Study Guide Exam 2:

Behavior-Modification Programs:

Behavior modification: ⦁ Issues of control are central to the etiology of these disorders. ⦁ For the program to be successful, the client must perceive that he or she is in control of the treatment. ⦁ Successes have been observed when the client ⦁ Is allowed to contract for privileges based on weight gain ⦁ Has input into the care plan ⦁ Clearly sees what the treatment choices are The client has control over: ⦁ Eating ⦁ Amount of exercise pursued ⦁ Whether to induce vomiting ⦁ Staff and client agree about ⦁ Goals ⦁ System of rewards The client has a choice whether to: ⦁ Abide by the contract ⦁ Gain weight ⦁ Earn the desired privilege

Social Phobia:

- A chronic mental health condition in which social interactions cause irrational anxiety.

Chart 25-6 Patient at Risk for Pressure Ulcers Asses Cardiovascular Status:

- Absence of presence of peripheral edema - Hand-vein filling in dependent position - Neck-vein filling (Recumbent or sitting position) - Weight gain or loss Assess Cognition and Mental Status: - LOC - Orientation Assess Condition of Skin: - General cleanliness - Observe all areas - Measure/Record any signs of redness - Photograph areas of concern - Note moistness of skin - If wound present, remove dressing & clean and note: • Presence, amount, & nature of exudate • Measure • Amount & type of necrotic tissue • Presence of granulation/epithelium • Presence of absence of cellulitis • Presence or absence of odor • Take temp Assess patient's understanding of illness and compliance with treatment: - Manifestations to report - Ambulation - Dressing/ Skin Changes - Nutrition Modifications Assess patient's nutritional status: - Change in muscle mass - Recent weight loss (5%) - Impaired oral intake - Difficulty swallowing - Generalized edema

Chart 23-3 Nursing Interventions for the Patient at Risk for Infection:

- Asses patients for risk for infections - Monitor S&S of infection - Monitor lab test results, such as cultures and WBC count and differential; - Screen all visitors - Inspect skin and mucous membranes for redness, heat, pain, swelling, and drainage - Promote sufficient nutritional intake (Protein) - Encourage fluid intake to treat fever - Teach the pt. and family S&S of infection & when to report to HCP - Teach pt. and family how to avoid infections

Chart 23-2 Nursing Interventions for the Patient at Risk for Infection:

- Assess those at risk for infection - Monitor S&S of infection - Monitor labs (C&S, WBC count and differential) - Screen all visitors for infections - Inspect skin and mucous membranes for redness, heat, pain, swelling, drainage - Promote sufficient nutritional intake (protein) - Encourage fluids - Teach pt. and family s&s of infections when when to report - Teach how to avoid infections

Borderline-Personality Disorder:

- 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 1-2% of population - More common in women than men - Split staff due to black and white "good or bad" thinking - Designated as "Borderline" because of the tendency of these clients to fall on the border between neuroses and psychoses -Instability of interpersonal relationships -Unstable self-image - Marked impulsivity - Intensity of affect and behavior Common Behaviors: - Chronic Depression - Inability to be alone - Clinging and distancing - Splitting - Manipulation - Self-destructive behavior - Impulsivity Predisposing Factors: Biological Influences- - Biochemical: Possible serotonergic defect - Genetic: Possible familial connection with depression ⦁ Psychosocial Influences: - Childhood trauma and abuse - Developmental factors fixed in the rapprochement phase of development (16-24 months) the child fails to achieve task of autonomy

Schizoid Personality Disorder:

- Characterized by a profound defect in the ability to form personal relationships - Failure to respond to others in a meaningful emotional way - Diagnosis occurs more frequently in men than in women - Prevalence within the general pop. has been estimated at 3-7.6% ⦁ Clinical Picture: - Aloof and indifferent to others - Emotionally cold - No close friends; prefers to be alone - Appears shy, anxious, or uneasy in the presence of others - Inappropriately serious about everything and difficulty acting in a light-hearted manner ⦁ Predisposing Factors: - Possible hereditary link ⦁ Childhood has been characterized as: - Bleak - Cold - Unempatetic - Notable lacking in nurturing

Obsessive-Compulsive Disorder:

- Characterized by inflexibility about the way in which things are done - Devotion to productivity at the exclusion of personal pleasure - Relatively common - Occurs more often in men than women - Within the family constellation, it appears to be most common in older children ⦁ Clinical Picture: - Especially concerned with matters of organization and efficiency - Tend to be rigid and unbending - Socially polite and formal - On the surface, appear to be very calm and controlled - Lack spontaneity - Preoccupied with rules/regulations ⦁ Underneath there is a great deal of: - Ambivalence - Conflict - Hostility Rank-conscious: - Ingratiating with authority figures - Autocratic and condemnatory with subordinates ⦁ Predisposing Factors: - Over-control by parents - Notable parental lack of positive reinforcement for acceptable behavior - Frequent punishment for undesirable behavior

Command Hallucinations:

- Command hallucinations are most dangerous - May tell client to harm self or others

Epidemics:

- Current concerns related to infection and infection control include the risk of global bioterrorism, emerging infectious diseases, and multidrug-resistant organisms. - Preparation for and education about bioterrorism has been a major focus of the U.S. government since September 11, 2001. - Sources of infection with Escherichia coli O157:H7 include contamination of food or water. Common sources include spinach, ground beef, lettuce, strawberries, unpasteurized milk or apple cider, and soft cheeses made from raw milk. - Other ways for contamination to occur include working with dairy animals, changing diapers, swallowing lake water, touching the environment after touching animals, and eating food prepared by those with E. coli on their hands. - Anthrax and smallpox both have a high fatality rate in humans and are agents that could be used in bioterrorism. - The federal government and health care agencies around the United States include the risk of pandemic disease in their disaster planning. - Pandemic infections such as influenza, have occurred throughout history and is why we have fly vaccinations available. - C. Diff is associated with antibiotic therapy use, especially; Spread by indirect contact with inanimate objects like medical equipment and commodes; - Oral metronidazole (flagyl) and vancomycin have been the drugs of choice - New controversial treatment such as fecal bacterio-therapy is transplanting stool with another normal healthy persons stool

Fungal Infections:

- Dermatophyte infections especially superficial infections differ in lesion appearance, body location, and species. - Tinea is used to describe dermatophytoses Tinea Pedis (Athletes foot) Tinea Manus (Hands) Tinea Cruris (Groin/ Jock-Itch) Tinea Capitis (Head) Tinea Corporis (Ringworm/Body) - Depending on species, they live mainly in the soil, on animals, and on humans - Some are spread by direct contact (RingWorm) - Tinea Capitis and Tinea Corporis can be transmitted by inhumane objects Candida Albicans: Yeast Infection - Grows in moist areas Risk Factors: - Immunosuppression - Long-term Antibiotics - Diabetes - Obesity Common Areas to Develop: - Vagina - Under Breasts - Axillae - Mouth - Perineum Prevention: - Keeping skin folds clean and dry - Proper hygiene - Topical antifungals are usually used Antifungal Drug Ketoconazole (Nizoral): Classification: Therapeutic: Antifungals (systemic) Indications: Treatment of: Candidiasis (disseminated and mucocutaneous), Chromomycosis, Coccidioidomycosis, Histoplasmosis, Paracoccidioidomycosis, Blastomycosis. Should only be used when other effective antifungal therapy is NOT available AND the potential benefits of oral ketoconazole outweigh its potential risks. Action: Disrupts fungal cell membrane. Interferes with fungal metabolism. Also inhibits the production of adrenal steroids Pharmacokinetics: Absorption: Absorption from the GI tract is pH dependent; increasing pH decreases absorption. Distribution: Widely distributed. CNS penetration is unpredictable and minimal. Crosses the placenta; enters breast milk. Protein Binding: 99%. Metabolism and Excretion: Partially metabolized by the liver. Excreted in feces via biliary excretion. Route/Dosage: PO (Adults): 200- 400 mg/day, single dose. Contraindicated in: Hypersensitivity; Liver disease; Concurrent dofetilide, quinidine, pimozide, alprazolam, triazolam, midzolam (PO) Use Cautiously in: History of liver disease; Achlorhydria or hypochlorhydria; Alcoholism GI: Hepatotoxicity, nausea, vomiting Assessment ● Assess patient for symptoms of infection prior to and periodically during therapy. ● Specimens for culture should be taken prior to instituting therapy. Therapy may be started before results are obtained. ● Lab Test Considerations: Monitor hepatic function tests

Table 26-7 Needs to Address Before Discharge of the Patient with Burns:

- Early patient assessment - Financial assessment - Evaluation of family resources - Weekly discharge planning - Psychological referral - Designation of principal learners (family who will help with care) - Development of teaching plan - Training for wound care - Rehab referral - Home assessment - Medical equipment - Public health nursing referral - Visit to referral agency - Re-entry programs for school or work - Long-term care placement - Environmental interventions - Auditory testing - Speech therapy - Prosthetic rehab

Chart 23-1 Factors That May Increase Risk for Infection in the Older Patient:

- Factor Aging-Associated Changes or Conditions - Immune System Decreased anti-body production, lymphocytes, and fever response - Integumentary System Thinning skin, decreased subcutaneous tissue, decreased vascularity, slower wound healing - Respiratory System Decreased cough and gag reflux - GI System Decreased gastric acid and intestine motility - Chronic Illness Diabetes, COPD, neurologic impairment - Functional/Cognitive Immobility, incontinence, dementia - Invasive Devices Urinary catheters, feeding tubes, IV, trach - Institutionalization Increased person-to-person contact and transmission

Sepsis:

- If infections are not treated or are inadequately treated, systemic sepsis (septicemia), septic shock, and disseminated intravascular coagulation may result.

Chart 26-4 Fluid Resuscitation of the Burn Patient:

- Initiate and maintain at least one large-bore IV in an area of intact skin - Coordinate with physician for appropriate fluid type & volume to be infused during first 24h - Adminsiter at least 1/2 of total 24-hour prescribed volume within the first 8 hours & the remaining over the next 16 hours - Assess IV site, infusion rate, and volume hourly - Avoid diuretics to prevent fluid loss - Mannitol does not cross the blood brain barrier so an elevated plasma osmolality due to a infusion of hypertonic mannitol is effective in removing fluid from the brain. This is called 'mannitol osmotherapy'. May also be used to restore and maintain urine output as a last resort. Urinary Output should be 30mL/hr - Fluid resuscitation is provided at the rate needed to maintain urine output at 30-50mL per hour or 0.5mL/kg/hr Monitor these vitals hourly: - BP - Pulse - RR - Breath sounds - Voice Quality - O2 Saturation - End-Tidal CO2 levels Assess Urine Output: - Volume - Color - Specific Gravity - Character - Presence of Protein Assess for Fluid Overload: - Formation dependent edema - Engorged neck veins - Rapid, thready pulse - Presence of lung crackles or wheezes on auscultation - Measure any additional body fluid output hourly

Schizoaffective Disorder:

- Manifested by schizophrenic behaviors, with a strong element of symptomatology associated with the mood disorders - Decisive factor in the diagnosisof schizoaffective disorder is the presence of hallu-cinations and/or delusions that occur for at least 2 weeks in the absence of a major mood episode - Prognosis for schizoaffective disorder is generally better than that for other schizo-phrenic disorders but worse than that for mooddisorders alone

Table 23-4 Possible Allergic Reactions to Antibiotic Therapy:

- N/V - Flushing - Wheezing - Sneezing - Pruritis - Urticaria - Rashes - Maculopapular to Exfoliative dermatitis - Vascular eruptions - Erythema (Steven's Johnson Syndrom) - Angioneurotic Edema - Serum sickness (headache, fever, chills) - Anaphylaxis (laryngeal edema, hypotension, brochospasm) - Death

Inhalation Injury:

- Patients who were injured in closed area - Patients with extensive burns or with burns to the face - Intra-oral charcoal, especially teeth and gums - Pt. was unconscious at injury - Pt. coughing carbonaceous sputum - Changes in voice (Hoarse, Brassy) - Use of accessory muscles or stridor - Poor oxygenation - Edema, erythema, and ulceration of airway mucosa - Wheezing, bronchospasm *Critical Rescue: - For burn pt. who is hoarse or has a brassy cough, drools or has difficulty swallowing, or produces audible breath sound on exhalation, immediately apply O2 and notify Rapid Response Team

Antisocial Personality Disorder:

- Prevalence estimates in the U.S. range from 2-4% in men and about 1% in women Pattern of behavior that is: - Socially irresponsible - Exploitative - Without remorse - They often project their behaviors on others ⦁ Behaviors reflects a disregard for the rights of others ⦁ Clinical Picture: - Fails to sustain consistent employment - Fails to conform to law - Exploits and manipulates others for personal gain - Fails to develop stable relationships Remember Callous Man: C- onduct disorder before age 15; current age is 18y A-ntisocial acts, commits acts tat are grounds for arrest L-ies frequently L-acunae; lacks a superego O-bligations not honored U-nstable- can't plan ahead S-afety or self and others ignored M-oney problems; spise and childen are not supported A-ggressive; assaultive N-ot occuring exclusively during schizoprenia or mania

Neuroleptic Malignant Syndrome:

- Rare, but life-threatening, idiosyncratic reaction to neuroleptic medications that is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction. NMS often occurs shortly after the initiation of neuroleptic treatment, or after dose increases. S&S: - Severe muscular rigidity - Hyperthermia (temperature >38°C) - Autonomic instability - Changes in the level of consciousness - Diaphoresis - Pallor - Dysphagia - Dyspnea - Tremor

Respiratory Emergency:

- Respiratory problems are caused by super-heated air, steam,toxic fumes, or smoke. - These are a major cause of death in patients with burns and are most likely to occur when the burn takes place indoors - Resp. failure from burn can be from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns that restrict movement, and carbon monoxide poisoning - Upper airway is affected when inhaled smoke or irritants cause edema and obstruct the trachea. - Ciliated membranes trap foreign materials and smoke and gases slow this activity, allowing particles to enter the bronchi. - Lung tissue injuries result from toxic irritant damage to the alveoli and capillaries. -A change in respiratory pattern may indicate a pulmonary injury. The patient may: - Become progressively hoarse - Develop a brassy cough - Drool or have difficulty swallowing - Produce sounds on exhalation that include audible wheezes, crowing, and stridor - Immediately apply O2 and call rapid response team

Abnormal Involuntary Movement Scale:

- The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was designed in the 1970s to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications. - The AIMS test has a total of twelve items rating involuntary movements of various areas of the patient's body. These items are rated on a five-point scale of severity from 0-4. The scale is rated from 0 (none), 1 (minimal), 2 (mild), 3 (moderate), 4 (severe). Two of the 12 items refer to dental care. The patient must be calm and sitting in a firm chair that doesn't have arms, and the patient cannot have anything in his or her mouth. The clinician asks the patient about the condition of his or her teeth and dentures, or if he or she is having any pain or discomfort from dentures. - The remaining 10 items refer to body movements themselves. In this section of the test, the clinician or rater asks the patient about body movements. The rater also looks at the patient in order to note any unusual movements first-hand. The patient is asked if he or she has noticed any unusual movements of the mouth, face, hands or feet. If the patient says yes, the clinician then asks if the movements annoy the patient or interfere with daily activities.

CDC:

- The Centers for Disease Control and Prevention (CDC) collects information about the occurrence and nature of infections and infectious diseases. - The CDC recommends guidelines to health care agencies for infection control and prevention. - Certain diseases, such as tuberculosis, must be reported to health departments and the CDC by the health care provider. - A health care professional certified in infection control is responsible for tracking infections through surveillance and ensuring compliance with federal, state, and local requirements. - Infections can be prevented or controlled through hand hygiene, disinfection/sterilization, personal protective equipment, patient placement, and adequate staffing. Proper hand hygiene and gloves are the most important intervention because health care workers' hands are the primary way in which disease is transmitted from patient to patient. - Handwashing and alcohol-based hand rubs are two methods of hand hygiene. - The CDC recommends a ban on artificial fingernails for health care professionals when they are caring for patients at high risk for infection. - Standard Precautions are used with all patients in health care settings, assuming that all body excretions and secretions are potentially infectious. - Airborne Precautions are used for patients who have infections transmitted through the air, such as tuberculosis. - Droplet Precautions are used for patients who have infections transmitted by droplets, such as influenza and certain types of meningitis. - Contact Precautions are used for patients who have infections transmitted by direct contact or contact with items in the patient's environment. - Patients who have transmission precautions may feel isolated, anxious, depressed, neglected, and dissatisfied with their care. - Help isolated patients cope with these feelings through verbalization and collaboration with the health care team.

Alcohol-Based Hand Sanitizer:

- When hands are visibly soiled or contaminated wash with soap and water - If hands aren't visibly soiled, use alcohol-based hand rub or wash with soap and water - Use either alcohol-based hand rub or wash with soap and water before direct contact with patients - Decontaminate hands before donning sterile gloves - Decontaminate hands after contact with patient's intact skin - Decontaminate hands after removing gloves - Decontaminate hands after contact with inanimate objects in the vicinity of patient

Antimicrobial Therapy:

- Works on MRSA, Enteroccocus, C. Diff, - Gentamicin and Vancomycin - Ensure to check WBC and Differential; C&S Side Effects for Vanc: - Red man Syndrome - Ototoxicity - Nephrotoxicity

Adaptive Levels of Functioning:

Adaptive functioning means how well a person handles common demands in life and how independent they are compared to others of a similar age and background. During an adaptive functioning assessment, you are asked questions about Practical skills: how you: • manage your home and personal care • manage money, • use the telephone • get from place to place eg-do you use the bus or need a ride to places? • stay safe and healthy, • follow schedules and routines, • work Social skills: • how you behave, talk to and understand others, • how you feel about yourself • how you solve problems • whether you make your own mind up about things or whether other people influence you • how you follow rules, obey the law and whether you are easy to take advantage of Conceptual Skills: • are you able to plan and organize? • can you use abstract concepts like time, money, numbers?

Anorexia Nervosa:

Anorexia nervosa: ⦁ Characterized by a morbid fear of obesity ⦁ Symptoms include gross distortion of body image, preoccupation with food, and refusal to eat ⦁ Weight loss is extreme, usually more than 15 percent of expected weight. ⦁ Other symptoms include hypothermia, bradycardia, hypotension, edema, lanugo, and a variety of metabolic changes. ⦁ Amenorrhea is typical and may even precede significant weight loss. ⦁ There may be an obsession with food. ⦁ Feelings of anxiety and depression are common. ⦁ Anorexia nervosa may be associated with high levels of endogenous opioids. ⦁ There has been some speculation about a primary hypothalamic dysfunction in anorexia nervosa. ⦁ Anorexia nervosa is more common among sisters and mothers of those with the disorder than it is among the general population.

Global Terrorism:

Anthrax: High fatality rate in humans and are agents that could be used in bio-terrorism. - Usually seen in animals and may be spread to the skin or inhaled - Vaccines are being researched and stockpiled Ebola (mentioned in another card)

Alzheimer's Disease:

As the disease progresses, symptoms may include: ⦁ Aphasia ⦁ Apraxia ⦁ Irritability and moodiness, with sudden outbursts over trivial issues ⦁ Inability to care for personal needs independently ⦁ Wandering away from the home ⦁ Incontinence ⦁ Alzheimer's disease (AD) accounts for 50 to 60 percent of all cases of NCD ⦁ Acetylcholine decreases with Alzheimers and the medication will delay that destruction but not cure it. ⦁ AD can be described in stages Stage 1. No apparent symptoms: Stage 2. Forgetfulness: - Losses in short-term memory are common - Symptoms aren't observed by others Stage 3. Mild cognitive decline: - Interference with work performance - Concentration may be interrupted & difficulty recalling names or words Stage 4. Mild-to-moderate cognitive decline: - May forget major events in personal history, such as his or her own child's birthday; - Decline in abilities performaing tasks such as shopping - May deny a problem exists by covering up memory loss with confabulation (creating imaginary events to fill in memory gaps) Stage 5. Moderate cognitive decline: - Lose the ability to perform ADLs - Frustration, withdrawal, and self-absorption are common Stage 6. Moderate-to-severe cognitive decline: - Unable to recall recent major life events or even the name of his or her spouse - Symptoms seen to worsen in late afternoon and evening- phenomenon known as sundowning. - Communication becomes more difficult Stage 7. Severe cognitive decline: - Individual is unable to recognize family - Usually bedfast and aphasic - Problems with immobility such as decubiti and contractures, may occur. - During late-stage, the person become chair-bound or bed-bound; Muscles rigid contractures may develop and primitive reflexives may be present - Depressed immune system may lead to development of pneumonia, UTI, sepsis, PU. - Appetite decreases and dysphagia occurs - Sleep-wake cycle is greatly altered Predisposing Factors: ⦁ NCD due to Alzheimer's disease ⦁ Onset is slow and insidious ⦁ Course of the disorder is generally progressive and deteriorating Etiologies may include: ⦁ Acetylcholine alterations ⦁ Plaques and tangles ⦁ Head trauma ⦁ Genetic factors

Body System Changes:

Cardiac Changes Resulting From Burn Injuries: - HR increases and CO decreases because of initial fluid shifts and hypovolemia - CO may remain low for up to 18-36 hours - Proper fluid resuscitation and support with oxygen prevent further complications Pulmonary Changes Resulting From Burn Injury: - Respiratory problems are caused by super-heated air, steam,toxic fumes, or smoke. - These are a major cause of death in patients with burns and are most likely to occur when the burn takes place indoors - Resp. failure from burn can be from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns that restrict movement, and carbon monoxide poisoning - Upper airway is affected when inhaled smoke or irritants cause edema and obstruct the trachea. - Ciliated membranes trap foreign materials and smoke and gases slow this activity, allowing particles to enter the bronchi. - Lung tissue injuries result from toxic irritant damage to the alveoli and capillaries. GI Changes Resulting from Burn Injury: - Fluid shifts and decreased CO decreased BF to GI tract causing gastric mucosal tissue and motility to become impaired - Increased secretion or epinephrine and norepinephrine inhibit GI motility and further reduce BF - Secretions and gases collect in GI tract causing abdominal distention - Curling's Ulcer: Acute gastroduodenal ulcer that occurs with the stress of severe injury may develop in 24h due too reduced GI BF - Ulcers develop from decreased mucus and increased hydrogen ion production - Pt. is given H2 histamine blockers, Proton-Pump Inhibitors, and early enteral feeding to prevent such complications Metabolic Changes Resulting from Burn Injury: - Bad burns increase secretions of catecholamines, ADH, Aldosterone, and Cortisol. - With hypermetabolism oxyegn needs and calorie needs are high - Catecholamines activate the stress response - Increased production (and loss) of heat breaks down protein and fat (catabolism), rapidly uses glucose and calories, and increases urine nitrogen loss. - Heat and water loss also increase metabolic rate and calorie needs - Pt. will need increased caloric needs - Rates will peak 4-12 days after the burn and can remain elevated for months - Hypermetabolic state causes the body to lose heat and results in a low temp to adjust Immunologic Changes Resulting from Burn Injury: - Injury activates inflammatory response and often suppresses all immune functions

Table 26-1 Classification of Burn Depth:

Characteristic: Superficial: Color: Pink-Red Edema: Mild Pain: Yes Blisters: No Eschar: No Healing: 3-6 Days Graft Required: No Example: Sunburn, Flash Burn Superficial Partial-Thickness: Color: Pink-Red Edema: Mild-Moderate Pain: Yes Blisters: Yes Eschar: No Healing: 2 Weeks Graft Required: No Example: Scalds, Flames, Brief Contact with hot objects Deep Partial-Thickness: Color: Red-White Edema: Moderate Pain: Yes Blisters: Rare Eschar: Yes, Soft & Dry Healing: 2-6 Weeks Graft Required: Can be used if healing is prolonged Example: Scalds, Flames, Prolonged Contact with hot objects, tar, grease, chemicals Full-Thickness: Color: Black, Brown, Yellow, White, Red. Edema: Severe Pain: Yes and No Blisters: No Eschar: Yes, Hard & Inelastic Healing: Weeks to Months Graft Required: Yes Example: Scalds, Flames, Prolonged contact with hot objects, tar, grease, chemicals, electricity Deep Full-Thickness: Color: Black Edema: Absent Pain: Absent Blisters: No Eschar: Yes, Hard & Inelastic Healing: Weeks to Months Graft Required: Yes Example: Flames, Electricity, Grease, Tar, Chemicals

Dry Skin:

Chart 25-1 Prevention of Dry Skin: - Use a humidifier - Take complete bath or shower every other day - Use tepid water - Use a superfatted, non-alkaline soap - Rinse soap thoroughly - Add oil to end of bath - Pat rather than rub skin dry - Avoid clothing that rubs the skin - Maintain a daily fluid intake of 3000mL unless C/I - Do not apply rubbing alcohol or astringents to skin - Avoid caffeine and alcohol ingestion

Donepezil (Aricept):

Classification Therapeutic: Anti-Alzheimer's agents Pharmacologic: Cholinergics (cholinesterase inhibitors) Indications Mild, moderate, or severe dementia/neurocognitive disorder associated with Alzheimer's disease. Action Inhibits acetylcholinesterase thus improving cholinergic function by making more acetylcholine available. Pharmacokinetics Absorption:Well absorbed after oral administration. Distribution: Unknown. Protein Binding: 96%. Metabolism and Excretion: Partially metabolized by the liver Contraindicated in: Hypersensitivity to donepezil or piperidine derivatives. Use Cautiously in: Underlying cardiac disease, especially sick sinus syndrome or supraventricular conduction defects; Adverse Reactions/Side Effects CNS: headache, abnormal dreams GI: diarrhea, nausea Metab: hot flashes, weight loss Route/Dosage: Mild to Moderate Alzheimer's Disease- PO (Adults): 5 mg once daily; after 4- 6 wk mayqto 10 mg once daily (dose should not exceed 5 mg/day in frail, elderly females). Severe Alzheimer's Disease- PO (Adults): 5 mg once daily; mayqto 10 mg once daily after 4- 6 wk; after 3 mo, may thenqto 23 mg once daily. Assessment ● Assess cognitive function (memory, attention, reasoning, language, ability to perform simple tasks) periodically during therapy. ● Monitor heart rate periodically during therapy. May cause bradycardia.

Cyproheptadine (Periactin):

Classification: Therapeutic: Allergy, cold, and cough remedies, antihistamines Indications: Relief of allergic symptoms caused by histamine release including: Seasonal and perennial allergic rhinitis, Chronic urticaria, Cold urticaria. Action: Antagonizes the effects of histamine at H-receptor sites; does not bind to or inactivate histamine. Also blocks the effects of serotonin Pharmacokinetics: Absorption: Apparently well absorbed after oral dosing. Distribution: Unknown. Metabolism and Excretion:Mostly metabolized by the liver Contraindicated in: Hypersensitivity; Acute attacks of asthma; Lactation; Known alcohol intolerance (syrup only). Use Cautiously in: Geri: Appears on Beers list. Geriatric patients are sensitive to anticholinergic effects and have increased risk for side effects Adverse Reactions/Side Effects: CNS: drowsiness EENT: blurred vision GI: dry mouth Route/Dosage: PO (Adults): 4 mg q 8 hr(range 4- 20 mg/day in 3 divided doses; up to 0.5 mg/kg/day). Assessment ● Geri: Assess for adverse anticholinergic effects (delirium, acute confusion, dizziness, dry mouth, blurred vision, urinary retention, constipation, tachycardia). ● Allergy: Assess symptoms (rhinitis, conjunctivitis, hives) prior to and periodically throughout therapy.

Topiramate (Topamax):

Classification: Therapeutic: Anticonvulsants, mood stabilizers Indications: Seizures including: partial-onset, primary generalized tonic-clonic, seizures due to Lennox-Gastaut syndrome. Action: Action may be due to: Blockade of sodium channels in neurons, Enhancement of gamma-aminobutyrate (GABA), an inhibitory neurotransmitter, Prevention of activation of excitatory receptors. Pharmacokinetics: Absorption:Well absorbed (80%) after oral administration. Distribution: Unknown. Metabolism and Excretion: 70% excreted unchanged in urine. Contraindicated in: Hypersensitivity; Recent alcohol use (within 6 hr before and after use of extended-release product); Metabolic acidosis (on metformin) (with extended-release product only); Lactation Use Cautiously in: All patients (may increase risk of suicidal thoughts/behaviors); Renal impairment (dose reduction recommended if CCr 70 mL/min/1.73 m2); Hepatic impairment; Dehydration; Adverse Reactions/Side Effects CNS: Suicidal Thoughts, dizziness, drowsiness, fatigue, impaired concentration/memory, nervousness, psycho-motor slowing, speech problems, sedation EENT: abnormal vision, diplopia, nystagmus GI: nausea Route/Dosage: Epilepsy (monotherapy) PO (Adults and children 10 yr): Immediate-release—25 mg twice daily initially, gradually increase at weekly intervals to 200 mg twice daily over a 6- wk period; Extended-release—50 mg once daily initially, gradually increase at weekly intervals to 400 mg once daily over a 6- wk period. Assessment ● Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression. ● Seizures: Assess location, duration, and characteristics of seizure activity.

Fluoxetine (Prozac):

Classification: Therapeutic: Antidepressants Pharmacologic: Selective serotonin re-uptake inhibitors(SSRIs) Indications: Major depressive disorder. Obsessive compulsive disorder (OCD). Bulimia nervosa. Panic disorder. Acute treatment of depressive episodes associated with bipolar I disorder (when used with olanzapine) Action: Selectively inhibits the re-uptake of serotonin in the CNS Pharmacokinetics: Absorption:Well absorbed after oral administration. Distribution: Crosses the blood-brain barrier. Protein Binding: 94.5%. Metabolism and Excretion: Converted by the liver to norfluoxetine Contraindications/Precautions: Contraindicated in: Hypersensitivity; Concurrent use of MAO inhibitors or MAOlike drugs (linezolid or methylene blue) Use Cautiously in: History of seizures; Debilitated patients ( Increased risk of seizures); Adverse Reactions/Side Effects CNS: Neuroleptic Malignant Syndrome, Seizures, Suicidal Thoughts, anxiety, drowsiness, headache, insomnia, nervousness GU: Sexual dysfunction Derm: Increasing sweating, pruritus Route/Dosage: Bulimia nervosa—60 mg/day (may need to titrate up to dosage over several days). Assessment ● Monitor mood changes. Inform health care professional if patient demonstrates significant increase in anxiety, nervousness, or insomnia. ● Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient.

Chlorpromazine (Thorazine):

Classification: Therapeutic: Antiemetics, antipsychotics Pharmacologic: Phenothiazines Indications: Second-line treatment for schizophrenia and psychoses after failure with atypical antipsychotics Action: Alters the effects of dopamine in the CNS. Has significant anticholinergic/alpha-adrenergic blocking activity Pharmacokinetics: Absorption: Variable absorption from tablets. Well absorbed following IM administration. Distribution: Widely distributed; high CNS concentrations. Crosses the placenta; enters breast milk. Protein Binding: 90%. Metabolism and Excretion: Highly metabolized by the liver and GI mucosa. Contraindicated in: Hypersensitivity; Hypersensitivity to sulfites (injectable); Cross-sensitivity with other phenothiazines may occur Use Cautiously in: Diabetes; Respiratory disease; Prostatic hyperplasia; CNS tumors; Epilepsy; Intestinal obstruction Adverse Reactions/Side Effects: CNS: Neuroleptic malignant Syndrome, sedation, extrapyramidal reactions EENT: blurred vision, dry eyes CV: hypotension (IM, IV) GI: constipation, dry mouth Route/Dosage: PO (Adults): Psychoses—10- 25 mg 2- 4 times daily; may increase every 3- 4 days (usual dose is 200 mg/day; up to 1 g/day) IM (Adults):Severe psychoses—25- 50 mg initially, may be repeated in 1 hr; increase to maximum of 400 mg q 3- 12 hr if needed (up to 1 g/day) Assessment: ● Assess mental status (orientation, mood, behavior) prior to and periodically during therapy. ● Assess weight and BMI initially and throughout therapy. Refer as appropriate for nutritional/weight and medical management. ● Assess positive (hallucinations, delusions, agitation) and negative (social withdrawal) symptoms of schizophrenia

Clomipramine (Anafranil):

Classification: Therapeutic: Antiobsessive agents Pharmacologic: Tricyclic antidepressants Indications: Obsessive-Compulsive Disorder (OCD).Unlabeled Use: Depression, neuropathic pain/chronic pain. Action: Potentiates the effect of serotonin (antiobsessional effect) and norepinephrine in the CNS. Has moderate anticholinergic effects. Pharmacokinetics: Absorption:Well absorbed from the GI tract. Distribution:Widely distributed, enters breast milk. Protein Binding: 90%. Metabolism and Excretion: Mostly metabolized by the liver Contraindicated in: Hypersensitivity; Angle-closure glaucoma; Recent myocardial infarction Use Cautiously in: History of seizures (threshold may be lowered); Patients with pre-existing cardiovascular disease; Older men with prostatic hyperplasia Adverse Reactions/Side Effects: CNS: Seizures, Suicidal Thoughts, lethargy, sedation, weakness, EENT: blurred vision, dry eyes, dry mouth GI: constipation, nausea, vomiting GU: male sexual dysfunction Route/Dosage: Antidepressant—25 mg 3 times daily, may be increased as needed (unlabeled). Assessment: ● Monitor mental status (orientation, mood, behanior) frequently. Assess patient for frequency of OCD. Note degree to which these thoughts and behaviors interfere with daily functioning. ● Monitor BP and pulse before and during initial therapy. Notify physician or other health care professional of decreases in BP (10- 20 mmHg) or sudden increase in pulse rate. Patients taking high doses or with a history of cardiovascular disease should have ECG monitored before and periodically during therapy.

Olanzapine (Zyprexa):

Classification: Therapeutic: Antipsychotics, mood stabilizers Pharmacologic: Thienobenzodiazepines Indications: Schizophrenia. Acute therapy of manic or mixed episodes associated with bipolar I disorder Unlabeled Use: Management of anorexia nervosa. Treatment of nausea and vomiting related to highly emetogenic chemotherapy. Action: Antagonizes dopamine and serotonin type 2 in the CNS. Also has anticholinergic, antihistaminic, and anti- alpha1-adrenergic effects Pharmacokinetics: Absorption:Well absorbed but rapidly metabolized by first-pass effect, resulting in 60% bioavailability. Conventional tablets and orally disintegrating tablets (Zydis) are bioequivalent. IM administration results in significantly higher blood levels (5 times that of oral). Distribution: Extensively distributed. Protein Binding: 93%. Metabolism and Excretion: Highly metabolized (mostly by the hepatic) Contraindicated in: Hypersensitivity; Lactation: Discontinue drug or bottle feed; Phenylketonuria (orally disintegrating tablets contain aspartame). Use Cautiously in: Patients with hepatic impairment; Patients at risk for aspiration; Cardiovascular or cerebrovascular disease Adverse Reactions/Side Effects: CNS: Neuroleptic Malignant Syndrome , Seizures, Suicidal Thoughts, agitation, delirium, dizziness, headache, restlessness, sedation, weakness EENT: amblyopia, rhinitis GI:constipation, dry mouth, increase liver enzymes, weight loss or gain Route/Dosage: PO (Adults —Most Patients): 5- 10 mg/day initially; may increase at weekly intervals by 5 mg/day (target dose 10 mg/day; not to exceed 20 mg/day). Assessment: ● Assess mental status (orientation, mood, behavior) before and periodically during therapy. Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression. ● Monitor BP (sitting, standing, lying), ECG, pulse, and respiratory rate before and frequently during dose adjustment. ● Assess weight and BMI initially and throughout therapy

Paranoid:

Extreme suspiciousness of others; (I wont eat this food. I know it has been poisoned) - Common in those with schizophrenia

Anorexiant Medications:

Fluoxetine (Prozac) and clomipramine (Anafranil) in clients with anorexia nervosa, and particularly those with depression or obsessive-compulsive symptoms. Cyproheptadine (Periactin),in its unlabeled use as an appetite stimulant, and the antipsychotic chlorpromazine (Thorazine) have also been used to treat this disorder in selected clients. Success has been reported in a controlled trial of olanzapine (Zyprexa) in clients with anorexia nervosa.

MRSA Skin Infections:

Furuncle (Boils): Folliculitis: Superficial infection involving only the upper portion of the follicle and is often caused by Staph (Rash is usually red and raised) Furuncles (Boils): Also caused by Staph; but the infection is much deeper (May or may not have a pustular head) Cellulitis: Often occurs as generalized infection with either staph or strep and involved deeper connective tissues - Minor skin problems usually occur before the appearance of folliculitis or furuncles and may contribute to development of cellulitis. - Common skin problem is MRSA it can range from mild folliculitis to extensive furuncles - Easily spread by direct contact - Doesn't respond to cleansing with anti-bacterial soap or most oral antibiotics - If MRSA infects blood streamdeep wound damage and even death can occur

Herpes Zoster:

Herpes Zoster (Shingles): - Infection caused by reactivation of the varicella-zoster virus (VZV) in patients who have had chickenpox - Dormant virus lies in the dorsal root ganglia of sensory nerves - Occurs after several days of discomfort, which may vary from minor irritation to itching to severe, deep pain - Postherpetic Neuralgia is severe pain persisting after the lesions has resolved - Occurs most often in older people or anyone who is immunosupressed - It is contagious to anyone who hasn't been vaccinated Complications: - Full-thickness skin necrosis - Bell's Palsy - Eye infection - Scarring Manifestations: Nursing Care: Isolation Needed: Airborne Shingles Vaccination (Zostavax): - Live viral vaccine and should not be used in patients with severe immunosuppression because of the high risk for viral dissemination.

Burn Signs of Infection:

Local Indicators: - Conversion of partial-thickness to full-thickness injury - Ulceration of healthy skin - Erythematous, nodular lesions in uninvolved skin and vesicular lesions in healed skin - Edema of healthy skin surrounding burn - Excessive burn wound drainage - Pale, boggy, dry, or crusted granulation tissue - Sloughing of grafts - Wound breakdown - Odor Systemic Indicators: - Altered LOC - Changes in vitals (Tachycardia, tachypnea, Temp instability, Hypo-tension) - Increased fluid for maintenance of normal UO - Hemodyanamic instability - Oliguria - GI dysfunction (diarrhea, vomiting, abdominal distention) - Hyperglycemia - Thrombocytopenia - Change WBC (Above or Below Normal) - Metabolic Acidosis - Hypoxemia

Alzheimer's medications will delay the destruction of acetylcholine.

Medications are not a cure.

Table 26-2 Classification of Burn Injury and Burn Center Referral Criteria:

Minor Burns: - Partial-Thickness less than 10% TBSA (Total Body Surface Area) - Full-thickness burns less than 2% TBSA - No burns on eyes, ears, face, hands, feet, or perineum - No electrical burn - No inhalation injury - No complicated additional injury - Patient is younger than 60 with no chronic cardiac, pulmonary, or endocrine disorder (Patients in this category should receive care at the scene and be taken to regular hospital. A special burn unit is not necessary.) Moderate Burns: - Partial-Thickness burns 15-25% TBSA - Full-Thickness burns 2-10% TBSA - No burns on eyes, ears, face, hands, feet, or perineum - No electrical burn - No inhalation injury - No complicated additional injury - Patient is younger than 60 with no chronic cardiac, pulmonary, or endocrine disorder (Patients in this category should receive care at the scene and be transferred to a special expertise or designated burn center) Major Burns: - Partial-Thickness burns greater than 25% TBSA - Full-Thickness burns greater than 10% TBSA - Any burn involving eyes, ears, face, hands, feet, perineum - Electrical injury - Inhalation injury - Patient older than 60 - Burn complicated - Patient has cardiac, pulmonary, or other endocrine disorders (Patients who meet any one of the criteria should receive emergency care at nearest ER and then be transferred to designated burn center ASAP)

The rapid increase in numbers of NCDs has occured because more people now survive into the high-risk period

People are dying when they are older.

Schizophrenia Phases:

Phase I: Premorbid phase: - Social maladjustment - Antagonistic thoughts and behavior - Shy and withdrawn - Poor peer relationships - Doing poorly in school - Antisocial behavior Phase II: Prodromal phase: - 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 (Paranoia) Phase III: Schizophrenia: - In the active phase of the disorder, psychotic symptoms are prominent - Delusions - Hallucinations - Impairment in work, social relations, and self-care A. Two (Or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated) At least one of these must be: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (diminished emotional expression or avolition) B. Significant portion of the time since the onset of disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is below the level achieved prior to the onset C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because of 1. no major depressive or manic episodes concurrently with active-phase symptoms; or 2. if mood episodes have occured during active-phase symptoms, they have been present for a minority of total duration E. Disturbance is not attributable to the physiological effects of a substance F. History of autism spectrum disorder or a communication disorder of childhood onset, schizophrenia is made only prominent delusions or hallucinations, in addition to other required symptoms of schizophrenia for at least 1 month Specify if: First episode, currently in acute, partial, or full remission; Continuous, Unspecified Specify if: Current severity Phase IV: Residual phase: - Symptoms similar to those of the prodromal phase - Flat affect and impairment in role functioning are prominent - Symptoms are either absent or no longer prominent - Often increases between episodes of active psychosis Prognosis: ⦁ A return to full premorbid functioning is not common ⦁ Factors associated with a positive prognosis include: - Good premorbid functioning - Later age at onset - Female gender - Abrupt onset precipitated by a stressful event - 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 - No family history of schizophrenia

Chart 25-2 Preventing Pressure Ulcers:

Positioning: - Pad contact surfaces with foam, gel, silicon - Don't keep HOB elevated above 30 degrees - Use sheet to lift/move patient - Re-position every 2 hours while in bed, and 1 hour when sitting - No rubber ring or donut on sacrum area - Place foam wedges between bony prominences Nutrition: - Fluid intake of 2000-3000ml/day - Help pt. maintain adequate intake of protein Skin Care: - Daily inspection - Document/report any s&s of infection - Use moisturizers daily - Keep moisture away from prolonged contact with skin - Dry areas where skin surfaces touch - Place absorbent pads down - Use moisture barriers Skin Cleaning: - Clean skin after soiling ASAP - Use milf, heavily fatted soap -Used tepid water - In perineal area use peri-cloth - Minimum scrubbing - NO POWDER!!! directly on perineum - After cleansing, apply skin barrier cream

BOX 15-2 Positive and Negative Symptoms of Schizophrenia:

Positive symptoms: Tend to reflect an alteration or distortion of normal mental functions - Associated with normal brain structures Content of thought: ⦁ Delusions: false personal beliefs - Delusions of persecutions makes the individual feel threatened or believe that others intend to harm or persecute him or her - Delusions of grandeur makes the individual feel like they have an exaggerted feeling of importance, power, knowledge, or identity - Delusion of reference makes the individual feel that all events within the environment are referred by the psychotic person to him/her; When in presence of others they feel that they are the object of their discussion or ridicule - Delusion of control or influence makes the individual believe certain objects have control over his or her behavior - Somatic delusion makes the individual have a false idea about the functioning of his or her body (I'm 70 years old and will be the oldest person to give birth) - Nihilistic delusion makes the individual have a false idea that the self, a part of the self, others, or the world is nonexistent (I have no heart; The world no longer exists) ⦁ Religiosity: excessive demonstration of obsession with religious ideas and behavior; May believe the voice they hear are God ⦁ Paranoia: extreme suspiciousness of others; (I wont eat this food. I know it has been poisoned) ⦁ Magical thinking: ideas that one's thoughts or behaviors have control over specific situations; (It snowed last night because I wished very hard that it would) Form of thought: ⦁ Associative looseness (also called loose association): shift of ideas from one unrelated topic to another; (We wanted to take the bus, but the airport took all the traffic. Driving is the ticket when you want to get somewhere) ⦁ Neologisms: made-up words that have meaning only to the person who invents them; (She wanted to give me ride in her new uniphorum) ⦁ Concrete thinking: literal interpretations of the environment (I'm climbing the walls; It's raining men) ⦁ Clang associations: choice of words is governed by sound (often rhyming); (It is very cold. I am cold and bold) ⦁ Word salad: group of words put together in a random fashion (Most forward action grows life double plays) ⦁ Circumstantiality: delay in reaching the point of a communication because of unnecessary and tedious details ⦁ Tangentiality: inability to get to the point of communication due to introduction of many new topics ⦁ Mutism: inability or refusal to speak ⦁ Perseveration: persistent repetition of the same word or idea in response to different questions Perception: interpretation of stimuli through the senses Hallucinations: false sensory perceptions not associated with real external stimuli. ⦁ Auditory- False perceptions of sound; - May hear clicks, rushing noises, music, etc. - Command hallucinations are most dangerous - Most common type ⦁ Visual- False visual perceptions - May consist of formed images, such as of people, or of unformed images, such as flashes of light ⦁ Tactile- False perceptions of the sense of touch, often something on or under the skin - One specific tactile hallucination is formication; sensation that something is crawling under or on the skin ⦁ Gustatory- False perception of taste - Described as an unpleasant tastes ⦁ Olfactory- False perceptions of the sense of smell Illusions: misperceptions of real external stimuli Sense of self: The uniqueness and individuality a person feels. ⦁ Echolalia: repeating words that are heard ⦁ Echopraxia: repeating movements that are observed ⦁ Identification and imitation: taking on the form of behavior one observes in another ⦁ Depersonalization: feelings of unreality Negative Symptoms: Reflect a diminution or loss of normal functions. - They are not only difficult to treat and respond less well to antipyschotics than positive symptoms, but they are also the most destructive because they render the patient inert and unmotivated. Affect: the feeling state or emotional tone. ⦁ Inappropriate affect: emotions are incongruent with the circumstances (Laughing when told of the death of her mother) ⦁ Bland: weak emotional tone ⦁ Flat: appears to be void of emotional tone (Overt expressions or feelings) ⦁ Apathy: disinterest in the environment (Bland affect is a manifestations of the emotional apathy) Volition: impairment in the ability to initiate goal-directed activity. ⦁ Emotional ambivalence: coexistence of opposite emotions toward same object, person, or situation (Opposing emotions may interfere with person's ability to make even a very simple decision) ⦁ Deterioration in appearance: impaired personal grooming and self-care activities Impaired interpersonal functioning and relationship to the external world. ⦁ Impaired social interaction: clinging and intruding on the personal space of others, exhibiting behaviors that are not culturally and socially acceptable ⦁ Social isolation: a focus inward on the self to the exclusion of the external environment Psychomotor behavior: ⦁ Anergia: deficiency of energy ⦁ Waxy flexibility: passive yielding of all movable parts of the body to any effort made at placing them in certain positions; (May even stay in uncomfortable positions) ⦁ Posturing: voluntary assumption of inappropriate or bizarre postures ⦁ Pacing and rocking: pacing back and forth and rocking the body Associated features: ⦁ Anhedonia: inability to experience pleasure ⦁ Regression: retreat to an earlier level of development

Predisposing Factors for both Anorexia and Bulimia:

Predisposing factors: ⦁ Biological influences ⦁ Genetics: 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. ⦁ Neuroendocrine abnormalities ⦁ There has been some speculation about a primary hypothalamic dysfunction in anorexia nervosa. ⦁ Neurochemical influences ⦁ Bulimia nervosa may be associated with the neurotransmitters serotonin and norepinephrine. ⦁ Anorexia nervosa may be associated with high levels of endogenous opioids. ⦁ Psychodynamic influences ⦁ Suggests that eating disorders result from very early and profound disturbances in mother-infant interactions, resulting in ⦁ Delayed ego development ⦁ Unfulfilled sense of separation-individuation Family influences: ⦁ Conflict avoidance ⦁ Families may promote and maintain psychosomatic symptoms, including anorexia nervosa, in an effort to avoid spousal conflict. ⦁ The sick child becomes the problem, and focus on the conflict is diverted. Elements of power and control: ⦁ Power and control may become the overriding elements within the family. ⦁ Parental criticism promotes an increase in obsessive and perfectionistic behavior on the part of the child, who continues to seek love, approval, and recognition. ⦁ Ambivalence toward the parents develops, and distorted eating patterns may represent rebellion against the parents. ⦁ Eating disorder is seen as a way to gain control.

If a patient is diagnosed with vascular neurocognitive disorder the nurse should be concerned if the pt. smokes cigarettes

Rationale: Cause of vascular NCD is related to an interruption of blood flow to the brain Lack of circulation in vascular NCD if pt. smokes you need to teach them smoking cessation because smoking will interrupt blood flow

Chart 25-3 Types of Wound Exudate:

Serosanguineous Exudate: Blood-tinged amber fluid consisting of serum and RBCs - Normal for the first 48h after injury - Sudden increase in amount precedes wound dehiscence in wounds closed by first intention Purulent Exudate: Creamy yellow pus- Colonization with staph Greenish-Blue Pus causing staining of dressings and accompanied by a fruity odor- Colonization of pseudomonas Beige pus with a fishy odor- Colonization with Proteus Brownish pus with a fecal odor- Colonization with aerobic coliform and becteroides (usually occurs after intestinal surgery)

Schizophrenia Spectrum Disorder:

The spectrum of psychotic disorders includes schizophrenia, schizoaffective disorder, delusional disorder, schizotypal personality disorder, schizophreniform disorder, brief psychotic disorder, as well as psychosis associated with substance use or medical conditions.

Table 23-7 Care for Patients with Ebola Virus Disease:

Transmission of the Disease: - Primary source of the Ebola virus is most likely contaminated bats or primates (apes and monkeys) - Not spread via air, water, or food - Nurses can help identify people at high risk for having or transmitting the disease by taking a complete hx, including travel to West Africa, or exposure of family who have Ebola - Disease can be transmitted by unprotected contact with infected people or those who have died from it - Teach patients to recover from Ebola and their partners that the virus is present for up to 3 months; using condoms may prevent transmission Prevention of Disease: - Avoid direct contact with body fluids - Use standard, contact, and droplet precautions (PPE) - Isolate patient - Use dedicated or disposable medical equipment - Practice proper sterilization measures Assessment: Assess for- - Fever - Severe Headache - Muscle Pain - Weakness - Fatigue - Diarrhea - Vomiting - Abdominal Pain - Unexplained hemorrhage Patient-Centered Collaborative Care: - No drug or vaccine is yet approved - Remember virus can enter through broken skin or unprotected mucous membranes Supportive Care Includes- - IV fluid & electrolyte replacement - O2 & ventilation support - BP support - Treatment of other infections - Care and comfort - Symptomatic care - Emotional Support - possible end-of-life care

Common Skin Infections/Disorders:

Xerosis (Dry Skin) • Pruritus (itching)- caused by stimulation of itch-specific nerve fibers at the dermal-epidermal junction by physical or chemical agents. • Sunburn • Urticaria (hives)- are white or red edematous papules or plaques of various sizes caused by exposure to allergens that releases histamine in the dermal tissue. - The exact cause is rarely identified, although drugs, foods, infections, autoimmune diseases, cancer, and physical stimuli often trigger urticaria. Skin infections can be bacterial, viral, or fungal. - A common skin problem is infection with methicillin-resistant Staphylococcus aureus. - The most common viral agent to cause infection is herpes simplex virus. - The vaccine Zostavax is available to prevent varicella zoster virus reactivation and shingles. - The Centers for Disease Control and Prevention recommends the vaccine for anyone over the age of 60 years who has a healthy immune system. - This one-time subcutaneous injection is reported to reduce the incidence of shingles by as much as 64%. - Candida albicans, also known as yeast infection, is a common fungal infection of skin and mucous membranes. - Handwashing and not sharing personal items with others are the best ways to prevent skin infection, especially bacterial and fungal. - Take precautions during the physical assessment of the skin to avoid the spread of infection. Effects of Old Age: Altered Inflammatory Response: Local- Arteriosclerosis Diabetes Vasculitis Venous Insufficiency Mechanism: (Reduced local tissue circulation, resulting in ischemia, impaired leukocytic response to wounding, and increased probability of wound infection) Systemic- Leukemia Prolonged administration of high-dose anti-inflammatory - Corticosteroids/ Aspirin Mechanism: (Systemic inhibition of leukocytic response, resulting in impaired hose resistance to infection) Impaired Cellular Proliferation: Local- Wound infection Foreign Body Necrotic Tissue Mechanism: (Prolonged inflammatory response, which can result in low tissue oxygen tension and further tissue destruction) Systemic- Aging Chronic Stress Nutritional Deficiencies Impaired oxygenation Mechanism: (Impaired cellular proliferation and collagen synthesis; Decreased wound contraction)

MDRO's:

• "MDROs" • Microorganisms have become resistant to certain antibiotics • Most common MDROs - Methicillin-resistant Staphylococcus aureus - Vancomycin-resistant Enterococcus - Carbapenum-resistant Enterococcus Examples of multidrug-resistant organisms include MRSA and vancomycin-resistant Enterococcus organisms. - Patients most at risk for health care-associated MRSA are older adults and those who have suppressed immunity, have a long history of antibiotic therapy, have invasive tubes or lines, or are intensive care unit patients. - One of the newest discoveries to explain the increase in HAIs, especially the rise in drug-resistant infections, is the formation of biofilms. - A biofilm, also called glycocalyx, is a complex group of microorganisms that functions within a "slimy" gel coating on medical devices, such as urinary catheters, orthopedic implants, and enteral feeding tubes; on parts of the body, such as the teeth (plaque) and tonsils; and in chronic wounds. - Biofilms are extremely difficult to treat, and mechanical disruption strategies are the mainstay of management and research. - Antibiotic therapy may increase the growth of microbes within biofilms. - Silver dressings have been known to be effective for infections with staph - These MDRO's may be effectively treated with linezolid (Zyvox) and Quinupristin-Dalfopristin (Synercid)

Pressure Ulcers:

• Compression of skin and underlying soft tissue between bony prominence and external surface for extended period • Mechanical forces create ulcers - Pressure - Friction - Shear - A pressure ulcer is a loss of tissue integrity caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period, leading to ischemia, inflammation, and tissue necrosis. - Ulcers occur most often in people with limited mobility because they are unable to change their position, or from friction or shearing forces. - Incontinence or prolonged moisture in contact with the skin can irritate and destroy tissue integrity. - A pressure ulcer prevention program consists of identification of high-risk patients and implementation of aggressive prevention using pressure-relieving or reduction devices. - An effective pressure-relieving mattress or device is recommended for patients who cannot turn to prevent extension of skin breakdown that has already occurred and to promote healing for breakdown present on several turning surfaces. - Avoid rubbing or massaging reddened skin areas directly or use donut-shaped pillows to reduce pressure. - The appropriate device depends upon the degree of immobility and the extent or presence of pressure-related injury. - The actual turning or re-positioning schedule for each patient must be individualized to prevent loss of skin tissue integrity. - Patients with cognitive impairments may not readily report discomfort from inadequate pressure relief. - Select a dressing material with properties that promote an optimal environment for healing. - Depending on the dressing material used, dressings help remove debris either through: - Mechanical débridement (mechanical entrapment and detachment of dead tissue) - Topical chemical débridement (enzyme preparations applied topically to loosen necrotic tissue) - Natural chemical débridement (creating an environment that promotes self-digestion of dead tissues by naturally occurring bacterial enzymes [autolysis]) - A hydrophobic or nonabsorbent, waterproof material is useful when the wound is relatively free of drainage and the purpose is to protect the ulcer from external contamination. - A hydrophilic or absorbent material draws excessive drainage away from the ulcer surface, preventing maceration. - Record and document the progression of the wound. - Inspect the wound margins for cellulitis (inflammation of the skin and surrounding tissue). This may indicate an increased risk for infection if proper measures for pressure relief have been taken. - Hyperbaric oxygen therapy is the administration of oxygen under high pressure, raising the tissue oxygen concentration. It is usually reserved for life- or limb-threatening wounds such as burns, necrotizing infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers. - Electrical stimulation is the application of a low-voltage current to a wound area to increase blood vessel growth and promote granulation. - Topical growth factors are biologically active substances that stimulate cell movement and growth to restore tissue integrity. - Skin substitutes are engineered products that aid in the temporary or permanent closure of different types of wounds. - High-risk patients who are chair bound should also be periodically assisted to a standing position to promote tissue perfusion and prevent breakdown over the sacral area. - Differentiate between contamination and infection of a wound. Stages: Concept Map: Individuals at Risk: Labs- Albumin, C&S, WBC Assessment, Prevention:

Unstageable Pressure Ulcer:

• Eschar presesnt and can't be staged until debrided off

Vascular Changes Resulting from Burn Injuries:

• Fluid shift: Third spacing or capillary leak syndrome, usually occurs in first 12 hr, can continue 24 to 36 hr - Fluid shift occurs after initial vasoconstriction as a result of blood vessels near near the burn dilating and leaking - Impaired F&E lead to loss of plasma and proteins, which decrease blood volume and BP • Fluid shift with excessive weight gain occurs in first 12 hr, can continue 24 to 36 hr - Edema develops as plasma and electrolytes escape into the interstitial space • Profound imbalance of fluid, electrolyte, acid-base; hyperkalemia and hyponatremia levels; hemoconcentration - Hyperkalemia occurs as a result of direct cell injry that releases large amounts of K+ - NA+ is retained by the body, but aldosterone increases, leading to sodium re-absorption by the kidneys - However, this NA+ quickly passes the interstitial space and most is trapped there so a NA+ deficit occurs - Hemoconcentration (Elevated blood osmolarity, H&H) develops from vascular dehydration which increases blood viscosity reducing BF and increases tissue hypoxia • Fluid re-mobilization starts after 24 hr once capillary leak stops; - Diuretic stage begins 48 to 72 hr after injury as capillary membrane integrity returns and edema fluid shifts from interstitial to intravascular; Blood volume increases and increased kidney blood flow and diuresis and body weight returns to normal; - During this phase, hyponatremia occur because of increased kidney NA+ excretion and then hypokalemia occurs as well from K+ moving back into cells - Metabolic acidosis is possible because of the loss of bicarb & increased rate of metabolism

Stage 3 Pressure Ulcer:

• Full-thickness skin loss • Subcutaneous tissue and underlying fascia may be damaged or necrotic • Bone, tendon, muscle NOT exposed • May have undermining and tunneling

Stage 4 Pressure Ulcer:

• Full-thickness skin loss with exposed or palpable muscle, tendon, or bone • Undermining and tunneling common with sinus tracts possible • Slough and eschar often present

Infectious Process:

• Reservoir- Sources of infection Animate Reservoir: People, Animals, Insects Inanimate Reservoir: Soil, Water, Medical Equipment; - A person with an active infection or asymptomatic carrier is a reservoir - Bacterias like Neisseria meningitidis can exist in the respiratory tract while causing no illness; Same as enterococcus which live sin normal flora of GI - Continued multiplication of a pathogen is sometimes accompanied by toxin production; Toxin: Protein molecules released by bacteria to affect host cells at a distant site Exotoxins: Released into environment (Botulism, Tetanus, Diptheria, and E. Coli) Endotoxins: Produced in cell walls and released with cell lysis • Susceptible host- Host factors influence the development of infection - Breakdown of the defense mechanisms results in infection - Immune system plays a large role Passive Immunity: Short duration and either natural or trans-placental of antibodies (mother, immunoglobulins) Active Immunity: Lasts for years and is natural by infection or artificial by stimulation (Vaccination) • Mode of transmission - Body's skin is the most important defense in transmission of microorganisms - Microorganisms may enter through: - Respiratory Tract - GI Tract - Genitourinary Tract - Skin - Mucous Membranes - Blood Routes of Transmission: Respiratory Tract: Invades through droplets in the air when someone talks, coughs, or sneezes. -Pathogen localizes in lungs & distributed through lymph and blood - Strep, TB, Flu Gastrointestinal Tract: Invades through contaminated food or putting hands in mouth - Results in many hospitalizations and deaths - Salmonella, Shigella Genitourinary Tract: Invades through devices such as catheter or from being unhygienic or through sex - UTI is one of the most common health-care associated infection - CAUTI is most common among older adults Skin/ Mucous Membranes: Invades through broken or intact skin & mucous membranes - Some organisms can enter even through intact skin such as (Treoponema Pallidum) - Most enter through breaks or mucous membranes - Fragile skin of older adults and of those receiving prolonged steroid therapy increases infection risk Bloodstream: Invades via the blood through IV or other medical device or tubes - In community biting insects can cause infection to spread via the bloodstream (Lyme disease, West Nile Virus, Viral Encephalitis)

Stage 1 Pressure Ulcer:

• Skin intact • Area usually over bony prominence, does not blanch with external pressure • Observable pressure-related alterations of intact skin

Stage 2 Pressure Ulcer:

• Skin not intact • Partial-thickness skin loss of epidermis or dermis • Ulcer is superficial, may appear as abrasion, blister, or shallow crater • Bruising not present

Evaluation for Anorexia Nervosa/ Bulimia Nervosa:

■Has the client steadily gained 2 to 3 pounds per week to at least 80 percent of body weight for age and size? ■Is the client free of signs and symptoms of mal-nutrition and dehydration? ■Does the client consume adequate calories as determined by the dietitian? ■Have there been any attempts to stash food from the tray to discard later? ■Have there been any attempts to self-induce vomiting? ■Has the client admitted that a problem exists and that eating behaviors are maladaptive? ■Have behaviors aimed at manipulating the environment been discontinued? ■Is the client willing to discuss the real issues concerning family roles, sexuality, dependence/independence, and the need for achievement? ■Does the client understand how he or she has used maladaptive eating behaviors in an effort to achieve a feeling of some control over life events? ■Has the client acknowledged that perception of body image as "fat" is incorrect?

Antipyschotic Medication:

⦁ Antipsychotics ⦁ Used to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders Action: ⦁ Typicals: dopaminergic blockers with various affinity for cholinergic, α-adrenergic, and histaminic receptors; Work by blocking postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla ⦁ Atypicals: weak dopamine antagonists; potent 5HT2A antagonists; also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors; Weaker dopamine receptor antagonists than the conventional antipyschotics, but are more potent antagonists of the serotonin Contraindications/Precautions: - Clients with known hypersensitivity (cross-sensitivity may exist among phenothiazines) - Caution should be taken inadministering these drugs to clients who are elderly, severely ill, or debilitated, and to diabetic clients or clients with respiratory insufficiency, prostatic hypertrophy, or intestinal obstruction Atypical Antipsychotics: CI: Hypersenstivity, comatose or severely depressed, with dementia-related psychosis, and lactation Caution should be taken in administering these drugs to elderly or debilitated patients; cardiac, hepatic, or renal insufficiency, to those with a hx of seizures, patients with diabetes (risk factors) Side Effects: ⦁ Anticholinergic effects ⦁ Nausea; GI upset ⦁ Skin rash ⦁ Sedation ⦁ Orthostatic hypotension ⦁ Photosensitivity ⦁ Hormonal effects ⦁ ECG changes ⦁ Hypersalivation ⦁ Weight gain ⦁ Hyperglycemia/diabetes ⦁ Increased risk of mortality in elderly clients with dementia ⦁ Reduction in seizure threshold ⦁ Agranulocytosis ⦁ Extrapyramidal symptoms ⦁ Tardive dyskinesia ⦁ Neuroleptic malignant syndrome Extrapyramidal symptoms (EPS) include: ⦁ Pseudoparkinsonism ⦁ Akinesia ⦁ Akathisia ⦁ Dystonia ⦁ Oculogyric crisis Antiparkinsonian agents may be prescribed to counteract EPS Client/Family Education on Antipsychotics: The client should: ⦁ Not stop taking the drug abruptly ⦁ Use sunscreens and wear protective clothing when spending time outdoors ⦁ Report weekly (if receiving clozapine therapy) to have blood levels drawn and to obtain a weekly supply of the drug ⦁ Be aware of possible risks of taking antipsychotics during pregnancy ⦁ Not drink alcohol while receiving antipsychotic therapy ⦁ Not consume other medications (including over-the-counter drugs) without the physician's knowledge

Bulimia Nervosa:

⦁ Bulimia nervosa is an episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period (binging). ⦁ The episode is followed by inappropriate compensatory behaviors to rid the body of the excess calories (self-induced vomiting or the misuse of laxatives, diuretics, or enemas). ⦁ Fasting or excessive exercise may also occur. ⦁ Most patients with bulimia are within a normal weight range, some slightly underweight, some slightly overweight. ⦁ Depression, anxiety, and substance abuse are not uncommon. ⦁ Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalances.

Delirium:

⦁ Characterized by a disturbance in level of awareness and a change in cognition ⦁ Develops rapidly over a short period ⦁ Usually brief (1 week; rarely more than 1 month) and upon recovery from underlying determinant, symptoms usually diminish over a 3-7 day period, but in some instances may take as long as weeks 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 ⦁ Disturbance in level of consciousness, with interruption of the sleep-wake cycle ⦁ Psychomotor activity that fluctuates between agitation and restlessness and a vegetative state ⦁ Emotional instability Symptoms include autonomic manifestations such as: - Tachycardia - Sweating - Flushed face - Dilated pupils - Elevated blood pressure ⦁ Usually begins abruptly ⦁ Can have a slower onset if underlying etiology is systemic illness or metabolic imbalance ⦁ Duration is usually brief and subsides completely on recovery from underlying determinant Predisposing Factors: Delirium due to a general medical condition: Examples- ⦁ Infections, febrile illness, metabolic disorders, head trauma, seizures, migraine headaches, brain abscess, stroke, electrolyte imbalance, others Substance-Induced Delirium: ⦁ May be caused by intoxication or withdrawal from certain substances, such as ⦁ Anticholinergics, antihypertensives, corticosteroids, anticonvulsants, analgesics, and others ⦁ Alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, and others ⦁ Toxins, including organic solvents and fuels, lead, mercury, arsenic, carbon monoxide, and others Medication-Induced Delirium: ⦁ Includes anticholinergics, antihypertensives, corticosteroids, anticonvulsants, cardiac glycosides, analgesics, anesthetics, antineoplastic agents, antiparkinson drugs, H2 receptor antagonists, etc

Avoidant Personality Disorder:

⦁ Characterized by: - Extreme sensitivity - Social withdrawal - Want relationship but may be too shy - Prevalence is 1% and is equally common in men and women ⦁ Clinical Picture: - Awkward and uncomfortable in social situations - Desire close relationships but avoid them because of fear of being rejected - Perceived as timid, withdrawn, or cold and strange - Often lonely and feel unwanted - View others are critical and betraying ⦁ Predisposing Factors: - No clear cause is known - May be combination of biological, genetic, and psycho-social influences - Primary psycho-social influence: parental rejection and censure, which are often reinforced by peers

Neurocognitive Disorders:

⦁ Impairment in the cognitive functions of thinking, reasoning, memory, learning, and speaking ⦁ Neurocognitive disorder (NCD) may be classified as mild or major, depending on severity of symptoms. ⦁ Mild NCD has also been called Mild Cognitive Impairment. ⦁ Major NCD constitutes what was previously described in the DSM as dementia. ⦁ Primary NCDs are those in which the disorder itself is the major sign of some organic brain disease not directly related to any other organic illness (e.g., Alzheimer's disease) ⦁ Secondary NCDs are caused by or related to another disease or condition (e.g., HIV disease or cerebral trauma) Symptoms: ⦁ Impairment exists in abstract thinking, judgment, and impulse control ⦁ Conventional rules of social conduct are disregarded ⦁ Personal appearance and hygiene are neglected ⦁ Language may or may not be affected ⦁ Personality change is common Reversible NCD may be more appropriately termed temporary dementia. It can occur as a result of: ⦁ Stroke ⦁ Depression ⦁ Side effects of medications ⦁ Nutritional deficiencies ⦁ Metabolic disorders Vascular NCD: ⦁ NCD occurs as a result of significant cerebrovascular disease ⦁ There is a more abrupt onset than is seen in association with Alzheimer's disease, and the course is more variable Etiologies may include- ⦁ Hypertension ⦁ Cerebral emboli ⦁ Cerebral thrombosis Frontotemporal NCD: ⦁ Occurs as a result of shrinking of the frontal and temporal anterior lobes of the brain ⦁ Previously called Pick's disease ⦁ Exact cause is unknown, but genetics appears to be a factor NCD due to traumatic brain injury: (Lewy Body) ⦁ Similar to Alzheimer's disease, but progresses more rapidly ⦁ Appearance of Lewy bodies in the cerebral cortex and brainstem ⦁ Progressive and irreversible ⦁ May account for 25 percent of all NCD cases NCD due to Parkinson's disease: ⦁ Caused by a loss of nerve cells located in the substantia nigra and a decrease in dopamine activity ⦁ Cerebral changes in NCD due to Parkinson's disease sometimes resemble those of Alzheimer's disease NCD due to HIV infection: ⦁ Caused by brain infections with opportunistic organisms or by the HIV-1 virus directly ⦁ Symptoms may range from barely perceptible changes to acute delirium to profound cognitive impairment Substance-induced NCD: Occurs as a result of reactions to, or the overuse or abuse of, substances such as: ⦁ Alcohol ⦁ Inhalants ⦁ Sedatives, hypnotics, and anxiolytics ⦁ Medications that cause anticholinergic side effects ⦁ Toxins, such as lead and mercury NCD due to Huntington's disease: ⦁ This disease is transmitted as a Mendelian dominant gene ⦁ Damage occurs in the areas of the basal ganglia and the cerebral cortex ⦁ The client usually declines into a profound state of dementia and ataxia ⦁ Average course of the disease is based on age at onset, with juvenile-onset and late-onset having the shortest duration NCD due to Prion disease: ⦁ The disorder is attributable to prion disease (e.g., Creutzfeldt-Jakob disease or bovine spongiform encephalopathy) ⦁ Onset of symptoms typically occurs between ages 40 and 60 years; course is extremely rapid, with progression from diagnosis to death in less than 2 years ⦁ Five to 15 percent of cases have a genetic component NCD due to another: ⦁ Hypothyroidism ⦁ Hyperparathyroidism ⦁ Pituitary insufficiency ⦁ Uremia ⦁ Encephalitis ⦁ Brain tumor ⦁ Pernicious anemia ⦁ Thiamine deficiency ⦁ Multiple sclerosis medical condition, such as ⦁ Pellagra ⦁ Uncontrolled epilepsy ⦁ Cardiopulmonary insufficiency ⦁ Fluid and electrolyte imbalances ⦁ CNS and systemic infections ⦁ Systemic lupus erythematosus

Substance-Induced Psychotic Disorder:

⦁ The presence of prominent hallucinations and delusions that are judged to be directly attributable to substance intoxication or withdrawal ⦁ Diagnosis is made when the symptoms are more excessive and severe than those usually associated with the intoxication or withdrawal syndrome ⦁ Substances that are believed to induce psychotic disorders are presented in table 15-1 Table 15-1: Drugs of Abuse: - Alcohol - Amphetamines - Cannabis - Cocaine - Hallucinogens Medications: - Anesthetics and Analgesics - Anticholingeric Agents - Antidepressants - Antihypertensives - Antihistamines Toxins: - Anticholinesterase - Nerve Gases - Carbon Dioxide - Carbon Monoxide - Fuel, Paint, Gas