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Kaplan Psych Integrated Exam Review
Concepts Of Psychiatric-Mental Health Nursing (NUR 4250)
Nova Southeastern University
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Kaplan Psych Integrated Exam Review
{Schizophrenia}
Session Objectives: ▪ Objective 1- Recognize subtypes of schizophrenia, including signs and symptoms of each subtype. ▪ Objective 2 - Identify treatments for schizophrenia. ▪ Objective 3 - Identify nursing considerations, including client safety and developing a therapeutic relationship.
APoints of Emphasis:
▪ Point 1 - Subtypes of schizophrenia include disorganized, catatonic, paranoid, undifferentiated, and residual.
▪ Point 2 - Acute treatment focuses on client safety and symptom control (often with medications).
▪ Point 3 - A client diagnosed with schizophrenia may be prescribed a first, second, or third generation antipsychotic.
▪ Point 4 - Communicate therapeutically with the client (respond with feeling tone, but do not reinforce delusions).
Schizophrenia: Overview
Chronic illness resulting in psychotic behavior.
Diagnosis is usually made in late adolescence or early adulthood.
Indications:
- Inappropriate or no display of feelings.
- Hypochondriasis and depersonalization.
- Hallucinations - false sensory perceptions in the absence of external stimulus, may be auditory or visual.
- Delusions - persistent false beliefs.
- Short attention span.
- Regression.
- Inability to meet basic survival needs.
Nursing care:
- Maintain client safety - protecting from altered thought processes and inappropriate behavior.
- Administer antipsychotic medication as ordered.
- Decrease risk for sensory stimuli.
- Remove from areas of tension.
- Validate reality.
No arguing.
Recognize client is experiencing hallucinations or delusions.
Respond to feeling or tone of hallucination or delusion.
Communicate in calm, authoritative tone.
Address client by name.
Observe for early signs of escalating behavior.
Schizoaffective Disorder: - Observable bodily expression of emotions of a person. - Commonly used terms for affect: flat, blunted, inappropriate, labile.
Catatonic Schizophrenia:
- Catatonic - usually pronounced decrease in amount of movement, client may not move for hours on end.
- Nursing care:
- Maintain client safety - protect from altered thought processes and inappropriate behavior.
- Administer antipsychotic medication as ordered.
- Decrease risk for sensory stimuli.
- Remove from areas of tension.
- Validate reality.
- No arguing.
- Recognize client is experiencing hallucinations.
- Responding to feeling or tone of hallucination or delusion.
- May require measures to prevent skin breakdown.
Nursing Focus & Concepts: Schizophrenia
Definition: - Severe psychiatric disorder. - Marked by: - Withdrawal from reality. - Illogical thinking. - Delusions. - Hallucinations. Signs and Symptoms: - Positive symptoms: - Delusions. - Hallucinations. - Negative symptoms: - Apathy. - Lack of motivation. - Blunted affect. - Poverty of speech. - Anhedonia. - Asociality. - Disorganized symptoms:
o Mood disorder with swings between mania and depression o Manic episodes usually begin suddenly with rapid escalation o Two subtypes ▪ Type 1 - One or more episodes of mania with or without depression ▪ Type 2 - Episodes of major depression and hypomania o Indication ▪ Elevated or expansive mood, agitation, accelerated speech, thought and movement, distractibility, self-confidence, aggression, sarcasm, inappropriate dress, inattention to personal hygiene, anorexia, weight loss, constipation, and insomnia. o Treatment ▪ Lithium
▪ Anticonvulsant meds → carbamazepine, valproate, or lamotrigine
o Nursing responsibilities ▪ Maintain physical health and safety: nutrition, rest, sleep, elimination ▪ Monitor for lithium or anti-convulsant toxicity ▪ Orient client to reality ▪ Limit stimuli ▪ Set limits, be consistent o Mania ▪ Elevated mood and behaviors ▪ Might not be able to focus on reality ▪ Behavior is frenzied, excessive, irritable ▪ May or may not display psychoses
{Depression}
Session Objectives: ▪ Objective 1: Recognize assessment findings consistent with a diagnosis of depression. ▪ Objective 2: Discuss medical management for a client diagnosed with depression. ▪ Objective 3: Discuss nursing management for a client diagnosed with depression.
Points of Emphasis: Two questions provide a screen for depression: During the past month have you felt bothered by feeling down, depressed, or hopeless? Have you been bothered by having little interest or pleasure in doing things?
SIG-E-CAPS is a helpful way to remember the DSM-5 criteria for major depression. The (M) is added to account for the change in mood.
SIG(M)ECAPS
S: Changes in sleep patterns (insomnia or hypersomnia) I: Loss of interest or pleasure in most or all activities G: Thoughts of worthlessness or guilt M: Depressed mood E: Low energy C: Poor concentration A: Changes in appetite or weight P: Psychomotor disturbances (retardation or agitation) S: Recurrent thoughts about death or suicide Rule out medical problems.
Rule out Medical Problems. Focused tests may help to rule out other medical conditions that cause or contribute to depressive episodes.
- Depression o Abnormal feelings of sadness, low self-esteem, helplessness or hopelessness, obsessive thoughts and fears, sense of doom or failure o Somatic indications: gastrointestinal distress, change in appetite, pain, irritability, sleep disturbances, lack of energy, changes in sex drive, palpitations, dizziness
o Tx → antidepressants, electroconvulsive therapy, individual or group therapy
o Nursing responsibilities ▪ Be alert for signs of self-destructive behavior ▪ Assist client in meeting physical needs ▪ Support self-esteem ▪ Help decrease social withdrawal ▪ Adolescents - Screen for depression or suicidal risk if: o Grades begin to decline o Adolescent experiences chronic sadness or hopelessness o There are family problems or a personal hx of drug or alcohol abuse - If feeling depressed, refer to mental health professional
- Persistent depressive disorder o Preciously dysrhythmic disorder o Chronically depressed mood presents more than 50% of the time for at least 2 years in adults or 1 year for children or adolescents o Characterize by feelings of being chronically sad
o Indications → poor appetite or overeating, insomnia or hypersomnia, low self-esteem, feelings
of hopelessness
o Tx → tricyclic antidepressants or MAOI
o Nursing considerations ▪ Listen attentively without being judgmental ▪ Encourage journaling of thoughts ▪ Encourage self-affirming thoughts for depressive thought patterns
- Crisis o Dangerous point in disease process or time frame in life
Concepts: - Psychosocial. - Stress & Coping. - Stress. Assessment: - Signs and symptoms of stress response. - How client has handled stressful situations in the past. - Use of coping skills. - Practice of effective stress reducing activities. - Support system. Diagnosis: - Ineffective coping. - Potential for anxiety. - Anxiety. - Anticipatory grieving. - Potential for spiritual distress. - Fear. - Lack of knowledge. - Readiness for increased coping. - Potential for infection. - Potential for imbalanced nutrition. Planning: Referral to counselor/mental health provider as needed. Implementation: - Teach the client relaxation techniques: - Deep breathing. - Listening to music. - Progressive head to toe muscle relaxation. - Listen to client actively. - Use therapeutic communication. - Provide comfortable atmosphere, and privacy, as necessary. - Keep client calm and encourage rest and relaxation. - Discuss alternate techniques to control stress: - Meditation: - Thought to relieve stress through an effect called the relaxation response. - Natural protective mechanism against overstress. - Biofeedback: - Uses electronic monitors. - Teaches clients how to exert conscious control over autonomic functions by adjusting: - Thoughts. - Breathing pattern. - Posture. - Muscle tension. - Discuss modifying habits, nutritional intake, and exercise routine. - Encourage client to use healthy coping strategies successful in the past. Evaluation:
Client will practice relaxation techniques and/or seek counseling.
Client will verbalize reduction in feelings of stress. Interdisciplinary Focus & Medical Management Stress Definition:
Emotional or mental strain or concern about a situation or difficult circumstance.
May be actual or potential.
Varies in individuals, and how it affects a person from one time to another. Physiology:
Release of corticotropin releasing hormone from hypothalamus causes pituitary to release corticotropin.
Corticotropin travels to adrenal glands where cortisol is secreted.
Cortisol is primary glucocorticoid secreted during stress.
Cortisol increases glucose and fatty acid availability to increase energy and help the stress response. Pathophysiology of Stress:
Can cause negative effects on clients already physically ill.
Increases in sympathetic responses:
Tachycardia.
Hypertension.
Tachypnea.
May cause panic attack. Risk Factors:
Change in physical or functional status.
Death of loved one.
Loss of job or income. Signs & Symptoms:
Diarrhea or constipation.
Insomnia.
Weight loss or gain.
Fatigue. Diagnostic Testing: Cortisol levels analyzed to diagnose chronic stress response. Treatment:
Medications.
Cognitive-behavioral therapy.
Mindfulness Based Stress Reduction. Client Teaching:
Personal habits may contribute to stress.
Ways to modify habits.
Change can affect stress management.
Healthy ways to respond to change.
Importance of effective sleeping environment.
Exercise and several helpful exercises.
Nutrition plan.
Importance of healthy body and mind. Complications:
Misconception common
Hallucinations, delusions, wild desperate actions, extreme withdrawal
Ineffective verbal and nonverbal communication
Feeling of terror
Feeling of being crazy, having life-threatening illness, losing control, being emotionally weak
If untreated, it can lead to physical and/or emotional exhaustion leading to a life- threatening situation o Nursing care for anxiety ▪ Assess level of anxiety ▪ Keep environmental stresses/stimulation low when anxiety is high ▪ Assist client cope with anxiety more effectively ▪ Maintain an accepting and helpful attitude toward client o Displacement ▪ Transferring one’s feelings from one target to another considered less or not threatening
{OCD}
o Indications ▪ Repetitive ▪ Uncontrollable thoughts (obsession) ▪ Actions (compulsions) o Nursing interventions ▪ Accept ritualistic behavior ▪ Structure environment ▪ Provide for physical needs ▪ Offer alternative activities, especially ones using hands ▪ Guide decisions, minimize choices ▪ Encourage socialization ▪ Administer tricyclic antidepressant or selective serotonin reuptake inhibitor (SSRI) o Panic attack ▪ Sudden onset of extreme apprehension or fear ▪ May feel they are losing their minds or having a heart attack ▪ May report palpitations, chest pain, SOB, nausea ▪ Nursing consideration
- Keep environmental stresses low, decrease stimulation
{Phobic disorder}
o Indications ▪ Persistent irrational fears of an activity, object, or situation, with desire to avoid or escape.
• Examples → acrophobia (heights), claustrophobia (closed areas),
agoraphobia (open spaces), social phobia o Nursing interventions ▪ Avoid confrontation and humiliation ▪ Do not focus on getting client to stop being afraid
▪ Teach relaxation techniques ▪ Model unafraid behaviors ▪ Assist with cognitive behavioral techniques such as systematic desensitization o Treatment
▪ Agoraphobia → tricyclic antidepressant, SSRI, benzodiazepine
▪ Social phobia → Benzodiazepine, SSRI, MAOI, TCA, beta blocker
▪ Specific phobia → anti-anxiety med short term
- Reaction formation o Develops behaviors or emotions opposite from current, unacceptable emotions, or behaviors. o Way of controlling unacceptable emotions or behaviors and keeping them out of awareness
- Signal anxiety o Involves a known stressor and clients related anxiety o May be related to anticipated event ▪ A test ▪ Change in residence or lifestyle, such as marriage ▪ Anticipated change in a client’s career o Contract to “free-floating anxiety” which is a feeling of impending doom, unrelated to any anticipated event
o Treatment → psychotherapy, anti-anxiety medication
o Nursing consideration ▪ Recognize signs of major stress or anxiety in ALL age groups ▪ Recommend counseling ▪ Maintain therapeutic communication
- Social anxiety disorder o Severe anxiety or fear when placed in a social or performance situation o Fear of being seen negatively by others o Fear of saying or doing something that will be evaluated by others in a negative way o Need to avoid situations where anxiety may occur
o Treatment → desensitization and psychotherapy
- Therapeutic communication o Establishes nurse-client relationship o Listening to and understanding client while promoting clarification and insight o Goals ▪ Understand client’s message ▪ Facilitate client’s verbalization of feelings ▪ Communicate nurses understanding and acceptance ▪ Identify problems, goals, and objectives o Techniques ▪ Using silence ▪ Using general leads or broad openings ▪ Clarification ▪ Reflecting ▪ Ask about thoughts and feelings o Avoid non-therapeutic techniques ▪ Reassuring
▪ Assess for nutritional deficits, fluid and electrolyte imbalances, liver dysfunction
{Eating Disorders: Anorexia vs. Bulimia}
Session Objectives:
Objective 1: Recognize assessment findings consistent with diagnoses of anorexia and bulimia.
Objective 2: Discuss nursing and medical management for a diagnosis of anorexia. Objective 3: Discuss nursing and medical management for a diagnosis of bulimia.
Points of Emphasis:
Both anorexia and bulimia are characterized by a distorted body image and a phobia of gaining weight.
Clients with anorexia consistently engage in caloric restriction and typically have an underweight body mass index (BMI). They also may engage in purging behaviors but do not usually engage in binge-eating behaviors.
Clients with bulimia consistently engage in caloric restriction but experience episodes of binge- eating and then engage in purging behaviors.
Clients with both disorders are at risk for dehydration, hypotension, electrolyte disturbances, and cardiac dysrhythmias.
The nurse should monitor the client with anorexia or bulimia during mealtimes and
afterward and supervise the client during bathroom visits.
{Suicide}
Session Objectives: Objective 1: Review risk factors for suicide.
Objective 2: Identify behavioral clues of impending suicide.
Objective 3: Explore nursing considerations for a client who is suicidal.
Points of Emphasis: Risk factors for suicide include social isolation, personality disorder, psychiatric or mental health disorder, history of previous attempts, family history of suicide, identifying as a sexual minority, childhood adversity (e., abuse, neglect), easy access to lethal methods (e., firearms, opioids), military service, physical illness, or chronic pain.
Triggers for suicide may include a diagnosis of a life-limiting illness, the death of a loved one, divorce, job loss, major financial loss, or academic failure.
The period from 10 to 14 days following the start of an antidepressant medication is a
particularly high-risk time for suicide. Clients often start experiencing an increase in energy at this point, but they still experience some depressive symptoms. They may now carry out suicide plans that they previously lacked the energy to carry out, or they may now have energy to act impulsively and commit suicide.
Behavioral cues for impending suicide may include a sudden change in the client’s behavior, an increase in energy following a period of depression, giving away possessions, appearing upset, or becoming socially withdrawn.
When caring for a client with suicidal ideation, the nurse should provide a safe physical environment and ensure one-on-one observation of the client. The nurse should consistently treat the client who is suicidal in a positive and accepting manner.
Because suicide is often about taking control when clients see their lives as uncontrollable, it is important to provide clients with a way to exert control, when possible. Offer them choices about meals and activities, when possible. However, recognize that clients who are depressed or extremely anxious may have difficulty with decision-making and problem-solving. Try offering two options, such as, “Do you want chicken or beef?” or “Would you like to go to art therapy or sit with the group and watch a movie?”
- Suicide o Self-destructive, self-harm o Highest priority is protecting clients from inflicting harm on themselves o Impending suicide indicators ▪ Sudden changes in behavior ▪ Becoming energetic after a period of severe depression ▪ Improved mood 10-14 days after taking an antidepressant: may mean suicidal plans are made ▪ Finalizing business or personal affairs ▪ Giving away valuables or pets ▪ Having means for suicide: weapons, razors, pills ▪ Having a death plan ▪ Making direct or indirect statements (I may not be around) ▪ Suicidal ideation o Nursing considerations ▪ Establish a trusting relationship ▪ Ask client directly if considering suicide ▪ Implement suicide precautions ▪ Establish a no suicide contract ▪ Monitor for suicidal signs ▪ Remove all potentially dangerous items from room - Glass (use unbreakable) - Use plastic utensils - Assign to multiple client room - Keep electric cords to minimum
▪ Nausea
▪ “Drugged” feeling
▪ Abnormal thinking
▪ Leukopenia
▪ Myalgia
ZALEPLON
- Purpose ▪ short-term treatment of insomnia
- Nursing Considerations
▪ Elderly patients generally benefit the most
▪ Because of rapid onset, patients should take immediately before bedtime
▪ Avoid alcohol while using this medication
▪ May be habit-forming
▪ “Sleep driving” may occur
▪ Rx C-IV; Preg Cat C
- Side Effects
▪ Headache, tremors
▪ Myalgia
▪ Dizziness, confusion
▪ Bronchitis
▪ Dyspepsia, dry mouth
▪ Eye pain, vision change
TEMAZEPAM
- Purpose ▪ short-term treatment of insomnia
- Nursing Considerations
▪ Should be avoided in patients under the age of 18
▪ Avoid alcohol while taking this drug
▪ Not intended for use for more than 10 days
▪ Take without regard to food
▪ Increases the effect of CNS depressants
▪ “Sleep driving” may occur, especially if taken with alcohol or CNS depressants
▪ Rx C-IV; Preg Cat X
- Side Effects
▪ Drowsiness
▪ Dizziness, headache
▪ Lethargy, fatigue
▪ Weakness
▪ Euphoria
▪ Chest pain, hypotension
▪ Blurred vision
▪ Nausea, vomiting, anorexia
LITHIUM
- Purpose ▪ management of manic phase in bipolar disorder, prevention of bipolar manic-depressive psychosis
- Nursing Considerations
▪ Use caution in potentially hazardous activities
▪ Check serum levels twice weekly during treatment, q 2–3 months on maintenance; draw blood in a. prior to dose
▪ Target serum levels: treatment = 0 to 1 mEq/L, maintenance = 0–1. mEq/L
▪ Take with meals to avoid GI upset
▪ Avoid abrupt withdrawal; discontinue gradually
▪ Avoid use with alcohol, CNS depressants
▪ Monitor for suicidal thoughts or behavior
▪ Patient should wear medical information tag
▪ Rx; Preg Cat D
- Side Effects
▪ Myelosuppression
▪ Dizziness, drowsiness
▪ Hepatitis
▪ Diplopia, rash
▪ Renal failure
▪ Photosensitivity
▪ Nausea, vomiting
▪ Dysrhythmias
▪ Impotence
▪ Bone marrow suppression
▪ Osteoporosis
▪ Hypocholesterolemia
METHYLPHENIDATE
- Purpose ▪ treatment of ADD/ADHD in children over 6 years old, treatment of narcolepsy
- Nursing Considerations
▪ Concerta is time-released and should be swallowed whole, not chewed
▪ Dosage is adjusted in 18-mg increments to a maximum of 54 mg/day
▪ Avoid alcohol, caffeine, and OTC preparations
▪ Do not stop abruptly; taper over several weeks
▪ Monitor for adverse psychiatric symptoms
▪ Rx C-II
- Side Effects
▪ Headache
▪ Fever, arthralgia
▪ Visual disturbance
▪ Abdominal pain
▪ Nausea, anorexia
▪ Insomnia
▪ Restlessness
▪ Urticaria, rash
▪ Leukopenia
▪ Growth retardation
AMPHETAMINE/DEXTROAMPHETAMINE
- Purpose ▪ treatment of ADHD and narcolepsy
- Nursing Considerations
▪ Take in the morning
▪ High potential for abuse
▪ Rx C-II
- Side Effects
▪ Headache, dizziness
▪ Weight loss
▪ Abdominal pain
▪ Mood changes
▪ Tachycardia
▪ Insomnia
Kaplan Psych Integrated Exam Review
Course: Concepts Of Psychiatric-Mental Health Nursing (NUR 4250)
University: Nova Southeastern University
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