Psychiatric Mental Health Nursing (Exam 4)

Discuss the symptoms of substance abuse

Drowsiness, slurred speech, lack of coordination, irritability, problems concentrating, memory problems, involuntary eye movements lack of inhibition

Typical course of substance abuse using alcohol as the example

Alcohol Intoxication and Overdose Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream. Initially, the effects are relaxation and loss of inhibitions. With intoxication, there is slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judgment. Some people become aggressive or display inappropriate sexual behavior when intoxicated. The person who is intoxicated may experience a blackout. An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression. This combination can cause aspiration pneumonia or pulmonary obstruction. Alcohol-induced hypotension can lead to cardiovascular shock and death. Treatment of an alcohol overdose is similar to that for any central nervous system depressant—gastric lavage or dialysis to remove the drug, and support of respiratory and cardiovascular functioning in an intensive care unit. The administration of central nervous system stimulants is contraindicated (Burchum & Rosenthal, 2018). The physiological effects of repeated intoxication and long-term use are listed in Box 19.1. Withdrawal and Detoxification Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremens. Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however; and withdrawal may take 1 to 2 weeks. Because alcohol withdrawal can be life-threatening, detoxification needs to be accomplished under medical supervision. If the client's withdrawal symptoms are mild and he or she can abstain from alcohol, he or she can be treated safely at home. For more severe withdrawal or for clients who cannot abstain during detoxification, a short admission of 3 to 5 days is the most common setting. Some psychiatric units also admit clients for detoxification, but this is less common. Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms. Withdrawal can be accomplished by fixed-schedule dosing known as tapering, or symptom-triggered dosing in which the presence and severity of withdrawal symptoms determine the amount of medication needed and the frequency of administration. Often, the protocol used is based on an assessment tool such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, shown in Box 19.2. Total scores less than 8 indicate mild withdrawal, scores from 8 to 15 indicate moderate withdrawal (marked arousal), and scores greater than 15 indicate severe withdrawal. Clients on symptom-triggered dosing receive medication based on scores of this scale alone, while clients on fixed-dose tapers can also receive additional doses depending on the level of scores from this scale. Both methods of medicating clients are safe and effective.

Define "psychosomatic illness" in terms of psychosomatic being the connection between the mind (psyche) and the body (soma) in states of health and illness

Essentially, the mind can cause the body to create physical symptoms or to worsen physical illnesses. Real symptoms can begin, continue, or be worsened as a result of emotional factors.

Explain that delirium is usually resolved by treating the underlying medical condition whereas no treatments have been found to reverse dementias; current therapies only temporarily slow the progress.

Delirium: Treatment and Prognosis The primary treatment for delirium is to identify and treat any causal or contributing medical conditions. Delirium is almost always a transient condition that clears with successful treatment of the underlying cause. Nevertheless, some causes such as head injury or encephalitis may leave clients with cognitive, behavioral, or emotional impairments even after the underlying cause resolves. People who have had delirium are at higher risk for future episodes. Psychopharmacology Clients with quiet, hypoactive delirium need no specific pharmacologic treatment aside from that indicated for the causative condition. Many clients with delirium, however, show persistent or intermittent psychomotor agitation, psychosis, and/or insomnia that can interfere with effective treatment or pose a risk to safety. Sedation to prevent inadvertent self-injury may be indicated. An antipsychotic medication, such as haloperidol (Haldol), may be used in doses of 0.5 to 1 mg to decrease agitation and psychotic symptoms, as well as to facilitate sleep. Haloperidol is useful in a variety of situations because it can be administered orally, intramuscularly (IM), or intravenously (IV). Historically, short- or intermediate-acting benzodiazepines, such as lorazepam (Ativan), have been used, but benzodiazepines may worsen delirium, especially in the elderly. Their use should be reserved for treatment of sedative-hypnotic withdrawal (Fabian & Solai, 2017). Clients with impaired liver or kidney function could have difficulty metabolizing or excreting sedatives. The exception is delirium induced by alcohol withdrawal, which is usually treated with benzodiazepines (see Chapter 19). Other Medical Treatment While the underlying causes of delirium are being treated, clients may also need other supportive physical measures. Adequate nutritious food and fluid intake speed recovery. IV fluids or even total parenteral nutrition may be necessary if a client's physical condition has deteriorated and he or she cannot eat and drink. If a client becomes agitated and threatens to dislodge IV tubing or catheters, physical restraints may be necessary so that needed medical treatments can continue. Restraints are used only when necessary and stay in place no longer than warranted because they may increase the client's agitation. Dementia: Treatment and Prognosis Whenever possible, the underlying cause of dementia is identified so that treatment can be instituted. For example, the progress of vascular dementia, the second most common type, may be halted with appropriate treatment of the underlying vascular exercise, control of hypertension, or diabetes). Improvement of cerebral blood flow may arrest the progress of vascular dementia in some people. The prognosis for the progressive types of dementia may vary as described earlier, but all prognoses involve progressive deterioration of physical and mental abilities until death. Typically, in the later stages, clients have minimal cognitive and motor function, are totally dependent on caregivers, and are unaware of their surroundings or people in the environment. They may be totally uncommunicative or make unintelligible sounds or attempts to verbalize. For degenerative dementias, no direct therapies have been found to reverse or retard the fundamental pathophysiological processes. Levels of numerous neurotransmitters such as acetylcholine, dopamine, norepinephrine, and serotonin are decreased in dementia. This has led to attempts at replenishment therapy with acetylcholine precursors, cholinergic agonists, and cholinesterase inhibitors. Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl, Razadyne, Nivalin) are cholinesterase inhibitors and have shown modest therapeutic effects and temporarily slow the progress of dementia (Table 24.2). They have no effect, however, on the overall course of the disease. Tacrine (Cognex) is also a cholinesterase inhibitor; however, it elevates liver enzymes in about 50% of clients using it. Lab tests to assess liver function are necessary every 1 to 2 weeks; therefore, tacrine is rarely prescribed. Memantine (Namenda) is an NMDA receptor antagonist that can slow the progression of Alzheimer in the moderate or severe stages. Namzaric (memantine and donepezil) is a newer combination of two other medications, thereby having the actions of both cholinesterase inhibition and NMDA receptor antagonist

intoxication

Intoxication is use of a substance that results in maladaptive behavior.

Address the pattern of events, such as blackout, tolerance, tolerance break, and the later course; describe spontaneous remission.

Much research on substance use has focused on alcohol because it is legal and more widely used; thus, more is known about alcohol's effects. The prognosis for alcohol p. 356 p. 357 use in general is unclear because only people seeking treatment for problems with alcohol are usually studied. In the United States, the average age for an initial alcohol intoxication episode is during adolescent years (Schuckit, 2017). However, the early course of alcoholism typically begins much earlier, with the first episode of intoxication between the ages of 12 and 14 years; the first evidence of minor alcohol-related problems is seen in the late teens. Episodes of "sipping" alcohol may occur as early as 8 years (Sartor et al., 2016). A pattern of more severe difficulties for people with alcoholism begins to emerge in the mid-20s to the mid-30s; these difficulties can be the alcohol-related breakup of a significant relationship, an arrest for public intoxication or driving while intoxicated, evidence of alcohol withdrawal, early alcohol-related health problems, or significant interference with functioning at work or school. During this time, the person experiences his or her first blackout, which is an episode during which the person continues to function but has no conscious awareness of his or her behavior at the time or any later memory of the behavior. As the person continues to drink, he or she often develops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect. After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol intoxicate the person. The later course of alcoholism, when the person's functioning is definitely affected, is often characterized by periods of abstinence or temporarily controlled drinking. Abstinence may occur after some legal, social, or interpersonal crisis, and the person may then set up rules about drinking, such as drinking only at certain times or drinking only beer. This period of temporarily controlled drinking soon leads to an escalation of alcohol intake, more problems, and a subsequent crisis. The cycle repeats continuously. For many people, substance use is a chronic illness characterized by remissions and relapses to former levels of use. Relapse rates range from 60% to 90%, with nearly half of individuals relapsing in the year after treatment (Thompson et al., 2018). A minority of people remain sober after the first treatment experience. The highest rates for successful recovery are for people who abstain from substances, are highly motivated to have a substance-free lifestyle, and who actively work on relapse prevention. Reports exist that some people with alcohol-related problems can modify or quit drinking on their own without a treatment program; this is called spontaneous remission or natural recovery. Although there is a dearth of recent scientific literature, anecdotal reports state that the abstinence was often in response to a crisis or a promise to a loved one and was accomplished by engaging in alternative activities, relying on relationships with family and friends, and avoiding alcohol, alcohol users, and social cues associated with drinking. Poor outcomes have been associated with an earlier age at onset, longer periods of substance use, and the coexistence of a major psychiatric illness. With extended use, the risk for mental and physical deterioration and infectious disease such as HIV and AIDS, hepatitis, and tuberculosis increases, especially for those with a history of intravenous (IV) drug use. An increased number of alcohol-dependent people commit suicide.

Opioids

Opioids Opioids are popular drugs of abuse because they desensitize the user to both physiological and psychological pain and induce a sense of euphoria and well-being. Opioid compounds include both potent prescription analgesics such as morphine, meperidine (Demerol), codeine, hydromorphone, oxycodone, methadone, oxymorphone, hydrocodone, and propoxyphene as well as illegal substances such as heroin, illicitly produced fentanyl, and normethadone. Fentanyl (Duragesic, Actiq) is a synthetic opioid used in clinical settings for anesthesia. It is 50 to 100 times more potent than morphine. Illicitly produced fentanyl use has skyrocketed in the past decade and is thought to be responsible for the dramatic increase in deaths from opioid overdose. People who abuse opioids spend a great deal of their time obtaining the drugs; they often engage in illegal activity to get money to purchase them. Health care professionals who abuse opioids often write prescriptions for themselves or divert prescribed pain medication for clients to themselves. Intoxication and Overdose Opioid intoxication develops soon after the initial euphoric feeling; symptoms include apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory. Severe intoxication or opioid overdose can lead to coma, respiratory depression, pupillary constriction, unconsciousness, and death. Administration of naloxone (Narcan), an opioid antagonist, is the treatment of choice because it reverses all signs of opioid toxicity. Naloxone is given every few hours until the opioid level drops to nontoxic; this process may take days (Burchum & Rosenthal, 2018). Opioid overdoses have increased dramatically in the United States; many first responders now carry naloxone in autoinjector form (Evzio). Withdrawal and Detoxification Opioid withdrawal develops when drug intake ceases or decreases markedly, or it can be precipitated by the administration of an opioid antagonist. Initial symptoms areanxiety, restlessness, aching back and legs, and cravings for more opioids. Symptoms that develop as withdrawal progresses include nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia. Symptoms of opioid withdrawal cause significant distress, but do not require pharmacologic intervention to support life or bodily functions. Short-acting drugs such as heroin produce withdrawal symptoms in 6 to 24 hours; the symptoms peak in 2 to 3 days and gradually subside in 5 to 7 days. Longer acting substances such as methadone may not produce significant withdrawal symptoms for 2 to 4 days, and the symptoms may take 2 weeks to subside. Methadone can be used as a replacement for opioids, and the dosage is then decreased over 2 weeks. Substitution of methadone during detoxification reduces symptoms to no worse than a mild case of flu (Burchum & Rosenthal, 2018). Withdrawal symptoms such as anxiety, insomnia, dysphoria, anhedonia, and drug craving may persist for weeks or months. **Opioid overdose can severely decrease respirations, eventually leading to death if left untreated

Discuss ASD-related disorders

Related Disorders Tic Disorders A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. Tics can be suppressed but not indefinitely. Stress exacerbates tics, which diminish during sleep and when the person is engaged in an absorbing activity. Common simple motor tics include blinking, jerking the neck, shrugging the shoulders, grimacing, and coughing. Common simple vocal tics include clearing the throat, grunting, sniffing, snorting, and barking. Complex vocal tics include repeating words or phrases out of context, coprolalia (use of socially unacceptable words, frequently obscene), palilalia (repeating one's own sounds or words), and echolalia (repeating the last-heard sound, word, or phrase). Complex motor tics include facial gestures, jumping, or touching or smelling an object. Tic disorders tend to run in families. Abnormal transmission of the neurotransmitter dopamine is thought to play a part in tic disorders. Tic disorders are usually treated with risperidone (Risperdal) or olanzapine (Zyprexa), which are atypical antipsychotics. It is important for clients with tic disorders to get plenty of rest and to manage stress because fatigue and stress increase symptoms . Tourette disorder involves multiple motor tics and one or more vocal tics, which occur many times a day for more than 1 year. The complexity and severity of the tics change over time, and the person experiences almost all the possible tics described previously during his or her lifetime. The person has significant impairment in academic, social, or occupational areas and feels ashamed and self-conscious. This rare disorder (4 or 5 in 10,000) is more common in boys and is usually identified by 7 years of age. Some people have lifelong problems; others have no symptoms after early adulthood (Jummani & Coffey, 2017). Chronic Motor or Tic Disorder Chronic motor or vocal tic differs from Tourette disorder in that either the motor or the vocal tic is seen, but not both. Transient tic disorder may involve single or multiple vocal or motor tics, but the occurrences last no longer than 12 months. Learning Disorders A specific learning disorder is diagnosed when a child's achievement in reading, mathematics, or written expression is below that expected for age, formal education, and intelligence. Learning problems interfere with academic achievement and life activities requiring reading, math, or writing. Reading and written expression disorders are usually identified in the first grade; math disorder may go undetected until the child reaches fifth grade. Approximately 5% of children in U.S. public schools are diagnosed with a learning disorder. The school dropout rate for students with learning disorders is 1.5 times higher than the average rate for all students (Tannock, 2017). Low self-esteem and poor social skills are common in children with learning disorders. As adults, some have problems with employment or social adjustment; others have minimal difficulties. Early identification of the learning disorder, effective intervention, and no coexisting problems is associated with better outcomes. Children with learning disorders are assisted with academic achievement through special education classes in public schools. Motor Skills Disorder The essential feature of developmental coordination disorder is impaired coordination severe enough to interfere with academic achievement or activities of daily living. This diagnosis is not made if the problem with motor coordination is part of a general medical condition, such as cerebral palsy or muscular dystrophy. This disorder becomes evident as a child attempts to crawl or walk or as an older child tries to dress independently or manipulate toys such as building blocks. Developmental coordination disorder often coexists with a communication disorder. Its course is variable; sometimes lack of coordination persists into adulthood. Schools provide adaptive physical education and sensory integration programs to treat motor skills disorder. Adaptive physical education programs emphasize inclusion of movement games such as kicking a football or soccer ball. Sensory integration programs are specific physical therapies prescribed to target improvement in areas where the child has difficulties. For example, a child with tactile defensiveness (discomfort at being touched by another person) might be involved in touching and rubbing skin surfaces (Patacki & Mitchell, 2017). Stereotypic movement disorder is characterized by rhythmic, repetitive behaviors, such as hand waving, rocking, head banging, and biting, that appears to have no purpose. Self-inflicted injuries are common, and the pain is not a deterrent to the behavior. Onset is prior to age 3 years and usually persists into adolescence. It is more common in individuals with intellectual disability. Comorbid disorders, such as anxiety, ADHD, OCD, and tics/Tourette syndrome, are common and often cause more functional impairment than the stereotypic behavior (Doyle, 2017). Communication Disorders A communication disorder involves deficits in language, speech, and communication and is diagnosed when deficits are sufficient to hinder development, academic achievement, or activities of daily living, including socialization. Language disorder involves deficit(s) in language production or comprehension, causing limited vocabulary and an inability to form sentences or have a conversation. Speech sound disorder is difficulty or inability to produce intelligible speech, which precludes effective verbal communication. Stuttering is a disturbance of fluency and patterning of speech with sound and syllable repetitions. Social communication disorder involves the inability to observe social "rules" of conversation, deficits in applying context to conversation, inability to tell a story in an understandable manner, and inability to take turns talking and listening with another (Koyama & Beitchman, 2017). Communication disorders may be mild to severe. Difficulties that persist into adulthood are related most closely to the severity of the disorder. Speech and language therapists work with children who have communication disorders to improve their communication skills and to teach parents to continue speech therapy activities at home. Elimination Disorders Encopresis is the repeated passage of feces into inappropriate places such as clothing or the floor by a child who is at least 4 years of age either chronologically or developmentally. It is often involuntary, but it can be intentional. Involuntary encopresis is usually associated with constipation that occurs for psychological, not medical, reasons. Intentional encopresis is often associated with oppositional defiant disorder (ODD) or conduct disorder. Enuresis is the repeated voiding of urine during the day or at night into clothing or bed by a child at least 5 years of age either chronologically or developmentally. Most often, enuresis is involuntary; when intentional, it is associated with a disruptive behavior disorder. Of children with enuresis, 75% have a first-degree relative who has had the disorder. Most children with enuresis do not have a coexisting mental disorder. Both encopresis and enuresis are more common in boys than in girls; 1% of all 5-year-olds have encopresis and 5% of all 5-year-olds have enuresis. Encopresis can persist with intermittent exacerbations for years; it is rarely chronic. Most children with enuresis are continent by adolescence; only 1% of all cases persist into adulthood. Impairment associated with elimination disorders depends on the limitations on the child's social activities, effects on self-esteem, degree of social ostracism by peers, and anger, punishment, and rejection on the part of parents or caregivers. Enuresis can be treated effectively with imipramine (Tofranil), an antidepressant with a side effect of urinary retention. Both elimination disorders respond to behavioral approaches, such as a pad with a warning bell, and to positive reinforcement for continence. For children with a disruptive behavior disorder, psychological treatment of that disorder may improve the elimination disorder (Mikkelsen, 2017). Sluggish cognitive tempo (SCT) is a syndrome that is not a DSM-5 diagnosis. It includes daydreaming, trouble focusing and paying attention, mental fogginess, staring, sleepiness, little interest in physical activity, and slowness in finishing tasks. Many of these are observed in children with ADHD; however, there is no hyperactivity or impulsivity—just the opposite. This leads some to believe that it is separate for ADHD, while others believe it is a variant of ADHD. Investigation is ongoing (Becker & Willcutt, 2019).

Illness anxiety disorder was formerly known as hypochondriasis, or a hypochondriac

a preoccupation with fear that one has a serious disease or will get one. Person possibly interprets their physical symptoms incorrectly.

Explain effective treatment for bulimia

cognitive-behavioral therapy; psychopharmacology

Describe the characteristics of dementia

first sign is increased forgetfulness and/or short-term memory loss), pointing out the multiple areas of cognitive impairment.

Discuss medications used for substance abuse treatment

see screenshot Pharmacologic treatment in substance abuse has two main purposes: (1) to permit safe withdrawal from alcohol, sedative-hypnotics, and benzodiazepines and (2) to prevent relapse. Table 19.1 summarizes drugs used in substance abuse treatment. For clients whose primary substance is alcohol, vitamin B1 (thiamine) is often prescribed to prevent or to treat Wernicke-Korsakoff syndrome, which are neurologic conditions that can result from heavy alcohol use. Cyanocobalamin (vitamin B12) and folic acid are often prescribed for clients with nutritional deficiencies. Alcohol withdrawal is usually managed with a benzodiazepine anxiolytic agent, which is used to suppress the symptoms of abstinence. The most commonly used benzodiazepines are lorazepam, chlordiazepoxide, and diazepam. These medications can be administered on a fixed schedule around the clock during withdrawal. Giving these medications on an as-needed basis according to symptom parameters, however, is just as effective and results in a speedier withdrawal. Barbiturates can be used for benzodiazepine-resistant cases of alcohol withdrawal (Martin & Katz, 2016). Disulfiram (Antabuse) may be prescribed to help deter clients from drinking. If a client taking disulfiram drinks alcohol, a severe adverse reaction occurs with flushing, a throbbing headache, sweating, nausea, and vomiting. In severe cases, severe hypotension, confusion, coma, and even death may result (see Chapter 2). The client must also avoid a wide variety of products that contain alcohol, such as cough syrup, lotions, mouthwash, perfume, aftershave, vinegar, and vanilla and other extracts. The client must read product labels carefully because any product containing alcohol can produce symptoms. Ingestion of alcohol may cause unpleasant symptoms for 1 to 2 weeks after the last dose of disulfiram. Acamprosate (Campral) may be prescribed for clients recovering from alcohol abuse or dependence to help reduce cravings for alcohol and decrease the physical and emotional discomfort that occurs especially in the first few months of recovery. These include sweating, anxiety, and sleep disturbances. The dosage is two tablets, 333 mg each, three times a day. Individuals with renal impairment cannot take this drug. Side effects are reported as mild and include diarrhea, nausea, flatulence, and pruritis. Acamprosate is often thought to be more effective with "relief cravers," while naltrexone (discussed later in this section) is more effective with "reward cravers" (Roos, Mann, & Witkiewitz, 2017). Relief cravers seek mediation of negative effects of withdrawal, while reward cravers seek positive effects of drinking. Methadone, a potent synthetic opiate, is used as a substitute for heroin in some maintenance programs. The client takes 1 daily dose of methadone, which meets the physical need for opiates but does not produce cravings for more. Methadone does not produce the high associated with heroin. The client has essentially substituted his or her addiction to heroin for an addiction to methadone; however, methadone is safer because it is legal, controlled by a physician, and available in tablet form. The client avoids the risks of IV drug use, the high cost of heroin (which often leads to criminal acts), and the questionable content of street drugs. Levomethadyl is a narcotic analgesic with the only purpose of treating opiate dependence. It is used in the same manner as methadone. Buprenorphine/naloxone (Suboxone) is a combination drug used for opiate maintenance and to decrease opiate cravings. Buprenorphine is a semisynthetic opioid, and naloxone is an opioid inverse agonist. The client takes 1 daily sublingual dose. Medication ingestion is supervised, at least initially, because Suboxone has the potential for abuse and diversion (Burchum & Rosenthal, 2018). Clients can be tapered from this medication after treatment and with adequate psychosocial support. Some clients may remain on a maintenance dose for an extended time. Naltrexone (ReVia) is an opioid receptor antagonist often used to treat overdose. It blocks the effects of any opioids that might be ingested, thereby negating the effects of using more opioids. It has also been found to reduce the cravings for alcohol in abstinent clients. Extended-release naltrexone has been effective in reduction of cravings during treatment and at 30- and 60-day intervals post-treatment (Crèvecoeur-MacPhail, Cousins, Denering, Kim, & Rawson, 2018). Naltrexone is also available as a once-monthly injectable marketed as Vivitrol. There are four medications that are sometimes prescribed for the off-label use of decreasing craving for cocaine. They are disulfiram (discussed earlier); modafinil (Provigil), an antinarcoleptics; propranolol (Inderal), a beta-blocker; and topiramate (Topamax), an anticonvulsant also used to stabilize moods and treat migraines. Nalmefene is an opioid receptor antagonist marketed as Revex and is used in the United States to combat opioid overdose. In Europe, it has been approved in oral tablet form to diminish alcohol and opioid cravings. It has not been approved for this use by the FDA. Clonidine (Catapres) is an alpha-2-adrenergic agonist used to treat hypertension. It is given to clients with opiate dependence to suppress some effects of withdrawal or abstinence. It is most effective against nausea, vomiting, and diarrhea, but produces modest relief from muscle aches, anxiety, and restlessness (Burchum & Rosenthal, 2018). Ondansetron (Zofran), a 5-HT3 antagonist that blocks the vagal stimulation effects of serotonin in the small intestine, is used as an antiemetic. It has been used in young males at high risk for alcohol dependence or with early-onset alcohol dependence. It is being studied for treatment of methamphetamine addiction. It is important to remember that medications will help the client manage or tolerate symptoms, such as withdrawal or cravings, but pharmacology is not a specific treatment for substance abuse. Participation in treatment and follow-up with community aftercare (such as AA meetings) are essential for long-term positive outcomes.

Review the seven classes of substances and effects of intoxication, overdose, withdrawal, and detoxification, medications (drug class and name - example benzodiazepines for detox symptoms, such as lorazepam or Diazepam), treatments

1.Alcohol 2.Sedatives, hypnotics, and anxiolytics 3.Stimulants 4.Cannabis 5.Opioids 6.Hallucinogens 7.Inhalants

Alzheimer's disease

Alzheimer disease is a progressive brain disorder that has a gradual onset but causes an increasing decline in functioning, including loss of speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions, hallucinations, inattention to hygiene, and belligerence. It is evidenced by atrophy of cerebral neurons, senile plaque deposits, and enlargement of the third and fourth ventricles of the brain. Risk for Alzheimer disease increases with age, and average duration from onset of symptoms to death is 8 to 10 years. Research has identified genetic links to both early- and late-onset Alzheimer disease

Identify the distinguishing features of anorexia and bulimia (weight loss / weight gain common with each)

Anorexia: earlier age of onset and below-normal body weight, failure to recognize eating behavior as a problem Bulimia: later age of onset, near-normal body weight, shame/embarrassment by eating behavior

Other types of eating disorders

Anorexia nervosa is a life-threatening eating disorder characterized by the client's restriction of nutritional intake necessary to maintain a minimally normal body weight, intense fear of gaining weight or becoming fat, significantly disturbed perception of the shape or size of the body, and steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists. Clients with anorexia have a body weight that is less than the minimum expected weight considering age, height, and overall physical health. In addition, clients have a preoccupation with food and food-related activities and can have a variety of physical manifestations Clients with anorexia nervosa can be classified into two subgroups depending on how they control their weight. Clients with the restricting subtype lose weight primarily through dieting, fasting, or excessive exercising. Those with the binge eating and purging subtype engage regularly in binge eating followed by purging. Binge eating means consuming a large amount of food (far greater than most people eat at one time) in a discrete period of usually 2 hours or less. Purging involves compensatory behaviors designed to eliminate food by means of self-induced vomiting or misuse of laxatives, enemas, and diuretics. Some clients with anorexia do not binge but still engage in purging behaviors after ingesting small amounts of food. Clients with anorexia become totally absorbed in their quest for weight loss and thinness. The term "anorexia" is actually a misnomer; these clients do not lose their appetites. They still experience hunger but ignore it and also ignore the signs of physical weakness and fatigue; they often believe that if they eat anything, they will not be able to stop eating and will become fat. Clients with anorexia are often preoccupied with food-related activities, such as grocery shopping, collecting recipes or cookbooks, counting calories, creating fat-free meals, and cooking family meals. They may also engage in unusual or ritualistic food behaviors such as refusing to eat around others, cutting food into minute pieces, or not allowing the food they eat to touch their lips. These behaviors increase their sense of control. Excessive exercise is common; it may occupy several hours a day. Bulimia nervosa, often simply called bulimia, is an eating disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to avoid weight gain, such as purging, fasting, or excessively exercising. The amount of food consumed during a binge episode is much larger than a person would normally eat. The client often engages in binge eating secretly. Between binges, the client may eat low-calorie foods or fast. Binging or purging episodes are often precipitated by strong emotions and followed by guilt, remorse, shame, or self-contempt. The weight of clients with bulimia is usually in the normal range, though some clients are overweight or underweight. Recurrent vomiting destroys tooth enamel, and incidence of dental caries and ragged or chipped teeth increases in these clients. Dentists are often the first health care professionals to identify clients with bulimia. Binge eating disorder is characterized by recurrent episodes of binge eating; no regular use of inappropriate compensatory behaviors, such as purging or excessive exercise or abuse of laxatives; guilt, shame, and disgust about eating behaviors; and marked psychological distress. Binge eating disorder frequently affects people over age 35, and it occurs more often in men than does any other eating disorder. Individuals are more likely to be overweight or obese, overweight as children, and teased about their weight at an early age (Call et al., 2017). Night eating syndrome is characterized by morning anorexia, evening hyperphagia (consuming 50% of daily calories after the last evening meal), and nighttime awakenings (at least once a night) to consume snacks. It is associated with life stress, low self-esteem, anxiety, depression, and adverse reactions to weight loss. Most people with night eating syndrome are obese. Treatment with selective serotonin reuptake inhibitor (SSRI) antidepressants has shown limited, yet positive effects (McCuen-Wurst, Ruggieri, & Allison, 2018). Eating or feeding disorders in childhood include pica, which is persistent ingestion of nonfood substances, and rumination, or repeated regurgitation of food that is then rechewed, reswallowed, or spit out. Both of these disorders are more common in persons with intellectual disability. Orthorexia nervosa, sometimes called orthorexia, is an obsession with proper or healthful eating. It is not formally recognized in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, but some believe it is on the rise and may constitute a separate diagnosis. Others believe it is a type of anorexia or a form of obsessive-compulsive disorder. Behaviors include compulsive checking of ingredients; cutting out increasing number of food groups; inability to eat only "healthy" or "pure" foods; unusual interest in what others eat; hours spent thinking about food, what will be served at an event; and obsessive involvement in food blogs (Costa, Hardi-Khalil, & Gibbs, 2017). Comorbid psychiatric disorders are common in clients with anorexia nervosa and bulimia nervosa. Mood disorders, anxiety disorders, and substance abuse/dependence are frequently seen in clients with eating disorders. Of those, depression and obsessive-compulsive disorder are most common. Both anorexia and bulimia are characterized by perfectionism, obsessive-compulsiveness, neuroticism, negative emotionality, harm avoidance, low self-directedness, low cooperativeness, and traits associated with avoidant personality disorder. In addition, clients with bulimia may also exhibit high impulsivity, sensation seeking, novelty seeking, and traits associated with borderline personality disorder. Eating disorders are often linked to a history of sexual abuse, especially if the abuse occurred before puberty. Such a history may be a factor contributing to problems with intimacy, body satisfaction, sexual attractiveness, and low interest in sexual activity (Mitchison et al., 2018). Clients with eating disorders and a history of sexual abuse also have higher levels of depression and anxiety, lower self-esteem, more interpersonal problems, and more severe obsessive-compulsive symptoms. Childhood neglect, both physical and emotional, is also associated with eating disorders (Pignatelli, Wampers, Loriedo, Biondi, & Vanderlinden, 2017). Whether sexual abuse has a cause-and-effect relationship with the development of eating disorders, however, remains unclear.

Discuss the characteristics, risk factors, of autism spectrum disorder (ASD) - on the spectrum (no longer specified as Asperger's syndrome, etc.).

Autism spectrum disorder (ASD) is the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) diagnosis that includes disorders previously categorized as different types of a pervasive developmental disorder (PDD), characterized by pervasive and usually severe impairment of reciprocal social interaction skills, communication deviance, and restricted stereotypical behavioral patterns. Previous PDDs, such as Rett disorder, childhood disintegrative disorder, and Asperger disorder, are now viewed on a continuum called the autism spectrum. This change helps eliminate problems that existed when attempting to distinguish among these sometimes similar disorders. Also, there is a great deal of difference among individuals diagnosed with autism, ranging from mild to very severe behaviors and limitations, which is easier to conceptualize along a continuum. ASD, formerly called autistic disorder, or just autism, is almost five times more prevalent in boys than in girls, and it is usually identified by 18 months and no later than 3 years of age. The behaviors and difficulties experienced vary along the continuum from mild to severe. Children with ASD have persistent deficits in communication and social interaction accompanied by restricted, stereotyped patterns of behavior and interests/activities. These children may display little eye contact with and make few facial expressions toward others; they use limited gestures to communicate. They can have limited capacity to relate to peers or parents. They may lack spontaneous enjoyment, express no moods or emotional affect, and may not engage in play or make-believe with toys. There can be little intelligible speech. These children engage in stereotyped motor behaviors, such as hand flapping, body twisting, or head banging (Box 22.1). These behaviors and difficulties are less prominent on the milder end of the autism spectrum and more pronounced on the severe end. Behaviors Common with ASD •Not responding to own name by 1 year (e.g., appears not to hear) •Doesn't show interest by pointing to objects or people by 14 months of age •Doesn't play pretend games by 18 months of age •Avoids eye contact •Prefers to be alone •Delayed speech and language skills •Obsessive interests (e.g., gets stuck on an idea) •Upset by minor changes in routine •Repeats words or phrases over and over •Flaps hands, or rocks or spins in a circle; answers are unrelated to questions •Unusual reactions to sounds, smells, or other sensory experiences Eighty percent of cases of autism are early onset, with developmental delays starting in infancy. The other 20% of children with autism have seemingly normal growth and development until 2 or 3 years of age, when developmental regression or loss of abilities begins. They stop talking and relating to parents and peers and begin to demonstrate behaviors previously described (Volkmar et al., 2017). Autism was once thought to be rare and was estimated to occur in four to five children per 10,000 in the 1960s. Current estimates are one in 59 children in the United States across all ethnic, racial, and socioeconomic groups, and 1% to 2% worldwide (Centers for Disease Control and Prevention, 2018). The increase in prevalence has been observed worldwide, though it is somewhat lower in countries outside North America and Europe. Figures on the prevalence of autism in adults are unreliable. Autism does have a genetic link; many children with autism have a relative with autism or autistic traits (Volkmar et al., 2017). Controversy continues about whether measles, mumps, and rubella (MMR) vaccinations contribute to the development of late- or regressive-onset autism. The National Institute of Child Health and Human Development, Centers for Disease Control and Prevention, and the Academy of Pediatrics have all conducted research studies for several years and have concluded that there is no relationship between vaccines and autism and that the MMR vaccine is safe. Studies specifically targeting children with regressive-onset ASD and any relationship to vaccines have found that no relationship exists (Goin-Kochel et al., 2016). However, litigation and class action lawsuits are still in progress because some parents and public figures refuse to accept these results. Autism tends to improve, in some cases substantially, as children start to acquire and use language to communicate with others. If behavior deteriorates in adolescence, it may reflect the effects of hormonal changes or the difficulty meeting increasingly complex social demands. Autistic traits persist into adulthood, and most people with autism remain dependent to some degree on others. Current research estimates that 20% of adults with ASD achieve most independent living outcomes, while 46% require substantial levels of support in most independent living outcomes (Farley et al., 2018). Many continue to live with parents or adult relatives. Manifestations vary from little speech and poor daily living skills throughout life to adequate social skills that allow relatively independent functioning. Social skills rarely improve enough to permit marriage and child-rearing. Adults with autism may be viewed as merely odd or reclusive, or they may be given a diagnosis of obsessive-compulsive disorder (OCD), schizoid personality disorder, or mental retardation. Until the mid-1970s, children with autism were usually treated in segregated, specialty outpatient, or school programs. Those with more severe behaviors were referred to residential programs. Since then, most residential programs have been closed; children with autism are being "mainstreamed" into local school programs whenever possible. Short-term inpatient treatment is used when behaviors such as head banging or tantrums are out of control. When the crisis is over, community agencies support the child and family. The goals of treatment of children with autism are to reduce behavioral symptoms (e.g., stereotyped motor behaviors) and to promote learning and development, particularly the acquisition of language skills. Comprehensive and individualized treatment, including special education and language therapy, as well as cognitive behavioral therapy for anxiety and agitation, is associated with more favorable outcomes. Pharmacologic treatment with antipsychotics, such as haloperidol (Haldol), risperidone (Risperdal), aripiprazole (Abilify), or combinations of antipsychotic medications, may be effective for specific target symptoms such as temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors (Sharma, Gonda, & Tarazi, 2018). Other medications, such as naltrexone (ReVia), clomipramine (Anafranil), clonidine (Catapres), and stimulants to diminish self-injury and hyperactive and obsessive behaviors, have had varied but unremarkable results. There are no medications approved for the treatment of ASD itself. Risk Factors: Having a sibling with ASD. Having certain genetic or chromosomal conditions, such as fragile X syndrome or tuberous sclerosis. Experiencing complications at birth. Being born to older parents.

Delirium tremens or "DT's."

When alcohol withdrawal progresses to psychosis, confusion, and disorientation, it is called delirium tremens, or "DT's."

withdrawal syndrome (delirium tremens)

Withdrawal syndrome refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases. Severe alcohol withdrawal symptoms such as shaking, confusion, and hallucinations. Delirium tremens usually starts two to five days after the last drink, and it can be fatal. Shaking, confusion, high blood pressure, fever, and hallucinations are some symptoms. Alcoholism treatment may start with detoxification at a medical facility. Sedatives may prevent delirium tremens. Symptoms withdrawal begin 4-12 hours after - hand tremors, sweating, elevated pulse and BP, insomnia, anxiety, N/V..........severe untreated alcohol withdrawal can progress to transient hallucinations, seizures, delirium tremens. Clients are provided benzos to help this not happen.

Describe the symptoms of bulimia

recurrent episodes of binge eating followed by inappropriate compensatory behaviors to avoid weight gain such as purging (self-induced vomiting or use of laxatives, diuretics, enemas, or emetics, can erode teeth), fasting, or excessively exercising. · Discuss common medical complications of both forms of eating disorders

Identify the common theme in somatic symptom illnesses

as occurring in people who do not express conflicts, stress, and emotions verbally Emphasize that as clients learn to express their emotions and needs directly, physical symptoms subside. Identify that somatic complaints are not under client's voluntary control.

Discuss appropriate interventions for eating disorders

establishing nutritional eating patterns including observation of eating patterns and monitoring of weight

Complex motor tics

facial gestures, jumping, or touching or smelling an object., learning disorders, motor skill disorders, communication disorders, and elimination disorders, and describe their characteristic behaviors

Pain disorder

has the primary physical symptom of pain, which is generally unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance. *Emphasize that physical pathology must be ruled out first in the assessment process.

Describe the diagnostic criteria for anorexia

refusal or inability to maintain a minimally normal body weight, intense fear of gaining weight or becoming fat, significantly disturbed perception of the shape or size of the body, and steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists, a body weight that is less than the minimum expected weight for the person's age and height and physical health; have experienced amenorrhea for at least three consecutive cycles, and have a preoccupation with food and food-related activities; and can have a variety of physical manifestations

Conversion disorder, sometimes called conversion reaction

involves unexplained, usually sudden deficits in sensory or motor function (e.g., blindness, paralysis). These deficits suggest a neurologic disorder but are associated with psychological factors. There is usually significant functional impairment.

Discuss the treatment for anorexia

medical management (weight restoration, nutritional rehabilitation, rehydration, and correction of electrolyte imbalance); psychopharmacology; psychotherapy (family therapy, individual therapy)

Discuss how nurses can assist in identifying emotions and developing coping strategies

mention self-monitoring as a technique, journaling to help client have better self-awareness and sense of feeling in control. Self-esteem is poor. Teaching should include information about the harmful effects of purging by vomiting and laxative abuse. (Dentist often finds the problem first when the patient's teeth enamel is eroding by the acid of vomiting so much.) Emphasize the need to remain empathetic and nonjudgmental when working with patients with eating disorders.

Tourette disorder

multiple motor tics and one or more vocal tics, which occur many times a day for more than 1 year. Tourette disorder involves multiple motor tics and one or more vocal tics, which occur many times a day for more than 1 year. The complexity and severity of the tics change over time, and the person experiences almost all the possible tics described previously during his or her lifetime. The person has significant impairment in academic, social, or occupational areas and feels ashamed and self-conscious. This rare disorder (4 or 5 in 10,000) is more common in boys and is usually identified by 7 years of age. Some people have lifelong problems; others have no symptoms after early adulthood

Normal IQ ranges and when considered having an intellectual disability

normal IQ is i85 to 115, with most people at about 100. IQ of 70 or below is considered having an intellectual disability) Albert Einstein's IQ was 205 to 225

Discuss the three central features of somatic symptom illnesses

o physical complaints suggest major medical illness but have no demonstrable organic basis; o psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the symptoms; o symptoms or magnified health concerns are not under the client's conscious control.

Confabulation

telling falsehoods which make sense to the patient to fill in gaps in their memory

Define somatic symptom illnesses

the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis to account fully for them

Benzodiazepines can cause symptoms similar to alcohol withdrawal, including seizures and death. Medically supervised taper and detoxification is advised. (Know what medications are benzodiazipines)

they end in "pam" or "lam" Benzodiazepines (diazepam (valium), lorazepam (Ativan), chlordiazepoxide (Librium) are used to detox off of alcohol or benzo's (tapering doses)

Symptoms of alcohol withdrawal

tremors, headache, nausea, anxiety, visual/auditory/tactile hallucinations. Untreated, alcohol withdrawal can progress to DT's, seizure, and even death; this is why it is recommended to withdraw under medical supervision if there is a history of heavy drinking or previous seizures during withdrawal.

Alcohol Tolerance - Signs/Symptoms

As the person continues to drink, he or she often develops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect. After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol intoxicate the person. S&S: cardiac myopathy, low BP, respiratory depression, wernicke encephalopathy, korsakoff psychosis, pancreatitis, esophagitis, hepatitis, cirrhosis, leukopenia, thrombocytopenia, ascites

Describe characteristics of conduct disorder

Children with conduct disorder have a difficult time following rules and behaving in a socially acceptable way. Their behavior can be hostile and sometimes physically violent. In their earlier years, they may show early signs of aggression, including pushing, hitting and biting others. swearing, vandalism, screaming arguing, threatening, anger outbursts

Discuss the characteristics, defense mechanisms, risk factors, and family dynamics prevalent with substance use disorders

Characteristics: bloodshot eyes, sudden weight loss or weight gain, deterioration of physical appearance, unusual smells on breath, body or clothing, tremors, slurred speech, impaired coordination. Defense mechanisms: Some people use alcohol as a coping mechanism or to relieve stress and tension, increase feelings of power, and decrease psychological pain. High doses of alcohol, however, actually increase muscle tension and nervousness. Risk factors: Cultural factors, social attitudes, peer behaviors, laws, cost, and availability all influence initial and continued use of substances. In general, younger experimenters use substances that carry less social disapproval such as alcohol and cannabis, while older people use drugs such as cocaine and opioids that are costlier and rate higher disapproval. Alcohol consumption increases in areas where availability increases and decreases in areas where costs of alcohol are higher because of increased taxation. Many people view the social use of cannabis, though still illegal in most states, as not harmful; many advocate legalizing the use of marijuana for social purposes. Currently in the United States, there is a federal law that still classifies marijuana as a Schedule 1 drug, but some individual states have or are in the process of legalizing medical use or recreational use or both. Urban areas where cocaine and opioids are readily available also have high crime rates, high unemployment, and substandard school systems that contribute to high rates of cocaine and opioid use, and low rates of recovery. Thus, environment and social customs can influence a person's use of substances. Family dynamics prevalent with substance use disorders: Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are children of nonalcoholic parents. This increased risk is partly the result of environmental factors, but evidence points to the importance of genetic factors as well. Several studies of twins have shown a higher rate of concordance (when one twin has it, the other twin gets it) among identical than fraternal twins. Adoption studies have shown higher rates of alcoholism in sons of biologic fathers with alcoholism than in those of nonalcoholic biologic fathers. These studies led theorists to describe the genetic component of alcoholism as a genetic vulnerability that is then influenced by various social and environmental factors. About 60% of the variation in causes of alcoholism was the result of genetics, with the remainder caused by environmental influences . Neurochemical influences on substance use patterns have been studied primarily in animal research. The ingestion of mood-altering substances stimulates dopamine pathways in the limbic system, which produces pleasant feelings or a "high" that is a reinforcing, or positive, experience. Distribution of the substance throughout the brain alters the balance of neurotransmitters that modulate pleasure, pain, and reward responses. Researchers have proposed that some people have an internal alarm that limits the amount of alcohol consumed to one or two drinks so that they feel a pleasant sensation but go no further. People without this internal signaling mechanism experience the high initially but continue to drink until the central nervous system depression is marked and they are intoxicated. In addition to the genetic links to alcoholism, family dynamics are thought to play a part. Children of alcoholics are four times as likely to develop alcoholism compared with the general population. Some theorists believe that inconsistency in the parent's behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse. Others hypothesize that even children who abhorred their family lives are likely to abuse substances as adults because they lack adaptive coping skills and cannot form successful relationships .

Detoxification

Detoxification is the process of safely withdrawing from a substance.

Explain that the course of delirium is acute and fluctuating, whereas dementia is progressive. Early symptom of dementia is memory impairment.

DELIRIUM Delirium is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. Delirium usually develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the day. Clients with delirium have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. An electrical cord on the floor may appear to them as a snake (illusion). They may mistake the banging of a laundry cart in the hallway for a gunshot (misinterpretation). They may see "angels" hovering above when nothing is there (hallucination). At times, they also experience disturbances in the sleep-wake cycle, changes in psychomotor activity, and emotional problems such as anxiety, fear, irritability, euphoria, or apathy. Elderly patients are the group most frequently diagnosed with delirium. Between 14% and 24% of people admitted to the hospital for general medical conditions are delirious, which may worsen in the hospital. Delirium is reported in 10% to 15% of general surgical patients, 30% of open heart surgery patients, and more than 50% of patients treated for fractured hips. Delirium develops in 80% of terminally ill patients. In many cases, the causes of delirium are multiple stressors, such as trauma to the central nervous system (CNS), drug toxicity or withdrawal, and metabolic disturbances related to organ failure (Fabian & Solai, 2017). Risk factors for delirium include increased severity of physical illness, older age, hearing impairment, decreased food and fluid intake, medications, and baseline cognitive impairment such as that seen in dementia. Children may be more susceptible to delirium, especially that related to a febrile illness or certain medications such as anticholinergics. Etiology Delirium almost always results from an identifiable physiological, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal. The most common causes are listed in Box 24.1. Often, delirium results from multiple causes and requires a careful and thorough physical examination and laboratory tests for identification. Most Common Causes of Delirium Physiological or metabolic Hypoxemia; electrolyte disturbances; renal or hepatic failure; hypoglycemia or hyperglycemia; dehydration; sleep deprivation; thyroid or glucocorticoid disturbances; thiamine or vitamin B12 deficiency; vitamin C, niacin, or protein deficiency; cardiovascular shock; brain tumor; head injury; and exposure to gasoline, paint solvents, insecticides, and related substances Infection Systemic: Sepsis, urinary tract infection, pneumonia Cerebral: Meningitis, encephalitis, HIV, syphilis Drug related Intoxication: Anticholinergics, lithium, alcohol, sedatives, and hypnotics Withdrawal: Alcohol, sedatives, and hypnotics Reactions to anesthesia, prescription medication, or illicit (street) drugs

Compare and contrast delirium and dementia (SEE SCREENSHOT)

Delirium is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. Delirium usually develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the day. Clients with delirium have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. An electrical cord on the floor may appear to them as a snake (illusion). They may mistake the banging of a laundry cart in the hallway for a gunshot (misinterpretation). They may see "angels" hovering above when nothing is there (hallucination). At times, they also experience disturbances in the sleep-wake cycle, changes in psychomotor activity, and emotional problems such as anxiety, fear, irritability, euphoria, or apathy. Elderly patients are the group most frequently diagnosed with delirium. Between 14% and 24% of people admitted to the hospital for general medical conditions are delirious, which may worsen in the hospital. Delirium is reported in 10% to 15% of general surgical patients, 30% of open heart surgery patients, and more than 50% of patients treated for fractured hips. Delirium develops in 80% of terminally ill patients. In many cases, the causes of delirium are multiple stressors, such as trauma to the central nervous system (CNS), drug toxicity or withdrawal, and metabolic disturbances related to organ failure (Fabian & Solai, 2017). Risk factors for delirium include increased severity of physical illness, older age, hearing impairment, decreased food and fluid intake, medications, and baseline cognitive impairment such as that seen in dementia. Children may be more susceptible to delirium, especially that related to a febrile illness or certain medications such as anticholinergics. Dementia refers to a disease process marked by progressive cognitive impairment with no change in the level of consciousness. It involves multiple cognitive deficits, initially, memory impairment, and later, the following cognitive disturbances may be seen (Graziane & Sweet, 2017): •Aphasia, which is deterioration of language function •Apraxia, which is impaired ability to execute motor functions despite intact motor abilities •Agnosia, which is inability to recognize or name objects despite intact sensory abilities •Disturbance in executive functioning, which is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior These cognitive deficits must be sufficiently severe to impair social or occupational functioning and must represent a decline from previous functioning. In the DSM-5, mild NCD refers to a mild cognitive decline, and a modest impairment of performance that doesn't prevent independent living but may require some accommodation or assistance. A major NCD refers to a significant cognitive decline and a substantial impairment in performance that interferes with activities of daily independent living. As people progress from mild to major NCD, it is not always easy for the diagnostician to decide which one to use Dementia must be distinguished from delirium; if the two diagnoses coexist, the symptoms of dementia remain even when the delirium has cleared. Table 24.1 compares delirium and dementia.

Drugs to treat dementia

Donepezil (Aricept) 5-10 mg orally per day Monitor for nausea, diarrhea, and insomnia. Test stools periodically for gastrointestinal bleeding. Rivastigmine (Exelon) "mine" 3-12 mg orally per day divided into two doses Monitor for nausea, vomiting, abdominal pain, and loss of appetite. Galantamine (Reminyl, Razadyne, Nivalin) "mine" 16-32 mg orally per day divided into two doses Monitor for nausea, vomiting, loss of appetite, dizziness, and syncope. Memantine (Namenda) "mine" 10-20 mg/day divided into two doses Monitor for hypertension, pain, headache, vomiting, constipation, and fatigue.

Relapse

For many people, substance use is a chronic illness characterized by remissions and relapses to former levels of use. Relapse rates range from 60% to 90%, with nearly half of individuals relapsing in the year after treatment. A minority of people remain sober after the first treatment experience. The highest rates for successful recovery are for people who abstain from substances, are highly motivated to have a substance-free lifestyle, and who actively work on relapse prevention.

For the client with delirium, review the symptoms of altered consciousness and cognition, difficulty focusing. Delirium is a temporary/transient condition. Maintaining safety is priority when the patient has altered consciousness

General Appearance and Motor Behavior Clients with delirium often have a disturbance of psychomotor behavior. They may be restless and hyperactive, frequently picking at bed clothes or making sudden, uncoordinated attempts to get out of bed. Conversely, clients may have slowed motor behavior, appearing sluggish and lethargic with little movement. Speech may also be affected, becoming less coherent and more difficult to understand as delirium worsens. Clients may perseverate on a single topic or detail, may be rambling and difficult to follow, or may have pressured speech that is rapid, forced, and usually louder than normal. At times, clients may call out or scream, especially at night. Mood and Affect Clients with delirium often have rapid and unpredictable mood shifts. A wide range of emotional responses is possible, such as anxiety, fear, irritability, anger, euphoria, and apathy. These mood shifts and emotions usually have nothing to do with the client's environment. When clients are particularly fearful and feel threatened, they may become combative to defend themselves from perceived harm. Thought Process and Content Although clients with delirium have changes in cognition, it is difficult for the nurse to assess these changes accurately and thoroughly. Marked inability to sustain attention makes it difficult to assess thought process and content. Thought content in delirium is often unrelated to the situation, or speech is illogical and difficult to understand. The nurse may ask how clients are feeling, and they will mumble about the weather. Thought processes are often disorganized and make no sense. Thoughts also may be fragmented (disjointed and incomplete). Clients may exhibit delusions, believing that their altered sensory perceptions are real. Sensorium and Intellectual Processes The primary and often initial sign of delirium is an altered level of consciousness that is seldom stable and usually fluctuates throughout the day. Clients are usually oriented to people but frequently disoriented to time and place. They demonstrate decreased awareness of the environment or situation and instead may focus on irrelevant stimuli such as the color of the bedspread or the room. Noises, people, or sensory misperceptions easily distract them. Clients cannot focus, sustain, or shift attention effectively, and there is impaired recent and immediate memory. This means the nurse may have to ask questions or provide directions repeatedly. Even then, clients may be unable to do what is requested. Clients frequently experience misinterpretations, illusions, and hallucinations. Both misperceptions and illusions are based on some actual stimuli in the environment; clients may hear a door slam and interpret it as a gunshot or see the nurse reach for an IV bag and believe the nurse is about to strike them. Examples of common illusions include clients believing that IV tubing or an electrical cord is a snake and mistaking the nurse for a family member. Hallucinations are most often visual; clients "see" things for which there is no stimulus in reality. When more lucid, some clients are aware that they are experiencing sensory misperceptions. Others, however, actually believe their misinterpretations are correct and cannot be convinced otherwise. Judgment and Insight Judgment is impaired. Clients often cannot perceive potentially harmful situations or act in their own best interests. For example, they may try repeatedly to pull out IV tubing or urinary catheters; this causes pain and interferes with necessary treatment. Insight depends on the severity of the delirium. Clients with mild delirium may recognize that they are confused, are receiving treatment, and will likely improve. Those with severe delirium may have no insight into the situation. Roles and Relationships Clients are unlikely to fulfill their roles during the course of delirium. Most regain their previous level of functioning, however, and have no long-standing problems with roles or relationships. Self-Concept Although delirium has no direct effect on self-concept, clients often are frightened or feel threatened. Those with some awareness of the situation may feel helpless or powerless to do anything to change it. If delirium has resulted from alcohol, illicit drug use, or overuse of prescribed medications, clients may feel guilt, shame, and humiliation, or think, "I'm a bad person; I did this to myself." This would indicate possible long-term problems with self-concept.

Inhalants

Inhalants Inhalants are a diverse group of drugs that include anesthetics, nitrates, and organic solvents that are inhaled for their effects. The most common substances in this category are aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint. Less frequently used halogenated hydrocarbons include cleaners, correction fluid, spray can propellants, and other compounds containing esters, ketones, and glycols. Most of the vapors are inhaled from a rag soaked with the compound, from a paper or plastic bag, or directly from the container. Inhalants can cause significant brain damage, peripheral nervous system damage, and liver disease. Intoxication and Overdose Inhalant intoxication involves dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision. Stupor and coma can occur. Significant behavioral symptoms are belligerence, aggression, apathy, impaired judgment, and inability to function. Acute toxicity causes anoxia, respiratory depression, vagal stimulation, and dysrhythmias. Death may occur from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomitus (Howard, Bowen, & Garland, 2017). Treatment consists of supporting respiratory and cardiac functioning until the substance is removed from the body. There are no antidotes or specific medications to treat inhalant toxicity. Withdrawal and Detoxification There are no withdrawal symptoms or detoxification procedures for inhalants as such, though frequent users report psychological cravings. People who abuse inhalants may suffer from persistent dementia or inhalant-induced disorders, such as psychosis, anxiety, or mood disorders even if the inhalant abuse ceases. These disorders are all treated symptomatically.

List nursing diagnoses commonly appropriate for the care of the person with conduct disorder.

Risk for other-directed violence related to aggression to other people or animals. Noncompliance related to resentment of those in authority. Ineffective coping related to low self-esteem. Impaired social interaction related to hostility towards those in authority. Chronic low self esteem related to lack of value to self.

Describe the characteristic behaviors associated with ADHD, including onset and clinical course and the biologic and environmental causes thought to cause ADHD

Onset and Clinical Course ADHD is usually identified and diagnosed when the child begins preschool or school, though many parents report problems from a much younger age. As infants, children with ADHD are often fussy and temperamental and have poor sleeping patterns. Toddlers may be described as "always on the go" and "into everything," at times dismantling toys and cribs. They dart back and forth, jump and climb on furniture, run through the house, and cannot tolerate sedentary activities such as listening to stories. At this point in a child's development, it can be difficult for parents to distinguish normal active behavior from excessive hyperactive behavior. By the time the child starts school, symptoms of ADHD begin to interfere significantly with behavior and performance. The child fidgets constantly, is in and out of assigned seats, and makes excessive noise by tapping or playing with pencils or other objects. Normal environmental noises, such as someone coughing, distract the child. He or she cannot listen to directions or complete tasks. The child interrupts and blurts out answers before questions are completed. Academic performance suffers because the child makes hurried, careless mistakes in schoolwork, often loses or forgets homework assignments, and fails to follow directions (Zendarski, Sciberras, Mensah, & Hiscock, 2017). Socially, peers may ostracize or even ridicule the child for his or her behavior. Forming positive peer relationships is difficult because the child cannot play cooperatively or take turns and constantly interrupts others. Studies have shown that both teachers and peers perceive children with ADHD as more aggressive, bossier, and less likable (Grygiel, Humenny, Rebisz, Bajcar, & S´witaj, 2018). This perception results from the child's impulsivity, inability to share or take turns, tendency to interrupt, and failure to listen to and follow directions. Thus, peers and teachers may exclude the child from activities and play, may refuse to socialize with the child, and/or may respond to the child in a harsh, punitive, or rejecting manner. Approximately 60% to 85% of children diagnosed with ADHD continue to have problems in adolescence. Typical impulsive behaviors include cutting class, getting speeding tickets, failing to maintain interpersonal relationships, and adopting risk-taking behaviors, such as using drugs or alcohol, engaging in sexual promiscuity, fighting, and violating curfew. Many adolescents with ADHD have discipline problems serious enough to warrant suspension or expulsion from high school. The secondary complications of ADHD, such as low self-esteem and peer rejection, continue to pose serious problems. Previously, it was believed that children outgrew ADHD, but it is now known that ADHD can persist into adulthood. Estimates are that 60% of children with ADHD have symptoms that continue into adulthood. In one study, adults who had been treated for hyperactivity 25 years earlier were three to four times more likely than their brothers to experience nervousness, restlessness, depression, lack of friends, and low frustration tolerance. Approximately 70% to 75% of adults with ADHD have at least one coexisting psychiatric diagnosis, with social phobia, bipolar disorder, major depression, and alcohol dependence being the most common (McGough, 2017). Box 22.2 contains a screening questionnaire for ADHD in adults. Environmental factors include maternal smoking during pregnancy and duration of breastfeeding. In recent years, the results of several studies have indicated that lifestyle factors—including the number of hours spent sleeping or watching television—may also influence the onset of ADHD.

Wernicke's encephalopathy

Pharmacologic treatment in substance abuse has two main purposes: (1) to permit safe withdrawal from alcohol, sedative-hypnotics, and benzodiazepines and (2) to prevent relapse. Table 19.1 summarizes drugs used in substance abuse treatment. For clients whose primary substance is alcohol, vitamin B1 (thiamine) is often prescribed to prevent or to treat Wernicke-Korsakoff syndrome, which are neurologic conditions that can result from heavy alcohol use. Cyanocobalamin (vitamin B12) and folic acid are often prescribed for clients with nutritional deficiencies. Thiamine (vitamin B1)- Prevents or treats Wernicke-Korsakoff syndrome in alcoholism 100 mg/day

Discuss that families need to be involved in the treatment too

Providing Client and Family Education Parents may also need help in learning social skills, solving problems, and behaving appropriately. Often, parents have their own problems, and they have had difficulties with the client for a long time before treatment was instituted. Parents need to replace old patterns such as yelling, hitting, or simply ignoring behavior with more effective strategies. The nurse can teach parents age-appropriate activities and expectations for clients, such as reasonable curfews, household responsibilities, and acceptable behavior at home. The parents may need to learn effective limit setting with appropriate consequences. Parents often need to learn to communicate their feelings and expectations clearly and directly to these clients. Some parents may need to let clients experience the consequences of their behavior rather than rescuing them. For example, if a client gets a speeding ticket, the parents should not pay the fine for him or her. If a client causes a disturbance in school and receives detention, the parents can support the teacher's actions instead of blaming the teacher or school. For Conduct Disorder •Teach parents social and problem-solving skills when needed. •Encourage parents to seek treatment for their own problems. •Help parents identify age-appropriate activities and expectations. •Assist parents with direct, clear communication. •Help parents avoid "rescuing" the client. •Teach parents effective limit-setting techniques. •Help parents identify appropriate discipline strategies.

Discuss the use of antidepressants in some cases

SSRI's (such as fluoxetine/Prozac, paroxetine/Paxil, sertraline/Zoloft) have sometimes been found to be helpful. Side effects of these meds to include in teaching: insomnia, appetite loss, and others specific to each med.

substance abuse/substance dependence

Substance abuse can be defined as using a drug in a way that is inconsistent with medical or social norms and despite negative consequences. Substance abuse denotes problems in social, vocational, or legal areas of the person's life, while substance dependence also includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance. This distinction between abuse and dependence is frequently viewed as unclear and unnecessary because the distinction does not affect clinical decisions once withdrawal or detoxification has been completed. Hence, the terms substance abuse and substance dependence or chemical dependence can be used interchangeably. In this chapter, the term substance use is used to include both abuse and dependence; it is not meant to refer to occasional or one-time use.

Introduce the psychiatric disorders usually first diagnosed in infancy, childhood, and sometimes in adolescence.

The disorders of childhood and adolescence most often encountered in mental health settings include ASD and ADHD.

Treatment for delirium is aimed at the underlying cause so the patient can return to their normal cognition baseline

The primary treatment for delirium is to identify and treat any causal or contributing medical conditions. Delirium is almost always a transient condition that clears with successful treatment of the underlying cause. Nevertheless, some causes such as head injury or encephalitis may leave clients with cognitive, behavioral, or emotional impairments even after the underlying cause resolves. People who have had delirium are at higher risk for future episodes.

Illustrate questions to consider that would evaluate successful treatment outcome

Treatment is considered effective if the client stops behaving in an aggressive or illegal way, attends school, and follows reasonable rules and expectations at home. The client will not become a model child in a short period; instead, he or she may make modest progress with some setbacks over time.

Donepezil (Aricept) and other dementia medications will not cure Alzheimer's, but they help to slow disease progression. They also help neurons temporarily connect better.

Treatment and Prognosis Whenever possible, the underlying cause of dementia is identified so that treatment can be instituted. For example, the progress of vascular dementia, the second most common type, may be halted with appropriate treatment of the underlying vascular condition (e.g., changes in diet, exercise, control of hypertension, or diabetes). Improvement of cerebral blood flow may arrest the progress of vascular dementia in some people. The prognosis for the progressive types of dementia may vary as described earlier, but all prognoses involve progressive deterioration of physical and mental abilities until death. Typically, in the later stages, clients have minimal cognitive and motor function, are totally dependent on caregivers, and are unaware of their surroundings or people in the environment. They may be totally uncommunicative or make unintelligible sounds or attempts to verbalize. For degenerative dementias, no direct therapies have been found to reverse or retard the fundamental pathophysiological processes. Levels of numerous neurotransmitters such as acetylcholine, dopamine, norepinephrine, and serotonin are decreased in dementia. This has led to attempts at replenishment therapy with acetylcholine precursors, cholinergic agonists, and cholinesterase inhibitors. Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl, Razadyne, Nivalin) are cholinesterase inhibitors and have shown modest therapeutic effects and temporarily slow the progress of dementia (Table 24.2). They have no effect, however, on the overall course of the disease. Tacrine (Cognex) is also a cholinesterase inhibitor; however, it elevates liver enzymes in about 50% of clients using it. Lab tests to assess liver function are necessary every 1 to 2 weeks; therefore, tacrine is rarely prescribed. Memantine (Namenda) is an NMDA receptor antagonist that can slow the progression of Alzheimer in the moderate or severe stages. Namzaric (memantine and donepezil) is a newer combination of two other medications, thereby having the actions of both cholinesterase inhibition and NMDA receptor antagonist (Graziane & Sweet, 2017). Clients with dementia demonstrate a broad range of behaviors that can be treated symptomatically. Doses of medications are one-half to two-thirds lower than usually prescribed. Antidepressants are effective for significant depressive symptoms; however, they can cause delirium. Selective serotonin reuptake inhibitor antidepressants are used because they have fewer side effects. Antipsychotics, such as haloperidol (Haldol), olanzapine (Zyprexa), risperidone (Risperdal), and quetiapine (Seroquel), may be used to manage psychotic symptoms of delusions, hallucinations, or paranoia, and other behaviors, such as agitation or aggression. The potential benefit of antipsychotics must be weighed with the risks, such as an increased mortality rate, primarily from cardiovascular complications. Owing to this increased risk, the U.S. Food and Drug Administration (FDA) has not approved antipsychotics for dementia treatment, and there is a black box warning issued. Lithium carbonate, carbamazepine (Tegretol), and valproic acid (Depakote) help stabilize affective lability and diminish aggressive outbursts. Benzodiazepines are used cautiously because they may cause delirium and can worsen already compromised cognitive abilities. These medications are discussed in Chapter 2. Pimavanserin (Nuplazid) has been specifically FDA approved to treat delusions and hallucinations that some experience with Parkinson disease (Combs & Cox, 2017). One 34-mg capsule per day is the recommended dose. It is known to prolong the Q-T interval. Both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia-related psychosis.

For the person with conduct disorder (Refer to Nursing Care Plan: Conduct Disorder): Discuss significant assessment findings revealed in the person's history, general appearance and motor behavior, mood and affect, thought process and content, sensorium and intellectual processes, and judgment and insight. Discuss expected changes in self-concept, roles and relationships, and physiologic status

Assessment History Children with conduct disorder have a history of disturbed relationships with peers, aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules (e.g., truancy, running away from home, staying out all night without permission). The behaviors and problems may be mild to severe. General Appearance and Motor Behavior Appearance, speech, and motor behavior are typically normal for the age group but may be somewhat extreme (e.g., body piercings, tattoos, hairstyle, clothing). These clients often slouch and are sullen and unwilling to be interviewed. They may use profanity, call the nurse or physician names, and make disparaging remarks about parents, teachers, police, and other authority figures. Mood and Affect Clients may be quiet and reluctant to talk, or they may be openly hostile and angry. Their attitude is likely to be disrespectful toward parents, the nurse, or anyone in a position of authority. Irritability, frustration, and temper outbursts are common. Clients may be unwilling to answer questions or cooperate with the interview; they believe they do not need help or treatment. If a client has legal problems, he or she may express superficial guilt or remorse, but it is unlikely that these emotions are sincere. Thought Process and Content Thought processes are usually intact—that is, clients are capable of logical rational thinking. Nevertheless, they perceive the world to be aggressive and threatening, and they respond in the same manner. Clients may be preoccupied with looking out for themselves and behave as though everyone is "out to get me." Thoughts or fantasies about death or violence are common. Sensorium and Intellectual Processes Clients are alert and oriented with intact memory and no sensory-perceptual alterations. Intellectual capacity is not impaired, but typically, these clients have poor grades because of academic underachievement, behavioral problems in school, or failure to attend class and to complete assignments. Judgment and Insight Judgment and insight are limited for developmental stage. Clients consistently break rules with no regard for the consequences. Thrill-seeking or risky behavior is common, such as use of drugs or alcohol, reckless driving, sexual activity, and illegal activities such as theft. Clients lack insight and usually blame others or society for their problems; they rarely believe their behavior is the cause of difficulties. Self-Concept Although these clients generally try to appear tough, their self-esteem is low. They do not value themselves any more than they value others. Their identity is related to their behaviors such as being cool if they have had many sexual encounters or feeling important if they have stolen expensive merchandise or been expelled from school. Roles and Relationships Relationships with others, especially those in authority, are disruptive and may be violent. This includes parents, teachers, police, and most other adults. Verbal and physical aggression is common. Siblings may be a target for ridicule or aggression. Relationships with peers are limited to others who display similar behaviors; these clients see peers who follow rules as dumb or afraid. Clients usually have poor grades, have been expelled, or have dropped out. It is unlikely that they have a job (if old enough) because they would prefer to steal. Their idea of fulfilling roles is being tough, breaking rules, and taking advantage of others. Physiological and Self-Care Considerations Clients are often at risk for unplanned pregnancy and STDs because of their early and frequent sexual behavior. Use of drugs and alcohol is an additional risk to health. Clients with conduct disorders are involved in physical aggression and violence including weapons; this results in more injuries and deaths compared with others of the same age.

chronic motor or tic disorders

Complex vocal tics - repeating words or phrases out of context coprolalia (use of socially unacceptable words, frequently obscene) palilalia (repeating one's own sounds or words) echolalia (repeating the last-heard sound, word, or phrase)

Dementia nursing intervention "reminiscence"

Reminiscence therapy (thinking about or relating personally significant past experiences) is an effective intervention for clients with dementia. Rather than lamenting that the client is "living in the past," this therapy encourages family and caregivers to also reminisce with the client. Reminiscing, also called nostalgia, uses the client's remote memory, which is not affected as severely or quickly as recent or immediate memory. Photo albums may be useful in stimulating remote memory, and they provide a focus on the client's past. Sometimes clients like to reminisce about local or national events and talk about their roles or what they were doing at the time. In addition to keeping clients involved in the business of living, reminiscence can also build self-esteem as clients discuss accomplishments. Engaging in active listening, asking questions, and providing cues to continue promote successful use of this technique. Reminiscence therapy can also be effective with small groups of clients as they collectively remember their early life activities. Provide opportunities for reminiscence or recall of past events on a one-to-one basis or in a small group. Long-term memory may persist after loss of recent memory. Reminiscence is usually an enjoyable activity for the client.

List and PRIORITIZE nursing diagnoses commonly appropriate for the physical care and the psychosocial care of the person with a substance use issue

Denial, ineffective individual coping, powerlessness imbalanced nutrition, low self esteem, altered family process, sexual disfunction, deficient knowledge, other possible nursing care plans

Munchausen syndrome (commonly known as Munchausen syndrome by proxy)

when a person inflicts illness or injury on someone else to gain the attention of Emergency medical personnel or to be a "hero" for saving the victim.

Review the process of somatization

when people convert unexpressed emotions into physical symptoms (a defense mechanism). For example, physicians will find no physical cause for the symptoms the patient has.

Describe the characteristics of delirium, pointing out the changes in both consciousness and cognition

Delirium is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. Delirium usually develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the day. Clients with delirium have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. An electrical cord on the floor may appear to them as a snake (illusion). They may mistake the banging of a laundry cart in the hallway for a gunshot (misinterpretation). They may see "angels" hovering above when nothing is there (hallucination). At times, they also experience disturbances in the sleep-wake cycle, changes in psychomotor activity, and emotional problems such as anxiety, fear, irritability, euphoria, or apathy.

Explain what is meant by "psychosomatic illness" or "somatoform disorder"

Psychosomatic disorder is a psychological condition involving the occurrence of physical symptoms, usually lacking a medical explanation. People with this condition may have excessive thoughts, feelings or concerns about the symptoms — which affects their ability to function well. Somatoform disorders are the major forms of psychosomatic illness. The physical symptoms of somatoform disorders are all too real, they have psychological roots instead of physical causes. The symptoms often times resemble symptoms of medical illness.

What is attention-deficit/hyperactivity disorder (ADHD) and medication(s) used to treat

Attention-deficit/hyperactivity disorder (ADHD) is characterized by inattentiveness, overactivity, and impulsiveness. ADHD is a common disorder, especially in boys, and probably accounts for more child mental health referrals than any other single disorder. The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity and impulsivity more common than generally observed in children of the same age. ADHD affects 5% to 8% of school-aged children, with 60% to 85% having symptoms persisting into adolescence. Up to 60% continue to be symptomatic into adulthood. The ratio of boys to girls ranges from 2:1 in nonclinical settings to 9:1 in clinical settings (Spaniardi, Greenhil, & Hectman, 2017). To avoid overdiagnosis of ADHD, a qualified specialist, such as a pediatric neurologist or a child psychiatrist, must conduct the evaluation for ADHD. Children who are very active or hard to handle in the classroom can be diagnosed and treated mistakenly for ADHD. Some of these overly active children may suffer from psychosocial stressors at home, inadequate parenting, or other psychiatric disorders. It is essential to have a thorough and accurate diagnosis for ADHD. There are other disorders and situations that may look similar to ADHD, such as bipolar disorder or behavioral acting out in response to family stress, such as divorce, parental mental disorders, and so forth. A key feature of ADHD is the consistency of the child's behavior—every day, in almost all situations, and with almost all caregivers, the child demonstrates the problematic behaviors. Distinguishing bipolar disorder from ADHD can be difficult but is crucial to prescribe the most effective treatment. DHD is usually identified and diagnosed when the child begins preschool or school, though many parents report problems from a much younger age. As infants, children with ADHD are often fussy and temperamental and have poor sleeping patterns. Toddlers may be described as "always on the go" and "into everything," at times dismantling toys and cribs. They dart back and forth, jump and climb on furniture, run through the house, and cannot tolerate sedentary activities such as listening to stories. At this point in a child's development, it can be difficult for parents to distinguish normal active behavior from excessive hyperactive behavior. Medications: Stimulants and Antidepressants SNRIs (see screenshot)

Nursing assessment - prioritization of assessment, care, and outcomes for the patient with a substance or alcohol abuse emergency

CIWA Assessment N/V Tremor Paroxysmal Sweats Anxiety Agitation Tactile Disturbances Auditory disturbances Visual disturbances Headache Orientation Seizure precautions

Important to be supportive to parents, non-judgmental, they usually have high anxiety about their child with ADHD, teach them specific helps

CLIENT AND FAMILY EDUCATION For ADHD •Include parents in planning and providing care. •Refer parents to support groups. •Focus on child's strengths as well as problems. •Teach accurate administration of medication and possible side effects. •Inform parents that child is eligible for special school services. •Assist parents in identifying behavioral approaches to be used at home. •Help parents achieve a balance of praising child and correcting child's behavior. •Emphasize the need for structure and consistency in child's daily routine and behavioral expectations. Ensuring Safety Safety of the child and others is always a priority. If the child is engaged in a potentially dangerous activity, the first step is to stop the behavior. This may require physical intervention if the child is running into the street or attempting to jump from a high place. Attempting to talk to or reason with a child engaged in a dangerous activity is unlikely to succeed because his or her ability to pay attention and to listen is limited. When the incident is over and the child is safe, the adult should talk to the child directly about the expectations for safe behavior. Close supervision may be required for a time to ensure compliance and to avoid injury. Explanations should be short and clear, and the adult should not use a punitive or belittling tone of voice. The adult should not assume that the child knows acceptable behavior but instead should state expectations clearly.

Discuss appropriate nursing interventions by describing specific areas needed for client and family education (Refer to Client and Family Education for Substance Abuse), addressing family issues (codependence), and promoting coping skills

CLIENT AND FAMILY EDUCATION For Substance Abuse •Substance abuse is an illness. •Dispel myths about substance abuse. •Abstinence from substances is not a matter of willpower. •Any alcohol, whether beer, wine, or liquor, can be an abused substance. •Prescribed medication can be an abused substance. •Feedback from family about relapse signs, for example, a return to previous maladaptive coping mechanisms, is vital. •Continued participation in an aftercare program is important. Addressing Family Issues Alcoholism (and other substance abuse) is often called a family illness. All those who have a close relationship with a person who abuses substances suffer emotional, social, and sometimes physical anguish. Codependence is a maladaptive coping pattern on the part of family members or others resulting from a prolonged relationship with the person who uses substances. Characteristics of codependence are poor relationship skills, excessive anxiety and worry, compulsive behaviors, and resistance to change. Family members learn these dysfunctional behavior patterns as they try to adjust to the behavior of the substance user. One type of codependent behavior is called enabling, which is a behavior that seems helpful on the surface but actually perpetuates the substance use. For example, a wife who continually calls in to her husband's job to report that he is sick when he is really drunk or hungover prevents the husband from having to face the true implications and repercussions of his behavior. What appears to be a helpful action really just assists the husband in avoiding the consequences of his behavior and to continue abusing the substance. Roles may shift dramatically, such as when a child actually looks out for or takes care of a parent. Codependent behaviors have also been identified in health care professionals when they make excuses for a client's behavior or do things for clients that clients can do for themselves. An adult child of an alcoholic is someone who was raised in a family in which one or both parents were addicted to alcohol and who has been subjected to the many dysfunctional aspects associated with parental alcoholism. In addition to being at high risk for alcoholism and eating disorders, children of alcoholics often develop an inability to trust, an extreme need to control, an excessive sense of responsibility, and denial of feelings; these characteristics persist into adulthood. Many people growing up in homes with parental alcoholism believe their problems will be solved when they are old enough to leave and escape the situation. They may begin to have problems in relationships, have low self-esteem, and have excessive fears of abandonment or insecurity as adults. Never having experienced normal family life, they may find that they do not know what "normal" is (Haverfield & Theiss, 2016). Without support and help to understand and cope, many family members may develop substance abuse problems of their own, thus perpetuating the dysfunctional cycle. Treatment and support groups are available to address the issues of family members. Clients and families also need information about support groups, their purpose, and their locations in the community. NURSING INTERVENTIONS For Substance Abuse •Health teaching for the client and family •Dispel myths surrounding substance abuse •Decrease codependent behaviors among family members •Make appropriate referrals for family members •Promote coping skills •Role-play potentially difficult situations •Focus on the here-and-now with clients •Set realistic goals such as staying sober today Promoting Coping Skills Nurses can encourage clients to identify problem areas in their lives and to explore the ways that substance use may have intensified those problems. Clients should not believe that all life's problems will disappear with sobriety; rather, sobriety will assist them in thinking about the problems clearly. The nurse may need to redirect a client's attention to his or her behavior and how it influenced his or her problems. The nurse should not allow clients to focus on external events or other people without discussing their role in the problem. It may be helpful to role-play situations that clients have found difficult. This is also an opportunity to help clients learn to solve problems or to discuss situations with others calmly and more effectively. In the group setting in treatment, it is helpful to encourage clients to give and to receive feedback about how others perceive their interaction or ability to listen. The nurse can also help clients find ways to relieve stress or anxiety that do not involve substance use. Relaxing, exercising, listening to music, or engaging in activities may be effective. Clients may also need to develop new social activities or leisure pursuits if most of their friends or habits of socializing involved the use of substances. The nurse can help clients focus on the present, not the past. It is not helpful for clients to dwell on past problems and regrets. Rather, they must focus on what they can do now regarding their behavior or relationships. Clients may need support from the nurse to view life and sobriety in feasible terms—taking it one day at a time. The nurse can encourage clients to set attainable goals such as, "What can I do today to stay sober?" instead of feeling overwhelmed by thinking "How can I avoid substances for the rest of my life?" Clients need to believe that they can succeed.

Cannabis

Cannabis Cannabis sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and for oil from its seeds. It has become widely known for its psychoactive resin. This resin contains more than 60 substances, called cannabinoids, of which δ-9-tetrahydrocannabinol is thought to be responsible for most of the psychoactive effects. Marijuana refers to the upper leaves, flowering tops, and stems of the plant; hashish is the dried resinous exudate from the leaves of the female plant (Hall & Degenhardt, 2017). Cannabis is often smoked in cigarettes (joints), and it can also be eaten. The legal status of cannabis has changed in the United States. While federal law still considers most cannabis use illegal, some individual states have changed their laws. States may have legalized medical marijuana use, recreational use, both, or neither. This will continue to change in future years but is a state-by-state approach at this point in time. Research has shown that cannabis has short-term effects of lowering intraocular pressure, but it is not approved for the treatment of glaucoma. It has also been studied for its effectiveness in relieving the nausea and vomiting associated with cancer chemotherapy and the anorexia and weight loss of AIDS. Currently, two cannabinoids, dronabinol (Marinol) and nabilone (Cesamet), have been approved for treating nausea and vomiting from cancer chemotherapy. Cannabis-related drugs have shown promise in the control of seizures in people who do not experience seizure control from other medications (Thomas & Cunningham, 2018). Intoxication and Overdose Cannabis begins to act less than 1 minute after inhalation. Peak effects usually occur in 20 to 30 minutes and last at least 2 to 3 hours. Users report a high feeling similar to that with alcohol, lowered inhibitions, relaxation, euphoria, and increased appetite. Symptoms of intoxication include impaired motor coordination, inappropriate laughter, impaired judgment and short-term memory, and distortions of time and perception. Anxiety, dysphoria, and social withdrawal may occur in some users. Physiological effects, in addition to increased appetite, include conjunctival injection (bloodshot eyes), dry mouth, hypotension, and tachycardia. Excessive use of cannabis may produce delirium or rarely, cannabis-induced psychotic disorder, both of which are treated symptomatically. Overdoses of cannabis do not occur. Withdrawal and Detoxification Although some people have reported withdrawal symptoms of muscle aches, sweating, anxiety, and tremors, no clinically significant withdrawal syndrome is identified.

Primary biologic risk factor as being genetic influence

Children of parents who are alcoholics are more likely to develop alcoholism and drug dependence Children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are children of nonalcoholic parents. This increased risk is partly the result of environmental factors, but evidence points to the importance of genetic factors as well (Haverfield & Theiss, 2016). Several studies of twins have shown a higher rate of concordance (when one twin has it, the other twin gets it) among identical than fraternal twins. Adoption studies have shown higher rates of alcoholism in sons of biologic fathers with alcoholism than in those of nonalcoholic biologic fathers. These studies led theorists to describe the genetic component of alcoholism as a genetic vulnerability that is then influenced by various social and environmental factors. About 60% of the variation in causes of alcoholism was the result of genetics, with the remainder caused by environmental influences (Schuckit, 2017). Neurochemical influences on substance use patterns have been studied primarily in animal research. The ingestion of mood-altering substances stimulates dopamine pathways in the limbic system, which produces pleasant feelings or a "high" that is a reinforcing, or positive, experience (Cooper, Robison, & Mazei-Robison, 2017). Distribution of the substance throughout the brain alters the balance of neurotransmitters that modulate pleasure, pain, and reward responses. Researchers have proposed that some people have an internal alarm that limits the amount of alcohol consumed to one or two drinks so that they feel a pleasant sensation but go no further. People without this internal signaling mechanism experience the high initially but continue to drink until the central nervous system depression is marked and they are intoxicated.

Describe the characteristic behaviors associated with ASD and the biologic and environmental causes known to cause ASD

Children with ASD seem detached and make little eye contact with and few facial expressions toward others. They do not relate to peers or parents, lack spontaneous enjoyment, and cannot engage in play or make-believe with toys. Autism is often treated with behavioral approaches. Months or years of treatment may be needed before positive outcomes appear. Children with ASD seem detached and make little eye contact with and few facial expressions toward others. They do not relate to peers or parents, lack spontaneous enjoyment, and cannot engage in play or make-believe with toys. Autism is often treated with behavioral approaches. Months or years of treatment may be needed before positive outcomes appear. Biologic and Environmental Risk Factors: A sibling with autism Older parents Certain genetic conditions, such as Down, fragile X, and Rett syndromes Very low birth weight Advanced parental age at time of conception Prenatal exposure to air pollution or certain pesticides Maternal obesity, diabetes, or immune system disorders Extreme prematurity or very low birth weight Any birth difficulty leading to periods of oxygen deprivation to the baby's brain Air pollution Metals, pesticides and other contaminants Nutrition

Describe the characteristic behaviors associated with conduct disorder, including onset and clinical course and the biologic and psychosocial causes thought to cause conduct disorder

Conduct disorder is characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others. These children and adolescents have significantly impaired abilities to function in social, academic, or occupational areas. Symptoms are clustered in four areas: aggression to people and animals, destruction of property, deceitfulness and theft, and serious violation of rules. Children with conduct disorder often exhibit callous and unemotional traits, similar to those seen in adults with antisocial personality disorder. They have little empathy for others, do not feel "bad" or guilty or show remorse for their behavior, have shallow or superficial emotions, and are unconcerned about poor performance at school or home. These children have low self-esteem, poor frustration tolerance, and temper outbursts. Conduct disorder is frequently associated with early onset of sexual behavior, drinking, smoking, use of illegal substances, and other reckless or risky behaviors. In the United States, 8% of children and adolescents have conduct disorder (Valley Behavioral Health, 2019). Onset of conduct disorder behaviors before age 10 occurs primarily in boys; onset after age 10 occurs in girls and boys. As many as 30% to 50% of these children are diagnosed with antisocial personality disorder as adults Onset and Clinical Course Two subtypes of conduct disorder are based on age at onset. The childhood-onset type involves symptoms before 10 years of age, including physical aggression toward others and disturbed peer relationships. These children are more likely to have persistent conduct disorder and develop antisocial personality disorder as adults. Adolescent-onset type is defined by no behaviors of conduct disorder until after 10 years of age. These adolescents are less likely to be aggressive, and they have more normal peer relationships. They are less likely to have persistent conduct disorder or antisocial personality disorder as adults. Behaviors associated with conduct disorders fall into categories of aggression, destruction, deceit/theft, and rule violation, but they can vary in intensity. They are often described as mild, moderate, or severe. •Mild: The child has some conduct problems that cause relatively minor harm to others. Examples include repeated lying, truancy, minor shoplifting, and staying out late without permission. •Moderate: The number of conduct problems increases as does the amount of harm to others. Examples include vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity. •Severe: The person has many conduct problems that cause considerable harm to others. Examples include forced sex, cruelty to animals, physical fights, cruelty to peers, use of a weapon, burglary, robbery, and violation of previous parole or probation requirements. The course of conduct disorder is variable. People with the adolescent-onset type or mild problems can achieve adequate social relationships and academic or occupational success as adults. Those with the childhood-onset type or more severe problem behaviors are more likely to develop antisocial personality disorder as adults. Even those who do not have antisocial personality disorder may lead troubled lives with difficult interpersonal relationships, unhealthy lifestyles, and an inability to support themselves. Etiology Researchers generally accept that genetic vulnerability, environmental adversity, and factors such as poor coping interact to cause the disorder. Risk factors include poor parenting, low academic achievement, poor peer relationships, and low self-esteem; protective factors include resilience, family support, positive peer relationships, and good health (Gescher et al., 2018). There is a genetic risk for conduct disorder, though no specific gene marker has been identified. The disorder is more common in children who have a sibling with conduct disorder or a parent with antisocial personality disorder, substance abuse, mood disorder, schizophrenia, or ADHD. A lack of reactivity of the autonomic nervous system has been found in children with conduct disorder; this unresponsiveness is similar to adults with antisocial personality disorder. The abnormality may cause more aggression in social relationships as a result of decreased normal avoidance or social inhibitions. Research into the role of neurotransmitters is promising. Poor family functioning, marital discord, poor parenting, and a family history of substance abuse and psychiatric problems are all associated with the development of conduct disorder. Studies have shown that adolescents with conduct disorder had their first experience with alcohol and other drugs before age 12 years and were more likely to engage in higher risk behaviors, including, but not limited to, continued alcohol and substance use (Connor, 2017). Prenatal exposure to alcohol causes an increased risk for conduct disorder. Child abuse is an especially significant risk factor (Carliner, Gary, McLaughlin, & Keyes, 2017). The specific parenting patterns considered ineffective are inconsistent parental responses to the child's demands and giving in to demands as the child's behavior escalates. Exposure to violence in the media and community is a contributing factor for the child at risk in other areas. Socioeconomic disadvantages, such as inadequate housing, crowded conditions, and poverty, also increase the likelihood of conduct disorder in at-risk children. Academic underachievement, learning disabilities, hyperactivity, and problems with attention span are all associated with conduct disorder. Children with conduct disorder have difficulty functioning in social situations. They lack the abilities to respond appropriately to others and to negotiate conflict, and they lose the ability to restrain themselves when emotionally stressed. They are often accepted only by peers with similar problems.

Discuss the characteristics, risk factors, and family dynamics of disruptive behavior disorders

Disruptive behavior disorders include problems with the person's ability to regulate his or her own emotions or behaviors. They are characterized by persistent patterns of behavior that involve anger, hostility, and/or aggression toward people and property. The primary disorders in this category include oppositional defiant disorder (ODD), conduct disorder, and intermittent explosive disorder (IED). It has been posited by some psychiatrists that ODD and conduct disorder can be viewed on a continuum concept that would include antisocial personality disorder (see Chapter 18). Others believe that ODD is a milder variant of conduct disorder. IED is viewed as an impulse control disorder, but it is included in this discussion because it involves aggression toward people and property. The age of onset for IED can occur after age 6, but is often diagnosed from adolescence to young adulthood.

Review Etiology ADHD

Etiology o Environment o Prenatal Influences o Heredity o Damage to brain structure and functions - brain image findings Although much research has taken place, the definitive causes of ADHD remain unknown. There may be cortical-arousal, information-processing, or maturational abnormalities in the brain. Combined factors, such as environmental toxins, prenatal influences, heredity, and damage to brain structure and functions, are likely responsible. Prenatal exposure to alcohol, tobacco, and lead and severe malnutrition in early childhood increase the likelihood of ADHD. Although the relation between ADHD and dietary sugar and vitamins has been studied, results have been inconclusive (Spaniardi et al., 2017). Brain images of people with ADHD suggest decreased metabolism in the frontal lobes, which are essential for attention, impulse control, organization, and sustained goal-directed activity. Studies have also shown decreased blood perfusion of the frontal cortex in children with ADHD and frontal cortical atrophy in young adults with a history of childhood ADHD. Another study showed decreased glucose use in the frontal lobes of parents of children with ADHD who had ADHD themselves (Spaniardi et al., 2017). Evidence is not conclusive, but research in these areas seems promising. There seems to be a genetic link for ADHD that is most likely associated with abnormalities in catecholamine and, possibly, serotonin metabolism. Having a first-degree relative with ADHD increases the risk of the disorder by four to five times more than that of the general population (Spaniardi et al., 2017). Despite the strong evidence supporting a genetic contribution, there are also sporadic cases of ADHD with no family history of ADHD; this furthers the theory of multiple contributing factors. Risk factors for ADHD include family history of ADHD; male relatives with antisocial personality disorder or alcoholism; female relatives with somatization disorder; lower socioeconomic status; male gender; marital or family discord, including divorce, neglect, abuse, or parental deprivation; low birth weight; and various kinds of brain insult

Discuss appropriate interventions by describing specific ways to decrease violence and improve social and coping skills. Explain limit setting and time-out, emphasizing the need for consistency

For Conduct Disorder •Decreasing violence and increasing compliance with treatment •Protect others from client's aggression and manipulation. •Set limits for unacceptable behavior. •Provide consistency with the client's treatment plan. •Use behavioral contracts. •Institute time-out. •Provide a routine schedule of daily activities. •Improving coping skills and self-esteem •Show acceptance of the person, not necessarily the behavior. •Encourage the client to keep a diary. •Teach and practice problem-solving skills. •Promoting social interaction •Teach age-appropriate social skills. •Role model and practice social skills. •Provide positive feedback for acceptable behavior. •Providing client and family education Improving Coping Skills and Self-Esteem The nurse must show acceptance of clients as worthwhile individuals even if their behavior is unacceptable. This means that the nurse must be matter of fact about setting limits and must not make judgmental statements about clients. He or she must focus only on the behavior. For example, if a client broke a chair during an angry outburst, the nurse would say, Promoting Social Interaction Clients with conduct disorder may not have age-appropriate social skills, so teaching social skills is important. The nurse can role model these skills and help clients practice appropriate social interaction. The nurse identifies what is not appropriate, such as profanity and name calling, and also what is appropriate. Clients may have little experience discussing the news, current events, sports, or other topics. As they begin to develop social skills, the nurse can include other peers in these discussions. Positive feedback is essential to let clients know they are meeting expectations.

Hallucinogens

Hallucinogens Hallucinogens are substances that distort the user's perception of reality and produce symptoms similar to psychosis, including hallucinations (usually visual) and depersonalization. Hallucinogens also cause increased pulse, blood pressure, and temperature; dilated pupils; and hyperreflexia. Examples of hallucinogens are mescaline, psilocybin, lysergic acid diethylamide, and "designer drugs" such as ecstasy. Phencyclidine (PCP), developed as an anesthetic, is included in this section because it acts similarly to hallucinogens. Intoxication and Overdose Hallucinogen intoxication is marked by several maladaptive behavioral or psychological changes: anxiety, depression, paranoid ideation, ideas of reference, fear of losing one's mind, and potentially dangerous behaviors such as jumping out a window in the belief that one can fly. Physiological symptoms include sweating, tachycardia, palpitations, blurred vision, tremors, and lack of coordination. PCP intoxication often involves belligerence, aggression, impulsivity, and unpredictable behavior (Bertron, Seto, & Lindsley, 2018). Toxic reactions to hallucinogens (except PCP) are primarily psychological; overdoses as such do not occur. These drugs are not a direct cause of death, though fatalities have occurred from related accidents, aggression, and suicide. Treatment of toxic reactions is supportive. Psychotic reactions are managed best by isolation from external stimuli; physical restraints may be necessary for the safety of the client and others. PCP toxicity can include seizures, hypertension, hyperthermia, and respiratory depression. Medications are used to control seizures and blood pressure. Cooling devices such as hyperthermia blankets are used, and mechanical ventilation is used to support respirations (Burchum & Rosenthal, 2018). Withdrawal and Detoxification No withdrawal syndrome has been identified for hallucinogens, though some people have reported a craving for the drug. Hallucinogens can produce flashbacks, which are transient recurrences of perceptual disturbances like those experienced with hallucinogen use. These episodes occur even after all traces of the hallucinogen are gone and may persist for a few months up to 5 years. **Psychosis cause from hallucinogens can cause bizarre, aggressive, unsafe behavior

Discuss methods used to treat conduct disorder

Many treatments have been used for conduct disorder with only modest effectiveness. Early intervention is more effective, and prevention is more effective than treatment. Dramatic interventions, such as "boot camp" or incarceration, have not proved effective and may even worsen the situation. Treatment must be geared toward the client's developmental age; no one treatment is suitable for all ages. Preschool programs, such as Head Start, result in lower rates of delinquent behavior and conduct disorder through use of parental education about normal growth and development, stimulation for the child, and parental support during crises. For school-aged children with conduct disorder, the child, family, and school environment are the focus of treatment. Techniques include parenting education, social skills training to improve peer relationships, and attempts to improve academic performance and increase the child's ability to comply with demands from authority figures. Family therapy is considered to be essential for children in this age group (Carr, Hartnett, Brosnan, & Sharry, 2017). Adolescents rely less on their parents and more on peers, so treatment for this age group includes individual therapy. Many adolescent clients have some involvement with the legal system as a result of criminal behavior, and consequently, they may have restrictions on their freedom. Use of alcohol and other drugs plays a more significant role for this age group; any treatment plan must address this issue. The most promising treatment approach includes keeping the client in his or her environment with family and individual therapies. The plan usually includes conflict resolution, anger management, and teaching social skills. Medications alone have little effect, but may be used in conjunction with treatment for specific symptoms. For example, the client who presents a clear danger to others (physical aggression) may be prescribed an antipsychotic medication, such as risperidone (Risperdal). Clients with labile moods may benefit from lithium or another mood stabilizer such as carbamazepine (Tegretol) or valproic acid (Depakote) (Connor, 2017).

Wandering is a symptom of Alzheimer's type dementia

Mood and Affect Initially, clients with dementia experience anxiety and fear over the beginning losses of memory and cognitive functions. Nevertheless, they may not express these feelings to anyone. Mood becomes more labile over time and may shift rapidly and drastically for no apparent reason. Emotional outbursts are common and usually pass quickly. Clients may display anger and hostility, sometimes toward other people. They begin to demonstrate catastrophic emotional reactions in response to environmental changes that clients may not perceive or understand accurately or when they cannot respond adaptively. These catastrophic reactions may include verbal or physical aggression, wandering at night, agitation, or other behaviors that seem to indicate a loss of personal control.

Correlate the role of denial in identifying persons with substance use problems

Nursing Diagnosis Ineffective Denial: Unsuccessful attempt to ignore or minimize reality of events or situations that are unpleasant to confront ASSESSMENT DATA •Denial or minimization of alcohol use or dependence •Blaming others for problems •Reluctance to discuss self or problems •Lack of insight •Failure to accept responsibility for behavior •Viewing self as different from others •Rationalization of problems •Intellectualization EXPECTED OUTCOMES Immediate The client will •Participate in a treatment program; for example, attend activities and participate in group and therapy sessions within 24 to 48 hours. •Identify negative effects of his or her behavior on others within 24 to 48 hours. •Abstain from drug and alcohol use throughout treatment program. •Verbalize acceptance of responsibility for own behavior, including alcohol dependence and problems related to alcohol use (such as losing his or her job) within 24 to 48 hours. Stabilization The client will •Express acceptance of alcoholism as an illness. •Maintain abstinence from alcohol. •Demonstrate acceptance of responsibility for own behavior. •Verbalize knowledge of illness and treatment plan. Community The client will •Follow through with discharge plans regarding employment, support groups, and so forth; for example, identify community resources and make initial appointment or schedule time to participate in support group sessions. IMPLEMENTATION Nursing Interventions Rationale Give the client and significant others information about alcoholism in a matter-of-fact manner. Do not argue, but dispel myths such as "I'm not an alcoholic if I only drink on weekends," or "I can learn to just drink alcohol socially."* Most clients lack factual knowledge about alcoholism as an illness. If the client can engage you in semantic arguments or debates, the client can keep the focus off him or herself and personal problems. Avoid the client's attempts to focus only on external problems (such as marital or employment problems) without relating them to the problem of alcoholism. The problem of alcoholism must be dealt with first because it affects all other areas. Encourage the client to identify behaviors that have caused problems in his or her life. The client may deny or lack insight into the relationship between his or her problems or behaviors. Do not allow the client to rationalize difficulties or to blame others or circumstances beyond the client's control. Rationalizing and blaming others give the client an excuse to continue his or her behavior. Consistently redirect the client's focus to his or her own problems and to what he or she can do about them. You can facilitate the client's acceptance of responsibility for his or her own behavior. Positively reinforce the client when he or she identifies or expresses feelings or shows any insight into his or her behaviors or consequences. You convey acceptance of the client's attempts to express feelings and accept responsibility for his or her own behavior. Encourage other clients in the program to provide feedback for each other. Peer feedback is usually valued by the client because it comes from others with similar problems.

Discuss the types of disruptive behavior disorders and the various views of this spectrum of disorders

Oppositional defiant disorder (ODD) consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations. A certain level of oppositional behavior is common in children and adolescents; indeed, it is almost expected at some phases such as 2 to 3 years of age and in early adolescence. Table 23.1 contrasts acceptable characteristics with abnormal behavior in adolescents. ODD is diagnosed only when behaviors are more frequent and intense than in unaffected peers and cause dysfunction in social, academic, or work situations. The disruptive, defiant behaviors usually begin at home with parents or parental figures and are more intense in this setting than settings outside the home. Intermittent explosive disorder (IED) involves repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts, usually lasting less than 30 minutes. During these episodes, there may be physical injury to others, destruction of property, and injury to the individual as well. The intensity of the emotional outburst is grossly out of proportion to the stressor or situation. In other words, a minor issue or occurrence may result in rage, aggression, and assault of others. The episode may occur with seemingly no warning. Afterward, the individual may be embarrassed and feel guilty or remorseful for his or her actions. But that does not prevent future impulsive, aggressive outbursts. Kleptomania is characterized by impulsive, repetitive theft of items not needed by the person, either for personal use or monetary gain. Tension and anxiety are high prior to the theft, and the person feels relief, exhilaration, or gratification while committing the theft. The item is often discarded after it is stolen. Kleptomania is more common in females and often has negative legal, career, family, and social consequences. Pyromania is characterized by repeated, intentional fire-setting. The person is fascinated about fire and feels pleasure or relief of tension while setting and watching the fires. There is neither any monetary gain or revenge or other reason, such as concealing other crimes, nor is it associated with another major mental disorder. Pyromania as a primary disorder is rare. Persons, if caught, become part of the legal rather than mental health system.

Most frequently assessed in kids - teachers refer them to be tested (they let parents know)

Patients with ADHD have abnormalities in the frontal lobe of the brain Strategies for Home and School Medications do not automatically improve the child's academic performance or ensure that he or she makes friends. Behavioral strategies are necessary to help the child master appropriate behaviors. Environmental strategies at school and home can help the child succeed in those settings. Educating parents and helping them with parenting strategies are crucial components of effective treatment of ADHD. Effective approaches include providing consistent rewards and consequences for behavior, offering consistent praise, using time-out, and giving verbal reprimands. Additional strategies are issuing daily report cards for behavior and using point systems for positive and negative behavior. In therapeutic play, play techniques are used to understand the child's thoughts and feelings and to promote communication. This should not be confused with play therapy, a psychoanalytic technique used by psychiatrists. Dramatic play is acting out an anxiety-producing situation such as allowing the child to be a doctor or use a stethoscope or other equipment to take care of a patient (a doll). Play techniques to release energy could include pounding pegs, running, or working with modeling clay. Creative play techniques can help children to express themselves; for example, by drawing pictures of themselves, their family, and peers. These techniques are especially useful when children are unable or unwilling express themselves verbally.

Discuss the maintenance of cognitive functioning with interventions, such as providing emotional support, and specific ways to promote interaction with the environment (reminiscence, distraction, time away, going along with their reality)

Providing Emotional Support The therapeutic relationship between client and nurse involves "empathic caring," which includes being kind, respectful, calm, and reassuring and paying attention to the client. Nurses use these same qualities with many different clients in various settings. In most situations, clients give positive feedback to the nurse or caregiver, but clients with dementia often seem to ignore the nurse's efforts and may even respond with negative behavior such as anger or suspicion. This makes it more difficult for the nurse or caregiver to sustain caring behavior. Nevertheless, nurses and caregivers must maintain all the qualities of the therapeutic relationship even when clients do not seem to respond. Because of their disorientation and memory loss, clients with dementia often become anxious and require much patience and reassurance. The nurse can convey reassurance by approaching the client in a calm, supportive manner, as if nurse and client are a team—a "we can do it together" approach. The nurse reassures the client that he or she knows what is happening and can take care of things when the client is confused and cannot do so. Promoting Interaction and Involvement In a psychosocial model of dementia care, the nurse or caregiver plans activities that reinforce the client's identity and keep him or her engaged and involved in the business of living. The nurse or caregiver tailors these activities to the client's interests and abilities. They should not be routine group activities that "everyone is supposed to do." For example, a client with an interest in history may enjoy documentary programs on television; a client who likes music may enjoy singing. Clients often need the involvement of another person to sustain attention in the activity and to enjoy it more fully. Those who have long periods without anything to engage their interest are more likely to become restless and agitated. Clients engaged in activities are more likely to stay calm. A wide variety of activities have proven beneficial for clients with dementia. Music, dancing, pet- or animal-assisted therapy, aromatherapy, and multisensory stimulation are examples of activities that can be explored to maximize the client's involvement with the environment and enhance the quality of his or her life

Sedatives

Sedatives, Hypnotics, and Anxiolytics Intoxication and Overdose This class of drugs includes all central nervous system depressants: barbiturates, nonbarbiturate hypnotics, and anxiolytics, particularly benzodiazepines. Benzodiazepines and barbiturates are the most frequently abused drugs in this category. The intensity of the effect depends on the particular drug. The effects of the drugs, symptoms of intoxication, and withdrawal symptoms are similar to those of alcohol. In the usual prescribed doses, these drugs cause drowsiness and reduce anxiety, which is the intended purpose. Intoxication symptoms include slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, and even stupor and coma. Benzodiazepines alone, when taken orally in overdose, are rarely fatal, but the person is lethargic and confused. Treatment includes gastric lavage followed by ingestion of activated charcoal and a saline cathartic; dialysis can be used if symptoms are severe (Burchum & Rosenthal, 2018). The client's confusion and lethargy improve as the drug is excreted.Barbiturates, in contrast, can be lethal when taken in overdose. They can cause coma, respiratory arrest, cardiac failure, and death. Treatment in an intensive care unit is required using lavage or dialysis to remove the drug from the system and to support respiratory and cardiovascular function. Withdrawal and Detoxification The onset of withdrawal symptoms depends on the half-life of the drug (see Chapter 2). Medications such as lorazepam, with actions that typically last about 10 hours, produce withdrawal symptoms in 6 to 8 hours; longer acting medications, such as diazepam, may not produce withdrawal symptoms for 1 week. The withdrawal syndrome is characterized by symptoms that are the opposite of the acute effects of the drug—autonomic hyperactivity (increased pulse, blood pressure, respirations, and temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitation. Seizures and hallucinations occur only rarely in severe benzodiazepine withdrawal (Tamburin et al., 2017). Detoxification from sedatives, hypnotics, and anxiolytics is often medically managed by tapering the amount of the drug the client receives over a period of days or weeks, depending on the drug and the amount the client had been using. Tapering, or administering decreasing doses of a medication, is essential with barbiturates to prevent coma and death that occur if the drug is stopped abruptly. For example, when tapering the dosage of a benzodiazepine, the client may be given Valium, 10 mg four times a day; the dose is decreased every 3 days, and the number of times a day the dose is given is also decreased until the client safely withdraws from the drug.

Stimulants

Stimulants Stimulants are drugs that stimulate or excite the central nervous system and have limited clinical use (with the exception of stimulants used to treat attention-deficit/hyperactivity disorder; see Chapter 22) and a high potential for abuse. Amphetamines (uppers) were popular in the past; they were used by people who wanted to lose weight quickly or stay awake. Cocaine, an illegal drug with virtually no clinical use in medicine, is highly addictive and a popular recreational drug because of the intense and immediate feeling of euphoria it produces. Methamphetamine is particularly dangerous. It is highly addictive and causes psychotic behavior. Brain damage related to its use is frequent, primarily as a result of the substances used to make it—that is, liquid agricultural fertilizer. The percentage of people admitted to inpatient settings for methamphetamine abuse had increased in 49 of the 50 states in the United States from 2000 to 2005. Use of methamphetamine, however, seems to have peaked and actually declined in the past few years (Iannucci & Weiss, 2017). It may well increase again in the future, reflecting the pattern of use of many substances. Intoxication and Overdose Intoxication from stimulants develops rapidly; effects include the high or euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic or repetitive behavior, anger, fighting, and impaired judgment. Physiological effects include tachycardia, elevated blood pressure, dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmias. Overdoses of stimulants can result in seizures and coma; deaths are rare (Iannucci & Weiss, 2017). Treatment with chlorpromazine (Thorazine), an antipsychotic, controls hallucinations, lowers blood pressure, and relieves nausea (Burchum & Rosenthal, 2018). Withdrawal and Detoxification Withdrawal from stimulants occurs within a few hours to several days after cessation of the drug and is not life-threatening. Marked dysphoria is the primary symptom and is accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation. Marked withdrawal symptoms are referred to as "crashing"; the person may experience depressive symptoms, including suicidal ideation, for several days. Stimulant withdrawal is not treated pharmacologically.

Tic Disorders

Tic Disorders A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. Tics can be suppressed but not indefinitely. Stress exacerbates tics, which diminish during sleep and when the person is engaged in an absorbing activity. Common simple motor tics include blinking, jerking the neck, shrugging the shoulders, grimacing, and coughing. Common simple vocal tics include clearing the throat, grunting, sniffing, snorting, and barking. Complex vocal tics include repeating words or phrases out of context, coprolalia (use of socially unacceptable words, frequently obscene), palilalia (repeating one's own sounds or words), and echolalia (repeating the last-heard sound, word, or phrase). Complex motor tics include facial gestures, jumping, or touching or smelling an object. Tic disorders tend to run in families. Abnormal transmission of the neurotransmitter dopamine is thought to play a part in tic disorders. Tic disorders are usually treated with risperidone (Risperdal) or olanzapine (Zyprexa), which are atypical antipsychotics. It is important for clients with tic disorders to get plenty of rest and to manage stress because fatigue and stress increase symptoms. Tourette disorder involves multiple motor tics and one or more vocal tics, which occur many times a day for more than 1 year. The complexity and severity of the tics change over time, and the person experiences almost all the possible tics described previously during his or her lifetime. The person has significant impairment in academic, social, or occupational areas and feels ashamed and self-conscious. This rare disorder (4 or 5 in 10,000) is more common in boys and is usually identified by 7 years of age. Some people have lifelong problems; others have no symptoms after early adulthood.

Review psychopharmacology and behavioral strategies that can be used with ADHD

Treatment No one treatment has been found to be effective for ADHD; this gives rise to many different approaches such as sugar-controlled diets and megavitamin therapy. Parents need to know that any treatment heralded as the cure for ADHD is probably too good to be true. ADHD is chronic; goals of treatment involve managing symptoms, reducing hyperactivity and impulsivity, and increasing the child's attention so that he or she can grow and develop normally. The most effective treatment combines pharmacotherapy with behavioral, psychosocial, and educational interventions. Psychopharmacology Medications are often effective in decreasing hyperactivity and impulsiveness and improving attention; this enables the child to participate in school and family life. The most common medications are methylphenidate (Ritalin) and an amphetamine compound (Adderall). Methylphenidate is effective in 70% to 80% of children with ADHD; it reduces hyperactivity, impulsivity, and mood lability and helps the child pay attention more appropriately. Dextroamphetamine (Dexedrine) and pemoline (Cylert) are other stimulants used to treat ADHD. The most common side effects of these drugs are insomnia, loss of appetite, and weight loss or failure to gain weight. Methylphenidate, dextroamphetamine, and amphetamine compounds are also available in a sustained-release form taken once daily; this eliminates the need for additional doses when the child is at school. Methylphenidate is also available in a daily transdermal patch, marketed as Daytrana. Because pemoline can cause liver damage, it is the last of these drugs to be prescribed. Giving stimulants during daytime hours usually effectively combats insomnia. Eating a good breakfast with the morning dose and substantial nutritious snacks late in the day and at bedtime helps the child maintain an adequate dietary intake. When stimulant medications are not effective or their side effects are intolerable, antidepressants are the second choice for treatment (see Chapter 2). Atomoxetine (Strattera) is the only nonstimulant drug specifically developed and tested by the U.S. Food and Drug Administration for the treatment of ADHD. It is an antidepressant, specifically a selective norepinephrine reuptake inhibitor. The most common side effects in children during clinical trials were decreased appetite, nausea, vomiting, tiredness, and upset stomach. In adults, side effects were similar to those of other antidepressants, including insomnia, dry mouth, urinary retention, decreased appetite, nausea, vomiting, dizziness, and sexual side effects. In addition, atomoxetine can cause liver damage, so individuals taking the drug need to have liver function tests periodically (Burchum & Rosenthal, 2018). Table 22.1 lists drugs, dosages, and nursing considerations for clients with ADHD.