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LAST MINUTE REVIEW &REVIEW

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Nurse Practitioner - Core Values for Culturally

Competent Care:

Respect / Knowledge of cultural belief and practices

Advocacy for the development of culturally

appropriate pt care services.

Partnership with the pt to develop the TP.

o Cultural expected response to stressor doesn’t mean there is a mental illness.

o Understand Cultural Context of the symptoms.
o Cultural Assessment / Cultural Formulation Interview:
Helps clarify meaning of the pt illness
Helps empower the pt.
Help contextualize pt’s symptoms in their local world
The pt may present with Cultural Syndrome = Offer Brief Supportive Therapy.
o Respect pt’ understanding of what cause the illness. (e.g., Native Americans think that mental illness can be
caused by Imbalance btw Individual Relationships with the World)
o Native Americans:
Ethnic group in the US with the highest suicide rate / suicide attempts - Also High level of Domestic Violence
They believe in the healing stick – if in the hospital, let the pt have his healing stick.
Make accommodations for them to have the healing stick / educate other members of the team on Cultural
Sensitivity.
Make accommodations for the traditional healer to be part of the Plan of Care – First obtain clearance for
Inform Consent.
o Health Promotion in the Community / Nursing Conference (if attendees are from different cultures):
provide multicultural teaching/education.
Use Ethnospecific Assessment Parameters.

 D – Respect mother’s understanding of the Child’s illness.

 Build rapport with the mother.

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o Least
Lest Weight Gain Antipsychotics:
Latuda (Lurasidone)
Abilify (Aripiprazole) – also least sedating
Geodon (Ziprasidone)

 If pt presented with a 1st psychotic episode – use atypical antipsychotic (less EPS), especially IMs:
Invega (Paliperidone)
Olanzapine (Zyprexa)
Abilify (Aripiprazole)
Geodon (Ziprasidone)

 Interprofessional collaboration is Encouraged.

Staff cases
Address discrepancy
Identify problems (e.g., woman getting discharged after they deliver without proper psy screening – post-
partum depression / psychosis afterwards – now collaboration with OB to address this issue.

 Medical evaluations are out of scope – these answers is to refer pts.

 If mood disorders – check THS

 Hypothyroidism (cold intolerance) mimics Depression

 Hyperthyroidism (heat intolerance) mimics Mania
1st check TSH (0.5 – 5.0)
2nd check T4
If T4 high – THS is low.
If T4 low – THS is high

HEPATOTOXIC DRUGS:
(Hypotonia)
Depakote (50 – 125) Toxic > 150
Spina Bifida / Neural Tubes Defects (TERATOGENIC)
Hepatotoxicity
RUQ Pain
Reddish brown urine
Complete LFT
When toxic (Confusion, Lethargy, Resp Depression, Disorientation)
If Toxicity:
o D/C;
o Check Valproic Acid Levels.
o Check Ammonia Levels.
o LFT

KAVA – Herbal Supplement

Use for insomnia, anxiety
Is also hepatotoxic
Complete LFT (priority labs)
No BNZs + KAVA

TCA
Hepatotoxic.

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 Lamotrigine (Lamictal)
Can cause Steven Johnson Syndrome (SJS)
Cause the less weight gain among the Mood stabilizers.

Carbamazepine (Tegretol) “A.A.A” (Anemia, Agranulocytosis, Asians)

Can cause SJS in the Asian population – always screen for the
theHLA-B
ALAB-1502 allele
Can cause Agranulocytosis (A serious condition that occurs when there is an extremely low number of

Clozapine (Clozaril)
Can cause Agranulocytosis
If ANC < 1000 = D/C even if the pt is no showing S/S of infections.
Monitor for S/S of Infections (sore throat, fever, fatigue, chills)
Decrease Suicide Ideations in pts with schizophrenia

 Always check HCG in females (12 – 51 years) before starting Mood Stabilizers.

LITHIUM (0.6 – 1.2) - Toxicity ≥ 1.5

Check TSH
Creatinine (0.6 – 1.2)
BUN (10-20)
Urinalysis (check for proteins, 4+)
Neuroprotective treatment for Bipolar Disorder (protect nerve cells from damage)
Gold Standard for treatment in Bipolar
Decrease Suicide Ideations in BD
Can cause Epstein Anomaly – especially during the 1st trimester.

Meds that can increase Lithium Levels (by reducing renal clearance):
NSAIDs (ibuprofen; naproxen; diclofenac; celecoxib; indomethacin; high-dose aspirin)
Thiazides (Chlorothiazide; Chlorthalidone; Hydrochlorothiazide).
ACE-Is (Captopril; Enalapril; Lisinopril)
Dehydration

Side Effects:
Leukocytosis (High white blood cell count)
Hypothyroidism
Maculopapular rash
T-Wave Inversion. - Do EKG if > 50 y/o.
Fine hand tremors
If Coarse hand tremors = Toxicity.
GI upset (Nausea, Vomiting, Diarrhea, Anorexia) – monitor pt closely for toxicity.

Signs and Symptoms of Lithium Toxicity:

Severe GI symptoms / Metallic taste
Muscle weakness
Confusion
Palpitation
Coarse Hand tremor

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 Drowsiness
o 1st D/C
o 2nd Check Lithium levels

NEUROLEPTIC MALIGNANT SYNDROME Vs. SERATONIN SYNDROME

NEUROLEPTIC MALIGNANT SYNDROME (NMS)

Caused by antipsychotics
Extra muscle rigidity
Mutism – Dysphagia
Muscle Contraction/Destruction (Increased CPK - Increased Myoglobinuria)
Leukocytosis (High white blood cell count)
Increased LFT
TT:
o D/C
o Bromocriptine (Dopamine Agonist)
o Dantrolene (Muscle Relaxant) “Mr. Dan” (Muscle Relaxant Dantrolene)

SERATONIN SYNDROME (SS)

Caused by antidepressants (SSRI, TCA, MAOIs, SNRI).
o Wait 2 weeks btw MAOIs to SSRI (including Prozac)/TCA
o Wait 5-6 weeks btw Prozac (longer half-life) to MAOIs
Triptans can also cause SS. (avoid SSRI, TCA, SNRI, MAOIs, etc. if the is already taking a Triptan – place pt on a
NDRI: Wellbutrin)- Tramadol and Demerol (Meperidine) can also cause SS.
Hyperreflexia
Myoclonic Jerks
TT:
o D/C
o Cyproheptadine (antihistamine with additional anticholinergic, and local anesthetic properties)

 If Pt goes to the Gym a lot – presents reddish/cherry urine – check for Myoglobinuria.
 SSRI is 1st Line Treatment for depression bc is safer in OD.
 If pt is depressed + cancer = SSRI (Citalopram, Escitalopram bc of the less potential of drug-to-drug interactions)
 SSRI = Sexual problems
 If depressed, and wants to avoid sexual problems = NDRI (Wellbutrin)
 If depressed + Low energy/fatigue = NDRI (Wellbutrin)
 If depressed + Neuropathic Pain = SNRI (Duloxetine)
 1st Line of Treatment for Neuropathic Pain:
o SNRI
o TCA
o Gabapentin / Pregabalin *[alpha-2 delta ligand]
 Antidepressant Black Box Warning in children, teens and young adults – SI (assess for SI, frequency and severity).
 If depressed pt – assess for alcohol intake bc they might be “self-medicating” with alcohol.
 Little evidence of antidepressants in children Vs. Adults – Children had a less placebo rate.

SCHIZOPHRENIA

Onset in males (18-25)

Onset in females (25-35)
One of the highest – Suicidal Ideation (more than depression, more than BD)

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 Can cause aggression DSM-5 not longer uses the speci ers:
1- Paranoid
Impulsivity 2- Disorganized
3- Undifferentiated
Abstract thinking problems
Only remains:
1- Catatonia
2- Currently in partial remision.

MRI / PET Scan:

o Everything is decreased in sizes (all the lobes), but the Ventricles are enlarged.
o Decreased blood flow
Don’t give stimulant bc this potentiates Dopamine release (especially if the Pt has Positive Symptoms).
Non-Pharmacological Treatments: Assertive Community Treatment (ACT):
o Especially if Long-Term Hx of non-compliance, or non-medication adherence)
o Refer to an ACT (Interdisciplinary team with CM, nurses, therapists, specialists)
o Referral post-discharge of the hospital (not while at the hospital) – This is a form of rehab post-
hospitalization.
Pt need social skills training (Tertiary Level of Prevention [Rehab])
May required referral to an Exercise Program – Benefits of Aerobic Exercise:
o Help improve cognition
o Improve quality of life
o Improve Long-term health
If the pt is High Risk of Relapse (e.g., multiple hospitalizations, or many medication trials and is not responding) –
he would need to change from PO Haldol to IM Haldol:

 Highest Homicidal Ideation - Antisocial Personality Disorder.

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 MENTAL STATUS EXAM

 Delusion – False believe firmly maintained despite evidence of the contrary.

 If is a MSE from a preschooler (3-5 years old) – Its conducted through observation, listening cues from the child
(clinical observation of the child behavior).

Components of the MSE:

Thought Process: Assess how organized are the thoughts / if they are logical / normal or abnormal
o Tangential (never getting to the point / moving from topic to topic)
o Circumstantial (the pt goes in Circles, providing unnecessary details before getting to the point)

Thought Content: SI/HI/Plans; Hallucinations.

CLOCK DRAWING TEST

Screening Tool to Test for Neurological Symptoms (e.g., Dementias)
Easy to administer
1-2 mins to administer
If pt unable to draw the face of the clock = problem with right hemisphere / right parietal lobe

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 DEPRESSION / MANIA / PSYCHOSIS
Inducing meds

after
- Start only 12 hrs stopping alcohol intake / No alcohol-containing products for 2 weeks after D/C
treatment / Increases the LFT.
- Disul ram Increases Warfarin (Coumadin) levels - increasing the risk of bleeding.

(Anastrozole - for breast cancer)

2D6
Other Inhibitors:

*Grapefruit Juice

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 Paradoxical Effect = the medication is causing the oppositive effect of the expected result – avoid this medication
in the future.
 Apoptosis – neuronal loss / cell death.

BIPOLAR DISORDER

 self-esteem
Pressure speech / difficult to interrupt
Irritability
Uncooperative

RISK FACTORS FOR BD:

 Family Hx if one of the risk greatest factors (  Heritable)
 If the pt is ≥45-year-old, and if 1st diagnosed with BP = medical condition (e.g., CVA)

 Neurotransmitter involved in Mood Disorder (DNS + GABA):

o Dopamine
o Norepinephrine
o Serotonin
o GABA

BORDERLINE PERSONALITY DISORDER

 Recurrent SI behaviors / Self-harming Behaviors

 Use Dialectical Behavioral Therapy (DBT) to decrease SI.
o DBT was originated by Marshal Linehan
 If pt with BPD + Mood Symptoms (Depression, Emotional Lability) = Rx Depakote
 To proper Dx BPD ask the pt to do Journaling/Diary (as per the DSM-5 diagnosis process)

CONVERSION DISORDER (CD)

 Sudden onset of Neurological Symptoms after a stressful experience (death, loss, etc.):
o Paralysis
o Mutism
o Blindness
o Paresthesia (numbness, tingling)

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 ADJUSTMENT DISORDER (AD)

 Onset of Emotional / Behavioral Symptoms (within 3 months) after a stressful experience (death, loss, etc.):
o Depression
Modi ers o Anxiety
o Mixed
o Disturbed of Emotions and Conduct:
• Common in children (e.g., after moving out from home; divorce of parents; recent loss of the pet; etc.)
• Presentation: Crying all the time; Insomnia; Peer Conflicts; Verbal Altercations; Truancy.

AD Vs. MDD
 Adjustment Disorder – Has an identified Stressor - Only 2 symptoms of depression / Acute
 Major Depressive Disorder – Does not have an identified Stressor.≥ 5 symptoms of depression / Chronic

FACTITIOUS DISORDER

When pt introduce foreign substances to their body to fall sick.

Drinking urine
Eating feces
Putting Feces on their catheter.
Factitious Disorder Imposed on Another:
o Common btw the caregiver (parents / legal guardian) and the children.
o The caregiver would lie saying that the child is sick (for attention)
o Is considered a form of abuse bc the child would suffer all the medical procedures.
o If identified, collect more proof, and then report findings to CPS. (Duty to report)

OPPOSITIONAL DEFIANT DISORDER (ODD)

The child is defiant

Vindictive / resentful
Won’t follow requests / rules from authority figures
Deliberately annoys others / blames others
The is NO aggression.
Therapy: - DO therapy before anything else!!
o Family Therapy focused on Child Management Skills
o Parenting Skills
o Positive reinforcement
o Boundaries Settings
This could progress to Conduct Disorder.

CONDUCT DISORDER
*Persistent behavior that violates the rights of others, social norms, rules.

towards people or animals

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 ADHD

Parts of the brain implicated on ADHD:

o Frontal Cortex
o Basal Ganglia Screening Tests:
o Reticular Activating System Vanderbilt ADHD Parents/Teacher
M-CHAT
Neurotransmitter involved in ADHD are the DNS: ADOS-G
o Dopamine ASQ
o Norepinephrine
o Serotonin
Inattentive Symptoms are caused by
Abnormality / Deficits of the function of the Prefrontal Cortex (regulates attention and executive function)
A part of the Prefrontal Cortex is the Dorsolateral Prefrontal Cortex:
o Attention
o Executive Function
o Regulates Cognitive Processes (working memory / problem solving)
Treatment could be stimulant meds, but If the kid has tics ≠ Non-stimulants (Guanfacine / Clonidine)
Before starting the stimulant:
o Assess 1st personal / family Medical Hx of Cardiovascular Disease.
o If positive Hx – complete ECG 1st .
If the stimulant medication wears off in a couple of hrs. the teacher would report it (bc the child is re-
experiencing the ADHD symptoms again). Give another dose for the school nurse to administer during the day.
If when psycho-educating a parent regarding the child’s ADHD, the mother/parent is very anxious – stop
education and address the mother’s anxiety, provide Brief Supportive Therapy.
 Aftercare Plans Starts upon Admission (Provide information regarding behavioral management to the parents
upon admission; don’t wait until they leave the hospital).
≥3 y/o Amphetamines ; ≥ 6 y/o Methylphenidate ≥ 6 y/o Guanfacine & Clonidine

OBSESSIVE COMPULSIVE DISORDER (OCD)

Neurotransmitters involved in OCD:

o Serotonin
o Norepinephrine
Obsession:
o Intrusive images
o Persistent thoughts
Compulsion (behaviors in response to the Obsessions):
o Tics could be also a Compulsion.
Streptococcal Infections could cause OCD in children:
o PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep Infections).
o If sudden onset of OCD in children, screen for strep throat.
o If the child is being treated for a strep throat – look for OCD in the answer.
Treatment:
o Children (SSRI – Prozac) FDA-Approved: Fluoxetine
TCA: Clomipramine
o Adults (SSRIs, TCAs) A-AP: Risperidone

 We can see Tics in OCD and Tourette’s, but in Tourette’s there are no intrusive thoughts.

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 6. The pt cannot resist aggressive impulse.
7. This could result in serious attacks / destruction of property
8. Typically followed by guilt / remorse
✤ Use SSRIs, or Lithium / CBZ for refractory // or B-Blockers
✤ DO NOT Use Venlafaxine

skills

organize the toys in long tidy rows

RETT SYNDROME
Development of specific deficits following a period of normal functioning after birth.
**Common in Girls
Onset of symptoms after 5-7 months of normal development.
Small head growth
Loss of acquired hand skills - stereotyped hand movements.
Poor social engagement
Seizures
Irregular respirations
Scoliosis
Flatt affect.

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 POST-TRAUMATIC STRESS DISORDER
PTSD
Intrusive re-experiencing of the traumatic event Acute 1-3 Months
Chronic ≥ 3 Months
Increased arousal (hyper arousal) Delayed > 6 months.
Avoidance
Nightmares – use Prazosin for this.
CBT, Exposure Therapy & Response Prevention; Supportive Group Therapy —Goal of Therapy: Adaptive resolution.
FDA-SSRI: Paroxetine, Sertraline - If ashbacks - antipsychotics (Shapiro)
Avoid exacerbation of symptoms:
o Assessment (Collect Data) by completing Exposure; Discuss Fears.
No BNZs

PANIC ATTACK Vs. PANIC DISORDER

Panic attack – Acute – Once in a while

Panic Disorder – Chronic – Impending Doom feelings.

TOURETTE DISORDER / SYNDROME

For Dx (lasted > 1 year): If tics + ADHD, give Non-stimulants like:

o At least 2 Motor Tics
o At least 1 Vocal Tic (It could be noises, or clearing of the throat)
Stimulants can cause tics. If pt also has ADHD + Tics ≠ No Stimulants Meds.
Its normal for children to present some motor / vocal tics. This usually goes away in adolescence.
Treatment:
o If Children - (Guanfacine / Clonidine)
o Haldol
o Pimozide
o Abilify
Neurotransmitters in Tourette’s (DNS):
o Dopamine
o Norepinephrine
o Serotonin
Hyperactivity of Dopaminergic neurons in the brain = Tourette’s.

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 DELIRIUM

Acute (within hrs. to days)

Acute onset
Acute Disturbance of Level of Consciousness (LOC) Risk Factors:
Acute disturbance of Cognition (acute onset of memory problems) 1- B12 De ciency in the diet
Inattention 2- Substance abuse (alcohol)
3- Neurocognitive Disorders
Agitation and psychosis – treat with:
o Haldol
o Atypical antipsychotics
 If older female pt (≥65 years old) is presented with Delirium – order Urinalysis with Culture and Sensitivity. UTI in
older female pts could cause Delirium

DEMENTIA
Chronic (months to years)
Progressive declining of cognitive status
Irritability
Personality Changes
If suspected Dementia check:
o Folic Acid Levels
o Vitamin B12 Levels

TYPES OF DEMENTIA

HIV-Related Dementia (Subcortical Dementia) Huntington’s Disease (Subcortical Type)

Early Signs: Motor Incoordination (Chorea)
o Cognitive Deficit Psychomotor Retardation
o Behavioral and Motor Abnormalities Depression
Psychosis
o Lack of Coordination
o Motor slowing
o Difficult with motor tasks
o Difficult using hands

 You are getting a new pt that uses IV drugs and is presenting HIV-Related Dementia signs and symptoms – order
HIV test.
 If HIV-Related Dementia – Treatment is with Antiretrovirals.

PSEUDODEMENTIA

Primary Dx is Depression = Causing Memory Problems

Common in older pts.
Complete Cognitive screening (e.g., MMSE)
To differentiate btw Pseudodementia Vs. Dementia:
o In Pseudodementia:
• the onset of symptoms is less than a year (weeks to months).
• Pt would answer: “I don’t know” – general responses.
o In Dementia:
• the symptoms have persisted for more than a year (chronic).
• Pt would lack answer or would tell “near miss.”
• Pt would confabulate.
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 2nd most common type of dementia.

 Elderly with depression could present:

o Irritability
o Agitation

Present visual hallucinations. - Also presents Parkinson Features (Bradykenisia, Rigidity, Tremors) - No treat with A.Psy. Meds

FRONTO-TEMPORAL DEMENTIA / FRONTAL LOBE DEMENTIA / PICKS DISEASE

Problems in Frontal Lobe:

o Problems with expressive speech – slurred language. (Could be due to Dementia or Tumor)
o Most focal area for personality development – personality problems / behavioral problems.
o Social skills affected.

Problems with Temporal Lobe:

o Problem with speech comprehension.

SOCIAL JUSTICE
Provide Services to the ones who need them the most, but don’t have access
access to it: to it.
1. Sometimes is at micro level (e.g., care for a # of pt pro-bono each year; volunteer at Mission Clinics in the Community)
2. Sometimes is at macro level (e.g., working with a group to effect health law change, trying to make it an Universal Right)

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 Pts that lives in rural areas, especially in houses from the ‘70s could be at high risk of lead poisoning

 If taking care of infant that is about to die – give infant to parent so they can grief the loss.

 Risk factors for Osteoporosis:

o Smoking
o Caffeine
o Lack of exercise
o Low calcium – Vitamin D Diet

THERAPIES

DBT – Marsha Lyneham Use for Borderline Personality Disorder - Decrease SI

Cognitive Therapy:
o Replace irrational thoughts / automatic negative thoughts for more acceptable/positive ones.

Behavioral Therapy:
o Teach Behavioral Techniques:
o Problem-Solving
o Skill Training
o Muscle Relaxation
o Exposure
o Modeling

Cognitive Behavioral Therapy (CBT):

o Combination of Cognitive + Behavioral Therapies.
o Select CBT with covering these two therapies
o Techniques:
• Cognitive Restructuring – restructuring negative thoughts.
• Journaling / Daily Log

 If doing Group Therapy and the pt is uncomfortable sharing his problems in the group setting, but NP wants to
promote Interpersonal Learning (he needs to be part of the group):
o Encourage pt to continue with Group Therapy
o Provide Adjunctive Individual Therapy – to facilitate group involvement.

Humanistic Therapy / Person-Centered Therapy

Self-Actualization
Self-Directed growth

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 Interpersonal Therapy
For Interpersonal Issues (problems when socializing with other – problems at work, school, home)
For marital conflicts / relationship problems
Last 12-16 weeks. Time-Limited

Multisystemic family Therapy

Targets youth who present:
o Serious Antisocial / Problematic Behaviors / Severe Bipolar
Empower Parents by: Multi-systemic Therapy
o Providing resources and skills / Provide services at school and at home Provide services at home and school
o Reducing Barriers to resources for effective management of their child. Empower parents and teachers

Strategic Therapy
Problem-focused
Symptom-focused
Paradoxical Directive / Paradoxical Intervention / Paradoxical Strategy (Inversed Psychology).
Straight Forward Directive
Reframe Belief System.

Solution-Focused Family Therapy

Focus on what works
Asses on what has worked on the past during the same situation
Miracle Questions / Miracle Solutions. (“If you were to be granted a miracle, what would you ask for?”)
Exception Finding Questions (“When was a time that this problem did not existed?”)
Scaling Questions (“In a scale from 1-10, rate your…”)

Family System Therapy / Systemic Family Therapy

Self-Differentiation
Triangles
Triangulation
Genograms

Structural Family Therapy

Boundaries
Hierarchies
Genograms

 Genograms are found in both, Systemic and Structural Family Therapy.

 When education pts about Medication – also teach about muscle relaxation
 Exercise Program / Physical Activity in children improves body image:
o Self-esteem
o Self-Awareness
o Self-worth
o Promote resilience
o Improve Relationships
o Improve Social Anxiety.

 When communicating with pt:

o Use Open-Ended Questions
o Empathy (use empathy when pt reports sad information to improve rapport, gain access to more
information.
o Use Closed-Ended questions when pt (e.g., child) is unable to construct a narrative.

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 If appointment for Couple Therapy, but only one spouse shows up = reschedule the app until both can be
present.

 If pt is moving out of state, and if there is no imminent danger/risk, provide patient with enough medication until
he finds a new provider (2-3 months).

 Mother call NP informing that her 5 years old was sodomized/molested/abused by her 15 years old:
o Request mother not to leave the 5 y/o alone with the brother again
o Call CPS
o Organize / schedule Family Crisis Therapy / Counseling.

 If pt presents Rheumatoid Arthritis (RA) – check of Erythrocytes Sedimentation Rates Levels (ESR Levels).

 If Researching a Topic in Nursing, develop PICOT questions:

o P – Problem, Population of Patient
o I – Intervention
o C – Compare
o O – Outcome
o T – Time

 Always provide Evidenced-Based Care by:

o Reading Current Journals.

 Shrill (high-pitched / penetrating) Cry in infants could be caused by Intracranial Pressure

 Is normal to 3-6 years old to play with the gentiles – Phallic Stage
 Normal to masturbate

 Normal for young boys (9-16 years old) to:

o Develop swelling and tenderness in the genitals.
o Breast enlargement
o This disappears within 6 months.

 Decrease sex drive in older females may be caused by:

o Decreased testosterone.
o Decreased blood flow to the pelvic region.

 The enzyme Alcohol Dehydrogenase:

o Metabolizes alcohol
o Men  quantities of this enzyme
o Women  quantities of this enzyme, therefore:
• Woman are
• Woman are

 Grief response varies depending on the person – there are no standard guidelines on how someone is supposed
to grief.
 While pt grieving, NP doesn’t provide Prescriptive Advice (you don’t tell him how to grief, e.g.: “Stop going to
school so you can process you pain.” “Get extra busy so you don’t think about your loss.”).
 To normalize Grief and Loss in Children:
o The most important is to guarantee an Intact Family System.
o Group Therapy so the child can learn from other children with similar losses

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  Increase Mental Health Access to needed people (e.g., OB clinic)

 Grasp/Palmar reflex (normal up to 6 months) – if reflex persist > 6 months, this is an abnormal finding.
 Moro Reflex / Startle (normal up to 6 months)
 Babinski / Plantar Reflex (normal up to 2 years) – fanning out the toes.

 PDE5 Class of medication – For Sexual Dysfunction (e.g., Viagra) – They are rapidly absorbed after PO
administration
 Normocytic Macrocytic Anemia – check for Folic Acid, Vitamin B12, and Iron Levels

ANOREXIA Vs. BULIMIA NERVOSA

Anorexia:
o Very low BMI - if BMI < 16, Hospitalize the pt.
o Amenorrhea (loss of menstruation) - T-wave inversion / QT Prolongation / Bradycardia / Hypotension
o Emaciation (abnormally thin)
o Send for medical evaluation if medically unstable (hypotensive, bradycardia)
• If the parents refuse medical referral – report case for CPS

Bulimia – Normal BMI - FDA-Approved: Fluoxetine

 If NP reads article that indicates that Adolescence

with ADHD
are high risk for substance abuse. To apply this evidence into
practice:
o Screen adolescence with ADHD for substance abuse.
o Screen adolescence with substance abuse for ADHD.

 Acupuncture could be used for

o Pain
o Depression.

 Only refer if there is nothing you can do (within the scope of practice). Always select something you can DO as
PMHNP (e.g., drug screening).
 HABEAS CORPUS
o Legal concept that protects pts against unlawful hospitalization.
o Protects pt’s rights.
o The pt can use this concept to leave against medical advice (LAMA)

 When Dx a pt, and trying to review a specific timeframe / timeline, but the pt doesn’t remember:
o Ask specific questions to anchor the memory
o Ask specific questions about memorable events

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s

  NP trying to create a new Policy, but need information from other PMHNPs:
o Host online form / survey where
when PMHNP can go an enter their responses.

 NP trying to create a new Policy in a specific facility, but the coworkers/colleagues are against the new policy.
How to convince them about the importance of this new policy?
o Educate in how this new policy is going to improve the outcome of quality in pt care.
o Explain the benefits of this new policy.

 NP trying to ensure Continues Improvement of the Quality of Pt Care in a specific facility:

o Create/Develop an Instrument to monitor clinical outcomes.
Cytokines are small proteins that are crucial in controlling the
 Autoimmune Disease can lead to increased Cytokines Levels. growth and activity of other immune system cells and blood
cells. When released, they signal the immune system to do its
job.
 If pediatric pt is still wetting the bed (nocturnal enuresis), non-pharmacological treatments:
o Set an alarm clock.
o Desmopressin – this decrease urine production.

 Don’t look pt’s info on social media – This is trust violation.

Acute disseminated encephalomyelitis (ADEM) is a rare kind of in ammation that
 Disseminated Encephalomyelitis: affects the brain and spinal cord, usually in children. It damages the coating that
protects nerve bers, called myelin. Symptoms may be severe, but they can be
o Affected Nervous System treated. Most people make a full recovery and don't have another attack
o Complete neuro exam
o Presentation:
o Asymmetrical body movements (extremities).
Health literacy:
 Education is an Intervention - when starting a new medication: Is the ability to obtain, read, understand, and use
o 1st assess the pt knowledge / believe about the medication healthcare information in order to make appropriate
health decisions and follow instructions for
o 2nd Educate treatment.

 When there is conflict of interest btw pharmaceutical companies and the PMHNPs; these companies are
promising to sponsor for the NPs studies if they use their product (medication). The PMHNP want to create a
new policy that address this conflict of interest:
o 1st assess the relationship btw the Industry Provided Samples and the Industry Sponsored Education.

 This pt was started on medication “X”, but he went online and found there is a Black Box Warning for this
medication. The PMHNP next action is to research the Benefits and Risks of Continuing administration of this
medication.

 When using a medication for Off-Label Use, Documentation is very important. Document a Full Disclosure,
documenting risks and benefits of the medication (e.g., Trazodone is an antidepressant, but it could also be used
for insomnia. This medication can cause priapism)

 Risk Factors for Sleep Apnea:

o Smoking
o Excess Weight
o Diabetes
o Obesity
o Narrowed Airways
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 SCREENING TOOLS

SEVERE 0-
MODERATE 10-2
MILD 21-2
NORMAL 25-30

ANXIETY

**TO START SCHEDULE TREATMENT:

D (#*2)-1
A CIWA (8*2)-1 = 15
 Learn only the Moderate Values for
N
Depression, Anxiety,
COWS (7*2)-1 = 13 an bstance Abuse.
Labs Findings in Alcohol Disorder:

AST up to 2x > ALT

AST (5-40)
ALT (5-35)

If AST>ALT - liver problems

Elevation in mean corpuscular value, total cholesterol, triglycerides,
Decrease hemoglobin, hematocrit, platelets, albumin.

FDA-approved for Alcohol Disorder: Acamprosate (Campral) / Disul ram (Antabuse) / Naltrexone (Vivitrol)
General health maintenance medication to treat vitamin deficiencies in persons with alcohol dependence include thiamine, folic
acid, and B-complex vitamins.
 With the COWS, if Mild, the PMHNP can:
o Prescribe Clonidine
 With the COWS, if Moderate, the PMHNP can start with scheduled medication:
o Prescribe Buprenorphine or Suboxone (sublingual medication)

 With the CIWA, if ≥8, the PMHNP can:

o Start on symptom-triggered PRN medication (e.g., nausea, vomiting, diarrhea, etc.)
 With the CIWA, if ≥15, the PMHNP can start with scheduled medication + PRNs:
o Diazepam
o Librium
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 o Ativan
 If the pt has a liver disease, and he is withdrawing from alcohol, give only “Out The Liver”:
o Oxazepam
o Temazepam
o Lorazepam (Ativan)

 If PMHNP receives a pregnant pt withdrawing from alcohol / substance = Priority action is to send this pt to a
Residential Treatment Center for detoxication with Addiction Specialist and OB.
 No BNZs for anxiety + alcohol/drug withdrawal symptoms = Rx Buspirone or Vistaril and refer pt to Residential
Treatment Center.

1) Suboxone (Buprenorphine + Naloxone) - Decrease Craving

2) Buprenorphine - Decrease Craving

1) Acamprosate (Campral) - Decrease Craving

2) Disul ram (Antabuse) - Aversion Therapy

3) Naltrexone (Revia) / Altrexone XL IM (Vivitrol) - Opioid

Agonist.

 IRVIN YALOM

 Focus on the strength of the organization, on what the employees are doing right.
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  Reflective Practice:
o The goal is to improve practice.
o Reflect about incidents
o Gain Insight about incidents
o Enhances critical thinking to problem-solve, and decision-making.
o When there is an incident on the unit, and you’re a team leader, it’s important to provide feedback to
improve practice.
o Use Debriefing strategies techniques.

 If pt has Insomnia when taking Prozac, ask the pt to take it QAM

Verify - Correc
States Board of Nursing Report - Incorrect
 dictates what you can do or can’t do (scope of practice)
 When there are answer options that require the NP to Verify information with the State Board of Nursing, most
of the time are Correct.
 If the PMHNP wants to do TMS, and he is not sure, he would have to verify with the State Board of Nursing.
 When there are answer options that require the NP to Report someone with the State Board of Nursing, most of
the time are Incorrect.

Standard of Practice
 Quality of care provided to the patient.
 Protocols and guidelines to follow are determined by ANA
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 When disclosing Psychiatric information and Substance Abuse / Chemical Information, the PMHNP needs two
separate Signed Informed Consents.

 If the pt is unable to provide Informed Consent, but he is not a danger to himself or others, Assess for possible
Involuntary Treatment.

Nonmaleficence – Prevents Imminent Danger (e.g., pt wis long hx of substance abuse and is requesting BNZs =
do not Rx BNZs bc of risk of relapse – Doing no Harm)

Beneficence – Do what is right to the pt (e.g., depressed pt needing treatment = Initiating treatment with SSRIs –
Doing what it right for the pt)

 Patient’s Rights:
o Lest Restrictive environment.
o Confidentiality
o Give / withdraw informed consent

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  A, B, C are Interventions, D is the only Assessment. (Assessment 1st)

 Just Culture – Is about Patient’s Safety (e.g., after a nurse error, the 1st action of the PMHNP is to make sure that
the pt is safe after this error; Then further steps: report incident, the nurse, etc.)
(E.g., nd the error, and identify what went wrong.)

 C – There is strength in numbers! – If PMHNP wants to develop and advocate for policy is needed support from
other NPs, and joining a professional association.

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 D – Stigma can be shown as Shame
 One of the Best ways to reduce Stigma regarding Mental Illness is through Education.
 To reduce stigma always target the largest/broadest populations through TV, Radio, Newspapers.

A – Autonomy (the pt has the right of Self-Determination / refuse treatment – as long he is not in Imminent
Danger)

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RECOVERY MODEL
Focus is on skills, abilities, interests
Self-direction
o The pt has Autonomy.
o the pt reports in what areas he needs help.
o pt has control over the resources.
Individualized care.
Non-Linear:
o Learning for experience
o Use relapse as learning opportunities.

Quality Improvement Initiative

e.g., is to complete a Retrospective Chart review post-discharge of the pt.

Process / Strategy to complete the Quality Improvement Initiative:

Process of Quality Improvement (PDSA):
o Plan
o Do
o Study
o Act-Process

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

 If you get a woman informing that she just got a message from her husband informing that he wants to commit
suicide. The PMHNP steps are:
o Ask for the husband’s current location
o Notify the Police / Crisis Unit

Erickson’s Stages

Piaget stages – Cognitive development.

Preoperational Stage (2-7 years old)
o Magical thinking is normal
o Dream with monsters.
Formal Operational Stage (≥ 12 years old)
o Child use logic (science project; test hypothesis in science)
o Abstract thinking
o Algebra

 D – Has 5 Risk factors (Age, Single, Caucasian, Male and Depression)

 For suicide, count the Risk Factors in the Answers. The Answer with the most Risk factors is correct.
 When counting Risk Factors, no Risk Factor is Bigger than the other.

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  The Highest Risk Factor for Suicide is a Previous Suicide Attempt.

CONFIDENCE INTERVALS
Small Sample Size Fewer # of outcomes events Less Precision in estimate of Effect Wider Con dence Interval

If a Sample Size is too small, the the Study will have insuf cient Power to detect differences between the groups. This could
lead
Type Ito a Type
Error is the II error (when
mistaken rejectioninvestigator
of an actually falsely
true null reject the(also
hypothesis null known
hypothesis [p-value
as a "false positive"> nding
0.05]orand conclude there is no
conclusion.
relationship
Type II Error is btw the variables,
the mistaken acceptance when
of aninactually
fact, there is one).
false null Type
hypothesis I Error
(also known- When
When there
there
as a "false is no
is no
negative" a relation,
relationship, but
nding orbut investigator
the saysYes
Investigator says
conclusion. no.

Law: “What has to be done” “What you can/ can’t do”- De ned by the The State Statues on Nursing
Policy: “How it will be done”
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 APPRECIATIVE INQUIRY (AI) [5 Ds Process]

The Scope and Standards of Practice for Nursing Administration describes Appreciative Inquiry (AI)
as a framework for nursing leadership.

AI is the study of human systems when they function at their best by asking questions in a positive
way to identify what is at the core of success.

AI build organizations in what works, rather on trying to x what it does not work.

AI is an organizational change strategy that directs attention from failures and focus on potential
and positive elements.

1 DEFINITION
2 DISCOVERY - Identify the problem
3 DREAM - analyze the problem
4 DESIGN - generate solutions
5 DESTINY - implement best outcomes.

BUSINESS MODEL OF HEALTH CARE

DELIVERY SYSTEM
1- COST
2- ACCESS
3- QUALITY “QAC”
“C.A.Q.”
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PARITY LAWS
The Mental Health Parity Act of 1996 (MHPA) provided that large group health plans cannot
impose annual or lifetime dollar limits on mental health bene ts that are less favorable than any
such limits imposed on medical/surgical bene ts.

Resuming: People will receive the same money for treatment of mental health conditions, that
they would receive for physical health conditions / surgical procedures.
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 DOPAMINE PATHWAYS

If Dopamine is  then Acetylcholine is  = EPS

If Dopamine is  then Prolactin is  = Hyperprolactinemia:

o Amenorrhea (absence of menstruation)
o Galactorrhea (breast discharge)
o Sexual Dysfunction
o Gynecomastia (breast enlargement)
o Osteoporosis

 Risperidone – Increases Prolactin levels – Breast Discharge.

 Normal Prolactin Levels on Men (<20 mg/ml)
 Normal Prolactin Levels on Women (<25 mg/ml)

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Typical Antipsychotics D2 Receptor Inhibitors
Haloperidol
Chlorpromazine
Flufenazine
Thioridazine

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 EXTRAPYRAMIDAL SIDE EFFECTS (EPS)

Initially start with IM Benztropine

Looks like anxiety Use the Barres Akathisia Rating Scale or EPD Rating
Scale

Propranolol

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 Reglan: Antiemetic and Gut motility stimulator

 If the pt is on antipsychotics + Reglan/Compazine = Monitor of S/S of Tardive Dyskinesia.

(Metoclopramide)

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ATYPICAL ANTIPSYCHOTIC MEDICATION Block D2 + Serotonin (5HT2a)

1. Risperidone (Risperdal)
2. Quetiapine (Seroquel)
3. Olanzapine (Zyprexa)
4. Clozapine (Clozaril)
5. Ziprasinone (Geodon)
6. Aripripazole (Abilify) - Can cause visual hallucinations.
7. Lurasidone (Latuda) - Have with food that contains at least 350 calories to increase the absorption.
8. Paliperidone (Invega)

Less Sedation: Abilify Monitor:

Metabolic Syndrome
Weight Neutral: Abilify; Geodon, Latuda. Diabetes
HTN
Hyperlipidimia
If 1st psychotic episode, use IM: Cardiovascular Problems
Invega
Zyprexa If older adults - high mortality (Black Box Warning)
Abilify
Geodon

36
 Highest
Highest HI.HI.

Highest
Highest HI.SI

Classic Symptoms
of Social Anxiety

Doesn’t want to be alone

Need other to make
decisions, assume
responsibility.

Overly strict with rules,

organization, work,
productivity.
Rigid
Tacaño
Stubborn
Cuadrado con todo!*

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Contraindicated if Suicidal Ideations

38
AREAS / FUNCTIONS OF THE BRAIN

39
 (REGULATES BODY FUNCTIONS) (SENSORY STATION)

Homeostatic
Functions

(MEMORY) (EMOTIONS/FEAR)

(MOVEMENT)

40
(RN is the most involved circuit in anxiety disorders)

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42
 ID “I Want

EGO “I think / I evaluate

SUPEREGO “I Should

EGO DEFENSE MECHANISMS:

”

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44
 / Constancy

Magical thinking

2
Beginning of Logical Thinking

45
Types of Crisis
1- Situational: deaths, changes in employment / nances, relationship status,
illness, suicide.
(These crises are seen as part of life)

2- Adventitious: Associated by chance - natural disasters; crimes; violence.

(These crises are not seen as part of life - or typically considered “everyday
occurrences” - They can be considered as “disastrous”)

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