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:
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:
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:
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:
PHOBIAS
DEFINITION/DESCRIPTION:
- pt experiences irrational fear of a certain object or situation.
PATHOHYSIOLOGICAL CHANGES: ASSESSMENT: NURSING DX: OUTCOMES: INTERVENTIONS: EVALUATION:
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:
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:
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.
- Cognitive Impairment
- Bizarre Behaviors - Sensory Perceptions
- Hallucinations; Delusions
- 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:
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:
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:
Relaxation training
used to control pain, tension and anxiety
Flooding
involves exposing a client to a great deal of undesirable stimulus in an attempt to turn off the anxiety response- useful for phobias
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
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
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
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
Schizoaffective disorder
presence of two disorders
-schizophrenia and Mood disorder (depression or bipolar)
- delusions
- hallucinations
- disorganized speech
- disorganized behavior
- negative characteristics
Collaborative Management assessment
- Chief complaint
- onset
- clinical manifestations
- clients perceptions
- suicidal ideation
- previous hx of hospitalization
- support system
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
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
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
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
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
Maintenance Therapy
Depot injections of fluphenazine, haloperidol
effects last 2-4 weeks
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.
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
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
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
conversion disorder
is named so because it appears to convert a source of stress into a physical problem
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.
Depersonalization
out of body experience, feeling like you floating above the ground
Derealization
stating that objects/ surrounding is far away or really small/ unreal
Amnesia
lack of memory for extended period of time
Eustress
beneficial stress - used to help people to develop skills needed to solve problems and meet personal goals
stressor
trigger
distress
damaging/detrimental- high and prolonged, chronic stress
EPS
Extra pyramidal SXS- Drug induced movement disorders
Beneficence
quality of doing good- charity, spending extra time to help calm and extremely anxious patient
autonomy
clients right to make their own decision, client must accept responsibility of consequences
Recognizing a patients right to refuse treatment
Justice
fair and equal treatment for all
fidelity
Maintaining loyalty and commitment to the patient and doing no wrong to the patient
veracity
Honesty- the duty to communicate truthfully
involuntary vs voluntary admission
court ordered/ they brought themselves in
Restraints
physical or injectable
- document
- must be an order
- all other avenues explored first
- reevaluation of removal and new order every 24 hours
Tardive Dyskinesia (TD)
EPS of antipsychotic drugs
- usually appears after prolonged treatment
- serious, is not always reversible
- involuntary tonic muscular spasms that typically involve the tongue, fingers, toes, neck, trunk or pelvis
- fasciculations of the tongue, constant lip smacking. Can develop into uncontrollable lip biting, checking or sucking motions, an open mouth and lateral movements of the jaw.
Acute Dystonia
- common EPS of antipsychotic drugs
- ## severe spasms of the muscles of the tongue, head and neck; upward fixed deviation of the eyes; severe back spasms the arch the trunk forward and thrust and head and lower limbs backward
akathisia
- EPS of antipsychotic drugs
- internal restlessness and external restless pacing and fidgeting
pseudoparkinsonism
- EPS of antipsychotic drugs
- stiffening of muscular activity in the face, body, arms and legs
