Académique Documents
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Culture Documents
Specific Rights
NUR 114 2
Exam #1 Study Guide
- Client consent
- * MUST have
- Verbal or Implied
- Implied - Ex. Pt holds out hand for medication and puts pills in mouth
- Anything without consent is forced
- Communication
- Visitors, Mail, Telephone calls - Need Code
- No code, cannot give any information!!!
- Freedom from harm
- Nurses responsibility
- Freedom from harm from other pt’s, sharp objects/utensils, etc...
- Dignity and Respect
- Confidentiality
- Must ask pt if you can be there nurse before looking at pt’s chart
- ANA asserts the duty of the nurse to protect confidential pt information
- RNs legal duty to maintain pt’s confidentiality
- No conversations
- No information without signed consent
- No picture or recordings
- Participation in plan of care
- *Best way
- Explain and involve pt, get them to comply
Voluntary Admission
- Admitted by patient or guardian
- through a written application to the facility
NUR 114 3
Exam #1 Study Guide
- Right to demand release
- have the right to demand and obtain release
- May need written release notice to facility
- Pt submits written release notice to the facility staff. Who reevaluate the pt’s
condition for possible conversion to involuntary status according to criteria
established by stat law
- Written statement is looked at within 24 hours. Can take up too 72 hours. No
guarantee of release
Involuntary Admission
- No consent is given
- Desperately needs treatment
- Risk of harm to self or others
- Cannot meet basic needs
- Have rights still too...
- Medications - information about, refusal
- Unnecessary restraints - least restrictive
- Informed consent - to request and refuse treatment
- A specific number of physicians must certify that a pt’s mental health status
justifies detention and treatment
Discharge
NUR 114 4
Exam #1 Study Guide
- Depends on the pt’s admission status
- Informal or Voluntary admission
- Pt’s have the right to request and receive release
- Conditional release
- Enables the treating MD to order continued treatment on an outpatient basis if the pt needs warrant
further care
- Usually requires treatment for a specified period of time ti determine the pt’s adherence with
medications, ability to meet basic needs and reintegrate into the community
- Unconditional discharge
- Termination of pt / hospital relationship
- Patient cannot be at harm to self or others
- Against Medical Advice (AMA)
- When treatment seems beneficial, but there is no compelling reason to seek an involuntary
continuance of stay. Pt’s may be released AMA.
- Only way to keep is if pt is a danger to themselves or others
Tort Law - Civil wrongs for which money damages can be collected
Battery
- Physical violence
Protection of Clients
Defamation of Character
- Any communication written or spoken that harms someones reputation
False Imprisonment
Assault
- Threat of harm
Unintentional tort
- Equal less jail time may only be a fine.
Intentional tort
- Equal jail time.
- Intentional torts include battery, assault, and false imprisonment
NUR 114 6
Exam #1 Study Guide
Suicide
Suicide
Define - Intentional act of killing oneself
- Suicide attempt - is inflicted life threatening attempt on one’s life which did not lead
to death
- Suicidal ideation - is thinking about self harm
- Physician assisted suicide - Not legal in NC
Requirements:
- No psychosis or mental illness
- 2 physicians must agree upon
- Prognosis of 6 months to live
- Bipolar disorders emerge between childhood and 50 years of age, with most cases
manifesting between 15 and 19 years of age.
Statistics - Third leading cause of death among adults 15-24 years old
- Second cause in ages 25-34
- One in 5 deaths of veterans r/t PTSD
- 90% of people who die by suicide suffer from a mental condition
Long-term
- Minimize destructive behaviors
- Increase problem solving skills
NUR 114 8
Exam #1 Study Guide
Implementation - Initiate one on one
- Document observations q15min
- Remove all potentially dangerous items
- Maintain safe environment
- Do not assign to private room and always keep door open
- Limit time at risk patients spend alone
- Involve significant others in treatment
- Medications
- CBT
- Problem solving skills
- Therapeutic communication
NUR 114 9
Exam #1 Study Guide
Mood Disorders: Bipolar Spectrum Disorders
Bipolar Spectrum Disorders
Define - Bipolar Spectrum Disorders are the sixth leading cause of death in pt’s with mental
health disorders
- Bipolar disorders are chronic, recurrent, and life-threatening; Require lifetime
monitoring
- Characterized by two opposite poles: Depression and Mania
- Periods of normal functioning may alternate with periods of illness
Unipolar - Effect more women
- Insomnia - Difficulty falling asleep or waking repeatedly at night
- Appetite loss
- Depression
- Agitation
- Pacing
- Episodes last longer
Bipolar - Men and women effected equally
- Earlier onset - Teenage years
- Generally takes 10 years to dx
- Hyper-insomnia - Excessive tiredness and difficult morning waking, sleep a lot
- Binge eating
- Cravings - Crave carbohydrates (Ex. Sweets, pastas)
- Have weight fluctuations
- Psychomotor retardation
- At risk of substance abuse and suicide
- Have a tendency to have a dual/mixed diagnosis - Ex. Drug use -> At risk for
infection, STI/HIV, Cardiovascular disorder, Endocrine issues (DM, Tumors)
- Patients must take medications daily and understand the importance of taking
medications
Bipolar I Behavior
- 1 episode of Mania with major depression
Additional Symptoms
- May or may not have psychosis
Prevalence
- Men and women equally
Bipolar II Behavior
- Depressive episodes alternating with hypomania
Additional Symptoms
- Euphoria
- Suicide
Prevalence
- Men and women equally
NUR 114 10
Exam #1 Study Guide
Cyclothymic Behavior
- Hypomania alternating with minor depression (lasting 2 years)
Additional Symptoms
- Irritability with hypomania
Prevalence
- Begins in adolescence or early adulthood
- 50% will subsequently develop Bipolar I or II disorder
Rapid Cycling Behavior
- 4 mood changes in 12 months
Additional Symptoms
- Decreased GAF score
- High reoccurrence
- Resistance to treatment
Prevalence
- Reported more cases in women
Mixed Episodes - A mixture of hypomania or just mania plus depression
- Highest risk of suicide
Prevalence and - Begin between childhood and 50 years old
Co-morbidities of - BP I and BP II occur equally in men and women
Bipolar Spectrum - 76% have a co-morbid disorder
Disorders - Co-morbid disorders include: Anxiety, Behavioral, Substance abuse
- Substance abuse will have rapid cycling or mixed dysphoria (highs and lows of
emotions)
- Medical co-morbidities worsen the prognosis and increase suicide
- Medical co-morbidities include: Cardiovascular issues, Metabolic dx (DM), HIV
Neurobiology - First generation relative may have schizophrenia
- Interactions between neurotransmitters and hormones: Serotonin, norepinephrine
and dopamine
- Bipolar Mania: Decreased Serotonin and Dopamine, Increased Norepinephrine
- Depression: Decreased Norepinephrine
- Hypothalamic-pituitary-thyroid-adrenal axis (HPA) regulate the stress response and
is involved in maintaining homeostasis - causing increased cortisol levels - which cause
mood swings
- MRI image of the brain showed brain atrophy and volume reduction
- Stressful events can trigger symptoms of bipolar disorders
Characteristics of - Underlying depression
Acute Mania - Significant and persistent problems
- Difficulties in psychosocial areas: Environment, Occupational and Relationships
- Flight of ideas: Speech - Rapid, loud, vulgar
- Grandiosity - Idea of extreme self-importance “I’m the best!”
- Poor judgement
- Suicidal thoughts or plans
- Clang association - Rhyming without regard to meaning. “Bang, clang, shebang”
NUR 114 11
Exam #1 Study Guide
Hypomanina - Functioning
- Sleep less than 6 hours per night
- Increased sex drive
- Life of the party
- Flight of ideas
- Peppy, humor and sociable
- Enthusiastic
- Self-confidence
- Overactive
- Easily distracted
- Big appetite
- May not sleep
- Spend lots of money
Acute Mania - Demanding of time
- Intrusive
- Crude sexual remarks
- Flight of ideas
- May use clang association
- Humor turns to hostility
- Grandiose
- Short attention span
- Restless
- Disorganized
- Outburst/Tantrums
- Too busy for: Sex, Food, Sleep
Delirious Mania - Out of touch with reality
- Uses clang association
- Destructive
- Aggressive
- May hallucinate
- Dangerous state
- Hyperactive motor activity
- No sex
- Cannot eat or sleep
- Too disorganized
Assess for Danger - Suicidal thoughts/plans
to Self or Others - Intrusive behavior - In acute mania
- Delusions of grandeur - Think they are or know famous people
- Self-care needs - Unable to preform? - At risk for infection, malnutrition,
dehydration (Ex. Cannot eat, dress self or clean after self)
- Assess for medical status, co-existing medical conditions
Nursing Diagnosis - Risk for injury
- Risk for violence: Self or Others - Acute Mania
- Imbalance Nutrition - Acute and Delirious Mania
- Ineffective impulse control
- Impaired social interactions
- Disturbed sleep - Need at least 6 hours of sleep
NUR 114 12
Exam #1 Study Guide
Outcome Criteria Phase I: Acute Mania - 24 hours
- Prevent physical and psychological injury
- Ex. “Pt will make no attempt at self harm”
When taking Lithium observe the pt for motor tremors, orthostatic hypotension, Advise pt
to avoid caffeinated food and beverage and to take with meals to decrease gastric acid
- Polyuria - common side effect when taking for the first time
- Tetratogenic to fetus
- Monitor Liver function tests
- Infants, elderly, children may require decreased dose
- Start low, go slow - always applies to the elderly. often monitor q3-4days
Anxiolytics or Benzodiazepines
- Given early to control behavior, Calms patients
- Dangerous to the elderly or substance abusers
- Clonazepam (Klonopin)
- Lorazepam (Ativan)
Antipsychotics
- 2nd generation
- Work to treat anxiety, agitation, and psychosis
- Olanzapine (Zyprexa)
- Quetiapine (Seroquel) - Helps with sleep
- Ziprasidone Hcl (Geodon) - Helps with aggresion
NUR 114 15
Exam #1 Study Guide
To Treat Mania Antipsychotics
until Lithium - Slow speech
becomes - Inhibit aggression
Effective - Decrease psychomotor activity
Lithium: Early - Call MD, medication should be withheld, measure blood lithium levels and re-
Signs of Toxicity evaluate the dose
- Anything that can deplete hydration levels ; check blood lithium levels. Ex.
Diarrhea, Vomiting, Polyuria, Thirst, etc..
- The most
common - Blood levels should not exceed 1.5 mEq/L
adverse effects
Signs and Symptoms:
to Lithium are:
- Nausea
Nausea, - Vomiting
Diarrhea, - Diarrhea
Tremor, and - Thirst
Lethargy - Polyuria (Increased urine output)
- Slurred speech
- Muscle weakness
Lithium: - Blood levels 1.5-2.0 mEq/L
Advanced Toxicity Signs and Symptoms:
- Course hand tremors
- Severe GI upset
- Confusion
- Muscle hyper-irritability
- ECG changes
- Incoordination
Lithium: Severe - Blood levels 2.0-2.5 mEq/L
Toxicity Signs and Symptoms:
- Ataxia (lack of voluntary coordination of muscle movement)
- Know - Serious EKG changes
known antidote - Blurred vision
for Lithium - Clonic movements
poisoning - Large output of diute urine - signals renal damage
- Seizures
- Stupor
- Severe hypotension
- Coma/Death
Lithium: - Cardiovascular disease
Contradictions - Brain damage
- Renal disease
- Thyroid disease
- Myasthenia gravis - muscle weakness and fatigue
- Pregnancy
- Breastfeeeding
- Children younger than 12 years of age
NUR 114 16
Exam #1 Study Guide
Patient and - Effects of treatment
Family Teaching - Need to monitor blood levels
for Lithium - Side effects
Therapy - Toxic effects
- Effects of OTC medications
- When to call the MD
ECT - - Only for severe manic behavior
Electroconvulsive - Rapid cycling
Therapy - Paranoid, destructive features
- Acutely suicidal behavior
Interventions/ - CBT used with pharmacotherapy after mania subsides
Evaluations - Family therapy - Focused on communication within the family, teaches
communication skills, prepares the entire family for relapses episodes
- Effect of interventions and outcomes
- Revise plan of care as needed
NUR 114 17
Exam #1 Study Guide
Depression
Define Mood
- Sustained objective state of how one feels subjectively (pt’s words)
- How a person feels over time
- Able to observe emotions
- Judge based off the way you saw the pt the first time to now
Affect
- External manifestation of feelings or emotions, tone, voice, or body language
- Communicated outwardly of what the individual is feelings
- Inner feelings projected outward
- At the moment
Descriptors
Mood Affect
- Agitated - Angry
- Disturbed - Inappropriate
- Humorous - Joy/Sad/Tearful
- Relaxed - Appropriate
Depression
- Effects all races, ages, and genders
- Most common mental health issue
- Women 70% more likely
- The base of depression is anxiety
NUR 114 18
Exam #1 Study Guide
Mood Disorders Major Depressive Disorder (MDD)
- Depression without manic symptoms
- Pt’s are hospitalized
Subtypes
Dysthymic Disorder (DD)
- Chronic form of depression
- Not generally hospitalized unless having suicidal thoughts
- Lasts for at least 2 years
Situational Depression
- Individual is unable to adjust to or cope with a particular stressor
Bipolar Disorder
- Mania
- Depression
Postpartum Depression
- Can begin anytime within the first year after childbirth
- Characterized by: mood swings, feeling sad, anxious, overwhelmed, crying spells, lose
appetite or trouble sleeping
MDD and DD - Sadness
have in common - Despair
- Emptiness
- Anhedonia (No pleasure in life)
- Low self-esteem
- Social withdrawal
- Apathy (Lack of feeling emotion, interest, concern)
- Irritability
- Suicidal ideation - Vary between MDD and DD
NUR 114 19
Exam #1 Study Guide
Assessing Health History
Alteration in - Disease processes
Mood and Affect - Medications
- Hx alterations
- Family history
- Co-Morbidities?
Psychological Status
- Mood
- Affect
- Coping skills - Hopelessness/Powerlessness
- Cognition - How the pt is processing information Ex. Slow speech
- Concentration
- Appetite
- Sleep - Disturbed sleep patterns and Fatigue
Major Depressive - Lasts 9 months
Disorder - Affects children, teenagers, adults and the elderly
(MDD) - Pt’s suffer from mental, social, occupational disability without manic features
- Hospitalized
- Accompanies other mental disorders
- Mixed anxiety/Depression
- Excessive sleeping
- Crying/ Irritability
- Suicidal ideation
- Decreased appetite
- May complain of pain that does not seem to have a physical cause Ex.Headache
- Vegetative signs = no appetite, loss of sexual drive, crying spells, trouble thinking
Dysthymia - Chronic depression
Disorder - Lasts at least 2 or more years
(DD) - Onset: Early childhood to early adulthood
- Decrease functions at work - able to work just not at optimal levels
- Eat too much or not enough
- Energy loss
- Low self-esteem
- Negative thinking
- Hyper-insomnia
- No hospitalization unless having suicidal thoughts
NUR 114 20
Exam #1 Study Guide
Prevalence - Girls at higher risk than boys
- High reoccurrence rate
- Family hx increases chances
- Early treatment and CBT, first 12 weeks assist in remission
- Older adults at risk
- Suicidal risks increase with age
- Medical conditions mask dx
- Tricyclic / Antidepressant medications to treat the elderly is controversial. Due to risk
for: Falls, Stroke, and/or Seizures
Neurobiology Neurotransmitters
- Serotonin - important regulator of sleep, appetite and libido
- Norepinephrine - decreased level may cause angeria (lack of energy), anhedohia (no
pleasure in life), decreased concentration and libido
- Dopamine - disrupted in depression
- GABA
- Acetylcholine
- Animal therapy, Music therapy and Message therapy - Help to decrease depression
Milieu Therapy
- Assess pt’s risk for suicide
- Maintain safe environment
- Support pt’s
- Encourage attending group
- Ensure right medications
Psychotherapy
- CBT
- Interpersonal
- Mindfulness-based cognitive therapy
- Group - Increases social skills and allows pt’s to share
- Pharmacological
- Must ask
- Used for major depressive disorders
“Are you having
- Anxiety
suicidal - Obsessive/Compulsive
thoughts?” - Panic
- Phobias
- St. Johns - PTSD
Wort can cause
Serotonin - Citalopram (Celexa)
Syndrome - Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
Side Effects:
- Decreased libido
- Weight changes (Generally weight gain)
- Sexual dysfunction
Why pt’s are less compliant to take
- S/E’s also include: Nausea, Headache, Anxiety, Insomnia
Adverse Reactions
- Serotonin syndrome (SES) - occur when SSRI’s taken with an MAOI or taking 2 SSRI’s
together
- Restlessness - Generally due to the lack of O2
- Elevated B/P
- Delirium
- Hostile
- Seizures
- Abdominal pain
- Diarrhea
- Fever, Shock, Death
Side Effects
- Orthostatic hypotension
- Sedation
- Dry mouth
- Constipation
- urinary retention
- Blurred vision
- Tachycardia
Adverse Effects:
- Orthostatic hypotension
- Headache
- Insomnia
- Diarrhea
Hypertensive crisis
- Occurs when MAOI is used with other antidepressants and foods containing tyramine
Symptoms:
- Stiff neck
- Nausea
- Flushing
- Palpitations
- Occipital headaches
- Transdermal patch can be used without diet restrictions. Known as Selequilene (STS)
patch = 6 mg
- Patch dose greater than 9 mg must follow diet - NO tyramine
- Phenelzine (Nardil)
- Isocarboxazid (Marplan)
NUR 114 26
Exam #1 Study Guide
Foods containing Fruits
Tyramine - Avocado
- Bananas
- No - Raisins
guacamole, soy - Papaya
sauce, - Figs
chocolate, yeast
bread, - Soy sauce (Avoid Chinese Restaurants)
beer/wine, no
organ meats, Dairy Products
processed Aged cheese
meats, no Sour cream
coffee (NO Yogurt
caffeine)
Alcohol - Wine and Beer (Esp. Red Wine)
- Know
fruits Yeasts - Yeast bread
Meats
- Liver
- Pickled meats
- Pepperoni
- Salami
- Sausage
- Bologna
- Hot dogs
- Chocolate
- Pickles
- Caffeine
- Coffee
Electroconvulsive - Given 2-3 times per week to equal up to 12 treatments
therapy - Then on maintenance ECT - Every month
(ECT) - For psychosis attached to depression you may have to utilize ECT
- Must have consent
- Short-term memory loss - Assess upon return to unit - Can last up too 2-3 weeks
- NO important decisions should be made at this time
- Immediately check ABC’s after procedure and ensure the body is functioning: Bowel
sounds? Gag reflex present?
- Monitor heart rate for dysrhythmias
- Catatonic/Vegetative states receive ECT
- Produces a seizure in the brain
Moderate Anxiety
- Narrow perception
- Difficulties concentrating
- Increases P, RR, muscle tension
Severe Anxiety
- Focused on one detail
- Distorted
- Confusion
- N&V
- Tachy
- Dizziness
- Speech loud, rapid, demanding
Panic Anxiety
- Unable to focus on environment
- Mute
- Psychomotor agitation
- Irrational reasoning
- Terror
- Immobility
- Dilated pupils
- Sleeplessness
- Delusions
- Splitting - Inability to integrate the positive and negative qualities of oneself or others
into cohesive image.
- Person believes they are only good or only bad. Do not understand they can be both.
- Alprazolam (Xanax)
- Clonazepam (Klonopin)
- Lorazepam (Ativan)
- Buspirone (BuSpar) - Not addictive, Ideal for substance users, Good for anxiety
disorders: PTSD, OCD, and Phobias. Takes 2-3 weeks to work.
- Phenobarbitals - Sedative, not good for addictive behaviors
- Benzodiazepines given for primary anxiety for a short time to relieve acute cases of
anxiety.
- Biggest danger with taking Benzodiazepines = Drug Dependency
Flumazenil - Antidote to any kind of Benzodiazepines
(Romazicon)
Diagnosis
- Anxiety
- Ineffective coping
- Social Isolation - Do they have time in-between ritual? (Always washing hands in room
no time for socialization) Nurse should encourage pt to “dry hands and come outside” “Are
you feeling anxious this morning?”
- Self care deficit - Preoccupied with ritual cannot care for self
- Impaired Skin Integrity - R/T constant washing of hands
Planning
- Involve pt in planning process
- Offer the pt choices
- Allow pt to set goals
- #1 to enhance compliance
- Implement CBT therapy: Modeling, Systemic desensitization, Response prevention,
and Thought stopping
NUR 114 33
Exam #1 Study Guide
Personality Disorders
Personality Disorders
Define - Personality - Style a person adopts to deal with world. Remains the
same , cannot change
- Complex and challenging behaviors to deal with
A lot of the time they have co-morbidities such as: (Coexist with everything)
- Anxiety
- Depression
- Substance abuse
- Eating d/o
- Medical condition
Risk factor
- Chronic trauma/abuse
NUR 114 34
Exam #1 Study Guide
Categories of Group A.
Personality - Remember the word PASS
Disorders - When you see these individuals you want to walk right pass them
- Odd behavior
- Patients - Paranoid
can have 2 at - Schizoid
the same time - Scizotypal
Group B.
- Drama queens, Emotional or Erratic
- Inappropriate, disruptive behaviors
- Antisocial
- Borderline
- Histrionic
- Narcissistic
Group C.
- “Scaredy Cats”
- Anxious, Fearful, Insecure
- Avoidant
- Dependent
- OCD
- Passive-Aggressive