y y y

Medical conditions are negatively effected by mood disorders Medical Conditions can cause mood disorders Decision trees for diagnosing - 1st question is "due to a med. condition?"

p People with psychiatric illness develop medical illnesses p Patients with no psychiatric illness can develop one (depression) in response to altered health status p Some medications can cause depression p People who have had psychiatric illness in the past can relapse because of stress/illness

Untreated depression in the medically ill can result in: p Increased length of stay p Increase risk adverse events p Increased morbidity and mortality rates p Poor compliance

 Prognosis is negatively effected by depression  Higher CV mortality among pts. with major depression  Depression may be a risk factor for heart disease (not just increased severity)  Depression plays a role in developing heart disease  CV disease and Depression = 2 most prevalent causes of death

y y y y

Mental disorder due to a general medical condition Adjustment Disorder (situational adjustment reaction) o Due to an identifiable stressor Major Depressive Disorder Bipolar Disorder  MDD and BPD more prone to admission due to suicide attempt

y y

When a medical problem is the cause of mental problems, treatment of the medical condition dramatically improves psych. symptoms Nurse needs to recognize symptoms of depression to provide effective intervention  Develop adaptive coping mechanisms

y Everyday 'Blues': short-lived response to everyday stressors  Blues become a trend = Depression y Major Depressive Disorder p Overwhelming depression dominates ones life p Interferes with daily functioning p A Brain Disease (altered neurotransmitter levels and functioning) p Requires Treatment

 Depressed or sad mood  Changes in appetite, concentration, sleep  People will react differently, look for changes  Unable to experience pleasure  Fatigue/Decreased energy  Irritability  Lack of Concentration  Social Isolation  Decreased libido  Anxiety p May present as vague non-specific complaints  Many go unrecognized

Depression= p Hopeless p Helpless p Worthless Depressive Symptoms leads to inability to cope as well: Cope less=more depression=cope less=more depression.....

 Need to assess for Suicidal Thoughts

Depression related to Medications and Substance Abuse p Aggravate Depression       Antihypertensive Drugs Steroids Benzodiazepines Anabolic Steroids Cancer chemotherapeutic agents Psychoactive Agents: Alcohol, Amphetamines, Opioids

y Depression in the Elderly p From loss of health and function p May not arise from increased age (not because they are older)  Not normal part of the aging process but Logical

Mental Status Exam p Appearance p Behavior p Mood p Affect p Thoughts p Interactions p Past History  Appearance, Behavior, Conversation

How does a pts. medical condition affect Quality of Life? p Ability to Function p Relationship with significant others p Quality of coping skills Pts. with medical condition are vulnerable to psychosocial stressors p Can result in feelings of hopelessness, helplessness, worthlessness, despair

 Educate the pt. on what s actually happening  Patient response depends on quality of nursing intervention!

Nursing Interventions p Meet the patient where they are at p Be there and Care p Be a therapeutic presence p Active Listening/Mindful Listening p Encourage talking about feelings and fears p Provide quiet reassurance  'It's ok to be depressed...it's ok to feel...' p Educate p Ask about suicidal thoughts  Continually Assess Depression can be contagious

p p p p

Nurses' reaction depends on: p Knowledge p Personal beliefs/reactions p Counter Transference  Difficult to see pt. in front of us because we are stuck on past experience Identification with patient Over-Involvement Frustration/Inadequacy Rejection/Depression/Anger

Collaborative Intervention: p Psychiatric Consult p Psychiatric Liaison Nurse Medications: p SSRI's (Celexa, Lexapro, Paxil, Prozac) p Novel Antidepressants/Serotonin & Norepinephrine (Effexor, Cymbalta, Wellbutrin) p Tricyclic s (Elavil, Anafranil, Aventyl)  Sedating (give at bedtime)  Used for chronic pain patient p MAOI (Marplan, Nardil)  Have life threatening Hypertensive side effects

Bipolar Disorder p Pathological Mood Swings (from Mania to Depression)  Mania <-> Hypomania <-> Balanced <-> Mild depression<-> severe depression (MDD) Symptoms of hypo/mania p Outgoing p Restless/Frenzied/Out-of-Control Activity p Rapid/Pressured Speech p Loose Associations/non-coherent p Irritable to Hostile p May become delusional p No Fear/Unsafe Behavior

Risk Factors p Genetic p Biochemical dysregulation  Depression: Decreased Serotonin and Decreased Norepinephrine  Mania: Decreased Serotonin and Increased Norepinephrine p Psychological  Defense mechanism p Infections (Flu, Encephalitis p Illness (hyperthyroidism, Drugs) p Drugs (substance induced Mood Disorder)  Can be non-compliant with meds

Nurses need to be: p Be prepared p Don't take it personal p Set Limits (Firm but comfortably) Keep patient safe p Consistency p Structure p Predictability p Talk slower and Lower p Support/Educate patient and Family  Don't feed into delusions p Prevent embarrassment

y Bipolar medications: p Lithium (Mood Stabilizer)  Monitor fluid intake (Lithium=Salt; can effect concentration)  4-6 weeks to become effective  Narrow therapeutic Window (.6-1.2)  Adverse Effects = hypothyroidism, toxicity  Do Not Use: renal conditions, cardiac conditions p Anticonvulsants (Tegretol, Depakote, Lamictal)  Lamicatal=start low, go slow ->Steven Johnson Syndrome p Atypical Antipsychotics (Zyprexa, Geodonm Seroquel, Abilify)

Suicidal Client  Mood disorder is responsible for 1/2 of all suicides  70% of suicides are ppl with active or chronic med. condition  90% of suicides have at least 1 psychiatric diagnosis p Suicide is preventable (attach to part that wants to stay alive)

 Anyone who talks about, threatens, or attempts suicide must be taken seriously  Always assess for suicidal thoughts  Suicidal Ideation = thoughts about harming oneself  Suicidal Threat = verbal threat to commit suicide (increased risk)

Risk Factors for Suicide p Psychiatric Diagnosis p Physical Illness p Lack of social support p Recent stressful event p Childhood trauma/abuse p Family History p Hopelessness, Anxiety, impulsiveness, aggression Warning Signs: p Verbal Clues p Behavioral changes (withdrawal, change in personality) p Situational Clues (loss, injury, illness)

 p p p p p p

Assessment of Suicidal Client: Ask, Assess, Act p Appearance p Behavior p Mood p Affect p Thought (SAD PERSONAS) Sex p Social support lacking Age p Organized plan Depression p No spouse Past attempts p Availability of means Etoh p Sickness Rational thinking Loss p 1-4 (low), 5-6 (med), 7+ -high

Collaborative Intervention  Psychiatric Consult  Psychopharmacology  Keep patient Safe

 Pathology: the study of the nature of disease and its causes, processes, development, and consequences  Physiology: branch of biology that deals with the functions and activities of life or living matter (organs, tissues, cells) and of the physical and chemical phenomena involved  Pathophysiology: involves the study of functional or physiological changes in the body that result from disease processes p Is a disease or condition p Usually involves changes at the organ or system level, as well as cellular level p Focuses on changes at the organ level

Pathophysiology p Explains the changes in normal processes in the body that result in the signs and symptoms of a disease p Helps to understand how the alterations in structure and function disrupt the human body as a whole  To develop useful questions  To understand implications of this information  To decide on the necessary precautions or modifications required to prevent complications

Pathophysiology Basics: p It begins with the cell p External stressors disrupt homeostasis p Cell uses reserves, adapts, or dies

Pathophysiology Includes: p Lab studies for cells and tissues related to disease p Acquired through biopsy, surgical specimens, body fluids, autopsy p Helps to establish the cause of disease

p Pathophysiologic changes seen depend upon the cause of the disease  Infection? Neoplasm? Genetic Defect? p Explains the changes in normal processes within the body that result in the signs or symptoms of a disease p Is not concerned with the treatment of the disease

Etiology p The cause of the disease  Age, gender, exposure, genetic predisposition, personal behavior can cause disease Cause may be intrinsic, extrinsic, or idiopathic p Intrinsic: malfunction/change within the body (genetics, age, gender) p Extrinsic: Outside the body (smoking, infectious disease p Idiopathic: disease with No Known Cause p Iatrogenic: disease as a result of procedure, treatment, error

Correlation p Relationship between variables that may be negative or positive p A tendency for variation in on variable to be related to variation in another variable p Correlation is an association, connection, link, relationship Correlation of Pathophysiology p Examines how one disease impacts other disease processes and bodily functions p By understanding this we are better prepared to anticipate a patients physiologic response and therefore anticipate needs

Problem Oriented Documentation p Identify the Problem p Offer a Solution p Obtain Follow-Up Results

y y y

Basic Components to Problem Documentation p Baseline information is obtained at Admission  Keep Active and Current Chronological list of all the patient s problem p New problems added PRN Orders/Care plans p Keep current and DC d as needed Progress notes for each identified problem

24hour Clinical Progress Record (computer offline)  Includes labs, Pharmacy, Nutrition, Etc. p Date and Military time every page, front and back p Must be signed with full name and credential p Legible, permanent, black ink p Only approved abbreviations p Errors = single line, word error, date, signature p Fill in blank with a straight line p First time you document: full name, signature, credential  Late Entries (any entry out of chronological order): Date and time of documentation followed by date and time of intervention

Elements of Effective Charting p Confidentiality p Permanence of the record p Appropriateness  Just Facts & quotes p Timing (real/sequence)  Real time Charting: exact time you initiate documentation  Sequence Charting: Chronological time an assessment, intervention, and patient response is documented

y y y
y

Box in problem area you are addressing * on care record next to information you will chart about I/O is totaled at 2pm, 6pm, 10pm

 to denote normal/no problem

Make sure you have the correct patient (label both sides)

y y y y y y y

Avoid labeling patient behaviors  Objectively describe you patients behaviors Do not refer to staffing problems Document just facts (do not mention reports that have been filed) Do not explain why the mistake happened Do not put in opinion of other nursing care Do not put that you have informed someone unless you said, I want to inform you Do not refer to another patient by name

Case Management: a collaborative process of delivering patient care that emphasizes quality patient outcomes as well as efficient, cost effective care  Role of case manager is expanding to multiple places, not just hospital  Goal= Safe Patient Discharge p ADOD=anticipated date of discharge p Discharge planning starts the day of admission

Case Management Process p Assess with patient and family to determine needs p Plan with specific goals and actions p Implement plan p Coordinate by organizing/modifying resources p Monitor/Modify p Evaluate Phases p Establish ADOD p Communicate ADOD/goal to family and staff p Assess patient needs early in stay p Discuss ways to accomplish goals

Benefits of Case Management p Patient gains an advocate p Patient gets emotional support p Help foster independence p Complicated cases are facilitated and expedited p Decrease in length of stay (resulting in lower cost)

All patients will receive: p Right Care at the p Right Time in the p Right Place by the p Right Person for the p Right Reason

Look at:  Risk  Progress  Barriers  Discharge  Assign Accountability y

Focus on:  Mobility  Mental Status Exam  Nutrition  Skin  Respiratory  DME  Meds Prevent readmission: p Pt. education during stay p Medication (Compliance) p Homecare Intervention p PCP appt/follow-up

Parenteral Medications p Any route that's not enteral/GI p Commonly refers to medication given by injection , Invasive Procedure -->Must use aseptic (sterile) technique Reasons for administration: p Can be absorbed quickly (rate of absorption depends on site)  Can't swallow  NPO  GI Surgery  IV antibiotics: High doses, Systemic

Needles  Can be attached to syringe or packaged separately p Hub - fits on the tip of the syringe  Usually color coded p Shaft - connects to the hub  Stainless steel  Inside = Lumen , Must be Sterile p Bevel - slanted tip, creates a narrow slit when injected into tissue and closes quickly when needle is removed

, Dispose in sharps container p Follow rules to avoid accidental needle stick

Needles vary in length (1/4-3inches) p Depends on age, size of patient, and type of injection  IM = 1-1.5in  SC = 3/8 to 5/8in  ID = 5/8in Gauge p Depends on viscosity of medication (OR = large Bore) , Smaller the gauge --> Larger the bore/diameter/lumen

, Never Recap a Used Needle , May use scoop method after drawing med/before injection

Syringes (.5-60cc)  Cylindrical Barrel with Close fitting plunger , Plunger is Sterile (Can touch outside of barrel and handle of plunger) p Luer lock or slip tip to connect needle to hub p May have needle attached p Large syringes for special IV delivery, add meds to IV solutions or irrigation , Tuberculin syringe = long, thin barrel and attached needle  Calibrated in 100's of a ml up to 1ml p Used to measure doses under 1ml , Insulin Syringe = measured in Units with needle attached

Carpujet p Used for medications that are in a pre-filled sterile syringe  Ex) Morphine p Cartridge is disposed of in sharps after use p Carpujet is reusable Powdered Medications p Amount of dilute and solution type is listed on label p Inject recommended amount of solution into vial , Label multi-dose vial with date, time, and concentration  May require refrigeration after mixing

Ampule p Single dose, 1-10ml p Made of glass with scored neck that is easily broken p No air is instilled prior to aspirating medication  Tap with finger then break , Filter needle must be used to withdrawal meds from ampule p Prevents aspiration of glass particles p Never used to inject meds to patient y Vials p Single or multi dose; liquid or powder p Air must be injected into the vial before withdrawing med  Closed System p Clean top with alcohol after removing dust cap

Types of Injections p Intradermal (ID) p Subcutaneous (SC/SQ) p Intramuscular (IM) p Intravenous  Intrathecal  Intra-articular  Intra-arterial Angles of Injection p Intramuscular - 90degrees p Subcutaneous - 45degrees , Insulin and Heparin - 90degrees p Intradermal - 15degrees

Intradermal Injections (ID) p 15degree injection dropping to 5 --> leaves a bubble on the skin p Injected into the dermis, directly under the skin p Decreased blood supply allows for slower medication of highly potent medications that can't be absorbed to rapidly  ex) Tb and Allergy testing p Avoid areas of bruising, rashes, inflammation, edema, discolored p Locations: p Below antecubital space, above wrist p Areas on back p Insert Bevel up (to make bubble) p Keep skin taught

Intra-arterial p Injected directly into the artery p Done in emergent or intensive care situation Intrathecal p Injected directly into CSF  chemotherapy, anesthesia Intra-articular p Injected directly into joint

Subcutaneous (SC/SQ) p Injection into loose connective tissue just below dermis p Medication absorption slower p Body weight proportional to depth of injection p Body weight determines length of needle p Length of needle (short) --> 3/8 - 5/8in p Small doses --> .5 - 2ml (max) p Gauge --> 25-58G (very small) p 45degree angle injection , Insulin and Heparin = 90degrees

Locations of SC Injections: p Back of Upper Arms p Anterior and Lateral thighs p Abdomen (avoid 2in around umbilicus)

, Complication = Sterile Abscess p Hot, Hard, Leaky (too much med) , Do not need to aspirate for blood (b/c low chance of hitting vein or blood vessel) p SJHHC policy - aspirate all SQ injections except insulin and heparin

Atypical SQ Injection: Insulin p Angle of Injection - 90degrees p Needle Gauge - 28G p Same area (but rotate within that area) for 4-5 injections p Rate of absorption is important consideration when selecting insulin site p Sites:  upper arm  anterior and lateral thigh  buttocks  abdomen (avoid in hospital) p Avoid scars, moles, bruises (could change absorption rate) , Syringes: Marked in units (usually 50u or 100u) with needle

Atypical SQ Injection: Heparin p 10000 units/cc  5000 units standard , Must show math p Angle of Injection - 90degrees p Needle gauge - 27G  May change needle p Location: Abdomen (avoid 2in around umbilicus) p Avoid skin lesions, bony prominence, bruise, large muscle, nerves ---> go to inner thigh , Hold for 10 seconds with skin pinched before withdrawing

, Low weight Heparin (Lovenox) - do not need to hold for 10s