NUR 2033 Exam 3

Focus on Diversity and Culture Cultural Interpretations of Abuse

Some Latin American cultures discipline children by having them kneel on uncooked rice for a short period of time. Practices similar to this are common in many areas of the world, and not considered to be harmful. Elder abuse is a growing problem around the world, and is overlooked and ignored in numerous cultures. Depending on an individual's interpretation of the Qur'an, a man may be permitted by religious law to hit his wife at his own discretion. For her to object could be seen as an act of disrespect and defiance. Many victims of intimate partner violence from other countries who live in the United States do not report abuse to authorities because of a fear of deportation for themselves or their families. Some individuals do not report intimate partner violence because it would be a matter of dishonor or shame for their families. Individuals who reported this custom were originally from South Asia, Bangladesh, China, Japan, Jordan, Latin America, and Vietnam.

Abuse: NONpharmalogical therapy

Therapy, counseling, and support groups Domestic violence shelters Pediatric considerations: -Play therapy -Art therapy -Journaling

Hormone replacement therapy (HRT)

Administration of hormones, usually estrogen and a progestin, to alleviate the symptoms of menopause.

TABLE 31-10 Examples of Specific Phobias

Acrophobia - Heights Arachnophobia - Spiders Aviophobia - Flying Claustrophobia - Enclosed spaces Hematophobia - Blood Hydrophobia - Water Nyctophobia - Darkness, nighttime

Menopause Nuring Dx

Deficient Knowledge Ineffective Sexuality Pattern Situational Low Self-Esteem Disturbed Body Image.

Anxiety Disorder Clinical Manifestations (General)

Anxiety disorders are clustered around a range of physiological, psychological, behavioral, and cognitive manifestations. Though each of the disorders is distinct (generalized anxiety disorder is completely distinct from acute stress disorder, and so on), the symptoms of all the disorders cluster around excessive, irrational fear and dread. Worry is a major component of each of the anxiety disorders. Individuals in anxiety states experience the emotion as both a subjective condition and as a range of physical symptoms resulting from muscular tension and autonomic nervous system activity. Chronic anxiety can lead to bodily discomforts and disabilities, including constipation, diarrhea, epigastric distress, and heart- burn, as well as musculoskeletal aches and pains. Anxiety can come either suddenly or gradually, and it may be expressed as either relatively mild bodily symptoms or as an incapacitating outbreak of acute anxiety

Menopause Complementary and Alternative Therapies

As a result of the controversy surrounding the use of HRT, nontraditional or alternative therapies have been more popular. The following complementary therapies, some of which are more effective than others, are examples of those used by menopausal women to reduce associated discomforts: Acupuncture. Randomized, placebo-controlled trials are scarce, and the evidence about the efficacy of acupuncture is unconvincing. Massage. Both massage and aromatherapy massage are effective in decreasing menopause symptoms. Bioidentical hormones. There is insufficient evidence that bioidentical hormone therapy is safe or effective. There are concerns about the content, purity, and labeling of these products. Meditation. Randomized clinical trial evidence suggests that mindful meditation relieves vasomotor symptoms of menopause. Yoga. A review of seven studies from 14 databases determined that the evidence is insufficient to suggest that yoga relieves vasomotor symptoms. Botanicals. Black cohosh, red clover, soy, dong quai, ginseng

Older Adult's Response to Loss: Culture and diversity considerations:

Asians, Muslims, & Native Americans Traditional Asian cultural beliefs: -expected to take care of their parents if they need assistance in later life Muslims: -dishonorable for older muslim adult to be placed in retirement or nursing home if a child or grandchild is still available to care Native Americans: -Older adults are cared for by all members of tribe -Death is not something to be feared, soul is condidered immortal

Clinical Manifestations and Therapies of Mild Anxiety Disorders

CLINICAL MANIFESTATIONS: Increase in sensory perception and arousal, Increase in alertness, Sleeplessness, Increase in motivation, Restlessness and irritability CLINICAL THERAPIES: typically is resolved by an individual's coping mechanisms. may be helpful to the client to accentuate focus and concentration. Clients who are distressed may benefit from: Improved sleep hygiene, Relaxation techniques, Behavior therapy, Massage, Aromatherapy.

Older Adult's Response to Loss Pathophysiology

Grief and loss as experienced by older adults can be more complicated than at other ages. A single death may trigger multiple losses. For example, a woman in the early stages of Alzheimer disease may be able to live in her home while her husband is in good health. When he dies and she moves in with one of her children, her loss of independence may accelerate. Older adults will lose friends and acquaintances in their age group, and as that happens they begin to anticipate their own death as well as the death of their partners.

Abuse: Cultural considerations

In asian cultures: cupping and coin rubbing are used as a healing method and should be differentiated from signs of abuse -- not considered abusive Other cultures may injure child for their inappropriate behaviors: not the nurse's place to judge; however, nurses are mandated reporters of child abuse, even if it is a cultural form of discipline. ***

What etiology causes clinical manifestations such as hot flashes?

Vasomotor instability

Sexual abuse

also known as sexual violence, is defined by the CDC as "any sexual act that is perpetrated against someone's will." Sexual abuse can include rape, attempted sexual acts, unwanted sexual contact, or even noncontact sexual abuse, which includes voyeurism and sexual harassment. All individuals can be at risk for sexual violence regardless of gender, age, education, IQ, or socioeconomic status. Sexual abuse is often perpetrated by an individual the victim knows such as an acquaintance, family member, teacher, authority figure, parent, sibling, or spouse. The majority of offenders involved in child sexual abuse are family members or are known to the child in some manner

child abuse and neglect

are defined as "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation" or "an act or failure to act which presents an imminent risk of serious harm" Approximately 47% of children who were abused in 2011 were 5 years old or younger, with 27% of these victims being 3 years of age or younger. Overall, the difference between boys and girls who were abused was almost negligible, with boys accounting for 48.6% and girls accounting for 51.1%. Child abuse is often defined as having three forms: neglect, physical abuse, or sexual abuse. Neglect accounts for the highest percentage of child mistreatment cases in the United States. Most often children are maltreated by their parents (81% in 2011), but other perpetrators are generally childcare providers, relatives, or a partner or spouse of the child's parent In a study conducted with a group of forensic nurses, the following five themes were highlighted as important when talking to potential victims: a child-friendly environment, building rapport and trust, active listening, believing the child, and the potential for false reports Nurses are also "mandatory reporters," meaning that if a child discloses information about abuse the nurse must report the situation; therefore, it would also be a false promise to say, or imply, that any information will be kept only between the nurse and the child.

what is seen in intermittent claudication

atherosclerosis

Erectile dysfunction Clinical Manifestations

can manifest as either the complete inability to attain an erection or the inability to sustain an erection. A man may achieve erection but be unable to sustain it, or the penis may become semi-erect but lack rigidity sufficient for intercourse. Erectile dysfunction can occur in men of any age and can be chronic, intermittent, or episodic. A medical diagnosis of ED requires that the problem be present at least 3 months

Nicotine addiction: Epidemiology

causes a bunch of probz lol p. 1546 Second hand smoke affects children: -more likely to die from SIDS -asthmatic children to have more frequent and sever attacks -Increased risk for respiratory symptoms and otitis media -More likely to have lower-birth weight babies

under mandatory reporting, nurses must report STD's occurrences to whom first?

county health dept

intermittent claudication is exacerbated because nicotine causes the release of _______________, which triggers vasoconstriction.

epinephrine

what happens during the increase in adrenal function that causes the sugar to rise?

glucocorticoids released, resulting in gluconeogenesis

OCD Risk Factors

having a first-degree relative with the disorder. A history of childhood sexual or physical abuse also increases the risk, as does exposure to other stressful or traumatic events during childhood

what is the #1 disease risk for smokers

heart disease

What are the 4 main types of support when working through trying situations?

professional friend family spiritual

what causes the destruction of alveoli?

tar

Box 28-4 Key Facts About Major Depressive Disorder

The average age of onset of MDD is the mid-twenties, although the disorder can begin at any age and seems to be occurring in younger people. Women are two to three times as likely to develop depression as men. First-degree biological relatives (parents or siblings) of people with MDD are two to four times as likely to develop depression as are members of the general population. Symptoms of MDD usually develop over a period of time. The person may experience anxiety and mild depression for several days, weeks, or months before the onset of a full major depressive episode. If untreated, major depression lasts 6 or more months. In some individuals, depressive symptoms persist for longer periods ranging from months to years. This is considered a partial remission and thought to be predictive of later depressive episodes and the development of chronic depression.

Menopause Implementation Phase

Discuss Knowledge of Menopause Because manifestations of menopause vary widely, it is difficult to predict their effect on an individual woman. However, the well-informed woman is better prepared to deal with whatever symptoms she experiences. To prepare the client, the nurse should do the following: Discuss physiological manifestations, such as hot flashes and night sweats. The underlying cause of hot flashes is the rapid change in estrogen levels. Many physiological effects of menopause are amenable to either HRT or nonpharmacologic methods of relief, such as lifestyle changes. Provide information about dietary recommendations. The recommended daily intake of calcium for women over age 50 is 1,200 mg. This dosage helps to prevent osteoporosis. Some women need to use calcium supplements or calcium-containing antacid tablets to meet this requirement. Emphasize the importance of weight-bearing exercise. Weight-bearing exercise reduces the rate of bone loss, helps maintain optimum weight, and reduces cardiovascular risk. Provide information about the benefits and risks of HRT. Not every woman will need or want it. Every woman needs to understand both the risks and the benefits before deciding whether to use HRT. Encourage the woman to obtain yearly mammograms, clinical breast examinations, and Pap tests until 65 years old. The increased risk for cancer of the breast and pelvic reproductive organs makes healthcare provider screening during and after menopause even more important. Promote Effective Sexuality Pattern Vaginal dryness and atrophy, together with the emotional effect of menopause, can interfere with sexual expression and satisfaction. Suggesting measures to help the woman and her partner cope with these changes can enable them to continue or resume a mutually satisfying sexual relationship. Encourage expression of feelings and concerns about how menopause is changing her sex life. Midlife and older women may not be comfortable discussing their intimate sexual behavior. Suggest ways to increase vaginal lubrication, such as spending more time in foreplay and/or using water-soluble gels (e.g., Replens) for vaginal lubrication. A more leisurely approach to sexual activity can be mutually gratifying for the woman and her partner. Use of water-soluble gels can prevent vaginal pain and irritation and improve the quality of the sexual experience. Plant estrogens, found in food such as brown rice, sweet potatoes, carrots, apples, corn, green beans, lemon and orange peels, and tofu, are mildly estrogenic and may improve vaginal dryness. Explain that as women age, it may take longer for vaginal lubrication and orgasm to occur. This information is important to prevent the woman from believing something is wrong with her or to prevent her partner from believing he or she is no longer interesting or sexually exciting. Promote Self-Esteem Each woman responds to the aging process in her own way, and most women have coping skills that adequately equip them to deal with the gradual changes associated with aging. Among the factors that may provoke a self-esteem disturbance are the loss of youth, a sense of emptiness as children leave home, and the need to redefine one's self-concept and roles as parenting becomes less important. Women who place a high value on their physical attractiveness may experience a painful psychological response to the physical changes of menopause. The nurse can help the client to negotiate the changes to her self-image by doing the following: Encourage expression of fears and concerns related to changes in interpersonal and family functions. Many women associate aging with "uselessness" and unattractiveness. Suggest volunteer activities or employment for the woman who has extra time. This enables the woman to feel that she is still a contributing member of society. Volunteering for activities involving young people can help reduce anxiety about the loss of reproductive ability or any late regrets about not having had children. Discuss the importance of a healthy lifestyle in maintaining physical attractiveness. Identify risk factors and high-risk behaviors. Lifestyle habits and behaviors affect many body systems and physical appearance. For example, cigarette smoking and overexposure to the sun make the skin age faster, contributing to wrinkles. Active women who exercise and eat a well-balanced diet look and feel better. Promote Healthy Body Image As a woman progresses through the perimenopausal period, changes in appearance and the loss of childbearing ability may combine to make her feel "old," "ugly," and "useless." Although this is far from the truth, with women living at least one third of their lives after menopause in productive careers and activities, it nevertheless is the perception of women as well as society. The physical changes the woman often experiences include growth of facial hair, excessive perspiration and flushing of the face, and weight gain. The nurse can help the woman deal with physical changes of menopause by doing the following: Encourage the woman to describe her perceptions of her own body. This information is necessary to obtain data to establish an individualized plan of care. Encourage verbalization of feelings of concern, anger, anxiety, loss, and fear over body changes. Expressing these emotions can facilitate the grieving process and acceptance of change. Stress that certain physical characteristics of an individual cannot be changed; emphasize the importance of learning to recognize and appreciate one's own special strengths. These help the woman gain acceptance and a realistic appraisal of self. Refer, as appropriate, for dietary management, exercise, stress management, and cosmetic assistance (e.g., for aggravating facial hair). These actions increase wellness and a positive sense of self.

Anxiety Disorder Pharmacologic Therapies

Medication does not cure anxiety disorders, but it can control the associated signs and symptoms while the client enters psychotherapy. The medications usually used for anxiety disorders are antidepressants, antianxiety drugs, and beta-blockers, though antipsychotics are sometimes used as well. Antidepressants were developed to treat depression, but the drugs are also effective for anxiety disorders. These medications begin to alter brain chemistry after the first dose, but their full effect requires a few weeks because a series of neurobiological changes must take place before the mediations achieve efficacy. Selective serotonin reuptake inhibitors (SSRIs) alter the levels of the neurotransmitter serotonin in the brain. SSRIs are commonly prescribed for anxiety disorders. SSRIs are generally started at low doses and then increased as their effectiveness becomes apparent. SSRIs have fewer side effects than previous generations of antidepressants, but they sometimes generate nausea, jitters, and occasionally sexual dysfunction. The most commonly used antianxiety drugs are benzodiazepines. These drugs have few side effects other than drowsiness, but higher and higher doses may be necessary over a long period of time, so benzodiazepines are typically prescribed for a short time. Because they take only hours to reach efficacy, they often are prescribed for clients experiencing severe or panic levels of anxiety. Clients with panic disorder can typically take benzodiazepines for up to a year without harm. Examples of benzodiazepines used in the treatment of anxiety include alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium). Some clients experience withdrawal symptoms if they stop taking benzodiazepines abruptly, and anxiety can return immediately after cessation. These potential problems have led some physicians to shy away from using these drugs. Buspirone, an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include nausea, headaches, and dizziness. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an antianxiety effect. Beta-blockers, such as propranolol, which is used to treat heart conditions, can prevent physical abnormalities (such as blushing and hyperventilation) that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted, the physician may prescribe a beta-blocker to keep the physical symptoms of the anxiety under control. At times, antipsychotic medications—drugs typically reserved for conditions such as bipolar disorder and schizophrenia—are used to treat anxiety disorders. Typical antipsychotics, the first drugs of this type, include haloperidol, chlorpromazine, and loxapine. These drugs have been shown to produce a significant reduction in neurotic anxiety. Atypical antipsychotics, a later generation of antipsychotics, provide potential benefits for clients with generalized anxiety disorder. Extended-release quetiapine has been shown to prevent relapse anxiety in clients with GAD, but more studies need to be performed to examine the risks and benefits of using antipsychotic medications for anxiety disorders

Erectile Dysfunction Risk Factors

The risk factors mirror the causes for ED and are numerous. They include advancing age, diseases such as heart disease and diabetes, trauma, the use of prescription or illicit drugs, and excessive use of alcohol

Clinical Manifestations and Therapies Obsessive-Compulsive Disorder

-Aggressive, sexual, and religious obsessions with checking compulsions >Clinical Manifestations: Checks doors, locks, appliances, written work. Confesses frequently (to anything). Needs to ask others repeatedly for assurance. -Symmetry obsessions with ordering, arranging, and repeating compulsions >Clinical Manifestations: Needs to have objects in fixed and symmetrical positions. Repeats movements, such as going in and out of doorways, getting in and out of chairs, touching objects. Counts or spells silently or aloud. -Contamination obsessions with washing and cleaning compulsions >Clinical Manifestations: Repeatedly washes hands, showers, bathes, brushes teeth. Cleans personal space frequently. -Hoarding, saving, and collecting symptoms >Clinical Manifestations: Compulsively acquires items. Has difficulty discarding items. Lives with extreme clutter. CLINICAL THERAPIES Pharmacologic therapies include SSRIs: fluoxetine (Prozac) sertraline (Zoloft) fluvoxamine (Luvox) paroxetine (Paxil) Antipsychotic medications such as risperidone (Risperdal) may be helpful for those who do not respond to SSRIs. Cognitive behavior therapy may include desensitization therapy in which the person is carefully exposed over a period of time to an object that promotes fear. For example, the therapist and client may, at an appropriate time, agree that the client will touch the door knob. Other therapies; for example, deep brain stimulation may be helpful to those who are treatment resistant.

Phobia Oviewview

A phobia is defined as an intense, persistent, irrational fear of a simple thing or social situation that compels the individual to avoid the stressor that elicits the fear. The stressor can be anything; needles and syringes, airplanes, spiders, dogs, closed areas, performing, and social activities are a few examples. The individual with a phobic disorder will experience severe panic upon contact with the stressor. The intensity of the fear drives the individual to avoid the situation at all costs. Adults suffering from a phobic disorder are aware that the fear is irrational; children are not always able to make that distinction. The maladaptive coping mechanism associated with phobias is the defensive mechanism known as displacement. The individual's unconscious, unresolved emotional issues are symbolically placed on the external object or situation. The individual moderates his or her anxiety by avoiding the object of fear. To be classified as a disorder, the phobia must be severe enough to interfere with the individual's daily functioning.

Abuse Pathophysiology and Etiology

Abuse is often related to control; one individual attempts to control another individual and for this to happen a form of abuse must occur. The three main forms of abuse are physical, emotional, and sexual. All of these can work to break down an individual's self-confidence and self-worth. Some common elements of abuse are humiliation, intimidation, and physical injury. Abuse sometimes start as emotional abuse—such as telling the victim he is not smart enough, or that no one will ever love him but over time emotional abuse can escalate to physical abuse or even sexual abuse. Physical abuse is generally accompanied by emotional abuse. In cases of sexual abuse, especially childhood sexual abuse, victims will often be exposed to forms of psychological abuse whereby the perpetrator will use the child's need for love and approval against him in order to force the child to submit. Ultimately cases of abuse involve both the use of control and manipulation.

Anxiety Disorder Etiology

Across the range of anxiety disorders, there are some important similarities in the basic causes of the anxious response. Biological causes seem to play a significant role in the development of anxiety disorders. Abnormal function of structures in the limbic system and certain parts of the cortex seem to be involved. The neurotransmitters most closely involved with the anxiety response are gamma aminobutyric acid (GABA), norepinephrine, and serotonin. Genetic contributions to each of the common disorders play a role as well, with at least part of the genetic vulnerability being nonspecific, or common across the disorders. Psychosocial and behavioral causal factors include the classical conditioning of fear and a perception of lack of control over one's environment, an attitude that begins in childhood. Vulnerability refers to the individual's susceptibility to react to a specific stressor. Individual vulnerability stems from biological and environmental sources, both of which have been the subjects of etiological research. Current explanations of the origin of anxiety disorders include neurobiological, neurochemical, psychosocial, behavioral, genetic, and humanistic theories.

Situational Depression Overview

Adjustment disorder with depressed mood represents a change in mood and affect following a stressor, such as the end of a relationship, or multiple stressors; it may also be called situational depression. Symptoms generally begin 3 months after the event and typically last no more than 6 months. Adjustment disorder with depressed mood is differentiated from an appropriate change in mood following a sad or stressful event in that the distress experienced by the client is out of proportion to the event and results in significant impairment in functioning

Phobia Risk Factors

Age. Social anxiety disorder (formerly known as social pho- bia) typically develops between the ages of 11 and 15 and almost never after the age of 25. Situational phobias generally develop by the mid-20s. Gender. Girls and women are twice as likely to develop phobias as men, although this figure may be slightly skewed because men are less likely to seek help for anxiety disorders. Family. Individuals are at higher risk of developing a phobia if an immediate family member has the phobia. An additional factor predisposing individuals to anxiety and phobias is an external locus of control. We describe locus of control as the extent to which an individual believes he has control over the events in his life. Individuals with an internal locus of control believe their actions, choices, and behaviors impact life events. Those with an external locus of control believe that powers outside of themselves, such as luck or fate, determine life events. factors that may predispose an individual to development of a phobia include the following: Traumatic events (e.g., animal attack, being trapped in an elevator) Witnessing others as they experience traumatic events Unexpected panic attacks while in a specific environment (e.g., experiencing a panic attack while traveling via airplane, which may lead to subsequent panic attacks in relationship to air travel) Exposure to extensive reports of traumatic events (e.g., media coverage of terrorist attacks, plane crashes, environ- mental disasters, or natural disasters).

Menopause Clinical Manifestations

Although menopause is an age-related process, not a pathological one, some women have troublesome health experiences after the cessation of menses. As estrogen decreases, various tissues are affected. Breast tissue, body hair, skin elasticity, and subcutaneous fat decrease. The ovaries and uterus become smaller, and the cervix and vagina decrease in size and become pale in color. These changes may result in problems with vaginal dryness, dyspareunia, urinary stress incontinence, urinary tract infections (UTIs), and vaginitis. Atrophic vaginitis may lead to urogenital infection, ulceration, and uncomfortable sexual intercourse. Vasomotor instability often results in hot flashes, palpitations, dizziness, and headaches. Other problems resulting from vasomotor instability include insomnia, frequent awakening, perspiration (night sweats), osteoporosis, and increased cardiovascular disease. The woman may experience irritability, anxiety, and depression as a result of these events. Long-term estrogen deprivation results in an imbalance in bone remodeling and osteoporosis, leading to fractures and kyphosis. The risk for cardiovascular diseases increases in response to an increase in atherosclerosis (from an increase in the LDL-to-HDL cholesterol ratio). Menopause, however, is a very individual experience that involves biocultural variation. Each woman experiencing menopause has had decades of physiological responses to her environment. Nutrition, smoking, body mass index, immune, reproductive, social, and cultural history all affect how each woman will respond to this physiological transition. Emotionally, some women may celebrate menopause; others may experience negative feelings about themselves and their body image; others may attach no significance to it.

Situational Depression Risk Factors

Any life-altering event can create risk for the occurrence of adjustment disorder with depressed mood. This risk is further increased by a preexisting mental health issue, ineffective or unhealthy coping mechanisms, or lack of a support network. Clients with these preexisting conditions may find that adjustment disorder with depressed mood has exacerbated their condition. For example, in an attempt to diminish feelings of depression, a client who has remained sober after a history of alcohol abuse may resume drinking as a coping mechanism following a stressful event. Older adults are at high risk for adjustment disorder with depressed mood, especially when they experience two or more stressors in proximity. Loss of independence, be it cognitive, physical, or otherwise, often results in adjustment disorder with depressed mood in the older adult. Even those older adults who "see the glass as half full" are challenged by these types of stressors. The loss of driving privileges (due to physical or cognitive changes) is a huge loss to older adults, often putting a great deal of strain on family members who must accommodate the older adult who can no longer drive, as well provide support as the individual learns to cope with this loss of independence.

What causes painful intercourse in menopausal women?

Atrophic vaginitis may lead to uncomfortable sexual intercourse. As estrogen levels fall as women approach and pass menopause, the resulting dryness and thinning of vaginal tissues can cause penetration and intercourse to be uncomfortable for many women. At menopause, you're most likely to have pain from: Hormone changes. Dwindling estrogen due to menopause is the No. 1 reason for sex pain at midlife and beyond. Hormone shifts make the tissues in your vagina become thin and dry. Dryness can add friction during sex. Your vagina also stretches less, which makes it feel tight. Fear and worry about pain. Once painful sex happens, you may dread its return. Fear can make your muscles tight and add dryness. A health problem. Other issues not due to menopause may be at fault, like chronic pain syndrome in the vulva, the area around the entrance to your vagina. Or you may have a urinary tract or yeast infection, or a skin problem. Being stressed or depressed, problems with your partner, or past sexual abuse can also make sex painful.

Menopause Pharmacologic Therapy

Before 2002, hormone replacement therapy (HRT) was a common medical choice for relieving the symptoms of menopause. The choices of HRT included estrogen/progestin combinations (EPT) for women who still had a uterus and estrogen only (ET) for women who had a history of hysterectomy. Research evidence had proven that the addition of progestin protects the endometrium from estrogen-induced hyperplasia and cancer. This routine medication for women experiencing menopausal symptoms changed when a landmark study, the Women's Health Initiative (WHI), came to an early halt based on data concerning women who were using the EPT. The early data (3 years before the planned ending of the study) revealed that women using EPT were at greater risk for congestive heart failure, breast cancer, pulmonary embolism, and stroke than the women who were taking placebos. The ET arm of the study continued but was halted 1 year prior to the planned ending because the women in this part of the study were having more strokes than women on placebos and the incidence of breast cancer had increased. This abrupt stop to this large government-sponsored study led many women to choose to stop HRT. It also led to a marked decrease in the numbers of prescriptions for HRT that physicians were willing to write. In the years that have passed since the WHI, experts have debated and studied the safety and efficacy of HRT for menopausal symptoms. Most recently, the Kronos Early Estrogen Prevention Study (KEEPS) results have been made available. This is a 4-year study that included 727 participants. It demonstrated that lower dose estrogen/progestin started soon after menopause appears to be safe, relieves hot flashes and vaginal dryness, improves mood and bone density, and decreases risks for cardiovascular disease. As a result of research findings such as this and the expert opinions available, the North American Menopause Society has issued a position statement on HRT. The U.S. Preventive Services Task Force has also issued a recommendation statement. The two documents are consistent in the recommendations made, which include the following: Most healthy, recently menopausal women (up to age 59 or within 10 years of menopause) can use HRT for relief of hot flashes and vaginal dryness, if they choose. Treatment choices should be individualized. HRT is the most effective treatment of menopausal hot flashes and vaginal dryness. If vaginal dryness or dyspareunia are the only symptoms, then low-dose vaginal estrogen is preferred. Risks for blood clots in the legs and lungs are increased with HRT, but occurrence is rare in women ages 50-59. The risk is further lowered by using low-dose estrogen pills or transdermal patches, gels, or sprays. Increased risk in breast cancer does occur when continuous EPT is used for 5 or more years or ET is used for 7 years or more, but the risk stops when the hormone is stopped.

Planning Care for Family Response to Health Alterations

Being sensitive to cultural differences is important in assessment and planning care. The nurse should determine who makes most of the decisions in the family, especially healthcare decisions, so he knows whom to obtain information from and whom to instruct. The extended family unit is found in many cultures, and different health beliefs and health practices may exist within the family. Building a trusting relationship with these families by talking with them about their beliefs and practices is the first step toward planning more effective care. Nursing care includes assisting the family with planning realistic goals/outcomes and strategies that enhance family functioning, such as improving communication skills, identifying and utilizing support systems, and developing and rehearsing parenting skills. Anticipatory guidance may assist well-functioning families in preparing for predictable developmental transitions that occur in the life of families. To help families reintegrate the client into the home following hospitalization or rehabilitation, nurses use data gathered during family assessment to identify family resources and deficits. By formulating mutually acceptable goals for reintegration, nurses help families cope with the realities of the illness and the changes it may have brought about. Such changes may include new roles and functions of family members or the need to provide continued medical care to the client. Working together, nurses and families can create environments that restore or reorganize family functioning during illness and throughout the recovery process.

Clinical Manifestations and Therapies of Moderate Panic Disorders

CLINICAL MANIFESTATIONS: Inability to focus, Perception distorted, Terror, Feelings of doom, Bizarre behavior, Dilated pupils, Trembling, sleeplessness, palpitations, pallor, diaphoresis, muscular incoordination, Immobility or hyperactivity, incoherence CLINICAL THERAPIES: Immediate, structured intervention required. Immediate therapies include the following: Placing client in a quiet, less stimulating environment, Use of repetitive or physical task to diffuse energy, Administration of antianxiety medications Long-term therapies include the following: Cognitive and behavioral therapy, Pharmacologic therapy, Relaxation techniques, Improved sleep hygiene, CAM therapies such as massage, acupuncture, yoga, hydrotherapy, Nutrition consultation, Mental health counseling

Clinical Manifestations and Therapies of Moderate Anxiety Disorders

CLINICAL MANIFESTATIONS: Narrowing of perceptual field and attention span (a process called "selective inattention"), Reduction in alertness and awareness of surroundings, Feeling of discomfort and irritability with others, Self-absorption, Increased restlessness, Increase in respirations, heart rate, and muscle tension, Increase in perspiration, Rapid speech, louder tone, and higher pitch CLINICAL THERAPIES: Cognitive and behavior therapy to identify triggers and learn improved coping techniques, Relaxation techniques, Complementary and alternative therapies such as yoga, acupuncture, massage, Low-dose anti-anxiety medications if symptoms do not improve with other therapies or if the medications exacerbate chronic conditions

Clinical Manifestations and Therapies of Moderate Severe Disorders

CLINICAL MANIFESTATIONS: Perceptual field greatly reduced, Difficulty following directions, Feelings of dread, horror, Need to relieve anxiety, Headache, Dizziness, Nausea, trembling, insomnia, Palpitations, tachycardia, hyperventilating, diarrhea CLINICAL THERAPIES: Cognitive and behavior therapy to learn to identify triggers and to learn better coping techniques, Antianxiety medications (may include benzodiazepines), Relaxation techniques, Complementary therapies such as yoga, acupuncture, massage, Hospitalization may be required initially to manage until improved coping mechanisms are developed

Nicotine Addiction: Clinical manifestations (related to etiology)

Carcinogens: -Lung cancer -Stomach cancer -Bladder cancer -Oral cancer -Laryngeal cancer Smoke, chemicals, and heat: -chronic cough -COPD -Increased mucous production -chronic hypercapnia Secondary smoke: Children at risk of .. -otitis media and respiratory tract infections External exposure affecting cellular regeneration: -Wrinkles in skin -Premature aging -Yellowing of fingernails and fingers Smell of smoke is prevalent: -reduced sense of smell -hair, skin, and clothing smelling of smoke

Summary Criteria for Generalized anxiety disorder

Characterized by intense tension and worry, even in the absence of external stressors. May demonstrate anticipation of disaster and/or preoccupation with health issues, money, familial problems, or work-related challenges. Affected individuals usually recognize that their anxiety is disproportionate to the circumstances. Manifestations include difficulty relaxing, pronounced startling, trouble concentrating, and difficulty falling asleep. Somatic symptoms include fatigue, headache, muscle tension and aches, digestive issues, irritability, feeling out of breath, and hot flashes. Diagnostic criteria include excessive anxiety about everyday problems for at least 6 months.

Application of Cognitive-Behavioral Techniques in the Treatment of Clients With Phobias

Cognitive restructuring - Application of learned reframing/reinterpretation of anxiety- or fear-provoking stimuli to reduce the associated anxiety and fear. Example: A client who is terrified of thunder recognizes that thunder, in and of itself, poses no threat to life and that he is not at risk for harm as a result of the sound of thunder. Systematic desensitization (exposure therapy) - Through exposure to situations that elicit increasing levels of anxiety, the client is desensitized to a given stimulus. Example: A client who is terrified of spiders is interviewed with regard to his fear. Next, the client is engaged in discussions about spiders until she is able to discuss them without extreme anxiety. The client is then exposed to photographs of spiders until she is able to complete the activity without extreme anxiety. Finally, the client is exposed to an actual spider, with the goal being that she may be so exposed without a sense of panic, fear, or anxiety. Reciprocal inhibition - The phobic stimulus is combined with a stimulus that evokes a response that counteracts the undesired response. Example: The client who fears using public transportation uses biofeedback training to reduce his fear and anxiety while traveling on a public railway system.

Lifespan Considerations OCD in Childhood and Adolescence

Current research suggests that some children with OCD develop the condition after experiencing one type of streptococcal infection. Initially referred to by the acronym PANDAS, which stands for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, researchers have proposed revision of this condition to pediatric acute-onset neuropsychiatric syndrome (PANS). Its hallmark is a sudden and abrupt exacerbation of OCD symptoms after a strep infection. The cause of this form of OCD appears to be antibodies mistakenly attacking a region of the brain. The SSRIs appear effective in alleviating symptoms of OCD in children. Several randomized, controlled trials revealed SSRIs to be effective in treating children and adolescents with OCD. CBT has been used to treat OCD, but the evidence is not conclusive.

Summary Criteria for Separation anxiety disorder

Developmentally inappropriate and excessive anxiety about separation from home and people to whom the person is attached. Evidence for this condition includes recurrent distress when separated from home and family, persistent and excessive worry about harm befalling major attachment figures, persistent refusal to leave attachment figures, persistent fear of being alone, persistent reluctance to go to sleep away from a major attachment figure, and complaints of physical symptoms. Duration of symptoms of at least 4 weeks. Onset before age 18 years. Clinically significant distress or impairment in important areas of functioning. Disturbance does not occur exclusively during the course of other disorders.

Erectile Dysfunction Overview

Erectile dysfunction (ED) is the inability of a male to attain and maintain an erection sufficient to permit mutually satisfactory sexual intercourse with his partner. ED may involve a total inability to achieve erection, an inconsistent ability to achieve erection, or the ability to sustain only brief erections. ED may or may not be associated with a loss of libido (sexual desire). The incidence of ED is difficult to estimate because many affected men may not report the disorder. It has been estimated that about 30 million men in the United States have ED. The incidence increases with age with about 4% of men ages 50-59 years affected, 17% of men ages 60-69, and about 47% of men over age 75. However, ED is not inevitable in all men, and it is treatable at any age.

Client Teaching Deep Breathing and Progressive Relaxation

Essential teaching for individuals suffering from anxiety and phobias includes deep breathing and progressive relaxation techniques to lower anxiety responses. Avoidance of stimulants, caffeine, and nicotine is essential. Instructing individuals on the use of cognitive techniques can be helpful in lowering the individual's response to the threat. Strategies such as thought blocking, self-talk, and conversation with a support person all assist the individual to manage and empower more adaptive coping skills. Physical exercise that makes use of large muscle groups, such as walking, running, weight lifting, hiking, and various sport activities, can dissipate pent-up energy. Exercising also releases natural chemicals such as endorphins, improving mood and natural pain relief.

Client Teaching Adaptive Coping

Establishing a therapeutic relationship provides the nurse with an opportunity to promote healthy adaptive coping. Client teaching about the nature of obsessive thinking is critical to lowering the client's feelings of shame and anxiety. The nurse can help the client realize that fears of hurting or killing family members arise from the disease, not from any actual desire of the client to harm others. Nurses can help clients reframe how they think about their disease and help them reframe thought processes in order to reduce ritual performance, such as helping the client meditate versus performing a ritual and then recognizing that nothing bad happened as a result of the absence of the ritual. The nurse has an essential role in helping the client with OCD understand that he or she can decrease anxiety and gain control over the disease through pharmacologic and behavior therapies.

Clinical Manifestations and Therapies Menopause

Etiology - Increase in vaginal pH Clinical Manifestations - Risk of urinary tract infection (burning, frequency, hesitancy, and urgency to urinate) & Vaginal infection (vaginitis, vaginal drainage) Clinical Therapies - Medications (antibiotics or antifungals) may be prescribed. Encourage adequate fluid intake. Teach importance of wiping from front to back. Teach symptoms to report. Etiology - Reduced vaginal lubrication Clinical Manifestations - Dyspareunia, injury, and fungal infections Clinical Therapies - Teach use of artificial water-based lubricant to reduce symptoms. Treat fungal infection. Etiology - Vasomotor instability Clinical Manifestations - Hot flashes, Diaphoresis, Increased risk of heart disease Clinical Therapies - Teach women to dress in layers, wear cotton underwear, drink cool liquids. If severe, hormone supplements may be prescribed. Etiology - Osteoporosis Clinical Manifestations - Fractures, increased bone fragility, Kyphosis Clinical Therapies - Teach importance of calcium, vitamin D, and phosphorus intake. Suggest weight-bearing exercises.

Exercise and depression

Extensive evidence indicates that exercise is effective in reducing symptoms of depression. However, an extensive search of the research literature revealed no studies specifically investigating the role of exercise in adjustment disorder with depressed mood or situational depression. It clearly showed that exercise is beneficial in reducing depressive symptoms. Further analysis showed that resistance exercise, or resistance exercise combined with aerobic exercise, was more effective than aerobic exercise alone, and that exercising three times a week or more was more effective than exercising only once a week. In the United States, exercise is not recognized as a first-line treatment for depression. However, in the United Kingdom, the National Institute for Health and Clinical Excellence recommends structured, supervised exercise programs, three times a week (45- to 60-minute sessions) for 10 to 14 weeks to treat mild depression, and exercise program referrals are available for clients consulting physicians for a complaint of depression. There is some evidence that physical exercise is as effective as CBT or medication in reducing depression, but further research is needed. Mindful exercise practices, such as yoga, qigong, and tai chi, that combine cognitive meditation with physical movement were found to significantly improve symptoms of depression in five out of six studies in a systematic review. Based on the evidence, physical exercise should be recommended to clients who are diagnosed with adjustment disorder with depressed mood.

Complicated Grief

For the individual suffering from complicated grief, the grieving process does not progress. Instead, an overwhelming sense of grief persists and sometimes worsens over a period of months. The individual may experience profound emotions associated with memories of the deceased, along with an inability to accept the reality of the loss. Auditory and visual hallucinations are not uncommon for those suffering this form of prolonged grief. In addition to these symptoms, bereaved individuals may become distrustful or uncaring toward others, forcing themselves into a form of self-imposed isolation. Complicated grief arises in approximately 6%-25% of the bereaved who still feel intense, disruptive grief for a prolonged period of many months, or even years, while typically grief begins to lessen in intensity within 3-6 months. In the first 6 months after a loss, an individual is expected to experience some of the same symptoms seen in individuals with complicated grief, such as extreme distress and an inability to function normally in day-to-day activities. However, if after 6 months these symptoms have not lessened and individual functioning is significantly impaired or the individual is at an increased risk for suicide, then complicated grief may be diagnosed. The earliest this diagnosis can be made is 6 months; however, many still debate about how much time must elapse before this diagnosis can be made. Treatment of complicated grief is often in the form of psychotherapy targeting specific symptoms related to the disorder. Physician Katherine Shear developed Complicated Grief Treatment (CGT), a form of psychotherapy administered over 16 sessions in accordance with a published manual that describes this treatment. According to Shear, healing from a loss is composed of a loss-oriented process and a restoration-oriented process. During the first process, the individual accepts the loss; during the restoration process, the individual begins to move on to a life without the deceased. CGT has been shown to be helpful to clients on its own, but some have used it in combination with antidepressants. While recent studies have shown that antidepressants may be helpful to those with depression related to grief, they do not appear to be as effective for clients with complicated grief. However, combining the use of antidepressants with CGT has proved to be quite effective in helping clients to work through their grief.

Promoting Safety Violence Implementation

In cases of abuse, the client's safety is the primary concern. Due to mandatory reporting laws, nurses must report all suspected cases of child abuse. In some states it is also legally mandated for nurses to report the abuse or neglect of an older adult. Cases of intimate partner violence are often left to the victim to report, but some areas have laws concerning mandatory reporting of IPV. The use of specific weapons and the nature of the injuries are often a factor for mandatory reporting of IPV in states with those laws. Nurses must be aware of regulations within the state where they are practicing, and abide by those laws. When abuse is suspected, the nurse should follow institutional policies and guidelines for reporting. In the clinical setting, the nurse usually is required to notify a supervisor to begin the reporting process. When mandatory reporting is not indicated, it is imperative for nurses to provide the client with information about resources for seeking help. Resources can be in the form of the client's friends and family members or community liaisons who can work to help the individual find a secure living environment. Other resources can be offered such as police, lawyers, and agencies that can provide ongoing assistance for the victim. Nurses encourage the client to accept help in seeking an abuse-free living situation, but the decision ultimately lies with the client. Some individuals will not be ready to seek help, and while the nurse may disagree with this decision, he must refrain from judgment and be respectful of the client's decision. All nurses can do in these situations is offer assistance and resources; this lets the victim know that help is available if it is needed in the future.

Lifespan Considerations Separation Anxiety Disorder

Infants and Toddlers From 8-14 months, children often become frightened when they meet new people or visit unknown places. When infants are separated from their parents, they feel unsafe. This is called separation anxiety, and is a normal developmental phase. Normal separation anxiety usually ends when the child is around 2 years old. Children and Adolescents A child's feeling of anxiety when separated from loved ones is diagnosed as SAD when symptoms are powerful enough to interfere with daily life and last for at least 4 weeks. Children with the condition have an overwhelming fear of being lost from their family or that something bad will happen to a loved one. In children, SAD occurs equally in males and females, and the first indications of the condition usually occur between the ages of 7 and 9. Approximately 4% of younger children have the condition, and the estimate for adolescents is slightly lower. Adults Adult separation anxiety disorder (ASAD) usually has its first onset in adulthood, although it can represent the persistence or recurrence of childhood SAD. ASAD is associated with high levels of disability, and may interfere with committed relationships, work, and interactions with family and friends

Collaboration Family Response to Health Alterations

Interventions vary based on the identified risks and actual or potential alterations in health. Nurses may collaborate with various healthcare professionals during the course of caring for the client and family, including social workers, grief counselors, psychiatrists, physicians, pediatricians, surgeons, and pharmacists. Nurses also need to understand the importance of collaborating with parents. Nurses working with pediatric clients may collaborate with the school nurse, homebound teacher, guidance counselors, and other professionals. Collaboration with parents is key, because they often are the experts not only on their child but also on their child's illness, making them an extremely valuable member of the healthcare team.

Instill Hope in depressed patients

It is equally important to help clients identify the aspects of their lives that are not within their control. Being able to accept what cannot be changed is just as essential as developing the ability to bring about positive change. This skill is particularly helpful in reorienting clients from feelings of hopelessness to a more hopeful aspect. Other interventions to help clients combat hopelessness include the following: Help clients identify their personal strengths. It may be useful to write these down. Recognize that it often takes time for clients to realize that they have any strengths. Recognizing strengths helps a client design an activity or engagement plan that the client is more likely to enjoy and find successful. Engage clients in setting goals for themselves. Direct clients to focus on small goals at first. For example, instead of "going to yoga twice a week," the initial goal might be to go to the yoga center and get a list of class times and teachers or sit in on a class. Help clients weigh and choose alternatives. Taking responsibility even for small choices such as when or where to eat helps the client regain self-esteem. Explore problem-solving models with the client, including practicing problem-solving. "When you found out the toaster was broken, you threw it against the wall. You said all that did was put a dent in the wall and make a mess for you to clean up. What might you do differently next time that might be more helpful?" Help clients to identify resources such as family, community, or friends who can provide support and encouragement in overcoming problems they identify. Planning for discharge should begin with the first client contact and is particularly important with hopeless, dependent clients. Help these clients and their families and significant others identify resources in the community they can use to build support systems. Support groups, therapy groups, and social groups can help clients separate from caregivers more readily when the time comes to end therapy.

Older Adult's Response to Loss Etiology

Losses associated with aging are varied and may include loss of independence, loss of mobility, loss of health, and loss of memory. Unfortunately, these create a misperception among some younger adults that with age inevitably comes frailty and deterioration of mental function. Misperceptions such as this are considered a form of ageism, which involves forming stereotypes about older adults. Nurses must guard against such misperceptions. Many older adults live active, healthy, fulfilling lives.

Benzodiazepines Drug examples: alprazolam (Xanax) clonazepam (Klonopin) diazepam (Valium) lorazepam (Ativan) temazepam (Restoril)

MECHANISMS OF ACTION: Potentiate the effect of the naturally occurring inhibitory neurotransmitter gamma-aminobutyric acid (GABA), leading to promotion of relaxation and a decrease in the subjective experience of anxiety. NURSING CONSIDERATIONS: Not recommended for long-term use due to habit-forming properties. Monitor client for excess sedation and dizziness. Use cautiously in clients with impaired hepatic function and monitor liver function studies for these clients. Counsel client to avoid alcohol in combination medications in this classification.

Anxiolytics Drug example: buspirone (BuSpar)

MECHANISMS OF ACTION: Act as a dopamine agonist in the brain and also inhibit serotonin reuptake (leading to increased circulating serotonin), producing antianxiety effect. Used to treat GAD. NURSING CONSIDERATIONS: Assess for side effects including nausea, headaches, and dizziness. Monitor for dystonia, motor restlessness, and involuntary repetitive muscle movements (primarily facial or in the cervical neck region). Advise client this medication requires daily administration for at least 2 weeks to produce antianxiety effect.

Antipsychotics Drug examples: risperidone (Risperdal) olanzapine (Zyprexa)

MECHANISMS OF ACTION: Interfere with action of serotonin and dopamine in the brain; as a result, for some clients, they promote reduction of compulsive behaviors and decreased agitation. In conjunction with other therapies, may be used in the treatment of clients with OCD or panic disorders NURSING CONSIDERATIONS: Monitor for neuroleptic malignant syndrome and tardive dyskinesia, and immediately report signs and symptoms of these conditions. Assess for side effects including drowsiness, excess sedation, somnolence, or increased agitation. Monitor CBC, kidney and liver function studies, serum electrolytes, and serum glucose level.

Antidepressants Drug examples: SSRIs, such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) tricyclic antidepressants, such as imipramine (Tofranil)

MECHANISMS OF ACTION: SSRIs inhibit reuptake of the neurotransmitter serotonin in the brain, resulting in circulation of increased levels of serotonin. Although primarily used for treatment of depression, certain SSRIs are also effective in the treatment of clients with anxiety, OCD, and panic disorder. Tricyclic antidepressants block presynaptic neuronal reuptake of serotonin and norepinephrine, resulting in increased circulating levels of these neurotransmitters. Tricyclic antidepressants may be used in the treatment of clients with panic disorders. NURSING CONSIDERATIONS: Monitor for development of suicidal ideation or worsening of symptoms Assess for adverse effects, including dizziness or drowsiness. Counsel clients to avoid alcohol in combination with SSRIs or tricyclic antidepressants. Periodically obtain complete blood count (CBC) with differential, serum electrolyte panel, and liver and kidney function studies.

Beta-Blockers Drug example: propranolol (Inderal)

MECHANISMS OF ACTION: Selectively block cardiac and bronchial beta receptors, compete with epinephrine and norepinephrine, and reduce effects of sympathetic nervous system stimulation, such as increased heart rate, increased cardiac contractility, and increased blood pressure. Unlabeled uses include management of anxiety states and prevention of acute panic states (such as those related to public speaking). NURSING CONSIDERATIONS: Assess blood pressure and heart rate prior to administration. Withhold medication if systolic blood pressure <90 mmHg or apical pulse rate <60 bpm, or if blood pressure and apical pulse rate do not meet parameters defined by the prescribing provider. Monitor for adverse effects, including bradycardia, confusion, fatigue, and drowsiness.

Clinical Manifestations and Therapies Depressive Disorders

Major depressive disorder CLINICAL MANIFESTATIONS: Symptoms must last 14 days or longer and may include: Feelings of sadness and hopelessness Somatic complaints such as pain, stomachaches Anxiety, anger, irritability Loss of interest in pleasurable activities Sleep disturbances CLINICAL THERAPIES: Pharmacologic therapies include: • Selective serotonin reuptake inhibitors (SSRIs) • Tricyclic antidepressants (TCAs) • Atypical antidepressants • Electroconvulsive therapy (most often used for those who are resistant to treatment with medications) Persistent depressive disorder (dysthymic disorder) CLINICAL MANIFESTATIONS: Symptoms are not as severe as those of major depressive disorder, but last beyond 2 years with period of relief lasting less than 2 months. CLINICAL THERAPIES: Cognitive-behavioral therapy Pharmacologic therapies are the same as for MDD. Electroconvulsive therapy (most often used for those who are resistant to treatment with medications) Cognitive-behavioral therapy Seasonal affective disorder CLINICAL MANIFESTATIONS: Depressive symptoms occur in relation to the seasons; usually during the winter months, when days are shorter. CLINICAL THERAPIES: Bupropion extended-release Light therapy Cognitive-behavioral therapy

Abuse Risk Factors

Many risk factors exist in accordance with abuse, thereby helping to predict which populations are at a higher risk for victimization. Specific risk factors include age, gender, physiological development, cultural and socioeconomic factors, a spouse's history of substance abuse, and having firearms in the house. Abuse can happen to any individual regardless of how many personal risk factors they have, but it is helpful to understand the statistics and reasoning behind some areas of abuse. Age - Some age groups, particularly younger children and older adults, are at increased risk for abuse due to abusers considering these age groups to be more helpless than others. Young children in particular are at the highest risk for an abuse injury with approximately 27% of all child abuse cases in 2011 occurring in children younger than 3 years old. In cases of elder abuse, it is virtually impossible to know the full extent of instances of abuse because many are not reported. However, it is known that as older adults age the risk for abuse increases. Abuse in older adults is commonly in the form of neglect, but can also be in terms of physical, emotional, or sexual abuse Gender - in cases of child abuse there is virtually no difference between the number of female victims and the number of male victims. Intimate partner violence, however, does show a higher instance of women being abused than men. Debates exist over reported numbers of IPV victims, with many claiming that the majority of male victims do not report being abused by their spouse. Some family conflict studies have even indicated that an equal percentage of men and women are victims of abuse from their spouse. Trends in elder abuse, though, show a clear delineation of women being abused more often than men. Physiological Development - Physiological illnesses and disabilities may present one of the highest risk factors for all forms of abuse. Individuals with disabilities are more likely to be seen as easy targets for abuse, with perpetrators assuming that the victim will not, or cannot, report the crime. Some common reported disabilities associated with cases of abuse include intellectual disabilities, physical and learning disabilities, visual or hearing impairments, dementia, and Alzheimer disease. Cultural Factors - Asians/shame, Hispanic Americans, traditional Asian cultures, and some Middle Eastern cultures/physical abuse Socioeconomic Factors - Some researchers consider the culture of poverty to be the largest risk factor and predictor of child abuse and neglect. Substance Abuse - Alcohol and other substances do not create an abusive situation; other factors also need to be considered such as the personality of the individual using the substances. However, substance and/or alcohol abuse is one of the leading risk factors for perpetrators of all forms of abuse.

Erectile Dysfunction Diagnostic Tests

Medical management of ED begins with a medical and sexual history to determine the degree of the problem and to reveal disease, lifestyle habits, or medication use that may be contributing to ED. It has been estimated that about 25% of all cases of ED are medication related. The physical examination will provide clues about any systemic problems, signs of low androgen, and any structural problems within the penis. The diagnostic tests that may be ordered include blood studies, penile monitoring, and penile blood flow. Blood chemistry, CBC, urinalysis, lipid profile, kidney and liver function testing, testosterone, prolactin, thyroxin, and PSA levels are measured to identify metabolic and endocrine problems that may be causing the dysfunction. Nocturnal penile tumescence and rigidity monitoring helps differentiate between psychogenic and organic causes. Physically healthy men have involuntary erections during sleep. These tests can be performed in a sleep laboratory, although home testing with portable devices is an alternative. Tests for nocturnal erections are not completely reliable but do give more information about the problem. The number and quality of erections occurring during REM sleep can be determined. At this point, a trial of oral medications may be prescribed to determine response. If an inadequate response to oral medication is determined, injections into the penis may be used. If injections do not produce the effect desired, then vascular studies with duplex ultrasound, penile cavernosometry, and cavernosography of the corpora or pudendal arteriography can be done to determine whether the problem is arterial or venous. These studies also determine whether or not the client is a candidate for vascular surgery

Menopause Overview

Menopause is the permanent cessation of menses. The climacteric, or perimenopausal, period denotes the time during which reproductive function gradually ceases. For most women, the perimenopausal period lasts several years. It begins with a decline in the production of the hormone estrogen, includes the permanent cessation of menstruation due to loss of ovarian function, and extends for 1 year after the final menstrual period, at which time a woman is said to be postmenopausal. The average woman will live one third of her life after menopause. Menopause is neither a disease nor a disorder, but a normal physiological process. It is included here because it does increase the risk of physical disorders and does affect various aspects of women's health. Many women welcome the freedom from monthly menstrual periods and have relatively minor physical effects from the estrogen depletion. However, the hormonal changes that occur can be accompanied by side effects. Wide variation is seen in how individual women experience these side effects. In the United States, most women stop menstruating between 48 and 55 years of age. Earlier menopause is associated with genetics, smoking, higher altitude, and obesity. Certain health risks increase after menopause, including heart disease, osteoporosis, macular degeneration, cognitive changes, and breast cancer.

Manifestations of the Perimenopausal Period

Menstrual cycles become erratic. Menstrual flow varies widely in amount and duration and eventually ceases. Vaginal, vulval, and urethral tissues begin to atrophy. Vaginal pH rises, predisposing the woman to bacterial infections. Vaginal lubrication decreases, and vaginal rugae decrease in number. This may result in dyspareunia, injury, and fungal infections. Vasomotor instability due to a decrease in estrogen may result in hot flashes and night sweats. A hot flash starts in the chest and moves upward toward the face and may last from seconds to several minutes. Psychological symptoms may include moodiness, nervousness, insomnia, headaches, irritability, anxiety, inability to concentrate, and depression.

Figure 28-4 Characteristics of major depression.

Mood depressed; Memory problems Anxious; Apathetic; Appetite changes "Just no fun" Occupational impairment Restless; Ruminative Doubts self; Difficulty making decisions Empty feeling Pessimistic; Persistent sadness; Psychomotor retardation Reports vague pains Energy gone Suicidal thoughts and impulses Sleep disturbances Irritability; Inability to concentrate Oppressive guilt "Nothing can help" (Hopelessness)

Supporting Family Function in clients with situational depression

Mood disorders affect not only the client, but also family and friends. Nurses must provide care to the family as well as to the client with situational depression. During acute episodes, clients may be dependent and needy or may need firm direction and limit setting. Help caregivers acknowledge clients' dependency and assume appropriate responsibility. Provide information about clients' condition in accordance with client preferences, remembering the importance of confidentiality. Provide the family with a list of community resources and encourage them to participate in support groups. In some cases, the stressor that causes the client's adjustment disorder with depressed mood also directly disrupts family processes. For example, a mother who is injured in a motor vehicle crash and confined to bed rest for more than a few days requires someone to step in and assume her normal roles until she is able to perform them again. In cases like this in which family processes and patterns are disrupted, the nurse can support the family by providing referrals to outside resources and by helping the father or another adult family member develop a plan to "cover the bases" until the mother returns to health. Families who have experienced a loss or stressor that disrupts family processes are at increased risk for family conflict. Nurses working with these families should encourage them to resolve disagreements in a healthy manner and not allow the situation to overrun their family strengths.

Nicotine Addiction: Patho and etiology

Nicotine --> psychoactive substance found in tobacco Release dopamine & epinephrine -- causing vasoconstriction: -increase heart rate, blood pressure, peripheral vascular resistance, increase heart workload. GI effects Difficulty falling asleep bc nicotine is a stimulant (refraining from smoking after evening meal helps sleep better) **Nicotine dependence result from chronic use (dopaminergic processes have a role in regulating the reinforcing effects, making cessation difficult) -withdrawl symptoms p. 1546

Nicotine Pathophysiology

Nicotine is a psychoactive substance found in tobacco. In low doses, nicotine stimulates nicotinic receptors in the brain to release dopamine (a precursor to norepinephrine) and epinephrine, causing vasoconstriction. This increases the heart rate, blood pressure, and peripheral vascular resistance, increasing the heart's workload. GI effects include an increase in gastric acid secretion, an increase in the tone and motility of GI smooth muscle, nausea, and increased risk of vomiting. In the CNS, nicotine occupies the receptors for acetylcholine in both dopamine and serotonin neural pathways. This causes the release of dopamine and norepinephrine. Initially, nicotine increases mental alertness, and cognitive ability, but eventually it depresses those responses. Smokers often have more difficulty falling asleep than non-smokers do because nicotine acts as a stimulant. Smokers are usually easily aroused and often describe themselves as light sleepers. By refraining from smoking after the evening meal, the person usually sleeps better; moreover, many former smokers report that their sleeping patterns improve once they stop smoking. Withdrawal symptoms include craving, nervousness, restlessness, irritability, impatience, increased hostility, insomnia, impaired concentration, increased appetite, and weight gain. Gradual reduction in nicotine use seems to prolong suffering. Chronic health problems from smoking have been well established in the form of cancer, heart disease, emphysema, hypertension, and death

Erectile Dysfunction Pathophysiology and Etiology

Normal, physiological erection that enables the penis to enter the vagina is a neurovascular event that requires functional autonomic and somatic nerves, smooth and striated muscles in the penile shaft and pelvic floor, and adequate arterial blood flow. The erectile reflex to sexual stimulation occurs when the chambers within the erectile tissue of the penis become filled with blood via arterioles that relax and dilate in response to nitrous oxide. At the same time, contractions of pelvic muscles help increase the rigidity of the penis and veins of the penis constrict, blocking blood outflow until orgasm or removal of the sexual stimuli occurs.

Abuse: Prevention

Nurses can help prevent abuse by observing signs and symptoms of violence If its a child --> must report IPV --> its the individual's choice to seek help in stopping the situation

Menopause Nursing Process

Nursing care during and after the menopausal period focuses on minimizing the symptoms associated with hormonal changes; reducing the risk of cardiovascular disease, cancer, and osteoporosis; and educating the client about lifestyle changes important to health and well-being. The American Cancer Society (2013a) recommends periodic cancer-related checkups after the age of 20. This checkup includes examination for cancers of the thyroid, ovaries, lymph nodes, oral cavity, and skin. Other important checkups include screening for cervical, breast, and colorectal cancer. The current recommendation for screening for breast cancer includes yearly clinical breast exam and mammograms after age 40. Breast self-exam is an option for women. To screen for colorectal cancer, a yearly fecal occult blood test or fecal immunochemical test is recommended unless there is family history or other risk factors for colorectal cancer. Women over age 65 who have had normal Pap test results on a regular basis should not be tested for cervical cancer. If there is history of cervical precancer, the Pap test should be done annually for 20 years after the diagnosis is made, even if it extends past age 65. Health counseling should also include information about alcohol and tobacco use, sun exposure, diet and nutrition, exercise, risk factors, sexual practices, and environmental and occupational exposures. It is important to discuss the benefits of rest and exercise, as well as a diet that includes fruits, vegetables, and fiber. In addition, the nurse should suggest the following resources for further information: National Institute on Aging Centers for Disease Control and Prevention North American Menopause Society Association of Reproductive Health Professionals Women's Health Initiative National Women's Health Information Center.

Promoting Hope for clients with situational depression

Nursing interventions to help clients return to a hopeful attitude include exploring their previous achievements, encouraging them to identify their strengths and abilities, and facilitating the evaluation of their behavior. Help clients to identify ways in which they have control of their lives. Help them learn to identify situations in which they can become more autonomous, especially through vocational, social, and community activities. Many people with mood disorders believe they have lost control over their lives, rights, and responsibilities and have lost the ability and right to effectively advocate for themselves. Nursing activities designed to help clients advocate for themselves provide them with hope and self-esteem. The nurse may assist clients in the following ways: Encourage them to believe in themselves. Inform them of their rights. Help them clarify what they need and want by setting clear goals. Provide accurate information, preferably in writing. Help them strategize by using the problem-solving process. Identify and facilitate resources such as friends, family, self- help groups, and advocacy organizations. Encourage identification of the best person(s) to assist with this problem. Foster effective communication so clients can get their message across; use suggestions such as these: Be brief, stick to the point, do not get diverted, and state the concern and how things should be changed. Promote firmness and persistence so clients can get what they need for themselves.

OCD Overview

Obsessive-compulsive disorder (OCD) is a disabling disorder characterized by obsessive thoughts and compulsive, repetitive behaviors that dominate an individual's life. An obsession is a recurrent, unwanted, and often distressing thought or image that leads to feelings of fear and anxiety. A compulsion is a repetitive behavior or mental activity (such as counting) used in response to the obsessive thoughts to help the individual lower his or her anxiety level. To be diagnosed with OCD, the individual must experience distress and lose time (more than 1 hour a day) due to the consuming rituals and repetitive behaviors associated with the disorder

Older Adults Complicated Grief

Older adults may be at greater risk for a complicated grief reaction because their support system may have become limited as a result of past losses, including the death of close family members and friends and even children and grandchildren. For example, an older adult who has already lost her husband may be more likely to experience complicated grief if her child dies, as she finds herself without her partner to help her mourn the loss of their child. Further, these accumulated substantial losses may result in complicated grieving. Having a past history of numerous losses may make the grieving process harder for older adults, as a new loss may serve as a reminder of past losses. Symbolic losses are also more prevalent among older adults; for example, older adults are more at risk than other age groups of losing their independence, their memory, and their mobility, as well as other significant assets. Symbolic losses may occur as a consequence of the death of a spouse or caregiver. For example, a husband with limited mobility may rely on his wife for transportation, cooking, and assistance with daily living. If she dies, man faces a number of losses in addition to mourning her death.

Medications Addictions

Opioid Antagonists Drug example: naloxone Used to treat a narcotic overdose, these drugs block narcotic receptor sites and quickly reverse the effect of the narcotic if administered via IV therapy. Monitor client condition, including respiratory rate, and anticipate the need for pain management as narcotic effects are reversed. Acetaldehyde Dehydrogenase Inhibitors Drug example: disulfiram Inhibit the enzyme that metabolizes alcohol, causing the client to become violently ill if alcohol is consumed while taking this medication. Symptoms include shortness of breath, headache, nausea, and vomiting. Teach client to avoid all alcohol, including that found in substances such as mouthwash, liquid medications, and food. Use of this medication requires a client who is highly motivated. Assess client's motivational level to quit drinking. Antiseizure Drugs Drug examples: phenytoin carbamazepine valproic acid Raise the threshold of cerebral excitation, reducing the likelihood and severity of seizure activity that can occur as the result of withdrawal from substances such as sedatives and hypnotics. Implement seizure precautions to maintain client safety. If a seizure occurs, place a pillow under the client's head and time the seizure, noting client behavior during and after the event. Nicotine Replacement Therapy Drug examples: nicotine patch nicotine gum nicotine lozenge nicotine nasal spray nicotine inhaler Supplies the body with nicotine to support smoking cessation therapy. Client support is an important element of smoking cessation, and clients benefit from behavior modification teaching in addition to pharmacotherapy. Antidepressants Drug examples: bupropion hydrochloride Some antidepressants have been shown to reduce the craving for nicotine and support smoking cessation programs. Can also be administered to reduce depression occurring as the result of substance withdrawal. Monitor and question clients about thoughts of suicide. Assess for drug side effects, including drowsiness, insomnia, and blurred vision. Teach client about self-administration of medications and symptoms to report. Nicotine Acetylcholine Receptor Agonists Drug example: varenicline Stimulates nicotine receptors more weakly than nicotine itself does, reducing cravings for and decreasing the pleasurable effects of tobacco. Assess for nicotine withdrawal symptoms such as depression, agitation, and exacerbation of pre- existing mental health disorders. Suicide and suicidal ideation have been associated with use of varenicline. Assess clients for thoughts of suicide or changes in mood and affect.

Phobia Pharmacologic Therapy

Pharmacologic therapy options for the phobic client include benzodiazepines, SSRIs, and some antipsychotics. Because of their addictive qualities, benzodiazepines should be used for only a short period of time. Benzodiazepines work rapidly to alleviate emotional distress and induce relaxation. The level of distress with phobias and panic is severe and readily alters the quality of life for the individual. A short course of benzodiazepines may sufficiently reduce anxiety to allow the client to begin participation in psychotherapy where the client can learn new ways of coping with anxieties. Clients who need pharmacologic support for a longer period of time may benefit from the use of SSRIs, which have fewer side effects than antipsychotics. It is critical that the nurse working with a client with a phobia explain the importance of cognitive-behavioral therapy as a treatment for the client's phobia and that any medication used as treatment will be less effective if not used in combination with CBT.

Implementation phase of diagnosing phobia

Phobias with panic and severe anxiety must be treated immediately. As the level of an individual's anxiety increases, her judgment and ability to listen, remember, and learn is impaired. This is not the time to teach or present new information. The professional nurse does not argue with the individual regarding her perception of reality or reaction to the object of the phobia. Empathic nurses offer understanding, support, and direction to ensure safety. The nurse validates concerns and fears; offers a quiet, safe environment; and pro- vides the following: One-to-one supervision. This helps alleviate the client's anxiety by providing assurance to the client that she is in no danger. One-to-one supervision should be provided until the antianxiety medications have begun to take affect and the nurse has assessed that the client can be safely left alone. Structure and direction for the individual. This includes informing the client about the next step in the treatment process (e.g., "We're waiting to the doctor to finish with another client; then he will see you"). It may include gentle reminders to the client such as "You're safe here. Let's practice deep breathing again." Antianxiety agents as prescribed. Once the individual is stabilized, the nurse can effectively facilitate adaptive coping skills. The nurse encourages the client to vent feelings and describe his perception of the episode. As always, the nurse provides emotional support in a nonjudgmental manner. Specific interventions for the client experiencing phobia may include the following: Assist the individual to rethink or reframe the ability to manage his anxiety. Assist the client to reappraise the level of the threat as less damaging. The first opportunity to do this will likely occur after the antianxiety medication has begun to take effect and the client's immediate anxiety level has decreased. Teach the client relaxation techniques, such as deep breathing. Assist the client to gain insight into his reactions. Nurses working with the client over a period of time will have the opportunity to teach knowledge of defense mechanisms, to help the client work through unresolved issues and anxiety, and to help the client develop more adaptive coping mechanisms.

TABLE 31-7 Wellness Promotion for Clients With Stress-Related Disorders

Physical Exercise Promote regular physical exercise. Educate the client about the benefits of physical exercise. RATIONALE: Regular physical exercise offers physiological benefits, including improved cardiac and pulmonary function, enhanced muscle tone and joint mobility, and weight control. Psychological benefits include tension relief, stress reduction, enhanced sense of well-being, and promotion of relaxation following activity. Sleep/Rest Patterns Promote balance between sleep/rest and activity. Teach relaxation techniques to promote relaxation and sleep. RATIONALE: Adequate sleep and rest are essential to survival. Sleep allows for physical healing, restoration, and removal of free radicals, which are believed to be associated with illness and disease. Adequate sleep enhances cognitive function. Nutrition Provide education related to balanced nutrition. Facilitate referrals to dietary professionals and nutritionists. RATIONALE: Inadequate nutrition reduces physical resistance to illness and increases susceptibility to disease and illness. Excessive intake of caffeine and use of nicotine may interfere with sleep/rest patterns. Time Management Promote balance between fulfilling personal responsibilities (e.g., related to work, family, school) and time for rest, socialization, and extracurricular activities. Assist with identifying potential schedule modifications to allow for more effective time management. Encourage implementation of personal boundaries. RATIONALE: Effective time management is associated with an increased sense of control and decreased sense of stress. Identification of the client's roles and demands allows for identification of potential stressors. Boundaries aid in determining the appropriateness of requests/ demands made by others and allow the individual to identify which requests/demands can be fulfilled while still maintaining her or his wellness.

Evidence-Based Practice Adolescents and Their Control of Tobacco Use

Problem In 2011, young adults ages 18-25 had the highest rate of current use of a tobacco product (39.5%) compared with youths ages 12-17 and adults ages 26 or older. Young adults had the highest usage rates of each of the specific tobacco products as well. In 2011, the rates of past month use among young adults were 33.5% for cigarettes, 10.9% for cigars, 5.4% for smokeless tobacco, and 1.9% for pipe tobacco. Evidence Researchers examined the effectiveness of different types, or modalities, of tobacco-use prevention programs designed to decrease incidence and prevalence of tobacco use among youth. The preventive strategies were varied and included policy regulations such as tax increases, warning labels, limits on access, smoke-free policies, and restrictions on marketing; mass media programming; school-based classroom education; family involvement; and involvement of medical, social and political community agents. It was suggested that the most effective means of prevention might involve a careful selection of program type combinations. Careful coordination of combination programs may be the means to maximize effectiveness. Implications Importantly, for future research and practice, examination of tobacco use prevention as a complex system may be needed to maximize effects from combinations of modalities of prevention programming. Future studies will need to more systematically consider and uncover the combination rules and related incremental effects underlying efficacious multi-pronged community-based programming.

Summary Criteria for Panic disorder

Recurrent unexpected panic attacks, when at least one of the attacks has been followed by 1 month of persistent concern about having more attacks, worry about the implications of the attack, or a significant change in behavior related to the attacks. The attacks are not due to the physiological effects of a substance. The attacks are not better accounted for by another mental disorder

Phobia Collaboration

Short-term goals of care for clients with phobias include assisting the individual with learning strategies for successfully coping with the anxiety produced by the triggering object, event, or situation. Long-term goals include facilitating the collaborative care of these clients, which may include pharmacologic interventions and psychotherapy.

Anxiety Disorder Pathophysiology

Research suggests that people are more likely to suffer from anxiety disorders if their parents have anxiety disorders. However, it is not clear whether biological or environmental factors play a greater role in the development of these conditions. Research suggests traumatic brain injury may increase an individual's susceptibility for development of an anxiety disorder. In any case, scientists have found that certain areas of the brain, including the amygdala, function differently in people with anxiety disorders. The appearance of an anxiety disorder in an individual of any age requires attention by both healthcare professionals and caregivers. Family and friends may be the first to notice anxiety symptoms. Healthcare professionals recognize that many medical problems—including hormonal and neurological conditions—might cause symptoms of anxiety. The primary symptom of anxiety disorders is what psychiatrists sometimes refer to as free-floating anxiety. This is characterized by excessive worry about everyday events, worry that is hard to control and the focus of which may shift from moment to moment. Free-floating anxiety is anxiety that is not connected to a specific stimulus.

Anxiety Disorder Risk Factors

Risk factors for anxiety disorders include the dysregulation of neurotransmitters such as serotonin, norepinephrine, GABA, and a neuropeptide known as cholecystokinin. Other risk factors include the following: Childhood adversity, including witnessing traumatic events Family incidence Social factors, such as lack of social connection Serious or chronic illness Traumatic events Personality factors such as shyness and worrying Multiple stressors, such as chronic illness concurrent with loss of employment. CHILDREN Childhood anxiety disorders are reported more frequently in girls than in boys. Symptoms are more prevalent in girls and minority children from low socioeconomic backgrounds. All children from disadvantaged socioeconomic backgrounds are more vulnerable to emotional illness than their more advantaged peers. Familial predisposition is also a contributing vulnerability factor. Studies suggest that, in general, 3%-5% of children and adolescents have an anxiety disorder of some kind. Children with anxiety disorders run the risk of developing other anxiety disorders, depression, and substance abuse. OLDER ADULTS Older adults with cognitive impairments or one or more chronic physical impairments are at increased risk for developing anxiety. Significant emotional loss, such as the death of a spouse, also increases the older adult's risk for anxiety. In older adults, manifestations of anxiety may overlap with medical illness, resulting in older adults presenting first to their primary care provider. Although the prevalence rates of anxiety disorders in older adults are lower than in the general population, this may be due as much to the lack of appropriate diagnosis rather than to an actual lower rate of anxiety in older adults. Risk factors for anxiety disorders in older adults include lower education levels, presence of multiple chronic illnesses, and being unmarried

Nicotine Addiction Prevention

Smoking and smokeless tobacco use are initiated and established primarily during adolescence. Adolescents and young adults are uniquely susceptible to social and environmental influences to use tobacco, and tobacco companies spend billions of dollars on cigarette and smokeless tobacco marketing. Counter-advertising mass-media campaigns (i.e., TV and radio commercials, posters, and other media messages targeted toward youth to counter pro-tobacco marketing) Comprehensive school-based tobacco-use prevention policies and programs (e.g., tobacco-free campuses) Community interventions that reduce tobacco advertising, promotions, and commercial availability of tobacco products Higher costs for tobacco products through increased excise taxes.

Nicotine Eitology

Smoking harms nearly every organ in the body, and is a main cause of lung cancer and chronic obstructive pulmonary disease (COPD, including chronic bronchitis and emphysema). It is also a cause of coronary heart disease, stroke, and a host of other cancers and diseases. More women in the United States die from lung cancer than any other type of cancer, and cigarette smoking causes most cases. Smoking also causes cancers of the esophagus, larynx, mouth, throat, kidney, bladder, pancreas, stomach, uterine cervix, and acute myeloid leukemia. Graves disease, infertility, early menopause, dysmenorrhea, impotence, osteoporosis, and degenerative disc disease have also been associated with smoking. Other less serious consequences include discolored teeth and fingernails, premature aging and wrinkling, bad breath, reduced sense of smell and taste, strong smell of smoke cling- ing to hair and clothing, and gum disease. Smoking during pregnancy has been associated with preterm labor, spontaneous abortion, low-birth-weight infants, sudden infant death syndrome (SIDS), and learning disorders. Nonsmokers who are exposed to secondhand smoke at home or work increase their lung cancer risk by 20%-30%. Concentrations of many cancer-causing and toxic chemicals are higher in secondhand smoke than in the smoke inhaled by smokers. Secondhand smoke presents a number of dangers, particularly to children of smokers. According to the CDC: Infant children of mothers who smoke are more likely to die from SIDS than children born to nonsmoking mothers. Exposure to secondhand smoke causes asthmatic children to have more frequent and severe attacks. Children exposed to secondhand smoke are at increased risk for respiratory symptoms and otitis media. Mothers who smoke and mothers who are exposed to secondhand smoke are more likely to have lower-birth-weight babies

Nicotine Addiction Risk Factors

Some of the most common factors that influence people to smoke are emotions, social pressure, alcohol use, lack of education, and age. People of lower socioeconomic status are more likely to smoke than those of higher socioeconomic status, partially because smoking is more socially acceptable in groups with fewer resources. Furthermore, quitting smoking is less successful in lower socioeconomic groups because they lack high-quality health education, lack support for quitting, and are exposed to smoking more often.

Table 31-9 Examples of Commonly Occurring Obsessions and Compulsions

Symmetry - Counting. Ensuring orderliness of items. Fixation on maintaining symmetrical positioning of items Cleaning - Repetitive environmental cleaning. Avoiding contamination. Repetitive performance of decontamination practices Forbidden or taboo thoughts - Acting out aggressive or sexual behavior toward self or others. Conducting religious behaviors or practices that are incongruent with the accepted norm for a particular religious group or community (e.g., repeated recitation of prayers to the extent that the activity interferes with daily life) Injury - Extreme avoidance of activities or circumstances that may cause injury Hoarding - Excessive collection and accumulation of objects. Extreme cluttering of the living environment. Lack of insight with regard to the embarrassment of family members or others whose living space is impacted by the appearance of the home environment. Often associated with reluctance or refusal by family members to allow outsiders to enter the home, leading to social isolation

Lifespan Considerations Symptoms of Depression

Symptoms of depression can vary among age groups, although sadness and anhedonia are common at all ages. Differences include the following: Children and Adolescents Toddlers can show regressive behaviors in toileting and other activities. Preschoolers have less symbolic and other play activities and demonstrate self-destructive play themes. They may whine and show irritability, disinterest, and lack of confidence. School-age children may show a decrease in academic performance, increased or decreased physical activity, somatic complaints, and loss of friends. The older school- age child may talk of running away or show signs of boredom and low self-esteem. The adolescent can have a wide array of symptoms (e.g., decreased social contact, poor school performance, lack of involvement in typical activities, poor self-care, difficulty with parents and teachers, or a focus on violence). Older Adults Depression is common among older adults, but it is important to note that it is not a normal part of aging. Manifestations of depression in older adults may include memory problems, social withdrawal, sleep disturbances, loss of appetite, and irritability. Some individuals may experience delusions or hallucinations. Depression in older adults can complicate treatment of other conditions because impairment of functioning due to depression may impair the individual's ability or motivation to participate in treatment. Other medical conditions can complicate treatment of depression if nurses and clinicians dismiss symptoms as related to another medical condition (or side effects of treatment) without doing a full assessment for depression.

Resilience Factors

The capacity to respond successfully to stressors is called resilience. Resilience is the ability not only to survive and bounce back from difficult and traumatic experiences, but also to continue to grow and develop emotionally and psychologically. The notion of resilience encompasses the biological and psychological characteristics intrinsic to an individual, such as personality style and quality of interpersonal relationships, that confer protection against the development of psychopathology. Resilience probably explains why not all individuals who experience stress or social isolation develop mental health problems as adults. Researchers and clinicians alike have been surprised by the prevalence of the capacity for resilience, and clinicians are beginning to focus on uncovering and energizing pathways to resilience in their clients. Individuals without a history of mental illness can succumb to adjustment disorder with depressed mood following a stressful event. Resilience factors can make a great deal of difference in preventing the adjustment disorder with depressed mood from becoming a depressive disorder. Nurses working with clients experiencing adjustment disorder with depressed mood should help them identify their resilience factors and use those factors as supportive mechanisms during this critical time. Resilience factors may include a close-knit family, close friends, a good job with benefits, membership in a volunteer organization, or any other number of factors.

Erectile Dysfunction Etiology

The causes of ED are multiple and can be divided into psychological and physical causes. Physical causes can be further divided into vascular, neurogenic, hormonal, and iatrogenic. Although age alone may not cause ED, age-related cellular and tissue changes in the penis, decreased sensory activity, hypogonadism, and the effects of chronic illness that tend to occur with aging do increase the risks for developing ED. In the penis, a change from elastic collagen to a more rigid collagen results in decreased distensibility (a less rigid erection). This, in turn, interferes with the veno-occlusive mechanism, which prevents blood from "leaking" out of the penis into the general vasculature prematurely. Problems with this mechanism result in incomplete erections. Vibrotactile sensation over the skin of the penis declines with age. This decline may explain why some older men require longer stimulation to achieve an erection. Hypogonadism, common in aging men, results in decreased testosterone levels. There may be a relationship between lower androgen levels and erectile function. Damage to arteries, smooth muscles, and fibrous tissues are the most common causes of ED. Diseases such as diabetes, kidney disease, chronic alcoholism, atherosclerosis, and vascular disease are often responsible for organic ED. Iatrogenic causes, that is, problems that result from treatment and therapy, must always be considered. For example, innervation and blood flow to the penis may be damaged during surgery, prostate surgery in particular. Given the effects of vasculature damage on the penis, the increased incidence of chronic illness, and the multiple medications and treatments required to manage those illnesses, it is not surprising that many older men have problems with ED.

Menopause Pathophysiology

The menopausal period marks the natural biological end of reproductive ability. Surgical menopause occurs when the ovaries are removed in premenopausal women, dramatically reducing the production of estrogen and progestins. Chemical menopause often occurs during cancer chemotherapy, when cytotoxic drugs arrest ovarian function. As ovarian function decreases, the production of estradiol (E2), the most biologically active estrogen, decreases and is ultimately replaced by estrone as the major ovarian estrogen. Estrone is produced in small amounts and has only about one tenth the biological activity of estradiol. With decreased ovarian function, the second ovarian hormone, progesterone, which is produced during the luteal phase of the menstrual cycle, also is markedly reduced.

OCD Clinical Manifestations

The most frequently reported obsessions in OCD are repeated thoughts about contamination from shaking hands, repeated doubts with fear of having hurt someone or leaving a door unlocked, and a need to have things in a certain order. Aggressive impulses are often of a sexual nature or obscene. The obsessions are not rational or real-life problems. The client with OCD is, at some point, aware that the obsessions are not real. Compulsions are also part of OCD. Commonly reported repetitive behaviors include hand washing, ordering, checking, and counting. Common themes of the associated intrusive, repetitive thoughts include those which are considered by the individual to be forbidden or taboo; for example, religious or sexual obsessions and fears related to self-harm or injury of others. Compulsive behavior does not produce a sense of pleasure for the client with OCD. Rather, the individual feels driven to perform the compulsion to reduce the anxiety produced by the obsession.

Nicotine Addiction Nursing Process - Implementation

The nurse's role regarding smoking is to (a) serve as a role model by not smoking, (b) provide educational information regarding the dangers of smoking, (c) help make smoking socially unacceptable (e.g., by posting no-smoking signs in client lounges and offices), and (d) suggest resources such as hypnosis, lifestyle training, and behavior modification to cli- ents who want to stop smoking. Nurses also can promote health related to tobacco by being aware of marketing efforts that target young adults. The tobacco industry has developed very effective campaigns to encourage smoking among young adults by advertising and sponsoring entertainment events. Nurses also need to be aware of research that shows that risk factors for young adult smokers include perceiving that teenage smoking is useful or widespread, as well as being around people smoking, engaging in binge drinking, and seeing ads in bars and clubs.

OCD Nursing Process

The primary nursing goals for the client with OCD are to ensure client safety and to alleviate anxiety and distress. Care must be taken not to prevent the performance of rituals that the client uses to reduce anxiety, but rather to promote new behavioral patterns and coping mechanisms to make the rituals unnecessary while maintaining the safety of the client. Dx: Appropriate nursing diagnoses for OCD may vary depending on the nature of the obsessive thoughts and compulsive behaviors and the severity of the illness. The presence of comorbid or co-occurring disorders must also be taken into consideration. For example, a hoarder who has allergic asthma may be at risk for ineffective airway clearance and ineffective breathing pattern due to the presence of dust and debris in the house. Possible diagnoses for OCD clients include the following: Anxiety Fear Ineffective Coping Stress Overload Disturbed Sleep Pattern Insomnia Fatigue Deficient Knowledge Risk for Caregiver Role Strain. Implementation Implementation A supportive and nonjudgmental demeanor is essential when working with clients with OCD. Often the individual is aware that the compulsive behaviors are unreasonable and feels embarrassed. Compulsive behaviors are designed to lower the level of anxiety or defensively "undo" the obsessive thoughts. Interrupting an individual during a ritual or compulsive behavior creates more anxiety and frequently leads to redoing or repeating the behavior to reduce anxiety. Working with the client to fit the ritual into the routine of the hospital may be necessary until relief is experienced from the pharmacologic agents or CBT. Administration of medications to lower anxiety and reevaluation of the client's response to the medication are the responsibility of the nurse in collaboration with the healthcare provider and the client.

Situational Depression Clinical Manifestations

The symptoms of adjustment disorder with depressed mood are similar to those of the other depressive disorders and include sleep disturbances, feelings of hopelessness and sadness, loss of self-esteem, irritability, difficulty concentrating, and anhedonia. Behaviors that may occur include ignoring financial responsibilities; arguing and fighting; performing poorly at work or school; and behaving recklessly, such as driving while intoxicated or vandalizing others' property.

Table 19-3 Causes of Erectile Dysfunction

Vascular - Atherosclerosis Hypertension Heart disease Hyperlipidemia Chronic obstructive lung disease Diabetes mellitus Direct injury to penis that affects vascular supply or nerves Neurogenic - Spinal cord injury Stroke Nerve disease Multiple sclerosis Parkinson disease Alzheimer disease Hormonal - Low levels of testosterone, prolactin Alterations in thyroid function Lifestyle Choices - Smoking Alcohol use Overweight Not exercising Psychological - Stress Anxiety Guilt Depression Low self-esteem Fear of sexual failure Iatrogenic- Side effects of: Antihypertensives Antihistamines Antidepressants Tranquilizers Appetite suppressants Cimetidine / Surgery: Radical prostate and bladder surgery

Improve Self-Esteem for depressed patients

While low self-esteem is a chronic problem, the nurse can take a number of actions to reduce negative thinking, thereby promoting improved self-esteem: Provide distraction from self-absorption by involving the client in recreational activities and pleasant pastimes. Simple conversation with a staff member or another client helps interrupt the pattern of negative thoughts. Use care to select activities that are not too complex for the client's current level of functioning. Experiences of success, not more failures, are needed. Increase the complexity of activities as the client progresses. Dispel the notion that clients often have that when they feel better, they will want to engage in activities. Explain that they must begin doing things in order to feel better. Being active promotes a more balanced feeling state. Acknowledge that it takes self-discipline and energy to do something when one doesn't really feel like it. Recognize accomplishment, but do not use flattery or excessive praise. Give positive, matter-of-fact reinforcement, such as "I notice that you combed your hair," rather than overly enthusiastic compliments such as "What a great hairstyle!" Appropriate recognition increases the likelihood that the client will continue the positive behavior, while insincerity can be perceived as ridicule or infantilizing. Be accepting of clients' negative feelings, but set limits on the amount of time spent discussing accounts of past failures. Be alert for opportunities to interrupt negative conversational patterns with more neutral ones. Teach assertiveness techniques, such as the ability to say "no" to protect one's rights while respecting the rights of others. Clients with low self-esteem often allow others to take advantage of them. Defining passive, aggressive, and assertive behavior and giving examples of each also are helpful when teaching assertiveness. Practice these techniques with the client, providing feedback on how it feels to the recipient of assertive communication or an assertive action.

Erectile dysfunction Pharmacologic Therapy

can be treated with medications taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. Oral Medications The oral medications used to treat erectile dysfunction include sildenafil citrate (Viagra), vardenafil hydrochloride (Levitra), tadalafil (Cialis), and avanafil (Stendra). All of these drugs are selective phosphodiesterase type 5 inhibitors that enhance erections only when sexual stimulation is present. These drugs act within 30-60 minutes, so they should be taken about an hour before sexual activity. The action will persist for up to 36 hours. All four drugs enhance the effects of nitrous oxide to facilitate relaxation of the smooth muscle in the penis during sexual stimulation to increase blood flow. These drugs should be taken no more than once a day and should not be taken by men who are also taking nitrate-based drugs (for heart problems) or alpha-blockers (used to treat hypertension and prostate enlargement). Injectable Medications Hormone replacement therapy with testosterone injections (200 mg IM every 3 weeks) or topical patches may be used for men who have documented androgen deficiency and do not have prostate cancer. Injectable medications, including papaverine and prostaglandin E injections, may be used. When injected directly into the penis using a tuberculin syringe or metered-dose injection device, prostaglandin E and papaverine relax the arterioles and smooth muscles of the cavernosum, thus inducing tumescence (swelling). An erection usually develops that lasts from 30 minutes to 4 hours. Side effects can include bruising, local pain, infection, and priapism. Priapism would require medical attention. One problem with this type of treatment is its mode of delivery. There is a high attrition rate, and clients report dissatisfaction with lack of spontaneity, loss of interest in sex, physical limitations, cost, and occasionally pain. These injectables are rarely used today except in clients who cannot take oral drugs like Viagra. Alprostadil (Caverject) may be given as a minisuppository into the urethra or as an injection into the cavernosa. It works like papaverine but does not work as well. The strength of the erection produced with this drug can be enhanced with the use of a constriction ring (O-ring) at the base of the penis.

Social Anxiety Disorder Clinical Manifestations

formerly known as social phobia, is characterized by a pervasive, extreme fear of one or more social situations that may lead to scrutiny by others. Exposure to the particular situation (such as giving a speech, drinking or eating in the presence of others, or meeting strangers) usually triggers an immediate anxiety reaction. Although adolescents and adults usually recognize their fear as being excessive, pediatric clients do not always have this insight. Most clients with social anxiety disorder will avoid their phobic stimulus; however, some affected individuals will endure the experiences, despite an intense sense of anxiety or fear. Typically, the anxiety, fear, or avoidant behaviors associated with social anxiety disorder persist for at least 6 months. Diagnosis of this disorder is made only if marked distress is present or if the individual's related anxiety, fear, or avoidance behaviors significantly interfere with her daily routine or occupational, academic, or social life. Affected individuals may also demonstrate inadequate attempts at assertiveness or excessively submissive behaviors. Less commonly, these clients may demonstrate excessive control of conversations. The physical symptoms associated with social anxiety disorder typically correlate with anxiety, and may include blushing, stammering speech, excessive sweating, and gastrointestinal distress. Some individuals may choose to self-medicate with drugs or alcohol prior to exposure to their phobic stimulus. Because of the limitations imposed by this disorder, establishment and maintenance of friendships and interpersonal relationships may be extremely challenging. Clinical Therapies for all three: The short-term use of antianxiety agents, such as the benzodiazepines, may be indicated in severe cases (should not be used more than 2-4 weeks). SSRIs may be used for longer periods. Tricyclic antidepressants are also recommended. Psychological therapies include: CBT, Supportive therapy, Desensitization and implosion therapy for specific phobias, Self-help groups and bibliotherapy (therapy that incorporates written forms of expression) based on CBT. Discuss exercise and healthy nutrition. Phobic clients should decrease caffeine and nicotine intake. Assess alcohol intake.

why dose the sugar go up when people are feeling stressed?

increase in adrenal function

What etiology causes vaginal infection in peri-menopausal women?

increase in vaginal pH

what is a physiological response that may be seen in pt's experiencing stress?

increased glucose

Agoraphobia Clinical Manifestations

is characterized by anxiety associated with two or more of the following situations: being in enclosed spaces, being in open spaces, utilizing public transportation, being in a crowd or standing in a line of people, or being alone outside the home environment. Anxiety related to the triggering circumstances is linked to a fear of the inability to escape or a fear that needed assistance may not be available in the event that panic-related symptoms develop. Alternatively, the client with agoraphobia may fear the development of other potentially embarrassing or debilitating manifestations. Most clients with agoraphobia also meet the criteria for diagnosis of other forms of mental illness. As with most other behaviors, an individual's choice to remain inside the home environment is impacted by cultural influences. Additionally, in some cultures, remaining inside the home and limiting public social interaction may be a cultural expectation. Adherence to cultural expectations to remain inside one's home typically does not reflect agoraphobia. Clinical Therapies for all three: The short-term use of antianxiety agents, such as the benzodiazepines, may be indicated in severe cases (should not be used more than 2-4 weeks). SSRIs may be used for longer periods. Tricyclic antidepressants are also recommended. Psychological therapies include: CBT, Supportive therapy, Desensitization and implosion therapy for specific phobias, Self-help groups and bibliotherapy (therapy that incorporates written forms of expression) based on CBT. Discuss exercise and healthy nutrition. Phobic clients should decrease caffeine and nicotine intake. Assess alcohol intake.

Intimate partner violence (IPV)

is the act of inflicting sexual, emotional, or physical harm on a current or previous partner or spouse. IPV can occur among any couple including same-sex couples, adolescent couples, and older adult couples. The four main forms include physical violence such as punching, kicking, or biting; sexual violence including forced sexual acts or physically violent sexual contact; threats of both physical and/or sexual violence; and emotional abuse such as humiliating the victim or controlling the victim by diminishing self-esteem. Stalking can also be a form of IPV and is defined as repeated harassment or threats often including action such as following the victim and/or vandalizing the person's property. Although IPV is commonly believed to be committed pri- marily by men, research does not support this perception. Family conflict studies suggest 50% of victims of IPV are men. Research indicates that men and women demonstrate similar motives for asserting control and inflicting harm when abusing their spouse. Even so, societal views of IPV and misperceptions can influence the care and treatment of male victims. For example, a study of men who have sought help for instances of IPV described male victims who were ridi- culed or arrested as they were assumed to have started the fight or been the aggressor. Even with proof of physical injuries, many men were denied help or ignored because it was considered inconceivable that a man could be abused by a woman. When conducting an assessment of a potential victim of IPV, nurses must remain nonjudgmental regardless of gender, sexual orientation, culture, or the socioeconomic status of the victim. Intimate partner violence can result in long-lasting physical and emotional complications, and if the victim feels helpless or as though she will not be believed, then the violence is likely to continue. Most cases of IPV begin as mild emotional or physical abuse, but they eventually escalate to more severe violence, and can even end in death. Nurses can help to prevent this form of violence by being observant to the manifestations of IPV and helping to empower the victim.

Elder abuse

is the intentional physical, emotional, or sexual mistreatment or neglect of an individual 65 years of age or older. elder abuse has been on the rise. It is believed that this upward trend is due to increased reporting of elder abuse as the problem receives more attention. Even so, recent studies estimate that only 1 in every 14 cases of elder abuse is actually reported. The reasons behind decreased reporting are numerous, but are believed to be the result of an unwillingness to report family members—who are the primary perpetrators of elder abuse. Other reasons for low reporting involve the physical or mental inability to report the abuse, as well as a heightened fear of retaliation from the abuser. The abuse of older adults—whether it is physical, emotional, or sexual—results in numerous consequences including decreased health, inability to heal from broken bones, and an increased risk for mortality. Studies have also shown that elder abuse that results in hospitalization for the victim often leads to the individual being discharged to a nursing home or long-term care facility, as opposed to returning home A study conducted in 2009 reported that between nursing homes, assisted living facilities, and paid home care, residents of nursing homes reported the highest incidences of all forms of abuse, including neglect. The risk for being abused by a caretaker in a nursing home was the highest among all cases of caretaker abuse reported

Specific Phobia Clinical Manifestations

refers to intense or extreme fear with regard to a particular object or situation. The object or situation that triggers the fear is referred to as the phobic stimulus. Both actual and anticipated exposure to the phobic stimulus may evoke a response, the intensity of which may vary from the sudden onset of fear to an incapacitating panic attack Phobias adversely impact the affected individual's quality of social, occupational, and academic function and also interfere with activities of daily living. In many cases, adults with phobias recognize their fear as being disproportionate to the given object or situation; however, they are prone to overestimating the degree of danger associated with the phobic stimulus. These clients usually practice active avoidance of the phobic stimulus, meaning that they minimize or avoid contact with it Specific phobias frequently are comorbid with numerous other psychiatric alterations, including depressive disorders, anxiety disorders, bipolar disorders, and substance-related disorders. Clinical Therapies for all three: The short-term use of antianxiety agents, such as the benzodiazepines, may be indicated in severe cases (should not be used more than 2-4 weeks). SSRIs may be used for longer periods. Tricyclic antidepressants are also recommended. Psychological therapies include: CBT, Supportive therapy, Desensitization and implosion therapy for specific phobias, Self-help groups and bibliotherapy (therapy that incorporates written forms of expression) based on CBT. Discuss exercise and healthy nutrition. Phobic clients should decrease caffeine and nicotine intake. Assess alcohol intake.

PROTOTYPE DRUG Fluoxetine (Prozac, Sarafem) Classification: Therapeutic: Antidepressant, antianxiety drug Pharmacologic: Selective serotonin reuptake inhibitor (SSRI)

the first SSRI marketed to treat major depressive disorder in the United States subsequently approved to treat bulimia nervosa, the first medication ever approved for this condition. It was the first SSRI approved for the treatment of pediatric depression. It is approved for the treatment of OCD in both adults and children, panic disorder, and premenstrual dysphoric disorder. is available as tablets, capsules, oral solution, and delayed-release capsules. Off-label indications include anorexia nervosa, obesity, alcohol dependence in patients with alcoholism, fibromyalgia, autism, refractory orthostatic hypotension, premature ejaculation, and menopausal hot flashes. Although patients gradually begin to feel less depressed after about 2 weeks of therapy, optimal response may take 8 weeks or longer. is extensively metabolized in the liver to norfluoxetine, have long half-lives; it takes 30 to 60 days after discontinuing the drug for them to be eliminated by the body. This duration is even more prolonged in patients with liver disease. Mechanism of Action: As with other serotonin reuptake inhibitors, it blocks the uptake of the neurotransmitter serotonin (but not norepinephrine) at the neuronal presynaptic membrane. This increases the amount of neurotransmitter available at the postsynaptic receptor sites, thus enhancing the actions of serotonin. Herbal/Food: Increased CNS effects may occur if fluoxetine is given concurrently with lavender, kava, or hops. There is an increased risk of serotonin syndrome with the concurrent use of St. John's wort. Increased anticholinergic effects may result from the use of jimsonweed or corkwood. Because grapefruit juice may cause elevated serum levels of fluoxetine, it should be avoided during therapy. Onset of action - Peak plasma level: 6-8 h ; Duration of action - Half-life: 2-3 days Adverse Effects: The most common adverse effects are nausea and vomiting, which diminish as therapy progresses. Other common GI effects include diarrhea, anorexia, cramping, and flatulence. Fluoxetine does not cause sedation; in fact, insomnia may occur in as many as 25% of patients receiving the drug. Significant anorexia and weight loss occur in 10% to 15% of patients, whereas others experience a weight gain of as much as 20 pounds or more. Patients may experience various types of sexual dysfunction, including delayed ejaculation, impotence, anorgasmia, decreased libido, and priapism. The drug may induce seizures in patients with preexisting seizure disorders or during overdoses. Other adverse effects include cramping, constipation, poor concentration, diarrhea, hot flashes, palpitations, and nervousness. Serotonin syndrome can occur. Pediatric patients may experience personality disorders or hyperkinesia. Black Box Warning: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults. Patients of all ages should be monitored and observed closely during therapy for clinical worsening, suicidality, or unusual changes in behavior. Abrupt withdrawal of fluoxetine or other SSRIs can result in a withdrawal syndrome; the patient may experience dizziness, headache, tremor, anxiety, dysphoria, and sensory disturbances. These symptoms usually begin 1 to 7 days after the last dose and may continue for 1 to 3 weeks. Because fluoxetine has an extended half-life and serum levels diminish gradually, withdrawal symptoms are generally less serious than those of the shorter-acting SSRIs. Tapering the dose over 2 weeks or longer can prevent withdrawal symptoms. Contraindications/Precautions: Hypersensitivity to fluoxetine is a contraindication to using the drug. The drug should not be administered to patients with bipolar disorder because it may precipitate a manic episode. It must be used cautiously in persons with cardiac dysfunction, diabetes, or seizure disorders. Children or young adults with a history of attempted suicide should not receive fluoxetine. There are no known age-related precautions for use in the elderly, but children may experience more behavioral adverse effects such as restlessness and insomnia. Caution must be used when fluoxetine is administered late in pregnancy. The neonate may exhibit symptoms of withdrawal, including irritability, respiratory distress, tremors, abnormal crying, and, possibly, seizures. With supportive care, symptoms of withdrawal in the neonate will disappear in a few days. In most cases, the benefits of treating pregnant women who have major depression with fluoxetine are greater than the potential risks to the neonate.