When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include:
(Next to all the incorrect answers, note which personality disorder you believe is actually being described)
1.preoccupation with minute details; perfectionist:
2. impulsive, restless, socially aggressive behavior:
3. socially anxious, rambling stories, peculiar ideas:
4.charm, drama,
seductiveness; seeking admiration:
5.difficulty being alone; indecisive, submissiveness:
6.grandiosity, self-importance, and a sense of entitlement:
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Schizophrenia definition
-inability to think/communicate accurately
-loss of ego boundaries
There is often a pre-psychotic phase prior to acute onset of schizophrenia...what will you see?
-disturbed sleep
cycle
-poor nutrition
-poor hygiene habits
-overall change in normal personality
What about amphetamines? How would this impact someone with schizophrenia?
-they make symptoms worse because of the increase in dopamine levels
Psychosis
severe mental disorder in which a persons ability to think, reason, and respond, and behave appropriately toward reality is impaired grossly enough to not meet the ordinary demands of life
Delusions
-ideas
Clanging
meaningless rhyming
Concrete thinking
take everything literally
Neologisms
made up words
Hallucinations
the feelings
Command hallucinations
voices are telling the patient to do something, such as harm themselves
Depersonalization
the pt does not feel real
Derealization
the environment does not feel real
If a patient all of a sudden begins to act out and threatens to hurt themselves, what do you do?
1. "I am here to help you" aka orient them, and remove the weapon if there is one
2. remove other patients from the room (ask a fellow RN to help with this)
3. tell another nurse to grab the pt's PRN med while you
stay with the patient
4. take the pt to a secure area to administer the med
5. the RN that pulled the med has to be the one to deliver it
6. whoever first witnessed the event fills out the incident report, even if the person is unlicensed
You believe that the young man you are admitting to your unit is suffering from command hallucinations.
What would be some questions to ask him?
"what are
the voices telling you to do?"
"have you heard this voice before?"
"what makes the voices louder/quieter?"
"when did the voices start?"
Illusions
misperceptions or misinterpretations of a real experience
waxy flexibility
body parts are rigid but you can move them
echopraxia
copying movements
echolalia
repetition of words
avolition
loss of motivation
anhedonia
loss of pleasure
anergia
loss of energy
Positive schizophrenic symptoms (primary symptoms)
-hallucinations/delusions
Negative schizophrenic symptoms
-affect disturbances
-poor response to traditional antipsychotics (thorazine, haldol)
-poor social functioning
-withdrawn
-loner
-insidious onset
-hx of emotional problems
-chronic
deterioration
-abnormalities in neuro testing
How long does one have to have schizophrenic symptoms to be diagnosed?
6 months
-less than 6 months will have diagnosis of schizophreniform
water intoxication
symptoms of schizophrenia
Catatonic schizophrenia
motor immobility or excitability
Disorganized schizophrenia
prominent negative symptoms
Paranoid schizophrenia
positive symptoms
Loose associations in a person with schizophrenia indicate:
A. paranoia
B. mood instability
C. depersonalization
D. poorly
organized thinking
D
which assessment finding represents a negative symptom of schizophrenia?
A. apathy
B. delusion
C. motor tic
D. hallucination
A
What are the 1st gen antipsychotics?
Thorazine
Haldol
Prolixin
What are some nursing implications for Thorazine (chlorpromazine)?
photosensitivity, so wear sunblock and glasses
Haldol (haloperidol); Prolixin (fluphenazine)
-targets positive symptoms
-low anticholinergic effects
-does not have ortho hypo as a side effect
-high EPS
-low sedative properties
-PO, IM, decanoate (long acting, lasts 4 weeks, will be called Haldol D/Prolixin
D)
-decanoate would be used for noncompliance
Side effects of conventional antipsychotics- 1st gen
-all antipsychotics can have anticholinergic (ACH) and extrapyramidal side effects (EPS)
Which antipsychotic is similar to haldol and prolixin?
thiothixene
Which antipsychotic is most likely to have ACH side effects?
Thorazine
Which antipsychotic is most likely to have EPS side effects?
haldol and prolixin
Define Extrapyramidal (EPS) effects
-pseudoparkinsonism (parkinson-like symptoms)
-may switch neuroleptics in order to treat
When do EPS side effects occur?
5-30 days of med administration
EPS symptoms
parkinson symptoms
shuffling
Dangerous EPS complications
-acute dystonic reactions
-akathisia
-anticholinergic toxicity
-tardive dyskinesias
When does tardive dyskinesias occur?
a month after the med administration
Define tardive dyskinesias
tongue thrusting
drooling
brain damage and parkinson symptoms that NEVER END!
Define akathisia
constant need to move
Define acute dystonic reactions
painful muscle contractures
Define Neuroleptic malignant syndrome (NMS)
acute adverse reaction caused by antipsychotics
What are the NMS symptoms?
high fever
delirium
severe EPS
rigid diaphragm
COGWHEELING TREMOR
Neuroleptic malignant syndrome (NMS) interventions
-stop the med
-cool body
-hydration
-correct electrolytes and arrhythmias
-ECT in some cases
-heparin drip to decrease risk of pulmonary emboli
What can 2nd gen antipsychotics used for?
-treat both positive and negative symptoms
-can also be used for migraines and insomnia
What are the 2nd gen antipsychotics?
Risperdal
Invega
Zyprexia
Geodon
Seroquel
2nd gen antipsychotics have ____________ EPS side effects or tardive dyskinesia.
little to no
2nd gen antipsychotics can have major _____________ side effects.
metabolic (weight gain, HTN, hyperglycemia, hyperlipidemia)
What effects can risperdal have on males?
breast development
How can Invega be given?
1 month and 3 month dose
How can zyprexa be given?
dissolvable tongue strip
Which 2nd gen antipsychotic is given mostly for bipolar?
Zyprexa
Which 2nd gen antipsychotic should NOT be given to a patient with cardiac issues?
Geodon
Which 2nd gen antipsychotic can help with insomnia?
Seroquel
Which are more expensive, 1st gen or 2nd gen antipsychotics?
1st gen
What is an atypical antipsychotic?
Clozaril (clozapine)
Clozapine has a high risk of EPS side effects, true or false?
false
What are some nursing implications for clozapine?
increase
dose slowly
weekly blood draws for neutropenia
What are some Clozaril (clozapine) side effects?
orthostatic hypotension
tachycardia
severe drooling
seizures
What are the 3rd gen antipsychotics?
-aripiprazole (abilify)
-dopamine system stabilizer
-improves positive and negative symptoms and cognitive
function
-little risk of EPS or tardive dyskinesia
-used with other meds
Ability has little to no risk of __________________.
EPS side effects
Can ability be used with other meds?
YES
What occurs during Phase 1 (acute)?
pt safety and med stabilization
What occurs during Phase 2 (stabilization)?
adhere to treatment
stabilize meds
control or cope w/ symptoms
What occurs during Phase 3 (maintenance)?
maintain achievement
prevent relapse
achieve independence
Treatment modalities
-social
skills group
-NAMI
-AA/NA
-psychoeducation groups
-rehab/occupational training
-housing/group homes
-individual therapy
-regular sleep pattern
-be aware of increased stress and anxiety
-keep in touch with support network
-encourage activities pt enjoys
-TAKE MEDS!!!!
-attention to client strengths as well as deficits
-holistic model
-encourage positive coping skills
Define schizophreniform disorder
given to patient with symptoms for 6 months
Define schizoaffective disorder
looks like schizophrenia with a mood disorder
A patient with schizophrenia says, "There are worms under my skin eating the hair follicles." How would you classify this assessment finding?
A. positive symptom
B. cognitive symptom
C.
depressive symptom
D. negative symptom
A
How does a patient receive a diagnosis of MDD?
they have one or more major depressive episodes
NO episodes of bipolar
NO history of manic or hypomanic episodes
MAY include psychotic features though
Define Disruptive Mood Dysregulation Disorder
children that are depressed, appear tired constantly
Who does MDD affect the most?
children/adolescents and elderly
Who is most at risk for being successful at committing suicide?
-elderly white males
MDD S/S
-anhedonia
-wt
changes
-increased/decreased motor activity
-anergia
-suicidal thoughts with/without plan
-anger/irritability
-occur for at least 2 weeks
How long do symptoms occur for MDD?
at least 2 weeks
Which question would be a priority when assessing for symptoms of major depression?
A. "Tell me about any special powers you believe you have."
B. "You look really sad. Have you ever thought of harming yourself?"
C. "Your family says you never stop. How much sleep do you get?"
D. "Do you ever find that you don't remember where you've been or what you've done?"
B
Can a person who is depressed experience delusions or hallucinations?
yes
Is guilt common with people that are depressed?
yes
Can a depressed patient have another Axis I disorder?
yes
What is the reason it is important for a nurse to perform a self-assessment of his/her feelings?
-if the nurse has experienced depression, they should reflect on their own experience because it will likely differ from the pt's
MDD interventions
-mileau
-psychotherapy
-meds
-ECT
-light therapy
-group therapy
-transcranial magnetic stimulation
-vagus nerve stimulation
-family therapy
-communication
-therapeutic silence
-improve self care and coping
-empathy
How is depression different than normal grief?
-worthlessness
-suicidal
ideas
-psychomotor retardation
-severe impairment
-pervasive, unremitting
How long do ECT usually last?
6-12 treatments over 2-3 weeks
When is ECT used for MDD?
only used after trial of antidepressant medication has failed or the depression is non responsive
You are
worried about a close friend who recently broke up with a boyfriend. She is taking the breakup very hard and seems depressed.
What are some questions you could ask to assess for suicide ideation?
"are you thinking of harming yourself?"
"do you want to go to sleep and not wake up?"
"i've noticed a change in your behavior"
What is the primary level of suicide prevention?
activities that provide support, information, and education to prevent suicide
What is the second level of suicide prevention?
treatment of the actual suicidal crisis
What is the tertiary level of suicide prevention?
interventions with the family and friends of a person who has committed suicide to reduce the traumatic aftereffects
What is done for the patient threatening suicide?
-1:1 monitoring OR q15 checks
-do not assign to a private room
-do not allow alone time in room
-break away shower rods, recessed shower nozzles
-short electrical cords
-lock unbreakable windows
-lock utility and exam rooms, kitchens, stairwells, etc
-inspect gifts from visitors
-ensure that visitors do not leave behind
harmful objects
-search pt for harmful objects on return from pass
A patient is hospitalized with major depression and suicidal ideation. For the first 2 days of hospitalization the patient stays in his room between groups. By the fourth day, the nurse observes that the patient is more sociable, is eating meals, and has a bright affect. Which factor should the nurse consider?
A. The patient is showing improvement and may be ready for discharge.
B. The patient may have decided to commit suicide; the nurse should reassess suicidality.
C. The patient is feeling rested, supported by the therapeutic milieu, and less depressed.
D. The patient is benefiting from the antidepressant he has been taking for 4 days.
B, b/c the meds take 4-8 weeks to work an suicide risk is highest in first weeks b/c they are still depressed but now have the energy to follow through with plans of suicide!
Dysthymia (persistent depressive disorder)
-occurs over 2 year period (1 year for adolescents and children)
-chronic depressed mood
-changes in appetite, sleep, low energy, fatigue, poor concentration, indecisive, and feelings of hopelessness and despair
-usually don't have suicidal thoughts
-these pts never know what it's like to be happy or have a good day
Which assessment finding in a patient with major depression represents a vegetative sign?
A. restlessness
B. hypersomnia
C. feelings of guilt
D. frequent crying
B
A person with which psychiatric problem is most likely to complete suicide?
A. personality disorder
B. major depression
C. substance abuse
D. schizophrenia
B
Which method of suicide has the highest lethality?
A. cutting one's wrists
B. overdose
C. gunshot wound
D. drinking
C
A patient was just admitted to your unit with bipolar disorder I and is in the manic state. What symptoms might you expect to see?
-labile mood (happy then sad very suddenly)
-disturbed
sleep
Define Bipolar disorder 1
at least one manic episode and depressed episode
Define Bipolar disorder 2
no manic history, have at least one episode of hypomania and depression
Define Cyclothymia
hypomanic symptoms and depressive symptoms fall short of MDD for 2 years in Adults, 1 year children
Bipolar 1 is more common is ______________.
males
Rapid cycling is most common in ___________ with bipolar disorder.
children
Outcomes identification for bipolar
-acute phase: prevent
injury
-continuation: relapse prevention
-maintenance phase
Planning: bipolar
-acute phase: med stabilization, maintaining safety, self care needs
-continuation phase: maintenance med adherence, psychoeducational teaching, referrals
-maintenance phase: prevent relapse
Define Rapid cycling
4+ episodes of bipolar disorder disorder a year (manic to depressed)
Bipolar disorder: nutrition
-provide finger foods!!
Cyclothymia
-occurs over a 2 year period
NO delusions or hallucinations
SSRIs block _____________ uptake
serotonin
What is the 1st line of therapy for mood disorders?
SSRIs
What are the SSRIs used for mood disorders?
Prozac (fluoxetine)
Zoloft (sertraline)
Celexa (citalopram)
Luvox (fluvoxemine)
Paxil (paroxetine)
Lexapro (escitalopram)
What SSRI is used for OCD?
Luvox
SSRIs side effects
anxiety
sleep disturbance
tremor
sexual dysfunction
anticholinergic effects
Define Central serotonin syndrome
too high dose or reactions with other drugs
What makes CSS worse?
MAOIs
What are the S/S of CSS?
abdominal pain
sweating
fever
increased BP
irritability
How long do antidepressants take to have therapeutic effect?
4-8 weeks
How should a patient stop SSRIs?
taper them slowly!!
TCA side effects
-anticholinergic
-ortho hypo
tachy, ECG changes, HF, arrythmias
-lethal in OD
-contraindicated for pt who has had recent MI, pregnancy, narrow angled glaucoma, hx of seizures
MAOIs
Nardil (phenalzine),
Parnate (tranylcypromine)
What should patients not eat with MAOIs?
tyramine foods!
MAOI side effects
weight gain
-sexual dysfunction
-wt gain
MAOIs+Tyramine= hypertensive crisis
-severe HA
-flushing cold clammy skin
-stiff or sore neck
-N/V
-tachy
-severe nose bleeds, dilated pupils
-chest pains, stroke, coma, death
-occurs within a few hours
Serotonin-Norepinephrine Reuptake Inhibators (SNRIs)
-effexor, cymbalta, remeron
-remeron can help with sleep
SNRIs side effects
-nausea
-sweating
-asthenia
-abnormal ejaculation/orgasm
-anorexia
What would be an advantage of a SNRI like Cymbalta or Effexor?
not habit forming so can be used for pain!
Cymbalta and the elderly
-diabetic neuropathy
-comorbid with other problems (HTN, arthritis, neuro conditions, stroke)
-these impair ADLs and quality of life
Wellbutrin is the recommended med for _________________.
rapid cycling bipolar
-will not cause a manic episode
-lack of
sexual side effects
-for rapid cycling bipolar pt
-side effects: nausea
-adverse effects: increased risk for med induced seizures
Wellbutrin has an increased risk of ___________________.
seizures
Trazadone
-can be used for sedation
-may cause ortho hypo
-low wt gain/sexual dysfunction
Your patient was just diagnosed with a major depressive disorder.
What medication do you anticipate the health care provider will start the patient on? What side effects might the patient experience?
-SSRIs
-nausea, wt changes, GI upset, sleep disturbances
What is Lithium used as?
-mood stabilizer for pure manic episodes
-not as effective
with mixed mania or rapid cycling
How long does it take for lithium to reach therapeutic levels?
7-14 days
What is a nursing implication for lithium?
patient should not change salt or fluid intake
take with food
avoid ETHOL
check urine specific gravity
labs drawn regularly
What are long term risks of lithium?
Kidney function
hypothyroidism
Lithium: expected side effects
polyuria
hand tremor
mild thirst
wt gain
Lithium: unexpected side effects TOXICITY
N/V
diarrhea
slurred speech
muscle weakness
Lithium toxicity advanced signs
hand tremor
GI upset
mental changes
hyper-irritability of muscles (ataxia)
seizures
Anticonvulsants
Tegretol
Depakote/Depakene
Lamictal (lamotrigine)
Neurontin (gabapentin)
Nueortontin
JUST SAY NO!
Benefits of anticonvulsants
-better for continuous rapid cycling pts
-can facilitate withdrawal from alcohol and benzodiazepines
Tegretol
-give with meals
-NO ETHOL
-DONT stop med abruptly!
Tegretol side effects
drowsy
dizzy
N/V
Tegretol adverse effects
STATUS EPILEPTICCUS if abrupt withdrawal!
CHF
arrhythmias
abnormal LFTs
jaundice
hepatitis
Tegretol: pt teaching
-monitor therapeutic levels
-frequent blood tests during first 3 months, monthly after that (to check LFTs)
Tegretol signs of toxicity
fever
sore
throat
mouth ulcers
bruising/bleeding
joint pain
Depakene/Depakote pt teaching
-similar to tegretol
-perform baseline liver tests
Depakene/Depakote side effects
tremors
GI upset
weight gain
alopecia
Which anticonvulsant medication might be prescribed for a
patient with bipolar disorder?
A. Divalproex sodium (Depakote)
B. Clonazepam (Klonopin)
C. Olanzapine (Zyprexa)
D. Lithium (Lithobid)
A
Anxiety disorders
-panic disorder
-phobias
-OCD
-GAD
-PTSD
Panic disorder S/S
-panic attacks
-worry
-change in behavior
-w/
or w/o agoraphobia
-feel like losing mind
-sudden onset or fear
-often first seen in ER
Generalized Anxiety Disorder (GAD) S/S
-difficulty making decisions
-poor focus
-fear of making mistakes
-overall anxiousness
-insomnia
-restless
-fatigue
-irritable
GAD interventions and meds
-SSRIs
-relaxation
therapy
-nutrition
-adaptive coping skills
-cognitive restructuring
Phobias
-intense fear of a specific object/activity/situation
-fear is persistent and irrational
Phobias interventions
-anxiolytics, antidepressants
-systemic desensitization
-flooding and biofeedback
-guided imagery
-cognitive
restructuring
OCD
obsessions:
-thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind
compulsions:
-ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety
OCD interventions
-luvox (SSRI), anafranil (TCA), prozac
-relaxation
therapy
-nutrition
-adaptive coping skills
-cognitive restructuring
-flooding and thought stopping with rubber band
PTSD S/S
-event threatened life
-dreams and images
-flashbacks, hallucinations
-avoidance of stimuli and trauma
-symptoms of hyperarousal
-exaggerated startle response
-re experience trauma
-trust issues
-difficulty in relationships
PTSD interventions
-SSRIs, atypical antipsychotics, mood stabilizers
-psychotherapy
-hypnosis
-psychodrama
-play therapy for children
-group therapy
Defenses in anxiety disorders
-phobias= displacement
-obsession= reaction formation
-compulsion= undoing
-PTSD= isolation and repression
Benzodiazepines are _____________________.
anziolytics
-end in lam or pam
Benzodiazepines
xanax
valium
ativan
Benzodiazepines pt teaching
-habituating, gradual tapering
-short term tx, given for an acute panic attacks/other episodes
BuSpar is NOT an _________________, it is similar to a _________________.
anxiolytic
SSRI
BuSpar is NOT ____________________.
habit forming
BuSpar benefits
less sedating
takes only 3 weeks to be effective
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