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INTERACTION OF BODY AND MINDCHAPTER 67 TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with
Psychobiologic Disorders
LIMBIC SYSTEM
Controls Emotions and memory Includes:
Thalamas – modulates movement, sensation, behavior, and emotions
Hypothalamus – controls the autonomic nervous system
RECEPTORS Found on the surface of cells throughout
body and brain
Function: Sense and pick up chemical messengers in extracellular fluid
Chemical messenger: Specific key; Natural or synthetic; Neurotransmitters
You hold the key
To my receptor
NEUROTRANSMITTERS
Endogenous chemical messengers Synthesized in the neurons Stored in the vesicles of the Axons Bind momentarily to receptors on postsynaptic
neurons
Broken down Reuptake Diluted
NEUROTRANSMITTERS
Serotonin (5-HT) Imbalances: depression, eating disorders, sleep
disturbances, Obsessive–compulsive disorder
Dopamine (DA) Excess: disorganized thought patterns, Schizophrenia Deficient: Parkinson’s disease, impaired judgment
Norepinephrine (NE) Excess: Neurodegenerative diseases Deficient: depression
Acetylcholine (ACH) Gamma-aminobutyric acid (GABA) Glutamate (GT)
NEUROPEPTIDES
Separate type of neurotransmitter Substance P
Transmits sensation of pain Endorphins
Interrupt transmission of substance P. Promote feeling of well-being (morphine-like)
Neurohormones Endocrine System
Receptors for neurotransmitters are found throughout CNS, endocrine, and immune systems
Mind and emotions can affect physical well being
Physical well-being can affect the mind and emotions
PSYCHOBIOLOGIC ILLNESS
Biologic Factors Neurotransmitters
Psychological Factors Forces that shape behavior
Intrapersonal Development Conflicts within oneself
Freud Interpersonal Interaction
Consequences of social development Relationships, Interactions, Social Systems
Erikson, Stack-Sullivan Learning
Positive and Negative reinforcement Skinner
ASSESSMENT FINDINGS
Signs and Symptoms Affect relationships, interfere with responsibilities
American Psychiatric Association DSM-IV-TR
Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision)
Classifies psychiatric disorders Psychological Tests
MMPI, MMPI-A, Beck, DAP, WAT, TAT, Rorschach Diagnostic Findings
CT, MRI, EEG, PET, QEEG, Brain mapping Mental Status Examination
MENTAL STATUS EXAMINATION
Physical appearance Orientation Attention and concentration Short-term and long-term memory Movement and coordination Speech problems Mood Intellectual performance Perception Insight Judgment Thought content
MENTAL STATUS EXAMINATION
What is the year? What is today date? In what city are we in? Spell globe backward Repeat the following sentence: “A rolling
stone gathers no moss.” Write a sentence of your own choice.
Evaluate the sentence. Does it have a subject, verb, object?
MEDICAL AND NURSING MANAGEMENT
Determined by the disorder Drug therapy
Correcting the underlining biochemical abnormality
Psychotherapy Talk therapy
Freudian
Cognitive therapy Changing the patterns of thought
Self help books
Behavioral therapy Behavior modification
Pavlov
PSYCHOSOMATIC FUNCTION
Role of Stress on Health Stress implicated in development or
exacerbation of Autoimmune disorders Thyroid conditions Heart disease Diabetes Chronic pain Functional and inflammatory disorders of the GI
system Anorexia nervosa OCD And on and on and on…
STRESS
Eustress Maintaining a healthy balance Just right amount of stress
Distress Ill-timed unrelieved
General Adaptation Syndrome
STRESS RESPONSE
Physiologic Autonomic Nervous System Sympathetic
Norepinephrine Fight or flight
Parasympathetic Frozen with fear
Psychologic Coping Mechanisms
Temporarily avoid the emotional effects of a stressful situation Used correctly they maintain psychological equilibrium Overuse causes dysfunction
Hardiness
PSYCHOSOMATIC ILLNESSES
Psyche = MindSoma = Body
“Pertaining to the mind-body relationship”
Also known as stress-related disorders These are actual medical conditions
associated or aggravated by stress Most illnesses have psychosomatic
components
BIOLOGIC FACTORS
Stress affects the immune system
The brain sends messages directing the immune system’s actions Immunopeptides
Cytokines Function as neurotransmitters
Immune Cells Secrete neurochemicals
Nerve cells Connect the immune system to the brain
PSYCHOLOGICAL FACTORS
Anger Suppressing Anger
Compromised immune system Excessive Expression of Anger
Heart disease
Dependence Fear of rejection/abandonment Heplessness Powerless
Increase illness
Ambivalence Unresolved conflicts
Affect immune systme
MEDICAL AND NURSING MANAGEMENT
Stress Management Techniques Relaxation techniques Coping strategies Anger management Assertiveness training
Support Groups referral
Nutrition Depending on individual
THE PLACEBO EFFECT
Healing or improvement that takes place because the individual believes a treatment will be effective
Observed during research trials We can not use placebos in practice
CARING FOR CLIENTS WITH ANXIETY DISORDERSCHAPTER 68 TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with
Psychobiologic Disorders
ANXIETY AND FEAR
Anxiety A vague uneasy feeling, the cause of which is not readily
identifiable. Evoked when a person anticipates nonspecific danger
Fear A feeling of terror in response to someone or
something specific that a person perceives as dangerous or threatening
LEVELS OF ANXIETY Mild
Attention and sensory perception increased, reality intact, person feels in control. HR, BP, RR slightly increased, perspiration noticeable. Good for learning.
Moderate Concentration slightly impaired, learning takes more
effort, irritable, may feel inadequate. Hand or leg tremors, voice changes
Severe Cannot concentrate or stay focused, person feels
discomfort and incompetent. Palpitations, hyper-ventilation, limited communication
Panic Thoughts fragmented, learning not possible, feel helpless,
speech incoherent, dyspnea, tremors, diaphoresis
ANXIETY
Anxiety disorders sometimes have familial patterns
Symptom manifestations caused when norepinephrine floods the limbic system
Biochemical changes brought on by the ANS trigger physical arousal in cortex and neuroendocrine pathways
Biochemical mechanismsDysregulation of gamma-aminobutyric
(GABA)Depletion of serotonin
ANXIETY DISORDERS
Psychobiologic illness that results from activation of the autonomic nervous system
Tends to be chronic Appears without logical explanation Sometimes leads to other psychobiologic
conditions Depression Substance abuse Binge eating disorder Compulsive eating
GENERALIZED ANXIETY DISORDER
Chronic worrying on a daily basis for 6 months or more.
Usually more than one focus of worry
Usually out of proportion with reality
Signs and symptoms of anxiety accompany client’s distress
PANIC DISORDER
Abrupt onset of physical symptoms Intense apprehension, tachycardia, palpitations, chest
pain, smothering, choking sensations, hyperventilation, lightheadedness, feeling of impending doom, fear of fainting, dying, losing control, or going insane
Lasts minutes to less than an hour then subsides Often referred to as attacks, interrupt daily activities
First instinct is to escape to safety Unexplained fight from work, school, etc
Learn to avoid events that trigger attacks Can lead to phobias
Agoraphobia-fear of experiencing a panic attack in public
PHOBIC DISORDER
Person manifests an exaggerated fear Insects, animals, heights, flying, enclosed
spaces, etc
Social Phobia Common phobia Client afraid they will be embarrassed or
criticized
POST TRAUMATIC STRESS DISORDER
Delayed anxiety response 3 months or more
after an emotionally traumatic experience. Must be extraordinarily severe to cause PTSD Involve actual or threatened death or injury to
self or others Produce fear, helplessness, or horror
Psychic Numbing Initially avoid dealing with the tragedy and
detaches from the situation Flashbacks
Memories or recurrent nightmares in which the client feels as if they are reliving the event.
OBSESSIVE COMPULSIVE DISORDER
Performance of an anxiety-relieving ritual (compulsion) that relieves a disturbing, persistent thought (obsession).
Anxiety escalates if ritual is stopped, interrupted, altered, or forbidden.
Clients recognize their thoughts and behaviors are absurd, but they are helpless to stop independently.
May lead to problems in social relationships, failure in school, or loss of employment
ASSESSMENT FINDINGS
Most Clients seek treatment for physical signs and symptoms Palpitations Increased BP, HR, RR Chronic fatigue Headaches Sleep disturbances
Some will seek treatment due to unrealistic worries, flashbacks, performing rituals
NURSING CARE
Building Trust Be available and attentive Avoid leaving anxious clients alone
Restoring Comfort Providing relief. Asking client to suggest methods
that may be personally comforting Modifying Communication
Avoid interrupting anxious clients Reduce distracting stimuli Verbalize client’s right to privacy You may offer a referral to a health professional such
as a psychologist or social worker Respect your client’s right not to discuss their
anxieties and fears if they choose not to
NURSING CARE
Adjusting Teaching Limited attention and concentration Provide simple and repeated directions Determine level of comprehension Reductions in sensory stimulation Avoid expecting the client to show a great deal of self-reliance
Helping Problem-Solve Step-by-step problem-solving process Talking helps to process information and explore methods for
dealing with problems Avoid giving advise or influencing decisions Advocate on the client’s behalf
Ensuring safety Remain calm and reduce anxiety One nurse interaction Unstable client-avoid getting physically close
MEDICAL MANAGEMENT Drug Therapy
Reduce or block levels of norepinephrine Normalize levels of serotonin Avoid caffiene
Benzodiazepines Xanax, Ativan, Valium May lead to drug dependence Abrupt discontinuation can lead to withdrawal symptoms
Nonbenzodiazepines Buspar, Paxil, Luvox
beta-adrenergic blockers Inderal, Tenormin, Lopressor
central-acting sympatholytics Catapres, Aldomet, Wytensin
MEDICAL MANAGEMENT
Cognitive Therapy Alter irrational thinking, correct faulty belief
systems, and replace negative self-statements with positive ones
Behavioral Therapy Extinguish undesirable responses by learning
other adaptive techniques Desensitization-AKA exposure therapy
CARING FOR CLIENTS WITH MOOD DISORDERSCHAPTER 69TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with
Psychobiologic Disorders
MOOD DISORDERS
Affect Nonverbal behavior that communicates feelings
Euthymic Normal moods
Manic Frenzied state of euphoria
Depressed A persistent sad mood
MAJOR DEPRESSION
Reactive (Secondary Depression) Attributed to a situation, usually self-limiting
Major Depression Sad mood with no obvious relationship to events
MAJOR DEPRESSION
Genetics Prevalent among close blood relatives
Neuorotransmitter dysregulation Imbalance of Serotonin, Norepinephrine,
Dopamine Neuroendocrine Imbalance
Changes in hormone levels (Cortisol, Thyroid) Influence of the hypothalamus
MAJOR DEPRESSION
Signs and symptoms Persistent sad mood Physiologic changes Cognitive changes SAD IMAGES
Diagnostic Findings 5-HIAA Blood levels of neurotransmittters Clinical presentation CT, MRI, PET R/O thyroid, brain tumor, etoh/sedative use,
withdrawal, hypoxia, side effects
MAJOR DEPRESSION
Tricyclic antidepressants block reuptake of serotonin and norepinephrine
Monoamine oxidase inhibitors (MAOIs) Block enzyme that breaks down monoamines
Selective Serotonin reuptake inhibitors Block reuptake of serotonin and some
norepinnephrine Serotonin norepinephrine reuptake inhibitors
Block reuptake of serotonin, norepinephrine and reduces sensitivity to glutamate
Atypical antidepressant drugs Buproprion, maprotiline
MAJOR DEPRESSION
Serotonin Syndrome Excessive serotonin in the blood Multiple classes of antidepressants Not enough weaning time Other serotonergic agonists combined with
antidepressant therapies
Treatment Temporarily withhold antidepressants
MAJOR DEPRESSION
Psychotherapy Psychodynamic Cognitive Behavioral
Electroconvulsive Therapy Electric stimulus to one or both temporal regions,
produce brief seizure Vagus Nerve Stimulation Deep Brain Stimulation Transcranial Magnetic Stimulation
SEASONAL AFFECTIVE DISORDER
Pathophysiology, EtiologyPrevalence: Winter months only; States
north of 40 to 50 degrees of latitude Primitive biologic response; Triggered by
photoperiods; Melatonin Assessment Findings: Bimodal depression;
Cycles with the seasonsWinter: Sleepy, fatigued, lethargic; Irritable
Unable to concentrate; Suicidal; Increased craving for carbohydrates; Poor social interaction
SEASONAL AFFECTIVE DISORDER
• Assessment Findings: Spring– Lifting of spirits; Feeling energetic and
motivated; Hyperactive; Euphoria; Remains until late fall
Medical Management Phototherapy: Use of artificial light Move to sunny location
Nursing Management
BIPOLAR DISORDER
Pathophysiology, Etiology: Cycling between depression, euthymia, and euphoriaExtremes in monoamine levels; Genetic
predisposition Assessment Findings: Signs and Symptoms
Depressive phase: Similar to major depression
Manic phase: Hyperactivity; Exaggerated self-importance; Anger; Aggressiveness; Impaired judgment; Reckless behavior; No sleep; Rapid thinking; Racing speech Psychotic features
BIPOLAR DISORDER
Diagnostic FindingsGene mappingHistory
Pattern of emotional ‘highs’ and ‘lows’Family member with bipolar disorderSubstance abuse
BIPOLAR DISORDER
Medical ManagementAnticonvulsants: Enhance GABA action
Carbamazepine (Tegretol)Acute mania; Decreases mood swings among rapid cyclers; Risk for infection
Valproic acid derivatives: Depakote Enhance GABA activity; Used with lithium for long-term management
Unsafe during pregnancy; Side effects- GI symptoms, sedation, and ataxia
BIPOLAR DISORDER
Medical ManagementLithium: Mood equalization; Regulates
activity between neurotransmitters and receptor sitesDisadvantages: Ineffective for some; Time lag; Narrow safety range; Side effectsPeriodic lab tests; Lithium toxicity Maintain adequate ingestion of salts
Nursing Management
CARING FOR CLIENTS WITH EATING DISORDERSCHAPTER 70 TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with
Psychobiologic Disorders
EATING DISORDERS
Normal Eating: In response to hunger; Ceases with satiety
Eating Disorder: Outside range of normal; Accompanied by anxiety, guilt; Result in physiologic imbalances, medical complicationsAnorexia nervosaBulimia nervosaBinge eatingCompulsive overeating
ANOREXIA NERVOSA
Obsession for thinness achieved via self-starvation12 – 18 y.o. females: 1 of 200Males less likely to develop, report
Two TypesSevere restriction of caloric intakeBulimarexia
ANOREXIA NERVOSA
Pathophysiology, Etiology: UnknownNeurotransmitter role; Complications
Assessment Findings: Signs and SymptomsAppear skeleton-like; Significantly less
weight than similar builds; Lanugo; Hypotensive; Irregular bradycardia; Menstruation absence; Wear bulky clothes
Diagnostic Findings: BMI (Healthy: 18.5–24.9)
ANOREXIA NERVOSA
Medical Management: Goal – normal eating patternsNutritional therapy: Nourishing meals;
Supplements; IV fluids, electrolytes; Tube feedings; TPN
Drug therapy: Antidepressants; Antipsychotic; Supplements; Stool softeners
Psychotherapy: Promote compliance with weight gain regimen; Family counseling
Nursing Management
BULIMIA NERVOSA
Minimum of two binges per week, followed with behaviors to prevent weight gain; Lasting at least six monthsBinging then purgingBinging then fasting
Pathophysiology, Etiology: Potential neurotransmitter, neurohormone connectionConsume 3500 – 11,500 calories ≤ 2 hoursComplications
BULIMIA NERVOSA
Assessment Findings: Signs and SymptomsSignificant weight fluctuation; Hoarseness;
Inflammation of esophagus, oral pharnyx; Calluses: Back of hands, fingers; Tooth enamel erosion; Swollen parotid glands
Diagnostics Findings: Clinical findings, history of binging/purging; Radiograph; Blood labs
Medical Management: Drug therapy (antidepressants); Individual and group therapy; Behavior modification
Nursing Management
BINGE EATING DISORDER, COMPULSIVE OVEREATING
Binge Eating Disorder: Inability to control overeating plus guilty feeling; No compensating behaviors to prevent weight gain
Compulsive Overeating: Eating in absence of hunger or full feeling
Pathophysiology, Etiology: Unknown; Potential neurotransmitter, neurohormone connection; Coping mechanism; Complications
Assessment Findings: Overweight; Eat in absence of hunger; Preference for high-sugar, high-fat foods
BINGE EATING DISORDER, COMPULSIVE OVEREATING
Diagnostics Findings: BMI ≥ 30; Elevated blood sugar, cholesterol, serum lipids
Medical ManagementWeight reduction: Reasonable goal of 10%
- 20% weight lossPsychotherapy, self-help support groupsShort-term drug therapy (antidepressants)
Nursing Management
CARING FOR CLIENTS WITH CHEMICAL DEPENDENCECHAPTER 71 TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with
Psychobiologic Disorders