EXAM 2 Psych in class notes PDF

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Notes from mental health and psychiatric nursing lecture. To be studied for exam number 2. discusses different medications and mental health disorders....

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 Chapter 16: Schizophrenia   

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Schizophrenia Distorted and bizarre thoughts, perceptions, emotions, movements, behavior Categories of symptoms (refer to Box 16.1) o Positive (hard/ something that is happening to the patient)  Examples: delusions, hallucinations o Negative (soft)  Examples: flat affect, lack of volition, inattention Usually diagnosed in late adolescence or early adulthood Peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. Prevalence is estimated at about 1% of total population o In the United States, nearly 3 million people are, have been, or will be affected by the disease.

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Schizoaffective disorder o Client is severely ill. o Mixture of psychotic and mood symptoms o All symptoms of schizophrenia, and the symptoms of mood disorders like bipolar.

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Clinical Course Onset: abrupt or insidious; most with slow, gradual development of signs and symptoms Diagnosis usually with more actively positive symptoms of psychosis Immediate-term course: two patterns o Ongoing psychosis, never fully recovering o Episodes of psychotic symptoms alternating with episodes of relatively complete recovery Long-term course: o intensity of psychosis diminishes with age o disease becomes less disruptive o clients may live independently later in life o many have difficulty functioning in the community.

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Related Disorders Schizophreniform disorder o acute reactive psychosis for less than 6 months Catatonia o characterized by psychomotor disturbance. Either too much movement or motionlessness. Treated with Adorvan (a benzo). Delusional disorder o When a PT has one or more non-bizarre delusions. It is a believable delusion.

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o Command delusion: hearing voices telling them to do something Brief psychotic disorder o At least one psychotic symptom. Can last from a day to a month. Usually due to extreme stressor Shared psychotic disorder o 2 people have a similar delusion. A more submissive person may begin to rapidly improve if removed from the more dominant person. Schizotypical personality disorder o Someone has very odd or eccentric behaviors. About 20% of people with this disorder will be diagnosed with schizophrenia. Can be mistaken for autism and can evolve into psychosis.

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Biologic theories o Genetic factors (genetic risk is polygenic) o Neuroanatomic and neurochemical factors (less brain tissue and cerebrospinal fluid; dopamine excess and serotonin modulation of dopamine) o Immunovirologic factors (Body’s response to viral exposure; cytokines)  Researchers focusing on infections in pregnant women as a possible origin  After influenza epidemics  Respiratory ailments

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Flat affect and social withdrawal are negative symptoms of schizophrenia.

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Cultural Considerations Ideas considered delusional in one culture possibly commonly accepted by other cultures Auditory or visual hallucinations as normal part of religious experiences in some cultures Culture-bound syndromes o BouffAe dAlirante o Ghost sickness  Preoccupation with death and the disease. Symptoms: bad dreams, feelings of danger, sense of suffocation, fear. Usually seen in Native Americans o Jikoshu-kyofu  Fear of offending others with foul body odor. o Locura o Qi-gong psychotic reaction o Zar Ethnic differences in response to psychotropic medications o Black ethnicity is associated with lower plasma levels, Asian backgrounds metabolize drugs more slowly.

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Psychopharmacology Treatment Conventional antipsychotics (dopamine antagonists; see Table 16.1) o Targeting positive signs o No observable effect on negative signs Second-generation antipsychotics (dopamine, serotonin antagonists) o Diminish positive symptoms o Lessen negative symptoms o Clozipine, Risperidone, Zyprexa First-generation targets the positive signs, but do nothing for the negative signs. Maintenance Therapy A form of psychopharmacologic therapy Six antipsychotics available in depot injection form: o Fluphenazine in decanoate and enanthate preparations (prepared in sesame oil, check for allergies. Absorbed slowly into the system. Takes 2-4 weeks and don’t need any other daily meds) o Haloperidol in decanoate (prepared in sesame oil. Check for allergies. Absorbed slowly into the system. Takes 2-4 weeks and don’t need any other daily meds) o Risperidone o Paliperidone o Olanzapine o Aripiprazole May take several weeks of oral therapy to reach stable dosing level before transition to depot injections Neurologic side effects o Extrapyramidal side effects (reversible movement disorders caused by neuroleptic medications)  Acute dystonic reactions  spasms in different muscle groups. Usually neck, eyes, tongue, trouble swallowing. Treat with benedryl/ diphenhydramine or benzotropine. Given IM or IV  Akathisia  restless movements. Pacing/ cannot sit still. Can be painful for the patient  Parkinsonism  shuffling gait, mask-like face, stiff muscles. Symptoms appear within the first few days within starting or increasing the dose o Tardive dyskinesia  Irreversible. Caused by antipsychotics.  Usually appears later on  Lip smacking, tongue protrusion, movements of the hands or feet  Can cause social isolation

o Seizures o Neuroleptic malignant syndrome  Serious and fatal condition  Seen in patients taking antipsychotics  Muscle rigidity. High fever, increased muscle enzymes, leukocytosis  Closipine given in structured setting, have to get blood work weekly, WBC have to be in normal range to receive medication. It is one of the best working antipsychotics, but it has dangerous side effects. 

Nonneurologic side effects (for side effects and interventions, see Table 16.2) o Weight gain (Giedon is an antipsychotic that can help reduce the incidence of weight gain, but it must be taken with at least 300 calories) sedation, photosensitivity o Anticholinergic symptoms (dry mouth, blurred vision, constipation, urinary retention) o Orthostatic hypotension

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Psychosocial Treatment Individual and group therapy o Medication management, use of community supports Social skills training Cognitive adaptation training Cognitive enhancement therapy (CET) o Combines online training with group training Family education and therapy

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Tardive dyskinesia is a neurologic side effect of antipsychotic therapy. o Blurred vision, sedation, and agranulocytosis (seen with Closipine) are nonneurologic side effects.

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Schizophrenia and Nursing Process Application Assessment o History:  age at onset  previous suicide attempts  current support systems  perception of situation o General appearance, motor behavior, and speech:  may appear odd  may exhibit psychomotor retardation  word salad  jumbled words or phrases that are completely disconnected and make no sense

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echolalia  someone is repeating or imitating what they are saying  latency of response (see Box 16.3) o Mood and affect are flat (no facial expression or emotion) and blunted:  anhedonia o Thought process and content:  thought blocking  patient believes that someone/ something is stopping them from saying what they want to.  Broadcasting  When they think that others can hear their thoughts  Withdrawal  Insertion  They feel others are taking their thoughts and putting them into the patient’s mind o Delusions (see Box 16.4 for different types) o Sensorium and intellectual processes:  hallucinations (auditory, visual, olfactory, tactile, gustatory, cenesthetic (the patient can feel body functions that are not normally detectable), kinesthetic)  depersonalization Assessment—(cont.) o Judgment and insight:  usually impaired o Self-concept:  loss of ego boundaries o Roles and relationships:  social isolation  frustrating in fulfilling family and community roles o Physiological and self-care considerations:  inattention to hygiene and grooming  failure to recognize sensations  polydipsia (increased thirst. Can cause water intoxication or seizures from severely low Na levels) Data analysis/nursing diagnoses o Risk for other-directed violence o Risk for suicide o Disturbed thought processes o Disturbed sensory perception o Disturbed personal identity o Impaired verbal communication

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Outcome identification (acute psychosis; treatment) o Focus on safety of client and others o Contact with reality o Interact with others in environment o Express thoughts and feelings in a safe, socially acceptable manner o Adhere to interventions

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Interventions o Safety of client and others o Therapeutic relationship o Therapeutic communication (no judgement, do not be pushy) o Interventions for delusional thoughts o Interventions for hallucinations o Coping with socially inappropriate behavior o Client and family education  Signs and symptoms of relapse (see Box 16.5)  Self-care, nutrition  Social skills  Medication management o Perform an ongoing assessment to determine if the outcomes were perceived, and the patient’s perception of the care is important.

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When a client is experiencing delusions, the nurse should focus on the reality and not confront or reinforce the client’s delusions.

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Elder Considerations Late onset: after age 45 Psychotic symptoms later in life usually associated with depression or dementia, not schizophrenia Variety of long-term outcomes for elderly o Approximately one-fourth experiencing dementia, resulting in steady, deteriorating health decline o Approximately one-fourth experiencing reduction in positive symptoms o Remainder mostly unchanged

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Community-Based Care Housing with family or independently Assertive community treatment programs Behavioral home health care Community support programs Case management services

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Mental Health Promotion

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Goal of psychiatric rehabilitation Early intervention o Accurate identification of those at risk o Recognize prodromal signs

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Self-Awareness Issues Recognize client’s suspicious or paranoid behavior is part of the illness, not a personal affront. Nurse may be frightened; acknowledge those feelings and take measures to ensure safety. Don’t take client’s success or failure personally. Focus on the amount of time client is out of hospital. Visualize the client as he or she gets better.

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Chapter 19: Addiction 

Substance Abuse o National health problem o Actual prevalence of substance abuse difficult to determine o Detrimental effects  Alcohol-related death is the third leading preventable cause of death in United States.  Absenteeism at work  Prenatal exposure  Increased violence

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Categories of Drugs o Alcohol o Sedatives, hypnotics, and anxiolytics o Stimulants o Cannabis o Opioids o Hallucinogens o Inhalants

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Diagnostic Classes of Substance Abuse o Important terms  Intoxication  Using a substance results in a maladaptive behavior  Withdrawal syndrome  Negative psychological and physical reaction that occur when substance use decreases or ends  Detoxification  Process of safely withdrawing from a substance. Inpatient  Substance abuse  Using a drug or substance inconsistently with medical or social norms  Substance dependence  Problems associated with addiction, such as tolerance. Leads to unsuccessful attempts to stop  Substance use  Can include abuse and dependence, not referring to occasional uses.

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Onset and Clinical Course o Average age for first episode of intoxication is adolescence. o Episodes of “sipping” as early as 8 years old

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o Pattern of more severe difficulties emerges in mid-20s to mid-30s. o Blackout  So intoxicated, there is no concious awareness of what is going on. The person does not remember. o Tolerance o Tolerance break  After continued heavy use, the person will have a break where a small amount will intoxicate them instead of needing a large amount o Periods of abstinence or temporarily controlled drinking  Leads to escalation of alcohol use and subsequent crisis  Cycle continues o For many, substance use is chronic illness.  Remissions and relapses  Relapse rates 60% to 90% o Highest rates for successful recovery—abstinence and high level of motivation  Those who go to NA or AA, they have a higher success rate than those who try to manage it on their own. Spontaneous remission o The patient is not on scheduled medical treatment, they have done it on their own naturally. o Poor outcomes associated with earlier age at onset

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Related Disorders o Gambling disorder o Caffeine and tobacco additions o Substances can induce symptoms similar to other mental illness diagnoses.

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Etiology o Biologic factors  Genetic vulnerability  Neurochemical influences  Dopamine pathways in the brain: what produces the high o Psychological factors  Family dynamics  Coping styles o Social and environmental factors  Cultural factors, social attitudes, peer behaviors  Laws, cost, availability

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Cultural Considerations o Attitudes vary in different cultures.  Muslims do not drink alcohol.  Wine is an integral part of Jewish religious rites.

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Some Native American tribes use peyote (hallucinogen) in religious ceremonies. o Genetic traits of certain ethnic groups as predisposing to or protective against alcoholism o Variations in enzymatic activities among Asians, African Americans, whites  Alcohol abuse:  a part in the five leading causes of death for Native Americans and Alaska Natives  One-eighth of Native Americans identified as needing treatment for alcohol or drugs  Japan:  alcohol not regarded as a drug  Russia:  high rates of alcohol abuse, suicide, and cigarette smoking in male population 

Alcohol o Intoxication and overdose  CNS depressant: relaxation/loss of inhibitions  Slurred speech, unsteady gait, lack of coordination, and impaired attention, memory, judgment  Aggressive behavior or display of inappropriate sexual behavior; blackout  Overdose: vomiting, unconsciousness, respiratory depression  Treatment: gastric lavage or dialysis to remove the drug and support of respiratory and cardiovascular functioning in an intensive care unit o Withdrawal (see Box 19.2)  Onset within 4 to 12 hours after cessation or marked reduction of alcohol intake; usually peaks on the second day and complete in about 5 days  Symptoms: coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety  Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium (DTs).  Withdrawal can be life-threatening.  Benzodiazepines for safe withdrawal

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Sedatives, Hypnotics, and Anxiolytics o Intoxication and overdose  CNS depressants  Intensity depends on drug.  Intoxication symptoms: slurred speech, lack of coordination, unsteady gait, labile mood, stupor

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Barbiturate overdose possibly lethal; coma, respiratory arrest, cardiac failure, death  Clonapine is the “safest” benzo to help with withdrawals. o Onset of withdrawal dependent on half-life of drug  Xanax has short half-life, Clonapine has long half-life  Symptoms opposite of drug’s acute effect o Detoxification via drug tapering 

Stimulants (Amphetamines, Cocaine) o CNS stimulants o Intoxication and overdose  High or euphoric feeling, hyperactivity, hypervigilance, anger; elevated blood pressure, chest pain, confusion  Seizures, coma with overdose  Cocaine has no use in the medical field, gives a euphoric feeling.  Meth is addictive, cause psychotic behavior and potentially brain damage. o Withdrawal  Onset within hours to several days  Primary symptom is marked dysphoria.  “Crashing”  Not treated pharmacologically

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Cannabis (Marijuana) o Used for psychoactive effects o Medical applications  Can be used for glaucoma, lowering vomiting and nausea associated with chemo, helps control seizures  Starts to work less than 1 minute after inhalation, peak affects last 2-3 hours.  Can cause cannabis hyper-emesis syndrome. o Intoxication  Lowered inhibitions, relaxation, euphoria, increased appetite  Symptoms of intoxication include impaired motor control, impaired judgment  Delirium, cannabis-induced psychotic disorder  No overdose o No clinically significant withdrawal syndrome  Possible symptoms of insomnia, muscle aches, sweating, anxiety, tremors

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Opioids o Desensitization to pain, euphoria, well-being

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o Intoxication: apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory o Overdose: coma, respiratory depression, pupil constriction, unconsciousness, death  Naloxone (Narcan) Withdrawal o Nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia o Symptoms cause significant distress, but do not require pharmacologic intervention to support life or bodily functions o Short-acting drugs (e.g., heroin): onset in 6 to 24 hours; peaking in 2 to 3 days and gradually subsiding in 5 to 7 days o Longer acting drugs (e.g., methadone): onset in 2 to 4 days, subsiding in 2 weeks Hallucinogens o Reality distortion; symptoms similar to psychosis including hallucinations (usually visual), depersonalization  Cause increased pulse, blood pressure, and temperature; dilated pupils; and hyperreflexia o Intoxication: maladaptive behavioral/psychological changes, anxiety, depression, paranoid ideation o No overdose; toxic reactions are primarily psychological o PCP toxicity: seizures, hypertension, hyperthermia, respiratory depression  Medications to control seizures and blood pressure  Cooling devices  Mechanical ventilation No withdrawal syndrome o Some report a craving for the drug Flashbacks possible for few months up to 5 years Inhalants Intoxication: neurologic, behavioral symptoms o Gasoline, glue, spray paint, paint thinners Acute toxicity o Anoxia, respiratory depression, vagal stimulation, dysrhythmias o Death possible from bronchospasm, cardiac arrest, suffocation, or aspiration o Can lead to dementia or asthma No withdrawal or detoxification o Frequent users report cravings Symptomatic treatment of related disorders . Substance Abuse Treatment

o Concept: medical illness that is progressive and chronic, characterized by remissions and relapses o Treatment models:  Hazelden Clinic model  12-step program of Alcoholics Anonymous (AA; see Box 19.3) o Individual, group counseling o Treatment settings o Pharmacologic treatment: safe withdrawal; prevent relapse (see Table 19.1)  Medications help manage withdrawal or cravings, but is not a specific treatment for substance abuse.    

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Dual Diagnosis Substance abuse + another psychiatric illness Estimated 50% of people with a substance abuse disorder also have mental health diagnoses Successful treatment, relapse prevention strategies (see Nursing Care Plan) o Healthy, nurturing, supportive living environments o Help with fundamental life changes, such as finding job, abstinent friends o Connections with other recovering people o Treatment of comorbid conditions Assessment o History:  chaotic family life  family history  crisis that precipitated treatment o General appearance and motor behavior o Mood and affect:  Tearful  expressing guilt  remorse  angry  sullen  quiet  unwilling to talk o Thought process and content:  minimize substance us  ...