Unit 2 Exam 144 Condensed Review PDF

**[Deinstitutionalization:]** - Took place in late 1960s/70s - **Lead to:** - the discharge of patients from institutions - classification of mental illness as a disability - **Result from deinstitutionalization:** - increase of patients who were homeless - This hurt se...

**[Deinstitutionalization:]** - Took place in late 1960s/70s - **Lead to:** - the discharge of patients from institutions - classification of mental illness as a disability - **Result from deinstitutionalization:** - increase of patients who were homeless - This hurt severely ill patients. - Mentally ill able to claim disability - Universalized understanding allowed for regulation of involuntary admittance, no one can just drop someone off and say they are unfit anymore. - Common Laws: - Cognitive standard **(M'Naghten Rule)** *not criminally responsible at the time of the act, due to mental illness* - Right to treatment **(Wyatt v. Stickney)**- *safe care in **least restrictive environment*** - Right to refuse treatment **(Rogers v. Okin)**- *can't be forced to take medication against their will* - Duty to warn **(Tarasoff v. Regents of UNC)**- *duty to warn of threats of harm to others.* - Torts-Civil laws: - **Negligence:** failure to do or not do what a reasonable person would do under the circumstances - **Malpractice:** professional negligence - **Assault:** deliberate threat + the ability to do physical hard to another - **Verbally** threatening to force the patient to take medication - **Battery:** intentionally touching of another person in a socially impermissible manner - **False imprisonment:** unlawful restraint - **Patient's Rights:** - Right to treatment with the least restrictive environment - Right to confidentiality of records - Right to freedom from restraints + seclusion - A physician's order is required within 1 hour of restraint; check q15 min. - Reevaluate the need for restraints q 2 hrs. - Right to give or refuse consent to treatment - **Suspension of rights:** for the protection of patients or others - **Involuntary patients:** dangerous to self or others or gravely disabled - Risk of harm through self-neglect, grave disability, or failure to meet basic needs - Risk that person might physically injure or kill himself or others - **Incapacitated patients:** treatment of a person who does not have the legal capacity to consent to treatment. Gravely disabled *(inability to provide food, clothing + shelter for oneself because of mental illness)* **[Me, Meds, Milieu:]** - **[Me:]** nurse-patient relationship - [Therapeutic Communication:] - **Offering self:** showing interest and concern. *"I'll sit with you for a while"* - **Active listening:** paying close attention to verbal + nonverbal communication, patterns of thinking, feelings, and behavior. - **Silence:** allowing the patient to think and say more. Maintain eye contact, convey interest + concern in facial expressions. - **Empathy:** *"I can hear how painful it is for you to talk about this"* - **Questioning:** using open-ended questions - *"Who?" "What?" "Where?" "What happened" "Tell me about it"* - **General Leads:** *"Go on, I'm listening"* - **Restating:** *"You say you are going home soon." "Your mother wasn't happy to see you?"* - **Verbalizing the implied:** Rephrasing pts words to highlight an underlying message - **Pt:** *"There is nothing to do at home."* Nurse *"It sounds as if you might be bored at home."* - **Clarification:** *"What do you mean by 'feeling sick inside'?* - **Making Observations:** *"You seem restless."* - **Presenting reality:** offering a view of what is real + what is not without arguing - *"I know the voices are real to you, but I do not hear them"* - **Encouraging description of perceptions:** Asking for pts views of their situations - *"What do you think is happening to you right now?"* - **Voicing doubt:** Expressing uncertainty about the reality of a pts perceptions + conclusions - *"Is that the only way to interpret it?" "What other conclusions could there be?"* - **Placing an event in the time or sequence:** asking for relationships among events - *"When did you do this?" "What is the connection between....?"* - **Encouraging comparisons:** *"How does this compare to the last time?"* - **Identifying themes:** *"What do you do each time you argue with your wife?"* - **Summarizing:** *"Let's see, so far you have said..."* - **Focusing:** pursuing a topic until it's meaning, or importance is clear - *"Explain more about.." "What bothers you about..?"* - **Interpreting:** providing a view of the meaning or importance of something - *"It sounds as if this is very important to you."* - **Encouraging evaluation:** asking the pts views of the meaning or importance of something - *"So what does all this mean to you?" "How important is it to change this behavior?"* - **Suggesting collaboration:** offering to help pts solve problems - *"I can help you understand this better." "Let's see if we can find an answer."* - **Encouraging goal setting:** asking pts to decide on the type of change needed - *"What do you think needs to change?" "What do you want to do differently?"* - **Giving Information:** providing information that will help pts make better choices - *"I can tell you about your medicines." "What would be the advantage of trying....?"* - **Encouraging consideration of options:** asking pts to consider pros + cons of possible options - *"Which is the best alternative for you?"* - **Encouraging decisions:** asking pts to make a choice among options - *"What would work best?"* - **Encouraging the formulation of a plan:** probing for step-by-step actions that'll be needed - *"What exactly will it take to carry out your plan?"* - **Rehearsing:** *"Tell me exactly what you will say to your wife on Friday."* - **Role Playing:** *"I'll play your wife. What do you want to say to me?"* - **Supportive Confrontation:** acknowledging the difficulty in change but pushing for action - *"I know this isn't easy to do, but I think you can do it."* - **Limit setting:** discouraging nonproductive feeling + behaviors + encouraging productive ones - *"You're slipping into an aggressive tone again. Try it again" "That is a negative comment about yourself. Tell me something positive about yourself"* - **Feedback:** pointing out specific behaviors + giving + impressions of reactions: - *"I thought you conveyed anger when you said.."* - **Reinforcement:** giving feedback on positive behaviors - *"This new approach worked for you. Keep it up"* - **[Nurse-Patient Relationship:]** - Series of goal-directed interactions that focus on the pt's thoughts, feelings, behaviors, + potential solution to problems. - **Orientation stage:** build trust, orient them to the unit, beginning assessment, managing emotions, providing support+ structure, discuss discharge *(when you will go home you will... discharge starts at admission)* - **Working Stage:** start working on goals w/ the pt *(Therapeutic technique of collaboration),* offer self, identify relapse triggers *(warning signs to identify relapse symptoms-keep them out of hospital example: not taking showers-no self care)* - **Termination Stage:** prepare for discharge + discharge-when the person goes from the hospital to home or an outpatient program group home possibly - [Milieu: Environment ] - The nurses role is to manage the milieu to make sure *environment* is *safe* - The nurses set tone for pts. The nurse is neg the pts can feel that & creates uncomfortable environment - The nurse creates a schedule and guide lines- ensuring the pt has consistency for things like group helps pt become more successful! - When a pt is decompensating in the environment the nurse must start with least restrictive form of punishment and then continue up as it escalates. - COMMUNICATE FIRST, build off of that. - The goal of milieu therapy is for the pt to learn to communicate with peers *(when in community setting such a psychiatric unit, everyone has to get along as part of milieu therapy. They have to learn interpersonal relationship skills to avoid he said/she said arguments)* - **[Meds]** - Antipsychotics - **Chlorpromazine** - 1^st^ generation/typical: works on positive schizophrenic symptoms - **Haloperidol** - 1^st^ generation/typical: works on positive schizophrenic symptoms. - [Symptoms: ] - Extrapyramidal symptoms (EPS): - **acute dystonia**: occurs within a few hrs to days - treated with a shot of Benadryl - **akathisia:** ours within a few days or weeks - very restless - **parkinsonian** like muscle rigidity, resting tremor: weeks to months - **Tardive Dyskinesias**: irreversible months or longer. - Increase prolactin- men will have gynecomastia, painful breast tissue - Increased QT interval- base line EKG needed bc torsades de pointes can occur. - Dry mouth, DRY EVERYTHING UP! - Sedation - Antidepressants: **amitriptyline** - SSRI- selective serotonin reuptake inhibitors - Drugs will become effective as an anti-depressant between 2-4 weeks. Teach pt they will need to remain on the course for it to become effective. - Will cause sexual dysfunction - **Aripiprazole** - [Indication:] Schizophrenia (negative), Bipolar Disorder - Decreases excitable, paranoid, withdrawn behavior, mood swings, agitation - [Adverse Reactions:] Agranulocytosis, NMS, EPS - **Clozapine** - Atypical- antipsychotic - [Indication:] Schizophrenia - \*\* risk for: agranulocytosis or severe granulocytopenia\*\* - [Monitor:] WBC count - All MAOI drugs you MUST wait 14 days before beginning another drug. - **Escitalopram, Fluoxetine** - Mood Stabilizer - **Carbamazepine, lorazepam** - **Lithium carbonate** - [Indication:] bipolar - [Therapeutic range:] 0.5-1.5 - [Lithium Toxicity presents as:] blurred vision, unstable balance, slurred speech, vomiting, diarrhea, tremors, muscle weakness, tinnitus. - [Teach pt:] signs to look for with lithium toxicity, risk of unstable lithium levels based on exercise/fluid intake, teach pt to continue to use table salt, - If pt. does change salt level, it can cause lithium toxicity - Communicate out any lifestyle changes to pcp so they can evaluate lithium level. - Monitor renal function- can also cause toxicity - MAOI- monoamine oxidase inhibitors - **Phenelzine** - [Indication:] antidepressants - [Contraindicated in:] foods with tyramine- avocados, overripe fruits, wine, aged cheeses, cured meats, pickled foods. - [Patient teach]: very restrictive with food, if you eat food high in tyramine you will have a hypertension crisis. - Benzodiazepines: **Diazepam** - Opioid analgesics - **Methadone** - Opioid replacement therapy, pain management on the medical side. - **Buprenorphine** - Opioid withdrawal drug - Opioid Antidote: **naloxone** - Anti-Alzheimer's agent/cholinergic: **Donepezil** - Anti-anxiety - **Buspirone** - Relief in 7-10 days but maximal therapeutic gain in 3-6 weeks - **Patient Teaching:** avoid large amounts of grapefruit juice, not addictive. - Most meds will cause dry mouth! [**Schizophrenia:**] *long term inability to tell what is real and not real, affects how a person thinks or feels* - Continuous signs of disturbance persist for at least 1 to 6 months - Objective signs of Schizophrenia: What we see as nurses - Alterations in **personal relationships**: *Inadequate or inappropriate community, hostility, withdrawal* - Alterations in **activity and behavior**: *Psychomotor agitation, catatonic rigidity, echopraxia (repetitive movements), stereotypy (repetitive acts or words)* - Altered **perceptions:** *Hallucinations, illusions, paranoid thinking* - Alteration of **thought:** *Loose associations (disorganized thinking), retardation, blocking (interruption of a thought + inability to recall it), Autism (introspective to the extent that they're distracted from external events), Ambivalence (love/hate), Delusions (fixed, false beliefs), Poverty of speech, ideas of reference, mutism.* - Altered **consciousness:** *Confusion, incoherent speech, clouding, sense of "going crazy"* - Alterations of **affect:** *Inappropriate, blunted (weak response), flattened (no response), or labile affect (emotional tone changes quickly); Apathy, Ambivalence, Overreaction* - Positive (Type 1) symptoms: Excessive dopamine: *(meth) (psychotic)* - Hallucinations, Abnormal thoughts, bizarre behavior, excitement, feelings of persecution, grandiosity, hostility, illusion, insomnia, suspiciousness - Delusions: - Erotomaniac: *pt believes Sandra Bullock is in love w/ him* - Somatic: *after medical tests confirm otherwise, pt states "I have cancer"* - Grandiose: *"I am the president"* - Religious: *"The devil told me kill my children"* - Nihilistic: *"I am dead" "How can you talk if you're dead?" "I don't know, but I am dead"* - Delusions of reference: *"The TV is talking about me. The guests on Oprah are making fun of me"* - Delusions of influence: *"I can control her w/ my thoughts"* - Paranoid: *"They all think that I am a homosexual."* - Delusions means **SAFETY** is a priority. **ALWAYS** assess for self-harm higher incidence of suicide in schizophrenia pts. - Negative (Type 2) symptoms: too little dopamine *(depression):* - Alogia *(poverty of speech)*, Anergia *(lack of energy),* Asocial behavior, Attention deficits, Avolition *(lack of motivation in goal-directed behavior)* - Blunted affect, communication difficulties, difficulty w/ abstractions, passive social withdrawal, poor grooming + hygiene, poor rapport - Nurse-Patient Schizophrenic Patient Care: - Do not reinforce or challenge hallucinations or delusions. - Focus on real people + real events - Don't touch without warning - Continuum of Care for People w/ Schizophrenia: - Acute Symptoms: Hospitalization - Treatment-resistant: Long term hospitalization - Stable but Chronic: Day treatment - Some level of supervision: Supportive housing for those who cannot live with family **[Bipolar Disorder:]** - Mood disorder that is extreme mania or extreme depression. *Euphoric-Depressed* - **Manic Episode:** elevated, expansive, or irritable mood - Begins suddenly, escalates rapidly, lasts a few days-several months. - Elevated mood for at least 1 week: - Inflated self-esteem, grandiosity, Decreased need for sleep *(insomnia)*, Very talkative *(loud, rapid speech),* Flight of ideas, racing thoughts, Distractibility, Increased goal-directed activity, agitation *(irritability, anger),* Excessive Involvement in pleasurable activity - Mood disturbance causing social, work, or interpersonal problems - Judgement is impaired - Involvement w/ alcohol or drugs is common - **Hypomanic** **episode**: less severe than manic - At least 4 days in duration - Not severe enough to warrant hospitalization - **Depressive episode:** - Atypical symptoms: Withdrawal, Passivity, Hypersomnia, daytime sleepiness, Hyperphagia *(binge eating),* craving for carbohydrates, weight gain, Difficulty concentrating, distractibility, Diminished interest in activities and sex, Decrease in speech - **Bipolar 1:** Swings between manic episodes + major depression - Manic episode required - Manic phase will be hospitalized - **Symptoms:** pressured speech, hallucinations, flamboyant, high incidence of drug use, very sexually motivated, drug use: stimulants-cocaine. - **Bipolar 2:** swings between hypomanic episodes + major depression. - Simple not as severe- not normally hospitalized. - **Interventions for all Bipolar episodes:** - Approach the patient in a calm, matter-of-fact manner. - Give clear, concise directions + comments. - Accept that the pt cannot sit still during a manic episode, allow pacing as appropriate. - Set limits in a direct but non-challenging manner. - Provide portable food/snacks, + drinks with which the pt can run (finger food) - Provide high-protein, high-calorie foods + drinks - Weigh the patient regularly - Structure to avoid stimulating activities during the evening. - Assess sleep-rest patterns. **[Suicide:]** - An escape, a means of ensuring control, a solution, a cry for help. - **Risk Factors:** - Male, Caucasian and Native America, Age 60 years or older, hopelessness, family history, no religious belief, General medical illness, Substance abuse, Living alone, Prior suicide attempts, unemployed/financial problems, recent losses, poor impulse control, loss of social support, recent release from inpatient setting. - The more depressed + hopeless, the more detailed the plan, the more lethal and accessible the method, the greater the likelihood that suicide effort will end in death. - If positive for suicidal ideations, ask about a plan It is essential to ask about previous suicide attempts. **[OCD:]** - Obsessions or compulsions or both. Obsessions are recurrent + persistent thoughts, ideas, impulses, or images that are experienced as intrusive + unwanted. - Ensure that basic needs are met *(food, rest, grooming)* - Provide time to perform rituals - Convey empathy, acceptance and understanding. - Structure simple achievable activities, games, or tasks - Reinforce + recognize non-ritualistic behaviors to increase self-esteem + self-worth **[Personality Disorders:]** - Cluster A: Odd-Eccentric - Paranoid Personality Disorder - Exhibits paranoia: *suspicious, mistrust of others, on guard, blames others* - Schizoid Personality Disorder - Exhibits: *emotional detachment, introverted, lack of interest in social relationships* - Schizotypal Personality Disorder - Exhibits: *Magical thinking, perceptual distortions, eccentric, odd, unusual fears* - Nursing Care: - Respect isolation: *if they aren't hurting anyone, there's nothing wrong with it.* - Help client focus + address feelings of delusions *(paranoid)* - Facilitate communication + identify negative thoughts. - Cluster B: Dramatic-erratic - Antisocial Personality Disorder - Exhibits: Disregard for law, Manipulative, aggressive, lack of remorse - Borderline Personality Disorder - **Patient can be:** impulsive, manipulative, erratic emotions, self-destruction *(risk for suicide),* unstable relationships *(all good or all bad),* self-imagine disturbance, all-or-nothing thinking. - **Nurse-Patient Relationship Interventions:** - Use of empathy maintain clear boundaries, write in a notebook/journal on daily basis - Consistency, limit setting, supportive confrontation: - *Enforce unit rules, provide clear structure, place responsibility for appropriate behaviors.* - DBT: *Dialectical Behavior Therapy* - Behavioral contract, Provide safety for increases risk of suicide - Histrionic Personality Disorder - **Patient can be:** attention-seeking, over-react for attention, flirty or seductive, manipulative. - **Nurse-Patient Relationship Interventions:** Be assertive - Narcissistic Personality Disorder - **Patient can be:** arrogant, lack empathy, need constant attention, exaggerated sense of self-worth. - Nursing Care: - Set limits, Provide consistency, Encourage socialization to improve skills - Cluster C: Anxious-Fearful - Avoidant Personality Disorder - **Patient will:** Avoid social situations due to fear of rejection or abandonment. - **Patient Can be:** lonely, feels unwanted. - **Patient wants:** close relationships but is scared. - Dependent Personality Disorder - **Patient can:** have an excessive need to be taken care of, clingy, fear of separation, avoid responsibility. - Obsessive-Compulsive Personality Disorder - **Patient will:** Desire perfection, be rigid + unbending in their ways, calm + controlled. **[Eating Disorders:]** - **Anorexia Nervosa:** - Intense fear of gaining weight or being fat, although underweight, body image disturbance - If 75% or below their intended body weight pt must be hospitalized. - **Exhibits:** Very low weight, Hormonal Imbalances, amenorrhea, Constipation if not using laxatives - PT weight must be stabilized before they are able to be admitted to psych unit. - **Bulimia Nervosa:** - Recurrent episodes of binge eating + compensatory behavior to prevent weight gain - Bingeing + compensating occurring at least twice weekly over 3 months - **Exhibits:** More normal weight, F/E imbalance, GI problems r/t bingeing/purging **[Delirium ]** - There is an identifiable cause for delirium - Can be caused by a medication interaction at times, or sickness, something else. - Sudden onset-can happen within a day or two **[Dementia]** - Slow gradual insidious onset - Starts out very slow-not rapid onset - Begins with forgetfulness and builds off that - Nursing Consideration: - Monitor food and fluid intake; Recommended finger food - Give step-by-step instructions - Environmental safety: - Rug placement, Well lit, Gates by stairs - Create a bowel schedule - **Give Med: donepezil (Aricept):** slows down dementia progression. - Does best with set structure -- simple tasks. **[Substance Abuse:]** **Alcohol: sedative** - Highly treatable addiction - **To Assess:** Michigan Alcoholism Screen Test, CAGE Questionnaire - **Withdrawal:** can be painful, scary + lethal - ALOCHOLICS SHOULD NEVER COLD TURKEY QUIT ALCOHOL - **Patients will exhibit:** tremors, anxiety, anorexia, N/V/D, insomnia, rapid pulse, hypertension *(increased blood pressure),* profuse perspiration, fever, unsteady gait, difficulty concentrating, cravings. - **Risk for seizures:** may occur 24-48 hours after last drink - begins 6-8 hrs after last drink - **Ask:** when they had their last drink - **Thorough assessment:** Start with basic questions; non-threatening + build to things like alcohol & drug use. - **Delirium Tremens:** medical emergency happens first 72 hrs of withdrawal - **Patients will exhibit:** tachycardia, diaphoretic, increased anxiety, not sleeping, confused, fall risk, tremors, unaware of where they are, sudden onset. - **Treated with:** benzodiazepines - Patient normally ends in ICU are placed on a lot of sedatives, intubated, and on a phenobarbital drip. **Inhalants:** - **Side effects**: mouth ulcers, GI problems, anorexia, confusion, headache, ataxia - **Signs of use:** rash around the nose + mouth, residue on face + clothing **Opioids:** - **Side effects:** respiratory depression, constipating, hypotension, pinpoint pupils, bradycardia, drowsiness, fall risk - **Withdrawal:** not lethal (maximal 36-72 hr Subsides in about 1 week), rhinorrhea (running nose), diaphoresis, chills, tremor, restlessness, muscle aches, N/V/D, leg spasm - **Antidote: Naloxone** **Stimulants/Amphetamines** *(Cocaine, Meth, Ecstasy)* - **Side Effects**: euphoria, increased mental alertness, increased strength, anorexia, tachycardia, hypertension, arrhythmias, dilated pupils, paranoia. - **Overdose:** Increased HR, Increased BP, cardiac ischemia, cerebral hemorrhage, seizures, coma **Hallucinogens** *( weed)* - **Side Effects:** sense of well-being, relaxation, euphoria, impaired balance + stability + decision making + short-term memory, dry mouth, sore throat, dilated pupils, conjunctival irritation, Increased HR. **Nursing-Patient Relationship Interventions for substance abuse:** - Goal is abstinence - Approach the pt in a manner that encourages forthrightness - Show **genuine** concern, express **empathy** + provide a safe environment - It is a Chronic, remitting, ongoing, lifelong process - Foster feelings of hope for the future - Confront denial + manage manipulation - Group Therapy - Use terms like: *"problem with drinking" "difficulties with drug use"* instead of alcoholic/addict - Asses pt's readiness for change *(transtheoretical model)* - **Precontemplation:** not thinking about change - **Contemplation:** recognizes behavior as a problem. Start considering pros + cons to change - **Preparation:** intending to take action - **Action:** making overt medication to behavior - **Maintenance:** sustain action + work to prevent relapse to old behaviors - **Relapse:** recycles from action or maintenance to an earlier stage