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Psych Exam III (from blueprint)

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olanjones's version from 2017-02-18 17:00

Neurobiology of Depression

Question Answer
↓Serotonin is associated w/disruption of appetite, sleep & sexual dysfunction, impulsivity, aggression, & suicide
↓Norepinephrine is associated w/fatigue, apathy, cognitive disturbance, slowness in information processing, & poor memory.
↓Dopamine is associated w/lack of pleasure and psychomotor retardation
2 main neurotransmitters affected by depressionnorepi & serotonin
↓Dopamine theoryless dopamine = less pleasure and functioning. Dopamine is associated with emotions, coordination, voluntary judgment normally.
↑ levels of acetylcholineshown to cause depression/anxiety in mice
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PDD & MDD

Question Answer
Dysthymia aka Persistent Depressive DisorderChronically depressed mood but not as severe as MDD - "down in the dumps" w/ at least 2 other symptoms of depression; may also have intermittent episodes of MDD (double depression)
How long can dysthymia last in children and adults?DSM criteria: must be in a depressed mood for most of the day for the majority of days over at least a 2 year period (by subjective account or the observation of others), can last a lifetime. In children/adolescents, duration must be at least 1 year, and the mood can be irritable
Major Depressive DisorderMust have 5 of the specific clinical findings which must occur every day for a minimum of 2 weeks (lasts for most of the day).
MDD: clinical findingsanhedonia; social & occupational impairment (2 weeks worth); no history of manic behavior or psychotic features; no connection to medical issues or substance abuse.
Dysthymia (PDD) or MDD can be episodic?MDD
What are the commonalities of PDD and MDD?↓ social & emotional functioning
PDD or MDD more severe?MDD-it is incapacitating
PDD or MDD more chronic?PDD (no remissions for greater than 2 months signifies chronic aspect of the disorder)
Symptoms of Depressionanhedonia, grief, guilt, self-injury, psychomotor retardation.
Vegetative sx of depressioninsomnia, loss of appetite, over activation of stress hormones
Factors that may lead to depression (generally speaking)Female gender; postpartum; active alcohol/substance abuse; personality trait of hypersensitivity to negative stimuli; family hx of MDD; childhood maltx; hx of suicide attempts; comorbidity; lack of social support; widowed, separated or divorced marital status; lower socioeconomic status; lower educational achievement; unemployment; stressful life events that cause loss of self-esteem, or feelings of entrapment.
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Nursing Care Depression

Question Answer
Assessmentrefer to pt.’s risk factors, any previous instances of depression. Subjective data: refer to cardinal s/s of depression. Objective: affect, behavior, cognitive, physiological.
Standardized screening tools usedHamilton Depression Scale; Beck Depression Inventory; Geriatric Depression Scale
This type of therapy is extremely important for implementation of patient-centered careMileu therapy
Key aspects of Mileu Therapysuicide risk, self-care, communication (Important to keep sentences simple, not long and comprehensive so that they can stay focused), maintenance of safe env’t, counseling, problem solving, ↑ coping mechanisms, changing negative thinking to positive, ↑ self-esteem, assertiveness training, using available community resources.
Psychotherapycognitive behavior therapy; dialectical behavior therapy; group; family; interpersonal.
Alternative therapyLight; Electroconvulsive Therapy (ECT); Transcranial Magnetic Stimulation (TMS); Vagus Nerve stimulation (VNS).
Discharge teachingsreview manis of depression with client/family in order to ID relapse; reinforce intended effects & potential adverse effects of meds; explain benefits of clients adherence to therapy; exercise 30 minutes 3-5 times daily each week (this improves depression, releases endorphins)
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Drugs for depression

Question Answer
SSRIssertraline, citalopram, fluoxetine: few SE (drowsy, nausea, dry mouth, ↓sex drive); Watch for serotonin syndrome (HTN, tremors, sweating, hyperpyrexia, ataxia) DNU with St. John’s Wort.
Barbituatesphenobarbital *Rarely used today d/t high tolerance; depresses CNS at all levels
Tricyclicsamitriptyline: Watch SE of anticholinergic effects! Inhibits reuptake of NE & Serotonin
MAOI'sphenezeline: ↑’s availability of NE, Dopamine & Serotonin. AVOID: foods with tyramine (aged cheese, red wine, soy sauce, salami, bananas, fermented sausages, liver)→ can cause HTN CRISIS: parasthesias, sedation/insomnia, anticholinergic effects
Atypical antidepressantsbuproprion: inhibits reabsorption of NE & Dopamine; DNU with MAOIs; SE: nausea, HA, dizzy, ↓ appetite, risk of seizures
SNRI'svenlafaxine, duloxetine: DNU with MAOI’s; SE: nausea, sweating, constipation & ↓ appetite
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Bipolar Disorder & Treatment

Question Answer
Symptoms of bipolar disorder (particularly mania)mood is elevated, expansive or irritable - the indiv. may put their health, safety & well-being at risk through excessive spending, risky activities, self-neglect, inappropriate behaviors & sexual indiscretions.
Bipolar IAt least 1 episode of mania alt. w/ MDD
Bipolar II1 or more hypomanic episodes alt. w/ MDD
CyclothymicAt least 2 yrs of repeated hypomanic manifestation (that do not meet the criteria for hypomanic episodes) alt. w/ minor depressive episodes
Behaviors seen in bioplar-Manic: ↓sleep, ↑activity, euphoria, racing thoughts, irritability/sensitivity, money spending, promiscuity
-Hypomanic: lively, carefree, unrealistic thinking, witty attitude, uses jokes/puns/sarcasm/needling, racing thoughts, poor concentration, unaware/uncaring of others feelings- no insight into own behavior
-Mixed Episodes: Manic & MDD experience simultaneously
-Rapid Cycling: 4 or more episodes of acute mania w/in 1 yr
NC: Assessmentsymptoms of manic states are usually described according to 3 stages: hypomania, acute mania, & delirious mania
NC: DiagnosisDepending on which episode pt. is experiencing. Ex: manic excitement, delusional thinking, hallucinations & impulsivity = Risk for violence
NC: Interventionsacute phase you should focus on safety & physical health, provide a safe env’t; ↓ stimulation w/o isolating client, if possible; be aware of noise, music, TV, & other clients (these can escalate behavior). Sometimes seclusion is necessary for safety concerns though. Maintenance of self-care needs; monitor sleep, fluid intake & nutrition, provide portable/nutritious food bc client may not be able to sit & eat; supervise choice of clothes; give step-by-step reminders for hygiene & dress.
NC: Communicationuse a calm, matter of fact, specific approach. Give concise explanation, be consistent with expectations & limit setting, avoid power struggles, do not react to client’s comments, listen to & act on legit client grievances, reinforce non-manipulative behaviors, avoid power struggles & do not react personally to client’s comments. Listen to & act on legit client grievances & reinforce non-manipulative behaviors.
Drug class used for bipolar disorderMood-stabilizing agents indicated for prevention & treatment of manic episodes: lithium & anticonvulsants (also sometimes CCB, antipsychotics)
Lithium MOAmay modulate certain neurotransmitters such as norepi, serotonin, dopamine, glutamate, GABA & stabilizes sx
Lithium SEdrowsy, dizzy, h/a; dry mouth, thirsts, GI upset, n/v; fine hand tremors; hypoTN, arrhythmias, pulse irregularities; polyuria; dehydration; weight gain; pot. for toxicity.
Lithium toxicityEarly: 1.5-2.0 mEq/L - blurred vision, ataxia, tinnitus, persis N/V, severe diarrhea
Advanced: 2.0-3.5 mEq/L - dilute polyuria, tremors/muscle irritation, psychomotor retardation, confusion/giddy
Severe: >3.5 mEq/L - impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmia/MI/CV collapse
Anticonvulsant SEn/v, dizzy, prolonged bleeding time, risk of rash, ↓ efficacy of oral contraceptives; risk of suicide w/ antiepileptic drugs
CCB SEdrowy, dizzy, nausea, constp (should report if: irreg heart beat, chest pain, SOB, swelling of hands/feet, persis. HA)
Patient teaching anticonvulsantsRefrain from discontinuing the drug abruptly. Report the following symptoms to the physician immediately: skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin/eyes. Avoid using alcohol/OTC meds w/out approval from physician
Patient/family teaching lithiumtake med regularly; do not skimp on sodium; drink 6-8 glasses of water each day; notify PCP if vomiting or diarrhea occur (or other signs of toxicity occur); have lithium levels checked Q 1-2months by PCP
Therapeutic range lithium 1.0-1.5 (acute mania) and 0.6-1.2 (maintenance)
Interventions lithium toxicityensure client consumes adequate sodium & fluid in diet (may need gastric decontamination, hemodialysis)
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Suicide

Question Answer
Biological factors in assessmentmay include family history of suicide, physical disorders, such as AIDS, cancer, cardiovascular disease, stroke, chronic renal failure, cirrhosis, dementia, epilepsy, head injury, multiple sclerosis, Huntington’s disease.
Psychosocial factors in assessmentinclude sense of hopelessness, intense emotions, such as rage, anger or guilt, poor interpersonal relationships at home, school, and work, developmental stressors, such a those experienced by adolescents.
Subjective & Objective Data verbal/nonverbal cues; over/covert comments; laceration, scratches & scars; SAD person scale
Nursing care for a client with suicidal ideations (SI) Nurses who work personally with suicide clients can benefit personally by debriefing, sharing, and collaborating with other health professionals; Suicide precautions include milieu therapy within the facility
SI precautions: supervisioninitiate 1:1 constant supervision, always having the client in sight and close, Document the client’s location, mood, quoted statements, & behavior every 15 min/per facility protocol
SI precautions: environmental hazardsRemove all contraband, Allow client to use plastic utensils to eat, Check the environment for possible hazards such open windows, overhead pipes that are easily accessible
SI precautions: meds & monitoring clientDuring observation period always check clients hands (esp if hidden from sight), Do not assign to a private room if possible and keep open doors at all times
Ensure the client swallow all medications, Identify if client’s current medications can be lethal with overdose (collaborate w/ PCP to have less dangerous meds)
SI precautions: visitors and discharge teachingRestrict the visitors from bringing possible harmful items to the client; Discharge teaching: initiate and have pt. sign or verbalize a no-suicide contract.
Care for survivors after a suicideEncourage them to talk about it, Be aware of blaming/scapegoating, Listen to feelings of guilt & gently move them to reality of situation
Encourage family to discuss loved one’s individual relationships & focus on both positive and negative, Everyone will grieve in their own way
Recognize how it has affected family’s coping mechanisms, look for new and adaptive methods of coping, ID resources that provide support: religious, support groups, community
Assess potential of violence and safety precautionsPast hx, current diagnosis, & current behaviors
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Electroconvulsive therapy (ECT)

Question Answer
IndicationsMDD, Acute manic episode of bipolar, OCD, personality disorders
MOAunknown; biochemical theory that it results in significant ↑'s in circulating levels of serotonin, norepi, & dopamine
Contraindications↑ ICP (from brain tumor, recent CVA or other cerebrovascular lesion; MI, aortic or cerebral aneurysm; severe underlying HTN & CHF
Side effectstemporary memory loss
Risks/ComplicationsPermanent memory loss and brain damage (mortality is rare)
Nursing Role in administration of ECTthorough exam (CV, pulm status, labs, urine, xray); informed consent; assess mood/anxiety level, thought & communication patterns; vitals
Nursing role in preparing the client for treatmentvoid and removing dentures, eyeglasses or contact lenses, jewelry, and hairpins.
Drugs administered via PCP orders approx. 30 min prior to treatmentAtropine sulfate or glycopyrrolate
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Grief

Question Answer
Types of lossActual, Perceived, Situational/developmental, Anticipatory
Age influence loss & grief responsesAs one ages, they become more familiar with loss, usually increasing their understanding and acceptance of life, loss, and death. Children differ not only in their understanding of loss but also in the way they may be affected (e.g. loss of a parent)
Bereavement vs. Mourningbereavement is the subjective experience of the survivor, mourning is the behavioral process through which grief is eventually resolved/altered
Culture & religion impact on grief responseculture may determine how death is viewed and how mourners behave, rituals (religious/spiritual) may help legitimize emotional/physical ventilation, provide a focus for managing confusion, disorganization, and loss of control which promoting social interaction
Ways nurse may facilitate grieving processExplore & respect cultural, religious, personal values; Teach what to expect; Encourage expression & sharing of grief with support system
ResolutionCan last weeks-years; must be done at one's own pace, healing occurs when the pain is less, memories of loved one (both +/-) integrated with daily living
Bereavement overloadAccumulated grief, one experiences numerous losses in a relatively short time
Maladaptive Grieving-Prolonged (assoc w/ denial & anger) Mani: disorganization, ↓ functioning
-Delayed/inhibited (assoc w/ denial) Mani: No emotional pain but anxiety, somatic disorders, sleep/eating disorders
-Distorted (assoc w/ anger) Mani: Guilt, Helplessness, Hopelessness, Anger - Pathological depression
Anticipatory GrievingIndividuals begin work of grieving before actual loss occurs; most people re-experience grief at time of actual loss but preparation may ↓ length & intensity of response
Complicated GrievingOccurs after the death of a significant other in which the experience of distress accompanying bereavement fails to follow normative (or cultural) expectations and manifests in functional impairment
Characteristics of Complicated GrievingDecreased functioning in life roles, experiencing somatic symptoms of deceased, verbalizes feeling of shock, detachment, disbelief, persistent painful memories
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