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Tuesday, January 22, 2008

Myk's Psychiatric Nursing Notes 4

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EATING DISORDERS

ANOREXIA NERVOSA ---------------BULIMIA NERVOSA
- Eat, eat, eat --------------------------- Eat, eat, vomit
- Less 85% expected body weight ------- Normal weight
- 3 months amenorrhea --------------- Irregular menstruation


BULIMIA NERVOSA
• Metabolic alkalosis (vomiting results to decrease hydrochloric acid)
• Metabolic acidosis (diarrhea results to decrease bicarbonate)
• Dental caries
• Wound in knuckles

MANAGEMENT
• Fluid and electrolyte imbalance
• Meal contract
• Weight gain for client
• After eating stay with client for 1 hour and accompany when going to the comfort room

PHARMA NOTES:
ANTI – PSYCHOTIC DRUG
• Stelazine
• Serentil
• Thorazine
• Trilafon
• Clozaril
• Mellaril
• Haldol
• Prolixin

SCHIZOPHRENIA
• Ego disintegration
• Impaired reality perception
• Genetic vulnerability
• Stress – Diathesis Model
• Biological theory – increase dopamine level
• Exact cause unknown

ASSESSMENT
• Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete)
• Ambivalence: pulled into 2 opposing forces
Autism
• Looseness, no idea, not related to one another

ASSESSMENT
NEGATIVE ------------------------POSITIVE
Hypoactive ------------------------ Hyperactive
Withdrawn ------------------------- Sociable
Thought Blocking ------------------Flight of ideas
Apathy

I. ASSESS
• Content of thought

NURSING DIAGNOSIS
• Disturbed thought process
PLANNING/IMPLEMENTATION
• Present reality
• Provide safety
EVALUATION
• Improved thought process

II. ASSESS
• Hallucinations/Illusions

NURSING DIAGNOSIS
• Disturbed sensory perception
PLANNING/IMPLEMENTATION
• Present reality
• Safety
EVALUATION
• Improved sensory perception

III. ASSESS
• Suspicious

NURSING DIAGNOSIS
• Risk for other directed violence
PLANNING/IMPLEMENTATION
• Present reality
• Safety
EVALUATION
• Eliminate/minimize risk for other directed violence

IV. ASSESS
• Suicidal

NURSING DIAGNOSIS
• Risk for self directed violence
PLANNING/IMPLEMENTATION
• Present reality
• Safety
EVALUATION
• Eliminate/minimize risk for self directed violence

LOOSENESS OF ASSOCIATION
• Thinking that is overgeneralized, diffuse, and vague with only a tenuous connection between one thought and the next

FLIGHT OF IDEAS
• Jumping from on topic to another

AMBIVALENCE
• Pulled between 2 strong opposing forces

MAGICAL THINKING
• acting like magician

ECHOLALIA
• Client repeats what you say

ECHOPRAXIA
• Client repeats what you do

WORD SALAD
• Just words no rhyme

CLANG ASSOCIATION
• Words that rhyme

NEOLOGISM
• Formation of new words (needs clarification)

DELUSION: PERSECUTORY
• “The NBI is out to get me”

DELUSION: RELIGIOUS
• “I am Jesus Christ the savior”

DELUSION: GRANDEUR
• “ I am the queen of the world”

DELUSION: IDEAS OF REFERENCE
• “The nurses are talking about me”

CONCRETE ASSOCIATION
• Also known as “pilosopo”

THOUGHT BLOCKING
• Unable to think

-----------------------HALLUCINATIONS------ ILLUSIONS
STIMULUS ------------ ABSENT------------ PRESENT
VISUAL ----------------ABSENT------------ PRESENT
AUDITORY ----------- ABSENT------------ PRESENT
TACTILE ABSENT --- ABSENT------------ PRESENT

• Present reality to clients experiencing hallucinations
• Technique in handling clients with hallucinations
Hallucinations
Acknowledgement “I know the voices are real to you”
Reality orientation “I know the voices are real but I don’t hear them”
Diversion “Lets go to the garden”
• 10% of schizophrenic clients hear voices

PARKINSON’S DISEASE
• If acethylcholine (on switch) is increased there is excessive movement resulting to decrease in dopamine (off switch)

ANTI-PSYCHOTIC
Decrease dopamine level
Parkinson like effect
Extra pyramidal side effect
With akathesia
Restless, inability to rest

AKINESIA
• Muscle rigidity

DYSTONIA
• Torticollis (wryneck)

OCULOGYRIC CRISIS
• Fixed stare

OPISTHOTONUS
• Arched back
• Lips – smacking
• Tongue – protruding
• Cheeks – puffing
• The 3 are irreversible and called tardive dyskinesia
• Neuroleptic malignant syndrome – hyperthermia

ANTI – PARKINSON
Anticholinergics Dopaminergics
(Decrease Ach) (Increase Dopa)
Artane, Akineton Parlodel
Benadryl Larodopa
Cogentin Eldepryl
Symmetrel

OTHER SIDE EFFECTS OF DECREASE DOPAMINE
• Photosensitivity
• Agranulocytosis – decrease WBC
• Clients prone to infection due to decrease WBC
• First sign for infection is sore throat

TYPES OF SCHIZOPHRENIA

DISORGANIZED SCHIZOPHRENIA
- Sad but smiles (inappropriate affect)
- No reaction (flat affect)
- Flight of ideas (disorganized speech)
- Giggling (hebephrenic giggle)
- Combination of positive and negative signs and symptoms

CATATONIC SCHIZOPHRENIA
- Ambivalence
- Waxy flexibility
- Favorite word is “No”
- Negativism (client do not follow what you tell them to do)
Nursing management: meet needs

PARANOID SCHIZOPHRENIA
- Suspicious
- Mistrust, scared, withdrawn
Nursing management:
- Gain trust by 1 to 1 short interaction but frequent
- Foods should be in a sealed container
- Medications should be in tamper resistant foil.
Violent:
- Keep door open
- Position near door
- Don’t touch client
- Call for reinforcement
- One arms length away from the client.

PARANOID SCHIZOPHRENIA
- No more positive symptoms just withdrawn

UNDIFFIRENTIATED SCHIZOPHRENIA
- Mixed classification, cant be classified


PHAMRA NOTES:

BI-POLAR, MANIC
• Lithium: undergo first kidney test and check for blood levels
• Level: .6 – 1.2 meq/L
• Increase urination
• Tremors, fine hand
• Hydration of 3L/day
• Increase
• Uu (diarrhea)
• Mouth dry

Signs of Lithium toxicity
• Nausea, vomiting, diarrhea
• Increase sodium
* Wait for 2 – 4 weeks before lithium therapy takes effects

BIPOLAR DISORDER/MANIC PROFILE
• 20 years old
• Female
• Stress
• Obese

ASSESSMENT
• Decrease appetite (give finger foods)
• Decrease sleep (place in a private room)
• Hyperactive
• Increase sexual activity – only means of addressing anxiety so decrease level of anxiety
• Risk for injury/other directed violence
• Impaired social interaction (care giver role: strain and stay with client)
• Self esteem decrease (to cover up their sadness there is compensation to cover defective doing)
• Because there is decrease self esteem there will be increase compensation resulting to increase interference with ADL’s and harm to others
• Compensation is the culprit
Management: increase self esteem to decrease compensation and decrease interference with ADL’s and harm to others

HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS
T- no sports (basketball, volleyball), no fine motor skills only gross motor skills
A lot energies toward more productive endeavors (sublimation)
S - escorted walk outdoors
K – punching bag (displacement)


PHARMA NOTES:

ANTI – DEPRESSANTS
• Asendin
• Norpralamin
• Tofranil
• Sinequan
• Anafranil
• Aventyl
• Vivactil
• Elavil
• Prozac
• Paxil
• Zoloft

ALCOHOL LEADS TO:
• Blackout: awake but unaware
• Confabulation: inventing stories to increase self esteem
• Denial: “I am not an alcoholic”
• Dependence: cant leave with out leading to enabling where in the significant other tolerates the abuser co dependence is another term
• Tolerance: gradual increase in amount of stimuli to experience the same euphoria

MANAGEMENT
• Detoxification: withdrawal with medical doctor supervision
• Avoid alcohol therapy
• Aversion therapy a more technical term for avoid alcohol therapy
• Antabuse: Disulfiram makes the client never drink alcohol because it causes vomiting
• Alcoholics anonymous
• Interval of 12 hours after last dose of alcohol or experience nausea and vomiting and hypotension
• Alcoholism may result to Vitamin B1 (Thiamine) deficiency

WERNICKE’S ENCEPHALOPATHY
• Problem with motor

KORSAKOFF’S PSYCHOSIS
• Problem with memory
• 24 – 72 hours after last dose of alcohol expect:
• Delirium Tremens: sympathetic nervous system
• Prevent hallucinations/Illusions by placing client in a well lit room
• Formication: feeling of bugs crawling under the skin

ALZHEIMERS DISEASE
• Axon (away) and Dendrites (toward) nerve
• Neurofibrillary tangles
• Neurotic plaques

--------------------------ALCOHOL --- ALZHEIMERS
ONSET -------------------- Abrupt -------- Gradual
LEVEL OF CONSCIOUSNESS -- Fluctuating ----Unaffected
DURATION ----------- Hours to days --- Progressive
MEMORY -------------- Short term ---Short and long term

5 A’s OF ALZHEIMERS
1. Amnesia – memory loss
2. Anomia – don’t know the name
3. Agnosia – sensory problems smell, taste, sight
4. Aphasia
- expressive: cant say/express
- frontal lobe is affected particularly broca’s area
- receptive: cant hear
- temporal lobe is affected particularly wernicke’s area
5. Apraxia – cant do simple things
* Reminiscing Therapy – talk about past
• Patients with alzheimer’s may experience hallucinations, illusions thus becomes restless and may wander
• As sun goes down client becomes restless, agitated, disoriented called sundowning
• Drug of choice is Cognex and Aricept a cholinesterase inhibitor that increases Ach causing delay in disease progression

SEROTONIN
• Responsible for happiness
• Decrease serotonin clients becomes sad give anti-depressants

SELECTIVE SEROTONIN REUPTAKE INHIBITOR
Safest drug
Side effects low
R
I to 4 weeks
- Increases serotonin and affects only serotonin
- Prozac, Paxil, Zoloft

TRICYCLIC ANTI DEPRESSANT
Two – four weeks
C
A
- Has higher incidence of side effects
- Also increases norepinephrine
- Asendin, Norpralamin, Tofranil, Sinequan, Anafranil, Aventyl, Vivactil, Elavil


MONO AMINE OXIDASE INHIBITORS
• MAO kills serotonin
• Increased MAO results to decreased serotonin the more depressed the client becomes
• MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine, norepinephrine, dopamine but client becomes prone to hypertensive crisis
• Avoid tyramine rich foods
Avocado, Alcohol
Beer
Chocolates, Cheese (aged)
Fermented foods
Pickles
Preserved foods
Soy sauce
• There is increase incidence of side effects after 2 – 6 weeks
Marplan, Nardil, Parnate


PERSONALITY DISORDERS
1. Schizophrenia
- They avoid people because there is no enjoyment
2. Avoidant
- They avoid people because they are afraid of criticisms
- They have talent but has no confidence
3. Anti-Social
- Constantly breaks law
- Project charm
- They are witty and articulate
- Manipulative
4. Borderline
- They perceive life as an empty glass
- They like splitting friends
- Sudden change in mood “labile affect”
- Prone to suicide
5. Dependent
- “Cant live if living is without you”
6. Histrioinic
- Constantly wants to be the center of attention
- Excited, dramatic, manipulative
7. Narcissistic
- “I love myself”
- They get jealous even with achievement of family members
8. Obsessive – Compulsive
- “I am so organized”
9. Paranoid
- Suspicious
- May lead to domestic violence


ANTI – DEPRESSANT SIDE EFFECTS:
Male – erectile dysfunction, prone to impotence


GRIEF PROCESS
1. Denial – shock/disbelief
2. Anger – question “why me?”
3. Bargaining – if, then
4. Depression – 2 weeks or more sign and symptoms becomes major clinical depression
5. Acceptance – client acts according to situation


ASSESSMENT
• Decrease self actualization
• Decrease self esteem
• Withdrawn: stay with client
• Suicidal: risk for self directed violence
• Increase/decrease eat, increase/decrease sleep, hypoactive, decrease sexual urge
• Be sensitive to clients needs


FOR SUICIDAL OBSERVE FOR
Verbal
• “I wont be a problem”
• “This is my last day on earth”
• “I’ll soon be gone”
Non verbal
• Giving away of valuables
• Sudden change in mood


WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DO
Direct: “Do you plan to commit suicide?”
Irregular/interval visits
Endorsement period, early morning clients are most likely to commit suicide


DOWNERS
Alcohol
Barbiturate
Opiates
Narcotics
Marijuana
Morphine
Codeine
Heroine


Resulting to:
• Bradycardia
• Bradypnea
• Moist mouth
• Pupils constrict
• Constipation
• Urinary retention
• Hypotension
• Coma
• Weight gain
• Narcotics overdose: give narcotic antagonist (Narcan, Naloxone hydrochloride)


UPPERS
Cocaine
Hallucinogens
Amphetamines
Resulting to:
• Tachycardia
• Awake
• Tachypnea
• Dry mouth
• Pupils dilate
• Hypertension
• Seizures
• Weight loss




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3 comments:

Anonymous said...

sir can you clarify the meaning of your loose of association and flight of ideas because your meaning differs from ray a. gapus' meaning..
hope you answer this..
thanks and Godbless..
=)

Nurse Review said...

Thanks for pointing that out. I updated it.

NLE Review said...

You can checkout my recent post regarding NLE Review: Common Psychiatric Terms


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