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Nurse-Patient confidentiality
The patient should always be aware some information discussed (suicide plan) with the nurse must be
shared with other team members for the patient safety or optimal therapy.
As a result the nurse can never tell a client here she will not tell anyone about the discussion
Therapeutic Communication (Words to avoid on an exam)
you should.
Youll have to..
You cant..
If it were me Id
I think you
Dont worry.
Everyone..
Why?..........
just a second. I know..
Bad, right, wrong, or nice
Therapeutic communication (useful phrases)
tell me about.
Go on.
Id like to discuss what youre thinking.
What are your thoughts?...... are you saying that?........
what are you feeling?
It seems as if.
Basic communication principles for psychiatric patients
establish trust (number 1 intervention)
demonstrate a nonjudgmental attitude
offer self, be empathetic not sympathetic
use active listening
clarify & verify client statements
use a matter of fact approach
What is the most important nursing intervention when the psychiatric client describes a physical
problem?
1. Assessment (Asses, Assess, Assess)- Never ignore the psychiatric patients physical needs. If a
paranoid schizophrenia is complaining of chest pain check their blood pressure.
***FIVE TOP INTERVENTIONS FOR PSYCH PATIENTS**
1. safety
2. setting limits
3. establish trusting relationship
4. meds
5. leas restrictive methods & environment are always attempted first (offering a oral med, injecting
an IM med, then lastly placing the client in seclusion)
Common psychiatric conditions
1. Anxiety- unexplained discomfort, tension, apprehension or uneasiness, which occurs when a person feels a
threat to self. The threat may be real or imagined and is very subjective experience.
Levels of Anxiety
1. Mild anxiety
a. is associated with daily life & motivate learning
b. produces increased levels of sensory awareness and alertness
c. allows for logical thinking and problem solving
d. client appears calm and in control
2. Moderate anxiety
a. continues to motivate learning with assistance from others
b. allows for attentive focus and problem-solving but not at an optimal level
c. does perception of sensory stimuli; client becomes hesitant
d. client speech rate and volume increases; patient becomes a wordy
e. client becomes restless with frequent body movement and gestures
f. may be converted into his physical symptoms such as:
i. headaches, nausea, diarrhea, and tachycardia
3. Severe anxiety
a. simulates flight or flight response
b. cause a century stimuli input to be disorganized
c. causes distorted perceptions and him peers concentration and problem-solving ability
d. results and selective attention, focusing on only one detail at a time
e. causes tremors, increase motor activity such as pacing or wringing hands
4. Panic
a. causes perceptions to be grossly distorted; pt cant differentiate real from unreal
b. causes client to be unable to concentrate or problem solve, loss of rational logical thinking and
hallucinations may occur
c. causes the client to feel overwhelmed and helpless
Common physical responses to any level of anxiety
1. increased heart rate and blood pressure
2. rapid shallow respirations
3. dry mouth and tight feeling in the throat
4. tremors and muscle tension
5. anorexia
6. urinary frequency
7. Palmer sweating
Most important nursing intervention for a pt with anxiety: STAY CALM
anxiety is very contagious and easily transferred from person to person
a calmness helps the client to gain control, decreased anxiety, and increase feelings of security
Anxiety Disorders
1. Generalized Anxiety Disorder
Unrealistic, excessive, or persistent, (lasting six months or longer) anxiety and worry about two or more
life circumstances
2. Panic Disorders & Phobias
is characterized by an irrational fear of an external object, activity, situation, and feelings of impeding
doom
its a chronic condition that has exacerbations and remissions
Common Phobias
1. Acrophobia- fear of heights
2. Agoraphobia- fear of crowds are open places
3. Claustrophobia- fear of closed in places
4. Hydrophobia- fear of water
5. Nyctophobia- fear of the dark
6. Thanatophobia- fear of death
Nursing Interventions for Phobias
Desensitization- cannot occur until the nurse acknowledges the fear and establishes trust with the pt
assist client to recognize the factors associated with the feared stimuli
teach and practice with alternative adaptive coping strategies such as use of thought substitution
(replacing a fearful thought with a pleasant thought)
expose the client progressively to the feared stimuli offering support with the nurses presence
provide positive reinforcement when a decrease in phobic reaction occurs
that are should place and anxious client where there are reduced environmental stimuli (a quiet area of
the unit AWAY from the nurses station
Administer: SSRIs & other anti-anxiety meds
2. Obsessive-Compulsive Disorder (OCD)
Anxiety Associated with
o Obsessions (repetitive thoughts)
o Compulsions (perform an action)
Anti-Anxiety Medications
BENZODIAEPINES
Drugs
Chlordiazepoxise HCL (Librium)
Diazepam (Valium)
Alprazolam (Xanax)
Clorazepate Dispotassium
(Tranxene)
Lorazepam (Ativan)
NON- BENZODIAEPINES
Drugs
Buspirone (BuSpar)
Zolpidem (Ambien)
Ramelteon (Rozerem)
Indications
Reduce anxiety
Induce sedation, relax muscles,
inhibit convulsions
Treat alcohol and drug
withdrawal symptoms
Safer than the sedative-hypontics
Reactions
Sedation & Drowsiness are the
most common side effects for
Antianxiety Medications ***
Ataxia (uncontrolled movements)
Irritability
Blood dyscrasias (abnormal blood
cellular elements)
Habituation and increased
tolerance
Can cause respiratory depression
if mixed with another depressant
such as alcohol
Indications
Reduce anxiety
Help to control symptoms such
as insomnia, sweating, and
palpitations associated with
anxiety
Reactions
Dizziness
Daytime drowsiness
Dizziness
Nursing implications
Administer a bedtime to
alleviate daytime sedation
Greatest harm occurs when
combined with alcohol or other
CNS depressants
Instruct to avoid driving or
working around equipment
Gradually taper drug therapy
due to withdrawal effects: do
not stop suddenly
Used only as short-term drug
and has supplemented other
medications
Flumazenil (Romazicon)- Is
used to treat Benzodiazepine
Toxicity (Overdose)
Nursing implications
Is contraindicated for concurrent
use with MAOI antidepressant,
or for14 days after MAOIs are
D/C,
Taken several weeks for the
anti-anxiety effects to become
apparent
Intended for short-term use only
Give with food 1-1 hours
before bedtime
Appropriate for clients with the
late sleep onset
Selective serotonin reuptake inhibitors (SSRIs)- Used for the treatment of Anxiety Disorders
The first choice medication for anxiety disorders because they have less side effects but a longer half-life so that will take longer time for them to
work.
Drug name
Indications
Therapeutic Uses
Complications
Nursing Implications
1. Paroxetine (Paxil)
2. Sertraline (Zoloft)
3. Escitalopram
(Lexapro)
4. Fluoxetine (Prozac)5. Fluvoxamine (Luvox)
6. Duloxetine
(Cymbalta)
7. Citalopram (Celexa)
8. Vilazodone (Viibryd)
1. Generalized Anxiety
Disorder (GAD)
2. Depression
Disorders** 2 major
uses for SSRIs
3. Panic Disorder
4. OCD5. PTSD
6. Anorexia
7. Aggression
1. SSRIs are
contraindicated in clients
taken MAOIs or Tricyclic
antidepressants
2. Use SSRIs cautiously in
clients with liver and renal
dysfunction, seizure
disorders, or history of G.I.
bleeding
3. Use SSRIs cautiously in
clients who have bipolar
disorder d/t risk for mania.
4. Taken With Food in the
morning to minimize
sleep disturbances
5. Caution pt about use with
St.John Wort
Disassociative disorders
these disorders involve alteration in the function of consciousness, personality, memory, or identity.
They can be sudden and temporary or gradual and chronic
persons affected by these disorders handle social situations by splitting from the situation and going
into a fantasy state
Types of Disassociative disorders (most common)
1. Psychogenic Amnesia- is the sudden temporary inability to recall extensive personal information
Its usually occurs after a dramatic event such as a threat of death or injury, an intolerable life
situation, or natural disaster.
2. Psychogenic Fugue- is characterized by a person suddenly leaving home or work with inability to recall
his or her identity, they may even assume a new identity.
3. Dissociative identity disorder- is a presence of two or more distinct personalities with an individual, is
believed to be caused by child abuse
4. Depersonalization- is characterized by temporary loss of ones reality inability to feel an expression of
motions, patient describes a sense of strangeness and the surrounding environment.
Nursing Assessment: Signs & Symptoms
Depression, mood swings, insomnia, and potential for suicide
varying degrees of orientation & anxiety
Nursing Interventions
reduce environmental stimuli to decrease anxiety
stay with the client during periods of depersonalization
encourages client to identify stressful situations that can cause a transition from one personality to
another
help the client identify effective coping patterns
AVOID giving clients with dissociative disorders too much information about past events at one time.
Personality Disorders
Cluster A: Paranoid, Schizoid, Schizotypal (Odd or Eccentric)
Cluster B: Antisocial, Borderline, Histrionic, Narcissistic (Dramatic & emotional)
Cluster C: Avoidant, Dependent, Obsessive-Compulsive (Anxious, fearful)
Eating Disorders
1. Anorexia Nervosa
a. a voluntary refusal to eat (W/excessive exercise) & maintain a minimum weight for height & age
b. deals with issues of control (of their bodies & own weight) and struggle between dependence
and independents
Signs & Symptoms
c. weight loss of at least 15% of ideal or original body weight
d. excessive exercise
e. hair loss and dry skin
f. hypothermia (cool extremities)
g. Edema (peripheral)
h. Muscle weakness
i. Vital Signs: irregular heartbeat, decreased pulse and blood pressure (orthostatic hypotension)
resulting from decreased fluid volume could lead to heart failure
j. amenorrhea for at least three months
k. dehydration and electrolyte imbalance (decreased potassium, sodium, and chloride) from:
i. diet pill abuse, enema and laxative abuse, diuretic abuse or self-induced vomiting
Abnormal Lab Data
1. Thrombocytopenia (low platelets leads to hemorrhagic tendencies ) Decreased RBC
2. Hypokalemia (low potassium)
Decreased H&H
3. Abnormal LFTs and TFTs
Decreased Calcium
4. Increased serum Amylase with increased cholesterol
Hypoglycemia
2. Bulimia Nervosa- an eating disorder characterized by eating excessive amounts of food followed by
self-induced purging by vomiting, misuse of laxatives, diuretics, fasting, or extensive exercise.
Bulimia deals with loss of control by binge eating in guilt by purging
Signs and Symptoms of Bulimia
diarrhea or constipation, abdominal pain, bloating
dental damage due to excessive vomiting (gastric hydrochloric acid erodes dental enamel)
sore throat and chronic inflammation of the esophageal lining, with possible ulceration and
hoarseness while talking
Parotid swelling
Russells Sign- calluses of the knuckles
not usually underweight
Often use syrup of ipecac to induce vomiting. *** if ipecac is not vomited and is absorbed,
cardiotoxicity may occur and can cause conduction disturbances, fatal myocarditis, and circulatory
failure.
EKG changes: cardiac dysrhythmias
Abnormal Lab Values
Hypokalemia & Hyponatremia Hypokalemia- (normal 3.5-5mEq/) decreased potassium- muscle
cramps, thirst, drop in BP, arrhythmias & can lead to seizures.
Hypochloremia- decreased chlorine Cl (97-107)
Elevated serum amylase
History & Physical: Initial treatment for a new pt admitted to the hospital with a diagnosis of bulimia
1. Blood work (number 1 intervention, to evaluate electronic status)
2. cardiac monitoring
3. replenish electrolytes and fluid as indicated
4. careful monitoring for evidence of vomiting
Remember: With anyone with an eating disorder such as anorexia or bulimia have increased risk for
cardiac dysrhythmias and heart failure due to low potassium and electrolytes.
Nursing interventions: assess for edema and listen to breath sounds carefully
Treatment for eating disorders: usually family therapy is most effective because issues of control are
common in these disorders.
Mood Disorders
1. Depression disturbances in mood manifested by extreme sadness or extreme elation
Signs and symptoms of depression
the most important signs and symptoms of depression are a depressed mood with a loss of interest in the
pleasures in life.
Significant changes in appetite, weight (loss or gain),
insomnia or hyperinsomnia (pt often sleeps during the day d/t anxiety at night)
fatigue or lack of energy, abilities concentrate, preoccupation with death or suicide
feelings of hopelessness, worthlessness, guilt, or over responsibility
psychomotor retardation, gi complaints, and pain.
Abnormal Lab Test for Depression
Cortisol> 5 mg/dl
Decreased serotonin
a decrease in norepinephrine
Nursing Interventions:
***Assess for sudden elevation in mood & energy levels: this may indicate increased risk for suicide
o directly asked the client about feelings and plans of suicide or harming them self
o initiate suicide precautions if necessary
insist the pt participate in ADLs, do not give the pt a choice about participation (e.g. its time to go to
the gym for basketball)
Bupropion (Wellbutrin)- only antidepressant that does NOT cause weight gain
Nursing Intervention
1. Given at bedtime
2. Takes 2-6 weeks to obtain therapeutic effect
3. 1-3 weeks should elapse between DC tricyclics
and beginning MAOIs
4. Avoid use of antihypertensive drugs
5. Can be lethal in OD
****LITHIUM Mnemonic
L-level of therapeutic affect is 0.5-1.5*******
I-indicate mania
T-toxic level is 2-3 but S&S can begin at 1.5 mEq/L - N/V, diarrhea, tremors
H-hyrdrate 2-3L of water/day
I-increased UO and dry mouth
U-uh oh; give Mannitol and Diamox if toxic s/s are present
M-maintain Na intake of 2-3g/day
Lithium Toxicity Begins when levels are > 1.5 mEq/L
Early Signs & Symptoms of Lithium Toxicity
1. Diarrhea
2. vomiting
3. drowsiness
4. muscle weakness
5. lack of coordination
Adverse Reactions of Lithium
1. Nausea
2. fatigue
3. thirst
4. polyuria
5. fine hand tremors
6. weight gain
7. hypothyroidism
8. possible renal impairments
Medications\Food Interactions for Lithium
Diuretics- sodium is excreted with the use of diuretics, with decreased serum sodium (hyponatremia), lithium
excretion is decrease which can lead to toxicity
Maintain adequate hydration while on lithium 2,000ml-3,000ml per day
Maintain adequate intake of sodium (2-3g/day)
NSAIDs- (Ibuprofen (Motrin) Celebrex)- concurrent use will increase renal reabsorption of lithium, leading to
TOXICITY
Anticholinergics (antihistamines, tricyclic antidepressants) abdominal discomfort and can result from
anticholinergic-induce urinary retention and polyuria
Mood stabilizing antiepileptic (anticonvulsants) drugs (AEDs) used to treat bioloar
1. Carbamazepine (Tegretol)- used as an ALTERNITIVE to lithium
2. Valproic Acid (Depakote)- used alone or with lithium
3. Lamotrigine (Lamictal) used or alone or with others
Schizophrenia- psychiatric disorder characterized by thought disturbance, altered effect, withdrawal from
reality, regressive behavior, difficulty with communication, and it appeared interpersonal relationships
Signs and symptoms of schizophrenia (4 As)
1. Autism (preoccupied with self)
2. Affect (flat)
3. Associations (loose associations -lack of clear connection from one thought to the next)
4. Ambivalence (difficulty making decisions)
Delusions- fixed false belief that cannot be changed by reason
Hallucinations- false sensory perception usually auditory or visual in nature
Illusions- misinterpretation of external environment
o
Benzos (Ativan, Lorazepam, etc) good for Alcohol withdrawal and Status Epilepticus
o
Antabuse for Alcohol deterrence Makes you sick with OH intake
o
Alcohol Withdrawal = Delerium Tremens Tachycardia, tachypnea, anxiety, nausea, shakes,
hallucinations, paranoia (DTs start 12-36 hrs after last drink)
o
Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose, dilated pupils, NVD, cramps
o
Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep
126. SSRIs (antidepressants) take about 3 weeks to work.
127. Obsession is to thought. Compulsion is to action
128. if patients have hallucinations redirect them. In delusions distract
them.
129. Thorazine, haldol (antipsychotic) can lead to EPS (extrapyramidal side
effects)
130. Alzheimers disease is a chronic, progressive, degenerative cognitive disorder that accounts for more
than 60% of all dementias
1. Used to
control
psychiatric
behavior
are less sedated
than
Phenothaiazines
Nursing Intervention
1. Takes 2 to 3 weeks to achieve therapeutic effect
2. Keep the client SUPINE for 1 hour after
administration and advise to change positions slowly
because of effects of orthostatic hypotension
3. Teach to avoid
1. Alcohol
2. Sedatives (will potentiate effects of CNS
depressants)
3. Antacids (will reduce absorption of the drug)
1. Severe extrapyramidal
reactions
2. Leukocytosis
3. Blurred vision
4. Dry mouth
5. Urinary retention
Adverse Reactions
1. Risperdal- neuroleptic
malignant syndrome (NMS), EPS,
dizziness, G.I. symptoms (Nausea
& constipation) & anxiety
2. Zyprexa- drowsiness, dizziness,
EPS, agitation
3. Seroquel- drowsiness, dizziness,
headache, EPS, weight gain &
anticholinergic effects
4. Clozapine- agranulocytosis is a
major concern
Nursing Intervention
1. Monitor WBC weekly for the first six months than
biweekly
teach patient to change positions slowly
Seroquel- Monitor lipids, especially for obese,
diabetic, or hypertensive clients
Long-Acting Meds
Haldol Decanoate & Fluphenazine
Deconate
ATYPICAL ANTIPSYCHOTIC DRUGS
Drugs
Indications
1. Risperidone (Risperdal) 1. Treat positive &
2. Olanzapine (Zyprexa)
negative symptoms of
3. Quetiapine (Seroquel)
schizophrenia without
4. Aripiprazole (Ablify)
significant EPS
5. Ziprasidone (Geodon)
2. Use for clients who do
6. Clozapine (Clozaril)
not respond well to
typical antipsychotics
3. Clozapine has
superior efficacy
inclined to have been
treatment resistant
Substance Abuse
Alcohol withdrawal symptoms:
Begin shortly after drinking stops, as early as 4 to 6 hours after.
Nausea, anxiety, insomnia, tremors, hyperalertness, & restlessness
Sudden or gradual increase in all vital signs (autonomic hyperactivity)
use of denial and rationalization as coping mechanisms- they use must be confronted so the client
accountability for his or her own behavior can be developed
** *Delirium Tremens: (DTs) may appear 12 to 36 hours after the last drink, signs and symptoms include:
1. tachycardia, tachypnea, diaphoresis
2. Anxiety
3. Nausea
4. Shakes
5. Marked tremors
6. hallucinations
7. paranoia
8. confusion
Chronic alcohol-related illnesses:
1. Chronic gastritis
2. Cirrhosis and hepatitis
3. Korsakoff syndrome: is a syndrome that frequently follows DTs associated with chronic alcoholism
a. Caused by a lack of Thiamine (B1) in the brain
4. Wernicke Syndrome: consisting of encephalopathy (a severe life-threatening disorder) occurring in
chronic alcoholics, due to deficiency of vitamin B1. Is treated with Thiamine chloride
5. Malnutrition and dehydration
6. Pancreatitis
7. peripheral neuropathy
Nursing interventions during alcohol withdrawal
1. maintain safety, nutrition, hygiene, and rest
a. nutrition is a priority because alcohol and drug intake has superseded the intake of food
2. implement suicide progresses if assessment indicates risk
3. prevent aspiration by implementing seizure precautions
4. reduce environmental stimuli
Benzodiazepines: Including Antianxiety medications are used in Alcohol Withdrawal
1. Usually Librium or Ativan
2. Valium or Xanax can also be used
5. provide a high protein diet with adequate fluid intake
6. provide vitamin supplements especially vitamins B1 and B complex
Alcohol Deterrents- are used as treatment for alcoholism but not withdrawals:
client teaching should include the effects of consuming any alcohol while on such medications, severe
side effects can occur at any alcohol is mixed with Antabuse. They include
o nausea vomiting
o hypotension and headaches
o rapid pulse respirations
o flushed face and bloodshot eyes
o confusion
o chest pain
o weakness or dizziness
encourage clients to read all the labels of over-the-counter medications & food products that may contain
small amounts of alcohol, should be avoided.