Mania notes and questions

RMH
RMHRMH

Mania questions and answers

What to know on the Exam
Mania - 7 questions
Mania
Several theories: hereditary, possible excess of norepinephrine
and dopamine, electrolytes, possible cholinergic or
acetylcholine link is also noted with an inadequate amount
accounting for mania
Signs and symptoms can be described according
to three stages
Signs and symptoms of mania
(listed for children but probably in adults
too)
Euphoric/expansive mood: extremely
happy, silly, or giddy
Irritable mood: hostility and rage,
often over trivial matters
Grandiosity: believes abilities to be
better than everyone else’s
Decreased need for sleep: may only
sleep 4-5 hours per night and wake up
feeling rested
Pressured speech: loud, intrusive, and
difficult to interrupt
Racing thoughts: rapid change of
topics
Distractibility: unable to focus on
anything for very long
Increase in goal-directed
activity/psychomotor agitation:
activities become obsessive, increased
psychomotor agitation
Excessive involvement in pleasurable
or risky activities: exhibits behavior
that has an erotic, pleasure seeking
quality about it
Psychosis: may experience
hallucinations and delusions
Suicidality: may exhibit suicidal
behavior during a depressed or mixed
episode or when psychotic
Stage I – Hypomania
(pt enjoys this phase, not a cause for social or occupational
impairment, does not require hospitalization)
Mood: cheerful and expansive, underlying irritability that surfaces
rapidly when wishes and desires go unfulfilled, nature is volatile
and fluctuating
Cognition and Perception: idea of self being of great worth and
ability, thinking flighty, rapid flow of ideas, easily distracted by
irrelevant stimulation so that goal-directed activities are difficult
Activity and behavior: increased motor activity, very extroverted
and sociable – therefore many acquaintances but not many close
friendships, talk and laugh a lot loudly and inappropriately, horny,
some anorexic, may phone the President or over spend on credit
cards
Stage II – Acute Mania
(marked impairment in functioning, requires hospitalization, may get so hyper will die from sleep deprivation)
Mood: euphoria and elation, on continuous “high”, but subject to frequent variation, can go to irritable and
angry to sad and crying
Cognition and Perception: racing and disjointed thinking, flight of ideas (if severe may be incoherent),
pressured speech, distractibility is all-pervasive, hallucinations and delusions (usually of grandeur and paranoia)
Activity and behavior: psychomotor activity is excessive, increased horniness, poor impulse control, may be
sexually uninhibited, excessive spending, ability to manipulate others to carry out wishes, skillfully projects
responsibility of failure to others, energy is inexhaustible, need for sleep is diminished, hygiene may be
neglected, dress may be neglected, flamboyant, or bizarre, excessive use of make-up and jewelry
Assess the clinical picture – behavior on the unit
What are the nursing priorities?
Limit setting-how to handle the pt with mania
Safety and physiologically
How do you manage and prioritize, safety and
take care of psych & physio needs
Stage III – Delirious Mania
(grave for of disorder)
Mood: very labile, despair then quickly to unrestrained merriment and ecstasy, then irritable, or totally
indifferent, may have panic anxiety
Cognition and Perception: clouding of consciousness, confusion, disorientation and sometimes stupor,
religiosity, delusions of grandeur or persecution, auditory and visual hallucinations, extremely distractible,
incoherent
Activity and behavior: frenzied psychomotor activity, agitated purposeless movements, exhaustion, injury to
self, or death without intervention
Prioritize these diagnoses by Maslow’s Hierarchy of needs. Another big part of the intervention for manic
patients is to educate them about meds --- see lithium below. Also teach about causes and symptoms of mania
to pt and family, along with assertiveness and anger management, crisis hotline, support groups, psychotherapy
and financial assistance.
Lithium - 4 questions
Toxic levels and their side effects
Patient teaching
N/D-Potential for injury-What is the
nurses responsibility in terms of injury?
Lithium – Antimanic Mood Stabilizer –
Nursing Diagnosis
Risk for injury r/t
hyperactivity
Risk for violence – self &
others r/t manic excitement,
delusions, hallucinations
Imbalance nutrition – less than
req r/t refusal to sit still & eat
Disturbed thought process r/t
biochem. alt. in brain AEB
delusions
Disturbed sensory perception
r/t biochem. Alt. in brain AEB
hallucinations
Impaired social interaction r/t
egocentric, narcissistic
behavior AEB no friends
Disturbed sleep pattern r/t
excessive hyperactivity
Outcomes
Pt exhibits no injury
Pt has not harmed anyone
Pt exhibits no agitation
Pt eats well balanced diet
Pt verbalizes accurate
interpretation of environment
Pt verbalizes hallu. have stopped
Pt accepts resps for behavior
Pt does not manipulate others
Pt interacts appropriately
Pt is able to fall asleep in 30 min
Pt is able to sleep 8 hours
Interventions
Reduce stimuli, private room, noise low,
remove hazards, stay with pt, provide phys.
activities, admin tranquilizers
Reduce stimuli, ck q 15 min, remove
hazards, physical activity, maintain calm
attitude, have enough staff to show
strength, admin tranquilizers, restraints
Provide high-protein & calorie snacks for
eating on the run (finger food), snacks
available at all times, record I & O’s, have
favorite food, admin vit & minerals, walk
or sit w/client while eating
Assist client to define and test reality
Assist client to define and test reality
Ignore charm or arguments, set limits on
violations, positive reinforcement on non-
manipulative behavior, help client identify
his/her good aspects
Used for prevention and treatment of manic episodes of
bipolar disorders. Also used for bipolar depression.
Unlabeled uses: major depression, neutropenia (abnormally
small amt of neutrophils in the blood), cluster or migraine
headache prophylaxis, alcohol dependence
How does it work – may enhance
reuptake of norepinephrine and
serotonin – may take 1-3 weeks to
decrease symptoms
Contraindications – hypertension, cardiac or renal disease,
dehydration, sodium depletion, brain damage, preg and lact.
caution w/ thyroid disorders, diabetes, urinary retention,
history of seizures, and elderly
Dose
For acute mania 1800-2400 mg/daily, For maintenance 900-1200 mg/daily
Therapeutic Plasma Range
For acute mania – 1.0-1.5 mEq/L, For maintenance – 0.6-1.2mEq/L
#1 Nursing Diagnosis with any patient on Lithium is Risk for Injury r/t lithium toxicity
MEDS (20 questions)
How do you treat:
Anxiety – antianxiety drugs or anxiolitics (aka minor tranquilizers)
Because ?
The therapeutic range is VERY
narrow! Therefore, serum
lithium levels s/b checked once
or twice a week until serum
levels are stable, then monthly
during maintenance therapy.
Blood draws s/b drawn 12 hrs
after last dose.
Teach pt & family about follow
up blood checks!!!
Because ?
Lithium is chemically similar to sodium in the
body. If you loose sodium (by vomiting,
diarrhea, sodium restriction due to diet,
dehydration, sweating, fever, diuresis) the lithium
will replace sodium in the blood increasing serum
lithium levels causing toxicity.
Teach pt & family about sodium and to avoid
excess or strenuous exercise, notify Dr w/
vomiting or diarrhea, eat right!!!
Recognize Lithium Toxicity:
Mild toxicity – levels 1.5-2.0 mEq/L
Blurred vision, ataxia (loss of muscle coordination), tinnitus, persistent nausea &
vomiting, severe diarrhea
Moderate toxicity – levels of 2.0-3.5 mEq/L
 Excessive dilute urine, increasing tremors, muscular irritability, psychomotor retardation,
mental confusion, giddiness
 Severe toxicity – levels above 3.5 mEq/L
Impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias,
myocardial infarction, cardiovascular collapse
So recognize these! Teach patient to recognize these! Teach family to recognize these!
If you see them, if patient says he/she has them, HOLD one med (don’t stop abruptly),
check lithium levels and notify physician if levels are above 1.5 mEq/L.
What are the anxiolitics?
Atarax, vistaril
Xanax
Librium
Klonopin
Tranxene benzodiazepines
Valium
Ativan
Serax
Miltown
Buspar
What should we remember about theses anxiolitics?
They’re CNS depressants
o So makes pt drowsy, confused, lethargic
o Alcohol is CNS depressant too
Work by GABA potentiating
They act immediately
o so may be ordered as PRN meds
They are very addictive
o So don’t give drug addicts, just be new
addiction
Pt gets dependence, builds tolerance – therefore must
be tapered off
o do not stop abruptly
Orthostatic hypertension
o dangle
What should we remember about
this anxiolitics?
Takes 2.5-3.5 half lives or
weeks to be effective
o So not a PRN
Does not depress CNS
Must be tapered off this med
How do you treat:
Depression – antidepression drugs or antidrepressants
SSRI’s, MAOI’s, Trycyclics, others
What are the
SSRI‟s?
Celexa
Prozac, Sarafem
Luvox
Lexapro
Paxil
Zoloft
What are the
MAOI‟s?
Marplan
Nardil
Parnate
What are MAOI‟s?
Monoamine oxidase is an enzyme that destroys or inactivates unused monoamine
neurotransmitters in the synaptic cleft. A monoamine is dopamine, epinephrine,
norepinephrine, histamine, serotonin, melatonin, and more. Therefore, a MAOI or
monoamine oxidase inhibitor stops this enzyme leaving more of these amines available
in the brain to do their job.
What has tyramine?
Aged cheese, raisin, wines,
smoked or processed meat,
caviar, corned beef, liver,
soy sauce, brewer’s yeast,
yogurt, sour cream, beer,
coffee, tea, chocolate,
bouillon, figs, all alcohol
What are SSRI‟s?
These drugs inhibit the reuptake of excess serotonin in the synaptic cleft.
Serotonin is thought to be needed for a happy and well mood. Therefore, the
SSRI or selective serotonin reuptake inhibitor leaves more serotonin in the
body to do its job.
What teaching goes with SSRI‟?
Serotonin syndrome is a possibility if concurrent
w/other serotonin increasing antidepressants
Taper off these meds or pt may get discontinuation
syndrome which presents with flu-like symptoms
Insomnia is fairly common
o Also headache, weight loss, sexual dysfunction,
GI distress, ^ BP, ^ HR
What are things to remember about antidepressants in general (applied to all)?
A patient with bad or vegetative depression with not have energy to carry out suicide, but as these
antidepressants start to do their job but have not quite brought the patient to a happy mood, they
will have enough of an energy increase to carry out suicide. Therefore, a nursing diagnosis for any
patient starting antidepressants is Risk for Suicide.
All antidepressants cause dry mouth, sedation, nausea, discontinuation syndrome.
Symptoms of Serotonin
syndrome:
Mental status changes,
restlessness, myoclonus,
hyperreflexia,
tachycardia, labile blood
pressure, diaphoresis,
shivering, tremors
Teaching for all antidepressants:
 Don’t drink with antidepressants
 Don’t stop taking meds abruptly
 Don’t stop because your symptoms went away
 Usually takes 4 weeks for drug to take effect
 Always carry a card with your drug information on it
What teaching that goes with MAOI‟s?
Can’t take them with other antidepressants
o If switch, must be 2-3 wk period
between
Will have a hypertensive crisis with:
o Foods with tyramine
Ethnopharmacology exists for
Blacks and Asians. They
will probably get started on a
lower than typical dose.
These all work in different ways
Ludiomil (maprotiline) and Remeron (mirtazapine) have anticholinergic side
effects
They all have sedative effects exception Zyban,Wellbutrin (bupropion)
Desyrel (trazodone) can give you priapism – prolonged or inappropriate erection
(hold meds and contact physician immediately)
Serzone (nefazodone) may cause life-threatening liver failure (report jaundice,
anorexia, GI complaints, or malaise immediately). FDA has put a black box warning
on this drug for that reason.
Remeron (mirtazapine) causes patient to gain weight
How do you treat:
Mood Disorder – mood stabilizing drugs or
antipsychotic mood stabilizers
What are the
Tricyclid‟s?
Elavil, Endep
Asendin
Anafranil
Norparmin
Sinequan
Tofranil
Aventyl, Pamelor
Vivactil
Sumontil
What are the
“other‟s”?
Zyban, Wellbutrin
Ludiomil
Remeron
Desyrel
Serzone
Effexor
Cymbalta
What are Tricyclid‟s (TCA)?
These are the bad guys. They do many things: inhibit the reuptake of serotonin, and
norepinephrine, block alpha1 receptors, Ach receptors, histamine1 receptors
histamine1 function
Ileum contractions
Modulate circadian
cycle
Systemic vasodilation
Bronchoconstriction
alpha1 function
Smooth muscle contraction,
includes vasoconstriction – so
you get orthostatic
hypotension
Blocking the Ach receptor causes
anticholinergic side effects:
Patients only get one
week’s worth of these
prescribed at one time
because they are so
dangerous and good to
use for suicide
Other side effect from
TCA’s:
Sedation
Weight gain
Cardiac arrhythmias
What are they?
There are 4 different kinds of mood stabilizing drugs:
Antimanic:
Lithium
Antipsychotic:
Zyprexa Risperdal
Abilify Geodon
Thorazine
Seroquel
Anticonvulsant:
Klonopin
Tegretol
Depakene, Depakote
Lamictal
Neurontin
Topamax
Calcium Channel
Blocker:
Calan, Isoptin
(Verapamil)
Asendin
has high
risk for
EPS
How do you treat:
 Schizophrenia – antipsychotic drugs
What to remember about mood stabilizing drugs?
 Lithium is the oldest and most often used mood stabilizer. Is often used with other mood
stabilizing drugs
 Lamictal (lomotrigene) causes an increased risk of Stevens Johnson Syndrome
 Depakene, Depadote (valproic acid) causes and increased risk of prolonged bleeding time
 Antipsychotic drugs used for mood stabilization have the „anticholinergic‟ and „EPS‟ side effects

What are the antipsychotic drugs (aka neuroleptic)?
Three types according to Ms. Nelson
What is Stevens Johnson Syndrome?
 Another kind of SJS is Toxic Epidermal Necrolysis (TEN)
 It is a severe adverse reaction to drugs which is a rash on the mucous
membranes
 Starts out with
o Flu symptom
o Blisters in mouth, eyes, ears, nose
o Burning during urination
 Stop the meds immediate at first signs of blister
 Literature as links to NSAIDS and carbamazepine (tegretol)
1st
generation – targeted the
positive symptoms
Phenothiazines – chemical
class:
Thorazine (chlorpromazine)
Prolixin (fluphenazine)
Trilafon (perphenazine)
Compazine
(prochlorperazine)
Mellaril (thioridanzine)
Stelazine (trifluoperazine)
2nd
generation – targeted
the negative symptoms –
Thioxanthene – chemical
class:
Navane (thiothixene)
Butyrophenone – chemical
class:
Haldol (haloperidol)
Atypical – targeted both
positive and negative
symptoms – Various
chemical classes:
Risperdal (risperidone)
Loxitane (loxapine)
Moban (molindone)
Clozaril (clozapine)
Orap (pimozide)
Zyprexa (olanzapine)
Seroquel (quetiapine)
Geodon (ziprasidone)
Abilify (aripiprozole)
What do we need to remember in general with antipsychotic drugs (applies to all)?
Most work by blocking dopamine receptors with some muscarinic and adrenergic blocking also.
Even with just 8% of the dopamine receptors blocked, Extrapyramidal symptoms (EPS) occur AND this is
the major reason for noncompliance for antipsychotics drugs.
With the muscarinic blocking, Anticholinergic symptoms occur.
With long-term use, Tardive dykinesia is a risk (can be irreversible)
There is a risk of Neuroleptic malignant syndrome (NMS).
Orthostatic hypertension occurs but will usually go away after 3-4 weeks
Hormonal effect occur including: retrograde ejaculation (ejaculation into the bladder), gynecomastia
(large and lactating breast on men), amenorrhea ( no menstrual period for women)
ECG changes or arrhythmia car occur (including prolonged QT interval)
Agranulocytosis can occur
If a diabetic takes antipsychotic drugs their risk of hyperglycemia is increased
These drugs lower the threshold for seizures – so watch pt w/ seizure history closely.
Skin rash, GI upset, sedation, photosensitivity
Clients have to decide whether they
want altered thoughts or altered
body control
Extrapyramidal
symptoms (EPS)
include:
Pseudoparkinsonism
Akinesia
Akathasia
Dystonia
Oculogyrics crisis
Tardive dyskinesia (or dystonia) includes:
Face (tics, blinking, grimacing)
Tongue (chewing, protrusion, tremor, writhing)
Lips (smacking, pursing puckering)
Limbs (toe-tapping, pill rolling, writhing)
Respiratory ( irregular breathing, grunting)
Neuroleptic malignant
syndrome (NMS) symptoms
include:
Parkinsonian muscle rigidity
Hyperpyrexia (107oF)
Autonomic dysfunctions
Tachycardia, Tachypnea,
labile BP, diaphoresis, HTN,
altered consciousness,
urinary increase
Elevated WBC (white blood
count) CPK (creatine kinase)
LFT (liver function test)
EPS’s are fixed with the ABC’S
Artane (anticholinergic)
Benadryl (antihistamine)
Cogentin (anticholinergic)
Symmetrel (dopaminergic
agonist)
Important to
know about
TD’s:
Don’t panic with
mild symptoms
and stop drug
because
patient’s chance
of committing
suicide is great.
TD’s are
potentially
irreversible. They
can be acutely
suppressed with an
increased dose
(Ms. Nelson).
Drug should be
stopped
immediately at
first signs to stop
chance of
permanence
(book).
NMS can be fatal. Stop drug
immediately. Counteract with
Dantrium or Parlodel.
Agranulocytosis is potentially fatal blood disease
where the WBC count false extremely low levels:
 WBC – below 3,000 mm3
(normal is 4,100-10,800 mm3)
 Granulocytes – below 1,500 mm3
It is reversible if caught early.
Symptoms:
 Sore throat
 Fever
 Malaise
Stop meds immediately.
If not, pt may have to have
chemotherapy and be on
neutropenic diet.
What are the things we need to know about specific antipsychotics?
Clozaril (clozapine)
 It makes you drool (hypersalivation) which is embarrassing and a risk for aspiration.
 There is a significant risk for Agranulocytosis with this drug and pt should get blood
draws weekly for the first 6 months and then monthly after that (can get expensive)
 5% of these patients will experience seizures
 It has a very high occurrence of anticholinergic symptoms and sedation, and a high
occurrence of HTN and seizures.
 These things make Clozaril a last line drug – try everything else first.
Geodon (ziprasidone)
 Particularly prone to give patients arrhythmias
Risperdal (risperidone)
Although this drug is atypical and is listed as having low side effect, Ms. Nelson says:
“Risperdal is Haldol in drag and at 2-4 mg it comes out of the closet.”
Haldol has a high occurrence of EPS and Risperdal’s normal dosage is 1-6 mg per day.
Depression/suicide-5 questions
Suicide Assessment
Who is at higher risk? Age group
Who will follow through? Age group
How do you monitor them?
Suicide Assessment
According to our notes in depression:
o Ask “Do you have ideas of suicide?”
o Get a safety contract for them promising that they will tell you before they do
anything to harm themselves
o Other information you would want to assess so that Maslow’s hierarchy of needs
could be handled would be
 Have you gained or lost any weight recently?
 How have you been sleeping lately?
According to the Suicide section of the power points:
o Assess their demographics because all of these increase risk
 Age
3rd
leading cause of death for 15-24
5th
leading cause of death for 25-44
8th
leading cause of death for 45-64
 Gender – men more than women
 Ethnicity – highest whites, then in order Native American, African
American, Hispanic Americans, Asian Americans
 Marital status – single more likely by 50%
 Socioeconomic status – highest and lowest class more than middle
 Occupation – health care professionals and executives more
 Method – presents of fire arms more than overdose
 Religion – with affiliation, risk is lowered
 Family history of suicide – with history more
o Assess for presenting signs or diagnosis of psychiatric disorders – more likely
o Assess for suicide ideations:
 Seriousness of intent
 Plan – do they have a specific plan
 Means – how will they do it and do they have access to that means
 Behavioral clues – have they been giving away possessions, writing suicide
notes, putting financial affairs in order, sudden lift is mood
 Verbal clues – “I want to die”, “I’m going to kill myself”, “This is the last
time you’ll see me”, “I won’t be around much longer”, “I don’t have
anything worth living for”
o Interpersonal support system – do they have one
o Analysis of the suicide crisis
 Precipitating stressors – divorce, recent loss of loved person or anything else
 Relevant history – have they tried suicide before
 Life-stage issues – grief overload
o Family history – relatives that had depression or other
o Coping strategies – has pt handled previous crisis’s, how is this one different
Ms. Nelson:
o White men over the age of 80
have the highest occurrence of
suicide
Ms. Nelson:
Men more
than women
because they
choose a
more lethal
means
How do you monitor?
o Check every 15 minutes.
o With pt starting on antidepressants, look for increased energy, but not mood – likely for suicide
o Remove items that pt might use to harm themselves
o Razors, sharps, cords (phone, extension, equipment, curtain), belts, matches, cigarettes,
window locks, break-proof glass and windows, plastic flatware
Schizophrenia – 15 questions
Describe the clinical picture
Know negative and positive symptoms
The 4 A’a of Schizophrenia
1. Affect
a. Flat
b. Blunt
c. Inappropriate
d. Incongruent
2. Associative Looseness
a. Jumbled illogical thinking
b. Blocking
c. Echolalia
d. Word salad
e. Clang associations
f. Concrete thinking
3. Ambivalent
a. Conflicting thoughts
b. Simultaneously for and
against, like and dislike
4. Autism
a. Delusions
b. Hallucinations
c. Illusions
Classic Symptoms of Schizophrenia
Ideas of Reference
o Misconstruing trivial events or remarks
and giving them personal significance
Persecution
o Think they are being singled out for
harm
Grandeur
o Think they are a powerful, important or
famous person
Somatic
o The body is changing (“I have worms
crawling all over me”)
Jealousy
o One’s spouse is unfaithful
Positive Symptoms:
Hallucinations
o Auditory
o Visual
o Olfactory
o Gustatory
o Tactile
Delusions
o Persecution
o Grandeur
o Reference
o Control or influence
o Somatic
Disorganized thinking or speech
o Loose associations
o Incoherence
o Clang associations
o Word salad
o Neologisms
o Concrete thinking
o Echolalia
o Tangentiality
o Circumstantiality
Disorganized Behavior
o Disheveled appearance
o Inappropriate sexual behavior
o Restless, agitated behavior
o Waxy flexiblity
Negative Symptoms
Affective Flattening
o Unchanging facial expression
o Poor eye contact
o Reduced body language
o Inappropriate affect
o Diminished emotional expression
Alogia (Poverty of Speech)
o Brief, empty responses
o Decreased fluency of speech
o Decreased content of speech
Avolition/Apathy
o Inability to initiate goal-directed
activity
o Little or no interest in work or
social activities
o Impaired grooming/hygiene
Anhedonia
o Absence of pleasure in social
activities
o Diminished intimacy/sexual
interest
Social isolation
Remember, Ms. Nelson said that 1st
generation
psychotropic drugs took away positive symptoms, 2nd
generation took away negative symptoms and atypical
took away both.
Nursing care for client with paranoid schizophrenia, catatonic schizo-monitor nursing care involved.
Pt with altered perception-what is the right thing to say.
Know thought process-
Communications to a Hallucinating Client
Ask directly about hallucinations
Watch for cues that client is
hallucinating
Avoid reacting to hallucinations as if
they are real
Do not negate the client’s experience
o Book says to say “That’s hard
to believe”
Offer you own perception
Focus on reality-based diversions
Be alert to client anxiety
Communications to delusional client
Be open, honest, reliable
Be matter-of-fact calm
Ask to describe
Avoid arguing but interject doubt
Focus on feelings the delusion generates
Once delusion is described, don’t dwell on it
Observe events that trigger delusion
Validate any true part of delusion
With a catatonic client, you should speak to them, describe
what you’re doing just like they could hear you or like you
would speak to any other patient.
In the event that any client’s anxiety level reaches a point where it is thought that he/she might become
dangerous, clear the room of everyone else but the nurse and large techs that indicates a show of strength.
Then you try to calm them by “talking down” with the “one to one”, then give medications as ordered, then the
mechanical restraints, if necessary.
“I understand that it is very scary (or upsetting) for you, but I don’t see it.” per Ms. Nelson. In
words be empathetic but don’t treat it as if real.
The books says to say “that’s hard to believe”.
Associative Looseness: Thinking is characterized by speech in which ideas shift from one
unrelated subject to another. With associative looseness, the individual is unaware that the
topics are unconnected. When the condition is severe, speech may be incoherent.
Neologisms: The psychotic person invents new words, or neologisms, that are meaningless to
others but have symbolic meaning to the psychotic person.
Clang associations: Choice of words is governed by sounds. Clang associations often take the
form of rhyming.
Word salad: A group of words that are put together randomly, without any logical connection.
Concrete Thinking: Concreteness, or literal interpretations of the environment, represents a
regression to an earlier level of cognitive development. Abstract thinking is very difficult.
Circumstantiality: The individual is delayed in reaching the point because of unnecessary &
tedious details. The point or goal is usually met but only w/ numerous interruptions by the
interviewer to keep the person on track of the topic being discussed.
Tangentiality: Tangentiality differs from circumstantiality in that the person never really gets
to the point of the communication. Unrelated topics are introduced, & the original discussion is
lost.
Mutism: The individual’s inability or refusal to speak.
Perseveration: The individual who exhibits perseveration persistently repeats the same word
or idea in response to different questions.
Ideas of reference
Less rigid than “delusions of reference”. An example of an idea of reference is irrationally thinking
that one is being talked about or laughed at by other people.
Types of delusions
Delusions: false personal beliefs, inconsistent w/ the person’s intelligence or cultural background.
The individual continues to have the belief in spite of obvious proof that it is false or irrational.
Delusions are subdivided according to their content.
Delusions of Persecution: The individual feels threatened & believes that others intend to harm or
persecution toward him or her in some way.
Delusions of Grandeur: The individual has a exaggerated feeling of importance, power, knowledge,
or identity.
Delusions of Reference: All events within the environment are referred by t he psychotic person to
himself.
Somatic Delusion: The individual has a false idea about the functioning of his or her body.
Nihilistic Delusion: The individual has a false idea that the self, a part of the self, others, or the
world is nonexistent.
Religiosity: An excessive demonstration of or obsession w/ religious ideas or behavior. The
individual w/ schizophrenia may use religious ideas in an attempt to provide rational meaning &
structure to his or her behavior.
Magical thinking: The individual believes that his or her thoughts or behaviors have control over
specific situations or people. Magical thinking is common in children.
Paranoia: Individuals w/ paranoia have extreme suspiciousness of others & of their actions or
perceived intentions.
Extrapyramidal Symptoms defined:
Dystonia - involuntary muscular movements (spasms) of the face, arms, legs, and neck.
Akathisia
o Objective: Restlessness; an urgent need for movements, fidgeting (normally in the
chest or thighs, can’t be still.
o Subjective: Also a restlessness that is inside and can’t be seen
o These patient’s commit suicide more often because it gets very severe, it usually goes
undiagnosed, or it’s misdiagnosed and the patient is given more meds.
Akinesia Muscular weakness or a loss or partial loss of muscle movement, flaccid.
Pseudo-parkinsonism tremor, shuffling gait, tremor, rigidity, flat affect, absence of arm
swing, very slow movement. Most often occurs in women, elderly, and dehydrated
individual.
Oculogyric crisis An attack of involuntary deviation and fixation of the eyeballs, usually ion
the upward position, lasting several minutes to hours. Get Cogentin, stay with the patient
until it takes effect

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Mania notes and questions

  • 1. What to know on the Exam Mania - 7 questions Mania Several theories: hereditary, possible excess of norepinephrine and dopamine, electrolytes, possible cholinergic or acetylcholine link is also noted with an inadequate amount accounting for mania Signs and symptoms can be described according to three stages Signs and symptoms of mania (listed for children but probably in adults too) Euphoric/expansive mood: extremely happy, silly, or giddy Irritable mood: hostility and rage, often over trivial matters Grandiosity: believes abilities to be better than everyone else’s Decreased need for sleep: may only sleep 4-5 hours per night and wake up feeling rested Pressured speech: loud, intrusive, and difficult to interrupt Racing thoughts: rapid change of topics Distractibility: unable to focus on anything for very long Increase in goal-directed activity/psychomotor agitation: activities become obsessive, increased psychomotor agitation Excessive involvement in pleasurable or risky activities: exhibits behavior that has an erotic, pleasure seeking quality about it Psychosis: may experience hallucinations and delusions Suicidality: may exhibit suicidal behavior during a depressed or mixed episode or when psychotic Stage I – Hypomania (pt enjoys this phase, not a cause for social or occupational impairment, does not require hospitalization) Mood: cheerful and expansive, underlying irritability that surfaces rapidly when wishes and desires go unfulfilled, nature is volatile and fluctuating Cognition and Perception: idea of self being of great worth and ability, thinking flighty, rapid flow of ideas, easily distracted by irrelevant stimulation so that goal-directed activities are difficult Activity and behavior: increased motor activity, very extroverted and sociable – therefore many acquaintances but not many close friendships, talk and laugh a lot loudly and inappropriately, horny, some anorexic, may phone the President or over spend on credit cards Stage II – Acute Mania (marked impairment in functioning, requires hospitalization, may get so hyper will die from sleep deprivation) Mood: euphoria and elation, on continuous “high”, but subject to frequent variation, can go to irritable and angry to sad and crying Cognition and Perception: racing and disjointed thinking, flight of ideas (if severe may be incoherent), pressured speech, distractibility is all-pervasive, hallucinations and delusions (usually of grandeur and paranoia) Activity and behavior: psychomotor activity is excessive, increased horniness, poor impulse control, may be sexually uninhibited, excessive spending, ability to manipulate others to carry out wishes, skillfully projects responsibility of failure to others, energy is inexhaustible, need for sleep is diminished, hygiene may be neglected, dress may be neglected, flamboyant, or bizarre, excessive use of make-up and jewelry Assess the clinical picture – behavior on the unit What are the nursing priorities? Limit setting-how to handle the pt with mania Safety and physiologically How do you manage and prioritize, safety and take care of psych & physio needs Stage III – Delirious Mania (grave for of disorder) Mood: very labile, despair then quickly to unrestrained merriment and ecstasy, then irritable, or totally indifferent, may have panic anxiety Cognition and Perception: clouding of consciousness, confusion, disorientation and sometimes stupor, religiosity, delusions of grandeur or persecution, auditory and visual hallucinations, extremely distractible, incoherent Activity and behavior: frenzied psychomotor activity, agitated purposeless movements, exhaustion, injury to self, or death without intervention
  • 2. Prioritize these diagnoses by Maslow’s Hierarchy of needs. Another big part of the intervention for manic patients is to educate them about meds --- see lithium below. Also teach about causes and symptoms of mania to pt and family, along with assertiveness and anger management, crisis hotline, support groups, psychotherapy and financial assistance. Lithium - 4 questions Toxic levels and their side effects Patient teaching N/D-Potential for injury-What is the nurses responsibility in terms of injury? Lithium – Antimanic Mood Stabilizer – Nursing Diagnosis Risk for injury r/t hyperactivity Risk for violence – self & others r/t manic excitement, delusions, hallucinations Imbalance nutrition – less than req r/t refusal to sit still & eat Disturbed thought process r/t biochem. alt. in brain AEB delusions Disturbed sensory perception r/t biochem. Alt. in brain AEB hallucinations Impaired social interaction r/t egocentric, narcissistic behavior AEB no friends Disturbed sleep pattern r/t excessive hyperactivity Outcomes Pt exhibits no injury Pt has not harmed anyone Pt exhibits no agitation Pt eats well balanced diet Pt verbalizes accurate interpretation of environment Pt verbalizes hallu. have stopped Pt accepts resps for behavior Pt does not manipulate others Pt interacts appropriately Pt is able to fall asleep in 30 min Pt is able to sleep 8 hours Interventions Reduce stimuli, private room, noise low, remove hazards, stay with pt, provide phys. activities, admin tranquilizers Reduce stimuli, ck q 15 min, remove hazards, physical activity, maintain calm attitude, have enough staff to show strength, admin tranquilizers, restraints Provide high-protein & calorie snacks for eating on the run (finger food), snacks available at all times, record I & O’s, have favorite food, admin vit & minerals, walk or sit w/client while eating Assist client to define and test reality Assist client to define and test reality Ignore charm or arguments, set limits on violations, positive reinforcement on non- manipulative behavior, help client identify his/her good aspects Used for prevention and treatment of manic episodes of bipolar disorders. Also used for bipolar depression. Unlabeled uses: major depression, neutropenia (abnormally small amt of neutrophils in the blood), cluster or migraine headache prophylaxis, alcohol dependence How does it work – may enhance reuptake of norepinephrine and serotonin – may take 1-3 weeks to decrease symptoms Contraindications – hypertension, cardiac or renal disease, dehydration, sodium depletion, brain damage, preg and lact. caution w/ thyroid disorders, diabetes, urinary retention, history of seizures, and elderly Dose For acute mania 1800-2400 mg/daily, For maintenance 900-1200 mg/daily Therapeutic Plasma Range For acute mania – 1.0-1.5 mEq/L, For maintenance – 0.6-1.2mEq/L
  • 3. #1 Nursing Diagnosis with any patient on Lithium is Risk for Injury r/t lithium toxicity MEDS (20 questions) How do you treat: Anxiety – antianxiety drugs or anxiolitics (aka minor tranquilizers) Because ? The therapeutic range is VERY narrow! Therefore, serum lithium levels s/b checked once or twice a week until serum levels are stable, then monthly during maintenance therapy. Blood draws s/b drawn 12 hrs after last dose. Teach pt & family about follow up blood checks!!! Because ? Lithium is chemically similar to sodium in the body. If you loose sodium (by vomiting, diarrhea, sodium restriction due to diet, dehydration, sweating, fever, diuresis) the lithium will replace sodium in the blood increasing serum lithium levels causing toxicity. Teach pt & family about sodium and to avoid excess or strenuous exercise, notify Dr w/ vomiting or diarrhea, eat right!!! Recognize Lithium Toxicity: Mild toxicity – levels 1.5-2.0 mEq/L Blurred vision, ataxia (loss of muscle coordination), tinnitus, persistent nausea & vomiting, severe diarrhea Moderate toxicity – levels of 2.0-3.5 mEq/L  Excessive dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness  Severe toxicity – levels above 3.5 mEq/L Impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, cardiovascular collapse So recognize these! Teach patient to recognize these! Teach family to recognize these! If you see them, if patient says he/she has them, HOLD one med (don’t stop abruptly), check lithium levels and notify physician if levels are above 1.5 mEq/L. What are the anxiolitics? Atarax, vistaril Xanax Librium Klonopin Tranxene benzodiazepines Valium Ativan Serax Miltown Buspar What should we remember about theses anxiolitics? They’re CNS depressants o So makes pt drowsy, confused, lethargic o Alcohol is CNS depressant too Work by GABA potentiating They act immediately o so may be ordered as PRN meds They are very addictive o So don’t give drug addicts, just be new addiction Pt gets dependence, builds tolerance – therefore must be tapered off o do not stop abruptly Orthostatic hypertension o dangle What should we remember about this anxiolitics? Takes 2.5-3.5 half lives or weeks to be effective o So not a PRN Does not depress CNS Must be tapered off this med
  • 4. How do you treat: Depression – antidepression drugs or antidrepressants SSRI’s, MAOI’s, Trycyclics, others What are the SSRI‟s? Celexa Prozac, Sarafem Luvox Lexapro Paxil Zoloft What are the MAOI‟s? Marplan Nardil Parnate What are MAOI‟s? Monoamine oxidase is an enzyme that destroys or inactivates unused monoamine neurotransmitters in the synaptic cleft. A monoamine is dopamine, epinephrine, norepinephrine, histamine, serotonin, melatonin, and more. Therefore, a MAOI or monoamine oxidase inhibitor stops this enzyme leaving more of these amines available in the brain to do their job. What has tyramine? Aged cheese, raisin, wines, smoked or processed meat, caviar, corned beef, liver, soy sauce, brewer’s yeast, yogurt, sour cream, beer, coffee, tea, chocolate, bouillon, figs, all alcohol What are SSRI‟s? These drugs inhibit the reuptake of excess serotonin in the synaptic cleft. Serotonin is thought to be needed for a happy and well mood. Therefore, the SSRI or selective serotonin reuptake inhibitor leaves more serotonin in the body to do its job. What teaching goes with SSRI‟? Serotonin syndrome is a possibility if concurrent w/other serotonin increasing antidepressants Taper off these meds or pt may get discontinuation syndrome which presents with flu-like symptoms Insomnia is fairly common o Also headache, weight loss, sexual dysfunction, GI distress, ^ BP, ^ HR What are things to remember about antidepressants in general (applied to all)? A patient with bad or vegetative depression with not have energy to carry out suicide, but as these antidepressants start to do their job but have not quite brought the patient to a happy mood, they will have enough of an energy increase to carry out suicide. Therefore, a nursing diagnosis for any patient starting antidepressants is Risk for Suicide. All antidepressants cause dry mouth, sedation, nausea, discontinuation syndrome. Symptoms of Serotonin syndrome: Mental status changes, restlessness, myoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis, shivering, tremors Teaching for all antidepressants:  Don’t drink with antidepressants  Don’t stop taking meds abruptly  Don’t stop because your symptoms went away  Usually takes 4 weeks for drug to take effect  Always carry a card with your drug information on it What teaching that goes with MAOI‟s? Can’t take them with other antidepressants o If switch, must be 2-3 wk period between Will have a hypertensive crisis with: o Foods with tyramine Ethnopharmacology exists for Blacks and Asians. They will probably get started on a lower than typical dose.
  • 5. These all work in different ways Ludiomil (maprotiline) and Remeron (mirtazapine) have anticholinergic side effects They all have sedative effects exception Zyban,Wellbutrin (bupropion) Desyrel (trazodone) can give you priapism – prolonged or inappropriate erection (hold meds and contact physician immediately) Serzone (nefazodone) may cause life-threatening liver failure (report jaundice, anorexia, GI complaints, or malaise immediately). FDA has put a black box warning on this drug for that reason. Remeron (mirtazapine) causes patient to gain weight How do you treat: Mood Disorder – mood stabilizing drugs or antipsychotic mood stabilizers What are the Tricyclid‟s? Elavil, Endep Asendin Anafranil Norparmin Sinequan Tofranil Aventyl, Pamelor Vivactil Sumontil What are the “other‟s”? Zyban, Wellbutrin Ludiomil Remeron Desyrel Serzone Effexor Cymbalta What are Tricyclid‟s (TCA)? These are the bad guys. They do many things: inhibit the reuptake of serotonin, and norepinephrine, block alpha1 receptors, Ach receptors, histamine1 receptors histamine1 function Ileum contractions Modulate circadian cycle Systemic vasodilation Bronchoconstriction alpha1 function Smooth muscle contraction, includes vasoconstriction – so you get orthostatic hypotension Blocking the Ach receptor causes anticholinergic side effects: Patients only get one week’s worth of these prescribed at one time because they are so dangerous and good to use for suicide Other side effect from TCA’s: Sedation Weight gain Cardiac arrhythmias What are they? There are 4 different kinds of mood stabilizing drugs: Antimanic: Lithium Antipsychotic: Zyprexa Risperdal Abilify Geodon Thorazine Seroquel Anticonvulsant: Klonopin Tegretol Depakene, Depakote Lamictal Neurontin Topamax Calcium Channel Blocker: Calan, Isoptin (Verapamil) Asendin has high risk for EPS
  • 6. How do you treat:  Schizophrenia – antipsychotic drugs What to remember about mood stabilizing drugs?  Lithium is the oldest and most often used mood stabilizer. Is often used with other mood stabilizing drugs  Lamictal (lomotrigene) causes an increased risk of Stevens Johnson Syndrome  Depakene, Depadote (valproic acid) causes and increased risk of prolonged bleeding time  Antipsychotic drugs used for mood stabilization have the „anticholinergic‟ and „EPS‟ side effects  What are the antipsychotic drugs (aka neuroleptic)? Three types according to Ms. Nelson What is Stevens Johnson Syndrome?  Another kind of SJS is Toxic Epidermal Necrolysis (TEN)  It is a severe adverse reaction to drugs which is a rash on the mucous membranes  Starts out with o Flu symptom o Blisters in mouth, eyes, ears, nose o Burning during urination  Stop the meds immediate at first signs of blister  Literature as links to NSAIDS and carbamazepine (tegretol) 1st generation – targeted the positive symptoms Phenothiazines – chemical class: Thorazine (chlorpromazine) Prolixin (fluphenazine) Trilafon (perphenazine) Compazine (prochlorperazine) Mellaril (thioridanzine) Stelazine (trifluoperazine) 2nd generation – targeted the negative symptoms – Thioxanthene – chemical class: Navane (thiothixene) Butyrophenone – chemical class: Haldol (haloperidol) Atypical – targeted both positive and negative symptoms – Various chemical classes: Risperdal (risperidone) Loxitane (loxapine) Moban (molindone) Clozaril (clozapine) Orap (pimozide) Zyprexa (olanzapine) Seroquel (quetiapine) Geodon (ziprasidone) Abilify (aripiprozole) What do we need to remember in general with antipsychotic drugs (applies to all)? Most work by blocking dopamine receptors with some muscarinic and adrenergic blocking also. Even with just 8% of the dopamine receptors blocked, Extrapyramidal symptoms (EPS) occur AND this is the major reason for noncompliance for antipsychotics drugs. With the muscarinic blocking, Anticholinergic symptoms occur. With long-term use, Tardive dykinesia is a risk (can be irreversible) There is a risk of Neuroleptic malignant syndrome (NMS). Orthostatic hypertension occurs but will usually go away after 3-4 weeks Hormonal effect occur including: retrograde ejaculation (ejaculation into the bladder), gynecomastia (large and lactating breast on men), amenorrhea ( no menstrual period for women) ECG changes or arrhythmia car occur (including prolonged QT interval) Agranulocytosis can occur If a diabetic takes antipsychotic drugs their risk of hyperglycemia is increased These drugs lower the threshold for seizures – so watch pt w/ seizure history closely. Skin rash, GI upset, sedation, photosensitivity Clients have to decide whether they want altered thoughts or altered body control
  • 7. Extrapyramidal symptoms (EPS) include: Pseudoparkinsonism Akinesia Akathasia Dystonia Oculogyrics crisis Tardive dyskinesia (or dystonia) includes: Face (tics, blinking, grimacing) Tongue (chewing, protrusion, tremor, writhing) Lips (smacking, pursing puckering) Limbs (toe-tapping, pill rolling, writhing) Respiratory ( irregular breathing, grunting) Neuroleptic malignant syndrome (NMS) symptoms include: Parkinsonian muscle rigidity Hyperpyrexia (107oF) Autonomic dysfunctions Tachycardia, Tachypnea, labile BP, diaphoresis, HTN, altered consciousness, urinary increase Elevated WBC (white blood count) CPK (creatine kinase) LFT (liver function test) EPS’s are fixed with the ABC’S Artane (anticholinergic) Benadryl (antihistamine) Cogentin (anticholinergic) Symmetrel (dopaminergic agonist) Important to know about TD’s: Don’t panic with mild symptoms and stop drug because patient’s chance of committing suicide is great. TD’s are potentially irreversible. They can be acutely suppressed with an increased dose (Ms. Nelson). Drug should be stopped immediately at first signs to stop chance of permanence (book). NMS can be fatal. Stop drug immediately. Counteract with Dantrium or Parlodel. Agranulocytosis is potentially fatal blood disease where the WBC count false extremely low levels:  WBC – below 3,000 mm3 (normal is 4,100-10,800 mm3)  Granulocytes – below 1,500 mm3 It is reversible if caught early. Symptoms:  Sore throat  Fever  Malaise Stop meds immediately. If not, pt may have to have chemotherapy and be on neutropenic diet. What are the things we need to know about specific antipsychotics? Clozaril (clozapine)  It makes you drool (hypersalivation) which is embarrassing and a risk for aspiration.  There is a significant risk for Agranulocytosis with this drug and pt should get blood draws weekly for the first 6 months and then monthly after that (can get expensive)  5% of these patients will experience seizures  It has a very high occurrence of anticholinergic symptoms and sedation, and a high occurrence of HTN and seizures.  These things make Clozaril a last line drug – try everything else first. Geodon (ziprasidone)  Particularly prone to give patients arrhythmias Risperdal (risperidone) Although this drug is atypical and is listed as having low side effect, Ms. Nelson says: “Risperdal is Haldol in drag and at 2-4 mg it comes out of the closet.” Haldol has a high occurrence of EPS and Risperdal’s normal dosage is 1-6 mg per day.
  • 8. Depression/suicide-5 questions Suicide Assessment Who is at higher risk? Age group Who will follow through? Age group How do you monitor them? Suicide Assessment According to our notes in depression: o Ask “Do you have ideas of suicide?” o Get a safety contract for them promising that they will tell you before they do anything to harm themselves o Other information you would want to assess so that Maslow’s hierarchy of needs could be handled would be  Have you gained or lost any weight recently?  How have you been sleeping lately? According to the Suicide section of the power points: o Assess their demographics because all of these increase risk  Age 3rd leading cause of death for 15-24 5th leading cause of death for 25-44 8th leading cause of death for 45-64  Gender – men more than women  Ethnicity – highest whites, then in order Native American, African American, Hispanic Americans, Asian Americans  Marital status – single more likely by 50%  Socioeconomic status – highest and lowest class more than middle  Occupation – health care professionals and executives more  Method – presents of fire arms more than overdose  Religion – with affiliation, risk is lowered  Family history of suicide – with history more o Assess for presenting signs or diagnosis of psychiatric disorders – more likely o Assess for suicide ideations:  Seriousness of intent  Plan – do they have a specific plan  Means – how will they do it and do they have access to that means  Behavioral clues – have they been giving away possessions, writing suicide notes, putting financial affairs in order, sudden lift is mood  Verbal clues – “I want to die”, “I’m going to kill myself”, “This is the last time you’ll see me”, “I won’t be around much longer”, “I don’t have anything worth living for” o Interpersonal support system – do they have one o Analysis of the suicide crisis  Precipitating stressors – divorce, recent loss of loved person or anything else  Relevant history – have they tried suicide before  Life-stage issues – grief overload o Family history – relatives that had depression or other o Coping strategies – has pt handled previous crisis’s, how is this one different Ms. Nelson: o White men over the age of 80 have the highest occurrence of suicide Ms. Nelson: Men more than women because they choose a more lethal means How do you monitor? o Check every 15 minutes. o With pt starting on antidepressants, look for increased energy, but not mood – likely for suicide o Remove items that pt might use to harm themselves o Razors, sharps, cords (phone, extension, equipment, curtain), belts, matches, cigarettes, window locks, break-proof glass and windows, plastic flatware
  • 9. Schizophrenia – 15 questions Describe the clinical picture Know negative and positive symptoms The 4 A’a of Schizophrenia 1. Affect a. Flat b. Blunt c. Inappropriate d. Incongruent 2. Associative Looseness a. Jumbled illogical thinking b. Blocking c. Echolalia d. Word salad e. Clang associations f. Concrete thinking 3. Ambivalent a. Conflicting thoughts b. Simultaneously for and against, like and dislike 4. Autism a. Delusions b. Hallucinations c. Illusions Classic Symptoms of Schizophrenia Ideas of Reference o Misconstruing trivial events or remarks and giving them personal significance Persecution o Think they are being singled out for harm Grandeur o Think they are a powerful, important or famous person Somatic o The body is changing (“I have worms crawling all over me”) Jealousy o One’s spouse is unfaithful Positive Symptoms: Hallucinations o Auditory o Visual o Olfactory o Gustatory o Tactile Delusions o Persecution o Grandeur o Reference o Control or influence o Somatic Disorganized thinking or speech o Loose associations o Incoherence o Clang associations o Word salad o Neologisms o Concrete thinking o Echolalia o Tangentiality o Circumstantiality Disorganized Behavior o Disheveled appearance o Inappropriate sexual behavior o Restless, agitated behavior o Waxy flexiblity Negative Symptoms Affective Flattening o Unchanging facial expression o Poor eye contact o Reduced body language o Inappropriate affect o Diminished emotional expression Alogia (Poverty of Speech) o Brief, empty responses o Decreased fluency of speech o Decreased content of speech Avolition/Apathy o Inability to initiate goal-directed activity o Little or no interest in work or social activities o Impaired grooming/hygiene Anhedonia o Absence of pleasure in social activities o Diminished intimacy/sexual interest Social isolation Remember, Ms. Nelson said that 1st generation psychotropic drugs took away positive symptoms, 2nd generation took away negative symptoms and atypical took away both.
  • 10. Nursing care for client with paranoid schizophrenia, catatonic schizo-monitor nursing care involved. Pt with altered perception-what is the right thing to say. Know thought process- Communications to a Hallucinating Client Ask directly about hallucinations Watch for cues that client is hallucinating Avoid reacting to hallucinations as if they are real Do not negate the client’s experience o Book says to say “That’s hard to believe” Offer you own perception Focus on reality-based diversions Be alert to client anxiety Communications to delusional client Be open, honest, reliable Be matter-of-fact calm Ask to describe Avoid arguing but interject doubt Focus on feelings the delusion generates Once delusion is described, don’t dwell on it Observe events that trigger delusion Validate any true part of delusion With a catatonic client, you should speak to them, describe what you’re doing just like they could hear you or like you would speak to any other patient. In the event that any client’s anxiety level reaches a point where it is thought that he/she might become dangerous, clear the room of everyone else but the nurse and large techs that indicates a show of strength. Then you try to calm them by “talking down” with the “one to one”, then give medications as ordered, then the mechanical restraints, if necessary. “I understand that it is very scary (or upsetting) for you, but I don’t see it.” per Ms. Nelson. In words be empathetic but don’t treat it as if real. The books says to say “that’s hard to believe”. Associative Looseness: Thinking is characterized by speech in which ideas shift from one unrelated subject to another. With associative looseness, the individual is unaware that the topics are unconnected. When the condition is severe, speech may be incoherent. Neologisms: The psychotic person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the psychotic person. Clang associations: Choice of words is governed by sounds. Clang associations often take the form of rhyming. Word salad: A group of words that are put together randomly, without any logical connection. Concrete Thinking: Concreteness, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development. Abstract thinking is very difficult. Circumstantiality: The individual is delayed in reaching the point because of unnecessary & tedious details. The point or goal is usually met but only w/ numerous interruptions by the interviewer to keep the person on track of the topic being discussed. Tangentiality: Tangentiality differs from circumstantiality in that the person never really gets to the point of the communication. Unrelated topics are introduced, & the original discussion is lost. Mutism: The individual’s inability or refusal to speak. Perseveration: The individual who exhibits perseveration persistently repeats the same word or idea in response to different questions.
  • 11. Ideas of reference Less rigid than “delusions of reference”. An example of an idea of reference is irrationally thinking that one is being talked about or laughed at by other people. Types of delusions Delusions: false personal beliefs, inconsistent w/ the person’s intelligence or cultural background. The individual continues to have the belief in spite of obvious proof that it is false or irrational. Delusions are subdivided according to their content. Delusions of Persecution: The individual feels threatened & believes that others intend to harm or persecution toward him or her in some way. Delusions of Grandeur: The individual has a exaggerated feeling of importance, power, knowledge, or identity. Delusions of Reference: All events within the environment are referred by t he psychotic person to himself. Somatic Delusion: The individual has a false idea about the functioning of his or her body. Nihilistic Delusion: The individual has a false idea that the self, a part of the self, others, or the world is nonexistent. Religiosity: An excessive demonstration of or obsession w/ religious ideas or behavior. The individual w/ schizophrenia may use religious ideas in an attempt to provide rational meaning & structure to his or her behavior. Magical thinking: The individual believes that his or her thoughts or behaviors have control over specific situations or people. Magical thinking is common in children. Paranoia: Individuals w/ paranoia have extreme suspiciousness of others & of their actions or perceived intentions. Extrapyramidal Symptoms defined: Dystonia - involuntary muscular movements (spasms) of the face, arms, legs, and neck. Akathisia o Objective: Restlessness; an urgent need for movements, fidgeting (normally in the chest or thighs, can’t be still. o Subjective: Also a restlessness that is inside and can’t be seen o These patient’s commit suicide more often because it gets very severe, it usually goes undiagnosed, or it’s misdiagnosed and the patient is given more meds. Akinesia Muscular weakness or a loss or partial loss of muscle movement, flaccid. Pseudo-parkinsonism tremor, shuffling gait, tremor, rigidity, flat affect, absence of arm swing, very slow movement. Most often occurs in women, elderly, and dehydrated individual. Oculogyric crisis An attack of involuntary deviation and fixation of the eyeballs, usually ion the upward position, lasting several minutes to hours. Get Cogentin, stay with the patient until it takes effect