Transcript Overview of Treatment Methods

Chapter 35
Care of the Patient with a
Psychiatric Disorder
-Overview of Treatment Methods
-Application of Nursing Process
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Overview of Treatment Methods
• Communication and Therapeutic Relationship

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Confidentiality is a dilemma when therapeutic
effectiveness of care depends on patient’s willingness
to talk about feeling and thoughts
Let patient know information is shared among
healthcare team
• To curtails patients’ manipulating the staff, or pitting one
staff member or patient against another

Nurse has duty to report child abuse and must also
warn
• Patient may threaten to kill some one or hurt someone

Nurse must report to proper authority
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 2
Overview of Treatment Methods
• Communication and Therapeutic Relationship

Therapeutic techniques for psychiatric disorders
• Psychotherapy
• Electroconvulsive therapy (ECT)
• Psychopharmacology

Key component to psychiatric-mental health treatment
• To develop helping–trust relationship
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Maximizes patient’s strengths, maintains self-esteem,
and assists patient to develop and use coping skills
Nurse assists patient in learning new ways of
responding to people and situation
• Therapeutic Dialogue, pg 1153
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 3
Overview of Treatment Methods
• Communication and Therapeutic Relationship

Psychotherapy
• Psychiatric problems are treated using one or more of
the following psychological techniques:
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Behavior therapy
Cognitive therapy
Group therapy
Play therapy
Hypnosis
Psychoanalysis
Adjunctive therapies
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
Overview of Treatment Methods
• Communication and Therapeutic Relationship

Psychotherapy
• Behavioral therapy
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To relieve anxiety by conditioning and retraining of
behavioral responses by repetition
Phobias may be resolved by this technique
• Cognitive therapy
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Focuses on breaking negative thought patterns and
developing positive feelings about memories or thoughts
• Group therapy
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Used in a hospital setting or day treatment programs
Patients with similar problems gain insight through
discussion and role palying
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 5
Overview of Treatment Methods
• Communication and Therapeutic Relationship

Psychotherapy
• Play therapy

Used to help children express themselves by using
toys such as puppets as their “spokesperson” of
feelings
• Hypnosis
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To help person recover deeply repressed emotions
and speed recovery
Help change habits like smoking
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 6
Overview of Treatment Methods
• Communication and Therapeutic Relationship

Psychotherapy
• Psychoanalysis
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Developed by Sigmund Freud
Long-term and intense form of therapy that allows
individual to bring unconscious thoughts to surface
Free association (speaking thoughts without
censorship) and dream interpretation
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 7
Overview of Treatment Methods
• Communication and Therapeutic Relationship

Psychotherapy
• Adjunctive therapies
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Occupational therapy, recreational therapy, music
therapy, magnetic therapy, art therapy and
hydrotherapy
Allow expression of feelings, help increase selfesteem, and promote positive interaction and reality
orientation
Used in group setting or individually
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 8
Overview of Treatment Methods
• Electroconvulsive Therapy (ECT)
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Introduced by Ugo Cerletti and Lucio Bino in the late
1930’s
 Muscle relaxants and anesthesia are part of therapy
• To reduce fracture, contusion, and sprains from
seizures
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Treatment for depression, mania, or schizophrenia
disorders that do not respond to other treatments
A very small amount of electrical current required to
trigger a tonic-clonic (grand mal) seizure
• Temporary memory loss
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Last a few hours to a few days
• Confusion

Lasts a few hours
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 9
Overview of Treatment Methods
• ECT (continued)
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Done as out patient treatment
When used properly, it’s effectiveness is as great
or even greater than other treatment
Tests before ECT
• Physical examination, blood chemistry, survey,
CBC, urinalysis

To detect unsuspected conditions
• Mental examination, EEG to rule out electrical
abnormalities, chest and lumbosacral spine
radiography to rule out abnormalities, ECG
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 10
Overview of Treatment Methods
• ECT (continued)
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Nursing Interventions
• Pre-ECT
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Informed consent; NPO for 8 hours
Baseline vital signs; void prior to treatment
All jewelry, glasses, contacts, dentures, and hairpins
removed
IV line inserted; pre-ECT medications given
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Slide 11
Overview of Treatment Methods
• ECT (continued)
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Nursing Interventions
• Post-ECT
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Frequent vital signs; warm bath
Constant supervision due to confusion
Light meal or snack and assist in mobility
Should not drive until completely confusion free
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Slide 12
Overview of Treatment Methods
• Psychopharmacology

Psychotropic (psychoactive) medications are used in
conjunction with other therapies to help modify an
individual’s behavior
 Use to control symptoms
 Nursing responsibility
• Monitor for effectiveness and side effects
• Must understand the use of these drugs (pg: 11561157)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 13
Overview of Treatment Methods:
Psychopharmacology
• Antidepressants
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Work in different ways in brain
Assist in alleviating signs and symptoms of
depression
• Decreased appetite or sleep pattern disturbances,
prolonged sadness and lack of concentration
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Effects are seen 2 to 4 weeks before
improvement is noted
Effects on depression is described as “fog lifting”
Maintained for several months to a year to
prevent symptoms recurrent
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 14
Overview of Treatment Methods:
Psychopharmacology
• Antidepressants (cont’d)
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Selective serotonin reuptake inhibitors (SSRIs)
• Fluoxetine (Prozac), sertraline (Zoloft), venlafaxine
(Effexor), citalopram (Celexa), paroxetine (Paxil)
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Serotonin syndrome
o
o
o
o
Potentially life-threatening condition
Occurs due to an interaction between SSRI and
another serotonergic agent
Occur in older adult patients taking only SSRI
SX: altered mental status, autonomic dysfunction,
and neuromuscular abnormalities
• Use is preferred due to fewer side effects
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 15
Overview of Treatment Methods:
Psychopharmacology
• Antidepressants (cont’d)
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Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin syndrome
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Labs: elevated CPK from muscle disintegration,
elevated WBC, and transaminases, decreased
serum bicarbonate level
Treatment: slowly decrease dosage of drug
Sudden drug decrease leads to: dizziness, nausea,
vomiting, muscle pain, headache, fatigue, anxiety,
crying spells and irritability
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 16
Overview of Treatment Methods:
Psychopharmacology
• Antidepressants (continued)
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Tricyclics
• Amitriptyline (Elavil), amoxapine (Asendin), desipramine
HCl (Norpramin), imipramine HCl (Tofranil), nortriptyline
HCl (Avnetyl, Pamelor)
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Monoamine oxidase inhibitors (MAOIs)
• Phenelzine sulfate (Nardil)
• Tranylcypromine sulfate (Parnate)
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Triazolopyradines
• Trazodone (Desyrel)
• Bupropion (Wellbutrin)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 17
Overview of Treatment Methods:
Psychopharmacology
• Antidepressants (continued)
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Autonomic dysfunctions
• BP fluctuation, tachycardia, hyperthermia,
mydriasis (dilated pupils), shivering, diaphoresis
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Neuromuscular symptoms
• Akathisia, jittery feeling inside, ataxia
(incoordination), dystonia, dyskinesia,
hyperreflexia, tremors and seizures
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 18
Overview of Treatment Methods:
Psychopharmacology
• Antimanics
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Stabilizes mood and behavior of a patient with mania
Therapeutic blood level required (lithium carbonate)
• May take 7-10 days to achieve
Lithium carbonate (Eskalith, Lithobid)
• Chief drug to manage mania
• Monitor for lithium toxicity
 Serum level above 1.5 mEq/L
 Signs of toxicity: Nausea, vomiting, diarrhea,
drowsiness, muscle weakness, and ataxia, leads to
seizure and death
 Poor fluid intake and salt restriction in diet increases
risk of toxicity
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 19
Overview of Treatment Methods:
Psychopharmacology
• Antipsychotics
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Major tranquilizers
Treatment of schizophrenia, organic mental disorders
with psychosis, and the manic phase of bipolar mood
disorder
Provide symptomatic control; not a cure
Side effects
• Postural hypotension and sedation
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Consider safety measures to prevent fall
• Photosensitivity
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Sunscreen and hats
• Autonomic reactions
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Urinary retention, dry mouth, constipation, edema, weight
gain
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 20
Overview of Treatment Methods:
Psychopharmacology
• Antipsychotics (continued)
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Side effects
• Extrapyramidal symptoms
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Pseudoparkinsonism – tremor with rigid posture
Akathisia – inability to sit still, with continuous hand,
mouth, or body movements (foot tapping)
Dystonias – aberrant posturing (hand spasms)
Dyskinesia – involuntary movement (lip smacking,
tongue protrusion)
Tardive dyskinesia – due to reduction of medication
and can have a permanent effect
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 21
Overview of Treatment Methods:
Psychopharmacology
• Antipsychotics (continued)
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Treatment of extrapyramidal symptoms
• Reduce or stop the drug, parenteral
diphenhydramine, antiparkinson drugs
(trihexyphenidyl [Artane], or benztropine [Cogentin])
Example: pg 1156
• Chlorpromazine (Thorazine)
• Thioridazine HCl (Mellaril-S)
• Trifuloperazine HCl (Stelazine)
• Fluphenazine HCl (Prolixin, Permitil)
• Perphenazine (Trilafon)
• Thiothixene (Navane)
• Haloperidol (Haldol)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 22
Overview of Treatment Methods:
Psychopharmacology
• Antianxiety
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Minor tranquilizers
Help individuals experiencing moderate to severe
anxiety
Benzodiazepine sedatives like lorazepam (ativan)
• Used to relieve tension without losing motivation
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Drugs in this category are commonly abused
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 23
Overview of Treatment Methods:
Psychopharmacology
• Antianxiety
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Examples
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•
•
•
•
Alprazolam (Xanax)
Busipirone (Buspar)
Chlordiazepoxide HCl (Librium)
Clorazepate dipotassium (Tranxene)
Lorazepam (Ativan)
Oxazepam (Serax)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 24
Alternative Therapies
• Use of natural or herbal medications has gained
tremendous popularity.
• Control and manufacture of these medications do
not fall under the laws of the U.S. Food and Drug
Administration.
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Quality and quantity vary from manufacturer to
manufacturer.
Claims and clinical studies are not always consistent.
• Nurse should ask about the use of herbs when
obtaining drug history.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 25
Alternative Therapies
• Examples

St. John’s wort (Hypernicum)
• Interacts with MAOIs and can trigger hypertension
taken with allergy medication containing monoamines
or phenylalanine
 Taken withamino acid supplement containing tyrosine
• Used for mild depression
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Kava (Piper methysticum)
• Used in treating anxiety and insomnia
• Proven sedative effects
• S/E: scaly rash on back of hands and forearms and soles
of foot
• Alcohol potentiates its effects and if taken with BNZ, can
become toxic and induce coma
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 26
Alternative Therapies
• Examples
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Ginkgo and Ginseng
• Used to improve memory and boost energy
• Ginkgo: provide memory and cognitive improvement in
treatment of early Alzheimer’s disease
 Increases cerebral blood flow
 Potentiates anticoagulant drugs like aspirin and
warfarin which can lead to hemorrhage
 Affect insulin release
• Ginseng: decreases blood glucose level in diabetics
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 27
Alternative Therapies
• Examples

Aromatherapy
• Used to enhance or potentiate another remedy
• Scented oils for massage, volatile oils to sniff or
inhale, scented candles or incense
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Triggers chemical activity in the brain to relieve
imbalance in the body
• Citrus essences, peppermint, cedar wood,
rosemary, sandal wood, chamomile, lavander
Essential oils help relieve stress and anxiety
 Chamomile tea, sandal wood candle, lavander bath
• Focuses on atmosphere of moment and uses body’s
senses to achieve balance within
• A place in holistic care

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 28
Nursing Process Application
• LPN/LVN participates in nursing process as member of
mental health care team that includes RN, MD, therapist
• LPN/LVN observation of patient behavior and therapeutic
communications with patient

Assist RN in collecting data to form nursing diagnoses
 Ensure appropriate patient intervention
• Health promotion interventions focus on:

Prevention of relapse
 Management of symptom
 Simple, concrete, clear patient teaching is most successful
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 29
Nursing Process Application
• Evaluation
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Ongoing
At intervals or when patient’s response dictates, care
plan is updated
Examination of documentation and personal
observations are considerations when evaluating the
plan of care
• Documentation methods:
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Ongoing and include assessment criteria used by
health care team
Information are accurate and descriptive
Avoid terms “appears depressed” and use “no eye
contact noted during conversation”
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 30