Mental Health Nursing

Psychiatric Nursing
SUPPLEMENTAL

BULLETS

TYPICAL PROFILE OF PATIENT WITH ANOREXIA NERVOSA

FEMALE , ADOLESCENT,UPPER CLASS ,PERFECTIONIST

A PaTIENT WITH AN EATING DISORDER UNCONSCIOUSLY

ASSOCIATES FOOD WITH LOVE AND AFFECTION

LITHIUM LEVEL TOXIC AT 2.0 mEq / L

NEUROLOGIC SIGNS AND SYMPTOMS INCLUDE NAVDA,

TREMOR, HYPERREFLEXIA,FASCICULATIONS, BRADYCARDIA ,
ARRYTHMIAS ,SEIZURES AND COMA

Korsakoffs Psychosis : inability to process new information ( to

form new memories). This is a reversible condition resulting from
brain damage induced by a thiamine deficiency which is generally
secondary to chronic alcoholism.

Werniches Encepalopathy : This disease is also due to an

alcoholic-induced thiamine deficiency. It is an irreversible disease in
which the brain tissues break down, become inflammed, and bleed

Pharmacological treatment of alcohol withdrawal

benzodiazepines or barbiturates
First symptom of Alzheimers Disease progressive memory loss
Effective long term treatment for alcoholics AA
Methadone causes analgesia without euphoria,withdrawal symptoms less
severe than heroin

Medical/ health professionals prone to have anxiety and depression

treated by generalist rather than physicians

Delirium reversible organic mental syndrome reflecting deficits in

attention, organized thinking, orientation , speech, memory and
perception. Patients are frequently confused, anxious , excited
and have hallucinations. A change in consciousness can be
observed(clouding of consciousness)

Dementia irreversible impaired functioning secondary to

changes / deficits in memory, spatial concepts, personality ,
cognition , language , motor and sensory skills, judgement or
behavior. No change in consciousness

Substances that mimic generalized anxiety amphetamines , cocaine ,

anticholinergics, alcohol and sedative withdrawal

Geriatric drug induced hallucinations commonly due to

propanolol

Major risk or TCAs orthostatic hypotension leading to falls

Symptoms of alcohol withdrawal and their temporal relations

Hallucinations after 24 hours

Autonomic hyperactivity after 6-8 hours
Global confusion 1-3 days after

Side effects of Ritalin insomnia abdl. Pain,

depression, anorexia, HA and HPN
First episode of Bipolar disease mania before depression
Lithium used for mania and bulimia , anorexia nervosa, alcoholism with
mood d/o, headaches

Borderline personality d/o Chronic Boredom

Parotid gland swelling and erosion of teeth enamel, elevated serum

amylase and hypokalemia Bulimia

Conversion d/o internal psychological conflict that manifests as somatic

symptoms.

Dysthymia chronic d/o more than 2 years

Symptoms of depression

I
Nterest down
Sleep
Appetite
Depressed mood
Concentration diff.
Activity
Guilt
Energy low
Suicide

Dystonic rxn side effect of neuroleptics-muscle spasm

of tongue, face and neck and back,laryngospasm
and extraocular muscle spasm
Dystonic rxn treated with Benadryl or Cogentin
Hallucinogens affect serotonin
Munchausen syndrome harm oneself factitious d/o
manchausen by proxy seeks medical care for another (e.g. child)

Haloperidol prefrred neuroleptic few side effects ,

can be used IM during emergencies( but high
frequency of extrapyramidal effects)
Clozapine no tardive dyskinesia but can develop agranulocytosis ,
seizures,hypotension, over sedation.

Benzodiazepine contrindications pregnancy ( 1 st trim)acute narrow angle

glaucoma, and hypersensitivity

Extrapyramidal Rxns- involuntary spontaneous motor movements

dystonis, akathisia and parkinson like syndrome

Obsessive Compulsive d/o begins before 25 y.o.

SSRI and exposure therapy beneficial
Positive operant conditioning reinforce positive behavior
PTSD possible even though there is no actual witnessing of

event
Flashbacks , nightmares,intense fear,avoidance and diminished
memory of event with an exagerrated startle response onset occurs
at least 6 months - PTSD

Post partum psychosis first few weeks post-partum(710 d/6-8wk,) primiparous,poor social support and

previous depression

Schizophrenia

Association looseness
Ambivalence
Autism
Affect inappropriate
Hallucinations + As + Regression + Delusions + Stimuli comprehension low

(HARDS)

Somatization d/o multiple , unexplained medical

symptoms(four unexplained pain Sx)
Suicide bipolar d/o, depression, substance abuse and schiz.
Reliable predictors of potentially violent patient male gender ,
Hx of violence , history of substance abuse

Organic brain syndrome most frequent mood irritability

Labile affect rapid shifts of mood

Medication used to relieve extrapyramidal effects of

psychotropic medications:

Benadryl
Artane
Cogentin

School age w/ terminal illness honestly explain in

understandable terms. Provide reassurance that he will not be alone.

Prodromes of violent behavior

anxiety,defensiveness,volatility and physical
aggression
Akathisia-internal restlessness-Tx propanolol
Echolalia meaningless automatic repition of someone elses
words

Catalepsy maintains same posture for a long period of time

Waxy flexibility offers resistance to change in position but

gradually allows to be moved to anew posture

Institutionalization only if patient poses a danger to self

or others

10 most stressful events(Holmes and Rahe)

Death of a spouse or child

Divorce
Separation
Institutional detention
Death of a close family member
Major personal illness/injury
Marriage
Job loss
Marital reconciliation
retirement

Standard care for domestic violence

Establish confidential system of identification

Document
Collect evidence
Evaluate safety issues
Formulate safety plan
Give insight to options and resources
Refer for counseling nad legal asst.
Coordinate w/ law enforcement
Transport to shelter prn

Follow up w/ DV advocate

Common anti cholinergic meds- AtSO4,

TCAs,antihistamines, phenothiazines and
antiparkinsonian drugs
Lithium toxicity sign: tremor, symptoms:weakness and ECG
findings: flattening of T-waves.

Tx for Wernickes Encephalopathy thiamine IV

Organic Brain Syndrome manifestations

Hallucinations
Perception aberration
Mental status change
Focal neurologic sign

Imipramine HCl TCA dry mouth X drink

excessively leads to electrolyte imbalance just
ice chips/ gum
Least therapeutic around depressed clients Cheerfulness or gaiety
Theory behind interpersonal model of behavior therapy: Behavioral
Changes result from stress on the individual and his body systems

Systems model theory behavior results from interaction between

individual and environment

Haldols CNS adverse reaction Extrapyramidal side effects

Significant features of each AXIS in the Diagnosis

Statistical Manual for mental disorders IV
Axis 1 organic brain syndromes,psychosis,affective d/o and
substance abuse

Axis 2 personality disorders

Axis 3 medical problems

Axis 4 - Life events leading to problems

Psychosocial and environmental

Axis 5 patient adaptation to problems

Schiz. patient priority safety then self care needs ,

then health needs then behavior goals
Major goals of psychosocial rehabilitation program teaching
independent living skills

OC d/o substitution and undoing

Adolescent behavior influence - peers

Organic mental d/o :

Agnosia,insomnia,amnesia,confusion delirium and depression

Attributes negative traits to others - projection

Showing emotion opposite to what is truly felt reaction formation
Alcohol aversion therapy antabuse
Alcoholism rationalization substituting a more acceptable reason for
ones behavior

Heroin overdose ABCs

Cocaine red excoriated nostrils, tachycardia , nervousness and pupillary

dilation

AA independent responsible arrangements(personally done)

Barbiturate overdose -respiratory failure

Drug given at a non- intoxicating dose for barbiturate withdrawal
Pentobarbital Na ( Nembutal)

Long term amphetamine abuse emotional lability,

depression,dependency , hallucinations and delusions

Severe anxiety and withdrawn diversion activities and

increased social contact
Anorexia nervosa when exercising interrupt and redirect
activity

Antisocial egocentrc and unconcerned

Ultimate nursing goal for severe anxiety disorder

development of adaptive coping behaviors and problem solving skills

Inderal use to relieve physical symptoms of anxiety

Disclosure of a plan to kill someone report to the staff

and AP asap
Obtained sense of self awareness, attributes , defense mechanisms and
behaviors gained INSIGHT

Priority for suicidal depressed patients safety and security ( not cause
personal harm)

Suicide an individual decision cannot be influenced by nurses questions

Sudden increase in energy level or mood- warning sign

Client under influence of cocaine agitated, aggressive

and paranoid priority safety / protect pnt.
Tardive dyskinesia involuntary twitching or muscle
movements

Dystonia uncoordinated spastic movements of the body

Discharge preparation for termination of NPR

Delusional withdrawn encourage participation reinforces
reality and brief one on one contacts in his own room

Fluphenazine decanoate ( prolixin ) drug of choice for

Schiz. given only once every 2-4 weeks
Prolixin edema , blood dyscrasias and BP fluctuations check weight ,
WBC count and BP.

Schiz complaints of hallucinations assess for compliance

Clients discharge from involuntary admission determined by legal or

medical approval

Confused client promote safety, prevent injury and maintain quality of life

Alcohol intoxication allow pnt. Sleep it off

Support gropu for spouses and significant others of alcoholics
Al-non

Breaking defenses of denial may lead to mental disorganization

and depression

Thorazine reduces seizure threshold

Heroin addiction symptoms of late withdrawal navda

recovery principle to ease anxiety one day at a time

Barbiturates + alcohol depressant effect

2-3 days barbiturate withdrawal generalized convulsionsGiven nembutal to decrease seizure possibility

Anorexia nervosa goal of Tx stabilize weight and facilitate

entry into outpatient care

Xanax short term Tx tolerance can occur

Do not respond to a client who tries to evoke feelings of anger /

negative response

Endogenous depression biochemical in nature

amitriptyline HCl urinary retention
Elderly reminiscing reduce depression, lessen feelings of isolation and
loneliness

Alcohol detoxification inquire alcohol consumption past 24-48 hours to

determine withdrawal severity ( auditory hallucinations common)

Delirium Tremens quiet , well lighted room with companion , last resort
restrain if violent only

Heroin injection tested for HIV and Hepa B

Methadone liquid form under direct supervision

Best measures to recovery success number of chemically free days
Drug tolerance requires increasingly larger doses to achieve the same
desired effect

Severe Sx of barbiturate with drawal postural hypotension,psychosis,

hyperthermia and seizures

Anorexia nervosa focus nutritional status

Patient on librium avoid alcohol

Disciplining unacceptable behavior person still accepted

Alcohol disulfiram Rxn vomiting , dyspnea,

hypotension,vertigo,syncope,confusion,respiratory
depression,convulsions,coma,death
Alcoholism defense rationalization , repression /suppression,
denial

Heroin overdose antidoteNarcan(naloxone)increased

HR,BP and LOC ( but short acting )
Barbiturate ,Opiate or Benzodiazepine sluggish, irritable,
slurred speech , impaired judgement and walking diff.Buspar not
prn therapeutic effect 7 10 daysfull effect 3 -4 weeks

Epinephrine decrease peristalsis

Restraints discontinued when subj. and obj. assessments

indicate an absence of aggression

Abusive family characteristics :

History of family violence

Unbalanced power ratio
Stereotypical role playing
Dysfunctional expression of feelings
Strict boundaries
Lack of empathy
Substance abuse

Low self esteem common trait of abuse victims

Medication can only be forced to a patient if he poses a

threat to himself and others

Anti social personality limit setting on behaviors

Psychophysiological anxiety d/o activities that promote rest, involve

relaxation

Self awareness towards mortality needed to be effective in caring for the

terminally ill

Organic mental d/o safe simple envt. To help his orientation

Anorexia nervosa perfectionists ,self starvation and rigorous exercise

high cal and high CHON diet.subconcious conflicts parental , autonomy,
identity

Isolation , medication and warning others short term

anger mngt. Does not place responsibility on the
patient for his own behavior, ineffective in behavior
modification
Positive reinforcement for good behaviors
For manipulative clients limit setting and positive
reinforcement

Personality traits for ulcerative colitis OC,

perfectionist, inflexible, difficulty in showing emotions
and obstinate
Four point retraints monitor circulation and skin, provide
sensory stimulation,means of elimination and nutrition and change in
position

MAO therapeutic effects 4 weeks

Turning unacceptable feelings into physical Sx that has no

identifiable cause conversion rxn

Sarcasm expression of anger

Confabulation unconscious behavior used to hide memory
loss by replacing it with fabrication

Unconscious forgetting of traumatic events repression

Projecting feelings or thought to someone transference

MAO headache and neck stiffness hypertensive crisis

Communication for someone who refuses to

speak open ended questions focussing on
expression of feelings

Anti-psychotics abrupt discontinuation- nausea and seizures

Manipulative behavior lack of trust

Verbally and physically abusive patients try setting limits

verbally before physical and chemical restraints

Abused child little showing of emotion and little

response to pain
Depressed clients readiness evaluated by responsibility for own
well being , ADLs and continuing Treatment.

Abused child same primary nurse everyday promote trust

and provide continuity of care

Anti social continue to enforce rules and set limits on

behavior( provide appropriate explanation)

Demerol C/I for clients taking MAOIs,can cause

death
Alzheimers memory and emotion difficulties stage 1
Memory loss, confusion , wanderin aphasia, inability to do self care
stage 3

Lithium therapy monitor sodium

Tyramine rich foods- smoked , aged , pickled or fermented

Stage 1 alzheimers recent memory loss only

Hallucination episodes redirect to reality ( activities)

Lithium carbonate therapeutic level in 2 weeks

Dementia wandering constant supervision
A client exhibiting mania placed on lithium carbonate and Thorazine
simultaneouslyThorazine controls manic behavior until lithium reaches its
therapeutic levella belle indifference lack of concern for profound disability

Highest treatment priority for anorexia nervosa-correction of nutritional and

electrolyte imbalance
Seclusion for promotion of therapeutic limit setting, reduces overwhelming
environmental stimulation, protects patient from self injury or injury to othersif patient does not respond to less restricted interventions until pnt. Can
assume self control

Compulsion irresistable urge to perform an irrational act

Self esteem needs- self worth ,self respect ,self reliance ,

dignity and independence

Love and belongingness affiliation , affection and intimacy

Minnesota Multiphasic Personality Inventory MMPI- 550

question test assess personality and detects d/o
such as schizophrenia and depression
ECT 6-12 treatments of 2-3 per week
Circumstaniality disturbance in associate thought and speech
patterns

Lithium levels checked every 6 8 weeks

Primary purpose of psychotropic medications to

decrease symptoms to allow participation in therapy
First step in drug overdose or toxicity management- establish and
maintain airway

Korsakoffs syndrome hallucinations,confabulation,amnesia and

disorientation

TCA s

A/R: orthostatic hypotension,tremors

overdosage: seizures HPN shock arrythmias

Most common psychiatric disorder

depression