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Mental Health Nursing II NURS by sanmelody


									Mental Health Nursing II
      NURS 2310
          Unit VI
 Psychiatric/Mental Health
     Treatments and
                Objective 1

 Reviewing medications used for
treatment of the psychiatric/mental
           health client
Psychotropic medication
 affects psychic function, behavior, or
 effects the neuronal synapse, producing
  changes in neurotransmitter release and
  the receptors they bind to
Neurotransmitter = a chemical that is stored
  in the presynaptic neuron and is released
  by an electrical impulse through the neuron
Receptor = molecules situated on the cell
  membrane that are binding sites for
Antianxiety Agents
 Also called anxiolytics and minor
 Used to treat anxiety disorders, anxiety
  symptoms, acute alcohol withdrawal,
  skeletal muscle spasms, convulsive
  disorders, status epilepticus, and
  preoperative sedation
 Act by depressing subcortical levels of the
  CNS (limbic system)
 All levels of the CNS can be effected
    – mild sedation  hypnosis  coma
   Exception is Buspar (does not depress CNS)
          Types of Antianxiety Agents
 Antihistamines
    – Hydroxyzine (Atarax, Vistaril)
   Benzodiazepines
    – Alprazolam (Xanax)
    – Chlordiazepoxide (Librium)
    – Clonazepam (Klonopin)
    – Clorazepate (Tranxene)
    – Diazepam (Valium)
    – Lorazepam (Ativan)
   Buspirone (Buspar)
 Used to treat dysthymic disorders,
  depression, alcoholism, schizophrenia,
  mental retardation, and bipolar disorder
 Elevate mood and alleviate other symptoms
  associated with moderate to severe
 SSRIs and tricyclics act by increasing
  concentration of norepinephrine, serotonin,
  and/or dopamine in the body by blocking
  the reuptake of these neurotransmitters
 MAOIs inhibit monoamine oxidase enzymes
  that inactivate norepinephrine, serotonin
  and/or dopamine in the body
            Types of Antidepressants
 Tricyclics
    – Amitriptyline (Elavil)
    – Clomipramine (Anafranil)
    – Imipramine (Tofranil)
    – Nortriptyline (Pamelor)
   SSRIs (Selective Serotonin Reuptake
    – Citalopram (Celexa)
    – Fluoxetine (Prozac)
    – Escitalopram (Lexapro)
    – Paroxetine (Paxil)
    – Sertraline (Zoloft)
     Types of Antidepressants (cont’d)
 MAOIs (Monoamine Oxidase Inhibitors)
    – Isocarboxazid (Marplan)
    – Phenelzine (Nardil)
    – Tranylcypromine (Parnate)
   Miscellaneous Agents
    – Bupropion (Zyban, Wellbutrin)
    – Mirtazapine (Remeron)
    – Trazodone (Desyrel)
    – Venlafaxine (Effexor)
    – Duloxetine (Cymbalta)
Mood-Stabilizing Agents
   New drugs of choice for treatment and
    management of bipolar mania have been
    discovered in recent years

   Lithium carbonate continues to be used
    extensively for bipolar disorder alone or in
    combination with other medications

   May enhance reuptake of norepinephrine
    and serotonin, decreasing levels in the body
    and resulting in decreased hyperactivity
      Types of Mood-Stabilizing Agents
 Antimanics
    – Lithium carbonate (Eskalith, Lithobid)
   Anticonvulsants
    – Clonazepam (Klonopin)
    – Valproic acid (Depakote)
    – Lamotrigine (Lamictal)
    – Gabapentin (Neurontin)
    – Topiramate (Topamax)
   Calcium Channel Blockers
    – Verapamil (Isoptin)
  Types of Mood-Stabilizing Agents (cont’d)
 Antipsychotics
  – Olanzapine (Zyprexa)
  – Aripiprazole (Abilify)
  – Chlorpromazine (Thorazine)
  – Quetiapine (Seroquel)
  – Risperidone (Risperdal)
  – Ziprasidone (Geodon)
Antipsychotic Agents
   Also called major tranquilizers and

   Used to treat acute and chronic psychoses
    (especially when accompanied by increased
    psychomotor activity)

   May work by blocking postsynaptic
    dopamine receptors in the basal ganglia,
    hypothalamus, limbic system, brainstem,
    and medulla
     Types of Antipsychotic Agents
– Chlorpromazine (Thorazine)
– Fluphenazine (Prolixin)
– Thioridazine (Mellaril)
– Thiothixene (Navane)
– Risperidone (Risperdal)
– Haloperidol (Haldol)
– Clozapine (Clozaril)
– Olanzapine (Zyprexa)
– Quetiapine (Seroquel)
– Ziprasidone (Geodon)
– Aripiprazole (Abilify)
   Used in the short-term management of
    various anxiety states and to treat insomnia

   Cause generalized CNS depression

   May produce tolerance with chronic use

   Potential for psychological or physical
         Types of Sedative-Hypnotics
 Barbiturates
    – Secobarbital (Seconal)
   Benzodiazepines
    – Flurazepam (Dalmane)
    – Temazepam (Restoril)
    – Triazolam (Halcion)
   Miscellaneous Agents
    – Chloral Hydrate (Noctec)
    – Zaleplon (Sonata)
    – Zolpidem (Ambien)
    – Eczopiclone (Lunesta)
        Disorder Agents
   Used for ADHD in children and adults

   CNS stimulant

   Increases levels of neurotransmitters in the

   Diminishes sense of fatigue and brightens
         Types of ADHD Agents
 Amphetamines
    – Dextroamphetamine sulfate (Dexedrine)
    – Methamphetamine (Desoxyn)
   Amphetamine Mixtures
    – Dextroamphetamine/amphetamine (Adderall)
   Miscellaneous Agents
    – Methylphenidate (Ritalin, Concerta)
    – Atomoxetine (Strattera)
    – Buproprion (Wellbutrin)
           Objective 2

Discussing side effects and adverse
    effects of selected psychiatric
Antianxiety Agents
   Increased effects when taken with:
    – Alcohol
    – Barbiturates
    – Narcotics
    – Antipsychotics
    – Antidepressants
    – Antihistamines
    – Neuromuscular blocking agents
    – Herbal depressants
   Decreased effects when taken with:
    – Nicotine
    – Caffeine
   Most common side effects:
    – Drowsiness
    – Confusion
    – Lethargy
 Other side effects may include paradoxical
  excitement and blood dyscrasias
 Nursing considerations:
    – Tolerance and physical/psychological dependence
    – Abrupt withdrawal may be life-threatening
    – Withdrawal symptoms include depression,
      insomnia, increased anxiety, abdominal and
      muscle cramps, tremors, vomiting, sweating,
      convulsions, & delirium
 Buspirone (Buspar)
  – no tolerance or dependence concerns
  – delayed onset (10 days to 2 weeks)
  – no PRN dosing
 May decrease seizure threshold
 Nursing Considerations:
    – Increases suicide potential
    – Watch for sudden lifts in mood
   Common side effects:
    – Dry mouth
    – Sedation
    – Nausea
    – Discontinuation syndrome (dizziness, headache,
      nausea, lethargy, panic attacks, worsening of
      depression symptoms): taper gradually to prevent
      withdrawal symptoms
   Tricyclics
    – Increased effects when taken with buproprion,
      haloperidol, SSRIs, and valproic acid
    – Common side effects include blurred vision,
      constipation, urinary retention, orthostatic
      hypotension, tachycardia/arrhythmias,
      photosensitivity, weight gain
   SSRIs
    – Impairment of mental and motor skills with
      concurrent use of alcohol
    – Seratonin syndrome (changes in mental status)
      may occur with tryptophan, amphetamines,
      buspirone, lithium, or dopamine agonists
    – Common side effects include insomnia/agitation,
      headache, sexual dysfunction
   MAOIs
    – Hypertensive crisis when used with other
      antidepressants, amphetamines, methyldopa or
      levodopa, dopamine, epinephrine or
      norepinephrine, vasoconstrictors, or foods
      containing tyramine
    – Symptoms of hypertensive crisis include severe
      occipital headache, palpitations, nausea/vomiting,
      nuchal rigidity, fever, sweating, marked increase
      in blood pressure, chest pain, and coma
    – Hypertension/hypotension, coma, convulsions,
      and death may occur with narcotic analgesics
    – Avoid using MAOI within 2 weeks of adverse
      agent, and 5 weeks of Prozac therapy
         Tyramine-Containing Foods
– Aged cheeses
– Raisins, fava beans, flat Italian beans, Chinese
  pea pods
– Red wines
– Smoked and processed meats
    salami
    bologna
    pepperoni
    summer sausage
– Caviar, picked herring, corned beef, chicken, beef
– Soy sauce, brewer’s yeast, meat tenderizer (MSG)
Mood-Stabilizing Agents
   Lithium Carbonate
    – Increased risk of neurotoxicity with
      carbamazepine, haloperidol, or methyldopa
    – Increased serum lithium levels with fluoxetine or
      loop diuretics
    – Decreased lithium levels or lithium toxicity with
    – Very narrow margin between therapeutic and toxic
      levels; lithium toxicity can be life-threatening
    – Symptoms of lithium toxicity include blurred
      vision, ataxia, persistent nausea and vomiting,
      severe diarrhea, psychomotor retardation, mental
      confusion, seizures, coma, cardiovascular collapse
    – Ensure adequate salt intake, as decreased sodium
      in the body can increase risk of lithium toxicity
Antipsychotic Agents
 Common side effects include dry mouth,
  blurred vision, constipation, nausea/GI upset,
  skin rash, sedation, orthostatic hypotension,
  photosensitivity, amenorrhea, weight gain
 Reduces seizure threshold
 ECG changes (prolonged QT interval)
    – Routine ECG completed before beginning therapy
   Hyperglycemia/diabetes in clients using
    atypical antipsychotics (risperidone, clozapine,
    olanzapine, quetiapine, ziprasidone, and
   Agranulocytosis
    – Most common with clozapine (Clozaril)
    – Potentially fatal blood disorder
    – WBCs drop to extremely low levels
    – Baseline WBC count completed before initiation of
      Clozaril therapy
        counts done weekly for first 6 months
        counts done biweekly for next 6 months
        counts done monthly thereafter
        Clozaril prescription only extended for these time
   Extrapyramidal symptoms (EPS)
    – Pseudoparkinsonism = tremor, shuffling gait,
      drooling, rigidity
    – Akinesia = muscle weakness
    – Akathisia = continuous restlessness and fidgeting
    – Dystonia = involuntary muscular
      movements/spasms of face, arms, legs, and neck
    – Oculogyric crisis = uncontrolled rolling back of the
      eyes; may appear to be seizure activity
    – Dystonia and oculogyric crisis are considered
      emergency situations, and require medical
      intervention; benztropine mesylate commonly
      administered IV or IM to relieve these side effects
   Tardive dyskinesia = bizarre facial and tongue
    movements, stiff neck, and difficulty
    – All long-term clients at risk
    – Potentially irreversible
    – Withdraw antipsychotic at first sign of symptoms
   Neuroleptic Malignant Syndrome = severe
    Parkinsonian muscle rigidity, hyperpyrexia (up
    to 107 degrees), tachycardia, stupor/coma
    – Rare, but potentially fatal
    – Routine assessment should include temperature
    – Discontinue immediately and give Parlodel
   Additive CNS depression when taken with
    alcohol, antihistamines, antidepressants, or
    any other CNS depressants

   Should not be used with MAOIs

   Barbiturates may decrease effectiveness of
    drugs metabolized by the liver
        Disorder Agents
 Common side effects include overstimulation,
  restlessness, insomnia, palpitations,
  tachycardia, anorexia/weight loss, nausea and
  vomiting, constipation, new or worsened
  psychiatric symptoms
 Tolerance develops rapidly
 Do not withdraw abruptly
 Should not be used within 14 days of taking
  an MAOI
 Buproprion contraindicated in clients with
  known/suspected seizure disorder
 Atomoxetine may cause severe liver damage
Objective 3

 Reviewing the risks and
 benefits of electroconvulsive
Electroconvulsive therapy (ECT) = the
  induction of a grand mal seizure through
  the application of electrical current to the
 Used for clients who are
    – acutely suicidal
    – severely depressed
    – experiencing psychotic symptoms
    – psychomotor retardation
    – neurovegetative changes (disturbances in
      sleep, appetite, and energy)
   Only considered as final treatment measure
Side effects and risks associated with ECT:
 Temporary memory loss
    – lasts approximately 30 minutes
 Confusion
 Mortality
    – 2 : 100,000
    – MI or stroke in compromised clients
   Permanent memory loss
    – specific to time surrounding treatment
    – possible longer-term effects
   Brain damage
    – oxygenation
Objective 4

              types of
Psychotherapy takes place on a one-to-one
  basis between a client and a therapist
  (APRN, psychiatric social worker,
  psychiatrist, psychologist, or LMHP)
 Psychoanalysis: client gains insight and
  understanding about current relationships
  and behavior patterns by confronting
  unconscious conflicts that surface in the
  transference relationship with the analyst
  – free association
  – dream analysis
  – hypnosis
  – catharsis
        Modes of psychotherapy (cont’d)
 Interpersonal psychotherapy: time-limited
  therapy developed for the treatment of
  major depression
 Reality therapy: promotes the conviction
  that although an individual is a product of
  the past, he/she does not need to continue
  as its victim
  – based on power (self-empowering), belonging,
    freedom, fun, and survival
  – hope is instilled when therapy does not dwell
    on past failures, and client is able to look
    forward toward a change in behavior
Relaxation therapy:
 Deep-breathing exercises
 Progressive relaxation
 Meditation
 Mental imagery
 Biofeedback
Assertiveness training
Cognitive therapy: the individual is taught to
    control thought distortions that are
    considered to be a factor in the
    development and maintenance of mood
    disorders; goal is to provide symptom and
    identify dysfunctional patterns of thinking
         Objective 5

Examining behavior modification
Behavior Modification = an operant
    conditioning treatment approach that
    replaces undesirable behaviors with more
    desirable ones through positive or negative

   Positive reinforcement
    – rewarding good behavior
   Negative reinforcement
    – punishing bad behavior
   Extinction
    – removing the response (i.e. “time-out”)
           Objective 6

Exploring alternative
interventions for the
health client
Alternative medicine = interventions that differ
  from the traditional or conventional
  biomedical treatment of disease; refers to an
  intervention that is used instead of
  conventional treatment.
 Acupuncture
 Blue light/artificial light treatment
 Lifestyle/dietary changes
 Herbal medicine
 Chiropractic medicine
 Relaxation techniques
 Chelation therapy
Complementary medicine = therapeutic
  intervention that is different from, but used in
  conjunction with, traditional or conventional
  medical treatment.
 Herbal medicine
 Acupressure/Acupuncture
 Diet/Nutrition
 Chiropractic medicine
 Massage
 Therapeutic touch
 Yoga
 Pet therapy

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