1
Q
Peplau’s 4 phases of the Nurse-Patient Relationship
A
Orientation: pt and nurse mutually identify the pt’s problem; establish trust
Identification: pt identifies with the nurse accepting help for the problem
Exploration: pt makes use of the nurses’s help (puts into action. some call this the exploitation phase)
Resolution: pt accepts new goals and fees self from the help of the nurse
2
Q
Primary prevention
A
- identifying persons at risk
- reinforcing existing coping responses
- education/teaching
- collaborate w/patients and families
- measures must be culturally sensitive and congruent w/person’s values & belief system
3
Q
secondary prevention
A
- measures are used to curtail the disease process
- case management is a good example of secondary prevention
- once sxs are identified and interventions are initiated
- treatment focuses on minimizing long-term disability
4
Q
tertiary prevention
A
- minimize relapse and chronic disability
- institute outpatient treatment plans for patients to maintain best baseline in community setting
- Examples: ongoing health education, supportive housing, relapse prevention programs, fostering of patients adaptive coping behaviors, reinforcement of patient’s strengths
5
Q
essential qualities of PMHN
A
- therapeutic use of self
- genuineness and warmth
- empathy
- acceptance
- maturity and self-awareness
- leadership
6
Q
the limbic system
A
- the part of the brain associated with behavior, physiologic changes and emotional “tone” or feeling
- responses to mood, memory, and learning.
- temporal cortex
7
Q
the brain stem
A
- midbrain, pons, medulla
- central nerve pathway that receives and sends impulses between the brain and the rest of the body
- important in respect to the hypothalamus
8
Q
hippocampus & amygdala
A
- structures generally considered being part of the limbic system
- recent studies indicate that dysregulation may play a role in exaggerated stress responses found in various anxiety disorders such as PTSD
- amygdala: modulates fear response. converts short term experiences to long term ones.
9
Q
hypothalamus
A
- influences sensory and motor tracts that meet and diverge in the brain stem for normal physiologic maintenance
- plays a role along with the pituitary gland, in producing stress and anxiety responses (cortisol).
- HPA axis: hypothalamus, pituitary, adrenal
- cortisol: changes in people’s behaviors
10
Q
dopamine
A
- largely secreted in the substantia nigra
- hyperactivity of the dopaminergic system is implicated in schizophrenia and mania
- hypoactive dopamine systems are believed to contribute to Parkinson’s Disease and Depression
- Dopamine plays a major role in addiction because drugs (cocaine, opiates, alcohol) increase the amount of dopamine to act on D2 receptors and stimulate the reward system in the brain
- Id stage of Freud’s theory
11
Q
serotonin (5-HT)
A
- secreted in the raphe nuclei (brain stem)
- hypothesized to play a significant role in states of consciousness, mood, depression, anxiety, and possibly schizophrenia
- highest concentrations in blood platelets and GI tract: nausea at onset of taking SSRIs
- alters platelet count- anticoagulation effect
- nausea at onset
- helps with anxiety and depression
12
Q
GABA
A
- inhibitory in nature
- serves as the brains modulator and limits the effects of excitatory transmitters
- inhibits neuronal transmission by hyperpolarizing the receptor site to render it less sensitive to continual stimulation (anti-kindling effect)
- low levels of brain GABA predispose a person to convulsions (seizures) and disorganized sensorimotor function
- benzos enhance GABA binding to receptor sites and are effective in treating anxiety
- limits anxiety and mania
13
Q
Anticonvulsants
A
- work in a similar manner to GABA to modulate hyper-stimulation by their anti-kindling effect to prevent seizures
- the efficacy of anticonvulsants as mood stabilizers stem from these properties
14
Q
goals of mental status exam
A
- gather baseline data about the patient’s functioning
- identify actual and potential problems
- assist the team in making accurate psychiatric and medical diagnoses
- tool for assessing psychological dysfunction
15
Q
general description of MSE
A
First part.
A. Appearance
B. Behavior & Psychomotor activity
C. Attitude toward examiner
16
Q
MSE- mood & affect
A
Second part.
mood- assessment of current emotional state. pervasive feeling or state of mind.
affect- flat: unresponsive; bipolar: expansive
appropriateness- respectful boundary
17
Q
MSE: speech
A
third part.
- tone
- quality
- express thoughts, ideas, feelings?
- paranoia: whisper
- trauma: hesitancy
- bipolar: spontaneous, rapid
18
Q
MSE: perceptual disturbances
A
fourth part.
- hallucinations: false sensory stimuli. auditory most common
- delusions: fixed false belief. No way to change patients’ mind.
- illusion: misinterpretation of external stimuli. Seeing a shadow, thinking it’s a person.
19
Q
Neurobiological Theory
A
- all behaviors are a reflection of brain function
- all thought processes represent a range of functions mediated by nerve cells in the brain (neurons)
- brain is the origin of disorders of affect, perception, and cognition
20
Q
MSE- thought
A
thought process: manner in which thoughts are associated/connected.
thought content: subject matter that occupies the person’s thoughts. Congruent with mood & affect.
21
Q
MSE- sensorium & cognition
A
- alertness & LOC
- orientation: a&o? eye contact?
- memory: ability to have recent & remote memory. 3 objects/words test.
- concentration: very important. sustain thoughts. write down discharge instructions.
- abstract thinking: get past concrete concepts. Use of proverbs. Indiv. with schizophrenia and dementia have a hard time with this.
- fund of information & intelligence: everyday information. news, education, grammar.
22
Q
MSE- impulse control
A
ability to control aggressive impulses. Explore history of violence, drugs, alcohol abuse.
23
Q
MSE- insight and judgement
A
patient’s ability to talk about illness. how they handle their emotions, previous symptoms in the past.
24
Q
MSE- reliability
A
reality testing. how they judge the world outside for themselves and manage feelings. Common for competency evaluation.
25
DSM Axis I
- clinical disorders: schizophrenia, bipolar, depression
- biological
- substance abuse
26
DSM Axis II
- personality disorders
- mental retardation
- developmental disorders
27
DSM Axis III
- general medical conditions.
| - intertwine with medical and psychiatric conditions. DM, HTN, stroke.
28
DSM Axis IV
- psychosocial and environmental problems
| - events and problems that affect diagnosis. family, relationships, homelessness.
29
DSM Axis V
- global assessment of functioning (GAF)
- functionality on a scale of 0-100.
- changes frequently
- healthiest person usually in the 80s.
- lower values- suicidal.
30
elements of psychosocial assessment
- recent stressors
- strengths
- current medications
- hx of psychiatric treatment
- substance use, abuse, dependence
- quality of support systems and strengths
- presence and hx suicidal/homicidal ideations
- present and past coping skills
- self-concept, self-esteem, strengths
- spiritual and cultural needs
- legal and occupational hx
31
Freud's stages of development
oral stage: birth-18 months. fixating, oral gratification. narcissistic.
anal stage: 18mo-3yr. toilet training. translates to releasing (flamboyant and compulsive) and holding in(anal retentive).
phallic: 3-6. attracted to parent of opposite sex. object relations.
latency: 6-12. internal and external demands. super ego.
prepuberty/adolescence: 12-15.
genital stage: 15-adult. heterosexual behavior becomes evident. personality develops in the 1st 5 years.
32
Freud's psychoanalytic theory
anxiety plays a central role in maladaptive behavior
33
Erikson's stages of ego development
```
birth-18mo: trust vs. mistrust
18mo-3yr: autonomy vs. shame
3-6yr: initiative vs guilt
6-12: industry vs. inferiority
12-20: identity vs. role confusion
20-30: intimacy vs. isolation
30-65: generativity vs. stagnation (self-absorption)
65-death: ego integrity vs. despair
```
34
basis of Maslow's theory
- needs are hierarchical: lower level needs are essential to survival and must be met prior to achievement of higher level needs
- goal: self actualization. "a sense of fulfillment in life and actualization of one's potential."
- supports human growth. needs motivate behavior.
35
Maslow's hierarchy
(most basic to goal)
- physiologic: food, shelter, water.
- safety: security, order, physical safety, avoiding harm.
- love and belonging: affection, companionship, group identification
- esteem and recognition: self-esteem, respect, prestige
- self-actualization: unique potential
36
Harry Stack Sullivan's Interpersonal Theory
ties individual behavior and personality development to interpersonal relationships
- Personal or self-concept: good me, bad me, not me.
37
Interpersonal theory application to nursing
creates a nurse/patient relationship that:
- creates an environment of acceptance that instills hope
- helps patients understand their situational stressors about relationships, related sxs and maladaptive behaviors
- improves pt's self esteem & worth, dignity
- promotes healthier social interaction and interpersonal skills
38
Bowlby's attachment theory
- early key interactions with primary caregivers play a key role in how an individual perceives themselves and others (quality of relationships)
- the infant internalizes early child-caregiver experiences and forms cognitive models or schemata
- if the person deserves care (self-perception)
- whether others are reliable providers of care (perception of others)
seen a lot in anxiety disorders
39
Id
first structure to develop in personality, operates on the pleasure principle to reduce tension
characterized by:
- primary process thinking
- irrational thinking, not based in reality
40
Ego
CEO of the mind
- mediating between the drives, forces or conflicts of the Id and Superego. Anxiety can develop
- maintains a reality orientation for the person
- keeps strong forces of the Superego from being extremely inhibitive
- keeps the Id from causing person from being overly exhibitionistic
41
Superego
- our conscience, a residue of internalized values and moral training of early childhood
- two main functions: reward, punishment
inhibitive. imbedded moral reasoning
42
Ego defense mechanisms
- Denial
- Displacement
- projection
- rationalization
- reaction formation
- regression
- sublimation
- suppression: only conscious effort.
- repression: most basic defense mechanism.
43
Psychoanalytic Theory chain of events
stimulus--drive--response--resolution
- human beings are stimulus driven: external and internal stimuli
- stimuli produces state of excitation known as drive or instinct
- response: engages Id, Ego, Superego
- resolution
44
differential diagnosis
- temporal lobe epilepsy, Parkinsonism
- tumor, stroke, brain trauma, TBI
- infectious encephalitis, neurosyphilis, AIDS
- Autoimmune (e.g. Lupus)
- Alzheimer's, Huntington's
- Drug induced: stimulants, amphetamines, cocaine
- hallucinogens
- withdrawal from ETOH, barbiturates, anticholinergics
45
Psychiatric Disorders with Psychotic Symptoms
Axis I: major depression with psychotic features; bipolar disorder, manic episode; schizoaffective disorder (bipolar presentation); delusional disorders
Axis II: Personality disorders (clustered A,B,C. these are A)
- paranoid, schizotypal, borderline personality disorder
46
major types of schizophrenia
- catatonic
- disorganized
- paranoid
- undifferentiated
- residual
47
catatonic schizophrenia
- not seen very often
- stuporous state
- mute
- stay rigid in one position for long periods of time
48
disorganized schizophrenia
- looseness of association
- confusion
- inappropriate affect
- hard time focusing
49
paranoid schizophrenia
- 1 or more delusions
- persecutory, auditory hallucinations with a single theme
- sensitive to environment
- possibly history of abuse
50
undifferentiated schizophrenia
- most common form
- pronounced hallucinations
- combination of everything
51
residual schizophrenia
- process "burns out"
- absence of pronounced delusions.
- end stages of schizophrenic process
52
definition of psychosis
a person's symtom state that refers to the presence of reality misinterpretations, disorganized thinking, and lack of awareness regarding true and false reality
53
definition of hallucinations
distorted perceptions of reality e.g. auditory, visual, olfactory, gustatory, or tactile perceptions
we are most concerned with command hallucinations that are suicidal or homicidal in nature
54
types of delusions
fixed false beliefs.
- grandiose
- somatic
- nihilistic
- persecutory/paranoid
- religious
- bizarre
- ideas of reference
55
definition of illusions
misinterpretations of actual events
- external stimuli
- sensory impression
56
positive symptoms of schizophrenia
- hallucinations
- delusions
- illusions
- disorganized thinking (Alogia)
- bizarre behavior
57
negative symptoms of schizophrenia
- flat affect
- anhedonia: decrease in pleasure
- avolition: decrease in motivation
- social isolation (secondary to poverty of speech)
- diminished self-care: ADLs
58
typical antipsychotics
- prolixin
- haldol
- thorazine
only suppress dopamine
severe control of D2 receptor sites leads to EPS.
long term use: tardive dyskinesia
59
atypical antipsychotics
- abilify
- risperdal
- zyprexa
- seroquel
- geodon
- clozaril
- invega
60
how to test for tardive dyskinesia
AIMS test: Abnormal Involuntary Movement Scale
61
medications used to counteract EPS sxs
- Symmetrel
- Cogentin: most popular
- Benadryl: EPS and can't sleep
- Artane: older med
- Inderal: akathisia
62
major side effects of atypicals
- weight gain
- type II diabetes
- hypercholesterolemia
(syndrome X)
63
Clozaril
first atypical on the market. The white blood count (WBC) must be monitored by law because of the concern for agranular cytosis – a WBC count below 2.0 that puts a patient at risk for life threatening infections. Patient education is very important with teaching the patients to monitor signs of infection. There has been recent concerns over myocarditis. WBC monitoring starts weekly for the first 6 months, then bi-weekly for 6 months and then monthly. Concern for Metabolic Syndrome.
64
Zyprexa
very effective for mood stylization of psychotic symptoms but along with Clozaril is the biggest culprit for the metabolic syndrome. Can see hugh weight gains and this can be a reason to discontinue treatment.
65
Seroquel
helpful medication for calming of patient and used to assist with sleep. Can be very sedating at low doses.
66
Risperdal
he most effective in the group of atypicals to deal with hallucinations and other psychotic symptoms. Can see EPS. Can cause increase in Prolactin levels which can effect menses in females and breast tissue/cyst formation in males and females. Also comes in long acting injectible form known as Risperdal Consta, given every 2 weeks.
67
Abilify
one of the more dramatic contributions in this class of medications. You can see improvement in patient alertness and mood symptoms. Also has an FDA indication as an “add-on” to anti-depressant for treatment resistant depression.
68
Geodon
Good overall symptom control and can activate patients similar to Abilify.
69
Invega
one of the newer meds. Is the improved version of Risperdal, controlling positive symptoms but with fewer EPS and Prolactin issues.
70
psychosocial interventions and psychotherapy
- psychoeducation: using guidelines from NAMI
| - social skills education: vocational and career educational counseling
71
symptoms of childhood depression
Behavioral problems including:
- aggression
- apathy
- sleep disturbances
- weight loss
- irritable versus sad or depressed mood
- must be assessed for suicide
72
symtoms of adolescent depression
- prevalence increases with age and is more common in girls
- may express somatic complaints and have irritable mood
Behavioral problems including:
- poor academic and social performance
- suicidal ideations
- apathy
- social withdrawal
- rebelliousness
- low self-esteem
- aggressive behaviors
- risky behaviors e.g. substance use, promiscuity
73
older adulthood depression
- may present with atypical features such as low mood which may be masked: anxiety and cognitive impairments may be prominent features
- late onset variables include: biological, psychological, and social factors
- triggers: bio/psycho/social. debilitating aches and pains.
- shift in life: loss, guilt, lack of trust, shame.
- social: isolation, loss, loneliness
74
criteria for MDD
a period of 2 weeks during which there are 5 of the following sxs that represent a change from previous funtioning: at least one is either depressed mood or anhedonia
- alterations in appetite or weight
- sleep disturbance
- fatigue
- concentration disturbances
- feelings or worthlessness, inadequacy, guilt
- recurrent thoughts of death or suicidal ideations, plans, or attempts
75
diagnosis of dysthymia
Depressed mood for most of the day, more days than not, as indicated by either subjective acct or observation by others for at least 2 years:
- poor appetite or overeating
- insomnia or hypersomnia
- low energy or fatigue
- low self-esteem
- poor concentration or difficulty making decisions
- feelings of hopelessness
76
treatment modalities: depression
- psychotherapy: interpersonal connectedness
- pharmacotherapy: management of side effects.
- ECT: induction of a grand mal seizure. hits memory center, helps with forgetting depressive thoughts. used a lot in older indiv. Never a 1st line tx.
- light therapies: lamp of artificial light equal to that of outdoors. Important for pregnant women. Reduces melatonin secretion.
77
4 tasks of mourning
1. accept the reality of loss: make sure it doesn't become maladaptive
2. work through the pain of grief
3. adjust to environment in which person is missing
4. emotionally relocate the deceased and move on with life.
78
4 grief reactions
1. chronic grief: never stop grieving
2. delayed grief: not sufficient grieving. loss of first piggybacks onto second to feel both losses at once.
3. exaggerated grief response: intensification of mourning/grieving. can lead to alcoholism.
4. masked grief reaction: maladaptive. masked by physical symptom similar to that of deceased.
79
Erikson: birth-18mo
- trust vs. mistrust
| - difficulty relating to people
80
Erikson: 18mo-3yrs
- autonomy vs. shame
- can create self-doubt
- shy, hiding
81
Erikson: 3-6yrs
- initiative vs. guilt
- self-directed towards having a purpose, filling their time
- inadequacy can develop- guilt
82
Erikson: 6-12 yrs
- industry vs. inferiority
- feel competent, move forward in life
- difficulty in learning, can't assert self
83
Erikson: 12-20 yrs
- identity vs. role confusion
- firmer grasp of self, not feeling as confused
- able to start asserting self, knowing self
84
Erikson: 20-30 yrs
- intimacy vs. isolation
- to be able to love, connect with people
- inability= isolation
85
Erikson: 30-65 yrs
- generativity vs. stagnation (self absorption)
- how adult is able to be productive, work on core of their being
- moving forward in life
86
Erikson: 65yrs- death
- ego integrity vs. despair
- able to find meaning through lifetime achievements
- memory is important component
87
denial
refusal to admit a painful reality. treat it like it doesn't exist
88
displacement
redirect negative urges or feelings onto something safer
89
projection
blaming own feelings/thoughts on other people. common in paranoia.
90
rationalization
effort to replace or justify acceptable reasons for beliefs/thoughts
91
reaction formation
anxiety-producing or unacceptable emotions and impulses are mastered by exaggeration (hypertrophy) of the directly opposing tendency
92
regression
to an earlier developmental stage
93
sublimination
normal form of dealing with undesirable feelings/thoughts
94
suppression
only conscious defense mechanism. deliberate forgetfulness.
95
repression
most basic. purposeful forgetting of dangerous thoughts.
96
purpose of the therapeutic alliance
developing trust and assessing, while working toward resolving the patient's presenting symptoms
97
introduction phase
- establish professional boundaries
- diagnostic evaluation
- mutually sets treatment objectives (termination begins in this phase)
- watch out for excessive pt disclosures
98
working phase
- implementation of treatment plan
- measure/evaluate outcomes of care
- re-prioritize plan of care as needed
- countertransference (nurse to patient)
99
termination phase
- review patient's progress
- establish long-term plan of care
- focus on self-management strategies
- disengage from relationship
- refer to other services as needed
100
differences between dementia and depression
dementia:
- shallow affect
- memory impairment
- more insidious
- not oriented
- does not respond to treatment
depression
- rapid onset, stressor related
- always alert and oriented
- responds to treatment
Acute Psych
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