Depression
Depression symptoms
What is SIGECAPS?- Sleep disturbance, lack of interest, guiltiness/worry/hopelessness, lack of energy, lack of concentration, loss of appetite, psychomotor disturbances.
Opioid/heroin overdose/withdrawal
overdose-What are Pinpoint pupils, hypotension respiratory depression, and bradycardia?
withdrawal-What is flu-like symptoms?
Agitated clients with schizophrenia and bipolar mania nursing priority.
What is the risk of violence directed toward others?
What is a risk for violence directed towards the self?
Safety is the highest priority for both clients and others.
Symptoms of mania
What is rapid speech, pressured speech, flight of ideas, pacing, lack need for sleep, demanding, manipulative, extreme energy.
Intervention for OCD
What is provide enough time to complete rituals at the beginning and decrease time-spent each time. provide structured activities, routine, bathroom breaks.
Restrict food intake and purge if they do. Underweight(BMI below 18), low vitals signs, lanugo, enlarged parotid glands, lanugo, dental erosions, Russel's sign, amenorrhea, dehydration, organ failures...
What is anorexia nervosa?
Suicide risks ranked.
What is the more the risk factors the more likely to commit suicide? ^History of suicide attempt>history of depression>elderly, male caucasian.
Alcoholic parents, Genetics, external locus of control
What are the risk factors for substance use disorders?
Schizophrenia high-priority assessment
What is command hallucinations, paranoid, and persecutory delusions? High risk for violence or harm. Ask what the voice is telling the client, acknowledge the client's perception, and do not argue, or agree or encourage the client.
Bipolar Nursing problems
Risk for self harm, disturbed socialization, loneliness, hopelessness, sleep deprivation, impaired decision making, risk for nutritional imbalance.
OCD personality
What is obsession cause anxiety and ritualistic acts is client's effort to reduce anxiety.
binge eating then purge or use laxatives. normal weight, electrolytes imbalance(hypokalemia), dental erosions, Russel's sign, menses irregularity, constipation
What is bulimia nervosa?
Suicide Precaution
What is 1:1 around the clock, remove any object client can use to harm self, screen food and visitors for any object that can be used to harm self. escort to bathroom, never leave client alone
Assess for neurological and ABC systems first.
What is the priority in care for clients with substance use emergencies?
Side effects of antipsychotics
sexual dysfunction, orthostatic hypotension, anticholinergic effects (dry mouth, constipation, dry skin, blurred vision, urinary retention), weight gain, metabolic syndrome(hyperlipidemia, hypertension, diabetes), sedation, photosensitivity , agranulocytosis- fatal
Mania nursing intervention
What is protect the client from uninhibited behaviors, safety is No. 1, set limit and be direct, frequent staff meeting to deal with client, provide finger food, allocate time to sleep.
Antisocial PD
What is a lack of remorse or empathy? manipulative, demanding, provocative- frequent staff meetings, set limits on behaviors, and be consistent.
Outcome; client gain insight into how their behaviors affect others and themselves
Eat large amounts of food i one sitting without compensating. Obese or morbidly obese, risk for hyperlipidemia, hypertension, diabetes.
What is binge eating?
Suicide covert messages
What is concealed statements and behaviors that imply underlying suicide ideation? ask directly if considering suicide. giving away processions, "I have a plan to fix all this...," I wish I sleep and never wake up"...
Signs and symptoms of alcohol withdrawal
What are tremors, anxiety, elevated BP, HR, and diaphoresis?
EPS
What is AdAPT mnemonic? Acute dystonia (face, eye, and neck muscle spasm, stiffness-give diphenhydramine), Akathisia (restlessness- give beta blockers), Parkinsonism(Muscle stiffness, tremor), Tardive dyskinesia (Lip smacking, tongue rolling)
Priority for bipolar mania
What is safety from self-harm or injury or nutrition if physiological needs are not met e.g hungry for days, pacing for hours
OCD Response prevention therapy
What is the client resists the urge to perform rituals? The goal is to help the client tolerate anxiety caused by obsessive thoughts without performing rituals.
Journaling, Cognitive reframing, CBT
What are therapeutic approaches for eating disorders? Change their perception of food and their body. Outcome: self-awareness and sense of control over eating
Suicide overt messages
What is messages that clearly states client intent o harm themselves? e.g. "I wish I am dead" "I want to die so I stop suffering." "I am going to kill myself."
The medical emergency alcohol withdrawal symptoms
What is delirium tremens?. Signs- hallucinations, delusions, seizures, very high BP, HR, dysthymia
Neuroleptic Malignant Syndrome
What is F.E.V.E.R.? High temperature, encephalopathy (confusion, disoriented), vital signs instability, elevated CPK, WBC, Muscle rigidity- its an emergency- stop all meds initiate ICU protocol, give bromocriptine
Medications for Bipolar
What is Lithium, Anticonvulsants (valproate, lamotrigine, carbamazepine)
Splitting
Client with borderline PD unable to see people can have both good and bad qualities but see only either good or bad but not both. form of manipulative mechanism- "No wonder others hate you..."Oh the best nurse ever..."
Stay with the client during meals and 2 hrs after meals, accompany to the bathroom, monitor exercise, and make behavioral contracts.
What is nursing intervention for eating disorders? expected outcome; normalize food and maintain healthy weight.
SSRIs-Selective serotonin Reuptake inhibitors
What are fluoxetine, paroxetine, citalopram, and sertraline? Side effects-weight gain, bruxism, Gi upset-diarhea, insomnia, and sexual dysfunction.
Detoxification treatment?
What is benzodiazepines as alcohol substitutes (LAMS and PAMS). What is given B12 and folic acid? Assess for albumin, and give IV fluids. get EKG. Delirium tremens-cardiac monitoring, transfer to ICU..?
"I see Snakes on the ceiling"
What is Visual hallucination. "It must be very frightening to see snakes on the ceiling but i do not see anything."
Lithium nursing considerations
What is monitor therapeutic levels (0.8-1.5), No altering intake of salt and fluids, monitor thyroid and kidney function. levels above 1.5 can cause toxicity.
Nursing care for borderline PD
Access for SI and be a matter of fact about self-mutilation or nonsuicidal self-injuries—frequent staff meetings to discuss the client's manipulative behavior and how to deal with it.
Nutritional needs
What is highest priority nursing consideration for eating disorders? weight gain is the goal
Serotonin syndrome
What is the adverse effect of taking more than one antidepressant simultaneously? It is a medical emergency. Symptoms- high fever, elevated vital signs, encephalopathy, hyperreflexia, diaphoresis/sweating
Medication that ends with LAMs and PAMS
What are benzodiazepines used as alcohol substitutes during detoxification?
"They Stake the skate and sturk the turk"
What is clang association "I do not understand what you just said."?
pregnancy, breastfeeding
What is contraindication for bipolar medication?
Personality disorders
What is Cluster A, B and C- Frequent staff meetings to address unpredictable behaviors. rules and expectations to prevent manipulations
Hypokalemia and hypernatremia.
What is electrolyte imbalance for anorexia and bulimia nervosa?
Sertraline, Fluoxetine, Paroxetine
What is examples of SSRIs?
Disulfiram
What is alcohol abstinence medication given at discharge that can cause severe reactions if one consumes alcohol?
Auditory hallucinations
What is asking what the voices are telling the client, assess for safety?
lithium toxicity
What is severe diarrhea, severe vomiting, seizures,
Flamboyant, extreme makeup, showing off.
What is Histrionic personality disorder
Bradycardia, hypotension, no improvement in outpatient treatment, low temp.
What are the hospitalization criteria for anorexia nervosa?
Priority for depression
what is safety?
Condependency
What is maladaptive family member behavior/relationship with a substance user that enables the behavior?
"Great like the sun. The sun is powerful, like Superman. Superman flies to the moon, and the moon has cheese"
What is associative looseness?
SIGECAPS
What are the signs of bipolar depression?
Avoidant
What is cluster C example?
childhood obesity, dieting at an early age, controlling parents, overachievers, OCD, athletes, female gender...
What are risk factors for eating disorders?