Chap.

7 The Nursing Process and QSEN

Steps of nursing process; pertinent nursing diagnosis, outcomes; apply QSEN principles
Chap. 10 Understanding responses to Stress
Symptoms of stress;

Anxiety, panic attacks

Depression or melancholia
Anorexia or overeating
Lowered resistance to infection, illness
Hypertension; insulin-resistant diabetes
Amenorrhea; loss of sex drive; impotence
Increased fatigue, irritable; decreased memory, learning
Increased risk for cardiac event, blood clot, stroke
Increased respiratory problems

Stress reduction and coping;

Elicit the relaxation response (meditation, prayer, mindfulness)

Perform physical activity, which deepens breathing, relieves muscle tension, and can elevate
levels of the bodys own endorphins, which induces a sense of well-being (yoga, tai chi,
running, walking briskly)
Seek social support (close family ties, acquaintances, spouse, and friends).
Spiritual/cultural support
For more on selected stress reduction techniques, refer to Box 10-1 in the textbook.

Importance of support systems;

Studies have shown that social interactions provide great buffers for stress and help people cope
better with stress
Mind-body connection;
Patient education
Chap. 11 Anxiety & Anxiety Disorders
Communication;
Coping skills;
Nursing interventions;
GAD,

Is a chronic disorder.
Is characterized by excessive anxiety or worry.
Lasts 6 months or longer.
Different from other anxiety disorders:
o Cognitive dysfunction
o Poor health-related outcomes
o No fear of external object or situation
Self-medication may lead to substance disorders.
Symptoms include restlessness, fatigue, poor concentration, irritability, and sleep
disturbances.
Free-floating anxiety anxious about everything. Worry is out of proportion to the true
effect of the situation of focus. Persons with GAD often are unable to fulfill job
responsibilities, care for family members, maintain household chores, keep appointments,
maintain adequate interpersonal relationships. These constant worries leave the limbic
system in a perpetual state of alertness. Impaired decision making, dread of making a
mistake, poor concentration, somatic symptoms (sweating, nausea, vomiting)

OCD;

Obsessions:
o Unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause
significant anxiety or distress
Compulsions:
o Unwanted, repetitive behavior patterns or mental acts intended to reduce anxiety but
not to provide pleasure or gratification.
Obsessive-Compulsive behavior includes both obsessions and compulsions. A person
can have one or the other. The disorder seems to occur most frequently in persons with
other neurological disorders. It is normal to experience mild obsessive-compulsive
behavior (locked doors, turn off iron, knocking on wood, stepping on cracks, etc.). At the
severe end, the thoughts and behaviors typically center on dirtiness, contamination and
germs. The person with OCD does have a decrease in anxiety following the anxiety,
however this is temporary.
Most severe symptoms include persistent thoughts of sexuality, violence, illness, and
death.
OCD patients are responsive to SSRIs whereas most other antidepressants are ineffective.
Clomipramine (TCA) has also proved to be especially effective.
Panic disorder;
Panic attack:

Feelings of terror
Suspension of normal function
Misinterpretation of reality
Can occur suddenly
Increased rates of suicide and suicide attempts
Symptoms include:
Palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation,
breathing difficulties, nausea, feelings of choking, chills, hot flashes, and gastrointestinal
symptoms
It is not uncommon for someone rushed to the emergency department with signs and symptoms
of a heart attack (chest pain, difficulty breathing, and dizziness, excessive fatigue) to have an
extensive medical workup that proves negative for cardiac problems.
The patient needs a referral for the potential diagnosis and treatment of an anxiety disorder.
At times people with panic disorder may have agoraphobia
Agoraphobia-Is an intense and excessive level of anxiety and a fear of being in places
and situations from which escape is impossible.
Feared places are avoided to control anxiety.
Avoidance behaviors can be debilitating and life constricting.

PTSD;
4 stages of anxiety,

a. Mild anxiety
i. A person sees, hears, and grasps more information, and problem solving
becomes more effective.
ii. May display physical symptoms such as slight discomfort, restlessness,
irritability, or mild tension-relieving behaviors (nail biting, foot or finger
tapping, fidgeting)
b. Moderate anxiety
i. The individual sees, hears, and grasps less information than someone who
is not in that state.
ii. May display selective inattention- only certain things in the environment
are seen or heard. Ability to think clearly is hampered, but learning and
problem solving can still take place, although not at an optimal level.
iii. Physical symptoms1. voice tremors
2. change in voice pitch
3. difficulty concentrating
4. shakiness
5. repetitive questioning
6. Somatic complaints gastric discomfort, urinary frequency and
urgency, headache, backache, insomnia.
7. Increased respiration rate
8. Increased pulse rate
9. Increased muscle tension
10. More extreme tension-reliving behavior; pacing, banging hands on
table.
c. Severe anxiety
i. The person will have difficulty noticing events occurring in the
environment, even when they are pointed out by another.

ii. Learning and problem solving are not possible at this level, and the person
may be dazed and confused. Behavior is automatic and aimed at reducing
anxiety.
iii. Physical symptoms
1. Feelings of dread
2. Ineffective functioning
3. Confusion
4. Purposeless activity
5. Sense of impending doom
6. Somatic complaints- dizziness, nausea, headache, insomnia
7. Hyperventilation
8. Tachycardia
9. Withdrawal
10. Loud and rapid speech
11. Threats and demands
d. Panic level anxiety
i. Individual is not able to process events in the environment and may lose
touch with reality. The resulting behavior may be confusion, shouting,
screaming, or withdrawal.
ii. Hallucinations, or false sensory perceptions such as seeing people or
objects that are not present, may be experienced by people at panic levels
of anxiety.
iii. Physical symptoms1. Experience of terror
2. Immobility or severe hyperactivity or flight
3. Dilated pupils
4. Unintelligible communication or inability to speak
5. Severe shakiness
6. Insomnia
7. Severe withdrawal
Symptoms & nursing interventions;
Suicide ideation;
Serotonin syndrome
Medications (side effects) anxiolytics, antidepressants, non-benzodiazepines
Defense mechanisms
Chap. 15 Depressive Disorders
Signs & symptoms; communication techniques; nursing diagnosis & interventions; ECT (pre- & postprocedure; safety
Medications (classifications, side effects, food restrictions); TCA, SSRI, SNRI, MAOI
Chap. 16 Bipolar Disorders
General assessment; communication; nursing interventions; medications (classifications and side effects
and toxicity); diagnostic tests/labs; effect of environmental stimuli; safety measures; nursing response to
aggressive behaviors; limit setting
Chap. 26 Children and Adolescents
1. Risk for development of mental illness;

2. description of disorders (s/sx);

o Intellectual developmental disorder (IDD)
Is traditionally known as mental retardation.
Can be caused by genetic , perinatal, trauma, or poisoning
Can be mild, moderate, severe, or profound.
Intelligence quotients not used to define level of impairment.
Intellectual Disability problem solving; abstract thinking. Deficits such as
reasoning, problem solving, planning, abstract thinking, judgment, academic
learning, and learning from experience
Deficits in general abilities
communication; social interaction
Adaption; self-care
Disruptive behaviors
Daily activities such as communication, functioning at school or at work,
personal independence, and impairment in adaptive functioning
o Autism Spectrum Disorder (ASDs)
Median age of the earliest diagnosis for autistic spectrum disorder (ASD) is
between 4.5 and 5.5 years of age.
Diagnosis -Demonstrates two or more of the following:
Social skills: resists physical contact; plays alone; failure to bond
Repetitive speech, motor movements, repetitive use of objects
Excessive adherence to routines, rituals; resistance to change
Fixated interests that are abnormal in intensity
Impaired social skills and communication
Important Assessment
Developmental spurts and lags, uneven development, or loss of
previously acquired abilities
Quality of relationship between the child and parent:
o Lack of bonding, anxiety, tension, and difficulty-of-fit between
parent, child, and caregiver temperaments
Co-occurring conditions
Childs strengths
Be aware that children with behavioral and developmental problems are
at risk for abuse.
Nursing diagnosis and intervention
Fear
Defensive and ineffective coping
Delayed growth and development; self-care deficits
Impaired verbal communications and social interaction
Implementation:
No medications are available to treat ASD.
Risperidone is used for the symptoms of aggression, deliberate selfinjury, and/or temper tantrums.
Propranolol is preferred; it has lower side effects.
Selective serotonin reuptake inhibitors (SSRIs) may be used with caution
in ASD.
Diagnosis: At risk for:
Impaired parent and child attachments

Injury
Self-mutilation
Other-directed violence
Children with Disabilities Act:
Includes therapeutic nursery schools, day treatment programs, and
special education classes in public schools.
Includes working with parents.
Long term outcomes
Attain an increased interest in reciprocal interactions.
Provide for the development of psychomotor skills.
Facilitate:
o Appropriate expression of emotions
o Development of cognitive skills
Foster the development of:
o Social skills
o Self-concepts (e.g., identity, self-awareness, body image, selfesteem)
o Self-control, including impulse control
Pharmacologic Interventions: ADHD
Affects 3% to 10% of children and adolescents.
20% of children who have been diagnosed with ADHD .
No known cause exists.
Cause of ADHD
Predisposing factors include the following:
Family history; parenting issues, harsh discipline, and out-of home
placements; ; large family; absence of or presence of an alcoholic father
Prenatal or perinatal influences , low birth weight, postnatal influences
(central nervous system [CNS] trauma, infections)
Brain scans reveal underdeveloped and inactive frontal lobes.
Psychostimulantsa sluggish frontal lobe
Methylphenidate (Ritalin) po; transdermal patch (Daytrana).
Concerta is an extended-release Ritalin
Adderall is a combination of dextroamphetamine and amphetamine that also
calms; it comes in an extended-release form.
Side effects of psychostimulants related to sleep and appetite.
70-90% respond
Alternatives and adjuncts include:
Clonidine hydrochloride (HCl)
Quanfacine HCl: Treats aggression and insomnia.
Tetracyclic antidepressants (TCAs) or bupropion HCl
Assessment:
Difficult to diagnose before the age of 4 years.
Exhibits excessive gross motor activity that becomes less pronounced as
the child matures.
Identified when child tries to adjust to elementary school; control of
behavior is expected.
Increased incidence of depression
Symptoms for Attention Deficit Hyperactivity Disorder
Inattention

 Hyperactivity
Impulsivity
ADHD Nursing Process
Outcomes and Interventions
Risk for other-directed violence
Risk for caregiver role strain (discuss in class)
Risk for injury
Impaired social interaction
Ineffective coping
Chronic low self-esteem
Disturbed thought processes
Many others
Explore the effects of behaviors on family life.
Working with parents in developing consistent methods of response to
child.
Behavior modification and pharmacologic agents
Plan activities that are geared to clients abilities for success.
Provide recognition and feedback when a child succeeds.
Identify learning needs; provide educational information about
medications.
Refer the parent or caregiver to the appropriate educational or support
groups.
application of nursing process (assessment-evaluation); age appropriate interventions & therapies; safety;
dealing with disruptive behavior.
Chap. 28 Older Adults
Depression, substance abuse, delirium( table 28-1 pg. 531) ;
Assessment

Delirium

Dementia

Depression

Onset

Abrupt

Gradual

Either

Course

Worse in PM

Progressive

Worse in AM

Prognosis

Reversible

Irreversible

Variable

Cause or contributing
factors

Hypoglycemia, fever,
dehydration, hypotension,
infection, other conditions
that disrupt bodys
homeostatic; adverse drug
reaction; head injury;
change in environment
(hospitalization); pain;
emotional stress.

Alzheimers disease,
vascular disease, HIV
infection, neurological
disease, chronic
alcoholism, head trauma.

Life-long history, losses,

loneliness, crises,
declining health, medical
conditions

Cognition

Impaired memory,
judgment, calculation,
attention span; can
fluctuate throughout the
day

Impaired memory,
judgment, calculations,
attention span, abstract
thinking; agnosia

Difficulty concentrating,
forgetfulness, inattention

Memory

Impaired recent &

immediate

Impaired recent & remote

Selective impairment

Activity Level

Increased or decreased;
restlessness, behaviors
may worsen in evening
(sundowning); sleep-wake
cycle may be reversed.

Not altered; behaviors

may worsen in evening
(sundowning)

Usually decreased;
lethargy fatigue, lack of
motivation; may sleep
poorly and awaken in
early morning.

Emotional Status

Rapid swings; fearful,

anxious, suspicious

Flat; delusions

Extreme sadness, apathy,

irritability, anxiety,
paranoid ideation.
Physical symptoms

use of restraints;
poly-pharmacy (527-528);
safety;
application of nursing process (540-542)