Psych Test 2 HH PDF

Helpful Hint: Psych Exam 2 1. Assessment Components on ALZ – Meds , Etiology , Affected Structure of the Brain Lect 1 (36:55) zv Alzheimer’s: degenerative, progressive neuropsychiatric disorder (of older ad...

Helpful Hint: Psych Exam 2 1. Assessment Components on ALZ – Meds , Etiology , Affected Structure of the Brain Lect 1 (36:55) zv Alzheimer’s: degenerative, progressive neuropsychiatric disorder (of older adults) that results in cognitive impairment, emotional and behavioral changes, physical and functional decline, and ultimately death and has 3 stages (mild, moderate, severe) Two subtypes: ○ Early onset- 65 and younger (more rapid progression!) ○ Late onset- 65 and older (more common!) It is a cortical dementia and affects the cortex of the brain! Cardinal Signs- Amnesia, Aphasia (trouble speaking), Apraxia (inability to execute motor activities effectively), Agnosia (failure to recognize or identify objects [Paperclip or Penny] despite intact sensory function; A GOOD INDICATOR!), Disturbance of executive functioning (leaving stove on) Etiology: (50:06) zv ○ Genetic Factors: approximately half of the cases of early onset AD appear to be transmitted as a pure genetic, autosomal dominant trait caused by mutations in genes on chromosomes 1 and 14. Chromosome 21 is also associated with AD because amyloid plaques and neurofibrillary tangles accumulate consistently in older people with Down syndrome (trisomy 21) who have AD ○ Beta-Amyloid Plaques/Senile Plaques: Sticky clumps found between nerve cells that may either cause or be the result from the disease. The clumps block communication at synapses that are normally protected by tau proteins and healthy microtubules. They may also activate immune system cells that trigger inflammation and devour disabled cells. ○ Neurofibrillary Tangles (axons and dendrites): Abnormal collections of protein threads inside nerve cells. They are composed mainly of a protein called tau. Tangles disrupt the transport of food molecules, cell parts, and other key elements. This disruption results in cell death. ○ Cell Death and Neurotransmitters Depletion: Deficits in Acetylcholine (helps offset deterioration). Cell death and neurotransmitters—In pts with AD, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Several major neurotransmitters are affected. Acetylcholine is associated with cognitive functioning, and disruption of cholinergic mechanisms damages memory in animals and humans. Other neurotransmitters include norepinephrine and serotonin (deficits) ○ Granulovascular Degeneration: is another active process in the disease and it results in the filling of brain cells with fluid and granular material. Increased degeneration accounts for increased loss of mental function. Also brain atrophy is observable in cerebral ventricles (Ct Scan, MRI) Medications: (Mitigation of the BEHAVIORS)**** (1:01:04) zv ○ Cholinesterase Inhibitors (1st or 2nd stage) (demonstrates positive effects not only on cognition but also on behavior and function in ADLS in mild/moderate AD) Galantamine (Razadyne) Rivastigmine (Exelon) Donepezil (Aricept) ○ N-methyl-D aspartate (first drug to target symptoms of AD during moderate to severe stages- benefits are still time limited) Memantine (Namenda) ○ Atypical antipsychotics (for fighting/aggression/violence) (behavioral symptoms)  ○ SSRIs (coexisting depression) ○ START LOW & GO SLOW!!!*** 2. Sexual Assault Interventions (Pg 540) Improvement that may be indicated prior to leaving acute care settings includes verbalizing details of the experience, expressing feelings, understanding the common responses to assault, identifying a short-term plan to deal with the immediate situation, and connecting with a community-based rape victims' advocate. Longer-term goals include physical healing, emotional healing of intrusive memories and nightmares, reduction in fear and anxiety, and improved social interactions. The patient might also need information about community support and how to access them 3. Intimate Partner Violence Education (Go Back in the BOOK) Page 518 Educating communities about IPV is vital in identifying, supporting, and protecting individuals from abuse, ultimately reducing the prevalence of violence in intimate relationships. 4. Elder Abuse Economic Failure to provide for the older adults’ basic needs or to protect them from harm Family members, custodians, and care facility personnel may inflict physical abuse and sexual abuse Financial abuse is an additional problem in this population Caretakers may steal cash or credit cards or coerce the older person to transfer property or accounts. Victims also lose personal belongings, medications, and food stamps 5. Difference Between Delirium/Dementia Lect 1 (6:47) zv Delirium: a sudden decline from a previous level of functioning A medical emergency!!! ○ Reversible if treated quickly ○ 25% of patients do NOT survive Caused by general medical conditions (UTI) or substance-induced (intoxication or withdrawal) Results in disturbances of: ○ Consciousness (key criteria!!) ○ Attention ○ Cognition (try giving directions***) ○ Perception (hallucinations) ○ Motor abilities Cognitive changes/problems with: ○ Memory ○ Orientation ○ Language ○ Attention ○ Perception Common in the older adult population but can happen in any age group Risk Factors: ○ Pre-existing cognitive impairments ○ Elderly  ○ Male gender (over 65 w alcohol) ○ Alcohol abuse ○ Lower levels of education attainment ○ Fractures (higher dopamine release or shock) ○ Depression ○ Impaired vision ○ Post-op (anesthesia use) Etiology: ○ Post-op ○ Drug intoxications/withdrawal ○ Infections ○ Metabolic disorders (diabetes/thyroid issues) ○ Medications ○ Neurological diseases (MS/Parkinsons) ○ Tumors (in brain) ○ Psychosocial stressors (body is in a vulnerable state) Interventions for Delirium: ○ Elimination/correction of underlying cause ○ Symptomatic/supportive measures COMFORT*** Rest and fluid/electrolyte maintenance Injury protection ○ Hallucinations/disorientations: Promote relaxation Gentle reorientation Safety Resolve underlying stressor Reassurance (give reasons for pt. to be calm DON’T DISCOUNTER**) ○ BIGGEST GOAL IS TO LOWER THE RISK OF FALLS AND INJURY Dementia: a gradual loss of intellectual abilities (not feelings or emotions) (33:18) zv Continual, irreversible decline (consistent and persistent!) Types: ○ Alzheimers Accounts for 50-60% of all dementias Primary Dementia (most common/likely to develop) Vascular Dementias (hardening of arteries), d/t diet, Parkinsons, AIDS, or substance-induced Can be classified as cortical or subcortical to denote the location of the underlying pathology ○ Cortical Dementia: globally affects the cortex (ALZHEIMERS) ○ Subcortical Dementia: dysfunction/deterioration of deep gray or white matter structures inside the brain and brainstem (more localized and tend to disrupt arousal/attention/motivation but have many manifestations) 6. Differences in Stages of Dementia/Mental Status Exam Got From GOOGLE Mild: Symptoms include memory loss, confusion about familiar places, and taking longer to complete daily tasks. People with mild dementia can still live independently and may only need reminders Moderate: Symptoms include increased memory loss and confusion, mood swings, and difficulty with language. People with moderate dementia may need full- or part-time caregiver assistance  Severe: Symptoms include weight loss, difficulty swallowing, and lack of bladder or bowel control. People with severe dementia may require 24-hour supervision 7. Multi Infarct Dementia – Definitions Got From GOOGLE Multi-Infarct Dementia (MID), also known as vascular dementia, is a type of dementia caused by multiple small strokes (infarcts) that damage the brain over time. These strokes disrupt blood flow, leading to the death of brain tissue=== Dementia 8. Dementia Meds- Hormone Effect Aggression Lect 1 (1:01:04) zv Pharmacological (Mitigation of the BEHAVIORS)**** a. Cholinesterase inhibitors (1st or 2nd Stage) i. Galantamine (Razadyne) ii. Rivastigmine (Exelon) iii. Donepezil (Aricept) b. N-methyl-D aspartate i. Memantine (Namenda) c. Atypical antipsychotics (for Fighting, Aggression, Violence) d. Start Low and GO Slow!!!**** 9. Bipolar Disorders Impulse Control Disorders Lect 3 (0:00) zv Bipolar II: hypomania alternating with major depression ○ Personality disturbance (borderline-like), impulse difficulties, mood instability, recurrent depression ○ Criteria is same as for manic episodes, except that the time criterion is at least 4 days, rather than 1 week, and no marked impairment in social or occupational functioning is present; psychosis is NOT present! ○ Milder! 10. Mood Disorder: Depressive Disorders Overdose on Antidepressants Lect 2 (55:50) zv SSRIs Selective serotonin reuptake inhibitors or SSRIs---examples include: Lexapro, Prozac, Zoloft, Paxil, Celexa a. Serotonin norepinephrine reuptake inhibitors (SNRIs)– include: Effexor, Serzone, Cymbalta b. Second-generation drugs i. Second-generation drugs selectively target the neurotransmitters and receptors thought to be associated with depression and to minimize side effects. c. Newer d. Much less side effects**** e. Safer in Overdose*** f. Side effects: GI, sexual dysfunction, weight gain (some) g. Serotonin Syndrome i. Is a potentially serious side effect caused by drug-induced excess of intrasynaptic serotonin. Most often reported in patient taking two or more medications that  increase CNS serotonin levels by different mechanisms; can cause death; yet is mild in most pts, who usually recover with supportive care alone; develops within hours or days after initiating or increasing the dose; s/s include—AMS, autonomic dysfunction and neuromuscular abnormalities. (Page 359) Tricyclic Antidepressants (58:05) zv ○ First-generation drugs Cyclic antidepressants, which include the tricyclic antidepressants (TCAs)---examples--Elavil, Tofranil, Sinequan, Pamelor ○ Efficacy established ○ Less expensive ○ Side effects: antihistaminic, anticholinergic, orthostasis, cardiac Most common side effects associated with TCAs are the antihistamine side effects (sedation and weight gain) and anticholinergic side effects (potentiation of CNS drugs, blurred vision, dry mouth, constipation, urinary retention, sinus tachycardia, and decreased memory) ○ Take at bedtime to minimize side effects ○ SE should subside after a few weeks ○ Lethal in Overdose! Monoamine Oxidase Inhibitors (MAOIs) (1:00:30) zv ○ First-generation drugs MAOIs include—Nardil, Parnate MAOIs usually are reserved for pts whose depression fails to respond to other antidepressants or pts who cannot tolerate typical antidepressants. ○ Not used much d/t side effects ○ May precipitate hypertensive crisis***** ○ Food Cautions If coadministered with food or other substances containing tyramine (ex- aged cheese/blue cheese, draft beer, smoked salmon, soy sauce, red wine), MAOIs can trigger a hypertensive crisis that may be life threatening. Symptoms include sudden, severe pounding or explosive headache in the back of the head or temples, racing pulse, flushing, stiff neck, chest pain, nausea and vomiting, and profuse sweating. More lethal in Overdose than are the newer antidepressants and thus should be prescribed with caution if the patient’s suicide potential is elevated. Generally is given in divided doses to minimize side effects; drugs are used cautiously in pts who are suicidal. 11. Types of Depression Inventories Screening tools ○ Becks Depression Inventory (21 item, self report rating inventory that measures characteristic attitudes and symptoms of depression) ○ Geriatric Depression Scale (a self report measure of depression in older adults, yes/no format, 30 item instrument)  12. Domestic Violence Aggressions Got From Google Mostly males cause the problems Refer to various forms of abusive behavior used by one individual to control or dominate a partner or family member within a domestic setting. Domestic violence can involve physical, emotional, sexual, psychological, and financial abuse, with the aggressor using these tactics to maintain power and control over the victim. Requires early intervention, support from law enforcement, legal resources, and access to counseling and support services. Victims often need safe spaces, such as shelters or hotlines, and must be empowered to make decisions that protect their safety and well-being. 13. Mourning Grief Dying, Death, and Grieving Definition Bereavement: state of being bereaved or deprived of something. “Shorn off or torn up.” Grief: persons response to bereaved state. Emotions, mental perceptions, physical reactions. Mourning: culturally patterned expressions of grief. Process of adjustment to bereavement. Complicated grief: no longer termed prolonged d/t connotation that there is a “right” time limit and old grief may reappear with new deaths. ○ Signs: sustained severe depression, substance abuse, suicidal imagery, persistent sleep with weight loss, medical illnesses. 14. Seclusion and Restraints Legal Lect 3 Seclusion or Restraints Seclusion: Involuntary confinement alone in a room that the patient is physically prevented from leaving Restraints: Any manual method, physical or mechanical device, material, or equipment that restricts freedom of movement Guidelines for Use of Mechanical Restraints Indications for use Legal requirements Documentation Clinical assessments Observation Release procedure Restraint tips 15. Safety Medical Conditions that are Associated with Depression Psychiatric problems that accompany depression can be schizophrenia, substance abuse, eating disorders, schizoaffective disorder, and borderline personality disorder. Combination of anxiety and depression is the most common. In older adults, major depressive disorder can resemble neurocognitive disorders like Alzeihmers. Google says: Ppl with depression are more at risk for developing heart disease, diabetes, stroke, pain, osteoporosis, and Alzheimer's disease. 16. Bipolar Disorder MAOIs – Know Names, Side Effects SNRI’s Lect 2 (1:00:30) zv Monoamine Oxidase Inhibitors (MAOIs) ○ First generation drugs ○ Nardil and Parnate ○ Reserved for pts. whose depression fails to respond to other antidepressants or pts. who cannot tolerate typical antidepressants Not used much d/t side effects May precipitate HYPERTENSIVE CRISIS Food Cautions: If coadministered with food or other substances containing tyramine (ex- aged cheese/blue cheese, draft beer, smoked salmon, soy sauce, red wine), MAOIs can trigger a hypertensive crisis that may be life threatening. Symptoms include sudden, severe pounding or explosive headache in the back of the head or temples, racing pulse, flushing, stiff neck, chest pain, nausea and vomiting, and profuse sweating. More lethal in overdose than are the newer antidepressants and thus should be prescribed with caution if the patient’s suicide potential is elevated. Generally is given in divided doses to minimize side effects; drugs are used cautiously in pts who are suicidal Selective Norepinephrine Reuptake Inhibitors (SNRIs) ○ Second generation drugs ○ Effexor, Serzone, Cymbalta ○ Newer, much less side effects** ○ Safer in overdose** ○ SE- GI, sexual dysfunction, weight gain (some), serotonin syndrome 17. Dietary Needs of MAOIs Food Cautions: If coadministered with food or other substances containing tyramine (ex- aged cheese/blue cheese, draft beer, smoked salmon, soy sauce, red wine), MAOIs can trigger a hypertensive crisis that may be life threatening. Symptoms include sudden, severe pounding or explosive headache in the back of the head or temples, racing pulse, flushing, stiff neck, chest pain, nausea and vomiting, and profuse sweating. More lethal in overdose than are the newer antidepressants and thus should be prescribed with caution if the patient’s suicide potential is elevated. Generally is given in divided doses to minimize side effects; drugs are used cautiously in pts who are suicidal 18. Safety Plans with Psychosis Psychosis definition: altered cognition, altered perception, amd am impaired ability to determine what is or is not real. Justify and rationalize with pt 19. Most Appropriate Responses for Nurses to Patient with Suicide Ideation Have you ever felt that life was not worth living? Have you been thinking about death recently? Do you ever think about suicide? Have you ever attempted suicide? Do you have a plan for ending your life? If so, what is your plan for suicide? ○ Ex Response: “Tell me about it, Theresa. I want to understand how you feel. What’s meaningless?” 20. ECT Lecture 2 (48:44) zv Grand mal seizure artificially induced. Pt is sedated, treatments usually 6-12, 2-3x/week, response rate of 80%, usually tried after pharmacotherapy fails, safe for pregnancy. Adverse Effects-headaches, memory difficulties, muscle soreness. ○ Although the therapeutic mechanism of action is unknown, electroconvulsive therapy (ECT) is an effective treatment for severe depression. It is generally reserved for patients whose disorder is refractory or intolerant to initial drug treatments and who are so severely ill that rapid treatment is required (pts with malnutrition, catatonia, or suicidality). (MEDICATION RESISTANT MEDICATIONS) ○ Is contraindicated for pts with increased intracranial pressure. Other high-risk pts include recent MIs, recent CVAs, retinal detachment, or pheochromocytoma (tumor on adrenal cortex or other tumors) and those at risk for complications of anesthesia. ○ Vagus Nerve Stimulation—book talk about, yet I have not seen used in this area of the country; a surgically implanted device—usually in left upper chest; sends electrical impulses to the left vagus nerve in the neck at regular intervals; still being studied/researched 21. PTSD (BROU Texted me saying that we talked about PTSD during this unit… idk) ~ zv 22. Redirecting Violent Behaviors Address him with simple directions and a calming voice. Give reasons for pt to stay calm, do not discounter the pt. A calming voice and simple, nonemotional directions can help de-escalate the patient’s anxiety. This is an initial intervention, so do not threaten him with seclusion or resort to antipsychotics. Rubbing his shoulders is inappropriate and may contribute to anxiety, not calm. 23. Plans -Safety Levels 1:1, Close Supervision, Visual Contact, and Short Term Outcomes Lect 2 (1:15:50) Safety: 1:1, close observation, 15 minute checks Remove objects such as belts and shoelaces, mirrors, etc. Contracting Monitor medications a. Suicide indicates the imminent failure of coping mechanisms b. Talk about survivors of suicide 24. Dysthymia Lect 2 (1:07:09) zv Long standing constant depression that does not go away Dysthymic Disorder, DSM-IV Diagnosis: Depressed mood for most days for at least 2 years ○ Dysthymic Disorder is a milder but more chronic form of major depressive disorder.  ○ There is a depressed mood that fluctuates with a normal mood; the symptoms in dysthymic disorder are less severe than in major depression—chronic—lasts longer 2 or more of following symptoms ○ Poor appetite or overeating ○ Insomnia or oversleeping ○ Low energy or fatigue ○ Low self-esteem ○ Poor concentration or difficulty making decisions ○ Feelings of hopelessness 25. Alternate Responses if Med Resistant (?????) Electroconvulsive therapy (ECT) is an effective treatment for severe depression. It is generally reserved for patients whose disorder is refractory or intolerant to initial drug treatments and who are so severely ill that rapid treatment is required (pts with malnutrition, catatonia, or suicidality). (MEDICATION RESISTANT MEDICATIONS) 26. Zoloft (Sertraline), Paxil (Paroxetine), Celexa (Citalopram) Lect 2 (55:50) zv SSRI ○ First-Line of treatment for Major Depression** ○ Risk of lethal overdose minimized with SSRIs ○ Second-generation drugs Second-generation drugs selectively target the neurotransmitters and receptors thought to be associated with depression and to minimize side effects. ○ Newer ○ Much less side effects**** ○ Safer in overdose*** ○ Side effects: GI, sexual dysfunction, weight gain (some) ○ Serotonin Syndrome Is a potentially serious side effect caused by drug-induced excess of intrasynaptic serotonin. Most often reported in patient taking two or more medications that increase CNS serotonin levels by different mechanisms; can cause death; yet is mild in most pts, who usually recover with supportive care alone; develops within hours or days after initiating or increasing the dose; s/s include—AMS, autonomic dysfunction and neuromuscular abnormalities. (Page 359) 27. Bipolar Manic Episode Nursing Interventions Lect 3 (10:30) zv Manic Episode— DSM-V Three (or four—including irritable) of the seven: ○ Inflated self-esteem or grandiosity (I’m Jesus!!!) ○ Decreased need for sleep ○ Being more talkative or having pressured speech ○ Flight of ideas (comes out your mouth) or racing thoughts (in your head)*** (decreased logical connection b/t thoughts)  ○ Distractibility ○ Increase in goal-directed activity or psychomotor agitation (restlessness, repetitious usually non-productive excessive motor activity) ○ Excessive involvement in pleasurable activities that have high potential for painful consequences (Gambling, Sexual Acts, Shopping Sprees)***** Unaware of their consequences!!!!!!!! Interventions (SAFETY, SAFETY, and PROMOTE SLEEP!!!! (34:40) zv Medically stabilize!!!!*** (physical body and safety before any mental conditions!) =NCLEX Use short explanations (to the point, avoid any confusion) Remain neutral, be consistent Distract pt to more constructive activities Maintain low level of environmental stimuli (heighten the problem if not) Supervise choice of clothes (women often dress seductively) Finger foods & fluids (utensils are dangerous) Promote sleep (let the mind rest) 28. Assessment Plan for Suicidal Ideation and Safety Priority Lect 2 ALWAYS assess for SUICIDAL IDEATIONS ○ Do you have thoughts of hurting yourself? ○ How often do these thoughts occur? ○ Do you have a plan? (Planning to Kill Yourself) Assessment: “Have you thought about killing yourself?” “Do you have a plan?” Are the means to carry out this plan available to the pt? Assess plan for lethality (the more planned out, the more likely) Contract for safety (showing support) Elopement risk Attempt history (If you attempted before its more probable for you to try it again) ○ Giving Stuff Away ○ Making Lists 29. Major Depressions Diagnosis and Nursing Interventions Lect 2 (1:07:09) zv Dysthymic Disorder, DSM-IV Diagnosis: Depressed mood for most days for at least 2 years Dysthymic Disorder is a milder but more chronic form of major depressive disorder. There is a depressed mood that fluctuates with a normal mood; the symptoms in dysthymic disorder are less severe than in major depression—chronic—lasts longer 2 or more of following symptoms ○ Poor appetite or overeating ○ Insomnia or oversleeping ○ Low energy or fatigue ○ Low self-esteem  ○ Poor concentration or difficulty making decisions ○ Feelings of hopelessness Assessment: “Have you thought about killing yourself?” “Do you have a plan?” Are the means to carry out this plan available to the pt? Assess plan for lethality (the more planned out, the more likely) Contract for safety (showing support) Elopement risk Attempt history (If you attempted before its more probable for you to try it again) ○ Giving Stuff Away ○ Making Lists Goal: (1:15:50) zv Pt will not self harm Interventions: Safety: 1:1, close observation, 15 minute checks Remove objects such as belts and shoelaces, mirrors, etc. Contracting Monitor medications ○ Suicide indicates the imminent failure of coping mechanisms. ○ Talk about survivors of suicide 30. Milieu Management on Depression Unit Just know about a safe environment 31. Drugs used for Acute Management of Violent Behavior Antianxiety Agents (BENZOs) ○ Lorazepam (Ativan) ○ Alprazolam (Xanax) ○ Diazepam (Valium) First Generation Antipsychotics ○ Haloperidol (Haldol) ○ Perphenazine ○ Chlorpromazine (Thorazine) ○ Loxapine (Adasuve) Second Generation Antipsychotics ○ Risperidone (Risperdal) ○ Olanzapine (Zyprexa) ○ Ziprasidone (Geodon) Combinations (B52!) ○ Haloperidol (Haldol) ○ Lorazepam (Ativan) ○ Diphenhydramine (Benadryl) 32. Drugs Used for Long Term Management of Chronic Aggression Lect 3 (41:35) zv Selective Serotonin Reuptake Inhibitors (SSRIs)  ○ Depression ○ Anxiety ○ Personality Disorder ○ Dementia ○ Intellectual Disability Lithium (Gold Standard for MOOD STABILIZERS use if CHRONIC MANIA is present) ○ Acute Tx of Mania (often first choice of treatment) and Depressive Episodes ○ Therapeutic range 0.6-1.5 mEq/L ○ Major long term risks are hypothyroidism/renal impairment (its a SALT) Anticonvulsant ○ Depakote (divalproex, valproic acid), Lamictal (lamotrigine), Tegretol (carbamazepine [use to be for ADHD kids before adderall]) ○ Bipolar Disorders ○ Therapeutic level (50-100)*** ○ Other anticonvulsants: Neurontin/Topamax/Gabitril (for mild hypomania symptoms and mild mood disorders) Gabapentin ○ Co-Existing Anxiety Disorders and Personality Disorders Benzodiazepines ○ Anxiety Second-Generation Antipsychotics ○ Schizophrenia, Psychosis, Mania Beta Blockers (Propranolol (Catapres)) ○ Brain Injury, Intellectual Disability, Anxiety Psychostimulants ○ ADHD in children & adults 33. AV Hallucinations/Illusions Auditory Hallucinations: Hearing Voices or Sounds Visual Hallucinations: Seeing people or things. Involves the distortion of visual stimuli or may be formed and realistic images. Seeing individuals and animals that do not exist is the most common type of visual hallucination. Illusions: Misinterpretations of a real experience. (Ex: a man sees a coat on a shadowy coat rack and believes it to be a bear)