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Study guide unit 4

4.1 loss, death & dying


1.1 key terms
1.2 grief bereavement, mourning, & chronic sorrow
Grief:
normal & inevitable life experiences. Viewed as a natural response to loss of an attachment figure.
Bereavement:
period after a loss, when one is experiencing the state of having lost a loved one.
Mourning:
process by which people adapt to a loss.
Chronic sorrow:
form of grief that often includes characteristics of other forms of grief but that differs w/ regard to several
essential aspects.
Response to ongoing loss (chronic illness of loved one), persons who are experiencing chronic sorrow seldom
experience disability (major depression)
1.3 hospice nursing
specialized care
focus on comfort & quality of life rather than cure
1.4 common psychological & behavioral phenomena in various theories about death & grieving
Kubler Ross 5 stages of grieving
Denial -refusal to believe
Anger- displaced or turned inward
Bargaining- promises made to delay the loss
Depression- full impact is felt
acceptance- resignation, peace, can move on
other theories:
similar to Kubler's
stages of loss- similar for both the person dying (losing their life) & those that are left behind & mourning the loss
Common themes across theories:
Avoidance (numbing/blunting) forgets/remembers; shock/pain
Confrontation (disorganization & despair) lengthy period of active morning, gradual readjustment to loss,
uneven, unpredictable & individualized
Reestablishment (reorganization & recovery)
1.5 identify assessment techniques for dying person
spiritual assessment:
the core values that underlie spiritual assessment are belief & meaning based upon the individual's view of life,
what is important & gives meaning to life.
What beliefs does the person have that give meaning & purpose to life?
What are imp. Symbols that reflect the beliefs?
How does the person's life story reflect or demonstrate these underlying themes?
Do any areas of the person's life story come into conflict w/ these underlying foundational beliefs?
Do any current situations or problems come into direct conflict w/ these beliefs?
Is the person able to consciously communicate these beliefs?
In what ways are these beliefs an unconscious part of the person's worldview?
Faith- helps provide coping skills
a belief/trust in a higher power
ability to draw on spiritual resources w/ requiring physical or empirical evidence
an internal certainty based on an experience w/ the divine
Religion- shared set of beliefs that helps explain the meaning of life, suffering, health & illness
determines important rituals that are meanigful during transitions in life (maturational passages, including
death)
63% of participants in one study wanted spiritual needs included in their plan of care.
Spirituality- helps one cope w/ the fear of death & loss of oneself & others by providing a sense of hope &
meaning to otherwise overwhelming experiences
often a key component of the healing process & integral part of the p/t's treatment plan

a spiritual intervention- 1st acknowledge & validate the p/t's feelings & then help the p/t rewrite their life story
so as to incorporate these experiences
1.6 nursing process
assessment factors that promote or inhibit the grief process
assessment encompasses:
the grief experience of the mourner
the factors that inhibit or promote working though the grief process (cultural & religious norms)
mourner's ability to mobilize cognitive, behavioral, & emotion-based coping strategies.
Physical disturbances-weakness, anorexia, SOB, GI disturbances
cognitive disturbances- preoccupation w/ images & thoughts of the deceased.
Behavioral & relation disturbance- talk of the death, unable to participate in relationships.
Affective disturbances- sadness, depression, anger, & guilt. Cultural norms of continuing on w/ everyday life
& getting back to normal inhibit the expression of these feelings.
Nursing dx & outcomes
identify problems of a physical or psychologic nature & try to alleviate discomfort
do not impede normal discomfort of grieving
extreme discomfort may require pharmacologic intervention based on p/t needs & safety issues
Ndx may also relate to acute grief, complicated grief, chronic sorrow, & other Ndx
major risks are for harm to self & others. Withdrawal/isolation & interpersonal conflicts
outcomes
focus on enhancement of emotional coping skills/methods & cognitive/behavioral coping strategies
prioritized according to p/t needs & safety issues
Nursing interventions:
focus is on helping to resolve the grief through emotional, cognitive & behavioral means
directly comfort SUD issues as a major barrier to grief resolution (including Rx'd meds)
evaluate safety issues- risk for self-harm, suicide, violence to others
facilitate p/t expression of feelings r/t to the loss & validate feelings expressed by the p/t
help the p/t understand the relationship b/t him/herself & the lost object & to express & understand the grief
feelings
facilitate expression of grief by allowing the expression of positive & negative feelings
promote interaction w/ others, social support, & social groups
1.7 describe communication strategies to assist grieving families
1.8 examine own feelings
1.9 advanced directives
legal documents which are used as guides, identifying an individual's wishes to inform their healthcare team of the
kind of care desired in the event they cannot speak on their own behalf due to illness &/or incapacity
living wills- medical directives w/ written instructions for care r/t to a situation of incapacity
Durable power of attorney for medical care- document appointing a person as healthcare proxy or p/t
advocate in the event an individual can no longer 'speak for themselves'. It requires that the individual
appointing a DPOA communicates clearly & completely about their healthcare wishes & make family
members or pertinent others aware of the person name & their role responsibilities.
cognitive disorders 4.2
1.1 key terms
1.2 primary or secondary dementia, delirium and amensic disorder
Primary (irreversible) dementia: progressive/insidious onset; not secondary to other GMC; 70% of all dementias
are Alzheimer's; 20% are multi-infarct dementia (stroke)
Alzheimer's disease
vascular dementia- impaired circulation to brain
Pick's disease- proteins in brain
Huntington's disease- genetic degenerative disease
Parkinson's dementia
Creutzfeldt-Jakob disease- proteins fold on themselves (Not mad cow disease)/rare

other 10%
frontotemporal lobe dementia- degeneration, atrophy of lobes
Parkinson's dementia often associate w/ AD/ decrease in dopamine
Huntingtons chorea
Creutzfeldt-Jakob disease (spongiform encephalopathy)
Lewy body disease -lumps of protein
Reversible Dementia (secondary): similar to delirium but involves less fluctuation of consciousness. Depression is
common w/ reversible dementia.
Etiology factors:
toxic causes- alcoholism, barbiturate intox., metabolic disorders, polypharmacy, K loss from selfpurgation (vomiting).
Other electrolyte disturbances- hepatic disease, porphyria
nutritional causes- under-nutrition by prolonged neglect or self-isolation, chronic malabsorption
syndrome, vit. B12 deficiency, nicotinic acid encephalopathy
infective causes- chronic respiratory infection w/ cardiac decompensation, pulmonary TB, bacterial
endocarditis, endocrine disease, myxedema, pituitary insufficiency, addison's disease
Cerebral disease- slow-growing cerebral tumor (e.g frontal meningioma), multiple cerebral emboli,
normal-pressure hydrocephalus
Delirium: syndrome w/ multiple causes that affects consciousness, perception, thought, memory, & behavior.
Disorientation to time, place, & situation; inability to focus or shift attention; incoherent speech; & continual
& aimless physical activity characterize this condition.
Develops over a short-period of time as a result of a MC, SU or both.
change in consciousness
comes & goes -transient
identify the cause & it can be corrected
A RISK FOR ALL HOSPITALIZED ELDERLY MEDICALLY ILL
Amnestic disorders: disturbance in learning & memory in an alert & responsive person.
Memory disturbance can last hours or days. Chronic amnesia lasts for more than a month.
Leading cause of amnestic disorders is a nutritional deficiency of thiamine (vitamin B1) result of alcohol
abuse Korsakoff's syndrome or Wernicke's encephalopathy
other causes herpes encephalitis, hypoxia, vasicular disorders, head injury & meds (benzo's)
1.3 pathophysiological changes w/ AD & other dementias
accumulation of Amyloid Plaques (senile plaques/neuritic plaques) classic characteristics of AD interfere w/
cell-to-cell communication & result in decreased ACH.
Inflammation- proinflammatory cytokines (signaling proteins secreted by cells) are increased in p/ts' w/ AD.
Increase in neurofibrillary tangles
Lewy bodies & Lewy body disease neuronal cells or lesions w/ colored bodies that are found in the nuclei of the
midbrain.
Genetic mutations- 10%-40% of AD cases are genetic
NT deficiencies- cholinergic neurons normally decrease in # as people age, which makes less ACh available >
neurons that produce Ach are destroyed early during the course of AD.
Angiopathy & blood-brain barrier incompetence- capillary wall changes are often found in the brains of persons w/
AD.
1.4 assess using 3-stages of dementia
stage 1: Mild 2-4 yrs
recent memory loss
cognitive loss in the following areas:
communication
calculation
recognition
anxiety & confusion
mild behavior problems, such as the inability to initiate & complete task
Neologisms
loss of interest & spontaneity & personality changes
depression

p/t, family, & caregivers might think it's normal aging


repetition of things, lose things easily, get lost frequently.
Require support & guidance
Stage 2: Moderate 2-10 yrs
symptoms increase
behaviors problems increase:
catastrophic reactions- sudden or gradual negative change in behavior caused by the inability to understand &
cope w/ environmental stimuli.
Sundowing- irritation or conclusion occurring during the afternoon or evening. R/t to reduced stimulation &
routine & tiredness from struggling to interpret the environment during the day.
Perseveration- repetitive verbalizations or motions or persistent repetition of the same idea in response to
different questions.
Sleep disturbances- restlessness & wandering
aimless pacing
confusion
incontinence, mild
hypertonia
hallucinates & becomes depressed & argumentative.
Require close supervision
Stage 3: Severe 1-3 yrs
symptoms increase
p/ts cannot use or understand words, unable to recognize themselves or others.
No longer able to care for themselves, total dependence on others
chocking
emaciation
progressive gait disturbances that lead to nonambulatory status
total incontinence
immobility pneumonia, UTI, pressure ulcers
loss of ability to swallow aspiration death
caregiver makes all decisions about p/ts medical & social needs
1.5 assessment for p/ts
Environment:
positive & emotional environment free from distractions
maintain eye contact, speak clearly & directly to the p/t in a low tone.
Make sure their hearing aids or glasses are in place & working
Cognitive Assessment tools:
administer test in sections if p/t becomes tired, has short attention span or shows sings of anxiety.
Test p/t alone
MMSE
30 questions that assess orientation, registration, attention span, calulation, language recall, & perception.
Scores less than or equal to 24 indicate cognitive impairment.

dementia severity rating scale


assess elderly p/t's ability to function in the home

the Geriatric Depression Scale


simple yes or no ?s
for AD p/ts when able to comprehend the ?s
the Memory Impairment screen
4 item test
recommended for p/ts who belong to ethnic minorities b/c it doesn't show education or language bias

& the Mini-Cog.


3 item test for screening of dementia
test of executive functioning, visuospatial, & object recall
Functional Assessment Staging tool (FAST) identify specific stages of dementia.
Neurological Deficits:
amyloid plaques, neurofibrillary tangles, & fibrillary deposits in cerebral vessels.

PALMER:
perception & organization, attention span, language, memory, emotional control, & reasoning & judgment
(look under each heading pg 376-377)
Emotional status:
mood & state of mind informal assessment each time nurse approaches a p/t
Depression Geriatric Depression Scale
Functional ability
Behavior people w/ dementia manifest their needs & discomfort w/ behaviors.
Physical Manifestations:
alteration in nutritional status inability to purchase & prepare food, lack of financial resources to buy food,
medical conditions that decrease the older p/t's appetite, or cognitive dysfunction that prevents the p/t from
remembering to eat.
Note any w.t changes
family need to monitor p/ts food intake dehydration
aspiration critical risk factiry during stage 3 of AD aspiration pneumonia leads to death.
90-degree angle, keep chin toward the chest when swalliwung rather than hyperextending the chin.
Thick liquids easier to swallow, sit 30 min after meal
changes in gait vision problems, neuropathy, general decrease of righting reflex.
Feel p/ts skin for temp.
incontinence in later stages of AD assess for potential environmental constraints (side rails, poor lighting &
wheelchair seatbelts)
Physical & lab exams
rule out neoplasia (brain tumors), metabolic disorders, systemic illnesses (hypertension, HIV, polypharmacy)
no lab test exists to confirm AD
test thyroid function, liver function, B12 & folate levels, complete blood cell count, serum blood, blood urea
nitrogen & creatinine levels.
MRIs, CT
1.6 nursing dx, outcomes, interventions & evaluations
nursing dx
risk: for aspiration, imbalanced body temp., infection, injury, powerlessness
outcome
maintain health & safety w/ caregiver help
reach & maintain the highest functional level possible within his/her capacity
nursing interventions
inform all caregivers about the nx care plan
identify the p/ts current functional state, & encourage p/t to use his/her skills
keep all interactions w/ the p/t pleasant, calm, & reassuring
do not ask the p/t to participate in ADLs when he/she is agitated
attempt to understand the p/ts feelings
simplify the verbal message & use no more than 5 or 6 words at a time
break down each task into separate components
repeat the message. Use same words.
Provide p.t w/ opportunity to make simple choices
avoid ?s for which the answer could be no
praise success , facilitate use of the p/ts remaining strengths
1.7 meds & other treatments
acetylcholinesterase (AChE)- responsible for the breakdown of ACh cholinesterase inhibitors (drugs that inhibt
the action of AChE) improve symptoms of AD by increasing ACh in the synapses.
Goal improve symptoms & stop the progression of the disease
tacrine (Cognex)
1st cholinesterase inhibitor. Rarley used now b/c of its side effect profile, hepatic toxicity, & the need to take 4
doses/daily.
Donepezil (Aricept)
well tolerated, requires only 1/daily dosing.
Enhances cholinergic function by the reversible inhibition of the hydrolysis of ACh by AChE

effective when cholinergic neurons are intact overtime degeneration of neurons occurs, & the effect may
lessen.
GI side effects
rivastigmine (Exelon)
treats mild-moderate AD & PD
inhibits AchE selectively in the cortex & the hippocampus more than in other parts of the brain.
Tablet (2/daily), oral solution (2/daily), patch (effective, fewer SE compared to oral)
advantage for p/ts who do not respond to other anticholinergic drugs or who are in later stages of AD
side effects: nausea, vomiting, dizziness.
Galantamine (Razadyne)
newest AChE inhibitor reversible inhibitor of AChE
treats mild-moderate AD
effects nicotinic cholinergic receptors
decreases agitation & increases cognition.
Immediate release form requires 2/daily dosing extended release form allows for 1/daily dosing
other treatments
memantine (Namenda) moderate-severe AD
alkaline agents (antacids) increase levels of memantine
blocks the excitotoxic effects of glutamate while allowing normal gultamate neurotransmission.
Multisensory experience
controlled, safe, & comfortable environment that is designed to provide a multitude of sensory experiences for
therapeutic benefit.
Therapeutic Activity Program
any project that a person enjoys & that produces a positive feeling.
4.3 Crisis-Part 1
1.1 Define crisis and crisis intervention
Crisis: a stressful event w/ the potential to overwhelm an individual's ability to cope effectively w/ a challenge or
threat as well as a turning point or opportunity for growth & change.
A struggle for emotional balance (equilibrium)
perceived threatnot the event but the perception that the event exceeds a person's resources or coping
abilities.
May lead to personality disorganization
4 characteristics:
crisis are specific-unexpected-time limited
create uncertainty
create perception of threat/are overwhelming
crisis are processes of transformation during which the old system can no longer be maintained & the
need for change is identified.
Crisis Intervention: short-term strategic therapy w/ action-oriented interventions that focus on solving the
immediate problems r/t to the emotional, mental, physical, & behavioral distress that results from the crisis.
Goals:
alleviation of the acute distress
restoration of independent functioning
prevention of psychologic trauma
intervention done by: nurses, trained workers, other HCP.
General approach:
listen, observe, ask ?s to understand & caregorize the crisis.
Decide order & type of intervention.
Coordinate w/ other agencies
anticipate futrue needs.
Assess immediate needs & treats
connect to support groups, social services, disaster relief, etc.
trauma treatment plans, treatment of acute stress reactions & trauma recovery groups
integrates several models of crisis assessment & intervention.
1.2 Caplan's theory

Phase 1: one is exposed to a stressor leads to problem-solving techniques & coping strategies
Phase 2: previous coping & problem-solving strategies fail to relieve the stressor confused, helpless,
disorganized, distress prevails.
Phase 3: Resources from within & outside of the person are mobilized to resolve the problem & to alleviate the
discomfort caused by the stressor anxiety may escalate to panic. Withdraw or flee the situation, & decline in
function.
Phase 4: the absence of crisis resolution leads to major disorganization tension escalates to a breaking point,
cognitive function declines substantially, emotions become labile, & behavior may become irrational, aggressive,
or self-injurious.
1.3 risk factors that effect ability to cope
presence of concurrent or multiple biopsychosocial stressors
multiple losses, unexpected life changes, & unresolved problems
limitations in adaptive ability & coping skills
chronic physical or psychologic pain or disability
concurrent psychiatric disorders, SU, & suicidality
poor social support networks
limited access to health care services.
1.4 give 4 types of crisis situations
External (situational) crisis: loss of a job, death of a loved one, change in financial status, divorce, eviction or
foreclosure.
Internal (subjective) crisis: response to aging, loss, abandonment, or a breach of loyalty that results in profound
feelings of betrayal, fear or victimization. Also result from a threat to a deeply held belief or value, thereby
triggering spiritual distress or a loss of faith.
Phase-of-life (maturational) crisis: midlife crisis, child leaves home for first time for college or military, reduced
memory, loss of strength.
Disasters (adventitious) crisis: precipitated by a disaster that is not part of everyday life.
Natural disasters (earthquakes)
national or global disasters (war)
crimes of violence (rape)
1.5 psychological stages after a disaster
Heroic phase: occurs right after an event time of altruism & heroic behavior in the community.
Honeymoon phase: 1 week to 3-6 months after the event when feelings of community sharing & high social
attachment exist
Disillusionment phase: 2 months to 1-2 yrs after the event feelings of disappointment, anger, resentment, &
bitterness regarding the expectations of support that were not met.
Reconstruction phase: 2 months to 1-2 yrs after the event physical & emotional reinvestment take place.
Some individuals tend to feel empathy or survivor guilt after a disaster disaster often transforms behavior from
isolation to increased interaction w/ others after the 1st response of shock & disbelief.
1.6 basic goals of crisis intervention & how they differ from traditional mental heath approaches
Basic goals:
Alleviation of the acute distress
Restoration of independent functioning
Prevention of psychologic trauma
short-term strategic therapy
action-oriented interventions that focus on solving the immediate problems r/t to emotional, mental, physical, &
behavioral distress
stabilize psychologic disturbance & minimize prolonged psychologic trauma
1.7 crisis focused nursing assessment & 1.8
gathering comprehensive biopsychosocial-spiritual data from a variety of sources
the more focused the assessment is in the short term, the more immediate the relief can be for the problem.
After assessing application of the assessment data
nurses help individuals to return to their precrisis level of functioning, and in some cases improve it.
490 box 21-2
1.9 nursing interventions at the primary, secondary, & tertiary levels of prevention
Primary:
promote mental health & reduce mental illness

Secondary:
prevent prolonged anxiety from diminishing
personal effectiveness
personality organization
Tertiary:
provide support to
facilitate optimal levels of functioning
prevent further emotional disruptions
1.10 barriers to effective crisis intervention
secondary gain crisis-focused assessment provides clues to this issue
failure to learn from from experience learned helplessness
Existing mental disorders cognitive impairment
therapist-patient boundary problems overidentification/countertransference
sociocultural considerations lack of resources, health insurance
1.11 examine & prioritize nursing intervention approaches for p/ts experiencing crisis
General approach:
listen, observe, ask ?s to understand & categorize the crisis.
Decide order & type of intervention.
Coordinate w/ other agencies
anticipate future needs.
Assess immediate needs & treats
connect to support groups, social services, disaster relief, etc.
trauma treatment plans, treatment of acute stress reactions & trauma recovery groups
integrates several models of crisis assessment & intervention.
4.3 Crisis-Part 2
1.1 define key terms
1.2 scope of problem, demographics & coexisting factors of family violence (women, children, & elderly)
prevalence:
half of all Americans have experienced violence in their families
co-morbidity:
secondary effects of violence:
anxiety
depression
suicidal ideation
Family violence:
Phase 2: Assault of women & children
newborns & children b/t ages 1 & 4 yrs are more vulnerable to homicide than are children b/t ages 5-9 yrs.
Female murder victims more likely than male murder victims to have been killed by an intimate partner.
Battered women:
1.8 million wives in the U.S are abused every year by their husbands
25-50% of all women are abused by their intimate partners at least once
20-25% of women who seek treatment in ED are there as a result of battering injuries.
2-8% of these women identified abuse as the cause of their injuries
7-17% of pregnant women experience physical abuse by their partners
physically abused children:
2 million children abused each year by their parents & caregivers, 1000 die
25% of the 2 million abused children are physically abused; 20% are sexually abused; 55% are
neglected; 25% of the 2 million abused are younger than 5; 60% are b/t ages 5 & 14
children younger than 3 yrs old are at a greater risk for fatal abuse than older children
abused & neglected children are at greater risk for later delinquency, adult criminality, & violent
crimes than are non-abused or non-neglected children
Elderly:
most studies do not distinguish b/t elder abuse & elder neglect
families are unlikely to report the abuse
many elderly people are homebound

older women more likley than men to sudder from abuse


older victims have smaller support systems, fewer physical, psychologic, & economic reserves.
1.3 causal theories on family violence
social & cultural perspective:
feminist theory- unequal power distribution b/t men & women subjects women to male dominance in all
spheres of life.
Social isolation- victims are isolated from friends, family of origin, neighbors, or anyone who could become
acquainted w/ the events.
Generational Transmission of Violence- among adults who were abused as children, more than 1/5 later abuse
their own children
Developmental Traumatology: A neurobiologic perspective:
how mechanisms of abuse & neglect that result from early childhood trauma can affect adult survivors.
Family violence has been linked to MI & PD
Assaultive & Homicidal behavior- early attachment disturbance & the impairment of self-regulation are major
diagnostic issues among traumatized children.
Cycle of Violence:
Phase 1 (tension building):
major battering usually does not occur. Perpetrator establishes complete control usually by
inflection of emotional abuse.
Phase 2 (Acute battering):
tension can no longer be contained & acute battering occurs
Phase 3 (Honeymoon stage):
Perpetrator begs for forgiveness, promises never to do it again. Appears to have remorse, then
tension starts to build and cycle is repeated.
1.4 types of maltreatment among women, children, & the elderly
Women:
battered: injuries in the breast, chest, abdomen
stalking
violence in pregnancy
rape
Children:
child neglect, nutritional, medical, emotional, & caregiver.
Physical, psychological, sexual abuse
scalding, cigarette burns

Elderly:
physical, sexual, psychological abuse or neglect
self-neglect
financial exploitation
denial of adequate medical treatment
1.5 assess p/ts for types of abuse
Women:
anxious, frightened
depressed, passive
ashamed, embarrassed
poor eye contact
wt problems
looks to partner for answers
partner smothering, possessive
We often see women who have been hurt by their partners. Is your partner responsible for your injuries?
Has your partner ever hurt you?
Have you noticed any pattern to this behavior, such as increase in frequency & severity?
Does he threaten to use or has he ever used a weapon to hurt you?
Children:
holistic approach

get as much info as possible w/o subjecting the child to unnecessary & repeated probing & questioning
complete physical exam if suspicious of child abuse
disheveled, malnourished
failure to thrive
fearful, watchful
asses relationship b/t child & caregiver
Do you know why you have come to see me?
What have you been told?
What kinds of games do you & (alleged abuser's name) play when your mom isn't around?
Are there any games that you & (alleged abuser's name) play that you don't like?
Elderly:
poor eye contact
anxious, fearful, passive
looks to caregivers for answers
poor hygiene
underweight, malnourished, dehydrated
physical needs not met
untreated medical conditions
Are you happy living w/ (the name of the suspected abuser)?
Please tell me about your financial assets & how they are managed?
Whom do you turn to when you are feeling down?
How are family disagreements handled in your household?
Has anyone ever hurt you or touched you when you didn't want to be touched?
The Don'ts:
do not judge
do not use loaded words (abuse & battered)
don't display anger, horror, shock, or disapproval
do not force a child or anyone else to remove clothing
Interview guidelines:
physicians & nurses should routinely screen all p/ts in all settings for the possibility of family violence. Need
to ask direct, specific ?s on abuse. They often do not seek treatment directly.
1.6 nursing dx
risk: for self-directed & other-directed violence, injury
anxiety, fear, disabled family coping, powerlessness, caregiver role strain
1.7 outcome measures
evidence that the victim is no longer hurt or exploited
evidence that physical abuse has stopped
evidence that emotional abuse has stopped
1.8 nursing interventions & plan
Remind victims no one deserves abuser
know how to identify the partner's increasing levels of abuse leading to violence
identify supports including: family, friends, neighbors, local shelters, counselor, & others
memorize the address & phone # to police & the local abuse shelter
if they are afraid the abuser will approach them at work, notify the employer, as they may have a protocol for
violence
during a violent episode try to get a confined room if possible w/ a phone
ask a trusted neighbor to call the police if they hear the sounds of violence
Plan: survival kit
drivers license & ID for self & children such as birth certificates & SS cards
house & car keys if they do not have a car, plan a way to get to a police station or public shelter
insurance papers & other imp. Documents
cash & checkbook or credit cards
medical records
children's school records & books
meds

extra clothing
custody papers
imp. Personal items such as a fav. Toy or keepsake
a non-traceable (no GPS) cell phone
1.9 evaluate
1.10 sexual abuse & forms of sexual assault (rape) & theories
sexual abuse: any form of exposure or contact w/o consent. Exhibitionism, foundling or manipulation of the
genitals, digital penetration, penile penetration of the vagina or rectum, genital contact, insertion of foreign objects
into the genitals or rectum. Non contact sexual activity such as sexually explicit language directed toward a child,
telephone calls, showing of pornographic materials to a child, & voyeurism. Definition of sexual abuse varies by
state jurisdiction.
Rape is a crime of violence & aggression expressed through sexual means. The act is against the victims will or
against someone who cannot give consent.
Rape is an aggressive act, the motive is power & control, not sexual satisfaction
victim can be any age
more than half of rapes are committed by someone known to the victim
same-sex rape can occur b/t partners but is most common in institutes
the victim:
highest risk age group is 16-24
single women, often close to home
stranger rape, wrong place, wrong time
presence of a weapon
Date rape drugs:
y-hydroxybutyrate & Rohypnol (CNS depressants)
1.11 long term psychological effects of rape & sexual assault
depression suicide
self-mutilation
anxiety disorders
chemical dependency
OCD/difficulties w/ daily functioning
low self esteem
sexual acting out behaviors
somatic complaints
PTSD
intrusive thoughts
increased motor activity
increase emotional lability
fears & phobias
4.4 eating disorders
1.1 key terms
1.2 what is an eating disorder prevalence comorbidity
eating disorders include extreme emotions, attitudes, & behaviors surrounding w.t & food issues
ED are serious emotional & physical problems that can have life-threatening consequences
A compulsion to eat or avoid eating & or w.t gain
all encompassing & affect every aspect of the persons life
Prevalence + co-morbidity
more common in females
worldwide increase in ED
depression & dysthymia in 40-75%
OCD
PD
hx of sexual abuse
high risk of death & suicide
highest mortality rate of all MI
1.3 Etiologic & psychosocial factors that provide insights into the causes of ED

Biological:
family hx of ED
genetic predisposition that involves high-risk personality traits
premorbid neurobiologic dysregulation that causes anxiety or depression
Sociocultural:
diet & fitness industry
changes in women's & family roles
fashion industry
stress r/t to the developmental tasks of adolescence
Psychologic:
low self-esteem
dichotomous thinking (view of situations as all good or all bad), control fallacies (one feels solely responsible
for the happiness & failure of others), personalization (individuals compare themselves endlessly w/ others &
percieve others' behavior as a direct reaction to them)
perfectionism
emotional immaturity
interoceptive deficits
ineffectiveness
compliance & conflict avoidance
Familial:
enmeshment & poor conflict -resolution skills
focus on social acceptance, achievement, ideal body image, & parental dieting
separation & individuation issues
some incidence of alcoholism or physical or sexual abuse
1.4 assess p/ts
all ED:
low self-esteem
compliance & conflict avoidance
sense of ineffectiveness Alexithymia (difficulty naming & expressing emotions) Interoceptive deficits
(inability to accurately identify & respond to bodily cues)
Anorexia Nervosa:
perfectionism
rigidity
risk & harm avoidance
DSM IV:
refusal to maintain body w.t for age & h.t , w.t 15-25% below expected
intense fear of becoming fat, gaining w.t
disturbance in the way in which the body is viewed (feel fat even when underweight)
absence of at least 3 menstrual cycles amenorrhea
no known physical illness causing w.t loss
specific type:
restricting type- during the current spisode of anorexia nera, the person has not regularly engaged in
binge eating or purging behavior ( self-induced vomiting or the misuse of laxatives, diuretics, or
enemas)
Binge-eating/purging type- during the current episode of anorexia nervosa, the person has regularly
engaged in binge eating or purging behavior
Bulimia Nervosa: Alexithymia
impulsivity
emotional dysregulation- oversensitivity to & difficulty w/ modulating emotions & behavior
DSM IV:
recurrent episodes of binge eating (large amt of food in a small amt of time) characterized by both of the
following:
eating, in a discrete period of time (within any 2-hr period), an amt that is definitely larger than most
people would eat during a similar period of time & under similar circumstances
a sense of lack of control over eating during the episode ( feeling that one cannot stop eating or

control what or how much one is eating)


recurrent inappropriate compensantory behavior to prevent w.t gain, such as self-induced vomiting;
misuse of laxatives, diuretics, enemas, or other meds; fasting; or excessive exercise
minimum of 2 binging episodes a week for a least 3 months
persistent over concern w/ body w.t & shape
the disturbance does not occur exclusively during episodes of anorexia nervosa
specific type:
purging type- during the current episode of bulimia nervosa, the person has regularly engaged in selfinduced vomiting of the misuse of laxatives, diuretics, or enemas
non-purging type- during the current episode of bulimia nevosa, the person has used other
inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly
engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas
ED not otherwise specified:
DSM IV
for females, all of the criteria for anorexia nervosa except that the individual has regular menses
all of the criteria for anorexia nervosa are met except that, despite significant w.t loss, the individual's current
w.t is in the normal range
all of the criteria for bulimia nervosa are met except that the frequency of binge eating & inappropriate
compensatory mechanisms occurs less than 2x a week or for less than 3 months
the regular use of inappropriate compensatory behavior by an individual of normal body w.t after eating small
amounts of food (self-induced vomiting after the consumption of 2 cookies)
individual repeatedly chews & spits out, but does not swallow, large amounts of food
binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate
compensatory behaviors characteristic of bulimia nervosa .
Binge eating disorder (BED): ex. Of ED not otherwise specified & included in the DSM-IV-TR as a proposed dx
for further study.
Described specifically as a:
recurrent episodes pf binge eating during which the individual eats more than most people eat during a similar
period and feels out of control while eating
distress, guilt, disgust regarding behavior eating
1.5 medical complication re-feeding syndrome
electrolyte imbalances
anemia
amenorrhea
osteoporosis
bradycardia
hypotension
cardiac arrest
abnormal thyroid function elevated TSH hyperthyroidism
Russel's sign
parotid gland enlargment
dental problems
cardiac arrhythmias
Refeeding syndrome
possible life threatening complication, is high in the early phase of treating a severely malnourished c/t
assess for edema, CHF, hypophosphatemia & other serious electrolyte imbalance
1.6 examine personal values
sensitivity, thoroughness, sharp observation skills.
1.7 nursing dx
imbalanced nutrition
risk for injury
decreased cardiac output
chronic low self-esteem
disturbed body image
risk for imbalanced fluid volume

anorexia nervosa:
anxiety, disturbed body image, nutrition imbalance: less than body req., social isolation
bulimia nervosa:
ineffective coping, deficient fluid volume, chronic low self-esteem.
1.8 outcome criteria:
anorexia nervosa:
participate in therapeutic contact w/ staff
consume adequate calories for his/her age, ht, & metabolic needs
achieve a minimum normal w.t
maintain normal fluid & electrolyte levels
resume a normal menstrual cycle
demonstrate improvement in body image w/ a more realistic view of body shape & size
demonstrate more effective coping skills to deal w/ conflicts
manage family conflicts more effectively
verbalize awareness of underlying psychologic issues
achieve ideal body w.t
Bulimia nervosa:
participate in therapeutic contact w/ staff
consume adequate calories for his/her age
cease binge/purge episodes while in the inp/t setting & cease dieting
perceive body shape & w.t as normal & acceptable
1.9 interventions
provide safe, non-threatening enviornment
assess for risk of suicide
restore a minimum w.t & nutrition balance through a behavioral program
encourage the c/ts to express thoughts, feelings , & concerns about body & body image
assist the c/t to increase understanding of body image distortion
Anorexia Nervosa:
under supervision, re-feed, re-introduce health food plan
discuss need for food supplements ( may include nasogastric feedings)
provide support w/ the above interventions
Bulimia Nervosa:
w/ supervision, eat meals provided by dietician
avoid purging by maintaining 1:1 nursing supervision post-meals
create a structured, supportive enviornment w/ clear, consistent, & firm limits
coordinate w/ dietician to construct a behavioral plan w/ specific w.t gain goals of approx. 3lbs/week, specific
eating foals of consuming 90-100% of meals.
1.10 interdisciplinary roles of HC team
1.11 pharmacologic, cognitive, behavioral therapies
pharmacologic:
SSRIs fluoxetine (Prozac) bulimia nervosa
no SSRI or SNRI directly treat anorexia nervosa, but prozac is effective for preventing relapse in wt-restored
p.ts + for OCD
Atypical antipsychotics help anorexics tolerate wt gain Zyprexa + Risperdal (promote wt gain)
hypokalemia oral & IV K+ supplements
nutrional anemia iron supplements
gastroparesis metoclopramide (Reglan)
infected parotid glands antibiotics
Cognitive & behavioral therapies
establish trust
assist c/t to identify triggers
identification of distorted thought pattern
disturbed body image
believing that all food is fattening
1 cookie destroys 1 day of dieting

journaling
cognitive therapy:
helps c/t re-frame negative or distorted thoughts
introduces more realistic thinking:
maintaining a thought record (journal)
reframing thoughts
cognitive restricting
often paired w/ behavioral therapy
Behavioral therapy:
focuses on the behavior the needs to be changed
self-monitoring of eating behaviors is an effective behavioral interventions
behavioral contracts for gain, regulated eating & restricted exercise are useful
extinguishing binging/purging behaviors are also useful
exposure to the problem (binging) w/ response prevention (stop purging) is an effective behavioral
intervention for bulimia.
1.12 evaluate