NURS 3554: Exam 5

Childhood and neurobiological disorders: risk factors

**All nurses working with children or adolescents should be knowledgeable about "normal" stages of developmental process -Parent with psychiatric diagnosis (genetic predisposition/ vulnerabilities) -Parent's inability to model coping strategies -> learned helplessness (when faced with a difficult situation, already feel there is nothing they can do to make a change) -Children who have been abused and/or neglected *neglect is most prevalent form of child abuse in U.S. -Witnessing violence -Children who have been bullied

Childhood and neurobiological disorders: introduction

-75% of adults diagnosed with psychiatric disorders first diagnosed between ages 11 and 18 years -Disruption to normal pattern of childhood development -Difficulty diagnosing younger people due to process of development, limited language skills, inability to understand and perceive things fully, don't ant to attach a lifelong diagnosis and subject individual to stigmatization -Want to avoid treating children with medications if not needed -Lack of services and premature termination of treatment -20% of children and adolescents have one or more mental health issues -Assessing child AND family, need parental permission for any interventions

ADHD (module 5 review)

-ADD: without hyperactivity -Symptoms: Problems with concentration and focus, easily distracted, appearing not to listen, lack of follow-through, organizational and time-management challenges, and forgetfulness -Symptoms present in 2 or more settings -Interventions: Behavioral therapies, psychostimulants *Don't take psychostimulants at night, drug holiday, can lose weight, affect growth and development, don't use if don't have to, behavioral therapies (alternate activities to keep them engaged in classroom)

Delirium (module 5 review)

-Always secondary to underlying condition -Acute onset -Altered level of consciousness -Rapid mood swings -Sundowning -Reversible What is the underlying cause? -Delirium most common, especially with older women -Guides interventions Safety CRITICAL (hallucinations, misinterpretations, etc.) -Scared, confused, agitated -Proper lighting, prevention of fall risk, eyeglasses, hearing aids, dentures, etc. -Reality orientation to time and place -Avoid arguing, confrontational, be compassionate

Assessment of IED

-Assess history, frequency, and triggers for violent burst -Assess SA -Explore current and possible support systems -Identify triggers to explosive behaviors -Explore any situations when trigger present and client not explosive Looking for a cycle, triggers for violent outbursts, and resulting remorse

Impulse control disorders interventions (module 5 review)

-CBT -Psychotherapy -DBT (more inclusive, mindfulness, written assignments, individual therapy, more interprofessional, comprehensive, a little bit of everything, well organized and structured, has been integrated into adolescence too -Parent child interaction therapy Very helpful -Parent management therapy -Multisystemic therapy very helpful Managing disruptive behaviors: role model, limit setting; restructuring, behavioral contracts, counseling, redirection, etc.

Conduct disorder (module 5 review)

-Childhood (<10 yo) & Adolescent onset (>10yo) -Lack of guilt & remorse, violate societal rules, aggressive people/animals -Deceitful or theft -Serious violations of rules Childhood onset Adolescent onset Treatment: similar to ODD Sense of themselves, if they want to do something they can no matter what, want to see what harm to others feels like, lack of empathy towards others

Disruptive behaviors: advanced practice interventions

-Cognitive-behavioral therapy (CBT) -Psychodynamic psychotherapy -Dialectical behavioral therapy (DBT): mindfulness, emotion regulation, distress tolerance, personal effectiveness, coping with extreme, unstable, labile, volatile emotions coupled with harmful behaviors -Parent-child interaction therapy (PCIT): strategies given to parents to reduce problematic behavior at home between parent and child, nurse becomes the mediator to see where the disconnect is -Parent management training (PMT): focus on parents, reinforce positive behaviors, consequences -Multisystemic therapy (MST): much more intensive therapy, therapists are on call 24/7 and always available, similar to visiting home nurse, able to assess home environment, provide support, suggest ways to intervene with the system as a whole

Intellectual disability (module 5 review)

-Deficits in intellectual functioning, social functioning, and daily functioning -Spectrum: mild to severe -Etiology: hereditary, environmental perinatal (Previously called mental retardation) Assessment: -Delays in cognitive, social, and personal development -Ability to function independently -Evidence of abuse/neglect -Community resources -Family services

Autism spectrum disorder (module 5 review)

-Deficits in social and communication interactions, as well as repetitive patterns of behaviors, interests, or activities, connections with others -Diagnosis includes level of severity -Spectrum: mild to severe -Rigidly adhere to routines**, deviations throw them off (comfort in routine, safety element, less anxiety) -Sensory disturbances (noise, texture of food, clothing) -See symptoms between 18 months - 2 yo -Treatment based on clinical presentation -Aggression - FDA approved (aripripazole and Risperdal; Inderal) EARLY INTERVENTIONS KEY: determine greatest deficit, provide support and skills, retraining, developing in that certain area, interrupting disruptive behaviors, keep them connected to reality and world around them, keep them safe Often see lack of eye contact, tend to play on side, don't interact with others, repetitive behaviors (hand shaking, rocking), distinctions in behavior and interactions

Types of dissociative disorders

-Depersonalization/ derealization disorder -Dissociative amnesia -Dissociative identity disorder Important to remember dissociation is unconscious defense mechanism to relieve anxiety S/S include memory loss of specific times, people, events, out of body experiences, detachment from emotions, emotional numbness, lack of self identity, develops in response to trauma like abuse, military combat, very stressful environment leading to overwhelm

Learning disorders

-Dyslexia (reading) -Dyscalculia (math) -Dysgraphia (written expression) Often first noticed in school settings

Acute stress disorder

-Exposure to highly traumatic event -Symptoms develop immediately after the event: typically last 3 days to one month (if longer, considered PTSD) -Symptoms similar to PTSD but to a lesser degree and resolves within weeks to one month -Establish therapeutic relationship to help them feel safe, monitor responses to stimuli in the environment, promote problem solving, support groups (family and friends education), tools to resolve issues of trauma

General interventions for children with mental health issues (module 5 review)

-Expressive art therapy (Ms. Kendra) -Bibliotherapy: talk about situations that are difficult to talk about, abuse in different forms, relating to character in story, express emotions in safe way -Journaling (adolescents) -Family therapy -Music therapy (depends on music, can be helpful or detrimental), can use in calming way -Disruptive behavior management (IN THE BOOK), ways to distract, deescalate, manage escalating behavior before aggression -Quiet room -Time out -Techniques for managing disruptive behaviors (page 185)

Risk factors of mental health issues in children and adolescents (module 5 review)

-Genetics -Biochemical: changes in brain and neurotransmitters -Environmental -ACES: lead to trauma-informed care, many long term physical and emotional consequences, play therapy and writing letters to express feelings, promote resilience as nurses, assess for these when very young, resilience can be taught and promoted in individuals

Alzheimer's disease: communication

-Give one simple direction at a time -Limit number of choices given to the patient -Provide cues to help with orientation -Give step by step directions during ADLs -Speak slowly and respectfully -Maintain eye level with the patient when talking, do not stand above them (overpowering stance) -Do NOT approach the patient from behind: this will frighten them (approach from front) -Avoid frustrating with questions -Offer choices when possible -Simple directions and cues

Dementia (module 5 review)

-Gradual onset (insidious) -Alzheimer's, Lewy body, Fronto-temporal -Level of consciousness not altered -Mood not altered -Sundowning -Progressive Progressive from mild to moderate to severe to late -Confusion, lose things, can't recall or trace back, forget stories, confabulate, deny, make up stories to fill in gaps, avoid talking about certain topics, perseverate, defense mechanisms (recognize don't have recall and memory) -Cardinal symptoms: aphasia, apraxia, amnosia, etc. -Communication is SO important, always treat individual with respect, even when they can't remember -Approach from front, respect, getting to know them well, knowing essence of patient, eye contact, talk slow, clear, not talking down to them, avoid medical jargon, think about what you are going to say -Distraction, bring them somewheres else, deescalation, involved in another activity -Inclusive, activities with all patients that keep them oriented -Wandering, seizures, hyperorality, hypermetamoprhosis -Caretaker considerations (grieving, family centered care) Meds for alzheimer's: -Cholinesterase inhibitors (prevents breakdown of acetylcholine), helps with delaying process, does not cure (early assessment and evaluation KEY)

Dissociative amnesia

-Inability to recall important personal information -Often of traumatic or stressful nature -Cannot remember events in a certain period or pieces of events Dissociative fugue: sudden unexpected travel -Inability to remember who you are, information about your past, amnesic and away from home, assumes new identity, no recollection during flight to new place, new identity, family, etc., severe form of dissociation

Child and adolescent mental health issues assessment (module 5 review)

-MSE, History & Physical, Psychosocial, Education -Appropriate to age of child (drawings, games, books) -Include varying context (home, school, sports) -Cultural aspects

Symptoms of Alzheimer's disease

-Memory impairment (beyond normal age related changes in memory) -Disturbances in executive functioning -Aphasia: not able to recall or understand speech, problem with speech and getting words out, understanding words -Apraxia: inability to make purposeful movements, moderate to severe (remembering to swallow, blink, button shirt, zipper, use washcloth) -Agnosia: inability to recognize objects or people, difficult for family members -Agraphia: inability to write, early sign (trying to write checks, cards, letters jumbled) -Hyperorality: often seen in later stages, want to put everything in their mouth, preoccupied with tasting, chewing, putting things in mouth -Hypermeta-morphosis: preoccupied with touching things, not trying to harm you, but will attempt to grab at shirts, pull on it, touch you -Sundowning: as the day ends, tendency of mood to deteriorate, increase in agitation, emotional fluctuations, decrease in light causes confusion with environment

Dementia: nursing assessment and intervention (module 5 review)

-Mild, Moderate, Moderate to Severe, Late -Cardinal symptoms aphasia, amnesia, apraxia, agnosia -Defense mechanisms: denial, confabulation -Communication is Key: guidelines!! -SAFETY: wandering, seizures late stagers, hyperorality, poor sleep -Caretaker considerations

Autism spectrum disorder

-Neurobiological disability -Developmental disability -Appears during first 3 years of life Characterized by: -Persistent challenges with social interactions, speech and verbal communication, repetitive restrictive movements -Difficulty managing day to day changes -Difficulties understanding Affects 3 major areas: -Social interactions -Speech and verbal cues -Repetitive and restrictive behaviors Statistics: -1 in 54 children -Over half classified as having an intellectual or borderline intellectual disability -Boys 4x more likely -40% of autistic children do not speak -25-35% have some words at 12-18 months and then lose them -Appears within first 3 months of life -Not affected by race, SES -Does not affect life expectancy -More prone to having other types of problems with decision making and other accidents Key to success is EARLY INTERVENTION -No cure, but early intervention and treatment greatly improves outcome

Dissociative disorders

-Occur after significant adverse experiences/traumas Individuals respond to stress with severe interruption of consciousness -Unconscious defense mechanism -Protects individual against overwhelming anxiety through emotional separation, -Failure of ability to control normal processes and integration of awareness of what is going on, may be aware of some stimuli in the environment, but not linked to reality, no longer in their own body, separate from emotions -Positive symptoms: flashbacks -Negative symptoms: memory problems, inability to sense or controls part s of their body, decreases their awareness of what is happening to them

Adjustment disorder

-Precipitated by stressful event -Milder, less specify version of And and PTSD -Debilitating cognitive, emotional, and behavioral symptoms that negatively impact normal functioning -Responses to stressful event may include combinations of depression, anxiety, and conduct disturbances -Guilt, distress -Events like retirement, chronic illness, breakup -Typically resolves over time and with support/interventions

Delirium: nursing implementation

-Prevent physical harm due to confusion, aggression, or fluid and electrolyte imbalance -Perform comprehensive nursing assessment to aid in identifying cause (adjustment in environment, adaptations to alleviate cause, remedy for delirium) -Assist with proper health management to eradicate underlying cause -Use supportive measures to relieve distress (music, eyeglasses, hearing aids, reorientation, providing clocks, calendars, adequate lighting, good rest, good intake and nutrition)

Intermittent explosive disorder (module 5 review)

-Recurrent behavioral outbursts, inability to control aggressive impulses -Cycle: tension builds up base on some trigger, explosive outburst, sense of relief and release -Interferes with relational, social, occupation -Treatment: combination of psychotherapy and psychopharmacology -SSRIs, antipsychotics, beta blockers *REMORSE Find triggers, often things that they are thinking about, then can look at stress that builds up inside them, tension building, this is point to do therapy, give them other things to do before getting to explosive outburst, other ways of managing (CBT), deep breathing, distract selves, mantras (DBT), psychopharmacology (SSRIs or beta blocker best)

Oppositional defiant disorder

-Recurrent pattern of negativity, disobedience, hostility, defiant behavior toward authority figures -Deliberately annoying, blaming others, blaming mistakes or misbehaviors on another person -May exhibit in on or multiple settings -Violate rules but does NOT go as far as to violate the rights of others -Spiteful, malicious, refuses rules and regulations, vindictive acts in adulthood -More prevalent in boys before puberty -Typically diagnosed around age 8 (seen as early as 3) -If left untreated, individual may outgrow this disorder, but most continue to experience severe social difficulties -**ODD is a developmental antecedent to conduct disorder Treatment: -Anger management -CBT -Family therapy -Anticonvulsants: Valproate (Depakote) , helpful in managing certain aggressive behaviors

Delirium: nursing diagnoses

-Risk for injury -Acute confusion -Deficient fluid volume -Insomnia, Sleep deprivation -Impaired verbal communication -Fear -Self-care deficit -Disturbed thought process Prioritize dependent on symptoms

Delirium: nursing assessment and intervention (module 5 review)

-SAFETY: proper lighting, fall risk, eye glasses -Communication: illusions/ delusions -Medical evaluation -Reality orientation: white boards, calendars, clocks

Kleptomania

-Strong urges to steal objects -Buildup of tension before stealing, release when stealing occurs

Motor disorders (module 5 review)

-Tic DO: movement disorder involving head, torso, or limbs -Tourettes (CNS stimulants increase tics): face movements, eye blinking -Drugs: FGA, SGA, clonidine (help slow things down, sedating effects) -Deep brain stimulation

Trauma

-Traumatic life events include a wide range of situations: some more dramatic than others -Trauma often precedes many psychiatric disorders -Trauma-informed care needs to be integrated in all settings where health care is provided -Differing severities of trauma

Characteristics of healthy child/adolescent

-Trusts others and sees world as being safe -Interprets reality correctly and can self-determine -Behaves in appropriate developmental way -Has positive self-concept and developing self identity -Uses age appropriate coping skills to manage and adapt to stressors -Can learn and master age appropriate developmental skills -Expresses self in creative and spontaneous manner -Develops and maintains satisfying relationships

4 Cardinal Features of Delirium

1. Acute onset and fluctuating course 2. Reduced ability to direct, focus, shift, and sustain attention 3. Disorganized thinking 4. Disturbance of consciousness

Which child would be most difficult to diagnose for a neurodevelopmental disorder? A. 3 year old B. 5 year old C. 8 year old D. 12 year old

A. 3 year old

ADHD: psychopharmacological interventions

Antipsychotics: -Can be used for hyperactivity, agitation, mood instability, aggression, self-injury and stereotypic behaviors -Used very cautiously, only in severe cases due to power of drugs and side effects -Haloperidol has been used but with caution R/T EPS and TD -Atypical antipsychotics, Risperidone, has less side effects and studies corroborated effectiveness -Dosage based on with of child and clinical response -SE's - drowsiness, mild increase appetite, nasal congestion, constipation, drooling, dizziness, fatigue and weight gain **some reports of EPS but no cases of TD reported Stimulants: -Methylphenidate (Ritalin) may reduce target symptoms of inattention, impulsivity and overactivity with ADD/ADHD -Activation of dopamine in basal ganglia, surpasses motor activities SSRI's -Not well studied in children with ADD -Causes behavioral activation [insomnia, hyperactivity, impulsiveness, talkativeness -Treatment of comorbities of depression

Alzheimer's disease: nursing interventions

Assess and monitor cognitive deficits (MMSE) -Mild: monitor cognitive deficits, mini-cog exam, ask about recall, retention of information Monitor I&O: maintain nutritional status -Offer finger goods; weigh weekly -Avoid foods patient can choke on -Break into small pieces, make sure they are chewing and swallowing, dentures are in Patient-centered care -Learn the likes/dislikes of your patient; learn their life history; what job did they have; family members, values, spiritual belief Family centered care -Include family members in their care -This is difficult for family members; be empathetic & supportive Provide consistent caregivers and introduce yourself every time you are providing care Label room and clothing with patients name Always introduce self to patient

Attention deficit hyperactivity disorder: nursing process

Assessment -Level of physical activity, attention span, talkativeness -Social skills: friendships, defiance, acting out, success in school -Comorbidity: depression, oppositional defiance disorder, conduct disorder Diagnosis Outcomes Identification Implementation -Psychosocial interventions (behavioral contracts, counseling, psychotherapy, positive reinforcement, planned ignoring, decrease in attention to negative behaviors, helping child to gain behavioral control, implementing eye contact, redirection, limit setting, managing impulsivity and inattention -Psychobiological interventions: Psycho-pharmacology (antipsychotics, stimulants SSRIs) Evaluation

Trauma-related disorders in children: application of the nursing process

Assessment -Presence of trauma in child's life Interview, observe interactions, testing -Developmental assessment: any abnormalities in expected growth and development -Consider home, academic, social environments -Mandated to report suspected abuse, do not need to prove abuse, just need suspect -Recognize early signs of attachment disorders (lack of eye contact, shying away from parents touch, rejecting efforts to comfort them, crying incosolably, difficult to settle down, no signs of separation anxiety, not interested in playing, lack of smiling or laughing) Nursing diagnoses -Risk for impaired attachment -Risk for delayed development Outcomes identification -Ability to demonstrate an emotional bond (developing trusting relationship) Implementation -Establish trust -Age appropriate communication -Education Family involvement (unless perpetrators) -Normalize experience -Teach emotional regulation -Provide safe and stable environment -Predictability of environment and care -Integration back into school and normal routine -Diminish emotional dysregulation, coping skills, normalizing the experience -Play therapy, recreational activities, movies, drawing, stories, expressive therapy of trauma -Role model trust, communication Advanced practice interventions -CBT -EMDR: used often for trauma, l. particularly PTSD, designed to alleviate distress from traumatic memories -Combines CBT techniques of reframing with visual stimulation exercises, access traumatic memories and replace with more positive ones -Use eye movements to deal with overwhelming emotions of trauma they experienced Psychopharmacology -Target specific symptoms and comorbidities Manage their emotions, emotional regulation, trusting relationships and bonding, practice calming and coping techniques to handle reemergence of flashbacks, memories

Conduct disorder: application of the nursing process

Assessment -Suicide risk: high risk, impulsivity -Assessment tools: screening for disruptive behaviors (oppositional and conduct disorders), ACEs -History of frequency, triggers of violent outbursts -Power struggles with parents and authority -Persistent vs intermittent, ability to show emotional control, seriousness of disorder, number of settings, how often -Moral development, problem solving, aggression, belief systems, ability to feel remorse or guilt, to form relationships with others, show empathy -Assess for substance abuse, -Self assessment Diagnosis (Table 21-2) Outcomes identification (Table 21-3)

Assessing development and functioning

Assessment data: -Best source is determine information about feelings, emotions Data collection -Interview family members, teachers, coaches, etc. -Use games, pictures, drawing -Adapt to the child's developmental age Mental status examination -Appearance -Behaviors -Social interactions -Changes in mood, affect, thoughts Developmental assessment -Adolescents: HEADSSS pscyhosocial techniques (home environment, education, activities, drug and alcohol abuse, safety, sexuality, suicide) -Is the child growing, adapting, developing according to anticipate development in age group? -Denver II developmental screening test (social, personal, fine motor, language, gross motor)

Autism spectrum disorder: application of the nursing process

Assessment: -Developmental assessment -MSE (appearance, interactions, mood, processing information, following cues) -Marked impairment in communication, social interactions -Marked impairment in movements - restrictive & repetitive (rocking, banging head, biting hands, scratching, dancing, movements with hands) -Resistance to change in schedule -Fixation with a particular object (toy, instrument, animal, stuffed animal, blanket, COMBS) -Hyper or hypo reactivity to sensory input (hypersensitivity to sensory input, can become upset with loud noises, music, textures, tastes, etc.) -Withdrawal into self or fantasy world

Which statement demonstrates that a parent understands the diagnosis of attention deficit hyperactivity disorder? A."My child will never be able to graduate or go to college but may be able to learn a vocational skill." B."My child's performance will improve in a structured setting that provides rewards for appropriate behavior." "Nothing is wrong with my child. The school hasn't provided qualified teachers and classroom settings." "My child is just going through a stage. This problem will go away with time."

B."My child's performance will improve in a structured setting that provides rewards for appropriate behavior."

Conduct disorder

Behavior is usually abnormally aggressive -In all areas of child's life -Towards people animals, property -Violation of rules, initiation of fights -Violate rights of others WITHOUT sense of remorse -Break, disregard rules, don't pay attention to feelings of others -Do what they feel is right to get what they want -Anger, irritable, defiant, vindictive behaviors -Often involved with juvenile court Rights of others are violated and societal norms or rules are disregarded Complications -Academic failure, school suspensions and dropouts, juvenile delinquency, drug and alcohol abuse, and juvenile court involvement Angry and irritable mood Defiant and vindictive behavior Experience -Social difficulties -Conflicts with authority figures, juvenile delinquent office -Academic problems, dropping out of school -Home life difficulties Risk factors: -Adverse childhood experiences -Trauma -Mental health issues As adults: -Aggression -Breaking rules -Stealing -Breaking parole -Disregard for others

Childhood and neurobiological disorders; etiology

Biological factors -Genetic vulnerability (parent, sibling, grandparent, etc.) -Neurobiological (myelination of brain helps with processing information, brain not yet fully developed in children to make decisions to process situations fully, frontal lobe still developing) Psychological factors -Temperament (style of behaving in a certain way to cope with demands and life expectations, shaped by parents, nurses, peers, etc.) -Resilience (innate and inborn strength to handle stressful situations, adapt to changes in environment, form nurturing relationships with others, protective factor) Environmental factors -Adverse childhood experiences -Abuse, neglect, family history of psych disorders, bullying household experiences -Long term negative efects -Poor academic and work performances -Cardiac issues -Alcohol use, financial problems, intimate partner violence, smoking, sexual activity, suicide Cultural -Every culture has certain expectations, placement of certain demands and expectations children -Anxiety, depression, suicide defined differently in different cultures

Impulse control disorder

Characteristic traits: -Impulsive behaviors (lack of control of impulses, behaviors, emotions) -Aggressive behaviors and emotional lability -Problems relating in socially acceptable ways -Interference with interpersonal lives, being able to relate to other individuals Major Disorders in this classification per APA -Oppositional -Defiant Disorder -Intermittent -Explosive Disorder -Conduct Disorder

Post-traumatic stress disorders: adults (module 5 review)

Characterized by persistent re-experiencing of highly traumatic event that involves actual or threatened death or serious injury to self or others Symptoms can begin a month after from exposure Classic Symptoms: -Intrusive thoughts - flashbacks -Avoidance of situations that are problematic -Alterations in cognition and mood: anxious, depressed, risk for suicide -Alterations in arousal and reactivity: hypervigilance

Types of conduct disorder

Childhood-onset conduct disorder -Usually before age 10 -Usually seen in males -Poor peer relationships -Little concern for others, lack of feelings or remorse, regret, empathy, emotional connection -Misperceive other's intentions as hostile, believe aggression is justified, rationalize their behavior -Little frustration tolerance -Persists in to adolescence -Development of antisocial personality disorder in adulthood Adolescent-onset conduct disorder -No symptoms prior to age 10 -Symptoms include stealing, fighting, vandalizing school property running away, truancy, substance abuse, sexual promiscuity, lack of empathy, no remorse, guilt, or concern for others -Schoolwork, family life affected -Tend to be unemotional, shallow, unexpressive, callused towards other individuals May need long term therapy Risk factors: -Brain changes structurally and functionally -Amygdala and limbic system does not connect with other individuals -Genetic factors -ACEs and environmental factors (rejection, harsh discipline, drug use when brain is developing) Two problems -Pyromania -Kleptomania

Alzheimer's medications (module 5 review)

Cholinesterase Inhibitors -Aricept, Razadyne, Exelon, Conex N-methy-d aspartate [NMDA] glutamate antagonist -Namenda

General interventions for children and adolescents

Cognitive-behavioral therapy -Replacing repetitive self defeating, irrational thoughts that lead to maladaptive behaviors with more realistic and accurate thoughts Disruptive Behavior management *** -Time out -Quiet room -Seclusion & Restraint (can be psychological and physically damaging to children, last resort) -Children can only be restrained for 1 hour at a given time Bibliotherapy -Stories to help child express feelings, relate to character in book Play therapy -Therapeutic tool using hand puppets, dolls, play dough, blocks, expression of feelings Therapeutic drawing -Helpful in showing difficult or confusing emotions -Ex. adolescents drawing a timeline of their vision for the next 5 years Music therapy -Outlet of freely expressing self through dance, singing -Caution with choosing appropriate music that is not triggering or contains disruptive/disturbing words Psychopharmacology -Depends on symptoms and severity Teamwork and safety -Consistency in every area of child's life

Child and adolescence mental health issues (module 5 review)

DSM-5 Domains to Determine Severity: -Conceptual: Academic learning, speech -Social: Interactions with others -Practical: Ability for self-care and life management WHY DIFFICULTY TO DIAGNOSE?? -Hard to communicate -Not fully developed, brain and thought processes changing -Don't want to diagnose early and stigmatize (ex. ADHD) -Can't always verbalize what is going on or what they are feeling (drawing, playing, pictures, stories) Always look at different settings, school and/or home, may be something else if it only happens in one location

Pyromania

Deliberate fire setting -Becomes excited about setting fires -Satisfaction when setting fire -Preoccupied obsessively about setting a fire and feel a sense of release when they engage in behavior, tension diminishes

Delirium vs dementia

Delirium: -Onset: sudden, hours to days -Contributing factors: infection, fever, dehydration, hypoglycemia, recent hospitalization, adverse drug reaction, hypotension -Cognition: impaired memory, judgment, calculations, attention span -LOC: altered -Emotions: rapid swings, fearful, anxious, aggressive, suspicious -Speech/language: incoherent, rapid, inappropriate -Prognosis: reversible with timely and proper treatment -ALWAYS underlying factors, UTI most common with older patients, medication interactions, may be multifactorial Dementia: -Onset: Slowly, over months -Contributing factors: Alzheimer's, vascular disease, chronic alcoholism, head trauma, neurological disease -Cognition: impaired memory, judgment, calculation, attention span, abstract thinking, agnosia -LOC: not altered -Emotions: flat, delusional -Speech/language: incoherent, slow, rambling, repetitious -Prognosis: not reversible, progressive Cognition impaired in both Onset and LOC differs for both

Depersonalization/derealization disorder

Depersonalization: focus on self -Feeling detached from emotions, emotional numbness, watching movie of yourself, out of body experience, looking down on yourself Derealization: focus n outside world -Looks more outward into world, things around you, people, things, environment looks unreal, can no longer recognize it, can experience both Can last minutes or over time

Pharmacological interventions for Alzheimer's disease

Drugs used to treat cognitive impairment, don't cure disease but can prolong and hold off production of acetylcholine *Cholinesterase inhibitors prevent destruction of acetylcholine, making acetylcholine more available, retention of memory longer (Aricept, Rivastigmine, Cognex, Razadyne) -Used mainly in early to moderate stages Tacrine (Cognex) - 40 to 60 mg -SE: dizziness, headache, GI upset, elevated transaminase Donepezil (Aricept) - 5 to 10 mg -SE: insomnia, dizziness, GI upset, headache Rivastigmine (Exelon) - 6 to 12 mg -SE: dizziness, HA, fatigues, GI upset, insomnia Galantamine (Razadyne) - 8 to 24 mg -SE: dizziness, GI upset, headache Memantine (Namenda) - 5 to 20 mg (NMDA receptor antagonist, regulates glutamate activity, helps prevent memory loss differently than cholinesterase inhibitors) -SE: dizziness, headache constipation -Used in MODERATE TO SEVERE alzheimers

Alzheimer's disease: Mild stage

Early stage: -Problems coming up with correct words -Trouble remembering names -Losing or misplacing objects (i.e. keys) -Increased trouble planning and organizing *SAFETY important, don't increase level of anxiety, respond in compassionate way, not accusatory

Trauma-related disorders in adults: etiology

Epidemiology -55-90% of population have at least 1 traumatic experience, trauma-informed care significant role due to large percentage of population that has some sort of trauma Comorbidity -Depression, anxiety, substance use, help us manage responses in body, calm down responding to trauma we have just experienced Psychological factors -Polyvagal theory: third type of autonomic nervous system response, mixture of fight or flight, activation of ANS and calming effect, vagus nerve serves parasympathetic nervous system to calm down, often triggered after traumatic experience, but can get stuck in the traumatic memory and the body responds as if it is still happening

Trauma-related disorders in children: epidemiology

Epidemiology -Attachment disorders rare -Neglect most prevalent form of abuse, sexual and physical abuse, witnessing domestic violence Comorbidity -Phobias, impulse control, learning disabilities Biological factors -Genetic: variability, methylation -Neurobiological: trauma leads to disruption of brain processes -Adversity in early life can cause brain disruptions and alterations in the brain myelination, variability in brain development -As brain develops, emotions stored in amygdala, memories stored in hippocampus, experiences in childhood affects memories and brain development, instinctive responses Psychological factors -Attachment theory: patterns in relating to others, form and acquire based on caregiver-child relationship, influences attachment with others -Humans are designed to relate and connect (Peplau, Sullivan), attempts to form intimate relationships, friendships, friendships, marriage, etc. Environmental factors -Poverty, abuse, violence -Early experiences explain tendencies in later relationships -Dysfunctionality, non-nurturing, chaotic families Cultural considerations -Family expectations, stability

Conduct disorder: etiology

Epidemiology -May be increasing in prevalence, difficult to make these kind of diagnoses for young individuals -Must rule out other cause prior to making a diagnosis -Identify how problematic behaviors are, deviation from dorms of childhood -Identify triggers, childhood experiences, other disorders like anxiety, OCD, depression Comorbidity -Anxiety -Depression -Substance abuse for ODD, conduct disorder -Learning disabilities -ADD Etiology -Biologic factors: genetic, runs in families -Neurobiological causes: lense density in grey matter in left prefrontal brain (area of impulse control, self regulation, ability to feel remorse and guilt), differences in serotonin regulation influences impulsivities, aggression, ability to regulate emotions -Psychological factors: behaviors often passed generation to generation, abusive and overt controlling parents -Environmental factors: ACEs, family distress, inadequate parenting, lack of social support, lack of attachment, emotional detachment Often appear to use very immature ways of coping and problem solving -Compensation for low self esteem -Explosiveness is a form of protection against low self esteem and vulnerability

Dissociative disorders: etiology

Epidemiology: -2-5% of population, not common Comorbidity -OCD, eating disorders, reactive attachment disorders, ADHD, borderline personality disorders Etiology -Genetic variability plays a role in stress response -High intensity traumatic experiences Biological factors Genetic Neurobiological -Limbic system involved in emotional events, hippocampus stores memories, when overwhelmed brain separates from reality to diminish overwhelming Psychological factors -Theory of structural dissociation: complex trauma will separate it out, have that memory be something they don't identify with, depersonalize or dissociate Environmental factors -In response to overwhelming trauma or environment factors, combat, motor vehicle accidents, explosions, etc. Cultural considerations: -There are some cultures with culture bound disorders, like trance like states, amnesic behaviors, have to understand there may be cultural implications for this too

Dementia: assessment

General assessment -Defense mechanisms (seen in early stages, denying memory loss) -Denial -Confabulation: fill in gaps for memory loss, create a story that sounds good -Perseveration: repetition of statements or questions over and over again -Avoidance of questions, not responding, changing the subject -Distinction between dementia and delirium -Safety -Intake, output -Phase and severity (PG 438***) Self assessment

Alzheimer's disease: safety

Gradually restrict driving, operating machinery Remove throw rugs that move: fall risk -Ex. Step stools, coffee tables, should be removed, clear environment, distinction in coloring Wandering -Wear ID bracelet -Use locks at the top of a door to prevent leaving -Use complex locks if necessary -Use alarms or a bell to alert if the patient is near an exit Encourage safe activities Keep patient clean to prevent infection, prevent patient from putting things in mouth to prevent choking

Dissociative disorders assessment

History -Trauma -Gaps in memory -When did this start -How long has it been going on for -Gaps in memory Physical assessment: -Rule out TBI, brain lesions, head injuries, intoxication, seizure activity Moods Impact on patient and family -Disturbing to imagine family members going from one personality to another Suicide risk -If many comorbities such as depression, substance abuse, alcohol use, may be at high risk due to impulsivity, emotional regulation, lability, risk for suicidal ideations and plans Self-assessment -Realizing this disorder does exist, often skeptical -Make sure we have data and history we need, evidence to collect to support this diagnosis

Trauma, stress related and dissociative disorders (module 5 review)

Importance of recognizing long term physiological and psychological effects of trauma Seen with the ACEs video - importance of trauma informed care Trauma: -PTSD disorders -Attachment disorders -Acute stress disorder -Adjustment disorder Dissociative disorders: -Depersonalization/ derealization -Dissociative amnesia/ fugue -Dissociative identity disorder Trauma informed care!! Always approach with assumption that patient has experienced some trauma in life

Additional pharmacological interventions for Alzheimer's disease

In patients with co-existing depression, the choice of agents is usually based on the side effect profile. Selective serotonin reuptake inhibitors (SSRIs) have a low side effect profile and are better tolerated. The following are also good choices: -Bupropion (Wellbutrin) -Venlafaxine (Effexor) -Mirtazapine (Remeron)

Intermittent explosive disorder

Inability to control aggressive impulses -Pattern of behavioral outbursts, emotional dysregulation, tantrums, verbal aggression, physical aggression to people, animals, property, themselves -Pattern is persistent in different areas of life -Intense rage followed by REMORSE -Cycle continues Adults 18 years or older Leads to problems with -Interpersonal relationships -Occupational difficulties -Criminal difficulties Risk factors: -Higher levels of inflammatory markers -Decrease in neurons in amygdala -Abnormal serotonin in limbic system -Environmental factors: violence, maltreatment Therapy: -Anger management -CBT -SSRIs -Antipsychotics: hep with explosive behaviors, mood regulation

Attention deficit hyperactivity disorder (ADHD)

Inappropriate degree of: -Inattention -Impulsiveness ' -Hyperactivity To diagnose, behaviors have to be present in at least 2 settings before 12 years of age -Home, school, sports, youth groups Other signs: -Low frustration tolerance -Labile mood -Low self esteem May also have oppositional defiance disorder, conduct disorder, poor social boundaries (frequent interruptions), distraction and disorganized, unable to complete tasks, impulsive

ADHD: pharmacotherapy

Methylphenidate (Ritalin) -10- 60 mg in 2 or 3 divided doses -Duration 3-5 hours Dexmethyphenidate (Focalin) -2.5 mg bid up to 10 mg daily -Duration 4-5 hours Dextroamphetamine (Dexedrine) -5 to 10 mg daily; up to 40 mg total daily -Duration 4-6 hours Amphetamine mixture (Adderall) -2.5 mg daily for children; 5 mg daily once; 5 mg bid NTE 40 mg daily -Duration 4-6 hours Atomoxetine (Strattera) -A dose range of 1.2 to 1.8 mg/kg/day -Duration 24 hours -NOT a stimulant, inhibits reuptake of norepinphrine -Helps with ADHD without anorexia effects -N/V can occur, take with food to minimize GI upset -May cause constipation (increase fiber, good nutrition) -Liver damage, itching, malaise, fever, sore throat -Rebound syndrome (+ Guanephisine) Clonidine and Guaphinisine can be given to decrease CNS stimulation -Can cause sedation, caution with driving Important administration information: -Medicate in the morning up until the mid afternoon to help with focus and behavioral control during school day -Avoid administering past 4 pm because of risk for insomnia -Can cause weight loss (monitor weight and intake) -Tolerance can develop, drug holidays are important especially during summer and breaks when direct focus is not needed -Wean off, do not stop abruptly -Must be carefully watched an monitored -Do not make up missed dose of medication

Alzheimer's disease: moderate stage

Middle stage: -Forgetfulness of events and part's of own personal history -Withdrawing from socially challenging situations, blank look, not understanding what is going on, not emotionally present -Confusion about where they are or what day it is -Increased risk of wandering and becoming lost -Changes in personality and mood -Need help choosing proper clothing for the seasons -Sleep pattern changes (sleep during day, awake at night) -Wandering is a SERIOUS risk, can become lost

Dementia: clinical picture

Mild neurocognitive disorders -Impairment doesn't necessarily interfere with ADLs -Cognitive decline beyond normal issues with aging -Accommodations to be independent Major neurocognitive disorders -Impairments in ADL abilities and independence -More major memory deficits and ability to problem solve and think Due to: -Alzheimer's disease -Frontotemporal -Lewy bodies -Vascular -Traumatic brain injury -Substances -HIV infection -Prior disease -Parkinson's disease -Huntington's disease -Medical condition

Autism spectrum disorders: diagnoses and outcomes

Nursing diagnoses: -Impaired social interaction -Impaired verbal communication -Delayed growth and development Outcome indicators: -Follows simple rules of interactive games with peers -Speech understood by strangers -Expresses emotions during play activities EARLY INTERVENTION KEY (preventing negative outcomes) -Behavioral therapy, rewards for positive behaviors -Establish realistic education goals -Family education, enforcing consistency -Speech therapy to prove verbal communication, social appropriateness -Occupational therapy: implementing social activities to bridge social cues and interactions -Consistency with approaches, decreasing disruptions, stress, stimuli in environment -Medications: antipsychotics may help with thought processes, managing behaviors, keeping patient safe from harmful behaviors to self or others (Risperidal, Olanzapine, Abilify, Seroquel), may use SSRIs (not as often)

Antipsychotics and Alzheimer's disease

Only used to treat agitation, aggression, thought disorder, wandering -Not first choice, prefer non pharmacological interventions first Risperidone (Risperdal)- 1 to 4 mg SE: agitation, HA, insomnia, EPS Olanzapine (Zyprexa) - 5 mg SE: hypotension, dizziness, constipation, sedation, weight gain, dry mouth Quetiapine (Seroquel) - 25 mg SE: hypotension, dizziness, constipation, sedation, weight gain, dry mouth Haloperidol (Haldol) - 1 to 4 mg SE: dry mouth, blurred vision, orthostatic hypotension, EPS, sedation Start low and go slow!! -Can add to confusion and disturbances in cognition, contributing to cognitive deficits -Last resort mediation choice

Trauma related disorders (module 5 review)

PTSD - Children Clinical presentation: reluctance to play, play may represent aspects of trauma experienced, irritability, aggressive behaviors, sleep disturbance, destructive behavior, hypervigilance Assessment: MSE, severity of presenting problems, observations of interactions with others, in various settings, testing (language, intellect, etc), drawing events, playing with toys, writing, be gentle, encourage them to have a safe place Treatment: TRUST and safety, use appropriate developmental interventions, reduce emotional arousal, identify strategies to cope for the developmental age, family therapy and involvement in treatment

Delirium assessment

Physical needs -Wandering, fall risk, hypervigilance, poor ADLs Mood and physical behaviors -Agitation, restlessness, fear, confusion, erratic emotions Self assessment Nursing assessment: -Assess for acute onset of confusion (mini mental status exam) -Evaluate for cognitive or perceptual disturbances, delusions, perceptual differences, hallucinations, fear, paranoia, suspicion, hypervigilance, elevated BP and HR -Assess individual's awareness of environment -Establish baseline LOC and cognition from family -Identify any recent infections, medical conditions, new medications: physical status -Determine level of fall risk -Monitor situations that worsen condition -Physical needs: safe environment, reduce stimuli, leave light on, orient to time, place, person -Level of awareness altered, confusion, orientation altered (adequate lighting, eyeglasses, hearing aids) -Assess mood and behaviors, agitation, irritability, fluctuations in moods CRITICAL TO TREAT UNDERLYING CAUSE

Trauma-related disorders in adults

Post-traumatic disorders in adults 4 classic symptoms of PTSD: -Re-experiencing of the trauma (flashbacks, hyper vigilant, intense fear of being helpless, unsafe, horror) -Avoidance of stimuli associated with trauma (avoid going into situations that are overwhelming with stimuli, ex. fourth of July, fireworks) -Persistent symptoms of increased arousal (hypervigilance, always on high alert, labile emotions, oversttimlation, anxiety, depression, complete shut down) -Alterations in mood

Trauma-related disorders in children

Posttraumatic stress disorder in preschool children -Manifests differently than in adulst -Aggression, irritability, delinquent behavior, low self-esteem, poor performance in school, more negative emotions, withdrawal, less interest in activities, sleep disturbances, potential drug use, hypervigilance Reactive attachment disorder -Consistent pattern of being emotionally withdrawn -Do not seek comfort from adults -No normal bonding and attachment seen during the developmental process -Not seeking attention from adults Disinhibited social engagement disorder -Overly friendly and familiar with the individuals -Willing to go with anyone, walk away with strangers, too engaging and trusting of others

Dissociative identity disorder

Presence of two or more distinct personality states (formerly known as multiple personality disorders) -Moving between different identities with different voices, names, characteristics, mannerisms, ways or dressing, interacting with the world, social relationships, writing, information about themselves (EEGs different, heart rates different) -Uncommon Each alternate personality (alter) has own pattern of: -Perceiving -Relating to -Thinking about the self and environment Primary personality: host personality, scattered memory, lost days, events to alternate identities, unable to remember certain personal information or what was done in the alternate personality Goal: -Primary personality (host) assimilates the rpersonalities, become whole and absorbing alternate personalities into main personality when working through trauma and recognition that each person that has developed during dissociative periods was used to manage overwhelming anxiety at that time -Long term treatment , coming to resolution with events that came at the times of personality developments

Intellectual development disorder

Previously called mental retardation Deficits in: -Intellectual functioning -Social functioning -Managing age-appropriate activities of daily living, functioning at school or work, and performing self-care -Difficulties with communication, language and academic difficulties, interpersonal relationships with peers Risk factors: -Chromosomal (Fragile X, Downs syndrome) -Phenylketonuria -Malnutrition (affects growth and development in utero)

Nursing management of disruptive behaviors

Priority is safety of environment !! *When behaviors are not deemed dangerous and can feed into attention seeking ONLY then can behaviors be ignored -Impulsivity, unpredictability, disruptive behaviors, explosive outbursts, aggression towards self and others -Observe for indications of stress such as hand wringing, shifting in seat, sudden staring, becoming quiet, glaring, pacing and intervene early to manage emotions in order to stop cycle of disruptive behaviors from beginning -Planned ignoring when behavior is no dangerous (tapping hand, shifting seat, rolling eyes, defiant disrespectful behaviors), implemented consistently Limit setting: clearly state expectations -Consequences when violated Redirection: attempt to engage or re-engage in appropriate activity -First deescalation technique to use -Redirect focus to something else Modeling: demonstrate appropriate skills -Staff demonstrates appropriate behavior for patients -Watch what we do and say as nurses Behavioral contract -Verbal or written agreement coupled with a reward(s) Role-play: -Acting out a specific script to get a better understanding of patient situation -Better understanding of underlying issues with adult figures Medications: -Used to manage symptoms: aggressive behaviors, anxiety, depression -No medication specifically for ODD or CD Provide structure and definite boundaries to provide sense of safety and security with consistency -Clarification as needed, decrease urge to strike out -Decrease stimulation, frustration -Help patient feel heard, safe, cared for

Dementia

Progressive deterioration of cognitive functioning and global impairment of intellect No change in consciousness Difficulty with memory, thinking, and comprehension Refers to a collection of symptoms, not a specific disease -Mild and major neurocognitive disorders -Ability to think, respond, and comprehend information impaired -Slow deterioration, death of family member

Dissociative disorders: implementation

Psychoeducation: decrease frequencies, improve coping strategies, manage movements of overwhelming stress to prevent further dissociative episodes Pharmacological interventions: no specific meds, prescribed based on symptoms -Hyperarousal, intrusive symptoms: antidepressants, antianxieties -Depression: antidepressants -Frequent dissociation: antipsychotics -During dissociative episode, overwhelming anxiety: benzodiazepine Advanced practice interventions -Somatic therapy: experience fragmentation of consciousness, use things that will center their body and connection with their body -CBT: goal to recognize negative thoughts -DBT: coping skills to combat overwhelming anxiety, destructive urges, regulate emotions, improve relationships -Mindfulness, meditation, regulated breathing, self-soothing -Management of suicidal tenders or self-destructive urges -EMDR: alleviate distress associated with traumatic memories (CBT and visual stimulation) Evaluation: -Goal: no longer dissociation, integrate alters as part of host personality

Disruptive behaviors: nursing implementation

Psychosocial interventions: -Promote safety -Establish rapport -Consistency with unit rules -Follow through with consequences, structure, and boundaries Pharmacological interventions: -SSRIs -Antipsychotics for aggression -Mood stabilizers Health teaching and health promotion: -Support groups -Parental training: S/S of depression, anxiety, suicidal ideation, differences in normal growth and development and outside these boundaries, red flags for suicide, persistent behaviors and enforcing rules with consequences for breaking rules, contract with the parent, adherence -Family therapy -Individual therapy -Nursing support for families Teamwork -Communication, working together, same treatment plan, collaboration Seclusion and restraint -Last intervention used when all other techniques have been ineffective -Clear, thorough documentation Evaluation

Attachment disorder (module 5 review)

Reactive attachment disorder: consistent pattern of inhibited and emotionally withdrawn behavior -Don't seem to bond or connect -Don't seek comfort Lack of bonding (neglect, many caregivers) does not seek others for comfort Disinhibited social engagement disorder: remarkably friendly with strangers and confident Rarely check back with adults caregivers - separation does not bother them -Reach out to anyone, not just caregivers -No sense of needing to find caregivers, overly friendly Treatment: improve interactions between caregivers and child; hugging therapy Rare

Alzheimer's disease: late stage

Severe: -Require full time around the clock assistance with daily personal care -Lose awareness of recent experiences as well as their surroundings -Require high level of assistance with daily activities -Have increasing difficulty communicating -Become vulnerable to infections, especially pneumonia due to aspiration risk -Body and mind shutting down *SAFETY: prevent choking, help patient care for themselves

Motor disorders

Stereotypic movement disorder -Repetitive yet purposeless movements, such as hand waving, nail biting, head banging, teeth grinding, rocking back and forth -Interventions: make sure whatever movement they are involved in does not present danger, some kind of injury (ex. Head banging needs helmet, make sure safe, protect patient) -Naltrexone: opioid receptor, blocks good feeling from doing behaviors, considered for these patients Tourette's disorder -Tic disorder involving motor or verbal tics (grimacing, lip protrusion, skipping, verbal sayings, cocosalia (uttering obscenities)) -Diagnosis important to avoid giving patients CNS stimulants which may worsen tics -Reversal of tic: behavioral intervention similar to OCD to prevent behavior from happening -Haloperidol, Riprabasal helpful in reducing tics -Botox to avoid facial grimacing, tic Captopris helpful in movement disorders

Impulse control disorders assessment (module 5 review)

Suicide risk - comorbidities ODD: issues that result in power struggles, settings behavior is present, consequences, problem solving skills IED: history, frequency and triggers to violent behaviors; assess use of substances, identify when control is maintained CD: seriousness of destructive behaviors towards property, animals, others; ability for remorse (moral development); ability to form meaningful relationships; presence of empathy -Can work with young children to prevent continuation into adulthood and become antisocial personality disorder, help then build empathy, learn that their behavior is not societally acceptable -May be in juvenile prisons

Delirium: nursing outcomes

TREAT UNDERLYING CAUSE -Patient will return to premorbid level of functioning -Patient will remain safe and free from injury while in the hospital -Patient will be oriented to time, place, and person -Patient will be free from falls and injury (fall risk one of the highest concerns for safety, avoid restraints, make sure someone is always with them providing reorientation)

Alzheimer's disease: diagnoses

Table 23-3 -Risk for injury -Impaired verbal communication Based on clinical presentation and stage of progression

Neurocognitive disorders

Three main classifications 1. Delirium short term & reversible 2. Mild neurocognitive DO may or may not progress to major, some cognitive deficits, allow functioning with some modifications with everyday activities 3. Major neurocognitive DO commonly referred to as dementia progressive & irreversible

Antianxiety medications and Alzheimer's disease

Used to treat anxiety: -Can be helpful if agitated -Used in low doses -Not used continuously (addiction risk) Lorazepam (Ativan) - 1 to 2 mg SE: drowsiness, dizziness, GI upset, hypotension, tolerance, dependence Oxazepam (Serax) - 10 to 30 mg SE: drowsiness, dizziness, GI upset, hypotension, tolerance, dependence

Antidepressants and Alzheimer's disease

Used to treat depressed mood: Paroxetine (Paxil) SSRI - 10 to 40 mg SE: dizziness, HA, insomnia, somnolence, GI upset Nortriptyline (Pamelor) TCA - 10 to 50 mg SE: anticholinergic, orthostatic hypotension, sedation, arrhythmia

Hypnotic drugs and Alzheimer's disease

Used to treat insomnia: -Try non pharmacological methods of sleep promotion first (warm milk, music, reading, going to bed at the same time, keeping patient company, reducing fear and confusion, placing patient near nursing station) Trazodone (Desyrel) - 50 mg SE: dizziness, drowsiness, dry mouth, blurred vision, GI upset Temazepam (Restoril) - 15 mg SE: drowsiness, dizziness, GI upset, hypotension, dependence Zolpidem (Ambien) - 5 mg SE: HA, drowsiness, dizziness, GI upset Eszopiclone (Lunesta) - 1 to 2 mg SE: HA, drowsiness, dizziness, GI upset, unpleasant taste Mirtazapine (Remeron) - 7.5 to 15 mg SE: somnolence, dry mouth, constipation, increased appetite

Acute onset of disordered thinking is most associated with a. delirium. b. dementia. c. depression.

a. delirium.

A nurse assesses a patient diagnosed with dissociative identity disorder. Which finding would likely be part of the patient's history? a. Travel to a foreign country b. Physical or sexual abuse c. Thyroid dysfunction d. Eating disorder

b. Physical or sexual abuse

A 4-year-old frequently lashes out in anger at adults and other children. This child's style of behavior is an aspect of a. neurobiology b. temperament c. resilience d. culture

b. temperament

A patient with dementia attempts to brush his teeth with a spoon. Which problem is evident? a. Aphasia b. Apraxia c. Agnosia d. Perseveration

c. Agnosia

An adolescent with a conduct disorder is taken to the principal's office after assaulting and injuring another student. Which comment is this adolescent most likely to make? a. "I lost my temper, but it will not happen again." b. "I'm sorry and embarrassed that this happened." c. "I failed my math test, and guess I was just having a bad day." d. "So what if that kid was hurt? I should have beaten him more."

d. "So what if that kid was hurt? I should have beaten him more." Violation of rights of others, norms, rules, no remorse

Impulse control disorder (module 5 review)

•Characterized by aggressive behaviors and emotions •Problems relating to others in a socially acceptable manner •May lead to criminal behaviors Major Disorders: -Oppositional defiant disorder -Intermittent explosive disorder -Conduct disorder Etiology: biological (brain neurotransmitter dysfunction), heredity, environment Oppositional Defiant Disorder - the behaviors need to occur "more persistently and frequently" pattern of angry/irritable mood, argumentative and defiant behavior or vindictiveness, towards those in authority positions Mild, moderate, severe - number of settings see behaviors/emotions -Mild: 1 setting -Moderate: 2 settings -Severe: more than 2 settings Typically diagnosed around 8 years of age Treatment: -Anger management -Parent training -Group therapy -Consistency, limit setting Meds: divalproex sodium (managing aggressive symptoms)

Assessment of Conduct Disorder

✓Assess seriousness and types of disruptive behaviors ✓Ask how behavior has been managed in past ✓Assess client ability to form therapeutic relationship ✓Determine client's ability to be honest and committed to treatment ✓Assess co-morbidity - presence of depression, anxiety, substance abuse More serious disorder, assess how to motivate child to move beyond themselves to recognize emotions and feelings of other individuals, begin to feel a sense or remorse

Assessment of ODD

✓Identify triggers that precipitate power struggles and outbursts ✓Ask about client's views on his/her behaviors and how the behaviors impact others ✓Explore feelings of empathy or remorse ✓Explore barriers and motivators for change ✓Explore how child can exert self control and coping skills May give authority figures a hard time, blame others for their behavior, not take responsibility