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83 Cards in this Set

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Transference and Countertransference
transference: client's unconscious displacement of feelings for significant people in the past onto the nurse in the current relationship

countertransference: nurse's emotional rxn to the client based on significant relationships in the nurse's past
Patients' Rights
Freedom from Seclusion and Restraint

Right to refuse treatment

Confidentiality

Informed consent
Exceptions to Client Right of Confidentiality
When duty to warn and protect are mandated

When a nurse is a mandated child/elder abuse reporter

State laws requiring reporting of certain communicable diseases

State laws requiring reporting of gunshot wounds

State laws that do not give nurses "privilege" (re: disclosures made within the context of the nurse-client relationship)
Duty to Warn aka Tarasoff
if a patient has a history of physical violence known to the licensed health care provider, and the provider has a reasonable basis to believe that there is a clear and present danger the patient will harm the victim, there is a duty to warn

identify the potential victim; document all communication (patient, nurse, victim, police); keep copies of letters/receipts
Dopamine (DA)
monoamine

➧involved in fine muscle movement, integration of emotions and thoughts, decision-making
➧stimulates hypothalamus to release hormones (sex, thyroid, adrenal)

↓: Parkinson's disease; depression

↑: schizophrenia; mania
Norepinephrine (NE) (noradrenaline)
monoamine

➧level in brain affects mood
➧attention & arousal
➧stimulates sympathetic branch of autonomic NS for "fight or flight" in response to stress

↓: depression

↑: mania; anxiety states; schizophrenia
Serotonin (5-HT)
monoamine

➧plays a role in sleep regulation, hunger, mood states, pain perception, aggression and sexual behavior
➧hormonal activity

↓: depression

↑: anxiety states
Histamine
monoamine

➧involved in alertness & inflammatory response
➧stimulates gastric secretion

↓: sedation; weight gain
Gamma-aminobutyric acid (GABA)
amino acid

➧plays a role in inhibition, reduces aggression, excitation, anxiety
➧may play role in pain perception
➧anticonvulsant and muscle-relaxing properties
➧may impair cognition & psychomotor functioning

↓: anxiety states; schizophrenia; mania; Huntington's disease

↑: reduction of anxiety
Glutamate (NMDA, AMPA)
amino acid

➧excitatory
➧AMPA plays role in learning & memory

↓NMDA: psychosis

↑NMDA: prolonged increased state can be neurotoxic; neurodegeneration in Alzheimer's

↑AMPA: improvement of cognitive performance in behavioral tasks
Acetlycholine (ACh)
cholinergic

➧plays role in learning & memory
➧regulates mood: mania & sexual aggression
➧affects sexual & aggressive behavior
➧stimulates parasympathetic NS

↓: Alzheimer's; Huntington's; Parkinson's

↑: depression
Medical Conditions That May Mimic Depression
neuro: CVA; MS; seizures

infections: mono; hepatitis; HIV

endocrine: Cushing's; thyroid

GI: cirrhosis; pancreatitis

CV: hypoxia; CHF

Resp: sleep apnea

nutritional: vitamin & protein deficiencies

Collagen vascular: Lupus; RA

cancer
Medical Conditions That May Mimic Anxiety
neuro: CVA; Huntington's

infections: encephalitis; meningitis

endocrine: thyroid; hypoglycemia

metabolic: low CA, K; liver failure

CV: angina; CHF; PE

Resp: pneumothorax; asthma; emphysema

Drugs: stimulants; sedative withdrawal

lead, mercury poisoning
Medical Conditions That May Mimic Psychosis
medical: migrane HA; Addison's; HIV; temporal lobe epilepsy; occipital tumors; encephalitis; hypothyroid

drugs: hallucinogens; alcohol withdrawal; coccaine; corticosteriods
DSM-IV TR Criteria for Major Depressive Disorder
represents a change in previous functions

>5 Sx including depressed mood and/or anhedonia (for >2wks)
➧significant weight change
➧psychomotor agitation/retardation
➧pervasive loss of energy/fatigue
➧feelings of worthlessness/excessive or inappropriate guilt
➧difficulty concentrating
➧sleep disturbance
➧recurrent thought of death/suicide
Risk Factors for Major Depressive Disorder
genetic/bio: inheritance; female between menarche & menopause; male before young adulthood & after middle adulthood; Black American; high levels of neuroticism; postpartum period

environment/social: poverty; lack of social support; stressful event; substance abuse; medical co-morbidity; Southern USA residence; unmarried

other: sibling relationship, neonatal stress
Clinical Course of Major Depressive Episode
usually develops over days/weeks

episode is minimal 2wks

unTx lasts 6mon or more, but then remits in most cases

recovery of 8wks remission
Nursing Assessment of Major Depression
suicidal ideation

anhedonia & anergia

psychomotor retardation/agitation

vegetative signs

sad affect

slow and/or negative thinking

hopeless, helpless, worthless feelings

poor memory, concentration
Nursing Assessment for Suicide: SADPERSONAS
Sex, Age, Depression, Previous attempt, Ethanol use, Rational thought loss, Social supports lacking, Organized plan, No spouse, Access to lethal mass, Sickness

0-2: send home with follow up
3-4: closely follow up; consider hospitalization
5-6: strongly consider hospitalization
7-10: hospitalize or commit
Risk Factors for Suicide
family Hx; males; Hx attempts; Native American; substance abuse; White; mini epidemic in community; Hx delinquency w/o depression; firearms presence; suicidal ideation; plan; co-occurring psych/medical illness; Hx abuse; lack of social support; unemployment; recent stressful life event; hopelessness; panic attacks; feelings of shame/humiliation; impulsivity; aggressiveness; loss of cognitive function; impending incarceration; low frustration tolerance; sexual orientation issues

if no Hx, SEX + AGE trumps all factors
males: 65+yo d/t loss of spouse, retirement, illness
females: 45-64yo d/t menopause, kids leaving, etc
Nursing Diagnoses for Major Depression
anxiety; decisional conflict; fatigue; grieving/dysfunctional; hopelessness; low self-esteem; risk for suicide; disturbed sleep pattern; imbalanced nutrition
Treatments for Major Depression
1st line = psychopharmacology plus:
➧problem-solving therapy for primary care (to develop coping skills)
➧interpersonal psychotherapy (to develop upon relationships, social skills and conflicts)

2nd line = psychopharmacology plus:
➧cognitive behavioral therapy (for problem solving, sleep, activation)
Serotonin Syndrome
reported in usage of: antidepressants, dopamine agonists, analgesics; wait 2wks after d/c MAOI & starting SSRI, wait 5-6wks when d/c SSRI & starting MAOI

associated w/: amphetamines, analgesics, antibiotics, anticonvulsants, antiemetics, antimigranine, bariatric, abuse, herbs, OTC

Sx: rapid onset of flu-like Sx = agitation, myoclonus, hyperreflexia, fever, shivering, diaphoresis, ataxia, diarrhea

Tx (moderate): d/c drugs; place on fall precautions; replace fluids

Tx (severe): admit ICU; administer cooling blankets (NOT NSAIDS) for temp; administer benzodiazepines for agitation
Indications for ECT
medication-refractory depression

psychotic depression

depression with medical complications

Hx of positive response to ECT

catatonia

mania unresponsive to medication
DSM-IV TR Criteria for Dysthymic Disorder
occurs over a 2yr period (1yr for kids), depressed mood

>2 Sx:
➧decreased/increased appetite
➧insomnia or hypersomnia
➧low energy or chronic fatigue
➧decreased self-esteem
➧poor concentration or difficulty making decision
➧feelings of hopelessness or despair
Protective Factors against Suicide
sense of responsibility to family; pregnancy; religion; satisfaction with life; positive social support; access to health care; effective coping skills; effective problem-solving skills; intact reality testing
Lethality of Suicide Plan
hard method: (ex) gun, jumping, hanging, CO poisoning

soft method: (ex) cutting, natural gas inhalation, pill ingestion

lethal if proposed method is available or psychotic/command hallucinations
Parietal Lobe
Sensory and motor

➧receive/ID sensory info
➧concept formation and abstraction
➧proprioception and body awareness
➧reading, math
➧right/left orientation
Frontal Lobe
Thought processes

➧formulate or select goals
➧initiate, plan, terminate actions
➧decision-making
➧insight
➧motivation
➧social judgment
➧start of voluntary motor ability
Temporal Lobe
Auditory

➧language comprehension
➧sound storage into memory (language, speech)
➧connects with limbic system (emotion) to allow expression of emotions
Occipital Lobe
Vision

➧interprets visual images
➧visual association
➧visual memories
➧involved with language formation
Bipolar I v Bipolar II
Bipolar I: combo of major depression & full manic episodes

Bipolar II: combo of major depression & hypomania
Mania v Hypomania
mania:
➧1wk duration
➧severe impairment in functioning
➧psychotic features

hypomania:
➧4day duration
➧change in functioning
➧no psychosis
Diagnostic Specifiers of Bipolar Disorder
mixed episodes: both manic and depressive episodes

hypomanic episode: same as manic but <4days

secondary mania: cause by medical disorders or Tx

rapid cycling: 4 or more episodes w/i 12mon
Neurological Findings of Bipolar Disorder
enlarged 3rd & lateral ventricles

smaller area/vol of corpus callosum

↓intracranial & white matter vol

hyperintensities revealed by T2 (weighted MRI) esp in frontal lobe

the more frequent the psychosis = the more damage to the brain
Circadian and Sleep Function Disruption in Bipolar Disorder
sleep disturbance & instability of 24h rhythms continue when BD pts are not acutely ill

biological sensitivity to light is a trait marker of BD

circadian rhythms (activity, body temp, melatonin, cortisol, thyrotropin) are altered in acute episodes
Bipolar Disorder in Children
characterized by intense rage episodes for up to 2-3hr in kids 5-10

Sx of BD reflect developmental level of child

often have other psychiatric d/o: ADHD, ODD

must distinguish from normal teen behavior

earlier onset = greater impairment
Bipolar Disorder in Elderly
more neuro abnorms & cognitive disturbances

poorer prognosis b/c of comorbid medical conditions
Bipolar Disorder in Pregnant Women
most women experience BPD episodes in 2wks postpartum

half experience exacerbation during pregnancy

10%-25% Dx w/ postpartum psychosis

Tx prophylactically
Nursing Assessment of Bipolar Disorder
observed: little sleep, little eating, thyroid issues, hypersexual, substance abuse

manic episode: euphoric for 1wk; great amt of energy/little need for sleep; talking fast; racing thoughts; easily distracted; inflated feeling of power; reckless behavior (money, sex, drugs); flamboyant appearance
Nursing Assessment of Hypomanic (Bipolar Disorder)
speech: humorous, pressured, loud, dramatic

affect: euphoric, poor judgment, grand schemes

thinking: grandiose ideas, inflated self-esteem, flight of ideas

psychomotor: ↑libido, sexually indiscreet, voracious appetite, sleeps only in naps
Nursing Assessment of Manic (Bipolar Disorder)
speech: vary labile, laughing to anger, excessive use of profanities

affect: anger & irritability, acutely sensitive to criticism

thinking: persecutory/sexual/religious delusions

psychomotor: naked in public areas, too hyper to eat/sleep
Nursing Assessment of Psychotic (Bipolar Disorder)
speech: out of touch w/ reality, use of clang expressions, speech so pressured it's incomprehensible

affect: physically threatening, verbally abusive, enraged

thinking: vivid visual hallucinations consistent w/ mood

psychomotor: extremely agitated, motor activity so unrelenting as to necessitate sedation/restraint
Nursing Diagnosis for Bipolar Disorder
Disturbed sleep pattern, sleep deprivation
Imbalanced nutrition, hypothermia, deficit fluid balance Disturbed sensory perception
Disturbed thought processes
Defensive coping
Risk for suicide Ineffective role performance
Interrupted family processes
Impaired social interaction
Impaired parenting
Compromised family coping
Risk for violence
Ineffective coping
Nursing Interventions for Bipolar Disorder
communication: firm, calm; be neutral; consistent limits; redirect energy

structured solitary activities (w/ staff)

frequent high calorie/protein snacks

encourage rest; reduce stimulation
Mental Status in Psychotic Depression
appearance: incapable of caring for self, poor hygiene

vegetative signs: severe psychomotor disturbances (retardation or agitation); regressive behavior

mood: extremely blunted affect; non-reponsive

thought content: nihilistic or paranoid delusions; somatic delusions of body rotting; may be secretive of delusions/suicidality
Postpartum Psychosis
S/S appear 3wks after delivery

mood: extreme feelings of worthlessness, tearfulness, anxious

thoughts: inordinate concern w/ baby's health; delusions of baby being defective/dead; auditory hallucinations to harm baby

impulsivity: baby may be subjected to physical abuse/death

prognosis: 95% improve to premorbid state in 2-3mon w/ conventional Tx for psychotic depression
Familial and Environmental Risk for Schizophrenia
familial: genetic inheritance

environment: stress in womb, LBW, maternal infection; cannabis use
Neuroanatomical Findings in Schizophrenia
grey matter loss

↓frontal lobe activity

atrophy of amygdala, hippocampus & parahippocampus

irregular dopamine pathways
Signs and Symptoms of Schizophrenia
positive: hallucinations; delusions; disorganized speech; bizarre behavior

negative: blunted affect; poverty of thought (alogia); loss of motivation; inability to feel pleasure/joy (anhendonia)

cognitive: inattention/easily distracted; impaired memory; poor problem-solving; poor decision-making; illogical thinking; impaired judgement

co-occuring problem: anxiety; depression; substance abuse; suicide

what's affected: occupation; interpersonal relationships; self-care; social functioning; quality of life
DSM IV Diagnosis of Schizophrenia
during 1mon period, at least 2 of following 5 conditions:

➧positive Sx
➧negative Sx
➧1 or more areas of social/occupational limits in functioning
Types of Schizophrenia
paranoid: paranoid delusions or hallucinations predominate

disorganized: incoherence, extreme social malfunctioning

catatonic: marked ↓ in reactivity to the enviro

undifferentiated: can't classify in just one of the above categories

residual: signs of illness present, but not as prominent as in the other types; functioning but chronically impaired
Bizarre Delusions of Schizophrenia
persecutory: being singled out for harm by others

delusions of reference: in which events/people have particular and unusual significance (ex. a TV commentator is mocking him)

thought broadcasting: thoughts are broadcast from one's head to the external world so that others can hear them

thought insertion: thoughts that are not one's own are being inserted in one's head

grandiose: false belief that one is a very powerful & important person

somatic: false belief that the body is changing in an usual way
Prominent Hallucinations of Schizophrenia
auditory:
➧frequently involve voices (singular or multiple; often insulting/persecutory)
➧command hallucinations (voices that demand the person behave in a certain way)
➧occasionally sounds instead of voices

tactile: typically involve electrical, tingling or burning sensations

somatic: sensations of snakes crawling inside the abd

visual: seeing a person, object, or animal that does not exist in the environment

gustatory: tasting sensations which have no stimulus in reality

olfactory: smelling odors that are not present in the environment

VISUAL, GUSTATORY & OLFACTORY occur but with less frequency and raise the possibility or organic mental disorder or drug induced psychosis (ex. LSD or cocaine)
Phases of Schizophrenia
1. prodromal

2. active

3. residual or chronic

4. remission
Prodromal Phase of Schizophrenia
first phase

onset: teen or young adult

Sx: sleep disturbance; anxiety; irritability; deterioration in role; depression; social withdrawal; poor concentration; suspiciousness; loss of motivation; perceptual disturbance; motor changes; weight loss

at risk: suicidal thoughts; self-harm; cannabis use 4x higher

Tx: low dose atypical antipsychotic; CBT

GOAL: reduce risk of transition to psychosis
Active Phase of Schizophrenia
second phase

onset: develops <1yr after prodromal phase; 18-25yo male, 25-35yo female

active psychosis injures the pathological processes in the brain

GOAL: reduce the morbidity of schizophrenia w/ effective initial Tx
Residual or Chronic Phase of Schizophrenia
third phase

20%-40% Tx resistant; 35% yearly relapse rate
Remission Phase of Schizophrenia
forth phase

10yrs after 1st episode 10% will have less Sx

30yrs after 1st episode 25%-35% have minimal Sx
Prognosis for Schizophrenia
dependent on: age of onset; early intervention w/ meds; vocation/rehab Tx; CBT; family Tx & support; socioeconomic status; substance abuse

predictors for nonremission: noncompliance w/ antipsychotics; persistent substance use

predictors of remission: younger age; employed; living independently; early Tx w/ atypical antipsychotics; early intervention
Nursing Diagnosis for Schizophrenia
Disturbed thought processes
Disturbed sensory perceptions
Disturbed body image
Risk of violence, suicideSelf-care deficit
Disturbed sleep pattern
Ineffective therapeutic regimen management
Imbalanced nutrition
Excess fluid volume
Schizophrenia PORT Guidelines for Psychosocial Treatments
#1 Assertive Community Treatment
#2 Supported Employment
#3 Skills training
#4 CBT
#5 Token Economy Interventions
#6 Family Based Treatment
Continuum of Care for Schizophrenia (Nursing Intervention)
Support groups
Half-way or residential treatment
Partial Hospital
Psychiatric rehabilitation or Sheltered workshop
Family interventions: support groups; local and state resources; help negotiate provider system

Supported Employment Programs/Individual Placement and Support Model: Ongoing individual support provided indefinately; small caseload for employment consultant

Social Skills Training: Vocational skills; Social Milieu Training; Self-Care Activities; Communication Skills
Psychotic Disorders Other Than Schizophrenia
schizophreniform disorder: <1mon, >6mon; impaired social/occupational functioning but may not develop into schizophrenia

brief psychotic disorder: sudden onset of psychosis or disorganized catatonic behavior lasting >1day and <1mon; often precipitated by stressors & return to premorbid functioning

schizoaffective disorder: MDD, manic, or mixed mood episode presenting w/ schizophrenia Sx

delusional disorder: nonbizarre delusions for 1mon; no marked impairment

shared psychotic disorder (folie a deux): one person shares delusions of someone they are close with; much smaller impairment than other person

induced or secondary psychosis: from substances or medical conditions
In a behavioral managed care system, if a client who has stopped taking psychotropic medication requires hospitalization for crisis management, what length of stay would be identified in the treatment plan?
Cost containment dictates that the shortest possible stay would be chosen. This might be from 48 to 96 hours, but probably less than 1 week. Clients seem to fare well with brief hospitalization and rapid return to the community as long as the problems that precipitated admission can be resolved before discharge.
An ongoing, critically important responsibility of nurses working on an inpatient psychiatric unit is...
Nursing is the discipline primarily responsible for maintenance of a therapeutic milieu, an environment that serves as a real-life training ground for learning about self and practicing communication and coping skills in preparation for a return to the community outside the hospital.
Which is a characteristic of a therapeutic inpatient milieu?
Because the acuity level on inpatient units is high, nurses are responsible for ensuring that the environment is safe and that elopement and self-harm opportunities are minimized.
What three structural components comprise a nursing diagnosis?
The components of the nursing diagnosis are problem, etiology, and supporting data.
Maslow's theory of human needs has provided nursing with a framework for...
holistic assessment

Central to Maslow's theory is the assumption that human beings are active rather than passive participants in life, striving for self-actualization. Maslow (1968) focuses on human need fulfillment, which he describes in six incremental stages, beginning with physiological survival needs and ending with self-transcendent needs (Figure 2-2). Although these needs are present in all human beings, the behaviors that emanate from them differ according to a person's individual biological makeup and environmental factors. This picture is broader and more holistic.
The premise underlying behavioral therapy is...
The premise underlying behavior therapy is that behavior is learned and can be modified. Behaviorists agree that behavior can be changed without insight into the underlying cause.
Sullivan viewed anxiety as...
According to Sullivan, the purpose of all behavior is to get needs met through interpersonal interactions and decrease or avoid anxiety. He viewed anxiety as a key concept and defined it as any painful feeling or emotion arising from social insecurity or blocks to getting biological needs satisfied.
Which client problem would be most suited to the use of interpersonal therapy?
Interpersonal therapy is considered to be effective in resolving problems of grief, role disputes, role transition, and interpersonal deficit.
A cognitive therapist would help a client restructure the thought "I am stupid!" to...
"What I did was stupid."

Cognitive therapists help clients identify, reality test, and correct distorted conceptualizations and dysfunctional beliefs, such as realizing that doing a stupid thing does not mean the person is stupid.
Freud believed that individuals cope with anxiety by using...
The ego develops defenses or defense mechanisms to ward off anxiety by preventing conscious awareness of threatening feelings.
What effect of stress can be attributed to stimulation of the hypothalamus-pituitary-adrenal cortex in the short term?
Increase of gluconeogenesis stimulated by release of cortisol ensures increased amounts of glucose are available to the individual. Increased glucose levels heighten and maintain energy levels to meet the demands of a crisis or stressor.
What effect of stress can be attributed to stimulation of the hypothalamus-pituitary-adrenal cortex over the long term?
Insulin resistance and obesity are considered long-term sequalae of the high blood glucose levels incurred when the body responds to stress.
A nurse is asked by a client about the basis for use of alternative and complementary therapies. The best reply would incorporate the information that alternative and complementary therapies are based on...
Culture and long experience with certain remedies are the basis for many alternative and complementary therapies.
When a nurse is asked to give an example of an alternative medical system, the best example would be...
Homeopathy is listed as one of the five major domains of complementary and alternative health care by National Center for Complementary and Alternative Medicine. Other examples are oriental medicine and naturopathy.
Using a minute amount of a substance that produces the same symptom as that of the client's chief symptom to stimulate the body's immune system is the rationale for use of the remedies prescribed in...
Homeopathy attempts to stimulate the body's immune system to relieve the client's distress and uses tiny amounts of substances known to produce the symptoms from which the client is experiencing.
Beck suggests that the etiology of depression is related to...
Beck is a cognitive theorist who developed the theory of the cognitive triad of three automatic thoughts responsible for people becoming depressed: (1) a negative, self- deprecating view of self, (2) a pessimistic view of the world, and (3) the belief that negative reinforcement will continue.
no-suicide contract
A no-suicide contract is quite straightforward in seeking a promise not to kill oneself within a specified period. When that time expires, a new contract is negotiated.
The nurse is working with a client who has very low self-esteem and is distrustful of unit staff. The client is facing role transition from wife to wife and mother. According to Maslow's theory, the priority problem for the nurse to address is...
establishing trust with the client.

Maslow describes basic needs as "D-motives" or "deficiency needs," meaning that they are so basic to existence that they must be resolved to reduce the tension associated with them. These needs have the greatest strength and must be satisfied before a person turns his attention to higher-level needs.
One of the values of Maslow's model for nursing care is that it helps the nurse...
identify that human potential and the client’s strengths are key to building nurse-client relationships.

The value of Maslow's model in nursing practice is twofold. First, the emphasis on human potential and the client's strengths is key to successful nurse-client relationships. The second value lies in establishing what is most important in sequencing of nursing actions in the nurse-client relationship.