Mental Health Hesi Topics
1. Schizophrenia
Clinical Picture
In about 75% of those with schizophrenia the disorder develops gradually, usually presenting
between 15 and 25 years of age (Dean et al., 2016). However, there are also child-onset (before
15 years) and late-onset (after 40 years) forms as well. People who later
develop schizophrenia often experience a prodromal phase during which some milder
symptoms of the disorder develop, often months or years before the disorder becomes fully
apparent (Miller, 2016). During the prodromal phase the person may do less well in school than
his or her peers, be less socially engaged or adept, and demonstrate memory impairment,
suspiciousness, and/or disorganization or oddities in speech or thought.
All people diagnosed with schizophrenia have at least one psychotic symptom such as
hallucinations, delusions, and/or disorganized speech or thought. The symptoms are severe
enough to disrupt normal activities such as school, work, family and social interaction, and self-
care; in children and young adults they often delay or halt achievement of age-appropriate
milestones. Basic needs such as hygiene, nutrition, and healthcare are often neglected, and
socialization and relationships are often disrupted. The full criteria for schizophrenia are listed in
the DSM-5 box.
General Assessment
Not all people with schizophrenia have the same symptoms, and some of the symptoms
of schizophrenia are also found in other disorders. Fig. 12.1 describes the four main symptom
categories in schizophrenia:
1. Positive symptoms : The presence of something that should not be present. Positive symptoms
include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or
speech.
2. Negative symptoms : The absence of something that should be present. Negative symptoms
include the inability to enjoy activities, social discomfort, or lack of goal-directed behavior.
3. Cognitive symptoms : Subtle or obvious impairment in memory, attention, thinking (e.g.,
disorganized or irrational thoughts), judgment, or problem solving.
4. Affective symptoms : Symptoms involving emotions and their expression.
2. Community Hlth/Psychiatric/Mental Hlth - Anxty/Commnictns - Crisis
intervention-empathy
Empathy Versus Sympathy
You may wonder how empathy differs from sympathy. A simple way to distinguish them is that
in empathy, we understand the feelings of others, and in sympathy, we feel pity or sorrow for
, others. Although these are considered nurturing human traits, they may not be particularly
useful in a therapeutic relationship.
The following examples clarify the distinction between empathy and sympathy. A friend tells
you that her mother was just diagnosed with inoperable cancer. Your friend then begins to cry
and pounds the table with her fist.
Sympathetic response: “I feel so bad for you (tearing up). I know how close you are to your
mom. She is such an amazing person. Oh, I am so sorry.” (You hug your friend.)
Empathetic response: “This must be devastating for you (silence). It must seem so unfair. What
thoughts and feelings are you having?” (You stay with your patient and listen.)
Empathy is not a technique but rather an attitude that conveys respect, acceptance, and
validation of the patient’s strengths. Empathy may be one of the most important qualities that a
psychiatric-mental health nurse can possess.
3. Drugs/Nursing action - Lithium-creatinine
Patients' kidney function should be evaluated before they take lithium and monitored regularly.
4. action - Cymbalta-SSNRI
Duloxetine (Cymbalta) is an SNRI indicated for both depression and GAD, as well as diabetic
peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain.
Generic
Action Notes Side Effects Warnings
(Trade)
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Duloxetine Blocks the synaptic Cymbalta may Nausea, dry May reduce pain
reuptake of be more mouth, associated with
(Cymbalta) serotonin and effective insomnia, depression and
norepinephrine than SSRIs somnolence, is approved for
in the constipation, fibromyalgia
treatment of reduced and pain of
severe appetite, diabetic
depression fatigue, peripheral
sweating, neuropathy
blurred vision
,5. Abuse - Alcohol abuse - codependent behaviors
Family Assessment
Understanding the process of addiction from a holistic perspective requires careful attention to
the family. Living with an individual who misuses alcohol or other substances is a source of
stress and requires family system adjustments. Codependence is a cluster of behaviors originally
identified through research involving the families of alcoholic patients. People who
are codependent often exhibit overly responsible behavior—doing for others what others could
just as well do for themselves. People who are codependent often define their self-worth in terms
of caring for others to the exclusion of their own needs.
6. Psychiatric/Mental Hlth - Abuse - Alcohol support group
For therapy groups, the expected outcomes will focus more on insights, behavior changes, and
reduction in symptoms. For example, in an alcohol treatment group, an expected outcome might
be that the patient develops insight into the connection between drinking and negative
consequences. An expected behavioral outcome would be abstinence from alcohol use. In
groups that focus primarily on emotional issues such as depression or anxiety, you can use
standardized symptom surveys to measure symptom reduction as an outcome
of group participation.
7. Psychiatric/Mental Hlth - Abuse - DTs-1st signs
Alcohol Withdrawal
Alcohol withdrawal occurs after reducing or quitting alcohol after heavy and prolonged use. The classic sign
of alcohol withdrawal is tremulousness, commonly called the shakes or the jitters, that begins 6 to 8 hours
after alcohol cessation (Sadock et al., 2015). Mild to moderate alcohol withdrawal includes agitation, lack of
appetite, nausea, vomiting, insomnia, impaired cognition, and mild perceptual changes. Both systolic and diastolic
blood pressure increases, as does pulse and body temperature. Chlordiazepoxide (Librium) is useful for
tremulousness and mild to moderate agitation.
Psychotic and perceptual symptoms may begin in 8 to 10 hours. If your patient is undergoing withdrawal to the
point of psychosis, it should be considered a medical emergency because of the risks of unconsciousness, seizures,
and delirium. The benzodiazepines lorazepam (Ativan) or chlordiazepoxide (Librium) can be given either orally or
intramuscularly and tapered over the following 5 to 7 days.
Withdrawal seizures may occur within 12 to 24 hours after alcohol cessation. These seizures are generalized
and tonic-clonic. Additional seizures may occur within hours of the first seizure. Diazepam (Valium) given
intravenously is a common treatment for withdrawal seizures.
Alcohol withdrawal delirium, also known as delirium tremens (DTs), is a medical emergency that can result
in death in 20% of untreated patients, usually as a result of medical problems such as pneumonia, renal disease,
hepatic insufficiency, or heart failure (Sadock et al., 2015). Alcohol withdrawal delirium may happen anytime in
the first 72 hours. Autonomic hyperactivity may result in tachycardia, diaphoresis, fever, anxiety, insomnia, and
hypertension. Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium.
, Delusions and hallucinations may result in unpredictable behaviors as patients try to protect themselves from
what they believe are genuine dangers. Patients on any medical floor are at risk for this condition after cessation
of heavy drinking for 3 days and are a danger to themselves and others. Serious physical illness such as hepatitis
or pancreatitis may increase the likelihood of alcohol withdrawal delirium. It is rare to see this syndrome in
individuals in good physical health.
Prevention of alcohol withdrawal delirium is the goal. Oral diazepam (Valium) may be useful in the symptomatic
relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis. Chlordiazepoxide
(Librium) may keep your patient out of danger. However, once delirium appears, intravenous lorazepam (Ativan) is
used to treat these severe symptoms. Seclusion may be necessary. Dehydration, often exacerbated by diaphoresis
and fever, can be corrected with oral or intravenous fluids.
8. Psychiatric/Mental Hlth - Abuse - IPV-difficulty leaving
Victims are at greatest risk for violence when they threaten to or actually leave the
relationship.
9. Psychiatric/Mental Hlth - Anxty/Commnictns - Anxiety.cognitive behavioral
techniques
Cognitive therapy is based on the belief that patients make errors in thinking that lead to
mistaken negative beliefs about self and others. For example, “I have to be perfect or my
boyfriend will not love me.” Through a process called cognitive restructuring, the therapist
helps the patient (1) identify automatic negative beliefs that cause anxiety, (2) explore the basis
for these thoughts, (3) reevaluate the situation realistically, and (4) replace negative self-talk with
supportive ideas.
Behavioral Therapy
There are currently several forms of behavioral therapy, which involve teaching and physical
practice of activities to decrease anxious or avoidant behavior:
• Modeling: The therapist or significant other acts as a role model to demonstrate appropriate
behavior in a feared situation, and then the patient imitates it. For example, the role model rides
in an elevator with a claustrophobic patient.
• Systematic desensitization: The patient is gradually introduced to a feared object or experience
through a series of steps, from the least frightening to the most frightening (graduated exposure).
The patient is taught to use a relaxation technique at each step when anxiety becomes
overwhelming. For example, a patient with agoraphobia would start with opening the door to the
house to go out on the steps and advance to attending a movie in a theater. The therapist may
start with imagined situations in the office before moving on to in vivo (live) exposures.
• Flooding: Unlike systematic desensitization, this method exposes the patient to a large amount of
an undesirable stimulus in an effort to extinguish the anxiety response. The patient learns through
prolonged exposure that survival is possible and that anxiety diminishes spontaneously. For
example, an obsessive patient who usually touches objects with a paper towel may be forced to
touch objects with a bare hand for 1 hour. By the end of that period, the anxiety level is lower.
1. Schizophrenia
Clinical Picture
In about 75% of those with schizophrenia the disorder develops gradually, usually presenting
between 15 and 25 years of age (Dean et al., 2016). However, there are also child-onset (before
15 years) and late-onset (after 40 years) forms as well. People who later
develop schizophrenia often experience a prodromal phase during which some milder
symptoms of the disorder develop, often months or years before the disorder becomes fully
apparent (Miller, 2016). During the prodromal phase the person may do less well in school than
his or her peers, be less socially engaged or adept, and demonstrate memory impairment,
suspiciousness, and/or disorganization or oddities in speech or thought.
All people diagnosed with schizophrenia have at least one psychotic symptom such as
hallucinations, delusions, and/or disorganized speech or thought. The symptoms are severe
enough to disrupt normal activities such as school, work, family and social interaction, and self-
care; in children and young adults they often delay or halt achievement of age-appropriate
milestones. Basic needs such as hygiene, nutrition, and healthcare are often neglected, and
socialization and relationships are often disrupted. The full criteria for schizophrenia are listed in
the DSM-5 box.
General Assessment
Not all people with schizophrenia have the same symptoms, and some of the symptoms
of schizophrenia are also found in other disorders. Fig. 12.1 describes the four main symptom
categories in schizophrenia:
1. Positive symptoms : The presence of something that should not be present. Positive symptoms
include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or
speech.
2. Negative symptoms : The absence of something that should be present. Negative symptoms
include the inability to enjoy activities, social discomfort, or lack of goal-directed behavior.
3. Cognitive symptoms : Subtle or obvious impairment in memory, attention, thinking (e.g.,
disorganized or irrational thoughts), judgment, or problem solving.
4. Affective symptoms : Symptoms involving emotions and their expression.
2. Community Hlth/Psychiatric/Mental Hlth - Anxty/Commnictns - Crisis
intervention-empathy
Empathy Versus Sympathy
You may wonder how empathy differs from sympathy. A simple way to distinguish them is that
in empathy, we understand the feelings of others, and in sympathy, we feel pity or sorrow for
, others. Although these are considered nurturing human traits, they may not be particularly
useful in a therapeutic relationship.
The following examples clarify the distinction between empathy and sympathy. A friend tells
you that her mother was just diagnosed with inoperable cancer. Your friend then begins to cry
and pounds the table with her fist.
Sympathetic response: “I feel so bad for you (tearing up). I know how close you are to your
mom. She is such an amazing person. Oh, I am so sorry.” (You hug your friend.)
Empathetic response: “This must be devastating for you (silence). It must seem so unfair. What
thoughts and feelings are you having?” (You stay with your patient and listen.)
Empathy is not a technique but rather an attitude that conveys respect, acceptance, and
validation of the patient’s strengths. Empathy may be one of the most important qualities that a
psychiatric-mental health nurse can possess.
3. Drugs/Nursing action - Lithium-creatinine
Patients' kidney function should be evaluated before they take lithium and monitored regularly.
4. action - Cymbalta-SSNRI
Duloxetine (Cymbalta) is an SNRI indicated for both depression and GAD, as well as diabetic
peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain.
Generic
Action Notes Side Effects Warnings
(Trade)
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Duloxetine Blocks the synaptic Cymbalta may Nausea, dry May reduce pain
reuptake of be more mouth, associated with
(Cymbalta) serotonin and effective insomnia, depression and
norepinephrine than SSRIs somnolence, is approved for
in the constipation, fibromyalgia
treatment of reduced and pain of
severe appetite, diabetic
depression fatigue, peripheral
sweating, neuropathy
blurred vision
,5. Abuse - Alcohol abuse - codependent behaviors
Family Assessment
Understanding the process of addiction from a holistic perspective requires careful attention to
the family. Living with an individual who misuses alcohol or other substances is a source of
stress and requires family system adjustments. Codependence is a cluster of behaviors originally
identified through research involving the families of alcoholic patients. People who
are codependent often exhibit overly responsible behavior—doing for others what others could
just as well do for themselves. People who are codependent often define their self-worth in terms
of caring for others to the exclusion of their own needs.
6. Psychiatric/Mental Hlth - Abuse - Alcohol support group
For therapy groups, the expected outcomes will focus more on insights, behavior changes, and
reduction in symptoms. For example, in an alcohol treatment group, an expected outcome might
be that the patient develops insight into the connection between drinking and negative
consequences. An expected behavioral outcome would be abstinence from alcohol use. In
groups that focus primarily on emotional issues such as depression or anxiety, you can use
standardized symptom surveys to measure symptom reduction as an outcome
of group participation.
7. Psychiatric/Mental Hlth - Abuse - DTs-1st signs
Alcohol Withdrawal
Alcohol withdrawal occurs after reducing or quitting alcohol after heavy and prolonged use. The classic sign
of alcohol withdrawal is tremulousness, commonly called the shakes or the jitters, that begins 6 to 8 hours
after alcohol cessation (Sadock et al., 2015). Mild to moderate alcohol withdrawal includes agitation, lack of
appetite, nausea, vomiting, insomnia, impaired cognition, and mild perceptual changes. Both systolic and diastolic
blood pressure increases, as does pulse and body temperature. Chlordiazepoxide (Librium) is useful for
tremulousness and mild to moderate agitation.
Psychotic and perceptual symptoms may begin in 8 to 10 hours. If your patient is undergoing withdrawal to the
point of psychosis, it should be considered a medical emergency because of the risks of unconsciousness, seizures,
and delirium. The benzodiazepines lorazepam (Ativan) or chlordiazepoxide (Librium) can be given either orally or
intramuscularly and tapered over the following 5 to 7 days.
Withdrawal seizures may occur within 12 to 24 hours after alcohol cessation. These seizures are generalized
and tonic-clonic. Additional seizures may occur within hours of the first seizure. Diazepam (Valium) given
intravenously is a common treatment for withdrawal seizures.
Alcohol withdrawal delirium, also known as delirium tremens (DTs), is a medical emergency that can result
in death in 20% of untreated patients, usually as a result of medical problems such as pneumonia, renal disease,
hepatic insufficiency, or heart failure (Sadock et al., 2015). Alcohol withdrawal delirium may happen anytime in
the first 72 hours. Autonomic hyperactivity may result in tachycardia, diaphoresis, fever, anxiety, insomnia, and
hypertension. Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium.
, Delusions and hallucinations may result in unpredictable behaviors as patients try to protect themselves from
what they believe are genuine dangers. Patients on any medical floor are at risk for this condition after cessation
of heavy drinking for 3 days and are a danger to themselves and others. Serious physical illness such as hepatitis
or pancreatitis may increase the likelihood of alcohol withdrawal delirium. It is rare to see this syndrome in
individuals in good physical health.
Prevention of alcohol withdrawal delirium is the goal. Oral diazepam (Valium) may be useful in the symptomatic
relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis. Chlordiazepoxide
(Librium) may keep your patient out of danger. However, once delirium appears, intravenous lorazepam (Ativan) is
used to treat these severe symptoms. Seclusion may be necessary. Dehydration, often exacerbated by diaphoresis
and fever, can be corrected with oral or intravenous fluids.
8. Psychiatric/Mental Hlth - Abuse - IPV-difficulty leaving
Victims are at greatest risk for violence when they threaten to or actually leave the
relationship.
9. Psychiatric/Mental Hlth - Anxty/Commnictns - Anxiety.cognitive behavioral
techniques
Cognitive therapy is based on the belief that patients make errors in thinking that lead to
mistaken negative beliefs about self and others. For example, “I have to be perfect or my
boyfriend will not love me.” Through a process called cognitive restructuring, the therapist
helps the patient (1) identify automatic negative beliefs that cause anxiety, (2) explore the basis
for these thoughts, (3) reevaluate the situation realistically, and (4) replace negative self-talk with
supportive ideas.
Behavioral Therapy
There are currently several forms of behavioral therapy, which involve teaching and physical
practice of activities to decrease anxious or avoidant behavior:
• Modeling: The therapist or significant other acts as a role model to demonstrate appropriate
behavior in a feared situation, and then the patient imitates it. For example, the role model rides
in an elevator with a claustrophobic patient.
• Systematic desensitization: The patient is gradually introduced to a feared object or experience
through a series of steps, from the least frightening to the most frightening (graduated exposure).
The patient is taught to use a relaxation technique at each step when anxiety becomes
overwhelming. For example, a patient with agoraphobia would start with opening the door to the
house to go out on the steps and advance to attending a movie in a theater. The therapist may
start with imagined situations in the office before moving on to in vivo (live) exposures.
• Flooding: Unlike systematic desensitization, this method exposes the patient to a large amount of
an undesirable stimulus in an effort to extinguish the anxiety response. The patient learns through
prolonged exposure that survival is possible and that anxiety diminishes spontaneously. For
example, an obsessive patient who usually touches objects with a paper towel may be forced to
touch objects with a bare hand for 1 hour. By the end of that period, the anxiety level is lower.
