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Psychology II 2


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Axis I
-Major Depression
-Bipolar Disorder
Axis II
-Personality Disorders and Mental Retardation
-Antisocial Personality Disorder
-Borederline Personality Disorder
-Language Skills Disorder
Axis III
-General Medical Conditions
-Affects mental state or things that need to be known (hip precautions for someone who just had hip surgery)
Axis IV
-Psychosocial and Environmental Problems
-Problems with primary support groups
-Educational problems
-Occupational problems
Axis V
-Global Assessment of Functioning Scale (GAF)
-Looks at psychological, social, and occupational functioning
-Score is give for current functioning
-Score is between 1-100 where 100 is the healthiest score
-Lanterman, Petris, Short Act
*legislated legal protections for the patients
*LPS conservatorship
*created the psych health facilities
*least restrictive setting: people should be housed in place with the least amount of restrictions and structure to keep them safe
Short-Doyle Act
-To provide funding for the provisions in the LPS act to be carried out
-Legal hold for 3 days (72 hours)
-Period of evaluation
-Date and time must be on admittance paper work (nurse's responsibility to verify)
-No legal recourse
-Created by the LPS act
-Must meet one of the following:
*Daner to self
*Danger to others
*Gravely disabled (unable to provide or utilize clothing, shelter, or food)
-Hold up to 14 days in length
-Probable cause hearing:
*Pt and Pt Advocate
*Represenative for facility
-Writ of Habeus Corpus:
*if patient loses probable cause hearing they can request a writ hearing
*In courtroom with judge and attorney
-Legal hold up to 30 days
-Probable cause hearing
-Writ hearing if requested by pt
-Temporary Conservatorship (T con)
*30 days to allow the facility to prepare a case for conservatorship
*Is decided if pt is still not able to care for self after 47 days at facility
-Conservatorship: 1 year in length then must be renewed
*pt can request a jury hearing once during conservatorship
*Pt does not have: right to sign legal documents, decide where to live, contol over money
Legal Holds
-4011.6: come from jail for evaluation
-1368: evaluated to see if fit competent to stand trial (at least two months)
-1370: incompetent to stand trial by reason of mental illness
-To be competent to stand trial pt must:
*Understand charges being brought against them and
*Be able to work with an attorney
Pt Rights and hearings
-Pt has right to refuse medication unless:
*they are on a conservatorship
*a harm to themselves or others right at that moment
-Riese hearing: for pts who refuse to take their medications
-Copacity Hearing: ability of pt to give conformed consent
Affective/Mood Disorders
-Affect: facial expression
-Major Depression
-Bipolar Disorder
Major Depression
-Orientation: should be x3
-Eye contact: lessoned, fleeting
-Affect: flat, unchanging, sad, crying
-Appearance: could be anything
-Behavior: aggitated, anxious, lying in bed
-Activity: probably wanting to disengage/withdrawn
-Thought flow: thinking organized or tangential
-Speech: could be queit
Major Depression with psychotic Features
-In addition to previous criteria there must also be:
*Hallucinations: any 5 senses (sensory perceptions occurs in absence of external stimuli
*Delusions: a personal belief that is most certainly not true (can't change this believe with facts or medication)
-Illusion: misinterpretation of real stimuli
-Most common in elderly
Recognizing Escalation
-Display increasing signs of anger/irritation
-Loss of self control
-Notify staff immediately
-Early intervention is important for safety
Setting Limits
-Goal: help patient establish behaviors that fit into society and encourage socialization
Safe Student Behavior
-Arms length away from pt
-Larger personal space
-Don't touch pt without permission
-Don't turn your back on pt
-Keep pt in line of sight
-Don't be alone in room with pt
-Don't be in room with door shut
-Watch nonverbal behavior (crossed arms)
-Same level as pt
Assesssing a Person's Mental Health
-Orientation to person, place, time
-Apperance: hygiene/dress
-Eye contact
-Affect: facial expression
-Activity: groups, pacing
-Thought content: what is being thought
-Thought Flow or process
Depressive symptoms in the Elderly
-Loss of interest in usual activities
-Fewer complaints of guilt and lowered self-esteem
-c/o poor memory and poor concentration
-multiple symptoms
-early morning awakening
Depressive Signs in Teens
-Change in function at school
-Low self-concept
-Drug abuse
-often irritable rather than sad
-Cyring a lot
-Thoughts of harming the baby
-Thoughts of harming self
-Lack of interest in the baby
-Symptoms go on and on
-Lack of sleep doesn't help
-These are normal in a new mom but the sx or brief
*more = better mood
-GABA: gamma amino butyric acid
Depression is caused by a neurotransmitter dysregulation
*decreased amounts of serotonin and/or norepinephrine will cause mood to decrease
Major Depression Recurrence Rate
-50-60% after first episode
-70% after second episode
-90% after third episode
Major Depression Treatment
-Antidepressant Medication:
*TCAs: tricyclic antidepressants
*SSRIs: selective serotonin reuptake inhibitors
*MAOIs: monoamine oxidase inhibitors
-PEP and other support groups
Tricyclic Antidepressants (TCAs)
-Oldest anti-dep. drugs
-Onset of action: 7-10 days
-Full affect 4 weeks
-Action: inhibits reuptake of norepinephrine or serotonin at the presynaptic neuron
-Suicide risk increases during the first 2-3 weeks of treatment due to more energy and increase in restlessness, aggitation, and anxiousness
-Phone contact important
TCA Side Effects
-Cardiovascular: tachycardia, orthostatic BP changes, (20-30 SBP), arrhythmias, T-wave abnormalities
-Psych: anxiety, confusion, psychotic behavior (must have an adequate baseline)
-Neuro: tremors, drowsiness, hung-over feeling
-Endocrine/Metabolic: increase or decrease libido, impotence, weight gain
-Easily fatal if mixed with ETOH
-Other uses:
*enuresis control
*chronic pain
Anticholenergic Side Effects
-Dry mouth
-Aggitated and anxious
-Urinary Retention
-Blurred Vision
-Can't see, can't pee, can't spit, can't shit
-4 weeks for full affect
-Serotonin and norepinephrine reuptake inhibitors
-buproprione (Wellbutrin)
-mirtazepine (Remeron): mostly older people d/t wght gain d/t increased appetite
-trazadone (Desyrel): makes people sleepy
Heterocyclics Side Effects
-Dry mouth
-Priapism: continually erect penis seen mainly in Desyrel
-Seizures: Wellbutrin d/t decreased seizure threshold
Selective Serotonin Reuptake Inhibitors
-fluoxetine (Prozac)
-paroxetine hydrochloride (Paxil)
-sertaline (Zoloft)
-citalopram (Celexa)
-escitalopram (Lexapro)
-fluvoxamine (Luvox)
-Onset of action: 7-10 days
-Full effect 4 weeks
SSRIs Side Effects
-Insomnia or somnolence (want to sleep)
Serotonin Syndrome
-Occurs when SSRIs are taken at the same time or within several wks as other drugs that increase Serotonin such as MAOIs
-Diarrhea, cramping
-Tachycardia, labile bp, hyperflexia
-Fever, Diaphoresis (profuse sweating), shivering
-Staggering gait
-Restlessness, disorientation, confusion
Nonselective Reuptake Inhibitors (NSRI)
-venlafaxine (Effexor)
-nefazodone (Serzone)
-duloxetine (Cymbalta)
-Full effect: 4 wks
*inhibits neuronal reuptake of Serotonin and Norepinephrine
*weak inhibitor of dopamine
NSRIs Side Effects
-Dry Mouth
Monoamin Oxidase Inhibitors (MAOIs)
-Last Resort
-Mechanism: Increases morepinephrine stored in adrenergic neurons
-Examples: Nardil (most common) & Parnate
-Full effect: 4 wks
-Special Diet: No Tyramin (amino acid)
*Aged, smoked, fermented products
*Bananas, avacado, chicken liver
*only small amounts of caffeine ok
MAOIs Side Effets
-Hepatic Necrosis: can be fatal
-Eating Tyramine foods: can lead to hypertensive crisis, intracranial bleed, and death
-Interaction with other meds:
*Sympathomimetics can cuase release of stored norepinephrine, hypertensive crisis
*asthma meds: albuteral, Terbutaline
*Cold and hay fever meds
*Weight reducing meds
-Refer pt to pharmacy when doing teaching
-Should not be prescribed to someone who is unable to have strict compliance
-Drugs partially or completely mimic the actions of epinephrine or norepinephrine
-Epi and Norepi stimulate the SNS (fight or flight)
-SNS regulates heart and peripheral vasculature, esp. in response to stress
Sympathomimetics Side Effects
-Aggravation of psychosis (out of touch with reality)
Bipolar Disorder: Mania
Distinct mood of abnormally and persistently elevated exansive, or irritable mood lasting at least a week
*Inflated self-esteem or grandiosity
*Decreased need for sleep
*Pressured speech/more talkative than usual
*Flight of ideas or feeling thoughts are racing
Mood Stabilizing Drugs
-Antimanics: lithium (Lithobid)
-Only drug classified antimanic
*Action: enhances re-uptake of norepi and serotonin, decreases levels in the body
*Takes 1-3 weeks to work
*Therapeutic Blood Levels: 0.6-1.5
*Titrate 4-5 days after treatment is started
Antimanics: lithium
-Side Effects:
*Drowsiness, dizziness, H/A
*Dry mouth, thirst
*GI upset (take with food)
*Fine hand tremors
*Hypotension, arrhythmias, pulse irrug.
*Polyuria, dehydration
*Weight gain
-Over dose
*vomiting and diarrhea leads to ataxia and slurred speech then coma, seizures, electrolyte imbalance the cardiac arrest (li > 2.0)
*Diuretics, NSAIDs and ASA with lithium lead to decrease in renal clearance of Li and could cause death
-Adverse Reactions:
*Renal Failure
Mood Stabilizing Drugs: Anticonvulsants
-carbamazepine (Tegretol)
-divalproex sodium (Depakote)
*used for bipolar disorder: rage reactions, resistant schizophrenia
*SE: drowsiness, dizziness, N/V
*carbamazepine: monitor CBC, platelets, chem panel and lytes
*divalproex sodium: thrombocytopenia
-Monitor blood levels and keep in therapeutic range
Misperceptions and misinterpretations of externally real stimuli
An important personal belief that is almost certainly not true
A sensory perception that occurs in the absence of external stimuli
-Axix I
-2 or more of the following:
*grossly disorganized or catotonic
*netative symptoms: affective flattening, alogia, avolition
*Social/occupational dysfunction: work, interpersonal relations, self-care
*Continuou sypmtoms for 6 months: d/t schizophrenia looking like other illnesses or drug use
Schizophrenia: positive symptoms
Delusions and Hallucinations
Schizophrenia: Negative Symptoms
-Something that missing or present in normal people
*flat affect
*alogia: without speech
*avolition: without motivation
Schizophrenia Subtypes
-Paranoid: Prominent delusions and/or hallucinations
*Later onset: 30-35 years of age
-Disorganized: speech, behavior, flat or inappropriate affect
*Early onset: 16-25 years of age
*Need step-by-step instructions
-Catontonic: marked by psychomotor disturbance, immobility (wax flexibility), like a wood structure
*echolalia: repeating phrases/words
*echopraxia: repeating gestures
*short term tx: ativan
-Undifferentiated/Mixed: symptoms not clearly falling into any of the other subtypes
Types of Delusions
-Grandiose: queen of England
-Jealous: SO having an affair
-Persecutory: FBI out to get me
-Somatic: something to do with body
*thought broadcasting: sending ideas out of head into another person's
*thought insertion: someone putting thoughts into head
*being controlled by a dead person
Nursing Interventions for Delusions
-Ignore Delusions:
-Set Limits:
-Give PRN medications:
-Present Reality: done only when related to delusions d/t anethesia and/or pain medication
-Delusions are not effectively treated with medications
-Try to address the feelings around/behind the delusion
Nursing Interventions for Agitation
-Regonize escalation
-Decrease environmental stimuli
-Talk down patient
-Set limits
-Give PRN meds
Nursing Interventions for Hallucinations
-Decrease environmental stimuli
-Give PRN meds (work well)
-Present reality: r/t reversible cond.
-Attempt to identify percipitating factors
Nursing Interventions for Suspiciousness
-Be sincere and honest
-Avoid making promises that can't be kept
-Face the patient when talking
-Avoid whispering
-Explain tests and procedures
-Allow the patient to prepare own food if refuses to eat because he feels he is being poisoned
-Used for:
*Schizoaffective Disorder: disorder with mixed affective and psychotic sx
*Various dementias
*Any psychotic sx
-Action: decreases delusions, hallucinations and allows thinking more clearly
-Injection that lasts 2-4 weeks
-Available only in Prolixin, Haldol, and Risperdal Consta
-Expensive: $100 per dose
-Give deep IM
-For those that are noncompliant, have difficulty swallowing, or have memory issues
Old/Typical Antipsychotics/Neuroleptics
*generics end in azine
*haloperidol (Haldol)
*thiothixene (Navane)
*loxapine (Loxitane)
Old/Tyoical Antipsychotic/Neuroleptics Side Effects
Extra Pyramidal Symptoms (EPS)
-Acute Dystonic Reaction
*spasms or muscle stiffness
*black man from video
-Parkinsonian Syndrome
*slowness in movements, tremors, change in gait or posture
*severe form of restlessness (compulsion to move), mostly seen in the thighs and abdomen
-Tardive Dyskinesia
*set of late onset irreversible movement disorders
*constant random movement
*dystonia, tics, and myaclonus
Acute Dystonic Reaction
-Bizarre and severe muscle contractions
-Torticollis: wry neck (pulls head off to side, contracting neck muscles)
-Opisthotonos: arched backwards due to contraction of spinal muscles
-Occulogyric crisis: contraction of eye muscles causes eyes to roll in different directions
-Jaw stiffness
-Resting Tremors
-Rigid posture with slow voluntary movements
-Shuffling gait
-Client feels motor restlessness
-Feels urge to pace
-Shifts weight from one foot to the other
-Feels can't sit or stand still
Tardive Dyskinesia
-Involuntary movements of face, jaw, tongue, lips
-Lip smacking
-Protrusion of tongue
-Jerky or writhing movements of extremities
Anticholinergic Side Effects
-Dry mouth
-Blurred vision
-Urinary retention/hesitance
Anticholinergic/Antiparkinsonian Meds
-benztropine (Cogentin)
-trihexyphenidyl (Artane)
-diphenhydramine (benadryl)
Neuroleptic Malignant Syndrom: Sx
-Comes on rapidly
-Mute: disoriented and confused
-Profound diaphoresis
-Febrile Temp 107
-Increased CPK: creatine phosphate kinase (muscle damage)
-Increased LDH
-Increasd HCT d/t dehydration
-Increased BUN and creatine Dehydration
-Tx: stop medication (neuroleptics), give fluids, lower temp. (hypothermia blanket and antipyretics)
Atypical Antipsychotics
-clozapine (Clozaril)
-risperidone (Risperdal): no decrease in WBCs same SE as clozapine
-olanzapine (Zyprexa): widely used, high risk of causing diabetes II & wght
-quetiapine (Seraquel): widely used
-ziprasidone (Geodon)
-Aripiprazole (Abilify)
-Action: binds to dopamine and serotonin receptors to block dop & ser.
-Dopamine blocks: decreases + sx of schizophrenia (hall and delusions)
-Serotonin blocks: decreases - sx of schizophrenia (flat affect, social withdrawl)
-SE: hyperglycemia, wght gain, may cause diabetes, black box warning
-Requires a WBC check every week while on drug
-onset 2-4 weeks
Antisocial Personality Disorder
-AKA sociopath, psychopath
-Early onset: usually before age 15
-Does not respond to medication
-Rights of others are ignored
-More common in males
-Relatively anxiety-free
-Requires immediate gratification
*set limits
*do not bargain, argue, rationalize
*do not seek approval
*do not be influenced by flattery or verbal attacks
*use contracts and peer pressure
*teach delayed gratification
Borderline Personality Disorder
-Fear of real or imagined abandonment
-Intense, unstable relationships
-Identity Diffusion: negative stage of Eriksons (get stuck here)
-Gender Identity confusion
*seeing the world as all good or all bad
*split the staff against each other
-Mashochistic: self inflicted pain
-Affective instability: labile mood
-Feelings of empiness
-Intense anger or projection of anger
*trouble seperating from parents
*traumatic experience around 18mos old
*75% are abused as children
Boderline Personality Disorder Interventions
-Frequent staff discussions
-Treat consistently: have a single person be in charge
-Encourage client to set daily goals and to talk about body image (long term setting)
-Teach constructive coping methods
*journal writing
-Maintain cosistent, firm limits
-Matter of fact, but caring approach
Somatoform Disorders:
-Body like Symptoms: physical but no physiological disorder is present
Conversion Disorder
-A conversion of anxiety into a somatic complaint.
-It involves a loss of or change in bodily functioning resulting from a psychologic conflict
-Convert anxiet into a physical sx
-Saw something awful - became blind
Somatization Disorder
-Seek medical attention for recurrent and multiple somatic complaints of several years duration that are without a physical cause
-Preoccupied with the fear or belief that they have a serious disease
Anxiety Disorders
-Acute Stress Disorder:first 30 days then changes to PTSD
-Posttraumatic Stress Disorder: intrusive recollections
-Generalized Anxiety Disorder
-Social Phobia (social anxiety disorder)
-Specific Phobia
-Obsessive-Compulsive Disorder
-Substance-Induced Anxiety Disorder
-Panic Disorder
-Panic Disorder with agoraphobia
Social Phobia
-Marked or persistent fear of social or performance situations in which embarrassment may occur
*has intense anxiety as a result or in anticipation
*avoids the situations
*interferes with normal routine or desired activities
Obsesive Compulsive Disorder
-Axis I
-Persistent ideas, thoughts, or images experienced as intrusive
-Can't get it out of mind
-Most of the time recognized as products of own mind
-Repetitive, purposeful, intentional behavior to reduce anxiety or distress
-Clearly excessive behavior
*> 1 hour/day or interferes with usual functioning
*clomipramine TCA
*fluoxetine (Prozac) SSRI
*fluvoxamine SSRI
-Anxiety about being in places or situations where escape may be difficult or embarrassing or in which help might not be available
Antianxiety/Anxiolytic Drugs
-Benzodiazepines = sedatives
*alprazolam (Xanax)
*chlordiazepoxide (Librium)
*diazepam (Valium)
*lorazepam (Ativan)
*oxazepam (Serax)
-Action: potentiate GABA in the limbic area of the brain, depresses the CNS
*decrease anxiety
*decrease withdrawl sx from ETOH
*control convulsions
*produces skeletal muscle relaxation
-Side Effects:
*Blurred Vision
*Othostatic BP changes
Nursing Considerations for Benzodiazepines
-Do not take with ETOH or other CNS depressants
-Peak levels in 1-4 hours (long half life)
-Withdrawl sx: wean gradually over several weeks
-Caffeine interferes with effectiveness
*Potential for dependance and tolerance
-Overdose Tx:
*Call a code
*Open airways/give O2
*Stimulate verbally to keep awake "breath deeply"
*Start IV
*give flumazenil (Mazicon)
Other Anxiolytic Drugs
-buspirone (Buspar): 2wks to work
*good for generalized anxiety disorder
*diphenhydramine (Benadryl)
*hydroxyzine (Vistaril IM, Atarax PO)
Paroxysmal Excitement
-Disinhibition: adverse reaction
-Opposite of what should happen
-Associated with Xanax and Ativan
-Done for suspected substance abuse
*C: cutting down on drinking
*A: annoyed about being asked about drinking
*G: guilt
*E: eye opener, drinking first thing in the morning
disulfiram (Antabuse)
-Causes severe nausea, vomiting, flushing, dizziness, and hypotension when taken with ETOH withing 48 hours
-Can lead to shock and death
-Inhibits acetaldehyde dehydrogenase which normally metabolizes the actaldehyde
Alcohol Equiv.
-1 1/4 oz 80 proof ETOH is the same as:
*12oz beer
*4oz wine

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