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UNIT 1

What are the obstacles of therapeutic communication?


a) Resistance- lack of awareness of problems in order to avoid anxiety b) Transference- unconscious assoc. NS with someone significant in his/her life. c) Countertransference- Ns emotional response to a specific client. d) Boundary violations- occurs when Ns enters into a personal/social relationship with client

What are the traits of therapeutic communication?


a) b) c) d) e) f) Genuineness- being consistent with both verbal and nonverbal behaviours Positive Regard respect and acceptance eg. addressing client by name they prefer, sitting and listening, Empathy ability to see things from the clients viewpoint Trustworthiness- being responsible and dependable ex. Keeping commitments and promises Clarity- be specific and clear Responsibility- language involves the use of I statements when being assertive. g) Assertiveness- the ability to express thoughts and feelings comfortably and confidently in a positive, honest, and open manner.

Describe Mental Health:

MENTAL HEALTH consists of a persons perceptions, thoughts, emotions, and behaviours

Discuss DSM-IV: A. Clients diagnosis has 5 parts or AXIS: 1. AXIS I: Psychiatric Dx 2. AXIS II: Personality disorder or mental retardation 3. AXIS II: Medical dx 4. AXIS IV: Psychosocial stressors 5. AXIS V: Global Assessment of Fxning (GAF)- considered Psychologic, social and occupational fxn on a hypothetical continuum of MENTAL HEALTH-ILLNESS. B. What does GAF Measure? The clients functional state @ the time of admission and within the last year

Safety is the top priority in mental health setting.


Discuss Client rights: I. RIGHT TO TREATMENT: A. People w/ mental illness have a right to tx. B. State cannot detain individuals who are non-dangerous without providing some mode of tx. C. MHN has professional obligations to help pts. Seek out and engage tx for mental illness 2 the least restrictive level. II. RIGHT TO REFUSE TX: A. Voluntary and involuntary clients have the right to refuse medication. B. During emergency situations, if there is potential danger, the client can be forcibly medicated C. Right to refuse medication is upheld if client is involuntary and competent

What are the types of COMMITMENTS? A. Voluntary Those who want to be discharged must give written notice of intent to leave and must be discharged within 3 days. B. Emergency C. Civil/judicial commitment- Legal basis <<LEAST RESTRICTIVE ALTERNATIVE means providing MH tx in the least restrictive environment using the least restrictive tx. >> What is Duty to warn? Establishes responsibility of a treating MPH to notify an intended, identifiable victim. Describe Neuroanatomy: LOBE FRONTAL NORMAL FXN
execution of voluntary motor fxn thought processes ex. Planning, abstract thought, decision making, critical thinking Intellectual insight, judgment Expression emotion Sensory and motor Interprets sensory information Right and left orientation Hearing, connects with limbic system, allows connection of emotions, responsible for language comprehension

PARIETAL TEMPORAL OCCIPITAL III.

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ANTIPSYCHOTIC MEDICATIONS: A. Also called NEUROLEPTICS used for tx psychosis, behavioural problems in children, schizophrenia etc. Controls symptoms like delusions, hallucinations and thought disorders Two types: i. CONVENTIONAL or TYPICAL - block dopamine, acetylcholine and epinephrine Phenothiazines (first generation) and non-phenothiazines ex. Haldol, Thorazine, Stelazine a. Side effects: extrapyramidal symptoms, dry mouth, orthostatic hypotension ii. UNCONVENTIONAL or ATYPICAL blocks action of dopamine and serotonin. Ex. Clozaril, Zyprexa, Risperdal, Abilify 1. Less side effects, few or no EPS 2. Work on negative and positive symptoms of schizophrenia ANTIDEPRESSANTS: B. Partially block reuptake of norepinephrine and serotonin. 4 classes: i. Selective Serotonin Reputake Inhibitors (SSRIs)- work by inhibiting reuptake of serotonin These treat major depressive disorder ex. Prozac, Zoloft, Paxil ii. Tricyclic Antidepressant (TCA)- act by blocking the reuptake of Serotonin and norepinephrine. This increases serotonin and norepinephrine in the nerve cell. These are used to treat major depression. iii. Side effects: orthostatic hypotension, sedation, iv. Monoamine Oxidase Inhibitors- MAOIs inhibit Monoamine oxidase enzyme---result=increased availability neurotransmitter Ex. Nardil, Parnate 1. Side effects: HYPERTENSIVE CRISIS 2. Avoid foods with Tyramine v. Atypical Antidepressant- used tx major depression and anxiety. Effects one or two of these neurotransmitters: serotonin, norepinephrine, and dopamine. Ex. Wellbutrin, Cymbalta, Effexor a. Side effects: Headache, dry mouth, Seizures, suppress appetite

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MEDICATIONS ALZHEIMERS DX: A. Anticholinesteras inhibitors (AChe) are used tx Alzheimers dx. B. Common inhibitors: Tacrin (Cognex), Donepezil (Aricept), Rivastigmine (Exelon) C. M of A= increase acetylcholine concentration in CNS by inhibiting cholinesterase breakdown. ANTI-ANXIETY/ANXIOLYTIC MEDICATIONS: A. Used to control anxiety and treat status epileptics; preoperative sedation, insomnia B. Major group = benzodiazepines ex. Valium, Xanax...Buspar (non-benzodiazepine)takes 4 weeks C. M. Of. A= is to enhance the inhibiting action of Gamma-aminobutyric acid (GABA an inhibitory neurotransmitter in the CNS) 1. Side effects: Fatigue, dry mouth, sedation MEDICATION TREAT ATTENTION DEFICIT DISORDER: D. Two types drugs used in tx ADHD: i. Amphetamine- like drugs (psycho-stimulant) Ritalin, Adderall, Concerta. Increases release and blocks reputake of monoamines so more is available to inhibit an overactive part of the limbic system. MOOD STABILIZERS: E. Used for tx. Bipolar disorder. F. Eg. Lithium citrate and antiepileptic drugs (Tegretol, Depakote) G. M. of. A= is alteration electrical conductivity in neuron 1. Side effects: Arrhythmias, Tremor, Polyuria,

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a. GENERAL ADAPTATION SYNDROME: bodys response to stressful stimuli, which produces biologic, emotional and psychological responses b. What influences a persons response to stress? i. Age ii. Past experience iii. Lifestyle iv. Culture v. Developmental level vi. Health status c. Define DISTRESS: Subjective response to stimuli that are threatening or perceived as threatening. Includes fatigue, pain, fear, or acute/chronic dx d. Define EUTRESS: Stress response (nonspecific) assoc. with desirable events ex. Wedding, job promotion, birth of child. e. Define PSYCHOLOGIC STRESS: All processes of the person that require cognitive appraisal of the event before a response f. What is GIS? Activated automatically as response to survival; POSSOM RESPONSE. Results overstimulation of PNS, activated by life threatening situations

g. Stages of GAS:

ALARM REACTION alerts you to presence of stressful stimuli


fight or flight ANS releases EPINEPHRINE to alert body of stressor activates HPA AXIS (hypothalamus, pituitary gland, adrenal gland) causes release of cortisol from adrenal glands leads to increase BP, tachycardia, vasoconstriction of vessels, increase in muscle tone, dilated pupils, increased alertness and increase sugar levels etc.

RESISTENCE
stressor should be overcome in this stage your body attempts to adapt to the stressor Prolonged stage resistance mobilizes energy resources to maintain adaptations

EXHAUSTION
if stressor isn't overcome, it will spread throught body causing dx BODY CAN'T MAINTAIN ADAPTATIONS Exhaustion occurs when resources are used up and individual can no longer maintain adaptations leads to illness or death

Holistic/alternative care beliefs strengthen individuals inner resistance to dx, healing from within, or enhance bodys innate healing powers

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COMPLEMENTARY AND ALTERNATIVE THERAPIES: ALTERNATIVE THERAPY FIELDS:

A. Complementary and alternative medicine (CAM): 7 categories: i. Alternative medicine systems ii. Mind-body interventions iii. Pharmacologic and biologic based therapies iv. Herbal medicines v. Diet, nutrition, supplements and lifestyle changes vi. Manipulative and body-based methods vii. Energy therapies<<Box 25-1 p. 573>>

ANXIETY DISORDERS: I. What is anxiety? Feelings of uneasiness, uncertainty, apprehension or tension in response to an unknown object or situation.

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DEFENSE MECHANISMS:

EGO DEFENSE MECHANISMS Conversion Denial Dissociation

DEFINITION Unconscious expression of a mental conflict as a physical symptom to relieve anxiety Unconscious refusal to face reality. Separation and detachment of a strong, emotionally charged conflict from one's consciousness Unconscious attempt to identify with personality traits or actions of another to preserve one's selfesteem Unconscious assignment of unacceptable thoughts or characteristics of self to others Justification of one's ideas, actions, or feelings to maintain self-respect, prevent guilt feelings, or obtain social approval Demonstration of the opposite behaviour, attitude, or feeling of what one would normally show in a given situation Voluntary rejection of unacceptable thoughts or feelings from conscious awareness Use of external objects to become an outward representation of an internal idea, attitude, or feeling
Defense mechanisms used Mood Suicide potential Thought content and process Severity of subjective experience of anxiety Understanding of specific disorder

Identification

EXAMPLE Woman experiences blindness after witnessing a robbery. Woman denies that her marriage is failing Male victim of car-jacking exhibits symptoms of traumatic amnesia the next day. Teenager dresses, walks, and talks like his favourite basketball player. Man who was late for work blames wife for not setting the alarm clock. Student states he didn't make the golf team because he was sick. Man who dislikes his mother-in-law is very polite and courteous toward her. Student who failed a test states she isn't ready to talk about her grade. An engagement ring symbolizes love and a commitment to another person.

Projection Rationalization

Reaction-formation

Suppression Symbolization

Nursing Assessment: Assess psychological, cognitive, and behavioural symptoms.


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Nursing Interventions Reducing Symptoms of Anxiety: 1. Maintain safety for the client and the environment 2. Assess own level of anxiety 3. Recognize the clients use of relief behaviours 4. Inform client limiting caffeine, nicotine, and other CNS stimulants 5. Teach client to distinguish anxiety that is connected to identifiable sources 6. Instruct client to practice stress reduction techniques 7. Help client build on coping methods 8. Activate the client to identify support persons 9. Assist client gain control of overwhelming feelings and impulses 10. Help client structure quiet environment 11. Assess the presence and degree of depression and suicide ideation 12. Administer anxiolytics

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Types of ANXIETY: i. Panic Anxiety: Recurrent unexpected anxiety attacks with thoughts of dread, impending doom, death and fear of being trapped. ii. Phobias: Client experiences panic attack in response to particular situations Types: Agoraphobia fear of being alone in public places, without escape, Social Phobia fear of social or performance situations. Eg. Speaking, eating in public iii. Posttraumatic Stress Disorder (PTSD): Describes and individuals reaction to traumatic events eg. Combat, sexual abuse, physical abuse, disasters, and grieving a. Efforts to avoid thoughts, feeling, or conversation about the trauma b. Efforts to avoid persons or places that evoke memories of trauma c. Inability to remember important aspects of trauma d. Diminished interest in significant activities e. Restricted range of effect f. A sense of impending doom. 1. Must have two of the following present: a. Sleep disturbances, irritability or angry outbursts, difficulty concentrating, Hypervigilance and exaggerated startle response. iv. Acute Stress Disorder: Symptoms occur during or immediately after trauma a. Develops three or more dissociative symptoms: i. Subjective sense of numbing or detachment ii. Absence of emotional responsiveness iii. Feeling dazed (reduced awareness of surroundings) iv. Derealisation (unreal feeling) v. Depersonalization (feeling alienated) vi. Dissociative amnesia v. General Anxiety Disorder: Excessive anxiety and worry that is difficult to control vi. Obsessive Compulsive Disorder: 1. Obsessions are recurrent and persistent thoughts, impulses or images 2. Individuals try to suppress the thoughts and impulses 3. Compulsions are repetitive behaviours that the person feels driven to perform in response to an obsession vii. Somatoform disorders: Characterized by physical symptoms that cant be explained by known physical mechanisms. They: a. Involve multiple organs b. have early onset and are chronic without signs of impairment c. No laboratory evidence of medical condition Types: a. BODY DYSMORPHIC DISORDER-Preoccupation with imagined defect in appearance in a normal-appearing person b. CONVERSION DISORDER- Development of Neurologic disorder (blindness, deafness, loss of touch, or pain sensation) or Involuntary motor function (aphonia, impaired coordination, paralysis, or seizures). c. HYPOCHONDRIASIS-Preoccupation with fears of having/ has a serious disease despite appropriate medical tests and assurances to the contrary d. SOMATIZATION DISORDER-History of many physical complaints before age 30. History of pain in at least four different sites or functions viii. Dissociative disorders: a. Depersonalization disorder b. Dissociative amnesia-One or more episodes of inability to recall important information (usually of a traumatic or stressful nature) c. Dissociative fugue-Sudden, unexpected travel away from home or one's place of work with inability to remember past

XIII. COGNITIVE AND BEHAVIOURAL THERAPY: a. Distorted and dysfxnal thinking causes psych disturbances expressed in mood and behaviour b. GOAL: assist the client in beginning to I.D automatic thoughts and the feelings connected to them. XIV. RATIONAL EMOTIVE THERAPY: a. Precursor to cognitive behavioural therapy b. Psychologic symptoms come from disturbed thinkingleads irrational beliefs not based in actual fact- You are responsible for your irrational beliefs and thus mental disturbance MEDICATIONS THAT TREAT ANXIETY: XV. Anti-anxiety A. Benzodiazapines a. How it works: by enhancing the inhibitory action of GABA thus causing generalized CNS depression b. Therapeutic effect: relief of anxiety c. Interactions: DO not use with MAOIs, additive effect when taken with alcohol, antihistamines i. Diazapam (Valium)- 2-10mg 2-4xs /dy ii. Alprozolam (Xanax)- .25-.5mg 3xs/dy d. SE: dizziness, drowsiness lethargy, mouth dryness o Treat overdose of benzos by: a. Administering an antiemetic in conscious pt. and gastric lavage in unconscious patient B. Non-Benzodiazapine a. How it works: decrease reputake of dopamine and increase serotonin in the CNS b. Therapeutic effect: decrease depression c. Interactions: grapefruit juice can cause toxicity, use with MAOI may cause HTN 1. Buspirone HCL (BusPAR) -5mg 2-3x/dy d. SE: dry mouth, nausea, vomiting, agitation, headache, blurred vision, constipation Antidepressant: 4 groups: B. Tricyclics a. How it works: blocks reputake of norepinephrine and serotonin b. Interactions: do not use with MAOI and avoid concurrent use with SSRIs 1. Amitriptyline (Elavil)-25mg 3xs up to 200mg/dy 2. Imipramin (Tofranil)-25-50mg 3-4 up to 300mg/dy c. SE: orthostatic hypotension, sedation, suicidal thoughts, blurred vision, dry mouth C. SRRIs: a. How it works: blocks reputake of serotonin b. Interactions: St. Johns wart causes central serotonin syndrome 1. Fluoxetine (Prozac) 2. Sertraline (Zoloft) 3. Paraxentine (Paxil) c. SE: nervousness, sexual dysfunction, headache, insomnia D. MAOI: a. How it works: inhibiting monoamine oxidase causing a rise in neurotransmitters b. Interactions: avoid foods with 1. Phenelzine Sulfate (Nardil) 2. Tranylaypromine Sulfate (Parnate) c. SE: HYPERTENSIVE CRISIS s/s: headache, seizure, edema, chest pain, SOB, nausea, vomiting, severe anxiety, unresponsiveness.

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E. Atypical antidepressant: a. How it works: effects serotonin, dopamine, and norepinephrine b. Interactions: do not use w/ MAOI, should not be taken within 14dys of MAOI use 1. BuPropion (Wellbutrint) 2. Venlafaxine (Effecor) 3. Doloxetine (Cymbalta) c. SE: headache, dry mouth, seizures, appetite suppression F. Mood Stabilizers: a. How it works: alters electrical conductivity of cell b. Interactions: make sure have adequate Na intake for Lithium 1. Lithium c. Monitor: therapeutic levels G. Anti-epileptics: a. How it works: increases inhibitory action of GABA b. Interactions: increased CNS depression with consumption of alcohol 1. Divalproex sodium (Depakote) 2. Carbamazepine (Tegretol) c. SE: agranulocytosisso check WBC, sedation d. Monitor: I/O H. Beta-Blockers: Anti-anginals a. How it works: blocks beta 1 receptors thus decreasing BP and HR b. SHOULD NOT 50mg daily, Ccr=15-35mL/min 1. Atenolol (tenormin)- 50-200mg/dy 2. Propranolol (Inderal)- 40-100mg/dy c. SE: fatigue, weakness, bradycardia, CHF, pulmonary edema d. Monitor: vitals, I/O, daily weight, assess CHF. Take apical pulse before admin, if ,50bpm do not administer I. Antihistamines: a. How it works: blocks effects histamine @ H1 receptor, creating CNS depression b. Interactions: additive CNS depression with alcohol and antidepressants 1. Diphenhydramin (Benadryl) 2. Hydroxyzine HCL (Atarax) 3. Hydroxyzine Pamoate (Vistaril) c. SE: dry eyes, constipation, dry mouth, and blurred vision, can decrease anxiety so asses mood, mental status and behaviour. J. Herbal Therapy: a. Kava-Kava: used for anxiety 1. How it works: alters limbic system modulation of emotional processes 2. SE: dizziness, headache, drowsiness, extrapyramidal effects, HEPATIC TOXICITY. When taken with Benzos additive CNS depression b. Valerian: for anxiety 1. How it works: may increase concentrations of GABA 2. SE: drowsiness, headache

SLEEP DISORDERS: I. Types: a. Dyssomnias- abnormalities in amt, quality or timing of sleep i. Insomnia- most common, difficulty initiating and maintaining sleep ii. Hypersomniaiii. Narcolepsy- excessive daytime sleepiness, sudden onset sleep attacks. Can have cataplexy (sudden loss muscle tone and involuntary muscle movement) or sleep paralysis iv. Breathing-related sleep disorder-e.g sleep apnea v. Circadian rhythm sleep disorder- e.g jet lag, shift work type and delayed sleep phase b. Parasomnias- abnormal behaviour during sleep i. Nightmare disorder- occurs during REM ii. Sleep terror- occurs during non-REM iii. Sleepwalking- typically ages 4-8, occurs during non-REM NSG PROCESS: a. Assessment: subjective and objective data sources and sleep hx b. NSG DX: i. Sleep deprivation ii. Insomnia iii. Ineffective bx iv. Anxiety v. Fatigue vi. Ineffective coping c. Outcome I.D i. I.d primary causes sleep alteration ii. Communicate interventions and implement them iii. Demonstrate reduction sleep disturbance iv. Participate discharge planning d. Planning: participation multidisciplinary team e. Implementation/Interventions: i. Monitor sleep patter and id risks ii. Have client keep sleep diary iii. Develop hygiene plane iv. Teach symptom management v. Make environment quiet vi. Help client i.d stressors vii. Promote development coping skills viii. i.d clients support system ix. promote compliance medications x. teach limit substances cause sleep disturbances xi. educate about circadian rhythms xii. refer sleep specialist

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GRIEF: I. Types: a. Anticipatory grief- pre-mourning- grief assoc. With anticipation predicted death or developing loss b. Acute Grief- painful exper. After a loss c. Dysfunctional grief- ex. PTSD. Lasts longer than other types and has greater disability ex. Traumatic loss, complicated grief, chronic grief d. Chronic sorrow- response to ongoing loss ex. Parents w/ disabled children. Interventions: a. Assess risk kill or harm self and others b. Promote ns-relationship c. Facilitate expression feelings related to loss d. Help client understand relationship between self and lost person e. Facilitate full expression grief f. Promote interactions with others

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COGNITIVE DISORDERS: I. Types: 1. Dementia- It is the gradual and progressive deterioration of intellectual functioning. 2. Delirium- an acute state of confusion, disorientation to person and place, rapid onset and short duration

SYMPTOMS DEMENTIA Judgment Impaired Mood Fluctuates Apathetic Memory Impaired Cognition Disordered reasoning Orientation Disoriented Thoughts Confused Suspicious Paranoid Perception No change Consciousness Speech

DELIRIUM May be impaired Fluctuates (fluctuating consciousness) Reduced ability sustain attention Impaired Disordered reasoning Disorientation Confused Suspicious Incoherent Misinterpretations, Visual hallucinations and delusions Clouded Sparse or fluent Incoherent Agitation May wander Insomnia Poor testing Improves when medically stable Improves with treatment Usually remain stable unless medically unstable

Normal Sparse Repetitive Behavior Agitation Wanders Insomnia Mental status Poor testing Progressively worsens Inappropriate answers Activities of daily Deteriorate as dementia progresses living No return to pre-morbid function, chronic, Return to pre-morbid function if cause is PROGNOSIS depends on cause as is generally insidious correctable and is corrected in time. Generally in onset acute onset

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STAGES OF ALZHEIMERS: 1. Stage1: Mild (2-4yrs) i. Recent memory loss, neologisms ii. Cognitive loss in: 1. Communicating 2. Calculating 3. Recognition iii. Anxiety and confusion iv. Mild behavioural problems 2. Stage2: Moderate i. Stage1 symptoms increase ii. Behavioural probs increase and include: 1. Catastrophic rxs 2. Sundowning- behavioural disturbance in the morning or evening 3. Preservation-excessive repetition 4. Aimless pacing 5. Wandering 6. Incontinence 7. Hypertonia 3. Stage3: Severe: i. Stage2 symptoms increase ii. Total incontinence iii. Choking iv. Emaciation v. Total care needed vi. Progressive gait disturbance leading to non-ambulatory status NSG DX: 1. Risk aspiration 2. Imbalanced body temp 3. Infection 4. Injury 5. Physical mobility 6. Anxiety 7. Impaired verbal communication 8. Chronic confusion 9. Grieving OUTCOME IDENTIFICATION: 1. Maintain health and safety with caregiver help 2. Reach and maintain highest fxn level possible within capacity 3. Maintain best possible physical status 4. Participate therapeutic activity program 5. Participate planning for care INTERVENTION: 1. Inform all caregivers nsg plan 2. i.d client current fxnal; state and encourage use of skills 3. set up structured routines 4. allow client time alone 5. remain flexible with schedule 6. keep all interactions with client calm and reassuring 7. do not ask client participate ADLs when agitated 8. attempt understand feeing 9. respond clients feelings and validate them 10. help client maintain self-esteem by keeping interactions at adult level 11. simplify verbal messages and provide simple choices

CRISIS INTERVENTIONS/RAPE-TRAUMA: I. Types crisis: a. External (situational)- external stressor which is apparent to another observer. Centres on real events threaten health, shelter, loss loved one. b. Internal (subjective) crisis- internal stressor threatens well being ex. Aging, loss independence c. Phase-of-life (maturational) crisisd. Disaster (adventitious crisis)- man-made and natural disasters ex. Terrorism, tornados 5 steps Crisis interventions: a. Assess the individual and the problem: i. Assess the individual and the problem- in the field and in office (physical safety principles, medical hx, introduction and boundaries, chief complaint, hx present illness, family/social hx, mental status, past medical & psychiatric hx, drug & alcohol hx, cultural and spiritual issues, strengths and support, coping skills, GAF etc b. Plan therapeutic intervention: i. Express caring and consolation ii. Assess reality of situation iii. Develop and begin to utilize an immediate plan for intervention iv. Coordinate w/ other agencies v. Anticipate future needs related to crisis c. Intervention d. Resolution of the crisis e. Anticipatory planning 10 stages acute traumatic stress i. Assess for danger/safety ii. Consider mechanism of injury iii. Address medical needs iv. Evaluate level of responsiveness v. Observe and identify who exposed vi. Ground the individual vii. Normalize the response viii. Prepare for the future

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DOMESTIC VIOLENCE: I. Risk factors domestic violence: a. Social isolation b. Control by the abusive person c. Alcohol and other drugs d. Intergenerational transmission e. Legal marriage or pregnancy f. An attempt to leave the relationship Interview questions: ask in private only: ask SAFE Questions a. Have you ever been emotionally or physically hurt by your partner or someone important to you? b. Within the last year, have you been hit, slapped, kicked, or physically hurt by someone? By whom? How many times? c. Within the last year, has anyone forced you to have sexual activity? Who? How many times? d. Are you afraid of your partner or anyone else?

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Rape-trauma syndrome: a. Acute Phase: i. Occurs immediately after the assault ii. May lst for a few weeks iii. Lifestyle disorganized iv. Somatic symptoms are common v. Reaction in cognitive, affective and behavioural functions b. Long-term reorganization phase: i. Intrusive thoughts ii. Increased motor activity iii. Increased emotional lability iv. Fears and phobias Violence Interventions: a. Follow your institutions protocol for sexual assault b. Do not leave the person alone c. Maintain a non-judgemental attitude d. Ensure confidentiality e. Encourage the person to talk, listen empathetically f. Emphasize that the person did the right thing to save his/her life g. Keep accurate records: i. Physical trauma ii. Ask permission to take photos iii. Take verbatim statements as to clients reaction to rape iv. Document emotional status h. Explain everything that you are going to do before hand i. Obtain medicolegal specimens with clients written permission j. Alert client as to what he/she may experience during the long-term reorganization phase k. Arrange for support follow-up, for ex.: i. Support groups ii. Group therapy iii. Individual therapy iv. Crisis counselling Long-term effects rape: a. Depression b. Suicide c. Anxiety d. Fear e. Difficulties with daily functioning f. Low self-esteem g. Sexual dysfunction h. Somatic complaints

MOOD DISORDERS: A. Leading cause of disease burden i. Types: 1. Major depression 2. Dysrhythmic disorder- chronic low-level depression 3. Bipolar disorder-pattern of manic, hypomania and depressed episodes 4. Cyclothymic disorders- chronic mood disturbance b. Nsg process: i. Assessment- mood, affect and temperament 1. Mental status criteria a. Mood b. Affect c. Temperament d. Emotion e. Emotional reactivity f. Emotional regulation g. Range of affect ii. Nsg DX: 1. Activity intolerance 2. Anxiety 3. Constipation etc. Box 11-5 iii. Interventions: 1. Conduct a suicide assessment 2. Maintain a safe environ 3. Establish a rapport and demonstrate respect 4. Assist client verbalize feelings 5. Identify clients social support system and encourage client 6. Praise the client for attempt 7. Promote self-care 8. Assist s at alternate activities and interactions with others 9. Gently refuse to be part of secrecy agreements with the client 10. Monitor and implement strategies to ensure adequate fluid intake and output, food intake and weight 11. Refer p.235 c. Pharmacology: i. SSRIs- citalopram (celexa), fluoxetine (Prozac), paroxetine (paxil), sertraline (Zoloft), venlafaxine (Effexor) ii. Atypical antidepressants iii. TCA- amitriptyline (elavil), clomipramine (anafranil), imipramine (tofranil), desipramine (norpramin), iv. MAOI- phenelzine(Nardil), Parnate v. Mood stabilizers: lithium and anticonvulsants Tegretol and Depakote

SUICIDE: I. Assessment: a. The observable behaviour of client e.g increased irritation, increase in energy b. Hx from the client- gathering self-defeating coping patterns c. Information from friends and familyd. Hx suicidal gestures or attempts e. MSE-disturbance concentration, memory, orientation f. Physical exam-signs substance abuse, irritability, euphoria, slurred speech g. Nurses intuition Interventions: a. Provide safety and prevent violence: ex. Safe environment, remove all weapons b. Assist with improvement of coping skills c. Enhance family and support system

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EATING DISORDERS: Sign/Symptoms: 1. Anorexia: a. Self-starvation b. Rituals/compulsive behaviours regarding food c. Self-induced vomiting, laxatives, diuretics, or excessive exercise d. Weight loss 15% below ideal e. Amenorrhea f. Slow pulse g. Cachexia-muscle wasting h. Lanugo i. Constipation j. Cold sensitivity k. Denial seriousness l. Irrational fear gaining weight m. Preoccupation food n. Delayed psychosexual development Bulimia Nervosa: 1. Recurrent episodes binge eating 2. Purging behaviours: self-induced vomiting, use laxatives, diuretics, diet pills, ipecac, enemas, exercise, periods fasting 3. Purging 4. Hypokalemia 5. Alkalosis 6. Dehydration 7. Idiopathic edema 8. Hypotension 9. Cardiac arrhythmias 10. Cardiomyopathy 11. Hypogycemia 12. Constipation 13. Esophageal reflux 14. Mallory-weiss syndrome 15. Dental enamel ersosion 16. Paratid gland enlargement 17. gastroparesis

Outcomes anorexia: 1. participate therapeutic contact staff 2. consume adequate calories 3. achieve normal weight 4. maintain normal fluid and electrolyte balance 5. resume normal menstrual cycle 6. demonstrate improvement body image 7. demonstrate effective coping skills 8. manage family conflicts

Outcomes Bulimia: 1. participate therapeutic contact staff 2. maintain normal fluid and electrolyte levels 3. consume adequate calories 4. cease binge/purge episodes 5. demonstrate effective coping skills 6. Demonstrate age-approp. Boundaries 7. Verbalize improved body awareness 8. Normal perception of body weight and shape

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Complications: a. Electrolyte imbalance b. Cardiac arrhythmias c. Cardiac arrest d. Diabetes mellitus e. hypertension Interventions: a. Provide safety b. Assess suicide c. Engage therapeutic relationship d. Restore min. Body weight and nutritional balance e. Create structured, supportive environment, with limits f. Coordinate with dietician g. Encourage client express thought, feelings, concerns body image h. Cont help client recall positive eating exper. i. Assume caring matter of fact approach j. P.400 for rest

SCHIZOPHRENIA: I. II. Neurobiologic brain disorder, results impaired thoughts, perceptions, cog. Fxn, mood and motivation Signs/symptoms and course: a. Premorbid: contributing factors b. Prodromal: one mth to 1yr before diagnosis: i. Mood-Anxiety, irritability, dysphoria ii. Cognitive- distractibility, concentration difficulties, disorganized think iii. Obsessive behaviours and rituals iv. Sleep disturbance v. Weak positive symptoms c. Psychotic phase: i. Acute phase- pos. And neg. symptoms, unable to perform self-care ii. Maintenance phase- able to care for self iii. Stable phase- remission Types: a. Paranoid b. Disorganized c. Catatonic d. Residual e. Undifferentiated Positive symptoms: a. Alterations perceiving: hallucinations (false perceptions), delusions (false beliefs), loss ego boundaries b. Alterations thinking: concrete thinking, loose associations, flight of ideas, ideas of reference, ideas persecution, ideas grandiosity, ideas being controlled, though broadcasting, thought insertion, thought withdrawal c. Alterations speech: neologisms, echolalia, clang assoc, word salad, circumstantiality, tangential (superficial speech) d. Alterations behaviour: bizarre behaviour, agitation, waxy flexibility, stupor, negativity, echopraxia, symbolism

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VI. VII.

VIII.

Negative symptoms: a. Cognitive: Poverty of speech (alogia), Poverty of thought. Thought blocking, Problems with attention, memory, Impaired decision making/judgement, problem solving, Disorganized think b. Behavioural: anhedonia, anergia, avolition, depression, hopelessness, social isolation, decreased spontaneity, anxiety, irritability, drug abuse. Medical comorbidity NSG DX: bassed on assessment pos and neg symptoms NSG interventions: a. for the agitated: i. safety ii. reduce stimulation iii. brief, concise statements iv. det. stressors v. redirect vi. prevent agitation b. for those in acute crisis: crisis intervention, stabilization, safety and limit setting c. for those in maintenance and stable phase: give small amts infor, i.d signs of relapse Psychopharmacology: a. Typical antipsychotics, which block dopamine, phenothiazines: treat positive symptoms i. Ex. Thorazine, Mellaril, Navane, Stelazine, Haldol and Prolixin ii. SE: anticholinergic- dry eyes, mouth, constipation, sedation, orthostatic hypotension, lowered seizure thresholds, jaundice, ESP (use antiparkinson drugs...cogentin, artane), dystonica, neuroleptic malignant syndrome, tardive dyskineasia b. Atypical antipsychotics- block serotonin and norepinephrine. Work on pos and neg symptoms. Produce metabolic syndromes (so check weights) i. Ex. Clozoril (monitor for agranulocytosis and WBC), seroquel (quetiapine), Risperdal (risperidone), geodon (ziprasidone), abilify(aripiorazole) EPS S.E: Neuroleptic malignant syndrome: Akathsia Fever Akinesia Muscle rigidity Dystonias Altered consciousness Acute distonic rx Rapid breathin Pseudo parkinsonism Stupor-coma Tardive dyskinesia Excessive salivation Neuroleptic malignant syndrome Elevated CPK

SUBSTANCE ABUSE: Support groups: AA, NA, CA Al-Anon, Al-a-teen, Adult children of alcoholics, inpatient, outpatient, hospitalization, intensive outpatient, halfway houses.

Withdrawal from alcohol: Irritability, anxiety, agitation Insomnia Diaphoresis Tremors Delirium Seizures Possible death

Withdrawal from stimulants: Headache Anxiety Restlessness Cravings dreaming Depression Decreased BP Psychomotor retardation

Withdrawal from CNS depressants: Cravings Abdominal cramps Diarrhea Nausea and vomiting Bone/muscle pain Muscle spasm Tremor Chills Diaphoresis

IX.

Signs/symptoms: CNS stimulants: Euphoria Feelings impending doom Agitation or combativeness Hallucinations/paranoia Seizures Cardiovascular events, palpitations, tachycardia, Hypertension, irregular rhythms, can lead to infarct Hallucinogens: Panic attack/anxiety Psychosis Delirium Altered moods flashbacks

CNS Depressants: Decreased inhibitions Impaired judgement, attention, memory Drowsiness Slurred speech Unsteady gate Hypotension Bradycardia Pinpoint pupils Weak rapid pulse Depressed respirations Can lead com/death X. Meds for withdrawal: Tx emergency CNS depressant: Life support Narcan (naloxone) Lavage or dialysis Control seizures with phenobarbitol Tx CNS depressants withdrawal symptoms: Opiod substitution Methadone (dolophine) Buprenorphine (subutex) Naltrexone (ReVia) Suboxone-used for maintenance

Tx acute overdose alcohol: ABCs Thiamine Nutritional glucose Clonidine (catapress) for GI symptoms Benzos Long-term tx: Antabuse Naltrexone Zofran and topamax decrease cravings as well

Tx CNS intoxication: Treat cardiac symptoms Benzos for agitation and seizures Antipsychotics for hallucinations

XI.

XII.

Classes of drugs of abuse: a. Cannabis-weed, pt, hashish b. CNS depressants: alcohol, sedatives, hypnotics, anxiolytics c. CNS stimulants: amphetamines, caffeine, cocaine, ephedra, Benzedrine, nicotine d. Hallucinogens- LSD, Peyote, PCP, mescaline e. Inhalants- glue, hydrocarbons, nitrates f. Anabolic-androgenic steroids g. OTC-antihistamines, sleeping pills, herbals, laxatives h. Club drugs- ecstasy, ghb, rhohipnol, ketamine, methamphetamines Interventions SA: a. Maintain airway, monitor vitals b. Maintain safety c. Observe s/s overdose, withdrawal, drug-drug interactions d. Assess physiologic/Psychologic symptoms withdrawal e. Initiate interventions to treat withdrawal symptoms f. Provide emotional support g. Support nutrition/metabolic needs h. Refer nutritionist i. Increase carb intake, offer straws and edible things to chew on j. Initiate vit/mineral replacement etc.

PERSONALITY DISORDERS: I. In General PD: a. Higher death rates b. Higher rates suicide attempts c. Increased rates separation, divorce and involvement legal proceedings d. Increased rate criminal behaviour, alcoholism, and drug abuse 4 common characteristics: a. Inflexibility, maladaptive response stress b. Disability in working and loving c. Ability cause interpersonal conflict in others d. Capacity to irritate others 4 maladaptive patterns: a. Faulty perceptions b. Emotional lability c. Poor impulse control d. Difficult interpersonal functioning Characteristics: a. Repetitive maladaptive behaviour b. Behaviour not recognized as abnormal so dont seek treatment c. Ability achieve developmental tasks are limited d. Seek help only in crisis e. Starts in adolescence f. Maladaptive behaviour used fulfill need and bring satisfaction General interventions: Asses suicide ideation Implement suicide precautionsevery 15min Establish contract for safety Encourage attendance all group sessions Assess for escalating anger or rage Contract not to harm staff or others Teach manage anger and impulsive feelings and behaviours Discuss angry and aggressive feelings Assess client for evidence self-mutilation.

II.

III.

IV.

V. 1. 2. 3. 4. 5. 6. 7. 8. 9.

VI.

s/s antisocial Interventions: personality: 1. Prevent/decrease 1. Hx antisocial effects manipulation behaviour 2. Guard against being 2. Deceitful, liar manipulated 3. Aggressive 3. Set clear and realistic towards limits behaviour others 4. All limits must be 4. Lack remorse adhered to by all staff hurting others 5. Carefully document 5. Presents as objective physical charming, selfsigns of assured and manipulation/ adept aggression 6. Interacts others through manipulation, aggressiveness and exploitation 7. Lack empathy or concern Etiology/factors: a. Lower socioeconomic status b. Substance abuse c. Genetics

s/s borderline Interventions: personality; 1. Set limits 1. Relationship with 2. Provide others intense boundaries and aunstable and limits that 2. Poor impulse are clear and control consistent 3. Recurrent 3. Consistent suidical/self staff: asses for mutilation suicide and 4. Attention self mutilating seeking/manipula behaviour tive 5. No boundaries 6. Outbursts odd anger and hostility 7. Intense and primitive rage 8. Rapid idealization and devaluation