stressful life events can trigger borderline personality disorders o Co-morbidity _ Psychologicanxiety d/o, panic attacks, substance/anxiety d/o worsen the prognosis and greatly increase risk of suicide _ Medicalcardiovascular, metabolic disorder, HIV, seizure d/o Phases of Mania o Acutestabilize, safety, self-care needsfinger foods, protein shake, French friesmanic=less amount of sleeping/eatingkeep pt safe o Continuationmaintaining meds, teach, referralsmake sure patient keeps taking meds, teach about safe sex, legal referral (shared bank account can help when patient in manic phase) o Maintenance phasepreventing relapse2-3 relapse will occur before realizing the need to stay on medication Delirious maniahallucinations, paranoid, agitated, aggressive, thoughts all over, change in speech Maniawill not sleep! May need POA Hypomania **encourage reduction of stimuli, suicidal/homicidal attempts will get you institutionalized During acute phase of mania o Patient cannot pay attention _ Maintain consistency _ Firmly redirect energycoloring, walking at your pace (not patients) do not want patient to overexert self!! o Safety is key _ Reduce stimuli _ De-escalate (therapeutic communication) _ Chemical restraints _ Restraint/seclusion **Be consistent to avoid manipulationpt uses splitting as a way to distract staff and to loosen staff limits (tells stories Nurse Sally let me Well this is what the hospital policy is Milieu Therapyseclusion o Reduces overwhelming environmental stimuli o Protects patient from harm to self or others o Prevent destruction of property Lithium (Mood Stabilizer)GOLD standard o If sodium is down, lithium is up!!!! o Therapeutic Range: 0.8-1.4 o Anything over 1.4 is TOXIC!!! _ Expected side effects Fine hand tremors, polyuria, and mild thirstmay persist Mild nausea and general discomfortoften subside o Can give w/ food to decrease nausea Weight Gain (diet, exercise, nutritional mgmt.) _ Early signs of toxicity NVD, thirst, polyuria, slurred speech, muscle weakness o Hold med, lithium level _ Advanced signs of Toxicity Coarse hand tremor, persistent GI upset, mental confusion, muscle hyperirritability, EEG changes, incoordination _ Severe Toxicity Ataxia, serious EEG changes, blurred vision, clonic movement, lg. output of dilute urine, tinnitus, seizures, stupor, severe hypotension, come, death is usually secondary to pulmonary complications o No antidote of lithium poisoning! Stop drug! If patient is alert emetic is given, otherwise gastric lavage and tx w urea, mannitol, and aminophylline hasten excretion _ More severe! Progress rapidly; coma, cardia dysrhythmias, peripheral circulatory collapse, proteinuria, oliguria and death o Use interventions above, but HD (hemodialysis) may be used Anticonvulsant (seizure meds) o Divalproex (Depakote)GOLD standard! _ Dont take during pregnancy _ AST, ALTliver fx _ CBC for WBC=agranulocytosis (lowered WBC) o Lamotrigine (Lamictal) _ RashSTEVEN JOHNSONS SYNDROME Report to MD!!!! AnxiolyticsTx resistant mania, psychomotor agitation o Clonazepam (Klonopin) o Lorazepam (Ativan)IM Atypical Antipsychotics o Risperidone (Risperdal) o Quetiapine (Seroquel)experiencing hallucinations Other Tx o ECTshock, induces grand mal seizure, resets brain, last resort o Milieu Mgmt.reduce stimuli o Support groupstalking, support emotionally o Health teaching and health promotioneducate how to stay safe **Depression can happen to anyone! Men dont actively seek help! Major Depressive Disorder o More prevalent in women, if hx in immediate family o 50-60% will suffer recurrence o Severe symptomssuicide o Minimum amount of time to stay on meds is 1 year! o Loss of function or loss of independence can cause depression _ Depression often secondary to a medical condition o Anhedonialoss of ability to experience joy or pleasure **Depression is often misdiagnosed/undiagnosed in elderly people for dementiasad, confused, pain, restlessness, agitation Depression _ Geneticsone 1st degree relative w/ depression _ Biochemical deficiency of serotonin/norepinephrine SSRIs, SNRIs _ Becks Triadworthlessness, pessimistic view on world o Mildminor impairment, normal grieving o Moderatepsychomotor slowing, poor concentration o Severecan include psychosis (delusion, hallucination), thoughts of suicide, feeling worthlessness, flat affect _ 2nd generation antipsychotics adjuncts for depression Dysthymic Disorder (type of depression) o No psychosis o At least 2 years o Down, in the dumpsdepressed most of the day Postpartum Depression o Psychosis o Concerned w/ safety (breastfeeding w/ meds) o Affects up to 70% of women for 1st 10 days PP Seasonal Pattern o Tx w/ light therapy o Begin in fall or winter, end of spring o In higher latitudes o Can also be red flag for bipolar d/o Major depression w/ psychotic features o Includes delusions or hallucinations (mostly auditory) _ Possibly command type **extreme depressionperson may be mutestill talk, they will listen **avoid platitudes itll be ok minimizes feelings Nursing Diagnoses o ALWAYS RISK FOR SUICIDE for individuals with depression Antidepressants o SSRIs1st line therapy _ Zoloft, Paxil, Prozac, Lexapro, Luvox, Celexa _ Serotonin Syndrome Greatest risk when SSRI and MAOI administered together o WASHOUT PERIOD o Tricyclicsanticholinergic properties (blurred vision, urinary retention) _ Can be fatal in overdose r/t being lipid soluble _ HTN crisis w/ MAOIs _ Other usespain, enuresis (bed wetting), tinnitus Amitriptyline _ Start low, go slow o MAOIS _ HTN CRISIS Avoid otc meds, foods containing tyramine o Cheese, wine, organ meats, pepperoni, smoked meats Somatic Tx o ECTextreme cases, last resort _ Pt is suicidal/homicidal _ Hx of poor drug response _ Possibly increase neurotransmitters _ Memory loss is usually temporary Suicide o Men commit approx. 72% of suicides o Ideationthink about killing self o Previous attemptshighest risk is first 2 years after _ Especially first 3mo. _ Relative that committed suicide o Exhibiting sudden or unexpected improvement in mood after being depressed and withdrawn o Highly lethal _ Guns, hanging, carbon monoxide, MVA o Lower riskcan be rescued _ Cutting wrists, inhaling natural gas, ingesting pills Overt statements o I cant take it anymore o life isnt worth living Covert statements o its ok now, everything will be fine o I want to give my body to science _ When? Time frame makes statement concerning Family response to suicide o Ultimate rejection o Guilt, shame, anger _ These emotions will happen, allow for expression, support groups should be encouraged **If you, as a nurse, feel concern, always ask: are you thinking of harming or killing yourself? **Risk for suicide; priorityself-restraint from suicide is the hoped-for outcome **Red flagspatient gives away treasured possessions MODULE 05 Defense mechanisms o Intellectualizationavoid expressing actual emotions associated w/ stressful situation by reasoning and analysis (doesnt want to move but talks about the advantages of the move) o Rationalizationmakes excuses, logical reasons to justify unacceptable feelings or behaviors (I need a drink bc its the only way to deal w/ my horrible job)making it ok o Sublimationrechanneling of drives that are unacceptable into activities that are constructive (A mother who son killed by drunk driver, starts program about mothers against drunk drivers)trauma turns into something constructive o Projectionproject self onto partner (youre a liar so you accuse your partner of being a liar) o Displacementnever was addressed where shouldve been o Suppressionvoluntarily puts off for time being, comes back to deal with later o Repressioninvoluntarily puts off, trauma, doesnt remember Fearreaction to a specific danger Anxietya feeling of apprehension, uneasiness (real or perceived) o d/olonger than 2 weeks, must cause dysfunction o substance abuse: self-medicating o normal-test anxiety o acute-sudden o chronic-long term Stages of anxiety o Moderatenarrowed perceptual fieldcant hear name getting called bc so focused o Severefocus on specific detailnot interacting with environment around o Panicdread, terrorcant respond to verbal stimuli, out of the blue, hits that level immediately, do not leave alone, speak calmly, reduce stimuli **Asian culture: often w/ somatic symptoms; korophysical pain; actually, feel it Phobia o Persistent, intense, irrational fear o Agoraphobia _ Intense and excessive level of anxiety and fear of being in places and situations from which escape is impossible _ Lack control in wide open spaces, cannot control environment o Txsertaline, paroxetine, buspirone, imipramine Panic Disorders o Often mistaken for MI o Feeling of terror o Sudden, limited perceptual field, suspension of normal fx _ Palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nausea, feelings of choking, chills hot flashes and GI symptoms o What is the trigger? Major life event? o Txdeep breathing exercises, benzos (acute situations), SSRIs, tricyclics, antihypertensive agents (clonidine, propranolol)change positions slowly Generalized Anxiety Disorder o Symptoms must occur more days than not >6mo.; must cause dysfunction o Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances o TxSSRIs, buspirone (Buspar)Tx long-term, no dependence, but takes 3-4 weeks to work Social Anxiety D/Osocial phobias o SAD _ Sever anxiety provoked by exposure to social situation _ Fear of public speaking most common _ PREVENT ANXIETY OCD o Obsessionsunwanted, intrusive, persistent ideas, thoughts, impulses o Compulsionsunwanted repetitive behavior patterns or mental acts intended to reduce anxiety o Hoarding is common o Provide time for rituals, give patient time frame, no rituals if interfere w/ safety or emergency situation o Txtherapy and meds _ 1st line: SSRI (fluvoxamine(Luvox), sertraline) _ 2nd line: SNRI (venlafaxine) _ Tx resistant OCD: second gen antipsychotics (risperidone, quetiapine, olanzapine) _ Cognitive therapyexamine relationships between thoughts, feelings, and behaviors _ Exposure therapyconfronting avoided situation _ Response prevention therapydelay or avoid rituals **teach family to avoid giving advice, trying to fix, be patient, can take a break, monitor family own anxiety levels Medications that Tx anxiety D/O o Benzodiazepinesshort term, sedative, avoid driving, operating machinery, watch for orthostatic hypotension, substance abuse _ -pams and -lams _ Atypical benzoLunesta (eszopicolone), Sonata (zaleplon) Most suppress REM, causing daytime fatigue o Buspironenon-addictive, long term, 3-4 weeks to work _ Works best before benzos are tried o SSRIsfirst line tx for anxiety d/o, OCD, BDD _ Celexa, Lexapro (not for SAD, PD), Prozac, Luvox, Paxil, Zoloft o SNRIsPAD, GAD, SAD _ Cymbalta, Effexor o Tricyclicssecond or third line use for PD, GAD, and SAD, clomipramine is effective in OCD _ Amitriptyline, Imapramine (Tofranil) o MAOIstx resistant conditions o Beta-Blockerswatch for decrease HR, BP _ Propranolol, atenolol ** One event may be traumatic to one but not anotheracute event <3 monthsPTSD >3 months Stress o ANS-increases adrenalinincrease HR, BP, RR, Blood flow o Stressed out can mean trouble sleeping and eating, headache, back pain, irritable o When stress is prolonged chemicals produced are: cortisol, adrenaline, and other catecholamineswhich can damage the body PTSD o Flashbackscompletely feel it, they dont just think about it o Avoidance of stimuli o Childhood physical abuse, torture, kidnapping, military, terrorist attacks, assault, dx of life-threatening illness o Psychotherapy is tx of choice _ Prazosin (Minipress) tx nightmares Acute stress D/O o Witnessing or experiencing a violent or gruesome death of or by in intimate _ 1st responders exposed to picking up body parts _ Policer officers exposed to details of child abuse o Resolves in one monthby definition MODULE 06 Schizophrenia facts o Psychosissymptom _ total inability to recognize reality (delusion, hallucination) _ usually includes substance abuse (Tobacco) o Prodromal: pre-psychotic phasedecline in fx _ Social maladjustment _ Irritability _ Withdrawn, shy, poor relationship _ This phase last a year or more, clean decline o Phase 1: acutesafety, med stabilization, refrain from acting on delusions/hallucinations _ Two or more symptoms present for 1-month periods Delusions, hallucinations, disorganized speech, disorganized behaviors, affective flattening, alogia, avolution (negative symptoms) Likely hospitalization r/t safety, symptoms stabilization o Phase 2: stabilizationmed adherence, understanding, compliance o Phase 3: maintenanceavoid another psychotic break _ Remission, exacerbations _ Residual (stabilization) impairment increases between episodes of active psychosis o Must rule out medical or substance induced psychosis **phase 2/3pt & family education, medications, communication; identify situations that might be triggers Nursing Dx o Positive symptomsadd to patient/situationhallucinations and illusions _ Gustatory false perception of tasterotten, decaying, poison _ Hears voices, commandsmost common _ Tactile feels things crawling on skin _ Misconceptions of real external stimuli Disturbed sensory perceptionHALLUCINATIONS Disturbed thought processDELUSIONS AND ILOGICAL THINKING o Negative symptomstake away from patientmore difficult to txcan mimic depression _ Social isolation _ Risk for violence _ Ineffective coping _ Constipation Needs assistance w/ everyday tasks Neglects personal hygiene Speaks very little Expressionless Delusional thinking o Dont whisper in front of patient o Be cautious with touching patient o Use the same staff to increase familiarity and trust o Cannot argue delusions o Goal to decrease anxiety o Can provide individual package mealnot family style meals o Delusions are most challenging, you cannot rationalize w/ patient _ Ideas of referencecommercial billboard is meant for them _ Persecutionfeels like government after themuse emotion in this case _ Being controlledpuppet _ Thought broadcastingaluminum foil in windows Hearing voices o Use distraction and bring client back to reality o How many voices? o Are you afraid of voice? o What is the voices telling you? Hurt yourself or another (command) Alterations in speech o Flight of ideasassociative loose thoughts, repeats sentences, each relates to another topic o Neologismsmade up words that have meaning only to pt o Echolaliarepeats words spoken to them o Clang associationox, fox, box (Dr. Suess books) o Word saladwords jumbled together, cannot put words in correct order to make sense More positive symptoms of schizo o Waxy flexibilitygumby, frozen **prolixin or Invega after 3rd-4th psychotic break **always focus on the here and now, do not pretend to understand pt if you do not, be honest/consistent **patient can refuse to be bathed Treatment o Conventional (1st gen) antipsychoticsdopamine _ Positive symptoms _ Haldol, thorazine EPS o Akathisiarestlessness o Acute dystoniastiffness o Psuedoparkinsonismshakiness _ Give Benadryl for TX of EPS Tardive dyskinesiatongue move, grimacing, pill rolling NMSlife threatening, stiff and rigid, decreased LOC, increase temp. and increase BP Agranulocytosisrisk for infectionreport sore throat, malaise, fever Lower seizure threshold anticholinergic o Atypical (2nd gen) antipsychoticsdopamine and serotonin _ Positive and negative _ Have fewer side effects _ Tx anxiety, depression and decrease suicidal behavior Clozapine (Clozoril) o Agranulocytosis o Decrease seizure threshold _ NO EPS o Watch for metabolic syndromeincrease in cardiovascular disease, increase weight, altered glucose, hyperlipidemia, diabetes, CAD **educate patient about nicotine replacement, birth control, dress appropriately for weather [Show less]
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