A.T Maryville NURS 663 Exam 2

Lithium labs - level, NA, Ca, P, EKG, Creatinine, Urinalysis, CBC, TSH bipolar meds: depression - lurasidone (13+), olanzapine + fluoxetine (10+)(symbyax) bipolar acute and mixed mania - aripiprazole, risperidone, olanzapine (13+), quetiapine (acute only), asenapine (10+) classic mood stabilizers - Lamotrigine (excellent medication to use), lithium, Depakote (avoid in females if possible due to PCOS and Pregnancy), Tegretol, Trileptal (no evidence for true Bipolar disorder) anti-depressants - class not used w/bipolar disorder lithium - Anti-manic, antidepressant, anti-suicidal Lithium side effects - Frequent urination, increased thirst, weight gain, sedation lithium toxicity - sudden onset tremors, N/V/D, muscle weakness, slurred speech, confusion, seizures (slowing down, feel really out of it) Persistent Motor or Vocal Tic Disorder - pt in front of you only has one or the other but not both—they usually don't even know it is a tic, it is only meaningful if it's affecting their quality of life Tourette's d/o - Multiple motor and at least one vocal tic (some tics come and go, they don't have them all at the same time to receive the diagnosis) HRT - habit reversal training can be used to manage tics Tics tx - Alpha agonists (clonidine, guanfacine); Haldol is not the first-line txt Developmental Coordination Disorder - a motor disorder characterized by marked impairment in the development of motor coordination; movement isn't consistent w/age Stereotypic Movement Disorder - a motor disorder characterized by repetitive, seemingly driven, and apparently purposeless motor behavior, such as hand waving or head banging, but not include ASD sx Specific Learning Disorders - difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical abilities; dx by other professionals w/specialized training; NP tx comorbid d/o Anorexia nervosa - an eating disorder in which an irrational fear of weight gain leads people to starve themselves; restrictive or binge/purge/exercise Bulimia nervosa - an eating disorder characterized by episodes of overeating, usually of high-calorie foods, followed by vomiting, laxative use, fasting, or excessive exercise Binge-eating disorder - significant binge-eating episodes, followed by distress, disgust, or guilt, but without the compensatory purging, fasting, or excessive exercise Avoidant/restrictive eating disorder - avoiding or restricting foods in childhood. significantly low BMI; no distortion of body image or fear of gaining wt. r/o delusions around food Pica - an abnormal craving or appetite for nonfood substances, such as dirt, paint, or clay that lasts for at least 1 month; decrs incidence with incr age Feeding and Eating Disorders tx - Talk therapy (counseling is needed for the distress) (intensive outpatient, partial inpatient or actual inpatient admission may be needed); most have associated depression and/or anxiety Feeding and Eating Disorders meds - fluoxetine help but not direct tx Vyvanse approved for binge eating but not because of stimulant effects Encopresis - a childhood disorder characterized by repeated defecating in inappropriate places, such as one's clothing Enuresis - involuntary urination Encopresis Treatment - Behavior management: toilet refusal behavior, scheduled toileting time, incentives. Prevention of constipation Counseling Enuresis treatment - 1. First line is behavioral interventions: bed alarms, toileting at bedtime and during the night, bladder training 2. reassurance, resolves spontan, normal 4-5 yo Enuresis meds - Desmopressin nasal spray; Major Depressive Disorder Dx - 5+ for at least a 2-week period; either #1 or 2 req 1. Depressed mood most of the day, nearly every day (can be irritability in children & adolescents) 2. Diminished interest or pleasure in all, or almost all, activities 3. Change appetite/weight; kids not wt goals Insomnia or hypersomnia nearly every day 4. Up or down Psychomotor 5. Fatigue or loss of energy 6. Worthlessness/excessive or inappropriate guilt 7. Diminished ability to think or concentrate, or indecisiveness (don't confuse with ADHD, address mood first) 8. Recurrent thoughts of death, thoughts of suicide, or suicidal plan/intent: if hosp then 2 wk not req. SLAP - Social supports; lethal; access to means; plan and previous attempt Suicide risk: IS PATH WARM - Ideation, substance abuse, purpose to live gone; anxiety, trapped feeling; hopelessness, w/d from soc supports, anger w/rage; reckless, dramatic moods SIGECAPS - Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicide bipolar vs unipolar: look at bipolar if - 1. family hx: 1st degree relatives 2. Substance use: chasing high or low 3. Response to SSRI: no resp to multiple tries or evidence of mania with use (not diagnostic) coprolalia - involuntary utterance of obscenities or inappropriate remarks Bipolar I criteria - One manic episode required Mania - elevated, expansive, energetic + 3, (unless irritable mood then requires 4+) 1. SX Lastat least one week-any duration if hosp 2. Inflated self-esteem, grandiosity 3. Decreased need for sleep 4. More talkative, pressure to keep talking 5. Flight of ideas or racing thoughts 6. Distractibility: r/o ADHD (constant) intermit w/BD 7. Increase in goal-directed activity 8. Risky, impulsive behaviors (sex, money, pot for harm) hypomania vs mania - a milder form of elevated mood that are less severe and cause less impairment than ______ and (usually) don't require hospitalization Mania impairment - severe in work, social activities, or relationships or to necessitate hosp or there are psychotic features Hypomania impairment - cause a change in functioning but not severe Mood disorder r/o - No symptoms can be due to a substance or general medical condition Most common anxiety disorder in children - separation anxiety disorder-per p 193 & 222 in DSM-V Panic attack vs anxiety attack - thoughts of impending death distinctive for panic Selective Mutism - developmental disorder characterized by a consistent failure to speak in specific social situations despite speaking in other situations generalized anxiety disorder - an anxiety disorder in which a person is continually tense, apprehensive, and in a state of autonomic nervous system arousal for 6 mo or more Separation Anxiety Disorder (SAD) - A form of anxiety disorder in which the individual displays age-inappropriate, excessive, and disabling anxiety about being apart from his or her parents or away from home; fears for caregiver safety and health social anxiety disorder - an anxiety disorder involving the extreme and irrational fear of being embarrassed, judged, or scrutinized by others in social situations; avoidance of soc situations Phobias - A group of anxiety disorders involving a pathological fear of a specific object or situation Anxiety disorder tx - - First line tx: SSRIs: most effective, least s/e - Anti-anxiety drugs: buspirone, hydroxyzine, benadryl - Beta blockers: propranolol - Psychotherapy Avoid benzos Anxiety disorder meds - Fluoxetine, sertraline, escitalopram, citalopram, paroxetine, duloxetine, venlafaxine, desvenlafaxine, vilazodone (Viibryd), vortioxetine (Trintellix) from most to least often used/EBP SSRI mechanism of action - Blocking reabsorption / reuptake, of serotonin, leaves more serotonin available, which improves mood SNRI mechanism of action - Inhibit reuptake of both serotonin and norepinephrine Anti-depressant education - Always teach the Black Box warning for incr SI risk up to 24 y/o. Schizophrenia - a psychological disorder characterized by 2 of the following for at least 1 mo; must include at least one of first 3: 1. delusions, 2. hallucinations, 3. disorganized speech 4. Grossly disorganized/catatonic behavior 5. diminished, inappropriate emotional expression 6. IF have ASD or comm d/o then delu or hall a must bizarre delusions - clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences; do not play into delusions positive symptoms of schizophrenia - Delusions of reference, delusions of persecution, delusions of grandeur, thought broadcasting, though insertion, hallucinations, disorganized thought, disorganized behavior, catatonia negative symptoms of schizophrenia - Diminished emotions expression of face exp, eye contact, prosody, other non-verbal comm (hand, head, face movements; Avolition: dec self-motivated behav Alogia: diminished speech Anhedonia: diminished pleasure/interest Asociality: lack of interest in soc interation Prosody - intonation and rhythm of speech Positive symptoms - something is added Negative symptoms - something is removed Prodromal phase of schizophrenia - disorganized behavior, loss of interest, no hallucination, anxious, diffi making decisions acute phase of schizophrenia - meets criteria for diagnosis residual phase of schizophrenia - apparent psychosis has subsided, but symptoms remain (ex. Delusional thought content is still there) recovery phase of schiz - does not currently meet criteria and appears to not be in the midst of an episode Schizophrenia treatment - SGAs most common because they are better for neg sx; FGA better for pos sx. Pos sx respond better to tx. Most commonly used in children - risperidone, aripiprazole, olanzapine Third generation anti-psychotics (TGA) - Abilify, Vraylar and Rexulti--partial dopamine agonists metabolic syndrome - A syndrome marked by the presence of three or more of a group of factors: high blood pressure, abdominal obesity, high triglyceride levels, low HDL levels, Elevated BG Decreased insulin sensitivity metabolic syndrome tx - assess family hx for diabetes Start metformin prophylactically Psychiatric Scales for C/A - PHQ-9 SCARED-Child/SCARED-Parent (great for anxiety) Vanderbilt ADHD scales Brief Psychiatric Rating Scale Positive and Negative Symptom Scale Child Mania Rating Scale GAD-7 CBT - Anxiety and depression Change behavior to change thoughts and feelings Highly goal-oriented and focused Exposure therapy - behavioral techniques, such as systematic desensitization, that treat anxieties by exposing people (in imagination or actuality) to the things they fear and avoid; form of CBT Mania in adolescents - misdiagnosed as antisocial personality disorder or schizophrenia. Symptoms include: psychosis, alcohol or other substance abuse, suicide attempts, academic problems, philosophical brooding, OCD symptoms, multiple somatic complaints, marked irritability resulting in fights Sadock p364 Incidence of C/A living with SUD adult - Eight million children younger than age 18 live with at least one adult who has a ____;that is a rate of more than one in 10 children Families w/SUD - 1. Disrupts attachment, rituals, roles routines, communication soc life and finances 2. Secrecy, loss, conflict, violence, abuse, emo chaos, role reversal and fear 3. Impairs eye contact, tone, volume/rhythm of voice, soothing touch, read needs of infant: impaired attachment EMDR: reprocessing phases - focuses momentarily on past memories, present triggers or anticipated future experiences while simultaneously focusing on a set of external stimuli: tones, tapping, eye movement EMDR - combining rapid eye movement with recall of traumatic experience to reduce distress from that memory; cognitive restructure = beh/emo change interpersonal therapy (IPT) - treatment that strengthens social skills and targets interpersonal problems, conflicts, and life transitions, or change their perspectives of same DBT - 1.Acceptance and validation of behavior as it is in the moment 2. Treating therapy‐interfering behaviors of both client and therapist 3. The assumption that the therapeutic relationship is essential to the treatment 4. Dialectic process: persuasive dialogue, focus on reality Pregnancy risks for meds - SSRIs generally okay Depakote: for any woman of child bearing age Mood stabilizers: cardiac anomolies, neural tube defects Drugs in 3rd tri rarely teratogenic Lithium uses - 1. manic episodes of manic-depressive illness 2. maintenance treatment for manic-depressive pts with a hx. of mania 3. bipolar depression 4. MDD (adjunctive) 5. treatment -resistant depression 6. Reduces suicide risk 7. Works well in combination with atypical antipsychotics and/or mood stabilizing anticonvulsants such as valproate lithium common SE - 1. tremor, ataxia, dysarthria, delirium memory problems 2. polyuria, polydipsia, 3. diarrhea, nausea, vomiting 4. Weight gain Lithium: Life-Threatening SE's - 1. toxicity 2. Renal impairment 3. Nephrogenic diabetes insipidus 4. Arrhythmia, CV changes, sick sinus syndrome, bradycardia, hypotension, Twave flattening and inversion 5. rare seizures Lithium mgmt - 1. Lower the dose 2. Take at night 3. Change to different preparation (e.g. controlled-release) 4. Reduce dosing from TID to BID 5. If toxicity symptoms- DISCONTINUE 6. Stomach upset- take with food 7. Tremor- avoid caffeine 8. May need to switch to another agent Lithium lab monitoring - frequent _________levels-every 1-2 weeks until desired serum concentration achieved, then every 2-3 months for 1st 6 months, then every 6-12 months if remains stable lithium range - 1.0-1.5 mEq/L for acute treatment and 0.6- 1.2 mEq/L for chronic treatment Megacolon - chronic rectal distention from large, hard fecal masses can cause loss of tone in the rectal wall and desensitization to pressure Encopresis dx - 1. Repeated passage of feces into inappropriate places (involuntary or intentional) 2. Occurs each month for at least 3 months 3. At least age 4 or equivalent developmental level 4. Behavior not attributable to substances or medical conditions except through a mechanism involving constipation Associative Looseness - Speech shifts to unrelated subjects. Pt. unaware they are unconnected. When severe, speech may be incoherent Neologisms - Invented meaningless words but are symbolic to pt Concrete Thinking - Difficulty describing abstract sayings; "I'm climbing the walls," or "It's raining cats and dogs." Takes things literally. Clang Associations - Uses rhyming words; "I am cold and bold. The gold has been sold." Word Salad - flow of unconnected words that convey no meaning to the listener