Mental Health Nursing

Psychiatric Nursing
SUPPLEMENTAL BULLETS

TYPICAL PROFILE OF PATIENT WITH ANOREXIA NERVOSA –

FEMALE , ADOLESCENT,UPPER CLASS ,PERFECTIONIST
A PaTIENT WITH AN EATING DISORDER UNCONSCIOUSLY
ASSOCIATES FOOD WITH LOVE AND AFFECTION
LITHIUM LEVEL TOXIC AT 2.0 mEq / L
NEUROLOGIC SIGNS AND SYMPTOMS INCLUDE NAVDA,
TREMOR, HYPERREFLEXIA,FASCICULATIONS, BRADYCARDIA ,
ARRYTHMIAS ,SEIZURES AND COMA

Korsakoff’s Psychosis : inability to process new information ( to

form new memories). This is a reversible condition resulting from
brain damage induced by a thiamine deficiency which is generally
secondary to chronic alcoholism.
Werniche’s Encepalopathy : This disease is also due to an
alcoholic-induced thiamine deficiency. It is an irreversible disease in
which the brain tissues break down, become inflammed, and bleed
Pharmacological treatment of alcohol withdrawal –
benzodiazepines or barbiturates
First symptom of Alzheimer’s Disease – progressive memory loss
Effective long term treatment for alcoholics – AA
Methadone causes analgesia without euphoria,withdrawal symptoms less
severe than heroin
Medical/ health professionals prone to have anxiety and depression treated by
generalist rather than physicians

Delirium – reversible organic mental syndrome reflecting deficits in

attention, organized thinking, orientation , speech, memory and
perception. Patients are frequently confused, anxious , excited and
have hallucinations. A change in consciousness can be
observed(clouding of consciousness)
Dementia –irreversible impaired functioning secondary to changes /
deficits in memory, spatial concepts, personality , cognition ,
language , motor and sensory skills, judgement or behavior. No
change in consciousness
Substances that mimic generalized anxiety – amphetamines , cocaine ,
anticholinergics, alcohol and sedative withdrawal
Geriatric drug induced hallucinations commonly due to propanolol
Major risk or TCA’s – orthostatic hypotension leading to falls
Symptoms of alcohol withdrawal and their temporal relations
Hallucinations – after 24 hours
Autonomic hyperactivity – after 6-8 hours
Global confusion 1-3 days after

Side effects of Ritalin – insomnia abdl. Pain,

depression, anorexia, HA and HPN
First episode of Bipolar disease – mania before depression
Lithium used for mania and – bulimia , anorexia nervosa, alcoholism with mood
d/o, headaches
Borderline personality d/o – Chronic Boredom
Parotid gland swelling and erosion of teeth enamel, elevated serum amylase
and hypokalemia – Bulimia
Conversion d/o – internal psychological conflict that manifests as somatic
symptoms.
Dysthymia – chronic d/o more than 2 years
Symptoms of depression

I
Nterest down
Sleep
Appetite
Depressed mood
Concentration diff.
Activity
Guilt
Energy low
Suicide

Dystonic rxn – side effect of neuroleptics-muscle spasm

of tongue, face and neck and back,laryngospasm and
extraocular muscle spasm
Dystonic rxn – treated with Benadryl or Cogentin
Hallucinogens affect – serotonin
Munchausen syndrome – harm oneself – factitious d/o –
manchausen by proxy – seeks medical care for another (e.g. child)

Haloperidol – prefrred neuroleptic – few side effects ,

can be used IM during emergencies( but high
frequency of extrapyramidal effects)

Clozapine – no tardive dyskinesia but can develop agranulocytosis ,

seizures,hypotension, over sedation.
Benzodiazepine contrindications – pregnancy ( 1st trim)acute narrow angle
glaucoma, and hypersensitivity
Extrapyramidal Rxns- involuntary spontaneous motor movements – dystonis,
akathisia and parkinson like syndrome
Obsessive – Compulsive d/o –begins before 25 y.o. –
SSRI and exposure therapy beneficial
Positive operant conditioning – reinforce positive behavior
PTSD possible even though there is no actual witnessing of event
Flashbacks , nightmares,intense fear,avoidance and diminished
memory of event with an exagerrated startle response onset occurs
at least 6 months - PTSD
Post partum psychosis – first few weeks post-partum(7-
10 d/6-8wk,) primiparous,poor social support and
previous depression
Schizophrenia –
Association looseness
Ambivalence
Autism
Affectinappropriate
Hallucinations + A’s + Regression + Delusions + Stimuli comprehension low
(HARDS)

Somatization d/o – multiple , unexplained medical

symptoms(four unexplained pain Sx)
Suicide – bipolar d/o, depression, substance abuse and schiz.
Reliable predictors of potentially violent patient – male gender , Hx
of violence , history of substance abuse
Organic brain syndrome most frequent mood – irritability
Labile affect – rapid shifts of mood
Medication used to relieve extrapyramidal effects of
psychotropic medications:
Benadryl
Artane
Cogentin
School age w/ terminal illness – honestly explain in understandable
terms. Provide reassurance that he will not be alone.

Prodromes of violent behavior –

anxiety,defensiveness,volatility and physical aggression
Akathisia-internal restlessness-Tx – propanolol
Echolalia – meaningless automatic repition of someone else’s
words
Catalepsy – maintains same posture for a long period of time
Waxy flexibility –offers resistance to change in position but
gradually allows to be moved to anew posture
Institutionalization only if patient poses a danger to self
or others

10 most stressful events(Holmes and Rahe)

Death of a spouse or child
Divorce
Separation
Institutionaldetention
Death of a close family member
Major personal illness/injury
Marriage
Job loss
Marital reconciliation
retirement

Standard care for domestic violence

Establish confidential system of identification
Document
Collect evidence
Evaluate safety issues
Formulate safety plan
Give insight to options and resources
Refer for counseling nad legal asst.
Coordinate w/ law enforcement
Transport to shelter prn
Follow up w/ DV advocate
Common anti cholinergic meds- AtSO4,
TCA’s,antihistamines, phenothiazines and
antiparkinsonian drugs
Lithium toxicity –sign: tremor, symptoms:weakness and ECG
findings: flattening of T-waves.

Tx for Wernicke’s Encephalopathy – thiamine IV

Organic Brain Syndrome – manifestations
Hallucinations
Perception aberration
Mental status change
Focal neurologic sign

Imipramine HCl – TCA – dry mouth – X drink

excessively – leads to electrolyte imbalance – just ice
chips/ gum
Least therapeutic around depressed clients – Cheerfulness or gaiety
Theory behind interpersonal model of behavior therapy: Behavioral Changes
result from stress on the individual and his body systems
Systems model theory – behavior results from interaction between individual
and environment
Haldol’s CNS adverse reaction – Extrapyramidal side effects
Significant features of each AXIS in the Diagnosis
Statistical Manual for mental disorders IV
Axis 1 – organic brain syndromes,psychosis,affective d/o and
substance abuse
Axis 2 – personality disorders
Axis 3 – medical problems
Axis 4 - Life events leading to problems
Psychosocial and environmental
Axis 5 – patient adaptation to problems
Schiz. patient – priority safety then self care needs ,
then health needs then behavior goals
Major goals of psychosocial rehabilitation program – teaching
independent living skills
OC d/o – substitution and undoing
Adolescent behavior influence - peers
Organic mental d/o :
Agnosia,insomnia,amnesia,confusion delirium and depression

Attributes negative traits to others - projection

Showing emotion opposite to what is truly felt – reaction formation
Alcohol aversion therapy – antabuse
Alcoholism – rationalization – substituting a more acceptable reason for one’s
behavior
Heroin overdose – ABC’s
Cocaine – red excoriated nostrils, tachycardia , nervousness and pupillary
dilation
AA – independent responsible arrangements(personally done)

Barbiturate overdose -respiratory failure

Drug given at a non- intoxicating dose for barbiturate withdrawal –
Pentobarbital Na ( Nembutal)
Long term amphetamine abuse – emotional lability,
depression,dependency , hallucinations and delusions

Severe anxiety and withdrawn – diversion activities and

increased social contact
Anorexia nervosa when exercising – interrupt and redirect activity
Antisocial – egocentrc and unconcerned
Ultimate nursing goal for severe anxiety disorder – development of
adaptive coping behaviors and problem solving skills
Inderal use to relieve physical symptoms of anxiety
Disclosure of a plan to kill someone – report to the staff
and AP asap
Obtained sense of self – awareness, attributes , defense mechanisms and
behaviors – gained INSIGHT
Priority for suicidal depressed patients – safety and security ( not cause
personal harm)
Suicide an individual decision cannot be influenced by nurses questions
Sudden increase in energy level or mood- warning sign
Client under influence of cocaine – agitated, aggressive
and paranoid – priority safety / protect pnt.
Tardive dyskinesia – involuntary twitching or muscle movements
Dystonia – uncoordinated spastic movements of the body
Discharge – preparation for termination of NPR
Delusional withdrawn – encourage participation – reinforces reality
and brief one on one contacts in his own room

Fluphenazine decanoate ( prolixin ) drug of choice for

Schiz. – given only once every 2-4 weeks
Prolixin– edema , blood dyscrasias and BP fluctuations – check weight , WBC
count and BP.
Schiz – complaints of hallucinations – assess for compliance
Client’s discharge from involuntary admission – determined by legal or medical
approval
Confused client – promote safety, prevent injury and maintain quality of life

Alcohol intoxication – allow pnt. Sleep it off

Support gropu for spouses and significant others of alcoholics – Al-
non
Breaking defenses of denial may lead to mental disorganization and
depression
Thorazine reduces seizure threshold
Heroin addiction symptoms of late withdrawal – navda
recovery principle to ease anxiety – “ one day at a time”
Barbiturates + alcohol – depressant effect

2-3 days barbiturate withdrawal – generalized convulsions-Given

nembutal to decrease seizure possibility
Anorexia nervosa goal of Tx – stabilize weight and facilitate entry
into outpatient care
Xanax – short term Tx – tolerance can occur
Do not respond to a client who tries to evoke feelings of anger /
negative response
Endogenous depression – biochemical in nature
amitriptyline HCl – urinary retention
Elderly – reminiscing – reduce depression, lessen feelings of isolation and
loneliness
Alcohol detoxification – inquire alcohol consumption past 24-48 hours to
determine withdrawal severity ( auditory hallucinations – common)
Delirium Tremens quiet , well lighted room with companion , last resort –
restrain if violent only
Heroin injection – tested for HIV and Hepa B

Methadone – liquid form under direct supervision

Best measures to recovery success – number of chemically free days
Drug tolerance – requires increasingly larger doses to achieve the same
desired effect
Severe Sx of barbiturate with drawal – postural hypotension,psychosis,
hyperthermia and seizures
Anorexia nervosa – focus – nutritional status
Patient on librium avoid alcohol
Disciplining unacceptable behavior – person still accepted
Alcohol disulfiram Rxn – vomiting , dyspnea,
hypotension,vertigo,syncope,confusion,respiratory
depression,convulsions,coma,death
Alcoholism defense – rationalization , repression /suppression,
denial

Heroin overdose – antidoteNarcan(naloxone)increased

HR,BP and LOC ( but short acting )
Barbiturate ,Opiate or Benzodiazepine – sluggish, irritable, slurred
speech , impaired judgement and walking diff.Buspar – not prn –
therapeutic effect 7 – 10 days…full effect 3 -4 weeks
Epinephrine – decrease peristalsis
Restraints discontinued when subj. and obj. assessments indicate
an absence of aggression
Abusive family characteristics :

History of family violence

Unbalanced power ratio
Stereotypical role playing
Dysfunctional expression of feelings
Strict boundaries
Lack of empathy
Substance abuse

Low self esteem – common trait of abuse victims

Medication can only be forced to a patient if he poses a
threat to himself and others
Anti social personality – limit setting on behaviors
Psychophysiological anxiety d/o – activities that promote rest, involve relaxation
Self awareness towards mortality needed to be effective in caring for the
terminally ill
Organic mental d/o – safe simple envt. To help his orientation
Anorexia nervosa – perfectionists ,self starvation and rigorous exercise – high
cal and high CHON diet.subconcious conflicts – parental , autonomy, identity
Isolation , medication and warning others –short term
anger mngt. Does not place responsibility on the patient
for his own behavior, ineffective in behavior
modification
Positive reinforcement for good behaviors
For manipulative clients – limit setting and positive reinforcement
Personality traits for ulcerative colitis – OC,
perfectionist, inflexible, difficulty in showing emotions
and obstinate
Four point retraints – monitor circulation and skin, provide sensory
stimulation,means of elimination and nutrition and change in position
MAO therapeutic effects – 4 weeks
Turning unacceptable feelings into physical Sx that has no
identifiable cause – conversion rxn

Sarcasm – expression of anger

Confabulation – unconscious behavior used to hide memory loss by
replacing it with fabrication
Unconscious forgetting of traumatic events– repression
Projecting feelings or thought to someone – transference
MAO – headache and neck stiffness – hypertensive crisis

Communication for someone who refuses to

speak – open ended questions focussing on
expression of feelings
Anti-psychotics abrupt discontinuation- nausea and seizures
Manipulative behavior – lack of trust
Verbally and physically abusive patients – try setting limits verbally
before physical and chemical restraints
Abused child little showing of emotion and little
response to pain
Depressed clients readiness evaluated by responsibility for own
well being , ADL’s and continuing Treatment.
Abused child – same primary nurse everyday – promote trust and
provide continuity of care
Anti –social – continue to enforce rules and set limits on behavior(
provide appropriate explanation)
Demerol C/I for clients taking MAOI’s,can cause
death
Alzheimers memory and emotion difficulties – stage 1
Memory loss, confusion , wanderin aphasia, inability to do self care – stage 3
Lithium therapy – monitor sodium
Tyramine rich foods- smoked , aged , pickled or fermented
Stage 1 alzheimers – recent memory loss only
Hallucination episodes – redirect to reality ( activities)

Lithium carbonate therapeutic level in 2 weeks

Dementia –wandering – constant supervision
A client exhibiting mania placed on lithium carbonate and Thorazine
simultaneously…Thorazine controls manic behavior until lithium reaches its
therapeutic levella belle indifference – lack of concern for profound disability
Highest treatment priority for anorexia nervosa-correction of nutritional and
electrolyte imbalance
Seclusion for – promotion of therapeutic limit setting, reduces overwhelming
environmental stimulation, protects patient from self injury or injury to others- if
patient does not respond to less restricted interventions – until pnt. Can assume
self control
Compulsion – irresistable urge to perform an irrational act
Self esteem needs- self – worth ,self respect ,self –reliance , dignity
and independence
Love and belongingness – affiliation , affection and intimacy

Minnesota Multiphasic Personality Inventory MMPI- 550

question test assess personality and detects d/o such
as schizophrenia and depression
ECT … 6-12 treatments of 2-3 per week
Circumstaniality –disturbance in associate thought and speech
patterns
Lithium levels checked every 6 – 8 weeks
Primary purpose of psychotropic medications to
decrease symptoms to allow participation in therapy

First step in drug overdose or toxicity management- establish and maintain

airway
Korsakoff’s syndrome – hallucinations,confabulation,amnesia and disorientation
TCA ‘s
A/R: orthostatic hypotension,tremors
overdosage: seizures HPN shock arrythmias
Most common psychiatric disorder
depression