Presentation on theme: "NCLEX-RN PREPARATION PROGRAM"— Presentation transcript:
1NCLEX-RN PREPARATION PROGRAM MENTAL HEALTHDISORDERSModule 6, Part 2 of 3
2Major 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”:CognitionAffectivityInterpersonal functioningImpulse controlHinders one’s ability toMaintain meaningful relationshipsFeel fulfilled & enjoy lifeAdjust psychosocially (cope)The following traits are likely in individuals with a personality disorder: 1) interpersonal relations that range form distant to overprotective, 2) suspiciousness, 3) social anxiety, 4) failure to conform to social norms, 5) self-destructive behaviors, and 6) manipulation and splitting of staff. Prognosis is poor, and clients experience long-term disability and may have other psychiatric disorders.
4Personality Disorders Cluster 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 distrustCognitive impairment is more serious with Cluster A personality disorders than with cluster B & C disordersMost peculiar & maladaptive defensive stylesObserved in families with schizophrenia, especially schizotypal
5Personality Disorders Cluster B: Dramatic and Emotional Present oriented and want immediate gratificationAct without evaluating consequences (impulsive)BPD more likely to hurt self. APD more likely to aggress outwardAPD commonly involved in criminal activities and lack remorse or guilt - emotionally retardedSelf-centered and manipulativeSplitting (the inability to integrate the positive and negative qualities of oneself or others into a cohesive image)
6Personality Disorders Cluster C: Anxious-Fearful Present as primarily anxious or fearfulExperience impairment asRestricted affect: problems expressing feelingsNon-assertiveness, avoids conflictUnrealistic expectations of othersRely on others for support and decision-makingUnable to function without a partner or family member - stays in abusive relationship rather than be alone
7Bistro of the Personality Disorders (PDs) Schizoid - Orders home delivery; ingests food through mail slotSchizotypal - Eats soup using gardening equipment & chop sticksParanoid - Sits with back to the wall; spies on food prep areaAntisocial P.D. - Steals tip left by narcissistBorderline P.D. - When informed her boyfriend plans to go duck hunting, throws a drink at him, then uses glass to cut selfHistrionic - Does a belly dance in the center of the restaurantNarcissist - Expects best table without a reservationAvoidant - Tips generously for take-out serviceDependent - Vegetarian non-smoker eats veal in smoking areato please dateOCPD - Aligns cutlery & dispenses etiquette tips
8Personality Disorders Interventions Establish therapeutic relationshipControlMilieu therapyProvide experienced, consistent staffImplement a structure with rules that are firm & consistently enforced (limit setting with consequences)Protection from self-harmModify impulsive behaviorIncorporate behavioral strategies
9Personality Disorders Interventions (continued) Medications have a limited role:Decrease impulsivity, mood swings, anxietyTeach how to get needs met without manipulationMaintain matter-of-fact but caring approach; mobilize healthy aspects of personality
10Personality Disorders Goals Less impulsiveAble to meet needs without manipulatingIncreased satisfaction with quality of relationshipsParticipates in close relationshipsExpresses recognition of positive behavioral change
11A. Narcissistic personality disorder 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?C. Antisocial personality disorderA. Narcissistic personality disorderB. Histrionic personality disorderC. Antisocial personality disorderD. Borderline personality disorder
12A. Establish clear and enforceable limits. 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 unitrules should apply.A. Establish clear and enforceable limits.
13Anxiety Disorders Description An unrealistic fear in which the cause may or may not be identified.Symptoms: Anxiety and avoidance behaviorFamilial predispositionResults fromExposure to traumatic and stressful life eventsObserving others experiencing trauma or behaving fearfullyVicariously through watching movies and TVPhysical symptoms occurDefense mechanisms are unconscious strategies used by the psyche to control and reduce anxiety.
14Anxiety Disorders Central Features Pervasive anxiety Feelings of inadequacyTendency to avoidSelf-defeating behavior blocks growthCan stimulate action to alter stressful situationMost symptoms of the body involvedSee physician vs. psychiatrist for treatment
15Anxiety Disorders Assessment Restlessness and inability to relax Episodes of trembling and shakinessChronic muscular tensionDizzinessInability to concentrateFatigue and sleep problemsInability to recognize connection betweenanxiety and physical symptomsFocused on the physical discomfort
16Anxiety Disorders Generalized Anxiety Disorder GADChronic 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/excessiveMotor tension, autonomic hyperactivity, apprehensive expectations, vigilance & scanningExperiences at least 3 of the following:Restlessness, fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance
17Anxiety Disorders Panic Disorders Panic Disorder - discrete episode of intense fearSense of impending doom, helplessness, or being trappedPeaks within 10 minutesOccurs unexpectedly and on an intermittent basisConcern about additional attacksPanic Disorder with agoraphobiaAvoidance 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…)
18Anxiety Disorders Post-traumatic Stress Disorder PTSDDevelopment of physiologic/behavioral symptoms following a psychologically traumatic eventA traumatic event is unavoidable (terrorist attacks, war, rape, crime events, disasters, fires, childhood sexual abuse, kidnapping, hostages)Before exposure did not have psychological problemsSymptoms include: re-experiencing the trauma, avoiding reminders of the trauma, numbing of affect
19Anxiety Disorders Phobic Disorders Social phobia -Fear of scrutiny (evaluated or judged) by othersFearful of doing something or acting in a way that will be humiliating or embarrassingSpecific PhobiaPersistent irrational fears of specific objects or situationsi.e., Animals (zoophobia), fear of closed places (claustrophobia), & fear of heights (acrophobia)What are some other common phobias?
20Anxiety Disorders Obsessive-Compulsive Disorder OCDObsessionsUnwanted, persistent, & intrusive thoughts, impulses or images that cause anxiety or distressCompulsionsIrrational impulse to actBehaviors or mental rituals performed to neutralize/prevent the distressing thoughts or imagesThoughts about dirt, contamination and danger most common obsessions; cleaning & checking for danger most common ritual
21Anxiety Disorder Medications Buspirone (Buspar)Minimal CNS depressant actionsDoes not enhance effects of alcohol, barbiturates & other general CNS depressants. Takes several weeks to establish effectiveness.BenzodiazpamAdverse effects:CNS DepressionAmnesiaRespiratory DepressionDependence and abuseE.g. Valium, Librium, Xanax
22Anxiety Disorder Medications Beta-adrenergic blocking agents such as propranolol (Inderal) can relieve symptoms caused by autonomic hyperactivitySelective Serotonin Reuptake Inhibitors (Paxil, Proxac…), Tricyclic Antidepressants (Imipramine - Tofranil)BarbituatesCNS depressionHigh abuse potentialPowerful respiratory depressants with strong potential for fatal overdose
23Anxiety Disorder Assessment Take steps to lower anxiety levelEncourage trust/calm approachAssess current feelingsWhat happened immediately prior to onset?Client’s perspective of situationThought processesAffect, expression, nonverbal behaviorsCommunication ability, thought blocking
24Anxiety Disorder Interventions Establish trusting relationshipNurses’ self-awarenessRecognition of anxietyInsight into anxietyModifying environmentEncouraging activityPromote relaxation responseLearn new ways to cope with stressMedicationGoal: Client will demonstrate adaptive ways of coping with stress
25A. Mild B. Moderate C. Severe D. Panic 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. MildB. ModerateC. SevereD. PanicB. Moderate
26During 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 roomB. Given advance notice of approaching time for all group therapy sessionsC. Asked to keep a diary of feelings experienced if unable to groom self at willD. Allowed to use own cosmetics and grooming productsB. Given advance notice of approaching time for all group therapy sessions
27A. Cognitive dissonance and confusion 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 confusionB. Depression and suicidal ideationsC. Insomnia and nightmaresD. Palpitations and rapid heart beatD. Palpitations and rapid heart beat
28Somatoform Disorders Focus: Physical symptoms with absence of a pathophysiological problemSomatization DisorderHypochondriasisConversion DisorderPain DisorderBody Dysmorphic Disorder
29Somatoform Disorders Somatization Disorder Involvement of multiorgan system symptoms: pain, GI, sexual, pseudoneurologicalLack physical signs or structural abnormalitiesDifferent than hypochondriasis in that preoccupation occurs only during episodeHypochondriasisPreoccupation with fear of having serious illness and hypersensitive to body functionsBecomes central feature of self-image, topic of social interaction and response to life stresses
30Somatoform Disorders Conversion Disorder A symptom or deficit that affects motor or sensory functioningInappropriately unconcerned about symptomsSymptoms remit within 2 wks, recurrence commonCommon symptoms are blindness, deafness, paralysis and the inability to talkPain DisorderPreoccupation with pain after confirmation of absence of pathophysiologic causes
31Somatoform Disorders Body Dysmorphic Disorder Preoccupation with an imagined/exaggerated defect in physical appearanceCrooked lip, bumpy nose, falling faceSomatoform Interventions: Client educationMedications, Rx, lifestyle changes, ways to cope with anxiety & stress, relaxation training, physical activityGoal: Client will express feelings verbally rather than through physical symptoms
32An 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 gainB. Secondary gainC. Attention-seekingD. MalingeringB. Secondary gain
33What would the nurse expect a client who has a somatization disorder to reveal in the nursing history?A. Abrupt onset of physical symptoms at menopauseB. Episodes of personality dissociationC. Ignoring physical symptoms until role performancewas alteredD. Numerous physical symptoms in many organ areasD. Numerous physical symptoms in many organ areas
34A 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.”C. “I know that I don’t have a serious illness, even though I still worry about my symptoms.”
36Dissociative Disorders Avoids stress by dissociating self from core personality, characterized by sudden or gradual disruption in identity, memory or consciousnessDissociative AmnesiaDissociative FugueDissociative Identity DisorderDepersonalization Disorder
37Dissociative Disorders Dissociative AmnesiaInability to recall important personal informationToo extensive to be explained by ordinary forgetfulnessDissociative FugueSudden, unexpected travel away from home or workInability to recall one’s pastConfusion about personal identity (ID) or assumption of a new ID
38Dissociative Disorders Dissociative Identity DisorderFormally “Multiple Personality Disorder”Presence of 2 or more distinct identities that recurrently take over behaviorInability to recall important personal infoIdentity fragmentationOften a history of physical &/or sexual abuseDepersonalization DisorderRecurrent feeling of being detached from one’s mental processes or bodyIntact reality testing
39Dissociative Disorders: Interventions Development of insightIdentify stressorsClarify beliefs in relationship to feelings and behaviorsExplore use of coping resourcesDecrease anxiety through stress managementGoalObtain the maximum level of self-actualization to realize potential
40The 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.”A. “Your spouse will probably have no memory for events during the fugue.”
41Mood Disorders: Major Depressive Disorder and Bipolar Disorders A mood disorder is characterized by:Depressed mood or cycles of depressed and elated moodFeelings of hopelessness and helplessnessDecrease in interest or pleasure in usual activitiesDepression is the most common psychiatric diagnosis. A high incidence exists for persons with chronic illness or prolonged hospitalization/institutional care. Higher rate for women, often less than 40 when begins, more frequently single, widowed.
42Mood Disorders: Major Depressive Disorders Depression Models of CausationBiological factorsSerotonin, norepinephrine, and acetylcholine deficienciesEffect of light on moodGenetic factorsFamilial predispositionSituational, physiological, and psychosocial stressorsLearned hopelessness and helplessness and a negative self-viewFamily genetics: parent with depression, child 10-13% risk of depression. Seasonal Affective Disorder (SAD) occurs when client experiences recurrent depression that occurs annually at the same time. It is thought to be a reaction to environmental factors such as climate, latitude, and decreased light.
43Mood Disorders Depression: Signs and Symptoms Cognitive: Difficulty concentrating, focusing, and problem solving; ambivalence, confusion, sleep disturbancesLoss of interest or motivation, anhedoniaDecrease in personal hygieneAnxiety, worthlessness, helplessness, hopelessnessPsychomotor retardation/agitationVegetative signs: Hypersomnia, slowed bowel functionRisk of harm to self or other: Suicidal ideation or thoughts, self-destructive acts, violence, overt hostility often connected with suicidal thoughtsWithdrawal, social isolation
45Mood Disorders Selective Serotonin Reuptake Inhibitors (SSRIs): SSRI ConsiderationsSelective Serotonin Reuptake Inhibitors (SSRIs):Physical assessment: renal, liver function, seizuresAgitation vs. vegetative symptomsLevel of anxietyEase of complianceRisk for suicide by overdose
46Mood Disorders Serotonin Syndrome Cause: Excess Serotonin at receptor sitesOnset 3-9 daysSymptoms: fever, confusion, restlessness, agitation,hyper-reflexia, diaphoresis, shivering, diarrhea, fever,poor coordinationTriggered by high doses, concurrent MAOI, lithium or Trazadone administrationInterventions: Hold meds, notify MD, give P.O. fluids, supervise and support patient, antipyretics, cooling blanketResolves without specific treatment over 24 hours
50Mood Disorders Nursing Interventions for Depression: Maintain safety Question negative beliefsEncourage activities to increase self-esteemEncourage ADLsEncourage physical activityMedication teachingMilieu, group and/or individual therapyGoalsNo self-harmResolution of negative self-image and situational insightRestoration of normal physical functioningMedication compliance, relapse prevention
51The 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.”B. Insufficient serotonin activity in the CNS.
52A. The nature of the spouse’s present illness 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 illnessB. The client’s response to past lossesC. The dying spouse’s feelings about impending loss and deathD. The client’s relationship with the spouseB. The client’s response to past losses
53Mood Disorders: 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.Ensure that client’s needs are met when manic (e.g., sleep/rest, nutrition and fluids, hygiene, safety).
54Mood Disorders Bipolar Disorder Biological Factors Possible excess of norepinephrine, serotonin and dopamineIncreased intracellular sodium and calciumNeurotransmitters supersensitive to transmission of impulsesDefective feedback mechanism in limbic systemFamily genetics: one parent, child has 25% risk; two parents, 50-75% risk
55Mood Disorders Bipolar Disorder: Signs and Symptoms of Mania Impulsivity: Spending money, giving away money or possessions, hypersexual behaviorRacing thoughts, hyper-socialIncreased activity, grandiose view of self and abilitiesMood elation, progressively more hostileSpeech loud, jovial, pressuredPoor judgmentReduced sleepImpairment in social and occupational functioningDelusions, paranoia, and hallucination. Attention-seeking behavior: flashy dress and make-up, inappropriate behavior.
56Mood Disorders Bipolar Disorder: Psychotrophics Lithium Carbonate (Carbolith, Eskalith..)AnticonvulsantsValproate, (Depakote)Carbamazepine (Tegretol)Gabapentin (Neurontin)Topiramate (Topamax)Lamotrogene (Lamictal)BenzodiazapinesAntipsychotics such as Olanzapine (Zyprexa) and Arpiprazole (Abilify)Electroconvulsive therapyAnticonvulsant medications: Tegretol, Neurontin, and Clonazepam (Klonopin) have shown mood stabilization in clients with mania.
57Mood Disorders Bipolar Disorder: Medical Management Lithium can have potentially harmful effects on the kidney, thyroid gland, heart and developing fetusPre-lithium treatment lab testsThyroid Function Tests (e.g. TSH),CBC (benign elevation of WBCs),BUN, serum creatinine, electrolytesUrinalysis,ECG,, pregnancy testDuring Lithium treatment: TSH, BUN, serum creatinine, ECGs every 6 to 12 monthsHistory: family history, psychiatric history, social historyPhysical and mental status examinationSuicidal assessmentNutritional assessment, including caffeine intake and levels of vitamin and magnesium deficiencies
58Mood Disorders Bipolar Disorder: Medical Management Lithium Monitor serum levels or lithium ( mEg/L) to prevent toxicity and confirm compliance. Report sub-therapeutic or toxic levels to prescribing practitionerEncourage adequate hydration and adequate dietary saltTherapeutic improvement takes 1-3 weeksTremors and a metallic taste are side effectsAnticonvulsants as Mood StabilizersMonitor serum levels every 2-4 months (liver function tests, complete blood count, electrolytes, ECG, pregnancy test every 6-12 months)
59Mood Disorders Bipolar Disorder Nursing Interventions and Goals Maintain physical safety (self harm, assault, impulse control, exhaustion)Decrease sensory stimulationEstablish normal sleep/rest cycleEstablish adequate food/fluid intakeLimit escalation of behaviorProvide reality orientationPsychoeducation: 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
60The client has bipolar I disorder 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.”A. “Minor hand trembling often happens for a few days after Lithium is started. It usually decreases in 1 to 2 weeks.”
61Thought Disorders Schizophrenia Involves disturbances in: Reality, thought processes, perception, affect, social and occupational functioning1.5% of the population75% of cases diagnosed between ages 17 and 25Causation: 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 tissueClients with schizophrenia will have periods of remission and improved functioning, but there is no cure for the disorder. It is theorized that biological factors play a more important role than environmental influences in the development of the disorder. Family genetics: identical twins 50% risk; fraternal twins 15% risk
63Thought Disorders 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
64Thought Disorders Schizophrenia: Types Disorganized Type Paranoid Type Flat or inappropriate affect (such as silliness or giggling), bizarre behavior and social impairmentParanoid TypeParanoid delusions in which the individual falsely believes that others are out to harm him/her. The individual may be hostile, argumentative and aggressive
65Thought Disorders Schizophrenia: Types Undifferentiated Type Bizarre behavior that does not meet the criteria of other types of schizophrenia. Delusions and hallucinations are prominentResidual TypeIndividual who has had one major episode of schizophrenia with prominent psychotic symptoms and who has lingering symptoms
66Thought Disorders Schizophrenia: Diagnostic Criteria Delusions, hallucinations, disorganized speech and/or behaviorSocial and/or occupational impairmentSymptoms for at least 6 monthsNot attributable to another disorder
68Thought Disorders Schizophrenia: Positive Signs and Symptoms Hallucinations: Auditory, visual, olfactory, gustatory, tactileIllusions: False interpretations of external sensory stimuli and inappropriate responses to the perception.Alterations in thinkingDelusions - Fixed false beliefs (grandiose, persecutory, somatic…)Thought broadcasting, insertionIdeas of referenceFlight of ideasThought/language disruption
69Thought Disorders Schizophrenia: Co-Morbid Conditions and Effects Anxiety, depression, suicidal ideationSubstance abuseImpaired occupational and interpersonal relationshipsDecreased self-carePoor social functioningLowered quality of life
70Thought Disorders 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.Traditional antipsychotic medications: Haldol, Prolixin, ThorazineNewer antipsychotic medications: clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel),
72Thought Disorders Schizophrenia: Psychotrophic Side Effects Acute Dystonic reactionOcular crisisAgranulocytosisNeuroleptic malignant syndromeChronicTardive dyskinesiaPseudoparkinsonismPhoto sensitivityWeight gain
73Thought Disorders Schizophrenia: Psychotrophic Side Effects Sudden onset muscular rigidity, fever, elevated CPKEscalates over hoursLate: hypertension, confusion-coma, gross diaphoresis, dysphagia, tachycardiaHigh potency neuroleptics, dosage, mood disorders, concurrent lithium and polypharmacy
74Thought Disorders Schizophrenia: Factors Supporting Compliance Perception of illnessRisk for relapseKnowledge/involvement with treatment planOptimism regarding positive effectsAwareness of unpleasant effects when meds stoppedPsychoeducation regarding psychotropic medications’ action, purpose, intended effects, management of side effects, toxic or dangerous effects and treatment for side effects
75Thought Disorders Schizophrenia: Factors Inhibiting Compliance Delusions about medicationsReturn of enjoyable symptomsLack of social support regarding taking medsSide effects distressingRequires multiple changes in habitsMultiple medications
76Thought Disorders Schizophrenia: Interventions Establish & maintain safe environmentEstablish trustManage delusionsFocus on feelings versus delusionsEngage in reality testingValidate functional behaviorsAnxiety managementStress reduction strategies
77The major advantage of the newer atypical antipsychotics over older phenothiazines and high potency antipsychotic medication is:A. Less chance for agranulocytosisB. Availability as a long-lasting injectionC. Absence of EPSD. Resolution of positive and negative symptomsd. Resolution of positive and negative symptoms
78A 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'thear them.”B. “You need to get out of your room and get your mindoccupied so you don't hear the voices."C. “Don't worry. You're safe in the hospital. I won't letanything happen to you.”D. “The voices are coming from your imagination.”A.I know these voices are very real to you, but I don't hear them
80Substance AbuseMaladaptive, recurring use of substance accompanied by repeated detrimental effects of drugPresent for one year or moreEpisodic bingesCan occur without dependencyEncounters with law, school suspension, family/marital problems
81Substance Intoxication Maladaptive, reversible pattern of behaviorPerceptual disturbancesSleep—wake cycle changesDisturbs attention, concentration, thinking, judgment, psychomotor activityInterferes with relationships
82Substance DependenceCraving – strong inner drive to use substance - unsuccessful efforts to control useTolerance – decreased effectiveness of drug over time with need for increased doses of substance to achieve same effectWithdrawal – unpleasant, maladaptive changes in behavior as blood/tissue concentrations of substance decline after prolonged heavy useMuch time used in obtaining substanceActivities given up in lieu of substance useContinued use in spite of negative problems from usage
83Substance DependenceLarger amounts over longer time period than intendedPersistent desire/unsuccessful efforts to control useMuch time used in obtaining substanceActivities given up in lieu of substance useContinued use in spite of negative problems from usage
84Substance Dependence Mood swings, altered emotional state PHASESPhase 1Mood swings, altered emotional statePhase 2Hangover effects, guilt about behaviorPhase 3Dependent lifestyle, control over substance is lostPhase 4Dependency, addiction, blackouts, paranoia,helplessness
85Substance Abuse/Dependence Possible long-term effects of chronic alcohol abuseGastritisEsophagitisAcute or chronic pancreatitisCirrhosisCardiac problemsNeurological problemsWernicke-Korsakoff’s syndromeOsteoporosis and myopathy
86Alcohol Withdrawal Delirium Tremens (DTs) Accompanied by physiologic/cognitive symptoms from reduction in prolonged substance useEarly SignsDevelop within few hours after cessation/peak at hoursAnxiety, anorexia, insomnia, tremors, hyperactivity, irritability, “shaking inside,” hallucinations, illusions, nausea/vomiting, Increased Temp, pulse, and BPDelirium Tremens (DTs)Peak in hours after cessation of drinking – last 2-3 days20% fatality rate
87Nursing Interventions: Alcohol Dependence Medication – sedationHigh protein, high vitamin diet (B/C)Replace fluid/ electrolytes (I/O)Diuresis with blood alcohol level increaseFluid retention may occur (overhydration)MgSO4 to increase body’s response to thiamine/raise seizure thresholdVS q hour x 12 h, then q4hPulse good indicator of progress through withdrawal
88Vitamin 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
89Substance Dependence: Alcohol Maintaining abstinenceAntidepressents - SSRIs and Buspirone (BuSpar)Naltrexone (ReVia), Nalmefene (Revex) -opioid antagonists that help with alcohol dependence - reduces cravings and increases abstinenceDisulfiram (Antabuse) - Treat alcoholism. Inhibits aldehyde dehydrogenase, if alcohol ingested, causes facial flushing, tachycardia, decreased BP, nausea, vomiting, SOB, seating dizziness and confusion
90Substance Dependence: Alcohol Relapse preventionAccept as a chronic diseaseSelf-help groups, AAStress managementFamily support
92Substance Abuse/Dependence Types of Drugs Frequently AbusedBarbiturates, antianxiety drugs, hypnoticsOpioids (narcotics): heroin, morphine, meperidine, methadone, hydromorphoneAmphetamines: amphetamine, dextroamphetamine, methamphetamine (speed), some appetite suppressantsCocaine, hydrochloride cocaine (crack)Phencyclidine (PCP)Hallucinogens: LSD, mescalineCannabis: marijuana, hashish, THCAssessment findings and nursing interventions for overdose vary with particular drugPolydrug abusers: Synergistic effect and additive effect
93Substance Abuse/Dependence Reasons nurses are at high risk for substance use.Nurses see medication as solutions to problemsAccess to drugs at workAccess to physicians who prescribe drugsCompassion fatigue: Pressure and emotional pain feltat workAnger and frustration nurses feel at workEmotions felt at work respond to drugs– short term
94Substance Abuse/Dependence Signs of substance abuse in nursesChange in nurse’s behaviorMood changes, irritability, isolationChange in work performanceMultiple medication errors, missed deadlines, poorjudgment, absenteeismSigns of drug use or withdrawalRed eyes, ataxia, anxiety, use of breath mints andperfume, slurred speech
95Substance Abuse/Dependence Action plan if you suspect a peerReport the peer suspected of drug abuse to a manager or supervisor to:Protect the clients from harmProtect the peer from harming clients or selfGet diagnosis and treatment for impaired peers
96A 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 disorderB. ToleranceC. WithdrawalD. Alcohol abuseC. Withdrawal
97A. Rapid reduction in amount and frequency of the drug normally used 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 usedB. Abrupt discontinuation of the drug commonly usedC. Gradual downward reduction in dosage of the drug commonly usedD. Planned, progressive addition of an anti-psychotic drugC. Gradual downward reduction in dosage of the drug commonly used
98When 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.D. Provide withdrawal care based on unit protocol.
99Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the Microsoft Office Clip Art Gallery.