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Review exam i 2

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  • 1. Exam I Review
  • 2. The DSM-IV-TRMultiaxial System p 13-15 Axis I: Mental disorder that is the focus of treatment Axis II: Personality disorders and mental retardation Axis III: General medical disorder relevant to the mental disorder in axis I Axis IV: Psychosocial and environmental problems Axis V: Global Assessment of Functioning (GAF) 2
  • 3.  Stem: Unresolved issues in childhood  Levels of awareness ◦ Conscious ◦ Preconscious ◦ UnconsciousFreuds Psychoanalytic Theory 3
  • 4.  Personality structure ◦ Id Pleasure principle Reflex action Primary process ◦ Ego Problem solver Reality tester ◦ Superego Moral componentFreuds Psychoanalytic TheoryContinued 4
  • 5.  Defense mechanisms and anxiety ◦ Operate on unconscious level ◦ Deny, falsify, or distort reality to make it less threateningFreuds Psychoanalytic TheoryContinued 5
  • 6.  Attentive listening Transference and countertransference Therapy: psychoanalysis (lengthy) , free association, dream analysis, focuses on here and now Brief psychotherapyFreudian Theory and Nursing 6
  • 7.  Eight stages of development ◦ Personality continues to develop through old age Failures at one stage can be rectified at another stage Table p 29Eriksons Ego Theory 7
  • 8.  Rational-Emotive Behavior Therapy (Ellis) ◦ Perception influences thoughts which influence behavior ◦ Aims to eradicate irrational beliefs ◦ Recognize thoughts that are not accurate Cognitive-Behavioral Therapy (Beck) ◦ Test distorted beliefs and change way of thinking; reduce symptoms ◦ Automatic thoughts, cognitive distortions ◦ Table p 36Cognitive Theories 8
  • 9.  GABA is an inhibitory (calming) neurotransmitter in the CNS  Benzodiazepines (potentiate GABA) ◦ Diazepam (Valium) ◦ Clonazepam (Klonopin) ◦ Alprazolam (Xanax) ◦ Lorazepam (Ativan)Antianxiety and Hypnotic Drugs 9
  • 10. ◦ Flurazepam (Dalmane) ◦ Temazepam (Restoril) ◦ Triazolam (Halcion) ◦ Estazolam (ProSom) ◦ Quazepam (Doral) ◦ Patient teaching: Avoid heavy machinery, limit use due to tolerance and dependence, do not mix with alcohol or other depressantsAntianxiety and Hypnotic DrugsContinued 10
  • 11.  Short-Acting Sedative-Hypnotic Sleep Agents (“Z-hypnotics”) ◦ Zolpidem (Ambien) ◦ Zaleplon (Sonata) ◦ Eszopiclone (Lunesta) ◦ Patient teaching: Quick action – take immediately before retiring, short half- lives, may cause bad taste upon awakeningAntianxiety and Hypnotic DrugsContinued 11
  • 12.  Melatonin Receptor Agonist (Melatonin is a hormone secreted by the pineal gland that regulates circadian rhythm) ◦ Ramelteon (Rozerem) – low abuse potential, not restricted to short-term use ◦ Buspirone (BuSpar) – not a CNS depressant, less potential for addictionAntianxiety and Hypnotic DrugsContinued 12
  • 13. Antidepressant Drugs  Typical or standard antidepressants ◦ Tricyclic antidepressants (TCAs) block the reuptake of norepinephrine and serotonin ◦ Amitriptyline (Elavil) ◦ Imipramine (Tofranil) ◦ Nortriptyline (Pamelor) ◦ Cause anticholinergic side effects, sedation, drowsiness, and can cause death 13
  • 14.  Selective serotonin reuptake inhibitors (SSRIs) ◦ Fluoxetine (Prozac) ◦ Sertraline (Zoloft) ◦ Paroxetine (Paxil) ◦ Citalopram (Celexa) ◦ Escitalopram (Lexapro) ◦ Fluvoxamine (Luvox) ◦ Less lethal, no anticholinergic SE or sedation, cause apathy, low libido, n/vAntidepressant DrugsContinued 14
  • 15.  Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) ◦ Venlafaxine (Effexor) ◦ Duloxetine (Cymbalta) ◦ Can cause hypertension and lower seizure thresholdAntidepressant DrugsContinued 15
  • 16.  Serotonin-Norepinephrine Disinhibitors (SNDIs) ◦ Mirtazapine (Remeron) ◦ Has antiemetic properties also. Causes sedation and weight gain (good for anorexics)Antidepressant DrugsContinued 16
  • 17.  Monoamine oxidase inhibitors (MAOIs) (Monoamine oxidase is the enzyme that metabolizes norepinephrine. To inhibit it allows a consistent level of norepi at the synapse.) ◦ Phenelzine (Nardil) ◦ Tranylcypromine (Parnate) ◦ Selegiline (ENSAM) ◦ Seldom used due to dietary restriction of tyramine (with drug causes hypertensive crisis) Must avoid aged cheeses, pickles, smoked fish, wineAntidepressant DrugsContinued 17
  • 18.  Bupropion (Wellbutrin, Zyban) ◦ Can cause seizures, weight loss, and sexual dysfunction  Trazodone (Desyrel) ◦ Can cause priapism; given at night due to sedationOther Antidepressant Drugs 18
  • 19. Mood Stabilizers Lithium (reduces overactivity of neurons in brain) ◦ Dosing based on serum drug levels (monitored q week) ◦ Serum level should be 1.0 mEq/L ◦ Less than 0.5 mEq/L is subtherapeutic ◦ More than 1.5 mEq/L is toxic ◦ Greater than 3.0 mEq/L requires dialysis stat 19
  • 20.  Common side effects ◦ Mild nausea, diarrhea, anorexia ◦ Fine hand tremor ◦ Polydipsia and polyuria ◦ Metallic taste in mouth ◦ Weight gain ◦ AcneLithium 20
  • 21.  Toxic side effects ◦ Severe diarrhea ◦ Vomiting ◦ Drowsiness ◦ Muscle weakness ◦ Lack of coordination ◦ Can lead to renal failure and deathLithium 21
  • 22. Anticonvulsant drugs ◦ Valproate (Depakote, Depakene)  Causes wt gain, sedation, thrombocytopenia, liver & renal problems  Requires bloodwork (CBC & liver) before starting and periodically while on meds ◦ Carbamazepine (Tegretol)  Same SE as above plus anticholinergic SE and rash  Requires ongoing labs to monitor CBC, liver function and drug level (below 12 mcg/mL) 22
  • 23. ◦ Lamotrigine (Lamictal)  Watch for Stevens-Johnson Syndrome ◦ Gabapentin (Neurontin) ◦ Topiramate (Topamax)  Can cause blindness, weight loss, kidney stones ◦ Oxcarbazepine (Trileptal)Anticonvulsants (mania) 23
  • 24.  First-Generation or Conventional Antipsychotic Drugs ◦ Phenothiazines ◦ Thioxanthenes ◦ Butyrophenones  Strong antagonists (blocking agents) ◦ Bind to D2 receptors ◦ Block attachment of dopamine ◦ Reduce dopaminergic transmissionAntipsychotic Drugs 24
  • 25. Antipsychotics  Treats positive symptoms of schizophrenia (delusions, hallucinations)  Side effects include extrapyramidal symptoms (parkisonism, akinesia, akathisia, dyskinesi a, and tardive dyskinesia)  Monitor SE with Simpson scale (for acute SE) or Abnormal Involuntary Movement (AIMS)  Treat with benztropine (Cogentin), trihexyphenidyl (Artane), diphenhydramine (Benadryl)  Depot form 25
  • 26.  Binds to dopamine receptors in the limbic system ◦ Decreased motor side effects and EPS ◦ Increases the risk of metabolic syndrome with wt gain, hyperglycemia and increased triglycerides. (Can cause insulin resistance) Can cause sedation ◦ Clozaril causes agranulocytosis and requires weekly CBCs to get medsAtypical Antipsychotics(Second-Generation) 26
  • 27. Atypical Antipsychotics Continued Clozapine (Clozaril) Risperidone (Risperdal) Olanzapine (Zyprexa) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega) Review p 70 27
  • 28. Other Drugs For Attention Deficit Hyperactivity Disorder (ADHD) – Psychostimulants Block reuptake of norepinephrine and release monoamines that act as agonists at adrenergic receptor sites- sympathomimetics. SE include decreased appetite, wt loss, growth suppression 28
  • 29. Psychostimulants ◦ Methylphenidate (Ritalin) – do not take after 4 p.m.; monitor weight  Concerta  Daytrana ◦ Dextroamphetamine (Adderall) ◦ Methamphetamine – (Desoxyn) ◦ Dexmethylphenidate (Focalin) ◦ Lisdexamfetamine (Vyvanse) ◦ Atomoxetine hydrochloride (Strattera)  Nonstimulant – 24 hour dosing 29
  • 30.  For Alzheimers Disease cholinesterase inhibitors ◦ Tacrine (Cognex)  hepatotoxic ◦ Donepezil (Aricept) ◦ Revastigmine (Exelon) ◦ Galantamine (Reminyl) ◦ Memantine (Namenda) – works as glutamate antagonistOther Drugs 30
  • 31.  Admissions reserved for ◦ Suicidal ◦ Homicidal or ◦ Unable to care for basic needs (thus endangering self) ◦ Outpatient therapy is ineffectiveInpatient Psychiatric Care 31
  • 32. Inpatient Psychiatric Care Admission options ◦ Direct admission ◦ Hospital emergency department Criteria to justify admissions ◦ Danger to self or others or unable to care for basic needs Voluntary or involuntary 32
  • 33.  Hospitalized patients retain their rights as citizens. They have the right to: ◦ Vote ◦ Receive, forfeit or deny a driver’s license ◦ Make purchases and enter contraction relationships (unless incompetent) ◦ Press charges against another person ◦ Humane care and treatment (least restrictive) ◦ Due processPatient Rights 33
  • 34.  They have the right to: ◦ Religious freedom and practice ◦ Social interaction ◦ Exercise and participate in recreational opportunities ◦ Refuse treatment ◦ Informed consent ◦ Freedom from seclusion and restraint ◦ ConfidentialityPatient Rights 34
  • 35.  Exceptions to the rule ◦ Duty to warn and protect third parties ◦ Child and elder abuse reporting statutesConfidentiality 35
  • 36.  Review nonverbal communication patterns on p 105 for cultural variances
  • 37.  Assess general appearance ◦ Dress, hygiene, grooming ◦ Appropriate for age? Setting? Weather? ◦ Is the person disheveled? Unkempt? ◦ Does the person appear their stated age? ◦ How is the person’s posture? Eye contact? Facial expressions?Mental Status Exam 37
  • 38.  Assess motor behavior ◦ Automatisms ◦ Psychomotor retardation ◦ Waxy flexibility ◦ Speech (Do they clang? Do they create neologisms?)MSE 38
  • 39.  Assess mood and affect ◦ Mood – emotional state ◦ Affect – outward expression of mood ◦ Look for consistency between verbal and nonverbal communication ◦ Ask patient to rate his mood on a scale of 1-10MSE 39
  • 40. ◦ Is affect blunted? ◦ Is affect flat? ◦ Does patient have an inappropriate affect? ◦ Is affect restricted? ◦ Is affect labile?MSE 40
  • 41.  Assess thought process and content ◦ Can patient stay on track with thoughts? ◦ What is the content of patient’s thoughts? ◦ Listen for themes ◦ Assess if patient makes sense? Are ideas related? Do they flow logically so you can follow the conversation?MSE 41
  • 42. ◦ Circumstantial thinking ◦ Delusions – FALSE FIXED BELIEFS (i.e. grandiose, poverty, somatic, religious, persecution) ◦ Flight of ideas ◦ Ideas of reference ◦ Loose associations ◦ Tangential thinkingMSE 42
  • 43. ◦ Thought blocking ◦ Thought broadcasting ◦ Thought insertion ◦ Thought withdrawal ◦ Word saladMSE 43
  • 44.  Assess for suicidality Assess sensorium ◦ Oriented x 3 ◦ Memory ◦ Ability to concentrateMSE 44
  • 45.  Assess for sensory-perceptual alterations ◦ Hallucinations – FALSE SENSORY PERCEPTIONS (i.e. auditory, visual, tactile, etc.)MSE 45
  • 46.  Assess insight Assess self-concept Assess coping Assess relationships Assess judgment ◦ Use situational questionsMSE 46
  • 47.  Assess for neurovegetative changes ◦ Changes in eating or sleeping habits ◦ Weight gained or lost ◦ Hours slept per nightMSE 47
  • 48.  Needs of patient identified and explored Clear boundaries established Problem-solving approaches taken New coping skills developed Behavioral change encouraged Nurses needs are met outside of the relationshipTherapeutic Relationships 48
  • 49.  Transference – patient unconsciously displaces onto individual in current life emotions and behaviors from childhood that originated in relationships with significant others ◦ Transference intensified with person in authority in current lifeBlurring of Roles 49
  • 50.  Countertransference – nurse displaces feelings related to people in nurse’s past onto patient ◦ Patient’s transference to nurse often results in countertransference in nurse ◦ Common sign of countertransference in nurse is overidentification with the patientBlurring of RolesContinued 50
  • 51.  Orientation phase Working phase Termination phasePeplau’s Model of Nurse-PatientRelationship 51
  • 52.  Tools for enhancing communication ◦ Using silence ◦ Active listening ◦ Listening with empathy ◦ p 181-185Therapeutic CommunicationTechniques 52
  • 53.  Paraphrasing Restating Reflecting ExploringClarifying Techniques 53
  • 54.  Open-ended questions Closed-ended questionsAsking Questions and ElicitingPatient Responses 54
  • 55.  Excessive questioning Giving approval or disapproval Giving advice Asking “why” questionsNontherapeutic CommunicationTechniques 55
  • 56. Autism More common in males; more severe in girls Cause may be related to immunizations Present by early childhood (age 3) Little eye contact, few facial expressions, doesn’t communicate verbally or with gestures, doesn’t relate to peers or parents, lacks spontaneous enjoyment, cannot engage in make believe with toys. May exhibit hand flapping, body twisting, head banging Autism may improve if language skills improve Traits persist into adulthood 56
  • 57.  Short term care: decrease child’s level of anxiety (private room, touch as little as possible, minimize time in room, encourage parents to stay, bring in familiar objects from home, keep communication brief and concrete, maintain a predictable schedule as close to home as possible)Autism (cont) 57
  • 58.  Long term care: encourage social interactions, foster development of communication skills, encourage development of self control, provide opportunities for development of psychomotor skills.Autism (cont.) 58
  • 59. Attention Deficit Hyperactivity Disorder and Disruptive Behavior Disorders Attention deficit hyperactivity disorder ◦ Inattention ◦ Overactivity ◦ Impulsivity Oppositional defiant disorder Conduct disorder ◦ Childhood onset and adolescent onset 59
  • 60.  Fidgets constantly Makes excessive noise Normal environmental noises are distracting Cannot listen to directions or complete tasks Blurts out answers before questions are completedSymptoms 60
  • 61.  Hurried, careless mistakes in schoolwork Loses or forgets homework assignments Fails to follow directions Peers may ostracize Temper tantrums especially when youngSymptoms (cont) 61
  • 62. Outcomes Identification  Remains safe  Demonstrates effective coping methods  Develops friendships with peersAttention Deficit HyperactivityDisorderContinued 62
  • 63.  Help parents cope Teach parents: structure, limits, & consistency are key Provide consistent rewards and consequences for behavior Offer consistent praise Use time-outStrategies 63
  • 64.  Give verbal reprimands Issue daily report card for behavior Use a point system for positive and negative behaviors Teach coping skills (Stop & Think) Teach social skills Don’t talk about symptoms or illness in front of child or child will see self as sick 64
  • 65.  Role play ways to cope with stressful events Have child discuss and examine consequences of his/her behavior 65
  • 66.  Structure, limits and consistency Daily schedule Limit setting Behavioral contracts Time out or loss of privileges Tough love Individual therapy for child; family therapyTreatment forOppositional/Defiant Disorder andConduct Disorder 66
  • 67.  Depression is often just seen as misbehavior or irritability Anhedonia is losing interest in things that once child was passionate about Children & adolescents will give away prized possessions when suicidal Copy cat suicides are common; quick intervention needs to occur following a suicide Bipolar disorder is hard to differentiate from ADHDMood disorders 67
  • 68.  Anxiety is part of normal development Anxiety is a problem when: ◦ An individual fails to move beyond the fears associated with a particular problem ◦ It interferes with normal functioning over an extended period of time Two anxiety disorders of children and adolescents: ◦ Separation anxiety disorder ◦ Posttraumatic stress disorderAnxiety Disorders 68
  • 69. Separation Anxiety Disorder andPosttraumatic Stress DisorderContinuedImplementation Protect child from panic levels of anxiety. Provide emotional support to help child progress developmentally. Increase childs self-esteem and feelings of competence. Help child accept and work through traumatic event. Teach coping skills. Cognitive therapy ◦ Focused on underlying fears and concerns 69
  • 70.  Results: hypothalamus triggers adrenal glands to release adrenalin which increases SNS activity (e.g. tachycardia, tachypnea, hypertension, dilated pupils, blood shunted away from GI and GU tracts to muscles); hypothalamus causes adrenal cortex to release steroids to increase muscle endurance/stamina and mobilizes glucose in bloodstream, but also inhibits reproduction, growth and immunity. Endorphins are released to reduce sensitivity to pain/injury. 70
  • 71.  Interaction between nervous system and immune system during alarm phase of GAS Negatively affects body’s ability to produce protective factorsImmune Stress Responses 71
  • 72.  Stress Busters Box 11-1 Jacobson – Progressive muscle relaxation Benson’s relaxation techniques Meditation Guided imagery Breathing exercisesBehavior Stress-ManagementTechniques 72
  • 73.  Cognitive reframing Mindfulness Journaling HumorCognitive Approaches toStress Management 73
  • 74.  Mild anxiety Moderate anxiety Severe anxiety PanicLevels of Anxiety 74
  • 75.  Defense mechanisms (p 215-217) ◦ Automatic coping styles ◦ Protect people from anxiety ◦ Maintain self-image by blocking  feelings  conflicts and  memories ◦ Can be healthy or unhealthyDefenses Against Anxiety 75
  • 76.  Specific phobias p 220 Social phobia or social anxiety disorder (SAD)Phobias 76
  • 77.  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 anxietyObsessive-Compulsive Disorder(OCD) p 221 77
  • 78.  Flashbacks Avoidance of stimuli associated with trauma Experience of persistent numbing of responses Persistent symptoms of increased arousalPosttraumatic Stress Disorder(PTSD) 78
  • 79. Basic Level Nursing Interventions Do not set limits on rituals at first Teach relaxation exercises and practice them Explore coping behaviors that have worked in the past Decrease environmental stimuli Channel anxiety into physical activity Communicate with firm, short, simple statements and repetition Remain calm; stay with patient with severe anxiety 79
  • 80.  Promote self-care activities Reinforce reality Attend to physical needs (limit caffeine) Later, set limits on rituals while helping patient use relaxation (i.e. postpone performance of ritual by 5 minutes, then 10 minutes, while using relaxation) Pharmacological interventions Health teaching 80
  • 81. Advanced Practice Interventions Cognitive therapy ◦ Cognitive restructuring ◦ Cognitive behavioral therapy  Reframing  Decatastrophizing  Assertiveness training 81
  • 82. OtherInterventions Visual imagery Change of pace or scenery Exercise Music Massage (effleurage) Meditation, prayer Therapeutic touch Hypnosis 82
  • 83.  Behavioral therapy ◦ Relaxation training ◦ Modeling ◦ Systematic desensitization ◦ Flooding ◦ Response prevention ◦ Thought stopping 83
  • 84.  Medications ◦ Antianxiety (anxiolytics) ◦ Antidepressants (SSRIs) ◦ Antihistamines ◦ Beta blockers ◦ Anticonvulsants Herbal and complementary practices ◦ Kava kava 84
  • 85. Cluster A Personality Disorders Eccentric and odd behavior Unusual levels of suspiciousness Magical thinking Cognitive impairment Examples ◦ Paranoid PD p 436 ◦ Schizoid PD p 436 ◦ Schizotypal PD p 436 85
  • 86. Cluster B Personality Disorders• Dramatic, emotional, erratic behavior• Problems with impulse control• Examples – Antisocial PD p 437 – Borderline PD p 437 – Histrionic PD p 439 – Narcissistic PD p 439 86
  • 87. Cluster C Personality Disorders Anxious or fearful behavior Rigid patterns of social shyness Examples ◦ Avoidant PD p 440 ◦ Dependent PD p 441 ◦ Obsessive-compulsive PD p 441 87
  • 88. Interventions Basic level interventions ◦ Milieu management (structure, limits, confrontation and consistency) Watch for splitting ◦ Pharmacological interventions ◦ Case management ◦ Limit setting ◦ Interventions for aggressive behavior ◦ Interventions for impulsive behavior 88
  • 89. Somatoform Disorders Physical symptoms suggest a physical disorder for which there is no demonstrable base Strong presumption that symptoms linked to psychobiological factors 89
  • 90. Somatoform Disorders Somatization disorder Undifferentiated somatoform disorder Conversion disorder Pain disorder Hypochondriasis Body dysmorphic disorder Somatoform disorder not otherwise specified 90