MH final exam

ND for schizophrenia

**Disturbed sensory perception: auditory/visual R/T panic anxiety, extreme lonliness, and withdrawn to into self AEB inappropriate responses, disordered thought sequencing, rapid mood swings, poor concentration, disorientation** S&S: -auditory -verbalizes hearing voices -listening pose >impaired communication, disordered thought sequencing, rapid mood swings, poor concentration, disorientation, stops talking in midsentence, titls head to side as if to be listening Goals for treating disturbed sensory perception include discussing hallucinations, helping the client define and test reality, and verbalizing an understanding that the hallucinations are a result of the client's illness. -ST goals: client discusses content of hallucinations with nurse or therapists in one week *early intervention may prevent aggressive response to command hallucination -LT goals: client is able to define and test reality Intervention: avoid touching the client without warning him or her that you are about to do so *client may percieve touch as threatenig and may respond in an aggressive manner such as asking "what do you hear the voices saying to you?" INTERVENTION: An attitude of acceptancethis question is important to prevent possible injury to the client or others from commant hallucinations >INTERVENTIONS: DO NOT REINFORCE HALLUCINATION!!!! Use the voices instead of they *it is important the nurse to be honest and client must accept the perception as unreal >HELP THE CLEINT UNDERSTAND CONNECTION BETWEEN ANXIETY AND THE PRESENCE OF HALLUCINATIONS *if the client can learn to interrup excalating anxiety, hallucinations may be prevented! >TRY TO DISTRACT CLIENT FROM HALLUCINATION *explanation of actual hallucination >TURN ON RADIO OR TV TO HELP DISTRACT A CLIENT HAVING AUDITORY HALLUCINATIONS OR TEACH ABOUT VOICE DISMISSAL WITH THE TECHNIQUE OF HAVING THE CLIENT SHOUT "GO AWAY" TO DISMISS AUDITORY PERCEPTION! Interventions to achieve these goals include an attitude of acceptance, distracting the client from the hallucinations, and avoiding reinforcement of the hallucinations!!!!!!

ND for ECT

*Anxiety r/t impending therapy *Deficient knowledge R/T necessity for and side effect of ECT *Risk for injury r/t risks associated with ECT *Risk for aspiration R/T altered LOC immediately follwoing procedure *Decreased cardiac output R/T vagal stimulation occuring during ECT *monitor for any signs of bradycardia** *Impaired memory/acute confusion R/T SE of ECT *risk for activity intolerance r/t post ECT confusion and memory loss

Mood-Stabilizing Agents Planning and implementing care

*Clients who respond to lithium typically remain on the medication indefinitely. As such, one of the primary safety issues with lithium is its narrow therapeutic range. It is important to monitor serum lithium levels to assure they are within the therapeutic range.***** -For acute mania: 1.0 to 1.5 mEq/L -For maintenance: 0.6 to 1.2 mEq/L ~Lithium toxicity 1. Early signs - vomiting, diarrhea 2. Over 2mEq/L - tremors, sedation, confusion 3. Over 3.5 mEq/L - delirium, seizures, coma, cardiovascular collapse, death NURSING INTERVENTION: -instruct clien to report all medication, herbals, and caffeine use to physician -enourage client to maintain fluid intake at 2,000-3,000 mL/day & avoid activities in which excessive sweating and fluid loss are a risk since inadequate fluid intake can impact lithium levels -BLOOD LEVELS SHOULD BE DRAWN 12 HOURS AFTER THE LAST DOSE Another generally undesirable side effect of lithium is weight gain. -Hyponatremia (lithium) *Ensure that client consumes adequate sodium and fluid in diet. *assess for any episodes in nausea, vomiting, ha, muscle weakness, confusion, seizures, since these may be signs of hypoantremia STEVENS-JOHNSONS SYNDROME -toxic skin necrolysis can be life threatening -assess for and educate clients to report any signs of rash or unusal skin breakdown HYPOTENSION. ARRYTHMIAS (lithium) -moinotr vital signs and instuct client to report any symptoms of dizziness or palpitations BLOOD DYSCRASIAS (valproic acid, carbamezpine) educate pt to report infection or other illness DROWSINESS *The U.S. Food and Drug Administration requires that all antiepileptic (anticonvulsant) drugs carry a warning label indicating that use of the drugs increases risk for suicidal thoughts and behaviors. Patients treated with these medications should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior.****

Nontherapeutic Communication Techniques

*Giving advice -telling the client what to do or how to behave implies the nurse knows what is best for the client ex) dont say i think you should... instead say "what do you think you should do?" *Probing -persistent questioning of the client and pushing for answers to issues the client does not wish to discuss causes the client to feel used *defending ex) "no one here would lie to you" "you have a very capable physician" *requesting an explanation -asking client to provide the reasons for thoughts, feelings, behavior, and events -asking "why: a client did something or feels a certain way *giving reassurance ex) i wouldnt worry about that if i were you "everything will be alright" *rejecting *approving or disapproving -sanctioning or denouncing the client's ideas or behavior implies that the nurse has the right to pass judgment on whatever the client's ideas or behaviors are "good" or "bad" *agreeing or disagreeing -indicating accord with or opposition to the client's ideas or opinions implies that the nurse has the right to pass judgment on whether the clients ideas are right or wrong *interpreting -the nurse should avoid to make conscious what which is unconscious *introducing an unrelated topic *indicating the existence of an external source of power *belittling feelings expressed *making stereotyped comments ex) im fine, and how are you? *using denial -denying that a problem exists blocks discussion with the client and precludes helping the client identify and explore areas of difficulty ex) C: "I'm nothing" N: "of course you're something" better to say: "you're feeling like no one cares about you right now

Drugs interaction with TCAs

*MAOIs= high fever, convuslions and death *St. John's wort= seizures, seratonin syndrome *Clonidine, epinephrine= severe HTN *Actylecholine blockers= paralytic ilues *aLCOHOL & CARBAMAZEPINE (mood stabilizers)= block antidepressant action, increase sedation *cimetidine & bupropion (other atypical antidepressants)= increase TCA blood levels and increase SE

Pharmacological Intervention for ASD

*Pharmacological interventions are directed toward relief of targeted irritability symptoms such as aggression, hyperactivity, self-harm, impulsivity, and temper tantrums Two medications approved by the FDA -Risperidone (antipsychotic) AE: sedation, fatigue, weight gain, vomitting, somnolence (sleepiness), and tremor -Aripiprazole (antipsychotic)

Ineffective coping

*ritualistic behavior; obsessive thoughts, inability to meet basic needs to perform rituals (OCD) Defined as the inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources ST goal: within 1 week, the client will decrease participation in ritualistic behavior by half LT goal: by time of discharge from tx, the client will demonstrate the ability to cope effectively w/t resorting to obsessive-compulsive behaviors or increased dependency Interventions: -work with the client to determine the types of situations that increase anxiety and results in ritualistic behavior -Initially meet the client's dependency needs, encourage independence and and give positive reinforcement -in beginning of tx, allow plenty of time for rituals, to deny or disapprove may precipitate panic level of anxiety -explore the meaning and purpose of the behavior -Provide a structured schedule of activities, including adequate time for completion of rituals. THE ANXIOUS INDIVIDUAL NEEDS NEEDS A GREAT DEAL OF STRUCTURE -Gradually limit the amount of time allotted for ritualistic behaviors and the client becomes more involved in other activities -help client learn ways to interrupt compulsive and obseessive thoughts such as thought-stopping and relaxation techniques, physical exercises

Therapeutic Communication Techniques

*using silence ex) the client pauses midsentence in answering a question. The nurse remains quiet, does not "rescue" the client *Accepting -conveys and attitude of reception and regard. Eye contact & nodding ex) "yes i understand what you said" *Giving recognition ex) "Hello, Mr. J I notice that you made a ceramic ash tray in OT" *offering self EX) "ill stay with you awhile" *giving broad opening ex) "what would you like to talk about today?" *offering general leads *placing the event in time or sequence ex) "what seemed to lead up to..?" *making observations -verbalizing what is observed encourages the client to recognize specific behaviors and COMPARE perceptions with the nurse ex) "you seem tense" "i notice you are pacing a lot" "you seem uncomfortable when you" *encouraging the description of perceptions -asking the client to verbalize what is perceived is often used with clients experiencing hallucinations. ex) tell me what is happening, are you hearing the voices again, what do the voices seem to be saying? *encouraging comparison -asking the client to compare similarities & diff helps client recognize life experiences that tend to recur ex) "was this something like..?, how does this compare with the time when?, was your response the last time this situation occurred?" *restating -repeating the main idea of what the client has said lets the client know the idea has been understood ex) "I can't study. my mind keeps wandering" nurse: "you have trouble concentrating" "i cant take that new job" nurse "you're afraid you will fail in this new position" *reflecting -questions and feelings are referred back to the client so that they may be recognized and accepted -A GOOD TECHNIQUE TO USE WHEN THE CLIENT ASKS NURSE FOR ADVICE ex) what do you think i should do about my wife drinking problem? nurse "what do you think you should do?" *focusing *exploring -delving further into a subject for clients who choose to remain on superficial level **if client chooses to no disclose then nurse SHOULD REFRAIN from pushing *seeking clarification and validation *presenting reality ex) "i understand that the voices seem real to you but i do not hear any voices" *voicing doubt -expressing uncertainty as to the reality of the client's perception is a technique often used with clients experiencing delusional thinking . ex) "that seems rather doubtful to me" *verbalizing the implied ex) cl "it is a waste of time to be here. I can't talk to you or anyone" nurse " are you feeling that no one understands" *attempting to translate words in feelings -when feelings expressed indirectly, the nurse will desymbolize or investigate what has been said ex) cl "im way out into the ocean" nurse "you must be feeling very lonely right now" *formulating a plan of action -when client has a plant for dealing when what is considered to be stressful situation, having a plan in mind might de-escalate any unmanageable level rx) "what could you do to let your anger out harmlessly"

Predisposing factors-eating disorders

-A hereditary predisposition to eating disorders has been hypothesized. -Anorexia nervosa is more common among sisters and mothers of those with the disorder than it is among the general population. -Possible chromosomal linkage sites have been suggested. -There has been some speculation about a primary hypothalamic dysfunction in anorexia nervosa.

Predisposing Factors to ASD

-Abnormalities in brain structure or function -Familial association -Chromosomal involvement 3. Prenatal and perinatal influences -Maternal asthma or allergies

Mild depression

-Affective: Anger, anxiety -Behavioral: Tearful, regression -Cognitive: Preoccupied with loss -Physiological: anorexia, insomnia "Normal grief response"

Foods containing tyramine

-Aged cheeses -Raisins, fava beans -Red wines -Liqueurs -Smoke and processed meats - salami, bologna, peperoni, summer sausage -Caviar, pickled herring, corned beef, beef or chicken liver -Soy sauce, brewer's yeast, MSG and sauerkraut May eat occasionally - moderate tyramine content -Gouda cheese, processed American cheese, mozzarella -Yogurt, sour cream -Avocados, bananas -Beer, white wine, coffee, colas, tea, hot chocolate, Meat extracts - bouillon -Chocolate Low tyramine content - May eat limited quantities - permissible while on MAOI therapy 1. Pasteurized cheese - cream, cottage and ricotta 2. Figs 3. distilled spirits (in moderation)

Antipsychotics side effects

-Anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention, tachycardia) -Nausea; gastrointestinal upset -Skin rash -Sedation -Orthostatic hypotension -Photosensitivity -Hormonal effects -Electrocardiogram changes -Hypersalivation -Weight gain -Hyperglycemia/diabetes -Increased risk of mortality in elderly clients with dementia -Reduction in seizure threshold -Agranulocytosis -Extrapyramidal symptoms -Tardive dyskinesia (causes stiff, jerky movements of your face and body that you can't control) -Neuroleptic malignant syndrome *very high fever (102 to 104 degrees F), irregular pulse, accelerated heartbeat (tachycardia), increased rate of respiration (tachypnea), muscle rigidity, altered mental status, autonomic nervous system dysfunction resulting in high or low blood pressure

The Nursing Process: Antipsychotics

-Antipsychotic medications are also called neuroleptics. -The primary benefit over time is the alleviation of psychotic symptoms, such as hallucinations and delusions. -EPS seen after 5-10 days, occur more commonly in elderly patients Indications -Antipsychotics are used for the treatment of schizophrenia and other psychotic disorders. -Selected agents are used in the treatment of bipolar mania. -Others are used as antiemetics, in the treatment of intractable hiccoughs, and for the control of tics and vocal utterances in Tourette's disorder. Contraindications/precautions 1. Typical antipsychotics phenothiazines haloperidol loxapine pimozide *thiothizine -Clients with known hypersensitivity -Not to be used in comatose states or when CNS depression is evident; when blood dyscrasias exist; in clients with Parkinson's disease or narrow -angle glaucoma; for those with liver, renal, or cardiac insufficiency; in individuals with poorly controlled seizure disorders; or in elderly clients with dementia -related psychosis -Caution taken with clients who are elderly, severely ill, or debilitated, and to diabetic clients or clients with respiratory insufficiency, prostatic hypertrophy, or intestinal obstruction -interfere with normal movts, dystonia (muscle spasms), tardive dyskinesia (later-onset involunatry movt), parkinson like symptoms 2. Atypical antipsychotics apriprorazle asenapine clozapine olanzapine lurasidone ziprasidone brexpriprazole -Contraindicated in hypersensitive, comatose, or severely depressed patients; elderly patients with dementia -related psychosis; certain medications are contraindicated in patients with a history of QT prolongation or other heart issues -Caution with elderly or debilitated patients; patients with cardiac, hepatic, or renal insufficiency; those with a history of seizures; patients with diabetes or risk factors for diabetes; clients exposed to temperature extremes under conditions that cause hypotension; and pregnant clients or children -Atypical or Second Generation Antipsychotics have decreased risk for extrapyramidal side effects than the convential antipsychotics.

Psychopharmacology for schizo

-Antipsychotics *Used to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders *They are effective in the treatment of acute and chronic manifestations of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms Action 1. Typicals: Dopaminergic blockers with various affinity for cholinergic, α-adrenergic, and histaminic receptorsex) -chlorpormazine -fluphenazine -haloperidol -loxapine -perphanizine -pimozide -thiothizene 2. Atypicals: Weak dopamine antagonists; potent 5HT2A antagonists; also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors *dopamine blockage results in EPS and prolactin elevation ex) -aripiprazole -asenapine -brexipirazole -olanzapine -risperidone -ziprasidone

Borderline personality disorder predisposing factors

-Biochemical *Cleints with BPD have a high incidence of major depressive episodes and antidepressants have demonstraed benefits in some cases -Genetic *an increase prevalence of major depression and substance use disorders in first-degree relatives of individuals with BPD suggests that there are complex genetic vulnerabilities as was as environmental influences -Neurobiological *decrease in the volume of the left amygdala and right hippocampus are apparent -Childhood trauma and abuse *Seventy percent of borderline personality disorder clients report a history of physical and/or sexual abuse. -The child fails to achieve task of autonomy

Predisposing Factors to ADHD

-Biochemical theory *It is believed that certain neurotransmitters—such as dopamine, norepinephrine, and possibly serotonin -Anatomical influences -Prenatal, perinatal, and postnatal factors **Maternal smoking, intrauterine exposure to toxic substances, including alcohol, and maternal infections during pregnancy have also been associated with higher risks for ADHD Environmental influences -Environmental lead -Dietary factors Psychosocial influences -Disorganized or chaotic family environments -Maternal mental disorder or paternal criminality -Low socioeconomic status -Unstable foster care

Anorexia nervosa

-Characterized by a morbid fear of obesity -Symptoms include: *gross distortion of body image *preoccupation with food *refusal to eat *hypothermia *bradycardia *hypotension *edema *lanugo (fine, soft hair that covers the body) *a variety of metabolic changes. *AMENORRHEA -Weight loss is extreme, usually more than 15 percent of expected weight. -Amenorrhea is typical and may even precede significant weight loss. -There may be an obsession with food: For example, they may hoard or conceal food, talk about food and recipes at great length, or prepare elaborate meals for others, only to restrict themselves to a limited amount of low-calorie food intake -Feelings of anxiety and depression are common.

Autism Spectrum Disorder

-Characterized by a withdrawal of the child into the self and into a fantasy world of his or her own creation -Autism spectrum disorder is a heterogenous group of neurodevelopmental syndromes characterized by a wide range of communication impairments and restricted, repetitive behaviors. -The child has abnormal or impaired development in social interaction and communication and a restricted repertoire of activity and interests, some of which may be considered somewhat bizarre -ASD occurs more often in boys than in girls -Onset occurs in early childhood -ASD often runs a chronic course

Bipolar I disorder

-Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms -May also have experienced episodes of depression -Manic episode last for a week, present for most of the hour a day, and almost every day -Bipolar I disorder is the diagnosis given to a client who is currently experiencing a manic episode or has a history of one or more manic episode -This diagnosis is further specified by the current or most recent behavioral episode experienced -The specifier might be single manic episode or current episode manic, hypomanic, mixed, or depressed. Psychotic or catatonic (increase muscle tone at rest) features may also be present.

Disturbed body image/low self-esteem

-Disturbed body image is defined as "confusion in mental picture of one's physical self" -Low self-esteem is defined as "negative self-evaluating/feelings about self or self-capabilities" >For client with anorexia nervosa or bulimia -Promote feelings of control -Help client realize perfection is unrealistic 1. Goals should include verbally acknowledging misperception of body image, and demonstrating an increase in self-esteem, and pursuing weight loss 2. Interventions include helping the client develop a realistic perception of body image. Promoting feelings of control, have the client recall coping patterns, and determining the client's motivation for developing healthier patterns. -help client indentify positive self-attributes. Focus on strengths and past accomplishments rather than physical appearance

Disturbed thought processes/impaired memory and disturbed sensory perception

-Disturbed thought processes has been defined as a disruption in cognitive operations and activities. -Disturbed sensory perception is defined as a "change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli" -Impaired memory is defined as the "inability to remember or recall bits of information or behavioral skills." Short-term goals -Client will utilize measures provided to maintain reality orientation. -Client will experience fewer episodes of acute confusion. Long-term goal -Client will maintain reality orientation to the best of his or her cognitive ability. *The goal of treating clients with these disruptions should be to help the client maintain reality orientation.!!!!! INTERVENTIONS: FOR CLIENTS WHO IS DISORIENTED, -There are many interventions that a nurse can use to help achieve this goal, including using clocks, calendars, and signs and providing the client with items that may help promote feelings of security and orientation!!!! -place large, colorful signs on doors to identify client's room -allow client to have as many of their personal belongings -maintain consistency with staff FOR CLIENTS WITH DELUSIONS *For clients with delusions and hallucinations, it is important to discourage delusional thinking, provide reassurance that the client is safe, and focus on real situations and people. -do not ignore reports of hallucinations -ensure hearing aids are working properly -never argue that hallucinations is not real

Antipsychotics

-Do not discontinue drug abruptly. -Use sunblock when outdoors. -Rise slowly from a sitting or lying position. -Avoid alcohol and over-the-counter medications. -Continue to take the medication, even if feeling well and as though it is not needed; symptoms may return if medication is discontinued.

Extrapyramidal symptoms (EPS)

-Pseudoparkinsonism -Akinesia: partial or complete loss or supression of muscle movt -Akathisia: can not sit still, are jumpy or fidgety, restless -Dystonia: prolonged involuntary muscle contractions that may cause twisting of body parts, repitive movts, and increased muscular tone and may cause rhythmic jerks -Oculogyric crisis: a spasm of involuntary deviation and fixation of the eyeballs, usually upward, caused by phenothiazine!!! **Antiparkinsonian agents may be prescribed to counteract EPS.

ECT nursing intervention/planning

-Ensuring physician and anesthesiologist have obtained informed consent and signed permission form is on chart -Ensuring most recent laboratory reports and results of -ECG and x-ray examination are available 1 hour before treatment, taking and recording vitals -Have client void and remove dentures, eyeglasses or contact lenses, jewelry, and hairpins. -Following institutional requirements, client changes clothing **The client is given nothing by mouth (NPO) for 6 to 8 hours before the treatment** d/t risk for aspiration **ASSESS LAST TIME THEY HAD MEAL! -Client to remain in bed-30 minutes before treatment, administering pretreatment medication prescribed by physician *IM INJECTION OF SULFATE OR GLYCOPYRROLATE (ROBINUL)** -Staying with the client to help allay fears and anxiety -Maintain a positive attitude about the procedure, and encourage the client to verbalize feelings OP -In the treatment room *Client is placed on the table in a supine position. *Anesthesiologist intravenously administers a short-acting anesthetic. -A muscle relaxant is given intravenously to prevent severe muscle contractions during the seizure, thereby reducing the possibility of fractured or dislocated bones. **ASSESS RR, O2 state, watch BP & HR -may want to monitor cardiac status -An airway/bite block is used to facilitate the client's airway patency. -Electrodes are placed on the temples to deliver the electrical stimulation. -The nurse assists the psychiatrist and the anesthesiologist as required, and provides support to the client, both physically and emotionally. POST-OP -important to stay with client -take vitals signs q 15 minutes for first hour -After the treatment, anesthesiologist continues to oxygenate client with pure oxygen until spontaneous respirations return. -Most clients awaken within 10 or 15 minutes of the treatment and are confused and disoriented. -Some clients will sleep for 1 to 2 hours following the treatment. -All clients require close observation in this immediate posttreatment period. *give client reassurance *stay with client to reorient to time & place *Staying with the client until he or she is fully awake, oriented, and able to perform self-care activities without assistance. -Providing reassurance that confusion and memory loss will subside and memories should return following the course of ECT therapy. -lay client to the side to prevent aspiration BUT CLIENT MUST REMAIN IN BED -place HOB up AFTER TX: -Evaluation of the effectiveness of nursing interventions is based on the achievement of the projected outcomes.

Attention Deficit/Hyperactivity Disorder (ADHD)

-Essential behavior pattern is inattention and/or hyperactivity and impulsivity Hyperactivity -Excessive psychomotor activity that may be purposeful or aimless, accompanied by physical movements and verbal utterances that are usually more rapid than normal -Inattention and distractibility are common with hyperactive behavior personality disorder as adults Impulsiveness -The trait of acting without reflection and without thought to the consequences of the behavior -An abrupt inclination to act (and the inability to resist acting) on certain behavioral urges Categorized by clinical presentation subtypes -Combined type (meeting the criteria for both inattention and hyperactivity/impulsivity) -Predominantly inattentive presentation -Predominantly hyperactive/impulsive presentation

Distorted (exaggerated) grief

-Feelings of sadness, helplessness, hopelessness, powerlessness, anger, and guilt, as well as numerous somatic complaints, render the individual dysfunctional in terms of management of daily living. -All of the symptoms associated with normal grieving are exaggerated IN ANGER STAGE!

Indicators of Sexual Abuse

-Has difficulty walking or sitting -Suddenly refuses to change for gym or to participate in physical activities -Reports nightmares or bedwetting -Experiences a sudden change in appetite -Bizarre, sophisticated, or unusual sexual behavior -Becomes pregnant or contracts a STD -Runs away -Reports sexual abuse -Attaches quickly to strangers or new adults to the environment Sexual abuse may be considered a possibility when the parent or other adult caregiver -Is unduly protective of the child or severely limits the child's contact with other children, especially of the opposite sex -Is secretive and isolated -Is jealous or controlling with family members Characteristics of the child abuser -Parents who abuse their children were often victims of abuse in their own early lives and have impaired attachment with their child -Substance use disorders increase the risk of child abuse and neglect characteristics associated with an abusive parent -Isolated with little support from family and friends -Expects that the child should fulfill their emotional needs -Prone to depression -Frequent outbursts, anger and rage -Low frustration tolerance

symptoms of NCD

-Impairment is evident in abstract thinking, judgment, and impulse control. -The conventional rules of social conduct are often disregarded. -Behavior may be uninhibited and inappropriate. -Personal appearance and hygiene are often neglected. -Language may or may not be affected: Some individuals may have difficulty naming objects, or the language may seem vague and imprecise *in severe cases the pt may have aphasia -Personality change is common, may be manifested by either an alteration or accentuation of premorbid characteristics *For example, an individual who was previously very socially active may become apathetic and socially isolated *A previously neat person may become markedly untidy in his or her appearance *Conversely, an individual who may have had difficulty trusting others prior to the illness may exhibit extreme fear and paranoia as manifestations of the disorder. As the disease progresses, symptoms may include: -Aphasia -Apraxia: inability to purposive movements or INABILITY TO PERFORM LEARNED MOVEMENTS/which is the inability to carry out motor activities despite intact motor function, may develop -Irritability and moodiness, with sudden outbursts over trivial issues -Inability to care for personal needs independently -Wandering away from the home: These individuals can no longer be left alone because they are at serious risk for accidents. -Incontinence

Vascular NCD

-NCD occurs as a result of significant cerebrovascular disease -More abrupt onset than is seen in AD, and course is more variable *In vascular NCD, the syndrome of cognitive symptoms is due to significant cerebrovascular disease. When blood flow in the brain is impaired progressive intellectual deterioration occurs. -The cause of vascular NCD is directly related to an interruption of blood flow to the brain!!! -impairment may be located in large vessels or microvascular networks -VASCULAR ND IS THE SECOND-MOST COMMON FROM OF NCD AFTER AD!!!! >Vascular NCD differs from AD in that it has a more abrupt onset and runs a highly variable course. >In vascular NCD, progression of the symptoms occurs in "steps" rather than as a gradual deterioration; that is, at times the symptoms seem to clear up and the individual exhibits fairly lucid thinking. *Symptoms result from death of nerve cells in regions nourished by diseased vessels. Various diseases and conditions that interfere with blood circulation have been implicated. Etiology 1. Hypertension 2. Cerebral emboli 3. Cerebral thrombosis

Selective Serotonin reuptake Inhibitor (SSRI)

-NOT ENOUGH SERATONIN, HAVE DEPRESSION Increases availability of serotonin Should not be used with MAOI's - must wait 14 days after DC before starting SSRI (AND SNRIS) - should wait 5 weeks between discontinuation of fluoxetine (Prozac) before starting MAOI *can cause excess serotonin levels Takes 2-4 weeks to reach therapeutic effects *closely monitor the patients Monitor for serotonin syndrome: must have at least 3 symptoms Taper slowly if discontinuing or changing from on SSRI to another

The incestuous relationship

-Often there is an impaired spousal relationship 1. Father -Domineering, impulsive, physically abusive 2. Mother *Passive, submissive, and denigrates her role of wife and mother *Often aware of the incestuous relationship but uses denial or keeps quiet out of fear of being abused by her husband *Onset of the incestuous relationship typically occurs when the daughter is 8 to 10 years of age and commonly begins with genital touching and fondling*

Symptoms of suicide

-One of these is the acronym IS PATH WARM? *Ideation: Has suicide ideas that are current and active, especially with an identified plan *Substance abuse: Has current and/or excessive use of alcohol or other mood-altering drugs *Purposelessness: Expresses thoughts that there is no reason to continue living *Anger: Expresses uncontrolled anger or feelings of rage *Trapped: Expresses the belief that there is no way out of the current situation *Hopelessness: Expresses lack of hope and perceives little chance of positive change *Withdrawal: Expresses desire to withdraw from others or has begun withdrawing *Anxiety: Expresses anxiety, agitation, and/or changes in sleep patterns *Recklessness: Engages in reckless or risky activities with little thought of consequences *Mood: Expresses dramatic mood shifts

NCD due to AD

-Onset is slow and insidious -Course of the disorder is generally progressive and deteriorating -Memory impairment is an early and prominent feature!!! -Alzheimer's disease is characterized by the syndrome of symptoms identified as Mild or Major NCD and in the seven stages described previously Stage 3: Mild cognitive decline -In this stage, there is interference with work performance, which becomes noticeable to coworkers. The individual may get lost when driving his or her car. Concentration may be interrupted. There is difficulty recalling names or words, which becomes noticeable to family and close associates. Stage 7: Severe cognitive decline -In the end stages of AD, the individual is unable to recognize family members. He or she most commonly is bedfast and aphasic. Problems of immobility, such as decubiti and contractures, may occur. PREDISPOSING FACTORS!!!!! 1. Etiology -Exact cause of AD is unknown. -Experts believe, except rare cases of genetic mutations cause AD, multiple factors rather than a single cause influence development of this illness.

Medical Treatment Modalities for NCD

-Primary consideration is given to etiology, with focus on identification and resolution of potentially reversible processes. -The need for general supportive care with provisions for security, stimulation, patience, and nutrition, has been recognized and accepted.

Nursing interventions for the child with ASD are aimed at

-Protection of the child from self-harm *ST goal: client demonstrates alternative behavior in response to anxiety *try to determine the anxiety that triggers the behavior *try to intervene with diversions or replacement activities and offer self to child as anxiety levels start to rise *protect child when self-mutilative behavior start. Devices scuh as helmet, padded handmitts, or arm covers can protect the client! -Improvement in social functioning *assign a limited number of caregivers to child. Ensure that warmth, acceptance, and availability are conveyed. *provide child with familiar objects such as familiar toys or blankets *give positive reinforcements with something acceptable to child (food, familiar object). Gradually replace with social reinforcement (touch, smile, hug) -Improvement in verbal communication *maintain consistency in assignment of caregivers: this fascilitates trust and enhances the caregivers ability to understand childs attempt to communicate *anticipate and fulfill child's need until communication can be established; this helps minimize fustration *give postive reinforcement when eye contact is used to convey nonverbal expression -Enhancement of personal identity

Nursing care of the client with a trauma-related disorder

-Reassurance of safety -Decrease in maladaptive symptoms -Demonstration of more adaptive coping strategies -Adaptive progression through the grieving process -Assign the same staff -Make sure the client is with same sex -Be consistent with the client and keep your promises -Stay with client if they are having flashbacks & nightmares -hx of trauma events *Post-trauma syndrome is defined as "a sustained maladaptive response to a traumatic, overwhelming event.*

Profile of the victimizer-rape

-Sexual sadists who are aroused by inflicting pain -Exploitative predators who are using the victim to gratify needs such as dominance and power -Inadequate men who are obsessed with fantasies of sex that they believe can't be achieved without force -Those displacing anger

antipsychotic pt teaching

-Smoking increases the metabolism of antipsychotics, requiring an adjustment in dosage to achieve a therapeutic effect. Encourage the client to discuss this with the prescribing physician or nurse practitioner. -Dress warmly in cold weather and avoid extended exposure to very high or low temperatures. Body temperature is harder to maintain with this medication. -Avoid taking other medications (including over-the-counter products) without the physician's approval. Many medications contain substances that interact with antipsychotics in a way that may be harmful. -A significant number of clients on clozapine report excessive salivation. Sugar-free gum and medications (anticholinergic or alpha2 adrenoceptor agonists) may alleviate symptoms. cariprazine (Vraylor) can potentially reduce flat affect

Lithium

-Take the medication regularly. *When taking lithium, the client should continue taking the medication on a regular basis, even when feeling well!! -Do not drive or operate dangerous machinery. -Do not skimp on dietary sodium and maintain appropriate diet and avoid junk food! -Know pregnancy risks. -Carry identification noting taking lithium. -Be aware of side effects and symptoms of toxicity -Notify physician if vomiting or diarrhea occur, severe diarrhea, ataxia, blurred vision, tinnitus, excessive urine output, increasing tremors, or mental confusion -Have serum lithium level checked every 1 to 2 months. -Lithium levels monitored once or twice a week -blood sample be taken 12 hours after last dose taken Pt education: client miss high feeling and will want to adjust dose; explain benefits of it -weight gain an undesirable side effects and pt should monitor it at regular intervals *LOW-CALORIE DIETS & not making large changes in sodium intake **DECREASED DIETARY SODIUM INTAKE LOWERS THE EXCRETION OF LITHIUM. 1. Give lithium with food to minimize GI upset. 2. Ensure that the client gets adequate sodium in his or her diet. 3. Ensure that the client drinks 2500 to 3000 mL of fluid per day. 4. Check for lithium levels before administering the next dose. 5. Monitor client's intake and output. 6. May need to instruct client on proper diet to prevent weight gain.

Delayed or inhibited grief

-The absence of grief when it ordinarily would be expected -Potentially pathological because the person is not dealing with the reality of the loss -Remains fixed in the denial stage of the grief process -Grief may be triggered much later in response to a subsequent loss IN DENIAL STAGE

Delirium Assessment

-Usually begins abruptly if caused by an event such as a head injury or seizure. Other times they may take several hours or days to develop. -Key characteristic: Occurs suddenly, within hours and sometimes days (MUST identify cause and symptoms should subside within about a week) -Duration is usually brief and subsides completely on recovery from underlying determinant

Intimate partner violence

-Various terms describe the pattern of violence between intimate partners, including intimate partner violence (IPV), domestic violence, and battering. -Physical abuse between domestic partners may be known as spousal abuse, domestic or family violence, wife or husband battering, or IPV.

Client/Family Education Related to Antidepressants

-therapeutic effect may not kick in til week 4, so keep taking it! -caution when driving, no alcohol -do not discontinue abruptly -use sunblock -report adverse affects -rise slowly -no tyramine foods if taking MAOIs -no smoking if you are receiving TCA -no doubling up, especially with Wellbutrin (b/c of seizure risk) -carry card describing meds taken -correct selegiline transdermal patch application -Report sore throat, fever, malaise, yellow skin, bleeding, bruising, persistent vomiting or headaches, rapid heart rate, seizures, stiff neck and chest pain to physician. -If pt is suicidal, closely monitor the patient since they may get strong enough to carry out suicide plan -take frequent sips of water, chew sugarless gum, or suck on hard candy if dry mouth is a problem -avoid smoking while receiving TCA therapy. Smoking increases the metabolism of TCA requiring an adjustment in dosage to achieve the therapeutic effect -avoid OTC can precipitate hypertensive crisis BLACK BOX WARNING IN ADOLESCENTS AND CHILDREN INCREASE RISK FOR SUICIDE! NURSE MUST WATCH OUT FOR SUDDEN LIFT IN MOOD IT MAY BE A GOOD INDICATOR THE PATIENT AT RISK FOR SUICIDE!

Pharmaceutical agents for cognitive impairment

1) Cholinesterase inhibitors >Physostigmine (Antilirium) -the cholinesterase inhibitor physostigmine (Antilirium) has been shown to enhance functioning in individuals with mild-to-moderate AD >Tacrine (Cogex) >Donepezil (Aricept) -cholinesterase inhibitor -tx of cognitive impairment >Rivastigmine (Exelon) -cholinesterase inhibitor >Galantamine (Razadyne) -cholinesterase inhibitor 2) NMDA Antagonist >Memantine (Namenda) -effective in improving cognitive function and the ability to perform ADLs in clients with moderate to severe AD. -Pharmaceutical agents for agitation, aggression, hallucinations, thought disturbances, and wandering ANTIPSYCHOTIC DRUGS: -Risperidone (Risperdal) -Olanzapine (Zyprexa) -Quetiapine (Seroquel) -Ziprasidone (Geodon) *These drugs cause fewer anticholinergic and extrapyramidal side effects (EPS) than do older antipsychotics. *They carry a black box warning that all atypical antipsychotics are associated with an increased risk of death in elderly patients with dementia!

Nursing Diagnosis r/t Eating Disorders

1) Imbalanced nutrition 2) Deficient fluid volume 3) Denial 4) Obesity 5) Disturbed Body Image

Bulimia nervosa

1. An episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period (binging) 2. Episode is followed by inappropriate compensatory behaviors to rid the body of the excess calories (self-induced vomiting or the misuse of laxatives, diuretic or enemas). 3. To rid the body of the excessive calories, individual engages in purging behaviors (self-induced vomiting, or the misuse of laxatives, diuretics, or enemas). 4. Fasting or excessive exercise may also occur. 5. Most patients with bulimia are within a normal weight range, some slightly underweight, and some slightly overweight. 6. Depression, anxiety, and substance abuse are not uncommon. 7. Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalances.

Antipsychotics drug interactions

1. Antihhypertensives, CNS depressants -epinephrine or dopamine in combination with HALOPERIDOL or PHEMOTHIAZINES! *AE: Additive and potentially severe hypotension 2. Oral anticoagulants with phenothiazines AE: Less effective anticoagulant effects 3. Drugs that prolong QT intervals AE: Additive effects 4. Drugs that trigger orthostatic hypotension AE: Additive hypotension 5. Drugs with anticholinergic effects, prescription and over-the-counter drugs AE: Additive anticholinergic effects including anticholinergic toxicity which includes flushing, dry mouth, mydriasis (dilation of pupils), altered mental status, tachycardia, urinary retention, tremulousness, hypertension *Effects may include potentially sever hypotension if taken with antihypertensives, and less effective anticoagulant effects if taken with oral anticoagulants.

antypsychotic drugs interaction

1. Antihypertensives, CNS depressantsEpinephrine or dopamine in combination with haloperidol or phenothiazines= ADDITIVE & severe HYPOTENSION 2. oral anticoagulants w/ phenothiazines= less affective anticoagulants effects = less efective anticoagulant effect 3. Drugs that prolong QT interval= additive effects 4. drugs that trigger orthostatic htn= additive htn 5. anticholinergics= flushin, dry mouth, mydriasis, AMS, tachycardia, urinary retention, hypertension

Panic and GAD psychopharmacology

1. Anxiolytics *Benzodiazepines have been used with success in the treatment of generalized anxiety disorder. *Alprazolam, lorazepam, and clonazepam have been particularly effective in the treatment of panic disorder. >PT TEACHING: -high risk for physical dependence -withdrawal symptoms can be LT, DO NOT STOP ABRUPTLY! -SE: dependence with long term use, confusion, memory impairment, motor incoordination, depresses CNS -Avoid use of alcohol, barbs, narcotics, antipsychotics, antidepressants -decrease effects can be noted with cigarette smoking and caffeine consumption 2. BUSPIRONE (BuSpar) -antiaxiety agent BUT DOES NOT DEPRESS CNS 3. Antidepressants *The tricyclics clomipramine and imipramine have been used with success in clients experiencing panic disorder. *SSRI *SNRIs 4. Antihypertensive agents *Several studies have called attention to the effectiveness of beta blockers (e.g., propranolol) and alpha2-receptor agonists (e.g., clonidine) in the amelioration of anxiety symptoms.

Indicators of Neglect

1. Behavioral indicators of neglect -Is frequently absent from school -Begs or steals food or money -Lacks needed medical or dental care, immunizations, or glasses -Is consistently dirty and has severe body odor -Lacks sufficient clothing for the weather -Abuses alcohol or other drugs -States that there is no one at home to provide care 2. The possibility of neglect may be considered when the parent or other adult caregiver -Appears to be indifferent to the child -Seems apathetic or depressed -Behaves irrationally or in a bizarre manner -Is abusing alcohol or other drugs

Major depressive disorder

1. Characterized by depressed mood *irritable mood as well *depressed mood for most of the day, for more days for at least 2 weeks! 2. Loss of interest or pleasure in usual activities *loss of interest or pleasure in all or almost all activities, nearly everyday (either subjective or through observation) 3. Symptoms present for at least 2 weeks *poor appetite or overeating -weight loss w/o dieting or weight gain *insomnia or hyperinsomnia (excessive daytime sleeping) *low energy or fatigue or retardation *feelings of worthless or excessive or inappropriate guilt nearly q day *low self-esteem *poor concentration or difficulty making decisions *feelings of hopelessness (can't do anything right) *weight loss 4. No history of manic behavior 5. Cannot be attributed to use of substances or another medical condition **(DSM-5)** *5 or more of the following symptoms for 2 weeks

Borderline personality disorder clinical picture

1. Chronic depression 2. Inability to be alone -Because of this chronic fear of abandonment, clients with borderline personality disorder have little tolerance for being alone. They prefer a frantic search for companionship, no matter how unsatisfactory, to sitting with feelings of loneliness, emptiness, and boredom. 3. Patterns of interaction >Clinging and distancing behaviors *When clients are clinging to another individual, they may exhibit helpless, dependent, or even childlike behaviors. >Splitting *in their view, people are either ALL good or ALL bad *view nurse as a good person, but nurse looks at the patient a certain way or was not immediately available to be there for the patient then the nurse is devalued because the individual is unable to regulate his or her emotions *they like another nurse and the former nurse is seen as cruel and hateful *These shifting allegiances and valuing/ devaluing responses can generate conflict, anger, and frustration in staff members (or in any interpersonal relationships) unless this dynamic is clearly understood and managed appropriately. >Manipulation -in order to prevent seperation they so fear, cliets with this disorder becomes masters of manipulation >Self-destructive behaviors *although these acts can be fatal, most commonly they are manipulative gestures designed to elicit a rescue response from a signifcant other *Suicide attempts are quite common and result from feelings of abandonment following separation from a significant other. *Various theories abound regarding why these individuals are able to inflict pain on themselves. One hypothesis suggests they may have higher levels of endorphins in their bodies than most people, thereby increasing their threshold for pain. >other types of destructive behaviors include: cutting, scratching, and burning >Impulsivity *Impulsive behaviors associated with borderline personality disorder include substance abuse, gambling, promiscuity, reckless driving, and binging and purging. Many times these behaviors occur in response to real or perceived feelings of abandonment.

Issues in antipsychotic maintenance therapy

1. Clozaril and the risk for agranulocytosis *Agranulocytosis is a potentially fatal blood disorder in which the client's white blood cell (WBC) count can drop to extremely low levels. *MONITOR BASELINE WBC & COUNT NUETROPHILS DUE WEEKLY FOR 6 MONTHS AND IF IT IS WITHIN ACCPETABLE LEVELS KEEP USING 2. Extrapyramidal side effects *more common in typical than atypical *Akinesia: absence of impariment in volunatry movt *pseudoparkinsons: symptoms include tremor, shuffling gait, drooling, rigidity *oculogyric crisis: unctonrolled rolling back of the eyes *akathisia: continuous restlessness, and figeting *dystonia: involuntary muscle spasms in face, arms, legs, and neck *tardive dyskinesia: bizarre face and tongue movts (these symptoms can be permanet) 3. Hormonal side effects *decreased libido, retrograde ejaculation, and gynecomastia in men and amenorrhea in women

Kübler-Ross's five stages of the grief response

1. Denial: A stage of shock and disbelief -reality of loss not acknowledged 2. Anger: Envy and resentment toward individuals not affected by the loss are common-anger may be directed at themselves or displaced on loved ones, caregivers, & even God 3. Bargaining: A "bargain" is made with God in an attempt to reverse or postpone the loss-not evident-promise associated with feelings of guilt for not having performed satisfactorily or sufficiently 4. Depression: The sense of loss is intense, and feelings of sadness and depression prevail-full impact of loss is experienced 5. Acceptance: The final stage brings a feeling of peace regarding the loss that has occurred-a time of resignation and expectation

Antipsychotics Safety issues in planning and implementing care

1. Extrapyramidal side effects -instruct client to report any signs of muscle stiffness or spasms (hold medication if this occurs) -administer antiparkinsons agents as ordered and immediately when signs of acute dystonia are present 2. hyperglycemia, weight gain, and diabetes (COMMON WITH ATYPICAL ANTPSYCHOTIC) -assess for hx of diabetes -evaluate blood sugars -assess for s&s hyperglycemia (3 Ps) -instruct the client in these risks and importance of diet and exercise 3. Hypotension -educate the client about risk for htn -monitor BP 4. orthostatic htn -instruct client to rise slowly 5. lower seizure threshold (esp with clozapine) -assess client for hx of seizure -monitor evidence for seizure activity 6. Prolonged QT interval -assess hx of arrythmia, recent MI, HF 7. Anticholinergice effects *dry mouth (recommend hard candies; sips of water) good oral hygiene assess for urinary retention tachycardia tremulousness HTN 8. Sedation 9. Photosensitivity -instruct client to use sunblock or wear and to wear protective clothing 10. Agranulocytosis (more common with typical & atypical [clozapine] psychotics) -monitor WBC especially taking clozapine -report signs of sore throat, fever and malaise 11. NEUROLEPTICS MALIGNANT SYNDROME: instruct client to report immediatley fever, muscle rigidity, diaphoresis, tachycardia -assess vitals including temp -assess detoriorating mental status Smoking increases the metabolism of antipsychotics, requiring an adjustment in dosage to achieve a therapeutic effect. Encourage the client to discuss this with the prescribing physician or nurse practitioner. Body temperature is harder to maintain with this medication, so dress warmly in cold weather and avoid extended exposure to very high or low temperatures Avoid taking other medications (including over-the-counter products) without the physician's approval

Schizophrenia predisposing factors

1. Genetics 2. Biochemical influences -One theory suggests that schizophrenia may be caused by an EXCESS OF DOPAMINE ACTIVITY in the brain. -Abnormalities in other neurotransmitters have also been suggested. *EXCESS OF SERATONIN has been hypothesized to be responsible for both positive and negative symptoms of schizophrenia 3. Physiological influences -Viral infection -Anatomical abnormalities 4. Environmental influences >POVERTY has been linked with the development of schizophrenia. -Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse. -Studies of genetic vulnerability for schizophrenia have linked certain genes to increased risk for psychosis and particularly for adolescents who use cannabinoids.

Suicidal Planning and implementation

1. Intervention with the suicidal client following discharge or in an outpatient setting -Single interventions, including hospitalization, medication alone, and "no-suicide" contracts, are not supported by evidence as effective in reducing suicides -Clients need to be actively engaged as partners in each step of the assessment and intervention process-Enlist the help of family or friends to ensure that the home environment is safe from dangerous items, such as firearms or stockpiled drugs. -Help the client identify areas of life that are within his or her control and those cannot be controlled. Discuss feelings associated with these control issues. It is important for the client to feel some control over his or her life situation in order to perceive a measure of self-worth. -The physician or nurse practitioner may prescribe antidepressants for an individual who is experiencing suicidal depression. It is wise to prescribe no more than a three-day supply of the medication with no refills 2. Information for family and friends of the suicidal client -Take any hint of suicide seriously. -Do not keep secrets. *If a suicidal person says, "Promise you won't tell anyone," do not make that promise. Suicidal individuals are ambivalent about dying, and suicidal behavior is a cry for help. It is that ambivalence that leads the person to confide to you the suicidal thoughts. Get help for the person and for you. 1-800-SUICIDE is a national hotline that is available 24 hours a day. -Be a good listener. *If people express suicidal thoughts or feel depressed, hopeless, or worthless, be supportive. -Emphasize ways the person's suicide would be devastating to you and to others. *Many people find it awkward to put into words how another person's life is important for their own well-being, but it is important to stress that the person's life is important to you and to others. -Express concern for individuals who express thoughts about killing themselves. *The individual may make veiled comments or comments that sound as if they are joking, or be withdrawn and reluctant to discuss his or her thoughts and feelings. *In each case, ask questions, acknowledge the person's pain and feelings of hopelessness, and encourage the individual to talk to someone else if he or she does not feel comfortable talking with you. -Familiarize yourself with suicide intervention resources. -Restrict access to firearms or means of self-harm. -Communicate caring and commitment to provide support. 3. Suggestions for families and friends when interacting with someone who is suicidal -Acknowledge and accept their feelings. -Be active listener. -Try to give them hope. *remind them that what they are feeling is temporary. -Do not leave him or her alone. -Show love and encouragement. *Hold them, hug them, touch them. Allow them to cry and express anger. -Seek professional help. *Suicide Hotline 1-800-621-8504-Remove any items from the home (person may harm himself or herself) -Remove children from the home. *This type of situation can be extremely traumatic for children. -Do not judge or show anger toward the person or provoke guilt in him or her, discount their feelings, or tell them to "snap out of it." *They are in real pain. They feel the situation is hopeless and that there is no other way to resolve it aside from suicide. 4. Intervention with families and friends of suicide victims *bereavement process for families in which a family member has taken his or her life is complicated **Macnab identified the following symptoms that may be evident after the suicide of a loved one: -A sense of guilt and responsibility -Anger, resentment, and rage that can never find its "object" -A heightened sense of emotionality, helplessness, failure, and despair -A recurring self-searching: "If only I had done something," "If only I had not done something," "If only...." -A sense of confusion and search for an explanation: "Why did this happen?" -A sense of inner injury; the family feels wounded and does not know how they will ever get over it and get on with life. -A severe strain placed on relationships; a sense of impatience, irritability, and anger between family members. -A heightened feeling of vulnerability to illness and disease with this added burden of emotional stress. STRATEGIES FOR ASSISTING SURVIVORS OF SUICIDE VICTIMS!! >Encourage him or her to talk about the suicide. >Discourage blaming and scapegoating. >Listen to feelings of guilt and self-persecution. >Talk about personal relationships with the victim. >Recognize differences in styles of grieving. >Assist with development of adaptive coping strategies.Identify resources that provide support.

ASD Nursing Diagnoses

1. Risk for self-mutilation or self-injury related to neurological alterations 2. Impaired social interaction related to inability to trust and neurological alterations, evidecne by lack of responsivenss to, or intesrest in, people >ST goal: client demonstrates trust in one caregiver >LT goal: client initiates social interactions with caregiver by time of discharge 3. Impaired verbal communication related to withdrawal into the self; neurological alterations, evidence by inability or unwillingness to speak; lack of nonverbal communication 4. Disturbed personal identity related to neurological alterations; delayed developmental stage, evidence by difficulty seperating needs and personal boundaries from those of others ST goals: client names own body parts as separate and individuals from those of otehs LT goals: client develops ego indentity (able to recognize physical and emotional self as seperate from others) by time of discharge Interventions: assist child in learning to name own body parts. This can be done by mirror drawing and pictures of child

Disturbances in thought processes manifested in speech

1. Loose associations: Shift of ideas from one unrelated topic to another -when condition is severe speech may be incoherent ex) "we wanted to take the bus, but the airport took all the traffic" 2. Neologisms: Made-up words that have meaning only to the person who invents them ex) she wanted to give me a ride in her new uniphorum 3. Clang associations: Choice of words is governed by sound, often taking the form of rhythm -Clang associations often take the form of rhyming. ex) "it is very cold. I am cold and bold. The gold has been sold." 4. Word salad: Group of words put together in a random fashion without any logical connection ex) "most forward action grows life double plays circle uniform" 5. Circumstantiality: Delay in reaching the point of a communication because of unnecessary and tedious details *The point or goal is usually met but only with numerous interruptions by the interviewer to keep the person on track of the topic being discussed. 6. Tangentiality: Inability to get to the point of communication due to introduction of many new topics -Tangentiality differs from circumstantiality in that the person NEVER really gets to the point of the communication!!!!!! -Unrelated topics are introduced, and the focus of the original discussion is lost. -VEERING AWAY FROM THE TOPIC -Mutism is an individual's inability or refusal to speak. 7. Perseveration: Persistent repetition of the same word or idea in response to different questions 8. Echolalia: Echolalia refers to repeating words or phrases spoken by ANOTHER

Drug interactions with SSRIs

1. MOAIs= HYPERTENSIVE CRISIS S&S -severe occipital headache, palpitations, nausea and vomiting, nuchal rigidity, fever, sweating, marked increase in blood pressure, chest pain, and coma 2. Buspirone (Buspar), TCA (clomipramine), selegiline (Eldepryl), St. John's wort= SERATONIN SYNDROME!!! 3. warfarin, NSAIDS = increased risk for bleeding 4. Alcohol, benzo= increase sedation 5. antepileptics= lowered seizure threshold

Obsessive-Compulsive Disorder (OCD)

1. Obsessions -Recurrent thoughts, impulses, or images experienced as intrusive and stressful, and unable to be expunged by logic or reasoning 2. Compulsions -Repetitive ritualistic behavior or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded event or situation -ex) hand-washing, ordering, checking, praying, counting and repeating words silently. The manifestations of obsessive-compulsive disorder (OCD) -Presence of obsessions, compulsions, or both, the severity of which is significant enough to cause distress or impairment in social, occupational, or other important areas of functioning Assessment data -Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment

Nursing diagnoses-OCD & Anxiety

1. Panic anxiety (panic disorder and GAD) R/T real or percieved threat to biological integrity or self-concept AEB any or all of the physical symptoms identifies *panic disorder: palpitations, trembling, sweating, chest pain, SOB, fear of going crazy, fear of dying *GAD: excessive worrying, difficulty concentrating, sleep disturbance 2. Powerlessness (panic disorder and GAD) R/T verbal expressions of having no control over life situation; non-participation in decision making r/t own care of life situation; expressions of doubt regarding role performance (panic & GAD) 3. Ineffective role performance *inability to fulfill usual patterns of responsibility because of need to perform rituals 4. Ineffective coping *ritualistic behavior; obsessive thoughts, inability to meet basic needs; severe levels of anxiety

Effects of alcohol on the body

1. Peripheral neuropathy -Characterized by nerve damage, results in pain, burning, tingling, or prickly sensations of the extremities -Researchers believe it is the direct result of deficiencies in the B vitamins, particularly thiamine. This is reversible with abstinence from alcohol and restoration of nutritional deficiencies, but permanent muscle wasting and paralysis can occur with continued use. 2. Alcoholic myopathy -May occur as an acute or chronic condition -Thought to result from same B vitamin deficiency that contributes to peripheral neuropathy -In the acute condition, the individual experiences a sudden onset of muscle pain, swelling, and weakness. These symptoms are usually generalized, but pain and swelling may selectively involve the calves or other muscle groups. -Chronic alcoholic myopathy includes a gradual wasting and weakness in skeletal muscles. Neither the pain and tenderness nor the elevated muscle enzymes seen in acute myopathy are evident in the chronic condition. 3. Wernicke's encephalopathy -Most serious form of thiamine deficiency in alcoholic patients -Symptoms include paralysis of the ocular muscles, diplopia, ataxia, somnolence, and stupor. -if thiamine not replaced, death will occur -Treatment is with parenteral or oral thiamine replacemen 4. Korsakoff's psychosis -Syndrome of confusion, loss of recent memory, and confabulation (gaps in memory filled with misinterpreted information) in alcoholic patients 5. Alcoholic cardiomyopathy -Alcoholic cardiomyopathy generally relates to congestive heart failure or arrhythmia -Effect of alcohol on the heart is an accumulation of lipids in the myocardial cells -Symptoms include decreased exercise tolerance, tachycardia, dyspnea, edema, palpitations, and nonproductive cough -Changes may be observed by electrocardiogram, and congestive heart failure may be evident on chest x-ray films. -Treatment is total permanent abstinence from alcohol!!!! -Treatment of the congestive heart failure may include rest, oxygen, digitalization, sodium restriction, and diuretics. The death rate is high for individuals with advanced symptomatology 6. Esophagitis -Inflammation and pain in the esophagus -It also occurs because of frequent vomiting associated with alcohol abuse. 7. Gastritis -Effects of alcohol on the stomach include inflammation of the stomach lining -epigastric distress, nausea, vomiting, and distention -Alcohol breaks down the stomach's protective mucosal barrier, allowing hydrochloric acid to erode the stomach wall. Damage to blood vessels may result in hemorrhage. 8. Pancreatitis -Acute: Usually occurs 1 or 2 days after a binge *Symptoms include constant, severe epigastric pain, nausea and vomiting, and abdominal distention -Chronic: Leads to pancreatic insufficiency *pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus. 9. Alcoholic hepatitis -Caused by long-term heavy alcohol use -Enlarged, tender liver; nausea and vomiting; lethargy; anorexia; elevated white blood cell count; fever; and jaundice; also, ascites and weight loss in severe cases-Severe cases can lead to cirrhosis or hepatic encephalopathy. 10. Cirrhosis of the liver -Cirrhosis is the end-stage of alcoholic liver disease and is believed to be caused by chronic heavy alcohol use. -There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue. *Symptoms nausea and vomiting, anorexia, weight loss, abdominal pain, jaundice, edema, anemia, and blood coagulation abnormalities *Treatment includes abstention from alcohol, correction of malnutrition, and supportive care to prevent complications of the disease. 11. Leukopenia -Impaired production, function, and movement of white blood cells -places the individual at high risk for contracting infectious diseases as well as for complicated recovery 12. Thrombocytopenia -Platelet production and survival are impaired as a result of the toxic effects of alcohol -This places the alcoholic at risk for hemorrhage. -Abstinence from alcohol rapidly reverses this deficiency. 13. Sexual dysfunction -In the short term, enhanced libido and failure of erection are common. -Long-term effects include gynecomastia, sterility, impotence, and decreased libido. *For women, this can mean changes in the menstrual cycles and a decreased or loss of ability to become pregnant *For men, the altered hormone levels result in a diminished libido, decreased sexual performance, impaired fertility, and gynecomastia may develop secondary to testicular atrophy.

Complications of cirrhosis of the liver

1. Portal hypertension 2. Ascites 3. Esophageal varices 4. Hepatic encephalopathy *This serious complication occurs in response to the inability of the diseased liver to convert ammonia to urea for excretion. The continued rise in serum ammonia results in progressively impaired mental functioning, apathy, euphoria or depression, sleep disturbance, increasing confusion, and progression to coma and eventual death.

Nursing diagnoses for trauma-related disorders

1. Posttrauma syndrome related to distressing event considered to be outside the range of usual human experience evidenced by flashbacks, intrusive recollections, nightmares, psychological numbness related to the event, dissociation, or amnesia (partial or total loss of memory) INTERVENTIONS: -client may be suspicious of others. Establishing a trusting relationship with this individual is essntial before care can be given -stay with the client during periods of flashbacks and nightmares. Offer reassurance and safety and security -obtain accurate hx from signifcant others about the trauma -encourage client to talk about trauma at his pace 2. Complicated grieving related to loss of self as perceived before the trauma or other actual or perceived losses incurred during or after the event evidenced by irritability and explosiveness, self-destructiveness, substance abuse, verbalization of survival guilt (they were the one driving the car and their family member died), or guilt about behavior required for survival. *NURSING ACTIONS -acknowledges feelings of guilt or self-blame -assess client's stage in grief process -assess impact of trauma on ability to resume ADLs -assess for self destructive ideas of behaviors -assess for maladaptive coping (e.g. substance abuse) The client -Can acknowledge the traumatic event and the impact it has had on his or her life -Is experiencing fewer flashbacks, intrusive recollections, and nightmares than he or she was on admission -Can demonstrate adaptive coping strategies -Can concentrate and has made realistic goals for the future -Includes significant others in the recovery process and willingly accepts their support -Verbalizes no ideas or intent of self-harm -Has worked through feelings of survivor's guilt -Gets enough sleep to avoid risk of injury -Verbalizes community resources from which he or she may seek assistance in times of stress -Attends support group of individuals who have recovered or are recovering from similar traumatic experiences -Verbalizes desire to put the trauma in the past and progress with his or her life

Survivors of abuse planning/implementation

1. Rape-trauma syndrome -ST goal: client's physical wounds heal w/o complications -LT goals: cleint begins a healthy grief resolution; initiating the process of physical and psychological healing -Interventions: important to tell the cleint "you are safe here" "im glad you survived," explain every assessment procedure that wiill be conducted (decreases fear), ensure that client has adequate privacy for all immediate postcrisis interventions, try to have as few people as possible providing immediate care or collecting immediate evidence (additional people can increase the feeling of vulnerability), encourage client to give an account of assult (LISTEN, BUT DO NOT PROBE), discuss with client whome to call for support or assistance 2. POWERLESSNESS -ST goals: cleint recognizes and verbalizes choices available thereby percieving some control of life situation -LT goal: client exhibits control over life situation by making decision about what to do regarding living cycle of abuse -interventions: ensure that all physical wounds, fractures, and burns recieve immediate attnetion (take photographs if permitted), take client to a private area to interview, ensure her safety, ask if it has happened before, if abuser takes drugs, whether woman has some place to go, esure that rescue effort are not attempted by nurse offer support, but remember that the final decision must be made by client (making her own decision gives her a sense of control over her life situation), stress the client the importance of safety and must be informed of the resources out their to help her (knowledge of availble resources decrease the individuals sense of powerlessness 3. Risk for delayed development -ST goal: client develops trusting relationship with nurse and reporsts how evident injuries were sustained -LT goal: client demonstrates behavior consistent with age-appropritae growth and development -interventions: perform complete physical assesment, take note of bruises, lacerations, and clients c/o pain, do not discount the possibility of sexual abuse, conduct an in-depth interview with the parent and consider if the injury is reported as an accident is reasonable (fear of improsonment or loss of child custody may place the abusive parent on the defensive), the parent lie to cover up, use games or play therapy to gain child's trust (gaining trust is important since the child may not want to be touched) Other nursing concerns include -Tending to physical injuries -Staying with the client to provide security -Assisting the client to recognize options -Promoting trust -Reporting to authorities when there is reason to suspect child abuse or neglect

ABUSE & NEGLECT Diagnosis/Outcome Identification

1. Rape-trauma syndrome related to sexual assault evidenced by verbalizations of the attack; bruises and lacerations over areas of body; severe anxiety 2. Powerlessness related to cycle of battering evidenced by verbalizations of abuse; bruises and lacerations over areas of body; fear for her safety and that of her children; verbalizations of no way to get out of the relationship 3. Risk for delayed development related to abusive family situation. The Client Who Has Been Sexually Assaulted: -Is no longer experiencing panic anxiety. -Demonstrates a degree of trust in the primary nurse. -Has received immediate attention to physical injuries. -Has initiated behaviors consistent with the grief response. The Client Who Has Been Physically Battered: -Has received immediate attention to physical injuries. -Verbalizes assurance of his or her immediate safety. -Discusses life situation with primary nurse. -Can verbalize choices from which he or she may receive assistance. The Child Who Has Been Abused: -Has received immediate attention to physical injuries. -Demonstrates trust in primary nurse by discussing abuse through the use of play therapy. -Is demonstrating a decrease in regressive behaviors.

NDs for manic episodes

1. Risk for injury -extreme hyperactivity, increased agitation and lack of control over purposeless and potentially injurious movements S&S: increased agitation and extreme hyperactivity 2. imbalanced nutrition: Less than body requirements/ Insomnia **HAVE MANIC PHASE AND NOT EAT OR SLEEP FOR DAY S&S: weight loss and amenorrhea Goals: -ST: client will consume sufficient finger foods and between meal snakcs to meet recommended daily allowances *client will not full blown meal *within 3 days, with aid of sleping medications, client sleep 4-6 hours INTERVENTIONS: *Determine the number of calories required to provide adequate nutrition for maintenance *provide client with high-calore, high-protein, and nutrtious finger foos and drinks that can be consumed *maintain accurate record of I&O, & calorie count *assess for client activity levels: observe signs for increase restlessness, fine tremors and slurr speech *mointor sleep pattern *client avoid intake of caffeinated drink *AS (before bedtime) provide measure to promote sleep such as back rub, warm bath *administer sedatives *avoid intake of caffeinated drinks

Planning/Implementation-substance use disorder

1. Risk for injury Vulnerable to physical damage due to environmental conditions interacting with individual's adaptive and defensive resources, which may compromise health Goals and interventions -ST goal: client's condition will stabilize within 72 hours -LT goal: client will not experience physical injury Interventions: -assess clients level of disorientation to determine specific requirements for safety -obtain a drug history, it is important to determine the substance used, the time and amount last use -obtain urine sample -keep client in a quite environment. excessive stimuli may increase client's agitation -suicide precaution may need to instituted for someone withdrawing from CNS stimulants -monitor the client q 15 minutes 2. Denial R/T lack of coping skills to manage anxiety AEB statements indicating no problem with substance abuse Conscious or unconscious attempt to disavow knowledge or meaning of an event to reduce anxiety and/or fear, leading to the detriment of health -ST goals: client will focus on behavioral outcomes associated with substance abuse -LT goals: client will verbalize acceptance of responsibility for own behavior and acknowledge association between substance use and personal problems -Interventions: *convey an attitude of acceptance to the client. *provide information to correct misconceptions about substance abuse. Provide facts and debunk myths *identify recent maladaptive behaviors or situations that have occurred in the clients life. The first step in decreasing denial is for the client to see the relationship between substance use and personal problems *use confrontation with caring, confrontation interferes with the client's ability to use denial *do not accepet rationalization or projection as client attempts to make excuses or blame other people for his behavior 3. Ineffective coping *inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and or inability to use available resources -Establish trust -Set limits -Explore options *ST goals: client will express true feelings about using substances as a method of coping *LT goals: client will be able to verbalize use of adaptive coping mechanism Interventions -set limits on manipulative behaviors. Be sure that the client knows what is acceptable, what is not and consequences for violating the limits set -explain the effects of substance abuse -explore with the client the options available to assist with stressful situations rather than resorting to drugs 4.Dysfunctional family processes *psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized, which lead to conflict, denial of problems, resistance to change, ineffective problem solving, and a series of self-perpetuating crises Review history Provide information Involve the family -ST goals: *family members will participate in individual family programs *family will identify ineffective coping behavior LT goals: *family members will take action to change self-destructive behaviors Interventions -Review family history: current level of functioning, circumstances, alcohol use. Explore how family members have coped with addiction -determine the extent of enabling behaviors evidenced by family members. ENABLERS BEHAVIORS ARE THOSE THAT INHIBIT RATHER THAN PROMOTE CHANGE!! -provide information about enabling behaviors and addictive disease -identify and discuss the possibility of sabotage behaviors by family members. Family members may not want the individual to recover -assist the client's partner to understand that the client's abstinence and drug use are not the partner's responsibility and that the client may not change -involve the family in plans for discharge. Encourage involvement in AA

Nursing Diagnosis-ADHD

1. Risk for injury related to impulsive and accident-prone behavior and the inability to perceive self-harm *interventions: identify behaviors that put the child at risk, provide supervision 2. Impaired social interaction related to intrusive and immature behavior *interventions: discuss with client behaviors that are and not acceptable 3. Low self-esteem related to dysfunctional family system and negative feedback *ST goals: cleint independently directs own care and activities of ADL 4. Noncompliance with task expectations related to low frustration tolerance and short attention span *client participates and cooperates during therapeutic activities Nursing interventions for the child with ADHD are aimed at -Ensuring that client remains free of injury -Encouraging appropriate interactions with others -Increasing feelings of self-worth -Fostering motivation for compliance with tasks The client -Has not harmed self or others -Interacts with others in a socially appropriate manner -Accepts direction without becoming defensive -Demonstrates evidence of increased self-esteem by discontinuing exploitative and demanding behaviors toward others

Nursing diagnoses for antisocial personality disorder

1. Risk for other-directed violence *Defined as "vulnerable to behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to others" >R/T body language (rigid postures, clenching of fifsts and jaw, hyperactivity, pacing, breathlessness, threatening stances); cruelty to animals; rage reactions; hx of childhood abuse; hx of violence against otheres; impulsivity; substance abuse; negative role-modeling; inability to tolerate fustration +Short-Term Goals -Within 3 days, client will discuss angry feelings and situations that precipitate hostility. -Client will not harm others. +Long-Term Goal -Client will not harm others. NURSING ACTIONS: *Provide unconditional acceptance *keep environmental stimuli low, a stimulating environment may increase agitation and aggressive behavior *observe behavior routinely, avoid appearing watchful and suspicious *make environment safe *explore true object of anger *gradually encourage appropriate expression of anger *provide show of strength *remain calm toward the client as it may increase anxiety in client *administer antianxiety if hostile *restain if required *DO NOT USE THE WORD "YOU SHOULD," USE THE WORDS "YOU WILL BE EXPECTED TO.." 2. Defensive coping related to dysfunctional family *Defined as "repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard" >Disregard for social norms and laws; absence of guilt feelings; inability to delay gratification; denial of obvious problems; grandiosity; hostile laughter; projection of blame & responsibility; ridicule of others; superior attitute towards others Short-Term Goals -Within 24 hours after admission, client will verbalize understanding of treatment setting rules and regulations and the consequences for violation. -Client will verbalize personal responsibility for difficulties experienced in interpersonal relationships within (time period reasonable for client). Long-Term Goals -By the time of discharge from treatment, the client will be able to cope more adaptively by delaying gratification of own desires and following rules and regulations of the treatment setting. -By the time of discharge from treatment, the client will demonstrate ability to interact with others without becoming defensive, rationalizing behaviors, or expressing grandiose ideas. NURSING ACTION *explain acceptable behaviors and consequences of violation *explain clearly what is expected of the client *provide positive feedback and reward for acceptabe behavior *provie miliue environment *delay gratification by increasinf lenght of time of acceptable behavior. ex) two hours of acceptable behavior may be exchanged for a phone call *milieu unit provides the appropriate environment *it is not you, but your behavior that is unacceptable: an attitude of acceptance promote feelings of dignity and self-worth 3. Chronic low self-esteem -manipulation of others to fulfill own desires, inability to form close personal relationships; frequent lack of success in life evenets; passive-aggressivess 4. impaired social interaction -inability to form satisfactory enduring intimate relationship with another; dysfunctional interaction with others; use of unsuccessful social inteaction behaviors 5. Ineffective health maintenance -demonstration of inability to take responsibility for meeting basic health practices, hx of lack of health-seeking behaviors; demonstrate lack of knowledge regarding basic health practices

Planning/Implementation for BPD

1. Risk for self-mutilation Defined as "vulnerable to deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension" >risk factors: hx of self-injurious behavior, hx of inability to plan solutions; impulsitivity; irresistible to urge to damage self; feels threatened with loss of significant relationship >NI: -observer ethe clients behavior frequently: avoid appearing watchful and suspicious -if self-mutilation occurs do not offer sympathy rather lack of attention decreases repitition of use -administer tranquilizers 2. Risk for self-directed or other-directed violence Defined as "vulnerable to behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to self or others" >risk factors: hx of suicide attempts, suicidal ideation; suidicide plan; impulsiviness ; childhood abuse; fears of abandonment; internalized rage Short-Term Goals -The client will seek out staff member if feelings of harming self or others emerge.The client will not harm self or others. Long-Term Goal -The client will not harm self or others. 3. Risk for other-directed violence -risk factors: body language, hx of childhood abuse, impulsitivity, 4. Complicated grieving -Defined as "a disorder that occurs after the death of a significant in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment" >r/t depression, persistent emotional distress; rumination; seperation distress; traumatic disrtess; verbalzies empty; inappropriate expression of anger -Short-Term Goal Within 5 days, the client will discuss with nurse or therapist maladaptive patterns of expressing anger. -Long-Term Goal By the time of discharge from treatment, the client will be able to identify the true source of angry feelings, accept ownership of these feelings, and express them in a socially acceptable manner, in an effort to satisfactorily progress through the grieving process. **Nursing actions: create trusting relationships, encourage appropriate expression of anger, explore true source of anger, teach stages of grief, set limits on acting-out behavior 5. impaired social interaction -Defined as "insufficient or excessive quantity or ineffective quality of social exchange" >r/t alternating clinging and distance behavior; STAFF SPLITING; manipulation -Short-Term Goal Within five days, client will discuss with nurse or therapist behaviors that impede the development of satisfactory interpersonal relationships. -Long-Term Goal By the time of discharge from treatment, client will interact appropriately with others in the therapy setting in both social and therapeutic activities (evidencing a discontinuation of splitting and clinging and distancing behaviors). **Nursing actions: examine inappropriate behaviors, encourage independence and give postive reinforcement, explore fears, explain inappropriatenss of those behaviors, rotate staff to avoid dependence on particular individuals 6. disturbed personal identity r/t feelings of depersonalization and derealization 7. anxiety (severe to panic) 8. chronic low self-esteem

Depression ND

1. Risk for suicide (depressed mood, feelings of hopelessness and worthlessness, anger turn inward in the self) -INTERVENTIONS: create a safe environment for the client (remove all potentially harmful objects from the clients access), supervise closely during meals and medication time, convey an attitude of unconditional acceptance, observe q 15 minutes conducted at irregular intervals, make rounds at frequent irregular intervals especially at night 2. Complicated grieving (preoccupation with thoughts of loss, self-blame, fried avoidance) R/T real or perceived loss, bereavement overload AEB denial of loss, inappropriate expression of anger, idealization of or obsession with lost object, inability to carry out ADLs -INTERVENTIONS: determine the stage of grief, encourage client to express anger, help client to discharge pent-up anger through participation in large motor activities (walks, jogging, physical exercises) tea 3. Low self-esteem 4. powerlessness 5. spiritual distress (express anger toward God, express lack of meaning of life) 6. social isolation/impaired social interaction - 7. disturbed thought process *inappropriate thinking, confusion, difficulty concentrating 8. Imbalanced nutrition: less than body requirement (weight loss, poor muscle tone, pale conjuctiva and mucous membrane) 9. Insomnia (difficulty falling asleep, difficulty staying up, difficulty concentrating) 10. self-care deficit (uncombed hair, disheveled clothing, offensive body odor)

Nursing diagnoses for the suicidal client may include

1. Risk for suicide related to feelings of hopelessness and desperation NI: Have you had thoughts of harming yourself? If so do you have a plan? How strong are your intentions to die? Rationale: the risk for suicide is greatly increased if client has developed a plan with lethal means and particularly if means are accesible create a safe environment maintain close observation of client. provide one-to-one contact, constant visual observation, or q 15 minutes make rounds at frequent irregular intervals (especially at night) 2. Hopelessness related to absence of support systems and perception of worthlessness AEB verbal cues (I can't); decreased affect; lack of initiative; suicidal ideas or attempts The Client: -Has experienced no physical harm to self. -Sets realistic goals for self. -Expresses some optimism and hope for the future.

Drug interactions with MAOIs

1. SSRIs, TCAs, atomoxetine (Strattera), duloxetine (Cymbalta), dextromethorphan (an ingredient in many cough syrups), venlafaxine (Effexor), St. John's Wort, ginkgo= Serotonin syndrome 2. Morphine and other narcotic pain relievers,antihypertensives= Hypotension 3. All other antidepressants, pseudoephedrine, amphetamines, cocaine cyclobenzaprine (Flexeril), dopamine, methyldopa, levodopa, epinephrine, buspirone (BuSpar)= HYPERTENSIVE CRISIS (these side effects can occur even if taken within 2 weeks of stopping MAOIs) 4. Buspirone (BuSpar)= Psychosis, agitation, seizures 5. Antidiabetics= Hypoglycemia 6. Tegretol (mood stabilizer) = Fever, hypertension, seizures

Safety issues and nursing interventions for patients taking antianxiety agents

1. Tolerance and physical dependence -ABRUPT WITHDRAWAL CAN BE LIFE THREATENING S&S include sweating, agitation, tremors, nausea, vomiting, delirium, seizures 2. drowsiness confusion and lethargy are common 3. CNS derpessants are inreased 4. antianxiety may aggravate symptoms depression -assess clients mood and suicide risk 5. orthostatic htn 6. paradoxical excitement (opposite from desired effect) -elder patients at high risk 7. blood dyscrasias -assess for sore throat, fever, bruising or unual bleeding

OCD psychopharmacology

1. antidepressants *The SSRIs fluoxetine, paroxetine, sertraline, and fluvoxamine have been approved by the FDA for the treatment of OCD. >SE: sleep disturbance, HA, and restlessness 2. clomipramine (TCA)

Emotional neglect

A chronic failure by the parent or caretaker to provide the child with the hope, love, and support necessary for the development of a sound, healthy personality

Safety plan

A detailed safety plan should be developed that is an outgrowth of a comprehensive risk assessment and a collaborative, problem-solving discussion with the client. This intervention explores with the client what he or she will do to stay safe if there is a repeat or increase in suicidal thoughts or urges. 1. Recognizing warning signs that precede suicide crises 2. Identifying and employing internal coping strategies that the client can implement w/o needing to contact support people 3. Identifying supportive people and healthy social settings that he or she can use for general support and distraction from suicidal thoughts 4. Identifying family members and friends with whom he or she can discuss suicide 5. identify resources and contact information for mental health profressionals and agencies 6. problems solving with clients ways to reduce potential access to and use of lethal means

Chronic or prolonged grieving

A prolonged grief process may be considered maladaptive when certain behaviors are exhibited. -Behaviors aimed at keeping the lost loved one alive -Behaviors that prevent the bereaved from adaptively performing activities of daily living

Posttraumatic stress disorder (PTSD)

A reaction to an extreme trauma, which is likely to cause pervasive distress to almost anyone, such as natural or manmade disasters, combat, serious accidents, witnessing the violent death of others, being the victim of torture, terrorism, rape, or other crimes Characteristic symptoms -Re-experiencing the traumatic event -Sustained high level of anxiety or arousal -General numbing of responsiveness -Intrusive recollections or nightmares -Amnesia to certain aspects of the trauma -Depression -Survivor's guilt -Substance abuse -Anger and aggression -Relationship problems >May begin within the first 3 months after the trauma >May be a delay of several months or even years >The full symptom picture must be present for more than 1 month and cause significant interference with social, occupational, and other areas of functioning. Diagnostic criteria A. exposure to actual or threatened death, serious injury, or sexual violence B. presence of one or more of the following intrusion symptoms associated with the traumatic events >recurrent, involuntary and intrusive distressing memories of the traumatic events >recurrent or distressing dreams r/t event >dissociative reactions (flashbacks) in which individual feels or acts as it the traumatic events were happening C. Persistent avoidance to stimuli associated with the traumatic event beg. after traumatic event occured >avoidance of distressing memories D. Negative alterations in cognitions and mood associated with the traumatic events, beginning or worsening after event >inability to remember an important aspect of the traumatic event >persistent and exaggerated negative beliefs or expectations about oneself, other or the world >persistent, distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame himself.herself or others

Diagnostic criteria for manic episode

A. a distinct period of abnormally or persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy lasting ONE WEEK, PRESENT MOST OF THE DAY, NEARLY EVERY DAY B. During the period of mood disturbance and increased energy or activity, three of the following symptoms are present to a significant degree, and represent a noticeable change from usual behavior: 1. inflated self-esteem/gradiosity 2. decreased need for sleep (feels rested for only 3 hours) 3.More talkative than usual or pressure to keep talking 4. flight of ideas or subjective experience that thoughts are racing 5. distractability (attention to easily drawn) 6. increase goal directed activity or psychomotor agitation 7. excessive involvement in activities that have a high potential for painful consequences (engage in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others or there are psychotiic features D. The episode is not attributable to physiological effects of a substance (drug of abuse) or to another medical condition *full manic episode that emerges during antidepressant tx (medication and electroconvulsive therapy) but persist at a fully syndromal level beyond the physiological effect of that tx is sufficient evidence for a manic episode and there a bipolar 1 diagnosis

Stage II

Acute mania: Marked impairment in functioning; usually requires hospitalization *Elation and euphoria; a continuous "high" *Flight of ideas; accelerated, pressured speech *Hallucinations and delusions *Excessive motor activity *Social and sexual inhibition *Little need for sleep *Cognition and perception become fragmented and often psychotic in acute mania. Accelerated thinking proceeds to racing thoughts, overconnection of ideas, and rapid, abrupt movement from one thought to another and may be manifested by a continuous flow of accelerated, pressured speech to the point where trying to converse with this individual may be extremely difficult. Attention can be diverted by even the smallest of stimuli. *There is poor impulse control, low frustration tolerance, and the individual who is normally discreet may become socially and sexually uninhibited *Hygiene and grooming may be neglected **Dress may be disorganized, flamboyant, or bizarre, and the use of excessive make-up or jewelry is common.

Anticonvulsants

Anticonvulsants habe mood-stabilizing effects -Refrain from discontinuing the drug abruptly. -Report the following symptoms to the physician immediately: skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin or eyes. -Do not drive or operate dangerous machinery. -Carry identification noting taking lithium. -Avoid using alcohol and over-the-counter medications without approval from physician -avoid consuming alcohol beverages.

Application of the Nursing Process to ADHD

Assessment -Difficulty in performing age-appropriate tasks -Highly distractible -Extremely limited attention span -Impulsive -Difficulty forming satisfactory interpersonal relationships -Demonstrates behaviors that inhibit acceptable social interaction -Disruptive and intrusive in group endeavors -Excessive levels of activity, restlessness, and fidgeting; have boundless energy -Accident prone -Low frustration tolerance and temper outbursts

Role of nurse in ECT

Assessment -The nursing process is the method of delivery of care for the client receiving ECT. -The client must receive a thorough physical examination before initiation of therapy. -This examination should include assessment of cardiovascular and pulmonary status, as well as laboratory blood and urine studies. -A skeletal history and x-ray assessment should also be considered. -The nurse must ensure that informed consent has been granted. -The nurse must also assess mood, level of anxiety, thought and communication patterns, and vital signs. -Appropriate nursing diagnoses are formulated based on assessment data. **MAKE SURE INFORMED CONSENT HAS BEEN GRANTED*** -The nurse must also assess mood, level of anxiety, thought and communication patterns, and vital signs. *CHECK LEVEL OF ORIENTATION -Appropriate nursing diagnoses are formulated based on assessment data

Nursing Process: Assessment for suicide

Assessment -When nurses assess a client's suicide ideation, it is important to identify and distinguish ideas (thoughts), plans (intentions), and attempts (behavior). -When the client has attempted self-injury, it is important to distinguish between suicidal self-injury and nonsuicidal self-injury. 1. Demographics -Age *Adolescents and the elderly have been generally identified as high-risk group -Gender *Males are at higher risk for suicide than females, but females attempt suicide more frequently. -Ethnicity *The CDC reports highest rates of suicide among Caucasians followed by American Indians -Marital status *Single, divorced, and widowed individuals are at higher risk for suicide -Socioeconomic status *Individuals in the highest and lowest socioeconomic classes are at higher risk -Occupation *Healthcare professionals (especially physicians), law enforcement officers, dentists, artists, mechanics, lawyers, and insurance agents -Religion *People with close religious affiliations may be at lower risk for attempting suicide if they believe, for example, that suicide is an unforgivable sin that is strictly forbidden within the religion -Family history of suicide -Military history *Suicide rates among military personnel now exceed those of the general population 2. Presenting symptoms/medical-psychiatric diagnosis *Mood disorders (major depression and bipolar disorders) are the most common disorders that precede suicide *psychiatric disorders in which suicide risks have been identified include anxiety disorders, schizophrenia, anorexia nervosa, and borderline and antisocial personality disorders. -Assessment data must be gathered regarding any psychiatric or physical condition for which a client is being treated. 3. Suicidal ideas or acts -Individuals may provide both behavioral and verbal clues as to the intent of their act. -Determining whether the individual has a plan, and if so, whether he or she has the means to carry out that plan. *Examples of behavioral clues include giving away prized possessions, getting financial affairs in order, writing suicide notes, or sudden lifts in mood (may indicate a decision to carry out the intent). *Verbal clues may be both direct and indirect.ex) "I want to die" "this is the last time you'll see me" "i dont have anything worth living for" 4. Interpersonal support system -Lack of a meaningful network of satisfactory relationships may implicate an individual as a high risk for suicide during an emotional crisis. 5. Analysis of the suicidal crisis -Precipitating stressor *Adverse life events in combination with other risk factors, such as depression, may lead to suicide. Life stresses accompanied by an increase in emotional disturbance include the loss of a loved one either by death or by divorce, problems in major relationships, changes in social or occupational roles, or serious physical illness. -Relevant history *Has the individual experienced numerous failures or rejections that would increase his or her vulnerability for a dysfunctional response to the current situation? -Life-stage issues *The ability to tolerate loss and disappointment is often compromised if those losses and disappointments occur during stages of life in which the individual struggles with developmental issues (e.g., adolescence, midlife). 6. Psychiatric/medical/family history -Previous psychiatric treatment for depression, alcoholism, or previous suicide attempts -Medical history should be obtained to determine the presence of chronic, debilitating, or terminal illness 7. Coping strategies -How has the individual handled previous crisi situations? 8. Presenting symptoms

Application of the Nursing Process to ASD

Assessment 1. Impairment in social interaction -Children with ASD have difficulty forming interpersonal relationships with others. They show little interest in people and often do not respond to others' attempts at interaction -As infants they may have an aversion to affection and physical contact. As toddlers, the attachment to a significant adult may be either absent or manifested as exaggerated adherence behaviors. In childhood, there is a lack of spontaneity manifested in less cooperative play, less imaginative play, and less friendships. 2. Impairment in communication and imaginative activity -Both verbal and nonverbal skills are affected. In more severe levels of ASD, language may be totally absent or characterized by immature structure or idiosyncratic utterances whose meaning is clear only to those who are familiar with the child's past experiences. Nonverbal communication, such as facial expression or gestures, may be absent or socially inappropriate. 3.Restricted activities and interests -Even minor changes in the environment are often met with resistance or sometimes with agitated irritability -Attachment to, or extreme fascination with, objects that move or spin is common -Stereotyped body movements (hand-clapping, rocking, whole-body swaying) and verbalizations (repetition of words or phrases) are typical -Diet abnormalities may include eating only a few specific foods or consuming an excessive amount of fluids -Behaviors that are self-injurious, such as head banging or biting the hands or arms, may be evident

bipolar predisposing factors

Biological theories 1. Genetics -Twin and family studies -Other genetic studies: one parent has it then risk for child having it is 10-20% -Genetics play a part in it 2. Biochemical influences -Possible INCREASE of norepinephrine and dopamine; serotonin levels are LOW 3. Physiological influences -Neuroanatomical factors: changes in brain dysfunction -Medication side effects: steroids used to treat chronic illnesses such as MS & SLE, high doses of amphetamines, narcotics, or antidepressants, anticonvulsants Transactional model of stress and adaptation -Bipolar disorder clearly results from an interaction between genetic, biological and psychosocial determinants. *takes into consideration these etiological influences as well as those associated with past experiences, existing conidtion and individuals perceptions of the event ex) precipitated by an event (a loss), family hx of bipolar, past episode of mania triggered by steroid use/past hx of childhood physical, sexual or emotional trauma, possible electrolyte imabalance, primary (threat to, or loss of, self-esteem)

Bipolar disorder

Bipolar disorder is characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy Delusions or hallucinations may or may not be part of clinical picture. A somewhat milder form of mania is called hypomania.

Antisocial personality disorder

CLUSTER B (dramatic, emotional, or erratic) A pattern of socially irresponsible, exploitative, and guiltless behavior that reflects a general disregard for the rights of others. These individuals exploit and manipulate others for personal gain and are unconcerned with obeying the law. Behavior that is -Socially irresponsible -Exploitative -Without remorse -Behavior reflects a disregard for the rights of others Clinical picture -Fails to sustain consistent employment -Fails to conform to the law -Exploits and manipulates others for personal gain -Fails to develop stable relationships -Prevalence estimates in the United States range from 2 to 4 percent in men to about 1 percent in women -in prison populations the prevalence is 50 percent or higher. Diagnostic criteria A pervasive pattern of disregard for and violation of the rights of others occuring since age 15 years, 3 or more of the following 1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning other for personal proft or pleasure 3. irritability and aggressiveness as indicated by repeated physical fights or assaults 4. reckless disregard for safety of seld or others 5. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations 6. lack of remorse, or rationalizing having hurt mistreated or stolen from another

Borderline personality disorder

CLUSTER B (dramatic, emotional, or erratic) has been established for diagnosing what has been described as "a consistent and stable course of unstable behavior" Characterized by a pattern of intense and chaotic relationships with affective instability Fluctuating and extreme attitudes regarding other people Highly impulsive Emotionally unstable Directly and indirectly self-destructive Lacks a clear sense of identity Affects about 1 to 2 percent of the population More common in women than in men Instability of interpersonal relationships Unstable self-image Marked impulsivity Intensity of affect and behavior Individuals with borderline personality always seem to be in a state of crisis and have frequent mood swings. -They are sometimes described as "thriving on chaos" since their behaviors frequently generate chaos, particularly in interpersonal relationships.

Psychopharmacological Intervention for ADHD

Central nervous system (CNS) stimulants -Examples: Dextroamphetamine, methamphetamine, lisdexamfetamine, methylphenidate, dexmethylphenidate, dextroamphetamine/amphetamine mixture -Side effects: Insomnia, anorexia, weight loss, tachycardia, decrease in rate of growth and development -Children on ADHD drugs had a higher risk of injury-related hospital admissions. -these drugs are known to elevate dopamine and norepinephrine levels it has been hypothesized that their effectiveness is in response to neurotransmitter dysregulation *They have generally mild side effects but they are contraindicated in anyone with cardiac problems or risks for cardiac problems.* Contraindications: -ateriosclerosis -CV disease -HTN -hyperthyroidism -glaucoma -hyper-exctitability ND for medication -Risk for injury r/t overstimulation and hyperactivty (CNS stimulants) or seizures -Risk for suicide secondary to major deprssion -Imbalanced nutrition, less than body requirements r.t side effects of anorexia and weight loss -insomnia r/t overstimulation PT teaching -drowsiness, dizziness and bllurred vision may occur -not stop taking stimulants abruptly -avoid stimulants late in the day to prevent insomnia -monitor blood sugar 2-3x a day -avoid consumption of large amounts of caffeinated beverages -notify doctor if restlessness, insomnia, anorexia, or dry mouth becomes severe OUTCOME -the client is maintaining parameters of growth and development

Generalized anxiety disorder (GAD)

Characterized by chronic, unrealistic, and excessive anxiety and worry that have occured more days than not for at least 6 months and cannot be attributed to specific organic factors -The anxiety and worry are associated with muscle tension, restlessness, or feeling keyed up or on edge. *The symptoms in generalized anxiety disorder are intense enough to cause clinically significant impairment in social, occupational, or other important areas of functioning. The individual often avoids activities or events that may result in negative outcomes, or spends considerable time and effort preparing for such activities. Anxiety and worry often result in procrastination in behavior or decision-making, and the individual repeatedly seeks reassurance from others.

Cyclothymic disorder

Chronic mood disturbance At least 2-year duration Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either bipolar I or II disorder

Tricyclics (TCAs)

DECREASE ACYTELCHOLINE LEVELS Blocks re-uptake of serotonin *INCREASE SERATONIN & NOR-EPINEPHRINE* COMMON SE: a. Dry mouth (offer sugarless candy, ice, frequent sips of water) B. Constipation (increase fluids and foods high in fiber) C. Sedation (request physician to order given at bedtime) D. Orthostatic hypotension (teach client to rise slowly from a sitting or lying position; take vital signs every shift) D. Lower seizure threshold (closely observe client, especially those with history of seizures) Ex -amitriptyline (Elavil) -Imipramine (Tofranil) -Nortriptyline (Pamelor)

Goals/Interventions for Denial

Defined as a "conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety and/or fear, leading to the detriment of health" -Establish trusting relationship -Avoid arguing or bargaining with the client *ST goals: the client will understand correlation between emotional issues and maladaptiveeating behaviors *LT goals: -by discharge, client will demonstrate the ability to discontinue use of maladaptive behaviors and to cope with emotional issues in a more adaptive manner INTERVENTIONS -acknowledge the client's anger at feelings of loss of control brought baout by the established eating regimen -avoid arguing or bargaining with the client who is resistent to tx. State which behaviors are unacceptable and how privileges will be restricted for noncompliance

Planning/Implementation for Anxiety (Panic)

Defined as a vague uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger ST goal: the client verbalizes waus to intervene in escalating anxiety within 1 week LT goal: by time of discharge, the client is able to recognize symptoms of anxiety and interven before reaching panic level -Maintain calm, nonthreatening approach -Keep the immediate surroundings low in stimuli (dim lighting, few people, simple decor) -Teach the client signs of escalating anxiety and ways to interrupt its progression (relaxation such as deep-breathing exercises and meditation, physical exercises such as brisk walks and jogging). -Goals and interventions *Interventions should include not leaving a client alone when experiencing panic, using simple words and brief messages, and exploring the possible reasons for anxiety and panic. Interventions: 1. Stay with client & offer reassurance of safety and security. DO NOT leave the client in panic anxiety 2. Maintain a calm, nonthreatening, matter-of-fact approach 3. use simple words and brief messages, spoken calmly and clearly to explain hospital experiences 4. Hyperventilate may occur, so assist client to breathe into a paper bag 5. administer tranquilizer medication as ordered

Stage III

Delirious mania: A grave form of the disorder characterized by an intensification of the symptoms associated with acute mania *has become rare since the availability antipsychotic medication *cant get them out have TRUE MENTAL DYSFUNCTION! -Labile mood (may develop feelings of despair); panic anxiety, very delirious, very huge feelings of despair and experience irratibility -Clouding of consciousness w/ confusion; disorientation; stupor; auditory or visual hallucinations -Frenzied psychomotor activity -Exhaustion, injury to self and possibly death without intervention, The safety of these individuals is at stake unless this activity is curtailed

Antidepressants ND

Diagnosis 1. Risk for suicide r/t depressed mood 2. Risk for injury r/t se of sedation, lowered seizures threshold, orthostatic htn, hypertensive crisis, or seratonin crisis3. Social isolation R/T depressed mood 4. Risk for constipation r/t se of medication5. Insomnia r/t depressed mood and elevated levels of anxiety

antisocial disorder Outcome Criteria

Discusses angry feelings with staff and in group sessions Has not harmed self or others Can rechannel hostility into socially acceptable behaviors Follows rules and regulations of the therapy environment Can verbalize which behaviors are not acceptable Shows regard for the rights of others by delaying gratification of own desires when appropriate Does not manipulate others to increase self-worth Verbalizes understanding of knowledge required to maintain basic health needs

Negative symptoms

Disturbances in affect: feeling state or emotional tone Inappropriate affect: Emotions are incongruent with the circumstances ex) a young woman laughs when told her mom died Bland: Weak emotional tone -the individual with flat affect appears to be void of emoitonal tone 1. Flat: Appears to be void of emotional tone 2. Apathy: Disinterest in the environment 3. Avolition: inability to initiate goal-directed activity -make take the form of inadequate interest, lack of motivation, neglect of ADLs including personal hygiene, and appearance. Lack of interest or skills in interpersonal interaction Lack of insight -Some individuals lack awareness of having any illness or disorder even when symptoms appear obvious to others. The term for this is "anosognosia." Anergia -Anergia is a deficiency of energy. The individual with schizophrenia may lack sufficient energy to carry out activities of daily living or to interact with others. Anhedonia -Anhedonia is the inability to experience pleasure. Lack of abstract thinking ability Associated features 1. Waxy flexibility -Passive yielding of all movable parts of the body to any effort made at placing them in certain positions -allows body parts to be placed in bizarre or uncomfortable position and will remain there for a long period of time despite it being uncomfortable 2. Posturing -Voluntary assumption of inappropriate or bizarre postures 3. Pacing and rocking -Pacing back and forth and rocking the body 4. Regression -Retreat to an earlier level of development 5. Eye movement abnormalities

ND for schizophrenia

Disturbed thought processes S&S: delusional thinking and suspiciousness >delusional thinking; inability to concentrate; impaired volition; inability to problem-solve, abstract, or conseptualize; extreme suspiciousness of others; inaccurate interpretation of the environment AEB behaviors that indicated the presence of delusional thinking, suspiciousness, and inaccurate interpretation of the environment *defined as disruption in cognitive operation and activities *ST goals: by the end of 2 weeks, client will recognize and verbalize false ideas at times of inccreased anxiety *LT goal: by time of discharge, client verbalization will relflect reality based thinking with no evidence of delusional thinking -Interventions to achieve these goals include promoting the development of trust, focusing on reality, and maintaining an assertive yet genuine approach. *indicate that you do not believe the ideas being shared by the client that they are false *do not argue or deny belief. They will NOT be eliminated if you argue and can destroy rapport with patient *REINFORCE AND FOCUS ON REALITY! Talk about real events and real people!!!

Phase IV: Residual Phase

During this phase, symptoms of the active phase are either absent or no longer prominent. Negative symptoms may remain, and residual impairment often increases between episodes of active psychosis. Negative symptoms MAY REMAIN, and FLAT AFFECT AND IMPAIRMENT IN ROLE FUNCTIONING ARE COMMON. Residual phase -Symptoms are similar to those of the prodromal phase. -Flat affect and impairment in role functioning are prominent. *GOAL TO KEEP THE PERSON IN THE RESIDUAL PHASE

ECT mania

ECT is indicated in the treatment of acute manic episodes and is at least as effective as lithium. *ECT has been shown to be effective in the treatment of manic clients who do not tolerate or fail to respond to lithium or other drug treatmen -bipolar disorder -ECT is also indicated in the treatment of of bipolar disorders with mixed states. -It has been shown to be effective in treating manic clients who are refractory (stubborn) to antimanic drug therapy. -It is still only used when patient has failed to respond to medication. *ECT SHOULD NOT BE USED WHEN THE PATIENT ON LITHIUM**

Electroconvulsive therapy (ECT)

Episodes of acute mania are occasionally treated with ECT. Particularly when the client does not tolerate or fails to respond to lithium or other drug treatment or when life is threatened by dangerous behavior or exhaustion is the induction of a grand mal (generalized) seizure through the application of electrical current to the brain. *disrupt thought process and schizophrenia ECT has long had a negative reputation. Despite its controversial image, ECT has been used continuously for more than 50 years. ECT itself acts as an anticonvulsant, because the seizure threshold increases as treatment progresses. Movements are minimal because of the administration of a muscle relaxant before treatment. Most require 6-12 treatments; some require up to 20. Treatments administered every other day—3 times per week. *give sedatives before

CNS Stimulants

Examples: Amphetamines Caffeine Cocaine Nicotine Symptoms of Use: Hyperactivity, agitation, euphoria, insomnia, anorexia, increased pulse Symptoms of Intoxication: Euphoria, grandiosity, fighting, elevated vital signs, nausea and vomiting, psychomotor agitation Symptoms of Withdrawal -Anxiety, depressed mood, insomnia or hypersomnia, craving for the drug, suicidal ideas (with amphetamines and cocaine)

CNS Depressants

Examples: Anxiolytics Alcohol Sedatives Hypnotics Symptoms of Use: Relaxation, loss of inhibitions, lack of concentration, drowsiness, slurred speech Symptoms of Intoxication: -Aggressiveness, disinhibition, impaired judgment, incoordination, unsteady gait, slurred speech, disorientation, confusion Symptoms of Withdrawal -Tremors, nausea/vomiting, insomnia, seizures, hallucinations, irritability

Inhalants

Examples: Gasoline, lighter fluid, varnish remover, rubber cement, cleaning fluid, spray paint, typewriter correction fluid Symptoms of use: Same as CNS depressants Intoxication Belligerence, apathy, assaultiveness, impaired judgment, dizziness, nystagmus, slurred speech, unsteady gait, lethargy, depressed reflexes, tremor, blurred vision, stupor or coma, euphoria, irritation around eyes, throat, and nose

Cannabinols

Examples: Marijuana Hashish Symptoms of Use Relaxation, talkativeness, lowered inhibitions, euphoria, mood swings Intoxication: Impaired judgment, loss of recent memory, tremors, muscle rigidity, conjunctival redness, panic, paranoia Withdrawal: If high doses are used for a prolonged period, symptoms of nervousness, tremor, insomnia, and restlessness may occur upon cessation of use.

Hallucinogens

Examples: Mescaline LSD PCP Symptoms of Use: Visual hallucinations, disorientation, confusion, paranoia, euphoria, anxiety, panic, increased pulse Intoxication: Belligerence, impulsiveness, psychomotor agitation, increased heart rate and blood pressure, ataxia, seizures, panic reaction, delirium Withdrawal: The occurrence of a withdrawal syndrome with these substances has not been established.

Opioids

Examples: Opium Morphine Codeine Heroin Meperidine Symptoms of Use: Euphoria, lethargy, drowsiness, lack of motivation Symptoms of Intoxication: -Euphoria, lethargy, somnolence, apathy, dysphoria, impaired judgment, slurred speech, constipation, decreased respiratory rate and blood pressure Symptoms of Withdrawal: -Craving for the drug, nausea/vomiting, muscle aches, lacrimation, rhinorrhea, piloerection or sweating, diarrhea, yawning, fever, insomnia

Antisocial personality disorder common behaviors

Exploitation and manipulation of others for personal gain Belligerent and argumentative Lacks remorse Unable to delay gratification Low frustration tolerance Inconsistent work or academic performance Failure to conform to societal norms Impulsive and reckless Inability to function as a responsible parent Inability to form lasting monogamous relationship

Schizo Prognosis

Factors associated with a positive prognosis include -Good premorbid functioning -Later age at onset -Female gender -Abrupt onset precipitated by a stressful event (as opposed to gradual, insidious onset of symptoms) -Associated mood disturbance -Brief duration of active-phase symptoms -Minimal residual symptoms -Absence of structural brain abnormalities -Normal neurological functioning -Family history of mood disorder - depression, bipolar disorder -No family history of schizophrenia

Evaluation of Care for a Manic Episode

Final step of the nursing process -A reassessment is conducted. -This determines if the nursing actions have been successful in achieving the objectives of care. Nursing actions for client experiencing a manic episode Has the individual avoided personal injury? Has violence to client or others been prevented? Has agitation subsided? Have nutritional status and weight been stabilized Have delusions and hallucinations ceased? Is the client able to make decisions about own self-care? Is behavior socially acceptable? Is the client able to sleep 6 to 8 hours per night and awaken feeling rested? Does client understand the importance of maintenance medication therapy? Can the client taking lithium verbalize early signs of lithium toxicity?

Predisposing Factors to Antisocial Personality Disorder

Having a disruptive behavior disorder as a child (attention deficit/hyperactivity disorder; conduct disorder) History of severe physical abuse Absent or inconsistent parental discipline Extreme poverty Removal from the home Growing up without parental figures of both sexes Always being rescued when in trouble Maternal deprivation

Disturbances in perception

Hallucinations may involve any of the 5 senses -Auditory -Visual *Visual hallucinations may consist of formed images, such as of people, or of unformed images, such as flashes of light. -Tactile *Tactile hallucinations are false perceptions of the sense of touch, often of something on or under the skin. One specific tactile hallucination is formication, the sensation that something is crawling on or under the skin. -Gustatory *Gustatory hallucinations are false perceptions of taste. Most commonly, gustatory hallucinations are described as unpleasant tastes. -Olfactory *Olfactory hallucinations are false perceptions of the sense of smell. Illusions are misperceptions or misinterpretations of REAL EXTERNAL STIMULI Echopraxia imitates movements made by others

Criteria for Measuring Outcomes

Have a pt experience mania... >The client -Exhibits no evidence of physical injury *person thinks they can jump the building and still survive, they think they can fly VERY HIGHTENED SENSES -Has not harmed self or others -Is no longer exhibiting signs of physical agitation -Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status -Verbalizes an accurate interpretation of the environment -Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations -Accepts responsibility for own behaviors -Does not manipulate others for gratification of own needs; they will manipulate people to get their needs met and take feelings into consideration -Interacts appropriately with others -Is able to fall asleep within 30 minutes of retiring or laying down -Is able to sleep 6 to 8 hours per night rather than three in three nights

Stage 1

Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization. *Cheerful mood *Rapid flow of ideas; heightened perception but the individual is so easily distracted by irrelevant stimuli and goal-directed activities are difficult *Increased motor activity. They are perceived as being very extroverted and sociable, but they lack the depth of personality and warmth to formulate close friendships *they talk laugh very loudly & often inappropriate

ND for a manic episode

IMPAIRED SOCIAL INTERACTION R/T delusional thought process, underdeveloped ego and low self-esteem AEB inability to develop satisfying relationship and manipulation of others for own desires ST goals: client verbalize which of his or her interaction behaviors are appropriate LT Goals: client demonstrates use of appropriate interaction skills AEB lack of marked in decrease in manipulation of other to fulfill own desires *the nurse will set limits on MANIPULATIVE DISORDERS and tell the pt what the consequences are NURSING INTERVENTIONS *Do not argue or try to reason with patients; merely state the limits and expectations; confront pt if he/she is manipulative towards others *Provide positive reinforcement for nonmanipulative behaviors *help pt recongize he must accept consequences of bad behavior *help client identify positive aspects *help client indentify positive aspect about self, recongize accomplishments and feel good about them

ND for schizophrenia

Impaired verbal communication R/T panic anxiety, regression, withdrawal, disordered, unrealistic thinking AEB loose association of ideas, neologisms word salad, clang association, echolalia, verbalization that reflect concrete thinking, poor eye contact -Defined as decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols ST goal: client demonstrates the ability to remain on one topic, using appropriate, intermittent eye contact NI: attempt to decode incomprehensible communication pattern. Seek validation and clarification by stating "is it that you mean...?" LT goal: by the time of discharge from tx, client demonstrates ability to carry on a verbal communication in a socially acceptable manner NI: technique of verbalizing the implied who is mute. ex) that must have been a very difficult time for your mother left. you must feel alone" *shows empathy and encourages client to disclose painful issues -Orient client to reality as required. Call client by name. Validate those aspects of communication that help differentiate between what is real and not real -explanation must be required at client's level of comprehension Interventions include facilitating trust and understanding in a nonthreatening manner, orienting the client to reality as required, and avoiding abstract phrases and clichés.

Physical neglect of a child

Includes refusal of or delay in seeking health care, abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision

Severe depression

Includes symptoms of major depressive disorder and bipolar depression -feel worse early in the morning and somewhat better as the day progresses. -Affective: Feelings of total despair, worthlessness, flat affect -Behavioral: Psychomotor retardation, curled-up position, absence of communication -Cognitive: Prevalent delusional thinking, with delusions of persecution and somatic delusions; confusion; suicidal thoughts may not be able to follow through d/t low energy levels -Physiological: a general slow-down of the entire body *constipation, sluggish digestion, urinary retention, diminished libido -Severe depression (also called major depressive disorder), is characterized by an intensification of the symptoms described for moderate depression

Serotonin-norepinephrine reuptake inhibitors (SNRI)

Increase level of serotonin and norepinephrine EX: -venlafaxine (Effexor) -duloxetine (Cymbalta) Do not use with MAOI's can cause hypertensive crisis Should wait at least 14 days after DC MAOI's before starting SNRI Withdrawal slowly do not stop abruptly Watch for drops in blood pressure (postural hypotension)

Treatment Modalities for Bipolar Disorder

Individual psychotherapy Group therapy Family therapy Cognitive therapy

CASE (Chronological Assessment of Suicide Events)

It is described as flexible guide for interviewing that includes communication techniques designed to elicit and enhance detailed, valid feedback from clients about sensitive topics like suicide. 1. Normalizing communicates that the client is not the only one who experiences suicidal ideation. -Example: "Sometimes when people are in a lot of emotional pain, they have thoughts of killing themselves. Have you had any thoughts like that?" 2. Asking about behavioral events rather than the client's opinions -Example: "What did you do when you had those thoughts?" "How many pills did you take?" What happened next?" 3. Gentle assumptions encourage further discussion by assuming there is more to tell. -Example: "What other times have you tried to attempt suicide?" 4. Denial of the specific is helpful when a client generally denies suicidal ideation. -This strategy encourages more in-depth thought and response by asking questions that might trigger memories of specific events. Example: After the client denies suicidal ideation in response to a general question, the nurse asks more specifically, "Have you ever thoughts of overdosing?" "Have you ever had thoughts about shooting yourself?" 5. Chronologically exploring the presenting suicide event, recent suicide events, past suicide events, and finally the immediate suicide events can broaden our understanding of the patient's immediate suicidal intent in the context of their behavior over time.

Profile of the victimizer

Low self-esteem Pathologically jealous "Dual personality" Limited coping ability Severe stress reactions Views spouse as a personal possession

ECT indications

Major Depression -ECT has been shown to be effective in the treatment of severe depression. -ECT is typically considered only after a trial of therapy with antidepressant medication has proved ineffective. -May be considered the treatment of choice *When need for treatment response is urgent *Patients who are extremely suicidal or refusing food and nutritionally compromised

The Nursing Process: Mood-Stabilizing Agents

Mood-stabilizing agents For years, the drug of choice for treatment of bipolar mania was lithium carbonate. These drugs are in the class of anticonvulsant medications, which are now FDA-approved for mood stabilization. Some second-generation atypical antipsychotics have also demonstrated benefits for management of this disorder. "Bipolar disorder" is characterized by cycles of depression and manic episodes. The effective medication treatment for this disorder is one that reduces the "ups and downs." Lithium was first identified as an anti-manic but was successful for stabilizing the mood swings of bipolar disorder. Interactions: -With mood stabilizers, many drugs either increase or decrease their effectiveness. -As lithium is a salt, anything that depletes sodium will make more receptors sites available and increase the risk for lithium toxicity. -Other drugs that increase serum sodium levels also have an impact on lithium levels.

Antisocial personality disorder Nursing Process: Assessment

Not often seen in most clinical settings -Individuals with antisocial personality disorder are seldom seen in most clinical settings, and when they are, it is commonly a way to avoid legal consequences Most frequently encountered in prisons, jails, and rehabilitation services **Psychopathy is described as personality traits that include low fear, low empathy, domination, callous cruelty, and emotional insensitivity.*** -Antisocial personality disorder is a pattern of socially irresponsible, exploitative, and guiltless behavior that reflects a general disregard for the rights of others. These individuals exploit and manipulate others for personal gain and are unconcerned with obeying the law. They have difficulty sustaining consistent employment and in developing stable relationships. -Their pattern of impulsivity may be manifested in failure to plan ahead culminating in sudden job, residence, or relationship changes. When things go their way, individuals with this disorder act cheerful, even gracious and charming. Because of their low tolerance for frustration, this pleasant exterior can change very quickly.

Normal Versus Maladaptive Grieving

One crucial difference between normal and maladaptive grieving: the loss of self-esteem!!! Symptoms: -self-esteem is distrubed -usually does not directly express anger (since it is turned inward) -persistent state of dysphoria -anhedonia (inability to feel pleasure) is prevalent -does not respond to social interaction and support from others -feelings of hopelessness prevail -has generalized feelings of guilt -does not release feelings to a particular experience -expresses chronic physical complaints

Schizophrenia Nursing Process: Assessment

Positive symptoms -Disturbances in thought content -Delusions: False personal beliefs 1. Persecutory: belief that one is going to be harmed by others 2. referential: belief that cues in the environment are specifically referring to them 3. grandiose: belief that they have exceptional greatness 4. somatic: beliefs that center on ones body functioning -Paranoia: Extreme suspiciousness of others -Magical thinking: Ideas that one's thoughts or behaviors have control over specific situations -Hallucinations *Auditory (most common) *Visual *Tactile *Olfactory *Gustatory -Disorganized thinking -Grossly disorganized or abnormal motor behavior *hyperactivity *hypervigilance *hostility *agitation *catatonic excitement

Goals/Interventions for Imbalanced Nutrition and Deficient Fluid Volume

R/T refusal to eat/drink; self-induced vomiting; abuse of laxatives/diuretics AEB loss of weight, poor muscle tone and skin turgor, lanugo, bradycardia, htn, cardiac arrythmias; pale, dry mucous membranes -Do not focus on food and eating specifically -Keep a strict record of intake and output!! *ST goal: -client will gain x pounds per week -client will drink 125 ml of fluid each hour *LT goal: -by time of discharge from tx, client will exhibit no s&s of malnutrition and dehydration Interventions: -administer liquid via NG tube, weigh client daily, stay with client during established time of meals, if nutritional status detoriorates, NG tube will be enforced -do not focus only on food and eating specifically, focus on emotional issues -assessing vital signs and blood pressure to evaluate for bradycardia -assess skin turgor, color moistness -client should be observed for at least 1 hour following meals (client may use this time to discard meals)

Rape

Rape, a type of sexual assault, occurs over a broad spectrum of experiences ranging from the surprise attack by a stranger to insistence on sexual intercourse by an acquaintance or spouse. 1. Acquaintance rape (or date rape if the encounter is a social engagement agreed to by the victim) is a term applied to situations in which the rapist is acquainted with the victim 2. Marital rape 3. Statutory rape is defined as unlawful intercourse between a person who is over the age of consent and a person who is under the age of consent

Mood-Stabilizing diagnosis

Risk for injury related to manic hyperactivity Risk for self-directed or other-directed violence related to unresolved anger Risk for injury related to lithium toxicity Risk for injury related to adverse effects of mood-stabilizing drugs Risk for activity intolerance related to side effects of drowsiness and dizziness

Antipsychotics ND

Risk for other-directed violence related to panic anxiety and mistrust of others. Risk for injury related to medication side effects of sedation, photosensitivity, reduction of seizure threshold, agranulocytosis, extrapyramidal symptoms, tardive dyskinesia, neuroleptic malignant syndrome, and/or QT prolongation. Risk for activity intolerance related to medication side effects of sedation, blurred vision, and/or weakness. Noncompliance with medication regimen related to suspiciousness and mistrust of others.

Risk for trauma R/T impairment in cognitive and psychomotor functionig

Risk for trauma R/T impairment in cognitive and psychomotor functionig -Because the individual has impairments in cognitive and psychomotor functioning, it is important to ensure that the environment is as safe as possible to prevent injury. Short-term goals -Client will call for assistance when ambulating or conducting other activities (if within cognitive ability). -Client will maintain a calm demeanor, with minimal agitated behavior. -Client will not experience physical injury. Long-term goal -Client will not experience physical injury. Interventions -For an agitated client, maintain a low level of stimuli to try to mitigate irritability, hostility, aggression, and psychotic behaviors. -When caring for a client who wanders, keep the individual on a structured schedule, and provide a safe, enclosed space for wandering.-arrange the furniture and other items in the room to accomodate the client's disabilities -a room near the nurse station to ensure close observation -assist client with ambulation: provide cane or walker -teach client to hold on to hand rail if one is available *FOR AGITATED CLIENT -maintain a low level of stimuli to try to mitigate irritability, hostility, aggression, and psychotic behaviors. -antipsychotics use to help manage behavioral symptoms in patients -remain calm and undemanding *FOR CLIENT WHO WANDERS -keep the individual on a structured schedule of recreational activities and a strict feeeding and toileting schedule, and provide a safe, enclosed space for wandering.

ND for schizophrenia

Risk for violence Client goals -ST goal: within one week, the client will be able to recognize signs of increasing anxiety and agitation and report to staff for assistance -client will not harm others -LT goals: client will not harm others Interventions -maintain a low level of stimuli in the clients environment (low lighitng, few people, simple decor) -assess for presenc of suicidal ideation -Intervene at the first sign of increased anxiety, agitation, or verbal or behavioral aggression. -Validation of the client's feelings conveys a caring attitude and offering assistance reinforces trust -Observe client's behavior frequently while carrying out routine activities to avoid creating suspicion. Close observation is necessary so that intervention can occur if required to ensure client (and others') safety. -Assess for presence of suicidal ideation and/or command hallucinations that may be instructing the client to harm themselves, and remove all dangerous objects from client's environment so that the client may not use them to harm self or others. -It is important to maintain a calm attitude toward the client. As the client's anxiety increases, offer some alternatives: participating in physical activity (e.g., punching bag, exercise), talking about the situation, taking anti-anxiety medication. Offering alternatives gives the client a feeling of some control over the situation. -Have sufficient staff available to indicate a show of strength to client if it becomes necessary. This shows the client evidence of control over the situation and provides some physical security for staff. -use of restraint may be necessary. Restraints should be used only as a last resort, after all other interventions have been unsuccessful

Planning/Implementation

Risk for violence: Self-directed or other-directed S&S: manic excitement, delusional thinking, hallucinations *Remove all dangerous objects from the environment. *Maintain a calm attitude. *If restraint is deemed necessary, ensure that sufficient staff is available to assist. *limit stimuli if experiencing manic epidose: place in a quiet room (very few people) *Goals and interventions -Goals should include helping the client recognize signs of anxiety and agitation and preventing the client from harming themselves or others. -Interventions include maintaining a low level of stimuli, observing the client's behavior frequently (but don't spy on pt), and intervening at the first sign of agitation or aggression (important to remain calm around pt)

Risk for suicide

S&S -depressed mood -feelings of worthlessness and hopelessness -anger turned inward on self Defined as vulnerable to self-inflicted, life-threatening injury Short-term goals -Client will seek out staff when feeling urge to harm self -Client will not harm self Long-term goal -Client will not harm self Interventions -check for medication -ask if they have thoughts of suicide and if said yes then ask if they have a plan? -create a safe environment: remove all harmful objects, supervise closely during meals and medication (may save to OD) -Convey an attitude of unconditional acceptance of the client as a worthwhile individual -encourage client to actively participate in establishing a safety plan -provide one-to-one contact if the patient is at high risk for suicide such as making 15 minutes rounds conducting irregular intervals (patient will not know) -MAKING ROUNDS AT IRREGULAR INTERVALS -orient client to reality

Complicated grieving

S&S -fixed in anger stage of grief -social isolation -obsession with loss -loss of weight R/T real or perceived loss, bereavement overload AEB denial or loss, inappropriate expression of anger, idealization of or obsessions with lost object, inability to carry out ADLs Short-Term Goals -Client will express anger about the loss. -Client will identify coping strategies and rational thought patterns in response to loss. Long-Term Goal -Client will be able to recognize his or her own position in the grief process, while progressing at own pace toward resolution. Interventions: ASSESS THE STAGE OF GRIEF THE PATIENT IS IN! -Determine the stage of grief in which the client is fixed. Identify behaviors associated with this stage. -develop a trusting relationship w client -convey an acceptance attitude and enable client to express feeling openly -encourage client to express anger -help client discharge pent-up anger through participation in large motor activities (jog, running) -teach the normal stages of grief -communicate that crying is acceptable -encourage client to reach out for spiritual support

Low self-esteem/self-care deficit

S&S -self-negating comments -expressions of worthlessness -negative pessimistic outlook Low self-esteem -Defined as negative self-evaluating/feelings about self or self-capabilities 1. Short-Term Goals -Client will verbalize attributes he or she likes about self. -Client will participate in ADLs with assistance from healthcare provider. 2. Long-Term Goals -By time of discharge from treatment, the client will exhibit increased feelings of self-worth as evidenced by verbal expression of positive aspects of self, past accomplishments, and future prospects. -By time of discharge from treatment, the client will exhibit increased feelings of self-worth by setting realistic goals and trying to reach them, thereby demonstrating a decrease in fear of failure. -By time of discharge from treatment, the client will satisfactorily accomplish ADLs independently. Self-care deficit -Defined as impaired ability to perform or complete activities of daily living (ADLs) for self Interventions: -be accepting of the client -promote attendance in therapy groups -encourage client to recognize areas of change -teach assertiveness techniques -teach effective communications such as using "I" -emphasize ways to avoid making judgmental statements -encourage independence -keep strict records of food & fluid intake: offer nutritious snacks and fluids between meals -promote sleep such as back rubs, warm bath, soft music, and relation technique

Powerlessness

S&S: -feelings of no control over life -cannot perceive improvement in life situation Defined as the lived experience of lack of control over a situation, including a perception that one's actions do not significantly affect an outcome Short-Term Goal -Client will participate in decision-making regarding own care within 5 days. Long-Term Goal -Client will be able to effectively problem-solve ways to take control of his or her life situation by time of discharge from treatment, thereby decreasing feelings of powerlessness. Interventions -encourage client to take much responsibility as possible for his or her own self-care practices, client may have extreme difficulty making decisions so it may be helpful using ACTIVE COMMUNICATION to help the client accomplish ADLs. EX) "it is time to eat lunch" -allow the client to establish own schedule for self-care activities -help the client identify areas of his or her life situation can be controlled.

Phase III: Active Psychotic Phase

Schizophrenia is a chronic illness but is characterized by acute episodes in which symptoms are more pronounced. -Delusions -Hallucinations -Impairment in work, social relations, and self-care

Sexual Abuse of a Child

Sexual exploitation of a child -A child is induced or coerced into engaging in sexually explicit conduct for the purpose of promoting any performance, and child sexual abuse, in which a child is being used for the sexual pleasure of an adult Incest -Occurrence of sexual contacts or interaction between, or sexual exploitation of, close relatives, or between participants who are related to each other by a kinship bond that is regarded as a prohibition to sexual relations

Child Abuse

Signs of physical abuse -Unexplained injuries -Fading bruises or other marks -Child is frightened of adults -Shrinks at approach of adults -Child reports injury by parent or caregiver -Abuses animals or pets

Phase II: Prodromal Phase

Social withdrawal is not uncommon. -Lasts from a few weeks to a few years -Deterioration in role functioning and social withdrawal -Substantial functional impairment -Sleep disturbance, anxiety, irritability -Depressed mood, poor concentration, fatigue' -Perceptual abnormalities, ideas of reference, and suspiciousness herald onset of psychosis

Safety issues in planning and implementing care

Some of the common, but manageable, side effects of antidepressant medications include dry mouth, sedation, and nausea. Some patients taking SSRIs or SNRIs complain of sexual dysfunction. Nursing interventions: 1. drug interactions *instruct client to inform nurse and physician of all medications they are taking, including herbal preparation, OTC *monitor VS *protect from injury secondary to muscle rigidity or change in mental status *provide cooling blankets for temp regulations 2. Increase risk for suicide *assess frequently for presence of worsening suicide ideation *initiate suicide precautions 3. sedation * instruct client not to drive or operate heavy machinery 4. discontinuation syndrome -SSRIs: dizziness, lethargy, HA, nausea -TCAs: hypomania, akathisia, cardiac arrythmias, GI upset, panick attacks -MAOIs: flu-like symptoms, confusion hypomania *Pt educate: medicine should not be stooped abruptly 5. Photosensitivity -Pt educate: instruct client of their vulnerability of sunburn and recommend sunscreen 6. orthostatic htn (TCA) -instruct client to rise slowly from sitting to standing 7. tachycardia, arrythmias (TCA) *monitor vital signs 8. hyponatremia (SSRIs) -especially among the elderly -instruct client to report any symptoms of nausea, malaise, lethargy, muscle cramps -assess for disorientation or restlessness 9. blurred vision (TCAs) *avoid driving and reassure them that side side effect usually resolves within 3 weeks *monitor BP to rule out symptoms of high bp 10. Constipation recommend high-fiber, increase PO, increase exercise 11. . Dry mouth (offer sugarless candy, ice, frequent sips of wate OUTCOME -Manifests symptoms of improvement in mood (brighter affect, interaction with others, improvement in hygiene, clear thought, expressing hopefulness, ability to make decisions).

Moderate depression

Symptoms associated with dysthymic disorder *more problematic disturbance that have been going on for 2 years -Individuals with moderate depression feel best early in the morning and continually worse as the day progresses -Affective: Helpless, powerless, low self-esteem, feelings of sadness, difficulty experiencing pleasure -Behavioral: Slowed physical movements, slumped posture, limited verbalization -Cognitive: Retarded thinking processes, difficulty with concentration -Physiological: Anorexia or overeating, sleep disturbance, headaches "Dysthymia" (Persistent depressive disorder)

Outcome Criteria-schizophrenia

The client -Demonstrates ability to relate satisfactorily with others -Recognizes distortions of reality -Has not harmed self or others -Perceives self realistically -Demonstrates ability to perceive environment correctly -Maintains anxiety at a manageable level -Relinquishes the need for delusions and hallucinations -Demonstrates the ability to trust others -Uses appropriate verbal communication in interactions -Performs self-care activities independently OTHER NURSING DIAGNOSES -Risk for violence -impaired verbal communiation -self-care deficit -ineffective health maintenance -impaired home maintenance INTERVENTIONS WHEN WORKING WITH SUSPICIOUS CLIENTS -to promote dev. of trust, use the same staff -avoid physical contact. Ask the client's permission first before touching -avoid laughing, whispering, or talking quietly where the client can see you but cannot hear what is being said -extremely suspicious client may believe they are being poisoned and may refuse to eat so may be necessary to provide canned food -competitive activities may be threatening to suspicious clients. -maintian assertive. matter-of-fact yet genuine approache with suspicious client! Approaches that are overly directive or cheerful may increase client's suspiciousness

outcomes of eating disorders

The client -Has achieved and maintained at least 80 percent of expected body weight -Has vital signs, blood pressure, and laboratory serum studies within normal limits -Verbalizes importance of adequate nutrition -Verbalizes knowledge regarding consequences of fluid loss caused by self-induced vomiting (or laxative/diuretic abuse) and importance of adequate fluid intake -Verbalizes events that precipitate anxiety and demonstrates techniques for its reduction -Verbalizes ways in which he or she may gain more control of the environment and thereby reduce feelings of powerlessness -Expresses interest in welfare of others and less preoccupation with own appearance -Verbalizes that image of body as "fat" was misperception and demonstrates ability to take control of own life without resorting to maladaptive eating behaviors (anorexia nervosa) -Has established a healthy pattern of eating for weight control and weight loss toward a desired goal is progressing (BED) -Verbalizes plans for future maintenance of weight control (BED/bing-eating disorder)

Outcome Criteria for NCD

The client -Has not experienced physical injury -Has not harmed self or others -Has maintained reality orientation to the best of his or her capability -Discusses positive aspects about self and life -Participates in activities of daily living with assistance

BPD Diagnosis/Outcome Identification

The client -Has not harmed self -Seeks out staff when desire for self-mutilation is strong -Is able to identify true source of anger -Expresses anger appropriately -Relates to more than one staff member -Completes activities of daily living independently -Does not manipulate one staff member against the other in order to fulfill own desires Reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care.

Outcomes

The client -Is able to recognize signs of escalating anxiety and intervene before reaching panic level (panic and GAD) -Is able to maintain anxiety at manageable level and make independent decisions about life situation (panic and GAD)

Outcome Criteria/Evaluation OF SCHIZOPHRENIA

The client: -Has not harmed self or others. -Has not experienced injury caused by side effects of lowered seizure threshold or photosensitivity. -Maintains a WBC within normal limits. -Exhibits no symptoms of extrapyramidal side effects, tardive dyskinesia, neuroleptic malignant syndrome, or hyperglycemia. -Maintains weight within normal limits. -Tolerates activity unaltered by the effects of sedation or weakness. -Takes medication willingly. -Verbalizes understanding of medication regimen and the importance of regular administration.

The Nursing Process: Mood-Stabilizing Agents OUTCOME

The client: -Is maintaining stability of mood. -Has not harmed self or others. -Has experienced no injury from hyperactivity. -Is able to participate in activities without excessive sedation or dizziness. -Is maintaining appropriate weight. -Exhibits no signs of lithium toxicity. -Verbalizes importance of taking medication regularly and reporting for regular laboratory blood tests.

Maladaptive Responses to Loss

Three types of pathological grief reactions have been described 1. Delayed or inhibited grief 2. Exaggerated or distorted grief response 3. Chronic or prolonged grief

Phase I: Premorbid Phase

Traits that have been noted include being very shy and withdrawn, having poor peer relationships, doing poorly in school, and demonstrating antisocial behavior. -Social maladjustment -Antagonistic thoughts and behavior -Shy and withdrawn -Poor peer relationships -Doing poorly in school -Antisocial behavior

ANTIDEPRESSANTS

Tricyclics Selective serotonin reuptake inhibitors (SSRI) Monoamine oxidase inhibitors (MAOIs) Heterocyclics Serotonin-norepinephrine reuptake inhibitors (SNRI)

Bipolar II disorder

a disorder characterized by alternating periods of extremely depressed and mildly elevated moods Has never met criteria for full manic episode *Symptoms not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization

Schizophrenia

a group of severe disorders characterized by disorganized and delusional thinking, disturbed perceptions, and inappropriate emotions and actions Schizophrenia causes disturbances in -Thought processes -Perception -Affect *With schizophrenia, there is a severe deterioration of social and occupational functioning. *Symptoms generally appear in late adolescence or early adulthood, although they may occur in middle or late adult life. *The DSM-5 diagnostic criteria for schizophrenia includes the presence of delusions, hallucinations, disorganized speech and behavior, or negative symptoms, as well as decreased level of functioning in areas of work, personal relationships, or self-care.

no-suicide contract

a promise not to attempt suicide, or at least a promise to reestablish contact if the caller again considers suicide -used by clinicians in the context of a long-term therapeutic relationship in whcih the client promises to contact the clinician before acting on suicidal ideation A CONTRACT

Delirium

characterized by a disturbance in attention and awareness and a change in cognition that develop rapidly over a short period of time Symptoms -Difficulty sustaining and shifting attention -Extreme distractibility -Disorganized thinking -Speech that is rambling, irrelevant, pressured, and incoherent -Impaired reasoning ability and goal-directed behavior -Disorientation to time and place -Impairment of recent memory -Misperceptions about the environment, including illusions and hallucinations -Disturbances in the sleep-wake cycle: hypersomnolence and insomnia -Psychomotor activity that fluctuates between agitation and restlessness and a vegetative state resembling catatonic stupor -State of awareness may range from hypervigilance to stupor or semicoma -Sleep may fluctuate between hypersomnolence and insomnia -Vivid dreams and nightmares are common

Impaired verbal communication

decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols. Short-term goals -Client will be able to make needs known to primary caregiver. -Client is able to understand basic communications in interactions with primary caregiver. Long-term goal -In latter stages of the illness when client is unable to communicate, needs are anticipated and fulfilled by primary caregiver. *The goal of treating clients with impaired verbal communication is to ensure that the client is able to make their needs known and that needs are anticipated and fulfilled!!!!!!!!* INTERVENTIONS: -Interventions include keeping interactions calm and reassuring, using nonverbal gestures, and maintaining consistency. -use simple words, speak slowly, and keep face-to-face contact with client -always indentify yourself to the client and call him/her by name -ask one question at a time -always try to approach client from the front -maintaining consistency of staff and caregivers, this facilitates comfort and security

Seratonin syndrome

diarrhea, restlessness, agitation, hyperreflexia, fluctuations in vital signs, hyperthermia, uncontrolled shivering, epilepticus, CV collapse, and death

Self-care deficit

impaired ability to perform or complete activities of daily living Short-term goal -Client will participate in ADLs with assistance from caregiver. Long-term goals -Client will accomplish ADLs to the best of his or her ability. -Unfulfilled needs will be met by caregiver. INTERVENTIONS: -Interventions include providing guidance and support, minimizing confusion, and performing ongoing assessment of the client's ability and anticipating needs. -provide simple structured environment for the client, identify self-care deficits, -allow plenty of time for client to complete tasks -provide structured schedule of activities that does not change -ensure ADLs follow the cleint's usual routine

ECT contraindication

increased intracranial pressure or MI within the past 2 weeks -Myocardial infarction or cerebrovascular accident within preceding 3-6 months -aortic or cerebral aneurysm -severe underlying hypertension -congestive heart failure -Patients with intracranial lesions may be at risk for edema or brain herniation after ECT. -Patients with increased intracranial pressure are at increased risk related to increased cerebral blood flow during seizures. -Severe osteoporosis, acute and chronic pulmonary disorders, and high-risk or complicated pregnancy. *because oxytcin levels increase after ECT

Monoamine oxidase inhibitors (MAOI's)

inhibits destruction of monoamine oxidase (norepinephrine, serotonin) -The first antidepressant medications -DEADLY FOR ANYONE WHO ATE FOOD HIGH IN TYRAMINE Do not use with tricyclics may cause hypertensive crisis Ex -isocarboxazid (Marplan) -phenelzine (Nardil)

Nursing Process/Assessment for bipolar disorder

stage 1 stage 2 stage 3 -can be described according to three stages: hypomania, acute mania and delirious

ECT side effects

temporary memory loss and confusion (Proponents insist they are temporary and reversible)