PSYCHE - Tourette's

8/3/2019 PSYCHE - Tourette's

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TOURETTES

SYNDROME


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Gilles de la Tourette Syndrome(TS) is one of a number of tic

disorders No biological test Evolve in childhood Standard diagnostic criteria used

Impairment defines the condition Diagnosis and Treatment take

time

TOURETTES SYNDROME


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ANATOMY OF TOURETTE


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The cause of TouretteSyndrome is unknown. Thebasic defect is thought tobe a biochemicalabnormality in the basalganglia of the brain.

E T I O L O G Y


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Genetically transmitted byautosomal dominant gene

Patient has 50% chance of passing

the gene to children. However,that genetic predisposition mayexpress itself as TS, as a milder ticdisorder or as obsessivecompulsive symptom with no ticsat all

In some cases TS may not beinherited and are identified asSporadic TS. The cause in these

instances is unknown

TRANSMISSION


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Onset before age 18 Multiple motor tics One or more vocal tics

Tics evolve in a progressive pattern Symptoms wax and wane* Duration longer than one year Absence of precipitating illness Observation of tics by knowledgeable person

*Relapsing Remitting MS. RRMS is identified by distinct periods of disease activity (relapses)followed by longer periods of disease inactivity (remission)

DIAGNOSTIC CRITERIA


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Chronic Motor or Vocal Tic Disorder

Transient Tic Disorder

Terms that may be used by doctors because theduration of the tics is less than one year

OTHER TERMS


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Affects BOYS 3 - 4:1 morethan GIRLS

Involuntary with limitedcapacity to suppress

Mean age of onset for tics 6 7 years

Affects 2% of the generalpopulation- a conservativeestimate since it is an underdiagnosed condition

TOURETTES SYNDROME


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Simple

Eye blinking

Facial Grimacing Shoulder shrugging

Head jerking

Arm thrusting

Nose twitching

Mouth opening

Eye rolling

SYMPTOMS

MOTOR TICS

Complex

Touching objects

Touching or Hittingself/others

Biting lips or arms

Scratching persistently

Twirling Foot tapping/dragging

Jumping

Hopping


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SYMPTOMS

VOCAL TICS

Simple

Throat clearing

Sniffing Grunting

Humming

Whistling Spitting

Squealing

Clenching teeth

Complex

Stuttering

Echolalia - Repeating ofanothers words

Palallia - Repeatingones own words

Copralalia - Speakingobscene word/phrases


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Writing Disorders

Reading Comprehension Disorders

Math Disorders

Visual-Motor Integration is almost always aproblem

Processing Speed and Efficiency Difficulties

LEARNING DISABILITIES


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Common NANDA nursing care plansDiagnosis:

Risk for self-directed or other-directed violence Impaired social interaction Low self-esteem

Goal: Minimize impairment

Maximize adaptive skills

Most important in planning:Encourage self-esteemPrevent depression


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Psychological Counseling

Behavioral Therapy

Medications

Alternative Therapies

Understanding and support from peers and

adults

TREATMENT FOR TS


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Drugs such as pimozide

(O

rap) and clonidine(Catapres) are used tocontrol tics.

MEDICA

TIONS


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Stress increases tics - Teach coping skills to handle stress;may need to avoid competition. Intensive involvement inenjoyable activities (sports, music) decreases tics and stressand calms.

Waxing and waning of symptoms of comorbidities and tics -Explain to parents, peers, teachers that student has very

limited control and that expression of tics and othersymptoms are involuntary as well as ever-changing andcoming and going

NURSING INTERVENTIONS


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Cognitive dulling, lethargy, seeming lack of interest,decrease in coordination - Could be due to medicationand/or depression. If worsening or severe, Inform thePhysician for reevaluation; Infrom Parents to allow extratime and attention for tutoring, studying, and testing.

Short temper and argumentative - Provide opportunity for

physical movement; encourage relaxation and body controltechniques as well as movement education to increase bodycontrol. Provide explanations to parents and peers.



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ADHD(ATTENTIONDEFICIT HYPERACTIVITYDISORDER)


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Arise in early childhood.

Onset before age seven.

Long lasting and evident for atleast six months

Affects 3-5% of all school agedchildren.

3:1 boys than girls

9:1 in clinical settings

A

DHD


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ETIOLOGY


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Primarily Inattentive Type ofSymptoms:

Fails to give close attention to

details or makes careless mistakes. Has difficulty sustaining attention. Does not appear to listen. Struggles to follow through oninstructions.

Has difficulty with organization. Avoids or dislikes tasks requiringsustained mental effort. Is easily distracted. Is forgetful in daily activities.

SYMPTOMS


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Primarily Hyperactive/Impulsive Typeof Symptoms:

Fidgets with hands or feet or squirmsin chair. Has difficulty remaining seated. Runs around or climbs excessively. Has difficulty engaging in activitiesquietly.

Acts as if driven by a motor. Talks excessively. Blurts out answers before questionshave been completed. Has difficulty waiting or taking turns. Interrupts or intrudes upon others.

SYMPTOMS


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There is no "cure" for ADHD, however, many treatment approachesmay alleviate or significantly decrease ADHD symptoms. As a result,improvements are evident in school/work performance,

relationships with others improve, and self esteem increases.

TREA

TMENT


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Stimulants Dosage (mg/day) NursingConsiderations

Methylphenidate (Ritalin)

Sustained release (Ritalin-SR Concerta Metadate-CD

10-60 in 3-4 divided doses

20-60 in the morning

Monitor for appetitesuppression or growthdelays.Give regular tablets after

meals.Alert client that full drugeffect takes 2 days.

Transdermal patch(Daytrana)

15 Wear patch for 9 hours effect lasts 3 hours afterremoval.

Dextroamphetamine

(Dexedrine)

Sustained release(Dexerine-SR)



Monitor for insomia.

Give last dose earlyafternoon.Monitor for appetitesuppresion.Alert client that full drug

effect takes 2 days.

PSYCHOPHARMACOLOGY


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Stimulants Dosage (mg/day) NursingConsiderations

Amphetamine (Adderall)

Sustained Release(Adderall-XR)

Pemoline (Cylert)



37.5-112.5 in the morning

Monitor for insomia.

Monitor for elevated liverfunction tests and appetitesuppressionAlert client that full drugeffect takes 2 days.

PSYCHOPHARMACOLOGY

Antidepressant (SNRI) Dosage (mg/day) NursingConsiderationsAntomoxetine (Strattera) 1.2 mg/kg/day in 1 or 2

divided doses (children 70 kg and adults)

Give with food.Monitor appetite forsuppression.Use calorie free beverages torelieve dry mouthMonitor for elevated liverfunction tests


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Risk for self directed or other directedviolence

Defensive coping

Impaired social interaction Ineffective coping

Low self esteem

Noncompliance

Anxiety (moderate to severe)

Compromised family coping

Imbalanced nutrition: Less than bodyrequirements

Ineffective family therapeutic regimenmanagement

Interrupted family processes

Risk for impaired parenting

COMMON NURSING DIAGNOSIS


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Set realistic expectations and limits because thepatient with attention deficit hyperactivitydisorder is easily frustrated

Always remain calm and consistent with the

child. Keep all your instructions to the child short and

simple.

Provide praise and rewards whenever possible.

Provide the patient with diversional activitiessuited to his short attention span.

Help the parents and other family membersdevelop planning and organizing systems to helpthem cope more effectively with the child's shortattention span.

NURSING INTERVENTIONS FOR ADHD


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Risk for self directed or other-directed violence

Observe clients behavior frequently.

Observe for suicidal behaviors: Verbal statements, such as statement going to kill myself

Determine suicidal intent and available means. Ask how where andwhen you plan to kill yourself

Obtain contract from client not to harm self and agreeing to seek outstaff when ideation occurs.

Help client to recognize when anger occurs and to accept thosefeelings

Act as a role model for appropriate expression of angry feelings.

Give positive reinforcement.



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Defensive coping

Encourage client to recognize and verbalize feelings of inadequacy and need for acceptance from others and to recognize how these feelings provoke defensive behaviors Provide immediate, fact, nonthreatening feedback for

unacceptable behaviors Help client identify situations that provoke defensiveness

Practice with role play for appropriate responses Give positive feedback for acceptable behaviors Evaluate and discuss with client the effectiveness of the new

behaviors and any modifications for improvement


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Impaired social interaction

Develop trust relationship

Give to the clients constructive criticism and positivereinforcement for clients efforts

Give Positive feedback to client

Provide group situations for client


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Ineffective coping

Provide safe environment for continuous large musclemovement, If client is hyperactive

Provide large motoric activities

Do not debate, argue, rationalize, or bargain with the

client. Explore with client and discus alternative ways of

handling frustration that would be most suited forclient



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Anxiety

Establish a trusting relationship

Maintain an atmosphere of calmness Offer support during times of

elevated anxiety, Use of touch iscomforting for some clients

When anxiety diminishes, help clientto recognize specific events that

preceded onset of anxiety. Provide help to client to recognize

signs of escalating anxiety On escalating anxiety provide

tranquilizing medication, as ordered


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PSYCHE - Tourette's