Sedative-Hypnotics

Sedative-Hypnotics 150 150 Tony Guo

Sedative-Hypnotics

Indications

  • Short-term management of various anxiety states and treatment of insomnia; selected agents are used as anticonvulsants, as preoperative sedatives, and to reduce anxiety associated with alcohol withdrawal.

 

Action: Depression of the C N S

  • Exception: Ramelteon’s sleep-promoting properties are the result of agonist activity on selective melatonin receptors.

 

Contraindications

  • Contraindicated in known hypersensitivity, pregnancy, and lactation, and in severe hepatic, cardiac, respiratory, or renal disease. 

 

Precautions

  • Caution is advised with clients with hepatic, cardiac, renal, or respiratory insufficiency. 
  • Caution is also advised with those who are suicidal and those who have been addicted to drugs.

 

Drug Interactions

Interacting Drugs Adverse effects
Barbiturates Increased effects are present when used with other medications such as MAOI, CNS depressants, valporic acid and alcohol. May cause renal toxicity when used with methoxyflurane
Benzodiazepines
Eszopiclone Addictive effects
Zaleplon Addictive effects
Zolpidem Increased effects that may lead to cardiac arrhythmias 
Ramelteon

 

Nursing diagnosis

  • Risk for injury
  • Disturbed sleep pattern/insomnia
  • Risk for activity intolerance
  • Risk for acute confusion

 

  • Monitor client for the side effects such as abnormal thinking and behavioral changes like aggressiveness, hallucinations, and suicidal ideations. Other effects may be sleep-driving, preparing and eating food, and making phone calls with no memory of the action.

 

Psychostimulants

ADHD (Attention Deficit-Hyperactivity Disorder)

 

Indications

  • Attention deficit/hyperactivity disorder (A D H D) in children and adults
  • Medications are also used to treat narcolepsy and exogenous obesity

 

Medication action

  • The C N S stimulants increase levels of norepinephrine, dopamine, and serotonin in the C N S. Their effectiveness in the treatment of ADHD is thought to be based on the activation of dopamine D4 receptors in the basal ganglia and thalamus, which depress, rather than enhance, motor activity.
  • Atomoxetine inhibits the reuptake of norepinephrine, and bupropion blocks the neuronal uptake of serotonin, norepinephrine, and dopamine. 
  • Clonidine and guanfacine stimulate central alpha-adrenergic receptors in the brain, resulting in reduced sympathetic outflow from the CNS. 
  • The exact mechanism by which these non-stimulant drugs produce the therapeutic effect in ADHD is unclear.

 

Contraindications

C N S stimulants

  • Contraindicated in clients with hypersensitivity to sympathomimetic amines; clients with advanced arteriosclerosis, cardiovascular disease, hypertension, hyperthyroidism, glaucoma, agitated or hyper-excitability states; clients with a history of drug abuse; clients during or within 14 days of receiving therapy with MAOI’s; in children younger than 3 years of age; and in pregnancy and lactation

Atomoxetine and bupropion

  • Contraindicated in clients with hypersensitivity to the drugs, in lactation, and in concomitant use with or within 2 weeks of using MAOI’s

Alpha agonists

  • Contraindicated in clients with known hypersensitivity to the drugs

 

Precautions

C N S stimulants 

  • Use caution in children with psychoses; clients with Tourette’s disorder, anorexia, or insomnia; elderly, debilitated, or asthenic clients; and clients with a history of suicidal or homicidal tendencies; prolonged use may result in tolerance and physical or psychological dependence.

 

Dexmethylphenidate and methylphenidate

  • Effects of concomitant use
  • Hypertensive crisis may occur with coadministration of M A O I’s

Atomoxetine and bupropion

  • Use caution in clients with urinary retention; hepatic, renal, or cardiovascular disease; suicidal clients; pregnancy; and elderly and debilitated clients.

Alpha agonists

  • Use caution in clients with coronary insufficiency, recent M I, or cerebrovascular disease; in chronic renal or hepatic failure; the elderly; and in pregnant clients and those lactating.

 

Nursing diagnosis

  • Risk for injury
  • Risk for suicide
  • Imbalanced nutrition
  • Insomnia
  • Nausea related to side effects of atomoxetine or bupropion
  • Pain related to side effects of abdominal pain with atomoxetine or bupropion or headache
  • Risk for activity intolerance

 

Planning/Implementation

  • Monitor client for the following side effects:
  • Overstimulation, restlessness, insomnia, palpitations, tachycardia, anorexia, weight loss, tolerance, physical and psychological dependence, nausea and vomiting, constipation, dry mouth, sedation or rebound syndrome, potential for seizures, liver damage, and new or worsened psychiatric symptoms

 

Drug Classification Drug trade/ Generic names Actions Side effects Nursing implication
ADHD Ritalin (Methylphenidate)

Adderall(Amphetimine)

Stratt/’era (Atomoxatine).

Direct and indirect agonists to adrenergic receptor sites, mimicking the effects of norepinephrine or dopamine resulting in a calming effect. Agitation, exacerbation of psychotic thought processes, hypertension, and long term growth suppression.  Potential for abuse. With Strattera, decreased appetite, weight loss, fatigue, and dizziness. Monitor levels of activity, periodic vital signs.  Monitor growth activity.

 

Relationship Development and Therapeutic Communication

 

  • The nurse–patient relationship is the foundation on which psychiatric nursing is established.
  • The therapeutic interpersonal relationship is the process by which nurses provide care for patients in need of psychosocial intervention.
  • Therapeutic use of self is the instrument for delivery of care to patients in need of psychosocial intervention.
  • Therapeutic nurse–patient relationships can occur only when each views the other as a unique human being. When this occurs, both participants have needs met by the relationship

 

  • Goals are often achieved through use of the problem-solving model.
    • Identify the patient’s problem.
    • Promote discussion of desired changes.
    • Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively.
    • Discuss alternative strategies for creating changes that the patient desires to make.

 

  • Goals and the problem-solving model 
    • Weigh benefits and consequences of each alternative.
    • Help patient select an alternative.
    • Encourage patient to implement the change.
    • Provide positive feedback for patient’s attempts to create change.
    • Help patient evaluate outcomes of the change and make modifications as required.

 

Therapeutic Use of Self

  • Ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions
  • Nurses must possess self-awareness, self-understanding, and a philosophical belief about life, death, and the overall human condition

Conditions Essential to Development of a Therapeutic Relationship

  • Rapport- by getting acquainted and establishing rapport is the primary task in relationship development, and is accomplished by discussing non-health related topics. It promotes acceptance, warmth, friendliness, common interest, trust, and nonjudgmental attitude.

 

  • Trust- As an initial development task, it makes development of the relationship easier. It cannot be assumed but is earned. Things that may promote trust and build a relationship include:-
    • Providing a blanket when the patient is cold
    • Providing food when the patient is hungry
    • Keeping promises
    • Being honest (e.g., saying, “I don’t know the answer to your question, but I’ll try to find out”) and then following through
    • Simply and clearly providing reasons for certain policies, procedures, and rules
    • Providing a written, structured schedule of activities
    • Attending activities with the patient if he or she is reluctant to go alone
    • Being consistent in adhering to unit guidelines
    • Listening to the patient’s preferences, requests, and opinions and making collaborative decisions concerning his or her care
    • Ensuring confidentiality; providing reassurance that what is discussed will not be repeated outside the boundaries of the healthcare team

 

  • Respect- This shows dignity and worth of an individual regardless of their unacceptable behavior (Unconditional positive regard)

 

  • Genuineness- The nurse’s ability to be open, honest, and real in interactions with the patient.

 

  • Empathy- Do not confuse this with sympathy. In empathy the nurse accurately perceives or understands what the patient is feeling and encourages the patient to explore these feelings, while in sympathy the nurse shares what the patient is feeling and experiences a need to alleviate distress. Example

 

  • Situation: BJ is a patient on the psychiatric unit with a diagnosis of dysthymic disorder. She is 5 ft 5 in. tall and weighs 295 lb. BJ has been overweight all of her life. She is single, has no close friends, and has never had an intimate relationship with another person. It is her first day on the unit, and she is refusing to come out of her room. When she appeared for lunch in the dining room following admission, she was embarrassed when several of the other patients laughed out loud and call her “fatso.”

 

  • Sympathetic response: Nurse: “I can certainly identify with what you are feeling. I’ve been overweight most of my life, too. I just get so angry when people act like that. They are so insensitive! It’s just so typical of skinny people to act that way. You have a right to want to stay away from them. We’ll just see how loud they laugh when you get to choose what movie is shown on the unit after dinner tonight.”

 

  • Empathetic response: Nurse: “You feel angry and embarrassed by what happened at lunch today.” As tears fill BJ’s eyes, the nurse encourages her to cry if she feels like it and to express her anger at the situation. She stays with BJ but does not dwell on her own feelings about what happened. Instead she focuses on BJ and what the patient perceives are her most immediate needs.

 

Phases of Therapeutic Nurse-Patient Relationships

  • Pre-interaction phase
    • Obtain information about the patient from chart, significant others, or other health team members.
    • Examine one’s own feelings, fears, and anxieties about working with a particular patient.

 

  • Orientation (introductory) phase
    • Create an environment for trust and rapport.
    • Establish contract for intervention.
    • Gather assessment data and identify patient’s strengths and limitations.
    • Formulate nursing diagnoses and set mutually agreeable goals.
    • Develop a realistic plan of action.
    • Explore feelings of both patient and nurse.

 

  • Working phase
    • Maintain trust and rapport.
    • Promote patient’s insight and perception of reality.
    • Use problem-solving model to work toward achievement of established goals.
    • Overcome resistance behaviors.
    • Continuously evaluate progress toward
      goal attainment.
  • Transference: Occurs when the patient unconsciously displaces (or “transfers”) to the nurse feelings formed toward a person from the past
  • Countertransference: Refers to the nurse’s behavioral and emotional response to the patient

 

  • Termination phase
    • Therapeutic conclusion of relationship occurs when
    • Progress has been made toward attainment of the goals.
    • A plan of action for more adaptive coping with future stressful situations has been established.
    • Feelings about termination of the relationship are recognized and explored.

 

Boundaries in the Nurse-Patient Relationship

  • Material- Physical property
  • Social- Culture and how individuals are expected to behave in social situations
  • Personal- “physical distance boundaries” and “emotional boundaries”
  • Professional- limit and outline expectations for appropriate professional relationships with patients. Concerns associated include:-
    • Self-disclosure
    • Gift-giving
    • Types of touch- Functional-professional, Social-polite, Friendship-warmth, Love-intimacy, Sexual arousal
    • Friendship or romantic association

 

  • Warning signs that indicate that professional boundaries of the nurse–patient relationship may be in jeopardy
    • Favoring one patient’s care over another’s
    • Keeping secrets with a patient
    • Changing dress style when working with a particular patient
    • Swapping patient assignments to care for a particular patient
    • Giving special attention or treatment to one patient over others
    • Spending free time with a patient
    • Frequently thinking about the patient when away from work
    • Sharing personal information or work concerns with the patient
    • Receiving of gifts or continued contact and communication with the patient after discharge

 

The Impact of Preexisting Conditions

  • Values, attitudes, and beliefs
    • Learned ways of thinking
  • Culture and religion
    • Cultural mores, norms, ideas, and customs provide the basis for our way of thinking
  • Social status
    • High-status persons often convey their high-power position with gestures of hands on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status.
  • Gender
    • Masculine and feminine gestures influence messages conveyed in communication with others.
  • Age or developmental level
    • Example: The influence of developmental level on communication is especially evident during adolescence, with words such as dude, cool, awesome, and others.
  • The environment in which the transaction takes place
    • Territoriality, density, and distance are aspects of environment that communicate messages.
      • Territoriality: The innate tendency to own space
      • Density: The number of people within a given environmental space
      • Distance: The means by which various cultures use space to communicate

 

  • There are four kinds of distance in interpersonal interactions.
    • Intimate distance: The closest distance that individuals allow between themselves and others
    • Personal distance: The distance for interactions that are personal in nature
    • Social distance: The distance for conversation with strangers or acquaintances
    • Public distance: The distance for speaking in public or yelling to someone some distance away

 

Active Listening

  • To listen actively is to be attentive to what patient is saying, both verbally and nonverbally.
  • Several nonverbal behaviors have been designed to facilitate attentive listening.

 

Non-verbal behaviors that must be followed to facilitate active listening are included in the acronym SOLER:-

S: Sit squarely facing the patient

O: Observe an open posture 

L: Lean forward toward the patient

E: Establish eye contact 

R: Relax

 

Motivational Interviewing

  • Evidence-based, patient-centered style of communication that promotes behavior change by guiding patients to explore their own motivation for change and the advantages and disadvantages of their decisions
  • Incorporates active listening and therapeutic communication techniques but focuses on what the patient wants to do

 

Process Recordings

  • Process recordings are written reports of verbal interactions with patients.
  • They are written by the nurse or student as a tool for improving communication techniques.

 

The Nursing Process in Psychiatric Mental Health

  • The Nursing Process is a systematic framework for the delivery of nursing care that uses a problem-solving approach, goal-directed, with its objective being the delivery of quality client care, is dynamic, not static.

 

  • Standards of Practice for psychiatric nursing (ADOPIE)
    • Assessment: Information is gathered from which to establish a client database.
    • Diagnosis: Data from the assessment are analyzed. Diagnoses and potential problem statements are formulated and prioritized.
    • Outcome identification: Expected outcomes of care are identified. They must be measurable and estimate a time for attainment.
      • Nursing Outcomes Classification (N O C): A comprehensive, standardized classification of patient outcomes developed to evaluate the effects of nursing interventions.
    • Planning: Evidence-based interventions for achieving the outcome criteria are selected.
      • Nursing Interventions Classification (N I C): A comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties.
      • N I C interventions are based on research and reflect current clinical practice.
    • Implementation: Interventions selected during the planning stage are executed. 
      • Specific interventions include
      • Coordination of care; health teaching and health promotion; consultation
      • Prescriptive authority and treatment; pharmacological, biological, and integrative therapies
      • Milieu therapy; therapeutic relationship and counseling; psychotherapy
    • Evaluation: Measures progress toward attainment of expected outcomes.

 

Why Nursing Diagnosis

  • The identification and classification of nursing phenomena began in 1973 with the First National Conference on Nursing Diagnosis.
  • General and specialty standards are written around the six steps of the nursing process.
  • It is defined in most state nursing practice acts as a legal responsibility of nursing.
  • Promotes research in nursing.

 

Nursing Case Management

  • Case management: A health delivery process whose goals are to provide quality healthcare, decrease fragmentation, enhance the client’s quality of life, and contain costs.
  • Managed care: A concept designed to control the balance between cost and quality of care. Individuals receive care based on need, which is determined by coordinators of the provider-ship.
  • Case manager: The individual responsible for negotiating with multiple healthcare providers to obtain a variety of services for the client.
  • Critical pathways of care (C P C’s): ​The tools for provision of care in a case management system.
  • C P C’s
    • Determine which categories of care will be provided, by what date, and by whom.
    • Nurses may be identified as case managers and are ultimately responsible for ensuring that C P C goals are achieved within the designated time dimension.
    • C P C’s may be standardized because they are intended to be used with uncomplicated cases.

 

Role of the nurse in psychiatry

  • Assist with the client’s successful adaptation to stressors within the environment.
  • Goals are directed toward change in thoughts, feelings, and behaviors that are age-appropriate/congruent with local and cultural norms.
  • The nurse is a valuable member of the interdisciplinary team.

 

Concept Mapping

  • A diagrammatic teaching and learning strategy that shows interrelationships among medical and nursing diagnoses, assessment data, and treatments
  • Practical, realistic, and time-saving
  • Enhance critical-thinking skills
  • Based on the components of the nursing process
  • Helps students develop a holistic view of their clients

 

Documentation

  • Documentation of the steps of the nursing process is often considered as evidence in determining certain cases of negligence by nurses.
  • It is also required by some agencies that accredit healthcare organizations.
  • Examples of documentation that reflect use of the nursing process
    • Problem-oriented recording   
      • Has a list of problems as its basis
      • Uses subjective, objective, assessment, plan, intervention, and evaluation format
    • Focus charting
      • Main perspective is to choose a “focus” for documentation. 
      • The focus cannot be a medical diagnosis.
      • Focus charting uses a data, action, and response format.
    • A P I E method
      • A problem-oriented system
      • Uses flow sheets as accompanying documentation
      • Uses assessment, problem, intervention, and evaluation (A P I E) format

 

Electronic Documentation

  • Most healthcare facilities have implemented, or are in the process of implementing, some type of electronic health records (E H R’s) or electronic documentation system.
  • E H R’s have been shown to improve both the quality of client care and the efficiency of the healthcare system.

 

Eight core functions of E H R’s

  • Health information and data
  • Results management
  • Order entry/order management
  • Decision support
  • Electronic communication and connectivity
  • Patient support
  • Administrative processes
  • Reporting and population health management

 

Anxiety, Obsessive-Compulsive, and Related Disorders

 

  • Anxiety is an emotional response to anticipation of danger, the source of which is largely unknown or unrecognized.
  • Anxiety is a necessary force for survival. It is not the same as stress.
  • A stressor is an external pressure that is brought to bear on the individual.
  • Anxiety is the subjective emotional response to that stressor.
  • Anxiety may be distinguished from fear in that anxiety is an emotional process, whereas fear is a cognitive one.

 

Historical Aspects

  • Anxiety was once identified by its physiological symptoms, focusing largely on the cardiovascular system.
  • Freud was the first to associate anxiety with neurotic behaviors.
  • For many years, anxiety disorders were viewed as purely psychological or purely biological in nature.

Epidemiological Statistics

  • Anxiety disorders are the most common of all psychiatric illnesses.
  • More common in women than in men
  • A familial predisposition probably exists.

 

  • When anxiety is out of proportion to the situation that is creating it
  • When anxiety interferes with social, occupational, or other important areas of functioning

 

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