Patient Study Guide: Test 1 NURS355 153 box 8-6 (legal considerations for documentation for care)-look up Levels

of anxiety on BB, print out page 214 Pre orientation, orientation phase, working phase, termination phase anticholergernics, Cogentin, Benadryl; neurotransmitters, ssi and ssdi (norepeniphrine- sympathetic nervous system, dopamine-fine muscle movement, acetylcholine- stimulate parasympathetic, glutamate, serotonin, GABA) dopamine pathways (mesolimbic, nigrostriatal, mesocortical, tubero infundibular) catotonia

Pre-orientation phase-the environment and feeling the nurse gets before meeting the patient Orientation phase-first meeting on nurse and patient. Time of initial interviewtermination is introduced.nurse becomes aware of transference and countertransference o Establish rapport, confidentiality, formal and informal contract, confidentiality o Working phase-maintain the relationship, gather further data, overcome resistant behavior, evaluate problems and goals o Termination phase-determine ways for patient to involve coping strategies into daily life, summarize goals and objectives Richards & Peplau PMH Nursing slide 28 intro Hildegard Peplaus o 1952 theory of interpersonal relationships in nursing-developed framework for psychiatric nursing o First to identify psychiatric mental health nursing as general nursing and an area of specialty and started first advanced masters in PMH at Rutgers university o Emphasized therapeutic observations, and working with the patients and also self-awareness o Levels of anxiety-mild, moderate, severe, and panicshe promoted interventions to lower anxiety with the aim to improve patients ability to think Linda Richards o First PMH Nurse, McLean Hospital, Boston, MA o Helped establish first PMH program in 1913 at John Hopkins DSM-IV-TR; know what each Axis identifies (slide 17 intro ppt) Axis I: Clinical disorders mental disorders comparable to a general medical illness o Ex. Adjustment disorder with anxious mood Axis II: Personality Disorders and mental retardation o Obsessive compulsive personality Axis III: General medical conditions general medical illnesses or injuries o Chrons disease-acute bleeding episodes Axis IV: Psychosocial and environmental problems o Recent remarriage; death of father Axis V: Global assessment of functioning (GAF)- level of functioning, reported as a number from 0 to 100 based on the patients overall psychological, social and occupational function. (page 15) o 100 is superior functioning *deinstitutionalization Mental illness in an ever-growing homeless population; overuse of emergency psychiatric services; not enough professionals in the community; promise of psychopharmacology not yet realized. Deinstitutionalization- started where people were out in the community and should not have been possibly so things were done to check up on individuals with group work and medication management etc. Nursing Diagnosis Process in Psych Mental Health Nursing slides 71-85 on pp 1 ( intro) PES- problem, etiology, supporting data (Maslows Hierarchy, Safety, Principle of Least Restrictive Intervention-use least restrictive ways first and then move to things like physical restraint if completely necessary for patient safety and safety of others priority in psych nursing is patient SAFETY first in order from greatest priority to least

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o physiological needs-food, breathing, rest, even sex o safety needs- security protection, order ( maybe knowledge of meds) o love and belonging needs-relationships, love o esteem- self-esteem related to competency and achievement o self-actualization-becoming everything one is capable of o self-transcendence-going beyond ego Nursing Advocacy Patient Autonomy We dont want to do everything FOR the patient..its best to encourage patient to do what they can for themselvesnurse need sto educate the patient though..give them the tools but dont do it for them Diathesis-Stress Model (neurobiological-genetic model) 23 diathesis-biological predisposition (nature stress-envrionmental stress or trauma (nuture) Stress Management is important concept throughout PMHN as is examining types of potential patient responses in psych mental health situations. What does it do the boyd mind and decision making Social Securitys 2 federal programs to help people with disabilities: (SSDI and SSI) and the difference for when a patient is eligible and what it provides (See Chapter 4, page 78) Social security disability insurance (SSDI)-program to help with disability for people who have worked a certain amount of time, paid social security, and have been disabled for more than 12 months Supplemental security income (SSI)-provides benefits for economical need, usually for people who have not worked; most have brain disorders Theorists: Freud: psychotherapy/psychodynamic process, (free association) o Id-(unconscious) the source that drives us such as genetics, reflexes, needs..id does not tolerate frustration and also does not think logically..no problem solving o Ego- (both conscious and unconscious) develops because of needs and wishes of the id can not be met good enough throughreflex action. Emerges in fourth or fifth month of life and it is the problem solver. So the ego takes what the id wants and decides what can be done about it and when which is called REALITY TESTING o Superego- (conscious) your personality, decides the should nots it seeks perfection as oppose to seeking wants o Defense mechanisms-enxiety produces pain and the ego develops defense mechanisms to the pain All defense mechanisms operate on an unconcisous level They deny, distort, or falsify reality to make it less threatening Compensation Conversion-unconscious transformation of anxiety to a physical symptom Denial Displacement-transfer of emotions associated with a particular person or place to a nonthreatening person or object o Transference-when the patient experiences feelings towards the nurse that were orgnially held towards significant other in the patients life o Countertransference-the healthcare workers unconscious personal response to the patient; for example if the patient reminds u of someone u dont like, u wont like the patient o Psychodynamic therapy uses free association, dream analysis, transference, and countertransference; this is a long term therapy and the therapists may interact freely with the patient o Stages page 27phallic- 3 to 6; identification of parent with same sex `oral- 0-1 conflict is weaning and development of trust Anal-1 to 3 toilet training; control over impulses phallic- 3 to 6; identification of parent with same sex latency- 6 to 12 skill to cope with environment genital- 12 and over; the ability to be creative and fine pleasure in love and work Erikson: phases of development (see word document on erikson) and page 29 Sullivan: interpersonal relationships; security operations slide 55 intro o Defined personality as behavior that can be observed within interpersonal relationships o The purpose of all behaviors is to get needs met through interpersonal interactions and to decrease or avoid anxiety

Security operations-measures and individual employs to reduce anxiety and enhance security All security operations make up the self system Built foundation for peplau; Sullivan believed in participant observer-the nurse need to empathize with patient and interact like a human being not a worker and also use an accepting atmosphere o Interpersonal psychotherapy- identifies problems ( grief, role disputes, role transition, and interpersonal deficit) and has solution to problems Peplau: Interpersonal Relationships; Therapeutic Communication; Phases of Nurse-Patient Relationship. o Enforced a major shift to interpersonal relationships- changed from what nurses do to patients to what nurses do with patients o o Implemented sullivans nursing care of anxiety to PMH o Phases of nurse patient relationship Orientation-define problem and explain roles in the situation Identification-goal setting Exploitation- explore problem solving techniques Resolution- the end of professional help, atient has resolved issues Beck and Cognitive Behavioral Therapy 60 intro o Based on cognitive psychology and behavior theory o Active and direct and time limited approach to treat variety of psych disorders o How people think and act is based on how they feel about the outside world o We all have schemas- how we feel about the outside world and we have rapid unthinking responses to it called automatic thoughts or cognitive distortions o Therapy is designed to identify cognitive distortions and correct them Skinner & Operant Conditioning o Behaviorist; voluntary responses are learned through consequences and reinforcement or punishment o Extinction is when there is no reinforcement anymore Ellis and Rational Emotive Behavioral Therapy 60 intor o Get rid of core irrational believes by helping people to recognize that these thoughts are not accurate o Describes negative thinking as A-B-C A-activating event B-beliefs about the event C-(emotional) consequences about the event Boundaries Confidentiality: managing during nurse-patient interactions; Milieu Management- (Bettelheim) use of total enviropnemnt for treatment (usually in children) A comfortable and secure environment-using paints to warm the atmosphere All inclusive, 24 hour sevice using the people, setting, and structure, and emotional climate to make the patient comfortable Uses naturally occurring events and makes them learning experiences Therapeutic Communication Techniques; Concept of consequences (179-184) o Using silence o Active listening o Listen with empathy o Clarifying techniques o Exploring..tell me more o Asking questions Cultural implications in Psych Mental Health Therapeutic communications (186) Medication/treatment considerations as provided in the textbook, Chapter 6 Stress and immune system (Ch. 11) Biological Basis: Neurotransmitters (dopamine; serotonin) o Dopamine- effects voluntary movement and motivation, "wanting", pleasure, associated with

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addiction and love ; it is decreased in Depression, increased in psychosis and mania Serotonin- plays a role in memory, emotion, wakefulness, sleep and temperature regulation ; it is decreased in depression, increased in anxiety

PET Scans/MRIs: how are they different both in administration and in what they examine (slide 5 scitz)

Functional techniques Positron emition tomography (PET) Injected radioactive tracer travels to brain and concentrates in areas of high activity Scanned images are relayed to a computer for three-dimensional imaging PET can show decreased glucose utilization (ADD), abnormalities in temporal lobes (mood disorders), and abnormalities in dopamine receptors and limbic system (schizophrenia) Single Photon Emission Computed Spectometry (SPECT) Similar to PET ; can detect circulation of cerebrospinal fluid Functionally, PET and SPECT scans identify physiological and biochemical changes in live tissue Structual techniques Computed tomomography (CT)-three dimensional imaging with radiographs CT scans can detect ventricle enlargement & general cortical atrophy (two indicators of schizophrenia) Magnetic resonance imaging (MRI)- three dimensional visualtion with magnetic fields and computed radio waves emitted by cells MRI can show enlarged ventricles and reduction in size of temporal and prefrontal lobes

Mental Status Examination and all that implies (types of thinking; thought content; thought process; affect/mood; language/verbiage; speech rhythm, etc.) see powerpoint concrete thinking (mental status exam-when u ask the patient what brought u here and the patient says a cab that is concrete thinking rather than saying Schizophrenia: Symptoms: negative and positive o Positive symptoms-presence of something that is not normally there Hallucinations Delusions Bizarre behaviormaybe aggressive Disorganized thought and speech Inappropriate affect (emotion) o Negative-absence of something that is normally there but now is not Affective flattening-showing no emotions by facial and speech Alogia-not speaking Avolition, apathy- decreased movement, poor hygiene, reduced task completion Attention defecits Reduced ability to read others emotions Language/verbiage (clanging; neologisms; etc.) o Neologisms-made up words o Echolalia-repeating of anothers words (often seen in catatonia) o Echopraxia-mimicking of movement of others o Clang association-choice of words based on sound and rhyming instead of reason of the workd o Word salad- jumble of meaningless words Hearing voices/nursing therapeutics o Speak to patient by name and speak louder o Be non threatening and remain eye contact and try to bring patient back to conversation o Non judgmental Antipsychotic medications: typical and atypical Uses; Side effects and nursing as well as pharmacological considerations

o Example: clozaril/clozapine - agranulocytosis Classifications (know your antipsychotics from drug list) Neuroleptic Malignant Syndrome (NMS) Schizophrenia slides and in Chapter 15 o Psychopharmacology Drug List Extrapyramidal symptoms o Treatment-Anticholergenics (benedryl, Cogentin, akineton) o Tardive dyskinesia and prevention of if possible Persistent EPS Toungue perfusion, fish like movment of mouth Involuntary tonic muscle contrations Early symptom is constant smacking of the lips or uncontrollable biting or chewing o Dystonias (types of crises) and treatment for Acute sustained muscle contractions of the head and neck Could be prevented by lowering does and adding anticholergins such as Benadryl, Cogentin, and akineton Phases page 320-325 o Outcome identification Phase 1-if acute, the first phase is patient safety and medical stabilization Phase 2-helping patient become stable and adhere to treatment Phase 3-maintaning achievement and preventing relapse o Planning Phase 1-hospitalization for patient safety 2-patient and family education and relapse prevention o Implementation Determine necessary level of care for placement such as halfway house, day treatment, residential crisis center, or partal hospitalization Stabilization and maintenance depends on the person but is focused around psychoeducation and preventing relapse Table 15-1-types of delusions o Control-believeing that someone else or external force controls your thoughts, feelings, and behaviors o Ideas of reference-giving personal significance to trivial events; perceiving events as being related to u when they r not..ex. see people talking and think they r plotting against u o Persecution-believeing that one is being singled out for harm..usually as a plot by people In power such as the government o Grandeur-believeing that one is very powerful or important person o Somatic delusions-beliveing that the body is changing in an unusual way..ex. believing your insides r rotting away and heart has stopped o Erotomanic- believeing that another person desires u romantically o Jealousy-believeing that ones mate is unfaithful Dopamine pathways? o dopamine pathways (mesolimbic, nigrostriatal, mesocortical, tubero infundibular)

Catatonia and nursing care (priority nursing care: passive range of motion activities for those not moving; nursing application: do not just touch a patient; tell them when you are in the room; in short statements tell them when you are going to touch them and why . . . keep muscles limber and joints free. . . speak to them about everything because they do hear and have thoughts and feelings and they are responding even if you cannot see it). There are practice exams on Blackboard for you. Go to the Evolve Website of your Course Textbook (Varcarolis: Foundations of Psychiatric Mental Health Nursing, 6 Edition *Resources+). Go to Prepare for Class, Clinical, or Lab: Review the Answer Key for Chapter Review Answers and Rationales and go through the Prepare for Exams. Do this with each and every test in this course. You will be glad you did. I encourage you to also review all HESI practice quizzes (not necessarily for these tests but just to take advantage of them. You will be glad you did.
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Typical Antipsychotics 2. Improve the thought processes and the behavior of the client with psychotic symptoms, especially clients with schizophrenia 3. Affect dopamine receptors in the brain, reducing the psychotic symptoms 4. More common for weight gain Typical antipsychotics are more effective for positive symptoms of schizophrenia, such as hallucinations, aggression, and delusions

Haldol Loxitane Moban Mellaril Prolixin Serentil Stelazine Thorazine( risk for sunburn) Trilafon Navane

haloperidol loxapine molindone thioridazine fluphenazine mesidazine trifluperazine chlorpromazine perphenazine Thiothixene

typical antipsychotics are strong dopamine antagonist and block the dopamine receptors atypical (better for negative symptoms of schizophrenia)
Negative symptoms refer to a diminishment or absence of characteristics of normal function. They may appear with or without positive symptoms. They include: Loss of interest in everyday activities Appearing to lack emotion Reduced ability to plan or carry out activities Neglect of personal hygiene Social withdrawal Loss of motivation

atypical Clozaril (slide 7 schtz) Strongest but worst side effectsblood work once a week and check wbc Risperidal/ Zyprexa Seroquel Geodon Abilify Ivega Fanapt Saphris (sublingual) Latuda risperidone olanzapine quetiapine Ziprasidone aripiprazole paliperidone iloperodone asenapine lurasidone Clozapine

Description 5. Improve the thought processes and the behavior of the client with psychotic symptoms, especially clients with schizophrenia 6. Affect dopamine receptors in the brain, reducing the psychotic symptoms 7. Typical antipsychotics are more effective for positive symptoms of schizophrenia, such as hallucinations, aggression, and delusions 8. Atypical antipsychotic medications also block the chemoreceptor trigger zone and vomiting center in the brain, producing an antiemetic effect. 9. Atypical antipsychotics are more effective for the negative symptoms of schizophrenia, such as avolition, apathy and alogia. 10. The effects of antipsychotic medications are potentiated when given with other medications acting on the CNS. Side Effects Anticholinergic Effects 1. Dry mouth 2. Increased heart rate 3. Urinary retention 4. Constipation 5. Hypotension Extrapyramidal Side Effects (EPS) Monitor for extrapyramidal side effects in the client taking an antipsychotic medicationParkinsonism 1. Tremors

2. Mask-like facies 3. Rigidity 4. Shuffling gait 5. Dysphagia 6. Drooling Dystonias 1. Abnormal or involuntary eye movements, including oculogyric crisis 2. Facial grimacing 3. Twisting of the torso or other muscle groups Akathisia 1. Restlessness 2. Constant moving about Tardive Dyskinesia 1. Protrusion of the tongue 2. Chewing motion 3. Involuntary movements of the body and extremities Other Side Effects 1. Drowsiness 2. Blood dyscrasias 3. Pruritus 4. Photosensitivity (thorazine) 5. Elevated blood glucose level, dyslipidemia 6. Increased weight 7. Quetiapine (Seroquel) has increased risk of cataracts. It is recommended client have an eye exam prior to treatment and every six months thereafter. 8. Impaired body temperature regulation 9. Gynecomastia 10. Lactation Interventions 1. Monitor Vital signs For symptoms of neuroleptic malignant syndrome (NMS)(can occur with antipsychotic medications) Urine output Serum glucose level For EPS (TD) using the Abnormal involuntary Movement Scale (AIMS) 2. Administer medication with food or milk to decrease GI irritation For oral use, the liquid form might be preferred because some clients hide tablets in their mouths to avoid taking them The absorption rate is faster with the liquid form of oral medication Avoid skin contact with the liquid concentrate to prevent contact dermatitis Protect the liquid concentrate from light Dilute the liquid concentrate with fruit juice (Not Grapefruit Juice) 3. Inform the client that a full therapeutic effect of the medication may not be evident for 3 to 6 weeks after initiation of therapy; however, an observable therapeutic response may be apparent after 7 to 10 days 4. Inform the client that some medications may cause a harmless change in urine color to pinkish to redbrown 5. Instruct the client to use sunscreen, hats, and protective clothing when outdoors avoid alcohol or other CNS depressants change positions slowly to avoid orthostatic hypotension

report signs of agranulocytosis, including sore throat, fever, malaise report signs of liver dysfunction, including jaundice, malaise, fever, and right upper abdominal pain 6. When discontinuing antipsychotics, the medication dosage should be reduced gradually to avoide sudden recurrence of psychotic symptoms. Neuroleptic Malignant Syndrome (NMS) Description 1. Neuroleptic malignant syndrome (NMS) is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications 2. Although rare, NMS more commonly occurs at the initiation of therapy, after the client has changed from one medication to another, after a dosage increase, or when a combination of medications is used Assessment 1. Dyspnea or tachypnea 2. Tachycardia or irregular pulse rate 3. Fever 4. High or low blood pressure 5. Increased sweating 6. Loss of bladder control 7. Skeletal muscle rigidity, lead pipe rigidity 8. Pale skin 9. Excessive weakness or fatigue 10. Altered level of consciousness 11. Seizures 12. Severe extrapyramidal side effects (EPS) 13. Difficulty swallowing 14. Excessive salivation 15. Oculgyric crisis 16. Dyskinesia 17. Elevated white blood cell count, liver function results, and creatine phosphokinase level Interventions 1. Notify the physician 2. Monitor vital signs 3. Initiate safety and seizure precautions 4. Prepare to discontinue the medication 5. Monitor level of consciousness 6. Administer antipyretics as prescribed 7. Use a cooling blanket to lower the body temperature 8. Monitor electrolyte levels and administer fluids IV as prescribed Antipsychotic Medications Typical Antipsychotics Chlorpromazine (Thorazine) Pimozide (Orap) Fluphenazine decanoate (Prolixin Decanoate) Thiothixene (Navane) Haloperidol (Haldol) Trifluoperazine (Stelazine) Loxapine (Loxitane) Molindone (Moban)

Atypical Antipsychotics Aripiprazole (Abilify) Clozapine (Clozaril) Olanzapine (Zyprexa) Paloperidone (Invega)

Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)

Lurasidone (Latuda) Asenapine (Saphris) Iloperidone (Fanapt)

What is EPS? What are the symptoms of tardive dyskinesia? What is the oculogyric crisis and how is it treated? How do the symptoms of NMS differ from those of Serotonin syndrome? What is the treatment for NMS?