Mental Health Capstone
- ANS--Reaction-formation occurs when the client behaves in an opposite manner from his
actual feelings.
-Compensation occurs when a person overcomes a weakness by focusing on a more
desirable behavior or trait.
-The client is demonstrating rationalization by trying to justify his alcohol use by blaming his
boss.
-Suppression occurs when a person consciously denies a feeling that is disturbing to him.
#Bipolar Disorders - ANS-Mania: excessively elevated mood, requires hospitalization
Hypomania: less severe version, does not require hospitalization
S/S:●mood swings●restlessness●flight of ideas●pressured
speech●grandiosity●impulsiveness●poor judgement●decreased attention
span●insomnia●neglect of ADLs●hallucinations/delusion.
NURSING INTERVENTIONS:●safe environment●protect the pt from poor judgement (giving
away money, sexual activity, exc)●decrease stimulation●if r/f injury to self or others: 1 to 1
sitter or restraints or seclusion.●monitor sleep, fluid, food intake and provide high calorie and
nutrient *finger foods●frequent rest periods●set limits and give concise, short, and firm
explanations/directions.
MEDS:lithium, anticonvulsants, antidepressants, antipsychotic, antianxiety
Type 1:has had 1 episode of mania alternating with major depression
Type 2:has had 1 or more episodes of hypomania alternating with major depression
ADHD - ANS-Involves the inability of a person to control behaviors requiring sustained
attention.
The nurse should expect a school-age child who has ADHD to exhibit*●impulsivity (difficulty
waiting for turns, constantly interrupting others, and acting without the consideration of
consequences.)*●hyperactivity (fidgeting, an inability to sit still, running and climbing
inappropriately, difficulty with playing quietly, and talking excessively)*●decreased attention
span●talkativeness●decreased ability to follow directions●inability to complete tasks●poor
social skills*●intrusive behaviors (invades personal space)
●Inattentive and impulsive behavior can put the child at risk for injury.●Behaviors associated
with ADHD must be present prior to age 12 and must be present in more than one setting to
, be diagnosed as ADHD. Behaviors associated with ADHD can receive negative attention
from adults and peers.
Alcohol Withdrawal - ANS-MANIFESTATIONS
●Manifestations include abdominal cramping; vomiting; tremors; restlessness and inability to
sleep; increased heart rate; transient hallucinations or illusions; anxiety; increased blood
pressure, respiratory rate, and
temperature; and tonic‑clonic seizures.
●Alcohol withdrawal delirium can occur 2 to 3 days after cessation of alcohol. This is
considered a medical
emergency. Manifestations include severe disorientation,
psychotic manifestations (hallucinations), severe
hypertension, cardiac dysrhythmias, and delirium. Alcohol withdrawal delirium can progress
to death.
Alzheimer's Disease - ANS--a non reversible typeof dementia that progressively develops
over many years. Results in memory loss, problems with judgment, and personality changes
.-The earliest possible sign of Alzheimer's disease is when the client is aware of his memory
lapses.
-Genetic testing can be done prior to the occurrence of any manifestations of AD. The test
notes the presence of the apolipoprotein E-4 gene, which can indicate an increased risk of
developing AD.
S/S:-->Stage 1: MILD#●Memory lapses#*●Losing or misplacing familiar items#●Difficulty
concentrating and organizing#*●unable to remember material just read#●Still able to
perform ADLs●Short‑term memory loss noticeable to close relations
-->Stage 2: MODERATE●Forgetting events of one's own history#●Difficulty performing tasks
that require planning and organizing (paying bills, managing money)●Difficulty with complex
mental arithmetic (finances)#●Personality and behavioral changes: appearing withdrawn or
subdued, especially in social or mentally challenging situations; compulsive; repetitive
actions●Changes in sleep patterns#●Can wander and get lost (safety!)●Can be
incontinent●Clinical findings that are noticeable to others
-->Stage 3: SEVERE●Losing ability to converse with others#●Assistance required for
ADLs#●Incontinence●Losing awareness of one's environment●Progressing difficulty with
physical abilities (walking, sitting, and eventually swallowing)#●Eventually losses all ability to
move; can develop stupor and coma#●Death frequently related to choking or infection
-pt edu for minimizing behavioral problems at home:-explaining, arguing, or trying to reason
with the client when acting out will increase agitation and confusion.-briefly leave the room
when the client becomes agitated. Return in a short period of time to promote a sense of
safety. If the client is still agitate
Alzheimer's disease (AD) Cont'd... - ANS-NURSING INTERVENTION-provide safe
environment (falls/wandering)-monitors and bed alarms-room near nursing station-provide
prominently display calendar and clock to reorient often-maintain consistency in
caregivers-calm voice, short sentences, limit choices
MED:-donepezil - slows cognitive deteriation and improves ability to perform ADLs.
administered daily ACHS (se: GI upset, brady cardia. administer daily and bedtime)
- ANS--Reaction-formation occurs when the client behaves in an opposite manner from his
actual feelings.
-Compensation occurs when a person overcomes a weakness by focusing on a more
desirable behavior or trait.
-The client is demonstrating rationalization by trying to justify his alcohol use by blaming his
boss.
-Suppression occurs when a person consciously denies a feeling that is disturbing to him.
#Bipolar Disorders - ANS-Mania: excessively elevated mood, requires hospitalization
Hypomania: less severe version, does not require hospitalization
S/S:●mood swings●restlessness●flight of ideas●pressured
speech●grandiosity●impulsiveness●poor judgement●decreased attention
span●insomnia●neglect of ADLs●hallucinations/delusion.
NURSING INTERVENTIONS:●safe environment●protect the pt from poor judgement (giving
away money, sexual activity, exc)●decrease stimulation●if r/f injury to self or others: 1 to 1
sitter or restraints or seclusion.●monitor sleep, fluid, food intake and provide high calorie and
nutrient *finger foods●frequent rest periods●set limits and give concise, short, and firm
explanations/directions.
MEDS:lithium, anticonvulsants, antidepressants, antipsychotic, antianxiety
Type 1:has had 1 episode of mania alternating with major depression
Type 2:has had 1 or more episodes of hypomania alternating with major depression
ADHD - ANS-Involves the inability of a person to control behaviors requiring sustained
attention.
The nurse should expect a school-age child who has ADHD to exhibit*●impulsivity (difficulty
waiting for turns, constantly interrupting others, and acting without the consideration of
consequences.)*●hyperactivity (fidgeting, an inability to sit still, running and climbing
inappropriately, difficulty with playing quietly, and talking excessively)*●decreased attention
span●talkativeness●decreased ability to follow directions●inability to complete tasks●poor
social skills*●intrusive behaviors (invades personal space)
●Inattentive and impulsive behavior can put the child at risk for injury.●Behaviors associated
with ADHD must be present prior to age 12 and must be present in more than one setting to
, be diagnosed as ADHD. Behaviors associated with ADHD can receive negative attention
from adults and peers.
Alcohol Withdrawal - ANS-MANIFESTATIONS
●Manifestations include abdominal cramping; vomiting; tremors; restlessness and inability to
sleep; increased heart rate; transient hallucinations or illusions; anxiety; increased blood
pressure, respiratory rate, and
temperature; and tonic‑clonic seizures.
●Alcohol withdrawal delirium can occur 2 to 3 days after cessation of alcohol. This is
considered a medical
emergency. Manifestations include severe disorientation,
psychotic manifestations (hallucinations), severe
hypertension, cardiac dysrhythmias, and delirium. Alcohol withdrawal delirium can progress
to death.
Alzheimer's Disease - ANS--a non reversible typeof dementia that progressively develops
over many years. Results in memory loss, problems with judgment, and personality changes
.-The earliest possible sign of Alzheimer's disease is when the client is aware of his memory
lapses.
-Genetic testing can be done prior to the occurrence of any manifestations of AD. The test
notes the presence of the apolipoprotein E-4 gene, which can indicate an increased risk of
developing AD.
S/S:-->Stage 1: MILD#●Memory lapses#*●Losing or misplacing familiar items#●Difficulty
concentrating and organizing#*●unable to remember material just read#●Still able to
perform ADLs●Short‑term memory loss noticeable to close relations
-->Stage 2: MODERATE●Forgetting events of one's own history#●Difficulty performing tasks
that require planning and organizing (paying bills, managing money)●Difficulty with complex
mental arithmetic (finances)#●Personality and behavioral changes: appearing withdrawn or
subdued, especially in social or mentally challenging situations; compulsive; repetitive
actions●Changes in sleep patterns#●Can wander and get lost (safety!)●Can be
incontinent●Clinical findings that are noticeable to others
-->Stage 3: SEVERE●Losing ability to converse with others#●Assistance required for
ADLs#●Incontinence●Losing awareness of one's environment●Progressing difficulty with
physical abilities (walking, sitting, and eventually swallowing)#●Eventually losses all ability to
move; can develop stupor and coma#●Death frequently related to choking or infection
-pt edu for minimizing behavioral problems at home:-explaining, arguing, or trying to reason
with the client when acting out will increase agitation and confusion.-briefly leave the room
when the client becomes agitated. Return in a short period of time to promote a sense of
safety. If the client is still agitate
Alzheimer's disease (AD) Cont'd... - ANS-NURSING INTERVENTION-provide safe
environment (falls/wandering)-monitors and bed alarms-room near nursing station-provide
prominently display calendar and clock to reorient often-maintain consistency in
caregivers-calm voice, short sentences, limit choices
MED:-donepezil - slows cognitive deteriation and improves ability to perform ADLs.
administered daily ACHS (se: GI upset, brady cardia. administer daily and bedtime)
