Exam 2 study guide C7 - Exam review PDF

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Exam 2 Study Guide Anxiety: Anxiety and fear are indistinguishable except for the cause. Anxiety can be defined as a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized.  Normal anxiety: is a healthy life force that is necessary for survival. It provides the energy needed to carry out the tasks involved in living and striving toward goals. Anxiety motivates people to make and survive change. It prompts constructive behaviors, such as studying for an exam, doing a job interview, preparing a presentation, and working toward a promotion.  Acute anxiety: Is precipitated by an imminent loss or change that threatens an individual’s sense of security. Acute anxiety is normal and expected response to stress. Levels of anxiety: Mild: Mild anxiety occurs in the normal experience of everyday living. A person’s ability to perceive reality is brought into sharp focus. A person sees, hears, and grasps more information and problem solving becomes effective. S/S, slight discomfort, restlessness, irritability, or mild tension-reliving behaviors (nail biting, foot or finger tapping, fidgeting). Moderate anxiety: A person sees, hears, and grasps less information than someone who is not in that state. The ability to think clearly is hampered but problem solving, and learning can still take place. S/S tension, pounding heart, increased pulse and respirations, perspiration, and mild somatic symptoms (gastric discomfort, headache, urinary urgency). Severe Anxiety: The perpetual field of a person experiencing severe anxiety is greatly reduced. The person may focus on one particular detail or many scattered details. The person may have problems focusing on specific details. Learning and problem solving are not possible at this level, the person may be dazed and confused. S/S Headache, nausea, dizziness, insomnia, trembling, and pounding heart, the most common experiences are hyperventilation and a sense of impending doom or dread. Panic level of anxiety: The most extreme form and results in markedly disturbed behavior. An individual is not able to process events in the environment and may lose touch with reality. The resulting behavior may be confusion, shouting, screaming, or withdrawal. Hallucinations, or false sensory perceptions such as seeing people or objects that are not present, may be experienced by people at this level of anxiety. S/S physical behavior may be erratic, uncoordinated, and impulsive. Automatic behaviors are used to reduce and relieve anxiety, although such efforts may be ineffective. Acute panic attacks may lead to exhaustion. Experiences the most intense state of terror and emotional paralysis. Interventions: Mild to moderate levels of anxiety: The nurse can help the patient focus and problem solve with the use of specific communication techniques, such as employing open-ended questions, giving broad openings, and anxiety. Restricting topics of communication and introducing irrelevant topics can increase a person’s anxiety and are tactics that usually make the nurse, not the patient, feel better. Keeping the patient calm, helping them recognize the anxious patients distress, and being willing to listen. Evaluation of past coping mechanisms is useful. Often the nurse can help the patient consider alternatives to problem situations and offer activities that may temporarily relieve feelings of inner tension. Identify the anxiety, anticipate anxiety-provoking situations, encourage the patient to talk about their feelings, provide outlets of dissipating excess energy (walking, playing tennis, dancing, exercising). Severe to panic levels of anxiety: Extreme regression and aimless behaviors are behavioral manifestations of a person’s intense psychic pain. The nurse must be concerned with the patient’s safety and at times, with the safety of others. Physical needs (fluids and rest). Moving the person to a quiet room where there is minimal stimulation. Medication use may be considered. Medications and restraints should be used only after other more personal and less restrictive interventions have failed to decrease anxiety to safer levels. Although communication is scattered there are themes that the nurse must address. The feeling that one is understood can decrease the sense of isolation and reduce anxiety. Firm, short, and simple statements. Interventions for mild to moderate anxiety 1. Help the patient identify anxiety. “Are you comfortable right now?” 2. Anticipate anxiety-provoking situations. 3. Use nonverbal language to demonstrate interest (e.g., lean forward, maintain eye contact, nod your head).

4. Encourage the patient to talk about his or her feelings and concerns. 5. Avoid closing off avenues of communication that are important for the patient. Focus on the patient’s concerns. 6. Ask questions to clarify what is being said. “I’m not sure what you mean. Give me an example.” 7. Help the patient identify thoughts or feelings before the onset of anxiety. “What were you thinking right before you started to feel anxious?” 8. . Encourage problem solving with the patient.∗ 9. Assist in developing alternative solutions to a problem through role play or modeling behaviors. 10. Explore behaviors that have worked to relieve anxiety in the past. 11. Provide outlets for dissipating excess energy (e.g., walking, playing table tennis, dancing, exercising). Interventions for severe to panic levels pf anxiety: 1. Maintain a calm manner. 2. Always remain with the person experiencing an acute severe to panic level of anxiety. 3. Minimize environmental stimuli. Move to a quieter setting and stay with the patient. 4. Use clear and simple statements and repetition. 5. Use a low-pitched voice; speak slowly. 6. Reinforce reality if distortions occur (e.g., seeing objects that are not there or hearing voices when no one is present). 7. Listen for themes in communication. 8. Attend to physical and safety needs when necessary (e.g., need for warmth, fluids, elimination, pain relief, family contact). 9. Because safety is an overall goal, physical limits may need to be set. Speak in a firm, authoritative voice: “You may not hit anyone here. If you can’t control yourself, we will help you.” 10. Provide opportunities for exercise (e.g., walk with nurse, use a punching bag, play table tennis). 11. When a person is constantly moving or pacing, offer high-calorie fluids. 12. Assess need for medication. Defense mechanisms: responses to stress and anxiety are affected by factors such as, age, gender, culture, life experiences, and life style. Strong social supports from significant others can enhance mental and physical health and act as a significant buffer against distress. All defense mechanisms are on a unconscious level except sublimation.  Healthy defense mechanisms: Altruism, sublimation, humor, suppression  Intermediate defenses: repression, displacement, reaction formation, somatization, undoing, rationalization  Immature defense mechanism: passive aggression, acting-out behaviors, dissociation, devaluation, idealization, splitting, projection. Anxiety disorders: refers to a number of disorders including panic disorders, phobias, and general anxiety disorders. Anxiety disorders are the most prevalent lifetime psychiatric disorder. Panic disorders: consists of recurrent and unexpected “out of the blue” panic attacks. Panic attack is the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom. Panic attacks are sudden, are extremely intense, and can occur for 1-30 minutes before they subside. A person can present with all the symptoms of a heart attack (chest pain, difficulty breathing, dizziness, and excessive fatigue) have a full medical work up and show no signs of cardiac problems. At this point the person needs to be referred to a counselor for a potential diagnosis and treatment of an anxiety disorder. Phobias: A phobia is a persistent, intense irrational fear of a specific object, activity, or situation that leads to a desire for avoidance, or actual avoidance of the object, activity, or situation. Specific phobias are characterized by the experience of high levels of anxiety or fear in response to specific objects or situations, such as dogs, spiders, heights, storms, water, blood, closed spaces, tunnels, or bridges. Social anxiety disorders or social phobias: characterized by severe anxiety or fear provoked by exposure to a social situation or a performance situation, resulting in humiliation or embarrassment. Fear of social speaking is the most common social phobia. Social anxiety disorders are believed to be influenced by psychological factors such as the

quality of early attachments, the development of appropriate social skills, inadequate experiences interacting with others, and other negative environmental influences.  First degree relative of persons with social anxiety disorders are 3 times more likely to develop a social anxiety disorder.  The beta blocker PROPRANOLOL reduces physiological symptoms of anxiety, although not the cognitive symptoms.  More pervasive social anxiety may respond to monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs). Cognitive therapy interventions along with social skills training are helpful for many. Generalized Anxiety Disorder: A chronic psychiatric disorder associated with severe distress different from other anxiety disorders in that there is pervasive cognitive dysfunction, impaired functioning, and poor health-related outcomes. GAD also differs from other disorders in that patients do not fear a specific external object or situation, and there is not distinct symptomatic reaction pattern.  GAD is characterized by excessive, persistent, and uncontrollable anxiety, and by excessive ad constant worrying. Also referred to as the “worry disease.” A diagnosis is made if at least three of the following symptoms are present: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance. The individuals worry is out of proportion to the true effect of the event or situation about which the individual is focused for most days during a 6-month period in order to qualify for a diagnosis. Obsessive-compulsive and related disorders: Obsessive-compulsive disorder (OCD): usually begins in the late teens to early twenties and ranges from mild to severe. Here is substantial evidence that OCD has biological origins and I thought by many to be a neurologically based disorder. OCD seems to occur more often in patients with other neurological disorders.  There have been studies that show an increase metabolism in patients with OCD especially hyperactivity in the prefrontal cortex.  Obsessive-compulsive symptoms are common, but OCD can be disabling and painful.  Obsessions are defined as thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. Compulsions are ritualistic behaviors that an individual feel driven to perform in an attempt to reduce anxiety. Common compulsions can include repetitive hand washing and checking a door multiple times to see if its locked. Compulsions can be mental as well such as, counting, praying, or preforming a compulsive act that temporarily relieves anxiety. The compulsions and obsessions interfere with normal routine and social activities and relationship with others. Severe OCD consumes so much of the individuals mental process that the performance of cognitive tasks may be impaired. Suicide risk for these individuals, especially the presence of a co-occurring depression. Body Dysmorphic Disorder: BDD is a highly distressing and impairing disorder that ranges along the continuum from distressing to delusional severity. People with BDD usually have a normal appearance, although a small number do show minor defects. They think they are ugly or deformed. People with BDD have higher suicidal ideation, suicide attempts, and completed suicides than individuals who don’t meet the criteria.  Treatments include SSRI’s, antidepressants, and clompipramine, and cognitive behavior therapy. A second-generation antipsychotic added to an SSRI may help in the more severe delusional form of BDD. Hoarding: compulsive hoarding is associated with excessive collecting of items that are essentially worthless. These people often feel shame for their failure to discard excessive amounts of these items. People with severe hoarding have an extreme disruption of daily living. Mood disorders (depression): Depression is actually a syndrome not a disease. Depression can range from mild to severe. Depression is the most common mental illness seen in medical/ psychiatric practice today. Women are 70% more likely to be depressed then men. Women are more likely to seek help while men are more likely to selfmedicate with drugs and alcohol.  People with chronic health/ medical problems are at a higher risk than the general population to get a depressive disorder. A depressive syndrome is frequently accompanied by other psychiatric disorders such as anxiety, PTSD, schizophrenia, substance abuse, eating disorders etc.  African Americans have the highest rate of current depression followed by Hispanics and whites.  Depression in children may present with different signs then depression in adults. Their mood may be irritable, they may complain of feeling unwell, refuse to go to school, complain of vague physical complaints, show aggression, and act clingy. Adolescents may hide depression through sulking, being

negative, grouchy, getting into trouble at school, feeling misunderstood, withdrawing from others, or running away from home or center.  Depression in older adults is declining but suicide rate among elderly men is the highest of all age groups. Depression can remain undiagnosed around 50% of the time. Antidepressants can be risky in the use of older adults. Studies show that antidepressant use is elderly adults are associated with falls, stokes, seizures, and other adverse outcomes. Those taking SSRIs had more adverse events than those taking tricyclic antidepressants. SSRIs are less likely to be given to older adults.  Twin studies show a genetic factor related to the development of depressive disorders. The risk of depression for children who are born to depressive parents is the same as children adopted by nondepressive family. Persistent Depressive Disorder (PDD): commonly known as dysthymia or chronic depression. Is a less notably severe depression characterized by depressive symptoms that have been present for at least 2 years. MDD has more severe symptoms than PDD but PDD is more chronic.  S/S of PDD are: daytime fatigue, frequently but not always able to function at work and in social situations but not at the optimal level, chronic low/irritable mood, eating too much or too little, difficulty sleeping; in PDD there is often difficulty getting to sleep and once asleep it is excessive, and in MDD it is more common to find early-morning awaking, loss of energy, fatigue, and chronic tiredness even for simple tasks, decreased capacity to experience pleasure, enthusiasm, or motivation, irritability, negative pessimistic thinking, low self-esteem.  Assessment: A person who is depressed is always assessed for homicidal/suicidal intentions. White males complete more than 78% of all suicides. Evaluation of suicide might include the following statements: “you said you feel depressed, tell me what that is like for you?, when you feel depressed, what kind of thoughts go through your mind?, have you ever thought about taking your own life in the past, now, do you have a plan, would anything prevent you from carrying out your plan?  Assessment guidelines: Always evaluate the patients risk of suicide or harm to others, a thorough medical and neurological exam helps determine if the depression is primary or secondary to another disorder, Asses history of depression, if the patient has a history then determine the type of therapies used and if they were effective, assess support systems, family, and, significant others, asses for any events that could trigger a depressive episode, include a psychosocial assessment that includes cultural beliefs and spiritual practices related to mental health and treatment, determine if the depression is affecting the patients belief and practice. o Areas to asses: mood, physical changes, cognition. o Diagnosis: risk for suicide, hopelessness, impaired mood regulation, ineffective coping, social isolation, spiritual distress. o Interventions: Milieu therapy, psychotherapy, mindfulness-based cognitive therapy, group therapy. o Antidepressant therapy has one drawback, they take 1-3 weeks to take affect and if a person is suddenly suicidal this may be too long to wait. At this time ECT may result in a safe and more rapid elevation in mood.  Safety: Children, adolescents, and young adults taking SSRIs may experience untoward side effects such as violent behavior, mania, or aggression, all of which can contribute to suicidal behavior. All antidepressants include a black box warning of increase suicide in children and adolescents. Taking SSRIs during pregnancy is a concern since serotonin is essential in the formation of the fetus.  Classes of Antidepressants: o Tricyclic antidepressants (TCAs): Inhibit the reuptake of norepinephrine and serotonin by the presynaptic neuron in the CNS. The amount of time that serotonin and norepinephrine levels in the receptors is increased. Patient takes therapeutic doses for 10-14 days and full effects may not be evident for 4-8 weeks. Dosage should always be low initially and increased gradually. Caution for older adult do to slow metabolism “start low go slow.” TCAs cause anticholinergic effects (dry mouth blurred vision, tachycardia, constipation, urinary retention, and esophageal reflux). Administering to total dose of the TCA at night is beneficial for two reasons (sedative effects, and the minor side effects occur at night). Individuals who have recently had an MI (or other

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cardiovascular problems), those with narrow-angle glaucoma or a history of seizures and pregnant women should not be treated with TCAs, except with extreme caution and careful monitoring. Selective Serotonin reuptake inhibitors (SSRIs): Block the reuptake of serotonin. Have a lower incidence of anticholinergic side effects. Sexual dysfunction is the biggest complaint of patients taking SSRIs. Dry mouth, sweating, weight change, mild nausea, and loose bowel movements are a general side effects. Serotonin syndrome is a lie-threatening even associated with treatment with SSRIs. It is thought to be related to overreaction of the central serotonin receptors, caused either by too high a dose or by interaction with other drugs. S/S include abdominal pain, diarrhea, sweating, fever, tachycardia, increased BP, altered mental state, muscle spasms, increases motor activity, irritability, hostility, and mood change. Severe manifestation includes hyperpyrexia, cardiovascular shock, or death. Risk of this syndrome is when an SSRI is mixed with another serotonin increasing medication. (Five weeks is the half -life for fluoxetine). Other SSRIs have shorter half-lives of two weeks. Selective norepinephrine reuptake inhibitors (SNRIs) and norepinephrine dopamine reuptake inhibitors (SDRIs): these are referred to as dual action reuptake inhibitors. Each of these agents blocks different neurotransmitters and transmitter subtypes. Monoamine oxidase inhibitors (MAOIs): essentially MAOIs prevent the breakdown of norepinephrine, serotonin, and dopamine in the brain, thereby increasing the levels of the levels of these brain amines and resulting in elevated mood. are second line medications but have proven benefits for patients who have not responded to other medications or to ECT treatment. In particular, MAOIs have established efficiency in treatment of those with atypical depression. Inhibit the breakdown of tyramine in the liver, increased levels of tyramine can lead to high blood pressure, hypertensive crisis, and eventually cerebrovascular accident and death. Contraindications: cerebrovascular disease, hypertension and CHF, liver disease, consumption of foods containing tyramine, tryptophan, and dopam...