Exam I Blueprint Nur 215 2023 Kimberly PDF

**Nursing 215 - Physical/Mental Health Nursing II** **Exam I Blueprint** Approximately 60 questions worth 90 points and DA questions worth 10 points. Rounding rules per the Nursing Student Handbook will apply. This Blueprint outlines key components but is not all-inclusive. - The numbers are *...

**Nursing 215 - Physical/Mental Health Nursing II** **Exam I Blueprint** Approximately 60 questions worth 90 points and DA questions worth 10 points. Rounding rules per the Nursing Student Handbook will apply. This Blueprint outlines key components but is not all-inclusive. - The numbers are **approximate** and can overlap outline components. - Please refer to your Course Unit Outline for Assignments that facilitate this content. **[DA Problems -- DA problems worth 10 points -- no partial credit given]** - Be prepared to correctly set-up and show all components of Dimensional Analysis for the calculation of drug dosages. You will need to show ALL your work. - Know the rounding rules as identified in your Student Nursing Handbook and DA tutorial. - Know your conversions: examples include but not limited to mg/ml, mg/mcg, TBS/tsp/ml. **[Psychiatric Concepts and Nursing Principles \~ 10 questions]** - Nursing Practice & Law/Psychiatric Nursing, Patient Rights, Patient Identification, Consent, Restraints, HIPAA - **[Patient Rights]**: In psychiatric nursing, it is essential to respect and uphold the rights of patients. These rights include the right to confidentiality, informed consent for treatment, the right to refuse treatment (within legal boundaries), the right to a safe and therapeutic environment, and the right to dignity and respect. - **[Patient Identification:]** Properly identifying patients is crucial to ensure that care is provided to the correct individual. This helps prevent medication errors, wrong treatments, and other adverse events. - **[Consent:]** Informed consent is a fundamental ethical and legal principle in psychiatric nursing. It means that patients have the right to be fully informed about their treatment options, potential risks, benefits, and alternatives before they agree to any medical or psychiatric intervention. - **[Restraints]**: The use of physical or chemical restraints in psychiatric care is highly regulated due to the potential for abuse and harm. Restraints should only be used as a last resort when there\'s an imminent threat to the patient or others, and their use should be documented and monitored closely. - **[HIPAA (Health Insurance Portability and Accountability Act]**): HIPAA is a federal law that protects the privacy and security of patients\' health information. In psychiatric nursing, strict adherence to HIPAA regulations is crucial to safeguard - **Know voluntary vs. involuntary.** - In psychiatric nursing, \"voluntary\" and \"involuntary\" refer to the legal status of a patient\'s admission and treatment. These terms determine whether a patient has willingly sought treatment or has been admitted against their will, often due to concerns about their safety or the safety of others. - **[Voluntary Admission:]** - A patient is on a voluntary admission when they willingly seek psychiatric treatment and agree to be hospitalized or receive treatment voluntarily. - The patient has the right to sign themselves into the psychiatric facility and also has the right to request discharge or leave the facility against medical advice (AMA) as long as they are deemed competent to make such decisions. - Treatment plans and interventions are typically discussed with the patient, and their active participation in their care is encouraged. - **[Involuntary Admission:]** - Involuntary admission occurs when a patient is admitted to a psychiatric facility without their consent. This is typically done when there is a significant concern for the patient\'s safety or the safety of others due to their mental health condition. - Involuntary admission processes vary by jurisdiction but often involve the assessment of mental health professionals, legal authorities, or emergency psychiatric evaluations. - Patients on involuntary admission may have certain legal rights restricted temporarily to ensure their safety. However, these rights should be protected to the extent possible. - The goal of involuntary admission is to stabilize the patient\'s condition, and the patient\'s treatment plan is determined by the healthcare team, taking into consideration the patient\'s best interests. - If they are involuntarily committed, lose rights to refuse meds - Can only hold someone 24 hours before obtaining court order under involuntary commitment. **[Therapeutic Communication (what the nurse says and how the nurse acts) \~ 15 questions ]** - ***Be able to identify therapeutic and non-therapeutic phrases**.* - Prioritize therapeutic and non-therapeutic phrases as pertaining to specific client situations/scenarios. **[Therapeutic Communication]** Description: Includes both verbal and nonverbal interactions that include facial expressions, as well as body language, among the nurse, clients, colleagues, and health care providers. It is a reciprocal process that can create either a therapeutic interaction or communication barriers. 1. Communication is the primary tool used in the delivery of psychiatric nursing care and all nurse-client interactions (Table 7-1). 2. Face-to-face communication involves both the verbal and nonverbal expression of the sender\'s thoughts or feelings. 1. Voice inflection, rate of speech, and words convey cognitive and affective messages. 2. Nonverbal messages are communicated via body language, eye movements, facial expressions, and gestures (Fig. 7-1). 3. Messages are conveyed by the sender to the recipient through sight, sound, touch, and smell.\ Nonverbal messages can be very powerful; for ex-ample, wrinkling your nose at a malodorous client conveys a negative and rejecting message (Fig.\ 7-2. 4. The focus of therapeutic interaction is to establish a constructive relationship. 5. It is the means through which nurses influence the behavior of others; therefore it is critical to the successful outcome of nursing interventions - **[Know 5 elements of Therapeutic communication.]** - **Active Listening**: Actively listening means giving your full attention to the patient, focusing on their words and non-verbal cues. It involves making eye contact, nodding, and using verbal affirmations (e.g., \"I see,\" \"I understand,\" \"Tell me more\") to show that you are engaged and interested in what the patient is saying. Active listening helps patients feel heard and validated. - **Empathy**: Empathy is the ability to understand and share the feelings of another person. It involves recognizing the patient\'s emotions, acknowledging their experiences, and expressing understanding and compassion. For example, saying, \"I can imagine how difficult this must be for you\" demonstrates empathy. - **Non-Judgmental Attitude**: A non-judgmental attitude means withholding personal judgments or biases and refraining from criticizing or condemning the patient\'s thoughts, feelings, or behaviors. This creates a safe space for the patient to express themselves openly without fear of judgment. - **Open-Ended Questions:** Encouraging patients to share more about their thoughts and feelings through open-ended questions helps them explore their emotions and concerns in depth. Open-ended questions typically begin with words like \"what,\" \"how,\" or \"tell me about.\" For instance, instead of asking, \"Are you feeling sad?\" you might ask, \"Can you tell me how you\'ve been feeling lately?\" - **Reflection:** Reflection involves restating or paraphrasing what the patient has said to clarify and validate their feelings. Reflecting back their thoughts and emotions allows the patient to confirm that you understand them correctly. For example, if a patient says, \"I\'ve been feeling so overwhelmed with everything,\" you might reflect by saying, \"It sounds like you\'ve been experiencing a lot of stress.\" - **[Know/identify Types of Treatment Modalities ]** Types of Treatment Modalities A. Milieu therapy 1. The planned use of people, resources, and activities in the environment to assist in improving interpersonal skills, social functioning, and performing the activities of daily living (ADLs), as well as safety and protection for all clients. 2. Occurs in inpatient and outpatient settings by providing clients an opportunity to actively participate in treatment, decrease social isolation, encourage appropriate social behaviors, and educate clients in basic living skills. 3. Clients are provided with a safe place to learn and adopt mature and responsible behavior through staff limit setting and client responses to maladaptive social responses. 4. It uses limit setting; that requires consistent setting of appropriate limits by all staff, nurses, and physicians, and all health care workers to work with one another via shared communication to maintain and reestablish limit setting. 5. It uses activities that support group sharing, cooperation, and compromise (e.g., unit-governing groups). 6. Nursing interventions support client privacy and autonomy and provide clear expectations. B. Behavior modification 1. This process attempts to change ineffective or maladaptive behavioral patterns; it focuses on the consequences of actions rather than on peer pressure. 2. Positive reinforcement is used to strengthen desired behavior (e.g., a client is praised or given a token that can be exchanged for a treat or desired activity). 3. Negative reinforcement is used to decrease or eliminate inappropriate behavior (e.g., ignoring undesirable behavior, removing a token or privilege, giving a \"time out\"). 4\. Role modeling and teaching new behaviors are important interventions. C. Family therapy 1. This form of group therapy identifies the entire family as the client. 2. It is based on the concept of the family as a system of interrelated parts forming a whole. 3. The focus is on the patterns of interaction within the family, not on any individual member. 4. The therapist assists the family in identifying the roles assigned to each member based on family rules. 5. Life scripts (living out parents\' dreams) and self-fulfilling prophecies (unconsciously following what one thinks should happen, therefore setting it up to happen) are identified. 6. Congruent and incongruent communication patterns and behaviors are identified. 7. The goal is to decrease family conflict and anxiety and to develop appropriate role relationships. D. Crisis intervention 1. This form of therapy is directed at the resolution of an immediate crisis, which the individual is unable to handle alone. 2. A crisis may develop when previously learned coping mechanisms are ineffective in dealing with the current problem. 3. The individual is usually in a state of disequilibrium. 4. If a client is in a panic state as a result of the disorganization, be very directive. 5. Focus on the problem, not the cause. 6. Identify support systems. 7. Identify fast-coping patterns used in other stressful situations. 8. The goal is to return the individual to a precrisis level of functioning. 9. Crisis intervention is usually limited to 6 weeks. E. Cognitive therapy 1. It is directed at replacing a client\'s irrational beliefs and distorted attitudes. 2. It is focused, problem-solving therapy. 3. The therapist and client work together to identify and solve problems and overcome difficulties. 4. It is short-term therapy of 2 to 3 months\' duration. 5. It involves cognitive restructuring. G. Group intervention a. The group may be closed (set group) or open (new members may join. b. The group may be small or large (\>10 members). c. There are many types of groups (psychoeducation, supportive therapy, psychotherapy, self-help). d. Common nurse-led intervention groups include those that focus on medications, symptom management, anger management, and self-care. 3\. The phases in groups are as follows: a\. The initial, or orientation, phase is characterized by: 1. High anxiety 2. Superficial interactions 3. Testing the therapist to see if he or she can be trusted. b\. The middle, or working, phase is characterized by: 1. Problem identification 2. The beginning of problem solving 3. The beginning of the group sense of \"we\" c\. The termination phase is characterized by: 1. Evaluation of the experience 2. The expression of feelings ranging from anger to joy 4\. The advantages of groups are: a. The development of socializing techniques b. The opportunity to try new behaviors c. The promotion of a feeling of universality (i.e., not being alone with problems) d. The opportunity for feedback from the group, which may correct distorted perceptions e. The opportunity for clients to look at alternative ways of analyzing and dealing with problems - In psychiatric nursing, various treatment modalities are used to address the mental health needs of patients. These modalities can be tailored to the specific diagnosis, symptoms, and individual needs of each patient. Here are some common types of treatment modalities in psychiatric nursing: - **Medication Management**: Psychiatric medications, such as antidepressants, antipsychotics, mood stabilizers, and anxiolytics, are prescribed to manage and alleviate symptoms of mental disorders. Psychiatric nurses play a crucial role in administering and monitoring the effects and side effects of these medications. - **Individual Therapy**: One-on-one therapy sessions with a mental health professional, such as a psychiatrist, psychologist, or psychiatric nurse practitioner. Different therapeutic approaches, including cognitive-behavioral therapy (CBT), dialectical-behavior therapy (DBT), and psychoanalysis, may be used. - **Group Therapy:** Group therapy involves patients with similar mental health issues coming together to share their experiences, provide support, and learn coping strategies from each other. Psychiatric nurses often facilitate group therapy sessions. - **Family Therapy**: Family therapy aims to address family dynamics and interpersonal relationships that may contribute to or worsen mental health issues. It involves family members in the therapeutic process to improve communication and support for the patient. - Cognitive-Behavioral Therapy (CBT): CBT is a structured, goal-oriented therapy that helps patients identify and modify negative thought patterns and behaviors. It is often used to treat conditions like depression, anxiety, and PTSD. - Dialectical-Behavior Therapy (DBT): DBT is a specialized form of CBT designed for individuals with borderline personality disorder. It focuses on emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness. - Electroconvulsive Therapy (ECT): ECT is a medical procedure in which electrical currents are passed through the brain to induce controlled seizures. It is typically reserved for severe cases of depression, bipolar disorder, or schizophrenia. - Psychosocial Rehabilitation: This modality focuses on helping patients develop life skills, improve social functioning, and reintegrate into their communities. It can involve vocational training, education, and support in daily living. - Mindfulness and Relaxation Techniques: Techniques such as meditation, mindfulness, yoga, and progressive muscle relaxation can help patients manage stress, anxiety, and symptoms of various mental health disorders. - Art and Music Therapy: Creative therapies like art and music therapy can provide an outlet for self-expression and emotional processing, particularly for patients who have difficulty verbalizing their feelings. - Animal-Assisted Therapy: Interacting with trained therapy animals, such as dogs or horses, can have therapeutic benefits for individuals with various mental health issues, promoting emotional well-being and socialization. - Telehealth and Online Therapy: With advances in technology, psychiatric nursing can also involve telehealth services, allowing patients to receive therapy and support remotely via videoconferencing or other digital platforms. - **[Identify patient crisis and priority nursing interventions.]** - After anxiety, comes panic (this constitutes patient in crisis) - **Signs of a Patient Crisis**: need a lot of direction. - **Agitation and Restlessness**: A patient may become highly agitated, restless, and unable to sit still. They may display increased psychomotor activity. - **Verbal Aggression:** The patient may become verbally aggressive, making threats or expressing violent intentions toward themselves or others. - **Physical Aggression**: In some cases, the patient may become physically aggressive, attempting to harm themselves or those around them. - **Self-Harm or Suicidal Behavior**: Any signs of self-harm, suicide attempts, or suicidal ideation require immediate attention. - **Psychosis:** The patient may experience hallucinations, delusions, or severe disorganized thinking, making it difficult for them to understand reality. - **Severe Anxiety or Panic Attacks:** Intense anxiety or panic attacks can lead to hyperventilation, chest pain, and a sense of impending doom. - **[Priority Nursing Interventions in a Crisis:]** - **[Ensure Safety]**: The top priority is to ensure the safety of the patient, other patients, and staff. Remove any potential hazards or objects that could be used for self-harm or harm to others. - **[Call for Help]:** If the situation is escalating and you are unable to manage it alone, call for assistance from other healthcare providers or security personnel. - **[Engage in Therapeutic Communication:]** Attempt to establish rapport with the patient through calm and empathetic communication. Use a non-confrontational approach to de-escalate the situation. - **[Set Clear Boundaries:]** Clearly communicate behavioral expectations and limits to the patient. Let them know what behaviors acceptable and what consequences are may follow if they engage in aggressive or harmful actions. - **[Administer Medications:]** If prescribed, administer psychiatric medications to help stabilize the patient. This may include sedatives or antipsychotic medications, depending on the situation. - [**Physical Restraints (As a Last Resort**):] Only use physical restraints as a last resort when all other interventions have failed and there is an immediate threat to safety. Restraints should be used in accordance with legal and ethical guidelines and should be applied to and monitored by trained staff. - [**Continuous Observation**:] Assign a staff member to maintain continuous observation of the patient to ensure their safety and monitor their behavior. - **[Document the Crisis:]** Thoroughly document the patient\'s behavior, interventions implemented, and any medications administered. Accurate documentation is crucial for legal and clinical purposes. - **[Involve the Treatment Team:]** Inform the treatment team, including the psychiatrist or mental health professional, about the crisis situation so they can provide guidance and adjustments to the treatment plan. - **Debrief and Follow-Up**: After the crisis is resolved, conduct a debriefing session with the patient, family, and treatment team to discuss the incident, identify triggers, and develop a plan to prevent future crises. **[Characteristics/traits of Mental Health Disorders \~ 10 questions ]** - **[Anxiety and related disorders]** - **[Excessive Worry]:** Individuals with anxiety disorders often experience excessive, uncontrollable, and irrational worry about various aspects of life, such as health, relationships, work, or future events. - **[Restlessness]:** Restlessness or feeling on edge is a common symptom. People with anxiety may have difficulty sitting still or relaxing. - **[Physical Symptoms]**: Anxiety can manifest as physical symptoms, including muscle tension, trembling or shaking, sweating, headaches, stomachaches, nausea, and a racing heart (palpitations) with increased HR and BP, rapid shallow respirations, dry mouth and a tight feeling in the throat, anorexia, urinary frequency, and palmar sweating - **[Fatigue]:** Chronic anxiety can lead to fatigue and a feeling of being constantly drained, even if one gets enough sleep. - **[Irritability]:** Anxiety often contributes to irritability, making it difficult for individuals to remain patient and calm in various situations. - **[Sleep Problems]**: Anxiety can lead to sleep disturbances, including difficulty falling asleep, staying asleep, or experiencing restless, interrupted sleep. - **[Cognitive Symptoms:]** Anxiety can affect thinking and concentration, leading to difficulty focusing, memory problems, and racing thoughts. - **[Avoidance Behavior]:** People with anxiety disorders may go to great lengths to avoid situations or places that trigger their anxiety, which can interfere with daily functioning. - [**Panic Attacks**:] Panic disorder is characterized by recurrent panic attacks, which involve sudden and intense feelings of fear or terror, along with physical symptoms like a racing heart, shortness of breath, and a sense of impending doom. - **[Social Anxiety]:** Social anxiety disorder (also known as social phobia) involves intense fear of social situations or performance situations, leading to avoidance of such activities. - [**Specific Phobias**:] Specific phobias involve intense and irrational fears of particular objects or situations, such as spiders, heights, or flying. - [**Obsessions and Compulsions**:] Obsessive-Compulsive Disorder (OCD) is characterized by recurring intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) aimed at reducing anxiety. - **[Post-Traumatic Stress:]** Post-Traumatic Stress Disorder (PTSD) can develop after exposure to a traumatic event and involves symptoms like flashbacks, nightmares, severe anxiety, and avoidance related to the trauma. - **[Separation Anxiety:]** This condition is characterized by excessive anxiety about being separated from caregivers or loved ones, often seen in children but can persist into adulthood in some cases. - **[Generalized Anxiety Disorder (GAD):]** GAD is characterized by chronic and excessive worry about various aspects of life, often without a specific trigger, along with physical and cognitive symptoms of anxiety. - **[Levels Of Anxiety]** - **Mild anxiety** - Associated with daily life, motivates learning - Produces increased levels of sensory awareness and alertness - Allows client to appear calm and in control - **Moderate anxiety** - Continues to motivate learning with assistance from others - Allows client to be attentive and able to focus and problem solve-but not at an optimal level - Dulls perceptions of sensory stimuli; client becomes hesitant - Causes clients speech rate and volume to increase; client becomes wordy - Causes client to become restless - May be converted into physical symptoms, such as headaches, nausea, diarrhea and tachycardia - **Severe anxiety** - Stimulates SNS response - Causes sensory stimuli input to be disorganized - May cause perceptions to be distorted - Impairs concentration and problem-solving ability - Results in selective attention, focusing on only one detail - Results in the verbalization of emotional pain ( - "I need help, I can't stand this) - Causes tremors, increased motor activity - **Panic** - Causes perceptions to be grossly distorted; client is unable to differentiate real from unreal - Causes client to be unable to concentrate or problem solve - Loss of rational, logical thinking. Client may have hallucinations - Causes client to feel overwhelmed, helpless - Causes loss of control, inability to function - Can elicit behavior that may be angry and aggressive or withdrawn, with clinging and crying - Requires immediate intervention - Nursing interventions for panic disorders and phobias - Establish trust, listen, use a calm approach and direct, simple questions. Remain with client; do not leave alone - Provide a safe environment - Draw attention away from source of panic/phobia - Discuss alternate coping strategies - Suggest substitution of positive thoughts for negative ones - Assist in desensitizing client - Gradually and systematically introduce the client to the anxiety-producing stimuli - Administer antianxiety meds - Administer SSRI or other prescribed meds - Teach to decrease caffeine and nicotine intake - **[Panic disorders/Trauma/PTSD]** - **[Panic disorders- ]** - Discrete periods of intense fear or discomfort that are unexpected and may be incapacitating. - It is characterized by an irrational fear of an external object, activity, situation, and feelings of impending doom. - It is a chronic condition that has exacerbations and remissions. - The client transfers anxiety or fear from its source to a symbolic object, idea, or situation. - The client recognizes that the fear is excessive and unrealistic but "can't help it" - **[Trauma/PTSD]** - Description: DSM-5 no longer considers posttraumatic stress disorder (PTSD) as a component of anxiety disorders. New nomenclature is Traumatic and Stressor Related Disorders. These disorders include severe anxiety, which results from experiencing or witnessing a traumatic event (e.g., war, earthquake, rape, incest) directly or indirectly and can include a persistent re-experiencing of the trauma. Symptoms include intrusion, negative mood, dissociation, and arousal. A. Avoidance of events or situations that are reminders. B. Persistent negative alterations in cognitions and mood. C. Mood including numbing symptoms, as well as persistent negative emotional stress. D. Alterations in arousal and reactivity, including irritable or aggressive behavior and reckless or self-destructive behavior (suicidal ideation and substance abuse) A. Anxiety level is proportional to the perceived degree of threat experienced by the client. B. Anxiety is manifested in symptomatic behaviors: a. Intrusive thoughts b. Flashbacks of the experience c. Nightmares d. Emotional detachment C. Responses to anxiety include: shock, anger, panic, or denial. D. May manifest as self-destructive behavior such as suicidal ideation and substance abuse. E. Visible reminders of the trauma (e.g, scars, physical disabilities) may trigger reactions. - **Personality Disorders:** most personality disorders lack accountability, are very comfortable with themselves (can't treat someone who doesn't think they have a problem), may come across charismatic, but then reveal themselves as dysfunctional. - Involve lifelong dysfunctional patterns of relating and behaving that usually cause distress to others. - [Maladaptive] personality traits impair fulfillment of family, academic, employment or other functional roles. - Typically... non-psychotic illness characterized by [manipulative] behavior to satisfy some need. - Caused by [interaction] of biological, psychological, and social factors, including genetic components, life experiences, and environment. - All PD have four characteristics in common - Inflexible and maladaptive response to stress - Disability in work and relationships - Ability to evoke interpersonal conflict - Capacity to get under the skin of others - **Mood Disorders**; depressive, suicidal, bi-polar, manic-depressive/mania - **Bipolar Affective Disorder (BAD)** - Characterized by mood swings ranging from depression to mania with intervening periods of normal behavior. - It is marked by shifts in mood, energy, and ability to function - A chronic, recurrent illness that must be carefully managed throughout life. - 25% of patients with BAD have a family history - **Psychotherapeutic Management (Nurse Patient Relationship)** - - - - - - - - Calm & quiet environment - Avoid or caution with groups initially (1:1) - Encourage outlets for energy (walking, aerobics physical activities) - Structured activities - Psychotherapy - **Pharmacology for Mood Disorder** - - - - - **Schizophrenia-** - a major psychotic disorder (inability to recognize reality) characterized by withdrawal, affective disturbances, disruptive thought processes, and personality deterioration. - Positive s/s- excesses in behavior - disturbance in thought process - Symptoms are what you see - loud talking, hallucinations, delusions, disorganized speech, bizarre behavior - Negative s/s-missing behaviors - Disturbance with feelings or mood - Symptoms you cannot see - patient is withdrawn, has a decreased interest in pleasure (anhedonia) and lacks motivation (avolition), poverty of speech, inability to begin or sustain planned activities - more difficult to treat if these s/s are present - Cognitive symptoms: difficulty understanding information, trouble paying attention, inability to use info after learning it - A syndrome (cluster of s/s) that is profoundly disabling - **Characterized by:** - Disordered thinking (can't think clearly) - Perceptual disturbances (see and hear things) - Behavioral abnormalities (often inappropriate) - Affective disruptions (can't manage feelings) - Impaired social functioning (can't relate to others) - Sometimes lacks the ability to see that it's the meds that actually made them feel better - Often feels persecuted and has inappropriate behavior - **Nurse-patient relationship** - Establish trust - Provide a safe secure environment - Assist with hygiene and ADLs - Stress reality - Avoid arguing and avoid agreeing with inaccurate communications - **Psychopharmacology:** Antipsychotics Drugs - Traditional antipsychotics (phenothiazines) - Older drugs more side effects esp. extrapyramidal symptoms EPS - Non-phenothiazines - Long-acting drugs - Atypical antipsychotic drugs - newer drugs less severe side effects - Antiparkinsonian Drugs - **Milieu management:** - Limit setting - Avoid stressful environment - Structured time for activities (gross motor & noncompetitive) - Avoid fostering dependent relationship - Promote family involvement in therapy, teaching, medication - **Delusional Disorders** - **Psychosis** - **Characterized by:** - Inability to recognize reality - Altered thought process - Hallucinations - Delusions - CAN'T RELATE TO OTHERS - **Who is at risk for psychosis?** - Schizophrenia \*Depression - BAD \* PD (borderline) - Substance withdrawal \* Sensory deprivation - **Substance Abuse** - **Alcoholism:** a drinking pattern that interferes with physical, social, familial and emotional functioning - **Drug abuse**: state of dependency produced by repeated use of a substance that causes altered perceptions or mood, or both - **Physical evidence of drug use:** - Needle tract marks - Cellulitis at puncture sites - Poor nutritional status - Inflammation of nasal passages - Phenothiazides (Thorazine) may be used to decrease the discomfort of withdrawal - **Nurse-patient relationship:** - Many of those used for alcohol abuse will help here as well - Assess for rapid withdrawal which can be fatal - Confront denial (main coping style used by substance abusers) - Reinforce reality in simple, concrete terms - Encourage verbal expression of anger and depression - **Know S/S of alcohol withdrawal** - begin shortly after drinking stops (4-6 hrs) - anxiety, nausea, insomnia, tremors, hyper alertness - sudden or gradual increased in all V/S - delirium tremors (12-36 hrs after last drink) a\. diaphoresis, tachycardia, tachypnea b\. marked tremors c\. hallucinations d\. Paranoia - grand mal seizures are possible - **Provide care during withdrawal**: - Monitor v/s, I/O, electrolytes - Observe for delirium - Prevent aspiration, seizure precautions - Decrease stimulation - High protein with adequate fluids (limit caffeine) - Provide emotional support - **Psychopharmacology:** - Chlordiazepoxide HCL -Librium - Lorazepam - Ativan - Disulfiram - Antabuse - Vitamin B1 and B complex **[Mental Health Disorders -- Nursing Assessments, Interventions \~ 10 questions]** - For the disorders listed above; know nursing assessments and priority interventions. **[Neuroleptic Malignant Syndrome/Serotonin Syndrome \~ 2 questions ]** - Know characteristics of each. - **[Neuroleptic Malignant Syndrome (NMS):]** - **Cause**: NMS is primarily associated with the use of antipsychotic medications, especially first-generation (typical) antipsychotics but can occur with second-generation (atypical) antipsychotics as well. - **Onset**: NMS typically has a gradual onset but can develop rapidly. - **Core Features**: - Hyperthermia: A hallmark symptom of NMS is a very high fever, often exceeding 104°F (40°C). - Muscle Rigidity: Patients with NMS experience severe muscle stiffness and rigidity, which can lead to muscle breakdown and organ damage. - Altered Men - Mental Status: NMS can cause confusion, agitation, and altered consciousness, ranging from stupor to coma. - Autonomic Dysregulation: Patients may have autonomic nervous system dysfunction, resulting in fluctuations in blood pressure, heart rate, and diaphoresis (excessive sweating). - **Other Symptoms**: - Tachycardia (rapid heart rate). - Tremors. - Incontinence. - Elevated white blood cell count. - Elevated creatine kinase (CK) levels, indicating muscle breakdown. - Risk Factors: Risk factors for NMS include high-potency antipsychotics, rapid dose escalation, dehydration, and patient susceptibility. - **[Serotonin Syndrome:]** - **Cause:** Serotonin Syndrome is typically associated with the use of serotonergic medications, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or the concurrent use of multiple serotonergic drugs. - **Onset:** Serotonin Syndrome often has a rapid onset and can occur within hours to days of initiating or increasing serotonergic medications. - **Core Features:** - Mental Status Changes: Patients may experience agitation, confusion, delirium, or even seizures. - Autonomic Hyperactivity: Symptoms can include increased heart rate, high blood pressure, dilated pupils, sweating, and flushing. - Neuromuscular Abnormalities: Patients may exhibit muscle rigidity, twitching, tremors, and clonus (repetitive, rhythmic muscle contractions). - Other Symptoms: - Gastrointestinal symptoms, such as nausea, vomiting, and diarrhea. - Hyperreflexia (excessive reflex responses). - Myoclonus (sudden, brief muscle contractions). - **Risk Factors:** Risk factors for Serotonin Syndrome include the use of multiple serotonergic medications, overdose, or drug interactions. - **Distinguishing Between the Two:** - Both conditions can present with altered mental status, autonomic dysregulation, and muscle rigidity. - The key distinguishing factor is the cause: NMS is associated with antipsychotic medications, while Serotonin Syndrome is associated with serotonergic medications or drug combinations. - Temperature elevation is typically more extreme in NMS compared to Serotonin Syndrome. - Serotonin Syndrome may include gastrointestinal symptoms not typically seen in NMS. - Biggest difference - NMS has labile BP - Serotonin syndrome, BP rises **[ECT \~ 3 questions]** - **Know definition, assessments, interventions, patient teaching**. - ***What is ECT (Electroconvulsive Therapy) in psychiatric nursing, and when is it typically used*?** - **[Definition:]** Electroconvulsive Therapy (ECT) is a medical procedure used in psychiatric treatment. It involves the administration of electrical currents to the brain to induce controlled seizures. ECT is typically conducted under general anesthesia and with muscle relaxants to minimize physical movements during the seizure. - **[Usage:]** ECT is often used when other treatments, such as medication and psychotherapy, have not been effective in managing severe mental health conditions like major depressive disorder, bipolar disorder, and treatment-resistant schizophrenia. - ECT involves the use of electrically induced seizures for psychiatric purposes. It is used with severely depressed clients who fail to respond to antidepressant medications and therapy. It may be used with extremely suicidal clients because 2 weeks are needed for antidepressants to take effect. - ***What are the nursing assessments required before, during, and after ECT administration?***   1. **[Before ECT:]** 1. Prepare client by teaching what the treatment involves. 2. Avoid using the word \"shock\" when discussing the treatment with client and family. 3. An anticholinergic (e.g., atropine sulfate) is usually given 30 minutes before treatment to dry oral secretions. 4. A quick-acting muscle relaxant (e.g., succinylcholine \[Anectine\]) or a general anesthetic agent such as methohexital sodium is given to client before the ECT. This helps prevent bone or muscle damage. 5. Have an emergency cart, suction equipment, and Oz available in the room. - Nursing assessments involve obtaining a thorough medical history, including allergies, current medications, and medical conditions. - Baseline physical assessments, such as vital signs, ECG, and lab tests, are performed to ensure the patient\'s suitability for ECT. - Mental status assessments are conducted to establish a baseline for the patient\'s cognitive and emotional state. - **[During ECT:]** - Continuous monitoring of the patient\'s vital signs, including heart rate, blood pressure, and oxygen saturation, is essential during the procedure. - Anesthesia providers closely monitor the patient\'s respiratory and cardiovascular status. - The psychiatric nurse assists in positioning and ensuring patient safety during the procedure. - **[After ECT:]** - Maintain patent airway; client is in an unconscious state immediately after ECT. - Check vital signs every 15 minutes until the client is alert. - Reorient client after ECT (confusion is likely upon awakening, and short-term memory impairment may occur. - Monitor LOC, VS, and any adverse effects or complications. - Mental status assessments are performed to evaluate changes in mood, cognition, and behavior following ECT. - NEED TO HAVE SUCTION AND THE EMERGENCY CART AVAILABLE - Respiratory assessment (due to anesthesia) - ***What patient teaching should be provided before and after ECT sessions?*** - **[Before ECT]**: - Educate the patient and their family about the ECT procedure, including its purpose, potential benefits, and possible side effects. - Discuss the importance of informed consent and ensure that the patient understands and consents to the treatment. - Address any concerns or misconceptions the patient may have regarding ECT. - Provide instructions about fasting and medication management on the day of the procedure. - **[After ECT]**: - Inform the patient about the possible side effects they may experience immediately after the procedure, such as confusion, memory loss, and headache. - Common complaints are - Headache - Muscle soreness - Nausea - Retrograde amnesia - Reassure the patient that these side effects are usually temporary and resolve over time. - Encourage the patient to rest and refrain from making important decisions or operating heavy machinery for the remainder of the day. - Discuss the potential need for multiple ECT sessions and the overall treatment plan. - Patient teaching is crucial to help patients and their families make informed decisions about ECT and to alleviate anxiety or fear associated with the procedure. Providing support and education throughout the ECT process is essential for the patient\'s overall well-being and successful treatment outcome. **[Delegation and Priority \~ 2 questions]** - As the nurse, how will you assign tasks and assignments. **[Medications (knowledge of meds, classification) \~ 10 questions]** - **Nursing assessments and interventions for each class** - **Nursing priority actions/assessments to identify toxicities and/or drug effectiveness.** - **Pertinent Lab work for assessing drug effectiveness.** - **Therapeutic ranges as discussed in class and within Learning Guide** - **Example: know Lithium lab ranges, assessments, s/s toxicity, know priority assessments and patient teaching.** - **Antianxiety meds** - **BENZOS** (chlordiazepoxide, diazepam, lorazepam, xanax) - **S/E:** Sedation, drowsiness, ataxia, dizziness, irritability, blood dyscrasias, habituation and increased tolerance - **Nursing implications:** - Administer at bedtime to alleviate daytime sedation. - Do not consume alcohol with this med. - Avoid driving or working around equipment. - Gradually taper drug therapy d/t withdrawal effects. Do not stop suddenly. - **NON-BENZOS** (Buspirone, Zolpidem, Ramelton) - **S/E:** dizziness, daytime drowsiness - **Nursing implications:** - Buspirone: Takes several weeks for antianxiety effects to become apparent. Intended for short-term use. - Zolpidem: Give with food 1-1/2 hr before bedtime - Ramelton: appropriate for clients with delayed sleep onset - **Antidepressants** - **Tricyclics** (Amitriptyline, Nortriptyline) - **Adverse reactions:** - anticholinergic effects: dry mouth, blurred vision, constipation, and urinary retention - CNS effects: sedation, psychomotor slowing, and poor concentration - Cardiovascular effects: tachy, ortho hypo, quinidinelike effect on the heart (assess history of MI), prolonged QTc interval - GI effects: n/v - **Nursing implications:** - Administer at bedtime to minimize sedative effect - Takes 2-6 weeks to achieve therapeutic results - 1-3 weeks should elapse between discontinuing tricyclics and initiating MAOI - Teach client to avoid alcohol - Avoid concurrent use of antihypertensive drugs - Carefully evaluate suicide risk - Lethal in overdose - **MAOI** - **Adverse reactions:** Tachy, urinary hesitancy/constipation, impotence, dizziness, insomnia, muscle twitching, drowsiness, dry mouth, fluid retention, Hypertensive crisis, confusion - **Nursing implications:** - **Does not play well with a lot of other meds** - Must not be used with tricyclics - Major concern is for dietary restrictions. Certain food and drug interactions can cause htn crisis (tricyclics for example) - May not be used with SSRI's - Do not eat foods with high tyramine content: aged cheese, red wine, beer, yogurt, chocolate, beef, chicken, bananas - Teach warning signs of htn crisis: headache, palpitations, ↑ BP - **SSRI** (fluoxetine (prozac), paroxetine, sertraline, citalopram, Lexapro) - **Adverse reactions:** drowsiness, dizziness, headache, insomnia, decreased appetite - **Nursing implications:** - Effective 2-4 weeks after tx is initiated - Should NOT be used with MAOI. Can cause htn crisis - Should wait at least 14 days between d/c'ing MAOI and starting fluoxetine - At least 5 weeks should lapse between d/c'ing Prozac and starting MAOI - May be gvn in the evening if sedation occurs - Monitor for serotonin syndrome - Rapid onset of altered mental status, agitation, myoclonus, hyperreflexia, fever, shivering, sweating, ataxia, diarrhea - Must be tapered slowly if discontinued or changing from one SSRI to another - - **Atypical antidepressants** (trazodone) - **Adverse reactions:** safer than tricyclics and MAOI in terms of s/e - **Nursing implication:** effective 2-4 weeks after tx begins - **Antipsychotics** - **Phenothiazines (**Chlorpromazine HCL, Loxapine) - **Adverse reactions:** Drowsiness, ortho hypo, weight gain, anticholinergic effects, extrapyramidal effects, photosensitivity, blood dyscrasis (granulocytosis, leukopenia), NMS - **Nursing implications:** - EPS effects are a MAJOR concern. To combat EPS symptoms, use Cogentin (anti-parkinsons med) - Takes 2-3 weeks to achieve therapeutic effect - Keep client supine for 1 hour after administration and advise to change positions slowly (ortho hypo) - Avoid: alcohol, sedatives, antacids - **Atypical antipsychotics (**risperidone, olanzapine, ziprasidone, quetiapine, clozapine). These medications treat positive and negative symptoms of schizo without significant EPS. They also have fewer s/e - **Adverse reactions:** - Risperidone: NMS, EPS, dizziness, GI symptoms, anxiety - Olanzapine: drowsiness, dizziness, EPS, agitation - Quetiapine: drowsiness, dizziness, headache, EPS, weight gain, anticholinergic effects - Clozapine: agranulocytosis, drowsiness, dizziness, GI symptoms, NMS - **Nursing implications:** - Monitor WBC weekly for first 6 months then biweekly - Baseline VS and ECG - Monitor for NMS and EPS - Seroquel (quetiapine)- monitor lipids, especially for obese, diabetic, or htn crisis patients - **Mood stabilizing drugs** - **Lithium (**range: 0.5-1.2) - **Adverse reactions:** - nausea, fatigue, thirst, polyuria, and fine hand tremors - weight gain - hypothyroidism - early signs of toxicity: diarrhea, vomiting, drowsiness, lack of coordination - possible renal impairment - **Nursing implications:** - Lithium is excreted by the kidneys. Maintain adequate serum levels - Assess electrolytes, especially sodium - Baseline studies of renal, cardiac, and thyroid status must be obtained before therapy begins - Monitor for early s/s of toxicity. If drug continues, coma, convulsions, and death may occur - Use with diuretics is contraindicated. Diuretic induced sodium depletion can increase lithium levels, causing toxicity - **Anticonvulsant Mood Stabilizers** - **Valproic acid** - **Adverse reactions:** n/v, anorexia, hepatotoxicity, neuro symptoms such as tremors, sedation, headache, dizziness - **Nursing implications:** - Administer with food - Monitor blood levels - Maintain serum levels 50-125 ug/ml - **Carbamazepine** - **Adverse reactions:** dizziness, ataxia, blood dyscrasis - **Nursing implications:** - Maintain serum levels at 8-12 g/ml - Stop drug if WBC drops below 3000 or neutrophil count is below 1500 - Monitor hepatic and renal function