225 Nursing Bullets: Psychiatric Nursing Reviewer

High-yield psychiatric and mental health nursing facts for NCLEX review. Each point is a testable concept. Know them cold.

Theoretical Frameworks and Developmental Stages

Kübler-Ross Stages of Death and Dying

• The five stages are denial, anger, bargaining, depression, and acceptance.

Freud's Psychoanalytic Theory

• A basic assumption is that all behavior has meaning.
• The personality operates on three levels: conscious, preconscious, and unconscious.
• The id holds instinctual drives ("i" for instinctual, "d" for drive).
• The ego controls internal demands and interacts with the outside world at the conscious, preconscious, and unconscious levels.
• The superego holds morals, values, and ethics. It evaluates thoughts and actions, rewarding good and punishing bad (the "supercop" of the unconscious).
• Between ages 12 and 20, a person is in the genital stage: learning independence, increased interest in the opposite sex, and establishing an identity.
• Per the pleasure principle, the psyche seeks pleasure and avoids unpleasant experiences regardless of consequence.

Erikson's Psychosocial Stages

• School-age child (ages 6 to 12): industry versus inferiority.
• Identity versus role confusion: ages 12 to 20.
• Generativity versus despair: generativity (investing the self in the larger community) is expressed through procreation, work, community service, and creative work.
• Older adult (age 65 or older): integrity versus despair.
• Ritualism and negativism are typical toddler behaviors, occurring during autonomy versus shame and doubt.

General Adaptation Syndrome

• The three stages are alarm, resistance, and exhaustion.

Defense Mechanisms

• Denial: refusal to acknowledge the reality of an event, or to acknowledge feelings, thoughts, desires, impulses, or external facts that are consciously intolerable.
• Projection: unconsciously assigning a thought, feeling, or action to someone or something else ("scapegoating").
• Sublimation: channeling unacceptable impulses into socially acceptable behavior.
• Repression: unconsciously pushing unacceptable or painful thoughts, impulses, or memories from consciousness.
• Reaction formation: avoiding anxiety through behavior and attitudes opposite to repressed impulses.
• Displacement: transferring unacceptable feelings to a more acceptable or less threatening object or person.
• Regression: retreating to an earlier developmental stage.
• Suppression: voluntarily excluding stress-producing thoughts from consciousness.

Common Psychiatric Terms and Concepts

• Flight of ideas: skipping rapidly from one topic to another, unrelated one.
• La belle indifférence: lack of concern for a profound disability (blindness, paralysis) seen in conversion disorder.
• Echolalia: parrotlike repetition of another person's words.
• Thought blocking: loss of one's train of thought from a defect in mental processing.
• Idea of reference: the false belief that others' statements or actions refer to oneself.
• Circumstantiality: unnecessary, minute details and digressions that delay communicating the main idea.
• Confabulation: filling memory gaps with imaginary experiences or made-up information.
• Illusion: misinterpretation of an actual environmental stimulus.
• Delusion: a fixed, false belief.
• Thought broadcasting: a delusion that one's thoughts are broadcast for the world to hear.
• Compulsion: an irresistible urge to perform an irrational act, such as repeated handwashing or a strict ritual.
• Labile affect: rapid shifts of emotion and mood.
• Amnesia: loss of memory from an organic or inorganic cause.
• Fugue: a dissociative state in which a person leaves familiar surroundings, assumes a new identity, and has amnesia for the previous one ("flight from himself").
• Dysfunctional grieving: absent or prolonged grief.
• Catharsis: expression of deep feelings and emotions.
• Free-floating anxiety: generalized apprehension and pessimism for unknown reasons.

Psychiatric Disorders

Anxiety-Related Disorders

• Moderate anxiety narrows the perceptual field. The person is selectively inattentive and less able to perceive and concentrate.
• A patient with a phobic disorder uses self-protective avoidance as an ego defense.
• Phobias are treated with desensitization, gradually exposing the patient to the feared stimulus.
• Anxiety is nonspecific; fear is specific.
• Intense anxiety can trigger the fight-or-flight reaction (alarm reflex).
• Hyperalertness and an exaggerated startle reflex characterize posttraumatic stress disorder (PTSD).

Mood Disorders (Depression and Bipolar)

• With a depressed patient, the nurse's first priority is safety because of the increased suicide risk.
• Depression is clinically significant when sadness, melancholy, dejection, worthlessness, and hopelessness are out of proportion to reality.
• Depression is the most common psychiatric disorder.
• Major depressive disorder presents with depressed mood, inability to feel pleasure, sleep disturbance, appetite changes, decreased libido, and worthlessness.
• Reactive depression is a response to a specific life event.
• Always assess the depressed patient for suicidal ideation.
• Suicide is the third leading cause of death among white teenagers; most teens who die by suicide made a previous attempt and left telltale signs.
• A patient with a chosen method and a plan to act within the next 48 to 72 hours is at high risk. A "no self-harm" contract for a specified period helps reduce that risk.
• Bipolar II disorder is characterized by at least one major depressive episode accompanied by hypomania.
• During the manic phase, nursing care aims to slow the patient down, because self-induced exhaustion or injury can be fatal. Delusional thought patterns are common in mania.

Schizophrenia and Other Psychotic Conditions

• Apathy is typical in schizophrenia.
• When a patient with schizophrenia begins to hallucinate, redirect them to here-and-now activities.
• Organic brain syndrome is the most common form of mental illness in elderly patients.
• Delusional thought patterns and hallucinations are frequent in psychotic disorders.

Neurocognitive Disorders (Alzheimer's, Dementia)

• Memory disturbance is a classic sign of Alzheimer's disease.
• Diagnosis rests on clinical findings of two or more cognitive deficits, progressive memory worsening, and neuropsychological test results.
• Early stage (2 to 4 years): inappropriate affect, transient paranoia, disorientation to time, memory loss, careless dressing, impaired judgment.
• Middle stage (4 to 7 years): profound personality changes, loss of independence, confusion, inability to recognize family, nocturnal restlessness.
• Last stage (final year of life): blank facial expression, seizures, loss of appetite, emaciation, irritability, total dependence.
• Remote memory may be impaired in late-stage dementia.

Personality Disorders

• Borderline personality disorder: demanding and judgmental in relationships, will try to "split" staff by pointing to discrepancies in the treatment plan; violent outbursts are common.
• Antisocial personality disorder: frequently confronts and challenges authority figures.
• Paranoid personality disorder: suspicion, hypervigilance, hostility.
• Dependent behavior: constantly seeking approval or assistance from staff or others.
• Manipulative behavior: a maladaptive way of meeting one's needs that disregards others. Setting limits is the most effective control.
• Passive-aggressive personality disorder: manipulative behavior and indirect resistance to demands.

Eating Disorders

• In anorexia nervosa, the highest treatment priority is correcting nutritional and electrolyte imbalances.
• Signs of anorexia nervosa include amenorrhea, excessive weight loss, lanugo, abdominal distention, and electrolyte disturbances.
• Observe patients with anorexia nervosa or bulimia during meals and for some time afterward to prevent purging.
• Provide support at mealtime and record the amount eaten.

Childhood and Adolescent Disorders (Including Abuse)

• Common causes of child abuse are poor parental impulse control and lack of knowledge of child growth and development.
• Public Law 94-247 (Child Abuse and Neglect Act of 1973) requires reporting suspected child abuse to child protection services.
• Suspect sexual abuse in a young child with blood in the feces or urine, genital trauma, or a sexually transmitted disease.
• A child who dissociates ("spacing out," separating from reality) has probably been abused.
• Methylphenidate (Ritalin) is the drug of choice for ADHD in children; pemoline (Cylert) may also be used.
• Conduct disorder shows extreme behaviors such as cruelty to animals or people.
• Autism is often diagnosed between ages 2 and 3.

Substance Abuse and Alcohol Abuse

• Alcoholics Anonymous uses a 12-step program for sobriety; Al-Anon supports families of alcoholics.
• An alcoholic who achieves sobriety is a recovering alcoholic, because no cure exists.
• Tolerance is needing increasing amounts of a substance for the same effect.
• Early signs of alcohol withdrawal (anxiety, anorexia, tremors, insomnia) may begin up to 8 hours after the last drink.
• Detoxification works best in a structured environment with supportive, nonjudgmental staff.
• Caring for the withdrawing patient: keep the environment calm, minimize intrusions, speak slowly, adjust lighting, call the patient by name, and have a friend or family member stay if possible.
• Chlordiazepoxide (Librium) is the drug of choice for alcohol withdrawal.
• Alcohol withdrawal can precipitate seizures because alcohol lowers the seizure threshold in some people.
• In a hospitalized alcoholic, withdrawal delirium most commonly occurs 3 to 4 days after admission.
• Therapy often includes folic acid, thiamine, multivitamins, and adequate food and fluids to prevent deficiencies such as peripheral neuropathy or Wernicke-Korsakoff syndrome.
• Opiate withdrawal symptoms may appear within 12 hours of the last dose, with the most severe symptoms within 48 hours.
• Narcotic abstinence maintenance typically uses 10 to 40 mg of methadone (Dolophine) once daily, with ingestion monitored.
• Disulfiram (Antabuse) is aversion therapy for alcoholism. Drinking on disulfiram can cause severe, potentially life-threatening reactions, so the patient must also avoid hidden alcohol (cough syrups, sauces made with cooking wine).
• Do not give disulfiram with metronidazole (Flagyl); the interaction may cause a psychotic reaction.

Psychopharmacology

Lithium

• Lithium needs regular blood-level monitoring (usually monthly) because the therapeutic range is narrow.
• Normal therapeutic level is 0.5 to 1.5 mEq/L; levels >2.0 mEq/L are toxic.
• Toxicity can occur when sodium and fluid intake are insufficient, causing the body to retain lithium.
• Signs of toxicity: diarrhea, tremors, nausea, muscle weakness, ataxia, confusion.
• For toxicity symptoms, withhold the next dose and notify the physician.
• Improved concentration signals lithium is taking effect.
• Take lithium with food, and do not restrict sodium intake unless ordered.
• Stabilized patients have levels checked 2 to 3 times weekly in the first month, then weekly to monthly during maintenance.
• Stop lithium and call the physician for vomiting, drowsiness, or muscle weakness.

Monoamine Oxidase Inhibitors (MAOIs)

• Tyramine-rich foods (aged cheese, chicken liver, avocados, bananas, salami, Chianti wine, beer) can cause severe hypertension on an MAOI and must be avoided to prevent hypertensive crisis.
• For palpitations, headache, or severe orthostatic hypotension on an MAOI, withhold the drug and notify the physician.
• Cottage cheese, cream cheese, yogurt, and sour cream are safe on an MAOI.
• Weigh the patient biweekly and monitor for suicidal tendencies.

Antipsychotics and Extrapyramidal Symptoms

• Extrapyramidal effects are common with antipsychotics: parkinsonism, dystonia, akathisia ("ants in the pants"), and tardive dyskinesia.
• Diphenhydramine (Benadryl) can relieve extrapyramidal effects.
• For muscle rigidity and tremors, give an antiparkinsonian agent (benztropine/Cogentin or trihexyphenidyl/Artane) as ordered.
• Tardive dyskinesia causes excessive blinking, unusual tongue movements, and involuntary sucking and chewing.
• A major toxic risk of clozapine (Clozaril) is blood dyscrasia (agranulocytosis). It is contraindicated in pregnancy and in severe granulocytopenia or severe CNS depression.
• Haloperidol (Haldol) adverse effects: drowsiness, insomnia, weakness, headache, extrapyramidal symptoms.
• Do not give chlorpromazine (Thorazine) to a patient who has drunk alcohol; it can cause oversedation and respiratory depression.

Antidepressants

• TCA adverse reactions: tachycardia, orthostatic hypotension, hypomania, lowered seizure threshold, tremors, weight gain, sexual dysfunction, anxiety.
• Fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are SSRIs for depression. Prozac side effects may include diarrhea, decreased libido, weight loss, and dry mouth.
• Alcohol potentiates the effects of TCAs.

Other Notable Medications

• Methylphenidate (Ritalin) and pemoline (Cylert) treat ADHD.
• The primary purpose of psychotropic drugs is to decrease symptoms, improving function and treatment compliance.

Therapeutic Approaches and Communication

Nurse-Patient Relationship Phases

• Phase I (orientation): obtain an initial history; nurse and patient agree to a contract.
• Phase II (working): the patient discusses problems, behavioral change occurs, and self-defeating behavior is reduced.
• Phase III (termination): end the relationship and give positive feedback on accomplishments.

Communication and Intervention Techniques

• Open-ended questions are one of the best ways to elicit or clarify information.
• Confrontation points out discrepancies between the patient's words and behavior.
• Paraphrasing is active listening: restating what the patient just said.
• Encourage an angry patient to use a physical exercise program to ventilate feelings.
• When two psychiatric patients are in a threatening confrontation, separate them first for safety.
• Too many "why" questions overwhelm the patient and yield little information.
• Asking open-ended questions and exploring meaningful losses are key interventions with a depressed patient.

Specific Therapies

• Family therapy treats the family as a whole, reestablishing rational communication.
• Group therapy lets each participant examine interactions, practice interpersonal skills, and explore emotional conflicts.
• Psychodrama recreates life situations so participants gain insight and practice new skills.
• Behavior modification (time-outs, token economies, reward systems) is used for conditions such as ADHD.
• Stress management is a short-range goal of psychotherapy.

Seclusion, Restraints, and Safety

• Seclusion reduces overstimulation and protects against self-injury, harm to others, and property damage. Use it only after less restrictive interventions fail.
• The decision to use restraints must be based on the patient's safety needs.
• A patient admitted involuntarily loses the right to sign out against medical advice (AMA).
• Threatening a patient with an injection for refusing oral medication is assault.

Additional Nursing Care Points

• For a newly admitted psychotic patient, the primary concern is safety, followed by establishing trust.
• The patient should be able to predict the nurse's behavior and expect consistent, positive attitudes.
• When scheduling one-to-one interactions, state how long the conversation will last and hold to that limit.

Electroconvulsive Therapy

• ECT is typically used for severe depression unresponsive to drug therapy.
• Usually 6 to 12 treatments at 2 to 3 per week.
• One theory holds that ECT "resets" the brain's circuits, restoring normal function.
• Methohexital (Brevital) is the general anesthetic given beforehand; the skeletal muscle relaxant succinylcholine (Anectine) is given IV.
• Rarely, ECT can cause arrhythmias and death.
• Keep the patient NPO after midnight before ECT to prevent aspiration.
• After ECT, place the patient in the lateral position (head turned to one side) and monitor for post-shock amnesia.

Other High-Yield Points

• An alcoholic uses alcohol to cope with life's stresses.
• People with obsessive-compulsive disorder (OCD) know their behavior is unreasonable but feel powerless to stop it (ego-dystonia).
• "People who live in glass houses shouldn't throw stones" is a proverb used to test abstract thinking; a schizophrenic patient may take it literally.