N324 exam 1

CBT Treatment goals

* CBT uses a range of strategies such as psychoeducation, behavior modification, cognitive therapy, exposure therapy, and stress management to help manage behavior and change maladaptive beliefs and thoughts.

EMDR treatment goals

* EMDR therapy processes traumatic memories though a specific eight-phase protocol. The advanced practice nurse asks the patient to think about the traumatic event. At the same time the patient attends to other stimulation such as eye movements, audio tones, or tapping. The combination of thinking and other stimuli bring about neurological and physiological changes that help people process and integrate traumatic memories. Thus, decreasing arousal when encountering trauma associated cues

PTSD DSM-5 Criteria BOX

* Older than 6 * Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) ways * Presence of one (or more) intrusion symptoms associated with traumatic event(s), beginning after the traumatic event(s) occurred * Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. * Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). * Marked physiological reactions to cues * Persistent avoidance of stimuli * Negative alterations in cognitions and mood * Persistent distorted cognitions about the cause of * Persistent negative emotional state * Markedly diminished interest or participation in significant activities. * Feelings of detachment or estrangement from others. * Persistent inability to experience positive emotions * Marked alterations in arousal and reactivity * Duration of the disturbance is more than 1 month. * The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. * The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Overall Suicide Risk Factors

*Biological- Factors-genetics, epigenetics *Psychological-hopelessness. Cognitive styles that contribute to higher risk are rigid all-or-nothing thinking, inability to see different options, and perfectionism. *Environmental factors-A copycat suicide follows a highly publicized suicide of a public figure, an idol, or a peer in the community. Adolescents are at especially high risk due to their immature prefrontal cortex, the portion of the brain that controls the executive functions involving judgment, frustration tolerance, and impulse control. *Cultural factors- including religious beliefs, family values, sexual orientation, gender identity, bullying behavior, and attitude toward death, have an impact on suicide rates.

Assessing family history

-Current and past family structure and their ages -Descriptions of significant others in words of the patient -Traumas, deaths, or significant changes in family structure

Assessing the present problem

-Focus on whatever complaint the individual identifies as the reason for assessment -Evaluate danger of harm to self or others -Evaluate aggressiveness or homicidal tendencies -Evaluate any suspicion of child abuse

Assessing substance abuse

-Substance types -Onset of use -Length of time and duration of use -Amount of use -Any previous treatments for use -Does the patient feel like the use is negatively or positively impacting their life

Exam systems (appearance to insight/ judgment)

1. Appearance 2. Attitude 3. Behavior 4. Speech 5. Affect 6. Mood 7. Thought Processes 8. Thought Content 9. Perception 10. Orientation 11. Memory/ Concentration 12. Insight/Judgement

Mental Status Exam (MSE) interview components

1. Presenting problem and history 2. Biopsychosocial evaluation 3. Psychosocial evaluation

core concepts of patient-centered care

1. dignity and respect 2. information sharing 3. patient and family participation 4. collaboration in policy and program development

Reactive attachment disorder

Children with reactive attachment disorder have a consistent pattern of inhibited and emotionally withdrawn behavior. The child rarely directs attachment behaviors toward any adult caregivers and does not seek comfort from them when distressed. This problem is caused by a lack of bonding experiences with a primary caregiver by the age of 8 months. This lack of bonding may be due to severe neglect, repeated changes of primary caregivers, or care in an institutional setting

Cognitive reframing

Cognitive reframing stems from cognitive-behavioral therapy. The goal of cognitive reframing/restructuring is to change the individual's perceptions of stress by reassessing a situation and replacing irrational beliefs. When the perception of the disturbing event is changed, there is less stimulation to the sympathetic nervous system, which in turn reduces the secretion of cortisol and catecholamines that destroy the balance of the immune system. Cognitive distortions often include overgeneralizations ("He always..." or "I'll never...") and "should" statements ("I should have done better" or "He shouldn't have said that").

Despair

Despair is a deep discouragement and loss of faith about one's ability to find meaning, fulfillment, and happiness, to create a satisfactory future for oneself. "My life is over"

Distress

Distress is a negative draining energy that results in anxiety, depression, confusion, helplessness, hopelessness, and fatigue. Stressors such as a death in the family, financial overload, or school/work demands may cause distress.

Risk factors for PTSD

Genetics and epigenetics play a role in how individuals react to stress. Neurobiological-Trauma causes a disruption of the integration of our neural networks.The more helpless and less in control of the situation the person feels, the more vulnerable to pathophysiological changes a person is. Psychological-secure attachment protects against development of PTSD, whereas insecure attachment increases vulnerability to PTSD symptomology Environmental-Neuroplasticity of the brain is particularly intense in children. It is this neuroplasticity along with a dependency on others that can increase vulnerability to adverse childhood experiences (ACEs)

therapeutic encounter

Informal relationship that occurs and may not extend. Pt and nurse meet for only a few sessions.

Treatment

International guidelines recommend the use of two therapies with this population: cognitive-behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) therapy.

How does listening to stories help nursing students learn clinical judgement?

Listening helps nursing students disrupt stereotypes, promote empathy, embrace diversity, and challenge the status quo. Students are able to use their imagination and consider how they might react, what decisions they might make and why, and how their values and beliefs might affect the clinical situations.

Exam purpose

MSE is part of the assessment in all areas of medicine and is analogous to the physical examination in general medicine. The purpose is to evaluate an individual's current cognitive processes. • Establish rapport • Obtain an understanding of the current problem or chief complaint • Review physical status and obtain baseline vital signs • Assess for risk factors affecting the safety of the patient or others • Perform a mental status examination • Assess psychosocial status • Identify mutual goals for treatment • Formulate a plan of care • Document data in a retrievable format

Types of suicidal statements

Overt Statements • "I can't take it anymore." • "Life isn't worth living anymore." • "I wish I were dead." • "Everyone would be better off if I died." Covert Statements and Nonverbal Clues • "It's okay now. Soon everything will be fine." • "Things will never work out." • "I won't be a problem much longer." • "Nothing feels good to me anymore and probably never will." • "How can I give my body to medical science?"

Depersonalization

Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).

Derealization

Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Protective factors

Protective Factors (characteristics that make it less likely that individuals will consider, attempt, or die by suicide) • Effective mental healthcare; easy access to a variety of clinical interventions • Strong connections to individuals, family, community, and social institutions • Problem-solving and conflict resolution skills • Contact with providers (e.g., follow-up phone call from healthcare professional)

Psychosocial assessment

Provides additional information from which to develop a plan of care.

Prefrontal Functioning

Relates to the patient's personality variables such as judgement, planning, and insight

Individual Suicide Risk Factors

Risk Factors (characteristics that make it more likely that an individual will consider, attempt, or die by suicide) • Previous suicide attempt(s) • A history of suicide in the family • Substance use • Mood disorders (depression, bipolar disorder) • Access to lethal means (e.g., keeping firearms in the home) • Losses and other events (e.g., the breakup of a relationship or a death, academic failures, legal difficulties, financial difficulties, bullying) • History of trauma or abuse • Chronic physical illness including chronic pain • Exposure to the suicidal behavior of others

Effective stress busters

Sleep • 7 to 9 hours of sleep is recommended. Exercise (Aerobic) • 150 minutes a week (about 20 minutes a day) of moderate intensity aerobic activity such as walking is recommended. Reduction or Cessation of Caffeine Intake • No more than four cups of coffee or colas are recommended for anyone. Music • Listening to familiar music promotes relaxation. Pets • Can bring joy and reduce stress. • May provide real social support. • Alleviate medical problems aggravated by stress. Massage • Slows the heart rate and relaxes the body. • Improves alertness by reducing anxiety.

Patient safety plan template

Step 1: Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be developing Step 2: Internal coping strategies - Things I can do to take my mind off my problems without contacting another person (relaxation technique, physical activity) Step 3: People and social settings that provide distraction Step 4: People whom I can ask for help Step 5: Professionals or agencies I can contact during a crisis Step 6: Making the environment safe (getting rid of meds, guns, knives, etc.)

Clinical Judgement: Noticing

Students should be encouraged to identify what they noticed about the client's objective behaviors during the story, and how their noticing informed their understanding

Types of suicidal behavior

Suicidal behavior includes suicidal ideation (frequent thoughts of ending one's life), suicide attempts (the actual event of trying to kill one's self), and completed suicide (death occurs). Suicidal behavior is most often accompanied by intense feelings of hopelessness, depression, or self‐destructive behaviors (parasuicidal behaviors). Suicidal behavior is the result of interpersonal turmoil.

Types of suicidal thinking

Suicidal ideation is thinking about personal death, including the wish to be dead, considering methods of accomplishing death, and formulating plans to carry the act out.

General adaptation syndrome stage 1

The alarm stage is the initial, brief, and adaptive response (fight or flight) to the stressor. It begins with the eyes or ears sending information such as a car running a light or the sound of a fire alarm to the brain's amygdala. If the amygdala, which processes emotional data, interprets the event as dangerous, it sounds the alarm to the hypothalamus: fight or flight

General adaptation syndrome stage 3

The exhaustion stage occurs when attempts to resist the stressor prove futile. At this point, resources are depleted, and the stress may become chronic. The impact of long-term overexposure to cortisol renders people more vulnerable to all kinds of illness.

Clinical Judgement: Responding

The implementation of actions and interventions based on client need. Students should be able to discuss their feelings about the responses of the nurse and be encouraged to consider alternatives

Clinical Judgement: Reflecting

The process of thinking and learning from experience. Students should be encouraged to exchange differing perspectives with each other.

General adaptation syndrome stage 2

The resistance stage could also be called the adaptation stage because it is during this time sustained and optimal resistance to the stressor occurs. Usually, stressors are successfully overcome. Recovery, repair, and renewal may occur. At this point individuals have used up valuable resources and have reduced defenses and adaptive energy. If stressors continue, the body remains in a state of arousal and may transition to the final stage of the syndrome.

Clinical Judgement: Interpreting

The student's ability to make sense of what they noticed

Disinhibited social engagement disorders

These children come across as being remarkably friendly and confident. They demonstrate no normal fear of strangers and are usually willing to go off with people who are unknown to them. Their words (e.g., "I really like you") and physical behavior (e.g., attempts to sit on a stranger's lap) are overly familiar and inconsistent with culturally sanctioned and age-appropriate social boundaries. Children with disinhibited social engagement disorder rarely check back with adult caregivers and seemed unfazed by separation from them. By attaching to everyone they are really not attaching to anyone.

Suicide warning

Warning Factors (immediate risk of suicide) • Often talking or writing about death, dying, or suicide • Making comments about being hopeless, helpless, or worthless • Expressions of having no reason for living; no sense of purpose in life; saying things like "It would be better if I wasn't here" or "I want out" • Increased alcohol and/or drug misuse • Withdrawal from friends, family, and community • Reckless behavior or more risky activities, seemingly without thinking • Dramatic mood changes • Talking about feeling trapped or being a burden to others

evidence-based practice

a combination of clinical skill and the use of clinically relevant research in the delivery of effective patience centered care

mental status exam

a set of interview questions and observations designed to reveal the degree and nature of a client's abnormal functioning

nonverbal communication

communication using body movements, gestures, and facial expressions rather than speech

verbal communication

expressing ideas to others by using spoken words

Empathy

the ability to understand and share the feelings of another

transactional model of communication

the theory that views communication as a constant process in which all parties simultaneously play the roles of sender and receiver

Suicide prevention

• Integrate and coordinate suicide prevention activities across multiple sectors and settings. • Implement research-informed communication efforts designed to prevent suicide by changing knowledge, attitudes, and behaviors. • Increase knowledge of the factors that offer protection from suicidal behaviors and that promote wellness and recovery. • Promote responsible media reporting of suicide, accurate portrayals of suicide and mental illnesses in the entertainment industry, and the safety of online content related to suicide. • Develop, implement, and monitor effective programs that promote wellness and prevent suicide and related behaviors. • Promote efforts to reduce access to lethal means of suicide among individuals with identified suicide risk. • Provide training to community and clinical service providers on the prevention of suicide and related behaviors. • Promote suicide prevention as a core component of healthcare services. • Promote and implement effective clinical and professional practices for assessing and treating those identified as being at risk for suicidal behaviors. • Provide care and support to individuals affected by suicide deaths and attempts to promote healing and implement community strategies to help prevent further suicides. • Increase the timeliness and usefulness of national surveillance systems relevant to suicide prevention and improve the ability to collect, analyze, and use this information for action. • Promote and support research on suicide prevention. • Evaluate the impact and effectiveness of suicide prevention interventions and systems and synthesize and disseminate findings.

Other risk factors

• Race: Caucasian suicides account for the highest percentage of completed suicides, approximately 85% to 90%. • Religion: Religiosity is associated with decreased rates of suicide. Protestants and Jews have higher rates of suicide than Roman Catholics. • Marriage: Being married, especially with children in the home, significantly reduces the risk of suicide. Divorced men are more likely than divorced women to kill themselves. • Profession: Professionals are generally considered at higher risk for suicide, particularly if there is a loss in status. • Physical health: Those individuals who have chronic illnesses are at increased risk of suicide. Loss of mobility, disfigurement, and chronic pain are especially associated with suicide. psychological autopsies (i.e., retrospective reviews of the deceased person's life within several months of death to establish likely diagnoses at the time of death).