FINAL REVIEW B44

Steps of the problem-solving process

Identify the problem. State it in objective terms, minimizing emotianal overlay. Discuss possible solutions. Brainstorming solutions as a group can stimulate new solutions to old problems. Encourage individuals to think creatively, beyond simple solutions. Analyze identified solutions. The potential pros and cons of each possible solutian should be discussed in an attempt to narrow down the number ofviable solutions. Select a solution. Based on this analysis, select a solutian for implementation. Implement the selected solution. A procedure and timeline far implementation should accompany the implementation ofthe selected solution. Evaluate the solution's ability to resolve the original problem. The outcomes su rrounding the new solutian should be evaluated according to the predetermined timeline. The solution should be given adequate time ta become established as a new routine before it is evaluated. Ifthe solutian is deemed unsuccessful, the problem-solving process will need to be reinstituted and the problem discussed again

Stage 7. Very severe decline.

In the end stages of AD, the individual is unable to recognize family members. He or she most commonly is bedfast and aphasic. Problems of immobility, such as decubiti and contractures, may occur.

Evaluation (eating disorders)

• Evaluation of the client with an eating disorder requires reassessment of the behaviors for which the client sought treatment for. • Behavioral change will be required by client and family members.

Cognitive process

• Nurses must begin relationship development with a substance abuser by examining our own attitudes and personal experiences with substances. • • Recall Pre-orientation Phase

Family therapy for Eating Disorders

- Involves educating the family about the disorder - Assesses the family's impact on maintaining the disorder - Assists in methods to promote adaptive functioning by the client

Behavior modification for Eating Disorders

- 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 • • Has input into the care plan • • Clearly sees what the treatment choices are

Nursing Process • Nursing diagnoses eating disorder

- Imbalanced nutrition: less than body requirements related to refusal to eat - Deficient fluid volume (risk for or actual) related to decreased fluid intake, self-induced vomiting, and laxative and/or diuretic abuse - Ineffective denial related to delayed ego development and fear of losing the only aspect of life over which he or she perceives some control (eating) - Imbalanced nutrition: more than body requirements related to compulsive overeating • Disturbed body image/low self-esteem related to delayed ego development, dysfunctional family system, or feelings of dissatisfaction with body appearance • Anxiety (moderate to severe) related to feelings of helplessness and lack of control over life events

Psychopharmacology for Eating Disorders

- No medications are specifically indicated for eating disorders. - Various medications have been prescribed for associated symptoms, such as • Anxiety • Depression • • For anorexia nervosa - - Fluoxetine (Prozac)-SSRI - - Imipramine (Tofranil)-antidepressant - - Olanzapine (Zyprexa)-atypical antipsychotic possibly for weight gain and obsessional symptoms • • For bulimia nervosa-antidepressants - - Fluoxetine (Prozac)-FDA approved - - Imipramine (Tofranil) - - Desipramine (Norpramine)-decreases binge frequency - - Amitriptyline (Elavil) - - Nortriptyline (Aventyl) - - Phenelzine (Nardil)-MAOI • • For binge eating disorder with obesity - - Topiramate (Topamax) • • For obesity - - Fluoxetine (Prozac) - - Various anorexiants (CNS stimulants) - - Lorcaserin (Belviq)-appetite suppressant - - Phentermine/topiramate (Qsymia)- appetite suppressant

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.

Individual therapy for Eating Disorders

-Helpful when underlying psychological problems are contributing to the maladaptive behaviors.

BOX 22-4 Diagnostic Criteria for Histrionic Personality Disorder

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the center of attention 2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior 3. Displays rapidly shifting and shallow expression of emotions 4. Consistently uses physical appearance to draw attention to self 5. Has a style of speech that is excessively impressionistic and lacking in detail 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion 7. Is suggestible (i.e., easily influenced by others or circumstances) 8. Considers relationships to be more intimate than they actually are

BOX 20-5 Diagnostic Criteria for Dissociative Identity Disorder

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual. B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play. E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

BOX 20-1 Diagnostic Criteria for Somatic Symptom Disorder

A. One or more somatic symptoms that are distressing or result in significant disruption in daily life. B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: 1. Disproportionate and persistent thoughts about the seriousness of one's symptoms. 2. Persistently high level of anxiety about health or symptoms. 3. Excessive time and energy devoted to these symptoms or health concerns. C. Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). Specify if: With predominant pain (the somatic symptoms predominantly involve pain) Persistent (a persistent course is characterized by severe symptoms, marked impairment, and long duration [more than 6 months]) Specify current severity: Mild (only one of the symptoms specified in Criterion B is fulfilled) Moderate (two or more of the symptoms specified in Criterion B are fulfilled) Severe (two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints [or one very severe somatic symptom])

BOX 21-2 Diagnostic Criteria for Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than most individuals would eat during a similar period of time and under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify if: In partial remission In full remission Specify current severity: Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

BOX 21-1 Diagnostic Criteria for Anorexia Nervosa

A. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. Specify whether: Restricting Type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Binge-Eating/Purging Type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Specify if: In partial remission In full remission Specify current severity: Mild: BMI > 17 kg/m2 Moderate: BMI 16-16.99 kg/m2 Severe: BMI 15-15.99 kg/m2 Extreme: BMI < 15 kg/m2

Ch. 21- Eating Disorders

Behavior Modification Programs- Purpose p553 Anorexia-Differentiate from bulimia p538 Social influences-p538 Nursing Dx- prioritize p546 T-21-2 Outcomes/goals-Care plan p547 T21-3 Bulimia-differentiate from anorexia Dx criteria -p542 Box21-2

Community Resources for the Homeless Interfering Factors

Among the many issues that complicate service planning for homeless individuals with mental illness is this population's penchant for mobility. Frequent relocation confounds service delivery and interferes with providers' efforts to ensure appropriate care. Some individuals with serious mental illness may be affected by homelessness only temporarily or intermittently. These individuals are sometimes called the "episodically homeless." Others move around within neighborhoods or cities as needs change and based on whether or not they can obtain needed services. A large number of the homeless mentally ill population exhibits continuous unbounded movement over wide geographical areas. Not all homeless individuals with mental illness are mobile. Some studies have indicated that a large percentage remain in the same location over a number of years. Healthcare workers must identify movement patterns of homeless people in their area to at least try to bring the best care possible to this unique population. This effort may mean delivering services to those individuals who do not seek out services on their own.

Stage 6. Severe cognitive decline.

At this stage, individuals may be unable to recall the name of their spouse or may misidentify people (e.g., thinking a child is their spouse). Disorientation to surroundings is common, and the person may be unable to recall the day, season, or year. The person is unable to manage ADLs without assistance. Delusions often become apparent such as maintaining the belief that one must go to work even though the person is no longer employed. Urinary and fecal incontinence are common. Sleeping becomes a problem. Psychomotor symptoms include wandering, obsessiveness, agitation, and aggression. Symptoms seem to worsen in the late afternoon and evening—a phenomenon termed sundowning. Communication becomes more difficult with increasing loss of language skills. Institutional care is usually required at this stage.

TABLE 21-2 Assigning Nursing Diagnoses to Behaviors Commonly Associated With Eating Disorders

BEHAVIORS Refusal to eat; abuse of laxatives, diuretics, and/or diet pills; loss of 15 percent of expected body weight; pale conjunctiva and mucous membranes; poor muscle tone; amenorrhea; poor skin turgor; electrolyte imbalances; hypothermia; bradycardia; hypotension; cardiac irregularities; edema NURSING DIAGNOSES Imbalanced nutrition: Less than body requirements BEHAVIORS Decreased fluid intake; abnormal fluid loss caused by self-induced vomiting; excessive use of laxatives, enemas, or diuretics; electrolyte imbalance; decreased urine output; increased urine concentration; elevated hematocrit; decreased blood pressure; increased pulse rate; dry skin; decreased skin turgor; weakness NURSING DIAGNOSES Deficient fluid volume BEHAVIORS Minimizes symptoms; unable to admit impact of disease on life pattern; does not perceive personal relevance of symptoms; does not perceive personal relevance of danger NURSING DIAGNOSES Denial BEHAVIORS Compulsive eating; excessive intake in relation to metabolic needs; sedentary lifestyle; weight 20 percent over ideal for height and frame; BMI of 30 or more; reports the perception that eating is out of control NURSING DIAGNOSES Obesity BEHAVIORS Distorted body image; views self as fat, even in the presence of normal body weight or severe emaciation; denies that problem with low body weight exists; difficulty accepting positive reinforcement; self-destructive behavior (self-induced vomiting, abuse of laxatives or diuretics, refusal to eat); preoccupation with appearance and how others perceive it (anorexia nervosa, bulimia nervosa) Verbalization of negative feelings about the way he or she looks and the desire to lose weight (obesity) Lack of eye contact; depressed mood (all) NURSING DIAGNOSES Disturbed body image/Low self-esteem BEHAVIORS Increased tension; increased helplessness; overexcited; apprehensive; fearful; restlessness; poor eye contact; increased difficulty taking oral nourishment; inability to learn NURSING DIAGNOSES Anxiety (moderate to severe)

priority nursing diagnosis- Alcohol withdrawal FOR PATIENT WITHDRAWING FROM CNS DEPRESSANTS

BEHAVIORS Risk factors: CNS agitation (tremors, elevated blood pressure, nausea and vomiting, hallucinations, illusions, tachycardia, anxiety, seizures) NURSING DIAGNOSES Risk for injury

Avoiding/Withdrawling (conflict strategy)

Both parties know there is a conflict, but they refuse to face it or work toward a resolution. Can be appropriate for minor conflicts, when one party holds more power than the other party, or if the issue can work itself out over time. Because the conflict remains, it can surface again at a later date and escalate overtime. This is usually a lose-lose solution.

Nursing care Substance Abuse

Cognitive Process- Self-assessment CAGE Questionnaire

CH27- HOMELESS-

Community resources- interfering factors such as mobility p727 Health Issues- Outbreak challenges for CDC such as TUBERCULOSIS p728

Ch19 PTSD

Concept map p495;Sx/Criteria and duration of sx- p486 box19-1

Unit I-B Leadership-from your ATI Leadership

Conflict management strategies- There will be 3 Matching options for: Avoiding, Smoothing, Compromising

CRISIS Intervention (Ch 9)

Dealing with anger: nursing interventions T9-1 p175 Agression sx p173

Mental Health and Mental Illness (Ch 1)

Defense Mechanisms-Rationalization and Intellectualization-p7

Ch.13 Neurocognitive DO

Delirium-causes of (e.g medication induced)- p246 Alzheimer's Disorder- Review case study from class- Onset of symptoms- Review Stages 4 through 7- p249 Priority interventions-see care plan interventions re:self-care deficit-p263

Compromising/Negotiating (conflict strategy)

Each party gives up something. To consider this a win/lose-win/lose solution, both parties must give up something equally important. If one party gives up more than the other, it can become a win-lose solutian.

Concept map care plan for a patient with somatic symptom disorder

FIGURE 20-1 pg 529 Clinical Vignette: Veronica, age 51, has a long history of "doctor shopping" for numerous complaints of gastrointestinal distress, daily headaches, and abdominal pain. She has undergone numerous tests that show no evidence of pathophysiology. Her husband of 25 years recently died of a myocardial infarction (MI). Yesterday, she began having chest pains and was certain she was having a heart attack. Her daughter called 911, and Veronica was transported to the emergency department. The staff performed diagnostic studies and laboratory tests, which were all negative for pathophysiology. She was referred for psychotherapeutic treatment with a diagnosis of Somatic Symptom Disorder. The nurse develops the following concept map care plan for Veronica. Signs and Symptoms • Physical complaints • Absence of pathophysiology • Focus on self and physical symptoms Nursing Diagnosis Ineffective coping Nursing Actions • Perform ongoing assessment • Accept that the symptoms are real to the patient • Identify personal gains • Fulfill patient's needs • Do not give positive reinforcement to symptoms • Limit amount of time patient discusses symptoms • Teach adaptive coping strategies Medical Rx: Duloxetine 60 mg q day for chronic pain/depression/anxiety Outcomes: • Patient recognizes signs and symptoms of escalating anxiety • Patient is able to intervene before the exacerbation of physical symptoms Signs and Symptoms • Chest pains and fear of having a heart attack (following husband's sudden death from MI) Nursing Diagnosis Fear (of dying as husband did from acute MI) Nursing Actions • Perform ongoing assessment • Refer all new physical complaints to physician • Discuss patient fears and anxieties • Encourage verbalization of feelings associated with husband's death • Encourage participation in grief support group Medical Rx: Duloxetine 60 mg q day for chronic pain/depression/anxiety Outcomes: • Patient discusses feelings associated with husband's death • Fears of own serious illness have diminished • Patient uses adaptive coping mechanisms to diminish fears/anxieties

Concept map care plan for a patient with dissociative identity disorder

FIGURE 20-2 pg 529 Clinical Vignette: Wanda, age 32, was diagnosed 5 years ago with Dissociative Identity Disorder. History revealed severe childhood physical and sexual abuse by both parents. Several personalities have surfaced during years of therapy: an aggressive personality (Jamie), a suicidal personality (Ida), and 4-year-old child (Anna). Yesterday, following a particularly intense session with her therapist, the personality "Ida" surfaced and swallowed an undisclosed number of sertraline tablets. Wanda's group-home leader called 911, and Wanda was transported to the emergency department (ED). Following stabilization in the ED, Wanda was admitted to the psychiatric unit. The nurse develops the following concept map care plan for Wanda. Signs and Symptoms • The expression of more than one personality within the individual Nursing Diagnosis Disturbed personal identity Nursing Actions • Develop trust with each subpersonality that is expressed · Help patient understand her need for subpersonalities • Identify situations that precipitate transition · Help subpersonalities understand that integration means unifying into one • Provide support with therapy Outcomes: • Verbalizes understanding of multiple personalities and purpose they serve • Verbalizes knowledge of stress that precipitates transition • Desires to participate in integration therapy Signs and Symptoms • Depression and anxiety • Suicidal ideations (acted upon by personality "Ida") Nursing Diagnosis Complicated grieving Nursing Actions • Convey an accepting attitude • Allow patient to express anger in an appropriate manner • Explore with patient the true source of the anger • Explain process and stages of grieving and patient's position in the process • Until personalities are integrated, elicit assistance from personality "Jamie" to help control behavior of "Ida" Outcomes: • Verbalizes knowledge that anger is associated with maladaptive grieving • Is able to discuss original source of the anger

BOX 19-1 Diagnostic Criteria for Post-traumatic Stress Disorder

Note: The following criteria apply to adults, adolescents, and children older than 6 years. A. Exposure to actual or threatened death, serious injury, or sexual violence, in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work related. B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or effect of the dream is related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). C. Persistent avoidance of stimuli associated with the traumatic event(s) beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined"). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupation, or other important areas of functioning. H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Specify whether: With dissociative symptoms (depersonalization or derealization) With delayed expression (full diagnostic criteria not met until at least 6 months after the event)

Table 21-3 | CARE PLAN FOR PATIENT WITH EATING DISORDERS: ANOREXIA NERVOSA AND BULIMIA NERVOSA NURSING DIAGNOSES: IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS/DEFICIENT FLUID VOLUME (RISK FOR OR ACTUAL) RELATED TO: Refusal to eat/drink; self-induced vomiting; abuse of laxatives/diuretics EVIDENCED BY: Loss of weight; poor muscle tone and skin turgor; lanugo; bradycardia; hypotension; cardiac arrhythmias; pale, dry mucous membranes

OUTCOME CRITERIA Short-Term Goals ■ Patient will gain x pounds per week (amount to be established by the interdisciplinary team including the patient, nurse, and dietitian). ■ Patient will drink x mL of fluid each hour during waking hours. Long-Term Goal ■ By time of discharge from treatment, patient will exhibit no signs or symptoms of malnutrition or dehydration. NURSING INTERVENTIONS 1. For the patient who is emaciated and is unable or unwilling to maintain an adequate oral intake, the physician may order a liquid diet to be administered via nasogastric tube. Nursing care of the individual receiving tube feedings should be administered according to established hospital protocol. RATIONALE 1. Without adequate nutrition, a life-threatening situation exists. NURSING INTERVENTIONS 2. For the patient who is able and willing to consume an oral diet, collaborate with the dietitian to determine the appropriate amount of calories and fluids required to provide adequate nutrition and realistic weight gain. RATIONALE 2. Adequate calories are required to allow a weight gain of 2-3 pounds per week. NURSING INTERVENTIONS 3. Explain to the patient that privileges and restrictions will be based on compliance with treatment and direct weight gain. Minimize the focus on food and eating. RATIONALE 3. The real issues have little to do with food or eating patterns. Focus on the control issues that have precipitated these behaviors. NURSING INTERVENTIONS 4. Weigh patient daily, immediately upon arising and following first voiding. Always use same scale, if possible. Keep strict record of intake and output. Assess skin turgor and integrity regularly. Assess moistness and color of oral mucous membranes. RATIONALE 4. These assessments are important measurements of nutritional status and provide guidelines for treatment. NURSING INTERVENTIONS 5. Stay with patient during established time for meals (usually 30 min) and for at least 1 hour following meals. RATIONALE 5. Lengthy mealtimes put excessive focus on food and eating and provide patient with attention and reinforcement. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting. NURSING INTERVENTIONS 6. If weight loss occurs, enforce restrictions. RATIONALE 6. Restrictions and limits must be established and carried out consistently to avoid power struggles, to encourage patient compliance with therapy, and to ensure patient safety. NURSING INTERVENTIONS 7. Ensure that the patient and family understand that if nutritional status deteriorates, tube feedings will be initiated. This is implemented in a matter-of-fact, nonpunitive way. RATIONALE 7. This intervention is carried out for the patient's safety and protection from a life-threatening condition. NURSING INTERVENTIONS 8. Encourage the patient to explore and identify the true feelings and fears that contribute to maladaptive eating behaviors. RATIONALE 8. Emotional issues must be resolved if these maladaptive responses are to be eliminated.

Table 21-3 | CARE PLAN FOR PATIENT WITH EATING DISORDERS: ANOREXIA NERVOSA AND BULIMIA NERVOSA NURSING DIAGNOSIS: DENIAL RELATED TO: Ineffective coping mechanisms, anxiety, fear of losing control EVIDENCED BY: Inability to admit the impact of maladaptive eating behaviors on life pattern

OUTCOME CRITERIA Short-Term Goal ■ Patient will verbalize understanding of the correlation between emotional issues and maladaptive eating behaviors (within time deemed appropriate for individual patient). Long-Term Goal ■ By time of discharge from treatment, patient will demonstrate the ability to discontinue use of maladaptive eating behaviors and to cope with emotional issues in a more adaptive manner. NURSING INTERVENTIONS 1. Establish a trusting relationship with the patient by being honest, accepting, and available, and by keeping all promises. Convey unconditional positive regard. RATIONALE 1. Trust and unconditional acceptance promote dignity and self-worth and provide a strong foundation for a therapeutic relationship. NURSING INTERVENTIONS 2. Acknowledge the patient's anger at feelings of loss of control brought about by the established eating regimen associated with the program of behavior modification. RATIONALE 2. Anger is a normal human response and should be expressed in an appropriate manner. Feelings that are not expressed remain unresolved and add an additional component to an already serious situation. NURSING INTERVENTIONS 3. Avoid arguing or bargaining with the patient who is resistant to treatment. State matter-of-factly which behaviors are unacceptable and how privileges will be restricted for noncompliance. RATIONALE 3. The person who is denying a problem and who also has a weak ego will use manipulation to achieve control. Consistency and firmness by staff will decrease use of these behaviors. NURSING INTERVENTIONS 4. Encourage patient to verbalize feelings regarding role within the family and issues related to dependence/independence, the intense need for achievement, and sexuality. Help patient recognize how maladaptive eating behaviors may be related to these emotional issues. Discuss ways in which he or she can gain control over these problematic areas of life without resorting to maladaptive eating behaviors. RATIONALE 4. When patient feels control over major life issues, the need to gain control through maladaptive eating behaviors will diminish.

Table 21-3 | CARE PLAN FOR PATIENT WITH EATING DISORDERS: ANOREXIA NERVOSA AND BULIMIA NERVOSA NURSING DIAGNOSIS: DISTURBED BODY IMAGE/LOW SELF-ESTEEM RELATED TO: Ineffective coping, history of trauma, guilt or shame EVIDENCED BY: Distorted body image, difficulty accepting positive reinforcement, depressed mood and self-deprecating thoughts

OUTCOME CRITERIA Short-Term Goal ■ Patient will verbally acknowledge misperception of body image as "fat" within specified time (depending on severity and chronicity of condition). Long-Term Goal ■ By time of discharge from treatment, patient will demonstrate an increase in self-esteem as manifested by verbalizing positive aspects of self and exhibiting less preoccupation with own appearance as a more realistic body image is developed. NURSING INTERVENTIONS 1. Help patient to develop a realistic perception of body image and relationship with food. Compare specific measurement of the patient's body with the patient's perceived calculations. RATIONALE 1. There may be a large discrepancy between the actual body size and the patient's perception of his or her body size. Patient needs to recognize that the misperception of body image is unhealthy and that maintaining control through maladaptive eating behaviors is dangerous—even life threatening. NURSING INTERVENTIONS 2. Promote feelings of control within the environment through participation and independent decision making. Through positive feedback, help patient learn to accept self as is, including weaknesses as well as strengths. RATIONALE 2. Patient must come to understand that he or she is a capable, autonomous individual who can perform outside the family unit and who is not expected to be perfect. Control of his or her life must be achieved in other ways besides dieting and weight loss. NURSING INTERVENTIONS 3. Help patient realize that perfection is unrealistic and explore this need with him or her. RATIONALE 3. As patient begins to feel better about self, identifies positive self-attributes, and develops the ability to accept certain personal inadequacies, the need for unrealistic achievement should diminish. NURSING INTERVENTIONS 4. Assess patient for history of trauma and other adverse childhood life events. RATIONALE 4. Assessing for trauma history is foundational to pursuing trauma-informed care.

Smoothing (conflict strategy)

One party attempts to "smooth" another party by trying to satisfy the ather party. Often used to preserve or maintain a peaceful work environment. The focus can be on what is agreed upon, leaving conflict largely unresolved. This is usually a lose-lose solution.

Conflict management strategies (CONFLICT RESOLUTION STRATEGIES)

PROBLEM -SOLVING - Open communication among staffand between staffand clients can help defray the need for conflict resolution. - When potential sources ofconflict exist. the use ofopen communication and problem- solving strategies are effective tools to de-escalate the situation. Actions nurses can take to promote open communication and de-escalate conflicts - Use "l" statements, and remember to focus on the problem, not on personal differences. - Listen carefully to what others are saying, and try to understand their perspective. - Move a conflict that is escalating to a private location or postpone the discussion until a later time to give everyone a chance to regain control of their emotions. - Share ground rules with participants. For example. everyone is to be treated with respect, only one person can speak at a time, and everyone should have a chance to speak.

Ch 20- Somatic Symptom and Dissociative Disorders

Somatic Symptom Disorder p513-514 Box20-1 p528 Dissociative Identity Disorder p518- Review Concept map outcomes (recall criteria for formulating outcomes/goals) on p529

Outcomes - formulate to be measurable, realistic / attainable, with a timeline (eating disorders)

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

HOMELESS- Health Issues-

Whereas tuberculosis (TB) rates in the United States have been on the decline for several years, the homeless remain an at-risk population; 5 percent of those with TB reported homelessness within the prior year (Centers for Disease Control and Prevention, 2018). Crowded shelters provide ideal conditions for spread of respiratory infections among their inhabitants. The risk of acquiring TB is also increased by the prevalence of alcoholism, drug addiction, HIV infection, poor nutrition, and lack of access to medical care among homeless individuals. Dietary deficiencies are a continuing problem for homeless individuals. Not only is the homeless person commonly in a poor nutritional state, but also the condition itself exacerbates a number of other health problems. Homeless people have higher mortality rates and a greater number of serious disorders than their counterparts in the general population.

Alcohol withdrawal symptoms

Within 4 to 12 hours of cessation or reduction in heavy and prolonged (several days or longer) alcohol use, Can be deadly. - coarse tremor of hands, tongue, or eyelids; - nausea or vomiting; - malaise or weakness; - tachycardia; - sweating; - elevated blood pressure; - anxiety; - depressed mood or irritability; - transient hallucinations or illusions; - headache; - insomnia. - possible seizure

Eating Disorders

• Eating behaviors are influenced by - Society - Culture • Historically, society and culture also have influenced what is considered desirable in the female body.

PTSD concept map

p495 Clinical Vignette: Charles is a 29-year-old veteran of two deployments to Afghanistan. He was honorably discharged from the army 2 years ago and has resumed his position as an assemblyman with a large automobile manufacturing company. His wife reports that he has begun having nightmares, seems angry and bitter, and feels guilty that he survived while many of his friends had not. Recently, while working in their backyard, he threw himself on the ground at the sound of a helicopter flying overhead. Lately, at work, he becomes very agitated and irritable at the sounds of loud noises in the factory, a behavior that is interfering with his productivity. Charles has been diagnosed with Post-traumatic Stress Disorder. The mental health nurse develops the following concept map care plan for Charles. Signs and Symptoms • Flashbacks • Intrusive recollections • Nightmares Psychological numbness/ amnesia Nursing Diagnosis Post-trauma syndrome Nursing Actions • Accept patient; establish trust • Stay with patient during flashbacks • Encourage verbalization about the trauma when patient is ready • Discuss coping strategies • Assist patient to try to comprehend the trauma and how it will be assimilated into his persona Medical Rx: Paroxetine 20 mg 9 AM Outcomes • Patient discusses trauma without experiencing panic • Patient has fewer flashbacks/nightmares • Patient can sleep without medication • Patient demonstrates use of adaptive coping strategies Signs and Symptoms Irritability Explosiveness • Self-destruction • Substance abuse • Survivor's guilt Nursing Diagnosis Complicated grieving Nursing Actions • Acknowledge feelings of guilt or self-blame • Assess patient's stage in grief process • Assess impact of trauma on ability to resume ADLs • Assess for self-destructive ideas or behavior • Assess for maladaptive coping (e.g., substance abuse) Medical Rx: Paroxetine 20 mg 9 AM Outcomes • Patient recognizes own position in grief process • Patient expresses relief from feelings of guilt • Patient maintains satisfactory relationships • Patient looks to the future with optimism

Treatment Modalities (eating disorders)

• 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. • Behavior modification (cont'd) - Successes have been observed when the client • • Has input into the care plan • • Clearly sees what the treatment choices are • Individual therapy -Helpful when underlying psychological problems are contributing to the maladaptive behaviors. • Family therapy - Involves educating the family about the disorder - Assesses the family's impact on maintaining the disorder - Assists in methods to promote adaptive functioning by the client • Psychopharmacology - No medications are specifically indicated for eating disorders. - Various medications have been prescribed for associated symptoms, such as • Anxiety • Depression • • For anorexia nervosa - - Fluoxetine (Prozac)-SSRI - - Imipramine (Tofranil)-antidepressant - - Olanzapine (Zyprexa)-atypical antipsychotic possibly for weight gain and obsessional symptoms • • For bulimia nervosa-antidepressants - - Fluoxetine (Prozac)-FDA approved - - Imipramine (Tofranil) - - Desipramine (Norpramine)-decreases binge frequency - - Amitriptyline (Elavil) - - Nortriptyline (Aventyl) - - Phenelzine (Nardil)-MAOI • • For binge eating disorder with obesity - - Topiramate (Topamax) • • For obesity - - Fluoxetine (Prozac) - - Various anorexiants (CNS stimulants) - - Lorcaserin (Belviq)-appetite suppressant - - Phentermine/topiramate (Qsymia)- appetite suppressant

Application of Nursing Process - Assessment - 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.

Planning and Implementation (eating disorders)

• Nursing care of the client with an eating disorder is aimed at restoring nutritional balance. • Emphasis is also placed on helping the client gain control over life situation in ways other than inappropriate eating behaviors. • Self-esteem and positive self-image are promoted in ways that relate to aspects other than appearance. Client/Family Education Nature of the illness - Symptoms of anorexia nervosa and bulimia nervosa - What constitutes obesity? - Causes of eating disorders - Effects of the illness or condition on the body Management of the illness - Principles of nutrition - Ways client may feel in control of life - Importance of expressing fears and feelings, rather than holding them inside - Alternative coping strategies - Correct administration of prescribed medications - Indication for and side effects of prescribed medications - Relaxation techniques - Problem-solving skills For the obese client - How to • Plan a reduced-calorie, nutritious diet • Read food content labels • Establish a realistic weight loss plan • Establish a planned program of physical activity Support services - Weight Watchers International - Overeaters Anonymous

Obesity

• has been defined as a body mass index of 30 or greater. • 68.5 percent of adult Americans are overweight, and 35 percent of these are in the obese range. • Obesity can contribute to increases in morbidity and mortality • Obese people are at higher risk for • Hyperlipidemia • Diabetes mellitus • Osteoarthritis • Angina • Respiratory insufficiency

Anticholinergic effects

dry mouth==can't spit urinary retention=can't urinate constipated =can't poop blurred vision=can't see

Stage 5. Moderately severe cognitive decline.

At this stage, individuals lose the ability to perform some ADLs independently, such as hygiene, dressing, and grooming, and require some assistance to manage these tasks on an ongoing basis. They may forget addresses, phone numbers, and names of close relatives. They may become disoriented about place and time, but they maintain knowledge about themselves. Frustration, withdrawal, and self-absorption are common.

Stage 4. Moderate cognitive decline.

At this stage, the individual may forget major events in personal history, such as his or her own child's birthday; experience declining ability to perform tasks, such as shopping, cooking, and managing personal finances; or be unable to understand current news events. He or she may deny that a problem exists by covering up memory loss with confabulation (creating imaginary events to fill in memory gaps). Depression and social withdrawal are common. At this stage the individual requires some assistance to maintain safety.

OCD medications

- RECALL - Antidepressants - - doses in excess of what is effective for treating depression may be required for OCD tx with SSRIs (e.g. fluvoxamine, fluoxetine and paroxetine, and sertraline) - RECALL - fluvoxamine (Luvox) have been approved by the FDA for the treatment of OCD. Doses in excess of what is effective for treating depression (10-50 (CR: 12.5-75)) may be required for OCD. - Common side effects include sleep disturbances, headache, and restlessness. These effects are often transient and are less troublesome than those of the tricyclics.

Rationalization (defense mechanism)

Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors Creating reasonable and acceptable explanations for unacceptable behavior John tells the rehab nurse, "I drink because it's the only way I can deal with my bad marriage and my worse job." ADAPTIVE USE: An adolescent says, "They must already have a boyfriend" when rejected by an another adolescent MALADAPTIVE USE: A young adult explains they had to drive home from a party after drinking alcohol because they had to feed the dog.

POSITIVE SYMPTOMS of Schizophrenia

(Added to the client) •Content of thought • Form of thought • Perception: interpretation of stimuli through the senses • Illusions: misperceptions of real external stimuli • Sense of self: The uniqueness and individuality a person feels Delusions (Fixed, False Beliefs) (examples) Persecutory—belief that one is going to be harmed by other(s) Referential—belief that cues in the environment are specifically referring to them Grandiose—belief that they have exceptional greatness Somatic—beliefs that center on one's body functioning Hallucinations (Sensory Perceptions Without External Stimuli) Auditory (most common in schizophrenia) Visual Tactile Olfactory Gustatory (NOTE: Hallucinations may be a normal part of religious experience in some cultural contexts.) Disorganized Thinking (Manifested in Speech) Loose association Tangentiality Circumstantiality Incoherence (includes word salad) Neologisms Clang associations Echolalia Grossly Disorganized or Abnormal Motor Behavior (Including Catatonia) Hyperactivity Hypervigilance Hostility Agitation Childlike silliness Catatonia (ranging from rigid or bizarre posture and decreased responsivity to complete lack of verbal or behavioral response to the environment) Catatonic excitement (excessive and purposeless motor activity) Stereotyped, repetitive movements Unusual mannerisms or postures

The Chemically Impaired Nurse-

(REVIEW) • It is estimated that 10 to 15 percent of nurses suffer from the disease of chemical dependency. • Alcohol is the most widely abused drug, followed closely by narcotics. • Clues for recognizing substance impairment in nurses vary according to the substance being used • High absenteeism may be present if the person's source is outside the work area (e.g. alcohol) • Or, the person may rarely miss work if the substance source is at work (e.g opiates) • Increase in "wasting" of drugs, higher incidences of incorrect narcotic counts, and a higher record of signing out drugs than for other nurses may be present • Poor concentration, difficulty meeting deadlines, inappropriate responses, and poor memory or recall • Problems with relationships • Irritability, tendency to isolate, elaborate excuses for behavior • Unkempt appearance, impaired motor coordination, slurred speech, flushed face • Patient complaints of inadequate pain control, discrepancies in documentation

The Chemically Impaired Nurse- State board response

(recall) • May deny, suspend, or revoke a license based on a report of chemical abuse by a nurse • Diversionary laws allow impaired nurses to avoid disciplinary action by agreeing to seek treatment • Evidence of regular attendance at nurse support groups or 12-step program • Random negative drug screens • Employment or volunteer activities

Panic and generalized anxiety disorder medications

- Anxiolytics (benzodiazepines) • Hydroxyzine (Vistaril) • Alprazolam (Xanax) • Chlordiazepoxide (Librium) • Clonazepam (Klonopin) • Clorazepate (Tranxene) • Diazepam (Valium) • Lorazepam (Ativan) • Oxazepam • Meprobamate - Non benzodiazepine • Buspirone (BuSpar) - Antidepressants- - Antihypertensive agents-(e.g. beta-blocker propanolol and alpha2-receptor clonidine)

Side effects Most commonly occur with MAOIs

- Hypertensive crisis- - Potentially fatal reactions with all other antidepressants, carbamazepine, buspirone, sympathomimetics, tryptophan, dextromethorphan, CNS depressants, and amphetamines (avoid use within 2 weeks of each other) - Hypertensive crisis when mixed with foods with tyramine (recall for exam)

Psychological dependence

- Overwhelming desire to repeat the use of a particular drug to produce pleasure or avoid discomfort - Use of the substance interferes with ability to fulfill role obligations - Attempts to cut down or control use fail - Intense craving for the substance - Excessive amount of time spent trying to procure the substance or recover from its use - Use of the substance causes the person difficulty with interpersonal relationships or to become socially isolated - Engages in hazardous activities when impaired by the substance - Tolerance develops and the amount required to achieve the desired effect increases - Substance-specific symptoms occur upon discontinuation of use

Client/Family Education Lithium

- REVIEW • • Take the medication regularly (due to therapeutic levels) • • Maintain a normal level of sodium. Do not skimp on dietary sodium- (needs to be maintained; would not be a good medication for patients on sodium restriction diet) • • Drink six to eight glasses of water each day. • • Notify physician if vomiting or diarrhea occur. • • Have serum lithium level checked every 1 to 2 months, or as advised by physician- • • • (See ranges in text p435 T17-3 7th Ed) Therapeutic range 0.6-1.2 mEq/L • • • (FYI -always include units of measurement) • • Notify physician if any of the following toxicity symptoms occur: • • • Persistent nausea and vomiting • • • Severe diarrhea • • • Ataxia • • • Blurred vision • • • Tinnitus • • • Excessive output of urine • • • Increasing tremors • • • Mental confusion - education related to mood stabilizing agents. - the client should continue taking the medication on a regular basis, even when feeling well. - The client should not drive or operate dangerous machinery until lithium levels are stabilized. - Notify the physician if vomiting or diarrhea occurs, and carry a card or other identification noting that he or she is taking lithium.

Depression Assessment Moderate depression

- Symptoms associated with dysthymic disorder ◦ Affective: helpless, powerless -- Feelings of sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self-esteem; difficulty experiencing pleasure in activities ◦ Behavioral: slowed physical movements, slumped posture, limited verbalization -- Sluggish physical movements (i.e., psychomotor retardation); slumped posture; slowed speech; limited verbalizations, possibly consisting of ruminations about life's failures or regrets; social isolation with a focus on the self; increased use of substances possible; self-destructive behavior possible; decreased interest in personal hygiene and grooming ◦ Cognitive: retarded thinking processes, difficulty with concentration -- Slowed thinking processes; difficulty concentrating and directing attention; obsessive and repetitive thoughts, generally portraying pessimism and negativism; verbalizations and behavior reflecting suicidal ideation ◦ Physiological: anorexia or overeating, sleep disturbance, headaches -- Anorexia or overeating; insomnia or hypersomnia; sleep disturbances; amenorrhea; decreased libido; headaches; backaches; chest pain; abdominal pain; low energy level; fatigue and listlessness; feeling best early in the morning and continually worse as the day progresses (this may be related to the diurnal variation in the level of neurotransmitters that affect mood and level of activity)

Cirrhosis of the liver

- is the end-stage of alcoholic liver disease and is believed to be caused by chronic heavy alcohol use. There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue. - Portal hypertension: elevation of blood pressure through the portal circulation results from defective blood flow through cirrhotic liver - Ascites: a condition in which an excessive amount of serous fluid accumulates in the abdominal cavity; occurs in response to portal hypertension - Esophageal varices: veins in the esophagus become distended because of excessive pressure from defective blood flow through the cirrhotic liver - Hepatic encephalopathy: occurs in response to the inability of the diseased liver to convert ammonia to urea for excretion. The continued rise in serum ammonia, if allowed to progress, leads to coma and eventual death. Sexual dysfunction

Active listening

- is to be attentive and to really desire to hear and understand what the patient is saying, both verbally and nonverbally. - creates a climate in which the patient can communicate; the nurse communicates acceptance and respect for the patient, and trust is enhanced. - A climate is established in the relationship that promotes openness and honest expression. - Several nonverbal behaviors have been designated as facilitative skills for attentive listening. - Those listed here can be identified by the acronym SOLER p110

panic disorder Symptoms and duration

- p454 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association [APA], 2013) states that at least four of the following symptoms must be present to identify the presence of a panic attack: ■ Palpitations, pounding heart, or accelerated heart rate ■ Sweating ■ Trembling or shaking ■ Sensations of shortness of breath or smothering ■ Feelings of choking ■ Chest pain or discomfort ■ Nausea or abdominal distress ■ Feeling dizzy, unsteady, lightheaded, or faint ■ Chills or heat sensations ■ Paresthesias (numbness or tingling sensations) ■ Derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself) ■ Fear of losing control or going crazy ■ Fear of dying Attacks usually last minutes, or more rarely, hours. The individual often experiences varying degrees of nervousness and apprehension between attacks. Symptoms of depression are common.

Alzheimer's Disorder Priority interventions NURSING DIAGNOSIS: SELF-CARE DEFICIT RELATED TO: Disorientation, confusion, and memory deficits EVIDENCED BY: Inability to fulfill ADLs

-p263 OUTCOME CRITERIA Short-Term Goal ■ Patient will participate in ADLs with assistance from caregiver. Long-Term Goals ■ Patient will accomplish ADLs to the best of his or her ability. ■ Unfulfilled needs will be met by caregivers. NURSING INTERVENTIONS 1. Provide a simple, structured environment: a. Identify self-care deficits and provide assistance as required. Promote independent actions as able. b. Allow plenty of time for patient to perform tasks. c. Provide guidance and support for independent actions by talking the patient through the task one step at a time. d. Provide a structured schedule of activities that does not change from day to day. e. ADLs should follow usual routine as closely as possible. f. Provide for consistency in assignment of daily caregivers. RATIONALE 1. To minimize confusion. NURSING INTERVENTIONS 2. Perform ongoing assessment of patient's ability to fulfill nutritional needs, ensure personal safety, follow medication regimen, and communicate need for assistance with activities that he or she cannot accomplish independently. RATIONALE 2. Patient safety and security are nursing priorities. NURSING INTERVENTIONS 3. Assess prospective caregivers' ability to anticipate and fulfill patient's unmet needs. Provide information to assist caregivers with this responsibility. Ensure that caregivers are aware of available community support systems from which they may seek assistance when required. Examples include adult day care centers, housekeeping and homemaker services, respite care services, or the local chapter of a national support organization: a. For Parkinson's disease information: National Parkinson Foundation Inc. 1501 NW 9th Ave. Miami, FL 33136-1494 1-800-473-4636 1-800- 4PD-INFO www.parkinson.org b. For Alzheimer's disease information: Alzheimer's Association 225 N. Michigan Ave., Fl. 17 Chicago, IL 60601-7633 1-800-272-3900 www.alz.org RATIONALE 3. To ensure provision and continuity of patient care.

Priority interventions Depression

-safety- Maintaining client safety - - Be direct. - - Maintain close observation at irregular intervals. - - Encouraging verbalizations of honest feelings. - Assisting client through grief process - - Communicate that crying is acceptable. - - Develop a trusting relationship with the client. - - Encourage the client to express emotions - Encouraging client self-control and control over life situation - Helping client to reach out for spiritual support of choice - Assistance in confronting anger that has been turned inward on the self - Ensuring that needs related to nutrition, elimination, activity, rest, and personal hygiene are met. - - Promoting increase in self-esteem - - Be accepting of the client. - - Encourage the client to recognize areas of change. - Encourage independence in the performance of activities of daily living. - Helping client to reach out for spiritual support of choice

Lithium Therapeutic range

0.6-1.2 mEq/L Acute mania: 0.5-1.5 mEq/L

BOX 14-4 The CAGE Questionnaire

1. Have you ever felt you should Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt bad or Guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (£ye-opener)?

Alzheimer's Disorder Review Stages

4 through 7- p249 Stage 4. Moderate cognitive decline. At this stage, the individual may forget major events in personal history, such as his or her own child's birthday; experience declining ability to perform tasks, such as shopping, cooking, and managing personal finances; or be unable to understand current news events. He or she may deny that a problem exists by covering up memory loss with confabulation (creating imaginary events to fill in memory gaps). Depression and social withdrawal are common. At this stage the individual requires some assistance to maintain safety. Stage 5. Moderately severe cognitive decline. At this stage, individuals lose the ability to perform some ADLs independently, such as hygiene, dressing, and grooming, and require some assistance to manage these tasks on an ongoing basis. They may forget addresses, phone numbers, and names of close relatives. They may become disoriented about place and time, but they maintain knowledge about themselves. Frustration, withdrawal, and self-absorption are common. Stage 6. Severe cognitive decline. At this stage, individuals may be unable to recall the name of their spouse or may misidentify people (e.g., thinking a child is their spouse). Disorientation to surroundings is common, and the person may be unable to recall the day, season, or year. The person is unable to manage ADLs without assistance. Delusions often become apparent such as maintaining the belief that one must go to work even though the person is no longer employed. Urinary and fecal incontinence are common. Sleeping becomes a problem. Psychomotor symptoms include wandering, obsessiveness, agitation, and aggression. Symptoms seem to worsen in the late afternoon and evening—a phenomenon termed sundowning. Communication becomes more difficult with increasing loss of language skills. Institutional care is usually required at this stage. Stage 7. Very severe decline. In the end stages of AD, the individual is unable to recognize family members. He or she most commonly is bedfast and aphasic. Problems of immobility, such as decubiti and contractures, may occur.

Stage I Hypomania

: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization • • • Cheerful mood • • • Rapid flow of ideas; heightened perception • • • Increased motor activity - At this stage the disturbance is not sufficiently severe to cause marked impairment in social or occupational functioning. - The mood of a hypomanic person is cheerful and expansive. There is an underlying irritability that surfaces rapidly when the person's wishes and desires go unfulfilled. - Perceptions of the self includes ideas of great worth and ability. Thinking is flighty, with a rapid flow of ideas. Perception of the environment is heightened, but the individual is so easily distracted by irrelevant stimuli and goal-directed activities are difficult. Hypomanic individuals' exhibit increased motor activity. They are perceived as being very extroverted and sociable, but they lack the depth of personality and warmth to formulate close friendships. They talk and laugh a great deal, usually very loudly and often inappropriately.

BOX 22-9 Diagnostic Criteria for Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behavior covered in criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. Identity disturbance: markedly and persistently unstable self-image or sense of self 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) (Note: Do not include suicidal or self-mutilating behavior covered in criterion 5.) 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days) 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. Transient, stress-related paranoid ideation or severe dissociative symptoms

BOX 22-8 Diagnostic Criteria for Obsessive-Compulsive Personality Disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost 2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met) 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification) 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes 8. Shows rigidity and stubbornness

BOX 17-2 Diagnostic Criteria for a Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment). Note: A full hypomanic episode that emerges during antidepressant treatment (medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.

BOX 17-1 Diagnostic Criteria for a Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or of any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity) 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or to another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

BOX 22-10 Diagnostic Criteria for Antisocial Personality Disorder

A. A pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure 3. Impulsivity or failure to plan ahead 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults 5. Reckless disregard for safety of self or others 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations 7 Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another B. Individual is at least 18 years. C. There is evidence of conduct disorder with onset before age 15 years. D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

BOX 18-3 Diagnostic Criteria for Obsessive-Compulsive Disorder

A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2) 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. B. The obsessions or compulsions are time consuming (e.g., take more than 1 hour a day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder). Specify if: With good or fair insight With poor insight With absent insight/delusional beliefs Specify if: Tic-related

BOX 15-1 DSM-V Criteria for Schizophrenia

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), (2), or (3): 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (i.e., diminished emotional expression or avolition) B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). 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) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated). Specify if: First episode, currently in acute, partial, or full remission; Multiple episodes, currently in acute, partial or full remission; Continuous; Unspecified; With catatonia Specify current severity.

Ch15- Schizophrenia

Assessment p349 Box15-4- p350 + Sx (e.g. delusions, magical thinking, paranoia, hallucinations, loose associations). and tx with antipsychotics (typical or atypical). Antipsychotic side effects-p82 Tardive dyskinesia (AIMS- test for movement disorders)- p83

Therapeutic Communication (Ch 6)

Active listening (SOLER) p110 Therapeutic communication: Reflecting; Broad Opening p108

INTELLECTUALIZATION (defense mechanism)

An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis Separation of emotions and logical facts when analyzing or coping with a situation or event Susan's husband is being transferred with his job to a city far away from her parents. She hides anxiety by explaining to her parents the advantages associated with the move. ADAPTIVE USE: A law enforcement officer blocks out the emotional aspect of a crime so they can objectively focus on the investigation. MALADAPTIVE USE: A person who learns they have a terminal illness focuses on creating a will and financial matters rather than acknowledging their grief.

Cognitive Therapy

Automatic thoughts (e.g.personalizing)- p407 Therapy focuses on changing "automatic thoughts" that occur spontaneously and contribute to the distorted affect. Following are examples of automatic thoughts that may be common cognitive distortions in depression: ■ Personalizing: "I'm the only one who failed." ■ All or nothing: A person who had a failure or disappointment thinks I can't do anything right, I'm a complete failure." ■ Mind reading: "He thinks I'm foolish." ■ Discounting positives: "The other questions were so easy. Any dummy could have gotten them right."

Foods and medications high in tyramine

Avoid when taking MAOIs to avoid HTN crisis. These include (pg410) Aged cheese Caviar Wine; beer Raisins Chocolate; colas Pickled herring Coffee; tea Yeast products Sour cream; yogurt Broad beans Smoked and processed meats Soy sauce Beef or chicken liver Cold remedies Canned figs Diet pills

TABLE 17-1 Assigning Nursing Diagnoses to Behaviors Commonly Exhibited by Individuals Experiencing a Manic Episode

BEHAVIORS Extreme hyperactivity; increased agitation and lack of control over purposeless and potentially injurious movements NURSING DIAGNOSES Risk for injury BEHAVIORS Manic excitement, delusional thinking, hallucinations, impulsivity NURSING DIAGNOSES Risk for violence: Self-directed or other-directed BEHAVIORS Loss of weight, amenorrhea, refusal or inability to sit still long enough to eat NURSING DIAGNOSES Imbalanced nutrition: Less than body requirements BEHAVIORS Delusions of grandeur and persecution; inaccurate interpretation of the environment NURSING DIAGNOSES Disturbed thought processes* BEHAVIORS Auditory and visual hallucinations; disorientation NURSING DIAGNOSES Disturbed sensory-perception* BEHAVIORS Inability to develop satisfying relationships, manipulation of others for own desires, use of unsuccessful social interaction behaviors NURSING DIAGNOSES Impaired social interaction BEHAVIORS Difficulty falling asleep, sleeping only short periods NURSING DIAGNOSES Insomnia

ABLE 18-2 Assigning Nursing Diagnoses to Behaviors Commonly Associated With Anxiety, Obsessive-Compulsive, and Related Disorders

BEHAVIORS Palpitations, trembling, sweating, chest pain, shortness of breath, fear of going crazy, fear of dying (panic disorder); excessive worry, difficulty concentrating, sleep disturbance (generalized anxiety disorder) Anxiety (severe/panic) BEHAVIORS Verbal expressions of having no control over life situation; nonparticipation in decision making related to own care or life situation; expressions of doubt regarding role performance (panic and generalized anxiety disorders) Powerlessness BEHAVIORS Behavior directed toward avoidance of a feared object or situation (phobic disorder) Fear BEHAVIORS Stays at home alone, afraid to venture out alone (agoraphobia) Social isolation BEHAVIORS Ritualistic behavior; obsessive thoughts, inability to meet basic needs; severe level of anxiety (OCD) Ineffective coping BEHAVIORS Inability to fulfill usual patterns of responsibility because of need to perform rituals (OCD) Ineffective role performance BEHAVIORS Preoccupation with imagined defect; verbalizations that are out of proportion to any actual physical abnormality that may exist; numerous visits to plastic surgeons or dermatologists seeking relief (body dysmorphic disorder) Disturbed body image BEHAVIORS Repetitive and impulsive pulling out of one's hair (trichotillomania) Ineffective impulse control

substitution therapy (alcohol use)

Benzodiazepines - act similarly to alcohol in their effects but can be administered in controlled doses to prevent adverse effects of alcohol withdrawal - Chlordiazepoxide (Librium), oxazepam (Serax), lorazepam (Ativan), and diazepam (Valium) are the most commonly used agents - start with relatively high doses and reduce the dosage by 20 to 25 percent each day until withdrawal is complete

Giving broad openings

Broad openings allow the patient to direct the focus of the interaction and emphasize the importance of the patient's role in the communication process. "What would you like to talk about today?" "Is there anything you want to discuss?"

Extrapyramidal symptoms (EPS) include

Can look like a negative symptom of schizophrenia. Pseudoparkinsonism Akinesia Akathisia Dystonia Oculogyric crisis Treatment of these symptoms Antiparkinsonian agents (e.g. benztropinea aka Cogentin) may be prescribed to counteract EPS (see lists in text) The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was developed in the 1970s by the National Institute of Mental Health to measure involuntary movements associated with tardive dyskinesia. The AIMS aids in early detection of movement disorders and provides a means for ongoing surveillance (see Box 4-2). A decision may be made to change to a different drug, adjust the dosage, or discontinue the drug. In 2017 the FDA approved the first drugs for treating tardive dyskinesia: valbenazine (Ingrezza) and deutetrabenazine (Austedo). Although their mechanism of action is unknown, both drugs are believed to inhibit monoamine uptake. In clinical trials, there were significant reductions in abnormal involuntary movements. Some extrapyramidal side effects can be life threatening and those that are not can sometimes be permanent. The abnormal movements in the tongue and lips can be very visible and even severe enough to interfere with a person's ability to speak or swallow. In addition to the drugs used to treat tardive dyskinesia, there are several medications that may be used to treat acute extrapyramidal side effects. These include anticholinergics such as benztropine (Cogentin), antihistamines such as diphenhydramine (Benadryl), or dopaminergic agents such as amantadine (Symmetrel). A list of these agents, their actions, contraindications, side effects, half-life, and daily dosages can be found in Chapter 15, Schizophrenia Spectrum and Other Psychotic Disorders.

E in SOLER means

Establish eye contact. Direct eye contact is another behavior that conveys the nurse's involvement and willingness to listen to what the patient has to say. The absence of eye contact, or the constant shifting of eye contact, gives the message that the nurse is not really interested in what is being said.

MAOIs-

Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline Transdermal System (Emsam)

NEGATIVE SYMPTOMS

Lack of Emotional Expression Blunted affect Lack of movement in head and hands that adds expression in communication Lack of intonation in speech Decreased or Lack of Motivation to Complete Purposeful Activities (Avolition) Neglect of activities of daily living Decreased Verbal Communication (Alogia) Decreased Interest in Social Interaction and Relationship (Asociality) Withdrawal Poor rapport Diminished Ability for Abstract Thinking Concrete interpretation of events and communication from others

L in SOLER means

Lean forward toward the patient. This nonverbal behavior conveys to the patient that you are involved in the interaction, interested in what is being said, and making a sincere effort to be attentive.

CARE PLAN FOR THE INDIVIDUAL WHO EXPRESSES ANGER INAPPROPRIATELY NURSING DIAGNOSIS: RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE RELATED TO: History of violence, inadequate management of anger, post-trauma stress

OUTCOME CRITERIA Patient does not harm self or others. Patient verbalizes anger rather than hit others. NURSING INTERVENTION 1. Observe for escalation of anger (called the prodromal syndrome):increased motor activity, pounding, slamming, tense posture, defiant affect, clenched teeth and fists, arguing, demanding, and challenging or threatening staff. RATIONALE 1. Violence may be prevented if risks are identified in time. NURSING INTERVENTION 2. When these behaviors are observed, first ensure that sufficient staff are available to help with a potentially violent situation. Attempt to defuse the anger beginning with the least restrictive means. RATIONALE 2. The initial consideration must be having enough help to diffuse a potentially violent situation. Patient rights must be honored while preventing harm to patient and others. NURSING INTERVENTION 3. Techniques for dealing with aggression include: RATIONALE Aggression control techniques promote safety and reduce risk of harm to patient and others: NURSING INTERVENTION a. Talking down. For example, say, "John, you seem very angry. Let's sit down and talk about it." (Maintain safe distance and opportunity to leave the immediate area if needed.) RATIONALE a. Promote a trusting relationship and may prevent patient's anxiety from escalating. NURSING INTERVENTION b. Physical outlets. For example, say, "Maybe it would help if you did some walking or other exercise for a while to help you safely release this energy" or "I'll stay here with you if you want." RATIONALE b. Provide effective way for patient to release tension associated with high levels of anger. NURSING INTERVENTION c. Medication. If agitation continues to escalate, offer patient choice of taking medication voluntarily. If he or she refuses, reassess the situation to determine if harm to self or others is imminent. RATIONALE c. Tranquilizing medication may calm patient and prevent violence from escalating. NURSING INTERVENTION d. Call for assistance. Remove self and other patients from the immediate area. Call violence code, push "panic" button, call for assault team, or institute measures established by the institution. Sufficient staff to indicate a show of strength may be enough to de-escalate the situation, and patient may agree to take the medication. RATIONALE d. Patient and staff safety are of primary concern. Many states, accrediting bodies, and/or facilities require that staff members working with hospitalized psychiatric patients be trained and/or certified in psychiatric emergency interventions to ensure that the strategies used are in the best interest of staff and patient safety. NURSING INTERVENTION e. Seclusion or restraints. If patient is not calmed by talking down or by medication, use of mechanical restraints and/or seclusion may be necessary. Be sure to have sufficient staff available to assist and appropriately deal with an out-of-control patient. Follow protocol for restraints/seclusion established by the institution. Restraints should be used as a last resort after all other interventions have been unsuccessful and patient is clearly at risk of harm to self or others. RATIONALE e. Patients who do not have internal control over their own behavior may require external controls, such as mechanical restraints, in order to prevent harm to self or others. NURSING INTERVENTION f. Observation and documentation. Hospital policy typically dictates the requirements for observation of patient in restraints. Basic safety principles include that patient in restraints should be observed throughout the period of restraint. Every 15 minutes, patient should be monitored to ensure that circulation to extremities is not compromised (check temperature, color, pulses). Assist patient with needs related to nutrition, hydration, and elimination. Position patient so that comfort is facilitated and aspiration can be prevented. (Patients should never be restrained in a prone position). Document all observations. RATIONALE f. Patient and staff safety are of primary concern. Many state regulations, accrediting bodies (such as The Joint Commission), and/or facility policies require that staff members working with hospitalized psychiatric patients be trained and/or certified in psychiatric emergency interventions to ensure that the strategies used are in the best interest of staff and patient safety.Patient well-being is a nursing priority. NURSING INTERVENTION g. Ongoing assessment. As agitation decreases, assess patient's readiness for restraint removal or reduction. With assistance from other staff members, remove one restraint at a time while assessing patient's response. This measure minimizes the risk of injury to patient and staff. RATIONALE g. Gradual removal of the restraints allows for testing of patient's self-control. Patient and staff safety are of primary concern, as is ensuring that the patient is offered the least restrictive treatment option effective in maintaining safety NURSING INTERVENTION h. Debriefing. It is important when a patient loses control for staff to follow up with a discussion about the situation. This discussion should occur with patient and among other staff. The staff should discuss factors that necessitated the crisis intervention, factors that contributed to the failure of less restrictive interventions, and staff's thoughts about the safety and effectiveness of the intervention. When patient has regained control, a debriefing should occur in which patient is encouraged to discuss thoughts about what contributed to the crisis situation and about staff interventions and to explore strategies to avert a crisis situation in the future. It is also important to discuss the situation with other patients who witnessed the episode so they understand and process what happened. Some patients may fear that they could be at risk for experiencing a crisis or that they might be in danger when someone else's behavior becomes aggressive RATIONALE h. Debriefing helps to process the impact of the intervention. Mutual feedback is shared; staff and patient have an opportunity to process and learn from the event.

Stage II Acute mania:

Marked impairment in functioning; usually requires hospitalization • • • Elation and euphoria; a continuous "high" • • • Flight of ideas; accelerated, pressured speech • • • Hallucinations and delusions • • • Excessive motor activity • • • Social and sexual inhibition • • • Little need for sleep - Symptoms of acute mania may be a progression in intensification of those experienced in hypomania, or they may be manifested directly. Most individuals experience marked impairment in functioning and require hospitalization. - characterized by euphoria and elation. The person appears to be on a continuous high, but mood is always subject to frequent variation. - Cognition and perception become fragmented and often psychotic in acute mania. Accelerated thinking proceeds to racing thoughts, overconnection of ideas, and rapid, abrupt movement from one thought to another and may be manifested by a continuous flow of accelerated, pressured speech to the point where trying to converse with this individual may be extremely difficult. Attention can be diverted by even the smallest of stimuli. Hallucinations and delusions are common. - Psychomotor activity is excessive. Sexual interest is increased. There is poor impulse control, low frustration tolerance, and the individual who is normally discreet may become socially and sexually uninhibited. Energy seems inexhaustible, and the need for sleep is diminished. They may go for many days without sleep and still not feel tired. Hygiene and grooming may be neglected. Dress may be disorganized, flamboyant, or bizarre, and the use of excessive make-up or jewelry is common.

TABLE 11-3 | CARE PLAN FOR THE SUICIDAL PATIENT NURSING DIAGNOSIS: RISK FOR SUICIDERELATED TO: Feelings of hopelessness and desperation

OUTCOME CRITERIA Patient will not harm self. NURSING INTERVENTIONS 1. Ask directly: "Have you thought about harming yourself in any way? If so, what do you plan to do? Do you have the means to carry out this plan?" RATIONALE 1. The risk of suicide is greatly increased if patient has developed a plan and particularly if means are accessible for the patient to execute the plan. NURSING INTERVENTIONS 2. Create a safe environment for patient. Remove all potentially harmful objects from patient's access (sharp objects, straps, belts, ties, glass items, alcohol). Supervise closely during meals and medication administration. Perform room searches as deemed necessary. RATIONALE 2. Patient safety is a nursing priority. NURSING INTERVENTIONS 3. Maintain close observation of patient. Depending on level of suicide precaution, provide one-to-one contact, constant visual observation, or every-15-minute checks. Place in room close to nurse's station; do not assign to private room. Accompany to off-unit activities if attendance is indicated. May need to accompany to bathroom. RATIONALE 3. Close observation is necessary to ensure that patient does not harm self in any way. Being alert for suicidal and escape attempts facilitates being able to prevent or interrupt harmful behavior. NURSING INTERVENTIONS 4. Maintain special care in administration of medications. RATIONALE 4. Prevents saving up to overdose or discarding. NURSING INTERVENTIONS 5. Make rounds at frequent, irregular intervals (especially at night, toward early morning, at change of shift, or other predictably busy times for staff). RATIONALE 5. Prevents patient from saving up to overdose or discarding medication. Prevents staff surveillance from becoming predictable. To be aware of patient's location is important, especially when staff is busy and least available and observable. NURSING INTERVENTIONS 6. Encourage patient to express honest feelings, including anger. Provide activities for appropriate outlets for anger if needed. RATIONALE 6. Depression and suicidal behaviors may be viewed as anger turned inward on the self. If this anger can be verbalized in a nonthreatening environment, patient may be able to eventually resolve these feelings. OUTCOME CRITERIA Patient develops a safety plan for management of suicidal thoughts and urges. NURSING INTERVENTIONS 1. Establish a trusting, therapeutic relationship to encourage open discussion of suicide. RATIONALE 1. Establishing trust and open communications encourages client to share thoughts and feelings. NURSING INTERVENTIONS 2. Collaborate with patient to develop a safety plan that includes recognition of warning signs, coping strategies, supportive people and places, resources and contact information for crisis management, and plans to restrict access to lethal means. RATIONALE 2. Development of a comprehensive collaborative safety plan concretizes resources and management strategies. Actively engaging the patient in collaboration on the development of a safety plan promotes client ownership and investment in the processg. NURSING INTERVENTIONS 3. Assess verbal and nonverbal clues to identify the likelihood that patient intends to follow through with the established safety plan and evaluate patient's follow-through with safety plan measures while still hospitalized. RATIONALE 3. Assessment of patient safety includes analyzing congruence of verbal communication, nonverbal communication, and behavior.

side effects and symptoms associated with lithium toxicity

Notify the physician if any of the following symptoms occur: • • • Persistent nausea and vomiting • • • Severe diarrhea • • • Ataxia • • • Blurred vision • • • Tinnitus • • • Excessive output of urine • • • Increasing tremors • • • Mental confusion

Ch. 17 Mood DO

Nursing Process- Assessment- Hypomania vs Mania- p427 Sx documentation-mood-p428 Lithium- Pt Education-p438; Toxicity-p438

Ch 14 Substance Abuse

Nursing care-Cognitive Process- Self-assessment Substance- Addiction-psychological desire to produce pleasure- p280 Alcohol withdrawal symptoms-p287 Alcohol withdrawal (CNS depressant) priority nursing diagnosis- T14-9;10 p316-317 Alcohol withdrawal priority/intervention-assessment (e.g.heart rate,BP) p317-318 substitution therapy-p327 Alcohol use disorder outcomes-inpt/outpt. recall properly formulated criteria for outcomes Blood alcohol levels-intoxication-p287 Cirrhosis-hepatic encephalopathy-DIET r/t low protein- The chemically impaired nurse- Behaviors, State board laws-p322

TABLE 11-3 | CARE PLAN FOR THE SUICIDAL PATIENT NURSING DIAGNOSIS: HOPELESSNESS RELATED TO: Absence of support systems and perception of worthlessness EVIDENCED BY: Verbal cues (despondent content, "I can't"); decreased affect; lack of initiative; suicidal ideas or attempts

OUTCOME CRITERIA Patient will verbalize a measure of hope and acceptance of life and situations over which he or she has no control. NURSING INTERVENTIONS 1. Identify stressors in patient's life that precipitated current crisis. Include assessing the degree of emotional pain and hopelessness in relationship to feelings of connectedness or lack of connectedness with others. RATIONALE 1. It is important to identify causative or contributing factors in order to plan appropriate assistance. NURSING INTERVENTIONS 2. Determine coping behaviors previously used and patient's perception of effectiveness then and now. RATIONALE 2. It is important to identify patient's strengths and encourage their use in current crisis situation. NURSING INTERVENTIONS 3. Encourage patient to explore and verbalize feelings and perceptions related to reasons for wanting to die as well as reasons for wanting to live. RATIONALE 3. Identification of feelings underlying behaviors helps patient to begin process of taking control of own life and enables the nurse to help the patient focus on maximizing his or her reasons for wanting to live. NURSING INTERVENTIONS 4. Provide expressions of hope to patient in positive, low-key manner (e.g., "I know you feel you cannot go on, but I believe that things can get better for you. What you are feeling is temporary. It is okay if you don't see it just now." "You matter.") RATIONALE 4. Even though patient feels hopeless, it is helpful to hear positive expressions from others. Patient's current state of mind may prevent him or her from identifying anything positive in life. It is important to accept patient's feelings nonjudgmentally and to affirm the individual's personal worth and value. NURSING INTERVENTIONS 5. Help patient identify areas of life situation that are under own control. RATIONALE 5. Patient's emotional condition may interfere with ability to problem solve. Assistance may be required to perceive the benefits and consequences of available alternatives accurately. NURSING INTERVENTIONS 6. Identify sources that patient may use after discharge when crises occur or feelings of hopelessness and possible suicidal ideation prevail. RATIONALE 6. Patient should be made aware of local suicide hotlines or other local support services from which he or she may seek assistance following discharge from the hospital. A concrete plan provides hope in the face of a crisis situation.

Table 18-3 | CARE PLAN FOR THE PATIENT WITH ANXIETY, OBSESSIVE-COMPULSIVE, AND RELATED DISORDERS NURSING DIAGNOSIS: FEAR RELATED TO: Causing embarrassment to self in front of others, being in a place from which one is unable to escape, or a specific stimulus EVIDENCED BY: Behavior directed toward avoidance of the feared object or situation

OUTCOME CRITERIA Short-Term Goal ■ Patient will discuss the phobic object or situation with the healthcare provider within (time specified). Long-Term Goal ■ By time of discharge from treatment, patient will be able to function in presence of phobic object or situation without experiencing panic anxiety. NURSING INTERVENTIONS 1. Reassure patient that he or she is safe. RATIONALE 1. At the panic level of anxiety, patient may fear for his or her own life. NURSING INTERVENTIONS 2. Explore patient's perception of the threat to physical integrity or threat to self-concept. RATIONALE 2. It is important to understand patient's perception of the phobic object or situation to assist with the desensitization process. NURSING INTERVENTIONS 3. Discuss reality of the situation with patient to recognize aspects that can be changed and those that cannot. RATIONALE 3. Patient must accept the reality of the situation (aspects that cannot change) before the work of reducing the fear can progress. NURSING INTERVENTIONS 4. Include patient in making decisions related to selection of alternative coping strategies. (e.g., client may choose either to avoid the phobic stimulus or to attempt to eliminate the fear associated with it). RATIONALE 4. Allowing the patient choices provides a measure of control and serves to increase feelings of self-worth. NURSING INTERVENTIONS 5. If patient elects to work on elimination of the fear, techniques of desensitization or implosion therapy may be employed. (See explanation of these techniques under 'Treatment Modalities" at the end of this chapter.) RATIONALE 5. Fear is decreased as the physical and psychological sensations diminish in response to repeated exposure to the phobic stimulus under nonthreatening conditions. NURSING INTERVENTIONS 6. Encourage patient to explore underlying feelings that may be contributing to irrational fears and to face them rather than suppress them. RATIONALE 6. Exploring underlying feelings may help the patient to confront unresolved conflicts and develop more adaptive coping abilities.

Table 18-3 | CARE PLAN FOR THE PATIENT WITH ANXIETY, OBSESSIVE-COMPULSIVE, AND RELATED DISORDERS NURSING DIAGNOSIS: INEFFECTIVE IMPULSE CONTROL RELATED TO: Possible genetic or biochemical factors; poor parent-child relationship; history of child abuse or neglect EVIDENCED BY: Recurrent pulling out of the hair in response to stressful situations

OUTCOME CRITERIA Short-Term Goal ■ Patient will verbalize adaptive ways to cope with stress by means other than pulling out own hair (time dimension to be individually determined). Long-Term Goal ■ Patient will be able to demonstrate adaptive coping strategies in response to stress and a discontinuation of pulling out own hair (time dimension to be individually determined). NURSING INTERVENTIONS 1. Support patient in his or her effort to stop hair pulling. Help patient understand that it is possible to discontinue the behavior. RATIONALE 1. Patient realizes that the behavior is maladaptive but feels helpless to stop. Support from the nurse builds trust. NURSING INTERVENTIONS 2. Ensure that a nonjudgmental attitude is conveyed, and criticism of the behavior is avoided. RATIONALE 2. An attitude of acceptance promotes feelings of dignity and self-worth. NURSING INTERVENTIONS 3. Assist patient with habit reversal training (HRT). Three components of HRT include the following: RATIONALE 3. HRT has been shown to be an effective tool in treatment of hair-pulling disorder. NURSING INTERVENTIONS a. Awareness training. Help the patient become aware of times when the hair pulling most often occurs (e.g., client learns to recognize urges, thoughts, or sensations that precede the behavior; the therapist points out to the patient each time the behavior occurs). RATIONALE a. This helps the patient identify situations in which the behavior occurs or is most likely to occur. Awareness gives the patient a feeling of increased self-control. NURSING INTERVENTIONS b. Substituting an incompatible behavior may help to extinguish the undesirable behavior. RATIONALE b. Competing response training. In this step, the patient learns to substitute another response to the urge to pull his or her hair. For example, when a patient experiences a hair-pulling urge, suggest that the individual ball up his/her hands into fists, tightening arm muscles, and "locking" his/her arms so as to make hair pulling impossible at that moment. NURSING INTERVENTIONS c. Social support. Encourage family members to participate in the therapy process and to offer positive feedback for attempts at habit reversal. RATIONALE c. Positive feedback enhances self-esteem and increases patient's desire to continue with the therapy. It also provides cues for family members to use in their attempts to help the patient in treatment. NURSING INTERVENTIONS 4. Once patient has become aware of hair-pulling times, suggest that patient hold something (a ball, paperweight, or other item) in his or her hand at times when hair pulling is anticipated. RATIONALE 4. This would help to prevent behaviors occurring without patient being aware that they are happening. NURSING INTERVENTIONS 5. Practice stress management techniques: deep breathing, meditation, stretching, physical exercise, listening to soft music. RATIONALE 5. Hair pulling is thought to occur at times of increased anxiety. NURSING INTERVENTIONS 6. Offer support and encouragement when setbacks occur. Help patient to understand the importance of not quitting when it seems that change is not happening as quickly as he or she would like. RATIONALE 6. Although some people see a decrease in the behavior within a few days, most will take several months to notice the greatest change.

Table 18-3 | CARE PLAN FOR THE PATIENT WITH ANXIETY, OBSESSIVE-COMPULSIVE, AND RELATED DISORDERS NURSING DIAGNOSIS: DISTURBED BODY IMAGE RELATED TO: Repressed severe anxiety EVIDENCED BY: Preoccupation with imagined defect; verbalizations that are out of proportion to any actual physical abnormality that may exist; and numerous visits to plastic surgeons or dermatologists seeking relief

OUTCOME CRITERIA Short-Term Goal ■ Patient will verbalize understanding that changes in bodily structure or function are exaggerated out of proportion to the change that actually exists. (Time frame for this goal must be determined according to individual patient's situation.) Long-Term Goal ■ Patient will verbalize perception of own body that is realistic to actual structure or function by time of discharge from treatment. NURSING INTERVENTIONS 1. Assess patient's perception of his or her body image. Keep in mind that this image is real to the patient. RATIONALE 1. Assessment information is necessary in developing an accurate plan of care. Denial of the patient's feelings impedes the development of a trusting, therapeutic relationship. NURSING INTERVENTIONS 2. Help patient to see that his or her body image is distorted or that it is out of proportion in relation to the significance of an actual physical anomaly. RATIONALE 2. Recognition that a misperception exists is necessary before the patient can accept reality and reduce the significance of the imagined defect. NURSING INTERVENTIONS 3. Encourage verbalization of fears and anxieties associated with identified stressful life situations. Discuss alternative adaptive coping strategies. RATIONALE 3. Verbalization of feelings with a trusted individual may help the patient come to terms with unresolved issues. Knowledge of alternative coping strategies may help the patient respond to stress more adaptively in the future. NURSING INTERVENTIONS 4. Involve patient in activities that reinforce a positive sense of self not based on appearance. RATIONALE 4. When the patient is able to develop self-satisfaction based on accomplishments and unconditional acceptance, significance of the imagined defect or minor physical anomaly will diminish. NURSING INTERVENTIONS 5. Make referrals to support groups of individuals with similar histories (e.g., Adult Children of Alcoholics [ACOA], Victims of Incest, Survivors of Suicide [SOS], Adults Abused as Children). RATIONALE 5. Having a support group of understanding, empathic peers can help the patient accept the reality of the situation, correct distorted perceptions, and make adaptive life changes.

Table 18-3 | CARE PLAN FOR THE PATIENT WITH ANXIETY, OBSESSIVE-COMPULSIVE, AND RELATED DISORDERS NURSING DIAGNOSIS: PANIC ANXIETY RELATED TO: Real or perceived threat to biological integrity or self-concept EVIDENCED BY: Any or all of the physical symptoms identified by the DSM-5

OUTCOME CRITERIA Short-Term Goal ■ The patient will verbalize ways to intervene in escalating anxiety within 1 week. Long-Term Goal ■ By time of discharge from treatment, the patient will be able to recognize symptoms of onset of anxiety and intervene before reaching panic level. NURSING INTERVENTIONS 1. Stay with the patient and offer reassurance of safety and security. Do not leave the patient in panic anxiety alone. RATIONALE 1. The patient may fear for his or her life. Presence of a trusted individual provides a feeling of security and assurance of personal safety. NURSING INTERVENTIONS 2. Maintain a calm, nonthreatening, matter-of-fact approach. RATIONALE 2. Anxiety is contagious and may be transferred from staff to patient or vice versa. Patient develops a feeling of security in the presence of a calm staff person. NURSING INTERVENTIONS 3. Use simple words and brief messages, spoken calmly and clearly, to explain hospital experiences. RATIONALE 3. In an intensely anxious situation, the patient is unable to comprehend anything but the most elemental communication. NURSING INTERVENTIONS 4. Hyperventilation may occur during periods of extreme anxiety. Hyperventilation causes the amount of carbon dioxide (CO2) in the blood to decrease, possibly resulting in lightheadedness, rapid heart rate, shortness of breath, numbness or tingling in the hands or feet, and syncope. If hyperventilation occurs, assist the patient to breathe into a small paper bag held over the mouth and nose. Six to 12 natural breaths should be taken, alternating with short periods of diaphragmatic breathing. RATIONALE 4. Hyperventilation may result in injury to the patient, and patient safety is a nursing priority. The technique here should not be used with patients who have coronary or respiratory disorders, such as coronary artery disease, asthma, or chronic obstructive pulmonary disease. NURSING INTERVENTIONS 5. Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor). RATIONALE 5. A stimulating environment may increase level of anxiety. NURSING INTERVENTIONS 6. Administer tranquilizing medication, as ordered by physician. Assess for effectiveness and for side effects. RATIONALE 6. Antianxiety medication provides relief from the immobilizing effects of anxiety. NURSING INTERVENTIONS 7When level of anxiety has been reduced, explore possible reasons for occurrence. RATIONALE 7. Recognition of precipitating factor(s) is the first step in teaching client to interrupt escalation of anxiety. NURSING INTERVENTIONS 8. Teach signs and symptoms of escalating anxiety, and ways to interrupt its progression (relaxation techniques, such as deep-breathing exercises and meditation, or physical exercise, such as brisk walks and jogging). RATIONALE 8. Relaxation techniques result in a physiological response opposite that of the anxiety response. Physical activities discharge excess energy in a healthful manner.

Table 18-3 | CARE PLAN FOR THE PATIENT WITH ANXIETY, OBSESSIVE-COMPULSIVE, AND RELATED DISORDERS NURSING DIAGNOSIS: INEFFECTIVE COPING RELATED TO: Underdeveloped ego, punitive superego; avoidance learning; possible biochemical changes EVIDENCED BY: Ritualistic behavior or obsessive thoughts

OUTCOME CRITERIA Short-Term Goal ■ Within 1 week, the patient will decrease participation in ritualistic behavior by half. Long-Term Goal ■ By time of discharge from treatment, patient will demonstrate ability to cope effectively without resorting to obsessive-compulsive behaviors. NURSING INTERVENTIONS 1. Work with patient to determine types of situations that increase anxiety and result in ritualistic behaviors. RATIONALE 1. Recognition of precipitating factors is the first step in teaching the patient to interrupt the escalating anxiety. NURSING INTERVENTIONS 2. In the beginning of treatment, allow plenty of time for rituals. Do not be judgmental or verbalize disapproval of the behavior. RATIONALE 2. To deny patient this activity may precipitate panic anxiety. Conversely, indulging the patient's need for ritualistic behavior initially decreases anxiety and promotes the ability to learn alternative coping strategies. Learning is best accomplished when the patient's anxiety is at a mild level. NURSING INTERVENTIONS 3. Support patient's efforts to explore the meaning and purpose of the behavior. RATIONALE 3. Patient may be unaware of the relationship between emotional problems and compulsive behaviors. Recognition is important before change can occur. NURSING INTERVENTIONS 4. Provide structured schedule of activities for patient, including adequate time for completion of rituals. RATIONALE 4. Structure provides a feeling of security for the anxious patient. NURSING INTERVENTIONS 5. Gradually begin to limit amount of time allotted for ritualistic behavior as patient becomes more involved in other activities. RATIONALE 5. Anxiety is minimized when patient is able to replace ritualistic behaviors with more adaptive ones. NURSING INTERVENTIONS 6. Give positive reinforcement for nonritualistic behaviors. RATIONALE 6. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors. NURSING INTERVENTIONS 7. Help patient learn ways of interrupting obsessive thoughts and ritualistic behavior with techniques such as thought stopping, relaxation, and physical exercise. RATIONALE 7. Knowledge and practice of coping techniques that are more adaptive will help patient change and let go of maladaptive responses to anxiety.

Table 14-10 | CARE PLAN FOR THE PATIENT WITH A SUBSTANCE-RELATED DISORDER NURSING DIAGNOSIS: RISK FOR INJURY RELATED TO: Central nervous system (CNS) agitation secondary to withdrawal from alcohol or other CNS depressant

OUTCOME CRITERIA Short-Term Goals ■ Patient's condition will stabilize within 72 hours. Long-Term Goal ■ Patient will not experience physical injury. NURSING INTERVENTIONS 1. Assess patient's level of disorientation. RATIONALE 1. Determination of specific requirements for safety must be made. NURSING INTERVENTIONS 2. Obtain a drug history, if possible. It is important to determine the type of substance(s) used, the time and amount of last use, the length and frequency of use, and the amount used on a daily basis. RATIONALE 2. This information is essential to know what to expect during the withdrawal process and to establish an appropriate plan of care. NURSING INTERVENTIONS 3. Obtain a urine sample for laboratory analysis of substance content. RATIONALE 3. A subjective history is often not accurate. NURSING INTERVENTIONS 4. Keep the patient in as quiet an environment as possible. A private room is ideal. RATIONALE 4. Excessive stimuli may increase patient agitation. NURSING INTERVENTIONS 5. Observe the patient's behaviors frequently. If seriousness of the condition warrants, it may be necessary to assign a staff person on a one-to-one basis. RATIONALE 5. Patient safety is a nursing priority. NURSING INTERVENTIONS 6. Accompany and assist the patient when ambulating and use a wheelchair for transporting the patient long distances. RATIONALE 6. In weakened condition, patient will require assistance to prevent falls. NURSING INTERVENTIONS 7. Pad the headboard and side rails of the bed with thick towels. RATIONALE 7. Individuals in withdrawal from CNS depressants are at risk for seizures. Padding will offer protection from injury should a seizure occur. NURSING INTERVENTIONS 8. Ensure that smoking materials and other potentially harmful objects are stored away from the patient's access. Institute suicide precautions, if necessary, for patients withdrawing from CNS stimulants. RATIONALE 8. A patient in withdrawal has impaired judgment. The environment must be made safe for him or her. NURSING INTERVENTIONS 9. Monitor the patient's vital signs every 15 minutes, and less frequently as acute symptoms subside. RATIONALE 9. Accurate assessment is vital for the provision of safe and effective nursing care. NURSING INTERVENTIONS 10. Follow the medication regimen as ordered by the physician. RATIONALE 10. Medication-assisted treatment will be prescribed to ease the symptoms of withdrawal from substances. (See section on "Medication-Assisted Treatment.")

CARE PLAN FOR THE INDIVIDUAL WHO EXPRESSES ANGER INAPPROPRIATELY NURSING DIAGNOSIS: INEFFECTIVE COPING RELATED TO: (Possible) negative role modeling, feelings of helplessness EVIDENCED BY: Yelling, name calling, hitting others, and temper tantrums as expressions of anger

OUTCOME CRITERIA Patient recognizes anger in self and takes responsibility before losing control. NURSING INTERVENTION 1. Remain calm when dealing with an angry patient. RATIONALE 1. Anger expressed by the nurse will most likely incite increased anger in patient. NURSING INTERVENTION 2. Set verbal limits on behavior. Clearly delineate the consequences of inappropriate expression of anger, and always follow through. RATIONALE 2. Consistency in enforcing the consequences is essential if positive outcomes are to be achieved. Inconsistency creates confusion and encourages testing of limits. NURSING INTERVENTION 3. Have patient keep a diary of angry feelings, what triggered them, and how they were handled. RATIONALE 3. Journaling provides a more objective measure of the problem. NURSING INTERVENTION 4. Avoid touching patient when he or she becomes angry. RATIONALE 4. Patient may view touch as threatening and could become violent. NURSING INTERVENTION 5. Help patient determine the true source of the anger. RATIONALE 5. Often, anger is being displaced onto a safer object or person. If resolution is to occur, the first step is to identify the source of the problem. NURSING INTERVENTION 6. Help patient find alternative ways to release tension, such as physical outlets, and more appropriate ways to express anger, such as seeking out staff when feelings emerge. RATIONALE 6. Patient will likely need assistance to problem solve more appropriate ways of behaving. NURSING INTERVENTION 7. Model appropriate ways to express anger assertively, such as, "I dislike being called names. I get angry when I hear you saying those things about me." RATIONALE 7. Role modeling is one of the strongest methods of learning.

O in SOLER means

Observe an open posture. Posture is considered "open" when arms and legs remain uncrossed. This posture suggests that the nurse is "open" to what the patient has to say. With a "closed" posture, the nurse can convey a somewhat defensive stance, possibly invoking a similar response in the patient.

Alzheimer's Disorder

Onset of symptoms - is slow and insidious, and the course of the disorder is generally progressive and deteriorating. - Memory impairment is a prominent feature.

BOX 15-4 Positive and Negative Symptoms of Schizophrenia

POSITIVE SYMPTOMS Delusions (Fixed, False Beliefs) (examples) Persecutory—belief that one is going to be harmed by other(s) Referential—belief that cues in the environment are specifically referring to them Grandiose—belief that they have exceptional greatness Somatic—beliefs that center on one's body functioning Hallucinations (Sensory Perceptions Without External Stimuli) Auditory (most common in schizophrenia) Visual Tactile Olfactory Gustatory (NOTE: Hallucinations may be a normal part of religious experience in some cultural contexts.) Disorganized Thinking (Manifested in Speech) Loose association Tangentiality Circumstantiality Incoherence (includes word salad) Neologisms Clang associations Echolalia Grossly Disorganized or Abnormal Motor Behavior (Including Catatonia) Hyperactivity Hypervigilance Hostility Agitation Childlike silliness Catatonia (ranging from rigid or bizarre posture and decreased responsivity to complete lack of verbal or behavioral response to the environment) Catatonic excitement (excessive and purposeless motor activity) Stereotyped, repetitive movements Unusual mannerisms or postures NEGATIVE SYMPTOMS Lack of Emotional Expression Blunted affect Lack of movement in head and hands that adds expression in communication Lack of intonation in speech Decreased or Lack of Motivation to Complete Purposeful Activities (Avolition) Neglect of activities of daily living Decreased Verbal Communication (Alogia) Decreased Interest in Social Interaction and Relationship (Asociality) Withdrawal Poor rapport Diminished Ability for Abstract Thinking Concrete interpretation of events and communication from others

TABLE 11-2 Guiding Principles for Suicide Risk Assessment

PRINCIPLES Screening for suicide risk should be conducted as an essential component of health assessment, and risk factors, warning signs, and threats should be taken seriously. EXPLANATION This includes identifying through detailed assessment the individual's unique situation to discern additional resources, consults, and interventions needed to ensure patient safety. PRINCIPLES Establishment of a therapeutic relationship is foundational to effective suicide risk assessment. EXPLANATION This includes establishing trust through empathy and respect, which provides a safe environment for the client to tell his or her story. PRINCIPLES Suicide risk assessment is complex and challenges the nurse to use many different communication strategies. EXPLANATION This includes exploring the client's thoughts, feelings, and behaviors from a variety of perspectives. PRINCIPLES Suicide risk assessment is an ongoing process, and level of risk can increase or decrease over time. EXPLANATION This includes assessing over time for fluctuations in risk factors, changes in stress level, changes in intensity of ideation, changes in intention to act on suicide ideation, and changes in support systems. PRINCIPLES Collaboration with the client and other sources of information facilitates confidence in clinical judgments. EXPLANATION This includes information provided by other people who are familiar with the client from home, work, or school and other clinical team members. Collaboration also implies that all those involved in the client's care are working together. PRINCIPLES Suicide risk assessment uses direct rather than indirect language. EXPLANATION This includes using terminology such as "suicide" and "death" rather than "not happy with living" or other indirect statements. It also communicates to the client that these are acceptable topics to discuss. PRINCIPLES Suicide risk assessment attempts to discern the underlying message. EXPLANATION This includes attempting to discern when the patient is communicating unbearable distress, feeling trapped, feeling hopeless, and/or feeling driven to avoid additional emotional or physical pain. PRINCIPLES Suicide risk assessment considers cultural context. EXPLANATION This includes recognizing that anyone regardless of race, religion, or culture may be at risk for suicide. Some cultural or religious prohibitions may influence someone's willingness to openly discuss personal feelings. PRINCIPLES Suicide risk assessment is documented in detail. EXPLANATION This includes risk factors, warning signs, underlying themes, level of risk, clinical judgments, and recommended interventions.

Reflecting

Questions and feelings are referred back to the patient so that the patient is empowered to actively engage in problem-solving rather than simply asking the nurse for advice. Pt: "Don't you think I should tell my boss I'm not putting up with that?" Nurse: "What do you think you should do?" Pt: "She makes me so upset!" Nurse: "So you're feeling angry at your boss?"

Therapeutic communication

Reflecting; Broad Opening p108

R in SOLER means

Relax. Whether sitting or standing during the interaction, the nurse should communicate a sense of being relaxed and comfortable with the patient. Restlessness and fidgetiness communicate a lack of interest and may convey a feeling of discomfort that is likely to be transferred to the patient.

Depression (Ch 11,16)

SUICIDE-assessment, interventions (re: level of observation) T16-2 care plan p399 safety as priority Outcomes- safety- recall criteria when formulating outcomes Depression-Assessment- moderate depression p396 Priority interventions-safety Antidepressants- MAOIs-interactions (e.g with tricyclics, foods, etc) p410 Cognitive Therapy- Automatic thoughts (e.g.personalizing)- p407

SUICIDE assessment

See Ch. 11 Presenting symptoms/medical-psychiatric diagnosis -Mood disorders -Substance use disorders -Anxiety disorders -Schizophrenia -Borderline personality disorder -Antisocial personality disorder • See Table 11-2 for guiding principles for suicide risk assessment • Suicidal ideas or acts-Be direct with assessment questions "Are you suicidal?" -Seriousness of intent -Existence of a plan "Do you have a plan?" -Availability and lethality of means "Do you have a gun/pills?" -Behavioral clues -Verbal clues

Care plan-nurse's attitude with limit setting on behaviors

Signs and Symptoms: Disregard for societal norms and laws Absence of guilt Inability to delay gratification Nursing Actions - Explain acceptable behaviors and consequences of violation - Explain clearly what is expected of patient - Provide positive feedback and rewards for acceptable behaviors - Provide milieu environment - Promote insight development - Maintain attitude of acceptance Nursing Diagnosis Defensive coping Outcomes - Demonstrates socially acceptable behavior on the unit - Is able to delay personal gratification - Does not manipulate others for own desires

S in SOLER means

Sit squarely facing the patient. This gives the message that the nurse is there to listen and is interested in what the patient has to say.

SUICIDE interventions

TABLE 11-3 | CARE PLAN FOR THE SUICIDAL PATIENT - pg216 • Do not leave the person alone • Develop a detailed safety plan • Enlist the help of family or friends to ensure home is safe from weapons or stockpiled drugs • Schedule frequent appointments-daily or every other day • Provide a small supply of antidepressants • Discuss the current crisis in the client's life • Establish rapport and promote a trusting relationship • Be direct and talk matter-of-factly about suicide

Anxiety, Obsessive-Compulsive, and Related Disorders (Ch18)

Symptoms of Panic DO and duration -p454 Nursing Dx for sx of Panic DO- p465 T18-2 Contrast-Obsessive-Compulsive DO vs OCPD-assessment data-p460 and p571 Interventions for ritualistic behavior p467 Tx- SSRIs (fluvoxamine-Luvox) dosages p476 Agoraphobia- onset of sx 451 Generalized Anxiety DO- Behaviors-p450 Tx with medications-Benzodiazepines aka ANXIOLYTICS (hint! fill-in) long term tx— Benzodiazdepines vs buspirone-

Tardive dyskinesia (AIMS- test for movement disorders)- p83

This later-onset adverse effect is characterized by bizarre facial and tongue movements, stiff neck, and difficulty swallowing; it may occur with all classifications but is more common with first generation antipsychotics. All patients receiving long-term (months or years) antipsychotic therapy are at risk, and the symptoms are potentially irreversible. Nurses should immediately report any early signs of tardive dyskinesia (usually abnormal tongue movements) to the prescribing physician or nurse practitioner. The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was developed in the 1970s by the National Institute of Mental Health to measure involuntary movements associated with tardive dyskinesia. The AIMS aids in early detection of movement disorders and provides a means for ongoing surveillance (see Box 4-2). A decision may be made to change to a different drug, adjust the dosage, or discontinue the drug. In 2017 the FDA approved the first drugs for treating tardive dyskinesia: valbenazine (Ingrezza) and deutetrabenazine (Austedo). Although their mechanism of action is unknown, both drugs are believed to inhibit monoamine uptake. In clinical trials, there were significant reductions in abnormal involuntary movements. Some extrapyramidal side effects can be life threatening and those that are not can sometimes be permanent. The abnormal movements in the tongue and lips can be very visible and even severe enough to interfere with a person's ability to speak or swallow.

Aggression can be identified by (Assessment)

a cluster of characteristics that include: • Pacing; restlessness • Verbal/physical threats • Threats of homicide or suicide • Loud voice; argumentative • Tense facial expression and body language - may be evidenced in many behaviors, including (but not limited to) the following defining characteristics ■ Pacing, restlessness ■ Threatening body language ■ Verbal or physical threats ■ Loud voice, shouting, use of obscenities, argumentativeness ■ Threats of homicide or suicide ■ Increase in agitation, with overreaction to environmental stimuli ■ Panic anxiety, leading to misinterpretation of the environment ■ Suspiciousness and defensive posturing ■ Angry mood, often disproportionate to the situation ■ Destruction of property ■ Acts of physical harm toward another person - can arise from a number of feeling states, including anger, anxiety, guilt, frustration, or suspiciousness. - behaviors can be classified as mild (e.g., sarcasm), moderate (e.g., slamming doors), severe (e.g., threats of physical violence against others), or extreme (e.g., physical acts of violence against others). - Kassinove (2016) states that aggression may include verbal and physical attacks that intend harm to another and often reflect a desire for dominance and control.

Delirium-causes

a mental state characterized by an acute disturbance of cognition, which is manifested by short-term confusion, excitement, disorientation, and a clouding of consciousness. Hallucinations and illusions are common. medication induced - p246 Medications that have been known to precipitate delirium include anticholinergics, antihypertensives, corticosteroids, anticonvulsants, cardiac glycosides, analgesics, anesthetics, antineoplastic agents, antiparkinson drugs, H2-receptor antagonists (e.g., cimetidine), and others (Fabian & Solai, 2017; Sadock et al., 2015). In addition, polypharmacy is, at times, implicated in precipitating delirium. Substance Intoxication In this subtype, the symptoms of delirium are attributed to intoxication from certain substances, such as alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedative, hypnotic, and anxiolytics, or other (or unknown) substance (APA, 2013). Substance Withdrawal Withdrawal from certain substances can precipitate symptoms of delirium that are sufficiently severe to warrant clinical attention. These substances include alcohol, opioids, sedative-hypnotics and anxiolytics, and others. Due to Another Medical Condition or to Multiple Etiologies There may be evidence from the history, physical examination, or laboratory findings that the symptoms of delirium are associated with another medical condition or can be attributable to more than one cause. The current evidence supports that delirium is usually the result of many factors rather than one (Fabian & Solai, 2017).

Buspirone (BuSpar)

and SSRIs have demonstrated efficacy in treating anxiety disorders as well and have the added benefit of not being addictive chemicals. • 10 to 14 day delayed onset of action - not recommended for prn administration.

Benzodiazepines (ANXIOLYTICS)

have been the traditional medication used for the treatment of acute anxiety states. - prescribed on an as-needed basis when the client is feeling particularly anxious - By reducing anxiety, they allow learning and adaptation to take place. - they also have the potential for dependence, they are typically a short-term intervention. - they pose certain risks for some patients, including those who are pregnant; the elderly; those who have current or past substance use disorders; current users of prescribed opioids (risk of respiratory depression and death); and patients with chronic obstructive pulmonary disease (Weber & Duchemin, 2018). • Hydroxyzine (Vistaril) • Alprazolam (Xanax) • Chlordiazepoxide (Librium) • Clonazepam (Klonopin) • Clorazepate (Tranxene) • Diazepam (Valium) • Lorazepam (Ativan) • Oxazepam • Meprobamate

Outcomes (SUICIDE)

include short- and long-term goals. Timelines are individually determined. The criteria that follow may be used for measurement of outcomes in the care of the suicidal patient. The patient ■ Has experienced no physical harm to self. ■ Sets realistic goals for self. ■ Expresses some optimism and hope for the future.

Alcohol intoxication

occurs at blood alcohol levels between 100 and 200 mg/dl - Death has been reported at levels ranging from 400 to 700 mg/dL.

Hepatic encephalopathy:

occurs in response to the inability of the diseased liver to convert ammonia to urea for excretion. The continued rise in serum ammonia, if allowed to progress, leads to coma and eventual death. - Treatment includes complete abstention from alcohol; reduction of protein in the diet; reduction of intestinal ammonia using neomycin, rifaximin, or lactulose; and treatment of electrolyte imbalances (sodium and potassium), kidney failure, and infections (National Library of Medicine, 2017).

Alcohol use disorder outcomes-inpt/outpt

recall properly formulated criteria for outcomes The patient: ■ Has not experienced physical injury. ■ Has not caused harm to self or others. ■ Accepts responsibility for own behavior. ■ Acknowledges association between personal problems and use of substance(s). ■ Demonstrates adaptive coping mechanisms that can be used in stressful situations (instead of taking substances). ■ Shows no signs or symptoms of infection or malnutrition. ■ Exhibits evidence of increased self-worth by attempting new projects without fear of failure and by demonstrating less defensive behavior toward others. ■ Verbalizes importance of abstaining from use of substances in order to maintain optimal wellness.

Alzheimer's Disorder Review case study from class- Onset of symptoms-

slow and gradual progression of symptoms

atypical antipsychotics

treat negative and positive symptoms-p341f Antipsychotic Medications Clozapine, olanzapine, quetiapine, aripiprazole, risperidone, iloperidone, ziprasidone, paliperidone, asenapine, lurasidone Aripiprazole (Abilify) (Abilify MyCite; with tracking sensor) Aripiprazole lauroxil (Aristada) Asenapine (Saphris) (SL) Brexpiprazole (Rexulti) Cariprazine (Vraylor) Clozapine (Clozaril) Iloperidone (Fanapt) Lurasidone (Latuda) Olanzapine (Zyprexa) Paliperidone (Invega) Quetiapine (Seroquel) Risperidone (Risperdal) Long-acting risperidone (Perseris) Ziprasidone (Geodon)

Typical Antipsychotics

treat positive symptoms- p340f Antipsychotic Medications Phenothiazines Haloperidol Chlorpromazine Fluphenazine Haloperidol (Haldol) Loxapine Perphenazine Pimozide (Orap) Prochlorperazine Thioridazine Thiothixene (Navane) Trifluoperazine

Generalized Anxiety Disorder- RECALL Behaviors

• Characterized by chronic, unrealistic, and excessive anxiety and worry for more days than not for 6 months or more-RECALL • Symptoms cannot be attributed to organic factors

Antianxiety agents- Side effects of antianxiety agents

• Drowsiness, confusion, lethargy • Tolerance; physical and psychological dependence (this does not apply to buspirone) - * REVIEW • Potentiates effects of other CNS depressants • Orthostatic hypotension • Dry mouth; nausea and vomiting • 10 to 14 day delayed onset of action (with buspirone) - * REVIEW

agoraphobia

• Onset usually occurs in 20s and 30s persisting for many years-RECALL • Examples • Traveling in public transportation • Being in open spaces • Being in shops, theaters, or cinemas • Standing in line or being in a crowd • Being outside of the home alone in other situations

Predisposing Factors (substance abuse) - Psychological factors

• Personality factors: certain personality traits are thought to increase a tendency toward addictive behavior, including - Low self-esteem - Frequent depression - Passivity - Inability to relax or defer gratification - Inability to communicate effectively

mood DO Assessment

• Symptoms may be categorized by degree of severity (REVIEW STAGES). • • Stage I. Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization • • • Cheerful mood • • • Rapid flow of ideas; heightened perception • • • Increased motor activity • • Stage II. Acute mania: Marked impairment in functioning; usually requires hospitalization • • • Elation and euphoria; a continuous "high" • • • Flight of ideas; accelerated, pressured speech • • • Hallucinations and delusions • • • Excessive motor activity • • • Social and sexual inhibition • • • Little need for sleep • • Stage III. Delirious mania: A grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. The condition is rare since the advent of antipsychotic medication. • • • Labile mood; panic anxiety • • • Clouding of consciousness; disorientation • • • Frenzied psychomotor activity • • • Exhaustion and possibly death without intervention

Antipsychotics

• Typicals: treat positive symptoms- p340f Antipsychotic Medications • Atypicals: treat negative and positive symptoms-p341f Antipsychotic Medications

Antipsychotic Medications Side Effects

•Anticholinergic effects •Nausea; GI upset •Skin rash •Sedation •Orthostatic hypotension •Photosensitivity •Hormonal effects •ECG changes •Hypersalivation •Weight gain Extrapyramidal symptoms (EPS) include: Pseudoparkinsonism Akinesia Akathisia Dystonia Oculogyric crisis Antiparkinsonian agents (e.g. benztropinea aka Cogentin) may be prescribed to counteract EPS (see lists in text)

Histrionic Personality Disorder:

∙ ∙ Colorful, dramatic extroverted behavior. Attention seeking, outgoing & sociable, seductive, manipulative. Seek constant affirmation of approval and acceptance. Highly distractible, difficulty paying attention to detail, strongly dependent.

Borderline Personality Disorder:

∙ ∙ Pattern of intense and chaotic relationships, fluctuating attitudes, impulsive, self-destructive, lack a clear sense of identity, emotionally unstable

Antisocial Personality Disorder:

∙ ∙ Pattern of socially irresponsible, exploitative, and guiltless behavior. - Total disregard for the rights of others, without remorse. - Fails to conform to the law and sustain consistent employment. - very low tolerance for frustration, act impulsively, and are unable to delay gratification - are restless and easily bored, often taking chances and seeking thrills, as if they were immune to danger. - Their pattern of impulsivity may be manifested in failure to plan ahead, culminating in sudden job, residence, or relationship changes