NUR 144 Unit 2 Guide PDF

NUR 144 UNIT 2 REVIEW SUICIDAL OR HOMICIDAL ASSESSMENT: (remove things like shoelaces, shower curtains, lanyards in milieu)  Are you suicidal or homicidal?  Do you have a plan?  Do you have the means to execute your plan?  Nurses’ roll is to direct and escort Pt to appropri...

NUR 144 UNIT 2 REVIEW SUICIDAL OR HOMICIDAL ASSESSMENT: (remove things like shoelaces, shower curtains, lanyards in milieu)  Are you suicidal or homicidal?  Do you have a plan?  Do you have the means to execute your plan?  Nurses’ roll is to direct and escort Pt to appropriate service and to report dangerous Pt to authorities o Nurse is responsible for making sure authorities know of threat, so follow up w/charge nurse or whoever you reported to in order to make sure they told the authorities  PLAN, METHOD, REHEARSAL, Hx, PREVENTION OF RESCUE, RISK FACTORS o Risk Factors: No support system, unemployed, debt, Major Depressive Disorder COMMON PROBLEMS YOU SEE w/PSYCH PTs:  Depression, ADLs & Nutrition LEVEL OF CARE: (Based on safety, level of supervision needed, Severity of S/S, Level of Fx, Tx)  In-Pt: Usually 3-5 days, DISCHARGE PLANNING BEGINS UPON ADMISSION (Ins. & hosp. planning req. this), crisis intervention and safety  Long-term: state-run (Declining type of care) Group Home, Half-way Home, Nursing Homes  Intense Out-Pt/Partial Hospitalization: Minimal supervision (4-8 hrs/day for 1-5 days/wk) Usually 40 hrs/wk, less likely to develop psychosis than in-Pts, Pt performs own ADLs, maintain some independence  Out-Pt: Private or Clinic (Pts must be stable & adhere to meds), appts around Pt’s needs  Self-Help: Run by non-professionals ex.AA EPIDEMIOLOGY:  51.5 million adults su er from mental disorder (approx. 21%)  Major Mental Disorders include Major Depressive, Schizophrenia, Bipolar & Alcoholism  BENCHMARKS: o I-1790’s: Asylums o II-Mid-late 1800’s: Scientific studies o III-1950’s: Psychotropic Drugs (antidepressants/antipsychotics) Lithium (mood stabilizer) o IV-1960’s: From deinstitutionalization to trans-institutionalization. ED treat acute pscyh Pts, overwhelmed, dehumanized & sterile o V-1990’s: Brain research, DSM revision HOMELESS PROBLEM   About 25% of homeless have a severe mental illness  54% homeless ♀ & 84% homeless ♂ have drug &/or alcohol addiction  Approx. 2.5 million children in US are homeless CONCEPTUALIZATION OF CONTINUUM OF CARE  Focus on recovery & reintegration  Focus less on symptom stabilization  Involve consumers and family members  Focus on holistic issues (housing, medical health, finances) LEGAL Hx  Cognitive standard: Not responsible for crimes if mentally ill at time (Test for criminal insanity is M’Naghten Rule)  Pts have Right to Tx (least restrictive environment, minimal sta ing, humane Tx, Pt is not hospital labor)  Right to Refuse Tx  Taraso DUTY TO WARN: If Pt makes threat against someone and has the ability to carry out the threat, RN has an ABSOLUTE duty to warn. o This is a NATIONAL standard of practice o Report to charge nurse, supervisor, or police o Follow-up to make sure authorities were told and DOCUMENT  Tort Law: o Negligence: Have duty to care and fail to act or not act, as reasonable person under the same circumstance, in breach of that duty, causing injury to Pt o Malpractice: Professional Negligence – Employer responsible for employee’s actions if employee was acting within scope of employment INVOLUNTARY COMMITMENT (Danger to self or others, or Gravely disabled)  Need 2 independent assessments by 2 di erent doctors to verify need to commit  Can hold Pt up to 72 hours  Need court order to extend beyond 72 hours  Hearing o icer determines if needs Pt long-term care but refuses help  Probable cause is required by 4th Amendment, and Pt must be released when no legal basis to detain exists INCAPATITATED PT COMMITMENT  Gravely disabled  Can’t provide food, clothing, & shelter for self, due to mental illness (incompetent) o Loses rights to marry, vote, drive, or enter into contracts o Conservators and guardians: Must act in best interest of incapacitated Pt   Have Power of Attorney, Healthcare Proxy (until retracted) or Surrogate Form (temp power) FREEDOM FROM RESTRAINTS OR SECLUSION  Doctor’s order required w/n 1 hr of restraint or seclusion (order can be written by Physician’s Assistant or Advanced Nurse Practitioner too) o Order MUST have type of restraint or seclusion, rationale for use, and time limitations (PRN orders not allowed for restraint or seclusion) o Renewed every 24 hours  Pt should be informed what behaviors are expected for release  Use least restrictive method  Make sure you document why restraining & RN’s actions while Pt restrained  Pt must be checked every 15 minutes – circulation, pulses  Toileting, Food & Fluids o ered every 2 hours  Reassess need for restraints every 2 hours  Death of Pt in restraints must be reported to FDA ADVANCED DIRECTIVES  Dictates Pt’s wishes for Meds, Tx, Drs, Visitors, Tx Records & Research Participation BARRIERS TO CULTURALLY COMPETENT CARE  Miscommunication b/t nurse and Pt  Lack of knowledge & sensitivity  PT’s unaware of the nurse’s cultural perspectives, & misinterprets health care recommendations from nurse  Failure to assess the patient’s cultural perspective  Bias PRIMARY WORLD VIEWS (Pts may have a mix of them)  Analytic: Values details to time, individuality & possessions (Hands-on learning)  Relational: Values relationships & spirituality (Verbal learning)  Community: Community more important than individual (Reading, meditation, quiet learner)  Ecological: Take care of the earth (Learns by observing & contemplating) ALTERNATIVE THERAPIES  Acupuncture (Best one according to Prof Carroll)  Acupressure  Nutritional Therapy (Good for migraines)  Skin Scrapping (Spoon w/oil brings stagnant blood to muscle surface)   Moxibustion (Herbal Tx relieves tension)  Cupping (Manual or heat vacuum that leaves circular bruising) NURSES’ ROLE IN CULTURAL ASSESSMENT  Communication (May consider “Touch” to be inappropriate)  Orient Pt to unit they’re on & explain how Pt can obtain cultural needs  Nutrition  Family  Health Beliefs  Education  Spiritual or Religious Views (Blood transfusions may be against)  DEFNS: o Cultural preservation: Nurse’s ability to acknowledge, value, & accept Pt’s beliefs o Cultural negotiation: Nurse’s ability to work w/n Pt’s belief system o Cultural repatterning: Nurse’s ability to incorporate cultural preservation & negotiation to identify Pt needs, develop outcomes, & evaluate plans NURSING Dx RELATING TO SPIRITUALITY (NANDA Dx)  Moral distress  Hope/Hopelessness  Religiosity  Spiritual distress INTERVENTIONS RELATED TO SPIRITUALITY  Motivational Interviewing (Tell me something good that happened)  Support Groups  Arrange for friends and family members to visit  Take Pt for a walk outside  Educate on coping mechanisms CONSCIOUSNESS V. UNCONSCIOUSNESS  Consciousness: Info w/n person’s awareness  Unconsciousness: Info cannot recall at-will  Pre-Consciousness: Info that can be recalled to consciousness w/some e ort  Insight: Insight about meaning of symptoms facilitates change! DEFENSE MECHANISMS  Transference: Pt transfers feelings about x,y,z onto nurse (Pt mad at dad & then mad at ♂ nurse (but really mad at dad)  Counter-transference: Nurse transfers feeling about x,y,z onto Pt   Denial: Unconscious refusal to accept situation  Repression: Unconscious, involuntary forgetting of painful memory  Suppression: Conscious exclusion from awareness of anxiety-producing memories  Rationalization: Conscious or unconscious attempt to justify feelings or behaviors  Intellectualization: Conscious or unconscious logical explanation w/o emotional component  Dissociation: Unconscious separation of painful feeling & emotions  Identification: Conscious or unconscious attempt to model oneself after respected person  Introjection: Unconscious incorporation of values & attitudes of others  Compensation: Conscious covering up of weakness by overemphasizing desirable trait  Sublimation: Conscious or unconscious channeling instinctual drives into acceptable activities (ie: sports)  Reaction Formation: Conscious behavior that is opposite of unconscious feeling  Undoing: Conscious counteracting or making up for transgression  Displacement: Unconscious discharge of pent-up feelings to less threatening object  Projection: Unconscious or conscious blaming someone else for di iculties  Conversion: Unconscious expression of intrapsychic conflict symbolically through physical symptoms  Regression: Unconscious return to earlier developmental level ERIKSON’s DEVELOPMENTAL MODEL (don’t need for Unit 2, but need for Final)  Trust v Mistrust (0 to 18 months): Developing realistic trust of self & others  Autonomy v Shame (18 months to 3 years): Developing self-control & willpower  Initiative v Guilt (3 to 5 years): Developing an adequate conscience  Industry v Inferiority (6 to 12 years): Sense of competence  Identity v Role Di usion (12 to 20 years):Confident sense of self  Intimacy v Isolation (18 to 30 years): ability to give & receive love  Generative lifestyle v Stagnation or Self-Absorption (30 to 65 years): productive, constructive, creative activity  Integrity v Despair (65 to death): feelings of self-acceptance THERAPEUTIC COMMUNICATION  Pt-centered  Planned  Directed by professional  Meets Pt’s needs  Guides Pt to explore personal issues and painful feelings  Listener objective  Info shared with health team TECHNIQUES OF THERAPEUTIC LISTENING  O er self; Active Listening; Silence; Empathy; Open-ended Questions; General Leads; Restating; Verbalizing the implied; Clarification; Making observations Presenting reality; Restating; Verbalizing the implied; Clarification; Making observations; Presenting reality; Encouraging description of perceptions; Voicing doubt; Placing an event in time or sequence; Encouraging comparisons; Identifying themes; Summarizing; Focusing; Interpreting; Encouraging evaluation; Suggesting collaboration; Encouraging goal setting; Giving info; Encouraging consideration of options; Encouraging decisions; Encouraging formulation of a plan; Rehearsing; Role-playing  Don’t lie to Pts (don’t give them drink w/meds and tell them plain drink…) PHASES OF NURSE/PT COMMUNICATION  Orientation: Intros; Establish rapport & boundaries; Explain confidentiality (if Pt threatens self or other RN has duty to tell)  Working: Gather data & identify & practice problem-solving & coping skills with Pt; Provide education to Pt; Evaluate progress towards Pt goals  Termination: Summarize goals achieved; Discuss using newly learned skills in Pt’s life discuss discharge plans Features:  Depressed Mood  Anhedonia: Lack of interest or joy from anything  Appetite changes/Weight changes  Sleep Disturbances: Sleep more, but interrupted; Can’t get out of bed  Psychomotor disturbance: Tremors, Pacing, Inability to concentrate, Restlessness, Restless leg syndrome, Inability to make decisions  Fatigue or loss of energy  Worthlessness/guilt  Recurrent thoughts of death/suicide Types of Depressive Disorders  Disruptive mood dysregulation disorder  Persistent Depressive Disorder (AKA Dysthymia): Chronic depression  Premenstrual Dysphoric Disorder (PDD): PMS on steroids o Tx: Fluoxetine: Interacts w/MAOIs - the combo can cause SERETONIN SYNDROME  Major Depressive Disorder Behaviors Associated w/Depression   Objective: o Less active o Less social interactions  Subjective o Lower moods o Flat a ect o Changes in Cognition and Perception o Physical changes: Weight gain/Not performing ADLs (like hygiene) Causes of Depression  Low serotonin & norepinephrine  Genetic  Endocrine Issues  Changes to brain  Circadian Rhythm/Sleep cycle disturbances  Prior trauma & Life Experiences Nurse/Pt Relationship  Build Rapport & Trust  Focus on Pt’s strengths & accomplishments (Motivational Interviewing)  Acknowledge Emotional Pain  Cognitive Behavioral Therapy (reframe the negative to a positive)  Reinforce e orts to make decisions that promote health and wellness  Do not reinforce hallucinations or delusions (point out reality w/o challenging perceptions)  Accept Pt’s anger & negativity but don’t reinforce them  Spend time w/Pt if they’re comfortable w/that  Provide achievable activities  Make decisions for patients who are severely indecisive  Assess for hopelessness & helplessness (Biggest indicators of suicidal ideations)  Assess for suicidal intentions Tx Depression o ALL DEPRESSION MEDS TAKE 4-6 wks to work  Note: Serotonins should not be combined w/St Johns Wart (can cause toxicity)  SSRIs  Fluoxetine: Interacts w/MAOIs - the combo can cause SERETONIN SYNDROME o Wait 14 days if switching from MAOI to Fluoxetine  o Wait minimum of 6 weeks if switching from Fluoxetine to MAOI o Assess BP o Pt Teaching: Can take days to weeks to start working  Escitalopram: (short-term Tx general anxiety; Major Depressive Disorder). Interacts w/MAOIs - the combo can cause SERETONIN SYNDROME  SNRIs  MAOIs (S/E: HTN)  Phenelzine Sulfate: Antidepressant, Interacts with tyramine-rich foods (processed, cured or smoked meats, dried fish, caviar, aged cheese, increased ca eine, fermented or pickled foods, sauerkraut, alcohol, chocolate, raisins, figs, bananas, liver, meat tenderizers, yogurt soybeans)  Amitriptyline: Tricyclic Antidepressant – Increase risk of suicidal ideations; S/E: CNS: Sedation (30%), ataxia (coordination issues), confusion, delirium, insomnia, excitement, headache, blurred vision (10%), decreased tears, dry mouth (30%), constipation (10%), decreased sweating, di iculty urinating, Cardiac: (Orthostatic hypotension (10%), dizziness, tachycardia (10%), palpitations, arrythmias). Extrapyramidal S/E: (Weight gain, Sexual Dysfunction (2%), Increased ocular pressure, photophobia, diarrhea). Small Overdose can cause toxicity o Works well for chronic pain & headaches (but not so well or depression) o Agitation & Anxiety can be treated w/Rescue Meds (anti-anxiety meds) (Lorazepam is also for status epilepticus (long, repetitive seizures))  Benzodiazepines: Addictive & LINKED TO DEMENTIA so not for long-term use  Diazepam & Lorazepam S/E: CNS: blurred vision, drowsiness, headaches, confusion, tremors, insomnia, mydriasis (dilate pupils), orthostatic hypotension, tachycardia, cough, constipation, dry mouth. CONTRAINDICATED w/ narrow-angle glaucoma. WORK VERY FAST Serotonin Syndrome:  S/S: Fever, rigid muscles, HTN, tachycardia, mental changes (1st sign)  Can be fatal Mileu Interventions  Positive feedback & Accomplishment   Assertiveness training  Avoid embarrassment  Supportive group activities  Assist with grooming and hygiene (ADLs)  Brief and frequent interpersonal contacts  Assist with nutrition and adequate fluids  Protect from suicidal intent  Prevent constipation  Get them moving around  Increase fluids  Monitor and promote nighttime sleep (discourage day time napping)  Make sure room is quiet and dark at night Somatic Therapies (Pts who can’t tolerate pharmacotherapy)  Electroconvulsive therapy (modified shock therapy) is most e ective antidepressant remedy available o 2-3x/week for 6-12 treatments o Indications: Major Depressive Disorder o Rapid response: Suicidal or catatonic patients o Safe and e ective o Temporary relief, not a cure Suicide Risk Assessment Discharge:  Make sure to tell Pt about Diagnosis, and provide suicide hotline info Features:  Extremes of Mood Polarity  Highly Genetic  Do not need Depressive episode for Diagnosis of Type 1  Cannot have both Major Depressive Order and Bipolar Disorder together o If have mania or hypomania it is Bipolar, not Major Depressive Disorder Definitions: Mania: Elevated mood for at least 1 week w/ 3 of the following:  Inflated self-esteem, grandiosity  Decreased need for sleep   Very talkative  Flight of ideas, (racing thoughts, easily distracted, one-subject-to-another)  Distractibility  Increased goal-directed activity, agitation  Excessive involvement in pleasurable activity  Mood disturbance causing social, work, or interpersonal problems Hypomania: Impairment less severe than manic episode (doesn’t warrant hospitalization)  Persistent elevated, expansive, or irritable mood w/ 3 of the following: o Increased self-esteem or grandiosity o Decreased need for sleep o Distractibility, talkativeness, racing thoughts o Increased goal-directed activity or pleasurable activities with high potential for negative consequences Depressive Episode: Not necessarily same S/S as w/Major Depressive Disorder (Atypical S/S)  Hypersomnia, daytime sleepiness  Hyperphagia (Very hungry) leads to Weight gain  Craving for carbohydrates  Leaden paralysis  Paranoid thoughts, hallucinations  Irritability (Go from 0 to 100 in seconds and can’t be talked-down)  Bipolar depression more disabling than manic or hypomanic episodes but less likely to land Pt in hospital as Manic S/S  First symptom in over 50% of patients with BD and lasts longer  Usually more debilitating than unipolar depression (Literally cannot get out of bed & Fx)  Usually develops at a younger age than unipolar depression with more paranoia, irritability, and hallucinations  Types: BIPOLAR Type 1:  Requires Dx of MANIC Episode (must be for at least 1 week)  May swing b/t manic episodes and major depression  Rapid cycling of mood episodes in previous year  Melancholic features  Psychotic features  Anxious distress BIPOLAR Type 2:   Requires Dx of HYPOMANIA (must have had at least 1 hypomanic episode that lasted at least 4 consecutive days) and major DEPRESSIVE episode (lasting at least 2 weeks) o No true manic episode in Type 2  Other S/S similar to Type 1 CYCLOTHYMIC DISORDER  Numerous swings between a hypomanic episode and dysthymia (depression)  Swings either way are not severe as mania or major depression  S/S for at least 2 years, w/o symptom remission for more than 2 months  Swing faster than regular mania-depression cycle Behaviors Associated w/Bipolar:  Objective: o Disturbed Speech Patterns (rapid, pressured, loud…) o Failed Relationships (Manipulative behavior, Job loss, Sexual promiscuity) o Violent Behavior o Academic Failure  Subjective o Altered A ect o Altered Perceptions Nurse/Pt Relationship:  Matter-of-fact tone.  Clear, concise directions and comments.  Allow pacing as appropriate.  Limit setting Tx Bipolar:  May need Mood Stabilizers & Antipsychotics  Goals: MUST TREAT MANIA FIRST; Preventing relapse; Med management  DO NOT GIVE SSRIs (will treat depression but make mania worse) Need mood stabilizers! Meds:  Lithium Carbonate: Antimatic: Treats Manic Episode of BD – prevents manic depressive psychosis. Therapeutic Range 0.6-1.2 mEq/L. (If too low, still symptomatic. If too high, Lithium toxicity) Check levels every 2 weeks o Lithium Toxicity: Blurred Speech, Diarrhea, N/V, Muscle weakness, Confusion o S/E: CNS: Headache, Drowsiness, Dizziness, Tremors, Twitching, Ataxia (poor coordination), Seizures, Slurred Speech, Restlessness, Confusion, Stupor,  Memory Loss, Clonic Movements (Involuntary Muscle Contrax), Dry Mouth, Anorexia, N/V, Hypotension, Diarrhea, Leukocytosis, Blurred Vision, Hypothyroidism, Hyponatremia, Muscle Weakness (Flu-like but w/slurred speech) o Contraception is required b/c lithium may harm fetus  Chlorpromazine: Mania. S/E: CNS Parkinsonism, Akathisias, Dystonia, Tardive Dyskinesia. Interacts w/ Alcohol & other CNS Depressants – increases risk of CNS Depression & EPSEs  Risperidone: Atypical Anti-psychotic, serotonin/dopamine antagonist; Pt. Ed.: Causes orthostatic hypotension, Notify PCP before taking OTC b/c interactions, causes photosensitivity; Monitor decrease in +/- S/S  Aripiprazole: Atypical Antipsychotic (+/- S/S):  PRN Meds may be needed if they’re acting o Interventions:  Nutrition Interventions: Portable high-protein, high calorie food/snacks (ie: High-calorie Shakes) for when can’t stay still (akathisia – can’t resist urge to move); Multivitamins; Regular Weigh-ins;  Sleep Interventions: MUST SLEEP b/c lack of sleep leads to mania (can go from hypomania to mania) Quiet environment; Assess sleep patterns; No stimulating activities in evening; Reduce ca eine intake; Provide meds to get them to sleep even before they start mood stabilizer  Consider non-antidepressant therapy; Adjunctive antidepressants ok if relapse occurs;  No antidepressant monotherapy; No tricyclic antidepressants (TCAs) or venlafaxine (high risk of mania behavior); Monitor closely Mileu:  Don’t pace w/them or encourage it if they’re pacing (Let them pace till meds work but set parameters for pacing)  SAFETY (If too wild- PRN meds) o Haloperidol:Traditional antipsychotic/Tx for mania; S/E: Akathisias (ants in pants); Dystonias (involuntary muscle contrax); Tardive dyskinesia (facial tics & lip smacking); NMS (rare); Blurred vision; Impaired vision; Irregular pulse; Arrythmias  Interacts w/ alcohol & other CNS depressants causing increased CNS depression  Interacts w/anticholinergics (atropine, H-1 antihistamines, antidepressants) causing increased risk for excessive atropine-like S/E or toxic e ects  Consistency/Routines (avoid anxiety & confusion)  Calm, de-escalate   ADLs (hygiene, nutrition, sleep) (avoid embarrassment)  Achievable goals to improve self-esteem Discharge:  Pt. Ed. S/S relapse; Med S/E & therapeutic e ects; coping strategies; community service & BD support groups; how to get emergency Tx if S/S put-of-control Anxiety: Features:  Sense of powerlessness; MUST Identify Triggers; Can be contagious TX for Anxiety:  SSRIs  Fluoxetine: (Prozac) o Wait 14 days if switching from MAOI to Fluoxetine o Wait minimum of 6 weeks if switching from Fluoxetine to MAOI o Assess BP o Pt Teaching: Can take days to weeks to start working  Escitalopram: (Lexapro) (short-term Tx general anxiety; Major Depressive Disorder).  Benzodiazepines: Addictive & LINKED TO DEMENTIA so not for long-term use (Lorazepam is also for status epilepticus (long, repetitive seizures))  Diazepam & Lorazepam S/E: CNS: blurred vision, drowsiness, headaches, confusion, tremors, insomnia, mydriasis (dilate pupils), orthostatic hypotension, tachycardia, cough, constipation, dry mouth. CONTRAINDICATED w/ narrow-angle glaucoma. WORK VERY FAST  SSRIs are prescribed instead of Buspirone HCl b/c Buspirone needs to be taken 3x/daily instead of 1x daily like Benzos Interventions: o Teach Coping Mechanisms: Deep breathing; Meditation; Meds; Drinking (Unhealthy) Panic Attack:  Features:  Increased Respirations  Sweat  Can’t control bodily Fx  Frozen in time or space Tx of Panic Attack:  Do NOT leave Pt alone  Use therapeutic touch  Short sentences/One direction at a time  Stay calm  Rebreathe in brown bag (Carroll says not to do this b/c airway threat if suck in bag)  Allow to cry & pace  COMMUNICATION is key  Move away from Trigger  Encourage discussion of fear once attack subsides  Benzodiazepines: Addictive & LINKED TO DEMENTIA so not for long-term use (Lorazepam is also for status epilepticus (long, repetitive seizures)) o Diazepam & Lorazepam S/E: CNS: blurred vision, drowsiness, headaches, confusion, tremors, insomnia, mydriasis (dilate pupils), orthostatic hypotension, tachycardia, cough, constipation, dry mouth. CONTRAINDICATED w/ narrow-angle glaucoma. WORK VERY FAST OCD:  Provide new Pts time to perform ritual & work therapy around the rituals  Ensure basic needs are met  Clear expectations, routines, changes & Limits  Non-judgment  Simple, achievable activities  Reinforce non-ritualistic behaviors to increase self-esteem & self-worth Tx for OCD:  No short-acting meds work for OCD  SSRIs  Fluoxetine:  o Wait 14 days if switching from MAOI to Fluoxetine o Wait minimum of 6 weeks if switching from Fluoxetine to MAOI o Assess BP o Pt Teaching: Can take days to weeks to start working  Escitalopram: (short-term Tx general anxiety; Major Depressive Disorder).  Therapy PTSD:  Trauma in past causes overwhelming stress, anxiety or panic in present (secondary survivors can su er from PTSD) Interventions:  Non-judgment  Empathy & support/Reduce Pt guilt  Make connection b/t past event & present behavior  Allow Pt to express anger/other feelings  Encourage establishment or reestablishment of relationships Tx for PTSD: (hard or treat)  Ketamine has been helpful  Therapy is needed SOMATIC SYMPTOM DISORDER:  Medical complaint w/no medical explanation (ie: Stomach ache, numbness, amnesia)  Can be caused by underlying stress or anxiety Interventions:  Matter-of-fact approach  Encourage description of feelings (help Pt verbalize)  Positive Reinforcement when Pt focuses on something other than S/S/Encourage diversional activities  Consistency  Pt. Ed. Distinguishing b/t actual somatic sensations & those w/no identifiable source  DO NOT Push insights into conflicts or problems Tx of Somatic Symptom Disorder:  SSRIs may help  Therapy Features:  Disconnect from environment & watch from afar  Disruption & fragmented in feelings, behaviors, thoughts & identity  Disruption in CONSCIOUS, memory body representation, motor control & behavior  Depersonalization/Derealization  Dissociative Identity Disorder: Multiple Personality Disorder TX of Dissociative Disorders:  Help Pt gain control of feelings through brief, direct verbal interactions  Coping strategies that helped in past traumatic experiences  Support person to help comfort Pt  Pt Ed. Avoid anxiety-producing situations  Meds  Therapy Findtrigge.toAvoidtrigger Features:  Age of onset: ♀ 25-35 & ♂ 15-25  Almost always caused by stress (especially + S/S)  Highly Genetic Disorder  Drugs that block dopamine receptors are therapeutic o Dopamine is the neurotransmitter that regulates schizophrenia  Psychosis: Diminishes thought, language, emotions & ability to relate o Common S/S: Hallucinations, Delusions (false perception unchanged by logic), Disorganized thinking (minimal connection b/t ideas, flight of ideas)  Disturbances in: Perception, feelings, thought process, reality testing, attn, motivation & behavior Course of Illness:  ACUTE PHASE: Severe Psychotic S/S – often appear at ED or jail -usually have paranoid delusions  STABILIZING PHASE: Prescribe Antipsychotics – Pt improving   STABLE PHASE: May still experience delusions & hallucinations but not as severe or debilitating Interventions:  Redirect delusions, don’t contradict (ok to tell Pt that you don’t see it, but then move on)  CONTINUUM OF CARE o Acute S/S: Hospitalization o Tx-Resistant: Long-term Hospitalization o Stable but Chronic: Partial Hospitalization/Day Tx o Many are homeless or jailed Nurse/Pt Relationship:  Be calm/Have one-on-one interactions/Build rapport  Non-judgment/Don’t embarrass Pt/Respect Pt  Do not lie/Keep promises  Consistency  Do not reinforce or challenge hallucinations (It’s ok to say you don’t see them)  Orient Pt to Time, Place, Person  DO NOT TOUCH w/o permission – even if for medical reason  Avoid whispering/laughing when Pt can’t hear convo  Reinforce good behavior/Encourage verbalization of feelings  Educate on importance of med adherence Mileu:  Disruptive Pt: o Set Limits & fair consequences (Invoke consequences) o Calm o Monitor behavior o Limit potential weapons o Restraint Protocol if necessary  Withdrawn Pt: o Non-threatening activities o Arrange meetings at table so Pt sits w/people o Reinforce hygiene & grooming o Psychosocial Rehabilitation  Hallucinating Pt: o Distraction techniques o Discourage talk of hallucinations o Monitor TV shows o Monitor command hallucinations (Hallucinations that tell Pt to act)  o Have sta there to discuss “real things” w/Pt Types of Schizophrenia & Tx (May need both typical & atypical antipsychotics to treat)  Positive, TYPE 1: Severe S/S related to having too much dopamine(hyperdopaminergic process); S/S get Pt in trouble (ie. Hallucinations, Delusions) Tx: TYPICAL ANTIPSYCHOTICS o POSITIVE S/S include Hallucinations, Delusions, Paranoia, Hostility, Psychomotor agitation, Echopraxia (repetitive movements), Echolalia (repeat your words back), Stereotypy (Repetitive actions or words), Loose Associations, Confusion, Incoherence o Chlorpromazine: S/E: CNS Parkinsonism, Akathisias, Dystonia, Tardive Dyskinesia. Interacts w/ Alcohol & other CNS Depressants – increases risk of CNS Depression & EPSEs o Haloperidol:Traditional antipsychotic/Tx for mania; S/E: Akathisias (ants in pants); Dystonias (involuntary muscle contrax); Tardive dyskinesia (facial tics & lip smacking); NMS (rare); Blurred vision; Impaired vision; Irregular pulse; Arrythmias  Interacts w/ alcohol & other CNS depressants causing increased CNS depression  Interacts w/anticholinergics (atropine, H-1 antihistamines, antidepressants) causing increased risk for excessive atropine-like S/E or toxic e ects  Negative, TYPE 2: Subtle S/S that won’t get you put in jail (ie. Apathy, anxiety, anhedonia (loss of interest & joy); Tx: ATYPICAL ANTIPSYCHOTICS o May mimic Major Depressive Disorder (flat a ect, depressed, isolate themselves) o Related to structural changes in brain o NEGATIVE S/S: Decreased grooming, Withdrawal from others, Catatonic rigidity, depressed, Inappropriate, blunted or labile a ect o Risperidone: Atypical Anti-psychotic, serotonin/dopamine antagonist; Pt. Ed.: Causes orthostatic hypotension, Notify PCP before taking OTC b/c interactions, causes photosensitivity; Monitor decrease in +/- S/S o Aripiprazole: Atypical Antipsychotic (+/- S/S): o Clozapine:Refractory to other antipsychotics. Contraindicated if Pt has Hx of clozapine-induced agranulocytosis. S/E: Agranulocytosis (low type of WBC. Increases risk of Infections. Can be fatal. Special Monitoring System to make sure WBC count is ok Behaviors Associated w/Schizophrenia:  Objective: o Alterations in relationships   Decreased attn to grooming/hygiene  Hostility  Withdrawal o Alterations in activities and behaviors  Psychomotor agitation  Catatonic rigidity (If Pt is catatonic, must monitor for fluid & food intake)  Echopraxia (repetitive movements)  Echolalia (repeat words back)  Stereotypy (repetitive actions or words)  Subjective: o Altered Perceptions  Hallucinations and Delusions o Altered Thought  Loose Associations/Flight of Ideas o Altered Consciousness  Confusion, Incoherence o Altered A ect  Inappropriate, blunted or labile a ect DELIRIUM: Features:  Rapid Onset  Secondary to another physical issue  Reversible  Impaired short-term memory  Fluctuating LOC (may lose consciousness)  Slurred Speech  Hallucinations (visual & tactile)  Anxiety or Fear Tx of Delirium:  Reorient Pt (Make sure they know where they are)  Talk to Pt DEMENTIA (including Alzheimer’s): Features:  Insidious, Slow, progressive development  Usually primary disorder   Impaired short-term memory w/ slow loss of long-term memory  LOC unchanged  Thought process starts out normal but then slows  Loss of ability to abstract  Misidentification & Delusions & Hallucinations & Illusions  Altered A ect  Jealousy  Stealing odd things STAGES OF ALZHEIMER’S:  MILD: Decreased short-term memory, di iculty finding words, decreased decision-making & focus, denial, repetitive questions, getting lost  MODERATE: Blunted a ect, wanders, disorientation, sleep disturbance, delusions, Need help w/ADLs, Emotional lability (mood swings), urinary incontinence, Sundowning (Act up when sun goes down (Tx. Keep them busy)) o Apraxia (Inability to perform complex tasks & use familiar objects) o Aphasia (Loss of comprehension/expression of speech/visual or other senses)  Wernicki’s Aphasia (mix up words) o Agnosia (Inability to identify something normally hear, touch, feel or see) o Amnesia (Loss/Impairment of memory)  SEVERE: Gait disturbance, Cannot self-feed, Urinary & Bowel incontinence, Bedridden, dysphagia, Require 24 hr supervision, Thinking a deceased person is still alive (one of last stages), Sundowning Causes of Alzheimer’s:  Neuronal loss  Neurofibrillary Fibers  Plaques  Brain atrophy  Genetics  Long-term use of Benzodiazepines or Antipsychotics Interventions:  Communication  Scheduling  Nutrition  Toileting  Wandering  Memory Aids (Calendars, notes, large-print directions, illustrations) Milieu:   Pt’s preference for Temp & Lighting  Reduce noxious sounds  Purposeful viewing of TV only  Memory Aids  Match Roommates by Personailty Tx of Alzheimer’s:  ACE Inhibitors: Donepezil: (for mild to moderate) S/E: Seizure potential: Can interact w/NSAIDS to cause GI Irritation and GI Bleeding DIFFERENCE b/t DELIRIUM & DEMENTIA:  Rapid v Slow onset  Reversible v. Irreversible  Change in Consciousness v. No change Features:  Require THERAPY and Behavior changes Cluster A: Odd, Eccentric Behaviors  Paranoid personality disorder: Paranoid  Schizoid personality disorder:- S/S of schizophrenia – withdrawn but NOT depressed  Schizotypal personality disorder: S/S similar to but less severe than schizophrenia Cluster B: THESE NEED THERAPY! Dramatic, Emotional, Erratic Behaviors  Antisocial personality disorder: Disregard of others’ rights without guilt. Become criminals  Borderline personality disorder: COMPLAIN; Problems with identity, interpersonal relationships, impulsivity, promiscuity, emotional dysregulation, self esteem & self-injury; Always the victims, family push-&-pull relationship  Narcissistic personality disorder: Over-evaluation of self, arrogance, and indi erence to the criticism of others; Never wrong  Histrionic personality disorder: Dramatic, attention seeking, and superficiality; Obsessed w/cost; Stems from low self-esteem, Unlike Border line, they don’t exude negative energy Cluster C: Anxious, Fearful Behaviors  Dependent personality disorder: Submissive, helpless, fear of responsibility, & reliance on others for decision-making  Avoidant personality disorder: Timid, socially withdrawn, and hypersensitive to criticism   Obsessive-compulsive personality disorder: Indecisive, perfectionist, inflexible, & has di iculty expressing feelings; Similar to OCD but not too extent of OCD Interventions:  Assess Pt for self-harm or risk for suicide (cutting scars, threats, prior attempts) Especially if BPD  Assess Pt’s anger & Hx of violence (protect Pt and sta )  Pt Ed: Strategies for managing impulsive feelings and erratic behaviors (ie. Count to 10 before responding, Slow deep breaths until impulse passes) PARAPHILIC DISORDERS: Tx is Therapy!  Pedophilic disorder: Have sex w/or look at kids  Exhibitionistic disorder: Like to show everyone  Fetishistic disorder:  Frotteuristic disorder:  Sexual masochism disorder: Like to receive pain during sex  Sexual sadism disorder: Like to inflict pain  Transvestic disorder: No longer in the DSM5  Voyeuristic disorder: Like to watch Nurse-Patient Relationship for Paraphilias:  Help Pt confront disorder  Non-judgment  Assure confidentiality, (Explain that child abuse or potential child abuse must be reported)  Pt & Family Ed about disorder & consequences  Address physical S/S (anorexia, insomnia, weight loss)  Address Emotional distress (guilt, shame, helplessness)  Set limits on what is shared in group therapy GENDER DYSPHORIA:  Inconsistency b/t birth gender and desired gender (THOUGHT process)  Di ers from transgender – b/c transition has not yet happened  Much higher risk for self-harm or suicide ALCOHOL:  Leading drug problem   You can overdose from alcohol  Disinhibition & Decrease Judgment  Assume Pt is drinking at least twice as much as they say they are  Biggest Risk of Alcoholism is WITHDRAWAL o HTN, Sweating, Tremors, Tachycardic, N/V, Seizures, Anxiety, Depression o Tx for Withdrawal: Vitamin B Supplements & Benzodiazepines  Benzodiazepines: Addictive & LINKED TO DEMENTIA so not for long-term use (Lorazepam is also for anxiety & status epilepticus (long, repetitive seizures))  Diazepam & Lorazepam S/E: CNS: blurred vision, drowsiness, headaches, confusion, tremors, insomnia, mydriasis (dilate pupils), orthostatic hypotension, tachycardia, cough, constipation, dry mouth. CONTRAINDICATED w/ narrow-angle glaucoma. WORK VERY FAST OPIOIDS (Narcotics):  Opium; morphine, codeine, and heroin  Routes: smoked; IV; oral; IM; SC (skin-popping)  Overdose can be fatal (respiratory depression)  Withdrawal: unpleasant but not life-threatening Assessment:  Build trust  Euphoric  Drowsy  Constrictive Pupils Tx of Opioids/Narcotics: Overdose can be fatal. Cause respiratory depression  ie: Opium, Morphine, Heroin, Codeine  Buprenorphine: Management of moderate to severe pain & Opioid Detox. Interacts w/CNS Depressants & makes it worse  Methadone: Opioid Maintenance Therapy & Narcotic withdrawal; S/E: CNS: drowsiness, dizziness, confusion, headache, sedation, euphoria, N/V, anorexia, constipation, cramps, increased urinary output, dysuria (painful urination); rash, urticaria (hives); Bruising, Flushing, Sweating, Pruritis (Itching), Respiratory Depression, Tinnitus, Blurred Vision, Miosis (constricts pupils); Diplopia (Double Vision); Palpitations, Bradycardia, BP Changes  Naloxone (OTC): Opioid Receptor Blocker Given by First Responders for Narcotic- Induced Respiratory Depression. IT DOES NOT improve respiratory depression from non-narcotics. Should have resuscitation equipment nearby  o Protect yourself when give b/c they won’t be happy STIMULANTS:  ie. Ca eine and Cocaine Assessment:  Energetic  Dilated Pupils  Sleeplessness E ects of overdose:  Agitation, tachycardia, cardiac arrhythmias, and convulsions MARAJUANA Assessment:  Relaxes  High  Hungry  Pain Management  Dilates Pupils  Turns Eyes Red Recovery Groups:  Alcohol addiction:12-step program groups; Alcoholics Anonymous (AA or Al-Anon) (for patients and partners); Alateen (for children/teenagers of alcoholic parents) Features: 90% ♀ & 10% ♂ Anorexia Nervosa: Restriction of food & calories; require daily weights Interventions:  Small, high-fat, high calorie, supervised meals  Give meal choices  Set limits around food  Daily weights  Can be involuntarily admitted by 2 doctors for 72 hours. Needs to be extended o May be forced to have NG tube Bulemia Nevosa: Binging & Purging (may also restrict intake) Assessment: Tooth Decay from vomiting, Pyrosis, Acid Reflux, Fluid Volume; Electrolyte depletion Binge Eating Disorder: May not eat for a long time and then binge and eat a tremendous amount Pica: Eating non-edible things (Pregnancy is a risk factor) Features:  A ects:  Mood  Emotions  Thought Process  Behaviors E ects:  Shock, disbelief, fear, anxiety, powerlessness, Insecurity, guilt, shame, spiritual distress, unresponsiveness, dissociation, numbness, decreased concentration, confusion, panic, terror, sense of violation, anger, rage, aggression, fantasies of revenge, impulsiveness, helplessness, hopelessness, despair, suicidal or homicidal ideation, self-mutilation, mistrust, suspiciousness, paranoia, alienation, estrangement, withdrawal, isolation, fatigue, insomnia, nightmares, flashbacks, memory disturbances, amnesia, hyperarousal, stress sensitivity, startle response, denial, repression, suppression, intellectualization, body kinesthetic memories, psychosomatic symptoms, extreme passivity, loss of self- esteem, depression, prolonged grieving, substance abuse, PTSD, sexual dysfunction, eating disorders, anxiety disorders, labile emotions, personality changes, PTSD, posttraumatic stress disorder Nurse/Pt Relationship:  STAY W/THEM, build trust & establish rapport  Safety  Move slowly  Tell/Explain to Pt everything that you’re doing Intervention:  Know or refer to someone who can provide them w/their legal rights  Refer them to community resources  Rebuild foundation of Confidence & Self-esteem  Pt must have a safety plan in place before leave CHILD ABUSE:  Childhood Manifestations: Disturbed growth and development, early protector/caretaker role at own expense, ambivalence, denial of experience, sleep, eating disturbances, enuresis, anxiety, depression, aggression, sexualized play, sexual aggression, poor impulse control, somatization, fear, shame, self-blame, self-destructive, running away, truancy, overt dysfunctional coping, impulsive acting out, self-destructive behaviors, self-mutilation, suicide attempts, sleep, eating, substance abuse disorders, running away, truancy, delinquency, prostitution, early marriage  Adolescent Manifestations: Overt dysfunctional coping, impulsive acting out, self- destructive behaviors, self-mutilation, suicide attempts, sleep, eating, substance abuse disorders, running away, truancy, delinquency, prostitution, early marriage  Adult Manifestations: Memory disturbances, anxiety, relationship issues, addiction, body symptoms, detachment, control, self-punishment, anger, sexual identity