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Transcript
Chapter 55
Psychiatric Disorders
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
1
Learning Objectives
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Describe the differences between social relationships
and therapeutic relationships.
Describe key strategies in communicating therapeutically.
Describe the components of the mental status examination.
Identify target symptoms, behaviors, and potential side
effects for the following types of medications: antianxiety
(anxiolytic), antipsychotic, and antidepressant drugs.
Summarize current thinking about the etiology of schizophrenia
and the mood disorders.
Identify key features of the mental status examination
and their relevance in anxiety disorders, schizophrenia,
mood disorders, cognitive disorders, and personality disorders.
Identify common nursing diagnoses, goals, and interventions
for persons with anxiety disorders, schizophrenia, mood disorders,
cognitive disorders, and personality disorders.
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
2
Establishing Therapeutic
Relationships
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
3
Being Available
• When working with a patient, direct your
attention completely toward that person
• Avoid involvement in any other activity, such as
reading a newspaper or watching television,
which might be interpreted by the patient as
lack of availability
• Avoid interruptions in your conversation with
the patient as much as possible
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
4
Listening
• Concentrate on what patient is saying; try to hear how
he/she experiences and describes his/her life
• When listening therapeutically, avoid cutting the patient
off or jumping to conclusions
• Get essence of how patient perceives his/her situation,
experiences certain symptoms, and describes
circumstances
• Listening is done by concentrating on the patient and
by refraining from thinking of responses while the
patient is speaking
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
5
Clarifying
• One way of validating that you understand
what the patient is saying
• Asking questions may also help patients clarify
their thoughts
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
6
Sharing Observations
• Patients benefit from knowing what you see
and hear while listening
• Provides patient with input that he/she is heard
and that you are really listening
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
7
Accepting Silence
• Sometimes therapeutic to allow moments of
silence between you and the patient
• Important that you feel comfortable with silence
because silence enables patients to consider
their own thoughts as well as what you are
communicating to them
• Silences allow patients to sort through their
feelings and organize their thinking
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
8
Nursing Assessment of the
Psychiatric Patient
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
9
Psychiatric History
• Ask patient to tell you what has been
happening recently that has caused him/her to
seek treatment
• Inquire about past psychiatric history
• Ask if patient has been treated for anxiety,
depression, or other mental health problems
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
10
Appearance
• Appearance in relation to stated age
• Appropriateness of clothing in relation to
patient’s particular peer group or subculture
• Personal grooming and hygiene
• Unique physical characteristics
• Motor activity
• Recent change in the patient’s activity level
(increase or decrease)
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
11
Mood and Affect
• Mood
• A sustained feeling state or emotion that a person
experiences in several aspects of life
• Assessed by intensity, depth, duration, and
fluctuation
• Words that describe mood: irritable, anxious,
depressed, euphoric, labile (up and down), and
despairing
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
12
Mood and Affect
• Affect
• External presentation of a feeling state and emotional
responsiveness
• Ranges from blunted, flat, and constricted to euphoric,
expansive, and intense
• Normal affect: person’s body language, mannerisms, and
verbal responses consistent with person’s mood and within an
average range of emotional intensity
• Appropriate affect: person’s outward emotional expression
matches what he/she is saying or doing
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
13
Speech and Language
• Speech is normal rate, rhythm, volume
• Unusual findings include mutism (not speaking),
long pauses before responding, minimal or
very little speech (paucity), and pressured
speech (loud and insistent)
• Clues to problems of thought evidenced in a
person’s speech (see following section)
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
14
Thought Content
• Tangential speech
• Patient starts toward a particular point but veers away
• Commonly an indicator of disorganized thinking
• Thought blocking
• Person stops speaking before reaching the point
• Loose associations
• Continual shifting from topic to topic—and shifting between
topics to the point of incoherence (“word salad”)
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
15
Thought Content
• Obsessions—repetitious, unwanted thoughts
• Compulsions—actions repeatedly carried out in a
specific manner; typically include washing, counting, or
checking
• Phobias—unrealistic fears of specific objects or
situations
• Delusions—false ideas not based on reality and not
congruent with the patient’s specific religious and
cultural orientation
• Suicidal ideations—thoughts and/or plans of killing
oneself
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
16
Perceptual Disturbances
• Involve any of the senses such as vision, hearing, taste,
touch, and smell
• Illusion
• Specific stimulus, such as a spot on the wall, misinterpreted
• Hallucination
• Sensory experience that occurs without an external stimulus
• May include a person sitting alone, talking as if
someone were present, or looking around as if
someone is talking to or calling the patient
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
17
Insight and Judgment
• Insight
• The ability to understand the correct cause or
meaning of a situation
• Judgment
• The ability to assess a situation accurately and
determine appropriate course of action
• Insight and judgment are often considered in
relation to suicide potential
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
18
Sensorium
• Orientation in terms of time, place, person, and
self
• Data obtained by asking patient direct
questions
• Patient’s level of consciousness noted
• Comatose, stuporous, drowsy, or alert
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
19
Memory and Attention
• Assessed by comparing patient’s memory of
past events with what is recalled by other
reliable historians
• A quick way to determine recent memory is to
ask what was eaten at the previous meal
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
20
General Intellectual Level
• Estimated by determining the patient’s
vocabulary and knowledge of current events
• Ask patient to name the president of the United
States and the name of the previous president
• Abstract thinking
• Evidence of the intellectual level by asking the
patient to identify the common element of two
objects such as a banana and an apple
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
21
Types of Psychiatric Disorders:
Anxiety Disorders
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
22
Manifestations
• Patient with anxiety disorder directly experiences
uncomfortable feeling of anxiety or a symptom like
compulsive hand washing that prevents or reduces the
occurrence of anxiety
• Signs and symptoms: increased heart rate, elevated
blood pressure, sweaty palms, trembling, urinary
frequency, diarrhea, a tight sensation in the chest, and
difficulty breathing
• Psychological manifestations: irritability, restlessness,
tearfulness, thought blocking, and lack of concentration
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
23
Types of Anxiety Disorders
• Mild anxiety can be useful
• May motivate a person to take constructive action or focus
attention on a particular task
• Moderate anxiety often considered the optimal level for
learning to take place
• As anxiety progresses to severe or panic levels, an
individual’s ability to think clearly and to solve problems
become impaired
• All people experience anxiety
• For most it is episodic; does not interfere with day-to-day
functioning
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
24
Panic Disorder
• The person experiences recurrent panic attacks, which
are episodes of intense apprehension of variable
length, at times to the point of terror, and are often
accompanied by feelings of impending doom
• Physical symptoms of severe anxiety, such as
increased pulse, elevated blood pressure, trembling,
diaphoresis, shortness of breath, chest pain, and
nausea also are present
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
25
Agoraphobia
• The person is extremely fearful of situations outside
the home
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
26
Obsessive-Compulsive Disorder
• Recurrent obsessions (thoughts) or compulsions (behaviors), or
both, that produce distress, are time-consuming, and interfere with
functioning
• Obsessions involve intrusive thoughts about unpleasant or even
violent acts that a person cannot stop
• Compulsive behaviors evolve as a way to reduce the anxiety
experienced as a result of obsessive thoughts
• The person experiencing obsessions and compulsions knows
these thoughts and behaviors are not “normal” and often is
embarrassed by them
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
27
Posttraumatic Stress Disorder
• Cluster of symptoms following distressing event that is
outside the range of normal events; person
experienced intense fear, helplessness, and/or horror
• Symptoms: reexperiencing the trauma through
repeated and intrusive recall; avoiding situations that
remind person of event; feeling detached from other
people; having a heightened sense of arousal, which is
experienced as difficulty falling asleep, hypervigilance,
an exaggerated startle response, or a combination of
these
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
28
Acute Stress Disorder
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
29
Types of Psychiatric Disorders:
Somatoform Disorders
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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Definition
• Individual experiences physical symptoms
without actual physiologic dysfunction or with
physical cause(s) that are affected by
psychological factors in terms of onset, severity,
duration, or continuance of symptoms
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
31
Conversion Disorder
• Symptoms may include blindness, deafness, or
paralysis of the legs without a physiologic
cause
• Usually symptoms are neurologic and occur in
response to some threatening or traumatic
event
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
32
Pain Disorder
• Patient experiences pain in one or more sites
that causes significant distress or impairment
in function
• Psychological factors play a significant role in
the experience of the pain; however, the pain is
not intentionally produced or contrived
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
33
Hypochondriasis
• Individuals convinced that they have a serious
medical problem in spite of the absence of any
concrete medical findings
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
34
Types of Psychiatric Disorders
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
35
Dissociative Disorders
• A change in identity, memory, or consciousness
• Change may be sudden or gradual, transient or
occurring over a long period, and is thought to
be an escape from anxiety
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
36
Dissociative Disorders
• In a sense, persons unconsciously dissociate or
remove themselves psychologically from anxietyprovoking situations
• Amnesia: a gap in memory, usually of a traumatic or stressful
nature, that is too extensive to be explained by normal
forgetfulness
• Dissociative identity disorder is a relatively rare dissociative
disorder in which two or more distinct personalities exist within
the person and repeatedly take control of the person’s
behavior
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
37
Medical Treatment
• Drug therapy
• Anxiolytic (antianxiety)
• Benzodiazepines
• Diazepam (Valium), chlordiazepoxide (Librium), lorazepam
(Ativan), alprazolam (Xanax), and clonazepam (Klonopin)
• Antidepressants
• Venlafaxine (Effexor), nefazadone (Serzone), duloxetine
(Cymbalta)
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
38
Care of the Patient with Anxiety,
Somatoform, or Dissociative Disorder
• Assessment
• Patient’s symptoms and objective observations help
determine the presence and level of anxiety (mild,
moderate, severe, or panic). Relevant mental status
examination categories include motor activity,
speech and language, and thought content
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
39
Care of the Patient with Anxiety,
Somatoform, or Dissociative Disorder
• Interventions
• Remain calm; speak firmly with short, simple
instructions; and walk to a less stimulating area of
the unit
• Once anxiety is reduced to a manageable level,
assist patients in exploring what happened,
clarifying their usual ways of relieving anxiety and
identifying what triggered the anxiety
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
40
Schizophrenia
• Group of very serious, usually chronic, thought
disorders in which the affected person’s ability to
interpret the world accurately is impaired by psychotic
symptoms
• Psychosis
• Person has distorted perceptions of reality
• Psychotic symptoms include delusions, hallucinations,
and impaired speech or behavioral patterns
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
41
Schizophrenia
• Etiology and risk factors
• The cause is not certain
• Stress-diathesis model
• Integrates diverse potential causes states that patients who
are most vulnerable to acquiring the disorder encounter
factors (stress) that precipitate the disorder
• In men, first occurs between 15 and 25 years
• Usual age for women is 25 to 35
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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Schizophrenia
• Medical treatment: drug therapy
• Neuroleptic (antipsychotic), antiparkinsonian drugs
• Anxiolytics administered with the neuroleptics
• Side effects
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Agitation and akathisia
Orthostatic hypotension
Extrapyramidal side effects (EPS)
Acute dystonic reactions
Parkinsonian syndrome
Tardive dyskinesia
Neuroleptic malignant syndrome
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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Schizophrenia
• Assessment
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Appearance
Activity
Mood and affect
Speech and language
Thought content
Perceptual disturbances
Insight and judgment
Sensorium
Memory
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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Schizophrenia
• Interventions
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•
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Disturbed Thought Processes
Disturbed Sensory Perception
Impaired Verbal Communication
Self-Care Deficit
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
45
Mood Disorders
• Significantly elevated or depressed moods
• An episode of persistent depressed mood is
major depression
• Elevated mood is a manic episode
• Alternation between significantly depressed
mood and significantly elevated mood over
time is bipolar disorder
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
46
Mood Disorders
• Etiology and risk factors
• Definite causes have not been established
• Probable causes: neurotransmitter dysregulation,
neuroreceptor deficits, neuroendocrine dysfunctions,
genetic factors, loss of significant others, learned
helplessness, and negative thoughts about life
experiences
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
47
Mood Disorders: Medical Treatment
• Drug therapy
• Antidepressant medications
• Selective serotonin reuptake inhibitors (SSRIs), newer
agent antidepressants such as nefazodone (Serzone),
venlafaxine (Effexor), and duloxetine (Cymbalta), tricyclic
antidepressants (TCAs), and monoamine oxidase inhibitors
(MAOIs)
• Manic medications
• Lithium or divalproex (Depakote)
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
48
Mood Disorders: Medical Treatment
• Electroconvulsive therapy
• Electrical current is introduced to the brain through
electrodes placed on the temples
• Produces a grand mal seizure; however, drugs
administered to minimize the manifestations of a
seizure
• Temporary memory loss and confusion are common
side effects of ECT, and instances of prolonged
memory loss have occurred
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
49
Mood Disorders
• Nursing care of the patient with major
depression
• Interventions
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Risk for Self-Directed Violence
Chronic or Situational Low Self-Esteem
Altered Nutrition: Less Than Body Requirements
Disturbed Sleep Pattern
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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Mood Disorders
• Nursing care of the patient with bipolar disorder
with manic episodes
• Risk for Injury
• Risk for Other-Directed Violence
• Imbalanced Nutrition: Less Than Body
Requirements
• Disturbed Sleep Pattern
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
51
Cognitive Disorders
• Impairments in cognition or memory
• Delirium and dementia: deficits in orientation,
memory, language comprehension, and
judgment
• Delirium is potentially reversible, whereas dementia
is not
• Delirium is usually fairly rapid in onset; dementia is
slow in its onset
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
52
Cognitive Disorders
• Causes of delirium are meningitis, neoplasms,
drugs ranging from alcohol to steroids,
electrolyte imbalance, endocrine dysfunction,
liver abnormalities, renal failure, thiamine
deficiency, and postoperative states
• Common types of dementia are dementia of
the Alzheimer’s type, vascular dementia, Pick’s
disease, and Parkinson’s disease
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
53
Personality Disorders
• Paranoid personality disorder—distrust and
suspiciousness; others’ motives interpreted as hostile
• Schizoid personality disorder—detachment from social
relationships and a restricted range of emotional
expression
• Schizotypal personality disorder—difficulties in social
and interpersonal relationships in which the person
suffers from acute discomfort with close relationships
and therefore has a decreased capacity for such
relationships
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
54
Personality Disorders
• Antisocial personality disorder—disregard for and
violation of the rights of others
• Borderline personality disorder—instability in
interpersonal relationships, self-image, and affect;
marked impulsivity
• Histrionic personality disorder—excessive emotionality
and attention seeking
• Narcissistic personality disorder—grandiosity, need for
admiration, and lack of empathy
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
55
Personality Disorders
• Avoidant personality disorder—social inhibition
accompanied by feelings of inadequacy and
hypersensitivity to negative evaluation
• Dependent personality disorder—submissive and
clinging behavior related to an excessive need to be
taken care of
• Obsessive-compulsive personality disorder—
preoccupation with orderliness, perfectionism, and
control
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
56
Borderline Personality Disorder
• Person has unstable relationships, unstable
self-image, and unstable mood
• Two theories
• First, because families of patients with this disorder
have a greater history of alcoholism, a genetic
influence is thought to exist
• The second explanation is related to particular
developmental experiences
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
57
Borderline Personality Disorder
• Assessment
• Mood, affect, feelings: patient may experience mood
swings or chronic feelings of emptiness and
boredom or intense anger
• Insight and judgment: patient makes repeated
suicidal threats and gestures and exhibits selfmutilating behavior
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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Borderline Personality Disorder
• Interventions
• Risk for Self-Directed Violence/Risk for SelfMutilation
• Impaired Social Interaction
• Disturbed Personal Identity
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
59