Medications
Name the 1st gen antipsychotic medications, the adverse effects, contradiction
*BONUS: Name the LAIs and how often they take it
- p.s. they are not all 1st gens
Typical antipsychotics (1st gen): Haloperidol (Haldol) - high potency, Fluphenazine (Prolixin) - High potency, Chlorpromazine (Thorazine) - Low potency.
SS: Cause EPS... Akathisia, Acute dystonia, Psuedoparkinsonism; Also Tardive dyskinesia (TD), Neuroleptic malignant syndrome (NMS)... Anticholingeric SS: Constipation, dry mouth, dry eyes, urinary hesitancy or rentention, blurred vision, cognitive impairment
*** High potency causes EPS while low potency causes anticholingeric symptoms and orthostatic hypotension
*BONUS: Risperdal Consta q2weeks, Paliperidone (Invega) q1month, Aripiprazole (Abilify) q1month, Haloperidol (Haldol) q3-4weeks.
Identify all the Involuntary commitment lengths of stay
*BONUS: Name some situations where we don't need consent and the criteria for admission
Emergency commitment: 48 hours
Order of Protective Custody: up to 2 weeks
Temporary Commitment: up to 3 months
Extended Commitment: up to 1 year
(mandated outpatient commitment exist)
*** Does NOT have to stay whole time if they are appropriate for discharge
*B: When it is court ordered, the Dr switches them to involuntary
Admitted due to being a harm to self or others, gravely disabled, acutely psychotic, suicidal or homicidal?
Describe the differences between Bipolar 1,2, and Cyclothymic disorder
B1: Full blown mania w severe depression, there must be a hx of one or more manic episode, there is a hx of major depression, more severe,
B2: Lower level mania alternating w serious depression, Not have mania, has hypomania, there is a hx of at least one hypomanic episode alternating w periods of depression but not full mania
Cyclothymic: Hypomania w mild to moderate depression, No manic or depressive episodes, episodes of hypomania and numerous periods of depressed mood, dysthymia not major depression - for 2 years, chronic, sometimes described as "mild"
Describe Cognitive Behavioral Therapy (CBT)
Identify and test negative distortions, develop alternatives by challenging distortions, rehearsing, Cognitive & REFRAMING - identifying alternate ways to view situations, teaches pts how to identify and change distorted thinking
Name symptoms that occur before entering the acute stage of schizophrenia and the courses of illness for schizophrenia
Prodromal: "going downhill", occurs in most people prior to acute phase. O: Decreased attention to grooming and social amenities, hostility, withdrawal, psychomotor agitation, catatonic rigidity, echopraxia (rep movements), stereotypy (rep actions or words)
Acute: The pt experiences severe psychotic symptoms (Most symptomatic)
Stabilization: Decrease acute symptoms, especially pos symptoms, can be dangerous, pt is getting better
Maintenance: Remission, mostly remission, might still be experiencing hallucination and delusions but not as severe or disabling like in the acute phase
Name the 2nd gen antipsychotic medications, the adverse effects, contradiction
*BONUS: what drug causes a blood problem and what is that complication called?
Atypical antipsychotics: Clozapine (Clozaril), Risperadone (Risperdal), Quetiapine (Seroquel), Olanzapine (Zyprexa), Iloperidone (Fanapt), Lurasidone HCl (Latuda), Ziprasidone HCl (Geodon), Aripiprazole (Abilify) 3rd gen, Paliperidone (Invega), Cariprazine (Vraylar)
- Target Pos and Neg symptoms of schizophrenia
SS: Produce fewer EPS... Risk for metabolic syndrome -> weight gain, dyslipidemia, altered glucose, triglycerides, insulin resistance. Risk for diabetes, hypertensions, atherosclerosis and increase in heart disease
*B: Clozapine may cause agranulocytosis: monitor CBC weekly for 6 months and every 2 weeks for the next 6 months and than every month on med
Describe the responsibility, priority, concerns to be aware of and side effects post seizure as a nurse when a pt is going through electroconvulsive therapy?
R: Ventilate pt w 100% O2, monitor all VS, reorient pt, continue to observe confusion after treatment, if agitated give benzo, documentation, not to drive 24 hrs after ECT
P: Confirm consent is obtained, physical exam, basic labs and EKG done first, person is NPO 6-8hrs prior, persons bladder is empty, place the IV, pts has a patent airway
C: Recent MI? Cardiac conditions? Brain tumors? Causes of increased intracranial pressure?
SE: Postictal confusion, HA, nausea, troublesome memory impairment
- Anterograde (can't remember new things): around time of treatment usually clears quickly
- Retrograde (can't remember memories before treatment): may extend longer: others spotty memory 6 months prior
Name some risk factors for suicide
*BONUS: Name risk factors specific to the older adult population
despair, hopelessness, feeling useless, medical issues, pain, functional disability and loss, other losses, financial problems
Age and Gender: males, adolescents, elderly
Family hx of depression or suicide
Hx of MDD, schizophrenia, bipolar d/o, PTSD, personality d/o, TBI, or substance abuse
Inadequate social support
Recent loss
*B: White men, 65 years of age and older, are at risk five times higher than the general population
Identify key differences between a therapeutic and a social relationship
*BONUS: Name the 4 stages of a therapeutic relationship
SR: Friendship, Socialization, Enjoyment, Mutual needs are met
TR: The nurse and pt identify areas that need exploration, establish clear boundaries, encourage alternate problem-solving approaches, help the pt develop coping skills, and support behavioral changes
Stage 0: Pre Orientation - getting report, learning about them before meeting them
Stage 1: Orientation - assessment, meeting them, establishing rapport, trust, agree upon goals and limits
Stage 2: Working Stage - help pt achieve goals via problem solving, coping skills, education (transference and countertransference), "doing work", assisting them to own treatment
Stage 3: Termination - evaluate outcomes, summarize progress, referrals
Name the types of therapeutic techniques
Silence: helps the pt formulate their thoughts and feelings, conveys respect
Active listening: Your undivided attention encourages pts to problem solve which conveys a sense of reassurance to pts that they are not alone and enhances their confidence and self-esteem
Paraphrasing: Restating the basic contents of a pts message in different (usually fewer) words
Restating: Repeating the same key words a pt has just spoken
Reflecting: Can either be in the form of a question or a simple statement that conveys the nurses observations
Exploring: Allows a pt to express a more meaningful communication
Clarifying: If you're unsure of your understanding of a pts comments or questions. ask them to clarify or restate their remarks
Open-ended questions: Encourages a pt to share info, avoid questions which may lead the pts response
Closed-ended questions: Allows you to get specific info, usually used during an initial assessment
- Broad opening, giving recognition, offering self, reflecting feelings, clarifying, sequencing events, giving information, and encouraging formation of a plan
Can you name the antianxiety medications, side effects and any contradictions
*BONUS: What should you not mix with Benzos that would cause a synergistic effect? 1+1=5
Benzodiazepines: clonazepam (Klonopin) and lorazepam (Ativan), diazepam (Valium), alprazolam (Xanax), chlordiazepoxide (Librium)
* Slow the activity of the brain – enhance GABA, Quick acting, Useful in treatment of acute mania, Used for agitation, anxiety, insomnia, Used until other medications take effect. If abruptly stopped may cause seizures. Contraindicated in clients with acute narrow angle glaucoma; used very cautiously in older adults. Used for SHORT TERM
SE: sedation, ataxia, dizziness, headaches, blurred vision, hypotension, constipation, urinary incontinence, paradoxical CNS excitement, behavior change
*** Addiction potential is high
Buspirone (Buspar, NON-Benzo): Takes 1-2 weeks for initial effect , 4-6 weeks for full effect, Mainly used for GAD, No addiction potential documented compared to benzos or CNS depression. Used for LONG TERM
SE: dizziness, headache, lightheadedness
Antihistamines: diphenhydramine (Benadryl), hydroxyzine (Vistaril), hydroxyzine hydrochloride (Atarax)
Used for SHORT TERM for mild anxiety usually
SE: dizziness, headache, sleepiness, dry mouth
Others used for anxiety; Propranolol (Inderal)—Beta adrenergic blocker used for panic disorder and social anxiety disorder, reduces physical responses, ie: racing heart...Clonidine (Catapres)--Alpha 2 agonist, a blood pressure medication can reduce physical responses to anxiety...Gabapentin (Neurontin) an anticonvulsant is also used for anxiety
**Sedation potentiates falls, accidents, Cautious use in older adults, renal, liver problems
*B: Alcohol!!!
Identify some of the characteristics between parts of the mental status assessment
Thought process v Thought content
Mood v Affect
Insight v Judgement
TP: Confusion, circumstantial, tangential, and flight of ideas
TC: Suicide, phobias, paranoia, and obsessions
M: Patient states how he/she feels (Subjective)
A: external manifestation of patient’s internal emotional state assessed by you (Objective)
I: degree of awareness or understanding of own situation; connection to illness/behaviors, problems and known causes
J: soundness of problem solving and decisions; how understanding and awareness of situation are being utilized
Name all of the patients rights
1. Right to treatment/timely evaluation/qualified staff/individualized treatment plan
2. Right to refuse treatment/medications
3. Right to informed consent
4. Least restrictive environment
5. Confidential
6. Right to choose or refuse visitors
7. Right to vote
8. Right to legal counsel
9. Right to be involved in treatment plan and decisions and more (pt needs to be involved in treatment plan)
*** a pts right can be suspended if harm to self or others
**** NO standing orders for restraints
What are some ways you can establish rapport?
What is Trauma informed Care?
Almost all persons with mental illness have a significant history of trauma
Appropriate care involves avoiding re-traumatizing the patient and demonstrating respect and consideration
- effects a persons way of interacting/seeing the world
Name all the antidepressants with their side effects and any major contradictions
*BONUS: Name the different classifications of drugs that a pt should not mix w alcohol (it could lead to death)
SSRIs: citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), escitalopram (Lexopro), fluvoxamine (Luvox), and sertraline (Zoloft)
SE - Sexual dysfunction, dry mouth, sweating, weight gain, mild nausea, agitation and anxiety, headache, sleep problems, *Serotonin Syndrome* When taken with other medications that enhance serotonin, LIFE THREATENING
Atypical antidepressants (non SSRIs): *Bupropion (Wellbutrin) (Zyban too) Norepinephrine-dopamine reuptake inhibitor NDRI, *Duloxetine (Cymbalta) Selective serotonin-norepinephrine reuptake inhibitor SNRI, *Venlafaxine (Effexor) Selective serotonin-norepinephrine reuptake inhibitor SNRI, Mirtazapine (Remeron) Nonadrenergic antagonist-specific serotonin antagonist NaSSA, *Trazodone (Desyrel) Serotonin Agonist and Reuptake inhibitor SARI
TCAs: amitriptyline (Elavil), *desipramine (Norpramin), *imipramine(Tofranil), maprotiline (Ludiomil), nortriptyline (Pamalor); doxepin (Sinequan); protriptyline (Vivactil)
SE - Cardiac -> MI, heart block, tachycardia, dysrhythmia, Seizures, cardiac arrest weight gain, Urinary retention and constipation, sedation and orthostatic hypotension
*** Usually given at night, do not take w MAOIs, barbiturates, Antabuse, benzodiazepines, Need to get EKG before hand
MAOIs: tranylcypromine sulfate (Parnate), *phenelzine (Nardil), *isocarboxazid (Marplan), *selegiline (Emsam)
SE - Hypertensive crisis, Dangerously high blood pressure, headache, increased heart rate, tremors, seizure
*** Avoid tyramine in DIET!!!! EX: aged cheeses, cured meats, avocados, bananas
*BONUS: barbiturates, benzodiazepines, opioids, antipsychotics, antidepressants, and others
What are some sign and symptoms of schizophrenia?
HINT: there is 4 categories
Pos: Hallucinations, Delusions... Delusions of reference (paranoid, grandiose, persecutory, somatic, jealousy, control, thought broadcasting, thought insertion, thought withdrawal, delusions of being controlled), Disorganized speech, Bizarre behavior, Concrete thinking, Impaired reality testing (new stuff thats there that wasn't before)
Neg: Flat affect, sexual withdrawal, Alogia, Avolition, Anergia, Anhedonia, Poverty of Speech, Poor social functioning (Deficit, things that should be there that aren't)
Cognitive: Trouble focusing or paying attention, problems with working memory, difficulty w decision making, judgement, planning and problem solving, poor executive functioning
Mood: Anxiety, Depression, Suicidality, Dysphoria, Hopelessness
Describe the key differences between Anxiety and Aggression... Also, the interventions
Anxiety: characterized by feelings of apprehension, uneasiness, dread resulting from a real or perceived threat. Is unspecified! Occurs in degrees of intensity, mild to pain, and affects ones ability to function. Anxiety = Stress response
I: Select interventions based on anxiety level (Mild, Moderate, Severe, Panic), Provide relaxation/tension-reducing methods, Promote/teach adaptive coping, Self-care strategies (e.g ADLs, Sleep hygiene), Lifestyle management (e.g avoiding caffeine), Cognitive and behavioral therapies (CBT), and Integrative and complementary therapies such as meditation
Aggression: External, hostility, anger, agitation
I:
Can you identify the role of a psychiatric nurse?
*BONUS: Can you describe professional boundaries with pts? As in, what are they meant for?
Assessment and data collection, develop and implement plans of care, assist and supervise mental health workers, maintain a safe and therapeutic environment, teaching, oversee seclusion and restraint, coordinate care by the treatment team
*B: Professional boundaries with clients are meant to support the key elements of the N/P relationship: trust, compassion, mutual respect and client growth.
Describe the different types of crisis
*BONUS: what is the length of treatment?
Developmental/Maturational (stages of life) - Eriksons stages of growth and development (8), each stage constitutes a development crisis, new coping mechanisms must develop to replace old ones. EX: marriage, birth of child/parenthood, adolescent, retirement
Existential crisis - questioning life, purpose, or spirituality. Can be brought on by significant events, pos or neg, can lead to positives and negatives
Situational crisis - arises from an external sourse and is often unexpected EX: death of a loved one, fired from job, unwanted pregnancy
Adventitious crisis/crisis of disaster - large scale, uncommon, impacts community or more, unplanned/catastrophic. EX: Covid19
*B: 4-6 weeks
Can you name the anticonvulsant/mood stabilizer medications, side effects and any contradictions
*BONUS: what level would be considered toxic when taking lithium?
Lithium: Used for mania and depression, Take with meals to reduce nausea, Reputation for decreasing suicide (risk 10 %)
SE: fatigue, edema, fine tremor, dizziness, nausea, vomiting, diarrhea, dry mouth, weight changes, weakness, excessive thirst and urination, and hypothyroidism.
Early signs of toxicity 1.5 m Eq/L – above plus vomiting, diarrhea, slurred speech, muscle weakness
Advanced signs of toxicity 1.5-2.0 m Eq/L – coarse hand tremor, mental confusion, incoordination, sedation
Severe toxicity 2.0- 2.5 m Eq/L-ataxia, blurred vision, clonic movements, large output dilute urine, seizures, stupor, hypotension, coma
> 2.5 m Eq/L - delirium, seizures, coma, death
*** DON'T take lithium w Diuretics or NSAIDs, inform pt to stop taking if experiencing diarrhea, vomiting, or sweating
Valproate/Depakote: monitor liver function and platelet count periodically.
Carbamazepine/Tegretol: monitor liver function and platelet count periodically.
Lamotrigine/Lamictil: good for bipolar depression. Report rash to HCP. (Adverse Reaction: Steven Johnson Syndrome-a rare, serious disorder of the skin and mucous membranes)
*B: toxicity symptoms are seen when concentrations are greater than 1.5
Name interventions and some symptoms you see in both Mania and Hypomania
M: are longer and more intense, MAY include hallucinations and delusions, day to day life is significantly impaired, hospitalization often needed for safety and stabilization, increase in energy, talkativeness, decrease need for sleep, appetite, concentration, exaggerated, elevated mood
Starts of happy, positive -> agitation, irritability and psychosis
HM: Less extreme version, no psychosis, duration at least 4 days, energetic, talkative, confident, grandiosity, creative, agitation, irritability, decreased need for sleep, easy distractibility, talking very fast w racing thoughts, pressured speech, NO hallucinations or delusions; impairments of judgement, risk taking behavior, impulsivity
Interventions: SAFETY, rest, hydration, nutrition, reestablish physical well being; will not be capable of judging the need for rest, develop rapport
Cluster A: "odd, or eccentric," have unusual behaviors, avoid interpersonal relationships; often indifferent. Paranoid, Schizoid, and Shizotypal personality d/o
Cluster B: Emotional reactivity, poor impulse control, manipulation, unclear sense of identity.
Antisocial: disregard to others, law large % criminal arrest, lack of remorse, entitlement, manipulative, male>female, aggressive, irritable
Borderline: Difficulty w self-regulation, unable to self-sooth in times of stress, splitting, self-mutilation, characterized by impulsivity and instability in interpersonal relationships, self image, and emotion
Narcissistic: Grandiose, entitled, arrogant, think they are important, need to be admired/believe others are envious of their success/ envy success of others, male>female
Histrionic: Emotional and attention seeking, need to be center of attention, manipulate others by being "dramatic", drawing attention to physical appearance, and emotional liability
Cluster C: High anxiety and outwards signs of fear, inhibited, internalizing blame, even when not to blame. Avoidant, Dependent, Obsessive compulsive personality d/o
Describe depression and the different types of depressive disorders. Name some treatments for depression
*BONUS: Name important points when caring for a pt w depression
Depression: Leading cause of disability in the United States-most common psychiatric disorder, May lead to disability-diminished role functioning
Major Depressive Disorder: So depressed that one cannot function or depression causes clinically significant impairment. S/S - depressed mood, anhedonia, fatigue, sleep disturbances, changes in appetite, feelings of hopelessness or worthlessness, persistent thoughts of death or suicide, inability to concentrate or make decisions, sleep disturbance change in physical activity, others
Persistent Depressive Disorder: Feelings of depression persist consistently for at least 2 years, Social and occupational distress but usually not severe enough to require hospitalization, Chronic condition- almost constant presence; may also have episode(s) of major depression, Onset usually in childhood/teenage years, Able to function but life is an ongoing and unremitting burden
T: CBT, Electroconvulsive therapy (ECT), Transcranial magnetic stimulation, Vagus nerve stimulation, Deep brain stimulation, Light therapy, St. Johns Wort, and Exercise
*B: Assessment: Continuously assess for the possibility of suicidal thoughts and ideation throughout the patient’s course of treatment and recovery.
Implementation: The dysfunctional attitudes of learned helplessness and hopelessness can be alleviated through cognitive therapy or other psychotherapeutic interventions.
*** Depression is NOT a normal part of aging
Name some interventions for ADHD and ASD.
*BONUS: What is the acronym for CAGE, and what is it used for? Also, what is the timeline for alcohol withdrawal?
ADHD: Parent education (early recognition/treatment), teaching the child coping skills, rewards for positive behaviors (short term rewards), clear limits and clear consequences, structure and routine in Childs environment, environmental modifications; school accommodation, modify nutrition, promote sleep, provide opportunities for large muscle activity
MEDs: Stimulants - methylphenidate (Ritalin), amphetamine (adderrall), Vyvanse lisdexamfetamine (Vyvanse), work within 30 minutes
Second line meds: Nonstimulants - atomoxetine (Strattera) SNRI (takes 2-4 weeks to acheive steady state, guanfacine (tenet) alpha antagonist, viloxazine (Qelbree) antidepressant
ASD: Applied Behavioral Analysis, School setting varies, depending on level of functioning, from mainstream to specialized environments, support pt, address bullying issues immediately
MEDs:
Antipsychotics for aggression and irritability - risperidone (risperdal), ariprprazole (abilify)
SSRIs for anxiety or obessive traits - fluoxetine (Prozac), sertraline (Zoloft)
Or Beta Blockers for anxiety and obsessive behaviors
*B: Cut down, Annoyed, Guilty, Eye opener. It is used as a screening for alcohol
- Symptoms start within 2 hrs, 48-72 hours peak (severe), 2-5 days taper