Mental Health Exam 2 Blueprint Answers PDF

lOMoARcPSD|23617240 Mental Health Exam 2 Blueprint Answers Mental Health Nursing II (Herzing University) Studocu is not sponsored or endorsed by any college or university Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 Unit 4 Material Loss and Grief: NSG221.04.01.01 Mour...

lOMoARcPSD|23617240 Mental Health Exam 2 Blueprint Answers Mental Health Nursing II (Herzing University) Studocu is not sponsored or endorsed by any college or university Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 Unit 4 Material Loss and Grief: NSG221.04.01.01 Mourning rituals ● Mourning is the outward expression of grief ○ Rituals of mourning include having a wake, sitting shiva, holding religious ceremonies, and arranging funerals NSG221.04.01.02 Areas of loss after death of loved one ● Loss of security and a sense of belonging ○ loss of a loved one affects the need to love and the feeling of being loved ○ accompanies changes in relationships, such as birth, marriage, divorce, illness, and death ■ as the meaning of a relationship changes, a person may lose roles within a family or group. ● Loss of self-esteem: ○ Any change in how a person is valued at work or in relationships or by him or herself can threaten self-esteem ○ may be an actual change or the person’s perception of a change in value ○ Death of a loved one, a broken relationship, loss of a job, and retirement are examples of change that represent loss and can result in a threat to self-esteem ● Loss related to self-actualization: ○ an external or internal crisis that blocks or inhibits striving toward fulfillment may threaten personal goals and individual potential ○ When we realize our goals in life will never materialize ○ These are losses that the person will grieve NSG221.04.02.01 Stages of Grief Kubler Ross 1. Denial a. shock and disbelief regarding the loss. 2. Anger a. may be expressed toward God, relatives, friends, or health care providers. 3. Bargaining a. occurs when the person asks God or fate for more time to delay the inevitable loss. 4. Depression a. results when awareness of the loss becomes acute. 5. Acceptance a. occurs when the person shows evidence of coming to terms with death. NSG221.04.02.01 Rando- tasks of grieving 1 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 1. 2. 3. 4. Recognize: Experiencing the loss, understanding that it is real, and that it has happened React: Emotional response to loss, feeling the feelings Recollect and re-experience: Memories are reviewed and relived Relinquish: Accepting that the world has changed (as a result of the loss) and that there is no turning back 5. Readjust: Beginning to return to daily life; loss feels less acute and overwhelming 6. Reinvest: Accepting changes that have occurred; reentering the world, forming new relationships and commitments ● *Grieving tasks or mourning, bereaved person faces involve active rather than passive participation ○ sometimes called “grief work” because it is difficult and requires tremendous effort and energy to accomplish NSG221.04.02.02 Cultural considerations after death 1. Hmong (people of a mountainous region of Southeast Asia) a. believe that the deceased person enters the next world appearing as she or he did at the time of death b. may lead to a request for removal of needles, tubes, or other foreign objects before death 2. African Americans a. many mourning rituals are tied to religious traditions due to their history of being slaves to European American and Christian groups b. Typically, the deceased is viewed in church before being buried in a cemetery. c. Mourning may also be expressed through public prayers, black clothing, and decreased social activities d. mourning period may last a few weeks to several years e. Catholic and Episcopalian services, hymns may be sung, poetry read, and a eulogy spoken f. Baptist and Holiness traditions may involve singing, speaking in other languages, and liturgical dancing 3. Muslim Americans a. Islam does not permit cremation b. important to follow the 5 steps of the burial procedure, which specify washing, dressing, and positioning of the body i. 1st step is the traditional washing of the body by a Muslim of the same gender 4. Haitian Americans a. Some practice vodun (voodoo), also called “root medicine.” i. Derived from Roman Catholic rituals and cultural practices of western Africa (Benin and Togo) and Sudan ii. practice of calling on a group of spirits with whom one periodically makes peace during specific events in life 2 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 iii. 5. 6. 7. 8. 9. can be found often throughout the American South and in some communities within New York City Chinese Americans a. have strict norms for announcing death, preparing the body, arranging the funeral and burial, and mourning after burial b. Burning incense and reading scripture are ways to assist the spirit of the deceased in the afterlife journey c. If the deceased and his or her family are Buddhists, meditating before a shrine in the room is important. d. For 1 year after death, the family may place bowls of food on a table for the spirit Japanese Americans a. Buddhist Japanese Americans view death as a life passage b. Close family members may bathe the deceased with warm water and dress the body in a white kimono after purification rites c. For 2 days, family and friends bearing gifts may visit or offer money for the deceased while saying prayers and burning incense Filipino Americans a. Most are Catholic b. depending on how close one was to the deceased, wearing black clothing or armbands is customary during mourning c. Family and friends place wreaths on the casket and drape a broad black cloth on the home of the deceased d. Family members commonly place announcements in local newspapers asking for prayers and blessings on the soul of the deceased Vietnamese Americans a. predominately Buddhists, who bathe the deceased and dress him or her in black clothes b. may put a few grains of rice in the mouth and place money with the deceased so that he or she can buy a drink as the spirit moves on in the afterlife c. body may be displayed for viewing in the home before burial i. When friends enter, music is played as a way to warn the deceased of the arrival Hispanic Americans a. have their origins in Spain, Central and South America, Cuba, Puerto Rico, and the Dominican Republic b. predominately Roman Catholic c. may pray for the soul of the deceased during a novena (9-day devotion) and a rosary (devotional prayer) d. manifest luto (mourning) by wearing black or black and white while behaving in a subdued manner e. Respect for the deceased may include not watching TV, going to the movies, listening to the radio, or attending dances or other social events for some time. f. Friends and relatives bring flowers and crosses to decorate the grave g. Guatemalan Americans may include a marimba band in the funeral procession 3 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 and services. i. Lighting candles and blessing the deceased during a wake in the home are common practices. 10. Native Americans a. Ancient beliefs and practices influence the more than 500 i. though many are now Christian b. tribe’s medicine man or priestly healer, who assists the friends and family of the deceased to regain their spiritual equilibrium, is an essential spiritual guide c. Ceremonies of baptism for the spirit of the deceased seem to help ward off depression of the bereaved. d. Perceptions about the meaning of death and its effects on family and friends are as varied as the number of tribal communities i. Death may be viewed as a state of unconditional love in which the spirit of the deceased remains present, comforts the tribe, and encourages movement toward life’s purpose of being happy and living in harmony with nature and others. ii. Belief in and fear of ghosts and believing death signifies the end of all that is good are other views iii. another view is the belief in a happy afterlife called the “land of the spirits”; proper mourning is essential not only for the soul of the deceased but also for the protection of community members. e. To designate the end of mourning, a ceremony at the burial grounds is held during which the grave is covered with a blanket or cloth for making clothes. i. Later, the cloth is given to a tribe member. f. A dinner featuring singing, speech-making, and contributing money completes the ceremony. 11. Orthodox Jewish Americans a. custom is for a relative to stay with a dying person so that the soul does not leave the body while the person is alone i. To leave the body alone after death is disrespectful b. family of the deceased may request to cover the body with a sheet i. eyes of the deceased should be closed ii. body should remain covered and untouched until family, a rabbi, or a Jewish undertaker can begin rites c. organ donation is permitted, autopsy is not (unless required by law) d. burial must occur within 24 hours unless delayed by the Sabbath e. Shiva is a 7-day period that begins on the day of the funeral i. represents time for mourners to step out of day-to-day life and to reflect on the change that has occurred ii. Depending on how strictly the family practices, shiva may be shorter than 7 days. NSG221.04.02.02 Responses to grief 4 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 1. Cognitive a. pain that accompanies grieving results from a disturbance in the person’s beliefs b. loss disrupts, if not shatters, basic assumptions about life’s meaning and purpose i. Disruption of assumptions and beliefs c. Grieving often causes a person to change beliefs about themselves and the world d. Additional changes in thinking and attitude include reviewing and ranking values, becoming wiser, shedding illusions about immortality, viewing the world more realistically, and reevaluating religious or spiritual beliefs e. Questioning and trying to make sense of the loss f. Attempting to keep the lost one present g. Believing in an afterlife and as though the lost one is a guide 2. Emotional a. Feeling numb b. Vacillating emotions c. Profound sorrow, loneliness d. Intense desire to restore bond with lost one or object e. Depression, apathy, despair during phase of disorganization f. Sense of independence and confidence as phase of reorganization evolves g. Anger, sadness, and anxiety are the predominant emotional responses to loss h. grieving person may direct anger and resentment toward the dead person and his or her health practices, family members, or health care providers or institutions i. Guilt over things not done or said in the lost relationship is another painful emotion j. Feelings of hatred and revenge are common when death has resulted from extreme circumstances ex. suicide, murder, or war k. some may also experience feelings of loss of control in their lives, uncharacteristic feelings of dependency on others, and even anxiety about their own deaths l. Emotional responses are evident throughout the grieving process m. common first response to the news of a loss is to be stunned, as though not perceiving reality n. Emotions alternate in frequency and intensity i. may function automatically in a state of calm and then suddenly become overwhelmed with panic ii. outcry of emotion may involve crying and screaming or suppressed feelings with a stoic face to the world o. When reality begins to set in they often reverts to the behaviors of childhood by acting similar to a child who loses his or her parent in a store or park i. may express irritability, bitterness, and hostility toward clergy, medical providers, relatives, comforters, and even the dead person ii. hopeless yet intense desire to restore the bond with the lost person compels the bereaved to search for and recover him or her 5 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 iii. interprets sounds, sights, and smells associated with the lost one as signs of the deceased’s presence, which may intermittently provide comfort and ignite hope for a reunion p. As hopes for the lost one’s return diminish, sadness and loneliness become constant i. may last several months and seems necessary for the person to begin to acknowledge the true permanence of the loss q. As they begin to understand the loss’s permanence, he or she recognizes that patterns of thinking, feeling, and acting attached to life with the deceased must change r. As they give up all hope of recovering the lost one, he or she inevitably experiences moments of depression, apathy, or despair i. acute sharp pain initially experienced with the loss becomes less intense and less frequent s. Eventually the individual begins to reestablish a sense of personal identity, direction, and purpose for living i. gains independence and confidence ii. New ways of managing life emerge, and new relationships form iii. person’s life is reorganized and seems “normal” again, though different than before the loss iv. person still misses the deceased, but thinking of them no longer evokes painful feelings 3. Spiritual a. Closely associated with the cognitive and emotional dimensions of grief b. These beliefs are deeply embedded personal values that give meaning and purpose to life c. values and the belief systems that sustain them are central components of spirituality and the spiritual response to grief d. within this dimension of human experience that a person may be most comforted, challenged, or devastated e. may become disillusioned (having lost faith or trust in) and angry with God, other religious figures, or members of the clergy f. anguish of abandonment, loss of hope, or loss of meaning can cause deep spiritual suffering g. perceived abandonment h. Ministering to the spiritual needs of those grieving is an essential aspect of nursing care i. client’s emotional and spiritual responses become intertwined as they grapple with pain j. astute awareness of such suffering, nurses can promote a sense of well-being i. Providing opportunities for clients to share their suffering assists in the psychological and spiritual transformation that can evolve through grieving ii. Finding explanations and meaning through religious or spiritual beliefs, 6 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 iii. client may begin to identify positive aspects of grieving grieving person can also experience loss as significant to their own growth and development 4. Physiological a. Physiologic symptoms and problems associated with grief responses are often a source of anxiety and concern for the grieving person as well as for friends or caregivers b. grieving person may complain of insomnia, headaches, impaired appetite, weight loss, lack of energy, palpitations, indigestion, and changes in the immune and endocrine systems i. Sleep disturbances are among the most frequent and persistent bereavement-associated symptoms 5. Behavioral a. Behavioral responses to grief are often the easiest to observe b. may function “automatically” or routinely without much thought, indicating that the person is numb i. reality of the loss has not set in c. Tearfully sobbing, crying uncontrollably, showing great restlessness, and searching behaviors are evidence of the outcry of emotion d. may actually call out for the deceased or visually scan the room for him or her e. Irritability and hostility toward others reveal anger and frustration in the process f. Seeking out and avoiding places or activities once shared with the deceased and keeping or wanting to discard valuables and belongings of the deceased shows fluctuating emotions and perceptions of hope for a reconnection g. Possibly abusing drugs or alcohol h. Possible suicidal or homicidal gestures or attempts i. Seeking activity and personal reflection during phase of reorganization j. disorganization or working through grief, the cognitive act of redefining selfidentity is essential but difficult i. May start off as superficial by efforts made in social or work activities are behavioral means to support the person’s cognitive and emotional shifts ii. Drug or alcohol abuse indicates a maladaptive behavioral response to the emotional and spiritual despair iii. Suicide and homicide attempts may be extreme responses if the bereaved person cannot move through the grieving process k. grief process is a profound and poignant “search for meaning in life l. phase of reorganization, or recovery, the bereaved person participates in activities and reflection that are personally meaningful and satisfying i. Redefining the meaning of life and finding new activities and relationships restore the person’s feeling that life is good again NSG221.04.02.03 Complicated grieving- risks 1. Complicated grieving is when the grief is happening outside the cultural norm 7 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 a. a person is void of emotion, grieves for prolonged periods, or has expressions of grief that seem disproportionate to the event b. may suppress emotional responses to the loss or become obsessively preoccupied with the deceased person or lost object c. suffer from clinical depression when they cannot make progress in the grief process d. Previously existing psychiatric disorders may also complicate the grief process, so nurses must be particularly alert to clients with psychiatric disorders who are grieving. e. Grief can precipitate major depression in a person with a history of the disorder. These clients can also experience grief and a sense of loss when they encounter changes in treatment settings, routine, environment, or even staff 2. Risk for Complicated Grief a. Death of a spouse or child b. Death of a parent (particularly in early childhood or adolescence) c. Sudden, unexpected, and untimely death d. Multiple deaths e. Death by suicide or murder 3. Treatment of complicated grief includes: a. understanding the grief process b. managing painful emotions c. thinking about the future d. strengthening relationships e. telling the story of the death f. learning to live with reminders g. remembering the person who died *Sudden and violent losses, including natural or man-made disasters, military losses, terrorist attacks, or killing sprees by an individual are all more likely to lead to prolonged or complicated grief* NSG221.04.02.04 Assessment of coping after death & therapeutic response- dimensions of grief Assessment of Coping after Death: 1. involves observing all dimensions of human response: what the person is thinking (cognitive), how the person is feeling (emotional), what the person’s values and beliefs are (spiritual), how the person is acting (behavioral), and what is happening in the person’s body (physiologic) 2. Effective communication skills during assessment can lead the client toward understanding his or her experience 3. assessment facilitates the client’s grief process 4. essential to remember that the grieving response is individual a. individuals may move back and forth, may spend a long time in one particular phase, or pass through a phase so quickly it is not recognized 8 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 b. no one right way to grieve c. is a dynamic process, not an orderly progression through easily identifiable stages 5. observing client responses in the dimensions of grieving, the nurse explores three critical components in assessment: a. Adequate perception regarding the loss b. Adequate support while grieving for the loss c. Adequate coping behaviors during the process Dimensions (Responses) and Symptoms of the Grieving Client: 1. Cognitive responses a. Disruption of assumptions and beliefs b. Questioning and trying to make sense of the loss c. Attempting to keep the lost one present d. Believing in an afterlife and as though the lost one is a guide 2. Emotional responses a. Anger, sadness, anxiety b. Resentment c. Guilt d. Feeling numb e. Vacillating emotions f. Profound sorrow, loneliness g. Intense desire to restore bond with lost one or object h. Depression, apathy, despair during phase of disorganization i. Sense of independence and confidence as phase of reorganization evolves 3. Spiritual responses a. Disillusioned and angry with God b. Anguish of abandonment or perceived abandonment c. Hopelessness, meaninglessness 4. Behavioral responses a. Functioning “automatically” b. Tearful sobbing, uncontrollable crying c. Great restlessness, searching behaviors d. Irritability and hostility e. Seeking and avoiding places and activities shared with lost one f. Keeping valuables of lost one while wanting to discard them g. Possibly abusing drugs or alcohol h. Possible suicidal or homicidal gestures or attempts i. Seeking activity and personal reflection during phase of reorganization 5. Physiologic responses a. Headaches, insomnia b. Impaired appetite, weight loss c. Lack of energy d. Palpitations, indigestion 9 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 e. Changes in immune and endocrine systems 6. Therapeutic: a. What does the client think and feel about the loss? b. How is the loss going to affect the client's life? c. What information does the nurse need to clarify or share with the client? Unit 5 Anger, Hostility, Aggression, and Disruptive Behavior: NSG221.05.01.02 Strategies for helping clients with anger management/control 1. nurse can help clients express anger appropriately by serving as a model and by roleplaying assertive communication techniques 2. Assertive communication uses “I” statements that express feelings and are specific to the situation 3. Some try to express their angry feelings by engaging in aggressive but safe activities such as hitting a punching bag or yelling 4. activities are called catharsis, are supposed to provide a release for anger 5. Activities not aggressive, such as walking or talking with another person, are more likely to be effective in decreasing anger 6. Cognitive behavioral therapy techniques, distraction, problem-solving, and changing one’s perspective or reframing can be effective in managing situations or problems that provoke anger 7. Effective methods of anger expression, should replace angry aggressive outbursts of temper such as yelling or throwing things 8. Controlling one’s temper or managing anger effectively should not be confused with suppressing angry feelings NSG221.05.01.03 Mental Illness Diagnoses associated with anger 1. clients with a variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior 2. paranoid delusions may believe others are out to get them; believing they are protecting themselves, they retaliate with hostility or aggression 3. auditory hallucinations that command them to hurt others 4. Aggressive behavior is also seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders 5. Some clients with depression have anger attacks 6. sudden intense spells of anger typically occur in situations in which the depressed person feels emotionally trapped 7. involve verbal expressions of anger or rage but no physical aggression 8. Clients describe these anger attacks as uncharacteristic behavior that is inappropriate for the situation and followed by remorse 9. seen in some depressed clients may be related to irritable mood, overreaction to minor 10 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 annoyances, and decreased coping abilities 10. Intermittent explosive disorder (IED) is a rare psychiatric diagnosis characterized by discrete episodes of aggressive impulses that result in serious assaults or destruction of property 11. aggressive behavior the person displays is grossly disproportionate to any provocation or precipitating factor 12. diagnosis is made only if the client has no other comorbid psychiatric disorders 13. describes a period of tension or arousal that the aggressive outburst seems to relieve 14. Afterward person is remorseful and embarrassed, and there are no signs of aggressiveness between episodes 15. are often are men with dependent personality features who respond to feelings of uselessness or ineffectiveness with violent outbursts NSG221.05.01.04 Workplace bullying and prevention regulations and requirements, nursing leadership responsibilities 1. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a sentinel event alert concerning “intimidating and disruptive behaviors” that undermine a culture of safety and lead to errors, decreased patient satisfactions, preventable adverse outcomes, increased health care costs, and loss of qualified personnel a. undesirable behaviors include overt actions ex. verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or an uncooperative attitude 2. Disruptive and intimidating behaviors are often demonstrated by health care providers in power positions a. manifest as reluctance or refusal to answer questions, return phone calls, or answer pages; condescending or intimidating language or voice tone/volume; and impatience 3. 2016, JCAHO added workplace bullying, also known as lateral or horizontal violence, to this initiative a. Bullying is defined as abusive conduct, such as verbal abuse, threatening, intimidating or humiliating behaviors, and work interference (sabotage), which prevents work from getting done 4. prompted JCAHO to include new standards on leadership effective January 2009 a. accredited health care organization must now have a code of conduct that defines acceptable, disruptive, and inappropriate behaviors b. leaders in these organizations must create and implement a process for managing disruptive and inappropriate behaviors c. 7 action steps have been suggested to accomplish this new standard of behavior, including: i. A code of conduct outlines acceptable and inappropriate/unacceptable behavior ii. A process for managers to handle disruptive or unacceptable behavior iii. Education of all team members on expected professional behavior 11 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 iv. Zero tolerance for unacceptable behaviors, meaning all persons are held accountable NSG221.05.01.05 Stages of escalation: 1. triggering phase (incident or situation that initiates an aggressive response) 2. an escalation phase 3. a crisis phase a. client’s behavior escalates toward the crisis phase, they loses the ability to perceive events accurately, solve problems, express feelings appropriately, or control their behavior i. may lead to physical aggression 4. a recovery phase 5. post-crisis phase *interventions during the triggering and escalation phases are key to preventing physically aggressive behavior* De-escalation techniques: 1. triggering phase, nurse should approach client in a nonthreatening, calm manner in order to deescalate the client’s emotion and behavior a. Conveying empathy for the client’s anger or frustration is important 2. nurse can encourage client to express their angry feelings verbally, suggesting that the client is still in control and can maintain that control a. Use of clear, simple, short statements is helpful 3. nurse should allow the client time to express themself 4. nurse can suggest that the client go to a quiet area or may get assistance to move other clients to decrease stimulation 5. Medications (PRN, or as needed) should be offered if ordered 6. client’s anger subsides, the nurse can help the client use relaxation techniques and look at ways to solve any problem or conflict that may exist a. Physical activity, may also help the client relax and become calmer 7. techniques are unsuccessful and the client progresses to the escalation phase (the period when the client builds toward loss of control), the nurse must take control of the situation a. nurse should provide directions to the client in a calm, firm voice i. client should be directed to take a time-out for cooling off in a quiet area or their room b. nurse should tell the client that aggressive behavior is not acceptable and that the nurse is there to help the client regain control c. If client refused medications during the triggering phase, nurse should offer them again 8. client’s behavior continues to escalate and they are unwilling to accept direction to a quiet area, the nurse should obtain assistance from other staff members 12 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 a. 4-6 staff members should remain ready within sight of the client but not as close as the primary nurse talking with the client b. sometimes called a “show of force,” indicates to the client that the staff will control the situation if the client cannot do so c. Sometimes, presence of additional staff convinces the client to accept medication and take the time-out necessary to regain control 9. client becomes physically aggressive (crisis phase), the staff must take charge of the situation for the safety of the client, staff, and other clients a. Psychiatric facilities offer training and practice in safe techniques for managing behavioral emergencies, and only staff with such training should participate in the restraint of a physically aggressive client i. nurse’s decision to use seclusion or restraint should be based on the facility’s protocols and standards for restraint and seclusion 1. nurse should obtain a physician’s order as soon as possible after deciding to use restraint or seclusion ii. 4-6 trained staff members are needed to restrain an aggressive client safely 1. 4 staff members each take a limb, 1 staff member protects the client’s head, and 1 staff member helps control the client’s torso, if needed 2. client is transported by gurney or carried to a seclusion room, and restraints are applied to each limb and fastened to the bed frame iii. If PRN medication has not been taken earlier, the nurse may obtain an order for intramuscular (IM) medication in this type of emergency situation iv. nurse performs close assessment of the client in seclusion or restraint and documents the actions b. Children, adolescents, and female clients can be just as aggressive as adult male clients c. client is informed that their behavior is out of control and that the staff is taking control to provide safety and prevent injury 10. client regains control (recovery phase), they are encouraged to talk about the situation or triggers that led to the aggressive behavior a. nurse should help the client relax, perhaps sleep, and return to a calmer state b. important to help the client explore alternatives to aggressive behavior by asking what the client or staff can do next time to avoid an aggressive episode c. nurse should also assess staff members for any injuries and complete the required documentation i. incident reports and flow sheets d. staff usually has a debriefing session to discuss the aggressive episode, how it was handled, what worked well or needed improvement, and how the situation could have been defused more effectively e. important to encourage other clients to talk about their feelings regarding the incident i. aggressive client should not be discussed in detail with other clients 13 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 11. postcrisis phase, the client is removed from restraint or seclusion as soon as they meets the behavioral criteria a. nurse should not lecture or chastise the client for the aggressive behavior i. discuss the behavior in a calm, rational manner b. client can be given feedback for regaining control with the expectation that they will be able to handle feelings or events in a nonaggressive manner in the future c. client should be reintegrated into the milieu and its activities as soon as they can participate Nursing process working with patients with anger problems: 1. Assessment and effective intervention with angry or hostile clients can often prevent aggressive episodes 2. Early assessment, judicious use of medications, and verbal interaction with an angry client can often prevent anger from escalating into physical aggression 3. nurse should be aware of factors that influence aggression in the psychiatric environment or unit milieu 4. Aggressive behavior is less common on psychiatric units with strong psychiatric leadership; clear staff roles; and planned and adequate events such as staff–client interaction, group interaction, and activities 5. lacking, clients often feel frustrated and bored, and aggression is more common and intense 6. lack of psychological space—having no privacy, being unable to get sufficient rest—may be more important in triggering aggression than a lack of physical space 7. the nurse needs to assess individual clients carefully 8. history of violent or aggressive behavior is one of the best predictors of future aggression 9. Determining how the client with a history of aggression handles anger and what the client believes is helpful is important in assisting them in controlling or non-aggressively managing angry feelings 10. Clients who are angry and frustrated and believe no one is listening to them are more prone to behave in a hostile or aggressive manner 11. history of being personally victimized and/or one of substance abuse increases a client’s likelihood of aggressive behavior 12. Individual cues can help the nurse recognize when aggressive behavior is imminent 13. Clients who believe their hallucinated voices to be all-powerful, malevolent, and irresistible are more likely to be aggressive 14. what the client is saying; changes in the client’s voice (volume, pitch, speed); changes in the client’s facial expression; and changes in the client’s behavior 15. nurse should assess the client’s behavior to determine which phase of the aggression cycle they are in so that appropriate interventions can be implemented 16. 5 phases of aggression-see section above Nursing process- working with patients with anger problem- priority outcomes. 1. Expected outcomes for aggressive clients may include 14 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 a. b. c. d. client will not harm or threaten others. client will refrain from behaviors that are intimidating or frightening to others. client will describe his or her feelings and concerns without aggression. client will comply with treatment NSG221.05.02.01 Nursing Diagnoses associated with anger/disruptive behavior problems Conduct Disorder 1. Risk for other-directed violence related to aggression to other people or animals. 2. Noncompliance related to resentment of those in authority. 3. Ineffective coping related to low self-esteem. 4. Impaired social interaction related to hostility towards those in authority. 5. Chronic low self esteem related to lack of value to self. NSG221.05.02.02 Signs and symptoms of diagnoses associated with disruptive behavior problems NSG221.05.02.03 Principles of limit setting 1. nurse must protect others from the manipulative or aggressive behaviors common with these clients a. must set limits on unacceptable behavior at the beginning of treatment i. involves the following 3 steps 1. Inform clients of the rule or limit. 2. Explain the consequences if clients exceed the limit. 3. State expected behavior 2. Providing consistent limit enforcement with no exceptions by all members of the health team, including parents, is essential 3. limit setting to be effective, the consequences must have meaning for clients 4. nurse can negotiate with a client a behavioral contract outlining expected behaviors, limits, and rewards to increase treatment compliance a. client can refer to the written agreement to remember expectations, and staff can refer to the agreement if the client tries to change any terms b. can help staff avoid power struggles over requests for special favors or attempts to alter treatment goals or behavioral expectations c. Whether there is a written contract or treatment plan, staff must be consistent i. clients will attempt to bend or break rules, blame others for noncompliance, or make excuses for behavior d. Consistency in following the treatment plan is essential to decrease manipulation Unit 6 Disorders of Addiction and Dependence NSG221.06.01.01 Professional response to impaired colleague 15 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 1. issue of reporting colleagues with suspected substance abuse is an important and extremely sensitive one a. difficult for colleagues and supervisors to report their peers for suspected abuse 2. Nurses may hesitate to report suspected behaviors for several reasons: a. difficulty believing that a trained health care professional would engage in abuse b. may feel guilty or fear falsely accusing someone; or they may simply want to avoid conflict 3. Serious issue that endangers patients 4. Nurses have an ethical responsibility to report suspicious behavior to a supervisor and, in some states, a legal obligation as defined in the state’s nurse practice act a. should not try to handle such situations alone by warning the coworker i. often just allows the coworker to continue to abuse the substance without suffering any repercussions 5. General warning signs of abuse include poor work performance, frequent absenteeism, unusual behavior, slurred speech, and isolation from peers a. More specific behaviors and signs that might indicate substance abuse i. Incorrect drug counts ii. Excessive controlled substances listed as wasted or contaminated iii. Reports by clients of ineffective pain relief from medications, especially if relief had been adequate previously iv. Damaged or torn packaging on controlled substances v. Increased reports of “pharmacy error” vi. Consistent offers to obtain controlled substances from pharmacy vii. Unexplained absences from the unit viii. Trips to the bathroom after contact with controlled substances ix. Consistent early arrivals at or late departures from work for no apparent reason 6. Nurses can become involved in substance abuse a. Nurses with abuse problems deserve the opportunity for treatment and recovery b. Reporting suspected substance abuse could be the crucial first step toward a nurse getting the help he or she needs NSG221.06.01.02 Nursing assessment of risk factors contributing to substance use disorders 1. Biologic Factors a. Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence 2. Psychological Factors a. family dynamics are thought to play a part i. Some believe that inconsistency in the parent’s behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse 1. Some believe that even children who dislike their family lives are 16 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 likely to abuse substances as adults because they lack adaptive coping skills and cannot form successful relationships b. Some use alcohol as a coping mechanism or to relieve stress and tension, increase feelings of power, and decrease psychological pain i. High doses of alcohol increase muscle tension and nervousness 3. Social and Environmental Factors a. Cultural factors, social attitudes, peer behaviors, laws, cost, and availability all influence initial and continued use of substances i. general, younger experimenters use substances that carry less social disapproval such as alcohol and cannabis, while older people use drugs, such as cocaine and opioids that are costlier and rate higher disapproval b. Alcohol consumption increases in areas where availability increases and decreases in areas where costs of alcohol are higher c. Many people view the social use of cannabis, still illegal in most states, as not harmful i. United States, there is a federal law that still classifies marijuana as a Schedule 1 drug 1. some individual states have or are in the process of legalizing medical use or recreational use or both ii. many advocate legalizing the use of marijuana for social purposes d. Urban areas where cocaine and opioids are readily available also have high crime rates, high unemployment, and substandard school systems that contribute to high rates of cocaine and opioid use, and low rates of recovery e. environment and social customs can influence a person’s use of substances NSG221.06.01.04 Delirium tremens- safeguarding the patient. 1. Alcohol Withdrawal and Detoxification a. Symptoms of withdrawal usually begin 4-12 hours after cessation or marked reduction of alcohol intake i. coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting b. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremens i. Agitation, aggression, or irritability. ii. Confusion. iii. Severe autonomic hyperactivity such as trembling, sweating, tachycardia, nausea, and vomiting. iv. Impaired consciousness. v. Visual, tactile, or auditory hallucinations. vi. Tremors or seizures. vii. Hyperreflexia (hand tremors) viii. Diaphoresis (sweating) ix. Hallucinations 17 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 x. Increased VS 1. Tachycardia (over 100) 2. Hypertension 3. Fever xi. Mood 1. Anxiety and agitation xii. Mental 1. Confused restless xiii. Seizures 1. Implement precautions c. withdrawal usually peaks on the second day and is over in about 5 days i. can vary 1. withdrawal may take 1 to 2 weeks d. withdrawal can be life-threatening, detoxification needs to be accomplished under medical supervision i. withdrawal symptoms are mild and they can abstain from alcohol, they can be treated safely at home ii. more severe withdrawal or for clients who cannot abstain during detoxification, a short admission of 3 to 5 days is the most common setting 1. Some psychiatric units also admit clients for detoxification, a. less common iii. Safe withdrawal is usually accomplished with the administration of benzodiazepines 1. lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms iv. Withdrawal can be accomplished by fixed-schedule dosing known as tapering or symptom-triggered dosing in which the presence and severity of withdrawal symptoms determine the amount of medication needed and the frequency of administration e. protocol used is based on an assessment tool such as the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA Scale), Revised i. Total scores less than 8 indicate mild withdrawal ii. scores from 8 to 15 indicate moderate withdrawal (marked arousal) iii. scores greater than 15 indicate severe withdrawal iv. Clients on symptom-triggered dosing receive medication based on scores of this scale alone v. clients on fixed-dose tapers can also receive additional doses depending on the level of scores from this scale Nursing management and medications used in withdrawal syndromes- alcohol and opiate Alcohol Withdrawal 1. Symptoms of withdrawal usually begin 4-12 hours after cessation or marked reduction of alcohol intake 18 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 2. 3. 4. 5. a. coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremens withdrawal usually peaks on the second day and is over in about 5 days a. can vary i. withdrawal may take 1 to 2 weeks withdrawal can be life-threatening, detoxification needs to be accomplished under medical supervision a. withdrawal symptoms are mild and they can abstain from alcohol, they can be treated safely at home b. more severe withdrawal or for clients who cannot abstain during detoxification, a short admission of 3 to 5 days is the most common setting i. Some psychiatric units also admit clients for detoxification, 1. less common c. Safe withdrawal is usually accomplished with the administration of benzodiazepines i. lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms d. Withdrawal can be accomplished by fixed-schedule dosing known as tapering or symptom-triggered dosing in which the presence and severity of withdrawal symptoms determine the amount of medication needed and the frequency of administration protocol used is based on an assessment tool such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised a. Total scores less than 8 indicate mild withdrawal b. scores from 8 to 15 indicate moderate withdrawal (marked arousal) c. scores greater than 15 indicate severe withdrawal d. Clients on symptom-triggered dosing receive medication based on scores of this scale alone e. clients on fixed-dose tapers can also receive additional doses depending on the level of scores from this scale Opiate Withdrawal 1. Initial symptoms are anxiety, restlessness, aching back and legs, and cravings for more opioids 2. Symptoms that develop as withdrawal progresses include nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia 3. Symptoms of opioid withdrawal do not require pharmacologic intervention to support life or bodily functions a. Only causes significant distress 4. Withdrawal symptoms such as anxiety, insomnia, dysphoria, anhedonia (loss of interest in activities or a reduced ability to find pleasure in normally enjoyable experiences) and drug craving may persist for weeks or months 19 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 NSG221.06.01.05 Relapse prevention strategies 1. Providing Health Teaching for the Client and Family a. Clients and family members need facts about the substance, its effects, and recovery i. nurse must dispel the myths and misconceptions b. Education about relapse is important c. should be aware that clients who begin to revert to old behaviors, return to substance-using acquaintances, or believe they can “handle myself now” are at high risk for relapse i. loved ones need to take action d. Whether a client plans to attend a self-help group or has other resources, a specific plan for continued support and involvement after treatment increases the client’s chances for recovery e. For Substance Abuse i. Substance abuse is an illness. ii. Dispel myths about substance abuse. iii. Abstinence from substances is not a matter of willpower. iv. Any alcohol, whether beer, wine, or liquor, can be an abused substance. v. Prescribed medication can be an abused substance. vi. Feedback from family about relapse signs, for example, a return to previous maladaptive coping mechanisms, is vital. vii. Continued participation in an aftercare program is important. NSG221.06.01.05 & NSG221.06.01.01 Nursing implications when caring for persons with addiction – detox and recovery phases 1. Detoxification is the initial priority a. Priorities for individual clients are based on their physical needs and may include safety, nutrition, fluids, elimination, and sleep b. Requires medical supervision 2. Recovery Phases a. Safety b. A.D.P.I.E c. S.M.A.R.T Goals d. S.M.A.R.T Implementation e. Primary goal is total abstinence i. Identify triggers ii. Express accountability iii. Develop healthy coping skills iv. Set goals Mental status exam findings 1. General Appearance and Motor Behavior 20 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 2. 3. 4. 5. 6. a. usually reveals appearance and speech to be normal b. may appear anxious, tired, and disheveled if they have just completed a difficult course of detoxification c. Depending on overall health status and any health problems resulting from substance use, clients may appear physically ill d. Most are somewhat apprehensive about treatment, resent being in treatment, or feel pressured by others to be there i. may be the first time in a long time that clients have had to deal with any difficulty without the help of a psychoactive substance Mood and Affect a. Wide ranges of mood and affect are possible b. Some are sad and tearful, expressing guilt and remorse for their behavior and circumstances c. may be angry and sarcastic or quiet and sullen, unwilling to talk to the nurse d. Irritability is common because clients are newly free of substances e. may be pleasant and seemingly happy, appearing unaffected by the situation, i. especially if still in denial about the substance use Thought Process and Content a. are likely to minimize their substance use, blame others for their problems, and rationalize their behavior b. may believe they cannot survive without the substance or may express no desire to do so c. may focus their attention on finances, legal issues, or employment problems as the main source of difficulty d. may believe that they could quit “on their own” if they wanted to, and they continue to deny or minimize the extent of the problem Sensorium and Intellectual Processes a. generally are oriented and alert unless they are experiencing lingering effects of withdrawal b. Intellectual abilities are intact unless clients have experienced neurologic deficits from long-term alcohol or inhalant use Judgment and Insight a. likely to have exercised poor judgment, especially while under the influence of the substance b. Judgment may still be affected c. may behave impulsively, such as leaving treatment to obtain the substance of choice d. Insight is usually limited e. may have difficulty acknowledging their behavior while using or may not see loss of jobs or relationships as connected to the substance use f. may still believe they can control the substance use Self-Concept a. generally have low self-esteem i. may express directly or cover with grandiose behavior 21 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 b. do not feel adequate to cope with life and stress without the substance i. often uncomfortable around others when not using c. often have difficulty identifying and expressing true feelings i. past, have preferred to escape feelings and avoid any personal pain or difficulty with the help of the substance 7. Roles and Relationships a. usually have experienced many difficulties with social, family, and occupational roles i. Absenteeism and poor work performance are common b. family members have told clients the substance use was a concern, and may have been the subject of family arguments i. Relationships in the family are often strained ii. may be angry with family members who were instrumental in bringing them to treatment or who threatened loss of a significant relationship 8. Physiological Considerations a. Many have histories of poor nutrition (using rather than eating) and sleep disturbances that persist beyond detoxification b. may have liver damage from drinking alcohol, hepatitis or HIV infection from IV drug use, or lung or neurologic damage from using inhalants 2 items NSG221.06.02.01 Treatment medications for withdrawal syndromes – alcohol 1. Alcohol withdrawal is usually managed with a benzodiazepine anxiolytic agent, which is used to suppress the symptoms of abstinence a. most commonly used are lorazepam, chlordiazepoxide, and diazepam i. Lorazepam (Ativan) 1. Monitor vital signs and global assessments for effectiveness; may cause dizziness or drowsiness ii. Chlordiazepoxide (Ativan) 1. Monitor vital signs and global assessments for effectiveness; may cause dizziness or drowsiness 2. Side/Adverse Effects a. sedation, depression, lethargy, disorientation, and delirium b. taking high dosages may experience paradoxical excitatory reactions during the first few weeks of treatment c. alterations in pulse and blood pressure, urticaria, constipation, diarrhea, dry mouth, jaundice, changes in libido, and blood dyscrasias iii. Diazepam b. medications can be administered on a fixed schedule around the clock during withdrawal i. Giving these medications on an as-needed basis according to symptom parameters, is just as effective and results in a speedier withdrawal 22 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 c. Barbiturates can be used for benzodiazepine-resistant cases Medications used in medication assisted treatment alcohol and opiate addiction- recovery 1. Levomethadyl (Orlaam) a. Do not take drug on consecutive days; take-home doses are not permitted b. a narcotic analgesic with the only purpose of treating opiate dependence c. used in the same manner as methadone i. client takes 1 daily dose 1. meets the physical need for opiates but does not produce cravings for more ii. does not produce the high associated with heroin iii. essentially substituted their addiction to heroin for an addiction to methadone 1. safer because it is legal a. controlled by a physician, and available in tablet form iv. avoids the risks of IV drug use, the high cost of heroin (which often leads to criminal acts), and the questionable content of street drugs 2. Buprenorphine/naloxone (Suboxone) a. May cause orthostatic hypotension, sedation; avoid CNS depressants b. combination drug used for opiate maintenance and to decrease opiate cravings i. Buprenorphine is a semisynthetic opioid ii. naloxone is an opioid inverse agonist iii. takes 1 daily sublingual dose 1. Medication ingestion is supervised, at least initially a. has the potential for abuse and diversion iv. can be tapered from this medication after treatment and with adequate psychosocial support v. Some may remain on a maintenance dose for an extended time 4 items NSG221.06.02.01 Math 5 items (Disorders of Addiction and Dependence/Dosage calculation) Unit 7 Disorders of Anxiety What is Anxiety: ● A vague feeling of dread or apprehension ○ A response to external or internal stimuli that can have behavioral, emotional, cognitive or physical symptoms NSG 221.07.01.01 (x2) Levels of Anxiety 1. Mild a. A sensation that something is different and needs special attention i. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect him 23 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 or herself ii. motivates people to make changes or engage in goal-directed activity b. Psychological Responses i. Wide perceptual field ii. Sharpened senses iii. Increased motivation iv. Effective problem-solving v. Increased learning ability vi. Irritability c. Physiological Responses i. Restlessness ii. Fidgeting iii. GI “butterflies” iv. Difficulty sleeping v. Hypersensitivity to noise d. Nursing Interventions: i. No direct interventions 2. Moderate a. disturbing feeling that something is definitely wrong i. becomes nervous or agitated b. can still process information, solve problems, and learn new things with assistance from others c. has difficulty concentrating independently but can be redirected to the topic d. Psychological Responses i. Perceptual field narrowed to immediate task ii. Selectively attentive iii. Cannot connect thoughts or events independently iv. Increased use of automatisms e. Physiological Responses i. Muscle tension ii. Diaphoresis iii. Pounding pulse iv. Headache v. Dry mouth vi. High voice pitch vii. Faster rate of speech viii. GI upset ix. Frequent urination f. Nursing Interventions: i. Nurse must be certain the client is following what they are saying 1. Use short, simple, and easy-to-understand sentences 3. Severe 24 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 a. Psychological Responses i. Perceptual field reduced to one detail or scattered details ii. Cannot complete tasks iii. Cannot solve problems or learn effectively iv. Behavior geared toward anxiety relief and is usually ineffective v. Doesn’t respond to redirection vi. Feels awe, dread, or horror vii. Cries viii. Ritualistic behavior ix. Trouble thinking and reasoning b. Physiological Responses i. Severe headache ii. Nausea, vomiting, and diarrhea iii. Trembling iv. Rigid stance v. Vertigo vi. Pale vii. Tachycardia viii. Chest pain ix. Muscle tightness x. Increase VS xi. Pacing xii. Restless xiii. Irritable xiv. Angry c. Nursing Interventions: i. No longer paying attention or taking in new information ii. nurse’s goal must be to lower the person’s anxiety level to moderate or mild before proceeding with anything else iii. essential to remain with the person because anxiety is likely to worsen if he or she is left alone iv. Talking to the client in a low, calm, and soothing voice can help. If the person c v. Helping the person take deep, even breaths can help lower anxiety 4. Panic a. Psychological Responses i. Perceptual field reduced to focus on self ii. Cannot process any environmental stimuli iii. Distorted perceptions iv. Loss of rational thought v. Doesn’t recognize potential danger vi. Can’t communicate verbally vii. Possible delusions and hallucination 25 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 viii. May be suicidal b. Physiological Responses i. May bolt and run or totally immobile and mute ii. Dilated pupils iii. Greater increase in blood pressure and pulse iv. Flight, fight, or freeze c. Safety is the priority i. cannot perceive potential harm and may have no capacity for rational thought d. Nursing Interventions: i. nurse must keep talking to the person in a comforting manner, even though the client cannot process what the nurse is saying ii. small, quiet, and nonstimulating environment may help reduce anxiety 1. nurse can reassure the person that this is anxiety, it will pass, and he or she is in a safe place iii. nurse should remain with the client until the panic recedes. iv. Panic-level anxiety is not indefinite, but it can last from 5 to 30 minutes. *severe and panic anxiety the more primitive survival takes over, defensive responses follow, cognitive skills decrease. NSG 221. 07.01.02 (x1) Holistic assessment of multiple types of symptoms 1. Nursing Interventions a. First and foremost, the nurse must assess the person’s anxiety level because that determines what interventions are likely to be effective b. Mild i. No direct interventions c. Moderate i. Nurse must be certain the client is following what they are saying ii. Use short, simple, and easy-to-understand sentences iii. nurse must stop to ensure that the client is still taking in information correctly iv. nurse may need to redirect the client back to the topic if the client goes off on a tangent d. Severe i. nurse’s goal must be to lower the person’s anxiety level to moderate or mild before proceeding with anything else ii. essential to remain with the person because anxiety is likely to worsen if he or she is left alone iii. Talking to the client in a low, calm, and soothing voice can help. If the person cannot sit still, walking with him or her while talking can be 26 Downloaded by Mboma Kayola ([email protected]) lOMoARcPSD|23617240 iv. v. effective Helping the person take deep, even breaths can help lower anxiety can no longer pay attention or take in information 1. What the nurse talks about matters less than how he or she says the words e. Panic i. nurse must keep talking to the person in a comforting manner, even though the client cannot process what the nurse is saying ii. small, quiet, and nonstimulating environment may help reduce anxiety iii. nurse can reassure the person that this is anxiety, it will pass, and he or she is in a safe place iv. nurse should remain with the client until the panic recedes. f. nurse must be aware of his or her own anxiety level i. Remaining calm and in control is essential if the nurse is going to work effectively with the cl