Module 3 Exam

Paraphilic Disorder Interventions:

Behavior Management: Sexual Definition: Delineation and prevention of socially unacceptable sexual behaviors Activities∗: • Discuss consequences of unacceptable behavior. • Discuss the negative impact that behavior has on others. • Encourage expression of feelings about past crises. • Provide opportunities for caregivers to process their feelings about the patient. Self-Esteem Enhancement Definition: Assisting a patient to increase his/her personal judgment of self-worth Activities∗: • Encourage patient to identify strengths. • Assist in setting realistic goals to achieve higher self-esteem. • Assist patient to accept dependence on others, as appropriate. • Explore previous achievements of success. • Encourage patient to accept new challenges. Social Skills Behavior Modification Definition: Assisting the patient to develop or improve interpersonal social skills Activities∗: • Assist in identifying problems resulting from social skill deficits. • Encourage verbalization of feelings regarding social interaction. • Identify a specific skill to improve. • Identify steps to reach skill and role-play the steps. ∗ Partial list. Data from Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2013). Nursing interventions classification (NIC; 6th ed.). St. Louis, MO: Mosby. Teamwork and Safety When the patient who has a paraphilic disorder is in a crisis that requires hospitalization, providing a safe environment is fundamental. All patients on a psychiatric inpatient unit should be informed on admission about unit rules regarding personal contact between patients and between patients and staff. Limit setting is done consistently when it is needed, and staff work together as a team to this end. Individuals with paraphilic disorders tend to isolate themselves. The unit environment may be a challenge. Sharing meals with others may result in discomfort, and the patient might wonder what other people are thinking about him or her. A particular challenge may be interacting in formal group settings and the expectation of participation. But the group setting may actually provide patients with the greatest opportunity for growth in that they can experience others as humans with feelings, perhaps learning how much anguish and pain personal violations have caused them. The group milieu can mean having others present who empathize with one's background and current distress. Pharmacological Interventions Two classes of pharmacological agents, antiandrogens and serotonergic antidepressants, may be prescribed for paraphilic disorders (Garcia et al., 2013). Medication is not used independently without other interventions. Drugs that reduce levels of testosterone may be used to treat sex offenders. The drugs that are frequently used are progestin derivatives including medroxyprogesterone acetate (MPA; an analog of progesterone) and cyproterone acetate (CPA; an inhibitor of testosterone). Both of these drugs act to decrease libido and reduce compulsive deviant sexual behavior. They work best in patients with paraphilic disorders and a high sexual drive, such as pedophiles and exhibitionists, and less well in those with a low sexual drive or an antisocial personality (Becker et al., 2014). SSRIs are also used off-label without specific FDA approval in the treatment of sexual disorders. Fluoxetine (Prozac) has been used successfully to treat patients with exhibitionism, voyeurism, and pedophilia and people who have committed rape. These drugs may work to improve mood, reduce impulsivity, decrease sexual obsessions, and cause sexual dysfunction. In addition to fluoxetine, other drugs, such as clomipramine (Anafranil) and fluvoxamine (Luvox), have been used in the treatment of sexual obsessions, addictions, and paraphilic disorders. Advanced Practice Interventions Psychotherapy The usual treatment plan for working with patients with paraphilic disorders is cognitive-behavioral therapy. An attempt is made to help the person learn a new sexual response pattern that will eliminate the need for the activity that is causing the problem. Techniques range from positive reinforcement for appropriate object choices to aversion techniques, in which mild electrical shocks may be applied for inappropriate choices. Other treatment modalities include psychodynamic techniques designed to help the patient understand the origin of the paraphilia.

Detecting Delirium in Older Adults

Problem Delirium is the most frequent complication of hospitalization in older adults. Not only is this problem costly, but delirium is also associated with morbidity and mortality. Timely recognition is essential to offset these negative outcomes. Purpose of Study The purpose of the study was to identify factors associated with the recognition of delirium among registered nurses. Methods Researchers conducted a literature search for quantitative studies regarding nurses recognizing delirium. Key Findings Seven major factors related to poor recognition of delirium by nurses were identified. The factors included: • Fluctuating nature of delirium • Lack of delirium education • Communication barriers • Insufficient use of assessment tools • Poor understanding of delirium • Perception of delirium as burdensome • Poor differentiation between dementia and delirium Implications for Nursing Practice As a future nurse, you will be in a prime position to notice delirium. Any time a patient experiences an acute onset of confusion, you should consider delirium. Nurses need to be aware of the nature of delirium, especially how it differs from dementia. Standardized assessment scales can improve your ability to detect delirium.

Facticious Disorder

A disorder in which an individual feigns or induces physical symptoms, typically for the purpose of assuming the role of a sick person Popularly known as Munchausen Syndrome highly treatment-resistant

began drinking alcohol **daily** after retirement and says, "A few drinks keeps my mind off my arthritis." (self-medicating)

A nurse assesses four clients between the ages of 70-80 years. Which client has the HIGHEST risk for alcohol abuse?

Has altered comfort and activity needs

A nurse assessing a client diagnosed with a somatic symptom disorder is most likely to note which client characteristic? The client:

"I needed to make my child sick so that someone else would take care of them for a while."

A nurse is counseling several clients. Which of the following client statements should the nurse identify as expected for factitious disorder?

Provide consistent expectations while allowing the child to appropriately express their feelings

A nurse leads a group session for parents of children diagnosed with an impulse control disorder. The nurse should give which recommendation for establishing consequences?

Depression and suicide

A nurse plans a staff education program for employees of a senior living community. Which topic has PRIORITY?

Interventions for Delirium

Definition: Provision of a safe and therapeutic environment for the patient experiencing an acute confusional state. • Initiate therapies to reduce or eliminate factors causing delirium. • Monitor neurological status on an ongoing basis. However, avoid frustrating the patient by quizzing with orientation questions that cannot be answered. • Administer prn (as needed) medications for anxiety or agitation with caution. • Assist with needs related to nutrition, elimination, hydration, and personal hygiene. • Physical restraints may increase symptoms and should be avoided if at all possible. Family members can assist in maintaining safety to avoid restraint use. • Acknowledge patient's fears and feelings. • Provide optimistic but realistic reassurance. • Provide patient with information about what is happening and what can be expected. • Limit need for decision making, if frustrating or confusing to patient. • Accept patient's perceptions or interpretation of reality and respond to the theme or feeling tone. • Inform patient of person, place, and time, as needed. • Approach patient slowly and from the front and address patient by name. • Always introduce self to patient when approaching. • Communicate with simple, direct, descriptive statements. • Encourage significant others to remain with patient. • Maintain a well-lit, hazard-free environment. • Place identification bracelet on patient. • Provide a consistent physical environment, daily routine, and caregivers. • Use environmental cues (e.g., signs, pictures, clocks, calendars, and color coding of environment) to stimulate memory, reorient, and promote appropriate behavior. • Provide a low-stimulation environment for patient in whom disorientation is increased by overstimulation. • Encourage use of aids that increase sensory input (e.g., eyeglasses, hearing aids, and dentures)

Malingering Disorder

a consciously motivated act of fabricating an illness or exaggerating symptoms. This is done for secondary gain to become eligible for such things as disability compensation, committing fraud against insurance companies, obtaining prescription medications, evading military service, or receiving a reduced prison sentence. Reported pains are vague and hard for clinicians to prove or disprove (e.g., back pain, stomach ailments, headache, or toothache). Malingering is likely more common in men than in women. It is nearly impossible to determine the prevalence of malingering due to the concealment of its origins. Childhood neglect and abuse are possible causes. A childhood history of frequent illnesses, especially those that result in hospitalization, may also be present in people who develop this disorder. Malingering is associated with antisocial, narcissistic, and borderline personality disorders.

the tension-building stage

Abuser- angry, moody, can't be pleased easily frustrated Victim- tries to please, avoids problems, tiptoes around abuser

Delirium

An adult client takes multiple medications daily. Over 2 days, the client developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are MOST characteristic of?

The client will be able to state two new effective coping skills within 2 weeks

An adult client was diagnosed with a somatic symptom disorder. Based on knowledge of somatization, what is an expected outcome of the clients treatment plan?

Reactive Attachment Disorder

Children have a consistent pattern of inhibited and emotionally withdrawn behavior. The child rarely directs attachment behaviors toward any adult caregivers and does not seek comfort from them when distressed. This problem is caused by a lack of bonding experiences with a primary caregiver by the age of 8 months. This lack of bonding may be due to severe neglect, repeated changes of primary caregivers, or care in an institutional setting.

Treatment Settings for Older Adults

Care for older adults may become unmanageable at home. Medical providers are responsible for determining an appropriate level of care. This may range from acute hospitalization, to skilled nursing care facility, to adult day care, to community-based programs, or to respite care. A discussion of several care settings follows. Geropsychiatric Units An older adult may require acute inpatient psychiatric healthcare for conditions such as acute mental status changes with agitation, psychotic symptoms, major depression with suicidal intent, bipolar disorder, and schizophrenia. Inpatient treatment is recommended when the patient is at risk of self-harm, whether intentional or unintentional, or poses a risk of harm to other people. BOX 31.9 Patient and Family Teaching: Drug Safety • Learn about your medicines: Read medicine labels and package inserts and follow the directions. • If you have questions, ask your nurse, pharmacist, or primary care provider. • Talk to your team of healthcare professionals about your medical conditions, health concerns, and all the medicines you take (prescription and over-the-counter medicines), as well as dietary supplements, vitamins, and herbal supplements. The more they know, the more they can help. • Keep track of side effects or possible drug interactions, and let your doctor know right away about any unexpected symptoms or changes in the way you feel. • Be sure to keep all care provider appointments. • Use a calendar, pillbox, or something to help you remember what medications you need to take and when. • Write down information your healthcare provider gives you about your medicines or your health condition. • Take a friend or relative to your doctor's appointments if you think you need help to understand or remember what the doctor tells you. • Have a "medicine check-up" at least once a year. Go through your medicine cabinet to get rid of old or expired medicines. • Ask your healthcare provider or pharmacist to go over all the medicines you now take. Remember to tell them about all the over-the-counter medicines, vitamins, dietary supplements, and herbal supplements you take. Hospitalization may be an opportunity for the patient to receive much-needed assessment of the skin, feet, hair, mouth, and perineal areas. These assessments often can uncover hidden infections, unhealed wounds, and growths that may otherwise have been missed and can lead to needed medical attention. Specialized geropsychiatric units provide a comprehensive and specialized approach to care. These units utilize a multidisciplinary approach to assessment, treatment planning, implementation, and evaluation of care. Ideally, the team consists of registered nurses, geriatric psychiatrists, geriatricians, social workers, pharmacists, psychologists, dietitians, occupational therapists, and physical therapists. One of the major roles of the nurse is milieu management. This involves assisting in adjustment to the environment, keeping the unit safe by making sure roommates are compatible, call lights are within reach, and patients at risk for falling are close to the nurses' station. Recognizing the tone of the unit and making modifications when needed, such as reducing noise levels and de-cluttering areas, are critical roles of the staff nurse. Another vital aspect of nursing is the prevention and reduction of agitation by maintaining a visible presence on the unit and anticipating the patient's needs. Crisis intervention techniques may be necessary if an agitated patient does not respond to redirection or verbal attempts to deescalate agitation. As a crisis situation unfolds, staff response will largely determine the outcome, and a well-trained crisis team improves these outcomes. The crisis team leader is usually a nurse for several reasons: 1. Nurses provide professional care 24 hours a day, 7 days a week, and have detailed knowledge of patients and the milieu. 2. The nurse is aware of the patient's medical condition. 3. The nurse is able to guide the team and help prevent injury to patients who may need physical restraint. After the crisis has been deescalated, the team leader, the team, and other patients (as indicated) need to discuss the situation; this will help restore a sense of safety and calm. As the agitated patient gains control, it is important to help the individual ease back into the milieu with dignity. Skilled Nursing Facilities As acute hospital care of older adults with psychiatric illnesses is decreasing, the use of long-term skilled nursing facilities is increasing. The use of these facilities to treat older adults with severe mental illness is controversial. Opponents fear that skilled nursing facilities will become the psychiatric institutions of the 21st century, providing little more than custodial care. Whereas some long-term care settings provide specialized psychiatric-mental healthcare or behavioral units, most do not. There may be little consistency in the education of nurses and nursing assistants in appropriate psychiatric assessment and intervention. Staff may believe that patients who refuse personal hygiene, medication, or wound care are exercising their rights to refuse care rather than recognizing the negative symptoms of schizophrenia or depression. Nurses who repeatedly accept these refusals without further evaluation may inadvertently contribute to a patient's deterioration. Federal legislation has had a significant impact on the treatment of older adults in extended-care facilities. The PSDA of 1990 declared that nursing-home residents have the right to be free from unnecessary drugs and physical restraints. Clinicians have begun to focus on the use of nonpharmacological interventions for the treatment of agitation, wandering, confusion, yelling, and aggression. Drugs that are avoided include antipsychotics, antidepressants, antianxiety agents, and sedatives. Nurses can play an important role in advocating for psychiatric evaluation and intervention to assist with (1) medication management, (2) monitoring and documenting behavioral issues, (3) notifying the physician of behavioral changes, and (4) planning care for the needs of those residents with mental illness. Due to past inappropriate use of restraints, which led to injuries and deaths, federal legislation regarding their safe use was put into place. The requirements governing the use of restraints include the following: 1. Consultation with a physical and/or occupational therapist. 2. The least restrictive measures must be considered and documented. 3. A physician's order is required. 4. Consent of the resident or family must be obtained. 5. Documentation must be provided that the restraint enables the resident to maintain maximum functional and psychological well-being. Assisted Living This setting is utilized when a resident needs minimal assistance with ADLs. Meals are provided as well as 24-hour assistance as needed. Care is tailored to the needs of the resident, and care is paid for based on needs. This level of care is usually not covered by insurance and can be quite expensive. There are waiver programs in some states that provide for Medicaid reimbursement. Respite Care Family caregivers are at great risk for burnout. Respite care is designed to allow caregivers to have a break for a specific number of days. During this time, the patient is admitted to a nursing facility for a planned number of days. Family can then go on vacation, travel, or just have a needed break from caregiving. Respite care can also be provided in the home as well. Residential Care As discussed in Chapter 4, the psychiatric care system has increasingly become focused on the goal of community living rather than institutional living, but resources necessary to meet this goal have been chronically underfunded. Patients who would benefit from residential care are often moved from the most structured environment (inpatient care) to unstructured environments. These settings vary greatly and families and guardians should be educated to investigate what specific services will be provided. Partial Hospitalization Partial hospitalization programs are recommended for ambulatory patients who do not need 24-hour nursing care. They provide structured activities along with nursing and medical supervision, intervention, and treatment. These programs tend to be located within general hospitals, in psychiatric hospitals, or as part of the community mental health system. Day Care Programs Multipurpose senior centers provide a broad range of services including: (1) health promotion and wellness programs; (2) health screening; (3) social, educational, and recreational activities; (4) meals; and (5) information and referral services. For those in need of mostly custodial care services, adult day care is an appropriate choice. Older adults are cared for during the day and stay in a home environment at night. The programs allow older adults to continue their present living arrangements and maintain their social ties to the community; they also relieve families of the burden of 24-hour-a-day care for older adult dependents. Home Healthcare Home-based healthcare assists the homebound older adult to adjust to and manage illness and disability either before or after hospitalization. It is often the role of the health homecare nurse to help a person affected by a cognitive disorder, medical illness, or a severe and persistent mental illness to remain in the home. The National Association of Area Agencies on Aging assists in providing local home care services, such as housekeeping, meal preparation, and assistance with ADLs, to increase the older adult's ability to live independently. Chapter 4 discusses home psychiatric-mental healthcare in greater detail. Community-Based Programs Community-based programs are an alternative to promote the older adult's independent functioning and reduce the stress on the family system. These programs provide specialized case management services that assist older adults with coordination of care and other supports, such as Meals on Wheels and transportation.

Family Boundaries

Clear boundaries are those that maintain distinctions between individuals within the family and between the family and the outside world. Clear boundaries allow for balanced flow of energy between members. Roles of children and parent or parents are clearly defined. Diffuse or enmeshed boundaries are those in which there is a blending together of the roles, thoughts, and feelings of the individuals so that clear distinctions among family members fail to emerge. Rigid or disengaged boundaries are those in which the rules and roles are adhered to no matter what.

PTSD in Adults:

Clinical Picture: characterized by persistent reexperiencing of a highly traumatic event that involves actual or threatened death or serious injury to self or others, to which the individual responded with intense fear, helplessness, or horror. PTSD may occur after any traumatic event that is outside the range of usual experience. Examples are military trauma, natural disasters, human disasters (e.g., airplane crashes), crime-related events, or a diagnosis of a life-threatening illness. PTSD may be brought about by indirect exposure to trauma, such as learning that a loved one or friend has experienced violence or accidentally died. First responders who are subjected to repeated or extreme exposure to gruesome scenes or details are also at risk. PTSD symptoms can begin after a month from exposure, but a delay of months or years is not uncommon. -defined as having a "sustained maladaptive response to a traumatic overwhelming event" Assessment: Screening tools for PTSD in adults include the Primary Care PTSD Screen and the PTSD Checklist. A more comprehensive assessment is indicated for those who initially screen positive. The Severity of Posttraumatic Stress Scale Additional history about the time of onset, frequency, course, severity, level of distress, and degree of functional impairment is important. Further assessment for suicidal or violent ideation, family and social supports, insomnia, social withdrawal, functional impairment, current life stressors, medication, past medical and psychiatric history, and a mental status exam are indicated. The diagnosis of PTSD involves a comprehensive clinical interview that assesses all symptoms collectively. Interventions: A primary consideration for caring for the person with PTSD is establishing a therapeutic relationship through nonjudgmental acceptance and empathy. In this context, the nurse assists the person in managing his or her arousal level. The latter can be accomplished through providing a safe predictable environment. Teaching strategies to manage anxiety such as deep breathing, imagery, and mindfulness exercises is a fairly simple intervention. You can also help the patient to connect with support groups, family, and friends. The person often feels guilty and responsible for the event, and the nurse, as a witness through listening and reflecting back to the person his or her concerns, can gently suggest that the person was not responsible for what happened. By sharing the experience, the patient can begin to heal and integrate what happened into his or her life. Psychoeducation: Initial education should include reassurance that reactions to trauma are common and that these reactions do not indicate personal failure or weakness. The nurse should inform the patient and significant others of the many ways that trauma can be manifested. Interpersonal problems with family and friends, occupational problems, and/or substance-use disorders and problems with alcohol use are common symptoms. Strategies to improve coping, enhance self-care, and facilitate recognition of problems are essential. Patients experiencing such severe stress will benefit from relaxation techniques and in the avoidance of caffeine and alcohol. Psychopharmacology: The best evidence supports the use of selective serotonin reuptake inhibitors (SSRIs) for PTSD symptoms. Currently, the FDA has approved two drugs: sertraline (Zoloft) and paroxetine (Paxil). From the perspective of the FDA, all other medications are used off label. Phenelzine (Nardil) is a monoamine oxidase inhibitor that has been used with some success in PTSD. A serotonin norepinephrine reuptake inhibitor (SNRI) such as venlafaxine (Effexor) may be used to decrease anxiety and depressive symptoms. Tricyclic antidepressants (TCAs) or mirtazapine (Remeron) may be prescribed if SSRIs or SNRIs are not tolerated or do not work. Clonidine (Catapres) is a centrally acting alpha-2 receptor agonist used to address hyperarousal and intrusive symptoms. Prazosin (Minipress) is an alpha-receptor antagonist used for nightmares and sleep disturbances. Propranolol (Inderal), a beta-blocker, is used for hyperarousal and panic. The most difficult to tolerate side effect of these medications is hypotension. The FDA recently agreed to new trials for MDMA, the illegal party drug known as Ecstasy, as a relief for PTSD patients (Phillips, 2016). Phase III clinical trials of the drug are under way as a final step for approval of Ecstasy as a prescription drug. After three doses of MDMA, patients reported a 56% decrease in symptom severity on average. Follow-up examinations found that improvements lasted more than a year after therapy. The drug reduces painful memories and helped patients to stop substance use.

malingering

Deliberate faking of a physical or psychological disorder motivated by gain.

neglect

Failure to provide for physical, emotional, educational, or healthcare needs

Blaming

Family members blame others for failures, errors, or negative consequences of an action to deflect the focus from them.

Placating

Family members pretend to be well meaning to keep peace in the family. "Don't yell at the children, dear. I put the shoes on the stairs."

By engaging the parasympathetic nervous system

How do relaxation techniques help clients who have experienced major traumas?

Manipulation

Instead of asking directly for what is wanted, family members manipulate others to get what they want. For example, a child starts a fight with a sibling to get attention. Another example is when a request is granted with "strings attached" so that the other person has a difficult time refusing the request: "If you clean my room for me, I won't tell Daddy you are getting bad grades in school."

Dysfunctional Communication

Manipulating, Distracting, Generalizing, Blaming, and Placating

Nursing Care for Gender Dysphoria

Individuals dealing with gender dysphoria may feel profound social and internal guilt and shame related to their sexual proclivities. "I am disgusted by how hairy my body is" and "I have never wanted to be macho; I have always been sensitive and caring." A nursing diagnosis that goes along with this problem includes disturbed personal identity related to incongruence between expressed (beliefs) and assigned (inborn) gender. Outcomes include seeking social support, using healthy coping behaviors to resolve sexual identity issues, and acknowledging and accepting sexual identity. Advanced Interventions Psychotherapy Children There is lack of consensus as to the best approach in treating children. However, the goal is to optimize the child's psychological adjustment and well-being. One approach is to let the child identify with the opposite gender and provide support for the stresses of familial and peer responses (e.g., bullying). Another is to accept the parents' goal of having the child accept his natal gender and then working on making him comfortable it. In this approach, family dynamics are also examined for their role in perpetuating the cross-gender behavior. Another family-directed approach is to provide supportive therapy while waiting to see whether the dysphoria will continue. Adolescents and adults Gender dysphoria in adolescents will likely continue into adulthood. Individual and family therapy is helpful. Adolescents will need help with coping skills to deal with harassment. Long-term psychotherapy is recommended to address gender dysphoria and comorbid conditions (Shafer, 2016). A thorough psychological evaluation is commonly required before sex reassignment. Pharmacological Pharmacological interventions in adolescents may be used to delay puberty. Supporters of this reversible approach suggest that this gives adolescents time to explore gender-related issues. Adults with gender dysphoria may choose to take hormones to alter their chemistry toward their preferred gender. A female who would like to become a male takes testosterone. This results in more muscle, facial hair, clitoral enlargement, amenorrhea, and increased sex drive. When a male takes estrogen, it results in decreased penis and testicles size, less muscle, more fat on the hips, less facial and body hair, and slight increase in breast size. Surgical When gender dysphoria in adults and even adolescents is severe and intractable sex reassignment surgery is an option. If the patient is considered appropriate for sex reassignment, psychotherapy is usually initiated to prepare the patient for the cross-gender role. The patient is then instructed to live in the cross-gender role before surgery—including going to work or attending school—to help the individual determine whether he or she can interact successfully with members of society in the cross-gender mode. Legal and social arrangements are made such as changing names on legal documents. New employment may be sought if it is necessary to leave a former job because of discrimination. Relationship issues, such as what to tell parents, children, and former spouses, must be addressed. Males are instructed to have electrolysis and to practice female behaviors. Females are instructed to cut their hair, bind or conceal their breasts, and similarly take on the identity of a man. If these measures have been successful and the patient still wishes reassignment, hormone treatment is begun. After a period of time on hormone therapy, the patient may be considered for surgical reassignment if it is still desired. In men, surgery may include removal of the penis (penectomy) and testes (orchiectomy) and the addition of a vagina (vaginoplasty). In females, surgical procedures may include the removal of the breasts (mastectomy), optional removal of the uterus (hysterectomy) and ovaries (oophorectomy), and the construction of a penis (phalloplasty) in females. Efforts to create an artificial penis have met with mixed results. Do people regret having sex reassignment surgery? In a study by Dhejne and colleagues (2014), regret for the surgery was found in only about 2% of people who underwent sex reassignment surgery. Still psychotherapy is indicated after surgery to help the patient adjust to the surgical changes and discuss sexual functioning and satisfaction. Box 20.4 describes a case of sex reassignment gone wrong.

somatic symptom disorder S/S

Pain: head, chest, back, abdomen, joints GI issue: dysphagia, nausea, constipation Cardiac: palpation, SOB, C/P, dizzy

family psychoeducation

Often, the most compelling family need is psychoeducation. This is particularly true for families who have a member with a severe mental illness. The primary goal of family psychoeducation is the sharing of mental healthcare information. Family education groups help family members better understand their member's illness, prodromal symptoms (symptoms that may appear before a diagnosis is reached or a relapse occurs), and medications needed to help reduce the symptoms. Educational family meetings or multiple family meetings allow feelings to be shared and strategies for dealing with these feelings to be developed. Families can share painful issues of anger or loss, feelings of stigmatization or sadness, and feelings of helplessness. They can then put these feelings in a perspective that the family and individual members can deal with more satisfactorily. An area in which family psychoeducation has been applied successfully is in treatment of the patient with schizophrenia. Families are extremely valuable and positive resources for patients, and family work promotes and supports families in coping with a member who has a severe psychiatric disorder. Psychoeducational groups also have proven helpful in parent management training such as teaching a parent to work with a child with a conduct disorder. Advanced Practice Interventions Psychiatric-mental health advanced practice registered nurses may conduct family therapy. Care providers have applied family therapy to virtually every type of disorder among children, adolescents, and adults (Abbott, 2012). Treating the whole family appears to be particularly helpful in the treatment of substance abuse disorders, child behavioral problems, marital relationship distress, and as an element of the treatment plan for schizophrenia (Deane et al., 2012). Although therapists may adhere to different theories and use a wide variety of methods, the psychiatric advanced practice nurse will aim to (Nichols, 2013): • Reduce dysfunctional behavior of individual family members • Resolve or reduce intrafamily relationship conflicts • Mobilize family resources and encourage adaptive family problem-solving behaviors • Improve family communication skills • Increase awareness and sensitivity to other family members' emotional needs and help family members meet their needs • Strengthen the family's ability to cope with major life stressors and traumatic events including chronic physical or psychiatric illness • Improve integration of the family system into the societal system (e.g., school, medical facilities, workplace, and especially the extended family) • Promote appropriate individual psychosocial development of each member of the family Family therapy may not be helpful in some circumstances. For example, when the therapeutic environment is not safe and there is a risk for harm by information, uncontrolled anxiety, or hostility, a shared therapy session should be avoided. If the therapist is fairly sure that family members are not being honest, it is likely that the work being done will not be productive. If parental conflict involves issues of sexuality that are not appropriate for the children, these issues should be discussed in couples' counseling. In most other situations, however, family therapy is useful. Family therapy is often combined with psychopharmacology in the treatment of families who have a member with a psychiatric disorder such as bipolar disorder, major depressive disorder, or schizophrenia. Other families may choose psychoeducational family therapy and/or self-help groups, which are good options that may be less costly and time consuming. Advanced practice nurses are trained in the provision of these modalities of treatment.

Somatic Disorders Interventions

Reattribution treatment is a structured intervention designed to provide a simple explanation of somatic symptoms to patients. Reattribution skills from the healthcare provider help the patient feel understood and help the patient make the link between physical complaints and psychological distress. The four stages of reattribution are: Stage 1: Feeling Understood Empathetic listening skills are used in taking the history of physical, emotional, and psychosocial factors of the presenting symptoms including patient beliefs and perceptions of the causality of illness, when is it worse, and what helps. This stage includes a brief focused physical examination. Stage 2: Broadening the Agenda The care provider gives feedback and implications of assessment findings, and acknowledges the patient's distress. Stage 3: Making the Link The care provider uses patient cues to give an empowering explanation of the symptoms. For example, "You may have a heightened sensitivity to particular stressors that is affected by genetics, your personal experiences, and the environment" is a patient-centered comment that removes any sense of blame from the patient Stage 4: Negotiating Further Treatment The provider and the patient create a treatment plan that includes regular follow-up visits. To be successful, therapeutic interventions address ways to help the patient get needs met without resorting to somatization. The secondary gains derived from illness behaviors become less important to the patient when underlying needs can be met directly. Given that multiple healthcare providers are often involved in the management of this disorder, good communication among treating clinicians is required to maintain a consistent approach. In an ideal situation, a multidisciplinary team of caretakers, including an advanced practice psychiatric-mental health registered nurse who provides consultation to nurses outside of psychiatry, would be involved in the treatment of patients with somatic symptom disorders. Using the data from the holistic assessment, nurse clinicians, along with a physician, are in a position to provide useful and effective interventions. People who have distressing symptoms are vulnerable to a variety of psychosocial stresses. How they cope with these stresses may make the difference between living with an acceptable quality of life and giving in to despair, withdrawal, helplessness, or hopelessness. Nurses are in a position to assess and understand patients' psychosocial stressors, identify needed coping skills, and teach stress-management techniques. Nurses can play an important role not only in managing patients' immediate care but also in helping patients to improve their ability to cope and increase the quality of life during the course of somatic disorders. Patients can learn various effective coping skills such as assertiveness training, cognitive reframing, problem-solving skills, and social supports. Nurses are in key positions to assess, educate, or provide referrals to a patient to enable healthier ways of looking at and dealing with illness. Teaching relaxation techniques, such as progressive muscle relaxation, meditation, guided imagery, and breathing exercises, promotes self-care and provides a distraction from obsessive somatic thoughts. For many symptoms seen in primary healthcare, there is no evidence of physical disease. The high prevalence of behavioral health problems and the interrelated nature of mental and physical treatment have led the Institutes of Medicine (IOM) to call for integration of behavioral and physical care. One of the advantages for integrating mental health services into primary healthcare includes less stigmatization. Because primary healthcare services are not associated with any specific health conditions, individuals reduce the stigma when seeking mental healthcare from a primary healthcare provider. In the Netherlands, several models have been developed to integrate behavioral health and primary care. They launched the Depression Initiative Primary Mental Health Collaborative Care Model. This model consists of a primary care provider prescribing an antidepressant, a psychiatrist available for consult, and a nurse case manager who monitors patient progress and provides behavioral healthcare. The Netherlands expects that 80% of mental disorders will be treated in the primary care setting. Psychiatric-mental health nurses can bring a strong perspective in assessing and managing both physical and mental health needs in such integrated care settings. Advocating for models such as the one used in the Netherlands is an important aspect of leadership in nursing. ****The following interventions have all been shown to positively affect a patient's recovery:**** • Educating the patient regarding specific treatments • Referring the patient to community support groups (or systems) • Teaching patients more effective coping skills that take into consideration patients' values, preferences, and lifestyle • Focusing on a patient's strengths and reinforcing coping skills that work (e.g., prayerfulness, participation in hobbies, relaxation techniques) General recommendations for healthcare providers in working with patients with somatic symptoms include six key elements for effective relationships and treatment: 1. Provide continuity of care. 2. Avoid unnecessary tests and procedures. 3. Provide frequent, brief, and regular office visits. 4. Always conduct a physical examination. 5. Avoid making disparaging comments such as, "Your symptoms are all in your head." 6. Set reasonable therapeutic goals such as maintaining function despite ongoing pain. Psychosocial Interventions Nursing interventions for patients with somatic symptom disorders generally take place in the home or clinic setting and entail helping the patient improve overall functioning through the development of effective coping strategies. The Nursing Interventions Classification (NIC) offers several categories pertinent to caring for patients with somatic symptom disorders: assertiveness training, family involvement promotion, limit setting, self-awareness enhancement, and self-esteem enhancement Promotion of Self-Care Activities When somatization is present, the patient's ability to perform self-care activities may be impaired, and nursing intervention is necessary. In general, interventions involve the use of a matter-of-fact approach to support the highest level of self-care of which the patient is capable. For patients manifesting paralysis, blindness, or severe fatigue, an effective nursing approach is to support patients while expecting them to support themselves. For example, the patient who demonstrates paralysis of an arm can be expected to eat using the other arm. To encourage the patient experiencing blindness to feed himself, he can be told at what numbers on an imaginary clock the food is located on the plate. These strategies are effective in reducing secondary gain. Assertiveness training is often identified as appropriate teaching for patients with somatic symptom disorders. Use of assertiveness techniques gives patients a direct means of getting needs met, thereby decreasing the need for somatic symptoms. Teaching an exercise regimen, such as doing range-of-motion exercises for 15 to 20 minutes daily and taking regular walks if possible, can help the patient feel in control, increase endorphin levels, and help decrease anxiety. Pharmacological Interventions It is unclear whether medications are useful for treatment of the somatic symptom disorders. Certainly if there are underlying psychiatric diagnoses, appropriate utilization of medication is indicated and may result in a decrease of somatic symptoms. The decision to medicate patients with a somatic symptom disorder should weigh the benefits against the possibility that these patients may misuse their medication or take it irregularly. While there are no medications that have received FDA approval specifically for somatic disorders, some medications are used off-label. Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) may be helpful in somatic disorders directly by reducing depressive symptoms and subsequent somatic responses. They may also help by affecting nerve circuits that affect not only mood but fatigue, pain perception, gastrointestinal distress, and other somatic symptoms. Medication trials with other antidepressants including serotonin norepinephrine reuptake inhibitors (SNRIs)—venlafaxine (Effexor) and duloxetine (Cymbalta)—and a noradrenergic specific serotonergic antidepressant—mirtazapine (Remeron)—have been effective with somatic disorders, but further controlled trials are necessary (Garcia-Martin et al., 2012). Patients may also benefit from short-term use of benzodiazepine antianxiety medication, which must be monitored carefully because of the risk of dependence. The nurse may administer these medications in certain settings, but teaching patients and families about the medication is helpful in all settings. Health Teaching and Health Promotion Patients who use somatization as a way of coping with anxiety tend to be less educated than average. Teaching these patients basic information about bodily functions is often necessary. Pictures and charts can be helpful, and it is useful to review the same information with the family because their knowledge may also be faulty.

Sexual dysfunction Assessment

Sexual Dysfunction 1. A sexual assessment should be conducted in a setting that allows privacy and eliminates distractions. 2. Although note-taking may be necessary for the beginner, it can be distracting to the patient and interrupt the flow of the interview. When note-taking is necessary, it should be unobtrusive and kept to a minimum. 3. The interviewer should be aware of personal biases and attitudes that could block open discussion of sexual issues. 4. Good eye contact, relaxed posture, and friendly facial expressions facilitate the patient's comfort and communicate openness and receptivity on the part of the nurse. General Assessment: Sexual assessment includes both subjective and objective data. Many psychiatric hospitals use a nursing history tool that is biologically oriented and has few questions on sexual functioning. Health history questions pertaining to the reproductive system may be limited to menstrual history, parity, history of sexually transmitted diseases, method of contraception, and questions regarding safe sex practices. There may be a few vague questions about sexual functioning or sexual concerns. Patients may cue the nurse into the presence of sexual concerns without explicitly verbalizing them. Box 20.2 presents a discussion of these cues. The nurse may ask the patient if there is concern in the area of sexual functioning. Generally, it is more comfortable for the patient if the nurse first asks questions in a general manner and then proceeds to the patient's experience. For example, the nurse might say, "Some people who are prescribed this medication find it difficult to achieve an erection. Have you had this problem?" This allows the patient to feel that he is not alone in what he is experiencing. Table 20.2 provides facilitative statements for the interviewer conducting a sexual assessment. The sexual history includes the patient's perception of physiological functioning and behavioral, emotional, and spiritual aspects of sexuality. It also includes cultural and religious beliefs with regard to sexual behavior and sexual knowledge base. During the assessment, both the nurse and the patient are free to ask questions and clarify information. It is reasonable to defer lengthy sexual health assessment when acute psychiatric symptoms prevent a calm thoughtful discussion. As symptoms subside and rapport is developed, the assessment may be resumed. With experience, the nurse is able to identify those patients who are at greater risk for difficulties in sexual functioning. This includes patients with a history of certain medical problems or surgical procedures (see Table 20.1) and patients taking some drugs (Table 20.3). Self-Assessment Discomfort in assessing sexual history may be due to poor training, inexperience, inadequate time, or beliefs that sexual history is not important. Indeed, you may experience discomfort exploring sexual issues with patients, fearing that this discussion will be personally embarrassing and embarrassing to the patient. You may fear that you will not know what questions to ask or why the questions should be asked. Nonverbal Behaviors • Showing discomfort by blushing, looking away, making tight fists, fidgeting, crying • Openly engaging in overt sexual behaviors (e.g., touching own body parts, masturbating, exposing genitals, placing nurse's hand on genitals, making sexually suggestive sounds) Verbal Behaviors • Telling sexually explicit jokes • Making sexual comments about the nurse • Asking inappropriate questions about the nurse's sexual activity • Discussing sexual exploits • Expressing concern about relationship with partner: • "I don't feel the same about my partner." • "My partner doesn't feel the same about me." • "We're not as close." • "Our relationship has changed." • "My personal life has changed." • Expressing concern that sexuality has been diminished (e.g., feeling less of a man, less of a woman): • "I've lost my manhood." • "I'm not as desirable as I once was." • Expressing concern over lack of sexual desire: • "I'm not interested in sex anymore." • "My desire has changed." • "I'm not the man/woman I used to be." • "We don't click anymore." • Expressing concern over sexual performance: • "I've lost my power." • "What will happen to my ability to perform?" • "I can't perform like I used to." • Expressing concern about one's love life: • "My love life has changed." • "The spark is gone." • Expressing concern over the sexual impact of drugs, surgery, or some other medical treatment: • "Will this drug interfere with my sex life?" • "Will I still be able to perform sexually after surgery?" Concerns related to age and gender differences are understandable. Maybe your patient is approximately your age and of the opposite sex. In this case, you might wonder whether talking about sexuality is inappropriate or whether the patient might decide that you are a little too interested. Discussing issues related to sexuality with people who are your parents' or grandparents' age may also create a level of discomfort, especially if you grew up in a home where such topics were avoided. Remembering your position as a professional and addressing the topics in a tone and manner appropriate of a professional will increase your comfort, along with the patient's. Also, letting the patient know why you are asking such personal questions increases openness and cooperation. For example, "People who are depressed sometimes find that it affects their sexual desire. Because you have been depressed, have you noticed a change in your interest in sex?" Sometimes a more subtle approach that shifts the focus away from the patient is helpful. "Because you have been depressed, has your husband felt as if you are less interested in him?"

Distracting

To avoid functional problem solving and resolving conflicts within the family, family members introduce irrelevant details into problematic issues.

economic abuse

To restrict, exploit an sabotage a partners access to money and other resources, such as food, clothing, transportation, and a place to live

Testosterone

When attempting to determine the cause of low sexual drive, the nurse can expect evaluation of the client's serum level of which hormone?

Delay the interview if symptoms related to anxiety are observed

When obtaining the sexual history for a client, a nurse should:

Memantine

Which medication prescribed by clients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels RATHER than cholinesterase?

bulemia nervosa

a disorder in which cycles of overeating are followed by some form of purging or clearing of the digestive tract recurrent episodes of uncontrollable binging inappropriate compensatory behaviors: vomiting, laxatives, diuretics, or exercise self-image largely influenced by body image

anger

an emotional state consisting of annoyance, displeasure, or hostility.

aggression

an overt or covert interaction that may result in a verbal or physical attack

bullying

an unwanted, aggressive behavior among school-age children that involves a real or perceived power imbalance

Clear boundaries

are adaptive and healthy. All members of the family understand these boundaries and they give family members a sense of self. They are firm, yet flexible, and provide a structure that responds and adapts to change. Clear boundaries allow family members to take on appropriate roles and to function without unnecessary or inappropriate interference from other members. They reflect structure while simultaneously supporting healthy family functioning and encouraging individual growth.

pica

compulsive eating of nonnutritive substances such as clay, dirt, or ice

Dialectical Behavioral Therapy

emotional regulation therapy Provided by Advanced Practice Nurse rather than a staff nurse

apraxia

inability to perform once familiar and purposeful movement

agnosis

loss of sensory ability to recognize objects

confabulation

make up stories to preserve self esteem

Refeeding syndrome

metabolic alterations that may occur during nutritional repletion of starved patients

somatic symptom disorder

psychological disorder in which the symptoms take a somatic (bodily) form without apparent physical cause It is characterized by a focus on somatic (physical) symptoms, such as pain or fatigue, to the point of excessive concern, preoccupation, and fear. It is authentic They experience a high level of functional impairment Chronic and relapsing

perserveration

repetition of a word or phrase

sundowning

tendency for mood to deteriorate and agitation to increase late in the day.

deescalation techniques

• Maintain the patient's self-esteem and dignity • Maintain calmness (your own and the patient's) • Assess the patient and the situation • Identify stressors and stress indicators • Respond as early as possible • Use a calm clear tone of voice • Invest time • Remain honest • Determine what the patient considers to be needed • Identify goals • Avoid invading personal space; in times of high anxiety, personal space increases • Avoid arguing • Give several clear options • Use genuineness and empathy • Be assertive (not aggressive) • Do not take chances; maintain personal safety

Phases of sexual response cycle

• Phase 1: Desire • Phase 2: Excitement • Phase 3: Orgasm • Phase 4: Resolution

Chapter 11 Key Points

• One in five children and adolescents in the United States suffers from a major mental illness that causes significant impairments at home, at school, with peers, and in the community. • Factors known to affect the development of mental and emotional problems in children and adolescents include genetic influences, biochemical (prenatal and postnatal) factors, temperament, psychosocial developmental factors, social and environmental factors, and cultural influences. • The characteristics of a resilient child include an adaptable temperament, the ability to form nurturing relationships with surrogate parental figures, the ability to distance the self from emotional chaos in parents and family, good social intelligence, the ability to perceive a future, and problem-solving skills. • Use seclusion and restraint as last resorts after less restrictive interventions have failed and only in the case of dangerous behavior toward self or others. Seclusion and restraint require continuous monitoring by trained staff and must not be used as a punishment. Notify parents/guardians if such measures are used. • Communication disorders are a deficit in language skills acquisition that creates impairments in academic achievement, socialization, or getting self-care. • Motor disorders are manifested by impairments in gross and fine motor skill acquisition. They can range from mild to profound in severity. Purposeless, repetitive movements that interfere with daily living activities characterize stereotypic movement disorders. • Tics are sudden, nonrhythmic, and rapid motor movements or vocalizations. Tic disorders vary in severity and degree of interference with the child's social and academic functioning. • Learning disorders may be in the areas of reading, mathematics, or written expression with performance in those areas below the level expected for the age and cognitive level. Interventions are designated in an Individualized Education Program (IEP) and provided through special education in public schools. • Autism spectrum disorder typically occurs within the first 3 years of life, yielding deficits in social interaction and communication skills. Children with autism spectrum disorder are referred to early intervention programs and continue to receive school-based services as they enter the public education system. • Attention-deficit/hyperactivity disorders are evidenced by symptoms of inattentiveness and/or hyperactivity and impulsivity that are developmentally inappropriate. These disorders cause the child problems in a number of settings, such as home, school, and community. ADHD is treated primarily with stimulant medications and behavioral therapies. • Treatment of childhood and adolescent disorders requires a multimodal approach in almost all instances, and family involvement is seen as critical to improvement in outcomes. • Nurses can be important advocates for children with severe emotional and behavioral disorders.

Considerations for Staff Safety

- Avoid wearing dangling earrings, necklaces and scarves - Ensure that there is enough backup staff - Always know the layout of the area - Do not stand in front of the patient or in front of the doorway. The patient may view this as confrontational. Always stand off to the side and encourage the patient to sit down - If the patient's behavior escalates, provide feedback possibly allowing the patient to explore feelings and hopefully deescalate - Avoid confrontation. Verbal confrontation and discussion of the incident needs to occur when the patient is calm. If security is involved keep them in the background until they are needed to assist. The presence of security may escalate the patient

Provide a well-lit room without glare or shadows. Limit noise and stimulation

A client diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this client?

Assist the client to perform simple tasks by giving step-by-step directions

A client has progressive memory deficits associated with dementia. Which nursing intervention would BEST help the individual function in the environment?

Facts and Myths about Aging:

Facts • The senses of vision, hearing, touch, taste, and smell decline with age. • Muscular strength decreases with age. Muscle fibers atrophy and decrease in number. • Regular sexual expressions are important to maintain sexual capacity and effective sexual performance. • At least 50% of restorative sleep is lost as a result of the aging process. • Older adults are major consumers of prescription drugs because of the high incidence of chronic diseases in this population. • Older adults have a high incidence of depression. • Many individuals experience difficulty when they retire. • Older adults are prone to become victims of crime. • Older widows appear to adjust better than younger ones. Myths • Most adults past the age of 65 have dementia. • Sexual interest declines with age. • Older adults are unable to learn new tasks. • As individuals age, they become more rigid in their thinking and set in their ways. • The aged are well off and no longer impoverished. • Most older adults are infirm and require help with daily activities. • Most older adults are socially isolated and lonely

Polypharmacy in Older Adults

In older adults, it is important to perform a systematic review of current medication use known as medication reconciliation. Medication reconciliation is the process of developing the most accurate list possible of all medications a patient is taking. This list should include drug name, dose, frequency, and route. The purpose of this process is to reduce adverse incidents, side effects, and potentially lethal combinations. Assessing the use of multiple medications (polypharmacy) includes prescription, over-the-counter drugs, and herbal agents. Adverse drug reactions or negative responses to drugs are common among the older adult. Older adults are at greater risk for these events due to multiple medical problems and memory issues that may result in taking too little or too much medication. Renal and liver impairment affect excretion and are associated with dose-related adverse reactions. Metabolic changes and decreased drug clearance compound the risk of drug-drug interactions. The risk of adverse drug reactions doubles for people taking five to seven medications as compared with those taking fewer than five medications (Onder et al., 2010). For people taking eight or more medications, the risk of adverse drug reactions increases by four times. The American Geriatrics Society (2015) recently updated the criteria for and list of potentially inappropriate medications for older adults. Many psychiatric medications appear on the list including benzodiazepines, anticholinergics, antipsychotics, antidepressants, antiepileptics, and antiparkinson drugs. Nurses must be diligent in reviewing senior's medication lists for completeness.

hyperorality

tendency to taste, chew, or put everything into their mouth

derealization

the focus is on the outside world. It is the recurring feeling that one's surroundings are unreal or distant Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Chapter 17 Key Points

• There is irrefutable evidence that emotional conditions may precipitate and often increase the severity of physical symptoms. Likewise, physical illnesses are often accompanied by a spectrum of emotional responses. • Somatic symptom disorders are characterized by the presence of multiple real physical symptoms with or without an identifiable medical illness. • Somatic symptom disorders are responses to psychosocial stress although the patient often shows no insight in the potential stressors. • The course of somatic symptom disorders may be brief, with acute onset and spontaneous remission, or chronic, with a gradual onset and prolonged impairment. • The nursing assessment is especially important to identify symptoms of adverse childhood events, depression, anxiety, posttraumatic stress disorder, and substance use that are contributing to the somatic symptom disorder. • Integrated holistic interventions target both the psychological and medical problems to increase adherence to the care regimen, maximize quality of life, promote healing, and minimize healthcare costs. • The advanced practice psychiatric-mental health registered nurse is in a key position to assist other healthcare personnel to view patients in an integrated, holistic approach in both inpatient and outpatient settings. • Factitious disorders, in contrast to other somatic disorders, are under conscious control. Nurses are challenged to provide care for persons who are pretending to have disorders when there are others with real illnesses who need their time.

Assessment Guidelines for Delirium

1. Do not assume that acute confusion in an older person is due to dementia. 2. Assess for acute onset and fluctuating levels of awareness. 3. Assess the person's ability to attend to the immediate environment including responses to nursing care. 4. Establish the person's usual level of cognition by interviewing family or other caregivers. 5. Assess for past cognitive impairment—especially an existing dementia diagnosis—and other risk factors. 6. Identify disturbances in physiological status, especially infection, hypoxia, and pain. 7. Identify any physiological abnormalities documented in the patient's record. 8. Assess vital signs, level of consciousness, and neurological signs. 9. Assess potential for injury, especially in relation to potential for falls and wandering. 10. Maintain comfort measures, especially in relation to pain, cold, or positioning. 11. Monitor situational factors that worsen or improve symptoms. 12. Assess for availability of immediate medical interventions to help prevent irreversible brain damage

Etiology of Sexual Dysfunction

System/State Organic Disorders Sexual Impairment Endocrine- Hypothyroidism, adrenal dysfunction, hypogonadism, diabetes mellitus Low libido, impotence, decreased vaginal lubrication, early impotence Vascular- Hypertension, atherosclerosis, stroke, venous insufficiency, sickle cell disorder Impotence, but ejaculation and libido intact Neurological- Spinal cord damage, diabetic neuropathy, herniated disk, alcoholic neuropathy, multiple sclerosis, temporal lobe epilepsy Sexual disorder—early signs: low or high libido, impotence, impaired orgasm Genital: Male—Priapism, Peyronie's disease, urethritis, prostatitis, hydrocele (Low libido, impotence) Female—Imperforate hymen, vaginitis, pelvic inflammatory disease, endometriosis (Genito-pelvic pain, low libido, decreased arousal) Systemic- Renal, pulmonary, hepatic, advanced malignancies, infections Low libido, impotence, decreased arousal Psychiatric: Depression (Low libido, erectile dysfunction) Bipolar disorder (manic phase)- (Increased libido) Generalized anxiety disorder, panic disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD)- (Low libido, erectile dysfunction, reduced vaginal lubrication, anorgasmia) Schizophrenia- Low desire, bizarre sexual fantasies Personality disorders (passive-aggressive, obsessive-compulsive, histrionic)- Low libido, erectile dysfunction, premature ejaculation, anorgasmia Surgical-postoperative: Male—Prostatectomy, abdominal-perineal bowel resection (Impotence, no loss of libido, ejaculatory impairment) Female—Episiotomy, vaginal prolapse repair, oophorectomy (Genito-pelvic pain, decreased lubrication) Male and female—Leg amputation, colostomy, ileostomy (Mechanical difficulties in sex, low self- image, fear of odor) CV Drugs: Methyldopa Thiazides Clonidine Propranolol Digoxin Clofibrate Statins GI drugs: Cimetidine Methantheline bromide Sedatives: Alcohol Women: Increased libido Men: Decreased libido, delayed ejaculation, gynecomastia, testicular atrophy Antianxiety drugs: Alprazolam Diazepam Women: Decreased libido, decreased orgasm Men: Impotence, decreased libido, delayed ejaculation Antipsychotics: First generation antipsychotics Second generation antipsychotics Antidepressants: SSRIs SNRIs Atypical (trazodone) Tricyclics MAOIs Antimanic drugs: Lithium

Rigid Boundaries

are the opposite of diffuse boundaries. Families with this type of boundary demand adherence to rules and roles—some apparent and some less so—regardless of circumstances or outcomes. Boundaries can be so firmly closed that family members are disengaged and avoid one another, resulting in little sense of family loyalty. In families in which rigid boundaries predominate, communication is minimal, and members rarely share thoughts and feelings. Isolation may be marked feature in such family systems. Disengaged family members lead highly separate and distinct lives. Because they do not learn intimacy in the family setting, individuals from disengaged families do not tend to develop insights into their own feelings and emotions. As a result, they may have a hard time bonding with others and participating in new family structures when they leave their families of origin and begin their lives as adults.

anorexia nervosa

refuse to maintain a minimally normal weight for height and express intense fear of gaining weight intense fear of weight gain distorted body image restricted calories with significantly low BMI Subtypes: -restricting (no consistent bulimic features) -binge/eating/purging (primary restriction, some bulimic behaviors)

violence

the intentional use of force that may result in injury to another person

Family Therapy

As a treatment approach, family therapy began to emerge in the 1920s as social psychologists recognized that behaviors among family members mutually influence the behaviors of individual members (Perreau, 2016). The two major aims of family therapy are to: 1. Improve the skills of the individual members 2. Strengthen the functioning of the family as a whole Family therapists are trained and practice at the advanced level. While you will not be conducting family therapy without an advanced degree, registered nurses often lead family groups for the purpose of education or support. Knowledge of basic family therapy skills will help you with group work. It will also provide you with information you can use for community referrals. Family therapists use various strategies to assess a family's level of functioning. However, the following areas are almost always explored: • Cohesiveness—how much time do members spend together as a family unit? • Communication—do the members respectfully listen to one another's concerns and ideas and allow for open discussion when disagreement arises? • Appreciation—do the individual members contribute in meaningful ways to the functioning of the family and offer gratitude to one another that supports self-esteem? • Commitment—do the individual members consider the impact of their actions on the family as a whole and in a manner that promotes unity? • Coping—do the family members demonstrate the ability to support one another during times of crisis? • Beliefs and values—does the family identify with or practice within a collective moral, ethical, or spiritual set of standards? Specific approaches to therapy vary according to the philosophical viewpoint, education, and training of individual therapists. Family therapy's effectiveness is not tied to any particular theoretical approach (Keeney & Keeney, 2012). Table 35.1 lists specific therapies; identifies some of the therapists who contributed to their development and use; and highlights assumptions, concepts, and goals related to each therapy. Multiple-family group therapy is a useful therapeutic modality for families who are facing similar difficulties. By hearing other families discuss their problems, family members identify and gain insight into their own problems. New skills can be modeled and learned in the context of the group. In the case of multiple-family therapy, several families meet in one group with one or more therapists, usually once a week.

PTSD in Children:

Clinical Picture: PTSD in preschool children may manifest as a reduction in play, repetitive play that includes aspects of the traumatic event, social withdrawal, and negative emotions such as fear, guilt, anger, horror, sadness, shame, or confusion. Children may blame themselves for the traumatic event and manifest persistent negative thoughts about themselves such as "I am a bad person." In addition there may be a feeling of detachment or estrangement from others and diminished interest or participation in significant activities. Often there is irritability, aggressive or self-destructive behavior, sleep disturbances, problems concentrating, and hypervigilance. Assessment: The observation-interaction part of a mental health assessment begins with a semi-structured interview in which the nurse asks the young person to describe the home environment, parents, and siblings. Information about the school environment, teachers, and peers is also collected. Play activities, such as games, drawings, and puppets, are used for younger children who cannot respond to a direct approach. The initial interview is key to observing interactions among the child, caregiver, and siblings (if available) and to building trust and rapport. Essential assessment data include posttraumatic symptoms such as: • Nightmares • Night terrors • Hallucinations • Intrusive traumatic thoughts and memories • Reexperiencing or flashbacks of trauma • Traumatic reenactments in play • Self-injurious behaviors Traumatized children may have dramatic mood swings and exhibit uncontrollable rage and negative symptoms such as numbing and avoidance. Somatic symptoms may manifest as headaches, stomachaches, or pain. Memory problems include amnesia, forgetfulness, difficulty concentrating, or trance states. Specific assessment tools include the Child Dissociative Checklist (Putnam et al., 1993), Trauma Symptoms Checklist for Children (Briere, 1996), and the Child Sexual Behavior Inventory (Friedrich et al., 2001). Interventions: Establish trust and safety in the therapeutic relationship. Use developmentally appropriate language to explore feelings. Teach relaxation techniques before trauma exploration to restore a sense of control over thoughts and feelings. Help the child to identify and cope with feelings through the use of art and play to promote expression. Involve the parents or appropriate caretakers in 1:1s unless they are the cause of the trauma. Educate the child and parents about the grief process and response to the trauma. Assist parents in resolving their own emotional distress about the trauma. Coordinate with social work for protections as indicated.

Adjustment Disorder

Considered a milder form of ASD and PTSD Like ASD and PTSD, it is precipitated by a stressful event. However, the event—including retirement, chronic illness, or a breakup—may not be as severe and may not be considered a traumatic event. This problem may be diagnosed immediately or within 3 months of exposure. The hallmarks of adjustment disorder are cognitive, emotional, and behavioral symptoms that negatively impact functioning. Responses to the stressful event may include combinations of depression, anxiety, and conduct disturbances. Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, anxiety, and anger. These feelings may be combined with other manifestations of distress, including physical complaints, social withdrawal, or work or academic inhibition. Quality of life scores are higher with adjustment disorder than for major depression but lower than for people without any disorder (Fernández et al., 2012). There is a type of adjustment disorder that addresses the needs of those who have lost a loved one within the past 12 months—a sort of complicated grief. This type of adjustment disorder is manifested by intense yearning/longing for the deceased and intense sorrow and emotional pain or preoccupation with the deceased or the circumstances of the death. In addition, the person may feel anger, a diminished sense of self, emptiness, and/or difficulty in relationships or in planning future activities. This may be in accordance with cultural norms. The reported prevalence of adjustment disorder varies widely depending on the setting studied. For example, in those hospitalized, adjustment disorder was found to occur in 50% of the population (APA, 2013), whereas in a primary care setting, it is estimated at 3% of the population (Fernández et al., 2012). Thus treatment of adjustment disorder is not uniform due to the lack of specificity of the problem, and practitioners do not usually recognize this disorder. Symptoms are generally treated with antidepressants.

Basic Level Interventions for Somatic System Disorders

Offer explanations and support during diagnostic testing. After physical complaints have been investigated, avoid further reinforcement (e.g., do not take vital signs each time patient complains of palpitations). Spend time with patient at times other than when patient summons nurse to voice physical complaint. Observe and record frequency and intensity of somatic symptoms. (Patient or family can give information.) Do not imply that symptoms are not real. Shift focus from somatic complaints to feelings or to neutral topics. Assess secondary gains "physical illness" provides for patient (e.g., attention, increased dependency, and distraction from another problem). Use matter-of-fact approach to patient exhibiting resistance or covert anger. (Avoids power struggles; demonstrates acceptance of anger and permits discussion of angry feelings) Have patient direct all requests to case manager (Reduces manipulation) Help patient look at effect of illness behavior on others Show concern for patient while avoiding fostering dependency needs. reinforce patients strengths and problem solving abilities Teach assertive communication. Teach patient stress-reduction techniques, such as meditation, relaxation, and mild physical exercise.

Aging and Suicide Risk

The risk of suicide for men increases with age, particularly for white men ages 65 and older whose risk is seven times that of females of the same age. According to the National Institute of Mental Health (NIMH; 2015), 80% of all suicides in those 65 and older are white males. In 2014 the highest suicide rate (19.3%) was among people 85 years or older. The second highest rate (19.2%) occurred in those between 45 and 64 years of age (American Foundation for Suicide Prevention, 2016). Even though the known suicide rate among older adults is high, especially among white non-Hispanic males, suicide in this group is probably underreported. The Centers for Disease Control and Prevention (CDC, 2015) estimates for every one completed suicide, there are four suicide attempts in the older adult population. The numbers also do not reflect those who passively or indirectly commit suicide by abusing alcohol, starving themselves, overdosing or mixing medications, stopping life-sustaining drugs, getting into auto accidents, or simply losing the will to live. Treating depression is cost effective, saves lives, and decreases healthcare expenditures. Chapter 25 provides an in-depth discussion of suicide. Early identification of risk factors and treatment for depression are key measures for suicide prevention. Risks for suicide include: • Diagnosable psychiatric illness (psychosis, anxiety, substance use, previous suicide attempts) • Psychological alterations (personality, emotional reactivity, impulsiveness) • Stressful life events Other risk factors include access to weapons, access to large doses of medications, and chronic or terminal illness. Some protective factors include spiritual beliefs, being married, personal resilience, perception of social/family support, and having children. Selective serotonin reuptake inhibitors (SSRIs) are the first-line of treatment for depression. This category is often helpful if anxiety, worry, or rumination is problematic. If pain or diabetic neuropathy is a comorbid condition, serotonin norepinephrine reuptake inhibitors (SNRIs) are often prescribed. Treatment-resistant depression can be treated with psychostimulants such as methylphenidate. Electroconvulsive therapy is also a good alternative approach for depression, particularly in older adults who may not tolerate medication or fail to improve.

Interventions for Older Adults

The trend for patient-centered care, relationship-based care, and the patient as a participant in care may be foreign concepts to the older adult. Most have experienced medical care as "listening to the doctor" regardless of whether or not they agree. This shift in approach may need much reinforcement with the older adult who has been socialized as a passive recipient of healthcare. Certain psychotherapeutic methods are especially useful for older adults: • Providing empathetic understanding and active listening • Encouraging ventilation of feelings and normalizing emotional responses • Reestablishing emotional equilibrium when anxiety is moderate to severe • Providing health education, discussing alternative solutions, and encouraging questions • Assisting in the use of problem-solving approaches • Allowing adequate time to process information • Ensuring hearing aids are working or using an amplifier to facilitate good communication • Providing written information in large print

Prescribing Cascade

happen when drug-induced symptoms are treated with another drug. The provider may assess the side effect of the first drug as part of the original medical problem or a new one. Prescribing cascades are particularly problematic and complicated. One of the most common examples is when a person begins antiparkinson therapy for symptoms brought about by antipsychotics. Antiparkinson drugs may bring about new and dangerous symptoms such as delirium and orthostatic hypotension. Anticholinesterase inhibitor drugs used to treat dementia (e.g., donepezil, rivastigmine, and galantamine) may cause urinary incontinence and diarrhea. These symptoms may result in a prescribing cascade with use of an anticholinergic such as oxybutynin, which can cause cognitive dulling and confusion. Pharmacists have begun to play a critical role in reviewing and advising on matters of prescribing for the older adult. The American Geriatrics Society (2015) has updated the Beers List and Criteria, which was developed in 1991 to identify inappropriate medications for the older adult. Maher et al. (2014) identify how polypharmacy affects the older adult. They cite nine negative clinical consequences of inappropriate drug use: 1. Increased healthcare costs 2. Adverse drug reactions 3. Drug interactions 4. Nonadherence 5. Decline in functional status 6. Increased cognitive impairment 7. Increased falls 8. Increased urinary incontinence 9. Increased risk of malnutrition Common problems associated with medication include confusion, which can be caused by anticholinergics, antihistamines, and benzodiazepines. Psychosis has been linked to the use of levodopa, steroids, and even cholesterol-lowering medications. Depressive symptoms have been linked with alpha-adrenergics and opiates

Diffuse Boundaries

result in unclear boundaries and lack of independence. Individuals in families with diffuse boundaries may have problems defining who they are. When boundaries are diffuse, individuals tend to become overly involved with one another. This overinvolvement is referred to as enmeshment. When boundaries are diffuse, everyone, and thus no one, is in charge. It is not clear who is responsible for decisions and who has permission to act. Diffuse boundaries are particularly problematic when parent/child role enactment becomes blurry, for example, when a parent may be unemployed and one of the children takes responsibility for earning money to meet the family's basic needs. In families with diffuse boundaries, individual members are discouraged from expressing their own views. Differentiation, or the ability to possess a strong identity and sense of self while maintaining an emotional connection with the family, is also discouraged. To an outsider, it may appear that family members are extremely close, and family members may believe that they are of one mind. They may take comfort that everyone thinks the same way. "No one in our family likes seafood." That sense is typically false, and deeper analysis often results in the discovery of suppressed frustrations, anger, and passive-aggressive behaviors. Expression of separateness or independence is viewed as being disloyal to the family. Members are prone to psychological or psychosomatic symptoms, probably as a function of the individuals' inability to actually say or even to recognize how they feel. During times of change or crisis, whether the crisis is one of normal development (such as when a baby is born or an elderly grandparent dies) or one that is unanticipated (such as the loss of a pregnancy or serious debilitating injury to a family member), adaptation of both individuals and of the family as a whole is extremely difficult.

binge eating disorder

significant binge-eating episodes, followed by distress, disgust, or guilt, but without the compensatory purging, fasting, or excessive exercise that marks bulimia nervosa recurrent episodes of uncontrollable binging without compensatory behaviors binging episodes induce guilt, depression, embarrassment, or disgust

Depersonalization

the focus is on oneself. It is an extremely uncomfortable feeling of being an observer of one's own body or mental processes Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly)

Chapter 18 Key Points

• A number of theoretical models help explain the origins of eating disorders. • Neurobiological theories focus on neurotransmitters in the brain that regulate mood and hunger. • Psychological theories explore issues of control in anorexia and affective instability and poor impulse control in bulimia. • Genetic theories postulate the existence of vulnerabilities that may predispose people toward eating disorders. • Sociocultural models look at our present societal ideal of being thin. • Anorexia nervosa is a potentially life-threatening eating disorder that includes severe underweight; low blood pressure, pulse, and temperature; dehydration; and dysrhythmias. • Anorexia may be treated in an inpatient treatment setting in which milieu therapy, psychotherapy (cognitive), development of self-care skills, and psychobiological interventions can be implemented. • Long-term treatment is provided on an outpatient basis and aims to help patients maintain healthy weight. It includes treatment modalities such as individual therapy, family therapy, group therapy, psychopharmacology, and nutrition counseling. • Patients with bulimia nervosa are typically within the normal weight range, but some may be slightly below or above ideal body weight. • Assessment of the patient with bulimia nervosa may show enlargement of the parotid glands, dental erosion, and caries if the patient has induced vomiting. • Acute care may be necessary when life-threatening complications such as gastric rupture (rare), electrolyte imbalance, and cardiac dysrhythmias are present. • The goal of interventions is to interrupt the binge-purge cycle. Psychotherapy and self-care skill training are included in the treatment plan. • Therapy is the long-term treatment focus to address coexisting depression, substance abuse, and/or personality disorders that are causing the patient distress and interfering with the quality of life. Self-worth and interpersonal functioning eventually become issues that are useful for the patient to target. • Effective treatment for obese patients with binge-eating disorder includes binge abstinence, improvement of depressive symptoms, and achievement of an appropriate weight for the individual. • Patients with binge-eating disorder often have upper and lower GI problems that bring them to medical professionals for management. • Feeding disorders have multiple etiologies and are often associated with developmental delays of childhood. • Feeding disorders may result in significant nutritional deficiencies and can be fatal. Behavioral interventions to increase appropriate food consumption are the primary treatments

Chapter 16 Key Points

• Childhood trauma changes the brain and can cause medical and psychological problems in adulthood. • A phase model of treatment is most effective with safety and stabilization first. • Evidenced-based treatments for trauma are eye movement desensitization and reprocessing (EMDR) therapy and cognitive-behavioral therapy (CBT). • Understanding patients as traumatized changes the conversation from "What is wrong with this person?" to "What happened to this person?" • Trauma is stored in the body and often manifests as physical symptoms. Healing involves connection and integration. • Dissociative disorders involve a disruption in consciousness with significant impairments in memory, identity, and perception of self. • Assessment is especially important in clarifying the history of symptoms and obtaining a complete picture of the current physical, psychological, and safety status. • Psychotherapy is the treatment of choice for trauma, with medication prescribed only to ameliorate symptoms. • Patients with trauma-related disorders are often treated on an outpatient basis except during a period of crisis such as suicidal risk. • Crisis intervention is important for stabilization. Referral for psychotherapy to attain sustained improvement in level of functioning is typically necessary.

Chapter 21 Key Points

• Impulse control disorders include oppositional defiant disorder, intermittent explosive disorder, and conduct disorder. These are disorders of impulse that are seen in mental healthcare settings and in the criminal justice system. • Chaotic and punitive environments are strongly correlated with the development of these disorders. • Impulsivity and aggression in this population make the possibility of suicide attempts and other-directed violence more likely. Continual assessment of suicidal risk and other-directed violence is an essential component of care. • Nurses are often attracted to healthcare to help people who want and need their assistance. Patients with impulse control disorders may create a level of discomfort as they resist help and seem to be self-defeating and unkind. Remembering the tragic etiology of these disorders may help increase empathy and therapeutic responses. • Nursing diagnoses are focused on protection of others and self from impulsive and premeditated acts, improvement of coping skills, and development of an increased self-esteem. • The three most important interventions with this population are to promote a climate of safety for the patient and for others, establish rapport with the patient, and set limits and expectations. • Pharmacological treatments are generally aimed at co-occurring conditions such as attention deficit hyperactivity disorder. Some medications such as second-generation antipsychotics will target aggressive symptoms that accompany each of these disorders. • A variety of advanced practice interventions should be considered for this population. Most of them are evidence-based and effective. • An important concept when working with impulse control disorders is expressed emotion. To create a positive atmosphere of teamwork and safety, expressed emotion on the part of caregivers should be low to prevent emotional and behavioral reactivity.

Chapter 23 Key Points

• Neurocognitive disorder is a term that refers to disorders resulting from changes in the brain and marked by disturbances in orientation, memory, intellect, judgment, and affect. • Delirium and dementia are discussed in this chapter because they are the neurocognitive disorders most frequently seen by healthcare workers. • Delirium has an acute onset, noticeable disturbances in consciousness, and symptoms of disorientation and confusion that change by the minute, hour, or time of day. • Delirium is always secondary to an underlying condition. Therefore it is usually temporary, transient, and may last from hours to days once the underlying cause is treated. If the cause is not treated, permanent damage to the brain can result. • Dementia usually has a more insidious onset than delirium. Global deterioration of cognitive functioning (e.g., memory, judgment, ability to think abstractly, and orientation) is often progressive and irreversible, depending on the underlying cause. • All types of dementia are diagnosed as either mild or major neurocognitive disorders, differentiated by the person's functional ability. • Signs and symptoms change according to the three stages of Alzheimer's disease: stage 1 (mild), stage 2 (moderate), and stage 3 (severe). • Behavioral manifestations of Alzheimer's disease include confabulation, perseveration, agraphia, aphasia, apraxia, agnosia, hyperorality, hypermetamorphosis, and sundowning. • No known cause or cure exists for Alzheimer's disease, although a number of drugs that increase the brain's supply of acetylcholine (a nerve-communication chemical) or regulate glutamate are helpful in slowing the progression of the disease. • People with Alzheimer's disease have many unmet needs and present numerous management challenges to both their families and healthcare workers. • Specific nursing interventions for cognitively impaired individuals can increase communication, safety, and self-care. The need for family teaching and support is crucial

Chapter 35 Key Points

• Primary characteristics essential to healthy family functioning are flexibility and clear boundaries. • The aim of family therapy is to decrease emotional reactivity, enhance awareness, strengthen communication among family members, and encourage personal differentiation. • The genogram is an efficient clinical summary and format for providing information and defining relationships across at least three generations. • Registered nurses with basic training can interact and counsel families in most settings. Triangulation with patients and patients' families can be a challenge. Using direct communication and encouraging direct communication within families best address this problem. • Psychiatric-mental health advanced practice registered nurses who have specialized training may provide family therapy using a variety of theoretical approaches.

Chapter 29 Key Points

• Sexual assault is a common and often underreported crime of violence. • Females are far more likely to be victims of sexual assault and tend to know their perpetrators. Sexual assault of males tends to be underreported due to the humiliation and stigma attached to such victimization. • Psychoactive substances play a major role in sexual assault, and alcohol is the most commonly used date-rape drug. Other disinhibiting and amnestic substances play a role in forcible sex acts. • A rape survivor experiences a wide range of feelings, which may or may not be exhibited to others. • Sexual assault is often followed by feelings of fear, degradation, anger, and rage. Helplessness, anxiety, sleep disturbances, disturbed relationships, flashbacks, depression, and somatic complaints are also common. • The initial medical evaluation may be frightening and stressful. A police interview, repeated questioning by health professionals, and the physical examination itself all have the potential to add to the trauma and revictimization of the sexual assault. • Nurses can minimize repetition of questions and support the patient as she goes through the medical and legal evaluation. • Survivors require long-term healthcare that can include counseling to minimize long-term effects of the rape and assisting in an early return to a normal living pattern. • Telephone and online resources are available to assist sexual assault and rape survivors.

Chapter 20 Key Points

• Sexual dysfunction is an extremely common problem that involves a disturbance in the desire, excitement, or orgasm phases of the sexual response cycle or pain during sexual intercourse. • There are seven different disorders of sexual dysfunction. • Sexual problems have the potential to disrupt meaningful relationships. • Healthcare workers are often uncomfortable asking questions related to sexuality. Providing professional and holistic care requires that nurses include this vital area of assessment. • Certain medical and surgical conditions and some drugs result in a variety of sexual dysfunctions, including low libido, impotence, erectile dysfunction, anorgasmia, and priapism. • There are distinctions between biological sex and gender identity. Gender dysphoria is a strong and persistent cross-gender identification accompanied by anxiety, discomfort, and unhappiness. • Paraphilia is a term used to identify repetitive or preferred sexual fantasies or behaviors that involve preference for use of a nonhuman object, repetitive sexual activity with humans involving real or simulated suffering or humiliation, and repetitive sexual activity with nonconsenting partners. • Paraphilic disorders include exhibitionistic disorder, fetishistic disorder, frotteuristic disorder, pedophilic disorder, sexual masochism disorder, sexual sadism disorder, transvestic disorder, voyeuristic disorder, and paraphilic disorders not otherwise specified. • In addition to conducting a sexual assessment, nurses are involved in milieu and behavioral therapy, counseling, education, and medication management. • Nursing interventions for paraphilic disorders involve administration of medications (e.g., medroxyprogesterone [Depo-Provera] and SSRIs) and therapy. • Advanced practice nurses may specialize in the area of sexual counseling, treatment, and therapy.

Chapter 31 Key Points

• The older adult population is increasing exponentially. • The increase in the number of older adults poses a challenge not only to nurses but also to the entire healthcare system to respond to the special needs of this population. • Attitudes toward older adults are often negative, reflecting ageism—a bias against older adults based solely on age. Ageism occurs at all levels of society and even among healthcare providers, which affects the way we render care to our older patients. • Maintaining a positive regard that demonstrates respect will improve interactions with older adults. • Nurses who care for older adults in various settings may function at different levels. All should be knowledgeable about the process of aging and be aware of the differences between normal and abnormal aging changes. • The Patient Self-Determination Act established guidelines and a philosophy of care that call for patients to be free from unnecessary use of drugs and physical restraints. • The use of more than five medications doubles the risk of an adverse reaction. • Accurate pain assessment is important, and the nurse must remember that older adults tend to understate their pain. • Nurses working with older adult patients with concurrent mental health problems should be knowledgeable about psychotherapeutic approaches relevant for the older adult. • When it comes to dying and death, older adults' wishes and those of their families are frequently ignored. The implementation of the Patient Self-Determination Act, passed in 1990, allows patients autonomy and dignity in death. • A variety of treatment settings are available to older adults. The level of disability, cognitive abilities, and psychiatric disorders influence the choice of setting

Chapter 27 Key Points

• Violence in the United States is widespread. Nurses are particularly likely to come across anger, aggression, and violence if they work in the emergency room, psychiatric units, geriatric units, and intensive care units. • Understanding patient cues to escalating aggression, appropriate goals for intervention for individuals in a variety of situations, and helpful nursing interventions is important for nurses in any setting. • The expression of anger can lead to increased anger and to negative physiological changes. • Biological factors and psychological factors provide explanations for anger, aggression, and violence. • It is helpful for providers of care to know what cues to look for and what to assess verbally and nonverbally when a patient's anger is escalating. • A patient's past aggressive behavior is the most important indicator of future aggressive episodes. • Working with angry and aggressive patients is a challenge for all nurses, and a careful understanding and recognition of one's personal responses to angry or threatening patients can be crucial. • Many approaches are effective in helping patients deescalate and maintain control. • Different interventions are used, depending on the patient's coping abilities, cognitive status, and potential for violence. • Specific medications such as antipsychotics, mood stabilizers, and antianxiety medications may be useful in treating acute episodes of agitation in the long term. • Seclusion and restraints may be necessary to ensure the safety of the patient, other patients, and the staff. They should be used only when other less restrictive measures such as verbal intervention, offering as needed medication, and reducing stimuli have failed. • Each unit should have a protocol for the safe use of restraints and for the humane management of care during the time the patient is restrained and clear guidelines for understanding and protecting the patient's legal rights. • Patients who are overwhelmed, possess marginal coping skills, or have cognitive deficits require special attention to reduce and prevent episodes of anger, aggression, and violence.

The client has a court date this week for driving under the influence. The client has a history of physical abuse by a stepfather. The client has a history of narcissistic personality disorder.

An adult client is admitting to a med-surg unit with complaints of abdominal pain, dizziness, and headaches. Results of a physical workup have been negative so far. Today the client tells the nurse, "Now I am having back pain." Which of the following in the clients electronic medical record may alert the nurse to the possibility of MALINGERING?

Consent signed by the client (they have the right to refuse)

An emergency department nurse prepares to assist with evidence collection for the sexual assault. Prior to photographs and examination, what documentation is the PRIORITY?

Use the client's glasses and hearing aids

An older client in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful?

Generalizing

Members use global statements such as "always" and "never" instead of dealing with specific problems and areas of conflict. Family members may state, "Harry is always angry" instead of exploring why Harry is upset.

Patient Cues that May Indicate Concerns about Sexuality

Non-Verbal behaviors: -showing discomfort by blushing, looking away, making tight fists, fidgeting, or crying -openly engaging in overt sexual behaviors (examples: touching own body parts, masturbating, exposing genitals, placing nurses hand on genitals, making sexual suggestive sounds) Verbal behaviors: -telling sexually explicit jokes -making sexual comments about the nurse -asking........BOX 20.2

sexual dysfunction

involves the disturbance in the desire, excitement, or orgasm phases of the sexual response cycle or pain during sexual intercourse.

Delirium

is a time-limited medical condition caused by physiological changes usually due to an identifiable underlying pathology. Fluctuations in consciousness and changes in cognition develop over a short period of time (hours to days). Unfortunately, disorientation in older adults may be labeled as dementia and disregarded. It is crucial to obtain data from family or caregivers about a baseline level of functioning. A patient who is newly confused, falling, disrobing, and fighting with staff should be assessed for delirium. Asking family members questions such as "Has your mother been shopping and cooking for herself?"; "Does she pay her own bills?"; or "Does she ever get lost when driving?" may give subtle clues about whether changes are acute or have been coming on slowly. Treatment of delirium begins with identifying the cause. You may ask, "Is your father taking any new medication?" or "Has your father fallen or hit his head recently?" The delirium may be due to drug reactions or toxicity, infections, electrolyte or metabolic imbalances, anemia, thyroid dysfunction, vitamin deficiencies, stroke, and a multitude of other problems. A multidisciplinary approach is often helpful to identify causation. Pharmacists are helpful in identifying possible drug-related effects. Geriatricians provide a comprehensive approach to physical assessment. Psychiatric consultation can provide mental status evaluation and recommendations for treatment of behaviors.

Agraphia

loss of language ability

Acute Stress Disorder

may develop after exposure to a highly traumatic event such as those listed in the section on PTSD. Symptoms develop immediately after the event, but a diagnosis is not made until they have persisted for 3 days. The diagnosis must be made within a month of the trauma. After a period of a month the stress response will begin to resolve or go on to become PTSD. As with PTSD, an appropriate nursing diagnosis for a patient with ASD (NANDA, 2012) is posttrauma syndrome related to victimization as manifested by: • Alterations in concentration • Anger • Dissociative amnesia • Headache • Irritability • Nightmares The nurse's role in caring for a patient with ASD begins with establishing a therapeutic relationship with the person. Based on this relationship the nurse can help keep the person safe and monitor response to treatment. Promoting problem solving, connecting the person to supports such as family and friends, and providing education about ASD are also important interventions. Other responsibilities include coordination of care through collaboration with others and providing referrals for continued treatment. There are few studies that evaluate the efficacy of treatments for ASD. Historically, critical incident stress debriefing (CISD) has been used for those who had suffered from acute trauma. Typically debriefing occurs within 12 to 48 hours after the traumatic event and is often offered as a group intervention. Group members receive information on the facts of the event and psychological consequences of trauma and the possible ways of coping, and they exchange the details of the incident. Research on CISD has not supported its efficacy as an intervention after a traumatic event. In fact several studies have found a higher incidence of PTSD for those who received CISD

cycle of violence

pattern of behavior that perpetrators of violence may use to control their partners. This cycle consists of three stages: the tension-building stage, the acute battering stage, and the honeymoon stage

factitious disorder

onsciously pretend to be ill to get emotional needs met and attain the status of patient. The term factitious comes from the Latin word meaning "artificial or contrived." Patients with this disorder artificially, deliberately, and dramatically fabricate symptoms or self-inflict injury with the goal of assuming the sick role. Similar to substance use disorders, this problem is compulsive and individuals consciously conceal the true nature of the illness through deception. Factitious disorder results in disability and immeasurable costs to the healthcare system. The contrived illness may be physical or psychiatric. Examples of manufactured illnesses include bleeding, fever, hypoglycemia, seizures, hallucinations, and even cancer. Individuals with factitious disorder may report depression and suicidality after the death of a spouse despite the fact that the death is not true or that he was not even married (APA, 2013). An older term for factitious disorder is Munchausen syndrome, which was named for Baron Karl Friedrich Hieronymus von Münchausen (1720-1797). He was an 18th-century German officer with a reputation for fabricating outrageous tales such as traveling to the moon, riding a cannonball, or fighting a 40-foot crocodile. Clinical Picture Factitious Disorder Imposed on Self Admission to the hospital often begins in the emergency room with a dramatic description of an illness using unusually proper medical terminology. The patient is often reluctant for professionals to speak with family members, friends, or previous healthcare providers. Once admitted, the patient is frequently demanding and requests specific treatments and interventions. Negative test results are often followed by new or additional symptoms. If the healthcare team sets limits and does not follow through with requests, the patient may become angry and accuse the staff of incompetence and maltreatment. Patients go from one primary care provider or hospital to another. Serious complications and sepsis may result from self-injections of toxins such as E. coli. Patients may have "crisscrossed" or "railroad-track" abdomens due to scars from numerous exploratory surgeries to investigate unexplained symptoms. In the extreme, amputations may even result from this disorder. Factitious Disorder Imposed on Another The most insidious form of factitious disorder is factitious disorder imposed on another (also known as Munchausen syndrome by proxy) in which a caregiver deliberately falsifies illness in a vulnerable dependent. The diagnosis is imposed on the perpetrator and not the victim. People with this disorder do not do it to receive awards such as insurance money or other compensation. They do it for the purpose of the attention and excitement and to perpetuate the relationship with healthcare providers of that dependent. The parent or guardian is frequently a healthcare worker or someone with extensive knowledge of the healthcare system. The disorder results in unnecessary medical visits and sometimes-harmful medical procedures. Examples of this falsified problem include inducing premature delivery by rupturing the amniotic sac with a fingernail, infant apnea and sudden infant death, and introducing microorganisms into a child's wound. Falsification of illnesses results in extreme pain, surgical procedures, and even the death of dependents. Assessment and Diagnosis Many of the principles of care for somatic symptom disorders apply to factitious disorders. Often, determining if a patient's signs and symptoms are conscious or unconscious (i.e., whether they are a somatic disorder or a factitious disorder) is a challenge for clinicians, particularly those in the position to diagnose psychiatric disorders. Your role as a nurse, whether you work in psychiatry or any other setting, is to carefully assess the patient and document your care. A general principle in treating people with a factitious disorder is to avoid confrontation, which may result in the patient's defensiveness, elusiveness, or departure from the treatment facility. Self-Assessment Nurses who work with patients with factitious disorders— patients who intentionally and consciously fake illnesses—are often angry and resentful. After all, there are patients who really need care and have no control over how sick they are, and then there are patients with factitious disorders who are probably causing their own problems. If this happens to you, it helps to acknowledge and address these reactions through discussions with other members of the treatment team. Planning and Implementation In cases of self-directed factitious disorder and particularly other-directed factitious disorder, the nurse must consider safety. Nurses must carefully monitor patients who may purposefully inflict damage to themselves, and report suspicious activities to the healthcare team for discussion. It is essential that the nurse share any information that may prevent a person or a vulnerable and unsuspecting child from undergoing unnecessary surgery or treatments.

emotional abuse

the undermining of a persons worth

sexual assult

unwanted touching, attempt or penetration of another individuals body without explicit consent from the individual

hypermetamorphosis

urge to touch everything

Dissociative Identity Disorder (Multiple Personality Disorder)

the presence of two or more distinct personality states that recurrently take control of behavior. Each alternate personality (alter) has its own pattern of perceiving, relating to, and thinking about the self and the environment. It is believed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to the development of dissociative identity disorder. Dissociative identity disorder is associated with at least two dissociative identity states: one is a state or personality that functions on a daily basis and blocks access and responses to traumatic memories, and another state (also referred to as an alter state) is fixated on traumatic memories. Each alter is a complex unit with its own memories, behavioral patterns, and social relationships that dictate how the person acts when that personality is dominant. Often the original or primary personality is religious and moralistic, and the alters are pleasure-seeking and nonconforming. The alter personalities may behave as individuals of a different sex, race, or religion. The dominant hand and the voice may also be different; intelligence and electroencephalographic findings may also be altered. The primary personality or host is usually not aware of the alters and is perplexed by lost time and unexplained events. Experiences such as finding unfamiliar clothing in the closet, being called a different name by a stranger, or not having childhood memories are characteristic of dissociative identity disorder. Alters may be aware of the existence of each other to some degree. Transition from one personality to another (switching) occurs during times of stress and may range from a dramatic to a barely noticeable event. Some patients experience the transition when awakening. Shifts may last from minutes to months, although shorter periods are more common. Several movies and TV shows that explore case studies of individuals diagnosed with dissociative identity disorder have been produced. They include Sybil (1976), The Three Faces of Eve (1957), Fight Club (1999), Me, Myself and Irene (2000), and the television series The United States of Tara. Assessment Many patients with dissociative disorders seek help for depressive and anxiety disorders. Living with symptoms such as feeling unreal, perceiving the world as unreal, forgetting significant events, and losing track of time are obviously disturbing and depressing. Specific information about life events, memory, suicide risk, and the impact of the disorder on the patient and the family are important dimensions to assess. Life Events The nurse gathers information about events in the person's life. Has the patient sustained a recent injury such as a concussion? Does the patient have a history of epilepsy, especially temporal lobe epilepsy? Does the patient have a history of early trauma such as physical, mental, or sexual abuse? If you suspect dissociative identity disorder, ask the following questions: 1. Have you ever found yourself wearing clothes you cannot remember buying? 2. Have you ever had strange persons greet and talk to you as though they were old friends? 3. Does your ability to engage in things such as athletics, artistic activities, or mechanical tasks seem to change? 4. Do you have differing sets of memories about childhood? Memory The nurse should consider the following when assessing memory: 1. Can the patient remember recent and past events? 2. Is the patient's memory clear and complete or partial and fuzzy? 3. Is the patient aware of gaps in memory such as lack of memory for events such as a graduation or a wedding? 4. Do the patient's memories place the self with a family, in school, or in an occupation? 5. Is the patient oriented to time, place, person, and situation? 6. Does the patient ever lose time or have blackouts? 7. Does the patient ever find herself or himself in places with no idea how she or he got there? Suicide Risk Whenever a patient's life has been substantially disrupted, the patient may have thoughts of suicide. Nurses should be alert for expressions of hopelessness, helplessness, or worthlessness. Directly addressing the possibility of suicidal ideation, intent, and plans are always important interventions when working with this population. Asking questions for self-mutilating compulsions and behaviors is important, as is directly assessing for physical harm since dissociative patients may be unaware of injury. Impact on Patient and Family Dissociative disorders impair an individual's ability to relate to the world, which results in significant impairment of interpersonal relationships. Feelings of being unreal or the world being unreal negatively impact normal communication patterns and satisfaction in relationships. Patients with depersonalization/derealization disorder are often fearful that others may perceive their appearance as distorted and may avoid being seen in public. Patients with dissociative amnesia and identity disorder often have employment and family problems. Memory loss often renders them unable to work and impairs normal relationships. Employers dislike the lost time that may occur due to dissociative symptoms. Families often direct considerable attention toward the patient but may express concern over having to assume roles that were once assigned to the patient. Families find it difficult to accept the seemingly erratic behaviors of the patient. The high anxiety that accompanies dissociative disorders makes it difficult to keep relationships stable. Assessment Tools Reviewing assessment tools can help you remember the symptoms of dissociation and to understand what your patient is experiencing. Scales have been developed to assess dissociation. The Cambridge Depersonalization Scale (Sierra & Berrios, 2000) measures both depersonalization and derealization. General dissociation is assessed with the Dissociative Experience Scale (DES; Bernstein & Putnam, 1986) and the Somatoform Dissociation Questionnaire (SDQ; Nijenhuis et al., 2012). Both are available online. General Guidelines for Assessment General guidelines for assessment of a patient with a dissociative disorder include: 1. Assess for a history of self-harm. 2. Evaluate level of anxiety and signs of dissociation. 3. Identify support systems through a psychosocial assessment. 4. Refer patient to therapist. Self-Assessment It is natural to experience feelings of discomfort when working with people who lose self-awareness. You may simply be skeptical that someone could forget who they are and believe that they are being manipulative and want to leave their responsibilities behind. On the other hand, some nurses experience feelings of fascination and are caught up in the intrigue of caring for a patient with these dramatic disorders. Self-awareness, managing overly negative or positive responses, and recognizing professional boundaries are essential skills when working with this population. The overall goal for dissociative disorder is to develop an integrated and complete perception of self. Planning The setting and presenting problem influence the planning of nursing care for the patient with a dissociative disorder. However, a phase-oriented treatment model is recommended and includes the following: Phase 1: Establishing safety, stabilization, and symptom reduction. Phase 2: Confronting, working through, and integrating traumatic memories. Phase 3: Identity integration and rehabilitation. The nurse will most often encounter the patient in times of crisis (i.e., when the patient is admitted to the hospital for suicidal or homicidal behavior). The care plan will focus on Phase 1 strategies to ensure safety and crisis intervention. The patient may also come for treatment of a comorbid depression or anxiety disorder in the community setting. Planning will address the presenting complaint with appropriate referrals for treatment of the dissociative disorder. Implementation Healing trauma can be thought of as a process of integration and linking neural networks that have become disconnected during an overwhelming event. You should offer an emotional presence during the recall of painful experiences, provide a sense of safety, and encourage an optimal level of functioning. NIC topics that offer relevant interventions include anxiety reduction, coping enhancement, self-awareness enhancement, self-esteem enhancement, and emotional support Intervention: Provide undemanding, simple routine Ensure patient safety by providing safe, protected environment and frequent observation. Confirm identity of patient and orientation to time and place. Encourage patient to do things for self and make decisions about routine tasks. Assist with major decision making until memory returns. Support patient during exploration of feelings surrounding the stressful event. Do not flood patient with data regarding past events. Allow patient to progress at own pace as memory is recovered. Provide support through empathetic listening during disclosure of painful experiences. Teach patient grounding techniques such as taking a shower, deep breathing, touching fabric on chair, exercising or stomping feet. Accept patient's expression of negative feelings. Teach stress-reduction methods. If patient does not remember significant others, work with involved parties to reestablish relationships. Somatic Therapy Dissociation causes people to experience a distressing fragmentation of consciousness and a sense of separation from themselves. Disturbances of perception, sensation, autonomic regulation, and movement are common for those who have suffered significant trauma because trauma is often stored physically in the body. Verbal and bodily psychotherapies are seen as complementary by the discipline of Dance Movement Therapists in working with traumatized dissociative patients in emotional recovery (Koch & Harvey, 2012). Sensorimotor psychotherapy combines talk therapy with body-centered interventions and movement to address dissociative symptoms (Ogden et al., 2006). This therapy is based on the premise that the body, mind, emotions, and spirit are interrelated, and a change at one level results in changes in the others. Awareness, focusing on the present, and recognizing touch as a means of communicating are some of the principles of this therapy. During psychotherapy sessions, the patient describes current physical sensations. The goal is to safely disarm the pathological defense mechanism of dissociation and replace it with other resources, especially body awareness and mindfulness.

chapter 28 key points

• Abuse can occur in any family and can be predicted with some accuracy by examining the characteristics of perpetrators and vulnerable people in which violence is likely. • Abuse can be physical, sexual, emotional, economic, or can be caused by neglect. • The most common form of child abuse is neglect. • Risk factors for child abuse include being younger than 4, being a child who is somehow different, and an impairment in the emotional bond between parent and child. • Intimate partner violence tends to become progressively worse and can end in death. • A cycle of violence with tension-building, acute battering, and honeymoon stages is commonly present in cases of intimate partner violence. • Older adult abuse is far too common and is often difficult to uncover due to dependency. • Family members and custodial healthcare workers are most often implicated in abuse of older adults. • Assessment includes identifying indicators of abuse, levels of anxiety, coping mechanisms, support systems, suicide and homicide potential, and alcohol and drug misuse. • Registered nurses are legally mandated to report suspected or actual abuse in the case of children and vulnerable adults. • Community referral and support are essential in helping individuals and families with abusive situations.

Somatic Symptom Disorder Assessment Guidelines

1. Assess for nature, location, onset, characteristics, and duration of the symptoms 2. Explore past history of adverse childhood events 3. Identify symptoms of anxiety, depression, and past trauma that may be contributing to somatic symptoms and ability to meet basic physical, and safety/security needs 4. Determine current quality of life, social support, and coping skills including spirituality 5. Identify any secondary gain that the patient is experiencing from symptoms 6. Explore the patient's cognitive style and ability to communicate feelings and needs 7. Assess current psychosocial and biological needs 8. Screen for misuse of prescribed medication and substance use

window of tolerance

A term that refers to a balance between sympathetic and parasympathetic arousal.