Unit 4- 60 questions4.1 7 QuestionsGrief- natural & normal reaction to loss, & it is part of the human experience. Signs & symptoms of grief: physical distress, preoccupation w/ the image of the deceased, guilt, anger, hostile reactions, & disruptions in normal patterns of conduct.Physical: weakness, numbness, anorexia, feelings of choking, SOB, tightness in chest, dry mouth, GI disturbances. Also fatigue, exhaustion, insomnia, crying are common. Link b/t grief & increased vulnerability to mental & physical illness.

Cognitive: Preoccupation w. the deceased person (conversations w/ deceased). Normal grief, recognizes deceased is not actually present. Difficulty concentrating (sometimes hallucinations), ruminating, fantasizing, confused.

Behavioral: inability to perform even basic activities of daily living, obsessive reflection, reminiscence, sense of isolation, despair, hopelessness, crying, agitated, withdrawn, searching, avoidant.

Affective: sadness, guilt, loneliness, hopelessness, anger (most common).

Existential-disruption of life's certainties & questioning of beliefs.

Kubler-Ross stages:Denial -refusal to believe

Anger- displaced or turned inward

Bargaining- promises made to delay the loss

Depression- full impact is felt

acceptance- resignation, peace, can move on

Hospice philosophy:specialized care that focuses on comfort & quality of life rather than cure.

Spiritual Assessment:the core values that underlie spiritual assessment are belief & meaning based upon the individual's view of life, what is important & gives meaning to life.What beliefs does the person have that give meaning & purpose to life?

What are imp. Symbols that reflect the beliefs?

How does the person's life story reflect or demonstrate these underlying themes?

Do any areas of the person's life story come into conflict w/ these underlying foundational beliefs?

Do any current situations or problems come into direct conflict w/ these beliefs?

Is the person able to consciously communicate these beliefs?

In what ways are these beliefs an unconscious part of the person's worldview?

Therapeutic communication: learned skill that involves both nonverbal & verbal communication. Enhance p/t growth. therapeutic response to grieving personsthis must be a difficult time for you. I would like to sit here w/ you for a while

it's ok to feel anger or any other emotion at this time

most people experience these feelings during a loss

guilt is a common response when a loved one dies. Are you having any other feelings?

if you want to talk about your thoughts & feelings, I am here to listen

Do you have someone who can stay w/ you at home for a while?

Self-reflection:knowing yourself allows you be therapeutic to others. Identifying ones own negative or unresolved issues. Johari window:Open known to self & others

Blind known only to others, unknown to self

Hidden known only to self, unknown to others

Unknown unknown to self or others

4.2 20 questionsNursing process for dementia & deliriumassessment for p/tsEnvironment:

positive & emotional environment free from distractions

maintain eye contact, speak clearly & directly to the p/t in a low tone.

Make sure their hearing aids or glasses are in place & working

Cognitive Assessment tools:

administer test in sections if p/t becomes tired, has short attention span or shows sings of anxiety.

Test p/t alone

MMSE30 questions that assess orientation, registration, attention span, calulation, language recall, & perception.

Scores less than or equal to 24 indicate cognitive impairment.

dementia severity rating scaleassess elderly p/t's ability to function in the home

the Geriatric Depression Scalesimple yes or no ?s

for AD p/ts when able to comprehend the ?s

the Memory Impairment screen4 item test

recommended for p/ts who belong to ethnic minorities b/c it doesn't show education or language bias

& the Mini-Cog. 3 item test for screening of dementia

test of executive functioning, visuospatial, & object recall

Functional Assessment Staging tool (FAST) identify specific stages of dementia.

Neurological Deficits:

amyloid plaques, neurofibrillary tangles, & fibrillary deposits in cerebral vessels.

PALMER:perception & organization, attention span, language, memory, emotional control, & reasoning & judgment (look under each heading pg 376-377)

Emotional Status:mood & state of mind informal assessment each time nurse approaches a p/t

Depression Geriatric Depression Scale

Functional ability

Behavior people w/ dementia manifest their needs & discomfort w/ behaviors.

Physical Manifestations:alteration in nutritional status inability to purchase & prepare food, lack of financial resources to buy food, medical conditions that decrease the older p/t's appetite, or cognitive dysfunction that prevents the p/t from remembering to eat.

Note any w.t changes

family need to monitor p/ts food intake dehydration

aspiration critical risk during stage 3 of AD aspiration pneumonia leads to death.

90-degree angle, keep chin toward the chest when swallowing rather than hyperextending the chin.

Thick liquids easier to swallow, sit 30 min after meal

changes in gait vision problems, neuropathy, general decrease of righting reflex.

Feel p/ts skin for temp.

incontinence in later stages of AD assess for potential environmental constraints (side rails, poor lighting & wheelchair seatbelts)

Physical & lab exams

rule out neoplasia (brain tumors), metabolic disorders, systemic illnesses (hypertension, HIV, polypharmacy)

no lab test exists to confirm AD

test thyroid function, liver function, B12 & folate levels, complete blood cell count, serum blood, blood urea nitrogen & creatinine levels.

MRIs, CT

Nursing dx, outcomes, interventionsNursing dx:risk: for aspiration, imbalanced body temp., infection, injury, powerlessness

Outcomes:maintain health & safety w/ caregiver help

reach & maintain the highest functional level possible within his/her capacity

Nursing interventions:inform all caregivers about the nx care plan

identify the p/ts current functional state, & encourage p/t to use his/her skills

keep all interactions w/ the p/t pleasant, calm, & reassuring

do not ask the p/t to participate in ADLs when he/she is agitated

attempt to understand the p/ts feelings

simplify the verbal message & use no more than 5 or 6 words at a time

break down each task into separate components

repeat the message. Use same words.

Provide p.t w/ opportunity to make simple choices

avoid ?s for which the answer could be no

praise success , facilitate use of the p/ts remaining strengths

Stages of ADstage 1: Mild 2-4 yrs

recent memory loss

cognitive loss in the following areas:communication

calculation

recognition

anxiety & confusion

mild behavior problems, such as the inability to initiate & complete task

Neologisms

loss of interest & spontaneity & personality changes

depression

p/t, family, & caregivers might think it's normal aging

repetition of things, lose things easily, get lost frequently.

Require support & guidance

Stage 2: Moderate 2-10 yrs

symptoms increase

behaviors problems increase:catastrophic reactions- sudden or gradual negative change in behavior caused by the inability to understand & cope w/ environmental stimuli.

Sundowing- irritation or conclusion occurring during the afternoon or evening. R/t to reduced stimulation & routine & tiredness from struggling to interpret the environment during the day.

Perseveration- repetitive verbalizations or motions or persistent repetition of the same idea in response to different questions.

Sleep disturbances- restlessness & wandering

aimless pacing

confusion

incontinence, mild

hypertonia

hallucinates & becomes depressed & argumentative.

Require close supervision

Stage 3: Severe 1-3 yrs

symptoms increase

p/ts cannot use or understand words, unable to recognize themselves or others.

No longer able to care for themselves, total dependence on others

choking

emaciation

progressive gait disturbances that lead to nonambulatory status

total incontinence

immobility pneumonia, UTI, pressure ulcers

loss of ability to swallow aspiration death

caregiver makes all decisions about p/ts medical & social needs

Communication strategies:Simplify the verbal message & use no more than 5 or 6 words at a time. Accompany words w/ visual or tactile clues to decrease confusion & to increase the clarity of the message.

Break down each task into separate components to avoid confusion & frustration.

Repeat the message, if needed, & allow time for the p/t to respond. Use the same words. Do not go on to another message until you are sure that the p/t understands the first one; do not leave & return to explain it in a different way. Using these techniques will avoid or lessen such common behavior problems as catastrophic reactions & sundowning, & they will prevent excess disability.

Meds:acetylcholinesterase (AChE)- responsible for the breakdown of ACh cholinesterase inhibitors (drugs that inhibt the action of AChE) improve symptoms of AD by increasing ACh in the synapses.

Goal improve symptoms & stop the progression of the disease

tacrine (Cognex)1st cholinesterase inhibitor. Rarley used now b/c of its side effect profile, hepatic toxicity, & the need to take 4 doses/daily.

Donepezil (Aricept)well tolerated, requires only 1/daily dosing.

Enhances cholinergic function by the reversible inhibition of the hydrolysis of ACh by AChE

effective when cholinergic neurons are intact overtime degeneration of neurons occurs, & the effect may lessen.

GI side effects

rivastigmine (Exelon)treats mild-moderate AD & PD

inhibits AchE selectively in the cortex & the hippocampus more than in other parts of the brain.

Tablet (2/daily), oral solution (2/daily), patch (effective, fewer SE compared to oral)

advantage for p/ts who do not respond to other anticholinergic drugs or who are in later stages of AD

side effects: nausea, vomiting, dizziness.

Galantamine (Razadyne)newest AChE inhibitor reversible inhibitor of AChE

treats mild-moderate AD

effects nicotinic cholinergic receptors

decreases agitation & increases cognition.

Immediate release form requires 2/daily dosing extended release form allows for 1/daily dosing

memantine (Namenda) moderate-severe ADalkaline agents (antacids) increase levels of memantine

blocks the excitotoxic effects of glutamate while allowing normal gultamate neurotransmission.

Pathological brain changes with AD:accumulation of Amyloid Plaques (senile plaques/neuritic plaques) classic characteristics of AD interfere w/ cell-to-cell communication & result in decreased ACH.

Inflammation- proinflammatory cytokines (signaling proteins secreted by cells) are increased in p/ts' w/ AD.

Increase in neurofibrillary tangles

Lewy bodies & Lewy body disease neuronal cells or lesions w/ colored bodies that are found in the nuclei of the midbrain.

Genetic mutations- 10%-40% of AD cases are genetic

NT deficiencies- cholinergic neurons normally decrease in # as people age, which makes less ACh available > neurons that produce Ach are destroyed early during the course of AD.

Angiopathy & blood-brain barrier incompetence- capillary wall changes are often found in the brains of persons w/ AD.

4.3 20 questions (8 crisis, 12 Violence) :Crisis intervention outcomes: 3 guidelines for outcome criteriaCongruent w/ c/ts needs:needs

values

cultural expectations

Safety:is c/t potentially suicidal or homicidal

how safe is the environment

Reduce anxiety:so inner resources can be used

Interventions: Express caring & consolation. Listen, observe, & encourage the expression of thoughts & feelings.

Assess the realities of the situation, & put tangible threats before those that are perceived & intangible to determine the degree of the crisis & the types of interventions necessary.

Develop & begin to use an immediate plan for intervention that is based on the comprehensive, crisis-focused nursing assessment & the crisis intervention model that best fits the p/ts needs & the type of crisis situation.

Coordinate w/ other agencies. This approach is essential, during large scale disasters w/ tangible threats such as fires, earthquakes, wars, & acts of terror. Be familiar w/ resources that offer support w. basic needs such as foods, clothing, shelter, & financial support. Have referral info & crisis hotline telephone #s available.

Anticipate future needs r/t to crisis, & develop a plan w/ the p/t for meeting these needs.

Barriers to interventions:secondary gain crisis-focused assessment provides clues to this issue

failure to learn from from experience learned helplessness

Existing mental disorders cognitive impairment

therapist-patient boundary problems overidentification/countertransference

sociocultural considerations lack of resources, health insurance

Assessment:First assess for suicidal or homicidal ideations or gestures

Box 21-2 pg 490

Types of crisis:External (situational) crisis: loss of a job, death of a loved one, change in financial status, divorce, eviction or foreclosure.

Internal (subjective) crisis: response to aging, loss, abandonment, or a breach of loyalty that results in profound feelings of betrayal, fear or victimization. Also result from a threat to a deeply held belief or value, thereby triggering spiritual distress or a loss of faith.

Phase-of-life (maturational) crisis: midlife crisis, child leaves home for first time for college or military, reduced memory, loss of strength.

Disasters (adventitious) crisis: precipitated by a disaster that is not part of everyday life. Natural disasters (earthquakes)

national or global disasters (war)

crimes of violence (rape)

Primary/Secondary/Tertiary interventions:Primary:promote mental health & reduce mental illness

Secondary:prevent prolonged anxiety from diminishing personal effectiveness

personality organization

Tertiary:provide support tofacilitate optimal levels of functioning

prevent further emotional disruptions

Myths Battered Women: online not in the bookWomen provoke battering or are masochistic

once a battered woman, always a battered woman

battered woman can always leave

Assessment/dx/interv. w/ elder, women, child abuseWomen:anxious, frightened

depressed, passive

ashamed, embarrassed

poor eye contact

wt problems

looks to partner for answers

partner smothering, possessive

We often see women who have been hurt by their partners. Is your partner responsible for your injuries?

Has your partner ever hurt you?

Have you noticed any pattern to this behavior, such as increase in frequency & severity?

Does he threaten to use or has he ever used a weapon to hurt you?

Children:holistic approach

get as much info as possible w/o subjecting the child to unnecessary & repeated probing & questioning

complete physical exam if suspicious of child abuse

disheveled, malnourished

failure to thrive

fearful, watchful

asses relationship b/t child & caregiver

Do you know why you have come to see me?

What have you been told?

What kinds of games do you & (alleged abuser's name) play when your mom isn't around?

Are there any games that you & (alleged abuser's name) play that you don't like?

Elderly: poor eye contact

anxious, fearful, passive

looks to caregivers for answers

poor hygiene

underweight, malnourished, dehydrated

physical needs not met

untreated medical conditions

Are you happy living w/ (the name of the suspected abuser)?

Please tell me about your financial assets & how they are managed?

Whom do you turn to when you are feeling down?

How are family disagreements handled in your household?

Has anyone ever hurt you or touched you when you didn't want to be touched?

nursing dxrisk: for self-directed & other-directed violence, injury

anxiety, fear, disabled family coping, powerlessness, caregiver role strain

outcome measuresevidence that the victim is no longer hurt or exploited

evidence that physical abuse has stopped

evidence that emotional abuse has stopped

nursing interventions & planRemind victims no one deserves abuser

know how to identify the partner's increasing levels of abuse leading to violence

identify supports including: family, friends, neighbors, local shelters, counselor, & others

memorize the address & phone # to police & the local abuse shelter

if they are afraid the abuser will approach them at work, notify the employer, as they may have a protocol for violence

during a violent episode try to get a confined room if possible w/ a phone

ask a trusted neighbor to call the police if they hear the sounds of violence

Cycle of Violence:Phase 1 (tension building):major battering usually does not occur. Perpetrator establishes complete control usually by inflection of emotional abuse.

Phase 2 (Acute battering):tension can no longer be contained & acute battering occurs

Phase 3 (Honeymoon stage):Perpetrator begs for forgiveness, promises never to do it again. Appears to have remorse, then tension starts to build and cycle is repeated.

Safety Plan:survival kitdrivers license & ID for self & children such as birth certificates & SS cards

house & car keys if they do not have a car, plan a way to get to a police station or public shelter

insurance papers & other imp. Documents

cash & checkbook or credit cards

medical records

children's school records & books

meds

extra clothing

custody papers

imp. Personal items such as a fav. Toy or keepsake

a non-traceable (no GPS) cell phone

4.4 13 QuestionsAssess/dx/interventions w/ anorexia & bulimiaall ED:low self-esteem

compliance & conflict avoidance

sense of ineffectiveness Alexithymia (difficulty naming & expressing emotions) Interoceptive deficits (inability to accurately identify & respond to bodily cues)

Anorexia Nervosa:perfectionism

rigidity

risk & harm avoidance

Bulimia Nervosa: Alexithymia impulsivity

emotional dysregulation- oversensitivity to & difficulty w/ modulating emotions & behavior

nursing dximbalanced nutrition

risk for injury

decreased cardiac output

chronic low self-esteem

disturbed body image

risk for imbalanced fluid volume

anorexia nervosa:anxiety, disturbed body image, nutrition imbalance: less than body req., social isolation

bulimia nervosa:ineffective coping, deficient fluid volume, chronic low self-esteem.

outcome criteria:anorexia nervosa:participate in therapeutic contact w/ staff

consume adequate calories for his/her age, ht, & metabolic needs

achieve a minimum normal w.t

maintain normal fluid & electrolyte levels

resume a normal menstrual cycle

demonstrate improvement in body image w/ a more realistic view of body shape & size

demonstrate more effective coping skills to deal w/ conflicts

manage family conflicts more effectively

verbalize awareness of underlying psychologic issues

achieve ideal body w.t

Bulimia nervosa:participate in therapeutic contact w/ staff

consume adequate calories for his/her age

cease binge/purge episodes while in the inp/t setting & cease dieting

perceive body shape & w.t as normal & acceptable

interventionsprovide safe, non-threatening environment

assess for risk of suicide

restore a minimum w.t & nutrition balance through a behavioral program

encourage the c/ts to express thoughts, feelings , & concerns about body & body image

assist the c/t to increase understanding of body image distortion

Anorexia Nervosa:under supervision, re-feed, re-introduce health food plan

discuss need for food supplements (may include nasogastric feedings)

provide support w/ the above interventions

Bulimia Nervosa:w/ supervision, eat meals provided by dietician

avoid purging by maintaining 1:1 nursing supervision post-meals

create a structured, supportive environment w/ clear, consistent, & firm limits

coordinate w/ dietician to construct a behavioral plan w/ specific w.t gain goals of approx. 3lbs/week, specific eating foals of consuming 90-100% of meals.

Communication techniques:sensitivity, thoroughness, sharp observation skills. Refeeding:close medical & nursing monitoring neededrefeeding w/ meals, supplements, nasogastric tube

w.t gain of 3lbs/week is safe

self starvation results in energy conserving metabolic changes, which shift quickly during refeeding process & is at risk for refeeding syndrome

Procedure for severely malnourished (15% below ideal w.t)not eating 90% of meals on day 1 receives dietary receives 3 dietary supplements on day 2

supplements continue daily until p/t eats 100% of their meal

if supplements are not finished on day 2 tube feeding will be started on day 3

tube feeding continues until 100% of all meals are eaten for 1 day

if p/t refuses tube feeding she will be discharged

Assess for edema, CHF, hypophosphatemia, & other serious electrolyte imbalance

Previous Modules 40 questions1.3 2 rightsrights of c/tsright to vote, manage financial matters, enter into contractual relationships, assert the constitutional right to seek the advice of an attorney. Rights to send & receive unopened mail, wear one's rights to owns clothes, receive visitors, keep & use personal possessions, & access to telephone.

Rights to be informed about potential risks, benefits, reasonable alternatives before giving consent to any therapy, surgery or treatment, including meds.

Right to treatmentright to privacy & dignity, right to the least restrictive treatment & individual treatment plans.

Cannot keep an individual in a mental hospital w/ treatment

cannot detain individuals who are not dangerous w/ providing some mode of treatment

Right to refuse treatmentvoluntary & involuntary p/ts have the right to refuse meds

during emergency situations, if there is potential danger, p/ts can be forcibly medicated. In the case of involuntary p/t, as long a nurses follow due process guidelines as established & the administration complies w/ accepted professional judgment, meds can be given.

The right to refuse treatment is upheld if the p/t is involuntary & competent. Judge rules if incompetent.

2.1 4 questions alternative therapies, stress response, defense mechanisms, cognitive therapyencompasses a broad range of healing philosophies, approaches, therapies & their accompanying theories & beliefs.

More than 1800 approaches to healing in this field

NCCAM classified this into 7 broad categories alternative medicine systemstraditional Chinese medicine, including acupuncture

folk medicine

naturopathy

mind-body interventionsmediation

prayer

yoga

humor

exercise

hypnosis

pharmacologic & biologic-based therapiesvaccines & medicines not yet approved by mainstream medicine (animal cartilage, chelating chemicals)

herbal medicationsChinese herbals

American herbals

European herbals

diet, nutrition, supplements, & lifestyle changesvitamins, minerals , supplements

vegetarian diets

ethnic-based diets

manipulative & body-based methodschiropractic

acupressure

therapeutic touch

energy therapiesbiofeedback

light therapy

bone-growth stimulation

Stress Response:discuss the general adaptation syndrome according to Selyestress- both as a response to noxious or stressful stimuli & as a stimulus that produces biologic, emotional, & psychologic responses.

Distress (negative)- subjective response to internal or external stimuli that are threatening or perceived as threatening to the self. Includes fatigue, pain, fear, and acute/chronic disease.

Eustress (positive)- nonspecific stress response that is associated w/ desirable events. Ex. Wedding, job promotion, birth etc.

Psychologic stress- all processes, internal or external, that demand a cognitive appraisal of the event before a response or the activation of any other system.

General adaptation syndrome- three stages of the individuals innate behavioral responses to any stress stimulus.

A brief alarm-fight-or-fight stage, which alerts the individual to the presence of stressful stimuli.

Reciprocal reaction b/t the autonomic nervous system, endocrine, and the immune system

release of hormone epinephrine from the sympathetic branch of the autonomic nervous systemplaces the person on alert

activation of the hypothalamic-pituitary-adernal axisresults in the release of cortisol

elevation of bp; tachycardia; constriction of blood vessels and the diversion of blood from nonessential organs to the heart, brain, & skeletal muscles; increased blood sugar; dilated pupils; increased muscle tone; increased alertness; and free-floating anxiety

fight or flight response

Resistance- body stabilizes & returns to normal homeostasis.

Stabilization

Hormonal levels return to normal

Parasympathetic nervous system activity

Adaptation to stressors

If the body does not adapt and the stressor continues to be prominent the individual enters the 3rd stage

3. Exhaustion- all the individual's resources are used & the individual is unable to adapt to the stressor.Body becomes exhausted & Is unable to sustain the necessary changes that are activated during the alarm stage.

Can manifest itself in the form of illness such as infections, headaches, hypertension, asthma attacks, chronic fatigue syndrome, depression, anxiety disorders, & many other chronic conditions

increased physiological response as noted in the alarm reaction

decreased energy levels

decreased physiological adaptation

death

general inhibition syndrome (possum response)- person freezes or shuts down & is unable to respond in any manner. Result of over-stimulation of the parasympathetic nervous system, & it is activated automatically as a means of survival that has a paralyzing or numbing effect when a person is facing a life-threatening event

Defense Mechanisms:coping- use of resourcefulness & the ability to manage the stress of daily circumstances

conscious/unconscious adaptive/maladaptive conscious mechanisms are sometimes learned unconscious mechanisms are often referred to as protective ego defenses

adaptive conscious mechanisms-distractions such as reading, praying, meditating, using relaxation techniques, & seeking social support.

Maladaptive conscious mechanisms- withdrawing from social contacts, changes in dietary habits, smoking, drug & alcohol abuse, participating in other unhealthy behaviors & sudden outbursts of anger.

Unconscious ego defense mechanisms- repression, denial, rationalization, & regression. Often prevent the individual from realistically appraising himself/herself, other people, or situations.

The goal is to use strategies that minimize unnecessary sources of stress & to promote effective adaptive responses.

People use these responses to protect their integrity. A response is often a temporary measure until the immediate crisis is resolved or until the person is able to control the situation.

Cognitive therapy:Help p/ts to reinterpret the meaning of body sensations. Used to treat p/ts w/ somatoform disorders & dissociate disorders. P/ts ability to understand that physical symptoms are a response to thoughts or feelings that occur in daily life.

2.2 7 questions Application of the nursing process w/ the anxiety disorders & communication techniquesit is important for all nurses to identify dysfunctional manifestations of anxiety so that treatment can be implemented promptly.

Nurses are the first HCP to come in contact with p/t's who are experiencing their first symptoms of panic disorders.

The p/t w/ agoraphobia sometimes comes to the attention of a nurse when the nurse is preparing a p/t for diagnostic testing that includes a CT or MRI.

Most often p/ts w/ anxiety symptoms do not present w/ anxiety as their primary reason for seeking treatment.

Nurses who use an assessment tool that addresses each identified human response pattern will obtain cues from the p/t who is experiencing anxiety that indicate further assessment.

thoroughly assess each p/t w/o considering the possibility that the p/t is feigning the physical symptoms.

Understand the possible anxiety precipitants of the somatic concerns will help the p/t to reduce his/her focus on the physical sensations.

Diagnosis nurse relies on info that is obtained during the assessment process.

Nurse identifies defining characteristics of the target dx from the p/t & together the nurse & p/t jointly identify etiologic factors.

Etiologic factors influence the selection of the appropriate interventions.

Risk for suicide; anxiety; death anxiety; hopelessness: chronic pain (191+211)

Outcome Identificationsomatization disorder: p/t will construct an exercise program that includes anxiety reducing techniques

address 2 positive somatic responses (e.g, massage therapy, the satisfied feeling after a successful exercise session.)

keep a journal to document somatic preoccupation & stressors, including intrusive thoughts & concerns

help the therapist to coordinate the info from the primary care provider & any other involved specialists.

Take meds as prescribed & be able to identify the rationales for the meds

contact the therapist for more frequent visits if somatization increases.

Dissociative identity disorder: p/t willalert the therapist or use a hotline such as or 1-800-273-TALK when feeling suicidal

respond to his/her name when addressed by a member of the treatment team

refer to himself/herself in the first-person pronoun form (e.g., I think)

identify periods of increasing anxiety

inform others about dissatisfaction in a nonthreatening manner

use assertive-response behaviors to meet his/her needs

keep a written journal to identify stressors & when the dissociation occurs.

Generalized anxiety disorder: p/t willdemonstrate a significant decrease in physiologic, cognitive behavioral, & emotional symptoms of anxiety.

Demonstrate the use of mindfulness meditation when experiencing symptoms of heightened anxiety (concentrate on body; pay attention to the act of breathing; observe the act of breathing; meditation discourages, p/t agrees to deal w/ the subject of the intrusive thought at a later time; p/t feels in control of his/her body)

OCD: p/t willparticipate actively in learned strategies to manage anxiety & to decrease OCD behaviors.

Demonstrate the ability to cope effectively when thoughts or rituals are interrupted.

PSTD: p/t willdemonstrate concern for personal safety by beginning to verbalize worries.

Assume a decision making role for his/her own health care needs

Planningcomplex & varied

p/ts w/ severe BBD often require hospitalization to prevent a suicidal occurrence.

Treated in an outpatient setting, often w/ the use of different modalities, including individual psychotherapy, group therapy, family therapy, art therapy.

Nurses provide p/ts & families w/ information about treatment alternatives, & they also provide comprehensive discharge planning.

Implementation (interventions)identify the degree of suicidal ideation & depression in p/ts w/ all types of anxiety & associated disorders.

Monitor your own level of anxiety, & make a conscious effort to remain calm. Anxiety is readily transferable from one person to another. Individuals w/ somatoform illnesses have high risk.

Recognize that the p/ts use of relief behaviors focuses on somatic sensations as indicators of anxiety

more on pg 213

anxiety-reducing strategies include progressive relaxation techniques; mindfulness mediation; slow deep- breathing exercises; focusing on a single object in the room; listening to soothing music or relaxation tapes; visual imagery or nature r/t DVDs; exercise

Evaluationif p/t does not make satisfactory progress, the nurse modifies either the expected outcomes or the interventions.

Examines all factors that relate to the outcomes.

Somatoform disorders & the dissociative disorders are chronic & enduring. It takes patience & support for the p/t to determine the pattern of his/her behavior & to incorporate methods to initiate change.

2.3 2 Questions Sleep assessment, sleep disordersSleep assessment:Obtain both subjective data from the affected individual & his/her bed partner

obtain comprehensive, objective and quantifiable data

Assess # of hrs of sleep per night

Time of day/night that the p/t goes to bed or falls asleep

any recent changes in established sleep patterns & routinesif changes reportedassess inhibiting/enhancing factors

regularityregular/irregular

night time awakenings (describe)

napping (describe)

use of sleep aids or substances that disrupt sleep (e.g, stimulants, antidepressants, sleep meds, alcohol)

present stressors & those from recent or remote past

objective data from the bed partner (e.g, snoring, apneic periods) or from parents (e.g, sleepwalking, nightmares)

Sleep disorders:

Primary sleep disorders (biologic disturbances) Dyssomnias- occur as a result of abnormalities of the physiologic mechanisms that regulate sleep and wakefulness. Abnormalities in amount, quality, or timing of sleep. Insomnia- difficulty initiating or maintaining sleep or of experiencing nonresotrative sleep for a least 1 month.

Narcolepsy- sudden onset of brief sleep attacks that last 10-20 min. & typically take place 2-6x/day. They fall asleep while engaging in meaningful activities such as driving a car, eating, or interacting w/ people. Not common in children; generally initially recognized during puberty/adolescence.Cataplexy- a common sign of Narcolepsy. Sudden loss of muscle tone & voluntary muscle movement. Strong emotional experiences such as laughing or crying may cause this reaction.

Sleep paralysis- also reported in people w/ narcolepsy. Not able to speak or move just before the onset of or upon awakening from a brief sleep attack. Some report hallucinations & experience vivid sensory perceptual experiences either upon wakening (hypnopompic hallucinations) or when entering the brief sleep episode (hypnagogic hallucinations).

Breathing-related sleep disorders-result from a sleep-related breathing condition such as obstructive or central sleep apnea syndrome or central alveolar hypoventilationobstructive sleep apnea- typically have some degree of narrowing or the complete obstruction of the upper airway. Results in loud snoring and regular apneic periods during sleep that last for 10-30 sec. (sleep apnea- absence of breathing)

Risk factor obesity & large neck circumference

Circadian Rhythm sleep disorder- sleep pattern disturbances w/ a persistent or recurrent pattern of sleep disruption that result from a difference in an imposed sleep wake cycle & the individual's own circadian sleep-wake pattern requirements. Result from a delayed sleep phase, jet lag, shift work, or an unspecified source.

Parasomnias- occur as a result of the activation of physiologic systems at incorrect times during the sleep wake cycle, thereby resulting in abnormal behavior or physiologic events during the sleep state. Abnormal behavior or events occurring in association w/ sleep. More common among children. Nightmare disorder takes place during the REM period late in the sleep cycle. Fragmented sleep

frighting dreams that threaten their survival, security, or self-esteem.

Able to recall the nightmares in vivid details

Sleep terror disorder- experience of arousal during NREM sleep.Awakening during the early part of the night due to extreme anxiety or panic.

Crying, screaming, and may appear disoriented

unable to recall the event

Sleepwalking disorder- (somnambulism)engagement in walking, dressing, toileting, and driving while they are in a deep NREM stage of sleep.

Appears to be in a trance, and arousal is difficult.

Sometimes they wake up while performing complex tasks, but most frequently returns to sleep.

Unable to recall events that took place during the sleepwalking episode

Parasomnia not otherwise specified / due to General Medical Condition or substance use

Secondary sleep disorders (often result from a variety of psychiatric illness or medical conditions) mood disorders

effects of substances- alcohol, stimulants (caffeine), amphetamines, cocaine, sedatives (opiates, hypnotics & antianxiety meds)

general medical conditions (endocrine)

2.4 10 questions Mood disorders assessment/outcomes/interventions, communication techniques, risk for suicide, medsAssessment:nurses must maintain awareness of their own personal reactions to the p/t & the ways in which these reactions affect the nurse-p/t relationship & subsequent care.

Mental status criteriaMood: the internal manifestation of a subjective feeling state

Affect: the external expression or manifestation of a feeling state

Temperament: observable differences in the intensity & duration of arousal & emotionality

Emotion: The experience of a feeling state

Emotional reactivity: tendency to respond to internal or external events w/ emotion

Emotional regulation: ability to control or modify the occurrence & intensity of feelings

Range of affect: the span of emotional expression experienced & displayed by an individual

Outcomes:p/t will remain safe & free from harm

verbalize suicidal ideations & commit to a contact to not harm himself or herself or others

verbalize absence of suicidal or homicidal intent or plans

express the desire to live & not to harm others

report increased feelings of self-worth & confidence

more on pg 239

Interventions:Interventions cover a wide range of biopsychosocial areas, w/ consideration of the effects of depression & mania on the physiologic, cognitive, psychologic, behavioral, & social domains.

Interventions require nurse to maintain self-awareness & boundaries regarding their own reactions to p/ts b/c p/t depression, irritability, anger, negativity, euphoria, & hyperactivity can readily influence nursing responses.

Be consistent, caring, concerned, empathetic, & genuine.

A knowledgeable, non demanding, & matter-of-fact approach is reassuring to p/ts & promotes their confidence in the nurse.

Risk for suicide:Be alert to suicidal ideation & intent among p/ts w/ depression & p/ts w/ mania who are cycling into depression or whose insight & judgment are impaired. A high risk time is 1-6 weeks after the initiation of antidepressant therapy, before therapeutic levels are reached.

Meds:TricyclicClassification: Tricyclic antidepressants (TCAs) are a class of antidepressant medications that share a similar chemical structure and biological effects.

Action: Tricyclic antidepressants increase levels of norepinephrine and serotonin, two neurotransmitters, and block the action of acetylcholine, another neurotransmitter.

Side effects: blurred vision, dry mouth, constipation, weight gain or loss, low blood pressure on standing, rash, hives, and, increased heart rate.

Use w/ MAOIs may increase risk of neuroleptic malignant syndrome, seizures. Hypertensive crisis, & hyperpyrexia

use w. oral anticoagulants can result in bleeding. Use w/ clonidine can cause severe hypertension

herbal considerations: St. John's wort & SAM-e may increase the p/ts risk for serotonin syndrome.

Monoamine:Antidepressants such as MAOIs ease depression by affecting chemical messengers (neurotransmitters) used to communicate between brain cells. Like most antidepressants, MAOIs work by changing the levels of one or more of these naturally occurring brain chemicals.

An enzyme called monoamine oxidase is involved in removing the neurotransmitters norepinephrine, serotonin and dopamine from the brain. MAOIs prevent this from happening, which makes more of these brain chemicals available. This is thought to boost mood by improving brain cell communication.

The most common side effects of MAOIs include: Dry mouth, Nausea, diarrhea or constipation, Headache, Drowsiness, Insomnia, Skin reaction at the patch site, Dizziness or light headedness

Avoid caffeine, chocolate, & all tyramine-containing foods ( aged cheese) within several hrs of ingestion of MAOIs b/c the combination may cause sudden & severe hypertension or hypertensive crisis

Third line agents after SSRIs & TCAs have been tried

signs of toxicity include increased headaches & palpitations

MAOIs should not be taken within 14 days of taking SSRIs

herbal considerations: parsley & St. John's wort pose some risk for serotonin syndrome

SSRIsSSRIs block the reabsorption (reuptake) of the neurotransmitter serotonin in the brain.

SSRIs are called selective because they seem to primarily affect serotonin, not other neurotransmitters.

Side effects of SSRIs may include, among others: Nausea, Nervousness, agitation or restlessness, Dizziness, Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction), Drowsiness, Insomnia, Weight gain or loss, Headache, Dry mouth, Vomiting, Diarrhea

first-line antidepressant therapy

may cause fatal reactions w/ MAOIs by causing serotonin syndrome, hypertensive crisis, rigidity, & neuroleptic malignant syndrome

serotonin syndrome- occur when medicines that are used to treat migraine headaches (5-hydroxytryptamine receptor agonists, & medicines that are used to treat depression SSRIs & serotonin-norepinephrine reuptake inhibitors (SNRIs) which are medicines from different classes) are used together

episodes of self-harm & potential suicidal behavior are reportedly higher in p/ts who are younger than 18.

use w/ caffeine increases agitation; use w/ alcohol increases sedation. Effectiveness is decreased w/ cigarette smoking.

Should not be taken w/ lithium

herbal considerations: st. John's wort & SAM-e may cause serotonin syndrome. Use w/ ascorbic acid (grapefruit juice) may alter the elimination of the drug & it's plasma concentration.

SNRIsSNRIs block the absorption (reuptake) of the neurotransmitters serotonin and norepinephrine in the brain.

The most common side effects of SNRIs include: Nausea, Dry mouth, Dizziness, Excessive sweating

indicated for social anxiety disorder & general anxiety disorder

Venlafaxine is not approved for indications in children & adolescents b/c of the lack of efficacy & concerns about increased hostility & suicidal ideation.

Mood stabilizers including lithiumMood stabilizers balance certain brain chemicals (neurotransmitters) that control emotional states and behavior.

effective for the treatment of mania in p/ts w/ bipolar disorders.

Most widely used is lithium

lithium acts as a salt within the body, & its blood levels are closely linked to the p/ts hydration & sodium intake.

Side effects of lithium: neuromuscular &CNS effects (tremor, forgetfulness, slowed cognition), gastrointestinal effects (nausea, diarrhea), weight gain, hypothyroidism & renal effects (polyuria).

blood levels of 0.6 mEq/L to 1 mEq/L more than 1.5 is toxic

lithium excreted through the kidneys, nurses need to use caution w/ p/ts w/ renal disease.

Herbal considerations: dandelion, goldenrod, juniper, & parsley increase lithium's effects & toxicity

Monitor p/t's sodium intake, b/c significant changes will alter lithium excretion. Black & green tea, coffee, cola nut, guarana, plantains, & yerba mate may all decrease lithium levels.

Anticonvulsantsdivided into 3 classes (first, second, & third generation) indicated for manic symptoms

Anticonvulsants work by calming hyperactivity in the brain in various ways. For this reason, some of these drugs are used to treat epilepsy, prevent migraines, and treat other brain disorders.

They are often prescribed for people who have rapid cycling four or more episodes of mania and depression in a year.

Anticoagulants used to treat bipolar disorder include: Depakote, Depakene (divalproex sodium, valproic acid, or valproate sodium), Lamictal (lamotrigine) , Tegretol (carbamazepine)

Common side effects include: Dizziness, Drowsiness, Fatigue, Nausea, Tremor, Rash, Weight gain.

Used in place of lithium

abrupt withdrawal may cause seizures

labs=liver function, CBC w/ diff.

AntipsychoticAntipsychotics are thought to work by altering the effect of certain chemicals in the brain, called dopamine, serotonin, noradrenaline and acetylcholine.

atypical antipsychotics. These are sometimes called second-generation antipsychotics and include: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole.

typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and include: chlorpromazine, flupentixol, haloperidol, levomepromazine, pericyazine, perphenazine, pimozide, sulpiride, trifluoperazine, and zuclopenthixol.

side-effects include: Dry mouth, blurred vision, flushing and constipation

Immediate treatment of psychotic behavior necessary to prevent exhaustion & infection due to body working too hard. W/o treatment cardiac collapse can occur.

3.1 10 Questions Meds, outcomes/interventions, prodormal s/s, priority assessmentProdromal: 1 month to 1 year before dx/S&S of this phase includemood symptoms (anxiety, irritability, dysphoria, anguish)

cognitive symptoms (distractibility, concentration, difficulties, disorganized thinking)

obsessive behaviors

social withdrawal & role functioning deterioration

sleep disturbances

attenuated (weaker) positive symptoms (illusions, ideas of reference, magical thinking, superstitiousness)

Priority assessment:subjective & objective plus secondary sources,

biological indicators

what p/t says in the interview p/ts w/ psychotic disorders have impaired processing of perceptual info.

Listen attentively to p/t & complete a physical exam

vital signs & nutrition, exercise, sleep patterns

schizophrenia metabolic syndrome ( cluster of findings that include increased visceral adiposity, measure by circumference, hyperglcemia, hypertension, dyslipidemia) PHATS

disturbances in perception, thought, feelings & behavior imp. Categories for p/ts w/ shizophrenia

Outcomes/Interventions:demonstrate an absence of suicidal behaviors or violent behaviors towards others

demonstrate absence of self-mutilating behaviors

demonstrate a significant reduction in hallucinations & delusions

demonstrate realty-based thinking & behaviors

more on pg 281

Interventions:supplement the individuals ADL & instrumental activities of daily living

manage the environment

provide protection of the p/t, others, family members, & significant others

encourage self-management & manage relapse

Meds:typical/conventional antipsychotic/1st generationwork by blocking the D2 dopamine receptors in the limbic region of the brain

Phenothiazines: Chlorpromazine (Thorazine) (first drug to treat psychosis in the 50s), Thioridazine (Mellaril), Trifluoperazine (stelazine) & Fluphenazine (Prolixin)most effective for treating positive psychotic symptoms only

has many side effects which causes clients to stop taking them

blocks dopamine in the motor centers (Extrapyramidal Nerve tract) causes movement disorders or EPSincluding Tardive dyskinesia (a neurologic syndrome that consists of abnormal, involuntary, irregular choreoathetoid movements of the muscles, the head, the limbs and trunk)

choreoathetosis is the occurrence of involuntary movements in a combination of chorea (irregular migrating contractions) & athetosis (twisting & writhing)-manifested by tongue protrusion, puffing of the cheeks, chewing or puckering of the mouth-occurs rarely, but may be irreversible

AIM scale (autonomic involuntary movement scale)- performed not less than every 6 months when a p/t is taking either typical or aytypical antipsychotics

then came Butyrophenons: Haloperidol (haldol)

others: Thiothixene (Navane)

Extrapyramidal symptoms: serious reactions that appear r/t to high dose of neuroleptic medsAkathisia- subjective feeling of muscular discomfort that causes the p/t to become agitated, pace, alternately sit & stand & feel a lack of control

Parkinsonian- muscle stiffness, cogwheel, rigidity, shuffling gate, perioral tremor, hypersalvation, & mask like expression

acute dystonias-spasmodic movements caused by slow, sustained, involuntary muscle contractions such as:torticollis (abnormal, asymmetrical head or neck position)

opisthotonos ( body is rigid & arches the back, w/ the head thrown backward)

oculogyric crisis ( prolonged involuntary upward deviation of the eyes)

EPS can involve the neck, jaw, tongue or entire body

Drugs of treatment:Antiparkinson drug Benztropine (cogentin), trihexyphenidyl (Artane)

Acute emergencies Acute dystonic reactions, NMS (neuroleptic malignant syndrome)

Tardive dyskinesia life-threatening irreversible sweating, fever, unstable bp, stupor, muscle rigidity, autonomic dysfunction, elevated CPK, excessive salvation, occurs in 1% but 10% die

other side effects of typicals:anticholinergic (dry mouth, blurred vision, urinary retention, nasal congestion, constipation, ejaculatory inhibition)

sedation (most common during early stage of treatment, need to avoid alcohol, antihistamines, & sleeping aids)

postural hypotension

arrhythmias, palpitations, & prolonged QT intervals

lowered seizure threshold

weight gain increased risk for type II diabetes

photosensitivity & skin changes

poikilothermia loss of ability to regulate internal body temp. watch older adults in hot weather

galactorrhea & gynecomastia breast enlargement or tenderness

cholestatic jaundice

Atypicals- Clozoril (clozapine) was the first in the 90s1st to effectively treat both + & - symptoms of schziophrenia

not used as a first resort due to risk for agranulocytosis ( bone marrow does not make enough of a certain type of mature white blood cells (neutrophils)- regular & frequent serum lab testing required

used for refractory schizophrenia

other atypicals:Seroquel (quetiapine)

Risperdal (risperidone)

Geodone (ziprasidone) problem prolonged QT interval

Zyprexa (olanzapine) similar to clozapine w/o the risks of agranulocytosis, does have high risk for seizures- common side effect is gain weight

both serotonin + dopamine antagonists

work on + & - symptoms

fewer EPS side effects, but there still may be

less risk for tardive dyskinesia

cost more

elderly w/ dementia r/t to psychosis increased risk for death when taking these medsblack box warning contraindicated

mostly death r/t to cardiac failure/sudden death or infection (pneumonia)

3.2 3 Questions Family reactions, recovery, interventionsInterventions:nurse focuses on treating & supporting the p/t through the drug withdrawal process detoxification. Focus on education during stages of recovery.

FYI : cross-tolerance used to prevent withdrawal effects of drugs or alcohol. Ex. Ativan has a cross-tolerance w/ alcohol b/c both affect the GABA receptors in the brain. It is used & gradually decreased to manage withdrawal symptoms.

Family Reactions:I have no clue, I hate this class. Recovery:psychotherapy active involvement in a recovery program in addition to participating in individual or group therapies.

Addresses p/t's addiction as well as any comorbid disorders or life threatening behaviors.

Relapse prevention help p/ts avoid or take control of situations in which relapse is possible.

Practices what to do if relapse occurs & develops a comprehensive plan to follow.

Harm reductiontechniques that help a person to change patterns of use to decrease the risk of harm & to adapt to a healthier life-style.

Opiate replacements, needle-exchange programs

residential, half way houseprovide living situations for c/ts who will need to totally reshape their lives, friends, social network, reconnect w/ family & friends.

Outpatient careteach the p/t to change & adjust to life w/o drugs while living in a real-life situation.

Community & faith based organizationsafter-school programs, mentoring activities, sports

spirituality important to recovery for many individuals

3.3 2 questions borderline & antisocial disorderAntisocial PDirresponsible

failure to honor financial obligations, plan ahead or provide children w/ basic needs.

Involvement in illegal activities

lack of guilt

difficulty learning from mistakes

initial charm dissolves in coldness, manipulation, & blaming others

lack of empathy

irritability

abuse of substance

Epidemiology: APD usually diagnosed before 18 yrs, Hx, conduct disorder before 15 years; males (characteristics in early childhood) more than females (characteristics evident by puberty); Many in SUD programs or prison; incidence higher among lower socioeconomic populations; impulsive behavior common; approx. 1% of U.S population 18 yrs or older.

Borderline PDrecurrent suicidal &/or self-mutilating behaviors

poor impulse control & engage in impulsive acts (gambling, binging, spending money, reckless driving, unsafe sex).

Negative or angry affect

feeling emptiness or boredom

difficulty being alone or feelings of abandonment

difficulty identifying self

perception of people all good or bad

intense & stormy relationship

Epidemiology: condition diagnosed in 1.6% of population 18+ yrs; often hx of physical or sexual abuse, neglect, hostile or conflictual experiences, & early parental loss or separation; more females than males.