NURSING NOTES http://www.nursingnotes.

info/
Chapter One
FOUNDATIONS OF PSYCHIATRIC MENTAL HEALTH NURSING
Mental Health
The WHO defines heath as a state of !o"pete ph#si!a$ "enta$ and so!ia weness$ not "ere# the a%sen!e of disease or
infir"it#.
&enta heath is infuen!ed %# indi'idua fa!tors$ in!uding %ioogi! "a(eup$ autono"#$ and independen!e$ sef)estee"$
!apa!it# for growth$ 'itait#$ a%iit# to find "eaning in ife$ resiien!e or hardiness$ sense of %eonging$ reait# orientation$ and
!oping or stress "anage"ent a%iities* %# interpersona fa!tors$ in!uding effe!ti'e !o""uni!ation$ heping others$ inti"a!#$
and "aintaining a %aan!e of separateness and !onne!tedness* and %# so!ia/!utura fa!tors$ in!uding sense of !o""unit#$
a!!ess to resour!es$ intoeran!e of 'ioen!e$ support of di'ersit# a"ong peope$ "aster# of the en'iron"ent$ and a positi'e
#et reaisti! 'iew of the word +da"n$ that was a "outhfu,-.
Mental Illness
The ./. +0111- defines a mental disorder as 2a !ini!a# signifi!ant %eha'iora or ps#!hoogi!a s#ndro"e or pattern that
o!!urs in an indi'idua and that is asso!iated with present distress or disa%iit# or with a signifi!ant# in!reased ris( of
suffering death$ pain$ disa%iit#$ or an i"portant oss of freedo"3.
4e'iant %eha'ior does not ne!essari# indi!ate a "enta disorder.
Dianosti! and statisti!al man"al o# mental disorders
The DSM$I%$TR is a ta5ono"# pu%ished %# the ./.. The 4S&)I6)TR des!ri%es a "enta disorders$ outining spe!ifi!
!riteria for ea!h %ased on !ini!a e5perien!e and resear!h.
Sel#$a&areness iss"es
Sel#$a&areness is the pro!ess %# whi!h the nurse gains re!ognition of his or her own feeings$ %eiefs$ and attitudes.
Chapter Two
NEURO'IOLOGIC THEORIES AND PSYCHOPHARMACOLOGY
The Ner(o"s s)stem and ho& it &or*s
The !ere%ru" is the !enter for !oordination and integration of a infor"ation needed to interpret and respond to the
en'iron"ent.
The !ere%eu" is the !enter for !oordination of "o'e"ents and postura ad7ust"ents.
The %rain ste" !ontains !enters that !ontro !ardio'as!uar and respirator# fun!tions$ seep$ !ons!iousness$ and i"puses.
The i"%i! s#ste" reguates %od# te"perature$ appetite$ sensations$ "e"or#$ and e"otiona arousa.
Ne"rotransmitters
Neurotrans"itters are the !he"i!a su%stan!es "anufa!tured in the neuron that aid in the trans"ission of infor"ation
throughout the %od#.
o The# either e5!ite or sti"uate an a!tion in the !es +e5!itator#- or inhi%it or stop an a!tion +inhi%itor#-.
o .fter neurotrans"itters are reeased into the s#napse +point of !onta!t %etween the dendrites and the ne5t neuron-
and rea# the "essage to the re!eptor !es$ the# are either transported %a!( fro" the s#napse to the a5on to %e stored
for ater use +reupta(e- or are "eta%oi8ed and ina!ti'ated %# en8#"es$ pri"ari# monoamine o+idase ,MAO-.
Do/amine$ a neurotrans"itter o!ated pri"ari# in the %rain ste". 4opa"ine is genera# e5!itator# and is s#nthesi8ed fro"
tyrosine$ a dietar# a"ino a!id.
o .ntips#!hoti! "edi!ations wor( %# %o!(ing dopa"ine re!eptors and redu!ing dopa"ine a!ti'it#.
Nore/ine/hrine and E/ine/hrine
o Norepinephrine$ the "ost pre'aent neurotrans"itter$ is o!ated pri"ari# in the %rain ste". It pa#s a roe in "ood
reguation.
o Epinephrine is aso (nown as noradrenaine and adrenaine. Epinephrine has i"ited distri%ution in the %rain %ut
!ontros the fight)or)fight response in the periphera ner'ous s#ste".
Serotonin
o . neurotrans"itter found on# in the %rain$ is deri'ed fro" tryptophan$ a dietar# a"ino a!id.
o The fun!tion of serotonin is "ost# inhi%itor#$ in'o'ed in the !ontro of food inta(e$ seep and wa(efuness$
te"perature reguation$ pain !ontro$ se5ua %eha'ior$ and reguation of e"otions.
o So"e antidepressants %o!( serotonin reupta(e$ thus ea'ing it a'aia%e onger in the s#napse$ whi!h resuts in
i"pro'ed "ood.
Histamine
9
o The roe of hista"ine in "enta iness is under in'estigation.
A!et)l!holine
o .!et#!hoine is a neurotrans"itter found in the %rain$ spina !ord$ and periphera ner'ous s#ste". It !an %e
e5!itator# or inhi%itor#. It is s#nthesi8ed fro" dietar# !hoine found in red "eat and 'egeta%es and has %een found
to affe!t the seep)wa(e !#!e and to signa "us!es to %e!o"e a!ti'e.
o Studies ha'e shown that peope with .8hei"er:s disease ha'e de!reased a!et#!hoine se!reting neurons.
Gl"tamate
o Guta"ate is an e5!itator# a"ino a!id that at high e'es !an ha'e "a7or neuroto5i! effe!ts.
Gamma$Amino0"t)ri! A!id ,GA'A-
o G.;. is a "a7or inhi%itor# neurotrans"itter in the %rain and has %een found to "oduate other neurotrans"itter
s#ste"s rather than to pro'ide a dire!t sti"uus.
o 4rugs that in!rease G.;. fun!tion su!h as %en8odia8epines are used to treat an5iet# and to indu!e seep.
Ne"ro0ioloi! !a"ses o# mental illness
Current theories and studies indi!ate that se'era "enta disorders "a# %e in(ed to a spe!ifi! gene or !o"%ination of genes
%ut that the sour!e is not soe# geneti!* nongeneti! fa!tors aso pa# i"portant roes.
Two geneti! in(s to .8hei"er:s disease are !hro"oso"es 9< and 09.
The Hu"an Geno"e /ro7e!t$ funded %# NIH and the US 4epart"ent of Energ#$ is the argest of its (ind. It has identified a
hu"an 4N.. In addition$ the pro7e!t aso addresses the ethi!a$ ega$ and so!ia i"pi!ations of hu"an geneti!s resear!h.
Stress and the Imm"ne s)stem ,Ps)!hoimm"nolo)-
This is a reati'e# new fied of stud#$ whi!h e5a"ines the effe!t of ps#!hoogi!a stressors on the %od#:s i""une s#ste".
In#e!tion as a /ossi0le !a"se
So"e resear!hers are fo!using on infe!tion as a !ause of "enta iness. Studies su!h as this are pro"ising in dis!o'ering a
in( %etween infe!tion and "enta iness.
The N"rse1s role in resear!h and ed"!ation
The nurse "ust ensure that !ient:s and fa"iies are we infor"ed a%out progess in these areas and "ust aso hep the" to
distinguish %etween fa!ts and h#potheses. The nurse !an e5pain if or how new resear!h "a# affe!t a !ient:s treat"ent or
prognosis. The nurse is a good resour!e for pro'iding infor"ation and answering =uestions.
Ps)!ho/harma!olo)
Effi!a!# refers to the "a5i"a therapeuti! effe!t that a drug !an a!hie'e.
/oten!# des!ri%es the a"ount of the drug needed to a!hie'e that "a5i"u" effe!t* low-potency drugs re=uire higher doses to
a!hie'e effi!a!#$ whereas high-potency drugs a!hie'e effi!a!# at ower doses.
Haf >ife is the ti"e it ta(es for haf of the drug to %e re"o'ed fro" the %oodstrea". 4rugs with shorter haf)ife "a# need
to %e gi'en three or four ti"es a da#$ %ut drugs with a onger haf)ife "a# %e gi'en on!e a da#.
The ?4. "a# issue a %a!()%o5 warning when a drug is found to ha'e serious or ife)threatening side effe!ts. This "eans
that pa!(age inserts "ust ha'e a highighted %o5$ separate fro" the te5t$ whi!h !ontains a warning a%out the serious side)
effe!ts.
Anti/s)!hoti! dr"s
.so (nown as neuroepti!s$ are used to treat the s#"pto"s of ps#!hosis$ su!h as the deusions and the hau!inations seen in
s!hi8ophrenia$ s!hi8oaffe!ti'e disorder$ and the "ani! phase of %ipoar disorder.
.ntips#!hoti!:s wor( %# %o!(ing re!eptors of the neurotrans"itter$ dopa"ine.
4opa"ine re!eptors are !assified into su%!ategories +49$ 40$ 4@$ 4<$ and 4A- and 40$ 4@$ and 4< ha'e %een asso!iated
with "enta iness.
The t#pi!a antips#!hoti! drugs are potent antagonists +%o!(ers- of 40$ 4@$ and 4<. This "a(es the" effe!ti'e in treating
target s#"pto"s %ut aso produ!es "an# extrapyramidal side effe!ts %e!ause of the %o!(ing of the 40 re!eptors.
Newer$ at#pi!a antips#!hoti! drugs su!h as !o8apine +Co8ari- are reati'e# weak blockers of D2$ whi!h "a# a!!ount for
the ower in!iden!e of e5trap#ra"ida side effe!ts.
The newer antips#!hoti!s aso inhi%it the reupta(e of serotonin$ in!reasing their effe!ti'eness in treating the depressi'e
aspe!ts of s!hi8ophrenia.
E+tra/)ramidal Side E##e!ts
+E/S- are the "a7or side effe!ts of antips#!hoti! drugs. The# in!ude a!ute d#stonia +proonged in'ountar# "us!uar
!ontra!tions that "a# !ause twisting of the %od# parts$ repetiti'e "o'e"ents$ and in!reased "us!uar tone-$
0
pseudopar(insonis"$ and a(athisia +intense need to "o'e a%out-. ;o!(age of the 40 re!eptors in the "id%rain region of the
%rain ste" is responsi%e for the de'eop"ent of E/S. In!uded in the E/S are:
o Torti!ois: twisted head and ne!(
o Opisthotonus: tightness of the entire %od# with head %a!( and an ar!hed ne!(.
o O!uog#ri! !risis: e#es roed %a!( in a o!(ed position.
I""ediate treat"ent with anti!hoinergi! drugs usua# %rings rapid reief.
/seudopar(insonis"$ or drug)indu!ed /ar(insonis" if often referred to %# the generi! a%e of E/S. S#"pto"s in!ude a
stiff$ stooped posture* "as()i(e fa!ies* de!reased ar" swing* a shuffing. festinating gait* drooing* tre"or* %rad#!ardia* and
!oarse pi roing "o'e"ents of the thu"% and fingers whie at rest.
Treat"ent of these s#"pto"s !an in!ude adding an anti!hoinergi! agent or a"antadine$ whi!h is a dopa"ine agonist that
in!reases trans"ission of dopa"ine %o!(ed %# the antips#!hoti! drug.
Ne"role/ti! Malinant s)ndrome
+N&S- is a potentia# fata idios#n!rati! rea!tion to an antips#!hoti!. 4eath rates ha'e %een reported at 91B to 01B.
S#"pto"s in!ude rigidit#$ high fe'er* autono"i! insta%iit# su!h as unsta%e %ood pressure$ diaphoresis$ and paor*
deiriu"* and ee'ated e'es of en8#"es$ parti!uar# !reatine and phospho(inase.
Cients with N&S are !onfused and often "ute* the# "a# fu!tuate fro" agitation to stupor.
4eh#dration$ poor nutrition$ and !on!urrent "edi!a iness a in!rease the ris( of N&S.
Treat"ent in!udes i""ediate dis!ontinuation of the antips#!hoti! and the institution of supporti'e "edi!a !are to treat
deh#dration and h#perther"ia.
Tardi(e D)s*inesia
+T4- is a s#ndro"e of /ermanent in'ountar# "o'e"ents. This is "ost !o""on# !aused %# the ong)ter" use of
antips#!hoti! drugs.
There is no treat"ent a'aia%e.
The s#"pto"s of T4 in!ude in'ountar# "o'e"ents of the tongue$ fa!ia$ and ne!( "us!es$ upper and ower e5tre"ities$
and trun!a "us!uature. Tongue thrusting and protruding$ ip s"a!(ing$ %in(ing$ gri"a!ing$ and other e5!essi'e
unne!essar# fa!ia "o'e"ents are !hara!teristi!.
One T4 has de'eoped$ it is irre'ersi%e.
Aran"lo!)tosis
So"e antips#!hoti!s produ!es agranuo!#tosis. This de'eops sudden# and is !hara!teri8ed %#:
o ?e'er
o &aaise
o U!erati'e sore throat
o >eu!openia
The drug "ust %e dis!ontinued i""ediate# if the W;C drops %# A1B or to ess that @$111.
Antide/ressant dr"s
.though the "e!hanis" of a!tion is not !o"pete# understood$ antidepressants so"ehow intera!t with the two
neurotrans"itters$ norepinephrine and serotonin.
.ntidepressants are di'ided into four groups:
o Tri!#!i! and the reated !#!i! antidepressants
o See!ti'e serotonin reupta(e inhi%itors +SSRIs-
o &.O inhi%itors +&.OIs-
o Other antidepressants su!h as 'enafa5ine +Effe5or-$ %upropion +We%utrin-$ duo5etine +C#"%ata-$ tra8odone
+4es#re-$ and nefa8odone +Ser8one-.
&.OIs ha'e a ow in!iden!e of sedation and anti!hoinergi! effe!ts$ the# "ust %e used with e5tre"e !aution for se'era
reasons:
o . ife)threatening side effe!t$ h#pertensi'e !risis$ "a# o!!ur if the !ient ingests food !ontaining t#ra"ine +an a"ino
a!id- whie ta(ing &.OIs.
&ature or aged !heeses
.ged "eats +sausage$ pepperoni-
Tofu
.>> tap %eers and "i!ro%rewer# %eer.
Sauer(raut$ so# sau!e$ or so#%ean !ondi"ents
Cogurt$ sour !rea"$ peanuts$ &SG
o &.OIs !annot %e gi'en in !o"%ination with other &.OIs$ tri!#!i! antidepressants$ 4e"ero$ CNS depressants$
and h#pertensi'es$ or genera anestheti!s.
o &.OIs are potentia# etha in o'erdose and pose a potentia ris( for !ients with depression who "a# %e
!onsidering sui!ide.
@
SSRIs$ 'enafa5ine$ nefa8odone$ and %upropion are often %etter !hoi!es for those who are potentia# sui!ida or high#
i"pusi'e %e!ause the# !arr# no ris( of etha o'erdose in !ontrast to the !#!i! !o"pounds and the &.OIs. Howe'er$ SSRIs
are on# effe!ti'e for "id to "oderate depression.
The "a7or a!tions of antidepressants are with the "onoa"ine neurotrans"itter s#ste"s in the %rain$ parti!uar#
norepinephrine and serotonin.
o Norepinephrine$ serotonin$ and dopa"ine are re"o'ed fro" the s#napses after reease %# reupta(e into pres#napti!
neurons. .fter reupta(e$ these three neurotrans"itters are reoaded for su%se=uent reease or "eta%oi8ed %# the
en8#"e &.O.
o The SSRIs %o!( the reupta(e of serotonin* the !#!i! antidepressants and 'enafa5ine %o!( the reupta(e of
norepinephrine pri"ari# and %o!( serotonin to so"e degree* and the &.OIs interfere with en8#"e "eta%ois".
Mood sta0ili2in dr"s
&ood sta%ii8ing drugs are used to treat %ipoar disorder %# sta%ii8ing the !ient:s "ood$ pre'enting or "ini"i8ing the highs
and ows that !hara!teri8e %ipoar iness$ and treating a!ute episodes of "ania.
>ithiu" is !onsidered the first)ine agent in the treat"ent of %ipoar disorder.
o >ithiu" nor"ai8es the reupta(e of !ertain neurotrans"itters su!h as serotonin$ norepinephrine$ a!et#!hoine$ and
dopa"ine. It aso redu!es the reease of norepinephrine through !o"petition with !a!iu".
o >ithiu" produ!es its effe!ts intra!euar# rather than within neurona s#napses.
o >ithiu" seru" e'es shoud %e a%out 9.1 "E=/>. >e'es ess than 1.A "E=/> are rare# therapeuti!$ and e'es of
"ore than 9.A "E=/> are usua# !onsidered to5i!.
o If >ithiu" e'es e5!eed @.1 "E=/>$ dia#sis "a# %e indi!ated.
The "e!hanis" of a!tion for anti!on'usants is not !ear as it reates to their off)a%e use as "ood sta%ii8ers.
o 6aproi! a!id and topira"ate are (nown to in!rease the e'es on the inhi%itor# neurotrans"itter$ G.;.. ;oth are
thought to sta%ii8e "ood %# inhi%iting the (inding pro!ess.
The (inding pro!ess !an %e des!ri%ed as the snow%a)i(e effe!t seen when "inor sei8ure a!ti'it# see"s to
%uid up into "ore fre=uent and se'ere sei8ures. In sei8ure "anage"ent$ anti!on'usants raise the e'e of
the threshod to pre'ent these "inor sei8ures. It is suspe!ted that this sa"e (inding pro!ess "a# o!!ur in
the de'eop"ent of fu)%own "ania with sti"uation %# "ore fre=uent$ "inor episodes.
Antian+iet) dr"s ,An+iol)ti!s-
;en8odia8epines "ediate the a!tions of the a"ino a!id G.;.$ the "a7or inhi%itor# neurotrans"itter in the %rain. ;e!ause
G.;. re!eptor !hannes see!ti'e# ad"it the anion !horide into neurons$ a!ti'ation of G.;. re!eptors h#perpoari8es
neurons and thus is inhi%itor#.
;en8odia8epines produ!e their effe!ts %# %inding to a spe!ifi! site on the G.;. re!eptor.
Stim"lants
Toda#$ the pri"ar# use of sti"uants is for .4H4 in !hidren and adoes!ents$ residua attention defi!it disorder in aduts$
and nar!oeps#.
Sti"uants are often ter"ed indirectly acting amines %e!ause the# a!t %# !ausing reease of the neurotrans"itters
+norepinephrine$ dopa"ine$ and serotonin- fro" pres#napti! ner'e ter"inas as opposed to ha'ing dire!t agonist effe!ts on
the posts#napti! re!eptors. The# aso %o!( the reupta(e of these neurotrans"itters.
;# %o!(ing the reupta(e of these neurotrans"itters into neurons$ the# ea'e "ore of the neurotrans"itter in the s#napse to
hep !on'e# ee!tri!a i"puses in the %rain.
C"lt"ral !onsiderations
I:" not going to go "u!h into this. Dust (now that !ients fro" 'arious !utures "a# "eta%oi8e "edi!ation at different rates
and therefore re=uire aterations in standard dosages.
/s#!hoso!ia Theories and Therap#
Sim"nd Fre"d3 the Father o# Ps)!hoanal)sis
?ounded the personait# !o"ponents* Id$ Ego$ and Superego
o Id: The part of ones nature that refe!ts %asi! or innate desires su!h a peasure see(ing %eha'ior$ aggression$ and
se5ua i"puses. The id see(s instant gratifi!ation$ !auses i"pusi'e thin(ing %eha'ior$ and has no rues or regard for
so!ia !on'e!tion.
o Superego: The part of ones nature that refe!ts "ora and ethi!a !on!epts$ 'aues$ parenta and so!ia e5pe!tations*
therefore$ it is the dire!tiona opposite to the id.
o Ego: The %aan!ing or "ediating for!e %etween the id and the superego. The ego represents "ature and adapti'e
%eha'ior that aows a person to fun!tion su!!essfu#.
/s#!hose5ua de'eop"ent
<
o Ora +%irth to 9E "onths-
o .na +9E to @F "onths-
o /hai!/Oedipa +@ to A #ears-
o >aten!# +A to 99 or 9@ #ears-
o Genita +99 or 9@ #ears-
Transferen!e and Countertransferen!e
o Transferen!e o!!urs when the !ient onto the therapist/nurse attitudes and feeings that the !ient pre'ious# fet in
other reationships.
o Countertransferen!e o!!urs when the therapist/nurse dispa!es onto the !ient attitudes or feeings fro" his or her
past.
De(elo/mental Theorists4 Eri*son and Piaet
Eri(son fo!used on personait# de'eop"ent a!ross the ife span whie fo!using on so!ia and ps#!hoogi!a de'eop"ent in
ife stages.
o Trust 's. &istrust +infant-
o .utono"# 's. Sha"e and 4ou%t +todder-
o Initiati'e 's. guit +pres!hoo-
o Industr# 's. Inferiorit# +s!hoo age-
o Identit# 's. Roe !onfusion +adoes!en!e-
o Inti"a!# 's. isoation +#oung adut-
o Generati'it# 's. stagnation +"idde adut-
o Ego integrit# 's. despair +"aturit#-
Eri(son %eie'ed that ps#!hoso!ia growth o!!urs in se=uentia stages$ and ea!h stage is dependent on the !o"petion of the
pre'ious stage/ife tas(.
/iaget e5pored how inteigen!e and !ogniti'e fun!tioning de'eop in !hidren.
o Sensori"otor +%irth to 0 #ears-: The !hid de'eops a sense of sef as separate fro" the en'iron"ent and the !on!ept
of o%7e!t per"anen!e. ;egins to for" "enta i"ages.
o /reoperationa +0)F #ears-: Chid %egins to e5press hi"sef with anguage$ understands the "eaning of s#"%oi!
gestures$ and %egins to !assif# o%7e!ts.
o Con!rete operations +F)90 #ears-: Chid %egins to app# ogi!a thin(ing$ understands re'ersi%iit#$ is in!reasing#
so!ia and a%e to app# rues* howe'er$ thinking is still concrete.
o ?or"a operations +90 to 9A #ears and %e#ond-: Chid earns to thin( and reason in a%stra!t ter"s$ further de'eops
ogi!a thin(ing and reasoning$ and a!hie'es !ogniti'e "aturit#.
Harr) Sta!*s S"lli(an4 Inter/ersonal Relationshi/s and Milie" thera/)
The i"portan!e and signifi!an!e of interpersona reationships in one:s ife was Sui'an:s greatest !ontri%ution to the fied of
"enta heath.
Sui'an de'eoped the first therapeuti! !o""unit# or "iieu with #oung "en with s!hi8ophrenia in 9G0G. He found that
within the "iieu$ the intera!tions a"ong !ients were %enefi!ia$ and then the treat"ent shoud e"phasi8e on the roes of the
!ient)!ient intera!tion.
o &iieu therap# is used in the a!ute !are setting* one of the nurses: pri"ar# roes is to pro'ide safet# and prote!tion
whie pro"oting so!ia intera!tion.
Hildeard Pe/la"4 Thera/e"ti! n"rse$/atient relationshi/ ,The 0om0$diit) o# n"rsin-
4e'eoped the !on!ept of the therapeuti! nurse)patient reationship$ whi!h in!udes < phases: orientation$ identifi!ation$
e5poitation$ and resoution.
o The orientation phase is dire!ted %# the nurse and in'o'es engaging the !ient in treat"ent$ pro'iding e5panations
and infor"ation$ and answering =uestions. 4uring this ti"e the nurse woud orient the patient to the rues and
e5pe!tations +if in an a!ute setting-.
o The identifi!ation phase %egins when the !ient wor(s interdependent# with the nurse$ e5presses feeings$ and
%egins to fee stronger. This phase !an %egin either within a few hours to a few da#s* the patient !an identif# the
nurse and en'iron"ent on his own. The# 2!o"e together3. Hin(#.
o In the e5poitation phase$ the !ient "a(es fu use of the ser'i!es offered. He "o'es toward independen!e.
o In the resoution phase$ the !ient no onger needs professiona ser'i!es and gi'es up dependent %eha'ior.
o Heep in "ind that after the resoution phase$ the !ient !an regress and "o'e %a!( into the a%o'e "entioned phases.
/apau defined an5iet# as the initia response to a ps#!hi! threat$ des!ri%ing < e'es of an5iet#: a!ute$ "oderate$ se'ere$ and
pani!.
A
o .!ute an5iet# is a positive state of heightened awareness and sharpened senses$ aowing the person to earn new
%eha'iors and so'e pro%e"s. The person !an ta(e in a a'aia%e sti"ui +per!eptua fied-.
o &oderate an5iet# in'o'ed a decreased per!eptua fied +fo!us on i""ediate tas( on#-* the person !an earn new
%eha'ior or so'e pro%e"s only with assistance. .nother person !an redire!t the person to the tas(. Re"e"%er$ this
is the idea an5iet# state for tea!hing a !ient regarding heath !on!erns su!h as dia%etes$ as Cath# sa#s so.
o Se'ere an5iet# in'o'es feeings of dread or terror. The person C.NNOT %e redire!ted to a tas(* he fo!uses on# on
s!attered detais and has ph#sioogi! s#"pto"s su!h as ta!h#!ardia$ diaphoresis$ and !hest pain. The !ient "a# go
to the ER thin(ing he is ha'ing a heart atta!(. In e!ture$ Cath# stated that this person !an sti %e 2ta(ed down3.
The first priorit# is to "o'e the person awa# fro" a sti"ui$ and then atte"pt to ta( with the" to !a" down.
o /ani! an5iet# !an in'o'e oss of rationa thought$ deusions$ hau!inations$ and !o"pete ph#si!a i""o%iit# and
"uteness. The person "# %ot and run ai"ess#$ often e5posing hi"sef and others to in7ur#.
H"manisti! Theories5 Maslo&1s Hierar!h) o# needs.
He used a p#ra"id to arrange and iustrate the %asi! dri'es or needs to moti(ate peope.
o The "ost %asi! needs$ ph#sioogi! needs$ need to %e "et first. This in!udes food$ water$ sheter$ seep$ se5ua
e5pression$ and freedo" of pain. These &UST %e "et first.
o The se!ond e'e in'o'es safet# and se!urit# needs$ whi!h in'o'e prote!tion$ se!urit#$ freedo" fro" har" or
threatened depri'ation.
o The third e'e is o'e and %eonging needs$ whi!h in!ude enduring inti"a!#$ friendship$ and a!!eptan!e.
o The fourth e'e in'o'es estee" needs$ whi!h in!udes the need for sef)respe!t and estee" fro" others.
o The highest e'e is sef)a!tuai8ation$ the need for %eaut#$ truth$ and 7usti!e. ?ew peope a!tua# %e!o"e sef)
a!tuai8ed.
o Re"e"%er$ trau"ati! ife e5perien!es or !o"pro"ised heath !an !ause a person to regress to a ower e'e of
"oti'ation.
Pa(lo(4 Classi! !onditionin ,'eha(ior theor)-
/a'o' %eie'ed that %eha'ior !an %e !hanged through !onditioning with e5terna or en'iron"enta !onditions or sti"ui.
Crisis Inter(ention
&aturationa !rises$ so"eti"es !aed developmental crises$ are predi!ta%e e'ents in the nor"a !ourse of a ife$ su!h as
ea'ing ho"e for the first ti"e$ getting "arried$ ha'ing !hidren$ et!.
Situationa !rises are unanti!ipated or sudden e'ents that threaten an indi'iduas integrit#* su!h as a death of a o'ed one and
oss of a 7o%.
.d'entitious !rises$ so"eti"es !aed social crises$ in!ude natura disasters i(e foods$ earth=ua(es$ or hurri!anes* war$
terrorist atta!(s* riots* and 'ioent !ri"es su!h as rape or "urder.
NON$%IOLENT CRISIS INTER%ENTION
The heart of !risis inter'ention is:
Care
Wefare
Safet# +I9,-
Se!urit#
/eope in !risis need !are and wefare.
Staff responses shoud %e safet# and se!urit#.
An+iet)4
In!rease or !hange in %eha'ior. Can %e an#thing different fro" usua %eha'ior +e5!ite"ent$ pa!ing-.
Nursing inter'entions:
o .s( 2What:s going onJ3
o Gi'e supporti'e !are and et the patient (now that #ou:re there.
De#ensi(e4
>oss of rationait#.
Nursing inter'entions:
o 4ire!t approa!h to setting i"its.
o Ta(e awa# pri'ieges.
o Gi'e the patient so"e !ontro and !hoi!es.
A!tin o"t /erson4
F
>oss of rationa !ontro.
Nursing inter'entions:
o E'er#thing Cath# showed us on non)'ioent ph#si!a !risis inter'ention
Tension$Red"!tion4
Su%siding of energ#.
Nursing inter'entions:
o Esta%ish therapeuti! rapport
o /ri"e ti"e to ta( and tea!h a%out pre'entions of %eha'ior.
6hat i# the /atient sim/l) re#"ses7
Set i"its,
&a(e the i"its reasona%e and enfor!ea%e.
Releasin8 %entin8 Mad as he!*9
.ow the patient to do this,
Dust sta# !a" as a nurse
Whie the#:re 'enting$ the#:re aso reeasing. This is a good thing.
Intimidation4
This is NOT . GOO4 THING.
What if the patient tes #ouKJ
o I (now what !ar #ou dri'e.
o I (now #our ast na"e.
o I (now #ou ha'e 0 dogs and I:" going to (i the".
Nursing inter'entions:
o Get a witness, 4o not %e %# #oursef with this patient,
Non$(er0al 0eha(ior that a##e!t /ro+emi!s
?a!tors that affe!t:
o Si8e$ gender$ disa%iit#$ en'iron"ent$ agitation$ histor#$ and speed.
9E)@F3 is persona spa!e +usua# how wide ones ar" ength is-.
.wa#s %e the !osest to the door.
:inesi!s ,'od) lan"ae-
?a!ia e5pressions$ stan!e$ posture$ %reathing$ hand gestures
When approa!hing a !ient$ stand at <A degree ange
Stand with hands to side +espe!ia# when with a paranoid !ient-
&o'e when the patient "o'es.
;e as !a" as possi%e.
Para(er0al !omm"ni!ation
AAB non'er%a
LB 'er%a
@EB para'er%a it:s not what #ou sa#* it:s how #ou sa# it,
T6C +tota 'oi!e !ontro-
o Tone
o 6ou"e
o Caden!e
.wa#s re"e"%er not to ose e#e !onta!t.
I# )o"1re 0ein ra00ed8
Gain ph#sioogi! ad'antage
o Hnow where the wea( point of gra% is
o >e'erage) use what #ou ha'e,
o &o"entu"Mit !o"es in hand#
Gain ps#!hoogi!a ad'antage
o Sta# !a"
o Ha'e a pan
L
o 4on:t forget the ee"ent of surprise
Non$%iolent /h)si!al !ontrol and restraint sho"ld 0e "sed as a LAST RESORT.
MOOD DISORDERS
Cateories o# Mood disorders
Unipoar
o &a7or depression
;ipoar
o &ania
o 4epression
o /eriod of nor"a!#
Uni/olar4 Ma;or de/ression
Sad "ood or a!( of interest in ife for 0 or "ore wee(s
.nother < s#"pto"s "ust aso %e present
o Change in appetite +in!rease or de!rease-
o Change in seep patterns +too "u!h or too itte-
o Una%e to !on!entrate and "a(e de!isions
o >oss of sef)estee" +guit) how #ou were raised* how worth# a person per!ei'es the"se'es-.
Those at ris(:
o /&S//&44
o Suffering fro" an5iet# and irrita%iit#
o // depression
o Chroni! iness +dia#sis-
o /TS4
o Grief and oss
Can %e o%ser'ed %# others$ or the depression is 7ust in one:s 2head3
In!iden!e
&a7or depression o!!urs at east twi!e as often in wo"en
Singe and di'or!ed peope ha'e the highest rates of depression
Treatments
/s#!hotherap# +groups$ !ounseor-
/s#!hophar"a!oog# +&eds-
ECT
Ele!tro!on("lsi(e thera/)
The %iggest !on!ern is "e"or# oss.
/atient is pre)"edi!ated$ "u!h i(e a pre)op patient
Eders are treated for depression with ECT "ore fre=uent# than #ounger persons.
o Eder persons ha'e in!reased intoeran!e of side effe!ts of antidepressants
o ECT produ!es a "ore rapid response
S"i!idal Ideation
Safet# is pri"ar# !on!ern
Wat!h for o'ert !ues of sui!ide +O%'ious- a!ti'e
Co'ert !ues are "ore su%teMpassi'e
/eope who sudden# are happier are of great !on!ern* "a# ha'e "ade the sui!ida pan are !ontent with their de!ision.
/eope whose "eds are fina# wor(ingMha'e enough energ# to !arr# out the a!t
Client1s A##e!t
Co"pare 'er%a with non)'er%a %eha'iorsMdo the# "at!h upJ
.so!ia: Withdrawa fro" fa"i# and friends
.nhedoni!: >ose sense of peasure
E
When !onfronting these !ient:s a%out their %eha'ior$ use 2I3 state"ents
o 2I rea# wish #ou:d 7oin the group3
<"dment
?ee o'erwhe"ed with nor"a a!ti'ities
4iffi!ut# with tas( !o"petion
.wa#s e5hausted
Sel# Con!e/t
Ru"inate: Worr# to e5!ess.
>a!( energ# for nor"a a!ti'ities +awa#s tired-
Inter(entions
.ssess safet# for !ient +/RIORITC,-
/erfor" sui!ide ethait# assess"ent
Orient !ient to new surroundings +the# need stru!ture-
Offer e5panations of unit routine +again$ need stru!ture-
Start to pro"ote a therapeuti! reationship* s!hedue short intera!tion ti"es.
Patient and Famil) tea!hin
Stress i"portan!e of foow)up !areM(eep it stru!tured* "a(e appoint"ent for the".
Stress i"portan!e of !ontinuing "edi!ations* assess if the# !an afford the"
&a(e phone nu"%er ists of how to get hep if the# need it.
'i/olar disorder
Condition with !#!i! "ood !hanges
/erson has "ani! episodes$ periods of profound depression$ and ti"es of nor"a %eha'ior in)%etween
O!!urs e=ua# in "en and wo"en* often seen in high# edu!ated peope.
Clini!al !o"rse o# mania
Episode of unusua$ grandiose$ or agitated "ood asting at east one wee( with three or "ore of the foowing s#"pto"s:
o E5aggerated sef)estee"
o Seepessness
o /ressured spee!h
o ?ight of ideas
o Redu!ed a%iit# to fiter out sti"ui
o 4istra!ti%iit#
o &ore a!ti'ities with in!reased energ#
Dr" treatment
>ithiu"
o >ithiu" is not "eta%oi8ed* rather$ it is rea%sor%ed %# the pro5i"a tu%ue and e5!reted in the urine.
o Thought to wor( in the s#napse to in!rease destru!tion of dopa"ine and norepinephrine* de!reases sensiti'it# to
posts#napti! re!eptors +;asi!a#) when a person is in a "ani! phase$ the# are s#napsing super fast. >ithiu" heps
sow this s#napsing down-.
o Onset of a!tion is A)9< da#s* other drugs "ust %e used during the a!ute phases to redu!e s#"pto"s of "ania or
depression.
o &aintenan!e ithiu" e'e is 1.A)9.1 "E=/>.
@ is to5i!,
o >ithiu" is a sat !ontained in the hu"an %od#. It not on# !o"petes for sat re!eptor sites %ut aso affe!ts !a!iu"$
potassiu"$ and "agnesiu" ions as we as gu!ose "eta%ois".
&UST !o"pete an ee!tro#te %ood pane +fo!us on Choride-.
o Ha'ing too "u!h sat in the diet !an !ause the ithiu" e'e to %e too ow.
o Not ha'ing enough dietar# sat !an !ause the ithiu" e'es to %e too high.
o /ersistent thirst and diuted urine !an indi!ate the need to !a the &4* ithiu" dosage "a# need to %e redu!ed.
.nti!on'usant drugs: "e!hanis" is un!ear$ %ut the# raise the %rains threshod for deaing with sti"uation* this pre'ents the
person fro" %eing %o"%arded with e5terna and interna sti"ui.
o Tegreto
Huge !on!ern a%out agranuo!#tosis +a de!rease in W;C-.
G
Need seru" e'es "onitored 90 hours after ast dose.
o 4epa(ote
Need to "onitor seru" e'e$ C;C with pateets$ i'er fun!tion in!uding a""onia e'e +a""onia is a %#)
produ!t of i'er "eta%ois"-
o Honopin
.nti!on'usant and %en8odia8epine
4rug dependen!e !an o!!ur
&onitor C;C$ i'er fun!tion
Withdrawa drug sow# to pre'ent GI issues
Cannot %e used aone to "anage %ipoar* "ust %e used in !on7un!tion with ithiu" or another "ood
sta%ii8er.
Hel/#"l hints to !are #or 0i/olar !lients
Cou !an:t tea!h a "ani! !ient
Safet# is a huge issue %e!ause their 7udg"ent is poor.
On# spend short periods of ti"e with patient
&ust %e fe5i%e in ta(ing inta(e assess"ent* "a# need to o%tain data in se'era short sessions as we as ta(ing to fa"i#
"e"%ers.
.s( the !ient to e5pain an# !oded spee!h
.ssist the !ient to "eet so!ia# a!!epting %eha'iors. 2Hath#$ #ou are too !ose to "# fa!e. /ease stand %a!( two feet.3
?eed the" finger foods high in !aories whie in a "ani! phase* pro'ide nutritiona support,
Use si"pe senten!es when !o""uni!ating. It is aso hepfu to as( !ient to repeat %rief "essages to ensure the# ha'e heard
and in!orporated the".
o 2/ease spea( "ore sow#. I:" ha'ing trou%e foowing #ou.3
.'oid %e!o"ing in'o'ed in power strugges o'er who wi do"inate the !on'ersation.
S"i!ide
< out of A who a!tua# !o""it sui!ide ha'e "ade at east one prior atte"pt
In a "a7orit# of !ases$ there are !ear indi!ators hat the person was 'er# trou%ed.
?ew than 9AB of sui!ide 'i!ti"s ea'e sui!ide notes
The sui!ide ris( is greatest in the G1 da#s foowing a "a7or depressi'e episode.
2sur'i'or guit3 happens when 9 or "ore fa"i# "e"%ers fee guit# that the# are sti i'ing
2Separation an5iet#3 "a# !ause the# sur'i'ing to 27oin the %eo'ed de!eased3
&a(e the patient sign a 2!ontra!t for ife3
Crisis inter'entionM"a# need 9:9 !are. The !ient is no "ore than 0)@ feet awa# fro" a staff "e"%er at an# ti"e$ in!uding
going to the %athroo".
AN=IETY DISORDERS > SU'STANCE A'USE
In!iden!e
&ost !o""on e"otiona disorder in the U.S.
/re'aent in wo"en* age N<A
Ph)sioloi! res/onses
?ight or fight responses
S#"patheti! fi%ers in!rease the 'ita signs
.drena gands reease adrenalin whi!h !auses the %od# to:
o Ta(e in "ore o5#gen
o 4iate the pupis +%rings "ore ight into e#es* %etter 'ision-
o In!rease the arteria %ood pressure and heart rate
o Constri!t periphera 'esses +"a(es s(in !oo and pae-
o In!rease g#!ogeno#sis to free gu!ose for fue +g#!ogen is %eing %ro(en down in the i'er-
o Shunt %ood fro" GI and reprodu!ti'e organs
Ps)!holoi!al res/onse
4iffi!ut# with ogi!a thought
In!reased agitation with "otor a!ti'it#
91
In!reased 'ita signs
Cient wi tr# to !hange the feeings of dis!o"fort %#:
o Changing %eha'ior %# adaptation
o Changing %eha'ior with defense mechanisms
An+iet) disorders
/ani! disorder
/ho%i! disorder
.gorapho%ia
O%sessi'e)!o"pusi'e
/TS4
Generai8ed an5iet#
.n5iet# reated to "edi!a !onditions
Su%stan!e)indu!ed an5iet# disorder
De(elo/ment o# An+iet) Disorders
/redisposing fa!tors
o Onset: .!ute or insidious +%uids up-
o /re!ipitating e'ent
o Chroni! stressors
o Unusua %eha'ior
o ?ears disproportionate to reait#
Le(els o# an+iet)
&id:
o /s#!hoogi!a: Wide per!eptiona fied$ sharpened senses$ in!reased "oti'ation$ effe!ti'e pro%e" so'ing$ in!reased
earning a%iit#$ irrita%iit#.
o /h#sioogi!: Restessness$ fidgeting$ 2%utterfies3$ diffi!ut# seeping$ h#persensiti'it# to noise.
&oderate:
o /s#!hoogi!a: per!eptua fied narrowed to i""ediate tas($ see!ti'e# attenti'e$ !annot !onne!t thoughts or e'ents
independent#$ in!reased use of auto"atis"s
o /h#sioogi!: &us!e tension$ diaphoresis$ pounding puse$ H.$ dr# "outh$ high 'oi!e pit!h$ faster rate of spee!h$ GI
upset$ fre=uent urination
Se'ere:
o /s#!hoogi!a: /er!eptua fied narrowed to one detai or s!attered detais* !annot !o"pete tas(s* !annot so'e
pro%e"s or earn effe!ti'e#* %eha'ior geared toward an5iet# reief and is usua# ineffective* doesn:t respond to
redire!tion* fees awe$ dread$ or horror* !ries* rituaisti! %eha'ior.
o /h#sioogi!: Se'ere H.$ N/6$ diarrhea$ rigid stan!e$ 'ertigo$ pae$ ta!h#!ardia$ !hest pain.
/ani!:
o /s#!hoogi!a: /er!eptua fied redu!ed to fo!us on sef* !annot pro!ess an# en'iron"enta sti"ui* distorted
per!eptions* oss of rationa thought* doesn:t re!ogni8e potentia danger* !an:t !o""uni!ate 'er%a#* possi%e
deusions or hau!inations* "a# %e sui!ida.
o /h#sioogi!: &a# %ot and run OR tota# i""o%ie and "ute* diated pupis$ in!reased %ood pressure and puse*
fight$ fright$ or free8e.
Se)le Res/onse to stress
.ar" rea!tion
o /h#sioogi! response
o ;od# prepares to defend itsef
Resistan!e stage
o ;od# wi defend %# fight or fight
o If the stress is gone* %od# rea5es
E5haustion stage
o Negati'e response to an5iet# and stress
o ;od# stores are depeted
Pani! disorders
99
.n episode asting 9A)@1 "inutes in whi!h a !ient e5perien!es rapid$ intense$ es!aating an5iet#* great e"otiona dis!o"fort*
and ph#sioogi! dis!o"fort.
4efined as re!urrent$ une5pe!ted pani! atta!(s foowed %# a "onth of persistent !on!ern or worr# a%out ha'ing another
atta!(.
LAB with pani! disorder ha'e spontaneous atta!(s with no triggers
Others ha'e atta!(s sti"uated %# pho%ias or !he"i!a !hanges within the %od#.
Treatment
/s#!hotherap#
o /ositi'e refra"ing
o .sserti'eness training
/s#!hophar"a!oog#
o SSRIs
o .n5io#ti!s
o .ntidepressants
o &.OIs
Pho0ias
.n illogical$ intense$ persistent fear of a spe!ifi! o%7e!t or so!ia situation that !auses e5tre"e distress and interferes with
having a normal life.
Treat"ent for pho%ias:
o /s#!hophar"a!oog#
.n5io#ti!s
;en8odia8epines
SSRIs
;eta ;o!(ers
o /s#!hotherap#
;eha'iora therap#
S#ste"i! desensiti8ation
2?ooding3 Getting rid of fear a at one ti"e
O0sessi(e$Com/"lsi(e Disorder ,OCD-
O%sessions: Re!urrent thoughts$ ideas$ 'isuai8ations$ or inappropriate i"puses that distur% a person:s ife* has no control
over them.
Co"pusions: ;eha'iors or rituas !ontinuous# !arried out to get rid of the o%sessi'e thoughts and redu!e an5iet#.
Higher in!iden!e with groups in higher e!ono"i! status and with "ore edu!ation
Nursing inter'entions:
o Re"e"%er$ a ot of the ti"e peope fee guit# a%out their thoughts and %eha'iors.
o 4o not tr# to stop the a!t uness the a!t is har"fu +dangerous-
o Ta( to the", Use 2I3 state"ents
o If the# are too down on the"se'esMi"it #our ti"e with the". ?or instan!e$ 2I hate "#sef. No one !ares a%out
"e. I:" fat and ug#.3 The nurse woud then sa#$ 2I a" going to !o"e %a!( in @1 "inutes. In that ti"e fra"e$ I want
#ou to thin( of #our good =uaities.3
o 4o not argue with OC4 person.
o In7e!t reait#. If a teenager thin(s she is pregnant despite a negati'e pregnan!# test$ te her the TEST IS
NEG.TI6E. Ta(e the" %a!( into reait#.
o If the# repetiti'e# do an a!t o'er and o'er again* hep the" set a goa. ?or instan!e$ 2>et:s tr# to on# wash #our
hands on!e e'er# ten "inutes.3
Post Tra"mati! Stress disorder
Three !usters if s#"pto"s are present
o Rei'ing the e'ent
&e"ories$ drea"s$ or fash%a!(s
o .'oiding re"inders of the e'ent
Sta#ing awa# fro" an# sti"ui that !oud %e asso!iated with the trau"a.
o ;eing on guard +h#per)arousa-
>ess responsi'e to sti"ui
90
Inso"nia$ irrita%iit#$ or angr# out%ursts
.t ris( peope in!ude:
o Co"%at 'eterans
o 6i!ti"s of 'ioen!e
o .%used 'i!ti"s
o Chidren in traffi! a!!ident +and the parents-
On# <FB of parents sought hep for their !hidren. HI4S NEE4 HE>/.
S#"pto"s of /TS4 o!!ur @ "onths or "ore after the trau"a.
So"e "ore signs of /TS4:
o Ha'e issues with authorit# figures
o Their first e"otions are anger$ rage$ and guit
o Their guit !o"es out as anger +'ioent %eha'ior-
o Isoate the"se'es
o Cr#
o 4on:t want to ta( a%out it
o 4rug and a!oho a%use
o Night"ares
o &anifests in ph#sioogi!a s#"pto"s +H.$ GI distress-
o Irrita%e
o Inso"nia
Nursing inter'entions:
o Ha'e spe!ifi! staff "e"%ers assigned to !ient to fa!iitate %uiding trust
o Consisten!# is the (e#
o ;e non)7udg"enta* en!ourage !ient to ta(
o Hep the" a!(nowedge where grief is !o"ing fro"
o In'o'e fa"i#
o Gi'e positi'e feed%a!(
Goas for /TS4:
o Short ter": Safet#$ de!rease inso"nia$ identif# sour!e$ grie'e,
o >ong ter": .!!ept the fa!t that the e5perien!e happened and i'e heath#.
S"0stan!e a0"se
O'erdose of a!oho:
o .!oho is a depressant* de!reased respirations and %ood pressure$ 'o"iting "a# !ause aspiration.
O'erdose of %en8odia8epines re=uire a gastri! a'age in!uding instiation of a!ti'ated !har!oa.
Sti"uants
o Co!aine$ a"pheta"ines$ and Ritain
o In!reases HR and ;/* de!reases !ardia! output and o5#gen
o Co!aine spe!ifi!a# !auses &I:s
6ithdra&al
Two purposes:
o Safe withdrawa with "edi!ation
Suppress s#"pto"s of a%stinen!e
.round the !o!( s!hedue and /RN
Ne'er$ e'er go !od tur(e#.
o /re'ent reapse
&a# need to go to .. for rest of ife.
COGNITI%E DISORDERS
Deliri"m
4istur%an!e of !ons!iousness a!!o"panied %# !hange in !ognition* disoriented
o .ert and oriented to person on#
o T#pi!a# ha'e pro%e"s re!aing on "e"or# and ti"e.
4e'eops o'er a short period of time
Easi# distra!ted
9@
4iffi!ut# !on!entrating
Iusions$ hau!inations
Onset is rapid
;rief duration
>e'e of !ons!iousness is i"paired
Surred spee!h
.n5ious "ood
Ca"ses o# Deliri"m
&eta%oi!
Infe!tionMUTI
>ow sodiu"
o Nor"a is 9@A)9<A "E=/>
o .wa#s !he!( ee!tro#tes,
4rug reated
o Or$ withdrawa fro" drugs and a!oho
o Sedati'es and %en8odia8epines !ause !onfusion
Effe!ts of anesthesia
The n"rsin /ro!ess4 Assessment
Inter'iew with si"pe =uestions and e5panations
?re=uent %rea(s
Histor# of onset* not reia%e fro" !ient
o Inter'iew fa"i# "e"%ers* as(: 2Is this how #our "o" t#pi!a# a!tsJ3
&ood/.ffe!t
o ?re=uent# assess "oods* "oods !hange =ui!(#
Thought pro!ess/!ontent
o &an# ha'e 'isua hau!inations
o 6er# restess* hard to (eep in %ed.
N"rsin /ro!ess4 Goals
?ree fro" in7ur#
o ?a pre!autions
4e"onstrate in!reased orientation
o Use reait# orientation and 'aidate feeings
.de=uate %aan!e of a!ti'it# and rest
o Hep the patient (eep da#s and nights straight
.de=uate nutrition
o Often forget to eat* needs nutritiona suppe"ents
Return to opti"a e'e of fun!tioning
. goa needs a ti"eine to "a(e it "easura%e,
N"rsin /ro!ess4 Inter(ention
/atient safet#
&anaging !onfusion
o Often frightened at night.
/ro"ote !o"fort and rest
.de=uate fuids and nutrition
o .wa#s offer itte sips of water,
N"rsin /ro!ess4 E(al"ation
Su!!essfu treat"ent of under#ing !auses for deiriu" returns !ient to for"er e'e of fun!tioning
Cient and fa"i# edu!ation a%out a'oidan!e of re!urren!e
&onitor !hroni! heath pro%e"s
Carefu use of "edi!ations
9<
No a!oho or other non)pres!ri%ed drugs
DEMENTIA
Dementia
&ore progressi'e$ gradua$ and per"anent
In'o'es "utipe !ogniti'e defi!its
o /ri"ari# "e"or# i"pair"ent
In'o'es at east one of the foowing:
o .sphasia +deterioration of anguage fun!tion-
o .pra5ia +i"paired a%iit# to e5e!ute "otor fun!tions-
o .gnosia +ina%iit# to na"e or re!ogni8e o%7e!ts-
o 4istur%an!e in e5e!uti'e fun!tioning +a%iit# to thin( a%stra!t# and to pan$ initiate$ se=uen!e$ "onitor$ and stop
!o"pe5 %eha'ior-
&a# aso present:
o E!hoaia +e!hoing what is heard-
o /aiaia +repeating words or sounds o'er and o'er-
Clini!al !o"rse o# Dementia
&id:
o ?orgetfuness
o 4iffi!ut# finding words
o ?re=uent# oses o%7e!ts and e5perien!es an5iet# a%out these osses.
o O!!upationa and so!ia settings are ess en7o#a%e$ and the person "a# a'oid the".
&oderate:
o Confusion is present aong with "e"or# oss
o The person !annot !o"pete !o"pe5 tas(s %ut re"ains oriented to person and place.
o Sti re!ogni8es fa"iiar peope.
o So"e assistan!e with !are
o E5e!uti'e fun!tioning suffers +espe!ia# with .4>s-
Se'ere:
o /ersonait# and e"otiona !hanges o!!ur
o &a# %e deusiona$ wander at night$ forget the na"es of spouse and !hidren and re=uire assistan!e in .4>s.
o &ost i'e in EC?.
Ca"ses o# Dementia
4e!reased "eta%oi! a!ti'it#
Geneti! !o"ponent
Infe!tion
.8hei"er:s disease +I9-
Creut8fed)Da!o% disease +CNS disorder* de'eops at <1)F1 #ears. Causes %# infe!tious parti!e that is resistant to %oiing-
/ar(inson:s disease
Huntington:s disease +inherited gene* %rain atroph#$ de"#eination$ and enarge"ent of the %rain 'entri!es. ;egins in ate
@1:s-
6as!uar 4e"entia +I0-
o S#"pto"s si"iar to .8hei"er:s$ %ut "ore a%rupt$ foowed %# rapid !hanges in fun!tioning* a pateau* "ore
a%rupt !hanges$ another pateau$ and so on.
o Caused %# de!reased %ood supp# to the %rain.
C"lt"re
Nati'e ."eri!ans and Eastern !ountries hod eders in a position of authorit#$ respe!t$ power$ and de!ision "a(ing for
fa"i#* this does not !hange despite "e"or# oss or !onfusion.
&a# fee the# are %eing disrespe!tfu and reu!tant to "a(e de!isions or pans for eders with de"entia.
Treatment #or Dementia
Under#ing !ause
o E5a"pe: 6as!uar de"entia !an %e heped %# diet$ e5er!ise$ !ontro of h#pertension or dia%etes.
9A
/s#!hophar"a!oog#
o Cogne5 and .ri!ept are !hoinesterase inhi%itors and ha'e shown therapeuti! effe!ts* sow the progress of de"entia.
The) do not re(erse damae alread) done.
&ust ha'e i'er fun!tion tests done with Cogne5.
?u)i(e s#"pto"s$ diarrhea$ seep distur%an!es are !o""on.
o Tegreto and 4epa(ote hep sta%ii8e "ood and di"inish aggressi'e out%ursts.
These doses are often O)0/@ ess ower than pres!ri%ed for sei8ures$ therefore$ does not need to %e in the
2therapeuti! e'e3 for %ood wor(.
o ;en8odia8epines "a# !ause deiriu" and !an worsen aread# !o"pro"ised !ogniti'e a%iities.
N"rsin /ro!ess4 Assessment
Histor#
o Re"e"%er$ inter'iew fa"i#
&otor %eha'ior and genera appearan!e
o 4ispa# aphasia
o Con'ersation repetiti'e
o .pra5ia +su!h as !o"%ing hair-
o Gait distur%an!e
o Uninhibited behavior* ne'er ha'e dispa#ed these %eha'iors %efore.
&ood and .ffe!t
o Grie'e at first
o E"otiona out%ursts are !o""on
o /attern of withdrawa* ethargi!$ apatheti!$ oo( da8ed and istess.
Thought pro!ess and !ontent
o E5e!uti'e fun!tioning i"paired
o Ha'e to stop wor(ing
o Cient "a# a!!use others of steaing ost o%7e!ts
Sensoriu" and Intee!tua /ro!esses
o ?irst affe!ts re!ent and i""ediate "e"or#$ e'entua# i"pairs the a%iit# to re!ogni8e fa"i# "e"%ers and onesef.
o Confa%uation: !ients "a(e up answers to fi in "e"or# gaps* often inappropriate words or fa%ri!ated ideas
+SCREW COU$ .SSHO>E-.
o 6isua hau!inations are !o""on.
Dudg"ent and insight
o Underesti"ate ris(
Sef !on!ept
o Initia# grie'e$ and then sow# ose sense of sef.
Roes and Reationships
/h#sioogi! and sef)!are !onsiderations
o .tered seep)wa(e !#!e
o So"e !ients ignore interna !ues su!h as hunger or thirst
o Nege!t %athing and groo"ing* %e!o"e in!ontinent.
N"rsin Pro!ess4 Inter(entions
4e"onstrate !aring attitude
Heep !ients in'o'ed* reate to en'iron"ent
6aidate !ient:s feeings of dignit#
Offer i"ited !hoi!es
Refra"ing +offering aternate points of 'iew to e5pain e'ents-
S.?ETC,
o /h#si!a and Che"i!a restraint shoud %e the ast option
N"rsin /ro!ess4 E(al"ation
Goas !hange as disease progresses
Reassess"ent is 'ita,
Cient awa#s needs assessed$ goas and inter'entions !onstant# re'ised
E'auation is a !ontinuing pro!ess.
Re"e"%erK short term oals5 all oals need a time #rame.
9F
SCHI?OPHRENIA
T#pes of s!hi8ophrenia
/aranoid s!hi8ophrenia
o Suspi!iousness
o Hostiit#
o 4eusions
o .uditor# hau!inations
o .n5iet# and anger
o .oofness
o /erse!utor# s!he"es
o 6ioen!e
4isorgani8ed s!hi8ophrenia
o E5tre"e so!ia withdrawa
o 4isorgani8ed spee!h or %eha'ior
o ?at or inappropriate affe!t
o Siiness unreated to spee!h
o Stereot#ped %eha'iors
o Gri"a!ing "anneris"s
o Ina%iit# to perfor" a!ti'ities of dai# i'ing
Catatoni! s!hi8ophrenia
o Signifi!ant ps#!ho"otor distur%an!es
o I""o%iit#
o Stupor
o Wa5# fe5i%iit#
o E5!essi'e purposeess "otor a!ti'it#
o E!hoaia
o .uto"ati! o%edien!e
o Stereot#ped or repetiti'e %eha'ior
Undifferentiated s!hi8ophrenia
o Undifferentiated s!hi8ophrenia does not "eet the !riteria for paranoid$ disorgani8ed$ or !atatoni! s!hi8ophrenia
o 4eusions and hau!inations
o 4isorgani8ed spee!h
o 4isorgani8ed or !atatoni! %eha'ior
o ?at affe!t
o So!ia withdrawa
Residua s!hi8ophrenia
o 4iagnosed as s!hi8ophreni! in the past
o Ti"e i"ited %etween atta!(s %ut "a# ast for "an# #ears
o The !ient e5hi%its !onsidera%e so!ia isoation and withdrawa and i"paired roe fun!tioning
Inter(entions
.ssess the !ient:s physical needs
Set i"its on the !ient:s %eha'iors when it interferes with others and %e!o"es disrupti'e
&aintain a safe en'iron"ent
Initiate one)on)one intera!tion and progress to s"a groups as toerated
o .though$ reintegrating the !ient into the "iieu as soon as possi%e is essentia
Spend ti"e with the !ient e'en if !ient is una%e to respond
&onitor for atered thought pro!esses
&aintain ego %oundaries and a'oid tou!hing the !ient
o Tou!hing others without warning or in'itation
o Intruding in others: i'ing spa!es
o Ta(ing to or !aressing inani"ate o%7e!ts
o Undressing$ "astur%ating$ or urinating in pu%i!
>i"it the ti"e of intera!tion with the !ient
o Initia#$ the !ient "a# on# toerate A)91 "inutes of !onta!t at one ti"e.
9L
.'oid an o'er#)war" approa!h* a neutra approa!h is ess threatening
4o not "a(e pro"ises to the !ient that !annot %e (ept
Esta%ish dai# routines
.ssist the !ient to i"pro'e groo"ing and to a!!ept responsi%iit# for sef)!are
Sit with the !ient in sien!e if ne!essar#
/ro'ide short$ %rief and fre=uent !onta!t with the !ient
Te the !ient when #ou are ea'ing
Te the !ient when #ou do not understand
4o not 2go aong3 with the !ients deusions or hau!inations
/ro'ide si"pe !on!rete a!ti'ities su!h as pu88es or word ga"es
Reorient the !ient as ne!essar#
Hep the !ient esta%ish what is rea and unrea
Sta# with the !ient if he is frightened
Spea( to the !ient in a si"pe dire!t and !on!ise "anner
Reassure the !ient that the en'iron"ent is safe
Re"o'e the !ient fro" group situations if the !ient:s %eha'ior is too %i8arre$ distur%ing$ or dangerous to others
o Reassure others that the !ient:s inappropriate %eha'iors or !o""ents are not his faut +without 'ioating
!onfidentiait#-.
Set reaisti! goas
Initia# do not offer !hoi!es to the !ient$ and gradua# assist the !ient in "a(ing own de!isions
Use !anned or pa!(aged food$ espe!ia# with the paranoid s!hi8ophreni! !ient
/ro'ide a radio or tape pa#er at night for inso"nia
E5pain to the !ient e'er#thing that is %eing done
Set i"its on the !ient %eha'ior if the !ient is una%e to do so
4e!rease e5!essi'e sti"ui in the en'iron"ent
&onitor for sui!ide ris(
.ssist the !ient to use aternati'e "eans to e5press feeings through "ust or art therap# or writing.
N"rsin inter(entions #or the !lient e+/erien!in del"sions
.s( the !ient to des!ri%e the deusion
;e open and honest in intera!tions to redu!e suspi!iousness
?o!us the !on'ersation on reait# %ased topi!s rather than the deusion
En!ourage the !ient to e5press feeings and fo!us on the feeings that the deusions generate
If the !ient o%sesses on the deusion$ set fir" i"its on the a"ount of ti"e for ta(ing a%out the deusion
4o not dispute with the !ient nor tr# to !on'in!e the !ient that the deusions are fase
6aidate if part of the deusion is rea
Re!ogni8e a!!o"pish"ents and pro'ide positi'e feed%a!( for su!!esses
N"rsin inter(entions #or the !lient e+/erien!in hall"!inations
&onitor for hau!ination !ues
Ei!it des!ription of hau!ination to prote!t the !ient and others
o The nurses understanding of the hau!ination heps the nurse (now how to !a" or reassure the !ient
Inter'ene with one on one !onta!t
4e!rease sti"ui or "o'e the !ient to another area
.'oid !on'e#ing to the !ient that others are aso e5perien!ing the hau!ination
Respond 'er%a# to an#thing rea the !ient ta(s a%out
.'oid tou!hing the !ient
En!ourage the !ient to e5press feeings
4uring a hau!ination$ atte"pt to engage the !ient:s attention through a !on!rete a!ti'it#
o Tea!hing the !ient to ta( %a!( to the 'oi!es for!efu# aso "a# hep hi" or her "anage auditor# hau!inations
.!!ept and do not 7udge or 7o(e a%out the !ient:s %eha'ior
/ro'ide easy a!ti'ities and a stru!tured en'iron"ent with routine a!ti'ities of dai# i'ing
&onitor for signs or in!reasing fear$ an5iet#$ or agitation
/ro'ide se!usion if ne!essar#
.d"inister "edi!ations as pres!ri%ed
9E
Lan"ae and !omm"ni!ation dist"r0an!es
Cang asso!iation: Repetition of words or phrases that are si"iar in sound %ut in no other wa#.
E!hoaia: Repetition of words or phrases heard fro" another person
&utis": .%sen!e of 'er%a spee!h
Neoogis": . new word de'ised that has a spe!ia "eaning to the !ient
Word saad: ?or" of spee!h in whi!h words or phrases are !onne!ted "eaningess#
>aten!# of response: hesitation %efore the !ient responds to =uestions. This aten!# or hesitation "a# ast @1)<A se!onds and
usua# indi!ates the !ient:s diffi!ut# with !ognition or thought pro!esses.
Thought %road!asting: %eie'e that others !an hear their thoughts
Thought withdrawa: %eie'e others are ta(ing their thoughts
Thought insertion: others are pa!ing thoughts in their "ind against their wi
A0normal motor 0eha(iors
.(athisia: 4ispa#ing "otor restessness and "us!uar =ui'ering* the !ient is una%e to sit or ie =uiet#
E!hopra5ia: Repeating the "o'e"ents of another person
Wa5# fe5i%iit#: ha'ing one:s ar"s or egs pa!ed in a !ertain position and hoding that sa"e position for hours
4#s(inesia: I"pair"ent of the power of 'ountar# "o'e"ents
Chid and adoes!ent disorders
/s#!hiatri! disorders are not diagnosed as easi# in !hidren as the# are in aduts.
Chidren a!( the a%stra!t !ogniti'e a%iities and 'er%a s(is to des!ri%e what is happening.
Mental retardation
&id retardations: IP A1)L1
&oderate retardation: IP @A)A1
Se'ere retardation: IP 01)@A
/rofound retardation: IP ess than 01.
Adoles!ent de/ression
So"e issues are due to %a!(ground and fa"i# issues
Transition into aduthood often 'er# diffi!ut
4epression is a"ost awa#s due to a !o"%ination of fa!tors
;o#s are "ore su!!essfu in !o""itting sui!ide* "ore 'ioent in atte"pts
o .!eta"inophen affe!ts i'er
o I%uprophen affe!ts (idne#s
/resents as 2!assi!3 s#"pto"s in girs
In %o#s$ depression is "ore i(e# to %e 2a!ted out3 with aggressi'e %eha'ior su!h as ris( ta(ing$ su%stan!e a%use$
!onfrontations with authorit#.
o 4rin(ing in teenage #ears +ages 9A)9L- stops e"otiona growth. Hids that grow into aduts are stu!( in this stage
+Identit# 's. Roe !onfusion-. The# earn that drin(ing is the wa# to !ope. This is not aweso"e.
?irst "a7or episode are during adoes!ent #ears* often %etween the ages of 9A)9G
&ani! depression
o Teens "a# %e sad and goo"# one da# and e5!ited and ee'ated the ne5t
o &ood sta%ii8ers are i"portant in de!reasing "ood swings
>ithiu" +!he!( %ood e'es,-
4epa(ote
Tegreto
Neurontin
In depression$ one of the first !ues is a arge drop in s!hoo perfor"an!e
Other s#"pto"s disguised:
o 4rug/a!oho a%use
o >a!( of !on!entration
o Restessness or h#pera!ti'it#
o .nti)so!ia %eha'ior +!ondu!t disorder-
E5tre"e fatigue$ seep a the ti"e %ut are not rested
9G
Sui!ide warning signsK
o Constant inso"nia* "a# %e on !o"puter at a hours of the night
o Changes in %eha'ior
o 4ropping gradesMagain$ s!hoo is a huge issue
Inter'entions for sui!ide
o High ris( teens "a(e their de!isions after a 2disaster3 has o!!urred: %rea()ups$ a!ade"i! faiure$ fight with parents$
or run)in with authorit#
o .!oho is in'o'ed in O of a sui!ides* serious# i"pairs 7udge"ent
Sui!ide is not !hosen* it happens when pain e5!eeds resour!es for pain
Ta( to #our (ids,
o The %est pa!e is in the !ar when the#:re trapped$ haha.
Start with the %asi!s* 2How are #ou doingJ3
Then$ praise
Then get down and dirt# to the rea su%7e!t
Childhood S!hi2o/hrenia
Group of disorders of thought processes !hara!teri8ed %# gradua disintegration of "enta fun!tion
O!!urs in adoes!ents or as #oung aduts
Sui!ide is the I9 !ause of death in #oung peope with s!hi8ophrenia
Treat"ent and prognosis
o >ifeti"e of therap# and fa"i# support
o &edi!ations
o Strugge for fa"i# to sta# in'o'ed
Often re7e!ted or 7ust !an:t ta(e an#"ore disruption in their i'es.
O0sessi(e$Com/"lsion disorder
S#"pto"s often %egin sow# and gradua# during their !hidhood or teenage #ears and in!rease in se'erit# as ti"e goes on.
Though a !hroni! disease$ there wi %e periods of redu!ed s#"pto"s foowed %# 2fare)ups3$ often stressfu ti"es in
person:s ife.
Reief is on# te"porar#* usua# %oth o%sessions and !o"pusions o!!ur together
Re!ogni8e thoughts or %eha'iors are irrationa* %ut are !o"peed to !ontinue the" 2against their wi3.
Treat"ent:
o E5posure and response pre'ention
o SSRIs hep redu!e s#"pto"s of OC4M"onitor for side effe!ts
Co"pusions
o Washing$ !eaning$ !onstant !he!(ing$ "enta !ounting rituas
o Tou!hing$ ordering$ rearranging
o .s(ing for reassuran!e or !onfessing
o &astur%ationMespe!ia# seen in !hidren who ha'en:t #et dis!o'ered this is so!ia# una!!epta%e %eha'ior
A"tisti! disorder
&ost pre'aent in %o#s* identified no ater than @)#ears of age
Chid has itte e#e !onta!t$ few fa!ia e5pression$ doesn:t use gestures to !o""uni!ate
4oes not reate to parents or peers$ a!(s spontaneous en7o#"ent$ apparent a%sen!e of "ood and e"otiona affe!t$ !an not %e
engaged in pa# or "a(e %eie'e
Repetiti'e "otor %eha'iors su!h as hand)fapping$ %od# twisting$ or head %anging
&a# i"pro'e as !hid a!=uires anguage s(is
Short ter" i"patient therap# is used when %eha'iors su!h as head %anging or tantru"s are out of !ontro
o Hado or Risperado "a# %e effe!ti'e +prn$ of !ourse-
Goas of treat"ent:
o Redu!e %eha'iora s#"pto"s
o /ro"otes earning and de'eop"ent
o >anguage s(is de'eop"ent
Attention de#i!it disorder
Chara!teri8ed %# patterns of inattention$ h#pera!ti'it#$ and i"pusi'eness
.!!ount for "ost "enta heath referras
01
Needs to %e ph#si!a# seen for a renewa of .4H4 drugs "onth#
Often diagnosed when a !hid starts s!hoo
4istinguishing %ipoar disorder fro" .4H4 !an %e diffi!ut %ut is !ru!ia %e!ause treat"ent is so different for ea!h disorder
Signs and s#"pto"s
o Inattenti'e %eha'iors
o H#pera!ti'e/i"pusi'e %eha'iors
?idgets
Often ea'es seat
Can:t pa# =uiet#
Interrupts
Cannot wait turn
Treat"ent
o The "ost effe!ti'e treat"ent !o"%ines phar"a!otherap# with %eha'iora$ ps#!hoso!ia$ and edu!ationa
inter'entions
/s#!hophar"a!oog#
o &eth#phenidate +Ritain-
o ."pheta"ine !o"pound +.ddera-
The "ost !o""on side effe!ts of these drugs are inso"nia$ oss of appetite$ and weight oss or faiure to
gain weight.
Gi'ing sti"uants during da#ti"e hours usua# !o"%ats inso"nia.
Gi'e the !hid %rea(fast and sna!(s to gain weight
o .to"o5etine +Strattera-
Non)sti"uant drug* is an antidepressantMsee!ti'e norepinephrine reupta(e inhi%itor.
&ost !o""on side effe!ts were de!reased appetite$ N/6$ tiredness$ and upset sto"a!h.
Can !ause i'er da"age$ "ust ha'e i'er fun!tion tests periodi!a#.
Strategies for Ho"e and S!hoo
o ;eha'iora strategies are ne!essar# to hep the !hid "aster appropriate %eha'iors.
o Effe!ti'e approa!hes:
/ro'ide !onsistent rewards
Conse=uen!es for %eha'ior
Offer !onsistent praise
Use ti"e out
Gi'e 'er%a repri"ands
Use dai# report !ards for %eha'ior
/oint s#ste" for positi'e and negati'e %eha'ior
Therapeuti! pa#* use pa# to understand thoughts and feeings and heps with !o""uni!ation.
Edu!ate parents,
Cutura !onsiderations
o /arents fro" different !utures ha'e a different threshod for toerating spe!ifi! t#pes of %eha'ior.
Genera appearan!e and &otor %eha'ior
o Spee!h is uni"paired$ %ut the !hid !annot !arr# on a !on'ersation* he interrupts$ %urts out answers %efore the
=uestion is finished$ and fais to pa# attention to what is said.
&ood and affe!t
o &ood "a# %e a%ie$ e'en to the point of 'er%a out%ursts or te"per tantru"s.
o .n5iet#$ frustration$ and agitation are !o""on
Dudg"ent and insight
o &a# fai to per!ei'e har" or danger and engage in i"pusi'e a!ts su!h as running into the street and 7u"ping off of
high o%7e!ts.
/h#sioogi! and Sef)!are !onsiderations
o Chidren with .4H4 "a# %e thin if the# do not ta(e ti"e to eat proper# or !annot sit through "eas.
o &a# %e a histor# of ph#si!a in7uries due to ris()ta(ing %eha'iors
Nursing diagnoses
o Ris( for in7ur#
Chid wi re"ain free fro" in7ur#
If the !hid is engaged in a potentia# dangerous a!ti'it#$ the first step is to stop the %eha'ior.
This "a# re=uire ph#si!a inter'ention if the !hid is running into a street or 7u"ping off of a high
pa!e.
09
.tte"pting to ta( or reason to a !hid engaged in a dangerous a!ti'it# is uni(e# to su!!eed
%e!ause of their ina%iit# to pa# attention and to isten.
When the in!iden!e is o'er and the !hid is safe$ ta( to the !hid a%out the %eha'ior.
o Ineffe!ti'e roe perfor"an!e
Wi not 'ioate others %oundaries
Gi'e positi'e feed%a!( for "eeting e5pe!tations.
State a!!epta%e %eha'ior !ear#
o I"paired so!ia intera!tions
4e"onstrate age)appropriate so!ia s(is
Super'ise the !hid !ose# whie he is pa#ing.
It is often ne!essar# to a!t first to stop the har"fu %eha'ior %# separating the !hid fro" the friend
o I"pro'ed roe perfor"an!e
Si"pif# instru!tions and dire!tionsMgi'e one step of a pro!ess at a ti"e
Gi'e the !hid positi'e feed%a!( and sense of a!!o"pish"ent
&anage the en'iron"ent
&ini"a noise and distra!tion
?a!e the tea!her in the front row and awa# fro" window or door
o Ineffe!ti'e fa"i# !oping
Wi !o"pete tas(s
?a!e the !hid on his e'e and use good e#e !onta!t
Gi'e the !hid fre=uent %rea(s
Routines are i"portant* !hid with .4H4 do not ad7ust to !hanges readi#
o /arenta support
>isten to parent:s feeings
;e!ause these !hidren often are not diagnosed unti the 0
nd
or @
rd
grade$ the# "a# ha'e "issed "u!h %asi!
earning for reading and "ath. /arents shoud (now that it ta(es ti"e for the" to !at!h up to other !hidren
the sa"e age.
o E'auation
&edi!ations are often in de!reasing h#pera!ti'it# and i"pusi'it# reati'e# =ui!(#.
I"pro'ed so!ia%iit#$ peer reations$ and a!ade"i! a!hie'e"ent happen "ore sow#.
Cond"!t disorder
Chara!teri8ed %# persistent antiso!ia %eha'ior in !hidren and adoes!ents that signifi!ant# i"pair their a%iit# to fun!tion in
so!ia$ a!ade"i!$ or o!!upationa area.
o S#"pto"s are !ustered into < areas
.ggression to peope and ani"as
4estru!tion to propert#
4e!eitfuness and theft
Serious 'ioation of rues and the aw
o &ore s#"pto"s
4e!reased sef)estee"
/oor frustration toeran!e
Te"pter often out of !ontro
Ear# onset of se5ua %eha'ior$ a!oho and su%stan!e a%use$ s"o(ing$ ris(# %eha'ior
.nti)so!ia
T#pes of !ondu!t disorder
o Cassified %# age of onset
.does!ent)onset t#pe is defined %# no %eha'iors of !ondu!t disorder unti after 91 #ears of age.
>east i(e# to %e aggressi'e
Ha'e "ore nor"a peer reationships
>ess i(e# to ha'e persistent !ondu!t disorder or antiso!ia personait# disorder as aduts
Chidhood)onset t#pe in'o'es s#"pto"s %efore 91 #ears of age
/h#si!a# aggressi'e
4istur%ed peer reationships
&ore i(e# to ha'e persistent !ondu!t disorder and to de'eop antiso!ia personait# disorder as
aduts
o Can %e !assified as:
&id: few !ondu!t pro%e"s !ausing "inor har" to others
00
>#ing$ truan!#$ sta#ing out ate without per"ission
&oderate: Nu"%er of !ondu!t pro%e"s in!rease as does the a"ount of har" to others.
6andais" and theft
Se'ere: &an# !ondu!t pro%e"s that !ause !onsidera%e har" to others.
?or!ed se5$ !ruet# to ani"as$ weapons$ %urgar#$ ro%%er#.
Treat"ent of !ondu!t disorder
o &UST ;E GE.RE4 TOW.R4 4E6E>O/&ENT.> .GE
o S!hoo aged:
Chid$ fa"i#$ and s!hoo en'iron"ent are the fo!us of treat"ent
?a"i# therap# is essentia
o .does!ents
Re# ess on their parents$ so treat"ent is %ased on indi'idua therap#.
Confi!t resoution$ anger "anage"ent$ so!ia s(is
Tr# to (eep the adoes!ent in his en'iron"ent +ho"e-
o &edi!ations ha'e itte effe!t
.ntips#!hoti!s for !ients who present a !ear danger to others
&ood sta%ii8ers for !ients with a%ie "oods
Cutura !onsiderations
o ;e !arefu of diagnosis of Condu!t disorder$ "ust (now histor# and !ir!u"stan!es of ea!h !hid.
High areas of !ri"e rates
Coud %e a "atter of sur'i'a
Nursing pro!ess
o Ris( for Other)dire!ted 'ioen!e
The !ient wi not hurt others or da"age propert#
SET >I&ITS
Infor" the !ient of the rue or i"it
E5pain the !onse=uen!es if %ro(en
State e5pe!ted %eha'ior
;eha'iora !ontra!t
Ti"e out* not a punish"entMa pa!e to regain sef !ontro
Gi'e !ient a s!hedue of dai# a!ti'ities
o Non!o"pian!e
The !ient wi parti!ipate in treat"ent
&ore i(e# to parti!ipate in treat"ent and dai# routines if the# ha'e input !on!erning the
s!hedue
o Ineffe!ti'e !oping
The !ient wi earn effe!ti'e pro%e")so'ing and !oping s(is
Hep identif# the pro%e" and to so'e pro%e"s effe!ti'e#.
o I"paired so!ia intera!tion
The !ient wi use age)appropriate and a!!epta%e %eha'iors when intera!ting with others.
Tea!h so!ia s(is
4is!uss the news$ sports$ or other topi!s as the !ient "a# not (now how to ha'e a nor"a !on'ersation.
o Chroni! ow sef)estee"
The !ient wi 'er%ai8e positi'e$ age)appropriate state"ents a%out sef
O//ositional De#iant disorder
Consists of an enduring pattern of un!ooperati'e$ defiant$ and hostie %eha'ior toward authorit# figures without "a7or
antiso!ia 'ioations.
. !ertain e'e of oppositiona %eha'ior is !o""on in !hidren in adoes!en!e.
Oppositiona defiant disorder is diagnosed on# when %eha'iors are "ore fre=uent and intense than unaffe!ted peers and
!ause d#sfun!tion in so!ia$ a!ade"i!$ or wor( situations.
TIC disorders
Sudden$ rapid$ re!urrent$ non)rh#th"i! "otor "o'e"ent or 'o!ai8ation
Stress and fatigue e5a!er%ates ti!s
Treat"ent: Risperado and Q#pre5ia
Co"pe5 'o!a ti!s
0@
o Coproaia: Use of so!ia# una!!epta%e words$ often o%s!ene
o /aiaia: Repeating own sounds or words
o E!hoaia: Repeating the ast heard sound$ word$ or phrase
To"rette1s s)ndrome
&utipe "otor ti!s and one or "ore 'o!a ti!s
&a# o!!ur "an# ti"es a da# for o'er a #ear
Usua# identified %# L #ears of age
Elimination disorders
En!opresis: repeated passage of fe!es into inappropriate pa!es su!h as !othing or foor %# a !hid who is at east < #ears of
age either !hroni!a# or de'eop"enta#. Often in'ountar#$ %ut !an %e intentiona +oppositiona defiant disorder or !ondu!t
disorder-. .sso!iated with !onstipation that o!!urs for ps#!hoogi!a$ not "edi!a reasons.
Enuresis: Repeated 'oiding of urine during the da# or night into !othing or %ed %# a !hid at east A #ears of age.
Treated with i"ipra"ine +Tofrani-$ an antidepressant with a side effe!t of urinar# retention.
o Was on!e treated with 'asopressin whi!h de!reases !ir!uator# 'ou"e.
EATING DISORDERS
The distinguishing fa!tor of anore5ia in!udes an earier age of onset and %eow)nor"a %od# weight* the person fais to re!ogni8e the
eating %eha'ior as a pro%e". Cients with %ui"ia ha'e a atter age at onset and a near)nor"a %od# weight. The# usua# are asha"ed
and e"%arrassed %# the eating disorder.
Eating disorders appear to %e e=ua# !o""on a"ong Hispani! and white wo"en and ess !o""on a"ong .fri!an ."eri!an and
.sian wo"en.
Anore+ia Ner(osa
. ife)threatening eating disorder !hara!teri8ed %# the !ient:s refusa or ina%iit# to "aintain a "ini"a# nor"a %od#
weight$ intense fear of gaining weight or %e!o"ing fat$ signifi!ant# distur%ed per!eption of the shape or si8e of the %od#$ and
steadfast ina%iit# or refusa to a!(nowedge the seriousness of the pro%e" or e'en that one e5ists.
Has e5perien!ed a"enorrhea for at east @ !onse!uti'e !#!es
Co"paints of !onstipations and a%do"ina pain
Cod intoeran!e
H#potension$ h#pother"ia$ %rad#!ardia
o Intra'as!uar 'ou"e is de!reased* ess %ood to pu"p through heart$ aso due to e5!essi'e e5er!ise
Ee'ated ;UN
o Nor"a e'es: 91)01 "g/d
o Urea is for"ed in the i'er and is the end produ!t of protein "eta%ois".
o In anore5ia$ the %od# has aread# used fat for energ#* it is now %rea(ing down "us!es for energ#Mthe reason for
the ee'ated ;UN
4e!reased a%u"in
o Nor"a e'es: @.A)A g/d
o &easures a"ount of protein in the %od#* a%u"in is a protein for"ed in the i'er.
o .%u"in tests are a great indi!ator of nutritiona status
>eu(openia and "id ane"ia
o Not enough food and nutrients to repenish !es
Has a preo!!upation with food and food)reated a!ti'ities
Can %e di'ided into 0 su%groups:
o Restri!ting su%t#pe: ose weight pri"ari# through dieting$ fasting$ or e5!essi'e# e5er!ising.
o ;inge eating and purging su%t#pe: engage reguar# in %inge eating foowed %# purging.
Engage in unusua or rituaisti! food %eha'iors
o Refusing to eat around others
o Cutting food into "inute pie!es
o Not aowing the food the# eat to tou!h their ips
E5!essi'e e5er!ise is !o""on
4iagnosed %etween 9< and 9E #ears of age
/eased with their a%iit# to !ontro their weight and "a# e5press this.
.s the iness progresses$ depression and a%iit# in "ood %e!o"e "ore apparent
0<
Isoate the"se'es
;eie'e peers are 7eaous of their weight oss and %eie'e fa"i# and heath !are professionas are tr#ing to "a(e the" 2fat
and ug#3.
Cients who use a5ati'es are at a greater ris( for "edi!a !o"pi!ations.
.utono"# "a# %e diffi!ut in fa"iies that are o'erprote!ti'e or in with enmeshment +a!( of !ear %oundaries- e5ists. ;#
osing weight$ these !ients ha'e so"e !ontro in their i'es.
Ha'e %od# i"age distur%an!e
Can %e 'er# diffi!ut to treat %e!ause the# are often resistant$ appear uninterested$ and den# their pro%e"s.
Treat"ent:
o ?o!using on weight restoration
o Nutritiona reha%iitation
o Reh#dration
o Corre!tion of ee!tro#te i"%aan!es
o Se'ere# "anourished indi'iduas "a# re=uire T/N$ tu%e feedings$ or h#perai"entation to re!ei'e ade=uate
nutritiona inta(e.
o .!!ess to the %athroo" is super'ised to pre'ent purging as !ients %egin to eat "ore food.
o Weight gain and ade=uate food inta(e are "ost often the !riteria for deter"ining the effe!ti'eness of treat"ent.
o ."itript#ine +Ea'i- and the antihista"ine !#proheptadine +/eria!tin- in high doses +up to 0E"g/d- !an pro"ote
weight gain in inpatients.
o Oan8apine +Q#pre5a- has %een used with su!!ess %e!ause of %oth its antips#!hoti! effe!t +on %i8arre %od# i"age
distortions- and asso!iated weight gain.
o ?uo5etine +/ro8a!- has shown so"e effe!ti'eness in pre'enting reapse in !ients whose weight has %een partia#
or !o"pete# restored* !ose "onitoring is needed %e!ause weight oss !an %e a side effe!t.
?a"i# "e"%ers often des!ri%e !ients with anore5ia as perfe!tionists with a%o'e a'erage inteigen!e$ dependa%e$ eager to
pease$ and see(ing appro'a %efore their !ondition %egan.
Cients with anore5ia appear sow$ ethargi!$ and fatigued* the# "a# appear e"a!iated$ depending on the a"ount of weight
oss. &a# %e sow to respond and ha'e diffi!ut# de!iding what to sa#.
Reu!tant to answer =uestions fu# %e!ause the# do not want to a!(nowedge an# pro%e".
Often wear oose !othing in a#ers
Sedo" s"ie$ augh$ or en7o# an# atte"pts at hu"or
'"limia Ner(osa
Chara!teri8ed %# re!urrent episodes +at east twi!e a wee( for @ "onths- of %inge eating foowed %# inappropriate "easures
to a'oid weight gain su!h as purging +'o"iting$ a5ati'es$ diureti!s$ ene"as$ or e"eti!s-$ fasting$ or e5!essi'e# e5er!ising.
Engaging in %inge eating se!ret#
;inging or purging episodes are often pre!ipitated %# strong e"otions and foowed %# guit$ re"orse$ sha"e$ or sef)
!onte"pt.
Re!urrent 'o"iting destro#s tooth ena"e$ has denta !aries and ragged or !hipped teeth. 4entists are often the first heath
!are professionas to re!ogni8e this.
;ui"ia is t#pi!a# diagnosed at 9E or 9G.
Cients with %ui"ia are aware that their eating %eha'ior is pathoogi! and go great engths to hide it fro" others.
Cients with a !o)"or%id personait# disorder tend to ha'e poorer out!o"es than those without.
&ost are treated on an outpatient %asis
.ntidepressants are "ore effe!ti'e than the pa!e%os in redu!ing %inge eating
Cients are often fo!used on peasing others and ha'e a histor# of i"pusi'e %eha'ior su!h as su%stan!e a%use and shopifting
as we as an5iet#$ depression$ and personait# disorders.
&a# %e underweight$ o'erweight$ %ut are genera# !ose to e5pe!ted %od# weight for age and si8e
.ppear open and wiing to ta(* initia# peasant and !heerfu as though nothing is wrong
N"rsin o"t!omes@inter(entions
I"%aan!ed Nutrition: >ess than/&ore than %od# re=uire"ents
The !ient wi esta%ish ade=uate nutritiona eating patterns
o I"pe"ent and super'ise the regi"en for nutritiona reha%iitation
o . diet of 9011)9A11 !aories is ordered$ with gradua in!reases in !aories unti !ients are ingesting ade=uate
a"ounts for height$ a!ti'it# e'e$ and growth needs.
Start sow#Mwi ha'e "assi'e diarrhea
0A
o The !ient with anore5ia "a# %e !riti!a# "anourished.
T/N through !entra ine
Ee!tro#te %aan!e
Tu%e feeds
o . i=uid protein suppe"ent is gi'en to repa!e an# food not eaten to ensure !onsu"ption to ensure tota nu"%er of
!aories pres!ri%ed
o &ust "onitor "eas and sna!(s and wi sit at the ta%e during eating awa# fro" the other !ients
. "a7or goa is to first get the" to the ta%e
o 4iet %e'erages and food su%stitutions "a# %e prohi%ited
o Spe!ified ti"e "a# %e set for !onsu"ing ea!h "ea and sna!(
o 4is!ourage !ients fro" perfor"ing food rituas su!h as !utting food into tin# pie!es or "i5ing foods in unusua
!o"%inations
o ;e aert for an# atte"pts %# !ient to hide or dis!ard food
o &ust re"ain in 'iew of staff for 9)0 hours to ensure the# do not 'o"it* a!!ess to %athroo"s is super'ised.
o Cient is weighed dai# on awa(ening and after the# ha'e e"ptied their %adder. Ha'e the !ient wear a hospita
gown ea!h ti"e the# are weighed* the# "a# atte"pt to pa!e o%7e!ts in their !othing to gi'e the appearan!e of
weight gain.
o In %ui"ia$ the !ients shoud sit at a ta%e in a (it!hen or dining roo".
o Write out a gro!er# ist$ it is easier to foow a nutritious eating pan
Ineffe!ti'e !oping
The !ient wi ei"inate use of !o"pensator# %eha'iors su!h as e5!essi'e e5er!ise and use of a5ati'es and diureti!s
The !ient wi de"onstrate !oping "e!hanis"s not reated to food
The !ient wi 'er%ai8e feeings of guit$ anger$ an5iet#$ or an e5!essi'e need for !ontro
o Hep the !ient re!ogni8e e"otions su!h as an5iet# or guit %# as(ing the" to des!ri%e what the# are feeing* aow
ade=uate ti"e for response. 4o not as( 2are #ou an5iousJ SadJ3 %e!ause the !ient "a# =ui!(# agree rather than
strugge for an answer
o En!ourage sef)"onitoring* a %eha'ior)!ogniti'e approa!h
4istur%ed %od# i"age
The !ient wi 'er%ai8e a!!eptan!e of %od# i"age with sta%e %od# weight
o Hep !ients identif# areas of persona strength that are not food)reated %roadens !ients: per!eptions of the"se'es.
SOMATOFORM DISORDERS
Somati2ation4 The transferen!e of "enta e5perien!es and states into %odi# s#"pto"s.
Somato#orm disorders4 Chara!teri8ed as the presen!e of ph#si!a s#"pto"s that suggest a "edi!a !ondition without de"onstra%e
organi! %asis to a!!ount fu# for the". The three !entra features of so"atofor" disorders are as foows:
/h#si!a !o"paints suggest "a7or "edi!a iness %ut ha'e no de"onstra%e organi! %asis.
/s#!hoogi!a fa!tors and !onfi!ts see" i"portant in initiating$ e5a!er%ating$ and "aintaining the s#"pto"s.
S#"pto"s or "agnified heath !on!erns are not under the !ient:s !ons!ious !ontro.
The fi'e spe!ifi! so"atofor" disorders are as foowed:
So"ati8ation disorder: Chara!teri8ed %# "utipe ph#si!a s#"pto"s. It %egins %# @1 #ears of age$ e5tends o'er se'era
#ears$ and in!udes a !o"%ination of pain and GI$ se5ua$ and pseudoneuroogi! s#"pto"s.
o Cient:s 7u"p fro" one ph#si!ian to the ne5t$ or "a# see se'era pro'iders at on!e in an effort to o%tain reief of
s#"pto"s.
o The# tend to %e pessi"isti! a%out the "edi!a esta%ish"ent and often %eie'e their disease !oud %e diagnosed of
the pro'iders were "ore !o"petent.
Con'ersion disorder: In'o'es une5pained$ usua# sudden defi!its in sensor# or "otor fun!tion +%indness$ para#sis-. These
defi!its suggest a neuroogi!a disorder %ut are asso!iated with ps#!hoogi!a fa!tors. .n attitude of la belle indifference$ a
see"ing# a!( of !on!ern or distress$ is the (e# feature.
/ain disorder: /ain is the pri"ar# ph#si!a s#"pto" whi!h is genera# unreie'ed %# anagesi!s and great# affe!ted %#
ps#!hoogi!a fa!tors in ter"s of onset$ se'erit#$ e5a!er%ation$ and "aintenan!e.
H#po!hondriasis: /reo!!upation with the fear that one has a serious disease +disease !on'i!tion- or wi get a serious disease
+disease pho%ia-. It is thought that !ients with this disorder "isinterpret %odi# sensations or fun!tions.
;od# d#s"orphi! disorder: /reo!!upation with an i"agined or e5aggerated defe!t in persona appearan!e su!h as thin(ing
one:s nose is too arge or teeth are !roo(ed and unattra!ti'e.
0F
S)m/toms o# a somati2ation disorder
/ain s#"pto"s: !o"paints of heada!he$ pain in the a%do"en$ head$ 7oints$ %a!($ !hest$ re!tu"* pain during urination$
"enstruation$ or se5ua inter!ourse.
GI s#"pto"s: nausea$ %oating$ 'o"iting +other than pregnan!#-$ diarrhea$ or intoeran!e of se'era foods.
Se5ua s#"pto"s: Se5ua indifferen!e +don:t !are to do the dirt#-$ ere!tie or e7a!uator# d#sfun!tion$ irreguar "enses$
e5!essi'e "enstrua %eeding.
/seudoneuroogi! s#"pto"s: I"paired !oordination or %aan!e$ para#sis or o!ai8ed wea(ness$ diffi!ut# swaowing or
u"p in throat$ aphonia +oss of spee!h sounds-$ urinar# retention$ swoen tongue$ hau!inations$ dou%e 'ision$ %indness$
deafness$ sei8ures* disasso!iati'e s#"pto"s su!h as a"nesia* or oss of !ons!iousness other than fainting.
Related disorders4
&aingering: The intentiona produ!tion of fase or gross# e5aggerated ph#si!a or ps#!hoogi!a s#"pto"s* it is motivated
%# e5terna in!enti'es su!h as a'oiding wor($ e'ading !ri"ina prose!ution$ o%taining finan!ia !o"pensation$ or o%taining
drugs. Their purpose is so"e e5terna in!enti'e or out!o"e that the# 'iew as i"portant and resuts dire!t# fro" their iness.
/eope who "ainger !an stop the ph#si!a s#"pto"s as soon as the# ha'e gained what the# wanted.
?a!titious disorder: This is aso (nown as &un!hausen s#ndro"e. O!!urs when a person intentiona# produ!es or feigns
ph#si!a or ps#!hoogi!a s#"pto"s soe# to gain attention.
o &un!hausen s#ndro"e %# pro5# o!!urs when a person infi!ts iness or in7ur# to so"eone ese to gain the attention
of e"ergen!# "edi!a personne or to %e a 2hero3 for sa'ing the 'i!ti". This o!!urs "ost often in peope who are in
or fa"iiar with "edi!a professions$ su!h as nurses$ ph#si!ians$ "edi!a te!hni!ians$ or hospita 'ounteers.
/ri"ar# gain: 4ire!t e5terna %enefits that %eing si!( pro'ides$ su!h as reief of an5iet#$ !onfi!t$ or distress.
Se!ondar# gains: Interna or persona %enefits re!ei'ed fro" others %e!ause one is si!($ su!h as attention fro" fa"i#
"e"%ers and !o"fort "easures +%eing %rought tea$ re!ei'ing a %a!( ru%-.
Treatment4
Treat"ent fo!uses on "anaging s#"pto"s and i"pro'ing =uait# of ife.
. trusting reationship heps to ensure that !ient:s sta# with and re!ei'e !are fro" one pro'ider instead of 2do!tor shopping.3
SSRIs are !o""on# used for depression that "a# a!!o"pan# so"atofor" disorders.
Assessment
The nurse "ust in'estigate ph#si!a heath status thorough# to ensure there is no under#ing pathoog# re=uiring treat"ent. It
is i"portant not to dis"iss a future !o"paints %e!ause at an# ti"e the !ient !oud de'eop a ph#si!a !ondition that woud
re=uire "edi!a attention.
In "an# !ases$ the !ient:s appearan!e %rightens and the# oo( "u!h %etter as the assess"ent inter'iew %egins %e!ause the#
ha'e the nurse:s undi'ided attention.
Cient:s often ha'e seep pattern distur%an!es$ a!( %asi! nutrition$ and get no e5er!ise.
N"rsin dianoses
Ineffe!ti'e !oping
o The !ient wi identif# the reationship %etween stress and ph#si!a s#"pto"s.
Emotion-focused coping strategies hep the !ients rea5 and redu!e feeings of stress. This in!udes
progressi'e rea5ation$ deep %reathing$ guided i"ager#$ and distra!tions su!h as "usi!.
Problem-focused coping strategies hep to reso'e or !hange a !ient:s %eha'ior or situation or to "anage
ife stressors. This in!udes earning pro%e" so'ing "ethods.
The nurse shoud hep the !ient roe pa# the a%o'e situations.
Ineffe!ti'e denia
o The !ient wi 'er%a# e5press e"otiona feeings
The nurse shoud not atte"pt to !onfront !ients a%out so"ati! s#"pto"s or atte"pt to te the" that these
s#"pto"s are not 2rea.3
En!ourage the !ient to write in a dai# 7ourna
>i"iting the ti"e that !ients !an fo!us on ph#si!a !o"paints aone "a# %e ne!essar#.
The nurse "a# ha'e to e5pain to the fa"i# a%out pri"ar# and se!ondar# gains* this wi en!ourage
reati'es to stop reinfor!ing the 2si!( roe.3
I"paired so!ia intera!tions
o The !ient wi foow an esta%ished dai# routine
0L
The nurse "ust hep the !ient to esta%ish this that in!udes i"pro'ed heath %eha'iors.
The !haenge for the nurse is to 'aidate the !ient:s feeings whie en!ouraging hi" to parti!ipate in
a!ti'ities.
The nurse shoud hep the !ient pan so!ia !onta!t with others$ what to ta( a%out +other than the !ient:s
!o"paints-$ and !an i"pro'e the !ient:s !onfiden!e in "a(ing reationships.
.n5iet#
o The !ient wi de"onstrate aternati'e wa#s to dea with stress$ an5iet#$ and other feeings
4istur%ed seep pattern
o The !ient wi de"onstrate heathier %eha'iors regarding rest$ a!ti'it#$ and nutritiona inta(e.
The nurse e5pains that ina!ti'it# and poor eating ha%its perpetuate dis!o"fort and that often it is ne!essar#
to engage in %eha'iors e'en though one doesn:t fee i(e it.
?atigue
/ain
0E