HESI Psychiatric Nursing

Types of Treatment Modalities………………………………..……1

Therapeutic Communication………………………………......……2

Common Psychiatric Disorders

Anxiety, 4
Phobias, 5

Antianxiety Med [Med table]

Benzodiazepine, 6
Nonbenzodiazepine, 6
SSRI, 7
OCD…………………………………………………………………7
PTSD………………………………………………………………...8
Somatoform Disorders……………………………………………....8
Dissociative Disorders……………………………………………….9
Personality Disorders……………………………………………….10

Eating disorder
anorexia 10
bulimia 11

Mood disorder………………………………………………………12
Depression, 13
Bipolar disorder, or manic depressive illness, 14

Antidepressants Medication [Med table]

Tricyclics 15
MAOIs 15

Thought disorders
Schizophrenia, 16

Psychotic Med [Med Table]

Typical Antipsychotics (Phenothiazines), 19
Atyipical Antipsychotics drugs, 20

Substance Abuse ………………………………………………….20

Child Abuse ……………………………………………………….21
Organic Disorder…………………………………………………. 22
Childhood and Adolescent disorders………………………………23
Types of treatment modalities
1. Milieu therapy= taking care of patient/ environment
a. focuses on the here and now (assisting the client in dealing with the realities of today rather
than focusing on situation and behaviors of the past
b. it uses limit setting
2. Behavior modification
a. this process is used to change ineffective behavior patterns: if focuses on the consequences
of action rather than peer pressure
b. positive reinforcement- is used to strengthen desired behavior
c. negative reinforcement- is used to decrease or eliminate inappropriate behavior
3. Family therapy
a. Identifies the entire family as a client
b. Based on the concept of the family as a system of interrelated parts forming a whole
c. The focus is on the patterns of interaction within the family not on any individual member.
4. Crisis intervention= short term.
a. Is directed at the resolution of immediate crisis
5. Cognitive therapy= counseling
6. ECT- involves the use of electronically induce seizures for psychiatric purposes
a. Its use would severely depressed clients who failed to respond to antidepressant medication
and therapy
b. Often used with extremely suicidal clients because two weeks are usually needed for
antidepressant to take effect, while this therapy produces results more quickly.
Nursing care prior
T to ECT
1. prepare the client by teaching what the treatment involves
2. avoid the word shock
3. administer anticholinergic (atrophine sulfate) 30 minutes before treatment to dry
oral secretions and prevent aspiration
4. A quick acting muscle relaxant (succincholine [Anectine]) or a general anesthetic
agent such as methohexital sodium is given to the client before the ECT
5. Have emergency cart, suction equipment and oxygen available in the room

Nursing care after ECT

1. Maintain patient airway: client is unconscious immediately following ECT
2. Check vital sign every 15 minutes until client is alert
3. Reorient client after ECT(confusion is likely upon awakening)

Common Side Effects Following ECT

1. headache
2. muscle soreness
3. nausea- very common
a. Vomiting by an unconscious client can lead to aspiration, because post ECT clients
are unconscious. The nurse must observe closely for the possibility of aspiration.
Always remember to maintain a patent airway.
4. Retrograde amnesia (short-term memory loss/impairment)

2
 Therapeutic Communication
 The goal of therapeutic communication is to allow the client the autonomy to make choices
when appropriate
 Keep statements value free, advice free, and false reassurance free (i.e. Everything is going
to be okay)
 Just remember the facts not opinions
 The nurses nonverbal communication may be more important than the verbal

Nurse-Patient Confidentiality
 The patient should always be aware some information discusses (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 that she will not tell anyone about the discussion

Therapeutic Communication (words to AVOID on an exam)

 You should… You’ll have to…
 You can’t… If it were me I’d…
 I think you… Don’t worry…
 Everyone… Why?...
 Just a second… I know…
 Bad, right, wrong, or nice

Therapeutic Communication (useful phrases)

 Tell me about… Go on…
 I’d like to discuss what you’re thinking…
 What are your thoughts… Are you saying that?...
 What are your feelings? It seems as if…

Basic Communication principles of psychiatric patients

 Establish trust (number 1 intervention)
 Demonstrate a nonjudgmental attitude
 Offer self, be empathetic not sympathetic
 Use active listening
 Clarify and verify clients statements
 Use a matter of fact approach

What is the most important nursing intervention when the psychiatric client describes a physical
problem?
1. Assessment (ASSESS, ASSESS, ASSESS!)- never ignore the psychiatric patient physical needs.
a. If a paranoid schizophrenia is complaining of chest paint, then check their blood pressure
b. If OB client who has delivered a dead fetus complains of perineal pain- look at the perineal
area (she may have hematoma)
c. Just because the focus of the client’s situation is on his/her psychological needs, it does not
mean that the nurse can ignore physiological needs
3
***FIVE TOP INTERVENTIONS FOR PSYCH PATIENTS***
 Safety
 Setting limits
 Establishing trusting relationship
 Meds
 Least restrictive methods, and environment are always attempted first (offering an 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 a very subjective experience

Levels of Anxiety
1. Mild Anxiety
a. Is associated with daily life and 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 increase the perception of sensory stimuli; client become hesitant
d. Client speech rate and volume increases; patient becomes wordy
e. Client becomes restless with frequent body movement and gestures
f. May be converted into physical symptoms such as
i. Headaches, nausea, diarrhea and tachycardia

3. Severe Anxiety
a. Simulates fight or flight response
b. Cause sensory stimuli input to be disorganized
c. Causes distorted perceptions and decrease concentration and problem-solving
ability
d. Results in selective attention, focusing only on one detail at a time
e. Causes tremors, increase motor activity such as pacing or wringing hands
NEW:
Physical symptoms appear: headaches, palpitations, insomnia, trembling, diarrhea, urinary frequency,
tachycardia, and nausea.-Emotional symptoms appear: confusion, dread, horror…may be evident
oIntense need to relieve the anxiety
-Basically all overt behavior is aimed at relieving the anxiety.
-Neurosis: excessive anxiety that is either expressed as is or as a defense mechanism
oCommon symptoms: phobias, sexual dysfunction, compulsion/obsession
oCharacteristics: person is aware of maladaptive behaviors and distress, feel helpless, don’t lose contact w/
reality, BUT unaware of possible psychological causes of distress

4
 4. Panic
a. Causes perceptions to be grossly distorted; client can’t 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 overwhelm and helpless
NEW:
Misperceptions are common, and a loss of contact with reality may occuro
Person may experience hallucinations or delusions-Human functioning and communication with others is
ineffective
Person may feel terror and individuals may be convinced that they have a life-threatening illness or fear
that they are “going crazy,” are losing control, or are emotionally weak.
O May exhibit bizarre behaviors like: shouting, screaming, running around wildly, clinging to
anyone/thing that provides sense of safety and/or extreme withdrawal.
Can eventually lead to psychosis.
-Physical and emotional exhaustion and can be a life-threatening situation if a person is in this state for a
prolonged amount of time
-Physical characteristics:dilated pupils, labored breathing, severe trembling, diaphoresis/pallor, muscular
incoordination, incoherence/unable to verbalize
-Psychosis: characterized by impaired reality via hallucinations, delusions, disorganized, catatonic behavior
oPt. is unaware of maladaptive behavior/psychological problem, exhibit minimal distress (ex. flat
tone/inappropriate), attempting to mentally escape stressful world into a less stressful world in
which they are trying to adapt

Common physical responses to any level of anxiety

1. Increased heart rate ad 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 client 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
a. Unrealistic, excessive or persistent (lasting six months or longer) anxiety and worry
about two or more life circumstances
2. Panic Disorders and Phobias
a. Is characterized by an irrational fear of an external object, activity, situation and
feelings impeding doom
5
 b. It’s a chronic condition that has exacerbations and remissions

Common Phobias
1. Acrophobia- fear of heights
2. Agoraphobia- fear of crowds and open places
3. Claustrophobia- fear of closed in spaces
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 patient
 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 (rplacing a fearful thought with a pleasant thought)
 Expose the client prograssively to the feared stimuli; offer support with the nurse presence
 Provide positive reinforcement when a decrease in phobic reaction occurs
 The nurse should place an anxious client where there are reduced environmentla stimuli ( a
quiet area of the unit AWAY from the nurses station)
 Administer: SSRIs and other anti-anxiety meds

6
Anti-Anxiety Medications
BENZODIAZEPINES
Drugs Indications Reactions Nursing Implications
Chlodiazepoxise Reduces anxiety Sedation and Administer at bedtime
HCL (Librium) Induce sdation, relax Drowsiness are the most to alleviate daytime
Diazepam (Valium) muscles, inhibit common side effects for sedation
Alprazolam ( convulsions antianxiety Greatest harm occurs
Xanax) Treat alcohol and drug medications*** when combined with
Clorazepate withdrawal symptoms Ataxia (uncontrolled alcohol or other CNS
Dispotassium More safe than the movements) depressants
(Tranxene) sedative- hypontics Irratibility Instruct to avoid
Lorazepam (Ativan) Blood dyscrasias driving or working
(abnormal blood cellular around equipment
elelments) Gradually taper drug
Habituations and theraphy due to
increases tolerance withdrawal effects do
Can cause respiratory not stop suddenly
depression if mixed with Used only as short-
another depressant such term drug and has
as alcohol supplemented other
medications
★Flumazenil
(Romazicon)- is used to
treat Benzodiazepine
Toxicity (Overdose)

NON- BENZODIAZEPINES
Drugs Indications Reactions Nursing Implications
Buspirone (BuSpar) Reduces anxiety dizziness contradicated for
Help to control concurrent use with
symptoms such as MAOI antidepressant, or
insomnia, sweating, and for 14 days after MAOIs
palpitations associated are D/C
with anxiety it takes several weeks
for the anti-anxiety
effects to become
apparent
intended for short-term
use only
Zolpidem (Ambien) Used for short-term Daytime drowsiness Give with food 1- 1 ½
treatment of insomnia hours before bedtime

7
 Ramelteon (Rozerem) approved for long- dizziness appropriate for clients
term treatment of with the late sleep onset
insomnia
selectively binds to
belatonin receptors
Selective serotonin inhibitiors (SSRIs)- used for the treatment of Anxiety
DisordersThe first choice medication for anxiety disorders because they have less side effects but a longer
half-life so that it will take longer time for them to work
Drug Name Indications Therapeutic Uses Complication Nursing Implications
1.Paroxetine 1.Allow more 1.generalized 1.Serotonin 1.SSRIs are
(Paxil) serotonin to stay at anxiety disorder syndrome: contradicated in
the junction site of (GAD) *** client that have taken
2.Sertraline the neurons MAOIs or Tricyclic
(Zoloft) 2. Depression 2. Sexual antidepressants
2.it does not block Disorders ** 2 dysfunction
3.Escitalopram reuptake of major uses for 2. Use SSRIs
(Lexapro) dopamine or SSRIs 3.Weight Gain cautiously in clients
norepinephrine with liver and renal
4.Fluoxetine 3.Panic Disorder dysfunction, seizure
(Prozac) 3.causes CNS disorders, or history of
stimulations, which 4.OCD HI bleeding
5. Fluvoxamine causes insomia
(Luvox) 5.PTSD 3.Use SSRIs
4.has an extensively cautiously in clients
6.Duloxetine long half-life, about 6.Anorexia who have bipolar
(Cymbalta) 5 weeks are disorder d/t risk for
necessary to 7.Aggression mania
7.Citalopram produce therapeutic
(Celexa) medication levels 4. taken with food in
the morning to
8.Vilazodone minimize sleep
(Viibryd distubrances

5.caution pt about use

with St.John’s Wort

*** Serotonin Syndrom: is define by at least three of the following symptoms***

1. rapid onset (2-72 hours after the initiation of treatment ) and altered mental state
2. agitation
3. myoclonus
4. hyperreflexia
5. fever
6. shivering
7. diaphoresis
8. ataxia
9. diarrhea

8
Obsessive-Compulsive Disorder (OCD)
 Anxiety Associated with
o Obsessions ( repetitive thoughts)
o Compulsions (perform an action)

Nursing Assessments: Signs and Symptoms of OCD

 Fear of losing control
 Reoccuring intrusive thoughts and repetitive behaviors that interfere with normal functioning
 Magical thinking (belief that one’s thoughts or wishes can control other people or events)
 Evidence of destructive, hostile, aggressive and delusional thought content
 Interference with normal activities
 Safety issues involved in repetiitve performance of ritualistic acitivity (i.e. dermatiitis occurs a s a
result of continuous hand washing)

Nursing Interventions for OCD

 Allow performance of compulsive acitivity while attention is given to safety but not reinforceing it
 Explore meaning and purpose of the behavior
 Avoid punishing and criticizing
 Establish a routine to avoid anciety producing changes
 **limit the time for performance of ritual, and encourage the client to gradually decrease the
time.
 Administer- antianxiety medications, SSRIs, and tricyclic antidepressants

HESI HINTS associated with OCD

 The best time for Nurse- Client interaction is at the completion of the performed ritual. The client
anxiety is lowest at this time, therefor it is an optimal time for learning
 Compulsive acts ae used in response to anxiety, which may or may not be related to the obsession.
 Interfering with compulsions will increase anxiety, they should be allowed if they are violences free
The nurse should:
o Actively listen to the client’s obsessive themes 

o Acknowledge effects that ritualistic acts have on the client 

o Demonstrate empathy 

o Avoid being judgemental

PTSD
For clients with postraumatic stress disorder, the nurse should:


 Actively listen to client’s stories of experiences surrounding the traumatic event

 Assess suicide risk
 Assist client to develop objectivity about the event and problem solve regarding possible means of
controlling anxiety related to the event 

 Encourage group therapy with other clients who have
experienced the same or related traumatic
events 


9
Somatoform Disorders
 A group of disorders characterized by the expression of unexplained physical symptoms that have
no physical basis.
 Somatoform disorders occur more often in females and came before age 30
 Secondary Gain occurs when a child may learn physical complains are acceptable coping strategies
and are rewarded by receiving attention for this behavior
 these clients may abuse analgesics without relief from pain or discomfort

Types of Somatoform Disorders

1. Somatization Disorder- recurrent somatic complaints for which frequent medical attention is
sought byt no medical pathology is present ( i.e a pt complained of chest pain but ECG and cardiac
enzyme are normal)
2. Hypochondriasis – the belief in and fear of having a disease including mininterpretation of
physical signs as “proof” of the presence of the disease. ( a minor rash is believed to be serious such
as Lupus)
3. Conversion Disorder- characteried by transferring a mental conflict into a physical symptom for
which there is no organic cause (blindnes, paralysis, seizures, deafness, and pseudocyeis aka false
pregnancy)

Nursing Assessment: Signs and Symptoms of Somatoform Disorders

 Preoccupation with pain or bodily function for at least six months duration
 Absence of emotional conern regarding the physical impairment
 Women may report excessive dysmenorrheal
 Depression and presence of suicial idealiations
 Excessive use of analgesic or drug abuse
 Vital signs may be elevated as in a panic attack
 La Belle indifference- a term used to describe the lack of concern over a physical illness

Nursing Interventions (not treated with drugs long term because the illness is a cognitive
impairment not a physical, a one time dose of Benzo can be given IV or PO in the ED for acute sedation)
 Always acknowledges the symptom or complaint as real
 Re-affirm that diagnostic tests results reveal no organic pathology
 Determine any secondary gains acquire by the clinet (i.e reqard obtained from the “sick role”)
 Determine the primary gains ( i.e decrease in anxiety resulting from the ability to deal with the
stressful situation)
 Treatment is aimed at cognitive behavioral therapy or ECT

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
 Person affected by these disorders handle social situations by “splitting” from the situation and
going into a fantasy state

Type of Dissassociate Disorder (most common)

1. Psychogenic Ammnesia- is the sudden temporary inability to recall extensive personal information

10
 a. Its usually occurs after dramatic event such as a threat of death or injury, an intolerable life
situation or natural disaster
2. Psychogenic Fugue
a. Is characterized by a person suddenly leaving home or work with inability to recall his or
her identiy, they may even assume a new identity
3. Dissassociative identiy disorder
a. Is a presenc eof two or more distinct personalities with an individual, is believed to be
caused by child abuse
4. Depersonalization
a. Is characterized by temporary loss of one’s reality, inability to feel and expression of
motions, patient describes a sense of “strangeness” about the surrounding environment

Nursing Assessment: Sign and Symptoms

 Depression, modd swings, insomnia, and potential for suicide
 Varying degress of orientation and anxiety

Nursing Interventions
 Reduce environmental stimuli to decrease anxiety
 Stay with the client during periods of depersonilization
 Encourages client to identify stressfull situations that can cause a transiition from one personality to
another
 Help the client identify ffective coping pattenrs
 AVOID giving client with dissociative disorders too much information about past events at one
time.
o The various types of amnesia, which accompany dissociative disorders, provide protection
form pain. Too much, too sun, may cause decompensation.

Personality Disorders
Cluster A: Paranoid, Schizoid, Schizotypal (Odd or Eccentric) PSS
Cluster B: Antisocial, Borderline, Histrionic, Narcissistic (Dramatic and emotional) ABHN
Cluster C: Avoidant, Dependent, Obsessive-Compulsive (Anxious, fearful) ADO

 Personality disorders are long-standing behavioral traits that are maladaptive responses to anxiety
and cause difficulty in relating and working with other individuals. NCLEX-RN questions test
personality disorder content by describing management situations. 

 Persons with a personality disorder are usually comfortable with their disorder and believe that they
are right and the world is wrong. These individuals usually have very little motivation to change.
Think of them as a CHALLENGE. 


Eating Disorders
1. Anorexia Nervosa
a. Voluntary refusal to ear (w/ excessive exercise) & maintian a minimum weight for height &
age
b. Deals with issues of control (of their bodies & own weight) and struggle between
dependence and independents
c. People with Anorexia gain pleasure from providing others with food and watching them eat.
11
 These behaviors reinforce their perception of self-control. Do not allow these clients to plan
or prepare food for unit-based activities

Signs &symptoms
 Weight loss of at least 15% of ideal or original body weight
 Excessive exercise
 Hair loss and dry skin
 Hypothermia (cool extremeities
 Edema (peripheral)
 Muscle weakness
 Vital signs: irregular heartbeat, decrease pulse and blood presssure (orthostatic hypotension)
resulting from decreased fluid volume could lead to heart failure
 Amenorrhea for at least three months
 Dehydration and electrolyte imbalance (decreased potassium, sodium and chloride) from:
o Diet pill abuse, enema and laxative abuse, diuretic abuse or self-induced vomiting

Abnormal Lab Data

1. Thrombocytopenia (low platelets leas to hemorrhagic tendencies) Decreased RBC
2. Hypokalemia (low potassium) Decrease H&H
3. Abnormal LFTs and TFTs Decrease Calcium
4. Increase 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 laxative, diuretics, fasting or extensive
exercise.
a. bulimia deals with loss of control by binge eating in guilt and purging
Signs and Symptoms of Bulimia
 diarrhea or constipation, abdominal pain, bloating
 dental damage due to excessive vomiting (gastic hydrochloric acid erodes dental enamel)
 sore throat and chronic inflammation of the esopheageal lining, with possible ulceration and
hoarseness while talking
 parotid swelling
 Russell’s Sign- calluses of the knuckles
 Not usually underweight
 Often use syrup of ipecac to induce vomiting. *** if ipecac is not vomitted and is absorbed,
cardiotoxicity may occur and can cause conduction distubrances, fatal myocarditis, and
circulatory fialure
 EKG changes: cardiac dysrrythmias

Abnormal Lab Values

 Hypokalemia and hyponatremia
o Hypokalemia ( normal 3.5-5 mEq) cause muscle cramps, thirst, drop in BP, arrythmias and
can lead to seizures.
o Hypochloremia- decrease in chlorine Cl (97-107)
o Elevated serum amylase

12
 History and Physical: initial treatment for a new patient admitted to the hospital with a diagnosis
of bulimia
1. Blood word (number 1 intervention, to evaluate electrolyte 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: People with Bulimia often use syrup of ipecac to induce vomiting
which may cause cardiovascular problems such as congestive heart failure (CHF). Because
CHF is not usually seen in young people, it is often overlooked. Assess for edema and listen
to breath sounds carefully

Treatment for eating disorders: Physical assessment and nutritional support are a priority; the
physiological implications are great. Nursing interventions should increase self-esteem and develop
a positive body image. Behavior modification is useful and effective. Family therapy is most
effective since issues of control are common in these disorders. (Therapy is usually long term). 


13
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
pleasure in life
 Significant changes in appetite, weight (loss or gain)
 Insomnia or hyperinsomia ( pt often sleeps during the day d/t anxiety at night)
 Fatique or lack of energy, abilities to conentrate, preoccupation with death or suicide
 Feelings of hopelessness, worthlessness guilt, or over responsibility
 Loss of ability to concentrate or think clearly
 Psychomotor retardation, GI complaints, and pain
HESI HINTS:
 There are always drug questions on the NCLEX-RN. Here are some tips: Know common side
effects for drug groups. For example:
o Anti-anxiety drugs = sedation, drowsiness 

o Antidepressant drugs = anticholinergic effects, postural 
hypotension 

o MAO inhibitors = hypertensive crisis 

 Know specific problems or concerns for drug therapy. For example:
o Lithium requires renal function assessment and monitoring 

o Phenothiazines cause extrapyramidal effects (EPS); tardive dyskinesia can be
permanent if client is not assessed 
regularly for signs of tardive dyskinesia! 


 Know specific client teaching for drug therapy. For example:

o Phenothiazines = photosensitivity, need to wear protective 
clothing, sunglasses
o MAO inhibitors = dietary restrictions to prevent hypertensive 
crisis 

 Manic clients can be very caustic toward authority figures. Be prepared for personal “put
downs.
o Avoid arguing or becoming defensive.
 What activities are appropriate for a manic client? = Noncompetitive physical activities, which
require the use of large muscle groups.
 Where should a manic client be placed on the unit? = Make every attempt to reduce stimuli in
the environment. Place the client in a quiet part of the unit.
 What interventions should the nurse use if a client becomes abusive?
o Redirect negative behavior or verbal abuse in a calm, firm, 
non-judgmental, non-
defensive manner 

o Suggest a walk or physical activity 

o Set limits on intrusive behavior. For example, “When you 
interrupt, I cannot
explain the procedure to the others; please 
wait your turn.” 

o If necessary, seclude or administer medication if client 
becomes totally out of
control. Always remember to use compassion because nurses are “nice” people. 

o Two atypical antipsychotic drugs are also indicated for mania (risperidone and olanzapine).

14
 Abnormal Lab Test for Depression
 Cortisol >5 mg/dL
 Decreased serotonin
 A decrease in norepinephrine

Nursing Interventions:
 *** Assess for sudden elevation in mood and energy: this may indicate increased risk for
suicide
o directly asked the client about feelings and plans of suicide or hamring themself
o initiate suicide precaution if neccesary
 insist the patient participate in ADLs, do not give the pt a choice about patitipation (e.g it’s
time to go to the gym for basketball)
 administer antidepressant medications
 Tricyclic
 MAOI
o Easy way to remmebr MAOI’S! Think of PANAMA!
 PA- parnate
 NA- naradil
 MA- marplan
 SSRI
 Atypical
o Trazodon (Desryl)
 SNRIs
o Bupropion (Wlbutrin)- only antidepressant that does NOT cause weight gain
o All the other info is the same as SSRI
 *****Remember: when aswering HESI/NCLES questions you are at Utopia general and
there’s plenty of time & staff to provide ideal nursing care. DO not let the realities of
clinical situations to tear you from choosing th best nursing intervention
o ****the best intervention for depressed patient is to sit quietly with the client,
offering support with your presence.
o Spend time with client to return when promised
o Depressed clients have difficulty hearing and accepting complements because of
their lowered self-concept
 Comment on signs of improvedment by noting the behavior (i.e I noticed
you comb your hair today, NOT you look nice today because the client can
also intepret that as them not looking nice other days.)
o The nurse knows depressed clients are improving when they begin to take an
interest in their parents or begins to perform self-care activities that were previously
of little or no interest
 Suicide Precautions
o Obtain a history: a previous suicide attempt is the msot significant risk factor
o Always stay with the client: never leave a suicida patient alone
Warning signs of impeding suicide attempt
 a client begins giving away his or he rpossesions
 a previously depressed client becomes happy. This indicated here that he or she
has made the decision to commit suicide, is no longer debating the possibility
and has figured out how to accomplish the suicide

15
 2. Bipolar Disorder, or Manic-Depressive Ilness
a. Is an affective disorder manifested by mood swings including euphoria, grandiosity, and an
inflated snese of self-worth
b. To be diagnosed with bipolar disorder, the patient must have at least one episode of major
depression. A client may cycle. Going from elevation to depression, with periods of normal
activity in between.
Treatments:
Number 1 Med of choice for Bipolar Disorder is Lithium
Lithium Carbonate #1 med use to treat bipolar especially during the manic phase
Normal Lithium level is between 0.8-1.2 mEq****
a. ***Nursing interventions monito serium lithium levels carefully *****
b. the thearpeutic and toxic levels are very close to each other on the readings. Signs of toxicity
are evident when lithium levels are mroe than 1.5 mEq/L
c. blood levels should be drawn 12 hours after the last dose was given.
d. While on Lithium the patient requires renal function asessment and monitoring

16
Tricyclics Antidepressant (cause anticholinergeic Effects)*** Treat DEPRESSION
Drugs Indications Adverse Reactions Nursing Intervention
1.Amitriptyline (Elavil) 1.Depressions 1.Anticholinergic side 1.Given at bedtime
2.Desipramine effects (DRY 2.take 2-6 weeks to
(Norpramin) EVERYTHING) obtain therapeutic levels
3.Imipramine (Tofranil) dry mouth 3.1-3 weeks should
4.Nortriptyline (Aventyl) blurred vision elaspe between DC
5. Protriptyline photophobia tricyclics and beginning
(Vivavtil) urinary hesistancy or MAOIs
Maprotiline retention 4.Avoid the use of
(Lumdiomil) constipation antihypertensive drugs
2.Cannot be taken with 5.Can be lethal in OD
MAOIs due to
development of a
hypertensive crisis
3. postural hypertension
4.tachycardia
5. GI: Nausea and
vomitting

Monoamine Oxidase Inhibitors (MAOIs)- last resort for depression

These medications block MAO-A in the brain thereby increasing the amount of norepinephrine,
dopamine and serotonin available for transmission of impulses. An increased amount of those
neurotransmitters at nerve endings intensifies responses and relieves depression
Drugs Indications Adverse Rections Nursing Intervention
1.Phenelzine (Nardil) 1.Depression ***Hypertensive Crisis 1. Must NOT be used with
2.Isocarboxazid 2.Phobias resulting from intake of dietary tricyclics
(Marplan) 3.Anxiey tyramine or combination of 2.Need for dietary
3.Tranylcypromide Tricyclic- severe hypertension as restriction of tyramine,
(Parnate) a result of intensive foods that contain it:
4.Selegilne (Eldepryl) vasoconstriction and stimulation aged cheese
of the heart red wine or beer
Remember PANAMA Manifestations may include: liver
Severe hYPERTENSION yeast
Headache yogurt
nAUSEA/VOMITING soy sauce
Increased Heart Rate chocolate
Fever bananas
Sweating 3.Do not take with SSRIs
2. Urinary hesistancy, 4.Pt cannot take OTCs
constipation unless prescribed by the
3.Impotence HCP
4.Dizziness &dROWSINESS** 5.Warnin signs of
5.Fluid Retention hypertensive crisis
6.Confusion headaches
7.Muscle Twitching palpiations
17
 8.Insomnia increased BP

***LITHIUM Mnemonic
L- level of therapeutic affect is 0.5-1.5 ******
I- indicate mania
T- toxic level level 2-3 but S&S can begin at 1.5 mEq/L- N/V, diarrhea, tremors
H- hydrate 2-3 L of water/day
I-increase UO and dry mouth
U-uh oh; give Mannitol and Diamox if toxic s/s are present
M- maintain Na intake of 2-3 g/day

Lithium Toxicity Begins when levels are > 1.5 mEq/L

Early Signs and symptoms of Lithium toxicity
1. Diarrhea
2. Vomitting
3. Drowsiness
4. Muscle Weakness
5. Lack of coordination
Adverse Reactions of Lithium
1. Nausea
2. Fatique
3. Theirst
4. Polyuria
5. Fine hand tremors
6. Wieght gain
7. Hypothyroidism
8. Possible renal impairments
Kind of like hypoglycemia, give mannitol which is sugar to fix the toxicity

Medications and Food Interaction for Lithium

Diuretics- sodium is excreted with the use of diuretics, with decrease sodium (hponatremia), lithium
excretion is decrease which can lead to toxicity
 Maintain adequate hydration while on lithium 2,000ml-3000ml per day
 Maintain adequate intake of sodium (2-3 g/day)

NSAIDs- (ibuprofen (Motrin) Celebrex)- concurrent use will increase renal reabsorption of lithium, leading
to TOXICITY
Anticholinergics (antihistamines, tricyclic antidepressant) abdominal discomfort and can result from
anticholinergic-induce urinary retention and polyuria
Mood stabiizing antiepileptic (anticonvulsants) drugs (AEDs) used to treat bipolar
1. Carbamazepine (Tegretol)- used as an ALTERNATIVE to lithium
2. Valproic Acid (Depakote)- used alone r with lithium
3. Lamotrigine (Lamictal) used or alone with others

Thought Disorders: Schizophrenia- psychitric disorder characterized by thought

disturbance, altered effect withdrawal from reality, regressive behavior, difficulty with communication, it
appeared interpersonal relaitonship
18
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 decision)

Delusions- fixed false belief that cannot be changed by reason

Hallucinations- false sensory perception usually auditory or visual in nature
Illusions- misinterpreation of external environment

Nursing interventions for a delusional verus hallucinating client

Client is Delusional
1. Encourage recognition of distorted reality
2. (?)Denver focus from delusional thought to
reality; do not permit rumination on false
light years
3. Do not argue with or support the delusions
4. Be very matter-of-fact
5. Avoid physically touching the patient
6. Administer antipsychotic drugs
7. Administer antiparkinsnian drugs
Client is hallucinating
1. Protect the patient from injury that may
result from responding to auditory
commands
2. Avoid denying arguing with client about the
hallucination
3. Discuss your observations with the client (
you appear to be listening to something)
4. Make frequent but brief remarks to intepret
the hallucination

Antipsychotic Medications used to treat Schizophrenia (and psychosis)

Medications are used to treat:
1. Positive symptoms related to behavior, thoughts, speech (agitaiton, delusions, hallucinations,
tangential speech patterns)
2. Negative symptoms (social withdrawal, lack of emotion, lack of energy, flattened affect, decrease
motivation, decreased pleasure in activities)

1. Typical Antipsychotics (Phenotaiazines (Conventional)

 Treats only positive symptoms
 Causes increased extrapyramidal effects (EPS) more than atypical
 Increased anticholinergic effects (dry everything)
 ***Cause photosensitivity: so clients must wear protective clothing and sunglasses***
 Anticholinergic Drugs are given to people on typicals to help reduce the EPS

2. Aytpical antipsychotic agents

 Advantages of atypical antipsychotic bagents include
o Relief of both positive and negative symptoms
o Decrease in affective symptoms ( depression and anxiety) and suicidal behaviors
o Improvement of neurocognitive defects, such a poor memory
o Fewer or no extrapyramidal symptoms (EPS), including Tardive dyskinesia, due to less
dopamine blockade.
o Fewer anticholinergic effects, with the exception of Clozapine (Clozaril), which has a high
incidenc eof anticholinergic effects. This is because msot of the atypical antipsychotics
cause little or no blockade of cholinergic receptors
o Less relapse
3. Anticholinergic Drugs
19
  Helps reduce Extrapyramidal effects (EPS)
 Causes Anticholinergic Effects : they include (drying)
o Dry mouth => can’t spit
o Uirnary retention=> can’t pee
o Constipated => can’t shit
o Blurred vision=> can’t see

Anticholinergic Drugs Include

1. Trihexyphenidyl HCL (Artane)
2. Benztropine mesylate (Congentin)
3. Amantadine (Symmetrel)

Side Effects of Psychotropic Drugs and Nursing Interventions

Blood Dyscrasias
1. Agranulocytosis- occurs in the first weeks of treatment, as evident by sore throat, fever, or chills.
Very important to protect the patient from infections.
2. Thrombocytopenia: decreased platelet, as evidenced by bruises easily, petechia, teach the patient
safety measures and implement bleeding precaustions as necessary.

Extrapyramidal Side Effects (EPS)*** Mainly caused by Typical Antipsychotics

1. Akathisia- psychomotor restlessness including pacing or fidgeting, foot taping, rocking. Inability to
sit still
a. Manage symptoms with: Beta-blocker, benzodiazepines or anticholinergic medication
2. Acute dystonia- can occur as early as 1-2 days after initiation of treatmentL
a. It includes: contraction/spasms of muscles, usually in the head and neck, spontaneous,
painful. Uncoordinated jerky movement, difficulty speeking (dysarthria) & Bdiificulty
swallowing (dysphagia)
b. Treat with anticholinergic agents- such as benztropine (Cogentin) or diphenhydramine
(Benadryl)
3. Pesudoparkinsonism- rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia,
mark-like face (signs and symptoms seen in Parkinson’s)
a. Treat with anticholinergic agents- such as benztropine (Cogentin) or diphenhydramine
(Benadryl) or amantadine (Symmeterel)
4. ***Tardive Dyskinesia 9TD or TDK)- is a persistent, serious, irreverisble EPS that usually appears
after prolonged treatment & persists even after the medication has been discontinued.
a. TDK- consists of involuntary tonic muscular contractions/spasms that typically involve the
toungue, fingers, toes, neck trunk or pelvus.

Other side effects of Antipsychotic Medication

1. Photosensitivity- when in contact with sunlight exposed skin turns blue in color; changes occur in
the eyes but do not cause vision impairment
a. Nursing interventions will include teahcing the client to stay out of the sun, wearing
protective clothing ans sunglasses. Discoloration of the skin will disappear wihtin six
months after drug is disconinuted.
2. Neuroleptic Malignant Syndrome (NMS)- is a life-threatening emergency: Signs and Symptoms:
a. High fever
b. Tachycardia
c. Stupor
d. Increased respirations
20
 e. Severe muscle rigidity
Nursing Interventions for NMS
1. Early recognition is important, and transportation to a medical facility is indicated
2. Hydration with IV fluids
3. Nutritional support
4. Treatment of possible respiratory failure in renal failure
3. Serotonim Syndrome- includes confusion, disorientation, automatic dysfunction. It’s the nursing
responsibilities to notify the healthcare provider STAT

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
halluincations, paranoia… (DTs start 12-36 hrs after last drink)
o Opiate (heroin, morphine, etc) Withdrawal= watery eyes, runny nose, dilated pupils, NVD, cramps
o Stimulant Withdrawal= depression, fatique, anxiety, disturbed sleep

126. SSRI’s (antidepressants) takes about 3 weeks to work

127. Obsession is to thought. Compulsion is to action.
128. If patients have hallucinations redirect them. In delusion distract them.
129. Thorazine, haldol (antipsychotic) can lead EPS (extrapyramidal side effects)
130. Alzheimer’s disease is a chronic, progressive, degenrative cognitive disorder that accounts for more
than 60% of all dementias

TYPICAL ANTIPSYCHOTICS DRUGS (PHENOTHIAZINES)

Drugs Indications
1.Chlorpromazine HCL
(Thorazine)
2.Trifluoperazine HCL
(Stelazine)
3.Thioridazine (Mellaril)
4.Perphenazine (Trilafon)
5.Triflupromazine (Vesprin)
6.Loxaoine (Loxitane)
Adverse Reactions
1. To control psychiatric
behavior: such as
hallucinations, delusions, and
bizarre behavior
Nursing Intervention
1.Drowsiness 1. Takes 2 to 3 weeks to
2.Orrthostatic hypotension achieve therapeutic effect
3.Weight 2. Keep the client SUPINE
4.Anticholinergic effects for 1 hours after
5.Extrapyramidal effects administration and advise to
6. Photosensitivity change positions slowly
7. Blood dyskinesia because of effects of
8. Neuroleptic malignant orthostatic hypotension
syndrome 3. Teach to avoid
1. Alcohol
2. Sedatives (will
potentiate effects of CNS
depressants)
3. Antacids (will reduce
absorption of the drugs)

Non- Phenothiazines
(are typicals but have
different structure)
1. Haliperidol (Haldol)
2. Thiothixene HCL
(Navane)
3.Pimozide (Orap)
1. used to control psychiatric
behavior
- less sedated than
Phenothaiazines
1.Severe extrapyramidal 1.Teach the patient to avoid
reactions alcohol
2.Leukocytosis 2.Orap is used only for
3.Blurred Vision Tourette syndrome
4.Dry mouth
5.Urinary retention

Long-acting Meds

21
Haldol Deconate &
Fluphenazine Deconate

22
ATYPICAL ANTIPYCHOTIC DRUGS
Drugs Indications
1.Risperidone (Risperdal) 1.Treat positive and negative
2.Olanzapine (Zyprexa) symptoms of schizophrenia
3.Quetiapin (Seroquel) without significant EPS
4.Aripirazole (Abilify) 2. Use for clients who do not
5.Ziprasidone (Geodon) resond well to tyical
6.Clozapine (Clozaril) antipsychotics
3.Clozapine has superior
efficacy inclined to have been
treatment resistant
Adverse Reactions
1.Risperdal- neuropleptic
malignant syndrom (NMS)
,EPS, dizziness, G.I
symptoms (nausea and
constipation) and anxiety
2.Zyprexa- drowsiness,
dizziness, EPS, agitation
3.Seroquel-drowsiness,
dizziness, headache, EPS,
weight gain & anticholinergic
effects
4. Clozapine- agranulocytosis
is major concern.
Nursing Intervention
1. Monitor WBC weekly for
the first six months then
biweekly
2.Teach patient to change
position slowly
3.Seroquel- monitor lipids,
especially for obese, diabetic,
or hypertensive clients.

Substance Abuse
Alcohol withdrawal symptoms
o Begin shortly after drinking stops, as early as 4 to 6 hours after
o Nausea, anxiety, insomnia, tremors, hyperalertness, & restlessness
o Sudden or gradual increase in all vital signs (autonomic hyperactivity)
o Use of denial and rationalization as coping mechanisms- their use must be confronted so the client
accountability for his or her own behavior can be developed
o Nutrition is a priority***
*** 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. Hallunications
7. Paranoia
8. Confusion

Chronic alcohol-related illnesses:

1. Chronic gastrogastritis
2. Cirrhosis and hepatitis
3. Korsakoff syndrome: is a syndrome that frequently follows DTs associated with chronic
alchoholism
a. Caused by a lack of Thiamin (B1) in the brain
4. Wernicke Syndrome: consisting of encelopathy (a severe life-threatining disorder) occuring in
chronic alcoholics, due to defieciency of vitamin B1. Is treated Thimaine chloride
5. Malnutrition and dehydration
6. Pancreatitis
7. Periperheral neuropathy

Nursing Interventions during alcohol withdrawal

1. Maintain safety, nutrition progressess if assessment indicates risk
2. Prevent aspiration by implementing seizure precausetions
23
 3. Reduce environment stimuli

Benzodiazepines: including antianxiety medications are used in Alcohol Withdrawal

1. Usually Librium or Ativan
2. Valium or Xanax can also be used
3. Provide a high protein diet with adequate fluid intake
4. Provide vitamin supplements especially vitamins B1 and B complex

Alcohol Deterrents- are used as treatment for alcoholism but withdrawals:

o Client teaching should include the effects of consuming any alcohol while on such medications,
severe side effects can occur at any alcohol mixed with antaabuse. They include
o Nausea and vomitting
o Hypotension and headaches
o Rapid pulse respirations
o Flushed face and blooshot eyes
o Confusion
o Chest pain
o Weakness or dizziness
o Encourage clients to read all of the labels of over-the-counter medications & food products that may
contain small amounts of alcohol, should be avoided.
Alcohol Deterrents include:
1. Disulfirm (Antabuse)
2. Acamprosate (Campral)

Drug Withdrawal Symptoms

Opiate (Heroin, Morphine, etc.) withdrawal- watery eyes, runny nose, dilated pupils, NVD,
cramps
Stimulants withdrawal= depression, faqtiue, anxiety disturbed sleep

Child Abuse
 Most important indicators of child abuse include
o Injuries not congruent with the child’s developmental age or skills
o Injuries are not correlated with the stated cause
o A delay in seeking medicla care
 Bruises or fractures in unusual places and in various stages of healing
 Whipleash injuries caused by being shaken
 Bald patches were here and has been pulled out
 Parent seeing child as “different” from other children
 The child appears frightened and withdrawn in the presenc eof the parents or other adult
 Family history of frequent moves, unstable employment, family violence
 One parent answring all the questions

Nursing Interventions
 Nurses are legally required to report all cases of suspected child abuse to the appropriate local or
state agency
 Nurses take color photographs of the injuries
 Document the factual objective statments, Philly interaction interview
 Establish trust with the child
24
 o Establish only one nurse to care for the abuse child: abuse children have difficulty
establishing trust. The child will be less anxious with one constant care giver.
HESI HINT for Child Abuse : during an exam if it’s an option then:
***** It is always the correct answer to report suspected cases of child abuse*****
HESI HINTS: reguarding physicla and sexual abuse, usually focuses on three aspects
1. Physical manifestation of abuse
2. Client safety
3. Legal responsibilities of the nurse:
a. For children, the nurse legally responsible for reporting all suspected cases of abuse.
b. In intimate partner abuse it is the adult decision to report the abuse: the nurse should be
supportive of the court’s decisions
c. Remedy document objective factual assessment data and the client exact words in cases of
sexual abuse or rape

Organic Disorders
 abnormal psychological or behavioral signs and symptoms that occur as a result of cerebral diseases
 systemic dysfunction, or use of or exposure to exogenous substances

Hesi Hints:
Confusion in the elderly is often “accepted” as part of growing old. This confusion may be due to
dehydration with resulting electrolyte imbalance. Think “sudden change” when obtaining a
history. Such changes are usually due to a specific stressor, and treatment for the causative
stressor will usually result in correcting the confusion. 

Confabulation is not lying. It is used by the client to decrease anxiety and protect the ego. 

Nursing interventions for the confused elderly should focus on: 

- Maintaining the client’s health and safety 

- Encouraging self care 

- Reinforcing reality orientation (e.g., “Today is Monday,” and 
call the client by name).


- Providing a consistent, safe environment – engage client in 
simple tasks, activities to
build self-esteem 

• Providing consistent caregiver is a priority in planning nursing care for the confused older client.
Change increases anxiety and confusion. 

• May also use atypical antipsychotics such as resperidine, quetiapine, olanzapine, Clozaril is not a front-
line agent due to side-effects. May also give mood stabilizers and antianxiety medications as
indicated. 


****Difference between Delirium & Dementia- the basic difference between delirium and dementia is
that delirium is acute and reversible (think of a sudden change), whereas dementia is gradual impermanent.

Causes for delirium include Signs & symptoms of Dementia 4 As

 infection 1. Agnosia inability- to interpret sensations and

 drug reaction hence to recognize things
 substance intoxication or withdrawal 2. Amnesia- a partial or total loss of memory.
25
  eventually imbalance
 head trauma sleep deprivation
CHILDHOOD AND ADOLESCENT DISORDERS
HESI HINTS:
3. Aphasia- loss of ability to understand or express
speech
4. Apraxia- inability to perform particular
purposive actions

o Children also experience depression, which often presents as headaches, stomachaches, and other
somatic complaints. Be sure to assess suicidal risks, especially in the adolescent. 

o The client’s lack of remorse or guilt about their antisocial behavior represents a malfunction of the
superego or conscience. The id functions on the basic instinct level and strive to meet immediate
needs. The ego is in touch with 
external reality and is the part of the personality that makes
decisions.
o Important points to remember when answering NCLEX-RN questions:
- These children may be involved in self-fulfilling prophecy (e.g., “Mom says that he/she is a
trouble-maker, therefore, he/she must live up to Mom’s expectations”).
- Confront the client with his/her behavior, e.g., lying. This gives the client a sense of
security.
- Provide consistent interventions – helps to prevent manipulation. Inconsistency does not
help the client develop self-control.

26