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NCLEX-RN PREPARATION PROGRAM. MENTAL HEALTH DISORDERS Module 6, Part 2 of 3. Major Mental Health Disorders. PERSONALITY DISORDERS (PD) Diagnostic criteria (Axis II, DSM-IV): “Enduring pattern of inner experience & behavior that deviates from expectations in 2 or more areas”:

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Nclex rn preparation program

NCLEX-RN PREPARATION PROGRAM

MENTAL HEALTH

DISORDERS

Module 6, Part 2 of 3


Major mental health disorders
Major Mental Health Disorders

PERSONALITY DISORDERS (PD)

  • Diagnostic criteria (Axis II, DSM-IV): “Enduring pattern of inner experience & behavior that deviates from expectations in 2 or more areas”:

    • Cognition

    • Affectivity

    • Interpersonal functioning

    • Impulse control

  • Hinders one’s ability to

    • Maintain meaningful relationships

    • Feel fulfilled & enjoy life

    • Adjust psychosocially (cope)


Personality Disorder Clusters

A. Odd-eccentric

  • Paranoid

  • Schizoid

  • Schizotypal

B. Dramatic-Emotionally Erratic

  • Borderline (BPD)

  • Antisocial (APD)

  • Narcissistic

  • Histrionic

C. Anxious-Fearful Dependent

  • Obsessive-Compulsive

  • Avoidant


Personality disorders cluster a odd eccentric
Personality DisordersCluster A: Odd-Eccentric

A profound deficit in the ability to form personal relationships or respond to others in a meaningful way. Appear indifferent, aloof and/or unresponsive to praise or criticism. Typically have no close friends and prefer to be alone. Social detachment and consequent impairment in social & occupational functioning.

  • Paranoid - pervasive distrust

  • Cognitive impairment is more serious with Cluster A personality disorders than with cluster B & C disorders

  • Most peculiar & maladaptive defensive styles

  • Observed in families with schizophrenia, especially schizotypal


Personality disorders cluster b dramatic and emotional
Personality DisordersCluster B: Dramatic and Emotional

  • Present oriented and want immediate gratification

  • Act without evaluating consequences (impulsive)

  • BPD more likely to hurt self. APD more likely to aggress outward

  • APD commonly involved in criminal activities and lack remorse or guilt - emotionally retarded

  • Self-centered and manipulative

  • Splitting (the inability to integrate the positive and negative qualities of oneself or others into a cohesive image)


Personality disorders cluster c anxious fearful
Personality DisordersCluster C: Anxious-Fearful

  • Present as primarily anxious or fearful

  • Experience impairment as

    • Restricted affect: problems expressing feelings

    • Non-assertiveness, avoids conflict

    • Unrealistic expectations of others

    • Rely on others for support and decision-making

    • Unable to function without a partner or family member - stays in abusive relationship rather than be alone


Bistro of the Personality Disorders (PDs)

Schizoid - Orders home delivery; ingests food through mail slot

Schizotypal - Eats soup using gardening equipment & chop sticks

Paranoid - Sits with back to the wall; spies on food prep area

Antisocial P.D. - Steals tip left by narcissist

Borderline P.D. - When informed her boyfriend plans to go duck hunting, throws a drink at him, then uses glass to cut self

Histrionic - Does a belly dance in the center of the restaurant

Narcissist - Expects best table without a reservation

Avoidant - Tips generously for take-out service

Dependent - Vegetarian non-smoker eats veal in smoking area

to please date

OCPD - Aligns cutlery & dispenses etiquette tips


Personality disorders interventions
Personality Disorders Interventions

  • Establish therapeutic relationship

    • Control

    • Milieu therapy

  • Provide experienced, consistent staff

  • Implement a structure with rules that are firm & consistently enforced (limit setting with consequences)

  • Protection from self-harm

  • Modify impulsive behavior

  • Incorporate behavioral strategies


Personality disorders interventions continued
Personality Disorders Interventions (continued)

  • Medications have a limited role:

    Decrease impulsivity, mood swings, anxiety

  • Teach how to get needs met without manipulation

  • Maintain matter-of-fact but caring approach; mobilize healthy aspects of personality


Personality disorders goals
Personality DisordersGoals

  • Less impulsive

  • Able to meet needs without manipulating

  • Increased satisfaction with quality of relationships

  • Participates in close relationships

  • Expresses recognition of positive behavioral change


A client recently released from prison for embezzlement has a history of becoming defensive and angry when criticized and blaming others for personal problems. The client has expressed no remorse or emotion about the actions that resulted in the prison term, but instead says that the embezzlement was justifiable because the employer “did not treat me fairly.” The nurse concludes these behaviors are consistent with which of the following mental health problems?

  • A. Narcissistic personality disorder

  • B. Histrionic personality disorder

  • C. Antisocial personality disorder

  • D. Borderline personality disorder


Which intervention strategy should the nurse routinely include in the nursing care plan for a client with antisocial personality disorder?

  • A. Establish clear and enforceable limits.

  • B. Vary unit rules based on client demands.

  • C. Vary unit rules based on staff needs.

  • D. Let the client have a voice in when unit

    rules should apply.


Anxiety disorders
Anxiety Disorders include in the nursing care plan for a client with antisocial personality disorder?

Description

An unrealistic fear in which the cause may or may not be identified.

  • Symptoms: Anxiety and avoidance behavior

  • Familial predisposition

  • Results from

    • Exposure to traumatic and stressful life events

    • Observing others experiencing trauma or behaving fearfully

    • Vicariously through watching movies and TV

  • Physical symptoms occur


Anxiety disorders1
Anxiety Disorders include in the nursing care plan for a client with antisocial personality disorder?

Central Features

  • Pervasive anxiety

  • Feelings of inadequacy

  • Tendency to avoid

  • Self-defeating behavior blocks growth

  • Can stimulate action to alter stressful situation

  • Most symptoms of the body involved

  • See physician vs. psychiatrist for treatment


Anxiety disorders2
Anxiety Disorders include in the nursing care plan for a client with antisocial personality disorder?

Assessment

  • Restlessness and inability to relax

  • Episodes of trembling and shakiness

  • Chronic muscular tension

  • Dizziness

  • Inability to concentrate

  • Fatigue and sleep problems

  • Inability to recognize connection between

    anxiety and physical symptoms

  • Focused on the physical discomfort


Anxiety disorders generalized anxiety disorder
Anxiety Disorders include in the nursing care plan for a client with antisocial personality disorder?Generalized Anxiety Disorder

GAD

  • Chronic excessive worry about a number of events or activities for at least 6 months.

    • History of uncontrollable & unpredictable life stress -prone to Generalized Anxiety Disorder (GAD)

    • Unrealistic/excessive

    • Motor tension, autonomic hyperactivity, apprehensive expectations, vigilance & scanning

  • Experiences at least 3 of the following:

    • Restlessness, fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance


Anxiety disorders panic disorders
Anxiety Disorders include in the nursing care plan for a client with antisocial personality disorder?Panic Disorders

Panic Disorders

  • Panic Disorder - discrete episode of intense fear

    Sense of impending doom, helplessness, or being trapped

    Peaks within 10 minutes

    Occurs unexpectedly and on an intermittent basis

    Concern about additional attacks

  • Panic Disorder with agoraphobia

    Avoidance of places or situations in which escape is difficult or help not available in the event of a panic attack (i.e., outside the home alone, being in a crowd…)


Anxiety disorders post traumatic stress disorder
Anxiety Disorders include in the nursing care plan for a client with antisocial personality disorder?Post-traumatic Stress Disorder

PTSD

  • Development of physiologic/behavioral symptoms following a psychologically traumatic event

  • A traumatic event is unavoidable (terrorist attacks, war, rape, crime events, disasters, fires, childhood sexual abuse, kidnapping, hostages)

  • Before exposure did not have psychological problems

  • Symptoms include: re-experiencing the trauma, avoiding reminders of the trauma, numbing of affect


Anxiety disorders phobic disorders
Anxiety Disorders include in the nursing care plan for a client with antisocial personality disorder?Phobic Disorders

Phobic Disorders

  • Social phobia -

    • Fear of scrutiny (evaluated or judged) by others

    • Fearful of doing something or acting in a way that will be humiliating or embarrassing

  • Specific Phobia

    • Persistent irrational fears of specific objects or situations

    • i.e., Animals (zoophobia), fear of closed places (claustrophobia), & fear of heights (acrophobia)

    • What are some other common phobias?


  • Anxiety disorders obsessive compulsive disorder
    Anxiety Disorders include in the nursing care plan for a client with antisocial personality disorder?Obsessive-Compulsive Disorder

    OCD

    • Obsessions

      • Unwanted, persistent, & intrusive thoughts, impulses or images that cause anxiety or distress

    • Compulsions

      • Irrational impulse to act

      • Behaviors or mental rituals performed to neutralize/prevent the distressing thoughts or images

    • Thoughts about dirt, contamination and danger most common obsessions; cleaning & checking for danger most common ritual


    Anxiety disorder medications
    Anxiety Disorder include in the nursing care plan for a client with antisocial personality disorder?Medications

    • Buspirone (Buspar)

      • Minimal CNS depressant actions

      • Does not enhance effects of alcohol, barbiturates & other general CNS depressants. Takes several weeks to establish effectiveness.

    • Benzodiazpam

      • Adverse effects:

        • CNS Depression

        • Amnesia

        • Respiratory Depression

        • Dependence and abuse

        • E.g. Valium, Librium, Xanax


    Anxiety disorder medications1
    Anxiety Disorder Medications include in the nursing care plan for a client with antisocial personality disorder?

    • Beta-adrenergic blocking agents such as propranolol (Inderal) can relieve symptoms caused by autonomic hyperactivity

    • Selective Serotonin Reuptake Inhibitors (Paxil, Proxac…), Tricyclic Antidepressants (Imipramine - Tofranil)

    • Barbituates

      • CNS depression

      • High abuse potential

      • Powerful respiratory depressants with strong potential for fatal overdose


    Anxiety disorder assessment
    Anxiety Disorder include in the nursing care plan for a client with antisocial personality disorder?Assessment

    • Take steps to lower anxiety level

    • Encourage trust/calm approach

    • Assess current feelings

    • What happened immediately prior to onset?

    • Client’s perspective of situation

    • Thought processes

    • Affect, expression, nonverbal behaviors

    • Communication ability, thought blocking


    Anxiety disorder interventions
    Anxiety Disorder include in the nursing care plan for a client with antisocial personality disorder?Interventions

    • Establish trusting relationship

    • Nurses’ self-awareness

    • Recognition of anxiety

    • Insight into anxiety

    • Modifying environment

    • Encouraging activity

    • Promote relaxation response

    • Learn new ways to cope with stress

    • Medication

    • Goal: Client will demonstrate adaptive ways of coping with stress


    A client who is hospitalized for panic disorder is experiencing increased anxiety. The client exhibits selective inattention and tells the nurse, “I’m anxious now.” The nurse determines that the degree of the client’s anxiety is:

    • A. Mild

    • B. Moderate

    • C. Severe

    • D. Panic


    During an assessment interview, the client tells the nurse, “I can’t stop worrying about my makeup. I can’t go anywhere or do anything unless my makeup is fresh and perfect. I wash my face and put on fresh makeup at least once and sometimes twice an hour.” The nurse’s priority should be to adjust the client’s plan of care so the client will be:

    A. Required to spend daytime hours out of own room

    B. Given advance notice of approaching time for all group therapy sessions

    C. Asked to keep a diary of feelings experienced if unable to groom self at will

    D. Allowed to use own cosmetics and grooming products


    A client asks why a beta blocker (Inderal) medication has been prescribed for anxiety. When answering this question, the nurse should explain that this medication class is effective for treatment of which symptoms associated with anxiety?

    A. Cognitive dissonance and confusion

    B. Depression and suicidal ideations

    C. Insomnia and nightmares

    D. Palpitations and rapid heart beat


    Somatoform disorders
    Somatoform Disorders been prescribed for anxiety. When answering this question, the nurse should explain that this medication class is effective for treatment of which symptoms associated with anxiety?

    Focus: Physical symptoms with

    absence of a pathophysiological problem

    • Somatization Disorder

    • Hypochondriasis

    • Conversion Disorder

    • Pain Disorder

    • Body Dysmorphic Disorder


    Somatoform Disorders been prescribed for anxiety. When answering this question, the nurse should explain that this medication class is effective for treatment of which symptoms associated with anxiety?

    Somatization Disorder

    • Involvement of multiorgan system symptoms: pain, GI, sexual, pseudoneurological

    • Lack physical signs or structural abnormalities

    • Different than hypochondriasis in that preoccupation occurs only during episode

      Hypochondriasis

    • Preoccupation with fear of having serious illness and hypersensitive to body functions

    • Becomes central feature of self-image, topic of social interaction and response to life stresses


    Somatoform disorders1
    Somatoform Disorders been prescribed for anxiety. When answering this question, the nurse should explain that this medication class is effective for treatment of which symptoms associated with anxiety?

    Conversion Disorder

    • A symptom or deficit that affects motor or sensory functioning

    • Inappropriately unconcerned about symptoms

    • Symptoms remit within 2 wks, recurrence common

    • Common symptoms are blindness, deafness, paralysis and the inability to talk

      Pain Disorder

    • Preoccupation with pain after confirmation of absence of pathophysiologic causes


    Somatoform disorders2
    Somatoform Disorders been prescribed for anxiety. When answering this question, the nurse should explain that this medication class is effective for treatment of which symptoms associated with anxiety?

    Body Dysmorphic Disorder

    • Preoccupation with an imagined/exaggerated defect in physical appearance

    • Crooked lip, bumpy nose, falling face

  • Somatoform Interventions: Client education

    • Medications, Rx, lifestyle changes, ways to cope with anxiety & stress, relaxation training, physical activity

  • Goal: Client will express feelings verbally rather than through physical symptoms


  • An older client with chronic low back pain receives cooking and cleaning help from her extended family. The mental health nurse anticipates that this client benefits from which of the following in this situation?

    A. Primary gain

    B. Secondary gain

    C. Attention-seeking

    D. Malingering


    What would the nurse expect a client who has a somatization disorder to reveal in the nursing history?

    A. Abrupt onset of physical symptoms at menopause

    B. Episodes of personality dissociation

    C. Ignoring physical symptoms until role performance

    was altered

    D. Numerous physical symptoms in many organ areas


    A client treated for hypochondriasis would demonstrate understanding of the disorder by which statement to the nurse?

    A. “I realize that tests and lab results cannot pick up on the seriousness of my illness.”

    B. “Once my family realizes how severely ill I am, they will be more understanding.”

    C. “I know that I don’t have a serious illness, even though I still worry about my symptoms.”

    D. “I realize that exposure to toxins can cause significant organ damage.”


    Dissociative disorders
    Dissociative Disorders understanding of the disorder by which statement to the nurse?


    Dissociative disorders1
    Dissociative Disorders understanding of the disorder by which statement to the nurse?

    • Avoids stress by dissociating self from core personality, characterized by sudden or gradual disruption in identity, memory or consciousness

      • Dissociative Amnesia

      • Dissociative Fugue

      • Dissociative Identity Disorder

      • Depersonalization Disorder


    Dissociative disorders2
    Dissociative Disorders understanding of the disorder by which statement to the nurse?

    Dissociative Amnesia

    • Inability to recall important personal information

    • Too extensive to be explained by ordinary forgetfulness

      Dissociative Fugue

    • Sudden, unexpected travel away from home or work

    • Inability to recall one’s past

    • Confusion about personal identity (ID) or assumption of a new ID


    Dissociative disorders3
    Dissociative Disorders understanding of the disorder by which statement to the nurse?

    Dissociative Identity Disorder

    • Formally “Multiple Personality Disorder”

    • Presence of 2 or more distinct identities that recurrently take over behavior

    • Inability to recall important personal info

    • Identity fragmentation

    • Often a history of physical &/or sexual abuse

      Depersonalization Disorder

    • Recurrent feeling of being detached from one’s mental processes or body

    • Intact reality testing


    Dissociative disorders interventions
    Dissociative Disorders: Interventions understanding of the disorder by which statement to the nurse?

    • Development of insight

    • Identify stressors

    • Clarify beliefs in relationship to feelings and behaviors

    • Explore use of coping resources

    • Decrease anxiety through stress management

      Goal

    • Obtain the maximum level of self-actualization to realize potential


    The spouse of a client who is experiencing a fugue state asks the nurse if the spouse will be able to remember what happened during the time of fugue. What is the nurse’s best response?

    A. “Your spouse will probably have no memory for events during the fugue.”

    B. “Your spouse will be able to tell you – if you can gently encourage talking.”

    C. “It is not possible to predict whether your spouse will remember the fugue state.”

    D. “Avoid mentioning it, or your spouse may start alternating old and new identities.”


    Mood disorders major depressive disorder and bipolar disorders
    Mood Disorders: Major Depressive Disorder and Bipolar Disorders

    Mood Disorder

    A mood disorder is characterized by:

    • Depressed mood or cycles of depressed and elated mood

    • Feelings of hopelessness and helplessness

    • Decrease in interest or pleasure in usual activities


    Mood disorders major depressive disorders
    Mood Disorders: Major Depressive Disorders Disorders

    Depression Models of Causation

    • Biological factors

      • Serotonin, norepinephrine, and acetylcholine deficiencies

      • Effect of light on mood

    • Genetic factors

      • Familial predisposition

    • Situational, physiological, and psychosocial stressors

    • Learned hopelessness and helplessness and a negative self-view


    Mood disorders
    Mood Disorders Disorders

    Depression: Signs and Symptoms

    • Cognitive: Difficulty concentrating, focusing, and problem solving; ambivalence, confusion, sleep disturbances

    • Loss of interest or motivation, anhedonia

    • Decrease in personal hygiene

    • Anxiety, worthlessness, helplessness, hopelessness

    • Psychomotor retardation/agitation

    • Vegetative signs: Hypersomnia, slowed bowel function

    • Risk of harm to self or other: Suicidal ideation or thoughts, self-destructive acts, violence, overt hostility often connected with suicidal thoughts


    Mood disorders1
    Mood Disorders Disorders

    Depression: Psychotrophics

    • Selective Serotonin Reuptake Inhibitors

      • Rapid onset, fewer side effects, higher rate of compliance, lower overdose harm

      • Citalopram (Celexa)

      • Paroxetine (Paxil)

      • Fluoxetine (Prozac)

      • Sertraline (Zoloft)

      • Escitalopram (Lexapro)

      • Fluvaxamine (Luvox)


    Mood disorders2
    Mood Disorders Disorders

    SSRI Considerations

    Selective Serotonin Reuptake Inhibitors (SSRIs):

    • Physical assessment: renal, liver function, seizures

    • Agitation vs. vegetative symptoms

    • Level of anxiety

    • Ease of compliance

    • Risk for suicide by overdose


    Mood disorders3
    Mood Disorders Disorders

    Serotonin Syndrome

    • Cause: Excess Serotonin at receptor sites

    • Onset 3-9 days

    • Symptoms: fever, confusion, restlessness, agitation,

      hyper-reflexia, diaphoresis, shivering, diarrhea, fever,

      poor coordination

    • Triggered by high doses, concurrent MAOI, lithium or Trazadone administration

    • Interventions: Hold meds, notify MD, give P.O. fluids, supervise and support patient, antipyretics, cooling blanket

    • Resolves without specific treatment over 24 hours


    Mood disorders4
    Mood Disorders Disorders

    Depression: Psychotrophics

    • Novel antidepressants:

      • Bupropion (Wellbutrin)

      • Nefazadone (Serzone)

      • Trazadone (Desyrel)

      • Venlafaxine (Effexor)

      • Mirtazipine (Remeron)

      • Duloxetine (Cymbalta)


    Mood disorders5
    Mood Disorders Disorders

    Depression: Psychotrophics

    • Tricyclic antidepressants

      • Amitriptyline (Elavil)

      • Clomipramine (Anafranil)

      • Desipramine (Norpramin)

      • Doxepin (Sinequan)

      • Imipramine (Tofranil)

      • Nortriptyline (Pamelor)

      • Trimipramine (Surmontil)


    Mood disorders6
    Mood Disorders Disorders

    Depression: Psychotrophics

    • Monoamine Oxidase Inhibitors

      • Tranylcypromine (Parnate)

      • Phenelzine (Nardil)

      • Isocarboxazid (Marplan)

      • Tyramine-rich foods to avoid: aged cheese, sausage, beer on tap, sauerkraut, soy sauce,red wine

      • OTC cold remedies, tricyclic antidepressants, narcotics, antihypertensives, stimulants


    Mood disorders7
    Mood Disorders Disorders

    Nursing Interventions for Depression:

    • Maintain safety

    • Question negative beliefs

    • Encourage activities to increase self-esteem

    • Encourage ADLs

    • Encourage physical activity

    • Medication teaching

    • Milieu, group and/or individual therapy

      Goals

    • No self-harm

    • Resolution of negative self-image and situational insight

    • Restoration of normal physical functioning

    • Medication compliance, relapse prevention


    The nurse has explained to a client the biologic theories of depression. The nurse concludes that the teaching has been effective if the client says, “I now know that my depression may be caused from:

    A. Excessive serotonin activity in the central nervous system (CNS).”

    B. Insufficient serotonin activity in the CNS.”

    C. Excessive norepinephrine in the CNS.”

    D. Insufficient acetylcholine activity in the CNS.”

    E. A genetic mutation on chromosome 6.”


    A 63-year-old male client expresses feelings of hopelessness and helplessness about his spouse’s illness and anticipated death. On which of the following issues should the nurse initially assist the client to focus?

    A. The nature of the spouse’s present illness

    B. The client’s response to past losses

    C. The dying spouse’s feelings about impending loss and death

    D. The client’s relationship with the spouse


    Mood disorders bipolar disorder
    Mood Disorders: Bipolar Disorder and helplessness about his spouse’s illness and anticipated death.

    Bipolar Disorder

    • A mood disorder, formerly known as manic depression, characterized by recurrent and typically alternating episodes of depression and mania.

    • Either phase may be predominant at any given time or elements of both phases may be present simultaneously.


    Mood disorders8
    Mood Disorders and helplessness about his spouse’s illness and anticipated death.

    Bipolar Disorder

    • Biological Factors

    • Possible excess of norepinephrine, serotonin and dopamine

    • Increased intracellular sodium and calcium

    • Neurotransmitters supersensitive to transmission of impulses

    • Defective feedback mechanism in limbic system


    Mood disorders9
    Mood Disorders and helplessness about his spouse’s illness and anticipated death.

    Bipolar Disorder: Signs and Symptoms of Mania

    • Impulsivity: Spending money, giving away money or possessions, hypersexual behavior

    • Racing thoughts, hyper-social

    • Increased activity, grandiose view of self and abilities

    • Mood elation, progressively more hostile

    • Speech loud, jovial, pressured

    • Poor judgment

    • Reduced sleep

    • Impairment in social and occupational functioning


    Mood disorders10
    Mood Disorders and helplessness about his spouse’s illness and anticipated death.

    Bipolar Disorder: Psychotrophics

    • Lithium Carbonate (Carbolith, Eskalith..)

    • Anticonvulsants

      • Valproate, (Depakote)

      • Carbamazepine (Tegretol)

      • Gabapentin (Neurontin)

      • Topiramate (Topamax)

      • Lamotrogene (Lamictal)

    • Benzodiazapines

    • Antipsychotics such as Olanzapine (Zyprexa) and Arpiprazole (Abilify)

    • Electroconvulsive therapy


    Mood disorders11
    Mood Disorders and helplessness about his spouse’s illness and anticipated death.

    Bipolar Disorder: Medical Management

    • Lithium can have potentially harmful effects on the kidney, thyroid gland, heart and developing fetus

    • Pre-lithium treatment lab tests

      • Thyroid Function Tests (e.g. TSH),

      • CBC (benign elevation of WBCs),

      • BUN, serum creatinine, electrolytes

      • Urinalysis,

      • ECG,, pregnancy test

      • During Lithium treatment: TSH, BUN, serum creatinine, ECGs every 6 to 12 months


    Mood disorders12
    Mood Disorders and helplessness about his spouse’s illness and anticipated death.

    Bipolar Disorder: Medical Management

    Lithium

    • Monitor serum levels or lithium (0.5-1.0 mEg/L) to prevent toxicity and confirm compliance. Report sub-therapeutic or toxic levels to prescribing practitioner

    • Encourage adequate hydration and adequate dietary salt

    • Therapeutic improvement takes 1-3 weeks

    • Tremors and a metallic taste are side effects

      Anticonvulsants as Mood Stabilizers

    • Monitor serum levels every 2-4 months (liver function tests, complete blood count, electrolytes, ECG, pregnancy test every 6-12 months)


    Mood disorders13
    Mood Disorders and helplessness about his spouse’s illness and anticipated death.

    Bipolar Disorder Nursing Interventions and Goals

    • Maintain physical safety (self harm, assault, impulse control, exhaustion)

    • Decrease sensory stimulation

    • Establish normal sleep/rest cycle

    • Establish adequate food/fluid intake

    • Limit escalation of behavior

    • Provide reality orientation

    • Psychoeducation: Disease process, target symptoms, self monitoring, alternative coping behaviors, self-care measures, medication management, medication compliance, laboratory monitoring, side effect management, community resources, relapse prevention, reinforce abstinence from drugs and alcohol


    The client has bipolar I disorder. Lithium carbonate (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    A. “Minor hand trembling often happens for a few days after Lithium is started. It usually decreases in 1 to 2 weeks.”

    B. “There’s no reason to worry about that. We won’t, unless it lasts longer than a couple of weeks.”

    C. “Just in case your blood level is too high, I am not going to give you your next dose of Lithium.”

    D. “I wouldn’t worry about it if I were you. It’s a small tremor that doesn’t interfere with your functioning.”


    Thought disorders
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia

    • Involves disturbances in:

      • Reality, thought processes, perception, affect, social and occupational functioning

      • 1.5% of the population

      • 75% of cases diagnosed between ages 17 and 25

      • Causation: Heredity/genetic transmission, psychodynamics, stress, drug abuse, excessive dopamine. CT and MRI studies show decreased brain volume, enlarged ventricles, deeper fissures, and/or underdevelopment of brain tissue


    Thought disorders1
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Types

    • Catatonic

    • Disorganized

    • Paranoid

    • Undifferentiated

    • Residual


    Thought disorders2
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Types

    • Catatonic Type

      Catatonic stupor, evidenced by extreme psychomotor retardation and posturing, and catatonic excitement, extreme psychomotor agitation with purposeless movements that may harm self or others


    Thought disorders3
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Types

    • Disorganized Type

      Flat or inappropriate affect (such as silliness or giggling), bizarre behavior and social impairment

    • Paranoid Type

      Paranoid delusions in which the individual falsely believes that others are out to harm him/her. The individual may be hostile, argumentative and aggressive


    Thought disorders4
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Types

    • Undifferentiated Type

      Bizarre behavior that does not meet the criteria of other types of schizophrenia. Delusions and hallucinations are prominent

    • Residual Type

      Individual who has had one major episode of schizophrenia with prominent psychotic symptoms and who has lingering symptoms


    Thought disorders5
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Diagnostic Criteria

    • Delusions, hallucinations, disorganized speech and/or behavior

    • Social and/or occupational impairment

    • Symptoms for at least 6 months

    • Not attributable to another disorder


    Thought disorders6
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia:

    Positive and Negative Symptoms

    • Positive: delusions, hallucinations, bizarre behavior, agitation, pressured speech, suicidal ideation

    • Negative: Flat affect, poor eye contact, withdrawal, anhedonia, poverty of speech, apathy, inattention, lack of motivation


    Thought disorders7
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia:

    Positive Signs and Symptoms

    • Hallucinations: Auditory, visual, olfactory, gustatory, tactile

    • Illusions: False interpretations of external sensory stimuli and inappropriate responses to the perception.

    • Alterations in thinking

      Delusions - Fixed false beliefs (grandiose, persecutory, somatic…)

      Thought broadcasting, insertion

    • Ideas of reference

    • Flight of ideas

    • Thought/language disruption


    Thought disorders8
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia:

    Co-Morbid Conditions and Effects

    • Anxiety, depression, suicidal ideation

    • Substance abuse

    • Impaired occupational and interpersonal relationships

    • Decreased self-care

    • Poor social functioning

    • Lowered quality of life


    Thought disorders9
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Psychotrophics

    • Antipsychotic medications decrease the intensity and frequency of psychotic symptoms.

    • Anti-Parkinsonian medications are used to counteract the extrapyramidal symptoms (EPS) associated with antipsychotic medications.


    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Psychotrophics

    • Phenothiazines

      • Chlorpormazine (Thorazine), trifluoperazine (Stelazine), Thioridazine (Mellaril)…

    • Atypical

      • Clozapine (Clozaril), Olanzapine (Zyprexa), Risperidone (Risperdal), Ziprasidone (Geodon), Arpiprazole (Abilify), Quetiapine Fumarate (Seroquel)


    Thought disorders10
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Psychotrophic Side Effects

    • Acute

      • Dystonic reaction

      • Ocular crisis

      • Agranulocytosis

      • Neuroleptic malignant syndrome

    • Chronic

      • Tardive dyskinesia

      • Pseudoparkinsonism

      • Photo sensitivity

      • Weight gain


    Thought disorders11
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia:

    Psychotrophic Side Effects

    • Sudden onset muscular rigidity, fever, elevated CPK

    • Escalates over 24-48 hours

    • Late: hypertension, confusion-coma, gross diaphoresis, dysphagia, tachycardia

    • High potency neuroleptics, dosage, mood disorders, concurrent lithium and polypharmacy


    Thought disorders12
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Factors Supporting Compliance

    • Perception of illness

    • Risk for relapse

    • Knowledge/involvement with treatment plan

    • Optimism regarding positive effects

    • Awareness of unpleasant effects when meds stopped

    • Psychoeducation regarding psychotropic medications’ action, purpose, intended effects, management of side effects, toxic or dangerous effects and treatment for side effects


    Thought disorders13
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Factors Inhibiting Compliance

    • Delusions about medications

    • Return of enjoyable symptoms

    • Lack of social support regarding taking meds

    • Side effects distressing

    • Requires multiple changes in habits

    • Multiple medications


    Thought disorders14
    Thought Disorders (Lithium) 300 mg four times a daily has been prescribed. After 3 days of lithium therapy, the client says, “What’s wrong? My hands are shaking a little.” The best response of the nurse is:

    Schizophrenia: Interventions

    • Establish & maintain safe environment

    • Establish trust

    • Manage delusions

    • Focus on feelings versus delusions

    • Engage in reality testing

    • Validate functional behaviors

    • Anxiety management

    • Stress reduction strategies


    The major advantage of the newer atypical antipsychotics over older phenothiazines and high potency antipsychotic medication is:

    • A. Less chance for agranulocytosis

    • B. Availability as a long-lasting injection

    • C. Absence of EPS

    • D. Resolution of positive and negative symptoms


    A patient with schizophrenia tells you that voices in his head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    A. “I know these voices are very real to you, but I don't

    hear them.”

    B. “You need to get out of your room and get your mind

    occupied so you don't hear the voices."

    C. “Don't worry. You're safe in the hospital. I won't let

    anything happen to you.”

    D. “The voices are coming from your imagination.”


    Substance abuse dependence
    Substance Abuse/Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    • Incidence

      • Alcohol dependence/abuse 14%

      • Drug dependence 3%

      • Co-morbidity common

    • Defense Mechanisms

      • Rationalization, projection, denial

    • CNS depressants

      • Alcohol, benzodiazapines, barbituates


    Substance abuse
    Substance Abuse head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    • Maladaptive, recurring use of substance accompanied by repeated detrimental effects of drug

    • Present for one year or more

    • Episodic binges

    • Can occur without dependency

    • Encounters with law, school suspension, family/marital problems


    Substance intoxication
    Substance Intoxication head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    • Maladaptive, reversible pattern of behavior

      • Perceptual disturbances

      • Sleep—wake cycle changes

      • Disturbs attention, concentration, thinking, judgment, psychomotor activity

      • Interferes with relationships


    Substance dependence
    Substance Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    • Craving–strong inner drive to use substance - unsuccessful efforts to control use

    • Tolerance – decreased effectiveness of drug over time with need for increased doses of substance to achieve same effect

    • Withdrawal– unpleasant, maladaptive changes in behavior as blood/tissue concentrations of substance decline after prolonged heavy use

    • Much time used in obtaining substance

    • Activities given up in lieu of substance use

    • Continued use in spite of negative problems from usage


    Substance Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    • Larger amounts over longer time period than intended

    • Persistent desire/unsuccessful efforts to control use

    • Much time used in obtaining substance

    • Activities given up in lieu of substance use

    • Continued use in spite of negative problems from usage


    Substance dependence1
    Substance Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    PHASES

    • Phase 1

      • Mood swings, altered emotional state

    • Phase 2

      • Hangover effects, guilt about behavior

    • Phase 3

      • Dependent lifestyle, control over substance is lost

    • Phase 4

      • Dependency, addiction, blackouts, paranoia,

        helplessness


    Substance abuse dependence1
    Substance Abuse/Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    Possible long-term effects of chronic alcohol abuse

    • Gastritis

    • Esophagitis

    • Acute or chronic pancreatitis

    • Cirrhosis

    • Cardiac problems

    • Neurological problems

    • Wernicke-Korsakoff’s syndrome

    • Osteoporosis and myopathy


    Alcohol withdrawal
    Alcohol Withdrawal head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    Accompanied by physiologic/cognitive symptoms from reduction in prolonged substance use

    • Early Signs

      • Develop within few hours after cessation/peak at 24-48 hours

      • Anxiety, anorexia, insomnia, tremors, hyperactivity, irritability, “shaking inside,” hallucinations, illusions, nausea/vomiting, Increased Temp, pulse, and BP

    • Delirium Tremens (DTs)

      • Peak in 48-72 hours after cessation of drinking – last 2-3 days

      • 20% fatality rate


    Nursing interventions alcohol dependence

    Medication – sedation head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    High protein, high vitamin diet (B/C)

    Replace fluid/ electrolytes (I/O)

    Diuresis with blood alcohol level increase

    Fluid retention may occur (overhydration)

    MgSO4 to increase body’s response to thiamine/raise seizure threshold

    VS q hour x 12 h, then q4h

    Pulse good indicator of progress through withdrawal

    Nursing Interventions: Alcohol Dependence


    Vitamin b1 deficiency
    Vitamin head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be: B1 Deficiency

    • Vitamin B1 (Thiamine) and niacin deficiency

    • Encephalopathy and psychosis primarily in alcoholics caused by thiamine deficiency, due to poor dietary intake and malabsorption (Wernicke-Korsakoff Syndrome)

    • Permanent progressive cognitive loss


    Substance dependence alcohol
    Substance Dependence: Alcohol head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    • Maintaining abstinence

      • Antidepressents - SSRIs and Buspirone (BuSpar)

      • Naltrexone (ReVia), Nalmefene (Revex) -opioid antagonists that help with alcohol dependence - reduces cravings and increases abstinence

      • Disulfiram (Antabuse) - Treat alcoholism. Inhibits aldehyde dehydrogenase, if alcohol ingested, causes facial flushing, tachycardia, decreased BP, nausea, vomiting, SOB, seating dizziness and confusion


    Substance dependence alcohol1
    Substance Dependence: Alcohol head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    • Relapse prevention

      • Accept as a chronic disease

      • Self-help groups, AA

      • Stress management

      • Family support


    Substance abuse dependence2
    Substance Abuse/Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    • Narcotic opiates commonly abused

      • Heroin, Demerol, Dilaudid, Oxycontin

    • Treatment

      • Recognition of drug seeking

      • Manage intoxication/overdose

      • Opioid withdrawal: Naltrexone (ReVia), Buprenophine (Buprenex), Dolophine (Methadone)

      • Self-help groups, Narcotics Anonymous (NA)

      • Relapse prevention


    Substance abuse dependence3
    Substance Abuse/Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    Types of Drugs Frequently Abused

    • Barbiturates, antianxiety drugs, hypnotics

    • Opioids (narcotics): heroin, morphine, meperidine, methadone, hydromorphone

    • Amphetamines: amphetamine, dextroamphetamine, methamphetamine (speed), some appetite suppressants

    • Cocaine, hydrochloride cocaine (crack)

    • Phencyclidine (PCP)

    • Hallucinogens: LSD, mescaline

    • Cannabis: marijuana, hashish, THC

    • Assessment findings and nursing interventions for overdose vary with particular drug

    • Polydrug abusers: Synergistic effect and additive effect


    Substance abuse dependence4
    Substance Abuse/Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    Reasons nurses are at high risk for substance use.

    • Nurses see medication as solutions to problems

    • Access to drugs at work

    • Access to physicians who prescribe drugs

    • Compassion fatigue: Pressure and emotional pain felt

      at work

    • Anger and frustration nurses feel at work

    • Emotions felt at work respond to drugs– short term


    Substance abuse dependence5
    Substance Abuse/Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    Signs of substance abuse in nurses

    • Change in nurse’s behavior

    • Mood changes, irritability, isolation

    • Change in work performance

    • Multiple medication errors, missed deadlines, poor

      judgment, absenteeism

    • Signs of drug use or withdrawal

    • Red eyes, ataxia, anxiety, use of breath mints and

      perfume, slurred speech


    Substance abuse dependence6
    Substance Abuse/Dependence head are telling him he is in danger, and that he must stay in his room. He asks you, "Do you hear them?" Your best therapeutic response would be:

    Action plan if you suspect a peer

    Report the peer suspected of drug abuse to a manager or supervisor to:

    • Protect the clients from harm

    • Protect the peer from harming clients or self

    • Get diagnosis and treatment for impaired peers


    A client says, “I have a very small drink every morning to calm my nerves and stop my hands from trembling.” The nurse concludes that this client is describing which of the following?

    A. An anxiety disorder

    B. Tolerance

    C. Withdrawal

    D. Alcohol abuse


    A client asks the nurse to provide information about the detoxification process and withdrawal from a benzodiazepine. The nurse should inform the client that the process will involve which of the following?

    A. Rapid reduction in amount and frequency of the drug normally used

    B. Abrupt discontinuation of the drug commonly used

    C. Gradual downward reduction in dosage of the drug commonly used

    D. Planned, progressive addition of an anti-psychotic drug


    When the nurse is caring for a client experiencing delirium tremens, what is the most important nursing intervention?

    A. Present psycho-education on the dangers of drug and alcohol use.

    B. Encourage the client to develop a relapse prevention plan.

    C. Administer anti-craving medications.

    D. Provide withdrawal care based on unit protocol.


    Photo Acknowledgement: tremens, what is the most important nursing intervention?All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.


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