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Exam 2 Therapeutic Clarification is key, restate, reflection, speed of speech, communication attitude, tone, eye level Answers will be cheesy but think of compassion Education level, literacy, culture, age, set boundaries...

Exam 2 Therapeutic Clarification is key, restate, reflection, speed of speech, communication attitude, tone, eye level Answers will be cheesy but think of compassion Education level, literacy, culture, age, set boundaries Distractions o Not seeing and sensing nonverbal affects, interruptions Nonadherence/noncompliance o Educate, financial abilities, transportation, hours available/work, support, figure out why they are noncompliant Teaching methods o Teach back, visuals/videos (not surgery), pamphlets, handouts, draw, lecture, activities Discussion o What to expect before during and after o Case management, therapy discuss with the patient o Have patient write down any questions Positive vs. Negative reinforcement o Positive: reinforcing good behavior o Negative: intimidating (not doing this... this will happen) sometimes needed some people respond better to this o Assess/outcomes/readiness/resources Ensure privacy, encourage questions Honest communication PACU 2 phases Phase 1 o 1 on 1 with nurse directly after surgery, respiration, AIRWAY/bleeding most important o Watch for shock, BP (can drop or go up) LOC, cardiac monitor o Pain, fever, n/v (alcohol pad fan under nose, scopolamine patch do not touch patch then touch eye it can dilate eyes), no oral meds after during phase one, bronchospasms common after surgery Phase 2 o Next unit, MedSurg, discharge Chest x-ray if susception of fluid overload  Racemic (inhaled) epi (for broncho spasms), neb, albuterol Have pt cough, blow nose Mood and affect Dementia o Stroke-vascular dementia o Lewy body dementia (LBD) progressive brain disorder characterized by presence of abnormal protein- deposits called Lewy bodies in the brain affecting cognitive functions, movement, and hallucinations, fluctuations in alertness, motor symptoms like Parkinson's disease. Overlapping symptoms with Alzheimer's and Parkinson's. o Mixed dementia- having more than one type of dementia o Alzheimer’s: amyloid plaques and tangles of tau proteins. o Symptoms of dementia vary but typically include problems with memory, reasoning, communication, daily functioning. With progression individuals may experience changes in personality and behavior. o TX: manage symptoms and improve quality of life. o Fall risk: fracture risk due to antidepressants, antiparkinsonian meds, antipsychotics, anxiolytics, benzos, sedatives, steroids, PPI’s, thyroid hormones. o Geriatric depression scale ▪ CAMDOSS, Mini-cog, MMSE, Nuchan Conference scale o Mild- reorientate ▪ Mild memory loss, difficulty with daily task, confusion and mood changes o Moderate- reorientate, reduce stimuli, remove barriers/fall risk, limit daytime napping, assist with ADL ▪ More pronounced memory loss, difficulty with ADL, personality changes, increased confusion. o Severe- Cognitive decline, loss communication, severe memory impairment. ▪ Full time care, ADL assistance can last 1-3 yrs before becoming bedridden. Loss, Grief, Dying o Engels stages of grief ▪ Shock and disbelief, develop awareness (physical and emotional response), restitution (rituals surrounding loss-expressions of  mourning), resolving loss (dealing with the void), idealization (exaggeration of good qualities), outcome (final resolutions) o Kubler-Ross death and dying ▪ Shock, denial isolation, anger, bargaining, depression, acceptance. o Uniform Determination of Death Act 1981 ▪ Irreversible cessation of circulatory, respiratory functions, and functions of entire brain including the brainstem. ▪ 2 Separate clinical exams ▪ Breathing stops no response to deep painful stimuli, lack of reflexes, flat encephalogram, absent Pulse, respirations, and blood pressure o Dying person’s bill of rights ▪ Palliative care: mind, body and spirit ▪ Hospice limited life expectancy (6 months or less) o S/S of burnout ▪ Overwhelmed, lose interest, isolation, sick a lot, troubles sleeping, fatigue o Traumatic grief in children ▪ Stomach aches, somatic complaints (body physical symptoms without reasonable cause) o Assisted suicide ▪ Pt can dose their medication themselves Obstetrics and mental health o Engrossment ▪ Parents over the top with baby, important for early contact with partner with newborn for bonding o Postpartum affective disorders ▪ PP blues: occur 80% mothers, mother experiences a rapid cycling mood in first postpartum week, emotional liability peak day 5 and resolved by 10, 20% go into PP depression ▪ PP depression: can persist for 6 months w/o tx. Cues: resless, feeling worthless, guilty, hopeless, moody, sad, overwhelmed, decrease joy, energy and libido. Edinburg postnatal depression scale TX: antidepressants, anxiolytics, psychotherapy, zulresso, neuroactive  steroid infusion for 60 hrs with brexanolone titrate up then taper down. ▪ PP Psychosis 1/1000 births occur first year Abrupt and unexpected, although previous hx of mental health issues High risk suicide and infanticide (killing infant/baby) Needs hospitalization for months/psychotropic drugs Medications for depression o SSRI ▪ Given first thing in morning ▪ Adverse effects: anxiety, agitation, akathisia (tx with Beta blocker), nausea, insomnia, sexual dysfunction ▪ Insomnia lifted 3-4 days, appetite and energy improve by day 7, mood can improve by day 10, ▪ Serotonin syndrome: cause MAOI/SSRI, cues: agitation, sweating, fever, increase pulse, decrease BP, rigidity, hyperreflexia, coma and death. o Tricyclics ▪ Adverse effects: anticholinergic, dexual dysfunction, blurred vision, orthostatic hypotension, sedation, wt gain, tachycardia ▪ Relieves hopelessness, anhedonia (no pleasure), guilt, contraindicated with liver dysfunction, recent MI, glaucoma. ▪ Electroconvulsive therapy: can be good for relapse prevention, elderly works quickly. Can be given 6-15 treatments 3x per week. o MAOI’s ▪ Adverse effects: daytime sedation, insomnia, dry mouth, wt gain, orthostatic hypotension, sexual dysfunction. ▪ Hypertensive crisis occurs with tyramine or sympathomimetic meds (amphetamines, demerol, isoproterol, pseudoephedrine, SSRI, tricyclics) cues: increased BP, P, T, diaphoresis tremors. Can happen quickly or slowly. o Anticonvulsants  ▪ Carbamazepine, oxcarbazepine, lamotrigine (risk of steven Johnson syndrome especially if less than 16yrs) o Valproic acid ▪ Depakote, risk for spina bifida o Carbamazepine ▪ Risk for agranulocytosis (decrease WBC) Major depressive disorder (MDD) o At least 2 weeks of unplanned wt gain/loss, hypomania, insomnia, sense of worthlessness, hopelessness, guilts, fatigue, pessimistic, anhedonia, change in sleep/energy/concentration/decisions/esteem/goals o 2X more likely in women often single or divorced o Superego takes over and unable to achieve, inward anger. o Serotonin, norepinephrine and dopamine lessen o Zulresso (brexalone) 60 hr infusion taper up and down. ▪ Positive allosteric modulation of GABA receptors. Bipolar disorder o Mania must occur for a week. o Cues: less sleep, pressured speech, flight of ideas, distracted, increase activity, risks, blame others, hallucinations and delusions. o Hypomania: elevated expansive irritable mood, milder, w/o signs of mania, can still function and be productive absent psychosis. o Bipolar1 ▪ More mania, with some depression o Bipolar2 ▪ More depressive with at least one episode of hypomania o BPD mixed: both o Cyclothymic disorders ▪ Swings hypomania and depression but can function o ADHD often become BPD o Mania nursing interventions ▪ Safe environment, limit behavior, distraction, decrease in stimuli, calm and relaxed, consistent structured environment, keep promises, watch competitive situations, provide space, finger foods.  Suicide o 65 and older 25% suicide, increased in ages 45-65 o Risk: depression, bipolar, schizophrenia, substance, PTSD, cancer, liver and kidney disease, HIV, AIDS, DM, CVA, SCI, impulsive and unusual behavior and lifestyles. o Active: seeking ways to end life o Passive: wanting or wishing to die. o Increase risk of suicide for those with previous attempt especially in first 3 months, more a risk of close relative that has committed. o Increase energy before. o High risk antidepressant medication therapy. o Children ▪ Bullied, unsafe homes, undergo trauma. ▪ Protective measures: close to parent, academic achievement, family stability, connect to peers. o Disruptive mood dysregulation ▪ Age 6-18 yr old, depression and anxiety with temper outburst at least 3x a week. Anxiety Generalized anxiety disorder (GAD) o Unrealistic concerns over past behavior, future events, and personal competence. o Triggers autonomic nervous system response to fear and anxiety generate involuntary activities of the body that are involved in self preservation. o Moderate anxiety: urinary frequency, headache, backache, insomnia Social phobia o Persistent irrational fear of something posing no real threat, speaking or eating in front of others, using public restroom, or speaking to authorities. Selective mutism o Persistent failure to speak, typically in big social areas. Separation anxiety o More common in children than adolescents, remain close to parents, and child worries focus on separation. OCD  o Compulsions (repetitive behaviors such as cleaning, washing, or checking something) performed to reduce anxiety about obsessions. o Typically occur in late adolescents, early childhood with boys o SSRI’s, second gen antipsychotics (risperidone, risperdal, aripiprazold, abilify for treatment Active negativism: consistently doing the opposite of what is asked Agoraphobia o Excessive fear of certain situations, often involved in crowded or public places where escape or help might be difficult or unavailable. Neologism o Alteration in speech where a fictitious word only has meaning to the client Posttraumatic stress disorder (PTSD) o Anxiety disorder after a traumatic event later experiencing physiologic arousal when a stimulus triggers memories of event. Patho (anxiety) o Disrupted modulation within CNS, under activation of serotonergic system and overactivation of noradrenergic system thought to be responsible for the dysregulation of physiologic arousal. Disruption in y-aminobutyric acid (GABA) may also play a role. Therapeutic management o Anxiolytics/antidepressants most common, cognitive behavioral therapy, individual, family, or group psychotherapy, relaxation techniques. Screening tools o Multidimensional anxiety scale for children (MASC) o Spence children’s anxiety scale (SACAS) o Preschool anxiety scale o Beck anxiety inventory for youth Psychoimmunology o Effect of psychosocial stressors on the body’s immune system Efficacy o Max therapeutic effect a drug can achieve. Potency o Amount of drug needed to achieve max effect Half life o Time for half the drug to be removed from bloodstream Risk evaluation and mitigation strategy (REMS) o Specific actions/safeguards govern the use of drugs Histrionic personality disorder  o Chronic consistent pattern of pervasive attention-seeking behaviors and exaggerated emotional displays. Kindling process o Snowball like effect when minor seizure activity seems to build up into more frequent and severe seizures. Lithium o Side effects: diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, metallic taste in mouth, fatigue or lethargy, wt gain, acne. Propranolol used to improve fine tremor. o Toxic effects: severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination. If toxic level exceeds 3, dialysis may be needed. o Number 1 med to normalized reuptake of serotonin, norepinephrine, acetylcholine and dopamine. Carbamazepine/valproic acid o Side effects: drowsiness, sedation, dry mouth, blurred vision, rash, orthostatic hypotension, wt gain, alopecia, hand tremor o Can cause hepatic failure, liver function before and frequently after especially the first 6 months. (Valproic acid) o Aplastic anemia, and agranulocytosis, pretreatment hematologic baseline, and through tx to discover lowered WBC or platelet (carbamazepine. Topiramate o Side effects: dizziness, sedation, wt loss, increased incidence of renal calculi. When checking blood levels 12 hrs after last dose of medication. Anxiolytics o Tx: anxiety, insomnia, OCD, depression, PTSD, alcohol withdrawal Stimulant drugs o Amphetamines ▪ ADHD, narcolepsy Hans Selye 3 stages of reaction to stress o Alarm reactions stage: stimulate the body to send messages from hypothalamus to the glands(adrenal to send out adrenaline and norepinephrine for fuel) and organs (liver, to reconvert glycogen stores to glucose for food) to prepare for potential defense needs Resistance stage o Digestive system reduce function to shunt blood to areas needed for defense. Lungs take in more air, heart beat faster and harder ( highly oxygenated and highly nourished blood to muscles to defend body)  Exhaustion stage o Negatively responded to anxiety and stress, body stores are depleted or emotional components are not resolved resulting in continual arousal of physiologic responses and little reserve capacity. Adrenaline is epinephrine o causes the body to take in more oxygen, dilate the pupils, and increase arterial pressure and heart rate while constricting the peripheral vessels and shunting blood from the gastrointestinal (GI) and reproductive systems and increasing glycogenolysis to free glucose for fuel for the heart, muscles, and central nervous system. Benzodiazepines (pam) o Most common not associated with causing much sedation, relieve anxiety quickly. Generally depress cortex, RAS, and cerebellum, increase GABA effects. Blood pressure changes, arrhythmias, anticholinergic effects, loss of libido. o Alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam, estazolam, flurazepam o Beta blockers for anxiety (propranolol) Barbiturates o CNS depressants interact with body’s neurotransmitters to produce sedation, relaxation, and anesthesia. o Pentobarbital, phenobarbital, secobarbital o Liver and kidney test o Only use few weeks its addictive, titrate off not titrating seizures Psychodynamic theories o Intrapsychic/psychoanalytic ▪ Dependence on defense mechanisms can inhibit emotional growth, lead to poor problems (solving skills, and create difficulty with relationships) o Interpersonal theory ▪ Anxiety generated from problems in interpersonal relationships. o Behavioral theory ▪ Anxiety is learned through experiences. Nursing tx for anxiety o Stay with them, low stimuli, deep breathing, guided imagery, one thing at a time. Buspar o Non addictive, non sedative, does not lower lipids, does not affect blood sugar Cognition Hippocampus o Small complex brain structure playing key role in learning, emotional processing, decision making, and memory, helps short term to long term memory. o Relies on acetylcholine to process and store. Acetylcholine o Neurotransmitter in nervous system communicates with nerve cells and muscles enabling muscle contraction. o In myasthenia gravis and autoimmune disorder typically from the thymus destroys Ach reason also given cholinesterase inhibiter and thymus is removed. Acetylcholine is LOW o Adequate levels of acetylcholine facilitate adequate synaptic connection for memory consolidation in AD it is destroyed, the cholinesterase inhibitor attempt to increase the acetylcholine. o Organ meat contains acetylcholine o Memory retrieval in hippocampus where neuro-memories are formed o Parasympathetic Cholinesterase inhibitors (donzepil, aricept) o Alleviate symptoms by enhancing cholinergic activity. o Too much acetylcholine is cholinergic crisis (SLUDGE) everything excretes water. o Too little acetylcholine myasthenia crisis ▪ Autoimmune neuromuscular disorder, muscle weakness can lead to respiratory failure, droopy eye lids biggest sign. o Used in Alzheimer's to break down acetylcholine Anticholinergics o Blocks action of acetylcholine at muscarinic receptors in the body by inhibiting acetylcholine. o Reduce parasympathetic nervous system activity, leading to decreased secretions, increased heart rate, and relax smooth muscles. o Used in motion sickness, Parkinson's, COPD Cognitive behavioral therapy o Psychotherapy that focuses on modifying dysfunctional emotions, behaviors, and thoughts by interrogating and uprooting negative irrational behaviors. Reframe how you react. Cognitive therapy o Just focus on how you think about things Intrapersonal therapy (relationships) Trichotillomania  o Impulse control disorder characterized by a recurring and irresistible urge to pull out ones own hair, can also include skin picking. o Tx: cognitive behavioral therapy, SSRI/antidepressants. Alzheimer's o Big for diagnostics is the accumulation of amyloid beta and phosphorylated tau protein, disrupts normal cellular process leading to neuronal death and synaptic loss. Schizophrenia o Chronic, severe mental disorder, disruptions in thought process, perceptions, emotional responsiveness, and social interactions. o Symptoms: delusions (false beliefs), hallucinations (typically auditory), disorganized thinking and speech, impaired functioning. Diminished emotional expression, difficulty with daily task and relationships. o Typically emerge in late adolescence/early adulthood. Requiring long term management, often medication therapy and supportive services. o Genetics, neurobiological (abnormalities in brain structure and function, including neurotransmitter imbalances especially dopamine and glutamate) o Neurodevelopment: complications during pregnancy or birth such as exposure to infections/malnutrition o Enviromental: Stressful life events, trauma, drug abuse o Chemical: dysregulation of neurotransmitters, particularly dopamine, and glutamate o Glutamate: most abundant excitatory neurotransmitter. Plays crucial role in neural communication by transmitting signals between nerve cells, facilitating learning, memory, and cognitive functions. ▪ Increased glutamate: excitotoxicity, potentially damaging neurons and contributing to symptoms like hallucinations and delusions. o Impaired glutamate modulation: disruption in regulation of flutamate release and receptor activity can affect brain connectivity and function, impacting thought process and emotional regulation. o Paranoia-persecute-grandiosity o Disorganized schitzo: disorganized, flat speech and emotions o Cationic schizo: unusual body posturing o Undifferentiated schizo: multiple symptoms o Residual: reduced positive symptoms but negative still exist.  o Avolition: reduced motivation to initiate and sustain purposeful activities, leading to neglect of personal hygiene, work, or social responsibilities. o Early onset has worse prognosis, abrupt onset typically do better. 1/3-½ will relapse within a year. o Long periods of untreaded psychosis lead to poor long-term outcomes. Extrapyramidal side effects (Neuroleptic malignant syndrome: sweaty high fever, bp) o Reversible movement disorders induced by neuroleptic medication. Dystonic reactions ▪ Pseudo parkinsonism, acute dystonia, tardive dyskinesia, akathisia. ▪ Lactic acid buildup which can kill you ▪ Use antipyretic medications, and dantrolene ▪ Can happen with antipsychotics, and anesthetics. o S/S EPS ▪ Muscle spasms of neck, fidgeting, tremors of hands Echolalia: repetition or imitation of what someone else says. Lithium o Neurotransmitter regulations: modulates levels of neurotransmitters, particularly serotonin and dopamine, helping stabilize mood swings. o Neuroprotective effects: promotes neurogenesis and has neuroprotective properties, which can help in maintaining brain health and reducing mood symptoms. Typical antipsychotics o Treat positive symptoms, dopamine antagonists o No effect on negative signs o Chlorpromazine, thioridazine, mesoridazine, haloperidol Atypical antipsychotics o Positive, and negative symptoms o Dopamine and serotonin antagonist o Clozapine, risperidone, olanzapine, apriprazole, lurasidone, quetiapine. Antipsychotics o Anticholinergic effects, no seizure disorders, bone marrow suppression. Don’t support false beliefs, do not argue “I see no evidence of that” give reassurance of safety Stool softeners, but laxatives should be avoided. Forgotten dose of antipsychotic meds take if it is only 3-4 hours late, if it is more than 4 hrs late omit the forgotten dose.  Clozapine o Causes Agranulocytosis (extreme neutropenia)