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Anxiety Levels

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Mild anxiety: Patient is alert, calm, speaks clearly Moderate anxiety: Patient displays muscle tension, appears nervous Severe anxiety: Patient has dry mouth, diaphoresis, trouble focusing, urinary urgency Panic: Patient is hyperventilating, displays impaired thinking, appears terrified

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Mild to Moderate anxiety

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• See themselves as successfully carrying out their activites of daily living

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Sever anxiety

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Can only focus on narrow area of concern (ex: only focus on about her boss that she hates)

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Panic anxiety

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• Has intense physical symptoms such as chest pain, diaphoresis (발한), shortness of breath without identifiable cause

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Involuntary Treatment

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• Unable to meet basic self-care needs in such a way that he or she is a danger to self (ex: psychoses, excessive malnutrition) • Plan to harm themselves or others

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Anna Gray

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• 52-year-old • African American • Widowed female • Sad, rarely eyecontact, cry, don't care

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Hears a scary voice

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• (o)What is the voice saying to you? The nurse must assess the content of the auditory hallucinations for the presence of command hallucinations • (x) How long have you been hearing the voice? Can be helpful, but not priority • (x) Have you ever been hospitalized for depression? Gathering data about past hospitalizations and successful treatment outcomes is helpful, but not priority

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Strategies for working with patients who have HALLUCINATIONS

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• Establish a trusting, interpersonal relationship • Assess for symptoms (duration, intensity, frequency) • Focus on the symptoms • Ask the patient to describe what's happening • Identify whether drugs or alcohol have been used • If asked, point out simply that you are not experiencing the same stimuli- rather, respond by letting the patinet know what is actually happening in the environment • Do not leave the person alone when an hallucination occurs • Find, explore, connect social support to the patient • Help the patinet describe and compare current and past hallucination • Help the patient recognize symptoms, symptom triggers, and symptom management strategies

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Assess Risk factors for suicide [SAD PERSONS scale]

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• S: Sex - Men kill themselves more, althought women attempts more • A: Age - Younger than 19, Older than 45, especially older than 65!! • D: Depression • P: Previous attempts • E: ETOH - Alcohol use is associated with up to 65% of suicides • R: Rational Thinkin loss- psychoses • S: Social supports lacking -a suicidal person often lacks social interaction with others, meaningful employment, and other supports • O: Organized plan - the presence of a specific plan (date, place, means) signifies a person at hight risk • N: No spouse - no significant others, widowed, separated, divorced, or single • S: Sickness - severe illnes cause hopelessmess and depression. It may lead to suicide

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Results of SAD PERSONS scale

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• 0~2: Home treatment with follow-up care • 3~4: Closely follow up and consider possible hospitalization • 5~6: Stronly consider hospitalization • 7~10: Hospitalize

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Symptoms of Depression

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• Poor concentration • Slowed thought process -difficult making decisions (x) give two choices of clothes • Poor grooming and hygiene • Slow motor activity

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Severely depressed patients with decreased energy

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Plan a scheduled rest period • It is best to plan rest period according to the client's energy level • Some clients feel best in the morning and others feel best in the evening

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Depressed patients with sleep disturbance

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• Encourage to exercise according to client's energy level • Minimize caffeine late in the day • Discourage frequent naps

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Tell the patient that antidepressants are the best treatment option (x)

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• A combination of treatment modalities are the best options for treating depression • Include medications, group therapy, individual therapy, and activity therapy

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Depressed patient eating 50% of meals

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• Eating 50% of her meals is acceptable because most of the depressed patients have decreased appetite, provided that the client is not losing weight • If the client continues to eat at least 50% of her meals, this is not the priority physiologic need unless weight loss occurs • But, weight weekly and document!! - monitor closely and frequently weigh patients to document any changes in weight

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Depression [Biological Approach]

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• In the depressd state, sparse amounts of neurotransmitter are available in the synapse of a depressed person • Depression occus when a depletion of neurotransmitter in the synapse causes the transmitter receptors to increase • As the antidepressants make more transmitters available, it takes the receptors several weeks to return their numbers back to normal and allow normal synaptic activity

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Hypothyroidism & Depression

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• Thyroid levels can help detect hypothyroidism • Hypothyroidism can lead to depression and feeling sluggish • Addison's disease also correlate with depression and fatigue • Grave's disease (autoimmune conditions) causes excessive thyroid secretion - emotional stress, nervousness, fatigue, weight loss, heat intolerance, and GI symptoms

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Depressed patients - Help ADLs

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• When a client is very depressed, it is necessary for the nurse to assist with ADL because the client has decreased energy • Physical care is more important with severe depression

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Fluoxetine (Prozac)

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• Antidepressants • SSRI (Selective Serotonin Reuptake Inhibitor), zoloft • Sedation - minimal • Weight gain - rare • GI disturbances -nausea and diarrhea • (X) anticholinergic, sediative effects • Sexual Dysfunction!!!! • Toxic Effects - Serotonin syndrome • It takes 1 to 3 weeks to be effective

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Why SSRI antidepressants? rather than Tricyclics antidepressants?

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• Fewer side effects • Tricyclics can be lethal in an overdose because they are CARDIOTOXIC • Tricyclics have anticholinergic effects

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Benzodiazepines

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• Enhance GABA

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Traditional antipsychotic medications

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• Extrapyramidal side effects (EPS)

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Serious side effect of antipsychotic medications

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• Rare • Neuroleptic malignant syndrome - autonomic hyperactivity and muscle rigidity

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Antipsychotic medications

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• Target symptoms related of thinking such as psychosis and behaviors associated with agitation and disorganization or speech and behavior

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Haloperidol (Haldol)

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•Conventional antipsychotic drug. •Used for positive symptoms in schizophrenia. •Long term use may cause tremors, nausea, vomiting or uncontrolable shaking of small muscle groups -report these symptoms to the physician

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Risperidone (Risperdal)

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•A typical antipsychotic. •Improve mood and affect •Used to treat negative symptoms of schizophrenia, hallucination, paranoic deluion, garble speech •Blocks specific dopamine and serotonin receptors.

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Lab test - VDRL (RPR)

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• A VDRL is a serum screening test for SYPHILLIS • can be undetected and dormant • can cause COGNITIVE IMPAIRMENT in later stages

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DSM-IV-TR

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• Uses a multiaxial system • Gives attention to various mental disorders, general medical conditions, aspects of the environment, and areas of functioning that might be overlooked if the focus were exclusively on assessing a single presenting problem.

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Axes

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• Axis I: Clinical syndromes (hallucination, delusion) • Axis II: Personality disorders, mental retardation • Axis III: General medical conditions (ex: diabetes) • Axis IV: Psychosocial and environmental problems • Axis V: Global assessment of functioning

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Axes I and II

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• Include the entire classification of mental disorders plus conditions that are not attributable to a mental disorder but that are a focus of attention or treatment

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Axis III

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• Allows the clinician to identify any physical disorder relevant to the understanding or treatment of the individual

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Axis IV

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• For reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders

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Axis V

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• For reporting the clinician's judgment of the individual's overall level of functioning. This information is useful in planning treatment, measuring its impact, and predicting outcomes

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Crisis

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• Maturational Crisis (=Developmental Crisis) • Situational Crisis • Adventitious Crisis

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Maturational (=Developmental Crisis)

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• Associated with Erikson's 8 stages • When a person arrives at a new stage, formerly used coping styles are no longer effective, and new coping mechanisms have yet to be developed. Thus for a time the person is without effective defenses. This often leads to increased tension and anxiety, which may manifest as variations in the person's normal behavior • Ex)Adolescence, Marriage, Retirement, Perception of age

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Situational Crisis [Unexpected]

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• Events that are extraordinary, external rather than internal, and often unanticipated • Ex) loss or change of a job, the death of a loved one, an abortion, a change in financial status, divorce, and severe physical or mental illness.

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Adventitious Crisis [Accidential, Nature-caused, Crime of Violence]

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• An adventitious crisis is not a part of everyday life; it results from events that are unplanned and may be accidental, caused by nature, or human-made • Ex) (1) a natural disaster (e.g., flood, fire, earthquake), (2) a national disaster (e.g., acts of terrorism, war, riots, airplane crashes) (3) a crime of violence (e.g., rape, assault or murder in the workplace or school, bombing in crowded areas, spousal or child abuse).

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Powelessness

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• A result of Hopelessness • Nurse can work with patient to feel mored empowered

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Anxiolytics (Anti-anxiety drugs)

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• Don't wait till anxiety becomes uncontrollable • Waiting until anxiety is "uncontrollable" makes the anxiety worse • Make your anxiety on a scale, then decide when to take it • Self-monitoring tools promote independence and teach the patient to track symptoms

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Antidepressants & Anxiety

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• Clients who suffer from anxiety may experience increased anxiety when taking antidepressants

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Antidepressants

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• Antidepressants should be taken on a daily basis • Continuing to take the medication for a minimum of 1 year decreases the chance for future episodes of depression

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Patient who takes antidepressants -Always most important to ask suicidal thougths

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• Once the patient started taking antidepressants, it is most important for nurses to ask the patient about suicidal thoughts. The ultimate goal of giving the medication was to improve their anxiety, but assessment for dangerousness to oneself or others is always the first priority when assessing the depressed client • Then, ask "How do you plan to hurt yourself?" • And then, make a no-self harm plan • Presence or absence of a support system is useful information

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Bupropion (Wellbutrin XL)

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• Don't take it at bedtime because it often causes insomnia • Contraindications: Anorexia, bulimia, seizures • Anorexia and bulimia are both contraindication for bupropion because of a higher incidence of seizures experienced by clients treated for bulimia • Clients with a history of seizures are at high risk for seizures when taking bupropion • Do not consume alcohol while taking the medication because it may increase the risk of seizures • Headache can happen early in treatment, but it usually go away within a few days. So nurse should encourage the patient to continue taking their medication

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Most Commonly Used Antianxiolytics

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• Alprazolam • Lorazepam

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Call the police?

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• Although calling the police is an option, it is also important for the nurses to maintain a good relationship with the client. However, if the client refuses to go to the hospital and there is no family or friend on site to safely transport the client, then the police is the bsetoption

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Contact to client's family about suicidal trial?

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• Contacting the family and revealing what the client said would threaten the nurse-client relationship and violate HIPAA guidelines

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When assessing the medication combination and therapy are working

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• Assess the causes of client's INITIAL COMPLAINTS have been resolved

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Defense Mechanism [Compensation]

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• Conceal their mistakes or shortcomings by overacheiving or exaggeration

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Defense Mechanism [Reaction formation]

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• Clients turn their feelings or impulses into their opposites

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Risk factors for high blood pressure

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• Sedentary lifestyle • Alcohol consumption • African-American

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