Personality Disorder; Patient Who is Angry; Child/Adolescent with Psych.-Mental Health Problems; Child Abuse

Data Collection and Assessment of APD

* Inability to follow social/legal norms resulting in: - property distraction - legal and illegal substance abuse - promiscuity - legal problems (DWI, prostitution, assaults, thefts) - spouse/child abuse - lying, truancy, fights, thefts, animal abuse in children (diagnosed as Conduct Disorder)

Implement Teaching

* Nature of Personality Problems: - S/S - Employment and interpersonal issues * Management of Personality Problems: - Self-awareness and communication - Crisis intervention - Med teaching - Group therapy - Assistance with substance abuse problems - Long-term therapy and follow up care

Evidence-Based Practice

* Nurses' attitudes affect outcomes for pt with BPD * Psychopaths: How can you spot one? * Use a dialectical Bhvr therapy and good communication * Bhvr interventions to help pts who harm themselves to improve coping skills

Common DM in BPD

* Primitive idealization; - unrealistically views others outside the self as "all good" * Splitting: others viewed as fluctuating b/w being good and bad * Projective Identification" - projection with bhvrs that control others and reinforce the projected thought

Evaluation

* Remember! ACTIONS speak louder than words (what they do is more important than what they say) * Demonstration of a bhvr change is more indicative of personal growth that the pt talking about changing bhvrs *** p. 610 and 615

Pt Outcomes for the "At Risk" Individual

* What can I do NOW? 1. no harm to others/self 2. maintains control of emotional response to anger 3. verbalizes less frustration. anxiety, and anger 4. stops (target) bhvr 5. communicates needs appropr. to staff 6. establishes at least one therapeutic relat-p with a member of the Tx team 7. ID own feelings of anger 8. ID triggers to anger 9. demonstrates knowledge of safe bhvr 10. ID self-responsibility for bhvr 11. manages anger appropr.: a. refrains from verbal outburst b. refrains from violating other's personal space c. displaces anger to a meaningful activities 12. ID consequences to aggressive bhvr

Substance Abuse and Mental Services Administration (SAMHSA) set forth a bold vision to reduce and ultimately eliminate the use of seclusion and restraint in bhvr-ral healthcare settings. Possible Options:

- Aesthetics - Exercise - Drop in centers - Recovery thorugh the arts - Comfort rooms - Service animals - Psych. advanced directives - Dispute resolution/mediation practices

Managemt of the PT at Risk for Other-Directed Violence

- Aggression rarely occurs suddenly and unexpectedly - Prevention in the BEST plan - Trust your own intuition when you feel that a person may be violent

Most mentally ill ppl do NOT commit violent acts against others

- Anger is NORMAL emotional response to frustration, displeasure or threat. - Positive bhvr-ral responses to anger are healthy for human beings (p. 197) - Negative bhvr-ral responses to anger are unhealthy and unsafe. Violent bhvr is an extremely unhealthy response to anger (p. 199)

Assessment of Angry Bhvr

- Clenched jaws - Frowning, glaring - Intense staring - Flushing of face and neck - Lip biting - Smirking grin - Dilated pupils - Pacing - Pounding fists - Heightened vigilance (suspicious) - Confrontation stance - Aggression toward objects (slamming doors) - Possession of a weapon *** Violence does not usually occur as an isolated act but rather as part of a process. Knowing this helps the nurse to ID the potential and choose the appropr. intervention.

Data Collection and Assessment of BPD: Behaviors/Features

- Demanding and needy - Fear of abandonment - Inability to sublimate causing chronic boredom and feelings of "emptiness"

Common DM in APD

- Denial - Projection - Rationalization - Other DM may occur depending on how the pt presents

Pt/Family Teaching

- How to manage Sx's - Anger management - Relaxation exercises - Expectations after D/C - Role of Meds - How to handle crisis - Crisis prevention plan - Early signs of relapse - Housing and social resources - Life skills training - Social skills - Problem solving/Communication - Assertiveness training - Conflict resolution

What Other Actions May Mandated Reporters Take?

- In addition to filing a report - Protective Custody - Legal Protection for Mandated Reporters: a. Immunity b. Confidentiality Consequences of Failing To Report Suspicion of Child Abuse: a. Class A Misdemeanor charge and b. Civil liability for the damages proximately caused by such failure

Features of Personality Disorder (PD)

- Inflexible, maladaptive long term traits - Pervasive failure to adapt to demands of everyday life causing functional impairment, subjective distress, and problems with self-identity - Begins in adolescence, characterizes adult life and may diminish in middle/old age

Implementation

- Maintain consistent and structured approach to decr. "staff splitting" (rotate staff) - State reality simply and in a neutral tone of voice - Set limits and boundaries in relat-p - Clarify pt distortions and misinterpretations - Encourage pt to seek out/work with the appropr. staff member who is assigned to him/her - Assist pt to strengthen ego by helping pt acknowledge/express feelings appropr. and accept responsibility for actions - Help pt cope with/control emotions - Utilize meds for Sx relief

Assessment in Ability to Meet Basic Needs

- Physiological Needs typically not a concern with these pts - Safety and Security Needs most evident (eg. love and belonging and self-esteem)

Data Collection and Assessment of APD - Behaviors/Features

- Poorly developed superigo and strong id tendencies - Persuasive and charming personality - Articulate, verbal, convincing arguments about ppl, have no empathy and exhibit lack remorse regarding their bhvr - Involved in illegal, criminal activities

Data Collection and Assessment of BPD

- Recurring crisis of chronic boredom, anger, depression, self-destructive acts and transient (intermittent) psychosis - Substance use/ppl abuse may occur - Weak, unstable ego causing poor sense of self and identity confusion/diffusion

Risk Factors - Diagnosis

- Schizophrenia - Depression - Bipolar - Substance abuse - APD - BPD - Intermittent explosive disorder - Neurocognitive Disorders

Prodormal Syndrome

- Strong precursor to activation of violent bhvr. - Overlapping feelings - anxiety, tension, verbal outbursts, profanity and incr-ng hyperactivity - Overlapping Bhvrs - rigit posture, clenched fists, defiant affect, talking in a rapid, raised voice, arguing, demanding, threatening, pounding, slamming - Do not occur in stages When the "prodromal syndrome" is assessed, quick management of the pt is necessary

NI - Expressing Feelings - Catharsis

- Therapeutic Relat-p - Promote interactions that incr. the pt's sense of trust - Use non-threatening body language - State to the pt what you see him doing and how you think they may be feeling - Determine if you understand the pt correctly - Encourage the pt to describe the experience to incr. awareness - Give positive verbal feedback when pt uses words to express his feelings

Assessment of Angry Words

- Threats of harm - Loud, demanding voice tone - Abrupt silence - Negative responses to staff requests - Sarcastic remarks - Pressured speech - Illogical responses - Yelling, screaming - Statements of fear and/or suspicion

NI - Safety

- Violence Precautions/Monitor Environment - Assign pt to a private room - Do not touch the pt - Respect personal space and boundaries - Offer the pt choices - Be sure that you are b/w the pt and the door - Stand a 45 degree angle to pt - Maintain eye contact but do not stare - Limit setting - be consistent and firm - Establish the expectation that pt will remain in control - Pharmacologic Management

Nurse Self-Assessment - Questions to Ask Yourself

- What s my level of self-esteem - How do I feel when someone around me gets angry? - How do I feel about caring for an angry pt? - How do I feel when ppl get angry at me? - How do I react? - What do I need to work on to be therapeutic and safe with my angry pts? - What causes me to become angry? - How do I know when I am angry? - How do I usually do with my anger? - What helps me to calm down?

Risk Factors - Past Hx (p. 198)

- being cruel to animals - setting fires - witnessing family violence - legal convictions - violent bhvr - frequent psych. hospital admissions - aggressive bhvr - emotional deprivation in childhood - substance use/abuse - impulsive bhvr/poor impulse control - early age of onset of psych Sx's - unpredictable bhvr

Background Assessment Data - ADHD

- difficulties in performing age-appropriate tasks. - - distractible and have extremely limited attention spans. - shift from one uncompleted activity to another. - Impulsivity, or deficit in inhibitory control - difficulty forming satisfactory interpersonal relationships. - behaviors that inhibit acceptable social interaction. - disruptive and intrusive in group endeavors. - difficulty complying with social norms. - aggressive or oppositional - regressive and immature behaviors. - Low frustration tolerance and outbursts of temper boundless energy, exhibiting excessive levels of activity, restlessness, and fidgeting. - continuously running, jumping, wiggling, or squirming. - greater than average number of accidents

Risk Factors - Current Feelings/Experiences

- helplessness - the inability to express anger to the person he/she is dependent upon for survival - poor frustration tolerance - ineffective coping skills - feelings of personal threat, rage, fear - intoxication - homicidal ideation - severe psychopathology - hallucination - delusions - suspicious agitation - escalating signs of anger - problems with environment a. space and location b. architectural design c. activity level d. staffing patterns - strong need for attention - ruminates (compulsively focused attention on the symptoms of one's distress, and on its possible causes and consequences, as opposed to its solutions)

There are Specific Times when Pts are Likely to Become Aggressive

- on admission - change of shift - meal times - evenings - visiting hours - in elevators - during periods of change

Borderline Personality Disorder

- refers to "border" b/w moderate and severe MI - individual cannot cope with stress of young/middle adulthood

Symptoms of AN

- underweight or even emaciated (excessively thin) - hypothermia, bradycardia, hypotension with orthostatic changes, peripheral edema, lanugo (fine, neonatal-like hair growth), and a variety of metabolic changes. - Amenorrhea (absence of menstruation)

Background Assessment Data - Conduct Disorder

- use of physical aggression in the violation of the rights of others. - The behavior pattern manifests itself in virtually all areas of the child's life (home, school, with peers, and in the community). - Stealing, lying, and truancy are common problems. The child lacks feelings of guilt or remorse. - The use of tobacco, liquor, or nonprescribed drugs, as well as the participation in sexual activities, occurs earlier than at the expected age for the peer group. Projection is a common defense mechanism. - Low self-esteem is manifested by a "tough guy" image. Characteristics include poor frustration tolerance, irritability, and frequent temper outbursts. Symptoms of anxiety and depression are not uncommon. - Level of academic achievement may be low in relation to age and IQ. Manifestations associated with ADHD (e.g., attention difficulties, impulsiveness, and hyperactivity) are common in children with conduct disorder.

Conduct Disorder

-Long-standing behaviors that violate the rights of others and rules of society; Physical aggression toward others (people and animals); Participation in mugging, shoplifting, burglary Destruction of others' property; Breaking rules; Impaired school performance; Skipping school; Suspensions from school

Autism Spectrum Disorder

-Neurodevelopmental disorder; thought to be genetic -Wide spectrum of behaviors affecting the individual's ability to communicate or interact with others -Withdraw of the child into a fantasy world -Preoccupation with objects & self stimulating behavior -Little eye contact; few facial expressions -Onset in early childhood -More common in boys than girls

Attention Deficit Hyperactivity Disorder (ADHD)

-developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity -often diagnosed when child starts school but can persist into adulthood -symptoms must be present before 12 years of age and be present in more than one setting - highly distractible and unable to contain stimuli. - Motor activity is excessive, and movements are random and impulsive.

Two Types of PD

1. Antisocial Personality Disorder (APD) 2. Borderline Personality Disorder (BPD)

ADHD Risk Factors

1. Biological Influences - Biochemical Theory - dopamine, norepinephrine, and possibly serotonin - Anatomical - decreased volume and activity in the prefrontal cortex, anterior cingulated, globus pallidus, caudate, thalamus, and cerebellum - Prenatal, Perinatal, and Postnatal Factors - Maternal smoking during pregnancy has been linked to hyperkinetic-impulsive behavior in offspring; Alcohol 2. Environmental Influences - Environmental Lead - Diet Factors - food dyes and additives, such as artificial flavorings and preservatives, and sugar 3. Psychosocial Influences - Disorganized or chaotic environments or a disruption in family - non-intact family, young maternal age at birth of the target child, paternal history of antisocial behavior, and maternal depression.

Risk Factors - Conduct Disorder

1. Biological Influences - Genetics - Temperament - refers to personality traits that become evident very early in life and may be present at birth. - Neurobiological Factors 2. Psychosocial Influences - Peer Relationships - Poor academic performance and social maladaptation often lead to affiliations with a deviant peer group. 3. Family Influences: Parental rejection, neglect, or severe physical and verbal aggression Inconsistent or harsh, punitive discipline Parental sociopathy Lack of parental supervision Frequent changes in residence Economic stressors Parents with antisocial personality disorder, severe psychopathology, and/or alcohol/other substance dependence Marital conflict and divorce (particularly where there is persistence of hostility)

Risk factors for Eating Disorders

1. Biological Influences - Genetics - family Hx - Neuroendocrine Abnormalities (primary hypothalamic dysfunction in anorexia nervosa) - Neurochemical I( in bulimia may be associated with the neurotransmitters serotonin and norepinephrine) 2. Psychodynamic Influences - unfulfilled sense of separation-individuation 3. Family Influences - overcontrolling and perfectionistic

Nursing Diagnoses for APD and BPD

1. Communication 2. Socialization 3. Coping 4. self-esteem (chronic low self-esteem) *** APD - inwardly self distorted; BPD - outwardly self distorted

Prevention Strategies

1. Comprehensive violence assessment on admission 2. Careful ON-GOING Assessment of pt bhvrs to predict potential for violence (p. 199)

Nursing Interventions: Child Abuse

1. Conduct a physical exam: - Interview the child - Interview parent or caretaker - Observe the child's interactions with parents and other adults 2. Ensure the child's safety and well-being. 3. Try to establish some trust 4. Facilitate the child's ability to talk and think about the abuse with decreasing anxiety. 5. Make it clear to the child that you understand that talking about the abuse is difficult. 6. Create a safe and predictable environment in which the child feels supported. 7. Provide a private place and time to talk. - DO NOT PROMISE NOT TO TELL. - Do not express shock or criticize their family - Use their vocabulary to discuss body parts - Avoid using any leading statements that can distort their report - Reassure them that they have done the right thing by telling - Tell them that the abuse is not their fault, that they are not bad or to blame - Let the child know what is likely to happen when you report the abuse

NI for ADHD

1. Ensure that client has a safe environment. Remove from immediate area objects on which client could injure self as a result of random, hyperactive movements. 2. Identify deliberate behaviors that put the child at risk for injury. Institute consequences for repetition of this behavior. 3. If there is risk of injury associated with specific therapeutic activities, provide adequate supervision and assistance, or limit client's participation if adequate supervision is not possible. 1. Develop a trusting relationship with the child. Convey acceptance of the child separate from the unacceptable behavior. 2. Discuss with client those behaviors that are and are not acceptable. Describe in a matter-of-fact manner the consequences of unacceptable behavior. Follow through. 3. Provide group situations for client. 1. Ensure that goals are realistic. 2. Plan activities that provide opportunities for success. 3. Convey unconditional acceptance and positive regard. 4. Offer recognition of successful endeavors and positive reinforcement for attempts made. Give immediate positive feedback for acceptable behavior. 1. Provide an environment for task efforts that is as free as possible of distractions. 2. Provide assistance on a one-to-one basis, beginning with simple, concrete instructions. 3. Ask client to repeat instructions to you.

Pt Outcomes for Autism Spectrum Disorder

1. Exhibits no evidence of self-harm. 2. Interacts appropriately with at least one staff member. 3. Demonstrates trust in at least one staff member. 4. Is able to communicate so that he or she can be understood by at least one staff member. 5. Demonstrates behaviors that indicate he or she has begun the separation/individuation process.

After the Phone Call

1. Family does not need to be told that report is being made 2. Do NOT tell family if sexual abuse is involved. It could result in further violence

NI - ED

1. For the client who is emaciated and is unable or unwilling to maintain an adequate oral intake, the physician may order a liquid diet to be administered via nasogastric tube. Nursing care of the individual receiving tube feedings should be administered according to established hospital protocol. 2. For the client who is able and willing to consume an oral diet, the dietitian will determine the appropriate number of calories required to provide adequate nutrition and realistic weight gain. 3. Explain to the client that privileges and restrictions will be based on compliance with treatment and direct weight gain. Do not focus on food and eating. 4. Weigh client daily, immediately upon arising and following first voiding. Always use same scale, if possible. Keep strict record of intake and output. Assess skin turgor and integrity regularly. Assess moistness and color of oral mucous membranes. 5. Stay with client during established time for meals (usually 30 min) and for at least 1 hour following meals. 6. If weight loss occurs, enforce restrictions. 7. Ensure that the client and family understand that if nutritional status deteriorates, tube feedings will be initiated. This is implemented in a matter-of-fact, nonpunitive way. 8. Encourage the client to explore and identify the true feelings and fears that contribute to maladaptive eating behaviors 1. Establish a trusting relationship with the client by being honest, accepting, and available, and by keeping all promises. Convey unconditional positive regard. 2. Acknowledge the client's anger at feelings of loss of control brought about by the established eating regimen associated with the program of behavior modification. 3. Avoid arguing or bargaining with the client who is resistant to treatment. State matter-of-factly which behaviors are unacceptable and how privileges will be restricted for noncompliance. 4. Encourage client to verbalize feelings regarding role within the family and issues related to dependence/independence, the intense need for achievement, and sexuality. Help client recognize how maladaptive eating behaviors may be related to these emotional issues. Discuss ways in which he or she can gain control over these problematic areas of life without resorting to maladaptive eating behaviors. 1. Help client to develop a realistic perception of body image and relationship with food. Compare specific measurement of the client's body with the client's perceived calculations. 2. Promote feelings of control within the environment through participation and independent decision-making. Through positive feedback, help client learn to accept self as is, including weaknesses as well as strengths. 3. Help client realize that perfection is unrealistic, and explore this need with him or her.

Risk Factors

1. Genetic factors IN APD and BPD (highly sensitive) 2. a. Biological and physical factors in APD: - frontal lobe injury - electroencephalogram (EEG) abnormalities - decr. grey matter b. Biological and physical factors in BPD: - innate oversensitivity - anatomical diff-ces in amygdala and prefrontal cortex 3. Decr-d serotonin levels in both disorders 4. Environmental factors: - Hx of abuse/trauma - inconsistent parenting - abandonment

Content of report must include

1. Identity and location of potentially abused child - Age of the child - Jurisdiction - where the abuse occurred, current location of child - Person(s) legally responsible for the child - Allegations of abuse or neglect 2. Submit a written report within 48 hours of the phone call 3. Send the form to the local child protective services for children living at home 4. Send to the Central Registry in Albany for foster or group home children

Effects of APD and BPD

1. Impairment in social relat-ps 2. Employment problems 3. Mood disturbances 4. Dramatic, emotional, erratic, and impulsive bhvr which is disruptive and destructive in the pt's life and on acute in-pt psych unit

APD

1. Legal problems 2. Usually male 3. "Acts out" by turning feelings outward in a destructive manner and hurting others 4. Not psychotic 5. Forced (mandated) Tx 6. Lack of awareness of interpersonal issues 7. Rationalization, denial of problems, projection, blaming others 8. Substance use

BPD

1. Legal problems rare 2. Usually female 3. "Acts out" by turning feelings inward in a self-destructive manner 4. Transient psychosis 5. Wants Tx - needy and dependent 6. Many interpersonal issues and fears of abandonment 7. Idealization, splitting, and projection/projective identification 8. Substance use

Topics for Client and Family Education Related to Eating Disorders

1. NATURE OF THE ILLNESS Symptoms of anorexia nervosa Symptoms of bulimia nervosa Causes of eating disorders Effects of the illness or condition on the body Behaviors that may reinforce unhealthy responses, such as television and social media, peer focus on clothing sizes, eating, and weight. Internet sources have become a means for sharing information among people with anorexia about how the individual can distract parents and health-care providers from recognizing the extent of weight loss. Family members can learn more about some of these behaviors to look out for and may want to monitor their child's use of Internet and social media resources 2. MANAGEMENT OF THE ILLNESS Principles of nutrition (foods for maintenance of wellness) Ways client may feel in control of life (aside from eating) Importance of expressing fears and feelings, rather than holding them inside Alternative coping strategies (to maladaptive eating behaviors) Correct administration of prescribed medications Indication for and side effects of prescribed medications Relaxation techniques Problem-solving skills Discuss the Maudsley approach for treatment of anorexia nervosa as an evidence-based option for family involvement in the recovery program 3. SUPPORT SERVICES

Autism Spectrum Disorder Risk Factors

1. Neurological Implications: Total brain volume, the size of the amygdala, and the size of the striatum have all been identified as enlarged in very young children (under 4 years of age), and there is evidence of a decrease in size over time 2. Genetics: Genetic mutation related to multiple genes 3. Prenatal and Perinatal Influences: Advanced parental age, fetal exposure to valproate, gestational diabetes, and gestational bleeding

NI for Conduct Disorder

1. Observe client's behavior frequently through routine activities and interactions. Become aware of behaviors that indicate a rise in agitation. 2. Redirect violent behavior with physical outlets for suppressed anger and frustration. 3. Encourage client to express anger, and act as a role model for appropriate expression of anger.. 4. Ensure that a sufficient number of staff is available to indicate a show of strength if necessary. 5. Administer tranquilizing medication, if ordered, or use mechanical restraints or isolation room only if situation cannot be controlled with less restrictive means. 1. Observe client's behavior frequently through routine activities and interactions. Become aware of behaviors that indicate a rise in agitation. 2. Redirect violent behavior with physical outlets for suppressed anger and frustration. 3. Encourage client to express anger, and act as a role model for appropriate expression of anger. 4. Ensure that a sufficient number of staff is available to indicate a show of strength if necessary. 5. Administer tranquilizing medication, if ordered, or use mechanical restraints or isolation room only if situation cannot be controlled with less restrictive means. 1. Develop a trusting relationship with client. Convey acceptance of the person separate from the unacceptable behavior. 2. Discuss with client which behaviors are and are not acceptable. Describe in matter-of-fact manner the consequence of unacceptable behavior. Follow through. 3. Provide group situations for client. 1. Explain to client the correlation between feelings of inadequacy and the need for acceptance from others and how these feelings provoke defensive behaviors, such as blaming others for own behaviors. 2. Provide immediate, matter-of-fact, nonthreatening feedback for unacceptable behaviors. 3. Help identify situations that provoke defensiveness, and practice through role-play more appropriate responses. 4. Provide immediate positive feedback for acceptable behaviors. 1. Ensure that goals are realistic. 2. Plan activities that provide opportunities for success. 3. Convey unconditional acceptance and positive regard. 4. Set limits on manipulative behavior. Take caution not to reinforce manipulative behaviors by providing desired attention. Identify the consequences of manipulation. Administer consequences matter-of-factly when manipulation occurs. 5. Help client understand that he or she uses this behavior in order to try to increase own self-esteem. Interventions should reflect other actions to accomplish this goal.

Preventive Mental Health Care for Angry Pts

1. Primary Prevention - attempts to alleviate illness before they occur by removing possible causes and risk factors. Exaples: - Conflict resolution programs in schools - Stress management classes - Parent training classes - Lifestyle counseling programs - Encourage "zero tolerance" policies - Educate that violence is NOT a normal aspect of healthy relat-p 2. Secondary Prevention - the early ID and Tx of violent bhvr. Focus on pro-active Tx b/c prognosis is affected by the duration of the mental disorder. Examples: - In-pt units - out-pt groups (anger management) 3. Tertiary Prevention - the elimination or reduction of the aftermath of illness. Rehabilitation (anger management) Examples: - case management - support services - probation - parole

The Proces of Anger Management

1. Pt Anger Escalation: - Feelings/Thoughts - Behvrs; Prodormal Syndrome - Violence 2. NI for Angry PT: - Talking; Talking /Addressing Behvrs - Limit setting - Seclusion/Restraints 3. NI with a Pt to remove Seclusion/Restraints: - Seclusion/Restraints - Limit Setting - Addressing Bhvr/Talking - Talking *** Follow institution policies and procedures

Nursing Diagnosis for Autism Spectrum Disorder

1. Risk for self-mutilation or self-injury related to neurological, cognitive, or social deficits. 2. Impaired social interaction related to inability to trust; neurological alterations, evidenced by lack of responsiveness to or interest in people 3. Impaired verbal communication related to withdrawal into the self; neurological alterations, evidenced by inability or unwillingness to speak; lack of nonverbal expression 4. Disturbed personal identity related to neurological alterations; delayed developmental stage, evidenced by difficulty separating own physiological and emotional needs and personal boundaries from those of others

PATIENT WHO IS ANGRY - COMMUNICATION

1. Speak in a normal tone of voice, low and calm 2. Identify patient's feelings and confirm with the patient 3. Encourage the patient to describe the problem 4. Use open ended questions 5. Help the patient problem-solve

Child's Physical Indicators: Physical Abuse

1. Unexplained Bruises and welts On face, lips or mouth On torso, back, buttocks and thighs Various stages of healing Clustered, forming regular patterns, reflecting shape of article On several different surface areas Regularly appear after absence, weekend or vacation Bald spots on head 2. Unexplained burns cigar/cigarette especially on soles, palms, back & buttocks Immersion burns patterned like electric burner, iron, etc. Rope burns on arm, neck, legs, torso. 3. Unexplained fractures To skull, nose, facial structure In various stages of healing Multiple or spiral fractures Swollen or tender limbs 4. Unexplained lacerations/abrasions to mouth, lips, gums, or eyes to external genitalia on backs of arms, legs or torso Human bite marks Frequent injuries that are "accidental" 5. Internal injuries/unusual bleeding

REPORTING CHILD ABUSE

1. What Constitutes Reasonable Cause to Suspect Abuse? - Be able to entertain the possibility that a situation could be caused by neglect or by non-accidental means - Reports by a parent or person legally responsible for the child 2. Steps for Reporting - Remember: It is not necessary that a reporter be able to prove that abuse has occurred. - Know your agency's policy for mandated reporting, in addition to NYS law. 3. Immediately call: The NYS Central Registry of Child Abuse 1-800-635-1522 - For mandated reporters 1-800-342-3720 - For general public reporters

NI for Autism Spectrum Disorder

1. Work with the child on a one-to-one basis. 2. Try to determine if the self-mutilative behavior occurs in response to increasing anxiety, and if so, to what the anxiety may be attributed. 3. Try to intervene with diversion or replacement activities and offer self to the child as anxiety level starts to rise. 4. Protect the child when self-mutilative behaviors occur. Devices such as a helmet, padded hand mitts, or arm covers may provide protection when the risk for self-harm exists. 1. Assign a limited number of caregivers to the child. Ensure that warmth, acceptance, and availability are conveyed. 2. Provide child with familiar objects, such as familiar toys or a blanket. Support child's attempts to interact with others. 3. Give positive reinforcement for eye contact with something acceptable to the child (e.g., food, familiar object). Gradually replace with social reinforcement (e.g., touch, smiling, hugging) 1. Maintain consistency in assignment of caregivers. 2. Anticipate and fulfill the child's needs until communication can be established. 3. Seek clarification and validation. 4. Give positive reinforcement when eye contact is used to convey nonverbal expressions. 1. Assist child to recognize separateness during self-care activities, such as dressing and feeding. 2. Assist the child in learning to name own body parts. This can be facilitated by the use of mirrors, drawings, and pictures of the child. Encourage appropriate touching of, and being touched by, others.

NI - Child Abuse - Cont.

8. Plan interventions that will encourage affective release in a supportive environment. Child victims must be able to experience a range of emotions. a. Play therapy helps children play out traumatic themes, fears and distorted beliefs. It is a non-threatening way to process thoughts and feelings associated with the abuse both symbolically and directly. b. Art therapy provides an opportunity to express feelings for which there are no words. c. Therapeutic stories present the traumatic issue of abuse, link victim's feelings and behaviors and describe new coping methods to children. d. Journal writing can help children over age 10 cope with intrusive thoughts and feelings. They often chose to bring their journals into the one-to-one sessions with their therapist. **** The nurse does not become the substitute parent. The goal is to provide a role model for the parents in helping them to relate positively and constructively to their child and to foster a therapeutic environment for the child in his/her reprieve from the abusing situation.

• Child Maltreatment/Neglect

A "maltreated" child is a child under 18 years of age whose physical, mental or emotional condition has been impaired or is in danger of becoming impaired as a result of the failure of the caretaker to exercise a minimum degree of care.

Behavioral Indicators - Emotional Abuse

Age inappropriate behaviors (older or younger) Developmental delays (emotional/psychological) Behavioral extremes (compliant, passive, aggressive, demanding) Anorexia Nervosa (especially in adolescents) Social Isolation

Behavioral Indicators: Child Neglect

Begging for or stealing food Signs of malnutrition Longer stays at school Truancy Constant fatigue Alcohol or drug abuse States there is no caretaker

Behavioral Indicators:Physical Abuse

Behavioral Extremes: aggressiveness, withdrawal, passivity, regressiveness Little or no response to pain/Lack of separation anxiety Disorganized thinking; self-injurious or suicidal behavior Fear of parent or caretaker Fear of going home Apprehension when other children cry Verbal reporting of abuse Extreme hyperactivity, irritability and distractibility Seeks affection from any adult Wearing clothing that covers the body that may be inappropriate for warm weather Running away from home or engaging in illegal behavior such as drug abuse or stealing Displaying severe depression Cheating, lying or poor achievement in school Inability to form satisfactory peer relationships

Bulimia Nervosa

Bulimia nervosa is an episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period of time (binging), followed by inappropriate compensatory behaviors to rid the body of the excess calories. - usually terminated by only abdominal discomfort, sleep, social interruption, or self-induced vomiting. - To get rid of food - purging behaviors (self-induced vomiting or the misuse of laxatives, diuretics, or enemas) or other inappropriate compensatory behaviors, such as fasting or excessive exercise.

Methylphenidate

Classifications: central nervous system (cns) agent; cerebral stimulant Acts mainly on cerebral cortex exerting a stimulant effect. U: attention deficit disorder SE: nervousness, insomnia, HEPATOTOXICITY, exfoliative dermatitis NI: Assessment & Drug Effects •Monitor BP and pulse at appropriate intervals. •Lab tests: Obtain periodic CBC with differential and platelet counts during prolonged therapy. •Chronic abusive use can lead to tolerance, psychic dependence, and psychoses. •Assess patient's condition with periodic drug-free periods during prolonged therapy. •Supervise drug withdrawal carefully following prolonged use. Abrupt withdrawal may result in severe depression and psychotic behavior. Patient & Family Education •Report adverse effects to physician, particularly nervousness and insomnia. These effects may diminish with time or require reduction of dosage or omission of afternoon or evening dose. •Check weight at least 2 or 3 times weekly and report weight loss. Check height and weight in children; failure to gain in either should be reported to physician. •Do not breast feed while taking this drug without consulting physician.

Dextroamphetamine/Amphetamine

Classifications: central nervous system agent; respiratory and cerebral stimulant; amphetamine; anorexiant A: it inhibits or reverses the transporter proteins for the monoamine neurotransmitters (namely the serotonin, norepinephrine and dopamine transporters) when there are high cytosolic concentrations of the monoamine neurotransmitters and it releases these neurotransmitters from synaptic vesicles U: attention deficit disorder with hyperactivity in children SE: restlessness, insomnia, with prolonged use —severe depression, psychotic reactions NI: Assessment & Drug Effects •Monitor growth rate closely in children. •Interrupt therapy or reduce dosage periodically to assess effectiveness in behavior disorders. • Note: Tolerance to anorexiant effects may develop after a few weeks, however, tolerance does not appear to develop when dextroamphetamine is used to treat narcolepsy. Patient & Family Education •Swallow sustained release capsule whole with a liquid; do not chew or crush. •Do not drive or engage in other potentially hazardous activities until response to drug is known. •Taper drug gradually following long-term use to avoid extreme fatigue, mental depression, and prolonged sleep pattern. •Do not breast feed while taking this drug.

Physical Indicators - Child Emotional Abuse

Conduct disorders are more frequent Habit disorders (rocking, biting, sucking fingers) Neurotic disorders (speech, inhibition of play) Psychoneurotic reactions (phobias, compulsions) Lags in physical development Failure to thrive

CHILD EMOTIONAL/PSYCHOLOGICAL ABUSE

Emotional injury involves a pattern of behavior on the part of the caretaker that results in serious impairment of the child's social, emotional or intellectual functioning

Outcomes

Has achieved and maintained an expected BMI for age with consideration for body build, weight history, and any physiological disturbances 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 (anorexia nervosa, bulimia nervosa). 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 less preoccupation with own appearance (anorexia nervosa, bulimia nervosa).

Pt Outcomes for ADHD

Has experienced no physical harm. Interacts with others appropriately. Verbalizes positive aspects about self. Demonstrates fewer demanding behaviors. Cooperatives with staff in an effort to complete assigned tasks.

Outcomes for Conduct Disorder

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.

Physical Interventions

If the pt is still hasn't calmed down, the nurse, along with other staff, will need to use more restrictive measures which include using a "show of force/support" and seclusion or restraints. Be sure to explain to the pt what is about to happen. If the pt is put in restraints, be sure the health care team has the opportunity to talk about the event

Assessment and ND of Eating Disorders

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

Physical Indicators: Child Neglect

Inappropriate or soiled clothing Consistent hunger Poor hygiene, bad breath, body odor Unattended physical problems Medical/Dental problems Abandonment

Child Abuse

Inflict or allows injury Allows risk of physical injury Commits or allow sexual abuse or offense

Anorexia Nervosa

Is characterized by a morbid fear of obesity. Symptoms include gross distortion of body image, preoccupation with food, and refusal to eat

What about HIPPA

Mandate supersedes HIPPA laws Mandated reporters need to provide records necessary for CPS irrespective of HIPPA proscriptions or any other privilege.

Mandatory Reporting Laws

Mandatory reporting laws require that nurses report suspected abuse in all states; there are criminal and civil penalties for not reporting.

Nurse Self-Assessment

Nurse's feelings can be "split" or divided b/w - positive (nurturing and "feeling sorry for") - negative (anger and frustration) toward pt Fluctuations and changes in feelings occur periodically and cont-sly Health care team can also be "split"

Attention Nurses!

Nurses must be aware of possible abuse, particularly if injuries are unexplained or the explanation does not match the physical picture.

Nurse Self-Assessment When Working with an "At Risk" Pt

Nurses working with angry pts need to monitor themselves regarding the following: - Your ability to use anger and not to take pt's anger personally - Your capacity for clear verbal communication - Your capacity for self-analysis - Your capacity to listen - Your ability to establish and maintain empathetic linkages to pts and to disengage emotionally - Your ability to understand your fears and anxieties about violence - Your belief that violent pts are amenable to Tx

What is the impact of angry bhvr on helping a pt meet basic needs?

Nursing Diagnosis that are helpful in the care of the angry pt: 1. Risk for other-directed violence 2. Ineffective coping (p. 201)

Types of Abuse

Physical Emotional/Psychological Sexual Neglect

Nursing Diagnosis for ADHD

Risk for injury related to impulsive and accident-prone behavior and the inability to perceive self-harm Impaired social interaction related to intrusive and immature behavior Low self-esteem related to dysfunctional family system and negative feedback Noncompliance with task expectations related to low frustration tolerance and short attention span

Nursing Diagnosis for Conduct Disorder

Risk for other-directed violence related to characteristics of temperament, peer rejection, negative parental role models, dysfunctional family dynamics Impaired social interaction related to negative parental role models, impaired peer relations leading to inappropriate social behaviors Defensive coping related to low self-esteem and dysfunctional family system Low self-esteem related to lack of positive feedback and unsatisfactory parent-child relationship

Behavioral Indicators: Child Sexual Abuse

Seductive behavior, advanced sexual knowledge for the child's age, promiscuity, prostitution Expressing fear of a particular person or place Compulsive masturbation, precocious sex play, excessive curiosity about sex Withdrawal, fantasy or infantile behavior Sexually abusing another child Appearance of an inordinate number of gifts or money from a questionable source Drop in school performance or sudden non-participation in school activities/truancy/delinquency Self-injurious behavior Poor peer relationships Reports sexual assault by caretaker Exaggerated aversion to closeness or physical contact Sudden onset of enuresis Excessive anxiety Expression of low self-worth; verbalizations of being "damaged" Excessive bathing Suicide attempts

Planning

Selected pt outcomes must be written corrrectly with action verbs and desired bhvrs noted: - Outcomes may be r/t safety concern - Express feelings appropr. (eg. talk before acting out) - ID and seek out appropr. support pt's/resources - Discuss current family issues and f-ly Hx inn relation to own actions - Demonstrate frustration and anxiety tolerance - Demonstrate problem-solving to meet needs - Demonstrate incr. responsibility and role performance

Background Assessment Data - Autism Spectrum Disorder

Some individuals who meet criteria for ASD may be highly functional and highly intelligent in spite of communication impairments and repetitive or restrictive behaviors. 1. Impairment in Social Interaction - They show little interest in people and often do not respond to others' attempts at interaction. Inability to accurately process others' feelings or affect. 2. Impairment in Communication and Imaginative Activity - Both verbal and nonverbal skills are affected 3. Restricted Activities and Interests - Even minor changes in the environment are often met with resistance or sometimes with agitated irritability.

Nursing Diagnosis for APD and BPD

That address safety: 1. Risk for other-directed violence (APD) 2. Risk for self-directed violence (BPD) 3. Risk for self-mutilation (BPD) 4. Risk for suicide (BPD)

Physical Indicators: Sexual Abuse

Torn, stained or bloody underclothing Frequent UTI's Any STD of the throat/mouth Difficulty or pain in walking or sitting Foreign matter in the bladder, rectum or vagina Rashes or itching of the genital area; scratching the area a great deal or fidgeting when seated Bruises or pain in the genital area Genital or rectal bleeding; vaginal discharge Pregnancy, especially in early adolescent years Sleep problems, nightmares

ASD Tx with Meds

Treatment of irritability associated with ASD: 1. risperidone (Risperdal; in children and adolescents 5 to 16 years) 2. aripiprazole (specifically Abilify; in children and adolescents 6 to 17 years). When administering risperidone, caution must be maintained concerning less common but more serious possible side effects, including neuroleptic malignant syndrome, tardive dyskinesia, hyperglycemia, and diabetes. With aripiprazole, the most frequently reported adverse events included sedation, fatigue, weight gain, vomiting, somnolence, and tremor. The most common reasons for discontinuation of aripiprazole were sedation, drooling, tremor, vomiting, and extrapyramidal disorder.

NI - Assist with Problem-solving

Verbal Interventions: - Do NOT approach an already violent pt alone, use show of force/support - "Talking down" the pt - Make short, concise statements: "What is going on?" "What happened that has gotten you so angry?" "An hour ago, you were fine. Now you are upset. What has changed?" - Talk right away with an angry pt - Validate the pt's feelings; help pt address the unmet need - Avoid using "always" and "never" - Helpful verbal wording - safe and healthy - Avoid threats - When the pt has calmed down, offer choices and options for diversional activities such as: a. exercise/walking b. change of surroundings c. release from schedule and demands d. relaxation/music/quiet periods e. help the pt write an anger diary thinking about alternative ways to manage anger

EBP

Very limited/not clear if better as group vs individual: - Cognitive Therapy - Relaxation-Based - Skills training - Multiple approaches applied in therapy *** Successful Tx does exist. Brief seems to be better (about 8 sessions)

NURSING ASSESSMENT

Warning Signs - Parental Behavioral Indicators • Inappropriate response of caregiver, such as an Overly protective/domineering or absent emotional response; refusal to sign for additional tests or adamantly insist on necessary treatment • Parents cannot be found • Injuries with no report of trauma • Delay in seeking treatment for a significant injury • Parent attempts to conceal full extent of injury • Changes in the child's or adult's story of what happened. • Histories that are inconsistent with severity of trauma • Unusual injuries for a child of that particular age or level of development. • Parent demonstrates inconsistent behavior toward child • Parents treat children differently

Assessment of PT at Risk for Other-Directed Violence

Who are the pts most likely to choose violence as a response to anger? Aggression is commonly an overreaction to feelings of impotence, helplessness, and perceived or actual humiliation

Determine whether the statements below are therapeutic (T) or nontherapeutic (N).

___T___ You seem upset. ___N___ Why did you lose your temper like that? ___N___ It's not good to be angry. ___T__ How are you feeling now? ___N___ You'll need to be put in seclusion if that happens again. ___T___ What was the problem? ___N___ Let's not talk about what happened. It won't happen again. ___T___ What were you talking about? ___N___ You better not get upset like that again. ___T___ I saw you yelling and pounding your fist on the table. You seem angry. ___T___ How did the yelling start? ___T___ What do you think would help the situation?

Characteristics of Abusive Caretakers

• Often suffered from abuse, neglect or severe discipline as a child • Isolated from friends, family & neighbors • Have unmet dependency needs • May have substance abuse problems/chronic illness/low IQ • Have high expectations of other people's behavior • May be hostile and blame others for their problems • Impulsive and immature with low self-esteem • Are generally law abiding and only a danger to family • Are extreme disciplinarians who believe in physical punishment • Poor parenting skills with high expectations of child • Use threats or intimidation to control the victim • May state "no hope" that child will behave • See child as bad, evil, friend of the devil • Home environment is choatic/no routine • Exposes child to unsafe living conditions • Concerned about child's gender or performance before birth • May have had pregnancy or labor/delivery difficulties