N481 Exam 1

TRAUMA acronym (PTSD)

-Traumatic Event -Re-experience (intrusive memory/nightmare) -Avoiding things associated with the trauma; and emotional numbing -Unable to function -(1) Month at least -Arousal (intense startle response)

sedative/hypnotic/insomnia drugs

-Zolpidem -Zaleplon -Eszopiclone -first two start w/ Z (zzz) -eszopiclone (if you see a clone of yourself, you need a sedative)

working phase

-a strong patient-nurse relationship is maintained -further data is gathered -patient problem solving, self-esteem, and language-usage; behavioral-change facilitated -resistance behaviors are overcome -practice and expression of alternative adaptive behaviors are promoted -the nurse works to identify unconscious motivations and assumptions that keep patients from finding satisfaction

mild anxiety (ability to learn)

-able to work effectively toward a goal and examine alternatives

stress

-any type of change that causes physical, emotional, or psychological strain... everyone experiences it in some way, shape or form, and there are both "good" and "bad" forms (Eustress & Distress respectively)

shared planning

-appropriate for mild/moderate anxiety -may not be suitable for those experiencing severe levels of anxiety

introductory or beginning phase

-atmosphere of genuineness, empathy, positive regard, and consistency are established to build rapport between patient and nurse -the nurse's role is clarified -patient and nurse's responsibilities are defined -a contract is established to emphasize the patient's participation and responsibility -confidentiality is both discussed and assumed -termination terms are introduced -the patient articulates problems -goals are mutually agreed upon

distress

-bad stress -causes problems both emotionally (emotional distress) & physically (physiological harm) -it can cause great pain, anxiety or sorrow -acute physical or mental suffering → may have trouble eating/sleeping, experience physical aches/pains, lose interest in favorite activities, feel tense, become irritable, and often feel powerless -can be acute/long-term

controlling

-can indicate nurse is blurring boundaries -asserting authority and assuming control of patients "for their own good"

overhelping

-can indicate nurse is blurring boundaries -doing for patients what they are able to do for themselves or going beyond the wishes/needs of patients

narcissism

-can indicate nurse is blurring boundaries -needing to find weakness/helplessness/disease in pts to feel helpful at expense of recognizing/supporting pts healthier/stronger/competent features

PTSD attributes

-can occur in anyone who has experienced/witnessed severe trauma outside normal human experience -common element: feeling of helplessness/powerlessness in the face of overwhelming circumstances -can begin within a few months or later

identification

-child adopts values/principles of same-sex parent -5-year old girl dresses in mother's shoes and dress & meets father at door

four stressors

-environmental (loud noises, extreme heat/cold, or other disturbing physical conditions) -psychological/psychosocial (threats to low self-esteem, low social status, feeling disrespected/stigmatized) -spiritual (existential crisis) -socio-economic status (poverty)

introjection

-ex) after wife's death, husband has transient complaints of chest pain which is the symptom his wife had before she died

compensation

-excelling in one area to make up for shortcoming in another -ex) short man becomes assertive and excels in business

panic anxiety sxs

-experience of terror -immobility or severe hyperactivity or flight -dilated pupils -unintelligible communication or inability to speak -severe shakiness -sleeplessness -severe withdrawal -hallucinations or delusions; likely out of touch with reality

severe anxiety sxs

-feelings of dread -ineffective functioning -confusion -purposeless activity -sense of impending doom -more intense somatic complaints (dizziness, nausea, headache, sleeplessness) -hyperventilation -tachycardia -withdrawal -loud and rapid speech -threats and demands

nurse's role in nurse-patient relationship

-focus on the patient's problem and needs and not your own -facilitate communication of distressing thoughts and feelings -assist pts w/ problem solving to help facilitate ADLs -help pts examine self-defeating behaviors & test alternatives -promote self-care & independence

termination phase

-goals and objectives from the relationship are summarized -new coping strategies are discussed -situations from the nurse and patients' interactions are discussed; memories are exchanged to facilitate closure of the relationship -the patient potentially expresses feelings and emotions regarding termination of the relationship -the nurse may demonstrate caring for the patient -the patient's plans for the future may be considered

eustress

-good stress -normal, beneficial -motivates ppl to develop the skills they need to problem solve and meet personal goals

severe anxiety (perceptual field)

-greatly reduced and distorted perceptual field -focuses on details or one specific detail -attention is scattered -nearly all behavior is directed at reducing the anxiety -an example of this is your response to your car skidding on wet pavement

humor

-healthy defense mechanism -an individual may deal with emotional conflicts or stressors by emphasizing the amusing or ironic aspects of the conflict or stressor through ___________

suppression

-healthy defense mechanism -conscious denial of a disturbing situation or feeling -ex) "I can't worry about paying my rent until after my exam tomorrow."

altruism

-healthy defense mechanism -pt receives gratification either vicariously or from the response of others -ex) say you lost your dad, then you attend grief counseling sessions with others who have lost loved ones. you obtain satisfaction/pleasure from helping others work through their pain

sublimation

-healthy defense mechanism -unconscious process of substituting constructive/socially acceptable activity for strong impulses that are not usually considered acceptable -ex) Regina George and lacrosse

mild anxiety (perceptual field)

-heightened perceptual field -focus is flexible and is aware of the anxiety -stimuli in the environment are perceived and understood, and learning can easily take place

Ramelteon

-hypnotic drug; sleep aid -acts in same way as endogenous melatonin -high selectivity at melatonin-1 receptor site (thought to regulate sleepiness) and melatonin-2 site (thought to regulate circadian rhythms)

acting-out behaviors

-immature defense mechanism -addresses emotional conflicts or stressors by actions rather than by reflections or feelings -ex) tearing apart files in the office after not getting a promotion

idealization

-immature defense mechanism -attributing exaggerated positive qualities to others, only to be let down when you realize they're human & make mistakes -the disappointment leads to lowered self-esteem and hate towards that person

dissociation

-immature defense mechanism -disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment (usually only seen with severe stressors ex) not remembering a traumatic event

devaluation

-immature defense mechanism -emotional conflicts or stressors are handled by attributing negative qualities to self or others -ex) woman is jealous and says "oh, Kathy won that award? well it doesn't mean anything anyways." minimizes other woman's accomplishment

denial

-immature defense mechanism -escaping unpleasant realities by ignoring their existence -ex) "no, I don't believe my wife is dead. the doctor said she was fine."

splitting

-immature defense mechanism -inability to integrate (+) and (-) qualities of oneself or others into cohesive image -prevalent in people with personality disorders -ex) Alice thinks her therapist is so nice, but when she doesn't write an rx for valium Alice says she's the worst therapist ever

passive aggression

-immature defense mechanism -indirectly and unassertively expressing aggression towards others -ex) wife is mad at husband and "accidentally" burns his dinner

projection

-immature defense mechanism -unconsciously rejecting one's emotionally unacceptable personality features & attributes them to other ppl, objects or situations -ex) a man who is unconsciously attracted to other women teases wife about flirting

SNRIs

-inhibit/block the reuptake of serotonin and NE; making it stay longer in synapse and available for use -used for anxiety AND neuropathic pain

SSRIs

-inhibit/block the reuptake of serotonin making it stay longer in the synapse and available for use -treats panic disorders, GAD, OCD, PTSD & social phobia

repression

-intermediate defense mechanism -exclusion of unpleasant/unwanted experiences, emotions, or ideas from conscious awareness -considered the cornerstone of defense mechanisms; it is first line of psych defense against anxiety -ex) forgetting name of former boyfriend; forgetting an apt to discuss poor grades

rationalization

-intermediate defense mechanism -justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations for the behavior -ex) everyone cheats, so why shouldn't I?

somatization

-intermediate defense mechanism -occurs when repressed anxiety is demonstrated in the form of physical sxs that have no organic cause -can be an unconscious way of avoiding a situation that is anxiety provoking or an indirect way to communicate need for help in a socially acceptable manner -ex) it is considered "acceptable" to ask for help when you're "physically" sick -ex) cancelling on a date saying you are not feeling well but you're fine

undoing

-intermediate defense mechanism -performing an action to make-up for previous behavior -ex) giving a gift to "undo" an argument -ex) compulsive handwashing

displacement

-intermediate defense mechanism -transfer of emotions associated w/ a specific person, object or situation to another person, object or situation that is nonthreatening -common but not always adaptive -spousal/child/elder abuse are extreme cases of displaced hostility -ex) the boss yells at man, man yells at wife, wife yells at kid, kid kicks cat

reaction formation

-intermediate defense mechanism -unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior/emotion -ex) a person who harbors hostility toward children becomes a boy scout leader

secondary crisis intervention

-interventions to prevent prolonged anxiety -primary focus is to ensure safety

moderate anxiety (perceptual field)

-narrowed perceptual field -grasps less of what is going on but can still hear, see & understand -focuses on source of anxiety; less able to pay attention -felt as a heightened sense of awareness, such as when you are about to take an exam -learning can still take place, although it may require more direction

panic anxiety (ability to learn)

-no learning takes place -may be mute or have extreme psychomotor agitation leading to exhaustion -shows disorganized or irrational reasoning

care of pts' in crisis

-nurses typically only encounter pts' w/ dissociative disorders when they're experiencing a crisis -usually self-harm, SI/HI -w/ these patients specifically, care/interventions will FOCUS ON SAFETY -trust is a central issue in all DDs (esp. DIDs) d/t etiology of trauma/abuse -goal: facilitate return to pre-crisis/optimal levels functioning -nurse should assess pt's perception of the events and assess support & coping skills -3 interventions: primary, secondary, tertiary

phases of nurse-patient relationship

-pre-orientation phase -introductory or beginning phase -working phase -termination phase

benzodiazepines

-previously one of the most common anxiety med class, but d/t tolerance, abuse, and recent connections w/ dementia, they're losing favor -MOA: binds to GABA -antiseizure d/t reduced neuronal excitement -short term use -CNS depressant -can be sedating; may interfere w/ motor ability & judgement

tertiary crisis intervention

-provides support for those who have experienced a crisis and are recovering

regression

-psychoanalytic defense mechanisms where individual faced w/ anxiety retreats to a more infantile psychosexual stage, where some psychic energy remains fixated -ex) a four year old boy w/ new baby brother starts sucking his thumb and wants a bottle

anxiety

-psychological experience that may, or may not be associated with an identifiable stressor that causes feelings of apprehension, uneasiness, dread or uncertainty from a real, or perceived threat -it is normal; it occurs as a rxn to a stressful event, or difficult time -"fight or flight" response --> helps our body adapt, adjust to and overcome stress -caused by complex interaction of biological (genetic vulnerability), psychological and environmental factors -no one size fits all reason for why __________ disorders manifest in ppl

countertransference

-refers to the tendency of the nurse to displace onto the patient feelings related to people in his/her past. frequently, the pt's transference to the nurse evokes countertransference feelings in the nurse -if this happens, acknowledge the situation internally and ensure the pt of their autonomy and goals

sedative/hypnotics/insomnia

-sedative medication; no anxiety/anticonvulsant/muscle-relaxant effects -MOA: binds to GABA -SE: dizziness w/ impaired motor activity, sedation, possibility of amnesia, abnormal thinking -short term use -risk of complex behaviors after taking (sleep driving, cooking, walking, talking, etc.) -rapid onset of action (take and go to bed ASAP)

SHIVERS

-serotonin syndrome symptoms -Shivering -Hyperreflexia -Increased temp -Vital sign changes -Encephalopathy -Restlessness -Sweating

severe/panic levels of anxiety

-severe and panic levels prevent problem solving and discovery of effective solutions -unproductive relief behaviors are implemented, thus perpetuating a vicious cycle

communication skills during a clinical interview

-silence -active listening -clarifying techniques -provide structure -open-ended questions (esp. to start an interview) -avoid leading questions -help pts elaborate -reflect your pts' feelings back to them -paraphrase the pts' thoughts -summarize what pt has said -no "why" questions

mild anxiety sxs

-slight discomfort -restlessnessIrritability or impatience -mild tension-relieving -behavior: foot or finger tapping, lip chewing, fidgeting

cognitive processing therapy (CPT)

-teaches evaluating/changing upsetting thoughts experienced since the trauma occurred -changing thoughts can change how you feel

prolonged exposure (PE) therapy

-teaches pt to gradually confront trauma (memories/feelings/situations) that have been avoided -confronting decreases sxs

moderate anxiety (ability to learn)

-the ability to think clearly is somewhat hampered, but learning and problem solving can still take place, just not at optimal ability -benefits from guidance of others

pre-orientation phase

-the nurse identifies their concerns about working w/ patients -nurse discusses possible responses to patients w/ peers and nurses -ground rules for safety are set

transference phenomenon

-the process whereby a person unconsciously and inappropriately displaces (transfers) patterns of behaviors & emotional reactions toward another person that originated in relation to significant figures in childhood -ex) pt may say, "you remind me of my... (brother, sister, mother, etc.)"

care of pts' in trauma

-those who've experienced trauma are at an increased risk of suicide, so you must assess pt for SI -evaluate SUD and withdrawal from substances (both can be life threatening) -ensure traumatizing event is not currently a risk -psychotherapy and psychopharmacology are used together to tx trauma and other often co-occuring conditions -first line tx: PSYCHOTHERAPY

Buspirone

-treats anxiety w/o causing immediate sedative & mildly euphoric effects of benzos -MOA: largely unknown -high affinity for serotonin -delayed onset -non-habit forming -SE: dizzy, nausea, HA, insomnia, nervousness

how to respond to a transference phenomenon

-turn the conversation into whoever/whatever the person/thing that is being reminded of -ex) "tell me about one person who is cold and unfeeling toward you" if you remind them of someone cold

3 kinds of anxiety

-typical -acute -chronic

panic anxiety (perceptual field)

-unable to attend to the environment -focus is lost; may feel unreal (depersonalization) or that the world is unreal (derealization) -overwhelming and results in either paralysis or dangerous hyperactivity -individual cannot communicate, function, or follow directions

severe anxiety (ability to learn)

-unable to see connections between events or details -has distorted perceptions -learning and problem solving are significantly affected at this level

moderate anxiety sxs

-voice tremors -change in voice pitch -difficulty concentrating -shakiness -repetitive questioningS -somatic complaints (urinary frequency and urgency, headache, backache, insomnia) -increased respiration rate -increased pulse rate -increased muscle tension -moderate tension-relieving behavior: pacing, banging hands on table

blurring examples

-when the relationship slips into a social context -when the nurse's needs are met at the expense of the patient's needs

PTSD risk factors

-young age -female gender -lower education level -prior trauma exposure -prior mental illness/ substances use disorder -extra stress after event -limited or no support -level of trauma

care for patient's with PTSD

Trauma-Informed Care: --Awareness of prevalence of trauma --Understanding impact of trauma on health --How trauma can impact behaviors around seeking treatment --Understanding that current service systems can potentially retraumatize individuals --Assessment --Safety --Other mental illness --Current problematic symptoms

care of patients experiencing GAD

WORRY Nursing interventions - Depend on level of anxiety the patient is experiencing - Mild to moderate: able to problem-solve - Severe to panic: unable to solve problems - Try to notice signs when the patient is in level 1 or 2

conversion

a student is unable to take final exam b/c of terrible headache

best evidence available

base all interventions on the...

nursing diagnoses

focus of care based on the presenting symptoms

planning and implementation

it is important to encourage individuals to participate in planning their care sharing the decision making (patient-centered care) ← better outcomes

mild/moderate levels of anxiety

mild and moderate levels of anxiety can alert the person that something is wrong and can stimulate appropriate action

primary crisis intervention

promotes mental health to decrease incidence of crisis

outcomes identification

short-/long-term outcomes for specific anxiety disorders

suicidal or self-harming

those with anxiety and OCD rarely need hospitalization, unless they are...

severe/panic anxiety nursing interventions

- DO NOT LEAVE PT ALONE!! - Important to consider physical needs such as food, fluids & rest to prevent exhaustion/other physical complications - Ways the nurse can help reduce the anxiety: - Moving person to quiet environment with reduced stimulation - Encourage gross motor activities i.e., pacing - Use of meds may be considered - Only use restraints when ABSOLUTELY necessary ← used for prevention of either danger or harm (to self or others) - ONLY used when all, less restrictive interventions have failed - Help the patient feel understood ← can decrease sense of isolation and can help reduce anxiety - Modified communication may be required, firm, short, and simple statements better understood by pt., Aka be direct - Speaking more slowly, waiting longer for responses, and repeating comments will facilitate pt. ability to comprehend

nursing interventions for trauma pts

- Intrusive symptoms (flashbacks/nightmares): Stay with the patient (don't leave them alone!) and offer reassurance & emotional safety - Nurses help the pt. to recognize avoidance behaviors and develop strategies to increase social supports ← psychoeducation useful for helping S/O provide support - Negative cognitions: Lead to survivor's guilt, depression, & anxiety. ← ↑ risk of suicide, self-harm, & other maladaptive coping. Nurses able to provide therapeutic relationship to share concerns & promote adaptive coping - Alterations in Arousal: May cause sleep disturbances, & destructive behaviors (angry out-burst, reckless behaviors). ← provide pharma & nonpharma interventions to facilitate sleep & help person find adaptive ways to ↓ destructive behaviors - Stress Reduction techniques: - Relaxation (meditation, prayer, mindfulness & deep breathing) - Physical activity ← Relieve muscle tension, & elevate endorphin levels. Induces a sense of well-being. Recommendation: Aerobic 30-60 min x3-4 p/week - Social Support via family/friends ← social interactions provide buffers against stress & improve coping with stressful events

anxiety assessment

- ensure a physical and neuro exam is done to rule out whether the anxiety is primary or secondary another problem - Assess for SI/HI - Psychosocial Assessment, ask "what has happened recently that might be increasing your anxiety?" - Assess cultural beliefs and background (anxiety can manifest differently in different cultures)

care of patients with OCD

- establishing nurse-patient relationship - providing support - milieu therapy - promotion of self-care activities - health teaching - limits, do not interrupt compulsive acts - teach client to use alternate coping mechanisms to decrease anxiety - client's behavior may be frustrating to staff and family, power struggles often result, consistency to approach to care is critical - assess the client's needs carefully - provide an environment that has structure and predictability as a strategy to decrease anxiety -CONSISTENT/CONGRUENT CARE: ex-- if the nurse on day shift cut the hand-washing to 30 minutes instead of 60, make sure the night nurse knows this and follows/implements the 30 minutes as well.

mild/moderate anxiety nursing interventions

- help the patient focus ← use active listening communication techniques - Use broad openings, exploring, reflecting & clarifying - Remember: restrict topics of communication & introducing irrelevant topics can increase a person's anxiety - Establish a therapeutic relationship - self-awareness of verbal/non-verbal relief behaviors - Identification of possible solutions ← ask about past coping mechanisms/skills pt. has seen others use - Introduce new coping strategies/activities - Support pt. carrying out new plan/evaluation of effectiveness of the plan

care of patients experiencing panic

- maintain calmer demeanor - always remain with the person - minimize environmental stimuli - use clear and simple statements, repeat if needed - use low pitched, slow speech - reinforce reality if distortions occur - listen for themes in communication - Attend to physical and safety needs - set limits for violence/safety is a goal - provide opportunities for movement (walks) - high calorie fluids if pacing - assess need for meds Key characteristic: panic attacks Anticipatory anxiety

5 components of active listening

- observing patient's nonverbal behaviors - listening to and understanding patient's verbal message - listening to and understanding the person in the context of the social and cultural setting of his/her life - listening for "false notes" (i.e. inconsistencies/something that needs clarification) - providing patient with feedback about themself of which the patient might be unaware

trauma medications (psychopharmacology)

-2 FDA approved drugs: --Sertraline (SSRI) --Paroxetine (SSRI) -other drugs include SSRI/SNRI, medical marijuana, antipsychotics, anticonvulsants, anxiolytics, antiadrenergic, prazosin -benzos NOT recommended (ineffective/harmful)

SSRI drugs

-Citalopram -Escitalopram -Fluoxetine -Fluvoxamine -Paroxetine -Sertraline -CEFFPS: when you're on SSRIs, you Can't Even Feel F*ckin Pissed Son

SNRI drugs

-Duloxetine -Venlafaxine -Desvenlafaxine -DVD: if you're anxious or feeling neuropathic pain, stay home and put in a DVD!

3 groups RN can lead/general RN role

-Education groups (med ed, dual-diagnosis, symptom mgmt, stress mgmt, self-care) -Talk groups -Support groups --Nurses role as the group leader is to start, maintain, and terminate a group

SSRI & SNRI side effects

-GI upset (serotonin is in the GI system) -nausea -HA -initial anxiety -sexual dysfunction -difficulty sleeping

benzodiazepine drugs

-Lorazepam -Clonazepam -Alprazolam -end w/ pam & lam

Prazosin

-MOA: blocks a1 adrenergic receptors to reduce hyperactivation -reduces severity & frequency of nightmares d/t PTSD -SE: dizzy, lightheaded, HA, blurred vision, fatigue -monitor for hypotension

serotonin syndrome

-SSRI/SNRI black box warning -potentially life-threatening d/t the buildup of too much serotonin -symptoms: SHIVERS

social anxiety

-Stems from fear of being evaluated, and/or rejected by others (fear of public speaking most common) - Propranolol (beta-blocker)- reduces the physiological symptoms of anxiety, not the cognitive worry symptoms - Used successfully by many performers/lecturers before appearing in front of an audience - More pervasive social anxiety therapy may better respond to antidepressant therapy such as SSRIs - CBT along with social skills training also helpful for many

therapeutic milieu's relation to group therapy

Orienting new members - Encouraging patients to engage in the treatment - Evaluating the treatment program - Increase patients' self-esteem - Decrease social isolation - Encourage appropriate social behaviors - Educate patients in basic living skills