Memory tricks for mental health nursing

Always ask directly — research shows asking does NOT increase suicidal ideation. SAL assessment: Specific plan (do they have one?), Access to means (gun, pills, etc. — remove if possible), Lethality (how deadly is the method?). Other risk factors: prior attempts (strongest predictor), male gender, elderly or adolescent, substance use, social isolation, hopelessness, recent loss, chronic illness. Protective factors: reasons for living, social support, religious beliefs, children at home. Interventions: do NOT leave alone, remove harmful objects, therapeutic relationship, no-harm contract (limited value), hospitalization if imminent risk. Safety planning: identify warning signs, coping strategies, support people, crisis numbers.

Therapeutic techniques: Open-ended questions ('Tell me what you're experiencing'), Reflection (mirror feelings back), Silence (therapeutic — allows processing), Clarification ('Help me understand...'), Empathy (not sympathy), Focusing, Summarizing. Non-therapeutic — AVOID: False reassurance ('You'll be fine soon'), Agreeing with delusions ('Yes, the government is after you'), Arguing with hallucinations, 'Why' questions (defensive), Giving advice ('You should...'), Minimizing ('It's not that bad'), Offering personal opinion. With psychosis: acknowledge feelings without validating delusion ('I understand you feel frightened, but I don't hear/see what you do').

Positive symptoms (excess of normal functions): hallucinations (auditory most common — 'voices'), delusions (fixed false beliefs — paranoid most common), disorganized thinking/speech (word salad, loose associations), disorganized behavior, catatonia. Negative symptoms (deficit of normal functions): flat affect, Alogia (poverty of speech), Avolition (lack of motivation), Anhedonia (inability to feel pleasure), social withdrawal — FLAT mnemonic. Antipsychotics: typical (haloperidol/Haldol — EPS side effects, good for positive symptoms), atypical (risperidone, olanzapine, quetiapine, clozapine — fewer EPS, better for negative, but metabolic effects). Clozapine: reserved for treatment-resistant — risk of agranulocytosis (weekly WBC monitoring).

Mild anxiety: increased awareness, can learn, slight tension. Nursing: use for health teaching. Moderate anxiety: narrowed focus, miss details, voice changes. Nursing: simple directions, focus attention. Severe anxiety: greatly reduced field of perception, cannot solve problems. Nursing: stay calm, walk with patient, direct simple commands ('Take a breath'). Panic: completely disorganized, feels like dying (MI-like), terror, possible depersonalization. Nursing: stay with patient (never leave), simple one-step directions, calm tone, quiet environment, medication (benzodiazepine). Never leave a panicking patient alone. Do NOT use long explanations during any anxiety higher than mild.

SIGECAPS (5+ symptoms for 2+ weeks for MDD): Sleep changes (insomnia or hypersomnia), Interest loss (anhedonia), Guilt/worthlessness, Energy loss/fatigue, Concentration impairment, Appetite/weight changes, Psychomotor changes (agitation or retardation), Suicidal ideation. Highest suicide risk: when antidepressants START working (energy returns before mood lifts — now has energy to act on plan). Monitor closely in first 2–4 weeks. Black box warning on SSRIs: increased suicidality in <25 year olds. SSRIs take 2–6 weeks for full effect — educate patient. Electroconvulsive therapy (ECT): effective for severe depression, not as a punishment.

Mania — DIGFAST: Distractibility, Impulsivity/Indiscretion, Grandiosity, Flight of ideas, Activity increased, Sleep decreased, Talkativeness (pressured speech). Hypomania: less severe, no psychosis, no hospitalization needed. Nursing during mania: high-calorie finger foods (too busy to sit for meals), simplify environment (reduce stimulation), matter-of-fact limit-setting on behavior, safety (poor impulse control → risky behaviors), monitor for exhaustion. Lithium: first-line mood stabilizer. Therapeutic 0.6–1.2 mEq/L. Toxicity: fine tremor, GI → coarse tremor, ataxia, seizure. Na+ depletion increases toxicity (dehydration, diuretics, sweating). Maintain adequate Na+ and fluid intake.

Cluster A ('Weird'): Paranoid (distrustful), Schizoid (isolated, no interest in relationships), Schizotypal (magical thinking, odd perceptions). Cluster B ('Wild'): Antisocial (no remorse, manipulative — do not be deceived, set limits consistently), Borderline (unstable relationships, self-harm, splitting — staff consistency essential), Histrionic (attention-seeking, dramatic), Narcissistic (grandiosity, lack empathy). Cluster C ('Worried'): Avoidant, Dependent, OCD. Borderline PD nursing: splitting (seeing staff as all-good or all-bad) — consistent approach by all staff, team communication essential. Self-harm: assess intent, safety plan, do NOT shame or dismiss.

Alcohol withdrawal timeline: 6–24 hrs — anxiety, tremors, diaphoresis. 24–48 hrs — seizures (risk — give benzodiazepines prophylactically). 48–72 hrs — Delirium Tremens (DTs): hallucinations (visual, tactile — 'bugs'), severe confusion, autonomic instability, hyperthermia, FATAL if untreated. CIWA-Ar scale: monitors severity, guides benzo dosing. Treatment: benzodiazepines (lorazepam, chlordiazepoxide), thiamine BEFORE glucose (Wernicke's encephalopathy prevention), hydration, seizure precautions. Opioid withdrawal: NOT life-threatening but very uncomfortable — flu-like symptoms, GI cramping, piloerection, myalgias, anxiety. Methadone or buprenorphine (Suboxone) for management.

Crisis: sudden overwhelming event disrupting equilibrium — person's usual coping mechanisms fail. Duration: acute crisis usually 4–6 weeks. Resolution: person returns to pre-crisis level, may develop new coping, or may deteriorate. NOT long-term therapy. Phases: 1) Assess safety (is there a suicide/homicide risk?), 2) Establish rapport, 3) Identify the problem (focus on precipitating event), 4) Assess coping (what has worked before?), 5) Plan interventions (what can they do NOW?), 6) Follow up. Balancing factors: realistic perception of event, adequate situational support, adequate coping mechanisms. Telephone crisis intervention: stay on line, get location, call emergency services if imminent danger.

Anorexia Nervosa: intense fear of weight gain, distorted body image, BMI <17.5. Medical: bradycardia, hypotension, hypothermia, lanugo (fine body hair — thermoregulation), amenorrhea, electrolyte imbalances (K+, Na+, phosphate), osteoporosis. Refeeding syndrome: rapid correction → severe hypophosphatemia → cardiac arrest (start nutrition slowly). Bulimia Nervosa: recurrent binge-purge cycles, normal or above-normal weight. Signs: dental enamel erosion (acid), parotid gland enlargement, Russell's sign (calluses on knuckles from self-induced vomiting), hypokalemia (most dangerous — cardiac dysrhythmias). Nursing: do NOT make weight the focus of conversation, supervise mealtimes, monitor electrolytes, therapeutic relationship, no shaming.

Voluntary admission: patient signs in, can request discharge at any time (may have 24–72 hr hold if danger). Involuntary commitment: 5150 (California) / 302 (Pennsylvania) / varies by state — criteria: danger to self, danger to others, or gravely disabled. 72-hour hold without hearing. Patient rights RETAINED: right to refuse treatment (except court-ordered), right to communicate, right to least restrictive environment, right to informed consent for procedures. Confidentiality: HIPAA — share only with treatment team. Exception: duty to warn (Tarasoff — if specific threat to specific person, must warn). Capacity vs competence: capacity = clinical (can patient understand?), competence = legal (court determination).

Milieu therapy: the therapeutic community — the entire environment (staff, patients, activities, rules) is the treatment. Principles: safety, structure (predictable schedule reduces anxiety), consistency (all staff respond the same way), community meetings (patient governance, voice), activity therapy (occupational, recreational, art). Admission safety check (contraband): sharps (razors, scissors, nail files), belts, shoelaces, drawstrings, electrical cords, glass containers, alcohol-based products (mouthwash, hand sanitizer — alcohol content), cell phones (privacy of other patients). Observation levels: general, every 15 minutes, every 5 minutes, 1:1 (constant), arm's length. Elopement precautions: patients may attempt to leave — know the facility's procedures.

SOLER is the body language framework for therapeutic presence. HOW you listen is as important as WHAT you say in psychiatric nursing. Avoid: crossed arms (closed off), avoiding eye contact (disinterested), fidgeting (anxious). These nonverbal cues come up repeatedly on NCLEX mental health questions about therapeutic vs non-therapeutic responses.

Lithium has the narrowest therapeutic window in psychiatry. Key teaching: keep sodium intake CONSISTENT — low Na causes more Li reabsorption, raising to toxic range. Avoid NSAIDs and thiazide diuretics. Dehydration is a major toxicity trigger. A fine tremor is normal on lithium; a coarse tremor = toxicity sign. Monitor levels regularly.

EPS from antipsychotics follow a predictable timeline. Dystonia = hours (acute muscle spasm — Benadryl IM). Akathisia = days (can't sit still — propranolol). Pseudoparkinsonism = weeks (tremor, rigidity — Cogentin). Tardive dyskinesia = months/years (lip smacking, tongue thrusting — often irreversible). Clozapine requires weekly CBC for agranulocytosis.

BPD is defined by "splitting" — viewing people as entirely good or entirely bad with rapid switching. A patient may say "you're the only nurse who cares" one shift, then "you're the worst nurse ever" the next. Nursing approach: consistent limits, consistent staff, no special treatment, avoid power struggles. DBT (Dialectical Behavior Therapy) is the gold standard treatment. Never take it personally.

The most tested non-therapeutic responses: "Everything will be fine" (false reassurance — shuts down communication), "Why did you do that?" (judgmental and defensive), "I know how you feel" (cliché), "You should..." (advising — removes autonomy). Instead: reflect feelings, clarify, use open-ended questions, sit with silence. Silence is therapeutic — resist filling it.

The most important SSRI teaching: anxiety may WORSEN in the first 1-2 weeks before improving — this is expected and the patient should not stop. Suicidal ideation risk is highest in first 2 weeks, especially under age 25 — monitor closely. Never stop abruptly — discontinuation syndrome (brain zaps, flu symptoms, irritability). Sexual dysfunction is a common reason patients stop — address it proactively.

Anorexia nervosa has the highest mortality rate of all psychiatric disorders. Signs: BMI below 17.5, lanugo, bradycardia, hypotension, amenorrhea, ego-syntonic (doesn't see problem). Bulimia: usually normal weight, ego-dystonic (knows it's wrong), dental erosion, parotid enlargement, hypokalemia, Russell's sign (knuckle calluses from purging). Refeeding syndrome is the major medical risk in anorexia treatment — monitor electrolytes closely.

IS PATH WARM is the American Association of Suicidology warning sign framework. Most dangerous combination: specific plan + lethal means + stated intent + hopelessness. MYTH: asking about suicide plants the idea — this is FALSE. Direct questioning is clinically required and does not increase risk. Protective factors include: reasons for living, children at home, religious beliefs, social support, access to care.

Typical (1st gen): haloperidol, chlorpromazine — high EPS risk, high tardive dyskinesia risk, effective for positive symptoms. Atypical (2nd gen): olanzapine, risperidone, quetiapine — less EPS, but metabolic syndrome (weight gain, diabetes, hyperlipidemia). Clozapine: most effective overall, last resort due to agranulocytosis risk — weekly CBC required. Monitor all antipsychotics for QTc prolongation.

Benzodiazepines work fast — acute anxiety, panic, alcohol withdrawal. Risk: dependence, respiratory depression. Never stop abruptly — fatal withdrawal. SSRIs are first-line for chronic anxiety and depression — 2-6 week onset. Buspirone: non-addictive, non-sedating — 2-4 week onset — ideal for GAD but cannot be used PRN. Cannot be used for acute anxiety (too slow).