Psychiatric Nursing

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PSYCHIATRIC NURSING Psychosexual development Theory (Sigmond Freud) • Oral (0-18 mos) – relief of anxiety through oral gratification of needs; security and trust • Anal (18mos- 3 yrs)- learning independence and control • Phallic/ oedipal (3-6yrs)identification with parent of the same sex, development of sexual identity and focus on genital organs • Latency (6-12yrs)- sexually repressed and focus on the rel. with peers of the same sex; superego • Genital (13-20yrs)- libido reawakend as genital organs mature and focus on rel with members of the opposite sex Psychosocial Development Theory (Erikson) • Oral-sensory (0-18 mos)- trust vs mistrust • Musculo-anal (18 mos – 3 yrs)autonomy vs shame & doubt • Locomotor-genital (3-5 yrs)initiative vs guilt • Latency (6-12 yrs)- industry vs inferiority) • Adoloscence (12-18 yrs)- identity vs role confusion • Young adulthood (18-30 yrs)intimacy vs isolation • Adulthood (30-60 yrs)generativity vs stagnation • Maturity (65-above)- ego integrity vs despair Cognitive Development Theory (Piaget) • Sensorimotor (0-2yrs) • Pre--operational (2-6 yrs)language, understanding symbolic

gestures, object permanence, classify objects • Concret operational (6-12 yrs)reversibility and spatiality, application of rules, thinking is concrete • Formal operational (12-15 yrs)- abstract, scientifically, logical thinking, cognitive maturity Moral Reasoning (Kohlberg) Level I Preconventional Level (4-10 yrs) Stage 1: Punishment & obedience orientation “I must follow the rules otherwise I will be punished” Stage 2: Instumental Relativist orientation “I must follow rules for the reward & favor it gives”. Level II: Conventional Level (10-13 yrs) Stage 3: Good-boy-nice-girl “I must follow the rules so I will be accepted” Stage 4: Society maintaining orientation “I must follow rules so there is order in the society” Level III: Conventional Level (adolescents & onwards) Stage 5: Social contract orientation “I must follow rules as there are reasonable laws for it” Stage 6: Universal ethical principle orientation “I must follow rules because my conscience tells me” Healthy Interpersonal Theory (Sullivan) Infancy (birth-onset of language) - Gratification of needs Childhood (onset of language-6yrs) - Language and movement to avoid anxiety

Juvenile (6-9 yrs) - Satisfactory relationships within peer groups Preadolescence (9-12 yrs) - Developing relationships with persons if the same sex Early adolescence (12-14 yrs) - Relationships with member of the opposite sex Late adolescence (14-21 yrs) - Interdependence within the society; lasting, intimate rel. Alterations of Body Image 4 Phases: 1. Impact phase- anger & guilt 2. Retreat phase- regress and deny 3. Acknowledgement phase- focus and strength 4. Reconstruction phase- adapts Best Responses C – clarify and validate behaviors U – use of silence but express presence R – reflect and focus on feelings E – encourage clients to express more fully Distance (Proxemics) Intimate: 0-18” Personal: 18-4 ft. Social: 4-12 ft. Public: 12 ft- above Neurotransmitters Cholinergic: Acetylcholine • First neurotransmitter • Major effector chemical in the ANS • Synthesized by red meat and vegetables • Functions: sleep-wake cycle, coordination of movement, memory acquisition and retention • Inactivated be acetylcholine • ↑: anxiety

• ↓: Alzheimer’s disease,

Huntington’s chorea, Parkinson’s disease and Myasthenia Gravis Monoamines: Norepinephrine • Most prevalent neurotransmitters in the CNS • Function: fight or flight • Inactivated by monoamine oxidase (MAO) and catechomethyltransferase (COMT) • ↑: anxiety, mania and schizophrenia • ↓: memory loss, social withdrawal and depression Dopamine • Complex movements and coordination, sensory integration and voluntary decision making • Inactivated by monoamine oxidase (MAO) and catechomethyltransferase (COMT) • ↑: mania and Schizophrenia • ↓: Parkinson’s Disease and depression Serotonin • Sleep and arousal, libido, appetite, mood • Catabolized by MAO • Contributes to the delusion, hallucination and withdrawn behavior in schizophrenia • ↑: anxiety • ↓: depression Amino Acids: Gamma-amino-butyric-acid (GABA) • Major inhibitory neurotransmitter (CNS) • Interrupts the progression of electrical impulse at the synapse

• Function: slow down of bodily functions and modulates other neurotransmitters • Enhanced by benzodiazepines= calming effect • Catabolized by GABA transaminase • ↓: Huntington’s chorea, anxiety, schizophrenia and various forms of epilepsy Glycine • Function: inhibition of motor neurons and regulation of spinal cord and brainstem reflexes • ↑: glycin encephalopathy • ↓: spastic motor movements Dopamine – Schizophrenia, Parkinson’s and mania Acetylcholine- Alzheimer’s Norepinephrine- Mania GABA- Anxiety disorders Serotonin- Depression and anxiety states

II- Personality disorders and mental retardation III- General Medical Conditions IV- Psychosocial and environment problems V- Global Assessment of Functioning (GAF) Scale- single measure of the individual’s psychological, social, and occupational functioning Psychopharmacology Antidepressants • Major depression ( acute, atypical, bipolar, and dysrhythmic depression) • Anxiety disorders ( panic disorders, OCD, social phobia, generalized anxiety disorder and PTSD) • Therapeutic: lag 2-4 weeks • AVOID ALCOHOL MAOI: third-line agents (PAMATE) Tranylcypromine (PAmate), Maclobemide (MAnerex), Phenelzine (NArdil) • Not used so much because they have potentiollt fatal interactions • Maclobide does not cause hypertensive crisis • The only antidepressant that inhibit neurotransmitter breakdown as their primary mechanism of action • Side effects: CNS (sedation & hyperstimulation, restlessness and euphoria) Cardiovascular (hypotension with no compensatory tachycardia [can lead to heart failure], & orthostatic hypotension), Anticholinergic effects • Hypertensive crisis- results when MAOIs are taken with certain drugs and tyramine-containing foods; presents with geadache, sweating, palpitations, stiff neck, and intracranial hemorrhage

• Phentolamine mesylate (Regitine) TCA: second-line agents (TO NO EL SI) Imipramine (TOfanil), NOrtriptyline (aventyl, palmerol), Amitriptyline (ELavil), Doxepin (SInequan) • Secondary amines- activating antidepressants (norepinephrine) can combat lethargy ( most common symptom of depression • Tertiary amines- sedating antidepressants (serotonin) Side effects: • PNS: anticholinergic effects, cardiac effects ( reflect tachycardia, arrhythmia, heart block, and MI), adrenergic effects ( orthostatic hypertension, prevention of vasoconstriction) • Mydriasis and blurred vision may precipitate acute glaucoma • Amitriptyline is the most cardiotoxic • Improved appetite, urinary hesistancy ( childhood enuresis) • TCA overdose: cathartics or gastric lavage with activated charcoal • Not addicting • Avoid use with: drugs that depress or stimulate CNS, have anticholinergic properties, MAOIs (fatal) • Antidote: Physostigmine (Antilirium) SSRI: first-line agents (PROZOPA) Fluoxetine (PROzac), Sertraline (ZOloft), Paroxetine (PAxil) • Fewer side effects than TCAs • Side effects: GI symptoms, hypernatremia (elderly), CNS (dec. libido, impotence, ejaculatory delay),

akathesia- treated with propanolol (Inderal) or Benzodiazepine • Indicated for bulimia, obesity, and OCD • Taken in AM for 4 weeks for full effect • Antidepressant apathy syndromeinduced by these drugs; presents with lack of motivation, indifference, disinhibition, and poor attention • Fluoxetine (Sarafen) is approved for the treatment of bulimia, premenstrual dysmorphic disorder, pain mgt. and smoking cessation; assoc. w/ suicidal and homicidal behaviors; has long half-life, led likely to cause withdrawal syndrome • Paroxetin indicated for the prevention of depressive relapse; it is teratogenic • Abrupt cessation causes SSRI withdrawal symptoms Serotonin Syndrome • Can occur if combined with MAOIs, St, john’s Wort & Typtophan • SSRI + MAOI = fatal • s/s: mental status changes • discontinue the offending agent: resolves on its own 24h Antipsychotics/ Neuroleptics/ major tranquilizers • SE dizziness • Indicated for schizophrenia, schizoaffective disorder, organic brain syndrome with psychosis and delusional disorder • High Potency: ProHaNaStela - Fluphenazine (Prolixine), Haloperidol (Haldol), Thiothixene (Navane), Triflouperazine (Stelazine) - SE: EPS • Moderate Potency: LoMoTril

• Cerebral cortex- decision

making and abstract reasoning • Limbic System- emotional behavior, memory and learning • Basal ganglia- coordinate involuntary movements to muscle tone • Hypothalamus- regulating pituitary hormones, temperature, appetite, thirst, and libido • Locus ceruleus- norepinephrine • Raphe nuclei- serotonin • Sunstatia nigra- dopamine • Amygdala- EQ DSM-IV-TR Organizational framework I – Clinical disorders and other conditions that may be a focus of clinical attention

-

Perphenazine (Trilafon), Loxapine (Loxitane), Molindone (Moban) • Low Potency: ThoSeTaMe - Chlorpromazine (Thorazine), Thioridazine (Mellari), Taractan, Serentil - SE: mopre intense anticholinergic effects • Thiorazidine is therapeutic in children with severe behavioral problems marked by combativeness • Fluophenazine decanoate (Prolixin decanoate) long-acting form (injectable) of prolixine, lasts 2-3 wks • Parenteral haloperidol alone or in combination with the benzodiazepine lorazepam (Ativan) is used to help aggressive or psychiatric patients stay in control • Haloperidol decanoate is a longacting form can be bgiven at 2-4 wks intervals or longer; px who struggle for compliance • Thioridazine has a minimum upperlimit of 800mg/day bec. Of possible poigmentary retinopathy (dec visual acuity, impairs night vision, and pigmentation deposits in the fundus) • Atypical Antipsaychotics: CloRis - Clozapine (Clorazil), Risperidone (Risperidal - Reduced or no risk for EPS - Increased effectiveness in treating negative and cognitive symptoms: dopamine is increased - Minimal risk of TD - Absence of prolactin-level elevation - Clozapine is the first truly antipsychotic; available in injectable form; proven effective in treating acute mania and bipolar disorder - SE: agranulocytosis (neutrophil < 500/mm3), dose related seizures,

excessive salivation and myocarditis - Risperidone is the most frequently prescribed antipsychotic: injectable long-acting - SE: orthostatic hypertention, sedation, appette stimulation, insomnia, agitation, headache, anxiety, and rhinitis. Higher doses: EPSEs and hyperprolactemia - Olanzapine has a similar side effect with risperidone • New generation antipsychotics - Aripirazole (Abilify)- dopamine system stabilizers; controls symptoms without side effects - Tolerance usually develops be the third month - Dec. dose of drugs - Add a drug to treat EPSE, then taper after 3rd month on the antipsychotic - Use a drug lower EPSE profile • Side effects Sedation Enduce pseudoparkinsonism Dystonia Akathisia, atrophine psychosis Tardive dyskinesia Effects on hormones Bradykinesia Orthostatic hypotension Pisa effect Extrapyramidal side effects • Acute dystonia- acute muscular rigidity - Torticollis- neck - Oculogyric crisis- eyes upward - Writer’s clamp- hand - Laryngeal-pharyngeal spasm (lifethreatening) - Opisthotonus- back  Occurs in males; high potency drugs (haloperidol and thiotixine)  Painful and frightening to the px

 Tx: anticholinergic drugscongentin, Benadryl • Pseudoparkinsonism- shulling gait/festinating gait, coarse pillrolling  Symptoms may appear 1-5 days following initiation of antipsychotic medication  Occurs in women, elderly, dehydrated clients  TX: shifting to an antipsychotic medications with s lower incidence of EPSE or by adding an anticholinergic agent or amantadine (Symmetrl)dopamine antagonist • Akathisia- continuous restlessness, fidgeting, jittery feeling and nervousness  Most common EPSE and responds poorly to TX  TX: change in antipsychotic med. With a lower incidence of EPSE or by adding an oral agent such as beta blocker, anticholinergic, or benzodiazepine • Akinesia and bradykinesia  Akinesia- absence of movement  Badykinesia- slowed movement  Responds to anticholinergics • Pisa syndrome-leaning towards onbe side • Neuroleptic malignant syndrome  Fever, tachycardia,alteredconsciousness, automatic hyperactivity (diaphoresis, pallor)  Potentially lethal  Occur in high-potency antipsychotics (haloperidol) and dehydrated px  Onset within a week  Immediately d/c all drugs

 Dantrolene (Dantrium), Bromocriptine (parlodel) – drug of choice  Antipsychotics should not be reinstituted for 2 wks

Anti-extrapyramidal side effects Congentin (Benztropine) Artane (Trihexyphenidyl) Benadryl (Diphenhydramine HCL) Akineton (Biperiden) Side Effects: • Tardive dyskinesia- stereotyped involuntary movements - Late-appearing and irreversible - Symptoms stops with sleep - Atrophine psychosis - “red as a beet” (flushed face with skin hot to touch without fever) - “dry as a bone” (dehydration) - “mad as a hatter” (altered mental status)  Rereduce / d/c med  Hydration • Sedation • Photosensitivity • Anticholinergic effects  Blurred vision will subside after a few weeks  Alert for aggravation of narrowangle glaucoma, prostatic hypertrophy (difficult urination) &, triggering of arrhythmias that lead to death • Agranulocytosis - Feverm malaise, ulcerative sore throat and leucopenia  Emergency & develops abruptly  Weekly CBC  d/c drug immediately ( when WBC drops below 50% or < 3,000) • seizures • orthostatic hypotension • hormonal effects

Mood Stabilizers L – Lethal if > 3 mEq/L (needs hemodialysis) I – indicated for bipolar disorders T – therapeutic range: 0.6-1.2 mEq/L H – hyponatramia – toxicity I – increase excretion with mannitol and diamox U - uncoordination and coarse hand tremors= early sign of toxicity M – metallic taste and fine hand tremors = normal *Lithium blood level takenv 8-12 hrs after the last dosage *Thiazide and K+ sparing diuretics increases lithium levels Anticonvulsants Carbamazepine (Tegretol), Valproic Acid (Depakene, Depakote), Lamotrigine (Lamictal), Gabapentin (Neuorotin), Topiramate (Topamax), Oxcarbazepine (Trileptal) Second line: Lamotrigine (Lamictal)- FDA approved for bipolar disorder Third line: Carbamazepine (Tegretol) • Divalproex is a derivation of valproic acid (superior therapeutic index + better toxicity profile + effectiveness in bipolar subtypes = surpassed lithium as the most commonly used drug for bipolar) • Lamotrigine- delays onset of mood episodes • Carbamazepine can cause dec of serum levels of other anticonvulsants, benzodiazepines, anticoagulants, and oral contraceptives • Oxcarbazepine- new compound r/t to carbamazepine that does not cause the serious adverse reactions; therapeutic serum level: 15-35 mcg/mL - Kindling occurs when the brain becomes neurochemically

sensitisized in events or the effects of street drugs that eventually seem to cause the brain to spontaneously and dysfunctionally respond in absence of these events - Theorized to cause cyclical illnesses such as bipolar illness and the intermittent symptoms of other illnesses such aspanic attacks or craving of substances  Lamitrogine: dizzinessheadache, double vision, unsteadiness, sedation & uncomplicated rash; it inc. the risk for steven-johnson’s syndrome (fatal)  Divalproex: GI problems (n/v, anorexia, diarrhea), neurological symptoms ( tremor, sedation, headache, dizziness, ataxia), inc appetite, & wt. gain; it thrombocytopenia w/ bruising, petechiae, hematoma, & bleeding = dec. dose  Carbamazepine can cause lethal overdose  Topiramate is the only anticonvulsant mood stabilizer that is not assoc. w/ wt. gain= assoc. w/ wt. loss Calcium Channel Blockers Verapamil (Calan, Isoptin), Nifedipine (Adalat, Procardia), Nimodipine (Nimotop) • Px who have not been responded well to lithium or aniconvulsants will not be likely respond to channel blockers • Best used in bipolar px w/ hypertension or supraventricular arrhythmias, or pregnant bipolar patients bec. Teratogenic risk is much lower *Benzodiazepines and antipsychotics are also used for mood stabilizers in bipolar disorder *Olanzepine is FDA approved for the treatemtn of acute mania

Anxiolytics Benzodiazepines Antianxiety: Alprazolam (Xanax), Chlordiazepoxide (Librium), Clonazepam (Klonopin) Clorazepam (Tranxene), Diazepam (Valium), Halazepam (Paxipam), Lorazepam (Ativan), Oxazepam (Serax), Prazepawm (Centrax) Sedative-hypnotic: Estrazolam (ProSom), Flurazopam (Dalmane), Termazepam (Halcion), Quazepam (Doral) • Not the first line agents for the anxiety DO • 5 major affect: reduces anxiety, promotes sleep, prevents seizures, & produces amnesia • IV diazepam & lorazepam are the first-line agents for status epilepticus & Clonazepam as anticonvulsant • Since benzodiazepines have the same pharmacological effect as alcohol, 6they can be use to suppress alcohol withdrawal syndrome and are the tx of choice for this indication - Alcohol and other CNS depressantinc sedation and CNS depression - Antacids- impaired absorption rate of benzodiazepine - Phnytoin- inc. anticonvu;sant serum level - TCAs- inc sedation, confusion, impaired major function - MAOIs- CNS depression - Succinylcholine- dec. neuromuscular blockage - Lorazepam and oxazepam are the best for elderly - Common side effects: drowsiness, sedation, ataxia, dizziness, Feeling of detachment, inc. irritability or hostility, retrograde amnesia, cognitive effects with long-term use (concentration and memory interference), tolerance,

dependency, rebound insomnia/ anxiety & dec coordination Benzodiazepine Withdrawal Syndrome - Agitation, anorexia, anxiety, autonomic arousal, dizziness, generalized seizures, hallucinations, headache, hyperactivity, insomnia, irritability, n/v, sensitivity to light & sounds, tinnitus, & tremulousness - Paradoxical reactions: agitation, emotional lability, & occasional rage. Children, older adults & px w/ poor impulse control, & organic brain syndrome are most at risk Nonbenzodiazepines Antianxiety: Buspirone (BuSpar), Propanolol (Inderal), Clonidine (Catapres) Sedative-hypnotic: Zolpidem (Ambien), Zalepton (Sonata) Antihistamines: Diphenhydramine (Benadryl), Hydroxyzine (Atarax, Vistaril) Antidepressants: Trazadone (Dysyrel) SSRI: Fluoxetin (Prozac) • SSRIs are the first-line agents for anxiety spectrum DO • Clomipramine (Anafil) and Fluvoxamine (Luvox) are the most effective drug for COD • Buspirone has no addictive potential and FDA approve for GAD; not effective mgt for drug or alcohol withdrawal or panic DO; it takes several wks to take effect - Hazardour in px taking MAOI bec of the elevation of BP - Take w/ food and drink a lot of grapeful fruit • Zolpidem is the firsdt of a new class of compounds for short term tx of insomnia. It is under schedule IV controlled substance. SE: daytime drowsiness, dizziness, & diarrhea • Antihistamines are not as effective as benzodiazepine but they do not cause dependence or abuse and are

OTC. They have lower seizure threshold and cause anxiety in insomnia or some Antidemantia Cholinesterase Inhibitors: • Tacrine (Cognex) is the first cholinesterase inhibitor but is seldom prescribed sice it cuases serious hepatic effects • Donepezil (Aricept) is a reversivle inhibitor of cholinesterase that soes not cauise hepatotoxicity, has a long half-life, ans can ve taken w/ or w/o food; GI problems and bradycardia • Rivestagmine (Exolon) is a irrcersible inhibitoe of cholinesterase (until thr enzyme is complete). Halflife of 2 hrs but inhibition time of 10 hrs; inhibits the action of enzyme cholinesterase (can metabolize 5000 molecules of acethycholine)- inc. availability • Falantamine (Razadyne) anticholinergic effects NDMA antagonist • Memantine (Namenda)- has a long half-life, only w/ a few drugs and has few side effects, co-prescribed w/ donepezil; too much NDMA stimulation= neural death, while too little= psychotic behavior

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