Final Exam Blueprint_ Mental Health PDF

lChapter 1: Mental Health and Mental Illness Objective: Define mental health and mental illness ​ Mental Health ○​ Successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appro...

lChapter 1: Mental Health and Mental Illness Objective: Define mental health and mental illness ​ Mental Health ○​ Successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms ​ Mental Illness ○​ Maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms, and interfere with the individual’s social, occupational, and/or physical functioning Chapter 2: Biological Implications Objective: Describe the role of neurotransmitters in the central nervous system ​ Role: chemicals that convey information across the synaptic clefts to neighboring target cells Name MOA Physiological Effects Dopamine Excitatory Controls complex movements, motivation, cognition; regulates emotional responses Norepinephrine Excitatory Causes changes in attention, learning and memory, sleep and wakefulness, mood Epinephrine Excitatory Controls fight or flight response Serotonin Inhibitory Controls food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions Histamine Neuromodulator Controls alertness, gastric secretions, cardiac stimulation, peripheral, allergic responses Acetylcholine Excitatory or Inhibitory Controls sleep and wakefulness cycle; signals muscles to become alert Neuropeptides (endorphins) Neuromodulators Enhance, prolong, inhibit, or limit the effects of principal neurotransmitters Glutamate Excitatory Plays a key role in cognitive functions GABA (gamma-aminobutyric Inhibitory Regulates brain activity and other acid) transmitters Chapter 3: Ethical and Legal Issues Objective: Describe legal issues relevant to psychiatric/mental health nursing ​ Statutory laws are those that have been enacted by legislative bodies, and common laws are derived from decisions made in previous cases. Both types of laws have civil and criminal components. ​ Civil law protects the private and property rights of individuals and businesses, and criminal law provides protection from conduct deemed injurious to the public welfare. ​ Legal issues in psychiatric mental health nursing center on confidentiality and the right to privacy, informed consent, restraints and seclusion, and commitment issues. ​ Nurses are accountable for their own actions in relation to legal issues, and violation can result in malpractice lawsuits against the physician, the hospital, and the nurse. The Right to Refuse Treatment ​ Patients have the right to refuse treatment unless the treatment requires immediate intervention to prevent death or serious harm to the patient or another person or to prevent deterioration of the patient’s clinical state. Overriding Right to Refuse Treatment/Involuntary Commitment ​ Sometimes patients are involuntarily hospitalized because they are at risk of harming themselves or others and do not recognize the dangerousness of their symptoms. ​ Involuntary hospitalizations are made for various reasons. Most states commonly cite the following criteria: ○​ The person is imminently dangerous to himself or herself (i.e., suicidal intent). ○​ The person is a danger to others (i.e., aggressive, violent, or homicidal). ○​ The person is unable to take care of basic personal needs (the “gravely disabled”). HIPAA  ​ Health Insurance Portability and Accountability Act (HIPAA) is a federal privacy rule that pertains to data called protected health information (PHI) and applies to most individuals and institutions involved in health care. ​ Under HIPAA, individuals have the right to access their medical records, to have corrections made to their medical records, and to decide with whom their medical information may be shared. The actual document belongs to the facility or the therapist, but the information contained therein belongs to the client. Communication and Documentation ​ Effective communication with patients and other caregivers. ○​ The SBAR model of reporting information, which stands for Situation, Background, Assessment, and Recommendations, has been identified as a useful tool for effective communication with caregivers. Establishing rapport with clients encourages open and honest communication. ​ Accurate and complete documentation in the medical record ○​ Careful record-keeping using statements that are objective and nonjudgmental, care plans that are specific in their prescriptive interventions, and documentation that describes those interventions and their subsequent evaluation. Civil Liberties ​ Civil liberties are freedoms guaranteed by the U.S. Constitution (primarily from the First Amendment). They are natural rights which are inherent to each person. ​ Ex. ○​ Freedom of speech ○​ Freedom of religion ○​ Right to privacy ○​ Etc. Professionalism ​ Providing top-quality care to patients, while also upholding the values of accountability, respect, and integrity. Chapter 4: Psychopharmacology Objective: Apply the steps of the nursing process to the administration of psychotropic medications 1.​ Assessment 2.​ Diagnosis 3.​ Outcomes 4.​ Planning 5.​ Implementation  6.​ Evaluation Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing implications for the following classifications of drugs: Antidepressants -​ Indications: -​ Dysthymia, major depressive disorder, depression associated with organic disease, alcoholism, schizophrenia, intellectual disability, depressive phase of bipolar disorder, and depression accompanied by anxiety -​ The benefits of antidepressant medications for patients experiencing severe depression can be substantial -​ Actions: -​ Increase concentration of norepinephrine, serotonin, and/or dopamine in the body -​ SSRI (selective serotonin reuptake inhibitors): inhibit reuptake of serotonin -​ Tricyclic antidepressants (TCAs): inhibit the reuptake of serotonin & norepinephrine by blocking norepinephrine, acetylcholine, & histamine receptor -​ MAOIs (monoamine oxidase inhibitors): increase norepinephrine and serotonin by inhibiting the enzyme that degrades them (MAO-A) -​ Contraindications: -​ SSRI: not suitable for people with bipolar disorder in a manic phase, bleeding disorders, type 1 or 2 diabetes, narrow-angle glaucoma, or serious heart, kidney, or liver problems. SSRIs should only be taken if epilepsy is well controlled and if epilepsy gets worse, stop the drug -​ TCAs: not suitable for people with a history of heart disease, liver disease, porphyria, bipolar disorder, schizophrenia, pheochromocytoma, enlarged prostate gland, glaucoma, or epilepsy -​ MAOIs: not suitable for people with a history of seizures or epilepsy, alcoholism, angina, severe headaches, blood vessel disease, diabetes, kidney or liver disease, recent heart attack or stroke, overactive thyroid, or pheochromocytoma -​ Precautions: -​ Can cause dizziness, drowsiness, and blurred vision, particularly when you first start taking them. If you do experience these problems, do not drive or use tools and machinery -​ Side effects: -​ SSRI: nausea, agitation, headache, sexual dysfunction -​ TCAs: sexual dysfunction, sedation, weight gain, dry mouth, constipation, blurred vision, urinary retention, postural hypotension and tachycardia  -​ MAOIs: sedation, dizziness, sexual dysfunction, hypertensive crisis (interaction with tyramine) -​ Nursing implications: -​ Instruct patient to inform their physician or nurse practitioner of all medication they are taking, including herbal preparations, OTC drugs, and any medications they have stopped within the previous 2 weeks -​ Notify the physician immediately when any symptoms of serotonin syndrome are assessed. Don’t administer the offering agent -​ Assess frequently for the presence or worsening of suicide ideation -​ Monitor patient’s use of medication as prescribed, since these medications can be lethal in overdose -​ Instruct patient not to drive or operate dangerous machinery when experiencing sedation -​ Instruct patient to rise slowly from sitting to standing to avoid orthostatic hypotension -​ Instruct patients that all antidepressants have some potential for discontinuation syndrome and should not be stopped abruptly but rather should be tapered off Sedative-hypnotics -​ Indications: -​ Used in the short-term management of various anxiety states and to treat insomnia. Selected medications (pentobarbital, phenobarbital) are used as anticonvulsants, and some medications (pentobarbital, secobarbital)l as preoperative sedatives and in the management of alcohol withdrawal -​ Actions: -​ Cause generalized CNS depression -​ Contraindications: -​ Contraindicated in individuals with hypersensitivity to the drug or to any drug within the chemical class -​ During pregnancy & lactation (exceptions based on benefit-to-risk ratio may be made in certain cases) -​ Severe hepatic, cardiac, respiratory, or renal disease -​ Children younger than 15 for flurazepam -​ Children younger than 18 for estazolam, quzepam, temazepam, triazolam -​ Zolpidem, zaleplon, eszopiclone, and ramelteon are contraindicated in children -​ Precautions: -​ Caution should be used in administering sedative-hypnotics to patients with cardiac, hepatic, renal, or respiratory insufficiency  -​ Caution should be used with patients who may be suicidal or who may previously have been addicted to drugs -​ Hypnotic use should be short-term -​ Elderly clients may be more sensitive to CNS depressant effects, and dosage reduction may be required -​ High potential for tolerance with chronic use and have the potential for dependence, most sedative-hypnotic medications are schedule IV controlled substances -​ Side effects: -​ Abnormal thinking and behavior changes (aggressiveness, hallucinations, suicidal ideations) -​ Dependence on long-term use -​ Confusion -​ Memory impairment -​ Motor incoordination -​ Nursing implications: -​ Instruct the patient not to stop taking the drug abruptly due to possible tolerance and physical dependence -​ Education the patient about symptoms of withdrawal -​ Instruct the patient not to drive or operate dangerous machinery while until response to medication is known -​ Instruct the patient not to drink alcohol or take other CNS depressants, as well as antihistamines, cimetidine, antidepressants, neuromuscular blocking agents -​ Instruct female patients to discuss with her physician if she is pregnant or anticipating pregnancy while on these drugs to explore alternative treatment options -​ Assess the patient’s mood and assess for suicide risk Anti-anxiety agents -​ Indications: -​ Anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation -​ Actions: -​ Depress subcortical levels of the CNS, particularly the limbic system and reticular formation -​ Contraindications: -​ Avoid taking anti-anxiety drugs if you are also taking opioids, as the combination can be fatal -​ Avoid mixing benzodiazepines with alcohol -​ Don’t take anti-anxiety drugs at the same time as MAOIs -​ Can be habit-forming (addiction), especially if taken for a long time  -​ Taking more than the prescribed dose can result in coma or death -​ Side effects: -​ Dependence on long-term use -​ Confusion -​ Memory impairment -​ Motor incoordination -​ Nursing implications: -​ Instruct the patient not to stop taking the drug abruptly due to possible tolerance and physical dependence -​ Educate the patient about the symptoms of withdrawal -​ Instruct the patient not to drive or operate dangerous machinery until response to medication is known -​ Instruct the patient not to drink alcohol or take other CNS depressants, as well as antihistamines, cimetidine, antidepressants, neuromuscular blocking agents -​ Instruct female patients to discuss with their physician if she is pregnant or anticipating pregnancy while on these drugs to explore alternative treatment options -​ Assess the patient’s mood and assess for suicide risk Mood-stabilizing agents -​ Indications: -​ Bipolar disorder is characterized by a roller-coaster cycle of “ups and downs” in mood, generating cycles of depression and manic episodes that may manifest as grandiose thinking and behavior, rapid thoughts, hyperactivity, and/or agitation -​ Actions: -​ The mechanism is unclear, but the impact on cellular sodium transport, GABA (gamma-aminobutyric acid) modulation, and raising seizure threshold have all been advanced as possible explanations. -​ Contraindications: -​ Lithium should be given with caution to patients over 60y due to renal functioning decreasing with age and lithium is cleared through the kidney -​ Lithium should be avoided in those with cardiac failure due to its ability to alter the functioning of the sodium-potassium transporter, which can worsen arrhythmias -​ Valproic acid should be avoided during pregnancy -​ Patients can potentially develop skin changes or new rashes after initiation of mood stabilizer -​ Precautions: -​ Increased risk of sensitivity to the sun -​ Regular blood testing may be required to check safe levels of drugs in body  -​ Side effects: -​ Weight gain -​ Upset stomach -​ Nausea -​ Metallic taste in mouth -​ Headaches -​ Confusion -​ Aggression -​ tiredness -​ Nursing implications: -​ Instruct patient to report all medications, herbals, and caffeine use to physicians or nurse practitioners to evaluate for drug interactions -​ Instruct patient about the importance of regular monitoring of serum lithium levels -​ Assess for suicide risk regularly, and inform patient of risks associated with anticonvulsants -​ Monitor vital signs and instruct the patient to report any symptoms of dizziness or palpitations -​ Instruct the patient not to drive or operate dangerous machinery until response to medication is known -​ Educate the patient to report infections or other illnesses while on these medications -​ Instruct female patients on the risks of birth defects, and provide education about contraception as desired Antipsychotics agents -​ Precautions: -​ Caution with elderly or debilitated patients -​ Caution with patients with cardiac, hepatic, or renal insufficiency -​ Caution with those with a history of seizures -​ Caution with patients with diabetes or risk factors for diabetes -​ Caution with clients exposed to temperature extremes under conditions that cause hypotension -​ Caution with pregnant clients or children -​ Side effects: -​ Hormonal side effects: sexual side effects include decreased libido, retrograde ejaculation, gynecomastia, amenorrhea -​ Extrapyramidal side effects: -​ Caused by excessive dopamine blockage -​ Side effects include:  -​ Dystonia (muscle spasms) (can be life-threatening) -​ Pseudoparkinsonism (Parkinson-like symptoms) -​ Tardive dyskinesias (later onset involuntary movement disorders primarily in tongue, lips, and jaw but may also involve other movement disturbances) -​ Akinesia (loss of ability to move your muscles voluntarily) -​ Akathisia (inability to remain still) -​ Oculogyric crisis (uncontrolled rollin g back of the eyes) -​ Treatment includes: -​ Anticholinergics (benztropine) -​ Antihistamines (benadryl) CNS Stimulants -​ Side effects: -​ Restlessness -​ Insomnia -​ Palpitations -​ Tachycardia -​ Anorexia -​ Weight loss -​ Tolerance Process of reuptake of a neurotransmitter -​ Reuptake is the process of neurotransmitter inactivation by which the neurotransmitter is reabsorbed into the presynaptic neuron from which it had been released -​ Blocking the reuptake process allows more of the neurotransmitter to be available for neuronal transmission -​ Some antidepressants also block receptor sites that are unrelated to their mechanisms of action on mood and emotions -​ These include α-adrenergic, histaminergic, and muscarinic cholinergic receptors -​ Blocking these receptors is associated with the development of certain side effect Medication tolerance -​ Medication tolerance can occur over time. Occurs when a specific dose is well tolerated yet becomes less effective due to metabolism, tissue accumulation, and increased excretion rates Steps of the nursing process to the administration of psychotropic medications -​ Assessment:  -​ A thorough baseline assessment must be conducted before a client is placed on a regimen of psychopharmacological therapy. A history and physical examination, an ethnocultural assessment, and a comprehensive medication assessment are all essential components of this assessment -​ Ethnocultural assessment is necessary because genetic variations in selected populations and cultural factors, including dietary preferences, may influence response to some medications -​ Medication administration and evaluation: -​ A nurse is the key healthcare professional in direct contact with patients receiving psychotropic medications in inpatient settings, partial hospitalization programs day treatment centers, home health care, and other settings -​ Medication administration is followed by continuous monitoring for side effects and adverse reactions -​ The nurse also evaluates the therapeutic effectiveness of the medication -​ It is essential for nurses to have thorough knowledge of psychotropic medications to be able to anticipate potential problems and outcomes associated with their administration -​ Patient education: -​ Information associated with psychotropic medication is copious and complex -​ Important role of the nurse is to translate complex information into terms that are easily understood by the patient -​ Patients must understand why the medication has been prescribed when it should be taken, and what they may expect in terms of side effects and possible adverse reactions -​ Patient should know who to contact when they have a question and when it is important to report to their physician -​ Medication education encourages patient cooperation and promotes accurate and effective management of the treatment regimen -​ Nurses should use the latest informatics resources to provide current and relevant education on this and other medication-related topics -​ Diagnoses: -​ Anti-anxiety: -​ Risk for injury related to seizures, panic anxiety, acute agitation from alcohol withdrawal (indications), abrupt withdrawal from the medication after long-term use, and effects of medication intoxication or overdose -​ Anxiety (specify) related to threat to physical integrity or self-concept. -​ Risk for activity intolerance related to side effects of sedation, confusion, and/or lethargy. -​ Disturbed sleep pattern related to situational crises, physical condition, or severe level of anxiety.  -​ Antidepressants: -​ Risk for suicide related to depressed mood. -​ Risk for injury related to side effects of sedation, lowered seizure threshold, orthostatic hypotension, priapism, photosensitivity, arrhythmias, hypertensive crisis, or serotonin syndrome. -​ Social isolation related to depressed mood. -​ Risk for constipation related to side effects of the medication. -​ Insomnia related to depressed mood and elevated level of anxiety -​ Mood-stabilizing: -​ Risk for injury related to manic hyperactivity -​ Risk for self-directed or other-directed violence related to unresolved anger turned inward on the self or outward on the environment -​ Risk for injury related to lithium toxicity -​ Risk for injury related to adverse effects of mood-stabilizing drugs -​ Risk for activity intolerance related to side effects of drowsiness and dizziness -​ Sedative-hypnotics: -​ Risk for injury related to abrupt withdrawal from long-term use or decreased mental alertness caused by residual sedation -​ Disturbed sleep pattern/insomnia related to situational crises, physical condition, or a severe level of anxiety -​ Risk for activity intolerance related to side effects of lethargy, drowsiness, and dizziness -​ Risk for acute confusion related to action of the medication on the central nervous system -​ Evaluation for effectiveness: -​ Anti-anxiety: -​ Demonstrates a reduction in anxiety, tension, and restless activity. -​ Experiences no seizure activity. -​ Experiences no physical injury. -​ Is able to tolerate usual activities without excessive sedation. -​ Exhibits no evidence of confusion. -​ Tolerates the medication without gastrointestinal distress. -​ Verbalizes understanding of the need for, side effects of, and regimen for self-administration. -​ Verbalizes possible consequences of abrupt withdrawal from the medication -​ Antidepressants: -​ Has not harmed self.  -​ Has not experienced injury caused by side effects. -​ Exhibits vital signs within normal limits. -​ Manifests symptoms of improvement in mood (brighter affect, interaction with others, improvement in hygiene, clear thought, expressing hopefulness, ability to make decisions). -​ Willingly participates in activities and interacts appropriately with others. -​ Mood-stabilizing: -​ Is maintaining stability of mood -​ Has not harmed self or others -​ Has experienced no injury from hyperactivity -​ Is able to participate in activities without excessive sedation or dizziness -​ Is maintaining appropriate weight -​ Exhibits no signs of lithium toxicity -​ Verbalizes importance of taking medication regularly and reporting for regular laboratory blood tests -​ Sedative-hypnotics: -​ Demonstrates a reduction in anxiety, tension, and restless activity -​ Falls asleep within 30 minutes of taking the medication and remains asleep for 6 to 8 hours without interruption -​ Is able to participate in usual activities without residual sedation -​ Experiences no physical injury -​ Exhibits no evidence of confusion -​ Verbalizes understanding of taking the medication on a short-term basis -​ Verbalizes understanding of the potential for the development of tolerance and dependence with long-term use Chapter 5: Relationship Development and Therapeutic Communication Objective: Describe therapeutic and nontherapeutic verbal communication techniques ​ Therapeutic Verbal Communication Techniques ○​ Empathy vs sympathy ○​ Rephrasing ○​ Low and slow ​ Nontherapeutic ○​ Blaming ○​ Giving advice ○​ Disregarding feelings Chapter 8: Interventions in Group Objective: Identify various types of groups ​ Task groups  ○​ Groups are formed to accomplish a specific outcome or task ​ Teaching groups ○​ The focus is to convey knowledge and information to a number of individuals ​ Supportive/therapeutic groups ○​ The primary concern is to share thoughts, feelings, events, and coping strategies to help learn effective ways to deal with emotional stress arising from the situational or developmental crisis ​ Group therapy ○​ Has a sound theoretical base, and leaders generally have advanced degrees in psychology, social work, nursing, or medicine (SA victim groups) ​ Therapeutic groups ○​ Based to a lesser extent on theory. The focus is on group relations; not designed for psychotherapy (AA groups) ​ Self-Help groups ○​ Composed of individuals undergoing similar experiences; may or may not have a professional leader, ran by members, leadership often rotates from member to member (AA groups) Chapter 9: Crisis Intervention Objective: Define and differentiate between anger and aggression ​ Anger ○​ Frowning ○​ Clenched fists ○​ Low-pitched voice ○​ Yelling and shouting ​ Aggression ○​ Pacing; restlessness ○​ Verbal/physical threats ○​ Threats of homicide or suicide ○​ Loud voice; argumentative ○​ Destruction of property ○​ Suspiciousness and defensive posturing Objective: Identify the role of the nurse in crisis intervention ​ The goals of crisis intervention is resolution of the individuals immediate crisis and restoration to at least the level of functioning that existed before the crisis period of possibly to a higher level of functioning ○​ Phase 1: Assessment ○​ Phase 2: Planning of therapeutic intervention (desires/goals)  ○​ Phase 3: Intervention (set firm limits) ○​ Phase 4: Evaluation of crisis resolution and anticipatory planning Chapter 10: Recovery Objective: Discuss the 10 guiding principles of recovery as delineated by the Substance Abuse and Mental Health Services Administration (SAMHSA) 1.​ Recovery emerges from hope: The belief that recovery is real provides the essential and motivating message of a better future—that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them. 2.​ Recovery is person-driven: Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s) toward those goals. 3.​ Recovery occurs via many pathways: Individuals are unique, with distinct needs, strengths, preferences, goals, cultures, and backgrounds that affect and determine their pathway(s) to recovery. Recovery is built on the multiple capacities, strengths, talents, coping abilities, resources, and inherent value of each individual. 4.​ Recovery is holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. This includes addressing the following: self-care practices, family, housing, employment, education, clinical treatment for mental disorders and substance use disorders, services and supports, primary health care, dental care, complementary and alternative services, faith, spirituality, creativity, social networks, transportation, and community participation. 5.​ Recovery is supported by peers and allies: Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery. Peers encourage and engage other peers and provide each other with a vital sense of belonging, supportive relationships, valued roles, and community. 6.​ Recovery is supported through relationships and social networks: An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change. Family members, peers, providers, faith groups, community members, and other allies form vital support networks. 7.​ Recovery is culturally based and influenced: Culture and cultural background in all of their diverse representations are keys in determining a person’s journey and unique pathway to recovery. Services should be culturally grounded, attuned, sensitive, congruent, and competent, as well as personalized to meet each individual’s unique needs. 8.​ Recovery is supported by addressing trauma: The experience of trauma is often a precursor to or associated with alcohol and drug use, mental health problems, and related issues. Services and supports should be trauma-informed to foster safety and trust, as well as promote choice, empowerment, and collaboration. 9.​ Recovery involves individual, family, and community strengths and responsibility: Individuals, families, and communities have strengths and resources that serve as a foundation for recovery. In addition, individuals have a personal responsibility for their own self-care and journeys of recovery.  10.​Recovery is based on respect: Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems—including protecting their rights and eliminating discrimination—are crucial in achieving recovery. Chapter 11: suicide prevention Objective: apply the nursing process to individuals exhibiting suicidal behavior 1.​ Presenting Symptoms -​ Several acronyms have been developed as mnemonic devices to summarize important factors that may increase a person’s risk for suicidal behavior. One of these is the acronym IS PATH WARM? -​ Ideation: Has suicide ideas that are current and active, especially with an identified plan -​ Substance abuse: Has current and/or excessive use of alcohol or other mood-altering drugs -​ Purposelessness: Expresses thoughts that there is no reason to continue living -​ Anger: Expresses uncontrolled anger or feelings of rage -​ Trapped: Expresses the belief that there is no way out of the current situation -​ Hopelessness: Expresses lack of hope and perceives little chance of positive change -​ Withdrawal: Expresses desire to withdraw from others or has begun withdrawing -​ Anxiety: Expresses anxiety, agitation, and/or changes in sleep patterns -​ Recklessness: Engages in reckless or risky activities with little thought of consequences -​ Mood: Expresses dramatic mood shifts 2.​ Assessing Suicide Risk (Risk Factors) ​ Marital Status ○​ Widows and widowers, in some studies, have been identified as high risk. ○​ The study also found that divorced men were twice as likely as married men to die by suicide. ​ Sex ○​ More women than men attempt suicide, but men succeed more often (about 70% of men who attempt suicide succeed, and 30% of women who attempt it succeed). ○​ Women tend to overdose on drugs; men use more lethal means, such as firearms. ​ Age ○​ The most recent statistics, revealed that in 2018, the highest rate of suicide occurred in the 45-to-64 year old age group.  ○​ Although adolescents may statistically have a lower rate of suicide than some other age-groups, it is still important to note that it has been, over several years, the third-leading cause of death in this population, and in 2013 it jumped to the second-leading cause of death where it remained in 2019. ​ Religion ○​ Assessing religion’s role in risk for suicide is complicated by variables such as degree of affiliation, participation, religious doctrine, and others. ○​ Another study found that religious affiliation is associated with a decreased risk of suicide attempts in both the general population and in those with a mental illness. ​ Socioeconomic Influences ○​ Financial strain and unemployment have often been identified as risk factors for suicide. ○​ Suicide rates are higher in rural areas and with a twofold greater use of firearms as the means. ​ Ethnicity ○​ In 2019 the highest U.S. age-adjusted suicide rate was among white populations and the second-highest rate was among American Indians and Alaska Natives. ○​ Much lower rates were found among black populations and Asians and Pacific Islanders ​ Other Risk Factors ○​ The majority of people who die by suicide have a diagnosable mental illness, most commonly depression, bipolar disorder, or substance use disorder. ○​ Other major physical conditions have also been identified as contributing to increased risk for suicide, with three conditions (traumatic brain injury, sleep disorders, and HIV/AIDS) conferring a twofold increase in risk. ○​ Several studies have indicated a higher risk for suicide among lesbian, gay, bisexual, and transgender (LGBT) individuals. ○​ Higher risk is also associated with a family history of suicide, especially in a same-gender parent. ○​ Cyberbullying has also been associated with increased risk of depression and suicidal behavior among young people. 3.​ Plan of Care ​ The person should have immediate access to support systems and be tied to a system of care because the term following hospital discharge is a high-risk period.  Arrangements must be made for the client to stay with family or friends. If this is not possible, hospitalization should be reconsidered. ​ A detailed safety plan should be developed. This intervention explores with clients what they will do to stay safe if there is a repeat or increase in suicidal thoughts or urges. ○​ A safety plan should not be confused with a no-suicide contract. ​ Enlist the help of family or friends to ensure that the home environment is safe from dangerous items, such as firearms or stockpiled drugs. Give support persons the telephone number of the counselor or an emergency contact person in the event that the counselor is not available. ​ Appointments may need to be scheduled daily or every other day at first until the immediate suicidal crisis has subsided. ​ Establish rapport and promote a trusting relationship. It is important for the suicide counselor to become a key person in the client’s support system at this time. ​ Accept the client’s feelings in a nonjudgmental manner. Chapter 13: neurocognitive disorders Objective: describe clinical symptoms and use the information to assess clients with neurocognitive disorders -​ delirium -​ Delirium is characterized by a sudden onset of confusion, fluctuating symptoms, and altered level of consciousness, which differs from the gradual decline typically seen in other NCDs like dementia. -​ Delirium is usually reversible once the underlying cause is addressed, unlike many other NCDs which are progressive. -​ Symptoms:​ -​ Difficulty sustaining and shifting attention -​ Extreme distractibility -​ Disorganized thinking -​ Speech that is rambling, irrelevant, pressured and incoherent -​ Impaired reasoning and goal directed behavior -​ Disorientation to time and place -​ Impairment of recent memory -​ Misperceptions about the environment (including illusions and hallucinations) -​ Disturbances in levels of consciousness -​ Psychomotor activity that fluctuates -​ Emotional instability -​ Autonomic Manifestations -​ Dementia: -​ A gradual decline in mental state and behavior that occurs over months or years. Dementia is typically caused by a disease like Alzheimer's, vascular dementia, or lewy body dementia. -​ Delirium and dementia can share symptoms like confusion, agitation, and delusions. However, delirium is usually triggered by a specific illness, such as a urinary tract infection, dehydration, or illicit drug use. Medications that interact with each other can also cause delirium. -​ People with dementia are more likely to develop delirium, and delirium can accelerate the decline of cognitive abilities in people with dementia. -​ Alzheimer’s disease -​ Alzheimer’s disease (AD) accounts for 60% to 80% of all cases of neurocognitive disorder and is the most common cause of dementia in older adults. -​ Level of stages: -​ ​Stage 1: No apparent symptoms: In the first stage of the illness, there is no apparent decline in memory despite changes that are beginning to occur in the brain; a positron emission tomography (PET) scan can be used to detect these changes. -​ Stage 2: Very mild change: The individual begins to lose things or forget names of people. Losses in short-term memory are common. The individual is aware of the intellectual decline and may feel ashamed, becoming anxious and depressed, which in turn may worsen the symptom. Maintaining organization with lists and a structured routine provides some compensation. These symptoms often are not noticed by others and do not interfere with the individual’s ability to work or live independently. -​ Stage 3: Mild cognitive decline: In this stage there are changes in thinking and reasoning that interfere with work performance and become noticeable to coworkers. The individual may get lost when driving a car. Concentration may be interrupted. There is difficulty recalling names or words, which becomes noticeable to family and close associates. A decline occurs in the ability to plan or organize. -​ Stage 4: Moderate cognitive decline: At this stage, individuals may forget major events in personal history, such as their own child’s birthday; experience declining ability to perform tasks, such as shopping, cooking, and managing personal finances; or be unable to understand current news events. They may deny that a problem exists by covering up memory loss with confabulation (creating imaginary events to fill in memory gaps). Depression and social withdrawal are common. At this stage the individual requires some assistance to maintain safety.  -​ Stage 5: Moderately severe cognitive decline: At this stage, individuals lose the ability to perform some ADLs independently, such as hygiene, dressing, and grooming, and require some assistance to manage these tasks on an ongoing basis. They may forget addresses, phone numbers, and names of close relatives. They may become disoriented about place and time, but they maintain knowledge about themselves. Frustration, withdrawal, and self-absorption are common. -​ Stage 6: Severe cognitive decline: At this stage, individuals may be unable to recall the name of their spouse or may misidentify people (e.g., thinking a child is their spouse). Disorientation to surroundings is common, and the person may be unable to recall the day, season, or year. The person is unable to manage ADLs without assistance. Delusions often become apparent, such as maintaining the belief that one must go to work even though the person is no longer employed. Urinary and fecal incontinence is common. Sleeping becomes a problem. Psychomotor symptoms include wandering, obsessiveness, agitation, and aggression. Symptoms seem to worsen in the late afternoon and evening—a phenomenon termed sundowning. Communication becomes more difficult with increasing loss of language skills. Institutional care is usually required at this stage. -​ Stage 7: Very severe decline: In the end stages of AD, individuals are unable to recognize family members. They most commonly are bedfast and aphasic. Problems of immobility, such as pressure injuries and contractures, may occur -​ Nursing diagnoses and interventions -​ Risk for trauma -​ Ensure adequate supervision -​ Arange furniture/room carefully -​ Low bed/bed alarm -​ Provide a safe area for wandering/ doors locked and alarmed -​ Disturbed thought processes -​ Clocks and calendars that are easy to read -​ Personal items/ photographs -​ Low stimuli in environment -​ Reminiscence therapy -​ Validate feelings -​ Self-care deficit -​ Assess what can be done independently/ needs for assistance -​ Allow plenty of time to accomplish tasks -​ Talk through steps one at a time  -​ Structured and consistent schedule of activities -​ Regular bathroom trips -​ Promote nighttime sleep Objective: describe various treatment modalities relevent to care of clients with neurocognitive disorders -​ First step in tx of delirium is identification and correction of underlying cause -​ For NCD: -​ Donepezil (Aricept) -​ Cholinesterase inhibitor -​ memantine (Namenda) -​ NMDA receptor antagonist -​ These agents have been shown to slow down progression of cognitive decline but do not stop or reverse effects of the disease -​ Antipsychotics are sometimes used to manage agitation, aggression, hallucinations, thought disturbances and wandering. -​ However, there is a black box warning due to increased risk of death in elderly, particularly in those with dementia. Will not treat underlying cause of acute delirium or NCD Chapter 14: substance use and addiction disorders Objective: define addiction, intoxication, and withdrawal -​ Addiction: A compulsive or chronic requirement. The need is so strong as to generate distress (physical or psychological) if left unfulfilled -​ Intoxication: A state of disturbance in cognition, perception, behavior, level of consciousness, judgment, and other functions that is directly attributable to the effects of a psychoactive drug. It may be marked by a physical and mental state of exhilaration and emotional frenzy or lethargy and stupor -​ Withdrawal: Withdrawal is the physiological and mental readjustment that accompanies the discontinuation of an addictive substance Objective: Describe various modalities relevant to treatment of individuals with substance-related and addictive disorders -​ Treatment modality for substance-related disorders include: -​ Self-help groups (AA, SMART Recovery, etc.) -​ Individual counseling -​ Family therapy -​ Group therapy -​ Short term treatment / detox -​ Medication-assisted treatment is frequently implemented with clients experiencing substance intoxication and substance withdrawal and to prevent relapse -​ Opiate Replacement Therapy is the Gold Standard for OUD (Opiate Use Disorder)  -​ Best practice is for opioid agonist therapy to continue indefinitely -​ If treatment does need to be stopped, taper should be over several months -​ Harm reduction is also a critical part of treatment & recovery -​ Treatment modalities are implemented on an inpatient basis or in outpatient settings depending on the severity and condition of the patient -​ Goal of long-term management is to promote recovery and prevent relapse. In short term treatment, individuals can safely stop substances, focus on diversional activities, and start learning how to live without substances -​ Benefits of self-help groups are accountability and continued support from peers. It is also important to note that different groups may take a different approach. For example, AA tends to have an “abstinence only” philosophy, while others like SMART recovery may not Chapter 15: schizophrenia spectrim and other psychotic disorders Objective: describe appropriate nursing interventions for behaviors associated with these disorders -​ Disturbed Sensory Perception -​ Assess for signs of hallucinations -​ Do not reinforce the hallucinations -​ Use distraction -​ Disturbed Thought Process -​ Do not argue or deny the belief, voice reasonable doubt -​ Reinforce and focus on reality -​ For suspicious patients: use the same staff as much as possible, avoid physical contact and ask for permission before touching, provide packaged foods, mouth checks may be necessary, keep physical distance between yourself and the patient -​ Continuously assess for potential self-harm or harm to others, especially during episodes of extreme agitation or aggression -​ Educate the patient about medication benefits and side effects to encourage compliance, and assess for any adverse effects -​ Use grounding techniques, such as asking about the date or their surroundings, to help orient the patient to reality when appropriate -​ Educate family members about the disorder and involve them in the treatment plan to create a supportive environment -​ Encourage engagement in therapeutic activities like group therapy or recreational activities that foster social skills and cognitive functioning Objective: identify symptomatology associated with these disorders and use this information in client assessment -​ Symptomatology for psychotic disorders -​ Disruption of perception -​ Disorganized thoughts and behaviors -​ Loss of contact with reality -​ Delusions -​ Hallucinations  -​ Symptomatology with schizophrenia -​ Positive symptomology: thought to be caused by overactivity of dopamine in the mesolimbic pathway -​ Delusions -​ Hallucinations -​ Disorganized thinking/speech -​ Abnormal behavior -​ Negative symptomology: thought to be caused by under activity of dopamine in the mesocortical pathway -​ Avolition refers to an inability to initiate and complete goal-directed behaviors. It is similar to Apathy, which is a lack of interest, energy, and drive to engage in activities. -​ Anhedonia is when the ability to feel pleasure is reduced or absent. -​ Alogia is decreased verbal communication. It may present as thought blocking, which is when a person suddenly stops talking mid-sentence for no clear reason, or it may be a significant delay in conversational responses. -​ Asociality is a decreased interest in social interaction or relationships with others. Individuals may withdraw from others or demonstrate lack of social skill in interacting with others. -​ Affect describes the behavior associated with an individual’s feeling state or emotional tone. Affect is inappropriate when the individual’s emotional tone is incongruent with the circumstances. A flat or blunted effect may look like little to no facial expression and monotone speech Chapter 16: depressive disorders Objective: discuss implications of depression related to developmental stage -​ Childhood depressions -​ Younger than 3: Feeding problems, tantrums, lack of playfulness and emotional expressiveness -​ Age 3 to 5: Accident proneness, phobias, excessive self-reproach -​ Age 6 to 8: Physical complaints, aggressive behavior, clinging behavior -​ Age 9 to 12: Morbid thoughts and excessive worrying -​ Adolescence -​ Symptoms -​ Anger, aggressiveness -​ Running away -​ Delinquency -​ Social withdrawal -​ Sexual acting out -​ Substance abuse -​ Restlessness, apathy -​ Risks of suicide peaks in the mid-adolescence  -​ Older adults -​ often undetected or inadequatley treated -​ Symptoms may alos have somatic focus -​ Suicide rates peak during middle age, but a second peak occurs in those aged 75 years and older Objective: discuss various modalities relevant to treatment of depression -​ Treatment of Depressive Disorders -​ Can be treated in various settings (inpatient, outpatient, PHP, IOP) -​ Psychotherapy (variety of modalities) -​ Cognitive Behavioral Therapy (CBT) -​ Interpersonal Therapy -​ Psychodynamic Therapy -​ Pharmacotherapy -​ Several different classes of medications - commonly referred to as antidepressants: -​ Selective Serotonin Reuptake Inhibitor (SSRI) -​ Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) -​ Tricyclic Antidepressant (TCA) -​ Monoamine Oxidase Inhibitor (MAOI) -​ Other/Atypical Antidepressants -​ Herbal Remedies & Other Treatments -​ Other Approaches:​ -​ Electroconvulsive Therapy (ECT) -​ Light Therapy (Phototherapy) -​ Transcranial Magnetic Stimulation (TMS) -​ Alterative / Complementary Therapies Chapter 17: bipolar and related disorders Objective: discuss various modalities relevelnt to treatment of bipolar disorder ​ Individual Psychotherapy ○​ The focus of this therapy is helping clients to regulate their social rhythms or daily activities such as the sleep–wake cycle and exercise routines that may otherwise disrupt underlying biological rhythms and contribute to mood disturbances. ​ Group Therapy ○​ Once an acute phase of the illness has passed, groups can provide an atmosphere in which individuals may discuss issues in their lives that cause, maintain, or arise out of having a serious affective disorder. ​ Family Therapy ○​ The ultimate objectives in working with families of clients with mood disorders are to resolve the symptoms and initiate or restore adaptive family functioning. ○​ Family functioning and marital relationships are often disrupted in clients with bipolar disorder, especially when symptoms are contributing to disloyalty in the marriage and to financial problems related to the client’s excessive spending behaviors. Whether intervention occurs in the form of family education, support, formal therapy, or a combination of these approaches, it is clear that families need to be involved in treatment whenever possible. ​ Cognitive Behavior Therapy ○​ In cognitive behavior therapy, the individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of mood disorders. ○​ The general goals in cognitive behavior therapy are to obtain symptom relief as quickly as possible, assist the client in identifying dysfunctional patterns of thinking and behaving, and guide the client to evidence and logic that effectively test the validity of the dysfunctional thinking. ○​ Therapy focuses on changing “automatic thoughts” that occur spontaneously and contribute to the distorted effect. ○​ Examples of automatic thoughts in bipolar mania include the following: -​ Personalizing: “I’m the only reason my husband is a successful businessman.” -​ All or nothing: “Everything I do is great.” -​ Mind reading: “She thinks I’m wonderful.” -​ Discounting negatives: “None of those mistakes are really important.” ​ The Recovery Model ○​ Learning how to live a safe, dignified, full, and self-determined life in the face of the enduring disability which may, at times, be associated with serious mental illness. ○​ In bipolar disorder, recovery is a continuous process. -​ Client identifies goals. -​ Client and clinician develop a treatment plan. -​ Client and clinician work on strategies to help the individual manage the bipolar illness. -​ Clianian serves as a support person to help the individual achieve the previously identified goals. ○​ Although there is no cure for bipolar disorder, recovery is possible in the sense of learning to prevent and minimize symptoms, and to successfully cope with the effects of the illness on mood, career, and social life. Objective: describe appropriate nursing interventions for patients epxeriecning a manic episode ​ Nursing Diagnosis: Risk for Injury ○​ Nursing interventions… 1.​ Reduce environmental stimuli. Assign a private room with simple decor on a quiet unit if possible. Keep lighting and noise level low. 2.​ Remove hazardous objects and substances (including smoking materials). 3.​ Stay with the patient who is hyperactive and agitated. 4.​ Provide a structured schedule of activities that includes established rest periods throughout the day. Limit group activities. 5.​ Provide physical activities. 6.​ Administer tranquilizing medication as ordered by physician. ​ Nursing Diagnosis: Risk For Violence: Self-Directed or Other-Directed ○​ Nursing interventions… 1.​ Maintain a low level of stimuli in the patient’s environment (low lighting, few people, simple decor, low noise level). 2.​ Assess for concomitant substance use issues. 3.​ Observe the patient’s behavior frequently. Do this while carrying out routine activities so as to avoid creating suspiciousness in the individual. 4.​ Remove all sharp objects, glass or mirrored items, belts, ties, and smoking materials from the patient's environment. 5.​ Intervene at the first signs of increased anxiety, agitation, or verbal or behavioral aggression using empathic responses such as “You seem anxious” or “How can I help?” 6.​ Maintain and convey a calm attitude. Respond matter-of-factly to verbal hostility. 7.​ As anxiety increases, offer some alternatives: to participate in a physical activity (e.g., walking or other physical exercise), talking about the situation, taking some anti-anxiety medication. 8.​ Have sufficient staff available to safely redirect the patient if it becomes necessary. 9.​ If the patient is not calmed by “talking down” or by medication, use of mechanical restraints may be necessary. 10.​If restraint is deemed necessary, ensure that sufficient staff is available to assist. Follow protocol established by the institution. 11.​Observe the patient in restraints continuously and assess patient at least every 15 minutes to ensure that circulation to extremities is not compromised (check temperature, color, pulses); to assist the patient with needs related to nutrition, hydration, and elimination; and to position the patient so that comfort is facilitated and aspiration can be prevented.  12.​As agitation decreases, assess the patient’s readiness for restraint removal or reduction. Remove restraints gradually, one at a time while assessing the patient’s response. ​ Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements ○​ Nursing interventions… 1.​ Provide high-protein, high-calorie, nutritious finger foods and drinks that can be consumed “on the run.” 2.​ Have juice and snacks available on the unit at all times. 3.​ Maintain an accurate record of intake, output, calorie count, and weight. Monitor daily laboratory values. 4.​ Determine the patient’s likes and dislikes and collaborate with dietitians to plan meals. 5.​ Supplement diet with vitamins and minerals. 6.​ Walk or sit with the patient while the patient is eating. ​ Nursing Diagnosis: Impaired Social Interaction ○​ Nursing interventions… 1.​ Recognize the purpose that manipulative behaviors serve for the patient: to reduce feelings of insecurity by increasing feelings of power and control. 2.​ Set limits on manipulative behaviors. Explain to the patient what is expected and what the consequences are if the limits are violated. Terms of the limitations must be agreed on by all staff who will be working with the patient. 3.​ Do not argue, bargain, or try to reason with the patient. Merely state the limits and expectations. Confront the patient as soon as possible when interactions with others are manipulative or exploitative. Follow through with established consequences for unacceptable behavior. 4.​ Provide positive reinforcement for non manipulative behaviors. Explore feelings and help the patient seek more appropriate ways of dealing with them. 5.​ Help the patient recognize and accept the consequences of their own behaviors and refrain from attributing them to others. 6.​ Help the patient identify positive aspects about self, recognize accomplishments, and feel good about them. Chapter 18: Anxiety and Related Disorders Objective: Discuss various modalities relevant to treatment of anxiety, obsessive-compulsive, and related disorders. ​ Individual Psychotherapy  ○​ Most clients experience a marked decrease in anxiety when given the opportunity to discuss their difficulties with a concerned and sympathetic therapist. Supportive psychotherapy is designed to help clients identify their personal strengths and explore adaptive coping mechanisms. ​ Cognitive Behavior Therapy (CBT) ○​ Cognitive behavior therapy strives to assist the individual in reducing anxiety responses by altering cognitive distortions. Anxiety is described as resulting from exaggerated, automatic thinking. ​ Behavior Therapy ○​ Systematic Desensitization ​ In systematic desensitization, the client is gradually exposed to the phobic stimulus, in either a real or an imagined situation. ○​ Implosion Therapy (Flooding) ​ Implosion therapy, or flooding, is a therapeutic process in which clients, for a prolonged period, must imagine situations or participate in real-life situations they find extremely frightening. Objective: Describe appropriate nursing interventions for behaviors associated with anxiety, obsessive-compulsive, and related disorders. ​ Anxiety ○​ Stay with the patient and offer reassurance of safety and security. Do not leave the patient in panic anxiety alone. ○​ Maintain a calm, nonthreatening, matter-of-fact approach. ○​ Use simple words and brief messages, spoken calmly and clearly, to explain hospital experiences. ○​ Hyperventilation may occur during periods of extreme anxiety. Hyperventilation causes the amount of carbon dioxide (CO2) in the blood to decrease, possibly resulting in lightheadedness, rapid heart rate, shortness of breath, numbness or tingling in the hands or feet, and syncope. If hyperventilation occurs, assist the patient to breathe into a small paper bag held over the mouth and nose. Six to 12 natural breaths should be taken, alternating with short periods of diaphragmatic breathing. ○​ Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor). ○​ Administer tranquilizing medication, as ordered by physician. Assess for effectiveness and for side effects. ○​ When the level of anxiety has been reduced, explore possible reasons for occurrence.  ○​ Teach signs and symptoms of escalating anxiety and ways to interrupt its progression (relaxation techniques, such as deep-breathing exercises and meditation, or physical exercise, such as brisk walks and jogging). ​ Obsessive-compulsive ○​ Support the patient in efforts to stop hair pulling. Help the patient understand that it is possible to discontinue the behavior. ○​ Ensure that a nonjudgmental attitude is conveyed, and criticism of the behavior is avoided. ○​ Assist the patient with habit reversal training (HRT). Three components of HRT include the following: ​ Awareness training. Help the patient become aware of times when the hair pulling most often occurs (e.g., client learns to recognize urges, thoughts, or sensations that precede the behavior; the therapist points out to the patient each time the behavior occurs). ​ Competing response training. In this step, the patient learns to substitute another response to the urge to pull their hair. For example, when a patient experiences a hair-pulling urge, suggest that the individual ball up his/her hands into fists, tightening arm muscles, and “locking” his/her arms so as to make hair pulling impossible at that moment. ​ Social support. Encourage family members to participate in the therapy process and to offer positive feedback for attempts at habit reversal. ○​ Once the patient has become aware of hair-pulling times, suggest that the patient hold something (a ball, paperweight, or other item) in their hand at times when hair pulling is anticipated. ○​ Practice stress management techniques: deep breathing, meditation, stretching, physical exercise, listening to soft music. ○​ Offer support and encouragement when setbacks occur. Help the patient to understand the importance of not quitting when it seems that change is not happening as quickly as they would like. Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and identify the symptomatology associated with each. ​ Generalized anxiety disorder ○​ Generalized anxiety disorder (GAD) is characterized by persistent, unrealistic, and excessive anxiety and worry, which have occurred more days than not for at least 6 months and cannot be attributed to specific organic factors, such as caffeine intoxication or hyperthyroidism. ○​ The anxiety and worry are associated with three or more of the following symptoms: “restless or feeling keyed up or on edge, being easily fatigued,  difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbance” ​ Obsessive-compulsive ○​ The manifestations of obsessive-compulsive disorder (OCD) include the presence of obsessions (repetitive intrusive thoughts) or compulsions, or both, the severity of which is significant enough to cause distress or impairment in social, occupational, or other important areas of functioning. ○​ With compulsions the individual recognizes that the behavior is excessive or unreasonable but, because of the feeling of relief from discomfort that it promotes, is compelled to continue the act. Common compulsions include hand washing, ordering, checking, praying, counting, and repeating words silently. Chapter 19: Trauma and Stressor Disorders Objective: Describe the concepts and principles associated with trauma-informed care. Trauma-informed care generally describes a philosophical approach that values awareness and understanding of trauma when assessing, planning, and implementing care. SAMHSA (2019) advances the following principles (4Rs) in defining this approach. ​ Trauma-informed care: ○​ Realizes the widespread impact of trauma and various paths for recovery. ○​ Recognizes the signs and symptoms of trauma in clients, families, staff, and all those involved with the system. ○​ Responds by fully integrating knowledge about trauma in policies, procedures, and practices. ○​ Seeks to actively resist retraumatization. Chapter 21: Eating Disorders Objective: Evaluate the nursing care of patients with eating disorders. ​ Imbalanced nutrition: Less than body requirements ○​ Nursing Interventions: ​ For the patient who is emaciated and is unable or unwilling to maintain an adequate oral intake, the physician may order a liquid diet to be administered via nasogastric tube. Nursing care of the individual receiving tube feedings should be administered according to established hospital procedures. ​ For the patient who is able and willing to consume an oral diet, collaborate with the dietitian to determine the appropriate amount of calories and fluids required to provide adequate nutrition and realistic weight gain. ​ Monitor laboratory values for phosphate, potassium, calcium, and magnesium while nutrition is being restored. ​ Imbalanced nutrition: More than body requirements  ○​ Nursing Interventions: ​ Encourage the patient to keep a diary of food intake. ​ Discuss feelings and emotions associated with eating. ​ With input from the patient, formulate an eating plan that includes food from the required food groups with emphasis on low-fat intake. It is helpful to keep the plan as similar to the patient’s usual eating pattern as possible. ​ Identify realistic incremental goals for weekly weight loss. ​ Plan a progressive exercise program tailored to individual goals and choices. ​ Discuss the probability of reaching plateaus when weight remains stable for extended periods. ​ Provide instruction about medications to assist with weight loss if ordered by a physician. Chapter 22: Personality Disorders​ Objective: Discuss various modalities relevant to treatment of personality disorders. ​ Individual Psychotherapy ○​ Interpersonal (Individual) psychotherapy may be particularly appropriate because personality disorders largely reflect problems in interpersonal relationship skills. ​ Milieu or Group Therapy ○​ This treatment is especially appropriate for individuals with antisocial personality disorder who respond more adaptively to support and feedback from peers. In milieu or group therapy, feedback from peers is more effective than in one-to-one interaction with a therapist. ​ Group therapy ○​ Particularly supportive groups that emphasize the development of social skills—may be helpful in overcoming social anxiety and developing interpersonal trust and rapport in clients with avoidant personality disorder. ​ Cognitive Behavior Therapy (CBT) ○​ Behavioral strategies offer reinforcement for positive change. Social skills training and assertiveness training teach alternative ways to deal with frustration. ​ Dialectical Behavior Therapy (DBT) ○​ The four primary modes of treatment in DBT include the following: ​ Group skills training: These groups focus on teaching skills considered relevant to the particular problems experienced by people with BPD, such as core mindfulness skills, interpersonal effectiveness skills, emotion modulation skills, and distress tolerance skills. ​ Individual psychotherapy: Dysfunctional behavioral patterns, personal motivation, and skills strengthening are addressed in weekly sessions.  ​ Telephone contact: The therapist is available to the client by telephone, usually on a 24-hour basis, but according to limits set by the therapist. The purpose is to provide appropriate support, to counter abandonment fears, and to reduce episodes of self-harming behaviors. ​ Therapist consultation and team meeting: Therapists meet regularly to review their work with their clients. These meetings are focused specifically on providing support for each other, keeping the therapists motivated, and providing effective treatment to their clients. DBT has been well studied, and the evidence supports the benefits of this treatment for clients with BPD. O’Connell and Dowling (2014), citing a systematic review of seven studies (Binks et al., 2006), report that: ​ Psychopharmacology ○​ Psychopharmacology may be helpful in some instances. Although these medications have no effect in the direct treatment of the disorder itself, some symptomatic relief can be achieved. Antipsychotic medications show some benefits in treating cognitive-perceptual symptoms, selective serotonin reuptake inhibitors show some benefit in treating emotional dysregulation, and mood-stabilizing agents have shown some benefit in treating emotional dysregulation and impulsive aggressive symptoms. Chapter 23: Children and Adolescents Objective: Describe treatment modalities relevant to selected disorders of infancy, childhood, and adolescence. ​ Behavior Therapy ○​ Behavior therapy is a common and effective treatment with disruptive behavior disorders such as ADHD, ODD, and CD. With this approach, rewards are given for appropriate behaviors and withheld when behaviors are disruptive or otherwise inappropriate. The principle behind behavior therapy is that positive reinforcements encourage repetition of desirable behaviors, and aversive reinforcements (punishments) discourage repetition of undesirable behaviors. ​ Family Therapy ○​ Therapy for children and adolescents must involve the entire family if problems are to be resolved. Parents should be involved in designing and implementing the treatment plan for the child and should be involved in all aspects of the treatment process. ○​ The impact of family dynamics on disruptive behavior disorders has been identified. ​ Group Therapy ○​ Group therapy provides children and adolescents with the opportunity to interact within an association of their peers. Appropriate social behavior often is learned  from the positive and negative feedback of peers. Opportunity is provided to learn to tolerate and accept differences in others, to learn that it is acceptable to disagree, to learn to offer and receive support from others, and to practice these new skills in a safe environment. It provides a way to learn from the experiences of others. ​ Psychopharmacology ○​ Medication should never be the sole method of treatment. It is undeniable that medication can and does improve quality of life for families of children and adolescents with these disorders. However, research has indicated that medication alone is not as effective as a combination of medication and psychosocial therapy. Objective: Identify symptomatology and use the information in the assessment of clients with autism spectrum disorder, attention spectrum disorder, attention deficit-hyperactivity disorder, conduct disorder or oppositional defiant disorder. ​ Autism spectrum disorder ○​ Impairment in social interaction ​ Children with ASD have difficulty forming interpersonal relationships with others. They show little interest in people and often do not respond to others’ attempts at interaction. As infants, they may have an aversion to affection and physical contact. As toddlers, the attachment to a significant adult may be either absent or manifested as exaggerated adherence behaviors. In childhood, there is a lack of spontaneity manifested in less cooperative play, less imaginative play, and fewer friendships. ○​ Impairment in communication and imaginative activity: ​ Both verbal and nonverbal skills are affected. In more severe levels of ASD, language may be totally absent or characterized by immature structure or idiosyncratic utterances whose meaning is clear only to those who are familiar with the child’s past experiences. ○​ Restricted activities and interests: ​ Even minor changes in the environment are often met with resistance or sometimes with agitated irritability. Attachment to, or extreme fascination with, objects that move or spin (e.g., fans) is common. Stereotyped body movements (hand flapping, rocking, whole-body swaying) and verbalizations (repetition of words or phrases) are typical. ​ Attention spectrum disorder / Attention deficit-hyperactivity disorder (ADHD) ○​ The most frequently cited characteristics (in order of frequency) are hyperactivity, attention deficit, impulsivity, memory and thinking deficits, specific learning disabilities, and speech and hearing deficits. ○​ Children with ADHD are highly distractible and unable to contain stimuli. ○​ Motor activity is excessive, and movements are random and impulsive.  ​ Conduct disorder / Oppositional defiant disorder ○​ Oppositional defiant disorder (ODD) is characterized by a frequent and persistent pattern of angry mood and defiant behavior that occurs more frequently than is usually observed in individuals of comparable age and developmental level and interferes with social, educational, occupational, or other important areas of functioning. Chapter 25: Survivors of Abuse or Neglect​ Objective: Discuss characteristics of victims and victimizers. ​ Profile of the Victim ○​ Battered women represent all age, racial, religious, cultural, educational, and socioeconomic groups. ○​ They may be married or single, non-working, hourly workers, or business executives. ○​ Many women who are battered have low self-esteem, commonly adhere to feminine sex-role stereotypes, and often accept the blame for the batterer’s actions. ○​ Feelings of guilt, anger, fear, and shame are common. ○​ They may be isolated from family and support systems. ○​ Some women in violent relationships grew up in abusive homes and may have left those homes and gotten married at a very young age in order to escape the abuse. ○​ The battered woman views her relationship as male dominant, and as the battering continues, her ability to see the options available to her and to make decisions concerning her life (and possibly those of her children) decreases. ​ Profile of the Victimizer ○​ Batterers are typically characterized as persons with low self-esteem. ○​ Pathologically jealous, they present a “dual personality,” one to the partner and one to the rest of the world. ○​ They are often under a great deal of stress but have limited ability to cope with the stress. ○​ The typical abuser is very possessive and perceives his partner as a possession. ○​ He becomes threatened when she shows any sign of independence or attempts to share herself and her time with others. ○​ The abuser also may use threats of taking the children away as a tactic of emotional abuse. ○​ The victimizer achieves power and control through intimidation. Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for care of survivors of intimate partner violence, child abuse, and sexual assault ​ Partner violence  ○​ Nursing diagnoses ​ Powerlessness ○​ Goals of care ​ Short-Term Goal -​ Patients will recognize and verbalize choices available, thereby perceiving some control over life situations. ​ Long-Term Goal -​ Patients will exhibit control over life situations by making decisions about how to maintain personal safety. ○​ Appropriate nursing interventions ​ In collaboration with the physician, ensure that all physical wounds, fractures, and burns receive immediate attention. Take photographs if the individual permits. ​ Take the patient to a private area to do the interview. ​ If the patient has come alone or with children, reassure them of their safety. Encourage the patient to discuss the battering incident. Ask questions about whether this has happened before, whether the abuser takes drugs, whether the victim has a safe place to go, and whether the victim is interested in pressing charges. ​ Ensure that “rescue” efforts are not attempted by the nurse. Offer support but remember that the final decision must be made by the patient. ​ Stress to the patient the importance of safety. Provide information about available resources. These may include crisis hotlines, community groups for victims of abuse, shelters, counseling services, and information regarding the victim’s rights in the civil and criminal justice system. Respect the patient’s decision about whether to stay or leave the home or marriage. ​ Child abuse ○​ Nursing diagnoses ​ Risk for delayed development ○​ Goals of care ​ Short-Term Goal -​ Patients will develop trusting relationships with nurses and report how evident injuries were sustained. ​ Long-Term Goal -​ Patients will demonstrate behaviors consistent with age-appropriate growth and development. ○​ Appropriate nursing interventions ​ Perform complete physical assessment of the child. Take particular note of bruises (in various stages of healing), lacerations, and patient complaints  of pain in specific areas. Do not overlook or discount the possibility of sexual abuse. Assess for nonverbal signs of abuse: aggressive conduct, excessive fears, extreme hyperactivity, apathy, withdrawal, age-inappropriate behaviors. ​ Conduct an in-depth interview with the parent or adult who accompanies the child. Consider: If the injury is being reported as an accident, is the explanation reasonable? Is the injury consistent with the explanation? Is the injury consistent with the child’s developmental capabilities? ​ Use games or play therapy to gain the child’s trust. Use these techniques to assist in describing the child’s side of the story. ​ Sexual assault ○​ Nursing diagnoses ​ Rape-trauma syndrome ○​ Goals of care ​ Short-Term Goal -​ Patient’s physical wounds will heal without complication. ​ Long-Term Goal -​ Patients will begin a healthy grief resolution, initiating the process of physical and psychological healing (time to be individually determined). ○​ Appropriate nursing interventions ​ It is important to communicate the following to the individual who has been sexually assaulted: “You are safe here.”; “I’m sorry that it happened.”; “It’s not your fault. No one deserves to be treated this way.” ​ Explain every assessment procedure that will be conducted and why it is being conducted. Ensure that data collection is conducted in a caring, collaborative, nonjudgmental manner. ​ Ensure that the patient has adequate privacy for all immediate post-crisis interventions. Try to have as few people as possible providing immediate care or collecting immediate evidence. ​ Encourage the patient to give an account of the assault. Listen, but do not probe. ​ Discuss with the patient whom to call for support or assistance. Provide information about referrals for aftercare. Chapter 27: The Bereaved Individual Objective: Discuss the theoretical perspective of grieving as proposed by Elisabeth Kübler-Ross. 1.​ Denial ​ Occurs immediately on experiencing the loss. Usually lasts no more than a few weeks.  ​ Individuals have difficulty believing that the loss has occurred. 2.​ Anger ​ In most cases begins within hours of the loss. Peaks within a few weeks. ​ Anger is directed toward self or others. Ambivalence and guilt may be felt toward the lost entity. 3.​ Bargaining ​ The individual fervently seeks alternatives to improve the current situation. 4.​ Depression ​ Very individual. Commonly 6 to 12 months. Longer for some. ​ The actual work of grieving. Preoccupation with the lost entity. Feelings of helplessness and loneliness occur in response to realization of the loss. Feelings associated with the loss are confronted. 5.​ Acceptance ​ Resolution is complete. The bereaved person experiences a reinvestment in new relationships and new goals. The lost entity is not purged or replaced but relocated in the life of the bereaved. At this stage, terminally ill persons express a readiness to die.