ATI Capstone Content

Review: Mental Health - Tips of

the Week
Mental Health tips:
All clients should have a Mental Status Exam, which includes:

Level of consciousness

Physical appearance

Behavior

Cognitive and intellectual abilities

The nurse conducts the MSE as part of his or her routine and ongoing
assessment of the client. Changes in Mental Status should be investigated
further and the provider notified.

There are two types of mental health hospitalizations: Voluntary commitment

and involuntary or civil commitment. Involuntary commitment is against the
client’s will. Despite that, unless proven otherwise, clients are still considered
competent and have the right to refuse treatment.

Use the following communication tips when answering questions on

NCLEX:
* If the client is anxious or depressed – use open-ended, supportive
statements
* If the client is suicidal – use direct, yes or no questions to assess suicide
risk
* If the client is panicked – use gentle guidance and direction
* If the client is confused – provide reality orientation
* If the client has delusions / hallucinations / paranoia – acknowledge these,
but don’t reinforce
* If the client has obsessive / compulsive behavior – communicate AFTER the
compulsive behavior
* If the client has a personality or cognitive disorder – be calm and matter-of-
fact
Treatment for mental health illnesses and disorders can include medications,
talk and behavior therapy, and / or brain stimulation. Clients undergoing
care for mental health disorders may feel pressure to deny behavior or
issues to appear ‘normal’. The nurse should always carefully assess each
individual to ensure optimal response to therapies.

The most common type of brain stimulation therapy is electroconvulsive

therapy or ECT. ECT is generally performed for major depressive disorders,
schizophrenia, or acute manic disorders. Most clients receive therapy three
times a week for two to three weeks. Prior to ECT, carefully screen the client
for any home medication use. Lithium, MAOIs, and all seizure threshold
medications should be discontinued two weeks prior to ECT. After therapy,
reorient the client as short-term memory loss is common.

Anxiety disorders are common mental health disorders. Generalized Anxiety

Disorder, Panic Disorder, Phobias, Obsessive Compulsive Disorder, and
Posttraumatic stress disorder (PTSD) are all considered types of anxiety
disorders. Assess the client for risk factors, triggers, and responses.

A classic symptom of depression is change in sleep patterns, indecisiveness,

decreased concentration, or change in body weight. Any client who shows
these signs or symptoms should be asked if they have suicidal ideation.
Teach clients to never discontinue antidepressants suddenly.

Bipolar disorders are mood disorders with periods of depression and mania.
Clients have a high risk for injury during the manic phase related to
decreased sleep, feelings of grandiosity, and impulsivity. Hospitalization is
often required and nurses should provide for client safety.

There are several different types of abuse, including physical, sexual, or

emotional. Abuse tends to be cyclic, following a pattern of tension building,
battering, and honeymoon phase. When test questions appear related to
abuse, look for the phase to determine the correct response.

For the aggressive or violent client, setting boundaries and limits on behavior
is important. The nurse should maintain a calm approach and use short,
simple sentences.

More drug tips!

Common Psychiatric Medications
SSRIs: Selective Serotonin Reuptake Inhibitors. These medications
include Citalopram (Celexa), Fluoxetine (Prozac), or Sertraline (Zoloft). The
client should avoid using St. John’s Wort with these medications, and should
eat a healthy diet while on these medications.

TCAs: Tricyclic Antidepressants. Amitriptyline (Elavil) is an example.

Anticholinergic effects and orthostatic hypotension may occur.

MAOIs: Monoamine Oxidase Inhibitors. Phenelzine (Nardil) is an

example. Hypertensive crisis may occur with tyramine food ingestion, so
care must be taken to avoid these substances. Educate the client to avoid
all medications until discussed with provider.

Atypical antidepressants. Bupropion (Wellbutrin) is the most common

example. Appetite suppression is a common side-effect. Headache and dry
mouth may be severe and client should notify the provider if this occurs.
Atypical antidepressants should not be used with clients with seizure
disorders.

Serotonin Norepinephrine Reuptake Inhibitors. Common SNRIs include

Venlafaxine (Effexor) and Duloxetine (Cymbalta). Adverse effects may
include nausea, weight gain, and sexual dysfunction.

Antagonists
In order to understand how antagonist drugs work, you need to understand
how agonist drugs produce therapeutic effects. Agonists are simply drugs
that allow the body’s neurotransmitters, hormones, and other regulators to
perform the jobs they are supposed to perform. Morphine sulfate, codeine,
and meperidine (Demerol) are opioid agonists that act on the mu receptors
to produce analgesia, respiratory depression, euphoria, and sedation. These
drugs also work on kappa receptors, resulting in pain control, sedation, and
decreased GI motility. Antagonists, on the other hand, are drugs that
prevent the body from performing a function that it would normally
perform. To quote William Shakespeare & the US Army, these drug
classes allow the body’s functions “to be or not to be…all that they
can be.”

Common uses of antagonists:

· Treatment of opioids overdose, reversal of effects of opioids, or reversal of

respiratory depression in an infant

· Example: a postoperative client receiving morphine sulfate for pain control

experiences respiratory depression and is treated with naloxone (Narcan)

Nursing Interventions for antagonists:

 · Monitor for side/adverse effects

· Tachycardia and tachypnea

· Abstinence syndrome in clients who are physically dependent on opioid

agonists

· Monitor for symptoms to include cramping, hypertension, and vomiting

· Administer naloxone by IV, IM, or subcutaneous routes, not orally

· Be prepared to address client’s pain because naloxone will immediately

stop the analgesia effect of the opioid the client had taken

· When used for respiratory depression, monitor for return to normal

respiratory rate (16-20/min for adults; 40-60/min for newborns)

Antidotes

Antidotes are agents given to counteract the effects of poisoning related to

toxicity of certain drugs or substances. Antidotes are extremely valuable,
however most drugs do not have a specific antidote.

Antidote Drug/Substance Treated

Muscarinic agonists, cholinesterase inhibitors

Atropine · Bethanechol (Urecholine)
· Neostigmine (Prostigmin)

Anticholinergic drugs
Physostigmine (Antilirium)
· Atropine

Digoxin immune Fab (Digibind) Digoxin, digitoxin

Vitamin K Warfarin (Coumadin)

Protamine sulfate Heparin

Glucagon Insulin-induced hypoglycemia

Acetylcysteine (Mucomyst) Acetaminophen (Tylenol)

Bronchodilators
Bronchodilators are used to treat the symptoms of asthma that result from
inflammation of the bronchial passages, but they do not treat the
inflammation. Therefore, most clients with asthma take an inhaled
glucocorticoid concurrently to provide the best outcomes. The two most
common classes of bronchodilators are beta2-adrenergic
agonists and methylxanthines.

Beta2-adrenergic agonists : act upon the beta2 receptors in the bronchial

smooth muscle to provide bronchodilation and relieve spasm of the bronchial
tubes, inhibit release of histamines, and increase motility of bronchial cilia.
These short-acting preparations provide short-term relief during an asthma
exacerbation, while the long-acting preparations provide long-term control of
asthma symptoms.

The generic names for the inhaled form of these drugs end in“terol” =
“ T aking E ases R espiratory distress o r L abored breathing”

· Albu terol (Proventil, Ventolin)

· Formo terol (Foradil Aerolizer)

· Salme terol (Serevent)

The brand names of some drugs in this class provide a hint as well because
they contain the words “vent ” or “ breth ” referring to ventilation or
breathing:

· Albuterol (Pro vent il, Vent olin)

· Salmeterol (Sere vent )

· Terbutaline ( Breth ine)

Nursing interventions and client education:

· Short-acting inhaled preparations of albuterol (Proventil, Ventolin) can

cause systemic effects of tachycardia, angina, and tremors.

· Monitor client’s pulse rate before, during, and after nebulizer or inhaler
treatments

· Long-acting inhaled preparations can increase the risk of severe asthma or

asthma-related death if used incorrectly — mainly if used without concurrent
inhaled glucocorticoid use
· Oral preparations can cause angina pectoris or tachydysrhythmias with
excessive use

· Instruct clients to report chest pain or changes in heart rate/rhythm to

primary care provider

· Client should be taught proper procedure when using metered dose inhaler
(MDI) and spacer

· If taking beta2-agonist and inhaled glucocorticoid concurrently, take the

beta2-agonist first to promote bronchodilation which will enhance absorption
of the glucocorticoid

· Advise client not to exceed prescribed doses

· Advise client to observe for signs of impending asthma attacks and keep
log of frequency and intensity of attacks

· Instruct client to notify primary care provider if there is an increase in

frequency or intensity of asthma attacks

Methylxanthines: cause bronchial smooth muscle relaxation resulting in

bronchodilation.

Theophylline (Theolair) is the prototype medication and is used for long-term

control of chronic asthma

Nursing interventions:

· Monitor serum levels for toxicity at levels >20 mcg/mL

· Mild toxicity can cause GI distress and restlessness

· Moderate to severe toxicity can cause dysrhythmias and seizures

· Educate client regarding potential medication and food interactions that

can affect serum theophylline levels

· Caffeine, cimetidine (Tagamet), and ciprofloxacin (Cipro) can increase

levels

· Phenobarbital and phenytoin can decrease levels

ACE Inhibitors
ACE inhibitors block the production of angiotensin II which results in
vasodilation, sodium and water excretion, and potassium retention. Drugs in
this class are used for treating heart failure, hypertension, myocardial
infarction, and diabetic or nondiabetic nephropathy. Clients taking captopril
(Capoten) should be instructed to take med at least 1 hour before meals; all
other ACE inhibitors are not affected by food.

The generic names of ACE inhibitors end in “pril”:

· Capto pril (Capoten)

· Enala pril (Vasotec)

· Fosino pril (Monopril)

· Lisino pril (Prinivil)

· Rami pril (Altace)

Side/adverse effects include:

· Orthostatic hypotension with first dose

· Instruct client to monitor BP for at least 2 hours after first dose

· Cough, rash, or altered or distorted taste (dysgeusia)

· Instruct client to notify health care provider

· Angioedema

· Treated with epinephrine and symptoms will resolve once medication is

stopped

· Neutropenia is rare but serious with captopril (Capoten)

· Instruct client to report signs of infection

Hyperkalemia can be life-threatening

Monitor potassium levels to maintain normal range of 3.5-5.0 mEq/L

Medication/food interactions:

· Concurrent use with diuretics can lead to first-dose orthostatic hypotension

 · Concurrent use with other antihypertensives can lead to increased effect
resulting in hypotension

· Concurrent use with potassium supplements or potassium-sparing diuretics

increases the risk of hyperkalemia

· Concurrent use with lithium can increase serum lithium levels, leading to
lithium toxicity

· Concurrent use with NSAIDs can decrease the therapeutic effects of the
ACE inhibitor

Vasodilators
The term “vasodilators” refers to drugs that improve oxygenation of
tissues by dilating or opening up the body’s vascular system. While several
classes of drugs dilate vessels through different mechanisms, the goal is the
same — to provide improved circulation of oxygen to the body’s tissues. It
should be noted that concurrent use of any of these drugs with other
antihypertensive drugs can lead to severe hypotension.

Drug Classification/Names Important Information

Alpha Adrenergic Blockers

· Dilate veins and arteries
(Sympatholytics)
· Potential for 1st dose orthostatic hypotension
· Pra zosin (Minipress)
· Concurrent use of prazosin & NSAIDs or clonidine can interfere with reduction of BP
· Doxa zosin (Cardura)

· Vasodilation is result of CNS involvement

Centrally Acting Alpha2 Agonists
· CNS involvement can cause sedation or drowsiness that should diminish with time
· Clonid ine (Catapres)
· Concurrent use of clonidine and prazosin, MAOIs, or tricyclic antidepressants can
· Guanfac ine HCl (Tenex)
interfere with reduction of BP
· Methyldopa (Aldomet)
· Concurrent use with other CNS depressants can increase CNS depression

· Produce vasodilation by blocking production of angiotensin II

ACE Inhibitors
· Should be stopped if client experiences cough, rash, altered taste, angioedema, or signs of
· Capto pril (Capoten)
infections
· Enala pril (Vasotec)
· Can cause hyperkalemia so must monitor serum potassium levels
· Fosino pril (Monopril)
· Concurrent use with potassium supplements or potassium-sparing diuretics can cause
· Lisino pril (Prinivil)
hyperkalemia
· Rami pril (Altace)
· Concurrent use with lithium can lead to lithium toxicity
Angiotensin II Receptor Blockers
· Lo sartan (Cozaar)
· Produce vasodilation by blocking the action of angiotensin II
· Val sartan (Diovan)
· Can cause angioedema
· Irbe sartan (Avapro)
· Fetal injury can result if used by pregnant women during 2nd and 3rd trimester
· Cande sartan (Atacand)
· Olme sartan (Benicar)

Calcium Channel Blockers

· Vasodilation is result of blocking of calcium channels in blood vessels
· Nife dipine (Adalat, Procardia)
· Risk of reflex tachycardia, peripheral edema, and acute toxicity with nifedipine
· Amlo dipine (Norvasc)
· Risk of orthostatic hypotension, peripheral edema, constipation,
· Felo dipine (Plendil)
bradycardia, dysrhythmias, and acute toxicity with verapamil and diltiazem
· Nicar dipine (Cardene)
· Drinking grapefruit juice can lead to toxicity
· Verapamil (Calan)
· Concurrent use of digoxin with verapamil can lead to digoxin toxicity
· Diltiazem (Cardizem)

· Provide direct vasodilation of veins and arteries and rapid reduction of BP

Medication for Hypertensive Crisis
· Cyanide poisoning can occur and lead to cardiac arrest
· Sodium nitroprusside
· Thiocyanate poisoning can lead to altered mental status and psychotic behavior
· Labetalol (Trandate)
· Nitroprusside may be slightly brown, however solutions that are dark blue, red, or green
· Diazoxide (Hyperstat)
should be discarded
· Fenoldopam (Corlopam)
· Continuous BP and ECG monitoring should be performed during administration of these
· Trimethaphan (Arfonad)
drugs

· Dilates veins and prevents spasms of coronary arteries

· Headache is common so client should use with acetaminophen or aspirin
· Tolerance can occur with prolonged use
Organic Nitrates · Concurrent use with sildenafil (Viagra) can lead to life-threatening hypotension
· Nitr oglycerin (Nitrol, Nitrostat) · Use with alcohol can cause increased hypotension
· Isosorbide di nitr ate (Imdur) · Sublingual tablets, translingual spray, or transmucosal preparations should be used at the
first sign of angina
· Sustained-release capsules, transdermal patches, or topical ointment provide long-term
prophylaxis

Electrolyte Replacements
Electrolytes refer to salts that carry either positive or negative charges to
carry electrical impulses in the form of muscle contractions and nerve
impulses. Electrolyte balance must be maintained in the body to protect
cardiac and nerve function. Therefore, replacement is critical when
 electrolytes are lost due to sweating, vomiting, diarrhea, or gastric
suctioning.

Electrolyte Information Regarding Supplements

sodium (Na+)
· Administer isotonic IV therapy of 0.9% normal saline or
· Major electrolyte in extracellular fluid
Ringer’s lactate
· Normal range 135-145 mEq/L

· Potassium chloride (K-Dur)

· Oral or IV administration
· NEVER give IV push to avoid fatal hyperkalemia
potassium (K+) · Dilute potassium and give no more than 40 mEq/L per IV
· Essential for maintaining electrical excitability of muscle, to prevent irritation of vein
conduction of nerve impulses, and regulation of acid/base balance · Administer no faster than 10 mEq/L per IV
· Normal range 3.5-5.0 mEq/L · Concurrent use with potassium-sparing diuretics or ACE
inhibitors can cause hyperkalemia
· Administer Kayexalate for hyperkalemia with serum
potassium > 5.0 mEq/L

· Calcium citrate (Citrical)

calcium (Ca2+)
· Calcium carbonate or calcium acetate
· Essential for normal musculoskeletal, neurological, and
· Oral or IV administration
cardiovascular function
· Implement seizure precautions during administration and
· Normal range: 9.0-10.5 mEq/L
have emergency equipment on hand

· Magnesium sulfate
· Magnesium gluconate or magnesium hydroxide
magnesium (Mg2+)
· Monitor BP, pulse, and respirations with IV administration
· Regulates skeletal muscle contraction and blood coagulation
· Decreased/absent deep tendon reflexes indicates toxicity
· Normal range: 1.3-2.1 mEq/L
· Have injectable calcium gluconate on hand to counteract
toxicity when giving magnesium sulfate via IV

bicarbonate (HCO3-) · Sodium bicarbonate

· Maintains blood pH to prevent metabolic acidosis · Given orally as an antacid or via IV
· Normal pH range: 7.35-7.45 · Numerous incompatibilities with IV form

You are what you think. You are what you go for. You are what you
do!....Motivation Quotes by Bob Richards.