1. Slide 1 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chapter 35 Care of the Patient with a Psychiatric Disorder -Overview of Treatment Methods -Application of Nursing Process Chapter 35 Care of the Patient with a Psychiatric Disorder -Overview of Treatment Methods -Application of Nursing Process

2. Slide 2 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods Communication and Therapeutic Relationship  Confidentiality is a dilemma when therapeutic effectiveness of care depends on patient’s willingness to talk about feeling and thoughts  Let patient know information is shared among healthcare team To curtails patients’ manipulating the staff, or pitting one staff member or patient against another  Nurse has duty to report child abuse and must also warn Patient may threaten to kill some one or hurt someone  Nurse must report to proper authority

3. Slide 3 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods Communication and Therapeutic Relationship  Therapeutic techniques for psychiatric disorders Psychotherapy Electroconvulsive therapy (ECT) Psychopharmacology  Key component to psychiatric-mental health treatment To develop helping–trust relationship  Maximizes patient’s strengths, maintains self-esteem, and assists patient to develop and use coping skills  Nurse assists patient in learning new ways of responding to people and situation Therapeutic Dialogue, pg 1153

4. Slide 4 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods Communication and Therapeutic Relationship  Psychotherapy Psychiatric problems are treated using one or more of the following psychological techniques:  Behavior therapy  Cognitive therapy  Group therapy  Play therapy  Hypnosis  Psychoanalysis  Adjunctive therapies

5. Slide 5 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods Communication and Therapeutic Relationship  Psychotherapy Behavioral therapy  To relieve anxiety by conditioning and retraining of behavioral responses by repetition  Phobias may be resolved by this technique Cognitive therapy  Focuses on breaking negative thought patterns and developing positive feelings about memories or thoughts Group therapy  Used in a hospital setting or day treatment programs  Patients with similar problems gain insight through discussion and role palying

6. Slide 6 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods Communication and Therapeutic Relationship  Psychotherapy Play therapy  Used to help children express themselves by using toys such as puppets as their “spokesperson” of feelings Hypnosis  To help person recover deeply repressed emotions and speed recovery  Help change habits like smoking

7. Slide 7 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods Communication and Therapeutic Relationship  Psychotherapy Psychoanalysis  Developed by Sigmund Freud  Long-term and intense form of therapy that allows individual to bring unconscious thoughts to surface  Free association (speaking thoughts without censorship) and dream interpretation

8. Slide 8 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods Communication and Therapeutic Relationship  Psychotherapy Adjunctive therapies  Occupational therapy, recreational therapy, music therapy, magnetic therapy, art therapy and hydrotherapy  Allow expression of feelings, help increase self- esteem, and promote positive interaction and reality orientation  Used in group setting or individually

9. Slide 9 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods Electroconvulsive Therapy (ECT)  Introduced by Ugo Cerletti and Lucio Bino in the late 1930’s  Muscle relaxants and anesthesia are part of therapy To reduce fracture, contusion, and sprains from seizures  Treatment for depression, mania, or schizophrenia disorders that do not respond to other treatments  A very small amount of electrical current required to trigger a tonic-clonic (grand mal) seizure Temporary memory loss  Last a few hours to a few days Confusion  Lasts a few hours

10. Slide 10 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods ECT (continued)  Done as out patient treatment  When used properly, it’s effectiveness is as great or even greater than other treatment  Tests before ECT Physical examination, blood chemistry, survey, CBC, urinalysis  To detect unsuspected conditions Mental examination, EEG to rule out electrical abnormalities, chest and lumbosacral spine radiography to rule out abnormalities, ECG

11. Slide 11 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods ECT (continued)  Nursing Interventions Pre-ECT  Informed consent; NPO for 8 hours  Baseline vital signs; void prior to treatment  All jewelry, glasses, contacts, dentures, and hairpins removed  IV line inserted; pre-ECT medications given

12. Slide 12 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods ECT (continued)  Nursing Interventions Post-ECT  Frequent vital signs; warm bath  Constant supervision due to confusion  Light meal or snack and assist in mobility  Should not drive until completely confusion free

13. Slide 13 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods Psychopharmacology  Psychotropic (psychoactive) medications are used in conjunction with other therapies to help modify an individual’s behavior  Use to control symptoms  Nursing responsibility Monitor for effectiveness and side effects Must understand the use of these drugs (pg: 1156- 1157)

14. Slide 14 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antidepressants  Work in different ways in brain  Assist in alleviating signs and symptoms of depression Decreased appetite or sleep pattern disturbances, prolonged sadness and lack of concentration  Effects are seen 2 to 4 weeks before improvement is noted  Effects on depression is described as “fog lifting”  Maintained for several months to a year to prevent symptoms recurrent

15. Slide 15 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antidepressants (cont’d)  Selective serotonin reuptake inhibitors (SSRIs) Fluoxetine (Prozac), sertraline (Zoloft), venlafaxine (Effexor), citalopram (Celexa), paroxetine (Paxil)  Serotonin syndrome o Potentially life-threatening condition o Occurs due to an interaction between SSRI and another serotonergic agent o Occur in older adult patients taking only SSRI o SX: altered mental status, autonomic dysfunction, and neuromuscular abnormalities Use is preferred due to fewer side effects

16. Slide 16 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antidepressants (cont’d)  Selective serotonin reuptake inhibitors (SSRIs) Serotonin syndrome  Labs: elevated CPK from muscle disintegration, elevated WBC, and transaminases, decreased serum bicarbonate level  Treatment: slowly decrease dosage of drug  Sudden drug decrease leads to: dizziness, nausea, vomiting, muscle pain, headache, fatigue, anxiety, crying spells and irritability

17. Slide 17 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antidepressants (continued)  Tricyclics Amitriptyline (Elavil), amoxapine (Asendin), desipramine HCl (Norpramin), imipramine HCl (Tofranil), nortriptyline HCl (Avnetyl, Pamelor)  Monoamine oxidase inhibitors (MAOIs) Phenelzine sulfate (Nardil) Tranylcypromine sulfate (Parnate)  Triazolopyradines Trazodone (Desyrel) Bupropion (Wellbutrin)

18. Slide 18 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antidepressants (continued)  Autonomic dysfunctions BP fluctuation, tachycardia, hyperthermia, mydriasis (dilated pupils), shivering, diaphoresis  Neuromuscular symptoms Akathisia, jittery feeling inside, ataxia (incoordination), dystonia, dyskinesia, hyperreflexia, tremors and seizures

19. Slide 19 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antimanics  Stabilizes mood and behavior of a patient with mania  Therapeutic blood level required (lithium carbonate) May take 7-10 days to achieve  Lithium carbonate (Eskalith, Lithobid) Chief drug to manage mania Monitor for lithium toxicity  Serum level above 1.5 mEq/L  Signs of toxicity: Nausea, vomiting, diarrhea, drowsiness, muscle weakness, and ataxia, leads to seizure and death  Poor fluid intake and salt restriction in diet increases risk of toxicity

20. Slide 20 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antipsychotics  Major tranquilizers  Treatment of schizophrenia, organic mental disorders with psychosis, and the manic phase of bipolar mood disorder  Provide symptomatic control; not a cure  Side effects Postural hypotension and sedation  Consider safety measures to prevent fall Photosensitivity  Sunscreen and hats Autonomic reactions  Urinary retention, dry mouth, constipation, edema, weight gain

21. Slide 21 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antipsychotics (continued)  Side effects Extrapyramidal symptoms  Pseudoparkinsonism – tremor with rigid posture  Akathisia – inability to sit still, with continuous hand, mouth, or body movements (foot tapping)  Dystonias – aberrant posturing (hand spasms)  Dyskinesia – involuntary movement (lip smacking, tongue protrusion)  Tardive dyskinesia – due to reduction of medication and can have a permanent effect

22. Slide 22 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antipsychotics (continued)  Treatment of extrapyramidal symptoms Reduce or stop the drug, parenteral diphenhydramine, antiparkinson drugs (trihexyphenidyl [Artane], or benztropine [Cogentin])  Example: pg 1156 Chlorpromazine (Thorazine) Thioridazine HCl (Mellaril-S) Trifuloperazine HCl (Stelazine) Fluphenazine HCl (Prolixin, Permitil) Perphenazine (Trilafon) Thiothixene (Navane) Haloperidol (Haldol)

23. Slide 23 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antianxiety  Minor tranquilizers  Help individuals experiencing moderate to severe anxiety  Benzodiazepine sedatives like lorazepam (ativan) Used to relieve tension without losing motivation  Drugs in this category are commonly abused

24. Slide 24 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Treatment Methods: Psychopharmacology Antianxiety  Examples Alprazolam (Xanax) Busipirone (Buspar) Chlordiazepoxide HCl (Librium) Clorazepate dipotassium (Tranxene) Lorazepam (Ativan) Oxazepam (Serax)

25. Slide 25 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Alternative Therapies Use of natural or herbal medications has gained tremendous popularity. Control and manufacture of these medications do not fall under the laws of the U.S. Food and Drug Administration.  Quality and quantity vary from manufacturer to manufacturer.  Claims and clinical studies are not always consistent. Nurse should ask about the use of herbs when obtaining drug history.

26. Slide 26 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Alternative Therapies Examples  St. John’s wort (Hypernicum) Interacts with MAOIs and can trigger hypertension  taken with allergy medication containing monoamines or phenylalanine  Taken withamino acid supplement containing tyrosine Used for mild depression  Kava (Piper methysticum) Used in treating anxiety and insomnia Proven sedative effects S/E: scaly rash on back of hands and forearms and soles of foot Alcohol potentiates its effects and if taken with BNZ, can become toxic and induce coma

27. Slide 27 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Alternative Therapies Examples  Ginkgo and Ginseng Used to improve memory and boost energy Ginkgo: provide memory and cognitive improvement in treatment of early Alzheimer’s disease  Increases cerebral blood flow  Potentiates anticoagulant drugs like aspirin and warfarin which can lead to hemorrhage  Affect insulin release Ginseng: decreases blood glucose level in diabetics

28. Slide 28 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Alternative Therapies Examples  Aromatherapy Used to enhance or potentiate another remedy Scented oils for massage, volatile oils to sniff or inhale, scented candles or incense  Triggers chemical activity in the brain to relieve imbalance in the body Citrus essences, peppermint, cedar wood, rosemary, sandal wood, chamomile, lavander  Essential oils help relieve stress and anxiety  Chamomile tea, sandal wood candle, lavander bath Focuses on atmosphere of moment and uses body’s senses to achieve balance within A place in holistic care

29. Slide 29 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nursing Process Application LPN/LVN participates in nursing process as member of mental health care team that includes RN, MD, therapist LPN/LVN observation of patient behavior and therapeutic communications with patient  Assist RN in collecting data to form nursing diagnoses  Ensure appropriate patient intervention Health promotion interventions focus on:  Prevention of relapse  Management of symptom  Simple, concrete, clear patient teaching is most successful

30. Slide 30 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nursing Process Application Evaluation  Ongoing  At intervals or when patient’s response dictates, care plan is updated  Examination of documentation and personal observations are considerations when evaluating the plan of care Documentation methods:  Ongoing and include assessment criteria used by health care team  Information are accurate and descriptive  Avoid terms “appears depressed” and use “no eye contact noted during conversation”