivity
o Anti-social behavior (conduct disorder)
• Extreme fatigue, sleep all the time but are not rested
• Suicide warning signs…
o Constant insomnia; may be on computer at all
hours of the night
o Changes in behavior
o Dropping grades—again, school is a huge issue
• Interventions for suicide
o High risk teens make their decisions after a
“disaster” has occurred: break-ups, academic
failure, fight with parents, or run-in with authority
o Alcohol is involved in ½ of all suicides; seriously
impairs judgement
• Suicide is not chosen; it happens when pain exceeds
resources for pain
• Talk to your kids!
o The best place is in the car when they’re trapped,
haha.
Start with the basics; “How are you doing?”
Then, praise
Then get down and dirty to the real subject
Childhood Schizophrenia
Obsessive-Compulsion disorder
Autistic disorder
Conduct disorder
TIC disorders
Tourette’s syndrome
Elimination disorders
Eating disorders
Anorexia Nervosa
Bulimia Nervosa
Nursing outcomes/interventions
Somatoform disorders
Related disorders:
Treatment:
Assessment
• The nurse must investigate physical health status
thoroughly to ensure there is no underlying pathology
requiring treatment. It is important not to dismiss all
future complaints because at any time the client could
develop a physical condition that would require medical
attention.
• In many cases, the client’s appearance brightens and
they look much better as the assessment interview
begins because they have the nurse’s undivided
attention.
• Client’s often have sleep pattern disturbances, lack
basic nutrition, and get no exercise.
Nursing diagnoses
• Ineffective coping
o The client will identify the relationship between
stress and physical symptoms.
Emotion-focused coping strategies help the
clients relax and reduce feelings of stress.
This includes progressive relaxation, deep
breathing, guided imagery, and distractions
such as music.
Problem-focused coping strategies help to
resolve or change a client’s behavior or
situation or to manage life stressors. This
includes learning problem solving methods.
The nurse should help the client role play the
above situations.
• Ineffective denial
o The client will verbally express emotional feelings
The nurse should not attempt to confront
clients about somatic symptoms or attempt
to tell them that these symptoms are not
“real.”
Encourage the client to write in a daily
journal
Limiting the time that clients can focus on
physical complaints alone may be necessary.
The nurse may have to explain to the family
about primary and secondary gains; this will
encourage relatives to stop reinforcing the
“sick role.”
• Impaired social interactions
o The client will follow an established daily routine
The nurse must help the client to establish
this that includes improved health behaviors.
The challenge for the nurse is to validate the
client’s feelings while encouraging him to
participate in activities.
The nurse should help the client plan social
contact with others, what to talk about (other
than the client’s complaints), and can
improve the client’s confidence in making
relationships.
• Anxiety
o The client will demonstrate alternative ways to
deal with stress, anxiety, and other feelings
• Disturbed sleep pattern
o The client will demonstrate healthier behaviors
regarding rest, activity, and nutritional intake.
The nurse explains that inactivity and poor
eating habits perpetuate discomfort and that
often it is necessary to engage in behaviors
even though one doesn’t feel like it.
• Fatigue
• Pain