Block 11 Part 2

Community Health Nurse and the Community

*The community is the client for the Community Health Nurse* -Primary concern is to improve the health of the community -The nurse must first define what the community is -The CHN works collaboratively with the community using the nursing process to achieve improved health outcomes

Homeless Health Problems

-Acute physical health problems occurring at higher rates in adults in the homeless population include respiratory infections and trauma -Chronic disorders experienced at higher rates include hypertension, musculoskeletal disorders, GI problems, Respiratory problems, Neurological disorders, Serious mental illness and Minor emotional problems -Higher rates of drug and alcohol use exacerbate the existing acute and chronic physical and mental health problems -In men, self reports may underestimate problems with lack of knowledge and reluctance to seek care -Overall, higher mortality/morbidity rates than general population

Anger, Aggression, and Violence

-Anger is an emotional response to frustration of desires, a threat to ones needs (emotional or physical), or a challenge ; It is a normal emotion that can even be viewed as positive when it is expressed in a healthy way; It can be used as a motivator or an aid in survival, but problems begin to occur when anger is expressed through aggression or violence -Aggression is an action or behavior that results in a verbal or physical attack; Aggression tends to be used synonymously with violence; however; aggression is not always inappropriate and is sometimes necessary for self protection -Violence is always an objectionable act that involves intentional use of force that results in, or has the potential to result in injury to another person

Positive Symptoms of Schizophrenia

Associated with acute onset and usually appear early in the illness; their dramatic nature captures attention and often precipitates hospitalization -The symptoms most laypersons connect with insanity but are perhaps the least important prognostically as they usually respond to antipsychotic meds -Presence of something that is not normally present -These symptoms tend to respond well to medication, and individuals commonly function normally during remission -Include: -Alterations in thought (concrete thinking, paranoia and delusions) -Alterations in speech (clang associations, word salad, etc) -Alterations in perception (depersonalization, derealization, hallucinations) -Alterations in behavior (catatonia, motor retardation/agitation, impaired impulse control, etc.)

Rapid cycling

At least 4 mood episodes in a 12 month period -The cycling can also occur within the course of a month or even a 24 hour period -Rapid cycling is associated with more severe symptoms, such as poor global functioning, high recurrence risk, and resistance to conventional somatic treatments

Vulnerability

-Being susceptible to neglect or harm -Being at risk of poor social, psychological, and/or physical health outcomes -Often have higher mortality rates, decreased access to care, disparities in quality of care, no insurance or underinsured, lower life expectancy -Overall, vulnerable groups are more sensitive to risk factors and have worse health outcomes -Vulnerability can stem from: developmental problems, social problems, inadequate social support, deteriorating neighborhoods and environments

Predictors of Violence

Signs and symptoms that usually (not always) precede violence include: -Hyperactivity (pacing, restlessness); most important indicator of impending violence -Increasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self, sweating, SOB -Verbal abuse: profanity, argumentativeness -Loud voice, change of pitch; or very soft voice, forcing others to strain or hear -Intense eye contact or avoidance of eye contact -Recent acts of violence, including property violence -Stone silence -Alcohol or drug intoxication -Possession of a weapon or object that may be used as a weapon (fork, knife, rock) -Isolation that is new -Milieu characteristics conducive to violence (overcrowding, staff inexperience, provocative or controlling staff, poor limit setting, arbitrary revocation of privileges)

Signs and Symptoms of Alcohol Withdrawal

Mild to Moderate: -Restlessness/Irritability -Anorexia -Tremor/shakiness -Insomnia -Impaired Cognitive Functions -Mild Perceptual Changes Severe: -Obvious trembling of the hands and arms -Sweating -Elevation of pulse (above 100) and BP (over 140/90) -Nausea (sometimes with vomiting) -Hypersensitivity to noises and light *-Brief periods of auditory/visual hallucinations (risk for injury-high priority)* -Fever greater than 101 F -Grand Mal Seizures (most extreme form)

Schizophrenia Interventions: Phase II and III

Phase II: Stabilization Phase III: Maintenance -Long term care relies on a three pronged approach: med administration/adherence; relationships with trusted care providers, and community-based therapeutic services -Family psychoeducation (a key role of the nurse) is essential -Patients and family members should be given telephone numbers/addresses of local support groups and community health centers; 24-hour emergency services, and employment programs

Bipolar Interventions

-Maintain low level of stimuli to decrease anxiety -Provide structured, solitary activities with nurse or aid which provides security and focus for the patient -Provide frequent high calorie fluids to prevent serious dehydration -Provide frequent rest periods to prevent exhaustion -Physical exercise can decrease tension and provide focus -Redirect violent behavior -Use phenothiazines and/or seclusion to prevent harm when warranted -Observe for signs of lithium toxicity -Protect patient from giving away money and possessions; hold valuables in a safe place until rational judgment returns -Monitor I&O and vitals *-Offer frequent, high calorie protein drinks and finger foods and frequently remind patient to eat* -At night, provide warm baths, soothing music, and medication when indicated; Avoid caffeine -Supervise choice of clothes and minimize flamboyant and bizarre dress -Give simple step-by-step reminders for hygiene and dress -Monitor bowel habits to prevent fecal impaction; offer fluids and foods high in fiber; evaluate need for laxatives

De-escalation Techniques

-Maintain the patient's self -esteem and dignity -Maintain calmness (your own and the patient's) -Assess the patient and situation -Identify stressors and stress indicators -Respond as clearly as possible -Use a calm, clear tone of voice -Invest time -Remain honest -Establish what the patient considers to be his or her need -Be goal-oriented -Maintain a large personal space -Avoid verbal struggles -Give several options and make clear the options -Use a nonaggressive posture, genuineness and empathy -Attempt to be confidently aware -Use verbal and nonverbal communication skills -Be assertive (not aggressive) -Assess for personal safety Considerations for Safety include: -Avoid wearing dangling earrings or necklaces; ensure enough staff for backup; always know layout of area (exits); do not stand directly in front of the patient; provide feedback such as ("you seem very upset"); Avoid confrontation with the patient, either through a "show of support" with security guards; verbal confrontation and discussion of the incident must occur when the patient is calm; security personnel are best kept in the background until they are needed (this prevents escalation)

Borderline Personality Disorder

-Most well known and dramatic of personality disorders -Characterized by severe impairments in functioning -Major features are: patterns of marked instability in emotional control or regulation, impulsivity, identity or self-image distortions, unstable mood and unstable interpersonal relationships -One of the primary features is emotional lability: rapidly moving from one emotional extreme to another; typically the emotional shifts include responding to situations with emotions that are out of proportion to the circumstances, pathological fear of separation, and intense sensitivity to perceived personal rejection -Impulsivity is manifested in acting quickly in response to emotions without considering the consequences, often resulting in damaged relationships or suicide attempts -Self destructive behaviors and ineffective/harmful self soothing habits such as cutting, promiscuity and numbing with substances are common and may result in unintentional death; Co-occurring mood, anxiety, or substance disorders complicate the treatment and prognosis of the condition -Antagonism, which is marked by hostility, anger, and irritability in relationships is another characteristic and may lead to intimate/nonintimate partner violence -An unusual feature of the disorder is Splitting as a primary defense or coping style; splitting refers to the inability to view both positive and negative aspects of others as a part of a whole; the person quickly despises others after idolizing them due to a feeling of "let-down"; creating conflict gives the person a sense of control -People tend to seek out treatment for anxiety, depression, or impulsive-type behaviors including substance use; hospitalization may decrease self-destructive risks, but is not an effective long-term solution -Early abandonment may contribute to the unstable view of self and others; disruption in particular of the "rapprochement" phase of Separation-Individuation can be detrimental and the cause of the disorder

Bipolar Medications

-Patients often require multiple medications -For severe manic episodes, lithium or Depakote AND a second gen antipsychotic such as olanzapine or risperidone are recommended; antipsychotics act promptly to slow speech, inhibit aggression, and decrease psychomotor activity; As lithium becomes effective in reducing manic behavior, the antipsychotic drugs are usually discontinued -Individuals experiencing less severe symptoms may be given only one of these -There may be times when a benzo can help reduce agitation or anxiety; benzos act promptly to decrease psychomotor activity and will prevent exhaustion and coronary collapse (and subsequent death) until the Lithium kicks in -Anticonvulsants (Depakote, Tegretol, and Lamictal) have been approved for mood disorders -Antidepressants that may have been prescribed previously are often tapered and possibly discontinued to reduce mania or hypomania

Safety in Alcohol Intoxication/Withdrawal

-Safety is the primary focus of nursing care during acute alcohol intoxication or withdrawal -Maintain a safe environment to prevent falls; implement seizure precautions as necessary -Provide close observation for withdrawal symptoms, possibly one-on-one supervision; Physical restraint should be a last resort -Orient the client to person, place and time -Maintain adequate nutrition and fluid balance -Create a low-stimulation environment *-Administer meds as prescribed (on time!) to treat the effects of intoxication or to prevent/manage withdrawal* -Monitor for covert substance use during the detox period; drug-seeking behavior and monitoring for a safe environment (visitors) is necessary

Signs and Symptoms of Opioid Intoxication/Withdrawal

-Intoxication: everything is decreased -Bradycardia, Hypotension, Hypothermia, Sedation, Meiosis (pinpoint pupils), Hypokinesis (slowed movement), Slurred Speech, Head nodding, Euphoria, Analgesia, Calmness, Nystagmus -Withdrawal: everything is increased -Tachycardia, HTN, Hyperthermia, Insomnia, Mydriasis (dilated pupils), Hyperreflexia (abnormally heightened reflexes), Diaphoresis, Piloerection (goosebumps), Increased RR, Lacrimation, Yawning, Rhinorrhea (runny nose), Muscle Spasms, Abdominal Cramps, nausea, vomiting, Bone and muscle pain, Anxiety

Schizoaffective Disorder

-A Schizophrenia Spectrum Disorder -Characterized by an uninterrupted period of illness during which there is a major depressive, manic, or mixed episode of both -Concurrent with symptoms that meet the criteria for schizophrenia

Codependence

-A cluster of behaviors originally identified through research involving the families of alcoholic parents -People who are codependent often exhibit over responsible behaviors- doing for others what others could just as well do for themselves -They have a constellation of maladaptive thoughts, feelings, behaviors, and attitudes that effectively prevent them from living full and satisfying lives -Symptomatic of codependence is valuing oneself by what one does, what one looks like, and what one has, rather than by who one is -People often define their self-worth in terms of caring for others to the exclusion of their own needs -Nurses are at risk for codependency since the very nature of the profession can lead to viewing oneself exclusively as a provider for care

Antisocial Personality Disorder

-May be more commonly referred to as sociopaths -Symptoms tend to peak during the late teenage years and into the mid twenties and by age 40 symptoms may abate and even improve without treatment -Main characteristics include antagonistic behaviors such as being deceitful or manipulative for personal gain, or hostile if needs are blocked -Also characterized by disinhibited behaviors such as high risk taking, disregard for responsibility, and impulsivity; Criminal misconduct and substance abuse are common in this population -Persons are mostly concerned with gaining personal power or pleasure, and in relationships, they focus on their own gratification to an extreme that defies conforming to ethical or community standards -They have little or no capacity for intimacy and will exploit others if it benefits them in relationships -One of the most disturbing qualities is their profound lack of empathy, also known as callousness which results in a lack of concern about the feelings of others; the absence of remorse or guilt except when facing punishment, and a disregard for meeting school, family, and other obligations -Tend to exhibit shallow, unexpressive, and superficial affect; however, may be adept at portraying themselves as caring if it helps them manipulate or exploit others; may act witty or charming and may be good at flattery to get what they want -Genetically linked and may be due to an alteration in serotonin transmission; lower levels of serotonin along with dopamine hyperfunction may contribute to aggression, disinhibition, and substance abuse -Usually don't enter health care system for treatment unless court ordered to do so -Assess: Current life stressors; Suicidality and violence (including homicidal thoughts); Anxiety, aggression, and anger levels; Motivation for maintaining control; Substance misuse (past and present) -Nurse should be aware of charming nature of patient and avoid defending them; conversely, the nurse may feel disdain for the patient if they have a criminal history; The nurse should share concerns with others who are experienced working with this population and should be aware of own stress responses when approaching patient care -Diagnoses and care plans should be focused on: maintaining safety, providing structure for safety, protecting others and self from impulsive and premeditated acts and on improving coping skills -Outcomes should be geared toward small, incremental changes and progress as successful treatment is nearly impossible with this population-consistency is key!; Maintaining safety is priority; the nurse should plan to provide consistency, support, boundaries, and limits; Providing realistic choices may enhance adherence to treatment; Consequences should be established with patient input to identify unhealthy behaviors and their consequences; positive praise and feedback should be given for successful outcomes; be genuine and offer substantial instruction; positive experiences need to be repeated in learning healthy changes -Mood stabilizers such as lithium may be given for aggression and impulsivity; clonidine (an antihypertensive) may help as well -Most relevant nursing diagnoses are: Risk for other-directed violence; Defensive Coping; Impaired Social Interaction; Ineffective health maintenance

Bipolar Assessment

-The three most common initial symptoms during the onset of mania include elated mood, increased activity, and reduced sleep -Mood may be overly joyous and inappropriate for the circumstances; May change quickly to irritation and anger when the person is thwarted; May laugh, joke, and talk in a continuous stream with uninhibited familiarity; Self confidence is seemingly boundless and people are busy with grandiose plans and wild schemes at all hours of the day; The person often gives away possessions and spends exorbitant amounts of money beyond their means; As the clinical course progresses from hypomania to mania, sociability and euphoria are replaced by a stage of hostility, irritability, and paranoia -Behavior includes constant activity and a reduced need for sleep; some people may not sleep for days in a row; This nonstop physical activity and the lack of sleep and food can lead to physical exhaustion and even death if not treated; it therefore constitutes an emergency; Individuals experiencing mania may be manipulative, profane, fault finding, and exploitive; people often emerge from their mania startled and confused -Thought processes include: flight of ideas (continuous flow of accelerated speech with abrupt changes from topic to topic and change in direction; may be disorganized or incoherent); clang associations (stringing together of words because of their rhyming sounds without regard to meaning); and grandiosity (inflated self regard in which achievements or importance is exaggerated and the person may have delusions about knowing famous people or God) -Cognitive function: cognitive deficits in bipolar are milder but similar to those in patients with schizophrenia; deficits correlate with a greater number of manic episodes, history of psychosis, chronicity of illness, and poor functional outcome; early diagnosis and treatment are crucial to prevent illness progression -Self assessment: patient may engage in splitting; watch for feelings you have toward the client; consistency among staff is imperative if the limit setting is to be carried out effectively

Bipolar types

Bipolar I: characterized by at least one week-long manic episode that results in excessive energy and activity; so severe that the patient has difficulty maintaining social connections and employment; psychosis may occur during manic episodes; mania can be euphoric or dysphoric Bipolar II: low level mania alternates with low-level symptomology hypomania; the disorder is not usually severe enough to cause serious impairment in occupational or social functioning; hospitalization is rare, however, the depressive symptoms tend to put those who suffer in particular risk for suicide Cyclothymic disorder: symptoms of hypomania alternate with symptoms of mild to moderate depression for at least two years in adults and one year in children; neither set of symptoms constitutes an actual diagnosis of either disorder, yet they are disturbing enough to cause social and occupational impairment; may be difficult to distinguish from bipolar II; tend to have irritable hypomanic episodes

Cognitive Symptoms of Schizophrenia

Evident in most people with schizophrenia -Involve difficulty with attention, memory, information processing, cognitive flexibility and executive functions (decision making, judgment, planning and problem solving) -Patient has disordered thinking and difficulty concentrating -Memory deficits include problems with long term memory and working memory such as inability to follow directions or find an address -These impairments can lead to poor judgment and leave the patient less able to cope, learn, manage health or hold a job -The patient can find it very difficult to live independently

Social Determinants of Health

The economic and social conditions under which people live which determine their health -Need to consider social determinants of health on all levels: individual, aggregate, and population -Socioeconomic gradient of health: those at lowest levels of pay and occupations have an increase in mortality/morbidity rates

Bipolar Therapeutic Communication

*-Calm, Firm, Neutral, Consistent *-Use firm, calm approach (ex. "John, come with me"..."Eat this sandwich"); structure and control are provided for patient who is out of control; feelings of security can result from someone being in control -Use short and concise explanations or statements; Short attention span limits comprehension to small bits of info -Remain neutral; avoid power struggles and value judgments; patient can use inconsistencies and value judgments as justification for arguing and escalating mania -Be consistent in approach and expectations; consistent limits and expectations minimize potential for patient's manipulation of staff -With other staff, decide on limits and tell patient in simple, concrete terms with consequences (ex. "John, do not yell at or hit Peter. If you cannot control yourself, we will help you"...."The seclusion room will help you feel less out of control and will prevent harm to yourself or others"); clear expectations help the patient experience outside controls, as well as understand need for meds, seclusion, or restraints -Firmly redirect energy into more appropriate and constructive channels; distractibility is the nurse's most effective tool with the patient experiencing mania -Hear and act on legitimate complaints; underlying feelings of helplessness are reduced, and acting out behaviors are minimized -Reinforce non-manipulative behaviors

Healthy Communities

*A healthy community is the ability of the community to respond to change; healthy communities provide access to health services, educational opportunities, are safe and crime free, and promote health of its members* -Movements such as "Healthy Cities and Healthy Places" help community members to bring about positive health changes in their local environments -Involving many cities around the nation and the world, these models stress the interconnectedness among people and the public and private sectors as essential for local communities to address the causes of poor health -Each community and aggregate will have a unique perspective on critical health qualities that may even differ from the community health nurse, nevertheless, nurses and health professionals work with communities in developing effective solutions that are acceptable to the residents *-Building a community's capacity to address future problems is often referred to as developing community competence*; the nurse assesses the community's commitment to a healthy future and to foster open communication and elicit broad participation in problem solving

Concepts related to Substance Use Disorders

-Addiction: A primary, chronic disease of brain reward, motivation, and related circuitry; It is a disease of dysregulation in the hedonic (pleasure seeking) or reward pathway of the brain; manifestations include loss of behavioral control with craving and inability to abstain, loss of emotional regulation, and loss of ability to identify problematic behaviors and relationships -Intoxication: may manifest in a variety of ways depending on physiological response of the body to the substance being abused; individuals using substances are considered to be "under the influence", intoxicated, or high; terminology may vary depending on the substance (alcohol causes intoxication, but cocaine makes you high) -Tolerance: needing increasing amounts of a substance to receive the desired result or finding that using the same amount over time results in a much-diminished effect -Withdrawal: a set of physiological symptoms that begin to occur as the concentration of the chemical diseases in an individual's bloodstream; it is specific to the substance ingested and each substance has its own characteristic syndrome *Although alcohol is the drug with the greatest potential for and most serious symptoms of withdrawal, rising numbers of persons abusing prescription drugs has increased concern*

Defining the Community

-Aggregate of people, A location in space and time, and a Social System -Aggregate of people: (the "who") a community composed of people who have common characteristics; for example, members of a community may share membership in the same religious organization or similar demographic characteristics (age, ethnic background, etc.); may share in similar concerns or life experiences; communities may consist of overlapping aggregates in which some community members belong to multiple aggregates; a "community of solution" may form when common problems unite individuals to come up with a solution -Location in Space and Time: (the "where and when") Geographic or physical location may define communities of people; physical location is frequently delineated by boundaries and influenced by the passage of time; census tracts subdivide larger communities and help define them; A community's history illustrates its ability to change and how well it addresses problems over time -Social Systems: (the "why and how") A community is a complex social system and its interacting members constitute various subsystems within the community; *social systems in a community provide socialization and support of each other, and helps us fulfill our roles in the community*

Mania

-An abnormal elevated mood which may also be described as expansive (big, bold ideas) or irritable -Diagnosed as the presence of at least three of the following behaviors: Extreme drive and energy Inflated sense of self importance Drastically reduced sleep requirements Excessive talking combined with pressured speech Personal feeling of racing thoughts Distraction by environmental events Unusually obsessed with and overfocused on goals Purposeless arousal and movement Dangerous activities such as indiscriminate spending, reckless sexual encounters, or risky investments -Attention seeking behaviors -Neglect of ADLs/ Inappropriate dress -Euphoric mania feels wonderful in the beginning but turns scary and dark as it progresses toward loss of control and confusion -Dysphoric mania is also referred to as "mixed state" or agitated depression, with depressive symptoms along with mania; a person with dysphoric mania may be irritable, angry, suicidal, or hypersexual and may experience panic attacks, pressured speech, agitation, severe insomnia or grandiosity as well as persecutory delusions and confusion

Bipolar Assessment Guidelines

-Assess whether patient is a danger to self or others: Patients experiencing mania can exhaust themselves to the point of death Patients may not eat or sleep, often for days at a time Poor impulse control may result in harm to others or self Uncontrolled spending may occur -Assess need for protection from uninhibited behaviors ; external control may be needed to protect the patient from such consequences as bankruptcy -Assess need for hospitalization to safeguard and stabilize the patient -Assess medical status; a thorough medical examination helps to determine whether mania is primary ( a mood disorder-bipolar or cyclothymic) or secondary to another condition (medical or substance induced) -Assess for coexisting medical conditions or other situations that warrant special intervention -Assess patient's and family's understanding of bipolar disorder, knowledge of medications, and knowledge of support groups and organizations that provide information on bipolar disorder

Nursing for Borderline Personality Disorder

-Assessment: Semi-structured Interview (emotionally unstable person cannot tolerate a standard interview); Assess for suicidal or violent thoughts toward others; Determine whether the patient has a medical disorder or another psychiatric disorder that may be responsible for the symptoms; View the assessment about personality functioning from within the person's ethnic, cultural and social background; Ascertain whether the patient experienced a recent important loss; BPD is often exacerbated after the loss of a significant supporting person or in a disruptive social situation; Evaluate for a change in personality in middle adulthood or later, which signals the need for a medical workup or assessment for an unrecognized substance use disorder -Diagnosis: Self-mutilation is most often associated with this disorder; It is defined as: "deliberate, self-injurious behavior causing tissue damage with the intent of causing non-fatal injury to attain relief of tension"; Others include: Risk for suicide, Risk for self-directed violence, Social Isolation, Impaired Social Interaction, Disturbed Personality Identity, Ineffective Coping; *These should be prioritized by safety* -A therapeutic relationship is essential to establish because most patients have experienced failed relationships; distrust and hostility can be a setup for failure; when they blame and attack others, the nurse needs to know this springs from their feeling of being threatened -Personality change occurs with one learned skill and behavioral solution at a time; this takes time and repetition -Team management is a significant part of treatment; the primary goal is management of patient's affect in a group context; community meetings, coping skills groups, and socializing groups are helpful; dealing with emotional issues that arise requires a calm, united approach by the staff to maintain safety; Common problems from staff splitting can be minimized if staff communicates by weekly staff meetings to ventilate feelings; clear, straightforward communication and discussing goals to learn problem-solving skills in therapeutic groups can be helpful; The nurse should encourage the patient to journal the sequence of events leading up to any self-destructive behaviors before staff discusses the event with them- this encourages the patient to think independently about his behavior rather than merely venting feelings as well as facilitates discussion about alternative actions -Pharmacological interventions target mood and emotional disregulation; Anticonvulsant mood stabilizing meds, low dose antipsychotics, and omega 3 supplements as well as Naltrexone (ReVia) have been found helpful

MAOIs

-Increase Norepi, Serotonin, and Dopamine thus elevating mood -Not first line treatment; does not play well with other drugs and pt. must be on very strict diet -Increase in tyramine can cause HTN, hypertensive crisis, and eventually CVA, therefore, people on MAOIs should eliminate their intake of foods/drugs with high amounts of tyramine -Typically prescribed for people with unconventional depression characterized by mood reactivity, oversleeping, and overeating as well as anxiety disorders -Common side effects include: orthostatic hypotension, weight gain, edema, change in cardiac rate and rhythm, constipation, urinary hesitancy, sexual dysfunction, vertigo, overactivity, muscle twitching, hypomanic and manic behavior, insomnia, weakness, and fatigue -The most serious reaction is an increase in BP leading to intracranial hemorrhage, hperpyrexia, convulsions, coma, and death, therefore, monitoring of BP, especially during the first 6 months is imperative -Hypertensive crisis can occur within a few hours of ingestion of the contraindicated food/drug; watch for headache, stiff or sore neck, palpitations, chest pain with tachycardia or bradycardia -Foods to avoid include: avocados, fermented bean curd, soybean, soybean paste, figs, bananas, fermented, smoked, or aged meats including sausages and fish, all cheeses, yeast extract, some imported beers and chianti wine, protein dairy supplements, soups, shrimp paste, soy sauce, chocolate, fava beans, ginseng, caffeinated beverages -Ex. Nardil, Parnate, Marplan

Characteristics of Schizophrenia: Alterations in Speech

-Associative looseness is the interruption of the mental threads that tie one thought logically to another; Thinking becomes haphazard, illogical, and difficult to follow (ex. "I need to get a Band-Aid for my cut. My friend was talking about AIDS. Friends talk about French Fries and how can you trust the French?") -Clang association is choosing words based on their sound rather than meaning; often rhyming or having a similar beginning sound ("on the track...have a big mack....clack, clack") -Word Salad (schizophasia) is a jumble of words that is meaningless to the listener and (perhaps to the speaker) due to an extreme level of disorganization ("throat hoarse strength of a policy dreadfully essential Brazilian highlighters on a boat reigning supreme") -Neologisms are made up words or idiosyncratic uses of existing words that have meaning for the patient but a different or nonexistent meaning to others ("I was going to tell him the mannerologies of his hospitality wont do"); this eccentric use of words represents disorganized thinking and interferes with communication -Echolalia is the pathological repeating of another's words and is often seen in catatonia -Circumstantiality involves including unnecessary and often tedious details in one's conversation (ex. describing breakfast when asked how day is going) -Tangeniality includes leaving the main topic to talk about less important information; going off on tangents in a way that takes the conversation off topic -Flight of ideas includes moving rapidly from one thought to the next, making it difficult to follow the conversation -Alogia, or poverty of speech is a reduction in spontaneity or volume of speech, represented by a lack of spontaneous comments and overly brief responses -Rapid or pressured speech

Migrant Farm Workers

-Comprise a vulnerable population in regard to health risks because they have low income and migratory status -In many rural areas, community health nurses form the central link between farmworkers and health services through standing or mobile clinic sites -Lacking access to many types of preventative services, farmworkers often visit a migrant clinic with any number of health problems, including severe dental problems, unresolved communicable diseases, and untreated injuries -Barriers such as Poor, unsanitary working conditions; limited access to dental, mental health, and medical care; limited money for care; difficulty accessing care and fears of deportation are all issues impacting the farmworker's heath care -Cultural, linguistic, economic, and mobility barriers all contribute to the nature and magnitude of health problems observed in farmworkers; cultural and linguistic barriers are the most overt because many people in the community consider them outsiders -Farmworkers may be less likely to seek treatment for health problems that do not require emergency treatment as well as return to their country of origin to obtain treatment- this makes it hard to get complete, reliable data about disease rates -The Migrant Health Program (MHP) under the direction of the Bureau of Primary Health Care and the Health Resources an Services Administration requires that priorities be established according to where the greatest need is, therefore, the MHP has supported the ongoing and comprehensive assessment of the numbers of Farmworkers

Men's Health Status and Risk Factors

-Death rates for men are higher than women in the major categories of death -Gender differences place men at greater risk of death -Although the overall incidence rate for acute illness is higher for women than men, males continue to be at risk for death due to unintentional injury (suicide, homicide, and accidents are higher in men) -Women have a higher prevalence of chronic diseases that cause disease (morbidity), but men have higher rates of mortality -Men tend to perceive themselves to be in better health than women -Most men do not have routine checkups and seek ambulatory care less often (delay treatment and therefore require more intensive medical care and longer length of stay in hospital than women)

Vulnerable Populations

-Decreased income and education -Race/Ethnic Background -Age and Gender -Chronic disabilities -HIV/AIDS -Immigrants and Refugees -Mental Illness and Disability -Alcohol and Substance Abuse -Homelessness -Suicide and Homicide risk -High risk mothers and infants -Uninsured/Underinsured -Access to care has fewer choices, lack of a regular provider, insufficient transportation, fragmented health services (mentally ill) -Quality of Care: racial/ethnic groups feel more comfortable when care is provided by someone from their own racial group (feel that quality is better); most vulnerable groups feel that they are treated as second class citizens in health care facilities

Symptoms of Alzheimer's

-Defense mechanisms such as: denial, confabulation (creation of stories or answers in place of actual memories to maintain self esteem), preservation (repetition of phrases or behavior), avoidance of questions -Memory impairment: initially, the person has difficulty remembering recent events; gradually, deterioration progresses to include both recent and remote memory -Disturbances in executive functioning: planning, organization, abstract thinking -Aphasia: loss of language including difficulty finding the right word leading to eventual babbling or mutism -Apraxia: loss of purposeful movement in the absence of sensory or motor impairment; person is unable to perform once familiar and purposeful tasks (ex. putting on pants upside down) -Agnosia: loss of sensory ability to recognize objects; can lose ability to recognize sounds or familiar objects such as a toothbrush

Characteristics of Schizophrenia: Disturbances in Thought

-Delusions are false, fixed beliefs that cannot be corrected by reasoning; about 75% of people with schizophrenia experience delusions at some time; offering evidence of reality is counterproductive because the patient will offer an even stronger defense of their position; this may also irritate the patient and slow the development of a therapeutic relationship; The most common delusions are persecutory, grandiose, or those involving religious or hypochondriacal ideas; A delusion may be a response to anxiety or reflect areas of concern; looking for and addressing these themes or needs can be a key nursing intervention -Concrete thinking refers to an impaired ability to think abstractly (ex. nurse asks patient what brought him to the hospital; the patient answers "a cab."); Concreteness is often assessed through the patient's interpretation of proverbs such as "the grass is always greener on the other side"; the patient would interpret this as the grass being greener because it gets more sun on that side; Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time -Religiosity is an excessive preoccupation with religious themes -Magical thinking is believing one's thoughts or actions can affect others (commonly seen in children) -Paranoia is an irrational fear other others ranging from guardedness to profound; the patient may believe others want to harm them and may act defensively; this creates a risk to others -Cognitive retardation is a generalized slowing in the pace of thinking, represented by delays in responding to questions or difficulty finishing one's thoughts -Thought blocking includes a reduction in the amount of thinking; an abrupt stoppage of thought that derails the conversation -Thought insertion is the feeling that one's thoughts are not one's own or that they were inserted into one's mind -Thought deletion is the belief that one's thoughts have been taken or are missing -Illogical, disorganized or bizarre thinking -Inability to maintain attention is represented by easy distractibility, off-topic comments in a group, or unfinished tasks

Bipolar: Other meds

-Depakote, Tegretol, and Lamictal are approved anticonvulsants for mood disorders and are thought to be: -Superior for continuous/rapid cyclers -More effective when there is no family history of bipolar disease -Effective at dampening affective swings in schizoaffective patients -Effective at diminishing impulsive and aggressive behavior in some nonpsychotic patients -Helpful in cases of alcohol and benzo withdrawal -Beneficial in controlling mania and depression -Depakote (valproate/valproic acid) is useful in treating lithium nonresponders who are in acute mania, experience rapid cycling, are in dysphoric mania, or have not responded to Tegretol; also useful in preventing future manic episodes; Important to monitor liver function and platelet count (thrombocytopenia) -Tegretol (carbamazepine) is useful in treating patients with treatment-resistant bipolar when combined with lithium or an antipsychotic; seems to work better in patients with rapid cycling and in severely paranoid, angry, patients experiencing manias than in euphoric, overactive, overfriendly patients experiencing manias; liver function and platelet count should be monitored (liver failure, agranulocytosis, pancreatitis) -Lamictal (lamotrigine) is first line treatment for bipolar and is approved for acute and maintenance therapy; generally well tolerated however, serious life-threatening dermatological reaction should be monitored for (Stevens-Johnson Reaction/Rash) -Anxiolytics such as Klonopin (clonazepam), Ativan (lorazepam), Xanax (alprazolam), and Valium (diazepam) are useful in the treatment of acute mania; should be avoided in patients with a hx of substance abuse -Second Gen Antipsychotics: Show sedative properties in the early phases of treatment which help with insomnia, anxiety, and agitation, as well as have mood-stabilizing properties; most evidence supports the use of risperidone (Risperdal) or olanzapine (Zyprexa)

Nursing care following an aggressive/violent episode

-Discuss ways for the client to keep control during the aggression cycle -Encourage the client to talk about the incident, and what triggered and escalated the aggression from the client's perspective -Debrief the staff to evaluate the effectiveness of actions -Document the entire incident completely by including: Behaviors leading up to, as well as those observed throughout the critical incident; Nursing interventions implemented, and the client's response

Hypomania

-Elevation of mood with increases in activity but not as severe as in mania -The hypomania of bipolar II tends to be euphoric and often increases functioning -Like mania, hypomania is accompanied by excessive activity and energy for at least four days and involves at least one of the three behaviors listed under mania -Unlike mania, psychosis is never present in hypomania, although it may be present in the depressive side of the disorder

Depression Assessment

-Evaluate for suicidal/homicidal ideation *#1 priortity*; about 15% of people with clinical depression commit suicide; risk for suicide in patients with major depression is increased in the presence of severe hopelessness, overuse of alcohol, recent loss or separation, hx of suicide attempt and acute suicidal ideation -Statements or questions should include: tell me about your depression; what thoughts go through your mind?; have you thought about taking your own life or hurting someone? do you have a plan? do you have the means to carry out your plan? is there anything that would prevent you from carrying out your plan? -Assess for the "3 A's": Anhedonia (inability to find meaning or pleasure in life); Anergia (lack of energy); Anxiety -Assess for somatic complaints such as headaches, backaches, malaise, GI problems, chronic pain -Assess for Vegetative signs of depression: change in bowel movements and eating habits, poor hygiene, sleep disturbances and disinterest in sex -Assess affect: the outward representation of a person's internal state of being; posture is poor and the patient may look older than stated age; facial expressions convey sadness and the patient may have frequent bouts of weeping; the patient may also say she feels numb or is unable to cry; feelings of hopelessness and despair are noticeable-patient may not may eye contact or speak in a monotone voice with no facial expression (flat affect); frequent sighing is common -Assess thought processes: the person's ability to solve problems and think clearly is negatively affected; judgment is poor, and indecisiveness is common; the individual may complain that the mind is slowing down; memory and concentration are poor; patients may complain of intrusive negative thoughts; delusional thinking may be evident -Assess mood: a patient's mood can accurately be assessed by asking the person how he or she feels; feelings frequently reported include anxiety, worthlessness, guilt, helplessness, hopelessness, and anger -Feelings such as guilt, helplessness, and hopelessness, anger and irritability are common -Grooming, dress, and personal hygiene may be markedly neglected; people may neglect to bathe, change clothes, or engage in other basic activities -Changes in bowel habits including constipation is common -Assess spiritual health by asking how depression has affected their health; spiritual beliefs and practices may be associated with lower rates of depression and recurrence of depressive symptoms -Core symptoms of depression (sadness and loss of pleasure) in children and adolescents are the same, however, the symptoms may be displayed differently- in general, depressed children and adolescents may display increased irritability, negativity, isolation, and withdrawal in addition to a loss of energy; depression in this age group is frequently associated with anxiety and anger -Older adults may have comorbidities making it hard to ascertain whether their symptoms are a result of the illness or depression; it is important to note, however, that depression is not a normal part of aging -When depression lifts, the patient is at risk for suicide (they now have the energy to carry out plan)

Medications for Schizophrenia

-First Gen Antipsychotics: Dopamine antagonists (lower dopamine levels); Target positive symptoms of schizophrenia; Work quickly to control behaviors; Do not treat negative symptoms; Cause EPS (dystonia, akathisia, pseudoparkinsonism), tardive dyskinesia, and have Anticholinergic side effects; lowers seizure threshold (increases seizure risk);Rare side effects include: neuroleptic malignant syndrome, agranulocytosis, cholestatic jaundice; lowering dose of med and/or adding Congenin, Benedryl, or a benzo can be helpful in reducing EPS; Ex. Haldol, Thorazine, Stelazine, Prolixin -Second Gen Antipsychotics: First line antipsychotics; Treat both positive and negative symptoms; decreases suicidal behavior; produce minimal EPS or tardive dyskinesia; reduced side effects can help ensure medication adherence; Ex. risperidone, olanzapine, quetiapine, ziprasidone, and clozapine; clozapine produces agranuolcytosis and risk for seizure (WBC should be monitored frequently); liver impairment may occur (monitor liver function tests and symptoms); main side effect is weight gain (possibly leading to metabolic syndrome)

Implementation: Counseling Guidelines

-Help the patient question underlying assumptions and beliefs and consider alternate explanations to problems -Work with the patient to identify cognitive distortions that encourage negative self-appraisal such as: Overgeneralizations, Self-Blame, Mind Reading, Discounting of Positive Attributes -Encourage activities that can raise self-esteem, identify need for problem solving skills, coping skills, and assertiveness skills -Encourage exercise, such as running and/or weight lifting -Encourage formation of supportive relationships such as through support groups, therapy, and peer support -Provide information referrals, when needed, for religious or spiritual information (readings, programs, tapes, community resources)

Health Status of Homeless Adolescents/Youth

-Higher rates of STDs, Physical and Sexual abuse, Skin disorders, Anemia, Drug and Alcohol Abuse, and Unintentional injuries and pregnancies -Health problems from high risk behaviors at higher rates -Depression, suicidal ideation, and disorders of behavior, personality, or thought also occur at higher rates -Family disruption, school failures, prostitution or "survival sex" and involvement with the legal system indicate that homeless youths' social health is severely compromised -Pregnant homeless youth have more severe mental health problems and use alcohol and drugs more than nonpregnant homeless peers (leading to higher rates of negative pregnancy outcomes) -Both male and female homeless youth make up a large percentage of all youth involved in prostitution; many become involved for money; those involved in prostitution are more likely to report hx of physical and sexual abuse -Rates of attempted suicide are higher among gay homeless youth; majority of males involved in survival sex are gay or bisexual and face homophobia and prejudice

Health Status of Homeless Children

-Homeless children have higher rates of physical, mental health, behavioral, and educational problems than children in general populations; these rates are similar when compared with poor, housed children -Physical health problems include: Asthma, Iron deficiency anemia, and Obesity -Mental health problems, including behavioral health problems and developmental delays are higher than general population -These problems interact and adversely affect homeless children's educational achievement on tests -Missing days of school owing to family mobility, homeless children are more likely than other children to repeat grades -Homeless children may lack resources for clothing and school supplies and access to facilities for maintenance of personal hygiene; as a consequence, they may be at risk of teasing or bullying -Immunizations may be incomplete -Some shelters do not accept male children -Homeless families experience substandard living conditions, social isolation, and a myriad of physical health problems; Families are often separated -U.S. policies on assistance to the poor often view children as the most "blameless and deserving" of support

ECT: Nursing Care

-Informed consent is needed if being treated voluntarily- if treatment is involuntary, permission may be obtained by the next of kin or can be court ordered -Patient should be NPO for 6-8 hours before treatment -Atropine is given 30 minutes prior to treatment to reduce secretions -Contact lenses, hairpins, hearing aids, and dentures should be removed -Vitals , ventilation, and mental status should be assessed and monitored before, during, and after treatment -The patient is given a general anesthetic to induce sleep (short acting barbiturate such as IV Brevital ) and a muscle paralyzing agent (such as IV Anectine- succinylcholine) to minimize muscle distress and fractures; these meds have revolutionized the comfort and safety of ECT -ECG and EEG monitors are place on patient for constant brain and cardiac monitoring -Brief seizures (30-60 seconds) are deliberately induced by an electrical current transmitted through electrodes attached to the head -After awakening, the patient is often confused and disoriented for several hours; the nurse and family may need to orient the patient frequently during the course of treatment and implement injury precautions -Patients sometimes awaken agitated; may need to administer benzo -Assess client for return of gag reflex before taking off NPO -Assess for any cardiac or respiratory problems

Tricyclic Antidepressants

-Inhibit reuptake of norepi and serotonin by the presynaptic neurons in the CNS, thus increasing the amount available to the postsynaptic receptors- this elevates mood and increases activity and alertness -Have longer half lives, so can be taken daily at bedtime in a single dose (also have sedative effect so side effects have benefit of side effects occurring during sleep) -Patients must take therapeutic doses of TCAs for 10-14 days or longer before they begin to work; full effects may not be seen for 4-8 weeks -Doses should start low and increase gradually -Lethal in overdose (overdose is a medical emergency); Use cautiously with the elderly, cardiac disorders, elevated intraocular pressure, urinary retention, hyperthyroid, seizure disorders, and liver/kidney dysfunction -Side effects (anticholinergic): dry mouth, constipation, urinary retention, blurred vision, hypotension, cardiac toxicity (arrhythmia, MI, tachycardia, heart block- watch ekg and have cardiac workup before starting), sedation, weight gain, dizziness (risk for falls in elderly) -Ex: Elavil, Tofranil, Pamelor

Health Planning Project: Assessment

-It is essential to establish a professional relationship with the selected aggregate, which requires that a good community health nurse gains entry into the group -The nurse must initially clarify her position, organizational affiliation, knowledge, and skills; the nurse should also clarify mutual expectations and available times -Once entry into the aggregate is established, the nurse continues negotiation to maintain a mutually beneficial relationship; should ask what the aggregate wants to learn about; the nurse must portray empathy, give something back, and try to assimilate -The nurse may gather info about socioeconomic characteristics from a variety of sources, reviewing available charts, interviewing members of the aggregate and interviewing a key informant -In assessing health status, the nurse must consider both negative and positive factors; the specific aggregate determines the appropriate health status measures; disease categories, mortality rates, birth rates, unemployment, etc. -Suprasystem influences: presence or absence of hospitals, clinics, emergency departments, health centers, etc.; Support systems such as Meals on Wheels, recreational programs, etc. -A literature review is an important means of comparing the aggregate with the norm (community, state, national levels) -Identify health problems/needs: should relate directly to the assessment and literature review and should include a comparative analysis of the two; most importantly, it should reflect the aggregates perception of need (include input from clients); four types of needs should be assessed: needs expressed by behavior; needs determined by expert health professionals; needs expressed by group/client; relative need as expressed by health disparities between advantaged and disadvantaged group; Give priorities to health problems/needs and explain how this was determined

Major Indicators of Men's Health

-Longevity: Rates are increasing for both men and women; men still tend to have shorter expectancy; the change may be attributed to the advances in treatment of heart disease and cancer which have been the major causes of death in U.S. males -Mortality: Males lead females in mortality rates in each leading cause of death; heart disease remains the leading cause; men are more likely to die from unintentional injury and 3-4 times more likely to commit suicide; causes of death vary by racial and ethnic backgrounds -Morbidity: Rates are difficult to obtain; rates are impacted by: incidence of acute illness, prevalence of chronic conditions, use of medical care

Obsessive Compulsive Personality Disorder

-Most prevalent personality disorder in the general community and clinical populations -Main pathological personality traits are rigidity and inflexible standards of self and others along with persistence to goals long after it is necessary, even if it is self or relationship defeating -Persons feel genuine affection for friends and family but do not have insight into their own behavior -Internally, they are fearful of imminent catastrophe and rehearse over and over how they will respond in social situations -These individuals do not have full blown obsessions or compulsions, but may seek treatment for anxiety or mood disorders; the disorder has been associated with increased relapse rates of depression and an increase in suicidal risk in people with co-occurring depression -Associated with excessive parental criticism, control and shame; the child responds by trying to control his environment with perfectionism and orderliness -Heritable traits such as compulsivity, oppositionality, lack of emotional expressiveness, and perfectionism have all been implicated in this disorder -SSRIs such as fluoxetine, fluvoxamine, and sertraline or TCAs (clomipramine/ Anafranil) can be used for the more severe treatment of this disorder and may help reduce obsessions, anxiety, and depression; psychotherapy may provide additional support; group therapy and self help groups have been found to be especially helpful -Nursing Guidelines: Guard against power struggles with patient-need for control is very high; Intellectualization, rationalization, reaction formation, isolation, and undoing are the most common defense mechanisms

Chronically Homeless

-No permanent address for more than one year (deinstitutionalized mentally ill for example) or has had 4 episodes of homelessness in the last 3 years -Have one or more disabling condition; usually mental and substance abuse disorders -In 2011, 63% of chronically homeless were unsheltered -Chronically homeless use a disproportionate amount of homeless services -Those at high risk for death are individuals who have been homeless for 6 months or more with one or more of the following features: -More than 3 hospitalizations or ER visits in a year -More than 3 ER visits in the past 3 months -60 years or older -Cirrhosis of the liver -End stage renal disease -Hx of frostbite, immersion foot, or hypothermia -HIV/AIDS -Co-occurring psychiatric, substance abuse, and chronic medical conditions

Signs and Symptoms of Aggression

-Nursing Dx= Risk for other-directed violence/ Impaired Impulse control; S&S= -History of violence, victimization (best predictors of violence); history of family violence; substance abuse, impulsivity -Nursing Dx=Risk for self-directed violence/Risk for Suicide; S&S= Impulsivity, Suicidal ideation (has plan, ability to carry out); Overt or Covert Statements regarding killing self, feelings of worthlessness, hopelessness, helplessness -Nursing Dx= Stress Overload; S&S= Demonstrates feelings of anger, impatience; reports feelings of pressure, tension, difficulty in functioning, anger, impatience, experiences negative impact from stress; reports problems with decision making -Nursing Dx= Ineffective Coping; S&S=Difficulty with simple tasks, Inability to function at previous level, Poor problem solving, poor cognitive functioning, verbalizations of inability to cope

Health Planning Project: Planning

-Objectives need to be measurable, specific, and observable -The nurse should determine the intervention levels (subsystem, aggregate, suprasystem) and select a health problem or need and identify the ultimate goal of the intervention; describe any alternative interventions that are or might be necessary to accomplish the objectives -Then, the nurse should plan interventions for each system level which may center on the primary (health promotion that protects the client from illness), secondary (early diagnosis or treatment to reduce duration or severity of disease) , or tertiary (aims to rehabilitate/restore to optimal level of functioning) levels of prevention; plans should include goals and activities that reflect the identified problem's prevention level; the nurse should coordinate the planned intervention with the aggregate's input to maximize participation -Goals and Objectives need to be developed and identified; measureable objectives are the specific measures used to determine whether or not the nurse is successful in achieving her goal -Last, the nurse should validate the practicality of the planned interventions according to available personal as well as aggregate and suprasystem resources;

Rural Access to Care

-Primary Care: Rural areas have fewer primary care physicians; primary care doctors, nurses, and PAs tend to provide mental health care due to lack of mental health services -General Health Services: Population decline in rural areas is leaving a greater concentration of older people in a dwindling population; subsequently, hospital and pharmacy closures have occurred, causing greater distances of travel for medical services, and limited, if any choice of providers -Lack of local access forces rural residents to either go without or travel long distances-often over rural roads in dangerous weather conditions-to access care

Primary risk factors for depression

-Prior episode of depression -Family history, especially in first degree relatives -History of suicide attempts/family history of suicide -Female gender -Unmarried -Postpartum -Medical Illness/ Chronic pain -Absence of social support -Negative stressful life events, especially loss and humiliation -Substance abuse -Lower Socioeconomic status -Early Childhood Trauma -Ineffective coping ability -Alcohol or Substance abuse

Interventions for Rape-Trauma Syndrome

-Provide support person to stay with the patient -Explain legal proceedings to patient -Explain rape protocol and obtain consent -Document whether patient has bathed, showered, or douched since the incident -Document mental state, physical state (clothing, dirt, debris), history of incident, evidence of violence, and prior gynecological history -Determine presence of cuts, bruises, bleeding, lacerations, and other signs of physical injury -A sexual assault examiner (SANE) is specially trained nurse who performs exams and collects forensic evidence -Implement rape protocol and assist the sexual assault specialist with collection, documentation, and preservation of forensic eveidence (label and save soiled clothing, vaginal secretions, and vaginal hair combings) -Secure samples for legal evidence -Implement crisis intervention counseling -Evaluate for pregnancy and provide for prevention; Offer medication to prevent pregnancy, as appropriate -Offer prophylactic antibiotic medication against sexually transmitted disease -Inform patient of availability of HIV testing, as appropriate -Refer patient to rape advocacy program -Document according to agency policy -The rape victim has the right to refuse a medical exam or legal exam, which provides forensic evidence for the police -Call the client's available personal support system, such as partner or parents, if the client gives permission

Risk factors for Substance Use Disorders

-Psychiatric Comorbidity: Individuals with mood and anxiety disorders, antisocial behaviors, or histories of conduct or oppositional disorders as adolescents are more than twice as likely to have a substance use disorder; -Any insult (stress or trauma) during age 5-20 may alter the brain circuitry and cause long-term changes in the abilities of decision making, learning and memory, reward and affect, and behavioral control -Psychological Factors: Individuals who experience abuse or neglect during childhood report more depression and suicidality; Chronic stressors such as poverty, the time and financial obligations of caring for children, and harmful relationships can lead to depression -Domestic violence, combat experience, and exposure to other forms of trauma may lead to PTSD, major depression, GAD, and substance use disorders -Sociocultural Factors: Many chronic stressors have their roots in socioeconomic factors; Poverty raises the risk of unfavorable living environments, lack of parental supervision, poor educational resources, and impaired support systems; Coping mechanisms may include drugs and acting out behaviors leading to destructive consequences

Health Risks in Rural Areas

-Rural residents are more likely to be obese, smoke more heavily and engage in sedentary lifestyles -Less likely to use seat belts or engage in preventative screening -Intentional injuries against the self or another are most often the result of firearms usage; In rural areas, nonfatal firearm injuries occur most often at home -Firearm suicide in rural counties is an important public health concern; suicide is the second leading cause of death in rural areas (higher among ethnic minorities) -Decreased access to mental health services for treatment of depression may contribute to higher rates -Unintentional injuries (MVC, bicycle, all-terrain vehicle crashes) higher in rural areas (males 15-24 are most likely victims)

Characteristics of Rural Populations

-Rural residents have long been thought to be family farmers and ranchers, but today, Rural America is a diverse and important marketplace -Poverty continues to be greater in rural America than in urban areas -Not only is the economic base shifting, the age composition is as well; a decline in agricultural and manufacturing jobs means that younger people are leaving in search of work in urban areas; those left behind are increasingly older and isolated and have diminished access to health care -Retirees are moving in to rural areas as well, changing the demographic to 20% aged 60 or older -Three trends= aging in place, out-migration of young adults, and immigration of older persons to rural areas present challenges to already stressed communities that must provide adequate health care, housing and transportation -The rural population is also becoming more ethnically diverse (Hispanics are the most rapidly growing ethnic group) -Members of rural areas are more likely to be older, less educated, live in poverty, lack health insurance and access to health care -More problems r/t negative health behaviors (untreated mental illness, tobacco use, alcohol and drug use) -Higher infant/maternal mortality; Higher rates of chronic illness; Higher health occupational risks; Higher rates of suicide; Less likely to seek medical care -Residents of rural areas are almost twice as likely to die from unintentional injuries, including MVCs than urban residents; "rural culture" of prominent and persistent risk health behaviors may be to blame -Do have more of a sense of community

Screening and Assessment for Substance Use Disorders

-Screening, Brief Intervention, and Referral to Treatment (SBIRT) -Assess for substance abuse problems using screening tools such as AUDIT or CAGE-AID (be clear with instructions) -Discuss risks of substance abuse behaviors and provide feedback and advice (be non-judgmental) -Refer for brief therapy or treatments for patients who screen positively -Look for important trends: progression or loss of control; presence of tolerance or withdrawal -AUDIT can be administered by a clinician or self-report; Assesses for: frequency and amount and: not able to stop drinking once started failed responsibilities due to drinking how often needing a drink in the morning feeling guilt/remorse after drinking unable to remember what happened when drinking you or someone else injured when drinking others concerned about your drinking and ask you to cut down -CAGE-AID asks clients to determine how they perceive their current substance use; CAGE stands for: C= concerned; A=annoying/annoyed; G= guilt/remorse; E=eye opener -The substance abuse professional may choose to start with a brief intervention; FRAMES is an acronym to reflect the six components necessary; F=feedback about personal risk; R=responsibility should be encouraged; A=advice to change should be provided; M=menu of treatment or self-help options should be offered; E=empathetic communication should be used; S=self-efficacy or empowerment is the expected result

Health Planning Project: Evaluation

-Should include the participant's verbal or written feedback and the nurse's detailed analysis -Includes reflecting on each previous stage to determine the plan's strengths and weaknesses (process evaluation) -Process evaluation or formative evaluation allows one to evaluate both positive and negative aspects of each experience honestly and comprehensively and whether the desired outcomes were achieved (product evaluation) -During both process and product evaluations, the nurse may asks certain questions to determine why or why not outcomes were met -The intervention may have limited impact if the nurse fails to communicate follow up recommendations to the aggregate upon completion of the project

Sources of Data to Assess the Community

-The community health nurse must substantiate initial assessments and impressions with more concrete or defined data before he or she can formulate a community diagnosis and plan -Travelling through the area allows the community nurse to become familiar with the community and begin to understand its nature -Community health nurses often perform a "windshield survey" by driving or walking through an area and making organized observations; this offers the opportunity to understand the environmental layout, what businesses/agencies are located in the area; suprasystem influences and location of environmental concern using sight, sense and sound -Epidemiology involves the analysis of health data to discover the patterns of health and illness in a population; it also involves conducting research to explain the nature of health problems and identify aggregates at increased risk -Census data is extremely helpful to community health nurses familiarizing themselves with a new community; the census tabulates demographic variables and data is frequently used as denominators for morbidity and mortality rates; identifying attributes that make each community unique provides clues to the community's potential vulnerabilities and health risks and assists the nurse in modifying public health programs to meet the needs of the community -Vital statistics includes official birth, death, marriage, divorce, and adoption records which provide indicators of population growth or reduction and morbidity/mortality trends -Needs Assessment includes interviewing key informants (knowledgeable residents, elected officials, or health care providers), holding a community forum to discuss selected questions, mailing surveys to elicit information, or hold focus groups which can help to gather community views, particularly for vulnerable parts of the community

Counseling for Sexual Assault

-The most effective approach for counseling in the ED or crisis center is to provide nonjudgemental care and optimal emotional support -Confidentiality is crucial -The most helpful things the nurse can do are to listen and to let the patient talk; A patient who feels listened to and understood is no longer alone and feels more in control of the situation -It is especially important to help the survivor and significant others to separate issues of vulnerability from blame -Although the person may have made choices that made her more vulnerable, she is not to blame for the rape; She may, however decide to avoid some of these choices in the future *(bullshit)* -Focusing on one's behavior (which is controllable) allows the survivor to believe that similar experiences can be avoided in the future *(bullshit again)*

Lithium: Therapeutic and Toxic Levels

-Therapeutic range for lithium is 0.8-1.4 -Maintenance levels should range 0.4-1.3, although a level of 0.6 can be an effective level for many -To avoid serious toxicity, lithium levels should not exceed 1.5 -At levels above 1.5, early signs of toxicity can occur such as: Nausea, Vomiting, Diarrhea, Thirst, Polyuria, Lethargy, Slurred Speech, Muscle Weakness, and Fine Hand Tremor; Medication should be withheld, blood lithium levels measured, and dosage reevaluated -At levels 1.5-2.0, advanced signs of toxicity can occur such as: Coarse hand tremor, persistent gastrointestinal upset, mental confusion, muscle hyperirritability, electroencephalographic changes, incoordination, and sedation -At levels 2.0-2.5, severe toxicity and subsequent death can occur; Symptoms include: Ataxia, giddiness, serious electroencephalographic changes, blurred vision, clonic movements, large output of dilute urine, seizures, stupor, severe hypotension, and coma; Death is secondary to pulmonary complications; hospitalization is indicated; the drug is stopped, and excretion is hastened through gastric lavage, urea, mannitol and aminophylline; Hemodialysis may be necessary in extreme cases -Lithium levels should be measured at least 5 days after starting therapy and after any dosage change until the therapeutic level has been reached; After therapeutic levels have been reached, blood levels are determined every month; After 6 months -a year of stability, measurement of blod levels every 3 months should suffice -Blood draws should be done in the morning, 8-12 hours after last dose -For older adults, start low and go slow; levels are monitored every 3-4 days -Two major long-term risks of lithium therapy are hypothyroidism and impairment of kidney to concentrate urine; thyroid and renal function should be monitored -It is important to keep a normal diet with normal salt and fluid intake; drink 1500-3000 ml of fluid/day and do not take diuretics; watch for signs of dehydration and stop taking lithium if excessive vomiting, diarrhea or sweating occur (can lead to dehydration)

Common Medications for Substance Use Disorders

-To treat alcohol withdrawal: Diazepam (valium); lorazepam (Ativan); carbamazepine (Tegretol), clonidine (Catapres), chlordiaxepoxide (Librium) -For alcohol abstinence (cravings): disulfiram (Antabuse); naltrexone (Revia); acamprosate (Campral) -For Opioid withdrawal: methadone (Dolophine) substitution; clonidine (Catapres), buprenorphine (Subutex) -Anticonvulsants (Tegretol, Depakote, Neurotin) may cause dizziness or drowsiness and should be tapered off to prevent seizures -Librium (benzo) may increase seizure threshold and reduce withdrawal agitation; withdrawal may result in seizure -Valium may cause sedation and respiratory depression; withdrawal may result in seizure -Antabuse produces a toxic reaction that causes intense nausea and vomiting, headache, sweating, flushed skin, respiratory difficulties, and confusion; Must be taken consistently for the aversion to alcohol to be consistent; Nursing education includes identifying and avoiding use of substances/foods that include alcohol; educate on risks of using perfumes, aftershaves, alcohol wipes, etc; anything with alcohol has the potential to be lethal

Schizotypal Personality Disorder

-Very unusual and debilitating -Identified as both a personality disorder and the first of the schizophrenia spectrum disorders (listed from least to most severe) -Persons have severe social and interpersonal deficits; experience extreme anxiety in social situations and contributions to conversations tend to ramble with lengthy, unclear, overly detailed, and abstract content -An additional feature is paranoia; individuals are overly suspicious and anxious; tend to misinterpret the motivations of others as being "out to get" them and blame others for their social isolation -Odd beliefs or magical thinking are also common -Psychotic symptoms may also exist, but to a lesser degree and only briefly -A major difference between this disorder and schizophrenia is that people with schizotypal personality disorder can be made aware of their misinterpretations of reality-schizophrenia results in a far stronger grip on delusions -Generally diagnosed in adulthood, although signs may appear in childhood and adolescence (being an underperformer in school and difficulty connecting with peers) -There is no specific medication for treatment, but associated conditions may be treated; low-dose antipsychotics for psychotic-like symptoms and day to day functioning may be helpful and antidepressants can be used for associated depression/anxiety -Nursing guidelines: Respect patient's need for social isolation; Be aware of patient's suspiciousness and employ appropriate interventions; Perform careful diagnostic assessment as needed to uncover any other medical or psychological symptoms that may need intervention (suicidal thoughts, etc.)

Implementation: Interventions for Communication

-When a patient is mute, make observations (ex. "There are many new pictures on the wall; You are wearing your new shoes"); Direct questions can raise anxiety-pointing to commonalities draws the patient into and reinforces reality -Use simple, concrete words: Slowed thinking and difficulty concentrating impair comprehension -Allow time for patient to respond: Slowed thinking necessitates time to formulate a response -Listen for covert messages, and ask about suicide plans: People often experience relief and decrease in feelings of isolation when they share thoughts of suicide -Avoid platitudes such as "things will look up" or "everyone gets down once in a while": These minimize the patient's feelings and can increase feelings of guilt and worthlessness because the patient is unable to "look up" or "snap out of it" -Avoid choices and false reassurances -Be careful of giving compliments or approval

Major depressive disorder

AKA Major depression -Characterized by a persistently depressed mood lasting a minimum of two weeks -Children tend to be irritable rather than depressed -It may be a single episode or recurrent (more than one) episode -The depressed mood is accompanied by a lack of interest in previously pleasurable activity (anhedonia); fatigue; sleep disturbances; changes in appetite; feelings of hopelessness or worthlessness; persistent thoughts of death or suicide; an inability to concentrate or make decisions; and a change in physical activity -The patient must have a depressed mood or anhedonia as well as at least five of the other 8 symptoms labeled above in order to establish a diagnosis -Sleep disturbances include insomnia such as trouble falling or staying asleep (terminal insomnia- in which the person awakens early- is a red flag for depression) or hypersomnia- in which the person sleeps too much (12-16 hrs/day) -Changes in appetite include either appetite/weight loss or eating more and subsequent weight gain -Physical activity changes include psychomotor retardation, slow movements with stooped posture and lowered head as well as psychomotor agitation (fidgeting, position changes, wringing of hands, pacing) -Major depression can occur just once in a patient's lifetime or it can remit and recur

Demographic Characteristics of Homeless

Domestic violence victims Those with serious mental health issues Unaccompanied youth Veterans Substance Abuse problems (39%) Persons living with HIV/AIDS 63% men; 37% women 22.1% less than 18 60% minorities

Safety Plan for Intimate Partner Abuse

All persons experiencing abuse should be counseled about developing a safety plan -This is a plan for rapid escape when abuse recurs -Patients should be asked to identify the signs of escalation of violence and to pick a particular sign that will tell them in the future that "now is the time to leave." -If children are present, they can all agree on a code word that, when spoken by the parent, means "it's time to go" -If the individual plans ahead, it may be possible to leave before the violence occurs -It is important that the plan include a destination and transportation; the nurse should suggest packing important items ahead of time and the packed bag should be kept hidden from perpetrator

Characteristics of Schizophrenia: Disturbances in Behavior

Alterations in behavior include bizarre and agitated behaviors involving stilted, rigid demeanor or eccentric dress, grooming and rituals; other behavioral changes include: -Catatonia: a pronounced decrease in the rate and amount of movement; the most common being stuporous behavior in which the person hardly moves -Motor retardation: a pronounced slowing of movement -Motor agitation: excited behavior such as running or pacing rapidly, often in response to internal or external stimuli (risk for exhaustion, collapse or death to patient or risk of harm to others) -Stereotyped behaviors: repeated motor behaviors that do not serve a logical purpose -Waxy flexibility: the extended maintenance of posture, usually seen in catatonia (patient holds arm in statue like pose) -Echopraxia: mimicking of movements of another; also seen in catatonia -Negativism: akin to resistance but may not be intentional; patient does opposite of what he has been told to do (active) or fails to do what is requested (passive) -Impaired impulse control: reduced ability to resist one's own impulses (ex throwing unwanted food on the floor; interrupting in group) -Gesturing or Posturing: assuming unusual and illogical expressions (grimaces) or positions -Boundary impairment: impaired ability to sense where one's body or influence ends and another's begins (patient might stand too close or might drink another's beverage believing that because it is close, it is his)

Delirium

An acute, cognitive disturbance and often-reversible condition that is common in hospitalized patients, especially older patients -Cardinal symptoms are: Altered Level of Consciousness with altered awareness and inability to direct, focus, sustain, and shift attention; An abrupt onset with clinical features that fluctuate (including periods of lucidity); and Disorganized Thinking and poor executive functioning; Nurse must repeat questions (attention wanders and pt. distracted by irrelevant stimuli) -Other symptoms include: disorientation (time and place); Anxiety/Agitation; Poor memory (recall); Delusional Thinking, and Hallucinations, usually visual -Patients experience delirium as a sudden change in reality with a sense that they are dreaming while awake; they experience dramatic scenes that evoke feelings of anger, fear, and panic -Delirium is considered a medical emergency that requires immediate attention to prevent irreversible and serious damage Delirium is the most common complication of hospitalization in older patients and is always due to underlying physiological causes; there are predisposing factors such as: age, lower educational level; sensory impairment; decreased functional status; comorbid medical conditions; malnutrition, and depression -Postoperative conditions, systemic disorders, withdrawal of drugs and alcohol, drug toxicity and impaired resp. functioning can be the cause -The best evidence for prevention and management is early recognition and clinical protocols for minimizing risk factors -Suspect the presence of delirium when the patient abruptly develops a disturbance in consciousness that manifests as reduced clarity of awareness of the environment -Assess for cognitive and perceptual disturbances (illusions, hallucinations, fear/anxiety); Physical needs and safety (cues in environment, short periods of interaction, self-care deficits, autonomic signs, sleep/wake cycles, level of consciousness; hypervigilance -Priorities of treatment are to keep the patient safe while attempting to correct the underlying cause; use supportive measures to relieve stress (don't argue); keep patient orientated

Pharmacologic interventions for Depression

Antidepressant drugs can positively alter poor self concept, degree of social withdrawal, vegetative signs of depression, and activity level; Target symptoms include the following: Sleep disturbance; Appetite disturbance (increased or decreased); Fatigue; Decreased sex drive; Psychomotor retardation or agitation; Diurnal variations in mood (often worse in the morning); Impaired concentration or forgetfulness; Anhedonia -A drawback of antidepressants is that improvement in mood may take 1-3 weeks or longer; If a patient is acutely suicidal, ECT can be a reliable and effective alternative for some -The goal of antidepressant therapy is the complete remission of symptoms; Often, the first antidepressant prescribed is not the one that will ultimately bring about remission; aggressive treatment helps in efficiently finding the proper treatment; An antidepressant adequate trial for the treatment of depression is 3 months -Individuals experiencing their first depressive episode are maintained on antidepressants for 6-9 months after symptoms remit; Some people may have multiple episodes of depression or have a chronic form and benefit from indefinite therapy

Theories that explain Men's Health

Biological: males' experience of higher mortality rates for perinatal conditions is attributed to biological disadvantages such as males' greater risk of premature birth, higher rates of respiratory distress syndrome, and infectious disease in infancy resulting from the influence of male hormones on the developing lungs, brain and immune system; biological advantages for females may exist later in life because of estrogen-related mechanism that protects against heart disease; during the process of aging, Men's' brain cells die faster than women's brain cells; male immune systems are much weaker than women's Socialization: Society emphasizes assertiveness, restricted emotional display, concern for power, and reckless behavior in males; pursuit of these attributes results in higher risks in work, leisure, and lifestyle; engaging in health promotion may be viewed as a sign of weakness; popular male sports and play activities place men at high risk for injury; men drive faster and are less likely to wear seatbelts; men are five times more likely than women to drink heavily and have an overall greater use of substances ; men are more likely to be involved in violent crime; and have higher occupational injuries and hazards (carcinogens, injuries, hostility leading to heart disease) Illness Orientation: stereotypical view of men as strong and invulnerable is incongruent with health care promotion; boys are taught to "toughen up" and ignore symptoms; they may make a conscious effort to avoid getting treatment and being labeled as "sick"; men do not have routine reproductive health checkups like women which would detect problems at an early stage

Dementia

Broad term used to describe progressive deterioration of cognitive functioning and global impairment of intellect with no change in consciousness -It is not a specific disease but rather a collection of symptoms that are due to an underlying brain disorder -These disorders are characterized by cognitive impairments that signal a decline from previous functioning -When progressive, these disorders interfere with daily functioning and independence -While often characterized by memory deficits, dementia affects other areas of cognitive functioning, for example, problem solving and complex attention -Alzheimer's disease is the most common type of dementia; it is important to distinguish between normal forgetfulness and the memory deficit of Alzheimer's; Severe memory loss is not a normal part of growing older; memory loss that interferes with one's ADLs is cause for concern

Context vs. Composition in Rural Health

Context= defined by the characteristics of places of residence (Geography, Environment, Political, Social, and Economic Institutions) Composition= the collective health effects that result from a concentration of persons with certain characteristics (Age, Education, Income, Ethnicity, Health Behaviors) -Most public health problems include elements of both context and composition though they may be predominantly one or the other -Health Disparities Related to Place (Context): many rural regions that are already sparsely populated are losing residents, a process that often triggers a downward spiral; people leave and services are lost; the drugstore closes and the tax base will not support an ambulance service, so most seriously ill people must travel far distances to get care; jobs become sparse and people leave the area; retirees are attracted to lower costs but have no services; racial and ethnic minorities migrate to find employment -Health Disparities Related to Person (Composition): Poverty rates for rural people have always been higher than urban dwellers; There are variations in amount of poverty by Region; persistent poverty is highest in the south and lowest in the northeast and Midwest; Poverty among rural ethnic minorities are two to three times higher than rural whites; families with two or more adults are less likely to be poor (multiple sources of income); Female-headed (single mother) families have higher poverty rates due to lower labor force participation, shorter work weeks, and lower earnings; Children are particularly vulnerable to outcomes of poverty and among the poorest citizens in rural America; when race and ethnicity are taken into account, the poverty profile of children worsens dramatically; Low education and employment levels characterize all rural minority groups except Asians; skill requirements for rural employment continue to rise while low educational attainment is a challenge; lack of education is correlated with persistent poverty and poverty is a predictor of poor health

Teamwork and Safety with Schizophrenia

Effective care provides: 1) protection from undue stress 2) structure-a planned routine and external limits that create a sense of security -This therapeutic structure promotes a faster recovery than would occur in an unstructured setting such as one's residence -Hospital alternatives such as crisis centers also provide a structured milieu in a less restrictive setting (this provides a physical and social environment that maximizes safety, learning opportunities, and practicing skills such as conflict resolution) -Participation in activities and groups may decrease withdrawal, enhance motivation and modify behaviors; drawing, reading, poetry, etc. focus conversations and promote recognition and expression of feelings; self esteem is enhanced and skills are learned through recreational activities -A small percentage of patients with schizophrenia (esp during the acute phase) may exhibit a risk for physical violence typically in response to positive symptoms; when the potential for violence exists, measures to protect the patient and others becomes the priority; interventions include reducing stimuli, addressing paranoia, providing diversion and outlets for physical energy, teaching and practicing coping skills, using cognitive-behavioral therapy, verbal de-escalation, and using restraint when necessary; Suicide risk should always be assessed and addressed

Lithium

Effective in the treatment of Bipolar I acute and recurrent manic and depressive episodes -Lithium inhibits about 80% of acute manic and hypomanic episodes within 10-21 days -Lithium is less effective in people with mixed mania, those with rapid cycling, and those with atypical features -Lithium must reach therapeutic levels to be effective; this usually takes 7-14 days -Lithium is not a cure; many patients receive lithium for maintenance indefinitely and experience mania/depression if they discontinue the drug -Expected side effects include: fine hand tremor, polyuria, and mild thirst, mild nausea and general discomfort, weight gain -Particularly effective in reducing the following: -Elation, grandiosity and expansiveness -Flight of ideas -Irritability and manipulation -Anxiety -To a lesser extent, lithium controls the following: -Insomnia -Psychomotor agitation -Threatening or assaultive behavior -Distractibility -Hypersexuality -Paranoia

Atypical Antidepressants

Effexor: main Side effect is abnormal ejaculation and orgasm; hypertension Fetzima: newer SNRI used for major depressive disorder Wellbutrin: blocks reuptake of norepi and dopamine; lowers seizure threshold; does not impact libido; can be used for smoking cessation Trazodone: second line agent; usually used in combo with another drug; very sedative; may cause priapism Remeron: used for anxiety and depression Pristiq and Cymbalta: SNRI (newer meds)

Implementation: Health Teaching and Promotion

Health teaching is paramount because it allows patients to make informed choices; It is also an avenue for providing hope to the patient The patient should be informed that: -Depression is an illness beyond their control -It can be managed with medication and lifestyle change -Chronic illness depends on understanding personal signs and symptoms -Management of the illness depends on understanding prescribed meds and their side effects -Long-term management is best assured if the patient undergoes psychotherapy in conjunction with medication -Identifying and coping with the stress of relationships is key to illness management Families should also be included in discharge planning; Benefits include: -The family's understanding and acceptance is increased -The patient's use of aftercare facilities in the community is increased -Overall adjustment in the patient after discharge is better

Health Status of Homeless Women

Higher rates of pregnancy (including unintended pregnancy) and higher preterm birthrates and low birth weight infants -History of violence from childhood to adulthood; high risk for victimization when living on the street as well as having multiple sex partners and less likely to use health services -Report more stressful life events, foster care as children, IPV as adults, hospitalization for psychiatric problems than men -Women with children are more likely to use shelters and less likely to sleep on the streets -Homeless women veterans report hx of military sexual trauma -Women prefer care from shelter and outreach clinics designed specifically to meet their needs rather than from county/govmt. clinics -Social support affects women's physical and mental well being and ability to access health services -Promoting lasting change means meeting health needs and embedding community programs; Assume that support is needed for the long term -Homeless women do not differ from the problems that impede many women in the US, although their problems are likely to be more intense, frequent, and apt to occur in concert; Often homeless women have limited education, earning power, and fragmented support

Homelessness

Housing and Urban Development (HUD) summarizes statutory definitions of homelessness in four descriptive categories as follows: 1) Literally homeless: Individuals and families who lack a fixed, regular, and adequate nighttime residence and includes a subset for an individual who resided in an emergency shelter or a place not meant for human habitation and who is exiting an institution where he or she temporarily resided 2)Imminent Risk of Homelessness: Individuals and families who will imminently lose their primary nighttime residence 3) Homeless under other Federal statutes: Unaccompanied youth and families with children and youth who are defined as homeless under other federal statutes who do not otherwise qualify as homeless under this definition 4) Feeling/Attempting to Flee Domestic Violence: Individuals and families who are fleeing or attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous, life threatening conditions that relate to violence against the individual or a family member -May be temporarily homeless (due to catastrophe) -Can be episodic due to financial difficulties -Hidden homeless: those that stay with family members at times (couch surfers); can be immigrants, runaways, or unemployed

Critical incident debriefing

Immediately after a seclusion or restraint episode, the staff must debrief with one another -Staff analysis of the episode of violence is crucial for a number of reasons -First, a review is necessary to ensure that quality care was provided to the patient -Staff needs to critically examine their response to the patient; questions should include: -Could we have done anything to prevent the violence? If yes, why wasn't it done -Did we respond as a team? Were team members acting according to policies and procedures of the unit? If not, why? -How do staff members feel about this patient and/or about this situation? Feelings of fear/anger are discussed and handled -Employee morale, productivity, use of sick time leave, transfer requests and absenteeism are all affected by patient violence, especially if a staff member has been injured; staff members must feel supported by their peers as well as by the organizational policies to maintain a safe environment -Is there a need for additional staff education regarding how to handle violent patients? -How did the actual restraining process go? What could have been done differently? Do not focus only on whether staff members were acting like a team -If injury occurred, has it been reported and cared for? It has been shown that there is vast underreporting of violence of health care staff

Schizophrenia Interventions: Phase I

Interventions are geared toward the phase of the disorder -During the acute phase, the clinical focus is on crisis intervention, medication for symptom stabilization, and safety -Interventions are often hospital based; however, to reduce cost and provide treatment in the least restrictive setting, many patients in the acute stage are increasingly being treated in the community -Phase I: Acute; Interventions include: -Psychiatric, medical, and neurological evaluation -Psychopharmacology -Support, psychoeducation, and guidance -Supervision and structure in a therapeutic environment (milieu) -Monitoring fluid intake -The length of hospitalization during the acute phase is often short (days), ending when acute symptoms have been stabilized; this does not necessarily take into account the extended time needed for recovery from serious mental illness, making continued outpatient care all the more important after discharge -Community based services provide such care during the stabilization and maintenance phases

Characteristics of Schizophrenia: Disturbances in Perception

Involves errors in how one perceives reality; hallucinations are the most common form of altered perception; other alterations include the following: -Depersonalization: a feeling that one is somehow different or unreal or has lost his identity; people may feel that parts do not belong to them or that their body has drastically changed (ex. a patient may see her fingers as being smaller or more distant or not her own) -Derealization: a false perception that the environment has changed; everything seems bigger or smaller or familiar surroundings suddenly seem strange or unfamiliar -Hallucinations involve perceiving a sensory experience for which no external stimulus exists (ex. hearing a voice when no one is talking); hallucinations differ from illusions (misperceptions or misinterpretations of a real experience); for example, a man sees a coat on a shadowy coat rack and believes it is a bear- he sees something real but misinterprets what it is -Types of hallucinations include the following: auditory (hearing voices or sounds); visual (seeing persons or things); olfactory (smelling odors that aren't present); gustatory (experiencing tastes); tactile (feeling bodily sensations) -Auditory hallucinations are present in 60% of people with schizophrenia at some time during their lives; they may be vague sounds or indistinct or clear "voices"; voices typically seem to come from outside the person's head and auditory processing areas of the brain are activated during auditory hallucinations just as they are when a genuine noise is heard; voices may be familiar or unknown, single or multiple, supportive and pleasant or frightening; voices commenting on the person's behavior or conversing with the person are most common; competing with the auditory hallucinations (listening to loud music or talking loudly) may reduce them and are a recommended intervention -Command hallucinations direct the person to take an action; All hallucinations must be assessed and monitored carefully because the voices may command the person to do something harmful or destructive to themselves or others; they are often terrifying and may herald a psychiatric emergency; it is essential to assess what the patient hears and his ability to recognize the hallucination as not real and his ability to resist any commands; patients may require observation to determine if they are hearing voices but denying them (turning head to listen, suddenly stopping activity as if interrupted, talking to oneself or moving lips silently) -Visual hallucinations occur less frequently and are more likely to occur in organic disorders such as acute alcohol withdrawal or dementia; olfactory, tactile, or gustatory hallucinations are unusual; when present, other causes should be investigated

Bipolar Outcomes: Continuation Phase

Lasts for 4-9 months -Although the overall outcome of this phase is relapse prevention, many other outcomes must be accomplished to achieve relapse prevention; these include: -Knowledge of disease process and medications -Consequences of substance addictions for predicting future relapse -Knowledge of early signs and symptoms of relapse -Support groups or therapy (cognitive-behavioral; interpersonal) -Communication and problem-solving skills training -Client and family participation in psychoeducation classes

Negative symptoms of Schizophrenia

Negative symptoms develop slowly and are those that most interfere with a person's adjustment and ability to cope; these symptoms tend to be more persistent and crippling than positive symptoms because they reduce motivation and limit success -Negative symptoms impede one's ability to do the following: -Initiate and maintain conversations, relationships and employment -Make decisions and follow through with plans -Maintain adequate hygiene and grooming Negative symptoms contribute to poor social functioning and social withdrawal; they are difficult to assess during the acute phase because positive symptoms usually dominate Symptoms include: -Flat affect (immobile or blank expression) -Blunted affect (reduced or minimal emotional response) -Inappropriate affect (incongruent with actual state or situation; patient may laugh when peer threatens him) -Bizarre affect (odd, illogical, grossly inappropriate, or unfounded; includes giggling or grimacing) -Anergia: lack of energy; passivity; lack of persistence -Anhedonia: inability to experience pleasure -Avolition: reduced motivation; inability to initiate tasks such as grooming or other ADLs -Poverty of content of speech: speech is vague and conveys little info -Poverty of speech: reduced amount and spontaneity of speech -Thought blocking: sudden interruption of speech

Implementation: Vegetative signs of depression

Nutrition: Is of utmost importance; Offer small, high-calorie, high-protein snacks frequently throughout the day and evening- low weight and poor nutrition render the patient susceptible to illness; small, frequent snacks are better tolerated than large plates of food when the patient is anorexic Offer high protein and high calorie fluids frequently- these fluids prevent dehydration and can minimize constipation When possible, encourage family or friends to remain with the patient during meals; Ask the patient which foods he or she likes; offer choices and involve the dietician Weigh the patient weekly and observe eating patterns Sleep: 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 (tepid bath/ warm milk); Reduce environmental and physical stimulants in the evening-provide decaf coffee, soft lights, soft music, and quiet activities Elimination: Monitor intake and output- many depressed patients are constipated; if the condition is not checked, fecal impaction can occur; Offer foods high in fiber and provide periods of exercise-roughage and exercise stimulate peristalsis; Encourage fluids and evaluate need for laxatives and enemas Self Care deficits: Physical neglect in the depressed patient may be apparent -Nursing measures for improving physical well being and promoting adequate self care should be initiated -Nurses in the community can work with family members to encourage the patient to perform self-care activities -Nurses/family members should encourage the use of toothbrush, washcloth, soap, makeup, shaving equipment, etc.-this can help improve the patient's self-esteem -When appropriate, step-by-step reminders should be given ("wash this side of your face, now wash this side") due to slowed thinking and difficulty concentrating

Dysthymia

Occurs when feelings of depression persist consistently for at least two years -Insidious onset and characterized by chronic depressive symptoms -Symptoms are difficult for the patient to live with and bring about social and occupational distress, yet not usually severe enough to bring about hospitalization -Patients often express that they have "always felt this way" and being depressed seems like a normal way of functioning -Not uncommon for people with this low-level depression to also have periods of full-blown major depressive episodes

Bipolar Outcomes: Maintenance Phase

Overall outcomes continue to focus on relapse prevention and limitation of the severity and duration of future episodes -Participation in learning interpersonal strategies related to work, interpersonal, and family problems -Participation in psychotherapy, group, or other ongoing supportive therapy modality

Implementation: Teamwork and Safety

Safety is a primary concern for all patient situations, but it becomes the most important issue facing the 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 razors, scissors, and nail files; strangulation risks such as belts; and medications that can be used for 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

SSRIs

Selective Serotonin Reuptake Inhibitors -First line therapy for most types of depression -Block neuronal uptake of serotonin which increases availability of serotonin in the synaptic cleft -Have a relatively low side-effect profile compared with tricyclics (older antidepressants) -Do not create anticholinergic effects -Consistent adherence to the medication regimen is a crucial step toward recovery or remission of symptoms -Less dangerous when taken in an overdose (unlike tricyclics which have a high lethality risk in suicide attempts) -Also treat anxiety disorders such as OCD and panic disorder -Adverse reactions include: agitation, anxiety, sleep disturbance, tremor, sexual dysfunction (most common), tension headache, dry mouth, sweating, weight change, nausea, loose bowel movements -Serotonin syndrome is a rare but life-threatening side effect (most common when administered with another serotonin-enhancing agent such as an MAOI); symptoms include: abdominal pain, diarrhea, sweating, fever, tachycardia, HTN, altered mental state (delirium), muscle spasms, irritability, hostility, and mood change; severe manifestations include: hyperpyrexia (extremely high fever), cardiovascular shock, or death -Ex. Celexa, Prozac, Luvox, Paxil, Zoloft, Lexapro

Stages of Alzheimer's

Stage 1: No impairment; no memory problems Stage 2: Very mild cognitive decline; aware of memory lapses; forgetting familiar words; cannot be detected by others Stage 3: Mild cognitive decline; can be diagnosed in some, but not all patients; noticeable problems with memory and difficulty performing tasks; forgetting what was just read; losing valuables; increasing trouble with planning Stage 4: Moderate cognitive decline: mild or early-stage Alzheimer's; impaired ability to perform arithmetic; difficulty planning dinner, paying bills or managing finances; becoming moody or withdrawn Stage 5: Moderately severe cognitive decline (moderate or midstage Alzheimer's); Gaps in memory are noticeable; individuals begin to need day-to-day help; may be unable to recall own telephone numbers or addresses; become confused about where they are/what day it is; still remember significant details about self and others; still require no assistance with eating or using the toilet Stage 6: Severe cognitive decline; Personality changes may take place; individuals may lose awareness of recent experiences/their surroundings; remember own name but have difficulty with personal histories; can distinguish faces but have trouble remembering name of spouse or caregiver; need help dressing/toileting; becoming increasingly incontinent; major changes in sleep; major behavioral changes (paranoia, delusional, repetitive); tend to wander and become lost Stage 7: very severe cognitive decline; late stage Alzheimer's; lose ability to respond to environment, carry a conversation, and eventually to control movement; may still say words or phrases; at this stage, individuals need help with daily personal care including eating and using toilet; lose ability to smile, sit without support or hold head up; reflexes become abnormal and swallowing impaired

Bipolar Outcomes: Acute Phase

The primary outcome of the acute phase is injury prevention; outcomes in the acute phase reflect both physiological and psychiatric issues; For example, the patient will: -Be well hydrated -Maintain stable cardiac status -Maintain/obtain tissue integrity -Get sufficient sleep and rest -Demonstrate thought self-control -Make no attempt at self harm -Be free of injury -Report absence of delusions, racing thoughts, and irresponsible behavior -Demonstrate absence of destructive behavior and sexual activity -Provide outlets for physical activity that are appropriate (walking is good)

Therapeutic Communication for Schizophrenia

Therapeutic communication aims to lower the patient's anxiety, build trust, encourage interaction and build self esteem; It is important to remember that those with schizophrenia may have memory and cognitive impairment and think concretely; Communication and education should take this into consideration by using concrete examples and limiting interactions to less than 30 minutes (shorter but more frequent interactions may be better than longer, less frequent interactions) -Hallucinations: when a pt. is hallucinating, the nurse focuses on understanding the patient's experience and assessing for safety; hallucinations can be distracting during interactions- call patient by name, speak simply and loudly enough to be heard over the hallucinations, be non-threatening and supportive, maintain eye-contact and redirect patient's focus to your conversations; ask patient directly about the hallucination ("what are you hearing?"); avoid referring to hallucinations as if they are real; do not negate the patient's experience; focus on reality-based, "here and now" conversation ("the voice is a part of your illness, try to listen to me instead"); encourage use of competing auditory stimuli; address underlying emotions -Delusions: Impaired reality testing prevents self-correction when one misperceives his circumstances; the nurse should acknowledge the patient's experience, convey empathy about the fearfulness, avoid questioning the content of the delusion, and label the patient's feelings so they can be explored; talking about feelings is helpful, but extended focus on delusional material is not; it is NEVER useful to debate or attempt to dissuade the patient from the delusion- this can intensify irrational beliefs and cause the patient to view you as a threat; it IS helpful, however, to clarify misinterpretations gently; focusing on reality based activities helps minimize the focus on delusions; focus on the theme or feelings that underlie the delusion ("you seem to wish you could be more powerful"); validate the part of the delusion that is real ("yes, there is someone at the nurses station, but i did not hear him talk about you"); observe for delusion triggers; guide the patient to question his beliefs ("I wonder if there might be another reason why others might be avoiding you- instead of hating you, perhaps they are busy?") -Associative Looseness: Do NOT pretend to understand the patient when you don't; supportively state that you do not understand; Place the difficulty in understanding on yourself, not the patient ("I'm having trouble following what you're saying"); Tell the patient what you DO understand and reinforce clear communication and accurate expression of needs, feelings and thoughts; Look for recurring topics and themes in the patient's communications and tie these to events and timelines ("you've mentioned your brother several times-tell me about your visits with him"); Summarize or paraphrase the patient's communications to role-model clearer communication and give the patient a chance to correct anything that was misunderstood; Reduce stimuli and speak clearly and concretely in sentences rather than paragraphs

Factors Contributing to Homelessness

Three broad factors singly and interactively contribute to homelessness: Shortage of affordable housing; Insufficient income to meet basic needs; Inadequate and scarce support services -Housing is considered affordable if it costs a renter/owner no more than 30% of her income; Demand for low income housing far exceeds the supply -Insufficient incomes and lack of employment prevent people from leaving homelessness; a consequence of the shortage of affordable housing and insufficient income is an increasing number of low income people end up paying much more than they can afford for rent, leaving them without adequate resources such as food, clothing, and health care -Inadequacy and Scarcity of supportive services is a problem for people whose serious chronic mental health and/or substance abuse problems preclude their functioning in the workforce and whose behaviors frequently interfere with their ability to obtain housing stability; people in this group need income assistance and comprehensive behavioral and physical health care -Physical abuse or neglect, Inadequate support networks, Mental illness, Substance abuse, Changes in the labor market and Deinstitutionalization of the mentally ill are also contributing factors

Implementation: The Three Treatment Phases

Three phases in treatment and recovery from major depression include: the acute phase, continuation phase, and maintenance phase -The acute phase (6-12 weeks) is directed at *reduction of symptoms* and restoration of psychosocial and work function; *Hospitalization may be required*, and medication or other biological treatments may be initiated -The continuation phase (4-9 months) is directed at *prevention of relapse* through pharmacotherapy, education, and depression-specific psychotherapy -The maintenance phase (1 year or more) is directed at *prevention of further episodes of depression*; Depending on risk factors for relapse, medication may be phased out or continued -Both the continuation and maintenance phases are geared toward maintaining the patient as a functional and contributing member of the community after recovery from the acute phase

Normal Aging versus Dementia

Typical Age related changes Vs. Signs of Alzheimer's: -Making a bad decision once in a while vs. Poor judgment and decision making -Missing a monthly payment Vs. Inability to manage a budget -Forgetting which day it is and remembering later Vs. Losing track of the date or season -Sometimes forgetting which word to use Vs. Difficulty having a conversation -Losing things from time to time Vs. Misplacing things and being unable to retrace steps to find them

Electroconvulsive Therapy (ECT)

Used most commonly for depression -Useful in treating patients with major depression especially when psychotic symptoms are present -Clinical trials of ECT report a rate of 70-90% remission -Suicidal thoughts respond to ECT in 80% of cases -While medication is generally the first line of treatment for ease of use, ECT may be a primary treatment in the following cases: When a pt. is suicidal or homicidal and there is a need for rapid, definitive response If previous med trials have failed When there is marked agitation, marked vegetative symptoms, or catatonia For major depression with psychotic features or for pervasive hallucinations -Also indicated for manic patients whose conditions are resistant to treatment with lithium and drugs and for "rapid cyclers" (many episodes of mood swings close together- 4 or more in a year), schizophrenia, psychotic, and Parkinson's patients -ECT is not necessarily effective in patients with dysphoric disorder, unconventional depression, personality disorders, drug dependence, or depression secondary to situational or social difficulties -Usual course is 2-3 treatments/week for a total of 6-12 treatments -Provides temporary relief, but is not a cure -Short term memory loss is major side effect -There are no absolute contraindications for ECT if it is deemed necessary to save a patient's life -There are some medical conditions that place clients at higher risk including: Recent MI, Hx of CVA, Intracranial mass/lesion, IICP, Cerebrovascular malformation