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Mental Health Final Exam Study Guide
Mental Health Nursing (4552)
South College
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Mental Health Final Exam
Diagnostic Classes of Substance Abuse
Intoxication: use of a substance that results in maladaptive behavior Withdrawal syndrome: refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases Detoxification: the process of safely withdrawing from a substance Substance abuse: drug is used outside the medical or social norm despite negative consequences Substance dependence: problem associated with addiction
Alcoholism
First episode of intoxication → continuing problems with alcohol → first blackout → continued drinking → development of tolerance → tolerance break → continued drinking → functioning becoming affected → periods of abstinence/temporary controlled drinking → escalation of alcohol intake → more problems → subsequent crisis → continuation of cycle Related disorders: gambling, caffeine and tobacco additions CNS depressant: relaxation/loss of inhibitions 1. Slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judgment 2. Aggressive behavior or display inappropriate sexual behavior; the person who is intoxicated may experience a blackout Treatment of an alcohol overdose: gastric lavage or dialysis to remove the drug and support of respiratory and cardiovascular functioning in an intensive care unit Symptoms of withdrawal 1. Onset within 4 to 12 hours after cessation or marked reduction of alcohol intake; peaking on second day; complete in about 5 days 2. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium (DTs) 3. Benzodiazepines for safe withdrawal
Substance Abuse Treatment
Concept: medical illnesses, chronic, progressive, characterized by remissions and relapses Treatment models: Hazelden Clinic model and 12-step program of Alcoholics Anonymous Individual, group counseling Treatment settings Pharmacologic treatment: safe withdrawal; prevent relapse Medications help manage withdrawal or cravings, but is not a specific treatment for substance abuse
Alcohol Intoxication and Overdose
An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression This combination can cause aspiration pneumonia or pulmonary obstruction Alcohol-induced hypotension: can lead to cardiovascular shock and death Treatment: similar to that for any central nervous system depressant—gastric lavage or dialysis to remove the drug, and support of respiratory and cardiovascular functioning in an intensive care unit The administration of central nervous system stimulants is contraindicated
Physiological Effects of Alcoholism/Long Term (Box 19)
Cardiac myopathy Wernicke encephalopathy: an acute neurological condition characterized by a clinical triad of ophthalmoparesis with nystagmus, ataxia, and confusion Korsakoff psychosis: a late complication of persistent Wernicke encephalopathy and results in memory deficits, confusion, and behavioral changes Pancreatitis Esophagitis Hepatitis Cirrhosis Leukopenia Thrombocytopenia Ascites
Alcohol Withdrawal and Detoxification
Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms: coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremens Alcohol withdrawal usually peaks on the second day and is over in about 5 days; withdrawal may take 1 to 2 weeks Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms Total scores less than 8 indicate mild withdrawal, scores from 8 to 15 indicate moderate withdrawal (marked arousal), and scores greater than 15 indicate severe withdrawal (Clinical Institute Withdrawal Assessment of Alcohol Scale)
Disulfiram (Antabuse)
Accepting—indicating reception Broad openings—allowing the client to take the initiative in introducing the topic Consensual validation—searching for mutual understanding, for accord in the meaning of the words Encouraging comparison—asking that similarities and differences be noted Reflecting—directing client actions, thoughts, and feelings back to client Restating—repeating the main idea expressed Exploring—delving further into a subject or an idea Silence—absence of verbal communication, which provides time for the client to put thoughts or feelings into words, to regain composure, or to continue talking Voicing doubt—expressing uncertainty about the reality of the client’s perceptions
Nontherapeutic Techniques (Table 6)
Advising—telling the client what to do Challenging—demanding proof from the client Agreeing—indicating accord with the client Introducing an unrelated topic—changing the subject Disagreeing—opposing the client’s ideas Giving approval—sanctioning the client’s behavior or ideas Reassuring—indicating there is no reason for anxiety or other feelings of discomfort
Avoiding Nontherapeutic Communication
These responses cut off communication and make it more difficult for the interaction to continue Responses such as “everything will work out” or “maybe tomorrow will be a better day” may be intended to comfort the client, but instead may impede the communication process Asking “why” questions (in an effort to gain information) may be perceived as criticism by the client, conveying a negative judgment from the nurse Overt cues are clear, direct statements of intent, such as “I want to die.” The message is clear that the client is thinking of suicide or self-harm Covert cues are vague or indirect messages that need interpretation and exploration—for example, if a client says, “Nothing can help me.”
Components of Therapeutic Relationship
Trust
- Will build when the client is confident in the nurse and when the nurse establishes integrity and reliability
- Behaviors such as caring, interest, understanding, consistency, honesty, promise keeping, listening
- Congruence: occurs when words and actions match Genuine Interest
- When the nurse is comfortable with him or herself, aware of his or her strengths and limitations, and clearly focused, the client perceives a genuine person showing genuine interest
- Self-comfort, self-awareness of strengths and limitations, clear focus Empathy
- Empathy is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client
- Client and nurse giving “gift of self” (client feeling safe enough to share feeling and the nurse listening to understand)
- Different from sympathy (feelings of concern or compassion; focus shifting to nurse’s feelings
- Acceptance (no judgments; set boundaries)
- Positive regard (unconditional nonjudgmental attitude)
Nonverbal Communication Skills (more accurate, 2/3 of communication)
The primary mood disorders are major depressive disorder and bipolar disorder (formerly called manic-depressive illness) A major depressive episode lasts at least 2 weeks, during which the person experiences a depressed mood or loss of pleasure in nearly all activities About 20% have delusions and hallucinations; this combination is referred to as psychotic depression Bipolar disorder is diagnosed when a person’s mood fluctuates to extremes of mania and/or depression, as described previously Mania: a distinct period during which mood is abnormally and persistently elevated, expansive, or irritable (typically last 1 week or more) 1. Mania episode = inflated self-esteem, “pleasure driven” = high rate of consequences Pressured speech: unrelenting, rapid, often loud talking without pauses Hypomania: a period of abnormally and persistently elevated, expansive, or irritable mood and some other milder symptoms of mania Difference between Mania and Hypomania 1. Hypomanic episodes do not impair the person’s ability to function (in fact, he or she may be quite productive), and there are no psychotic features (delusions and hallucinations) Rapid Cycling: a mixed episode is diagnosed when the person experiences both mania and depression nearly every day for at least 1 week Major depressive disorder: lasts at least 2 weeks Bipolar I disorder: one or more manic or mixed episodes usually accompanied by major depressive episodes Bipolar II disorder: one or more major depressive episodes accompanied by at least one hypomanic episode
Anticonvulsants Used as Mood Stabilizers (Table 17)
Generic (Trade) Name Side Effects Nursing Implications
Carbamazepine (Tegretol)
Dizziness, hypotension, ataxia, sedation, blurred vision, leukopenia, and rashes
Assist client in rising slowly from sitting position Report rashes to physician
Divalproex (Depakote)
Ataxia, drowsiness, weakness, fatigue, menstrual changes, dyspepsia, nausea, vomiting, weight gain, and hair loss
Provide rest periods Administer with food Establish balanced nutrition
Lamotrigine (Lamictal)
Dizziness, hypotension, ataxia, coordination, sedation, headache, weakness, fatigue, menstrual changes, sore throat, flu-like symptoms, blurred or double vision, nausea, vomiting, and rashes
Assist client in rising slowly from sitting position Provide rest periods Administer with food Report rashes to physician
Bipolar Disorder (pg. 305)
Bipolar disorder: involves extreme mood swings from episodes of mania to episodes of depression They have poor judgment and rapid thoughts, actions, and speech If a person’s first episode of bipolar illness is a depressed phase, he or she might be diagnosed with major depression; a diagnosis of bipolar disorder may not be made until the person experiences a manic episode Manic episodes begin suddenly, last from a few weeks to several months Manic episodes typically begin suddenly with rapid escalation of symptoms over a few days, and they last from a few weeks to several months The diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem, sleeplessness, pressured speech, flight of ideas, reduced ability to filter extraneous stimuli, distractibility, increased activities with increased energy, and multiple, grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments
Treatment for Bipolar (Lifelong Tx) (pg. 306)
Warning
Lamotrigine: can cause serious rashes requiring hospitalization, including Stevens-Johnson syndrome and, rarely, life-threatening toxic epidermal necrolysis. The risk for serious rashes is greater in children younger than 16 year Lithium: toxicity is closely related to serum lithium levels and can occur at therapeutic doses. The serum lithium level should be about 1 mEq/L. Serum lithium levels of less than 0 mEq/L are rarely therapeutic, and levels of more than 1 mEq/L are usually considered toxic Valproic Acid/Derivatives: can cause hepatic failure, resulting in fatality. Liver function tests should be performed before therapy and at frequent intervals thereafter, especially for the first 6 months. Can produce teratogenic effects such as neural tube defects (e., spina bifida). Can cause life-threatening pancreatitis in both children and adults. Can occur shortly after initiation or after years of therapy Carbamazepine: can cause aplastic anemia and agranulocytosis at a rate five to eight times greater than the general population. Pretreatment hematologic baseline data should be obtained and monitored periodically throughout therapy to discover lowered WBC or platelet count
Mood Disorders (pg. 285)
Everyone occasionally feels sad, low, and tired, with the desire to stay in bed and shut out the world These episodes are often accompanied by anergia (lack of energy), exhaustion, agitation, noise intolerance, and slow thinking processes, all of which make decisions difficult At the other end of the mood spectrum are episodes of exaggeratedly energetic behavior In an elated mood, stamina for work, family, and social events is untiring. This feeling of being “on top of the world” also recedes in a few days to a euthymic mood (average affect and activity) Mood disorders, also called affective disorders, are pervasive alterations in emotions that are manifested by depression, mania or both Most common psychiatric diagnosis associated with suicide 1. Depression being one of the most important risk factors for suicide
Antidepressants
Use: major depressive illness, anxiety disorders, depressed phase of bipolar disorder, psychotic depression Off-label use: chronic pain, migraines, peripheral and diabetic neuropathy, sleep apnea, dermatologic disorders, panic and eating disorders Mechanism of action: interact with monoamine neurotransmitter systems, especially norepinephrine and serotonin Preferred drugs for clients at high risk for suicide
Groups of Antidepressants
Tricyclic and related cycle antidepressants (TCAs) Selective serotonin reuptake inhibitors (SSRIs) 1) Typically not fatal for OD, used for medium to moderate depression MAO inhibitors (MAOIs) Others (venlafaxine, bupropion, duloxetine, trazodone, nefazodone)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro)
Monoamine Oxidase Inhibitors (MAOIs)
Phenelzine (Nardil), Tranylcypromine (Parnate), Isocarboxazid (Marplan)
Cyclic Compounds
Imipramine (Tofranil), Desipramine (Norpramin), Amitriptyline (Elavil), Nortriptyline (Pamelor), Doxepin (Sinequan), Trimipramine (Surmontil), Protriptyline (Vivactil), Maprotiline (Ludiomil), Mirtazapine (Remeron), Amoxapine (Asendin), Clomipramine (Anafranil)
Other Compounds
Bupropion (Wellbutrin), Venlafaxine (Effexor), Desvenlafaxine (Pristiq), Trazodone (Desyrel), Nefazodone (Serzone), Duloxetine (Cymbalta), Vilazodone (Viibryd)
“S-S-S” (SSRI’s Adverse Effects)
Stomach upset Sexual dysfunction Serotonin syndrome
SSRI Drugs – “Effective for Sadness, Panic & Compulsions"
Effective = Escitalopram For- Fluoxetine = Fluvoxamine Sadness = Sertraline Panic = Paroxetine
Client Teaching (Antidepressants)
Time of dosage 1) SSRI first thing in morning 2) TCAs at night Actions for missed dose 1) SSRI up to 8 hours after missed dose 2) TCAs within 3 hours of missed dose Safety measures 1) Driving/operating heavy machinery = drowsy Dietary restrictions 1) Foods containing tyramine
“ SIG ”
Sleep disturbances Interest decreased Guilty feelings Depression assessment: monitor for signs and symptoms in clients that may be at risk for depression
“DIG FAST” (Manic attack = signs and symptoms)
Distractibility Indiscretion Grandiosity Flight of ideas Activity increase Sleep deficit Talkative
"IS PATH WARM" (Suicide Attempt Warning Signs)
Ideation Substance abuse Purposelessness Anxiety Trapped Hopelessness Withdrawal Anger Recklessness Mood changes
Ch. 12 Definitions – Abuse and Violence
Abuse: treat (a person or an animal) with cruelty or violence, especially regularly or repeatedly Child abuse: the intentional injury of a child Cycle of violence: a typical pattern in domestic battering: violence; honeymoon or remorseful period; tension building; and, finally, violence; this pattern continually repeats itself throughout the relationship Date rape (acquaintance rape): sexual assault that may occur on a first date, on a ride home from a party or when the two people have known each other for some time Elder abuse: the maltreatment of older adults by family members or caretakers Family violence: encompasses domestic or partner battering; neglect and physical, emotional, or sexual abuse of children; elder abuse; and marital rape Intergenerational transmission process: explains that patterns of violence are perpetuated from one generation to the next through role modeling and social learning Intimate partner violence: the mistreatment, misuse, or abuse of one person by another in the context of a close, personal, or committed relationship Neglect: malicious or ignorant withholding of physical, emotional, or educational necessities for the child’s well-being Ostracism: exclusion from a society or group Physical abuse: ranges from shoving and pushing to severe battering and choking and may involve broken limbs and ribs, internal bleeding, brain damage, and even homicide Psychological abuse (emotional abuse): includes name calling, belittling, screaming, yelling, destroying property, and making threats as well as subtler forms such as refusing to speak to or ignoring the victim Rape: a crime of violence, domination, and humiliation of the victim expressed through sexual means Restraining order: legal order of protection obtained to prohibit contact between a victim and a perpetrator of abuse Sexual abuse: involves sexual acts performed by an adult on a child younger than 18 years Sodomy: anal intercourse Stalking: repeated and persistent attempts to impose unwanted communication or contact on another person
Child Abuse
Intentional injury to a child 1. Physical abuse or injuries 2. Neglect or failure to prevent harm 3. Failure to provide adequate physical or emotional care or supervision 4. Abandonment 5. Sexual assault or intrusion 6. Overt torture or maiming
Treatment and Intervention of Child Abuse
Child safety, well-being a priority Psychiatric evaluation/possible long-term therapy/play therapy (for very young child) Family therapy if reuniting feasible Psychiatric or substance abuse for parents Foster care (short or long term)
Elder Abuse
Elder abuse: the maltreatment of older adults by family members or others in a caregiver role 1. Physical, sexual, psychological abuse, or neglect 2. Self-neglect 3. Financial exploitation 4. Denial of adequate medical treatment 60-65% are women, 10% of population over age 65 Bullying has also been identified in senior living facilities between residents People who abuse elders almost always in caretaker role or elders depend on them in some way Elders often reluctant to report abuse due to fear of alternative (nursing home) Clinical picture: variable depending on type of abuse
Potential Indicators of Elder Abuse (Box 12)
Physical Abuse Indicators 1. Frequent, unexplained injuries accompanied by a habit of seeking medical assistance from various locations Psychosocial Abuse Indicators 1. Change in elder’s general mood or usual behavior; isolated from previous friends/family Material Abuse Indicators 1. Unpaid bills; standard of living below the elder’s mean Neglect Indicators 1. Poor personal hygiene; lack of needed medications or therapies Indicators of Self-Neglect 1. Inability to manage personal finances, such as hoarding, squandering, or giving away money while not paying bills Warning Indicators from Caregiver 1. The elder is not given an opportunity to speak for self, have visitors, or see anyone without the presence of the caregiver
Treatment and Intervention of Elder Abuse
Caregiver stress relief Additional resources Possible removal of elder or caregiver
Characteristics of Violent Families
Family violence encompasses spouse battering; neglect and physical, emotional, or sexual abuse of children; elder abuse; and marital rape Common characteristics regardless of type of abuse (4) 1. Social isolation: members of these families keep to themselves and usually do not invite others into the home or tell anyone what is happening; abusers often threaten victims with even greater harm if they reveal the secret 2. Abuse of power, control: the abuser exerts not only physical power but also economic and social control; perception of any indication, real or imagined, of victim independence or disobedience, violence usually escalates 3. Alcohol, other drug abuse: alcohol does not cause the person to be abusive; rather, an abusive person is also likely to use alcohol or other drugs 4. Intergenerational transmission process: shows that patterns of violence are perpetuated from one generation to the next through role modeling and social learning; suggests that family violence is a learned pattern of behavior (not always present but a risk factor when we are assessing)
Intimate Partner Violence (IPV)
Intimate Partner Violence is the mistreatment or misuse of one person by another in the context of an emotionally intimate relationship The abuse can be emotional or psychological, physical, sexual, or a combination (which is common) 1. Psychological abuse (emotional abuse): includes name-calling, belittling, screaming, yelling, destroying property, and making threats as well as subtler forms, such as refusing to speak to or ignoring the victim 2. Physical abuse: ranges from shoving and pushing to severe battering and choking and may involve broken limbs and ribs, internal bleeding, brain damage, and even homicide 3. Sexual abuse: includes assaults during sexual relations such as biting nipples, pulling hair, slapping and hitting, and rape Pregnant women experience an increase in violence during pregnancy
Don’t take charge and do everything for the client
Treatment and Interventions for IPV
Laws related to domestic violence; arrest 1. Sometimes after police have been called to the scene, the abuser is allowed to remain at home after talking with police and calming down 2. If an arrest is made, sometimes the abuser is held only for a few hours or overnight Restraining order/civil orders of protection 1. Restraining order: provides only limited protection 2. Civil orders of protection: are more effective in preventing future violence when linked with other interventions such as advocacy counseling, shelter, or talking with health care providers Shelters 1. Shelters are crowded; some have waiting lists, and the relief they provide is temporary Individual psychotherapy/counseling, group therapy, support and self-help groups Treatment for anxiety/depression
Ch. 16 Definitions – Schizophrenia
Abnormal Involuntary Movement Scale (AIMS): tool used to screen for symptoms of movement disorders (side effects of neuroleptic medications) Alogia: a lack of any real meaning or substance in what the client say Anhedonia: having no pleasure or joy in life; losing any sense of pleasure from activities formerly enjoyed Catatonia: psychomotor disturbance, either motionless or excessive motor Command hallucinations: disturbed auditory sensory perceptions demanding that the client take action, often to harm self or others, and are considered dangerous; often referred to as “voices” Dystonic reactions: extrapyramidal side effect to antipsychotic medication; includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties Echolalia: repetition or imitation of what someone else says; echoing what is heard Echopraxia: imitation of the movements and gestures of someone an individual is observing Latency of response: refers to hesitation before the client responds to questions Neuroleptics: antipsychotic medications Polydipsia: excessive water intake Psychosis: cluster of symptoms including delusions, hallucinations, and grossly disordered thinking and behavior
Schizophrenia
Distorted and bizarre thoughts, perceptions, emotions, movements, behavior Usually diagnosed in late adolescence or early adulthood The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women Medication may control the positive symptoms, but frequently, the negative symptoms persist after positive symptoms have abated Schizoaffective disorder is diagnosed when the client has a mixture of psychotic and mood symptoms Often, second-generation antipsychotics are the best first choice for treatment; mood stabilizers or an antidepressant may be added if needed
Positive Symptoms of Schizophrenia (Box 16)
Positive or Hard Symptoms (elevated perspective) 1. Delusions: fixed false beliefs that have no basis in reality a) Grandeur delusions: false belief that one is powerful, association with a famous person b) Jealousy delusions: false belief that one’s partner is going out with other persons c) Paranoid delusions: thoughts that one is being singled out/aimed at for harm by others 2. Hallucinations: false sensory perceptions or perceptual experiences that do not exist in reality a) Auditory (hearing) b) Gustatory (taste) c) Olfactory (smell) d) Tactile (touch) e) Visual (sight) 3. Ambivalence: holding seemingly contradictory beliefs or feelings about the same person, event, or situation 4. Associative looseness: fragmented or poorly related thoughts and ideas 5. Echopraxia: imitation of the movements and gestures of another person whom the client is observing 6. Flight of ideas: continuous flow of verbalization in which the person jumps rapidly from one topic to another
Mental Health Final Exam Study Guide
Course: Mental Health Nursing (4552)
University: South College
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