Final Exam Review PDF

Intro to MH : - Therapeutic Milieu : goal is to provide safety & manage behavioral crisis - Voluntary commitment : individual applies in writing & agrees to treatment - Understand the need for treatment - Involuntary commitment : initiated by family, legal guardian, police, roomate...

Intro to MH : - Therapeutic Milieu : goal is to provide safety & manage behavioral crisis - Voluntary commitment : individual applies in writing & agrees to treatment - Understand the need for treatment - Involuntary commitment : initiated by family, legal guardian, police, roomate, court order, etc. - Individual does not want to be there - Can try this in court : writ of habeas or least restrictive doctrine - PEC : physician emergency certificate - Issued after initial exam by any physician; must be signed by 2 physician - Detained for 72 hours until coroner exam - If CEC is not signed after 72 hours, the patient can GO HOME!!!! - CEC : coroner emergency certificate - Detained for up to 15 days or no longer showing any symptoms - Restraint order : 1 time order for 24 hours - Document time of restraint, reason, & assess q15-30mins MMSE : - Components of MMSE : - Appearance, behavior, mood, speech, disorders of the form of thought, perceptual disturbances, cognition, ideas of harming self or others - KNOW ABOUT THOUGHT PROCESSES!!!! Schizophrenia : - Prodromal phase : onset; mild changes - May have anxiety, odd speech, obsessive thoughts (no psych symptoms) - Acute phase : exacerbation of symptoms, hallucinations, delusions, immediate treatment - Stabilization phase : symptoms are diminishing; movement towards a previous level of functioning - Most likely on meds - Maintenance phase : new baseline established - Med compliance - Positive symptoms : things that should NOT be present, but ARE - Hallucinations, delusions, disorganized speech - Negative symptoms : things that SHOULD be present, but are NOT - 6 A’s (anhedonia, avolition, asociality, affective blunting, apathy, alogia)  - Interventions for aggressive patients : control in a non-threatening manner, personal space, decrease stimuli, reassure patient, offer meds in a calm manner, protect other patients - Managing hallucinations : SAFETY, explore content of hallucinations, determine triggers - Managing delusions : focus on the meaning of the delusional content, offer clear explanations, distract from the delusions, refrain from touching - DRUGS : - 1st gen antipsychotics : haloperidol & chlorpromazine - Treats only positive symptoms - EPS symptoms involved - EPS side effects : acute dystonia, akathisia, pseudoparkinsonism, tardive dyskinesia - GO OVER DRUGS TO TREAT THESE!! - 2nd gen antipsychotics : risperidone, olanzapine, quetiapine - Treats positive and negative symptoms - No EPS symptoms involved - Can cause weight gain & metabolic syndrome - 3rd gen antipsychotics : aripiprazole, brexpiprazole, & cariprazine - Treats positive, negative, & cognitive symptoms - Little EPS symptoms involved - A/E of antipsychotics : - Anticholinergic toxicity : bladder distention, increased fever, decreased peristalsis - Treatment : hold meds, contact HCP, may require catheter, control fever - Physostigmine to reverse toxicity effects - Neuroleptic malignant syndrome : hyperpyrexia (temp 103 or higher), autonomic dysfunction, delirium, stupor, coma, severe muscle rigidity - Treatment : stop meds, monitor heart rhythm, IV fluids, heparin (for PE) - Dantrolene for muscle rigidity - Severe neutropenia : reduced neutrophil count, increased infections - Liver impairment : check liver enzymes frequently - ECG changes Bipolar : - Mania & depression - Types : - Mood bipolar disorder - Behavior bipolar  -Nursing interventions for manic episodes : finger foods, high calorie snacks, low stimuli, simple direct instructions, adequate fluids, weekly weights, skin turgor - DRUGS : - Lithium : blood level is 0.6-1.2; toxic is 1.5 or above - Track sodium levels (the are inverse, so if sodium goes up, lithium goes down & vice versa) - Monitor kidney & thyroid levels - Do NOT abruptly stop!!!! - Normal lithium signs : fine hand tremors - Early toxicity of lithium : coarse hand tremors - Late toxicity of lithium : dilute urine, seizures, coma - Severe signs : DEATH :(, anuria, convulsions - Valproate : anticonvulsant - May be used with lithium or alone - Therapeutic level : 50-100 - Monitor liver & platelet - REPORT : unusual bleeding, spontaneous bruising, dark urine, yellow skin or eyes ANXIETY : - Four levels : - Mild : everyday problems - Moderate : selective inattention, clear thinking hampered, SNS symptoms - Treatment for mild & moderate : relaxation hobbies, help identify triggers, ask open-ended questions, promote self-care - Severe : perceptual field greatly reduced, difficulty concentrating - Panic : markedly disturbed behavior, unable to process reality, cannot talk - Treatment for severe & panic : SAFETY, appropriate communication, reinforce reality, set limits, promote hygiene, maintain nutrition - DRUGS : - SSRI’s : paroxetine, fluoxetine, escitalopram, sertraline - SNRI’s : venlafaxine, duloxetine - Both take 4-6 weeks to take effect! - Long-term treatment : buspirone - Does NOT cause dependence! - NOT for patients with impaired hepatic or renal function! - Teachings : takes 2-4 weeks, take with meals - Short-term treatment : benzodiazepines (pam’s & lam’s) - Interventions for benzos : highly addictive, caffeine affects absorption, do NOT stop abruptly, caution in pregnancy, caution with driving or operating heavy machinery OCD : - DRUGS : SSRIs, TCA’s Delirium : - Sudden acute confusion; always due to a psychological disorder - Nursing interventions : treat underlying cause, SAFETY, reorient to reality, maintain adequate hydration & nutrition, maintain comfort Alzheimer’s Disease : - Memory deficit - Chronic, progressive disease process - Stages : - Mild : still independent, starting to forget things - Moderate : emotions changing, very irritated, cannot recall info, neglect ADL’s, changes in sleep patterns, suspicious of everyone - Severe : dependent, may not respond to environment, needs full time sitter, may lose ability to swallow/walk/sit, cannot complete ADL’s - Nursing interventions for chronic confusion : SAFETY, maintain consistency, decrease environmental stimuli, reorient to reality, use validation therapy, self-care needs, ask simple/direct questions, provide pictures, validate feelings, avoid excessive questioning, limit number of choices, introduce self to patient, manage aggressive behaviors - DRUGS : - Cholinesterase inhibitors : donepezil, rivastigmine, galantamine - Takes 4-6 weeks to see results - Do not take in the daytime - Side effects : GI, N/V, loss of appetite, weight loss, bradycardia, syncope, liver toxicity - NMDA receptor agonist :Memantine : 2nd line drug - Side effects : dizziness, headache, constipation Anorexia Disorder : - Intense fear of weight gain - Purging, low BMI - Interventions : evaluate suicide risk, nutrition, weight restoration programs (goal is 90% ideal body weight), vitals 3x/day, daily weights during first week, healthy food & exercise (goal is gaining 2-3 lbs in a week) - Complications : refeeding syndrome - eating too much too fast can cause muscle and cell loss in major organs Bulimia Nervosa : - Binging & purging - Binging : use of laxatives, vomiting, excessive exercise, fasting - LOOK AT S/S OF BULIMIA NERVOSA!!!! - Interventions : determine triggers, nutrition and meal plans, electrolyte levels, binge purge cycle education, - DRUGS : SSRI’s, TCA’s, MAOI’s Autism : - Deficits in social communication & social interaction - Levels : - Level 1 : issues with communication & social interactions but still able to communicate with others - Level 2 : hard to communicate with b/c of narrowed interest - Level 3 : severe impairment b/c children may be nonverbal & need total assistance with ADL’s - Interventions : early intervention program, behavior management/reward system, structure/consistency, parent education - DRUGS : SSRI’s, 2nd gen antipsychotics (ROQ), stimulants (Naltrexone) - Side effects : EPS symptoms, somnolence, & weight gain - Naltrexone : for ADHD & impulsiveness as well ADHD : - Inappropriate degree of inattention, impulsiveness, & hyperactivity - Diagnosis : before the age of 12, they must present with the S/S at home & school! - Interventions : manage disruptive behaviors, adapt positive coping mechanisms, behavior motivation therapy, outpatient treatment - DRUGS : stimulants (methylphenidate & amphetamine salts) & non-stimulants (atomoxetine) - Side effects & patient teachings of stimulant drugs : cause insomnia, do not give after 4pm, loss of appetite, stunt growth, risk of abuse, they are addictive, GI symptoms, works very quickly within an hour or so - Side effects & patient teachings of non-stimulant drugs : urinary retention, reduced appetite, weight loss, liver injury, GI upset, increased BP/HR, & insomnia, takes longer to work Borderline Personality Disorder : - Cluster B - Instability, impulsivity, self-mutilation, unstable mood, splitting, hostility, unstable interpersonal relationships, identity/self-image distortions  - Interventions : provide clear & consistent boundaries & limits, use straightforward communication, allow the patient to think independently about behavior, individual & group therapy, learning coping mechanisms - DRUGS : antipsychotics, lithium, & antidepressants Antisocial Personality Disorder : - Cluster B - Deceitful, manipulative, hostile, risk taker, disregard responsibility, impulsivity, lack of remorse - Interventions : set clear & realistic boundaries & consequences, set limits on manipulative behaviors, avoid discussing yourself/keeping secrets/accepting gifts/doing special favors - Coping mechanisms : physical outlets, therapeutic activities, individual & group therapy - DRUGS : antidepressants & mood stabilizers MDD : - Persistent mood lasting for a minimum of 2 weeks - DSM-5 : must present with at least one S/S - SAD : seasonal affective disorder - Treatment : light box therapy - DRUGS : SSRI’s (1st line drugs), SNRI’s (2nd line drugs), TCA’s, MAOI’s - Teachings for SSRI’s : no alcohol, watch liver & renal function, do NOT abruptly stop the med, avoid certain meds (digoxin, warfarin, coumadin, MAOI’s), careful with driving - Teachings for MAOI’s : avoid tyramine foods, can cause orthostatic hypotension, urinary hesitancy, constipation, urinary hesitancy, sexual dysfunction, can experience hypertensive crisis, weight gain, do NOT take SSRI’s 2-5 weeks before taking MAOI’s - ECT therapy : stimulates brief seizures (lasts 30-60 seconds) - Patient may be confused, retrograde amnesia, disoriented - Lasts for several hours Suicide : - Death caused by intentional self-inflicted injury by an individual - Lethality of suicide plan : 1. Is there a specific plan? 2. How lethal is the plan? 3. Does the individual have access to fulfill the plan? - Interventions : continuous one-on-one supervision, document every 15-30 minutes, plastic utensils only, environmental hazards, keep patient’s hands  visible, keep door open at all times, ensure all meds are swallowed, restrict visitors, make sure patient is not cheeking meds - Nursing interventions : education, peer support, medication, counseling, ECT, treatment centers, recreational activities Croup Syndrome : - AKA LTB & Epiglottitis - Characterized by barking cough & inspiratory stridor - Affects larynx, trachea, & bronchi Acute Epiglottitis : - Caused by H. influenzae - Rapid onset - Can get HIB vaccine to prevent it - S/S : fever up to 104, stridor, frog like sounds, sitting forward, tripod position, tongue protruding, drooling, poor feeding - Interventions : lateral neck X-ray (thumb print), NOTHING IN THE MOUTH!!!!, suction at bedside, ceftriaxone-rocephin (antibiotics IV then oral), corticosteroids, humidified oxygen LTB : - Caused by a virus - Slow progressive onset - S/S : low grade fever, stridor, seal cough, brassy cough - Complications : respiratory depression & dehydration - Interventions for mild (no stridor at rest) : cool air mist, nasal saline drops, suctioning with bulb syringe, treat fever & pain, encourage fluid intake, oral steroids - Interventions for LTB with stridor : airway/intubation, oxygen with mask, steroids, IV fluids, decrease anxiety, NEBULIZED RACEMIC EPINEPHRINE Q20-30MIN (FOR MUCOSAL EDEMA) Bronchitis & RSV : - Caused by respiratory syncytial virus - Interventions : oxygen above 90%, hi flow oxygen, fluid intake (IV vs. small sips), nasal suctioning, admission for respiratory distress or dehydration Streptococcal Pharyngitis : - Caused by group A beta-hemolytic streptococci (GABHS) - S/S : sore throat, fever, headache, exudate  - Interventions : PENICILLIN, educate about comfort, salt & warm water, teach about how it can transmit to others, change toothbrush every 24 hours, increase fluids - Complications : rheumatic fever, glomerulonephritis, Scarlet fever Otitis Media : - Main RF is bottle propping - Tympanic membrane is normally pearly gray, but in otitis media it is purulent discolored/bulging/yellow to reddened membrane - Interventions : ORAL AMOXICILLIN (80-90 MG/KG/DAY, DIVIDED INTO 2 DOSES), manage fever & pain, may need tympanostomy tube placement & adenoidectomy - Teaching about tympanostomy : wear ear plugs, no water in the ear, tubes will fall out on their own after about 1 year - Complication : hearing loss Type 1 Hypersensitivity : - 4 types : - Hay fever/allergic rhinitis - Triggered mostly by reaction to airborne allergens - S/S : clear mucus, stuffy nose, itchy, pain to headache & gums - Interventions : decongestants (Sudafed), antihistamines (Zyrtec, Claritin, Benadryl), corticosteroids (flonase & antibiotics), desensitization therapy (“allergy shots” - LAST RESORT!!!!) - Allergic asthma - Anaphylaxis - Interventions : notify the rapid response team, assess respiratory status, stop IV drug if causing the problem, prepare to admin epinephrine IM (if 3 IM’s do not work, then IV), high-flow oxygen, infuse normal saline, possibly administer other drugs, stay with the patient & reassure them - Angioedema - Involves all layers of the skin, MM, & SQ tissues - Mainly caused by ACE inhibitors & NSAID’s - Lip & face swelling - Can lead to airway obstruction & anxiety - Interventions : maintain airway, stop the drug or allergen, oxygen, intubation if needed, tracheostomy if intubation cannot be performed b/c of closed off airway, corticosteroids, epinephrine - Intubation reasons : drooling, inability to swallow, cannot talk SIDS : - Top 3 rules (ABC’s) : - Alone - On back - In the crib Asthma : - Inflamed MM → causes bronchoconstriction, mucus production, & edema → decreased airflow & gas exchange - S/S : SOB, prolonged exhalation, SILENT CHEST, tachypnea, wheezing, hypoxia, tachycardia, pallor, cyanosis - Interventions for home management : avoid allergens, drug therapy, exercise & activity, rest & sleep - Interventions for - DRUGS : bronchodilators (SABA’s & LABA’s), cholinergic antagonists (short-acting & long-acting), corticosteroids (long-acting) - SABA : albuterol & levalbuterol - LABA : salmeterol - Short-acting cholinergic antagonists : ipratropium - Long-acting cholinergic antagonists : tiotropium - Corticosteroids : fluticasone (long-acting) & prednisone - Teachings for drugs : use inhaler 30 minutes before exercise - Complication : status asthmaticus - Not responding to normal treatment! - Treatment : oxygen above 92%, inhaled nebulizers (SABA’s), systemic corticosteroid, epinephrine nebulizer, IV access for fluids, frequent ABG’s, electrolytes Respiratory Alkalosis : - Hyperventilation - S/S : tachypnea, inability to concentrate - Interventions : correct the underlying cause, oxygen therapy, rebreathing techniques, teach about stress relieving techniques & causes of anxiety Respiratory Acidosis : - Hypoventilation - S/S : confusion, coma, tachycardia, variable respirations, pale to cyanotic & dry skin - Interventions : improve ventilation & oxygen, oxygen therapy, position sitting upwards, breathing techniques, bronchodilators, assess for abnormal signs of breathing (can be a sign of complication) COPD : - Emphysema & chronic bronchitis - Emphysema : loss of elasticity & hyperinflation of the lung - Chronic bronchitis : inflammation of the bronchi & bronchioles - S/S : prolonged expiratory phase, wheezes, decreased breath sounds, barrel chest (with emphysema), tripod position, dyspnea, pursed lip breathing, sputum production (with chronic bronchitis), chest tightness, cyanosis to blue-tinged - Complications : respiratory infection (pneumonia), cardiac failure (cor pulmonale), cardiac dysrhythmia, polycythemia, respiratory failure (hypoxemia & hypercapnia), respiratory acidosis) - Interventions : monitor O2 sat q2h & PRN, keep O2 sat above 88% or higher, BIPAP, breathing techniques, position up, coughing, nutrition - Nutritional therapy : high-calorie & high-protein diet - Avoid : chewy foods, gas-forming foods, wait 1 hour before and after eating to exercise & do treatments Seasonal Influenza : - Abrupt onset - 7 days - Complications : pneumonia, ear or sinus infection - Interventions : vaccine to prevent, rest, fluids, antipyretic, analgesics, antivirals (Oseltamivir - Tamiflu) - ONLY give within 24-48 hours of symptoms - Teach that it does NOT cure the flu, ONLY treats the symptoms! Pneumonia : - Types : - Community-acquired pneumonia - Hospital acquired/healthcare acquired pneumonia - Aspiration pneumonia - Prevention : pneumonia vaccine (>65 years or chronic health problems) & influenza vaccine - S/S : dyspnea, tachypnea, pleuritic chest pain, green/yellow/rust-colored sputum, fine or coarse crackles, bronchial breath sounds Sepsis : - 4 types of infections that are often linked with sepsis : - Lung, urinary tract, skin, & GI tract - TIME pneumonic : - Temperature, infection, mental decline, & extremely ill  - S/S : metabolic encephalopathy, low urine output, tachycardia, increased respiratory rate, low BP - Diagnostics : elevated serum procalcitonin level, increased serum lactate level, increased band neutrophils level (left shift) - Interventions : antibiotics (broad spectrum - Rocephin, Levaquin, & Zosyn), oxygen therapy, incentive spirometer, bronchodilators nebulizers, IV steroids, expectorants Tuberculosis : - RF : homeless, residents of inner-city neighborhoods, foreign-born persons, living or working in institutions (includes healthcare workers), IV injecting drug users, poverty, poor access to health care, immunosuppression - Screening : TB test (Quantiferon-TB blood test & Mantoux intradermal test) - Intradermal test : induration of 10mm or greater diameter = positive for exposure 48-72 hours after - Elderly & immunocompromised is 5mm - Positive results do NOT confirm disease! - Latent TB : exposed not active disease, no symptoms, no transmission - Treatment : must be compliant to adhere to month long prescriptions - Active TB : exposed developed disease immediately or latent TB disease became active because of weakened immune system, disease can spread to others - Treatment : meds & isolate - Patients with active symptoms are considered contagious until test results are returned! - S/S : progressive fatigue, lethargy, nausea, anorexia, weight loss, low-grade fever, night sweats, cough, mucopurulent (mucus & pus), sputum, blood streaks (hemoptysis) - Diagnostics : sputum smear for acid-fast bacillus - Definitive : sputum culture of M. tuberculosis - DRUGS : - Isoniazid : avoid antacids before & after meals, take B-vitamins, avoid alcohol, report dark urine & jaundice - Rifampin : TRUMP DRUG!!!!, orange-reddish skin is expected, use an additional method of contraception, avoid alcohol, report dark urine & jaundice - Pyrazinamide : ask if they have a history of gout, drink 8 ounces of water when taking this drug, wear protective clothing from the sun, report dark urine & jaundice - Ethambutol : report vision changes, ask patients if they have a history of gout, drink 8 ounces of water when taking this drug - 3 negative sputum cultures = no longer infectious  - Directly observed therapy (DOT) for noncompliance (so patient is not cheeking meds) - Sputum specimens every 4 weeks - Teach about transmission & exposure to TB Diabetes : - Type 1 : absence of insulin from beta cells due to destruction of beta cells from the pancreas - Insulin dependent - Type 2 : insulin receptor sites are resistant - Decreased beta-cell secretion - Gestational diabetes : onset during pregnancy from hormones in the placenta that inhibit the action of insulin - Baby has fetal insulin (growth hormone) to protect itself from the high blood sugar coming from the Mom! - Effects to the baby : neural tube defects, cardiac defects, caudal regression syndrome, macrosomia, preterm delivery, hypoglycemia, hypocalcemia, hyperbilirubinemia, respiratory distress syndrome - Basically it affects the baby’s heart, lungs, spinal cord, size/weight, electrolytes, & development - Pre-gestational diabetes : type 1 or type 2 that existed prior to pregnancy - RF for diabetes : stress, glucocorticoids, PCOS, race, age, lifestyle factors - S/S : polydipsia, polyphagia, polyuria, weight gain/loss, blurred vision, frequent vaginal infections, yeast infections, dry mouth, slow-healing sores or cuts, itching skin (especially in the groin or vaginal area) - Diabetes can cause METABOLIC ACIDOSIS! - Metabolic acidosis : from the 3 P’s & dehydration - Kussmaul’s respirations b/c of ketone bodies - H&H elevated - BUN & creatinine levels elevated - Hypokalemia initially and then hyperkalemia or normal - Glucose tolerance test : taken in pregnancy during 24-28 weeks - Check blood after 1,2,3 hours - After 2 hours, blood glucose 200 mg/dL = diabetes - Goals for diabetic patients : - A1C at 7.0% or below - Premeal (pre-prandial blood glucose levels at 70-130 mg/dL - After meal (post-prandial) blood glucose levels are 250 with ketones - Deficiency of insulin that leads to hyperglycemia, ketosis, acidosis, dehydration, & electrolyte imbalance - Occurs in type 1 diabetes - HHS : blood glucose >600 with NO ketones - Type 2 diabetes has circulating insulin to avoid ketones - Occurs in type 2 diabetes - Hypoglycemia - Sick day rules : - Monitor blood glucose q4h - Test urine for ketones when blood sugar is >240 - Continue to take insulin or oral anti-diabetic agent, drink 8-12 ounces of sugar free liquids every hour (while awake) - Eat at regular times - If you cannot tolerate solids, drink liquids with carbs - Get rest - Call MD for complications - Hypoglycemia : - Management of a conscious patient : eat or drink 15gm of quick-acting carbs, wait 15 mins, recheck glucose, if