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ATI Mental Health Basics study guide...100% important.

ATI Mental Health Basics • Levels of Consciousness (alphabetic until C) o Alert : patient is responsive, opening eyes spontaneously, respond to question appropriately o Lethargic: falls asleep easily, opens eyes, responsive o Obtunded: respond to light shaking, confused, slow to respond o Stuporous: patient barely responds to painful stimuli (ex: rubbing sternum) o Comatose: unresponsive and abnormal posturing may be present  1 . decorticate: arms are flexed and internally rotated towards core, legs extends and internally rotated  2. Decerebrate: both arms and legs extended, head arched back • Nursing Ethics o Autonomy: patient has right to make own decision, even if it’s not in their best interest o Beneficence: doing what is best for patient o Fidelity: loyal, keeping promises o Justice: provide fairness in care and allocation in resources across patients o Non-maleficence: doing no harm o Veracity: telling the truth, being honest • Patient rights o Right to refuse treatment – applies to patients who are involuntary admitted o Confidentiality: patients medical information is protected by HIPPA and cannot be released unless permission given o Mandatory reporting: nurses are required to report suspicion of abuse, and to warn/protect third parties who are at risk for harm. • Informed Consent: o Provider Responsibilities:  Communicates purpose of procedure, and complete description of procedure in the patient’s primary language  Explain risks vs. benefits  Describe other options to treat condition o RN  Make sure provider gave the patient the above information  Ensure the patient is competent to give informed consent (i.e. patient is an adult or emancipated minor, not impaired)  Have patient sign consent document  Notify provider if patient has more questions or doesn’t understand any information • Restraints: o Always have alternatives before restraints. o Can do restraint in emergency BUT need written prescription from provider quickly after (1hr) o Provider will need to re-write prescription every 24 hours, no PRN prescription o Best Practice:  Wrist – two fingers  Quick release knot (slip knot, NOT SQURE)  Use a movable part of the bed frame so if you move the bed the restraints move with them o Types of restraints: physical (vest, belt, mitten) or chemical (sedative or antipsychotic medication) o Alternatives: provide verbal interventions, diversions, calm/quiet environment o Prescription:  Prescription must be in writing  If need for constraints continue, provider must re-write prescription every 24 hours  In an emergency situation, a nurse can use restraints but must obtain a written prescription per facility policy (15-30 minutes) o Time limits:  Adults: 4 hours  9-17: 2 hours  <8: 1 hour o Documentation:  Complete every 15 -30 minutes • Include: precipitating event, alternative interventions attempted, time treatment began, medication administered, patient assessment (current behavior, VS<, pain), patient are provided (food, toileting) o DC: restraints can be discontinued when patient can follow the nurses’ direction • Torts o Unintentional Torts  Negligence: forgetting to set bed alarm for a patient at risk for falls  Malpractice: medication error that harms patient o Intentional torts:  Assault: nurse threatens patient  Battery: nurse hits patients or administer medication against patients will  False imprisonment: nurse inappropriately restrains a patient or administers a chemical restraint such as a sedative • Communication o Intrapersonal communication: “self-talk”, thinking thoughts, but not verbalizing them o Interpersonal communication: one-on-one communication with another person o Open-ended questions: promotes interactive discussions o Closed-ended questions: used to obtain, specific data. Use sparingly as it can block further communication. • Communication techniques o Restating: repeat the patients exact words o Reflecting: return focus back to patient o Paraphrasing: restate patient’s feelings to confirm understanding of what patient is saying o Exploring: gathering more information about something patient has mentioned o General leads: allows patient to guide discussion o Presenting reality: communicate what is actually happening; dispel hallucinations, delusions, false beliefs. o Offering self: limited self-disclosure by nurse. Return focus to patient as soon as possible. • Therapeutic communication o WRONG  Asking why  Offering your opinion  Giving false reassurance  Giving advice  Changing the subject  Minimizing the patients feelings o RIGHT  Asking open-ended questions  Maintaining eye contact  Sitting/standing at eye level  Therapeutic tough to convey caring and provide comfort o Older adults:  Minimize distractions, discuss health in private settings  Face the patient when speaking  Use a lower pitch voice  Begin the interview by asking the patient to identify his/her needs and concerns  Limit the number of items on a questionnaire when gathering data  Allow plenty of time for the patient to respond to questions. • Defense Mechanisms o Altruism: dealing w/ stress/anxiety by helping others o Sublimation: substitute negative impulses into acceptable forms of expression (ex: working out hard at the gm) o Suppression: voluntary denial of unpleasant thoughts or feelings o Repression: unconscious denial of unpleasant thoughts or feelings o Regression: reverting back to childlike behaviors that are inappropriate for the patient’s current development level o Displacement: redirecting feelings about a person or situation towards a less threatening object/person (ex: dad loses his job, destroys his childs toy) o Reaction formation: demonstrating the opposite behavior vs what is actually felt (I love nursing exams) o Undoing: performing an act to make up for a previous behavior o Rationalization: creating an acceptable excuse for unacceptable behavior o Dissociation: temporary compartmentalization of feelings/thoughts (forgettin who you are during sexual assault) o Denial: pretending truth is not reality o Compensation: emphasizing strengths to make up for weaknesses • Anxiety o Levels of anxiety  Mild: enhances an individuals perception. Normal experience. • Symptoms: restlessness, irritability, fidgeting, foot-tapping  Moderate: slightly reduced perception and ability to think • Symptoms: pacing, difficulty concentrating; increased RR, HR,  Severe: perception greatly reduced; no ability to problem-solve • Symptoms: feelings of “doom”, tachycardia, hyperventilation, rapid speech  Panic level: individual loses touch with reality disturbed behaviors • Symptoms: dilated pupils, hallucinations, severe withdrawal, severe shakiness o Nursing interventions  Mild/moderate anxiety: active listening, evaluate patients past coping mechanisms, assist patient w/ problem solving, teach relaxation techniques (ex: abdominal breathing exercises), encourage exercise to reduce anxiety  Severe/panic-level anxiety: provide a quiet environment w/ minimal stimulation, remain with patient, set limits with short/simple statements, help patient to focus on reality. Problem solving is NOT realistic at this level of anxiety. • Therapeutic Relationship o Orientation: introduce self, discuss confidentiality, establish expectations and boundaries/parameters, identify patients needs and set goals. o Working: perform on-going assessments, assist patient with problem solving and behavior changes, evaluate coping strategies used by patient in the past, introduce patient to others on the unit, revise goals and plans as needed, support patients use of new coping skills. o Termination: summarize goals and achievements, allow patient to share feelings about termination of relationship, discuss ways for patient to incorporate new healthy behaviors into his/her life. • Transference and Countertransference o Transference: occurs when a patient views the nurse as being similar to an important person in his/her life (often a person of authority). Can result in patient treating nurse like this individual. o Countertransference: occurs when the patient reminds the nurse of someone in his/her life, which induces strong personal feelings and may cause the nurse to treat the patient differently. • Prevention o Primary: focus on prevention of MH problems (community education, programs) o Secondary: focus on early detection and screening for mental illness (screening for depression in older adults) o Tertiary: focus on rehabilitation and prevention of complications in patients who have already been diagnosed w/ mental illness (support group for those w/ substance abuse disorder) Non-pharmacological Therapies • Psychoanalysis: assesses unconscious thoughts and feelings. Based on belief that internal conflicts stem from early childhood experiences. Focuses on past relationships. • Cognitive reframing: identifies negative thoughts, examines the cause, and replaces negative self-talk with healthier and more constructive thinking (i.e. positive self statements) o Includes: priority restructuring, journal keeping, assertiveness training, monitoring thoughts • Behavioral therapies o Modeling: therapist serves as a role model for patient. Demonstrates appropriate behavior. o Operant conditioning: provides positive rewards for desired behavior. o Systemic desensitization: progressive exposure to anxiety causing stimuli while using relaxation therapies. o Aversion therapy: punishment for maladaptive behavior (ex: bitter taste, mild shock) to promote behavior change. o Others: guided imagery, biofeedback, thought stopping, muscle relaxation. • Group therapy: o Goals: allows members to share common feelings and experiences, learn alternative ways to solve problems.  Silent member: divide group into pairs to discuss topic, then summarizes discussion to group  Member constantly talking: ask group to discuss their feelings regarding the member’s monopolizing behavior  Angry/agitated member: move group members away from member to prevent injury. • Electroconvulsive therapy (ECT) o ECT: use of electrical activity to induce a seizure, which may enhance the effects of NT in the brain o Performed 2-3 times a week for a total of 6-12 treatments. o Indications: major depressive disorder (used in conjunction with antidepressants, does not replace medication therapy). Schizophrenia, acute manic episodes o Medications:  Anticholinergic: atropine – decrease secretions  Short acting anesthetic: Propofol  Muscle relaxant: succinylcholine, to paralyze muscles during seizure and prevent injury o Nursing care:  Get informed consent prior to procedure  Treat HTN and dysrhythmias before ECT  Monitor VS and mental status before, during, and after  Provide ongoing cardiac monitoring (ECG, BP, SPo2) as ECT puts stress on the heart during seizures. o Complications:  Short-term memory loss is expected, and may persist for several weeks.  Relapse of depression. ECT is not a permanent cure. • Transcranial l Magnetic Stimulation and Vagus Nerve stimulation o TMS: use of magnetic pulsations to stimulate the cerebral cortex of the brain. Performed as outpatient daily for 4-6 weeks. Electromagnet placed on patient’s scalp. Patient may feel tingling, tightening of jaw muscles. Used for depression resistant to pharmacological treatment. o VNS: device is surgically implanted in patient’s chest that provides electrical stimulation through the vagus nerve to the brain. Has been shown to increase levels of serotonin, NE, and dopamine in the body. Can be turned off by placing external magnet over site of implant. Used for depression resistant to ECT and pharmacological treatment. Mental Health Disorders • Obsessive Compulsive Disorder (OCD) o Patient has persistent thoughts or urges that cause anxiety. The patient engages in compulsive/obsessive behaviors to alleviate anxiety. Rituals are time consuming and limit time for other activities. Patient adheres to rigid set of rules. o Treatment and nursing care:  Help patient set time limits for compulsive behaviors and lengthen the time between rituals  Cognitive therapy to help the patient identify source of anxiety that leads to compulsive behavior  Thought stopping to interrupt OCD  Provide meds: SSRIs, SNRIs, anti-anxiety meds. • Posttraumatic Stress Disorder (PTSD) o Exposure to traumatic event (rape, physical abuse, military combat) that can cause the following manifestations: flashbacks, distressing dreams, difficulty concentrating, insomnia, anxiety, irritability, detachment from others, hypervigilance, exaggerated startle response, feeling of guilt and negative self-image. o Treatment options:  Cognitive behavioral therapy  Prolonged exposure therapy  Eye movement desensitization and reprocessing (EMDR)  Meds: SSRIs, SNRIs, TCAs  Other treatment options: hypnotherapy, biofeedback • Dissociative disorder o Types:  Depersonalization/derealization disorder. Feeling of detachment from one’s body environment.  Dissociative amnesia: lack of memory regarding personal information that is triggered by a traumatic event. o Nursing Care:  Help patient make decisions during dissociative periods  Encourage use of grounding techniques (ex: clap hands, touch objects) • Depressive Disorder o Risk factors:  Family history  Females between 15-40 YO  Patients over 65  Medical illness  Negative life event  Substance abuse disorder  Single l o s/s:  anergia, anhedonia, anorexia, fatigue, flat facial expression, poor grooming hygiene, slowed thinking and speech, indecisiveness, psychomotor changes. o Types of depressive disorders:  MDD: occurs every day for > 2 weeks within 5 or more of the following symptoms: depressed mood, insomnia or excess sleeping, difficulty concentrating, indecisiveness, suicide ideation, anhedonia, weight gain/loss of 5% over 1 month, psychomotor increase or decrease.  SAD: typically occurs in w inter. Light therapy is first-line treatment.  Dysthymic disorder: milder form of depression, usually with childhood onset. Contains at least 3 symptoms of depression.  PMDD: associated w/ luteal phase of menstrual cycle. Symptoms: rapid mood swings, anergia, overeating, difficulty concentrating. o Phases of MDD:  Acute phase: severe clinical signs of depression, 6-12 weeks in duration, possible need for hospitalization, greatest risk for suicide during this phase (1:1 observation needed). Goal: treat and reduce depressive manifestations.  Continuation phase: increased ability to function, 4-9 months in duration. Goal: relapse prevention through education, medication therapy, psychotherapy.  Maintenance phase: remission, can last for 1 or more years. Goal: prevention of future depressive episodes. o Nursing care:  Priority: assess patients suicide risk and implement 1:1 observation if indicated.  No private room (due to risk of self harm)  Communicate w/ simple sentences. Allow extra time for responses (due to slowed thinking and idecisiveness)  Provide meds as ordered: SSRIs, SNRIs, TCAs, MAOIs, atypical antidepressants, alternative therapies (St. Johns Wart)  For patients with suicidal ideation, there is increased energy to carry out a plan after 1 week of treatment  Procedures: ECT, TMS, VNS • Bipolar Disorder: o Mood disorder w/ recurrent episodes of mania and depression. o Behaviors:  Mania – excessively elevated mood, lasting >=1 week. Usually requires hospitalization.  Hypomania – less severe form of mania, does not require hospitalization  Rapid cycling - >= 4 episodes of mania or hypomania within 1 year. o Types of Bipolar:  Bipolar I: at least one episode of mania alternating with major depression  Bipolar II: one or more hypomania episodes, alternating w/ major depression.  Cyclothymic disorder: two years of repeated hypomanic episodes alternating w/ minor depression. o Risk factors:  Genetics, psychological stressors, neurological disorders, substance use disorder o Mania s/s:  Mood swings, restlessness, flight of ideas, pressured speech, grandiosity, impulsiveness, poor judgment, decreased attention span, insomnia (risk of physical examination), neglect of ADLs (including eating, drinking), possible hallucinations or delusions. o Depressive s/s:  Anergy, flat affect, anhedonia, crying, difficulty concentrating, possible risk for suicide, lack of grooming/hygiene, changes in sleep and appetite. o Nursing Care during manic episodes:  Provide safe environment. Protect patient from poor judgement (i.e. giving away money, sexual indiscretions).  Decrease stimulation  1:1 observation, seclusion, or restraints may be necessary if patient poses a risk to self or others.  Provide frequent rest periods.  Monitor sleep, fluid and food intake. Provide high-calorie portable snacks (finger foods)  Set limits, give concise explanations, use a calm approach. o Medications: lithium, anticonvulsants, antipsychotic meds, anti-anxiety meds, antidepressants. • Psychotic Disorders o Schizophrenia: Psychotic thinking/behavior for >=6 months. Functioning and relationships significantly impaired. o Schizotypal personality disorder: personality impaired, but not as severe as schizophrenia. o Schizophreniform disorder: psychotic thinking/behavior for 1-6 months. May not affect social and occupational functioning. o Schizoaffective disorder: patients meets criteria for schizophrenia AND depressive or bipolar disorder. o Psychotic disorders s/s:  Positive symptoms: presence of things not normally present – hallucinations, delusions, strange motor activity, speech alterations, agitation  Negative symptoms: affect, alogia, anergia, ahnedonia, avolition  Other s/s: disordered thinking, poor problem solving, difficulty concentrating, memory issues, hopelessness, possible suicide ideation, depersonalization, derealization. o Psychotic disorders: alterations in speech  Flight of ideas: each sentence relates to a different topic. Listener unable to follow patient’s thoughts.  Neologisms: made-up words that only the patient understands.  Echolalia: patient repeats exactly what is said to him/her.  Clang associations: meaningless rhyming of words  Word salad: words are jumbled together in a meaningless way. o Psychotic disorders: hallucinations  Sensory perception that do not have an external stimulus. Types: • Auditory: patient hears voices or sounds o Command hallucinations: voice instructs patients to perform action (at risk to hurt self or others) • Visual: patient sees person or things. • Olfactory: patient smells odors. • Gustatory: patient experiences tastes. • Tactile: patient feels body sensations. o Nursing Care:  Provides safe, structured environment  Attempt to identify and reduce symptoms triggers  Decrease environment stimuli  Priority: ask patient directly about hallucinations, including command hallucinations! Provide safety of patient and/or others (1:1 observation)  Do not argue or agree with hallucinations or delusions ex: “I don’t hear anything, but it must be scary to hear voices” o Medications:  Conventional and atypical antipsychotics • Personality Disorders o Types:  Paranoid: distrust and suspiciousness of others  Schizoid: emotional detachment, indifference  Schizotypal: magical thinking, odd beliefs, perceptual distortions.  Antisocial: exploitation, manipulation, and deceit of others. Verbally charming. Fails to accept personal responsibility.  Borderline: splitting behavior (characterize people or things as ALL good or ALL bad), emotional lability, impulsive behaviors, high risk of self-injury or suicide.  Histrionic: attention-seeking, seductive, flirtatious.  Narcissistic: arrogant, need for constant admiration, lack of empathy towards others.  Avoidant: avoids social situations and interpersonal contact due to extreme fear of rejection, abandonment.  Dependent: extreme dependency in a close relationships. Needs excessive input from others to make decisions.  OCD: focus perfection, order, and control that may prevent patient from completing a task. o Nursing: mod  Provide safety for patients at risks for self-injury or violence (ex: borderline personality disorder at high risk for self-injury)  Provide limits and consistency (especially for borderline and antisocial personality disorders)  Provide assertiveness training for dependent and histrionic personality disorders.  Respect the need for patients with schizoid and schizotypal personality disorder to isolate themselves. • Alzheimer’s Disease o Non-reversible neurocognitive disorder (i.e. dementia), resulting in memory loss, problems w/ judgement, and changes in personality.  Stage 1 (mild): memory lapses, frequently misplacing items, difficulty concentrating, no issues w/ ADLs.  Stage 2 (moderate): difficulty planning/organizing, wandering, personality and behavior changes.  Stage 3 (severe): assistance needed w/ ADLs, incontinent, loss of ability to move, death (usually due to infection or choking) o Defense mechanisms:  Denial: refusal to believe changes  Confabulation: patient makes up stories to prevent admitting that she/he does not remember things  Preservation: patient repeat o Medications:  Donepezil (cholinesterase inhibitor): slows cognitive deterioration and improves ability perform ADLs. Side effect includes GI upset, bradycardia. Administer once daily at bedtime. o Nursing care:  Provide safe environment (protect from falls, wandering)  Use monitors and bed alarams as needed  Place patient in room near nurses station  Provide prominently displaced calendar and clock.  Reorient patient as needed  Maintain consistently w/ caregivers  Use calm voice, short sentences  Limit choices o Home Safety  No scatter rugs  Install door locks  Lock away cleaning supplies  Provide good lighting (especially over stairs)  Mark step edges w/ colored tape  Install handrails in bathroom  Place mattress on the floor  Secure electrical cord to baseboards  Remove clutter • Dementia vs Delirium o Dementia  Gradual onset  Level of consciousness, vital signs unchanged  RT to neurological disorder (alzheimer’s disease, traumatic brain injury, parkinson’s, etc).  Progressive, irreversible o Delirium  Rapid onset  Level of consciousness altered, vital signs may become unstable  Extreme distractibility  Caused secondary to a medical condition (infection, electrolyte imbalances, substance abuse, et.)  Reversible if underlying cause corrected • Alcohol o S&S of intoxication: slurred speech, decreased motor skills, decreased level of consciousness, memory impairment, BAC >= 0.08 is considered legally intoxicated in most states. o Withdrawal:  Timing: starts within 4-12 hours of last drink, peaks at 24-48 hours  S&S: vomiting, tremors, restlessness, tachycardia, tachypnea, hypertension, fever, seizures. o Alcohol withdrawal delirium  Timing: 2-3 days after cessation of alcohol  S&S: hallucinations, severe HTN, delirium, cardiac dysrhythmias  **most important question: “when did you have your last drink?” o AA  Purpose: to stay sober and help other alcoholics achieve sobriety. AA encourages recovery through peer support  Key principles/points: • Total abstinence is the only cure for alcohol use disorder • Individuals should take responsibility for recovery rather than the addition • Individuals with an addiction cannot place blame on other people or issues for their addiction. • Individuals with an addiction must face their problems and their feelings. • Program is not intended for addiction to other substances • Securing a sponsor improves chance of recovery • Cocaine, Opioids o Cocaine  S&S intoxication: tachycardia, hypertension, dilated pupils, chest pain, tremor/seizures, irritability/agitation  S&S of withdrawal: fatigue, depression, decreased motor skills, disturbing dreams, agitation o Opioids  S&S of intoxication: slurred speech, decreased RR, decreased LOC, impaired judgement and memory  S&S of withdrawal: sweating, rhinorrhea, pupil dilation, tremors, irritability, insomnia, GI upset, muscle spasms • Anorexia Nervosa o Eating disorder characterized by distorted body image that causes an individual to restrict calorie intake. o S&S: low body weight, low BP, decrease pulse, decreased body temperature, constipation, lanugo, mottled/cool extremities, poor skin turgor, amenorrhea o Criteria for hospitalization:  Weight loss > 30% over 6 months  Heart rate <40 /min  SBP <70 mmHg  Body temperature <36 degrees C  EKG abnormalities  Electrolyte imbalances • Bulimia Nervosa o Eating disorder characterized by the ingestion of an abnormally large amount of food in short-term period, followed by an attempt to avoid gaining weight by purging what was consumed (though vomiting, diuretics, and/or enemas). o S&S: normal (or slightly higher) body weight calluses on knuckles (Russel’s sign) from self-induced vomiting, enlargement of parotid gland, tooth erosion, hypokalemia, metabolic alkalosis (from vomiting) or metabolic acidosis (from laxative use) • Eating Disorders: Nursing Care o Offer rewards for the amount of calories consumes, not the amount of weight gained. o Monitor VS, I/O, weight (weigh patient each morning before the intake of foods or fluids). o Restrict caffeine due to its stimulative and diuretic effects. o Provide a high-fiber diet to control constipation o Monitor and restrict the client’s exercise o Provide small, frequent meals at scheduled times o Closely monitor patient during and after meals • Somatic Symptom Disorder o Form a mental illness where the patient experiences physical manifestations that are the result of psychological factors (no underlying physical pathology). RT: conversion disorder. o Risk factors: female gender, teen/young adult, childhood trauma, mental illness (depression, anxiety, personality, disorder), recent stressful event. o Nursing care: acknowledge symptoms as being real to the patients o Reattribution treatment: helps patients identify the link between psychological factors and physical manifestations. o Administer medications as prescribed: antidepressants, anxiolytics. • Factitious Disorder o Form of mental illness that drives an individual to report non-existent physical or psychological symptoms in an effort to fill an emotional need for attention  Factitious disorder imposed on another: an individual deliberately causes injury/illness to a vulnerable person in order to get attention (or get relief from responsibility) o Nursing care: avoid confrontation, build rapport/trust with patient, ensure safety of vulnerable persons, communicate suspicion of factitious disorder of the health care team o Malingering: not a mental illness. Exaggeration of ling about symptoms to escape duty/work or collect disability. • Oppositional defiant disorder o Disorder in a child or adolescent characterized by defiant behavior against authority figures, such as parents or teachers. Individuals view their behavior as a response to unreasonable demands. Can develop into conduct disorder. o Manifestations: disobedience, hostility, stubbornness, argumentativeness, limit testing, refusal to compromise or take responsibility for misbehavior. o Interventions: use calm, firm approach. Provide short, clear expectations. Set clear limits for behavior. Incorporate physical activities to help child use energy. Model and reward acceptable behavior. • Conduct Disorder o Conduct disorder: persistent behavior in children or adolescents that violates the rights of others and disregards societal norms o Risk factors: neglect of abuse by parents, large family size, lack of supervision, difficult temperament as baby. o Manifestations: bullying behavior, recklessness, volatile, temper, cruelity towards animals or other people, destroys property, lies and steals, low self-esteem, suicide ideation. o Interventions: reduce environment stimuli. Use calm, frim approach. Provide short, clear expectations. Set clear limits for behavior. Incorporate physical activities to help child use energy. Model and reward acceptable behavior. • Attention deficit hyperactivity disorder (ADHD) o ADHD: condition characterized by inattention (difficulty paying attention and focusing, hyperactivity) (inability to sit still) and impulsivity (acting without regard to consequences). Increase risk for injury. o Interventions: use calm, firm approach. Set clear limits for behavior and consequences for unacceptable behavior. Incorporate physical activities to help child use energy. Provide safe environment (remove unnecessary equipment from child’s environment). Give positive feedback when child completes a task. Decrease distractions during meal time. o Meds: methylphenidate (Ritalin, methylin), amphetamine mixture • Autism o Genetic neurodevelopment disorder that affects an individual’s ability to communicate and interact with other people. Abilities range from highly functional to poor functioning. o S&S: lack of eye contact, repetitive actions, strict observance routines, language delay, sleep disorders, digestive problems, epilepsy, allergies o Interventions: provide referral for early intervention, provide structured environment, use short/concise communication, give plenty of notice before changing routines, determine emotional triggers, encourage verbal communication. Pharmacological Interventions Anxiety Medications • Benzodiazepines o Alprazolam (Xanax)  Other benzodiazepoines: diazepam, lorazepam (many end w/ pam except chlordiazepoxide)  Indications: anxiety, seizures, muscle spasms, alcohol withdrawal, and induce/maintain anesthesia.  Mode of action: enhances GABA effect in the CNS  Side effects: sedation, amnesia, dependency / withdrawal, respiratory depression  Key points: short-term use only! Do not DC abrupt. Antidote is flumazenil. • Atypical Anxiokytics o Buspirone (BuSpar)  Indications: anxiety, panic disorder, OCD, PTSD  Side effect: dizziness, nausea, headache  Key points: no sedation. Dependency not likely, long-term use ok. Full effects not felt for several weeks. Take with meals to decrease GI upset. Anxiety and Depression • SSRIs: o Fluoxetine (Prozac)  Other SSRIs: sertraline, paroxetine (many end with -ine)  Indications: anxiety, depression, OCD, PTSD  Mode of action: inhibits serotonin reuptake (i.e. increases serotonin)  Side effects: sexual dysfunction, weight gain, insomnia  Key points: watch for serotonin syndrome (symptoms: agitation, hallucinations, fever, diaphoresis, tremors). Do not wake with St. John’s wort as this increases the risk for serotonin syndrome. Full effects not felt up to a month. Depression • TCA: o Amitriptyline (Elavil)  Other TCA: imipramine  Indications: depression, neuropathy, fibromyalgia, anxiety, insomnia  Side effects: sedation, orthostatic hypotension, anticholinergic side effects (urinary retention, constipation, dry mouth, blurry vision, photophobia, tachycardia), sweating, seizures.  Key points: to counteract anticholinergic side effects – chew gum, wear sunglasses, high fiber diet, increase fluid intake. • MAOI: o Phenelizine (Nardil)  Other MAOI: tranylcypromine o Indications: depression o Side effects: agitation/anxiety, orthostatic hypotension, HTN crisis o Key points: interactions w/ many other medications (including OTC cold medications, which can result in severe HTN). Do no eat food rich in tyramine such as: aged cheese, avacadoe, bananas, red wine, salami/pepperoni, chocolate (i.e. all the yummy foods!_. • Atypical Antidepressants o Bupropion (Wellbutrin)  Indications: depression and as an aid to quit smoking  Side effects: insomnia, HA, GI distress, weight loss, agitation, seizures  Other atypical antidepressant: trazodone (major side effect is sedation) Bipolar Medications • Mood stabilizer o Lithium  Indications: bipolar disorder  Side effects: GI upset, fine hand tremors, polyuria, weight gain, kidney toxicity, electrolyte imbalances  Key points: monitor plasma levels. Toxicity over 1.5 meq/L. Symptoms of toxicity: coarse tremors, confusion, hypotension, seizures, tinnitus, coma/death. NO diuretics, anticholinergics, or NSAIDs. Contraindicated for patients with renal disease. Closely monitor sodium levels. Need adequate fluid intake (203 L) and sodium intake. • Antiepileptics o Carbamazepine (tegretol), valproic acid (Depakote)  Indications: bipolar disorder and used as an anticonvulsant / antiepileptic  Carbamazepine side effects: blood dyscrasias (anemia, leukopenia, thrombocytopenia), vision issues (nystagmus, double vision), hypo-osmolarity, rash.  Valproic acid side effects: GI upset, hepatotoxicity, pancreastitis, thrombocytopenia Antipsychotic medications • Conventional o Chlorpromazine (thorazine), haloperidol (Haldol)  Indications: schizophrenia, psychotic disorders, mainly controls positive symptoms (delusions, hallucinations)  Side effect (MANY): • EPS: dystonia, parkinson’s symptoms (shuffling gait, rigidity), tardive dyskinesia (lip smacking, tongue rolling), akathisia • Neuroleptic malignant syndrome (NMS): fever, dysrhythmias, BP fluctuations, muscle rigidity • Others: agranulocytosis, anticholinergic effects, orthostatic hypotension, sedation, seizures  Key points: monitor VS every 1-2 hours. Anticholinergics (benzotropine, diphenhydramine) can be used to control EPS symptoms. Muscle relaxant (dantrolene) can be used to NMS. • Atypical o Risperidone (Risperdal)  Other atypical antipsychotic: clozapine, olanzapine  Indications: schizophrenia. Controls positive and negative symptoms (anergia, anhedonia, social withdrawal)  Side effects: diabetes, weight gain, increased cholesterol, sedation, orthostatic hypotension, anticholinergic effects, menorrhagia, decreased libido, clozapine carries risk for agranulocytosis  Key points: risperidone can be administered by IM injection 1 2 weeks (for non-compliant patients). Avoid alcohol. ADHD medications • Methylphenidate (Ritalin, Methylin) o Other ADHD medication: amphetamine mixture (Adderall) o Indications: ADHD and conduct disorders o Side effects: insomnia, dysrhythmias, decreased appetite, weight loss o Key points: do not administer at night, give medication immediately before or after meals, monitor childs weight during therapy. Alcohol Abuse • Medications during alcohol withdrawal o Benzodiazepines: chlordiazepoxide, diazepam, lorazepam – used to stabilize VS, decrease risk of seizures, decrease withdrawal manifestations o Carbamazepine: decrease risk of seizures o Clonidine: decreases autonomic response (decrease BP, HR) o Beta blockers: propranolol, atenolol – decreases autonomic response (decrease BP, HR) and craving • Medications to promote abstinence o Disulfiram (Antabuse): if patients ingests alcohol, they will get many unpleasant side effects, including: N/V, sweating, palpitations, and hypotension. o Naltrexone (vivitrol): suppresses craving of alcohol (also available as monthly IM injections) o Acamprosate (Campral): decreases abstinence symptoms (anxiety, restlessness) Medications for Opioids and Nicotine Withdrawal • Opioid Withdrawal o Methadone – used for withdrawal and long-term maintenance • Nicotine withdrawal o Bupropion (Wellbutrin) o Nicotine replacements- gum, patch, nasal spray o Varencline (Chantix)- reduce cravings and withdrawal symptoms; monitor patients closely for depression/suicidal thoughts. Loss/grief and psychological interventions • Types of loss o Actual loss: loss of a valued person or object, recognized by others (ex: loss of a spouse) o Perceived loss: loss felt by patient, but not obvious to others (ex: loss of financial independence) o Maturational loss: loss experienced during normal life transitions (ex: child leaving for college) o Situational loss: unexpected loss caused by external event (ex: tornado, car accident) • Kubler Ross 5 stages of grief o Denial: individual does not accept the reality of the situation o Anger: individual expresses anger at others o Bargaining: individual tries to negotiate for more time (or a cure). Uses “If only” statements. o Depression: individual is sad, mournful. o Acceptance: individual acknowledges loss and moves forward in his/her life, emotions are more stable • Grief o Normal grief: individual has some acceptance by 6 months o Anticipatory grief: grieving before an actual loss o Maladaptive (complicated) grief: grief is prolonged, severe, interferes, with normal functioning months after loss. No acceptance after 6 months. o Nursing care:  Use therapeutic communication (“You sound angry. Angry is a normal feeling when you lose someone. Tell me more”  Encourage individual to share memories about loved one  Encourage individual to use coping mechanisms successfully used in the past. • Crisis management o Types of crisis:  Situational: crisis RT unanticipated loss of change (ex: physical illness, job loss)  Maturational: crisis associated with developmental stage. Naturally occurring event during the life span (ex: retirement, child leaving college).  Adventitious: crisis RT natural disaster or crime (ex: rape, hurricane) o Nursing care: provide for patient safety. Remain w/ patient, use therapeutic communication. Assess past ways of coping. Help patient develop an action plan. • Suicide o Risk factors: untreated depression or other mental illness, family history, prior suicide attempt, chronic health problems, substance use disorder (alcohol, drugs), loss of job or loved one. Cultural risk factors: American Indian, Alaskan native ethnic groups. o Protective factors: religious beliefs, social support network, effective coping skills, access to health care. o Priority assessments:  Assess patients risk of suicide: does the patient have a plan? How lethal is it? Does the patient have access to intended method?  Is the patient thinking about hurting himself/herself?  Has the patient had a sudden change in mood from sad to happy/peaceful? This may indicate an intention to commit suicide. o Nursing care:  Provide one-on-one constant supervision  Document patient behavior every 15 minutes  Search belongings at admission. Remove dangerous objects: metal silverware, belts, shoelaces, tweezers, razors, plastic objects, glass, shampoo, perfume.  Do not place patient in private room.  Ask patient to agree to a no-suicide contract (does not replace other suicide prevention interventions)  Make sure patient swallows all medication  Recognize behaviors that may indicate intention to commit suicide (ex: giving away possessions, sudden change in mood, having more energy, showing appreciation to loved ones, getting affairs in order) • Anger Management o Aggressive behavior  Provide safe environment for patient and others  Encourage patient to express feelings verbally  Provide for as much personal space as possible  Sit/stand at eye level, maintain eye contact  Set limits, present options clearly, and inform patient of consequences of behaviors.  Provide medications if limit setting is not effective.  Have 4-6 staff members visible as “show of force” and to assist if necessary. o Verbal abuse: leave the room immediately and return later to check on patient. Refrain from arguing with patient. • Violent/Abuse Risk factors o Female partner o Pregnancy o History of violence family o Substance abuse (drugs, alcohol) o Children under 3 o Physically or mentally disabled children, children from unwanted pregnancies o Older adults, due to poor health and dependence on caregiver o Individuals trying to leave an abusive relationship. o Most common within family groups (vs. strangers) o Occurs across all economic/education levels. • Family Violence o Cycle of violence  Tension-building phase: minor episodes of anger, verbal abuse, vulnerable person is tense  Acute battering phase: serious abuse takes place  Honeymoon phase: abuser becomes loving is sorry for behavior. Abuser promises to change.  **after honeymoon phase, cycle beings again and again with periods of escalation and de-escalation (decreasing time between two over time) • Types of Violence o Physical violence: physical harm is directed towards another child (ex: child, intimate partner, older adult at home) o Sexual violence: sexual contact w/out consent o Neglect: failure to provide physical care (ex: food, clean clothes), emotional care (ex: interaction w/ child), education, and/or health care. o Economic maltreatment: failure to provide for needs of vulnerable person when funds are available • Signs of abuse o Infants:  Signs of shaken baby syndrome: respiratory distress, bulging fontanels, increase in head circumference  Bruising on infants under 6 months of age o Preschoolers and older:  Unusual location of bruising (abdomen, back, buttocks). Note: bruising is expected on arms, legs  Bruises in different stages of healing  Forearm spiral fractures  Presence of multiple fractures  Small round burns (possibly cigarettes)  Burns covering hands or feet (possibly from immersion in boiling water) • Sexual assault o Forced sexual contact. It is a crime of violence, aggression, and power (NOT a crime of passion)  Majority of perpetrators are known to be the victim  Alcohol or other drugs are often associated with acquaintenance rape. o Rape-trauma syndrome: response to sexual assault that can include:  Expressed reaction: crying, anger, hysteria  Controlled reaction: confusion, numb feeling  Somatic reaction: physical manifestations such as headache, muscle tension, GI manifestations, genitourinary manifestations o PTSD: reliving assault, flashbacks, hyperarousal, exaggerated startle response, fears/phobias, difficulty with ADLs, depression, sexual dysfunction o Compound rape reaction: mental health issues (depression, substance use disorder), physical illness o Silent rape reaction: nightmares, changes in sexual behavior, sudden onset of phobia, no verbalization of sexual assault o ***patient showing interest in intimate relationships is an indication of recovery from a rape-trauma event. o Nursing care:  Sexual assault nurse examiner (SANE): trained nurse that examines and collects forensic evidence (ex: blood, oral samples, hair samples, nail samples, genital swabs, and anal swabs). Requires informed consent.  Provide for patient safety  Administer prophylactic treatment for sexually transmitted diseases.  Administer emergency contraception for pregnancy risk.  Provide 24 hour hotline for rape survivors  Provide referrals (individual or group therapy)

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ATI Mental Health Basics study guide/ATI Mental Health Homework Assorted Questions from Chapters 1-32 Completed A./ATI Mental Health Chapter 10 Brain Stimulation Therapies/NR 326 ATI MENTAL HEALTH Completed A/RN Leadership ATI 2020

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