Sem 3 Unit 5

Intellectual disability defined by the American Association on Intellectual and Developmental Disabilities in children consists of three components

(1) intellectual functioning, (2) functional strengths and weaknesses, (3) age younger than 18 years at time of diagnosis

Early Signs Suggestive of Cognitive Impairment

- Dysmorphic syndromes (e.g., Down syndrome, fragile X syndrome [FXS]) - Irritability or nonresponsiveness to environment - Major organ system dysfunction (e.g., feeding or breathing difficulties) - Gross motor delay - Fine motor delay - Language difficulties or delay - Behavior difficulties

Results of standardized tests are helpful in contributing to the diagnosis of Cognitive impairment (CI). Tests for assessing adaptive behaviors include the

- Vineland Social Maturity Scale - American Association on Mental Retardation Adaptive Behavior Scale.

Infants exposed to methamphetamine can experience signs of withdrawal such as

- agitation, - tremors, - hypertonia, - poor feeding, - state disorganization

Several physical problems are associated with Down syndrome

- congenital heart malformations, the most common being septal defects. - Respiratory tract infections are prevalent and, when combined with cardiac anomalies, are the chief causes of death (especially during the first yr of life) - Hypotonicity of chest and abdominal muscles and dysfunction of the immune system - thyroid dysfunction, especially congenital hypothyroidism, - increased incidence of leukemia.

Early studies of cocaine exposure identified an increased incidence of

- gastroschisis, - genitourinary anomalies, - stroke

There is increasing evidence that marijuana can cause problems with neurologic development including

- hyperactivity, - lower cognitive function, - attention problems

selective serotonin reuptake inhibitors (SSRIs) Signs of withdrawal in infants An increased risk for

- hypertonia, - tremulousness, - wakefulness, - high-pitched crying, - feeding problems. persistent pulmonary hypertension

Regarding excitability from cocaine, The behaviors of an excitable neonate can include

- hypertonicity, irritability, - an inability to be consoled, - an intolerance to changes in routine

the nature of substance use and addiction makes the user susceptible to disorders such as

- infection (HBV, HIV), - the hazards of inadequate nutrition - preterm birth.

Alcohol withdrawal in infants Signs and symptoms include

- jitteriness, - increased tone and reflex responses, - irritability. - Seizures are common.

Regarding neurobehavioral depression from cocaine, The behaviors of a depressed infant include

- lethargy, - hypotonia, - difficulty in arousing

facial features of fetal alcohol syndrome

- low nasal bridge - minor ear abnormalities - indistinct philtrum - micrognathia - thin upper lip - epicanthal fold - short palpebral fissures - flat midface and short nose

The degree of withdrawal is closely related to the The most severe symptoms are observed in the infants of mothers who have

- type and amount of drug the mother has habitually taken, - the length of time she has been taking the drug, - her drug level at the time of birth taken large amounts of drugs over a long period of time. - the nearer to the time of birth that the mother takes the drug, the longer it takes the child to develop withdrawal, and the more severe the manifestations.

Infants exposed only to heroin may begin to exhibit signs of drug withdrawal within

12 to 24 hours

Women with alcohol-related disorders have what percentage of risk of fetal alcohol syndrome?

35% risk of having a child with defects

The clinical manifestations can fall into any one or all of the following categories: CNS, GI, respiratory, and autonomic nervous system signs. The manifestations become most pronounced between

48 and 72 hours of age and can last from 6 days to 8 weeks, depending on the severity of the withdrawal

Signs of Neonatal Abstinence Syndrome Neurologic Gastrointestinal Autonomic Respiratory Miscellaneous

Neurologic • Irritability • Seizures • Hyperactivity • High-pitched cry • Tremors • Exaggerated Moro reflex • Hypertonicity of muscles Gastrointestinal • Poor feeding • Diarrhea • Dehydration • Vomiting • Frantic, uncoordinated sucking • Gastric residuals Autonomic • Diaphoresis • Fever • Mottled skin Respiratory • Tachypnea (>60 breaths/min) • Nasal flaring • Nasal stuffiness Miscellaneous • Disrupted sleep patterns • Diaphoresis • Excoriations (knees, face) • Temperature instability loose stools; tachycardia; fever; projectile vomiting; crying; nasal stuffiness; and generalized perspiration, which is unusual in newborns.

As adults, affected by Fetal Alcohol Syndrome individuals tend to have

a short stature

Caring for the child during hospitalization can be Frequently, nurses are unfamiliar with children who are To prevent engaging in this nontherapeutic approach, nurses must use the Parents should

a special challenge. cognitively impaired, and they may cope with their feelings of insecurity and fear by ignoring or isolating the child. - destructive to the child's sense of self-esteem and optimum development, and it may impair the parents' ability to cope with the stress of the experience mutual participation model in planning the child's care. stay with their child but not be made to feel as if the responsibility is totally theirs.

Optimal development involves more than achieving independence. It requires appropriate guidance for

acceptable social behavior and personal feelings of self-esteem, worth, and security.

Explain procedures to the child using methods of communication that are at the Generally, explanations should be Demonstration either through

appropriate cognitive level simple, short, and concrete, emphasizing what the child will physically experience. actual practice or with visual aids is always preferable to verbal explanation. - Include parents in preprocedural teaching to aid in the child's learning

When a child with CI is born, parents often need

assistance in promoting normal developmental skills that other children learn easily. - There is no way to predict when a child should be able to master self-care skills, such as feeding, toileting, dressing, and grooming, because a wide age variability exists in the CI child who is able to accomplish such functions.

Because both receptive and expressive skills may be impaired, children with CI need frequent

audiometric testing and should be fitted with hearing aids if indicated.

This is especially problematic from a social and legal standpoint because the pregnant woman is often aware of the consequences of admitting to substance abuse and therefore may be less likely to readily admit to the problem for fear of social and legal repercussions. If the mother has had good prenatal care, the practitioner is likely

aware of the problem and may have instituted therapy before birth.

For children with CI, Discipline must

begin early - Limit-setting measures need to be simple, consistently applied, and appropriate for the child's mental age.

Some SSRIs are transferred into

breast milk.

Alcohol-related birth defects (ARBD) refers to persons with

cardiac, renal, musculoskeletal, or hearing problems, or any combination of these

Down syndrome is the most common

chromosomal abnormality of a generalized syndrome

To protect the child or adolescent with CI from sexual abuse, parents must

closely observe their child or adolescent's activities and associates.

Researchers have concluded that variables such as the mother's lack of prenatal care; poor nutrition; and use of tobacco, alcohol, and other drugs during pregnancy compound the effects of

cocaine exposure in the infant

Children with CI have a marked deficit in their ability to However, these children can learn to

discriminate between two or more stimuli because of difficulty in recognizing the relevance of specific cues. discriminate if the cues are presented in an exaggerated, concrete form and if all extraneous stimuli are eliminated. - Their deficit in discrimination also implies that concrete ideas are learned much more effectively than abstract ideas

Heavy cocaine exposure has reported to result in (for the infant)

elevated or irregular heart rate after birth

Another cognitive deficit is in short-term memory. Whereas children of average intelligence can remember several words, numbers, or directions at one time, children with CI are Therefore, they need Use what?

less able to do so. simple, one-step directions. - Learning through a step-by-step process requires a task analysis in which each task is separated into its necessary components and each step is taught completely before proceeding to the next activity.

Regarding pregnant drug use, Loose stools, poor intake, and regurgitation after feeding predispose these infants to In addition, they burn up energy with What can be done for this?

malnutrition, dehydration, skin breakdown, and electrolyte imbalance continual activity and increased oxygen consumption - Frequent weighing, - careful monitoring of intake and output and electrolytes, - additional caloric supplementation

Cocaine effects on fetuses are secondary to what? Which include? Consequently, the fetus experiences

maternal effects, which include: - increased blood pressure (BP), - decreased uterine blood flow, - increased vascular resistance. decreased blood flow and oxygenation because of placental and fetal vasoconstriction

The long-term effects of methamphetamine exposure on children remain unclear; however, some studies have shown problems with

mathematics and language skills

The Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) may be used for

medically stable newborns who are at least 30 weeks of gestation and up to 48 weeks of corrected or conceptional age

The term intellectual disability has widely replaced the term

mental retardation

The teaching of socially acceptable sexual behavior in children with CI is especially important to

minimize sexual exploitation.

The Neonatal Abstinence Scoring System or Finnegan tool was developed to This system is also designed to help nurses and other health care professionals evaluate the

monitor infants in an objective manner and evaluate their response to clinical and pharmacologic interventions severity of infants' withdrawal symptoms

Breastfeeding infants whose mothers are taking SSRIs should be

monitored for sleep disturbances, irritability, and poor feeding

One critical area of learning that has had a tremendous impact on education for cognitively impaired individuals is

motivation or the use of positive reinforcement to encourage the accomplishment of specific tasks or behaviors.

Either of two types of behavior may emerge as a result of the effects of cocaine on fetal development:

neurobehavioral depression or excitability

Methadone treatment does not

prevent withdrawal reaction in neonates, but the clinical course may be modified.

Sudden infant death syndrome (SIDS) and HIV infection are observed more commonly in infants born to

users of methadone and heroin.

Techniques for Managing Disruptive Behaviors

- Behavioral contract: A verbal or written agreement between the patient and nurse or other parties (e.g., family, treatment team, teacher) about behaviors, expectations, and needs. The contract is periodically evaluated and reviewed and typically coupled with rewards and other contingencies, positive and negative. - Collaborative and proactive solutions: A therapeutic intervention used with parents and children designed to help both identify and define problematic behaviors, specific triggers, and develop a collaborative method for creating mutually agreeable solutions to the specific situation or trigger. - Counseling: Verbal interactions, role playing, and modeling to teach, coach, or maintain adaptive behavior and provide positive reinforcement. Best used with motivated youth and those with well-developed communication and self-reflective skills. - Modeling: A method of learning behaviors or skills by observation and imitation that can be used in a wide variety of situations. It is enhanced when the modeler is perceived to be similar (e.g., age, interests) and attending to the task is required. - Role playing: A counseling technique in which the nurse, the patient, or a group of youngsters acts out a specified script or role to enhance their understanding of that role, learn and practice new behaviors or skills, and practice specific situations. It requires well-developed expressive and receptive language skills. - Planned ignoring: When behaviors are determined by staff to be attention seeking and not dangerous, they may be ignored. Additional interventions may be used in conjunction (e.g., positive reinforcement for on-task actions). - Use of signals or gestures: Use a word, a gesture, or eye contact to remind the child to use self-control. To help promote behavioral change, this may be used in conjunction with a behavioral contract and a reward system. An example is placing your finger to your lips and making eye contact with a child who is talking during a quiet drawing activity. - Physical distance and touch control: Moving closer to the child for a calming effect, perhaps putting an arm around the child (with permission). Evaluate the effect of this because some children may find this more agitating and may need more space and less physical closeness. It also may involve putting the nurse or a staff member between certain children who have a history of conflict. - Redirection: A technique used after an undesirable or inappropriate behavior to engage or re-engage an individual in an appropriate activity. It may involve the use of verbal directives (e.g., setting firm limits), gestures, or physical prompts. - Additional affection: Involves giving a child planned emotional support for a specific problem or engaging in an enjoyable activity. It can be used to redirect a child away from an undesirable activity as well. This shows acceptance of the child while ignoring the behavior and can increase rapport in the nurse-patient relationship. - Use of humor: Use well-timed appropriate kidding about some external nonpersonal (to the child) event as a diversion to help the child save face and relieve feelings of guilt or fear. - Clarification as intervention: Breaking down a problem situation that a child experiences can help the child understand the situation, the roles of others, and his or her own motivation for the behavior. This can be done verbally and using worksheets depending on the age and functional level of the child. - Restructuring: Changing an activity in a way that will decrease the stimulation or frustration (e.g., shorten a story or change to a physical activity). This requires flexibility and planning and an alternative if the activity is not going well. - Limit setting: Involves giving direction, stating an expectation, or telling a child what to do or where to go. Caregivers should do this firmly, calmly, without judgment or anger, preferably in advance of any problem behavior occurring, and all staff should do this consistently in a treatment setting. An example would be, "I would like for you to stop turning the light on and off." - Simple restitution: Refers to a procedure in which an individual is required or expected to correct the adverse environmental or relational effects of his or her misbehavior by restoring the environment to its prior state, making a plan to correct his or her actions with the nurse, and implementing the plan (e.g., apologizing to the people harmed, fixing the chairs that are upturned). - Physical restraint: Using mechanical means to control and protect the child from impulses to act out and hurt self or others.

The cause of postpartum depression can be

- biologic, - psychologic, - situational, - multifactorial

Regarding down syndrome, Measures to lessen respiratory problems include

- clearing the nose with a bulb-type syringe, - rinsing the mouth with water after feedings, - increasing fluid intake, a - using a cool-mist vaporizer to keep the mucous membranes moist and the secretions liquefied. - changing the child's position frequently, - practicing good hand washing, - properly disposing of soiled articles, such as tissue

Realistic outcomes for autism

- follow simple rules of interactive games - Direct messages appropriately - Express emotions

comorbid conditions for OCD include

- major depressive disorder - bipolar disorder - eating disorders

tricyclic antidepressants (TCAs) take how long to work

10 to 14 days or longer before they begin to work. Full effects may not be seen for 4 to 8 weeks.

Regarding depression treatment, Light Therapy Ideal treatment consists of Negative side effects

30 to 45 minutes of exposure daily to a 10,000-lux light source - Morning exposure is best. headache and jitteriness.

Nursing Diagnosis Lack of cooperation or imaginative play with peers

Activity intolerance Situational low self-esteem Impaired social interaction

Nursing Diagnosis Frequent disregard for bodily needs

Bathing or toileting Risk for situational low self-esteem Self-care deficit

Nursing Diagnosis Head banging, face slapping, hand biting

Ineffective impulse control Risk for injury Risk for trauma Self-mutilation

Nursing Diagnosis Depression

Risk for self-directed violence Stress overload Spiritual distress

infants born to heavy drinkers have twice the risk for

congenital abnormalities than those born to moderate drinkers

Risky drinking is

consuming alcohol in excess of established guidelines set forth by the National Institute on Alcohol Abuse and Alcoholism

Regarding Paternal Postpartum Depression, Men are not routinely screened for perinatal depressive symptoms. There is no what? What can be used?

depression scale designed for this specific use. Some experts recommend using the Edinburgh Postnatal Depression Scale in combination with the Gotland Male Depression Scale to identify men with signs of PPND

SSRIs are frequently the first-line treatment in

depression.

Parents of autistic children have reported their child showed

less interest in social interaction (e.g., abnormal eye contact, decreased response to own name, decreased imitation, unusual repetitive behavior) and have verbal and motor delay

Regarding down syndrome, During infancy, the child's skin is Skin care involves the

pliable and soft. However, it gradually becomes rough and dry and is prone to cracking and infection. - use of minimum soap and application of lubricants. - Lip balm is applied to the lips, especially when the child is outdoors, to prevent excessive chapping.

Regarding Postpartum psychosis, The mother may think the infant is

possessed by the devil, has special powers, or is destined for a terrible fate. - Some women will insist that something is wrong with the baby or accuse nurses or family members of hurting or poisoning their child.

Postpartum baby blues usually go away when

quickly in 1-2 weeks

These adolescents also need practical sexual information regarding anatomy, physical development, and conception.* Because they are easy to persuade and lack judgment, they need a

well-defined, concrete code of conduct with specific instructions for handling certain situations.

A closely related set of disorders anxiety results in abnormal selective overattention or obsessions. These obsessive-compulsive and related disorders include the following:

• Obsessive-compulsive disorder • Body dysmorphic disorder • Hoarding disorder • Trichotrillomania (hair pulling) disorder • Excoriation (skin picking) disorder

Regarding Patient Teaching Smoking and Tobacco Use Cessation Use Approved Nicotine Replacement Systems

• Use a nicotine replacement agent unless you are a pregnant or nursing woman • Do not use other forms of tobacco when using nicotine replacement systems.

One example of a culture-bound syndrome of anxiety is ataque de nervios, or in English Symptoms are dramatic:

"attack of the nerves." - found primarily among Hispanic populations in response to stressful events such as a death, acute family discord, or witnessing an accident. - sudden trembling, - faintness, palpitations, - out-of-control shouting, - heat that moves from the chest to head, - seizure-like activities. - little memory of it.

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) consists of three components:

(1) screening or assessing for substance use problems using standardized screening tools, (2) brief intervention or teaching patients about the consequences of substance use and abuse, (3) referring those who screen positive for further treatment

Anhedonia refers to the

(an "without" + hedone "pleasure" = inability to feel happy) absence of happiness or pleasure in aspects of life that once made them happy.

Types of tricyclic antidepressants (TCAs) for stimulating or sedating Regardless of which TCA is given, the initial dose should always be

- A stimulating TCA, such as desipramine (Norpramin) or protriptyline (Vivactil), may be best for a patient who is lethargic and fatigued. - If a more sedating effect is needed for agitation or restlessness, drugs such as amitriptyline and doxepin (Sinequan) may be more appropriate choices. low and increased gradually.

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) CIWA-Ar categories, with the range of scores in each category, are as follows:

- Agitation 0-7 - Anxiety 0-7 - Auditory disturbances 0-7 - Headache 0-7 - Clouding of sensorium 0-4 - Paroxysmal sweats 0-7 - Tactile disturbances 0-7 - Tremor 0-7 - Visual disturbances 0-7

postpartum psychosis Medical Management It is usually advantageous for the mother to have

- Antipsychotics, mood stabilizers, benzodiazepines are the treatments of choice. - Other psychotropic medications such as antidepressants may be used based on the underlying diagnosis (e.g., bipolar mania, bipolar depression). - Electroconvulsive therapy (ECT) bilaterally administered - Psychotherapy is indicated after the period of acute psychosis has passed. contact with her baby if she so desires, but visits must be closely supervised.

screening tools for depression

- Beck Depression Inventory, - the Hamilton Depression Scale, - the Geriatric Depression Scale - The Patient Health Questionnaire-9 (PHQ-9)

Comorbidities for social anxiety disorder

- Bipolar disorder - body dysmorphic disorder - high-functioning autism - selective mutism

ADHD Environmental Manipulation

- Consistency between families and teachers in terms of reinforcing the same goals is essential - Children should be encouraged to make more appropriate choices and to take responsibility for their actions. - teaching parents how to make organizational charts (e.g., listing all activities that must be performed before leaving for school) - decrease distractions in the environment while the child is completing homework (e.g., turning off the television, having a consistent study area equipped with needed supplies), - helping parents understand ways to model positive behaviors and problem solving

The Care Continuum for Substance Use Disorders

- Detoxification (Detox) - Rehabilitation - Halfway Houses - Other Housing (community reintegration are also available in supportive housing units) - Partial Hospitalization Program - Intensive Outpatient Programs - Outpatient Treatment - Alcoholics Anonymous - Relapse Prevention

Regarding Patient Teaching Smoking and Tobacco Use Cessation Methods

- Develop a Quit Plan - Use Approved Nicotine Replacement Systems - Non-nicotine therapy options include the antidepressant bupropion (Zyban) (helps with withdrawal) - Support and Encouragement - Dealing With Urges to Use Tobacco - Avoiding Relapse - Behavioral therapy (helps with withdrawal) - Hypnosis (helps with withdrawal) - Clonidine (Catapres) (helps with withdrawal)

Nonpharmacological treatment for depression

- Electroconvulsive Therapy - Transcranial Magnetic Stimulation - Vagus Nerve Stimulation - Deep Brain Stimulation - Light Therapy - St. John's Wort - Exercise

Regarding substance abuse, For depressants opioid toxicity Nursing interventions

- First-line treatment administer naloxone (Naloxone reverses respiratory depression, coma, and other manifestations of toxicity.) - Monitor the patient closely because naloxone has a shorter duration of action than most opioids. (Repeated doses of naloxone may be required)

Gambling Disorder Treatment

- Gamblers Anonymous (GA) is a 12-step program (involves public confession, peer pressure, and peer counselors) - Hospitalization may help by removing patients from gambling environments. - selective serotonin reuptake inhibitors, - bupropion (Wellbutrin), - mood stabilizers (lithium), - anticonvulsants such as topiramate (Topamax - Naltrexone

Biological Factors of Depression

- Genetic - Biochemical - Hormonal - Inflammation - Diathesis-Stress Model

Guidelines for Counseling People with Depression Interventions

- Help the patient question underlying assumptions and beliefs and consider alternate explanations to problems. - Work with the patient to identify cognitive distortions that result in a negative self-perception. - Help the patient identify current coping skills and explore alternate coping skills. - Encourage exercise, such as running and/or weight lifting. - Encourage formation of supportive relationships, such as individual therapy, support groups, and peer support. - Provide information referrals, when needed, for religious or spiritual support (e.g., pastoral visits, readings, programs, tapes, community resources).

hypertensive crisis treatment

- If ingestion is recent, gastric lavage and charcoal may be helpful. - Pyrexia is treated with hypothermic blankets or ice packs. - Fluid therapy is essential, particularly with hyperthermia. - A short-acting antihypertensive agent such as nitroprusside, nitroglycerine, or phentolamine may be used. - Intravenous benzodiazepines are useful for agitation and seizure control.

Hallucinogen intoxication Intoxication is characterized by clinically significant psychological and behavioral changes. That includes, Treatment for hallucinogen intoxication includes

- Paranoia, - impaired judgment, - intensification of perceptions, - depersonalization, - derealization - talking the patient down. (reassurance that the symptoms are caused by the drug and that the symptoms will subside.) - In severe cases an antipsychotic such as haloperidol (Haldol) or a benzodiazepine such as diazepam (Valium) can be used in the short term.

Tricyclic Antidepressants (TCAs) Contraindications

- People who have recently had a myocardial infarction (or other cardiovascular problems), - those with narrow-angle glaucoma or a history of seizures, - women who are pregnant

Alcoholism Systemic Effects

- Peripheral Neuropathy - Alcoholic Myopathy - Alcoholic Cardiomyopathy - Esophagitis - Gastritis - Pancreatitis - Alcoholic Hepatitis - Cirrhosis of the Liver - Leukopenia - Thrombocytopenia - Cancer (head and neck, liver, breast, and colorectal cancers)

contributing factor to postpartum depression

- Poor nutrition - low Folate and vitamin B12

Substance abuse Environmental Risk Factors

- Poverty raises the risk of an unfavorable living environment, lack of parental supervision, poor educational resources, and impaired support systems - negative environmental events often begins within disadvantaged neighborhoods, increasing stress and anxiety along with a lack of or negative social ties, which contributes to depression - Coping mechanisms may include drugs and acting out behaviors leading to destructive consequences and interaction with the legal system.

There is evidence that depression has a negative effect on birth outcomes. Such as: We know that antidepressants cross the placenta. Treatment of severe depression, particularly with suicidal ideation, must

- Preeclampsia, diabetes, and hypertension - Low birth weight, preterm birth, and small size for gestational age weigh out the risks versus the benefits.

Risk for Situational Depression

- Problems at work/school - Illness - Death of loved one - Relationship problems, like divorce or fighting - Situational changes such as: retirement, going away to school (college), or divorce - Negative financial situations, such as money problems or losing a job - Life or death experiences such as physical assult, combat, or natural disaster - Existing mental health problems - Several difficult life circumstances happening at once - Biological factors including abnormalities in brain structures and chemistry, hormonal abnormalities, changes in genetics

Regarding Anxiety Pharmacological Interventions in Children and Adolescents, The FDA approved the

- SNRI duloxetine (Cymbalta) in 2014 for children aged 7 to 17 years for generalized anxiety disorder. - four medications for use in children with obsessive-compulsive disorder: clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft). - SSRIs are being used for generalized anxiety disorder, panic disorder, and social anxiety disorder with good results. For children with obsessive-compulsive and related disorders, SSRIs are also often used.

Anxiety Pharmacological Interventions

- SSRIs are considered the first line of defense in most anxiety and obsessive-compulsive-related disorders. - Monoamine oxidase inhibitors (MAOIs) - Benzodiazepines are most commonly used because they have a quick onset of action. - Buspirone (BuSpar) is an alternative antianxiety medication that does not cause dependence

Situation depression Symptoms

- Sadness - Hopelessness - Lack of enjoyment in normal activities - Regular crying - Constant worrying or feeling anxious or stressed out - Sleeping difficulties - Disinterest in food - Trouble focusing - Trouble carrying out daily activies - Feeling overwhelmed - Avoiding social situations and interactions - Not taking care of important matters like paying bills or going to work - Thoughts of suicide

Autism Pharmacological agents and what they do

- Second-generation antipsychotics risperidone (Risperdal) and aripiprazole (Abilify) have FDA approval for treating children 5 and 6 years of age and older, respectively. These drugs improve irritability that is expressed in severe temper tantrums, aggression, and self-injurious behavior. - The SSRIs are the most popular medication used in this population. They improve mood and reduce anxiety, which provides the patient with a higher degree of tolerance for new situations. - Stimulant medications may be used to target hyperactivity, impulsivity, or inattention.

Regarding substance abuse, Opioid abuse General treatment

- Support groups such as Narcotics Anonymous (NA), a 12-step program, are excellent sources of help - Methadone (Dolophine, Methadose) is used to decrease the painful symptoms of opiate withdrawal (will eventually need to be withdrawn due to dependence) - Neonatal withdrawal is usually mild and can be managed with paregoric. - Buprenorphine is used to help people reduce or quit their use of heroin or other opiates such as pain relievers like morphine. - Naltrexone (Vivitrol) is indicated for the prevention of relapse to opioid dependence, following opioid detoxification. (ReVia, is given once a month.)

Besides medication, there are few biological interventions available to disrupt the course of the anxiety and anxiety-related disorders.

- Surgery has been used in obsessive-compulsive disorder for those most severely affected - A Gamma Knife® creates irreversible damage known as lesions to certain areas of the brain, resulting in a disconnect of overactive circuits or regions. - reversible surgical treatment being used for obsessive-compulsive disorder is deep brain stimulation

Individuals with Autism may have

- abnormal electroencephalograms, - epileptic seizures, - delayed development of hand dominance, - persistence of primitive reflexes, - metabolic abnormalities (elevated blood serotonin), - cerebellar vermis hypoplasia (part of the brain involved in regulating motion and some aspects of memory), - infantile abnormal head enlargement

Regarding Alcohol Withdrawal, Wernicke's encephalopathy is characterized by Wernicke's encephalopathy responds rapidly to

- altered gait, - vestibular dysfunction, - confusion, - several ocular motility abnormalities (horizontal nystagmus, lateral orbital palsy, and gaze palsy). large doses of intravenous thiamine two to three times daily for 1 to 2 weeks

The most serious reaction to the MAOIs is Therefore routine monitoring of

- an increase in blood pressure with the possible development of intracranial hemorrhage, - hyperpyrexia, - convulsions, - coma, - death. - hypertensive crisis is a constant concern blood pressure, especially during the first 6 weeks of treatment, is necessary.

Complications may arise from the interaction of alcohol with commonly prescribed or OTC drugs. Drugs that interact with alcohol in an additive manner include Alcohol taken with aspirin may cause or exacerbate Alcohol taken with acetaminophen may

- antihypertensives, - antihistamines, - antianginals. GI bleeding. increase the risk of liver damage

Women at greatest risk for Postpartum depression are those with a history of

- anxiety or depression and especially those who had a previous episode of major depressive disorder in the past, including during or after pregnancy - younger age 13-19 - unintended pregnancy, - infertility, miscarriage, stillbirth - hormone levels - B6, serotonin, cortisol - personal history of severe premenstrual dysphoria, - family history of mood disorder, - unmatched expectations - unmarried status, - marital discord, worried about relationship - lack of social support, - socioeconomic deprivation, - lower education, substance abuse, - low self-esteem, - stressful life events - Complications of pregnancy or breastfeeding - Having a preterm, low-birth weight, and ill neonate - victims of intimate partner violence

Acute alcohol toxicity nursing interventions

- assess for injuries, diseases, and hypoglycemia - No antidote for alcohol is available. - Implement supportive care measures to maintain airway, breathing, and circulation (the ABCs) until the alcohol metabolizes - Treat alcohol-induced hypotension with IV fluids. - Patients with hypoglycemia may receive glucose-containing IV solutions. - IV thiamine may be given before or with IV glucose solutions to prevent Wernicke-Korsakoff syndrome, which can cause seizures and brain damage - patients may have low serum magnesium levels and other signs of malnutrition, so HCPs frequently add multivitamins and magnesium to the IV fluids. - Assess the patient for increasing belligerence and a potential for violence - patient is at risk for injury because of lack of coordination and impaired judgment, use protective measures.

Treatment plans for Autism include

- behavior management with a reward system, - teaching parents to provide structure, rewards, consistency in rules, - expectations at home to shape and modify behavior and foster the development of socially appropriate skills.

Women with generalized anxiety disorder may experience

- chest tightness, - shortness of breath, - tachycardia - dizziness or lightheadedness, - sweating, - trembling, - nausea, - abdominal pain, - fatigue, - constant worry, - sense of doom, - difficulty concentrating

Patients should have a pre-Electroconvulsive Therapy workup including a

- chest x-ray, - electrocardiogram - urinalysis, - complete blood count, - blood urea nitrogen, - an electrolyte panel.

Risk factors for social anxiety disorder include What are they at risk for?

- childhood mistreatment - adverse childhood events Chronic social isolation may increase the risk for major depression and Substance use

Prenatal diagnosis of Down syndrome is possible through

- chorionic villus sampling and amniocentesis (because chromosome analysis of fetal cells can detect the presence of trisomy or translocation.) - recent advances in development of noninvasive prenatal testing (NIPT) is a measurement of cell-free deoxyribonucleic acid (DNA)

Hallucinogens are found in some plants and mushrooms (or their extracts) or can be man-made. They are commonly divided into two broad categories:

- classic hallucinogens (e.g., LSD) - dissociative drugs (e.g., phencyclidine [PCP] and ketamine

The severity of impairment is demonstrated in the ability to

- communicate effectively, - meet one's self-care and safety needs, - socialize in an age-appropriate manner

Phencyclidine intoxication (Hallucinogen) PCP intoxication is a medical emergency that can result in PCP Treatment

- dangerous and violent side effects - belligerent, assaultive, impulsive, and unpredictable - nystagmus (involuntary eye movements), - hypertension, - tachycardia, - diminished response to pain, - ataxia (loss of voluntary muscle control), - dysarthria (unclear speech), - muscle rigidity, seizures, - coma, - hyperacusis (sensitivity to sound). - Hyperthermia - seizure activity - cannot be talked down and may require restraint and a calming medication such as a benzodiazepine. - Mechanical cooling may be necessary for severe hyperthermia.

Symptoms associated with autism spectrum disorder include

- deficits in social relatedness, which are manifested in disturbances in developing and maintaining relationships - stereotypical repetitive speech or body movements - obsessive focus on specific objects, - overadherence to routines or rituals, - hyperreactivity or hyporeactivity to sensory input (tag on shirt), - extreme resistance to change - language delay - may not communicate effectivity, repeat question instead of answering - lack of social interaction, failure to share enjoyment or emotions - abnormal eye movements or gestures - prefer symmetry

Key Assessment Findings of depression

- depressed mood and anhedonia - Anxiety - dwell on and exaggerate their perceived faults and failures and are unable to focus on their strengths and successes - Feelings of worthlessness, hopelessness, guilt, anger, and helplessness

Regarding substance abuse with opioids, with treatment Some serious side effects may occur while taking methadone. Patients should be instructed to seek medical care if they experience

- difficulty breathing or shallow breathing, - feel lightheaded or faint, - experience chest pain or a fast or pounding heartbeat. - Hives, rash, or swelling of the face, lips, tongue, or throat - Hallucinations or confusion should also be reported

tricyclic antidepressants (TCAs) side effects How about for older people?

- dry mouth, blurred vision, tachycardia, constipation, urinary retention, and esophageal reflux are common - urinary retention and severe constipation warrant immediate medical attention - The most serious effects of the TCAs are cardiovascular: dysrhythmias, tachycardia, myocardial infarction, and heart block. Because the cardiac side effects are so serious, TCA use is considered a risk in older adults and patients with cardiac disease. Postural hypotension can lead to dizziness and increase the risk of falls. For this reason older patients on TCAs must be monitored carefully for dizziness and falls.

Regarding substance abuse, Stimulant Withdrawal The patient may be depressed and experience Supportive care includes

- fatigue, - prolonged sleep, - vivid dreams - irritability, - increased appetite, - disorientation. - suicidal thoughts - maintaining a quiet environment and allowing the patient to sleep and eat as desired. - If a patient has severe depression, initiate suicide precautions and refer for further treatment. - depression can be treated with antidepressants such as bupropion (Wellbutrin) - Individual, family, and group therapy - Antipsychotics may be prescribed for a few days - if no psychosis, diazepam (Valium) is useful in treating agitation and hyperactivity. - Unscheduled urine drug testing is usually warranted.

Postpartum depression symptoms

- feelings of doom - lack of joy - difficulty concentrating - extreme anxiety - intense anger - emotional numbness - feeling like you should have never became a mother - feeling unable to care for yourself or you baby - thoughts of hurting yourself or your baby - desire to withdraw from others including you baby - guilt - exhaustion

Substance abuse Acute Intervention

- first priority of care is supporting the patient's ABCs, especially respiratory status. - assessing neurologic status and vital signs, - administering IV fluids to prevent dehydration, - orienting to time and place, - implementing patient safety measures. - Although blood and urine tests will help identify the substances, treatment is started while waiting for the test results - patient in this situation would usually receive naloxone. (If the patient does not respond to a total dose of 10 mg of naloxone, it is unlikely opioids are involved.) - If the substance used is a barbiturate or another CNS depressant, naloxone will not help the patient, but it will not hurt the patient either. - promote behavior change

ADHD Behavioral Therapy

- focuses on the prevention of undesired behavior - identify new appropriate contingencies and reward systems to meet the child's developing needs - Parents receive instruction in effective parenting skills, such as delivering positive reinforcement, rewarding small increments of desired behaviors, and providing age-appropriate consequences (e.g., time-out, response cost) - use of organizational charts for completing self-care activities and the use of a word processor instead of manually writing assignments are emphasized

For ADHD, The most common side effects of atomoxetine are Key aspects to assess/monitor? Patients and their families should be Atomoxetine should be used with extreme caution in those patients with

- gastrointestinal disturbances, - reduced appetite, - weight loss, - urinary retention, - dizziness, - fatigue, - insomnia. - liver injury in some patients - a small increase in blood pressure and heart rate. Ongoing monitoring of vital signs and regular screening of liver function are key aspects of assessment. clearly educated on the risks and benefits of treatment before starting this medication comorbid depression since its use has been associated with an increased suicidal ideation.

Psychotherapy methods for Postpartum depression include an SSRI is prescribed initially and if symptoms improve during a 6-week trial period, the medication is

- general counseling (listening visits), - interpersonal psychotherapy (IPT), - cognitive-behavioral therapy (CBT), - psychodynamic therapy continued for at least 6 months to prevent relapse.

Anxiety disorders are common during the postpartum period; these include Whos at greatest risk for postpartum anxiety

- generalized anxiety, - panic, - obsessive-compulsive, - social anxiety disorders. Women with a history of anxiety disorder are at greatest risk.

Characteristics of adult separation anxiety disorder include

- harm avoidance, - worry, - shyness, - uncertainty, - fatigability, - a lack of self-direction

Tobacco Cessation Nursing Intervention

- help people stop smoking or using tobacco - Patients who receive even brief advice and intervention from you are more likely to quit than those who receive no intervention. - Use these brief clinical interventions, called the "5 As," with each patient encounter. (help you identify tobacco users, encourage them to quit, determine their willingness to quit, assist them in quitting, and arrange for follow-up.)

The etiology of intellectual disability may be

- heredity, - problems with pregnancy or perinatal development, - environmental influences, - a direct result of a medical condition

postpartum psychosis Risk factors

- history of postpartum psychosis (50% chance of reoccurring) - bipolar disorder, - family history of bipolar disorder or postpartum psychosis, - recent discontinuation of lithium or other mood stabilizers. - Primiparous women especially if experienced obstetric complications

Tobacco Cessation programs may involve Many of these programs teach users to

- hypnosis, - acupuncture, - behavioral interventions, - aversion therapy, - group support programs, - individual therapy, - self-help options. avoid high-risk situations for smoking relapse (e.g., those that promote cue-induced craving) and help them develop coping skills, such as cigarette refusal skills, assertiveness, alternative activities, and peer support systems.

Child with autism in hospital Nursing interventions

- ideally should stay with the child as much as possible - Nurses should recognize that not all children with ASD are the same and that they require individual assessment and treatment. - Decreasing stimulation by using a private room, avoiding extraneous auditory and visual distractions, and encouraging the parents to bring in possessions the child is attached to may lessen the disruptiveness of hospitalization - physical contact often upsets these children, minimal holding and eye contact may be necessary to avoid behavioral outbursts - Take care when performing procedures on, administering medicine to, and feeding these children because they may be either fussy eaters who willfully starve themselves or gag to prevent eating, or indiscriminate hoarders who swallow any available edible or inedible items, such as a thermometer - Eating habits of ASD children may be particularly problematic for families and may involve food refusal accompanied by mineral deficiencies, mouthing objects, eating nonedibles, and smelling and throwing food - visits with staff caregivers kept short whenever possible (ASD need to be introduced slowly to new situations) - Because these children have difficulty organizing their behavior and redirecting their energy, they need to be told directly what to do. - Give concrete explanations - Explore childs behaviors of family and vice verse - teach how to create a safe environment

Electroconvulsive Therapy Procedure for depression To ensure that patients experience a seizure over the entire brain, a

- informed consent is obtained if the patient is being treated voluntarily. - patient treated involuntarily, permission may be obtained from the next of kin although in some states treatment must be court-ordered - patient is usually given a general anesthetic to induce sleep and a muscle-paralyzing agent to prevent muscle distress and fractures. - Benzodiazepines should be discontinued as they will interfere with the seizure process. blood pressure cuff may be inflated on the lower arm or leg before administration of the paralytic agent.

side effect while taking stimulant (adderall/ritalin) medications for ADHD

- insomnia - appetite suppression, - headache, - abdominal pain, - lethargy. - Treating with the minimum effective dose is essential.

Regarding substance abuse, For depressants Opioid withdrawal Manifestations include Treatment focuses on

- intense drug craving, - diaphoresis, - GI distress, - restlessness, - fever, - insomnia, - watery eyes, - tremors, - muscle aches, - runny nose, - altered mood. - relieving symptoms and often requires medications. - Management includes GI medications (e.g., loperamide [Imodium], Zofran, prochlorperazine [Compazine]), - acetaminophen for muscle aches and fever, - benzodiazepines for acute anxiety and sleep disturbances.

For Vagus Nerve Stimulation treating depression Adverse Reactions are

- is a surgical procedure, carrying with it the risks inherent in any surgical procedure (e.g., pain, infection, sensitivity to anesthesia). - Voice alteration and hoarseness are common side effects. - Other side effects include neck pain, cough, paresthesia, and dyspnea, which tend to decrease with time. - turn it off with magnet when engaging in public speaking or heavy exercise

ADHD Appropriate Classroom Placement

- need an orderly, predictable, and consistent classroom environment with clear and consistent rules - Homework and classroom assignments may need to be reduced, and more time may need to be allotted for tests - Verbal instructions should be accompanied by visual references, such as written instructions on the blackboard - Schedules may need to be arranged so that academic subjects are taught in the morning when the child is experiencing the effects of the morning dose of medication - Low-interest and high-interest classroom activities should be intermingled to maintain the child's attention - Regular and frequent breaks in activity are helpful - Computers are helpful for children who have difficulty with writing (dysgraphia) and fine motor skills; in such children, handwriting will not improve. (find alternatives to physical competition that requires coordination of movement.) - If the child has a learning disability, special training activities may be accomplished in self-contained classes limited to six to eight children, in special resource rooms with equipment and teaching teams, by mobile consultants who move from room to room to provide assistance to teachers and children, and in special first-grade programs in which high-risk children receive special attention to prevent or reduce the need for services as they progress

Breastfeeding is encouraged in mothers who are breastfeeding promotes mother-infant bonding, and small quantities of methadone or buprenorphine passed through breast milk is

- not using illicit substances, - do not have HIV infection, - are compliant with a treatment program; not harmful

Mild to Moderate Levels of Anxiety Nursing Intervention

- patient can be helped to focus and solve problems when you use specific nursing communication techniques such as asking open-ended questions, giving broad openings, and exploring and seeking clarification. - Closing off topics of communication and bringing up irrelevant topics can increase a person's anxiety, making the nurse, not the patient, feel better. - Avoid closing off avenues of communication that are important for the patient. Focus on the patient's concerns. - Reducing the patient's anxiety level and preventing escalation to more distressing levels can be aided by providing a calm presence, recognizing the anxious person's distress, and being willing to listen - Help the patient identify anxiety. "Are you comfortable right now?" - Anticipate anxiety-provoking situations. - Use nonverbal language to demonstrate interest (e.g., lean forward, maintain eye contact, nod your head). - Encourage the patient to talk about his or her feelings and concerns. - Ask questions to clarify what is being said. "I'm not sure what you mean. Give me an example." - Encourage problem solving with the patient.∗ - Assist in developing alternative solutions to a problem through role play or modeling behaviors.

The fetal and neonatal effects of maternal use of methamphetamines in pregnancy are A higher incidence of

- placental abruption, - preterm birth, - IUGR

Regarding postpartum depression, Nurses should include partners in discussions about

- postpartum depression, - raising awareness that fathers can also suffer from depression, - describing symptoms, - providing information about resources for help if the symptoms occur.

To diagnose a child with ADHD symptoms must be

- present in at least two settings (e.g., at home and school) - occur before age 12.

Marijuana use is associated with increased risk for

- preterm birth, - stillbirth, - IUGR.

Sequelae of prenatal cocaine exposure include

- preterm birth, - a smaller head circumference, - decreased birth length, - decreased weight.

Postpartum depression Nursing interventions

- provide individualized flexible postpartum care - screen using Edinburgh Postnatal Depression Scale - Provide supportive interactions and ongoing assessment - Involve partners and family members in the care for postpartum mothers experiencing depression - Facilitate opportunities for peer support - Promote self-care activities - educate patient and families of symptoms of postpartum depression (often undiagnosed or labeled as maternal fatigue) - Women may hide their feeling because of shame, guilt, and feelings of inadequacy. It is important to have them understand they have done nothing wrong and need help - Refer postpartum patients as necessary for follow up with mental health professionals - Assess for self harm ideation/behavior

Treatment options for Postpartum depression include

- psychotherapy (for mild cases) - antidepressant medication (used with psychotherapy for moderate to severe cases) SSRI - Sleep deprivation must be resolved; 4 to 5 hours of uninterrupted sleep for several days - hormone therapy, complementary or alternative therapies (herbs, dietary supplements, massage, aromatherapy, acupuncture, exercise, bright light therapy), - electroconvulsive therapy (ECT).

Postpartum Anxiety disorders may be treated with Medications include

- psychotherapy; - CBT - exposure response prevention (ERP) SSRIs and antianxiety drugs, although it can take 2 weeks for these medications to be effective. - Benzodiazepines provide short-term relief from anxiety symptoms, but should be used judiciously as they can be addictive.

postpartum psychosis is characterized by

- rapid onset of bizarre behavior, - auditory or visual hallucinations, - paranoid or grandiose delusions, - elements of delirium or disorientation, - extreme deficits in judgment accompanied by high levels of impulsivity that can contribute to increased risk for suicide or infanticide - Auditory hallucinations that command the mother to kill the infant can occur in severe cases. - usually occurs in first 4 weeks after birth

ADHD Prognosis

- relatively stable through early adolescence for most children - Some children experience decreased symptoms during late adolescence and adulthood, but a significant number of these children carry their symptoms into adulthood - goal for children with ADHD is to help them identify their areas of weakness and learn to compensate for them.

Severe to Panic Levels of Anxiety Nursing interventions

- remember unable to solve problems and may have a poor grasp of what is happening in the environment - provide for the safety of the patient and others and to meet physical needs (e.g., fluids, rest) to prevent exhaustion - Anxiety-reduction measures may take the form of guiding the person to a quiet environment. - use of medications and restraints/seclusion may have to be considered. As always, both medications and restraints should be used only after other less-restrictive interventions have failed to decrease anxiety to safer levels. - techniques suggested for communicating with people with mild to moderate levels of anxiety are not as effective at more severe levels. - they need to know they are safe from their own impulses - Always remain with the person experiencing an acute severe to panic level of anxiety. - Minimize environmental stimuli. Move to a quieter setting, and stay with the patient. - Use clear and simple statements and repetition. - Use a low-pitched voice; speak slowly. - Reinforce reality if distortions occur (e.g., seeing objects that are not there or hearing voices when no one is present). - Because safety is an overall goal, physical limits may need to be set. Speak in a firm, authoritative voice: "You may not hit anyone here. If you can't control yourself, we will help you." - Provide opportunities for exercise (e.g., walk with nurse, punching bag, ping-pong game). - When a person is constantly moving or pacing, offer high-calorie fluids.

Cocaine-exposed infants Nursing and Medical Interventions

- respond to swaddling - Positioning, - infant massage - limited tactile stimulation - Significant amounts of cocaine have been found in breast milk therefore mothers should be cautioned regarding this hazard to their infants. - Referral to early intervention programs, including child health care, parental drug treatment, individualized developmental care, and parenting education

A depressive syndrome frequently accompanies other psychiatric problems such as

- schizophrenia, - substance abuse, - eating disorders, - schizoaffective disorder, - borderline personality disorder

Depression Pharmacological treatment

- selective serotonin reuptake inhibitors (SSRIs) - The serotonin norepinephrine reuptake inhibitors (SNRIs) - norepinephrine dopamine reuptake inhibitor (NDRI) - noradrenergic and specific serotonergic antidepressant (NaSSA) - tricyclic antidepressants (TCAs)

Assessment of CI child

- self-care abilities. - any special devices that the child uses, - effective measures of limit setting, - unusual or favorite routines, - any behaviors that may require intervention. - functional level of eating and playing; - ability to express needs verbally; - progress in toilet training; - relationship with objects, toys, and other children. - child is encouraged to be as independent as possible in the hospital.

Regarding Anxiety Pharmacological Interventions, There are no FDA-approved drugs for the treatment of the following disorders:

- separation anxiety, - specific phobia, - body dysmorphic, - hoarding, trichotillomania, - excoriation these conditions are often treated with antidepressants, antianxiety agents, and the other classes

Autism Diagnosis

- severe impairments in social interactions and communication skills, often accompanied by stereotypical behavior, interests, and activities - intellectual disability (IQ <85), which will impact their academic performance as well. - severity of the impairment is evident in the degree of responsiveness to or interest in others, the presence of associated behavioral problems (e.g., head banging), and the ability to bond with peers

At the pathological end of the continuum is obsessive-compulsive disorder (OCD) with symptoms that occur on a daily basis and may involve issues of

- sexuality, - violence, - contamination, - illness, - death.

Under the Individuals with Disabilities Education Act (IDEA) of 1990 (Public Law 101-476), states are encouraged to provide full early intervention services and are required to provide educational opportunities for all children with disabilities from birth to 21 years of age. Services may be provided under

- state programs for Children with Special Health Care Needs (CSHCN) or Head Start, - by private organizations such as the National Down Syndrome Society,* Easter Seals,* or The Arc of the United States.

ADHD Psychobiological Interventions (meds)

- stimulant drugs: often dramatic and can quickly increase attention and task-directed behavior while reducing impulsivity, restlessness, and distractibility - Methylphenidate (Ritalin and others) and the mixed amphetamine salts (Adderall) are the most widely used stimulants because of their relative safety and simplicity of use. - A nonstimulant selective norepinephrine reuptake inhibitor, atomoxetine (Strattera) - Two centrally acting alpha-2 adrenergic agonists, clonidine (Kapvay) and guanfacine (Intuniv) Risk of taking meds when not needed

Regarding ADHD, To control aggressive behaviors, pharmacological agents including

- stimulants, - mood stabilizers (lithium and anticonvulsants) - alpha-adrenergic agonists (clonidine and guanfacine) - antipsychotics are used.

Most sufferers may experience mildly obsessive-compulsive behavior such as nagging doubts as to whether a door is locked or the stove is turned off. These doubts require the person to go back to check the door or stove. Mild compulsions about

- timeliness, - orderliness, - reliability

Neonatal abstinence syndrome (NAS) When Neonatal abstinence syndrome (NAS) is identified, nursing care is directed toward

- treating the presenting signs, - decreasing stimuli that can precipitate hyperactivity and irritability (e.g., dimming the lights, decreasing noise levels), - providing adequate nutrition and hydration, - promoting mother-infant attachment.

Infants who do not display the signs of Fetal alcohol syndrome (FAS) but are born to mothers who are also heavy alcohol drinkers have significantly more

- tremors, - hypertonia, - restlessness, - excessive mouthing movements, - crying, - inconsolability than infants of substance-abusive mothers who do not consume alcohol during pregnancy

The most severe of the perinatal mood disorders, postpartum psychosis, also known as postpartum depression with psychotic features, occurs in

1 to 2 per 1000 births during the first month, although it usually manifests within the first 2 weeks postpartum

Regarding cognitive therapy for depression, Beck found that people with depression process information in negative ways, and tend to ignore positive aspects of their lives. He believed that automatic, negative, repetitive, unintended, and not-readily-controllable thoughts perpetuate depression. Three assumptions constitute Beck's cognitive triad:

1. A negative, self-deprecating view of self 2. A pessimistic view of the world 3. The belief that negative reinforcement (or no validation for the self) will continue in the future

Regarding Nursing Interventions for the Person Experiencing Psychosis, Avoids interaction with peers Nursing Interventions

1. Actively convey acceptance and meet the patient where he is now and build from there. 2. Regularly engage with the patient. Connect at intervals and interact briefly about low-anxiety topics like the weather. Gradually increase the duration and/or frequency as interaction becomes more comfortable. 3. Offer encouragement to participate in unit activities, without pressure, such as "We would love to see you at the morning meeting." 4. Assure the patient he has control over his choices when possible. For example if he becomes uncomfortable in a group, he can leave and try another day. 5. Reinforce each step toward greater interaction. "It was nice to see you in the morning meeting today." 6. Pet therapy may help patients increase comfort with people.

Regarding Nursing Interventions for the Person Experiencing Psychosis, Poor self-esteem Nursing Interventions

1. Actively convey unconditional acceptance. 2. Engage regularly and supportively with the patient, guiding him to identify and express feelings. 3. Help the patient to recognize positive traits or accomplishments. 4. Educate the patient about how the illness may distort a person's self-view. Guide the patient to question distorted beliefs, and to replace these with a more realistic self-appraisal. 5. Arrange for interaction with individuals who also once experienced poor self-esteem but who have since improved

Regarding Nursing Interventions for the Person Experiencing Psychosis, Cheeking or palming medications Nursing Interventions

1. Address underlying reasons for wanting to avoid medications. 2. Seek to switch medication to a more difficult to conceal form such as a liquid or fast-dissolving tablet. 3. Long-acting injectable forms need only be addressed every 2-4 weeks or every 3 months.

The Five As for Users Who Desire to Quit Tobacco

1. Ask: Identify all tobacco users at every contact. 2. Advise: Strongly urge all tobacco users to quit. 3. Assess: Determine willingness to make a quit attempt. 4. Assist: Develop a plan with the patient to help the patient quit (e.g., counseling, medication). 5. Arrange: Schedule follow-up contact.

Regarding Nursing Interventions for the Person Experiencing Psychosis, Choking risk Nursing Interventions

1. Assess all patients for difficulty swallowing and identify causes if possible. 2. Address causes that can be corrected. With dry mouth, taking a sip of a beverage with each bite can make swallowing much easier. 3. Encourage smaller bites that are then thoroughly chewed. 4. Ensure that patients are not rushed to complete their meals, and encourage fast eaters to eat more slowly. 5. Be available at mealtime to assist if needed. This can give patients greater confidence, reducing anxiety and improving swallowing.

Assessment Guidelines Intellectual Disability

1. Assess for delays in cognitive and physical development or lack of ability to perform tasks or achieve milestones in relation to peers. Gather information from family, caregivers, or others actively involved in the child's life. 2. Assess for delays in cognitive, social, or personal functioning, focusing on strengths and abilities. 3. Assess for areas of independent functioning and the need for support/assistance to meet requirements of daily living (examples are hygiene, dressing, or feeding). 4. Assess for physical and emotional signs of potential neglect or abuse. Be aware that children with behavioral and developmental problems are at risk for abuse. 5. Assess for need of community resources or programs that can provide resources and support the child's need for intellectual and social development and the family's need for education and emotional support.

Assessment Guidelines Autism Spectrum Disorder

1. Assess for developmental delays, uneven development, or loss of acquired abilities. Use baby books and diaries, photographs, videotapes, or anecdotal reports from nonfamily caregivers. 2. Assess the child's communication skills (verbal and nonverbal), sensory, social and behavioral skills (including presence of any aggressive or self-injurious behaviors) 3. Assess the parent-child relationship for evidence of bonding, anxiety, tension, and fit of temperaments. 4. Assess for physical and emotional signs of possible abuse. Be aware that children with behavioral and developmental problems are at risk for abuse. 5. Ensure that screening for comorbid intellectual disability has been completed. 6. Assess the need for community programs with support services for parents and children including parent education, counseling, and after-school programs.

Regarding Nursing Interventions for the Person Experiencing Psychosis, Risk for other-directed violence Nursing Interventions

1. Assess for paranoid thoughts, command hallucinations, interpersonal conflict, irritability, impaired impulse control, increasing tension and desperation, and other factors that may increase the risk of violence. 2. Engaging regularly with the patient increases the opportunity for assessment and communication about concerns that may contribute to risk. 3. Provide increased supervision when risk is present. Placing the patient in a room near the nurses' station facilitates monitoring. 4. Ensure that patient is taking ordered medications (see "Cheeking or Palming Medications" section). 5. Monitor for and promptly de-escalate increasing tension. 6. Take action to help the patient feel safe and secure (e.g., if patient fears harm from outside the unit, note the locked doors and constant presence of staff). 7. Promote communication and venting in a safe manner to reduce desperation levels. 8. Teach and guide patient to practice coping skills to reduce stress and desperation. 9. Provide constructive diversion and outlets for physical energy. 10. If the patient, due to paranoia or other factors, targets specific peers, it may be necessary to relocate the patient or the targeted peer. Similar action may be needed if identifiable staff are targeted. 11. Only when truly necessary: use seclusion and/or chemical (medication) or physical restraint. 12. Search thoroughly on admission and repeat the search any time circumstances suggest the patient may have had an opportunity to make or acquire a weapon.

Regarding Nursing Interventions for the Person Experiencing Psychosis, Risk for self-directed violence Nursing Interventions

1. Assess for risk to self. Warning signs include a sudden brightening or worsening of mood, termination activities (e.g., saying goodbye or giving away possessions), increased suicidal ideation, or taking action to acquire a means of suicide. Assessment should be repeated regularly, particularly if the patient's situation changes. 2. Provide increased supervision when risk is present. Placing the patient in a room near the nurses' station can facilitate monitoring. 3. Make rounds or checks at predictable intervals such as every 15 minutes provide the patient with a window of opportunity. Preferably rounds should be at unpredictable intervals and adjusted based on risk. 4. Ensure that patient is receiving ordered medications (see "Cheeking or Palming Medications" section). Some medication may help reduce suicidality in schizophrenia (e.g., clozapine). 5. Extra precautions should be taken to assure that the patient has not acquired a weapon. See intervention #8 in the "Risk for Self-Directed Violence" section.

Patient and Family Teaching: Antianxiety Drugs

1. Caution the patient: - Not to change dose or frequency of medication without consultation with the prescriber. - These medications may make it unsafe to handle mechanical equipment (e.g., cars, saws, and machinery). - Avoid alcoholic beverages and other antianxiety drugs, due to unsafe depressant effects when combined. - Avoid drinking beverages containing caffeine because they decrease the desired effects of the drug. - Review prescription medications and doses that may cause or increase anxiety (e.g., thyroid hormones, steroids, decongestants). 2. Discuss the risks to the fetus and the risk of untreated anxiety disorders with prescriber should pregnancy occur or be considered. 3. Advise the patient to discuss breastfeeding with prescriber because these drugs are excreted in the milk and could have adverse effects on the infant. 4. Teach a patient who is taking monoamine oxidase inhibitors about the details of a tyramine-restricted diet (refer to Chapter 3). 5. Teach the patient that: - Cessation of benzodiazepine use after 3 to 4 months of daily use may cause withdrawal symptoms such as insomnia, irritability, nervousness, dry mouth, tremors, convulsions, and confusion. - Medications should be taken with or shortly after meals or snacks to reduce gastrointestinal discomfort. - Drug interactions can occur: Antacids may delay absorption; cimetidine interferes with metabolism of benzodiazepines, causing increased sedation; central nervous system depressants, such as alcohol and barbiturates, cause increased sedation.

Children with ADHD demonstrate one of three subtypes

1. Combined type—Six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity-impulsivity that persist for at least 6 months. Most children and adolescents with ADHD have the combined type. 2. Predominantly inattentive type—Six (or more) symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) that persist for at least 6 months. 3. Predominantly hyperactive-impulsive type—Six (or more) symptoms of hyperactivity-impulsivity (but fewer than six symptoms of inattention) that persist for at least 6 months. Inattention may often still be a significant clinical feature in such cases.

Regarding Nursing Interventions for the Person Experiencing Psychosis, Poor hygiene Nursing Interventions

1. Concisely and explicitly identify expected hygiene. Have patient try out each hygiene action while observing, assisting when needed, and providing positive reinforcement for each success. 2. Break tasks into smaller, easier to manage steps. 3. Use visual cues to prompt attention to hygiene tasks, such as putting a toothbrush and towels in the bathroom and clean clothes on bed. 4. Suggest ways that improved hygiene will benefit the patient, perhaps greater acceptance by peers, increased privileges. 5. Guide patient to use napkin or towel around neck when eating or if experiencing drooling. 6. Periodically remind patient and refocus to hygiene tasks as needed.

Regarding Nursing Interventions for the Person Experiencing Psychosis, Resistance to treatment, nonadherence Nursing Interventions

1. Do not be judgmental—treat patient with respect. 2. Establish trust and involve the patient collaboratively in planning treatment. 3. Explore concerns about treatment and suggest solutions. Perhaps medications that cause fatigue can be taken at bedtime. 4. Convey in a clear, concrete, and confident manner your belief that the patient will benefit from the treatment. 5. Tie the treatment to the patient's own goals. For example, the patient may not agree to take the medication for an illness, but if he believes it will quiet the voices or help him keep his job (his goals), then he will see more value to treatment.

Regarding Nursing Interventions for the Person Experiencing Psychosis, Depression, hopelessness, and despair Nursing Interventions

1. Engage in connecting regularly with the patient. 2. Actively convey empathy. "Sometimes having a mental illness can feel very discouraging...I wonder how you are feeling?" 3. If he cannot identify his feelings, suggest those that may apply. "Sometimes it's hard to say what you're feeling. Do you feel sad, frustrated, or lost?" 4. Validate the feeling is understandable and that he is not alone. Identify options for coping with those feelings such as keeping a journal. 5. Teach activities that reduce depression: physical activity, self-nurturing (such as taking a relaxing bath or listening to uplifting music), seeking support from others, and spending more time in outside if possible.

Regarding Nursing Interventions for the Person Experiencing Psychosis, Anosognosia Nursing Interventions

1. Establish a trusting relationship. Even a simple act such as offering the patient gum each day can increase patient comfort with staff. 2. Seek areas of commonality: What can both the patient and others agree upon? 3. Agree to disagree about whether these issues do or don't indicate an illness, but seek agreement that they are a problem. 4. The patient may be aware of illness in others. If so, suggest that, just as another patient cannot see his own illness, something similar might be happening in him or her as well. 5. Involve the patient in activities where he will encounter peers who have gained insight despite once having had anosognosia. A patient may find the reports of the peer to be more valid than similar information originating with staff.

Assessment Guidelines Attention-Deficit/Hyperactivity Disorder

1. Gather data from parents, caregivers, teachers, or other adults involved with the child. Ask about level of physical activity, span, talkativeness, frustration tolerance, impulse control, and the ability to follow directions and complete tasks. Also, assess these areas through your own observations and note any developmental variance in these behaviors. 2. Assess social skills, friendship history, problem-solving skills, and school performance. Gather this data from the family or caregiver and one or two additional sources. 3. Assess for comorbidities such as anxiety and depression. 4. Assess for any indicators of learning disorders, autism spectrum disorder, or intellectual disabilities. 5. Gather data on eating and sleeping patterns and monitor these regularly for the child treated with stimulants.

A substance use disorder is a pathological use of a substance that leads to a disorder of use. Symptoms fall into four major groupings:

1. Impaired control 2. Social impairment 3. Risky use 4. Physical effects (i.e., intoxication, tolerance, and withdrawal)

DSM-5 Criteria for Autism Spectrum Disorder The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) revised the definition for ASD based on two behavior domains that include difficulties in

1. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive 2. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive) 3. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life) 4. Symptoms together limit and impair everyday functioning 5. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level social communication and social interaction, and unusually restricted, repetitive behavior, interests, or activities

Regarding Nursing Interventions for the Person Experiencing Psychosis, Restlessness, agitation Nursing Interventions

1. Reduce excess stimulation—dim the lights, lower TV volume, redirect patient to less-stimulating areas or activities. 2. Assess for and treat akathisia with anti-EPS medications and anxiety reduction interventions. 3. Explore patient's feelings and perceptions that may be contributing and address these as indicated. 4. Promote verbal expression of negative emotions to reduce desperation or negative emotions. 5. Provide safe outlets for physical energy (e.g., walk with patient, allow pacing, provide access to safe exercise equipment). 6. Administer as needed calming medications if agitation is unresponsive to non-pharmacological interventions.

The Five Rs for Users Unwilling to Quit Tobacco

1. Relevance: Ask the patient to indicate why quitting is personally relevant (e.g., health). 2. Risks: Ask the patient to identify his or her potential risks/consequences of tobacco use. 3. Rewards: Ask the patient to identify potential benefits of stopping tobacco use. 4. Roadblocks: Ask patient to identify barriers or impediments to quitting. 5. Repetition: Repeat process every clinic visit.

There are three phases in treatment and recovery from major depression:

1. The acute phase (6 to 12 weeks) is directed at reduction of depressive symptoms and restoration of psychosocial and work function. Hospitalization may be required, and medication or other biological treatments may be initiated. 2. The continuation phase (4 to 9 months) is directed at prevention of relapse through pharmacotherapy, education, and depression-specific psychotherapy. 3. The maintenance phase (1 year or more) of treatment is directed at prevention of further episodes of depression.

Guidelines for basic nursing interventions for anxiety are

1. Use counseling, milieu therapy, promotion of self-care activities, and psychobiological and health teaching interventions as appropriate. 2. Guide patients through slow, deep breathing exercises along with progressive muscle relaxation. 3. Identify community resources that can offer the patient specialized treatment proven to be highly effective for people with a variety of anxiety disorders. 4. Identify community support groups for people with specific anxiety disorders and their families.

Regarding Nursing Interventions for the Person Experiencing Psychosis, Fall risk Nursing Interventions

1. Walk with all patients to assess their gait, providing physical support as needed. 2. Assess for orthostatic hypotension with lying and standing blood pressure checks. 3. With orthostatic hypotension, ensure that the patient is well hydrated and teach him to slowly change position from lying to sitting to standing. 4. Encourage the use of handrails or seek assistance when unsteady. 5. People who fear falling tend to look at their feet when they walk. Guide the patient to look ahead instead of down. 6. Locate the patient's room close to the nurses' station so that help is readily available.

Because many drugs, foods, and beverages can cause an increase in blood pressure in patients taking MAOIs, hypertensive crisis is a constant concern. The hypertensive crisis usually occurs within Early symptoms include When a hypertensive crisis is suspected, what is needed?

15 to 90 minutes of ingestion of the contraindicated substance. irritability, anxiety, flushing, sweating, and a severe headache. - anxious, restless, and develops a fever - Eventually the fever becomes severe, seizures ensue, and coma or death immediate medical attention is crucial.

Ineffective coping related to persistent anxiety, fatigue, difficulty concentrating. Interventions

1a. Stay with patient. 1b. Speak slowly and calmly. 1c. Use short simple sentences. 1d. Assure patient that you are in control and can assist him or her. 1e. Give brief directions. 1f. Decrease excessive stimuli; provide quiet environment. 1g. After assessing level of anxiety, administer appropriate dose of antianxiety drug as needed. 2a. Encourage patient to discuss preceding events. 2b. Link patient's behavior to feelings. 2c. Teach a cognitive therapy principle: Anxiety is the result of automatic thinking with a dysfunctional appraisal of a situation. 2d. Ask questions that clarify and dispute illogical thinking: "What evidence do you have?" "Are you basing that conclusion on fact or feeling?" "What's the worst thing that could happen?" 2e. Encourage patient to provide an alternative interpretation. 3a. Identify what has provided relief in the past. 3b. Have patient write assessment of strengths. 3c. Reframe situation in ways that are positive.

Regarding ADHD meds, Administering the medication no later than

4:00 in the afternoon or lowering the last dose of the day helps the insomnia side effect

DSM-5 Criteria for Attention-Deficit/Hyperactivity Disorder

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): 1. Inattention: Six (or more if under 16) of the following symptoms have persisted for at least 6 months to a degree inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. 2. Hyperactivity and impulsivity: Six (or more if under 16) of the following symptoms have persisted for at least 6 months to a degree inconsistent with development level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. B. Several inattentive or hyperactive-impulsive symptoms were present before age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

DSM-5 Criteria for Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required for children. 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder

DSM-5 Criteria for Obsessive-Compulsive Disorder

A. Presence of obsessions, compulsions, or both. Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder

DSM-5 Criteria for Panic Disorder

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four (or more) of the following symptoms occur: Note: The abrupt surge can occur from a calm state or an anxious state. 1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat sensations. 10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself). 12. Fear of losing control or "going crazy." 13. Fear of dying. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms. B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy"). 2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks such as avoidance of exercise or unfamiliar situations). C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Regarding substance abuse, Stimulant Toxicity Assessment Findings Interventions

Assessment Findings Cardiovascular • Palpitations • Tachycardia • ↑ BP • Dysrhythmias • Myocardial ischemia or infarction Central Nervous System • Feeling of impending doom • Euphoria • Agitation • Combativeness • Seizures • Hallucinations • Confusion • Paranoia • Fever Interventions • Ensure patent airway. • Establish IV access and initiate fluid replacement as appropriate. • Obtain a 12-lead ECG and initiate ECG monitoring. • Treat ventricular dysrhythmias as appropriate with lidocaine, bretylium (Bretylol), or procainamide (Pronestyl). • Hypertension and chest pain may require administration of nitroprusside (Nipride) or phentolamine (Regitine). • Aspirin may be administered to lower the risk of myocardial infarction. • Administer IV diazepam (Valium) or lorazepam (Ativan) for seizures. • Administer IV antipsychotic drugs for psychosis and hallucinations. • Monitor vital signs and level of consciousness. • Initiate cooling measures for hyperthermia.

Emergency Management Depressant Toxicity Assessment Findings Interventions

Assessment Findings • Aggressive behavior • Agitation • Confusion • Lethargy • Stupor • Hallucinations • Depression • Slurred speech • Pinpoint pupils • Nystagmus • Seizures • Cold, clammy skin • Rapid, weak pulse • Slow or rapid shallow respirations • Decreased O2 saturation • Hypotension • Dysrhythmias • ECG changes • Cardiac or respiratory arrest Interventions • Ensure patent airway. • Anticipate intubation if respiratory distress evident. • Establish IV access. • Obtain temperature. • Obtain 12-lead ECG and initiate continuous ECG monitoring. • Obtain information about substance (name, route, when taken, amount). • Obtain specific drug levels or comprehensive toxicology screen. • Obtain a health history, including drug use and allergies. • Administer antidotes as appropriate. • Perform gastric lavage if necessary. • Administer activated charcoal and cathartics as appropriate. • Monitor vital signs, level of consciousness, and O2 saturation.

The scientific evidence to date shows no link between measles, mumps, and rubella (MMR) and thimerosal-containing vaccines and

Autism

Parents need expert counseling early in the course of the disorder and should be referred to the

Autism Society website

Children with autism do not always have the same manifestations, from mild forms requiring minimal supervision to severe forms in which self-abusive behavior is common. The majority of children with autism have some degree of

CI, with scores typically in the moderate to severe range.

Regrading Alcohol withdrawal syndrome (AWS), Use a symptom assessment tool, such as the

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), to determine treatment

Health Problems Related to Substance Use Cocaine Amphetamines Sedative-hypnotics Opioids Inhalants Cannabis

Cocaine • Cardiac dysrhythmias, myocardial ischemia and infarction • Seizures, stroke • Psychosis Amphetamines • Cardiac dysrhythmias, myocardial ischemia and infarction • Liver, lung, kidney damage • Mood disturbances, violent behavior, psychoses Sedative-hypnotics • Memory impairment • Personality changes, depression Opioids • Sexual dysfunction • Gastric ulcers • Glomerulonephritis Inhalants • Cognitive and motor impairment • Acute and chronic kidney injury Cannabis • Bronchitis, chronic cough • Depression, anxiety, schizophrenia • Memory impairment

Regarding Nicotine Replacement Agents, Nicotine Inhaler (Nicotrol nicotine inhalation system) Common Side Effects Considerations

Common Side Effects Cough, mouth and throat irritation, headache, nausea, hiccups Considerations - Requires a prescription. - Simulates smoking with mouthpiece and nicotine cartridge. - May not be advisable for those with asthma or pulmonary disease

Regarding Nicotine Replacement Agents, Nicotine Gum (OTC) (Nicorette) Common Side Effects Considerations

Common Side Effects Hiccups, mouth/jaw pain, mouth ulcers, indigestion, throat irritation, nausea Considerations - Specific 30-min chewing regimen with periods of holding the gum between cheek and teeth. - Take only water 15 min before and during use. - Difficult to use with dentures

Regarding Non-Nicotine Agents, bupropion (Zyban) Common Side Effects Considerations

Common Side Effects Insomnia, dry mouth, irritability, rash, tremors, anorexia Considerations - Contraindicated with history of seizures or eating disorders. - Promotes weight loss. - First choice for smokers with depression

Regarding Nicotine Replacement Agents, Nicotine Lozenge (OTC)(Commit) Common Side Effects Considerations

Common Side Effects Insomnia, nausea, sore throat, hiccups, cough, heartburn, headache, flatulence Considerations - Dissolves in mouth in 20 to 30 min. - Do not chew or swallow. - Avoid food and drink during use. - Occasionally rotate around the mouth.

Regarding Non-Nicotine Agents, varenicline (Chantix Common Side Effects Considerations

Common Side Effects Nausea, sleep disturbances, constipation, flatulence, vomiting, headache Considerations If taken concurrently with nicotine replacement therapy, incidence of nausea, headache, vomiting, dizziness, dyspepsia, and fatigue is increased, but nicotine pharmacokinetics not affected.

Regarding Nicotine Replacement Agents, Nicotine Nasal Spray (Nicotrol NS) Common Side Effects Considerations

Common Side Effects Nose and throat irritation, sneezing, rhinitis, headache, cough Considerations - Requires a prescription. - Provides fastest nicotine delivery. - Do not sniff or inhale while dosing. - Tilt head back slightly for best results.

Regarding Nicotine Replacement Agents, Nicotine Patch (OTC) (NicoDerm CQ, Habitrol, Nicotine transdermal system) Common Side Effects Considerations

Common Side Effects Transient itching, burning, and redness at patch site. Insomnia, nausea, headache Considerations - Provides steady level of nicotine and is easy to use. - Cannot be used by those with adhesive allergies. - Rotate site to diminish skin irritation.

Children with Autism may have significant gastrointestinal symptoms, such as

Constipation and can be associated with acquired megarectum in children with ASD

Regarding Intellectual disability, Intellectual functioning

Deficits in reasoning, problem solving, planning, judgment, abstract thinking, and academic ability.

Nursing Diagnosis Inability to feed, bathe, dress, or toilet self at age-appropriate level

Delayed growth and development Dressing, toileting, bathing self-care deficit

Drug Alert Varenicline (Chantix) and Bupropion (Zyban)

For smoking cessation • Serious neuropsychiatric symptoms such as changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide can occur. • Advise patients to stop taking these drugs and contact the HCP immediately if they experience any of these manifestations.

Clinical Manifestations of Down Syndrome Head and Eyes Nose and Ears Mouth and Neck Chest and Heart Hands and Feet Musculoskeletal and Skin Other

Head and Eyes - Separated sagittal suture - Brachycephaly - Rounded and small skull - Flat occiput - Enlarged anterior fontanel - Oblique palpebral fissures (upward, outward slant)* - Inner epicanthal folds - Speckling of iris (Brushfield spots) Nose and Ears - Small nose* - Depressed nasal bridge (saddle nose)* - Small ears and narrow canals - Short pinna (vertical ear length) - Overlapping upper helices - Conductive hearing loss Mouth and Neck - High, arched, narrow palate* - Protruding tongue - Hypoplastic mandible - Delayed teeth eruption and microdontia - Abnormal teeth alignment common - Periodontal disease - Neck skin excess and laxity* - Short and broad neck Chest and Heart - Shortened rib cage - Twelfth rib anomalies - Pectus excavatum or carinatum - Congenital heart defects common (e.g., atrial septal defect, ventricular septal defect) - Abdomen and Genitalia - Protruding, lax, and flabby abdominal muscles - Diastasis recti abdominis - Umbilical hernia - Small penis - Cryptorchidism - Bulbous vulva Hands and Feet - Broad, short hands and stubby fingers - Incurved little finger (clinodactyly) - Transverse palmar crease - Wide space between big and second toes* - Plantar crease between big and second toes* - Broad, short feet and stubby toes Musculoskeletal and Skin - Short stature - Hyperflexibility and muscle weakness* - Hypotonia - Atlantoaxial instability - Dry, cracked, and frequent fissuring - Cutis marmorata (mottling) Other - Reduced birth weight - Learning difficulty (average intelligence quotient [IQ] of 50) - Hypothyroidism common - Impaired immune function - Increased risk for leukemia - Early-onset dementia (in one-third)

Some individuals with autism spectrum disorder may have low These areas include This is a condition known as

IQs yet are brilliant in specific areas musical, visual-spatial, or intellectual abilities such as the ability to complete complex mathematical calculations or photographic memory recall. savant syndrome.

Criteria for Substance Use Disorder The following criteria (clustered in four groups) can be used to identify substance use disorder (SUD). The severity of SUD can be classified as mild (2-3 criteria), moderate (4-5 criteria), or severe (6 or more criteria).

Impaired Control • Taking more or for longer than intended • Failing to quit using despite multiple times of trying to do so • Spending a great deal of time obtaining, using, or recovering from use • Craving the substance Social Impairment • Missing school, work, or other responsibilities due to use • Continuing use despite problems caused or exacerbated by use • Giving up or reducing important activities because of use Risky Use • Recurrent use in hazardous situations • Continued use despite problems that are caused or worsened by use Pharmacologic Dependence • Physical tolerance to effects of the substance • Presence of withdrawal symptoms when not using or using less

Regarding Intellectual disability, Social functioning

Impaired communication and language, interpreting and acting on social cues, and regulating emotions.

Nursing Diagnosis Lack of responsiveness or interest in others, empathy, or sharing

Impaired social interaction Risk for impaired attachment Risk for impaired parenting Risk for social isolation

Nursing Diagnosis Language delay or absence, stereotyped, or repetitive use of language

Impaired verbal communication

Nursing Diagnosis Refusal to attend school

Ineffective coping Ineffective role performance Readiness for enhanced parenting

Nursing Diagnosis Failure to follow age-appropriate social norms

Ineffective coping Ineffective role performance Risk for ineffective relationships

Health Problems Related to Substance Use Injecting drugs Snorting drugs Risky sexual behavior Personal neglect

Injecting drugs • Blood clots, phlebitis, skin infections • Hepatitis B and C • HIV/AIDS • Other infections: endocarditis, tuberculosis, pneumonia, meningitis, tetanus, bone and joint infections, lung abscesses Snorting drugs • Nasal sores, septal necrosis or perforation • Chronic sinusitis Risky sexual behavior • HIV/AIDS • Hepatitis B and C • Sexually transmitted infections Personal neglect • Malnutrition, impaired immunity • Accidental injuries

Regarding ADHD, To control aggressive behaviors, Stimulants have a dose-dependent effect. Low doses do what? High doses do what?

Low doses stimulate aggressive behaviors while moderate to high doses suppress aggression.

Manifestations and Treatment of Alcohol Withdrawal For Alcohol Withdrawal Delirium Manifestations Interprofessional Care

Manifestations • Disorientation • Visual, tactile, or auditory hallucinations • Seizures • can result in death in 20% of untreated patients (caused by pneumonia, renal disease, hepatic insufficiency, or heart failure) Interprofessional Care • Continued use of benzodiazepines (once delirium appears, intravenous lorazepam (Ativan) is used to treat these severe symptoms) • Carbamazepine (Tegretol) or valproate (Depakote) to treat seizures • Antipsychotic agents (e.g., chlorpromazine [Thorazine], haloperidol [Haldol]) • Chlordiazepoxide (Librium) if psychosis persists after benzodiazepine administration • Seclusion may be necessary. • Treat dehydration with IV fluid

Manifestations and Treatment of Alcohol Withdrawal For Alcohol Withdrawal Syndrome Manifestations Interprofessional Care

Manifestations • tremulousness, commonly called the shakes or the jitters • Agitation • Anxiety • ↑ Heart rate • ↑ BP • Sweating • Nausea • Tremors • Insomnia • Hyperactivity Interprofessional Care • Chlordiazepoxide (Librium) is useful for tremulousness and mild to moderate agitation. • Benzodiazepines (e.g., lorazepam [Ativan], Diazepam (Valium), or midazolam [Versed]) to prevent seizures and delirium • Thiamine to prevent Wernicke-Korsakoff syndrome • Multivitamins (e.g., folic acid, B vitamins) • Magnesium sulfate to treat low serum magnesium • IV glucose solution to treat hypoglycemia • β-blockers (e.g., propranolol) or α2-agonists (e.g., clonidine) to stabilize VS • Respiratory support

Regarding Patient Teaching Smoking and Tobacco Use Cessation Avoiding Relapse

Most relapses occur within the first 3 months after quitting. Do not be discouraged if you start using tobacco again. Remember, most people try several times before they finally quit. Explore different ways to break habits. You may have to deal with some of the following triggers that cause relapse. • Change your environment. Get rid of cigarettes, tobacco (in any form), and ashtrays in your home, car, and place of work. Get rid of the smell of cigarettes in your car and home. • Alcohol. Consider limiting or stopping alcohol use while you are quitting tobacco. • Other smokers at home. Encourage housemates to quit with you. Work out a plan to cope with others who smoke, and avoid being around them. • Weight gain. Tackle one problem at a time. Work on quitting tobacco first. You will not necessarily gain weight, and increased appetite is often temporary. Eat healthy and exercise. • Negative mood or depression. If these symptoms persist, talk to your HCP. You may need treatment for depression. • Withdrawal symptoms. Your body will go through many changes when you quit tobacco. You may have a dry mouth, cough, or scratchy throat, and you may feel irritable. The nicotine patch or gum may help with cravings • Focus on the benefits of quitting: • Your BP and heart rate will lower almost immediately. • Your risk of a heart attack declines within 24 hours and the blood will become less likely to clot, making dangerous blood clots less likely. • Within a few weeks, you will be less short of breath, cough less, and have more energy. Your ability to smell and taste should improve. • Your immune system will be stronger, so you will be less likely to be sick. • Quitting will improve your night vision and help preserve your overall vision.

Interventions Targeting the Vegetative Signs of Depression

Nutrition (Anorexia): - Offer small, high-calorie, and high-protein snacks frequently throughout the day and evening. - Offer high-protein and high-calorie fluids frequently throughout the day and evening. - When possible, encourage family or friends to join the patient during meals. - Include the patient in choosing foods and drinks. Involve a dietitian if necessary - Weigh the patient weekly, and observe the patient's eating patterns. Sleep (Insomnia): - Provide periods of rest after activities. - Encourage the patient to get up and dress and to stay out of bed during the day. - Encourage the use of relaxation measures in the evening (e.g., a warm bath, warm milk, soothing music or sounds). - Provide decaffeinated coffee and soda. Self-Care Deficits: - Encourage the use of toothbrush, washcloth, soap, makeup, and shaving supplies. - When appropriate, give step-by-step reminders, such as, "Wash the right side of your face, now the left." Elimination (Constipation): - Monitor intake and output, especially bowel movements. - Offer foods high in fiber, and provide periods of exercise. - Encourage the intake of fluids. - Evaluate the need for laxatives and enemas.

Sexual and physical abuse in childhood or trauma increases the risk of

OCD

Regarding Alcohol Withdrawal, Wernicke-Korsakoff Syndrome occurs when (a specific issue) Wernicke's may clear up within a few weeks or may progress into Another problem is Korsakoff's syndrome, a chronic condition with a recovery rate of Treatment of Korsakoff's syndrome is also

People with a heavy use of alcohol for many years may suffer from short-term memory disturbances - One memory-reducing problem is Wernicke's (alcoholic) encephalopathy, an acute and reversible condition. Korsakoff's syndrome, the more severe and chronic version of this problem. only about 20% thiamine for 3 to 12 months. - Most patients with Korsakoff's syndrome never fully recover

Regarding Intellectual disability, Daily functioning

Practical aspects of daily life are impacted by a deficit in managing age-appropriate activities of daily living, functioning at school or work, and performing self-care

Attention-Deficit/Hyperactivity Disorder (ADHD) Diagnosis

Require home assessment AND school assessment - overactive - may display disruptive behaviors that are impulsive, angry, aggressive, and often dangerous. - difficulty with maintaining attention in situations - behaviors negatively impact their ability to develop fulfilling peer and family relationships - often in conflict with others, are noncompliant, do not follow age-appropriate social norms, and may use inappropriate ways to meet their needs.

Nursing Diagnosis Inability to concentrate, withdrawal, difficulty in functioning, feeling down, change in vegetative symptoms

Risk for suicide Anxiety Risk for situational low self-esteem

Regarding The Alcohol Use Disorders Identification Test (AUDIT): Self-Report Version, Score for further assessment

Score: 8 or more in men; 7 or more in women needs further assessment.

Substance Use Screening is a simple effective way to identify patients who need further assessment. The

Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach can be used

Patient Teaching Signs of Postpartum Blues, Depression, and Psychosis

Signs of baby blues (these should go away in a few days or 1 week): • Sad, anxious, or overwhelmed feelings • Crying spells • Loss of appetite • Difficulty sleeping Signs of postpartum depression (can begin any time in the first year): • Same signs as baby blues, but they last longer and are more severe • Thoughts of harming yourself or your baby • Not having any interest in the baby Signs of postpartum psychosis: • Seeing or hearing things that are not there • Feelings of confusion • Rapid mood swings • Trying to hurt yourself or your baby When to call your health care provider: • The baby blues continue for more than 2 weeks • Symptoms of depression get worse • Difficulty performing tasks at home or at work • Inability to care for yourself or your baby • Thoughts of harming yourself or your baby

Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Use Single-Question Tests Two-Question Tests

Single-Question Tests Use one of the following questions to screen for the presence of alcohol, drug, or tobacco use. • How often in the past year have you had 5 (men) or 4 (women) or more drinks in a day? • How many times in the past year have you used illegal drugs or prescription medications for nonmedical reasons? • In the past year, how often have you used tobacco products? Two-Question Tests Use the following two questions to screen for alcohol or drug use. • In the past year, have you ever drunk or used drugs more than you meant to? • Have you felt you wanted or needed to cut down on your drinking or drug use in the past year?

Regarding ADHD, Stimulant drugs

Stimulant drugs: - Amphetamine - Dexmethylphenidate - Dextroamphetamine - Lisdexamfetamine dimesylate - Methamphetamine - Methylphenidate HCL

Serotonin Syndrome: Signs and Interventions

Symptoms • Hyperactivity or restlessness • Tachycardia → cardiovascular shock • Fever → hyperpyrexia • Elevated blood pressure • Altered mental states (delirium) • Irrationality, mood swings, hostility • Seizures → status epilepticus • Myoclonus, incoordination, tonic rigidity • Abdominal pain, diarrhea, bloating • Apnea → death Interventions • Remove offending agent(s) • Initiate symptomatic treatment: - Serotonin-receptor blockade with cyproheptadine, methysergide, propranolol - Cooling blankets, chlorpromazine for hyperthermia - Dantrolene, diazepam for muscle rigidity or rigors - Anticonvulsants - Artificial ventilation - Induction of paralysis

What sports would not be good for a child with ADHD?

Team sports (swimming is the best, soccer and baseball not so much)

Scale for OCD Scale for hoarding Scale for phobias Scale for panic disorder Scale for GAD

The Yale-Brown Obsessive Compulsive Scale measures severity of compulsive behavior. The Hoarding Scale Self-Report Fear Questionnaire; Panic Disorder Severity Scale The Severity Measure for Generalized Anxiety Disorder

Alcohol withdrawal syndrome (AWS) can develop in The onset of AWS is variable depending on the

a hospitalized patient when the use of alcohol abruptly stops. quantity, frequency, pattern, and duration of alcohol use

Acute alcohol toxicity occurs when This leads to

a person has a high level of alcohol in his or her blood, generally after the ingestion of a large amount of alcohol. - behavior changes and alcohol-induced CNS depression, resulting in respiratory and circulatory failure. - Unconsciousness, coma, and possibly death can occur. - hypokalemia, hypomagnesemia, and hypoglycemia.

Most people with depression experience anergia, which refers to an Anergia may result in

abnormal lack of energy. psychomotor retardation, in which movements are extremely slow, facial expressions are decreased, and gaze is fixed.

Regarding substance abuse, Patients with acute marijuana toxicity can present with Cannabis can induce Nursing interventions

acute psychotic episodes, especially if the patient used a synthetic derivative. (depersonalization and derealization) tachycardia and hypertension, triggering dysrhythmias and myocardial infarction. - Panic and flashbacks are managed by providing a quiet environment and reassuring the patient. - Benzodiazepines provide symptom relief.

The DSM-5 is the diagnostic standard and states that the child with CI must demonstrate deficits in

adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility

The risk of this syndrome seems to be greatest when an SSRI is A patient should do what to prevent this?

administered in combination with a second serotonin-enhancing agent, such as a monoamine oxidase inhibitor (MAOI). discontinue all SSRIs for 2 to 5 weeks before starting an MAOI.

Genetic counseling and prenatal testing for down syndrome is especially important for women of

advanced maternal age and those who have a family history of the disorder

Initial symptoms or the recurrence of withdrawal symptoms can develop

after discharge from the hospital and last up to 6 months; therefore it is important to establish rapport and maintain contact with the family so they will return for treatment if this occurs

Nursing Alert Nurses are advised to be alert for mothers who are

agitated, overactive, confused, complaining, or suspicious. (Postpartum psychosis)

Panic disorder consists of unpredictable, intermittent episodes (attacks) of symptoms similar to those of generalized anxiety disorder. Women with panic disorder may develop

agoraphobia or fear of leaving home because they fear having another panic attack

Regarding substance abuse, With cannabis at low to moderate doses, THC produces effects similar to Manifestations

alcohol and other CNS depressants. - euphoria, - decreased inhibition, - impaired coordination. - Long-term use: cardiopulmonary and mental health

a person who binge drinks may not have a person who uses heroin or cocaine is likely to have

alcohol substance use disorder (SUD) but is at increased risk for it. severe substance use disorder (SUD) because these substances are highly addictive.

Binge drinking is

alcohol use that brings blood alcohol concentration (BAC) levels over the legal limit for intoxication at least once per month

When the child with CI is admitted, a detailed history is taken with special focus on Questions about the child's abilities are approached

all self-care abilities. positively. - For example, rather than asking, "Is your child toilet trained yet?" the nurse may state, "Tell me about your child's toileting habits."

Regarding ADHD, Two centrally acting alpha-2 adrenergic agonists, clonidine (Kapvay) and guanfacine (Intuniv): They may be used clonidine side effects The most common side effects of guanfacine are

alone or in conjunction with other ADHDA medications clonidine carries more side effects: - somnolence, - fatigue, - insomnia, - nightmares, - irritability, - constipation, - respiratory symptoms - dry mouth, - ear pain guanfacine: - somnolence, - lethargy, - fatigue, - insomnia, - nausea, - dizziness, - hypotension, - abdominal pain.

Vegetative signs of depression refer to

alterations in those activities necessary to support physical life and growth (e.g., eating, sleeping, elimination, and sex). - Appetite loss is common, and sometimes patients can lose up to 5% of their body weight in less than a month - Change in sleep pattern is a cardinal sign - Changes in bowel habits (Constipation) - Sexual interest declines (loss of libido) - Grooming, dressing, and personal hygiene may be markedly neglected

Regarding Anxiety Pharmacological Interventions, Buspirone (BuSpar) is an what? How long does it take for full effects? Buspirone is not recommended for individuals with The FDA recommends using the drug during

alternative antianxiety medication that does not cause dependence, but 2 to 4 weeks are required for it to reach full effects. impaired hepatic or renal function since in increased plasma levels and lengthened half-life may result. pregnancy and breastfeeding only if clearly necessary.

Regarding substance abuse, Stimulant Withdrawal is usually not Abrupt cessation can

an emergency. lead to a "crash."

Parental overprotection and adverse experiences are associated with

anxiety disorders.

Developmental disability can be described as

any significant lag or delay in a child's physical, cognitive, behavioral, emotional, or social development when compared against developmental norms.

Cognitive impairment (CI) is a general term that encompasses

any type of intellectual disability. - CI is used synonymously with intellectual disability.

Women with OCD are afraid they will harm their infants, but Women with postpartum psychosis who have the same thoughts are

are unlikely to do so. more apt to actually cause harm

About 15% of children with Down syndrome have atlantoaxial instability; almost all of the children are

asymptomatic.

Some children are inattentive, but not hyperactive. In this case the diagnosis is

attention-deficit disorder (ADD).

There is a genetic component to

autism spectrum disorder - most of the time if one twin is affected so is the other (more common in boys) - high risk for recurrence of ASD in families with one affected child

Regarding substance abuse, For depressants Common sedative-hypnotic and Antianxiety agents include Sedative-hypnotic and Antianxiety drugs do what Their use produces a tolerance may not develop to the brainstem-depressant effects. As a result, an increased dose may

barbiturates, benzodiazepines, and barbiturate-like drugs depress the CNS, causing sedation at low doses and sleep at high doses. - Craving is a typical feature euphoria and intoxication that resembles that of alcohol. - slurred speech, incoordination, unsteady gait, nystagmus, impaired thinking, Coma, Inappropriate aggression and sexual behavior, mood fluctuation, and impaired judgment trigger hypotension and respiratory depression, resulting in death.

Postpartum psychosis can be due to major depression. However, it is most commonly associated with

bipolar disorder (or manic-depressive disorder) and presents with symptoms of mania, depression, or both

Varenicline (Chantix) is a drug used to aid smoking cessation. If the person does resume smoking, its antagonist action Bupropion (Zyban), an antidepressant drug, reduces the

blocks the effects of nicotine at another subtype of nicotinic receptor, making smoking less enjoyable. urge to smoke, reduces some symptoms of withdrawal, and helps prevent weight gain associated with smoking cessation.

Monoamine oxidase inhibitors (MAOIs) The inability to What to do about this or what will happen? A transdermal patch, selegiline (EMSAM), does not require

break down tyramine sufficiently can result in a serious problem. People taking these drugs must reduce or eliminate their intake of foods and drugs that contain high amounts of tyramine. Individuals who take MAOIs and eat these foods are at risk for a hypertensive crisis, which is severe high blood pressure that can lead to a cerebrovascular accident. strict dietary restrictions.

Anxiety symptoms can interfere with the mother's ability to

care for herself, the infant, and her family.

Patients on any medical floor are at risk for Alcohol Withdrawal Delirium after What is the goal for this? How to do so?

cessation of heavy drinking for 3 days and are a danger to themselves and others. - hepatitis or pancreatitis may increase the likelihood of alcohol withdrawal delirium Prevention of alcohol withdrawal delirium is the goal - Oral diazepam (Valium) may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens - Chlordiazepoxide (Librium) may keep your patient out of danger. - once delirium appears, intravenous lorazepam (Ativan) is used to treat these severe symptoms.

Regarding ADHD, CBT is used to

change the pattern of misconduct by fostering the development of internal controls and working with the family to improve coping and support. - Development of problem solving, conflict resolution, empathy, and social skills is an important component of the treatment program.

Panic attacks in Latin Americans and Northern Europeans often involve sensations of Social anxiety in Japanese and Korean cultures may relate to beliefs that the individual's

choking, smothering, numbness, or tingling, as well as fear of dying blushing, eye contact, or body odor is offensive to others.

For children with milder forms of autism spectrum disorder it is reasonable to expect greater participation and input from the child. For individuals with more severe impairments, there will be greater reliance on the family. Family members must have

clear and realistic expectations of the long-term needs of their child and be linked with the appropriate resources to assist with care and long-term planning.

Nursing Alert Claims of beneficial results from the use of secretin, a peptide hormone that stimulates pancreatic secretion, has been studied extensively in multiple randomized control trials, denoting

clear evidence that it lacks any benefit

Persons with alcohol-related neurodevelopmental disorder (ARND) are likely to have

cognitive and learning disabilities and behavioral problems such as poor impulse control

Neurologic problems in persons with Fetal alcohol syndrome (FAS) can include some degree of They have been shown to

cognitive deficit, ADHD, diminished fine-motor skills, and poor speech lack inhibition, have no stranger anxiety, and lack appropriate judgment skills

Autism spectrum disorder is a

complex neurobiological and developmental disability that typically appears during a child's first 3 years of life.

The Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) is a The tool measures

comprehensive neurologic and behavioral assessment tool that may be used to identify newborns at risk as a result of intrauterine drug exposure. - stress or abstinence, - state, - neurologic status, - muscle tone in the context of the newborn's medical condition at the time of examination

Regarding Electroconvulsive Therapy for depression, Patients wake about 15 minutes after the procedure. The patient is often Most people experience what is called

confused and disoriented for several hours. The nurse and family may need to orient the patient frequently during the course of treatment. retrograde amnesia, which is a loss of memory of events leading up to and including the treatment itself.

Cannabis intoxication Delirium results in marked impairment in cognition and performance. Physical symptoms of intoxication include

conjunctival injection (red eyes from vessel dilation), increased appetite, dry mouth, and tachycardia.

Regarding down syndrome, Dietary intake needs supervision. Decreased muscle tone affects gastric motility, predisposing the child to What can help this?

constipation. Dietary measures, such as increased fiber and fluid, promote evacuation.

Regarding substance abuse, THC-based medications, dronabinol (Marinol) and nabilone (Cesamet), are available to Dronabinol is also used to Illegal synthetic THC derivatives (e.g., K2, Spice) contain

control nausea and vomiting resulting from cancer chemotherapy. stimulate the appetite in patients with acquired immunodeficiency syndrome (AIDS). varying amounts of different ingredients. - can cause death

Electroconvulsive Therapy is the most effective acute treatment for Risk of doing this

depression - risk of suicide and diminished quality of life - heart can be stressed at the onset of the seizure and for up to 10 minutes after, careful assessment and management in hypertension, congestive heart failure, cardiac arrhythmias, and other cardiac conditions is warranted - stresses the brain as a result of increased cerebral oxygen, blood flow, and intracranial pressure.

Most reported comorbid disorder is

depression (anxiety, substance abuse, sleep disorder, impulse control, learning disability)

People with separation anxiety disorder exhibit The anxiety is so intense that it adults with this disorder often have extreme difficulties in

developmentally inappropriate levels of concern over being away from a significant other - here may also be fear that something horrible will happen to the other person distracts sufferers from their normal activities and causes sleep disruptions and nightmares. - often manifested in physical symptoms such as gastrointestinal disturbances and headaches. romantic relationships and are more likely to be unmarried.

Regarding down syndrome, The hypotonicity of muscles and hyperextensibility of joints complicate positioning. The limp, flaccid extremities resemble the posture of a rag doll; as a result, holding the infant is Sometimes parents perceive this lack of molding to their bodies as evidence of The extended body position promotes What should be encouraged to the patient?

difficult and cumbersome inadequate parenting. heat loss, because more surface area is exposed to the environment. Encourage the parents to swaddle or wrap the infant snugly in a blanket before picking up the child to provide security and warmth.

attention-deficit/hyperactivity disorder (ADHD) is most often detected when the child has Attention problems and hyperactivity contribute to

difficulty adjusting to elementary school. low frustration tolerance, temper outbursts, labile moods, poor school performance, peer rejection, and low self-esteem.

The tolerant person is usually able to

drink large amounts without obvious impairment and perform complex tasks without problems at BAC levels much higher than levels that would produce obvious impairment in the nontolerant drinker.

Newborn urine, hair, or meconium sampling may be required to identify Meconium sampling for fetal drug exposure is reported to provide Urine toxicology screening reflects only Meconium and hair testing for drug metabolites has the advantages of being

drug exposure and implement appropriate early interventional therapies aimed at minimizing the consequences of intrauterine drug exposure more screening accuracy than urine screening because drug metabolites accumulate in meconium. recent substance intake by the mother noninvasive, more accurate, and easy to collect.

Children with autism spectrum disorder should be referred to Through case management and coordination of care, they may be treated in Their education and treatment with therapeutic modalities are mandated under the

early intervention programs once communication and behavioral symptoms are identified, typically in the second or third year of life. therapeutic nursery schools, day treatment programs, and special education classes in public or specialized private schools Children with Disabilities Act.

Nurses provide services to children with intellectual disabilities in a variety of settings. Children with intellectual disabilities are cared for in the community through Federal legislation, the Individuals with Disabilities in Education Act (IDEA), requires that public schools provide Individuals may also require short-term hospitalization related to socially impaired behaviors such as

early intervention programs or public school programs as they reach school age. services to assist children with emotional or developmental disorders to participate in school aggression, self-harm, or severe self-care deficits.

Regarding Assist in Measures to Prevent Cognitive Impairment, Interventions are directed toward improving maternal health by

educating women regarding the dangers of chemicals, including prenatal alcohol exposure, which affects organogenesis, craniofacial development, and cognitive ability - adequate prenatal care; optimal medical care of high-risk newborns; rubella immunization; genetic counseling; and prenatal screening, especially in terms of Down syndrome or FXS. - The use of folic acid supplements prevents neural tube defects during pregnancy and during the childbearing years; - use of newborn screening for treatable inborn errors of metabolism (e.g., congenital hypothyroidism, phenylketonuria, and galactosemia)

The demands of the drug-exposed infant on the caregiver are What is important to do as a nurse?

enormous and unrewarding in terms of positive feedback. - The infants are difficult to comfort, and they cry for long periods, which can be especially trying for the caregiver after the infant's discharge from the hospital. Long-term follow-up to evaluate the status of the infant and family is very important

Although no cure exists for Down syndrome, a number of therapies are advocated, such as surgery to correct serious congenital anomalies (e.g., heart defects, strabismus). These children also benefit from Evaluation of sight and hearing is essential, and treatment of otitis media is Periodic testing of thyroid function

evaluative echocardiography soon after birth and regular medical care required to prevent auditory loss, which can influence cognitive function. is recommended, especially if growth is severely delayed.

Regarding down syndrome, If prenatal testing indicates that the fetus is affected, the nurse must allow the parents to

express their feelings concerning elective abortion and support their decision to terminate or proceed with the pregnancy - It is important for nurses to be aware of their own attitudes regarding testing and related decisions.

For individuals with hoarding disorder, this purging would have been Nearly all hoarders (75%) also experience

extremely distressing major depressive and/or anxiety disorders

Regarding down syndrome and respiratory interventions, Inadequate drainage resulting in pooling of mucus in the nose also interferes with Because the child breathes by mouth, sucking for any length of time is When eating solids, the child may Parents are advised to

feeding. difficult. gag on the food because of mucus in the oropharynx. clear the nose before each feeding; give small, frequent feedings; and allow opportunities for rest during mealtime.

Regarding depression treatment, St. John's wort (Hypericum perforatum) is a Neither safety nor standardization of dose has been established. Therefore it should be used with caution during

flower that can be processed into tea or tablets. - increase the amount of serotonin, norepinephrine, and dopamine in the brain, resulting in antidepressant effects. pregnancy or in children.

Regarding substance abuse, For depressants and Sedative-Hypnotics and Antianxiety toxicity a patient with a benzodiazepine overdose may receive Place the patient on Since there are no antagonists for barbiturates or other sedative-hypnotic drugs, the patient who has overdosed on these agents receives

flumazenil, a specific benzodiazepine antagonist. safety precautions, as flumazenil can cause seizures. treatment to promote drug elimination - Dialysis is used to decrease the drug level and to prevent irreversible CNS effects and death. - If the airway can be maintained, gastric lavage and activated charcoal are options. - If unconscious, an intravenous fluid line should be established

Keep in mind that evaluating whether the use of defense mechanisms is adaptive or maladaptive is determined for the most part by their

frequency, intensity, and duration of use

Regarding Trichophagia, This ingestion may lead to

hair masses, or trichobezoar, in the gastrointestinal system. - The masses can be fatal if they progress to abdominal obstruction or perforation. - You may be interested to know that the masses of digested hair are also referred to as the Rapunzel syndrome.

Polypharmacy and the normal metabolic processes of aging contribute to concerns about prescribing antidepressants for older adults. SSRIs are a first-line treatment for older adults, but this population has the potential for aggravated side effects. Starting doses are recommended to be

half the lowest adult dose, with dose adjustments occurring no more frequently than every 7 days ("start low and go slow").

Life expectancy for those with Down syndrome The majority of individuals with Down syndrome survive to

has improved in recent years but remains lower than for the general population. 60 years of age and beyond

Speech requires adequate

hearing and interpretation (receptive skills) and facial muscle coordination (expressive skills).

Long-term alcohol use can lead to the development of Short-term, excess alcohol use Effects of Chronic Alcohol Use

high BP, heart disease, stroke, liver disease, and digestive problems. increases the risk of injury from motor vehicle crashes, falls, firearms, assault, drowning, and burns - Alcoholic dementia, - Wernicke-Korsakoff syndrome - Depression, anxiety, attention deficit, labile moods, seizures, insomnia - Increased susceptibility to infections, depressed immune function - Bone marrow depression, anemia, leukopenia, thrombocytopenia, blood clotting abnormalities - Myopathy, osteoporosis, gout - Hypertension, atrial fibrillation, cardiomyopathy, stroke - Diabetes mellitus

Regarding substance abuse, Amphetamine-related stimulants are While the use of crack cocaine and methamphetamine is illegal, amphetamines have a role in All stimulants increase People use these drugs to produce

highly addictive substances. treating narcolepsy and attention deficit disorder cardiac activity and excite the CNS by increasing levels of norepinephrine, serotonin, and dopamine. feelings of euphoria, increase alertness, and boost their energy.

Although there is no cure for Autism, numerous therapies have been used. The most promising results have been through In general, the objective in treatment is to

highly structured and intensive behavior modification programs promote positive reinforcement, increase social awareness of others, teach verbal communication skills, and decrease unacceptable behavior. - Providing a structured routine for the child to follow is a key in the management of ASD.

Some children may be taught sign language or Blissymbols—a

highly stylized system of graphic symbols representing words, ideas, and concepts. - Although the symbols require education to learn their meaning, no reading skill is required. - The symbols are typically arranged on a board, and the person points or uses some type of selector to convey a message.

Indecisiveness is associated with

hoarding.

Risk for suicide is increased when depression is accompanied by

hopelessness, substance use problems, a recent loss or separation, a history of past suicide attempts, and acute suicidal ideation

The core symptoms of depression in children and adolescents are the same as for adults, which are sadness and loss of pleasure. What differs is

how these symptoms are displayed. For example, a very young child may cry, a school-age child might withdraw, and a teenager may become irritable in response to feeling sad or hopeless. - Younger children may suddenly refuse to go to school while adolescents may engage in substance abuse or sexual promiscuity

The behaviors and symptoms associated with ADHD can include Peer relationships are strained due to They may be unable to

hyperactivity, impulsivity, inattention - may exhibit high degrees of distractibility and disorganization difficulty taking turns, poor social boundaries, intrusive behaviors, and interrupting others complete challenging or tedious tasks, become easily bored, lose things frequently, or require frequent prompts to complete tasks.

In anxiety due to a medical condition, the individual's symptoms of anxiety are a direct physiological result of a medical condition, such as

hyperthyroidism, pulmonary embolism, or cardiac dysrhythmias.

The general nursing care of the newborn exposed to these drugs is directed toward

identification of substance use in the mother and vigilance for signs of withdrawal in the neonate.

Any child who does not display language skills such as babbling or gesturing by 12 months of age, single words by 16 months of age, and two-word phrases by 24 months of age is recommended for

immediate hearing and language evaluation

The extended-release formulations of these medications have The long-acting versions allow for a

improved dosing and scheduling. morning administration with sustained release of the medication over the course of the day and with a decreased incidence of insomnia.

Individuals with attention-deficit/hyperactivity disorder (ADHD) show an

inappropriate degree of inattention, impulsiveness, and hyperactivity

Regarding children with intellectual disabilities, Treatment plans should be

individualized and realistic.

Interventions for patients with ADHD focus on recognizing

ineffective coping mechanisms, such as blaming others and denial of responsibility for their actions.

Separation anxiety is a normal part of

infant development that begins around 8 months of age, peaks about 18 months, and begins to decline after that

Regarding Acute alcohol toxicity, Obtain as accurate a health history as possible and assess for

injuries, diseases, and hypoglycemia

Fetal alcohol syndrome is the leading cause of

intellectual disability in the United States

Intellectual functioning is measured by the Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), new criteria recommend moving away from exclusively

intelligence quotient (IQ) test score of 70 and below or as high as 75. relying on IQ testing toward using additional measures of adaptive functioning

Postpartum depression, also known as PPD without psychotic features, is an It is more serious and persistent than postpartum blues, lasting These symptoms rarely

intense and pervasive sadness with severe and labile mood swings. lasting more than 2 weeks. - Intense fears, anger, anxiety, and despondency that persist past the baby's first few weeks are not a normal part of postpartum blues. disappear without outside help. Most of these mothers seek help only after reaching a "crisis point."

Alcohol during pregnancy inhibits

intrauterine growth and postnatal development resulting in microcephaly, craniofacial malformations, and limb and heart defects.

ADHD Multimodal Treatment

involves the use of pharmacotherapy and behavioral intervention as well as close follow-up and feedback from school personnel is more effective than intensive behavioral treatment alone

Regarding biological interventions for anxiety, A Gamma Knife® creates

irreversible damage known as lesions to certain areas of the brain, resulting in a disconnect of overactive circuits or regions.

Regarding substance abuse, Cannabis Withdrawal can occur in a hospitalized patient who heavily uses cannabis. The patient may experience Nursing Interventions

irritability, anxiety, anorexia, chills, disturbed sleep, fever, and tremors. - No specific drug therapy is effective in treating withdrawal. - Supportive care includes measures to ensure patient comfort, including analgesics and hydration.

A distinguishing feature of Postpartum depression is Feelings of A woman with PPD may have obsessive thoughts about harming the infant, and this can be very frightening to her. Often she does not

irritability. (with little provocation, and they sometimes escalate to violent outbursts or dissolve into uncontrollable sobbing.) detachment toward the newborn or not feeling love for the newborn are common symptoms of PPD. Women feel guilt and shame for having these feelings and are not likely to verbalize or discuss this with anyone. share these thoughts because of embarrassment; when she does, other family members become very frightened. On the other hand, some women feel very emotionally attached and connected to their infants

Regarding substance abuse, For depressants Withdrawal from sedative-hypnotics can be Early, the patient may experience Since the patient may experience delirium, seizures, and respiratory and cardiac arrest within 24 hours after the last dose, Withdrawal Treatment consists of

life threatening - manifestations are nearly identical to those of alcohol withdrawal weakness, anxiety, insomnia, fever, orthostatic hypotension, and disorientation. closely monitor the patient. - administering a long-acting benzodiazepine or phenobarbital in a tapered dose. - IV diazepam is an option for severe manifestations. - Supportive care includes implementing patient safety and comfort measures, frequently assessing neurologic status and vital signs, and providing reassurance and orientation.

Families and individuals with intellectual disabilities require

lifelong support, so evaluations will focus on both short- and long-term goals. - Long-term planning should include a goal of transitioning the child to a level of supervised or assisted care as he or she ages into adulthood.

Kava is used as a sedative with antianxiety effects. In 2010 the FDA issued a warning regarding its risk of

liver damage. - This inhibition could result in liver failure, especially when taken along with alcohol or other medications such as central nervous system depressants (antianxiety agents fall into this category).

This anxiety problem is often comorbid with

major depressive disorder

For older adults and substance abuse, The effects of alcohol and drug use can be mistaken for Because of the higher rate of co-existing medical problems, older adults are at greater risk for Physiologic changes may lead to Nursing interventions

medical conditions common among older adults (e.g., insomnia, depression, hypertension, dementia). medical problems associated with substance use. - Common problems include liver damage and cardiovascular, GI, and endocrine problems. - may cause confusion, delirium, memory loss, and neuromuscular impairment toxicity at levels that may not have been a problem at a younger age. - discuss all drug and alcohol use with older adult patients, including OTC, herbal, and homeopathic drug use. - Assess the patient's knowledge of currently used medications. - Common screening questionnaires may not identify an older adult with a substance use problem. - The Short Michigan Alcoholism Screening Test-Geriatric version (SMAST-G) is available as a short-form alcoholism-screening instrument for older adults

Because older adults are more likely to complain of physical illness than emotional concerns, depression The Geriatric Depression Scale is a 30-item tool can be helpful in determining

might be overlooked. suicidality in this population.

substance use disorder (SUD) is defined as

mild, moderate, or severe based on the person's pattern of use and the functional impact of use on the person's daily life.

Regarding ADHD, Families are actively engaged in therapy and given support in using parenting skills to provide nurturance and set consistent limits. They are taught techniques for If families are abusive, drug dependent, or highly disorganized, the child may

modifying behavior, monitoring medication for effects, collaborating with teachers to foster academic success, and setting up a home environment that is consistent, structured, and nurturing and that promotes achievement of normal developmental milestones. require out-of-home placement.

Panic is the

most extreme level of anxiety and results in markedly dysregulated behavior. - Hallucinations, or false sensory perceptions (e.g., seeing people or objects not really there) - erratic, uncoordinated, and impulsive.

Smoked tobacco is the Smoking causes

most harmful method of nicotine use and injures nearly every organ in the body. chronic lung disease, cardiovascular disease, and lung and other cancers and is a major factor in a variety of other conditions, including delayed wound healing and overall diminished health

Fetal alcohol syndrome (FAS) is the

most severe type of fetal alcohol spectrum disorder (FASD); affected individuals have abnormal facial features (e.g., small eyes or short palpebral fissures, a thin upper lip, a flat midface, and an indistinct philtrum), growth restriction, and neurodevelopmental deficits, with or without a confirmed history of maternal alcohol consumption

Cocaine is a CNS stimulant and peripheral sympathomimetic. Legally it is classified as a

narcotic, but it is not an opioid.

the Special Olympics continues to require that all athletes with Down syndrome receive

neck x-rays prior to sports participation, because neck x-ray is the only screen available (incase of atlantoaxial instability)

Sometimes the psychomotor slowing and cognitive effects of depression lead others to believe that the older adult is developing a

neurocognitive disorder such as Alzheimer's disease. - This condition is referred to as pseudodementia, a problem that can be reversed when the underlying depression is treated and eliminated.

Alcohol affects almost all cells of the body. It changes levels of

neurotransmitters in the central nervous system (CNS), affecting all areas and functions of the CNS. - include centers that control our impulses, mood, and behavior; coordinate motor activity; and promote respiratory and cardiac function.

Because most health care facilities are tobacco-free environments, admitted patients who are addicted to nicotine may experience withdrawal symptoms since they are unable to smoke. These symptoms are the same as for the person who stops using tobacco "cold turkey." Offering what can help

nicotine replacement therapy to those who desire it will assist in controlling withdrawal symptoms during hospitalization and promote continued cessation after discharge.

Body Dysmorphic Disorder patients tend to have a People may be well aware that their thoughts are Men tend to be concerned with Women focus on the appearance of their

normal appearance, their preoccupation with an imagined defective body part results in obsessional thinking and compulsive behavior such as mirror checking and camouflaging distorted, or they may be completely sure about existence of the defect. body build and the appearance of their genitals and body build. skin, stomach, weight, breasts, buttocks, thighs, legs, hips, and toes.

Autism spectrum disorder affects the

normal development of social interaction and communication skills.

Regarding down syndrome, The protruding tongue also interferes with feeding, especially of solid foods. Parents need to know that the tongue thrust is Parents are advised to use a

not an indication of refusal to feed but a physiologic response. small but long, straight-handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it should be refed.

Without intensive intervention, individuals with severe autism spectrum disorder may

not be able to live and work independently - Only about one-third achieve partial independence with restricted interests and activities.

During hospitalization, the nurse should also focus on growth-promoting experiences for the child. For example, hospitalization may be an excellent opportunity to emphasize to parents abilities that the child does have but has

not had the opportunity to practice, such as self-dressing.

Emerging information indicates e-cigs are Potentially harmful E-cigs containing nicotine have the potential to

not harmless chemicals have been found in some cartridges, including irritants, genotoxins, and carcinogens. - increase the risk of cardiovascular and respiratory problems similar to traditional cigarettes - seizures (attributed to inhaling chemicals in the vapor) - pneumonia (attributed to inhaling chemicals in the vapor)

Regarding down syndrome, The child's eating habits may need careful scrutiny to prevent

obesity. - Height and weight measurements should be obtained on a serial basis

Substance-induced obsessive-compulsive and related disorders are characterized by

obsessions and compulsions that develop with the use of a substance or within a month of stopping use of the substance

Drugs used to treat the movement disorders in Parkinson's disease have been reported to cause

obsessions with gambling, irresistible urges for sex, and out-of-control spending

Stressing moral lessons is

of little value to a child who lacks the cognitive skills to learn from self-criticism or evaluation of previous mistakes

TCAs and MAOIs have side-effect profiles that are more dangerous for Older adults should be cautioned against

older adults, specifically cardiotoxicity with TCAs and hypotension (risk of falls) with both classes. abrupt discontinuation of antidepressants because of the possibility of discontinuation syndrome, which causes anxiety, dysphoria, flulike symptoms, dizziness, excessive sweating, and insomnia.

A person with severe anxiety may focus on

one particular detail or many scattered details and have difficulty noticing what is going on in the environment, even when another points it out. - Learning and problem solving are not possible at this level, and the person may be dazed and confused. - Somatic symptoms (e.g., headache, nausea, dizziness, insomnia) often increase. Trembling and a pounding heart are common, and the person may experience hyperventilation and a sense of impending doom or dread.

Realizing that the child may be lonely in the hospital, the nurse makes certain that toys and other activities are provided. The child is placed in a room with other children of approximately the same developmental age, preferably a room with

only two beds to avoid overstimulation.

Regarding substance abuse, Many products found in the home or workplace, such as markers, glues, and cleaning fluid, contain chemicals with psychoactive properties when they are inhaled. Many people do not Managing inhalant toxicity usually consists of

onsider these products as drugs. However, they are sometimes misused. Inhalants are rapidly absorbed and reach the CNS quickly. - Most are depressants, and their effects are similar to alcohol, including slurred speech, lack of coordination, euphoria, and dizziness. - providing supportive care. (does not require any treatment) - in some cases, users need emergency treatment for dysrhythmias, heart failure, or CNS hyperactivity (e.g., seizures). - Using some inhalants (i.e., toluene) can result in nephrotoxicity; therefore monitor renal function. - require careful use of haloperidol (Haldol) to manage severe agitation.

Regarding Generalized Anxiety Disorder, Family members and friends are

overtaxed as the person with this disorder seeks continual reassurance and perseverates about meaningless details.

Panic attacks are the key feature of A panic attack is the sudden onset of Typically, panic attacks come

panic disorder extreme apprehension or fear, usually associated with feelings of impending doom. "out of the blue" (i.e., suddenly and not necessarily in response to stress), are extremely intense, last a matter of minutes, and then subside. - may believe they are losing their minds or having a heart attack.

Drug therapies to decrease withdrawal effects include

parenteral or oral administration of - phenobarbital, - buprenorphine, - clonidine, - methadone, - morphine.

Regarding Anxiety Pharmacological Interventions, These SSRIs include

paroxetine (Paxil), fluoxetine (Prozac), escitalopram (Lexapro), fluvoxamine (Luvox), and sertraline (Zoloft). - Fluoxetine and sertraline tend to be the most activating - Paroxetine seems to have a more calming effect than the other SSRIs - Venlafaxine (Effexor) is quite successful in the treatment of several anxiety disorders. - duloxetine (Cymbalta), is effective in the treatment of generalized anxiety disorder. - beta-blockers, antihistamines, anticonvulsants, and antipsychotics

The best predictor of Paternal Postpartum Depression is having a

partner with postpartum depression. Other risk factors are a: - history of depression, - age younger than 25 years, - low socioeconomic status, - being unmarried, - an inadequate support system, - family and social stressors.

An added concern regarding substance abuse is that many of the mothers often use several drugs such as tranquilizers, sedatives, amphetamines, phencyclidine, marijuana, and other psychotropic agents. These drugs can alter the mother's

perception of the newborn's cues and physical and emotional needs.

Teaching self-care skills also necessitates a working knowledge of the individual steps needed to master a skill. For example, before beginning a self-feeding program, the nurse

performs a task analysis. - After a task analysis, the child is observed in a particular situation, such as eating, to determine what skills are possessed and the child's developmental readiness to learn the task. Family members are included in this process, because their "readiness" is as important as the child's.

Holding tobacco in the mouth is associated with Smokeless tobacco produces the systemic effects of nicotine on the

periodontal disease and cancer of the mouth, cheek, tongue, throat, and esophagus. cardiovascular system, increasing the risk for cardiovascular disease

Major depressive disorder, or major depression, is characterized by a

persistently depressed mood lasting for a minimum of 2 weeks. - The length of a depressive episode may be 5 to 6 months

Irritable and hyperactive infants are likely to respond to Give example

physical comforting, movement, and close contact - Wrapping infants snugly and rocking and holding them tightly limit their ability to self-stimulate. - Arranging nursing activities to reduce the amount of disturbance helps decrease exogenous stimulation.

Children who are cognitively impaired have the same need for Therefore, the nurse will need to

play and exercise as any other child. - However, because of the children's slower development, parents may be less aware of the need to provide such activities guide parents toward selection of suitable play and exercise activities.

Some children develop OCD along with a

postinfectious autoimmune syndrome.

The change from the high levels of estrogen and progesterone at the end of pregnancy to the much lower levels of both hormones that are present after birth are important etiologic factors in the development of PPD. While all women experience these hormonal changes, there are some who are more sensitive to the mood-destabilizing effects of withdrawal from the pregnancy hormones and are therefore at risk for

postpartum depression

Women with a history of obsessive-compulsive disorder (OCD) often find that their symptoms increase during the For some women with no history of OCD, Women with postpartum OCD tend to have In the postpartum period, obsessive thoughts are likely to involve

postpartum period the first episode occurs postpartum. obsessive, intrusive thoughts, and they perform compulsive actions that temporarily reduce or alleviate the distress caused by the intrusive thoughts contamination and fear of germs; women often fear harm will come to the infant, either inflicted by themselves or others

For ADHD, In partial remission: When full criteria were

previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning.

Regarding substance abuse, Caffeine is the most widely used Used for A large caffeine intake can cause caffeine dependence can result in Treatment consists of

psychoactive substance in the world. - Wakefulness - Headaches - facilitating motor activity grand mal seizures, and respiratory failure may cause death, cardiac dysrhythmias, hypertension, disturbed sleep, and anxiety. muscle pain or stiffness, drowsiness, irritability, and headaches seizure control with benzodiazepines or phenobarbital and supportive care until the effects wear off

Regarding Anxiety Pharmacological Interventions, Benzodiazepines are most commonly used because they have a An important nursing intervention is to monitor for side effects of the benzodiazepines including Paradoxical reactions— Benzodiazepines are not recommended for patients with

quick onset of action. - However, due to the potential for dependence, these medications should be used for short periods, only until other medications or treatments reduce symptoms. sedation, ataxia, and decreased cognitive function reactions that are the exact opposite of intended responses—sometimes occur. - Symptoms such as anxiety, agitation, talkativeness, and loss of impulse control - a substance use disorder. - They are not recommended for elderly patients due to risk of delirium, falls, and fractures.

Autism spectrum disorder has no When may it become apparent

racial, ethnic, or social boundaries and is not influenced by family income, educational levels, or lifestyles. before age 3 due to impairments in social interactions, communication, imaginative play

Regarding Postpartum psychosis, These episodes are usually separated by periods of normal mood, but in some individuals, depression and mania rapidly alternate. These rapid changes in mood are known as

rapid cycling

The infant may not exhibit withdrawal symptoms until 7 to 10 days after birth, by which time most newborns have been discharged from the birthing facility, and caregivers are less likely to

recognize signs of irritability and poor feeding as withdrawal, thus predisposing the newborn to abuse or neglect and growth failure (failure to thrive). - further risk for subsequent abuse or neglect because of home conditions

Toys are selected for their

recreational and educational value.

Regarding Anxiety Pharmacological Interventions, The beta-blockers Anticonvulsants have shown some benefit in the management of Antihistamines are a Antipsychotic medications are useful in treating more

reduce physical manifestations of anxiety by slowing the heart rate and reducing blushing and have been used to treat social anxiety disorder. generalized anxiety disorder and social anxiety disorder. - Gabapentin (Neurontin) and pregabalin (Lyrica) safe nonaddictive alternative to benzodiazepines to lower anxiety levels and again are helpful in treating patients with substance use problems. severe symptoms of anxiety disorders.

Regarding ADHD, Due to the side effects of fatigue and somnolence, clonidine and guanfacine are helpful in

reducing agitation and rage and in increasing frustration tolerance.

Nicotine is a central nervous system stimulant. Within seconds of entering the body, nicotine reaches the brain, causing the The effects last about

release of adrenaline and creating feelings of a "high" or a "buzz. 1 to 2 hours before withdrawal symptoms occur, leaving the person feeling tired, irritable, and anxious.

Regarding down syndrome, Decreased muscle tone compromises the underdeveloped nasal bone causes a What does this force the child to do?

respiratory expansion. chronic problem of inadequate drainage of mucus - The constant stuffy nose forces the child to breathe by mouth, which dries the oropharyngeal membranes, increasing the susceptibility to upper respiratory tract infections.

Phobic reactions tend to

run in families. - Having a first-degree relative with a specific phobia puts one at greater risk for having the same specific phobia.

Regarding substance abuse, Commonly used depressants include

sedative-hypnotics and opioids

The person experiencing moderate anxiety sees, hears, and grasps less information and may demonstrate

selective inattention in which only certain things in the environment are seen or heard unless they are pointed out - ability to think clearly is hampered, but learning and problem solving can still take place although not at an optimal level. - Sympathetic nervous system symptoms begin (tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (e.g., gastric discomfort, headache, urinary urgency, voice tremor and shaking)

Regrading Alcohol withdrawal syndrome (AWS), Alcohol withdrawal delirium is a Death may result from

serious complication that can occur from 2 to 3 days after the last drink and last 2 to 3 days. - The greater the patient's dependence on alcohol, the greater the risk of alcohol withdrawal delirium - hyperthermia, - sepsis, - aspiration pneumonia, - peripheral vascular collapse

One rare and life-threatening event associated with SSRIs is The symptoms are many:

serotonin syndrome. - too high a dose or interaction with other drugs - abdominal pain, - diarrhea, - sweating, - fever, - tachycardia, - elevated blood pressure, - altered mental state (delirium), - myoclonus (muscle spasms), - increased motor activity, - irritability, hostility, and mood change. - Severe manifestations can induce hyperpyrexia (excessively high fever), cardiovascular shock, or death.

Neonatal abstinence syndrome (NAS) is the term used to describe the

set of behaviors exhibited by infants exposed to opioids in utero

Approximately 55% to 94% of infants born to mothers using opioids

show signs of withdrawal

Due to the increased need for supervision and assistance with daily living and the chronic nature of the disorder, families or caregivers may experience

significant stress and be at risk for impaired family functioning

The nurse should help in this area by providing parents with information about sexuality education that is geared to the child's developmental level. For example, adolescent girls need a

simple explanation of menstruation and instructions on personal hygiene during the menstrual cycle.

Regarding pregnant drug use, Hyperactive infants must be protected from Monitoring and recording the

skin abrasions on the knees, toes, and cheeks that are caused by rubbing on bed linens while in a prone position during waking periods. activity level and its relationship to other activities such as feeding and preventing complications are important nursing responsibilities

excoriation disorder Trichotillomania Trichophagia Both of the activities are irresistible to the individual who typically tries to Risk factors for both

skin picking disorder hair pulling disorder secretly swallowing the pulled hair hide the activity having OCD

For ADHD, nonstimulant selective norepinephrine reuptake inhibitor, atomoxetine (Strattera) Therapeutic responses develop This medication is preferable for individuals whose

slowly, and it may take up to 6 weeks for full improvement. anxiety is increased with stimulants. - It is also useful for those with comorbid anxiety, active substance use disorders, or tics.

People with tobacco use disorder (TUD) are dependent on the drug nicotine due to using tobacco products. A number of products contain nicotine, including

smoked tobacco (cigarettes, cigars, pipes), smokeless tobacco (chew, snuff, dip), and some electronic cigarettes. - Cigarette smoking is the main form of tobacco use

Fear of public speaking is the most common manifestation of

social anxiety disorder.

Children with Autism demonstrate core deficits primarily in

social interactions, communication, and behavior - Failure of social interaction and communication development is the one of the hallmarks of ASD.

If mothers have been taking methadone, the signs appear

somewhat later (i.e., anywhere from 1 or 2 days to 2 to 3 weeks or more after birth)

Autism Pharmacological agents target

specific symptoms and may be used to improve relatedness and decrease anxiety, compulsive behaviors, or agitation

Regarding social anxiety disorder, The trait of shyness is also

strongly heritable. - Having parents who are shy carries a double risk of genetic transmission and parental modeling.

Maternal habits hazardous to the fetus and neonate include

substance use and addiction, smoking or use of electronic cigarettes (vaping), and alcohol abuse.

Fetal effects of alcohol exposure vary from

subtle learning disabilities to obvious facial features and growth abnormalities.

Patients diagnosed with major depressive disorder should always be evaluated for

suicidal ideation

Regarding substance abuse with opioids, in treatment Because buprenorphine is a long-acting drug, once patients have been stabilized, they can sometimes

switch to alternate-day dosing instead of dosing every day.

Regarding substance abuse, Patients with stimulant toxicity present with The patient experiences Physical effects include

sympathetic overdrive (increased stimulation of the sympathetic nervous system). restlessness, hypervigilance, agitated delirium, impaired judgment, and paranoia with psychotic symptoms hypertension, tachycardia, fever, pupil dilation, seizures, confusion, and diaphoresis. Death may occur from stroke, dysrhythmias, or myocardial infarction

Regarding ADHD, To control aggressive behaviors, Antipsychotic medications have reduced violent behavior, hyperactivity, and social unresponsiveness. But due to the risk of

tardive dyskinesia associated with long-term use, antipsychotic medications are only recommended for severely aggressive behavior.

Children with CI often have greater success in individual and dual sports than in

team sports and enjoy themselves most with children of the same developmental level.

Regarding autism, It is imperative to help parents understand that they are not

the cause of the child's condition. - Nurses can help alleviate the guilt and shame often associated with this disorder by stressing what is known from a biologic standpoint and by providing family support

separation anxiety disorder is accompanied by a significant level of discomfort and disability that impairs social and occupational functioning and does not respond well to

the most popular type of psychotherapy, cognitive-behavioral therapy.

Mild anxiety occurs in

the normal experience of everyday living and allows an individual to perceive reality in sharp focus - sees, hears, and grasps more information, and problem solving becomes more effective.

Postpartum posttraumatic stress disorder (PTSD) is the result of exposure to trauma, either during Risk factors for postpartum PTSD include

the prenatal or intrapartum period, or it may be related to previous life experiences and events such as childhood sexual abuse or intimate partner violence - history of pregnancy loss, - high-risk pregnancy, - preterm birth, - infant in the NICU, - painful and/or difficult vaginal birth, - instrument-assisted vaginal birth, - emergency cesarean

Early intervention for children with autism spectrum disorder can greatly enhance

their potential for a full, productive life. - many families with a child with an autism spectrum disorder may not seek help early.

An early intervention program is a systematic program of

therapy, exercises, and activities designed to address developmental delays in children with disabilities to help achieve their full potentials

Regarding Alcohol Withdrawal, Wernicke-Korsakoff Syndrome is caused by

thiamine deficiency

Obsessions are defined as

thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind even though the individual attempts to do so

Obsessions are defined as Compulsions are

thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind even though the individual attempts to do so ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety or prevent an imagined calamity - Performing the compulsive act temporarily reduces anxiety

The Joint Commission mandates that every health professional is responsible for identifying

tobacco users and providing them with information on ways to stop using tobacco.

Regarding Anxiety Pharmacological Interventions, Monoamine oxidase inhibitors (MAOIs) are reserved for Contraindicated for patients with

treatment-resistant conditions because of the risk of life-threatening hypertensive crisis if the patient does not follow dietary restrictions (patients cannot eat foods containing tyramine and must be given specific dietary instructions). contraindicated in patients with comorbid substance use disorders

The usual course of Electroconvulsive Therapy for a patient with depression is

two or three treatments per week to a total of 6 to 12 treatments.

The prognosis for drug-exposed infants depends on the

type and amount of drug(s) taken by the mother and the stage(s) of fetal development in which the drug was taken.

fetal alcohol spectrum disorder (FASD) is an

umbrella term that describes the range of clinical effects; there are three types of FASDs, based on the symptoms.

The American Academy of Pediatrics no longer recommends screening asymptomatic children with Down syndrome for atlantoaxial instability with cervical spine x-rays due to

unproven value of detecting patients at risk for developing spinal cord compression injury

Regarding depression, Safety becomes the most important issue facing a team that cares for people with depression who may be at high risk for suicide. Suicide precautions are

usually instituted and include the removal of all harmful objects such as "sharps" (e.g., razors, scissors, and nail files), strangulation risks (e.g., belts), and medication that can be used to overdose. - Some patients with severe depression may need to have someone check on them frequently, perhaps every 15 minutes, or even have 1:1 observation

Parents should be encouraged early to teach their child with CI socially acceptable behavior:

waving goodbye, saying "hello" and "thank you," responding to his or her name, greeting visitors, and sitting modestly.

Regarding Anxiety Pharmacological Interventions, The decision to use benzodiazepines during pregnancy should be made by Benzodiazepine use shortly before delivery can result in a Prenatal benzodiazepine exposure increases the risk of The FDA warns against

weighing the risk of fetal exposure versus the risk of untreated anxiety disorders dystonia and muscle weakness in the newborn known as floppy infant syndrome. oral cleft lip and palate, although the absolute risk increases by only 0.01% breastfeeding while taking these drugs since they pass into breast milk.

Autism regression is

when the child seems to develop normally then regresses suddenly; this is a red-flag event that has been frequently displayed in expressive language

ADHD Treatment may include hospitalization for those Typically, treatment is provided on an

who pre-sent an imminent danger to self or others outpatient basis, using individual, group, and family therapy, with an emphasis on parenting issues

Nurses need to monitor vital signs frequently since an increase in pulse, blood pressure, and body temperatures are clear signs o

withdrawal

Anxiety Risk factors

• Affects all persons across the life span • Lifetime prevalence is increased in female populations • Highest prevalence occurs between the ages of 30 and 44 years • Non-Hispanic whites are more likely to suffer from an anxiety disorder • Familial patterns appear in certain anxiety disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; [APA], 2013) provides diagnostic criteria for the following psychoactive substances:

• Alcohol • Caffeine • Cannabis • Hallucinogen • Inhalant • Opioid • Sedative, hypnotic, and antianxiety medication • Stimulant • Tobacco

Inpatient Tobacco Cessation Interventions Take the following steps for every hospitalized patient.

• Ask each patient on admission if he or she uses tobacco and document tobacco use status. • For current tobacco users, list tobacco use status on the admission problem list and as a discharge diagnosis. • Use counseling and medication to help all tobacco users maintain abstinence and to treat withdrawal symptoms. • Provide advice and assistance on how to quit during hospitalization and remain abstinent after discharge. • Arrange for follow-up regarding smoking status. Supportive contact should be provided for at least a month after discharge.

Contraindications The use of MAOIs may be contraindicated with each of the following:

• Cerebrovascular disease • Hypertension and congestive heart failure • Liver disease • Consumption of foods containing tyramine, L-tryptophan, and dopamine • Use of certain medications • Recurrent or severe headaches • Surgery in the previous 10 to 14 days • Age younger than 16 years

Health teaching points for depression include:

• Depression is an illness beyond a person's voluntary control. • Although it is beyond voluntary control, depression can be managed through medication and lifestyle. • Chronic illness management depends in large part on understanding personal signs and symptoms of relapse. • Illness management depends on understanding the role of medication and possible medication side effects. • Long-term management works best if the patient receives psychotherapy along with medication. • Identifying and coping with the stress of interpersonal relationships—whether they are familial, social, or occupational—are key to stable illness management.

Regarding ADHD, Center for Quality Assessment and Improvement in Mental Health (2015) identify the following measures for improving child and adolescent mental healthcare:

• Family involvement in the treatment of ADHD • Stimulant medication treatment for ADHD

Manifestations Suggesting Substance Use

• Fatigue • Insomnia • Headaches • Seizure disorder • Changes in mood • Anorexia, weight loss • Vague physical complaints • Overuse of mouthwash or toiletries • Appearing older than stated age, unkempt appearance • Leisure activities that involve alcohol and/or other drugs • Sexual dysfunction, decreased libido, erectile dysfunction • Trauma secondary to falls, auto accidents, fights, or burns • Driving while intoxicated (more than one citation suggests dependence) • Failure of standard doses of sedatives to have a therapeutic effect • Financial problems, including those related to spending for substances • Defensive or evasive answers to questions about substance use and its importance in the person's life • Problems in areas of life function (e.g., frequent job changes; marital conflict, separation, or divorce; work-related accidents, tardiness, absenteeism; legal problems; social isolation, estrangement from friends or family)

Regarding Patient Teaching Smoking and Tobacco Use Cessation Dealing With Urges to Use Tobacco

• Identify situations that may cause you to want to smoke or use other tobacco, such as being around other smokers, being under time pressure, feeling sad or frustrated, and drinking alcohol. • Avoid difficult situations while you are trying to quit. Try to lower your stress level. • Exercise can help, such as walking, jogging, or bicycling. • Distract yourself from thoughts of smoking and the urge to use tobacco by talking to someone, going to a movie, getting busy with a task, or having a game night with friends. • Drink a lot of water. • Keep your hands busy with a pen or toothpick.

Intellectual disability is characterized by deficits in three areas:

• Intellectual functioning • Social functioning • Daily functioning

Regarding Patient Teaching Smoking and Tobacco Use Cessation Support and Encouragement

• Joining a quit-tobacco support group will increase your chances of stopping permanently. • If you get the urge for tobacco, call someone to help talk you out of it—preferably an ex-user. • Be proud every time you reach a quit milestone and reward yourself. • Do not be afraid to talk about how you feel while quitting, especially fears of not being able to quit for good. Ask your spouse or partner, friends, and co-workers to support you. Self-help materials, mobile phone applications, and hot lines are available: • American Lung Association

The DSM-5 classifies autism spectrum disorder in three levels depending on the degree of assistance and support the individual requires:

• Level 1 requires support • Level 2 requires substantial support • Level 3 requires very substantial support

ADHD Nursing Interventions

• Management begins with an explanation to the parents and the child about the diagnosis • If decreased appetite is a concern, parents can give the psychostimulants with or after meals rather than before, encourage consumption of nutritious snacks in the evening when the effects of the medication are decreasing, and serve frequent small meals with healthy "on-the-go" snacks. • Sleeplessness is reduced by administering the medication early in the day. • Play therapy for younger children • Children taking tricyclic antidepressants display a dramatic increase in the incidence of dental caries. (increases saliva viscosity and produces a dry mouth) • Emphasis on rigorous dental hygiene, conscientious home fluoride treatments, regular visits to the dentist, limited intake of refined carbohydrates, and use of artificial saliva is an important nursing function. • The child should drink plenty of fluids and be well hydrated. • drugs have the potential for abuse, and all children taking these drugs should be monitored closely for psychologic dependence, tolerance, depression, and other adverse behavior changes or idiosyncratic effects. • Most children with ADHD are not interested in abusing their drugs because the effect of the drugs • caution parents to keep these drugs safely stored away • therapy is not necessarily a panacea and that it will extend over a long period

Patient and Family Teaching: Selective Serotonin Reuptake Inhibitors (SSRIs)

• May cause sexual dysfunction or lack of sex drive. Inform nurse or primary care provider if this occurs. • May cause insomnia, anxiety, and nervousness. Inform nurse or primary care provider if this occurs. • May interact with other medications. Tell primary care provider about other medications patient is taking (e.g., digoxin, warfarin). SSRIs should not be taken within 14 days of the last dose of a monoamine oxidase inhibitor. • No over-the-counter drug should be taken without first notifying primary care provider. • Common side effects include fatigue, nausea, diarrhea, dry mouth, dizziness, tremor, and sexual dysfunction or lack of sex drive. • Because of the potential for drowsiness and dizziness, patient should not drive or operate machinery until these side effects are ruled out. • Alcohol should be avoided. • Liver and renal function tests should be performed and blood counts checked periodically. • Medication should not be discontinued abruptly. If side effects become bothersome, patient should ask primary care provider about changing to a different drug. Abrupt cessation can lead to serotonin withdrawal. • Any of the following symptoms should be reported to the primary care provider immediately: - Increase in depression or suicidal thoughts - Rash or hives - Rapid heartbeat - Sore throat - Difficulty urinating - Fever, malaise - Anorexia and weight loss - Unusual bleeding - Initiation of hyperactive behavior - Severe headache

Drugs that Can Interact with Monoamine Oxidase Inhibitors (MAOIs)

• Over-the-counter medications for colds, allergies, or congestion (any product containing ephedrine, phenylephrine hydrochloride, or phenylpropanolamine) • Tricyclic antidepressants (imipramine, amitriptyline) • Narcotics • Antihypertensives (methyldopa, guanethidine, reserpine) • Amine precursors (levodopa, L-tryptophan) • Sedatives (alcohol, barbiturates, benzodiazepines) • General anesthetics • Stimulants (amphetamines, cocaine)

Nursing Alert for down syndrome Immediately report any child with the following signs of spinal cord compression:

• Persistent neck pain • Loss of established motor skills and bladder or bowel control • Changes in sensation

The Drug Enforcement Agency (n.d.) classifies Scheduled Drugs in the following way:

• Schedule I drugs carry a high potential for abuse and have no acceptable medical use. Examples are heroin and lysergic acid diethylamide (LSD). • Schedule II drugs have a high potential for abuse, are considered dangerous, and are available only by prescription. Examples include methadone, meperidine (Demerol), and methylphenidate (Ritalin). • Schedule III drugs have a low to moderate potential for misuse and are available only by prescription. Examples are testosterone, acetaminophen/codeine (Tylenol with codeine), and buprenorphine (Suboxone) • Schedule IV drugs are low-risk drugs and are available by prescription. Examples of schedule IV drugs are alprazolam (Xanax), lorazepam (Ativan), and propoxyphene/acetaminophen (Darvocet). • Schedule V drugs contain limited quantities of certain narcotics for the treatment of diarrhea, coughing, and pain. Examples are atropine/dyphenoxylate (Lomotil), guaifenesin and codeine (Robitussin AC), and pregabalin (Lyrica), available over the counter.

Substance abuse test

• Screening, Brief Intervention, and Referral to Treatment (SBIRT) • Alcohol Use Disorders Identification Test (AUDIT) • Drug Abuse Screening Test (DAST-10) • CAGE (Questions: Have you felt you needed to cut down on your drinking? Are people annoyed by your drinking? Have you felt guilty about your drinking? Have you ever had a drink in the morning (eye-opener)? Score of 2 or more is significant, although a score of 1 requires further assessment. • CAGE-AID (Questions are the same as CAGE but refers to Adapted to Include Drugs.) • T-ACE (Tolerance, Annoyance, Cut down, Eye-opener)

the term anxiety disorder refers to a number of disorders including:

• Separation anxiety disorder • Specific phobia • Social anxiety disorder (social phobia) • Panic disorder • Agoraphobia • Generalized anxiety disorder

Regarding Patient Teaching Smoking and Tobacco Use Cessation Develop a Quit Plan

• Set a quit date, ideally within 2 weeks. • Talk to your HCP about getting help to quit. • Tell family, friends, and co-workers about quitting and request understanding and support. • Anticipate withdrawal symptoms and challenges when quitting. • Before quitting, avoid smoking in places where you spend a lot of time (work, car, home). • Throw away all tobacco products from your home, car, and work. • Have support options in place by your quit date.

Selection of the appropriate antidepressant is based on the following considerations:

• Symptom profile of the patient • Side-effect profile (e.g., sexual dysfunction, weight gain) • Ease of administration • History of past response • Safety and medical considerations • Genotyping (when available)

Patient and Family Teaching: Monoamine Oxidase Inhibitors (MAOIs)

• Tell the patient and family to avoid certain foods (especially those that are aged, cured, or ripened) and all medications (especially cold remedies) unless prescribed by and discussed with the patient's primary care provider. • Give the patient a wallet card describing the MAOI regimen. • Instruct the patient to avoid Asian restaurants (sherry, brewer's yeast, and other contraindicated products may be used). • Tell the patient to go to the emergency department immediately if he or she has a severe headache. • Ideally, blood pressure should be monitored during the first 6 weeks of treatment (for both hypotensive and hypertensive effects). • After the MAOI is stopped, instruct the patient that dietary and drug restrictions should be maintained for 14 days

Patient and Family Teaching: Tricyclic Antidepressants (TCAs)

• The patient and family should be told that mood elevation may take from 7 to 28 days. Up to 6 to 8 weeks may be required for the full effect to be reached and for major depressive symptoms to subside. • The family should reinforce this frequently to the depressed family member because depressed people have trouble remembering and respond to ongoing reassurance. • The patient should be reassured that drowsiness, dizziness, and hypotension usually subside after the first few weeks. • When the patient starts taking TCAs, the patient should be cautioned to be careful working around machines, driving cars, and crossing streets because of possible altered reflexes, drowsiness, or dizziness. • Alcohol can block the effects of antidepressants. The patient should be told to refrain from drinking. • If possible, the patient should take the full dose at bedtime to reduce the experience of side effects during the day. • If the patient forgets the bedtime dose (or the once-a-day dose), the patient should take the dose within 3 hours; otherwise, the patient should wait until the usual medication time the next day. The patient should not double the dose. • Suddenly stopping TCAs can cause nausea, altered heartbeat, nightmares, and cold sweats in 2 to 4 days. The patient should call the primary care provider or take one dose of TCA until the primary care provider can be contacted.