NURS 116 Unit IV - Substance-Related and Addictive Disorders PDF

NURS 116 UNIT IV INSTRUCTOR: MRS. HOOF, DR. ROBERSON CH.14 - SUBSTANCE-RELATED AND ADDICTIVE DISORDERS SUBSTANCE USE DISORDERS FOUR GROUPINGS OF SYMPTOMS ○ IMPAIRED CONTROL ○ SOCIAL IMPAIRMENT ○ RISKY USE ○ PHYSICAL EFFECTS DSM CATE...

NURS 116 UNIT IV INSTRUCTOR: MRS. HOOF, DR. ROBERSON CH.14 - SUBSTANCE-RELATED AND ADDICTIVE DISORDERS SUBSTANCE USE DISORDERS FOUR GROUPINGS OF SYMPTOMS ○ IMPAIRED CONTROL ○ SOCIAL IMPAIRMENT ○ RISKY USE ○ PHYSICAL EFFECTS DSM CATEGORIES ○ ALCOHOL ○ CAFFEINE ○ CANNABIS ○ HALLUCINOGENS ○ INHALANTS ○ OPIOIDS ○ SEDATIVES ○ HYPNOTICS ○ ANTI-ANXIETY ○ STIMULANTS ○ TOBACCO CONCEPTS OF SUBSTANCE USE DISORDERS  ADDICTION ○ CHRONIC MEDICAL CONDITION WITH ROOTS IN THE ENVIRONMENT, NEUROTRANSMISSION, GENETICS AND LIFE EXPERIENCES ○ AFFECT THE REWARD PATHWAY OF THE BRAIN INTOXICATION ○ USING A SUBSTANCE TO EXCESS ○ UNDER THE INFLUENCE, INTOXICATED, HIGH, DRUNK OR STONED TOLERANCE ○ A PERSON NO LONGER RESPONDS TO A SUBSTANCE IN THE WAY THEY INITIALLY RESPONDED WITHDRAWAL ○ PHYSIOLOGICAL SYMPTOMS THAT OCCUR WHEN USE OF A SUBSTANCE IS WITHHELD ○ SUBSTANCE SPECIFIC WITHDRAWAL CAN BE MILD OR LIFE-THREATENING EPIDEMIOLOGY NEARLY 100,306 INDIVIDUALS IN THE U.S DIED FROM A DRUG-INVOLVED OVERDOSE FROM 4/2020 TO 4/2021 (CDC, 2021). SCHEDULED DRUGS ○ I-HEROIN, LSD, MARIJUANA ○ II-OPIUM, MORPHINE, OXYCODONE, FENTANYL AND METHAMPHETAMINE (ADD AND ADHD MEDICATIONS) ○ III-TESTOSTERONE, SUBOXONE, TYLENOL WITH CODEINE KETAMINE ○ IV-XANAX, ATIVAN ○ V-LOMOTIL, ROBITUSSIN WITH CODEINE, LYRICA COMORBIDITY MAJOR DEPRESSIVE DISORDER BIPOLAR DISORDER ANXIETY DISORDERS ANTISOCIAL PERSONALITY DISORDER CONDUCT DISORDER RISK FACTORS GENETIC ○ ESTIMATES RANGE FROM 30% TO 40% FOR HALLUCINOGENS AND STIMULANTS AND 70% TO 80% FOR COCAINE AND OPIOIDS NEUROTRANSMITTERS-DOPAMINE, GABA, OPIOID ○ TOO LITTLE OPIOID ACTIVITY OR TOO MUCH OPIOID ANTAGONISM MAY SELF-MEDICATE ENVIRONMENTAL FACTORS ○ CHRONIC STRESSORS ○ POVERTY ○ LACK OF PARENTAL SUPERVISION ○ POOR EDUCATIONAL RESOURCES ○ IMPAIRED SUPPORT SYSTEM COPING MECHANISMS MAY INCLUDE DRUGS AND ACTING OUT BEHAVIORS CAFFEINE USE DISORDER MOST WIDELY USED PSYCHOACTIVE SUBSTANCE IN THE WORLD CAFFEINE INTOXICATION SYMPTOMS: ○ RESTLESSNESS ○ NERVOUSNESS ○ EXCITEMENT ○ AGITATION ○ RAMBLING SPEECH ○ INEXHAUSTIBILITY PHYSICAL CAFFEINE INTOXICATION SX ○ FLUSHED FACE ○ DIURESIS ○ GI DISTURBANCE ○ MUSCLE TWITCHING ○ TACHYCARDIA ○ CARDIAC ARRHYTHMIAS WITHDRAWAL SX: ○ HEADACHE, DROWSINESS, N/V/D, MUSCLE ACHES ○ OCCUR WITHIN 12-24 HOURS AFTER LAST DOSE CANNABIS USE DISORDER THIRD MOST COMMONLY USED PSYCHOACTIVE DRUG IN THE US INTOXICATION-HEIGHTENS SENSATIONS, MOTOR SKILLS IMPAIRED FOR 8-12 HR WITHDRAWAL-SYMPTOMS WITHIN A WEEK OF CESSATION: ○ IRRITABILITY ○ ANGER ○ AGGRESSION ○ ANXIETY ○ RESTLESSNESS  ○ DEPRESSED MOOD ○ INSOMNIA PHYSICAL SYMPTOMS ○ ABDOMINAL PAIN, SHAKINESS, SWEATING, FEVER, CHILLS OR HEADACHE TREATMENT ○ ABSTINENCE, FAMILY AND GROUP THERAPIES, ANTI-ANXIETIES HALLUCINOGEN USE DISORDER HALLUCINOGENS: SCHEDULE 1 CONTROLLED SUBSTANCES ○ NO MEDICAL USE AND CARRY HIGH ABUSE POTENTIAL INTOXICATION ○ PARANOIA, IMPAIRED JUDGMENT, HALLUCINATIONS SYNESTHESIA (E.G., HEARING COLORS OR SEEING SOUNDS) PCP INTOXICATION ○ MEDICAL EMERGENCY PCP INTOXICATION S/SX ○ HTN, TACHYCARDIA, DIMINISHED PAIN RESPONSE. MUSCLE RIGIDITY, SEIZURES, COMA, HYPERACUSIS, HYPERTHERMIA WITHDRAWAL ○ MAY LAST WEEKS, MONTHS, YEARS AND ARE OFTEN REEXPERIENCING PERCEPTUAL SYMPTOMS TREATMENT ○ BENZODIAZEPINES INHALANT USE DISORDER SOLVENTS, ADHESIVES, AEROSOLS, THINNERS, FUELS “SUDDEN SNIFFING DEATH”-CARDIAC ARRHYTHMIAS WITH INHALANT SUCH AS BUTANE AND PROPANE  INTOXICATION-(SMALL DOSES)-EUPHORIA AND DISINHIBITION; (LARGE DOSES)-FEARFULNESS, ILLUSIONS, HALLUCINATIONS, DISTORTED BODY IMAGE, APATHY, IMPAIRED JUDGMENT, IMPULSIVITY, AGGRESSION, NAUSEA, ANOREXIA, SLOWED REFLEXES, NYSTAGMUS, DELIRIUM, PSYCHOSIS, DEMENTIA TREATMENT-HALDOL FOR AGITATION OPIOID USE DISORDER INTOXICATION-PSYCHOMOTOR RETARDATION, SLURRED SPEECH, DROWSINESS, ALTERED MOOD, IMPAIRED MEMORY AND ATTENTION, PUPILLARY CONSTRICTION, COMA WITHDRAWAL-MOOD DYSPHORIA, N/V/D, MUSCLE ACHES, FEVER, INSOMNIA, WATERY EYES, RUNNY NOSE, YAWNING, PUPILLARY DILATION, GOOSEBUMPS ○ MORPHINE, HEROIN, AND METHADONE WITHDRAWAL-6 TO 8 HR AFTER LAST USE AND LASTS AROUND A WEEK ○ DEMEROL WITHDRAWAL-8 TO 12 HR AFTER LAST USE AND LASTS 5 DAYS OVERDOSE-USUALLY FROM RESPIRATORY DEPRESSION OVERDOSE TREATMENT-NARCAN AND MECHANICAL VENTILATION TREATMENT-METHADONE, SUBOXONE, BUPRENORPHINE SEDATIVE, HYPNOTIC, AND ANTIANXIETY MEDICATION USE DISORDER BENZOS, BARBITURATES, AMBIEN, LUNESTA, METHAQUALONE INTOXICATION-SLURRED SPEECH, INCOORDINATION, UNSTEADY GAIT, IMPAIRED THINKING, NYSTAGMUS, COMA, AGGRESSION, SEXUAL BEHAVIOR, MOOD CHANGES, IMPAIRED JUDGMENT WITHDRAWAL-REBOUND HYPERACTIVITY, INSOMNIA, AGITATION, ANXIETY, GRAND MAL SEIZURES WITHDRAWAL TREATMENT-WEANING!!  OVERDOSE TREATMENT-GASTRIC LAVAGE, IV LINE, POSSIBLE ET TUBE STIMULANT USE DISORDER AMPHETAMINES, COCAINE INTOXICATION-CHEST PAIN, ARRHYTHMIAS, BLOOD PRESSURE CHANGES, HEART RATE CHANGES, DILATED PUPILS, N/V, WT LOSS, CHILLS, PSYCHOMOTOR CHANGES, WEAKNESS, CONFUSION, SEIZURES, COMA WITHDRAWAL-BEGIN FEW HOURS TO SEVERAL DAYS; TIREDNESS, NIGHTMARES, INCREASED APPETITE, SLEEP DISTURBANCES, PSYCHOMOTOR CHANGES, DEPRESSION, SUICIDAL THOUGHTS TREATMENT FOR AMPHETAMINES-INPATIENT LIKELY; VALIUM, ANTIDEPRESSANTS TOBACCO USE DISORDER WITHDRAWAL-IRRITABILITY, ANXIETY, DEPRESSION, RESTLESSNESS, DIFFICULTY CONCENTRATING, INSOMNIA, DECREASED HEART RATE TREATMENT-BEHAVIORAL THERAPY, HYPNOSIS, REPLACEMENT THERAPY, BUPROPION, CHANTIX GAMBLING DISORDER MORE COMMON IN MALES GAMBLERS ANONYMOUS ALCOHOL USE DISORDER-DSM 5 CRITERIA AT LEAST TWO OF THE FOLLOWING WITHIN 12 MONTHS ○ ALCOHOL IN LARGER AMOUNTS OVER A LONGER PERIOD THAN INTENDED ○ PERSISTENT DESIRE OR UNSUCCESSFUL EFFORTS TO STOP USE  ○ GREAT DEAL OF TIME SPENT IN ACTIVITIES TO OBTAIN OR USE ALCOHOL AND RECOVER FROM THE EFFECTS ○ CRAVING ALCOHOL ○ RECURRENT USE RESULTING IN FAILURE TO FULFILL ROLES ○ CONTINUED USE DESPITE PROBLEMS CAUSED ○ ACTIVITIES ARE GIVEN UP DUE TO USE ○ RECURRENT ALCOHOL USE WHEN IT IS PHYSICALLY HAZARDOUS ○ CONTINUED USE DESPITE THE PSYCHOLOGICAL OR PHYSICAL PROBLEMS CAUSED ○ TOLERANCE ○ WITHDRAWAL ALCOHOL INTOXICATION - NOT TESTABLE MATERIAL ​20 MG/DL-2 DRINKS; ALTERED MOOD, SLOW MOTOR PERFORMANCE, ALTERED MOOD, REDUCED ABILITY TO MULTITASK 50 MG/DL-3 DRINKS; IMPAIRED JUDGMENT, EUPHORIA, EXAGGERATED BEHAVIOR, AND LOWER ALERTNESS 80 MG/DL-4 DRINKS; ALTERED SPEECH AND HEARING, POOR COORDINATION, IMPAIRED JUDGMENT, POOR SELF-CONTROL, DECREASED REASONING 100 MG/DL-5 DRINKS;SLURRED SPEECH, SLOWED THINKING, POOR COORDINATION 150 MG/DL-6 DRINKS; VOMITING AND LOSS OF BALANCE 200 MG/DL-8-10 DRINKS; NAUSEA, VOMITING, BLACKOUTS 300 MG/DL-10+ DRINKS; REDUCTION OF BODY TEMPERATURE, BLOOD PRESSURE, RESPIRATORY RATE, SLEEPINESS, AMNESIA 400 MG/DL-IMPAIRED VITAL SIGNS AND DEATH ALCOHOL WITHDRAWAL TREMORS OCCUR FIRST, 6-8 HOURS AFTER USE  AGITATION, LACK OF APPETITE, N/V, INSOMNIA, IMPAIRED COGNITION, INCREASE PULSE AND BP, INCREASED BODY TEMP-GIVE LIBRIUIM PSYCHOSIS CAN BEGIN IN 8-10 HOURS-GIVE ATIVAN AND LIBRIUM SEIZURE RISK!!-12 TO 24 HOURS AFTER CESSATION-GIVE VALIUM DELIRIUM TREMENS-GIVE VALIUM, LIBRIUM, ATIVAN IN FIRST 72 HOURS OF WITHDRAWAL TACHYCARDIA, FEVER, DIAPHORESIS, FEVER, ANXIETY, HTN, INSOMNIA, DELUSIONS, HALLUCINATIONS WERNICKE-KORSAKOFF SYNDROME WERNICKE’S ENCEPHALOPATHY ○ ALTERED GAIT, CONFUSION, VESTIBULAR DYSFUNCTION, NYSTAGMUS, GAZE PALSY, UNEQUAL PUPILS TREAT WITH THIAMINE SYSTEMIC EFFECTS OF ALCOHOL USE PERIPHERAL NEUROPATHY REDUCTION IN MUSCLE MASS CARDIOMYOPATHY ESOPHAGITIS GASTRITIS PANCREATITIS HEPATITIS CIRRHOSIS LEUKOPENIA LOW PLATELET COUNT CANCER SCREENING SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT (SBIRT) ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT) CAGE T-ACE PSYCHOSOCIAL INTERVENTIONS PROMOTE SAFETY AND SLEEP SUPPORT AND ENCOURAGEMENT FOR SELF-CARE THERAPEUTIC RELATIONSHIP GOAL SETTING PHARMACOLOGICAL INTERVENTIONS DISULFIRAM (ANTABUSE)-AVOID ALL ALCOHOL INCLUDING MOUTHWASH, COUGH DROPS ETC. NALTREXONE (VIVITROL, REVIA)-HELPS WITH CRAVINGS FOR ALCOHOL AND OPIATES ACAMPROSATE CALCIUM (CAMPRAL) BENZODIAZEPINES DURING WITHDRAWAL PHASE PSYCHOTHERAPY COGNITIVE BEHAVIORAL THERAPY MOTIVATIONAL INTERVIEWING STAGES OF CHANGE THEORY PERSON-CENTERED APPROACH TO STRENGTHEN MOTIVATION FOR CHANGE STAGES-PRECONTEMPLATION, CONTEMPLATION, PREPARATION, MAINTENANCE CARE CONTINUUM ALCOHOLICS ANONYMOUS ○ 12 STEP PROGRAM ○ FREE ○ DAILY MEETINGS ○ PEER SUPPORT ○ “ONE DAY AT A TIME” CH.13 - NEUROCOGNITIVE DISORDERS INTRODUCTION NEUROCOGNITIVE DISORDERS ARE THOSE IN WHICH A CLINICALLY SIGNIFICANT DEFICIT IN COGNITION OR MEMORY EXISTS, REPRESENTING A SIGNIFICANT CHANGE FROM A PREVIOUS LEVEL OF FUNCTIONING. THE OBJECTIVE OF CARE FOR THOSE WITH NEUROCOGNITIVE DISORDERS IS TO PROVIDE THESE INDIVIDUALS WITH THE DIGNITY AND QUALITY OF LIFE THEY DESERVE, WHILE OFFERING GUIDANCE AND SUPPORT TO THEIR FAMILIES OR PRIMARY CAREGIVERS. ○ SAFETY IS NUMBER 1!!! ○ MILD DOES NOT ALWAYS PROGRESS TO MAJOR IN THE DSM-5-TR, THEY INCLUDE DELIRIUM AND MILD AND MAJOR NEUROCOGNITIVE DISORDERS (APA, 2013). DELIRIUM CHARACTERIZED BY A DISTURBANCE IN THE LEVEL OF AWARENESS AND A CHANGE IN COGNITION  DISORIENTATION TO TIME AND PLACE, BUT RARELY TO SELF DEVELOPS RAPIDLY OVER A SHORT PERIOD ○ ACUTE VS NEUROCOGNITIVE WHICH IS PROGRESSIVE ○ INABILITY TO DIRECT, FOCUS, SHIFT, AND SUSTAIN ATTENTION ○ DISORGANIZED THINKING ○ SAFETY IS NUMBER 1 CONCERN, FIND THE CAUSE AND TREAT IT! ○ CAN BE REVERSIBLE UNLESS UNDERLYING CAUSE IS NOT FIXED/TREATED ○ AFFECTS SHORT TERM MEMORY, CAN HAVE HALLUCINATIONS/DELUSIONS DELIRIUM: SYMPTOMS DIFFICULTY SUSTAINING AND SHIFTING ATTENTION EXTREME DISTRACTIBILITY DISORGANIZED THINKING SPEECH THAT IS RAMBLING, IRRELEVANT, PRESSURED, AND INCOHERENT IMPAIRED REASONING ABILITY AND GOAL-DIRECTED BEHAVIOR DISORIENTATION TO TIME AND PLACE - NOT TO SELF IMPAIRMENT OF RECENT MEMORY MISPERCEPTIONS ABOUT THE ENVIRONMENT, INCLUDING ILLUSIONS AND HALLUCINATIONS DISTURBANCE IN THE LEVEL OF CONSCIOUSNESS, WITH INTERRUPTION OF THE SLEEP-WAKE CYCLE - SITTERS, CLOSE TO NURSES STATION, LOW BEDS, CALENDAR, CLOCK, MORE FREQUENT THAN Q2H, FAMILIAR ITEMS IN ROOM PSYCHOMOTOR ACTIVITY THAT FLUCTUATES BETWEEN AGITATION AND RESTLESSNESS AND A VEGETATIVE STATE EMOTIONAL INSTABILITY AUTONOMIC MANIFESTATIONS ○ TACHYCARDIA ○ SWEATING  ○ FLUSHED FACE ○ DILATED PUPILS ○ ELEVATED BLOOD PRESSURE USUALLY BEGIN ABRUPTLY - FIND OUT UNDERLYING CAUSE - SAFETY CAN HAVE A SLOWER ONSET IF UNDERLYING ETIOLOGY IS SYSTEMIC ILLNESS OR METABOLIC IMBALANCE DURATION IS USUALLY BRIEF AND SUBSIDES UPON ELIMINATION OF UNDERLYING CAUSES ○ SYMPTOMS USUALLY DIMINISH OVER A 3 - 7 DAY PERIOD PREDISPOSING FACTORS DELIRIUM DUE TO A GENERAL MEDICAL CONDITION ○ INFECTIONS, FEBRILE ILLNESS, METABOLIC DISORDERS, HEAD TRAUMA, SEIZURES, MIGRAINE HEADACHES, BRAIN ABSCESS, STROKE, ELECTROLYTE IMBALANCE, AND OTHERS ○ INDIVIDUALS OVER THE AGE OF 65 AT HIGH RISK SUBSTANCE-INDUCED DELIRIUM ○ MAY BE CAUSED BY INTOXICATION OR WITHDRAWAL FROM CERTAIN SUBSTANCES, SUCH AS: ANTICHOLINERGICS, ANTIHYPERTENSIVES, CORTICOSTEROIDS, ANTICONVULSANTS, ANALGESICS, AND OTHERS ALCOHOL, AMPHETAMINES, CANNABIS, COCAINE, HALLUCINOGENS, INHALANTS, AND OTHERS TOXINS, INCLUDING ORGANIC SOLVENTS AND FUELS, LEAD, MERCURY, ARSENIC, CARBON MONOXIDE, AND OTHERS DELIRIUM ASSESSMENT  ○ DIFFICULTY WITH ORIENTATION ILLUSIONS AND HALLUCINATIONS INTERVENTIONS ○ SAFETY IS THE PRIORITY CONCERN ○ FIND THE CAUSE, TREAT TO RESOLVE ○ FREQUENT REORIENTATION - SIMPLE, SHORT DIRECTIONS ○ AVOID SEDATIVE MEDICATIONS ○ MINDFUL OF SENSORY ADAPTATIONS GLASSES, HEARING AIDS, WORD BOARDS/DATES MAJOR AND MILD NEUROCOGNITIVE DISORDERS - DEMENTIA BROAD TERM USED TO DESCRIBE PROGRESSIVE DETERIORATION OF COGNITIVE FUNCTIONING AND GLOBAL IMPAIRMENT OF INTELLECT (DEMENTIA) NO CHANGE IN CONSCIOUSNESS VS DELERIUM YOU DO DIFFICULTY WITH MEMORY, PROBLEM-SOLVING, AND COMPLEX ATTENTION MILD: DOES NOT INTERFERE WITH ADLS; DOES NOT NECESSARILY PROGRESS TO MAJOR MAJOR: INTERFERES WITH DAILY FUNCTIONING AND INDEPENDENCE DEMENTIA IS A COLLECTION OF SYMPTOMS NEUROCOGNITIVE DISORDER SYMPTOMS IMPAIRMENT EXISTS IN ABSTRACT THINKING, JUDGMENT, AND IMPULSE CONTROL. CONVENTIONAL RULES OF SOCIAL CONDUCT ARE DISREGARDED (INAPPROPRIATE BEHAVIOR) - PROBLEMS WITH IMPULSE CONTROL PERSONAL APPEARANCE AND HYGIENE ARE NEGLECTED. LANGUAGE MAY OR MAY NOT BE AFFECTED.  ○ APHASIA: IN SEVERE CASES OF NEUROCOGNITIVE DISORDER, AN INDIVIDUAL MAY NOT SPEAK AT ALL. PERSONALITY CHANGE IS COMMON. LANGUAGE MAY OR MAY NOT BE AFFECTED. ○ APHASIA: IN SEVERE CASES OF NEUROCOGNITIVE DISORDER, AN INDIVIDUAL MAY NOT SPEAK AT ALL. ○ APRAXIA: LOSS OF PURPOSEFUL MOVEMENT ○ AGNOSIA: LOSS OF SENSORY ABILITY TO RECOGNIZE OBJECTS PERSONALITY CHANGE IS COMMON. SAFETY APRAXIA - NEED STEP BY STEP INSTRUCTIONS TO PERFORM SIMPLE TASKS AGNOSIA - MAY NOT RECOGNIZE THEIR SPOUSE OR CHILDREN OR THEMSELVES REVERSIBLE NEUROCOGNITIVE DISORDER REVERSIBLE NEUROCOGNITIVE DISORDER (NCD) MAY BE MORE APPROPRIATELY TERMED TEMPORARY NCD. IT CAN OCCUR AS A RESULT OF: ○ SUBDURAL HEMATOMAS ○ BRAIN TUMORS ○ DEPRESSION ○ SIDE EFFECTS OF MEDICATIONS ○ NUTRITIONAL DEFICIENCIES ○ METABOLIC DISORDERS NEUROCOGNITIVE DISORDER PROGRESSION AS THE DISEASE PROGRESSES, SYMPTOMS MAY INCLUDE: ○ APHASIA  ○ APRAXIA ○ IRRITABILITY AND MOODINESS, WITH SUDDEN OUTBURSTS OVER TRIVIAL ISSUES ○ INABILITY TO CARE FOR PERSONAL NEEDS INDEPENDENTLY ○ WANDERING AWAY FROM THE HOME ○ INCONTINENCE ALZHEIMER’S DISEASE ALZHEIMER’S DISEASE (AD) ACCOUNTS FOR 60% TO 80% OF ALL CASES OF NEUROCOGNITIVE DISORDER AND IS THE MOST COMMON CAUSE OF DEMENTIA IN OLDER ADULTS. STAGES OF AD - KNOW THE PHASES! ○ STAGE 1: NO APPARENT SYMPTOMS ○ STAGE 2: VERY MILD CHANGE ○ STAGE 3: MILD COGNITIVE DECLINE ○ STAGE 4: MODERATE COGNITIVE DECLINE ○ STAGE 5: MODERATELY SEVERE COGNITIVE DECLINE ○ STAGE 6: SEVERE COGNITIVE DECLINE ○ STAGE 7: VERY SEVERE DECLINE STAGE 1. NO APPARENT SYMPTOMS. IN THE FIRST STAGE OF THE ILLNESS, THERE IS NO APPARENT DECLINE IN MEMORY DESPITE CHANGES THAT ARE BEGINNING TO OCCUR IN THE BRAIN. STAGE 2. VERY MILD CHANGE. THE INDIVIDUAL BEGINS TO LOSE THINGS OR NEED TO REMEMBER THE NAMES OF PEOPLE. LOSSES IN SHORT-TERM MEMORY ARE COMMON. THE INDIVIDUAL IS AWARE OF THE INTELLECTUAL DECLINE AND MAY FEEL ASHAMED, BECOMING ANXIOUS AND DEPRESSED, WHICH MAY WORSEN THE SYMPTOMS. MAINTAINING AN ORGANIZATION WITH LISTS AND A STRUCTURED ROUTINE PROVIDES SOME COMPENSATION. THESE SYMPTOMS OFTEN ARE NOT NOTICED BY OTHERS AND DO NOT INTERFERE WITH THE INDIVIDUAL’S ABILITY TO WORK OR LIVE INDEPENDENTLY. STAGE 3. MILD COGNITIVE DECLINE. IN THIS STAGE, THERE IS INTERFERENCE WITH WORK PERFORMANCE, WHICH BECOMES NOTICEABLE TO COWORKERS. THE INDIVIDUAL MAY GET LOST WHEN DRIVING THEIR CAR. CONCENTRATION MAY BE INTERRUPTED. THERE IS DIFFICULTY RECALLING NAMES OR WORDS, WHICH BECOMES NOTICEABLE TO FAMILY AND CLOSE ASSOCIATES. STAGE 4. MODERATE COGNITIVE DECLINE. AT THIS STAGE, THE INDIVIDUAL MAY FORGET MAJOR EVENTS IN PERSONAL HISTORY, SUCH AS THEIR CHILD’S BIRTHDAY; EXPERIENCE A DECLINING ABILITY TO PERFORM TASKS, SUCH AS SHOPPING, COOKING, AND MANAGING PERSONAL FINANCES; OR BE UNABLE TO UNDERSTAND CURRENT NEWS EVENTS. THE INDIVIDUAL MAY DENY THAT A PROBLEM EXISTS BY COVERING UP MEMORY LOSS WITH CONFABULATION (CREATING IMAGINARY EVENTS TO FILL IN MEMORY GAPS). DEPRESSION AND SOCIAL WITHDRAWAL ARE COMMON. AT THIS STAGE, THE INDIVIDUAL REQUIRES SOME ASSISTANCE TO MAINTAIN SAFETY. STAGE 5. MODERATELY SEVERE COGNITIVE DECLINE. AT THIS STAGE, INDIVIDUALS LOSE THE ABILITY TO PERFORM SOME ACTIVITIES OF DAILY LIVING INDEPENDENTLY, SUCH AS HYGIENE, DRESSING, AND GROOMING, AND REQUIRE SOME ASSISTANCE TO MANAGE THESE TASKS ON AN ONGOING BASIS. THEY MAY FORGET ADDRESSES, PHONE NUMBERS, AND NAMES OF CLOSE RELATIVES. THEY MAY BECOME DISORIENTED ABOUT PLACE AND TIME BUT MAINTAIN KNOWLEDGE ABOUT THEMSELVES. FRUSTRATION, WITHDRAWAL, AND SELF-ABSORPTION ARE COMMON. STAGE 6. SEVERE COGNITIVE DECLINE. AT THIS STAGE, INDIVIDUALS MAY BE UNABLE TO RECALL THEIR SPOUSE’S NAME OR MAY MISIDENTIFY PEOPLE (E.G., THINKING A CHILD IS THEIR SPOUSE). DISORIENTATION TO SURROUNDINGS IS COMMON, AND THE PERSON MAY BE UNABLE TO RECALL THE DAY, SEASON, OR YEAR. THE PERSON IS UNABLE TO MANAGE ACTIVITIES OF DAILY LIVING WITHOUT ASSISTANCE. DELUSIONS OFTEN BECOME APPARENT, SUCH AS MAINTAINING THE BELIEF THAT ONE MUST GO TO WORK EVEN THOUGH THEY ARE NO LONGER EMPLOYED. URINARY AND FECAL INCONTINENCE ARE COMMON. SLEEPING BECOMES A PROBLEM. PSYCHOMOTOR SYMPTOMS INCLUDE WANDERING, OBSESSIVENESS, AGITATION, AND AGGRESSION. SYMPTOMS SEEM TO WORSEN IN THE LATE AFTERNOON AND EVENING—A PHENOMENON TERMED SUNDOWNING. COMMUNICATION BECOMES MORE DIFFICULT WITH THE INCREASING LOSS OF LANGUAGE SKILLS. INSTITUTIONAL CARE IS USUALLY REQUIRED AT THIS STAGE. STAGE 7. VERY SEVERE DECLINE. IN THE END STAGES OF ALZHEIMER’S, THE INDIVIDUAL CANNOT RECOGNIZE FAMILY MEMBERS. THE INDIVIDUAL MOST COMMONLY IS BEDFAST AND APHASIC. PROBLEMS OF IMMOBILITY, SUCH AS DECUBITI AND CONTRACTURES, MAY OCCUR. NEUROCOGNITIVE DISORDER DUE TO ALZHEIMER’S DISEASE: PREDISPOSING FACTORS ONSET IS SLOW AND INSIDIOUS. COURSE OF THE DISORDER IS GENERALLY PROGRESSIVE AND DETERIORATING. INCREASINGLY, CLINICIANS ARE ABLE TO IDENTIFY THE DISEASE WITH CONSIDERABLE ACCURACY USING DIAGNOSTIC TOOLS INCLUDING ○ MAGNETIC RESONANCE IMAGING AND COMPUTED TOMOGRAPHY TO IDENTIFY DEGENERATIVE PATHOLOGY ○ POSITRON EMISSION TOMOGRAPHY AND CEREBROSPINAL FLUID BIOPSIES TO IDENTIFY BIOMARKERS - MORE ACCURATE THAN MRI ETIOLOGIES MAY INCLUDE: ○ NEUROTRANSMITTER ALTERATIONS ↓ in the amt of the enzyme require to produce acetylcholine ≡ ↓ acetylcholine ≡ ↓ cognitive processes ○ PLAQUES AND TANGLES ○ HEAD TRAUMA  ? Individuals have ↑ incidence of head trauma ○ GENETIC FACTORS SUBSTANCE-INDUCED NEUROCOGNITIVE DISORDER: PREDISPOSING FACTORS OCCURS AS A RESULT OF REACTIONS TO, OR THE OVERUSE OR ABUSE OF, SUBSTANCES SUCH AS: ○ ALCOHOL ○ INHALANTS ○ SEDATIVES, HYPNOTICS, AND ANXIOLYTICS ○ MEDICATIONS THAT CAUSE ANTICHOLINERGIC SIDE EFFECTS ○ TOXINS, SUCH AS LEAD AND MERCURY NEUROCOGNITIVE DISORDER DUE TO OTHER CONDITIONS BRAIN TUMOR HYPOTHYROIDISM PERNICIOUS ANEMIA HYPERPARATHYROIDISM MULTIPLE SCLEROSIS PITUITARY INSUFFICIENCY THIAMINE DEFICIENCY UREMIA ENCEPHALITIS PELLAGRA UNCONTROLLED EPILEPSY CARDIOPULMONARY INSUFFICIENCY FLUID AND ELECTROLYTE IMBALANCES CENTRAL NERVOUS SYSTEM AND SYSTEMIC INFECTIONS SYSTEMIC LUPUS ERYTHEMATOSUS APPLICATION OF THE NURSING PROCESS/ASSESSMENT  THE PATIENT’S HISTORY ○ AREAS OF CONCERN TO BE ADDRESSED TYPE, FREQUENCY, AND SEVERITY OF MOOD SWINGS COGNITIVE CHANGES SUCH AS TROUBLE WITH AN ATTENTION SPAN THINKING PROCESS, PROBLEM-SOLVING, AND MEMORY LANGUAGE DIFFICULTIES ORIENTATION TO PERSON, PLACE, TIME, AND SITUATION APPROPRIATENESS OF SOCIAL BEHAVIOR CURRENT AND PAST USE OF MEDICATIONS, DRUGS, AND ALCOHOL POSSIBLE EXPOSURE TO TOXINS PATIENT AND FAMILY HISTORY OF SPECIFIC ILLNESSES APPLICATION OF THE NURSING PROCESS/ASSESSMENT PHYSICAL ASSESSMENT ○ ASSESSMENT FOR DISEASES OF VARIOUS ORGAN SYSTEMS THAT CAN INDUCE CONFUSION, LOSS OF MEMORY, AND BEHAVIORAL CHANGES ○ NEUROLOGICAL EXAMINATION TO ASSESS MENTAL STATUS, ALERTNESS, MUSCLE STRENGTH, REFLEXES, SENSORY PERCEPTION, LANGUAGE SKILLS, AND COORDINATION Diagnostic laboratory evaluations ○ Include blood and urine to test for: Various infections Hepatic and renal dysfunctions Diabetes or hypoglycemia Electrolyte imbalances Metabolic and endocrine disorders Nutritional deficiencies Presence of toxic substances  Other diagnostic evaluations may include ○ Electroencephalogram ○ Computed tomography scan ○ Positron emission tomography (PET) ○ Magnetic resonance imaging ○ Lumbar puncture to examine cerebrospinal fluid ○ Amyloid PET scan techniques PLANNING AND IMPLEMENTATION RISK FOR TRAUMA ○ GOALS - PREVENTING INJURIES ○ INTERVENTIONS - ADJUSTING FURNITURE, HOME MODIFICATIONS, FAM EDUCATION - SAFETY DISTURBED THOUGHT PROCESSES/IMPAIRED MEMORY AND DISTURBED SENSORY PERCEPTION ○ GOALS ○ INTERVENTIONS IMPAIRED VERBAL COMMUNICATION ○ GOALS - ENSURE PT. IS ABLE TO MAKE NEEDS KNOWN ○ INTERVENTIONS - KEEP CALM, REASSURANCE, NONVERBAL GESTURES, CONSISTENCY SELF-CARE DEFICIT ○ GOALS - ASSIST IN ADLS, GUIDANCE AND SUPPORT, MINIMIZE CONFUSION, HELP ANTICIPATE NEEDS ○ INTERVENTIONS SAFETY, SAFETY, SAFETY PATIENT/FAMILY EDUCATION  NATURE OF THE ILLNESS ○ POSSIBLE CAUSES ○ WHAT TO EXPECT ○ SYMPTOMS BOX 13-5 MANAGEMENT OF THE ILLNESS ○ WAYS TO ENSURE PATIENT SAFETY ○ HOW TO MAINTAIN REALITY ORIENTATION ○ PROVIDING ASSISTANCE WITH ACTIVITIES OF DAILY LIVING ○ NUTRITIONAL INFORMATION - HIGH CALORIE AND PROTEIN, PREVENT CONSTIPATION, HIGH FIBER, INCREASE FLUID INTAKE ○ DIFFICULT BEHAVIORS ○ MEDICATION ADMINISTRATION ○ MATTERS RELATED TO HYGIENE AND TOILETING SUPPORT SERVICES ○ FINANCIAL ASSISTANCE ○ LEGAL ASSISTANCE ○ CAREGIVER SUPPORT GROUPS ○ RESPITE CARE ○ HOME HEALTH CARE QUALITY AND SAFETY EDUCATION FOR NURSES INSTITUTE OF MEDICINE CHALLENGES HEALTH-CARE EDUCATORS TO ENSURE THAT THEIR GRADUATES HAVE ACHIEVED CORE COMPETENCIES INCLUDING ○ PROVIDING PATIENT-CENTERED CARE ○ MAINTAINING SAFETY ○ WORKING IN INTERDISCIPLINARY TEAMS ○ EMPLOYING EVIDENCE-BASED PRACTICE  ○ INCORPORATING QUALITY IMPROVEMENT ○ UTILIZING INFORMATICS MEDICAL TREATMENT MODALITIES DELIRIUM ○ DETERMINATION AND CORRECTION OF THE UNDERLYING CAUSES ○ STAFF TO REMAIN WITH PATIENT AT ALL TIMES TO MONITOR BEHAVIOR AND PROVIDE REORIENTATION AND ASSURANCE ○ ROOM WITH LOW STIMULUS LEVEL ○ LOW-DOSE ANTIPSYCHOTIC AGENTS TO RELIEVE AGITATION AND AGGRESSION ○ BENZODIAZEPINES COMMONLY USED WHEN ETIOLOGY IS SUBSTANCE WITHDRAWAL PG 287 NEUROCOGNITIVE DISORDER ○ PRIMARY CONSIDERATION IS GIVEN TO ETIOLOGY, WITH A FOCUS ON THE IDENTIFICATION AND RESOLUTION OF POTENTIALLY REVERSIBLE PROCESSES. ○ PHARMACEUTICAL AGENTS FOR COGNITIVE IMPAIRMENT PHYSOSTIGMINE (ANTILIRIUM) DONEPEZIL (ARICEPT)-CHOLINESTERASE INHIBITORS RIVASTIGMINE (EXELON) - CHOLINESTERASE INHIBITORS GALANTAMINE (RAZADYNE)-CHOLINESTERASE INHIBITORS MEMANTINE (NAMENDA)- NMDA ANTAGONIST ○ PHARMACEUTICAL AGENTS FOR AGITATION, AGGRESSION, HALLUCINATIONS, THOUGHT DISTURBANCES, AND WANDERING RISPERIDONE (RISPERDAL) OLANZAPINE (ZYPREXA)  QUETIAPINE (SEROQUEL) ZIPRASIDONE (GEODON) ○ PHARMACEUTICAL AGENTS FOR DEPRESSION SELECTIVE SEROTONIN REUPTAKE INHIBITORS OFTEN CONSIDERED FIRST-LINE DUE TO FAVORABLE SIDE-EFFECT PROFILE TRICYCLIC ANTIDEPRESSANTS OFTEN AVOIDED DUE TO ANTICHOLINERGIC AND CARDIAC SIDE EFFECTS TRAZODONE (DESYREL) GOOD CHOICE FOR PATIENTS WITH INSOMNIA DOPAMINERGIC AGENTS HELPFUL IN TREATMENT OF SEVERE APATHY ○ PHARMACEUTICAL AGENTS FOR ANXIETY (SHOULD NOT BE USED ROUTINELY FOR PROLONGED PERIODS) CHLORDIAZEPOXIDE (LIBRIUM) ALPRAZOLAM (XANAX) LORAZEPAM (ATIVAN) OXAZEPAM (SERAX) DIAZEPAM (VALIUM) NO BARBITURATES ○ PHARMACEUTICAL AGENTS FOR SLEEP DISTURBANCES (FOR SHORT-TERM THERAPY ONLY) FLURAZEPAM (DALMANE) TEMAZEPAM (RESTORIL) TRIAZOLAM (HALCION) ZOLPIDEM (AMBIEN) ZALEPLON (SONATA) RAMELTEON (ROZEREM)  ESZOPICLONE (LUNESTA) TRAZODONE (DESYREL) MIRTAZAPINE (REMERON) MEDICATIONS CHOLINESTERASE INHIBITORS ○ MILD TO MODERATE STAGES ARICEPT (DONEZEPIL) - MILD, MODERATE, AND SEVERE (PATCH) EXELON (RIVASTIGMINE) MILD, MODERATE, AND SEVERE (PATCH) PILL - MILD/MODERATE, TAKE WITH FOOD RAZADYNE (GALANTAMINE) PILL - MILD/MODERATE, TAKE WITH FOOD ○ USED IN EARLY STAGES PREVENTS THE BREAKDOWN OF ACETYLCHOLINESTERASE, MAKES MORE ACETYLCHOLINE AVAILABLE NAUSEA, VOMITING, DIARRHEA, INSOMNIA, FATIGUE, MUSCLE CRAMPS, HEADACHE, WEIGHT LOSS, INDIGESTION, BRADYCARDIA AVOID USE WITH NSAIDS EXELON SHOULD BE TAKEN WITH FOOD (CAN GET WEIGHT LOSS, APPETITE LOSS AND GI UPSET) ○ BECOMES LESS EFFECTIVE AFTER 1 YEAR NMDA ANTAGONIST ○ MODERATE TO SEVERE STAGES NAMENDA (MEMANTINE) NORMALIZES GLUTAMATE, PREVENTS DAMAGE TO THE BRAIN  DIZZINESS, HEADACHE, CONSTIPATION, AND CONFUSION ○ NOT FOR USE IN EARLY STAGES ○ WATCH CLOSELY IN CLIENTS WITH RENAL ISSUES ○ USED AFTER CHOLINESTERASE INHIBITORS, CAN BE USED IN CONJUNCTION WITH ANTIPSYCHOTICS ○ INDICATIONS: PARANOID THINKING AGITATION DELUSIONS METABOLIC SYNDROME ○ SEROQUEL GEODON RISPERDAL ZYPREXA LOWEST DOSE POSSIBLE DEATH HAS OCCURRED IN ELDERLY DEMENTIA PTS. HIGHEST R/F DELIRIUM CH.25 - SURVIVORS OF ABUSE AND NEGLECT INTRODUCTION ABUSE IS THE MALTREATMENT OF ONE PERSON BY ANOTHER CENTERS FOR DISEASE CONTROL AND PREVENTION 2018 REPORT 1 IN 4 WOMEN AND 1 IN 10 MEN EXPERIENCE CONTACT SEXUAL VIOLENCE, PHYSICAL VIOLENCE, AND/OR STALKING BY AN INTIMATE PARTNER THESE FORMS OF VIOLENCE MOST OFTEN OCCUR BEFORE THE AGE OF 25 YEARS FOR BOTH MEN AND WOMEN. CHILD AND ELDER ABUSE AND RELATED FATALITIES CONTINUE TO BE A SIGNIFICANT HEALTH CONCERN. HUMAN TRAFFICKING CONCERNS  ABUSE AFFECTS ALL RACES, RELIGIONS, ECONOMIC CLASSES, AGES, AND EDUCATIONAL BACKGROUNDS. LAWS NOW EXIST TO PROTECT CHILDREN AND THE ELDERLY. ABUSERS WERE MORE LIKELY TO HAVE BEEN VICTIMS REQUIRED MANDATED REPORTING OF CHILD ABUSE PREDISPOSING FACTORS BIOLOGICAL THEORIES ○ NEUROPHYSIOLOGICAL INFLUENCES AMYGDALA STRIATUM PREFRONTAL CORTEX ○ BIOCHEMICAL INFLUENCES SEROTONIN (USUALLY A DECREASE) TESTOSTERONE- ONGOING RESEARCH ○ GENETIC INFLUENCES POSSIBLE HEREDITARY FACTOR STRESSFUL LIFE EVENTS CAN INFLUENCE GENE VARIANTS ○ DISORDERS OF THE BRAIN ORGANIC BRAIN SYNDROMES BRAIN TUMORS/TRAUMA ENCEPHALITIS TEMPORAL LOBE EPILEPSY PSYCHOLOGICAL THEORIES ○ PSYCHODYNAMIC THEORY ○ LEARNING THEORY SOCIOCULTURAL THEORIES ○ SOCIETAL INFLUENCES INTIMATE PARTNER VIOLENCE  BATTERING INTIMATE PARTNER VIOLENCE (IPV PHYSICAL VIOLENCE SEXUAL VIOLENCE STALKING PSYCHOLOGICAL AGGRESSION PROFILE OF THE VICTIM ○ BATTERED WOMEN REPRESENT ALL AGE, RACIAL, RELIGIOUS, CULTURAL, EDUCATIONAL, AND SOCIOECONOMIC GROUPS ○ LOW SELF-ESTEEM ○ INADEQUATE SUPPORT SYSTEMS ○ SOME GREW UP IN ABUSIVE HOMES PROFILE OF THE VICTIMIZER ○ LOW SELF-ESTEEM ○ PATHOLOGICALLY JEALOUS ○ “DUAL PERSONALITY” ○ LIMITED COPING ABILITY ○ SEVERE STRESS REACTIONS ○ VIEWS SPOUSE AS A PERSONAL POSSESSION THE CYCLE OF BATTERING ○ THREE DISTINCT PHASES: PHASE ONE: TENSION-BUILDING PHASE PHASE TWO: ACUTE BATTERING INCIDENT PHASE THREE: CALM, LOVING, RESPITE (HONEYMOON) PHASE WHY DO THEY STAY? FEAR OF RETALIATION BY THE PARTNER FEAR OF LOSING CUSTODY OF THEIR CHILDREN LACK OF FINANCIAL RESOURCES LACK OF A SUPPORT NETWORK  RELIGIOUS REASONS HAVING HOPE THAT THE PARTNER WILL CHANGE, AND THEY CAN HAVE GOOD TIMES AGAIN LACK OF ATTENTION TO THE DANGER CHILD ABUSE PHYSICAL ABUSE: ANY NON ACCIDENTAL PHYSICAL INJURY CAUSED BY THE PARENT OR CAREGIVER ○ SIGNS AND SYMPTOMS ○ CHILD HAS UNEXPLAINED INJURIES. ○ CHILDREN ARE FRIGHTENED OF ADULTS. ○ CHILD REPORTS INJURY BY PARENT OR CAREGIVER. ○ A CONFLICTING OR UNCONVINCING EXPLANATION FOR INJURIES IS GIVEN. EMOTIONAL ABUSE: A PATTERN OF BEHAVIOR ON THE PART OF THE PARENT OR CARETAKER THAT RESULTS IN SERIOUS IMPAIRMENT OF THE CHILD’S SOCIAL, EMOTIONAL, OR INTELLECTUAL FUNCTIONING ○ INDICATORS OF ABUSE EXTREMES OF BEHAVIOR DELAYED PHYSICAL OR EMOTIONAL DEVELOPMENT LACK OF ATTACHMENT TO PARENT PHYSICAL NEGLECT ○ REFUSAL OF OR DELAY IN SEEKING HEALTH CARE ○ ABANDONMENT ○ EXPULSION FROM THE HOME ○ REFUSAL TO ALLOW A RUNAWAY TO RETURN HOME ○ INADEQUATE SUPERVISION EMOTIONAL NEGLECT  ○ FAILURE TO PROVIDE THE CHILD WITH THE HOPE, LOVE, AND SUPPORT NECESSARY FOR THE DEVELOPMENT OF A SOUND, HEALTHY PERSONALITY BEHAVIORAL INDICATORS OF NEGLECT ○ IS FREQUENTLY ABSENT FROM SCHOOL ○ BEGS OR STEALS FOOD OR MONEY ○ LACKS NEEDED MEDICAL OR DENTAL CARE, IMMUNIZATIONS, OR GLASSES ○ IS CONSISTENTLY DIRTY AND HAS SEVERE BODY ODOR ○ LACKS SUFFICIENT CLOTHING FOR THE WEATHER ○ ABUSES ALCOHOL OR OTHER DRUGS ○ STATES THAT THERE IS NO ONE AT HOME TO PROVIDE CARE SEXUAL ABUSE OF A CHILD ○ SEXUAL EXPLOITATION OF A CHILD ○ INCEST ○ INDICATORS OF SEXUAL ABUSE HAS DIFFICULTY WALKING OR SITTING REPORTS NIGHTMARES OR BEDWETTING EXPERIENCES A SUDDEN CHANGE IN APPETITE DEMONSTRATES BIZARRE, SOPHISTICATED, OR UNUSUAL SEXUAL KNOWLEDGE OR BEHAVIOR BECOMES PREGNANT OR CONTRACTS A SEXUALLY TRANSMITTED DISEASE CHARACTERISTICS OF THE CHILD ABUSER ○ PARENTS WHO ABUSE THEIR CHILDREN WERE LIKELY ABUSED AS CHILDREN THEMSELVES. ○ OTHER INFLUENCES INCLUDE: NUMEROUS STRESSES REPETITIVE SHAMING, BLAMING, TEASING, HUMILIATING WITHHOLDING CARE EXPECTING THE CHILD TO BE PERFECT  ABSENCE OF ADEQUATE SUPPORT SYSTEMS LACK OF KNOWLEDGE OF CHILD DEVELOPMENT OR CARE NEEDS OVERT OR VEILED THREATS OF PHYSICAL INJURY THE INCESTUOUS RELATIONSHIP ○ OFTEN, THERE IS AN IMPAIRED SPOUSAL RELATIONSHIP. ○ FATHER DOMINEERING, IMPULSIVE, PHYSICALLY ABUSIVE ○ MOTHER PASSIVE, SUBMISSIVE, AND DENIGRATES HER ROLE OF WIFE AND MOTHER OFTEN AWARE OF THE INCESTUOUS RELATIONSHIP, BUT USES DENIAL OR KEEPS QUIET OUT OF FEAR OF BEING ABUSED BY HER HUSBAND THE ADULT SURVIVOR OF INCEST ○ COMMON CHARACTERISTICS A FUNDAMENTAL LACK OF TRUST THAT ARISES OUT OF AN UNSATISFACTORY PARENT–CHILD RELATIONSHIP LOW SELF-ESTEEM AND A POOR SENSE OF IDENTITY ABSENCE OF PLEASURE WITH SEXUAL ACTIVITY PROMISCUITY SEXUAL ASSAULT RAPE IS AN ACT OF AGGRESSION, NOT PASSION. IT IS THE EXPRESSION OF POWER AND DOMINANCE BY MEANS OF SEXUAL VIOLENCE, MOST COMMONLY BY MEN OVER WOMEN, ALTHOUGH MEN MAY ALSO BE RAPE VICTIMS. ○ ACQUAINTANCE RAPE ○ MARITAL RAPE ○ STATUTORY RAPE PROFILE OF THE VICTIMIZER ○ IT IS DIFFICULT TO PROFILE A RAPIST.  ○ MANY RAPES ARE PREMEDITATED ○ PERPETRATOR SEEKS OUT VICTIM BASED ON OPPORTUNISTIC POSITIONING: GETTING THE VICTIM ALONE OR ISOLATED FROM OTHERS USING ALCOHOL OR DRUGS TO INCREASE VULNERABILITY RAPE CAN OCCUR AT ANY AGE. ○ THE HIGHEST-RISK GROUP APPEARS TO BE BETWEEN 16 AND 34 YEARS OF AGE. MOST VICTIMS ARE SINGLE WOMEN. THE ATTACK OFTEN OCCURS NEAR THEIR OWN NEIGHBORHOODS. VICTIM LIKELY EXPERIENCES A SENSE OF VIOLATION AND HELPLESSNESS. THE LONG-TERM EFFECTS DEPEND LARGELY ON THE INDIVIDUAL’S: ○ EGO STRENGTH ○ SOCIAL SUPPORT SYSTEM ○ TREATMENT AS A VICTIM VICTIM RESPONSES ○ EXPRESSED RESPONSE PATTERN ○ CONTROLLED RESPONSE PATTERN ○ COMPOUNDED RAPE REACTION ○ SILENT RAPE REACTION PLANNING/IMPLEMENTATION NURSING INTERVENTION FOR THE VICTIM OF ABUSE OR NEGLECT IS TO PROVIDE SHELTER AND PROMOTE REASSURANCE OF THEIR SAFETY. OTHER NURSING CONCERNS INCLUDE: ○ TENDING TO PHYSICAL INJURIES ○ STAYING WITH THE CLIENT TO PROVIDE SECURITY ○ ASSISTING THE CLIENT IN RECOGNIZING OPTIONS ○ PROMOTING TRUST  ○ REPORTING TO AUTHORITIES WHEN THERE IS REASON TO SUSPECT CHILD ABUSE OR NEGLECT FORENSIC NURSING FORENSIC NURSING IS A SPECIALIZED NURSING ROLE IN WHICH NURSES APPLY THEIR SKILLS TO THE CARE, EVALUATION, AND ADVOCACY FOR VICTIMS OF CRIME IN A VARIETY OF SETTINGS. PRESERVATION OF EVIDENCE INVESTIGATION OF WOUND CHARACTERISTICS TREATMENT MODALITIES CRISIS INTERVENTION SAFE HOUSE OR SHELTER FAMILY-BASED INTERVENTIONS CH. 21 - EATING AND FEEDING DISORDERS ANOREXIA NERVOSA, BULIMIA NERVOSA, & BINGE EATING DISORDER RISK FACTORS ○ PSYCHOLOGICAL FACTORS – PARENTAL PRESSURES; THE NEED TO SUCCEED (BALLET, MODELING, PAGEANT, OR SPORTS); PERFECTIONIST; OCD; ANXIETY; POWERLESSNESS; SENSE OF LACK OF CONTROL; DEPRESSION; DISTORTED BODY IMAGE; SELF-IDENTITY; BEING TEASED OR BULLIED DUE TO WEIGHT; UNABLE TO COPE WITH FEELINGS; LOW SELF-ESTEEM; AND POTENTIAL EMOTIONAL/PHYSICAL ABUSE OR NEGLECT. (BINGE EATING – FOOD INSECURITY)  ○ OTHER FACTORS – BASED ON LEARNED BEHAVIORS THAT HAS POSITIVE REINFORCEMENTS. CULTURAL INFLUENCES; MEDIA INFLUENCE AND PRESSURE FROM SOCIETY TO HAVE THE “PERFECT BODY”. ANOREXIA NERVOSA INTENSE FEAR OF GAINING ○ USUALLY, UNDERWEIGHT TWO TYPES: RESTRICTING AND BINGE-EATING/PURGING TYPE DSM-5 CRITERIA P. 565 SYMPTOMS (P. 564) ○ DISTORTION OF BODY IMAGE ○ PREOCCUPATION WITH FOOD ○ REFUSE TO EAT ○ HYPOTHERMIA ○ BRADYCARDIA, HYPOTENSION ○ LANUGO ○ AMENORRHEA DEPRESSION/ANXIETY/IRRITABILITY IS COMMON COMPLICATIONS ○ STARVATION ○ EMACIATION ○ REFEEDING SYNDROME (P.580) NO MEDICATIONS RECOMMENDED, USUALLY WHEN NUTRITION IS RESTORED, DEPRESSION, ETC. OFTEN IMPROVES. CBT BULIMIA NERVOSA  RECURRENCE OF BINGE EATING FOLLOWED BY VOMITING, LAXATIVES, DIURETICS, FASTING, AND/OR EXCESSIVE EXERCISE ○ NOT USUALLY UNDERWEIGHT EXCESSIVE CONCERN WITH PERSONAL APPEARANCE AND HOW OTHERS PERCEIVE THEM. DSM-5 CRITERIA P. 566 MOOD DISORDERS, ANXIETY, OR SUBSTANCE ABUSE IS COMMON ACUTE CARE ○ ADDRESS LIFE-THREATENING COMPLICATIONS. INTERRUPT THE CYCLE OF BINGE EATING/PURGING. COMPLICATIONS ○ DEHYDRATION/ELECTROLYTE IMBALANCE ○ VOMIT-EROSION OF TOOTH ENAMEL; CALLUSES ON KNUCKLES IS RUSSELL’S SIGN PHARMACOLOGICAL ○ SSRI ANTIDEPRESSANTS (FLUOXETINE) CBT ○ FIRST-LINE OF TREATMENT, THEN ADD ANTIDEPRESSANT AS NEEDED. ANOREXIA & BULIMIA NERVOSA - NURSING INTERVENTIONS (P.571-574) ACUTE CARE: ○ NG TUBE AND LIQUID DIET ○ IF ORAL DIET CONSULT DIETITIAN FOR ADEQUATE CALORIES AND FLUID ○ MONITOR LABS ESP. ELECTROLYTES ○ DAILY WEIGHTS, STRICT I/O ○ ASSESS SKIN AND ORAL MUCOUS MEMBRANES ○ STAY WITH PATIENT DURING MEALTIMES FOR AT LEAST 1 HOUR  ○ ESTABLISH RESTRICTIONS/LIMITS FOR COMPLIANCE AND SAFETY ○ ESTABLISH A TRUSTING RELATIONSHIP ○ ENCOURAGE AND ACKNOWLEDGE THE PATIENTS’ FEELINGS ○ AVOID ARGUING/BARGAINING ○ ENCOURAGE TALK ABOUT PATIENT’S ROLE IN THE FAMILY ○ ASSIST THE PATIENT TO RECOGNIZE THEIR MISPERCEPTION OF BODY IMAGE AND RELATIONSHIP WITH FOOD ○ PROMOTE FEELINGS OF CONTROL THROUGH PARTICIPATION WITH DECISION MAKING AND POSITIVE FEEDBACK ○ ASSESS FOR HISTORY OF TRAUMA AND CHILDHOOD LIFE EVENTS BINGE EATING REPEATED EPISODES OF BINGE EATING ESPECIALLY AFTER A STRESSFUL EVENT ○ NO PURGING, OVERWEIGHT/OBESITY NO CONTROL, OVEREATING A LARGE AMOUNT OF FOOD AT ONE SETTING. LOW SELF-ESTEEM, BORED, TRIGGERS SUCH AS STRESS, ETC. DSM-5 CRITERIA P. 567 ○ GI COMPLICATIONS (DELAYED GASTRIC EMPTYING) ACUTE CARE/GI COMPLICATIONS AVOID JUDGMENTAL TERMS, BE EMOTIONAL SUPPORTIVE, SOCIAL ISOLATION FOCUS ON REBUILDING A BALANCE OF DAILY INTAKE, POSITIVE COPING SKILLS FOR UNDERLYING ISSUES. APPETITE-SUPPRESSANT MEDICATIONS CAN BE SHORT-TERM IF SEVERELY OVERWEIGHT CBT NURSING INTERVENTIONS (P.574-576) ACUTE CARE – GI COMPLICATIONS  ESTABLISH A TRUSTING RELATIONSHIP ENCOURAGE A FOOD INTAKE DIARY DISCUSS FEELINGS AND EMOTIONS ASSOCIATED WITH EATING AND BEING OVERWEIGHT FORMULATE AN EATING PLAN IDENTIFY REALISTIC GOALS FOR WEIGHT LOSS PLAN A PROGRESSIVE EXERCISE PROGRAM DISCUSS COPING PATTERNS RELATED TO FOOD IN THE FAMILY DETERMINE PATIENT’S MOTIVATION HELP PATIENT TO IDENTIFY POSITIVE SELF-ATTRIBUTES ASSESS FOR HISTORY OF TRAUMA AND CHILDHOOD LIFE EVENTS EATING DISORDERS OUTCOME CRITERIA (P. 568) PLANNING/IMPLEMENTATION – COMPLICATIONS ○ MALNUTRITION ○ DEHYDRATION ○ ELECTROLYTE IMBALANCE ○ CARDIAC ARRHYTHMIAS, BRADYCARDIA ○ HYPOTHERMIA ○ HYPOTENSION ○ SUICIDE IDEATION EVALUATION (P. 576-579) CHAPTER 24 – THE AGING INDIVIDUAL (OLDER ADULT) HEALTH STATUS  PSYCHIATRIC ISSUES SUCH AS MAJOR DEPRESSION, COGNITIVE DEFICITS, AND PROLONGED GRIEVING ARE NOT A NORMAL PART OF AGING. MENTAL ILLNESS INCREASE OVER A LIFE CYCLE: DEPRESSION IS PREVALENT AND USUALLY UNDERDIAGNOSED OR UNDERTREATED SUICIDE IS A SERIOUS PROBLEM NEUROCOGNITIVE DISORDERS INCREASE MEMORY – SLOWER RESPONSE TIME, SHORT-TERM MEMORY CAN DETERIORATE WITH AGE. LONG-TERM MEMORY USUALLY DOES NOT HAVE CHANGES. INTELLECTUAL – SOLVING PROBLEMS TENDS TO DECLINE. LEARNING ABILITY – ADJUSTMENTS NEED TO BE MADE IN TEACHING METHODS AND TIME ALLOWED FOR LEARNING. ADAPTATION LOSS & GRIEF – MAY HAVE EXPERIENCED SEVERAL LOSSES AND MOURNING. CAN EXPERIENCE DEATH ANXIETY WITH THE FEAR OF DYING, EDUCATION IS BENEFICIAL IN REDUCING ANXIETY. ATTACHMENT TO OTHERS – INTERPERSONAL RELATIONSHIPS, PARTICIPATING IN ACTIVITIES FOR OLDER ADULTS, STAYING ACTIVE, ETC. DECREASES LONELINESS AND SUPPORT DURING STRESSFUL EVENTS. SELF-IDENTITY – INDIVIDUALS WHO LIFE CENTERS ENTIRELY ON THEIR JOB MAY STRUGGLE WITH RETIREMENT, SOCIALIZATION, ETC. PSYCHIATRIC DISORDERS LATER IN LIFE COGNITIVE DISORDERS, MOOD DISORDERS, PHOBIAS, AND ALCOHOL USE DISORDERS ARE THE MOST COMMON. MEDICAL CONDITIONS AND MEDICATIONS MAY CONTRIBUTE TO SYMPTOMS OF PSYCHIATRIC DISORDERS.  ALWAYS RULE OUT OTHER POSSIBLE CAUSES BEFORE ASSUMING A PSYCHIATRIC DISORDER. SUBSTANCE DISORDER: ○ PRESCRIPTION AND OTC ○ TOLERATING SOME DRUGS ○ ALCOHOL DEPENDENCY OLDER ADULTS WANT TO BE TREATED WITH THE RESPECT AND DIGNITY THEY DESERVE AND THEY WANT TO DIE WITH RESPECT AND DIGNITY. PAIN BARRIERS TO ACCURATE PAIN ASSESSMENT? ASSESSMENT TOOLS ○ WONG-BAKER FACES PAIN RATING SCALE ○ PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE PAIN MANAGEMENT ○ PHARMACOLOGICAL PAIN TREATMENTS ○ NON PHARMACOLOGICAL PAIN TREATMENTS PAIN MEDICATIONS FOR OLDER ADULTS? ○ ACETAMINOPHEN – MILD TO MODERATE PAIN ○ OPIOIDS – MODERATE TO SEVERE PAIN ○ PAIN MODULATORS (GABAPENTIN/PREGABALIN) – NEUROPATHIC PAIN HEALTH CARE CONCERNS OF OLDER ADULTS FINANCIAL BURDEN – MANY OLDER ADULTS ON FIXED INCOMES HAVE TO MAKE A CHOICE BETWEEN BUYING MEDICATION OR FOOD. CAREGIVER BURDEN – THE AMOUNT OF PHYSICAL, EMOTIONAL, FINANCIAL, AND PSYCHOSOCIAL SUPPORT PROVIDED TO A LOVED ONE WITH CHRONIC ILLNESS.  AGEISM - A BIAS AGAINST OLDER PEOPLE BASED ON ADVANCED AGE. THERE ARE FEDERAL, STATE, AND LOCAL AGENCIES DEDICATED TO OLDER ADULTS SUCH AS AARP. ELDER ABUSE (P. 683-685) PSYCHOLOGICAL, SEXUAL, PHYSICAL, FINANCIAL, AND/OR NEGLECT (BOX 24-1, P. 684) ABUSER IS OFTEN A RELATIVE, CAREGIVER RISK FACTORS: ○ ECONOMIC STRESS OR ANY STRESS ○ SUBSTANCE ABUSE ○ DIFFICULTY WITH CAREGIVER / DEPENDENCY ON ANOTHER INDIVIDUAL ○ LIVING LONGER ○ LEARNED VIOLENCE / HISTORY OF ABUSE IDENTIFYING ELDER ABUSE (P. 685) HEALTHCARE WORKERS ARE RESPONSIBLE FOR REPORTING ANY SUSPICIONS OF ABUSE SUICIDE (P. 685) RISK FACTORS LONELINESS FINANCIAL PROBLEMS PHYSICAL ILLNESS LOSS DEPRESSION HELPLESSNESS OR HOPELESSNESS APPLICATION OF NURSING PROCESS (P. 686)  ASSESSMENT ○ MULTIPLE PHYSICAL PROBLEMS ○ MULTIPLE CHANGES IN LIFE CYCLE ○ THOUGHT PROCESS – DISORIENTATION/CONFUSION ○ HEARING, VISUAL ○ AGING PROCESS OUTCOME CRITERIA (P. 687) EVALUATION (P. 688) NURSING INTERVENTIONS (TABLE 24-2 P. 689-693) SAFETY MEASURES FREQUENT ORIENTATION, SIMPLE EXPLANATIONS, TALK ABOUT REALITY, MONITOR MED SIDE EFFECTS PROVIDE A SIMPLE, STRUCTURED ENVIRONMENT ASSESS CAREGIVER SITUATIONS – PROVIDE INFORMATION, COMMUNITY SUPPORT, ENCOURAGE DISCUSSION OF FEELINGS, AND SUPPORT GROUPS. ENCOURAGE PATIENT TO EXPRESS FEELINGS ASSIST PATIENT WITH MEMORY DEFICIT ENCOURAGE REVIEW OF LIFE EVENTS/HISTORY (REMINISCENCE) ENCOURAGE PARTICIPATION IN GROUPS, SELF-CARE OF ADL PATIENT SAFETY IS A PRIORITY – VISION, HEARING, SCANNING ENVIRONMENT, ETC. CHAPTER 27 – THE BEREAVED INDIVIDUAL CH. 22 - PERSONALITY DISORDERS WHAT ARE CHARACTERISTICS OF A HEALTHY PERSONALITY  A PERSON HAS ○ INSIGHT INTO THEIR STRENGTHS AND WEAKNESSES ○ GRASP OF THEIR OWN BOUNDARIES ○ CAN IDENTIFY EVENTS THAT LEAD TO EXPRESSION OF STRONG EMOTIONS(ANGER, DISAPPOINTMENT, JOY) ○ DOES NOT DEPEND ON OTHERS TO MEET THEIR NEEDS ○ BALANCES WORK AND PLAY ○ CAN ACCOMPLISH GOALS ○ HAS A SENSE OF SPIRITUALITY THAT IS MEANINGFUL TO THEM SO, WHAT IS A PERSONALITY DISORDER? A PATTERN OF INNER EXPERIENCES AND BEHAVIORS THAT DEVIATES SIGNIFICANTLY FOR THE EXPECTATION OF THE PERSON’S CULTURE PERVASIVE AND INFLEXIBLE USUALLY, ONSETS IN ADOLESCENCE OR EARLY ADULTHOOD THAT IS STABLE OVER TIME BUT LEADS TO DISTRESS/IMPAIRMENT PREVENTS ACHIEVING GOALS (RELATIONSHIPS/OTHER) MAY ONLY SEEK TREATMENT IN EVENT OF CRISIS 4 CHARACTERISTICS OF PD INFLEXIBLE/ UNHEALTHY RESPONSE TO STRESS UNABLE TO FOSTER HEALTHY RELATIONSHIPS BOTH PERSONALLY AND AT WORK EVOKES INTERPERSONAL CONFLICT EASILY ANGERS, IRRITATES, “PUSHES AWAY” OTHERS TYPES OF PERSONALITY DISORDERS CLUSTER A- ODD, ECCENTRIC ○ PARANOID  ○ SCHIZOID ○ SCHIZOTYPAL CLUSTER B- DRAMATIC, EMOTIONAL, ERRATIC ○ BORDERLINE ○ ANTISOCIAL ○ HISTRIONIC ○ NARCISSISTIC CLUSTER C- ANXIOUS, FEARFUL ○ AVOIDANT ○ DEPENDENT ○ OBSESSIVE-COMPULSIVE CLUSTER A - ODD, ECCENTRIC - PARANOID CHARACTERISTICS ○ LONGSTANDING DISTRUST AND SUSPICION OF OTHERS ○ MAY BE APPARENT IN CHILDHOOD ○ SOCIAL ANXIETY IN CHILDHOOD ○ JEALOUS, CONTROLLING AS ADULTS ○ UNWILLINGNESS TO FORGIVE AND PROJECTION OF FEELINGS TREATMENT ○ COUNTERACT MISTRUST BY (A) ADHERING TO SCHEDULES AND (B) AVOIDING BEING OVERLY FRIENDLY, AND (C) PROJECTING A NEUTRAL BUT KIND AFFECT (D) USE SIMPLE, DIRECT LANGUAGE - WHATEVER YOU SAY, YOU MUST DO, ON TIME ○ PSYCHOTHERAPY VERSUS GROUP THERAPY - INDIVIDUAL THERAPY FIRST ○ SHORT-TERM ANTIDEPRESSANTS  ○ MUST TREAT EVERYONE THE SAME, I.E. DON'T LET SOMEONE GET AWAY WITH SOMETHING CLUSTER A - ODD, ECCENTRIC - SCHIZOID CHARACTERISTICS ○ SYMPTOMS APPEAR IN CHILDHOOD AND ADOLESCENCE ○ LONERS, POOR ACADEMIC PERFORMANCE ○ INCREASED PREVALENCE OF DISORDERED FAMILY LIFE ○ AVOID CLOSE RELATIONSHIPS ○ DEPERSONALIZATION, DETACHMENT ○ LACKS EMPATHY, AND NURTURING TREATMENT ○ PSYCHOTHERAPY ○ GROUP THERAPY ○ ANTIDEPRESSANTS ○ 2ND GEN ANTIPSYCHOTICS CLUSTER A - ODD, ECCENTRIC - SCHIZOTYPAL CHARACTERISTICS ○ SEVERE SOCIAL AND INTERPERSONAL DEFICITS ○ RAMBLING CONVERSATION ○ PARANOIA, SUSPICIOUSNESS, ANXIETY, DISTRUST ○ BRIEF, INTERMITTENT EPISODES OF HALLUCINATION OR DELUSION ○ MAY BE VULNERABLE TO INVOLVEMENT WITH CULTS OR UNUSUAL RELIGIOUS/OCCULT GROUPS  TREATMENT ○ RESPECT NEED FOR SOCIAL ISOLATION ○ PERFORM CAREFUL ASSESSMENT FOR SUICIDAL THOUGHTS ○ PSYCHOTHERAPY (INVESTIGATE POSSIBLE INVOLVEMENT WITH CULTS) ○ NO SPECIFIC MEDS ○ LOW-DOSE ANTIPSYCHOTICS ANTISOCIAL PERSONALITY DISORDER ETIOLOGY CHARACTERISTICS ○ “SOCIOPATHS” ○ MOST RESEARCHED PERSONALITY DISORDER CONNECTION WITH CONDUCT DISORDER AS CHILD ○ DISREGARD AND EXPLOITS OTHERS ○ UNLAWFUL ACTS ○ PROFOUND LACK OF EMPATHY ○ ABSENCE OF REMORSE OR GUILT ○ LACK OF CONCERN FOR CONSEQUENCES ○ CRIMINAL MISCONDUCT AND SUBSTANCE ABUSE CLINICAL PICTURE ○ FAILS TO SUSTAIN CONSISTENT EMPLOYMENT ○ FAILS TO CONFORM TO THE LAW ○ EXPLOITS AND MANIPULATES OTHERS FOR PERSONAL GAIN ○ FAILS TO DEVELOP STABLE RELATIONSHIPS MORE COMMON IN MEN THAN IN WOMEN ○ BOX 22-3 CRITERIA COMMON BEHAVIORS ○ EXPLOITATION AND MANIPULATION OF OTHERS FOR PERSONAL GAIN  ○ BELLIGERENT AND ARGUMENTATIVE ○ LACKS REMORSE ○ UNABLE TO DELAY GRATIFICATION ○ LOW FRUSTRATION TOLERANCE ○ INCONSISTENT WORK OR ACADEMIC PERFORMANCE MAINTAINING SAFETY IS THE PRIORITY TREATMENT ○ BOUNDARIES, CONSISTENCY, SUPPORT, AND LIMITS ○ REALISTIC CHOICES ○ TEAMWORK AND SAFETY (PRIME) ○ THERAPEUTIC COMMUNICATION ○ CBT, DBT, GROUP THERAPY ○ MEDS: TREAT AGGRESSION WITH LITHIUM, ANTICONVULSANTS, SSRI’S OUTCOMES THE CLIENT ○ DISCUSSES ANGRY FEELINGS WITH STAFF AND IN GROUP SESSIONS ○ HAS NOT HARMED SELF OR OTHERS ○ CAN RECHANNEL HOSTILITY INTO SOCIALLY ACCEPTABLE BEHAVIORS ○ FOLLOWS RULES AND REGULATIONS OF THE THERAPY ENVIRONMENT ○ CAN VERBALIZE WHICH OF THEIR BEHAVIORS ARE NOT ACCEPTABLE ○ SHOWS REGARD FOR THE RIGHTS OF OTHERS BY DELAYING GRATIFICATION OF OWN DESIRES WHEN APPROPRIATE ○ DOES NOT MANIPULATE OTHERS IN AN ATTEMPT TO INCREASE THE FEELING OF SELF-WORTH ○ VERBALIZES UNDERSTANDING OF THE KNOWLEDGE REQUIRED TO MAINTAIN BASIC HEALTH NEEDS PLANNING/INTERVENTION  RISK FOR VIOLENCE DIRECTED AT OTHERS ○ CONVEY AN ACCEPTING ATTITUDE ○ OBSERVE THE CLIENT’S BEHAVIOR FREQUENTLY ○ MAINTAIN AND CONVEY A CALM ATTITUDE ○ DO NOT ATTEMPT TO COAX OR CONVINCE THE CLIENT TO DO THE “RIGHT THING.” ○ PROVIDE POSITIVE FEEDBACK ○ TALK ABOUT PAST BEHAVIORS BORDERLINE PERSONALITY DISORDER ETIOLOGY CHARACTERISTICS ○ UNSTABLE INTERPERSONAL RELATIONSHIPS ○ RECURRENT SUICIDAL BEHAVIOR ○ DIFFICULT TO CONTROL ANGER ○ SEVERE IMPAIRMENTS IN FUNCTIONING ○ EMOTIONAL LABILITY ○ IMPULSIVITY ○ SELF-DESTRUCTIVE BEHAVIORS ○ ANTAGONISM ○ SPLITTING: INABILITY TO VIEW BOTH POSITIVE AND NEGATIVE ASPECTS OF OTHERS AS PART OF A WHOLE BOX 22-2 COMMON BEHAVIORS ○ CHRONIC DEPRESSION ○ BIPOLAR DISORDER  ○ INABILITY TO BE ALONE ○ CLINGING AND DISTANCING BEHAVIORS ○ SPLITTING ➡️ **SPLITTING IS THE INABILITY TO INCORPORATE POSITIVE AND NEGATIVE ASPECTS OF ONESELF AND OTHERS. IT IS THE PRIMARY DEFENSE MECHANISM FOR BORDERLINE PERSONALITY DISORDER. ○ MANIPULATION ○ SELF-DESTRUCTIVE BEHAVIORS ○ IMPULSIVITY TREATMENT ○ PROVIDE CLEAR AND CONSISTENT BOUNDARIES AND LIMITS ○ USE CLEAR, STRAIGHTFORWARD COMMUNICATION ○ MEDS: SSRIS, ANTICONVULSANTS, 2ND GEN ANTIPSYCHOTICS AND MOOD STABILIZER ○ THREE ESSENTIAL THERAPIES CBT DIALECTICAL BEHAVIOR THERAPY BY LINEHAN SCHEMA-FOCUSED THERAPY TABLE 22-3 CLUSTER B - MANIPULATIVE, ENTITLED, “WORLD REVOLVES AROUND THEM” - HISTRIONIC CHARACTERISTICS ○ EXCITABLE, DRAMATIC; OFTEN HIGH FUNCTIONING ○ LIMITED ABILITY TO DEVELOP MEANINGFUL RELATIONSHIPS  ○ ATTENTION-SEEKING, SELF-CENTERED; LOW-FRUSTRATION LEVEL ○ FLIRTATIOUS, SEXUALLY SEDUCTIVE ○ NO INSIGHT INTO DISORDER OR ROLE IN RUINING RELATIONSHIPS TREATMENT ○ PSYCHOTHERAPY WILL HELP WITH CLARIFICATION OF FEELINGS AND APPROPRIATE EXPRESSION ○ KEEP INTERACTIONS PROFESSIONAL; IGNORE FLIRTATIONS. CLUSTER B – MANIPULATIVE, ENTITLED, “WORLD REVOLVES AROUND THEM” - NARCISSISTIC CHARACTERISTICS ○ FEELINGS OF ENTITLEMENT, EXAGGERATED SELF IMPORTANCE (ARROGANT) ○ LACK OF EMPATHY; TENDENCY TO EXPLOIT OTHERS ○ WEAK SELF-ESTEEM AND HYPERSENSITIVITY TO CRITICISM ○ CONSTANT NEED FOR ADMIRATION ○ LESS FUNCTIONAL IMPAIRMENT THAN OTHER PERSONALITY DISORDERS TREATMENT ○ REMAIN NEUTRAL. ○ AVOID POWER STRUGGLES OR BECOMING DEFENSIVE. ○ ROLE MODEL EMPATHY. ○ DIFFICULT TO TREAT, PATIENTS NOT LIKELY TO SEEK HELP OR CONFRONT SHORTCOMINGS ○ COGNITIVE-BEHAVIORAL THERAPY (CBT) TO DECONSTRUCT FAULTY THINKING  ○ GROUP THERAPY; LITHIUM FOR MOOD SWINGS CLUSTER C - ANXIOUS, FEARFUL - AVOIDANT CHARACTERISTICS ○ LOW SELF-ESTEEM ○ SHYNESS THAT INCREASES WITH AGE ○ FEELINGS OF INFERIORITY ○ RELUCTANCE TO ENGAGE WITH NEW PEOPLE, BUT DESIRE CLOSE RELATIONSHIPS ○ SUBJECT TO DEPRESSION, ANXIETY, AND ANGER ○ PREOCCUPIED WITH REJECTION, HUMILIATION, AND FAILURE TREATMENT ○ FRIENDLY, ACCEPTING, REASSURING APPROACH ○ PSYCHOTHERAPY/GROUP- TEACH EXERCISES TO ENHANCE NEW SOCIAL SKILLS AND ASSERTIVENESS TRAINING ○ DESIGN EXERCISES TO PREVENT FAILURES ○ MEDS CLUSTER C - ANXIOUS, FEARFUL - DEPENDENT CHARACTERISTICS ○ HIGH NEED TO BE TAKEN CARE OF OVER-RELIANCE ON OTHERS TO MEET NEEDS ○ SUBMISSIVENESS ○ FEARS OF SEPARATION AND ABANDONMENT ○ MANIPULATING OTHERS TO TAKE RESPONSIBILITIES ○ INTENSE ANXIETY WHEN LEFT ALONE EVEN BRIEFLY TREATMENT ○ SET LIMITS THAT DON’T MAKE THE PATIENT FEEL PUNISHED  ○ BE AWARE OF STRONG COUNTERTRANSFERENCE ○ USE THERAPEUTIC RELATIONSHIP AS A TESTING GROUND FOR ASSERTIVENESS TRAINING ○ PSYCHOTHERAPY IS TREATMENT OF CHOICE CLUSTER C - ANXIOUS, FEARFUL - OBSESSIVE-COMPULSIVE CHARACTERISTICS ○ RIGIDITY; INFLEXIBLE STANDARDS FOR OTHERS AND SELF ○ CONSTANT REHEARSAL OF SOCIAL RESPONSES ○ EXCESSIVE GOAL-SEEKING THAT IS SELF-DEFEATING OR RELATIONSHIP-DEFEATING ○ STRICT STANDARDS INTERFERE WITH PROJECT COMPLETION ○ UNHEALTHY FOCUS ON PERFECTION TREATMENT ○ PATIENTS TEND TO SEEK HELP ○ PROVIDE STRUCTURE, BUT ALLOW SOME TIME TO COMPLETE HABITUAL BEHAVIORS ○ ALSO SEEK HELP FOR ANXIETY OR DEPRESSION ○ GROUP AND BEHAVIORAL THERAPY ○ CLOMIPRAMINE(ANAFRANIL) OR FLUOXETINE(PROZAC) FOR OBSESSIONS, ANXIETY, AND DEPRESSION COMMON CHARACTERISTIC ○ ANXIETY