Category Archives: Psych/Mental Health Nursing

Psych Medications: Mood Stabilizers

Anti-manic and Mood Stabilizing drugs (Lithium, Depakote, Lamictal, Tegretol, Trileptal)

  • LITHIUM is the drug of choice for controlling manic episodes
  • lithium has a narrow therapeutic index (~0.6-1.2), familiarize yourself with the different LEVELS OF TOXICITY
  • normal SE of lithium include fine tremors, mild thirst, mild nausea and general discomfort – if they persist, may indicate toxicity
  • remember that DEHYDRATION (excess nausea, diarrhea, sweating, diuretics) may cause lithium TOXICITY
  • SE of toxicity include coarse tremors, persistent GI upset, confusion, muscle irritabbility, ECG changes, incoordination
  • lithium level of > 2.5 may = DEATH
  • Tegretol may cause agranulocytosis – monitor WBCs
  • Lamictal may cause Steven-Johnson’s – monitor platelets
  • Depakote may cause hepatotoxicity and thrombocytopenia – monitor LFTs and platelets
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Psych Medications: Benzodiazepines

Benzodiazepines/Non-benzodiazepine Anxiolytics (Ativan, Klonopin, Valium, Xanax, Librium, Buspar, Inderal)

  • [Val and Xan the Klo Ind the Bus] “Val and Xan the Klown In the Bus”
  • benzos increase GABA, have rapid onset
  • few drug interactions, but can interact with other CNS depressants (alcohol) and manifest as sedation or death
  • there is potential for ABUSE, be cautious when giving to patients with history of substance abuse
  • benzos must be tapered to lessen S&S of withdrawal (fatigue, irritability, insomnia, tremors)
  • BUSPAR is a special drug: takes a while to work, so often is taken with a benzo while waiting for therapeutic effect; no potential for abuse; high cost
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Psych Medications: Antidepressants


I. Selective Serotonin Re-uptake Inhibitors
SSRIs (Lexapro, Celexa, Prozac, Paxil, Zoloft, Luvox)

  • [Luv Zolo Proz, Lexa Cel Pax] “Love solo pros. Lexa sells packs.”
  • SSRIs are FIRST LINE for depression
  • has fewer side effects than TCAs or MAOIs
  • no anticholinergic side effects, usual S&S include nausea, insomnia, sexual dysfunction

II. Atypical Antidepressants (new generation) (Cymbalta, Desyrel, Effexor, Remeron, Wellbutrin, Pristiq)

  • [Cymba Des Well Effex. Remer is imPrist] “Cymba does well effects. Rem is impressed.”
  • DESYREL can also be used for insomnia
  • EFFEXOR and CYMBALTA may cause HTN
  • CYMBALTA also used for neuropathic pain
  • WELLBUTRIN also used for smoking cessation

III. Tricyclic Antidepressants (Elavil, Anafranil, Norpramin, Tofranil, Vivactil, Pamelor, Sinequan)

  • Sounds like female names: Ela, Ana, Pam, Viv …; some end in -FRANIL or -IL
  • may take about 1-3w for effect and 6-8w for max response
  • have strong ANTICHOLINERGIC EFFECTS, so use with caution in elderly patients or patients with constipation, glaucoma or BPH
  • these medications also have strong CARDIOTOXIC effects
  • NORPRAMINE has low anticholinergic effects, which would be appropriate for the above
  • once daily dosing at bedtime helps to promote sleep through sedation effects and reduce daytime sleepiness
  • check the patient for HOARDING, especially if they are at RISK FOR SUICIDE

IV. Monamine Oxidase Inhibitors (MAOIs) (Nardil, Marplan, Parnate, EMSAM-patch)

  • [PaNaMA] or [No Popular Meds (N.P.M.)]
  • only used as a 2nd or 3rd choice for treatment of depression b/c of dietary restrictions and SE
  • dietary restriction of foods high in TYRAMINE (dried fruits, almost all cheeses, processed meats, soy products, avocados)
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Psychiatric/Mental Health: The Basics

The focus of this psychiatric/mental health nursing is usually around 4 main concepts:

  • therapeutic communication
  • safety
  • medications
  • specific psychiatric disorders

Therapeutic communication:
Communication is vital to the general nursing field, not just in psych, but it is especially important when interacting with a patient in the psychiatric setting. Much of the techniques learned in assessment applies such as reflection, active listening, empathy, etc. However, it is important to first look at the overall patient situation and determine which statement is most appropriate. For example, for a patient who is suicidal, you would want to ask more direct questions even if they seem very blunt such as “have you thought about harming yourself?”

Safety:
Recall that in the model Maslow’s Hierarchy of Needs, the care of the patient follows a stairstep priority list starting with physiological needs, followed by safety, emotional needs, self esteem. In psych, safety is always the priority. Consider interacting with an escalating angry patient. First step would  be to escort other patients away from the angry patient. Think about a patient who just told you he wants to kill himself. First thing would be to remove all objects that he could use to harm himself, such as ropes, bedsheets, even coke cans. Safety of the patient, other patients and nurse is crucial in these settings.

Medications:
Medications aren’t administered by students during the clinical shift, however, it is important for us as nurses to know the ins and outs of psych medications. There are several classes of medications covered in this course:

  • Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclics (TCAs), Monoamine Oxidase Inhibitors (MAOIs) and Atypicals
  • Antipsychotics – Conventionals and Atypicals
  • EPS drugs
  • Benzodiazepeines and related anxiolytics
  • Mood Stabilizers – Lithium, antiseizure medications
  • ADHD meds
  • Alzheimer’s agents
  • Herbals
  • Hypnotics
It isn’t enough to simply know what kind of drug it is, but also what is the specific name. Prozac is a SSRI, Geodon is an atypical antipsychotic.  There are several techniques to memorize the different drug names. I’ve seen pictures, acronyms and color coding. Once you know the different names and correlating class of drug, know their mechanism of action. Majority of these drugs work on neurotransmitters in the brain which in turn may produce the therapeutic effect as needed to relieve symptoms. Knowing the side effects is especially important. Some of these medications produce very uncomfortable side effects which may contribute to noncompliance. Teaching patients how to manage the side effects and administering the appropriate treatment is a critical part of medication administration.

Psychiatric Disorders:
There are several different psychiatric disorders covered in this coursed, including:

  • Schizophrenia
  • Anxiety disorders
  • Addictions
  • Depression
  • Bipolar disorder
  • Somatoform, Factitious, Dissociative disorders
  • Cognitive disorders
  • Personality disorders
  • Child/Adolescent disorders
  • Eating disorders

Alongside, there are other topics including death and dying, abuse, crisis intervention, etc. For each of the psych disorders, concentrate on the manifestations of the disorder, medications and relevant treatments, role of the nurse in caring for this particular patient, appropriate diagnoses and outcomes and patient teaching in managing their illness.

Whether you’re interested in working in the field of psychiatric nursing or not, the skills learned in this course may apply to all fields of nursing. Whether you’re working in critical care or general med/surg, there is a high possibility that some patients you meet may have comorbid psychiatric problems. Viewing the patient holistically includes addressing mental health and a efficient nurse is one who is competent in not only the medical, but the emotional and mental aspects of nursing care.

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“Reviews & Rationales”

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These supplemental reads were recommended by a nurse graduate YouTuber. She expressed how beneficial these books where in reviewing & emphasizing the material of the corresponding topics. They come in a variety of topics that cover from Pre-Nursing to Senior II. According to reviews on Amazon.com, many buyers recommend these reads as it has helped them during their courses.

I just ordered the Medical-Surgical & Mental Health R&R books to try them out. It couldn’t hurt to consider them if you’d want to spend a little extra. I personally have found them to be great as additional abbreviated material alongside the textbook material from the theory class. Below are the estimated, minimum, used prices.

Pre-Nursing:
Prentice Hall Nursing Reviews & Rationales: Anatomy & Physiology: Amazon ($14)
Prentice Hall Nursing Reviews & Rationales: Pharmacology: Amazon ($20)
Prentice Hall Nursing Reviews & Rationales: Pathophysiology: Amazon ($20)

Junior I:
Prentice Hall Nursing Reviews & Rationales: Nursing Fundamentals: Amazon ($15)
Prentice Hall Nursing Reviews & Rationales: Health Assessment: Amazon ($20)
Prentice Hall Nursing Reviews & Rationales: Fluid, Electrolyte, Acid-Base Balance: Amazon ($20)

Junior II:
Prentice Hall Nursing Reviews & Rationales: Medical-Surgical Nursing: Amazon ($20)
Prentice Hall Nursing Reviews & Rationales: Mental Health Nursing: Amazon ($18)

Senior I:
Prentice Hall Nursing Reviews & Rationales: Child Health Nursing: Amazon ($17)
Prentice Hall Nursing Reviews & Rationales: Maternal-Newborn Nursing: Amazon ($20)

Senior II:
Prentice Hall Nursing Reviews & Rationales: Nursing Leadership & Management: Amazon ($12)

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Care Plans

A care plan is an outline of the care that is expected to be provided to a patient based on their clinical picture. A well constructed care plan consists of the following:

  1. a holistic approach, taking into consideration psychosocial and socioeconomic concerns
  2. focuses on interventions to relieve or minimize a current health problem
  3. has mutually set goals and parameters that are SMART (Specific, Measurable, Action-oriented, Relevant, Time-bound)

NURSING DIAGNOSES
Nursing diagnoses are clinical judgments set based on a patient’s response to actual or potential health problems. The following is a typical set up of a nursing diagnosis:

(nursing diagnosis) related to (medical diagnosis or primary complaint) as evidence by (signs & symptoms)
Example: Acute pain R/T abdominal incision AEB grimacing, rating of pain 6/10.

The North American Nursing Diagnosis Association-International (NANDA-I) is the main organization for defining standard nursing diagnoses. It is important to note the different between a NURSING and a MEDICAL diagnosis.

A MEDICAL diagnosis focuses on the primary complaint, disease or illness.
A NURSING diagnosis focuses on the patient’s response to actual or potential health problems.

There are four types of nursing diagnoses as defined by NANDA-I:

  • Actual diagnosis – an existing health problem
  • Potential diagnosis – a “risk for” problem
  • Health promotion/Wellness diagnosis – readiness to enhance well-being and self health
  • Syndrome diagnosis – a cluster of nursing diagnoses that are better addressed together

In nursing school, take the time to construct these efficiently. These care plans are meant to train you to think like a nurse. What is the patient’s background? What is your plan of action? What are several nursing diagnoses you can associate with this patient? What is your priority intervention? All of these questions need to be answered once you begin your shift as an RN in the real world.

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Nursing Foundations: The Basic Study Skills

Foundations covers the basic knowledge and skills required to be a competent nurse. You have one semester to cover a variety of topics ranging from therapeutic communication and documentation to medication administration and end-of-life care. It may be overwhelming considering the amount of reading involved. My goal here is to show a more abbreviated way of studying while trying to get as much information possible out of the content, which is then applied in both exam questions and real life. It is all dependent on the student & his/her way of studying.
It is important to try to get a general grasp of this course because it is basically the “foundation” of nursing practice. A lot of the material here concerns nursing care and interventions, which is revisited throughout the upcoming semesters. Here’s some tips to get you up & running:

I. Pay attention to the objectives. They are a general overview of what you should learn after studying that particular chapter. Try to answer them as you go through the chapter.

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II. Don’t skip the information boxes. You’ll come across boxes with headlines such as “Focus on Older Adults”, “Concept Map”, Tables, Figures, “Cultural Aspects of Care”, “Client Teaching”, “Procedural Guidelines”, etc. They contain valuable information that is fair game for test questions. Review the “Nursing Care Plan” that comes with each chapter. They are great for putting all the information together in one coherent format as you would apply in real life.

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III. Do your EVOLVE modules early! You’ll find out how tedious doing these modules can be, but they are very helpful in supplementing the textbook material. They come with a variety of activities, diagrams, quizzes & photos as resource material.

IV. Do the Critical Thinking Exercises & NCLEX question at the end of the chapters. These help to reinforce the information you just learned & identifies any material that may need review.

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V. Utilize the resources provided for you to help you succeed in nursing school. The Learning Resource Center (LRC) has a software called NCLEX 4000. NCLEX 4000 breaks down question into certain topics (for this semester, concentrate on Nursing Fundamentals) & randomizes them to cover a variety of topics covered in your theory classes. You set up your own personalized exam to automatically give you rationales after answering a question. Another resource is the Student Success Center where you talk with instructors for any concerns you may have concerning your courses. There are also many supplemental books that are beneficial for use alongside your textbook. Examples include Reviews and Rationales, Saunders Comprehensive Review for the NCLEX and the Illustrated Guide to the NCLEX. The more you expose yourself to the material, the more it may become familiar to you. Evolve has multiple choice questions for each chapter. Although they are not completely reflective of an actual exam question, they are for knowledge-based practice.

VI. Attend the brown-bag sessions during the early part of the semester. They will be covering Test-taking Skills & Math for calculating medications. Being competent in math is one of the more important skills you’ll need this semester, not only because you’ll be required to take an exam in which you have to score 90%+ or else you’ll fail, but also you will be dealing with medications.

VII. Stay organized. As I mentioned earlier, you will be turning in many assignments throughout the course of the semester. Keeping them all in one place, like a binder, & make sure to turn them in one time. You’ll find that some assignments are only worth 1%-3% of you grade. Do not brush them off as unimportant. 1% could mean the difference between a letter grade. You’re a nursing student now, take your academics seriously.

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Content derived from Fundamentals of Nursing, 7th Edition.