Substance Abuse (Unit IV - Ineffective Coping) PDF

**Unit IV- Ineffective Coping** **Substance Abuse/Personality Disorders:** **Terms:** - **Abuse**: pt continues to use substance even though it affects them in relationships, work etc. Usually it's used recreationally. You keep doing it even when its causing problems - **Habituation*...

**Unit IV- Ineffective Coping** **Substance Abuse/Personality Disorders:** **Terms:** - **Abuse**: pt continues to use substance even though it affects them in relationships, work etc. Usually it's used recreationally. You keep doing it even when its causing problems - **Habituation**: craving, habit and wanting the substance - **Dependence:** physical symptoms that occur when there is abstinence. A compulsive or chronic requirement. The need is so strong as to generate distress - **Addiction:** habituation and dependence - **Withdrawal:** complex physical symptoms that occur when an addicted substance is stopped. The physiological & mental readjustment of an addictive substance - **Abstinence:** stopping use. - **Tolerance:** the need for more to get desired effect one got previously (crack is the worst) - **Synergistic:** effects from both drugs plus an added boast usually unknown factor. (1+1=3) **Etiology:** - **Biochemical/Genetic:** and learned behavior, biological determinant and genetic determinant, can be a learned behavior by copying one\'s parents, (i.e. Famous Irish curse), it is also in the genes. Alcohol may produce morphine like substance in the brain that is responsible for alcohol addiction. These substances are formed by (*dopamine, serotonin)* - **Personality traits:** lot's of difficulty w/ frustration and anxiety, rigid rules in childhood, punishment for expressing feelings, unable to delay the gratification of their needs, no love, relief from anxiety, escape, excessively dependent, passive aggressive. Freud: meets oral need, people have to put something in their body to feel better. Certain traits are though to increase tendency toward addictive behaviors. Ex. having low- self-esteem, frequent depression, and the inability to relax are common in individuals who abuse substances. - **Family:** It runs in families as a copying behavior not a gene. They use it to cope with problems, children learn coping behaviors that adults do, and drinking runs in family as copying and indenting not as a gene. **Behavioral Characteristics:** - **Anger:** rage (in state of drunkenness) aggression, hostility, resentment towards others, feelings of guilt and depression, typically feels powerless, may express their rage overtly in state of drunkenness, i.e. Bar room fight, Or covertly through chronic hostility. - **Manipulation:** uses others for their own gain; make promises just to get favors. - **Impulsiveness:** operating according to the pleasure principle, striving for immediate gratification, robs or kills others for purpose of getting next dose. - **Ego Defenses:** **Denia**l (that event wasn't important-minimizes impact on people, I can stop at any time), **Blend Denial**: minimizes the emotional and the effects of their behavior (I had a few drinks, so what? Well you got in car accident) **Rationalization** (can only work when drinking, going through a phase, helps me function better). **Reaction Formation**: (friendly to face but hostile and angry underneath). Uses defense mechanism to boost self-esteem. **Narcotics:** Also known as Opiates (are depressant) (heroin, morphine, Demerol, methadone.) Patterns of Abuse: starts as a therapeutic drug or a casual recreational substance. Narcotics in general are melo drugs, in sense that they are not interested in a picking fight with anybody they just chilling. Most common substance is heroin. - **Mode of action:** - Receptors in the brain & through out the body that stimulate the endorphins receptors and they make a person feel good. - [Effect on the body]: Acts on CNS depressant, endorphin receptor sight, and pain receptor sight. Builds tolerance so pt needs more. Analgesia, euphoria, freedom from anxiety, sedation and drowsiness, respiratory depression, cough suppression specially codeine, miosis (pupil constriction[), truncal rigidity] (reduced breathing due to increased tone of the truncal muscles, this is how a lot of drugs addicts get pneumonia bcuz fluid accumulates), can be GI symptoms, nausea and vomiting, bradycardia, constipation. - **Intoxication:** IV use (heroin) rush, followed by euphoria state of well being, followed by nodding falling sleepiness, heroin is a very mellow drugs, nobody fights on heroin, person is completely relaxed, no desire to do anything, all needs are met, pinpoint pupils, OD constricted pupils. - **Withdrawal:** different from other drugs (8-10 hrs after last dose) lacrimation (tearing), running nose (rhinorrhea), yawning, chills, sweating, goose bumps (piloerection), nausea & vomiting, muscular aches, hyper & hypotension, joint pain, irritable, noisy, joint pain (last up to 7-10 days sober[). These substances do not do any permanent damage, no organ damage.] Unless they use dirty needles but they are lethal in over dose. *Px do not have to go to the hospital to get detoxify.* - **Overdose:** leads to respiratory arrest death, (hotshot-potent form of heroin, will kill through resp. depression), respiratory rate below 12, decreased truncal rigity, HOT SHOT person gets the rush, goes into the nod, face becomes blue or white (circle moidal pallor), lack of oxygenation, friend walks them to start breathing. A lot of time the EMP gives them Narcan, 1 mg give up to 2 mg and it nocks the drug right out of the receptors, then they get withdrawal (this drug causes diarrhea so don't give more than 2mg) is a quick acting drug. Monitor vital sigs q15 mins, cuz u got to support respirations - **Treatment:** - *Methadone, (substitute, longer acting narcotic, similar to heroin), except it is taken* orally and knocks out heroin off receptor- can't do both. Emergency Treatment- Narcan IV (1mL/1mg ampules), Naltrexon-long acting version of Narcan. Also, another treatment Cold Turkey (non medical detox) - Its very cheap, you ca use low doses - Px doesn't usually get high on methadone but when we give it in the hospital the first hr they act a little chilling but it don't last. *The book says they don't get high but PX would tell u they do. Some times we detoxify heroin addicts right there in the unit* - The beauty of methane is it gets the PX out of the criminal element, it helps them function socially, *cuz addict's need this substance to make them feel normal, & that's what the methane does. But it causes cross addiction so now we got to get them of the methadone, but is a very cheap low cost drug* - Methadone can be used for any body for pain; 10 mg is the dose for pain. - It's a control substance that's why they don't prescribe it they need to get a urine test before they get the methadone. The PX who take this drug and is not an addict can die. Because the addict already has tolerance to it, they need more and more. - **NSG care:** when Narcan is given, monitor vital signs every 15 min, support airway and IV is running, make sure patient is alert and talking to you, get the respiratory rate back up. **Sedative/Hypnotics:** (alcohol, benzodiazepines, barbiturates) **Alcohol** - Patterns of abuse: people drink during meals, socially acceptable, recreational, for relaxation, wedding but then it turns in addiction. Has anti anxiety qualities, - Are absorbed through the stomach wall & within 7 mins of indigestion, the only way to slow down the absorption is to eat something fatty. Eat food before drinking - The blood levels is increased within 40 mins, 90% is metabolized by the liver, 10% is excreted trough the lungs and urine, that's how u blow big numbers when cops pull you over. - **Intoxication:** - Slurred speech, ataxia, and impaired judgment, uninhibited behavior, drunkenness, fluidizing effect to membranes, makes liquids less viscous. - Impaired judgment, impaired social or occupational functioning, incoordination, unsteady gait, and flushed face - Motor activities are affected, sedation, slurred speech, ataxia, uninhibited behavior, fluidizing affect on membranes. Increases GABA (calming affect). - Increases serotonin a couple of hours later decreases serotonin and causes depression. BAC: 0.08. The goal is to prevent respiratory arrest, when someone is drunk might fall and get cranial injury, or vomit and get aspiration [2 thing s u got to watch out for ] - The individual is legally intoxicates with a level of 0.08 to 0.10 percent. - **Effects on the body:** - Causes depression of the CNS - Vasodilatation can damage myocardial muscle; can cause hypotension, also used to slow labor, smooth muscle relaxation. - Can cause, esophagitis, gastritis, pancreatic, cirrhosis of the liver, ascites, sexual dysfunction, - It goes from front to back of the head. It causes impaired myocardial, causes vasodilatation (hypothermia) you lose you body temperature - Is a direct irritant to mucous membranes - Relaxes the uterus and slows labor. Accidents- hematomas from falling, liver damage, multiple vitamin deficiencies, organic mental syndromes, long term effects death due to liver disease, fatty liver, gastritis, pancreatitis, irritant to mucus membranes, multiple vitamin deficiencies, - Malabsorption, can lead to organic brain disease, nervous system: tolerance and physical dependence, withdrawal, effects on eyes, reduced visual acuity, mild anemia due to folic acid deficiency, inhibits the proliferation of bone marrow, increased bleeding time, BP and pulse go up, tachycardia, - Alcohol can be good for the coronary artery if used with limitations, testicular atrophy, milk in breast (happens to men and women) hyperglycemia, FAS (fetal alcohol syndrome), affects immune system. Damage to the Tells - All Cancer risk, mouth, larynx, esophagus, liver, and breast. - 80% of people drink in this country - **Withdrawal:** the worst withdrawal is delirium tremors (DT) also know as (autonomic arousal) motor agitation restlessness's the first sign of withdrawal & even DT, anxiety, insomnia, tremors, nausea, diaphoresis, loss of appetite, tachycardia, elevated blood pressure, nausea, vomiting, depressed mood. Never want an alcoholic to go into seizures the have a low seizure threads hold. - **Severe Withdrawal:** hallucinations, allusions (stimulated by something in the environment ex. they hear a car think someone is shooting at them) the nursing care is to explain reality, no that was car, (avoid shadows). The S&S of DT is similar to psychotic, but you must never give Haldol cuz it lowers the seizure threshold in a predispose PX. (Give Librium or ativan). Very distractible the goal is to prevent seizures and to restore electrolytes. They can die from DT (look at article) we give Librium (benzo) IM to treat it has anticonvulsive qualities but. It's an antidepressant give 100 mg it stops the person from going in to DT. We never put somebody on DT on restraints bcuz they fight it and can die. - **Overdose:** 3-5 drinks per day is considered alcohol abuse severe hypothermia, respiratory failure, pass out & vomit and chokes, person becomes almost paralyzed. Passed out - **Antagonist**: flumazenil (if you have too much) Benzodiazepine (it can reverse effect). Antibuse- causes a very unpleasant effect when alcohol is in the body. Acetylhyde stays in the body and makes ct sick. Flushing, headache, N & V, sweating, hypotension, confusion, last about 30min-1 hr. Pt is exhausted and sleeps it off. Teach abt-hidden alcohol in food and OTC meds. - **Treatment/Nursing care:** the goal is to prevent DT, if he has abstinence followed by restlessness (use Librium). Than give a drug called (disulfiram) is an antabuse, cannot take with alcohol cuz they can get a severe reaction. (Only give to plp who are educated and are compliant. Once the PX has the Antibuse in their body they cannot do any mind games cuz. If they do will get flushed then they faint, BP goes up and down, they vomit, they fill deftly ill they don't get a seizure (read on chapter) Don't give to any body who has a cardiac condition cuz it stimulates cardiac lead to heart attack. Px knows he can drink. - **12-step program:** (sobriety is the goal), sponsor, and medical intervention. 2 man came up with it stared with one doctor and one lawyer who both wanted to stay sober so they created the 12 step program. They support each other now is called AA meting; u can go there drunk or sober. Self diagnosing illness (the first step is realizing you have a drinking problem) - **Alanone:** Program for family of a substance abuser. They teach that you cant control an alcoholic you can only control yourself and your reaction to it, they talk about enabling behaviors which is what the spouse do (is unconscious) to control the person who drinks. Helps them cut back on enabling behaviors. - **4 phases of alcoholism** 1\. **Pre-alcoholic phase:** recreational use, child observed family drinking & learns that use of alcohol is an acceptable method of coping. Tolerance develops and the amount required achieving desired dose increases. 2\. **Blackout Phase-** pt doesn't remember how they got home, defensive of drinking, they are In denial & use a lot of rationalization. 3\. **Crucial phase-** loss of control, binge drinking. The ability to choose weather or not to drink is lost, drinking is the total focus & the individual is willing to risk everything that was once important. A lot of anger & aggression are seen. They might experience the loss of a job, marriage family & friends. 4\. **Chronic Phase-**: emotional, drink more than sober, self pity, hallucinations, tremors. The individual is usually more intoxicated than sober. Impairment in reality may result in psychosis. Abstention can lead to hallucinations, tremors, panic, depression, & ideas of suicide. **Codependence**: relationship in which a non-substance abusing partner remains w/ the substance-abusing partner. The relationship is dysfunctional. The non-abuser is over responsible and the abuser is under responsible. Codependence operates out of fear, resentment, helplessness, and hopelessness. They are obsessively driven to control the user's behavior and to solve the problems created by the user. When this is not effective the non-abuser becomes exhausted and depressed but is unable to stop helping- suffers from self-esteem and abandonment issues. Codependences are caretakers and they are compensating for feelings of inadequacy. Be careful not to judge if they are codependence. They are enabling. **Enabling behavior**: any action by a person that consciously and unconsciously facilitates substance dependence. Making excuses for partner with employer, (calling out sick for them) and lying to others about their abuse, protecting abuser from natural consequences of the problems. Cleaning them up after they vomit & taking care of them. *Enabling is a response to addiction not a cause.* Goal: desire to keep family together. (Elanon? Helps addict family deal with enabling behavior, learn that you cannot change anyone but yourself.) **Sedative/Hypnotics (Benzodiazepines)** - **Benzodiazepines (Valium) Valium:** - Includes lorazepam (ativan), diazepam (Valium), chlordiazepoxide (Librium,) we give theses in psyche to take the edge of anxiety. - Can't really overdose on this drug, can only be a problem when mixed with alcohol or other drugs. - It doesn't cause a lot of problems with the organ. - Is a control substance it can be very addictive but usually plp don't die from Valium even if they take 100 pills a day. - Valium longest acting, if person has a long going anxiety give them Valium so they are covered all day. - For substance withdrawal we give them Librium is intermediate. But if there is a psychotic PX and you just want to take the edge of the anxiety give them (ativan) (think about how long they act and why u would - Benzos will not go to coma and death in higher doses; general rule is Benzos go to GABA. When GABA is enhanced it inhibits the action of other neurotransmitters - Some of the benzo cause sedation induces sleep (hypnotics, can be used as, anesthesia, has anticonvulsive quality, is a muscle relaxant, if PX has COPD can suppress respiration. (This drugs are safer to use than barbiturates) - People don't usually die with Benzos unless is mixed with another substance - Benzo Sedation, some doses paradoxical effect (excitement and agitation, usually children and old ladies), hypnotic effects, induce sleep, induce anesthesia, anticonvulsant activity, and muscle relaxation, can be used for spastic clients, can cause cardiac and respiratory depression, but are dose related therapeutic doses. - Withdrawal effects: excitation, dependent seizures, detox in the hospital **Antagonist:** **Flumazenil** used if a PX does gets an over dose, it knocks the action out. **Sedative /hipnotics (Barbiturates)** - **Barbiturates-patterns of abuse** (Melo drugs, large doses are lethal 10x's normal dose) start off as a prescription for sleep. Large doses are lethal. Are sedatives, are used as sleeping pills can cause sedation in high doses are used as anesthetics. In over dose person can go to coma and death. Withdrawal can become fatal. It depresses all - **Mode of Action:** CNS depressant muscle relaxation (for MS, cerebalpalsye), can suppress respiration in normal doses w/ pt w/ COPD (no Valium), (sedation, agitation, or excitation) paradox effect- can facilitate amnesia, anticonvulsive effect. They depress the activity of the brain, heart, they reduce the metabolism they depress any system that uses energy. They cause all levels of CNS depression. The primary action is on nervous tissues. - **Effect on the body:** results in respiratory depression, hypotension in large doses, in high doses produces anesthesia & suppresses urine function. High doses can decrease body temperature; there is an initial increase in libido followed by a decrease in the ability to maintain an erection. - **Intoxication:** muscular in coordination, nystagmus-eyes jumping (jitter) from right to left, slurred speech, ataxia, stumbling and falling, bumping into stuff, unsteady on their fee, impaired judgment or impaired social or occupational functioning. Impairment in attention or memory, stupor. - **Overdose:** stupor, incoherent speech, mild brain damage, might hallucinate. Their eyes goes back and forth real fast, ataxia dizziness, slurred speech they fatal and get hit people don't fight when on this drug, may hallucinate, causes brain damage all the time - **Treatment and Nursing Care:** Detox in the hospital, tapering, no direct antagonist, and rehab. Drugs: (Phenobarbital, luminal-used for epileptics). Sudden withdrawal can be fatal. High doses will be used to prevent seizures. Jerky movements. Detox cuz if you suddenly stop the barbiturates they have severe seizures, they can die. They usually have to come to the hospital to get detoxify. They detox the PX with the same drug the PX is addicting; 10 times the normal dose is lethal. 5-700mg, can be given if is an addict, cuz normally we don't give no more than 200mg to normal PX. F you see this order look at the chart & see if is an addict. They do a decreasing dose start of with 700 and every 2 days decrease to 500, 400, and so on. - **Withdrawal:** sing &symptoms include hyperactive, sweating pulse greater than 100 bpm, increased hand tremors, insomnia, nausea or vomiting, hallucinations, illusions, psycho motor retardation, anxiety, & grand mal seizures. Has to be done gradually in a treatment facility, due to seizure activity. **Alcohol & barbiturates u must detoxify in the hospitals** **Central Nervous Stimulants:** - **Central nervous stimulant include:** (Crack, Cocaine-patterns of abuse) are identify by behavioral stimulation psychomotor agitation, & increase in thoughts, cocaine is the most potent stimulant derived from nature. Physician begins to use this drug as an anesthetic. Has also been used for cancer PX. Is still illegal to buy it. Acts like an antidepressant. Starts recreationally then people get addicted. If snorted it takes 3 min to get high. IV it takes 15 seconds, and smoked it takes 7 seconds to metabolize quickly. - **Crack- Rock of cocaine.** Most addictive substance known to man, most tolerance. High only last 15min, it is made from the rock of cocaine. It is the most addictive substance known to man. 1st high last 15min and all other drug activity are done to reach the 1st high. No withdrawal symptoms or side effects. Cocaine reduces the reuptake of norephinephrine, it depletes it **[Four phases]** 1. Preoccupation of getting the substance 2. Ritual and start doing it compulsively find a subject & get involved with it 3. Followed by regret & guilt, shamed 4. Hopelessness, powerlessness which leads them to come in to therapy - **Mode of Action:** cocaine when snored is absorbed within 3 min it can also be absorbed 7 seconds IV, 15 seconds if smoked, it metabolizes quickly. Crack very similar the high last 5-7 mins & then they looking for more. Psychoactive agents, substance alters perceptions, awareness, cognition, judgment and behavior. Blocks the uptake of norephinephrine and dopamine (same as TCA's). Pt's crash when they stop taking it, they crash and sleep. Severe depression b/c of depleting neurotransmitters, including serotonin. - **Effect on the body:** effects on the body is not permanent, it causes excitement, tremors & restlessness, there can be cardiovascular or pulmonary effects, causes more myocardial demand for oxygen, GI- contraction of the bladder, makes urinating difficult, sexual- increases urge in man & women, makes them feel very sexy & horny, some man have sexual dysfunction from cocaine, - **Intoxication:** intense euphoria short duration is highly addictive increase self-esteem and work performance. Highly addictive with increased self esteem and task performance (just in the beginning) does not damage any organs, will cause cardiac arrest. Mostly psychological dependence. Some physical. - **Symptoms:** (Psychological) psychomotor agitation, euphoria, nausea, paranoia, insomnia, pressured speech, tachycardia, hyper sexuality, grandiosity, hyper vigilant, grandiosity, can be violent and have nightmare (REM rebound, wild dreams when they are coming off of drug). (Physical) Nausea, fever, headaches, SOB, dilated pupils, Hnt w/sweating, weight loss, endocarditic (dirty needle), memory loss, bronchitis, anorexia, ataxia, cardiac arrhythmia, depression, fatigue, can be suicidal. - **Overdose:** In overdose is were you get rupture heart, cardiac arrest, seizures, respiratory difficulty, restlessness, tremors, hallucinations, assaultive, rapid respirations, panicky, cocaine psychosis, rash. - **Treatment:** they have to be in antidepressant for almost a year they get severely depressed, cuz it burns out dopamine cuz they keep getting high. Assess for cardiac changes, look for deviated septim and erosion of the nose, pt needs a quiet environment with decrease stimulation, nonjudgmental atmosphere, speak calmly and slowly. Meds- ativan, Valium really helps them, inderol (tachycardia and tremors). **Nursing management** - Keep px in a quiet environment - Reduce stimuli - Have a nonjudgmental attitude - Speak slowly & calmly, give px space - We only use restraints when needed but we try not to, we use valium & ativan for agitation related to cocaine abuse. - **Symptoms of withdrawal:** No severe withdraw symptoms, just depression & suicidal, but no seizures, don't do permanent damage. Depression, fatigue, sleeps changes, anxiety and irritability, become suicidal, psychomotor agitation. They experience something called crash they get severely depressed, irritable. The PX cannot sleep, for a couple of days. The PX needs to have their cocaine in order to feel normal once they stop they don't feel normal. They like sugar & always want 2 snacks. - Crack patients are very guarded and paranoid, very irritable, agitated don\'t sleep, hallucinations, tremors from adrenergic irritable give Inderal, CBM crack body movements, look like tardive. Tightness in their chest, cardiac arrhythmias. Increased appetite, teeth grinding, love sleep. Frequent observation. - **Co dependent relationships:** Statistics- \$400,000 a day spent on illegal drugs. 65 % of world's illegal drug use in the USA. ½ families has problem with drug use. **Stimulants- patterns of abuse** - (60\'s and 70\'s antidepressants.) Ex: Diet Pills Amphetamine (Benadrine, Dexedrine, Desoxylin) Prevents sleep - **Mode of Action:** (IV) speed, psychoactive, acts like MAOIS - **Intoxication:** increased vital signs, increased energy, increased sexual sharpness, and paranoia. Prolonged use can cause brain damage. It's called the poor man's cocaine. IV use = speed (run) Injection of repeated dosed up to 400 mg. Side effects: mental alertness, marked euphoria, can make paranoid and sometimes if too much illusions of bugs crawling all over body. Last longer than crack when smoked (hours). Speedball- (heroin & crack) IV causes infarctions, strokes, and respiratory depression. - **Overdose:** excitation, cardiac rupture and stroke. - **Treatment:** Antidepressants, it care for cocaine addicts. - **Withdrawal:** depressed than crash (sleep it off), eventually up and irritable. **Hallucinogens** - (LSD, Mescaline, Peyote) Mescaline and peyote are used in some religious ceremonies. Synastashesia -- causes schizo like symptoms (hallucinations) ex: can cause waves of color when listening to music, originally used in psychotherapy. - **Patterns of abuse**: (Non addictive). Can be smoked, snorted, pill, IV. Enhance interpersonal relationships used by psychologist increases perception to such an extent that people see waves of color when listening to music non-addictive but very dangerous (supernatural) patient can become schizophrenic (gene) you won't notice you took it till the effects start to show - **Mode of action:** psycho mimetic agent, psychedelic agents, mimics psychosis, increases dopamine because it gives schizo like symptom, hyper arousal of CNS. - **Intoxications**: perceptual distortion, perception of the supernatural, i.e. that person can fly, bad trip (panic reaction), have flash backs hallucinations come in small amounts and can last for hours. Increased introspection, cab be found in the morning glory seed, mushrooms, resembles dopamine, not addictive. - **Overdose:** stay high longer, be careful with touch, client may perceive your hand entering their body. Doesn't really damage the body its damage is the behavior 8-12hrs can be high for a day - **Treatment:** you have to talk them down orient them to reality no touching (they think your going in their body by breaking the barrier) **Other substances: patterns of abus**e (PCP, marijuana, inhalants, Methamphetamines) - **PCP:** (phencyclidine)- is an animal tranquilizer, horse tranquilizer, AKA angel dust, widely used (increases dopamine activity) will cause hallucinations, can be smoked, snorted, IV - **Symptoms** include tremors, nausea, blurred vision, parathesia, dizziness, and distorted perception, increased vital signs, over dose is fatal and its poison to the body - **Toxicity:** Panic, flashback, bad trip just like LSD. - **Treatment**- must acidify urine by using cranberry juice. Make them pee it out. Ammonia chloride IV to acidify the urine. Must tell ct you are going to touch them b/c they are paranoid. Must use Haldol on these cts. - Associated with a lot of violence, high aggression, can have symptoms of psychosis - **Marijuana:** (Cannabis) Stats -- 200-300 million people use it worldwide (most used substance). 30-40 in the USA uses it. - THC- active ingredient. You can smoke it or put it in food (ex: brownies). Hashish-more potent extracted resin. It is a mellow drug unless paranoid - Symptoms include euphoria, uncontrollable laughter, giggles, alteration in time perception, depersonalization (feeling like body isn\'t real), sharp vision, relaxation, increased impulse, red eye, increased introspection, increase vital signs, increases pulse, red conjunctiva, increase weight due to munchies. - Hazards include- chromosome damage, narrowing airway, bronchiole infections, orthostatic hypotension, and a motivational syndrome (squash rock), and increased infection. - Medical use: cancer pt's, chemo pt's, muscle spasm, MS, cerbalpalsye, viewed as anticonvulsant in some pt\'s. Can treat glaucoma and helps elderly to improve appetite. - THC is what they check for in the urine and it stays in your urine for 30 days - **Inhalants:** Industrial solvents, hydrocarbons, fluorocarbons, aerosols, organic nitrates, ether, gas paint thinners, anything in an aerosol can, nitrous oxide. Boys early teens 12-18 years may experiment with plastic bags and inhalants. This replaces a certain amount of oxygen in the brain. - Intoxication: poor concentration and drowsiness, numbness and euphoria, tingling, visual and audio disturbances. Getting high on an inhalant means using inhalant as 35% of inhaled air. 100% can lead to death. Replaces oxygen in the brain, person is inoxic. - Examples: Nail polish remover, white out, butane lighter fluid, degreaser, fabric protector, fingernail polish and polish remover, gasoline, liquid shoe polish, paint and paint thinner, engine starter, whipped topping, cleaning products, glue, fire extinguisher, hair spray - Warning signs: runny nose or nose bleed, sore and rashes around mouth and nose, chronic cough, nausea or loss of appetite, poor concentration, unusual breath odor, finding plastic baggies and empty cans in their room/trash, engaging in activitities that use a lot of solvents. - Sudden sniffing death: 100% of air inhaled is inhalant. - Sexual suicide. - Key terms: Anoxia, bagging (placing inhalant in plastic bag), huffing (soak a rag in gasoline and place it in their mouth), Nitrous oxide, poppers (butal nitrates used by heart patients, brings a rush to the head, homosexuals use it) - **Methamphetamines**: (Ice, Crystal) homemade crack or meth can cause fires, considered the workingman's drug. Acts like an MOAI has an antidepressant effect, which causes euphoria. - **Intoxication:** increased energy and all physiological functions are increased, dilated pupils, nausea and vomiting, become grandiose, impaired judgment, some euphoria, paranoid (may last for months), panic anxiety - **Withdrawal:** fatigue, depression, agitation, apathy, insomniac, craving, overdose, hyperpyrexia, come, stroke, MI, ruptured heart, and death. - **Overdose:** - **Treatment:** ambient cooling, acidify urine (cranberry) or ammonia chloride. **Other Substances:** (Ecstasy, Rohypnol): - Ecstasy (MDMA) amphetamine and LSD, stimulant and hallucinogen, appetite suppressant, last 4-19 hrs. - **Intoxication:** empathy for other people, not addictive but it is habit forming euphoria, increased energy, self-confidence, touchy feely drug. In men it causes impotence, increases empathy and introspection, was used in talk therapy because it increases introspection, a lot of controversy, people say its harmless. (Sold with Viagra), disinhabition and relaxation of involuntary muscles, amnesia potentiated by alcohol. - Dehydration, exhaustion, liver damage, impotence, teeth clenching, strange body sensation, place Vicks on skin because of menthol feeling, ice cubes on their eyes. - **Overdose:** passing out, HNT, renal failure, liver failure, mental depression, panic attacks, loss of consciousness, death brain damage, involuntary teeth clenching, muscle cramping. - Rohypnol-very fast acting, aka roofies date rape drug, short acting, benzodiazepine - **Robotripping:** slang term fro overdosing meds intentionally overdosing on OTC cold medication ex: robitussin and Nyquil, (DXM-dextromethorphan) drinking whole bottle, intentional overdosing. Death, psychosis, brain damage and seizures can ensue overdose can be FATAL, really large doses gives you psychedelic effects. DXM is the trouble ingredient Dextromethorphan. Dusting- abusing compressed air (ex: computer air) gets high from sniffing it, can be fatal, no **\* Medications Used to treat Substance Abuse**\* - **Antabuse (disulfiram):** causes sickness when taken with alcohol[, alcohol antagonist], only contraindication is cardiac problems. Teach client about reaction when alcohol is taken with it. If they do drink they feel blood pressure goes up and down they want to die vomiting all over ex guy on plane - **Librium (Chlordiazepoxide):** intermediate acting benzodiazepine, used to treat alcoholism. Drug of choice. Decreases brain swelling, decreases seizures. Stops tremors, tapers fast. Causes increased sleep and reduces anxiety, patient should remain recumbent 2-3 hours after IV or IM injection, may cause orthostatic hypotension, check BP and P before giving medication, monitor for S&S of agrenulocytosis, abrupt cessation may cause withdrawal symptoms, may cause photosensitivity. 100 mg IM decrease dos over a week - **Methadone (dolophine):** narcotic, agonist to heroin, knocks heroin off receptor, will knock heroin off receptors. Most pt is tapered off. Monitor respiratory status. Acts like a narcotic (is the substitute for heroin) - **Narcan:** emergency drug used in prn, narcotic antagonist. Bump heroin off receptor, addict will get up quickly. Must monitor vital signs every 15 minutes, check mental status. Too much causes terrible diarrhea. - **Naltrexon (Reveia):** long acting. Decreases cravings (alcohol and drugs) assists in detox and rehabilitation. Do not medicate with OTC drugs such as those for colds. Tell dentist and doctor before treatment. - **Ativan:** short acting, anxiolytic medication. Maintain equipment to keep a patent airway before and during IV administration, do not drive within 24-48 hr after taking drug, do not consume alcohol at least 24-48 hr after administration of the drug, do not self medicate with OTC drugs. Do not give to cardiac PX. **Personality Disorders (usually in axis II)** **Personality**: is the emotional and behavioral characteristic that are particular to a specific person and that remain somewhat stable and predictable over time. **Personality Disorders:** occur when traits become inflexible and maladaptive and cause either significant functional impairment or subjective distress. This disorder is coded on Axis II. - Description: individuals with personality disorder are not often treated in acute care settings for the personality disorder as their primary psychiatric diagnosis. - The behavior of borderline client is very unstable, and hospitalization is often required as a result of attempts at self-injury. - The antisocial personality disorder may enter the psychiatric arena as a result of judicially ordered evaluation. Psychiatric intervention may be an alternative to imprisonment for antisocial behavior if it is deemed potentially helpful. - **Description:** - Enduring personality traits that are inflexible and impair social and occupational functioning w/ the absence of mental illness. - Sense of entitlement, like the world owes them something, immature, lack of emotional distress, poor impulse control, chronic poor coping, poor frustration tolerance, disability in working and loving, notoriously unreliable and using people, ability to evoke conflict between people, intense effect on their people, when in the hospital they have been admitted for physical problems, - They will never tell you they have a psychological problem, very manipulative, very responsive to stimuli (action motivated people) can be part of substance abuse. Not the focus of treatment. - **4 components:** inflexible and poor responses to stress. Acting out when stressed, poor functioning w/ work or in relationships, all abt the sex. Can evoke conflict w/ other people and seeks help w/ physical problems (substance abusers). Biological causes mainly men; poor role models or fathers were cruel or sadistic. - **Statistics:** 10 million or 10% of populations have PD: 3% are males, 1% females, 4% are antisocial. With borderline, 1% males, and 3% female. - **Differences:** Borderlines are very liable, manipulative, can appear antisocial; BOARDERLINE SUFFERS decreased self esteem responds to treatment. Antisocial does not suffer, increased self-esteem, poor prognosis, does not have any guilt. - **Genetic components:** Borderlines are created by mother\'s behavior **Borderline Personality** - **Definition:** is characterized by a pattern of intense and chaotic relationships, with affective (mood) instability and fluctuating attitudes toward other people. These individuals are impulsive, directly and indirectly self destructive, and lack a clear sense of identity. (They keep you at a distance emotional wise) - 3% are women 1% man, occurs more in women - Specific and stable form of personality that lies between normal and psychosis. PX at times may look normal or narcotic but has transient psychotic episodes. PX maintains reality testing when not under stress but involvement w/ others they have difficulty with people and conflict. - **Childhood trauma**: sexually abuse by a non-caregiver. It has been linked to post-traumatic stress disorder in response to childhood trauma and abuse. - **Theory of object relations**: the mother experiences her own fear of abandonment and in return she rewards clinging, dependence behavior and punishes independent behavior in the child. The child wants to achieve independence but fears the mother will withdraw emotional support as a result. **Clinical Picture:** - ***Chronic Depression:*** Is common in Ct's with this disorder, it occurs in response to feelings of abandonment by the mother in early childhood. Depression is cause by rage turned inward on the self and externally on the environment. Rarely is the person aware of the true source of these feelings until well into long-term therapy. - ***Inability To Be Alone:*** Because of chronic fear of abandonment, these clients have little tolerance for being alone. They prefer a frantic search for companionship, no matter how unsatisfactory, to sitting with feelings of loneliness, emptiness, and boredom. - **Assessment:** less attractive of people w/ other diagnosis, angry feeling with many people argumentative, overly manipulative, demanding and act entitled, irritable, and sarcastic. Report feeling angry and lonely. - Reality testing intact, poor judgment but seems intelligent. "Borderline" was introduced to identify clients who seemed to fall in the border between neuroses and psychoses. - Transient psychotic episodes that develops when doing drugs. Impulsive, can slash wrist, or mutilate self. - Abuse alcohol and report unusual, afraid to be alone, sexual behavior. Lacks creative achievement. Good scholastic ability, but poor performance. Suicidal attempts seen as attention getting. - Regressed child like in hospital. Depressed and bipolar hypo manic episodes. Destructive with property. - Manipulative, clinging can't stand to be alone. Demanding, hostile, angry and intense. Seek out others to avoid being alone. Decreased empathy for others feelings, little friends. Sexually promiscuous, some eating disorders. - Use a lot of denial. Emotionally shallow, lacks a sense of identity. Preoccupied w/ self, inferiority, labile mood, depression, self mutilate (can be a call for help, however its so that they can feel something, when they see blood, it makes them feel live, relives anxiety), any disappointment can lead to anxiety and acting out. Stormy relationships, irritable and sarcastic. - Low performance, impulse, unusual sexual behavior, good scholastic ability, however they do not succeed, very manipulative, clinging, demanding. - **Psychological:** Problem with separation and individuation, problems separating from mothering one, mother is rewarding clingy behavior, mother withhold affection to reward independence. She incapacitates them from acting independent - **[Borderline Defenses:] Patterns Of Interactions** - **Splitting**: refers to the active unconscious effort to categorize people and events as either good or bad. Can also refer to self as all good or all bad. Precedes the development of ambivalence. (Mixed feelings or emotions) We were all splitters when we were young. When we feel good about ourselves everything is good, black and white. (Manipulating behavior, splitting staff, between hospital shifts, day people are mad at evening people and so on, patients know that and can get special favors). For this reason is it important for the staff to be on the same page. (Ex. carabello) - **Projective Identification**: getting rid of unwanted thoughts, feelings, fears, and attitudes by placing them in another person through an item of behavior, verbal or non-verbal thus, creating the feeling in the other person. Person gets involved in a behavior and creates a feeling in you. (What happens when you fall in love) Borderline will act a certain way to cause you to act a certain way, make you feel bad about yourself as a nurse. Border liners hate being alone & like to project sexuality. - **Denial (bland):** This form of denial refers to the act of disavowing the importance of an event and the feelings involved in an event or personal issue. The person will acknowledge that the event occurred but that it does not have an effect. Borderlines are known for this form of denial. The person knows they did something wrong but denies the importance of it - **Devaluation**: refers to finding fault with everything and everyone. Minimizes the importance of treatment and the helping person. "No one ever gets well here". Usually patient makes you feel useless. Making staff feel bad about their work, which some times makes them change their care plan - **Acting Out**: refers to the unconsciously participating in an activity in order to avoid acknowledging feelings. The activity is usually symbolic of a conflict. Teenagers do this, sex drugs, stealing. Indirectly they want someone to do something for them. - **Manipulation-** they use manipulation to prevent the separation they so desperately fear. Playing one individual against another is a common plan to prevent fears of abandonment. - **Self destructive behavior-** self mutilating behavior can be fatal, but most commonly they are manipulative gestures designed to elicit a rescue response from a significant others. Suicide attempts result from feelings of abandonment following separation from significant other. Their suicide plan includes a measure of "safety" (e.g. swallowing pills in an area where the person will surely be discovered by others or swallowing pills and making a phone call to report the action to someone) other destructive behaviors include cutting, scratching, and burning. The pain validates their existence. Their threshold for pain is low being that they are in a state of depersonalization and derealization. - **Impulsivity-** these individuals have poor impulse control based on the primary process functioning (pleasure principle). Include substance abuse, gambling, promiscuity, reckless driving, and binging and purging. (Eating a lot then making their self-vomit). Many times these acting-out behaviors occur in response to real or perceived feelings of abandonment. - **Nursing Diagnosis**: Personal identity disturbance r/t unresolved separation individualization AEB acting out, crying, splitting, anger, out burst, copying behavior of others. - **Goals:** ct will develop an integrated sense of self, stop impulsive behavior, help ct be safe. +-----------------------+-----------------------+-----------------------+ | **S &Sx:** | **S &Sx:** | **S &Sx:** | | | | | | Risk factor: | - Depressed mood | - Clinging and | | | | distancing | | - Parental | - Acting-out | behavior | | emotional | behavior | | | deprivation | | - Staff splitting | | (unresolved fear | | | | of abandonment) | | | +=======================+=======================+=======================+ | **Nsg Dx:** | **Nsg Dx:** | **Nsg Dx:** | | | | | | **Risk for | **Complicated | **Impaired Social | | Self-Mutilation** | Grieving** | Interaction** | +-----------------------+-----------------------+-----------------------+ | **Nursing Actions:** | **Nursing Actions:** | **Nursing Actions:** | | | | | | - Observe Ct's | - Create trusting | - Examine | | behavior | relationship | inappropriate | | frequently | | behaviors | | | - Encourage | | | - Secure verbal no | appropriate | - Encourage | | harm contract | expression of | independence and | | from ct. | anger | give positive | | | | reinforcement | | - Care for wounds | - Explore true | | | matter-of-factly | source of anger | - Explore fears | | | | | | - Encourage | - Teach stages of | - Explain | | verbalization of | grief | inappropriateness | | feelings | | of these | | | - Set limits on | behaviors | | - Make environment | acting-out | | | safe | behavior | - Rotate staff | | | | | | - Act as role model | - Give positive | | | | feedback | | +-----------------------+-----------------------+-----------------------+ | **Outcomes:** | **Outcomes:** | **Outcomes:** | | | | | | - Ct has not harmed | - Client expresses | - Relates to more | | self | anger | than one staff | | | appropriately | member | | - Seeks out staff | | | | when desire for | - Understands | - Completes ADL's | | self mutilation | stages of grief | independently | | occurs | and the need for | | | | personal | - Does not | | | progression | manipulate staff | | | through this | against each | | | process | other | +-----------------------+-----------------------+-----------------------+ | **Medical RX:** | | | | | | | | Olanzapine 5 mg bid | | | | | | | | Fluoxetine 20 mg | | | | daily | | | +-----------------------+-----------------------+-----------------------+ **Nursing interventions** - **Confrontation:** draw the line in a non-punitive way. Come with something that's positive. E.g. that's good you changed the tables, but you moved it on the wrong side of the room or "John you are ok but that behavior has to go") point out discrepancy's of what a pt said and what a pt does. 1\. Person who delivers the confrontation must have a therapeutic relationship w/ ct. 2\. Confrontation starts w/ a positive statement. 3\. Discrepancy is stated. 4\. Use silence. - **Limit Setting:** no yelling; do not decrease pt's self esteem w/ limit setting. - **Introspection:** is an examination of one's own thoughts and feelings - **Evaluation:** evaluate procedure to see if it was effective **Treatment modalities:** SSRIs and MAOI have been successful in decreasing impulsivity and self-destructive acts in these clients. The MAOI's are not commonly used, however, because of concern about violations of dietary restrictions and the highest risk of fatality with overdose. The combination of an SSRI and atypical antipsychotic has been successful in treating dysphoria, mood stability and impulsivity in ct's with borderline personality **Nursing Interventions:** Gordon's health Functions: 1. **Health Maintenance**: deal w/ behavior, scars, malnutrition, infection, mutilation, might be on welfare 2. **Nutrition:** Binge eating and purging. 3. **Activity:** impulsive, assaultive, seeks out other pt's, gossip, mind everybody's business, troublemaker, can't be alone. 4. **Cognitive:** judgment impaired, projecting, splitting, can't make goals. 5. Self Perception- undeveloped self concept, identity diffusion, mimic and copy behavior of others, feels extreme of emotions, mood swings, external events, impaired impulse control, bored, rage attacks, can be suicidal, intense but superficial relationships, split up families, school and work failure, acts like a victim. 6. **Sexuality:** frequent sex w/ many partners. Check for STD's and check for pregnancy. 7. **Coping:** poor problem solving skills, abuses substances. 8. **Values:** unclear value system (identity diffusion) - Teach ct socially acceptable ways to recognize and deal w/ feelings of anger. Contract focuses on therapeutic goals. Use a journal and go over feelings in journal, help ct label their feelings (does not know diff between empty and sadness). Be consistent with pt, Pt will play favorites with nurses (offer self). They are usually empty with no feeling, help them label their feelings **[Antisocial Personality Disorder]:** Have Sense of entitlement, long history of illegal activity. (Sociopath) - These individuals exploit and manipulate others for personal gain and have a general disregard for the law. - They have difficulty sustaining consistent employment and in developing stable relationships. **Description:** (DSM III)- - Disregard for rights of others, deceitful, lying and cunning, impulsive, get into fights, irresponsible, lack of remorse. (Has to be at least 18 years old for this diagnosis). - Unusually evidence of conduct disorder, grandiose, superficial charm. Need increased stimulation, compulsive behavior, (ex: food, sex, alcohol, gambling, drugs). Adopted children have higher incidence. - History of arson, bedwetting (neurological), cruelty to animals. Fail to develop superego, id dominating. Parent might have been antisocial. If you ask they going to say there wonderful, very nice people don't appreciate me, Parent usually father sadistic and beats child. There history have chronic trauma. - A lot of times men blame the mothers (inconsistent) and fathers maybe be beater, unloving, antisocial, they learn to manipulate and induce feelings in others that they want, usual have good physical health. Great imitators. - Do a very thorough assessment substance seeking. People usually stay away from them. Men are dependent on women. - **[Assessment:]** - Illegal activity (might have been in prison) - Not diagnosed for age before 18 (must be 18 or older) - Lie, impulsive, aggressive, start fights, irresponsible, lack of remorse for other, lack of empathy, grandiose superficial charm - Can get depressed don't notice it - Usually physically healthy, but can be malnourished - Substance seeking, pimps, lack concerns for others, break rules - They can imitate - Rescue fantasy, px seems normal & they speak as if educated (women works for them) - Sexually promiscuous, usually have STDs - Lifestyle problems: drugs, sex, homeless, physical assault, malnourished, poor appearance Cope: they act out to relieve stress, (rape, steal), they rape, steal, use drugs, fast cars, some have compulsive behaviors; food addicts, drug, sex and gambling. Clients are mostly seen in most clinical settings, and when they are, it is commonly a way to avoid legal consequences. Sometimes they are admitted to the health-care system by court order for psychological evaluation. Most frequently these individual may be encountered in prisons, jails, and rehabilitation services. (**Diagnostic criteria box 21-2)** - **[Clinical Picture:]** They appear cold and callous, often intimidating others with their brusque (blunt) and belligerent (aggressive) manner. They tend to be argumentative and at times, cruel and malicious. They lack warmth and compassion and are often suspicious of these qualities in others. They can be cheerful and charming however when things don't go their way they are likely to become furious and vindictive (desire for revenge) **Biology** -- (genetics) studies have shown that children of parents with antisocial behavior are more likely to be diagnosed with antisocial personality, even when they are separated at birth from their biological parents and reared by individuals without the disorder. - Characteristics such as temper tantrums, bullying attitude toward other children and daring are present from birth into childhood. **Family dynamics:** - Parental deprivation during the first 5 yrs - Severely physically abused in childhood. - Injury to the child's CNS - Other predispositions include: Absence of parental discipline, extreme poverty, removal from home, growing without parental figures off both sexes, maternal deprivation. **[Defenses]** - **Projection:** refers to getting rid of unwanted thoughts, feelings, fears and attitudes by placing them in another through an item of behavior, verbal or non verbal, thus creating the feeling in the other person. **E.g. Sue feels a strong sexual attraction to her track coach and tells her friend, "He's coming on to me!"** - **Rationalization:** attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors. **E.g. John tells the rehab nurse, "I drink because it's the only way I can deal with my bad marriage and my worse job."** - **Denial**: refusing to acknowledge the existence of a real situation or the feelings associated with it. **E.g.** **A woman drinks alcohol everyday and cannot stop, failing to acknowledge that she has a problem**. - **Acting Out:** Acting Out is performing an extreme behavior in order to express thoughts or feelings the person feels incapable of otherwise expressing. Instead of saying, "I'm angry with you," a person who acts out may instead throw a book at the person, or punch a hole through a wall. When a person acts out, it can act as a pressure release, and often helps the individual feel calmer and peaceful once again. For instance, a child's temper tantrum is a form of acting out when he or she doesn't get his or her way with a parent. Self-injury may also be a form of acting-out, expressing in physical pain what one cannot stand to feel emotionally. +-----------------------------------+-----------------------------------+ | **S & Sx:** | **S & Sx:** | | | | | **Risk Factors:** | - Disregard for societal norms | | | and laws | | - Rage reactions | | | | - Absence of guilt | | - Negative role modeling | | | | - Inability to delay | | - Inability to tolerate | gratification | | frustration | | +===================================+===================================+ | **Nsg. Dx:** | **Nsg. Dx:** | | | | | **Risk for Other-Directed | **Defensive Coping** | | Violence** | | +-----------------------------------+-----------------------------------+ | **Nurising Actions:** | **Nursing Actions:** | | | | | - Unconditional acceptance | - Explain acceptable behaviors | | | and consequences of violation | | - Low environmental stimuli | | | | - Explain clearly what is | | - Observe behavior routinely | expected of client | | | | | - Make environment safe | - Positive feedback and rewards | | | for acceptable behaviors | | - Explore true object of anger | | | | - Provide milieu environment | | - Show of strength, if | | | necessary | - Promote insight development | | | | | - Give meds as ordered | - Maintain attitude of | | | acceptance | | - Restrain if required | | +-----------------------------------+-----------------------------------+ | **Outcomes:** | **Outcomes:** | | | | | - Has not harmed self or others | - Demonstrate socially | | | acceptable behavior | | - Discusses angry feeling with | | | staff | - Is able to delay personal | | | gratification | | - Engages in physical exercise | | | to rechanneled hostile | - Does not manipulate others | | feelings | for own desires | | | | | | - Verbalizes inappropriateness | | | of past behaviors | +-----------------------------------+-----------------------------------+ | **Medical Rx:** | | | | | | **Lorazepam 2 mg q4 hr prn for | | | agitation** | | +-----------------------------------+-----------------------------------+ **Gordon's Health:** - **Health Percept:** usually healthy except for dirty needles, malnourished, can get beat up. - **Activity**- poor self-care, prostitution (can be pimps). - **Cognition-** lack of concern for rights of others, want to meet own needs. - **Self Perception**- never feel bad abt themselves, no guilt or anxiety. View self-positive. Blame others for misfortune. Do not feel depth of emotion but can act like they have emotions for manipulation. - **Role Relationship**: can be victim to violence, social isolation; speak as if they have great knowledge. Almost always get fired, very dependent on others, get women to work for them. Promiscuous, people users, like oral sex, STD's. - **Nursing Diagnosis**: Impaired social interaction r/t manipulation. - **Goal:** pt will not interfere w/ rights of others, be accountable for actions. - **Intervention:** Challenge w/ activities, can work own care plan, reward good behavior, teach a job skill, set limits on other ct's rights, use privileges w/ rewards, inexperienced nurses thinks' these pt's are normal. - **Evaluation:** reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care. - **Introspection:** is the self-examination of one's conscious thoughts and feelings. Is a purposeful and rational self-observation of one's mental state. - Lithium carbonate and Propanolol (inderal) may be useful for the violent episodes observed in cts with antisocial personality. - Personality disorders aren\'t really treatable disorder there more traits that get a bad name - Will come to our attention in psych if their withdrawal from substances need to be detox **Sexual Assault** - **Rape:** an act of aggression not of passion, expression of power and dominance by means of sexual violence usually men over women. - **Types:** - [Date Rape:] rapist known to victim (ex: college campus w/o roofies). - [Marital Rape:] spouse held liable for sexual abuse directed at partner (all 50 states). - [Statutory:] unlawful intercourse between a man under 16 years and a female under consent (14-21 y/o). - [Stranger Rape:] opportunistic, wrong place wrong time. - **Rapist profile:** Rapist's mothers were seductive but neglecting. Mom and son will share secrets growing up (physical) abusive homes (25-44 y/o). 51% are white, 47% African American, 2% other races. Usually married or living w/ someone at the time of offense. - **Victims:** rape can occur at any age (15 months-80 y/o), highest (16-24 y/o). 70 -75% are single women and attack usually occurs close to neighborhood. Victims were not chosen for any reason (Appearance or dress). It is out of convenience for rapist (stranger rape) **[Rape Trauma Syndrome]** **I-Acute Phase:** disorganization days to weeks, open expression of feelings or quiet fear, sleepless nights. Open expression of feelings, controlled response, and stoic. **II- Reorganization phase-** resolve their fears & feels empowered, reconnect w/ others - **Nursing Diagnosis:** Rape trauma syndrome r/t (specific rape), Powerlessness, Delayed Growth and development - **Goal:** ct's anxiety will be decreased and begin healthy grieving, ct will feel empowered; ct will integrate the rape experience. - **Interventions:** - Convey the ct's is safe, not to blame - Convey nurse's feelings of sorrow - Develop trust - Encourage description but do not probe - Explain all procedures - No hygiene interventions until all evidence is collected - Teach relaxation **Unit V- Non--psychotic Anxiety Disorders** - Description/ Definition: - **Primary gain:** relief of anxiety - **Secondary gain:** getting benefits from being sick, like the attention from caretaker. (milking sickness) - **Anxiolytic**: drug used to treat anxiety (Ativan) and other anti-anxiety drugs. - **Supportive psychotherapy:** talking therapy that helps pt's reintegrate, supports person\'s defenses - **Uncovering or insight psychotherapy:** ex: dream analysts, free association - **Mental Ventilation:** reviewing traumatic events in your life, talking about it over and over again in minute details until person is over event. - **Desensitization:** gradual exposure to a feared thought (like a phobia) or objects so that it becomes less and less traumatic. - Gradually talking about the situation until person is comfortable talking about it - If a phobia, gradually present the person to fear - **Transference:** feelings that a patient has toward a significant other get transferred to a nurse, usually a positive thing. i.e. mother transference - **Counter-transference:** feelings that nurses transfer to the patient. Like the reciprocate of transferred feelings i.e. Nurse treats patient like a child when patient treats patient like a mother. **Anxiety Disorder** - **Panic Disorder:** cardiac symptoms and GI symptoms, unpredictable, treated with antidepressants and Inderal. (Teach relaxation techniques). - **Phobias-** avoidance behavior, control anxiety by keeping real feelings out of awareness, symbolism operating, displacement, person practices avoidance behavior (avoid feared object), most phobias are symbolic of unconscious conflict. - [NSG DX]: + Anxiety r/t unconscious conflicts AMB irrational fear of the dark - **Agoraphobia-** never comes out of house - **Obsession-** intrusive thoughts, the person knows its irrational and he cannot control it - **Compulsion:** ritual or a behavior that reliefs the anxiety created by the obsession - **Obsessive Compulsive Disorder:** person who has intrusive thoughts that are irrational and engages in a behavior or ritual, control freak. - [NSG DX:] + Anxiety r/t unconscious conflicts AMB ritualistic cleaning or hand washing - **Post Traumatic Stress Disorder (PTSD)**: disorder in which experiences a severe or traumatic event that is not part of normal human experience. (ex: soldier, war, 911, a murder, any kind of personal violence) involves flashbacks and anxiety and terror attacks (relive the experience) - **Generalized Anxiety Disorder-** preoccupied people, constantly anxious. - **Somatoform Disorders:** disorders w/ physical complaints but no physical pathology. - **Hypochondriasis-** people who worry about their body function instead of focusing on their problems, considered a non-psychotic form instead of thinking about one\'s problems one focuses on their body. - **Malingering-** purposely faking an illness for their secondary gain (ex: call out sick to go shopping) OR patient sets up doctor, fake an illness and sue doctor. - **Somatization Disorder-** whenever they get anxious they feel it in their body, doctor shoppers goes from one doctor to another because they really believe there is something wrong with them, usually they are polysurgical patients, unnecessary surgery - **Conversion Disorder-** only occurs w/ the voluntary nervous system (ex: hearing, speaking, walking) pt may become paralyzed, blindness, deafness, muteness there are no organic findings. It an unconscious conflict. (Ex: Brothers both interested in girl one bro gets girl other bro gets arm paralyzed, he's torn between love for bro and being jealous. Unconscious conflict brother wants to beat the other one up). **Causation:** - [Genetic-] psycho genetic - [Cognitive-] in touch w/ reality but work and social life suffers, rarely requires hospitalization. - [Behaviorists-] faulty thinking - [Psychodynamic- Freud:] believes all these disorders except OCD is stuck in the phallic stage. The ID and the SUPEREGO are in conflict and the Ego can't solve conflicts so pt creates rituals. For OCP pt's Freud believes they are stuck in the Anal Stage. - People who have anxiety disorder suffer in the sense that their personal life is usually a mess but they still go to work, they do not understand what is going on with them, socially there is always problems. **Treatment:** [Medication-] Anxiolytic and Antidepressants, talking therapy, psychotherapy [Defenses:] to control anxiety and keep their conflicts out of awareness (unconscious) a. Repression: anxiety b. Conversion: repression, symbolism. c. Phobia's- Displacement, symbolism. **Nurse Care-** Assessment-Gordon's health Patterns - [Health Perception:] many physical complaints, frequent doc shopping, many fears Intervention: must follow up all complaints patient may actually feel pain even though its caused by anxiety. - [Activity-] ct's can be restless and pacing, have rituals and rarely participate in recreational activities b/c complain emotional fatigue, doesn't enjoy life, sometimes self care can be effected. - Intervention: Help client develop interest outside of himself, these patients have a lot of trouble playing games, help them with recreation. Do not stop a OCD client\'s ritual unless its damaging, we usually allow time unless its dangerous, do not confront a phobia patient with feared object (may cause panic attack), desensitized phobia patients in groups. - [Self Care:] if OCD or Phobia then ct suffer. Help them get involved in playing games, relaxation techniques. Never confront phobic w/ feared object unless it is part of care plan. - [Sleep/rest:] always sleep disturbance, over sleeping, then complains of fatigue - Intervention: teach relaxation technique. - [Cognitive-] aware of reality. Some feel stupid because cannot control symptoms obsessive thoughts - Intervention: teach ct and family about disorder, also teach relaxation, teach how to intervene on their own behalf. - [Self Perception-] ct is aware of anxiety; they feel doomed and can be suicidal. Helpless and self-med w/ alcohol. Loss self esteem because they have anxiety disorder - Intervention: subtle praise relaxations - [Self Esteem-] offer praise for accomplishments. - [Role Relationship-] diff to get along with especially OCD (control freaks). Stress in home, pt may have to be removed and placed in hospital because hospital is a neutral environment. **Nursing Diagnosis:** Anxiety r/t unconscious conflict. **Intervention:** (Phobias) - Emphasize acceptance, patient has a lot of self esteem problems, do not laugh at patient, client knows his fears are irrational, same with OCD, OCD needs rituals to relieve anxiety. Conversion disorder patient, is hysterically blind, their blinking rate is diminished, protect their corneas by using eye patches, hysterically blind, do ROM exercise, la bella indifference (patient do not care about illness) - Decrease environmental stimuli - Use touch stay w/ ct - Teach ct relaxation techniques - Med's prn - Positive reassurance, emphasize acceptance **(OCD)** 1\. Give ct time to do rituals as along as they are not harmful 2\. Give privacy **(Conversion disorder):** - Unique b/c they don't have anxiety - Give physical care - If pt has paralysis you have to do range of motion - Use matter of fact approach - Do not talk abt a list of symptoms b/c they will unconsciously take them on. **Psycho physiological Stress Disorder:** **(Psychosomatic Illness)** - **Definition:** real physical illness that involves the mind & the body, there's a psychological component. - **Somatization-** body's reaction to anxiety or stress. - **Physiological stress response-** body responding to stress (genetic) inherits organ weakness. --Hans Syle. - **Psychosomatic illness-** - **Cause-** - **Other Known Facts-** - Specific Manifestations and Dynamics: Autonomic nervous system is responsible. - [Peptic Ulcer:] dependence and independence problems, is independent but wants to be taken care of. Unconscious hostility. (Males may not tell he is in pain- give prn meds anyway) - [Colitis:] perfectionism, neat freaks, mess up their routine and they get bloody mucous stools (OCD problems) - [Essential Hypertension-] Mr. Nice guy, UNCONCIOUSLY resents authority figures. - [Bronchial Asthma-] structural damage, unconscious fear of dependence on mother, abandonment issues. **Skin Disorders**: shows anxiety right away (blush, hives, egsema) - [Rheumatoid Arthritis-] long time sacrifices self for others; only pleasure in life is to help others. - [Migraine Headaches-] perfectionist & inflexible people. - **Treatment and Nursing Care**: - observe ct, monitor vital signs, and provide autonomy as much as possible. Comfort measures, accept ct's feelings no interpreting, convey to the patient that the illness is real; it might be caused by anxiety. - Teach relaxation. Explain all diagnostic procedures. Avoid reinforcing secondary gain. - Use therapeutic communication, let patient talk out what they are feeling, anticipate client\'s needs and keep environment calm. Explain dx and treatment procedures, teach the client relaxation (deep breathing, counting) work with family members, - try to be non judgmental and empathic, and most important, avoid reinforcing secondary gain. - **Gordon's Health Patterns:** - [Health Maint:] ct's physical ailments, so give care. Monitor VS, and secondary gains. actual organic damage, real physical illness. - Activity: may be altered - [Cognition:] ct's can learn, they need info abt their illness. Assess anxiety level and teach procedures. Some clients may be experts on their illness but have no clue about anxiety. Inter: Teach about anxiety. - [Self Percept:] make aware abt outcome of treatments - [Coping:] no problem solving skills, no insight, cherish secondary gains. - [Spiritual:] believes that they were cured by a miracle, God cured them. - [Role relationship:] Focus of their family\'s attention. Can be very demanding. **Introspection:** Make sure you show acceptance. [The Hardy Personality:] don't breakdown with stress. Able to withstand stress and adapting to stress without developing physical illness. **Components:** (3 c's): - Commitment to your goals - Control over life, you perceive control over environment; you can make choices to change situation. - Challenge (view goals as a challenge, and look forward to meeting them). **Important Points:** show acceptance and understanding. Physical needs & nursing care. Monitor anxiety levels; minimize secondary gains, health teaching, meet ct's dependency needs in mature way. Encourage ct to talk. Enlarge social network.