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N3526 Psychiatric and Mental Health Care > Exam 1 - Study Material > Flashcards

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What is Psychiatric nursing?

Nursing that focuses on the care and rehabilitation of people with identifiable mental illnesses or disorders


What is Mental health nursing?

Nursing that focues on well and at risk patients to prevent mental illness or to provide immediate treatment for those with an early sign of a disorder.


What is a Therapeutic Nurse-Patient Relationship?

It is a mutual learning experience and a corrective emotional experience for the patient. It is based on the humanity of the nurse and patient, mutual respect, and acceptance of sociocultural differences.


What are the different phases of the Psychiatric Nurse-Patient relationship?

  1. Preinteraction phase
  2. Introductory or orientation phase
  3. Working phase
  4. Termination phase


Describe the preinteraction phase of the Psychiatric Nurse-Patient relationship

  • It is a time where the nurse explores his/her own professional strengths and limitations, explores thoughts and feelings about working in a psychiatric setting, gathers data about the patient and plans for the first interaction with the patient. 
  • Begins before the nurses 1st contact with the patient
  • Involves self-analaysis on the nurses's part


Describe the Introductory or orientation phase of the Psychiatric Nurse-Patient relationship

You meet with the patient to:

  • Determine why the patient sought help
  • Establish mutual goals for their care with them
  • Determine where you are going to meet and how often
  • Discuss issues of confidentiality
  • Establish a climate of trust and understanding
  • To explore their perceptions, thoughts, and feelings
  • To help the patient identify their problems


Describe the working phase of the Psychiatric Nurse-Patient relationship

  • The most therapeutic work is carried out during this phase
  • The nurse and the patient explore stressors and promote the development of insight in the patient by linking perceptions, thoughts, feelings, and actions.
  • This is the most difficult phase because patient do not want to change their behavior


Describe the termination phase of the Psychiatric Nurse-Patient relationship

  • This phase involves reviewing the progress of the therapy, exploring feelings of loss and rejection,
  • It's important to help the patient work and grow through the termination process, establish the reality of the separation.


What are the different types of "space" a person has?

  1. Intimate
  2. Personal
  3. Social-consultative
  4. Public space


Describe intimate space

  • up to 18 inches
  • This small degree of separation between people allows for maximal inter- personal sensory stimulation.


Describe personal space

  • 18 inches to 4 feet
  • This zone is used for close relationships and when touching distance may be desired.


Describe Social-consultative space

  •  9 to 12 feet
  • This zone is less personal; it requires that speech be louder


Describe public space

  •  12 feet and more
  • This is used in speech giving and other large gatherings.


What are 2 requirements for therapeutic communication?

  1.  All communication must preserve the self-respect of both individuals.
  2. One should communicate understanding and acceptance before giving any suggestions or advice.


What is the the first rule of a therapeutic relationship?

  • Listen to the patient!
  • It is the foundation on which all other therapeutic skills are built


What are some therapeutic communication techniques?

  1. Listening
  2. Using Broad Openings
  3. Broad Openings      
  4. Theme Identification
  5. Restating         
  6. Silence
  7. Clarification            
  8. Suggesting
  9. Reflection
  10. Humor
  11. Informing
  12. Sharing Perceptions
  13.  Focusing


Define the "listening" therapeutic communication technique, give an example, and its value in practice.

  • Definition: an active process of receiving information and examining reaction to the messages received
  • Example: maintaining eye contact and receptive nonverbal communication
  • Therapeutic value: nonverbally communicates to the patient the nurse’s interest and acceptance


Define the "broad openings" therapeutic communication technique, give an example, and its value in practice.

  • Definition: encouraging the patient to select topics for discussion
  • Example: “What are you thinking about?”
  • Therapeutic value: indicates acceptance by the nurse and the value of the patient’s initiative


Define the "restating" therapeutic communication technique, give an example, and its value in practice.

  • Definition: repeating the main thought the patient expressed
  • Example: “You say that your mother left you when you were 5 years old."
  • Therapeutic value: indicates that the nurse is listening and validates, reinforces, or calls attention to something important that has been said


Define the "clarification" therapeutic communication technique, give an example, and its value in practice.

  • Definition: Attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding or asking the patient to explain what he means
  • Example: “I’m not sure what you mean. Could you tell me about that again?”
  • Therapeutic value: helps to clarify feelings, ideas, and perceptions of the patient and provides an explicit correlation between the nurse and the patient’s actions


Define the "reflection" therapeutic communication technique, give an example, and its value in practice.

  • Definition: directing back the patient’s ideas, feelings, questions or content
  • Example: “You’re feeling tense and anxious, and it’s related to a conversation you had with your husband last night?”
  • Therapeutic value: validates the nurse’s understanding of what the patient is saying and signifies empathy, interest and respect for the patient


Define the "informing" therapeutic communication technique, give an example, and its value in practice.

  • Definition: the skill of information giving
  • Example: "I think you need to know more about how your medication works."
  • Therapeutic value: helpful in health teaching or patient education about relevant aspects of patient’s well-being and self-care


Define the "focusing" therapeutic communication technique, give an example, and its value in practice.

  • Definition: questions or statements that help the patient expand on a topic of importance
  • Example: “I think that we should talk more about your relationship with your father.”
  • Therapeutic value: allows the patient to discuss central issues and keeps the communication process goal directed


Define the "sharing perceptions" therapeutic communication technique, give an example, and its value in practice.

  • Definition: asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling
  • Example: “You’re smiling, but I sense that you are really very angry with me."
  • Therapeutic value: conveys the nurse’s understanding to  the patient and has the potential for clearing up confusing communication


Define the "theme identification" therapeutic communication technique, give an example, and its value in practice.

  • Definition: underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse-patient relationship
  • Example: “I’ve noticed that in all of the relationships that you have described, you’ve been hurt or rejected by the man. Do you think this is an underlying issue?”
  • Therapeutic value: allows the nurse to best promote the  patient’s exploration and understanding of important problems


Define the "silence" therapeutic communication technique, give an example, and its value in practice.

  • Definition: lack of verbal communication for a therapeutic reason
  • Example: sitting with a patient and nonverbally communicating interest and involvement
  • Therapeutic value: allows the patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse’s support, understanding, and acceptance.


Define the "Humor" therapeutic communication technique, give an example, and its value in practice.

  • Definition: the discharge of energy through the comic enjoyment of the imperfect
  • Example: “That gives a whole new meaning to the word nervous,” said with shared kidding between the nurse and patient.
  • Therapeutic value: can promote insight by making conscious repressed material, resolving paradoxes, tempering aggression, and revealing new options; a socially acceptable form of sublimation


Define the "suggesting" therapeutic communication technique, give an example, and its value in practice.

  • Definition: presentation of alternative ideas for the patient's consdieration relative to problem solving
  • Example: “Have you thought about responding to your boss in a different way when he raises that issue with you? For example, you could ask him whether a specific problem has occurred.”
  • Therapeutic value: increases the patient’s perceived options or choices


What are responsive dimensions?

Characteristics crucial to establish trust and open communication in a relationship and help convey a sense of hope


  1. Genuineness
  2. Respect
  3. Empathic understanding
  4. Concreteness


What is genuineness?

To be an open, honest, sincere person who is actively involved in the relationship.


What is respect?

Giving someone unconditional positive regard; the patient is regarded as a person of worth


What is empathy?

The ability to enter into the life of another per- son, to accurately perceive the person’s current feelings and their meanings, and to communicate this understanding to the patient.


What is concreteness?

  • The use of specific terminology rather than abstractions when discussing the patient’s feelings, experiences, and behavior.
  • It involves asking for examples and details rather than generalities.


What is confrontation?

It is an expression by the nurse of perceived discrepancies in the patient’s behavior in which the nurse attempts to make the patient aware of incongruence in feelings, attitudes, beliefs, and behaviors.


What is immediacy?

The process of focusing on the current interaction of the nurse and the patient in the relationship.


What is self-disclosure?

  •  Subjectively true, personal statements about the self, intentionally revealed to another person.
  • When self-disclosing, the nurse should have a par- ticular therapeutic goal in mind.


What is Catharsis?

  •  A process that envolves encouraging a patient to talk about things that are most bothersome
  • Catharsis brings fears, feelings, and experiences out into the open so that they can be examined and discussed with the nurse


What is role playing?

  • The process of acting out a particular situation
  • It increases the patient’s insight into human relations and can deepen the ability to see the situation from another person’s point of view.
  • it helps patients practice new and more adaptive behaviors.


What are therapeutic impasses?

 They are blocks in the progress of the nurse-patient relationship


What are some examples of therapeutic impasses?

  • Resistance
  • Transference

  • Countertransference

  • Boundary violations


What is resistance?

  • the patient’s reluctance or avoidance of talking about or experiencing troubling aspects of oneself.
  • Often caused by the patient’s unwillingness to change when the need for change is recognized (usually during the working phase)


What is transference?

  • An unconscious response in which patients experience feelings and attitudes toward the nurse that were originally associated with other significant figures in their life.
  • It is characterized by the inappropriate intensity of the patient’s response.


What is countertransference?

  • A therapeutic impasse created by the nurse’s specific emotional response to the qualities of the patient.
  • In such cases nurses identify the patient with individuals from their past, and personal needs interfere with their therapeutic effective- ness


Describe boundary violations

  • Occurs when a nurse goes outside the boundaries of the therapeutic relationship and establishes a social, economic, or personal relationship with a patient.
  • As a general rule, whenever the nurse is doing or thinking of doing something special, different, or unusual for a patient, often a boundary violation is involved


What were Hildegard Peplau's contributions to nursing?

  • She was Hildegard Peplau the mother of psych nursing; identified the heart of psych nursing as the role of counselor or psychotherapist
  • Differentiated between general practice nurses who worked on a psych unit and psychiatric nurses who have graduate degrees and specialize in psych nursing

  • Identified nursing as a significant therapeutic process



What were Contributions of Linda Richards to nursing?



the first American psychiatric nurse; emphasized the physical AND emotional needs of the patient


Describe Custodial care in 1800s

  • Focused on the patient’s physical needs, such as medications, nutrition, hygiene, and ward activities
  • Psych nurses had limited psych training and mostly used med-surg principles; their main qualification was being kind and more patient





What are the functions of neurotransmitters?

  • chemical “first” messengers
  • Give rise to human activity, body functions, consciousness, intelligence, creativity, memory, dreams, and emotion
  • Neurotransmission is a key factor in understanding how various regions of the brain function and how interventions, such as medications and other therapies, affect brain activity and human behavior







What is the function of Dopamine?

  • Involved in control of complex movements, motivation, and cognition and in regulating emotional responses
  • Dopamine plats a role in the sensation of pleasure


What is the function of Serotonin (5-HT)?

  • Levels fluctuate with sleep and wakefulness, plats a role in arousal and modulation of general activity levels of CNS, particularly onset of sleep
  • Involved in temperature regulation and pain-control system of body.


What is the function of melatonin?

Induces pigment-lightening effects on skin cells and regulates reproductive and immune function.


What is the function of acetylcholine?

  • Plays a role in sleep-wakefulness cycle.
  • Signals mus- cles to become active


What is the function of Glutamate and where is it found?

  • glutamate receptors control the opening of ion channels that allow calcium (essential to neurotransmission) to pass into nerve cells, propagating neuronal electrical impulses
  • Found in all cells of body, where it is used to synthesize structural and functional proteins


What are drugs that increase Gamma-aminobutyric acid (GABA) used for?


Drugs that increase GABA function, such as benzodiazepines, are used to treat anxiety and epilepsy and to induce sleep.


What is the function of histamine and where is it located?

  • May play a role in alertness and learning
  • Located in diencephalon


What are the functions of Endorphins, enkephalins, dynorphins, and endomorphins?

The opiates morphine and heroin bind to these endogenous opioid receptors on presynaptic neurons, blocking release of neurotransmitters and thus reducing pain


What is the function of substance P?

Found in pain transmission pathway. Blocking release of substance P by morphine reduces pain.



What are some changes seen in the brain with age?

  • At birth, an infant’s brain is almost the same size as an adult’s brain and contains most of the brain cells for one’s entire life
  • From birth, the brain matures from back to front. With aging, it degenerates in the opposite direction
  • A newborn’s brain grows about three times its size in the first year
  • The brains of 2-year-old children consume twice as much glucose as do adult brains
  • Compared to an environment with little stimulation, a stimulating environment can give a child a 25% greater ability to learn
  • By the age of 7 years, our brains are 95% their adult size
  • It is a myth that we use only 10% of our brains. In fact, we use it all
  • Your skin weights twice as much as your brain
  • The brain can live for 4-6 minutes without oxygen, and then it begins to die. No oxygen for 5-10 minutes will result in permanent brain damage


What is the function of the Cerebral cortex?

critical in decision making and higher order thinking, such as abstract reasoning


What is the function of the limbic system?

involved in regulating emotional behavior, memory, and learning

Basal ganglia: coordinate involuntary movements and muscle tone


What is the function of the Hypothalamus?

regulates pituitary hormones; temperature; and desires such as hunger, thirst, and sex drive


What is the function of the Locus ceruleus?

makes NE, a neurotransmitter involved in the body’s response to stress


What is the function of Raphe nuclei?

make serotonin, a neurotransmitter involved in the regulation of sleep, behavior, and mood


What is the function of Substantia nigra?

makes dopamine, a neurotransmitter involved in complex movements, thinking, and emotions


What is a Mental status exam?

Represents a cross section of the patient’s psychological life and the nurse’s observations and impressions at one point in time


Describe the mental status exam

  • The elements of the exam depend on the patient’s clinical presentation, as well as on the patient’s educational and sociocultural background
  • Exam itself is usually divided into several parts; they can be arranged in different ways, as long as the nurse covers all the areas
  • Some components of the exam are completed through simple observation of the patient, such as noting the patient’s clothing or facial expressions
  • Other aspects require asking specific questions, such as those related to memory or attention span
  • Most of all, the nurse should remember that the mental status exam does not reflect how the patient was in the past or will be in the future
  • The mental status exam is an evaluation of the patient’s current state
  • Info obtained during the exam is used along with other objective and subjective data


What sections are on the mental status exam?

  1. Appearance
  2. Speech
  3. Motor activity
  4. Interaction during the interview
  5. Affect
  6. Perceptions
  7. Thought content
  8. Thought process
  9. Level of consciousness
  10. Level of concentration and calculation

  11. Information and intelligence

  12. Judgment

  13. Insight


In a mental status exam what would you observe for with appearance and what are its clinical implications?


  • apparent age, manner of dress, cleanliness, posture, gait, facial expressions, eye contact, pupil dilation or constriction, general state of health and nutrition

​​​Clinical implications:

  • Dilated pupils are sometimes associated with drug intoxication

  • Pupil constriction may indicate narcotic addiction

  • Stooped posture is often seen in patients with depression

  • Manic patients may dress in colorful or unusual attire


In a mental status exam what would you observe for with speech and what are its clinical implications?

Observe for:

  • Rate: rapid or slow

  • Volume: loud or soft

  • Amount: paucity, muteness, pressured speech

  • Characteristics: stuttering, slurring of words, or unusual accents

Clinical implications:

  • Speech disturbances are often caused by specific brain disturbances. For example, mumbling may occur in patients with Huntington chorea, and slurring of speech may occur in intoxicated patients


In a mental status exam what would you observe for with motor activity and what are its clinical implications? 


  • Level of activity: lethargic, tense, restless, or agitated
  • Type of activity: tics, grimaces, or tremors
  • Unusual gestures or mannerisms: compulsive behavior

Clinical implications:

  • Excessive body movement may be associated with anxiety, mania, or stimulant abuse
  • Little body activity may suggest depression, organic mental disorders, catatonic schizophrenia, or drug-induced stupor
  • Tics and grimaces may suggest medication side effects
  • Repeated motor movements or compulsive behavior may indicate OCD
  • Repeated picking of lint or dirt off of clothing is sometimes associated with delirium or toxic conditiom


In a mental status exam what would you observe for when 
Interacting during the interview and what are its clinical implications? 


  • is the patient hostile, uncooperative, irritable, guarded, apathetic, defensive, suspicious, or seductive? The nurse may explore the observed behavior by asking, “You seem irritated by something. Is that true?”

Clinical implications:

  • Suspiciousness may be evident in patients with paranoia
  • Irritability may suggest an anxiety disorder


In a mental status exam what is "mood" and what would you observe for?

Mood is:

  • a self-report of one’s emotional state and reflects the patient’s life situation


  • If the potential for suicide is suspected, the nurse should ask the patient directly about thoughts of self-harm. To judge a patient’s suicidal or homicidal risk, the nurse should assess the patients plans, the patient’s ability to carry out those plans, the patient’s attitude about death, and support systems available to the patient


In a mental status exam what is "affect", what would you observe for, and what are its clinical implications?

Affect is:

  • the patient’s apparent emotional tone

Observations: affect can be described in terms of

  • Range
  • Duration
  • Intensity
  • Appropriateness
  • Flat affect: the absence of emotional expression, as seen by a patient who reports significant life events without showing any emotional response
  • Labile affect: expression by undergoing frequent changes from one affective response to another quickly in the same conversation
  • The nurse should also assess whether the patient’s emotional response is congruent or in agreement with the speech content; for example, it would be incongruent if a patient reports being persecuted by the police and then laughs

Clinical observations:

  • Labile affect is often seen in patients with mania
  • Flat affect and incongruent affect are often evident in those with schizophrenia


What are Hallucinations?

  • A hallucination is a perception in the absence of a stimulus
  • They are false sensory impressions or experiences
  • These sensory impressions are generated by the mind rather than by any external stimuli, and may be seen, heard, felt, and even smelled or tasted by the patient


What are Illusions?

false perceptions or false responses to a sensory stimulus


What are Command hallucinations?

are those that tell the patient to do something, such as kill oneself, harm another, or join someone in the afterlife


In a mental status exam what would you observe for with perceptions and what are its clinical implications?

Observations: hallucinations may occur in any of the five major sensory modalities:

  • Auditory – sound
  • Visual – sight
  • Tactile – touch
  • Gustatory – taste
  • Olfactory – smell
  • Cenesthetic: feeling body functions such as blood pulsing through veins, food digesting, or urine forming
  • Kinesthetic: sensation of movement while actually motionless

Clinical implications:

  • Auditory hallucinations suggest schizophrenia
  • Visual hallucinations suggest organic mental disorders
  • Tactile hallucinations suggest organic mental disorders, cocaine abuse, and delirium tremens


In a mental status exam what is "thought content", what would you observe for, and what are its clinical implications?

Thought content:

  • refers to “what” the patient is thinking


  • Delusions: false belief that is firmly maintained even though it is not shared by others and is contradicted by social reality (may be religious, somatic, grandiose, or paranoid)
  • Thought broadcasting: belief that one’s thoughts are being aired to the outside world
  • Thought insertion: belief that thoughts are being placed into one’s mind by outside people or influences
  • Depersonalization: the feeling of having lost self-identity and that things around the person are different, strange, or unreal
  • Hypochondriasis: somatic over concern with and morbid attention to details of body functioning
  • Ideas of reference: incorrect interpretation of casual incidents and external events as having direct personal references
  • Magical thinking: belief that thinking equates with doing, characterized by lack of realistic relationship between cause and effect
  • Nihilistic ideas: thoughts of nonexistence and hopelessness
  • Obsession: an idea, emotion, or impulse that repetitively and insistently forces itself into consciousness, although t is unwelcome
  • Phobia: a morbid fear associated with extreme anxiety

Clinical implications:

  • Obsessions and phobias are associated with anxiety disorders
  • Delusions, depersonalization, and ideas of reference suggest schizophrenia and other psychotic disorders
  • it is important that the nurse only obtain information about the patient’s thinking and not challenge or try to correct the patient’s beliefs


In a mental status exam what is "thought process", what would you observe for, and what are its clinical implications?

Thought process:

  • “how” of the patient’s self-expression


  • Circumstantial: thought and speech associated with excessive and unnecessary detail that is usually relevant to a question, and an answer is eventually provided
  • Flight of ideas: over-productive speech characterized by rapid shifting from one topic to another and fragmenting ideas
  • Loose associations: lack of a logical relationship between thoughts and ideas that renders speech and thought inexact, vague, diffuse, and unfocused
  • Neologisms: new word or words created by the patient; often a blend of other words
  • Perseveration: involuntary, excessive continuation or repetition of a single response, idea, or activity; may apply to speech or movement, but most often verbal
  • Tangential: similar to circumstantial but the person never returns to the central point and never answers the original question
  • Thought blocking: sudden halt in the train of thought or in the middle of a sentence
  • Word salad: series of words that seem totally unrelated

Clinical implications:

  • Circumstantial thinking may be a sign of defensiveness or paranoid thinking
  • Loose associations and neologisms suggest schizophrenia or other psychotic disorders
  • Flight of ideas indicates mania
  • Perseveration is often associated with brain damage and psychotic disorders
  • Word salad represents at the highest level of thought disorganization


In a mental status exam what would you observe for with level of consciousness and what are its clinical implications? 


  • Can be described as confused, sedated, or stuporous
  • In addition, the patient should be questioned regarding orientation to time, place, and person

Clinical implications:

  • Patients with organic mental disorders may give grossly inaccurate answers, with orientation to person remaining intact longer than orientation to time or place
  • Patients with schizophrenic disorders may say that they are someone else or somewhere else or reveal a personalized orientation to the world


In a mental status exam what would you observe for with memory and what are its clinical implications? 


  • Remote memory: recall of events, info, and people from the distant past
    • Confabulation is a possibility, because the nurse can’t tell what is true and isn’t from the past; the patient may make up stores about situations or events that cannot be remembered
  • Recent memory: recall of events, info, and people from the past week or so
  • Immediate memory: recall of info or data to which a person was just exposed

Clinical implications:

  • Loss of memory occurs with organic mental disorders, dissociative disorder, and conversion disorder
  • Patients with Alzheimer disease retain remote memory longer than recent memory
  • Anxiety and depression can impair immediate retention and recent memory


In a mental status exam what is "Level of concentration and calculation", what would you observe for, and what are its clinical implications?


  • is the patient’s ability to pay attention during the course of the interview


  • is the person’s ability to do simple math


  • Calculation can be assessed by:
    • Counting from 1 to 20 rapidly
    • Do simple calculations
    • Serially subtract 7 from 100

Clinical implications:

  • Many psychiatric illnesses impair the ability to concentrate and complete simple calculations
  • It is particularly important to differentiate among organic mental disorder, anxiety, and depression


In a mental status exam what would you observe for with Information and intelligence and what are its clinical implications?


  • The nurse should assess the patient’s last grade of schooling completed, general knowledge, and use of vocabulary

Clinical implications:

  • The patient’s educational level and any learning disabilities should be carefully evaluated
  • Mental retardation should be ruled out whenever possible
  • The patient’s level of literacy may be part of a general assessment, but it also is an important factor in any health teaching or didactic information presented to the patient
  • the nurse should be cautious about judging intelligence after a brief and limited contact typical of the time it takes to conduct a mental status exam


In a mental status exam what is "judgement", what would you observe for, and what are its clinical implications?


  • involves making decisions that are constructive and adaptive


  • can be evaluated by exploring the patient’s involvement in activities, relationships, and vocational choices

Clinical implications:

  • Judgment is impaired in organic mental disorders, schizophrenia, psychotic disorders, intoxication, and borderline or low IQ


In a mental status exam what is "insight", what would you observe for, and what are its clinical implications?


  • the patient’s understanding of the nature of one’s problem or illness


  • important for the nurse to determine whether the patient accepts or denies the presence of a problem or illness; in addition, the nurse should ask if the patient blames the problem on someone else or some external factors

Clinical implications:

  • Insight is impaired in those with many psychotic illnesses, including organic mental disorders, psychosis, substance abuse, eating disorders, personality disorders, and borderline or low IQ
  • Whether a  patient sees the need for treatment is important to the formation of the therapeutic alliance, establishment of mutual goals, and implementation of and adherence to the treatment plan
  • Motivational interviewing can assess the patient’s readiness to change


What is The mini-mental state examination (MMSE)?

a simplified, scored form of the cognitive mental status exam with 11 questions; requires 5-10 minutes


What are some Intelligence tests?

  1. Wechsler Adult Intelligence Scale (WAIS)
  2. Wechsler Intelligence Scale for Children (WISC)
  • Projective tests: reflect aspects of a person’s personality, including reality testing ability, impulse control, ego defense, interpersonal conflicts, and self-concept


What is the purpose of Behavioral rating scales

  • Measure the extent of the patient’s problems 

  • Make an accurate diagnosis 

  • Track patient progress over time 

  • Document the efficacy of treatment


What is Primary prevention?

lowering the incidence of a mental disorder by reducing the rate at which new cases of a disorder develop


What is Secondary prevention?

involves decreasing the prevalence of a mental disorder by reducing the number of existing cases through early case finding, screening, and prompt, effective treatment


What is Tertiary prevention?

attempts to reduce the severity of a mental disorder and its associated disability through rehabilitative activities


What are Maturational crises?

  • developmental events requiring role changes

  • Transitional periods during adolescence, parenthood, marriage, midlife, and retirement are key times for the onset of maturational crises


What are Situational crises?

  • occur when a life event upsets an individual’s or group’s psychological equilibrium
  • Examples: loss of a job, loss of a loved one, unwanted pregnancy, onset or worsening of a medical illness, divorce, school problems, witnessing a crime


What is Neurosis:?

describes a mental disorder characterized by anxiety that involves no distortion of reality; neurotic disorders are maladaptive anxiety responses associated with moderate and severe levels of anxiety 


What is Psychosis?

  • disintegrative and involves a significant distortion of reality; can emerge with the panic level of anxiety
  • The medical diagnoses related to anxiety include panic disorder with or without agoraphobia, agoraphobia, specific phobia, social phobia, OCD, PTSD, acute stress disorder, and GAD


What is Stigma reduction?

An important aspect of mental health promotion involves activities related to dispelling myths and stereotypes associated with vulnerable groups, providing knowledge of normal parameters, increasing sensitivity to psychosocial factors affecting health and illness, and enhancing the ability to give sensitive, supportive, and humanistic health care


What is a stigma and what are the 3 types?

  • Stigma: a mark of disgrace or discredit that is used to identify and separate out people whom society sees as deviant, sinful, or dangerous;
  • Three types:
    • Public – what the public does to those with mental illness
    • Self – when individuals internalize public stigma and harm themselves
    • Label avoidance - when individuals who are not mentally ill avoid mental health care so as not to be marked with the label 


Health consequences of stigmas? 

  • Makes people conceal or deny their symptoms
  • Results in delays in treatment
  • Discourages adherence to effective treatments
  • Isolates the individual and family
  • Lowers self-esteem and potential for self-care
  • Limits access to quality health care
  • Negatively affects the attitudes of health care providers
  • Contributes to more severe forms of illness
  • Limits the community’s response to illness 
  • Stigma reduction initiatives must take place on both individual and community levels

  • Everyone needs to understand that no one is immune to mental illness or emotional problems and that the fear, anxiety, and even anger felt about some people who experience these problems may reflect some of our own deepest fears and anxieties


What does the DSMV 5 axes 1 classify?

clinical syndromes


What does the DSMV 5 axes 2 classify?

  • personality disorders
  • Axis I and II include the entire classification of mental disorders plus conditions that are not attributable to a mental disorder but that are a focus of attention or treatment



What does the DSMV 5 axes 3 classify?

  • general medical conditions

  • Axis III allows the clinician to identify any physical disorder relevant to the understanding or treatment of the individual


What does the DSMV 5 axes 4 classify?

  • psychosocial and environmental problems
  • Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders


What does the DSMV 5 axes 5 classify?

  • global assessment of functioning
  • Axis V is for reportingthe clinician’s judgment of the individual’s overall level of functioning 


What is voluntary admission and what are some of its characteristics?

Voluntary admission:

  • any citizen of lawful age may apply in writing for admission to a public or private psychiatric hospital


  • The person agrees to receive treatment and abide by hospital rules
  • If someone is too ill to apply but voluntarily seeks help, a parent or legal guardian may request admission (people under the age of 16)
  • Voluntary admission is preferred because it is similar to a medical hospitalization and indicates that the patient acknowledges problems in living, seeks help in coping with them, and will participate in finding solutions
  • When voluntarily admitted, the patient retains all civil rights, including the right to vote, have a driver’s license, buy and sell property, manage personal affairs, hold office, practice a profession, and engage in a business 


What is involuntary admission?

Involuntary admission (commitment):

  • Means that the patient did not request hospitalization and may have opposed it or was indecisive and did not resist it; most laws permit commitment of the mentally ill on one or more of the following three grounds:
    1. Dangerous to self or others
    2. Mentally ill and in need of treatment
    3. Unable to provide for own basic needs

  • Emergency hospitalization: most state laws limit the length of emergency commitment to 48-72 hours 



Describe the commitment process

Commitment process:

  • Begins with a sworn petition by a relative, friend, public official, physician, or any interested citizen stating that the person is mentally ill and needs treatment
  • Then, one or two physicians must assess the person’s mental status (some states require psychiatrist)
  • The decision of whether to hospitalize the patient is made next; the person who makes the decision determines the nature of the commitment:
    • Medical certification means that physicians make the decision
    • Court or judicial commitment is made by a judge or jury in a formal hearing
    • Administrative commitment is determined by a special tribunal of hearing officers


What is Short term or observational hospitalization?

: used for diagnosis and short term therapy and does not require an emergency situation


What is Long term hospitalization?

provides for hospitalization for an indefinite time or until the patient is ready for discharge


What are the patients rights while in the hospital?

  1. Right to communicate 
  2. Right to keep personal effects
  3. Right to enter into contractual relationships
  4. Right to education

  5. Right to habeas corpus: 

  6. Right to privacy: 


Describe a patient's right to communicate

Right to communicate with people outside the hospital with telephone privileges, sending letters, etc


Describe a patient's right to keep personal effects

patient may bring clothing and personal items to the hospital, taking into consideration the amount of storage space available


Describe a patient's right to enter into contractural relationships

  • court considers contracts valid if the person understands the circumstances of the contract and its consequences


What is Incompetence?

Incompetence: a legal term without a precise medical meaning; the following must be shown in court:

  • The person has a mental disorder
  • This disorder causes a defect in judgment
  • This defect makes the person incapable of handling personal affairs
  • If ruled incompetent, a person cannot vote, marry, drive, or make contracts


Describe a patient's right to habeas corpus

provides for the speedy release of any person who claims to be detained illegally


Describe a patient's right to privacy

confidentiality means not disclosing information about a person to someone else unless authorized by that person


Describe a healthcare worker's responsibility to a patient's privacy

  • Every psychiatric professional is responsible for protecting a patient’s right to confidentiality, including even the knowledge that a person is in treatment or a hospital
  • Clinicians are free from legal responsibility if they release information after they obtain the patient’s written and signed consent
  • HIPAA guarantees patients four rights related to the release of information:
    • To be educated about HIPAA privacy protection
    • To have access to their own medical records
    • To request correction or amendment of their health information to which they object
    • To require their permission for disclosure of their own personal information


Who doe the original medical record belong to?

The physical record is property of the treatment facility or therapist, but the information inside of it belongs to the patient; thus the original record should never be given to the patient; only a copy of it should be provided


What is Testimonial privilege?

  • applies only in court related proceedings; includes communication between husband and wife, attorney and client, and clergy and church member
    • The right to reveal information belongs to the person who spoke, and the listener cannot disclose the information unless the speaker gives permission
    • Testimonial privilege between health professionals and patients exists only if established by law


What is the Circle of confidentiality?

  • A model that shows with whom patient information may be shared with
  • Within the circle are treatment team members, staff supervisors, health care students and their faculty, and consultants who actually see the patient
    • All these people must be informed about the patient’s clinical condition to be able to help
    • The patient is also inside the circle because they can reveal any aspect of their lives, problems, treatments, and expierences to anyone



What is major depressive disorder?

A mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or longer. It can occur once or repeatedly over the course of a lifetime.


What are the Diagnostic Criteria for
Major Depression?

Five or more of the following symptoms occurring in the same two week period:

  1. Weight gain or loss
  2. Insomnia or hypersomnia
  3. Psychomotor agitation or retardation
  4. Fatigue
  5. Feelings of worthlessness
  6. Impaired concentration
  7. Thoughts of suicide or death
AND At least one major symptoms:
  1. Depressed mood
  2. Anhedonia (inability to experience pleasure from activities usually found enjoyable)


What role does genetics play in mood disorders?

  • Both heredity and environment play an important role in severe mood disturbances; MDD and bipolar are familial disorders
  • The lifetime risk is 20% for relatives of people with depression and 24% for relatives of people with bipolar disorder
  • Identical twins has a 2-4 times greater risk than fraternal twins


What are some Essential features of major depressive disorder?

  • May involve a single episode or a recurrent depressive illness but does not include a manic episode 
  • Behaviors associated with depression: key element of a behavioral assessment is change of the patient’s usual patterns 
  • Anxiety often accompanies depression 
  • Somatic complaints 
  • Postpartum onset 


What are some characteristics of depression?

  • Culture affects the symptomatic expression, clinical presentation, and effective treatment of depression
  • A high incidence of depression is found among all patients hospitalized for medical illnesses & Depressive conditions are highly prevalent in primary care setting
  • More than 50% of those who have one episode will eventually have another, and 25% of patients will have chronic, recurrent depression
  • Only one third of all people with depression seek help, are accurately diagnosed, and obtain appropriate treatment


What are the different types of depression screening tools?

  • Beck Depression Inventory
  • Zung self-Rating Depression Scale
  • Hamilton Depression Rating Scale
  • Center for Epidemiological Studies – Depression Scale


What are some nursing interventions for depression?

  • Physical care, psychopharmacology, somatic therapies
  • Cognitive Behavioral Therapy: help patients explore their feelings and their view of the problem; focus on modifying the patient’s thinking; the patient can be helped to examine the accuracy of perceptions, logic, and conclusions
  • Be quiet, warm, and accepting
  • Rapport is best established with the depressed patient through shared time, even if the patient talks little, and through supportive companionship
  • Sleep deprivation therapy
  • Express feelings of hope for patient and that the future will be better; tell patient that expressing feelings is normal and necessary


What are some goals in the plan of care for patients with mood disorders?

The patient will be emotionally responsive and return to a preillness level of functioning


  • To allow recognition and continuous expression of feelings, including denial, hopelessness, anger, guilt, blame, helplessness, regret, hope, and relief, within a supportive therapeutic atmosphere

  • To allow for gradual analysis of stressors while strengthening the patient’s self-esteem

  • To increase the patient’s sense of identity, control, awareness of choices, and responsibility for behavior

  • To encourage healthy interpersonal ties with others

  • The promote understanding of maladaptive emotions and to acquire adaptive coping responses to stressors

  • Specific short-term goals should be developed based on the behaviors of the patient, present areas of difficulty, and relevant stressors

  • The patient’s participation in setting these goals can be significant first steps in regaining mastery over life


What are some medications used to treat depression?

  • Tricyclic antidepressants (TCA)
  • Monoamine oxidase inhibitors (MAOIs)
  • Selective serotonin reuptake inhibitors (SSRI)
  • Other antidepressants


What are Kubler-Ross's Stages of Grief?

  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance


What is a Delayed grief reaction?

persistent absence of emotion with undue delay in work of mourning or grieving


What is a Distorted grief reaction?

Emotions triggered by deliberate recall of circumstances surrounding loss or occurrence


What are some nursing interventions for grief?

  • Assess stage in the grief process.
  • Help actualize the loss by talking about it.
  • Encourage expression of feelings.


What is uncomplicated grief?

It is an adaptive response, it is a self-limited process of realization that makes the fact of the loss real


What is Dysthymia (Persistent Depressive Disorder)?

  • It is a milder form of depression lasting 2 or more years.
  • It is a chronic condition, and many patients with dysthymia eventually develop major depressive episodes, but there are fewer related depressive symptoms


What are some Nonpharmacological treatments for mood disorders?



  • Cognitive and behavioral therapy
  • Phototherapy
  • Sleep deprivation therapy
  • Transcranial magnetic therapy
  • Vagal nerve stimulation
  • Electroconvusive therapy


What is cognitive and behavioral therapy and what are the 3 goals for this therapy?

  • It is a method of changing patient's thought processes, behaviors, and emotions.
  • Has proven efficacy for both depressive and bipolar disorders
  • Nurses have three major aims:
    • To increase the patient’s sense of control over goals and behavior
    • To increase the patient’s self-esteem
    • To help the patient modify dysfunctional thinking patterns


What is phototherapy?

  • Light therapy; a physiological treatment in which patients are exposed to bright artificial light for a specified amount of time each day
  • Appears to be effective in the short-term treatment of mild to moderate SAD


What is sleep deprivation therapy?

Research indicates that depriving some depressed patients of a night’s sleep improves their clinical condition; MOA is unknown




What is Transcranial magnetic therapy?

  • Noninvasive procedure in which a changing magnetic field is introduced into the brain to influence the brain’s activity with the goal of treating mood disorders
  • Adverse effect: potential for inducing seizures
  • With TMS the brain is directly stimulated to produce neurochemical changes


Why is vagal nerve stimulation used and what are some side effects of this therapy?

  • It is used in the treatment of affective disorders, particularly treatment resistant depression
  • The left vagus is used because it is composed of mostly afferent sensory fibers that connect to the brainstem and deep brain structures
  • Side effects: hoarseness, throat pain, neck pain, headache, SOB


What is electroconvulsive therapy and for what type of patients is this therapy used for?

  • ECT is a specific therapy for patients with severe depressions who have somatic delusions and delusional guilt accompanied by a lack of interest in the world, suicidal ideation, and weight loss
  • Used with depressed patients, particularly those with recurrent depressions and resistance to drug therapy


What are some side effects of electroconvulsive therapy?

  • Cardiovascular effects
  • Systemic effects include: headaches, nausea, muscle soreness, and drowsiness may occur
  • Cognitive effects: confusion immediately after the seizure and memory disturbance during the treatment course
    • Short term memory loss

  • AFTER ECT check vital signs and precautions from general anesthesia


What are some nursing interventions for patients having electroconvulsive therapy?

  • Emotional support and education
  • Pretreatment nursing care: reviewing recommended consultations, noting that any abnormalities in lab tests have been addressed, and checking that equipment and supplies are adequate and functional
  • Nurse should remain with the patient throughout the treatment to provide support
  • Posttreatment care: the area should contain oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment
  • The nurse should clarify that most memory problems will pass within several weeks


What is bipolar disorder?

  • A condition in which people go back and forth between periods of a very good or irritable mood and depression.
  • The “mood swings” between mania and depression can be very quick 


What are some essential features of bipolar disorder?

  • Includes one or more manic episodes, with our without a major depressive episode 

  • Manic behavior, the essential feature of bipolar disorder, is a distinct period of intense psychophysiological activation; the predominant mood is elevated or irritable 

  • Patients may have misperceptions about their power and importance and may involve themselves in senseless, irresponsible, or risky activities 

  • Grandiose symptoms are evident 

  • Physical changes they experience, such as abundant energy and heightened sexual appetite, are caused by inadequate nutrition, partly because manic patients have no time to eat; serious weight loss is also related to their insomnia and overactivity 

  • As mania intensifies, formal and logical speech is replaced by loud, rapid, and confusing language, referred to as pressured speech -> can lead to loose associations and flight of ideas 

  • May experience lability of mood with rapid shifts to periods of depression


What is Bipolar disorder with rapid cycling?

Defined as having four or more episodes per year; four or more major depressive, manic, hypomanic, or mixed episodes within a 12 month period


What is Bipolar 1 disorder?

Occurs when a patient has one or more manic episodes and often one or more major depressive episodes. They are not better explained by other psychiatric disorders and are not the direct result of a substance or other medical condition.


What are the Criteria for a Manic Episode?

  • Period of abnormally persistent, elevated, and expansive, or irritable mood, lasting at least one week.

Three or more of seven symptoms must be present:

  • Inflated self esteem or grandiosity
  • Decreased need for sleeping
  • More talkative than usual or pressure to keep talking
  • Flight of ideas or subjective experience that thoughts are racing
  • Distractibility
  • Increase in goal-directed activity
  • Excessive involvement in pleasurable activities that have a high potential for painful consequences


What are some characteristics of  bipolar disorder?

  • Risk factors are being female and having a family history of bipolar
  • Most people start showing symptoms in their late teens
  • On average, a person is free of symptoms for about 5 years between the first and second episodes
  • Associated with increased premature mortality secondary to general medical illnesses


What are some Behaviors Associated with Mania?

  • Elevated, euphoric, or expansive moods
  • Irritability
  • Sleep disturbances
  • Excessive spending
  • Sexual overactivity
  • Flamboyant dress
  • Hyperactive, intrusive
  • Grandiosity
  • Verbosity
  • Flight of ideas
  • Rapid, pressured speech


What is bipolar 2 disorder?

  • Bipolar II is similar to bipolar I disorder, with moods cycling between high and low over time.
  • However, in bipolar II disorder, the "up" moods never reach full-on mania.  The less-intense elevated moods in bipolar II disorder are called hypomanic episodes, or hypomania.


What is the criteria to be diagnosed with Bipolar 2 disorder?

  • Presence or history of one or more major depressive episodes
  • Presence or history of at least one hypomanic episode
  • Has never had a manic episode
  • Symptoms are not from a substance or general medical condition
    • Symptoms can cause significant distress or impair social, occupational, or other functioning
  • Other psychiatric disorders are ruled out


What is hypomania?

  • Persistently elevated, expansive, or irritable mood that is clearly different from usual for at least 4 days
  • Has many of the symptoms of mania except no psychotic features
  • Function has changed, which others have observed
  • No marked impairment in social, occupational, or other functioning
  • Hospitalization not required


What is cyclothymic disorder?

It iss a disorder resembling bipolar disorder but with less severe symptoms, characterized by repeated periods of nonpsychotic depression and hypomania for at least two years


What is the criteria to be diagnosed with cyclothymic disorder?

  • Has for at least 2 years, had numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for major depressive episode
  • Has not been without symptoms for more than 2 months at a time
  • Has had no manic, hypomanic, or major depressive episodes during the 2 year period


What are some nursing interventions for bipolar disorder?

  • Patients with bipolar illness may be very talkative and need simple explanations and concise, truthful answers to questions
  • Constrictive limit setting on manic patients’ behavior is an essential part of the plan
  • One goal of nursing care is to increase the patient’s self-control, and this should be kept in mind when setting limits
  • Physiological treatments
  • Manic patients primarily need protection from themselves
  • Non-adherence is a major problem
  • Somatic therapy
  • Expressing feelings: these patients are often hyperverbal and need help from the nurse in pacing and moderating their expression
  • Helping the patients to speak more slowly and to follow one line of thought is an important area for nursing intervention
  • Cognetive behavioral therapy: behavior change; social skill building
  • Family group involvement
  • Education


What are some characteristics of suicide?

  • 10th leading cause of death in the US
  • 3rd leading killer of young people
  • Are most likely under-reported
  • Women attempt suicide three times as often as men: men are more likely to complete a suicide
  • Highest rate of suicide is among Caucasian men over 80 years of age.
  • Guns account for half of all completed suicides


What are some risk factors for suicide?

  • Hospitalized depressed patients
  • Elderly patients
  • Patients with alcoholism
  • Depressed adolescents
  • Patients with severe mood disturbances


What are some nursing diagnoses for patients at risk for suicide and what are some goals for these patients?

Nursing diagnoses:

  • Maladaptive self-protective responses are risk for suicide

  • self-mutilation

  • noncompliance

  • risk for self-directed violence

Goals of care:

  • Patient will not physically harm himself or herself; highest priority should be given to the preservation of life


What are some nursing interventions for patients with suicide?

  • Motivational interviewing

  • Assess patient’s judgment, availability of a responsible family member or close friend who is willing to stay with the patient

  • Protect the patient from harm!


What are some issues related to protection and safety for suicide patients?

  • The highest priority nursing activity with self-destructive patients is to protect them from inflicting further harm on themselves and, if suicidal, from killing themselves
  • Suicidal patients may appear to be feeling much better immediately before making an attempt
  • Although no suicide contracts have been used in clinical practice for many years, they have found to be NOT effective
  • The patient should be supervised at all times
  • The nurse should monitor any medications the patient receives


What are some strategies to prevent suicide?

  • Gun control and decreased availability of lethal weapons
  • Limitations on the sale and availability of alcohol and drugs
  • Increased public and professional awareness about depression and suicide
  • Less attention to and reinforcement of suicidal behavior in the media
  • Establishment of community-based crisis intervention clinics
  • Campaigns to decrease the stigma associated with psychiatric care
  • Increased insurance benefits for psychiatric and substance abuse disorders
  • Develop broad-based support for suicide prevention
  • Develop and implement strategies to reduce the stigma associated with being a consumer of mental health, substance abuse, or suicide prevention services
  • Develop and implement suicide prevention programs
  • Promote efforts to reduce access to lethal means and methods of self-harm
  • Implement training for recognition of at-risk behavior and delivery of effective treatment
  • Improve access to and community linkages with mental health and substance abuse services
  • Improve reporting and portrayals of suicidal behavior, mental illness, and substance abuse in the entertainment and news media
  • Promote and support research on suicide and suicide prevention
  • Improve and expand surveillance systems


What is the MOA for SSRI'S?

Block reuptake of serotonin at the presynaptic membrane. This results in an increase of available serotonin in the synapse and therefore at postsynaptic receptors, promoting serotonin neurotransmission


What are the side effects for SSRI'S?

Weight gain, lower seizure threshold, serotonin syndrome, agitation, anxiety, nausea, diarrhea, insomnia, sexual dysfunction


Cytochrome p-450 inhibition


What are the effects of inhibiting Cytochrome P-450?

  • Inhibits metabolism of TCAs, trazodone, barbiturates, most benzodiazepines, carbamazepine, narcotics, neuroleptics, phenytoin, valproate, verapamil
  • This effect can be potentially life threatening because it increases serum concentrations as well as therapeutic and toxic effects of these drugs


What is serotonin syndrome and what are some characteristics?

  • a life-threatening emergency resulting from excess CNS 5-HTcaused by combining 5-HT enhancing drugs or administering SSRIs too close to the discontinuation of MAOIs (SSRIs)
  • confusion, disorientation, shivering, Dilated pupils, Headache, diarrhea, rapid heart rate, heavy sweating


What is the MOA for Tricyclic Antidepressants?

serotonin and NE reuptake inhibition, as well as blockade of three receptors not implicated in depression: muscarinic cholinergic, histamine, and alpha-noradrenergic receptors


What are the side effects of Tricyclic Antidepressants?

TCAs can have dangerous cardiac side effects and are lethal in overdose, sedation, weight gain, orthostatic hypotension, dizziness


What is the MOA for MAOI's?

inhibit both types of the enzyme( MAO A and MAO B) that metabolizes serotonin and norepinephrine; this inhibition is irreversible; lasting until the body is able to manufacture new MAO after the drug is discontinued


What are the side effects of MAOI's?

Dangerous elevation in blood pressure can result from high levels of NE not metabolized by MAO; avoid foods and drugs that are NE agonists, they can cause hypertensive crisis


What is Tegretol used to treat and what are the side effects?

  • Used to treat bipolar disorder

  • Side effects: drowsiness, dizziness, ataxia, double vision, blurred vision, nausea, fatigue, GI upset, skin reactions, P450 drug, agranulocytosis (rare decrease in WBC that is permanent); lethal in overdose


What is depakote used for and what are the side effects?

  • Used for bipolar disorder, it is a derivative of valproic acid, it has a superior therapeutic index, a better toxicity profile, and a wider range of effectiveness in subtypes of bipolar disorder
  • Side effects: GI complaints, tremor, sedation, headache, dizziness, ataxia, increased appetite/weight gain, thrombocytopenia, pancreatitis, hepatic dysfunction


What is a hypertensive crisis and what are the signs and symptoms?

  • A severe and potentially life-threatening increase in blood pressure and can be caused by MOI's.
    • Don't take foods with tiramine (no wine, cherries, cheeses, blue cheese, cheddar cheese, sour cream, alvacado, chocolates) and MAOI's at the same time
  • Symptoms include:
    • flushed face, dialated pupils, headaches


What is the lithium and what is it used for?

A naturally occurring salt that is first line for patients with acute mania and for the long term prevention of recurrent episodes; exact MOA is unknown, but many neurotransmitter functions are altered by the drug


What are some side effects of taking lithium?

Because it is excreted by the kidneys, it can adversely affect the thyroid, has a narrow therapeutic index and can quickly become fatal, initial and ongoing health assessment and laboratory monitoring is required; lithium toxicity is a medical emergency requiring rapid treatment


What is the therapeutic range of lithium?

0.6 – 1.4 mEq/L Lithium in the blood


What are some common causes of an increase in lithium levels?

  • Decreased sodium intake
  • Diuretic therapy
  • Decreased renal functioning
  • Fluid and electrolyte loss, sweating, diarrhea, dehydration, fever, vomiting
  • Medical illness
  • Overdose
  • Nonsteroidal antiinflammatory drug therapy


How would you manage a patient with lithium toxicity?

  • Assess quickly; obtain rapid history of incident, especially dosing; offer support and explanations to the patient.
  • Hold all lithium doses
  • Obtain lithium blood level immediately; obtain electrolytes, BUN, creatinine, urinalysis, CBC when possible
  • Vigorously hydrate: 5 to 6 L/day; balance electrolytes; IV line; indwelling urinary catheter
  • Implement osmotic diuresis with urea or mannitol
  • Ensure adequate intake of sodium chloride to promote excretion of lithium


What is Schizophrenia?

 A mental disorder that makes it hard to yell the difference between what is real and not real


What causes schizophrenia?

Nobody is completely sure, there are:¨
  • Neurophysiological theories
  • Genetic theories
  • Environmental and developmental factors
  • Probably due to Abnormalities in brain structure



What areas of the brain are affected in Schizophrenia?

  • Pre-frontal cortex
  • Anterior cingulate cortex
  • Limbic regions-hippocampus
  • Striatum


What are some neurological soft signs associated with prefrontal cortical dysfunction in schizophrenia?

  • Astereognosis: Inability to recognize objects by the sense of touch (e.g., differentiating a nickel from a dime)
  • Agraphesthesia: Inability to recognize numbers or letters traced on the skin
  • Dysdiadochokinesia: Impairment of the ability to perform smooth, alternating movements (e.g., turning the hand face up and face down rapidly)
  • Mild muscle twitches, choreiform and ticlike movements, grimacing
  • Impaired fine motor skills and abnormal motor tone Increased rate of eye blinking
  • Abnormal smooth pursuit eye movements (SPEMs): Diff iculty following movement of objects


What are some neurological hard signs associated with prefrontal cortical dysfunction in schizophrenia?

Loss of function, weakness, diminished reflexes, paralysis caused by a cerebrovascular accident, tumor, traumatic injury, etc


What is the diagnostic criteria for schizophrenia?

A disturbance that lasts for at least 6 months and includes at least a month of active-phase symptoms” meaning 2 or more of the following:

  • delusions 
  • hallucinations
  • disorganized speech
  • grossly disorganized or catatonic behavior
  • negative symptoms


What is the Onset, Course, and Prognosis for schizophrenia?

¨Peak incidence:
  • Males: 15-25 years of age
  • Females: 25-35 years of age
Course of illness:
  • Extremely variable
  • Often chronic
  • Sometimes episodic only
  • Intensity of psychosis diminishes with age


What are some factors related to poor prognosis's with schizophrenai?

¨Factors related to poor prognosis:
  • Early age of onset
  • Insidious onset
  • Poor premorbid adjustment
  • Sustained emotional withdrawal
  • Inappropriate affective response
  • Enlarged cerebral ventricles
  • Perinatal brain injury
  • Poor response to medications


What are some positive symptoms associated with schizophrenia?

  • Delusions
  • Hallucinations
  • Though disorder
  • Disorganized speech
  • Bizarre behavior
  • Inappropriate affect


What are negative symptoms in relation to schizophrenia?

Diminished normal behaviors; diminution or loss of normal brain function; usually unresponsive to traditional antipsychotics and more responsive of atypical antipsychotics


What are positive symptoms in relation to schizophrenia?

They are exaggerated normal behaviors; an exaggeration or distortion of normal brain function; usually responsive to all categories of antipsychotic drugs


What are some negative symptoms associated with schizophrenia?

  • Affective flattening
  • Alogia
  • Avolition/apathy
  • Anhedonia/asociality
  • Attentional deficit


What are the gender differences associated with schizophrenia?

Tendencies of women compared with men:

  • Late onset schizophrenia
  • Less severe course of illness
  • Exhibit more positive and less negative symptoms
  • More affective symptoms
  • Respond to lower doses of antipsychotic medication
  • Higher level of social functioning
  • Fewer structural brain abnormalities


What are some Nursing Diagnoses related to schizophrenia?

  • Impaired verbal communication
  • Disturbed sensory perception
  • Impaired social isolation
  • Disturbed personal identity


What are some expected outcoes with a patient with schizophrenia?

the patient will live, learn, and work at a maximum possible level of success, as defined by the individual


What are the phrases of illness with schizophrenia?

  • Acute phase
  • Stabilization phase
  • Stable phase
  • Relapse


What are some nursing interventions during the Acute Phase of schizophrenia?

  • Provide for patient safety
  • Reduction of over stimulation
  • Stress reduction
  • Establishment of therapeutic relationship
  • Provide psychosocial education to patient and family


What are some nursing interventions during the stabilization phase of schizophrenia?

  • Psychoeducation
  • Psychosocial Rehabilitation



What are some nursing interventions during the stable phase of schizophrenia?

  • Independent living skills training
  • Social skills training
  • Cognitive rehabilitation
  • Vocational rehabilitation



How would you treat relapses during schizophrenia?

Teach patient and family:

  • Recognize warning signs
  • Get to a safe place where someone can monitor symptoms
  • Reduce stress demands
  • Take medications
  • Talk to a trusted person
  • Avoid negative people 


What are hallucinations?

False perceptual distortions that occur in maladaptive neurobiological responses, and there is no identifiable external orinternal stimuluses.


What are the different types of hallucinations?

  • Auditory
  • Visual
  • Olfactory
  • Gustatory
  • Tactile
  • Cenesthetic
  • Kinesthetic


What are auditory hallucinations?

Audible thoughts in which the patient hears voices that are speaking what the patient is thinking and commands that tell the patient to do something, sometimes harmful or dangerous


What are some characteristics of visualhallucinations?

Visual stimuli in the form of flashes of light, geometric figures, cartoon figures, or elaborate and complex scenes or visions. Visions can be pleasant or terrifying, as in seeing monsters


What are olfactory hallucinations?

Putrid, foul, and rancid smells such as blood, urine, or feces; occasionally the odors can be pleasant. Olfactory hallucinations are typically associated with stroke, tumor, seizures, and the dementias


What are gustatory hallucinations?

Putrid, foul, and rancid smells such as blood, urine, or feces; occasionally the odors can be pleasant.


What are tactile hallucinations?

Experiencing pain or discomfort with no apparent stimuli. Feeling electrical sensations coming from the ground, inanimate objects, or other people


What are cenesthetic hallucinations?

Feeling body functions such as blood pulsing through veins and arteries, food digesting, or urine forming


What are kinesthetic hallucinations?

Sensation of movement while standing motionless


How would you manage hallucinations?

  • Understanding characteristics of the hallucination and identifying the related anxiety level is important
  • Remember Hallucinations are very real to the person having them
  • Honesty, genuineness, and openness are the foundation for effective communication during hallucinations
  • Maintain eye contact, speak simply and in a slightly louder voice than usual, call the patient by name, use touch as appropriate (patient needs sensory validation to override the abnormal sensory processes that are occurring in the brain)


What is the goal of interventions for patients who are hallucinating?

To help them increase awareness of these symptoms so that they can distinguish between the world of psychosis and the world of reality experienced by others without schizophrenia



How would you manage a patient with delusions?

  • Patients cope with delusions in several ways. Some adapt by learning to live with them, others seek to understand the symptom and become empowered to manage delusions when they occur
  • Development of trust is important; easier through nonverbal communication
  • It is essential for the nurse to approach the patient with calmness and empathy
  • Patients are sensitive to rejection; nurse should not underestimate the power of delusions
  • Place the delusion in a time frame and identify triggers
  • Assess the intensity, frequency, and duration of the delusion
  • Identify emotional components of the delusion
  • Observe for evidence of concrete thinking
  • Observe speech for symptoms of a thought disorder
  • Observe for the ability to accurately use cause and effect reasoning
  • Distinguish between the description of the experience and the facts of the situation
  • Carefully question the facts as they are presented and their meaning
  • Discuss consequences of the delusion when the person is ready
  • Promote distraction as a way to stop focusing on the delusion


How would you prevent and management of Aggressive Behavior with schizophrenic patients?

  • Self awareness
  • Communication
  • Maintain safe environment
  • Administer psychopharmacology
  • Crisis management
  • Seclusion

When patient is aggressive try least restrictive measures first


What is Neuroleptic Malignant Syndrome

A rare but potentially fatal (14% to 30% mortality) side effect of antipsychotic drugs, side effects include:

  • fever
  • tachycardia
  • sweating
  • muscle rigidity
  • tremor
  • incontinence
  • stupor


How would you treat neuroleptic malignant syndrome?

Treatment for NMS includes stopping the triggering drug and initiating supportive care


What is cognition and how are people with schizophrenia affected?

  • Cognition is the act or process of knowing 

  • People with schizophrenia are often unable to produce complex logical thoughts or express coherent sentences, because neurotransmission in the brain’s information processing system is malfunctioning 


What are some memory problems associated with schizophrenia?

  • forgetfulness
  • disinterest
  • difficulty learning
  • lack of compliance w/ meds


What are some attention disturbances in schizophrenia?

  • difficulty completing tasks
  • difficulty concentrating on work
  • distractibility 


Describe the form and organization of speech of patients with schizophrenia

  • may include loose associations
  • word salad
  • tangentiality - with only slight relevance to the current subject
  • illogicality
  • circumstantiality
  • pressured speech
  • poverty of speech
  • distractible speech
  • clanging 


How do decision making problems affect patients with schizophrenia?

These problems affect one’s:

  • insight
  • judgment
  • logic
  • decisiveness
  • planning
  • ability to carry out decisions
  • abstract thought


What are some problems with thought content in schitzophrenic patients?

  • Paranoia

  • grandiosity

  • religious

  • nihilistic

  • somatic delusions 

    • Delusions can be further complicated by thought withdrawal, thought insertion, thought control, or thought broadcasting 


What is a delusion?

a personal belief based on an incorrect inference of external reality; false belief that is firmly maintained even though it is not shared by others and is contradicted by social reality


What is a perception?

the identification and interpretation of a stimulus based on information received through sight, sound, taste, touch, and smell.


What are some characteristics associated with emotion in schizophrenic patients?

  • Mood and affect: broad, restricted, blunted, flat, and inappropriate  

  • Schizophrenics usually have symptoms of hypoexpression

  • Alexithymia

  • Anhedonia

  • Apathy


What is Alexithymia?

difficulty naming and describing emotions 


What is Anhedonia?

inability or decreased ability to experience pleasure, joy, intimacy, and closeness


What is Apathy?

lack of feelings, emotions, interests, or concern


What are some behaviors and movements associated with schizophrenic patients?

  • Maladaptive behaviors in schizophrenia include deteriorated appearance, lack of persistence and work/school, avolition (lack of energy or drive), repetitive/stereotyped behavior, aggression, agitation, and negativism 

  • Maladaptive movements include catataonia, abnormal eye movements, grimacing, apraxia/echopraxia, abnormal gait, mannerisms, and extrapyramidal side effects of psychotropic medications


What are some socializing problems experienced by schizophrenic patients?

  • inability to communicate coherently
  • Loss of drive and interest
  • deterioration of social skills
  • poor personal hygiene
  • paranoia


What are some specific problems seen in schizophrenic patients when developing relationships?

  • Social inappropriateness
  • disinterest in recreational activities
  • inappropriate sexual behavior
  • stigma-related withdrawal by friends, families and peers


What are some atypical antipsychotics?

  • Aripiprazole (abilify)
  • Clozapine (Clozaril)
  • Risperidone (Risperdal) = EPS, tardive dyskinesia
  • Quetiapine (Seroquel) = draw cbc before drug is given, no new prescriptions given until the cbc is drawn
  • Olanzapine (Zyprexa) = metabolic syndrome
  • Ziprasidone (Geodon) = prolonged qt interval


What is the MOA for Atypical antipsychotics?

block effects at the dopamine2 and serotonin2 postsynaptic receptors; thus, they are DA and 5-HT antagonists


What are some characteristics of atypical antipsychotics?

  • Apriprazole is unique in that it is the first of a new generation of atypical antipsychotics, a dopamine-serotonin stabilizer; it is a partial agonist at D2 and 5-HT1A receptors and has antagonistic activity at 5-HT2A receptors
  • Atypical antipsychotics improve the positive symptoms of schizophrenia, but unlike the typical drugs, they also improve the negative symptoms
  • Reported to treat mood symptoms, hostility, violence, suicidal behavior, difficulty with socialization, and the cognitive impairment seen in schizophrenia


What are the 2 great disadvantages of atypical antipsychotics?

  • They can result in metabolic syndrome with problems related to weight gain, diabetes, and dyslipidemia, often resulting in cardiovascular disease
  • They cost considerably more than the typical antipsychotics


What are some side effects of atypical antipsychotics?

  • Resperidone tends to elevate serum prolactin levels and may cause extrapyramidal effects at higher doses
  • Sedation is commonly observed in patients taking quetiapine, olanzapine, or clozapine
  • Zirpasidone has been associated with mild to moderate QT interval prolongation in up to 5% of patients
  • Clozapine is often reserved for patients with treatment resistant illness because of its side effects of agranulocytosis, seizures, and myocarditis
  • Severe allergic reaction can occur with Saphris


What are some typical antipsychotic medications?

  • Haloperidol (Haldol)
  • Loxapine (Loxitane)
  • Thioridazine (Mellaril)
  • Molindone (Moban)


What is the MOA for typical antipsychotics?

predominantly dopamine antagonists; they block postsynaptic D2 receptors in several DA tracts in the brain, accounting for a decrease in positive symptoms of schizophrenia


What are the side effects for typical antipsychotics?

  • Extrapyramidal symptoms and tardive dyskinesia; result mainly from nonadherence with drug regimens
  • A rare but potentially fatal side effect is neuroleptic malignant syndrome; S/S include fever, tachycardia, sweating, muscle rigidity, tremor, incontinence, and stupor
    • Treatment includes stopping the triggering drug and initiating supportive care


How do extrapyramidal symptoms occur?

They often result in patient nonadherence with drug regimens


What are the 2 categories of extrapyramidal symptoms?

  • Dyskinesias are movement disorders.
  • Dystonias are muscle tension disorders.


What are dyskinesias?

Dyskinesias are movement disorders and can include any
of a number of repetitive, involuntary, and purposeless
body or facial movements:
  • Tongue movements, such as “tongue thrusts” or “flycatching” movements
  • Lip smacking
  • Finger movements
  • Eye blinking
  • Movements of the arms or legs.
  • An individual may or may not be aware of these movements.
These movements are recognizable, and many people
fear that others will know they are taking an antipsychotic medication due to these unusual movements


What are some nursing considerations for extrampyramidal symptoms?

  • General treatment principles:
  • Tolerance usually develops by the third month.
  • Decrease dose of drug.
  • Add a drug to treat EPS; then taper after 3 months on the antipsychotic.
  • Use a drug with a lower EPS profile.
  • Give patient education and support.


What are some drugs used to treat extrapyramidal side effects?

  • Anticholinergics:
    • Benztropine
    • Trihexyphenidyl
    • Biperiden
  • Antihistamine
    • Benadryl
  • Dopamine agonist:
    • Amantadine
  • Benzodiazepines
    • Diazepam
    • Lorazepam
    • Clonazepam


When do tardive dyskinesia symptoms occur?

symptoms appear during long-term treatment (often after several years) with an antipsychotic. They are more likely to be permanent even after the medication
is stopped.


What are some nursing considerations for tardive dyskinesia symptoms?

  • Can occur after use (usually long use) of conventional antipsychotics
  • stereotyped involuntary movements (tongue protrusion, lip smacking, chewing, blinking, grimacing, choreiform movements of limbs and trunk, foot tapping)
  • if using typical antipsychotics, use preventive measures and assess often
  • consider changing to an atypical antipsychotic drug
  • there is no treatment at present for TD


What is metabolic syndrome?

A group of problems related to weight gain, diabetes, dyslipidemia, often resulting in cardiovascular disease


What are some nursing considerations for metabolic syndrome?

Patient education on healthy lifestyle—eating, exercise, smoking cessation.


What is a religious delusion?

belief that one is favored by a higher being or is an instrument of that being


What is a somatic delusion?

belief that one’s body or parts of one’s body are diseased or distorted


What is a grandiose delusion?

belief that one possesses greatness or special powers


What is a paranoid delusion?

excessive or irrational suspicion and distrust of others, characterized by systematized delusions that others are “out to get them” or spying on


What is thought broadcasting?

belief that one’s thoughts are being aired to the outside world


What is thought insertion?

belief that thoughts are being placed into one’s mind by outside people or influences


What is depersonalization?

the feeling of having lost self-identity and that things around the person are different, strange, or unreal


What is Hypochondriasis?

somatic overconcern with and morbid attention to details of body functioning


What are ideas of reference?

incorrect interpretation of casual incidents and external events as having direct personal references


What is magical thinking?

belief that thinking equates with doing, characterized by lack of realistic relationship between cause and effect


What are nihilistic ideas?

thoughts of nonexistence and hopelessness


What is an obsession?

an idea, emotion, or impulse that repetitively and insistently forces itself into consciousness, although it is unwelcome


What is a phobia?

a morbid fear associated with extreme anxiety


What is a circumstantial thought process?

thought and speech associated with excessive and unnecessary detail that is usually relevant to a question, and an answer is eventually provided


What is the "flight of ideas" thought process?

overproductive speech characterized by rapid shifting from one topic to another and fragmenting ideas


What is the loose associations thought processes?

lack of a logical relationship between thoughts and ideas that renders speech and thought inexact, vague, diffuse, and unfocused


What are neologisms?

new word or words created by the patient, often a blend of other words


What is the "perseveration" thought process?

involuntary, excessive continuation or repetition of a single response, idea, or activity; may apply to speech or movement, but most often verbal


What is a "tangential" thought process?

similar to circumstantial but the person never returns to the central point and never answers the original question


What is "thought blocking"?

sudden halt in the train of thought or in the middle of a sentence


What is a "word salad"

series of words that seem totally unrelated


What is gaiting and how does it pertain to schizophrenia?

  • Gating is an electrical process involving electrolytes. It refers to inhibitory and excitatory nerve action potentials and the feedback occurring within the nervous system related to completed nerve transmissions.
  • Decreased gating is demonstrated by a person’s inability to selectively attend to stimuli.
  • For example, at a baseball game the person with schizophrenia would be unable to differentiate the noise from the crowd from the music ,the team,or the public address system


What is the kindling effect?

An increased responsiveness to low doses of stimulation overtime, resulting in seizures due to intermittent and repeated stimulating by low-level electrical impulses or low-dose chemicals such as cocaine.