Interactive Study Flashcards

GAD: Persistent, excessive worry for ≥6 months about multiple events. Symptoms: restlessness, fatigue, difficulty concentrating.

Panic Disorder: Recurrent unexpected panic attacks — intense fear peaking in minutes with palpitations, diaphoresis, chest pain, feeling of impending doom.

Positive symptoms (excess of normal function):
- Delusions (paranoid, grandiose, referential)
- Disorganized speech (loose associations, word salad)
- Disorganized/catatonic behavior

Negative symptoms (5 A's):
- Alogia, Avolition, Anhedonia, flat Affect, Attention deficit

Key: Positive symptoms respond better to antipsychotics than negative symptoms.

Bipolar I: At least one manic episode (euphoria, grandiosity, decreased need for sleep, risky behavior, pressured speech). May have depressive episodes.

Bipolar II: Hypomanic episodes (less severe, no psychosis) + major depressive episodes. Depression is the predominant problem.

Mnemonic: SIG E CAPS
Sleep changes
Interest loss (anhedonia)
Guilt/worthlessness
Energy decreased
Concentration impaired
Appetite/weight changes
Psychomotor agitation/retardation
Suicidal ideation

≥5 symptoms for ≥2 weeks

Post-Traumatic Stress Disorder — follows exposure to traumatic event:

1. Intrusion: Flashbacks, nightmares
2. Avoidance: Avoiding triggers/reminders
3. Negative cognition/mood: Guilt, detachment, inability to feel positive emotions
4. Arousal: Hypervigilance, irritability, exaggerated startle

Key features:
- Unstable relationships, self-image, and emotions
- Fear of abandonment (real or imagined)
- Impulsivity, self-harm, suicidal gestures
- Chronic emptiness, identity disturbance
- Intense, short-lived relationships

Treatment: Dialectical Behavior Therapy (DBT) is gold standard — teaches distress tolerance, mindfulness, emotion regulation.

Obsessions: Recurrent, unwanted intrusive thoughts causing anxiety (contamination, harm, symmetry)

Compulsions: Repetitive behaviors performed to reduce anxiety (handwashing, checking, counting)

Nursing: Do NOT interrupt rituals abruptly. Gradually limit ritual time. SSRIs (fluvoxamine) + CBT/ERP therapy.

Anorexia: Restriction of intake, intense fear of weight gain, distorted body image. BMI <17.5. Complications: bradycardia, amenorrhea, lanugo, electrolyte imbalance.

Bulimia: Binge-purge cycles. Often normal weight. Complications: Russell's sign (knuckle calluses), dental erosion, hypokalemia, esophageal tears.

1. Mild — Alert, perceptual field broad, best for learning
2. Moderate — Focus narrows, can still problem-solve with direction
3. Severe — Focus very narrow, difficulty thinking, physical symptoms increase
4. Panic — Loss of rational thought, terror, immobilization or flight

Nursing: Stay calm, use short clear statements at severe/panic levels.

Delirium: Acute onset, fluctuating consciousness, reversible. Causes: infection, medications, metabolic. Priority: treat underlying cause.

Dementia: Gradual onset, progressive and irreversible, alert consciousness. Memory loss, personality changes.

Key: Delirium = sudden & fixable. Dementia = slow & permanent.

Selective Serotonin Reuptake Inhibitors — first-line for depression/anxiety:
- Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Escitalopram (Lexapro)

Nursing: Takes 2-4 weeks for effect. Monitor for serotonin syndrome. Suicidal risk may increase initially. Do NOT stop abruptly.

Life-threatening excess serotonin activity. Triad:

1. Mental status changes — agitation, confusion
2. Autonomic instability — hyperthermia, tachycardia, diaphoresis
3. Neuromuscular — clonus, hyperreflexia, tremor

Nursing: Stop serotonergic drugs. Cyproheptadine (antidote). Cooling measures. This is a medical emergency.

Use: Bipolar disorder (mood stabilizer)

Therapeutic level: 0.6-1.2 mEq/L
Toxic: >1.5 mEq/L

Toxicity signs: N/V/D, coarse tremor, confusion, seizures

Nursing: Draw levels 12 hrs post-dose. Maintain adequate sodium and fluid intake. Monitor thyroid and renal function. Avoid NSAIDs and dehydration.

Typical (1st gen): Haloperidol, Chlorpromazine
- Block dopamine D2 receptors
- High risk of EPS (dystonia, akathisia, tardive dyskinesia)

Atypical (2nd gen): Risperidone, Olanzapine, Quetiapine, Clozapine
- Block serotonin + dopamine
- Lower EPS risk
- Risk: metabolic syndrome, weight gain
- Clozapine: requires ANC monitoring (agranulocytosis)

Life-threatening reaction to antipsychotics. Mnemonic: FEVER

Fever (high, >104°F)
Encephalopathy (confusion)
Vitals unstable (tachycardia, BP changes)
Elevated enzymes (CPK markedly elevated)
Rigidity ("lead-pipe" muscle rigidity)

Treatment: Stop antipsychotic. Dantrolene + Bromocriptine. Cooling. ICU monitoring.

Uses: Anxiety, seizures, alcohol withdrawal, insomnia

Examples: Lorazepam (Ativan), Diazepam (Valium), Alprazolam (Xanax), Clonazepam (Klonopin)

Nursing:
- High addiction potential — short-term use only
- CNS depression — monitor sedation
- Do NOT combine with alcohol/opioids
- Antidote: Flumazenil
- Never stop abruptly (seizure risk)

MAOIs (Phenelzine, Tranylcypromine) inhibit monoamine oxidase, preventing tyramine breakdown.

Avoid tyramine-rich foods:
- Aged cheese, cured meats, red wine, beer
- Soy sauce, sauerkraut, smoked fish

Why: Tyramine + MAOI = hypertensive crisis (severe headache, stiff neck, nausea, stroke risk). Emergency: Phentolamine IV.

Acute dystonia: Muscle spasms (neck, tongue, eyes). Treat: Benztropine (Cogentin) or Diphenhydramine IM

Akathisia: Restlessness, can't sit still. Treat: Propranolol, Benzodiazepines

Pseudoparkinsonism: Tremor, shuffling gait, rigidity. Treat: Benztropine

Tardive dyskinesia: Involuntary lip-smacking, tongue movements. Often irreversible. Stop offending drug.

Use: Mood stabilizer (bipolar), seizures, migraine

Therapeutic level: 50-100 mcg/mL

Nursing:
- Monitor liver function (hepatotoxicity risk)
- Monitor platelets (thrombocytopenia)
- Teratogenic — Category X in pregnancy (neural tube defects)
- GI upset — take with food
- Monitor ammonia levels

Acute withdrawal treatment:
- Benzodiazepines (Lorazepam, Chlordiazepoxide) — first-line, prevent seizures
- Thiamine (B1) — give BEFORE glucose (prevent Wernicke's)

Long-term relapse prevention:
- Disulfiram (Antabuse) — aversion therapy, causes severe N/V with alcohol
- Naltrexone (ReVia) — blocks opioid receptors, reduces craving
- Acamprosate (Campral) — restores GABA/glutamate balance

Ask directly — "Are you thinking about hurting yourself?"

Assess using SAD PERSONS:
Sex (male higher risk), Age (<19 or >45), Depression, Previous attempts, Ethanol use, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness

Key: Specific plan + means + timeline = HIGH risk

Priority: SAFETY

1. 1:1 continuous observation
2. Remove all sharps, belts, cords, medications
3. Place in room closest to nurses' station
4. Check belongings and visitors' items
5. No-suicide contract (not a substitute for monitoring)
6. Highest risk: When depression begins to lift (has energy to act)
7. Document all assessments and interventions

1. Remain calm, use low/even tone
2. Maintain safe distance, avoid cornering
3. Use short, simple statements
4. Acknowledge feelings: "I can see you're upset"
5. Offer choices: "Would you like to sit or walk?"
6. Set clear limits: "I want to help, but hitting is not okay"
7. Never argue, challenge, or threaten
8. Have an exit route — never turn your back

Last resort only — after all least-restrictive measures fail

- Physician order required within 1 hour
- Adults: renew Q4H. Children: Q2H
- Assess circulation, sensation, movement Q15 min
- Offer food, fluids, toileting Q2H
- Document behavior requiring restraint
- Release at earliest possible time
- Never restrain prone (aspiration risk)

Early (6-24 hrs): Tremors, anxiety, N/V, insomnia, tachycardia, diaphoresis

DTs (48-72 hrs):
- Hallucinations (visual: bugs, snakes)
- Seizures
- Severe confusion/agitation
- Autonomic instability (fever, severe HTN)
- Can be fatal if untreated

Nursing: Seizure precautions, CIWA scoring, benzodiazepines, thiamine

Safety first! Command hallucinations (voices telling patient to harm self/others) are highest risk.

Nursing priorities:
1. Ask directly: "Are the voices telling you to hurt yourself or someone?"
2. Do NOT argue about whether voices are real
3. Present reality: "I don't hear voices, but I understand they are real to you"
4. Maintain 1:1 supervision
5. Administer antipsychotic PRN as ordered

ECT: Electrical stimulation to brain under general anesthesia for severe depression unresponsive to meds.

Pre-ECT: NPO 6-8 hrs, informed consent, atropine (reduce secretions), remove dentures

Post-ECT:
- Temporary memory loss and confusion (expected)
- Reorient frequently
- Monitor vitals Q15 min
- Side-lying until gag reflex returns

1. Pre-crisis: Usual coping intact
2. Impact: Event overwhelms coping, anxiety rises
3. Crisis: Disorganization, inability to function
4. Resolution: New coping or deterioration

Nursing role:
- Active, directive approach (not passive)
- Focus on the here and now
- Help identify coping resources
- Crisis intervention is short-term (4-6 weeks)

Denial: Refusing to accept reality or facts to protect from painful truth.

Example: A patient diagnosed with liver cirrhosis from alcohol abuse says, "I don't have a drinking problem. The doctor is wrong."

This is one of the most primitive defense mechanisms and is common in addiction and grief (Kubler-Ross Stage 1).

Projection: Attributing your own unacceptable feelings to others. "You're the one who's angry, not me!"

Displacement: Redirecting emotions to a safer target. Yelling at spouse after being criticized by boss.

Rationalization: Making excuses to justify behavior. "I failed because the test was unfair" (instead of didn't study).

Regression: Returning to an earlier developmental stage when stressed.

Examples:
- A 6-year-old starts bedwetting after a new sibling is born
- A hospitalized adult becomes clingy and dependent
- An adult throws a tantrum when frustrated

Commonly seen in: Hospitalized children, during illness, high-stress situations. It's usually temporary.

Sublimation: Channeling unacceptable impulses into socially acceptable activities. This is a mature/healthy defense mechanism.
Example: Aggressive person takes up boxing.

Reaction Formation: Behaving in the opposite way of how you truly feel.
Example: A person who dislikes a coworker acts excessively friendly toward them.

Splitting: Viewing people or situations as all good or all bad — no middle ground (black-and-white thinking).

"You're the best nurse ever!" → next shift → "You're terrible!"

Nursing response:
- Consistent staff assignments
- Team communication to prevent staff splitting (playing staff against each other)
- Maintain neutral, non-reactive responses
- Document patterns of splitting behavior

Repression: Unconscious blocking of painful memories. Person is unaware. Child abuse survivor has no memory of events.

Suppression: Conscious, deliberate pushing aside of thoughts. "I'll think about that later." This is a mature mechanism.

Dissociation: Detachment from reality. Mental "escape" during trauma. Seen in Dissociative Identity Disorder.

Voluntary: Patient requests admission, retains rights, can request discharge (facility may require 24-72 hr notice).

Involuntary: Committed against will when patient is a danger to self or others or is gravely disabled. Requires physician certification and judicial review within timeframe set by state law.

Patient Bill of Rights includes:
- Right to refuse treatment (unless court-ordered)
- Right to least restrictive environment
- Right to confidentiality (HIPAA protected)
- Right to communicate freely (mail, phone, visitors)
- Right to dignity and respect
- Right to individualized treatment plan
- Right to voice grievances without retaliation
- Right to habeas corpus (challenge involuntary hold)

Duty to Warn (Tarasoff ruling):
Must break confidentiality when patient poses a credible threat to an identifiable person.

Other exceptions:
- Child/elder abuse — mandatory reporting
- Suicidal intent with specific plan
- Court-ordered disclosure
- Communicable disease reporting (state laws)

Document everything. Notify only those who need to know.

1. Autonomy — Respect patient's right to make decisions

2. Beneficence — Do good, act in patient's best interest

3. Nonmaleficence — Do no harm

4. Justice — Fair and equal treatment for all patients

Also: Veracity (truthfulness) and Fidelity (keeping promises/commitments)

Patient must be informed of and agree to treatment. Requires:

1. Capacity to understand information
2. Disclosure of treatment, risks, benefits, alternatives
3. Voluntary decision (no coercion)
4. Comprehension demonstrated

Exceptions: Emergency situations when patient cannot consent and delay would be dangerous. Legal guardian consent for incompetent patients.

Competent patients have the right to refuse.

Nursing actions:
1. Explore reasons for refusal (side effects? beliefs?)
2. Educate on risks of non-treatment
3. Document refusal and education provided
4. Notify physician
5. Do NOT force medication (unless court-ordered or imminent danger)
6. Offer alternatives when available

Exception: Emergency — patient is immediate danger to self/others.