Mental Health Exam #4

Pharmacological Intervention for ASD

*Pharmacological interventions are directed toward relief of targeted irritability symptoms such as aggression, hyperactivity, self-harm, impulsivity, and temper tantrums *There are no medications that treat the core symptoms of autism spectrum disorder Two medications approved by the FDA -Risperidone AE: sedation, fatigue, weight gain, vomitting, somnolence, and tremor -Aripiprazole Targeted for the following symptoms -Aggression -Deliberate self-injury -Temper tantrums -Quickly changing moods Dosage based on weight of child and clinical response

Anorexia nervosa

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

Nursing Diagnosis r/t Eating Disorders

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

Pharmacotherapy for alcoholism

1. Disulfiram (Antabuse) -Disulfiram (Antabuse) is a drug that can be administered as a deterrent to drinking to individuals who abuse alcohol. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a great deal of discomfort for the individual. Disulfiram therapy is not a cure for alcoholism, but rather a measure of control to avoid impulse drinking. Clients receiving disulfiram therapy are encouraged to seek other assistance with their problem, such as AA or other support group, to aid in the recovery process. 2. Other medications -Naltrexone (ReVia) -Nalmefene (Revex) -Selective serotonin reuptake inhibitors (SSRIs) -Acamprosate (Campral)

Indications for Hospitalization (Pt's with eating disorders)

1. Malnutrition: 20% below expected weight for height are recommended for inpatient treatment; 30% below expected weight for height are recommended for long term intensive treatment 2. Dehydration: Assessment includes thirst, orthostatic hypotension, tachycardia, elevated sodium levels and other symptoms. 3. Severe electrolyte imbalance: including potassium levels below 3 mml/L, phosphate levels below 3 mg/dL, magnesium levels below 1.4 mEq/L 4. Cardiac arrhythmia or severe bradycardia: ST segment and T wave changes usually related to electrolyte imbalances; below 50 BPM! 5. Hypothermia: body temperature below 96.8 6. Hypotension: -a pattern of low blood pressure or orthostatic hypotension (20 mm Hg or greater drop in systolic blood pressure with positional changes and pulse rate increase by 20 or more beats 7. Suicidal ideation

Diagnosis/Outcome Identification (bereavement)

1. Risk for complicated grieving related to loss of a valued entity/concept; loss of a loved one -ST goal: client acknowledges awareness of loss -interventions: assess the cleint's stage in grief process, assess bereavement risk factors, help client actualize loss by talking about it, help client identify and express feelings such as anger, guilt (the client may feel he/she did not do enough), anxiety/helplessness (help cleint recongize way that life was managed before loss) 2. Risk for spiritual distress related to complicated grief process -ST goals: client indentifies meaning and purpose in life, moving forward with hope -LT goal: cleint expresses achievment of support and personal from spiritual practices -Interventions: be accepting and nonjudgmental when client expressess anger (towards GOD), encourage client to ventialte feelings feelings r/t meaning of own existence in the face of current loss The client -Acknowledges awareness of the loss -Is able to express feelings about the loss -Verbalizes stages of the grief process and behaviors associated with each -Expresses personal satisfaction and support from spiritual practices

Substance-Induced Disorder

1. Substance intoxication *Intoxication is a physical and mental state of exhilaration and emotional frenzy or lethargy and stupor. -Substance intoxication is the development of reversible syndromes following excessive use of a substance. These symptoms are drug-specific and occur shortly after ingesting the substance. Judgment is disturbed, resulting in inappropriate and maladaptive behavior, and social and occupational functioning are impaired. -Development of a reversible syndrome of symptoms following excessive use of a substance -Direct effect on the central nervous system -Disruption in physical and psychological functioning -Judgment is disturbed and social and occupational functioning is impaired 2. Substance withdrawal *Occurs upon abrupt reduction or discontinuation of a substance used regularly over a prolonged period of time *Withdrawal is the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Substance withdrawal occurs upon abrupt reduction or discontinuation of a substance that has been used regularly over a prolonged period of time. *Substance-specific syndrome includes -Clinically significant physical signs and symptoms -Psychological changes, such as disturbances in thinking, feeling, and behavior

Effects of alcohol on the body

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

Emotional neglect

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

Sedative/Hypnotic/Anxiolytic Use Disorder

A profile of the substance - Barbiturates - Nonbarbiturate hypnotics - Antianxiety agents ex) xanax *Sedative/hypnotic/anxiolytic compounds are drugs of diverse chemical structures that are all capable of inducing varying degrees of CNS depression, from tranquilizing relief of anxiety to anesthesia, coma, and even death. They are generally categorized as barbiturates, nonbarbiturate hypnotics, and antianxiety agents. 1. The effects of CNS depressants are additive with one another and with the behavioral state of the user. *For example, when these drugs are used in combination with each other or with alcohol, the depressive effects are compounded. These intense depressive effects are often unpredictable and can even be fatal. Similarly, a person who is mentally depressed or physically fatigued may have an exaggerated response to a dose of the drug that would only slightly affect a person in a normal or excited state. 2. CNS depressants are capable of producing physiological addiction. -If large doses of CNS depressants are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs upon withdrawal of the drug. The response can be quite severe, even leading to convulsions and death. 3. CNS depressants are capable of producing psychological addiction. -CNS depressants have the potential to generate a psychic drive for periodic or continuous administration of the drug to achieve maximum functioning or feeling of well-being. 4. Cross-tolerance and cross-dependence may exist between various CNS depressants. -Cross-tolerance is exhibited when one drug results in a lessened response to another drug. Cross-dependence is a condition in which one drug can prevent withdrawal symptoms associated with physical addiction to a different drug. Effects on the body (KNOW THIS!!) -Effects on sleep and dreaming: decreases the amount *During drug withdrawal, dreaming becomes vivid and excessive. Rebound insomnia and increased dreaming are not uncommon with abrupt withdrawal. of sleep time spent in dreaming -Respiratory depression -Cardiovascular effects -Renal function: barbiturates may suppress urine function. -Hepatic effects: may produce jaundice with doses large enough to produce acute intoxication -Body temperature -Sexual functioning: increase in libido but then men are unable to maintain erection *Two main patterns of addiction exist. The first is one of an individual whose physician originally prescribed the drug as treatment for anxiety or insomnia. Use of the medication is justified on the basis of treating symptoms, but as tolerance grows, more and more of the medication is required to produce the desired effect. Substance-seeking behavior is evident as the individual seeks prescriptions from several physicians in order to maintain sufficient supplies. *The second pattern involves young people in their teens or early 20s who use substances that were obtained illegally for recreational use. This pattern of intermittent use leads to regular use and extreme levels of tolerance. Combining use with other substances is not uncommon. Physical and psychological addiction leads to intense substance-seeking behaviors, most often through illegal channels. Sedative, hypnotic, or anxiolytic INTOXICATION (KNOW THIS!!!) -With these CNS depressants, effects can range from disinhibition and aggressiveness mood lability, impaired judgment, or impaired social or occupational functioning to coma and death. -Impaired judgment -Impaired social function -Slurred speech -Coordination problems (unsteady gait) -Stupor -Problems with memory Sedative, hypnotic, or anxiolytic WITHDRAWAL (KNOW THIS!) -Onset of symptoms depends on the half-life of the drug from which the person is withdrawing. *With short-acting sedative/hypnotics, symptoms may begin between 12 and 24 hours after the last dose, reach peak intensity between 24 and 72 hours, and subside in 5 to 10 days. *Withdrawal symptoms from substances with longer half-lives may begin within 2 to 7 days, peak on the fifth to eighth day, and subside in 10 to 16. -Severe withdrawal from CNS depressants can be life threatening. *Severe withdrawal is most likely to occur when a substance has been used at high dosages for prolonged periods *Withdrawal symptoms associated with sedative/hypnotics include autonomic hyperactivity, increased hand tremor, insomnia, nausea or vomiting, hallucinations, illusions, psychomotor agitation, anxiety, or grand mal seizures.

Stimulant Use Disorder

A profile of the substance -Psychomotor stimulants induce stimulation by augmentation or potentiation of the neurotransmitters norepinephrine, epinephrine, or dopamine. -General cellular stimulants (caffeine and nicotine) exert their action directly on cellular activity. *CNS stimulants are identified by the behavioral stimulation and psychomotor agitation that they induce. *The average American consumes two cups of coffee (about 200 mg of caffeine) per day and caffeine is consumed in various amounts by about 90 percent of the population. *Next to caffeine, nicotine, an active ingredient in tobacco, is the most widely used psychoactive substance in U.S. society. ex) Cocaine is the most potent stimulant derived from nature *examples of stimulants: -amphetamines -synthetic stimulants -cocaine -caffeine -nicotine Patterns of use -CNS stimulant use is usually characterized by either episodic or chronic daily or near-daily use. *Many individuals who abuse or are addicted to CNS stimulants began using the substance for the appetite-suppressant effect in an attempt at weight control *Chronic users tend to rely on CNS stimulants to feel more powerful, more confident, and more decisive. They often fall into a pattern of taking "uppers" in the morning and "downers," such as alcohol or sleeping pills, at night. Effects on the body (KNOW THIS) -CNS effects: tremor, restlessness, anorexia, insomnia, agitation, and increased motor activity **Amphetamines, nonamphetamine stimulants, and cocaine produce increased alertness, decrease in fatigue, elation and euphoria, and subjective feelings of greater mental agility and muscular power.*** -Cardiovascular/pulmonary effects *Amphetamines can induce increased systolic and diastolic blood pressure, increased heart rate, and cardiac arrhythmias. These drugs also relax bronchial smooth muscle *Cocaine intoxication typically produces a rise in myocardial demand for oxygen and an increase in heart rate. Severe vasoconstriction may occur and can result in myocardial infarction, ventricular fibrillation, and sudden death. *Inhaled cocaine can cause pulmonary hemorrhage, chronic bronchiolitis, and pneumonia *Caffeine ingestion can result in increased heart rate, palpitations, extrasystoles, and cardiac arrhythmias. Caffeine induces dilation of pulmonary and general systemic blood vessels and constriction of cerebral blood vessels. *Nicotine stimulates the sympathetic nervous system, resulting in an increase in heart rate, blood pressure, and cardiac contractility, thereby increasing myocardial oxygen consumption and demand for blood flow. -Gastrointestinal and renal effects *Gastrointestinal effects of amphetamines are somewhat unpredictable, but a decrease in GI tract motility commonly results in constipation. *Contraction of the bladder sphincter makes urination difficul *caffeine=diuretics *Nicotine stimulates the hypothalamus to release antidiuretic hormone, reducing the excretion of urine. -Sexual function *CNS stimulants appear to increase sexual urges in both men and women. Women, more than men, report that stimulants make them feel sexier and have more orgasms *Some men may experience sexual dysfunction with the use of stimulants

Cannabis Use Disorder

A profile of the substance -Marijuana -Hashish Patterns of use -22.2 millions americans aged 12 years or or older were current users -many people incorrectly regard cannabis as a substance of low abuse potential Effects on the body 1. Cardiovascular -Cannabis ingestion induces tachycardia and orthostatic hypotension. With the decrease in blood pressure, myocardial oxygen supply is decreased. Tachycardia in turn increases oxygen demand. 2. Respiratory -Marijuana produces a greater amount of "tar" than its equivalent weight in tobacco. Because marijuana is most commonly smoked larger amounts of tar are deposited in the lungs, promoting deleterious effects to the lungs. -Although the initial reaction to the marijuana is bronchodilation, thereby facilitating respiratory function, chronic use results in obstructive airway disorders. Frequent marijuana users often have laryngitis, bronchitis, cough, and hoarseness. -Cannabis smoke contains more carcinogens than tobacco smoke. 3. Reproductive -men may have a decrease in sperm count, motility, and structure -In women, heavy marijuana use may result in a suppression of ovulation, disruption in menstrual cycles, and alteration of hormone levels. 4. CNS -Symptoms include feelings of euphoria, relaxed inhibitions, disorientation, depersonalization, and relaxation. At higher doses, sensory alterations may occur, including impairment in judgment of time and distance, recent memory, and learning abilit -Physiological symptoms may include tremors, muscle rigidity, and conjunctival redness. Toxic effects are generally characterized by panic reaction -Heavy long-term cannabis use is also associated with a condition called amotivational syndrome. Amotivational syndrome is defined as lack of motivation to persist in or complete a task that requires ongoing attention.!!!!! 5. Sexual functioning -The intensified sensory awareness and the subjective slowness of time perception are thought to increase sexual satisfaction -Marijuana also enhances the sexual functioning by releasing inhibitions for certain activities that would normally be restrained. Intoxication -Symptoms include impaired motor coordination, euphoria, anxiety, sensation of slowed time, and impaired judgment. -Physical symptoms include conjunctival injection, increased appetite, dry mouth, and tachycardia. -Impairment of motor skills lasts for 8 to 12 hours. Cannabis withdrawal (KNOW THIS) Symptoms occur within a week following cessation of use and may include -Irritability, anger, or aggression -Nervousness, restlessness, or anxiety -Sleep difficulty (e.g., insomnia, disturbing dreams) -Decreased appetite or weight loss -Depressed mood -Physical symptoms, such as abdominal pain, tremors, sweating, fever, chills, or headache

Length of the Grief Process

Acute grief -Usually lasts about 6 to 8 weeks; longer in older adults The grief process -Is very individual -May last for many years The grief response is more difficult if: -The bereaved person was strongly dependent on or perceived the lost entity as an important means of physical and/or emotional support -The relationship was an ambivalent one. A love-hate relationship may instill feelings of guilt that can interfere with the grief work. -The individual has experienced a number of recent losses. Grief tends to be cumulative, and if previous losses have not been resolved, each succeeding grief response becomes more difficult. -The loss is that of a young person. Grief over loss of a child is often more intense than it is over the loss of an elderly person. Increase incidence of PTSD in parents! -The bereaved person's health is unstable -The bereaved person perceives some responsibility for the loss *A number of factors influence the eventual outcome of the grief response. The grief response may be facilitated -The individual has the support of significant others -The individual has the opportunity to prepare for the loss. Grief work is more intense when the loss is sudden and unexpected.

Application of the Nursing Process to ADHD

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

Oppositional defiant disorder (ODD)

Characterized by a persistent pattern of angry mood and defiant behavior that occurs more frequently than is usually observed in individuals of comparable age and developmental level and interferes with social, educational, or vocational activities Predisposing factors 1. Family influences -If power and control are issues for parents, or if they exercise authority for their own needs, a power struggle can be established between the parents and the child, which sets the stage for the development of ODD.

The Bereaved Individual

Examples of loss -A significant other (person or pet) -Illness or debilitating conditions. Examples include (but are not limited to) diabetes, stroke, cancer, rheumatoid arthritis, multiple sclerosis, Alzheimer's disease, hearing or vision loss, and spinal cord or head injuries -Developmental/maturational changes or situations, such as menopause, andropause, infertility, "empty nest," aging, impotence, or hysterectomy -Decrease in self-esteem due to inability to meet self-expectations or the expectations of others. This includes a loss of potential hopes and dreams -Personal possessions that symbolize familiarity and security in a person's life

Physical neglect of a child

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

Planning/Implementation

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

Survivors of abuse planning/implementation

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

Normal Versus Maladaptive Grieving

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

Nursing interventions for the bereaved individual

Provide assistance through the grief process in a healthful manner toward resolution Encourage the individual to express feelings about the loss and how the loss will affect his or her life Encourage the individual to participate in usual religious practices from which he or she derives support Assist the client to identify positive aspects about his or her life, past relationships, and prospects for the future

Sexual Abuse of a Child

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

Anticipatory Grieving

The experiencing of feelings and emotions associated with the normal grief response before the loss actually occurs Difficulty arises when family members complete the process of anticipatory grief and detachment from the dying person occurs prematurely. Anticipatory grieving may be positive for some people and less functional for others.

Assessment

Battering -A pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence toward an intimate partner Intimate partner violence -Various terms describe the pattern of violence between intimate partners, including intimate partner violence (IPV), domestic violence, and battering. -Physical abuse between domestic partners may be known as spousal abuse, domestic or family violence, wife or husband battering, or IPV. *82 percent of victims of intimate violence were women, women ages 25 to 34 experienced the highest per capita rates of intimate violence Profile of the victim -Battered women represent all age, racial, religious, cultural, educational, and socioeconomic groups -Low self-esteem. and often accept the blame for the batterer's actions -Inadequate support systems -Some grew up in abusive homes, and may have left those homes, even gotten married, at a very young age in order to escape the abuse **The battered woman views her relationship as male dominant, and as the battering continues, her ability to see the options available to her and to make decisions concerning her life decreases**

Predisposing Factors to ADHD

Biological influences -Genetics -Biochemical theory *It is believed that certain neurotransmitters—such as dopamine, norepinephrine, and possibly serotonin—are involved in producing the symptoms associated with ADHD, but their involvement is still under investigation. -Anatomical influences -Prenatal, perinatal, and postnatal factors *Maternal smoking, intrauterine exposure to toxic substances, including alcohol, and maternal infections during pregnancy have also been associated with higher risks for ADHD *Perinatal and postnatal influences that may contribute to ADHD are low birth weight, trauma, early infancy infections, or other insults to the brain during this period. Environmental influences -Environmental lead -Dietary factors Psychosocial influences -Disorganized or chaotic family environments -Maternal mental disorder or paternal criminality -Low socioeconomic status -Unstable foster care

Predisposing factors-eating disorders

Biological influences 1. Genetics -A hereditary predisposition to eating disorders has been hypothesized. -Anorexia nervosa is more common among sisters and mothers of those with the disorder than it is among the general population. -Possible chromosomal linkage sites have been suggested. 2. Neuroendocrine abnormalities -There has been some speculation about a primary hypothalamic dysfunction in anorexia nervosa. ex) many people with anorexia experience amenorrhea before the onset of starvation and significant weight loss. 3. Neurochemical influences -Bulimia nervosa may be associated with the neurotransmitters SERATONIN and NOREPINEPHRINE. -high levels of opioid can cause the patient to not feel hunger, speculations have risen that narcan can be able to make the patient get hungry

Inhalant Use Disorder-Effects on the Body

CNS effects -Neurological damage, such as ataxia, peripheral and sensorimotor neuropathy, speech problems, and tremors, can occur. -other CNS problem is ototoxicity, encephalopathy, parkinsonism Respiratory effects -use range from coughing and wheezing to dyspnea, emphysema, and pneumonia. There is increased airway resistance due to inflammation of the passages. Gastrointestinal effects -Abdominal pain, nausea, and vomiting may occur. A rash may be present around the individual's nose and mouth. Renal system effects -Acute and chronic renal failure and hepatorenal syndrome have occurred. Renal toxicity from toluene exposure has been reported. -renal tubular acidosis, hypokalmeia, hypophasphatemia, hyperchloremia, azotemia, sterile pyruia, hematuria and proteinuria Inhalant intoxication -Develops during or shortly after use of or exposure to volatile inhalants 1. Symptoms *Dizziness, ataxia, muscle weakness *Euphoria, excitation, disinhibition *Nystagmus, blurred or double vision *Slurred speech, lethargy *Psychomotor retardation, hypoactive reflexes *Stupor or coma (at higher doses)

Psychopharmacological Intervention for ADHD

Central nervous system (CNS) stimulants -Examples: Dextroamphetamine, methamphetamine, lisdexamfetamine, methylphenidate, dexmethylphenidate, dextroamphetamine/amphetamine mixture -Side effects: Insomnia, anorexia, weight loss, tachycardia, decrease in rate of growth and development -Children on ADHD drugs had a higher risk of injury-related hospital admissions. -these drugs are known to elevate dopamine and norepinephrine levels it has been hypothesized that their effectiveness is in response to neurotransmitter dysregulation **They have generally mild side effects but they are contraindicated in anyone with cardiac problems or risks for cardiac problems.**

ODD assessment

Characterized by passive-aggressive behaviors -Stubbornness, procrastination -Disobedience, negativism -Carelessness, testing of limits -Resistance to directions -Unwillingness to cooperate -Running away -School avoidance and underachievement -Temper tantrums, fighting, and argumentativeness -Impaired interpersonal relationships Usually children do not see themselves as being oppositional. View the problem as arising from other people that they believe are making unreasonable demands on them Nursing Diagnosis: 1. Noncompliance with therapy related to negative temperament, denial of problems, underlying hostility 2. Defensive coping related to retarded ego development, low self-esteem, unsatisfactory parent/child relationship 3. Low self-esteem related to lack of positive feedback, retarded ego development 4. Impaired social interaction related to negative temperament, underlying hostility, manipulation of others The client -Complies with treatment by participating in therapies without negativism -Accepts responsibility for his or her part in the problem -Takes direction from staff without becoming defensive -Does not manipulate other people -Verbalizes positive aspects about self -Interacts with others in an appropriate manner Interventions: -Nursing care of the client with ODD is aimed at: *Encouraging cooperation with therapy *Helping client accept responsibility for own behaviors *Promoting increased feelings of self-worth Assisting in the development of socially appropriate behaviors in interactions with other

Opioid Use Disorder-Effects on the Body

-Abuse and addiction occur when the individual increases the amount and frequency of use, justifying the behavior as symptom treatment. CNS effects -Common manifestations include euphoria, mood changes, and mental clouding. Other common CNS effects include drowsiness and pain reduction -The nausea and vomiting commonly associated with opiate ingestion is related to the stimulation of the centers within the medulla that trigger this response. Gastrointestinal effects -Both stomach and intestinal tone are increased, whereas peristaltic activity of the intestines is diminished. These effects lead to a marked decrease in the movement of food through the GI tract -This is a notable therapeutic effect in the treatment of severe diarrhea Cardiovascular effects -Morphine is used extensively to relieve pulmonary edema and the pain of myocardial infarction in cardiac clients -hypotension Sexual functioning -decreased sexual function and diminished libido. Delayed ejaculation, impotence, and orgasm failure may occur. Opioid intoxication: -Symptoms are consistent with the half-life of most opioid drugs and usually last for several hours. -Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment. -Physical symptoms include pupillary constriction, drowsiness, slurred speech, and impairment in attention or memory -Severe opioid intoxication can lead to respiratory depression, coma, and death. -Euphoria, lethargy, somnolence, apathy, dysphoria, impaired judgment, slurred speech, constipation, decreased respiratory rate and blood pressure Opioid withdrawal: KNOW THIS! 1. Short-acting drugs (e.g., heroin) -Symptoms occur within 6 to 8 hours, peak within 1 to 3 days, and gradually subside in 5 to 10 days. 2. Long-acting drugs (e.g., methadone [syntehtic opiate-like drugs]) -Symptoms occur within 1 to 3 days, peak between days 4 and 6, and subside in 14 to 21 days. 3. Ultra-short-acting meperidine -Symptoms begin quickly, peak in 8 to 12 hours, and subside in 4 to 5 days. Symptoms of opioid withdrawal -Dysphoria, muscle aches, nausea/vomiting, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, abdominal cramping, diarrhea, yawning, fever, and insomnia

Distorted (exaggerated) grief

-All of the symptoms associated with normal grieving are exaggerated. -The individual becomes incapable of managing activities of daily living. -Feelings of sadness, helplessness, hopelessness, powerlessness, anger, and guilt, as well as numerous somatic complaints, render the individual dysfunctional in terms of management of daily living. -The individual remains fixed in the anger stage of the grief process. Anger may be directed towards others or turned inward on self -Depressed mood disorder is a type of distorted grief response. *However, many times the anger is turned inward on the self. When this occurs, depression is the result *depressive mood is an exaggerated grief reaction IN ANGER STAGE!

Conduct Disorder Assessment

-Classic characteristics of conduct disorder is the use of physical aggression in the violation of the rights of others -Use of drugs and alcohol -Sexual permissiveness -Low self-esteem manifested by a tough-guy" image -Problems with inattentiveness, impulsiveness, and hyperactivity -Lack of feelings of guilt or remorse -Use of projection as a defense mechanism -Inability to control anger -Low academic achievement Nursing Diagnosis 1. Risk for other-directed violence related to characteristics of temperament, peer rejection, negative parental role models, dysfunctional family dynamics 2. Impaired social interaction related to negative parental role models, impaired peer relations leading to inappropriate social behaviors 3. Defensive coping related to low self-esteem and dysfunctional family system 4. Low self-esteem related to lack of positive feedback and unsatisfactory parent-child relationship. Nursing Interventions: -Nursing care of the client with a conduct disorder -Ensuring safety of client and others -Assisting in the development of socially appropriate behaviors in interactions with others -Encouraging client to accept responsibility for own behaviors -Promoting increased feelings of self-worth -Nursing care of the client with a conduct disorder -Ensuring safety of client and others -Assisting in the development of socially appropriate behaviors in interactions with others -Encouraging client to accept responsibility for own behaviors -Promoting increased feelings of self-worth

Emotional abuse may be suspected when the parent or other adult caregiver

-Constantly blames, belittles, or berates the child -Is unconcerned about the child and refuses to consider offers of help for the child's problems -Overtly rejects the child

Disturbed body image/low self-esteem

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

Attention Deficit/Hyperactivity Disorder (ADHD)

-Essential behavior pattern is inattention and/or hyperactivity and impulsivity -More common in boys (14.1%) than girls (6.2%) -Prevalence among school-age children is 10.2 -60 to 70 percent persists into young adulthood -25 percent will meet criteria for antisocial personality disorder as adults Hyperactivity -Excessive psychomotor activity that may be purposeful or aimless, accompanied by physical movements and verbal utterances that are usually more rapid than normal -Inattention and distractibility are common with hyperactive behavior personality disorder as adults Impulsiveness -The trait of acting without reflection and without thought to the consequences of the behavior -An abrupt inclination to act (and the inability to resist acting) on certain behavioral urges *Onset of the disorder is difficult to diagnose in children younger than age 4 years because their characteristic behavior is much more variable than that of older children!! Categorized by clinical presentation subtypes -Combined type (meeting the criteria for both inattention and hyperactivity/impulsivity) -Predominantly inattentive presentation -Predominantly hyperactive/impulsive presentation

Hallucinogen Use Disorder

-Hallucinogenic substances are capable of distorting an individual's perception of reality and the ability to alter sensory perception and induce hallucinations. Some of the manifestations have been likened to a psychotic break. A profile of the substance -Naturally occurring hallucinogens ex) plants and fungi; psilocybin -Synthetic compounds ex) LSD, DMT, DET, PCP -Patterns of use -Use is usually episodic Patterns of use of hallucinogens is usually episodic -Because cognitive and perceptual abilities are so affected by these substances, the user must set aside time from normal daily activities for indulging in the consequences. *LSD, like other hallucinogens, does not lead to the development of physical addiction or withdrawal symptoms. *Psilocybin is an ingredient of the Psilocybe mushroom indigenous to the United States and Mexico. Ingestion of these mushrooms produces an effect similar to that of LSD but of a shorter duration *

Indicators of Sexual Abuse

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

Profile of the victimizer

-Low self-esteem -Pathologically jealous -"Dual personality" *one to the partner and one to the rest of the world -Limited coping ability -Severe stress reactions *They are often under a great deal of stress, but have limited ability to cope with the stress -Views spouse as a personal possession *He becomes threatened when she shows any sign of independence or attempts to share herself and her time with other -He insults and humiliates her and everything she does at every opportunity. He strives to keep her isolated from others and totally dependent on him

The incestuous relationship

-Often there is an impaired spousal relationship 1. Father -Domineering, impulsive, physically abusive 2. Mother *Passive, submissive, and denigrates her role of wife and mother *Often aware of the incestuous relationship but uses denial or keeps quiet out of fear of being abused by her husband -A great deal of attention has been given to the study of father-daughter incest. In these cases there is usually an impaired sexual relationship between the parents -Communication between the parents is ineffective, which prevents them from correcting their problems **Onset of the incestuous relationship typically occurs when the daughter is 8 to 10 years of age and commonly begins with genital touching and fondling** **In the beginning, the child may accept the sexual advances from her father as signs of affection. As the incestuous behavior continues and progresses, the daughter usually becomes more bewildered, confused, and frightened, never knowing whether her father will be paternal or sexual in his interactions with her.**

Nursing interventions for the child with ASD are aimed at

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

The victim-rape

-Rape can occur at any age -Highest-risk age group is females younger than age 34, those with lower income, and those living in rural areas -Most victims are single women, and the attack often occurs near their own neighborhoods

The Chemically Impaired Nurse-Peer assistance programs

-Recognize their impairment -Obtain necessary treatment -Regain accountability within profession *Since that time, the majority of state nurses' associations have developed (or are developing) programs for nurses who are impaired by substances or psychiatric illness. The individuals who administer these efforts are nurse members of the state associations, as well as nurses who are in recovery themselves. For this reason, they are called peer assistance programs.

Delayed or inhibited grief

-The absence of grief when it ordinarily would be expected -Potentially pathological because the person is not dealing with the reality of the loss -Remains fixed in the denial stage of the grief process -Grief may be triggered much later in response to a subsequent loss *The recognition of delayed grief is critical because, depending on the profoundness of the loss, the failure of the mourning process may prevent assimilation of the loss and thereby delay a return to satisfying living. IN DENIAL STAGE

Child Abuse

Child maltreatment typically includes physical or emotional injury, physical or emotional neglect, or sexual acts inflicted upon a child by a caregiver. -Children are vulnerable and relatively powerless, and the effects of maltreatment are infinitely deep and long lasting. Child maltreatment typically includes physical or emotional injury, physical or emotional neglect, or sexual acts inflicted upon a child by a caregiver. Signs of physical abuse -Unexplained injuries -Fading bruises or other marks -Child is frightened of adults -Shrinks at approach of adults -Child reports injury by parent or caregiver -Abuses animals or pets Physical abuse may be suspected when the parent or other adult caregiver -Offers conflicting, unconvincing, or no explanation for the child's injury -Describes the child as "evil," or in some other very negative way -Uses harsh physical discipline with the child -Has a history of abuse as a child -Has a history of abusing animals or pets Emotional abuse involves a pattern of behavior on the part of the parent or caretaker that results in serious impairment of the child's social, emotional, or intellectual functioning. *Examples of emotional injury include belittling or rejecting the child, ignoring the child, blaming the child for things over which he or she has no control, isolating the child from normal social experiences, and using harsh and inconsistent discipline. >Indicators of abuse -Extremes of behavior, such as overly compliant or demanding behavior, extreme passivity, or aggression -Inappropriately adult (e.g., parenting other children) or infantile behavior (e.g., frequently rocking or head-banging) -Delays in physical or emotional development -Suicide attempts -Lack of attachment to the parent

Dual Diagnosis

Clients with a coexisting substance disorder and mental disorder may be assigned to a special program that targets the dual diagnosis. Program combines special therapies that target both problems. Most dual diagnosis programs take a more supportive and less confrontational approach. ND: -Denial -ineffective coping -imbalanced nutrition: less than body requirements/ deficient fluid volume -risk for infection -chronic low self-esteem -risk for injury -risk for suicide The Client: -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 more 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

The adult survivor of incest

Common characteristics -A fundamental lack of trust that arises out of an unsatisfactory parent-child relationship -Low self-esteem and a poor sense of identity -Absence of pleasure with sexual activity -Promiscuity (indiscriminate mingling; having sexual relations with a number of partners on a casual basis

Comorbidity

Common comorbid psychiatric disorders are prevalent with ADHD. -Oppositional defiant disorder -Conduct disorder -Anxiety -Depression -Bipolar disorder -Substance use disorders *Depression and anxiety may be treated concurrently with ADHD. *Substance use disorder and bipolar disorder must be stabilized before beginning treatment for ADHD!!

Survivors of abuse Treatment Modalities

1) Crisis intervention -The focus of the initial interview and follow-up with the client who has been sexually assaulted is on the rape incident alone. -The client should be involved in the intervention from the beginning. This promotes a sense of competency, control, and decision-making -Because an overwhelming sense of powerlessness accompanies the rape experience, active involvement by the survivor is both a validation of personal worth and the beginning of the recovery process. -The goal of crisis intervention is to help survivors return to their previous lifestyle as quickly as possible. 2) Safe house or shelter -Most major U.S. cities have safe houses or shelters where women assured of protection for them and their children -These shelters provide a variety of services, and the women receive emotional support from staff and each other GOAL: Most shelters provide individual and group counseling; help with bureaucratic institutions such as the police, legal representation, and social services; child care and children's programming; and aid for the woman in making future plans, such as employment counseling and linkages with housing authorities. 3) Family therapy -Helps families who use violence to develop democratic ways of solving problems -Studies show that the more a family uses the democratic means of conflict resolution, the less likely they are to engage in physical violence. -Families need to learn to deal with problems in ways that can produce mutual benefits for all concerned, rather than engaging in power struggles among family members. -Members are encouraged to express honest feelings in a manner that is nonthreatening to other family members. -Active listening, assertiveness techniques, and respecting the rights of others are taught and encouraged.

Alcohol Use Disorder

1. A Profile of the Substance -Alcohol is a natural substance formed by the reaction of fermenting sugar with yeast spores. 2. Patterns of use >Phase I. Prealcoholic phase: Characterized by use of alcohol to relieve everyday stress and tensions of life -As a child, the individual may have observed parents or other adults drinking alcohol and enjoying the effects. -Tolerance develops, and the amount required to achieve the desired effect increases steadily. >Phase II. Early alcoholic phase: Begins with blackouts—brief periods of amnesia (partial or total loss of memory) that occur during or immediately following a period of drinking; alcohol is now required by the person -Common behaviors include sneaking drinks or secret drinking, preoccupation with drinking and maintaining the supply of alcohol, rapid gulping of drinks, and further blackouts. -The individual feels enormous guilt and becomes very defensive about his or her drinking. >Phase III. The crucial phase: Person has lost control; physiological dependence is clearly evident -addiction is evident -These episodes are characterized by sickness, loss of consciousness, squalor (dirty & unpleasant), and degradation. In this phase, the individual is extremely ill. Anger and aggression are common manifestations. By this phase of the illness, it is not uncommon for the individual to have experienced the loss of job, marriage, family, friends, and most especially, self-respect. >Phase IV. The chronic phase: Characterized by emotional and physical disintegration. The person is usually intoxicated more often than sober. -Emotional disintegration is evidenced by profound helplessness and self-pity -Impairment may result in psychosis -Life-threatening physical manifestations may be evident in virtually every system of the body -Unmanaged withdrawal from alcohol results in a terrifying syndrome of symptoms that include hallucinations, tremors, convulsions, severe agitation, and panic -Depression and ideas of suicide are not uncommon. For long term, heavy drinkers, abrupt withdrawal of alcohol can be fatal. **Alcohol exerts a depressant effect on the CNS, resulting in behavioral and mood changes. The effects of alcohol on the CNS are proportional to the alcoholic concentration in the blood. Alcohol can be harmless and enjoyable if used in moderation, but like any other mind-altering drug, has the potential for abuse**

Alcohol intoxication and withdrawal

1. Alcohol intoxication -Occurs at blood alcohol levels between 100 and 200 mg/dL *Symptoms of alcohol intoxication include disinhibition of sexual or aggressive impulses, mood lability, impaired judgment, impaired social or occupational functioning, slurred speech, incoordination, unsteady gait, nystagmus, and flushed face 2. Alcohol withdrawal -Occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use *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; and insomnia. In about 1% of alcoholic patients complicated withdrawal syndrome may progress to alcohol withdrawal delirium and concomitant medical problems may increase the risk.

Bulimia nervosa

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

Concepts of Death

Concepts of death: developmental issues -All individuals have their own unique concept of death, which is influenced by past experiences with death as well as age and level of emotional development. Children -Birth to age 2: Unable to understand death but can experience the feelings of loss and separation -Ages 3 to 5: Have some understanding about death but have difficulty distinguishing between fantasy and reality; believe death is reversible ex) For example, they may believe that their thoughts or behaviors caused a person to become sick or to die. -Ages 6 to 9: Beginning to understand the finality of death; difficult to perceive their own death; normal grief reactions include regressive and aggressive behaviors. They are able to understand a more detailed explanation of why or how a person died, although the concept of death is often associated with old age or with accidents. *they believe death is contagious -Ages 10 to 12: Understand that death is final and eventually affects everyone; feelings of anger, guilt, and depression are common; peer relations and school performance may be disrupted *They may ask questions about how the death will affect them personally Adolescents -Usually able to view death on an adult level -Have difficulty perceiving their own death -May or may not cry; may withdraw -May exhibit acting-out behaviors Elderly adults -A time in life of the convergence of many losses and mourning has become a life-long process -May lead to "bereavement overload" -Bereavement overload may result in depression

Application of the Nursing Process to IDD

1. Assessment -The extent of severity of IDD may be measured by the client's IQ level -Four levels have been delineated 1. Mild: Is capable of developing social skills and independent living, with assistance; IQ 50 to 70 2. Moderate: Capable of academic skill to second grade level; IQ 35 to 49 3. Severe: May be trained in elementary hygiene skills; requires complete supervision; IQ 20 to 34 4. Profound: . No capacity for independent functioning; IQ below 20. *The levels are differentiated between the ability of the child to perform self-care, cognitive and educational abilities, social and communication capabilities, and psychomotor capabilities. 2. Possible nursing diagnoses include -Risk for injury related to altered physical mobility or aggressive behavior -Self-care deficit related to altered physical mobility or lack of maturity -Impaired verbal communication related to developmental alteration -Impaired social interaction related to speech deficiencies or difficulty adhering to conventional social behavior -Delayed growth and development related to isolation from significant others, inadequate environmental stimulation, genetic factors -Anxiety (moderate to severe) related to hospitalization and absence of familiar surroundings -Defensive coping related to feelings of powerlessness and threat to self-esteem -Ineffective coping related to inadequate coping skills secondary to developmental delay The client -Has experienced no physical harm -Has had self-care needs fulfilled -Interacts with others in a socially appropriate manner -Has maintained anxiety at a manageable level -Is able to accept direction without becoming defensive -Demonstrates adaptive coping skills in response to stressful situations *Although the plan of care is directed toward the individual client, it is essential that family members or primary caregivers participate in the ongoing care of the client with IDD.* clients' families need to receive information regarding -The scope of the client's condition -Realistic expectations and client potentials -Methods for modifying behavior as required -Community resources from which they may seek assistance and support

Indicators of Neglect

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

Predisposing Factors to ASD

1. Neurological implications -Abnormalities in brain structure or function *Total brain volume, the size of the amygdala, and the size of the striatum have all been identified as enlarged in very young children and there is evidence of a decrease in size over time. -Role of neurotransmitters under investigation 2. Genetics -Familial association -Chromosomal involvement *About 15 percent of ASD cases are related to a known genetic mutation; in most cases, its expression is related to multiple genes. DNA studies have implicated areas on several chromosomes which contain genes that may contribute to the development of autism spectrum disorder. 3. Prenatal and perinatal influences -Maternal asthma or allergies *Some of the prenatal risk factors that have been associated with development of ASD include advanced parental age, fetal exposure to valproate, gestational diabetes, and gestational bleeding.

Interdisciplinary team

1. Nurses 2. Attendants: These individuals are usually the members of the team who spend the most time with the client. They assist with personal care and all activities of daily living. 3. Physicians: have input into the care of the hospice client. Orders may continue to come from the primary physician, whereas pain and symptom management may come from the hospice consultant. 4. Social workers: The social worker assists the client and family members with psychosocial issues, including those associated with the client's condition, financial issues, legal needs, and bereavement concerns 5. Trained volunteers: Volunteers are vital to the hospice concept. They provide services that may otherwise be financially impossible. They are specially selected and extensively trained, and they provide services such as transportation, companionship, respite care, recreational activities, light housekeeping, and in general are sensitive to the needs of families in stressful situations. 6. Rehabilitation therapists: Physical therapists may assist hospice clients in an effort to minimize physical disability. 7. Dietitian: A nutritional consultant may be helpful to the hospice client who is experiencing nausea and vomiting, diarrhea, anorexia, and weight loss 8. Counseling services: The hospice client may require the services of a psychiatrist or psychologist if there is a history of mental illness, or if neurocognitive disorder or depression has become a problem.

Goals/Interventions for Denial

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

Obesity

Defined as a condition in which an individual accumulates abnormal or excessive fat for age and gender that exceeds overweight -Encourage diary of food intake -Goals should include verbalizing an understanding of what must be done to lose weight and changing eating patterns to result in steady weight loss -Interventions should include discussing feelings and emotions associated with eating, formulating an eating plan, and identifying realistic goals for weekly weight loss. *identify realistic incremental goals for weekly weight loss ex) 1-2 pounds per week *provide education about weight suppressants drugs

Nursing Diagnosis-ADHD

1. Risk for injury related to impulsive and accident-prone behavior and the inability to perceive self-harm *interventions: identify behaviors that put the child at risk, provide supervision 2. Impaired social interaction related to intrusive and immature behavior *interventions: discuss with client behaviors that are and not acceptable 3. Low self-esteem related to dysfunctional family system and negative feedback *ST goals: cleint independently directs own care and activities of ADL *interventions: 4. Noncompliance with task expectations related to low frustration tolerance and short attention span *client participates and cooperates during therapeutic activities The client -Has experienced no physical harm -Interacts with others appropriately -Verbalizes positive aspects about self -Demonstrates fewer demanding behaviors -Cooperates with staff in an effort to complete assigned tasks Nursing interventions for the child with ADHD are aimed at -Ensuring that client remains free of injury -Encouraging appropriate interactions with others -Increasing feelings of self-worth -Fostering motivation for compliance with tasks The client -Has not harmed self or others -Interacts with others in a socially appropriate manner -Accepts direction without becoming defensive -Demonstrates evidence of increased self-esteem by discontinuing exploitative and demanding behaviors toward others

ASD Nursing Diagnoses

1. Risk for self-mutilation or self-injury related to neurological alterations 2. Impaired social interaction related to inability to trust and neurological alterations, evidecne by lack of responsivenss to, or intesrest in, people >ST goal: client demonstrates trust in one caregiver >LT goal: client initiates social interactions with caregiver by time of discharge 3. Impaired verbal communication related to withdrawal into the self; neurological alterations, evidence by inability or unwillingness to speak; lack of nonverbal communication 4. Disturbed personal identity related to neurological alterations; delayed developmental stage, evidence by difficulty seperating needs and personal boundaries from those of others ST goals: client names own body parts as separate and individuals from those of otehs LT goals: client develops ego indentity (able to recognize physical and emotional self as seperate from others) by time of discharge Interventions: assist child in learning to name own body parts. This can be done by mirror drawing and pictures of child The client -Exhibits no evidence of self-harm -Interacts appropriately with at least one staff member -Demonstrates trust in at least one staff member -Is able to communicate so that he or she can be understood by at least one staff member -Demonstrates behaviors that indicate he or she has begun the separation/individuation process

Body Mass Index

A BMI range for normal weight is 20 to 24.9. Obesity is defined as a BMI of 30 or greater. **Anorexia nervosa is characterized by a BMI of 17 or lower, or less than 15 in extreme cases** -Formula: Weight (kg) / Height (m2)

Intellectual developmental disorder (IDD)

A disorder marked by intellectual functioning and adaptive behavior that are well below average. Previously called mental retardation. Defines intellectual disability as a "disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains" Onset prior to age 18 years and is characterized by impairments in measured intellectual performance and adaptive skills across multiple domains.

Advance directives

A living will or durable power of attorney for health care Allows an individual to provide directions about his or her future medical care Allow the client to be in control of decisions at the end of life Spare family and loved ones the burden of making choices without knowing what is most important to the person who is dying Doctors usually follow clearly stated directives *It is important that the physician be informed that an advance directive exists and what the specific wishes of the client are Reasons why advance directives are sometimes not honored -The advance directive is not available at the time treatment decisions need to be made. This is especially true in emergency situations. -The advance directive is not clear. Statements such as "no heroic measures" can be interpreted in many different ways. -The health-care proxy is unsure of the client's wishes.

Inhalant Use Disorder

A profile of the substance -Aliphatic and aromatic hydrocarbons found in substances, such as fuels, solvents, adhesives, aerosol propellants, and paint thinners -Inhalant substances are readily available, legal, and inexpensive, three factors that make them attractive to children, teens, and young adults. Highest usage is by youths ages 12 to 17, and this is the only class of drugs used more frequently by younger rather than older teens. ex) *gasoline *varnish remover *lighter fluid *airplane glue *rubber cement *cleaning fluid *spray paint *shoe conditioner *gasoline Historical aspects -Use for altered consciousness or for religious rituals dates back to ancient times Patterns of use -Huffing: a procedure in which a rag soaked with the substance is applied to the mouth and nose and the vapors inhaled -Bagging: in which the substance is placed in a paper or plastic bag from which it is inhaled by the user -Inhaled through mouth or nose

Hospice

A program that provides palliative and supportive care to meet the special needs of people who are dying and their families Provides physical, psychological, spiritual, and social care for the person for whom aggressive treatment is no longer appropriate Pain and symptom management -Client is kept as comfortable as possible in all stages of the terminal illness. Emotional support -Client and family are encouraged to discuss the eventual outcome of the disease process. Hospice philosophy supports the individual's right to seek guidance or comfort in the spiritual practices most suited to that person. Care: Pastoral and spiritual care Bereavement counseling 24-hour on-call Staff support

Chronic or prolonged grieving

A prolonged grief process may be considered maladaptive when certain behaviors are exhibited. -Behaviors aimed at keeping the lost loved one alive -Behaviors that prevent the bereaved from adaptively performing activities of daily living ex) In some cultures, establishing a memorial ritual to the deceased is the norm, where in other cultures it might be perceived as prolonged grieving.

Codependency

Defined by dysfunctional behaviors that are evident among members of the family of a chemically dependent person, or among family members who harbor secrets of physical or emotional abuse, other cruelties, or pathological conditions -The concept of codependency arose out of a need to define the dysfunctional behaviors that are evident among members of the family of a chemically addicted person. The term has been expanded to include all individuals from families that harbor secrets of physical or emotional abuse, other cruelties, or pathological conditions. -Codependent people sacrifice their own needs for the fulfillment of others to achieve a sense of control. -Derives self-worth from others/partners, whose feelings and behaviors determine how the codependent should feel and behave -Feels responsible for the happiness of others -Commonly denies that problems exist -Codependent's home life is fraught with stress -Keeps feelings in control, and often releases anxiety in the form of stress-related illnesses, or compulsive behaviors, such as eating, spending, working, or use of substances -May have experienced abuse or emotional neglect as a child -Outwardly focused on others and know very little about how to direct their lives from their own sense of self *Personal identity is relinquished and boundaries with the other person become blurred. The codependent person disowns his or her own needs and wants in order to respond to external demands and the demands of others. Codependence has been called "a dysfunctional relationship with oneself." *In order for the codependent to feel good, his or her partner must be happy and behave in appropriate ways. If the partner is not happy, the codependent feels responsible for making him or her happy. Wesson describes the following behaviors characteristic of codependency. She stated that codependents: 1. Have a long history of focusing thoughts and behavior on other people 2. Are "people pleasers" and will do almost anything to get the approval of others 3. Outwardly appear very competent, but actually feel quite needy, helpless, or perhaps nothing at all 4. Have experienced abuse or emotional neglect as a child 5. Are outwardly focused towards others, and know very little about how to direct their own lives from their own sense of self

Treatment Modalities for Substance-Related Disorders

Alcoholics Anonymous (AA) -A major self-help organization for the treatment of alcoholism -Based on the concept of: 1. Peer support: acceptance and understanding from others who have experienced the same problems in their lives. 2. Acceptance 3. Understanding from others who have experienced the same problem -The 12 steps that embody the philosophy of AA provide specific guidelines on how to attain and maintain sobriety. -Total abstinence is promoted as the only cure; the person can never safely return to social drinking. *Each new member is assigned a support person from whom he or she may seek assistance when the temptation to drink occurs. AA provides a Twelve Step process to achieving and maintaining sobriety. These steps include: 1. Admitting powerlessness over alcohol 2. Believing that a greater power could restore sanity 3. Make a decision to turn lives over to the care of God 4. Making a moral inventory 5. Admitting wrongs 6. Become ready to have God remove defects of character 7. Ask God to remove shortcomings 8. Make a list of all persons harmed 9. Made direct amends to such people wherever possible except when to do so would injure them or others 10. Continued to take personal inventory admit wrongdoing 11. Seek to improve conscious contact with God 12. Carry the message to other alcoholics ex) cocaine anonymous

The Chemically Impaired Nurse

Approximately 10 percent of the general population suffers from chemical addiction. The prevalence of substance abuse among employed nurses is estimated to be 5.1 percent. *Nurses who abuse substances have an added vulnerability because they are often handling controlled substances when providing patient care. Alcohol is the most widely abused drug, followed closely by narcotics. Clues for recognizing substance impairment in nurses -High absenteeism may be present if the person's source is outside the work area. -Or, the person may rarely miss work if the substance source is at work. -there may be an increase in wasting of drugs, higher incidence of incorrect narcotic counts, and a higher record of signing out drugs than for other nurses -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 State board response -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. During the suspension period: -Successful completion of an inpatient, outpatient, group, or individual counseling treatment program -Evidence of regular attendance at nurse support groups or 12-step program -Random negative drug screens -Employment or volunteer activities -When a nurse is deemed safe to return to practice, he or she may be closely monitored for several years and required to undergo random drug screenings.

Application of the Nursing Process to ASD

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

Autism Spectrum Disorder

Autism spectrum disorder (ASD) -Characterized by a withdrawal of the child into the self and into a fantasy world of his or her own creation -Autism spectrum disorder is a heterogenous group of neurodevelopmental syndromes characterized by a wide range of communication impairments and restricted, repetitive behaviors. -The child has abnormal or impaired development in social interaction and communication and a restricted repertoire of activity and interests, some of which may be considered somewhat bizarre -Prevalence is about 1 in 68 children -ASD occurs more often in boys than in girls -Onset occurs in early childhood -ASD often runs a chronic course

Predisposing Factors to IDD

Genetic factors -Cause of disability in approximately 5 percent of cases -Inborn errors of metabolism: Tay-Sachs disease, phenylketonuria, and hyperglycinemia -Chromosomal disorders: down syndrome & Klinefelter's syndrome -Single gene abnormalities: fragile X syndrome, tuberous sclerosis and neurofibromatosis. Disruptions in embryonic development -Conditions that result in early alterations in embryonic development account for approximately 30 percent of intellectual disability cases. -Toxicity associated with maternal ingestion of alcohol or other drugs -Maternal illnesses and infections during pregnancy can result in congenital intellectual disability -Complications of pregnancy ex) Fetal alcohol syndrome is an example and this disorder has been identified as one of the leading preventable causes of intellectual disability!!!! Pregnancy and perinatal factors -Approximately 10 percent of cases of intellectual disability are the result of circumstances that occur during pregnancy or during the birth process. ex) trauma to the head incurred during the process of birth, placenta previa or premature separation of the placenta, and prolapse of the umbilical cord. General medical conditions acquired in infancy or childhood -Account for approximately 5 percent of cases -Infections (e.g., meningitis, encephalitis) -Poisonings (e.g., insecticides, medications, lead) -Physical traumas (e.g., head injuries, asphyxiation, hyperpyrexia) Sociocultural and other mental disorders -Between 15 and 20 percent of cases may be attributed to deprivation of nurturance and social stimulation and to impoverished environments associated with poor prenatal and perinatal care and inadequate nutrition. -Severe mental disorders, such as autism spectrum disorder

Predisposing Factors

Genetics -Apparent hereditary factor, particularly with alcoholism -Children of alcoholics are four times more likely than other children to become alcoholics Biochemistry -Although evidence shows that changes in brain structure and brain neurochemistry occur in the process of developing addiction, whether these changes wholly explain etiology remains controversial. Sociocultural factors 1. Social learning -Children and adolescents are more likely to use substances with parents who provide model for substance use. -Use of substances may also be promoted within peer group. 2. Conditioning -Pleasurable effects from substance use act as a positive reinforcement for continued use of substance. 3. Cultural and ethnic influences -Some cultures are more prone to substance abuse than are others. ex) a high incidence of alcohol addiction has existed within the Native American culture, whereas the incidence of alcohol addiction among Asians is relatively low

Theoretical Perspectives

Grief is deep mental and emotional anguish that is a response to the subjective experience of loss of something significant. The stages of the grief process were identified by Kübler-Ross in her extensive work with dying patients. Behaviors associated with each of these stages can be observed in individuals experiencing the loss of any concept of personal value. -Stage I: Denial -Stage II: Anger -Stage III: Bargaining -Stage IV: Depression -Stage V: Acceptance

CAGE Questionnaire

Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)?

Profile of the victimizer-rape

It is difficult to profile a rapist -Sexual sadists who are aroused by inflicting pain -Exploitative predators who are using the victim to gratify needs such as dominance and power -Inadequate men who are obsessed with fantasies of sex that they believe can't be achieved without force -Those displacing anger *Statistics show that the greatest number of rapists are between the ages of 25 and 44. Of rapists, 54 percent are white, 32 percent are African-American, and the remainder are of other races, mixed race, or of unknown race

Stimulant withdrawal

KNOW THIS! **Stimulant withdrawal is often referred to as "crashing." Symptoms include fatigue, cramps, depression, headaches, and nightmares. The dysphoria can be intense enough to result in increased risk for suicide. Peak withdrawal symptoms usually occur within 2-4 days of abstinence*** Anxiety, depressed mood, insomnia or hypersomnia, craving for the drug, suicidal ideas (with amphetamines and cocaine) -Amphetamine and cocaine withdrawal may result in dysphoria, fatigue, sleep disturbances, and increased appetite. -Withdrawal from caffeine may include headache, fatigue, drowsiness, irritability, muscle pain and stiffness, and nausea and vomiting. *The symptoms begin within 24 hours after last consumption -Withdrawal from nicotine may include dysphoria, anxiety, difficulty concentrating, irritability, restlessness, and increased appetite. -results in dysphoric or depressed mood; insomnia; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; and increased appetite or weight gain.

Stimulant intoxication

KNOW THIS! Produces maladaptive behavioral and psychological changes that develop during or shortly after use of these drugs! Amphetamine and cocaine intoxication produce euphoria, impaired judgment, confusion, and changes in vital signs (even coma or death, depending on amount consumed). Caffeine intoxication usually occurs following consumption in excess of 250 mg. Symptoms include restlessness, nervousness, excitement, insomnia, flushed face, diuresis, GI disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, and psychomotor agitation ***Restlessness and insomnia are the most common symptoms!!!! Euphoria, grandiosity, fighting, elevated vital signs, nausea and vomiting, psychomotor agitation

Withdrawal Assessment of Alcohol Tool

KNOW THIS!!! 1) Assess N/V 2) Assess Tremors (hold their hands out with fingers spread and observe) 3) Assess Tactile disturbances (Has pt had any itching, pins & needles, numbness, burning) 4) Auditory disturbances (Is pt more aware of sounds) 5) Assess for Paroxysmal sweats (6) Assess anxiety 7) Assess agitation 8) Assess visual disturbances (Light too bright) 9) Assess for HA or fullness in head 10) Assess orientation and clouding of sensorium (Where are you? What day is it? etc)-Will rate all of these symptoms

Opioid Use Disorder

Opioids exert both a sedative and an analgesic effect, and their major medical uses are for the relief of pain, the treatment of diarrhea, and the relief of coughing. Under close supervision, opioids are indispensable in the practice of medicine. They are the most effective agents known for the relief of intense pain. However, they also induce a pleasurable effect on the CNS that promotes their abuse. Drugs include: -Demerol -Hydrocodone -Morphine -Heroine -Dilaudid A profile of the substance -Opioids of natural origin -Opioid derivatives -Synthetic opiate-like drugs Patterns of use -Obtained by prescription for relief of a medical problem -Use for recreational purposes and obtain by illegal sources

Conduct Disorder

Persistent pattern of behavior in which the basic rights of others and major age-appropriate societal norms or rules are violated -Childhood-onset type -Adolescent-onset type Predisposing factors 1. Biological influences -Genetics -Temperament -Biochemical factors 2. Psychosocial influences -Peer relationships -Family influences -Parental rejection -Inconsistent management with harsh discipline -Early institutional living -Frequent shifting of parental figures -Large family size -Absent father -Parents with antisocial personality disorder, alcohol dependence -Marital conflict and divorce -Inadequate communication patterns -Parental permissiveness

Hallucinogens: Effects on the Body

Physiological -Nausea/vomiting -Chills -Pupil dilation -Increased blood pressure, pulse -Loss of appetite -Insomnia -Sweating, trembling -Elevated blood sugar -Decreased respirations Psychological -Heightened response to color, sounds, body -Distorted vision -Sense of slowed time -Fear of control loss -Magnified feelings -Paranoia, panic -Euphoria, peace -Depersonalization -Derealization -Increased libido **Flashbacks, or spontaneous repetition of a previous experience may occur in the absence of the substance** Intoxication -Intoxication occurs during or shortly after using the drug. -Symptoms include perceptual alteration, depersonalization, derealization, tachycardia, and palpitations. -Symptoms of phencyclidine (synthetic compound) intoxication include belligerence (aggressive) and assaultiveness, and may proceed to seizures or coma. -General effects of MDMA (Ecstasy) include increased heart rate, blood pressure, and body temperature; dehydration; confusion; insomnia; and paranoia. -Maladaptive behavioral or psychological changes include marked anxiety or depression, ideas of reference, fear of losing one's mind, paranoid ideation, and impaired judgment -Because hallucinogens are SYMPATHOMIMETICS, they can cause tachycardia, hypertension, sweating, blurred vision, papillary dilation, and tremors

Survivors of Abuse or Neglect

Predisposing Factors: Biological theories 1. Neurophysiological influences -Temporal lobe -Limbic system -Amygdaloid nucleus: lower volume of the amygdala plays a role in aggression. The amygdala is responsible for impulse control 2. Biochemical influences -Norepinephrine -Serotonin: LOW levels associated with increase in impulsivity and aggression -Dopamine: HIGH levels associated with aggression 3. Genetic influences -Possible hereditary factor *Studies have found a potential role for a gene in the etiology of antisocial behaviors and this may have implications for impulsivity and aggression -Genetic karyotype XYY has been implicated 4. Disorders of the brain -Organic brain syndromes -Brain tumors/trauma -Encephalitis -Temporal lobe epilepsy *Psychological theories 1. Learning theory -Children learn to behave by imitating their role models -Individuals who were abused as children or whose parents disciplined with physical punishment are more likely to behave in an abusive manner as adults *Sociocultural theories 1. Societal influences -Aggressive behavior is primarily a product of one's culture and social structure. -American culture was founded on a general acceptance of violence as a means of solving problems. -Societal influences also contribute to violence when individuals realize that their needs and desires are not being met relative to other people. -Poverty, prolonged unemployment, family breakdown, and exposure to violence in the community and in the family have all been linked to increases in aggression.

Fetal alcohol syndrome (FAS)

Prenatal exposure to alcohol can result in a broad range of disorders to the fetus, known as fetal alcohol spectrum disorders (FASDs), the most common of which is fetal alcohol syndrome (FAS) -Fetal alcohol syndrome (FAS) includes problems with learning, memory, attention span, communication, vision, and hearing. -Alcohol-related neurodevelopmental disorder -Alcohol-related birth defects -No amount of alcohol during pregnancy is considered safe, and alcohol can damage a fetus at any stage of pregnancy. -Women with alcohol-related disorders have a 35% risk of having a child with defects. Children with FAS may have the following characteristics or exhibit these characteristic behaviors. Characteristics of FAS: *Abnormal facial features *Small head size *Shorter-than-average height *Low body weight *Poor coordination *Hyperactive behavior *Difficulty paying attention *Poor memory *Difficulty in school *Learning difficulties *Speech and language delays *Intellectual disability *Poor reasoning skills *Sleep and sucking problems as a baby *Vision or hearing problems *Problems with the heart, kidneys, or bones

Goals/Interventions for Imbalanced Nutrition and Deficient Fluid Volume

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

Rape trauma syndrome

Rape trauma syndrome has two emotional patterns of response that may occur within hours after a rape and with which healthcare workers may be confronted in the emergency department or rape crisis center. 1. Expressed response pattern: the survivor expresses feelings of fear, anger, and anxiety through such behaviors as crying, sobbing, restlessness, and tension 2. Controlled response pattern: feelings are masked or hidden, and a calm, composed, or subdued affect is seen The following manifestations may be evident in the days and weeks after the attack: -Contusions and abrasions about various parts of the body -Headaches, fatigue, sleep pattern disturbances -Stomach pains, nausea and vomiting -Vaginal discharge and itching, burning upon urination, rectal bleeding and pain -Rage, humiliation, embarrassment, desire for revenge, and self-blame -Fear of physical violence and death Victim responses -Expressed response pattern, the survivor expresses feelings of fear, anger, and anxiety through such behaviors as crying, sobbing, restlessness, and tension -Controlled response pattern, the feelings are masked or hidden, and a calm, composed, or subdued affect is seen. -Compounded rape reaction, in which additional symptoms such as depression and suicide, substance abuse, and even psychotic behaviors may be noted -Silent rape reaction, in which the survivor tells no one about the assault *Anxiety is suppressed and the emotional burden may become overwhelming. The unresolved sexual trauma may not be revealed until the woman is forced to face another sexual crisis in her life that reactivates the previously unresolved feelings.

Rape

Rape, a type of sexual assault, occurs over a broad spectrum of experiences ranging from the surprise attack by a stranger to insistence on sexual intercourse by an acquaintance or spouse. 1. Acquaintance rape (or date rape if the encounter is a social engagement agreed to by the victim) is a term applied to situations in which the rapist is acquainted with the victim. They may be out on a first date, may have been dating for a number of months, or merely may be acquaintances or schoolmates. College campuses are the location for a large number of these types of rapes. 2. Marital rape which has been recognized only in recent years as a legal category, is the case in which a spouse may be held liable for sexual abuse directed at a marital partner against that person's will 3. Statutory rape is defined as unlawful intercourse between a person who is over the age of consent and a person who is under the age of consent. The legal age of consent varies from state to state, ranging from age 14 to 18.

ABUSE & NEGLECT Diagnosis/Outcome Identification

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

Binge eating disorder (BED)

Recurrent episode of eating significantly more than most people would eat in a similar time period under similar circumstances. -An eating disorder that can lead to obesity. -Individual binges on large amounts of food, as in bulimia nervosa. -BED differs from bulimia nervosa in that the individual does not engage in behaviors to rid the body of the excess calories. -50 percent of individuals with BED have a history of depression.

Sexual Violence

Sexual violence is often equated with rape, but that is only one type of sexual assault. Healthcare providers must be aware sexual violence includes any act of sexual coercion including penetration, unwanted sexual contact, and noncontact unwanted sexual experiences. -Rape *The expression of power and dominance by means of sexual violence, most commonly by men over women, although men may also be rape victims. Sexual assault is any type of sexual act in which an individual is threatened or coerced, or forced to submit against his or her will. Rape is an act of aggression, not passion.!!!!

Five stages of grief

Stage I: Denial -In this stage the individual has difficulty believing that the loss has occurred. This stage may protect the individual against the psychological pain of reality. Stage II: Anger -This is the stage when reality sets in. Feelings associated with this stage include sadness, guilt, shame, helplessness, and hopelessness. Self-blame or blaming of others may lead to feelings of anger toward the self and others. Stage III: Bargaining -At this stage in the grief response, the individual attempts to strike a bargain with God for a second chance, or for more time. The person acknowledges the loss, or impending loss, but holds out hope for additional alternatives. Stage IV: Depression -In this stage, the individual mourns for that which has been or will be lost. This is a very painful stage, during which the individual must confront feelings associated with having lost someone or something of value (called reactive depression). An example might be the individual who is mourning a change in body image. Feelings associated with an impending loss (called preparatory depression) are also confronted. Stage V: Acceptance -At this time, the individual has worked through the behaviors associated with the other stages and accepts or is resigned to the loss. Anxiety decreases, and methods for coping with the loss have been established.

Substance addiction

Substance addiction -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 **Individuals are considered to have a substance use disorder when use of the substance interferes with their ability to fulfill role obligations, such as at work, school, or home. Often the individual would like to cut down or control use of the substance, but attempts fail, and use of the substance continues to increase. -Use of the substance causes the person difficulty with interpersonal relationships or to become socially isolated. -The person engages in hazardous activities when impaired by the substance, when they are impaired by the substance, and continue to use the substance despite knowing that its use is contributing to a physical or psychological problem -Tolerance develops, and the amount required to achieve the desired effect increases. -Substance-specific symptoms occur upon discontinuation of use. -There is an intense craving for the substance

Psychopharmacology for substance intoxication and substance withdrawal

Substitution therapy may be required to reduce the life-threatening effects -Substitution therapy may be required to reduce the life-threatening effects of intoxication or withdrawal from some substances. The severity of the withdrawal syndrome depends on the particular drug used, how long it has been used, the dose used, and the rate at which the drug is eliminated from the body. Alcohol -Benzodiazepines most widely used drug dor alcohol withdrawal ex) Chlordiazepoxide (Librium), oxazepam (Serax), lorazepam (Ativan), and diazepam (Valium) -Anticonvulsants -Multivitamin therapy *in combination with daily injections or oral administration of thiamine, is common protocol -Thiamine *most commonly deficient in alcoholics Opioids -Narcotic antagonists 1. Naloxone (Narcan) 2. Naltrexone (ReVia) 3. Nalmefene (Revex) -Methadone *is given on the first day in a dose sufficient to suppress withdrawal symptoms. The dose is then gradually tapered over a specified time -Buprenorphine *Buprenorphine is less powerful than methadone but is considered to be somewhat safer and causes fewer side effects. -Clonidine *also has been used to suppress opiate withdrawal symptoms. As monotherapy, it is not as effective as substitution with methadone, but it is nonaddicting. Stimulants -Minor tranquilizers ex) chlordiazepoxide -Major tranquilizers ex)haloperidol (Haldol) *Antipsychotics should be administered with caution because of their propensity to lower seizure threshold. -Anticonvulsants -Antidepressants *Treatment is usually aimed at reducing drug craving and managing severe depression. The client is placed in a quiet atmosphere and allowed to sleep and eat as much as is needed or desired. Suicide precautions may need to be instituted. Antidepressant therapy may be helpful in treating symptoms of depression. Hallucinogens and cannabinols -Benzodiazepines *Substitution therapy is not required with these drugs, but when adverse reactions, such as anxiety or panic, occur, benzodiazepines (e.g., diazepam or chlordiazepoxide) may be prescribed to prevent harm to the client or others. -Antipsychotics *Psychotic reactions may be treated with antipsychotic medications.

outcomes of eating disorders

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

Evaluation

The final step of the nursing process involves reassessment. This determines if the nursing interventions have been effective in achieving the intended goals of care. Evaluation of the client with a substance-related disorder may be accomplished by using information gathered from the reassessment questions.

Nursing Process: Assessment

The nurse must examine his or her feelings about working with a client who abuses substances. If behaviors are viewed by the nurse as morally wrong it may be difficult to suppress judgmental feelings. Nurses must begin relationship development with a substance abuser by examining own attitudes and personal experiences with substances. Motivational interviewing: It uses skills like empathy, validation, open-ended questions, and reflection to explore the client's motivation, strengths, and readiness for change. -Used for clients with any disorder Various assessment tools are available for determining the extent of the problem a client has with substances. 1. Drug history and assessment 2. Clinical Institute Withdrawal Assessment of Alcohol Scale -The Clinical Institute Withdrawal Assessment of Alcohol Scale is an excellent tool that is used by many hospitals to assess risk and severity of withdrawal from alcohol -It may be used for initial assessment as well as ongoing monitoring of alcohol withdrawal symptoms 3. Michigan Alcoholism Screening Test (MAST) 4. CAGE Questionnaire -Some psychiatric units administer these surveys to all clients who are admitted to help determine if there is a secondary alcoholism problem in addition to the psychiatric problem for which the client is being admitted.

Rape survivors

Those who present themselves for care shortly after the crime occurred likely are experiencing an overwhelming sense of violation and helplessness that began with the powerlessness and intimidation experienced. The long-term effects of sexual assault depend largely on the individual's ego strength, social support system, and the way he or she was treated as a victim.

Cycle of battering

Three distinct phases Phase I: Tension-building phase -During this phase, the woman senses that the man's tolerance for frustration is declining. He becomes angry with little provocation but, may be quick to apologize. The woman may become very nurturing and compliant, anticipating his every whim in an effort to prevent his anger from escalating. She may just try to stay out of his way. -Minor battering incidents may occur during this phase and the woman accepts the abuse as legitimately directed toward her. She assumes the guilt for the abuse. -The minor battering incidents continue, and the tension mounts as the woman waits for the impending explosion. -The abuser begins to fear that his partner will leave him. His jealousy and possessiveness increase. Phase I may last from a few weeks to many months or even years. Phase II: Acute battering incident -This phase is the most violent and the shortest, usually lasting up to 24 hours -It most often begins with the batterer justifying his behavior to himself. By the end of the incident, however, he cannot understand what has happened, only that in his rage he has lost control over his behavior -Having come to a point in phase I in which the tension is unbearable, long-term battered women know that once the acute phase is behind them, things will be better -The beating is severe, and many women can describe the violence in great detail, almost as if dissociation from their bodies had occurred. The batterer generally minimizes the severity of the abuse!!!! ***TRIGERRING EVENT OCCURS AND THIS IS WHAT CAUSES PHASE 2 TO OCCUR*** Phase III: Calm, loving, respite (honeymoon) phase -In this phase, the batterer becomes extremely loving, kind, and contrite -He promises that the abuse will never recur and begs her forgiveness -He believes he now can control his behavior, and because now that he has "taught her a lesson," he believes she will not "act up" again -During this phase the woman relives her original dream of ideal love and chooses to believe that this is what her partner is really like Why do they stay? -Fear for their lives or the lives of their children *Probably the most common response that battered women give for staying is that they fear for their life and/or the lives of their children -Fear of retaliation by the partner -Fear of losing custody of their children -Lack of financial resources -Lack of a support network -Cultural/religious reasons -Hopefulness -Lack of attention to the danger

Maladaptive Responses to Loss

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

Substance Use Disorder

Two groups of substance-related disorders 1. Substance-use disorders: addiction 2. Substance-induced disorders: intoxication, withdrawal, delirium, neurocognitive disorder, psychosis, bipolar disorder, depressive disorder, obsessive-compulsive disorder, anxiety disorder, sexual dysfunction, and sleep disorders Addiction -A primary chronic disease of brain reward, motivation, memory, and related circuitry where a dysfunction in these circuits is connected to an individual pathologically pursuing reward and or relief by substance use and other behaviors >SUBSTANCE ADDICTION IS PART OF SUBSTANCE USE DISORDER!