Mental Health Exam 3 Concept Guide (Module 7-9) Chapter 12 – Somatoform Disorders, Exams of Nursing

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Mental Health Exam 3 Concept Guide (Module 7-9) Chapter 12 – Somatoform Disorders Somatoform Disorders: Persistently preoccupied with and distressed by their perceived health issues ❖ Hypochondriasis → now called Illness Anxiety Disorder ➢ Signs/symptoms: ■ Preoccupied with having or eventually developing a serious illness. ■ May or may not present with somatic symptoms (usually mild) ■ High level of anxiety and alarm about their health lasting at least 6 months, and may either excessively check for problems or avoid medical care. ■ Patients can misinterpret normal physical sensations such as sweating, abdominal cramping, or awareness of heartbeat as indicative of disease ■ Pt believes he has the sickness, even if test results prove otherwise ❖ Conversion Disorder → also Called Functional Neuro-biological Symptom Disorder ➢ Define: a somatic symptom disorder that presents with one or more symptoms of impaired motor or sensory function. ➢ S/Sx: weakness or paralysis, abnormal movement, swallowing or speech difficulties, seizures or attacks, sensory loss or anesthesia, or symptoms involving the senses (blindness or loss of smell) ➢ Patients may be highly distressed or show a lack of emotional concern ■ known as la belle indifférence ➢ Nursing intervention ■ Straight forward approach ■ Support pt, but yet be assertive ❖ Body Dysmorphic Disorder: ➢ Patients with BDD usually have a normal appearance (small amount do show minor defects). ➢ They feel they never truly look perfect, or one body part looks extremely abnormal, but other people do not see that. ➢ Feel shame, withdrawn. Plastic surgery is huge with these pts ➢ Avg onset is < 20 years ➢ Care Plan; Highest Priority--SAFETY (harm to self) ■ Risk for suicide ■ SSRIs, antidepressants, and clomipramine (a tricyclic antidepressant) ■ Cognitive behavioral therapy (CBT) ■ Atypical antipsychotic + SSRI (severe delusional form of BDD). ❖ Factitious Disorder Imposed on Self (Munchausen Syndrome) ➢ Displays as sick without obvious reward or gain (deceptive) ❖ Nursing Interventions for Somatoform Disorders: ➢ Offer explanations and support during diagnostic testing. ➢ After physical complaints have been investigated, avoid further reinforcement of the complaints. ➢ Spend time with the patient at times other than when he/she is expressing a physical complaint Mental Health Exam 3 Concept Guide (Module 7-9) ■ (e.g., when talking about a pet or TV program and give the “reward” of extra attention during those times). ➢ Observe and record frequency and intensity of somatic symptoms. ➢ Do not imply that symptoms are not real. ➢ Shift focus from somatic complaints to feelings or to neutral topics. Mental Health Exam 3 Concept Guide (Module 7-9) ➢ Most severe of dissociative disorders , Patients “lose time” ❖ Dissociative Fugue → Cannot recall some or all of past or identity → body’s response to trauma ➢ “Dissociative amnesia is related to a traumatic incident, and may be accompanied by a fugue where the patient flees from their normal life to another location and starts a new life. Gradually over time, memories of the original life may be triggered.” Pg 160 ➢ Forget who you are, what happened, where you are… “in a fog” ❖ CLUSTER A PERSONALITY DISORDERS: ➢ Schizotypal Personality Disorder → Magical, distortions, peculiar behavior, odd speech ➢ Schizoid Personality → cant establish relationships, restricted range of emotions (interpersonal) ➢ Paranoid Personality → suspiciousness and distrust ❖ CLUSTER B PERSONALITY DISORDERS ➢ Antisocial Personality Disorder ■ Disregard for and violation of the rights of others with an absence of remorse for hurting others & sense of entitlement ■ Do not adhere to traditional values or standards of morality as boundaries or law ■ History of persistent lying, use of aliases, conning others for personal profit or pleasure, and stealing (deceitfulness). ■ However, they do rely on others to conform to the social norms. ■ Interventions for manipulation ➢ Borderline Personality (Pg 169) ■ Unstable and intense relationship, and, instability of affect, marked by unstable and frequent mood changes. Poor impulse control is evident by suicide attempts, self-mutilation and other self destructive behaviors. They may feel irritable, have anxiety and dysphonia. Depression is common among these individuals. ● Challenge everything about you ● Self defeating cycles of behavior ➢ Narcissistic Personality Disorder (grandiose sense of personal achievements) ■ Sense of entitlement, lack of empathy, exploit others ➢ Histrionic Personality - Attention seeking ■ Manipulate others through their dramatic, rapidly shifting, charming, flamboyant, and sexually seductive behaviors. Excessively emotional behavior, center of attention, sudden emotional shifts and emotional lability, superficial/shallow relationships ■ Temper, tears, accusations all seeking attention ■ Interventions: set clear limits, avoid power struggles and escalation conversation ❖ Nursing Interventions ➢ Manipulation→ Set limits, be firm, all staff enforce limits, and AVOID: personal discussions, staff splitting, keeping secrets, accepting gifts ➢ Impulsive Behaviors → identify needs/feelings preceding the act, discuss current and previous impulsive acts, recognize cues of behaviors that may injure others & identify triggers Mental Health Exam 3 Concept Guide (Module 7-9) ➢ Refer to appropriate place to learn coping skills (e: anger mgmt) ❖ CLUSTER C PERSONALITY DISORDERS: ➢ Avoidant Personality Disorder ■ High anxiety and low self worth ■ Hypersensitive to criticism ➢ Obsessive-Compulsive Personality Disorder ■ Pattern ■ Limited interpersonal skills ➢ Dependent Personality ■ Believe → incapable of surviving if left alone and have an excess need to receive care. ■ Dependant on someone else to make decisions; submissive to others Chapter 14 – Eating Disorders ❖ Anorexia ➢ Signs/symptoms: intense irrational beliefs about shape/weight, self-starvation, fear of wt. gain, disturbance in self-evaluation of weight and its importance, amenorrhea (Pg. 182) Always feel like their fat. ■ Cachectic (severely underweight with muscle wasting) ■ Lanugo (a growth of fine, downy hair on the face and back) ■ Mottled, cool skin on the extremities ■ Hypotension, bradycardia, low temp ● Consistent with a malnourished and dehydrated state. ■ Cut food in smaller pieces and move it around on plate to make it look like they ate ■ Use laxatives or diuretics ■ Self induced vomiting or purge their food ■ Obsessed with exercise ➢ Medication: Olanzapine (Zyprexa) → weight gain and improved cognition/body image ➢ Assessment: Determine if medical or psychiatric condition warrants hospitalization ■ Weight loss more than 30% over 6 months, Rapid decline in weight, severe hypothermia (lower than 36° C or 96.8° F), HR < 40 Hg, Electrolyte imbalances, Electrocardiographic changes (especially dysrhythmias), Suicidal or self-mutilating behaviors, Uncontrollable use of laxatives, emetics, diuretics, or street drugs, do they want help/participate? ➢ Milieu management → patient privileges may be linked to wt gain and treatment plan compliance ■ Precise mealtimes ■ Adherence to the selected menu ■ Observation during and after meals ■ Regularly scheduled weigh-ins. ■ Close supervision of patients includes ● monitoring of all trips to the bathroom after eating Mental Health Exam 3 Concept Guide (Module 7-9) ● Patients may also need monitoring on bathroom trips after seeing visitors and after any hospital pass → Ensure no access to laxatives/diuretics ❖ All-or-Nothing Thinking ➢ Reasoning is absolute and extreme, in mutually exclusive terms of black or white, good or bad. All or nothing ■ “If I have one Popsicle, I must eat five.” ■ “If I allow myself to gain weight, I’ll blow up like a balloon.” ■ “If I don’t win the race, I’m a loser.” No inbetween ❖ Refeeding Syndrome → cardiovascular collapse due to addition of electrolytes ❖ Bulimia ➢ Prioritize nursing interventions ■ Risk for suicide ■ Vital signs (ABC’s) ■ Explore dysfunctional thoughts that maintain the binge/purge cycle. ■ Educate the patient that fasting can lead to continuation of bingeing and the binge/purge cycle, emphasizing its self-perpetuating nature. ■ Monitor patient during and after meals to prevent throwing away food and/or purging. ■ Acknowledge the patient’s overvalued ideas of body shape and size without minimizing or challenging patient’s perceptions. ■ Encourage patient to keep a journal of thoughts and feelings. ➢ Health teaching → meal planning, use of relaxation techniques, maintenance of a healthy diet and exercise, implementation of coping skills, and knowledge of the physical and emotional effects of bingeing and purging as well as the effects of cognitive distortions. ❖ Comorbidities of anorexia ➢ Other psychiatric illnesses. ■ > 50% of people with anorexia have 1+ concurrent psychiatric disorder ■ Mood and anxiety disorders, substance abuse, body dysmorphic disorders, impulse control disorders, and personality disorders, especially borderline and obsessive-compulsive personality disorders. ❖ Memory Care Chapter 18 – Neurocognitive Disorders ➢ Encourage reminiscing about happy times in life (Table 18-5) Mental Health Exam 3 Concept Guide (Module 7-9) ❖ Delirium – orientation ➢ Happens because of something (medication) Take away the reason for delirium = gone ➢ Elderly UTI Mental Health Exam 3 Concept Guide (Module 7-9) ➢ Reorienting them to the here and now. Do not play along with their confusion Chapter 19 – Addiction & Compulsions ❖ Alcohol Dependence → Relapse Prevention Plan (Health Teaching Box 19-5) ➢ Basics ■ Keep the program simple at first ■ Review instructions with health team members. ■ Use a notebook and record important information and telephone numbers. ➢ Skills - Take advantage of cognitive behavioral therapy to increase your coping skills. Identify which important life skills are needed: ■ Which situations do you have difficulty handling? ■ Which situations are you managing more effectively? ■ For which situations would you like to develop more skills to act more effectively? ➢ Relapse Prevention Groups - ■ Rehearse stressful situations using a variety of techniques. ■ Find ways to deal with current problems or ones that are likely to arise as you become drug free. ■ Providing role models to help you make necessary life changes. ❖ PCP Overdose → Nursing Interventions (Table 19-10) ➢ If alert: ■ Caution: Gastric lavage can lead to laryngeal spasms or aspiration. ■ Acidify urine (cranberry juice, ascorbic acid); in acute stage, ammonium chloride acidifies urine to help excrete drug from body—may continue for 10-14 days. ■ Put in room with minimal stimuli . ■ Do not attempt to talk down patient! Speak slowly, clearly, and in a low voice. ■ Administer diazepam. ■ Haloperidol may be used for severe behavioral disturbance (not a phenothiazine). ➢ Institute medical intervention for: ■ Hyperthermia, HTN, respiratory distress (like panic attack) ● Benzos (diazepam) ❖ Opioid Overdose & Heroin Overdose → Clinical Manifestations; Signs/Symptoms (Table 19-6) ➢ Constricted (Pin Point) pupils ➢ Decreased respiration ➢ Decreased Blood Pressure ➢ Decreased Body Temp (assuming due to decrease circulation?) ➢ Slurred speech ➢ Drowsiness ➢ Psychomotor retardation ➢ Cardiac arrest Mental Health Exam 3 Concept Guide (Module 7-9) ❖ Know about Narcan ➢ Treats opioid toxicity → quickly reverses central nervous system depression Mental Health Exam 3 Concept Guide (Module 7-9) ■ Social skills and other thinking may remain unaffected ❖ Potential Medications given for alcohol withdrawal, cravings or substance abuse (Table 19-2 & 19-4) ➢ For withdrawal: ■ Chlordiazepoxide (Librium) ■ Carbamazepine (Tegretol) & Valproic Acid (Depakote) ■ Magnesium Sulfate (decrease risk of seizures) ■ Benzodiazepines ➢ Maintenance Medications: ■ Disulfiram (Antabuse) → Helps prevent the relapse of alcohol abuse. ● Used after an individual has been alcohol free/sober for a number of months. ● Is a motivational aid for those who want to stay sober. ● If mixed with alcohol it can cause violent reactions, such as ponding in the chest, drop in BP, nausea, vomiting, facial flushing and possibly death. ● Takes 14 days for the effects of the drug to leave the body. ■ Naltrexone (ReVia) → Diminishes alcohol cravings & blocks the effects of opiates. ● Effective in those with a family history of alcoholism. ■ Vivitrol (Naltrexone for extended release, injectable suspension) → For alcohol abuse ● Should NOT be used if patient has opioid dependency. ■ Acamprosate (Campral)→ Diminished alcohol cravings. ● Reduces unpleasant symptoms of abstinence such as anxiety, tension, and dysphoria, which can also cut down the cravings. ➢ In a randomized trial Gabapentin was found to be effective in treating alcohol dependence and relapse- related symptoms of insomnia, anxiety, dysphoria, cravings, headaches, and or pain in individuals with a co-occurring substance use disorder. It has a favorable safety profile and is not harmful or lethal. ➢ CNS Depressants (Table 19-2) ■ Barbiturates ■ Benzodiazepines ■ Alcohol (EtOH) ➢ Alcohol withdrawal delirium (Table 19-4) ■ Sedatives ● Benzodiazepines ● Chlordiazepoxide (Librium) ● Diazepam (Valium) ■ Seizure control ● Carbamazepine (Tegretol) or Valproic acid (Depakote) ● Magnesium sulfate ● Thiamine (Vitamin B1) ■ ANS ● Beta blockers (Propranolol) or alpha blockers (Clonidine) ❖ CNS Stimulants Withdrawal (Table 19-7) (cocaine and meth) Mental Health Exam 3 Concept Guide (Module 7-9) ➢ Fatigue, depression, agitation, apathy, anxiety, sleepiness, disorientation, lethargy, cravings. (Methamphetamine can cause cardiac and neurological damage. ➢ Dilated pupils, Wakefulness (hallucinations), Tachycardia, nausea/vomiting ➢ Nursing interventions: monitor for suicidal ideation when coming down ■ Identify triggers ■ Use open ended questions ■ Set limits, boundaries ■ Use Benzodiazepines to calm ❖ Cocaine Abuse & Alcohol ➢ How are they related? Cocaine is stimulant, alcohol is depressant. ➢ When someone has cocaine addiction, they often have an alcohol addiction. When they have an upper, they need an downer ❖ Domestic Violence Chapter 21 – Child, Partner and Elder Violence ➢ Definition: thought of as occurring between more powerful (perpetrator) and less powerful victim (via PowerPoint) ➢ In the family. Toward female, or toward the male ➢ Psychological factors- low self esteem, poor problem solving skills, history of impulsive behaviors, hypersensitivity (sees self as the victim), and narcissism (centers on self, lacks compassion for others. ❖ Emotional Abuse ➢ Includes name calling, excessive criticism, ignoring accomplishments, yelling and swearing, mocking, isolating, locking the victim in a room, threats of intimidation, and denying abuse and blaming the victim. ❖ Child Abuse ➢ Nurse’s Legal Responsibility : ■ Mandated reporters. Report to your manager, social worker. Make sure proper procedures are being followed ➢ Potential Nursing Dx ■ Primary: Safety and Risk for injury ■ Others: Disabled family coping, post-trauma syndrome, anxiety, fear, impaired parenting, acute pain, delayed growth and development ➢ Nursing interventions (Table 21-2) ■ Adopt a nonthreatening, nonjudgemental relationship with parents ■ Understand that the child does not want to betray his or her parents ■ Provide a complete physical assessment of the child ■ Use of dolls or drawing might help the child tell how the injury or accident happened Mental Health Exam 3 Concept Guide (Module 7-9) ❖ Sexual Assault Chapter 22 – Sexual Violence Mental Health Exam 3 Concept Guide (Module 7-9) ➢ Autism Spectrum Disorder (ASD) Severity categorized into levels based on functional ability 1. Level 1: noticeable social deficit, but language and speech are normal a. Difficulty switching between activities b. Struggle with organization and planning 2. Level 2: noticeable deficit in both verbal and nonverbal social and communication skills a. Do not initiate social interaction b. Change in routine causes stress 3. Level 3: Social deficits are severe, with communication being limited and needs-based. a. May be nonverbal or speak in few-word sentences b. Difficult to understand c. Made odd noises d. Echo a word or sentence ever and over e. Aggression toward self or others ➢ Signs/Symptoms ■ Deficits in social and communication interactions ■ Repetitive patterns of behavior, interests, or behavior ■ Mannerisms may progress from self-stimulation to self- injurious (head banging, biting) ■ Focus on a certain subject and perseverate on it ■ Dislike physical affection and contact ■ Upset when routines are deviated from ■ Bonding with parents ■ Avoid eye contact ■ Communication delays ■ Severe frustration ■ Impulsive ➢ Implementation ■ Behavioral management ■ Cognitive behavioral therapies ■ Educational and school-based therapies ■ Medications ● Atypical antipsychotics (Risperidone) for aggression or self harm ● SSRI or beta-blockers for obsessive or anxious symptoms Chapter 28 – Older Adults ❖ Risk for suicide- 17th leading cause of death among those 65 and over. ➢ The elderly have many risk factors that can lead to suicide such as: ■ Feelings of hopelessness, uselessness & despair ■ Medical issues/ Acute illness / Chronic illness ■ Functional loss & Intractable pain Mental Health Exam 3 Concept Guide (Module 7-9) ■ Financial distress ■ History of suicide attempts ■ Widowhood/ Status change ■ Chronic sleep problem ■ Alcoholism ■ Depression ➢ Interview techniques ■ Gather preliminary data before the session & keep questionnaires relatively short. ■ Ask about often-overlooked problems, such as difficulty sleeping, incontinence, falling, depression, sexual activity, alcohol or drug use, or loss of energy. ■ Pace the interview to allow the patient to formulate answers, resist the tendency to interrupt prematurely. ■ Use simple choice questions if the older patient has trouble coping with open- ended questions. ■ Begin with general question such as, “How can I help you most at this visit?” or “What’s been happening?” ■ Be alert for information on the patients relationships with others, thought about family and coworkers, typical responses to stress, and attitudes towards aging, illness, occupation, and death. ■ Assess mental status for deficits in recent or remote memory, and determine if confusion exists. ■ Note all medications the patient is taking and assess for side effects, efficacy, possible drug interactions, and if the patient is taking them regularly and correctly. ■ Determine how fast the condition of the patient has been changing, and assess the extent of the patients concerns. ■ Include the family or significant other in the interview process for added input, clarification support, and reinforcement with patients permission. ❖ Risk for abuse- types of abuse ➢ Physical abuse: The infliction of physical pain or injury through slapping, hitting, kicking, pushing, restraining, overmedication, or sexually abusing. ➢ Psychological abuse: The infliction of mental anguish through yelling, name calling, humiliating, or threatening. ➢ Financial abuse or exploitation: The misuse of someone's property and resources by another person, or refusal by a caregiver to provide needed resources. ➢ Neglect:Failure to fulfill a caretaking obligation to provide nutrition, hydration, shelter clothing, utilities, medical services, or other basic needs. (This category may also include self- neglect) ➢ Sexual abuse:Nonconsensual sexually molesting, touching, inappropriate comments or exposure to videos or acts, or actual rape. Mental Health Exam 3 Concept Guide (Module 7-9) ***Know the difference between Objective and Subjective data in the nursing assessment*** Objective: observed Subjective: pts own personal thoughts and opinions- spoken