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NUR 3015 exam 1 > study guide exam 2 > Flashcards

study guide exam 2 Flashcards

1
Q

how do substances affect the brain

A

drugs of abuse taken in excess = direct activation of brain reward system involved in the reinforcement of behaviors and production of memories = intense activation of reward system leads to normal activities being neglected

  • direct activation of reward pathways
  • produces feeling of pleasures…“high”
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2
Q

characteristics of addiction (7)

A
  • heightened memory of substance’s rewarding effects: chasing the dragon “high”
  • reinforcement: seeking behavior
  • compulsive use: compelled to use substance
  • craving: drug of choice
  • tolerance: takes more to do less
  • dependence: psychological needs for drug
  • withdrawal: what patient experiences when stopped taking drug
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3
Q

characteristics of alcohol use ds. (4)

A

chronic, relapsing brain disease with 4 symptoms:
- craving: needing
- loss of control: of use
- physical dependence: alcohol W/D
- tolerance: doing more for same affect

continuous use reward in changes in brain structure and function in reward or pleasure center…in limbic system

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4
Q

DSM V criteria for alcohol use disorder

A

problematic use of ETOH with clinically signifiant impairment, manifested by at least 2 of the following within a 12 month period:
- larger amounts over longer period than intended
- persistent desire to cut down or control use
- great deal of time spent in obtaining, using, or recovering from its effect: W/D
- craving/strong desire or urge to use
- failure to fulfill major role obligations
- continued use despite problems caused by use: CPS
- important social, occupational activités given up
- recurrent use in situations that are hazardous
- use is continued despite knowledge of problems
- tolerance
- W/D

mild: 2-3 sx
moderate: 4-5 sx
severe: <6 sx

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5
Q

effects of alcohol

A
  • cancers (liver, esophagus, throat, larynx
  • cirrhosis, Brian damage, harm to fetus, pancreatitis, gastritis, esophageal varices
  • risks of death d/t accidents, homicides, suicides
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6
Q

prevalence of alcohol use ds.

A
  • common ds.
  • 4.6%: 12-17 year olds
  • 8.5%: adults age 18 and older
  • greater rates in men 12.4%;women 4.9%
  • decreases in middle age, greatest among 18-29 year olds
  • adults: native Americans and alaskans 12%; whites 9%; hispanics 9%; African Americans 7%; asian Americans/Pacific Islanders 4.5%
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7
Q

development & course of alcohol use DO

A
  • 1st episode of intoxication in mid-teens
  • onset: peaks in late teens or early-mid 20s
  • W/D occurs after DO is established
  • variable course, with periods or remission and relapse
  • decision to stop (crisis) follows with weeks of abstinence, then limited periods of controlled or problematic drinking
  • once intake resumes, rapid escalation & severe problems will develop once again
  • most severe cases represent small proportion of persons with DO
  • typical person with DO has more promising prognosis
  • adolescents: conduct DO and antisocial behavior often co-occur
  • most develop after age 40, 10% later onset
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8
Q

risks and prognostic factors (environmental)

A
  • cultural attitudes towards drinking & intoxication
  • availability
  • personal experiences w/ alcohol
  • stress levels
  • heavy peer substance use
  • exaggerated positive expectations & experiences with the effects
  • suboptimal ways of coping with stress
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9
Q

risk and prognostic factors (genetic & physiological)

A
  • runs in family
  • rate 3-4 times higher in close relatives
  • rate affected by greater number of affected relatives
  • closer genetic relationships to affected person
  • higher severity of alcohol related problems in those relatives
  • 3-4 times risk in children whose parent had the DO even when adopted and raised by parents without the DO
  • gene influence: certain phenotypes are known to identify high risk (preexisting schizophrenia or bipolar, impulsivity, any gene that modulates the dopamine reward system) & low risk (asians: flushed skin)
  • impulse issues: any one gene variation likely explains only 1-2% of risks for these DO
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10
Q

red flag indicators

A
  • blood alcohol concentration: can be used to judge tolerance to alcohol (0.08%mg/L Michigan)
  • 150mg of ethanol per deciliter (dL): does not show signs of intoxication = some degree of tolerance (0.15% mg/L)
  • 200mg/dL: most non tolerant individuals = severe intoxication (0.20%mg/L)
  • past hx blackouts; unsuccessful attempts at stopping ETOH
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11
Q

describe alcohol withdrawal delirium (DT’s) (medical emergency, what, peak, CIWA protocol, CIWA score)

A
  • medical emergency; mortality 5-10% rate
  • death d/t MI, fat emboli, vascular collapse, electrolyte imbalance, aspiration pneumonia
  • peaks 2-3 days after stopping drug, lasts up to 1 week
  • CIWA protocol: measures 10 sx. (agitation, anxiety, AV hallucinations, clouding sensorium, headache, N/V, sweats, tactile disturbances. tremors
  • score <8-10: minimal to mild W/D
  • score 8-15: moderate W/D
  • score >15: severe W/D
  • categories: rate each from 0-7
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12
Q

what is tolerance

A

a person no longer responds to the drug in the way the person initially responded

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13
Q

what is with-drawl

A

set of physiological symptoms that occur when a person stops using a substance

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14
Q

what is co-dependence

A

a cluster of behaviors originally identified through research involving the families of alcoholic patients
- exhibit overly responsible behavior (doing what others could just as well do for themselves).

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15
Q

what is substance abuse vs. dependence

A

substance abuse - can’t control intake of drug usage, feel like you need drug for specific feeling
dependence - physical body/mental dependence on drug

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16
Q

alcohol intoxication vs. withdrawal

A

alcohol intoxication: blood concentration of 80-100 mg ETOH mg/dL.
- s/sx: slower motor performance, decreased thinking ability, altered mood, and reduced ability to multitask, impaired judgement, exaggerated behavior, euphoria, lower alertness, slurred speech, blackouts, nausea, impaired VS, possibly death
alcohol withdrawal: occurs after reducing or quitting alcohol after heavy and prolonged use.
- s/sx: tremulousness (shakes, jitters), agitation, lack of appetite, N/V, insomnia, impaired cognition

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17
Q

tx. alcohol withdrawal

A
  • benzodiazepines: tapering doses, to prevent seizures
  • thiamine: prevents encephalopathy
  • magnesium sulfate: reduces seizures
  • anticonvulsants: for seizure control
  • folic acid (Vitamin B)/multivitamins: correct deficiencies
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18
Q

nursing process: assessment SBIRT (what, refer, considerations, sx, tx)

A
  • screening used standardized tools: non judgmental attitude is key
  • may need to refer to addition specialists
  • consider family assessments and codependence
  • recognize s/sx of intoxication & alcohol withdrawal
  • tx: rehab, ongoing support, medications
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19
Q

CNS depressants (OD, tx, W/D)

A

ETOH, Benzos, Barbs
- OD: cardiovascular & respiratory depression, coma, shock, convulsions, death
- tx: lavage/activated charcoal (takes toxins out), V/S, patent airways, IV fluids
- W/D: abrupt w/d may lead to death, detox with similar drug

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20
Q

CNS stimulants (OD, tx., W/D)

A

cocaine, amphetamines
- OD: assaultive, grandiose, paranoid, tachycardia, elevated BP, hyperpyrexia, convulsions, coma, death
- tx: antipsychotics PRN (calm pt.), cooling (fever), diazepam (seizures - reduce potential)
- W/D: antidepressants, dopamine agonist, bromocriptine

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21
Q

Opiates (OD, tx., W/D)

A

fentanyl, IV heroine
- OD: respiratory depression, coma, death
- Tx: narcotic antagonist, naloxone (narcan - emergency, blocks effects of opioids and reverses OD (respiratory depression)
- W/D: methadone taping (old school, prevents physical w/d, careful w/ drug transportation), clonidine-naltrexone detox (adjunct to w/d tx.), buprenorphine substitution (buprenorphine + nalazone = suboxone)

suboxone: cows scale to determine where patient is at in W/D

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22
Q

hallucinogens (intoxication, tx.)

A

LSD, mescaline, PCP (acid, shrooms)
- intoxication: paranoid ideas, anxiety, synesthesia, depersonalization, hallucinations
- tx: low stimuli, LSD (talk down), monitor VS, hydration

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23
Q

initial and active drug therapy

A
  • maintains abstinence from substances
  • demonstrates acceptance for own behavior (serious about tx.)
  • continues attendance for treatment & maintains sobriety (AA, NA, CA, group therapy, CBT, etc.)
  • attends relapse prevention program
  • verbalizes cues that pose increased risk of using
  • demonstrates new skills in dealing with troubling feelings (anger, loneliness, cravings, anxiety) - yoga, art
  • awareness for need of ongoing treatment
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24
Q

psychotherapy (types, issues, defenses, responses)

A
  • CBT, family, group, individual therapies
  • issues: recognizing signals that were cues to drinking & drugs, learn different responses (know triggers)
  • denial, rationalization, projection: common defenses
  • emotional responses - intense & can create anxiety (coping mechanisms learned)
  • responses of family & co-workers addressed (natural support system)
  • new coping skills to prevent relapse & ensure prolonged sobriety
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25
Q

outcome criteria for rehab

A
  • free of substance
  • acceptance of own behavior
  • continuation in therapy; attends relapse prevention program
  • aware of cues that stimulate drug abuse
  • drug free friends, able to form caring relationships
  • aware of addiction
  • develops new skills for coping
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26
Q

specific programs for rehab

A
  • AI-ANON, AI-A-Teen
    ** Alcoholics Anonymous, narcotics anonymous
  • residential programs
  • intensive outpatient programs
  • outpatient
  • continuing outpatient support groups
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27
Q

psychopharmacology (5 main)

A

1) naltrexone (revia): blocks opiates receptors, reduce alcohol and opiate preference
2) disulfiram (Antabuse): inhibits impulsive drinking with unpleasant side effects (headache, neck pain, flushing, sweating, resp. directress, n/v) - avoid all substances with ETOH in it
3) methadone hydrochloride (methadone): synthetic opiate, blocks cravings & effects of heroin, HIGHLY ADDICTIVE & produces W/D, used for detox & maintenance - not in itself a treatment option
4) buprenorphine (subutex oral, inj): for active W/D from opiates, also for maintenance
5) naltrexone hydrochloride: heroin, opiates, pathological gambling, detox, maintenance

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28
Q

facts about major depressive DO

A
  • one of most common DO (>13 million/year)
  • lifetime risk for MEN (5-12%), women (10-25%)
  • r/t: ethnicity, income, education, marital status: single mothers, unemployed, poverty HIGH RISK
  • single or recurring episodes
  • different from grief & bereavement
  • postpartum depression = 10% new moms
  • combined children & teens = 6%
  • elderly = 3.5 - 16%
  • nursing home = 15-20%
  • anxiety is COMMON
  • leading cause of disability in US
  • 1st appears at any age - Peaks 20s
  • later life: NO COMMON
  • course: variable - some rarely have readmission, others go for few years between episodes
  • indigence increases with chronic medical ds.
  • can exist with other psych ds.
  • recovery begins 3 months to 1 year (sooner the better prognosis)
  • worse prognosis if anxiety, psychosis, PD or severe sx.
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29
Q

risk factors of MDD

A
  • temperamental: high levels negative affectivity to stressful life events
  • environmental: adverse childhood experiences; stressful life events
  • genetic/physiological: first degree family members have increased risk for MDD
  • course modifiers: substance use, anxiety, BPD, chronic medical conditions (DM, obesity, CVD = all increase risk of MDD & affect tx. outcomes)
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30
Q

suicide risk of MDD

A
  • risk of suicidal behaviors exists at all times
  • common risk factor: past hx. suicide attempts/threats
  • most completely suicides are NOT preceded by unsuccessful attempts
  • other risks: male, single, living alone, hopelessness, BPD
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31
Q

theories of cause (unlikely, likely, 4 types)

A
  • unlikely: there is one cause
  • most likely: interconnection of genetics & life experiences
  • four common theories: biologic, psychodynamic, cognitive, learned helplessness
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32
Q

biological theories

A
  • genetic: familial tendencies apparent
  • biochemical: dysregulation of neurotransmitters - low serotonin, norepinephrine, dopamine
  • decreases in gaba and acetylcholine involved
  • hormonal regulation: elevated cortisol
  • stressors thought to trigger changes in levels of transmitters in brain
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33
Q

cognitive theory

A
  • psychological predisposition to depression
  • early life experiences lead to negative, illogical and irrational thoughts leading to emotions
  • process information in negative, illogical, and irrational ways
  • negative view of self, the world
  • a belief that nothing will change in the future
  • help by identifying negative thought patterns, scrutinize negative beliefs, learned to restructure
  • balanced, realistic, and appropriate alternatives
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34
Q

learned helplessness - seligman

A
  • anxiety in response to stress then depression
  • belief that there is no ability to control outcome
  • person is at fault, nothing can be done to change
  • relates to social groups: battered women, the aged
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35
Q

GRIEF vs. mdd

A
  • feelings of emptiness and loss
  • thoughts of bereaved
  • self esteem preserved
  • thoughts of wanting to join loved one
  • may move to MDD
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36
Q

grief vs. MDD

A
  • persistent depressed mood, plus other sx.
  • negative thoughts about self, self critical, pessimistic, rumination
  • worthlessness & self loathing are common
  • focus on ending life due to pain of depression
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37
Q

what are the 5 stages of loss

A

1) denial
2) anger
3) bargaining
4) depression
5) acceptance

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38
Q

comparison between MAJOR DEPRESSION & dysthymia

A
  • substantial pain & suffering
  • occupational, social & psychological affects
  • delusional or psychotic sx.
  • 60% recurrence
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39
Q

comparison between major depression & DYSTHYMIA

A
  • early, Late and insidious onset
  • chronic depressive sx.
  • sx. for at least 2 years
  • hard to distinguish from “usual” pattern
  • hospitalization rare
  • at risk for major depression
  • often seen in childhood teens
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40
Q

DSM 5 criteria for MDD

A
  • change in previous functions; sx. causes distress
  • 5 or more of following for 2 week period
  • depressed mood most of the day
  • anhedonia, anergia
  • wt. loss due to anorexia
  • insomnia/hypersomnia
  • feelings of hopeless, helpless, despair, guilt
  • decreased concentration
  • recurrent thoughts of death or suicidal ideation
  • SIG E CAPS
  • vegetative: bowel, appetite, sleep, sex
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41
Q

nursing diagnosis for MDD

A
  • risk for violence: self directed
  • ineffective coping
  • hopelessness
  • powerlessness
  • chronic low self esteem
  • impaired social interaction
  • social isolation
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42
Q

interventions for acute MDD

A

acute phase: 6-12 weeks
- if suicidal: hospitalization
- pharmacology
- psychotherapy
- ECT

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43
Q

interventions for continuation MDD

A

continuation phase: 4-9 months
- need to continue with medications, perhaps for life
- psychotherapy

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44
Q

interventions for maintenance MDD

A

maintenance phase (1 or more years)
- continuation of full dose antidepressants to prevent relapse

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45
Q

Electroconvulsive therapy (ECT)

A
  • induced grand Mal seizure -> alters activity if NTs (theory)
  • used for: drug resistant patients with MDD, MDD with psychotic features, bipolar manic, schizophrenia, schizoaffective disorder
  • 2-3 treatments/week for approximately 12 treatments
  • can be highly effective
  • side effects: confusion, disorientation early with memory deficits short term
  • may need maintenance treatments & medications
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46
Q

antidepressants 1st line of meds

A

serotonin reuptake inhibitors (SSRI’s)

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47
Q

SSRI medications

A
  • fluoxetine (prozac)
  • paroxetine (Paxil)
  • sertraline (zoloft)
  • citalopram (celexa)
  • fluvoxamine (Luvox)
  • escitalopram (lexapro)
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48
Q

SNRI’s medications

A
  • venlafaxine (efferxor)
  • duloxetine (Cymbalta)
  • pristique
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49
Q

NDRI (norepi Dopamine re-uptake inhibitors) medications

A
  • bupropion (Wellbutrin)
50
Q

tricyclics medications

A
  • amitriptyline (Elavil)
  • desipramine (norpramin)
  • doxepin (sinequan)
  • imipramine (tofranil)
  • nortryptiline (Pamelor)
51
Q

MAOI’s medications

A
  • phenelzine (nardil)
  • tranylcypromine (parnate)
52
Q

side effects of SSRIs

A
  • fewer than TCA’s, low lethality risk, less sedating
  • agitation, anxiety, sleep disturbance, sexual dysfunction, dry mouth, weight gain (WARNING: if agitation occurs early)
53
Q

side effects of NDRI antidepressants

A
  • fewer than TCA’s relatively safe
  • nausea, dizziness, headache, sedation, weight gain
54
Q

side effects of tricyclics

A
  • anticholinergics, cardiovascular arrhythmias, adverse reactions to other drugs (CAUTION: with elderly)
55
Q

side effects of MAOI’s

A
  • toxic: hypertensive crisis (CAUTION with etc meds)
  • avoid tyramine containing foods
  • waiting period between changing classes of medications
56
Q

possible toxic effects of SSRI’s

A
  • central serotonin syndrome: rare but life threatening
  • over activation of serotonin receptors…wait 5 weeks if changing from SSRI to MAOI
  • s/sx: abdominal pain, diarrhea, increased BP, confusion, muscle spasms, irritability, increased motor activity
  • if severe: high fever, shock, DEATH
57
Q

patient & family teaching SSRI’s

A
  • inform of side effects
  • 2-4 weeks to begin to address symptoms
  • do not stop drug abruptly…contact MD
  • avoid alcohol
  • if drowsy, avoid driving
  • inform RN of MD if agitation or anxiety occurs
58
Q

what is serotonin syndrome

A
  • rare and life threatening event associated with SSRI’s
  • over-activation of the central serotonin receptors caused by either too high a dose or interaction with other drugs
  • sx: abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, altered mental status (delirium), myoclonus (muscle spasms), increased motor activity, irritability, hostility, and mood change
  • severe manifestation: hyperpyrexia (excessively high fever), cardiovascular shock, or death
59
Q

describe Bipolar I

A
  • classic
  • most severe/mania with depression
  • alternating episodes of mania & depression
  • chronic mood disorder throughout life with normal periods between episodes (some pt. have more long lasting sx.)
60
Q

describe Bipolar II

A
  • hypomania with profound depression
61
Q

describe cyclothymic disorder

A

hypomania with mild to moderate depression for at least 2 years

62
Q

describe DSM-V criteria

A
  • mania: persistently & abnormally elevated expansive or irritable mood (1 week)
  • with 3 or more: inflated self esteem or grandiosity, decreased need for sleep, pressured speech & talkativeness, flights of ideas, racing thoughts, dis-tractability, increase in goal directed activity, excessive risk taking or extravagent behaviors
  • euphoric mania: initially “wonderful” turns to loss of control
  • dysphoric mania: AKA mixed state or agitated depression/irritable, angry, suicidal, hyper sexual, grandiosity, panic, pressured speech
63
Q

etiology bipolar DO

A
  • genetic: strong heritability (more than environment), strongest & most consistent risk factors
  • similar chromosome irregularities as schizophrenia on 13 & 15 (similar psychotic sx. in both)
  • complex interrelationship of NTs (norepi, dopamine, serotonin)
  • receptor site insensitivity
  • structural and functional brain changes found in prefrontal and temporal love areas
  • psychological impact: severe stressful event with predisposition
  • environment: high proportion among upper socioeconomic classes, higher education, more creative individuals, professionals, reason unclear, research in progress
64
Q

HYPOMANIA vs. mania

A
  • change in functioning from normal
  • disturbance in mood noticed by others
  • social/occupational impairments ABSENT
  • hospitalization NOT needed
65
Q

hypomania vs. MANIA

A
  • severe enough to affect occupational, social, or other relationships
  • hospitalization NEEDED
  • sx. not due to substances, etc.
  • sx: tangetiality, flight of ideas, grandiosity, clang association, hyperactivity
66
Q

nursing diagnosis for BPD

A
  • risk for injury
  • risk for other or self directed violence
  • ineffective coping
  • disturbed thought processes
  • impaired verbal communication
    -self care deficiet
  • disturbed sleep pattern
  • imbalanced nutrition
67
Q

acute phase BDP interventions

A
  • hospitalization to medically stabilize and for a structured and safe milieu PRN meds
  • lower physical activity, redirect energy increase food & keep hydrated, establish sleep, protect patient population, seclusion protocol
  • admission to first few days, not coherent, unstable, labile, cannot learn or comprehend)
68
Q

continuation phase BDP intervention

A
  • med compliance
  • prevent relapse
  • education
  • support
  • problem solving
  • psychotherapy
  • patient is coherent and can problem solve, learn
69
Q

maintenance phase BDP interventions

A
  • prevent relapse
  • periodic evals
  • support family, work, and social life
  • ongoing
  • discharged to home - prevent relapse)
70
Q

1st choice mood stabilizers

A
  • lithium carbonate
71
Q

lithium carbonate

A
  • effective in bipolar I acute and maintenance phase in 80% clients (effective, NOT CURE)
  • indefinite use for maintenance (vg for elation, grandiosity, flight of ideas, irritability, anxiety)
  • therapeutic: 7-10 days (routine blood levels)
  • therapeutic blood levels: 0.4 - 1.3 mEq/L
  • early signs of toxicity: <1.5 mEq/L
  • advanced toxicity: 1.5-2.0 mEq/L
  • severe: 2.0-2.5 mEq/L
  • death: >2.5 mEq/Lc
72
Q

common side effects of lithium carbonate

A

kidney failure
hypothyroidism

73
Q

pt/family teaching lithium carbonate

A
  • diet
  • hydration
  • monitor blood levels
  • some side effects subside with time (p. 241)
74
Q

anti-epileptic drugs

A
  • effective for mood disorders, impulsive/aggressive behavior, controlling mania, rapid cycling, mood swings, impulsivity, mania & depression
  • valproate (depakote), carbamazepine (tegretol), lamotrigine (lamictal)
  • can be used with or without lithium
75
Q

valproate (depakote)

A
  • good for lithium non responder, mania, rapid cycling, prevention
76
Q

carbamazepine (tegretol)

A
  • treatment resistant patients
  • blood levels for first 8 weeks -> increase liver enzymes
77
Q

lamotrigine (lamictal)

A
  • 1st line tx. for acute & maintenance
  • watch for RASH (LIFE THREATENING)
78
Q

antipsychotics/anxiolytics

A
  • atypical (second gen) antipsychotics in acute phase to sedate and rest, and manage agitation, insomnia, mood, violence, etc.
  • ex: olanzapine (zyprexa), ziporasidone (geodon), aripiprazole (abilify)
  • anxiolytics: lorazepam (Ativan) -> manage agitation seen in acute phase
79
Q

health teaching for BDP

A
  • awareness of illness, signs, relapse
  • need for medication compliance for life
  • alcohol, other drugs of abuse
  • sleep hygiene
  • psychosocial strategies: work, interpersonal issues
  • support network for patients and families
80
Q

what is borderline personality disorder

A
  • personality traits are inflexible & maladaptive, pervasive pattern of abnormality exists
  • cause significant functional impairment or subjective distress
  • limited ability to achieve trust, autonomy, independence, and meaningful relationships
  • may not affect all areas of life
  • patients with PD seek treatment with crisis or trauma
81
Q

what is antisocial personality disorder

A

a pattern of disregard for, and violation of, the rights of others
- commonly referred to as sociopath
- antagonistic behaviors such as being deceitful and manipulative for personal gain

82
Q

what are the 4 common characteristics of borderline personality and antisocial personality disorder

A

pervasive patterns exists
- inflexible and maladaptive response to stress
- disability in working and loving
- ability to evoke interpersonal conflict
- capacity to “get under the skin” of others

83
Q

what is the splitting major defense mechanism

A
  • the inability to view both positive and negative aspects of others as a whole
84
Q

what are nursing diagnosis for borderline PD

A
  • ineffective coping
  • anxiety
  • self mutilation
  • risk for other-directed violence
  • impaired parenting
  • social isolation
  • disturbed thought process
  • hopelessness, helplessness, risk for suicide
85
Q

nursing diagnosis for antisocial personality disorder

A
  • risk for other0directed violence, defensive coping, impaired social interactions, ineffective health maintenance
86
Q

what is the limit setting for borderline personality and antisocial personality disorder

A

1) limits: clear, consistent, enforceable
2) team: aware of limits, need for consistency (primary nurse)
- communicate expectations to client
- be realistic (which behaviors to limit)
- clear consequences of exceeding limits
- follow through with consequences in non-punitive manner
- assist client to limit own behavior
- assess insight and motivation to change
- avoid power struggles

87
Q

what is superficial cutting

A

self destructive behavior

88
Q

interventions for impulsive behaviors

A
  • identify antecedent needs and feelings
  • discuss current/previous impulsive acts
  • explore impact on self and others
  • refer or teach needed coping skills
  • discuss alternatives to impulsive behavior
  • role play new skills
  • provide feedback
  • support new skills
  • identify strengths and effective communication
89
Q

what are the specific interventions of borderline personality disorder

A
  • set clear, realistic goals
  • be aware of manipulative behaviors
  • clear, consistent boundaries/limits
  • behavioral problems: review therapeutic goals and tx. boundaries
  • avoid rejecting, rescuing
  • assess for suicidal, self mutilating behaviors
  • assess for “splitting” esp. in relation to staff (select primary nurse, adhere strictly to care plan, be aware of “all good, all bad” phenomena)
  • meds PRN, antidepressants, antipsychotics
90
Q

specific interventions for antisocial BPD

A
  • set clear, realistic limits on specific behaviors
  • all limits adhered to by all staff
  • document objective physical signs of manipulation or aggression
  • provide clear boundaries, consequences
  • guard against letting client make you feel guilty
  • guard against bing manipulated
91
Q

what is the epidemiology of schizophrenia

A
  • devastating disease of the brain; multifactorial cause likely involving chronic or recurring psychosis, with each relapse there is increased dysfunction
  • affects thinking, language, emotions, social behaviors, and ability to perceive reality
  • age of onset: late teens, mid 30s (1st episode), early 20s (males poorer prognosis with negative/cognitive ds), females (mood sx.)
  • slow insidious onset of sx
  • affects <1% of population, 40-50% have substance abuse
  • 10% recover, 55% chronic sx, 35% intermittent course
  • suicide -> leading cause of death, depression common
92
Q

theory of causes

A
  • combination of inherited genetic factors & extreme nongenetic factors affecting genes or direct injury to brain
  • origins: conception & “something more”
  • pregnancy & birth complications: hypoxia
  • disease: brain chemistry and activity
  • increase: dopamine, decreased serotonin, increased norepi, decreased gaba, all play a part
  • neurotransmitters & neural circuits are disrupted
  • atrophy of frontal lobe, cortex, cerebellum
  • enlargement of lateral cerebral ventricles = less grey matter, differences in white matter connectivity
  • overall decrease in brain volume
  • genetic contribution = increased in relatives
93
Q

what are prodrome symptoms

A
  • sx. from 1 month to 1 year before 1st psychotic break
  • clear deterioration in functioning
  • withdrawal, loneliness, depression in adolescents
  • plans for future vague, unrealistic
  • acute or chronic anxiety
  • pulling away from family, friends, school, activities
94
Q

DSM 5 diagnostic criteria

A

2 or more during 1 month period:
- delusions, hallucinations, disorganized speech & behavior, negative symptoms
- social/occupational dysfunction (1 or more areas are below premorbid functioning)
- duration: continuous signs atleast 6 months
- all other mental, physical, developmental diseases have been ruled out

95
Q

paranoid schizophrenia

A
  • delusions
  • hallucinations
  • no disorganization
  • later onset
  • higher functioning
96
Q

positive symptoms of schizophrenia

A
  • hallucinations
  • delusions
  • bizarre behavior (clothing, appearance, social, sexual, aggressive-agitated, repetitive)
  • formal thought disorder (derailment, tangentiality, incoherence, illogicality, circumstantiality, pressure of speech, distractible speech)
  • more florid symptoms and respond to meds
97
Q

negative symptoms of schizophrenia (6)

A
  • anhedonia (w/o pleasure): a reduced ability or inability to experience pleasure in everyday life
  • avolition (w/o making decision): loss of motivation; difficulty beginning and sustaining goal directed activities; reduction in motional or goal directed behavior
  • asociality: decreased desire for, or comfort during, social interaction
  • affective blunting: reduced or constricted affect (flat, inappropriate, bizarre)
  • apathy: decreased interest in, or attention to, activities or beliefs that would otherwise be interesting or important
  • alogia: reduction in speech (aka: poverty of speech)

slides:
- affective blunting: flat, inappropriate, bizarre
- anergia: lack of energy
- anhedonia: lack of pleasure
- avolition: apathy
- alogia: poverty of ideas/content of speech, thought blocking
- can be more debilitating and hard to treat with meds

98
Q

hallucinations (types)

A
  • auditory: hearing voices that do not exist, voices are projections of own inner thoughts
  • visual: seeing a person or object that does not exist in the environment
  • tactile: feeling strange sensations when no external stimulus exists
  • olfactory: smelling odors not actually present in the environment
  • gustatory: tasting sensations that have no stimulus
99
Q

delusions (types, firm/fixed beliefs)

A
  • ideas of reference: misconstructing trivial events/remarks and giving them personal significance
  • persecution: believing one is being singled out for harm by others
  • grandeur: believing one is a powerful, important personage
  • somatic: false belief that the body is changing
  • jealousy: false belief that one’s significant other is unfaithful
100
Q

cognitive symptoms of schizophrenia

A
  • affect 40-60% of people with the disorder
  • one of the major disabilities
  • difficulty with attention, memory, executive functions (decision making, problem solving)
  • disorganized speech & behavior & inappropriate affect stems from this

slides:
- inattention, easily distracted
- impaired memory
- poor problem solving skills
- poor decision making skills
- illogical thinking
- impaired judgement

101
Q

common nursing diagnosis

A
  • altered (disturbed) thought process
  • disturbed sensory perception
  • risk for harm to self and others
  • impaired verbal communication
  • social isolation
  • risk for loneliness
  • self care deficit
  • compromised family coping
102
Q

what is altered disturbed through process

A

conversation is derailed by unnecessary and tedious details (circumstantiality)

103
Q

acute phase schizophrenia

A
  • crisis intervention: safety & med stabilization, looking for decrease in intensity & frequency of sx.
  • may need hospitalization, structure & support, meds, limit setting, directive communication, evaluation, short day then DCed to community
104
Q

maintenance phase schizophrenia

A
  • pt./family psychoeducation
  • self effect management
  • cognitive & social skills enhancement
  • ID signs of relapse
  • attends to self care
  • social & work functioning
105
Q

communication for hallucinating client

A
  • ask directly about hallucinations
  • watch for cues that client is hallucinating
  • avoid reacting to hallucinations as if they are real
  • do not neglect client experience: respond to feelings
  • offer your own perceptions
  • focus on reality based diversion
  • be alert to client anxiety
106
Q

communication for delusional client

A
  • be open, honest, reliable
  • be matter-of-fact and calm
  • ask client to describe delusions
  • avoid arguing but interject doubt
  • focus on feelings the delusions generate
  • once delusion is described, do not dwell on it; set firm limits on time you will devout to them
  • observe events that trigger delusions; discuss w/ pt.
  • validate any true part of the decision
107
Q

ways of coping with voices and worry thoughts

A
  • distracting: listening to music, reading aloud, counting backwards, describing an object in detail, watching TV, exercising, cleaning house, bath, singing, play a instrument
  • interacting: telling voices to go away, agreeing to listen only at certain times, talking to friend, family, phoning a helpline, going to a drop in center
  • physical: taking extra medication-call MD, breathing exercised, relaxation exercises
108
Q

additional nursing interventions

A
  • brief interactions, several times a day
  • monitor safety ADLs
  • encourage socialization, even is only 1:1
  • reorient to reality
  • support
  • monitor symptoms and medicate as necessary
  • psychoeducation when ready
109
Q

1 generation antipsychotic drug therapy

A
  • less expensive than 2nd generation
  • are D2 receptor antagonists in both limbic and motor centers
  • motor = EPS -> add antiparkinsonian drugs, anticholinergics -> in the 1950’s (moderate EPS: “benchmark” drug)
110
Q

1st generation antipsychotic drug therapy examples

A
  • chlorpromazine (thorazine): 1st antipsychotic (1950s), moderate EPS (“benchmark” drug)
  • haloperidol (haldol): high EPS, used w/ aggressive pts. w/o hTN, good for elderly
  • fluphenazine (prolixin): among the least sedative, high EPS
  • thiothixene (Navane): high EPS, high incidence of akathisia
  • haldol decanoate: IM given Q3-4 weeks
  • prolixin decanoate: IM given Q2-4 weeks
111
Q

2nd generation antipsychotic drug therapy

A
  • emerged in 1990’s
  • often 1st line: Low EPS side effects, wt. gain, glucose, cholesterol increase (metabolic syndrome)
  • risk for: DM, HTN (works on +/- sx.)
112
Q

2nd generation antipsychotic drug therapy examples

A
  • clozapine (clozaril): used in refractory patients - weekly, WBC, agranulocytosis 0.8-0.1%
  • risperidone (risperdol): wt. gain, can be given IM
  • olanzapine (zyprexa): wt gain., Qday dosing, may interact with SSRI’s
  • Quietiapine (Seroquel): risk of TD & NMS low
  • Ziprasidone (geodon): ECG changes OQ prolonged, good with depressive symptoms, low wt. gain, IM
113
Q

antipsychotic side effects: anticholinergic sx.

A
  • dry mouth
  • urinary hesitancy/retention
  • constipation
  • blurred vision
  • photosensitivity
  • dry eyes
  • ejaculatory inhibition
114
Q

antipsychotic side effects: extrapyramidal effects + tx.

A
  • pseudoparkinsonism: artane, cogentin
  • acute dystonic reaction: Benadryl (ocluogyric crisis, opisthotonus, laryngeal dystonia)
  • Akathisia: D’C drug, benzes
  • tardive dyskinesia: no treatment
115
Q

antipsychotic side effects: 2nd generation

A
  • metabolic syndrome: glucose dysregulation
  • increased cholesterol
  • wt. gain 20-35% of body weight
  • risk for: DM, HTN, atherosclerosis
  • Emergency! -> Neuroleptic Malignant Syndrome

caused by sudden reduction in dopamine activity
- severe muscle rigidity, fever, HTN, tachycardia, diaphoresis, tachypnea, confusion
- occurs in 1% of those on antipsychotics
- tx: hold meds, supportive care, monitor fluids & lyres, ICU, bromocriptine

116
Q

schizoaffective disorder

A
  • sx. of schizo & mood disorder, somewhat controversial, DSM IV in ‘87
  • uninterrupted period of illness with major mood disorder (MDD or mania) with criteria A of schizophrenia
  • delusions or hallucinations <2 weeks, during lifetime
  • sx. of mood disorder present throughout illness
  • specific bipolar or depressed types
  • treat with antipsychotics, mood stabilizers, antidepressants
117
Q

community mental health

A
  • characteristics
  • treatment outcomes
  • interventions
  • settings
  • assertive community treatment (ACT)
118
Q

chronic mental illness

A
  • extends from acute to long term
  • marked by persistent impairment of functioning
  • deinstitutionalized to community mental health
  • erodes basic coping, quality of life, contact with others, employment, self image
119
Q

noncompliance

A
  • control
  • reluctance to give up behavior (smoking, drugs)
  • secondary gains from sick role
  • effects of the illness on the brain
  • negative family influences
  • inability to understand
  • side effects of medications
120
Q
A

NUR 3015 exam 1 (3 decks)

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