Exam 3 Study Guide chapter 16, 18, 19, 20

Impaired personality functioning (areas of identity, self direction, empathy, & intimacy) Pathological personality factors (negative affectivity, detachment, antagonism, disinhibtion, & psychoticism)

According to the Hybrid Model for Personality disorders, Personality disorders, are a generalized pattern of behaviors, thought, & emotions that begin in adolescence, remains stable over time, & causes stress/psychological damage. What are they characterized by?

ASSESSMENT diagnosis after 19 y/o low frustration tolerance impulsive needs gratification poor judgement challenges authority (rules/laws) lack of REMORSE socially unacceptable behavior liars (sexual promiscuity, cigs, sub abuse, illegal act) ineffective interpersonal relationships manipulative behaviors failure to learn/change behavior based on past experience/punishment failure to accept/handle responsibility high rate of depression, substance abuse, apd, poverty, divorces in families Erratic, neglectful, harsh, even abusive parenting in childhood Normal appearance; engaging/charming May have signs of mild/moderate anxiety (especially if another person arranged the assessment Displays false emotions that works in their advantage Client cannot empathize with the feelings of others

Antisocial Personality Disorder (Cluster B) Assessment

DATA Generally do not seek tx voluntarily unless they have something to gain May site stress as a reason for poor performance/absenteeism Inpatient tx setting not effective for these clients (MAY BRING OUT THEIR WORST QUALITIES) • Ineffective coping • Ineffective role performance • Risk for other-directed violence

Antisocial Personality Disorder (Cluster B) Data/Diagnosis

EVALUATION Changes may be slow/small. Degree of function impairment may vary. Clients with severe impairment is evaluated on the ABILITY TO BE SAFE & to REFRAIN FOR SELF-INJURY Others may be employed & fairly stable in interpersonal relationships When clients experience less frequent crisis, treatment is more successful FOCUS IS BEHAVIOR CHANGE Recognizing behaviors on their own

Antisocial Personality Disorder (Cluster B) evaluation

INTERVENTION Nurse provides structure in the therapeutic relationship that promotes responsible behaviors, identifies acceptable & expected behaviors Nurse minimizes attempts by the client to manipulate & control relationships LIMIT SETTING: technique 1 1. Stating the behavioral limit (describing the unacceptable behaviors) 2. Identifying the consequences if the limit is exceeded 3. Identifying the expected/desired behaviors Set limits in a consistent, nonjudgmental, matter-of-fact way "it is not acceptable for you to ask personal questions. If you continue, I will terminate our interaction." Nurse shouldn't become angry or respond to the client harshly/punitively Confrontation:technique 2 Designed to manage manipulative/deceptive behavior The nurse points out a client's problematic behavior while remaining neutral & stern (nurse avoids accusing client) Can be used to keep the client focused on topic in the present The nurse can focus on the behavior itself rather than on attempts by clients to justify it Clients have an established pattern of reacting impulsively when confronted with problems Nurse teaches problem-solving skills & help clients practice them Problem Solving identifies problems, exploring alternative & evaluation results Clients need to learn a step-by-step approach to deal with them Nurse can help client discuss the various oppositions & choose one so that he can go back to work Managing anger & frustration can be a major PROBLEM ONLY when clients are calm can the nurse encourage them to identify sources of frustration, HOW they respond, & the CONSEQUENCES Nurse assists clients to anticipate stressful situations & learn ways to avoids negative future consequences TIME-OUTS/leaving the area is often helpful to avoid IMPULSIVE reactions & ANGRY outbursts in emotionally charged situations, REGAIN control of emotions, & ENGAGE in constructive problem solving Nurse helps clients to identify SPECIFIC problems at work/home that are barriers to success in fulfilling roles Nurse assesses the use of ALCOHOL & other drugs is essential to role performance Clients tend to blame others/families for difficulties

Antisocial Personality Disorder (Cluster B) intervention

Outcome/PLANNING Treatment focus is behavior change Tx unlikely to affect the clients insight/view of world or others (possible to make changes in their behaviors) Treatment outcomes: • The client will demonstrate nondestructive ways to express feelings & frustration • The client will identify ways to meet their own needs that do not infringe on the rights of others • The client will achieve/maintain satisfactory role performance(at work/parenting)

Antisocial Personality Disorder (Cluster B) planning

1. We admitted we were powerless over alcohol, that our lives had become unmanageable 2. Came to believe that a Power greater than ourselves could restore us to sanity 3. Made a decision to turn our wills & lives over to the care of God as we understood him 4. made a searching & fearless moral inventory of ourselves 5. Admitting to God, to ourselves, and to another human being the exact nature of our wrongs 6. Were entirely ready to have God remove all these defects of character 7. Humbly asked him to removed our shortcoming 8. Made a list of all persons we had harmed, & became willing to make amends to them all 9. Made direct amends to such people whenever possible, except when to do so would injure them or others. 10. Continued to take personal inventory & when we were wrong promptly admitted it 11. Sought through prayer & mediation to improve our conscious contact w/ God as we understood him, praying only for knowledge for his will for us & the power to carry that out 12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics & to practice these principles in all our affairs

Box 19.3 The 12 steps of alcoholics anonymous

Disturbed eating habits Disturbed attitude towards food Eating in secret Preoccupation with food Eating, shape, weight preoccupation Fear of losing control over eating Wanting to have a completely empty stomach

Characteristics of those who developed an eating disorder included:

Anesthetics, Nitrates, Organic solvents inhaled for their effects Aliphatic & aromatic hydrocarbons found in gasoline, glue, paint thinner, & spray paint, Less frequently used halogenated hydrocarbons: Cleaners Correction fluids Spray can propellants Others containing esters, ketones, & glycols Most of vapor inhaled from material soaked with chemical Can cause significant brain damage, peripheral nervous system damage, & live disease Intoxication involves : Dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, blurred vision, stupor & coma may occur Behavioral sx: Belligerence, aggression, apathy, impaired judgment, & inability to function Acute Toxicity: Anoxia, respiratory depression, vagal stimulation, dysrhythmias Death from: Bronchospasms, cardiac arrest, suffocation, aspiration of the compound or vomitus Treatment: Supporting the respiratory & cardia functioning, until substance gone Not antidotes/specific meds to treat inhaled toxicity No withdrawal sx/detoxification procedures have been identified. Some have reported cravings for the drug No detoxification procedures Pt's may suffer from dementia, or inhalant-induced disorders (psychosis, anxiety, & mood disorders) even when inhalants cease Treat disorders symptomatically

Describe all things related to inhalation addiction

likely to have exercised poor judgement, especially while under the influence of the substance.. judgement may still be affected, clients may behave impulsively such as leaving treatment to obtain the substance of choice Insight usually is limited regarding substance use. Clients may have difficulty acknowledging their behavior while using or may not see loss of jobs or relationships as connected to the substance use. clients may still believe they can control the substance use

Describe how the judgement & insight of a client with an addiction would be

easy to obtain controlled substances also have higher rates of alcoholism nurse may hesitate to report because: others may have difficulty believing healthcare professional would engage in abuse action may feel guilty of falsely accusing may want to avoid conflict is serious because it can endanger the clients nurses have ethical responsibility to report suspicious behaviors nurse should not try to handle the situation by warning the coworker, this allows the coworker to continue to abuse the substance without any repercussions warning signs of abuse include: poor work performance frequent work absentieism unusual behavior slurred speech peer isolation more specific behaviors: incorrect drug counts a lot of drugs listed as wasted clients report ineffective pain relief damaged or torn packages a lot of pharmacy errors consistent offers to get narcs from pharmacy unexplained absences from the unit trips to the bathroom after contact with controlled substances consistent early arrivals at or late departure from work for no reason nurses deserve the opportunity for treatment & recovery (reproting could be the first crucial step towards getting the nurse help)

Describe substance abuse of healthcare professional

pervasive and enduring pattern of unstable interpersonal relationships, self-image, and affect; marked impulsivity; frequent self-mutilation behavior MOST COMMON PERSONALITY DISORDER Under stress transient psychotic sx present Many may suffer from permanent damage from self-mutilation (cutting/burning) Engage in deliberate self-harm (Nonsuicidal injury) Recurrent self-mutilation is a cry from help, an expression of intense anger/helplessness, or a form of self-punishment Pain from cutting/burning is to block emotional pain Self-mutilation is done to reinforce that client is still alive (physical pain is to become emotional numb) Working with these clients can be frustrating (may be clingy one minute, then angry & rejecting the next) Manipulation of staff to gain immediate gratification & sabotage treatment plan by failing to do what is agreed Clients have a labile mood, are unpredictable, & many behaviors that makes nurse feel like they are back at square one Bad early relationship with parents (18-30 months of age) Early attempts for developmental independence met with bad responses or support withdrawal from parents 50% experience sexual childhood abuse, or physical/verbal abuse, & parental alcoholism Clients use transitional objects often (teddy bears, pillows, blankets, & dolls) into adulthood. These items are similar to their favorite item in childhood that was used for comfort Mild-sever dysfunction (behaviors depends on clients present status) With severe dysfunctionclient disheveled, unable to sit still, labile emotions Other times client may be normal (in the emergency room may be threatening self-harm or suicide) The pervasive mood (dysphoric) involves unhappy, restlessness, malaise. May report loneliness, boredom, frustration, feeling "empty" Rarely experience satisfaction/well-being. Depressed affect but still unstable & erratic May become irritable, hostile, sarcastic, c/o panic anxiety Experience intense emotions (anger/rage) but rarely expresses them productively/usefully Usually hypersensitive to others emotions, which can easily trigger reactions MINOR change can bring about a severe emotional crisis (emotional trauma when their therapists take vacations, appointment changes Thinking about self/others is polarized & extreme (splitting) Adores & idolizes others encountered in brief acquaintance (devalues the person if they do not meet their standards) Excessive/chronic fear of abandonment (reflects their tolerance to being alone) Excessive rumination about everything (regardless of importance) May experience dissociative episodes (wakefulness/unaware of actions) self-harm occurs during this time, but at times client is aware of the self-injury Under extreme stress, develops transient psychotic sx (delusions/hallucinations) Intellectually intact, fully oriented to reality with the exception of transient psychotic sx (delusions/auditory hallucinations encourages self-harm MOST COMMON. This goes away when stress is relieved May report flashbacks of abuse/trauma....consistent with PTSD which is common with borderline personality disorder Impaired judgement, lack of care & concern for safety (gambling, shoplifting, reckless driving) decisions based on emotions not facts Difficulty accepting responsibility for meeting needs outside a relationship. Blames their problems on others actions which makes their INSIGHT limited Typically says "I wouldn't have gotten into this mess if"

Describe the clinical picture of a client with Borderline Personality Disorder (cluster B)

paranoid personality disorder characterized by pervasive mistrust and suspiciousness of others interprets others actions as harmful during stressful periods may develop transient psychotic sx 2-4% of population More in males than females Most do not seek treatment (have life-long problems living or working with others) Appear aloof or withdrawn may remain a considerable distance from the nurse (necessary for their protection) Guarded or hypervigilant May survey the room & contents/look behind furniture & doors, appear alert to any impending danger May choose to sit near doors to have an exit/backs against the walls to keep people from sneaking up on them Restricted affect/unable to demonstrate warmth or empathy(you look nice today/I'm sorry you're having a bad day) Labile mood/ quickly changes from quietly suspicious to angry & hostile Responses sarcastic for no reason Constant mistrust/suspicious distorts thoughts, thought processing, & content Malevolent (evil) actions perceived from others May spend disproportionate time examining & analyzing the behaviors or others to discover hidden or threatening meanings. Often feel attacked by others(devise plan or fantasies for protection) Devises elaborate violent plans to get even (fantasies of retribution) may not carry out but there is a potential Defense mechanisms used are Projection (blames others, institutions, events, government for problem) Conflict with authority figures on the job is common(resent being given direction by supervisor) Paranoia may extend to feelings of being singled out for menial task, treated as stupid, or being more closely monitored than others

Describe the clinical picture of a client with Paranoid Personality Disorder Cluster A

characterized by a pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy occurs in 1-6^ of population 50-75% of this population are men Narcissistic traits are common in adolescents but does not indicate personality disorder will develop in adulthood INDIVIDUAL THERAPY IS THE MOST EFFECTIVE TREATMENT, hospitalization is rare unless comorbid conditions exist that requires inpatient tx Clinical picture: overt grandiosity (may quietly expect recognition for their perceived greatness); need for admiration; lack of empathy; arrogant or haughty attitude; superior view; fragile, vulnerable self-esteem; ambitious; expresses envy/begrudge others recognition/material success (should be theirs) Preoccupied with fantasies of unlimited power, success, brilliance, beauty, or ideal love (fantasies reinforce their sense of superiority) Rumination over long overdue admiration & privilege & compare themselves favorably with famous/privileged people Thought process intact, INSIGHT limited/poor Unlikely to consider that their behavior has anything to do with their problem (everybody else's fault) Self-esteem is almost always FRAGILE/VULNERABLE Hypersensitive to criticism & need constant attention & admiration Display a sense of entitlement

Describe the clinical presentation of a client with narcissistic personality disorder

Delusions Initially, the nurse assesses the content and depth of the delusion to know what behaviors to expect and try to establish reality for the client. When eliciting information about the client's delusional beliefs, the nurse must be careful not to support or challenge them. The nurse might ask the client to explain what he or she believes by saying o "Please explain that to me" o "Tell me what you're thinking about that." **The nurse is assessing the client's delusion beliefs** Descriptions of delusions Persecutory/paranoid Delusions involve the client's belief that "others" are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way. Sometimes, the client cannot define who these "others" are. Examples: The client may think that food has been poisoned or that rooms are bugged with listening devices. Sometimes the "persecutor" is the government, FBI, or other powerful organization. Occasionally, specific individuals, even family members, may be named as the "persecutor." Grandiose delusions are characterized by the client's claim to association with famous people or celebrities, or the client's belief that he or she is famous or capable of great feats. Examples: The client may claim to be engaged to a famous movie star or related to some public figure, such as claiming to be the daughter of the president of the United States, or he or she may claim to have found a cure for cancer. Religious delusions often center around the second coming of Christ or another significant religious figure or prophet. These religious delusions appear suddenly as part of the client's psychosis and are not part of his or her religious faith or that of others. Examples: The client claims to be the Messiah or some prophet sent from God and believes that God communicates directly to him or her or that he or she has a "special" religious mission in life or special religious powers. Somatic delusions--. are generally vague and unrealistic beliefs about the client's health or bodily functions. Factual information or diagnostic testing does not change these beliefs. Examples: A male client may say that he is pregnant, or a client may report decaying intestines or worms in the brain. Sexual delusions involve the client's belief that his or her sexual behavior is known to others; that the client is a rapist, prostitute, or pedophile or is pregnant; or that his or her excessive masturbation has led to insanity. Nihilistic delusions are the client's belief that his or her organs aren't functioning or are rotting away, or that some body part or feature is horribly disfigured or misshapen. Referential delusions or ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her. Examples: The client may report that the president was speaking directly to him on a news broadcast or that special messages are sent through newspaper articles.

Describe the delusions a client experiences with schizohrenia

Forming an effective relationship with paranoid people is difficult Client takes everything serious & sensitive to the reactions & motivations of others Approach the client in a formal/businesslike manner & refrain from jokes & chitchat Be on time, keep commitments, be straightforward (essential to nurse-client relationship) These clients NEED to be in control (important to involve in their plan) Ask the client what they would like to accomplish in concrete terms (minimizing problems at work/getting along with others) More likely to engage in the therapeutic process if they feel like they have something to gain Most effective interventions if helping client validate ideas before taking action (requires the ability to trust & listen to one person(client can avoid problems if they can refrain from taking action until they have validated their ideas with another person) Helps prevent from acting on paranoid ideas/beliefs Assist to base decisions/actions on reality not distorted ideas/perception

Describe the nursing interventions for a client with paranoid personality disorder Cluster A

Primary medical tx for schizophrenia is psychopharmacology Meds known as neuroleptics, are prescribed primarily for their efficacy in decreasing psychotic symptoms. They do not cure schizophrenia; rather, they are used to manage the symptoms of the disease. The conventional or first-generation, antipsychotic medications are (dopamine antagonists) The atypical or second-generation, antipsychotic medications are both (dopamine and serotonin antagonists) The first-generation antipsychotics target the: positive signs of schizophrenia such as delusions, hallucinations, disturbed thinking, and other psychotic symptoms (have no observable effect on the negative signs) The second-generation antipsychotics treats both positive & negative signs: positive symptoms & negative signs of lack of volition and motivation, social withdrawal, and anhedonia with missed doses take if withing 3-4 hours late (over 4 hours omit until next day)

Describe the psychopharm treatment for clients with Schizophrenia

client is socially isolated partly because of the positive signs (delusions, hallucinations, loss of ego boundaries) self-concept is unclear issues with trust & intimacy (interferes with est. relationships) low self-esteem (negative signs of schizophrenia) feels strange or different from others experiences frustration trying to fulfill roles in family & community success in school/work can be severely compromised (difficulty thinking clearly, remembering, paying attention, & concentrating) lack motivation if develops at young age (poorer outcome) because they did not have the opportunity to succeed in those areas before the areas fulfilling the role of son/daughter/sibling is difficult erratic & unpredictable behavior frightens & embarrasses family. Family may feel guilty or responsible feeling they have failed clients may feel like they have disappointed their families because they cannot become independent or successful

Describe the role & relationship that Schizophrenic clients struggle with

Include client & family Nusrse must ask if client is comfortable with quality of life Evaluation based on o have sx disappeared o can client carry out their daily lives with sx of psychotic sx o does the client understand the prescribed med regimen? o Is the client committed to adherence of regimen o Does the client possess the functional ability for community living o Are community resources adequate to help the client live successfully in community o Is there significant t aftercare/crisis plan in place to deal with recurrence of sx/difficulty in community o Are the client/family adequately knowledgeable and schizophrenia o Does the client believe that they have a satisfactory life?

Discuss the evaluation of a client with Schizophrenia

An anorexic emaciated, starving client can be shocking nurse may want to take care of client & nurse back to health. Nurse can become angry, frustrated, incompetent when client resists/rejects help Client may view nurse as enemy (client may throw away/hide food or become overly hostile as anxiety about eating increases Nurse must remember the clients behavior is a symptom of the anxiety & fear of gaining weight & not personally directed to the nurse Taking the clients behavior personally may cause the nurse to feel angry & behave in a rejecting manner Nurse may wonder why the client cannot just eat Nurse may find it difficult to understand how a 75 pound client see themselves as fat The nurse may wonder why the client cannot exert the will to just stop Nurse must remember that the clients eating behavior has gotten out of control Eating disorders are mental illness Be empathetic & nonjudgmental (remember clients perspective/fear about weight/eating) Avoid sounding parental when teaching about nutrition or why laxatives are harmful Present info without chiding the client will obtain more positive results So not label client at "good" when they avoid binge/purge or eat an entire meal. Otherwise clients will believe they are " on the days they "bad" on the days the purge/fail to eat enough food

How does the nurse attain self-awareness with eating disorders

Nurses can educate parents, children, & young people about how to prevent eating disorders Including: • realizing that the "ideal" figure in advertisements/magazines are unrealistic' • developing realistic ideas about body size & shape • learning coping strategies for dealing with emotions & life issues • healthy people 20/20 includes objectives to increase comprehensive school education for variety of topics including: • unhealthy dietary patterns • inadequate physical injury all including young and adolescents National Eating Disorder Association 2015 • Getting rid of thoughts that the perfect body will make you happy • Learn everything about all the eating disorders • Challenge false ideas about thinness & weight loss & that body fat & weight gain are horrible/indicates laziness, worthlessness, or immortality • Avoid categorizing foods ad good/bad • Stop judging yourself & others based on body weight/shape. Turn off the voices in head

How does the nurse provide mental health promotion

Preparing Client & family education Primary nursing role in caring for clients with eating disorders is: • providing education to help them take control of nutritional requirements independently teaching can be done in the impatient setting during discharge planning or in outpatient setting The nurse can provide extensive teaching about basic nutritional needs & effects of restrictive eating, dieting, & the binge cycle Clients need encouragement to set realistic goals for eating throughout the day. Eating only salads & vegetables during the day may set clients up later for binges as a result of too little dietary fat & carbohydrates Clients who purge, the most important goal is to STOP Teaching should include information about harmful effects of purging by vomiting & laxative abuse The nurse explains That purging is an effective means of weight control & only disrupts the neuroendocrine system Purging promotes binge eating by decreasing anxiety that follows the binge The nurse explains that if the client can avoid purging they may be less likely to engage in binge eating Nurse teaches the techniques of distraction & delay because they are useful against both binge/purging The longer the clients can delay binging/purging the less likely they are to carry out the behavior Nurse explains to family/friends they are most helpful providing emotional support, love, & attention. They can express concern about the clients health, but rarely helpful to focus on food intakes, calories, & weight

How to prepare Client & family education

alcoholism is referred to as a family illness (suffer emotional social, & physical angish) codependence is maladaptive coping pattern from family member/others that results from a prolonged relationship with someone who uses substances poor relationship skills, excessive anxiety & worry, compulsive behaviors, & resistance to change, enabling w/o help & support may family members develop substance abuse, treatment & support groups are available

How would the nurse address family to assist clients with substance abuse issues

encourage the client to ID problem areas in their lives & explore ways substance abuse has intensified them all problems will not go away with sobriety, but client will be able to think about problems clearly nurse may need to redirect a clients attention to their behavior & how it has influenced their problems. Do not allow client to focus on external problems just themselves role-playing to assist in problem solving and situations clients found difficult in group setting clients should give/receive feedback about how others perceive their interaction/ability to listen nurse can help clients relieve stress/anxiety relaxing, exercising, listening to music, engaging in activities may be effective clients may need to develop new social activities/leisure pursuits if most of their friends/habits of socializing involved the use of substances help clients to focus on the present no the past (what they can do now with relationships & behaviors) support the client to view sobriety as feasible (one day at a time) clients need to believe they can succeed

How would the nurse promote coping skills with substance abusers

• early identification • appropriate referral routine screening of all young women in these settings would help identify those at risk for an eating disorder use the following screening questions: SCREENING QUESTIONS: • How often do you feel dissatisfied with your body shape/size? • Do you think you are fat or need to lose weight, been when others • Do thoughts about food, weight, dieting, & eating dominate your life? • Do you eat to make yourself feel better emotionally, & then feel guilty about it?

In all encounters/settings nurses PRIMARY RESPONSIBILITY is to

list of outcomes: • client will establish adequate nutritional eating patterns • client will eliminate use of compensatory behaviors such as excessive exercise & use laxatives & diuretic • client will demonstrate coping mechanisms not related to food • client will verbalize feelings of guilt, anger, anxiety, or an excessive need for control • client will verbalize acceptance of body image with stable body weight

List the expected outcomes for clients with eating disorders

amenorrhea Constipation Overly sensitive to cold, lanugo hair on body Hair loss Dry skin Dental caries Pedal edema Bradycardia Enlarged parotid glands & hypothemia Electrolyte imbalance

List the physical problems of anorexia nervosa

Nonneurological side effects: Weight gain, sedation, photosensitivity, & anticholinergic sx (dry mouth, blurred vision constipation, urinary retention, orthostatic hypotension EPS: induced by neuroleptic medications Acute dystonia (rigidity/spasms of neck & eyes) Torticollis Oculogyric crisis Treat with (anticholinergic benztropine/Cogentin & diphenhydramine/Benadryl) Use oral for less acute/IM or IV for serious for more benefit **stay with client an monitor airway until spasm go away 5-15 minsakathisia benztropine/Cogentin trihexyphendryl/Artane biperiden/akineton procyclidine/kemadrin diphenhydramine/Benadryl diazepam/valium lorazepam/Ativan propranolol/Inderal 1. increase fluids & fiber 2. use ice chips/hard candy for dry mouth 3. assess for memory impairment 4. for narcs observe for sedation & misuse 5. for propranolol observe for palpitations, dizziness, cold hands & feet Pseudoparkinsonism (pill rolling, shuffling gait, masklike face, muscle stiffness/cogwheeling rigidity, drooling, akinesia (slowness in movement of joint) o Starts the first few days after starting therapy/increasing dosage Treat by changing med to a lower potency med or by adding an anticholinergic: benztropine/Cogentin, a antidyskinetic trihexphenidyl/Artane, or amantadine/Symmetryl, & diphenhydramine/Benadryl for added benefit d/c med to see if they are still needed, admin atypical as prescribed Akathisia (Unable to sit/stand still & is in constant movement & agitated) Treat by changing medication or w/ beta blocker propranolol/Inderal, anticholinergics benztropine/Cogentin, or trihexphenidyl/Artane or benzodiazepines lorazepam(Ativan)/diazepam(valium) observe for 2 months after starting medications SIMPSON-ANGUS SCALES used

Name adverse effects of antipsychotic medications

Tardive Dyskinesia - movement of tongue, face, arms, legs, trunks lip-smacking, speech & eating disturbances (embarrassing for the client & can cause them to become socially isolated) o Irreversible once it appears o Decrease or stop medication to stop the progression o Clozapine/Clozaril-does not cause tardive dyskinesia (recommended for those who have experienced ) o Screen pt's using the AIM's scale Used to screen for movement diorders (in several positions w/severity rated from 0-4 o Administer every 3-6 months o Notify physician if score is increased to have dosage/drug can e changed to prevent advancement Seizures infrequent (1% of population) 5% increase with Clozapine in high doses (tx is a lowered dosage or different antipsychotic medication) NMS (Potentially fatal idiosyncratic reaction to antipsychotic (neuroleptics) : Muscle rigidity High fever Increased muscle enzymes(creatinine phosphokinase) Leukocytosis (increased leukocytes) 0.1%-1% experience NMS Ability to use another antipsychotics after NMS varies Dehydration, poor nutrition, & concurrent medical illness increase risk Agranulocytosis (CLOZAPINE) 7-14 day supply (failure of red bone marrow to produce WBCs) fever, malaise, leukopenia, & ulcerative sore throat o 18-24 weeks after start.(discontinue immediately) o Monitor weekly (WBC's) for first 6 months, then q2wks thereafter, then q4 wks. Decrease monitoring based on therapy. o WBC count above 3500 before refill

Name adverse effects of antipsychotic medications

6 antipsychotics as long acting injections (LAIs) formerly called depot injections for maintenance 1. Decanoate/enanthate fluphenazine/ Prolixin (sesame oil) duration 7-28 days 2. decanoate haloperidol/ Haldol (sesame oil) duration 4 weeks 3. risperidone/Risperdal Consta (polymer-based microspheres that degrade slowly in the body) 4. paliperidone/Invega Sustenna (polymer-based microspheres that degrade slowly in the body) 5. aripiprazole/Abilify Maintena (polymer-based microspheres that degrade slowly in the body) 6. Zyprexa Relprevv (polymer-based microspheres that degrade slowly in the body) Effects within 2-4 weeks (eliminates need to dose daily) May take several weeks before oral medications to reach a stable level before transitioning to LAI's (depots are not for acute episodes of psychosis) LAI's are good for clients requiring supervised med compliance over a long period Second generation LAI's are more effective than oral form in controlling the negative sx & improving psychosocial functioning (physicians may not prescribe because pt may be reluctant to take injections)

Name the long acting depot injections for maintenance therapy of Schizophrenia

Imbalanced nutrition: less/more than body requirements Ineffective coping Disturbed body image Chronic low self-esteem Deficient fluid volume Constipation Fatigue Activity intolerance

Names some possible eating disorder disorder diagnoses

Nursing Interventions Sit with client while eating Offer liquid protein supplements Adhere to restrictions Watch clients for 1-2 hours after meals Weigh clients daily in uniform clothing Be alert to attempts to hide/discard food/inflate weight Help client identify emotions & to develop effective coping Ask client to id feelings Keep a self-monitoring journal Relaxation techniques Distractions Assist clients to change stereotypical beliefs Help the clients deal with body image issues Help client recognize benefits of being near normal weight Assist to view self in ways not related to body image Identify personal strengths, interests, talents Provide family education

Nursing interventions for a client with eating disorders

Dealing with Body Image Issues The nurse can help the client accept a more normal body image Client agrees to : • Weigh self-more than they like • To be healthy • Stay out of the hospital When clients experience relief from: • emotional distress • have increased self-esteem • can meet their emotional needs in a healthy way they are more like to accept their weight & body image the nurse can also help clients to view themselves in other ways then just weight, size, shape, & satisfaction with body image Helping client identify area of personal strength that are food related broadens clients' perceptions of themselves. (includes identifying talents, interests, & positive aspect of character unrelated to body shape or size)

What are some interventions the nurse can help the client in dealing with Body Image Issues

Identifying emotions & developing coping strategies Because clients with anorexia have a problem with self-awareness they have difficulty identifying and problem expressing feelings (alexithymia) They express their feelings as somatic complaints (feeling fat or bloated) The nurse can help clients begin to recognize emotions (anxiety/guilt) by asking them to describe how they are feeling & allowing adequate response The nurse should NOT ask: • "ARE YOU SAD?" • "ARE YOU ANXIOUS?" the client will quickly agree rather than struggle for an answer Nurse encourages the client to describe their feelings. This approach will help the client to recognize their emotions & to connect their emotions to their eating behaviors

What are some interventions the nurse can help the client to Identifying emotions & developing coping strategies

Self-monitoring is a cognitive-behavioral technique designed to help clients identify behavioral patterns & then implement techniques to avoid/replace them Self-monitoring raises clients awareness about behavior & help them to regain a sense of self control The nurse encourages client to keep a diary of all food eaten throughout the day, including binges & to record moods, emotions, thoughts, circumstances, & interactions surrounding eating & binging/purging episodes (assist clients to see connections between emotions/situations, and eating behaviors) The nurse helps develop ways to manage emotions (anxiety, by using relaxation techniques/distraction with music or another activity) Important steps toward helping clients find ways to cope with people, emotions, & situations that do not involve food.

What are some interventions the nurse can help the client to Self-monitor

requires the nurse to focus on whats real & help shifts the clients response to reality initially the nurse must determine what the client is experiencing (what voices are saying/what client is seeing) increases the nurses understanding of clients feeling/behaviors with command hallucinations (client hears voices directing to do/hurt someone) nurse must elicit a description of the content of the hallucination so that health-care professionals can take precautions to protect client & others engage the client in a reality-based activity (playing cards), participating in occupational therapy, listening to music this make it difficult to pay attention to hallucinations (distraction) work with the client to identify certain situations/particular frame of mind that may trigger auditory hallucinations intensity of hallucinations are r/t anxiety levels (nurse should monitor & lower clients anxiety levels) client should recognize certain moods/patterns of thinking trigger the onset of voices may eventually be able to control/manage hallucinations by learning to avoid particular states of mind. (learning to relax when voices occur, engaging in diversion, correcting negative self talk, & seeking out/avoiding social interaction) teach the client to talk back to the voices forcefully may help client manage auditory hallucinations (PRIVATELY). voice-hearers group to assist people manage auditory hallucinations client can benefit from discussing voices with designated others who have similar experiences so the client does not feel isolated

What are the interventions for client who experience hallucinations

Establishing nutritional eating pattern Inpatient treatment is for clients with anorexia nervosa who is severely malnourished & Inpatient treatment is for those with bulimia whose binge eating & purging behaviors are out of control Primary nursing roles are to implement & supervise the regimen for nutritional rehabilitation Total parental nutrition/enteral feeding may be prescribed initially when health status severely compromised Clients diet is 1200-1500 calories/day with gradual increase until client ingests adequate amounts for height, activity level, & growth needs Allotted calories are divided into 3 meals & 3 snacks A liquid protein supplement to replace any food not eaten to ensure consumption of the total # of prescribed calories The nurse is responsible for monitoring meals & snakes & often initially will sit with the clients during eating at a table away from other clients Diet beverages & food substitutions may be prohibited & a specified time may be set for consuming each meal Clients should discard/move to the kitchen food that was kept at work, in the car, or in the bedroom Clients discouraged from food rituals (cutting food into small pieces or mixing food into unusual combinations) The nurse must be alert for any attempts by client to hide or discard food After each meal/snack client required to remain in view of staff for 1-2 hours to ensure no vomiting Some treatment programs limit clients access to the bathroom without supervision (after meal to discourage vomiting) As clients begin to gain weight & more independent in eating behavior, these restrictions reduce gradually Clients are weighed once daily in the morning after emptying their bladder. clients should wear minimal clothing(hospital gown) Clients may attempt to place objects in their clothing to give the appearance of weight gain Encourage client to eat meals with their families or friends Clients should always sit at a table with a designated eating area (kitchen/dining room) Easier for clients to follow a nutritious eating plan if written in advance & groceries are purchased for planned menus Clients must avoid buying foods frequently consumed during binges (cookies, candy bars, potatoes chips)

What are the interventions related to establishing nutritional eating patterns

ANOREXIA perfectionists causes no trouble dependable Appears slow, lethargic, fatigued, emaciated May have paranoid ideas about family & health care professionals (seen as enemy trying to make them fat) Generally alert & Oriented (except those severely malnourished w/ signs of starvation (mild confusion, slowed mental processes, difficulty concentrating & attention Slow to respond to questions & have difficulty deciding what to say Reluctant to answer any questions fully because they do not want to acknowledge any problems Wear loose fitting clothes in layers (regardless of the weather to hide weight & to keep warm (are generally COLD) Limited eye contact may turn away from the nurse (unwilling to discuss problem or enter treatment) Seldom smiles, laugh or enjoys humor (very serious) It is important to ask the client about thoughts of self-harm/suicide May engage in self-mutilation behaviors (cutting) Concerns about self-harm & suicide will increase with a history of sexual abuse Very limited insight & poor judgment (believe others are trying to interfere with their weight loss (desire body image) Failing health cannot convince the client to stop restricting foods or purging Does not believe they have a problem Continues to restrict food intake /engage in purging despite effects of health Tend to judge themselves harshly & see themselves as bad when eating certain foods Overlook other personal characteristics/achievements (less important than thinning) Perceive themselves as helpless, powerless, & ineffective Lack of control over themselves & environment fuels their desire to control their weight May begin to fail school (completely different from before anorexia) Withdrawal from peers w/ no attention to relationships. Believe others will not understand or will fear they will begin to eat in the presence BULIMIA LOW SELF ESTEEM try to please others to avoid conflict impulsive behaviors (drugs, stealing, anxiety, depression, personality disorder) Cannot think about themselves without thinking about weight & food Weight usually in the normal range (can be over/underweight) open/willing to talk increased cavities ragged & chipped teeth increase Dentist are usually the first to identify Depression & OCD most common Assessment tool: Eating Attitudes Test (can be used at the end of tx for evaluation because it is sensitive to changes) May be underweight/overweight (generally close to expected body weight for age & size) General appearance is not unusual & they appear open & willing to talk Get sense of power avoiding bad/fattening foods It is important to ask the client about thoughts of self-harm/suicide May engage in self-mutilation behaviors (cutting) Concerns about self-harm & suicide will increase with a history of sexual abuse Body image disturbance is delusional even when thin still feels fat Feel great shame about binging & purging (leads secret lives to binge privately) Generally alert & 0riented Ashamed of binge eating/purging Recognize bulimia as abnormal(will hide the purging and eating) They feel out of control and are unable to change though they recognize their behaviors as pathologic Tend to judge themselves harshly & see themselves as bad when eating certain foods Overlook other personal characteristics/achievements (less important than thinning) Perceive themselves as helpless, powerless, & ineffective Lack of control over themselves & environment fuels their desire to control their weight The time it takes to buy, eat, and purge can interfere with role performance and home & work May exercise excessively, to the point of exhaustion (to control weight) Sleep disturbance/insomnia/reduced sleep time/early morning wakening May have dental problems from vomiting: • Loss of tooth enamel • Chipped/ragged teeth • Dental caries Frequent vomiting may result in mouth sores NEED COMPLETE MEDICAL & DENTAL EXAMS

What are the main differences between anorexia nervosa & bulimia

Assessment tool: Eating Attitudes Test (can be used at the end of tx for evaluation because it is sensitive to changes)

What are the mental health exams relating to anorexia

Disturbed thought process: disruption in cognitive operations & activities Diagnoses based on Positive SX o Risk for other-directed violence o Risk for suicide o Disturbed thought process o Disturbed sensory perception o Disturbed personal identity o Impaired verbal communication Diagnoses based on negative SX o Self-care deficit o Social isolation o Deficient diversional activity o Ineffective health maintenance o Ineffective therapeutic regimen management

What are the nursing diagnoses for Schizophrenia

Promote safety (safety for the client/nurse is priority) A nursing Intervention priority for Clients with Schizophrenia would be: o Promoting safety of client and others o right to privacy and dignity client may be paranoid & suspicious of the nurse & the environment (may be threatened/intimidated) may believe his well-being is in jeopardy (nurse must approach client in nonthreatening manner) making demands/being authoritative increases clients fears give client ample space(this enhances sense of safety) a fearful/agitated client has the potential to harm self/others (observe for signs of agitation) o increased pacing o loud talking/yelling o hitting/kicking objects institute interventions to protect client/nurse/others o give meds o moving to a quiet/less stimulating area o extreme circumstances (use restraints/seclusion)

What are the nursing interventions for Shcizophrenia

Interventions PROMOTE CLIENTS/OTHERS SAFETY • Safety is priority • Consider suicide ideations which is chronic • The nurse determines when suicidal ideas are likely to be translated into actions • Nurse helps client avoid self injury • Encourage the client to engage in a no-self-harm contract (a promise to be safe to the client) • Self contract promotes self-responsibility & encourages dialogue with the nurse • When clients are calm the nurse can explore self-harm behaviors • The focus is identifying mood, affect, level of agitation, & distress, & circumstances (helps identify triggers) • If clients do injure themselves the nurse assesses injury & need for tx in calm-matter of a fact manner PROMOTING THERAPEUTIC RELATIONSHIPS • Nurse must provide structure & limit setting in therapeutic relationship (see client for scheduled appointments not when demanded) • The hospital setting the nurse plans a specific amount of time (no excess in access to nurse) LIMIT SETTING & CONFRONTATION helpful Establish boundaries in relationships • Clients are known for having difficulty maintaining satisfying interpersonal relationships • Unclear boundaries, erratic thinking & behaviors alienate them from others • Can misinterpret nurses interest and the nurse may feel flattered (Reestablish boundaries)

What are the nursing interventions for a client with Borderline Personality Disorder Cluster B

The focus of nursing care for clients w/ schizotypal personality disorder is the development of : • self-care • social skills • improved functioning nurse encourages client to establish a daily routine for hygiene & grooming this is important because it does not depend on the client to decide when hygiene/grooming is necessary it is best for the client to not have an appearance that is not bizarre/dissolved (comments/stares form others increase discomfort) nurse must help the client function in the community because they are uncomfortable around others by asking: • client to prepare a list of people in the community they may have contact with in the community (landlord, store clerk, pharmacist) this allow the client to practice making clear/logical requests to obtain services or to conduct personal business • clients can make written requests/phone calls (because face-to-face is so uncomfortable) social skills training may help the client talk clearly to reduce bizarre conversations identify one personal client can discuss their bizarre/unusual beliefs with (social worker/.family member) with an acceptable outlet the client can refrain from having negative interactions (leading to people reacting negatively)

What are the nursing interventions for a client with Schizotypical personality Disorder Cluster A

Nurse provides structure in the therapeutic relationship that promotes responsible behaviors, identifies acceptable & expected behaviors Nurse minimizes attempts by the client to manipulate & control relationships LIMIT SETTING: technique 1 1. Stating the behavioral limit (describing the unacceptable behaviors) 2. Identifying the consequences if the limit is exceeded 3. Identifying the expected/desired behaviors Set limits in a consistent, nonjudgmental, matter-of-fact way "it is not acceptable for you to ask personal questions. If you continue, I will terminate our interaction." Nurse shouldn't become angry or respond to the client harshly/punitively Confrontation:technique 2 Designed to manage manipulative/deceptive behavior The nurse points out a client's problematic behavior while remaining neutral & stern (nurse avoids accusing client) Can be used to keep the client focused on topic in the present The nurse can focus on the behavior itself rather than on attempts by clients to justify it Clients have an established pattern of reacting impulsively when confronted with problems Nurse teaches problem-solving skills & help clients practice them Problem Solving identifies problems, exploring alternative & evaluation results Clients need to learn a step-by-step approach to deal with them Nurse can help client discuss the various oppositions & choose one so that he can go back to work Managing anger & frustration can be a major PROBLEM ONLY when clients are calm can the nurse encourage them to identify sources of frustration, HOW they respond, & the CONSEQUENCES Nurse assists clients to anticipate stressful situations & learn ways to avoids negative future consequences TIME-OUTS/leaving the area is often helpful to avoid IMPULSIVE reactions & ANGRY outbursts in emotionally charged situations, REGAIN control of emotions, & ENGAGE in constructive problem solving Nurse helps clients to identify SPECIFIC problems at work/home that are barriers to success in fulfilling roles Nurse assesses the use of ALCOHOL & other drugs is essential to role performance Clients tend to blame others/families for difficulties

What are the nursing interventions for a client with antisocial personality disorder Cluster B

Clients with schizophrenia may have significant self-care deficits Inattention to hygiene and grooming needs is common, especially during psychotic episodes. The client can become so preoccupied with delusions or hallucinations that he or she fails to perform even basic activities of daily living. Polydipsia o leads to water intoxication o sodium levels decrease o leads to seizures o caused by behaviors/antidepressants o sleep problems Usually is seen in clients who have had severe and persistent mental illness for many years as well as long-term therapy with antipsychotic medications. Sleep problems are common. Hallucinations may stimulate clients, resulting in insomnia. Other times, clients are suspicious and believe harm will come to them if they sleep. As in other self-care areas, the client may not correctly perceive or acknowledge physical cues such as fatigue. Sleep To assist the client with community living, the nurse assesses daily living skills and functional abilities. daily living skills and functional abilities o bank accounts/paying bills o buying food/preparing meals o using public transportation

What are the physiologic & self-care considerations of schizophrenic clients

Severe intoxication Coma Respiratory depression. pupillary constriction, unconsciousness & death Opioid overdose tx: administer naloxone (Narcan) opioid antagonist, reverses all signs of opioid toxicity naloxone(Narcan) is given every few hours until the opioid level drops to Withdrawal/detox with intake ceases by a great margin/followed by an antagonist. Short-acting drugs -heroin Onset 6-24 hrs Peak 2-3 days Duration 5-7 days Longer acting substances methadone Onset 2-4 days Duration-2 wks Methadone can be used in place of a opioid, decreasing dosage over 2 weeks (to reduce sx to mild flu) anxiety, insomnia, dysphoria, anhedonia, & drug craving may persist for weeks/months Giving naloxone may take a few days until patient become nontoxic(process may take days) Pt is substituting heroin addiction with methadone, because it does not produce the high associated with heroin, its legal, is controlled by a physician, & available in tablet form Levomethadyl (narc analgesic) tx of opiate analgesics- used like methadone

What are the treatments for the clients addicted to heroin

Medical management focuses on : • weight restoration • nutritional rehabilitation • rehydration • correction of electrolyte imbalances client receive nutritional balanced meals & snacks that gradually increase caloric intake to a normal level for size, age, and activity level for severely malnourished patient's total parenteral nutrition (TPN) or hyperalimentation through PICC line is a priority access to a bathroom is supervised to prevent purging as clients intake increases weight gain & food intake are the criteria for determining the effectiveness of treatment Watch for 1-2 hours after eating to prevent purging Weigh at the same time every morning after they eat Cognitive behavioral therapy CBT For adolescents with anorexia nervosa is successful for initial treatment & relapse prevention CBT addresses: • body image disturbance/dissatisfaction • Perfectionism • mood intolerance • low self-esteem • interpersonal difficultie

What is the medical management & pharm of a client with anorexia

For severely malnourished their medical condition must be stabilized before psychiatric treatment can begin Medical stabilization may include: • parental fluids • total parental nutrition • cardiac monitoring

What is the treatment for clients with SEVERELY malnutritioned clients

Very limited insight & poor judgment (believe others are trying to interfere with their weight loss (desire body image) Failing health cannot convince the client to stop restricting foods or purging Does not believe they have a problem Continues to restrict food intake /engage in purging despite effects of health Tend to judge themselves harshly & see themselves as bad when eating certain foods Overlook other personal characteristics/achievements (less important than thinning) Perceive themselves as helpless, powerless, & ineffective

What makes clients with anorexia have poor judgment & insight

antisocial borderline avoidant narcissistic obsessive-compulsive schizophrenia

What personality disorders are included in the Hybrid Model For Personality Disorders?

characterized by a pervasive pattern of disregard for and violation of the rights of others and with the central characteristics of deceit and manipulation referred to as psychopathy/sociopathic/dyssocial/criminal/ personality disorders occurs in 3 % of population 30% of clinical population Occurs 3-4x's more in MEN than in women In prison populations 75% are diagnosed Antisocial personality disorder peaks in the 20s & dimishes are 45 • Deceit/manipulation (check/validate info form other sources) • Onset is in childhood or adolescence • Formal diagnosis at 18 y/o • Childhood hx of ENURESIS/SLEEPWALKING/SYNTONIC ACTS of cruelty are characteristic As a adolescent may be engaged in lying, truancy, sexual promiscuity, cigarette smoking, substance use, illegal activities (contact with police) Families have a high rate of depression, substance abuse, antisocial personality disorder, poverty, divorce Erratic, neglectful, harsh, even abusive parenting in childhood Normal appearance; engaging/charming May have signs of mild/moderate anxiety (especially if another person arranged the assessment Displays false emotions that works in their advantage Client cannot empathize with the feelings of others

describe the clinical picture of a client with Antisocial Personality Disorder Cluster B

schizotypal personality disorder characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and behavioral eccentricities clients may experience transient psychotic episodes in response to extreme stress (these client may develop schizophrenia) clients have an odd appearance which causes others to notice them unkempt & dissolved, with ill-fitting clothes that do not match & may be stained or dirty clients may wander & become preoccupied with environmental detail speech is coherent, but may be loose, digressive, or vague client provides unnecessary answers & are unable to specify or describe info clearly frequently use words incorrectly (make speech more bizarre) clients have a restricted RANGE OF EMOTIONS (lack the ability to express emotions like anger, happiness, pleasure) clients AFFECT is often flat , silly, inappropriate cognitive distortions include (ideas of reference, magical thinking, odd/unfounded beliefs, & preoccupation parapsychology, including extrasensory perception & clairvoyance clients may express ideas that indicate paranoid thinking & suspiciousness (about the motives of other people) Clients experience great anxiety around others especially unfamiliar people (anxiety may intensify) Clients do not improve with time or repeated exposures Beliefs that people cannot be trusted Clients do not view their anxiety from a problem with sense of self Interpersonal relationships are troublesome (may have only one significant relationship) first degree relatives May remain in parents' home into adulthood Limited capacity for close relationships even though they are unhappy & alone Clients cannot respond to normal social cues/cannot engage in superficial conversations Not employable without support/assistance Mistrust of others, bizarre thinking & bizarre ideas, & unkempt appearance can make it difficult for clients to get & keep jobs

describe the clinical picture of a client with Schizotypical personality Disorder Cluster A

usually impaired because it is based on the ability to interpret the environment correctly client has disordered thought processes & environmental misinterpretations will have great difficulty with judgment at times lack of judgement is so sever that clients cannot meet their needs for safety & protection & places themselves in harms way lack of judgement can range from failure to wear warm clothing in cold, failure to seek medical attention when ill, fail to recognize needs for sleep/food insight can be severely impaired especially early in illness when no one understand what is happening (overtime clients learn about illness & seek assistance) chronic difficulty results in in client who fail to understand schizophrenia as a long-term health problem requiring consistent managment

describe the judgement and insight of a client with schizophrenia

concept of self is a major problem in schizophrenia. The phrase loss of ego boundaries describes the client's lack of a clear sense of where his or her own body, mind, and influence end and where those aspects of other animate and inanimate objects begin. Lack of ego boundaries is evidenced by (depersonalization, derealization, object eith bigger/smaller/unfamiliar) ideas of reference Clients may believe they are fused with another person/object (may not recognize body parts/fail to know if they are male/female (these are a source of bizarre behavior) o Masturbating in public o Undressing in public o Speaking to self in third person o Clinging to objects o Body image distortion

describe the self concept of a client with schizophrenia

Thought process & content Clients may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute thought blocking . They also may state that they believe others can hear their thoughts thought broadcasting, that others are taking their thoughts thought withdrawal, or that others are placing thoughts in their mind against their will thought insertion Clients also may exhibit tangential thinking which is veering onto unrelated topics and never answering the original question.

describe the thought process & contents of a client with Schizophrenia

Prevalent in industrialized area Anorexia less frequent in African Americans & asians If there is no tv less prevalence of eating disorders Most common in US, Canada, Europe, Australia, japan, new Zealand, south Africa Immigrants from other cultures develop eating disorders as they assimilate Isreali males had easting disorders than other countries Eating disorder commonly equal amongst Caucasians & Hispanic women Minority women who are younger, BETTER educated, closer to middle class values are at increased risk for developing an eating disorder Eating disorders have increased amongst all US social classes & ethnic groups Views of the western ideal views thin as beautiful & desired

eating disorders cultural considerations

The nurse can use the assessment tool (Eating Attitudes Test)to detect improvement for clients with eating disorders Both Anorexia & Bulimia are chronic for many Residual symptoms: • dieting • compulsive exercising • experiencing discomfort when eating in a social setting treatment is considered successful when the client maintains a body weight within 5-10% of normal with no medical complications from starvation/purging

how does the nurse evaluate the nursing process with eating disorders

impaired cause & effect reasoning impaired information processing poor nutrition lack of sleep lack of exercise fatigue poor social skills, social isolation, loneliness interpersonal difficulties lack of control, irritability mood swings ineffective medication management low self-concept looks & act differently hopeless feelings loss of motivation anxiety & worry disinhibtion increased negativity neglecting appearance forgetfulness

name the early signs of relapse with a client who has schizophrenia

larger portions of food consumed binge eats secretly (between eats low calorie foods/fasts) binging or purging are followed by feelings of guilt/ remorse/ shame/self-contempt focused on please others & avoids conflict have a history of impulsive behavior such as substance abuse & shoplifting as well as anxiety, depression, & personality disorders Binging, eating, purging leafs to anxiety, depression, & feeling out of control Often seem sad, anxious,& worried Initially pleasant & cheerful, which disappears when they begin describing binge eating & purging (may express guilt, shame, & embarrassment Spend a great deal of time avoiding eat or eating :bad/wrong: foods Cannot think about themselves without thinking about weight & food Weight usually in the normal range (can be over/underweight) Vomiting destroys enamel Begins in late adolescence or early adulthood (18-19) Binge eating starts during or after dieting Between binging & purging clients eating may be restrictive (salads or low calories choices) This sets them up for the next episode of binging & purging May store food in car, desk, or secret locations around the house May drive from one fast food place to another ordering normal amounts of food (6 places in 1-2 hours) increased cavities ragged & chipped teeth increase Dentist are usually the first to identify Depression & OCD most common Assessment tool: Eating Attitudes Test (can be used at the end of tx for evaluation because it is sensitive to changes) May be underweight/overweight (generally close to expected body weight for age & size) General appearance is not unusual & they appear open & willing to talk Get sense of power avoiding bad/fattening foods It is important to ask the client about thoughts of self-harm/suicide May engage in self-mutilation behaviors (cutting) Concerns about self-harm & suicide will increase with a history of sexual abuse Body image disturbance is delusional even when thin still feels fat Feel great shame about binging & purging (leads secret lives to binge privately) LOW SELF ESTEEM Generally alert & 0riented Ashamed of binge eating/purging Recognize bulimia as abnormal(will hide the purging and eating) They feel out of control and are unable to change though they recognize their behaviors as pathologic Tend to judge themselves harshly & see themselves as bad when eating certain foods Overlook other personal characteristics/achievements (less important than thinning) Perceive themselves as helpless, powerless, & ineffective Lack of control over themselves & environment fuels their desire to control their weight The time it takes to buy, eat, and purge can interfere with role performance and home & work May exercise excessively, to the point of exhaustion (to control weight) Sleep disturbance/insomnia/reduced sleep time/early morning wakening May have dental problems from vomiting: • Loss of tooth enamel • Chipped/ragged teeth • Dental caries Frequent vomiting may result in mouth sores NEED COMPLETE MEDICAL & DENTAL EXAMS

name the symptoms of Bulimia Nervosa

1. HARM AVOIDANCE (exhibits fear of uncertainty, social inhibition, shy w/ stranger, rapid fragability, & pessimistic worry about problems) a high HA results in maladaptive inhibitions and excessive anxiety 2. NOVELTY SEEKING a high NS results in quick temper, curious, easily bored, impulsive, extravagant, disorderly, fickle with relationships, 3. REWARD DEPNDENCE (how a person responds to social cues) people high in RD are tenderhearted, sensitive, sociable, & social dependent. overly dependent for the approval of others, assumes ideas of others before their own. low RD are practical, tough-minded, cold, socially insensitive, irresolute, indifferent to being alone, social withdrawal, aloofness, detachment, disinterest in others 4. PERSISTENCE high persistence people work hard and are ambitious overachievers who respond to fatigue/frustration as a personal challenge. They continue even when a situation dictates they should change/stop. low persistence are inactive, indolent, unstable, & erratic, tends to give up easily when frustrated, rarely strive for higher accomplishments by the age of 2-3 years of age.

the Biological theories refers to 4 temperament traits that are genetically influenced by 50%, what are they? when are they ingrained into personality?

Health teaching for the client and family Dispel myths surrounding substance abuse Decrease codependent behaviors among family members Make appropriate referrals for family members Promote coping skills Role-play potentially difficult situations focus on the here & now with clients set realistic goal like being sober today

what are interventions for substance abuse

Late-onset schizophrenia refers to development of the disease after age 45; schizophrenia is not initially diagnosed in elder clients. Psychotic symptoms that appear in later life are usually associated with depression or dementia, not schizophrenia. Clients with schizophrenia are no longer hospitalized for long periods. Most return to live in the community with assistance provided by family and support services. assertive community treatment programs have shown success in reducing the rate of hospital admissions by managing symptoms and medications; Community support programs often are an important link in helping persons with schizophrenia and their families. Case management services often include helping the client with housing and transportation, money management, and keeping appointments as well as with socialization and recreation.

what are the considerations for elderly clients with schizophrenia

Nursing interventions self-awareness skills to avoid anger and frustration nurse uses a matter-of-fact approach nurse sets limits client may be rude & arrogant, unwilling to wait, & harsh & critical of the nurse The nurse must not internalize such criticism/take it personally THE GOAL: is to gain the cooperation of these clients with other tx The nurse teaches about comorbid medical/psychiatric conditions, medical regimen, & any needed self-care skills (in a matter fact way) The client sets limit on rude/verbally abusive behavior & explain their expectations of the clients

what are the nursing interventions for a client with Narcissistic personality disorder

Withdrawal begins 4-12 hours after cessation or noticeable reduction of alcohol intake Sx: course hand tremors, sweating, elevated pulse, B/P, insomnia, anxiety, & N/V Severe & untreated withdrawal Transient hallucinations Seizures/delirium(delirium tremens, DTs) Alcohol withdrawal usually peaks on 2nd day & is over in about 5 days Disulfiram(Antabuse) to deter client from drinking: Sever adverse reaction: Flushing Throbbing headache Sweating Nausea Vomiting Severe cases with disulfiram: Severe hypotension confusion, coma, & even death

what are the symptoms of alcohol withdrawal

Providing Health Teaching for client and family Clients and family members need facts about the substance, it's effects and recovery. The nurse must dispel the following myths and misconceptions: "It's a matter of will power." "I can't be an alcoholic if I only drink beer or if I only drink on weekends." "I can learn to use drugs socially" "I'm ok now, I could handle using once in a while." nurse provides education about relapse family & friends should be aware that clients that begin to revert are at risk for relapse & loved ones need to take action. Whether a client plans to attend a self-help group or has other resources, a specific plan for continued support and involvement after treatment increases the clients chances for recovery.

what health teaching is necessary for clients & family with substance abuse

Clients with anorexia can be difficult to treat because they can be resistant, appear uninterested, & deny the problems Treatment setting include: • inpatient specialty eating disorder units • partial hospitalization • day treatment programs • outpatient therapy choice of setting depends on the severity of illness: • amount of weight loss • physical sx • duration of binging & purging • drive for thinness • body dissatisfaction • comorbid psychiatric conditions major life threatening complications necessitate hospitalization include: • sever e fluid, electrolyte, & metabolic imbalances • cardiovascular complications • severe weight loss • suicide short hospital stay for those amenable (open and responsive to treatment) to weight loss and those that gain weight rapidly wile hospitalized longer inpatient stays for those that gain weight slowly & are more resistant to treatment outpatient therapy for those that have been ill for fewer than 6 months & are not binging/purging, and have parents that are likely to participate in family therapy cognitive behavioral therapy can be effective in preventing relapse & improving outcomes

what is the treatment & prognosis for client with anorexia

Outpatient Cognitive-Behavioral therapy most effective in the treatment of Bulimia Strategies are designed to change clients thinking (cognition) & actions (behaviors) CGT focuses on interrupting the cycle of dieting, binging, & purging & altering the dysfunctional thoughts & beliefs about food, weight, body image, & overall self-concept Web-based CGT & face time w/ therapist have been effective Nurse must work closely with client to establish a normal eating pattern & interrupt the binge/purge cycle SSRI (Prozac) Desipramine (norpramin) Imipramine (Tofranil) Amitriptyline(Elavil) Notriptyline (Pamelor) Phenelzine (Nardil) Fluoxetine (Prozac) SSRI all are used to treat depression Antidepressant were effective in reducing binge eating They also improved mood & reduced preoccupation with weight & shape (but results were short term) perhaps because meds are treating the comorbid disorders seen with bulimia

what is the treatment & prognosis for clients with bulimia