Areas of study for PMHNP 1

DIAGNOSTIC FORMS
Know Scoring on Hamilton Rating Scale...what would a score of 28 indicate? Although the HAM-D form lists 21 items, the scoring is based on the first 17. It generally takes 15-20 minutes to complete the interview and score the results. Eight items are scored on a 5-point scale, ranging from 0 = not present to 4 = severe. Nine are scored from 0-2. 0-7 = Normal 8-13 = Mild Depression 14-18 = Moderate Depression 19-22 = Severe Depression 23 = Very Severe Depression Mood Disorders Questionnaire Clinical trials have indicated that the MDQ has a high rate of accuracy; it is able to identify seven out of ten people who have bipolar disorder and screen out nine out of ten people who do not. If the patient answers: Yes to seven or more of the 13 items in question number 1; AND 2. Yes to question number 2; AND 3. Moderate or Serious to question number 3; POSITIVE SCREEN MMSE which question tests visuospatial 24-30 no cognitive impairment 18-23 mild cognitive impairment 0-17 severe cognitive impairment Drawing of a figure with intersecting sides

Areas of study for PMHNP 2 Beck Depression Inventory / Hamilton which is self-administered vs clinician administered Becks, 21 question self report CAGE how many points + dependence 4 questions Score 1: Evidence of AT RISK. Indicates need for further clinical investigation, including questions on amount and frequency, etc.. Score 2 or more : Evidence of CURRENT PROBLEM. Indicates need for further clinical investigation and/or referral as indicated by clinicians expertise. Score 3 or more: Evidence of dependence until ruled out. Evaluate, treat and/or referral as indicated by clinicians expertise. GAF scores determine IP vs. OP by score

HIV/AIDS

Multiple questions on effects of HIV on depression and dementia Dementia and depression common

What symptom the HIV dementia has that identifies it as HIV associated dementia? Myoclonus muscle twitching and ataxia ENCEPHALOPATHY underlying cause 14% of HIV patients The symptoms of HAD fall into three broad categories:

Motor: poor coordination, weakness in legs, difficulty maintaining balance, tendency to drop things, decline in clarity of handwriting, loss of bladder or bowel control. Cognitive: problems in concentration (difficulty following the thread of a conversation, short attention span, inability to complete routine tasks, trouble finishing a sentence); memory loss (trouble recalling phone numbers,

Areas of study for PMHNP 3 appointments, and medication schedules, forgetting agreements or previous conversations); and a generalized slowdown in mental functions (difficulty understanding and responding to questions, loss of sense of humor or wit). Behavioral: personality changes (increased irritability, apathy toward loved ones or life in general, loss of initiative, withdrawal from social contact), mood swings (depression, excitability, emotional outbursts); impaired judgment (impulsive decision-making, loss of inhibitions); and, on occasion, symptoms of psychosis (hallucinations, paranoia, disorientation, sudden rages).

MEDICAL DISORDERS
Learn - Endocrine disorders and childhood disorders 11-14 y/o Hypothyroidism decreased T4, increased TSH TSH The TSH (or Thyroid Stimulating Hormone) assay has been recognized as an sensitive indicator of thyroid status. TSH assays have therefore been widely adopted as the firstline thyroid function test. In ambulatory patients with intact hypothalamic and pituitary function, a normal TSH result excludes hypo- or hyperthyroidism; whereas elevated and suppressed TSH results are diagnostic of hypo- and hyperthyroidism, respectively. Abnormal TSH results are generally confirmed with a complementary determination of thyroid hormone levels. T4 The T4 (or Thyroxin) assay complements the TSH assay, and is used to confirm a thyroid disorder when suggested by an abnormal TSH. The free form of the hormone (Free T4) is generally considered to provide the more reliable indicator of true thyroid status, because only the free form of the hormone is physiologically active. The total hormone concentration (Total T4) is dependent on the concentration of thyroid transport proteins, specifically thyroid binding globulin (TBG), which is influenced by many common factors. Childhood disorders BOYS Fragile X and Klinefelters GIRLS Turners and Retts (boys usually die)

Areas of study for PMHNP 4 BOTH Wilsons Disease Klinefelters syndrome Klinefelter syndrome is a genetic condition that results when a boy is born with an extra copy of the X chromosome. Klinefelter syndrome is one of the most common genetic conditions affecting males. Klinefelter syndrome adversely affects testicular growth, and this can result in smaller than normal testicles. This can lead to lower production of the sex hormone testosterone. Klinefelter syndrome may also cause reduced muscle mass, reduced body and facial hair, and enlarged breast tissue. The effects of Klinefelter syndrome vary, and not everyone with it develops signs and symptoms. Klinefelter syndrome often isn't diagnosed until adulthood. Most men with Klinefelter syndrome produce little or no sperm. Babies Weak muscles Slow motor development taking longer than average to sit up, crawl and walk Delay in speaking Quiet, docile personality Problems at birth, such as testicles that haven't descended into the scrotum Boys and teenagers Taller than average stature Longer legs, shorter torso and broader hips compared with other boys Absent, delayed or incomplete puberty After puberty, less muscular bodies and less facial and body hair compared with other teens Small, firm testicles Small penis Enlarged breast tissue (gynecomastia) Weak bones Low energy levels Shyness Difficulty expressing feelings or socializing

Areas of study for PMHNP 5 Problems with reading, writing, spelling or math Attention problems Fragile X Boys Detectable by blood test Small set, long faces, low ears Most common cause of MR Turners Syndrome Most girls are born with two X chromosomes, but girls with Turner syndrome are born with only one X chromosome or they are missing part of one X chromosome. Turner syndrome prevents the ovaries from developing properly, which affects a girl's sexual development and the ability to have children. Because the ovaries are responsible for making the hormones that control breast growth and menstruation, most girls with Turner syndrome will not go through all of the changes associated with puberty unless they get treatment for the condition. Nearly all girls with Turner syndrome will be infertile, or unable to become pregnant on their own. A number of other health problems occur more often in girls with Turner syndrome, including kidney problems, high blood pressure, heart problems, overweight, hearing difficulties, diabetes, and thyroid problems. Some girls with the condition may experience learning difficulties, particularly in math. Many have a difficult time with tasks that require skills such as map reading or visual organization. In addition to short stature and lack of sexual development, some of the other physical features commonly seen in girls with Turner syndrome are: a "webbed" neck a low hairline at the back of the neck drooping of the eyelids differently shaped ears that are set lower on the sides of the head than usual abnormal bone development (especially the bones of the hands and elbows) a larger than usual number of moles on the skin Edema in the hands and feet

Areas of study for PMHNP 6 Wilsons disease Wilson disease is a genetic disorder that prevents the body from getting rid of extra copper. A small amount of copper obtained from food is needed to stay healthy, but too much copper is poisonous. In Wilson disease, copper builds up in the liver, brain, eyes, and other organs. Over time, high copper levels can cause life-threatening organ damage. People who get Wilson disease inherit two abnormal copies of the ATP7B gene, one from each parent. Wilson disease carriers, who have only one copy of the abnormal gene, do not have symptoms. Most people with Wilson disease have no known family history of the disease. A person's chances of having Wilson disease increase if one or both parents have it. About one in 40,000 people get Wilson disease. It equally affects men and women. Symptoms usually appear between ages 5 to 35, but new cases have been reported in people aged 2 to 72 years. Wilson disease is caused by a buildup of copper in the body. Normally, copper from the diet is filtered out by the liver and released into bile, which flows out of the body through the gastrointestinal tract. People who have Wilson disease cannot release copper from the liver at a normal rate, due to a mutation of the ATP7B gene. When the copper storage capacity of the liver is exceeded, copper is released into the bloodstream and travels to other organsincluding the brain, kidneys, and eyes. Wilson disease first attacks the liver, the central nervous system, or both. A buildup of copper in the liver may cause ongoing liver disease. Rarely, acute liver failure occurs; most patients develop signs and symptoms that accompany chronic liver disease, including swelling of the liver or spleen jaundice, or yellowing of the skin and whites of the eyes fluid buildup in the legs or abdomen a tendency to bruise easily fatigue A buildup of copper in the central nervous system may result in neurologic symptoms, including problems with speech, swallowing, or physical coordination tremors or uncontrolled movements muscle stiffness behavioral changes Other signs and symptoms of Wilson disease include anemia low platelet or white blood cell count

Areas of study for PMHNP 7

slower blood clotting, measured by a blood test high levels of amino acids, protein, uric acid, and carbohydrates in urine premature osteoporosis and arthritis

Kayser-Fleischer rings result from a buildup of copper in the eyes and are the most unique sign of Wilson disease. They appear in each eye as a rusty-brown ring around the edge of the iris and in the rim of the cornea. The iris is the colored part of the eye surrounding the pupil. The cornea is the transparent outer membrane that covers the eye. Retts Disorder Retts disorder girls. Boys usually die at birth. Progressive disease. After normal development stages, child regresses. Loses motor function and head becomes smaller. Profoundly mentally retarded. Poor gait, scoliosis, seizures.

PSYCHOLOGY THEORIES
Growth and development Erikson: Core Concepts Eight Stages of Development 1. Infancy (birth-12 months) Learning basic trust vs. basic mistrust HOPE 2. Younger years (1-3 years) Learning Autonomy vs. shame WILL 3. Early Childhood (3-5 years) Learning Initiative vs. guilt PURPOSE 4. Middle Childhood (6-10 years) Industry vs. Inferiority COMPETENCE 5. Adolescence (11-18 years) Learning Identity vs. diffusion FIDELITY 6. Early Adulthood (19-34 years) Learning Intimacy vs. Isolation LOVE 7. Middle Adulthood (35-60 years) Learning Generativity vs. Self-Absorption CARE 8. Later Adulthood(60-death) Integrity vs. Despair WISDOM Piaget: Stage Characterized by Sensory-motor (Birth-2 yrs) Differentiates self from objects Recognizes self as agent of action and begins to act intentionally: e.g. pulls a string to set mobile in motion or shakes a rattle to make a noise. Achieves object permanence: realizes that things continue to exist even when no longer present to the sense

Areas of study for PMHNP 8 Pre-operational (2-7 years) Learns to use language and to represent objects by images and words. Thinking is still egocentric: has difficulty taking the viewpoint of others. Classifies objects by a single feature: e.g. groups together all the red blocks regardless of shape or all the square blocks regardless of color Concrete operational (7-11 years) Can think logically about objects and events. Achieves conservation of number (age 6), mass (age 7), and weight (age 9). Classifies objects according to several features and can order them in series along a single dimension such as size. Formal operational (11 years and up) Can think logically about abstract propositions and test hypotheses systematically. Becomes concerned with the hypothetical, the future, and ideological problems Different kinds of Power....referent, expert, coercive etc. Identify what an NP uses in situations they give you Coercive power This is the power to force someone to do something against their will. It is often physical although other threats may be used. It is the power of dictators, despots and bullies. Coercion can result in physical harm, although its principal goal is compliance. Demonstrations of harm are often used to illustrate what will happen if compliance is not gained. Coercion is also the ultimate power of all governments. Although it is often seen as negative, it is also used to keep the peace. Parents coerce young children who know no better. A person holds back their friend who is about to step out in front of a car. Other forms of power can also be used in coercive ways, such as when a reward or expertise is withheld or referent power is used to threaten social exclusion. Reward power One of the main reasons we work is for the money we need to conduct our lives. There are many more forms of reward -- in fact anything we find desirable can be a reward, from a million dollar yacht to a pat on the back. Reward power is thus the ability to give other people what they want, and hence ask them to do things for you in exchange. Rewards can also be used to punish, such as when they are withheld. The promise is essentially the same: do this and you will get that. Legitimate power Legitimate power is that which is invested in a role. Kings, policemen and managers all have legitimate power. The legitimacy may come from a higher power, often one with coercive power. Legitimate power can often thus be the acceptable face of raw power.

Areas of study for PMHNP 9 A common trap that people in such roles can fall into is to forget that people are obeying the position, not them. When they either fall from power or move onto other things, it can be a puzzling surprise that people who used to fawn at your feet no long do so. Referent power This is the power from another person liking you or wanting to be like you. It is the power of charisma and fame and is wielded by all celebrities (by definition) as well as more local social leaders. In wanting to be like these people, we stand near them, hoping some of the charisma will rub off onto us. Those with referent power can also use it for coercion. One of the things we fear most is social exclusion, and all it takes is a word from a social leader for us to be shunned by others in the group. Expert power When I have knowledge and skill that someone else requires, then I have Expert power. This is a very common form of power and is the basis for a very large proportion of human collaboration, including most companies where the principle of specialization allows large and complex enterprises to be undertaken. Roys theory - adaptation model

The person is a bio-psycho-social being. The person is in constant interaction with a changing environment. To cope with a changing world, person uses both innate and acquired mechanisms which are biological, psychological and social in origin. Health and illness are inevitable dimensions of the persons life. To respond positively to environmental changes, the person must adapt. The persons adaptation is a function of the stimulus he is exposed to and his adaptation level The persons adaptation level is such that it comprises a zone indicating the range of stimulation that will lead to a positive response. The person has 4 modes of adaptation: physiologic needs, self- concept, role function and inter-dependence. "Nursing accepts the humanistic approach of valuing other persons opinions, and view points" Interpersonal relations are an integral part of nursing There is a dynamic objective for existence with ultimate goal of achieving dignity and integrity.

Learned helplessness theory Learned helplessness, as a technical term in animal psychology and related human psychology, means a condition of a human person or an animal in which it has learned to behave helplessly, even when the opportunity is restored for it to help itself by

Areas of study for PMHNP 10 avoiding an unpleasant or harmful circumstance to which it has been subjected. Learned helplessness theory is the view that clinical depression and related mental illnesses may result from a perceived absence of control over the outcome of a situation.

Acculturation Acculturation is the exchange of cultural features that results when groups of individuals having different cultures come into continuous first hand contact; the original cultural patterns of either or both groups may be altered, but the groups remain distinct

CBT Cognitive behavioral therapy (CBT) is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present. The title is used in diverse ways to designate behavior therapy, cognitive therapy, and to refer to therapy based upon a combination of basic behavioral and cognitive research.

Defense mechanisms Vaillant's categorization of defence mechanisms Level 1 - Pathological The mechanisms on this level, when predominating, almost always are severely pathological. These four defenses, in conjunction, permit one to effectively rearrange external experiences to eliminate the need to cope with reality. The pathological users of these mechanisms frequently appear irrational or insane to others. These are the "psychotic" defenses, common in overt psychosis. However, they are found in dreams and throughout childhood as well. They include: Delusional Projection: Grossly frank delusions about external reality, usually of a persecutory nature.

Areas of study for PMHNP 11 Denial: Refusal to accept external reality because it is too threatening; arguing against an anxiety-provoking stimulus by stating it doesn't exist; resolution of emotional conflict and reduction of anxiety by refusing to perceive or consciously acknowledge the more unpleasant aspects of external reality. Distortion: A gross reshaping of external reality to meet internal needs. Splitting: A primitive defense. Negative and positive impulses are split off and unintegrated. Fundamental example: An individual views other people as either innately good or innately evil, rather than a whole continuous being. Extreme projection: The blatant denial of a moral or psychological deficiency, which is perceived as a deficiency in another individual or group. Level 2 - Immature These mechanisms are often present in adults and more commonly present in adolescents. These mechanisms lessen distress and anxiety provoked by threatening people or by uncomfortable reality. People who excessively use such defenses are seen as socially undesirable in that they are immature, difficult to deal with and seriously out of touch with reality. These are the so-called "immature" defenses and overuse almost always leads to serious problems in a person's ability to cope effectively. These defenses are often seen in severe depression and personality disorders. In adolescence, the occurrence of all of these defenses is normal. They include: Acting out: Direct expression of an unconscious wish or impulse in action, without conscious awareness of the emotion that drives that expressive behavior. Fantasy: Tendency to retreat into fantasy in order to resolve inner and outer conflicts. Idealization: Unconsciously choosing to perceive another individual as having more positive qualities than he or she may actually have. Passive aggression: Aggression towards others expressed indirectly or passively such as using procrastination. Projection: Projection is a primitive form of paranoia. Projection also reduces anxiety by allowing the expression of the undesirable impulses or desires without becoming

Areas of study for PMHNP 12 consciously aware of them; attributing one's own unacknowledged unacceptable/unwanted thoughts and emotions to another; includes severe prejudice, severe jealousy,hypervigilance to external danger, and "injustice collecting". It is shifting one's unacceptable thoughts, feelings and impulses within oneself onto someone else, such that those same thoughts, feelings, beliefs and motivations are perceived as being possessed by the other. Projective identification: The object of projection invokes in that person precisely the thoughts, feelings or behaviors projected. Somatization: The transformation of negative feelings towards others into negative feelings toward self, pain, illness, and anxiety. Level 3 - Neurotic These mechanisms are considered neurotic, but fairly common in adults. Such defenses have short-term advantages in coping, but can often cause long-term problems in relationships, work and in enjoying life when used as one's primary style of coping with the world. They include: Displacement: Defense mechanism that shifts sexual or aggressive impulses to a more acceptable or less threatening target; redirecting emotion to a safer outlet; separation of emotion from its real object and redirection of the intense emotion toward someone or something that is less offensive or threatening in order to avoid dealing directly with what is frightening or threatening. For example, a mother may yell at her child because she is angry with her husband. Dissociation: Temporary drastic modification of one's personal identity or character to avoid emotional distress; separation or postponement of a feeling that normally would accompany a situation or thought. Hypochondriasis: An excessive preoccupation or worry about having a serious illness. Intellectualization: A form of isolation; concentrating on the intellectual components of a situation so as to distance oneself from the associated anxiety-provoking emotions; separation of emotion from ideas; thinking about wishes in formal, affectively bland

Areas of study for PMHNP 13 terms and not acting on them; avoiding unacceptable emotions by focusing on the intellectual aspects (e.g. isolation, rationalization, ritual, undoing, compensation, magical thinking). Isolation: Separation of feelings from ideas and events, for example, describing a murder with graphic details with no emotional response. Rationalization (making excuses): Where a person convinces him or herself that no wrong was done and that all is or was all right through faulty and false reasoning. An indicator of this defense mechanism can be seen socially as the formulation of convenient excuses - making excuses. Reaction formation: Converting unconscious wishes or impulses that are perceived to be dangerous into their opposites; behavior that is completely the opposite of what one really wants or feels; taking the opposite belief because the true belief causes anxiety. This defense can work effectively for coping in the short term, but will eventually break down. Regression: Temporary reversion of the ego to an earlier stage of development rather than handling unacceptable impulses in a more adult way. Repression: The process of attempting to repel desires towards pleasurable instincts, caused by a threat of suffering if the desire is satisfied; the desire is moved to the unconscious in the attempt to prevent it from entering consciousness;seemingly unexplainable naivety, memory lapse or lack of awareness of one's own situation and condition; the emotion is conscious, but the idea behind it is absent. Undoing: A person tries to 'undo' an unhealthy, destructive or otherwise threatening thought by engaging in contrary behavior. Withdrawal: Withdrawal is a more severe form of defense. It entails removing oneself from events, stimuli, interactions, etc that could remind one of painful thoughts and feelings. Level 4 - Mature These are commonly found among emotionally healthy adults and are considered mature, even though many have their origins in an immature stage of development. They have been adapted through the years in order to optimize success in life and

Areas of study for PMHNP 14 relationships. The use of these defenses enhances pleasure and feelings of control. These defenses help us integrate conflicting emotions and thoughts, while still remaining effective. Those who use these mechanisms are usually considered virtuous. They include: Altruism: Constructive service to others that brings pleasure and personal satisfaction. Anticipation: Realistic planning for future discomfort. Humor: Overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk about) that gives pleasure to others. The thoughts retain a portion of their innate distress, but they are "skirted round" by witticism. Identification: The unconscious modeling of one's self upon another person's character and behavior. Introjection: Identifying with some idea or object so deeply that it becomes a part of that person. Sublimation: Transformation of negative emotions or instincts into positive actions, behavior, or emotion. Thought suppression: The conscious process of pushing thoughts into the preconscious; the conscious decision to delay paying attention to an emotion or need in order to cope with the present reality; making it possible to later access uncomfortable or distressing emotions while accepting them. Psychic determinism: All behavior is meaningful

PHARMACOLOGY
Long term effects of antipsychotics in adolescents Prolactin elevation; and Weight gain and at least some metabolic abnormalities.

Areas of study for PMHNP 15 SSRIs time frame for effectiveness (adequate trial) 6-8 weeks Several Lithium questions....know basics.... Range 0.6-1.2 EKG contraindication - sick sinus syndrome Renal issues First signs - diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination. Nystagmus Inverts T-waves. Caution in diabetes increased risk of seizures. Ebsteins anomaly in 1st semester of pregnancy. NSAIDS increase lithium levels. Depakote Need to reduce Lamictal by 50%. Levels lowered by tegretol and dilantin. Aspirin inhibits metabolism and increases levels. Thrombocytopenia. Urea abnormalities. Prozac and motrin increases levels. DO NOT USE IN: pancreatitis, serious liver disease, urea cycle disorder. Pregnancy risk D. Inhibits most meds. SSRIs increase levels. Lots of tegretol questions and it's interaction with SSRI and other meds Induces own metabolism. Agranulocytocis, hyponatremia. Liver, kidney, thyroid. Cardiac caution. SSRIs increase level (especially prozac). Carbamazepine and lithium increased risk of neurotoxicity. Narrow angle glaucoma. Increase level of dilantin. Decreases level of birth control medication and coumadin. Increases dilantin levels. Lamotragine Steven Johnson Syndrome. Start low and go slow. Level doubled by depakote, decreased by everything else. Oral contraceptives and pregnancy can reduce levels. Renal and liver problems, reduce dose. Pregnancy level C. TCA Most dangerous of neuroleptics, number 1 cause of OD prolonged QT interval, 2nd degree AV block. QT elongation can cause V-Tach Panic D/0 treat with SSRIs

Areas of study for PMHNP 16 LITHIUM CARBONATE 0.51.4 mEq/L DIVALPROEX SODIUM 50100 g/mL

PARAMETER Therapeutic levels

CARBAMAZEPINE 412 g/mL

Serotonin Syndrome s/s Serotonin syndrome symptoms typically occur within several hours of taking a new drug or increasing the dose. Signs and symptoms include:

Agitation or restlessness Confusion Rapid heart rate and high blood pressure Dilated pupils Loss of muscle coordination or twitching muscles Heavy sweating Diarrhea Headache Shivering Goose bumps

In order of appearance: Diarrhea, restlessness (characteristic tapping of feet.. etc), agitation, hyperreflexemia DOES NOT PRODUCE MUSCULAR RIGIDITY Half-life Know how to calculate half-life, how much is excreted after a certain period of time. Neuroleptic Malignant Syndrome Life-threatening condition called neuroleptic malignant syndrome (NMS). Symptoms of NMS can include:
MUTISM Leukopenia Stiff muscles lead pipe rigidity High fever Confusion Irregular pulse or blood pressure A fast heart rate (tachycardia)

Areas of study for PMHNP 17

Sweating Irregular heart

rhythms (arrhythmias).

Combined Use of Haldol and Lithium An encephalopathic syndrome (characterized by weakness, lethargy, fever, tremulousness and confusion, extrapyramidal symptoms, leukocytosis, elevated serum enzymes, BUN, and fasting blood sugar) followed by irreversible brain damage has occurred in a few patients treated with lithium plus Haldol. A causal relationship between these events and the concomitant administration of lithium and Haldol has not been established; however, patients receiving such combined therapy should be monitored closely for early evidence of NMS and treatment discontinued promptly if such signs appear. Atypical and typical antipsychotics how do they work receptors in which tracts Definition: drugs that diminish psychotic thought processes (e.g. hallucination, delusions, ideas of reference) classified as either typical or atypical; atypical block 5HT2A receptors (5-hydroxytryptamine (5-HT) is serotonin) Typical D2 (Dopamine) receptor antagonists Cause extrapyramidal side effects (EPS) serum prolactin induce tardive dyskinesia with chronic use Prototype drug: Haloperidol probably less/no propensity to induce tardive dyskinesia Prototype drug: Clozapine Mechanism of Action - D2 receptor antagonists (D2 is one of five subclasses of Dopamine receptors) Direct correlation between dose and affinity Four Principal Dopamine Systems in the Human Brain: (1) Nigrostriatal projection: substantia nigra caudate-putamen

Areas of study for PMHNP 18 Blockade leads to: EPS and tardive dyskinesia (2) Mesolimbic projections: midbrain tegmentum cortex and limbic structures Blockade leads to: therapeutic effects (3) Mesocotical projections: midbrain tegmentum mesial-prefrontal and temporal areas of the cerebral cortex (4) Tubero-infundibular projection: hypothalamus pituitary Blockade leads to: elevated prolactin (remember that dopamine tonically inhibits prolactin release) Depolarization Blockade refers to lack of spontaneous and evoked responses by dopaminergic neurons after acute (1 day) or chronic (4 week) treatment with antipsychotic drugs typicals induce depolarization blockade of both substantia nigra and ventral tegmental area (VTA) DA neurons atypicals induce depolarization blockade of only the VTA DA neurons; substantia nigra not affected no EPS Atypical 5-HT2A (serotonin) and D1 receptor antagonists minimal to no EPS minimal to no in serum prolactin Mechanism of Action in general have higher affinities for 5-HT (particularly for 5-HT 2A) than for dopamine receptors high 5-HT2A/D1 affinity ratio predicts atypicality 5-HT2A receptors are concentrated in cortical regions: especially in limbic cortical regions (eg cingulate gyrus) 5-HT2A receptors are located on apical dendrites of pyramidal neurons LSD is a 5-HT2A receptor agonist and is hallucinogenic

Areas of study for PMHNP 19 Substance abuse Withdrawal causes opposite effect of high

NEUROBIOLOGY/DISORDERS
ADHD neurobiology of brain affected frontal cortex, basal ganglia, frontocortico pathways Abnormalities of reticular activating system. Structural abnormalities cause neurotransmitter dysfunction dopamine and norepinephrine Know side effects of stimulants in children Schizophrenia neurotransmitter deregulation theory/etiology of psychotic d/o; structural changes Ventricles enlarged and loss of temporal gray matter The classical "dopamine hypothesis of schizophrenia" postulates a hyperactivity of dopaminergic transmission at the dopamine D 2 receptor in the mesencephalic projections to the limbic striatum. Also decrease NE. Borderline Personality Disorder and object relations theory In 1975, Kernberg conceptualized borderline personality disorder to describe a group of patients with particular primitive defense mechanisms and pathologic internalized object relations (eg, splitting, projective identification ). The borderline personality organization is, according to Kernberg, a developmental disturbance originating during the third stage, the differentiation of self from object relations. The developmental task of this phase is to integrate the libidinally and aggressively invested representations of self and object into a more realistic self-concept and total object representations. Kernberg maintains that because the borderline patient has been unable to establish these integrations, the clinician observes nonmetabolized ego states, which consist of severe uctuations from one unintegrated self to another. Stage III (68 Months to 1836 Months) The third stage, Differentiation of Self from Object Relations, begins as the good (libidinally invested) self-object of the Symbiosis stage completely differentiates

Areas of study for PMHNP 20 into a good self and a good object. Shortly thereafter the bad (aggressively invested) self-object differentiates into a bad self and a bad object. This is the stage when splitting is seen as a normal mechanism of development that protects the ideal, good relationship with mother from contamination by bad self representations and bad representations of her (1976/1984a, p. 67). During this stage the child begins to integrate the self and object representations of different affective valences. Thus, good and bad self representations start to form an integrated self-concept, and good and bad object representations start to form total object representations, leading to Stage IV. Cranial nerves
Mnemonic Type No Name Function and test

On Old Olympus

Special sensory for smell Special sensory for vision Somatic motor up, down and in, and parasympathetic motor Towering M IV Trochlear Somatic motor to superior oblique down and out Top B V Trigeminal Sensory and motor jaw and chewing, back of tongue blink reflex A M VI Abducens Abduction of the eye, conjugate gaze and Wernickes encephalopathy Finn B VII Facial Taste, facial expression, sensation from the ear. Ptosis, bells palsy, raise eyebrows, open eyes. And S VIII Auditory (Vestibulococchlear) Vertigo, Rhine test, Weber German B IX Glossopharyngeal Pain from touch stimulus not normally causing pain, gag reflex Viewed B X Vagus On phonation, uvula moves to one side. A M XI Accessory Sternocleinomastoid and trapezius muscle head to side and shrug shoulders Hop M XII Hypoglossal Puff out cheeks and stick tongue straight out (Some say marry money, but my brother says big boobs matter most) Metabolic Syndrome Obesity, with your body fat concentrated around your waist (having an "apple shape"). For a metabolic syndrome diagnosis, obesity is defined by having a waist circumference of 40 inches (102 centimeters or cm) or more for men and 35 inches (89 cm) or more for women, although waist circumference cutoff points can vary by race.

S S M

I II III

Olfactory Optic nerve Oculomotor

Areas of study for PMHNP 21 Increased blood pressure, meaning a systolic (top number) blood pressure measurement of 130 millimeters of mercury (mm Hg) or more or a diastolic (bottom number) blood pressure measurement of 85 mm Hg or more. High blood sugar level, with a fasting blood glucose test result of 100 milligrams/deciliter (mg/dL), or 5.6 millimoles per liter (mmol/L), or more. High cholesterol, with a level of the blood fat called triglycerides of 150 mg/dL, (1.7 millimoles/liter or mmol/L) or more and a level of high-density lipoprotein (HDL) cholesterol the "good" cholesterol of less than 40 mg/dL (1.04 mmol/L) for men or 50 mg/dL (1.3 mmol/L) for women.

Suicide Risks determine person with highest risks SLAP S: Social support -- does the person have social support? Someone with little or no social support is at higher risk. L: Lethality -- If the person has a plan, how lethal is the method? A gun is more lethal than a pill overdose. A: Access -- This is access to the method. Does the person have the pills or would they have to get them? Do they have the bullets or would they have to stop by wal-mart? P: Plan/previous attempts -- Does the person have a plan about how they would kill themselves, or just some vague notion that it might be better if they were dead? People with a specific plan or who have previously attempted suicide are at higher risk. Sex: Males are three to five times more likely to die by suicide than females. Age: Elderly Caucasian males have the highest suicide rates. Dysthymia DSM criteria According to the DSM-IV, dysthymia is characterized by an overwhelming yet chronic state of depression, exhibited by a depressed mood for most of the days, for more days than not, for at least 2 years. (In children and adolescents, mood can be irritable and duration must be at least 1 year.) The person who suffers from this disorder must not

Areas of study for PMHNP 22 have gone for more than 2 months without experiencing two or more of the following symptoms: poor appetite or overeating insomnia or hypersomnia low energy or fatigue low self-esteem poor concentration or difficulty making decisions feelings of hopelessness Raphe nucleus depression locus cereleus anxiety Alcoholism Increased GGT, alkaline phosphatase, triglycerides

RESEARCH, ETHICS etc.,

Research validity, reliability Tarasoffs - Duty to Warn Answer is to check with state. Not all states have the same criteria for duty to warn. Scope of Practice delineated by State NPA Written consent to communicate with previous providers Obligation/when to report abuse Communication select best therapeutic statements Utilization of translators Always obtain a translator, regardless of expense or availability of family member. ACT Model criteria for referral, coordinating ACT in aftercare Assertive community treatment - ACT is a service-delivery model that provides comprehensive, locally based treatment to people with serious and persistent mental illnesses. Unlike other community-based programs, ACT is not a linkage or brokerage case-management program that connects individuals to mental health, housing, or rehabilitation agencies or services. Rather, it provides highly individualized services directly to consumers. ACT recipients receive the multidisciplinary, round-the-clock staffing of a psychiatric unit, but within the comfort of their own home and community.

Areas of study for PMHNP 23 To have the competencies and skills to meet a client's multiple treatment, rehabilitation, and support needs, ACT team members are trained in the areas of psychiatry, social work, nursing, substance abuse, and vocational rehabilitation. The ACT team provides these necessary services 24 hours a day, seven days a week, 365 days a year.

FINAL NOTE: There is a lot of theory, for example what would be used in a certain situation. CBT, family therapy, etc. ACT a few questions on this Hypothryroidism Mitral valve prolapse (anxiety)