Exam 2 (unit 6 &7)

Sexual Assault

Term that encompass unwanted sexual advances and sexual harassment to rape and drug-facilitated assault

A patient is pacing the hall near the nurses station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say:

Id like to talk with you about how youre feeling right now. Intervention should begin with an analysis of the patient and situation. With this response, the nurse is attempting to hear the patients feelings and concerns, which leads to the next step of planning an intervention.

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, Why are you such a stupid kid? The wife says, I have difficulty disciplining the children. Its so frustrating. Which comments by the nurse will facilitate the interview with these parents?

a. Tell me how you punish your children. b. How do you stop your baby from crying? c. Caring for four small children must be difficult. An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life.

Mood stabilizing medications have been effective for many patients with borderline personality disorder. Serotonin norepinephrine reuptake inhibitors (SNRI) or anxiolytics are not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

sexual assault nurse examiner

activities are in the scope of practice of a sexual assault nurse examiner +Collecting and preserving evidence +Obtaining signed consents for photographs and examinations +Providing pregnancy and sexually transmitted disease prophylaxis HIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within this practice role.

Signs of abuse in all ages or genders o victims may include

burns; bruises; scars; wounds in various stages of healing, particularly around the head and neck; and fractures of limbs, ribs, or jaw. Physical exam- ination includes assessing or signs of internal injuries such as bleeding, concussions, perforated eardrums, abdominal injuries, eye injuries, and strangulation marks on the neck. An examination might reveal burns from cigarettes, acids, scalding liquids, or appliances. Patterning of injuries can include bruises, lacerations, or contusions in the shapes of objects such as coat hangers, cords, irons, handprints, nger-grab prints, fly swatters, rope burns, bite or teeth marks, or belt buckles. Patterning can also refer to the location of the damage. Abusers often plan the location of abuse so that it cannot be easily noticed, such as on the torso, back, upper arms, and upper legs; inside body orifces; and under the hair. Examination should include attention to these hidden areas.

telephone counselor

explain immediate steps that a victim of rape should take. The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

Suppression

A student on spring break decides not to think about school.

Projection

A woman who dislikes her boss tells others her boss doesn't like her

Altruism

Serving as a volunteer to a disaster area

A patients spouse filed charges after repeatedly being battered. The patient sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statements by the patient supports an antisocial personality disorder?

"I hit because I am tired of being nagged. My spouse deserves the beating." The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common.

A patient says, "I get in trouble sometimes because I make decisions and act on them" Select the nurses most therapeutic response.

"Let's consider the advantages of being able to stop and think before acting." The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

Nursing intervention for interviewing rape victim A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patients in the emergency department ?

- Allow the patient to talk at a comfortable pace. -Place the patient in a private room with a caregiver. -Pose questions in nonjudgmental, empathetic ways. Neutral nonjudgmental care and emotional support are critical to crisis management for the rape victim should have privacy but not be left alone. The rape victims anxiety may escalate when touched by a stranger, even when the stranger is a nurse some rape victims prefer not to have family involved. The patients privacy may be compromise by family presence.

Intellectualization Defense Mechanism

- An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual process of logic, reasoning and analysis. A man describes the details of his wife's death with no emotion.

Haloperidol (Haldol) Fluphenazine (Prolixin) >If patient is noncompliant to taking the medication, give Depot formulation IM every 4 weeks (Haldol)and every 2-4 weeks (Prolixin HIGH Potency (Elixir and IM formulation)

**Give Benedryl, Cogentin, and Artin with High Potency drugs to reduce EPS Common S/E: ●EPS ●Anticholinergic SE ●Sedation ●**Weight Gain!

Ziprasidone (Geodon) >What do you need to check before startingGeodon and throughout the treatment?

*EKG before starting Geodon (increase HR)

A nurse in the emergency department assesses an unresponsive victim of rape. The victims friend reports, "that guy gave her salty water before he raped her". Which question is most important for the nurse to ask of the victims friend?

"has the victim consumed any alcohol?" Salty water is a slang/street name for GHB (g-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1-12 hours, but the duration is less important that the potential for respiratory depression. Seeking evidence is less important than the victims physiologic stability

Histrionic Personality disorder

-Center of attention -Flamboyant seductive or provocative behaviors -Shallow -Rapid shifting of emotions/dramatic expression of emotions -Overly concerned with impressing others a pattern of excessive emotion and attention seeking. People with histrionic personality disorder may be uncomfortable when they are not the center of attention, may use physical appearance to draw attention to themselves or have rapidly shifting or exaggerated emotions. Charm, drama, seductiveness, and admiration seeking are observed in patients diagnosed with histrionic personality disorder Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness.

Common Characteristics of Personality Disorders

1) Inflexible and maladaptive response to stress. 2) Disability in working and loving. 3) Ability to evoke interpersonal conflict. 4) Capacity to frustrate others.

Assessment Guidelines Personality Disorders

1. Assess suicidal and homicidal thoughts. 2. Determine whether the patient has a medical disorder or another psychiatric disorder. 3. View the assessment of personality functioning from within ethnic, cultural, and social backgrounds. 4. Ascertain recent and important losses. 5. Evaluate for changes in personality in middle adulthood or later: May signal an unrecognized substance use disorder. 6.Be aware of strong negative emotions that patients evoke.

Setting Limits maintaining consistent limits.

1. Set limits in only those areas in which a clear need exists to protect the patient or others. 2. Establish realistic and en orceable consequences o exceeding limits. 3. Make patient aware o limits and the consequences o not adhering to the limits be ore incidents occur. The patient should be told in a clear, polite, and rm manner what the limits and consequences are, and should be given the opportunity to discuss any feelings or reactions to them. 4. All limits should be supported by the entire sta , written in the care plan, and communicated verbally to all involved. 5. When a decision to discontinue the limits is made by the entire sta , the decision is based on consistent desired behavior, not promises or sporadic efforts. 6. The staff should formulate their own plan to address their own difficulty in maintaining consistent limits. The most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met is: Maintaining consistent limits Maintaining consistent limits is by far the most difficult intervention because of the patients superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan; positive reinforcement strategies for acceptable behavior are more effective than aversive techniques.

Some Predictive Factors or Violent Outcomes Assessment Guidelines Anger, Aggression, and Violent Acting Out

A history of prior aggression or violence is the best predictor of patients who may become violent. Patients diagnosed with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have co-existing anger, but violence is not often demonstrated. Patients experiencing paranoid delusions are at greater risk for violence than those with bizarre somatic delusions. 1. A history of violence is the single best predictor of future violence. 2. Paranoid ideation and rank psychosis (e.g., command hallucinations) are indicators o possible aggression or violence. 3. Patients who are hyperactive, impulsive, or predisposed to irritability are at higher risk or violence. 4. Assess the patient's risk or violence: • Does the patient have a wish or intent to harm? • Does the patient have a plan? • Does the patient have means available to carry out the plan? • Does the patient have demographic risk factors, including male gender, ages 14 to 24 years, low socioeconomic status, and low support system? 5. Aggression occurs most often in the context of limit setting by the nurse. 6. Patients with a history of inability to control anger and limited coping skills, including lack of assertiveness or use of intimidation, are at higher risk of using violence. 7. Assess sel or personal triggers and responses likely to escalate the individual's violence. 8. Assess personal sense o competence when in any situation o potential conf ict; consider asking or the assistance o another sta member. 9. Assess any personal negative thoughts or eelings you may hold toward the patient that could escalate both your anxiety and the anxiety o the patient. 10. Draw on previous knowledge o the policies and procedures or providing care to potentially violent patients. Signs and symptoms that usually (but not always) precede violence: a. Angry, irritable a ect b. Hyperactivity: most important predictor o imminent violence (e.g., pacing, restlessness, slamming doors) c. Increasing anxiety and tension: clenched jaw or st, rigid posture, xed or tense acial expression, mumbling to sel (patient may have shortness o breath, sweating, and rapid pulse rate) d. Verbal abuse: pro anity, argumentativeness e. Loud voice, change o pitch, or very so t voice orcing others to strain to hear f. Intense eye contact or avoidance o eye contact 2. Recent acts o violence, including property violence 3. Stone silence 4. Suspiciousness or paranoid thinking 5. Alcohol or drug intoxication (withdrawal) 6. Possession o a weapon or object that may be used as a weapon (e.g., ork, kni e, rock) 7. Milieu characteristics conducive to violence: a. Loud b. Overcrowding c. Sta inexperience d. Provocative or controlling sta e. Poor limit setting f. Sta inconsistency (e.g., arbitrary revocation o privileges) risk for family violence = An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3- year-old child. The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors.

Conversion

A man's arm becomes paralyzed after impulses to strike someone

consensual sex

A persons lover pleads to have oral sex. The person gives in but then regrets the decision. Consensual sex is not considered rape if the participants are, at least, the age of majority.

compensation

A physically unattractive teen becomes an expert dancer.

Identification

A resident physician dresses similarly as his teaching doctor.

Societal and Cultural Factors

According to the National Institute o Justice (NIJ, 2007), when abuse is seen in a amily system, other correlates are o ten present, including: • Poverty or unemployment • Communities with inadequate resources and overcrowding • Social isolation of families • Substance abuse • Early parenthood

Displacement

After being scolded by her Mom, a child yells at her little brother.

Etiology

Biological factors Genetic Neurobiological Psychological factors Environmental factors Diathesis-stress model

Crisis counseling

Crisis counseling should always be available to any person who has been sexually assaulted, including re errals to the amily physician, community psychologist, or community rape crisis line,

personality disorders vs personality traits

Disorders cause impairment in social and occupational functioning, whereas traits do not.

An 11 year old reluctantly tells the nurse, "My parents dont like me. They said they wish I was never born" Which type of abuse is likely?

Emotional Abuse Examples of emotional abuse include having an adult demean a childs worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

Evaluation

Evaluating treatment effectiveness in this patient population is difficult. Short-term outcomes may be accomplished. Patient can be given message of hope that quality of life can always be improved.

factors promoting the cycle of violence

Individual Risk Factors History of violent victimization Attention deficits, hyperactivity, or learning disorders History of early aggressive behavior Involvement with drugs, alcohol, or tobacco Low IQ Poor behavioral control Deficits in social cognitive or information-processing abilities High emotional distress History of treatment for emotional problems Antisocial beliefs and attitudes Exposure to violence and conflict in the family Family Risk Factors Authoritarian childrearing attitudes Harsh, lax, or inconsistent disciplinary practices Low parental involvement Low emotional attachment to parents or caregivers Low parental education and income Parental substance abuse or criminality Poor family functioning Poor monitoring and supervision of children Peer and Social Risk Factors Association with delinquent peers Involvement in gangs Social rejection by peers Lack of involvement in conventional activities Poor academic performance Low commitment to school and school failure Community Risk Factors Diminished economic opportunities High concentrations of poor residents High level of transiency High level of family disruption Low levels of community participation Socially disorganized neighborhoods

substance abuse

Information from a patients record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: Substance Abuse The nurse should suspect marginal coping skills in a patient with substance abuse. He or she is often anxious, may be concerned about inadequate pain relief, and may have a personality style that externalizes blame. The incorrect options do not signal as high a degree of risk as chemical dependence.

Chlorpromazine (Thorazine) >What labs need to be checked? lOW potency (Elixir and IM formulation

Labs:Check Fasting Blood Sugar (FBS)and Fasting Lipid Panel (FLP) >Common S/Eof Low Potency Agents ●AnticholinergicDry MouthConstipationBlurred VisionUrinary retentionConfusion ●Sedation-Histamine Blockage ●Adrenergic Blockage- Muscarinic/Hypotension ●EPS**

A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority?

Notify the health care provider and obtain a seclusion order. Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within the period specified by the state and agency. The incorrect options are not immediately necessary from a legal standpoint.

Outcomes identification

Pertinent categories based on: Aggression self-control Impulse self-control Social interaction skills Fear level Abusive behavior self-restraint Self-mutilation restraint

olanzapine (Zyprexa)

Olanzapine is a short acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention

Post-assaultive Stage

Once the patient no longer requires seclusion or restraints, the sta should review the incident with the patient as well as among themselves. Discussion with the patient is an important part o the therapeutic process. Reviewing the incident allows the patient to learn rom the situation, identi y the stressors that precipitated the out-o -control behavior, and plan alternative ways o responding to these stressors in the uture.

Contributing Risk Factors or Suicide

Other factors often involved in individuals who attempt or complete suicide are poor critical thinking skills, troubled emotional lives (anger, anxiety, guilt, boredom), and a low threshold or emotional pain. However, note that a person may experience one or more risk actors and not be suicidal. Poland (2009) cites assessment of markers or youth suicide that involve family and developmental background: • Children or teens who lost a parent to suicide (three times more likely to commit suicide) • Childhood maltreatment • Problematic family relations • History of bullying and victimization • Family history of suicide • Socioeconomic problems • Parental psychopathology • Peer problems • Legal and/or discipline problems

personality style that externalizes problems.

Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves. The incorrect options are less likely to have a bearing on this behavior.

Obsessive Compulsive Disorder OCD

Preoccupied with rules Perfectionistic Too busy to have friends Rigid control Superficial relationships Complains about others' inefficiencies and gives others directions ●Suppress persistent thoughts or urges that cause anxiety through impulsive or obsessive behaviors ●Repetitive hand washing ●Time-consuming obsessions ●Impaired social and occupational fx Persons with obsessive-compulsive personality disorder try to control the environment through perfectionism and orderliness. a pattern of preoccupation with orderliness, perfection and control. A person with obsessive-compulsive personality disorder may be overly focused on details or schedules, may work excessively not allowing time for leisure or friends, or may be inflexible in their morality and values. Preoccupation with minute details and perfectionism are observed in individuals diagnosed with obsessive-compulsive personality disorder.

Ensuring Safety SAFETY

Promoting safety is always a first consideration. Ensure your safety first. You must feel safe to be able to communicate in a calm manner. Staff and other personnel should be alerted in case reinforcement is needed. The goals are that no one will become hurt and the patient will experience the least restrictive interventions. The following is a list of specific interventions or working with a potentially angry, aggressive, or violent patient: 1. Move the individual to a calm and quiet place. 2. All patients should be searched or contraband and dangerous objects when admitted to the unit and a ter visits. 3. Give the patient space. Always minimize personal risks. Stay at least one arm's length away rom patient. Use more space i patient is anxious or i you want more space. Always trust your instincts. 4. Provide adequate space or the patient and sta to ensure easy withdrawal rom an escalating situation. 5. Know where panic buttons or alarms are located to be able to call or assistance rom other sta quickly i necessary. Sometimes it is necessary to wear a body alarm to ensure sa ety. 6. Exit strategies apply to both the nurse and the patient. The nurse should be positioned between the patient and the door, but not directly in ront o the patient or in ront o the doorway. Facing the patient can be interpreted as con rontational, and it can also make the patient eel trapped. It is better to stand o to the side and encourage the patient to have a seat. 7. Set limits at the outset using these de-escalation techniques (Box 24-2). • Direct approach: "Violence is unacceptable." Describe the consequences (medications, restraints, seclusion). Best or con used or psychotic patients. • Indirect approach: Use the indirect approach if patient is not con used or psychotic. Give patient a choice. "You have a choice. You can take this medication and go into the interview room (or hallway, or example) and talk, or you can sit in the seclusion room until you feel less anxious." 8. When interviewing a patient whose behavior begins to escalate: • Provide feedback about what you observe: "You seem to be very upset." Such an observation allows exploration o the patient's eelings and may lead to de-escalation o the situation. • If the patient's behavior continues to escalate, end the interview and assure the patient that the sta will provide or the patient's sa ety (as well as everyone else's sa ety); then leave the patient. 9. Having enough staff is essential or a show of strength and is often enough to avert confrontation. One person is chosen as spokesperson and is the only one who talks to the patient, but staff needs to maintain an unobtrusive and nonthreatening presence in case the situation escalates. 10. Give the patient the opportunity to walk to the quiet room voluntarily without assistance when team interventions seem appropriate. 11. Do not touch the patient unless the team is with you and you are ready or a possible restraint situation. 12. In the event of a restraint or seclusion situation, the team unctions as a single unit, with each member assigned a limb or a unction as previously practiced according to unit protocols and policy. 13. Avoid wearing dangling earrings, necklaces, or ponytails. The patient may become ocused on these and grab at them, causing serious injury. This is a serious danger.

Abuse Assessment Screen (AAS)

Question assessment that measure the amount of violence in pt's life consider the possibility that the patient is a victim of intimate partner violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.

Economic Abuse

Refers to controlling a person's access to economic resources

Attempted rape

Refers to threats of rape or intention to rape that is unsuccessful

nurses legal responsibility if child abuse or neglect is suspected

Report the suspected abuse or neglect according to state regulations. Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

rationale for why a nurse should be aware of personal feelings while working with a family experiencing family violence personal reaction by the nurse

Strong negative feelings interfere with assessment and judgment. Strong negative feelings cloud the nurses judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to over involvement with the victim. Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

educational neglect

The child is experiencing educational neglect when his parents deprive him of the opportunity to attend school. It is possible that the other children may be experiencing physical neglect, but more data should be gathered before making the actual assessment. There is insufficient information to conclude that the child is managing the situation well. The data do not indicate a high risk for sexual abuse, and no hard evidence of physical abuse is present.

Types of Child Abuse and Physical and Behavioral Indicators

Type of Abuse: Intentional physical injury inficted by a caregiver Physical Indicators Bruises, wounds, injuries in differing stages of healing Patterningo abuse, such as marks in shapes such as coat hangers or cigarette burns, or hidden under clothing where they are harder to discern Bald patches on scalpSubdural hematoma (child younger than 2 years) Retinal hemorrhage Behavioral Indicators Excessive fear of parents or constant effort to please Wary of adult contact . Nightmares or anxiety. Obvious attempts to hide bruises or injuries Withdrawn, depressed, aggressive, or disruptive behavior at home or school Regressive behavior Type of Abuse Neglect Failure to provide or the child's basic needs Physical Indicators Physical neglect: Malnourished Under weight, poor growth pattern Inadequately supervised Poor hygiene Unattended physical problems Inappropriate dress Educational neglect: School problems or failure Not enrolled in mandatory school for age of child Behavioral Indicators Soiled clothing, poor hygiene Begging, stealing food Emaciated or has distended belly Arrives early or stays late at school Psychosomatic complaints Delinquency Alcohol or drug abuse Chronic truancy Special educational needs not being attended Type of Abuse Sexual Abuse Sexual abuse perpetrated by amily ornonamilymember.Sometypes includeexhibitionism;touching; oral,anal,orvaginalpenetration; being orcedtowatchsexactsor pornography. In extreme cases, beingsold orsexual avors. Physical Indicators Difficulty in walking or sitting Itching in private areas Urinary tract infections, painful urination Torn, stained, or bloody underclothing Bruises or bleeding in external genitalia, vaginal, or anal areas Sexually transmitted infection, especially in preteens Swollen private areas or discharge Objects or liquid in vagina, rectum, or urethra Behavioral Indicators Mistrust of adults Abnormal or distorted view of sex Advanced or unusual sexual behavior or knowledge for age Phobias: fear of the dark, men, strangers, leaving the house Delinquency or running away Self injury or suicidal thoughts or behaviors Mental disorders may develop, including post traumatic stress disorder, depression, dissociative disorder, eating disorders, conduct disor- ders, mood swings, and anxiety. Type of Abuse- Emotional or Psychological Abuse Behaviors that convey to the child that he or she is worthless,f awed, unloved, or unwanted. These include constant criticism, threats, insults, yelling, ignoring, favoritism, and harsh demands. Physical Indicators Speech disorders Lag in physical development Behavioral Indicators Difficulty in learning and living up to potential Lack of self -confidence Inappropriate adult like behavior or infantile behavior Poor social skills Dramatic behavior changes such as aggressiveness, drug use, change in friends or clothing, self-harm behaviors, compulsiveness, and a needy pursuit of attention.

A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for not knowing enough to give me pain medicine when I need it. Which nursing intervention would best address this problem?

Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs.

Valproic Acid (Depakene, Depakote)

Valproic acid is for patients with bipolar disorder or borderline personality disorder. • Inhibits neural activity • Controls simple and complex absence seizures • Adjunct therapy for partial complex and generalized tonic-clonic seizures • Monitor for hair loss, tremor, increased liver enzymes, bruising, nausea and vomiting • Monitor CBC, PT, PTT, AST

reaction formation (defense mechanism)

switching unacceptable impulses into their opposites Reaction formation involves unconsciously doing the opposite of a forbidden impulse. - Preventing unacceptable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors. EX: Jane hates nursing. She attended nursing school to please her parents. During career day, she speaks to prospective students about the excellence of nursing as a career. A parent who unconsciously resents a child spoils the child with gifts

Impulsivity

tendency to act quickly without careful thought Patient with Impulsivity/ expect behavior characterized by: postponing gratification to an appropriate time. The impulsive individual acts in haste without taking time to consider the consequences of the action.

For which behavior would limit setting be most essential? The patient:

urges a suspicious patient to hit anyone who stares. The correct option is an example of a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of patients is at risk. Limit setting may be occasionally used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance.

egocentric behavior

when you believe your values are the only correct values client who refuses to compromise and consistently demands her own way is exhibiting ...

Antidepressants

(depression, eating disorders, pain disorder, smoking cessation, PMS, OCD, PTSD) It reduces sadness, irritability and anhedonia (inability to feel pleasure) while reducing hopelessness, pessimism, guilt, suicidal thoughts, improve concentration and memory. It also improves sleep disturbance.

Risperidone (Risperdal) >What symptoms does it treat?

> It's an antipsychotic and it treats both positive and negative symptoms

Clozapine (Clozaril) >What lab level do you need to look at?

>Baseline CBC (WBC count

Cluster C Personality Disorders

Anxious or fearful behavior. Rigid patterns of social shyness. Cluster C: Avoidant Personality Disorder Prevalence: 2.4% Characteristics Low self-esteem Shyness that increases with age Feelings of inferiority Reluctance to engage with new people Subject to depression, anxiety, and anger Preoccupied with rejection, humiliation, and failure Treatment: Individual and group therapy Psychotherapy focuses on trust and assertiveness training. Beta-adrenergic receptor antagonists (atenolol) Antidepressant medications: selective serotonin reuptake inhibitors (SSRIs): citalopram (Celexa) serotonin norepinephrine reuptake inhibitors (SNRIs): venlafaxine (Effexor) Serotonergic agents Guidelines for nursing care: Friendly, accepting, reassuring approach Acceptance of patient fears Group therapy Exercises to enhance new social skills Design exercises to prevent failures Assertiveness training Cluster C: Dependent Personality Disorder Prevalence: 0.5% Characteristics: High need to be taken care of Submissiveness Fears of separation and abandonment Manipulating others to take responsibilities Intense anxiety when left alone even briefly Treatment: Psychotherapy is treatment of choice Guidelines for nursing care: Help address current stressors Set limits that don't make the patient feel punished Be aware of strong countertransference Use therapeutic relationship as a testing ground for assertiveness training Cluster C: Obsessive Compulsive Disorder Prevalence: 2% to 8% Characteristics: Rigidity; inflexible standards for others and self Constant rehearsal of social responses Excessive goal-seeking that is self-defeating or relationship-defeating Strict standards interfere with project completion Unhealthy focus on perfection Treatment: Patients tend to seek help Also seek help for anxiety or depression Group and behavioral therapy Clomipramine or fluoxetine for obsessions, anxiety, and depression Guidelines for nursing care: Guard against power struggles Remember that the patient has difficulty dealing with unexpected changes

Basic Intimate Partner Violence Safety Plan

Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary. It is important, whenever possible, to work with a domestic violence advocate to develop a safety plan that fits your needs. • Move to a room with more than one exit, avoiding rooms with potential weapons such as kitchen knives or heavy objects. • Know the quickest route out o your home. • Know the quickest route out o your workplace. Determine resources the employer may have to protect employees, such as a security guard escort. • Keep a bag packed with essentials: clothes, valuables, documents (such as passports, Social Security cards, medical records, bank cards, birth certifcates ), a list of phone contacts, a month's supply of medications, and money. Keep it hidden but make it easy to grab quickly, or consider keeping it with a friend, relative, or at work so it is not discovered by the abuser. • Tell your neighbors about your abuse and ask them to call the police when they hear a disturbance. • Have a code word to use with your children, family, and friends when you need help. Consider some o the new phone apps or alerting significant contacts in an emergency. • Have a safe place selected in case you ever have to leave, such as a friend or relative's home or a shelter. • Use your instincts, and do not provoke the abuser when considering leaving. • Unless you are in danger at that moment, try to leave when the abuser is not at home or around you. • You have the right to protect yourself and your kids. • Call the National Domestic Violence Hotline at 1-800-799-7233 or further information and guidance.

IMPULSIVE The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by:

patient has a history of impulsively acting out anger by striking others nurse should plan . Help the patient identify incidents that trigger impulsive acting out. Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice. little time elapsed between thought and action acting without thought on urges or desires.

Undoing: Defense Mechanism

performing often ritualistic activity in order to relieve anxiety about unconscious drives (e.g. washing hands after murder; noisy teen cleans room without being asked) (undo the murder by washing hands) An employee brings cake for her boss after complaining about rules.

Depressive Personality Disorder

characterized by a pervasive pattern of depressive cognitions and behaviors in various contexts Assess self-harm risk

A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful?

"I'm sleeping better although I still have an occasional nightmare." Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victim's sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing

A nurse interviews a 17 year old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim?

"Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. "Why" questions represent probing, which is a non-therapeutic communication technique. The victim may or may not have friends who have had this experience, but it's important to talk about his feelings rather than theirs.

Schizotypal PersonalityDisorder

-Ideas of reference -Magical thinking or odd beliefs -Perceptual distortions -Frightened, suspicious, blunted -affect -Anxious -Socially inept Paranoid thoughts a pattern of being very uncomfortable in close relationships, having distorted thinking and eccentric behavior. A person with schizotypal personality disorder may have odd beliefs or odd or peculiar behavior or speech or may have excessive social anxiety. priority intervention for a nurse beginning a therapeutic relationship with a patient diagnosed with a schizotypal personality disorder is to Respect the patients need for periods of social isolation. Patients diagnosed with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Patients diagnosed with schizotypal personality disorder rarely engage in behaviors that violate the nurses rights or exploit the nurse. Individuals with schizotypal personality disorders are characterized by a pattern o peculiar behavior and odd speech and by the presence o cog- nitive perceptual distortions in the absence o psychosis These individuals avoid interpersonal rela- tionships, and may be indi erent to the reactions o others in their lives. They most closely resemble people with schizophrenia and are per- ceived by others as strikingly odd, strange, or eccentric. Individuals with schizotypal personality disorders o ten possess and demonstrate magi- cal thinking and rituals, hold belie s that they can control the actions o others, or have bizarre antasies or preoccupations that are not consistent with cultural norms. Their speech is peculiar in phrasing and syntax and may have meaning only to them. Reactions o con usion by others to their apparent illogical speech may cause these individuals to become suspiciouso othersandeventuallytodevelopparanoidthinking.Their eccentric and unkempt appearances, strange behaviors, and nonadher- ence to social conventions make it impossible or them to have give-and- take conversations. Because o these odd styles o behavior and inattention to social conventions, they lack riends.

Therapeutic communication

-the purposeful use of communication to build and maintain helping relationships with the client, families, and significant others -client centered: not social or reciprocal -purposeful, planned, and goal-directed Use accepting, nurturing, and empathetic communication techniques. Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victims needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust. Therapeutic Communication1.Identify personal and environmental factors that can impede communication.2.Discuss the differences between verbal and nonverbal communication, and identifyexamples of nonverbal communication.3.Identify attending behaviors the nurse might focus on to increase communication skills.4.Relate problems that can arise when nurses are insensitive to cultural aspects ofpatients' communication styles.5.Demonstrate the use of techniques that can enhance or detract communication.6.Provide examples of verbal and nonverbal communication of different cultural groups inthe areas of a) style, b) eye contact, and c) touch

Cluster A Personality Disorders

1) Eccentric and odd behavior 2) Unusual levels of suspiciousness 3) Magical thinking 4) Cognitive impairment Cluster A: Paranoid Personality Disorder Prevalence: 2% to 4% Characteristics: oMay be apparent in childhood oSocial anxiety in childhood oJealous, controlling as adults o Unwillingness to forgive and projection of feelings Treatment: oCounteract mistrust by (a) adhering to schedules and (b) avoiding being overly friendly, and (c)projecting a neutral but kind affect oPsychotherapy versus group therapy oShort-term antidepressants Cluster A: Schizoid Personality Disorder Prevalence: Nearly 5% of population Characteristics: oSymptoms appear in childhood and adolescence oLoners, poor academic performance oIncreased prevalence of disordered family life oAvoid close relationships oDepersonalization, detachment oTreatment: Psychotherapy oGroup therapy oAntidepressants Guides for nurses: oAvoid being too "nice" or "friendly" oDo not try to increase socialization oAssess for symptoms the patient is reluctant to discuss oProtect against group's ridicule Cluster A: Schizotypal Personality Disorder Prevalence: Varies from 0.64 to 4.6% population Characteristics: oSevere social and interpersonal deficits oAnxiety in social situations oRambling conversation oParanoia, suspiciousness, anxiety, distrustoBrief, intermittent episodes of hallucination or delusion oCan be made aware of their own odd beliefs oMay be vulnerable to involvement with cults or unusual religious/occult groups Treatment: oPsychotherapy (investigate possible involvement with cults) oLow-dose antipsychotics

Epidemiology and Comorbidity

13% in general populations Frequently co-occur with Disorders of mood Anxiety Eating Substance abuse

Interventions after the suicide Crisis Period

1. Arrange or patient to stay with amily or riends. I no one is available and the person is highly suicidal, hospitalization must be considered. Relieves isolation and provides sa ety and com ort 2. Weapons and pills are removed by riends, relatives, or the nurse. Helps ensure sa ety 3. Encourage patients to talk reely about eelings (anger, disappointments) and help plan alternative ways o handling anger and rustration. Gives patients alternative ways o dealing with overwhelming emotions and gaining a sense o control over their lives 4. Encourage patient to avoid decisions during the time o crisis until alternatives can be considered. During crisis situations, people are unable to think clearly or evaluate their options 5. Contact family members; arrange or individual or family crisis counseling. Re-establishes social ties and mobilizes amily support to deal with precipitating event(s) or overwhelming situation 6. Activate links to social supports in the community (e.g., sel -help groups). . Diminishes sense o isolation and provides contact with individuals who care about the suicidal person. 7. I anxiety is extremely high or patient has not slept in days, an antianxiety or antidepressant might be prescribed. Only a 1- to 3-day supply o medication should be given. Family member or signif cant other should monitor pills or sa ety . . Relie o anxiety and restoration a ter sleep loss can help the patient think more clearly and might help restore some sense o well-being. SSRIs are most commonly given, but they have Black Box warnings and patient and amily/ riends need to be educated.*

Sexual Assault assessment guidelines Nurse Nursing response to "its my fault"

1. Assess and document the circumstances o the event, including presence of threats ( force, trauma, weapons, resistance, sexual acts), location o incident, and circumstances surrounding the assault. Document in patient's own words when possible. 2. Gather data that may be used as criminal evidence in court using the institution's protocol. 3. After consent forms have been signed, forensic evidence (debris) should be obtained rom clothing, fingernail scrapings, head hair, and pubic hair; smears or sperm and/or acid phosphatase should be taken from any orfice involved. (Note: Elevated prostatic acid phosphatase levels are indicative o the presence o semen.) Permission or any photographs taken during the assessment also needs to be obtained. (Guidelines 3 through 8 are all considered forensic evidence that might be used in court at a later date and should be done by a forensically trained professional [e.g., SANE].) 4. Assess or evidence o any physical trauma (e.g., bites, stab wounds, contusions, gunshot wounds). Use drawings (body map) and photos to identi y the areas and size of trauma. 5. Perform pelvic exam to identify vaginal and cervical trauma (perform anal exam in males and sodomized females). Culture or STIs. 6. Perform psychological assessment, noting reactions to the rape event (e.g., crying, ear fulness, agitation, preoccupation, detachment). Describe all behavior in writing. 7. Perform a mental status examination. 8. Determine drug use by either the assailant or the survivor. Assess situation or potential involvement o date rape drug i it occurred in a large gathering (e.g., college campus, bar, party). A urine sample might be useful if timing is correct. Emphasize to individuals that even i they were drinking, they are not at fault or being assaulted. (Refer to Table 22-1 or drugs associated with sexual assault.) 9. Identify the victim's support system (e.g., family, friends, others the person trusts), and ask or permission to involve them. Explain possible delayed reactions that might occur. Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. Support the victim to separate issues of vulnerability from blame. You believe this would not have happened if you had not been alone? A reflective communication technique is helpful. Looking at ones role in the event serves to explain events that the victim would otherwise find incomprehensible.

Information to Help a Recent Victim of Sexual Violence in the Aftermath of Rape (Either on the Phone or in Person)

1. Go to a safe place immediately. 2. Consider reporting the rape to the police or to the campus police if it happened on campus. 3. You can report the assault and later choose not to pursue criminal proceedings. 4. If you choose not to report the assault immediately, you can do so at a later time. Preserve evidence of the rape: 1. Do not wash your hands or ace. 2. Do not shower or bathe. 3. Do not brush your teeth. 4. Do not change clothes or straighten up the area where the assault took place. Other information regarding the location o a sexual assault response team (SART), a violence prevention resource center, a crisis center, or an emergency department in the area. Explain that even i the victim chooses not to press charges, the victim can still have a forensic examination without the rape being reported to the police I feel so dirty. Please let me take a shower before the doctor examines me. The nurse should: explain that washing would destroy evidence. No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court.

questions to ask patient does the patient have a history o previous violence, substance abuse, or psychotic behavior?

1. Have you ever thought o harming someone else? 2. Have you ever seriously injured another person? 3. What is the most violent thing you have ever done?

The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) or Mental Health Pro essionals

1. IDENTIFY RISK FACTORS Note those that can be modified to reduce risk 2. IDENTIFY PROTECTIVE FACTORS Note those that can be enhanced 3. CONDUCT SUICIDE INQUIRY Suicidal thoughts, plans behavior and intent 4. DETERMINE RISK LEVEL/INTERVENTION Determine risk. Choose appropriate intervention to address and reduce risk 5. DOCUMENT Assessment o risk, rationale, intervention, and follow-up Risk Level Risks/ Protective Factor Suicidality Possible Interventions High Psychiatric disorder with severe symptoms o acute precipitating event protective actors not relevant Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal Admission generally indicated unless a signi cant change reduces risk. Suicide precautions Moderate Multiple risk actors, ew protective actors Suicidal ideation with plan, but no intent or behavior Admission may be necessary depending on risk actors. Develop crisis plan. Give emergency/crisis numbers Low Modi ed risk actors, strong protective actors Thoughts o death, no plan, intent or behavior Outpatient re erral, symptom reduction. Give emergency/ crisis numbers

Interventions or Follow -Up Psychotherapy after suicide crisis

1. Identi y situations that trigger suicidal thoughts (de ne the precipitating event). Identi es targets or learning more adaptive coping skills. 2. Assess patient's strengths and positive coping skills (talking to others, creative outlets, social activities, problem-solving abilities). Identi es areas to build on and draw rom when planning alternatives to sel -de eating behaviors 3. Assess patient's coping behaviors that are not e ective and that result in negative emotional sequelae: drinking, angry outbursts, withdrawal, denial, and procrastination. . Identi es areas to target or teaching and planning strategies or supplanting negative behaviors with more e ective and sel -enhancing behaviors. 4. Encourage patients to look into their negative thinking, and re rame negative thinking into neutral objective thinking.Cognitive re raming helps people look at situations in ways that allow or alternative approaches 5. Point out unrealistic and per ectionistic thinking. 6. Spend time discussing patient's dreams and wishes or the uture. Identi y short-term goals that can be set or the uture. 7. Identi y things that have given meaning and joy to li e in the past. Discuss how these things can be reincorporated in the present li estyle (e.g., religious or spiritual belie s, group activities, creative endeavors)

Five Kinds of Elder Abuse Interventions for Suspected Elder Abuse

1. Physical abuse: The infliction of physical pain or injury through slapping, hitting, kicking, pushing, restraining, overmedicating, or sexually abusing. 2. Psychological abuse: The infliction of mental anguish through yelling, name calling, humiliating, or threatening. 3. Financial abuse or exploitation: The misuse of someone's property and resources by another person, or refusal by a caregiver to provide needed resources. 4. Neglect: Failure to fulfill a caretaking obligation to provide nutrition, hydration, shelter, clothing, utilities, medical services, or other basic needs. This category may also include self-neglect. 5. Sexual abuse: Non-consensual sexually molesting, touching, inappropriate comments or exposure to videos or acts, or actual rape. 1. Check your state or laws regarding elder abuse. (All states have adopted laws to help protect elders and support their need or safety) 2. Involve Adult Protective Services (APS) if abuse is suspected. (APS can offer many sources to help guard the safety and well-being o abused elders.) 3. Meet with other family members to identify stressors and problem areas, including caregiver strain. (Other family members may be unaware o the abuser's stress level or the lack o safety available or the abused family member) 4. I there are no other amily members, noti y other community agencies that might help stabilize the situation, such as: • Support group or elderly patient or or abuser and family members • Meals on Wheels • Day care or seniors • Respite services • Visiting nurse services • Assisted living (Minimizes family stress and isolation, and increases safety) 5. Encourage abuser to seek counseling. (Increases coping skills and social supports) 6. Suggest that family members meet on a regular basis or problem solving and support. (Encourages family to learn and solve problems together) Some additional red flags more specifc to elderly victims • Fear of being alone with the caregiver • Malnutrition or begging for food, dehydration • Bedsores, skin tears, bruises, swelling, or fractures • In need of medical or dental care • Left unattended for long periods • Reports of abuse or neglect • Passive, withdrawn, or emotionless behavior • Appears overmedicated • Vaginal or rectal pain, tears, or bleeding, or STIs • Concern over nances • Inability to pay for medications or needed services • Transfer of property by an elder who lacks the mental capacity to consent • Valuables missing

Indicators for Domestic Violence

==Recurrent emergency department (ED) visits or physical injuries attributed to being accident prone. ==Somatic symptoms ref ecting anxiety or chronic stress, such as hyperven- tilation, gastrointestinal distress, hypertension, insomnia, nightmares, and even eczema or hair loss in some cases. ==Signs o depression, which can include sadness, tear ulness, sleep or appe- tite disturbance, irritability, loss o interest in usual activities, atigue, and in some cases thoughts o suicide.

Characteristics of abusive parents

=A history of violence, neglect, or emotional deprivation as a child =Low sel -esteem, feelings o worthlessness, depression =Poor coping skills =Social isolation, may be suspicious o others =Few or no friends, little or no involvement in social or community activities = Involved in a crisis situation such as unemployment, divorce, culties, abusive relationship =Rigid, unrealistic expectations of child's behavior =Frequently uses harsh punishment =History of severe mental illness, such as schizophrenia =Violent temper outbursts =Looks to child for satisfaction of needs for love, support, and reassurance =Projects blame onto the child or his or her problems =Lack of effective parenting skills =Inability to seek help rom others =Perceives the child as bad or evil =History o drug or alcohol abuse =Feels little or no control over li e =Low tolerance or rustration -Poor impulse contro

resources to stabilize the home situation

A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, My father doesnt like me. He calls me stupid all the time. The mother says the father is easily frustrated and has trouble disciplining the children. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wifes admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time.

Regression

A 7 year old wets the bed after noticing her mother giving more attention to her younger siblings.

matter-of-fact approach Matter of fact approach

A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: provide care in a matter-of-fact manner. A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. The incorrect options provide positive reinforcement of the behavior.

Dissociation

A patient states she feels disconnected from reality.

A nurse plans care or a patient diagnosed with borderline person- ality disorder. Which nursing diagnosis is most likely to apply to this patient? 3. Answer - a. Pages 169-170. People diagnosed with borderline per- sonality disorder requently use the de ense o splitting, which strains personal relationships. Splitting is the inability to integrate both the positiveandthenegativequalitieso anindividualintooneperson. The nurse assesses a new patient suspected o having a schizotypal personality disorder. Which assessment question is this patient most likely to answer a rmatively? 4. Answer - c. Page 168. Genetics seem to play a signi cant role in the development o schizotypal personality disorder, which is more common in amilies with a history o schizophrenia. A mental health nurse assesses a patient diagnosed with an anti- social personality disorder. Which comorbid problem is most important orthenursetoincludeintheassessment? 5. Answer - b. Page 169. Alcohol abuse is a commonly occurring problem in persons diagnosed with antisocial personality disorder.

A person shopli ts merchandise rom a community cancer thri t shop. When con ronted, the thie replies, "All this stu was donated,soIcantakeit."Thiscommentsuggests eatureso which personality disorder? 1. Answer - a. Pages 167-168. The correct response shows callous- ness, entitlement, lack o remorse, and disregard or the rights o others. These characteristics are common in persons diagnosed with antisocial personality disorder. After a power outage, a facility must serve a dinner o sandwiches and ruit to patients. Which comment is most likely rom a patient diagnosed with a narcissistic personality disorder? 2. Answer - c. Page 170. People diagnosed with narcissistic person- ality disorder consider themselves special and expect special treat- ment. Their demeanor is arrogant and haughty. They have a sense o entitlement.

DSM-5 DIAGNOSTIC CRITERIA for Borderline Personality Disorder

A pervasive pattern o instability o interpersonal relationships, self -image, anda ects,andmarkedimpulsivity,beginningbyearlyadulthoodandpresent inavarietyo contexts,asindicatedby ve(ormore)o the ollowing: 1. Frantic efforts to avoid real or imagined abandonment. (Not e: Do not include suicidal or sel -mutilating behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized byalternatingbetweenextremeso idealizationanddevaluation. 3. Identity disturbances: markedly and persistently unstable sel -image or sense of self . 4. Impulsivity in at least two areas that are potentially sel -damaging (e.g., overspending money, sex, substance abuse, reckless driving, binge eating). (Not e: Do not include suicidal or sel -mutilating behavior covered in Crite- rion 5.) 5. Recurrent suicidal behavior, gestures, or threats, or self mutilating behavior. 6. Affective instability due to a marked reactivity o mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days ). 7. Chronic feelings o emptiness. 8. Inappropriate, intense anger or di culty controlling anger (e.g., requent displays o temper, constant anger, recurrent physical ghts). 9. Transient, stress-related paranoid ideations or severe dissociative symptoms.

Denial

A smoker believes scientific evidence linking smoking with cancer is untrue. Denial is an unconscious motivated refusal to believe something. A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, I cant talk about it. Nothing happened. I have to forget! Disbelief is a common finding during the acute stage following sexual assault. Denial is evidence of the disbelief. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape.

Rationalization

A student watches TV instead of studying and says studying wouldn't help. A therapist recently convicted of multiple counts of Medicare fraud says, Sure I overbilled. Why not? Everyone takes advantage of the government, so I did too. These statements show: lack of guilt feelings. Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not exhibit anxiety, remorse, or guilt about the act. The patients remarks cannot be assessed as shameful. Lack of trust or concern that others are determined to cause harm is not evident.

Survivor

A survivor is an individual who has experience sexual assault, participated in interventions, and is moving forward in life. Victim refers to a person who experienced a recent sexual assault. Plaintiff refers to a person bringing a civil complaint to the court system. Perpetrator refers to a person who commits a crime.

Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patients needs and maintain a therapeutic milieu?

Ability to provoke interpersonal conflict Frequent team meetings are held to counteract the effects of the patient's attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings. See relationship to audience response question.

narcissistic personality disorder

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the characteristics of grandiosity, attention seeking, and arrogance are consistent with narcissistic personality disorder. Narcissistic behavior is characterized by grandiosity and exploitive behavior. a preoccupation with fantasies of success or power, and a need for constant attention or admiration. Grandiosity Arrogant attention seeking Fantasies of power or brilliance Need to be admired Sense of entitlement Rude, patronizing The client's mother catered to his every need and the client used temper tantrums to successfully get his way. "My mother never really seemed to see me as a person with my own thoughts and problems." a pattern of need for admiration and lack of empathy for others. A person with narcissistic personality disorder may have a grandiose sense of self-importance, a sense of entitlement, take advantage of others or lack empathy.

patient is angry and loudly complains to the nurse manager. Which is the nurse managers best response?

Acknowledge and validate the patients distress and ask, What would you like to have happen? When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should solve the problem with the patient by acknowledging the patients feelings, validating them as understandable, apologizing if necessary, and then seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step.

Aggression

An action or behavior that results in verbal or physical attack behavior best demonstrates aggression Stomping away from the nurses station, going to another room, and grabbing a snack from another patient. Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Signs of someone whose potential for aggression: A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member.

Anger

An emotional response to frustration of desires, a threat to one's needs or a challenge

Medications or Chronic Aggression

Anticonvulsants (e.g., carbamazepine) Labile mood, poor impulse control, organicity e.g., dementia Antipsychotics Disorganized behavior Beta blockers (propranolol) Organicity e.g., dementia Buspirone Organicity Clonidine Anxiety, agitation Lithium Labile mood, impulsivity Selective serotonin reuptake inhibitors (SSRI's) Anger "attacks" Benzodiazepines are o ten the rst choice or acute aggressive episodes, especially in episodic dyscontrol and incipient rage episodes Aggression, hostility, and violent behaviors are usually a result o the underlying psychiatric or medical disorder

trazodone (Desyrel)

Antidepressant Trazodone is for patients with depression, insomnia, or chronic pain

antisocial personality disorder Manipulative patients

Antisocial personality disorder is characterized by persistent disregard or and violation of the rights o others with an absence of remorse or hurting others People with antisocial PD have a sense of entitlement, which means they believe they have the right to hurt others, take what they want, Characteristics: Callous attitude, Aggression A personality disorder in which the person (usually a man) exhibits a lack of conscience for wrongdoing, even toward friends and family members. May be aggressive and ruthless or a clever con artist. Individuals diagnosed with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals diagnosed with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals diagnosed with antisocial personality disorders are more likely to be impulsive than to be perfectionists. -Has superficial charm -Violates rights of others -Lies, cheats, lacks guilt or remorse -Impulsive -Lacks empathy -As patients are aggressive and manipulative A intervention that is appropriate for a patient diagnosed with an antisocial personality disorder who frequently manipulates others is to..... Refer the patients requests and questions to the case manager. Manipulative patients frequently make requests of many different staff members, hoping someone will give in. Having only one decision-maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority. priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects is Risk for other-directed violence Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders rarely have psychotic symptoms. When patients with antisocial personality disorders use denial, they use it effectively. Although ineffective coping applies, the risk for violence is a higher priority. The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common. "I hit because Im tired of being nagged. My spouse deserved the beating." patient diagnosed with a personality disorder has used manipulation to get his or her needs met. The staff decides to apply limit-setting interventions. rationale: External controls are necessary while internal controls are developed. A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately.

severe anxiety

Anxiety is the result of a personal threat to the victims safety and security. In this case, the persons symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety.

reasons why personal and work relationships often fail or individuals with PDs:

Avoidance and fear of rejection Blurring of boundaries between the self and others so that closeness seems to lead to fusion, an intense and undesirable effect on both parties Insensitivity to the needs of others Demanding Fault nding (grievance collectors) Inability to trust Lack individual accountability Passive-aggressive traits Tendency to evoke intense interpersonal conflict

Schizoid Personality disorder

Avoids close relationships Socially isolated Appears cold, aloof and detached Poor occupational functioning Uncooperative being detached from social relationships and expressing little emotion. A person with schizoid personality disorder typically does not seek close relationships, chooses to be alone and seems to not care about praise or criticism from others. People with schizoid personality traits are characterized by an inability to establish relationships with others and a restricted range o emotions in interpersonal settings (APA, 2013). They are seen by others as eccentric, isolated, or lonely. They may exist on the periphery o society content to avoid relationships o even the most super cial nature. Their affect is usually at, which projects emotional coldness. They appear indi erent to praise or criticism by others. Although they invest no interest or energy into human relationships o any kind, they may invest enormous energy into nonhuman interests such as mathematics and astronomy. Typically loners, they spend much time daydreaming and are o ten very attached to animals. There is some evidence that people with schizoid personality traits may later develop schizophrenia or a delusional disorder. Although aloo , some individuals with schizoid traits have conceived, developed, and given our world genuinely original and creative ideas.

Repression (defense mechanism)

Banishes anxiety-arousing wishes and feelings from consciousness A traumatized solider has no memory of details of a close brush with death.

Interventions

Basic level interventions Milieu management Pharmacological interventions Case management Advanced practice interventions Dialectical behavioral therapy (DBT)

When a patients aggression quickly escalates, which principle applies to the selection of nursing interventions?

Begin with the least restrictive measure possible. Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out- of-control patient what to do is rarely helpful. It may be an effective strategy during the preassaultive phase but is less effective during escalation.

A nurse plans care for an individual diagnosed with antisocial personality disorder. Which character behaviors will the nurse expect? Select all that apply

Callous attitude Aggression

personality disorder

Causing behavioral dysfunction and inner distress appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others acknowledge manipulative behavior when it is called to his or her attention. Acknowledging manipulative behavior is an early outcome that paves the way for taking greater responsibility for controlling manipulative behavior at a later time. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. Ideally, the patient will use assertive behavior to promote the fulfillment of legitimate needs. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity and immediacy control. COMMON ASSESSMENT (personality disorder assessment )has self esteem issues, despite his or her outward presentation. Self esteem issues are present, despite patterns of withdrawal, grandiosity, suspiciousness, or unconcern. They seem to relate to early life experiences and are reinforced through unsuccessful experiences in loving and working. 1. Assess for suicidal or homicidal thoughts. If these are present, the patient needs immediate attention. 2. Determine whether the patient has a medical disorder or another psychiatric disorder that may be responsible for the symptoms (especially a substance use disorder). 3. View the assessment about personality functioning from within the person's ethnic, cultural, and social background. 4. Ascertain whether the patient experienced a recent important loss. Personality disorders are often exacerbated after the loss of significant supporting people or in a disruptive social situation. 5. Evaluate for a change in personality in middle adulthood or later, which signals the need for a thorough medical workup or assessment for unrecognized substance use disorder.

Behavioral Characteristics of Intimate Partner Violence

Characteristics of Violent Partner Denial and Blame: Denies that abuse occurs, shi ts responsibility o abuse to partner. Makes statements that the victim caused the abuse, caused the abuser to react that way Emotional Abuse: Belittles, criticizes, insults, uses name calling, undermines Control through Isolation: Limits amily or riends, controls activities and social events, tracks time or mileage on car and activities, stalks at work, takes to and rom work or school, may demand permission to leave house Control through Intimidation: Uses behaviors to instill ear, such as vile threats, breaking things, destroying property, abusing pets, displaying weapons, threatening children, threatening homicide or suicide, and increasing physical, sexual, or psychological abuse Control through Economic Abuse: Controls money, makes partner account or all money spent; i partner works, calls excessively, orces partner to miss work; re uses to share money Control through Power: Makes all decisions, de nes role in the relationship, treats spouse like a servant, takes charge o the home and social li e Characteristics of Battered Partner Eventually believes that i she does or says the right thing, the abuse will stop. I she does not do anything wrong, abuse will not occur. May be re-creating patterns rom abuse during childhood that are amiliar Becomes psychologically devastated and begins to believe partner's words. Lowered sel -esteem. Unhealthy bond with the abuser Gradually loses sight o personal boundaries or sel , children. Over time becomes unable to accurately assess the situation without validation from a supportive network. Results in constant ear and terror that becomes cumulative and oppressive; contemplates suicide, contemplates homicide, occasionally completes suicide or homicide in sel -de ense. Posttraumatic stress symptoms develop Economic and emotional dependency may result in depression, high risk or secret drug or alcohol abuse. I she works, requently loses job due to partner stalking and harassing. Is unable to save money to leave. Continues to lose sense o sel , becomes unsure o who she is, de nes sel in terms o partner, children, job, others; lacks personal power.

Potential Nursing diagnosis Page 467, table 24-3

Chronic low self-esteem, related to negative feedback from parents: An 11-year-old child says, My parents dont like me. They call me stupid and say I never do anything right, but it doesnt matter. Im too dumb to learn. The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the childs statements.

Cognitive Deficits and the Catastrophic Reaction: Making Contact

Cognitive deficits result in: • A decreased ability to interpret sensory stimuli • A decreased ability to tolerate sensory stimuli Striking out represents ear or the eeling that the environment is out o control. The presence o a second agitated person (e.g., sta member) leads to increased agitation; there ore: 1. Face the patient rom within 2 eet, remaining as calm and unhurried as possible. 2. Say the patient's name. 3. Gain eye contact. 4. Smile. 5. Repeat steps 2 through 4 several times i necessary, to gain and maintain eye contact. 6. Use gentle touch and keep voice so t (the person o ten matches this tone and lowers his or her voice also). 7. Ask the patient i there is a need to use the bathroom. 8. Help the patient regain a sense o control—ask what is needed. 9. Validate the patient's eelings: "You look upset. This can be a con using place." 10. Use short, simple sentences. Complex explanations just represent more noise. 11. Decrease sensory stimulation. 12. Get the patient to use rhythmic sources o sel -stimulation (e.g., humming, a rocking chair).

Foods Containing Tyramine

Concurrent ingestion of tyramine-rich foods and tranylcypromine sulfate (Parnate) may result in a life-threatening hypertensive crisis. Signs and symptoms of hypertensive crisis include chest pain, tachycardia or bradycardia, severe headache, nausea, vomiting, photosensitivity, neck stiffness, sweating, and enlarged pupils. I would caution Sylvia to avoid alcohol, CNS depressants, OTC drugs, and foods or beverages containing tyramine or excessive caffeine during and for at least 2 wk after therapy has been discontinued; they may precipitate a hypertensive crisis. I would also Instruct Sylvia to notify health care professional immediately if symptoms of hypertensive crisis (e.g. severe headache, palpitations, chest or throat tightness, sweating, dizziness, neck stiffness, nausea, or vomiting) develop. • aged cheeses (blue, Boursault, brick, Brie, Camembert, cheddar, Emmenthaler, Gruyère, mozzarella, Parmesan, Romano, Roquefort, Stilton, Swiss) • American processed cheese • avocados (especially over-ripe) • bananas • bean curd • beer and ale • caffeine-containing beverages (coffee, tea, colas) • caviar • chocolate • distilled spirits • fermented sausage (bologna, salami, pepperoni, summer sausage) • liver • meats prepared with tenderizer • miso soup • over-ripe fruit • peanuts • raisins • raspberries • red wine (especially Chianti) • sauerkraut • sherry • shrimp paste • smoked or pickled fish • soy sauce • vermouth • yeasts • yogurt

Pacing, Rigid posture with clenched jaw, Staring with narrowed eyes into the eyes of another behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive

Crying and a withdrawn affect are not cited by experts as behaviors indicating that the individual has a high potential to behave violently. The other behaviors are consistent with the increased risk for other-directed violence.

Vulnerable Individuals

Dementia: Older adults, particularly those with cognitive impairments, are at high risk for abuse. • Gender: Women have a higher vulnerability rate than men (approximately 3 to 1). Both genders are more vulnerable i they are handicapped, have cognitive problems, or have mental disorders. • Age: People ages 16 to 19 seem to have a higher rate o sexual victimization than any other age group. Children are most vulnerable between the ages o 8 and 12. One in three girls and one in six boys are sexually abused be ore the age o 18, which constitutes up to 44% o the total number o sexual assaults or rape. • Older adults: Domestic violence against older adults includes physical and sexual abuse; the perpetrators are most o ten adult children, especially sons, but can also include spouses, caregivers, health care providers, and other relatives. Although statistics are di cult to ascertain, when an older adult is cognitively or unctionally impaired, the likelihood o being sexually assaulted increases. • History of sexual violence: Women who were raped be ore the age o 18 are two to three times more likely to be sexually assaulted as adults. • Drug and alcohol use: Use o alcohol or drugs by the perpetrator, the victim, or both is related to increased rates o victimization. • High-risk sexual behavior: High-risk sexual behavior is a vulnerability that is o ten a consequence o childhood sexual abuse. • Poverty: Poverty can make women and children more vulnerable and place them in more dangerous situations. Poor women may be at risk when they need to support themselves or their children and trade sex or ood, clothing, money, or other necessary items. • Ethnicity or culture: Sexual violence against indigenous women in the United States is widespread. According to Amnesty International (2015), Native American and Alaskan Native women are more than 2.5 times more likely to be raped or sexually assaulted than other women in the United States. The majority o the perpetrators, up to 86%, were non-Native men according to the American Indian and Alaskan Native women survivors Alzheimer disease The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision.

Cluster B Personality Disorders

Dramatic, emotional, erratic behavior. Problems with impulse control. Cluster B: Borderline Personality Disorder Prevalence: 1.6% Epidemiology and comorbidity 10% suicide and mortality rate 85% of BPD patients have another mental illness Etiology High genetic association Separation-individuation factors Characteristics: Severe impairments in functioning Emotional lability Impulsivity Self-destructive behaviors Antagonism Splitting: Inability to view both positive and negative aspects of others as part of a whole patterns of marked instability in emotional control or regulation impulsivity identity or self-image distortions unstable mood unstable interpersonal relationships Treatment: -Pharmacological interventions Psychotropics geared toward symptom relief -Advanced practice interventions Assist staff in therapeutic alliance -Psychotherapy CBT Dialectical behavior therapy (DBT) Schema-focused therapy Cluster B: Narcissistic Personality Disorder Prevalence: For 0% to 6% Characteristics: Feelings of entitlement, exaggerated self importance Lack of empathy; tendency to exploit others Weak self-esteem and hypersensitivity to criticism Constant need for admiration Less functional impairment than other personality disorders Treatment: Difficult to treat: patients not likely to seek help or confront shortcomings Cognitive-behavioral therapy (CBT) to deconstruct faulty thinking Group therapy; lithium for mood swings Guidelines for Nursing Care: Remain neutral. Avoid power struggles or becoming defensive. Role model empathy. Cluster B: Histrionic Personality Disorder Prevalence: Nearly 2% of population Characteristics: Excitable, dramatic; often high functioning Bold external behaviors Limited ability to develop meaningful relationships Attention-seeking, self-centered; low-frustration level Excessive emotions; may be provocative; smothering No insight into disorder or role in ruining relationships Treatment: Psychotherapy is treatment of choice Guidelines for nursing care: Know that seductive behavior is a response to distress. Keep interactions professional; ignore flirtations. Model concrete language. Help patient clarify inner feelings Cluster B: Antisocial Personality Disorder Prevalence: 1.1% Characteristics Antagonistic behaviors Disinhibited behaviors Profound lack of empathy Absence of remorse or guilt antagonistic behaviors: being deceitful and manipulative for personal gain or hostile if needs are blocked disinhibited behaviors: high-risk taking, disregard for responsibility, and impulsivity. Criminal misconduct and substance abuse are common in this population. Treatment/Interventions: Boundaries, consistency, support, and limits Realistic choices Teamwork and safety (prime) Therapeutic communication Pharmacological interventions (mood stabilizers)

cognition (thinking) COGNITIVE cognitive technique

Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. effective nursing intervention to assist an angry patient to learn to manage anger without violence Anger has a strong cognitive component; therefore, using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management. mental activity that goes on in the brain when a person is organizing and attempting to understand information and communicating information to others A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, Dont touch me! You are so stupid. You will make it worse! Which intervention uses a cognitive technique to help this patient? Continue the dressing change, saying, Do you know this dressing change is needed so your wound will not get infected? Anger is cognitively driven. The correct answer helps the patient test his cognitions and may help lower his anger. The incorrect options will escalate the patients anger by belittling or escalating the patients sense of powerlessness.

Paranoid Personality Disorders

Individuals with paranoid personality disorder are suspicious and hostile and project blame. deficiencies in self structures are shielded against further damage by using hostility and suspicion to keep potentially injurious objects at a safe distance -Suspicious of others -Fear others will exploit, harm, or deceive them -Misread compliment as manipulation -Hypervigilant -Prone to counterattack -Hostile and violent a pattern of being suspicious of others and seeing them as mean or spiteful. People with paranoid personality disorder often assume people will harm or deceive them and don't confide in others or become close to them. People with paranoid personality disorder (PPD) exhibit traits that are characterized by pervasive, persistent, and inappropriate suspiciousness and distrust o others without the slightest justi cation (APA, 2013). Individuals with PPD are no strangers to the health care system. Nurses encounter people who are hostile, irritable, angry, injustice collectors, pathologically jealous o their partner, and litigious cranks; they are constantly suspicious and believe that others are lying, cheating, exploit- ing, or trying to harm them in some way. These individuals lack warmth, pay close attention to power and rank, and express disdain to those who are weak, sickly, and impaired. Although they may appear businesslike and e cient, they o ten generate ear and conf ict in others through their hostile, stubborn, and sarcastic expressions. Even when people are loyal to them (e.g., spouse, partner) they usually make others uncom ortable; they are keenly aware o the weaknesses o others and exploit these weaknesses to keep interpersonal distance. It has been said that individuals with per- sonalitytraits"lackthemilko humankindness."

Interventions during the suicidal Crisis Period

Inpatient 1. Follow institutional protocol or suicide regarding creating a safe environment (taking away potential weapons—belts, sharp objects; checking what visitors bring into patient's room). Provides safe environment during time patient is actively suicidal and impulsive; self -destructive acts are perceived as the only way out o an intolerable situation 2. Keep accurate and thorough records o patient's behavior—both verbal and physical—as well as all nursing and physician actions: • Establish frequent rapport with the person. • Assess patient or his or her ability to seek out staff when struggling with suicidal thoughts. I patient is unable to do this, place on close observation. These might become court documents. I patient's needs or requests are not documented, they do not exist in a court o law 3. Suicide precaution (one-on-one monitoring at arm's length away) or suicide observation (15-minute visual check o mood, behavior, and verbatim statements), depending on level o suicide potential. (. Protection and preservation o the patient's li e at all costs during crisis is part o medical and nursing staff responsibility. Follow institutional protocol. ) 4. Keep accurate and timely records and document patient's activity—usually every 15 minutes—including what patient is doing, with whom, etc. Follow institutional protocol. Accurate documentation is vital. The chart is a legal document regarding patient's "ongoing status" and interventions taken 5. I accepted at your institution, construct a no-suicide contract with the suicidal patient. Use clear, simple language. When contract expires, it is renegotiated.. The no-suicide contract helps patients know what to do when they begin to eel overwhelmed by pain (e.g., "I will speak to my nurse/counselor/support group/ family member when I first begin to think o harming myself ") 6. Encourage patients to talk about their feelings and problem solve alternatives. (. Talking about feelings and looking at alternatives can minimize suicidal acting-out.)

feelings that are most commonly experienced by nurses working with abusive families

Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

Management of chronic aggression

Management o chronic aggression requires comprehensive neuropsychological testing and cognitive behavioral assessment to establish the appropriate treatment approach or each individual. Besides psychopharmacological treatment, individual therapies may include behavioral management, cognitive behavioral techniques, amily interventions, and psychosocial supports

Interventions for the Abused Child and the Child's Family

Intervention 1. Adopt a nonthreatening, nonjudgmental relationship with parents. (If parents feel judged, they may become defensive and leave without receiving care or the child.) 2 . Understand that the child does not want to betray his or her parents . ( Even in an intolerable situation, the parents are the only security the child knows.) 3. Provide a complete physical assessment o the child. (Allows health care worker to provide care and document evidence.) 4.Use of dolls or drawing might help the child to tell how the injury or accident happened. (Young children might not have the vocabulary to explain what happened , or might be afraid of punishment.) Forensic Issues 1.Be aware of your agency's and state's policy in reporting child abuse. Contact supervisor or social worker to implement appropriate reporting. (Healthcareworkersaremandatedtoreportanycaseso suspectedoractual child abuse. Suspicion or verbalization is enough to report; you do not have to prove the abuse happened.) 2. Ensure that proper procedures are followed and evidence is collected. (Appropriate evidence helps protect the child's welfare.) 3.Keep accurate and detailed records of incident: (Accurate records could help ensure the child's safety and supports the legal process.) • Exact words o what the child or others involved say happened •Abodymaptoindicatesize,color,shape,areas,andtypeso injurieswith explanation • Physical evidence, when possible, o sexual abuseUseo photoscanbehelpul.Checkhospitalpolicy.Policemaybeinvolved or photographing injuries. 4.Forensic examination of the sexually assaulted child should be conducted according to specific protocols: ==Provided by law enforcement agencies ==Follows state guidelines (www.childwel are.gov) (proper collection, handling, and storage of forensic specimens are crucial. Whenever available, a trained team or individual should perform this type of evidence collection or accuracy and sensitivity to the child victim.)

Guidelines or Sexual Assault

Intervention 1. Have someone ( friend, neighbor, sexual assault advocate, or staff member) stay with the patient while he or she is waiting to be treated in the emergency department (ED). (. People in high levels o anxiety need someone with them until the anxiety level is down to moderate. Never leave the individual alone. 2. Very important: Approach patient in a nonjudgmental manner. (Nurses' attitudes can have an important therapeutic effect. Displays of shock, horror, disgust, or disbelief can increase anxiety and shame 3. Confidentiality is crucial. (The patient's situation is not to be discussed with anyone other than medical personnel involved unless patient gives consent.) 4. Explain to the patient the signs and symptoms that many people experience during the long-term phase, or example: (Many individuals think they are going crazy and are not aware that this is a process that many people in their situation have experienced.) a. Nightmares b. Phobias c. Anxiety, depression d. Insomnia e. Somatic symptoms 5. Listen and let the patient talk. Do not press the patient to talk. (When people eel understood, they eel more in control o their situation.) 6. Stress that the patient did the right thing to save his or her life. (Victims o rape might eel guilt or shame. Reinforcing that they did what they had to do to stay alive can reduce guilt and maintain self -esteem.) 7. Do not use judgmental language: (Pejorative terms often refect old myths and a lack of knowledge and understanding regarding the rape victim's experience and need or immediate intervention. Words like "alleged," "re used," and "intercourse" all minimize the devastation o the event.) • Reported not alleged • Declined not re used • Penetration not intercourse • Instead of reporting "no acute distress," describe the behavior Forensic Examination and Issues 1. Assess the signs and symptoms o physical trauma. (Most common injuries are to the ace, head, neck, and extremities) 2. Explain and get permission rom patient to take photos/videos and specimens. (Patient's consent is needed to collect and document evidence, which later may be used in court. ) 3. Make a body map to identify size, color, and location o injuries. Ask permission to take photos. (Accurate records and photos can be used as legal evidence in the future) 4. Care fully explain all procedures be ore doing them (e.g., "We would like to do a vaginal [rectal] examination and do a swab. Have you had a vaginal [rectal] examination be ore?"). (The individual is experiencing high levels o anxiety. Explaining in a matter-of - fact way what you plan to do and why you are doing it can help reduce ear and anxiety) 5. Explain the forensic specimens you plan to collect; in orm patient that specimens can be used or identi cation and prosecution o the rapist, or example: (Collecting body fluids and swabs is essential (DNA) or identifying the rapist.) • Debris in head hair and pubic hair • Skin rom underneath nails • Semen samples • Blood • Urine sample (i date rape drug is suspected) 6. Encourage patient to consider treatment and evaluation or sexually transmitted in ections be ore leaving the ED.(Many survivors are lost to ollow-up a ter being seen in the ED or crisis center and will not otherwise get protection) 7. Offer prophylaxis to pregnancy.* (. Approximately 5% to 6% o women who are raped become pregnant) 8. All data must be care fully documented: (Accurate and detailed documentation is crucial legal evidence.) • Verbatim statements • Detailed observations o physical trauma • Detailed observation o emotional status • Results rom the physical examination • All lab tests should be noted 9. Offer support follow-up: (Many individuals can be burdened with constant emotional trauma. Depression and suicidal ideation are frequent sequelae o rape. The sooner the intervention, the less complicated the recovery may be.) • Rape counselor • Support group • Group therapy • Individual therapy • Crisis counseling

Interventions or the Pre-assaultive Stage: Use of De-escalation Techniques

Intervention 1. Pay attention to angry and aggressive behavior. Respond as early as possible (see Box 24-1). (Minimization o angry behaviors and ine ective limit setting are the most requent actors contributing to the escalation o violence.) 2. Emphasize that you are on the patient's side (e.g., "We want to help you, not hurt you.") and that "this is a sa e place and you are sa e." The clinician should stand at an angle to the patient so as not to appear con rontational. (Establish yoursel as an ally who wants to help the patient gain control. Never provoke or use threats.) 3. Assess personal sa ety and provide or sel -care. (. Pay attention to the environment. • Leave door open or use hallway. Choose a quiet place, but one that is visible to sta . • Have a quick exit available. • I you are uncom ortable, have other sta nearby. • The more angry the patient, the more space is needed to eel com ortable. • Never turn your back on an angry patient. • I on home visit, go with a colleague. • Leave immediately i there are signs that behavior is escalating out o control.) 4. Appear calm and in control. (The perception that someone is in control can be com orting and calming to an individual who is beginning to lose control.) 5. Do not try to speak while the aggressive person is yelling. (Loudly arguing with the patient will only escalate anger and violence) 6. Speak so tly in a nonprovocative, nonjudgmental manner. (When the tone o voice is low and calm and words are spoken slowly, anxiety levels in others may decrease) 7. Demonstrate genuineness and concern. • Do not treat the individual in a humiliating manner. • Ask, "What will help now?" (Even the most psychotic schizophrenic individual may respond to nonprovocative interpersonal contact and expressions o concern and caring) 8. Set clear, consistent, and en orceable limits on behavior (see Box 24-2) (e.g., "It's okay to be angry with Tom, but it is not okay to threaten him. I you are having trouble controlling your anger we will help you."). (Gives patient understanding o expectations and consequences o not adhering to those behaviors.) 9. I patient is willing, both nurse and patient should sit at a 45-degree angle. Do not tower over or stare at the patient. (Sitting at a 45-degree angle puts you both on the same level but allows or requent breaks in eye contact. Towering over or staring can be interpreted as threatening or controlling by paranoid individuals) 10. When patient begins to talk, listen. Use clari cation. (Allows patient to eel heard and understood, helps build rapport, and energy can be channeled productively) 11. Acknowledge the patient's needs regardless o whether the expressed needs are rational or irrational, possible or impossible to meet. (. Contributes to individual's perception that the nurse is trying to understand the core o the aggression. Determine how some o the patient's needs can be met in a productive way.)

Potential Nursing Diagnoses for people with personality disorders

Intervention 1.Assessyourownreactionstowardpatient.I you eelangry,discusswith peers ways to re rame your thinking to de ray eelings o anger. 2.Assesspatient'sinteractions orashortperiodbeorelabelingasmanipulative. 3. Set limits on any manipulative behaviors, such as Arguing or begging Flattery or seductiveness Instilling guilt, clinging Constantly seeking attention Pitting one person, sta , group against another Frequently disregarding the rules Constant engagement in power struggles Angry, demanding behaviors 4. Intervene in manipulative behavior. All limits should be adhered to by all sta involved. Objective physical signs in managing clinical problems should be care ully documented. Behaviors should be documented objectively (give time, dates, circum- stances). Provide clear boundaries and consequences. Enforce the consequences. 5.Bevigilant;avoid: Discussing yoursel or other sta members with the patient Promising to keep a secret or the patient Accepting gi ts rom the patient Doing special avors or the patient Rationale 1.Angerisanaturalresponsetobeingmanipulated.Itisalsoablocktoe ec- tive nurse-patient interaction. 2.Apatientmightrespondtooneparticular,high-stresssituationwithmal- adaptive behaviors, but use appropriate behaviors in other situations. 3. From the beginning, limits need to be clear. It will be necessary to re er to theselimits requentlybecauseitistobeexpectedthatthepatientwilltest these limits repeatedly. 4. Patients will test limits, and, once they understand the limits are solid,this understanding can motivate them to work on other ways to meet their needs. It is hoped that this will be done with the nurse clinician by ollowing problem-solvingalternativebehaviorsandlearningnewe ectivecommuni- cation skills. 5.Patientscanusethiskindo inormationtomanipulateyouand/orsplitsta . Decline all invitations in a rm, but straight orward manner; or example: "I am here to ocus on you.""I cannot keep secrets rom other sta . I you tell me something I may have to share it.""I cannot accept gi ts, but I am wondering what this means to you." "You are to return to the unit by 4 pm on Sunday, period."

Interventions for Impulsive Behaviors

Intervention 1.Identiytheneedsand feelings preceding the impulsive acts. 2. Discuss current and previous impulsive acts. 3. Explore e ects o such acts on sel and others. 4. Recognize cues o impulsive behaviors that mayinjure others. 5. Identi y situations that trigger impulsivity, and discuss alternative behaviors. 6.Teachorreerpatienttoappropriateplacetolearnneededcopingskills(e.g., anger management, assertive skills). Rationale 1.Identiytriggerstoimpulsiveactions. 2.Helpslinkpatterno thoughtsoreventsthattriggerimpulsiveaction. 3. Helps patients evaluate the results o their behaviors on sel and others— may motivate change. 4. Once cues are recognized, planning alternatives to impulsive actions is possible. 5. Once aware o cause and e ect, patient can make choices. 6. Special skills training can potentiate positive change in behaviors.

Rape

Involves penetration of the vagina or anus with any object or body part or the oral penetration by a sex organ of another A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. I gave her what she wanted. Rape involves a need for control, power, degradation, and dominance over others. The correct response shows a lack of remorse or guilt, which is a common characteristic of an antisocial personality. The incorrect responses show an appreciation for women, psychological conflict, and self-disclosure, which are not expected from a perpetrator of sexual assault. primary motivator for most rapists is Desire to humiliate or control others Rape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

Violence

Involves the intentional use of force that results in injury to another person

Seclusion or restraint is used in the following circumstances

Justification for the use of seclusion is that the patient: The patients threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others • The patient presents a clear and present danger to self or others. • The patient has been legally detained for involuntary treatment and is thought to pose an escape risk. • The patient requests to be secluded or restrained. When deciding on whether to use restraints or seclusion, suggest: "I the patient is an immediate danger to others, restraint is indicated. Yet i a patient is only disruptive and uncooperative, but is not a danger to others, seclusion should be considered. I the patient seems willing to sit in a quiet room, then an unlocked seclusion room may be attempted. I not, then a locked seclusion is indicated. However, i the patient could or does become a danger to sel while in seclusion, restraint is appropriate. Even when restrained, a patient will engage." My fingers are tingly. is a immediate concern for a patient to say while in restraints and needs nurse intervention.

MONOAMINE OXIDASE INHIBITORS MAOIs

MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive. antidepressants, happy pills Tyramine: an amino acid released from proteins during aging, fermentation, pickling, smoking, and spoiling. >What foods do you need to teach the patient to avoid? (know) >In the body, tyramine triggers the release of norepinephrine from adrenergic nerve endings and is then deactivated by monoamine oxidase (MOA)in the liver and the intestine. However,in a patient taking an MOA inhibitor, tyramine levels may increase and cause large amounts of norepinephrine to be released= leading to a hypertensive reaction and IC bleed. The foods patients need to avoid include: ●Aged Cheeses ** ●Alcoholic beverages ●Fish ●Fruits ●Meats ●Vegetables ●Other sources containing caffeine or cheese-filled desserts ●Medications (pseudoephedrine, dextromethorphan)

characteristics of perpetrators of sexual assault

Many characteristics of perpetrators of sexual assault are the same as those ound in perpetrators o child abuse, intimate partner violence, and elder abuse (see Chapter 21). Not surprisingly, most perpetrators o sexual abuse report being sexually assaulted as children. Some other characteristics include: • Impulsive and antisocial tendencies • Association with sexually aggressive and delinquent peers • Preference or impersonal sex • Hostility toward women • Childhood history o sexual and physical abuse, or witnessing family violence as a child • Membership in a gang • Belonging to a societal group that o ten re uses to acknowledge acts of sexual assault (e.g., some parts o the military, prisons, and even parts o the Peace Corps to a smaller degree) An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

Drugs Associated with Sexual Assault

Mechanism of Action :GHB (γ-hydroxybutyric acid)* Central nervous system depressant Effect Onset is within 10 to 20 minutes; duration is dose related and is rom 1 to 4 hours Lower doses: Produces euphoria, amnesia, hypotonia, and depressed respiration Higher doses: Can cause seizures, unconsciousness, nausea and vomiting, coma, and death Additional Information GHB needs 12 hours to be excreted rom the body Used to treat narcolepsy Rapidly metabolized; di cult to detect in emergency departments and other treatment acilities Mechanism of Action Rohypnol (flunitrazepam)† Potent benzodiazepine; 10 times stronger than diazepam Monitoring for: respiratory depression. Effect Impact is within 10 to 30 minutes and lasts 2 to 12 hours Becomes more potent when combined with alcohol Causes dizziness, amnesia, lack o motor coordination, con usion, nausea and vomiting, respiratory depression, and blackout episodes lasting 8 to 24 hours Additional Information Not legal in United States Detected in urine or up to 72 hours Mechanism of Action Ketamine ‡ Anesthetic requently used in veterinary practice; also hallucinogenic substance related to PCP (phencyclidine) Effect Onset is rapid, 20 minutes orally; duration is only 30 to 60 minutes Amnesia effects may last longer Usually administered as a powder that is snorted, smoked, injected, or dissolved in drinks Causes dissociative reaction with a dreamlike state leading to deep amnesia and analgesia and complete compliance of the survivor Later, survivor may be confused, paranoid, delirious, and combative with drooling and hallucinations Additional Information

lithium (Eskalith)

Medication use for Mania symptoms of bipolar Lithium is for patients with bipolar disorder

Documentation of a Violent Episode

Most acilities provide standardized seclusion and restraint records. There are a number o areas or which the nurse must provide documentation in situations where violence either was averted or actually occurred: • Reason for seclusion or restraint • Assessment of behaviors that occurred during the pre-assaultive stage (time) • Nursing interventions and the patient's responses (time) • Evaluation of the interventions used • Detailed description of the patient's behaviors during the assaultive stage • All nursing interventions used to defuse the crisis • Patient's response to those interventions • Name(s) of person(s) called to assess the patient and order any medications, seclusion, and/or restraints (time) • Time patient put in restraints or seclusion • Observations of and interventions performed while the patient was in restraints or seclusion ( ood, toileting, vital signs, verbatim statements, and general behaviors) (15 to 30 minutes depending on state law) • Any injuries to staff or patient • The way in which the patient was reintegrated into the unit milieu (time and behavior) Documentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

A family history of these personality disorders are most likely to be genetic or hereditary .

Obsessive compulsive Antisocial Schizotypal Some personality disorders have evidence of genetic links; therefore the family history would show other family members with similar traits. Heredity plays a role in schizotypal and antisocial problems, as well as obsessive-compulsive personality disorder.

highest risk for directing violent behavior toward others

Paranoid delusions of being followed by a military attack team The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distractors have better reality-testing ability.

Avoidant Personality disorder

Patients with avoidant personality disorder are timid, socially uncomfortable, and withdrawn and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Social inhibition Feelings of inadequacy Hypersensitivity to criticism Preoccupation with fear of rejection and criticism Low self-esteem a pattern of extreme shyness, feelings of inadequacy and extreme sensitivity to criticism. People with avoidant personality disorder may be unwilling to get involved with people unless they are certain of being liked, be preoccupied with being criticized or rejected, or may view themselves as not being good enough or socially inept.

Emotional Abuse

Refers to the infliction of mental anguish - such as humiliating threatening, intimidating, and isolating child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, My parents dont like me. They call me stupid and say I never do anything right. Examples of emotional abuse include having an adult demean a childs worth or frequently criticize or belittle a child.

passive aggressive traits

People with passive-aggressive personality traits are chronically irritable and unjustifiably blame others. They are verbally aggressive, hostile, and manipulative, and their interpersonal relationships are usually marked by ambivalence and conflict. They resent being asked to do anything for anyone else either in work or in social situations, and their key traits are negativism and obstructiveness. Their demeanor is usually sullen and their work is often characterized by procrastination and inefficiency. People with passive-aggressive behavioral traits are more likely to express their negative/hostile feelings indirectly. Although they may openly agree to another's demands or requests, they rarely complete that demand or request. In fact, the actions of people with passive-aggressive personality traits are usually the opposite of their promises. Therefore, a person with passive-aggressive traits often disrupts or sabotages other people's projects or plans. Dealing with people with passive-aggressive personality traits is usually very difficult.

Key points to remember chapter 13 personality disorders

People with personality disorders (PDs) present with the most complex, di cult behavioral challenges or themselves and the people around them. People with PDs have in exible and maladaptive ways of handling stress; demonstrate disabilities in both work and intimate relation- ships; evoke strong, intense personal conf ict with those around them; and have di culty managing impulses. PDs often co-occur with other mental health disorders (e.g., depression, substance use disorder, somatization, eating disorders, PTSD, anxiety disorders), other personality disorders, and general medical conditions. It is unlikely there is any single cause for any of the personality dis- orders—most seem to have genetic and environmental risk actors. • • • • • • People with these disorders respond to stress (e.g., frustration, anger, loneliness) with more primitive de enses, resulting in outra- geous behaviors unmodi ed by "normal" de enses.Needs are experienced as rage, and sexuality and dependency are con used with aggression. Self-assessment is an important part of assessment when working with a person with a PD. When personal eelings are not recognized or con ronted, substantial interpersonal conf ict will ensue. Determining if there is a history of suicide/homicide/self-mutila- tion, and i there are co-occurring disorders as well, is a vital part o the initial assessment interview. Nursing diagnoses are given and re ect the problematic behaviors o the PD at the time.Communication guidelines for manipulative and impulsive behav- iors are outlined. Careful evaluation for antidepressants, anticonvulsants (for aggres- sive and impulsive behaviors), and antipsychotics ( or stress- inducedpsychoticthinking)mayo erthepatientrelie. Therapy has been used for patients with PDs; however, there is little evidence-based research comparing the e cacy o di erent thera- pies with di erent disorders, except or dialectical behavior therapy (DBT), which has been extremely e ective in people with border- line PD.

why abused partners stay

Perhaps one o the strongest motives or staying is ear that the attacks will become even more violent or that the woman or her children could be murdered i they leave and are ound by the batterer. This is a very real concern, and women are at the highest risk of further violence or even death when they threaten to leave or if they leave and are later ound by their abuser. Women may end up in an abusive relationship i they were abused as children and abuse •No other means of financial support is available. •No support system exists after living so long in isolation. •Are afraid to be alone, or they think they cannot survive without the partner. •Are in depression and have lost the psychologic energy necessary to leave. •Self-esteem is low; they believe the batterer is powerful and omniscient.

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger?

Periodically provide an update and progress report on the patient. Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouses presence and concerns.

physical management techniques when patients become assaultive

Practice and teamwork Intervention techniques are learned behaviors that must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention.

Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others?

Refer requests and questions related to care to the case manager. Manipulative people frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority.

Neglect

Refers to the failure of providing for physical, emotional, educational, and medical needs to a vulnerable person nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, I want to go to school, but we cant afford a babysitter. It doesnt matter; Im too dumb to learn. child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

Physical Abuse Physical Violence

Refers to the infliction of physical pain or bodily harm The assessment of physical abuse is supported by the nurses observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. older adult diagnosed with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Success of plan would be expresses frustration verbally instead of physically. The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically.

intervention team Before approaching the patient, the nurse should ensure that staff take these steps

Remove jewelry, glasses, and harmful items from the patient and staff members. Appoint a person to clear a path and open, close, or lock doors. Select the person who will communicate with the patient. Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

Documenting Documentation Caution is advised about the use o pejorative language when documenting the history, findings, and verbatim statements. For example:

Reported Penetration Declined The nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. Reported should be used instead of alleged. Penetration should be used instead of intercourse. Declined should be used instead of refused. • Instead of "alleged," use reported. • Instead of "re used," use declined. • Instead of "intercourse," use penetration. • Instead of "in no acute distress," describe the behavior. After the immediate medical issues o the patient have been addressed, it is important that forensically trained personnel perform as many elements of the forensic examination as the individual will allow. Once the evidence is collected, it is imperative that providers maintain a "chain of custody" until it is turned over to the authorities.

Modified SAD PERSONS Scale

SAD PERSONS can be modi ed to remedy the omission o an available lethal plan. This modifi cation reminds the clinician to ask about lethal means when assessing suicidality. I lethal means are available, the clinician can then take whatever action is reasonably indicated to reduce the likelihood o a suicide. S Sex 1 male A Age 1 i <19 or >45 years, or* D Depression or hopelessness† 2 P Previous attempts or psychiatric care 1 E Excessive alcohol or drug use 1 R Rational thinking loss (psychotic or organic illness) 1 S‡ Separated, widowed, divorced 1 O Organized plan or serious attempt 2 N No social support 1 A Availability o lethal plan S‡ Stated uture intent (determined to repeat or ambivalent) 1 Guidelines for Action Points- Clinical Action 0-5 May be safe to discharge (depending on circumstances). (I sent home, have ollow-up appointment arranged and discharge patient with amily or riend.) 6-8 Probably requires psychiatric consultation. >8 Probably requires hospital admission, voluntary or involuntary. (Would need agreement o two psychiatrists or involuntary admission.)

SSRIs (selective serotonin reuptake inhibitors)

SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. a group of second-generation antidepressant drugs that increase serotonin activity specifically, without affecting other neurotransmitters end in [pram], [ine] citalopram [Celexa]; escitalopram [Lexapro]; fluoxetine [Prozac]; paroxetine [Paxil] >Know S/E: ●seizures ●abnormal bleeding ●activation of mania and hypomania ●hyponatremia ●sexual dysfunction ●N/V **Teach patient to take with food to decrease nausea

Assessment of PDs

Semi-structured interview preferred Minnesota Multiphasic Personality Inventory (MMPI) to evaluate personality Patient history Medical history Past physical, sexual, or emotional abuse Risk of self or other directed harm

Neurobiological Aspects o Suicide

Serotonin (5-hydroxytryptamine; 5-HT) is an important neurotransmitter as it pertains to completed suicide. Studies o the brains o those who have completed suicide show abnormalities o the serotonin The noradrenergic system is a mediator o acute stress responses, and overactivity o that system has been associated with both severe anxiety or agitation and higher suicidal risk The hypothalamic-pituitary-adrenal (HPA) axis is another major stress response system. The HPA axis is associated with major depression, and suicide victims o ten exhibit HPA axis abnormalities

Short-Term Goals

Short-Term Goals The patient will: • Have a short-term plan or handling immediate situational needs be ore leaving the ED. • Have a written list o common physical, social, and emotional reactions that may ollow a sexual assault be ore leaving the ED. • State the results o the physical examination completed in the ED. • Have written access to in ormation on obtaining competent legal counsel and community supports (individual or group) be ore leaving the ED. • Have a ollow-up appointment with a rape counselor or crisis counselor. • Have support rom amily and riends. • Have a list with telephone numbers o clinics or rape crisis counselors. Long-Term Goals The ideal outcome is that the person eventually will be able to: • Find ongoing support to help the individual deal with the many con using and terri ying issues and thoughts regarding the event(s). • Return to precrisis level o unctioning with minimal or no residual symptoms (survivor). • Experience hope ulness and con dence in going ahead with li e plans. • Have com ortable and enjoyable sex ( or some, it may take many years or this to happen).

A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de- escalating this scenario?

State the expectation that the patient will stay in control. Offer to provide the patient with medication to help. Speak in a firm but calm voice. Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

Amygdala & Temporal lobe central nervous system structures are most associated with anger and aggression

The amygdala mediates anger experiences and helps a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The cerebellum manages equilibrium, muscle tone, and movement. The basal ganglia are involved in movement. The parietal lobe is involved in interpreting sensations.

Risk for other-directed violence

The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets and an arrest for disorderly conduct.

Dependent Personality disorder

The main characteristic of the dependent personality is a pervasive need to be taken care of that leads to submissive behaviors and a fear of separation. Inability to make daily decisions without advice and reassurance Need of others to be responsible for important areas of life Anxious and helpless when alone Submissive Patients diagnosed with dependent personality disorder often express difficulty being alone and are indecisive and submissive. example: Each time that the nurse asks the woman a question, she either defers to her husband to answer the question or provides a noncommittal answer that her husband then clarifies. include a family treatment a pattern of needing to be taken care of and submissive and clingy behavior. People with dependent personality disorder may have difficulty making daily decisions without reassurance from others or may feel uncomfortable or helpless when alone because of fear of inability to take care of themselves.

Benzodiazepines

The most common group of antianxiety drugs, which includes Valium and Xanax. drugs that lower anxiety and reduce stress

Medication / Medicating aggressive patients

The nurse should enter the day room: accompanied by three staff members and say, Please come to your room so I can give you some medication that will help you feel more comfortable. A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort. The security guards are likely to intimidate the patient and increase feelings of vulnerability.

Interventions for Intimate Partner Violence: Emergency Department

The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult. Intervention 1. Ensure that medical attention is provided to patient. Document injuries using body map. Ask permission to take photos. (If patient wants to file charges, photos boost victim's confidence to press charges now or in the future.) 2. Set up interview in private and ensure con dentiality. (Patient might be terrified of retribution and further attacks from partner if she reveals abuse.) 3. Assess in a nonthreatening manner in formation concerning: Sexual abuse Physical abuse Emotional abuse Abuse of children Drugs of abuse Thoughts of suicide or homicide (these are all vital issues in determining appropriate interventions or depression, anxiety, suicide prevention, and self -medication with alcohol or substances.) 4. Encourage patient to talk about the battering incident without interruptions, in a kind and gentle manner, without judgment. (When patients share their stories, attentive listening is essential.) 5.Ask how patient is caring with the children in the home. (In homes in which the mother is abused, children also tend to be abused or traumatized by what they witness.) 6. Assess i patient has a safe place to go when violence is escalating. If she does not, include a list of shelters or safe houses with other written information. Some hospitals provide small cards that can fit in a shoe, so that the victim is not endangered by the abuser finding shelter and escape resources. (When abused patients are ready to leave their abusers, they need to go quickly. A plan is advised and it is better to leave when the abuser is not home unless the person is in danger and must flee immediately. Instruct the victim not to con ront the abuser when leaving because this may worsen the rage. When a victim leaves, she is at the greatest risk or severe injury or being killed.) Legal Issues 1. Identity if patient is interested in pressing charges.If yes, give verbal and written in formation on: Local attorneys who handle spousal abuse cases Legal clinics Battered women's advocates and shelters Call CPS if children are involved. Call law enforcement to make a report and assist the victim. (Often the spouse or partner is afraid of retaliation, but when ready to seek legal advice and appropriate list of lawyers well trained in this specialty area is needed.) 2. Know the requirements in your state about reporting suspected spousal abuse. 3.Discusswithpatientasaetyandescapeplanduringescalationo anxiety be ore actual violence erupts (see Box 21-3). 4.Throughoutworkwithbatteredspouses,emphasizethatthebeatingsarenot their ault. 5.Encouragepatienttoreachoutto amilyand riendswhomtheymighthave been avoiding. 6 . Know the psychotherapists in the community who have experience working with battered spouses or partners. 7. I the patient is not ready to take action at this time, provide a list of community resources: a. Hotlines b . Shelters c. Battered women's groups and advocates d . Therapists e . Law en orcement f. Medical assistance or Aid to Families with Dependent Children (AFDC) g. Child Protective Services (CPS) has resources to support families, in addition to investigating allegations of abuse. patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Risk of intimate partner violence The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurses advocacy role necessitates an assessment for intimate partner violence.

Phenelzine Sulfate (Nardil)

Therapeutic Class antidepressants Pharmacological Class monamine oxidase inhibitors

Citalopram (celexa)

Therpeutic Class antidepressants Pharmacological Class selective serotonin reuptake inhibitors ssris

critical incident debriefing .... after controlling a patients aggressive behavior

Topics that should be the focus Patient behavior associated with the incident Intervention techniques used by staff Effect of environmental factors The patients behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing the views about the theoretical origins of aggression is less effective.

A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. The patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting?

Verbal abuse of another patient Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention and particularly relevant when interacting with a patient diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters.

Post rape ... PRIORITY what a nurse should do .... IF patient talks about suicide nurse should ask

When working with rape victims, immediate care focuses first on: helping the victim feel safe.... +The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might decline to have evidence collected or to involve law enforcement. Are you thinking of suicide? The victims words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the victim. A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: provide written information concerning the physical and emotional reactions that may be experienced. All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to at later times. Patients cannot be kept against their will or coerced into receiving medication as a condition of being allowed to leave. This constitutes false imprisonment. 1. ensure that medical attention is provided to patient. Document injuries using body map. Ask permission to take photos. 2. Set up interview in private and ensure con dentiality. 3. Assess in a nonthreatening manner in ormation concerning: Sexual abuse Physical abuse Emotional abuse Abuse of children Drugs of abuse Thoughts of suicide or homicide 4. Encourage patient to talk about the battering incident without interruptions, in a kind and gentle manner, without judgment. 5.Ask how patient is aring with the children in the home. 6. Assess i patient has a sa e place to go when violence is escalating. I she does not, include a list of shelters or safe houses with other written in formation. Some hospitals provide small cards that can fit in a shoe, so that the victim is not endangered by the abuser finding shelter and escape resources. Legal Issues 1.Identity I patient is interested in pressing charges. I yes, give verbal and written information on: Local attorneys who handle spousal abuse cases Legal clinics Battered women's advocates and shelters Call CPS if children are involved. Call law enforcement to make a report and assist the victim. 2. Know the requirements in your state about reporting suspected spousal abuse. 3.Discuss with patient a safety and escape plan during escalation of anxiety be ore actual violence erupts (see Box 21-3). 4.Throughout work with battered spouses, emphasize that the beatings are not their fault. 5.Encourage patient to reach out to family and friends whom they might have been avoiding. 6 . Know the psycho therapists in the community who have experience working with battered spouses or partners. 7. If the patient is not ready to take action at this time, provide a lis to community resources: a. Hotlines b . Shelters c. Battered women's groups and advocates d . Therapists e . Law en orcementf. MedicalassistanceorAidtoFamilieswithDependentChildren(AFDC)g.ChildProtectiveServices(CPS)hasresourcestosupport amilies,in additiontoinvestigatingallegationso abuse. Rationale 1. I patient wants to le charges, photos boost victim's con dence to press chargesnoworinthe uture. 2.Patient might be terrified of retribution and further attacks from partner if she reveals abuse. 3. These are all vital issues in determining appropriate interventions or depression, anxiety, suicide prevention, and sel -medication with alcohol or substances. 4. When patients share their stories, attentive listening is essential. 5. In homes in which the mother is abused, children also tend to be abused or traumatized by what they witness. 6.When abused patients are ready to leave their abusers, they need to go quickly. Aplan is advised and it is better to leave when the abuser is not home unless the person is in danger and must f ee immediately. Instruct the victim not to con ront the abuser when leaving because this may worsen the rage. When a victim leaves, she is at the greatest risk or severe injury or being killed. 1.Often the spouse or partner is afraid of retaliation, but when ready to seek legal advice an appropriate list of lawyers well trained in this specialty area is needed. 2.Many states have or are developing laws or guidelines or protecting battered women. 3. Document escape plan and include shelter and referral numbers. This can prevent further abuse to children and patient. 4.When self esteem is eroded, victims often believe that they deserved the beatings. 5. Old friends and relatives can make helpful allies and validate that the patient does not deserve to be beaten. The victim will need a lot of support. 6.Psychotherapy with victims of trauma requires special skills 7. It can take time or patients to make decisions to change their life situation. People need appropriate in ormation.

A new psychiatric technician says, "schizophrenia...schizotypal! what's the difference?" the nurses response should include which information.

With schizotypal personality dis-order, the person can be made aware of misinterpretations of reality The patient with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, they can be made aware of misinterpretations and overtly psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, and have more frequent and prolonged hospitalizations.

Normal Feelings for a nurse after being attacked

a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, I dread facing potentially violent patients. The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. The distractors are normal in a person who has been assaulted. Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the individual regain a sense of control, and make sense of the event.

Verbal abuse of another patient

a patient diagnosed with an antisocial personality disorder 1. lies to other patients, 2.verbally abuses a patient diagnosed with dementia, 3.and flatters the primary nurse. 4.This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? Verbal abuse of another patient Limits must be set in areas in which the patients behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention. The other concerns should be addressed during therapeutic encounters.

Ability to evoke interpersonal conflict

are characteristic of individuals diagnosed with personality disorders that makes it most necessary for staff to schedule frequent meetings. Frequent team meetings are held to counteract the effects of the patients attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings.

A patient with borderline personality disorder and a history of self mutilation has now begun dialectical behavior therapy on an outpatient basis. Counseling focuses on self harm behavior management. Today the patient telephones to say, "I'm feeling empty and want to cut myself" the nurse should

assist the patient to identify the trigger situation and choose a coping strategy. The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that reduces the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention, sedation may reduce the patient's ability to weigh alternatives to mutilating behavior. nursing diagnosis is the focus of this therapy: Risk for self-mutilation. Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore a high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority or related to this therapy.

sublimation (defense mechanism)

channeling threatening devices into acceptable outlets (e.g. working out) sublet-->outlet A woman on a restrictive diet learns to paint and paints fruit.

borderline personality disorder Splitting, the primary defense or coping style used by persons with borderline personality disorder, is the inability to incorporate positive and negative aspects of oneself or others into a whole image.

condition marked by extreme instability in mood, identity, and impulse control. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting. -Unstable -Intense relationships -Impulsivity -Self-mutilation -Rapid mood shifts -Chronic emptiness -Intense fear of abandonment -Splitting -Self-mutilation and suicide-prone behavior Common Symptoms Fear of abandonmen Constant need for reassurance History of unstable, insecure attachments personality disorder is most commonly found in clinical settings examples of self-harming behaviors Burning finger tips Pulling on one's hair Cutting own wrists Prognosis varies based on the degree of functional impairment and the client's motivation to change. Observe personal limits Be assertiv. Clearly communicate expectations. a pattern of instability in personal relationships, intense emotions, poor self-image and impulsivity. A person with borderline personality disorder may go to great lengths to avoid being abandoned, have repeated suicide attempts, display inappropriate intense anger or have ongoing feelings of emptiness. As a nurse prepares to administer a medication to a patient diagnosed with a borderline personality disorder, the patient says, Just leave it on the table. Ill take it when I finish combing my hair. What is the nurses best response Say to the patient, I must watch you take the medication. Please take it now. The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patients safety, as well as to prevent splitting other staff members. Why questions are not therapeutic. patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, Im feeling empty and want to cut myself. The nurse should: assist the patient to identify the trigger situation and choose a coping strategy. A component of dialectical behavior therapy is telephone access to the therapist for coaching during crises. The nurse can assist the patient to choose an alternative to self mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that reduces the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention; sedation may reduce the patients ability to weigh alternatives to mutilating behavior Treatment successful and effective when patient with history of hurting self says: I felt empty and wanted to cut myself, so I called you. Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. The cause of the self-mutilation is probably related to: fear of abandonment associated with progress toward autonomy and independence. Fear of abandonment is a central theme for most patients diagnosed with borderline personality disorder. This fear is often exacerbated when patients diagnosed with borderline personality disorder experience success or growth. behavior indicates that a patient diagnosed with borderline personality disorder is improving?The patient informs a staff member that she is having thoughts of harming herself. Centraltothecharactero peoplewithborderlinepersonalitydisor- der (BPD) is their unstable and intense relationship, and, instability of affect,markedbyunstableandfrequentmoodchanges.Feelingsof anxiety, dysphonia, and irritability can be intense though short lived (emotional lability). Poor impulse control is evidenced by recurrent suicide attempts, sel -mutilation, and other sel -destructive behaviors. Chronic depression is common. The use o the primitive defense mechanism of projected identification is common in patients with BPD

Antipsychotic

diminish or eliminate hallucinations, delusions, withdrawal symptoms

SAFETY WITH PATIENTS auditory hallucinations

hearing voices, noises, music, or sounds that are not actually real. The patient approaches the nurse, shaking a fist and shouting, Back off! and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: 1) make sure adequate physical space exists between the nurse and the patient. Making sure space is present between the nurse and the patient avoids invading the patients personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurses exit from the room is not wise. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patients aggression is abating. One arms length is inadequate space.

A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is:

impaired social interaction.

Introjection

integrating the beliefs and values of another individual into one's own ego structure An abused child becomes and abusive parent.

Mild/ Normal Stress

is considered to be healthy and is accomplished by a level of mild anxiety. With some assistance, coping with daily life is achievable. Nursing actions include: +Allowing expression of feelings +Employ empathy in communication +Demonstrate active listening +Help patient identify problems +Assist in problem solving +Evaluate, explore results, plan

Panic level

results in a person that is physically and emotionally exhausted from stress. The ability to cope and exert self-control is virtually non-existent. Nursing actions include: Assess potential for injury to self/others Conduct debriefing of unit community Call for therapeutic team support Call Physician for onsite assessment Conduct debriefings of staff and patient post-containment Throwing objects - Therapeutically contain patient. Full flight/fight mode, gross motor skills at highest level - conduct debriefing on unit community

Validation therapy for cognitive deficits

lets you begin emotionally where the client is It grounds the client where he or she feels most secure It is often more helpful to reflect back to the client the feelings behind her demand and to show understanding and concern for her worry. As the nurse establishes himself or herself as a safe understanding person, the client becomes calmer and more open to redirection. Validation therapy meets the patient where she or he is at the moment and acknowledges the patients wishes. Validation does not seek to redirect, reorient, or probe. example Patient: cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, I have to go home to cook dinner before my husband arrives from work. Nurse: You want to go home to prepare your husbands dinner?

Moderate Stress

lingers and continues to influence the person's life. The person experiences feelings of being overwhelmed and troubled. Nursing actions include: Offer a cool beverage Respect need for personal space Actively dialogue with patient to share feelings Create activities for distraction Explore alternative coping mechanisms Help patient focus on the here and now Pacing, avoids eye contact - offer cool beverage Avoids eye contact, "I don't know what to do" - respect personal space Mild and moderate levels of anxiety allow the person to function at a higher level.

Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right" Collectively, these interactions can be assessed as

manipulative Patients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evident in the comments.

Rape Trauma Syndrome Acute Phase long term reorganization phase

nursing diagnosis rape trauma syndrome Patient agrees to keep a follow-up appointment with the rape crisis center. Agreeing to keep a follow-up appointment is a realistic short-term outcome. Confusion and disbelief Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. The victims response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term reorganization, or anger phases. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase. Development of fears and phobias Feelings of numbness Flashbacks, dreams These reactions are common to the long-term reorganization phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes are not expected.

Severe Stress

occurs when the person's stress level has not been reduced and is now more obvious. Negative behaviors begin to intrude such as somatic complaints, agitations, and anger. Nursing actions include: Begin limit setting Make simple and direct statements Describe behavior needed Notify MD and administer medication Remove other patients from day room Explain consequences of behavior Shouting loudly, refusing to follow directions - begin limit setting Hyperextended neck, swearing - remove others from day room

honeymoon phase The violence cycle stages

phase in the cycle of violence prevents the patient from leaving The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

victim of sexual assault is discharged from the emergency department, the nurse should

provide referral information verbally and in writing. Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution.

Assessment Guidelines suicidal patient

suggest listening to the patient's suicidal thoughts and impulses without judgment because "they represent your client's unique e orts to cope with their interpersonal li e problems" (p. 306). Suicide Risk 1. Identify current feeling states: feelings of depression, hopelessness, helplessness, anxiety or panic, lack o interest or pleasure, and di culty sleeping. For example: "Sometimes when I eel ___ ( fill in the feeling state identifed by the patient), I think about suicide." 2. Ask directly. Always ask: "Are you thinking o , or have you been thinking o , killing yoursel ?" I yes, evaluate or (Sommers-Flanagan & Sommers-Flanagan, 2015): a. Frequency: How o ten do these thoughts occur? b. Duration: Once they have begun, how long do they persist? c. Intensity: On a scale rom 0 to 10, how likely are you to act on these thoughts? 3. Ask if the person has a plan. "When you think about suicide, do you have a way that you might do this?" 4. Determine the lethality of the plan in terms o risk. • How detailed is the plan? (The more detailed, the greater its lethality.) • How lethal is the proposed method? • Guns, hanging, carbon monoxide, and staging a car crash are extremely lethal. • Slashing wrists, inhaling natural gas, and ingesting pills are lower risk. • A plan that doesn't allow for a last-minute reversal of the action is consider more lethal. • Availability of means. Does the person have a gun? Access to a tall building? 5. Gather information about risk actors—patient's age, sex, medical problems, psychiatric problems or emotional distress, excessive use o drugs or alcohol, a recent signi cant loss, unemployment, lives alone, etc.—that would put the patient at higher risk. 6. I there is a history o a suicide attempt, assess: • Intent: Was there a high probability of being discovered? • Lethality: Was the method used highly lethal or less lethal? • Injury: Did the patient suffer physical harm (e.g., was the patient admitted to an intensive care unit)? 7. Consult with one or more professionals and collaboratively develop a safety plan with the patient. The patient thinks through and writes down ways to cope when eeling suicidal, who can be called, etc. 8. If the patient is to be managed as an outpatient, also assess the following: • Social supports: Is there someone who can stay with the patient? • Significant other's knowledge of the signs of potential suicidal ideation (e.g., increasing withdrawal, preoccupation, silence, remorse). • Provision of safety resources (knowledge of community resources, telephone numbers).

Splitting

when a client tends to adore and idealize other people even after a brief acquaintance but then quickly leaves them if these others do not met the client's expectations in some way A patient says they "hate" the nurse because of a minor mistake. Splitting involves loving a person and then hating the person; the patient is unable to recognize that an individual can have both positive and negative qualities A nurse set limits for a patient diagnosed with a borderline personality disorder. The patient tells the nurse, You used to care about me. I thought you were wonderful. Now I can see I was mistaken. Youre terrible. This outburst can be assessed as: Splitting, the primary defense or coping style used by persons with borderline personality disorder, is the inability to incorporate positive and negative aspects of oneself or others into a whole image.

characteristics of an abusive parent

• A history of violence, neglect, or emotional deprivation as a child • Low self-esteem, feelings of worthlessness, depression • Poor coping skills • Social isolation, may be suspicious o others • Few or no friends, little or no involvement in social or community activities • Involved in a crisis situation such as unemployment, divorce, financial difficulties, abusive relationship • Rigid, unrealistic expectations o child's behavior • Frequently uses harsh punishment • History of severe mental illness, such as schizophrenia • Violent temper outbursts • Looks to child or satisfaction of needs or love, support, and reassurance • Projects blame onto the child or his or her problems • Lack of efective parenting skills • Inability to seek help rom others • Perceives the child as bad or evil • History of drug or alcohol abuse • Feels little or no control over life • Low tolerance or frustratio

Key points CHAPTER 24 Anger, Aggression, and Violence

• Angry emotions and aggressive actions are dif cult targets for nursing intervention. • Nurses bene t from an understanding of how the angry and aggressive patient should be approached. • Understanding patient cues to escalating aggression, appropriate intervention goals or individuals in a variety o situations, and help ul nursing interventions is important or nurses in any setting. • The roles o sociocultural inf uences and neurobiological vulnerabilities are intertwined in a person's propensity or violence. • Cues to assess when anger is escalating (verbal and nonverbal, including acial expressions, breathing, body language, and posture) are provided. • Assess the patient's history. A patient's past aggressive behavior is the most important indicator o uture aggressive episodes. • Many approaches are effective in helping patients de-escalate and maintain control. • The general hierarchy of interventions for coping with aggression is verbal intervention, trauma-speci c interventions, psychopharmacology, seclusion, and then restraint. • Different interventions are used depending on the patient's level of anger. • Guidelines for de-escalation of patient behavior are given. • Speci c medications such as barbiturates, antipsychotics, lithium, selective serotonin reuptake inhibitors (SSRIs), and anticonvulsants may prove use ul or short- or long-term therapy. • As a last resort, seclusion or restraints may be needed to ensure the sa ety o the patient as well as the sa ety o other patients and the sta . • Each unit has a clear protocol for the safe use of restraints and for the humane management o care during the time the patient is restrained, as well as clear guidelines or understanding and protecting the patient's legal rights. • Careful documentation of any incidence of escalating violence, especially any violence leading to seclusion or restraints, must be made according to the laws o your state.

Sexual violence is divided into the following categories

• Completed or attempted orced penetration o a victim. (Unwanted vaginal or oral penetration or an insertion through the use o physical orce or threats to bring physical harm to the victim) • Completed or attempted alcohol- or drug- acilitated penetration o a victim. • Completed or attempted orced acts in which a victim is made to penetrate a perpetrator or someone else. • Completed or attempted alcohol- or drug- acilitated acts in which a victim is made to penetrate a perpetrator or someone else. • Nonphysically orced penetration that occurs a ter a person is pressured verbally, or through intimidation or misuse o authority, to consent or acquiesce. • Unwanted sexual contact. (Intentional touching, either directly or through the clothing, o the genitalia, anus, groin, breast, inner thigh, or buttocks of any person without their consent. It includes having the victim touch a perpetrator.) • Noncontact unwanted sexual experiences. (Does not include physical contact o a sexual nature between the perpetrator and the victim. It does include unwanted sexual violence such as exposure to pornography, verbal or behavioral sexual harassment, or exhibitionism, without consent or knowledge or to a person who is unable to consent or re use.) Sexual violence among children also includes: • Coercing children to inappropriately touch the molester, often a trusted person • Showing children pornographic photos and videos • Initiating inappropriate conversations involving sexual topics

Emergency Department Violence Against Women (2013) protocol emphasizes the following:

• Consider sexual assault patients a priority. • Perform a prompt, competent medical assessment. • Then respond to acute injury, the need or trauma care, and safety needs o patients be ore collecting evidence. • Alert forensic examiners (e.g., SANE) o the need or their services. • Contact victim advocates so they can offer services to patients, if not already done. • Assess and respond to safety concerns of victims upon arrival at the exam site (e.g., Are there threats to patient or sta ?). • Assess patients' need or immediate medical or mental health intervention prior to the evidentiary exam, ollowing acility policy. Physical signs o sexual assault include (Ernoehazy, 2013): • Presence o blood and/or sperm • Contusions • Lacerations • Abdominal trauma • Joint dislocation • Mechanical back pain • Lesions caused by orce ul genital penetration • Abruptio placentae

According to Women Organized Against Rape (WOAR, 2015), common reactions in children who have been sexually abused include

• Fear of being alone, of going to sleep, or of strangers • Outbursts of anger • Increased isolation • Physical symptoms such as headaches, stomach or genital discomfort, and skin rashes in the genital area • Regression to early behaviors, such as a return to bedwetting or not wanting to sleep alone. • Inappropriate sexual behaviors, such as sexually acting-out with other children or excessive masturbation

According to WOAR (2015), common reactions to a sexual assault in adults are:

• Feelings of fear, anxiety, anger, and sadness • Flashbacks or intrusive thoughts about the assault • Outbursts of anger • Eating and sleeping disturbances • Depression • Suicidal thoughts or self -harming behaviors • Increased use o alcohol or drugs • Changes in relationships with friends, family, and lovers • Decreased desire or sex Other common reactions after a sexual assault include "generalized pain throughout the body, and emotional reactions such as anger, fear, anxiety, guilt, humiliation, embarrassment, self -blame, and mood swings." This is true or males as well

factors related to youth suicide:

• Frequent episodes of running away • Frequent expressions of rage • Family loss or instability • Frequent problems with parents • Withdrawal from family and friends • Expression of suicidal thoughts or talk of death or the afterlife when sad or bored • Dif culty dealing with sexual orientation • Unplanned pregnancy • Perception of school, work, or social failure

KEY POINTS TO REMEMBER CHAPTER 21

• Physical and emotional trauma cause long lasting damage to individuals and communities and are often passed down in a generational manner. • Because the incidence of child, partner, and elder abuse is underreported, it is imperative that nurses learn to routinely assess for abuse. • All states have mandatory guidelines for reporting child and elder abuse. However, in the case o IPV the victim is o a consenting and nonprotected age. Although nurses can provide resources, support, and guidance, it is ultimately their choice and responsibility to le any report o abuse. • When a victim of IPV attempts to leave the abuser, the highest risk of severe harm or homicide exists. • Abusive parents have characteristics that can be recognized by health care providers. • Abuse often occurs in a cyclical pattern in which the tension grows, abuse occurs, then remorse and a honeymoon phase begin. The cycle will almost always continue and escalate without intervention. • Responsibilities of the nurse and other health care team members in various cases o abuse are discussed. • Nursing diagnoses, interventions, and outcomes are similar in all abuse cases, although each individual and age group has additional unique needs

bullying behaviors among nurses in the health care setting

• Providing unwanted or invalid criticism, excessively monitoring another's work • Gossiping, spreading lies or false rumors, assigning derogatory nicknames • Taking credit for another person's work without acknowledging his or her contribution, blocking career pathways and other work opportunities • Publicly making derogatory comments about staff members or their work, including use o body language (eye rolling, dismissive behavior), often in front of others • Using sarcasm or ridicule, making someone the target of practical jokes • Blaming someone without factual justification • Allocating unrealistic workloads and not supporting colleagues • Being condescending or patronizing • Using physical or verbal innuendo or abuse, using foul language, raising one's voice and shouting or humiliating someone in front of colleagues • Breaking confidences

Common symptoms o PTSD related to sexual assault include the following:

• Re-experiencing the trauma: Recurrent nightmares about the rape, f ashbacks, or uninvited, intrusive thoughts during the day or night • Social withdrawal: Called "psychic numbing," involves not experiencing eelings o any kind • Avoidance behaviors and actions: Avoidance o all places and activities, as well as thoughts or eelings, that could recall events about the rape • Increased psychological arousal characteristics: Exaggerated startle response, hypervigilance, sleep disorders, or di culty concentrating • Fears and phobias: Fear o being alone, ear o sexual encounters, and ear o the indoors or outdoors are just some examples

Key points to remember CHAPTER 22 Sexual Violence

• Sexual assault is an act o violence, control, and hate; it is a criminal offense that often results in severe long-term psychiatric trauma or the victim. • To preserve forensic evidence, the victim should be aware o precautions to take be ore contacting the police, crisis center, or emergency facility. • Contact with the sexual assault patient usually takes place in the ED. Only nurses with special training (e.g., sexual assault nurse examiners [SANEs]) assess the patient, collect data, and provide information and referrals (e.g., to therapists, legal counsel, support groups) or patients be ore they leave the ED. • Permission is necessary or collecting forensic data, per forming a pelvic examination, and taking photographs. Confidentiality is stressed. • Following the sexual assault, a forensic examination is conducted and evidence is collected. The patient should be given medications to protect against STIs, evaluated or pregnancy, offered prophylaxis, and if warranted tested or HIV and syphilis. I abrasions are noted, a tetanus shot may be indicated i not updated in the past 5 years, and inoculation or hepatitis B is needed. • Careful documentation of findings (diagrams and photos), observations o emotional status, and descriptions o the events surrounding the assault are documented using verbatim statements whenever possible. • Assessment or date rape drugs should be included i the description o the event (loss o consciousness, vomiting) indicates they are a possibility. In such a case, a urine sample may be obtained. • To help alleviate anxiety, explanations o all interventions or procedures are provided to the patient be ore they are performed. • Be ore leaving the ED, sexually assaulted individuals are told what kinds o reactions are commonly experienced by sexually traumatized victims following a crisis. • Follow-up counseling, support groups, and referrals to effective legal attorneys who specialize in sexual assault should always be given be ore discharge rom the ED.

Olanzapine (Zyprexa Zydis) Risperidone (Risperdal) M-Tab

●Increased appetite●Weight gain●Hyperglycemia ●Hyperlipidemia- Also Monitor FBS/FLP*