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UNIT 1

What are the obstacles of therapeutic communication?


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

What are the traits of therapeutic communication?


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

Describe Mental Health:


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

Discuss DSM-IV:
A. Clients diagnosis has 5 parts or AXIS:
A..1.

AXIS I: Psychiatric Dx

A..2.

AXIS II: Personality disorder or mental retardation

A..3.

AXIS II: Medical dx

A..4.

AXIS IV: Psychosocial stressors

A..5.

AXIS V: Global Assessment of Fxning (GAF)- considered

Psychologic, social and occupational fxn on a hypothetical continuum of


MENTAL HEALTH-ILLNESS.
B.
What does GAF Measure? The clients functional state @ the time of admission
and within the last year

Safety is the top priority in mental health setting.


Discuss Client rights:
I.

RIGHT TO TREATMENT:
A. People w/ mental illness have a right to tx.
B. State cannot detain individuals who are non-dangerous without providing some mode
of tx.
C. MHN has professional obligations to help pts. Seek out and engage tx for mental
illness 2 the least restrictive level.

II.

RIGHT TO REFUSE TX:


A. Voluntary and involuntary clients have the right to refuse medication.
B. During emergency situations, if there is potential danger, the client can be forcibly
medicated
C. Right to refuse medication is upheld if client is involuntary and competent

What are the types of COMMITMENTS?


A. Voluntary Those who want to be discharged must give written notice of intent to
leave and must be discharged within 3 days.

B. Emergency
C. Civil/judicial commitment- Legal basis

<<LEAST RESTRICTIVE ALTERNATIVE means providing MH tx in the least restrictive


environment using the least restrictive tx. >>

What is Duty to warn? Establishes responsibility of a treating MPH to notify an intended,


identifiable victim.

Describe Neuroanatomy:

LOBE
FRONTAL

NORMAL FXN

TEMPORAL

OCCIPITAL

PARIETAL

III.

execution of voluntary motor fxn


thought processes ex. Planning, abstract thought, decision making, critical
thinking
Intellectual insight, judgment
Expression emotion
Sensory and motor
Interprets sensory information
Right and left orientation
Hearing, connects with limbic system, allows connection of emotions,
responsible for language comprehension

vision

ANTIPSYCHOTIC MEDICATIONS:
A. Also called NEUROLEPTICS used for tx psychosis, behavioural problems in
children, schizophrenia etc. Controls symptoms like delusions, hallucinations and
thought disorders Two types:
A.i. CONVENTIONAL or TYPICAL - block dopamine, acetylcholine and
epinephrine Phenothiazines (first generation) and non-phenothiazines ex.
Haldol, Thorazine, Stelazine
A.i.1.a. Side effects: extrapyramidal symptoms, dry mouth,
orthostatic hypotension
A.ii. UNCONVENTIONAL or ATYPICAL blocks action of dopamine and serotonin.
Ex. Clozaril, Zyprexa, Risperdal, Abilify

IV.

A.ii.1.

Less side effects, few or no EPS

A.ii.2.

Work on negative and positive symptoms of schizophrenia

ANTIDEPRESSANTS:

B. Partially block reuptake of norepinephrine and serotonin. 4 classes:


B.i. Selective Serotonin Reputake Inhibitors (SSRIs)- work by inhibiting
reuptake of serotonin These treat major depressive disorder ex. Prozac,
Zoloft, Paxil
B.ii. Tricyclic Antidepressant (TCA)- act by blocking the reuptake of Serotonin
and norepinephrine. This increases serotonin and norepinephrine in the nerve
cell. These are used to treat major depression.
B.iii. Side effects: orthostatic hypotension, sedation,
B.iv. Monoamine Oxidase InhibitorsMAOIs inhibit Monoamine oxidase
enzyme----result=increased availability neurotransmitter Ex. Nardil, Parnate
B.iv.1.

Side effects:

HYPERTENSIVE CRISIS

B.iv.2. Avoid foods with Tyramine


B.v. Atypical Antidepressant- used tx major depression and anxiety. Effects one
or two of these neurotransmitters: serotonin, norepinephrine, and dopamine.
Ex. Wellbutrin, Cymbalta, Effexor
B.v.1.a. Side effects: Headache, dry mouth, Seizures, suppress
appetite

V.

MEDICATIONS ALZHEIMERS DX:


A. Anticholinesteras inhibitors (AChe) are used tx Alzheimers dx.
B. Common inhibitors: Tacrin (Cognex), Donepezil (Aricept), Rivastigmine (Exelon)
C. M of A= increase acetylcholine concentration in CNS by inhibiting cholinesterase
breakdown.

VI.

ANTI-ANXIETY/ANXIOLYTIC MEDICATIONS:
A. Used to control anxiety and treat status epileptics; preoperative sedation, insomnia
B. Major group = benzodiazepines ex. Valium, Xanax...Buspar (non-benzodiazepine)
takes 4 weeks
C. M. Of. A= is to enhance the inhibiting action of Gamma-aminobutyric acid (GABA an
inhibitory neurotransmitter in the CNS)
1. Side effects: Fatigue, dry mouth, sedation

VII.

MEDICATION TREAT ATTENTION DEFICIT DISORDER:


D. Two types drugs used in tx ADHD:
i. Amphetamine- like drugs (psycho-stimulant) Ritalin, Adderall,
Concerta. Increases release and blocks reputake of monoamines so more is
available to inhibit an overactive part of the limbic system.

VIII.

MOOD STABILIZERS:
E. Used for tx. Bipolar disorder.
F. Eg. Lithium citrate and antiepileptic drugs (Tegretol, Depakote)
G. M. of. A= is alteration electrical conductivity in neuron
a.i.1.

Side effects: Arrhythmias, Tremor, Polyuria,

a. GENERAL ADAPTATION SYNDROME: bodys response to stressful stimuli,


which produces biologic, emotional and psychological responses

b. What influences a persons response to stress?


b.i. Age
b.ii. Past experience
b.iii. Lifestyle
b.iv. Culture
b.v. Developmental level
b.vi. Health status

c. Define DISTRESS: Subjective response to stimuli that are threatening or perceived


as threatening. Includes fatigue, pain, fear, or acute/chronic dx

d. Define EUTRESS: Stress response (nonspecific) assoc. with desirable events ex.
Wedding, job promotion, birth of child.

e. Define PSYCHOLOGIC STRESS: All processes of the person that require cognitive
appraisal of the event before a response

f.

What is GIS? Activated automatically as response to survival; POSSOM


RESPONSE.
Results overstimulation of PNS, activated by life threatening situations

g. Stages of GAS:

I.

COMPLEMENTARY AND ALTERNATIVE THERAPIES:

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

I.

ALTERNATIVE THERAPY FIELDS:


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

ANXIETY DISORDERS:
I.

What is anxiety? Feelings of uneasiness, uncertainty, apprehension or tension in response


to an unknown object or situation.

X.

DEFENSE MECHANISMS:

EGO DEFENSE
MECHANISMS
Conversion

DEFINITION
Unconscious expression of a mental conflict as a
physical symptom to relieve anxiety
Unconscious refusal to face reality.

EXAMPLE
Woman experiences blindness after
witnessing a robbery.
Woman denies that her marriage is
failing
Separation and detachment of a strong, emotionally Male victim of car-jacking exhibits
charged conflict from one's consciousness
symptoms of traumatic amnesia the
next day.
Unconscious attempt to identify with personality Teenager dresses, walks, and talks
traits or actions of another to preserve one's self- like his favourite basketball player.
esteem
Unconscious assignment of unacceptable thoughts Man who was late for work blames
or characteristics of self to others
wife for not setting the alarm clock.
Justification of one's ideas, actions, or feelings to Student states he didn't make the
maintain self-respect, prevent guilt feelings, or
golf team because he was sick.
obtain social approval
Demonstration of the opposite behaviour, attitude, Man who dislikes his mother-in-law
or feeling of what one would normally show in a is very polite and courteous toward
given situation
her.
Voluntary rejection of unacceptable thoughts or
Student who failed a test states she
feelings from conscious awareness
isn't ready to talk about her grade.
Use of external objects to become an outward
An engagement ring symbolizes
representation of an internal idea, attitude, or
love and a commitment to another
feeling
person.

Denial
Dissociation
Identification
Projection
Rationalization
Reaction-formation
Suppression
Symbolization

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


o
o
o
o
o
o

Defense mechanisms used


Mood
Suicide potential
Thought content and process
Severity of subjective experience of anxiety
Understanding of specific disorder

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

12.

XII.

Administer anxiolytics

Types of ANXIETY:
a.i. Panic Anxiety: Recurrent unexpected anxiety attacks with thoughts of
dread, impending doom, death and fear of being trapped.
a.ii. Phobias: Client experiences panic attack in response to particular situations
Types: Agoraphobia fear of being alone in public places, without escape,
Social Phobia - fear of social or performance situations. Eg. Speaking, eating
in public
a.iii. Posttraumatic Stress Disorder (PTSD): Describes and individuals reaction
to traumatic events eg. Combat, sexual abuse, physical abuse, disasters, and
grieving
a.iii.1.a. Efforts to avoid thoughts, feeling, or conversation about
the trauma
a.iii.1.b. Efforts to avoid persons or places that evoke memories of
trauma
a.iii.1.c.

Inability to remember important aspects of trauma

a.iii.1.d. Diminished interest in significant activities


a.iii.1.e. Restricted range of effect
a.iii.1.f.

A sense of impending doom.

1. Must have two of the following present:


a. Sleep disturbances, irritability or angry outbursts, difficulty
concentrating, Hypervigilance and exaggerated startle response.
a.iv. Acute Stress Disorder: Symptoms occur during or immediately after
trauma
a.iv.1.a. Develops three or more dissociative symptoms:
a.iv.1.a.i. Subjective sense of numbing or detachment
a.iv.1.a.ii. Absence of emotional responsiveness
a.iv.1.a.iii. Feeling dazed (reduced awareness of surroundings)
a.iv.1.a.iv. Derealisation (unreal feeling)
a.iv.1.a.v. Depersonalization (feeling alienated)
a.iv.1.a.vi. Dissociative amnesia
a.v. General Anxiety Disorder: Excessive anxiety and worry that is difficult to
control
a.vi. Obsessive Compulsive Disorder:
a.vi.1.
Obsessions are recurrent and persistent thoughts, impulses or
images
a.vi.2.

Individuals try to suppress the thoughts and impulses

a.vi.3.
Compulsions are repetitive behaviours that the person feels
driven to perform in response to an obsession
a.vii. Somatoform disorders: Characterized by physical symptoms that cant be
explained by known physical mechanisms. They:
a.vii.1.a. Involve multiple organs
a.vii.1.b. have early onset and are chronic without signs of
impairment
a.vii.1.c. No laboratory evidence of medical condition
Types:
a. BODY DYSMORPHIC DISORDER-Preoccupation with imagined defect
in appearance in a normal-appearing person
b. CONVERSION DISORDER- Development of Neurologic disorder
(blindness, deafness, loss of touch, or pain sensation) or Involuntary
motor function (aphonia, impaired coordination, paralysis, or seizures).
c. HYPOCHONDRIASIS-Preoccupation with fears of having/ has a
serious disease despite appropriate medical tests and assurances to
the contrary
d. SOMATIZATION DISORDER-History of many physical complaints
before age 30. History of pain in at least four different sites or
functions
a.viii. Dissociative disorders:
a.viii.1.a. Depersonalization disorder
a.viii.1.b. Dissociative amnesia-One or more episodes of inability to
recall important information (usually of a traumatic or stressful
nature)
a.viii.1.c. Dissociative fugue-Sudden, unexpected travel away from
home or one's place of work with inability to remember past

XIII.

COGNITIVE AND BEHAVIOURAL THERAPY:


a. Distorted and dysfxnal thinking causes psych disturbances expressed in mood and
behaviour
b. GOAL: assist the client in beginning to I.D automatic thoughts and the feelings
connected to them.

XIV.

RATIONAL EMOTIVE THERAPY:


a. Precursor to cognitive behavioural therapy
b. Psychologic symptoms come from disturbed thinkingleads irrational beliefs not
based in actual fact- You are responsible for your irrational beliefs and thus mental
disturbance

MEDICATIONS THAT TREAT ANXIETY:


XV.

Anti-anxiety
A. Benzodiazapines
a. How it works: by enhancing the inhibitory action of GABA thus causing
generalized CNS depression
b. Therapeutic effect: relief of anxiety
c. Interactions: DO not use with MAOIs, additive effect when taken with
alcohol, antihistamines

c.i. Diazapam (Valium)- 2-10mg 2-4xs /dy


c.ii. Alprozolam (Xanax)- .25-.5mg 3xs/dy
d. SE: dizziness, drowsiness lethargy, mouth dryness
o

Treat overdose of benzos by:


d.i..a. Administering an antiemetic in conscious pt. and
gastric lavage in unconscious patient

B. Non-Benzodiazapine
A.a. How it works: decrease reputake of dopamine and increase serotonin in
the CNS
A.b. Therapeutic effect: decrease depression
A.c. Interactions: grapefruit juice can cause toxicity, use with MAOI may
cause HTN
A.c.1. Buspirone HCL (BusPAR) -5mg 2-3x/dy
A.d. SE: dry mouth, nausea, vomiting, agitation, headache, blurred vision,
constipation
XVI.

Antidepressant: 4 groups:
B. Tricyclics
B.a. How it works: blocks reputake of norepinephrine and serotonin
B.b. Interactions: do not use with MAOI and avoid concurrent use with
SSRIs
B.b.1. Amitriptyline (Elavil)-25mg 3xs up to 200mg/dy
B.b.2. Imipramin (Tofranil)-25-50mg 3-4 up to 300mg/dy
B.c. SE: orthostatic hypotension, sedation, suicidal thoughts, blurred vision,
dry mouth
C. SRRIs:
C.a. How it works: blocks reputake of serotonin
C.b. Interactions: St. Johns wart causes central serotonin syndrome
C.b.1. Fluoxetine (Prozac)
C.b.2. Sertraline (Zoloft)
C.b.3. Paraxentine (Paxil)
C.c. SE: nervousness, sexual dysfunction, headache, insomnia
D. MAOI:
D.a. How it works: inhibiting monoamine oxidase causing a rise in
neurotransmitters

D.b. Interactions: avoid foods with

tyramines

D.b.1. Phenelzine Sulfate (Nardil)


D.b.2. Tranylaypromine Sulfate (Parnate)
D.c. SE: HYPERTENSIVE CRISIS s/s: headache, seizure, edema, chest
pain, SOB, nausea, vomiting, severe anxiety, unresponsiveness.

E. Atypical antidepressant:
E.a. How it works: effects serotonin, dopamine, and norepinephrine
E.b. Interactions: do not use w/ MAOI, should not be taken within 14dys of
MAOI use
E.b.1. BuPropion (Wellbutrint)
E.b.2. Venlafaxine (Effecor)
E.b.3. Doloxetine (Cymbalta)
E.c. SE: headache, dry mouth, seizures, appetite suppression
F. Mood Stabilizers:
F.a. How it works: alters electrical conductivity of cell
F.b. Interactions: make sure have adequate Na intake for Lithium
F.b.1. Lithium
F.c. Monitor: therapeutic levels
G. Anti-epileptics:
G.a. How it works: increases inhibitory action of GABA
G.b. Interactions: increased CNS depression with consumption of alcohol
G.b.1. Divalproex sodium (Depakote)
G.b.2. Carbamazepine (Tegretol)
G.c. SE: agranulocytosisso check WBC, sedation
G.d. Monitor: I/O
H. Beta-Blockers: Anti-anginals
H.a. How it works: blocks beta 1 receptors thus decreasing BP and HR
H.b. SHOULD NOT 50mg daily, Ccr=15-35mL/min
H.b.1. Atenolol (tenormin)- 50-200mg/dy

H.b.2. Propranolol (Inderal)- 40-100mg/dy


H.c. SE: fatigue, weakness, bradycardia, CHF, pulmonary edema
H.d. Monitor: vitals, I/O, daily weight, assess CHF. Take apical pulse before
admin, if ,50bpm do not administer
I. Antihistamines:
I.a. How it works: blocks effects histamine @ H1 receptor, creating CNS
depression
I.b. Interactions: additive CNS depression with alcohol and antidepressants
I.b.1. Diphenhydramin (Benadryl)
I.b.2. Hydroxyzine HCL (Atarax)
I.b.3. Hydroxyzine Pamoate (Vistaril)
I.c. SE: dry eyes, constipation, dry mouth, and blurred vision, can decrease
anxiety so asses mood, mental status and behaviour.
J. Herbal Therapy:
J.a. Kava-Kava: used for anxiety
J.a.1. How it works: alters limbic system modulation of emotional
processes
J.a.2. SE: dizziness, headache, drowsiness, extrapyramidal effects,
HEPATIC TOXICITY. When taken with Benzos additive CNS
depression
J.b. Valerian: for anxiety
J.b.1. How it works: may increase concentrations of GABA
J.b.2. SE: drowsiness, headache

SLEEP DISORDERS:

I.

Types:
a. Dyssomnias- abnormalities in amt, quality or timing of sleep

a.i. Insomnia- most common, difficulty initiating and maintaining sleep


a.ii. Hypersomniaa.iii. Narcolepsy- excessive daytime sleepiness, sudden onset sleep attacks. Can
have cataplexy (sudden loss muscle tone and involuntary muscle movement)
or sleep paralysis
a.iv. Breathing-related sleep disorder-e.g sleep apnea
a.v. Circadian rhythm sleep disorder- e.g jet lag, shift work type and delayed
sleep phase
b. Parasomnias- abnormal behaviour during sleep
b.i. Nightmare disorder- occurs during REM
b.ii. Sleep terror- occurs during non-REM
b.iii. Sleepwalking- typically ages 4-8, occurs during non-REM
II.

NSG PROCESS:
a. Assessment: subjective and objective data sources and sleep hx
b. NSG DX:
b.i. Sleep deprivation
b.ii. Insomnia
b.iii. Ineffective bx
b.iv. Anxiety
b.v. Fatigue
b.vi. Ineffective coping
c. Outcome I.D
c.i. I.d primary causes sleep alteration
c.ii. Communicate interventions and implement them
c.iii. Demonstrate reduction sleep disturbance
c.iv. Participate discharge planning
d. Planning: participation multidisciplinary team
e. Implementation/Interventions:
e.i. Monitor sleep patter and id risks
e.ii. Have client keep sleep diary
e.iii. Develop hygiene plane
e.iv. Teach symptom management
e.v. Make environment quiet

e.vi. Help client i.d stressors


e.vii. Promote development coping skills
e.viii. i.d clients support system
e.ix. promote compliance medications
e.x. teach limit substances cause sleep disturbances
e.xi. educate about circadian rhythms
e.xii. refer sleep specialist

GRIEF:

I.

Types:
a. Anticipatory grief- pre-mourning- grief assoc. With anticipation predicted death or
developing loss
b. Acute Grief- painful exper. After a loss
c. Dysfunctional grief- ex. PTSD. Lasts longer than other types and has greater
disability ex. Traumatic loss, complicated grief, chronic grief
d. Chronic sorrow- response to ongoing loss ex. Parents w/ disabled children.

II.

Interventions:
a. Assess risk kill or harm self and others

b. Promote ns-relationship
c. Facilitate expression feelings related to loss
d. Help client understand relationship between self and lost person
e. Facilitate full expression grief
f.

Promote interactions with others

COGNITIVE DISORDERS:
I.

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

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

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

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

II.

STAGES OF ALZHEIMERS:
1. Stage1: Mild (2-4yrs)
1.i. Recent memory loss, neologisms

1.ii. Cognitive loss in:


1.ii.1.

Communicating

1.ii.2.

Calculating

1.ii.3.

Recognition

1.iii. Anxiety and confusion


1.iv. Mild behavioural problems
2. Stage2: Moderate
2.i. Stage1 symptoms increase
2.ii. Behavioural probs increase and include:
2.ii.1.

Catastrophic rxs

2.ii.2.

Sundowning- behavioural disturbance in the morning or evening

2.ii.3.

Preservation-excessive repetition

2.ii.4.

Aimless pacing

2.ii.5.

Wandering

2.ii.6.

Incontinence

2.ii.7.

Hypertonia

3. Stage3: Severe:
3.i. Stage2 symptoms increase
3.ii. Total incontinence
3.iii. Choking
3.iv. Emaciation
3.v. Total care needed
3.vi. Progressive gait disturbance leading to non-ambulatory status
III.

NSG DX:
1. Risk aspiration
2. Imbalanced body temp
3. Infection
4. Injury
5. Physical mobility
6. Anxiety
7. Impaired verbal communication
8. Chronic confusion

9. Grieving
IV.

OUTCOME IDENTIFICATION:
1. Maintain health and safety with caregiver help
2. Reach and maintain highest fxn level possible within capacity
3. Maintain best possible physical status
4. Participate therapeutic activity program
5. Participate planning for care

V.

INTERVENTION:
1. Inform all caregivers nsg plan
2. i.d client current fxnal; state and encourage use of skills
3. set up structured routines
4. allow client time alone
5. remain flexible with schedule
6. keep all interactions with client calm and reassuring
7. do not ask client participate ADLs when agitated
8. attempt understand feeing
9. respond clients feelings and validate them
10.

help client maintain self-esteem by keeping interactions at adult level

11.

simplify verbal messages and provide simple choices

CRISIS INTERVENTIONS/RAPE-TRAUMA:
I.

Types crisis:
a. External (situational)- external stressor which is apparent to another observer.
Centres on real events threaten health, shelter, loss loved one.
b. Internal (subjective) crisis- internal stressor threatens well being ex. Aging, loss
independence
c. Phase-of-life (maturational) crisisd. Disaster (adventitious crisis)- man-made and natural disasters ex. Terrorism,
tornados

II.

5 steps Crisis interventions:


a. Assess the individual and the problem:

a.i. Assess the individual and the problem- in the field and in office (physical
safety principles, medical hx, introduction and boundaries, chief complaint,
hx present illness, family/social hx, mental status, past medical & psychiatric
hx, drug & alcohol hx, cultural and spiritual issues, strengths and support,
coping skills, GAF etc
b. Plan therapeutic intervention:
b.i. Express caring and consolation
b.ii. Assess reality of situation
b.iii. Develop and begin to utilize an immediate plan for intervention
b.iv. Coordinate w/ other agencies
b.v. Anticipate future needs related to crisis
c. Intervention
d. Resolution of the crisis
e. Anticipatory planning
III.

10 stages acute traumatic stress


a.i. Assess for danger/safety
a.ii. Consider mechanism of injury
a.iii. Address medical needs
a.iv. Evaluate level of responsiveness
a.v. Observe and identify who exposed
a.vi. Ground the individual
a.vii. Normalize the response
a.viii. Prepare for the future

DOMESTIC VIOLENCE:
I.

Risk factors domestic violence:


a. Social isolation
b. Control by the abusive person
c. Alcohol and other drugs
d. Intergenerational transmission
e. Legal marriage or pregnancy
f.

II.

An attempt to leave the relationship

Interview questions: ask in private only: ask SAFE Questions


a. Have you ever been emotionally or physically hurt by your partner or someone
important to you?

b. Within the last year, have you been hit, slapped, kicked, or physically hurt by
someone? By whom? How many times?
c. Within the last year, has anyone forced you to have sexual activity? Who? How
many times?
d. Are you afraid of your partner or anyone else?

III.

Rape-trauma syndrome:
a. Acute Phase:
a.i. Occurs immediately after the assault
a.ii. May lst for a few weeks
a.iii. Lifestyle disorganized
a.iv. Somatic symptoms are common
a.v. Reaction in cognitive, affective and behavioural functions
b. Long-term reorganization phase:
b.i. Intrusive thoughts
b.ii. Increased motor activity
b.iii. Increased emotional lability
b.iv. Fears and phobias

IV.

Violence Interventions:
a. Follow your institutions protocol for sexual assault
b. Do not leave the person alone
c. Maintain a non-judgemental attitude
d. Ensure confidentiality
e. Encourage the person to talk, listen empathetically
f.

Emphasize that the person did the right thing to save his/her life

g. Keep accurate records:


g.i. Physical trauma
g.ii. Ask permission to take photos
g.iii. Take verbatim statements as to clients reaction to rape
g.iv. Document emotional status
h. Explain everything that you are going to do before hand

i.

Obtain medicolegal specimens with clients written permission

j.

Alert client as to what he/she may experience during the long-term reorganization
phase

k. Arrange for support follow-up, for ex.:


k.i. Support groups
k.ii. Group therapy
k.iii. Individual therapy
k.iv. Crisis counselling
V.

Long-term effects rape:


a. Depression
b. Suicide
c. Anxiety
d. Fear
e. Difficulties with daily functioning
f.

Low self-esteem

g. Sexual dysfunction
h. Somatic complaints

MOOD DISORDERS:
A. Leading cause of disease burden
a.i. Types:
a.i.1.

Major depression

a.i.2.

Dysrhythmic disorder- chronic low-level depression

a.i.3.
Bipolar disorder-pattern of manic, hypomania and depressed
episodes

a.i.4.

Cyclothymic disorders- chronic mood disturbance

b. Nsg process:
b.i. Assessment- mood, affect and temperament
b.i.1.

Mental status criteria


b.i.1.a.

Mood

b.i.1.b.

Affect

b.i.1.c.

Temperament

b.i.1.d.

Emotion

b.i.1.e.

Emotional reactivity

b.i.1.f.

Emotional regulation

b.i.1.g.

Range of affect

b.ii. Nsg DX:


b.ii.1.

Activity intolerance

b.ii.2.

Anxiety

b.ii.3.

Constipation etc. Box 11-5

b.iii. Interventions:
b.iii.1.

Conduct a suicide assessment

b.iii.2.

Maintain a safe environ

b.iii.3.

Establish a rapport and demonstrate respect

b.iii.4.

Assist client verbalize feelings

b.iii.5.

Identify clients social support system and encourage client

b.iii.6.

Praise the client for attempt

b.iii.7.

Promote self-care

b.iii.8.

Assist s at alternate activities and interactions with others

b.iii.9.

Gently refuse to be part of secrecy agreements with the client

b.iii.10. Monitor and implement strategies to ensure adequate fluid


intake and output, food intake and weight
b.iii.11.

Refer p.235

c. Pharmacology:
c.i. SSRIs- citalopram (celexa), fluoxetine (Prozac), paroxetine (paxil), sertraline
(Zoloft), venlafaxine (Effexor)
c.ii. Atypical antidepressants

c.iii. TCA- amitriptyline (elavil), clomipramine (anafranil), imipramine (tofranil),


desipramine (norpramin),
c.iv. MAOI- phenelzine(Nardil), Parnate
c.v. Mood stabilizers: lithium and anticonvulsants Tegretol and Depakote

SUICIDE:
I.

Assessment:
a. The observable behaviour of client e.g increased irritation, increase in energy
b. Hx from the client- gathering self-defeating coping patterns
c. Information from friends and familyd. Hx suicidal gestures or attempts
e. MSE-disturbance concentration, memory, orientation
f.

Physical exam-signs substance abuse, irritability, euphoria, slurred speech

g. Nurses intuition
II.

Interventions:
a. Provide safety and prevent violence: ex. Safe environment, remove all weapons
b. Assist with improvement of coping skills
c. Enhance family and support system

EATING DISORDERS:
Sign/Symptoms:
1. Anorexia:
a. Self-starvation
b. Rituals/compulsive behaviours
regarding food
c. Self-induced vomiting, laxatives,
diuretics, or excessive exercise
d. Weight loss 15% below ideal
e. Amenorrhea

Bulimia Nervosa:
1. Recurrent episodes binge eating
2. Purging behaviours: self-induced
vomiting, use laxatives, diuretics, diet
pills, ipecac, enemas, exercise, periods
fasting
3. Purging
4. Hypokalemia

f.
g.
h.
i.
j.
k.
l.
m.
n.

Slow pulse
Cachexia-muscle wasting
Lanugo
Constipation
Cold sensitivity
Denial seriousness
Irrational fear gaining weight
Preoccupation food
Delayed psychosexual
development

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

III.

5. Alkalosis
6. Dehydration
7. Idiopathic edema
8. Hypotension
9. Cardiac arrhythmias
10.
Cardiomyopathy
11.
Hypogycemia
12.
Constipation
13.
Esophageal reflux
14.
Mallory-weiss syndrome
15.
Dental enamel ersosion
16.
Paratid gland enlargement
17.
gastroparesis

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

Complications:
a. Electrolyte imbalance
b. Cardiac arrhythmias
c. Cardiac arrest
d. Diabetes mellitus
e. hypertension

IV.

Interventions:
a. Provide safety
b. Assess suicide
c. Engage therapeutic relationship
d. Restore min. Body weight and nutritional balance
e. Create structured, supportive environment, with limits

f.

Coordinate with dietician

g. Encourage client express thought, feelings, concerns body image


h. Cont help client recall positive eating exper.
i.

Assume caring matter of fact approach

j.

P.400 for rest

SCHIZOPHRENIA:
I.

Neurobiologic brain disorder, results impaired thoughts, perceptions, cog. Fxn, mood and
motivation

II.

Signs/symptoms and course:


a. Premorbid: contributing factors
b. Prodromal: one mth to 1yr before diagnosis:
b.i. Mood-Anxiety, irritability, dysphoria
b.ii. Cognitive- distractibility, concentration difficulties, disorganized think
b.iii. Obsessive behaviours and rituals
b.iv. Sleep disturbance
b.v. Weak positive symptoms
c. Psychotic phase:
c.i. Acute phase- pos. And neg. symptoms, unable to perform self-care
c.ii. Maintenance phase- able to care for self
c.iii. Stable phase- remission

III.

Types:
a. Paranoid
b. Disorganized
c. Catatonic
d. Residual
e. Undifferentiated

IV.

Positive symptoms:
a. Alterations perceiving: hallucinations (false perceptions), delusions (false
beliefs), loss ego boundaries
b. Alterations thinking: concrete thinking, loose associations, flight of ideas, ideas of
reference, ideas persecution, ideas grandiosity, ideas being controlled, though
broadcasting, thought insertion, thought withdrawal
c. Alterations speech: neologisms, echolalia, clang assoc, word salad,
circumstantiality, tangential (superficial speech)

d. Alterations behaviour: bizarre behaviour, agitation, waxy flexibility, stupor,


negativity, echopraxia, symbolism

V.

Negative symptoms:
a. Cognitive: Poverty of speech (alogia), Poverty of thought. Thought blocking,
Problems with attention, memory, Impaired decision making/judgement, problem
solving, Disorganized think
b. Behavioural: anhedonia, anergia, avolition, depression, hopelessness, social
isolation, decreased spontaneity, anxiety, irritability, drug abuse. Medical
comorbidity

VI.
VII.

NSG DX: bassed on assessment pos and neg symptoms


NSG interventions:
a. for the agitated:
a.i. safety
a.ii. reduce stimulation
a.iii. brief, concise statements
a.iv. det. stressors
a.v. redirect
a.vi. prevent agitation
b. for those in acute crisis: crisis intervention, stabilization, safety and limit setting
c. for those in maintenance and stable phase: give small amts infor, i.d signs of
relapse

VIII.

Psychopharmacology:
a. Typical antipsychotics, which block dopamine, phenothiazines: treat positive
symptoms
a.i. Ex. Thorazine, Mellaril, Navane, Stelazine, Haldol and Prolixin
a.ii. SE: anticholinergic- dry eyes, mouth, constipation, sedation, orthostatic
hypotension, lowered seizure thresholds, jaundice, ESP (use antiparkinson
drugs...cogentin, artane), dystonica, neuroleptic malignant syndrome, tardive
dyskineasia
b. Atypical antipsychotics- block serotonin and norepinephrine. Work on pos and neg
symptoms. Produce metabolic syndromes (so check weights)
b.i. Ex. Clozoril (monitor for agranulocytosis and WBC), seroquel (quetiapine),
Risperdal (risperidone), geodon (ziprasidone), abilify(aripiorazole)

EPS S.E:
Akathsia
Akinesia
Dystonias
Acute distonic rx
Pseudo parkinsonism
Tardive dyskinesia
Neuroleptic malignant syndrome

Neuroleptic malignant syndrome:


Fever
Muscle rigidity
Altered consciousness
Rapid breathin
Stupor-coma
Excessive salivation
Elevated CPK

SUBSTANCE ABUSE:

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

Withdrawal from alcohol:


Irritability, anxiety,
agitation
Insomnia
Diaphoresis
Tremors
Delirium
Seizures
Possible death

IX.

Withdrawal from stimulants:


Headache
Anxiety
Restlessness
Cravings
dreaming
Depression
Decreased BP
Psychomotor retardation

Withdrawal from CNS


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

Signs/symptoms:

CNS Depressants:
Decreased inhibitions
Impaired judgement,
attention, memory
Drowsiness
Slurred speech

CNS stimulants:
Euphoria
Feelings impending
doom
Agitation or
combativeness

Hallucinogens:
Panic attack/anxiety
Psychosis
Delirium
Altered moods
flashbacks

X.

Unsteady gate
Hypotension
Bradycardia
Pinpoint pupils
Weak rapid pulse
Depressed respirations
Can lead com/death

Hallucinations/paranoia
Seizures
Cardiovascular events,
palpitations,
tachycardia,
Hypertension, irregular
rhythms, can lead to
infarct

Meds for withdrawal:

Tx emergency CNS
depressant:
Life support
Narcan
(naloxone)
Lavage or
dialysis
Control seizures
with
phenobarbitol
Tx CNS depressants
withdrawal symptoms:
Opiod
substitution
Methadone
(dolophine)
Buprenorphine
(subutex)
Naltrexone
(ReVia)
Suboxone-used
for
maintenance

XI.

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

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

Classes of drugs of abuse:


a. Cannabis-weed, pt, hashish
b. CNS depressants: alcohol, sedatives, hypnotics, anxiolytics
c. CNS stimulants: amphetamines, caffeine, cocaine, ephedra, Benzedrine, nicotine
d. Hallucinogens- LSD, Peyote, PCP, mescaline
e. Inhalants- glue, hydrocarbons, nitrates
f.

Anabolic-androgenic steroids

g. OTC-antihistamines, sleeping pills, herbals, laxatives


h. Club drugs- ecstasy, ghb, rhohipnol, ketamine, methamphetamines
XII.

Interventions SA:
a. Maintain airway, monitor vitals
b. Maintain safety
c. Observe s/s overdose, withdrawal, drug-drug interactions
d. Assess physiologic/Psychologic symptoms withdrawal
e. Initiate interventions to treat withdrawal symptoms
f.

Provide emotional support

g. Support nutrition/metabolic needs


h. Refer nutritionist
i.

Increase carb intake, offer straws and edible things to chew on

j.

Initiate vit/mineral replacement etc.

PERSONALITY DISORDERS:
I.

In General PD:
a. Higher death rates
b. Higher rates suicide attempts
c. Increased rates separation, divorce and involvement legal proceedings
d. Increased rate criminal behaviour, alcoholism, and drug abuse

II.

4 common characteristics:
a. Inflexibility, maladaptive response stress
b. Disability in working and loving
c. Ability cause interpersonal conflict in others
d. Capacity to irritate others

III.

4 maladaptive patterns:
a. Faulty perceptions
b. Emotional lability
c. Poor impulse control
d. Difficult interpersonal functioning

IV.

Characteristics:
a. Repetitive maladaptive behaviour
b. Behaviour not recognized as abnormal so dont seek treatment

c. Ability achieve developmental tasks are limited


d. Seek help only in crisis
e. Starts in adolescence
f.
V.

Maladaptive behaviour used fulfill need and bring satisfaction

General interventions:
1. Asses suicide ideation
2. Implement suicide precautionsevery 15min
3. Establish contract for safety
4. Encourage attendance all group sessions
5. Assess for escalating anger or rage
6. Contract not to harm staff or others
7. Teach manage anger and impulsive feelings and behaviours
8. Discuss angry and aggressive feelings
9. Assess client for evidence self-mutilation.

s/s antisocial
personality:
1. Hx
antisocial
behaviour
2. Deceitful,
liar
3. Aggressive
towards
others
4. Lack
remorse
hurting
others
5. Presents as
charming,
self-assured
and adept
6. Interacts
others
through
manipulatio
n,
aggressiven
ess and
exploitation
7. Lack
empathy or
concern

Interventions:
1. Prevent/decrease
effects
manipulation
2. Guard against
being
manipulated
3. Set clear and
realistic limits
behaviour
4. All limits must be
adhered to by all
staff
5. Carefully
document
objective physical
signs of
manipulation/
aggression

s/s borderline
personality;
1. Relationship
with others
intense and
aunstable
2. Poor impulse
control
3. Recurrent
suidical/self
mutilation
4. Attention
seeking/manip
ulative
5. No boundaries
6. Outbursts odd
anger and
hostility
7. Intense and
primitive rage
8. Rapid
idealization
and
devaluation

Interventions:
1. Set limits
2. Provide
boundaries
and limits
that are
clear and
consistent
3. Consistent
staff: asses
for suicide
and self
mutilating
behaviour

VI.

Etiology/factors:
a. Lower socioeconomic status
b. Substance abuse
c. Genetics