Nursing 140 -Mental Health - Crisis/suicide -T2 - Olol

Front 1

Response to stress

Back 1

threat to homestasis
Needed is resilience

Front 2

Types of crisis

Back 2

1.Maturational- Adolescents, or other normal stresses of development (marriage, kids, retirement)
2.Situational- an traumatic event that affects a person's identity and role. usually follows the loss of an established support.
3.Adventitious- natural disasters-occurs outside of the person, hurricanes, floods etc.

Front 3

Factors of Crisis

Back 3

a.Individual or family- anxiety 1st,
b.use coping - ask for help-
c.previous problem solving
Skills -
d. perception of problem,
e. # and types of past crisis, time since last crisis,
d. vulnerable pop.

Front 4

Factors of Crisis

Back 4

1. Anxiety
2. Coping fails,
3. Reaches out for help
4. Inadequate support assistance “losing my mind”
Person with personality disorders will affect how to resolve the crisis

Front 5

When doing crisis interview:

Back 5

What is happening now. How can we help? Coping depends on above items. Goal intervention is to get them back to where they were. ID the problem 1st

Front 6

Intervention for Crisis

Back 6

-short term process to help client’s work through crisis, coping depends on process.
- id problem - patient and nurse have same perception of situation (pt frequently unable to focus on reality test)
focuses on the healthy aspects of the personality. no diag. of mental illness. more directive approach than traditional therapies

Front 7

Skills to resolve crisis

Back 7

Affective: focus on feelings-verbalize and id
Spiritual-meaning and understanding of event
Cognitive-cope with situation by understanding
Psychosocial- communicate with others for support- think they are alone, find others to give support and understanding

Front 8

Acute depression is

Back 8

usually self-limiting
Most common age of onset is 25-44
10-25% women-postpartum about 10%
5-10% men
Children and adolescence, number increasing –up to 18% of preadolescents
Elderly are under diagnosed-prevalence differs related to living arrangement
3-5% for those in the community up to 15% to 20% in nursing homes

Front 9

Biochemical factors for depression

Back 9

norepinephrine, acetylcholine, dopamine (neurotransmitters)

Front 10

. Sleep abnormalities

Back 10

up to 90% of pt has sleep problem loss of deep slow wave sleep and REM

Front 11

Psychodynamic influences & life events for depression

Back 11

stressors and interpersonal events appear to trigger certain
Physical and chemical changes in the brain. Early life-trauma may result in long-term hyperactivity on the CNS corticotrophin-releasing factor and norepinephrine systems with a neurotoxic effect on the hippocampus
These changes could cause sensitization to even mild stress in adulthood and predispose to major depression- some people seem to react to mild stress in a dramatic way-may be sensitized/ predisposed so mild stress may trigger this

Front 12

Cognitive factors in depression

Back 12

result of irrational or illogical thinking and negative processing of information
Automatic negative thoughts responsible for depression-negative, deprecating view of self pessimistic view of the world
Belief that negative reinforcement will continue in the future-
Negative thoughts-negative outlook, pessimistic, believe this will continue always will be bad

Front 13

Learned helplessness in depression

Back 13

anxiety is the initial response to a stressful situation, replaced by depression if the person feels no control over the outcome of the situation
Person believes that an undesired event is his or her fault and that nothing can be done to change it is prone to depression-
If does not get crisis intervention, then can turn into depression- more prone to depression

Front 14

Aspects of Depression

Back 14

Overall emotion in mood disorder is pervasive (affects everything)
1. Psychological- inability to function emotionally
2. Physical- numerous physical problems associated with depression
3. Behavioral response- anger, irritable, decreased energy, appetite, sleep, libido, slow speech, movements, though process
Can be severe with psychosis (hallucinations/delusions)-psychotic depression,

Front 15

Dysthymia

Back 15

mild to moderate, periods of depression experienced over most of the day occurs more days
than not, for at least 2 years, hospitalization rare,
Age of onset from early childhood to early adulthood – just not happy

Front 16

Nursing Assessment

Back 16

Standardized screening tools available: Beck, Hamilton, Zung Depression, Geriatric Depression Scale, etc.

Front 17

Affect in Depression

Back 17

sadness, dejection, and hopelessness are reflected.
Posture is slumped
Eye contact is poor
Crying may occur or client may be unable to cry
Anhedonia is present – lack/loss of interest

Front 18

Thought Processes in depression

Back 18

Assessment of suicidal ideation is the highest priority
Trouble concentrating or thinking for making decision
Judgment is poor, indecisiveness is common
Memory is impaired
Preoccupation with death
Excessive focus on worthlessness and guilt
Sometimes delusional especially about being punished- need to be punished, god does not like them

Front 19

Feelings in Depression

Back 19

Anxiety, worthlessness, guilt, anger, hopelessness and helplessness
Themes of inadequacy and incompetence are relentless
Guilt over present and past falling
Helplessness-inability to carry out even simple tasks
Hopelessness-negative expectations for future, loss of control over future
Passive acceptance of the senselessness of planning to achieve goals
Emotional negativism with despair, despondency or depression
Anger and irritability or outcomes of feelings of helplessness often expressed inappropriately in property destruction, hurtful verbal attacks or physical aggression toward others or self

Front 20

Physical Behavior in Depression

Back 20

1.Lethargy and fatigue leads to psychomotor retardation ranges from slowed movement to complete inactivity
2.Psychomotor agitation may be seen-rare
3.Grooming and personal hygiene are often neglected
4.Vegetative signs (activities that support life
5.Changes in appetite and eating patterns-anorexia mostly some overeat and gain wgt
6.Sleep pattern disturbances-key sign with terminal insomnia or hypersomnia
7.Change in bowel habits is common-constipation
8.Diarrhea sometimes occur with psychomotor agitation
9.Loss of libido-problems with spouse

Front 21

Communication and Social Symptoms in Depression

Back 21

1.Slow speech-muteness possible
2.Comprehension is slowed-more time is needed client to reply
3.Problems at work with organizing, initiating , completing tasks
4.Withdrawal from family and social interactions

Front 22

Suicide

Back 22

2 mil/yr 75 daily, 8th leading cause in US, 3rd amount 15-24, 4th for 10-14 yr old, men 4x
more, Native American and Alaskan native’s high rates
There is an increase in African American males
White men 85+ are highest (most saw MD month before)

Front 23

Factors associated with suicide

Back 23

Strongest risk factors-depression, SA, separation divorce, physical illness
A central underlying factor is hopelessness due to losses
Experienced overwhelming moods like rage or guilt
Personal threat-job, humiliation, possible incarceration
Id with suicide victim (copycat)
Wants to die, sees no other solution
Copycat,
Develops highly specific plan with lethal methods and low rescue potential
May show increased energy and mood after deciding on plan
Questions relationship with god
Has highly intrusive thought of suicide

Front 24

Psychobiological Factors in Suicide

Back 24

?

Front 25

Biochemical Factors in Suicide

Back 25

genetics, serotonin, hormones- did not give enough time to get information

Front 26

Adolescent and Suicide

Back 26

invincibility of teens may lead to dangerous risk taking,
Suicide by imitation concern

Front 27

Social isolation and suicide

Back 27

divorces, separation, and single marital status

Front 28

Severe life events and suicide

Back 28

(death, sickness, blows to self-esteem, and interpersonal problems new person in home, having to appear in court)

Front 29

Nursing Assessment and Suicide

Back 29

SAD person scale is used to evalute10 major risk factors for suicide potential. The higher the score, the greater the risk and the greater the need for hospitalization
Verbal cues: overt: “life isn’t worth living anymore
Covert: you won’t have to bother with me much longer
Behavioral clues: writing farewell notes and give away prized possessions
? clues include sleep disturbance, wgt loss, and focus on somatic symptoms
Emotional clues include social withdrawal, feeling of hopelessness, and complaint of exhaustion

Front 30

Assessment of Suicide

Back 30

relief to talk to someone about their despair.
Ask specific questions- pg 603
“Are you experiencing thoughts o f suicide?”
“Do you have a plan for committing suicide?
If yes, what is your plan?

Front 31

Lethality of Suicide Plan

Back 31

1.Specificity of details of the plan( more details the higher the risk)
2. Lethality of proposed method- i.e., how quickly the person would die (high-risk methods=gun, jumping off a high place, hanging inhaling carbon monoxide, and staging a car crash) low-risk methods include wrist slashing, ingesting pills
3.Availability of means- available risk is greater

Front 32

Assessing Risk for Suicide:
No or very low risk:

Back 32

1.Fleeting suicidal ideation
2.Mild thoughts of suicide
3.States will not make attempt
4.Uses support system
5.Identifies purpose for living

Front 33

Assessing Risk for Suicide:

Low Risk

Back 33

1.Thinks of suicide as way of problem solving
2.Wants to sleep and never awaken
3.Wants to escape more than to die
4.No explicit plan
5.Has supports but doesn’t use them
6.Deterred by religious beliefs

Front 34

Assessing Risk for Suicide:

Moderate to High Risk

Back 34

Needs Hospitalization
1.Makes gestures
2.Has intrusive thoughts of suicide
3.Tells others of suicidality
4.Gives away belongings
5.Puts legal matters in order
6.Does not use support system
7.Rationalizes religious beliefs

Front 35

Assessing Risk for Suicide:

High Risk

Back 35

Needs hospitalization
1.Specific plan and means of carrying out plan
2.No hope or reason to live

Front 36

Planning: identify suicide precautions needed-hospitalize versus outpatient

Back 36

1.Specificity of plan
2. of method
3.Availability of means
If outpatient, identify supports available, crisis intervention

Front 37

No-Suicide Contract

Back 37

I will talk to my counselor or someone else if I have thoughts of self-harm
I will wait until next week when I see my counselor before I take any action to harm myself
I will go to the hospital ER if I start having suicidal impulses
I won’t kill myself accidentally or on purpose for any reason

Front 38

Intervention for Suicide

Back 38

A.Primary- provide information and support
B.Secondary- treatment of crisis
C. Tertiary- interventions after attempt or completed suicide

Front 39

Health care worker’s reactions to suicidal patients

Back 39

1.Anxiety related to buried suicidal inclination in self or feelings of personal rejection by patient
2.Irritation associated with believing client is trying to get attention
3.Avoidance in response to feelings of helplessness
4.Denial of seriousness of suicidal ideation as way of avoiding feelings aroused by suicidal person

Front 40

Intervention in Recovery and treatmen

Back 40

Three phases in treatment and recovery from major depression
1.The acute phase (6-12 weeks) psychiatric management and initial treatment
2.The continuation phase (4-9 months) treatment continues to prevent relapse
3.The maintenance phase – continuation of antidepressants to prevent relapse

Front 41

Implementation for nursing as per Suicide: Physical

Back 41

1.Appetite-small high cal. Protein-food preferences, weigh
2.Sleep- out of bed, rest periods, decrease stimuli
3.Self-care, encourage, assist
4.Elimination-I&O fiber, fluids
5.Encourage exercise

Front 42

Implementation for nursing as per Suicide: Psychological

Back 42

6.Identify support persons
7.Structure calm environment
8.Teach relaxation, coping skills
9.Medication regimen

Front 43

Implementation for nursing as per Suicide: Communication

Back 43

1. May be unable to carry on conversation
2. Use technique of making observation: use simple, concrete words;
3. Allow time for client to respond
4. Listen for covert messages and ask about suicide plans
5. Avoid cliché or false reassurance
6. Help clients question underlying assumptions and beliefs and consider alternative explanations
7. Work with clients to identify cognitive distortions that encourage negative self-appraisal
8. Encourage activities that raise self-esteem
9. Assist in forming supportive relationships
10. Provide referrals to religious or spiritual resources as needed

Front 44

Specific types of interventions:

Back 44

Interpersonal psychotherapy focuses on the role of dysfunctional interpersonal relationships

1.Counseling should include clarification of interpersonal stresses and discussion of measure to reduce tension for the family system
2.Cognitive behavior therapy teaches the connection btw thoughts and feelings and the reframing of thinking
3.Behavioral component may be used to teach depressed clients effective social and coping skills
4.Group treatment and group therapy may also be helpful
5.Possible use of aftercare facilities can be explored

Front 45

Health Teaching:

Back 45

1.Help pts and families understand that depression is a medical illness
2.Biological symptoms of depression should be explained.
3.Teaching about medications

Front 46

Milieu Therapy: Depression & Suicidal thoughts

Back 46

1.Hospitalization is necessary for acutely suicidal thoughts, regulate medication or for ECT
2.Milieu protocols for safety : removal of potentially dangerous objects, 1:1 observation,
3.Supportive groups may also be helpful

Front 47

Treatments for Suicidal Ideologies

Back 47

1.Antidepressants can positively alter poor self-concept, degree of withdrawal, vegetative symptoms, and activity level
2.It may be necessary to take antidepressants for up to 3 weeks before response is shown
See tables under psychotropic medications pg 249- know patient and family teaching
Know: 1st line agents are considered to be SSRI’s , nobel antidepressants and tricyclics
2nd line agents are MAOI’s and ECT
Selective Serotonin Reuptake Inhibitors are 1st line therapy
1.Low anticholinergic side effects, low cardiotoxicity, and faster onset of action than tricyclics
2.Client compliance is better than with other antidepressants
3.SSRIs are prescribed with success for several anxiety disorders and for some clients with dysphonic disorder
4.Serious side effects include central serotonin syndrome (CSS) (feels like the flu), abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, delirium, moclonus, irritability, hyperpyrexia, cardiovascular shock

Front 48

Other Reuptake Inhibitors (newer)

Back 48

1. Cymbalta- mechanism unknown-inhibits serotonin and norepinephrine reuptake and dopamine reuptake (somewhat
2. Midalcipran- affects both norepinerpherine, serotonin reuptake equally (NSRI)

Front 49

Novel Antidepressants

Back 49

Nefazodone (Serzone), Venlafaxine (Effexor), Bupropion hydrochloride (Wellbutrin)
a. Affective for some clients who do not respond to TCAs
b. Safer than tricyclic and MAOI
c. Side effects include nausea, somnolence, dry mouth, dizziness, anorexia, abnormal ejaculation

Front 50

Cyclic Antidepressants

Back 50

a. Act by inhibiting reuptake of norepinephrine and serotonin by the presynaptic neurons
b. Require 10-14 days or longer to act-used only when new ones not effective
c. Common side effects: anticholinergic effects such as dry mouth, blurred vision, constipation, urinary retention, tachycardia, orthostatic hypotensionesophageal reflux
d. Serious side effects: cardiac dysrhythmia, myocardial infarction, heart block
e. Adverse drug interactions may occur when TCAs are taken with MAOIs, phenothiazines, barbiturates, disulfiram, oral contraceptives, anticoagulants, benzodiazepines, alcohol, nicotine, and some antihypertensives
f. Administer at night-sedative effects will aid sleep and minor side effects will occur during sleep when the client is unaware of them (fosters compliance)

Front 51

Monoamine Oxidase Inhibitors

Back 51

effective treatment for atypical depression and several anxiety disorders
a. Common side effects: orthostatic hypotension, wgt gain edema, change in heart rate and rhythm, constipation, urinary hesitancy, vertigo, hypomanic or manic behavior, insomnia, weakness, fatigue
b. Adverse reactions are an increase in BP with possible stroke, hyperpyrexia, convulsions, and death with tyramine-containing foods
c. Contraindications include: cerebrovascular accident, congestive heart failure, hypertension, liver disease, foods containing tyramine, tryptophan, and dopamine

Front 52

Electroconvulsive Therapy

Back 52

a. Given when a rapid response is needed to prevent suicide; extreme agitation or stupor occurs; risks of other treatment outweigh risks of ECT; there is poor response to drugs; or when a client prefers it
b. It is useful for major depressions and manic clients who are rapid cyclers
c. The procedure requires informed consent and preparation is similar to preoperative preparations; post-treatment is similar to care of unconscious client
d. Potential side effects: confusion, disorientation

Front 53

Alternative and Complementary Therapies

Back 53

a. Light therapy treats seasonal affective disorders-probably effective because of influence of light on melatonin
b. St. john’s Wort- plant product found to be somewhat effective for mildly to moderately depressed individuals. It interacts with a number of substances and drugs and my produce CSS and hypertensive crisis when tyramine is ingested
c. Exercise is effective against mild depression-stimulates endorphins, increases blood flow
d. Transcranial magnetic stimulation, a new technology, exposes the cerebral cortices to an electromagnetic field. There is no seizure induction. More research is indicated to evaluate its effectiveness- causes cells in cerebral cortex to fire

Front 54

Stress response and assertive commication techniques

Back 54

3 R's
Relax-deep breath
Reflect- use self-talk
Respond-

Front 55

Some periods of Maturation that Erik Erikson identified as risk for anxiety or stress increases

Back 55

mastering control of body functions, starting school, experienceing puverty, leaving home, getting married, becoming a parent, losing physical youthfulness, and entering retirement

Front 56

Crisis intervention is used for which?

Back 56

the physical manifestations of stress, what is going on now?
or the event that precipatated the crisis?

it is the 2nd

Front 57

What is the first assessment made by the nurse?

Back 57

the nurse first determines the client's perception of the stressful event. How theratened is the pt? is the client realistic or distorting the meaning of the event?

Front 58

What is the 2nd assessment made by the nurse?

Back 58

the nurse next focuses on who is available to support the client. Whom do you trust?, Who is your best friend?

Front 59

To assess coping skills what does the nurse ask?

Back 59

what do you do when a problem is difficult to resolve or how do you deal with anxiety or depression. find out what they do to cope. Do they have maladaptive coping skills, for ex: do they drink, do drugs, hurt themselves?

Front 60

The next item to ask a client is?

Back 60

Do you think about hurting yourself?

Front 61

Balancing factors:

Back 61

1.realistic perception of the event
2. adequate situational support
3. adequate coping mechanisms
4. resolution of the problem
5. equilibrium regained
6. no crisis

Front 62

One or more balancing factors absent

Back 62

1. distorted perception of the event
2. no adequate situational support
3. no coping mechanisma
4. results in problem unresolved
5. disequilibrium continues
6 crisis

Front 63

The nurse can teach the client to ask for help how?

Back 63

by role=playing

Front 64

Using Adaptive Coping

Back 64

help client develop:
openly express feelings
recognize that changing thoughts will change feelings,
using self-talk,
engaging in progressive relaxation,
exercising,
using various sleep hygiene techniques to aid relaxation and sleep