Download Life Span Mental Health Issues

NCLEX-RN PREPARATION
PROGRAM
MENTAL HEALTH
DISORDERS
Module 6, Part 3 of 3
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Pharmacologic Agents and
Mental Illness
Psychotherapeutic drug agents
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Symptomatic treatment
Psychotropic drugs
Effects on neurotransmitters
Lipid-solubility of brain barrier
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Classification of
Drug Agents
Psychotherapeutic drug agents
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Antianxiety agents
Antidepressants
Antimanic agents
Antipsychotic agents
Antiparkinson (anticholinergic) agents
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Drug-Related Information
for the Nurse
Psychotherapeutic drug agents
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Desired therapeutic effect
Side effects
Adverse effects
Normal dosage ranges
Indications for use/contraindications
Nursing diagnoses
Nursing interventions
Client/family teaching
Outcome evaluation
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Antianxiety (Anxiolytic) Agents
Psychotherapeutic drug agents
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Indications for use
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Anxiety and anxiety disorders
Acute alcohol withdrawal
Skeletal muscle spasms
Convulsive and seizure disorders
Status epilepticus
Preoperative sedation
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Therapeutic Antianxiety Agents
Psychotherapeutic drug agents
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Antihistamines
Benzodiazepines
Beta-Adrenergic Blockers
Miscellaneous
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Antidepressants
Psychotherapeutic drug agents
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Indications for use
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Major depression
Dysthymic and bipolar disorders
Childhood disorders
Obsessive-compulsive disorders
ADHD
Panic disorder
Chronic pain
Associated organic diseases
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Antidepressant Drug Agents
Psychotherapeutic drug agents
 Tricyclic antidepressants
 Heterocyclics
 Serotonin-specific Reuptake Inhibitors
(SSRIs)
 Nonselective Reuptake Inhibitors
 Monoamine Oxidase Inhibitors (MAOIs)
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Mood Stabilizing Drug Agents
Psychotherapeutic drug agents
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Indications for use
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Manic episodes associated with bipolar
disorders
Bipolar maintenance therapy
Migraine headaches
Schizoaffective disorders
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Mood Stabilizing Drug Agents
Psychotherapeutic drug agents
 Antimanic
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Lithium carbonate
Anticonvulsants
Calcium-channel blocker
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Antipsychotic Agents
Psychotherapeutic drug agents
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Indications for use
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Acute and chronic psychosis
Mania
Dementia-induced psychosis
Intractable hiccups
Control of tics and vocal disturbances
Adverse reactions and side effects
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Anticholinergic effects
Extrapyramidal side effects
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Life Span Mental Health Issues
12
Family Systems
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Understanding impact of present and past
family patterns of behavior on the choices
we make
Can lead to intentional desire to make
changes and refusal to continue cycle
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Family Systems
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Nuclear family of origin
Includes family history/relationships
Single emotional unit of relationships that
intermingle over generations
Family Dynamics – key to understanding current
behaviors
Tend to seek partners of similar differentiation
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Family Systems: Healthy
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Clear generational lines
Strong parental coalition
Maintenance of marital relationship
Communication is clear, honest, direct,
specific and congruent
Roles clear and not defined by gender
Rules defined and respected
Okay to express ideas that differ
Differences accepted
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Family Systems: Healthy
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Empathy, warmth & caring expressed
Feelings addressed
Level of conflict low and resolved
High self-esteem
Parents make decisions
Healthy lifestyle
Regular exercise & recreation
Absence of dangerous activities
No significant deviance in school or work
performance, or in relationships with others
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Family Systems: Troubled
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Strive to do well
Boundaries appear clear, but when under
pressure
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Turn inward (rigid) or
Problems spill into the environment (disordered,
diffuse)
Links to society may be mistrustful, with limited
input from larger society
Children learn power through manipulation
rather than learning responsibility
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Family Systems: Troubled
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Power may be diffuse and may not come from
parents
Little empathy shown
Conflict over rules & family norms
Caring is controlling rather than growth
producing
Self-esteem low
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Family Systems: Troubled
(continued)
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Parental coalition present, but weak and
ineffective
Parents may reach across generational
boundaries for comfort and support
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“Triangled” often symptom bearer
Overt or covert incestuous situations may be
present
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Family Systems: Troubled
(continued)
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Communication: May not be clear, honest or
specific
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Expressed with fear, guilt or anger
Incongruence between verbal and nonverbal
Disqualification through silence, ignoring,
evasiveness or changing subject
Excessive use of alcohol, nonprescription and
Rx drugs
Eventual dysfunction of one or more family
members
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Family System and Children
 Children are affected by family relationships
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Marital conflict
Fighting
Siblings
Boundaries
Parental psychopathology
Separation/loss: death, divorce, absent parent
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Family Psychoeducation
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Focus on education & support
Works best with family & client with major mental illness
Techniques
 Communication training
 Problem solving
Goals:
 Improve course of the family member’s illness
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 relapse rates
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 client and family functioning
Goals achieved through:
 Educating family about mental illness
 Teaching families techniques to cope
 Reinforcing family strengths
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Commonalities of Family Theories
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Individual symptoms understood in context of
family system
Facilitate interaction & communication among
family members
Family members directed to modify patterns of
their relationships
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Disorders of Infants,
Children and Adolescents
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Etiologic Factors
Etiology
 Genetic
(1st degree biological relative with disorder or family
history of mental issues)
 Environmental
Socioeconomic – neighborhood
Family income
Educational level of family members
 Parental divorce
 Combined factors
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Infancy: Attachment Theory
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Suggests most significant affectional bond between parent
and child
 Essential for healthy emotional development
Disruption
 Parental mental disorder, chemical dependence,
absence
Attachment experiences shape circuitry of brain
 Faulty circuitry leaves child vulnerable to later
emotional dysregulation
 Disruption correlated with development of psych
disorders
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Infancy: Eating Disorders
Pica:
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Eating 1 or more non-nutritive substances for at least 1
month and inappropriate for developmental level
Frequently associated with mental retardation (MR) and
pervasive development disorder (PDD)
Infancy Feeding Disorder
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Persistent failure to eat adequately
Significant failure to gain weight or weight loss for at least 1
month
R/0 medical condition
Temperamental characteristics and parental
psychopathology, child abuse/neglect
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Anxiety Disorders
Anxiety disorders
 Separation Anxiety Disorder - Developmentally
inappropriate excessive anxiety over separation from
home/attachment figures
 Worry about harm to self/parent
 Fear of sleep without attachment person present
 Attention-demanding behavior
Tic Disorders
 Rapid, rhythmic, involuntary movements or vocalizations
 Symptoms accentuated with stress, excitement & fatigue
 Tourette's Syndrome: Worst. Haloperidol (haldol)
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Elimination Disorders
Enuresis:
Bed wetting > 5 years old, 2x/ week for 3
consecutive months
Encopresis:
Stool in inappropriate places, voluntary or
involuntary: 1 incident per month for > 3
months
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Communication Disorders
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Variation in voice, rhythm or articulation
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Impairments in:
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Language expression (limited vocabulary, errors
in tense, difficulty recalling words or producing
sentences with dev. appropriate length)
Understanding language (i.e., words)
Phonology (speech & sound production)
Stuttering (sound & syllable repetition, sound
prolongation, etc.) Evidence for a genetic factor
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Pervasive Developmental Disorders
(PDD)
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Due to a mental and/or physical impairment (or combination)
Diagnosed before age 22, 60% co-existing psychiatric disorder
Functional limitations (in 3 areas):
 Self-care
 Language
 Learning
 Self-direction
 Mobility
 Independent living
 Economic self-sufficiency
May have average or above average IQ
e.g., autistic disorder, down syndrome, seizure disorder
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PDD: Autistic Disorder
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Onset < 2.5 years
75% retarded
Repetitive behavior: rocking, twisting
Upset over changes in routine
Poor coordination
Impaired communication
Lack emotional responsiveness & social
reciprocity
Fail to develop interpersonal skills
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Mental Retardation (MR)
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Diagnosed < age 18. Mild to profound
Sub-average intellectual functioning (IQ 70 or below)
Limitations in 2 or more adaptive skill areas:
 Self-care
 Communication
 Home living
 Self-direction
 Social skills
 Community use
 Academics
 Leisure, work
 Health & safety
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Disorders of Childhood
Motor Skills Disorder
 Motor coordination below expected for age and
measured intelligence
Learning Disorders
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Reading, math or writing skills below that
expected for age, schooling, level of
intelligence
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Behavior Disorders
Attention Deficit/Hyperactivity Disorder
 Dx’d under age 7 w/ > 6 months duration, more frequent
in males
 Problems paying attention & concentrating and/or with
hyperactive & impulsive behavior
 Unable to listen well, organize work and follow directions
 Risk failing at school
 1/3 substance-abuse problems
 Often continues into adulthood
  blood flow & lower levels of electrical activity - requires
more stimulation to feel optimally aroused
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Behavior Disorders: ADHD Tx
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Ritalin (methylphenidate) drug of choice
 Stimulant s availability of norepinephrine
 Helps adults/children  concentration
Other stimulant drugs: Adderall (amphetamine mixture),
Concerta (long acting Ritalin), Dexedrine, Cylert
New route of delivery - patch (good for those with
difficulty swallowing, remove after school)
At risk for stunted bone growth,  BP
 concern about abuse potential
70% respond to stimulants
Antidepressants may help
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Behavior Disorders: ADD/ADHD
Teaching points for ADD/ADHD
• Set clear limits for behavior
• Give positive reinforcement for desired behavior
• Give time out for undesired behavior
• Provide feedback as soon as possible after behavior
• Consistent approach from both parents
• Keep instructions simple
• Ask child to repeat instructions
• Set realistic goals for child’s behavior
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Behavior Disorders: ADD/ADHD
Stimulant Medication–teaching points for parents
• Assess for decreased appetite, weight loss, growth
delays, abuse
• Prevent insomnia–give no later than 6 hours before
bedtime
• Do not stop medication abruptly
• Give at mealtimes if weight loss; offer with favorite
foods
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Behavior Disorders
Oppositional Defiant Disorder (ODD)
Negative, defiant, disobedient, hostile
Argues incessantly without compromise
Defiant refusal to obey rules or laws
Vindictive, spiteful and resentful
Suspension and expulsion from school
Conduct Disorder (CD)
Disruptive, destructive behavior, rules violated, deceitful,
willful defiance, aggression, truancy, cruelty to animals
and people, impairment in social, academic or
occupational functioning
ADHD ODD CD APD
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Childhood Disorders
Many disorders not diagnosed until adulthood
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Substance abuse: Early use (by age 11) predicts more
sustained use
Depressive disorders: Adolescents express in acting out
behaviors to hide vulnerability
Bipolar disorders: Sleep disruption, energetic, grandiosity,
poor judgment
Thought disorders: Hallucinations and delusions less
detailed, delays in speech development, poor eating and
sleeping habits
High rate of co-occurring disorders
40
The nurse is providing community education
about autism to a group of parents. The nurse
concludes that teaching has been effective if the
parents describe which of the following as
common behavioral signs of autism?
A. Highly creative, imaginative play
B. Early development of language
C. Overly affectionate behavior toward parents
D. Indifference to being held or hugged
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The parent of a child with attentiondeficit/hyperactivity disorder (ADHD) tells the
nurse that the child doesn’t follow instructions
well. Which strategy should the nurse
recommend to the parent?
A. “Teach your child to be less aggressive and more
assertive.”
B. “Consider developing a predictable daily routine.”
C. “It could be helpful to assign time out if instructions
aren’t followed.”
D. “Try having your child repeat what was said before
starting the task.”
42
A 3-year-old client has been diagnosed with
attention-deficit/hyperactivity disorder (ADHD).
The child’s parents report that a friend told them
that the child will likely receive “lots of drugs.”
The nurse should reply that the child will most
likely be given a drug such as:
A. Amitriptyline (Elavil)
B. Paroxetine (Paxil)
C. Amphetamine and dextroamphetamine
(Adderal)
D. Haloperidol (Haldol)
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A 13-year-old child is brought to the clinic with a
history of a conduct disorder. The nursing
history reveals several facts about the family.
Which one is most likely to have contributed to
the child’s conduct problems? The parents:
A. Have very high expectations of the child
B. Employ harsh discipline and inconsistent limitsetting
C. Are excessively involved in the everyday life of
the child
D. Have no other children
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Which primary interventions should the nurse
plan for when a child has a conduct disorder
and is impulsive and aggressive?
A. Limit setting and consistency
B. Open communications and a flexible approach
C. Open expression of feelings
D. Assertiveness training
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Life Span Mental Health Issues
Effect of mental illness on child achieving
developmental tasks:
• May have increased difficulty of achievement
• May be stuck in stage at onset of illness
• May never achieve developmental task
• Can benefit from nursing interventions
46
Life Span Mental Health Issues
Helping a child with mental illness master developmental
tasks:
 Assess child’s behaviors related to developmental task
 Provide the child with normalizing experiences
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Allow to choose age-appropriate play activities
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Reinforcement for age-appropriate behaviors
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Healthy, pleasant environment
 Promote coping skills (decision making, stress
reduction, problem solving)
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Life Span Mental Health Issues
Interventions for increasing resilience in
children at risk for disruptive behaviors:
Provide a supportive relationship with community
member
Provide a positive environment
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at home
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at school
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in community
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Interventions: Play Therapy
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Commonly used with children
Purposeful use of toys and other equipment
Helps to communicate perceptions of the world
and to help master the environment
 self-esteem
Enhances problem solving
Gains perspective on traumatic event
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Interventions: Pharmacotherapy
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Prozac – the only antidepressant approved for children by
FDA. Paxil, Zoloft, Celexa and Effexor considered unsafe
and ineffective for most children and dangerous with
suicidal tendencies
Risk sudden of death on tricyclic antidepressants (TCAs).
Request baseline EKG, repeated when TCA ; blood levels
useful in confirming compliance.
Lab tests for anemia and thyroid function needed
Meds metabolized more efficiently so milligram/kilogram
base is used rather than a certain dose
Initial doses may be low, but can ultimately be as high as for
adults
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Childhood Interventions
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Family therapy
1:1 therapy
Play therapy
Case management
Behavior modification
Parent effectiveness training
School and community interventions
Parental involvement a key component of
achieving successful outcomes
51
The nurse employs play therapy with a small
group of 6-year-old clients. The primary
expected outcome is for the clients to do
which of the following?
A. Act out feelings in a constructive manner
B. Learn to talk openly about themselves
C. Learn how to give and receive feedback
D. Learn how to play
52
Therapeutic Issues of Adolescents
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Identity formation
Independence vs. rebellion
Social role
Acting out behaviors
Coordinate self-security, intimacy and
sexual satisfaction
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Depression & Suicide
Adolescent depression symptoms
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Masked via behavioral problems such as poor
school performance and acting out at school
Protects adolescent from appearing vulnerable
and dependent
Suicide is 3rd leading cause of death in 15-24
year olds
54
The nurse is conducting a community
education session about preventing deaths
in adolescents. Place in order from most
frequent to least frequent the causes of
preventable adolescent deaths that the
nurse needs to include in the presentation.
a.
b.
c.
d.
Accidents
AIDS
Homicide
Suicide
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When assessing an adolescent client for
depression, it is most important for the nurse
to recognize that depression in adolescents
is often:
A. Similar in presentation to depression in
adult clients
B. Masked by aggressive behavior
C. Situational and not as serious as
depression in adults
D. An indication of family dysfunction
56
Life Span Mental Health Issues
Adolescent Eating Disorders
 Anorexia nervosa is characterized by refusal to
maintain minimally normal weight.
Bulimia nervosa is characterized by repeated
episodes of binge eating followed by purging
behaviors.
57
Life Span Mental Health Issues
Anorexia Nervosa
 Maintenance of subnormal body weight for age/ height (<15%)
 Although underweight, individual has intense fear of
 becoming fat. Weight loss self-imposed
 Body image disturbance (self-image related to food)
 Obsessive preoccupation with food
 Denial of wt. loss, thinness and potential health hazards
 Develops symptoms of starvation
 Lack of sense of control or competence in any area of life
 besides weight control.
 Treatment goal is to restore healthy eating patterns and
 reverse physiological damage
58
The nurse is teaching a group of young
adolescents about eating disorders. The nurse
would consider the sessions effective if the
participants state that anorexia nervosa is best
defined as an eating disorder that occurs:
1. Only in young girls who are depressed
2. Mainly in young girls who perceive themselves to
be grossly overweight
3. Primarily in young girls who live in chaotic
families
4. In young boys and girls alike
59
The school nurse is conducting an assessment
to determine if a client has anorexia nervosa.
Which statement(s) by the client most suggest
that the client may indeed have anorexia
nervosa? Select all that apply.
A. “I don’t have periods anymore. I’m glad.”
B. “People say I’m skinny, but I’m fat and repulsive.”
C. “The idea of eating makes me nauseated.”
D. “I know that I have a problem with eating.”
60
In order to be admitted to an inpatient
treatment program, clients with anorexia
nervosa must meet the admission
criterion of having experienced at least a
30% weight loss over the immediate past
6 months.
The client currently weighs 84 pounds.
The nurse calculates that 6 months ago,
this client weighed at least _____pounds.
61
Life Span Mental Health Issues
Bulimia Nervosa
Binge eating with inability to stop (many calories)
Anxiety often triggers binge
Craving for high calorie/sweet food
Shame, 75% depressive symptoms
Secretive eating/stashing of food
Depression
Negative self-image
Purging: Induced vomiting, laxative/diuretic/enema use
Normal height/weight with little variation
Associated anxiety/personality disorder
Fasting and/or excessive exercise
Electrolyte imbalance, irregular HR
62
Life Span Mental Health Issues
Eating Disorder Not Otherwise Specified (NOS):
Binge Eating and Obesity
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One-third in U. S. obese
20%> ideal weight
Compensation for love & nurturing
Defensive against intimacy with opposite sex
R/O medical: hypothalamus or thyroid dysfunction
Ridiculed by peers, may be excluded - can affect selfesteem
63
Eating Disorders NOS
(continued)
Causes
 Societal (TV, junk food), overweight
parents with poor health habits, frequent
eating out
 Genetic - Identical twins reared apart are
similar in body shape/fat to those reared in
the same home (genetics)
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Nursing Interventions
Interventions with the adolescent
 Therapeutic alliance
 Identify feelings and relationship to behavior
 Reflect on negativism and critical attitudes
 Identify tendency to view from extremes
 Encourage catharsis
 Skillful milieu management of peer group
65
The nurse is evaluating the progress of an
adolescent bulimic client who is being treated
as an outpatient. Which behavior would
indicate that the client is making positive
progress? The client:
A. Asks the nurse many details about the nutritional
content of foods
B. Shows the nurse a completed food and emotion
diary
C. Reports enjoying spending time alone after meals
D. Describes eating at times other than when the
family members are eating
66
The nurse is conducting an in-service education
session about the relationship between anxiety
and bulimia nervosa. The nurse best describes
the relationship by saying, “When a client has
bulimia nervosa, an increase in the anxiety level
will generally result in:
A. Rigidly controlling what he or she eats
B. Binging and purging
C. Overeating
D. Consuming alcohol
67
Life Span Mental Health Issues
Older Adult: Assessment
Carefully assess older adults to differentiate
among dementia, delirium, and depression
Assess ability to accomplish physical and
instrumental activities of daily living
Mental health issues identified earlier continue to
manifest in old age
68
Life Span Mental Health Issues
Older Adult: Interventions
Older adults are more prone to the side effects
and toxic effects of many medications (at risk
populations also include children, pregnant and
lactating women).
Medications may initially be given at half the
normal adult doses and any increases in
dosages are made slowly.
69
Life Span Mental Health Issues
Older Adult: Delirium
•Associated with variety of medical conditions/psychosocial changes
•Develops quickly compared to dementia
•Symptoms can fluctuate within 24-hour period
•Disturbance in consciousness
•Confusion, anxiety, distractibility, appetite and sleep disturbances
•May have memory loss, hallucinations, delusions, language
disturbances and agitation
•Temporary condition, if underlying condition treated
•Memory impairment accompanied by disturbance in consciousness
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Life Span Mental Health Issues
Older Adult: Delirium
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Medical conditions
Medications
Substance toxicity
Toxin exposure
Combination of factors
**Older adults at greater risk (multiple diagnoses and
polypharmacy, decreased metabolism and excretion of
drugs)
Most cases are reversible with treatment
Must determine cause – which drives treatment
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Life Span Mental Health Issues
Older Adult: Dementia
• Develops gradually; may not be noticed for years
 First stage: Confusion, such as about directions (navigational)
and decisions
 Second stage: Difficulty recognizing family and friends
 Third stage: May refuse to do any Activities of Daily Living
(ADLs)
• Symptoms do not fluctuate in 24-hour period
• May be related to specific medical conditions, such as
Parkinson’s disease or HIV
• Irreversible, progressive cognitive decline including loss of
awareness, judgment, ability to reason…severe enough to
interfere with daily functioning and communication with others
72
Life Span Mental Health Issues
Older Adult: Dementia
Primarily affects:
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Cerebral cortex (conscious thought and language)
Production of acetylcholine (memory and learning)
Hippocampus (memory storage)
Neurons degenerate and lose synaptic connections
to other neurons
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Life Span Mental Health Issues
Older Adult: Dementia
Losses:
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Ability to do purposeful movement (Apraxia)
Inability to acquire and process new information
Recent memory – lost first
Remote memory – more marked as disease progresses
Language:
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Anomia – inability to find the right word
Agnosia – inability to identify an object
Aphasia – impairment in the significance or meaning of language
(inability to understand what is heard, follow instructions,
communicate needs)
74
Life Span Mental Health Issues
Older Adult: Dementia
Sundowning – What is it?
As the sun goes down those with Alzheimer’s tend to
exhibit
• increased confusion
• irritability
• restlessness
Cause could relate to decreased light = decreased
vision = increased perceptual problems = increased fear
75
Life Span Mental Health Issues
Older Adult: Dementia vs. Delirium vs. other
Accurate Diagnosis is important
• Diagnostic tests
• Complete psychological evaluation
Why?
• Delirium is reversible
• Client may have depression or other diagnosis
76
Life Span Mental Health Issues
Older Adult: Dementia vs. Delirium vs. other
Safety: Number 1 concern with cognitive disorders
• Delirium - may wander; have impaired judgment,
forget what things are for
• Dementia - may get lost; in later stages, prone
to choking, seizures, infections
77
Life Span Mental Health Issues
Older Adult:
Common Interventions for Dementia and Delirium
• Check on frequently
• Use alarm devices to warn of wandering
• Remove harmful items from environment
• Use respectful manner
• Place calendar and clock in room
• Reorient each time staff enter room
• Others? What others can you think of?
78
Life Span Mental Health Issues
Older Adult:
Common Outcomes for Dementia & Delirium
• Remain free of falls
• Perform oral and hair care by given period of time
• Remain in bed, on unit or in facility, whichever is
appropriate to client
• Recall a specific relative by name
Alzheimer’s disease:
• Locate his or her room at least once a day within the
following week
• Increase sleep period at night to ____ hours
79
Life Span Mental Health Issues
Older Adult: Depression
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No real/sustained memory impairment
Non-progressive
May accompany early stages of dementia
Changes in appetite, sleep patterns
Fatigue
Withdrawal, self-neglect, helplessness
Will not attempt to answer questions
Treatable. Responds to treatment – improvement
in cognitive ability - medications, therapy, ECT 80
The client with Alzheimer’s says to the
nurse, “I have a date tonight for the
Valentine’s dance.” What is the most
appropriate response by the nurse?




A. “You’re confused again. There isn’t a dance
tonight and this isn’t Valentine’s Day.”
B. “I didn’t think your spouse was still living. Who is
your date with?”
C. “I think you need some more medication. I’ll be
right back with your shot.”
D. “Today is January 11th. Tell me about some of the
other dances you’ve been to.”
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The nurse is teaching a family caregiver how
to help a client with early dementia complete
activities of daily living (ADLs). Which
information should be included in the
teaching?
A. Perform the ADLs for the client.
B. Have the client plan a schedule for ADLs.
C. Give the client ample time to perform the ADLs as
independently as possible.
D. Tell the client that the ADLs must be finished by 9:00
a.m.
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Photo Acknowledgement:
Unless noted otherwise, all photos and clip
art contained in this module
were obtained from the
2003 Microsoft Office Clip Art Gallery.
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