Study Guide (NSG 150) Test 2 (unit 2)

2.1 Stress

1.1 know key terms in chapters

1.2 compare/contrast the biological , multi causal & psychosocial theories of physiological diseases

Biological- views physiologic disease as a result of malfunctions of the body's organs & cells. Signs & symptoms are observable & quantifiable

does not explain the causes of all disease.

Multicausal- focus on the capability of every living organism to maintain its internal environment or homeostasis ( dynamic state that is created by the feedback & regulation processes). Three mast feedback systems in the body are:Neurologic, endocrine, and immune systems.

Systems are capable of managing & responding to multiple incoming stimuli from internal & external environments.

Psychosocial- emphasize the impact of stressful stimuli & the interaction of psychologic, physiologic, and social factors as supportive factors in the adaptation process & as causative factors in the development of illness or disease. Mental, spiritual & emotional response cause illness & disease

1.3 discuss the general adaptation syndrome according to Selyestress- both as a response to noxious or stressful stimuli & as a stimulus that produces biologic, emotional, & psychologic responses.

Distress (negative)- subjective response to internal or external stimuli that are threatening or perceived as threatening to the self. Includes fatigue, pain, fear, and acute/chronic disease.

Eustress (positive)- nonspecific stress response that is associated w/ desirable events. Ex. Wedding, job promotion, birth etc.

Psychologic stress- all processes, internal or external, that demand a cognitive appraisal of the event before a response or the activation of any other system.

General adaptation syndrome- three stages of the individuals innate behavioral responses to any stress stimulus.

A brief alarm-fight-or-fight stage, which alerts the individual to the presence of stressful stimuli.

Reciprocal reaction b/t the autonomic nervous system, endocrine, and the immune system

release of hormone epinephrine from the sympathetic branch of the autonomic nervous systemplaces the person on alert

activation of the hypothalamic-pituitary-adernal axisresults in the release of cortisol

elevation of bp; tachycardia; constriction of blood vessels and the diversion of blood from nonessential organs to the heart, brain, & skeletal muscles; increased blood sugar; dilated pupils; increased muscle tone; increased alertness; and free-floating anxiety

fight or flight response

Resistance- body stabilizes & returns to normal homeostasis.

Stabilization

Hormonal levels return to normal

Parasympathetic nervous system activity

Adaptation to stressors

If the body does not adapt and the stressor continues to be prominent the individual enters the 3rd stage 3. Exhaustion- all the individual's resources are used & the individual is unable to adapt to the stressor.Body becomes exhausted & Is unable to sustain the necessary changes that are activated during the alarm stage.

Can manifest itself in the form of illness such as infections, headaches, hypertension, asthma attacks, chronic fatigue syndrome, depression, anxiety disorders, & many other chronic conditions

increased physiological response as noted in the alarm reaction

decreased energy levels

decreased physiological adaptation

death

general inhibition syndrome (possum response)- person freezes or shuts down & is unable to respond in any manner. Result of over-stimulation of the parasympathetic nervous system, & it is activated automatically as a means of survival that has a paralyzing or numbing effect when a person is facing a life-threatening event.

1.4 Identify the appraisal-transaction theoryLazarus & Folkman stated that stress is a transaction process rather than an event

Process occurs as the person makes a cognitive appraisal of each stress encounter & assesses it's intensity as either harmful, a threat of harm, or a challenge to overcome.

Secondary appraisal determines what the response will be, such as selecting the coping method to use to reduce the effect of the stress.

Response depends on the individuals current & past experiences w/ stressors

timing of the event & person's use of coping skills also influence the response

problem-focused skills- strategies that help to resolve the stressful situation

emotion-focused coping responses- r/t to fear & anxiety frequently manifest as ego-defense mechanisms, such as denial or repression.

Daily hassles- annoying or troublesome concerns, states of confusion or turmoil, & events that the person cannot control.

1.5 rate yourself on the social adjustment scaleoutlines 43 stressors that are each assigned a point value

add up the # of points of the life events that occurred to you within the past year

the greater the # of points the higher the probability of developing a physical illness.

Job stress is commonly cited as a cause for frustration & illness

death of spouse is ranked # 1 100 point value-----minor violations of the law ranked last11 point value

1.6 Describe PNIE on the development of diseasesPsychoneuroimmunoendocrinology- a new multidisciplinary approach to the study of the intricate mind-body interactions among the neurologic system, the endocrine, & the immune system.

Examine the effect of perceived psychosocial stressors & the biopsychologic stress response on the development of disease.

Provides a holistic framework for research & screening risk factors of health problems, lifestyle, & sociologic factors.

A greater emphasis on health promotion across the life span, self-care management. & a holistic approach to the management of acute & chronic psychosocial & physiologic health problems.

1.7 Define the role of coping mechanisms in response to stressful eventscoping- use of resourcefulness & the ability to manage the stress of daily circumstances

conscious/unconscious adaptive/maladaptive conscious mechanisms are sometimes learned unconscious mechanisms are often referred to as protective ego defenses

adaptive conscious mechanisms-distractions such as reading, praying, meditating, using relaxation techniques, & seeking social support.

Maladaptive conscious mechanisms- withdrawing from social contacts, changes in dietary habits, smoking, drug & alcohol abuse, participating in other unhealthy behaviors & sudden outbursts of anger.

Unconscious ego defense mechanisms- repression, denial, rationalization, & regression. Often prevent the individual from realistically appraising himself/herself, other people, or situations.

The goal is to use strategies that minimize unnecessary sources of stress & to promote effective adaptive responses.

People use these responses to protect their integrity. A response is often a temporary measure until the immediate crisis is resolved or until the person is able to control the situation.

1.8 List examples of chronic diseases which have been linked to the mind-body response to stresscardiovascular, stroke, respiratory, & renal disorders

cancer

diabetes, HIV/AIDS, RA, MS

schizophrenia, bipolar disorder

amputations, paralysis, blindness

migraines

allergies

lupus

hypertension

Asthma

symptoms such as pain, fatigue, nausea, anorexia, sleep disturbances, & the steady decline in the functioning ability challenge coping skills.

Adaptation is a complex & continuous process of restructuring life around the chronic conditions

the uncertainty of the progress of chronic diseases often leads to depression, anger, & feelings of hopelessness & helplessness.

1.9 Identify the 3 stages of the stress response according to Selye (discussed in detail in previous EO)Alarm stage

resistance stage

exhaustion stage

1.10 Describe the locus of control & how perception determines response to stresshow individuals perceive the issues around them will determine how they will respond to untoward events

locus of controlcan be measured along a continuum b/t internal & external control

includes ones thoughts, beliefs, behaviors, aptitudes, culture, & value system

those who demonstrate an internal locus of control view their capability to have personal success or failure as having to do w/ their own efforts & their ability to complete a task.

Those who demonstrate an external locus of control view task completion as having to do w/ circumstances beyond his/her control, such as luck & the influence of external forces (e.g, nature).

1.11 describe the differences b/t complementary/alternative medicine & traditional therapiescomplementary/alternative medicineencompasses a broad range of healing philosophies, approaches, therapies & their accompanying theories & beliefs.

More than 1800 approaches to healing in this field

NCCAM classified this into 7 broad categories alternative medicine systemstraditional Chinese medicine, including acupuncture

folk medicine

naturopathy

mind-body interventionsmediation

prayer

yoga

humor

exercise

hypnosis

pharmacologic & biologic-based therapiesvaccines & medicines not yet approved by mainstream medicine (animal cartilage, chelating chemicals)

herbal medicationsChinese herbals

American herbals

European herbals

diet, nutrition, supplements, & lifestyle changesvitamins, minerals , supplements

vegetarian diets

ethnic-based diets

manipulative & body-based methodschiropractic

acupressure

therapeutic touch

energy therapiesbiofeedback

light therapy

bone-growth stimulation

Allopathic medicine ( traditional, or conventional, biomedical model)major focus is on disease rather than the p/t as a whole person

biomedical model is based primarily on the following assumptionsthe scientific method identifies the cause of a disease, & providers implement curative treatments to correct abnormal physiology

the germ theory defines infections

the prevention of disease is based on proper hygiene, public sanitation, & personal life style choices

disease is usually tangible & measurable

illness- highly individual & personal response that is exhibited as pain, suffering or distress.

1.12 describe mind-body interventions, pharmacologic, biological, & alternative medical practicesmind-body interventionsmediation- lowers heart-rate, bp rates, serum levels of adrenal corticosteroids. Increases immunity to disease, a sense of calmness, peace, & mental alternatives.Biofeedback, visual imagery, yoga

select a special time & place

assume a comfortable position

deep breathing exercise

focus attention on chosen mental image

Prayer- communication w/ God or a superior beingsilent or spoken

conversational or formal

mindfulness-based therapy-paying attention to ones own inner experience by quieting the mind & investigation the mind through personal experiences & asking questions such as who am I?one learns how to balance physical, mental , & spiritual health by using all the senses

the goal is not to change the thoughts but to allow an awareness to emerge by paying attention only to the present moment & being nonjudgmental about all thoughts that pass through the mind.

Use of the arts- music, dance, drama, literature, humor, & art.

Humor- relieves tensions & anxiety, expressing emotions, coping w/ painful or unpleasant situations.

Exercise

animal-assisted therapy

hypnosis

Pharmacolgoic & biological a variety of drugs & vaccines that are not yet included in the mainstream medicine.

Some stimulate the immune system to ward off disease & consist of older herbal remedies; all are considered nontoxic.

Shark & other animal cartilage that is used to treat AIDS, cancer, & arthritis

Alternative medical practicesacupuncture

ayurvedic

homeopathic

naturopathic

traditional Chinese medicines

environmental medicines

anthroposophically extended medicine

1.13 describe the negative side to alternative therapieslack of guidelines to ensure the purity & dosage accuracy of herbal remedies & supplements

many methods are not tested

potential interactions may occur w/the concurrent use of herbal treatments & other drugs w/ prescribed meds

1.14 list some of the more common food/herbal/drug interactions (box 27-5 Pg 635)Gingko-interferes w/ blood clotting

calcium carbonate- interferes w/ thyroid hormones

Grapefruit juice should be avoided with so many drugs, should advise not to use

St. Johns wort can cause central serotonin syndrome if used w/ SSRIs, also many drug interactions

many fortified foods (calcium fortified orange juice, breakfast cereals) have high calcium & other minerals that bind w/ antibiotics & prevent drugs from being absorbed

2.2 Anxiety disorder 1.1 define key terms

1.2 describe & contrast the 4 levels of anxiety as described by PeplauMild

Physiologic: vital signs normal; minimal muscle tension; pupils normal & constricted

Cognitive/Perceptual: Perceptual field is broad; awareness of multiple environmental & internal stimuli; thoughts are often random but controlled

Emotional/Behavioral: Feelings of relative comfort & safety; relaxed & calm; performance automatic; habitual behaviors occur

functioning people operate in this range.

Facilitates learning, creativity, & personal growth. (ex. Nursing students as they strive to excel in their work)

2. ModeratePhysiologic: vital signs normal or slightly elevated; tension experienced; p/t is uncomfortable or experiences pleasure (labeled as tense or excited)

Cognitive/Perceptual: Alert: perception narrowed & focused; optimum state for problem solving & learning; attentive

Emotional/Behavioral: feelings of readiness & challenges energized; engages in competitive activity & learns new skills; voice & facial expression interested or concerned.

Adaptive mechanism to cope w/ pleasant or unpleasant situation.(ex. Nursing student who is giving an important oral presentation)

moderate or severe anxiety are either acute or chronic

3. Severefight-or-flight response; ANS excessively stimulated (vital signs increased, diaphoresis, urinary urgency & frequency all increase, diarrhea present, dry mouth, appetite decreased, pupils dilated); muscles rigid & tense; senses affected hearing decreased; pain sensation decreased

Cognitive/Perceptual: perceptual field greatly narrowed; problem solving difficult; selective attention (focuses on 1 detail); selective inattention (blocks out threatening stimuli); distortion of time (things seem faster/slower than they actually are); dissociative tendencies; detachment; vigilambulism(automatic behavior)

Emotional/Behavioral: feels threatened & startles w/ new stimuli; feels on overload;activity increases/decreases (may pace, run away, wring hands, moan, shake, stutter, become very disorganized or withdrawn, freezes in position, or be unable to move); appears & feels depressed; demonstrates denial; complains of aches or pains; is agitated or irritable; need for space increases; eyes move around room or gaze is fixed; some p/ts close eyes to shut out the environment.

P/t focuses energy primarily on reducing the pain & discomfort of anxiety rather than on coping w/ the environment.

Often requires help to reverse the situation.

4. PanicPhysiologic: above symptoms increase until SNS release occurs; person becomes pale; Bp decreases; hypotension occurs; muscle coordination poor; pain & hearing sensations minimal

Cognitive/Perceptual: perception totally scattered or closed; unable to take in stimuli; problem solving & logical thinking highly improbable; perception or unreality about self, environment, or event; dissociation often occurs

Emotional/Behavioral: feels helpless, w/ a total loss of control; p/t is angry or terrified becomes combative or totally withdrawn, cries or runs away; completely disorganized; behavior is usually extremely active or inactive.

1.4 Discuss the etiology of anxiety disorders using the biological, psychodynamic & behavioral models.Biological ModelDarwin postulated that emotional expression & anatomic structures both changed during the course of evolution to enable the species to adapt to its environment.

Linked the endocrine system w/ emotions, first by establishing the relationship of the adrenal medulla in the production of epinephrine, which results in the fight-flight response.

Amygdala & the hippocampus relate to the fear response. Changes in size & function when an individual is experiencing symptoms seen w/ anxiety disorders such as PTSD, social phobia, & generalized anxiety disorder (GAD).

Amygdala is involved in the fight-or-flight response, some hypothesized that different anxiety disorders affect different parts of the amygdala.

Chronic stress possibly causes changes in the amygdala, hippocampus, & the pre-frontal cortex.

Genetics play a role. When performing functional MRI researchers found that some of the research subjects had one or two copies of a short variant of the human serotonin transporter gene as apposed to the long variant of this same gene.

They found that adults w/ one long gene and one short gene tended to be more anxious than those w/ two copies of the long gene.

Psychodynamic Modelin psychoanalytic terms, anxiety is a warning to the ego that it is in danger from either an internal or external threat.

Anxiety is involved in the development of personality & personality functioning & in the development & treatment of neuroses & psychoses.

3 types reality anxiety a painful emotional experience that results from the perception of danger in the external world, such as the fear of the possibility of a terrorist attack.

Moral anxiety the ego's experience of guilt or shame. (ex. Of moral anxiety is experiencing guilt for expressing anger at a family member)

Neurotic anxietyThe perception for a threat according to one's instincts. Neurotic symptoms develop in an attempt to defend against anxiety, including somatic symptoms, obsessions, compulsions, & phobias.

Behavioral ModelClinicians who believed that the psychoanalytic model & methods were lacking designed behavioral models in psychiatry & psychology.

They identified experimental psychology as a resource for ideas from which to develop new treatments.

The etiology of anxiety symptoms is a generalization from an earlier traumatic experience to a benign setting or objects. (ex. Awkward child whose parents ridiculed him while he was bowling. As a result, he associates embarrassment & shame w/ sports events in indoor facilities & develops panic attacks during BB games).

Anxiety occurs when an individual encounters a signal that predicts a painful or feared event.

Joseph Wolpe systematic desensitization is a method that comes from the learning theory. The therapist exposes a deeply relaxed p/t to a graded hierarchy of phobic stimuli. Others have redefined this method further into in vivo desensitization, whereby the therapist exposes the individual progressively to more anxiety provoking situations.

Systematic desensitization works for people who have agoraphobia (overwhelming fear of places)

1.5 Discuss the etiology of somatoform, factitious, & dissociative disorders using the biological behavioral, & cognitive theories.Somatoform disorders: include a group of disorders that convert anxiety into physical symptoms for which there is no identifiable physical dx.complex interactions b/t mind & body, w/ serious impairment in the person's social & occupational functioning.

Biological theory: changes in the structure & function of the brain caused by prolonged stress or trauma can result in somatoform disorders by altering the individual's perceptions & interpretations of bodily functions.

Behavioral theory: believe that some individuals learn to use somatic symptoms to communicate helplessness & to manipulate others. Alexithymia- the inability of an individual to describe his/her feelings in words. Tend to express feelings w/ somatic concerns.

Ex. a woman who is angry w/ her boss. Instead of being able to discuss her angry feelings w/ her friend, she reports stomach pain & frequently calls in sick to work.

Cognitive theory: p/ts w/ somatic symptoms misinterpret the meaning of body functions & sensations & become overly alarmed by them.

Somatization disorder- formerly called hysteria & briquet syndrome.Symptoms must begin before the p/t is 30 yrs old & not be adequately explained by any general medical disorder or the direct effects of a substance.

Symptoms have a distinct pattern that differs from general medical conditions in the following 3 criteria:there is involvement of multiple organ system (gastrointestinal, reproductive, neurologic)

the symptoms exhibit an early onset & a chronic course w/o the development of physical signs or structural abnormalities

the clinical laboratory abnormalities that are commonly associate w/ general medical conditions are absent.

Pain Disorder: pain in one or more anatomic sites. Associated w/ psychologic factors.

Conversion Disorder: exhibit one or more symptoms that affect voluntary motor or sensory function. Not intentionally produced. 3 defining characteristics:psychologic factors are identified as being r/t to the onset or exacerbation if the symptoms

specific & identifiable conflicts or stressors precede the development of the conversion symptoms

the person demonstrates an obvious lack of concern about the seriousness of the symptoms, which is inconsistent w/ the problem

this lack of concern is called la belle indifference or beautiful indifference

Hypochondriasis: six major criteria first, individual focuses on fears of having or the idea of having serious medical disorder on the basis of his/her misinterpretation of bodily symptoms.

Second, this misinterpretation of symptoms persists despite appropriate medical evaluation & reassurance.

Third, the individuals preoccupation w/ symptoms is not as intense or distorted as it would be w/ a delusional disorder nor is it as restricted as it would be with BDD.

Fourth, preoccupation causes clinically significant distress or impairment in social, occupational ,or other major areas of functioning.

Fifth, duration of the disturbance must be at least 6 months

sixth, is that hypochondriasis is not caused by another anxiety disorder, somatoform disorder, or major depressive episode

Body dysmorphic disorder: occurs when a p/t is preoccupied w/ self-perceived defect in appearance. Causes distress or impairment in social or occupational functioning, & is not the result of another mental disorder. ex. of symptoms include excessive grooming, checking in the mirror, skin picking, & multiple cosmetic surgeries to fix the deficit.

Factitious disorder:intentionally produce physical or psychologic sings & symptoms to assume the sick role.

Individual performs this behavior for economic gain, to avoid school or legal responsibility, or to improve his/her physical well-being.

Unconscious aspect to the p/t's behavior & thought pattern.

May also have a personality disorder. Their relationships are often disturbed, few attachments, some delusions or grandiosity as well as some thought distortions.

Dissociative Disorders dissociative amnesia: one or more episodes of inability to recall important personal info that is usually of a traumatic or stressful nature, & the loss of memory is too extensive for ordinary forgetting to explain.

Dissociative Fugue: sudden & unexpected travel away from home or ones customary place of work w/ an inability to recall one's past or where one has been.

Dissociative identity disorder: criteria for this disorderfirst criterion is that the individual must demonstrate two or more distinct identities or personality states, each w/ its own relatively enduring pattern of perceiving, relation to, & thinking about the environment & the self.

Second, at least two of these personality states recurrently take control of the person's behavior. The individual is unable to recall important personal info to a degree that is too extensive for ordinary forgetting to explain.

Depresonalization disorder: persistent or recurrent episodes of feelings of detachment or estrangement from one's self. Sensations of being outside of one's body or mental processes or being an observer of ones body often occur.

1.6 Describe cultural variations in the dx of anxiety disorders, samatoform, factitious, & dissociative disorders.Symptoms that define disorders are representative of U.S culture.

Establish cultural norms when evaluating p/ts for anxiety & r/t disorders.

Some cultures restrict womans participation in public activities, thus, agoraphobia is less commonly diagnosed.

Many cultures have rituals to mark important events in peoples lives. The observation of these rituals is not indicative of OCD unless it exceeds norms for that culture.

W/ the exception of OCD & social phobia, anxiety r/t disorders exhibit a higher prevalence among women than men. This represents a cultural variation.

1.7 & 1.8 & 1.9 Assess the p/t w/ a dx of anxiety, somatoform, factitious, or dissociative disordersit is important for all nurses to identify dysfunctional manifestations of anxiety so that treatment can be implemented promptly.

Nurses are the first HCP to come in contact with p/t's who are experiencing their first symptoms of panic disorders.

The p/t w/ agoraphobia sometimes comes to the attention of a nurse when the nurse is preparing a p/t for diagnostic testing that includes a CT or MRI.

Most often p/ts w/ anxiety symptoms do not present w/ anxiety as their primary reason for seeking treatment.

Nurses who use an assessment tool that addresses each identified human response pattern will obtain cues from the p/t who is experiencing anxiety that indicate further assessment.

thoroughly assess each p/t w/o considering the possibility that the p/t is feigning the physical symptoms.

Understand the possible anxiety precipitants of the somatic concerns will help the p/t to reduce his/her focus on the physical sensations.

Diagnosis nurse relies on info that is obtained during the assessment process.

Nurse identifies defining characteristics of the target dx from the p/t & together the nurse & p/t jointly identify etiologic factors.

Etiologic factors influence the selection of the appropriate interventions.

Risk for suicide; anxiety; death anxiety; hopelessness: chronic pain (191+211)

Outcome Identificationsomatization disorder: p/t will construct an exercise program that includes anxiety reducing techniques

address 2 positive somatic responses (e.g, massage therapy, the satisfied feeling after a successful exercise session.)

keep a journal to document somatic preoccupation & stressors, including intrusive thoughts & concerns

help the therapist to coordinate the info from the primary care provider & any other involved specialists.

Take meds as prescribed & be able to identify the rationales for the meds

contact the therapist for more frequent visits if somatization increases.

Dissociative identity disorder: p/t willalert the therapist or use a hotline such as or 1-800-273-TALK when feeling suicidal

respond to his/her name when addressed by a member of the treatment team

refer to himself/herself in the first-person pronoun form (e.g., I think)

identify periods of increasing anxiety

inform others about dissatisfaction in a nonthreatening manner

use assertive-response behaviors to meet his/her needs

keep a written journal to identify stressors & when the dissociation occurs.

Generalized anxiety disorder: p/t willdemonstrate a significant decrease in physiologic, cognitive behavioral, & emotional symptoms of anxiety.

Demonstrate the use of mindfulness meditation when experiencing symptoms of heightened anxiety (concentrate on body; pay attention to the act of breathing; observe the act of breathing; meditation discourages, p/t agrees to deal w/ the subject of the intrusive thought at a later time; p/t feels in control of his/her body)

OCD: p/t willparticipate actively in learned strategies to manage anxiety & to decrease OCD behaviors.

Demonstrate the ability to cope effectively when thoughts or rituals are interrupted.

PSTD: p/t willdemonstrate concern for personal safety by beginning to verbalize worries.

Assume a decision making role for his/her own health care needs

Planningcomplex & varied

p/ts w/ severe BBD often require hospitalization to prevent a suicidal occurrence.

Treated in an outpatient setting, often w/ the use of different modalities, including individual psychotherapy, group therapy, family therapy, art therapy.

Nurses provide p/ts & families w/ information about treatment alternatives, & they also provide comprehensive discharge planning.

Implementation (interventions)identify the degree of suicidal ideation & depression in p/ts w/ all types of anxiety & associated disorders.

Monitor your own level of anxiety, & make a conscious effort to remain calm. Anxiety is readily transferable from one person to another. Individuals w/ somatoform illnesses have high risk.

Recognize that the p/ts use of relief behaviors focuses on somatic sensations as indicators of anxiety

more on pg 213

anxiety-reducing strategies include progressive relaxation techniques; mindfulness mediation; slow deep- breathing exercises; focusing on a single object in the room; listening to soothing music or relaxation tapes; visual imagery or nature r/t DVDs; exercise

Evaluationif p/t does not make satisfactory progress, the nurse modifies either the expected outcomes or the interventions.

Examines all factors that relate to the outcomes.

Somatoform disorders & the dissociative disorders are chronic & enduring. It takes patience & support for the p/t to determine the pattern of his/her behavior & to incorporate methods to initiate change.

1.10 describe the drugs used to treat anxiety disorders by classification. Take into account actions, special considerations, side effects, & nursing interventions for the following med groups:Generalized anxiety disorder:excessive worry, poor concentration, insomnia, & an unidentifiable cause characterize anxiety disorder.

Symptoms last more than 6 months

treatment drugs used are:

Benzodiazepines:clonazepam(Klonopin) longer acting, lorazepam (ativan), & alprazolam (xanax) treat GAD

rapid onset (1 week or less)

disadvantages cognitive impairment, decreases coordination, potential drug abuse, & withdrawal symptoms

Antidepressants:2nd generation antidepressants have proven to be effective for treatment of anxiety disorders.

Venlafaxine more rapid onset than other other antidepressants treats GAD

advantages: effective for p/ts w/ co-occurring disorders such as major depression or other anxiety disorders; lower potential for drug dependence & abuse.

Disadvantage: longer onset of peak action compared to benzodiazepines (4 weeks vs 1); less efficacy for the treatment of the physical or somatic symptoms of anxiety.

Adverse effects of SSRIs & venlafaxine include GI upset, insomnia, irritability, headache, & sexual dysfunction.

Buspirone:not effective for panic disorders

disadvantage: longer onset (2-4 weeks).

Initial therapy includes the addition of benzopdiazepines until the p/t sees the effect of buspirone.

OCD:presence of either obsessions (persistent & recurrent thoughts, images, impulses & behaviors that are distressing to the individual & that impair daily function), compulsions (repetitive behaviors that the person feels driven to perform in response to an obsession ex. Repeated hand washing, checking), or both.

obsessive thoughts are part of their own thoughts as opposed to coming from somewhere else as occurs with thought insertion, which may be present w/ schizophrenia.

The behaviors or thoughts are an attempt to prevent or reduce the distress invoked by the obsession or to prevent some dreaded threatening situation from occurring.

Treatment drugs are:Antidepressants: SSRIs & clomipramine

choice of a particular SSRI depends on side effects, patient tolerance, & potential drug interactions.

Drug interactions occur w/ clozapine, TCAs. & theophylline; a reduction in the dose of these drugs is recommended.

Tricyclic Antidepressants Desipramine & imipramine are not. Clomipramine has the usual side-effect profile of the TCAs including sedation, anticholinergic side effects, orthostatic hypotension, sexual dysfunction & seizure risk. TCAs are second line therapy.

Augmentation therapy cognitive behavioral therapy nonpharmacologic intervention for OCD. Other augmentation therapies include the use of: 1. dopamine-blocking agents

2. buspirone(limit grapefruit juice 8oz daily or grapefruit b/c of drug food interaction leading to toxicity).

3. Lithium

4. clonazepam

PSTD:Pattern of response after a traumatic event. Person must have experienced or witnessed a traumatic event that included a feeling of being threatened w/ death or severe injury.

Responses include intense fear, helplessness, or horror. Person experiences the traumatic event by having recurrent & intrusive disturbing recollections of the trauma like thoughts, images or perceptions about the incident.

Evidence of avoidance & numbing:efforts to avoid thoughts, feelings or conversation about the trauma

efforts to avoid persons or places that evoke memories of the trauma

inability to remember an important aspect of the trauma (repression)

diminished interest or participation in significant activities

a feeling of estrangement or detachment from others

restricted range of affect

a sense of impending doom

increased arousal is common- sleep disturbances, irritability or angry outburst, difficulty concentrating, hypervigilance & an exaggerated startle response.

Treatment drugs:

Antidepressants: SSRIs; TCAs & MAOIs not used b/c of their side-effect profile, & potential drug & food interactions.

Benzopdiazepines: Clonazepam (effective to reduce flashbacks & nightmares). Problem is tolerance & dependence. Risk for p/t w/ alcohol abuse b/c of additive depressant effects.

Mood stabilizers: Lithium, divalproex, & carbamazpine are adjunct therapies for explosiveness, irritability, & other symptoms that are associated w/ PTSD.

Social Phobia:individual experiences an overwhelming fear of being in a social situation or having to interact w/ many people at once.

They have a great concern that people are criticizing him/her, & he/she worries about acting in a manner that will be humiliating or embarrassing.

Avoid situations or endure them in intense anxiety & fear

have difficulty in a group so group therapy might not be the best option

treatment individual attention and meds such as SSRIs (Paxil)

treatment drugs:antidepressants SSRIs (paroxetine, fluoxetine, fluoxamine, sertraline, & citalopram)

onset (4 weeks) , optimal effects seen after 8-12 weeks.

Benzodiazepines Clonazepam (Klonopin) & alprazolam (xanax)

Gabapentin 900-3600 mg/day. Side effects include sedation, dizziness, dry mouth

Herbal therapy for anxietyKava Kava (piper methysticum) herb that has anxiolytic & sedative properties. Recommended does 100-125mg dried kava kava root extract 3x/daily

Side effects: associated hepatitis, cirrhosis, & liver failure. Altered judgment, altered motor reflexes, GI upset, skin rash, & visual disturbances.

Herb-Drug interactions: barbiturates, benzodiazepines, dopamine agonists, alcohol, & MAOIs.

Valerian (valeriana officinalis) has anxiolytic & hypnotic properties.Treats mild-moderate insomnia as well as for restlessness & tension.

Dose for anxiety relief is 220mg 3x/daily

side effects: hepatotoxicity w/ the long term use of valerian. Sedation & withdrawal symptoms that are similar to those associated w/ the benzodiazepines

Beta BlockersBeta-blockers are drugs that bind to beta-adrenoceptors and thereby block the binding of norepinephrine and epinephrine to these receptors.

This inhibits normal sympathetic effects that act through these receptors. Therefore, beta-blockers are sympatholytic drugs.

Beta-blockers, (beta-adrenergic antagonists), such as propranolol, atenolol and pindolol, often rapidly reduce anxiety in panic disorder, GAD and social and specific phobias.

Beta-blockers may be useful in the treatment of anxiety in patients with pronounced cardiac symptoms or tremor, as the attenuation of physical symptoms has a calming effect in some patients.

Beta-blockers have a rapid onset of clinical effect and can be taken either as a single dose or on a regular basis

beta-blockers may increase peristalsis in the gastrointestinal tract, thereby exaggerating rather than diminishing the effects of anxiety on this system.

At high dosages, beta-blockers that can cross the bloodbrain barrier (eg propranolol) may cause tiredness, vivid dreams, depression and, rarely, delirium.

Antihistaminesoften sedating and so are sometimes used for the treatment of anxiety disorders; the sedation has a quick onset, and rapid relief from anxiety symptoms is observed.

Histamine is a neurotransmitter that plays an important role in arousal.

Antihistamines induce drowsiness, sedation and, in high dosages, impair psychomotor performance of complex tasks

side effects: disturbed co-ordination, weakness, inability to concentrate, urinary frequency, palpitations and hypotension.

Their anticholinergic properties make them poor choices for patients taking other anticholinergic agents, such as TCAs, neuroleptics and anti-arrhythmic agents.

no abuse potential, they have an immediate effect in relieving acute anxiety symptom

Summary: serotonergic antidepressants, particularly the SSRIs & venlafaxine are a better choice for treatment of anxiety disorders. The SSRIs & venlafaxine have better safety profiles & do not involve the risk of substance abuse, tolerance, & dependence that are associated w/ the benzodiazepines. However, they have slow onset of action. Benzodiazepines are still widely prescribed b/c of their rapid onset of action & lack of associated sexual dysfunction.

1.11 Discuss non-pharmacologic treatmentscognitive behavioral therapytreat p/ts w/ somatoform disorders & dissociative disorders

p/t's ability to understand that physical symptoms are a response to thoughts or feelings about behaviors that occur in daily life (important for success of treatment)

target symptoms & then examine the circumstances associated w/ the symptoms.

Change either the cognitions (thoughts) or the behaviors.

Short-term treatment that demands active participation on both the p/t & the therapist.

Rational emotive therapypeople's beliefs strongly affected their emotional functioning. In particular certain irrational beliefs made people feel depressed, anxious or angry and led to self-defeating behaviors

With an emphasis on the present, individuals are taught how to examine and challenge their unhelpful thinking which creates unhealthy emotions and self-defeating/self-sabotaging behaviors.

assist individuals in coping with and overcoming adversity as well as achieving goals

places a good deal of its focus on the present.

REBT addresses attitudes, unhealthy emotions (e.g., unhealthy anger, depression, anxiety, guilt, etc.) and maladaptive behaviors (e.g., procrastination, addictive behaviors, aggression, unhealthy eating, sleep disturbance, etc.) that can negatively impact life satisfaction.

2.3- Sleep Disorders

1.1 Identify and define key terms

1.2- define the sleep-wake regulation and the role of melatonin Circadian Rhythm- Body's internal biologic clock located in hypothalamus

adjust sleep-wake intervals to a cyclic 24-hr pattern because of its sensitivity to the external cues of light and darkness.

Events that can disrupt this biologic clock E.g., Shift work, travel over several time zones, etc.

Neurotransmitters No specific sleep neurotransmitter

Adenosine, acetylcholine, and melatonin have a sleep promoting function

serotonin, hypocretin, and norepinephrine most likely maintain arousal/wakefulness

Melatonina chemical mediator that promotes sleep from the pineal gland

Neurosensory stimulation of the photoreceptors in the retina by light suppresses the release of melatonin.Darkness stimulates its release

1.3 Compare and contrast primary and secondary sleep disorder

Primary sleep disorders (biologic disturbances) Dyssomnias- occur as a result of abnormalities of the physiologic mechanisms that regulate sleep and wakefulness. Abnormalities in amount, quality, or timing of sleep. Insomnia- difficulty initiating or maintaining sleep or of experiencing nonresotrative sleep for a least 1 month.

Narcolepsy- sudden onset of brief sleep attacks that last 10-20 min. & typically take place 2-6x/day. They fall asleep while engaging in meaningful activities such as driving a car, eating, or interacting w/ people. Not common in children; generally initially recognized during puberty/adolescence.Cataplexy- a common sign of Narcolepsy. Sudden loss of muscle tone & voluntary muscle movement. Strong emotional experiences such as laughing or crying may cause this reaction.

Sleep paralysis- also reported in people w/ narcolepsy. Not able to speak or move just before the onset of or upon awakening from a brief sleep attack. Some report hallucinations & experience vivid sensory perceptual experiences either upon wakening (hypnopompic hallucinations) or when entering the brief sleep episode (hypnagogic hallucinations).

Breathing-related sleep disorders-result from a sleep-related breathing condition such as obstructive or central sleep apnea syndrome or central alveolar hypoventilationobstructive sleep apnea- typically have some degree of narrowing or the complete obstruction of the upper airway. Results in loud snoring and regular apneic periods during sleep that last for 10-30 sec. (sleep apnea- absence of breathing)

Risk factor obesity & large neck circumference

Circadian Rhythm sleep disorder- sleep pattern disturbances w/ a persistent or recurrent pattern of sleep disruption that result from a difference in an imposed sleep wake cycle & the individual's own circadian sleep-wake pattern requirements. Result from a delayed sleep phase, jet lag, shift work, or an unspecified source.

Parasomnias- occur as a result of the activation of physiologic systems at incorrect times during the sleep wake cycle, thereby resulting in abnormal behavior or physiologic events during the sleep state. Abnormal behavior or events occurring in association w/ sleep. More common among children. Nightmare disorder takes place during the REM period late in the sleep cycle. Fragmented sleep

frighting dreams that threaten their survival, security, or self-esteem.

Able to recall the nightmares in vivid details

Sleep terror disorder- experience of arousal during NREM sleep.Awakening during the early part of the night due to extreme anxiety or panic.

Crying, screaming, and may appear disoriented

unable to recall the event

Sleepwalking disorder- (somnambulism)engagement in walking, dressing, toileting, and driving while they are in a deep NREM stage of sleep.

Appears to be in a trance, and arousal is difficult.

Sometimes they wake up while performing complex tasks, but most frequently returns to sleep.

Unable to recall events that took place during the sleepwalking episode

Parasomnia not otherwise specified / due to General Medical Condition or substance use

Secondary sleep disorders (often result from a variety of psychiatric illness or medical conditions) mood disorders

effects of substances- alcohol, stimulants (caffeine), amphetamines, cocaine, sedatives (opiates, hypnotics & antianxiety meds)

general medical conditions (endocrine)

1.4 Identify the role of biochemical alterations in neurotransmitters as they relate to the sleep-wake cycleBiochemical alterations in neurotransmitters such as serotonin, melatonin, neorepinephrine, and dopamine may play a major role in the deregulation of sleep and wakefulness. An inherent physiologic imbalance of these chemical mediators increases an individuals change of developing a sleep pattern disturbance.

Narcolepsy results from a deficiency of hypocretin, a neurotransmitter that is produced by the hypothalamus.

1.5 List psychiatric/medical conditions associated w/ secondary sleep disordersdepression

dysthymia

mania

generalized anxiety disorder

substance use/abuse/discontinuance

chronic pain

endocrine disorder

1.6 Assess the patient with a sleep pattern disturbanceObtain both subjective data from the affected individual & his/her bed partner

obtain comprehensive, objective and quantifiable data

Assess # of hrs of sleep per night

Time of day/night that the p/t goes to bed or falls asleep

any recent changes in established sleep patterns & routinesif changes reportedassess inhibiting/enhancing factors

regularityregular/irregular

night time awakenings (describe)

napping (describe)

use of sleep aids or substances that disrupt sleep (e.g, stimulants, antidepressants, sleep meds, alcohol)

present stressors & those from recent or remote past

objective data from the bed partner (e.g, snoring, apneic periods) or from parents (e.g, sleepwalking, nightmares)

1.7 formulate a nursing dx & develop, implement, & evaluate a plan of care for the p/t w/ a sleep disorder Nursing diagnosissleep deprivation

readiness for enhanced sleep

insomnia

ineffective breathing pattern

anxiety

fatigue

ineffective coping

ineffective role performance

risk for injury

impaired spontaneous ventilation

Planningrequires the active participation of the p/t w/ the members of the multidisciplinary health care team

comprehensive & includes relevant biologic, psychosocial, & cognitive treatment modalities.

Implementationmost p/t's w/ sleep pattern disturbances present in the community practice setting unless the sleep disturbance is a co-occurring problem that is associated w/ a psychiatric condition or medical disorder. In the latter instance, the p/t often presents in the acute care setting. Interventions: according to p/t's needs. From most urgent to least urgent. (p. 447)Assessment

Monitoring of sleep patterns and risk factors

Education regarding precursors

Teaching new coping skills

Medication compliance

Life-style changes (use of substances that impact sleep disorders)

Referral to a specialist when indicated

Evaluationpsychiatric nurse & the members of the health care teamincluding the p/tneed to participate in both formal & informal evaluation processes

1.8 Identify pharmacological & non-pharmacological interventions

Pharmacological: Insomnia-Benzodiazepine and non-benzodiazepines - for short term use only (2 weeks) to prevent tolerance & withdrawal symptoms

OTC antihistamines

Antidepressants when co-occurring mood disorders

Narcolepsy and Hypersomnia-CNS stimulant Modafinil (provigil)

CNS stimulants such as Dexedrine, Concerta, Ritalin (not usually the first choice)

Tricyclic Antidepressants or SSRIs (Wellbutrin)

Obstructive sleep apnea-SSRIs & tricyclic antidepressants b/c reduce REM sleep when apnea is most likely to take place.

Parasomnias-agents that suppress the REM sleep; tricyclic or benzodiazepine hypnotic drugs

Non-pharmacologicalcognitive reframing

behavioral modification

sleep practices/sleep hygiene

CPAP for apnea

light therapy for regulating circadian rhythms

exposure to sunlight

establishment of a sleep wake-cycle

2.4 Mood disorders (part 1)

1.2 Distinguish b/t unipolar & bipolar disorderUnipolar mood disordersp/ts who usually have only depressive episodes or, rarely, only manic episodes.

Bipolar disordersoccur when people experience periods of depression that alternate w/ periods of elevated mood, impulsivity, & hyperactivity, which is known as mania.

1.3 Define theories about the etiology of mood disorders including biological (neurotransmission, neuroendocrine dysregulation, & genetics) & psychosocial factors (psychodynamic, cognitive, hopelessness, stress, & adjustments).Biologic theories:Neutrotransmission:brain neurotransmitter functioning affects mood regulation & controls a wide range of behaviors & functions, including appetite, arousal, sleep, cognition, & movement.

Norepinephrine & serotonin, their metabolites, & their receptors as somehow being altered during episodes of depression & mania.

Less-than-normal neurotransmission activity during depression & more-than-normal neurotransmission activity during mania.

Recent investigations focused on changes n receptors; ion channel processes that involve sodium, potassium, & calcium; & neurotropic growth factors (brain-derived neurotropic factor) that nourish neurons

kindling- stress initially alters neutortransmission mechanisms, & results in a first episode of depression or mania.

This initial episode creates an electrophysiologic sensitivity to future stress, thereby requiring less stress to trigger another depressive or manic state.

Kindling creates new hard-wiring of the brain or long-lasting alterations of neuronal functioning that influence many changes in cellular processes, brain structures, cell dendrites, & cellular metabolism

PET scan examines the brain physiology of depressed persons and focus on metabolism of glucose & oxygen

prefrontal cortex & the limbic system (including the amygdala) appear to have physiologic & anatomic changes in the brains of persons who are experiencing depression.

Neuroendocrine Dysregulation mood disorders have been linked to dysregulation of the limbic hypothalamic-pituitary-adrenal (HPA) axis.

The hypothalamus, pituitary, adrenal glands, & the hippocampus make up the HPA axis, which controls physiologic responses to stress.

Hypothalamus: regulates endocrine functions & the ANS; r/t to fight-or-flight response, eating, sleep, & sex; manufactures serotonin (major neurotransmitter in mood disorders); releases corticotropin releasing hormone (stimulates the anterior pituitary to secrete adrencoricotropic hormone)

Adrencoricotropic hormone triggers release of cortisol (elevated during stress) stimulates ANS (which increases epinephrine & norepinephrine)

feedback mechanism cortisol levels signal the hypothalamus via the hippocampus to increase or decrease corticotropin-releasing hormone production.

Overtime high levels of cortisol can damage the hippocampus.

HPA axis r/t to the 24hr cycle of circadian rhythms that control physiologic processes.

Genetic Transmission researchers select families who exhibit mood disorders & then examine the risks that relatives have for developing these disorders.

The first degree relatives of persons w/ bipolar disorder & unipolar depression have a greater risk for the development of a mood disorder.

Risk is particularly high for relatives of persons w/ bipolar disorder, which indicates that genetics plays a greater role in bipolar disorder than in unipolar depression.

If one monozygotic twin suffers from bipolar disorder, there is a strong chance that the other twin will have a disorder as well.

Unipolar disorders continue to be higher for monozygotic twins & twin types have a higher concordance than individuals in the general population.

Psychodynamic theory unconscious processes result in the expression of symptoms, including depression & mania.

Freud: Loss generates intense hostile feelings toward the lost object. The person then turns these feelings inward onto the self, thereby creating guilt & loss of self-esteem. Thus, depression is linked w/ loss & aggression.

Mania is a defense against depression. P/t denies feelings of anger, low self-esteem, & worthlessness & reverses his/her affect so that there is a triumphant feeling of self-confidence.

Mania represents a conquered superego w/ little inclination to control id impulses; however, over time, this distorted view of reality waivers, & the p/t demonstrates outward hostility toward others, often focusing on the weaknesses of others that are similar to the internal weaknesses that they are avoiding.

Few data support this theory, but there is evidence that p/ts w/ depression have experienced more early childhood loss & trauma than persons w/o depression.

Cognitive theoryerrors of logical thinking may be one causative factor of depression.

Underlying cognitive structures, some of which are not fully conscious, influence mood.

In a diatheses-stress model, when individuals who are predisposed to depression w/ negative schemata encounter stress, the negative processing is activated, thereby resulting in depressive thinking.

Levels of cognition that influence depression: automatic thoughts, schemata or assumptions, & cognitive distortions.

Automatic thoughts- thoughts that a person responds to but usually does not recognize as a basis for behavior & thinking. They form the persons perception of a situation, it is this perception rather than the objective facts about the situation that results in emotional & behavioral responses. If perceptions are distorted, inferences & responses will be maladaptive.

Schemata- internal representations of the self & the world. They facilitate info processing, b/c the mind uses them to understand, code, & recall information.

Beck proposed a triad of thinking (schemata) that gives rise to the development of depression:negative, self-deprecating views of the self-care

pessimistic views of the world, which result in life experiences being interpreted in a negative way

belief that negativity will continue into the future, which promotes a negative view of future events.

This mind-set results in the misinterpretation of events & situations so that the p/t sees the self as worthless, & the world & the future as hopeless. This faulty cognitive processing leads to assumptions & continued errors of logic that result in depressive symptoms & an ongoing negative view of life.

All-or-nothing thinking (seeing only two opposite categories or options) discounting the positive (not believing that positive experiences matter) & magnification (placing a distorted emphasis on a single event or error)

Learned hopelessness theoryfurther revision of learned helplessness.

Hopelessness is a sufficient cause of depression.

Individual's inferred negative outcomes & negativity about the self are key elements of depression.

ex. p/t perceives that she is not able to recover from divorce (instability) that her entire life is ruined (globalization, and that her former marriage is the only focus of her life (importance).

Stress theoryall life events even pleasant ones are capable of causing various degrees of stress.

Early life stress, including child abuse & loss, influences the development of depression, most likely by disrupting the functioning of the HPA axis.

Individuals who experience early life stress become vulnerable w/ regard to how their stress response influences the onset & course of depression.

Adjustment life stressors sometimes can lead to adjustment disorders which are different from major depression.

The main distinction is that a specific psychosocial stressor can be identified for the adjustment disorder.

Adjustment disorders/adjustment reactions can occur in response to any type of stressor, including but not limited to loss, personal tragedy, change in life style, maturational crisis, or even success or gain.

Acute: occurs within 3 months of a stressor

chronic: symptoms last more than 6 months after the occurrence of the stressor.

Can occur in anyone, regardless of age, gender, or socioeconomic status.

Time limited

highly individualized.

1.5 discuss mood disorders across the life spanmood disorders- group of psychiatric illnesses in which the predominant symptom is the dysregulation of mood or emotion.

Occur throughout the life span, & often cause personal suffering, difficulty w/ relationships. Impaired functioning, high costs to society & health care systems.

Sometimes fatal, w/ high risk of suicide.

Depression (major depressive disorder) & bipolar disorder (manic-depressive illness) two severe mood disorders that pose significant public health problems that require attention & often long term treatment.

Characterized by shifts in mood which is a subjective feeling state.

1.6 describe how the comorbidity of other psychiatric diagnoses, medical conditions, & some meds & substances contribute to mood disorders.Medical conditions/ mood disorders/psychiatric diagnoses/meds/substances

comorbidity (co-occurrence) identified in several ways:a medical p/t develops a mood disorder as a stress response to a serious medical conditions a medical p/t develops a mood disorder as a physiologic response to either medical pathology or meds

a psychiatric p/t w/ persistent mood disorder develops common medical disorders

a psychiatric p/t w/ persistent mood disorder has an exacerbation of symptoms as a result of medical pathology or treatment

HCP identify previously unrecognized relationships b/t mood & medical disorders.

The pathophysiology of a medical condition or a response to the meds given for a medical condition sometimes results in a mood disorder.

Cardiovascular disorders linked w/ major depression.

Cancer, thyroid disease, HIV mood disturbances

high co-occurrence of mood disorders w/ other major mental illnesses, esp. substance abuse & dependence.

Increase in the # of p/ts who w/ comorbid medical & psychiatric disorders who are also showing signs of dementia.

30-50% of p/ts w/ Alzheimer's disease have significant depressive symptoms.

Two new diagnostic categories will become available that are separate from existing depressive disorders.

Substances associated w/ mood disordersdigitalis, Thiazide diuretics, Reserpine, Propranolol, Anabolic steroids, Oral contraceptives, Disulfiram, Sulfonamides, Alcohol & other substances of dependence, Marijuana

1.7 identify seasonal affective disorder, melancholic, atypical, & postpartum depression as additional types of mood disordersSeasonal Affective disorder: emotional depression b/t October/November & March/April

Melancholic depression: Emotional: Anhedonia; Increased depression in the morning

Cognitive: excessive feelings of guilt

Behavioral: waking at least 2 hrs before normal & being unable to fall back to sleep: psychomotor retardation or agitation; significant weight loss

Atypical depression: Emotional: mood reactivity; ability to react to positive stimuli

Cognitive: sensitivity to interpersonal rejection

Behavioral: significant weight gain or increase in appetite; hypersomnia; Leaden paralysis

Postpartum depression:Behavioral: Difficulty caring for child

1.8 Assess the p/t w/ mood disorder according to the mental status criteria

nurses must maintain awareness of their own personal reactions to the p/t & the ways in which these reactions affect the nurse-p/t relationship & subsequent care.

Mental status criteriaMood: the internal manifestation of a subjective feeling state

Affect: the external expression or manifestation of a feeling state

Temperament: observable differences in the intensity & duration of arousal & emotionality

Emotion: The experience of a feeling state

Emotional reactivity: tendency to respond to internal or external events w/ emotion

Emotional regulation: ability to control or modify the occurrence & intensity of feelings

Range of affect: the span of emotional expression experienced & displayed by an individual

1.9 List possible nursing dx for p/ts w/ mood disordersdepressionrisk for suicide

fatigue

insomnia

risk for loneliness

both types of imbalanced nutrition

powerlessness

anxiety

constipation

Maniarisk for self-directed & other -directed violence

disturbed thought processes

ineffective health maintenance

care-giver role strain

defensive coping

1.10 plan & implement the care of p/ts w/ mood disorders. Include teaching & monitoring activitiesPlanning & implementing care provided in every setting

nursing care addresses acute episodes & p/ts ongoing risk for recurrent episodes.

Interventions during the acute depressive or manic episodes are effective

plan interventions for each p/t on the basis of the p/ts particular behaviors, needs, & concerns.

Plan of action varies depending on whether p/t is depressed or manic.

Interventions cover a wide range of biopsychosocial areas, w/ consideration of the effects of depression & mania on the physiologic, cognitive, psychologic, behavioral, & social domains.

Interventions require nurse to maintain self-awareness & boundaries regarding their own reactions to p/ts b/c p/t depression, irritability, anger, negativity, euphoria, & hyperactivity can readily influence nursing responses.

Be consistent, caring, concerned, empathetic, & genuine.

A knowledgeable, non demanding, & matter-of-fact approach is reassuring to p/ts & promotes their confidence in the nurse.

1.11 Biological interventions: ECT, brain stimulating therapies, photo-therapyECTinvolves the use of electrically induced seizures to treat severe depression or less frequently intense mania that is not controlled w/ lithium or antipsychotics.

Believed to be r/t to the alteration of neurotransmission.

Brain stimulating therapiesTranscranial Magnetic Stimulationnoninvasive procedure in which an electromagnet is placed on the scalp. Electrical current is generated by rapid pulsing in the magnetic field, which causes the cortical neurons to depolarize.

Increases monoamine concentrations in the brain when used repetitively.

Effects unipolar depression

Vagal Nerve Stimulationinduced w/ a vagal nerve stimulator device that is implanted in the left chest wall under the collarbone to electrically stimulate the vagus nerve.

Helpful for p/ts w/ treatment-resistant depression

Deep Brain Stimulationelectrode is inserted deep into the brain, & an electrical current stimulates the brain.

Phototherapylessened symptoms of SAD

exposure to morning light causes a circadian rhythm shift that regulates the normal relationships b/t sleep & circadian rhythms & that ultimately affects mood regulation.

P/ts sit or lie in front of the light box for 30 min to several hours, depending on the strength of the light source

antidepressant effect usually occurs within 2-4 days & is complete after 2 weeks.

Some fail to respond, others experience only a partial response.

1.12 pharmacological interventions: include classification, actions, side effects, & adverse effectsTricyclicClassification: Tricyclic antidepressants (TCAs) are a class of antidepressant medications that share a similar chemical structure and biological effects.

Action: Tricyclic antidepressants increase levels of norepinephrine and serotonin, two neurotransmitters, and block the action of acetylcholine, another neurotransmitter.

Side effects: blurred vision, dry mouth, constipation, weight gain or loss, low blood pressure on standing, rash, hives, and, increased heart rate.

Use w/ MAOIs may increase risk of neuroleptic malignant syndrome, seizures. Hypertensive crisis, & hyperpyrexia

use w. oral anticoagulants can result in bleeding. Use w/ clonidine can cause severe hypertension

herbal considerations: St. John's wort & SAM-e may increase the p/ts risk for serotonin syndrome.

Monoamine:Antidepressants such as MAOIs ease depression by affecting chemical messengers (neurotransmitters) used to communicate between brain cells. Like most antidepressants, MAOIs work by changing the levels of one or more of these naturally occurring brain chemicals.

An enzyme called monoamine oxidase is involved in removing the neurotransmitters norepinephrine, serotonin and dopamine from the brain. MAOIs prevent this from happening, which makes more of these brain chemicals available. This is thought to boost mood by improving brain cell communication.

The most common side effects of MAOIs include: Dry mouth, Nausea, diarrhea or constipation, Headache, Drowsiness, Insomnia, Skin reaction at the patch site, Dizziness or light headedness

Avoid caffeine, chocolate, & all tyramine-containing foods ( aged cheese) within several hrs of ingestion of MAOIs b/c the combination may cause sudden & severe hypertension or hypertensive crisis

Third line agents after SSRIs & TCAs have been tried

signs of toxicity include increased headaches & palpitations

MAOIs should not be taken within 14 days of taking SSRIs

herbal considerations: parsley & St. John's wort pose some risk for serotonin syndrome

SSRIsSSRIs block the reabsorption (reuptake) of the neurotransmitter serotonin in the brain.

SSRIs are called selective because they seem to primarily affect serotonin, not other neurotransmitters.

Side effects of SSRIs may include, among others: Nausea, Nervousness, agitation or restlessness, Dizziness, Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction), Drowsiness, Insomnia, Weight gain or loss, Headache, Dry mouth, Vomiting, Diarrhea

first-line antidepressant therapy

may cause fatal reactions w/ MAOIs by causing serotonin syndrome, hypertensive crisis, rigidity, & neuroleptic malignant syndrome

serotonin syndrome- occur when medicines that are used to treat migraine headaches (5-hydroxytryptamine receptor agonists, & medicines that are used to treat depression SSRIs & serotonin-norepinephrine reuptake inhibitors (SNRIs) which are medicines from different classes) are used together

episodes of self-harm & potential suicidal behavior are reportedly higher in p/ts who are younger than 18.

use w/ caffeine increases agitation; use w/ alcohol increases sedation. Effectiveness is decreased w/ cigarette smoking.

Should not be taken w/ lithium

herbal considerations: st. John's wort & SAM-e may cause serotonin syndrome. Use w/ ascorbic acid (grapefruit juice) may alter the elimination of the drug & it's plasma concentration.

SNRIsSNRIs block the absorption (reuptake) of the neurotransmitters serotonin and norepinephrine in the brain.

The most common side effects of SNRIs include: Nausea, Dry mouth, Dizziness, Excessive sweating

indicated for social anxiety disorder & general anxiety disorder

Venlafaxine is not approved for indications in children & adolescents b/c of the lack of efficacy & concerns about increased hostility & suicidal ideation.

Mood stabilizers including lithiumMood stabilizers balance certain brain chemicals (neurotransmitters) that control emotional states and behavior.

effective for the treatment of mania in p/ts w/ bipolar disorders.

Most widely used is lithium

lithium acts as a salt within the body, & its blood levels are closely linked to the p/ts hydration & sodium intake.

Side effects of lithium: neuromuscular &CNS effects (tremor, forgetfulness, slowed cognition), gastrointestinal effects (nausea, diarrhea), weight gain, hypothyroidism & renal effects (polyuria).

blood levels of 0.6 mEq/L to 1 mEq/L more than 1.5 is toxic

lithium excreted through the kidneys, nurses need to use caution w/ p/ts w/ renal disease.

Herbal considerations: dandelion, goldenrod, juniper, & parsley increase lithium's effects & toxicity

Monitor p/t's sodium intake, b/c significant changes will alter lithium excretion. Black & green tea, coffee, cola nut, guarana, plantains, & yerba mate may all decrease lithium levels.

Anticonvulsantsdivided into 3 classes (first, second, & third generation) indicated for manic symptoms

Anticonvulsants work by calming hyperactivity in the brain in various ways. For this reason, some of these drugs are used to treat epilepsy, prevent migraines, and treat other brain disorders.

They are often prescribed for people who have rapid cycling four or more episodes of mania and depression in a year.

Anticoagulants used to treat bipolar disorder include: Depakote, Depakene (divalproex sodium, valproic acid, or valproate sodium), Lamictal (lamotrigine) , Tegretol (carbamazepine)

Common side effects include: Dizziness, Drowsiness, Fatigue, Nausea, Tremor, Rash, Weight gain.

Used in place of lithium

abrupt withdrawal may cause seizures

labs=liver function, CBC w/ diff.

AntipsychoticAntipsychotics are thought to work by altering the effect of certain chemicals in the brain, called dopamine, serotonin, noradrenaline and acetylcholine.

atypical antipsychotics. These are sometimes called second-generation antipsychotics and include: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole.

typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and include: chlorpromazine, flupentixol, haloperidol, levomepromazine, pericyazine, perphenazine, pimozide, sulpiride, trifluoperazine, and zuclopenthixol.

side-effects include: Dry mouth, blurred vision, flushing and constipation

Immediate treatment of psychotic behavior necessary to prevent exhaustion & infection due to body working too hard. W/o treatment cardiac collapse can occur.

Mood disorders (part 2)

1.1 compare & contrast interpersonal, psychoanalytical, & sociological theories regarding the etiology of suicideInterpersonal theoryharry Sullivan emphasized the importance of interpersonal relationship factors.

Individuals are never isolated from the interactions of significant people in their lives.

Suicidal act needs to be viewed within the context of the perceptions of the suicidal person by his/her significant others.

Suicide is evidence of a failure to resolve interpersonal conflicts.

Psychoanalytical theoryFreud described self-destruction as anger directed inward toward the internalized love object.

Menninger described several sources of suicidal impulses: the wish to be killed, & the wish to die.

Jung said the suicidal person holds an unconscious wish for spiritual rebirth after feeling that life has lost its meaning

Adler identified the importance of inferiority, narcissism (self-absorption), & low self-esteem in suicidal acts.

Horney believed that suicide was a solution for someone who is experiencing extreme alienation for the self as result of a great gap b/t idealized self & the perceived psychosocial self.

Sociological theoriesEmile Durkheim 4 subtypesAnomic- acts of self-destruction by individuals who have become alienated from important relationships in their groups, especially a this relates to their standard of living (suicides after 1929 stock market crash)

Egoistic- the self-inflicted deaths of individuals who turn against their own conscience (suicide of a devout Catholic adolescent after she has had an abortion that was forbidden by her religion)

Altruistic- self-inflicted deaths on the basis of obedience to a group's goals rather than reflecting the person's own best interests (falling on a grenade)

Fatalistic- self-inflicted deaths that result from excessive regulation (suicide of a convicted prisoner who hung himself to escape a prolonged period of incarceration)

1.2 discuss prevalence & factors contributing to suicide in the U.Spresent among people of all ages, members of both sexes, individuals in all ethnic groups and at all socioeconomic levels.

In 2007, 34,598 people died as a result of suicide in the U.S

recent psychiatric sources have cited on social media networks as a possible factor in depression & suicide in teens who may be vulnerable to cyber-bullying & other negative messages

females in general attempt suicide more frequently than males

suicidal behavior is strongly associated w/ psychiatric disorders

1.3 name important indicators of suicide including co-occurrence w/ other health issues.Suicidal behaviors is strongly associated w/ psychiatric disorders

mood disorders, substance abuse, schizophrenia, borderline personality, & panic disorders have a co-occurrence w/ high-risk suicidal behaviors.

Depression remains the single best predictor of suicide risk for all age groups

suicide is the leading cause of death during the first 10 years of the course of schizophrenic illness

the research is mixed regarding the correlation of suicide w/ panic disorders, but its associated w/ suicide risk, especially when panic disorder coexists w/ depression, OCD, or phobias

independent of another specific psychiatric dx, alcohol use & abuse are highly correlated w/ most suicidal acts, esp. among youth. Suicide is under diagnosed & underreported among older adults.

Chronic physical illness contributes to suicidal behavior. More than half of the outpatients who committed suicide in several studies had physical health problems.

1.4 assess risk factors, formulation of a plan, means to carry out plan, & lethality of the planRisk factorsage- b/t 15-24; older adults 65 yrs & older; 85 & over most vulnerable

sex-men have a greater incidence of completed suicides. Women have a higher rate of suicide attempts & gestures

Race & ethnicity- whites are 2x higher than those of nonwhites. African American men who are older than 85 are increasing faster than those for any other group. Native American males second most at risk.

Physical & emotional symptoms-serious depression, significant changes in weight, serious sleep disturbances, extreme fatigue & loss of energy, self-deprecation, anger, feelings of hopelessness, & preoccupation w/ themes of death & dying.

Suicide plan- plans that are more precise, detailed, & explicit about the method indicate high risk.

History of previous attempts

social supports & resources- lack of support or resources increase risk

recent losses- unresolved grief reactions lead to depression & suicidal behavior

medical problems

alcohol & other drugs

cognition & problem- solving ability

Lethality potential for causing death r/t to the level of danger associated w/ the suicide plan

3 elementsspecificity of details

lethality of proposed method

availability of means

p/ts level of hopelessness, intent (method chose & it's accessibility), imminence (likelihood that an event will occur within a specific time period) often help to determine the level of lethality & extent of interventions required for safety.

1.5 distinguish b/t suicidal ideation, gestures, threat, attempt (para suicide), & successful suicide.Suicidal ideation: this involves direct or indirect thoughts or fantasies of suicide or self-injurious acts that are expressed verbally or through writing or artwork w/o definite intent or action expressed. Sometimes p/ts this symbolically.

Suicide threats: these are direct verbal or written expressions of intent to commit suicide but w/o action.

Suicide gestures: these self-directed actions result in no injury or minor injury by persons who neither intended to end their lives nor expected to die as a result. However, they were done in such a way that others interpret the act as suicidal in purpose.

Suicide attempts: these are serious self-directed actions that sometimes result in minor or major injury by persons who intend to end their lives or to seriously harm themselves. Gestures & attempts that are unsuccessful & to low lethality are sometimes called (para suicidal) behavior.

Completed suicide: the deaths of persons who end their lives by their own means w/ conscious intent to die are described as complete suicide. However, it is important to note that some suicides sometimes occur on the basis of the unconscious intent to die (engaging in high-risk activities).

1.6 select appropriate nursing diagnoses for the suicidal p/t..risk for suicide

risk for self-directed violence secondary diagnoses may includeineffective coping

hopelessness

powerlessness

chronic low self-esteem

social isolation

disturbed thought processes

1.7 develop plan of care for the suicidal p/toutcome criteria remain safe & free from self-harm

verbalize the absence of suicidal ideation, planning or intention

therapeutic nursing interventionsall unit precautions for preventing suicide should be strictly enforced.

Routinely count silverware & all other sharp objects before & after the p/t's use of them

providing roommate

requesting visitors to clear all personal items for the p/t or any gifts w/ staff

1.8 implementpsychotherapeutic interventions vary & include insight oriented techniques, cognitive reframing, & brief solution focused crisis interventions.

ECT sometimes used w/ adults whose response patterns reflect a lack of positive response to medication.

Pharmacologic interventions is often primary consideration. Antidepressants, anxiolytics, & antipsychotic are often used.

1.9 evaluatep/t's response is crucial.

Helps nurse to target areas of outcomes that are critical to the p/t's continued survival.

Helps ensure the p/t's continued safety & readiness for discharge

1.10 examine your own beliefs & feelings about suicidal p/ts