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Summary - complete - Mental health nursing

Mental Health Nursing (Deakin University)

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HNN222 Mental Health Exam notes

Mental Health nursing, aetiology and pharmacology

Mental Health: State of wellbeing which every individual realizes their own potential, can cope with stress of life,
work productively and fruitfully and is able to make a contribution to community.
 ‘Mental wellbeing’ – a positive concept. Refers to resilience and good functioning, also incorporates
flourishing, happiness and getting the most out of life

Mental illness: A clinically recognizable set of symptoms related to mood, thought, cognition and behaviour that
is associated with distress and interferes with normal functioning.
 A diagnosed clinical condition

Therapeutic relationship: Purposeful, goal driven relationship between nurse and pt, aiming to support the
patient in their recovery.
 Elements: Trust, respect, empathy, collaboration, listening, communication.
How does therapeutic relationship and communication contribute to person centered care?
 Focus on individual needs, respect pt choices/beliefs/goals, tailored to individual

Personality disorder:
A diagnosis that occurs when manifestations of personality in an individual start to interfere negatively with the
individuals life.
 Maladaptive personality
 Abnormal behaviour pattern is enduring, long standing
 Effects personal and social situations

Borderline Personality Disorder:

 Terrified of abandonment
 Experiences intense + unstable moods – rapid changes
 Forms intense and unstable relationships
 Disturbance of identity
 Impulsive, self destructive behaviors – abuse, sex, spending, eating
 Recurrent suicidal behaviour
 Chronic feelings of emptiness and paranoia
 Anger
 Self image

Potential nursing management issues:

 Unpredictable behaviour- can lead to harm of nurse
 Maintaining boundaries
 Keeping pt/other staff/self safe
 May suicide watch

Antisocial personality disorder:

 No regard for right and wrong and often disregard the rights, wishes and feelings of others
 Tend to antagonize, manipulate or treat others harshly – showing no guilt or remorse
 Persistent lying
 Using charm or wit to manipulate others for personal gain

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Aetiology of mental illness:

 Biological, psychological, environmental

Biological aetiological theories for mental illness:

 Genetics = increased predisposition
 Biochemistry – neurotransmitter theory
 Brain structure abnormalities
 Endocrine system dysfunction (thyroid)

Psychotropic medications:
Psychotropic: psychiatric medicines that alter chemical levels of the brain = impact mood + behaviour
 Antipsychotics, antidepressants, mood stabilizers, ADHD drugs, anti anxiety
NEUROTRANSMITTERS:
Dopamine: Related to psychosis (schizophrenia)
Serotonin: Mood disorders (Depression)

Antidepressants
 SSRI (selective serotonin reuptake inhibitors)
 Atypical
 Tricyclic (TCA)
 MAOIs (Monoamine oxidase inhibitors)

SSRI’s
Increase serotonin by inhibiting its reuptake into pre-synaptic cell, increasing levels of serotonin in the synaptic
cleft available to bind to postsynaptic receptor.
 Block the uptake of serotonin back into brain cells = increase amount of serotonin available in the brain
for transmitting signals. This increase in improves symptoms of depression

Examples:
 Citalopram
 Fluoxetine (Prozac)
 Sertaline (Zoloft)
Side effects:
 Nausea
 Insomnia
 Dizziness
 Weight loss/gain
 Anxiety + restlessness
 Decreased sex drive
 Dry mouth
 Fatigue

Atypical:
 Reuptake inhibitors
 Include serotonin and norepinephrine reuptake inhibitors (SNRIs, NDRIs, NRIs)
 Alter chemical messages (neurotransmitters) used to communicate between cells
Examples: Bupropion, Mirtazapine
Side effects:
 Fatigue

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 Weight gain
 Nausea
 Headache
 Insomnia
 Blurred vision

Tricyclic:
 Inhibit the reuptake (absorption) of serotonin or norepinephrine (=more available in brain). Helping brain
cells send and receive messages= boosts mood.
 More side effects than other antiD’s
 Mostly been replaced due to side effects

Examples:
 Desipramine (Norpramin)
 Doxepin
Side effects:
 Dry mouth
 Blurred vision
 Constipation
 Urinary retention
 Drowsiness
 Increased appetite = weight gain
 Decreased sex drive

MAOIs
Inhibits the activity of monoamine oxidase (enzyme)=preventing the breakdown of monomine neurotransmitters
and increase the availability in synaptic cleft
 Reduces the breakdown of neurotransmitters norepinephrine, serotonin and dopamine = improve brain
cell communication
 First type of antiD invented, mostly been replaced due to MAOIs side effects
 Typically requires diet restrictions
 Can be used to treat other conditions e.g. Parkinsons

Examples:
 Phenelzine (nardil)
 Selegiline (Emsam)
Side effects:
 Dizziness or lightheadedness
 Insomnia
 Weight gain
 Headaches
 Sexual problems
 Nausea
 Diarrhea or constipation

Antipsychotics (neuroleptic)
Used to treat: Psychosis, schizophrenia, mania
Typical: 1st generation
 Act on dopamine levels (dopamine antagonists) – block dopamine receptors
 Reduce positive symptoms of schizophrenia
Atypical: 2nd generation (newer)

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 Act on dopamine and serotonin levels – block
 Reduce positive and negative schizophrenic symptoms
 Without the EPSE’s (extrapyramidal side effects) – effect the extrapyramidal motor system (same system
responsible for the movement disorders of Parkinson’s – can give antiparkinsonian meds to counteract
the epse’s

Typical Atypical
Examples:  Quetiapine (seroquel)
 Chlorpromazine (Largactil)  Rispiridone
 Halaperidol  Olanzapine
 Clozapine (last resort)
Side effects:  Weight gain – main
 Effects on CNS (EPSE’s: one
o Acute dystonic reaction (painful muscle spasms in head,  Constipation
back and torso)  Dizziness
o Seizures  Insomnia
o Akathisia: restlessness, leg aches, person cannot stay still  Headache
o Tardive dyskinesia – uncontrolled movement of persons  Drowsiness
mouth, tongue  Dry mouth
 Other:
o Dry mouth, blurred vision, urinary retention
o Weight gain, diminished libido
o Sedation

Clozapine:
 Regulations around it
 Treatment of schizophrenia in pts as a last resort
 Atypical
 Blocks dopamine receptors in brain = preventing excess activity of dopamine
 Side effects:
o Drowsiness
o Increased HR, Salivation
o Headache, tremor
o Fever

Antianxioytics – anti anxiety

Anxiety disorders – involve neurotransmitters serotonin, noradrenalin and dopamine
 Benzodiazepines and non-benzodiazepines
Benzodiazepines:
Commonly prescribed for short term relief of severe anxiety. Can assist with sleep
 Inhibit neurotransmitter GABA
 Depressant drug – slow down activity on CNS and messages travelling between brain and body
 Used a lot for prn meds
 High withdrawal symptoms
Side effect Nursing intervention
Drowsiness – lack of energy Encourage appropriate activity but warn against those such as driving
Dizziness/lightheadedness Observe and take steps to prevent falls
Feeling detached Encourage socialization
Dependency Encourage short term use, educate to avoid other drugs e.g. alcohol
 Slurred speech

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 Depression
 Memory loss/ forgetfulness
 Nausea
 Blurred vision

Examples: (most things ending in PAM)

 Diazepam (Valium)
 Alprazopam –( Xanax)

Biopsychosocial model:
Biological, psychological and social
factors contributing to mental health
and illness.

Biological:
 Physical health
 Medications
 Alcohol/drug use
 Sexual health
 Genetics
 Disability
Psychological:
 Thoughts
 Coping skills
 Mental status
 Self concept/esteem
Social:
 Occupation
 School/work
 Family/friends
 Social isolation/connection
 Cultural

CASE STUDY:
Read the following and develop and brief care plan based on the principles of the Biopsychosocial framework
Jenni is a 23 year old woman who arrived at ED with a friend after falling over and sustaining a deep laceration to
her arm. On arrival she appeared to be intoxicated, distressed and tearful. On examination she admitted to use
ketamine and alcohol at a club, but added she does not usually use drugs, but the past month she has been ‘out of
control’ since breaking up with her BF. She describes feeling depressed, unable to work, poor appetite and sleep
for the past 2 weeks.
BIO: Medication, harm minimization, referral drug/alcohol service
Psycho: Support, reassurance, mental health assessment, counseling
Social: referral to social support, employment assistance, youth mental health services

Recovery:
 Not about absence of illness – about managing symptoms and living with them
 Individual journey + goals
 Family/carer involvement

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Legality of mental health:

Mental health act:
 Only in public system (takes voluntary and involuntary)
AIMS:
 Provides care, treatment and protection of mentally ill people who do no consent to treatment
 Facilitate the provision of treatment + care
 Protects the pts rights
 Ensure the best possible treatment in the least restrictive environment

Section 8 criteria:
1. Appears mentally ill
2. At risk to self or others
3. Requires immediate treatment
4. Unable or refuses consent to treatment
5. Treatment in the least restrictive environment (a hospital)
MUST fit all criteria

Section 9 criteria ( request and recommendation)

 Anyone over 18 can make a request for someone to see a psychiatrist
 Must be recommended by a psychiatrist

Section 18: pts rights

 Dignity, respect, visitors, 2nd opinion

Seclusion:
 Small white room
 Little/ no stimuli (mattress, sheets, pillow)
 When an individual is at risk to themselves or others

Restraint:
 Risk of harming self/ others
 Medications (depot)
 Risk of damaging property

Seclusion + restraint:
 Must have good rational to why restraining – nurse can do it
 Let psychiatrist know why
 Whilst restrained :visual obs every 15 mins, reviewed every 4hrs by medical officer to make sure they are
physically able to be restrained

CTO – community treatment order:

 Order requiring person to obtain treatment for mental illness while not detained in a mental health
facility
 Must specify the duration of order
 May specify where the person must live
 A psychiatrist can make a CTO for a person who is subject to an ITO if they are satisfied that:
o Criteria for section 8 apply (criteria for involuntary treatment)
o The treatment required can be obtained through a CTO

Strengths and weakness of ITO:

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Strengths Weaknesses
 Prevent death and harm to pt + others  Higher rates of relapse after treatment
 Pt receives treatment and recovery plans =  Can cause pt to feel humiliated, lack of
increased quality of life control and devalued
 Positive impact on families  Seclusion and restraints can impact
 Family members/carers get support when negatively on pts
caring for loved one with MI
 Must specify:
o Treatment plan
o Regularity of treatment
o Location
o Additional services to be supplied
 Can be revoked at any time
 CBT, group therapy ect can minimize use of
coercive treatment

Mental health assessment:

Assessment: systematic collection and interpretation of Biopsychosocial info or data to determine current and
past health, functional status and human responses to mental health problems, both actual and potential
Purpose:
 Diagnose
 Treatment Forming a rapport with pt:
 Risk assessment  Trust
 Interventions  Empathy
 Non-judgemental
Setting: Formal assessment:  Compassion
 Privacy  Open minded
 Quiet
 Comfortable Key communication skills for conducting a
 Uninterrupted psychiatric interview:
 Saftey  Clear voice
 Eye contact
Safety considerations:  Posture
 Violent behaviour  Non judgmental
 Exacerbating anxiety/agitation levels in pt  Open ended qns
 Appear friendly and open to talk to
Genogram: Family history in pictures  Respectful
Barriers in communication:
 Social/culture/religion of pt
Mental state examination (MSE)  Age
PAMSGOTJIMI + R  Gender
 To find the mental state of person  Disabilities
 Must be followed by physical examination  Signs and symptoms

Components Description Examples

P Perception Inquire about all sensory info: visual, auditory,  Hallucinations
olfactory (smell), gustatory (taste), tactile (feel)  Delusions
A Affect How they present to you Type: eythymic (normal)

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 Objective Dysphoric (depressed, irritable, angry)
 Whether congruent/appropriate to situation/ Euphoric: elevated
mood Congruent: does it match the mood?
 Reactivity Appropriate: to situation
Flat, blunt, restricted
M Mood What they are saying about their mood  Euphoric, euthymic
‘I am feeling depressed’ Depressed, grieving, fearful, irritable,
 1-10 scale angry,
S Speech  Quiet (paranoid, depressed)  Rate: rapid/slow
 Loud/fast (anxious, agitated, manic)  Tone
 Slurred speech (alcohol/drug use)  Rate
G General  Disheveled (washed, clothing state)  Apparent age, race, build,
appearance  Groomed hairstyle + colour
 Posture  Physical abnormalities – scars,
 Clothes - appropriate for situation/weather tattoos
O Orientation To time/place?
T Thoughts  What are they telling you?  ‘flight of ideas’ – going from one
 Delusions? – are they in reality ? thing to another quickly
 Thought disordered, poverty of
Rapid thinking ideas, loose associations
Slow or hesitant .g. depression  Delusions of reference, control,
Spontaneous or only when qnd grandeur, thought blocking
Thought blocking (schizo)
J Judgment Right from wrong, consequence of actions
I Insight Are they aware of their mental illness and the  Denial
impacts  Intellectual insight
M Memory Immediate? Ask pt to repeat 6 figures after examiner
says them
Different types of memory
I Intelligence
R Risk Harm to self/others, homicide, financial, ADLS, falls
risk

Physical examination:
 General obs: HR, RR, BP, temp
 Tremor, sweating etc
 Urinalysis, height, weight, skin condition
 CVS, RS, GI, CNS exams

Risk assessment:
Process of weighing up all info attained in the assessment, with focus on known risk factors to determine overall
risk of pt (low, m, high, severe), which can be used for care plan.
 Suicide, self harm, violence, absconding, significant mental deterioration, loss of social standing,
economic loss, falls, accidental injury

Suicide risk assessment:

 Thoughts
 Plans
 Intent
 Means
Risk factors for suicide (get 1 point per risk factor) SADPERSONS

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S Sex (males 1 pt)
A Age (between 15-65)
D Depression
P Previous attempts
E Ethanol use - alcohol
R Rational thought loss (irrational)
S Social support (lack of)
O Organized plan
N No spouse
S Sickness (illness) eg. Diabetes
 0-2: send home
 3-4: Closely follow up
 5-6 strongly consider hospitalization
 7+: hospitalize

Psychosis:
‘psyche’ = mind/soul
‘osis’ abnormal condition

Diagnostic features:
 Impaired (different) reality
 Delusions
 Hallucinations

Delusion: Firm, fixed belief that is not based in reality – not shared by others and doesn’t respond to reason
Hallucination: Sensory perception in the absence of external stimuli – hearing voices

Psychotic disorders:
Mental illnesses that cause severe disturbances in thinking, perceiving, feeling and behaving.
 Schizophrenia
 Bipolar disorder (mania)
 Psychotic depression
 Schizoaffective disorder
 Delusional disorder
 Substance induced psychotic disorder

Psychotic episode:
The onset of symptoms or exacerbation of symptoms in which the person’s current mental state loses rational
though and/or loss of ability to accurately interpret the environment.
 Disturbance of thinking, perceiving and behaving

Early intervention Aims:

 Reduce delays in treatment by:
o Promoting early detection
o Collaborate engagement in community
 Optimize assessment and diagnosis by:
o Biopsychosocial assessment
 Maximize recovery by:
o Providing Biopsychosocial treatment
o Focus on person as a whole

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 Prevent relapse by:
o Ensure assertive follow up
o Psycho education
o Support systems

Symptoms of psychosis:
 Unable to think clearly
 Poor judgment + reasoning
 Behave inappropriately
 Can’t understand difference between reality and imagination
 Delusions and hallucinations

Person with psychosis may feel:

 Anxious or stressed
 Scared
 Confused
 Angry
 Hard to concentrate
 Start to avoid certain people, places or situations

Schizophrenia:
 Psychotic disorder characterized by disturbances of thinking, delusions and disorganized behaviour
 Associated with an over activity of dopamine and may lead to hallucinations and delusions
 Many people hear or see things not there, have odd beliefs, speak/behave in a disorganized way
Aetiology:
Biological theories:
 Neuroanatomical abnormalities:
o Reason for psychological disturbances is in neurological structure of brain
 Genetic predisposition
Biochemical theories:
 Dopamine hypothesis:
o Chemicals responsible for the transmission of nerve impulses across the synapse may be
responsible for development of schizop.
o Abnormal amount or action of dopamine
Diathesis – stress model
o Stress leads to schizo.

Criteria:
Individuals must have 2 of the following symptoms present during a period of 1 month (DSM 4)
1. Delusions
2. Hallucinations
3. Disorganized (incoherent or erratic) speech patterns
4. Behavioral disturbances
5. Negative symptoms (blunting of affect or avolition)
Subtypes:
 Paranoid:
o Paranoid delusions + unfounded suspiciousness
o Hallucinations
o Ideas of reference – thinking that messages through tv, radio are specifically for them
o E.g. neighbor is a spy, spying on them, then think that they have a special purpose e.g. a god
 Catatonic:

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o Severe and debilitating disorganization of motor movements
 Disorganized:
o Disorganized, purposeless, non-constructive behaviour
o Often described as ‘silly’ and inappropriate in behaviour and appearance
 Undifferentiated:
o Doesn’t fit into one category

Symptom Description
Content of thought:
 Delusion Fixed false belief that is inconsistent with ones cultural, social or religious beliefs which
cannot be reasoned with logic
 Ideas of reference Belief that insignificant or incidental object or event has special significance or meaning
to that individual
e.g. person on TV is talking to the person specifically
Thought disorder
 Thought Feeling that ones thought are being read or thoughts are being inserted into ones mind
broadcasting
 Loose associations Ideas that fail to follow one another with logical flow and sequence, shifting from one
topic to another
 Incoherence Verbal rambling in which recognition of any verbal content is impossible
Perceptual disturbances

 Auditory  The hearing of voices coming from outside the persons head
hallucinations  Comment on or command certain behaviors
 Other hallucinations Can involve other sensors
Affect
 Emotional blunting Being ‘flat’, voice is monotone
 Anhedonia Loss of feelings of pleasure previously associated with favored activities
 Incongruent A mismatch between the persons thoughts a emotions e.g. person may say they are
feeling depressed and low but be laughing and smiling
Psychomotor behaviors
 Catatonia Person may appear unconscious – so preoccupied in thoughts

Positive symptoms:
 In addition to normal experiences
 Reflect confusion in the brain
 Hallucinations +delusions
Negative symptoms:
 Loss/deterioration of normal functioning
 Anhedonia + blunted affect

Case study:
18 y/o at ED, reported screaming by her neighbours, appears frightened, suspicious, hearing the neighbours
talking about her and sending bad vibes. Disjointed speech , periods of silence. No p/h of psychiatric illness.
What are the potential risks associated with her current mental state?
 Risk of damaging property to stop neighbors sending ‘bad vibes’
 Risk of self harm + harm to others
 Self care deficit because she may be too afraid to leave her room
 Further distress
 Absconding

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Potential problems Intervention Outcome
Self care deficit Assist with ADLS Independence
Accidental self harm  Clear + safe environment Kept safe
 Medication
 Seclusion
Violence – harm to others  Find triggers  Deescalate
 Medication  Keep others safe
 Seclusion
Nutritional state  Refer to nutritionist
 Urinalysis
Damage to property
Deterioration of mental state Keep relaxed
Social isolation Encourage groups
Non adherence  Psychoeducation Take meds
 Find out why
Absconding  Lock wards
 60/60 visual obs

Mood disorder:
Mood: internal ‘typical’ state of an individual. A temporary state of mind or feeling

Depression:
Signs and symptoms:
 Depressed mood/sad  Worried
 tired  Poor diet- weight loss/gain
 lack of motivation  Insomnia or hypersomnia
 poor concentration  Reduced resilience
 withdrawn  Tearful
 closed posture  Hopeless/helpless
 disheveled  Low self esteem
 suicidal thoughts/self harm  Loss of interest in pleasurable activities
 poor memory

Case study:
55 y/o male diary farmer. Injured back in a fall, chronic pain, unable to work, poor sleep, increased alcohol
consumption, unmotivated, ‘hopeless’, wife concerned.

Biopsychosocial care plan:

Potential problems Intervention Outcome
Self care deficit Assist with ADLS Independence
Self harm/suicide  Risk assessment Kept safe
 Positive reinforcement
 MSE
Pain Medication management Pain manageable
Talk to doctor for review
Potential to continue with Refer to psych Depressive state decreased
depressive state
Risk of alcohol addiction Set boundaries Less alcohol consumption
Educate
Social withdrawal Encourage socialization

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Risk for insomnia Sleeping meds Good sleep
Risk of financial strain Refer to social worker Less financial strain

Bipolar:
Types:
 Bipolar 1 – 1 or more manic/mixed episode. May also have depressive episodes (not necessary for
diagnosis)
 Bipolar 2 – episode of hypomania and a depressive episode
 Cyclothymic disorder – rapid cycling
 Bipolar disorder NOS

Mania: Elevated mood (high), extreme excitement, euphoria, accelerated mental and physical activity
Hypomania: Milder form of mania not severe enough to cause marked social or occupational impairment
 No psychotic features

Manic episode criteria:

 Elevated, expansive or irritable mood
 Lasting at least 1 week
3 or more of the following:
1. Inflated self esteem
2. Decreased need for sleep
3. Talkative
4. Flight of ideas
5. Distractibility
6. Increased psychomotor agitation (moving quickly)
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences
(excessive shopping/gambling)

Risks associated with mania:

 Impulsive – accidental harm (meds, counseling)
 Aggression – harm to others and property (Try to deescalate symptoms/stimuli, MSE, risk assessment)
 Sexual promiscuity –STDs, unplanned pregnancy –(educate about risks)
 Loss of reputation
 Financial loss- overspending –(refer to social worker, ask family to take away credit card)
 Loss of social/family relationships
 Suicide/self harm (counseling, meds)
 Absconding – (inform to increase insight)
 Poor physical health – nutrition deficits, dehydration, exhaustion, reduced sleep (assist with ADLs)
 Risk of unemployment (Inform workplace (with permission), Refer to social worker)

Mood stabilizers:
 Lithium carbonate - Lithium
 Sodium valporate - Epilim
 Carbanazepine – Tegretol

Anxiety disorder:
Characterized by persistent, excessive worry.

Treatment/management/interventions of anxiety:
 CBT

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 Meds
 Meditation, relaxation techniques
 Journaling
 Exercise
 Distraction
 Guided imagery
 Building self esteem
 Dietary adjustments

GAD – Generalised anxiety disorder:

Excessive, long term worry/anxiety that is not focused on any one object or situation.
 Usually around activities or situations e.g. work, school, home
 Anxiety disrupts daily functioning during the majority of days over at least a 6 month period
 More prevalent in females
Symptoms:
 Worry
 Restlessness
 Fatigue
 Difficult concentrating
 Irritability
 Tension
 Sleep disturbances

Phobic disorder:
Irrational fear and anxiety triggered by a specific stimulus or situation
Disability occurs due to narrowing of activities etc. to avoid contact with object/situation

Social phobia:
 Fear of social or performance situations
 Hypersensitivity to criticism
 Low self esteem, poor social skills
 Often leading to avoidance behaviour
Specific phobia:
 Anxiety provoked by exposure to specific feared object or situation – often leading to distress and
avoidance
Agoraphobia:
 Fear of having a panic attack after having one previously

OCD:
 Repetitive obsessions – distressing, persistent, intrusive
 Compulsions and rituals
 E.g. hand washing

Panic disorder:
 The presence of recurrent, unexpected panic attacks followed by at least one month of persistent
concern about having another panic attack, or a significant behavioral change related to the PA.
 Individual must have experienced at least 2 panic attacks to be diagnosed
 Body’s fight or flight mechanisms create sensation that the body is in danger
 SSRI’s are the first choice in medication to prevent PA (smaller doses)
 2 types:

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o Panic disorder with agoraphobia
o Panic disorder without agoraphobia
Symptoms: same as symptoms of Panic attack
 Increased HR, RR, BP
 Perspiration
 Trembling
 SOB
 Nausea
 Dizziness

PTSD- post traumatic stress disorder:

Anxiety disorder resulting from traumatic experience.

Symptoms:
 Recurrent, intrusive recollections of the event
 Dreams of event
 Avoid talking/thinking about the trauma
 Decreased interest and participation in important activities
 Detached
Can occur at any age

Predisposing factors:
 Background
 Presence of preexisting mental disorder
 Clients pre morbid personality

Antianxioytics – anti anxiety

Benzodiazepines – short term relief (due to risk of dependence)
Some meds used to treat depression have been found to relieve symptoms of anxiety (SSRI, TCA, MAOIs)
 Diazepam (Valium)
 Alprazopam –( Xanax)
Side effects:
 Slurred speech
 Depression
 Memory loss/ forgetfulness
 Nausea
 Blurred vision
 Drowsiness, lack of energy

Panic attack:
 Not a disorder in itself
 A discrete period of intense fear or discomfort in the absence of real danger

Substance use disorders:

Substance use disorder:
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by
one + or the following, occurring within a 12 month period:
1. Recurrent substance use = failure to fulfill major role obligations at work, school or home (child neglect)
2. Recurrent substance use in situations in which it is physically hazardous (driving)
3. Recurrent substance related legal problems (arrests)

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4. Continued substance use despite having persistent r recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance (arguments with spouse about impacts of intoxication)

Substance dependence:
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by
one + or the following, occurring within a 12 month period:
1. Tolerance:
a. Need for markedly increased amounts of the substance to achieve intoxication or desired effect
b. Marked diminished effect with continued use of the same amount of substance
2. Withdrawal
a. Withdrawal syndrome
b. The same or close amount of substance is taken to relieve or avoid withdrawal symptoms
3. Substance is often taken in larger amounts of over a longer period than was intended
4. Persistent desire to cut down on substance
5. Great deal of time spent getting the drug
6. Important life events reduced because of substance use

Drug abuse: Pattern of substance (drug) use in which the user consumes the substance in amounts of with
methods which are harmful to themselves or others
Drug misuse: Use/abuse of prescription medication (pain, stimulant meds)
Substance abuse: the use of drugs or alcohol in a way that disrupts prevailing social norms; varying with culture,
gender and the environment

Symptoms:
 Tolerance
o Need more to get the same effect
 Withdrawal
o Withdrawal symptoms
 Anxiety, agitation, tremor, excessive sweating, altered consciousness, hallucinations
o Take more of the drug to avoid withdrawal
Types of drugs:
 Amphetamines– produced in a lab
 Heroin, cocaine – from plants
 Alcohol – legal
 Cannabis – illegal
Can cause harm through either intoxication or dependence

Categories:
 Depressants (alcohol, benzodiazepines, opiods)
 Stimulants (amphetamines e.g. speed, ice, caffeine)
 Hallucinogens (LSD – magic mushrooms, mdma – ecstasy (both a stimulant and hallucinogen)

Depressants:
Slow the activity of the brain
 Relaxation, drowsiness (small doses)
 Loss of consciousness (large doses)

Stimulants:
Increase activity of NS + increase sense of arousal
 Increase awareness + concentration and decrease fatigue (small doses)
 Irritability, nervousness, insomnia (larger doses)

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Hallucinogens:
Distort perception + induce hallucinations
 Reduce inhibitions + increase sociability (small doses)

Drug and alcohol assessment info:

 Type of substance used
 Quantities of substance
 Combinations
 Frequency and duration
 History of OD or other harms
 Physical and mental health – history and impacts of substance use
 Social impacts – employment, school, social supports, legal issues or problems related to substance use
 Level of insight
 Readiness to change
Harm minimization: approach focusing on reducing and preventing harms associated with drug use (clean
syringes to prevent HIV, education)

Eating disorders:
Characterized by one or more seriously disturbed eating behaviors.
 Highest mortality rate of all metal disorders
 Mostly affect women 15-25

Impacts of ED:
 Low self esteem, depression, shame, guilt
 Obsession and anxiety
 Interference with normal daily activity

Risk factors for ED:

Psychological:
 Low self esteem
 Feeling inadequate
 Incidence of depression or anxiety
 Ineffective coping strategies
 Perfectionism
 Impulsive or obsessive behaviors
Social:
 Cultural value placed on ‘thinness’ as a part of beauty
 Media
 Professionals with an emphasis on body shape and size (dancers, models, athletes)
Biological:
 Adolescence and the associated physical, hormonal and neural changes
 Genetic or family factors – family member with an ED = increased likelihood
Other:
 Loss of family member or friend, divorce of parents
 Dieting
 Peer pressure
 Troubled personal or family relationships
 History of teasing or bullying especially about weight

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Risks associated:
 Anaemia
 Reduced immune function
 Intestinal problems
 Kidney failure
 Osteoporosis
 Heart problems
 Loss of disturbances in menstrual periods
 Increased risk of infertility

Anorexia nervosa:
Persistent restriction of energy intake leading to significantly low body weight
 Either an intense fear of gaining weight, or persistent behaviour the interferes with weight gain
 Disturbance in the way one’s body shape is experienced
Subtypes:
 Restricting
 Binge/purge

Bulimia nervosa:
Recurrent episodes of binge eating. Characterized by:
 Eating, in a discrete time (2hr period), an amount of food that is definitely larger than most people would
eat during a similar period of time
 A sense of lack of control over eating during the episode
 Recurrent inappropriate compensatory behaviour to prevent weight gain – purging, lax misuse, diuretics,
fasting, excessive exercise
 The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week
for 3 months.

Assessing for eating disorders:

 History of weight fluctuations
 Actions taken to maintain, control or alter weight.
 Dieting
 Laxatives, diuretics, appetite suppressants, supplements
 Vomiting
 Excessive exercise
 Periods of binge eating or feeling a lack of control over food intake
 Comfort with current weight/shape
 Report of typical food intake + exercise
 Menstrual history
 Fam history or ED, depression, obesity

Treatment:
 Restore person to healthy weight
 Treat psychological issues related to ED
 Reduce or eliminate behaviors or thoughts that lead t insufficient eating and preventing relapse.
 Inpatient care
 Nutritional counseling
 Family therapy/counseling
 Psychotherapy
 CBT

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Psychopharmacology:
Research suggests that meds such as antidepressants, antipsychotics or mood stabilizers are most useful

Nursing interventions:
 Be genuine and honest with clients, accept them for who they are
 Treat anger and negative thinking as symptoms of the illness, not as personally targeted at the nurses
 Don’t reinforce hallucinations, delusions or irrational thoughts
 Focus on their strengths and positive reinforcement
 Medications
 Counseling/therapy
 Psychoeducation
 Risk assessment
 MSE
 Carer/family involvement/support – educate
 CBT
 ECT?
 Communicate with pt
 Build a therapeutic r/s
 Refer to: social worker, dietician, psychologist
 Provide a quiet peaceful environment
 Assess the clients: ability to meet hygiene needs, dietary intake etc

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