Module 1 and 2: Scientific Foundation and Advanced Practice Skills PDF

**Module 1 and 2: Scientific Foundation and Advanced Practice Skills** **Test Taking Strategies** 1. Read the entire question carefully before answering and identify what the question is seeking. Do not skin over the words or read them too quickly. a. When reading the question pay a...

**Module 1 and 2: Scientific Foundation and Advanced Practice Skills** **Test Taking Strategies** 1. Read the entire question carefully before answering and identify what the question is seeking. Do not skin over the words or read them too quickly. a. When reading the question pay attention to keywords 2. Do not read into the question. Only use the info provided by the examiner to answer the question without making any assumptions or adding more information in the question 3. Read all the answer choices b. Narrow down options to 2 possible right answers c. Partially correct answers are not the correct answer d. When 2 answer choices are the opposite of on another, one is usually the correct answer e. The right answer option might have the same word(s) as the test question; it can be the same word or a synonym of the word f. Choose client-focused answers i. Best answer/choice: answers that acknowledge a patient's feeling and make the patient feel heard g. When many response choices are remarkably similar in meaning, they are usually wrong h. Be wary of absolutes: all, only, always, every, must, never, none, everything, nothing, etc. usually wrong 4. Questions that use adjective like "**priority**", "**initial action**" test your ability to prioritize i. Airway, breathing, circulation j. Maslow's hierarchy of needs (physiological needs (food, water, warmth, rest), security, etc.) k. Nursing process (assessment before intervention) assessment is collecting data to support the problem towards a resolution 5. Safety for the patient and other is usually the right answer l. Safety may cause you to intervene prior to assessment m. Safety first\*\* 6. Culture is important to be included in all nursing care 7. Critical thinking is important -- focus on rationale 8. Interprofessional collaboration is encouraged n. Try not to delegate work o. Collaborating with a provider is better **Lithium (0.6-1.2 mEq/L) (p 180)** - Lithium toxicity can occur when this level reaches 1.5 mEq/L or higher - Discontinue? - Gold standard for treating manic episodes - Evidence for anti-suicidal effects - Neuroprotective treatment of choice for bipolar disorder [Baseline labs before initiation of lithium to ensure safety and efficacy] (p. 180) - Thyroid panel (TSH) - Hyperthyroidism can mimic symptoms of mania - Lithium can cause hypothyroidism - Serum creatinine (0.6-1.2 mg/dL) - Kidney function (excreted by kidneys) - Blood urea nitrogen (BUN) (10-20 mg/dl) - Kidney function - Pregnancy test (human chorionic gonadotropin (HCG)) - Causes congenital heart defects - ECG for clinets older than age 50 - Can cause cardiac side effects [Side effects of lithium] (p 181) +-----------------------------------+-----------------------------------+ | Organ System Affected | Clinical Finding | +===================================+===================================+ | Endocrine | weight gain | | | | | | impaired thyroid function | +-----------------------------------+-----------------------------------+ | Central nervous system | Fine hand tremors | | | | | | Fatigue | | | | | | Mental cloudiness | | | | | | Headaches | | | | | | Coarse hand tremors with toxicity | | | | | | Nystagmus | +-----------------------------------+-----------------------------------+ | Dermatological | Maculopapular rash | | | | | | Pruritis | | | | | | Acne | +-----------------------------------+-----------------------------------+ | Gastrointestinal | GI upset | | | | | | Diarrhea | | | | | | Vomiting | | | | | | Cramps | | | | | | Anorexia | +-----------------------------------+-----------------------------------+ | Renal | Polyuria with related polydipsia | | | | | | Diabetes insipidus | | | | | | Edema | | | | | | Microscopic tubular changes | +-----------------------------------+-----------------------------------+ | Cardiac | T-wave inversions | | | | | | Dysrhythmias | +-----------------------------------+-----------------------------------+ | Hematological | Leukocytosis | +-----------------------------------+-----------------------------------+ **Refer PB page 113 (third bullet point)** - Kidney disease or drugs that reduce renal clearance, such as NSAIDS (ibuprofen, Indocin), thiazides (hydrochlorothiazide), and ACE inhibitors (lisinopril), may increase serum concentration of drugs that are excreted by the kidneys (such as lithium) - Know MOA - Signs of lithium toxicity: severe nausea, vomiting, and diarrhea, confusion, convulsions, drowsiness, blurred vision, slurred speech, muscle weakness, heart palpitations, coarse hand tremors, and unsteadiness while standing or walking (ataxia) - Intervention: D/C lithium and check serum lithium levels - Hyperkalemia can increase lithium levels - Hyponatremia can increase lithium levels **Hypertensive crisis (p 157)** - Hypertensive crisis occurs when MOA are taken in conjunction with foods containing tyramine, a dietary precursor to norepinephrine - When MAO is inhibited, tyramine exerts a strong vasopressor effect, stimulating the release of catecholamine, epinephrine, and norepinephrine, which can increase blood pressure and heart rate - Hypertensive crisis is life threatening and cannot be reversed unless more MAO is produced by the body - Hypertensive crisis and death also can occur when MAOIs are taken in conjunction with certain medications - Meperidine - Decongestants - TCAs - Atypical antipsychotics - St. John's wort - L-tryptophan - Stimulants and other sympathomimetics - Asthma medications - Signs and symptoms of hypertensive crisis (p 157) - Blood pressure is 180/120 mm Hg or greater - Sudden, explosive-like headache, usually in occipital region - Elevated blood pressure - Facial flushing - Palpitations - Pupillary dilation - Diaphoresis - Fever - Treatment of hypertensive crisis - Discontinue the MAOI - Give phentolamine (binds with NE receptor sites, blocks NE) - Stabilize fever - Reevaluate the person's diet and adherence, and reiterate medication guidelines as necessary **Teratogenic risks of common psychiatric medications (p 118, last paragraph)** - Benzodiazepines: Floppy baby syndrome, cleft palate - Buspar, SSRIs safer in pregnancy - Carbamazepine (Tegretol): Neural tube defects - Lithium (Eskalith): Epstein anomaly - Lamotrigine safer in pregnancy - Divalproex sodium (Depakote): Neural tube defects, specifically spina bifida, atrial septal defect, cleft palate, and possible long-term developmental defects - Think spina bifida\* **Side effects of mood stabilizers (p 181, 8^th^ bullet point after the table)** **Lamotrigine (Lamictal)** - **Black box warning:** serious rash **Signs and symptoms of Stevens Johnson Syndrome (SJS) (184)** - SJS is a rare, potentially life-threatening immune reaction to a foreign antigen that can occur with exposure to any anticonvulsant drug. Treatment includes stopping the offending agent with supportive measures, often in a hospital burn unit. Signs and symptoms of SJS include: - Fever\* - Facial swelling - Tongue swelling - Macules, papules, and "burning", confluent erythematic rash - Skin sloughing - Prodromal headache, malaise, arthralgia, and painful mucous membranes may occur before rash occurs **Divalproex Sodium (Depakote) (181)** - **Black box warning:** hepatotoxicity and pancreatitis **Carbamazepine (Tegretol) (181-182)** - **Black box warning:** agranulocytosis (decreased white blood cells) and aplastic anemia (pallor, fatigue, headache, fatigue, fever, nosebleeds, bleeding gums, skin rash, SOB) - SJS, particularly in Asians (screen for HLA-B\* 1502 allele before initiating) - The HLA-B\* 1502 allele is highly associated with **the** **outcome of carbamazepine-induced SJS** - Check pregnancy status (human chorionic gonadotropin (HCG)) before starting a female patient of child-bearing age (12-51 years old) on a psychotropic medication - **Folic acid** -- supports neural tube development during the first month that a woman is pregnant - It is recommended that all women planning or capable of becoming pregnant take 0.4mg-0.8mg of folic acid daily **Clozaril and Carbamazepine** - Risk for neutropenia is monitored by the absolute neutrophil count (ANC) only, not in conjunction with the white blood cell count - Normal ANC is between **2,500 and 6,000** - The normal range of WBC's in the blood is **4,500 and 11,000 WBCs per microliter** - Monitoring for Clozaril: during first 6 months: weekly; during second 6 months: every two weeks; then monthly if ANC is normal - DC Clozaril/Carbamazepine at ANC less than 1000 mm3\*\* (because of risk of neutropenia) - DC Clozaril/Carbamazepine at WBC of 2000-3000 (because of risk of agranulocytosis) - Monitor patients for signs of infection **(sudden fever, chills, sore throat, weakness)** **Body Mass Index (BMI)** BMI = [\$\\frac{\\text{wight\\ in\\ pounds}}{\\left( \\text{height\\ in\\ inches} \\right)\\ x\\ (height\\ in\\ inches)}\$]{.math.inline} x 703 **BMI** **WEIGHT** **STATUS** -------------- ----------------------- Below 18.5 Underweight 18.5-24.9 Normal 25-29.9 Overweight 30 and above Obese **Bulimia Nervosa (348-349)** - Weight usually within normal range\* - Erosion of dental enamel - Russel's sign - Hypertrophy of salivary glad - Rectal prolapse **Anorexia nervosa (348-349)** - Low BMI\* - Amenorrhea - Emaciation - Bradycardia - Hypotension - ECG changes - Inversion of T-waves - ST segment depression - Prolonged QT interval - Hypothermia - Yellow skin secondary to carotenemia - Dry skin - Brittle hair and nails - Lanugo growth on face, extremities, and trunk - Peripheral edema - Hypertrophy of salivary glands - Erosion of dental enamel - Russel's sign -- scarring or calluses on the dorsum of the hand, secondary to self-induced vomiting **Pharmacological Management (351)** - Medication management as adjunctive therapy to psychotherapy - No specific medication therapy for anorexia nervosa - Fluoxetine is FDA-approved for bulimia nervosa - SSRIs and TCAs effective in reducing the frequency of binging and purging - Treat associated symptoms, such as depression and anxiety, with appropriate pharmacologic therapy **Nonpharmacological Management (351)** - Multimodal treatment - Medical and nutritional stabilization - Weight restoration - Correction of electrolyte disturbance - Vitamin supplementation - Nutrition counseling - Dental care - Community resources - Eating disorder support groups - 12-step programs **Psychotherapeutic Interventions (351)** - Individual psychotherapy - Behavioral therapy - CBT - Family therapy - Group therapy **Inducers and Inhibitors (112-113)** - Clozapine is an atypical antipsychotic medication that is metabolized to a major extent by the cytochrome P450 enzyme CYP1A2 - **Enzyme Inducers** can decrease the serum level of other drugs that are substrates of that enzyme, thus possibly cause subtherapeutic drug levels. Examples include tobacco and carbamazepine **For example** **X dose of sertraline** - Start smoking = increase dose - Smoking increases metabolism of the drug - Stopped smoking/started smoking cessation = decrease dose - **Enzyme Inhibitors** can increase the serum level of other drugs that are substrates of that enzymes, thus possibly causing toxic levels. Ex: clarithromycin and ketoconazole **Inhibitors** **Inducers** --------------------------------- ----------------------------- Bupropion Carbamazepine Clomipramine Hypericum (St. John's Wort) Cimetidine Phenytoin Clarithromycin Phenobarbital Fluoroquinolones Tobacco Grapefruit and grapefruit juice (Smoking in general) Ketoconazole Nefazodone SSRIs **P 113 (second bullet point)** - Liver disease will affect liver enzyme activity and first-pass metabolism, possibly resulting in toxic plasma drug levels **P 113 (third bullet point)** - Kidney disease or drugs that reduce renal clearance, such as NSAIDs, may increase serum concentration of drugs that are excreted by the kidneys (such as lithium) - Older adults are more sensitive to psychotropics because of their decreased intracellular water, protein binding, low muscle mass, decreased metabolism, and increased body fat concentration - Everything decreasing except body fat concentration\* **MNEMONIC** - **INDUCERS**: ***B**ull**S**hit **CRAP GPS** INDUCES my rage!* - **B**arbiturates - **S**t. John's wort - **C**arbamazepine - **R**ifampin - **A**lcohol (chronic) - **P**henytoin - **G**riseofulvin - **P**henobarbital - **S**ulfonylureas - Plus, cigarette smoking - **INHIBITORS**: **SickFaces.com** - **S**odium valproate - **I**soniazid - **C**imetidine - **K**etoconazole - **F**luconazole - **A**lcohol (acute) - **C**hloramphenicol - **E**rythromycin - **S**ulfonamide - **C**iprofloxacin - **O**meprazole - **M**etronidazole Question: What is an important consideration regarding effects of smoking on quetiapine - Smoking may increase the metabolism of quetiapine, potentially reducing its effectiveness and close monitoring is required **Neurotransmitters** - **Norepinephrine (Noradrenaline)**: Produced in the **locus coeruleus** and **medullary reticular formation** - Affects attention and focus, mood regulation, sleep wake cycles, memory formation and is involved in fight or flight response, which helps the body react to stressful situations - Imbalances can contribute to anxiety and depression - **Serotonin**: Produced in the **raphe nuclei** of the **brainstem** - Regulates mood, appetite, sleep, memory, and learning. Low levels of serotonin are associate with mood disorders - Disorders: depression, anxiety disorders, OCD - **Dopamine**: Produced in the **substantia nigra (regulate motor movements), nucleus accumbens, and the ventral tegmental area (VTA)** - Influences reward and pleasure centers, motivation, and movement - Dopamine imbalances are linked to psychosis ad the high found in drug use - Disorders: schizophrenia, bipolar disorder, addiction, depression - **Acetylcholine**: Synthesized by the basal **nucleus of Meynert** - Involved in memory, learning, and muscle movement - Deficits in acetylcholine are associated with cognitive decline - Disorders: Alzheimer's disease, dementia **P 69-70** - **GABA (Gamma-aminobutyric acid)** is the most abundant inhibitory neurotransmitter in the brain. Decreasing GABA would increase anxiety - GABA reduces neuronal excitability, which helps with relaxation and stress reduction - Benzodiazepines are use to bind with GABA receptors to potentiate anxiolytic (calming) effects of GABA - **Disorders**: anxiety disorders, epilepsy, and other neurological disorders - Implicated in addiction\* - **Glutamate**: Is the most abundant excitatory neurotransmitter in the brain (increased levels of glutamate will increase anxiety levels - Involved in cognitive functions such as learning and memory. Imbalances can contribute to mood disorders and neurodegeneration - Increased level of corticotropin releasing hormone in the amygdala, hippocampus, and locus coeruleus increases symptoms of anxiety - **Disorders**: schizophrenia, bipolar disorder, major depressive disorder **Lobes of the Brain (65)** A diagram of a brain Description automatically generated **Cerebrum (65)** - Largest part of the brain, which is divided into two halves, the right and left cerebral hemispheres - Left hemisphere: dominant in most people; controls most right-sided body functions - Right hemisphere: controls left-sided body functions - Normal functioning requires effective coordination of two hemispheres - Both hemispheres connected by a large bundle of white matter, the corpus callosum, an area of sensorimotor information exchange between the two hemispheres - Each hemisphere is divided into four major lobes, which work in an interactive and integrated manner, and each with a distinct function **Lobes of the brain (65-66)** - **Frontal lobe**: largest and most developed lobe. Functions include: - Motor function: responsible for controlling voluntary motor activity of specific muscles - Premotor area: coordinates movement of multiple muscles - Association cortex: allows for multimodal sensory input to trigger memory and lead to decision making - **Seat of executive functions**: working memory, reasoning, planning, prioritizing, sequencing behavior, insight, flexibility, judgement, impulse control, behavioral cueing, intelligence, abstraction - **Language (Broca's area):** expressive speech - **Personality variables**: the most focal area for personality development - **Problems in the frontal lobe can lead to personality changes, emotional, and intellectual changes** - **Temporal lobe**; functions include: - **Language (Wernicke's area**): receptive speech or language comprehension - Primary auditory area - Memory - Emotion - Integration of vision with sensory information - **Problems in the temporal lobe can lead to visual or auditory hallucinations, aphasia, and amnesia** - **Occipital lobe**; functions include: - Primary visual cortex - Integration area: integrates vision with other sensory information - **Problems in the occipital lobe can lead to visual field defects, blindness, and visual hallucinations** - **Parietal lobe**; functions include: - Primary sensory area - Taste - Reading and writing - **Problems in the parietal lobe can lead to sensory-perceptual disturbances and agnosia** **Clock drawing test (CDT)**: the clock drawing test is a simple tool that is used to screen people for signs of neurological problems, such as Alzheimer\'s and other dementias - It is also used to assess executive function and cognitive dysfunction - It is a very quick way to screen a person for possible dementia. It often requires only a minute or two for completion - Impairments on the CDT can be associated with damage to the right parietal lobe (right hemisphere) - **Constructional apraxia** is characterized by an inability or difficulty to build, assemble, or draw objects - Constructional apraxia may be caused by lesions in the parietal lobe following stroke or it may serve as an indicator for Alzheimer's disease **Limbic System (66)** - Essential system for the regulation and modulation of emotion and memory - **Hypothalamus**: plays key roles in various regulatory functions such as satiety, appetite, sensations of hunger and thirst, water balance, circadian rhythms, body temperature, libido, and hormonal regulation - **Thalamus**: sensory relay station except for smell; modulates flow of sensory information to prevent overwhelming the cortex; regulates emotions, memory, and related affective behaviors - **Hippocampus**: regulates memory and converts short-term memory into long-term memory - the hippocampus also regulates motivation, **stress, emotion,** and learning - **Amygdala**: responsible for mediating mood, emotional memories, **fear, anxiety, anger,** emotion, and **aggression** Refer p 248 - the MOA that makes an antipsychotic medication "atypical" is related to the serotonin (5HT2A) receptor antagonism - **Dopamine pathways** **(watch Dirty Medicine video on YouTube)** - **Mesolimbic pathway:** - Hyperactivity of dopamine in the mesolimbic pathway mediates positive psychotic symptoms - Antagonism of D2 receptors in the mesolimbic pathway treats positive psychotic symptoms - **Mesocortical pathway:** - Decreased dopamine in the mesocortical projection is postulated to be responsible for negative and depressive symptoms of schizophrenia - **Nigrostriatal pathway:** - The nigrostriatal pathway mediates motor movements - Dopamine blockade in this pathway can lead to increase acetylcholine levels (increase salivation, lacrimation, blurry vision) - Blockage of dopamine (D2) receptors in this pathways can lead to extrapyramidal symptoms (EPS), e.g., dystonia, parkinsonian symptoms, and akathisia - Longstanding D2 bloacke in the nigrostriatal pathway can lead to tardive dyskinesia - EPS: increase acetylcholine levels and decrease dopamine levels - **Tuberoinfundibular pathway:** - Blockade of D2 receptors in this pathway can lead to increase prolactin levels leading to hyperprolactinemia which clinically manifests as amenorrhea, galactorrhea (risperidone), sexual dysfunction, and gynecomastia - Long-term hyperprolactinemia can be associated with osteoporosis **Extrapyramidal Side Effects (EPSE) (249, table)**  +-----------------------------------+-----------------------------------+ | Side Effect | Definition | +===================================+===================================+ | Akathisia | Motor restlessness; inability to | | | remain still; rocking, pacing, or | | | constant motion of unilateral | | | limb; also can manifest as a | | | subjective sense of restlessness | | | without objective finding | | | | | | **Note**: often mistaken for | | | increasing anxiety | +-----------------------------------+-----------------------------------+ | Akinesia | Absence of movement, difficulty | | | initiating motion, subjective | | | feeling of lack of motivation to | | | move | | | | | | **Note**: often mistaken for | | | laziness or lack of interest | +-----------------------------------+-----------------------------------+ | Dystonia | Muscle spasm, spasticity of | | | muscle group, especially back or | | | neck muscles; subjectively | | | painful | | | | | | **Note**: often mistaken for | | | agitation or unusual, stereotypic | | | movements characteristic of | | | schizophrenia | +-----------------------------------+-----------------------------------+ | Pseudo-Parkinson's | Presence of symptoms of PD | | | produced by D2 blockade; includes | | | shuffling gait, motor slowing, | | | mask-like facial expression, pill | | | rolling, tremors, and muscle | | | rigidity | | | | | | **Note**: mask-like facial | | | expression often confused as | | | affective blunting or flattening | +-----------------------------------+-----------------------------------+ | Tardive dyskinesia | Involuntary abnormal muscle | | | movement of the mouth, tongue, | | | face, and jaw that may progress | | | to limbs; can be irreversible; | | | can occurs as an acute process at | | | initiation of medication or as | | | chronic condition at any point in | | | treatment | +-----------------------------------+-----------------------------------+ **Acute Dystonia**: muscle spasms of face, neck, tongue, especially back or neck muscles; stiff neck, subjectively painful; facial grimacing - Other rare presentations include oculogyric crisis, which can lead to permanent injury. On physical exam, patients in an oculogyric crisis have prolonged involuntary upwards deviation of the eyes bilaterally. Discontinue medication. - Benzotropine (Cogentin) **Akathisia** - Restless (inability to remain still) - Pacing - Feet constantly in motion, rocking - A commonly used rating scale for the measurement of akathisia includes **the Barnes Akathisia Rating Scale and Extrapyramidal Symptom Rating Scale** - **Treatment**: - **Betablocker** like propranolol (betablockers can cause bronchospasm, betablockers are contraindicated in patients taking bronchodilators like albuterol) - **Benztropine (Cogentin)** - **Benzodiazepine** **Akinesia** - Absence of movement, difficulty initiating motion, subjective feeling of lack of motivation to move - **Treatment**: Benztropine (Cogentin) **Pseudo-parkinsonian symptoms:** Presence of symptoms of PD produced by D2 blockade - Muscle rigidity, shuffling gait, motor slowing, mask-like facial expression, pill rolling tremors in fingers - **Treatment**: Benzotropine (Cogentin) **Tardive dyskinesia**: involuntary abnormal movements of the mouth, tongue, face, and jaw that may progress to limbs; can be irreversible - Protrusions and rolling of tongue - Lip smacking and sucking - Chewing motion - Facial dykinesia - Can take up to 1-2 years to occur - Can occur as an acute process at initiation or as a chronic condition at any point in treatment - The AIMS (**Abnormal Involuntary Movement Scale**) aids in the early detection of TD - Treatment of TD is either to reduce the current dose or change client to an atypical agent - Medications like Deutetrabenzene (Austedo) and Valbenazene (Ingrezza) are FDA approved to treat TD - Cogentin should not be used as it could worsen symptoms - Note: metoclopramide (Reglan) can cause EPS lake TD, pseudo parkinson's Less likely to cause hyperprolactinemia -- Seroquel, abilify **Pharmacodynamics and Pharmacokinetics (111-112)** **Pharmacokinetics**: study of what the body does to drugs; includes absorption, distribution, metabolism, and excretion **Pharmacodynamics (113)**: study of what drugs do to the body; target sites for drug actions include receptors, ion channels, enzymes, and carrier proteins - Target sites for drug actions include receptors. Several types of pharmacodynamics involve receptors: - **Agonist effect**: drug binds to receptors and activates a biological response (opens the ion channel) - **Inverse agonist effect**: drug causes the opposite effect of agonist; binds to same receptor (activates a biological response by closing the ion channel) - **Partial agonist effect**: drug does not fully activate the receptors - **Antagonist effect**: drug binds to the receptor but does not activate a biological response **Medications that induce depression or mania (119, table)** **Induce depression** **Induce mania** ------------------------ -------------------------------------------------- Beta blockers Steroids Steroids Disulfiram (Antabuse) Interferon Isoniazid (INH) Isotretinoin (Acutane) Antidepressants in persons with bipolar disorder Some retroviral drugs Antineoplastic drugs Benzodiazepines Progesterone - **Prednisone/Flonase** (steroids) -- can exacerbate depression/mania - Mania - Increase dose of Depakote, lithium, lamotrigine - Depression - Increase Lexapro **Neuroleptic Malignant Syndrome (NMS) (253)** - Rare but potentially life-threatening - Caused by antipsychotics: most common with typical but has been reported with atypical antipsychotics - Assessment for symptoms of autonomic instability - Mutism - Hypotension - Extreme muscle rigidity - Hyperthermia - Tachycardia - Diaphoresis - Tachypnea - Coma and potentially death - Elevated creatine phosphokinase (CPK) -- muscle contraction/muscle destruction - Myoglobinuria (rhabdomyolysis) - Elevated WBCs (leukocytosis) - Elevated liver function tests (LFTs) - Treatment - Seek immediate medical care for treatment - Discontinue antipsychotic medications - Administration of Dantrium (dantrolene) or Parlodel (bromocriptine) for antipsychotic induced dopamine receptor blockade - Bromocriptine -- dopamine (D2) agonist - Dantrolene -- muscle relaxant (muscle rigidity) - Antipyretic (acetaminophen) and cooling blanket for hyperthermia - Intravenous hydration - Benzodiazepine for muscular rigidity **Serotonin Syndrome (157 (last paragraph) -- 158)** - Caused by antidepressant - Hyperreflexia - Myoclonic jerks, and loss of coordination - Agitation, restlessness - Rapid HR and elevation in BP - Headache - Sweating, shivering, and goose bumps - Confusion, fever, seizures, unconsciousness - Treatment - Discontinue the offending agent - Mild symptoms such as restlessness may respond to removal of the offending agent, close monitoring, and judicious use of benzodiazepine - More severe symptoms constitute a medical emergency necessitating hospitalization and treatment such as: - Cyproheptadine, anticonvulsants, and autonomic support **Drug combinations that can cause serotonin syndrome (165)** SSRI/TCA/MAOI/SNRI - SSRIs and MAOIs - Drug and herbal interactions - SSRIs and St. John's wort - Being on more than one SSRI For example - When switching from a SSRI to a MAOI wait 2 weeks - When switching from fluoxetine to MAOI wait 5-6 weeks - \*\*\*When switching from MAOI back to Prozac wait 2 weeks - Note: a washout period of 5 half-lives between the cessation of a previous drug and the introduction of a new drug is the safest switching strategy from the point of view of drug interaction **Serotonin discontinuation syndrome (165, last paragraph)** SSRI/SNRI Discontinuation Syndrome in **Adults** **F.I.N.I.S.H.** - **F**lu-like symptoms: fatigue, muscle aches, headache, diarrhea - **I**nsomnia: vivid or disturbing dreams - **N**ausea - **I**mbalance: gait instability, dizziness, lightheadedness, vertigo - **S**ensory disturbance: paresthesia, "electric shock" sensation, visual disturbance - **H**yperarousal: anxiety, agitation - Onset: 24-72 hours - Resolution: 1-14 days - Incidence: about 20-40% (who have been treated at least 6 weeks) **Delusion**: A false belief firmly maintained despite evidence to the contrary **Referential thinking**: Patients may, for example, believe that certain new bulletins have a direct reference to them, that music played on the radio is played for them, or that car license plates have a meaning relevant to them -- positive symptoms of schizophrenia **Mental Status Exam** **Components** - Appearance - Behavior - Speech - Mood - Affect - **Thought process**: - Assess the organization of the patient's **thought and ideas** - **Normal**: logical, linear, coherent, and goal oriented - **Abnormal**: associations are not clear, organized, or coherent - **Tangentiality**: move from thought to thought that may or may not relate in some way but never get to the point - **Circumstantial**: provide unnecessary detail but eventually get to the point (goes in circles) - **Thought content**: refers to the themes that occupy the patient's thoughts and perceptual disturbances. Ex. **SI, HI, plan,** visual and auditory hallucinations **Insight:** it refers to the patient's awareness and understanding of their own thoughts, feelings, behaviors, and the presence of any mental health symptoms or conditions - **Assessment**: insight is assessed by exploring the patient's awareness of their mental health condition, including their ability to recognize symptoms, acknowledge the need for treatment, and understand the impact of their condition on their life - Examples: - Do you believe you have a mental health condition and might need medications? - Do you understand why you are taking medication or attending therapy? **Judgement**: refers to the ability of the patient to make sound decisions, evaluate situations, and anticipate the consequences of their actions based on social norms, cultural values, and personal goal - **Assessment**: judgement is typically evaluated through questions or hypothetical scenarios that assess the patient's ability to weigh options, consider alternations, and choose the most appropriate course of actions - Examples: - What would you do if you found a wallet on the street? - How would you handle a disagreement with a friend or family member? **Mini Mental Status Examination -- MMSE (Folstein scale)** - A screening tool that provides a quantitative evaluation of cognitive impairment and records cognitive changes over time in adults - The MMSE can screen for dementia (severity) and measure progression over time - Some components of the MMSE - **Concentration/attention/calculation**: I would like you to count backwards from 100 by sevens or do serial 7s, or subtract 7 from 100, or list all 12 months in reverse order - Math: use any simple mathematical test. Serial 7s are common: the patient is asked to start with 100 and to subtract 7, then 7 from 93, etc. Alternatively, ask how many nickels are in \$1.35 - **Orientation**: what is the year? Season? Date? Day? Month? Where are we (state, country, town, hospital, floor)? - **Registration/ability to learn new material**: say the names of three unrelated objects clearly and slowly, allowing approximately one second for each. After you have said all three, ask the patient to repeat them - **Recall (memory):** ask the patient if he or she can recall the 3 words you previously asked them to remember (repeat three objects after 5 minutes) - **Fund of knowledge**: who is the president/governor? **Other instruments for assessing level of cognition impairment (281)** - Montreal Cognitive Assessment (MoCA) - Mini-Cog - St Louis University Mental Status Examination (SLUM) **Suicide Assessment** **Risk factors for suicide (163)** - Ages 45 or older if male - Ages 55 or older if female - Divorced, single, or separated - White - Living alone - Psychiatric disorder - Physical illness - Substance abuse - Previous suicide attempt -- "one of the greatest risk factors" - Family history of suicide - Recent loss - Male gender - **Count risk factors in answers\* when comparing patients** **Therapeutic Relationship (38-39)** - Assumes the client and nurse enter into a mutual, interactive, interpersonal relationship specifically to focus on the identified needs of the client - Therapeutic relationships are focused on the client's needs, and are goal-directed, theory-based, and open to supervision - Characteristics of a therapeutic relationship: - Genuineness - Acceptance - Nonjudgement - Authenticity - Empathy - Respect - Professional boundaries - Use open ended questions to clarify and develop relationship\* - Time sensitive -- yes or no - Children -- yes or no if unable to make effective chronological responses **Refer p 38** - **Transference**: displacement of feelings for significant people in the client's past onto the PMHNP in the present relationship - **Countertransference**: the nurse's emotional reaction to the client based on her or his past experiences **Assessment tool for alcohol withdrawal, alcohol use disorder, and drug abuse** **CIWA-AR: (Clinical Institute Withdrawal Assessment-Alcohol Revised)** - Used to assess alcohol withdrawal (used to determine when to administer medication for ETOH withdrawal/detoxification) - Treatment starts when score is greater or equal to 8 or higher -- if ordered PRN only (symptom triggered method) - Total CIWA-AR score 15 or higher if on scheduled medication (scheduled + prn method) (Diazepam (Valium), Lorazepam (Ativan)) - Compromised liver -- choose Ativan over valium because Ativan has a shorter half-life **The Alcohol Use Disorders Identification Test (AUDIT)** - The AUDIT is a 10-item screening tool developed by the World Health Organization (WHO) to assess alcohol consumption, drinking behaviors, and alcohol-related problems - A score of 8 or more is considered to indicate hazardous or harmful alcohol use - Three medication are approved by the FDA to treat AUD (alcohol dependence): **acamprosate (Campral), disulfiram (Antabuse), and Naltrexone (Vivitrol)** (Naltrexone can also be used to treat opioid use disorder) - Acamprosate and naltrexone reduce alcohol consumptions and increase abstinence rates - Acamprosate not metabolized by the liver - Higher sensitivity and specificity compared to CAGE **Drug Abuse Screening Test (DAST-10)** - The DAST-10 is a 10-item brief screening tool that can be administered by a clinician or self-administered - The tool assesses drug use, not including alcohol or tobacco use, in the past 12 months **Disulfiram (Antabuse) (304, last paragraph, to 305, first and second bullet points)** **Aversion Therapy for AUD** - Disulfiram is a medication primarily used to treat chronic alcoholism - It works by inhibiting the enzyme aldehyde dehydrogenase, which is involved in the metabolism of alcohol - When someone taking disulfiram consumes alcohol, it leads to a build up or acetaldehyde in the blood, resulting in unpleasant symptoms such as nausea, vomiting, headache, flushing, and increased HR - These adverse effects are intended to discourage alcohol consumption - Advise client to refrain from using anything that contains alcohol (e.g., vinegar, aftershave lotion, perfumes, mouthwash, cough medicine) while taking disulfiram and up to 2 weeks after discontinuing disulfiram - Disulfiram can elevate LFTs, so monitoring is necessary **Signs and Symptoms of alcohol withdrawal (303)** - Nausea and vomiting - Tremors - Paroxysmal sweats - Tactile disturbances - Auditory and visual disturbances - Headaches - Anxiety - Agitation - Altered sensorium **COWS (Clinical Opiate Withdrawal Scale):** A tool used to assess opioid withdrawal **Signs and symptoms of opioid withdrawal** - Yawning - Irritability/anxiety - Pupillary dilation (pinpoint pupils can indicate opioid intoxication) - Piloerection - Muscle aches - Lacrimation - Rhinorrhea - Sweating - Insomnia - Nausea, vomiting, diarrhea A person sitting on a bench with various types of pain Description automatically generated **Mental Status** (blue = know everything) +-----------------------------------+-----------------------------------+ | **\*\*\*MMSE (0-30)** | **SLUM (0-30)** | +===================================+===================================+ | 25-30: normal | 27-30: normal | | | | | 21-24: mild cognitive | 21-26: mild | | impairment/or possible | | | carl-stage/mild-Alzheimer's | 0-20: dementia | | disease | | | | **MoCA** | | 10-20: moderate/middle | | | stage/moderate-Alzheimer's | 26-30: normal | | disease | | | | 18-25: mild cognitive impairment | | 0-9: severe/late stage/severe | | | Alzheimer's disease | 10-17: moderate cognitive | | | impairment | | | | | | Less than 10: severe cognitive | | | impairment | +-----------------------------------+-----------------------------------+ **Depression (know moderate levels)** +-----------------------+-----------------------+-----------------------+ | **PHQ-9 (0-27)** | **HAM D (0-76)** | **Beck (0-63)** | +=======================+=======================+=======================+ | 0-4: normal | 0-7: normal | 0-9: normal | | | | | | 5-9: mild | 8-13: mild | 10-18: mild | | | | | | 10-14: moderate | 14-18: moderate | 19-29: moderate | | | | | | 15-19: moderate to | 19-22: severe | 30-63: severe | | severe | | | | | \>23: very severe | | | 20-27: severe | | | | | **MADRS** | | | | | | | | 0-6: normal | | | | | | | | 7-19: mild | | | | | | | | 20-34: moderate | | | | | | | | 35-60: severe | | | | | | | | \>60: very severe | | +-----------------------+-----------------------+-----------------------+ Mild anxiety/depression -- therapy, nothing Moderate/severe -- anxiety/depression -- medication and/or therapy Scoring on the depression scale falls on the severe range = assess suicidal ideation Anxiety +-----------------------------------+-----------------------------------+ | **HAM A (0-56)** | **GAD (0-23)** | +===================================+===================================+ | \25: severe | 10-14: moderate | | | | | | 15-21: severe | +-----------------------------------+-----------------------------------+ Withdrawal +-----------------------------------+-----------------------------------+ | **COWS (opioid)** (start tx at 7) | **CIWA (alcohol)** (start tx at | | | 8) | +===================================+===================================+ | 0-4: none | 0-9: none | | | | | 5-12: mild -- clonidine | 10-15: mild | | | | | 13-24: moderate (give Subutex or | 16-20: moderate | | suboxone) | | | | \>21: severe | | 25-35: moderate to severe | | | | 8 and above: prns only | | \>36: severe | | | | 15 and above: scheduled meds + | | Moderate-severe | prns | | | | | Buprenorphine | - Diazepam (Valium) -- longer | | | half-life | | Suboxone (buprenorphine and | | | naloxone) | - Lorazepam (Ativan) -- shorter | | | half-life | | | | | | - Librium | +-----------------------------------+-----------------------------------+ Methadone can cause cardiac arrhythmias, requires close monitoring, cannot receive while at home **Screening Brief Intervention Referral to Treatment (SBIRT)**: screen for substance use disorders - SBIRT \> AUDIT \> CAGE, most to least comprehensive - **Brief intervention for alcohol** - The practice delivery for brief intervention is guided by the acronym **FRAMES**: - **F**eedback -- tell them about risk of their current level of use - **R**esponsibility -- reinforce any decision to change (or not) lies with the service user - **A**dvise -- based on facts about their drinking, offer simple and direct advise to the service user re impact on them and offer your advice to change - **M**enu -- provide them with a menu of options for behavior change - **E**mpathetic interviewing -- consider their perspective; be nonjudgemental - **S**elf-efficacy -- encourage the person to believe they can change **CAGE-AID (297)** 1. Have you ever felt you should **[c]ut down** on your drinking or drug use? 2. Have people **[a]nnoyed** you by criticizing your drinking or drug use? 3. Have you ever felt bad or **[g]uilty** about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning (**[e]ye opener**) to steady your nerves or to get rid of a hangover? "0" for no and "1" for yes. A score of 1 or above accurately detects 91% of alcohol users and 92% of drug users. A score of 2 or greater is considers clinically significant. **The CRAFFT**: behavioral health screening tool for use with children under the age of 21 - It consists of a series of 6 questions developed to screen adolescents for high-risk alcohol and other drug use disorders simultaneously 1. Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? 2. Do you ever use alcohol or drugs to **RELAX**, feel better about yourself, or fit in? 3. Do you ever use alcohol or drugs while you are by yourself **ALONE**? 4. Do you ever **FORGET** things you did while using alcohol and drugs? 5. Do your **FAMILY or FRIENDS** ever tell you that you should cut down on your drinking or drug use? 6. Have you ever gotten into **TROUBLE** while you were using alcohol or drugs? - Administration: the CRAFFT is a self-administered screening but it can be read to the adolescent if necessary - Scoring and interpretation: score (1) point for each "yes" answer. A score of 2 or more indicates the need for further assessment **CRAFFT Score** **Degree of problem r/t alcohol/other drug abuse** **Suggested action** ------------------ ---------------------------------------------------- ---------------------- 0-1 No problems reported None at this time 2 or more Potential of a significant problem Assessment required Question on FRAMES - discussing with the patient their responsibility and role in making decisions about their alcohol use - becomes emotional during discussion: express empathy and inquire about their feelings and concerns Question on BDI and Lexapro - increase after 8 weeks - maintain treatment at 4 weeks **Neurocognitive disorders (Chapter 12)** **Refer p 164, 271** **Delirium (271)** - acute onset - altered level of consciousness - inattention - confusion - change in cognition - poor prognosis: 1-year mortality rate of clients with delirium is up to 40% **Pharmacological Management (276)** **Symptomatic treatment** Agitation and psychotic symptoms - Antipsychotic agents - Haloperidol (Haldol): the preferred treatment for agitated delirious patients (as described by the guidelines of the APA) - Atypical antipsychotic agents - Anxiolytic agents for insomnia **Nonpharmacological Management (276)** - Monitor for safety needs - Pay attention to basic needs - It is helpful to have in the client's room familiar people; familiar pictures or decorations; a clock or calendar; and regular orientation to person, place, or time **Dementia (277)** **Cortical Dementia** 1. **Cerebral cortex affected**: cortical dementia primarily affects the cerebral cortex, the outer layer of the brain responsible for higher cognitive functions 2. **Memory and language**: memory loss and language difficulties are hallmark features of cortical dementia a. **Aphasia**: language impairment, is common in cortical dementia, leading to problems with communication 3. **Visuospatial issues**: individuals may experience visuospatial impairments, affecting their ability to navigate and recognize objects 4. **Apraxia**: can cause apraxia, leading to difficulties in performing purposeful movements 5. **Personality changes**: behavioral changes, such as personality shifts and increased impulsivity, can occur 6. **Hallucinations and delusions**: these symptoms can contribute to agitation and distress 7. **Common types**: Alzheimer's disease, frontotemporal dementia, and primary progressive aphasia are common forms of cortical dementia **Subcortical Dementia** 1. **Subcortical structures**: subcortical dementia primarily affects the brains' subcortical structures, which are located beneath the cerebral cortex 2. **Cognitive and motor symptoms**: it is characterized by a combination of cognitive and motor symptoms, including memory problems and movement difficulties a. Movement disorders, such as tremors, stiffness, and bradykinesia (slowness of movement), are often prominent in subcortical dementia b. **Gait and balance issues**: problems with walking and balance are common due to the involvement of motor pathways 3. **Emotional changes**: mood changes, depression, and apathy can be part of the symptom profile 4. **Slower processing speed**: individuals with subcortical dementia may experience slower thinking and processing speed compared to cortical dementia 5. **Common types**: Parkinson's disease dementia, Huntington's disease, and vascular dementis **Dementia of Alzheimer\'s type (DAT) (277)** - Most common type - Classified as a cortical dementia - **Gradual onset and progressive decline** without focal neurological deficits - Hallmark amyloid deposits and neurofibrillary tangles **Dementia due to HIV disease (277)** - Classified as subcortical dementia - **Early signs of HIV dementia**: cognitive decline, motor abnormalities (lack of coordination, tremors, dystonia, ataxia), and behavioral abnormalities **Clinical signs of late-stage HIV related dementia (277)** - Include cognitive, motor, behavioral, and affective impairment: - Global cognitive impairment - Mutism - Seizures - Hallucinations - Delusions - Apathy - Mania **Lewy body disease (279)** - Caused by Lewy inclusion bodies in the cortex - Presents with recurrent visual hallucinations - Parkinson features (bradykinesia, cogwheel rigidity, tremor) - Adversely react to antipsychotics **Vascular dementia (VD) (277)** - Second most common type - Formerly called multi-infarct dementia - Primarily caused by cardiovascular disease and characterized by step-type declines - Most common in men with preexisting high BP and cardiovascular risk factors - Hallmarks: carotid bruits, fundoscopic abnormalities, and enlarged cardiac chambers **Pick's disease (278)** - Also known as **frontotemporal dementia/frontal lobe dementia** - More common in men - **Personality, behavioral, and language changes (slurred) in early stage** - Cognitive changes can occur in later stages **Huntington's disease (278)** - **Subcortical type of dementia** - Characterized mostly by motor abnormalities - Psychomotor slowing and difficulty with complex tasks - High incidence of depression and psychosis - Memory, language, and insight usually intact until late stages **Etiology (278)** - Diffuse cerebral atrophy and enlarged ventricles in dementia of Alzheimer\'s type (DAT) - Decreased acetylcholine and norepinephrine in DAT - Genetic loading - Family history of dementia in first-order relative **Psychosis and agitation in Dementia (284)** - Try nonpharmacological therapies first - **Atypical antipsychotics** should be used as first-line agents in patients with psychotic symptoms of dementia - Use lowest effective dose and attempt to wean periodically - Benzodiazepine should be avoided, if possible, in most patients with dementia, as they are particularly vulnerable to their adverse effects such as sedation, falls, and delirium Question: treatment for AIDS dementia complex? Antiretroviral therapy **Levels of Prevention (103)** **Primary prevention**: aimed at decreasing the incidence (**number of new cases**) of mental disorders - Helping people avoid stressors or cope with them more adaptively - Example: stress management for graduate students, smoking prevention classes, DARE in elementary and middle school curriculum **Secondary prevention**: aimed at decreasing the prevalence (number of existing cases) of mental disorders - Early case finding - Screening - Prompt and effective treatment - Example: telephone hotlines, crisis intervention, disaster responses **Tertiary prevention**: aimed at decreasing the disability and severity of a mental disorder - Rehabilitative services - Avoidance or postponement of complications - Example: day treatment programs; case management for physical, housing, or vocational needs; social skill training - coming in for a refill of sertraline **Motivational Interviewing (46)** - focused, goal-directive therapy - builds on the **Transtheoretical Model of Change** - motivation is elicited from the client - nonconfrontational - listen with patient-centered, empathetic approach - empower the patient. The patient must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change **The basic skills of motivational interviewing (OARS)** **Ask open-ended questions** - the patient does most of the talking - gives the provider the opportunity to learn more about what the patient cares about (e.g., their values and goals) - Example: - I understand you have some concerns about your drinking. Can you tell me about them? **Versus** are you concerned about your drinking? **Make Affirmations** - Can take the form of compliments or statement of appreciation and understanding - Helps build rapport, validates, and supports the patient during the process of change - Most effective when the patient's strengths and efforts for change are noticed and affirmed - Example: - I appreciate that it took a lot of courage for you to discuss your drinking with me today - You appear to have a lot of resourcefulness to have coped with these difficulties for the past few years **Use Reflections** - Reflection in MI involved paraphrasing or repeating back what the client has just said in a way that demonstrates active listening and understanding - It helps the client feel heard, validated, and understood, fostering a therapeutic alliance - Encourages continual personal exploration and helps people understand their motivations fully - Reflections can be simple, where you repeat the client's words, or complex, where you delve deeper into the underlying emotions, thoughts - Can be used to amplify or reinforce desire for change - Example: - If a client says, "I'm not sure I can quit smoking; it's too hard", a reflection could be, "It sounds like you are feeling overwhelmed by the idea of quitting". **Use Summarizing** - Summarizing in MI involved condensing and bringing together various point or themes discussed during the conversation - It helps the client see the bigger picture, identify patterns, and gain insight into their situation - Ensure mutual understanding of the discussion so far - Links discussions and 'checks in' with the patient - It allows the client to reflect on what has been discussed and can highlight discrepancies or areas of change - Example: - At the end of an MI session, you might summarize, "So, today we've talked about your reasons for quitting smoking, your concerns about withdrawal, and your desire to improve your health. It seems like you have mixed feelings about quitting, but you are motivated to make positive changes". Difference between Reflection and Summarizing - Reflection is about actively listening and responding empathetically to what the client is saying, while summarizing involves condensing and bringing together the main points to help the client gain perspective and insight **The guiding principles of Motivational Interviewing** 1. **Express empathy**: show understanding, warmth, and empathy towards the client's experiences and feelings Example: "I can see that you are feeling overwhelmed by the idea of quitting smoking. It is completely normal to have mixed feelings about it". 2. **Develop discrepancy**: help the client recognize discrepancies between their current behavior and their goals or values Example: "You have mentioned that you value your health, but you are also continuing to smoke. Can you see how these two things might not align?" 3. **Roll with resistance**: avoid arguing with or confronting the client's resistance to change. Instead, acknowledge and explore their concerns Example: Client: "I'm not ready to quit drinking"; PMHNP: "I understand that you are not ready to quit at the moment. Can you tell me more about what's holding you back?" 4. **Support self-efficacy**: encourage the client's belief in their ability to change and make informed decisions Example: "You've made positive changes before, like cutting down on alcohol. What strategies have worked for you in the past, and do you think you can apply them again?" 5. **Avoid arguing and direct confrontation**: avoid direct confrontations, arguments, or confrontational statements that can lead to resistance Example (Avoiding confrontation): Client: "I don't think I have a problem with gambling"; PMHNP: "I hear you don't see it as a problem right now. Can you tell me more about your experiences with gambling?" **Transtheoretical model of change (46)** 1. **Precontemplation** - The person is not aware that there is a problem with their behavior - The person has no intention to change - **Action step**: provide information and feedback to raise the person's awareness of the problem and the possibility of change. Do not give prescriptive advice. - "Tell me about your current substance use. How often do you use, and what substances are you using?" - "How do you feel about your drug/alcohol use? Are there any aspects of it that concern you?" - "Where does the use of drugs/alcohol fit into a typical day?" - "Are there any aspects of your substance use that concerns you?" - "What do you think would happen if you stopped drinking alcohol today?" 2. **Contemplation**: in this stage, individual are aware that there is a problem and are actively thinking about making a change in the foreseeable future (usually within the next six months). However, they may still have mixed feeling and ambivalence about taking action - **Action step**: help the person see the benefits of changing and the consequences of not changing - "It sounds like you have mixed feelings about your substance use. Can you tell me more about the reasons you might want to change and the reasons you might want to continue?" - "What are some benefits you see in reducing or quitting your substance use? And what are some challenges or drawbacks you anticipate?" - "Can you imagine what your life would be life if you were able to make positive changes in your substance use? What are some things you would look forward to?" 3. **Preparation**: in this stage, individuals have made the decision to change their behaviors and are preparing to take action in the near future (typically within the next month) - They may be gathering information, setting goals, and seeking support - **Action step**: help the person find a change strategy that is realistic, acceptable, accessible, appropriate, and effective - "On a scale from 1-10, where do you feel you are right now in terms of making changes to your substance use?" - "What are some specific goals you have in mind regarding your substance use? What would you like to achieve?" - "Can you tell me about the strategies or actions you've thought about taking to reduce or quit using?" - "What are the people or resources you have in your support network that can help you on this journey?" 4. **Action**: individual have taken specific steps to change their behavior. This stage involves actively modifying their behavior, routines, or environment to achieve their desired outcome - **Action step**: support and be an advocate for the person. Help accomplish the steps for change - "What actions have you taken so far to reduce or quit using substance/alcohol. Can you tell me about your progress?" - "How has your experience been with the treatment or therapy you've been involved in? Are there aspects that you find particularly helpful?" 5. **Maintenance**: individuals have successfully changed their behaviors and are focused on preventing relapse - **Action step**: help the person identify the possibility of relapse and identify and use strategies to prevent relapse - They work to consolidate their gains and continue to engage in the new behavior over the long term - The person is engaging in behaviors to prevent relapse - "Tell me about how you've been able to maintain your recovery and stay substance-free since we last spoke" - "What specific relapse prevention strategies have you found most effective, and how do you implement them in your daily life?" - "How has your support system evolved, and who continues to be a key sources of support for you?" - **In addition to these five stages, the Transtheoretical Model also incorporate the concept of relapse** - Relapse is seen as a normal part of the change process and can occur at any stage - When relapse occurs, individuals may return to an earlier stage (from the maintenance stage to contemplation) or may cycle through the stages again - "What was your last relapse?" - "What led to the relapse and what are your plans for getting past it and avoiding another relapse?" - "What keeps you from having another relapse?" - "What insights or lessons have you taken away from this experience?" Facebook group: Georgette's PMHNP certification review study group