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Prof. Rolando Y. Fausto, RN, MAN
BASIC CONCEPTS IN PSYCHIATRIC NURSING
state of emotional, psychological, and social wellness evidenced by effective behavior and coping, (+) self concept and emotional stability. Characteristics : à attitude of self-acceptance
growth, development and selfactualization (maximization of one s potential) tolerance of life s uncertainties autonomous behavior reality orientation environmental mastery stress management
MENTAL ILLNESS A state of imbalance characterized by a disturbance in a persons¶ thoughts, feelings and behavior. CHARACTERISTICS Dissatisfaction with one s characteristics, abilities, and accomplishments. ineffective or nonsatisfying relationships. dissatisfaction with one s place in the world. ineffective coping with life events. lack of personal growth
Poverty and abuses
are major factors which increases the risk of mental illness in the home.
PSYCHIATRIC NURSING Interpersonal process whereby the professional nurse practitioner through the use of self, assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences.
Science in Psychiatric Nursing. the use of different theories in the practice of nursing, serves as the science of psychiatric nursing. Art in Psychiatric Nursing. The therapeutic use of self is considered as the art of psychiatric nursing.
Mental Hygiene. It is the science that deals with measures to promote mental health, prevent mental illness and suffering and facilitate rehabilitation.
CORE CONCEPT - It is the positive use of one s self in the process of therapy. - It requires self-awareness.
BASIS OF THERAPEUTIC USE OF SELF JOHARIS WINDOW
Known to self Known to others Not known to self
Public self Semi-public self I II Area of the unknown IV
Not known Private self to others III
METHODS USE TO INCREASE SELF AWARENESS INTROSPECTION à DISCUSSION à ENLARGING ONEÙS EXPERIENCE à ROLE PLAY
Psychosocial Theories and Therapy
Pioneered by Sigmund Freud (1856-1939) in Vienna.
THREE DIVISIONS OF THE MIND CONSCIOUS ± Part of the mind that is focused on awareness. SUBCONSCIOUS ± Part of the mind that contains information that can be recalled at will. UNCONSCIOUS ± largest part of the mind; contains materials and information that can never be recalled
STRUCTURES OF PERSONALITY ID ± has no sense of right and wrong; funtions based on the pleasure principles. EGO ± integrator of the personality; functions based on reality. SUPEREGO ± the conscience; functions based on morality.
THEORIES OF PERSONALITY DEVELOPMENT FREUD¶S PSYCHOSEXUAL THEORY 0 ± 18 MONTHS : ORAL STAGE AREA OF GRATIFICATION : MOUTH 18 MONTHS ± 3 YEARS OLD : ANAL STAGE AREA OF GRATIFICATION : BOWELS 3 ± 6 YEARS OLD : PHALLIC STAGE AREA OF GRATIFICATION : GENITALS
GENITALS 6 ± 12 YEARS OLD : LATENCY (QUIET STAGE) AREA OF GRARIFICATION : NONE; SEXUAL ENERGY IS DIVERTED TO PLAY ACTIVITIES. 12 -21 YEARS OLD : GENITAL STAGE AREA OF GRATIFICATION : SECONDARY SEX CHARACTERISTICS; REAWAKENING OF SEXUAL DRIVES
Psychoanalytic Theorists (cont¶d)
theory that all human behavior is caused and can be explained y Personality components conceptualized as id, ego, and superego y Behavior motivated by subconscious thoughts and feelings; treatment involving analysis of dreams and free association
Psychoanalytic Theorists (cont¶d)
y Ego defense mechanisms y Psychosexual stages of
development y Transference and countertransference Psychoanalysis is lengthy, expensive, and practiced on a limited basis today; however, Freud¶s defense mechanisms remain current.
EGO DEFENSE MECHANISM
Erik Erikson (1902-1994) was a psychoanalyst who described eight stages of psychosocial development that are still widely used today by many disciplines Jean Piaget (1896-1980) described cognitive and intellectual development in children in 4 stages: sensorimotor, preoperational, concrete operations, formal operations.
ERIKSON·S PSYCHOSOCIAL THEORY 0 ± 12 MONTHS : TRUST VS MISTRUST IF THE NEEDS OF THE CHILD CONSISTENTLY MET, TRUST DEVELOPS 1 ± 3 YEARS OLD ± AUTONOMY VS SHAME AND DOUBT IF TOILET TRAINING IS NOT HURRIED, AUTONOMY DEVELOPS
3 ± 6 YEARS OLD ± INITIATIVE VS GUILT IF THE CHILDS¶ SEXUAL CURIOSITY IS HANDLED WITHOUT ANXIETY , INITIATIVE DEVELOPS. 6 ± 12 YEARS OLD ± INDUSTRY VS INFERIORITY IF THE CHILDS¶ EFFORT AT LEARNING IS SUPPORTED, INDUSTRY DEVELOPS
12 ± 18 YEARS OLD ± IDENTITY VS ROLE CONFUSION IF THE ADOLESCENTS¶ VOCATIONAL DECISIONS IS SUPPORTED, IDENTITY DEVELOPS. 18 ± 25 YEARS OLD ± INTIMACY VS ISOLATION IF THE ADOLESCENTS¶ DECISION REGARDING LOVE RELATIONSHIP IS SUPPORTED, INTIMACY DEVELOPS.
25 ± 65 YEARS OLD ± GENERATIVITY VS STAGNATION IF AN ADULT ENJOYS¶ SUPPORT FROM FAMILY, GENERATIVITY DEVELOPS. 65 AND ABOVE ± INTEGRITY VS DESPAIR IF THE ELDERLY HAS A SATISFYING PAST RECOLLECTION, INTEGRITY DEVELOPS.
PIAGET·S COGNITIVE THEORY 0 ± 2 YEARS OLD : SENSORY MOTOR DEVELOPMENT PROCEEDS FROM REFLEX ACTIVITY TO SENSORY MOTOR LEARNING. CHILD LEARNS THAT HE IS SEPARATE FROM THE ENVIRONMENT. CHILD LEARNS THE CONCEPT OF OBJECT PERMANENCE. e.g. : peek-aboo.
2 ± 7 YEARS OLD : PRE-OPERATIONAL STAGE 2 ± 4 YEARS OLD : PRE-CONCEPTUAL ± DEVELOPMENT PROCEEDS FROM SENSORY MOTOR LEARNING TO PRELOGICAL THOUGHT. THE CHILD LEARNS LANGUAGE AND SYMBOLS 4 ± 7 YEARS OLD : INTUITIVE THOUGHT ± THE CHILD IS ABLE TO THINK IN TERMS OF CLASS.
- THE CHILD IS ABLE TO DETERMINE THAT INDIVIDUALS HAVE ROLES. 7 ± 12 YEARS OLD : CONCRETE OPERATIONAL STAGE DEVELOPMENT PROCEEDS FROM PRE-LOGICAL TO LOGICAL CONCRETE STAGE.
12 ± ADULTHOOD : FORMAL OPERATIONAL STAGE THE CHILD IS ABLE TO THINK ABSTRACTLY, ABLE TO APPLY THE SCIENTIFIC METHOD.
Harry Stack Sullivan (1892-1949)
Hildegard Peplau (19091999)
Hildegard Peplau (1909-1999) (1909y Leading
nursing theorist and clinician: developed the nursepatient relationship with phases and tasks y Identified roles of the nurse: stranger, resource person, teacher, leader, surrogate, counselor y Described four levels of anxiety (mild, moderate, severe, panic) still widely used today.
Abraham Maslow (1921-1970) y Hierarchy of needs: basic physiologic needs, safety and security needs, love and belonging needs, esteem needs, self-actualization
Carl Rogers (1902-1987) Client-centered therapy Concepts of unconditional positive regard, genuineness, and empathetic understanding
Behaviorism focuses on behaviors and behavior changes, rather than explaining how the mind works. B. F. Skinner, the most noted theorist in this area, developed theory and principles of operant conditioning: y All behavior is learned. y Behavior has consequences (reward or punishment). y Rewarded behavior tends to recur.
Positive reinforcement increases the frequency of behavior. y Removal of negative reinforcers increases the frequency of behavior. y Continuous reinforcement is the fastest way to increase behavior; random intermittent reinforcement increases behavior more slowly but with longer-lasting effect.
Positive punishment ± aversive consequences decrease a particular behavior. Negative punishment ± withdrawing reward decreases a particular behavior. Treatment modalities based on behaviorism include behavior modification, token economy, and systematic desensitization
Cognitive therapy focuses on immediate thought processing and is used by most existential therapists. Albert Ellis founded rational emotive therapy, based on the idea that people make themselves unhappy through ³irrational beliefs and automatic thinking´²the basis for the technique of changing or stopping thoughts. Viktor Frankl developed logotherapy in the belief that life must have meaning and therapy is the search for that meaning.
Existential Theories (cont¶d)
Gestalt therapy (Frederick ³Fritz´ Perls) emphasizes self-awareness and identifying thoughts and feelings in the here and now. Reality therapy (William Glasser) focuses on the person¶s behavior and how that behavior keeps the person from achieving life goals. Existential theorists believe that deviations occur when the person is out of touch with self or environment; thus, the goal of therapy is to return the person to an authentic sense of self.
Examples of Cognitive technique 1. Cognitive restructuring ± teaching the client maladaptive thoughts through positive self-statements and refuting irrational beliefs. 2. Thought s stopping ± the client is taught to consciously to say ³stop´ to maladaptive thoughts.
PSYCHOBIOLOGY - Is the scientific study of the
relationships among the structure and function of the brain, biochemical and hormonal processes, genetics, environmental experiences, and human behavior
Neuroanatomy and Behavior 1. Frontal lobe ± is responsible for higher order thinking, abstract reasoning, decision ±making, speech, and voluntary muscle movements. Dysfunction is associated with illogical and psychotic thinking, uninhibite behaviors and incoherent speech. 2. Occipital lobe ± is responsible for visual function. Dysfunction is associated with illusions and visual hallucinations.
3. Temporal lobe ± is responsible for judgment, memory, smell, sensory interpretation, and understanding sound. Dysfunction is associated with aggressive and violent behaviors, olfatory and auditory hallucinations and language abnormalities.
Diencephalon ± is embedded in the cerebrum is superior to the brain stem. It is composed of several structures: 1. Hypothalamus ± is the main visceral control center of the body and is vitally important to homeostasis. It regulates the autonomic nervous system, body temperature, food intake, water balance, biologic rhythms and drives, and hormonal output of the anterior pituitary gland
2. Thalamus ± receives and relays sensory information and plays a role in memory and in regulating mood. 3. Limbic system ± comprises the limbic lobe and the numerous structures functioning with it, including the frontal cortex, hypothalamus, amygdala, hippocampus, brain stem, and autonomic nervous system. Called the emotional brain the limbic system emotional responses
Neurotransmitters and receptor sites 1. Neurotransmitters are chemical messengers that carry an inhibitory or stimulating message from one neuron to another across the space between these (synapse). Many psychiatric disorders are associated with abnormal interactions between neurotransmitter system.
Serotonin ± is involved in depressive and anxiety disorders, and possibly in eating disorders. Many antidepressants increase levels of serotonin at synaapses. Dopamine ± is involved in schizophrenic disorders. Many antipsychotic drugs block dopamine at the post synapse to prevent it from binding to its receptors.
Norepinephrine ± is a catecholamine neurotransmitter of the symphatetic nervous system, which mediates emergency response. Changes in norepinephrine levels are associated with depressive disorders, including bipolar disorders. Gamma aminobutyric acid (GABA) ± is an inhibitory neurotransmitter. Antianxiety drugs increase effects of GABA.
Acetylcholine ± is a major neurotransmitter of the parasympathetic nervous system, which controls muscles, memory, and coordination. Changes in acetylcholine are associated with Alzheimer disease Hormonal Influence Hypothalamic-pituitary-adrenal axis (HPA) has been found to be hyperactive in individuals with depressive disorders. Underactive thyroiid gland ± is linked to depression
Stress response ± is a neuroendocrine response, that causes significant release of hormones, which affects multiple body systems and can lead to psychological and physiological symptoms. Biology and Environment. Research is ongoing about how an individual¶s affects brain development and functioning.
Early life experiences (e.g. psychological and physical abuse) can alter brain structure and affect production of hormones and neurotransmitters, which can be related to symptoms of mental disorders in later life. Seevere abuse in early life (e.g., physical or sexual abuse in infancy and early childhood) can permanently increase gene expression for corticotropin-releasing factor (CRF) and increase risk for depression in adulthood
Kindling model proposes that repeated environmental lead to progressively greater nueral responsiveness, which changes brain excitability and therefore behavioral responses o, ver time (Post, 1997). Example, an early life experience can contribute to an initial experience of mental illness, which is hypothesized to increase sensitivity of the brain and thus predispose to later episodes of mental illness, given continued life stressors.
Caplan (1964) described 4 stages of crisis: exposure to stressor; increased anxiety when customary coping is ineffective; increased efforts to cope; disequilibrium and significant distress. Crises can be maturational, situational, or adventitious; last 4-6 weeks; outcome is either return to previous functioning level, improved coping, or decreased coping.Crisis intervention techniques are authoritative. A balance of both types is most effective.
CRISIS AND CRISIS INTERVENTION CRISIS ± Situation that occurs when an individual µs habitual coping ability becomes ineffective to meet the demands of a situation.
CHARACTERISTICS OF CRISIS Highly individualized Lasts for 4 -6 weeks Person affected becomes passive and submissive Affects a persons¶ support system Ineffective coping mechanism realistic perception is affected
TYPES OF CRISIS MATURATIONAL/DEVELOPMENTAL CRISIS ± Expected, predictable and internally motivated. E.g.; Growth, parenthood SITUATIONAL/ACCIDENTAL ± Unexpected, unpredictable and externally motivated. E.g.; Car accident
SOCIAL CRISIS ± Due to acts of nature. E.g. earthquake, tidal waves. MIXTURE OF DEVELOPMENTAL/SITUATIONAL ± Rape victim who become pregnant.
CRISIS INTERVENTION A way of entering into the life situation of an individual, family, group, or community to help them mobilize their resources to decrease the effect of a crisis including stress. GOAL OF CRISIS INTERVENTION To enable the patient to attain an optimum level of functioning.
PHASES OF CRISIS Denial ± initial reaction Increased Tension ± the person recognizes the presence of crisis and continues to do ADL Disorganization ± the person is preoccupied with the crisis and is unable to do ADL Attempts to reorganize ± mobilizes previous coping mechanisms.
MENTAL STATUS EXAMINATION A ± appearance B ± behavior C ± communication J ± judgment O ± orientation I ± insight M ± memory A ± affect T ± thought process/thought content
COMMON BEHAVIORAL SIGNS AND SYMPTOMS 1. Disturbances in perception: Illusion misperception of an actual external stimuli. Hallucination false sensory perception in the absence of external stimuli. 2. Disturbances in thinking: Neologism pathological coining of new words.
Circumstantiality ± over inclusion of details. Word salad ± incoherent mixture of words and phrases. Verbigeration ± meaningless reception of words or phrases. Perseveration ± persistence of a response to a previous question. Echolalia ± pathological repetition of words of others.
Flight of ideas ± shifting of one topic form one subject to another in a somewhat related way. Looseness of association ± shifting of a topic from one subject to another in a completely unrelated way. Clang association ± the sound of the words gives direction to the flow of thought.
Delusion Öfalse belief which is
inconsistent with one¶s knowledge and culture and cannot be corrected by reasons. Thought broadcasting Ö a delusional belief that others can hear or know what the client is thinking. Thought insertion ± a delusional belief that others are putting ideas to client¶s head
Thought withdrawal ± a delusional belief that others are taking the client¶s thoughts away and the client is powerless to stop it. 3. Disturbances of affect. Inappropriate affect ± disharmony between the stimuli and the emotional reaction. Flat affect ± absence or near absence of emotional reaction. Apathy ± dulled emotional tone.
Blunted affect ± severe reduction in emotional reaction. Ambivalence ± presence of two opposing feelings. Depersonalization ± feeling of strangeness towards one¶s self Derealization ± feeling of strangeness towards the environment
4. Disturbances in motor activity Echopraxia ± the pathological imitation of posture/action of others. Waxy flexibility ± maintaining the desired position for long periods of time without discomfort. 5. Disturbances in memory. Confabulation ± filling in memory gap. Amnesia ± inability to recall past events.
Anterograde amnesia ± loss memory of the immediate past. Retrograde amnesia ± loss of memory of the distant past. Déjà vu ± feeling of having been to place which one has not yet visited. Jamais vu ± feeling of not having been to a place which one has visited.
THERAPEUTIC RELATIONSHIPS -It is a nurse-client interaction that is directed toward enhancing the client¶s well being. The client coul be an individual, family or community. Elements of the therapeutic relationships 1. Contract ± time, place, settings and the purpose of the meetings as well as the conditions for termination are established between the nurse and the client.
2. Boundaries ± The therapeutic nature of the relationships (as it differ from social relationships) are established. - Roles of participants are clearly defined. - The nurse is considered as a professional helper. - The client¶s needs and problems are the main concern.
3. Confidentiality ± This is the basic condition that the nurse should maintain in the therapeutic relationships - The nurse shares client¶s information to those who have a direct participation in the client¶s care. - The nurse shall ask a written permission from the client to share information to others that is outside the health care team.
4. Therapeutic nurse behaviors ± Are behaviors that a nurse must maintained during the relationships and should be consistent with the following: - Self-awareness - Unconditional positive regard (respect) - Empathy - Cultural sensitivity - Collaborative goal setting - responsible ethical practice
PHASES A. PRE-INTERACTION PHASE à Begins when the nurse is assigned to a patient. à Phase of NPR in which the patient is excluded as an active participant à Nurse feels certain degree of anxiety à Includes all of what the nurse thinks and does before interacting with the patient
à Major task of the nurse: develop self awareness à Data gathering, planning for first interaction B. ORIENTATION PHASE Begins when the nurse and the patients interacts for the first time à Parameters of the relationship are laid
à Nurse begins to know about the patient à Major task of the nurse: develop a mutually acceptable contract à Determine why the patient sought help à Establish rapport, develop trust, assessment
C. WORKING PHASE à It is highly individualized à More structured than the orientation phase à The longest and most productive phase of the NPR à Limit setting is employed à Major task: Identification and resolution of the patientÙs problems à Planning and implementation
D. TERMINATION PHASE It is a gradual weaning process à It is a mutual agreement à It involves feelings of anxiety à It should be recognized in the orientation phase à Major task: to assist the patient to review what he has learned and transfer his learning to his relationship with others
When to Terminate? à When goals have been accomplished à When the patient is emotionally stable à When the patient exhibits greater independence à When the patient able to cope with anxiety separation, fear and loss
How to Terminate? Gradually decreased interaction time à Focus on future oriented topics à Encourage expression of feelings à Make the necessary referral
BASIC ELEMENTS Sender ± originator of the message Receiver ± recipient of information. Channel ± mode of communication. Feedback ± return response. Context ± the setting of communication. Criteria of successful communication: Feedback Appropriateness Flexibility Efficiency
Nonverbal Aspects of therapeutic Communication Kinetics are body movements, such as postures, facial expressions, and mannerisms Proxemics ± are the physical spaces between communicators - intimate space ± o to 18 inches - 18 inches to 4 feet - social space ± more than 4 feet to 12 feet - Public space ± more than 12 feet
Touch ± can be use as therapeutic communication provided that the nurse should analyze the client¶s condition and the client¶s likely response (should be use with cautions). Specially to clients who are paranoid and mistrustful.
Common problems in communication à Dysfunctional communication à Double blind communication à Differences between the denotative and connotative meaning. à Incongruent communication.
Common Techniques in Communication To initiate conversation: - Giving broad opening: giving the client to take the initiative in introducing the topic. Example: Is there anything that you want to talk about? Where would you like to begin?
-Giving recognition: acknowledging, indicating awareness. Example: I noticed that you combed your hair today. Good morning, Mr. S To Establish Rapport and Build Trust - Giving information: making available the facts that the client needs. Example: Visiting hours are
-Use of silence: refraining from speech to give the patient a time to sort out thoughts and feelings. -Example: Nurse says nothing but continues to maintain eye contact and conveys interest. To Gather Information - Focusing: concentrating on a single topic. Example: Client: ³ This point seems worth looking at more closely.´ Nurse: ³Of all the concerns you mentioned, which is most troublesome.´
- Validating: confirming one¶s
observation. Example: ³Are you saying that«´ - Reflecting: directing client actions, thoughts and feelings back to the client. Example: Client: ³My sister spends all my money and then has the nerve to ask for more.´ Nurse: ³This causes you to feel angry?´
Restating: repeating the main idea expressed. Nurse repeats what the client has said approximately or nearly the same words the client has used. Example: Client: ³I can¶t sleep. I stay awake all night.´ Nurse: ³You have difficulty sleeping.´ Client: ³I¶m really mad, I¶m really upset.´ Nurse: ³You¶re really mad and upset.´
Summarizing: developing a concise resume of what has transpired
* The primary purpose of communication is to: Give information
COMMON PROBLEMS AFFECTING COMMUNICATION Transference the development of an emotional attitude of the patient either positive or negative towards the nurse Resistance development of ambivalent feeling towards selfexploration Counter transference as experienced by the nurse
LEVELS OF INTERVENTIONS IN PSYCHIATRIC NURSING à Primary Ö interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors Examples: Health education Information dissemination Counseling
Secondary Ö Intervention that limit the severity of a disorder Two components 1. Case finding 2. Prompt treatment Examples: Crisis intervention Administration of medications
Tertiary ± interventions aimed at reducing severity of mental disorder and its associated disability through rehabilitative activities. Two components 1. Prevention of complication 2. Active program of rehabilitation Examples: Alcoholic anonymous Occupational therapy
CHARACTERISTICS OF A PSYCHIATRIC NURSE Empathy ± the ability to see beyond outward behavior and sense accurately another persons¶ inner experiencing Genuineness/Congruence ± ability to use therapeutic tools appropriately Unconditional positive regard ± RESPECT
ROLES OF THE NURSE IN PSYCHIATRIC SETTINGS Ward manager ± creates a therapeutic environment Socializing agent ± assists the patient to feel comfortable with others Counselor ± listens to the patient¶s verbalizations Parent surrogate ± assists the patient in the performance of activities of daily living
Patient advocate ± enables the patient and his relatives to know their rights and responsibilities Teacher ± assists the patient to learn more adaptive ways of coping Technician ± facilitates the performance of nursing procedures
BASIC CONCEPTS ON PSYCHOPHARMACOLOGY à M-edicaion classification. à E-ffectiveness of the drug. Setting of parameters. à D-ue time. Exact time the drug should be given. Before meals, after meals, empty stomach or without regards to meal à S-afely give the drug. Identify intervention for side/adverse effect.
à Teachings Ö What to expect? Should be able to give instructions to the client about the therapeutic effect and side effect of the drug.
Psychopharmacolgic agents Tranquilizers/antipsychotic/neuroleptics Common indication : Schizophrenia Examples: Old generation/Typical Haloperidol (Haldol) Prochlorperazine (Compazine) Fluphenazine (Prolixin) Chlorpromazine (Thorazine) New Generation/Atypical Clozapine (Clozaril) Olanzapine (Zyprexa)
à Antipsychotic Decreased delusions, hallucinations, and looseness of association Best taken after meals Report sore throat and avoid exposure to sunlight. Report elevated temp. and muscle rigidity,unstable BP, diaphoresis, pallor. it indicate Neuroleptic Malignant Syndrome.
Check the BP, the drug causes hypotension. Observe for EPS, check the CBC, drug causes leukopenia Target: Dopamine B. Anti-Parkinsonian drugs Indication: EPS (Extrapyramidal Syndrome) Two Types: 1. DOPAMINERGIC DRUGS Ex: Amantadine (Symmetrel) Levodopa Levodopa-Carbidopa (Sinemet)
2. ANTICHOLINERGIC DRUGS Ex: Trihexylphenidyl HCL (Artane) Biperiden Hydrochloride (Akineton) Benztropine Mesylate (Cogentin) Diphenhydramine Hydrochloride (Benadryl)
à Antiparkinsonian drug Muscles become less stiff; decreased pill-rolling tremors à Best taken after meals à Avoid driving, the drug causes blurred vision à Check the BP, the drug may cause hypotension
C. Minor Tranquilizers/Anxiolytics Common indication: Anxiety D/O Ex: Diazepam (Valium) Oxazepam (Serax) Chlodiazepoxide (Librium) Chlorazepate Dipotassium (Tranxene) Alprazolam (Xanax)
à Antianxiety; given as muscle
relaxant to patientÙs in traction à Decreased anxiety, adequate sleep à Best taken before meals, food in the stomach delays absorption à Avoid driving, intake of alcohol and caffeine containing foods, since it alters the effect of drug à Administer it separately, it is incompatible with any drug
D. Tricyclic Antidepressants Examples: Imipramine Hydrochloride (Tofranil) Amitriptyline (Elavil) à Tricyclic anti-depressant; prevents the reuptake of norepinephrine à Increased appetite; adequate sleep
à Best given after meals
à Therapeutic effects may become evident only after 2 Ö 3 weeks of intake à Check BP, it causes hypotension, Check the heart rate, it causes cardiac arrythmias, it also causes constipation. àTarget: Norepinephrine Serotonin
E. Antidepressant MAO inhibitors Ex: Tranylcypromine (Parnate) Phenelzine (Nadril) Isocarboxazid (Marplan) à Antidepressant MAO inhibitors à Increased appetite; adequate sleep à Best taken after meals
hypertensive crisis, avoid tyramine containing foods like: Avocado Banana Cheddar and aged cheese Soy sauce and preserved foods It takes 2 ± 3 weeks before initial therapeutic effects become noticeable Monitor BP, There should be at least a two week interval when shifting from one antidepressant to another Note: If not, it will cause Serotonin Syndrome.
à Report headache; it indicates
F. Anti ² Manic Agent Lithium Carbonate à Anti- Manic à Decreased hyperactivity à Best taken after meals à Increase fluid intake (3L / day) and sodium intake (3 gm / day). Avoid activities that increase perspiration
à It takes 10 Ö 14 days before
therapeutic effect becomes evident. Antipsychotic is administered during the first two weeks to manage the acute symptoms of mania until lithium takes effect. Monitor serum level, normal is 0.5 Ö 1.5 meq/L, Therpeutic level is 0.8 Ö 1.2 meq/L NAUSEA, AOREXIA,VOMITING, WEAKNESS, DIARRHEA, AND ABDOMINAL CRAMPS indicates Lithium Toxicity, Mannitol is administered if toxicity occurs.
ELECTRO-CONVULSIVE THERAPY à Mechanism of action: Unclear at present. à Voltage applied to the patient: 70 Ö 150 volts à Duration of application: 0.5 Ö 2 seconds à Usual number of treatments to produce therapeutic effect: 6 Ö 12 treatments
à Frequency of treatments: An interval of 48 hours for each treatment. à Indications of effectiveness: Generalized tonic-clonic seizure à Indication for ECT: Depression, Mania, Catatonic Schizophrenia à Contraindication to ECT: Fever, Increased ICP, Cardiac problems, TB with history of hemorrhage, Recent fracture, Retinal detachment, Pregnancy. à Consent needed prior to ECT: YES
Medication prior to ECT (Modified type) Atropine Sulfate Ö to decrease secretions Anectine (Succinylcholine) Ö to promote muscle relaxation Methohexital Sodium (Brevital) Ö serve as an anesthetic agent COMMON COMPLICATIONS: Loss of memory, Headache, Apnea, Fracture (Long Bones), Respiratory depression.
COMMON PSYCHOTHERAPEUTIC INTERVENTIONS REMOTIVATION THERAPY ± treatment modalitythat promotes expression of feeling through interaction facilitated by discussion of neutral topics. 5 Different Steps 1. Climate of acceptance 2. Creating of bridge of reality 3. Sharing the world we live in
4. Appreciation of the works of the world 5. Climate of appreciation MUSIC THERAPY ± involves the use of music to facilitate relaxation, expression of feelings and outlet of tension. PLAY THERAPY ± treatment modality which enables the patient to experience intense emotion in a safe environment with the use of play.
FAMILY THERAPY Ö a method of psychotherapy which focuses on the total family as an interactional system. àMILIEU THERAPY Ö consists of treatment by means of controlled modification of the patients environment to facilitate positive behavioral change.
àGROUP THERAPY Ö treatment modality involving therapeutic interactions of three or more patients with a therapist to relieve emotional difficulties, increase selfesteem, develop insight and improve behavior in relation with others. The minimum number of members in a group therapy is 3, while the ideal number is 8 Ö 10.
àPSYCHOANALYSIS Ö a method of psychotherapy which focuses on the exploration of the unconscious, to facilitate identification of the patientÙs defenses. à HYPNOTHERAPY Ö a therapeutic modality which involves various methods and techniques to includes a trance state where the patient becomes submissive to instructions.
HUMOR THERAPY ± involves the use of humor to facilitate expression of feelings and to enhance interaction. BEHAVIOR MODIFICATION ± a therapeutic intervention involving the application of learning principles in order to change maladaptive behavior. TOKEN-ECONOMY ± an example of behavior modification technique which utilizes the principle of rewarding desired behavior to facilitate change.
of behavior modification in which a painful stimulus is introduced to bring about an avoidance of another stimulus with the end view of facilitating change in behavior. DESENSITIZATION ± periodic exposure of the individual to a feared object, until the undesirable behavior disappears or is lessened.
à AVERSION THERAPY ± an example
ANXIETY AND ANXIETY RELATED DISORDERS
Anxiety - is a vague feeling of dread that is unwarranted by the situation, with no identifiable stimulus, accompanied by feelings of uneasiness and apprehension.
COMPONENTS OF PERSONALITY ID ± pleasure principles, gratification of needs, urges and wants. EGO ± reality principles, represents ³self´, ³I´, referee, arbiter, balancer between the ID and SUPEREGO conflicts. SUPEREGO ± moral principles, values, what is right and what is wrong, mostly parent¶s introjected values.
ANXIETY±it is the product of conflicts between the ID and SUPEREGO EGO defense mechanisms these are utilize when anxiety occurs it is use to safeguard the selfesteem of an individual. it is mentally healthy because it reduces anxiety. it is a way of coping with psychological stress.
CAUTIONS: Over utilization of ego defense mechanisms preclude learning more adaptive coping. It overshadows reality when overused. It will lead to maladaptive coping when utilized excessively. Over utilization eventually will lead to mental disorders. Mental disorders replaces adaptive coping in dealing with anxiety.
Working with Anxious Clients Mild anxiety is an asset; can learn and solve problems effectively; receptive to teaching and suggestions. Perceptual fields are widely open. Moderate anxiety can cause client s attention to wander; nurse must redirect client back to topic and validate client has heard and understood. Perceptual fields become narrowed.
Severe anxiety causes impairment of many abilities; cannot learn or problemsolve; nurse must calm client and focus on lowering anxiety level. Perceptual fields are closed. INCIDENCE Anxiety disorders are the most common psychiatric disorders. More prevalent in women More common in annulled and separated persons
More common in persons of lower socioeconomic status Onset and clinical course are variable. Anxiety can be communicated nonverbally from one person to another. Defense mechanisms are used to reduce anxiety; when overused they preclude learning more adaptive coping skills.
Physiologic responses can include sympathetic stimulation (fight-orflight), discomfort, difficulty thinking clearly, agitated motor activity, tension headaches.
ETIOLOGY Biologic theories: Anxiety may have an inherited component. Neurotransmitters may be dysfunctional in persons with anxiety disorders.
Psychodynamic theories: overuse of defense mechanisms; results from problems in interpersonal relationships; as ³learned´ behavioral response TREATMENT Usually involves a combination of medication (anxiolytics and antidepressants) and therapy.
Cognitive-behavioral therapy includes positive reframing (turning negative messages into positive ones) and decatastrophizing (making a more realistic appraisal of the situation). Assertiveness training helps the client learn to negotiate interpersonal situations more successfully.
PANIC DISORDER Involves 15- to 30-minute episodes of intense, escalating anxiety with emotional fear and physiologic discomfort.
Characteristics Client feels unreal and detached from self during attack. Fears losing control or going insane Has temporarily disorganized thought process, feels he or she is dying Judgment is poor during an attack. Anticipation of attacks causes the person to limit social activities and may interfere with work, relationships, family life.
Data Analysis Nursing diagnoses include: Risk for Injury Anxiety Fear Social Isolation
Data Analysis (cont¶d) Situational Low Self-Esteem Ineffective Coping Powerlessness Ineffective Role Performance Disturbed Sleep Pattern
Intervention Promoting safety and comfort Using therapeutic communication Managing anxiety Client and family teaching
PHOBIAS A phobia is an illogical, intense, persistent fear of a specific object or social situation that causes extreme distress and interferes with normal life functioning. Specific phobia is irrational fear of an object or situation, such as storms, heights), seeing blood or receiving an injection, or others.
Social phobia involves severe anxiety, even panic, when confronted with situations involving people, eating in public, using public bathrooms, or being the center of attention. Etiology Biologic (phobias run in families, hormonal functions, or neurotransmitter activity)
Psychodynamic (faulty thinking, belief one doesn¶t control the environment, or learned by modeling from parents) Treatment and Prognosis Psychopharmacology: anxiolytics; SSRI antidepressants; beta blockers to slow heart rate and lower blood pressure
Behavioral therapies include systematic desensitization and flooding.
Obsessions are recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that cause marked anxiety and interfere with interpersonal, social, or occupational functioning.
Compulsions are ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety, such as repeated checking or counting rituals, excessive hand washing, repeating words, touching rituals, symmetry rituals, cleanliness, and so forth. The person knows the rituals are unreasonable but feels forced to continue them in an attempt to relieve anxiety caused by obsessions.
Treatment and Prognosis Treatment is most successful with behavior therapy and medication (SSRI antidepressants, fluvoxamine, clomipramine, buspirone, clonazepam). Behavior therapy techniques used are exposure (confronting anxiety-provoking stimuli) and response prevention (delaying or avoiding ritual performance).
APPLICATION OF NURSING PROCESS FOR OCD Assessment Client assessment focuses on what behaviors or rituals are performed when and how often, client¶s response, and so forth to discover the pattern of behavior.
Data Analysis Anxiety Ineffective Coping Fatigue Situational Low Self-Esteem Impaired Skin Integrity (if scrubbing or washing rituals
Intervention Using therapeutic communication Teaching relaxation and behavioral techniques Completing a daily routine Providing client and family education
GENRALIZED ANXIETY DISORDER
Excessive worry and anxiety that is unwarranted more days than not. Seen most often by family physicians Treated with SSRI antidepressants and buspirone.
CLINICAL PICTURE OF ABUSE AND VIOLENCE Abuse is the wrongful use and maltreatment of another person; can be child, spouse, partner, or elder parent. Victims of abuse and trauma can have both physical and psychological injuries that might include: Agitation anxiety, silence Suppressed anger or resentment Shame and guilt
Feelings of being degraded or dehumanized; low self-esteem Relationship problems; mistrust of authority figures CHARACTERISTICS OF VIOLENT FAMILIES Social isolation Power and control by abusive person Alcohol and other drug use Intergenerational transmission process
Domestic violence occurs in families of all ages and from all ethnic, racial, religious, socioeconomic, and sexual orientation backgrounds.
SPOUSE OR PARTNER ABUSE Involves the mistreatment of one person by another in the context of an intimate relationship 90% to 95% of domestic violence victims are women. Pregnancy escalates domestic violence. Abuse can occur in same-sex relationships.
Treatment and Intervention Domestic violence laws varies and are not always followed. Women may stay in abusive relationships for fear of violence to children, fear of increased violence or death, financial dependence. Identifying women in violent situations is a priority. More health care agencies are beginning to ask routine screening questions of all women.
Treatment and Intervention (cont¶d) Providing women with information about shelters, services, and so forth is essential. The nurse must never indicate that he or she thinks the woman should leave the relationship; need to keep the door open for further communication.
CHILD ABUSE Child abuse is intentional injury of a child. It may include physical abuse or injuries, sexual assault or intrusion, neglect or failure to prevent harm (failure to provide adequate physical or emotional care or supervision, abandonment), or psychological abuse. We have mandatory child abuse reporting laws that include nurses.
Parents who abuse children: Have minimal parenting knowledge & skills Are emotionally immature and needy Are incapable of meeting their own needs, much less those of a child Often raise their children the way they were raised, including corporal punishment and abuse Expect the child to meet all their needs for love and affection
Assessment Suspect child abuse when there are: Unusual injuries such as scalding and cigarette burns Delays in seeking treatment; inconsistent history, or illogical explanation for the injuries Urinary tract infections, red, swollen, or bruised genitalia, tears of vagina or rectum Old injuries that were not treated Multiple, unexplained bruises
Treatment and Intervention Getting the child to a safe place once abuse is identified Family therapy Individual therapy for the child Intensive involvement of social service agencies Treatment for parents for any substance abuse or psychiatric issues
ELDER ABUSE Elder abuse is maltreatment of older adults by family members or caretakers and can include physical, sexual, or psychological abuse, neglect, self-neglect, financial exploitation, or denial of adequate medical treatment. 60% perpetrators are spouses, 20% adult children, 20% others. People who abuse elders are almost always in a caretaker role.
Malnourished, dehydrated Rashes, sores, lice Elders are reluctant to report abuse because they fear the alternative (nursing home).
Reluctance to talk openly Helplessness Withdrawal or depression Anger or agitation Smell of urine, feces, dirt Failure to keep needed medical appointments Untreated medical condition Inability to manage own finances Inability to perform activities of daily living
Inadequate clothing Inability to manage money Unusual activity in bank accounts Different signatures on checks Recent changes in will that client could not make
Possible indicators of abuse by caregiver: Caregiver speaks for the elderly person. Caregiver shows indifference or anger. Caregiver blames elderly person for physical problems. Caregiver shows defensiveness. Caregiver and client give conflicting accounts
RAPE Rape is a crime of violence and aggression expressed through sexual means. The act is against the victim¶s will or against someone who cannot give consent. The victim can be any age. Half of rapes are committed by someone known to the victim. Rape is underreported to the police. Same-sex rape can occur between partners but is most common in institutions.
Male rapists have been categorized as: Sexual sadists aroused by pain of victim Exploitative predators Inadequate men Those who rape as a displaced expression of anger and rage
Physical and psychological trauma to rape victims is severe: Medical problems: victims are significantly less healthy; pregnancy, STDs, HIV are concerns. Victim may feel frightened, helpless, guilty, humiliated, and embarrassed; may avoid previously pleasurable activities. Relationship problems may occur.
Treatment and intervention include: Immediate support to ventilate fear and rage Care by persons who believe that the rape happened Coordination of all needed services in one location
Treatment and intervention include: Giving the victim control over choices whenever possible Prophylactic treatment for STDs Referral to therapy services; counseling, and groups for longerterm help
PSYCHIATRIC DISORDERS RELATED TO ABUSE AND VIOLENCE Two psychiatric disorders are associated with histories of violence and abuse: posttraumatic stress disorder (PTSD) and dissociative disorders.
PTSD Is disturbing behavior resulting after a traumatic event at least 3 months after the trauma occurred. Up to 60% of persons at risk (combat veterans, victims of violence, and natural disasters) develop PTSD. It includes persistent nightmares, memories, flashbacks, emotional numbness, insomnia, irritability, hypervigilance, and angry outbursts.
Dissociative Disorders Dissociation is a subconscious defense mechanism that helps a person protect the emotional self from recognizing the full impact of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory. Dissociation can occur both during and after the event and becomes easier with repeated use.
Amnesia Fugue Dissociative identity disorder (formerly multiple personality disorder) Depersonalization disorder
Treatment and Interventions Involvement in group and/or individual therapy in the community Clients with dissociative disorder or PTSD are seen in the acute setting for brief periods when symptoms are severe or there is concern for their safety.
APPLICATION OF NURSING PROCESS Assessment (PTSD) Often includes history of trauma or abuse Client often appears hyperalert. Mood and affect: client is fearful and anxious; needs large personal space; has a wide range of emotions. Thought processes and content: nightmares, flashbacks, destructive thoughts or impulses
Assessment (cont¶d) Sensorium and intellectual processes: disorientation (during flashbacks), memory gaps Judgment and insight: Impaired decision-making and problem-solving abilities Self-concept: client has low selfesteem.
ASSESSMENT (cont¶d) Roles and relationships: problems with relationships, work, authority figures. Physiologic considerations: difficulty sleeping, under- or overeating, use of alcohol or drugs for self-medication
Data Analysis Nursing diagnoses include: Risk for Self-Mutilation Ineffective Coping Post-Trauma Syndrome Chronic Low Self-Esteem Powerlessness
Intervention Promoting the client¶s safety Helping the client cope with stress and emotions using grounding techniques Helping to promote the client¶s self-esteem Establishing social support
FOUR ASPECTS OF SEXUALITY Genetic identity ± person¶s chromosomal gender Gender identity ± person¶s perception of his or her own maleness or femaleness. Gender role ± cultural role attributes of one¶s gender, such as expectations regarding behavior, cognitions, occupations, values, and emotional responses.
Sexuality orientations Heterosexuality- sexual attraction to opposite sex. Homosexuality ± sexual attraction to members of the same sex. Bisexuality ± attraction to both men and women. Transvestism ± cross-dressing, or dressing in the clothes of the opposite sex. Transexual ± going from one sex to another
Sexual orientation ± gender to which one is romantically attracted. Sexual Response Cycle Stage 1: Desire Sexual fantasies and the desire for sexual activity. Stage 2: Excitement Subjective sense of sexual pleasure along with physiological changes, including penile erection in the male and vaginal lubrication in the female
Stage 3: Orgasm Peaking of sexual pleasure and the release of sexual tension accompanied by rhythmic contractions of the perineal muscles and pelvic reproductive organs. Stage 4: Resolution Sense of general relaxation, muscular relaxation, and well-being. Females may be able to respond to additional stimulation almost immediately during this stage.
Common Problems: Females Lack of orgasm Vaginismus Males Erectile dysfunction Ejaculatory disorders - premature - inhibited - retrograde
Sexual Dysfunctions Hypoactive sexual desire disorder Female sexual arousal disorder Male erectile disorder Female orgasmic disorder Male orgasmic disorder Premature ejaculation Dyspareunia Vaginismus
Paraphilias Exhibitionism Fetishism Frotteurism Pedophilia Sexual masochism Sexual sadism Transvestic fetishism Voyeurism
Gender Identity Disorders Childhood, adolescence, or adulthood persistent and intense distress about being a male or a female, with an intense desire to be the opposite sex, a preoccupation with the activities of the opposite sex, and a repudiation of one¶s own anatomical structures.
abuse (using a drug in a way that is inconsistent with medical or social norms and despite negative consequences) is a major concern nationwide. y 14% of adults have an alcoholrelated disorder. y 6.2% have a substance-related disorder (excluding nicotine). y Adolescent substance abuse is rising.
numbers of babies are being born to substance-addicted mothers. y Half of all persons seeking alcohol-related treatment have at least one alcoholic parent.
Biologic factors include genetic vulnerability and failure of neurotransmitters to signal ³enough.´ Psychological factors include familial tendency (having an alcoholic parent or relatives) and social influences; for instance, there are higher rates of cocaine and opioid use in urban areas that have high crime rates, high unemployment, substandard schools. There are fewer social taboos against alcohol use.
Types of Substance Abuse
abuse includes alcohol, prescription and OTC medications, and illicit drugs. Polysubstance abuse is abuse of more than one substance and is common. . y Alcohol has been a major focus of research, so more is known about it: y First intoxication episode occurs at age 15 to 17 years (first drink may be much earlier). y Severe difficulties begin to appear in mid-20s to mid-30s.
occur (person continues to function but has no memory or awareness of what he or she has done). y There may be cycles of controlled drinking, abstinence, drinking problems, and so forth. y Programs attempting to teach ³social drinking´ have been failures. y There are some reports of spontaneous remission (quit drinking without treatment).
most, alcoholism is a chronic illness. Relapse and repeated treatment are common.
Alcohol Treatment and Prognosis y Treatment is based on the concept that alcoholism and drug addictions are a medical illness: chronic, progressive, characterized by remissions and relapses
is on group experiences involving education, problemsolving techniques, cognitive techniques to identify and modify faulty thinking, coping with life, stress, and other people without the use of substances y Treatment may be as an outpatient or inpatient depending on client¶s circumstances and ability to abstain from alcohol or drugs.
withdrawal from alcohol includes use of vitamin B1 (thiamine) supplements to prevent or treat WernickeKorsakoff¶s syndrome, folic acid, multivitamins, cyanocobalamin (vitamin B12) for nutritional deficiencies. y Alcohol withdrawal managed with benzodiazepines (Diazepam-Valium, Chlordiaxepozide-Librium)
(Antabuse) to help client abstain from alcohol; methadone as a substitute for heroin; Naltrexone (ReVia) to block effects of opioids and reduce cravings for alcohol; Clonidine (Catapres) to suppress opiate withdrawal; Bromocriptine (Parlodel) to decrease cocaine cravings
Denial is a major component of substance abuse, so identifying clients can be difficult. Several screening devices are available. Detoxification is a priority.
Key points to REMEMBER Substance abuse ± includes characteristics of withdrawal and tolerance Substance dependence ± includes characteristics of adverse consequences and repeated use. Co-dependent ± includes all the characteristics of a drug abuser that a partner usually inherited but not technically abuse drugs.
Danger in taking Inhalants ± sudden death from cardiac and respiratory depression.
CHILD AND ADOLESCENT DISORDERS
Degrees of Retardation Mild (IQ 50 to 70) Moderate (IQ 35 to 50) Severe (IQ 20 to 35) Profound (IQ below 20)
Causes Heredity, altered embryonic development, perinatal problems (fetal malnutrition, hypoxia, infections, trauma) Medical conditions of infancy Deprivation of nurturing or stimulation
PERVASIVE DEVELOPMENTAL DISORDERS Characterized by pervasive and usually severe impairment of reciprocal social interaction skills, communication deviance, restricted stereotypical behavioral patterns. 75% are also mentally retarded. Autistic Disorder Best known of these disorders More prevalent in boys Present by age 3
CONT¶D Child has little eye contact, few facial expressions, does not communicate verbally or with gestures, doesn¶t relate to peers or parents, lacks spontaneous enjoyment; apparent absence of mood and affect; cannot engage in play or make-believe with toys
Hand-flapping, body-twisting, head-banging Autism may improve, sometimes substantially, as language and communication skills are learned. Traits persist into adulthood. Few attain complete independence, marry, or have children.
CONT¶D Most autistic children are mainstreamed in school. Medications may be used to target specific behaviors but do not treat the autism. Goals are to reduce behavioral symptoms and promote learning, development, and language skills.
ATTENTION DEFICIT HYPERACTIVITY DISORDERS Inattentiveness, overactivity, and impulsiveness Affects 3% to 5% of school-aged children; affects boys more frequently Can persist into adulthood Often diagnosed when child starts school
Child may be ostracized by peers due to behavior No known cause; seems to be familial tendency
Onset and Clinical Course Most often diagnosed when child starts school or preschool
ETIOLOGY Essentially unknown, but likely to be a combination of factors such as environmental toxins, prenatal influences, heredity, damage to brain structure and function
TREATMENT Combination of behavioral strategies and psychostimulants (Ritalin) Side effects: insomnia, loss of appetite, weight loss or failure to gain weight Behavioral strategies are necessary at home and school to help the child succeed: consistent rewards and consequences for behavior, using time-out, points systems, structured routine and schedule for activities
APPLICATION OF NURSING PROCESS Assessment Information is gathered from all available sources, including the child. A checklist often helps parents focus on specific behaviors and keep track of them at home. History: Parents report all efforts to change child¶s behavior are unsuccessful.
Assessment (cont¶d) General appearance and motor behavior: cannot sit still, squirms and wiggles, darts around the room, cannot carry on conversation due to interrupting, blurting out answers, not paying attention to what is said, jumps from one topic to another
Assessment (cont¶d) Mood and affect: Mood may be labile with verbal outbursts or temper tantrums, anxiety, frustration, agitation; appears driven to keep talking or moving Thought processes and content: generally no problems in thought process or content but may be difficult to assess
Assessment (cont¶d) Sensorium and intellectual processes: child alert and oriented, no sensory or perceptual alterations; ability to concentrate and pay attention is markedly impaired; very distractible, says ³I don¶t know´ rather than taking time to answer; unable to complete tasks
Assessment (cont¶d) Judgment and insight: poor judgment, takes risks, doesn¶t perceive potential harm Self-concept: may be unaware that behavior is different from others, saying ³no one likes me´; generally low self-esteem due to lack of success and difficulty with peer relationships; may see self as stupid
CONT¶D Roles and relationships: unsuccessful; child is intrusive and disruptive, incites negative responses from others; parents and teachers chronically frustrated and exhausted Physiologic considerations: child may be thin if no time taken to eat properly, trouble settling down for bed, sleeps poorly, may have history of injury if engaged in risky behaviors
Data Analysis Nursing diagnoses include: Risk for Injury Ineffective Role Performance Impaired Social Interaction Compromised Family Coping
Intervention Can be used in variety of settings and taught to parents, teachers, and caregivers: Ensuring safety Improved role performance Simplifying instructions Providing a structured daily routine Providing client and family education and support
Persistent antisocial behavior of children and adolescents that significantly impairs ability to function in social, academic, or occupational areas Symptoms cluster around aggression to people and animals: destruction of property, deceitfulness and theft, serious violation of rules..
CONT¶D Associated with early sexual activity, drinking, smoking, use of illegal substances, and other reckless or risky behaviors Three times more common in boys 30% to 50% are diagnosed as antisocial personality disorder as adults. Symptoms can start before age 10 (and are more severe) or after age 10 (better outcomes as adults).
CONT¶D Classified as mild, moderate, or severe Etiology: genetic vulnerability, environmental adversity, poor coping Risk factors: poor parenting, low academic achievement, poor peer relationships, low self-esteem
Conduct disorder associated with family problems: child abuse, exposure to violence, socioeconomic disadvantages
ETIOLOGY Combination of genetic vulnerability, environmental adversity, and poor coping. Risk factors include poor parenting, low academic achievement, poor peer relationships, low self-esteem.
Assessment History: disturbed peer relationships, aggression toward people or animals, destruction of property, deceitfulness, theft, truancy, running away, staying out all night; may be mild to severe
Assessment (cont¶d) General appearance and motor behavior: typical for age group; may be extreme in terms of piercing, tattoos, use of profanity; disparaging remarks about parents and other authority figures
Assessment (cont¶d) Thought processes and content: has capacity for rational thought but believes ³everyone is out to get me´
Assessment (cont¶d) Judgment and insight: limited insight (blames others), poor judgment (taking risks)
Self-concept: may appear ³tough´ but has low selfesteem and doesn¶t value self
CONT¶D Roles and relationships: relationships disrupted, even violent; verbal and physical aggression common, unsuccessful in school, unlikely to work Physiologic and self-care considerations: risk for unplanned pregnancy and STDs; use of alcohol and drugs common; may have injuries from fighting
Data Analysis Nursing diagnoses include: Risk for Other-Directed Violence Noncompliance Ineffective Coping Impaired Social Interaction Chronic Low Self-Esteem
Intervention Decreasing violence Increasing compliance with treatment Improving coping skills and selfesteem Promoting social interaction Providing client and family education
EVALUATION Treatment is effective if client follows reasonable rules and expectations and stops behaving in aggressive or illegal ways.
OPPOSITIONAL DEFIANT DISORDER Enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures that does not involve major antisocial violations Behaviors cause dysfunction in social, academic, and work situations. 25% go on to develop conduct disorder.
CONT¶D 10% are diagnosed with antisocial personality disorder as adults. Treatment is similar to conduct disorder, depending on severity of behaviors.
TIC DISORDERS Rapid, sudden, recurrent, nonrhythmic stereotyped motor movement or vocalization Runs in families Treated with atypical antipsychotics such as olanzapine or risperidone
CONT¶D Tourette¶s Disorder Multiple motor tics and one or more vocal tics; vocal tics can be name-calling or profanity; can persist into adulthood Person is embarrassed and selfconscious and has significant impairment in academic, social, occupational areas.
CHRONIC MOTOR OR TIC DISORDER Has only vocal tic or only motor tics, not both like Tourette¶s
SEPARATION ANXIETY DISORDER Excessive anxiety about separation from home or loved ones, exceeding what would be expected Results from combination of temperament traits (passivity, avoidance, fearfulness or shyness of novel situations) Parenting behaviors that encourage avoidance as a way to deal with unknown situations
SELECTIVE MUTISM Persistent failure to speak in social situations where speaking is expected Excessively shy, socially withdrawn, isolated, clinging Temper tantrums
Eating disorders can be viewed on a continuum: the anorexic eats too little or is starving, the bulimic eats in a chaotic way, and the obese person eats too much. There is much overlap among the eating disorders: 50% of clients with anorexia exhibit bulimic behavior and 35% of normal-weight clients with bulimia have a history of anorexia. More than 90% of cases of anorexia nervosa and bulimia occur in females.
ANOREXIA NERVOSA Life-threatening eating disorder characterized by: Client¶s refusal or inability to maintain a minimally normal body weight Intense fear of gaining weight or becoming fat Significantly disturbed perception of the shape or size of the body Steadfast refusal by client to acknowledge the problem is severe or that there is even a problem at all
85% of expected body weight or less Amenorrhea Total absorption in quest for thinness and weight loss
Onset and Clinical Course Anorexia typically begins between 14 and 18 years of age. Ability to control weight give pleasure to the client. Client may feel empty emotionally and be unable to identify or express emotional feelings. As illness progresses, depression and labile moods are common.
Client is socially isolated, mistrustful of others; may believe that others are trying to make her fat and ugly
BULIMIA NERVOSA Characterized by recurrent episodes of binge eating, inappropriate compensatory behaviors to avoid weight gain (purging: self-induced vomiting, use of laxatives, diuretics, enemas, emetics, fasting, excessive exercise).
Binge eating is done in secret and the client recognizes the eating behavior as pathologic, causing feelings of guilt, shame, remorse, or contempt. Clients with bulimia are usually in normal weight range but may be underweight or overweight. Dentists may be the first to discover bulimia due to loss of tooth enamel, caries, chipped or ragged teeth.
Onset and Clinical Course Begins about age 18 or 19 Binge eating begins after an episode of dieting. Between binges, eating may be restrictive. Food is hidden in the car, desk at work, and secret locations around the house. Behavior may continue for years before it is discovered.
ETIOLOGY Specific etiology for eating disorders is unknown, but initially dieting may be the stimulus that leads to the eating disorder.
Assessment (EATING DISORDERS) History: Client with anorexia is described by parents as a model child, no trouble, dependable, before onset of anorexia. Clients with bulimia are eager to please and conform, avoid conflict, but may have history of impulsive behavior.
Assessment (cont¶d) General appearance and motor behavior: Clients with anorexia are slow, lethargic, even emaciated; slow to respond to questions, difficulty deciding what to say, reluctant to answer questions fully; often wear baggy clothes or layers to hide weight or keep warm; limited eye contact; unwilling to discuss problems or enter treatment.
Clients with bulimia generally have a normal appearance, are open and talkative. Mood and affect: Moods are labile, corresponding to eating or dieting behavior. Clients with anorexia may look sad and anxious and seldom smile or laugh. Clients with bulimia are initially cheerful but express intense emotions of guilt, shame, and embarrassment when discussing bingeing and purging behaviors.
Ask clients with eating disorders about suicidal ideas and self-harm urges; both are common. Thought processes and content: Clients spend most of their time thinking about food, dieting, foodrelated issues. Body image disturbance can be almost delusional. Clients with anorexia may have paranoid ideas about their family and health care professionals being the ³enemy,´ trying to make them fat.
Data Analysis Nursing diagnoses may include: Imbalanced Nutrition: Less Than/More Than Body Requirements Ineffective Coping Disturbed Body Image Other diagnoses such as Deficient Fluid Volume, Constipation, Fatigue, and Activity Intolerance may be indicated.
Intervention Establishing nutritional eating patterns Helping client identify emotions and develop coping strategies Dealing with body image issues Client and family education
Evaluation Body weight within 5% to 10% of normal No medical complications from starvation or purging
Somatoform disorders are characterized by the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis to account fully for the symptoms. Three central features of somatoform disorders: Physical complaints that suggest medical illness but have no demonstrable organic basis
Psychological factors and conflicts that seem important in initiating, exacerbating, and maintaining the symptoms Symptoms or magnified health concerns that are not under the client¶s conscious control
Five specific somatoform disorders: Somatization disorder: multiple physical symptoms; combination of pain, GI, sexual, and pseudoneurologic symptoms Conversion disorder: unexplained deficits in sensory or motor function such as blindness or paralysis associated with psychological factors; attitude of ³la belle indifference´ (lack of concern or distress)
Pain disorder: pain unrelieved by analgesics; psychological factors influence onset, severity, exacerbation, and maintenance Hypochondriasis: preoccupation with fear that one has or will get a serious disease Body dysmorphic disorder: preoccupation with imagined or exaggerated defect in physical appearance
Data Analysis Nursing diagnoses include: Ineffective Coping Ineffective Denial Impaired Social Interaction Anxiety Disturbed Sleep Pattern Fatigue Pain
Intervention Providing health teaching Assisting client to express emotions Teaching coping strategies
Evaluation Changes are likely to occur slowly. Using fewer medications, making fewer visits to physicians, improved coping skills, increased functional abilities would be indicators of treatment success.
Personality disorders are diagnosed when personality traits become inflexible or maladaptive and interfere with how one functions in society or cause emotional distress. They are diagnosed in adulthood, but maladaptive patterns can be traced to childhood or adolescence.
Cluster A: people whose behavior is odd or eccentric (paranoid, schizoid, schizotypal) Cluster B: people who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, narcissistic)
Cluster C: people who are anxious or fearful (avoidant, dependent, obsessivecompulsive) Disorders being considered for inclusion are depressive and passive-aggressive.
Treatment Individual and group therapy may be helpful to those desiring change, but any changes are slow. Improvement in relationships, improved basic living skills, relief of anxiety may be goals of therapy. Cognitive-behavioral techniques such as thought-stopping, positive self-talk, and decatastrophizing can be effective.
Pharmacologic treatment is based on the type and severity of symptoms rather than the particular personality disorder itself. The four system categories are: Aggression/impulsivity Mood dysregulation Anxiety Psychotic symptoms
CLUSTER A PERSONALITY D/O Paranoid personality disordermistrust and suspicion of others; guarded, restricted affect Schizoid personality disorder ± detached from social relationships; restricted affect; involved more with things than people Schizotypical personality disorder ± acute discomfort in relationships; cognitive or perceptual distortions; eccentric behavior
CLUSTER B PERSONALITY D/O Antisocial Personality Disorder Antisocial personality disorder is characterized by a pervasive pattern of disregard for and violation of rights of others; involves deceit and manipulation. 50% of prisoners have this disorder.
Assessment (ANTISOCIAL) History of problems in childhood and adolescence General appearance and motor behavior: appears ³normal´; may be charming and engaging, trying to manipulate Mood and affect: ³chooses´ emotions to be displayed that display him in a favorable light, but no true genuine feelings of empathy, remorse
Assessment (cont¶d) Thought processes and content: views the world as cold and hostile, thinks everyone else is as ruthless as he or she is, so trusts no one Sensorium and intellectual processes: intact Judgment and insight: lacks insight, poor judgment due to inability to delay gratification, impulsivity, or ethical/legal considerations of actions
Assessment (cont¶d) Self-concept: superficially appears self-assured and confident, even arrogant, but this covers low selfesteem; poor relationships due to exploitation and using others Roles and relationships: has trouble keeping jobs, being a parent, staying married, and so forth
DATA ANALYSIS Nursing diagnoses include: Ineffective Individual Coping Ineffective Role Performance Risk for Other-Directed Violence
Intervention Forming therapeutic relationship Promoting responsible behavior Helping client solve problems and control emotions Enhancing role performance
BORDERLINE PERSONALITY DISORDER Borderline personality disorder is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect and marked impulsivity.
Assessment (BORDERLINE) History: family problems common, especially alcoholism and sexual abuse General appearance and motor behavior: mildly dysfunctional clients appear normal; severely affected clients may be disheveled, unable to sit still, crying, out of control
ASSESSMENT COTN¶D Mood and affect: dysphoric mood, unhappy, restless, malaise; intense feeling of loneliness, boredom, frustration, abandonment by others; mood is labile and feelings are intense
CONT¶D Thought processes and content: polarized thinking is common; others are ³adored´ after a brief acquaintance, then despised if they don¶t meet client¶s expectations; obsessive and ruminative thoughts about abandonment, suicide, and selfharm; may have dissociative episodes
CONT¶D Sensorium and intellectual processes: oriented, intellectual functions intact; may experience transient psychotic symptoms such as hallucinations under severe stress; may have flashbacks of abuse (consistent with PTSD diagnosis)
CONT¶D Judgment and insight: judgment is poor; impulsive and reckless behaviors such as lying, shoplifting, gambling are common; limited insight: believes problems are due to others ³failing´ them
CONT¶D Self-concept: unstable and shifts rapidly: needy one minute, hostile and rejecting the next; frequent self-injury; lacks consistent view of self
CONT¶D Roles and relationships: difficulty fulfilling roles, especially involving mundane tasks (school, work); relationships are stormy given client¶s behavior, but client blames others; clings to people, then rejects them angrily; desires relationships/friendships, but behavior drives others away
CONT¶D Physiologic and self-care considerations: in addition to selfmutilation, bingeing and purging are common; abuse of alcohol or drugs, unprotected sex, reckless behavior; usually difficulty sleeping
Data Analysis Nursing diagnoses include: Risk for Suicide Risk for Self-Mutilation Ineffective Coping Risk for Other-Directed Violence Social Isolation
Interventions Promoting the client¶s safety Promoting the therapeutic relationship Establishing boundaries in relationships Teaching effective communication skills Helping the client to cope and control emotions Reshaping thinking patterns Structuring daily activities
OTHER CLUSTER B P.D. Histrionic personality disorder ± excessive emotionality and attention-seeking Narcissistic personality disorder ± grandiose; lack of empathy; need for admiration
CLUSTER C PERSONALITY D/O Avoidant personality disorder ± social inhibitions; feelings of inadequacy; hypersensitivity to negative evaluation Dependent personality disorder ± submissive and clinging behavior; excessive need to be taken care of Obsessive-compulsive personality disorder ± preoccupation with orderliness, perfectionism, and control
Mood disorders are diagnosed when these alterations in emotions are pervasive and interfere with the person¶s ability to live life.
CATEGORIES Major Depression Disorder: 2 or more weeks of sad mood, lack of interest in life activities, and other symptoms Bipolar disorder (formerly called manic-depressive illness): mood cycles of mania and/or depression and normalcy
RELATED DISORDERS Dysthymic disorder: sadness, low energy, but not severe enough to be diagnosed as major depression disorder Cyclothymic disorder: mood swings not severe enough to be diagnosed as bipolar disorder Seasonal affective disorder (SAD) Depressive personality disorder Postpartum or µmaternity¶ blues
RELATED D/O CONT¶D
Postpartum depression Postpartum psychosis
Biologic theories include genetics. neurochemical theories, and neuroendocrine or hormonal fluctuations.
MAJOR DEPRESSIVE DISORDER Twice as common in women and more common in single or divorced people Involves 2 or more weeks of sad mood, lack of interest in life activities, and at least four other symptoms, such as anhedonia, changes in weight, sleep, energy, concentration, decisionmaking, self-esteem, goal-setting
CONT¶D Untreated, can last 6 to 24 months; recurs in 60% of people Symptoms range from mild to moderate to severe.
Treatment and Prognosis Antidepressants SSRIs include Prozac, Zoloft, Paxil, Celexa. Prescribed for mild and moderate depression. Tricyclic antidepressants (TCAs) include Elavil, Tofranil, Norpramin, Pamelor, Sinequan; used for moderate and severe depression.
Atypical antidepressants include Effexor, Wellbutrin, Serzone. MAOIs include Marplan, Parnate, Nardil; used infrequently because interaction with tyramine causes hypertensive crisis. Electroconvulsive therapy (ECT) is used when medications are ineffective or side effects are intolerable. After anesthesia and muscle relaxants, a shock is administered via electrodes to produce seizure activity in the brain.
Treatments are administered in a series (for instance, three times a week for 6 weeks). Psychotherapy in conjunction with medication is considered most effective treatment. Useful therapies include behavioral, cognitive, interpersonal, family therapy.
MAJOR DEPRESSIVE DISORDER Assessment Must include determination of suicidal ideas and lethality and client¶s perception of the problem
ASSESSMENT CONT¶D Psychomotor retardation or agitation, feelings of helplessness, anxiety, sadness, guilt, frustration, negativism and pessimism, lack of pleasure, social withdrawal, reduced concentration & decision-making, fatigue & exhaustion, low self-esteem and rumination about past bad deeds or failures, loss of ability to function in life roles, sleep disturbances, overeating or undereating, lack of attention to hygiene and grooming
Data Analysis Nursing diagnoses may include: Risk for Suicide Imbalanced Nutrition Anxiety Ineffective Coping Hopelessness
Intervention Providing for the client¶s safety and the safety of others Promoting a therapeutic relationship Promoting activities of daily living and physical care Using therapeutic communication Managing medications Providing client and family teaching
BIPOLAR DISORDER Involves mood swings of depression (same symptoms of major depressive disorder) and mania. Major symptoms of mania include grandiose mood, agitation, exaggerated self-esteem, sleeplessness, pressured speech, flight of ideas, easily distractible, intrusive behavior, with lack of personal boundaries, high-risk activities with potentially severe consequences, poor judgment.
Treatment and Prognosis Treatment may involve medication with lithium; regular monitoring of serum lithium levels is needed. Anticonvulsant drugs are used for their mood-stabilizing effects: Tegretol, Depakote, Lamictal, Topamax, Trileptal, Neurontin; and Klonopin (a benzodiazepine)
Assessment (BIPOLAR DISORDER) General appearance and motor behavior: Assessing a client in the manic phase may be difficult and based more on observations of the client rather than client¶s responses to structured questions. Client jumps from one subject to another, cannot sit still, may wear flamboyant clothing or makeup.
CONT¶D Mood and affect: psychomotor agitation, racing thoughts, pressured speech, ignores directions or requests from others, unusual speech patterns
Thought processes and content:
starts many grandiose projects but finishes none; careless spending sprees
CONT¶D Sensorium and intellectual processes: loud voice; may be hypersexual Judgment and insight: poor Self-concept: false, grandiose sense of well-being that covers low selfesteem
Assessment (cont¶d) Roles and relationships: may be charming and playful, then sarcastic and angry; cannot take ³no´ for an answer Physiologic and self-care considerations: inattention to hygiene and grooming, hunger or fatigue
Data Analysis Nursing diagnoses may include: Risk for Other-Directed Violence Risk for Injury Imbalanced Nutrition Ineffective Coping Noncompliance
Intervention Providing for safety of client and others Meeting physiologic needs Providing therapeutic communication Promoting appropriate behaviors Managing medications
SUICIDE Families need support when a member has committed suicide or is making attempts to do so. They may feel guilty, angry, and ashamed and are at increased risk for suicide themselves. Assessment Populations at risk Warnings of suicidal intent Risky behaviors Lethality assessment
Outcomes The client will: Be safe from harm self or others Engage in a therapeutic relationship Establish a no-suicide contract Create a list of positive attributes Generate, test, and evaluate realistic plans to address underlying issues
Intervention Using an authoritative role Providing a safe environment Initiating a no-suicide contract Creating a support system list Supervision
Schizophrenia is a syndrome or disease process of the brain causing distorted and bizarre thoughts, perceptions, emotions, movements, and behavior. It is usually diagnosed in late adolescence and early adulthood (15 to 25 years for men, 25 to 35 years for women). Prevalence is 1% of total population.
Hard or positive symptoms are amenable to antipsychotic medication and include: Delusions Hallucinations Grossly disorganized thinking, speech, and behavior.
Soft or negative symptoms persist over time and are somewhat amenable to atypical antipsychotics only. They include: Flat affect Lack of volition (AVOLITION) Social withdrawal or discomfort Apathy Alogia (poverty of content)
TYPES OF SCHIZOPHRENIA Paranoid type: persecutory or grandiose delusions and hallucinations; sometimes excessive religiosity; hostile and aggressive behavior Disorganized type: grossly inappropriate or flat affect, incoherence, loose associations, extremely disorganized behavior
Catatonic type: marked psychomotor disturbance, motionless or excessive motor activity, extreme negativism, mutism, peculiarities of voluntary movement (echolalia, echopraxia) Undifferentiated type: mixed schizophrenic symptoms along with disturbances of thought, affect, behavior
Residual: at least one previous psychotic episode but not currently; social withdrawal, flat affect, loose associations
CLINICAL COURSE Varies among clients Most clients experience a slow and gradual onset of symptoms. Younger age of onset associated with poorer outcomes In first years after diagnosis, client may have relatively symptom-free periods between psychotic episode or fairly continuous psychosis with some shift in severity of symptoms.
Over the long term, psychotic symptoms diminish for most clients and are managed more easily. Many years of dysfunction are rarely overcome.
RELATED DISORDERS Schizophreniform disorder: symptoms of schizophrenia are experienced for less than the 6 months required for a diagnosis of schizophrenia Schizoaffective disorder: symptoms of psychosis and thought disorder along with all the features of a mood disorder Delusional disorder: one or more nonbizarre delusions with no impairment in psychosocial functioning
Brief psychotic disorder: one psychotic symptoms lasting 1 day to 1 month; may or may not have an identifiable stressor, such as childbirth Shared psychotic disorder (folie à deux): similar delusion shared by two people, one of whom has psychotic delusions
ETIOLOGY Current etiologic theories focus on biologic theories: Genetic Neuroanatomic theories Neurochemical theories Immunovirologic factors
TREATMENT Primary treatment of schizophrenia is neuroleptic or antipsychotic medication. Adjunctive Treatment Individual, group, and family therapy Structured milieu therapy Community support programs Client/family education and support
Assessment Previous hospitalizations Presence of suicidal ideation Current support system Client¶s perception, appearance, odd or bizarre speech or motor behavior History
ASSESSMENT CONT¶D General appearance and motor behavior Mood and affect: flat or blunted affect, anhedonia Thought processes and content: delusions Sensorium and intellectual processes: hallucinations, concrete or literal thinking Judgment and insight: impaired judgment, limited insight
CONT¶D Self-concept: may be distorted, with depersonalization, loss of ego boundaries resulting in bizarre behaviors Roles and relationships: often socially isolated, have difficulty fulfilling life roles
CONT¶D Physiologic and self-care considerations, may have multiple self-care deficits (inattention to hygiene, nutrition, sleep needs; polydipsia occasionally seen in longer-term clients)
Data Analysis Common nursing diagnoses for positive symptoms include: Risk for Other-Directed Violence Risk for Suicide Disturbed Thought Processes Disturbed Sensory Perception
Nursing diagnoses for negative symptoms and functional abilities include: Self-Care Deficits Social Isolation Deficient Diversional Activity Ineffective Health Maintenance
Intervention Promote safety of clients and others. Establish a therapeutic relationship. Interventions for delusional thoughts. Interventions for hallucinations. Protecting the client who has socially inappropriate behaviors. Client and family teaching
Cognition involves the brain¶s ability to process, retain, and use information. Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory. Disruption of these functions impairs the person¶s ability to make decisions, solve problems, interpret the environment, and learn new information.
Delirium is a syndrome that involves disturbance of consciousness accompanied by a change in cognition. It develops over a short period of time and fluctuates over time. It causes difficulty in paying attention, distractibility, and disorientation. Sensory disturbances include illusions, misinterpretations, hallucinations, disturbances in sleep/wake cycle, anxiety, fear, irritability, euphoria, apathy.
TREATMENT Treatment of the underlying
medical condition will usually resolve delirium. Clients with head injury or encephalitis may have cognitive, emotional, or behavioral impairment due to brain damage from the disease or injury.
TREATMENT CONT¶D Delirious clients who are quiet and resting need no other medication for delirium. Those who are restless or a safety risk may require low-dose antipsychotic medication. Sedatives and benzodiazepines may worsen the delirium.
TREATMENT CONT¶D Alcohol withdrawal is managed medically with benzodiazepines. IV fluids or total parenteral nutrition may be needed. Occasionally restraints are necessary so that tubes and catheters aren¶t pulled out. Use judiciously and for short periods because restraints may increase agitation.
Dementia involves multiple cognitive deficits, primarily memory impairment, and at least one of the following: aphasia, apraxia, agnosia, or disturbance in executive functioning. Dementia is progressive unless the underlying cause is treatable, such as vascular dementia, which is rare.
CLINICAL COURSE Mild (excessive forgetfulness, difficulty finding words, loses object, anxiety about loss of cognitive abilities) Moderate (confusion, progressive memory loss, can¶t do complex tasks, oriented to person and place, recognizes familiar people; by the end of this stage requires assistance and supervision) Severe (personality and emotional changes, delusional, wanders at night, forgets names of spouse and children, requires assistance with ADLs)
ETIOLOGY Various causes, but clinical picture similar for all: Alzheimer¶s disease Vascular dementia (may have sudden onset; progression may be arrested with treatment) Pick¶s disease Creutzfeldt-Jakob disease
Dementia due to HIV Parkinson¶s disease Huntington¶s disease Dementia due to head trauma
TREATMENT Underlying cause, as in vascular dementia, is treated to prevent further deterioration. Medications such as Cognex, Aricept, Exelon, Reminyl (stops progression for 2 to 4 months only) can be used to slow progression. Symptomatic treatment of behaviors such as delusions, hallucinations, outbursts, labile moods, which vary among clients
Major signs and symptoms Agnosia ± inability to recognize name of objects. Aphasia ± deterioration of language function. Apraxia ± impaired motor function Executive functioning ± inability to think abstractly.
DELIRIUM Onset: Sudden
Disorientation Acute Involves young and old Clouded sensorium Reversible Good prognosis EEG Abnormal
Gradual Loss/Impairment of memory Chronic Exclusive in the elderly Clear sensorium Irreversible Poor prognosis EEG Normal
DELIRIUM LOC impaired fluctuates Speech may be slurred, rambling, pressured, irrelevant Thought process Temporarily disorganized Duration Brief (hours to days)
DEMENTIA not affected normal in early stage, aphasia in later stage. impaired thinking, eventual lost of thinking abilities Progressive det.
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