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physical, mental, and social wellness, not merely the absence of disease or infirmity. • Mental health is influenced by individual factors, including biologic makeup, autonomy, and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities; by interpersonal factors, including effective communication, helping others, intimacy, and maintaining a balance of separateness and connectedness; and by social/cultural factors, including sense of community, access to resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive yet realistic view of the world (damn, that was a mouthful!). Mental Illness • The APA (2000) defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom”. • Deviant behavior does not necessarily indicate a mental disorder. Diagnostic and statistical manual of mental disorders • The DSM-IV-TR is a taxonomy published by the APA. The DSM-IV-TR describes all mental disorders, outlining specific criteria for each based on clinical experience and research. Self-awareness issues • Self-awareness is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes. Chapter Two NEUROBIOLOGIC THEORIES AND PSYCHOPHARMACOLOGY The Nervous system and how it works • The cerebrum is the center for coordination and integration of all information needed to interpret and respond to the environment. • The cerebellum is the center for coordination of movements and postural adjustments. • The brain stem contains centers that control cardiovascular and respiratory functions, sleep, consciousness, and impulses. • The limbic system regulates body temperature, appetite, sensations, memory, and emotional arousal. Neurotransmitters • Neurotransmitters are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body. o They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action (inhibitory). o After neurotransmitters are released into the synapse (point of contact between the dendrites and the next neuron) and relay the message to the receptor cells, they are either transported back from the synapse to the axon to be stored for later use (reuptake) or are metabolized and inactivated by enzymes, primarily monoamine oxidase (MAO). • Dopamine, a neurotransmitter located primarily in the brain stem. Dopamine is generally excitatory and is synthesized from tyrosine, a dietary amino acid. o Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity. • Norepinephrine and Epinephrine o Norepinephrine, the most prevalent neurotransmitter, is located primarily in the brain stem. It plays a role in mood regulation. o Epinephrine is also known as noradrenaline and adrenaline. Epinephrine has limited distribution in the brain but controls the fight-or-flight response in the peripheral nervous system. • Serotonin o A neurotransmitter found only in the brain, is derived from tryptophan, a dietary amino acid. o The function of serotonin is mostly inhibitory, involved in the control of food intake, sleep and wakefulness, temperature regulation, pain control, sexual behavior, and regulation of emotions. o Some antidepressants block serotonin reuptake, thus leaving it available longer in the synapse, which results in improved mood. • Histamine o The role of histamine in mental illness is under investigation. 1
Acetylcholine o Acetylcholine is a neurotransmitter found in the brain, spinal cord, and peripheral nervous system. It can be excitatory or inhibitory. It is synthesized from dietary choline found in red meat and vegetables and has been found to affect the sleep-wake cycle and to signal muscles to become active. o Studies have shown that people with Alzheimer’s disease have decreased acetylcholine secreting neurons. Glutamate o Glutamate is an excitatory amino acid that at high levels can have major neurotoxic effects. Gamma-Aminobutyric Acid (GABA) o GABA is a major inhibitory neurotransmitter in the brain and has been found to modulate other neurotransmitter systems rather than to provide a direct stimulus. o Drugs that increase GABA function such as benzodiazepines are used to treat anxiety and to induce sleep.
Neurobiologic causes of mental illness • Current theories and studies indicate that several mental disorders may be linked to a specific gene or combination of genes but that the source is not solely genetic; nongenetic factors also play important roles. • Two genetic links to Alzheimer’s disease are chromosomes 14 and 21. • The Human Genome Project, funded by NIH and the US Department of Energy, is the largest of its kind. It has identified all human DNA. In addition, the project also addresses the ethical, legal, and social implications of human genetics research. Stress and the Immune system (Psychoimmunology) • This is a relatively new field of study, which examines the effect of psychological stressors on the body’s immune system. Infection as a possible cause • Some researchers are focusing on infection as a cause of mental illness. Studies such as this are promising in discovering a link between infection and mental illness. The Nurse’s role in research and education • The nurse must ensure that client’s and families are well informed about progess in these areas and must also help them to distinguish between facts and hypotheses. The nurse can explain if or how new research may affect a client’s treatment or prognosis. The nurse is a good resource for providing information and answering questions. Psychopharmacology • Efficacy refers to the maximal therapeutic effect that a drug can achieve. • Potency describes the amount of the drug needed to achieve that maximum effect; low-potency drugs require higher doses to achieve efficacy, whereas high-potency drugs achieve efficacy at lower doses. • Half Life is the time it takes for half of the drug to be removed from the bloodstream. Drugs with shorter half-life may need to be given three or four times a day, but drugs with a longer half-life may be given once a day. • The FDA may issue a black-box warning when a drug is found to have serious or life-threatening side effects. This means that package inserts must have a highlighted box, separate from the text, which contains a warning about the serious sideeffects. Antipsychotic drugs • Also known as neuroleptics, are used to treat the symptoms of psychosis, such as the delusions and the hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder. • Antipsychotic’s work by blocking receptors of the neurotransmitter, dopamine. • Dopamine receptors are classified into subcategories (D1, D2, D3, D4, and D5) and D2, D3, and D4 have been associated with mental illness. • The typical antipsychotic drugs are potent antagonists (blockers) of D2, D3, and D4. This makes them effective in treating target symptoms but also produces many extrapyramidal side effects because of the blocking of the D2 receptors. • Newer, atypical antipsychotic drugs such as clozapine (Clozaril) are relatively weak blockers of D2, which may account for the lower incidence of extrapyramidal side effects. • The newer antipsychotics also inhibit the reuptake of serotonin, increasing their effectiveness in treating the depressive aspects of schizophrenia. Extrapyramidal Side Effects • (EPS) are the major side effects of antipsychotic drugs. They include acute dystonia (prolonged involuntary muscular contractions that may cause twisting of the body parts, repetitive movements, and increased muscular tone), pseudoparkinsonism, and akathisia (intense need to move about). Blockage of the D2 receptors in the midbrain region of the brain stem is responsible for the development of EPS. Included in the EPS are: 2
Neuroleptic Malignant syndrome • (NMS) is a potentially fatal idiosyncratic reaction to an antipsychotic. • SSRIs. and truncal musculature. • Treatment includes immediate discontinuation of the antipsychotic and the institution of supportive medical care to treat dehydration and hyperthermia. and neck muscles. lip smacking. blinking. and bupropion are often better choices for those who are potentially suicidal or highly impulsive because they carry no risk of lethal overdose in contrast to the cyclic compounds and the MAOIs. Demerol. stooped posture. festinating gait. tricyclic antidepressants. facial. drooling. This develops suddenly and is characterized by: o Fever o Malaise o Ulcerative sore throat o Leucopenia • The drug must be discontinued immediately if the WBC drops by 50% or to less that 3. they must be used with extreme caution for several reasons: o A life-threatening side effect. decreased arm swing. delirium. and concurrent medical illness all increase the risk of NMS. and coarse pill rolling movements of the thumb and fingers while at rest. bupropion (Wellbutrin). a shuffling. Agranulocytosis • Some antipsychotics produces agranulocytosis. particularly creatine and phosphokinase. Tardive Dyskinesia • (TD) is a syndrome of permanent involuntary movements. MSG o MAOIs cannot be given in combination with other MAOIs. • Treatment of these symptoms can include adding an anticholinergic agent or amantadine. upper and lower extremities. peanuts. bradycardia. or drug-induced Parkinsonism if often referred to by the generic label of EPS. However. norepinephrine and serotonin. • There is no treatment available. pepperoni) Tofu ALL tap beers and microbrewery beer. • Immediate treatment with anticholinergic drugs usually brings rapid relief. poor nutrition. This is most commonly caused by the long-term use of antipsychotic drugs. they may fluctuate from agitation to stupor. • MAOIs have a low incidence of sedation and anticholinergic effects. • Symptoms include rigidity. autonomic instability such as unstable blood pressure. grimacing. • The symptoms of TD include involuntary movements of the tongue. CNS depressants. antidepressants somehow interact with the two neurotransmitters. • Dehydration. and other excessive unnecessary facial movements are characteristic. and elevated levels of enzymes. Antidepressant drugs • Although the mechanism of action is not completely understood. • Antidepressants are divided into four groups: o Tricyclic and the related cyclic antidepressants o Selective serotonin reuptake inhibitors (SSRIs) o MAO inhibitors (MAOIs) o Other antidepressants such as venlafaxine (Effexor). Symptoms include a stiff. sour cream. Mature or aged cheeses Aged meats (sausage. may occur if the client ingests food containing tyramine (an amino acid) while taking MAOIs. high fever. hypertensive crisis. SSRIs are only effective for mild to moderate depression. diaphoresis. and hypertensives. nefazodone. Sauerkraut.o Torticollis: twisted head and neck o Opisthotonus: tightness of the entire body with head back and an arched neck. soy sauce. Death rates have been reported at 10% to 20%. venlafaxine. mask-like facies. it is irreversible. 3 . • Pseudoparkinsonism. o Oculogyric crisis: eyes rolled back in a locked position. trazodone (Desyrel). tremor. • Clients with NMS are confused and often mute. or general anesthetics. • One TD has developed. o MAOIs are potentially lethal in overdose and pose a potential risk for clients with depression who may be considering suicide. which is a dopamine agonist that increases transmission of dopamine blocked by the antipsychotic drug. duloxetine (Cymbalta). and pallor. Tongue thrusting and protruding. and nefazodone (Serzone). or soybean condiments Yogurt.000.
and narcolepsy. GABA. and serotonin) from presynaptic nerve terminals as opposed to having direct agonist effects on the postsynaptic receptors. • Benzodiazepines produce their effects by binding to a specific site on the GABA receptor.0 mEq/L. acetylcholine. The ego represents mature and adaptive behavior that allows a person to function successfully. It also reduces the release of norepinephrine through competition with calcium. In seizure management. serotonin. Both are thought to stabilize mood by inhibiting the kindling process. • By blocking the reuptake of these neurotransmitters into neurons. preventing or minimizing the highs and lows that characterize bipolar illness.5 mEq/L are rarely therapeutic. causes impulsive thinking behavior. Because GABA receptor channels selectively admit the anion chloride into neurons. and sexual impulses. Mood stabilizing drugs • Mood stabilizing drugs are used to treat bipolar disorder by stabilizing the client’s mood. aggression. the cyclic antidepressants and venlafaxine block the reuptake of norepinephrine primarily and block serotonin to some degree. residual attention deficit disorder in adults. the major inhibitory neurotransmitter in the brain. After reuptake. they leave more of the neurotransmitter in the synapse to help convey electrical impulses in the brain. o Superego: The part of ones nature that reflects moral and ethical concepts. and Superego o Id: The part of ones nature that reflects basic or innate desires such a pleasure seeking behavior. • Psychosexual development o Oral (birth to 18 months) o Anal (18 to 36 months) o Phallic/Oedipal (3 to 5 years) 4 . o Lithium serum levels should be about 1. o Lithium produces its effects intracellularly rather than within neuronal synapses. these three neurotransmitters are reloaded for subsequent release or metabolized by the enzyme MAO. The kindling process can be described as the snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures.• The major actions of antidepressants are with the monoamine neurotransmitter systems in the brain. it is the directional opposite to the id. activation of GABA receptors hyperpolarizes neurons and thus is inhibitory. and treating acute episodes of mania. the Father of Psychoanalysis • Founded the personality components. Just know that clients from various cultures may metabolize medication at different rates and therefore require alterations in standard dosages. • The mechanism of action for anticonvulsants is not clear as it relates to their off-label use as mood stabilizers.5 mEq/L are usually considered toxic. Stimulants • Today. dialysis may be indicated. minor episodes.0 mEq/L. parental and social expectations. It is suspected that this same kindling process may occur in the development of full-blown mania with stimulation by more frequent. and dopamine. They also block the reuptake of these neurotransmitters. • Stimulants are often termed indirectly acting amines because they act by causing release of the neurotransmitters (norepinephrine. o Valproic acid and topiramate are known to increase the levels on the inhibitory neurotransmitter. Id. Cultural considerations • I’m not going to go much into this. anticonvulsants raise the level of the threshold to prevent these minor seizures. o If Lithium levels exceed 3. o Ego: The balancing or mediating force between the id and the superego. o The SSRIs block the reuptake of serotonin. dopamine. and has no rules or regard for social convection. Antianxiety drugs (Anxiolytics) • Benzodiazepines mediate the actions of the amino acid GABA. Levels less than 0. the primary use of stimulants is for ADHD in children and adolescents. and the MAOIs interfere with enzyme metabolism. norepinephrine. and levels of more than 1. o Norepinephrine. values. Ego. The id seeks instant gratification. therefore. and dopamine are removed from the synapses after release by reuptake into presynaptic neurons. o Lithium normalizes the reuptake of certain neurotransmitters such as serotonin. Psychosocial Theories and Therapy Sigmund Freud. particularly norepinephrine and serotonin. • Lithium is considered the first-line agent in the treatment of bipolar disorder.
stagnation (middle adult) o Ego integrity vs. Inferiority (school age) o Identity vs. and each stage is dependent on the completion of the previous stage/life task. Shame and Doubt (toddler) o Initiative vs. guilt (preschool) o Industry vs. o Trust vs. He moves toward independence. 5 . and answering questions. providing explanations and information. o Formal operations (12 to 15 years and beyond): Child learns to think and reason in abstract terms. severe. exploitation. despair (maturity) • Erikson believed that psychosocial growth occurs in sequential stages. o The identification phase begins when the client works interdependently with the nurse. and resolution. is increasingly social and able to apply rules. understands reversibility. and begins to feel stronger. the client makes full use of the services offered. identification. Begins to form mental images. one of the nurses’ primary roles is to provide safety and protection while promoting social interaction. the client no longer needs professional services and gives up dependent behavior. o Milieu therapy is used in the acute care setting. and achieves cognitive maturity. • Piaget explored how intelligence and cognitive functioning develop in children. which includes 4 phases: orientation. understands the meaning of symbolic gestures. moderate. and panic. • Paplau defined anxiety as the initial response to a psychic threat. o Sensorimotor (birth to 2 years): The child develops a sense of self as separate from the environment and the concept of object permanence. expresses feelings. o Countertransference occurs when the therapist/nurse displaces onto the client attitudes or feelings from his or her past. • Sullivan developed the first therapeutic community or milieu with young men with schizophrenia in 1929.o o • Latency (5 to 11 or 13 years) Genital (11 or 13 years) Transference and Countertransference o Transference occurs when the client onto the therapist/nurse attitudes and feelings that the client previously felt in other relationships. the client can regress and move back into the above mentioned phases. and then the treatment should emphasize on the roles of the client-client interaction. o Keep in mind that after the resolution phase. describing 4 levels of anxiety: acute. Developmental Theorists: Erikson and Piaget • Erikson focused on personality development across the life span while focusing on social and psychological development in life stages. allowing the person to learn new behaviors and solve problems. During this time the nurse would orient the patient to the rules and expectations (if in an acute setting). o Preoperational (2-6 years): Child begins to express himself with language. o Concrete operations (6-12 years): Child begins to apply logical thinking. isolation (young adult) o Generativity vs. Kinky. o The orientation phase is directed by the nurse and involves engaging the client in treatment. further develops logical thinking and reasoning. thinking is still concrete. the interactions among clients were beneficial. the patient can identify the nurse and environment on his own. They “come together”. This phase can begin either within a few hours to a few days. The person can take in all available stimuli (perceptual field). Role confusion (adolescence) o Intimacy vs. Harry Stacks Sullivan: Interpersonal Relationships and Milieu therapy • The importance and significance of interpersonal relationships in one’s life was Sullivan’s greatest contribution to the field of mental health. and begins to classify objects. o In the exploitation phase. o Acute anxiety is a positive state of heightened awareness and sharpened senses. He found that within the milieu. Hildegard Peplau: Therapeutic nurse-patient relationship (The bomb-diggity of nursing) • Developed the concept of the therapeutic nurse-patient relationship. however. o In the resolution phase. Mistrust (infant) o Autonomy vs.
Panic anxiety can involve loss of rational thought. sleep. Anxiety: • Increase or change in behavior. These MUST be met first. delusions. Cathy stated that this person can still be “talked down”. and justice. • Nursing interventions: o Ask “What’s going on?” o Give supportive care and let the patient know that you’re there. or hurricanes. freedom from harm or threatened deprivation. terrorist attacks. sometimes called social crises. Staff responses should be safety and security. Defensive: • Loss of rationality. Crisis Intervention • Maturational crises. the need for beauty. o Take away privileges. Pavlov: Classic conditioning (Behavior theory) • Pavlov believed that behavior can be changed through conditioning with external or environmental conditions or stimuli. getting married. shelter. • Situational crises are unanticipated or sudden events that threaten an individuals integrity. such as a death of a loved one and loss of a job. hallucinations. Remember. physiologic needs. sexual expression. and violent crimes such as rape or murder. earthquakes. Severe anxiety involves feelings of dread or terror. The person my bolt and run aimlessly. diaphoresis. Acting out person: • Loss of rational control. need to be met first. security. etc. as Cathy says so. and then attempt to talk with them to calm down. o The most basic needs. include natural disasters like floods. the person can learn new behavior or solve problems only with assistance. he focuses only on scattered details and has physiologic symptoms such as tachycardia. NON-VIOLENT CRISIS INTERVENTION The heart of crisis intervention is: • Care • Welfare • Safety (#1!) • Security People in crisis need care and welfare. this is the ideal anxiety state for teaching a client regarding health concerns such as diabetes. • He used a pyramid to arrange and illustrate the basic drives or needs to motivate people. which includes the need for self-respect and esteem from others. sometimes called developmental crises. which involve protection. In lecture. o The third level is love and belonging needs. which include enduring intimacy. Another person can redirect the person to the task. riots. truth. o The second level involves safety and security needs. often exposing himself and others to injury. o The highest level is self-actualization. The client may go to the ER thinking he is having a heart attack. • Adventitious crises. and complete physical immobility and muteness. war. and freedom of pain. Few people actually become selfactualized. Can be anything different from usual behavior (excitement. The person CANNOT be redirected to a task. o Remember. pacing). o Give the patient some control and choices. are predictable events in the normal course of a life. • Nursing interventions: 6 . Maslow’s Hierarchy of needs. • Nursing interventions: o Direct approach to setting limits. having children. friendship. and acceptance. Humanistic Theories. o The fourth level involves esteem needs. and chest pain. traumatic life experiences or compromised health can cause a person to regress to a lower level of motivation. The first priority is to move the person away from all stimuli.o o o Moderate anxiety involved a decreased perceptual field (focus on immediate task only). water. This includes food. such as leaving home for the first time.
posture. it’s how you say it! • TVC (total voice control) o Tone o Volume o Cadence Always remember not to lose eye contact. • Be as calm as possible. breathing. 7 . o I know your last name. Releasing… Venting… Mad as heck! • Allow the patient to do this! • Just stay calm as a nurse • While they’re venting. history.o Everything Cathy showed us on non-violent physical crisis intervention Tension-Reduction: • Subsiding of energy. environment. • Nursing interventions: o Establish therapeutic rapport o Prime time to talk and teach about preventions of behavior. • 18-36” is personal space (usually how wide ones arm length is). and speed. If you’re being grabbed… • Gain physiologic advantage o Know where the weak point of grab is o Leverage.use what you have! o Momentum—it comes in handy • Gain psychological advantage o Stay calm o Have a plan o Don’t forget the element of surprise Non-Violent physical control and restraint should be used as a LAST RESORT. agitation. disability. • What if the patient tells you…? o I know what car you drive. Intimidation: • This is NOT A GOOD THING. stand at 45 degree angle • Stand with hands to side (especially when with a paranoid client) • Move when the patient moves. • Always be the closest to the door. stance. • Nursing interventions: o Get a witness! Do not be by yourself with this patient! Non-verbal behavior that affect proxemics • Factors that affect: o Size. o I know you have 2 dogs and I’m going to kill them. What if the patient simply refuses? • Set limits! • Make the limits reasonable and enforceable. Paraverbal communication • 55% nonverbal • 7% verbal • 38% paraverbal it’s not what you say. Kinesics (Body language) • Facial expressions. This is a good thing. gender. they’re also releasing. hand gestures • When approaching a client.
• Those at risk: o PMS/PMDD o Suffering from anxiety and irritability o PP depression o Chronic illness (dialysis) o PTSD o Grief and loss • Can be observed by others. or the depression is just in one’s “head” Incidence • Major depression occurs at least twice as often in women • Single and divorced people have the highest rates of depression Treatments • Psychotherapy (groups.MOOD DISORDERS Categories of Mood disorders • Unipolar o Major depression • Bipolar o Mania o Depression o Period of normalcy Unipolar: Major depression • Sad mood or lack of interest in life for 2 or more weeks • Another 4 symptoms must also be present o Change in appetite (increase or decrease) o Change in sleep patterns (too much or too little) o Unable to concentrate and make decisions o Loss of self-esteem (guilt. • Patient is pre-medicated. much like a pre-op patient • Elders are treated for depression with ECT more frequently than younger persons. o Elder persons have increased intolerance of side effects of antidepressants o ECT produces a more rapid response Suicidal Ideation • Safety is primary concern • Watch for overt cues of suicide (Obvious) active • Covert cues are more subtle—passive • People who suddenly are happier are of great concern. may have made the suicidal plan are content with their decision. use “I” statements o “I really wish you’d join the group” Judgment 8 .how you were raised. • People whose meds are finally working—have enough energy to carry out the act Client’s Affect • Compare verbal with non-verbal behaviors—do they match up? • Asocial: Withdrawal from family and friends • Anhedonic: Lose sense of pleasure • When confronting these client’s about their behavior. counselor) • Psychopharmacology (Meds) • ECT Electroconvulsive therapy • The biggest concern is memory loss. how worthy a person perceives themselves).
o Persistent thirst and diluted urine can indicate the need to call the MD. make appointment for them. periods of profound depression. and times of normal behavior in-between • Occurs equally in men and women. Bipolar disorder • Condition with cyclic mood changes • Person has manic episodes. o Not having enough dietary salt can cause the lithium levels to be too high. but they raise the brains threshold for dealing with stimulation. o Having too much salt in the diet can cause the lithium level to be too low. rather. 3 is toxic! o Lithium is a salt contained in the human body. schedule short interaction times. decreases sensitivity to postsynaptic receptors (Basically. CBC with platelets. this prevents the person from being bombarded with external and internal stimuli.• • • Feel overwhelmed with normal activities Difficulty with task completion Always exhausted Self Concept • Ruminate: Worry to excess. other drugs must be used during the acute phases to reduce symptoms of mania or depression. assess if they can afford them • Make phone number lists of how to get help if they need it. Patient and Family teaching • Stress importance of follow-up care—keep it structured. Need serum levels monitored 12 hours after last dose. need structure) • Start to promote a therapeutic relationship. • Stress importance of continuing medications. and magnesium ions as well as glucose metabolism.when a person is in a manic phase. It not only competes for salt receptor sites but also affects calcium. they are synapsing super fast. • Lack energy for normal activities (always tired) Interventions • Assess safety for client (PRIORITY!) • Perform suicide lethality assessment • Orient client to new surroundings (they need structure) • Offer explanations of unit routine (again.5-1. or agitated mood lasting at least one week with three or more of the following symptoms: o Exaggerated self-esteem o Sleeplessness o Pressured speech o Flight of ideas o Reduced ability to filter out stimuli o Distractibility o More activities with increased energy Drug treatment • Lithium o Lithium is not metabolized. o Depakote Need to monitor serum level. o Maintenance lithium level is 0. lithium dosage may need to be reduced.0 mEq/L. Clinical course of mania • Episode of unusual. often seen in highly educated people. it is reabsorbed by the proximal tubule and excreted in the urine. o Onset of action is 5-14 days. Lithium helps slow this synapsing down). o Thought to work in the synapse to increase destruction of dopamine and norepinephrine. • Anticonvulsant drugs: mechanism is unclear. liver function including ammonia level (ammonia is a byproduct of liver metabolism) 9 . MUST complete an electrolyte blood panel (focus on Chloride). potassium. grandiose. o Tegretol Huge concern about agranulocytosis (a decrease in WBC).
• Ask the client to explain any coded speech • Assist the client to meet socially accepting behaviors. may need to obtain data in several short sessions as well as talking to family members. Please stand back two feet.o Klonopin Anticonvulsant and benzodiazepine Drug dependence can occur Monitor CBC. better vision) o Increase the arterial blood pressure and heart rate o Constrict peripheral vessels (makes skin cool and pale) o Increase glycogenolysis to free glucose for fuel (glycogen is being broken down in the liver) o Shunt blood from GI and reproductive organs Psychological response • Difficulty with logical thought • Increased agitation with motor activity • Increased vital signs • Client will try to change the feelings of discomfort by: o Changing behavior by adaptation o Changing behavior with defense mechanisms 10 . must be used in conjunction with lithium or another mood stabilizer. • Prevalent in women.” • Feed them finger foods high in calories while in a manic phase.S. “Kathy. ANXIETY DISORDERS & SUBSTANCE ABUSE Incidence • Most common emotional disorder in the U. Suicide • • • • • • • • 4 out of 5 who actually commit suicide have made at least one prior attempt In a majority of cases. I’m having trouble following you. liver function Withdrawal drug slowly to prevent GI issues Cannot be used alone to manage bipolar.” • Avoid becoming involved in power struggles over who will dominate the conversation. you are too close to my face. including going to the bathroom. Helpful hints to care for bipolar clients • You can’t teach a manic client • Safety is a huge issue because their judgment is poor. “survivor guilt” happens when 1 or more family members feel guilty that they are still living “Separation anxiety” may cause they surviving to “join the beloved deceased” Make the patient sign a “contract for life” Crisis intervention—may need 1:1 care. Few than 15% of suicide victims leave suicide notes The suicide risk is greatest in the 90 days following a major depressive episode. It is also helpful to ask client to repeat brief messages to ensure they have heard and incorporated them. there are clear indicators hat the person was very troubled. o “Please speak more slowly. • Only spend short periods of time with patient • Must be flexible in taking intake assessment. provide nutritional support! • Use simple sentences when communicating. age <45 Physiologic responses • Flight or fight responses • Sympathetic fibers increase the vital signs • Adrenal glands release adrenalin which causes the body to: o Take in more oxygen o Dilate the pupils (brings more light into eyes. The client is no more than 2-3 feet away from a staff member at any time.
effective problem solving. flight. dilated pupils. N/V. ritualistic behavior. unexpected panic attacks followed by a month of persistent concern or worry about having another attack. rigid stance. escalating anxiety. loss of rational thought. body relaxes • Exhaustion stage o Negative response to anxiety and stress o Body stores are depleted Panic disorders • An episode lasting 15-30 minutes in which a client experiences rapid. faster rate of speech. or freeze. fidgeting. dread. selectively attentive. chest pain. possible delusions or hallucinations. increased learning ability. tachycardia. doesn’t recognize potential danger. cannot solve problems or learn effectively. high voice pitch. GI upset. o Physiologic: Restlessness. difficulty sleeping. pounding pulse. “butterflies”.Anxiety disorders • Panic disorder • Phobic disorder • Agoraphobia • Obsessive-compulsive • PTSD • Generalized anxiety • Anxiety related to medical conditions • Substance-induced anxiety disorder Development of Anxiety Disorders • Predisposing factors o Onset: Acute or insidious (builds up) o Precipitating event o Chronic stressors o Unusual behavior o Fears disproportionate to reality Levels of anxiety • Mild: o Psychological: Wide perceptional field. doesn’t respond to redirection. increased blood pressure and pulse. irritability. sharpened senses. o Physiologic: Severe HA. and physiologic discomfort. HA. vertigo. diarrhea. • • Seyle Response to stress • Alarm reaction o Physiologic response o Body prepares to defend itself • Resistance stage o Body will defend by flight or fight o If the stress is gone. increased motivation. 11 . • Defined as recurrent. feels awe. can’t communicate verbally. hypersensitivity to noise. distorted perceptions. Panic: o Psychological: Perceptual field reduced to focus on self. may be suicidal. great emotional discomfort. diaphoresis. fright. • Moderate: o Psychological: perceptual field narrowed to immediate task. dry mouth. behavior geared toward anxiety relief and is usually ineffective. cannot connect thoughts or events independently. cannot process any environmental stimuli. increased use of automatisms o Physiologic: Muscle tension. or horror. o Physiologic: May bolt and run OR totally immobile and mute. intense. • 75% with panic disorder have spontaneous attacks with no triggers • Others have attacks stimulated by phobias or chemical changes within the body. cannot complete tasks. pale. cries. frequent urination Severe: o Psychological: Perceptual field narrowed to one detail or scattered details.
“I hate myself. I’m fat and ugly. irritability.Treatment • Psychotherapy o Positive reframing o Assertiveness training • Psychopharmacology o SSRIs o Anxiolytics o Antidepressants o MAOIs Phobias • An illogical. • Treatment for phobias: o Psychopharmacology Anxiolytics Benzodiazepines SSRIs Beta Blockers o Psychotherapy Behavioral therapy Systemic desensitization “Flooding” Getting rid of fear all at one time Obsessive-Compulsive Disorder (OCD) • Obsessions: Recurrent thoughts. has no control over them. o Do not try to stop the act unless the act is harmful (dangerous) o Talk to them! Use “I” statements o If they are too down on themselves—limit your time with them. or flashbacks o Avoiding reminders of the event Staying away from any stimuli that could be associated with the trauma. • Compulsions: Behaviors or rituals continuously carried out to get rid of the obsessive thoughts and reduce anxiety.” Post Traumatic Stress disorder • Three clusters if symptoms are present o Reliving the event Memories. visualizations. For instance. Take them back into reality. tell her the TEST IS NEGATIVE. persistent fear of a specific object or social situation that causes extreme distress and interferes with having a normal life. or inappropriate impulses that disturb a person’s life. dreams. If a teenager thinks she is pregnant despite a negative pregnancy test. intense. help them set a goal. No one cares about me. o If they repetitively do an act over and over again. o Inject reality. o Being on guard (hyper-arousal) Less responsive to stimuli Insomnia. • Higher incidence with groups in higher economic status and with more education • Nursing interventions: o Remember. “Let’s try to only wash your hands once every ten minutes. In that time frame. ideas. For instance.” The nurse would then say.” o Do not argue with OCD person. or angry outbursts • At risk people include: o Combat veterans o Victims of violence o Abused victims o Children in traffic accident (and the parents) 12 . a lot of the time people feel guilty about their thoughts and behaviors. I want you to think of your good qualities. “I am going to come back in 30 minutes.
rage. o Prevent relapse May need to go to AA for rest of life. Symptoms of PTSD occur 3 months or more after the trauma. encourage client to talk o Help them acknowledge where grief is coming from o Involve family o Give positive feedback Goals for PTSD: o Short term: Safety. decreased respirations and blood pressure. • Stimulants o Cocaine. KIDS NEED HELP. identify source.• • • • Only 46% of parents sought help for their children. Substance abuse • Overdose of alcohol: o Alcohol is a depressant. ever go cold turkey. COGNITIVE DISORDERS Delirium • Disturbance of consciousness accompanied by change in cognition. and Ritalin o Increases HR and BP. hallucinations • Onset is rapid • Brief duration • Level of consciousness is impaired • Slurred speech • Anxious mood 13 . amphetamines. • Develops over a short period of time • Easily distracted • Difficulty concentrating • Illusions. Some more signs of PTSD: o Have issues with authority figures o Their first emotions are anger. decrease insomnia. grieve! o Long term: Accept the fact that the experience happened and live healthy. disoriented o Alert and oriented to person only o Typically have problems recalling on memory and time. GI distress) o Irritable o Insomnia Nursing interventions: o Have specific staff members assigned to client to facilitate building trust o Consistency is the key o Be non-judgmental. vomiting may cause aspiration. and guilt o Their guilt comes out as anger (violent behavior) o Isolate themselves o Cry o Don’t want to talk about it o Drug and alcohol abuse o Nightmares o Manifests in physiological symptoms (HA. • Overdose of benzodiazepines require a gastric lavage including instillation of activated charcoal. decreases cardiac output and oxygen o Cocaine specifically causes MI’s Withdrawal • Two purposes: o Safe withdrawal with medication Suppress symptoms of abstinence Around the clock schedule and PRN Never.
not reliable from client o Interview family members. hard to keep in bed. • Promote comfort and rest • Adequate fluids and nutrition o Always offer little sips of water! Nursing process: Evaluation • Successful treatment of underlying causes for delirium returns client to former level of functioning • Client and family education about avoidance of recurrence • Monitor chronic health problems • Careful use of medications • No alcohol or other non-prescribed drugs DEMENTIA Dementia • More progressive. ask: “Is this how your mom typically acts?” • Mood/Affect o Frequently assess moods. moods change quickly • Thought process/content o Many have visual hallucinations o Very restless. and permanent • Involves multiple cognitive deficits o Primarily memory impairment • Involves at least one of the following: 14 . withdrawal from drugs and alcohol o Sedatives and benzodiazepines cause confusion • Effects of anesthesia The nursing process: Assessment • Interview with simple questions and explanations • Frequent breaks • History of onset. needs nutritional supplements Return to optimal level of functioning A goal needs a timeline to make it measurable! Nursing process: Intervention • Patient safety • Managing confusion o Often frightened at night. Nursing process: Goals • Free from injury o Fall precautions • Demonstrate increased orientation o Use reality orientation and validate feelings • Adequate balance of activity and rest o Help the patient keep days and nights straight • • • Adequate nutrition o Often forget to eat.Causes of Delirium • Metabolic • Infection—UTI • Low sodium o Normal is 135-145 mEq/L o Always check electrolytes! • Drug related o Or. gradual.
Causes by infectious particle that is resistant to boiling) • Parkinson’s disease • Huntington’s disease (inherited gene. Culture • Native Americans and Eastern countries hold elders in a position of authority. control of hypertension or diabetes. o Benzodiazepines may cause delirium and can worsen already compromised cognitive abilities. a plateau. and stop complex behavior) May also present: o Echolalia (echoing what is heard) o Palilalia (repeating words or sounds over and over) o o o o Clinical course of Dementia • Mild: o Forgetfulness o Difficulty finding words o Frequently loses objects and experiences anxiety about these losses. brain atrophy. sleep disturbances are common. develops at 40-60 years. respect.• Asphasia (deterioration of language function) Apraxia (impaired ability to execute motor functions) Agnosia (inability to name or recognize objects) Disturbance in executive functioning (ability to think abstractly and to plan. another plateau. o Most live in ECF. but more abrupt. and enlargement of the brain ventricles. does not need to be in the “therapeutic level” for blood work. Flu-like symptoms. Begins in late 30’s) • Vascular Dementia (#2) o Symptoms similar to Alzheimer’s. o Still recognizes familiar people. o Tegretol and Depakote help stabilize mood and diminish aggressive outbursts. Causes of Dementia • Decreased metabolic activity • Genetic component • Infection • Alzheimer’s disease (#1) • Creutzfeld-Jacob disease (CNS disorder. • Moderate: o Confusion is present along with memory loss o The person cannot complete complex tasks but remains oriented to person and place. • Psychopharmacology o Cognex and Aricept are cholinesterase inhibitors and have shown therapeutic effects. sequence. o Some assistance with care o Executive functioning suffers (especially with ADLs) • Severe: o Personality and emotional changes occur o May be delusional. forget the names of spouse and children and require assistance in ADLs. These doses are often ½-2/3 less lower than prescribed for seizures. demyelination. monitor. diarrhea. slow the progress of dementia. exercise. therefore. initiate. wander at night. more abrupt changes. They do not reverse damage already done. 15 . and so on. o Caused by decreased blood supply to the brain. and decision making for family. Must have liver function tests done with Cognex. power. this does not change despite memory loss or confusion. followed by rapid changes in functioning. and the person may avoid them. Treatment for Dementia • Underlying cause o Example: Vascular dementia can be helped by diet. o Occupational and social settings are less enjoyable. • May feel they are being disrespectful and reluctant to make decisions or plans for elders with dementia.
Nursing Process: Interventions • Demonstrate caring attitude • Keep clients involved. o Visual hallucinations are common. eventually impairs the ability to recognize family members and oneself. • Thought process and content o Executive functioning impaired o Have to stop working o Client may accuse others of stealing lost objects • Sensorium and Intellectual Processes o First affects recent and immediate memory. • Roles and Relationships • Physiologic and self-care considerations o Altered sleep-wake cycle o Some clients ignore internal cues such as hunger or thirst o Neglect bathing and grooming. goals and interventions constantly revised • Evaluation is a continuing process. lethargic. • Mood and Affect o Grieve at first o Emotional outbursts are common o Pattern of withdrawal. o Confabulation: clients make up answers to fill in memory gaps. • Remember… short term goals. relate to environment • Validate client’s feelings of dignity • Offer limited choices • Reframing (offering alternate points of view to explain events) • SAFETY! o Physical and Chemical restraint should be the last option Nursing process: Evaluation • Goals change as disease progresses • Reassessment is vital! • Client always needs assessed. often inappropriate words or fabricated ideas (SCREW YOU. never have displayed these behaviors before. SCHIZOPHRENIA Types of schizophrenia • Paranoid schizophrenia o Suspiciousness o Hostility o Delusions o Auditory hallucinations o Anxiety and anger 16 . look dazed and listless. become incontinent. all goals need a time frame.Nursing process: Assessment • History o Remember. interview family • Motor behavior and general appearance o Display aphasia o Conversation repetitive o Apraxia (such as combing hair) o Gait disturbance o Uninhibited behavior. • Judgment and insight o Underestimate risk • Self concept o Initially grieve. and then slowly lose sense of self. apathetic. ASSHOLE).
brief and frequent contact with the client • Tell the client when you are leaving • Tell the client when you do not understand • Do not “go along” with the clients delusions or hallucinations • Provide simple concrete activities such as puzzles or word games 17 .• • • • o Aloofness o Persecutory schemes o Violence Disorganized schizophrenia o Extreme social withdrawal o Disorganized speech or behavior o Flat or inappropriate affect o Silliness unrelated to speech o Stereotyped behaviors o Grimacing mannerisms o Inability to perform activities of daily living Catatonic schizophrenia o Significant psychomotor disturbances o Immobility o Stupor o Waxy flexibility o Excessive purposeless motor activity o Echolalia o Automatic obedience o Stereotyped or repetitive behavior Undifferentiated schizophrenia o Undifferentiated schizophrenia does not meet the criteria for paranoid. or catatonic schizophrenia o Delusions and hallucinations o Disorganized speech o Disorganized or catatonic behavior o Flat affect o Social withdrawal Residual schizophrenia o Diagnosed as schizophrenic in the past o Time limited between attacks but may last for many years o The client exhibits considerable social isolation and withdrawal and impaired role functioning Interventions • Assess the client’s physical needs • Set limits on the client’s behaviors when it interferes with others and becomes disruptive • Maintain a safe environment • Initiate one-on-one interaction and progress to small groups as tolerated o Although. a neutral approach is less threatening • Do not make promises to the client that cannot be kept • Establish daily routines • Assist the client to improve grooming and to accept responsibility for self-care • Sit with the client in silence if necessary • Provide short. disorganized. reintegrating the client into the milieu as soon as possible is essential • Spend time with the client even if client is unable to respond • Monitor for altered thought processes • Maintain ego boundaries and avoid touching the client o Touching others without warning or invitation o Intruding in others’ living spaces o Talking to or caressing inanimate objects o Undressing. the client may only tolerate 5-10 minutes of contact at one time. • Avoid an overly-warm approach. masturbating. or urinating in public • Limit the time of interaction with the client o Initially.
Nursing interventions for the client experiencing delusions • Ask the client to describe the delusion • Be open and honest in interactions to reduce suspiciousness • Focus the conversation on reality based topics rather than the delusion • Encourage the client to express feelings and focus on the feelings that the delusions generate • If the client obsesses on the delusion.• • • • • • • • • • • • • • • Reorient the client as necessary Help the client establish what is real and unreal Stay with the client if he is frightened Speak to the client in a simple direct and concise manner Reassure the client that the environment is safe Remove the client from group situations if the client’s behavior is too bizarre. or agitation • Provide seclusion if necessary • Administer medications as prescribed Language and communication disturbances • Clang association: Repetition of words or phrases that are similar in sound but in no other way. anxiety. especially with the paranoid schizophrenic client Provide a radio or tape player at night for insomnia Explain to the client everything that is being done Set limits on the client behavior if the client is unable to do so Decrease excessive stimuli in the environment Monitor for suicide risk Assist the client to use alternative means to express feelings through must or art therapy or writing. disturbing. or dangerous to others o Reassure others that the client’s inappropriate behaviors or comments are not his fault (without violating confidentiality). attempt to engage the client’s attention through a concrete activity o Teaching the client to talk back to the voices forcefully also may help him or her manage auditory hallucinations • Accept and do not judge or joke about the client’s behavior • Provide easy activities and a structured environment with routine activities of daily living • Monitor for signs or increasing fear. This latency or hesitation may last 30-45 seconds and usually indicates the client’s difficulty with cognition or thought processes. • Echolalia: Repetition of words or phrases heard from another person • Mutism: Absence of verbal speech • Neologism: A new word devised that has a special meaning to the client • Word salad: Form of speech in which words or phrases are connected meaninglessly • Latency of response: hesitation before the client responds to questions. • Thought broadcasting: believe that others can hear their thoughts • Thought withdrawal: believe others are taking their thoughts • Thought insertion: others are placing thoughts in their mind against their will 18 . and gradually assist the client in making own decisions Use canned or packaged food. Set realistic goals Initially do not offer choices to the client. set firm limits on the amount of time for talking about the delusion • Do not dispute with the client nor try to convince the client that the delusions are false • Validate if part of the delusion is real • Recognize accomplishments and provide positive feedback for successes Nursing interventions for the client experiencing hallucinations • Monitor for hallucination cues • Elicit description of hallucination to protect the client and others o The nurses understanding of the hallucination helps the nurse know how to calm or reassure the client • Intervene with one on one contact • Decrease stimuli or move the client to another area • Avoid conveying to the client that others are also experiencing the hallucination • Respond verbally to anything real the client talks about • Avoid touching the client • Encourage the client to express feelings • During a hallucination.
They learn that drinking is the way to cope. one of the first cues is a large drop in school performance • Other symptoms disguised: o Drug/alcohol abuse o Lack of concentration o Restlessness or hyperactivity o Anti-social behavior (conduct disorder) • Extreme fatigue. praise 19 . the client is unable to sit or lie quietly • Echopraxia: Repeating the movements of another person • Waxy flexibility: having one’s arms or legs placed in a certain position and holding that same position for hours • Dyskinesia: Impairment of the power of voluntary movements Child and adolescent disorders Psychiatric disorders are not diagnosed as easily in children as they are in adults. Kids that grow into adults are stuck in this stage (Identity vs. sleep all the time but are not rested • Suicide warning signs… o Constant insomnia. seriously impairs judgement • Suicide is not chosen. depression is more likely to be “acted out” with aggressive behavior such as risk taking. more violent in attempts o Acetaminophen affects liver o Ibuprophen affects kidneys • Presents as “classic” symptoms in girls • In boys. often between the ages of 15-19 • Manic depression o Teens may be sad and gloomy one day and excited and elevated the next o Mood stabilizers are important in decreasing mood swings Lithium (check blood levels!) Depakote Tegretol Neurontin • In depression. academic failure. This is not awesome. Role confusion). • First major episode are during adolescent years. Mental retardation • Mild retardations: IQ 50-70 • Moderate retardation: IQ 35-50 • Severe retardation: IQ 20-35 • Profound retardation: IQ less than 20. Start with the basics. • Children lack the abstract cognitive abilities and verbal skills to describe what is happening. or run-in with authority o Alcohol is involved in ½ of all suicides.Abnormal motor behaviors • Akathisia: Displaying motor restlessness and muscular quivering. o Drinking in teenage years (ages 15-17) stops emotional growth. Adolescent depression • Some issues are due to background and family issues • Transition into adulthood often very difficult • Depression is almost always due to a combination of factors • Boys are more successful in committing suicide. confrontations with authority. “How are you doing?” Then. substance abuse. it happens when pain exceeds resources for pain • Talk to your kids! o The best place is in the car when they’re trapped. school is a huge issue • Interventions for suicide o High risk teens make their decisions after a “disaster” has occurred: break-ups. haha. fight with parents. may be on computer at all hours of the night o Changes in behavior o Dropping grades—again.
there will be periods of reduced symptoms followed by “flare-ups”. of course) • Goals of treatment: o Reduce behavioral symptoms o Promotes learning and development o Language skills development Attention deficit disorder • Characterized by patterns of inattention. psychosocial. body twisting. hyperactivity. lacks spontaneous enjoyment. constant checking. identified no later than 3-years of age • Child has little eye contact. few facial expression. doesn’t use gestures to communicate • Does not relate to parents or peers. or head banging • May improve as child acquires language skills • Short term impatient therapy is used when behaviors such as head banging or tantrums are out of control o Haldol or Risperadol may be effective (prn. • Treatment: o Exposure and response prevention o SSRIs help reduce symptoms of OCD—monitor for side effects • Compulsions o Washing. and impulsiveness • Account for most mental health referrals • Needs to be physically seen for a renewal of ADHD drugs monthly • Often diagnosed when a child starts school • Distinguishing bipolar disorder from ADHD can be difficult but is crucial because treatment is so different for each disorder • Signs and symptoms o Inattentive behaviors o Hyperactive/impulsive behaviors Fidgets Often leaves seat Can’t play quietly Interrupts Cannot wait turn • Treatment o The most effective treatment combines pharmacotherapy with behavioral. • Though a chronic disease. Obsessive-Compulsion disorder • Symptoms often begin slowly and gradually during their childhood or teenage years and increase in severity as time goes on. often stressful times in person’s life. apparent absence of mood and emotional affect. Then get down and dirty to the real subject Childhood Schizophrenia • Group of disorders of thought processes characterized by gradual disintegration of mental function • Occurs in adolescents or as young adults • Suicide is the #1 cause of death in young people with schizophrenia • Treatment and prognosis o Lifetime of therapy and family support o Medications o Struggle for family to stay involved Often rejected or just can’t take anymore disruption in their lives. cleaning. can not be engaged in play or make believe • Repetitive motor behaviors such as hand-flapping. and educational interventions 20 . • Relief is only temporary. but are compelled to continue them “against their will”. usually both obsessions and compulsions occur together • Recognize thoughts or behaviors are irrational. rearranging o Asking for reassurance or confessing o Masturbation—especially seen in children who haven’t yet discovered this is socially unacceptable behavior Autistic disorder • Most prevalent in boys. mental counting rituals o Touching. ordering.
o Anxiety. Most common side effects were decreased appetite. o Ineffective role performance Will not violate others boundaries Give positive feedback for meeting expectations.• • • • • • • • Psychopharmacology o Methylphenidate (Ritalin) o Amphetamine compound (Adderall) The most common side effects of these drugs are insomnia. is an antidepressant—selective norepinephrine reuptake inhibitor. State acceptable behavior clearly o Impaired social interactions Demonstrate age-appropriate social skills Supervise the child closely while he is playing. It is often necessary to act first to stop the harmful behavior by separating the child from the friend o Improved role performance Simplify instructions and directions—give one step of a process at a time Give the child positive feedback and sense of accomplishment 21 . General appearance and Motor behavior o Speech is unimpaired. Physiologic and Self-care considerations o Children with ADHD may be thin if they do not take time to eat properly or cannot sit through meals. and upset stomach. even to the point of verbal outbursts or temper tantrums. Can cause liver damage. Strategies for Home and School o Behavioral strategies are necessary to help the child master appropriate behaviors. This may require physical intervention if the child is running into a street or jumping off of a high place. talk to the child about the behavior. Giving stimulants during daytime hours usually combats insomnia. use play to understand thoughts and feelings and helps with communication. and fails to pay attention to what is said. and agitation are common Judgment and insight o May fail to perceive harm or danger and engage in impulsive acts such as running into the street and jumping off of high objects. and weight loss or failure to gain weight. the first step is to stop the behavior. he interrupts. o May be a history of physical injuries due to risk-taking behaviors Nursing diagnoses o Risk for injury Child will remain free from injury If the child is engaged in a potentially dangerous activity. N/V. loss of appetite. Give the child breakfast and snacks to gain weight o Atomoxetine (Strattera) Non-stimulant drug. but the child cannot carry on a conversation. Attempting to talk or reason to a child engaged in a dangerous activity is unlikely to succeed because of their inability to pay attention and to listen. When the incidence is over and the child is safe. Educate parents! Cultural considerations o Parents from different cultures have a different threshold for tolerating specific types of behavior. blurts out answers before the question is finished. o Effective approaches: Provide consistent rewards Consequences for behavior Offer consistent praise Use time out Give verbal reprimands Use daily report cards for behavior Point system for positive and negative behavior Therapeutic play. Mood and affect o Mood may be labile. must have liver function tests periodically. frustration. tiredness.
truancy. child with ADHD do not adjust to changes readily Parental support Listen to parent’s feelings Because these children often are not diagnosed until the 2nd or 3rd grade. alcohol and substance abuse. anger management. so treatment is based on individual therapy. social skills 22 . Forced sex. cruelty to animals. Parents should know that it takes time for them to catch up to other children the same age. weapons. peer relations. they may have missed much basic learning for reading and math.o o o Manage the environment Minimal noise and distraction Face the teacher in the front row and away from window or door Ineffective family coping Will complete tasks Face the child on his level and use good eye contact Give the child frequent breaks Routines are important. and school environment are the focus of treatment Family therapy is essential o Adolescents Rely less on their parents. o Symptoms are clustered into 4 areas Aggression to people and animals Destruction to property Deceitfulness and theft Serious violation of rules and the law o More symptoms Decreased self-esteem Poor frustration tolerance Tempter often out of control Early onset of sexual behavior. or occupational area. Conflict resolution. burglary. family. Vandalism and theft Severe: Many conduct problems that cause considerable harm to others. staying out late without permission Moderate: Number of conduct problems increase as does the amount of harm to others. Improved sociability. and academic achievement happen more slowly. Conduct disorder • Characterized by persistent antisocial behavior in children and adolescents that significantly impair their ability to function in social. Evaluation Medications are often in decreasing hyperactivity and impulsivity relatively quickly. • Treatment of conduct disorder o MUST BE GEARED TOWARD DEVELOPMENTAL AGE o School aged: Child. academic. smoking. risky behavior Anti-social • Types of conduct disorder o Classified by age of onset Adolescent-onset type is defined by no behaviors of conduct disorder until after 10 years of age. robbery. Least likely to be aggressive Have more normal peer relationships Less likely to have persistent conduct disorder or antisocial personality disorder as adults Childhood-onset type involves symptoms before 10 years of age Physically aggressive Disturbed peer relationships More likely to have persistent conduct disorder and to develop antisocial personality disorder as adults o Can be classified as: Mild: few conduct problems causing minor harm to others Lying.
Teach social skills Discuss the news. Often involuntary. sports. often obscene o Palilalia: Repeating own sounds or words o Echolalia: Repeating the last heard sound. defiant. rapid. or other topics as the client may not know how to have a normal conversation. High areas of crime rates Could be a matter of survival Nursing process o Risk for Other-directed violence The client will not hurt others or damage property SET LIMITS Inform the client of the rule or limit Explain the consequences if broken State expected behavior Behavioral contract Time out. not medical reasons. not a punishment—a place to regain self control Give client a schedule of daily activities o Noncompliance The client will participate in treatment More likely to participate in treatment and daily routines if they have input concerning the schedule o Ineffective coping The client will learn effective problem-solving and coping skills Help identify the problem and to solve problems effectively. recurrent. TIC disorders • Sudden. 23 . age-appropriate statements about self o Oppositional Defiant disorder • Consists of an enduring pattern of uncooperative. • A certain level of oppositional behavior is common in children in adolescence. o Chronic low self-esteem The client will verbalize positive.• • Try to keep the adolescent in his environment (home) Medications have little effect Antipsychotics for clients who present a clear danger to others Mood stabilizers for clients with labile moods Cultural considerations o Be careful of diagnosis of Conduct disorder. must know history and circumstances of each child. but can be intentional (oppositional defiant disorder or conduct disorder). o Impaired social interaction The client will use age-appropriate and acceptable behaviors when interacting with others. word. or work situations. • Oppositional defiant disorder is diagnosed only when behaviors are more frequent and intense than unaffected peers and cause dysfunction in social. non-rhythmic motor movement or vocalization • Stress and fatigue exacerbates tics • Treatment: Risperadol and Zyprexia • Complex vocal tics o Coprolalia: Use of socially unacceptable words. academic. Associated with constipation that occurs for psychological. and hostile behavior toward authority figures without major antisocial violations. or phrase Tourette’s syndrome • Multiple motor tics and one or more vocal tics • May occur many times a day for over a year • Usually identified by 7 years of age Elimination disorders • Encopresis: repeated passage of feces into inappropriate places such as clothing or floor by a child who is at least 4 years of age either chronically or developmentally. • Enuresis: Repeated voiding of urine during the day or night into clothing or bed by a child at least 5 years of age.
• Engage in unusual or ritualistic food behaviors o Refusing to eat around others o Cutting food into minute pieces o Not allowing the food they eat to touch their lips • Excessive exercise is common • Diagnosed between 14 and 18 years of age • Pleased with their ability to control their weight and may express this. appear uninterested. intense fear of gaining weight or becoming fat. hypothermia. an antidepressant with a side effect of urinary retention. • Treatment: o Focusing on weight restoration o Nutritional rehabilitation o Rehydration o Correction of electrolyte imbalances 24 . the person fails to recognize the eating behavior as a problem. it is now breaking down muscles for energy—the reason for the elevated BUN • Decreased albumin o Normal levels: 3. also due to excessive exercise • Elevated BUN o Normal levels: 10-20 mg/dl o Urea is formed in the liver and is the end product of protein metabolism. Clients with bulimia have a latter age at onset and a near-normal body weight. o Was once treated with vasopressin which decreases circulatory volume. o Albumin tests are a great indicator of nutritional status • Leukopenia and mild anemia o Not enough food and nutrients to replenish cells • Has a preoccupation with food and food-related activities • Can be divided into 2 subgroups: o Restricting subtype: lose weight primarily through dieting. • Clients who use laxatives are at a greater risk for medical complications. o Binge eating and purging subtype: engage regularly in binge eating followed by purging.• Treated with imipramine (Tofranil). • As the illness progresses. o In anorexia.5-5 g/dl o Measures amount of protein in the body. bradycardia o Intravascular volume is decreased. • Have body image disturbance • Can be very difficult to treat because they are often resistant. • Has experienced amenorrhea for at least 3 consecutive cycles • Complaints of constipations and abdominal pain • Cold intolerance • Hypotension. significantly disturbed perception of the shape or size of the body. and deny their problems. Eating disorders appear to be equally common among Hispanic and white women and less common among African American and Asian women. fasting. the body has already used fat for energy. EATING DISORDERS The distinguishing factor of anorexia includes an earlier age of onset and below-normal body weight. these clients have some control in their lives. and steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists. Anorexia Nervosa • A life-threatening eating disorder characterized by the client’s refusal or inability to maintain a minimally normal body weight. • Autonomy may be difficult in families that are overprotective or in with enmeshment (lack of clear boundaries) exists. They usually are ashamed and embarrassed by the eating disorder. depression and lability in mood become more apparent • Isolate themselves • Believe peers are jealous of their weight loss and believe family and health care professionals are trying to make them “fat and ugly”. albumin is a protein formed in the liver. less blood to pump through heart. or excessively exercising. By losing weight.
o Access to the bathroom is supervised to prevent purging as clients begin to eat more food. remorse. Family members often describe clients with anorexia as perfectionists with above average intelligence. May be slow to respond and have difficulty deciding what to say. or selfcontempt. lethargic. overweight. laxatives. depending on the amount of weight loss. • Clients with bulimia are aware that their eating behavior is pathologic and go great lengths to hide it from others. Dentists are often the first health care professionals to recognize this. with gradual increases in calories until clients are ingesting adequate amounts for height. Often wear loose clothing in layers Seldom smile. activity level. and growth needs. they may appear emaciated. and personality disorders. eager to please.• • • • • Severely malnourished individuals may require TPN. • Recurrent vomiting destroys tooth enamel. o Amitriptyline (Elavil) and the antihistamine cyproheptadine (Periactin) in high doses (up to 28mg/d) can promote weight gain in inpatients. 25 . or enjoy any attempts at humor o Bulimia Nervosa • Characterized by recurrent episodes (at least twice a week for 3 months) of binge eating followed by inappropriate measures to avoid weight gain such as purging (vomiting. or hyperalimentation to receive adequate nutritional intake. or emetics). enemas. Clients with anorexia appear slow. • Engaging in binge eating secretly • Binging or purging episodes are often precipitated by strong emotions and followed by guilt. fasting. has dental caries and ragged or chipped teeth. and fatigued. Start slowly—will have massive diarrhea o The client with anorexia may be critically malnourished. shame. • Clients with a co-morbid personality disorder tend to have poorer outcomes than those without. dependable. but are generally close to expected body weight for age and size • Appear open and willing to talk. laugh. • May be underweight. o Fluoxetine (Prozac) has shown some effectiveness in preventing relapse in clients whose weight has been partially or completely restored. Reluctant to answer questions fully because they do not want to acknowledge any problem. initially pleasant and cheerful as though nothing is wrong Nursing outcomes/interventions Imbalanced Nutrition: Less than/More than body requirements • The client will establish adequate nutritional eating patterns o Implement and supervise the regimen for nutritional rehabilitation o A diet of 1200-1500 calories is ordered. o Weight gain and adequate food intake are most often the criteria for determining the effectiveness of treatment. • Bulimia is typically diagnosed at 18 or 19. o Olanzapine (Zyprexa) has been used with success because of both its antipsychotic effect (on bizarre body image distortions) and associated weight gain. close monitoring is needed because weight loss can be a side effect. • Most are treated on an outpatient basis • Antidepressants are more effective than the placebos in reducing binge eating • Clients are often focused on pleasing others and have a history of impulsive behavior such as substance abuse and shoplifting as well as anxiety. depression. tube feedings. and seeking approval before their condition began. diuretics. access to bathrooms is supervised. or excessively exercising. TPN through central line Electrolyte balance Tube feeds o A liquid protein supplement is given to replace any food not eaten to ensure consumption to ensure total number of calories prescribed o Must monitor meals and snacks and will sit at the table during eating away from the other clients A major goal is to first get them to the table o Diet beverages and food substitutions may be prohibited o Specified time may be set for consuming each meal and snack o Discourage clients from performing food rituals such as cutting food into tiny pieces or mixing foods in unusual combinations o Be alert for any attempts by client to hide or discard food o Must remain in view of staff for 1-2 hours to ensure they do not vomit.
rectum. and maintenance. and pseudoneurologic symptoms. a behavior-cognitive approach Disturbed body image • The client will verbalize acceptance of body image with stable body weight o Help clients identify areas of personal strength that are not food-related broadens clients’ perceptions of themselves. • Hypochondriasis: Preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). disassociative symptoms such as amnesia. • Sexual symptoms: Sexual indifference (don’t care to do the dirty). menstruation. • Symptoms or magnified health concerns are not under the client’s conscious control. vomiting (other than pregnancy). Symptoms of a somatization disorder • Pain symptoms: complaints of headache. • Pain disorder: Pain is the primary physical symptom which is generally unrelieved by analgesics and greatly affected by psychological factors in terms of onset. pain during urination. These deficits suggest a neurological disorder but are associated with psychological factors. anxiety. aphonia (loss of speech sounds). In bulimia. is the key feature.o o o Client is weighed daily on awakening and after they have emptied their bladder. pain in the abdomen. exacerbation. • Conversion disorder: Involves unexplained. bloating. The five specific somatoform disorders are as followed: • Somatization disorder: Characterized by multiple physical symptoms. or an excessive need for control o Help the client recognize emotions such as anxiety or guilt by asking them to describe what they are feeling. it is easier to follow a nutritious eating plan Ineffective coping • The client will eliminate use of compensatory behaviors such as excessive exercise and use of laxatives and diuretics • The client will demonstrate coping mechanisms not related to food • The client will verbalize feelings of guilt. back. they may attempt to place objects in their clothing to give the appearance of weight gain. or sexual intercourse. swollen tongue. blindness. the clients should sit at a table in a kitchen or dining room. excessive menstrual bleeding. and maintaining the symptoms. chest. allow adequate time for response. or intolerance of several foods. erectile or ejaculatory dysfunction. exacerbating. • Pseudoneurologic symptoms: Impaired coordination or balance. severity. joints. Have the client wear a hospital gown each time they are weighed. urinary retention. Related disorders: 26 . head. • GI symptoms: nausea. or loss of consciousness other than fainting. anger. It is thought that clients with this disorder misinterpret bodily sensations or functions. It begins by 30 years of age. double vision. Somatoform disorders: Characterized as the presence of physical symptoms that suggest a medical condition without demonstrable organic basis to account fully for them. a seemingly lack of concern or distress. seizures. extends over several years. deafness. An attitude of la belle indifference. sexual. SOMATOFORM DISORDERS Somatization: The transference of mental experiences and states into bodily symptoms. o Client’s jump from one physician to the next. Do not ask “are you anxious? Sad?” because the client may quickly agree rather than struggle for an answer o Encourage self-monitoring. paralysis or localized weakness. irregular menses. The three central features of somatoform disorders are as follows: • Physical complaints suggest major medical illness but have no demonstrable organic basis. • Psychological factors and conflicts seem important in initiating. Write out a grocery list. paralysis). usually sudden deficits in sensory or motor function (blindness. and includes a combination of pain and GI. diarrhea. o They tend to be pessimistic about the medical establishment and often believe their disease could be diagnosed of the providers were more competent. or may see several providers at once in an effort to obtain relief of symptoms. • Body dysmorphic disorder: Preoccupation with an imagined or exaggerated defect in personal appearance such as thinking one’s nose is too large or teeth are crooked and unattractive. hallucinations. difficulty swallowing or lump in throat.
medical technicians. This includes progressive relaxation. such as attention from family members and comfort measures (being brought tea. Occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention.” • SSRIs are commonly used for depression that may accompany somatoform disorders. this will encourage relatives to stop reinforcing the “sick role. deep breathing. or obtaining drugs. The nurse should help the client plan social contact with others. such as relief of anxiety. This occurs most often in people who are in or familiar with medical professions. conflict. Their purpose is some external incentive or outcome that they view as important and results directly from their illness. and other feelings • Disturbed sleep pattern o The client will demonstrate healthier behaviors regarding rest. the client’s appearance brightens and they look much better as the assessment interview begins because they have the nurse’s undivided attention. Emotion-focused coping strategies help the clients relax and reduce feelings of stress. The nurse should help the client role play the above situations. Primary gain: Direct external benefits that being sick provides. or distress. obtaining financial compensation. or hospital volunteers. physicians.• • • • Malingering: The intentional production of false or grossly exaggerated physical or psychological symptoms. Factitious disorder: This is also known as Munchausen syndrome. • Client’s often have sleep pattern disturbances. o Munchausen syndrome by proxy occurs when a person inflicts illness or injury to someone else to gain the attention of emergency medical personnel or to be a “hero” for saving the victim. and nutritional intake. such as nurses. and distractions such as music. The challenge for the nurse is to validate the client’s feelings while encouraging him to participate in activities. lack basic nutrition.” • Impaired social interactions o The client will follow an established daily routine The nurse must help the client to establish this that includes improved health behaviors. • Fatigue • Pain 27 . activity. It is important not to dismiss all future complaints because at any time the client could develop a physical condition that would require medical attention. Problem-focused coping strategies help to resolve or change a client’s behavior or situation or to manage life stressors. Nursing diagnoses • Ineffective coping o The client will identify the relationship between stress and physical symptoms. The nurse explains that inactivity and poor eating habits perpetuate discomfort and that often it is necessary to engage in behaviors even though one doesn’t feel like it. Assessment • The nurse must investigate physical health status thoroughly to ensure there is no underlying pathology requiring treatment. Secondary gains: Internal or personal benefits received from others because one is sick. receiving a back rub). guided imagery. it is motivated by external incentives such as avoiding work. The nurse may have to explain to the family about primary and secondary gains. what to talk about (other than the client’s complaints). • In many cases. • Anxiety o The client will demonstrate alternative ways to deal with stress. and can improve the client’s confidence in making relationships. evading criminal prosecution.” Encourage the client to write in a daily journal Limiting the time that clients can focus on physical complaints alone may be necessary. People who malinger can stop the physical symptoms as soon as they have gained what they wanted. Treatment: • Treatment focuses on managing symptoms and improving quality of life. • Ineffective denial o The client will verbally express emotional feelings The nurse should not attempt to confront clients about somatic symptoms or attempt to tell them that these symptoms are not “real. anxiety. This includes learning problem solving methods. • A trusting relationship helps to ensure that client’s stay with and receive care from one provider instead of “doctor shopping. and get no exercise.
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