MH Exam 3
Cultural Considerations for childhood illness
-African American communities have higher risk for developing ADHD, not discussed much due to cultural beliefs, weren't aware that these were symptoms and that they were not problematic typically
The resilient child has the following characteristics
(1) adaptability to changes in the environment (2) ability to form nurturing relationships with other adults when the parent is not available (3) ability to distance self from emotional chaos (4) good social intelligence (5) good problem-solving skills (6) ability to perceive a long-term future
Binge Eating
-Although at risk for several comorbidities, not generally hospitalized for their disorder -GI issues -Dysfunctional eating pattern -Embarrassment -Social Isolation -Dx binge eating vs obesity
Oppositional Defiant Disorder
-Angry and irritable mood, Easily angered, very labile mood swings -Defiant and vindictive behavior: Refusing to complete tasks requested by adults and may result in a retaliation-type behavior, Deliberately annoys others and blames them for their mistakes or behavior, Children do not respond to penalties of behavior, so much as reward for not doing the "bad" behaviors -Children often Experience: Social difficulties often leads to emotional disorders in adulthood, *Conflicts with authority figures, Academic problems
Nursing Process for ADHD
-Assessment: Level of physical activity, attention span, talkativeness, Social skills, Comorbidity (often exists w/ other childhood psych disorders) -Diagnosis: Often disruptive, have poor impulse control, peer conflicts, difficulty following simple rules/directions -Outcomes: Target hyperactivity, self-control, self-esteem, positive coping skills
Sleep Requirements
-Basal sleep requirement= how much sleep is needed to be fully awake and sustain normal activity -Long sleepers: Require more than 10 hours of sleep each night -Short sleepers: Can function effectively on fewer than 5 hours of sleep per night
Conduct Disorder
-Behavior is usually abnormally aggressive: May use violence, intimidate, or use coercion to get their way -Child onset= before age 10; limited frustration tolerance and temper outbursts most common -Adolescent onset= after age 10; most often first signs are misbehavior w/ peer group -Kleptomania and pyromania are 2 disorders associated with this illness -Rights of others are violated and societal norms/rules are disregarded: Show blatant disregard for the welfare and rights of others, Lack normal feelings of guilt or remorse after violating acts -Complications: Academic failure, school suspensions and dropouts, juvenile delinquency, drug and alcohol abuse, legal troubles, Usually child is of high intelligence, but falls behind d/t behavior, Most often d/t to trouble in the home or low self-esteem
Tourette's disorder
-Characterized by involuntary motor and verbal "tics" -Motor tics= usually involve the head but can also be; tongue protrusion, squatting, hoping, skipping, touching, twirling while walking -Verbal tics= coprolalia (repeating obscenities)only in about 10% of cases; echolalia (repeating another's sentences or words, or their own) -usually permanent, remission periods may occur -usually coexists with depression, OCD, and ADHD
Intellectual Development Disorder (IDD)
-Deficits in: Intellectual functioning, Judgment, reasoning, abstract thinking, problem-solving, planning, and academic ability compared to peers, Social functioning, Communication and language are affected -Managing age-appropriate activities of daily living, functioning at school or work, and performing self-care: 10%= problems during pregnancy/childbirth 20%= environmental/societal factors Can occur as a genetic defect (Klinefelter's, Downs) or on a Autism spectrum -may require short term hospitalization related to socially impaired behaviors such as aggression, self harm, or severe self-care deficits
Speech Disorder
-Difficulty in pronouncing words/letters (w for r such as "wabbit") or disturbance in fluency (stutter or pause, repetitions), enough to impact the child's ability to communicate
Language Disorder
-Difficulty understanding or using words in context correctly; or speaking in coherent sentences; may manifest as inability to follow directions* -Social communication disorder: Difficulty using verbal and non-verbal means for interacting socially with others
Sleep terror Disorder
-Disturbance occurs in NREM sleep* -Awakening is during the early part of the night d/t feelings of extreme anxiety or panic -Screaming/crying typically accompanying awakening; disorientation may be present upon awakening, Usually cannot remember why they awaken -Occurs in 1% to 6% of children: Typically ages 3 to 8, More common in boys, Tends to run in families
Elimination Disorders
-Enuresis: Behavioral disorder in children who are developmentally >5yrs, Involuntary or intentional, May occur 2 x's/wk for >3 months, May be during the day only, night only, or both -Encopresis: Behavioral disorder in children who are developmentally >4yrs, Involuntary or intentional, May occur 1 x/month for >3 months, W/ or w/o constipation and overflow incontinence
milieu of eating disorder unit
-organized to assist the patient in establishing more adaptive behavioral patterns and normalization of eating -includes precise meal times, adherence to the selected menu, observation during and after meals, and regularly scheduled weighing
Consequences of Sleep Loss
-Excessive sleepiness -Mental impairment: May mimic psychiatric symptoms if sleep deprivation is prolonged -Psychomotor impairment: slowed down, clumsy -Increased risk for errors -health impairments: >6 hours of sleep: Hormone dysregulation: DM (leptin) Chronic inflammation: CV disease, DM (TNH, C-reactive protein) Motor impairment: Can mimic at times impairment induced by ETOH
Depersonalization/Derealisation Disorder
-Feelings/sensations may come and go or be present shortly after trauma, becoming permanent -Cause feelings of intense distress for individual -Depersonalization—focus on self; person is observing themselves or mental processes -Derealisation—focus on outside world; surroundings do not seem real, May feel "detached" from body, mechanical, dream-like
Regulation of Sleep
-Homeostatic process—promotes sleep: Large amounts of NREM 1 phase, shifting b/w sleep phases, or frequent wakening= fragmented sleep, This results in nonrestorative* sleep patterns -Circadian process—promotes wakefulness; influenced by: 1) Endogenous factors- NT deficiencies, anxiety, depression 2) Exogenous factors- caffeine, SEs of medication
Dissociative Amnesia
-Inability to recall important personal information -Person has the ability to recall past information but with extreme difficulty -NOT associated with physical trauma that would result in general amnesia -Often of traumatic or stressful nature -Dissociative fugue: Unexpected travel away from place of origin; inability to recall information/identity of past, Rare cases: a new identity/life is assumed, When individual realizes former identity; may then become amnesic
Attention Deficit Hyperactivity Disorder (ADHD)
-Inattention Distractible and disorganized; stop tasks out of frustration or boredom, may need frequent reminders to complete tasks -Impulsiveness Low frustration tolerance, "temper tantrums", labile mood, interrupting others -Hyperactivity Inability to focus or sit still; may need to be in constant movement; may be aggressive and take things from others or touch people/objects (intrusiveness)
NI for sleeping disorders
-Insomnia- (table 19-2, p. 376) Benzodiazepine (use <2 weeks)= temazepam, triazolam Nonbenzodiazepine= zolpidem Antidepressants- trazodone* (may be 1st choice) OTC medications- diphenhydramine*, melatonin -Narcolepsy- CNS stimulants= modafinil, methylphenidate Hypersomnia- modafinil or non-sedating bupropion -Nightmare, sleep terror, and sleepwalking disorders- Benzodiazepines (rare in sleep terror because may prolong NREM sleep) TCAs (nightmares)- suppression of REM sleep -Good sleep hygiene* -Relaxation techniques -Sleep diary -Stimulus control: 1) Go to bed ONLY when sleepy 2) Use bedroom ONLY for sleep/intimacy 3) Get OUT of bed if unable to sleep; engage in quiet activity elsewhere 4) Maintain regular sleep/wake schedule= get up at SAME time every day 5) Avoid DAYTIME napping (min of 20-30 min if needed)
Circadian Rhythm Sleep Disorder
-Misalignment between the timing of normal circadian rhythm and external factors that affect the timing or duration of sleep -Treatment—aggressive lifestyle management strategies aimed at adapting to or modifying the required sleep schedule
Autism Spectrum Disorder
-Neurobiological disability: Affects normal development of brain and communication; may have some level of IDD -Developmental disability Social relatedness and communication, non-verbal behaviors, deficits in age-appropriate behaviors -Others: repetitive speech, ritualistic, object fixation, hyper/hypo reactivity to sensory input, catastrophic reactions to change -Appears during first 3 years of life: Ranges from mild to severe symptoms -behavior management with reward system, teaching parents to provide structure, rewards, consistency in rules, and expectations at home in order to shape and modify behavior and foster the development of socially appropriate skills
pharmacological interventions for impulse control disorder
-ODD- usually not needed -Intermittent explosive- SSRI (Prozac), mood stabilizers (lithium), antipsychotics if needed -Conduct disorder- second generation antipsychotics: Risperdal, Zyprexa, Geodon, Seoquel; third generation- Abilify
Dissociative Disorders
-Occur after significant adverse experiences or trauma; Reality testing remains intact; not experiencing hallucinations or delusions -Individuals respond to stress with severe interruption of consciousness -Term on "auto pilot" where it is difficult to recall certain events -Unconscious defense mechanism (involuntary): Protects individual against overwhelming anxiety through emotional separation, Memories are not linked to event or fragmented; causes significant confusion/distress -Theory of structural dissociation of personality: Different parts of personality fail to integrate after intense trauma
Learning Disorders
-Performance is well below the expected range and that of their peers, Screening is imperative to catch disorders early -Dyslexia (reading) -Dyscalculia (math) -Dysgraphia (written expression)
Feeding Disorders in Children
-Pica: Eating non-food items -Rumination: Regurgitation with re-chewing, re-swallowing or spitting -Avoidant/restrictive food intake: Low BMI, No distortion of body image, Dependent on enteral feeding or experiencing nutritional deficiencies
Acute stress disorder
-Precipitated by highly traumatic event -Diagnosed 3 days- 1mo. following event, after one month it's PTSD -Diagnosis= 8 out of 14 symptoms: Sense of numbness, Derealization, Intrusive, distressing memories, Sleep disturbances; nightmares, Feeling as if event is recurring, Avoidance behaviours (thoughts/feelings), Hypervigilance; exaggerated startle response, Agitation, restlessness, Hostility or anger
Adjustment disorder
-Precipitated by stressful event ; milder version of PTSD or ASD; diagnosed immediately following event or 3 mo after exposure -usually once the stress is removed the symptoms resolve themselves -Debilitating cognitive, emotional, and behavioral symptoms that negatively impact normal functioning -Responses to stressful event may include combinations of depression, anxiety, and conduct disturbances -Can occur as complicated grief w/ intense longing and sorrow for the loved one; may be preoccupied with the deceased and circumstances surrounding the death; lasts longer then the typically grieving period; SSRIs, CBT, grief services and counseling to treat
Dissociative Identity Disorder
-Presence of two or more distinct personality states -Recurrently take control of behavior -Often the "host" (dominant) personality is unaware of "alters" -May notice unfamiliar clothes is closet, being called a different name by a "stranger", absence of childhood memories -Each personality has own pattern of: Perceiving, relating to, and thinking about the self and environment -1 dominant personality or "host"= tends to be more superego driven (moralistic, religious) -Usually not aware of time spent in alternate state -May be perplexed by loss of time and unexplained events
NI for Impulse control disorder
-Promote a climate of safety -Establish rapport -Set limits and expectations -Be consistent in following through with consequences for rule-breaking -Provide structure and boundaries -Provide activities and opportunities for achievement of goals to promote a sense of self-purpose -Family engagement is key with children and adolescents; teaching parents how to manage symptoms and include others involved in care
Anorexia Nervosa
-Refuse to maintain normal weight -Intense fear of weight gain -Do not necessarily have loss of appetite - refuse food intake -Poor perception of body shape/weight
Sleep Walking Disorder
-Repeated engagement in complex behaviors while in a deep NREM stage of sleep: Walking, Dressing, Toileting, Driving -Person appears to be in a trance, May waken during activity -Most often individual returns to sleep and awakens without knowledge of events taking place. -Occurs ages 4 to 8, with peak prevalence at 12 years of age: More common in boys
Narcolepsy
-Symptoms: Irresistible attacks of refreshing sleep, cataplexy, sleep paralysis, and hypnagogic hallucinations, Sudden onset of sleep during meaningful activity -Do not feel rested regardless of amount of sleep -Treatment- lifestyle modifications and long-acting stimulant medication
Nightmare Disorder
-Takes place during the REM period late in the sleep cycle* -Fragmented sleep is the result -Frightening dreams that threaten survival, security, self-esteem -Fully alert upon wakening -Recollection of dreams in vivid detail -More common in females or those w/ past trauma
Environmental factors leading to childhood disorders
-Witnessing violence, abuse, neglect, bullying
Genetics and eating disorders
-a genetic vulnerability may lead to poor affect and impulse control or to an underlying neurotransmitter dysfunction -but no specific gene has been identified
neurobiological factors of eating disorders
-altered brain serotonin function contributes to dysregulation of appetite, mood, and impulse control -personalities that include: perfectionism, OC, and dysphoric -tryptophan (obtained through diet): can cause up and downs of appetite and mood
Assessment for Autism
-assess for developmental delays or loss of acquired abilities -assess the parent-child relationship for evidence of bonding, anxiety, tension, and fit of temperment -assess for physical and emotional signs of possible abuse; these patients are at risk -know about community programs providing support services for parents and children, including parent education, counseling, and after-school programs
Early signs of Autism
-before 12 months: no joyful expressions, no sharing of sounds or facial expressions, no babbling, no gestures such as waving and pointing -after 12 months: no words (by 16 months), no meaningful two word phrases (by 24 months), lack of social interaction, prevalence of behavioral issues
NI for ADHD
-behavioral contracting (expectations plus rewards/punishment), use of gestures (putting finger over mouth to say shh), redirection, limit setting, physical restraint, generate mature coping mechanisms -Psychopharmacology- may take up to 6 weeks to see results of treatment -Stimulants: methylphenidate (Ritalin) and amphetamine salts (Adderall) -Non-stimulant: atomoexetine (Strattera)
Assessment of Bulimia Nervosa
-binge eating and often self induced vomiting -depressive signs and symptoms -problems with interpersonal relationships, self-concept, impulsive behavior -increased anxiety -sensitive to the perception of others regarding this illness and may feel shame or lack of control
Common factors for people with eating disorder
-childhood trauma and sexual abuse -individuals with abuse hx typically have poorer treatment outcomes -physical neglect, emotional abuse, and sexual abuse
PTSD Assessment and NI
-comprehensive screening process and specific screening for PTSD, assess for suicide, violence, social withdraw, life stressors, life history, cognitive abilities -assist with managing arousal levels and anxiety, maintain calm environment, discharge plans -psycho education, what they're experiencing is normal and not their fault (not a weakness), feeling this way due to past experiences -substance abuse education and no alcohol with certain drugs -SSRIs to treat anxiety initially -possibly treatment of Alpha agonist (clonidine) or beta blocker (propranolol) to lower body's sympathetic response to create false sense of decreased anxiety
Medical Complications of bulimia nervosa
-dehydration, electrolyte imbalance, bradycardia, arrhythmias (similar to anorexia) -Esophageal tears -Gastric dilation -Dental caries and tooth erosion -Parotid swelling -Cardiac failure/death -Drug abuse
Assessment and NI of Trauma-related Disorders in Children
-developmental assessment* (Erickson) -emotional or physical difference then norm of their age, possibly regression -identify tolerance window -Trauma/stress may severely delay maturation and produce developmental delays -increase self-regulation of emotions -teaching autonomy***
Nursing Process for Autism
-dx based on level of disability and how it affects the whole family -NI: early intervention programs (therapeutic nursery schools, day treatment programs, special ed. Classes), Pharmacology- aimed at reducing impulsivity, anxiety, compulsive behaviors and agitation
Hypersomnolence Disorders
-excessive daytime sleepiness, extremely hard time staying awake to a point that impairs functioning -acute or chronic -occurs a lot with depression (this or insomnia) -treat possibly underlying issue, maintain sleep-wake cycle
General Interventions for childhood illness
-family therapy: individual or group -group therapy: different for each age group ex. 1) younger children- uses play to work through problems 2) grade-school children- combines play, learning skills, and talking 3) adolescents- learning skills and talking on peer relationships and working through problems, CBT -Disruptive behavior management: Use of seclusion, restraints, therapeutic holding, Staff must be properly trained and debriefings should occur following incident -play therapy: child learns to master impulses and adapt to environment -therapeutic drawing and music therapy
Assessing Development and Functioning
-focus on the developmental history and assessment plus family history of developmental disorders -therapeutic games extremely helpful with data collection when you can't use direct approach -mental status exam to identify problems with thinking, feeling, and behaving -Developmental assessment: Provides information of maturational level that is compared to chronologic age, Abnormal findings may be r/t stress or adjustment disorder; possibly something more serious
Assessment of DID
-good detailed history, neurological illnesses, substance abuse, coexisting psych disorders, suicide risk -identity testing (themselves), changing voice and clothing often, using "we" or "us" instead of "I" -most don't seek help until depression, host will seek help because anxious about time laps -impact on patient's family -self-assessment: must be able to work with these patient's
Insomnia Disorder
-identified as: 1) Difficulty with sleep initiation 2) Sleep maintenance 3) Early awakening 4) Non-refreshing (nonrestorative) sleep -symptoms must occur three times a week for atleast 3 months -Predisposing factors- personal hx including risk factors -Precipitating factors- external events triggering insomnia -Perpetuating factors- maintain the sleep disturbance
Reactive attachment disorder
-inhibited and emotionally withdrawn behaviour; especially towards a caregiver (lack of bonding) -Negative experience w/ caregiver since infancy; often gross deprivation of care or successive multiple caregivers -Characteristics: Afraid/anxious, Watchful, Irritable/angry, Low frustration tolerance, Seeks approval or can't be comforted
Temperment
-learned behavior based on experiences -style of behavior used to cope with demands and expectations of environment -large impact from caregiver's role
Treatment of Bulimia Nervosa
-medical stabilization -treatment unit for suicide risk and CBT -units are designed to interrupt the cycle of binge eating and purging and to normalize eating habits -if substance abuse present, treatment of the substance abuse is first then eating disorder treatment
Treatment for anorexia nervosa
-medical stabilization in the hospital -treatment unit for suicide risk and weight restoration -Out-patient: Individual therapy, Group therapy, Family therapy, Pharmacological therapy, Integrative Medicine, Health teaching and promotion
Self assessment for anorexia nervosa
-must not see behaviors as choices -ensure that you are encouraging, but not authoritarian (assuming a parental role) -it is helpful to acknowledge the constant struggle - ultimate goal is weight gain - their biggest fear
Disinhibited social engagement disorder
-opposite of reactive attachment -Child unfazed by separation from caregiver; does not exhibit fear around strangers -Stems from harsh punishment or inconsistent parenting; emotional neglect or limited attachment opportunities -Unusual willingness to go off with people unknown to them -Often engages in "superficial" attachment to strangers; very sociable but does not identify w/ any common characteristics of social group -"Desperation" for interpersonal contact
NI for Dissociative Disorders
-process of linking mind with past experiences -psychoeducation to understand what they're experiencing is from past trauma, not their fault, they're not going crazy -grounded teaching: bringing awareness to real, reality checks with touching objects -daily journal for self awareness and explain timelaps -sensory motor: somatic therapy, combine movement with mind to realize when once changes they all change to learn to disarm body's defense mechanism (dissociating), relaxation techniques, one with the environment
Intermittent Explosive Disorder
-remorse unlike ODD -Inability to control aggressive impulses -Can be verbal or physical and directed towards anyone/anything, including themselves -Can be precipitated by any event that causes distress -Pattern ranges from becoming upset to remorse for actions: Tension and arousal from environment (anger/frustration builds), Explosive behavior and aggression, Sense of relief in their behavior, Delayed consequences follow: remorse, regret, embarrassment -Adults 18 years or older -Leads to problems with: Interpersonal relationships, Occupational difficulties, Criminal difficulties, Health-related consequences= linked to HTN and DM
Assessment of sleeping disorder
-sleep patterns -how do you feel in your daily routine, concentrating, mood swings, any pain, muscle cramps -assign homework of sleep diary including issues and rituals -can you fall back asleep after wakening, medications, what have you tried so far -how is your life negatively affected by sleep disurbances
Resilience
-strengths of handling stress
Trauma-related Disorders in Children
-strong connection with Attachment theory= importance of early relationship b/w infant and caretaker; schemas (memories) are formed, Negative schema can lead to attachment issues in adulthood -environmental factors can either protect or expose child to undue stress (substance abuse, violence, poverty); prolonged exposure can affect resilience (adaptation)
Treatment for Binge Eating
-usually no inpatient care for this but for diabetes, HTN, heart disease, ect -CBT and interpersonal psychotherapy to reduce number of binge eating -patients need behavioral weight loss programs or may just not gain more weight -Pharmacological: SSRI, Belviq (feel full after eating small meal), Qsymia (antiseizure to promote fullness, reduce taste sensation, and burn quicker calories, and an appetite suppressant) -Surgical -Teaching Support Groups
Normal Sleep Cycle
1) Non-REM (NREM) sleep -Composed of three stages -Make up 75-80% of total sleep time; stage 3= restorative sleep** 2) REM sleep -Reduction and absence of skeletal muscle tone -Bursts of rapid eye movement -Myoclonic twitches of facial and limb muscles -Dreaming** -Autonomic nervous system variability
Posttraumatic stress disorder (PTSD)
1) Re-experiencing of the trauma, Most experience shortly after trauma; can be delayed up to 1 month-years 2) Avoidance of stimuli associated with trauma 3) Persistent symptoms of increased arousal 4) Alterations in mood, Depression tends to be a comorbid factor; be aware of potential substance abuse or SI -Adverse childhood experiences (ACE) and adult trauma leading to PTSD- depression, anxiety, sleep disorders, substance abuse, dissociative disorders
Familial risk factors that correlate with psychiatric disorders in children
1) severe marital discord (2) low socioeconomic status (3) large families and overcrowding (4) parental criminality (5) maternal psychiatric disorders (6) foster-care placement Other factors for mental health problems include: Witnessing violence Children who have experienced abuse Bullying
Assessments for anorexia nervosa
Perception of problem Eating habits History of dieting Methods used to achieve weight control Value attached to a specific weight/shape Interpersonal and social functioning Mental status and physiological parameters
Bulimia Nervosa
Recurrent uncontrolled binging Inappropriate compensatory behaviors Self-image largely influenced by body-image Enlarged parotid gland do not appear to be ill typically chaotic family life impulsivity and compulsivity
Most common mental disorder associated with an eating disorder
depression
refeeding syndrome
a potentially catastrophic treatment complication involving a metabolic alternation in serum electrolytes, vitamin deficiency, and sodium retention
Signs and Symptoms of Anorexia Nervosa
low weight, amenorrhea, yellow skin, lanugo, cold extremities, peripheral edema, muscle weakening, constipation, cardiovascular problems, impaired renal function, hypokalemia, anemic, decreased bone density -electrolytes are a biggie