MENTAL HEALTH

OCD
 Rituals to reduce anxiety d/t unacceptable thoughts, images, or impulses.
 Client unaware of how long they’ve been doing rituals
 Let client be aware of time & redirect
 Don’t suddenly remove rituals – Can cause panic – Gradually limit it
 Care:
o Help client identify what causes the anxiety
o Over positive feedback for non-rituals
o Nonjudgement & empathy using reflective communication
o CBT (i.e. thought stopping)

ADHD
 Give calm, structures, organized, & consistent environment
 Usually continues into adulthood
 Offer fewer choices to reduce overstimulation/overwhelm
 School should accommodate for needed services
 Deep breathing helps slow down mind/body (blow up a balloon)
 Symptoms:
o Poor esteem
o Risk for depression/anxiety/substance abuse
o Work/school failure
o Poor interaction with others

ACUTE STRESS DISORDER (ASD)

 Following traumatic/stressful event
 Intrusive memories of event, negative mood, dissociative symptoms, arousal/reactivity symptoms (sleep problems, concentration, startled, etc)
 If symptoms continue over a month, becomes PTSD
 Interventions:
o Assess suicidal ideation
o Assess for ineffective coping (drugs/alcohol)
o Impact of ASD on work, relationships, sleep, ADLs
o Explain feelings/symptoms are normal to help alleviate anxiety
o Explore coping strategies used in the past
o Encourage talking about event
 Resilient people: deal with stress with stress-reduction techniques

PTSD
 Symptoms:
o Re-experience event
o Avoiding reminders of event
o Increased anxiety & emotional arousal
o Guilt/Shame
 Too much anxiety poses danger to self & others
 Let client know it’s not their fault

ANXIETY DISORDERS
 Social anxiety: Fear of social/performance situations
 Generalized anxiety: Everything
 Fear something will happen
 Shaking, hyperventilating, palpitations
 Do not leave client alone! Stay with them in the room!

SUSPECTED ABUSE
 If suspected, continue getting history, physical assessment, & report signs of abuse
 Examine parent-child interaction & document inconsistencies
 When interviewing child:
o Private
o Honest about reporting it
o Appropriate language
o Avoid assumptions
o Don’t communicate anger, shock, disapproval
o Let them know it’s not their fault
 Child abuse; ask:
o Caregiver’s perspective on child
o Methods of discipline
o Routine caregivers
o Caregiver stress, coping, support
o Who cares for child when caregiver is away?
 Abusers:
o Overly critical of child
o Confuses punishment with discipline
o Poverty, violence, illness, lack of support, isolation
 o Low esteem
o History of substance abuse
o Lacking parenting skills (teenagers)
o Resentment/Rejection
o Low tolerance
o Hides injuries
o Not concerned about injuries
o Abusers aren’t always out of control or agitated!
 Intimate Partner Violence occurs in EVERYONE (rich, poor, straight, gay, etc)


DELUSIONS
 Persecutory: Others “out to get me”
 Ideas of Reference: Events refer specifically to client
 Grandiose: Special importance or have powers
 Somatic: False ideas about bodily functions
 Interventions:
o Don’t argue/challenge the belief (increase more anxiety)
o Reinforce reality
o Encourage participation in real events

DISSOCIATIVE IDENTITY DISORDER

 2 or more identities
 Identities form due to abuse/trauma to protect true self from stress
 Treatment: merge identities into one
 Interventions:
o Establish relationship with each identity
o Listen for signs of self-harm
o Let client recall memories at own pace
o Encourage journaling (feelings/triggers)
o Teach techniques to counter dissociative episodes

PHOBIAS
 Face their fear
 Gradual exposure
 Agoraphobia: Fear of being in/anticipating certain situations or physical spaces
 Zoophobia: Animals

DEPRESSION
 Signs of depression in adolescents:
o Hyper somnolence/Insomnia (frequent napping)
o Low self-esteem
o Withdrawal from enjoyable activities
o Outbursts (acting out, absenteeism)
o Weight gain/loss

MAJOR DEPRESSIVE DISORDER

 Diagnosis: 5 or more for at least 2 weeks & 1 must be depressed mood/loss of interest
o SIGECAPS:
o Sleep (increase/decrease)
o Interest deficit (anhedonia)
o Guilt (worthless/hopeless)
o Energy deficit
o Concentration deficit
o Appetite (Increase/decrease)
o Psychomotor retardation/agitation (somatization – slow speech, movement, etc)
o Suicidal
 Help with ADL’s (“Come on lets go”)
 Listen, encourage to verbalize feelings, & help view in more realistic way

CATATONIC SCHIZOPHRENIA
 Diagnosis: Meet criteria for Schizophrenia & 2 of the following:
o Immobility (don’t move a lot)
o Remain mute
o Weird postures
o Negativism (resist instrustions/moving)
o Waxy flexibility (limbs stay where they were put)
o Staring
o Stereotypes movements, prominent mannerisms, grimacing
 High risk for dehydration & malnutrition d/t lack of meeting basic needs
 Needs help with ADLs
HALLUCINATIONS/SCHIZOPHRENIA
 Antipsychotics: first line treatment
 Auditory is most common
 Auditory: Give music or auditory stimulation to distract from voices
 Tell them you know they’re real but you don’t hear/see them yourself
 Don’t argue about it
 Direct to different topic that is reality
 “What are they saying to you?”
 Looks away – “What do you see?”
 Lack of social interaction skills – Introduce it by one-on-one first to establish trust/comfort
 Many things contribute to getting it aside from just genetic (biochemical, brain abnormalities, developmental, misc.)
 Thought processes:
o Neologisms: Made up words
o Concrete thinking: Literal (“Grass is greener on the other side”)
o Loss associations: One idea to another with no logic
o Echolalia: Repetition
o Tangentially: Changing topics without getting to the point
o Word Salad: Mix of words making no sense at all
o Clang Associations: Meaningless rhyming
o Perseveration: Same response to different questions
 If they walk away from you – Let them – They’re trying to relieve anxiety!
 Home modifications:
o Locks above/below eye level
o Motion sensors/Alarms
o Large stop sign on door
o Disguise door with curtain
o Childproof doorknob covers
o Place black mat/strip by exit (Might think its an impassable black hole)

COPING
 People with cancer are scared of death – Acknowledge fear, open-ended statements, & invite to talk about death
 Don’t use “Why” – Accusatory!
 Give emotional support & facilitate parent-child bond when child dies
 It’s good for parents to participate in postmortem care
 Reflect & don’t give the “It’ll get better over time” BS
 When someone’s death is imminent – Let family know and be with them

DELIRIUM
 Sudden onset
 Changing mental status
 Inattention
 Disorganized thinking (hallucinations)
 Altered LOC
 Risk:
o Old
o Neuro disease (stoke/dementia)
o Multiple drugs
o Coexisting medical problems
o ABG or acid-base imbalance
o Metabolic & electrolyte imbalance
o Impaired mobility (early ambulation helps prevent it!)
o Surgery (postop setting)
o Untreated pain
 UTI can cause delirium
 Interventions
o Near nurses’ station
o 1-to-1
o Frequent reorientation

DEMENTIA/ALZHEIMER DISEASE
 Slow onset
 Normal attention (consciousnes intact)
 Forgets
 Antipsychotics as last resort
 Intervention:
o Acknowledge
o Reassure (you’re safe)
o Distract (TV, music)
o Redirect (Hey, go do this)
 If they wander, lead them back “Time to go back to bed now”
 If caregiver is burnt out = Social worker for long-term care options
BIPOLAR
 Often neglects food, water, sleep, hygiene
 Give foods high in protein/calories

MANIA
 Characteristics:
o Excessive movements
o Euphoria
o Poor impulses
o Flight of ideas, talking a lot
o Poor attention
o Hallucinations/Delusions
o Insomnia
o Weird/Inappropriate clothing (Choose for them)
o Poor hygiene
o Poor nutrition
 Care:
o Reduce stimuli (quiet, less people, one-to-one interactions, low light) – Avoid group therapies, etc.
o Structure (RN takes charge of what they do for the day)
o Exercise
o High protein/calorie meals, snacks
o Set limits

PERSONALITY DISORDERS
 Dependent Personality Disorder: Submissive, clingy, don’t want separation
o Can’t make decisions
o Always need advice, reassurance
o Lack of confidence
o Afraid of confrontation or disagree with others
o Helplessness when alone
 Don’t let them make excuses & get away with it – Set rules, let them know it’s their responsibility
 Histrionic personality disorder: Attention seeking & exaggeration of emotions
 Paranoid personality disorder: Don’t trust & suspicious; Have need to control their environment; “Don’t make me go in that room, they poisoned the food”
 Narcissistic personality disorder: grandiose, need for admiration, lack of empathy; Show superior, unique, independence but empty inside
o They act that way to maintain self-esteem & protect ego from further psychic injury
 Borderline personality disorder: Make suicidal threats, gestures, attempts; Do it when abandoned by loved ones (Don’t leave me pls I love u, or I die) lol
 Obsessive-Compulsive personality disorder: On time, follow rules, need to control experiences; Inflexibile, rigid; “unacceptable, I planned my whole day!”

ELECTROCONVULSIVE THERAPY
 Depression with psychotic features & highly suicidal
 When unsafe to wait for drugs to work
 Don’t respond or can’t tolerate medications
 Anesthesia/Relaxant given before treatment
 Multiple treatments
 Temporary memory loss/confusion normal
 If anyone concern, assess knowledge (“Tell me what you know about ECT”)
 Preparation:
o NPO 6-8 hrs prior; Can take sips of water with meds
o Unconscious and feel no pain
NO driving

ALCOHOL WITHDRAWL
 Mild: anxiety, insomnia, tremors, sweating, palpitations, GI upset, intact orientation
 Seizures: single or multiple
 Alcoholic Hallucinosis: Hallucinations; Orientation intact; Stable vitals
 Delirium Tremens: Confusion, agitation, fever, tachycardia, HTN, sweating, hallucinations
 Benzos help with delirium tremens & other withdrawal symptoms!

DRUG ABUSE
 Opioid withdrawal:
o GI: N/V, diarrhea, cramping, increased sounds
o Cardiac: Increased pulse, BP, sweating
o Psychological: Insomnia, yarning, dysphoric mood
o Myalgia, arthralgia, lacrimation, rhinorrhea, piloerection, mydriasis
 Goals for Alcohol abusers:
o Express accountability
o Use insight to overcome rationalization/projection
o Coping skills
o Set goals for growth
o Abstinence
 Alcohol can cause hypoglycemia esp with those with DM! Check glucose levels because you can’t tell if its because of alcohol or DM!
 Alcohol can cause thiamine (vit. B1) deficiency d/t poor nutrient intake = Wernicke encephalopathy = death or neurologic morbidity
  Codependence: Someone does something to fulfill needs of addict; “I don’t get stressed so my spouse don’t drink a lot”

FUNCTIONAL DISORDERS
 Undiagnosable issues (epilepsy, migraines)
 Science can’t fully explain

SOMATIC SYMPTOM DISORDER

 Due to stress
 Unexplainable physical symptoms
 Redirect & limit talking about it because they’re either seeking attention or escaping responsibilities
 Will try to find everyone in the world to check them out (Bad – Reinforce teaching)

SUICIDE
 Long-term goals: less likely to commit it
 If client can’t definitively say if they’re suicidal – Treat it as a yes!
 Risk: SAD PERSONS
o Sex (men > women); Men complete more, women attempt more
o Age (teens & > 45)
o Depression
o Prior history of suicide
o Ethanol/Drug abuse
o Rational loss of thinking (hearing voice to kill self)
o Support system loss (living alone)
o Organized plan (and available guns, etc)
o No significant other
o Sickness (terminal)
 Minor cutting is not always suicidal – Could just be a coping mechanism

END OF LIFE CARE

 Don’t give advice or influence one’s decisions
 Open-ended & facilitate exploration of emotions, values, beliefs
 Stay with family if they ask you to (give support)

DEFENSE MECHANISMS
 Rationalization: Excuses (I did poor on test because questions were tricky)
 Displacement: Transfer thoughts/feelings onto another (Angry with boss, yells at wife)
 Regression: Go back to earlier life (Has temper tantrum when stuck in traffic)
 Introjection: Take on another person (Take political views of admired actor)
 Reaction Formation: Acting opposite of true feelings (Resentful of unplanned child but becomes overprotective; Cancer scared of dying but very optimistic)
 Repression: Keeping thoughts/events buried in unconscious (Raped person can’t recall event)
 Sublimation: Turn unacceptable thought/needs into acceptable (Boxing to deal with aggression)
 Compensation: Deficit in one area, makes up in another area (Poor in school, so focus on doing well in sports)
 Projection: Give something bad to another (Cheating, then accuses wife of cheating)

PHARMACOLOGY
 Memantine (NMDA antagonist): Alzheimer’s; Improves ADL’s by easing symptoms
 Serotonergic medications (sertraline) & some herbs (St. John’s Wort): Serotonin Syndrome
o Symptoms:
 Mental: anxiety, agitation, disorientation
 Autonomic: Hypothermia, sweating, tachycardia, HTN
 Neuromuscular: Termor, rigidity, clonus, hyperreflexia
 Diarrhea, mydriasis
 Opioid withdrawal treatment:
o Opioid agonist: Methadone or buprenorphine
o Nonopioid: Clonidine or adjunctive (antiemetic, antidiarrheal, benzos)

VIOLENCE
 Clear communication
 Encourage participation in care
 Low-stimulation environment
 Comfort with meds/non-med methods
 Give undivided attention

MENTAL RETARDATION
 Moderate:
o 2nd grade level
o Can self-care with some supervision
o Participate in simple activities
o Might have limited speech capabilities
 Autism: Give a schedule of activities, Limit visitors and choices to avoid overstimulation

COGNITIVE BEHAVORIAL THERAPY

  Education of disorder
 Self-observation & monitoring skills
 Physical control strategies
 Cognitive structuring
 Behavioral strategies

INTERPERSONAL PSYCHOTHERAPY
 Discuss difficulties that led to problems

PSYCHODYNAMIC/PSYCHOANALYTIC THERAPY
 Help develop insight into cause of disorder

EATING DISORDERS
 Anorexia
o No period
o Fear of weight gain
o Fluid/Electrolyte imbalances
o Decreased metabolic rate
o Lanugo (hairs)
o Cold intolerance
o A lot of exercise
 Anorexia goal: Increase weight gain & intake
o Don’t let them continue exercising as usual
o Don’t keep a log - don’t let them dwell on it
o Monitor weight same time each day
o Supervise when they eat
 Signs of bulimia:
o Bathroom after meals
o A lot of food gone
o Wrappers/Containers found hidden
o Smell vomit
o Enemas/Laxatives
o Night eating & bathroom after
o Intense exercise even with pain/fatigue
o Swollen cheeks (Damage to parotid gland)
o Stained teeth
o Periods of starving
o Occupied with weight, food, dieting
 Bulimia interventions: Monitor for 1-2 hrs after meals

SEXUALITY
 “How would you describe your gender orientation?” not “What would you like me to call you?”

STAGES OF CHANGE
1. Precontemplation: Don’t think problem exist
2. Contemplation: Sees change is needed but don’t decide to work on it or not
3. Preparation: Decides to change & establishes goals
4. Action: Develops a plan & active in changing
5. Maintenance: Continues changing & prevents relapse
6. Termination: Achieved desired change

EXAMPLES OF INVOLUNTARY ADMISSION

 Imminent danger to self/others
 Grave disability (Can’t complete ADL’s d/t mental illness)