NCLEX-RN PREPARATION PROGRAM

1. NCLEX-RN PREPARATION PROGRAM MENTAL HEALTH DISORDERS Module 6, Part 3 of 3

2. Pharmacologic Agents and Mental Illness Psychotherapeutic drug agents • Symptomatic treatment • Psychotropic drugs • Effects on neurotransmitters • Lipid-solubility of brain barrier

3. Classification of Drug Agents Psychotherapeutic drug agents • Antianxiety agents • Antidepressants • Antimanic agents • Antipsychotic agents • Antiparkinson (anticholinergic) agents

4. Drug-Related Information for the Nurse Psychotherapeutic drug agents • Desired therapeutic effect • Side effects • Adverse effects • Normal dosage ranges • Indications for use/contraindications • Nursing diagnoses • Nursing interventions • Client/family teaching • Outcome evaluation

5. Antianxiety (Anxiolytic) Agents Psychotherapeutic drug agents • Indications for use • Anxiety and anxiety disorders • Acute alcohol withdrawal • Skeletal muscle spasms • Convulsive and seizure disorders • Status epilepticus • Preoperative sedation

6. Therapeutic Antianxiety Agents Psychotherapeutic drug agents • Antihistamines • Benzodiazepines • Beta-Adrenergic Blockers • Miscellaneous

7. Antidepressants Psychotherapeutic drug agents • Indications for use • Major depression • Dysthymic and bipolar disorders • Childhood disorders • Obsessive-compulsive disorders • ADHD • Panic disorder • Chronic pain • Associated organic diseases

8. Antidepressant Drug Agents Psychotherapeutic drug agents • Tricyclic antidepressants • Heterocyclics • Serotonin-specific Reuptake Inhibitors (SSRIs) • Nonselective Reuptake Inhibitors • Monoamine Oxidase Inhibitors (MAOIs)

9. Mood Stabilizing Drug Agents Psychotherapeutic drug agents • Indications for use • Manic episodes associated with bipolar disorders • Bipolar maintenance therapy • Migraine headaches • Schizoaffective disorders

10. Mood Stabilizing Drug Agents Psychotherapeutic drug agents • Antimanic • Lithium carbonate • Anticonvulsants • Calcium-channel blocker

11. Antipsychotic Agents Psychotherapeutic drug agents • Indications for use • Acute and chronic psychosis • Mania • Dementia-induced psychosis • Intractable hiccups • Control of tics and vocal disturbances • Adverse reactions and side effects • Anticholinergic effects • Extrapyramidal side effects

12. Life Span Mental Health Issues

13. Family Systems • Understanding impact of present and past family patterns of behavior on the choices we make • Can lead to intentional desire to make changes and refusal to continue cycle

14. Family Systems • Nuclear family of origin • Includes family history/relationships • Single emotional unit of relationships that intermingle over generations • Family Dynamics – key to understanding current behaviors • Tend to seek partners of similar differentiation

15. Family Systems: Healthy • Clear generational lines • Strong parental coalition • Maintenance of marital relationship • Communication is clear, honest, direct, specific and congruent • Roles clear and not defined by gender • Rules defined and respected • Okay to express ideas that differ • Differences accepted

16. Family Systems: Healthy • Empathy, warmth & caring expressed • Feelings addressed • Level of conflict low and resolved • High self-esteem • Parents make decisions • Healthy lifestyle • Regular exercise & recreation • Absence of dangerous activities • No significant deviance in school or work performance, or in relationships with others

17. Family Systems: Troubled • Strive to do well • Boundaries appear clear, but when under pressure • Turn inward (rigid) or • Problems spill into the environment (disordered, diffuse) • Links to society may be mistrustful, with limited input from larger society • Children learn power through manipulation rather than learning responsibility

18. Family Systems: Troubled • Power may be diffuse and may not come from parents • Little empathy shown • Conflict over rules & family norms • Caring is controlling rather than growth producing • Self-esteem low

19. Family Systems: Troubled(continued) • Parental coalition present, but weak and ineffective • Parents may reach across generational boundaries for comfort and support • “Triangled” often symptom bearer • Overt or covert incestuous situations may be present

20. Family Systems: Troubled(continued) • Communication: May not be clear, honest or specific • Expressed with fear, guilt or anger • Incongruence between verbal and nonverbal • Disqualification through silence, ignoring, evasiveness or changing subject • Excessive use of alcohol, nonprescription and Rx drugs • Eventual dysfunction of one or more family members

21. Family System and Children • Children are affected by family relationships • Marital conflict • Fighting • Siblings • Boundaries • Parental psychopathology • Separation/loss: death, divorce, absent parent

22. Family Psychoeducation • Focus on education & support • Works best with family & client with major mental illness • Techniques • Communication training • Problem solving • Goals: • Improve course of the family member’s illness •  relapse rates •  client and family functioning • Goals achieved through: • Educating family about mental illness • Teaching families techniques to cope • Reinforcing family strengths

23. Commonalities of Family Theories • Individualsymptoms understood in context of family system • Facilitate interaction & communication among family members • Family members directed to modify patterns of their relationships

24. Disorders of Infants, Children and Adolescents

25. Etiologic Factors Etiology • Genetic (1st degree biological relative with disorder or family history of mental issues) • Environmental Socioeconomic – neighborhood Family income Educational level of family members • Parental divorce • Combined factors

26. Infancy: Attachment Theory • Suggests most significant affectional bond between parent and child • Essential for healthy emotional development • Disruption • Parental mental disorder, chemical dependence, absence • Attachment experiences shape circuitry of brain • Faulty circuitry leaves child vulnerable to later emotional dysregulation • Disruption correlated with development of psych disorders

27. Infancy: Eating Disorders Pica: • Eating 1 or more non-nutritive substances for at least 1 month and inappropriate for developmental level • Frequently associated with mental retardation (MR) and pervasive development disorder (PDD) Infancy Feeding Disorder • Persistent failure to eat adequately • Significant failure to gain weight or weight loss for at least 1 month • R/0 medical condition • Temperamental characteristics and parental psychopathology, child abuse/neglect

28. Anxiety Disorders Anxietydisorders • Separation Anxiety Disorder - Developmentally inappropriate excessive anxiety over separation from home/attachment figures • Worry about harm to self/parent • Fear of sleep without attachment person present • Attention-demanding behavior Tic Disorders • Rapid, rhythmic, involuntary movements or vocalizations • Symptoms accentuated with stress, excitement & fatigue • Tourette's Syndrome: Worst. Haloperidol (haldol)

29. Elimination Disorders Enuresis: Bed wetting > 5 years old, 2x/ week for 3 consecutive months Encopresis: Stool in inappropriate places, voluntary or involuntary: 1 incident per month for > 3 months

30. Communication Disorders • Variation in voice, rhythm or articulation • Impairments in: • Language expression (limited vocabulary, errors in tense, difficulty recalling words or producing sentences with dev. appropriate length) • Understanding language (i.e., words) • Phonology (speech & sound production) • Stuttering (sound & syllable repetition, sound prolongation, etc.) Evidence for a genetic factor

31. Pervasive Developmental Disorders(PDD) • Due to a mental and/or physical impairment (or combination) • Diagnosed before age 22, 60% co-existing psychiatric disorder • Functional limitations (in 3 areas): • Self-care • Language • Learning • Self-direction • Mobility • Independent living • Economic self-sufficiency • May have average or above average IQ • e.g., autistic disorder, down syndrome, seizure disorder

32. PDD: Autistic Disorder • Onset < 2.5 years • 75% retarded • Repetitive behavior: rocking, twisting • Upset over changes in routine • Poor coordination • Impaired communication • Lack emotional responsiveness & social reciprocity • Fail to develop interpersonal skills

33. Mental Retardation (MR) • Diagnosed < age 18. Mild to profound • Sub-average intellectual functioning (IQ 70 or below) • Limitations in 2 or more adaptive skill areas: • Self-care • Communication • Home living • Self-direction • Social skills • Community use • Academics • Leisure, work • Health & safety

34. Disorders of Childhood Motor Skills Disorder • Motor coordination below expected for age and measured intelligence Learning Disorders • Reading, math or writing skills below that expected for age, schooling, level of intelligence

35. Behavior Disorders Attention Deficit/Hyperactivity Disorder • Dx’d under age 7 w/ > 6 months duration, more frequent in males • Problems paying attention & concentrating and/or with hyperactive & impulsive behavior • Unable to listen well, organize work and follow directions • Risk failing at school • 1/3 substance-abuse problems • Often continues into adulthood •  blood flow & lower levels of electrical activity - requires more stimulation to feel optimally aroused

36. Behavior Disorders:ADHD Tx • Ritalin (methylphenidate) drug of choice • Stimulant s availability of norepinephrine • Helps adults/children  concentration • Other stimulant drugs: Adderall (amphetamine mixture), Concerta (long acting Ritalin), Dexedrine, Cylert • New route of delivery - patch (good for those with difficulty swallowing, remove after school) • At risk for stunted bone growth,  BP •  concern about abuse potential • 70% respond to stimulants • Antidepressants may help

37. Behavior Disorders:ADD/ADHD Teaching points for ADD/ADHD • Set clear limits for behavior • Give positive reinforcement for desired behavior • Give time out for undesired behavior • Provide feedback as soon as possible after behavior • Consistent approach from both parents • Keep instructions simple • Ask child to repeat instructions • Set realistic goals for child’s behavior

38. Behavior Disorders:ADD/ADHD Stimulant Medication–teaching points for parents • Assess for decreased appetite, weight loss, growth delays, abuse • Prevent insomnia–give no later than 6 hours before bedtime • Do not stop medication abruptly • Give at mealtimes if weight loss; offer with favorite foods

39. Behavior Disorders Oppositional Defiant Disorder (ODD) Negative, defiant, disobedient, hostile Argues incessantly without compromise Defiant refusal to obey rules or laws Vindictive, spiteful and resentful Suspension and expulsion from school Conduct Disorder (CD) Disruptive, destructive behavior, rules violated, deceitful, willful defiance, aggression, truancy, cruelty to animals and people, impairment in social, academic or occupational functioning ADHD ODD CD APD

40. Childhood Disorders Many disorders not diagnosed until adulthood • Substance abuse: Early use (by age 11) predicts more sustained use • Depressive disorders: Adolescents express in acting out behaviors to hide vulnerability • Bipolar disorders: Sleep disruption, energetic, grandiosity, poor judgment • Thought disorders: Hallucinations and delusions less detailed, delays in speech development, poor eating and sleeping habits • High rate of co-occurring disorders

41. The nurse is providing community education about autism to a group of parents. The nurse concludes that teaching has been effective if the parents describe which of the following as common behavioral signs of autism? A. Highly creative, imaginative play B. Early development of language C. Overly affectionate behavior toward parents D. Indifference to being held or hugged

42. The parent of a child with attention-deficit/hyperactivity disorder (ADHD) tells the nurse that the child doesn’t follow instructions well. Which strategy should the nurse recommend to the parent? A. “Teach your child to be less aggressive and more assertive.” B. “Consider developing a predictable daily routine.” C. “It could be helpful to assign time out if instructions aren’t followed.” D. “Try having your child repeat what was said before starting the task.”

43. A 3-year-old client has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). The child’s parents report that a friend told them that the child will likely receive “lots of drugs.” The nurse should reply that the child will most likely be given a drug such as: A. Amitriptyline (Elavil) B. Paroxetine (Paxil) C. Amphetamine and dextroamphetamine (Adderal) D. Haloperidol (Haldol)

44. A 13-year-old child is brought to the clinic with a history of a conduct disorder. The nursing history reveals several facts about the family. Which one is most likely to have contributed to the child’s conduct problems? The parents: A. Have very high expectations of the child B. Employ harsh discipline and inconsistent limit- setting C. Are excessively involved in the everyday life of the child D. Have no other children

45. Which primary interventions should the nurse plan for when a child has a conduct disorder and is impulsive and aggressive? A. Limit setting and consistency B. Open communications and a flexible approach C. Open expression of feelings D. Assertiveness training

46. Life Span Mental Health Issues Effect of mental illness on child achieving developmental tasks: • May have increased difficulty of achievement • May be stuck in stage at onset of illness • May never achieve developmental task • Can benefit from nursing interventions

47. Life Span Mental Health Issues Helping a child with mental illness master developmental tasks: • Assess child’s behaviors related to developmental task • Provide the child with normalizing experiences • Allow to choose age-appropriate play activities • Reinforcement for age-appropriate behaviors • Healthy, pleasant environment • Promote coping skills (decision making, stress reduction, problem solving)

48. Life Span Mental Health Issues Interventions for increasing resilience in children at risk for disruptive behaviors: Provide a supportive relationship with community member Provide a positive environment • at home • at school • in community

49. Interventions: Play Therapy • Commonly used with children • Purposeful use of toys and other equipment • Helps to communicate perceptions of the world and to help master the environment •  self-esteem • Enhances problem solving • Gains perspective on traumatic event

50. Interventions: Pharmacotherapy • Prozac – the only antidepressant approved for children by FDA. Paxil, Zoloft, Celexa and Effexor considered unsafe and ineffective for most children and dangerous with suicidal tendencies • Risk sudden of death on tricyclic antidepressants (TCAs). Request baseline EKG, repeated when TCA ;blood levels useful in confirming compliance. • Lab tests for anemia and thyroid function needed • Meds metabolized more efficiently so milligram/kilogram base is used rather than a certain dose • Initial doses may be low, but can ultimately be as high as for adults