Exam 15 - Care of the Patient with a Psych Disorder

Neurocognitive Mental Disorders

• Differ from other mental health disorders: An identifiable brain disease or dysfunction is the basis for the behavior.
• Affect cognitive/intellectual abilities: Effects range from mild memory lapses to severe loss and behavioral changes.
• Disorientation is a predominant characteristic.
• Delirium: Rapid change in consciousness over a short time, possible at any age.
  • Associated reduced awareness, disorganized thinking, sensory misinterpretation, and irrelevant speech.
  • Often disturbed sleep patterns.
  • Causes include: physical illnesses (fever, heart failure, pneumonia, azotemia, malnutrition), drug intoxication, anesthesia.
  • Treatment: Determine and correct the cause (homeostatic imbalance or chemical agents).
  • Nocturnal delirium (sundowning syndrome): Increased disorientation and agitation only at night.
• Dementia: Altered mental state secondary to cerebral disease.
  • Usually progressive, slow loss of intellectual function, often irreversible
  • Symptoms can severely interfere with daily activities.
  • Alzheimer's disease is the most common type (60-80% of cases in the US).
  • 5.7 million Americans had Alzheimer's in 2018, projected to be 14 million by 2050.
  • Nursing interventions include reality orientation and a safe environment.

Schizophrenia

• Thought process disorders: Bizarre, non-reality-based thinking.
• Defining characteristics: Gross distortion of reality, disturbed communication, social withdrawal, disorganization of thought, perception, and emotion.
• One of the most disabling mental illnesses.
• Onset typically in young adulthood, equal in both sexes, 1% of population experience at some point.
• Chronic disorder with residual disability.
• Often causes emotional and financial devastation for the family.
• Stress can exacerbate episodes.
• Biological basis, not poor mother-child relationship; brain tissue changes: enlarged ventricles (left larger than right), smaller cerebral cortex.
• Dopamine is present in excess.
• Possible pupil size differences, blinking rate changes, clumsiness, and right/left confusion.
• Behaviors are categorized as positive (excessive) or negative (absent).
  • Positive symptoms: Delusions (false beliefs), hallucinations (sensory experiences without stimuli), disordered thinking (loose association, concreteness).
  • Negative symptoms: Apathy (avolition), social withdrawal, alogia (reduced speech), blunted affect, anhedonia.
• Subtypes: Disorganized, paranoid (good prognosis with treatment), catatonic (fair prognosis), undifferentiated, residual (poor prognosis).
• Stages: prodromal (adolescence, lack of motivation, withdrawal, odd beliefs), prepsychotic (passive behavior, hallucinations/delusions), acute (loss of reality contact, inability to function), residual (symptoms similar to prodromal, followed by remission).
• Prognosis fair to poor, complex disorder.
• Treatment: Psychotherapies, antipsychotic drug therapy, therapeutic relationship.

Major Mood Disorders

• Mood disorders (affective disorders): Severe, inappropriate emotional responses, prolonged mood disturbances, thought distortions, symptoms associated with depression or mania.
• Mood: A prolonged emotion affecting a person's psyche.
• Extremes in mood: Depression to mania.
• Hereditary factors account for 60-80% of cases.
• Neurotransmitters (norepinephrine and serotonin) are deficient or excessive in mood disorders.
• Imbalances can be hereditary or due to environmental factors (stress, trauma).
• Depression: Exaggerated sadness, despair, low self-esteem, loss of interest, pessimism.
  • 8% of Americans experience moderate/severe symptoms in a 2-week period.
  • Affects all races, ethnicities, ages, socioeconomic groups.
  • Women affected twice as often as men.
  • Serious enough to cause suicidal thoughts/attempts.
  • Suicide prevention: recognize warning signs (verbal statements, actions).
  • Major depression (persistent depressive disorder): Repeated severe depressive episodes lasting over 2 years.
  • Dysthymic disorder: Daily moderate depression lasting over 2 years (lifestyle, but not enjoyable).
• Bipolar disorders (manic-depressive): Shifts between depression and mania.
  • Mania: Persistent overactivity, euphoria; if untreated, can lead to delirium and death.
  • Hypomania (early phase of mania).
• Cyclothymic disorder: Repeated mood swings of hypomania and depression, milder than bipolar.
  • No periods of normal function; frequently progresses to bipolar disorder
• Seasonal affective disorder (SAD) and postpartum depression are other affective disorders, connected to hormonal imbalances and respond well to treatment.

Anxiety Disorders

• Anxiety: Normal response to stress/threat (apprehension, uneasiness, agitation, uncertainty, fear).
  • Signal anxiety (learned response to event), free-floating anxiety (no identifiable source), anxiety trait (personality aspect of frequent anxious responses), generalized anxiety disorder.
• Panic attacks: Acute, intense, overwhelming anxiety (sudden symptoms peaking within 10 minutes).
  • Symptoms: Heart palpitations, sweating, trembling, dyspnea, chest pain, dizziness, fear of losing control, fear of dying, paresthesia, chills.
  • More common in women.
• Agoraphobia: Extreme anxiety triggered by situations with potential panic attacks, avoidance of potential triggers.
  • Treatment: Education, coping mechanisms, pharmaceutical blocking.
• Phobias: Irrational fear, thoughts focusing on phobia object, often recognizing irrationality but not controlling anxiety.
• Obsessive-Compulsive Disorder (OCD): Recurrent, intrusive, senseless thoughts (obsessions) that lead to compulsive behaviors (repetitive rituals to reduce anxiety).
• Post-traumatic stress disorder (PTSD): Response to intensely traumatic experiences, reliving experience in dreams/flashbacks.
  • Avoidance behaviors, guilt about survival, amnesia.
  • Types: Acute (symptoms within 6 months, about 6 months duration), Chronic (symptoms lasting 6 months or longer), Delayed (symptoms starting 6 months or more after).

Personality Disorders

• Inflexible, maladaptive patterns of behavior/thinking, impair functioning, typically emerge in adolescence/earlier, behaviors more troublesome to others than to the individual.
• Characteristics: Lack of insight, concrete thinking, poor attention, distorted self-perception, impaired relationships, poor impulse control, inflexible behavioral responses.
• 10 distinct personality disorders (DSM-V), clustered into groups based on behavioral similarities (Cluster A, B, C).

Somatic Symptom Disorders

• Physical disorder with a psychological trigger.
• Recurrent, multiple physical complaints/symptoms with no organic cause.
• Rule out other physical causes, drug reactions, mental health problems.
• Includes ulcerative colitis, irritable bowel syndrome, hypertension, etc.

Eating Disorders

• Anorexia nervosa: Self-imposed starvation, intense drive for thinness, fear of weight gain, distorted body image.
• Bulimia nervosa: Binge eating followed by purging or compensatory behaviors (e.g., excessive exercise, dieting).
• Binge-eating disorder: Frequent, recurrent binge eating without compensatory behavior.

Communication and Therapeutic Relationship

• Therapeutic communication, helping-trust relationship: Maximizes patient strengths, maintains self-esteem, assists in developing coping skills.
• Psychotherapy modalities: Behavior therapy, cognitive therapy, group therapy, play therapy, hypnosis, psychoanalysis.
• Adjunctive therapies: Occupational therapy, recreational therapy, music therapy, art therapy, hydrotherapy.
• Confidentiality limits: Duty to report child abuse/harm, duty to warn (patient expressing intent to harm).

Electroconvulsive Therapy (ECT)

• Treatment for severe depression, mania, or schizoaffective disorders unresponsive to other treatments.
• Brief electrical current induces a seizure.
• Muscle relaxants and anesthesia used to reduce complications (fractures, contusions).
• Temporary memory loss expected; confusion resolves in hours.
• Outpatient procedure.
• Pre-treatment tests are necessary (physical exam, blood work, EEG, X-rays).
• Post-treatment care: monitor vital signs, provide reassurance, supervision.
• Patient education is crucial for anxiety reduction.

Psychopharmacology

• Psychotropic medications (psychoactive): Control symptoms, monitoring for effectiveness and side effects.
  • Antidepressants: SSRIs/SNRIs, tricyclic agents, MAOIs.
    • Serotonin syndrome: Life-threatening, usually from SSRI interactions.
    • Symptoms: Altered mental status, autonomic dysfunction, neuromuscular abnormalities.
• Antimanic agents (lithium): Mood stabilizer for mania.
  • Narrow therapeutic range, requires close monitoring of blood levels, and careful diet management (sodium and fluid intake).
  • Lithium toxicity signs: Nausea, vomiting, diarrhea, drowsiness.
• Antipsychotic agents (neuroleptics): For schizophrenia, organic mental disorders with psychosis, and mania.
  • Dose-related side effects: Postural hypotension, sedation, photosensitivity, autonomic reactions, extrapyramidal symptoms, tardive dyskinesia.
• Antianxiety agents (anxiolytics): For anxiety.
  • Benzodiazepines, but abuse potential.

Alternative Therapies

• Herbal remedies (St. John's wort, kava, gotu kola, ginkgo, ginseng): Vary in quality and potency, potential drug interactions.
  • Patient education to avoid interactions, and require clarification of any interactions with prescription drugs.
• Aromatherapy: Use of scented oils, candles, incense.
  • Limited effects, use often amplifies that of other therapies.

Application of the Nursing Process

• Assessment, problem identification, planning, interventions, and evaluation.
• LPN/LVN participation in data collection, problem formulation, plan implementation, and evaluation.
• Patient teaching, health promotion interventions.
• Documentation accuracy, ongoing assessment, detailed descriptions.