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 (ANC monitoring, weekly at first).

PTSD develops after exposure to a traumatic event and requires symptoms from four clusters, persisting beyond one month: re-experiencing (flashbacks, intrusive memories, nightmares), avoidance (of trauma reminders, places, conversations), negative alterations in mood/cognition (guilt, detachment, distorted blame), and hyperarousal (hypervigilance, exaggerated startle response, sleep disturbance, irritability). Nursing priorities: therapeutic communication without pushing the patient to recount trauma details before they're ready, safety assessment (comorbid depression and suicide risk are common), and avoiding retraumatizing language. Trauma-focused CBT and EMDR (eye movement desensitization and reprocessing) are first-line therapies; SSRIs are the typical first-line medication class. Grounding techniques help during flashbacks or dissociation.

Obsessions are recurrent, intrusive, unwanted thoughts or images that cause significant anxiety. Compulsions are repetitive behaviors or mental acts (checking, washing, counting, ordering) performed to reduce that anxiety — but the relief is only temporary, and performing the compulsion reinforces the cycle, making the obsession more likely to return. Nursing priorities: never abruptly interrupt or forbid a ritual, since doing so spikes the patient's anxiety acutely; allow time for rituals early in the therapeutic relationship while building trust and understanding the pattern, then gradually work toward limit-setting as part of a structured treatment plan. Exposure and response prevention (ERP) — gradually facing the obsession-triggering situation while resisting the compulsion — is the gold-standard therapy. SSRIs, often at higher doses than used for depression, are first-line medication.

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; one must be depressed mood or interest loss): 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, OCPD. 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, significantly low body weight (BMI rates severity only), ego-syntonic (the patient doesn't see their behavior as a problem, which makes engagement in treatment harder). Medical: bradycardia, hypotension, hypothermia, lanugo (fine body hair — thermoregulation), amenorrhea, electrolyte imbalances (K+, Na+, phosphate), osteoporosis. Anorexia carries the highest mortality rate of any psychiatric disorder. Refeeding syndrome: rapid correction → severe hypophosphatemia → cardiac arrest (start nutrition slowly, monitor phosphorus/potassium/magnesium closely). Bulimia Nervosa: recurrent binge-purge cycles, usually normal or above-normal weight, ego-dystonic (the patient knows the behavior is wrong, which often makes them more receptive to intervention than anorexia patients). 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.

Anorexia has the highest mortality rate of any psychiatric illness. Most psychiatric symptoms are ego-dystonic, so patients want them gone. Anorexia is often ego-syntonic: restriction feels like part of who the patient is, so treatment has to work with ambivalence.

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 ANC monitoring (weekly for 6 months, then less often) 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.

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 — ANC monitoring required (weekly at first). 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).

Three presentations: Combined, Predominantly Inattentive, Predominantly Hyperactive-Impulsive. Stimulants (methylphenidate) work paradoxically — increase dopamine/norepinephrine in the prefrontal cortex, IMPROVING focus rather than worsening hyperactivity. Screen cardiac history before starting (rare but serious cardiac event risk). Monitor growth/weight — stimulants can suppress appetite and slow growth in children. Give in the morning to avoid insomnia. Never crush/chew extended-release forms. Contraindicated with MAOIs.

Levels 1-3 describe support needs, not severity judgment — Level 1 "requiring support" through Level 3 "requiring very substantial support." Symptoms present in early development, though may not be fully apparent until later. Nursing priorities: maintain routine/predictability, accommodate sensory sensitivities (lights, textures, sounds), and include elopement/wandering risk in safety planning. No scientific evidence links vaccines (including MMR) to autism. Don't automatically suppress self-soothing repetitive behaviors — they often serve a real regulatory function.

Indications: severe/treatment-resistant depression, bipolar during severe episodes, catatonia, severe schizophrenia. Anticonvulsants are often held or reduced per provider — they raise the seizure threshold. Remove dentures/glasses/hearing aids/hairpins. Continuous VS/EEG/EKG monitoring during; hyperventilate before/after. Used in pregnancy/elderly specifically to avoid psychotropic medication side effects. True adverse events (report these): sustained significant BP rise, prolonged weakness, disorientation well beyond the typical window.

Displacement: redirect emotion to a safer target (yelling at family after a bad work day). Projection: attribute YOUR OWN unacceptable feeling to someone else (an unfaithful partner accuses the other of cheating). Rationalization: logical-sounding excuse that isn't the real reason. Regression: reverting to earlier developmental behavior under stress. Sublimation: redirect an impulse into a constructive activity (mature/adaptive). Mature mechanisms: sublimation, humor, altruism, suppression. Immature: denial, projection, regression, splitting.