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1

ACUTE STRESS DISORDER

DEFINITION/DESCRIPTION: can occur after the same kind of triggers as PTSD, which include experiencing a violent event or traumatic experience.
* resolution of sxs within 1 month*

PATHOHYSIOLOGICAL CHANGES:
ASSESSMENT:
NURSING DX:
OUTCOMES:
INTERVENTIONS:
-critical incident stress debriefing
-benzodiazepines
-sedative-hypnotics ( for sleep)
-medications often used short term and in conjunction with other psychological treatments
EVALUATION:

2

POST TRAUMATIC DISORDER

DEFINITION/DESCRIPTION: occurs in any individual who has exposure to a trauma severe enough to be outside of the range of normal human experience. experience sxs longer than one month
- military personnel
-childhood physical abuse, kidnapping, torture
-sexual assault
-natural disasters
-diagnosis of severe illness

* individuals extraordinary helplessness or powerlessness in the face of overwhelming circumstance*


PATHOHYSIOLOGICAL CHANGES:
-stress response of the hypothalamus-pituitary-adrenal cortex is abnormal in these individuals

- more likely to have co-occurring conditions including osteoarthritis, diabetes, obesity, heart disease, elevated lipid levels, chronic pain, MDD

ASSESSMENT:
-intrusive re-experiencing of initial trauma (flashbacks)
-avoidance
-persistent negative alterations in cognitions and mood)
- alteration and arousal and activity ( irritability, angry outbursts, self-destructive behavior, exaggerated startle response, hyper-vigilance, sleep difficulties)

* sxs often begin within a few months of initial trauma, if not treated within 1 year the likely hood of chronic sxs increase*

NURSING DX:

OUTCOMES:
- patient and others will remain safe
-TX for co-occuring conditions
-attend support groups
-expand social support network
-exhibit increase in restful sleep periods
- have fewer nightmares/flashbacks
-express decrease in irritability
-demonstrate effective anxiety reduction techniques ( cognitive and behavioral)
INTERVENTIONS:
- goals of treatment: solid social support,
EVALUATION:

3

GENERALIZED ANXIETY DISORDER:

DEFINITION/DESCRIPTION: the patient exhibits uncontrollable, excessive worry for at least 6 months

-GAD causes significant impairment in one or more areas of functioning such as work duties

-SXS: restlessness, muscle tension, avoidance of stressful activities or events, increased time to prepare for possible stressful events, procrastination in decision making, seeks repeated reassurance

PATHOHYSIOLOGICAL CHANGES:
ASSESSMENT:
NURSING DX:
OUTCOMES:
INTERVENTIONS:
EVALUATION:

4

PANIC DISORDER

DEFINITION/DESCRIPTION: client experiences recurrent panic attacks

PATHOHYSIOLOGICAL CHANGES:
ASSESSMENT:
- attacks typically last 15-30 min
- FOUR or more of the following sxs present during an attack: palpitations, shortness of breath, choking or smothering sensation, chest pain, nausea, feelings of depersonalization, fear of dying or insanity, chills or hot flashes

-pt might experience behavior changes and/or persistent worries about when the next attack may occur

NURSING DX:
OUTCOMES:
INTERVENTIONS:
EVALUATION:

5

PHOBIAS

DEFINITION/DESCRIPTION:
- pt experiences irrational fear of a certain object or situation.

PATHOHYSIOLOGICAL CHANGES:
ASSESSMENT:
NURSING DX:
OUTCOMES:
INTERVENTIONS:
EVALUATION:

6

OBSESSIVE COMPULSIVE DISORDER

DEFINITION/DESCRIPTION:
-pt has intrusive thoughts of unrealistic obsessions and tried to control these thoughts with compulsive behaviors

PATHOHYSIOLOGICAL CHANGES:
ASSESSMENT:
NURSING DX:
OUTCOMES:
INTERVENTIONS:
EVALUATION:

7

SOMATOFORM DISORDERS

DEFINITION/DESCRIPTION: psychiatric disorder no organic basis for the physical SXS that are the chief complaints.

added risk factor if you have a co-occuring psychiatric disorders

PATHOHYSIOLOGICAL CHANGES:

Theory:
-amplified physiological response related to the brains inability to calm to central nervous system.

-Cardiovascular
-Musculoskeletal
-Respiratory
-GI/GU
-Integumentary

ASSESSMENT:
- full health assessment to rule out physical illness with organic basis

NURSING DX:
-ineffective individual
-inadequate coping
-family process
-body image disturbance
-chronic pain

OUTCOMES:
-identifies interactions of mind and body
-identifies the effects of stress on body
-** ASSUMES APPROPRIATE ROLES IN WORK/FAMILY/COMMUNITY**
-Employs self help strategies

INTERVENTIONS:
- SSRIs
-Anti-anxiety- short term due to dependency
-observe intensity and frequency of somatic sxs
-reinforce patients strengths and problem solving abilities

EVALUATION:

8

SCHIZOPHRENIA

DEFINITION/DESCRIPTION:
Schizophrenia is characterized by delusions, hallucinations, disorganized speech and behavior, and other symptoms that cause social or occupational dysfunction. For a diagnosis, symptoms must have been present for six months and include at least one month of active symptoms.

1.Cognitive Impairment
-Bizarre Behaviors

2. Sensory Perceptions
-Hallucinations; Delusions

3. Deterioration in psychosocial functioning


PATHOHYSIOLOGICAL CHANGES:
-Structural Changes
-Ventricular Enlargement
-Decrease cerebral & intracranial size
-Disordering of cells in hippocampus
-Physical Conditions
-Links with other neurological disorders

-Alterations in neurotransmitter systems
-Malfunction in transmission of information from one nerve cell across the synapses to postsynaptic receptors
-Post mortem-^ dopamine receptors
-Excess of dopamine & serotonin


ASSESSMENT:

Positive signs:
-hallucinations ( auditory, visual, olfactory (spices), gustatory ( metallic flavor), tactile

-paranoia

-delusions

-though disorganization

Negative signs:
-affective flattening ( no change in emotion/tone)
-impoverish speech
-apathy ( indifference)
-avolition ( inability to persist in goal directed behaviors; bathing- lack of motivation)
-alogia ( decreased fluency/content of speech)
-ambivalence
-anhedonia

Mood SXS:
-dysphoria
-anxiety
-agitation
-suicidality

Neuro-cognitive sxs:
-distractibility
-learning deficits
-memory deficits
-abstract thinking impairment

NURSING DX:
-altered thought process
-sensory/perceptual alterations
-risk for violence
-impaired communication
-self-care deficits
-intolerance to activity
-social isolation
-decisional conflict
-sensory/perceptual
-altered thought
-altered emotional response
-impaired home maintenance

OUTCOMES:
- pt will recognize distortions of reality
-demonstrate absence of violence, self harm
-demonstrate reality-based thinking and behavior
-maintain anxiety at manageable level
-perform self-care activities independently
-actively participate in unit activities
-comply with meds
-effective coping and problem solving
-participate in discharge planning

INTERVENTIONS:
- psychotherapy ( group, individual, behavioral, support and family)

-milieu therapy
-somatic or ECT Therapy

-antipsychotic meds

-Meet with patient each day for 30 minutes to establish trust and rapport.
-Explore the voices with the patient when they are the most threatening & note the circumstances.
-Provide noncompetitive/distracting activities that focus on the here and now
-Explore possible actions that minimize or reduce the hallucinations

EVALUATION:

9

ANOREXIA NERVOSA

DEFINITION/DESCRIPTION: pts have intense irrational beliefs about their shape and wt, and engage in self-starvation, express intense fear of gaining weight, and have a disturbance in self-evaluation of weight and its importance

PATHOPHYSIOLOGICAL CHANGES:
- amenorrhea in female pt's (can lead to interference with age-appropriate development, which ppl assume to coordinate with the fear of sexual maturity)
- significant compromise in every organ system of the body including - CV, GI, Endocrine, Derm, Hematological, Skeletal, and CNS
- brain imaging studies show unusual activity in frontal, cingulate, temporal, parietal areas
- serotonin pathways are abnormal --> key to anxiety responses, inhibition and distorted body image

ASSESSMENT:
-avg age onset in early to middle adolescence
- eating disorders are almost always comorbid with other psych illnesses
- low self-esteem and self-doubts about personal worth
- possible family infliction --> controlling, perfectionistic, achievement focused family
* - cachectic (severely underweight with muscle wasting)
- lanugo (growth of fine, downy hair on face and back)
- mottled, cool skin on extremities
- low BP, bradycardia, and temp
- BMI < 19
- electrolyte imbalances (fatigue, weak, lethargy)
- hypokalemic alkalosis (if vomiting or using laxatives/diuretics)

COGNITIVE DISTORTIONS:
- overgeneralization
"he didnt ask me out, it must be because im fat"
- all-or-nothing thinking
"if i allow myself to gain wt, ill blow up like a balloon"
- catastrophizing
"if i gain wt, my weekend will be ruined"
- personalization
"People wont like me unless im thin"
- emotional reasoning
"when i', thin, i feel powerful"

NURSING DX:
- restrictions of energy intake relative to requirements, leading to a signif low body wt in context of age, sex, development, and physical health
- intense fear of gaining wt or becoming fat, or persistent behavior that interferes with wt gain, even tho V low wt
- disturbed body image, persistent lack of recognition of the seriousness of low body wt

OUTCOMES: **highest mortality rate of ANY mental illness**
- refrain from self-harm
- normalize eating patterns as evidenced by eating 75% of 3 meals plus 2 snacks
- achieve 85-90% of ideal body wt
- demonstrate 2 new healthy eating habits
- participate in treatment of associate psych symptoms (mood/self-esteem)

INTERVENTIONS:
- watch for refeeding syndrome (CV collapse)
- restore pt's nutritional status (restoring wt within normal range)
- modify pt's distorted eating behaviors
- help change distorted belief about wt loss and body image
- self-care activities
- milieu therapy (normalize eating patterns)
- Olanzapine, second-gen antipsychotic, increasingly being reported to positively affect wt gain and improve cognition and body image
EVALUATION:

10

BULIMIA NERVOSA

DEFINITION/DESCRIPTION: engage in repeated episodes of binge eating followed by inappropriate compensatory behaviors (vom, laxatives, diuretics, excessive exercise)

PATHOHYSIOLOGICAL CHANGES:
- cardiac dysthymia
- orthostatic changes in pulse/BP
- electrolyte imbalance (hypOchloremia, hypoOkalemia, dehydration)
- esophageal tears
- Russell's sign (knuckles)

ASSESSMENT:
- binge eating
- self-induced vomit
- depressive signs and symptoms
- increased anxiety and compulsivity
- family may be chaotic and lack nurturing
* - medical stabilization
- psych evaluation (comorbidity)
- SI ?
- ask for us or diuretics, vom, laxatives, diet pills, amphetamines, energy pills, skinny tea's

NURSING DX:
- recurrent episodes of binge eating (within 2 hour period, v large amount of food paired with sense of lack of control)
- recurrent inappropriate compensatory behavior to prevent wt gain
- binge eating and comp behavior occur at least once a week, for THREE months
- self-evaluation is influenced by body shape and wt

OUTCOMES:
- refrain from binge/purge
- demonstrate at least 2 new skills for managing stress/anxiety/shame
- obtain and maintain normal electrolyte balance
- be free of self-directed harm
- express feelings in a non-food-related way
- name 2 personal strengths

INTERVENTIONS:
* - medical stabilization is FIRST PRIORITY (Fluid and Electrolyte, cardiac)
- milieu therapy (observe during and after meals to prevent purging, normalize eating patterns, maintain appropriate amount of exercise)
- CBT
- fluoxetine = GOLD STANDARD in treating BN

EVALUATION:

11

Relaxation training

used to control pain, tension and anxiety

12

Flooding

involves exposing a client to a great deal of undesirable stimulus in an attempt to turn off the anxiety response- useful for phobias

13

modeling

allows a client to see a demonstration of appropriate behavior in a stressful situation, goal of therapy is that pt will imitate the behavior

14

Systematic desensitization

begins with mastering or relaxation techniques, then pt is exposed to increasing levels of anxiety-producing stimuli and uses relaxation to over-come the resulting anxiety

15

Types of Delusions

persecution: feeling threatening, others are hostile and trying to harm them

ideas of Reference: believe that all events are directly related to them

somatic: body altered from normal

Thought broadcasting: idea that unspoken thoughts can be heard

Thought insertion- beliefs of others being inserted into ones mind

Thought withdraw- thoughts being taken away by outside agency


Grandiose: exaggerated feeling of importance, power, knowledge or identity


Control/Influence: One's actions or thoughts are controlled by external forces

jealousy-

Religiosity:

nihilistic: disbelief – everything is unreal

16

Types of Disorganized Speech

-word salad- jumble of word, meaningless to listener and/or the speaker

-loose association - flow one thought to the next with loos associations

-clanging- meaningless rhyming

-echolalia- meaningless repetition of another person's spoken words (mimicking) CATATONIA
echopraxia- mimicking of movements

-Neologicsm: invented word (uniphrom)

-Preservation: Inappropriate repetition of words or behaviors; abnormal compulsions (frontal lobe disorders)

-Circumstantiality: unnecessary details and inappropriate thoughts

-Tangentiality: detour from a topic that was logically progression but no return to the original topic

17

Schizoaffective disorder

presence of two disorders

-schizophrenia and Mood disorder (depression or bipolar)

-delusions
-hallucinations
-disorganized speech
-disorganized behavior
-negative characteristics

18

Collaborative Management assessment

-Chief complaint
-onset
-clinical manifestations
-clients perceptions
-suicidal ideation
-previous hx of hospitalization
-support system

19

Psychopharmacology/antipsychotic meds

First Generation/Conventional/Typical

Dopamine antagonists

Target positive sxs

High Potency :
-Haloperidol (Haldol)
-Trifluoperazine (Stelazine)
-Fluphenazine (Prolixin)

Medium Potency:
-Loxapine (Loxitane)
-Perphenazine (Trilafon)


Low Potency:
-Chlorpromazine (Thorazine)
-Thioridazine (Mellaril)


Adverse Effects:

Extrapyramidal Symptoms (EPSs)
-Akathisia
-Acute dystonia
-Pseudoparkinsonism

-Tardive dyskinesia (TD)

-Neuroleptic malignant
syndrome (NMS)


- anticholinergenic effects: dilated pupils, dry mouth, decreased sweating, slowed bowels and bladder

Antiadrenergic effects: orthostatic hypotension

-lowered seizure threshold
-photosensitivity

20

Psychopharmacology/antipsychotic meds

Second Generation/Atypical

Dopamine and serotonin antagonists

lessen the negative sxs

Adverse Effects:
Dystonia ( 1-2 days)
-Spasms of tongue and face

akathisia ( 1-6 wks) - restlessness

Tardive Dyskinesia ( late in treatment) - irregular, jerky muscle movements

-continuous restlessness
-slow arms and legs

Pseudoparkinsoniam ( 1-4 wks)
-muscle tremors, shuffling gait, drooling

21

Psychopharmacology/antipsychotic meds

Second Generation/Atypical

Dopmaine & seratonin antagonists

block norepinephrine, histamine and acetylcholine

lessen the negative sxs
Target positive and negative sxs

Adverse Effects:
Dystonia ( 1-2 days)
-Spasms of tongue and face

akathisia ( 1-6 wks)
Tardive Dyskinesia ( late in treatment)

-continuous restlessness
-slow arms and legs

Pseudoparkinsoniam ( 1-4 wks)

-muscle tremors, shuffling gait, drooling


Common drugs
-clozapine
can cause agranulocytosis: monitor WBC weekly and then biweekly, monitor weight gain

-risperidone
(NMS, EPS, GI; obtain baseline vitals and ekg)

-paliperidone

-olanzapine
-quetiapine
( these two can cause drowsiness, EPS, weight gain, orthostatic hypotension)


-ziprasidone
-aripiprazole

22

Neuroleptic Malignant Syndrome (NMS)

Rare but potentially fatal (Onset – within a week)

R/T Dehydration or high potency drugs (Haldol)

-Altered LOC
-Hyperpyrexia (Temp 101-103 F)
-Muscle rigidity
Autonomic hyperactivity
-Rhabdomyolitis : Myoglobinuria , Renal Failure

Treatment: Dantrolene (Dantrium) – skeletal muscle relaxant
Bromocriptine (Parlodel) – dopamine agonist


Do Not reinstitute antipsychotics for are least 2 weeks after complete resolution of NMS

23

Clozapine

Use: Treat refractory Schizophrenia

Adverse Effects: Agranulocytosis

Weekly monitoring WBC count required 1st 6 months and; bi-weekly

If WBC’s fall below < 2000 cells/mm3 -Discontinue drug and; patient never receive drug again

24

Maintenance Therapy

Depot injections of fluphenazine, haloperidol

effects last 2-4 weeks

25

Adjuncts to Antipsychotic Drug Therapy

Antidepressants are administered for severe depression.

Lithium and other mood stabilizers reduce aggressive behavior.

Benzodiazepine augmentation improves positive and negative symptoms.
-Clonazepam (Klonopin) – Decreases anxiety, agitation, and possibly psychosis.

26

Nurse’s Role Related to Psychopharmacology

-Assess for side effects before and after administering and intervene early
-Administer safely
-Know nursing considerations
-Promote education
-Teach lifelong skills for community living.
-Monitor quality-of-life issues.
-Information on diet, exercise, antacids, smoking

27

Interventions for hallucinations

-Protect the client from injury

-Share your observations with the client

-Make frequent & brief remarks to interrupt the hallucinations

-Avoid denying or arguing with the client about the hallucination

-Administer antipsychotic drugs prn

28

fugue state

Dissociative fugue, formerly fugue state or psychogenic fugue, is a dissociative disorder and a rare psychiatric disorder characterized by reversible amnesia for personal identity, including the memories, personality, and other identifying characteristics of individuality. The state can last days, months or longer.


Help by: providing grounding techniques such as stomping feet, clapping hands, touching physical oobjects

29

conversion disorder

is named so because it appears to convert a source of stress into a physical problem

30

depression and substance abuse among the sex's

Women are more likely than men to experience Depression; men are more likely than women to experience substance abuse.