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224 Cards in this Set
- Front
- Back
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Specific measurable symptoms that are expected to to improve with treatment
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Target symptoms
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Unwanted effects of medications
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Side effects
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If unwanted effects have serious physiologic consequences
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Adverse Reactions
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Adverse reactions range from _____ to ______.
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Mild; severe
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Intervention for:
Blurred Vision |
Reassurance
(generally subsides in 2 to 6 weeks) |
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Intervention for:
Dry mouth and lips |
Frequent rinsing of mouth, good oral hygiene, sucking sugarless candies or lozenges, lip balm, lemon juice, and glycerin mouth swabs
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Intervention for:
Dry Eyes |
Artificial tears may be required; increase use of wetting solutions for those wearing contacts, Alert opthalmologist; no eye examination for new glasses for at least 3 wk after a stable dose
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Intervention for:
Constipation |
High fiber diet; encourage bran , fresh fruits and vegies
Metamucil (must consume at least 16oz of fluid with dose) Increase hydration Exercise; increase fluids Mild laxative |
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Intervention for:
Urinary hesitancy or retention |
Monitor frequently for difficulty with urination,including changes in starting or stopping stream
Notify prescriber if difficulty develops A cholinergic agonist, such as bethanichol, may be required |
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Intervention for:
Nasal congestion |
Nose drops, moisturizer, not nasal spray
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Intervention for:
Sinus Tachycardia |
Assess for infections
Monitor pulse for rate and irregularities Withhold medication and notify prescriber if resting rate exceeds 120 beats / min |
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Intervention for:
Decreased labido, anorgasmia, ejaculatory inhibition |
Reassurance (reversible); change to another medication
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Postural Hypotension
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Frequent monitoring of lying-to-standing blood pressure during dosage adjustment period, immediate changes and accommodation, measure pulse in both positions; consider change to less anti-adrenergic drug
Advise pt to move slowly, avoid caffeine, increase hydration Change meds if persists |
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Intervention for:
Photosensitivity |
Protective clothing
Dark glasses Use of sunblock; remember to cover all exposed areas |
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Intervention for:
Dermatitis |
Stop medication usage
Consider medication change; may require a systemic antihistamine Initiate comfort measures to decrease itching |
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Intervention for:
Impaired psychomotorfunctions |
Advise patient to avoid dangerous tasks, such as driving
Avoid alcohol, which will increase this impairment |
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Intervention for:
Drowsiness and sedation |
Encourage activity during the day to increase accomodation
Avoid tasks that require mental alertness, such as driving May need to adjust schedule or, if possible, give a single dose at bedtime May need a cholinergic medication if sedation is the problem Avoid driving or operating potentially dangerous equipment May need to change medication Provide quiet and decreased stimulation when sedation is the desired effect |
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Intervention for:
Weight gain and metabolic changes |
Exercise and diet teaching
Caloric count |
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Intervention for:
Edema |
Check fluid retention
Reassurance May need a diuretic |
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Intervention for:
Irregular menstruation or amenorrhea |
Reassurance (reversible)
May need to change class of drug Reassurance and counseling (does not indicate lack of ovulation) Instruct patient to continue birth control measures |
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Intervention for:
Vaginal dryness |
Instruct use of lubricants
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Is responsible for the safety, efficacy, and security of human and veterinary drugs, biologic products, medical devices, our nation's food supply, cosmetics, and products that emit radiation
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Food and Drug Administration
FDA |
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If a medication is ordered and administered for a condition that is not approved by the FDA it is considered
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Off-label use
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the action or effects of drugs on living organisms
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Pharmacodynamics
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specific proteins intended to respond to a chemical
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Receptors
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substances that initiate the same response as the chemical normally present in the body are
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Agonists
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substances that block the response of a given receptor are
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Antagonists
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A drugs ability to interact with a given receptor type may be judged by what three properties?
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- Selectivity
- Affinity - Intrinsic activity |
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Psychiatric medications primarily target the CNS at the cellular, synaptic level, at what four sites?
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- Receptors
- Ion channels - Enzymes - Carrier Proteins |
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The ability of a drug to be specific for a particular receptor
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Selectivity
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____ ____ drugs will interact only with its specific receptors in the areas of the body where these receptors occur and therefore not affect tissues and organs where its receptors do not occur.
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Highly selective
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The ___ ___ the drug, the more receptors are affected and the more likely there will be unintended effects or side effects.
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Less selective
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The degree attraction or strength of the bond between the drug and its biologic target
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Affinity
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If a cell has more than one receptor to which a drug will adhere the affinity is ______.
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Increased
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A drug's ability to interact with a given receptor is
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Intrinsic Activity
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Some drugs directly block ____ _____ of the nerve cell membrane.
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Ion Channels
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Usually proteins that act as catalysts for physiologic reactions and can be targets for drugs
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Enzymes
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membrane proteins that transport a specific molecule across the cell membrane
recognizes sites specific for the type of molecule to be transported |
Carrier Proteins
(AKA uptake receptors) |
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The ability of a drug to produce a response and is considered when a drug is selected
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Efficacy
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refers to the dose of drug required to produce a specific effect.
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Potency
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If a drug is able to produce an effect at a lower dose it is said to be _____ potent.
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more potent
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rapid decrease in drug effects that may develop in a few minutes of exposure to a drug
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Desensitization
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True or false
Desensitization is common in psychiatric medications. |
False
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a gradual decrease in the action of a drug at a given dose or concentration in the blood.
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Tolerance
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the point at which concentrations of the drug in the bloodstream are high enough to become harmful or poisonous to the body
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Toxicity
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the ratio of the maximum nontoxic dose to the minimum effective dose
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Therapeutic index
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Means there is a large range between the dose at which the drug begins to take effect and a dose that would be toxic to the body
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High therapeutic Index
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Therapeutic index may be changed by co-administration of drugs.
True or False |
True
Alcohol consumption with the use of CNS-depressant drugs increases the chances of toxicity and or death |
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Variable rates and extent of absorption, depending on the drug
May be affected by the contents of the intestines |
Disadvantages of Oral tablet Medications
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Usually the most convenient route
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Oral Medication
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Basic prep. for most psychparmacologic agents, including antidepressants, antipsychotics, mood stabilizers, anxiolytics
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Oral Tablet
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Two classes of antipsychchotic drugs
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Typical
Atypical |
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Antipsychotic drugs are given for
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- schizophrenia, mania, autism, psychosis
- Symptoms of psychosis - Hallucinations, delusions - bizarre behavior |
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Absorption of antipsychotics
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-Varies with route
- Oral admin |
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Atypical drugs end in
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- ole
-pine - done - dal |
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Typical drugs end in
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- zine
- ixene - dol |
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Exceptions to Typical ending
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Molidone
Loxapine Both are Typical |
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Mood stabilizers Gold Standard
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Lithium
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Examples of Anticonvulsant Mood Stabilizers are:
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- Valproic Acid (Depakote)
- carbamazepine (Tegrol) - Lamotrigine (Lamictal) - Topiramate (Topamax) - Oxacarbazepine (Trileptal) - gabapentin (Neurontin) |
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Mood stabilizers include:
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- Lithium
- Anticonvulsants - Calcium channel blockers - Adrenergic blocking agents - Atypical antipsychotics |
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SSRI Antidepressants include:
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- fluoxitine (Prozac)
- citalopram (Celexa) - escitalopramoxalate (Lexapro) - setraline (Zoloft) - paroxetine (Paxil) - fluoxamine (Luvox) |
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SNRI Serotonin Norepinephrine Reuptake Drugs include
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- venlafaxine (Effexor)
- nefazodone (Serzone) - duloxetine (Cymbalta-sleep) - desipramine (Norpramine) |
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Tricylic Antidepressants (TCAs) include:
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- amitryptyline (Elavil)
- clomipramine (Anafranil) - doxepin (Sinequan) - imipramine (Tofranil) - trimipramine (Surmontil) - amoxapine ( Asendin) - desparimine (Norpramin) - nortiptyline (Aventyl, Pamelor) - protryptyline (Vivactil) |
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MAOI's (Monoamine Oxidase Inhibitors) Include:
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- phenelzine (Nardil)
- trancypromine (Parnate) - selegiline (Emsam) trans-dermal patch |
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Antianxiety and Sedative - Hypnotic Medications: Benzodiazepines include
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- alprazolam (Xanax)
- lorazepam (Ativan) - diazepam (Valium) - chlordiazepoxide (Librium) - flurazepam (Dalmane) - triazolam ( Halcion) - oxazepam (Serax) |
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Antianxiety and Sedative - Hypnotic Medications: Nonbenzodiazepines
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- Busprirone (Buspar)
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• Adverse reactions(serious) (side effects and allergic rxns-immunologic) include:
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o Allergies(unwanted that vary in degree and consequences can be life threatening, less common) and side effects(unwanted)
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o Mechanisms Causing Decreases in Medication Effects
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Change in receptors
Loss of receptors Exhaustion of NT supply Increased metabolism of the drug Physiologic adaption |
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process by which a drug is absorbed, distributed, metabolized, and eliminated by the body
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Pharmacokinetics:
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• Absorption
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Drug from administration site into plasma
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Factors that affect distribution
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Size of organ
Amount of blood flow Perfusion within organ Solubility Plasma protein binding Anatomic barriers Blood-brain barrier |
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Solubility
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Ability for drug to dissolve
Psych drugs lipid soluble: blood brain barrier (to protect brain, keep things out) |
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o Protein Binding
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Unbound molecules can act at receptor sites
High protein binding reduces concentration at receptor site |
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(process by which a drug is altered and broken down into smaller substances called metabolites)
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• Metabolism/biotransformation
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• Excretion
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Removal of drugs from the body either unchanged or as metabolites
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Total volume of blood, serum, or plasma from which drug is completely removed per unit of time
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o Clearance
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Individual Variations in Drug Effects include
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• Age
• Ethnopsychopharmacology o cultural variations and differences influencing effectiveness |
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Complete pysch eval
Physical and history assessment Meds are started Closely watched |
• Initiation phase
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Medication being titrated
Ongoing monitoring Looking for target signs and symptoms Is they problem getting better Side effects starting Happen in this phase Augmentation Adding another medication polypharmacy |
• Stabilization
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Improved
Continued to prevent relapse |
• Maintenance
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Closely tapered
Prevent withdrawing |
• Discontinuation
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Antipsychotic Medications (schizophrenia, mania, autism, psychosis)• Indications:
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schizophrenia; mania; autism; and the symptoms of psychosis, such as hallucinations, delusions, bizarre behavior, disorganized thinking, and agitation
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Antipsychotic Medications (schizophrenia, mania, autism, psychosis • Absorption:
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variable with oral administration; IM administration less variable (avoid first-pass effects); long-acting preparations (IM injection every 2–4 weeks)
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Antipsychotic Medications (schizophrenia, mania, autism, psychosis • Metabolism:
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liver
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Antipsychotic Medications (schizophrenia, mania, autism, psychosis • Excretion:
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slow; half-life of 24 hours and metabolites with longer half-lives; high lipid solubility
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Antipsychotic Medications: Side Effects
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• Cardiovascular: orthostatic hypotension
• Anticholinergic • Weight gain • Diabetes • Sexual side effects • Blood disorders: agranulocytosis (Clozaril) Decrease of granulocytes in bone Cannot command infection <500 cells sudden infection monitor labs closely • Neuroleptic malignant syndrome (atypical meds) Miss in high risk Already agitated/overly mentally ill Muscle rigidity Elevated temperature o Cascade of symptom Increase SNS Muscle and heart issues Usually beginning of treatment • Photosensitivity • Lowered seizure threshold • Medication-related movement disorders |
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Involuntary muscle spasm
Neck to side and tongue protrusion onset within a few days of initiating therapy |
Dystonia:
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abrupt or sudden onset within first 30 days of treatment
Rigidity Slow movement |
o Pseudoparkinsonism:
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possibly misdiagnosed as agitation or increased psychotic symptom
Restless pacing and rocking Hardness to treat and recognize |
o Akathisia:
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Treatment for Akathisia:
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Propranolol/inderal
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o (antipsychic med and have side effects that go untreated, more permanent, >6 months of side effects)
o (lip smacking, chewing, tongue protrusion-can’t control) o (cannot fix) o Long-term antipsychotic use o Irreversible |
Tardive dyskinesia
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• Therapeutic blood levels:
o 0.8 to 1.4 mEq/L |
Lithium (salt)
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Lithium (salt)
• Indications: |
mania; depressive episodes of bipolar illness
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Lithium (salt)
• Side effects: |
thirst, metallic taste, increased urinary frequency, fine hand tremor, drowsiness, and mild diarrhea
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Lithium (salt)
• Monitoring |
Blood levels for toxicity (severe diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination); drug held if symptoms occur
Creatinine concentrations, thyroid hormones, and CBC every 6 months Renal function (kidney damage possible) Thyroid function (possible alteration after 6 to 18 months; observation for dry skin, constipation, bradycardia, hair loss, and cold intolerance Blood for toxicity |
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• Reduce repetitive firing of action potentials in the nerves
• Used for elevated moods • Used when patients have not responded to lithium(salt-weight gain-non complaint) |
Mood Stabilizers: Anticonvulsants
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Mood Stabilizers: Anticonvulsants
• Examples: |
- Valproic acid (Depakote), carbamazepine (Tegretol-blood levels important)
- Lamotrigine (Lamictal-rashes), topiramate (Topamax) - Oxcarbazepine (Trileptal), gabapentin (Neurontin) |
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• Variable absorption; peak plasma levels in 2 to 6 hours
• Side effects: dizziness, drowsiness, tremor, visual disturbances, nausea and vomiting, weight gain, alopecia • Increased risk for aplastic anemia and agranulocytosis • Side effects minimized by treating in low doses; nausea reduced when given with food |
Mood Stabilizers: Carbamazepine
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• Side effects: benign skin rash, sedation, blurred or double vision, dizziness, nausea, vomiting, and other gastrointestinal symptoms
• In rare cases, severe, life-threatening rashes occurring within 2 to 8 weeks of treatment; risk highest in children-Stephen Johnson (dermis separates from epidermis) • Immediately discontinuation if a rash noted |
Mood Stabilizers: Lamotrigine (Lamictal)
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• Initial improvement with some within 7 days; complete relief of symptoms possibly taking several weeks
• Slow tapering necessary; antidepressants are not to be discontinued abruptly because of the uncomfortable symptoms that result • Increased risk of suicidal behavior in children and adolescents • Serotonin syndrome from overactivity of serotonin or an impairment of the serotonin metabolism o life-threatening condition |
Antidepressant Medications
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o Mental status changes
o Autonomic instability o Neuromuscular problems: hyperreflexia, incoordination o Nausea, vomiting, diarrhea • Serotonin syndrome can be life threatening • Discontinuation of medication= treatment |
• Symptoms of serotonin syndrome (started with confusion)
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Examples: fluoxetine (Prozac), citalopram (Celexa), escitalopram oxalate (Lexapro), sertraline (Zoloft), Paroxetine (Paxil), fluvoxamine (Luvox)
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Antidepressant Medications: SSRIs- Selective Serotonin Reuptake Inhibitors excitatory
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SSRIs- Selective Serotonin Reuptake Inhibitors excitatory
• Action: |
inhibition of reuptake of serotonin by blocking transport into presynaptic neuron
o More available for brain to bring in |
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SSRIs- Selective Serotonin Reuptake Inhibitors excitatory
• Side effects: |
headache, anxiety, insomnia, transient nausea, vomiting, diarrhea, sedation, sexual dysfunction, diastolic hypertension, increased perspiration
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Examples: venlafaxine (Effexor), nefazodone (Serzone), duloxetine (Cymbalta-sleep), desipramine (Norpramin)
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Antidepressant Medications: SNRIs- Serotonin Norepinephrine Reuptake Inhibitors
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Antidepressant Medications: SNRIs- Serotonin Norepinephrine Reuptake Inhibitors
• Action: |
prevention of reuptake of norepinephrine and serotonin at presynaptic site
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Antidepressant Medications: SNRIs- Serotonin Norepinephrine Reuptake Inhibitors
• Side effects: |
similar to SSRIs; increased blood pressure
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Example: bupropion (Wellbutrin, Zyban)
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Antidepressant Medications: NDRI- Norepinephrine Dopamine Reuptake Inhibitors)
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Antidepressant Medications: NDRI- Norepinephrine Dopamine Reuptake Inhibitors)
• Action: |
inhibition of norepinephrine(excitatory) and dopamine (feel good)
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Antidepressant Medications: NDRI- Norepinephrine Dopamine Reuptake Inhibitors)
• Side effects: |
agitation or anxiety, insomnia, appetite suppression, psychosis
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Example: trazodone (Desyrel)-
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Antidepressant Medications: SARI- Serotonin- 2 Antagonist Reuptake Inhibitor)
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Antidepressant Medications: SARI- Serotonin- 2 Antagonist Reuptake Inhibitor)
Action: |
• Blocking of serotonin-2A receptor potently and blocking serotonin reuptake pump less potently
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Antidepressant Medications: SARI- Serotonin- 2 Antagonist Reuptake Inhibitor)
• Side effects: |
sedation, weight gain, nausea, vomiting, constipation, dizziness, fatigue, incoordination, tremor
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before SSRI but more side effects and abused, once a day, more lethal when OD-passive to active depressive(mood elevation
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Antidepressant Medications: Tricyclic Antidepressants (TCAs) )
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Examples: amitriptyline (Elavil), clomipramine (Anafranil), doxepin (Sinequan), imipramine (Tofranil), trimipramine (Surmontil), amoxapine (Asendin), desipramine (Norpramin-kids and bed wetting), nortriptyline (Aventyl, Pamelor), protryptyline (Vivactil)
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Tricyclic Antidepressants
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Tricyclic Antidepressants
• Common side effects: |
sedation, orthostatic hypotension, anticholinergic side effects
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Tricyclic Antidepressants
• Other side effects: |
tremors, restlessness, insomnia, nausea and vomiting, confusion, pedal edema, headache, seizures, blood disorders, cardiac changes
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• Examples: phenelzine (Nardil), tranylcypromine (Parnate), selegiline (Emsam-transdermal patch)
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Antidepressants: MAOIs- (Monoamine Oxidase Inhibitors)
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Antidepressants: MAOIs- (Monoamine Oxidase Inhibitors)
• Food interactions: |
aged meat, cheese, beer and wine, thyme rich foods-MAOIs patches bypass stomach
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Antidepressants: MAOIs- (Monoamine Oxidase Inhibitors)
• Action: |
inhibition of MAO à increased serotonin and norepinephrine activity in the synapse
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Antidepressants: MAOIs- (Monoamine Oxidase Inhibitors)
• Side effects: |
dizziness, headache, insomnia, dry mouth, blurred vision, constipation, nausea, peripheral edema, urinary hesitancy, muscle weakness, forgetfulness, weight gain, sexual dysfunction
• Hypertensive crisis: interaction with tyramine-rich foods and certain medications • Many food and medication restrictions needed |
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• Examples: alprazolam (Xanax), lorazepam (Ativan), diazepam (Valium), chlordiazepoxide (Librium), flurazepam (Dalmane), triazolam (Halcion), oxazepam (Serax)
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Antianxiety and Sedative– Hypnotic Medications: Benzodiazepines
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Antianxiety and Sedative– Hypnotic Medications: Benzodiazepines
• Side effects: |
drowsiness, intellectual impairment, memory impairment, ataxia, reduced motor coordination, sedation, “hangover” effects; tolerance or psychological dependence
• Increased CNS depression with alcohol o Same receptor sites with alcohol • Abrupt discontinuation possibly leading to recurrence of the target symptoms (rebound insomnia or anxiety) • Addictive and not good for addictive personalities |
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• Example: buspirone (BuSpar)
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Antianxiety and Sedative–Hypnotic Medications: Nonbenzodiazepine
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Takes a while to get into system to be effective
• Not addictive • Effective for treating anxiety disorders without the CNS-depressant effects or the potential for abuse and withdrawal syndromes |
buspirone (BuSpar)
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buspirone (BuSpar)
• Side effects: |
dizziness, drowsiness, nausea, excitement, headache
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• Benzodiazepines
• GABA enhancers • Melatonergic hypnotics • Antihistamines are examples of : |
Antianxiety and Sedative–Hypnotic Medications: Sedative-Hypnotics
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Examples: Methylphenidate (Ritalin-older now too, little boost, paradoxical in adolescence), dexmethylphenidate (Focalin)
D-amphetamine (Dexedrine), amphetamine/ dextroamphetamine (Adderall) Lisamphetamine (Vyvanse) |
Stimulants and Wakefulness-Promoting Agents
• Stimulants: |
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o Modafinil (Provigil)
o Armodafinil (Nuvigil) |
• Wakefulness-promoting agents
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• St. John’s Wort
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for depression, pain, anxiety, insomnia, and premenstrual syndrome (take when on another depression-can OD)
o Serotonin, dopamine, and norepinephrine modulation o Risk of serotonin syndrome with other serotonergic drugs |
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for anxiety reduction
Interaction with dopaminergic transmission, inhibition of MAO-B enzyme system, and modulation of GABA receptor Risk of severe liver injury, thrombocytopenia, leukopenia, and hearing impairment |
• Kava
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• Use: severe depression; mania and schizophrenia when other treatments have failed
o • Generalized seizures initiated by electrical current • Procedure repeated two or three times per week (total, six to 12 treatments) • Rapid relief of depressive symptoms o 2-3 times a week o 6-8 months o comes back when stopped o best on elderly o sedated (complete, no memories) early not sedated |
Electroconvulsive Therapy (ECT)
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Electroconvulsive Therapy (ECT)
• Side effects |
Hypo- or hypertension, bradycardia or tachycardia, minor arrhythmias, headache, nausea, muscle pain immediately afterward
o Memory loss for months afterward |
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o Circadian rhythms reset
o Used for seasonal depression |
• Light therapy (phototherapy)
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o Alternative to ECT in managing symptoms of depression
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• Transcranial magnetic stimulation (TMS)
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adjunct for severe depression in adults unresponsive to four or more adequate antidepressant treatments; permanent implant
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• Vagus nerve stimulation (VNS):
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o Side effects (most common reason)
o Lack of awareness or denial of illness o Stigma o Feeling better o Confusion about dosage or timing o Difficulties in access to treatment o Substance abuse |
• Reasons for non-adherence
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o Basic framework of rational emotive behavior therapy
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• ABCDE
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The “A” in the ABCDE frame of rational emotive behavior therapy
o It represents an external or internal stimulus o Not necessarily an actual event, it may be an emotion, thought or expectation that is interpreted according to a set of beliefs |
• Activating event
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o The “B” in the ABCDE framework of rational emotive behavior therapy
o Beliefs underlying thoughts and emotions are shaped by rationality which is self-constructive, and irrationality, which is self-defeating |
• Belief systems
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• An internal process of perception, memory, and judgment through which an understanding of oneself and the world is developed
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Cognition
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o change or reframe an individual’s automatic thought patterns that develop over time and that interfere with the ability to function optimally
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• Cognitive interventions:
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o REBT (rational emotive behavioral therapy)
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• Albert Ellis
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o Cognitive behavioral theory
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• Aaron Beck
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o Solution focused grief therapy
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• Steven deShazer and Insoo Kim Berg
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• Used to alter distorted beliefs and problem behaviors: negative and inaccurate thoughts identified and replaced; rewards for behavior changed
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Cognitive Behavioral Therapy
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- Cognitive triad
Thought of self, world, and future in own perspective Altered thinking and impacts negatively perception - Cognitive distortions - Schema Life rules and act as fixture Filter Developed in early childhood and fixed in late childhood |
• Three cognitive processes involved in the development of mental disorders
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o People disturbed by the perception of event, not the event
o Whenever or however the belief develops, the individual believes it o Work and practice can modify beliefs, creating difficulties |
• Assumptions of CBT
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Life rules and act as fixture
Filter Developed in early childhood and fixed in late childhood |
Schema
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• Engagement and assessment
Establish rapport And theme for problem management Contract for future sessions • Interventions ID underlying beliefs that are framing problems Evidence Alternative explanations Examine implications if actually true Months to years depending on event/trauma • Evaluation and termination Pt gains sense of self Stopped or decreased with time • Only works with pts who understand process of CBT Does not work with psychotic pts (schizo, mania) |
Implementing CBT
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• Form of CBT
• Assumptions: o People are born with the potential to be rational (self-constructive) and irrational (self-defeating) o Irrational thinking, self-damaging habituations, wishful thinking, and intolerance are exacerbated by culture and family groups o Change irrational beliefs that cause stress into rational beliefs Decrease stress |
Rational Emotive Behavior Therapy
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Rational Emotive Behavior Therapy Framework
A: |
activating event to trigger automatic response
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Rational Emotive Behavior Therapy Framework
B: |
beliefs underlie thoughts and emotions
Irrational beliefs Demand Absolute thinking Catastrophizing Low frustration tolerance Global evaluations of human worth |
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Rational Emotive Behavior Therapy Framework
C: |
consequences
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Rational Emotive Behavior Therapy Framework
D: |
dispute or challenge with unreasonable
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Rational Emotive Behavior Therapy Framework
E: |
effective outlook developed by disputing
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Rational Emotive Behavior Therapy Framework
Interventions |
o Role-playing, assertion training, desensitization, humor, operant conditioning, suggestion, support
o Focus: developing rational beliefs to replace those that are irrational and interfere with quality of life |
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• Focus: solutions rather than problems; problems best understood in relation to solutions
• Emphasis on what is functional and healthful rather than on problems or symptoms • View of the patient as an individual with a collection of strengths and successes rather than as a diagnosis and collection of symptoms • Emphasis on the uniqueness of the individual and the capacity to make changes or deal with day-to-day lives |
Solution-Focused Brief Therapy
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• People with strengths and resources for problem solving
• Not necessary to know a lot about the complaint to resolve it • “Problem defined and dissected from patient’s perspective • Resolution of even longstanding issues • No right way or wrong way to see things • Change most likely when focused on what is changeable • Therapist’s job to identify and amplify change • The therapist and patient co-create reality • The therapist with expectation of change and movement |
Solution-Focused Brief Therapy Assumptions
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• Therapist in position of curiosity; asks questions
• Interventions focus on achievement of specific, concrete, and achievable goals |
Solution-Focused Brief Therapy Interventions
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Rooted in the belief that nothing is constantly present at the same level of intensity
Helps pt to identify times when whatever bothering them is not present |
Exception questions
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amplify and reinforce positive relationships
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relationship questions
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affirmations of the pt
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compliments
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o Solution-focused therapy
Goal and outcome based Shorter term Not reflection based o Journaling and “homework” assignments |
Use of Cognitive Therapies in Psychiatric Nursing
• Inpatient settings |
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o Cognitive approaches in combination with other interventions
o Primary care: CBT and SFBT o More time when not in hospital |
Use of Cognitive Therapies in Psychiatric Nursing
• Community settings |
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Basic framework of rational emotive behavior therapy
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• ABCDE
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o The “A” in the ABCDE frame of rational emotive behavior therapy
o It represents an external or internal stimulus o Not necessarily an actual event, it may be an emotion, thought or expectation that is interpreted according to a set of beliefs |
• Activating event
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o The “B” in the ABCDE framework of rational emotive behavior therapy
o Beliefs underlying thoughts and emotions are shaped by rationality which is self-constructive, and irrationality, which is self-defeating |
• Belief systems
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o Think or know
o Intellectual process |
• Cognition
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o Automatic thought generated by organizing distorted information or inaccurate interpretation of situation
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• Cognitive distortions
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o Interventions that aim to change or reframe an individual’s automatic thought patterns that develop over time and that interfere with the ability to function optimally
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• Cognitive interventions
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o Thoughts about self, world, and future
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• Cognitive triad
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o Affirmations of the patient
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• Compliments
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o Part of “C” in the ABCDE framework of rational emotive behavior therapy
o Results of the interaction between A (activating event) and B (belief system) that follow from flexible, rational beliefs |
• Dysfunctional consequences
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o Questions used to help the patient identify times when whatever is bothering him or her is not present or is present with less intensity based on the underlying assumption that during these times the patient is usually doing something to male things better
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• Exception question
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o Part of “C” in the ABCDE framework of rational emotive behavior therapy
o Results of the interaction between A (activating event) and B (belief system) that follow from flexible, rational beliefs |
• Functional consequences
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o Patients are asked to use their imagination in crafting their response to very specific questions about a scenario
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• Miracle question
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o Questions to amplify and reinforce positive responses to the other questions
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• Relationship questions
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o Question that quantify exceptions noted in intensity and in tracking change over time using a scale of 1 to 10
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• Scaling questions
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o Cognitive structure, or an individual’s life riles, that act as a filter that screens, codes, and evaluates the incoming stimuli through which the individual interprets events
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• Schema
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• Enhance understanding of self, conquer unwanted thoughts/feelings, learn new behaviors
• Cost effective • Two or more people developing interactive relationships • Sharing of at least one common goal or issue • More than the sum of its parts • Own personality, patterns of interaction, and rules of behavior |
Group
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o Does the purpose of the group match the needs of potential members?
o Does the potential member have social skills to function comfortably in the group? o Do other group members accept the new member? o What is the potential of the group member to commit to attending group meetings? o Usually it is group of convenience |
Member Suitability/Selecting Members
• Criteria |
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new and old members
New at disadvantage |
Open:
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no new members
People can leave but dynamics change if one leaves may not be able to function |
Closed:
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Cost effective
Less intense of countertransference and transference Best for specific problem smoking |
Large:
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Leader control the interaction by giving directions and information and allowing little discussion
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Direct
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Little or no guidance from group leader
Free following |
Indirect:
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Two people share responsibility
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Co-leadership
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• Space and privacy important
• Absence of physical barriers (e.g., tables) to improve communication flow • Members able to see and hear each other • Circular arrangement enhancing group work • Those sitting close to the group leader usually have more power in the group |
Seating Arrangement
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Rapport developing Setting frame work Testing members |
Beginning stage: Honeymoon
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Share ideas Group personality Norms Realization of purpose Meat of events happening |
Working stage
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Grief for loss of groups closeness Summary and future plans |
Termination stage
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o Development and culmination of the session to session interactions of the members that move the group toward its goal
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• Group process
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Support
Confrontation Advice and suggestions Summarizing Clarification Probing and questioning Repeating Reflecting feelings and behaviors |
Techniques in leading groups
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• Facilitation of verbal and nonverbal communication
• Encouraging interaction and active listening o Leader remains neutral • Monitoring verbal communication o Communication pathways • Monitoring nonverbal communication • Deciphering Content Themes o Group themes Collective conceptual underpinnings of a group Members’ underlying concern regardless of group purpose • Tracking group communication |
Group Communication
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• Initiator-contributor
• Information seeker • Information giver • Opinion giver • Elaborator • Coordinator • Orienter • Evaluator-critic • Energizer • Procedural technician • Recorder |
Group Members: Task Roles (keep on track)-informer
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• Encourager
• Harmonizer • Compromiser • Gatekeeper • Standard setter • Group observer • Follower o Not always negative |
Group Members: Maintenance Roles
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• Aggressor
• Blocker • Recognition seeker • Self-confessor • Playboy • Dominator • Help seeker • Special interest pleader |
Group Members: Individual Roles (disruptive)
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• Monopolizer
• “Yes, but. . .” • Disliked member • Silent member |
Challenging Group Behaviors
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o Enhance knowledge, solve problems
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• Psychoeducation groups
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o Specific for specific activity
o Equal member o Group cohesive |
• Task groups
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o Avoid group think
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• Decision-making groups
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o Help individuals
o Psych nurse primary role |
• Supportive therapy groups
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o Emotional problems
o Lots of theories o Psychoanalytic, cognitive, behaviors o Yaloms? |
• Psychotherapy groups
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o Coping with specific problems
o AA o Essential o Lead by members and share problems |
• Self-help groups
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o Age requirements
o Help group together |
• Age-related groups (refer to Box 13.5)
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• Instillation of hope
• Universality • Imparting information • Altruism • Corrective recapitulation • Development of socializing techniques • Group cohesiveness • Catharsis o Open expression to cleanse oneself • Existential factors o Ultimate concerns of existence |
Yalom’s Therapeutic Factos
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• Medication groups (refer to Box 13.6)
o Specific to nursing o Need cognitive ability and basic med knowledge o Health literacy o Don’t need specific med they are on o Med complication o Side effects o Not one on one • Symptom management groupss • Anger management groups • Self-care groups • Reminiscence groups |
Nursing Intervention Groups
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o All members begin at once
o New members are not admitted after first meeting |
• Closed group
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o Ability of a group to stick together
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• Cohesion
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o Two people share responsibility for leading a group
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• Co-leadership
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o Aspect of group interaction based on interaction patterns related to who is most liked in the group, who occupies a position of power, what subgroups have formed, and who is isolated from the group
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• Communication pathways
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o Leader controls the interaction of the group by giving directions and information and allowing little discussion
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• Direct leadership
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o Group of only two people who are usually related
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• Dyad
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o Designated leader and members of the group
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• Formal group roles
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o Collective conceptual underpinnings of a group that express the members’ underlying concerns or feelings, regardless of the group’s purpose
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• Group themes
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o Tendency of many group to avoid conflict and adopt a normative pattern of thinking that is often consistent with the group leaders’ idea
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• Groupthink
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o Leader who is primarily reelections the group members’ discussion and offers little guidance tor information to the group
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• Indirect leadership
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o Roles that either enhance or detract from the group’s functioning but have nothing to do with either the group task or maintenance
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• Individual roles
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o Positions within the group with implicit rights and duties that can either help or hinder the group’s process
o No formally sanctioned |
• Informal group roles
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o Informal roles of group members that encourage the group to stay together
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• Maintenance roles
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o Group in which new members can join at any time and old members leave at different sessions
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• Open group
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o Group role of an individual that is concern about the purpose of the group and keeps the focus on the task of the group
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• Task roles
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o Group consisting of three
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• Triad
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