Exam 2 Calendar Lecture Material: 1. 2. 3. 4. 5. Schizophrenia Ch. 15 & Ch. 24 (Suicide) Crisis Intervention Ch.

h. 23 Grief & Loss Ch. 32 pgs 715-724 Psychopharmacology Ch. 3 Mood Disorders Ch. 13 & 14

SCHIZOPHRENIA REQUIRED ASSIGNMENTS: 1) Varcarolis: Chapter 15 2) Case Study Psychosis, Schizophrenia OBJECTIVES: 1. Discuss the proposed etiologies of schizophrenia. 2. Identify signs and symptoms of schizophrenia using criteria from the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. 3. Describe the subtypes of schizophrenia. 4. Compare benefits versus risks of antipsychotic medications. 5. Explain the continuum of care for people with schizophrenia. 6. Apply the nursing process to the care of a person with schizophrenia. 7. Discuss specific nursing assessments and interventions related to patients with psychotic symptoms. 8. Define the following terms: 9. A serious and irreversible side effect of the phenothiazines and 1. Tardive Dyskinesia 2. Psychosis
related drugs; consists of involuntary tonic muscle spasms typically involving the tongue, fingers, toes, neck, trunk or pelvis. An extreme response to psychological or physical stressors that leads to pronounced distortion of disorganization of affective response, psychomotor function, and behavior. Reality testing is impaired , as evidenced by hallucinations or delusions. A false belief held to be true even with evidence to the contrary (ie the false belief that one is being singled out for harm by others). An error in the perception of a sensory stimulus. For example, a person may mistake polka dots on a pillow case for hairy spiders. A variety of signs and symptoms that are often side effects of the use of certain psychotropic drugs, particularly the phenotheiazines. Three reversible EPS are acute dystonia, akathisia, and pseudoparkinsonism. A fourth, tardive dyskinesia, is the most serious and not reversible. A state of indifference.

3. 4. 5.

Delusion Illusion Extrapyramidal Side Effects (EPS)

6.

Apathy

SCHIZOPHRENIA AND OTHER THOUGHT DISORDERS THE STIGMA OF SCHIZOPHRENIA I. Etiology PSYCH NOTES: Positive and Negative Symptoms of Schizophrenia A. Biologic Theories 1. Genetic Influences Positive Symptoms 2. Neurochemical and Neuroanatomic Changes Positive symptoms are excesses in behavior (excessive B. Psychosocial Theories function/distortions) 1. Stress-Vulnerability Model Delusions II. Signs and Symptoms Hallucinations (auditory/visual) A. The Disorganization Dimension Hostility Disorganized thinking/behaviors 1. Disorganized speech 2. Disorganized behavior Negative Symptoms 3. Incongruous affect Negative symptoms are deficits in behavior (reduced B. The Psychotic Dimension function; self care deficits) 1. Delusions Alogia 2. Hallucinations Affective blunting Anhedonia C. The Negative Dimension Asociality 1. Alogia Avolition 2. Affective flattening or blunting Apathy 3. Avolition 4. Anhedonia DIAGNOSTIC CRITERIA I. Subtypes of Schizophrenia A. Paranoid B. Disorganized C. Catatonic D. Undifferentiated E. Residual COMORBIDITIES AND DUAL DIAGNOSES 50-75% of persons with severe mental illness also have substance abuse problems Dual diagnosis: when a client has a serious mental illness in addition to a substance abuse disorder INTERDISCIPLINARY GOALS AND TREATMENT

Overall Goals of Treatment for Thought Disorders: 1. Safety in all settings 2. Stabilization on antipsychotic medications 3. Client and family education 4. Physical care of the client 5. Psychosocial support of client and family II. Pharmacologic Interventions 1. Traditional (Conventional) Antipsychotics a. Extrapyramidal Side Effects (EPS) b. Tardive Dyskinesia (TD) c. Neuroleptic Malignant Syndrome (NMS) 2. Atypical (Novel) Antipsychotics III. Psychosocial Interventions 1. Milieu Management 2. Individual and Group Therapy 3. Cognitive-Behavioral Therapy 4. Vocational Rehabilitation CONTINUUM OF CARE Discharge Planning Care in the Community Assertive Community Treatment (ACT) Intensive Case Management (CM) THE NURSING PROCESS FOR CLIENTS WITH THOUGHTDISORDERS I. Assessment 1. Mood and Cognitive State 2. Potential for Violence 3. Social Support 4. Knowledge II. Nursing Diagnosis III. Planning IV. Implementation a. Intervening in Disturbed Thoughts/Sensory b. Managing Violent Behavior c. Lessening Social Isolation d. Promoting Adherence to Medication Regimen e. Promoting Improved Individual Coping Skills f. Strengthening Family Processes g. Providing Client and Family Education V. Evaluation

I.

CRISIS INTERVENTION REQUIRED ASSIGNMENT: Varcarolis Chapter 23 OBJECTIVES: 1. Discuss the development phases of crisis theory. 2. Differentiate maturational, situational, and adventitious crisis.

3. 4. 5.

Discuss the goals and methods of crisis interventions. Apply the nursing process to patients experiencing crisis. Define the following terms: maturational crisis situational crisis adventitious crisis

CRISIS INTERVENTION CRISIS occurs when a person experiences a traumatic or overwhelming event. Any stressful event can trigger a crisis. A crisis often occurs when a person has a misperception of the stressor, has poor coping skills or an ineffective or unavailable support system. Crisis usually occurs between 4 6 weeks. Goal is to assist the person to resolve the immediate problem & regain emotional equilibrium. 1. Anxiety is the key feature of crisis. The persons failed attempts to cope heighten the anxiety. 2. The outcome of crisis is either: a) decompensation to a lower level of functioning b) adaptation and return to a previous level of functioning 3. Person is usually open to learning new ways of problem-solving. 4. The focus on the intervention will be on the problem or stressor. Types of Crises 1. Maturational or Developmental normal stresses of development (adolescence) 2. Situational sudden traumatic event, usually occurring with the loss of an established support (divorce) 3. Adventitious unexpected event (hurricane) Crisis Prevention 1. Preparing for maturational changes. 2. Balanced way of life (diet, exercise, fun). 3. Meditation, prayer, massage, etc. Role of the Intervener 1. Be empathetic. 2. Clarify messages. 3. Respect personal space. 4. Remain calm. 5. Ignore challenging questions or statements. 6. Use non-threatening non-verbal cues. 7. The intervener is an active participant, but doesnt take over the problem -solving, unless the patient is suicidal or homicidal. 8. The intervener helps the person: 1. ANALYZE the stressful event 2. EXPRESS feelings 3. EXPLORE ways to deal with the problem 4. SEEK support 5. PREVENT future crises Nursing Process in a Crisis I. Assessment a. Assessment of the person in crisis (MI, physical illness, substance abuse). b. Have the person talk about preceding the distress c. Have the patient describe their feelings. d. Assess support systems. e. Assess coping skills. f. Determine potential for self harm. II. Planning a. Allow the person to do what he can for himself. b. Be directive if person is distraught or confused. III. Implementation a. Assist the person is having a realistic perception of the event. b. Support appropriate coping mechanisms. c. Identify support systems. IV. Evaluation a. Has the person regained emotional equilibrium? b. Is the person able to identify S&S of relapse and preventative behaviors? GRIEF AND LOSS REQUIRED ASSIGNMENT: Varcarolis pages 715-724 OBJECTIVE: 1. Describe appropriate nursing interventions for patients experiencing grief and loss. 2. Identify the signs and symptoms of each stage of the grieving process.

3. 4. 5. I.

Apply the nursing process to grieving patients. Discuss complicated grief and appropriate nursing interventions. Identify community support for persons who are grieving.

GRIEF AND LOSS Grief - subjective emotions and affect that are a normal response to the Experience of loss II. Mourning outward expression of grief III. The process of grieving is one of the most difficult and challenging processes of human existence. IV. Examples of losses related to Specific Human Needs (Maslow): 1. Physiologic loss (air exchange) 2. Safety loss (domestic violence) 3. Loss of security and a sense of belonging (divorce) 4. Loss of self esteem (role function) 5. Loss related to self-actualization (loss of job / miscarriage) Grieving Process (E. Kubler-Ross) Stage 1 Denial= Denial is a defense mechanism and is protective. *Denial Ex: I didnt understand what the doctor was even saying. a) Includes denial b) Shock c) Disbelief Stage 2 Anger= Anger is often directed toward health care members. *Ex: Its just not fair. a) Depression b) Longing for the loved one c) Protesting the permanence of the loss d) Obsessive reviewing of the loss (discourage) e) Guilt f) Lack of concentration g) Sleep disturbances h) Appetite changes i) Fatigue j) General discomfort Stage 3 Bargaining (privately with God; seeking in vain for a way out) *Ex 1: I cant seem to go to the grocery store and come back with what I need. *Ex 2: I thought by now I would be over it. a) Cognitive disorganization b) Difficulty functioning c) Confiding in others to emote and to cognitively restructure the loss d) Adapting to the loss e) Wide variances in emotion and behavior Stage 4 Depression *Ex: I dont care anymore. a) Apathetic to the loss b) Loss of will to try to change things c) Signs of depression and possibly a lack of desire to live Stage 5 Acceptance *Ex 1: Changes checks to include only her/his name. *Ex 2: Looks back on the loss as a time of personal growth. *Ex 2: Reaches out to others who grieve. a) Cognitive reorganization b) Reintegrating sense of self c) Healing, integrating the loss d) Acute anguish dissipated The process of grieving: is very individual acute stages may last between 1-2 years. It is important to note that extreme anger or guilt may be associated with death resulting from suicide or murder. CRITICAL THINKING EXERCISE 1. Which stage of grieving is the client experiencing based on the following statements? a. I have a strong need to be with him. b. I just get mad to easily at everyone. c. I thought a priest would understand my need for support at this time. Why didnt he ask me how I was feeling when I told him my husband was having surgery?

d. I hope I can help Mary through her divorce. I know how hard it can be. e. Ive lost my appetite, and I just cant seem to get to sleep at night. Normal Grief Responses 1. Trying to make sense of the loss 2. Attempting to keep the loved one present 3. Believing in an afterlife and using the loved one as a spiritual guide 4. Examining the meaning of their own life, setting specific life goals, or developing a sense of their own destiny. 5. Interpreting sounds, sights and smells with the loved ones presence and begin searching for them 6. Think theyve heard the loved ones voice or heard them call their name 7. Experience extremely loneliness at night or time when loved one was close or at a ritual time of day. 8. Idealize the person (point out misrepresentations) 9. Apathy 10. Vascillating emotions Physiologic Responses 1. Persons experiencing grieving most commonly complain of insomnia, headaches, impaired appetite, weight loss, lack of energy, palpitations, and indigestion. Impaired immune and endocrine system effects may also occur. 2. Sleep disturbances are the most common and persistent symptom associated with bereavement. Spiritual Responses 1. Spiritual values and beliefs strongly affect a persons responses to loss. There is a strong research base regarding spiritua l beliefs and successful grieving. 2. A person may be comforted, challenged, or devastated spiritually during a time of loss. 3. The nurses role includes ministering to the spiritual needs of a patient. Bereavement Red Flags related to Complicated Grieving A. Social Isolation 1. Frequent thoughts of death 2. Sense of worthlessness 3. Extreme slowing of psychomotor functions 4. Prolonged, marked functional impairment 5. Psychosomatic illness for extended periods 6. Extreme hostility 7. Wooden or formal conduct 8. Activity detrimental to social or economic well-being - Substance abuse / Gambling 9. Very manic or depressive episodes 10. Failure to acknowledge the loss B. Risk Factors for Complicated Grieving 1. Low self esteem 2. Distrust of others 3. Psychiatric disorder 4. Previous suicide attempt or threats 5. Absent or unhelpful family members C. Disenfranchised Grieving 1. A relationship that has no legitimacy. 2. The loss itself is not recognized. 3. The griever is not recognized. D. Nurses Role When you are observing clients responses regarding grieving, we should assess in three specific areas: 1 - Adequate perception regarding the loss This may include determining how the loss will affect the person, how the person feels about the loss (spontaneous miscarriage vs. elected abortion) and what the person needs to know (as in anticipatory loss). Ex: The doctor was just here. Whats your understanding of what he said? 2 Adequate support while grieving for the loss The nurse should help the person identify his/her support systems, those who can provide love and security during the grieving period. Ex: Mrs. Jones, who in your life would really want to know what youve just been told? 3 Adequate coping behaviors during the grieving process Ex: This is best assessed by observing the persons behavior, remembering that behavior will be different with each individual. Write a therapeutic response to each of the following statements. This is unbearable. I cant believe shes gone. No one will want to hire me at this age. Theres nowhere for me to turn. Get out of here! Leave me alone! I dont need your help! I know this sounds strange, but I heard my baby crying last night. Cultural Responses to Grieving a. African Americans- singing, dances, a mourning period. (Jazz funeral)

Muslim Americans- specific steps of burial procedure (washing, dressing, positioning of the body) Vietnamese Americans- usually Buddhists bathe deceased and dress them in black. May put items in mouth to use during the journey to the afterlife. d. Hispanic Americans- Pray during novena, rosary, time of mourning and wearing black. TEST Q #1: What are our rituals, and how do they support the needs of the person who is grieving?

b. c.

Answer: Answer:

How could we alter our rituals to provide more support to those who are grieving?

THERAPEUTIC INTERVENTIONS *Tools include: Use simple, nonjudgmental statements to acknowledge loss: I want you to know that Im thinking of you. Refer to the loved one or object of loss by name. Words are not always necessary, touch or being there is important. Nursing Diagnoses 1) Grieving related to actual or perceived loss The client will: identify the effects of his/her loss. seek adequate support. apply effective coping strategies while expressing human responses to loss. 2) Anticipatory Grieving related to the intellectual and emotional responses by individuals. The client will: identify the meaning of the expected loss in his/her life. seek adequate support while expressing grief. develop a plan for coping with the loss as it becomes a reality. 3) Dysfunctional Grieving The client will: identify the meaning of his/her loss. recognize the negative effects of the loss on his/her life. seek or accept professional assistance to promote the grieving process. Resources Educational resources: www.therapeuticrescources.com/grief.html The only way to take the sorrow out of death is to take love out of life. -Author Unknown PSYCHOPHARMACOLOGY REQUIRED ASSIGNMENT: Varcarolis Chapter 3 OBJECTIVES:Describe the principles of psychopharmacology as they relate to the mental health patient. 1. Identify the pharmacokinetics related to psychotherapeutic drugs. 2. Differentiate the mechanisms of actions, uses, side effects, and nursing implications for major psychotropics. 3. Define the following terms: Tardive Dyskinesia Dystonia
A serious and irreversible side effect of the phenothiazines and related drugs; consists of involuntary tonic muscle spasms typically involving the tongue, fingers, toes, neck, trunk or pelvis. Abnormal muscle tonicity resulting in impaired voluntary movement. May occur as an acute side effect of neuroleptic (antipsychotic) medication, in which it manifests as muscle spasms of the face, head, neck, and back. Regular rhythmic movements, usually of the lower limbs; constant pacing may also be seen; often noticed in people taking antipsychotic medication. A rare and sometimes fatal reaction to high-potency neuroleptic drugs. Symptoms include muscle rigidity, fever, and elevated WBC count. It is thought to result from dopamine blockage at the basal ganglia and hypothalamus.
Signs and Symptoms Change in mental status, agitation, confusion, restlessness, flushing Diaphoresis, diarrhea, lethargy Myoclonus (muscle twitching or jerks), tremors IF SEROTONERGIC MEDICATION IS NOT DISCONTINUED, PROGRESSES TO: Worsening myoclonus, hypertension, rigor Acidosis, respiratory failure, rhabdomyolysis ALERT: Must discontinue serotonergic drug immediately. Emergency medical treatment and hospitalization needed to

Akathisia Extrapyramidal Symptoms Neuroleptic Malignant Syndrome

Serotonin Syndrome
Can occur if client is taking one or more serotonergic drugs (e.g., SSRIs), especially higher doses. Do not combine SSRIs/SNRIs/clomipramine with MAOI; also, tryptophan, dextromethorphan combined with MAOI can produce this syndrome. If stopping fluoxetine (long half life) to start an MAOI must allow a 5week wash-out period. At least 2 weeks for other SSRIs before starting an MAOI. Discontinue MAOI for 2 weeks before

starting another antidepressant or other interacting drug.

treat myoclonus, hypertension, and other symptoms.

Compliance Refractoriness I. PSYCHOPHARMACOLOGY Benzodiazepines 1) ATIVAN/LORAZEPAM a) Used to treat: anxiety, insomnia, seizures, panic disorders and alcohol withdrawal. b) Acts by depressing the CNS. c) Most common side effects: 1. Sedation 2. When given IV, can cause hypotension & cardiac arrest. d) Dangerous if used with other CNS depressants (alcohol, opiods, etc.) e) Should be D/C slowly to prevent withdrawal. f) These are schedule IV drugs which have some potential for abuse. Antidepressants a) Used to treat depressed mood, feelings of sadness, emotional upset, & chronic pain. b) Exact cause and cure is unknown. c) Depression is attributed to decreased amounts of the neurotransmitters norepinephrine and serotonin in the brain and neurotransmitter receptor function. d) Four major classes of antidepressants all take 2 weeks or more to become therapeutic A) TRICYCLIC AGENTS 1. Elavil /amitriptyline I. Act by blocking uptake of NOREPINEPHRINE and SEROTONIN. II. No longer first line drug treatment for depression. III. More side effects than newer agents. IV. Side effects: sedation, orthostatic hypotension, and ANTI-CHOLINERGIC effects (dry mouth, constipation, urinary retention, & blurred vision) V. Because of their ANTI-CHOLINERGIC properties, use CAUTIOUSLY with: 1. sympathomimetics 2. MAO inhibitors 3. anti-cholinergics. VI. Most serious side effect 1. CARDIAC TOXICITY/ARRHYTHMIAS. Screening EKG done before beginning TCAs. Lethal overdose with as little as 5-10 day supply. B) SSRIS SELECTIVE SEROTONIN REUPTAKE INHIBITORS 1. Prozac / fluozetine I. Very effective in treating major depression. II. Side effects: sexual dysfunction (70%), weight gain, nausea, headaches, insomnia, anxiety. 1. Most GI SE and headaches subside in a few weeks. III. Serotonin Syndrome 1. Usually begins with first few days of therapy. 2. Usually caused by drug interaction with other serotonergics / MAOI. 3. S&S hypertension, altered mental status, sweating, incoordination, fever, etc. 4. Should be withdrawn slowly to prevent withdrawal syndrome. 5. Symptoms of withdrawal include dizziness, tremor, dysphoria, and sensory disturbances C) SNRIS SEROTONIN & NOREPINEPHRINE REUPTAKE INHIBITORS 1. Effexor / venlafaxine I. Similar to SSRIs, however, side effects may include hypertension. D) MAO INHIBITORS 1. Parnate/tranylcypromine I. As effective as other antidepressants, but more dangerous II. Often used in atypical depression, bulimia, panic attacks, obsessive-compulsive disorders III. Adverse effects: CNS stimulation (anxiety, agitation, hypomania), orthostatic hypotension (this does not subside) IV. occurs if patient eats foods containing TYRAMINE, which promotes the release of NOREPINEPHRINE. 1. Has many drug interactions, mostly those that have

II.

2.

vasoconstrictive properties (ie- OTC cold meds, etc.) and enhance hypertensive crisis. Teach pt. to refrain from eating foods containing TYRAMINE (aged cheeses, red wine, beer, sausages like bologna, pepperoni, salami, & aged fish or meat).

St Johns Wort a) Mother Natures Prozac b) Has proven to have substantial antidepressant effects. c) Given by prescription in Europe with 3 million prescriptions / year. d) Currently, research has not supported FDA approval. e) Adverse Effects: photosensitivity, increases the metabolism of many drugs (warfarin/Coumadin, oral contraceptives)

III.

Drugs used to treat Bipolar Disorder 1) LITHIUM MOOD REGULATOR 2) DEPAKOTE/VALPROIC ACID ANTIEPILEPTIC AGENT 1) Lithium Mood Regulator Used to treat Bipolar disorder. Therapeutic Level 0.5 1.5mEq/L Narrow therapeutic range often requires informed consent due to high risk for toxicity. Blood levels are drawn 12 hours after last dose . Lithium is a salt and therefore is regulated by the body as sodium. Why would that be a problem regarding regulation of serum lithium levels? Side Effects: 75 % of patients taking lithium will have one or more of these side effects when drug IS IN THE THERAPEUTIC RANGE: 1. fine hand tremors 2. weight gain 3. fatigue 4. polydypsia 5. polyuria 6. edema 7. GI upset 8. slurred speech *****MOST OF THESE SE ARE TRANSIENT. VIIII. WHEN LEVEL IS ABOVE 1.5 SIDE EFFECTS INCLUDE: 1. coarse hand tremors 2. confusion 3. EKG changes 4. sedation 5. blurred vision & tinnitus ****THESE SYMPTOMS PROGRESS TO SEIZURE AND DEATH. X. Patient Teaching 1. Need for adequate fluid intake and Na moderation 2. Avoid sweating 3. Need for frequent drug serum levels 4. Side effects weight gain, & hypothyroidism 5. Importance of medication compliance 6. Teach that there are many drug-drug interactions (NSAIDS increase lithium levels) and should inform MD of all medications. I. II. III. IV. V. VI. VII. VIII.

IV.

Antiepileptic Agent 1) Depakote / valproic acid I. Equal in effectiveness with Lithium. II. Depakote works faster with less side effects. III. Side effects GI disturbances & weight gain (usually eliminated when drug is enteric coated) IV. MAJOR CONCERN TERATOGENIC Anti-psychotics a). Used to treat psychosis associated primarily with schizophrenia, which is characterized by: 1- positive signs- agitation, delusions, hallucinations, paranoia 2- negative signs - blunted affect, poor hygiene, poverty of speech, social withdrawal. b). Anti-psychotic agents work by decreasing amounts of neurotransmitters, primarily DOPAMINE & SEROTONIN in the CNS. c). Goal is to make the patient think more clearly. Schizophrenia is called a thought disorder. A) TYPICAL ANTI-PSYCHOTICS

V.

1. Haldol / haloperidol I. More effective at treating positive effects rather than negative effects of schizophrenia. II. Anti-psychotics have many side effects and require careful patient monitoring. III. Extrapyramidal symptoms (EPS) a. Early symptoms (usually occurring hours or days after initiating treatment: 1. akathisia continuous restlessness, inability to sit still 2. parkinsonism muscle tremors, shuffling gait, drooling, rigidity 3. dystonia spasms, prolonged contractions of muscle groups- dangerous and painful and can be treated. b. Treating EPS 1. Benadryl / diphenhydramine 2. Cogentin / benztropine a. Should be given parenterally for more rapid patient response. c. Late symptom: 1. Tardive dyskinesia (TD)= involuntary movements of the tongue and face (fly catching, smacking) a) assess often, using AIM (Abnormal Involuntary Movement) assessment form b) usually irreversible 2. Neuroleptic Malignant Syndrome = The most serious of all side effects. a) Characterized by lead-pipe rigidity, sudden high fever and changes in cognition. b) Dantrium / dantrolene is used for treatment . c) Early detection has dropped mortality from 30% to 4%. d) Other SE: 1) HYPERGLYCEMIA (metabolic syndrome) 2) ANTICHOLINERGIC EFFECTS = dry mouth, urinary retention, constipation, blurred vision, sexual dysfunction. orthostatic hypotension B) ATYPICAL ANTIPSYCHOTIC AGENTS 1. risperidone / Risperdal 2. ziprasidone / Geodon I. Effective in treating both negative and positive symptoms of schizophrenia. II. These agents cause fewer extrapyramidal (EPS) symptoms. III. Side effects: a. orthostatic hypotension b. sedation c. anticholinergic effects. 3. Clozaril / clozapine I. Major side effect of agranulocytosis WBC monitored frequently and patients are taught to report sore throat, fever, mucous membrane ulceration, fatigue. C) DEPOT DRUGS 1. These are long-acting, injectable formulations. a. Typically given every 2-4 weeks. 2. Goal is to prevent relapse of schizophrenia. 3. Drugs now available are Haldol and Risperdal. **TEST QUESTION: Based on what we just reviewed, give the rational for why each of the following diagnostics would be important to obtain prior to the patient beginning Lithium therapy? A. BUN / Creatinine B. Thyroid studies C. EKG D. CBC E. Electrolytes SUICIDE REQUIRED ASSIGNMENT: 1) Varcarolis Chapter 24 2) Case Study - Suicide OBJECTIVE: 1) Discuss assessment and interventions related to the suicidal patient. 2) Discuss legal-ethical issues related to care of the patient with suicidal ideations. 3) Apply the nursing process in caring for patients with suicidal ideations.

1.

2.

3.

4.

SUICIDE Risk Factors a. A most significant risk factor for suicide is a previous suicide attempt. b. Patient with a history of: Depression/Hopelessness Substance abuse Organic brain disease (Dementia) Serious medical problems (fatal diseases or diagnosis that is overwhelming to handle) Warning Signs a. Verbal and Nonverbal Clues: OVERT STATEMENTS I cant take it anymore. Life isnt worth living anymore. I wish I were dead. Everyone would be better off if I died. COVERT STATEMENTS Its ok now. Soon everything will be fine. Things will never work out. I wont be a problem much longer. Nothing feels good to me anymore, probably never will. How can I give my body to medical science. b. Giving away possessions c. After being depressed, become happy. They are no longer debating, no more conflict of choices. Assessing Patients Intent a. ASK Do you think about hurting yourself? b. If patient responds affirmatively, ask if they have a plan. The more lethal the method identified, the more serious the intent. c. Determine if means are available. Nursing Interventions a. Express concern. It concerns me that you feel so bad and want to hurt yourself. b. Share with the team; inform patient c. Offer hope. Youre feeling bad now, but there are medications and treatment that you can receive that will help you get through this bad time. d. Suicide Precautions What would keep you from hurting yourself? e. Follow agency policy f. Close observation g. Body / clothes search Remove all potentially dangerous objects (shoestrings, razors). Be an astute observer of other potential objects of danger (ribbon on flowers sent to the unit, waist tie on robe sent by family). h. May need to lock bathroom doors (most common site for suicide). i. Check for cheeking medications: attempt to hoard to take overdose. j. A common time for suicide is a few days/weeks after beginning anti-depressants. Energy level is increased, but mood is not.

MOOD DISORDERS REQUIRED ASSIGNMENTS: A. Varcarolis Chapter 13 and 14 2) Case Study Bipolar Disorder OBJECTIVES: 10. Describe types of mood disorders. 11. Discuss the incidence and prevalence of major mood disorders in the United States. 12. Analyze differences between theories of the etiology of mood disorders. 13. List the symptoms of mood disorders using criteria from the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. 14. Discuss interdisciplinary treatment modalities for patients with mood disorders. 15. Apply the nursing process to the care of patients with mood disorders. 16. Discuss pharmacologic treatment of patients with mood disorders. 17. Define the terms: Cyclothymia includes at least 2 years of hypomanic periods that do not meet the criteria for the other disorders.

Dysthymia Euthymic Hypomania Mania Mood

An ongoing low-grade depression of at least 2 years duration for more days than not and does not meet the criteria for major depression.

I.

MOOD DISORDERS Mood disorders, also called affective disorders, are pervasive alterations in emotion that are manifested by depression, mania, or both. They interfere with a persons life, affecting their self-esteem, occupation, and relationships. The primary mood disorders are major depressive disorders and bipolar disorder (formerly called manic-depressive illness). Mood disorders affect people irrespective of their ethnicity, social status, intellect, occupation or age. Abraham Lincoln, Queen Victoria, Mike Wallace, Edgar Allen Poe, Charles Spurgeon, and Barbara Bush have all suffered with a mood disorder. 1. Genetic Influence A. Twin study If an identical twin developed a major depressive disorder, the other twin had a 70% chance of developing the disorder. B. Depression is 2-3 times more common in first degree relatives with the disorder. C. Recently a gene was discovered that lies along chromosome 18 which seems to create a pre-disposition for bipolar disorder. D. It is believed that genetic, psychosocial, and other environmental forces are operating to influence the development and course of mood disorders. 2. Biochemical Influence A. Monoamine neurotransmitters (norepinephrine + serotonin= decrease) have shown to be mood regulators. B. It is believed that there is a link between seizure thresholds (which are influenced by norepinephrine) and the cycling of mood disorders. C. This is the rational for using anticonvulsants to treating bipolar disorder. 3. Biophysical Influence A. The hypothalmic-pituitary-adrenal axis that controls the release of cortisol doesnt appear to function correctly in depression. B. 50% of patients with depression fail to suppress cortisol levels in a dexamethasone suppression test. 4. Psychosocial & Environmental Influences A. Interpersonal Theory identifies the cause of depression as beginning in childhood when a person suffers the real or perceived loss of a valued object. If the child does not grieve appropriately, depression develops. B. Psychoanalytic theory focuses on unexpressed and unconscious rage as a reaction to being helpless or dependent on others or to a loss of loved one. The unexpressed anger is turned inward producing feelings of depression. C. Behavior theory focuses on learned helplessness as an antecedent to depression. A lifetime of experiences has taught them they are powerless to influence their suffering and gratification. D. Cognitive theory states that clients experience depression because of errors in thinking and unrealistic attitudes about themselves and the world. These cognitive errors involve undervaluing oneself, having a negative view of ones ability to achieve goals, and being pessimistic, resulting in low self-esteem and the inability to experience pleasure. ****All agree that psychologic stressors and interpersonal events are triggers for mood disorders. Types of Mood Disorders 1. MAJOR DEPRESSIVE DISORDER a) 22% of women and 16% of men experience a major depressive episode. Risk increases with age in women and decreases in age with men, with the usual onset in early adulthood (40 yo). Highest incidence occurs in those who are single or divorced. b) 50% of these will have 1-2 more major depressive episodes. c) Nearly 15% of patients with untreated depression commit suicide. Most have sought help from a MD within one month of death. d) 9% of patient experience psychotic features. e) Major depression is also called unipolar depression. f) Major depression occurring after childbirth is called postpartum depression. g) Depression which occurs without any relationship to external events is called endogenous depression. h) Depression occurring from a life event is called exogenous depression. ***SAD (seasonal affective disorder) is a depressive disorder believed to be triggered by decreased amount of sunlight in winter months. Characterized by anergia, hypersomnia, overeating, weight gain, and craving for carbohydrates, it responds to light therapy. DSM-IV Diagnostic Criteria A. Over 2 weeks, client has experienced a change from previous functioning with depressed mood or decreased interest or pleasure and at least four of the following: 1) Significant weight loss or marked change in appetite 2) Hypersomnia or insomnia: sleeping too much but most of it is not considered good sleep/not sleeping enough wake often and lose much sleep especial deep sleep. 3) Psychomotor agitation or retardation: may range from slowed and difficult movements to complete inactivity and incontinence. 4) Fatigue

5) Feelings of worthlessness or guilt 6) Difficulty concentrating or indecisiveness 7) Recurrent thought of death, with or without suicidal ideations B. Symptoms cause significant distress or impair functioning. C. Symptoms are not caused by a substance or medical condition. Nursing Assessment A. General Appearance 1) Sad, posture slouched with head down and minimal eye contact. 2) Psychomotor retardation with latency of response (may take up to 30 Seconds to respond) 3) Psychomotor agitation (pacing, racing thoughts, argumentativeness) B. Mood & Affect 1) Describe themselves as hopeless, helpless [AEB inability to carry out the cimplest tasks like grooming , housework, or caring for children], down or anxious. 2) Experience anhedonia (losing sense of pleasure) 3) May be frustrated, angry at self or others 4) Affect is sad, depressed, flat or tearful - May sit alone, stare into space 5) Interact minimally 6) Withdraw from stimulation (often remaining in bed or chair all day) 7) Anger and irritiability are natural outcomes of proufound feelings of helplessness C. Thought Processes and Content 1) Experience slowed thinking, may not respond verbally to questions. 2) Tend to be negative and pessimistic, believing they will always feel this bad 3) Make self-deprecating remarks, criticize self and have thoughts of dying or suicide 4) Tend to ruminate 5) If depression is severe and they experience psychosis they may have delusions that they are responsible for all the tragedies in the world. D. Judgment and Insight 1) Impaired judgment because they dont use cognitive abilities to solve problems. This may be related to their extreme apathy or belief that it doesnt matter anyway. 2) Lack of insight into their behavior, feelings and illness. May be more intact if they have experienced depression previously. 3) Lack of judgment and insight often lead to substance abuse. E. Role and Relationship 1) Difficulty fulfilling roles and responsibilities 2) - Often avoids family and social relationships because they feel overwhelmed, experience no pleasure from interactions or feel unworthy. 3) These changes lead to greater feelings of worthlessness. F. Physiologic & Self Care Considerations 1) Lose weight 2) Usually c/o insomnia 3) Lose interest in sexual activities 4) Neglect personal hygiene 5) May become constipated, dehydrated Nursing Considerations A. May take several short periods to complete an assessment. It is important not to rush clients. This is a time to begin developing a trusting relationship, demonstrate empathy. B. You assess the patients perception by asking when symptoms started, what was happening when they began, their duration and what the patient has tried to do about them. C. It is also important to determine any history of depression, treatment and response to previous treatment. D. Family history or mood disorders, suicide or attempted suicide is significant. 1) Depression in Children a. Symptoms include difficulties with schoolwork, lack of enthusiasm and energy, social withdrawal, impulsive, angry outburst. Other signs of anxiety and hyperactivity. Major sign of MDD in Children is irritability. 2) Depression in the Elderly a. Symptoms include confusion, memory loss, and agitation. Often mistaken for dementia (pseudodementia). 3) Cultural Considerations a. Manifestations of depression vary among cultures and are more apparent in cultures that avoid verbalizing emotions. b. Asians who are depressed are more likely to have somatic complaints of headache or backache. c. Latin cultures complain of nerves or headache. d. Middle eastern cultures complain of heart problems. Treatment A. Researchers believe that levels of neurotransmitters, especially norepinephrine and serotonin, are decreased in depression. Usually presynaptic neurons release these neurotransmitters to allow them to enter synapses and bind with postsynaptic receptors. B. Depression results if:

1) too few neurotransmitters are released. 2) they linger to briefly in synapses. 3) - the releasing presynaptic neurons reabosrb them too quickly. 4) conditions in synapses do not support linkage with postsynaptic receptors. 5) number of postsynaptic receptors has decreased. C. The goal of pharmacologic treatment is to increase the efficiency of available neurotransmitters and the absorption by postsynaptic receptors. D. Antidepressants establish a blockage for the reuptake of norepinephrine and serotonin into their specific nerve terminals. This permits them to linger longer in synapses and to be more available to postsynaptic receptors. 1) Antidepressants also increase the sensitivity of the postsynaptic receptors. Pharmacologic Treatment A. Major categories of antidepressants: 1) SSRI (selective serotonin reuptake inhibitors) 2) SNRI (selective norephinephrine / serotonin reuptake inhibitor) 3) Tricyclic antidepressants 4) Monoamine Oxidase Inhibitors (MAOI) B. Selection is based on symptoms, physical conditions, drugs that have or have not worked in the past for patient or blood relative, and other medications the patient is taking. C. It takes a minimum of 2-6 weeks for effects of therapy to become fully evident. D. Research indicates that people with depression who receive 18-24 months of antidepressant therapy have fewer relapses. E. Antidepressants are usually tapered rather than abruptly discontinued. If the patient is experiencing psychotic features, an anti-psychotic maybe added to the treatment plan. May be withdrawn when psychotic symptoms no longer are exhibited. Electroconvulsive Therapy (ECT) Used to treat depression in patient who do not respond to antidepressants or those who experience intolerable side effects to drug therapy. It is occasionally used for patients who are actively suicidal and waiting for medication to become effective. Psychotherapy A combination of psychotherapy and medication is considered the most effective treatment for depressive disorders. The goals of psychotherapy are: b) symptom remission c) psychosocial restoration d) prevention of relapse e) - reduced secondary consequences such as marital discord or occupational difficulties f) increasing treatment compliance. Interpersonal Therapy Focuses on difficulty in relationships such as grief reactions, role disputes, and role transitions. Ex: Person who as a child never learned how to make and trust a friend outside of their family. Behavior Therapy Seeks to increase the frequency of the patients positively reinforcing interactions with the environment and to decrease negative interactions. Also may focus on improving social skills. Cognitive Therapy Focuses on how the person thinks about themselves, others and the future and interprets his/her experiences. This model focuses on the patients distorted thinking that in turn influences feelings, behavior and functional abilities. Nursing Diagnoses 1- Risk for Suicide 2- Ineffective Coping 3- Anxiety 4- Imbalanced Nutrition: Less than Body Requirements 5- Hopelessness 6- Disturbed Sleep Pattern 7- Self Care Deficit 8- Ineffective Role Performance 9- Impaired Social Interaction 10- Chronic Low Self Esteem Patient Outcomes The patient will: 1. not injure self. 2. independently carry out ADLs. 3. establish a balance of adequate nutrition, hydration and elimination. 4. establish a balance of rest, sleep & activity. 5. evaluate self-attributes realistically. 6. socialize with peers, staff, family & friends. 7. comply with medication regimen. 8. verbalize symptoms of reoccurrence. 9. return to school or work activities. Nursing Interventions 1. Provide for physical needs.

2. Plan activities during increased energy periods. 3. Assume an active role in initiating communication. 4. Share your observations with patient (Your sitting all by yourself, looking sad. Is that how you feel?) 5. If psychomotor retardation, allow reaction time. 6. Dont act overly cheerful, but join in his/her humor & point out value of humor. 7. Encourage to discuss and journal feelings. 8. Provide structured routine encourage socialization. 9. Support basic hygiene and positive grooming. 10. Teach patient about medications. This is important to prevent relapse. 11. Help patient recognize distorted perceptions & link them to his depression. Encourage practicing positive statements. 12. Recognize suicide potential ASK !!! Realize that suicide risk often increases as depression lifts. Dysthymia a) Depressed or irritable mood for most of the day, occurring more days than not for at least 2 years (1 year in children and adolescents). The patient has had not more than 2 months in which symptoms are not present and has not experienced a manic or depressive episode. b) Considered a milder form of depression. c) Often predates major depression by as much as 3 years. d) Distress usually does not warrant hospitalization unless person becomes suicidal. The main difference between DD and MDD is duration and severity of symptoms e) May engage in behaviors to generate excitement such as gambling, criminal behavior, intensify work, substance abuse, overeating, or promiscuity. f) Symptoms are similar to depression only milder, however, they are chronic.

BIPOLAR DISORDER What is Bipolar Disorder? Disorder characterized by severe mood swings, from extreme highs (mania) to extreme lows (depression). Interspersed are periods of normal mood. Used to be called manic-depressive disorder. Statistics Most literature states women are affected to a greater extent than men. Usually begins between age 20 30. 50% of the patients with Bipolar disorder have difficulty in work performance and psychological functioning. 90% of the patients with one manic episode will have future episodes. Signs & Symptoms of Mania 1- Elation / Euphoria - expansive or grandiose - excessive social extroversion: seek out social engagement such as sitting on peoples laps or talking to everyone. 2- Hyper-excitability - psychomotor agitation - short attention span - rapid response to external stimuli 3 - Agitated or Irritable - sarcastic - angry 4- Rapid Thought & Speech - flight of ideas - easily distracted 5- Exaggerated Sexuality - promiscuous - dresses provocatively 6 - Decreased Sleep & Nutrition 7- Impulsivity 8- Impaired Judgment In extreme mania you may see: a. Delusions b. Paranoid thinking c. Hallucinations Hypomania a. Elevated or exaggerated mood resembling mania but less intense & lacks psychotic symptoms b. Not always dysfunctional sometimes positive - patient often enjoys this feeling and the resultant increased productivity. Long Term Effects of Mania

a. b. c. d. e. f. g. Rapid Cycling a. b. 1. 2. Bipolar I Bipolar II

Divorce Child Abuse Joblessness Bankruptcy Promiscuity (STDs, HIV, etc.) Unwanted Pregnancy Suicide

Four or more distinct periods of depression, mania, hypomania or mixed states occurring in a 12 month period. 10-20% of bipolar patients are rapid cyclers. Most are women.

One or more manic episodes, usually alternating with major depressive episodes.

Major depressive episode & at least one hypomanic episode, usually occurring immediately before or after a depressive episode. 3. Cyclothymic Disorder Resembles bipolar disorder with less severe symptoms lasting for 2 years. Often called sub-clinical bipolar disorder. Difficult to diagnose; often has more problems than the person with bipolar who is treated and has long periods of normal behavior. Often has many life disruption behaviors, such as substance abuse and the inability to sustain a relationship. Hypomania may be a defense or reaction formation against the painful experience of depression. Antidepressants 1. SSRIs Selective Serotonin Reuptake Inhibitors Side effects; nausea, nervousness, insomnia, headache, sexual dysfunction 2. Tri-cyclic Antidepressants Side effects: weight gain, cardiac arrythmias, & anticholinergic effects Lithium=Mood Regulator Therapeutic Level 0.5 1.5mEq/L Blood levels are drawn 12 hours after last dose. Requires adequate renal functioning. Lithium is a salt and therefore is regulated by the body as sodium. Why would that be a problem regarding regulation of serum lithium levels? **Signs & Symptoms of Toxicity 1.5 2 - thirst, fine hand tremors, D, V, hypo/hyper muscle irritability 2 -2.5 - ataxia, slurred speech, blurred vision, confusion, abdominal pain Over 2.5 - cardiac arrythmias, hypotension, seizures, coma, tinnitus Patient Teaching

Need for adequate fluid intake and Na moderation Avoid sweating Need for frequent drug serum levels

Side effects weight gain, & hypothyroidism TEST Q: Importance of medication compliance Based on what we just reviewed, give the rational for why each of the following diagnostics would be important to obtain prio r to the patient beginning Lithium therapy? - BUN / Creatinine - Thyroid studies - EKG - CBC - Electrolytes Anticonvulsants 1) DEPAKOTE / DIVALPROEX SODIUM - assess liver function - assess PT increases bleeding tendencies

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TEGRETOL / CARBAMAZEPINE - assess liver function - assess WBC may cause agranulocytosis - decreases effectiveness of hormonal birth control 3) LAMICTAL / LAMOTRIGINE - may cause Stevens-Johnson syndrome - may cause dizziness, ataxia, nausea, NON COMPLIANCE Many of the medications used to treat Bipolar disorder are often not taken due to unwanted side effects. Often takes patience to find a medication that is effective and well tolerated. Nursing Assessments related to the Manic Patient Thought Process & Content - Lacks introspection - Exaggerations & ambitious schemes - Grandiosity Speech a- rapid / pressured speech b- rythming speech c- word play (concerned more with phonics than word meaning) d- circumstantiality e- loose associations f- tangentiality Suicidal Ideations Intellectual Processes - impaired judgment - impaired insight - easily distracted - altered perceptions (illusions, delusions, hallucinations) Orientation - often disoriented Physical Effects - nutritional deficits (food, water) - poor hygiene Behavior - psychomotor agitation - intrusive / aggressive / agitated - inappropriate grooming - extravagant spending sexually provocative Nursing Diagnoses Which of the following should be addressed first and what are the most appropriate nursing interventions related to each? A. Risk for Violence: Self directed B. Ineffective Individual Coping C. Impaired Social Interactions D. Self esteem disturbance E. Altered Thought Process F. Risk for Injury G. Self Care Deficits H. Altered Family Processes I. Constipation J. Sexual Dysfunction K. Altered Nutrition: Less than Body Requirements L. Sleep Disturbances A. Risk for Violence Self directed: suicide precautions B. Ineffective Individual Coping: - decrease confrontations / gentle redirection / meet needs promptly - maintain calm environment - set limits - encourage journaling, drawing, etc. - allow patient to assist in therapeutic milieu arrange furniture, clean, etc. C. Impaired Social Interactions: - respond positively to demands (Ill think about that and get back with you.) - use persuasion instead of force - reinforce effective social skills - point out behaviors that lead to rejection by others - prevent intrusive behavior / avoid retaliation

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Self Esteem Disturbance: - point out positive changes in behavior - express gratitude for helpful gestures E. Altered Thought Processes: - reinforce reality - dont talk about or argue r/t delusions - assist patient in differentiating illusions vs. reality F. Risk for Injury: - when necessary, keep under close observation. G. Self Care Deficits: - encourage personal hygiene - use persuasion H. Altered Family Processes: - include family in planning and teaching regarding disease process - encourage family therapy I. Constipation: - fluids, high fiber diet - use of laxatives may be necessary J. Sexual Dysfunction: - teach patient risk factors K. Altered Nutrition: Less than Body Requirements: - provide nutritional finger foods L. Sleep Disturbance: Decreased sleep - encourage sleep - allow patient to groups, etc. - awaken patient only for meals ***Sleep deprivation often causes mania and altered thought processes in many patients. Clinical Situations Manic patient approaches to talk with you and stands six inches from you. 1) You are sitting in morning group and a manic patient enters wearing her blouse unbuttoned. 2) You notice during smoking break that one of the manic patients is hugging several of the other patients. 3) You notice the manic patient continuing to invade the space of other patients. 4) You are having a conversation with the patient and she is having flight of ideas. 5) You are conducting group and the manic patient is dominating the conversation or pacing in the room. 6) The patient who is manic approaches the nurses station loudly complaining about another patient.