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”: Cognition Affectivity Interpersonal functioning Impulse control Hinders one’s ability to Maintain meaningful relationships Feel fulfilled & enjoy life Adjust 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.

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 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 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 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 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) 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 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. 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 disorder A. Narcissistic personality disorder B. Histrionic personality disorder C. Antisocial personality disorder D. Borderline personality disorder

A. 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 unit rules should apply. A. Establish clear and enforceable limits.

Anxiety Disorders 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 Defense mechanisms are unconscious strategies used by the psyche to control and reduce anxiety.

Anxiety Disorders 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 Disorders 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 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 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 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 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 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 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 Medications 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 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 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. 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. Mild B. Moderate C. Severe D. Panic B. Moderate

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

A. 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 confusion B. Depression and suicidal ideations C. Insomnia and nightmares D. Palpitations and rapid heart beat D. Palpitations and rapid heart beat

Somatoform Disorders Focus: Physical symptoms with absence of a pathophysiological problem Somatization Disorder Hypochondriasis Conversion Disorder Pain Disorder Body Dysmorphic Disorder

Somatoform Disorders 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 Disorders 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 Disorders 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 B. Secondary gain

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

Dissociative Disorders

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

Mood Disorders: Major Depressive Disorder and Bipolar Disorders 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 Depression 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.

Mood Disorders: Major Depressive 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 Family 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.

Mood 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 Withdrawal, social isolation

Mood 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 Disorders Selective Serotonin Reuptake Inhibitors (SSRIs): 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 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 Disorders Depression: Psychotrophics Novel antidepressants: Bupropion (Wellbutrin) Nefazadone (Serzone) Trazadone (Desyrel) Venlafaxine (Effexor) Mirtazipine (Remeron) Duloxetine (Cymbalta)

Mood Disorders Depression: Psychotrophics Tricyclic antidepressants Amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor) Trimipramine (Surmontil)

Mood 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 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.” B. Insufficient serotonin activity in the CNS.

A. 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 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 B. The client’s response to past losses

Mood 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).

Mood Disorders 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 Family genetics: one parent, child has 25% risk; two parents, 50-75% risk

Mood Disorders 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 Delusions, paranoia, and hallucination. Attention-seeking behavior: flashy dress and make-up, inappropriate behavior.

Mood Disorders 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 Anticonvulsant medications: Tegretol, Neurontin, and Clonazepam (Klonopin) have shown mood stabilization in clients with mania.

Mood Disorders 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 History: family history, psychiatric history, social history Physical and mental status examination Suicidal assessment Nutritional assessment, including caffeine intake and levels of vitamin and magnesium deficiencies

Mood Disorders 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 Disorders 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 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.”

Thought Disorders 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 Clients 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

Thought Disorders Schizophrenia: Types Catatonic Disorganized Paranoid Undifferentiated Residual

Thought 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

Thought Disorders Schizophrenia: Types Disorganized Type Paranoid 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 Disorders 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 Disorders 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 Disorders 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 Disorders 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 Disorders 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 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, Thorazine Newer antipsychotic medications: clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel),

Thought Disorders Schizophrenia: Psychotrophics Phenothiazines Chlorpormazine (Thorazine), trifluoperazine (Stelazine), Thioridazine (Mellaril)… Atypical Clozapine (Clozaril), Olanzapine (Zyprexa), Risperidone (Risperdal), Ziprasidone (Geodon), Arpiprazole (Abilify), Quetiapine Fumarate (Seroquel)

Thought Disorders Schizophrenia: Psychotrophic Side Effects Acute Dystonic reaction Ocular crisis Agranulocytosis Neuroleptic malignant syndrome Chronic Tardive dyskinesia Pseudoparkinsonism Photo sensitivity Weight gain

Thought Disorders 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 Disorders 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 Disorders 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 Disorders 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 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.” A.I know these voices are very real to you, but I don't hear them

Substance Abuse/Dependence Incidence Alcohol dependence/abuse 14% Drug dependence 3% Co-morbidity common Defense Mechanisms Rationalization, projection, denial CNS depressants Alcohol, benzodiazapines, barbituates

Substance Abuse 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 Maladaptive, reversible pattern of behavior Perceptual disturbances Sleep—wake cycle changes Disturbs attention, concentration, thinking, judgment, psychomotor activity Interferes with relationships

Substance Dependence 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 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 Dependence Mood swings, altered emotional state 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/Dependence 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 Delirium Tremens (DTs) 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 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

Vitamin 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 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: Alcohol Relapse prevention Accept as a chronic disease Self-help groups, AA Stress management Family support

Substance Abuse/Dependence 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/Dependence 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/Dependence 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/Dependence 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/Dependence 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 C. Withdrawal

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

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. D. Provide withdrawal care based on unit protocol.

Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.