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HESI Psychiatric Nursing

Types of treatment modalities


1.Milieu therapy= taking care of patient/environment
focuses on the here and now (assisting the client in dealing with the realities of today rather than
focusing on situations and behaviors of the past)
it uses limit setting
2. Behavior modification
this process is used to change ineffective behavior patterns: if focuses on the consequences of actions
rather than on peer pressure
positive reinforcement-is used to strengthen desired behavior
negative reinforcement- is used to decrease or eliminate inappropriate behavior
3. Family therapy
identifies the entire family as a client
based on the concept of the family as a system of interrelated parts forming a whole
the focus is on the patterns of interaction within the family not on any individual member
4. Crisis intervention=short term.
Is directed at the resolution of immediate crisis
5. Cognitive therapy= counseling
6. ECT- involves the use of electronically induce seizures for psychiatric purposes.
Its used would severely depressed clients who failed to respond to antidepressant medication and
therapy
often used with extremely suicidal clients because two weeks are usually needed for antidepressants to
take effect, while this therapy produces results more quickly.
Nursing care prior to ECT
1. prepare the client by teaching what the treatment involves
2. avoid the word shock
3. Administer an anticholinergic (atropine sulfate) 30 minutes before treatment to dry oral
secretions and prevent aspiration
4. a quick acting muscle relaxant (succinlcholine (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 in an unconscious they immediately following ECT
2. check vital sign every 15 minutes until client alert
3. reorient client after ECT (confusion is likely upon awakening)
Common Side Effects Flowing ECT
1. headache
2. muscle soreness
3. nausea- is 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
maintain a patent airway.
4. retrograde amnesia (short-term memory loss/impairment)
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 (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 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)

Nursing Assessment: Signs & Symptoms of OCD

fear of losing control


Reoccurring intrusive thoughts and repetitive behaviors that interfere with normal functioning
magical thinking (belief that ones 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 repetitive performance of ritualistic activity (dermatitis occurs as a result of
continuous hand washing.
Nursing Interventions for OCD
allow performance of compulsive activity while attention is given to safety but not reinforcing it
explore meaning and purpose of the behavior
avoid punishing criticizing
establish routine to avoid anxiety 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, therefore it is an optimal time for learning.
Compulsive acts are 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 violence free
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 became before age 30
Secondary Gain occurs when a child may learn physical complaints 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 but
no medical pathology is present (A pt complained of chest pain but ECG and cardiac enzymes are normal)
2. Hypochondriasis the belief in and fear of having a disease including misinterpretation 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 characterized by transferring a mental conflict into a physical symptom for which
there is no organic cause (blindness paralysis seizures deafness and pseudocyesis aka false pregnancy)
Nursing Assessment: Signs & Symptoms of Somatoform Disorders
preoccupation with pain or bodily function for at least six months duration
absence of emotional concern regarding the physical impairment
women may report excessive dysmenorrheal
depression and presence of suicidal ideations
excessive use of analgesics or drug abuse
vital signs may be elevated as in a panic attack
La Belle indifference- 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
physical, a one time dose of a Benzo can be given IV or PO uin the ED for acute sedation)
Always acknowledge the symptom or complaint as real
reaffirm that diagnostic tests results reveal no organic pathology
determine any secondary gains acquired by the client ( rewards obtained from the sick role)
determine the primary gains (decrease in anxiety resulting from the ability to deal with the
stressful situation)
Treatment is aimed at cognitive behavioral therapy or ECT

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

Used for short-term treatment of


insomnia
Approved for long-term
treatment of insomnia
Selectively binds to melatonin
receptors

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. Allow more serotonin to


stay at the junction site of
the neurons.
2. It does not block reuptake
of dopamine or
norepinephrine
3. Causes CNS stimulation,
which causes insomnia
4. Has an extensive long
half-life, about 5 weeks are
necessary to produce
therapeutic medication
levels.

1. Generalized Anxiety
Disorder (GAD)
2. Depression
Disorders** 2 major
uses for SSRIs
3. Panic Disorder
4. OCD5. PTSD
6. Anorexia
7. Aggression

***Serotonin Syndrome: IS defined by at least 3 of the following symptoms: ******


1. Rapid onset (2-72 hours after initiation of treatment) & altered mental state
2. Agitation
3. Myoclonus
4. Hyperreflexia
5. Fever
6. Shivering
7. Diaphoresis
8. Ataxia
9. Diarrhea

1. Serotonin syndrome: ***


2. Sexual dysfunction
Weight Gain

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)

administer antidepressant medications


o Tricyclics
o MAOI
Easy way to remember MAOI'S! think of
PANAMA!
PA - parnate
NA - nardil
MA marplan
o SSRI
o Atypical
Trazodone (Desyrel)
o SNRIs

Bupropion (Wellbutrin)- only antidepressant that does NOT cause weight gain

All the other info is the same as SSRI


*****Remember: when answering HESI/NCLEX questions you are at Utopia general and theres
plenty of time & staff to provide ideal nursing care. Do not let the realities of clinical situations to
tear you from choosing the best nursing intervention.
o **** The best intervention for depressed patient is to sit quietly with the client, offering
support with your presence.
spend time with the client to return when promised
depressed clients have difficulty hearing and accepting complements because of their lowered selfconcept.
o Comment on signs of improvement by noting the behavior (I noticed you come to hair
today, NOT you look nice today)
The nurse knows depressed clients are improving when they begin to take an interest in their
parents or begin to perform self-care activities that were previously of little or no interest.
Suicide precautions
obtain a history: a previous suicide attempt is the most significant risk factor
always stay with the client: never leave a suicidal patient alone
Warning signs of impeding suicide attempt
a client begins giving away his or her possessions
a previous depressed client becomes happy. This indicates here her has made the decision to
commit suicide, Is no longer debating the possibility, And has figured out how to accomplish the
suicide.
Bipolar Disorder, or Manic-Depressive Illness
Is a affective disorder manifested by mood swings including euphoria, grandiosity, and an inflated sense
of self-worth
To be diagnosed with bipolar disorder, the pt 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 used to treat Bipolar especially the manic phase
Normal lithium level 0.8-1.2 mEq/ *****
a. ***Nursing interventions monitor serum lithium levels carefully. *****
b. The therapeutic and toxic levels are very close to each other on the readings. Signs of toxicity are
evident when lithium levels are more than 1.5mEq/L.
c. Blood levels should be drawn 12 hours after the last dose was given.
d. While on Lithium the pt requires renal function assessment & monitoring

Tricyclics Antidepressants (Cause Anticholinergic Side Effects)**** Treat DEPRESSION


Drugs
Indications
Adverse Reactions
1. Amitriptyline (Elavil)
1. Depression 1. Anticholinergic side effects (DRY
2. Desipramine (Norpramin)
EVERYTHING)
3. Imipramine (Tofranil)
dry mouth
4. Nortriptyline (Aventyl)
blurred vision
5. Protriptyline (Vivactil)
photophobia
6. Maprotiline (Lumdiomil)
urinary hesitancy or retention
constipation
2.Can not be taken with MAOIs due to
development of a Hypertensive crisis
3. Postural/ (AKA) Orthostatic Hypertension
4. Tachycardia 5. GI: Nausea & vomiting

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

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 Increase amount of those neurotransmitters at nerve endings intensifies responses and relieves depression
Drugs
Indications
Adverse Reactions
Nursing Interventions
1. Phenelzine (Nardil)
1. Depression ***Hypertensive Crisis resulting from intake of
1. Must not be used with tricyclics
2. Isocarboxazid (Marplan)
2. Phobias
dietary Tyramine or combination of Tricyclics-severe 2. Need for dietary restriction of
3. Tranylcypromine (Parnate) 3. Anxiety
hypertension as a result of intensive vasoconstriction
trramine, foods that contain it:
4. Selegiline (Eldepryl)
and stimulation of the heart.
1. Aged Cheese
Manifestations may include:
2. Red Wine or Beer
3.
Beef & chicken
Severe Hypertension
4. Liver
Headache
5. Yeast
Nausea/Vomiting
6. yogurt
Increased Heart Rate
7. Soy sauce
Fever
8. Chocolate
Sweating
9. Bananas
2. Urinary hesitancy, constipation
3.
Do
not take with SSRIs
3. Impotence
4. Pt can not take OTCs unless
4. Dizziness & Drowsiness**
prescribed by the HCP
5. Fluid Retention
5. Warning Signs of hypertensive
6. Confusion
crisis:
7. Muscle twitching
1. Headaches
8.Insomnia
2. Palpitations
3.Increased BP

****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

Nursing interventions for a delusional versus hallucinating client


Client Is Delusional
Client Is Hallucinating
1. Encourage recognition of distorted reality
1. Protect the patient from injury that may result from
2. Denver focus from delusional thought to reality; do responding to auditory commands
not permit rumination on false light years
2. Avoid denying arguing with client about the
3. Do not argue with or support the delusions
hallucination
4. Be very matter-of-fact
3. Discuss your observations with the client (you
5. Avoid physically touching the patient
appear to be listening to something)
6 Administer antipsychotic drugs
4. Make frequent but brief remarks to interpret the
7. Administer antiparkinsnian drugs
hallucination
Antipsychotic Medications used to treat Schizophrenia (& psychosis)
Medications are used to treat:
1. Positive symptoms related to behavior, thought, speech (agitation, 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 (Phenothaiazines) (Conventional)
Treats only positive symptoms
Causes increased Extrapyramidal effects (EPS) more so 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. Atypical antipsychotic agents Advantages of atypical antipsychotic agents include
o Relief of both positive and negative symptoms
o Decrease in a affective symptoms (depression, anxiety) and suicidal behaviors
o Improvement of neurocognitive defects, such as 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
incidence of anticholinergic effects. This is because most of the atypical antipsychotics cause
little or no blockade of cholinergic receptors.
o Less relapse
3. Anticholinergic Drugs
Helps reduce Extrapyramidal effects (EPS)
Causes Anticholinergic effects: They include (drying)
Dry mouth==can't spit
Urinary retention=can't ****
Constipated =can't ****
Blurred vision=can't see
Anticholinergic Drugs Include
1. Trihexyphenidyl HCL (Artane)
2. Benztropine mesylate (Cogentin)
3. Amantadine (Symmetrel)
Side Effects of Psychotropic Drugs & 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 platelets, as evidenced by bruises easily, petechia, teach the patient
safety measures and implement bleeding precautions as necessary.

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


1. Akathisia- Psychomotor restlessness including pacing or fidgeting, foot tapping, rocking. Inability to sit still
Manage symptoms with: Beta-blockers, Benzodiazepines or anticholinergic medication
2. Acute Dystonia- Can occur as early as 1-2 days after initiation of treatment:
It includes: contraction/spasims of muscles, usually in the head and neck, Spontaneous, painful. Uncoordinated
jerky movements, difficulty speaking (Dysarthria) & difficulty swallowing (Dysphagia)
Treat with Anticholinergic Agents- Such as Benztropine (Cogentin) or diphenhydramine (Benadryl)
3. Pseudoparkinsonism- Rigidity, shuffling gait, pill-rolling hand movements, Tremors, dyskinseia, masklike
face (signs and symptoms seen in Parkinsons)
Treat with Anticholinergic Agents- Such as Benztropine (Cogentin) or diphenhydramine (Benadryl)
or amantadine (Symmeterel)
**4. Tardive dyskinesia (TD or TDK)- Is a persistent, serious, irreversible EPS that usually appears after
prolonged treatment & persists even after the medication has been discontinued.
TDK- consists of involuntary tonic muscular contractions/spasms that typically involve the tongue,
fingers, toes, neck, trunk or pelvis.
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 teaching the client to stay out of the sun, wearing protective
clothing, and sunglasses. Discoloration of the skin will disappear within six months after drug it
discontinued.
2. Neuroleptic Malignant Syndrome (NMS) - is a life-threatening emergency: Signs and Symptoms:
a. high fever
b. tachycardia
c. stupor
d. increased respirations
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. Serotonin Syndrome- includes confusion, disorientation, automatic dysfunction. If the nursing
responsibilities and 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,
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

TYPICAL ANTIPSYCHOTICS DRUGS (PHENOTHIAZINES)


Drugs
Indications
Adverse Reactions
1. Chlorpromazine HCL
1. To control
1. Drowsiness
psychiatric
2. Orthostatic hypotension
(Thorazine)
2. Trifluoperazine HCL
behavior: such as 3. Weight gain
hallucinations,
4. Anticholinergic effects
(Stelazine)
3. Thioridazine HCL (Mellaril) delusions, and
5. Extrapyramidal effects
4. Perphenazine
(Trilafon) bizarre behavior 6. Photosensitivity
5. Triflupromazine (Vesprin)
7. Blood dyskinesia
6. Loxaoine (Loxitane)
8. Neuroleptic malignant
syndrome
NON-Phenothiazines
(Are typicals but have a different
structure)
1. Haloperidol (Haldol)
2. Thiothixene HCL (Navane)
3. Pimozide (Orap)

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

1. Teach the patient to avoid alcohol


2. Orap is used only for Tourette syndrome

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.

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, fatigue, anxiety, disturbed sleep
Child Abuse
most important indicators of child abuse include
o injuries not congruent with the childs developmental age or skills
o injuries are not correlated with the stated cause
o a delay in seeking medical care
bruises or fractures in unusual places and in various stages of healing
whiplash injuries caused by being shaken
bald patches were here has been pulled out
parent seeing child as different from other children
the child appears frightened and withdrawn in the presence of the parents or other adult
family history of frequent moves, unstable employment, family violence
one parent answering 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 statements, Philly interaction interviews
establish trust with the child
o Establish only one nurse to care for abuse child. Abuse children have difficulty establishing
trust .The child will be less anxious with one constant caregiver.
HESI HINT for Child Abuse: During an exam if its an option than:
****** It is always the correct answer to report suspected cases of child abuse.*********
HESI HINTS: Reguarding physical and sexual abuse usually focuses on three aspects
1. physical manifestations of abuse
2. client safety
3. legal responsibilities of the nurse:
a. For children, the nurse is 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 courts decision.
c. Remedy document objective factual assessment data and the clients 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
****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 hence to recognize things
drug reaction
2. Amnesia a partial or total loss of memory.
substance intoxication
3. Aphasia loss of ability to understand or express speech
or withdrawal
4. Apraxia inability to perform particular purposive actions
eventually imbalance
head trauma sleep deprivation