NCMB 317: Psychiatric Nursing PDF

NCMB 317: PSYCHIATRIC NURSING 2nd SEMESTER FINALS 3RD YEAR NURSING WEEK 13 - Psychopathology, Etiology, and Antihypertensive Drugs...

NCMB 317: PSYCHIATRIC NURSING 2nd SEMESTER FINALS 3RD YEAR NURSING WEEK 13 - Psychopathology, Etiology, and Antihypertensive Drugs ✓ Betablocker Psychodynamics of Psychosexual Disorders, Paraphilia, ✓ Diuretics and Gender Dysphoria ✓ Sympatholytic Others ✓ Cimetidine − Sexual Disorders are mental health conditions (Tagamet) characterized by problems in sexual responses. ✓ Sulfasalazine − Sexual dysfunctions are a heterogeneous group of (Azulfidine) disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond Categories of Sexual Disorder sexually or to experience sexual pleasure. − An individual may have several sexual dysfunctions at 1. Male Sexual Disorders the same time. Delayed ejaculation Contributing Factors in the development of sexual o Absent or delayed ejaculation despite dysfunctions adequate sexual stimulation. o Also called retarded ejaculation. 1. Psychosocial Factors Premature Ejaculation − These include: o Inability to control the timing of ejaculation Work-related stress Erectile Disorder Anxiety o Inability to achieve or maintain an erection Concern about sexual performance suitable for intercourse Marital or relationship problems Male Hypoactive Sexual Disorder (HSDD) Depression o Absence of sexual fantasies and thoughts, Feelings of guilt and/or desire for or receptivity to sexual Concerns about body image activity that causes the personal distress or Effects of a past sexual trauma difficulties in his relationship. 2. Medical conditions and surgical operations 2. Female Sexual Disorder − Medical conditions that affect sexual functions Neurological Female Orgasmic Disorder o Persistent delay or absence of orgasm − Spinal cord injury, Cervical disc problem, Multiple following a normal sexual excitement phase sclerosis Systemic Diseases Female Sexual Interest Disorder o Persistent failure to attain or maintain − Liver diseases, Renal diseases, Pulmonary diseases, lubrication–swelling response of sexual Arthritis excitement. Female Genital Diseases Genito–pelvic pain/ penetration Disorder − Infections, Cancer, Allergies to spermicide o Also called vaginismus. Vascular o It is a condition in which the pelvic floor − Atherosclerosis, Sickle cell anemia muscles around the vagina contract or tighten Endocrine involuntarily, a reflex action triggers tension in − Addisons disease, Cushing syndrome, the muscles resulting in pain. Hypothyroidism, Diabetes mellitus Male Genital Diseases Nursing Process for Sexual Disorders − Prostatitis, Orchitis, Tumor, Trauma 1. Assessment Antianxiety Drugs ✓ Xanax (alprazolam) ✓ Valium (Diazepam) Client’s sexual orientation ✓ Doxepin (Sinequan) Client’s Self-awareness of body image Antidepressant Drugs ✓ TCA Client’s comfort with own sexuality ✓ SSRI Client’s sexual deviated behavior or dysfunction ✓ MAOI Underlying factors that cause the disorder Antipsychotic Drugs ✓ Chlorpromazine Available support resources ✓ Other typical and atypical 2. Nurse self-awareness antipsychotic drugs Social Drugs ✓ Alcohol Nurses need to be aware of their attitudes, values, and ✓ Amyl nitrate beliefs regarding sexual health ✓ Lysergic acid Nurses need to be aware of their client’s sexual issues ✓ Marijuana Nurses need to be aware of how their personal ✓ Heroin attitudes, values, and beliefs affect her ability to ✓ Methadone recognize and react to clients’ sexual issues and Anticholinergic agents / ✓ Dilantin (Phenytoin) themes. Anticonvulsant drugs ✓ Carbamazepine o The nurses who have self-awareness is able Antiarrhythmic ✓ Disopyramide to do quality checks on the nursing care they (Norpace) 1 | JK LEI | IRIS  deliver. The unaware nurse is unable to do According to the DSM 5 Paraphilics are the following: this o The nurse should be aware of his/her own 1. Exhibitionism sexuality before he/she can help a client with sexual problems − Exposure of the genitals to a stranger, sometimes involving masturbation. 3. Nursing Interventions − Usually occurs before age 18 and is less severe after age 40. Encourage open discussion of feelings, and concerns − Diagnostic Criteria regarding sexual issues 1. Over a period of at least 6 months, recurrent Identify the underlying cause of the problem and intense sexual arousal from the exposure Assist the patient in understanding the nature of his/her of one’s genitals to an unsuspecting person, behavior disorder as manifested by fantasies, urges, or Help recognize the legal and interpersonal behaviors. consequences of his/her sexual behavior 2. The individual has acted on these sexual Redirect patient’s energies toward appropriate urges with a non-consenting person, or the activities. sexual urges or fantasies cause clinically Explore possible alternatives of sexual expression significant distress Provide acceptance, empathy, and non-judgmental 2. Fetishism attitude. Find new ways of coping to resolve conflict − Use of nonliving objects (the fetish) to obtain sexual excitement and/or achieve orgasm. 4. Evaluation − Common fetishes include women’s underwear, bras, Client achieved satisfying sexual behavior and lingerie, shoes, or other apparel. expressed a satisfying relationship with partner − The person might masturbate while holding or rubbing Client expressed awareness and acceptance of his/her the object. own sexuality − It begins by adolescence and tends to be chronic. Client expressed sexual function appropriately 3. Voyeurism 5. Management − Recurrent, intensely sexually arousing fantasies, Treat underlying physical of the disorder if any (use sexual urges, or behaviors involving the act of medication) observing an unsuspecting person who is naked, in the Resolve the psychological cause of the disorder process of undressing, or engaging in sexual activity. (Marriage counselling) − Voyeurism usually begins before age 15, is chronic, Use of pharmacology to enhance sexual functions. and may involve masturbation during the voyeuristic behavior. General Consideration for Counselling − Diagnostic Criteria 1. Over a period of at least 6 months, recurrent 1. Create an atmosphere of trust and acceptance for and intense sexual arousal from observing an objective, non-judgmental dialogue unsuspecting person who is naked. 2. Use language related to sexual behavior that is 2. The individual has acted on these sexual mutually comfortable and understood by the client and urges with a nonconsenting person, or sexual nurse. urges or fantasies cause clinically significant 3. Use alternative terms for definition. distress or impairment in social, occupational, 4. Determine the exact meaning of word and phrase since or other important areas of functioning. sexual words and expressions have different meanings 3. The individual experiencing the arousal to people with different backgrounds and experiences. and/or acting on the urges is at least 18 y.o. 5. There is a universal consensus about acceptable human sexuality. Each social group varies in definite 4. Sexual Masochism values regarding sex. 6. Counselors need to examine their own feelings, − Recurrent, intensely sexually arousing fantasies, attitudes, values, biases, and knowledge base. sexual urges, or behaviors involving the act of being 7. Help reduce fear, guilt, and ignorance. humiliated, beaten, bound, or otherwise made to suffer. 8. Offer guidance and education rather than − Some individuals act on masochistic urges by indoctrination or pressure to conform themselves, others with a partner. 9. Each person needs to be helped to make personal − Diagnostic Criteria choices regarding sexual conduct. 1. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of Paraphilia being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, − The word paraphilia derives from Greek; “para” means urges, or behaviors. around besides, and “philia” means love. 2. The fantasies, sexual urges, or behaviors − The definition of paraphilia is any emotional disorder clinically significant distress impairment in characterized by sexually arousing fantasies. social, occupational, − Urges, or behaviors that are recurrent, or intense, occur over a period of at least six months cause 5. Sexual Sadism significant distress or interfere with the sufferer’s work, social function, or other important areas of functioning. − Recurrent, intensely sexually arousing fantasies, sexual urges, or behaviors involving acts in which the 2 | JK LEI | IRIS  psychological or physical suffering of the victim is − Wherein the individual has the desire to be, or insist sexually arousing to the person. that he/she is of the other sex, accompanied by the − It can involve domination, restraint, spanking, beating, persistent discomfort of his/her assigned gender. electrical shock, rape, cutting, and in severe cases, torture, and death. Symptoms Include: − Victims may be consenting (those with sexual 1. Noticeable incongruence between the gender that the masochism) or nonconsenting. patient sees themselves are, and what their classified − Diagnostic Criteria gender assignment 1. Over a period of at least 6 months, recurrent 2. An intense need to do away with his or her primary or and intense sexual arousal from the physical secondary sex features. or psychological suffering of another person, 3. An intense desire to have the primary or secondary sex as manifested by fantasies, urges, or features of the other gender behaviors. 4. A deep desire to transform in another gender 2. The individual has acted on these sexual 5. A profound need for society to treat them as another urges with a nonconsenting person, or sexual gender urges or fantasies cause clinically significant distress or impairment in social, occupational, Treatment for Gender Dysphoria or other important areas of functioning. 1. Psychotherapy 6. Pedophilia 2. Pharmacologic therapy, as well as other non– pharmacologic therapies − Sexual activity with a prepubescent child (generally 13 3. Sexual reassignment (SRS) years or younger) by someone at least 16 years old Scientific evidence has shown the benefit of and 5 years older that the child. this procedures. − It can include an individual undressing the child and All the same, it should be stated that SRS looking at the child; exposing himself or herself. does not automatically mean any issue is − Masturbating in the presence of the child; touching and resolved, and much psychotherapy may be fondling the child; fellatio; cunnilingus; or penetration of needed after the procedure in order to child’s vagina, anus, or mouth. improve outcomes. − Diagnostic Criteria 1. Over a period of at least 6 months, recurrent, Care of Clients with Substance related disorders intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity Substance related disorder, or drug abuse as it is more with a prepubescent child or children generally referred to, (generally age 13 years or younger) o Is when you use any substance, whether 2. The individual has acted on the sexual urges prescribed or recreational, excessively to a or fantasies that cause marked distress or point that it leads to significant problems or interpersonal difficulty even long-term damage. 3. The individual is at least age 16 years and at least years older than the child or children in The DSM 5 recognizes Common Abused Substances that Criterion A. may results to substance related disorders: Treatment for Paraphilia 1. Central Nervous System Depressants ✓ Alcohol Cognitive Behavioral Therapy ✓ Sedatives-Hypnotics and Anxiolytics ✓ Opioids − Helps the paraphilic person anticipate situations that 2. Central Nervous System Stimulant increase their risk of sexually acting out and finding ✓ Caffeine ways to avoid or productively respond to those triggers. ✓ Nicotine (MhGAP) ✓ Amphetamine Medications ✓ Cocaine 3. Hallucinogens Serotonin reuptake ✓ Used to decrease sexual 4. Cannabis inhibitors (SSRIs) obsessiveness and urges 5. Inhalants associated with paraphilias and may help Etiology and psychodynamic of substance related disorder with increasing the paraphilic’s ability to The exact causes of drug use, dependence, and control his or her impulses. addiction are not known. Methylphenidate ✓ Can increase the Much of the research on biologic and genetic factors (Ritalin) effectiveness of SSRIs. has been done on alcohol abuse. Naltrexone ✓ Can decrease some of the sexual obsessiveness A. Biologic Factors associated with paraphilia. Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are Gender Dysphoria children of nonalcoholic parents. − Formerly called the gender identity disorders where This increased risk is partly the result of environmental individuals have a strong and persistent cross-gender factors, but evidence points to the importance of identification. genetic factors as well. 3 | JK LEI | IRIS  Several studies of twins have shown a higher rate of 2. Wanting to cut down or stop using the concordance (when one twin has it, the other twin gets substance but not managing to. it) among identical than fraternal twins. 3. Spending a lot of time getting, using, or o Adoption studies have shown higher rates of recovering from use of the substance. alcoholism in sons of biologic fathers with 4. Cravings and urges to use the substance. alcoholism than in those of nonalcoholic 5. Not managing to do what you should at work, biologic fathers. home, or school because of substance use. The ingestion of mood-altering substances stimulates 6. Continuing to use, even when it causes dopamine pathways in the limbic system, which problems in relationships. produces pleasant feelings or a “high” that is a 7. Giving up important social, occupational, or reinforcing, or positive, experience. recreational activities because of substance use. B. Psychological Factors 8. Using substances repeatedly, even when it puts you in danger. In addition to the genetic links to alcoholism, family 9. Continuing to use, even when you know you dynamics are thought to play a part. have a physical or psychological problem that Children of alcoholics are four times as likely to develop could have been caused or made worse by alcoholism compared with the general population. the substance. Some theorists believe that inconsistency in the 10. Needing more of the substance to get the parent’s behavior, poor role modeling, and lack of effect, you want (tolerance). nurturing pave the way for the child to adopt a similar 11. Development of withdrawal symptoms, which style of maladaptive coping, stormy relationships, and can be relieved by taking more of the substance abuse. substance. Psychological Factors: o Relieve tension, Help unwind, Drowning The Severity of Substance Use Disorders: sorrow, Making one feel free, Helping one to be sociable, Feeling of belongingness The DSM 5 allows clinicians to specify how severe or how much of a problem the substance use disorder is, C. Social and Environmental Factors depending on how many symptoms are identified. In general, younger experimenters use substances that Two or three symptoms indicate a mild substance use carry less social disapproval such as alcohol and disorder; cannabis, while older people use drugs. Four or five symptoms indicate a moderate substance Alcohol consumption increases in areas where use disorder, and availability increases and decreases in areas where Six or more symptoms indicate a severe substance use costs of alcohol are higher because of increased disorder. taxation. The DSM 5 recognizes Common Abused Substances that Many people view the social use of cannabis, though may results to substance related disorders: still illegal in most states, as not harmful; many advocates legalizing the use of marijuana for social 1. Central Nervous System Depressants purposes. Social Factors Signs and symptoms: o Influence of advertisement / advertising o Depression of major brain functions: mood, cognition, attention, concentration, campaign, Influence by peer and family, insight, judgment, memory, affects. Boredom and loneliness, Pressure at work o Social impairment and at home, Lack of parental and community o Psychomotor impairment: increased supervision. reaction time, interruption of hand-eye coordination, motor ataxia, nystagmus There are two groups of substance-related disorders: o Decreased REM sleep leading to more 1. Substance-use disorders are patterns of symptoms dreams and sometimes nightmares General depressant withdrawal syndrome: resulting from the use of a substance that you continue o Tremors, agitation/anxiety, diaphoresis, to take, despite experiencing problems as a result. sleep disturbance, increased pulse, 2. Substance-induced disorders, including intoxication, increased BP, hallucination, delusions, withdrawal, and other substance/medication-induced seizure, delirium tremens. mental disorders, are detailed alongside substance 1.1. Alcohol - is a CNS depressant that absorbed use disorders. quickly into the bloodstream o Route: Oral Criteria for Substance Use Disorders: o Short-Term Effects of Alcohol Substance use disorders span a wide variety of o Levels of intoxication - consuming more problems arising from substance use, and cover 11 than one beverage per hour can lead to different criteria: intoxication, raising an individual’s blood 1. Taking the substance in larger amounts or for alcohol content (BAC) with each drink. longer than what should be. ✓ 0.1% – 0.2% - Mild Intoxication 4 | JK LEI | IRIS  ✓ 0.2% - 0.3% - Moderate 4. Chronic phase - becomes Intoxication intoxicated all day to prevent ✓ 0.3% and above – Severe symptoms of withdrawal. Intoxication o Common behavioral problems seen in o Short-term effects of alcohol can individual who are alcoholic include: ✓ Destructive and rebellious ✓ Lowered inhibitions, trouble behavior concentrating, loss of ✓ Dominant and critical behavior coordination, loss of critical ✓ Difficulty with intimate judgement, dulled perception, relationships and tendency especially vision, mood swings, toward narcissism reduced core body temperature, ✓ Decreased self-esteem raised blood pressure, passing o Common defense mechanisms used by out, vomiting. alcoholic o Long-term effects of excessive drinking ✓ Denial - “I don’t have a problem; I may include: can quit anytime I want” ✓ Diminished gray matter and white ✓ Rationalization - “If you have the matter in the brain, memory loss, problems I have, you’d drink too” loss of attention span, trouble ✓ Projection - “Tom is the one who learning, alcoholic hepatitis, liver can’t hold his liquor” fibrosis, steatosis, cancer, high ✓ Minimization - “I only have a blood pressure, cardiomyopathy, couple of beers” stroke, irregular heartbeat. o Treatment for alcoholism: o Alcohol Overdose: Respiratory ✓ Pharmacology: depression, Cardiac arrest, Cardiogenic 1. Folic acid (Folate) 1 – 2 shock. mg/day o Treatment of alcohol overdose 2. Cyanocobalamin (Vit. ✓ Gastric lavage or dialysis (to B12) 25 – 50 mg/day remove the drug from the body) (treat nutritional ✓ Support of respiratory and deficiency). cardiovascular functioning (ICU) 3. Thiamine (Vit. B1) 100 o Effects of Alcohol Abuse on the Body: mg/day (prevent or treat ✓ Below are some of the ways Korsakoff’s-Wernicke’s alcohol may affect the body: Syndrome) liver, digestive system, pancreas, 4. Benzodiazepine – 50- central nervous system, 100 mg repeat in 2-4 cardiovascular health, hrs. if necessary but reproductive health, bones, should not exceed 300 psychological effects. mg/day (suppress the symptoms of o Withdrawal symptoms of Alcohol: abstinence) ✓ 3 – 24 hours after the last drink 5. Naltrexone (Revia, – called “SHAKES” or “Mild Trexan) (use to reduce Tremors”. alcohol craving) 50 mg / Sweating day for 12 weeks. Hypertension, and Also use to increased pulse and treat opioid heart rate abuse (blocks Anxiety / agitation the effects of kExcessive vomiting/ opiates) 350 nausea mg/week given Seizures/ tremors in 3 divided ✓ 36 – 72 hours after the last doses for drink - results to “Delirium opiate-blocking Tremens” or hallucination occurs effect. within 48 hours. 6. Disulfiram (Antabuse) o Phases of progression of alcoholism: 250-500mg/day for 1-2 1. Pre-alcoholic phase - social weeks then 125- drinking until tolerance begins to 250mg/day as develop maintenance (help client 2. Prodromal phase - blackout to maintain abstinence occurs, alcohol becomes a need, from alcohol) and denial begins to develop. Adverse 3. Crucial phase - cardinal signs of reactions for alcoholism develop, loss of mild: Flushing, control over drinking. throbbing headache, N/V, sweating. 5 | JK LEI | IRIS  Adverse after the last dose and reaction for peak at 24 to 72 hours severe: ✓ With longer-acting medications: hypotension, Phenobarbital, diazepam (Valium), or confusion, chlordiazepoxide (Librium) coma, death. Withdrawal symptoms begin 24 o What to avoid when in Antabuse to 48 hours after the last dose and therapy? peak within 5 to 8 days ✓ Food sauces made of wine o Pentobarbital (Nembutal) ✓ After shave lotion alcohol based ✓ Amobarbital (Amytal) ✓ Skin products ✓ Secobarbital (Seconal) ✓ Mouth wash o Chlordiazepoxide (Librium) ✓ Over the counter drugs o Lorazepam (Ativan) ✓ Vinegar o Oxazepam (Serax) ✓ Extract fruit flavored o Alprazolam (Xanax) o Self-help groups are concern (about o Diazepam (Valium) coping with a specific problem or life crisis) 1.3 Opioids - desensitize the user both physiologic ✓ Alcoholic anonymous – and psychological pain and endure a sense of alcoholics euphoria and well-being. ✓ Al-Anon – wives of alcoholics o Signs and symptoms: Euphoria, ✓ Ala-teen – children of alcoholics Relaxation, Relief from pain, Constricted 1.2 Sedatives-Hypnotics and Anxiolytics - pupil, Nausea, Drowsiness, Constipation Sedative-hypnotic drugs, sometimes called slurred speech, Respiratory depression, "depressants" and anxiolytic (antianxiety) drugs “Nodding out”. slow down the activity of the brain. o Overdose: Unconsciousness /coma, o Symptoms of dependence on sedative, Respiratory depression/arrest, Circulatory hypnotic or anxiolytic drugs: depression/cardiac arrest, Death. ✓ A craving for the drug, often with o Withdrawal: unsuccessful attempts to cut ✓ Initially: Drug craving, down on its use lacrimation, rhinorrhea, yawning, ✓ Physical dependence and diaphoresis (development of physical ✓ Occurs: within 12 – 72 hours withdrawal symptoms when a after the last take, resulting to person stops taking the sleep disturbances, anorexia, depressant) irritability, tremors, weakness, o Effects of Prolong Use: nausea, vomiting, diarrhea, chills, ✓ Depression of major brain fever, muscle spasms, flushing, functions: mood, cognition, spontaneous ejaculation, attention, concentration, insight, abdominal pain, hypertension, judgment, memory, affects. and increased respiration ✓ Social impairment ✓ Protracted withdrawal: results ✓ Psychomotor impairment: to hypersensitivity to sensory increased reaction time, stimuli, paresthesia, perceptual interruption of hand-eye distortions, muscle pains, coordination, motor ataxia, twitching tremors, headache, nystagmus sleep disturbances, tension, ✓ Decreased REM sleep leading to irritability, lack of energy, more dreams and sometimes impaired concentration, and nightmares maybe ✓ Depressant addiction can be a depersonalization/derealization long-term problem that lasts for o Treatment and Management for years Persons abusing CNS Depressants o As with alcohol, sedative, hypnotic or ✓ Methadone substitution (to anxiolytic drugs can cause symptoms stabilize symptoms of heroine during intoxication: withdrawal) ✓ Slurred speech, Problems with 10 – 40mg in the first 24 coordination or walking, hours and gradually Inattention, Memory difficulties, In tapered to 0. severe cases, Stupor or coma ✓ Clonidine (to stabilize symptoms o Withdrawal: of opiate withdrawal) ✓ With short-acting medications: 0.3 mg in 3 divided Pentobarbital (Nembutal), doses on the first 24 Secobarbital (Seconal), hours Alprazolam (Xanax), Check BP, it can cause Meprobamate (Miltown, Equanil), hypotension Methaqualone (Quaalude). ✓ Provide a new environment and Withdrawal symptoms peers begin 12 to 24 hours ✓ Health teachings: 6 | JK LEI | IRIS  IV use (leads to risk for who consume large amounts on a infection with blood daily basis. borne pathogens) ✓ High Blood Pressure - caffeine Chronic use (leads to doesn’t seem to increase the risk lack of concern about of heart disease or stroke. physical well-being) However, It has been Criminal behavior (may shown to raise blood occur as a means of pressure due to its acquiring money for stimulatory effect on the drugs) nervous system. 2. Central Nervous System Stimulants ✓ Rapid Heart Rate - stimulatory effects of high caffeine intake Route: Oral, IV, inhalation, smoking may cause your heart to beat Effects: Euphoria, Decrease appetite, faster. Wakefulness, Insomnia, Paranoia, Aggressiveness, It may also lead to Dilated pupils, Tremors altered heartbeat Overdose: Cardiac arrhythmias/arrest, Chest pain, rhythm, called atrial Decreased BP, Vomiting, Respiratory depression, fibrillation. (Reported in Seizures, Psychosis, Confusion, Dyskinesia or young people who dystonia, Coma consumed energy drinks Withdrawal: Amphetamine withdrawal/cocaine containing extremely withdrawal not as pronounced as: high doses of caffeine). o Intense and unpleasant feelings of ✓ Fatigue - coffee, tea and other depression caffeinated beverages are known o Fatigue then insomnia to boost energy levels. o Severe dysphoria and anxiety However, they can also o Vivid, unpleasant dreams have the opposite effect o Suicidal ideation by leading to rebound Prolong used: fatigue after the caffeine o Weight loss resulting to malnutrition and leaves your system. increased susceptibility to infectious ✓ Frequent Urination and diseases. Urgency - Increased urination is o May produced schizophrenia like a common side effect of high syndrome. caffeine intake (due to the 2.1 Caffeine - a substance that may boost your compound’s stimulatory effects mood, metabolism and mental and physical on the bladder). performance. (1 cup of coffee = 100mg and 250mg 2.2 Nicotine - is a highly addictive chemical = intoxication) compound present in the tobacco plant. (cigarettes, o Effects of Caffeine cigars, smokeless tobacco, hookah tobacco, and e- ✓ Anxiety - Although low-to- cigarettes). moderate doses of caffeine can o Signs and symptoms: increase alertness, larger ✓ Psychological - feeling of amounts may lead to anxiety or pleasure, increased alertness, edginess. enhanced mental performance Monitor your own ✓ Physical - increased heart rate, response in order to increased blood pressure, determine how much restricts blood flow to heart you can tolerate. muscles ✓ Insomnia - can help you stay o Overdose: None awake during the day, but it may o Withdrawal: negatively impact your sleep. ✓ Anger, anxiety, depressed mood, Cut off your caffeine difficulty concentrating (all of consumption by the which subside within 3-4 weeks) early afternoon to avoid ✓ Increased appetite and craving sleeping problems. for nicotine which may persist for ✓ Digestive Issues - many people months find that a morning cup of coffee o Management: helps get their bowels moving. A. Nicotine gum and nicotine patch Coffee’s laxative effect ✓ Dose: has been attributed to Gum - 2-4mg/hour the release of gastrin (a Patch – 21- hormone the stomach 22mg/24hour or produces that speeds up 15mg/16hr patch activity in the colon) Optimum length of ✓ Addiction - going without treatment before caffeine for several hours may tapering is 4-6 weeks lead to psychological or physical B. Bupropion – non-nicotine replacement withdrawal symptoms in those therapy 7 | JK LEI | IRIS  ✓ 150mg every morning for 3 days, ✓ Sudden death related to respiratory then 150 mg BID arrest ✓ Treatment should begin 1 – 2 o No clinical use in medicine weeks before the initial quit date ✓ It is highly addictive and a popular and should last for 8-12 weeks recreational drug because of the with 6 months of maintenance intense and immediate feeling of C. Clonidine and nortriptyline euphoria it produces. ✓ Are second line medications ✓ Use of cocaine may result to ✓ Suppresses opiate withdrawal psychosis. symptoms. o Management: Gradual withdrawal ✓ Smoking by pregnant women o Difference between Amphetamine and contributes to low birth weight, Cocaine incidence of stillborn and ✓ Methamphetamine premature babies. Synthetic ✓ Special considerations. Smoking produces high 2.3 Methamphetamine that last 8-24 hours o Long acting such as appetite suppressant Half-life is 12 hours (Lonamin, Adipax) Limited medical use o Used by performers and parties ✓ Cocaine (Benzadrine, Deredrines) Plant derived o Used by students during exam (Reactivan) Smoking produced high o Shabu which is the most potent and lasting 20-30 minutes dangerous. “Poor man’s cocaine” Half-life is 1 hour ✓ A slang term for Can be used as local the drug methamphetamine used anesthetic in Japan, Hong Kong, Philippines, 3. Hallucinogens - phencyclidine or similarly acting Malaysia and Indonesia. arylcyclohexylamines, and other hallucinogens, such as LSD ✓ Is commonly made from cheap 3.1 Cannabis - are related to hallucinogens medicines containing ephedrine. (alteration in perception) and to CNS depressants ✓ It is the drug of choice for 90% of (depressing higher brain centers). the Filipino drug users. o Marijuana o All of the above substances produce o Hashish (Hash) tetrahydrocannabinol (a contemporary anxiety and psychotic like raisin-like substance and is being mixed symptoms: with coffee or tea) ✓ Grandiosity, talkativeness, hostility, o Route: Smoking, oral aggressiveness, hallucination, o Effects: Euphoria/dysphoria, Relaxation & impaired judgment drowsiness, Reduced inhibitions, o Effects Heightened perception of colors and ✓ Vasodilators affecting capillaries in sound, Poor coordination, Distortion of the brain resulting to: intracranial time and perceptions, Unusual body hemorrhage (brain damage & acute sensations (weightlessness, tingling, etc.), psychosis or death). Dysarthria and food craving 2.4 Cocaine - drug in a powder form or crystal form. o Overdose: Increased pulse, conjunctival o The powder is usually mixed with injection (blood shoot eyes), dysphoria, substances such as cornstarch, talcum liability, disorientation powder and/or sugar or other drugs such o Withdrawal Symptoms: None as procaine (local anesthetic) or o Prolong used: can decrease motivation amphetamines. and cognitive deficits. ✓ Basulca - pure form of cocaine 3.2 Lysergic Acid Diethylamide (LSD) – is a ✓ Crack - mixture of water, cocaine, crystalline compound prepared from natural ergot and baking soda alkaloids or synthetically. ✓ Speed Ball - mixture of cocaine o Route: Oral and heroin o Effect: Euphoria/dysphoria, Altered body o Short-acting stimulant extracted from image, Distorted perceptions such as coca leaves. hallucinations, illusions, depersonalization, ✓ It was originally developed as a Bizarre behavior (good/bad trip), painkiller. Confusion, Incoordination, Impaired ✓ It is most often sniffed, with the judgment and memory, Signs of powder absorbed into the sympathetic and parasympathetic bloodstream through the nasal stimulation. tissues. o Overdose: Paranoia, Ideas of reference, o Cocaine use may lead to multiple physical Fear of losing one’s mind, problems Depersonalization, Derealization, Illusions, ✓ Destruction of the nasal septum Hallucination, Synesthesia, Self- related to snorting destructive/aggressive behavior, Tremors ✓ Coronary artery vasoconstriction o Withdrawal Symptoms: none ✓ Seizure ✓ Cerebrovascular accident / myocardial infarction 8 | JK LEI | IRIS  o Prolong used: “Flashbacks” that may last Injury: under the for several months, Permanent psychosis influence of inhalants, may occur. youth feel invulnerable o Management: Burns and frostbite can ✓ Psychotic reactions are managed by: also be caused by these Isolation from external chemicals stimuli Inhalant abuse may Physical restraint as result to dementia, necessary inhalant-induced ✓ Treatment of toxic reactions is psychosis, anxiety, or supportive. mood disorders 3.3 Phencyclidine (PCP) o Priority nursing diagnosis: Ineffective o Route: Smoking or ingestion individual coping o Signs and symptoms: o Treatment and management for ✓ Intensely psychotic experience substance abusers characterized by bizarre perceptions, ✓ Behavior modification (firmness- confusion, disorientation, euphoria, matter of fact attitude) hallucinations, paranoia, grandiosity, ✓ Detoxification (first step is agitation rehabilitation) ✓ Apparent enhancement of strength o Administer medications as ordered and endurance ✓ Antihypertensive/anti-anxiety ✓ Maybe agitated and hyperactive with (to patients who are abusing tendency toward violence or stimulants) catatonic and withdrawn or rage ✓ Anti-anxiety; antidepressants reactions (to patients who are abusing ✓ Red, dry skin; dilated pupils, depressants) nystagmus, ataxia, hypertension, ✓ Anti-anxiety (to patients who are rigidity, seizures abusing alcohol) ✓ Toxic psychosis o Overdose: seizure, coma, death o Withdrawal: none o Management: Symptomatic o Special consideration o NOTE: if flashback occur, they are mild and usually not disturbing 3.4 Inhalants - a solvent or other material producing vapor that is inhaled by drug abusers o Example: Gasoline, glue, paint thinner, aerosol spray paint, rugby o Route: inhalation o Signs and symptoms: o Psychological: Belligerence, assaultive Ness, apathy, impaired judgment, euphoria o Physical: dizziness, nystagmus, incoordination, slurred speech, unsteady gait, depressed reflexes, tremor, blurred vision, anorexia o Overdose: lethargy, stupor/coma, respiratory arrest, cardiac arrhythmia o Withdrawal: symptoms similar to alcohol withdrawal o Special considerations: ✓ May cause brain damage, peripheral nervous system and liver disease ✓ Death from inhalants can occur in different ways: Death may occur from bronchospasm, cardiac arrest or suffocation or aspiration Sudden death is caused by cardiac arrhythmia (sometimes this happens the first time the child uses inhalants) 9 | JK LEI | IRIS  NCMB 317: PSYCHIATRIC NURSING 2nd SEMESTER FINALS 3RD YEAR NURSING WEEK 14 - Mental Health Treatment Gap The mhGAP version 2.0, was launched in 2016 with updates. − This is a public health concern. o Incorporating new evidence- based guidance, − Is compounded by the fact that many individuals with enhanced usability, and new sections to Mental, Neurological, and Substance-related (MNS) expand its use by both health care providers conditions remain untreated despite the existence of as well as program managers. effective treatment. General Principles of Clinical Care Mental Health Gap Action Program (mhGAP) Use Effective Communication Skills − First launched in 2008, to scale up care for MNS Promote Respect and Dignity disorders − The program asserts that, with proper care, Essentials of Mental Health Clinical Practice: psychosocial assistance, and medication. 1. Assess Physical Health − Tens of millions of people could be treated for 2. Conduct a MNS Assessment depression, psychoses, and epilepsy, prevented from 3. Manage MNS Conditions suicide, and begin to lead normal lives – even where A. Treatment Planning resources are scarce B. Psychosocial Interventions − Its focus is to increase non-specialist care, including: Psychoeducation Non-specialized health care - to address the Reduce stress and strengthen social unmet needs of people with priority MNS supports conditions. Promote functioning in daily Non-specialized healthcare providers will activities be trained in basic mental health C. Psychological Treatment competencies - to identify and assess MNS D. Pharmacological Interventions conditions, provide basic care, and refer E. Referral to specialist/hospital if needed complex cases to specialist services. F. Follow-up Mental health specialists - will be equipped G. Involving Carers to work collaboratively with non-specialist H. Links with other sectors healthcare providers and offer supervision I. Consider the needs of Special Populations and support. mhGAP Master Chart Non-Specialized Healthcare Providers − This contains the overview of priority conditions and the − General physicians, family physicians, nurses emergency presentations of each NMS conditions. − First points of contact and outpatient care − This is where the common presentations of each MNS − First-level referral centers condition are shown that guides the assessment of the − Community/barangay health workers non-specialized health-care provider. − If the client presents features of more than one Reasons for Integrating Mental Health into Non-Specialized condition, then all relevant conditions need to be Healthcare assessed. − All conditions apply to all ages, unless otherwise − The burden of mental disorders is great specified. − Mental and physical health problems are interwoven − For the emergency presentation, this must be − The treatment gap for mental disorders is enormous assessed as the presence of any of the given − Enhance access to mental health care presentations require immediate management and − Promote respect of human rights care. − It is affordable and cost-effective − Generates good health outcomes Seven Priority Conditions mhGAP Intervention Guide 1. Depression This presents the integrated management of priority − This is primarily characterized by a persistent MNS conditions using algorithms for clinical decision- depressed mood with markedly diminished interest in, making. or pleasure from, activities. o Aimed to aid health-care providers to assess, − Symptoms must be present for at least two weeks. manage and follow-up individuals with priority Common Presentation (as presented in the mhGAP Master MNS conditions Chart) The first version was developed in 2010 as a simple technical tool Multiple persistent physical symptoms with no clear o To allow for integrated management of priority cause MNS conditions using protocols for clinical Low energy, fatigue, sleep problems decision-making. Persistent sadness or depressed mood, anxiety 10 | JK LEI | IRIS  Loss of interest or pleasure in activities that are ✓ If the symptoms are due to a normally pleasurable physical cause. o Do not prescribe an antidepressant if the Assessment person is pregnant/breastfeeding. (As first- line treatment, offer psychosocial intervention Consider physical conditions such as anemia, first). malnutrition and hypothyroidism as this can resemble ✓ Do not prescribe if the child is some manifestations of depression such as low younger than 12. energy, fatigue, low mood, lack of focus, etc. ✓ Do not prescribe to adolescents Assess for possible substance use or medication side- aged 12–18 as first-line treatment. effects as it may also cause mood changes. Offer psychosocial interventions Ask for history of mania, this can be a depressive first. episode in bipolar and would require a different form of o Avoid tricyclic antidepressants (TCAs) management. among: Major losses can also bring about grieving that can ✓ The elderly, people with normally result to depressed mood cardiovascular disease and people Assess for self-harm/suicide with dementia. ✓ People with ideas, plans or previous Management acts of self-harm or suicide – to minimize the risk of overdosing. Psychoeducation Reducing stress and strengthening social supports Follow Up Promoting functioning in daily activities Referral Observe if the client shows improvement or remains o Consider a referral to a mental health the same or deteriorating. specialist (where available): Monitor clients on antidepressants. ✓ If a person with depression shows Pharmacologic responses that will require action: any signs of psychotic symptoms o Symptoms of mania (e.g. hallucinations and delusions). o Inadequate response ✓ If the person presents with bipolar o No response. disorder. ✓ If the person is pregnant or a 2. Psychosis breastfeeding woman. ✓ In the cases of people with self- − Includes psychosis and bipolar disorder. harm/suicide. − This is the most common NMS condition that causes o Consider a referral to a hospital: stigma, discrimination, and human rights violation. ✓ If a person is unresponsive to − The nurse must also play a proactive role on treatment. decreasing stigma, discrimination, and human rights ✓ If a person shows serious side- abuses effects of and pharmacological − Psychosis is characterized by: disturbed perception, interventions. disturbed thinking and/or disturbed behaviors and ✓ If a person needs further treatment emotions for any comorbid physical condition. − Bipolar disorder is often characterized by significant ✓ There is a risk of self-harm/suicide. disturbance in mood and activity levels with manic ✓ Linkages. If the person has identified episodes (in which the person’s mood is elevated and that they would like to return to their their activity levels increase) and depressive episodes studies and/or start a livelihood (in which the person’s mood is lowered (depressive) activity, it is important to link them to and their energy levels decrease). livelihood organizations. ✓ Brief psychological treatments. Common Presentation (as presented in the mhGAP Master These interventions need to be Chart) delivered by trained individuals and the person should be supervised. Marked behavioral changes; neglecting usual o Group interpersonal therapy responsibilities related to work, school, domestic or o Multi-component behavioral treatment social activities o Cognitive behavioral therapy Agitated, aggressive behavior, decreased or increased ✓ Psychopharmacologic activity management. Fixed false beliefs not shared by others in the person's o Time for response to antidepressants is four culture to six weeks. o Treatment should continue for 9–12 months. Hearing voices or seeing things that are not there o Taper slowly if ceasing medication. Lack of realization that one is having mental health o Do not prescribe an antidepressant if there is problems no depression. For example: Assessment ✓ When the symptoms do not last two weeks and/or do not involve Establish communication and build trust impaired functioning). ✓ If the symptoms are part of a normal Evaluate for medical conditions such as delirium, grief reaction. medications, and metabolic abnormalities Evaluate for other relevant MNS condition 11 | JK LEI | IRIS Management Assessment Psychoeducation In order to receive a diagnosis of epilepsy, there needs o Not to try and convince the person that their to have been two or more recurrent unprovoked beliefs or experiences are false and not real. seizures (in the past 12 months): o Explain that instead carers should be open to o Recurrent = usually separated by days, listening to the person talk about their weeks or months. experience but should not have a judgment or o Unprovoked = there is no evidence of an opinion about the experiences. Instead stay acute cause of the seizure (e.g. febrile seizure neutral. in a young child). o Remind carers to stay calm and patient and Seizures are brief disturbances of the electrical not to get angry with the person. function of the brain. Promoting functioning in ADLs help a person cope with Assess for the following: and manage their symptoms o Signs of head and/or spinal trauma Pharmacological interventions o Pupils: Dilated? Pinpoint? Unequal? o Oral medication can be more dignified than Unreactive? using intramuscular treatment. o Signs of meningitis: stiff neck, vomiting. o It is also empowering as it means the person o Weakness on one side of the body or in one must take responsibility in their own recovery limb. by taking medication every day. ✓ In unconscious people who are o Only use intramuscular treatment if oral unresponsive to pain, you may routes are not possible. notice that one limb or side of the body is “floppy” compared with the Follow Up other. o Are they diabetic? Are they on any Follow up with a person with psychosis. medications? Focus on re-assessment of the symptoms. ✓ Could this be low blood sugar? Assessment of side-effects of medication. o Are they HIV positive? Are they on any medications? Assessment of psychosocial interventions specifically ✓ Could this be an infection (e.g. strengthening social support, reducing stress and life meningitis)? skills. o Is there any chance of poisoning? 3. Epilepsy o Is this person a drug user or a heavy drinker? ✓ If yes, in addition to managing their − Seizures are brief disturbances in the electrical acute seizures, you will need to do functions of the brain. an assessment according to the − There are potentially many different causes of epilepsy drug and alcohol use sections of the but it is not always easy to identify one. mhGAP-IG. − There are two types of epilepsy: Management 1. Convulsive epilepsy has features such as sudden abnormal movements including During an actual seizure: stiffening and shaking the body (due to a o Check ABCs convulsive seizure). o If the person is still unconscious, use the 2. Non-convulsive epilepsy has features such recovery position as changes in mental status (due to non- o Measure and document vital signs convulsive seizures). o Administer rectal diazepam − Seizures are considered as emergency due to the If you suspect a brain infection: following reasons: o Manage the seizure Treatment can end seizures or shorten o Initiate treatment for the underlying brain seizure duration, which limits the damage infection (such as I.V. antibiotic for they can cause. meningitis). Prolonged or repeated seizures can result in o Refer to the hospital as this is an emergency. brain injury. If you suspect trauma: Prolonged or repeated seizures can result in o Manage the seizure. death if not treated immediately. o Stabilize the neck: Seizures can be a symptom of a life- ✓ DO NOT move the neck. threatening problem, like meningitis. ✓ There could be a cervical spine Common Presentation (as presented in the mhGAP Master injury. Chart) ✓ Log roll the person when moving. o Assess for other evidence of trauma. Convulsive movement or fits/seizures o Refer to the hospital as this is an emergency. During the convulsion: loss of consciousness or If the person is a child with fever: impaired consciousness, stiffness, rigidity, tongue bite, o It could be a febrile seizure. injury, incontinence of urine or feces o Febrile seizures are events occurring in children (three months to five years of age), After the convulsion: fatigue, drowsiness, sleepiness, who are suffering from fever and don't have confusion, abnormal behavior, headache, muscle any neurological illness or brain infection. aches, or weakness on one side of the body o There are two types of febrile seizure: 12 | JK LEI | IRIS  1. Complex (these need to be ruled Management out) 2. Simple febrile seizures Psychosocial interventions for treatment of behavioral disorders 4. Child & Adolescent Mental and Behavioral Disorders o Behavioral interventions for children and adolescents, and caregiver skills training. − Children/adolescents with mental and behavioral Psychosocial interventions, treatment of emotional disorders face major challenges with stigma, isolation, disorders and discrimination as well as lack of access to health o Psychological interventions, such as CBT, care and educational facilities IPT for children and adolescents with emotional disorders, and caregiver skills Common Presentation (as presented in the mhGAP Master training focused on their caregivers Chart) Caregiver skills training for the management of developmental disorders Child/adolescent being seen for physical complaints or a general health assessment who Antidepressants among adolescents with moderate- has: severe depressive disorder for whom psychosocial o Problem with development, emotions or interventions have proven ineffective behavior (e.g. inattention, over- activity, or repeated defiant, disobedient and aggressive 5. Dementia behavior) − Dementia is a term used to describe a large group of o Risk factors such as malnutrition, abuse conditions affecting the brain which cause a and/or neglect, frequent illness, chronic progressive decline in a person’s ability to function. diseases (e.g. HIV/AIDS or history of difficult − It is not a normal part of aging. birth) − People with dementia can present with problems Carer with concerns about the child/adolescent's: in: o Difficulty keeping up with peers or carrying out Cognitive function: Confusion, memory, daily activities considered normal for age problems planning. o Behavior (e.g. too active, aggressive, having Emotion control: Mood swings, personality frequent and/or severe tantrums, wanting to changes. be alone too much, refusing to do regular activities or go to school) Behavior: Wandering, aggression. Physical health: Incontinence, weight loss Teacher with concerns about a child/adolescent o e.g. easily distracted, disruptive in class, often Difficulties in performing daily activities: Ability getting into trouble, difficulty completing to cook, clean dishes. school work Common Presentation (as p