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Discuss DSM-IV:
A. Clients diagnosis has 5 parts or AXIS:
1. AXIS I: Psychiatric Dx
2. AXIS II: Personality disorder or mental retardation
3. AXIS II: Medical dx
4. AXIS IV: Psychosocial stressors
5. AXIS V: Global Assessment of Fxning (GAF)- considered Psychologic, social and
occupational fxn on a hypothetical continuum of MENTAL HEALTH-ILLNESS.
B. What does GAF Measure? The client’s functional state @ the time of admission and within the last year
<<LEAST RESTRICTIVE ALTERNATIVE means providing MH tx in the least restrictive environment using
the least restrictive tx. >>
What is Duty to warn? Establishes responsibility of a treating MPH to notify an intended, identifiable victim.
Describe Neuroanatomy:
c. Define DISTRESS: Subjective response to stimuli that are threatening or perceived as threatening.
Includes fatigue, pain, fear, or acute/chronic dx
d. Define EUTRESS: Stress response (nonspecific) assoc. with desirable events ex. Wedding, job
promotion, birth of child.
e. Define PSYCHOLOGIC STRESS: All processes of the person that require cognitive appraisal of the
event before a response
f. What is GIS? Activated automatically as response to survival; “POSSOM RESPONSE”.
Results overstimulation of PNS, activated by life threatening situations
g. Stages of GAS:
ALARM REACTION
alerts you to presence of stressful stimuli
•ANS releases EPINEPHRINE to alert body of stressor
fight or flight activates HPA AXIS (hypothalamus, pituitary gland, adrenal
gland) causes release of cortisol from adrenal glands
leads to increase BP, tachycardia, vasoconstriction of vessels,
increase in muscle tone, dilated pupils, increased alertness
and increase sugar levels etc.
RESISTENCE
stressor should be overcome in this stage
•Prolonged stage resistance mobilizes energy resources to
your body attempts to adapt to the stressor maintain adaptations
EXHAUSTION
if stressor isn't overcome, it will spread throught body causing dx
Exhaustion occurs when resources are used up and individual can no
BODY CAN'T MAINTAIN ADAPTATIONS
longer maintain adaptations leads to illness or death
ANXIETY DISORDERS:
EGO DEFENSE
MECHANISMS DEFINITION EXAMPLE
Conversion Unconscious expression of a mental conflict as a Woman experiences blindness after
physical symptom to relieve anxiety witnessing a robbery.
Denial Unconscious refusal to face reality. Woman denies that her marriage is
failing
Dissociation Separation and detachment of a strong, Male victim of car-jacking exhibits
emotionally charged conflict from one's symptoms of traumatic amnesia the
consciousness next day.
Identification Unconscious attempt to identify with personality Teenager dresses, walks, and talks
traits or actions of another to preserve one's self- like his favourite basketball player.
esteem
Projection Unconscious assignment of unacceptable thoughts Man who was late for work blames
or characteristics of self to others wife for not setting the alarm clock.
Rationalization Justification of one's ideas, actions, or feelings to Student states he didn't make the
maintain self-respect, prevent guilt feelings, or golf team because he was sick.
obtain social approval
Reaction-formation Demonstration of the opposite behaviour, attitude, Man who dislikes his mother-in-law
or feeling of what one would normally show in a is very polite and courteous toward
given situation her.
Suppression Voluntary rejection of unacceptable thoughts or Student who failed a test states she
feelings from conscious awareness isn't ready to talk about her grade.
Symbolization Use of external objects to become an outward An engagement ring symbolizes
representation of an internal idea, attitude, or love and a commitment to another
feeling person.
Nursing Interventions
Reducing Symptoms of Anxiety:
1. Maintain safety for the client and the environment
2. Assess own level of anxiety
3. Recognize the client’s use of relief behaviours
4. Inform client limiting caffeine, nicotine, and other CNS stimulants
5. Teach client to distinguish anxiety that is connected to identifiable sources
6. Instruct client to practice stress reduction techniques
7. Help client build on coping methods
8. Activate the client to identify support persons
9. Assist client gain control of overwhelming feelings and impulses
10. Help client structure quiet environment
11. Assess the presence and degree of depression and suicide ideation
12. Administer anxiolytics
XII. Types of ANXIETY:
i. Panic Anxiety: Recurrent unexpected anxiety attacks with thoughts of dread, impending
doom, death and fear of being trapped.
ii. Phobias: Client experiences panic attack in response to particular situations
Types: Agoraphobia – fear of being alone in public places, without escape, Social Phobia -
fear of social or performance situations. Eg. Speaking, eating in public
iii. Posttraumatic Stress Disorder (PTSD): Describes and individuals reaction to traumatic events
eg. Combat, sexual abuse, physical abuse, disasters, and grieving
a. Efforts to avoid thoughts, feeling, or conversation about the trauma
b. Efforts to avoid persons or places that evoke memories of trauma
c. Inability to remember important aspects of trauma
d. Diminished interest in significant activities
e. Restricted range of effect
f. A sense of impending doom.
1. Must have two of the following present:
a. Sleep disturbances, irritability or angry outbursts, difficulty concentrating,
Hypervigilance and exaggerated startle response.
iv. Acute Stress Disorder: Symptoms occur during or immediately after trauma
a. Develops three or more dissociative symptoms:
i. Subjective sense of numbing or detachment
ii. Absence of emotional responsiveness
iii. Feeling dazed (reduced awareness of surroundings)
iv. Derealisation (unreal feeling)
v. Depersonalization (feeling alienated)
vi. Dissociative amnesia
v. General Anxiety Disorder: Excessive anxiety and worry that is difficult to control
vi. Obsessive Compulsive Disorder:
1. Obsessions are recurrent and persistent thoughts, impulses or images
2. Individuals try to suppress the thoughts and impulses
3. Compulsions are repetitive behaviours that the person feels driven to perform in
response to an obsession
vii. Somatoform disorders: Characterized by physical symptoms that can’t be explained by
known physical mechanisms. They:
a. Involve multiple organs
b. have early onset and are chronic without signs of impairment
c. No laboratory evidence of medical condition
Types:
a. BODY DYSMORPHIC DISORDER-Preoccupation with imagined defect in
appearance in a normal-appearing person
b. CONVERSION DISORDER- Development of Neurologic disorder (blindness,
deafness, loss of touch, or pain sensation) or Involuntary motor function (aphonia,
impaired coordination, paralysis, or seizures).
c. HYPOCHONDRIASIS-Preoccupation with fears of having/ has a serious disease
despite appropriate medical tests and assurances to the contrary
d. SOMATIZATION DISORDER-History of many physical complaints before age 30.
History of pain in at least four different sites or functions
viii. Dissociative disorders:
a. Depersonalization disorder
b. Dissociative amnesia-One or more episodes of inability to recall important
information (usually of a traumatic or stressful nature)
c. Dissociative fugue-Sudden, unexpected travel away from home or one's
place of work with inability to remember past
XIII. COGNITIVE AND BEHAVIOURAL THERAPY:
a. Distorted and dysfxnal thinking causes psych disturbances expressed in mood and behaviour
b. GOAL: assist the client in beginning to I.D automatic thoughts and the feelings connected to them.
XV. Anti-anxiety
A. Benzodiazapines
a. How it works: by enhancing the inhibitory action of GABA thus causing generalized CNS
depression
b. Therapeutic effect: relief of anxiety
c. Interactions: DO not use with MAOI’s, additive effect when taken with alcohol,
antihistamines
i. Diazapam (Valium)- 2-10mg 2-4x’s /dy
ii. Alprozolam (Xanax)- .25-.5mg 3x’s/dy
d. SE: dizziness, drowsiness lethargy, mouth dryness
o Treat overdose of benzo’s by:
a. Administering an antiemetic in conscious pt. and gastric lavage
in unconscious patient
B. Non-Benzodiazapine
a. How it works: decrease reputake of dopamine and increase serotonin in the CNS
b. Therapeutic effect: decrease depression
c. Interactions: grapefruit juice can cause toxicity, use with MAOI may cause HTN
1. Buspirone HCL (BusPAR) -5mg 2-3x/dy
d. SE: dry mouth, nausea, vomiting, agitation, headache, blurred vision, constipation
XVI. Antidepressant: 4 groups:
B. Tricyclic’s
a. How it works: blocks reputake of norepinephrine and serotonin
b. Interactions: do not use with MAOI and avoid concurrent use with SSRI’s
1. Amitriptyline (Elavil)-25mg 3x’s up to 200mg/dy
2. Imipramin (Tofranil)-25-50mg 3-4 up to 300mg/dy
c. SE: orthostatic hypotension, sedation, suicidal thoughts, blurred vision, dry mouth
C. SRRI’s:
a. How it works: blocks reputake of serotonin
b. Interactions: St. Johns wart causes central serotonin syndrome
1. Fluoxetine (Prozac)
2. Sertraline (Zoloft)
3. Paraxentine (Paxil)
c. SE: nervousness, sexual dysfunction, headache, insomnia
D. MAOI:
a. How it works: inhibiting monoamine oxidase causing a rise in neurotransmitters
b. Interactions: avoid foods withtyramines
1. Phenelzine Sulfate (Nardil)
2. Tranylaypromine Sulfate (Parnate)
c. SE: HYPERTENSIVE CRISIS s/s: headache, seizure, edema, chest pain, SOB, nausea,
vomiting, severe anxiety, unresponsiveness.
E. Atypical antidepressant:
a. How it works: effects serotonin, dopamine, and norepinephrine
b. Interactions: do not use w/ MAOI, should not be taken within 14dys of MAOI use
1. BuPropion (Wellbutrint)
2. Venlafaxine (Effecor)
3. Doloxetine (Cymbalta)
c. SE: headache, dry mouth, seizures, appetite suppression
F. Mood Stabilizers:
a. How it works: alters electrical conductivity of cell
b. Interactions: make sure have adequate Na intake for Lithium
1. Lithium
c. Monitor: therapeutic levels
G. Anti-epileptics:
a. How it works: increases inhibitory action of GABA
b. Interactions: increased CNS depression with consumption of alcohol
1. Divalproex sodium (Depakote)
2. Carbamazepine (Tegretol)
c. SE: agranulocytosis—so check WBC, sedation
d. Monitor: I/O
H. Beta-Blockers: Anti-anginals
a. How it works: blocks beta 1 receptors thus decreasing BP and HR
b. SHOULD NOT 50mg daily, Ccr=15-35mL/min
1. Atenolol (tenormin)- 50-200mg/dy
2. Propranolol (Inderal)- 40-100mg/dy
c. SE: fatigue, weakness, bradycardia, CHF, pulmonary edema
d. Monitor: vitals, I/O, daily weight, assess CHF. Take apical pulse before admin, if ,50bpm
do not administer
I. Antihistamines:
a. How it works: blocks effects histamine @ H1 receptor, creating CNS depression
b. Interactions: additive CNS depression with alcohol and antidepressants
1. Diphenhydramin (Benadryl)
2. Hydroxyzine HCL (Atarax)
3. Hydroxyzine Pamoate (Vistaril)
c. SE: dry eyes, constipation, dry mouth, and blurred vision, can decrease anxiety so asses
mood, mental status and behaviour.
J. Herbal Therapy:
a. Kava-Kava: used for anxiety
1. How it works: alters limbic system modulation of emotional processes
2. SE: dizziness, headache, drowsiness, extrapyramidal effects, HEPATIC
TOXICITY. When taken with Benzo’s additive CNS depression
b. Valerian: for anxiety
1. How it works: may increase concentrations of GABA
2. SE: drowsiness, headache
SLEEP DISORDERS:
I. Types:
a. Dyssomnias- abnormalities in amt, quality or timing of sleep
i. Insomnia- most common, difficulty initiating and maintaining sleep
ii. Hypersomnia-
iii. Narcolepsy- excessive daytime sleepiness, sudden onset sleep attacks. Can have cataplexy
(sudden loss muscle tone and involuntary muscle movement) or sleep paralysis
iv. Breathing-related sleep disorder-e.g sleep apnea
v. Circadian rhythm sleep disorder- e.g jet lag, shift work type and delayed sleep phase
b. Parasomnias- abnormal behaviour during sleep
i. Nightmare disorder- occurs during REM
ii. Sleep terror- occurs during non-REM
iii. Sleepwalking- typically ages 4-8, occurs during non-REM
II. NSG PROCESS:
a. Assessment: subjective and objective data sources and sleep hx
b. NSG DX:
i. Sleep deprivation
ii. Insomnia
iii. Ineffective bx
iv. Anxiety
v. Fatigue
vi. Ineffective coping
c. Outcome I.D
i. I.d primary causes sleep alteration
ii. Communicate interventions and implement them
iii. Demonstrate reduction sleep disturbance
iv. Participate discharge planning
d. Planning: participation multidisciplinary team
e. Implementation/Interventions:
i. Monitor sleep patter and id risks
ii. Have client keep sleep diary
iii. Develop hygiene plane
iv. Teach symptom management
v. Make environment quiet
vi. Help client i.d stressors
vii. Promote development coping skills
viii. i.d clients support system
ix. promote compliance medications
x. teach limit substances cause sleep disturbances
xi. educate about circadian rhythms
xii. refer sleep specialist
GRIEF:
I. Types:
a. Anticipatory grief- pre-mourning- grief assoc. With anticipation predicted death or developing
loss
b. Acute Grief- painful exper. After a loss
c. Dysfunctional grief- ex. PTSD. Lasts longer than other types and has greater disability ex.
Traumatic loss, complicated grief, chronic grief
d. Chronic sorrow- response to ongoing loss ex. Parents w/ disabled children.
II. Interventions:
a. Assess risk kill or harm self and others
b. Promote ns-relationship
c. Facilitate expression feelings related to loss
d. Help client understand relationship between self and lost person
e. Facilitate full expression grief
f. Promote interactions with others
COGNITIVE DISORDERS:
I. Types:
1. Dementia- It is the gradual and progressive deterioration of intellectual functioning.
2. Delirium- an acute state of confusion, disorientation to person and place, rapid onset and short
duration
I. Types crisis:
a. External (situational)- external stressor which is apparent to another observer. Centres on real
events threaten health, shelter, loss loved one.
b. Internal (subjective) crisis- internal stressor threatens well being ex. Aging, loss independence
c. Phase-of-life (maturational) crisis-
d. Disaster (adventitious crisis)- man-made and natural disasters ex. Terrorism, tornados
II. 5 steps Crisis interventions:
a. Assess the individual and the problem:
i. Assess the individual and the problem- in the field and in office (physical safety principles,
medical hx, introduction and boundaries, chief complaint, hx present illness, family/social
hx, mental status, past medical & psychiatric hx, drug & alcohol hx, cultural and spiritual
issues, strengths and support, coping skills, GAF etc
b. Plan therapeutic intervention:
i. Express caring and consolation
ii. Assess reality of situation
iii. Develop and begin to utilize an immediate plan for intervention
iv. Coordinate w/ other agencies
v. Anticipate future needs related to crisis
c. Intervention
d. Resolution of the crisis
e. Anticipatory planning
III. 10 stages acute traumatic stress
i. Assess for danger/safety
ii. Consider mechanism of injury
iii. Address medical needs
iv. Evaluate level of responsiveness
v. Observe and identify who exposed
vi. Ground the individual
vii. Normalize the response
viii. Prepare for the future
DOMESTIC VIOLENCE:
I. Assessment:
a. The observable behaviour of client e.g increased irritation, increase in energy
b. Hx from the client- gathering self-defeating coping patterns
c. Information from friends and family-
d. Hx suicidal gestures or attempts
e. MSE-disturbance concentration, memory, orientation
f. Physical exam-signs substance abuse, irritability, euphoria, slurred speech
g. Nurse’s intuition
II. Interventions:
a. Provide safety and prevent violence: ex. Safe environment, remove all weapons
b. Assist with improvement of coping skills
c. Enhance family and support system
EATING DISORDERS:
Sign/Symptoms:
SCHIZOPHRENIA:
I. Neurobiologic brain disorder, results impaired thoughts, perceptions, cog. Fxn, mood and motivation
II. Signs/symptoms and course:
a. Premorbid: contributing factors
b. Prodromal: one mth to 1yr before diagnosis:
i. Mood-Anxiety, irritability, dysphoria
ii. Cognitive- distractibility, concentration difficulties, disorganized think
iii. Obsessive behaviours and rituals
iv. Sleep disturbance
v. Weak positive symptoms
c. Psychotic phase:
i. Acute phase- pos. And neg. symptoms, unable to perform self-care
ii. Maintenance phase- able to care for self
iii. Stable phase- remission
III. Types:
a. Paranoid
b. Disorganized
c. Catatonic
d. Residual
e. Undifferentiated
IV. Positive symptoms:
a. Alterations perceiving: hallucinations (false perceptions), delusions (false beliefs), loss ego
boundaries
b. Alterations thinking: concrete thinking, loose associations, flight of ideas, ideas of reference, ideas
persecution, ideas grandiosity, ideas being controlled, though broadcasting, thought insertion,
thought withdrawal
c. Alterations speech: neologisms, echolalia, clang assoc, word salad, circumstantiality, tangential
(superficial speech)
d. Alterations behaviour: bizarre behaviour, agitation, waxy flexibility, stupor, negativity,
echopraxia, symbolism
V. Negative symptoms:
a. Cognitive: Poverty of speech (alogia), Poverty of thought. Thought blocking, Problems with
attention, memory, Impaired decision making/judgement, problem solving, Disorganized think
b. Behavioural: anhedonia, anergia, avolition, depression, hopelessness, social isolation, decreased
spontaneity, anxiety, irritability, drug abuse. Medical comorbidity
VI. NSG DX: bassed on assessment pos and neg symptoms
VII. NSG interventions:
a. for the agitated:
i. safety
ii. reduce stimulation
iii. brief, concise statements
iv. det. stressors
v. redirect
vi. prevent agitation
b. for those in acute crisis: crisis intervention, stabilization, safety and limit setting
c. for those in maintenance and stable phase: give small amts infor, i.d signs of relapse
VIII. Psychopharmacology:
a. Typical antipsychotics, which block dopamine, phenothiazines: treat positive symptoms
i. Ex. Thorazine, Mellaril, Navane, Stelazine, Haldol and Prolixin
ii. SE: anticholinergic- dry eyes, mouth, constipation, sedation, orthostatic hypotension,
lowered seizure thresholds, jaundice, ESP (use antiparkinson drugs...cogentin, artane),
dystonica, neuroleptic malignant syndrome, tardive dyskineasia
b. Atypical antipsychotics- block serotonin and norepinephrine. Work on pos and neg symptoms.
Produce metabolic syndromes (so check weights)
i. Ex. Clozoril (monitor for agranulocytosis and WBC), seroquel (quetiapine), Risperdal
(risperidone), geodon (ziprasidone), abilify(aripiorazole)
EPS S.E: Neuroleptic malignant syndrome:
Akathsia Fever
Akinesia Muscle rigidity
Dystonias Altered consciousness
Acute distonic rx Rapid breathin
Pseudo parkinsonism Stupor-coma
Tardive dyskinesia Excessive salivation
Neuroleptic malignant syndrome Elevated CPK
SUBSTANCE ABUSE:
Support groups: AA, NA, CA Al-Anon, Al-a-teen, Adult children of alcoholics, inpatient, outpatient,
hospitalization, intensive outpatient, halfway houses.
Withdrawal from alcohol: Withdrawal from stimulants: Withdrawal from CNS
Irritability, anxiety, agitation Headache depressants:
Insomnia Anxiety Cravings
Diaphoresis Restlessness Abdominal
Tremors Cravings cramps
Delirium dreaming Diarrhea
Seizures Depression Nausea and
Possible death Decreased BP vomiting
Psychomotor retardation Bone/muscle pain
Muscle spasm
Tremor
Chills
Diaphoresis
IX. Signs/symptoms:
PERSONALITY DISORDERS:
I. In General PD:
a. Higher death rates
b. Higher rates suicide attempts
c. Increased rates separation, divorce and involvement legal proceedings
d. Increased rate criminal behaviour, alcoholism, and drug abuse
II. 4 common characteristics:
a. Inflexibility, maladaptive response stress
b. Disability in working and loving
c. Ability cause interpersonal conflict in others
d. Capacity to irritate others
III. 4 maladaptive patterns:
a. Faulty perceptions
b. Emotional lability
c. Poor impulse control
d. Difficult interpersonal functioning
IV. Characteristics:
a. Repetitive maladaptive behaviour
b. Behaviour not recognized as abnormal so don’t seek treatment
c. Ability achieve developmental tasks are limited
d. Seek help only in crisis
e. Starts in adolescence
f. Maladaptive behaviour used fulfill need and bring satisfaction
V. General interventions:
1. Asses suicide ideation
2. Implement suicide precautions—every 15min
3. Establish contract for safety
4. Encourage attendance all group sessions
5. Assess for escalating anger or rage
6. Contract not to harm staff or others
7. Teach manage anger and impulsive feelings and behaviours
8. Discuss angry and aggressive feelings
9. Assess client for evidence self-mutilation.
s/s antisocial Interventions: s/s borderline Interventions:
personality: 1. Prevent/decrease personality; 1. Set limits
1. Hx antisocial effects manipulation 1. Relationship with 2. Provide
behaviour 2. Guard against being others intense boundaries
2. Deceitful, liar manipulated and aunstable and limits that
3. Aggressive 3. Set clear and realistic 2. Poor impulse are clear and
towards limits behaviour control consistent
others 4. All limits must be 3. Recurrent 3. Consistent
4. Lack remorse adhered to by all staff suidical/self staff: asses for
hurting others 5. Carefully document mutilation suicide and
5. Presents as objective physical 4. Attention self mutilating
charming, self- signs of seeking/manipula behaviour
assured and manipulation/ tive
adept aggression 5. No boundaries
6. Interacts 6. Outbursts odd
others through anger and
manipulation, hostility
aggressiveness 7. Intense and
and primitive rage
exploitation 8. Rapid idealization
7. Lack empathy and devaluation
or concern
VI. Etiology/factors:
a. Lower socioeconomic status
b. Substance abuse
c. Genetics