PSYCHIATRIC NURSING.docx

VII. PSYCHIATRIC NURSING REVIEW A. Depression: 1. Loss of interest in life’s activities 2. Negative view of the WORLD 3. Anhedonia, loss of pleasure in usually PLEASURABLE things 4. Usually related to loss 5. What does this client look like? Poor kept appearance. 6. Weight GAIN in mild depression. 7. Weight LOSS in severe depression. 8. Crying spells with mild to moderate depression. 9. No more tears with severe depression. 10. Clients may be IRRITABLE (due to decreased serotonin) 11. Do they have energy? NO 12. Do they need help with self-care? YES 13. Help experience accomplishments. 14. Careful with COMPLIMENTS, these may make the client feel worse. 15. Prevent isolation. 16. Interacting with others actually makes the client feel better, even if they don’t want to do it. 17. If severely depressed, sitting with client and making no demands may be the best thing that you can do. 18. Can these people make simple decisions? NO 19. Assess SUICIDE risk. 20. As depression lifts, what happens to suicide risk? IT GOES UP 21. A sudden change in mood towards the better may indicate that the client has made the decision to kill himself. 22. ELDERLY clients are particularly at risk for suicide; elderly MEN tend to be very successful by using very lethal methods. 23. Can they have delusions/hallucinations? YES 24. Are their thoughts slowed? YES 25. Can’t concentrate 26. Sleep disturbances common 27. In mild depression, hypersomnia.

28. In moderate depression to severe depression, may have INSOMNIA 29. Generally, depressed clients have difficulty falling asleep, staying asleep, or have early morning awakening. B. Mania: 1. S/S: a. Continuous HIGH b. Emotions labile c. Flight of ideas d. Delusions-false IDEA, • Delusions of grandeur (Example: you think you are JESUS_) • Delusions of persecution SOMEBODYS OUT TO GET YOU. • Do you argue about the belief? NO • Do you talk a lot about the delusion? NO • Let the client know you accept that he/she needs the belief, but you do not believe it. • Look for the underlying need in the delusion; for example, delusions of persecution, the need is to feel safe; delusions of grandeur, the need is to feel good about self or self-esteem needs. e. Constant motor activity→ EXHAUTION f. Inappropriate dress g. Can’t stop to eat h. Altered SLEEPpatterns i. Spending sprees j. Poor JUDGEMENTS k. No inhibitions l. Hypersexual, and may exploit other clients. m. Manipulates→ fails→ they get mad. • Manipulation makes them feel secure and CONFIDENT n. Set LIMITS; staff must be consistent. o. Decreased attention span p. Hallucinations 2. Tx: a. Nursing Considerations: • Decrease STIMULI. • Limit group activities. • Feels most secure in one-on-one RELATIONSHIPS • Remove hazards. • Stay with client as anxiety

• Structured SCHEDULE • Provide activity to replace purposeless activity. • Writing activities provide energy outlet without too much stimulation. • Brief, frequent contact with the staff. Too much intense conversation stimulates client. • Finger FOODS • Keep snacks available. • Weight SAME TIME, DAILY • Walk with client during MEALS. • Don’t argue or try to reason. • Will try to “charm” you • Blame everybody. • Make sure dignity is maintained. • Client may do things or say things that they wouldn’t normally do. Hurst Review Services 93 b. Medications: (*the list of psychotropic drugs begins at the end of the psych lecture notes) C. Schizophrenia: 1. S/S: a. Focus is inward; they create their own WORLD. b. Inappropriate affect, flat affect, or blunted affect c. Disorganized THOUGHTS (loose associations: interrupted connections in thought, confused thinking) d. Rapid thoughts e. Jump from idea to IDEA. f. Echolalia g. Neologism MAKING UP NEW WORDS. h. Seek clarification (“I don’t understand”). DON’T EVER ACT LIKE YOU UNDERSTAND. i. Do these words mean anything? j. Concrete thinking k. WORD- salad, JUMBLE OF WORDS. l. Delusions m. Hallucinations, auditory most common; VISUAL next most common. n. Child-like mannerisms o. Religiosity 2. Tx: a. Nursing Considerations: • Decrease STIMULATION

• Observe PATIENT without looking suspicious • Orient frequently (important to remember that client may know person, place, and time and still have delusions and hallucinations) • Keep conversations REALITYbased. • Make sure personal needs are met. b. Medications: (*the list of psychotropic drugs begins at the end of the psych lecture notes) D. Suicide: 1. S/S: a. Do they have a plan? b. What is the plan? c. How lethal is the plan? Guns, car crashes, hanging, and carbon monoxide are very lethal plans. d. Do they have access to the plan? e. Watch for: • Isolating self • Writing a WILL • Collecting harmful objects • Giving AWAY belongings f. Elderly men are particularly at risk, and are successful in attempts. Hurst Review Services 95 2. Nursing Considerations: a. Provide safe ENVIRONMENT (#1). b. Safe-proof room c. Contract to postpone. d. Direct, closed ended statements appropriate e. Re-channel anger→ THROUGH EXERCISE f. Stay calm→ anxiety is contagious E. Restraints: 1. Check every 15 minutes; remember hydration, nutrition, & elimination. 2. Not used much anymore on psychiatric units 3. Note: On NCLEX®, stay away from restraints as long as possible! 4. Observation at 15 and 30 minutes intervals or one-to-one if the client cannot contract for safety. F. Paranoia: 1. S/S:

a. Always suspicious, but have no reason to be b. Why? Because they are responding in a way that is consistent with their paranoid beliefs c. Remember, you can’t explain away delusions or FALSE beliefs. d. Guarded in relationships e. Pathologic JEALOUSY, CONSUMES THOUGHTS AND MINDS. f. Hypersensitive g. Can’t relax h. No HUMOR i. Unemotional j. Craves INTUITION k. Life is unfair. l. Everybody else has the PROBLEM m. Reacts with rage 2. Tx: a. Be reliable.!!!!!! b. If you say you will do something, you must do it! c. BRIEF visits d. Be careful with TOUCH. e. Respect personal space. f. Avoid WHISPERING. g. Don’t MIX meds. h. Can’t handle overfriendly nurse i. Be matter-of-fact. j. Always ID meds. k. Eating-sealed FOODS AND FOODS BROUGHT FROM HOME. l. Need consistent nurses , BUILD TRUST. m. No competitive n. Be honest. G. Anxiety: 1. S/S: a. A universal EMOTION b. We all have felt anxious c. It becomes a disorder when it interferes with EVERYDAY functioning. 2. General comments about anxiety: a. INCREASE performance at mild levels, decreases performance at high levels. b. Clients may not need the nurse’s presence in mild anxiety; however, nurse should stay with highly anxious client.

c. The client who is highly anxious needs step-by-step INSTRUCTION. H. Generalized anxiety disorder: 1. S/S: a. Chronic ANXIETY b. Person lives with it DAILY c. Fatigued due to constant anxiety and muscle tension d. Uncomfortable e. Seek HELP 2. Tx: a. Short-term use of anxiolytics b. Relaxation techniques: deep breathing, imagery, deep muscle relaxation c. Journaling over time to gain insight into anxiety, peaks and valleys, triggers I. Post-traumatic stress disorder: 1. S/S: a. Results from exposure to lifethreatening event; severe trauma, natural disasters, war. b. Relive the experience, nightmares, and flashbacks c. Emotionally NUMB d. Difficulty with relationships e. Isolates THEMSELVES 2. Tx: a. Support GROUPS. b. Talk about the experience, but don’t push. c. Medications may be helpful. J. Obsessive-Compulsive Disorder: 1. S/S: a. Obsession→ recurrent THOUGHT b. Compulsion→ recurrent ACTS c. Can’t stop d. Come from an unconscious conflict/anxiety e. Need structured SCHEDULE f. Do we give them time for their rituals? YES. g. Can’t perform rituals→ anxiety level goes up. h. You should never take away the ritual without replacing it with another coping mechanism, such as anxiety reduction techniques. i. Do not verbalize disapproval. 2. Tx: a. Time delay techniques, relaxation techniques

b. Medications, such as SSRIs (selective serotonin reuptake inhibitors) or TCAs (tricyclics antidepressants) K. Dissociative disorders: 1. S/S: a. The client uses dissociation as a COPING mechanism to protect self from severe physical and or psychological trauma. b. May see with clients who have PHYSICAL of physical or sexual abuse c. Not commonly occurring or seen. d. Client or others may be aware of the problem except that client may have periods of time or events that he cannot remember. e. Dissociative Identity Disorder (multiple personalities) is extreme example of dissociative disorder. 2. Tx: a. Client must process the trauma over time. b. Medications may be used to treat co-existing depression, anxiety. L. Alcoholism: Alcohol is a Depressant 1. Stages of Withdrawal: a. Stage I-Mild tremors, nervous, nausea b. Stage II-Increased tremors, hyperactive, nightmares, disorientation, hallucinations, increased pulse, increased BP c. Stage III-Most dangerous, severe hallucinations (visual and kinesthetic are most common), grand mal seizures. d. Stage II and III are DT’s (withdrawal delirium)……..Keep light on. DON’T KEEP IN DARK. SAFE ENVIRONMENT. e. Stage I and II→ walk and TALK to them. 2. Tx: a. Anxiolytics: don’t be afraid to give. • Remember that the client has a tolerance to alcohol, and a crosstolerance to other CNS depressants.

• He can handle medications every two hours. • DTs should be prevented. • The client is very frightened during the episode. b. Detox protocol usually includes thiamine injections, multivitamins, and perhaps magnesium. 3. Complications: a. Chronic problems: (caused by thiamine/niacin deficiencies) • Korsakoff’s syndrome (disoriented to time; confabulate-CAN’T REMEMBER, MAKE UP SOMETHING.) • Wernicke’s syndrome (emotions labile, moody, tire easily) 4. Other S/S: a. Peripheral neuritis b. Liver and pancreas problems , ALCOHOL KILLS GI TRACT c. Impotence , ALCOHOL KILLS NERVERS d. Gastritis e. Mg and POTASSIUM loss (ALCOHOL MAKES YOU DIURESE) f. Major defense mechanisms? DENIAL and rationalization 5. Rehabilitation: a. Antabuse: deterrent to DRINKING b. Client has to sign consent form, must stay away from any form of ALCOHOL, including cough syrups, aftershaves, colognes, etc. c. 12 step program very effective treatment d. Client must have a relapse prevention plan in place. • Must have support once detox is over e. Family issues emerge once the alcoholic is sober. • All of the dynamics change, and this causes stress. M. Other substance abuse/addiction: a. The issues are the same; intense craving, difficulty quitting, many attempts to quit, fatal if left untreated, use denial and rationalization. The client’s life is controlled by the drug. N. Anorexia: 1. S/S: a. Distorted body image

b. Sees an overweight person when looking in the mirror, even when weight is 75 pounds. c. Preoccupied with food, but won’t eat. • Plans meals for others d. Periods stop. e. Decreased SEXUAL development. REGRESS. f. Exercise, EXERCISE, EXERCISE. g. Lose WEIGHT. h. Uses intellectualization as defense mechanism i. High achiever, perfectionistic 2. Tx: a. Increase WEIGHT gradually. b. Monitor exercise routine. c. Teach healthy EATING and exercise. d. Allow client input into choosing healthy food items for meals. e. Limit activity and decisions if weight is low enough to be life threatening. O. Bulimia: 1. S/S: a. Overeat→ vomit b. Teeth ROTS c. Laxatives, diuretics d. Strict dieter; fasts; exercises e. Binges are alone and secret. • Out of control when binging (may consume thousands of calories at one sitting, may steal food from grocery or garbage cans) f. Client spends more and more time obtaining food. • Pleasurable→ intense self-criticism g. Normal BODY WEIGHT h. With both – feel like they are in CONTROL AS LONG AS THEY CAN EAT OR NOT EAT LIKE THEY WANT TO. 2. Tx: a. Sit with client at meals and observe for 1 hour after. b. Allow 30 minutes for meals. c. Take focus off of the food. d. Angry you’ve taken this control away Hurst Review Services 103 e. Family PROBLEM usually the cause

f. Families tend to deny conflict and problems. g. Self-esteem building is important. P. Personality disorders: 1. S/S: a. Most commonly encountered: borderline personality disorder b. Clients are intensely emotional. c. Manipulative d. Suicidal GESTURE e. Self-mutilation f. May also DEPRESSED or bulimic. g. May ABUSE substances h. Fear of abandonment, many negative relationships. i. To this person, any relationship is better than no relationship. j. May be sexually promiscuous. 2. Tx: a. Improve self-esteem. b. Treat co-diagnoses. c. RELAXATION techniques d. Enforce RULES and limits. * e. Don’t reinforce NEGATIVE any behaviors. f. Treat self-mutilation and suicide gestures in matter-of-fact way. Q. Phobia: 1. With a phobia, does the object the person is scared of present danger? NO USUALLY. 2. Must have a TRUSTING relationship 3. Desensitization, must occur over time 4. Don’t talk about PHOBIA a lot. 5. FOLLOW UP is the key to successful treatment. R. Panic Disorder: 1. Stay 6 feet away. 2. Simple WORDS. 3. Have to learn how to stop the anxiety 4. Teach that symptoms should peak within 10 minutes. 5. Teach journaling to manage ANXIETY. 6. Helps the client gain insight into the peak and valleys of anxiety and triggers. 7. Relaxation techniques S. Hallucinations: 1. Warn before YOU TOUCH THEM. 2. Don’t say “they”.

3. Let the client know you do not share the perception. 4. Connected with times of anxiety 5. Involve in an ACTIVITY. 6. Elevate head of bed. 7. Turn off TV. DECREASE STIMULI 8. Offer reassurance, the client is frightened. *TESTING STRATEGY* We get them out of their hallucination and into the real world. T. ECT (Electro-Convulsive Therapy): 1. Pre-procedure: a. Can induce a grand mal SEIZURE. b. For severe DEPRESSION, and manic episodes c. NPO, void, Atropine (Atreza®) WON’T ASPIRATE. d. Signed permit is necessary. e. Series of treatments, depend on client response f. Very effective treatment, and very humane with current medications g. Succinylcholine Chloride (Anectine®) 2. Post- procedure: a. Position on SIDE. SO WON’T ASPIRATE. b. Stay with client. c. Temporary memory loss d. Reorient e. Involve in day’s activities as soon as possible. Psychotropic Medications Antidepressants: TCA: Older drugs (amitriptyline, nortripyline, imipramine) Risk of overdose, only one week’s worth of meds if client has suicidal thoughts Used still for OCD and some depressed clients. Not first choice anymore. Anticholinergic side effects: dry mouth, blurred vision, urinary retention, decreased tears, dizziness, sedation Because they cause sedation, may be given at night. They aid in sleep then. SSRI: first line of drugs now. Fluvoxamine Maleate (Luvox®), Citalopram (Celexa®),

Fluoxetne Hydrochloride (Prozac®), Venlafaxine Hydrochloride (Effexor®) Less incidence of side effects. Common side effects: headache, increased sweating, blurred vision, sexual side-effects, weight loss. Not great risk of overdose. Two to six weeks before complete therapeutic effect: true with all antidepressants. Client may feel calmer right away, and worry less. MAOI: problem with food and drug restrictions Tranylcypromine (Parnate®), Phenelzine Sulfate (Nardil®), Isocarboxazid (Marplan®) Cause hypertensive crises if foods or drugs containing tyramine or epinephrine-like substances are ingested. Monoamine oxidase is needed to break down tyramine and epinephrine. If it is inhibited, then tyramine remains high and increased blood pressure occurs. Foods to avoid: aged cheese, avocados, raisins, beer, red wines. No over-the-counter cough or cold medications containing ephedrine or ephedrine –like substances. Warnings are on labels. Clients must be willing to abide by restrictions. These drugs are not first choice drugs anymore. Serotonin Syndrome: potentially fatal conditions. Serotonin levels are too high. Hurst Review Services 107 Symptoms: tachycardia, hypertension, fever, sweating, shivering, confusion, anxiety, restlessness, disorientation, tremors, muscle spasms, muscle rigidity. Increased risk when taking more than one antidepressant, use of St. John’s Wort with meds. Anxiolytics: Used for short-term treatment, client may abuse and become addicted.

Benzodiazepines: diazepam (Valium®), lorazepam (Ativan®), alprazolam (Xanax®), chlordiazepoxide(Dalmane®), flurazepam (Buspar®) Non-benzos: buspirone (not addictive). Benzos: sedate, dizziness, constipation, raise seizure threshold, relax the client. Antipsychotics: Typical, Atypical: Typical are older drugs Chlorpromazine (Throazine®), Thioridazine (Mellaril®), Fluphenazine (Prolixin®), Haloperidol (Haldol®). Work well on psychotic symptoms. Many side-effects including EPS (dystonia, akathisia, pseudoparkinsonism) What is dystonia? Tonic contractions of muscles of mouth and torso, many affect breathing if not treated. Needs immediate treatment with diphenhydramine hydrochloride (Benadryl®) or benztropine mesylate (Cogentin®). What is akathisia? Restlessness What is pseudoparkinsonism? Symptoms mimic Parkinson’s disease; pill-rolling tremors, masklike face, muscle rigidity, drooling. Potential irreversible effects: tardive dyskinesia TD is manifested by uncontrolled movements of tongue, face. Atypicals: are newer drugs Clozapine (Clozaril®), Risperidone (Risperdal®), Olanzapine (Zyprexa®), Ziprazidone (Geodon®), Aripiprazola (Abilify®) Less incidence of EPS. Neuroleptic malignant syndrome: potentially fatal adverse effect for any antipsychotic: Severe muscle rigidity, hyperpyrexia, stupor, dyspagia, labile pulse and blood pressure. Stop meds, treated symptomatically, and usually in ICU. Clozapine carries risk of agranulocytosis; therefore, WBC levels are monitored frequently. Hurst Review Services 109

Anticonvulsants: used to stabilize mood: Commonly used are: Carbamazepine (Tegretol®), Valproex Sodium (Depakote®), Gabapentin (Neurontin®), Lamotrigine (Lamictal®), Oxcarbazepine (Trilecliental®) Work well in manic states. Side effects include: drowsiness, vertigo, blurred vision, unsteady gait. Anticonvulsants are toxic to liver; therefore, liver function should be monitored. Lithium: used to stabilize mood Narrow therapeutic window Levels must be monitored. 0.6 to 1.2 mEq/L is maintenance level. Up to 1.5 mEq/L is used for acute manic states. Signs/symptoms of lithium toxicity: hand tremors, N & V, slurred speech, unsteady gait. Levels of 2.0 to 2.5 mEq/L are considered life-threatening. Client must be taught to keep food, fluid, and exercise levels constant. If changed, lithium levels change.