NUR 114 Psychosocial/Mental Health Readings

Mental Health Concept 1. Health Assessment: Assessing Mental Status; pages 732-734 (Fundamentals of Nursing) o Assessment includes: level of consciousness, level of awareness, behavior and appearance, memory, and language. 2. Antidepressant Agents; pages 351-368 (Pharmacology) o Drugs List o Tricyclic Antidepressants ▪ amitriptyline ▪ amoxapine ▪ clomipramine ▪ desipramine ▪ doxepin ▪ imipramine ▪ maprotiline ▪ nortriptyline ▪ protriptyline ▪ trimipramine o Monoamine Oxidase Inhibitors ▪ isocarboxazid ▪ phenelzine ▪ tranylcypromine o Selective Serotonin Reuptake Inhibitors ▪ citalopram ▪ escitalopram ▪ fluoxetine ▪ fluvoxamine ▪ paroxetine ▪ sertraline ▪ vilazodone ▪ vortioxetine o Other Antidepressants ▪ bupropion ▪ desvenlafaxine ▪ duloxetine ▪ levomilnacipran ▪ milnacipran ▪ mirtazapine ▪ nefazodone ▪ selegiline ▪ trazodone ▪ venlafaxine o Tricyclic Antidepressants  KEY POINTS ▪ Affect is a term that refers to the feelings that people experience when they respond emotionally. ▪ Depression is an affective disorder characterized by inappropriate sadness, despair, and hopelessness. ▪ According to the biogenic amine theory, depression is caused by a brain deficiency of the biogenic amines. Antidepressant drugs are thought to raise the level of the biogenic amines. o Monoamine Oxidase Inhibitors Key points ▪ The MAOIs prevent the breakdown of NE and 5HT by MAO, leading to an increased level of these biogenic amines in the synaptic cleft. This accumulation of the amines is thought to relieve the signs and symptoms of depression. ▪ Patients taking MAOIs need to avoid foods high in tyramine to prevent serious increases in blood pressure and hypertensive crises. o Selective Serotonin Reuptake Inhibitors key points ▪ The SSRIs prevent the reuptake of serotonin into the presynaptic nerve, leading to an accumulation of these biogenic amines in the synaptic cleft. This accumulation causes increased stimulation of the postsynaptic nerve and may be responsible for the antidepressant effects of these drugs. ▪ The SSRIs are not associated with many of the CNS, CV, and anticholinergic effects of other antidepressants. ▪ Combination of SSRIs with other SSRIs or with other drugs that are known to increase 5HT levels increase the risk of serotonin syndrome. ▪ Increased bleeding is possible with these drugs since they affect 5HT, a key component in platelet activity. Caution should be used if any of these drugs is combined with other drugs known to affect bleeding o Chapter Summery ▪ Depression is a very common affective disorder; it is associated with many physical manifestations and is often misdiagnosed. It could be that depression is caused by a series of events that are not yet understood. ▪ Antidepressant drugs—TCAs, MAOIs, and SSRIs—increase the concentrations of the biogenic amines in the brain. ▪ Selection of an antidepressant depends on individual drug response and tolerance of associated adverse effects. The adverse effects of TCAs are sedating and anticholinergic; those of MAOIs are CNS related and sympathomimetic. The adverse effects of SSRIs are fewer, but they do cause CNS changes. ▪ Other antidepressants with unknown mechanisms of action are also effective in treating depression. ▪ All of these drugs have a black box warning of the risk of suicidality, particularly in children, adolescents, and young adults. 3. Psychotherapeutic Agents; pages 369-387 (Pharmacology) o Drug List Antipsychotic/Neuroleptic Drugs ▪ Typical Antipsychotics • chlorpromazine • fluphenazine • haloperidol • loxapine • perphenazine • pimozide • prochlorperazine • thioridazine • thiothixene • trifluoperazine ▪ Atypical Antipsychotics • aripiprazole • asenapine • clozapine • iloperidone • lurasidone • olanzapine • paliperidone • quetiapine • risperidone • ziprasidone ▪ Drugs for Bipolar Disorders • aripiprazole • lamotrigine • lithium • olanzapine • quetiapine • ziprasidone ▪ Central Nervous System Stimulants • armodafinil • atomoxetine • dexmethylphenidate • dextroamphetamine • guanfacine • lisdexamfetamine • methylphenidate • modafinil o Schizophrenia, the most common type of psychosis, can be very debilitating and prevents affected individuals from functioning in society. Characteristics of schizophrenia include hallucinations, paranoia, delusions, speech abnormalities, and affective problems. This disorder, which seems to have a very strong genetic association, may reflect a fundamental biochemical abnormality. o Bipolar disorder involves extremes of depression alternating with hyperactivity and excitement. This condition may reflect a biochemical imbalance followed by overcompensation on the part of neurons and their inability to reestablish stability. o Narcolepsy is characterized by daytime sleepiness and sudden periods of loss of wakefulness. This disorder may reflect problems with stimulation of the brain by the reticular activating system (RAS) or problems with response to that stimulation. o Attention deficit disorders involve various conditions characterized by an inability to concentrate on one activity for longer than a few minutes and a state of hyperkinesis. These conditions are usually diagnosed in school-aged children but can occur in adults. o Antipsychotic/Neuroleptic drugs  KEY POINTS ▪ Mental disorders are thought process disorders that may be caused by some inherent dysfunction within the brain. A psychosis is a thought disorder, and schizophrenia is the most common psychosis in which delusions and hallucinations are hallmarks. ▪ Antipsychotic drugs are generally dopamine receptor blockers that are effective in helping people to organize thought patterns and to respond appropriately to stimuli. ▪ Antipsychotics can cause hypotension, anticholinergic effects, sedation, and extrapyramidal effects, including parkinsonism, ataxia, and tremors. o Drugs for bipolar disorder  KEY POINTS ▪ Lithium, a membrane stabilizer, is the standard antimanic drug. Because it is a very toxic salt, serum levels must be carefully monitored to prevent severe toxicity. ▪ Many other CNS drugs, including many of the atypical antipsychotics, are now approved for use in bipolar disorder. Many patients respond to a combination of these drugs to control their bipolar signs and symptoms. o Central nervous system stimulants  ket points ▪ An attention deficit disorder is a behavioral syndrome characterized by hyperactivity and a short attention span. ▪ Narcolepsy is a disorder characterized by daytime sleepiness and sudden loss of wakefulness. ▪ CNS stimulants, which stimulate cortical levels and the RAS to increase RAS activity, are used to treat attention deficit disorders and narcolepsy. These drugs improve concentration and the ability to filter and focus incoming stimuli. o Chapter summery ▪ Schizophrenia, the most common psychosis, is characterized by delusions, hallucinations, and inappropriate responses to stimuli. ▪ Bipolar disorder is a behavioral disorder that involves extremes of depression alternating with hyperactivity and excitement. ▪ An attention deficit disorder is a behavioral syndrome characterized by hyperactivity and a short attention span. ▪ Narcolepsy is a disorder characterized by daytime sleepiness and sudden loss of wakefulness. ▪ Lithium, a membrane stabilizer, is the standard antimanic drug. Because it is a very toxic salt, serum levels must be carefully monitored to prevent severe toxicity. Many other CNS drugs are now approved for use in bipolar disorder. ▪ CNS stimulants, which stimulate cortical levels and the RAS to increase RAS activity, are used to treat attention deficit disorders and narcolepsy. These drugs improve concentration and the ability to filter and focus incoming stimuli. Abuse/Neglect 1. Conception Through Young Adult: Child Maltreatment (including Table 22-2); page 535 (Fundamentals of Nursing) a. “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm” b. Most cases are from birth to 4 years of age c. Childhood abuse and neglect have a long term consequence for health. d. Risk factors for abuse and neglect i. Caregivers’ substance abuse; this includes manufacturing, distribution or selling, using, and prenatal exposure ii. Caregivers experiencing stress from poverty or unemployment iii. Caregivers’ mental illness or other health problems iv. History of violence in the family or community v. Physical or mental disabilities in the child or children that may increase caregiver burden vi. Caregivers’ lack of knowledge about parenting and the normal behaviors and development of children vii. Lack of family and social support for caregivers, social isolation of families, lack of family cohesion, single caregiver, young caregivers 2. Sexuality: Counseling in Cases of Abusive Relationships and Rape; pages (Fundamentals of Nursing) a. Sexual violence is NOT about love or sex; it is about power, violence, and control. b. Victims of sexual assault are 3 times more likely to suffer from depression, 6 times more likely to suffer from posttraumatic stress disorder, 13 times more likely to abuse alcohol, 26 times more likely to abuse drugs, and 4 times more likely to contemplate suicide. 3. Assessment and Management of Patients With Female Physiologic Process: Assessment/Health History: Intimate Partner Violence; page 1657 (Medical-Surgical Nursing) a. IPV involves four main types of violence: physical, sexual, stalking, and psychological aggression. b. It is rarely a onetime occurrence. c. Manifestations of abuse, maltreatment, and neglect may involve suicide attempts, drug and alcohol abuse, frequent emergency department visits, vague pelvic pain, somatic complaints, and depression. However, there may be no obvious signs or symptoms. 4. Assessment and Management of Patients With Female Physiologic Process: Assessment Health History: Incest and Childhood Sexual Abuse; pages (Medical-Surgical Nursing) a. Women who have experienced rape or sexual abuse may be very anxious about pelvic examinations, labor, pelvic or breast irradiation, or any treatment or examination that involves hands-on treatment or requires removal of clothing. Nurses should be prepared to offer support and referral to psychologists, community resources, and self- help groups. 5. Emergency Nursing: Violence, Abuse, and Neglect; pages (Medical-Surgical Nursing) a. Emergency Departments are often the first place where victims of family violence, abuse, or neglect go to seek help. b. Clinical manifestations  they may present with physical injuries or health problems such as anxiety, insomnia, or GI symptoms related to stress. i. In the ED, the most common physical injuries seen are unexplained bruises, lacerations, abrasions, head injuries, or fractures. ii. The most common clinical manifestations of neglect are malnutrition and dehydration. c. Assessment and diagnostic findings i. Asking questions in private—away from others—may be helpful in eliciting information about abuse, maltreatment, and neglect ii. Chart 72-8 ASSESSMENT  Assessing for Abuse, Maltreatment, and Neglect 1. The following questions may be helpful when assessing a patient for abuse, maltreatment, and neglect: a. I noticed that you have a number of bruises. Can you tell me how they happened? Has anyone hurt you? b. You seem frightened. Has anyone ever hurt you? c. Patients sometimes tell me that they have been hurt by someone at home or at work. Could this be happening to you? d. Are you afraid of anyone at home or work, or of anyone with whom you come in contact? e. Has anyone failed to help you to take care of yourself when you needed help? f. Has anyone prevented you from seeing friends or other people whom you wish to see? g. Have you signed any papers that you did not understand or did not wish to sign? h. Has anyone forced you to sign papers against your will? i. Has anyone forced you to engage in sexual activities within the past year? j. Has anyone prevented you from using an assistive device (e.g., wheelchair, walker) within the past year? k. Has anyone you depend on refused to help you take your medicine, bathe, groom, or eat within the past year? d. Management i. Whenever abuse, maltreatment, or neglect is suspected, the health care provider’s main concern should be the safety and welfare of the patient. Treatment focuses on the consequences of the abuse, violence, or neglect and on prevention of further injury. ii. Nurses must be mindful that competent adults are free to accept or refuse the help that is offered to them. Some patients insist on remaining in the home environment where the abuse or neglect is occurring. The wishes of patients who are competent and not cognitively impaired should be respected. However, all possible alternatives, available resources, and safety plans should be explored with the patient. iii. Mandatory reporting laws in most states require health care workers to report suspected child abuse or abuse of older adults to an official agency, usually Adult (or Child) Protective Services. 6. Emergency Nursing: Sexual Assault Page 2188 (medical-surgical nursing) a. Rape  forced sexual acts, especially if these acts involve vaginal or anal penetration. b. Attempted rape  may include verbal threats of rape c. Assessment and diagnostic findings i. Rape trauma syndrome  acute stress reaction to a life-threatening situation 1. An acute disorganization phase, which may manifest as an expressed state in which shock, disbelief, fear, guilt, humiliation, anger, and other such emotions are encountered or as a controlled state in which feelings are masked or hidden and the victim appears composed 2. A phase of denial and unwillingness to talk about the incident, followed by a phase of heightened anxiety, fear, flashbacks, sleep disturbances, hyper alertness, and psychosomatic reactions that is consistent with PTSD (see later discussion) 3. A phase of reorganization, in which the incident is put into perspective. Some victims never fully recover and go on to develop chronic stress disorders and phobias. d. Management i. A written, witnessed informed consent must be obtained from the patient (or parent or guardian if the patient is a minor) for examination, for taking of photographs, and for release of findings to police ii. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings iii. Treating potential consequences of Rape  prophylaxis against STIS; Antipregnancy measures 7. Perspectives on Maternal and Child Health Care: Factors Affecting Maternal and Child Health: Violence; pages 31-33 (Maternity and Pediatric Nursing) a. Pregnancy is often a time when physical abuse starts or escalates, resulting in poorer outcomes for the mother and the baby. The effects of intimate partner violence (IPV) on maternal health include insufficient or inconsistent prenatal care, poor nutrition, substance abuse, inadequate weight gain, and depression. Adverse neonatal outcomes include low birthweight, preterm birth, and small for gestational age infants (Alhusen et al., 2015). Many of these can lead to maternal or neonatal morbidity or mortality. b. Children of African American and American Indian or Alaska Native descent have higher rates of abuse and neglect (CDC, 2014b). c. Witnessing and being exposed to violence in childhood results in a higher tolerance, and greater use, of violence as an adult (Child Trends, 2013). 8. Growth and Development of the School-Age Child: Evidence-Based Practice 28.1: Benefits of Bully-Prevention Education; page 1069 (Maternity and Pediatric Nursing) a. Nursing Implications i. Nurses should continue to educate parents and teachers about bullying. Become actively involved in the local elementary school bullying-prevention program and encourage school-wide interventions. When bullies are identified, refer them for education in bullying prevention programs that focus on skill building. 9. Nursing Care of the Child with an Alteration in Behavior, Cognition, or Development: Abuse and Violence; pages (Maternity and Pediatric Nursing) a. A delay in seeking medical treatment, a history that changes over time, or a history of trauma that is inconsistent with the observed injury all suggest child abuse. 10. Abuse and Violence; pages 198-213 (Psychiatric-Mental Health Nursing) a. Family violence  encompasses spouse battering; neglect and physical, emotional, sexual, abuse of children; elder abuse; marital rape. b. BOX 12.1 CHARACTERISTICS OF VIOLENT FAMILIES i. Social isolation ii. Abuse of power and control iii. Alcohol and other drug abuse iv. Intergenerational transmission process c. Immigrant women are at a higher risk for domestic violence. Addictive Behaviors 1. Health Care of the Older Adult: Substance Abuse; page 208 (Medical-Surgical Nursing) a. Substance abuse caused by misuse of alcohol may be related to depression. 2. Pain Management: Addiction, Physical Dependence, and Tolerance; pages 238-239 (Medical-Surgical Nursing) a. Physical dependence  a normal response that occurs with repeated administration of the opioid for 2 or more weeks and cannot be equated with addictive disease. b. Tolerance  normal response that occurs with regular administration of an opioid and consists of a decrease in one or more effects of the opioid. It cannot be equated with addictive disease. c. Addiction  chronic, relapsing, treatable neurologic disease. The development and characteristics of addiction are influenced by genetic, psychosocial, and environmental factors. No single cause of addiction, such as taking an opioid for pain relief, has been found. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving to use the opioid for effects other than pain relief. This statement reinforces that taking opioids for pain relief is not addiction, no matter how long a person takes opioids or at what doses. 3. Preoperative Nursing Management: Nutritional and Fluid Status: Drug or Alcohol Use; pages 424-425 (Medical-Surgical Nursing) a. Presurgical  the use of illicit drugs and alcohol may impede the effectiveness of some medications. 4. Emergency Nursing: Substance Abuse (introduction); page 2180 (Medical-Surgical Nursing) a. Substance abuse is the misuse of specific substances, such as drugs or alcohol, to alter mood or behavior. b. Drug abuse is the use of drugs for other than legitimate medical purposes. 5. Addiction; pages 366-389 (Psychiatric-Mental Health Nursing) a. Types of substance abuse i. Alcohol ii. Sedatives, hypnotics, and anxiolytics iii. Stimulants iv. Cannabis v. Opioids vi. Hallucinogens vii. Inhalants b. Etiology  not known, but various factors are thought to contribute to the development of substance related disorders; Much of the research on biologic and genetic factors has been done on alcohol abuse, but psychologic, social, and environmental studies have examined other drugs as well. c. Types of substance and treatments i. Alcohol  CNS depressant that is absorbed rapidly into the bloodstream. 1. Effects  relaxation and loss of inhibitions 2. Slurred speech, unsteady gait, lack of coordination, impaired attention, concentration, memory, and judgement 3. Withdrawal symptoms  coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. 4. Safe withdrawal is usually accomplished with the administration of benzodiazepines such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium) to suppress the withdrawal symptoms ii. Sedatives, hypnotics, and Anxiolytics 1. central nervous system depressants: barbiturates, nonbarbiturate hypnotics, and anxiolytics, particularly benzodiazepines. 2. In the usual prescribed doses, these drugs cause drowsiness and reduce anxiety, which is the intended purpose. 3. Intoxication symptoms include slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, and even stupor and coma. iii. Stimulants (amphetamines, Cocaine) 1. Stimulate or excite the CNS and have limited clinical use 2. Used in past for people who wanted to lose weight or to stay awake 3. Intoxication from stimulants develops rapidly; effects include the high or euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic or repetitive behavior, anger, fighting, and impaired judgment. 4. Physiologic effects include tachycardia, elevated blood pressure, dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmias. 5. Treatment with chlorpromazine (Thorazine), an antipsychotic, controls hallucinations, lowers blood pressure, and relieves nausea iv. Cannabis (marijuana) 1. Cannabis sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and for oil from its seeds. 2. Currently, two cannabinoids, dronabinol (Marinol) and nabilone (Cesamet), have been approved for treating nausea and vomiting from cancer chemotherapy. 3. Users report a high feeling similar to that with alcohol, lowered inhibitions, relaxation, euphoria, and increased appetite. 4. Symptoms of intoxication include impaired motor coordination, inappropriate laughter, impaired judgment and short-term memory, and distortions of time and perception. Anxiety, dysphoria, and social withdrawal may occur in some users 5. Physiologic effects, in addition to increased appetite, include conjunctival injection (bloodshot eyes), dry mouth, hypotension, and tachycardia. 6. Excessive use of cannabis may produce delirium or, rarely, cannabis-induced psychotic disorder, both of which are treated symptomatically. 7. Overdoses of cannabis do not occur. v. Opioids 1. Desensitize the user to both physiologic and psychologic pain and induce a sense of euphoria and well-being. 2. Initial symptoms are anxiety, restlessness, aching back and legs, and cravings for more opioids. 3. Symptoms that develop as withdrawal progresses include nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia. 4. Symptoms of opioid withdrawal cause significant distress, but do not require pharmacologic intervention to support life or bodily functions. vi. Hallucinogens 1. Substances that distort the user’s perception of reality and produce symptoms similar to psychosis, including hallucinations, and depersonalization. 2. Hallucinogen intoxication is marked by several maladaptive behavioral or psychologic changes: anxiety, depression, paranoid ideation, ideas of reference, fear of losing one’s mind, and potentially dangerous behavior such as jumping out a window in the belief that one can fly. 3. Physiologic symptoms include sweating, tachycardia, palpitations, blurred vision, tremors, and lack of coordination. 4. PCP intoxication often involves belligerence, aggression, impulsivity, and unpredictable behavior 5. Toxic reactions to hallucinogens (except PCP) are primarily psychologic; overdoses as such do not occur vii. Inhalants 1. Diverse group of drugs that include anesthetics, nitrates, and organic solvents 2. The most common substances in this category are aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint. 3. Inhalant intoxication involves dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision. Stupor and coma can occur. 4. Significant behavioral symptoms are belligerence, aggression, apathy, impaired judgment, and inability to function. Acute toxicity causes anoxia, respiratory depression, vagal stimulation, and dysrhythmias. 5. Death may occur from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomitus d. Treatment and prognosis i. Drug Use Dosage Nursing Considerations Lorazepam (Ativan) Alcohol withdrawal 2–4 mg every 2–4 hours PRN Monitor vital signs and global assessments for effectiveness; may cause dizziness or drowsiness