Mental Health

ALCOHOLISM
Review Alcohol detoxification protocol.
a. How does the person in detox present?
Alcohol Withdrawal Symptoms
• May begin 4-6 hours after last drink
• May progress to delirium tremors 48 to 72 hours after last drink
(potentially lethal)
• Symptoms include:
tremors nausea and vomiting
weakness tachycardia
sweating increased blood pressure
irritability depressed mood
hallucinations headache
insomnia seizures

b. What is the nursing priority relative to alcohol withdrawal?

Nursing interventions
Detoxification
• Maintain fluid/electrolyte balance & stable vital signs
• Provide a safe supportive environment for the detox. process
• Administer substitution therapy as ordered (medications)
Intermediate Care
• Promote understanding and identify the causes of substance
dependence; explain physical symptoms
• Provide education and assistance to client and family
Rehabilitation
• Encourage participation in long‐term treatment
• Promote participation in outpatient support systems (AA, NA)
• Provide support for health promotion and maintenance
• Assist the client to identify alternative sources of satisfaction

c. Review patient teaching for Antabuse treatment

• Antabuse: blocks the oxidation of ETOH causing nausea, vomiting
and severe headache to occur with ETOH exposure
When alcohol is consumed it is metabolized by the body into acetaldehyde, a very toxic
substance that causes many hangover symptoms heavy drinkers experience. Usually, the
body continues to oxidize acetaldehyde into acetic acid, which is harmless.
Antabuse interferes with this metabolic process, stops the process with the production of
acetaldehyde and prevents the oxidation of acetaldehyde into acetic acid. Because of this,
antabuse will cause a build up of acetaldehyde five or 10 times greater than
normally occurs when someone drinks alcohol.
If you drink while taking antabuse, you can experience these symptoms:
 • Flushing, Nausea, Copious Vomiting, Sweating, Thirst, Throbbing in the Head
and Neck, Throbbing Headache, Respiratory Difficulty, Chest Pain, Palpitations,
Dyspnea, Hyperventilation,Tachycardia, Hypotension, Syncope, Marked
Uneasiness, Weakness, Vertigo, Blurred Vision, Confusion
• Those are the "mild" symptoms. Severe reactions can include respiratory
depression, cardiovascular collapse, myocardial infarction, acute congestive
heart failure, unconsciousness, arrhythmias, convulsions, and death.
• Because of the possible severe reactions, antabuse should not be given to anyone
with a history of severe heart disease, psychosis, or an allergy to antabuse.
Women who are pregnant should not take antabuse and no one taking
paraldehyde or metronidazole should use antabuse.

• Assessment of Nursing Goals

• Refrains from high risk behaviors that puts client and others at risk of harm
(driving while intoxicated)
• Vital signs and lab values are within normal limits
• Free from signs and symptoms of malnutrition/dehydration
• Maintains adequate sleep and rest
• Accepts responsibility for own behavior and recognizes association between
substance use and personal problems
• Demonstrates use of adaptive coping mechanisms, instead of substance use,
in response to stress.

DRUG ADDICTION
Review treatment protocol and intervention for individuals addicted to drugs – i.e.
(PCP, Heroin, Benzodiazepines)
• Generic Interventions-
o Observe for cardiac symptoms, monitor vitals, assess for signs of
depression and/or suicide, help reduce nausea, assess nutrition and
hydration, maintain a safe environment, supportive communication to
reduce anxiety and fear, respiratory support, anti-epileptic drugs, anti-
psychotics, ammonium chloride (to acidify urine for excretion of
amphetamines (bases)), anti-anxiety meds, anti-depressants.
• Treatment for Substance Use D.O.
o Therapies: Individual Psychotherapy; Group Therapy; Cognitive
Behavioral Therapy ; Harm Reduction and Behavior Modification
o Expressive Therapies: Writing, Art, Music, and Movement therapies;
as well as Exercise, Yoga and TaiChi
o Support Groups: 12 step meetings such as Alcoholics Anonymous ;
Rational Recovery and church groups
o Pharmacology: treatments for underlying mood and anxiety
symptoms; withdrawal and cravings

ANTI-DEPRESSANTS
Review teaching protocol for administering SSRI’s
Celexa, Lexapro, Prozac, Prozac Weekly, Paxil, Paxil CR, Zoloft.
• Side effects of SSRIs include:
 o Nausea, Sexual dysfunction, including reduced desire or orgasm
difficulties, Headache, Diarrhea, Nervousness, Rash, Agitation,
Restlessness, Increased sweating, Weight gain, Drowsiness, Insomnia.
• Serotonin Syndrome-
o Don't take any SSRIs while you're taking any MAOIs or within two weeks
of each other.
o Signs and symptoms of serotonin syndrome include: Confusion,
Restlessness, Hallucinations, Extreme agitation, Fluctuations in blood
pressure, Increased heart rate, Nausea and vomiting, Fever, Seizures,
Coma.
• Avoid Paxil during pregnancy! (During their first three months of pregnancy are
nearly two times more likely to give birth to a child with a birth defect — in
particular a heart defect; Increased risk of persistent pulmonary hypertension)
• SSRIs aren't considered addictive. However, stopping treatment abruptly or
missing several doses can cause withdrawal-like symptoms, including:
o Nausea, Headache, Dizziness, Lethargy, Flu-like symptoms
• In some cases, antidepressants may be associated with worsening symptoms of
depression or suicidal thoughts or behavior. These symptoms or thoughts are
most likely to occur early in treatment or when you change your dosage, but they
can occur at any time during treatment.

MOOD DISORDERS
Review intervention for individuals experiencing manic episodes.
• Mood Disorders include:
‐ Dysthymia (chronic, low level depression)
‐ Major Depression
‐ Cyclothymia (chronic episodes of mild depression & hypomania)
a milder form of bipolar II disorder consisting of recurrent mood
disturbances between hypomania and dysthymic mood. A single
episode of hypomania is sufficient to diagnose cyclothymic
disorder.
‐ Bipolar Affective Disorder I (episodes of mania & depression)
‐ Bipolar Affective Disorder II (both hypomania & depression)
Etiology of Mood Disorders
• Genetic Predisposition
• Acute Trauma
• Long term stress exposure
• Serotonin
• Dopamine/norepinephrine

Differentiate depression from normal stormy adolescent

behavior:
• A visible manifestation of behavioral change that lasts for several weeks.
• Most common precipitant to adolescent suicide: perception of abandonment
by parents or close peer relationship.

Epidemiology of Depression
• Age Depression is more common in young women than in older women;
has a tendency to decrease with age. The opposite is true for men
• Social class: There is an inverse relationship between social class and
report of depressive symptoms; the opposite is true with bipolar disorder.
• Race and culture: No consistent relationship between race and
affective disorder reported
• Marital status: Single and divorced people are more likely to experience
depression than married people.
• Seasonality: Affective disorders are more prevalent in the spring and in
the fall.

Nursing Process/Assessment
• Transient depression
– Symptoms at this level of the continuum not necessarily
dysfunctional
– Affective: The “blues” ‐ Behavioral: Some crying
• Mild depression
– Symptoms of mild depression are identified by clinicians as
associated
with normal grieving.
– Affective: Anger, anxiety, sadness ‐ Behavioral: Tearful, regression
– Cognitive: Preoccupied with loss; self‐blame and blaming of others
– Physiological: Anorexia or overeating, sleep disturbances, somatic
symptoms
• Moderate depression
– Symptoms associated with dysthymic disorder
• Affective: Helpless, powerless
• Behavioral: Slow physical movement, slumped posture,limited
verbalization
– Cognitive: Retarded thinking processes, difficulty with concentration
– Physiological: Anorexia or overeating, sleep disturbances, somatic
symptoms, feeling best early in morning and worse as the day
progresses.
• Severe depression
– Cognitive: Prevalent delusional thinking, with delusions of
persecution and somatic delusions; unable to concentrate; confusion
– Physiological: A general slow‐down of the entire body, anorexia,
insomnia, feels worse early in morning and somewhat better as the
day progresses.

Nursing Diagnoses Related to Depression

• Risk for suicide related to:
– Depressed mood ‐Feelings of worthlessness
– Anger turned inward on the self ‐ Misinterpretations of reality
• Low self‐esteem related to:
– Learned helplessness
– Feelings of abandonment by significant others
– Impaired cognition fostering negative view of self
• Powerlessness related to:
 – Complicated grieving process ‐ Lifestyle of helplessness
• Spiritual distress related to:
– Complicated grieving over loss of valued object
• Social isolation/Impaired social interaction related to:
– Developmental regression ‐ Egocentric behaviors
– Fear of rejection or failure of the interaction
• Disturbed thought processes related to:
– Withdrawal into self
– Impaired cognition fostering negative perception of self or
environment
• Imbalanced nutrition less than body requirements
• Insomnia
• Self‐care deficit

Planning/Implementation
• Nursing interventions are aimed at:
– Maintaining client safety
– Assisting client through grief process
– Promoting increase in self‐esteem
– Encouraging client self‐control and control over life situation
– Helping client to reach out for spiritual support of choice

BIPOLAR AFFECTIVE DISORDER

• Depressive episode almost always precedes a manic episode
• Usually not diagnosed until adolescence
• Diagnostic criteria are the same for all ages and include distinct periods of
elevated, expansive or irritable mood that lasts at least one week, with at
least three of the following symptoms:
‐ decreased need for sleep ‐ grandiosity
‐ racing thoughts ‐ pressured speech
‐ increase in goal‐directed activity ‐ flight of ideas
‐ excessive involvement in pleasurable activities ‐ distractibility
‐ Poor judgment and insight ‐ psychosis
• Characterized by mood swings from profound depression to extreme
euphoria (mania), with intervening periods of normalcy.
• Delusions or hallucinations may or may not be part of clinical picture.
• Onset of symptoms may reflect seasonal pattern.
Bipolar I Disorder
• Individual is experiencing, or has experienced, a full syndrome of manic or
mixed symptoms.
• May also have experienced episodes of depression.
-Average age at onset for a first manic episode is the early 20s.
Bipolar II Disorder
• Recurrent bouts of major depression
• Episodic occurrences of hypomania
• Has not experienced an episode that meets the full criteria for mania or
mixed symptomatology.
Manic Symptoms
Children: are rarely diagnosed; presents as irritable, poor attention and poor
behavioral control.
Adolescents: Increased psychotic symptoms then adults, hypersexual,
increased risk taking behaviors.
Adults: Hyper religious, hypersexual and increased spending, grandiose
delusions.
Elderly Adults: fewer manic episodes as adults age, increased irritability,
agitation and psychosis.
Bipolar Disorder in Children and Adolescents
• Guidelines for diagnosis and treatment have been developed by the Child
and Adolescent Bipolar Foundation (CABF):
– Frequency: Symptoms occur most days in a week
– Intensity: Symptoms are severe enough to cause extreme
disturbance
– Number: Symptoms occur 3 or 4 times a day
– Duration: Symptoms occur 4 or more hours a day
• Symptoms include:
– Euphoric/expansive mood: Extremely happy, silly, or giddy.
– Irritable mood: Hostility and rage, often over trivial matters.
– Grandiosity: Believes abilities to be better than everyone else’s.
– Decreased need for sleep: May only sleep 4 or 5 hours per night
and wake up feeling rested.
– Pressured speech: Loud, intrusive, difficult to interrupt.
– Racing thoughts: Rapid change of topics
– Distractibility: Unable to focus on school lessons
– Increase in goal‐directed activity/psychomotor agitation:
Activities become obsessive. Increased psychomotor agitation.
Excessive involvement in pleasurable or risky activities: Exhibits
behavior that has an erotic, pleasure‐seeking quality about it.
– Psychosis: May experience hallucinations and delusions.
– Suicidality: May exhibit suicidal behavior during a depressed or mixed
episode or when psychotic.
Nursing Process/Assessment
• Symptoms may be categorized by degree of severity
– Stage I—Hypomania: Symptoms not sufficiently severe to cause marked
impairment in social or occupational functioning or to require hospitalization.
• Mood: cheerful and expansive
• Cognition and perception: selfexultation; easily distracted
• Activity and behavior: increased motor activity; extroverted;
superficial
– Stage II—Acute mania: intensification of hypomanic symptoms; requires
hospitalization
• Mood: euphoria and elation.
• Cognition and perception: fragmented, disjointed thinking; pressured
speech; flight of ideas; hallucinations and delusions.
• Activity and behavior: excessive psychomotor behavior; increased
sexual interest; inexhaustible energy; goes without sleep; bizarre dress
and make‐up.
• Stage III—Delirious mania: A grave form of the disorder, characterized
by severe clouding of consciousness and representing an intensification of
the symptoms associated with acute mania.
– Has become relatively rare since the availability of antipsychotic
medication
Nursing Diagnosis Related to Bipolar Disorder
• Risk for Injury related to: ‐ Extreme hyperactivity
• Risk for violence: Self‐directed or other‐directed related to:
– Manic excitement ‐ Delusional thinking
– Hallucinations
• Imbalanced Nutrition less than body requirements related to:
– Refusal or inability to sit still long enough to eat
• Disturbed thought processes related to:
‐ Biochemical alterations in the brain
• Disturbed sensory perception related to:
– Biochemical alterations in the brain and to possible sleep deprivation
• Impaired social interaction related to:
– Egocentric and narcissistic behavior
• Insomnia related to:
– Excessive hyperactivity and agitation
Planning/Implementation
• Nursing interventions are aimed at:
– Maintaining safety of client and others
– Restoring client nutritional status
– Encouraging appropriate client interaction with others
– Assisting client to define and test reality
– Meeting client’s self‐care needs

• Review differences between suicide threat, gesture and attempt.

• Review essential nursing intervention for patients hospitalized due to suicidal
ideations.

Substance Dependence: Three of the following must be present for diagnosis:

1) Evidence of tolerance.
2) Evidence of withdrawal symptoms.
3) The substance is taken in larger amounts or over a longer period of time than was
intended.
4) A persistent desire or unsuccessful efforts to cut down.
5) A great amount of time is spent trying to obtain the substance or recover from it’s
effects.
6) Social, recreational or occupational activities are given up
7) Substance use is continued despite knowledge of the physical or psychological
damage it has caused.

Neurotransmitters
• Dopamine: Physical activation, movement and coordination,
emotions, voluntary decision making (decreased in Parkinson’s and
depression; increased in mania and psychosis)
• Norepinephrine: regulates mood, cognition and perception,
cardiovascular functioning, sleep and arousal (decreased in
depression; increased in anxiety and mania)
• Serotonin: sleep, arousal, libido, mood, appetite, aggression and pain
perception (decreased in depression)
• Gama Aminobutyric Acid (GABA): interrupts progression of electrical
impulses in the synaptic junction; which slows down the body activity
(decreased in anxiety and epilepsy)

Etiology
Biological Factors: genetic
Psychological Factors: developmental influences, personality factors
Sociocultural Factors: social learning, cultural and ethnic influences

Assessing Substance Usage

• Ask questions in a neutral, non-judgemental manner
Do not try to reason with someone who is acutely intoxicated.
Use short direct questions that focus on safety.
Always assess for suicidal and homicidal ideation.
When assessing substance use, always ask: what substance? how much? how
often? Duration? Why? Withdrawal/DTs Last used? Desire to stop/attempts to quit?

The CAGE Questionnaire

1) Have you ever felt that you should Cut down on your drinking?
2) Have people annoyed you by criticizing your drinking?
3) Have you ever felt bad or guilty about your drinking?
4) Have you ever had a drink first thing in the morning to steady your nerves or get
rid of a hangover?

Pharmacology
• Buprenorphine: mixed agonist and antagonist at the opioid receptors used for opioid
dependence.
• Methadone: synthetic opiate used for opiate withdrawal and maintenance.
• Naltrexone: opioid antagonist used to treat opiate overdose; used to prevent alcohol
relapse.
• SSRIs & SNRIs: anti-depressants.
• Benzodiazepines: Used during alcohol withdrawal (anti-seizure and anti anxiety).