●When a person with a mental disorder is taken to hospital, willingly or unwillingly, the person may be placed under confinement for a specified time. This is known as confinement in an institution.
●On arrival at the hospital, a doctor who considers that the person’s mental state presents a grave and immediate danger to the person or to others may place the person under observation without consent and without a court order, for a period of not more than 72 hours.
●A doctor may not conduct examinations on a person under preventive confinement without the person’s free and enlightened consent. A court order must be filled before psychiatric examination. If the order is issued, the initial examination must be conducted within 24 hours. If confinement is not necessary after the examination the person must be released. In other cases, a second psychiatric examination must be conducted by another doctor within 48 hours from the issue of the court order.
●Confinement following a court order.
●If both psychiatric reports conclude that the person should be confined in an institution, and if the person continues to refuse confinement, the Court of Québec may make a judgement ordering the person:
-to submit to confinement for the time determined by the judge (generally 21 to 30 days).
-to submit to the examinations required to determine if the person’s mental state continues to present a danger to the person or to others.
●Confinement following a court judgement.
●If necessary, authorized confinement may be extended for varying periods of time.
CONSENT AND AUTORIZATION FOR TREATMENT:
All individuals have the basic right to accept or refuse care. A physician who wishes to treat a person must first obtain his or her free and informed consent. All individuals are presumed capable of making decisions that concern their well-being, and physicians must respect these decisions.
However, if a person categorically refuses to receive any treatment and is suspected of being incapable to consent to care, the psychiatrist must submit a request to the Superior Court to obtain authorization to provide care to the person despite his or her refusal. The physician must prove that the person is incapable and demonstrate that the benefits of the treatment outweigh the inconveniences for the person.
EXTREME mood states of MANIA and DEPRESSION.
Recurrent thoughts of death and suicide.
Significant loss of interest/pleasure.
Severe guilt (feeling worthless).
LITHIUM: Mood stabilizer
Level therapeutic 0.6 – 1.2 (Labs: TSH, ECG, renal and electrolytes).
Intake with food.
Urine increase (Avoid coffee, tea, colas).
Must encourage fluid and have regular salt intake.
LITHIUM TOXICITY: “TOXICS” ●Tinnitus, Tremor. ●Oliguria. ●ataXia. ●Incoherent speech. ●Cardiovascular collapse. ●Seizure.
TOXICITY INTERVENTION: ●Cessation and lowering dose by MD. ●Mannitol or Diamox. ●Haemodialysis: severe toxicity.
NURSING INTERVENTIONS FOR MANIC: “BSN”
Behavior: ●Set limits (i.e. manipulation, bargaining, seduction).
Safety: ●Remove all dangerous objects. ●Provide a calm environment, offer a physical activity on aggressive behavior (punching bag).●Remain calm: offer tranquilizer. ●Restraint as last resort.
Nutrition: ●Offer food high in protein and Finger foods. ●Encourage during meal (be present).●Note: I&O, weight and electrolytes.
●Instruct patient to take medication as prescribed even if feeling better.
●If Na ↓ lithium is reabsorbed causing toxicity.
●Precaution on pregnancy: Teratogenic (cause congenital defects).
●If any diarrhea, N/V, and fever: Notify MD.
It is a mental illness characterized by impairments in the perception or expression of reality, usually involves hallucinations and delusions. TYPES: ●Paranoid. ●Catatonic. ●Disorganized. ●Undifferentiated.
1. PARANOID: Systematic persecutory delusions, auditory hallucinations, delusion of grandeur, anger, and violence. “VERY MAD”.
●Delusions and hallucinations.
2. CATATONIC: Characterized by alternating periods of extreme withdrawal and extreme excitement.
3. DISORGANIZED: Disorganized thoughts, speech (neologisms, loose of association, clang), and behavior.
4. UNDIFFERENTIATED: Characterized by some symptoms seen in all of the types, but not enough of any one of them to define it as another particular type of schizophrenia.
●Delusion and hallucinations.
●Feelings of persecution.
●Illusion, Insomnia, Suspicious.
●Abnormal thought form,
●Passive social withdrawal, poor hygiene, poor rapport, poverty of speech.
Provide basic needs (nutrition, fluids, safety).
Promote and build self-esteem.
Help family to collaborate and adapt to the situation.
Administer meds as ordered.
Explain all procedures.
Provide personal space.
Maintain eye contact.
Identify contributing factor.
Monitor command hallucinations.
Touch without warning.
Whisper or laugh in the presence of patient.
Argue and disprove delusions.
Participate in the hallucinations.
1. Classic antipsychotics: Higher risk for S/E.
2. Atypical antipsychotics: Lower risk for S/E.
3. Long acting antipsychotics: Used to treat patients who are non-compliant and has ulcer problems.
COMMON ANTIPSYCHOTIC SIDE EFFECTS:
1. Extrapyramidal symptoms: ●Tardive dyskinesia. ●Rigidity. ●Akathisia. ●Postural instability. Etc.
Treatments: ●Antiparkinsons: Cogentin (except Tardive dyskinesia). ●Antihistamines: Benadryl.
2. Anticholinergic effects: ●Xerostomia. ●Aptyalism. ●Constipation. ●Dysuria.
3. Agranulocytosis: Severe reduction of granulocytes (WBC: Basophils, eosinophils, neutrophils.). Caused by Clozaril.
Prevention: Blood test to monitor WBC count.
Monitor for any: Flu like symptoms, fever, sore throat, etc…
4. Others: ●Insomnia and agitation. ●Orthostatic hypotension. ●Weight gain. ●Photosensitivity. ●Pruritus.
● Most abuse substance!
●CNS depressant: Shortens deep sleep and increase wakefulness.
●Stimulate endorphins and enkephalins.
●Intoxication: 100-150 mg/dl or 0.15% (alcohol blood level), at 0.40%: comma, respiratory depression/death.
ALCOHOL WITHDRAWAL SIGN AND SYMPTOMS: “PAST NITE”
P-sychomotor agitation. N-ausea and vomiting.
A-nxiety. I-nsomnia, Irritability.
S-eizure. T-ransient Hallucinations or illusions.
T-remor. E-xcessive sweating.
●Seizure, confusion, disorientation, hypertension, hyperpyrexia, tachycardia, coarse tremors, agitation, cardiovascular collapse
●Symptom of alcohol withdrawal usually develops within 4-12 hours of stopping or reducing prolonged, or alcohol use.
●Drug of choice: BENZODIAZEPINE (LIBRIUM).
●Patient must abstain from alcohol at least 12 hours before initial dose.
●Disulfiram alcohol reaction: Flushing, throbbing headache, copious vomiting, tachycardia, hypotension, blurred vision.
●Avoid alcohol ingestion and substance with alcohol: Mouthwash, cough syrup, shaving cream, lotions, paints and varnish.
CAGE QUESTIONNAIRE: Two "yes" responses indicate that the possibility of alcoholism should be investigated further.
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
Other: Frequency, quantity, and duration of drinking.
SUPPORT GROUP: ●Alcohol Anonymous (AA): Help alcoholic achieve and maintain SOBRIETY! ●Al-Anon: For friends and relatives of Alcoholics, for people who have been affected by someone’s drinking.
FETAL ALCOHOL SYNDROME (FAS): Causes: Growth, Mental, Physical delays/problem.
SIGNS AND SYMPTOMS: ●Low birth weight. ●Failure to thrive. ●Developmental delays. ●Poor memory. Epilepsy. ●Small head circumference. ●Organ dysfunction. ●Poor coordination and lack of fine motor skills.
INTERVENTIONS: ●Avoid heat loss by keeping the baby warm. ●Offer a small frequent meal. ●Provide dim light and a quiet environment. ●Monitor weight and vital signs. ●Assess for seizure. ●Assess for sign and symptoms of respiratory depression. ●Side lying if the baby vomits.
Persistent sad or depressed mood, loss of interest in things that were once pleasurable with the disturbance in sleep, appetite, energy, and concentration.
SIGNS AND SYMPTOMS: “SADIFACES”
S-leep disturbance (increase or decrease).
A-ppetite changes (increase or decrease), weight change.
I-nterest loss or pleasure.
F-atigue or decreased energy.
A-gitation/retardation, feeling anxious or slowed down.
C-oncentration, decreased ability to focus.
E-steem decreased feelings of guilt and worthlessness.
SAD PERSON SCALE: Suicide risk!
A-ge: <18, >60.
R-ational thinking loss.
S-ocial support impaired.
O-rganized plan: Giving valuables.
N-o spouse, alone, nagging spouse/abusive.
S-ickness, especially chronic or terminal.
PROTECTIVE FACTORS FOR SUICIDE:
●Effective clinical care for mental, physical, and substance abuse disorder.
●Easy access to a variety of clinical interventions and support for help seeking.
●Family and community support (connectedness).
●Support from ongoing medical and mental health care relationships.
●Skills in problem solving, conflict resolution, nonviolent ways of handling dispute.
●Cultural and religious belief that discourage suicide and support instincts for self-preservation.
●Keep a regular sleep/wake schedule.
●Get into bright light soon after waking in the morning.
●Exercise during the day.
●Avoid afternoon naps.
●Limit caffeine and alcohol.
●Ask loved ones for help – you should not face depression alone.
●Offer preferred food and/or nutritious food.
●Monitor food intake and weight.
●Sit down with patient during meals and encourage eating.
3. Depressed mood:
●Encourage verbalization of feelings.
●Foster communication between family and friends.
4. Interest loss:
●Encourage participation in groups and social activities.
●Have an adequate sleep during the night (6-8h).
●Exercise and be active, give time for rest.
●Eating nutritious food, protein and complex carbohydrates + vit. A, B, and C.
●Meditation, stay away from stress, breathing exercises/relaxation techniques.
6. Anxiety and agitation:
●Develop methods of coping with the symptoms.
●Cognitive behavioral therapy.
7. Concentration (difficulty):
●Use a planner or checklist to help patient more organized.
●Develop a routine and try to stick on regular schedule.
●Divide task into smaller steps.
●Avoid overstimulation of brain with large amount of caffeine and energy drinks.
8. Esteem (feeling of worthlessness):
●Engaged in simple tasks (that the patient can succeed).
●Assist in identification of strength.
9. Suicidal thoughts:
●Maintain a safe environment (Wearing a hospital gown, confinement, no access of personal belongings, and removal of dangerous objects).
●Ask when, where, how?
●24-hour no suicide contract (verbal/written): if patient agreed – it doesn’t mean they will not commit suicide!
●Notify MD and head nurse.
●Assess suicide risk q8h.
●Continuous monitoring and Observations on patient’s attitude (sudden detachment, expression of negative feelings, desire to isolate himself/herself, remain silent, actively looking for a mean to hurt himself/herself).
●Offer support groups and counseling later on.
●Administer prescribed medications and ECT as last resort.
MEDICATIONS: 3-4 weeks to take effect.
1. Benzodiazepines: Anxiolytics: AlpraxoLAM (Xanax), LorazePAM (Ativan), OxazePAM (Serax), DiazePAM (Valium).
●Avoid CNS depressants and antacids (↓absorption).
●Side effects: Orthostatic hypotension, sedation, dizziness, weakness, headache, feeling of depression, sleep disturbance etc…
2. Tricyclic Antidepressants: Elavil, Sinequan, Ascendis, Tofranil.
●Don’t give with MAOI: produced fever, agitation, convulsions and even death.
3. MAOI: “Not Popular Meds” – Nardil, Parnate, Marplan
●Avoid tyramine rich food: Canned/processed foods, Aged cheese, Beer/red wine, yogurt, Soy sauce, prunes etc… cause HYPERTENSIVE crisis. ●Assess V/S especially BP.
4. SSRI: Celexa, Prozac, Luvox, Paxil, Zoloft.
Side effects: Nausea, insomnia, dizziness, weight gain or loss, tremors, sweating, anxiety or restlessness, dry mouth, headache etc…
Note: Liquid preparation medications are advisable.
COGNITIVE BEHAVIORAL THERAPY (CBT) is a type of therapy treatment that helps patients understand the thoughts and feelings that influence behaviors. It focuses on reducing negative thoughts, changing errors in thinking, and improving assertiveness and problem solving skills to reduce feelings of hopelessness and despair.
Note: Suicide precaution starts at the ONSET of depression and when depression begins to LESSEN or MEDICATION takes effect (patient is more prone to commit suicide).
1. Intense fear of gaining weight/becoming fat (even if underweight)
2. Amenorrhea for 3 cycles.
3. Refusal to maintain body weight.
Note: Advice family therapy, weight monitoring, and CBT.
SIGN AND SYMPTOMS:
1. Refuse to eat.
2. Plays with food and eats only very small amount.
3. Perceives body or body part as being fat even though it’s thin.
4. Dry skin, fine downy body hair.
6. Hypothermia, hypotension, and bradycardia.
1. Small frequent meals.
2. Monitor weight, Labs (electrolytes, urine, BUN), and I&O.
3. Encourage to verbalize feelings and set limits.
4. Encourage oral hygiene (bulimia).
5. Stay with patient during meal time, and at least 1 hour after eating (bulimia) – accompany patient in the bathroom.
N-o other reason of weight loss.
O-bviously thin but feels fat.
R-efusal to maintain body fat.
X-ymptoms of: Hiding foods, collecting recipes.
I-ntense fear of gaining weight.
A-lways thinking about food.
1. Binge eating: ●Eating a large amount of food, rapidly and discretely. ●Sense of lack of control over eating.
2. Compensatory behavior to prevent weight gain: ●Purging. ●Laxative use, diuretics, enema, fasting, and excessive exercise.
SIGN AND SYMPTOMS:
1. Binge eating followed by purging (binge-purged cycle).
2. Loss of tooth enamel (especially posterior front teeth).
3. Calluses on fingers or scars.
4. Reddened knuckles.
5. Enlarged parotid gland.
6. Increased peristalsis, rectal bleeding, or constipation.
1. Show feelings of disbelief, shock or disgust at eating disorder.
2. Confront and judge hostilities and anger, if they occur.
3. Compare patient behavior and appearance to others.
4. Allow long meals (set 30 minutes).
5. Discuss and explain food, diet or body (unless these are linked with patient feelings – if patient open up about topic).
U-sual onset: 15-24 y/o.
L-axative, diet pills and diuretics abuse.
I-nduce vomiting (purge).
M-inimum 2 binge eating per week for a period of 3 months.
I-ncrease peristalsis, rectal bleeding and constipation.
A-fraid of losing control over eating.
Assess nutritional status.
Establish a one-to-one therapeutic relationship.
Establish contract concerning nutritional plan.
Assist patient to identify precipitants to the eating disorder.
Encourage to express feelings.
Be accepting and non-judgmental.
Supervise patient during meal time.
Set time limit for each meal.
Record intake and output.
Weight the patient daily.
Refer to support groups.
COMMON DEFENSE MECHANISM
Regression: Retreat to an earlier, more comfortable level of adjustment.
Rationalization: Attempting to justify or modify unacceptable needs and feelings to the ego, in an effort to maintain self respect and prevent guilt.
Displacement: Feelings are transferred, re-directed or discharged from appropriate person or object to a less threatening person or object.
Denial: Blocking out or disowning thoughts or feelings.
Compensation: Attempting to make up for an offset deficiency.
Identification: Attempting to pattern or resemble the personality of an admired or idolized person.
Projection: Attributing one’s own unacceptable feelings and thoughts to others.
Suppression: Conscious forgetting.
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