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322 Final Study Guide
Behavioral Health Nursing (NSG-322)
Grand Canyon University
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Topic 14: Chapter 27 p. 432-433 SLEEP DISORDERS
REM Sleep Non-REM Sleep
Rapid eye movement sleep is characterized by inhibition of voluntary movement, fluctuating periods of rapid eye movement, and dreaming.
Divided into four stages that are characterized by specific electroencephalogram (EEG) patterns, and one’s ability to be aroused varies with each stage.
- Both REM and Non-REM can be disrupted by sleep disorders
- Sleep disorders often begin in early adulthood and generally worsen with age.
- Sleep loss contributes to physical health problems such as obesity, diabetes, cardiovascular disease, and impaired immune system functioning.
- Daytime drowsiness can reduce alertness and vigilance, impair judgment, and interfere with memory; these are particular concerns for night-shift workers in public safety and health care fields
- Assessment is by interview pertaining to sleep habits and patterns, subjective quality of sleep, and associated features such as sleepwalking or nightmares.
- Sleep journals are used to determine actual sleep patterns and duration more objectively, and formal sleep studies
Insomnia Disorder: Insufficient sleep, or sleep that is perceived as not restful
- Many physical, psychological, and social factors can contribute to insomnia (e., shift work, traumatic experiences, poor sleep hygiene).
- Insomnia can signal or contribute to relapse in depression, mania, and schizophrenia. Anxiety and worry are common sources of insomnia. Traumatic experiences and related disorders such as PTSD feature sleep disruptions such as insomnia and nightmares.
- Medications:
- Benzo-like: zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata)
- Nonbenzodiazepine hypnotic agents, such as zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta), demonstrate selectivity for GABAA receptors containing α1-subunits. Termed the “Z-hypnotics,” they have sedative effects without the antianxiety, anticonvulsant, or muscle-relaxant effects of benzodiazepines.
- Benzo-like: suvorexant (Belsomra)
- Can cause grogginess, impaired coordination and reflexes, dizziness, and increased fall risk in susceptible persons.
- Patients should be educated to use these with caution. Some are potentially addictive, and because tolerance can develop, they are encouraged to be used on a short-term basis.
- Benzodiazepines may increase the risk for dementia
- Melatonin
- Kava
- L-tryptophan supplements
- ramelteon (Rozerem) – increases the body’s melatonin production
- Benzo-like: zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata)
Obstructive Sleep Apnea (OSA): A temporary cessation (apnea) or decrease (hypopnea) in breathing during sleep. Usually due to a mechanical obstruction that increases when prone or when muscles relax during sleep, it is more common in obese persons. It sometimes occurs for nonstructural reasons as well. It can impair cognitive function and increase many health risks, including cardiovascular disease and mortality risk.
- An overnight sleep study (PSG) is used to diagnose obstructive sleep apnea. These can be done in a sleep lab or sleep center, or frequently in-home studies are done.
- Polysomnography (PSG): can be performed in-home or in a sleep center/lab (often the decision of which type of study is based on which suspected diagnosis the client has and the insurance company’s preference for cost coverage).
- Mechanical devices such as ventilation assistance devices (e., continuous positive airway pressure [CPAP] machines) may be necessary for obstructive sleep apnea
- BiPAP: auto adjusts
Narcolepsy: Sudden, irresistible urges to sleep. One may suddenly fall asleep under any circumstance; some continue automatic behavior as if in a mental fog. Episodes are not recalled after awakening.
Type 1 = Narcolepsy with cataplexy — sodium oxybate
Type 2 = Narcolepsy without cataplexy
Narcolepsy is treated with stimulants like modafinil (Provigil), which has fewer undesired effects on sleep; side effects include headache, irritability, and gastrointestinal complaints.
Multiple sleep latency test (MSLT) (sometimes called a “nap study”) are the primary diagnostics for narcolepsy
The MSLT is a full-day test that consists of five scheduled naps separated by two-hour breaks. During each nap trial, you will lie quietly in bed and try to go to sleep. Once the lights go off, the test will measure how long it takes for you to fall asleep. You will be awakened after sleeping for 15 minutes. If you do not fall asleep within 20 minutes, the nap trial will end.
Each nap will be taken in a dark and quiet sleep environment that is intended for your comfort and to isolate any external factors that may affect your ability to fall asleep. A series of sensors will measure whether you are asleep. The sensors also determine your sleep stage.
Stimulants are helpful for staying awake but do not take 4 hours before bed
Reducing stimulations (phones, TVs, noises, lights) is helpful for those with narcolepsy
Sleep latency: amount of time it takes the client to go from wakefulness to being asleep
REM latency: amount of time it takes the client to enter the REM stage of sleep (the final stage) after initially falling asleep.
Cataplexy: sudden loss of muscle tone while a person is awake leads to weakness and a loss of voluntary muscle control. It is often triggered by sudden, strong emotions such as laughter, fear, anger, stress, or excitement.
Most symptoms of PDs begin in early adulthood and present in a variety of contexts. Over time, the most dramatic symptoms associated with many of the PDs decrease in intensity, with less intensive symptoms shown in those who are middle-age and older.
Defense Mechanisms:
- Splitting: the division or polarization of beliefs, actions, objects, or persons into good and bad. Known as “black and white” thinking and is commonly seen in borderline PD.
- Projective Identification: Projection is the unconscious act of attributing a (usually difficult) thought or belief inside ourselves to someone else. - “I hate my boss but accuse my boss of hating me. In reality, my boss may actually like me.” This defense mechanism is evidenced in paranoid PDs
- Dissociation
Cluster A Cluster B Cluster C
Schizotypal PD
Schizoid PD
Paranoid PD
Antisocial PD
Borderline PD
Histrionic PD
Narcissistic PD
Avoidant PD
Dependent PD
Obsessive Compulsive PD
Odd or eccentric behavior
Suspicious
Cold
Withdrawn
Irrational
Dramatic, emotional behavior, manipulative
Attention-seeking behavior
Labile
Shallow
Increased rates of substance use and suicide
Anxious, fearful behavior
Tense
Overcontrolled
Depressed
CLUSTER As:
Schizotypal: A pattern of social and interpersonal deficits marked by a reduced capacity for close relationships.
- Cognitive and perceptual distortions, peculiar behavior, and odd speech
- Avoid interpersonal relationships
- Unconcerned the reactions of others
- Resembles schizophrenia and perceived to have odd thinking and beliefs
- Magical thinking and rituals
- Unusual perceptual experiences that are not consistent with cultural norms
- Inappropriate affect and an odd, eccentric, or peculiar appearance
- Suspicious of others and eventually to develop paranoid thinking
- Social anxiety and lack of friends
- Their eccentric and unkempt appearances, strange behaviors, and nonadherence to social conventions make it difficult for them to have give-and-take conversations.
- Under increased stress, these individuals may exhibit psychotic symptoms
- Low-dose antipsychotic medications, help ameliorate anxiety and psychosis-like features
Paranoid personality disorder (PPD): Characterized by pervasive, persistent, and inappropriate suspiciousness and distrust of others.
- Hostile, irritable, angry mood and affect
- Suspect that others are exploiting or deceiving them
- Reluctance to confide in others for fear the information will be used against them
- Reads hidden meanings into benign remarks and perceives attacks that are not apparent to others
- Inability to forgive perceived insults
- Suspicious and believe that others are lying, cheating, exploiting, or trying to harm
- Recurrent suspicion without justification about the infidelity of a spouse or partner
- Lack warmth, pay close attention to power and rank, and express disdain for those who are weak, sickly, and impaired
- Preoccupied with unjustifiable doubts about the trustworthiness of others
Schizoid Personality Disorder: Characterized by an inability to establish relationships with others and a restricted range of emotions in interpersonal settings
- Seen by others as eccentric, isolated, or lonely and take pleasure in few things
- Avoid even the most superficial relationships
- Flat affect and emotional coldness
- Indifferent to praise or criticism from others
- Choose solitary activities, lack friends, and have little desire for close relationships, including sexual experiences with another
- They may invest enormous energy in nonhuman interests such as mathematics and astronomy.
- Typically loners, they spend much time daydreaming and are often very attached to animals
- May later develop schizophrenia or a delusional disorder
CLUSTER Bs:
Antisocial Personality Disorder: Have a sense of entitlement, which means they believe they have the right to take what they want, treat others unfairly, destroy the property of others, and even hurt others if it is in their best interest.
- They do not adhere to traditional values or standards of morality as boundaries for their actions
- Lack regard for the law and the rights of others
- May engage in criminal behaviors
- Frequent history of persistent lying, deception, and conning of others for profit or pleasure
- May be charming, engaging, and uncanny in their ability to find just the right angle to lure a person into their intrigue with the intent to exploit them for money, favors, or more sadistic purposes.
- Behavior can be described as manipulative and irresponsible
- Promiscuity, reckless disregard for the safety of others, physical aggressiveness, failure to honor work or financial commitments, and drunk driving are common events in their lives
- Impulsive and fails to plan ahead
Histrionic Personality Disorder: A pattern of excessive emotionality and attention seeking.
- Manipulate others through self-dramatization, theatricality, and exaggerated expression of emotion. “Drama Queens”
- Speech may be excessively impressionistic and lacking in detail
- Remain the center of attention, so they can get the love and admiration that they require
- Act out with displays of temper, tears, and accusations when they are not getting the attention or praise they believe they deserve
- Uses inappropriate and sexually seductive or provocative behavior to draw others into a relationship or work project
- May use physical appearance to draw attention to themselves.
- There can be sudden emotional shifts and emotional lability (rapid change in mood)
- Relationships do not last long because of the constant need for attention and insensitivity to the needs of others
- Usually a lack of insight about their role in the failure of relationships
CLUSTER Cs:
Avoidant Personality Disorder: High levels of anxiety and outward signs of fear with feelings of low self-worth.
- Hypersensitive to criticism or rejection
- Avoid situations that require socialization
- They have strong desires for affection and for relationships, but are fearful of rejection, disappointment, criticism, or ridicule
- Spend most of their time in self-imposed social isolation and experience depression and anxiety
- View themselves as socially inept, personally unappealing, or inferior to others
- Constant low self esteem
- Reluctant to take personal risks for fear of embarrassment
- Feelings of inadequacy lead to inhibition in new interpersonal relationships and interpersonal intimacy
- Described as “shy,” “timid,” and “isolated.”
Obsessive-Compulsive Personality Disorder: Preoccupied with orderliness and mental and interpersonal control at the expense of openness or efficiency. The disorder is marked by a pervasive pattern of perfection and inflexibility.
Cautious and consider all choices in a methodical and inflexible manner
Preoccupied with rules and details and follow them rigidly, believing there is only one way to do things correctly
Rigid perfectionism — Perfectionism can sometimes interfere with task completion because strict standards are not met.
Reluctant to delegate tasks
Devotion to work may exclude pleasurable activities and friendships.
Have a very formal demeanor, lack a sense of humor, and have limited interpersonal skills
Rigid and stubborn, especially in matters of morality, ethics, or values
Experience distress in situations they cannot control or in which events are unpredictable
Are financially extremely stingy, and it is difficult for them to part with personal objects even if they are broken or worthless
People with this disorder do not display unwanted obsessions or compulsive ritualistic behavior
Clomipramine (TCA), SSRIs
Dependent Personality Disorder: Inhibited and fearful or reluctant to express disagreement for fear of rejection and loss of support.
- They do not respond with anger to rejection but, rather, withdraw or become passive
- Fearful that they are incapable of surviving if left alone and have an excessive need to be taken care of
- Solicit caretaking by clinging and being excessively submissive
- Have difficulty making everyday decisions without excessive advice and have difficulty initiating projects because of a lack of self-confidence
- Need others to take responsibility for most major areas of their lives
- Intense fear of separation and being alone is so great that they tolerate poor, even abusive treatment in order to stay in a relationship
- They are fearful and reluctant to express disagreement for fear of loss of support and may go to great lengths to obtain nurturance and support
- Once a relationship ends, there is an urgent need to get into another related to extreme feelings of helplessness when alone
- They are unrealistically preoccupied with fears of being left alone to take care of themselves
- Their high levels of anxiety intensify their inability to complete anything on their own
Dialectical behavior therapy (DBT): An evidence-based type of cognitive-behavioral therapy which helps change the self-destructive behaviors associated with the diagnosis of BPD. - The therapy addresses strategies for the extreme mood swings, the tendency to see the world in black and white, and the nonstop crises that are part of BPD. - 4 core concepts include 1. Mindfulness—living in the moment 2. Interpersonal effectiveness—skills that maximize the chance of achieving a goal without damaging a relationship or one’s self-respect 3. Distress tolerance—learning to bear emotional pain skillfully by accepting self and the current situation 4. Emotional regulation—recognizing and coping with negative emotions in a healthy manner Medications: - SSRIs: treat comorbid depression and panic attacks - Trazodone and venlafaxine: have low toxicity in overdose (Better than using benzos) - Carbamazepine: targets impulsivity and self-harm - Lithium, anticonvulsants, SSRIs: minimize aggression (helpful in antisocial PD) - Atypical antipsychotics: help with psychotic features in BPD under stress. - Low dose antipsychotics: especially helpful for schizotypal PD and Cluster A - Clomipramine (TCA) and SSRIs to ameliorate ruminative thinking and comorbid depression
Topic 12: Chapter 14 p. 184-198 EATING DISORDERS Environmental factors that may increase one’s risk of developing an eating disorder include the following: - Dysfunctional family and interpersonal relationships: Families with adolescents diagnosed with AN tend to report interpersonal boundary problems in which there may be separation and individuation developmental issues. - Trauma - Participation in career or sports in which being thin is promoted/required. - Cultural/peer pressure to be thin - Stressful life transitions - Comorbid anxiety disorder - Female athletes involved in running, gymnastics, or ballet and male bodybuilders or wrestlers are at increased risk
Disease: Anorexia Nervosa (AN)
Pathophysiology Signs and Symptoms Diagnostic Tests
- Terror of gaining weight
- Preoccupation with thoughts of food
- View of self as fat even when emaciated
- Peculiar handling of food:
- Cutting food into small bits
- Pushing pieces of food around plate
- Possible development of rigorous exercise regimen
- Possible self-induced vomiting; use of laxatives and diuretics
- Cognitive distortions: individual judges own
Diagnostic symptoms for AN include dangerously low body-weight measurements relative to the age and gender of the patient, intense fear of gaining weight, and disturbances in how one’s body weight is experienced.
self-worth by weight
Controls eating to feel powerful to overcome feelings of helplessness Risk Factors/Causes Complications RN Interventions + Patient Teaching
Family relationship
Trauma
Cultural or societal expectations
Comorbid anxiety
Sport or career requirements
Stress
Bradycardia
Hypotension
Orthostatic changes in pulse rate or blood pressure
Acrocyanosis (bluish color of hands and feet caused by slow circulation)
Carotenemia (elevated carotene levels in blood), which produces skin with a yellow pallor
Hypokalemic alkalosis (with self-induced vomiting or use of laxatives and diuretics)
Elevated serum bicarbonate levels, hypochloremia, and hypokalemia
Electrolyte imbalances, which lead to fatigue, weakness, and lethargy
Osteoporosis, indicated by low bone density
Elevated cholesterol levels
Amenorrhea
Abnormal thyroid functioning
Hematuria
Proteinuria
SCOFF Sick: Do you make yourself sick or vomit after a meal because you feel uncomfortably full? Control: Do you fear loss of control over how much you eat? One stone: Has the patient lost 14 lb in a 3-month period? (A stone is a unit of weight in Great Britain equivalent to 14 lb.) Fat: Do you believe you are fat even when others tell you that you are too thin? Food: Does food dominate your life?
Medications and Treatments Cognitive-behavioral therapy is used to diminish distortions in the patient’s thinking that result in problematic attitudes and eating-disordered behaviors. Enhanced CBT (CBT-E) is a structured, time-limited treatment specifically for eating disorders. The primary focus is to establish a regular pattern of stable, flexible eating and to address factors that reinforce the eating problem. Dialectical behavioral therapy is a form of CBT adapted to address emotional dysregulation. It has demonstrated effectiveness with adults with BN and BED, but there is less evidence for effectiveness with AN.
- Olanzapine *A potentially deadly complication of the refeeding process is the development of refeeding syndrome. This can occur when starved patients begin to eat and metabolize calories. The body shifts from a catabolic state (a state of breaking down tissues for nutrients) to an anabolic state (a state of rebuilding tissues/growth), causing a shift in fluids and electrolytes. Associated complications of this shift can include heart failure, arrhythmias, respiratory failure, muscle breakdown, and death.
Bulimia nervosa (BN): Engage in repeated episodes of binge eating (consuming large amounts of calories) followed by inappropriate compensatory behaviors such as self-induced vomiting; misuse of laxatives, diuretics, other medications; or excessive exercise.
Disease: Bulimia Nervosa (BN)
Pathophysiology Signs and Symptoms Diagnostic Tests
Engage in repeated episodes of binge eating (consuming large amounts of calories) followed by inappropriate compensatory behaviors such as self-induced vomiting; misuse of laxatives, diuretics, other medications; or excessive exercise.
Priority is the physiologic consequences of malnutrition, vomiting, and dehydration.
Risk Factors/Causes Complications RN Interventions + Patient Teaching - Cardiomyopathy (rare) - Cardiac dysrhythmias - Sinus bradycardia
- In working with a patient who has bulimia nervosa, the nurse needs to
Disease: BED
Pathophysiology Signs and Symptoms Diagnostic Tests
Binge-eating disorder is a variant of compulsive overeating.
Recurrent episodes of eating a large amount of food in a short period of time and usually feeling guilty or shameful after bingeing. The pattern is similar to BN, but with BED, there are no compensatory mechanisms used (e., self-induced vomiting or inappropriate use of diuretics/laxatives).
- Binge-eating behavior is described as soothing and helps to regulate their moods
Risk Factors/Causes Complications RN Interventions + Patient Teaching
BED usually exists with co-occurring psychiatric disorders such as bipolar disorder, depressive disorder, anxiety disorder, and to a lesser extent, substance use disorders
Morbid obesity
Medications and Treatments
Specialized cognitive behavior therapies offered individually or in a group setting, such as CBT-ED, have shown some effectiveness in changing problematic behaviors that perpetuate the disease. Guided self-help programs with supportive counseling have also demonstrated some effectiveness in modifying behaviors. lisdexamfetamine — mod-severe BED
Childhood feeding and eating disorders: - Pica: Pica involves the persistent eating of nonfood substances, such as sand or dirt, chalk, paint chips, ice, cloth, or hair. It is not part of a culturally accepted ritual or practice, and onset is common in childhood. There is potential for harm or death, depending on what is ingested. - Rumination disorder: This disorder involves repeated regurgitation of food, which is then re-chewed, re-swallowed, or spit out. The behavior may be self-soothing and often corrects itself if it occurs in infancy. - Avoidant/restrictive food-intake disorder: With this disorder, there is a persistent failure to meet nutritional or energy needs. It results in weight loss or failure to gain weight, significant nutritional deficiency, or dependence on supplements. - Eating disorders in children and teens can lead to a host of serious physical problems and even death. A child needs treatment right away because the best results occur when eating disorders are treated at the earliest stages.
Chapter 1: Recovery model as applied to mental health: The recovery model is focused on helping individuals develop the knowledge, attitudes, and skills they need to make good choices or change harmful behaviors - The recovery model originated from the 12-step program of Alcoholics Anonymous - Mental health care is to be consumer and family driven, with patients being partners in all aspects of care. - Care must focus on increasing consumer success in coping with life’s challenges and building resilience, not just managing symptoms. - An individualized care plan is to be at the core of consumer-centered recovery.
Trauma informed care: Trauma-informed care recognizes that trauma is almost universally found in the histories of mental health patients and is a contributor to mental health issues, substance abuse, chronic health conditions, and contact with the criminal justice system. - Trauma-informed care provides guidelines for integrating an understanding of how trauma affects patients into clinical programming. - A change in paradigm from one that asks, “What’s wrong with you?” to one that asks, “What has happened to you?” - Key principles include avoiding retraumatizing through restraints or coercive practices, an open and collaborative relationship between patient and provider, empowerment, and cultural respect.
Chapter 2 Mental health is a continuum: Mental health and mental illness are not specific entities but, rather, they exist on a continuum. The mental health continuum is dynamic and shifting, ranging from mild to moderate to severe.
Coping skills (positive and negative): Ability to problem solve and cope in ways that are not harmful (deep breathing, meditation). Poor coping that creates further dysfunction (substance abuse, self-harm)
Cellular Components (Neurons, Synaptic Transmission, Neurotransmitters, Receptors): An essential feature of neurons is their ability to initiate signals and conduct an electrical impulse from one end of the cell to the other, called neurotransmission (Fig. 4). Electrical signals within neurons are then converted at synapses into chemical signals through the release of molecules called neurotransmitters, which then elicit electrical signals on the other side of the synapse. Once an electrical impulse reaches the end of a neuron, the neurotransmitter is released from the axon terminal at the presynaptic neuron and diffuses across a synapse to a postsynaptic neuron. Here it attaches to specialized receptors on the cell surface and either inhibits or excites the postsynaptic neuron.
Chapter 5 Outpatient Care Settings:
Inpatient Care Settings What is the inpatient milieu and why is it important?
What is crisis intervention?
What are residential treatment programs?
Role of the psychiatric nurse and role of the Advanced practice psychiatric mental health nurse (PMHNP)
Specialty Treatment Settings
322 Final Study Guide
Course: Behavioral Health Nursing (NSG-322)
University: Grand Canyon University
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