Promotions: Unit 5 ( Learning plan 13 a,b, & c) study guide questions
Genetics-heredity—who is most at risk?
Children of alcoholic parent are 3-4x more likely to become an alcoholic
Who is more at risk for depression?
• Incidence higher in women vs. men • Psychiatric disorders • Socioeconomic class • Race/Culture • Marital Status • Seasonality
Profile of a victimizer of domestic abuse?
• Low self -esteem • Possessive, jealous • Poor communication skills • Unrealistic expectations of spouse/children • Unable to nurture others • Insults/degrades partner • Uses denial; blames others • Limited coping skills • Poor impulse control • Violent with increased stress • Isolated; Lack of support systems • Threatens to take children away/hurt them
What specifically happens in alcohol withdrawal?
Alcohol-dependent patient abruptly stops drinking= sudden withdrawal of alcohol causes hyperexcitability reaction in the brain (compensation continues), resulting in Alcohol Withdrawal Syndrome. (Because the depressant effect of alcohol is gone)
DSM-5 criteria for MDD?
5 or more of these symptoms have to be present during the same 2-week period and represent a change from previous functioning. One needs to be a depressed mood and loss of interest or pleasure. •Depressed mood most of the day, nearly every day. •Markedly diminished interest or pleasure in all or almost all activities. •Significant weight loss or gain when not dieting •Insomnia or hypersomnia •Psychomotor agitation or retardation •Fatigue or loss of energy nearly every day •Feelings of worthlessness inappropriate guilt •Diminished ability to think or concentrate or indecisiveness. •May c/o pain without a physical cause
What is anxiety?
A feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or a perceived threat.
What is domestic/partner abuse? Physical? Emotional? Sexual? Emotional? Financial?
A pattern of abusing power for the purpose of controlling an intimate partner 85-95% are women 15% are men Physical acts of violence: pushing, grabbing, pinching, hitting, kicking, slapping, choking, and other physical ways of hurting and controlling a partner Emotional abuse: Verbal assaults, manipulative and/or controlling behaviors toward a partner which cause that person to feel afraid, confused, overwhelmed, threatened, powerless, "crazy," inadequate, frustrated, rejected Sexual abuse: forcing unwanted sexual acts or withholding sexual intimacy or making degrading comments about someone's sexuality or attractiveness. Financial abuse: limiting access to money for the purpose of limiting resources available Additional Sub-categories: Intimidation: using gestures or actions to make someone feel afraid Interference with personal liberties: detaining someone or preventing another person from going somewhere, talking to someone, or doing something. Willful deprivation: withholding food or other critical resources to control someone. (NEGLECT) Stalking: following or pursuing someone who has asked to be left alone Harassment: persistent phone calls, conversations, other behavior that the other person has requested to stop.
Why is it important to be aware of alcohol withdrawal as a nurse?
Alcohol-dependent patient abruptly stops drinking= sudden withdrawal of alcohol causes hyperexcitability reaction in the brain (compensation continues), resulting in Alcohol Withdrawal Syndrome. (Because the depressant effect of alcohol is gone)
Who are the abusers in elder abuse?
Abusers are normally: • Usually a relative or a caregiver • Victims of family violence • Under economic stress • Substance abusers
Who are most at risk for child abuse? Who are the abusers?
Abusing adults often have been victims of abuse and/or substance abusers Occurs in all socioeconomic groups #1 cause of death-head injury (shaken baby or abusive head trauma) #2 cause of death-abdominal injuries -blunt force to the abdomen area—kick/punch can lead to rupture Intentional actions (commission) or acts of omission (neglect) Most common among toddlers (under age 3) -less communication skills and sometimes act out -don't listen "special" children (unwanted pregnancy, colic child, special needs child, physical or mental handicap, also at risk: single parent, families that move frequently, families with multiple children
What is the difference between Acute Anxiety and Pathological Anxiety?
Acute anxiety is normal anxiety and is the expected response to stress Pathological anxiety is more chronic in nature and is experienced for longer periods of time.
What is an ombudsman and their responsibilities?
Advocate for residence of nursing homes, board and care homes, and assisted living homes--they provide information on how to find a facility and how to get quality care. They are trained to resolve problems. They can assist with complaints
High Risk Demographics
Age: > 50 years & Adolescents (90% of teens that attempt or commit suicide have a treatable psychiatric disorder)—most suicides happen after school—adolescents: 15-24 years old (gay/lesbian, r/t drugs, bullying) Gender: Male > Female (women attempt suicide 3x more than men, but men kill themselves more) Ethnicity: Caucasians> Native Americans> African Americans Marital Status: Single, divorced or widowed > married Socioeconomic Status: Highest & lowest classes > middle class Occupation: Professional health care personnel & business executives are at highest risk Method: Use of firearms higher risk than overdose of substances Religion: Not affiliated with religious group > those affiliated Family History: Higher risk if individual has family history of suicide Others: 90% kids have a treatable psychiatric disorder. Victims of child/spousal abuse
What are some alcohol related cardiac medical problems? What is cardiomyopathy and what happens to the heart?
Alcoholic cardiomyopathy- (diminished strength and contractility of the heart-HTN) It is a disease in which the chronic long-term abuse of alcohol (ethanol) leads to heart failure. Alcoholic cardiomyopathy is a type of dilated cardiomyopathy Due to the direct toxic effects of alcohol on heart muscle, the heart is unable to pump blood efficiently, leading to heart failure. Alcoholic cardiomyopathy doesn't always cause symptoms. When symptoms do occur, they're often those of heart failure. They commonly include fatigue, shortness of breath, and swelling of the legs and feet. Decreased Strength and contractility of heart Increased Blood pressure (HTN)
What may we see with shaken baby syndrome/abusive head trauma? What happens?
Another name is abusive head trauma; it is a type of inflicted traumatic brain injury that occurs when a baby is violently shaken. (weak neck muscles and a large heavy head) When shaken the brain bounces back and forth inside the skull causing bruising, swelling, and bleeding (Subdural hematoma) which can lead to permanent severe brain damage or death*MR -coma -Death*
Psychoneurotic responses to anxiety?
Anxiety disorders (Characteristic features are symptoms of anxiety and avoidance behavior) Phobias, OCD, Panic disorder, Generalized Anxiety Disorder (GAD), PTSD Somatic symptom disorders- physical symptoms
What are some anxiolytics? Give some examples.
Azapirones-Buspar These drugs are used for patients that are compliant. They take 2-4 weeks to work and they are not addictive •Less sedative •Less likely to cause dependence Benzodiazepines-Diazepam (Valium), Lorazepam (Ativan), Clonazepam (Klonopin), Alprazolam (Xanax), Trazolam (Halcion), Temazepam(Restoril), Flurazepam(Dalmane)-- *tries to relax and brings the patients anxiety level down* Patient education: Avoid alcohol (synergistic effect) Avoid caffeine (antagonistic effect) Don't abruptly discontinue Beta Blockers -propranolol, atenolol--Help control the symptoms: racing heart (palpitations) They are used for social anxiety and are not addictive. •What for Orthostatic hypotension Antidepressants: * These are used for acute attacks. They are quick acting, but short term. Very addictive. •Tricyclic Antidepressants (TCA's) •Monoamine Oxidase Inhibitors (MAOI's) •Selective Serotonin Reuptake Inhibitors (SSRI's)
Nutritional deficiencies seen in depression?
B1, B6, B12, Fe, Folic Acid
What about BUN levels? Low? High?
BUN will decrease with liver disease (Normal BUN 10-20 mg/dL) BUN will increase with kidney dysfunction
Difference between blunted, flat, inappropriate, labile, and full range affect?
Blunted affect: Reduction in the intensity of outward emotional expression Flat affect: Complete or almost complete absence of outward emotional expression Inappropriate affect: Affect that doesn't match the situation (laughing when someone gives them bad news) Labile affect: Rapid and easily changing affect expression. From one end of the spectrum to the other. Full range affect: Consist with the feelings and content being expressed. What we want for most people. *Ideal
What are some examples of accidental vs suspicious findings? -burns, bruises, fractures, neglect
Burns Accidental: splash burns on front of the body, palm of hand (more severe on the upper body) accidental burns are more superficial, splash burn, palm of hand or front of body Suspicious: scald burns (most frequent burn type) on the child back. Donut type appearance (held down in hot water--no burn to the part of buttocks that was pressed against the tube) Also, immersion burns-stocking like appearance or glove appearance. (Suspicious is more on the back of the body, back of the hand, bilateral burns, or a definitive shape) Bruises Accidental: areas where skin is close to the bone (knees, elbows, shin) Suspicious: buttocks, lower back, genital areas, inner thigh, face, cheeks, ears, neck, upper lip) Bruises in different stages of healing, shaped like a belt buckle or other item of abuse) Fractures Accidental: more linear (meaning straight across) and clavicle fracture Suspicious: rib fractures, spiral fractures, children that don't walk, facial fractures. Multiple bilateral and radial fractures of ulnar and radius at different aging. (old healing callus and new fractures without plausible explanation) Fractures in different stages of healing. *Even when linear fractures* Neglect Accidental: Parent with no money to buy new shoes for child Suspicious: Child not attending school, ignoring crying child, no car seat provided for infant
What is CIWA?
CIWA is a Clinical Institute Withdrawal Assessment for Alcohol CIWA has 10 categories with a range of 0-4 or 0-7 range for scoring CIWA is used in the assessment and management of alcohol withdrawal. Nausea/vomiting? 0-none, 1-mild nausea w/o vomiting, 4-intermittent nausea, 7-Constant nausea with frequent dry heaves and vomiting. Anxiety? 0-none, 1-mild anxiety, 4-moderate anxious and guarded, anxiety is inferred, 7-equivalent to acute panic states seen in severe delirium or acute schizophrenic reactions. Paroxysmal Sweats? 0 - no sweats, 1- barely perceptible sweating, palms moist, 4 - beads of sweat obvious on forehead, 7 - drenching sweats Tactile disturbances? - Ask, "Have you experienced any itching, pins & needles sensation, burning or numbness, or a feeling of bugs crawling on or under your skin?" 0 - none, 1 - very mild itching, pins & needles, burning, or numbness, 2 - mild itching, pins & needles, burning, or numbness, 3 - moderate itching, pins & needles, burning, or numbness, 4 - moderate hallucinations, 5 - severe hallucinations, 6 - extremely severe hallucinations, 7 - continuous hallucinations Visual disturbances? - Ask, "Does the light appear to be too bright? Is its color different than normal? Does it hurt your eyes? Are you seeing anything that disturbs you or that you know isn't there?" 0 - not present, 1 - very mild sensitivity, 2 - mild sensitivity, 3 - moderate sensitivity, 4 - moderate hallucinations, 5 - severe hallucinations, 6 - extremely severe hallucinations, 7 - continuous hallucinations Tremors? - have patient extend arms & spread fingers. Rate on scale 0 - No tremor, 1 - Not visible, but can be felt fingertip to fingertip, 4 - Moderate, with patient's arms extended, 7 - severe, even w/ arms not extended Agitation - 0 - normal activity, 1 - somewhat normal activity, 4 - moderately fidgety and restless, 7 - paces back and forth, or constantly thrashes about Orientation and clouding of sensorium- Ask, "What day is this? Where are you? Who am I?"0 - Oriented, 1 - cannot do serial additions or is uncertain about date, 2 - disoriented to date by no more than 2 calendar days, 3 - disoriented to date by more than 2 calendar days, 4 - Disoriented to place and / or person Auditory Disturbance? - Ask, "Are you more aware of sounds around you? Are they harsh? Do they startle you? Do you hear anything that disturbs you or that you know isn't there?" 0 - not present, 1 - Very mild harshness or ability to startle, 2 - mild harshness or ability to startle, 3 - moderate harshness or ability to startle, 4 - moderate hallucinations, 5 - severe hallucinations, 6 - extremely severe hallucinations, 7 - continuous hallucinations Headache? - Ask, "Does your head feel different than usual? Does it feel like there is a band around your head?" Do not rate dizziness or lightheadedness. 0 - not present, 1 - very mild, 2 - mild, 3 - moderate, 4 - moderately severe, 5 - severe, 6 - very severe, 7 - extremely severe Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal) Scores of 15 or more indicate severe withdrawal. The assessment requires 2 minutes to perform
Mild Anxiety?
COPING MECHANISM (HEALTHY): Changes to thoughts, feelings and behaviors Seldom a problem •Associated with the tension experienced in response to the events of day-day-living •Prepares people for action •Sharpens the senses, increases motivation, increases perceptual field, heightened awareness of the environment •Learning is enhanced •Able to function at his or her optimal level •Experiences discomfort, restlessness, irritability
What are some signs and symptoms we would expect to see if a patient on Antabuse had a reaction from alcohol use?
Headache Nausea and vomiting Large red hot pruritic rash SOB Cardiac arrest Seizure Coma Death
Moderate Anxiety?
DEFENSE MECHANISM (REACTING): Daily life starts to be impacted by thoughts, feelings, and behaviors. •Reduced alertness to environmental events •Reduction in perceptual field •Decreased attention span •Decreased concentration •Can attend to needs and problem solve with direction •More problems in interpersonal relationships •Focus is on self •Increased restlessness Experiences: increased heart rate, BP, RR, Increased perspiration, Increased muscular tension, increased speech rate, volume and pitch
What about communication with the elderly regarding abuse? Nursing Do's and Don'ts.
Do's: •Conduct the interview in private •Be direct, honest, and professional •Use language the client understands •Ask the client to clarify words not understood •Be understanding and empathetic •Be attentive •Inform client if a referral/report must be made •Assess safety and help reduce danger Don'ts: •Try to "prove" abuse by accusations or demands •Display horror, anger, shock, or disapproval of the •perpetrator or the situation •Place blame or make judgments •Allow the client to feel "at fault" or "in trouble" •Probe or press for answers the client is not willing to give •Conduct the interview with a group of interviewers
What is the criteria for DD?
Dysthymia Depression (DD) Characterized by: Chronic Depressive symptoms present for at least 2 years Some Social and Occupational distress but still able to function Chronic low; great sadness (chronic in nature and harder to see a change in the person because it's that usual pattern of function--the way they have always been) Onset---early insidious onset (sneaks in) Onset can appear in childhood year and teenage years into early adulthood Less severe symptoms than MDD but Longer duration than MDD
When the cycle repeats what is the risk?
Escalation and De-escalation of emotions (high risk for violence when victim leaves) •Anger and fear escalate •Briefer periods of calm and feelings of safety •Violence increases over time and threatens to repeat itself •Self-esteem of both the victim and the abuser erode further •Victim believes the violence is deserved or accepts blame for it •Leads to feelings of depression, hopelessness, powerlessness, immobilization and self-depreciation
What are some alcohol related GI medical problems? What is esophagitis? And how does it happen? Varices are the result of what? And what happens? Gastritis? Pancreatitis? -what specifically happens?
Esophagitis: pain and inflammation of the esophagus Esophageal varices: Abnormal (prolapsed or pouched out) veins in the lower part of the tube running from the throat to the stomach. Esophageal varices usually develop when blood flow to the liver is blocked. They often occur in people with advanced liver disease. These can rupture, and hemorrhage---esophageal bleeds are very smelly. Treatments include beta blockers, medical procedures to stop bleeding, and, in rare cases, liver transplant. Gastritis: Inflammation of the stomach causing nausea, vomiting, burning, and distention. (damaged blood vessels) Pancreatitis: with chronic alcoholism-more likely to have repeated episodes of acute pancreatitis. Over time, this will cause permanent damage to the pancreas, causing chronic pancreatitis. —note: Cigarettes are thought to increase the harmful effects of alcohol on the pancreas. Pancreatic enzymes that the pancreas makes, normally are secreted in the stomach to help digest food. Instead they stay in the pancreas and the pancreatic enzymes start to eat the pancreas. S/S: epigastric pain, nausea, vomiting, stomach distention, and malnutrition
What is dissociation?
Everyone uses dissociation. Daydreaming, fantasizing, "zoning out" are all examples of healthy dissociation and can be used in creative ways to solve problems. However severe traumatic dissociation comes from major trauma, and an individual is unable to integrate the trauma into their psyche. Depending on the severity and impact of the event, a person may be unable to recall a specific event, experience depersonalize and derealization (refer to text), or in severe cases may separate off into fragmented emotional states, partially formed identities, or break off into full formed identities as in dissociative identity disorder (multiple personalities).
Tricyclic (TCA's), --what is the action? Side effects and how can we treat them? Why start low and go slow?
Examples: Amitriptyline (Elavil), Imipramine (Tofranil), Doxepin (Sinequan) Action: Prevent reuptake of norepinephrine and serotonin S/E: (affects histamine & acetylcholine) Dry mouth, drowsiness, urinary retention, sedation, constipation, decreased libido, blurred vision, weight gain, orthostatic hypotension. May take several weeks to reach therapeutic levels Contraindicated in: Narrow angled glaucoma, pregnancy, history of seizures, and recent MI. Serotonin Syndrome-potentially life-threatening drug reaction that causes the body to have too much serotonin Discontinuation Syndrome -More likely with a longer duration of treatment and a shorter half-life of the treatment drug Symptoms: F-I-N-I-S-H *Don't use alcohol (flu-like, Insomnia, N/V, Imbalance, Sensory, Hyperarousal) To alleviate some of the side effects: ►Dry mouth--chew gum or hard candy ►Drowsiness/sedation--take in PM ►Orthostatic hypotension--get up slowly ►Constipation--increase water and increase fiber ►Weight gain--increase exercise Drowsiness, dizziness, and increased blood pressure usually subsides after the first few weeks--body has to get used to the medication. Regardless which TCA is used. Start low and go slow (especially in the elderly) because low drug metabolism could be a problem.
Selective Serotonin Reuptake Inhibitors (SSRI's)-what is the action? Side effects and how can we treat them? How are these different than TCAs?
Examples: Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram), Lexapro (escitalopram), Luvox (fluvoxamine) Action: cause increase in available serotonin S/E: sexual dysfunction, nausea, vomiting, anorectic activity, weight loss, HA, nervousness/anxiety (transient), insomnia, ***Low anticholinergic S/E Several weeks for therapeutic result Discontinuation Syndrome Serotonin Syndrome: (may occur with St. John's wort) Avoid alcohol To alleviate some of the side effects: ►Nervousness/anxiety--avoid taking with caffeine ►Insomnia/drowsiness--take in the PM ►Headache—Tylenol
What is a hypertensive crisis? What foods do they have to stay away from?
Excessive amounts of tyramines can lead to hypertensive crisis—which is a toxic effect from taking MAOI's • Severe headache • Stiff, sore neck • Flushing; cold, clammy skin • Tachycardia • Severe nosebleeds, dilated pupils • Chest pain, stroke, coma, death • Nausea and vomiting
What is fetal alcohol syndrome and what effects would we expect to see?
Fetal alcohol syndrome is prenatal exposure to alcohol and is a lifelong condition that can include mental retardation, facial abnormalities, stunted growth, and learning disorders. Alcohol can also increase the risk of miscarriage, low birthweight, stillbirth and death in early infancy. There's no cure or specific treatment for fetal alcohol syndrome. The physical defects and mental deficiencies typically persist for a lifetime. However, early intervention services may help reduce some of the effects of fetal alcohol syndrome and may prevent some secondary disabilities
What are the basic antidepressant classes?
First-line agents • Cyclic antidepressants (e.g., TCAs) • SSRIs and SNRIs: • Atypical antidepressants Second-line agents • Monoamine oxidase inhibitors (MAOIs)
What neurotransmitter affects anxiety?
GABA (gamma-Aminobutyric acid), is a non-protein amino acid that is the primary inhibitory neurotransmitter in the brain. Its principal role is reducing neuronal excitability throughout the nervous system.
What are some possible risk factors/causes of substance abuse?
Genetics/Heredity Biochemical/Neurotransmitter Deficiency Psychological Sociocultural
What do antidepressants do for depression?
Goal of antidepressants is to alter the biochemical imbalance which will elevate the mood. Antidepressant medication benefits 65-80% of patients. Medication and treatment therapies used together are most beneficial. All antidepressant medications work equally well but do not work well for all individuals. Essentially, the core symptoms of depression improve with antidepressant therapy, and quality- of-life measures improve with certain psychotherapies. Antidepressant drugs can positively alter poor self-concept, degree of withdrawal, vegetative signs of depression, and activity level.
Define what the acronym "HITS" means in relation to alcohol withdrawal.
HITS is an acronym to represent the S/S of withdrawal. Hallucinations (auditory, visual, tactile) Increased vital signs, insomnia Tremens (fatal) Shakes, sweat, stomach (N/V)
What are some medications that would be ordered for a pt experiencing withdrawal and why?
Helps bind to GABA receptors and calm the signs and symptoms of withdrawal Ativan-lorazepam-intermediate (IV, IM, PO, SL) Librium-chlordiazepoxide-long (PO) Valium-diazepam-long (IV, IM, PO, SL) Phenobarbital
What other intervention strategies are there? Individual / group / inpatient /outpatient and what are these?
Individual Therapy: One on one Group Therapy: Group of individuals sharing the same conviction Inpatient treatment: admitted into a treatment facility Outpatient treatment: Treated and sent away. (able to leave)
Mild Anxiety Adaptation?
Individual develops own way to relieve stress • Sleeping • Eating/ Drinking • Physical Exercise • Laughing/ Crying • Cursing • Pacing • Nail biting • Foot swinging/tapping • Talking to someone
What are some symptoms of depression? Infants? Preschool? School age? Adolescents?
Infants-feeding problems, lack of playfulness, failure to thrive, delays Preschool-irritable, isolate, changes in sleep, aggressiveness, phobias School age-tantrums, behavior problems, poor school performance, psychosomatic complaints Adolescents-moody, aggressive, school problems, hypersomnia, fatigue, eating disturbance, social withdrawal, psychosomatic-increase risk of substance abuse, sexual acting out
What is kindling?
Kindling is when a patient attempts multiple episodes of withdrawal, neurons undergo long-term changes—causing subsequent episodes of withdrawal to progressively worsen. •Patients who've had multiple episodes of alcohol detoxification across their lifetime, tend to have an increased risk of withdrawal seizures. •Risk for seizures increase because of changes/damage to neurons and excitability. •Withdrawal triggers the bodies stress response •elevated levels of stress hormone Cortisol.
Korsakoff's psychosis-what happens? what are the symptoms? How to treat?
Korsakoff's Psychosis: is a chronic neurologic sequela of Wernicke's encephalopathy. It is a result of chronic brain damage. It is long-lasting and debilitating problem. Dementia with profound loss of recent memory. Normally follows WE. Treatment: thiamine (B-1) may improve function in early stages. Confabulation-can occur (This is invented memories to fill in the gaps) Amnesia and brain damage caused by disease may not respond to thiamine. Nursing interventions in the later stages: provide support for patient; custodial care---needs to be taken care of because of permanent brain damage.
How do hormones play a part in depression?
Levels of certain hormones, such as those produced by the thyroid gland, can be factors in depression. In addition, some symptoms of depression are associated with thyroid conditions. The same is true about conditions related to the menstrual cycle, such as premenstrual syndrome (PMS), Peri-menopause, and menopause Estrogen and progesterone
What do we listen for when gathering subjective findings of child abuse? What do we look for?
Listen for: •History inconsistent with injury •Uncertain or indifferent how injury occurred •History changes with repetition •Delay in seeking medical attention •Observe parent response to child/child response to parent •Multiple hospitalizations -Munchhausen syndrome by proxy •Do not ask single answer questions--ask open ended questions •Do not ask why questions •"Describe..."-what your child does to get you angry? Ask what they do when they get angry? Look for? •Burns •Bruises •Fractures •Traumatic hair loss--hair in various lengths with bald areas •Poor hygiene •Poor nutrition •Fatigue •Pain/itching/bruised genitals •Pain urinating •Stomach aches, vomiting, and/or failure to thrive
What are some alcohol related liver medical problems? What is hepatitis? Cirrhosis? What happens and what are the results? What is hepatic encephalopathy? What do we do to treat this? And how does that work?
Liver cirrhosis: cells of liver are damaged and can't repair self •Scar tissue forms; blood flow impaired •Poisons and wastes are not able to be filtered out of the blood by the liver •Build up •Symptoms: mental confusion, agitation, shaking, coma, death Portal hypertension: is an increase in the blood pressure within the portal venous system. Veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver. Hepatitis: Inflammation of the liver. The alcohol directly injures the cells of your liver. Over time, it can cause permanent damage and lead to liver failure and cirrhosis, a thickening and scarring of the liver. Hepatic encephalopathy: a serious brain condition caused by the accumulated toxins that result from liver disease and liver failure. Ammonia is the result of protein breakdown, liver converts to urea. When the liver is unable to convert the ammonia in the blood into urea to be eliminated by the urinary system, the increased ammonia caused alterations in mentation RX Treatment: Lactulose: (Constulose, Enulose, Generlac, and Kristalose) is an Ammonia reducer and laxative. It can treat constipation. It can also treat liver disease, hepatic encephalopathy, and IBS. S/E: Nausea, vomiting, diarrhea, abdominal pain, and cramps Warning: Tell your doctor if you are pregnant or breastfeeding, or if you have diabetes.
What is the criteria for MDD?
Major Depression Disorder (MDD) Characterized by depresses mood or loss of interest or pleasure in usual activities. Impaired social & occupational functioning. Has existed for at least 2 weeks No manic behavior Symptoms not attributed to use of substances or general medical condition. Specified to either a single episode or can be a recurrent thing they have Degree of severity—mild, moderate, or severe. The course is variable (average course can last 9 months) Severity of suicide risk may be noted with these patients**Need to watch and assess for suicide**
What is a black box warning? What meds are these placed on?
Medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects All antidepressant medications warn they ay result in increased risk of suicidal tendencies in children and adolescents. Warfarin, due to risk of bleeding to death. Fluoroquinolones, due to the risk of tendon ruptures. etc.
What are some motivations for suicide?
Mental Illness (Depression, anxiety, Bipolar, Schizophrenia) Traumatic experience: Any type of traumatic experience can lead a person to feeling helpless, guilty, and/or ashamed. If you were victim of physical abuse, sexual abuse, and PTSD. Bullying: Most people that are bullied end up feeling extremely depressed, worthless, and hopeless to change their situation. Personality disorders: People with a personality disorder may have trouble maintaining relationships, holding down a steady job, and/or coping with life. Drug Addiction / Substance Abuse: Many people use drugs to escape painful feelings of depression and hopelessness of their current life situation. Social Isolation/loneliness: Being socially isolated from society can take a toll on mental health and lead a person to become depressed and consider suicide Genetic/family history: Those who are from a family in which suicide is common are more likely to commit suicide themselves. Existential crisis/ philosophical Desire: When life seems void of meaning, people tend to question why they are even living and/or the entire purpose of their existence. This is often referred to as an "existential crisis" and can be difficult to overcome because people dealing with this issue often think themselves in circles of logic as to why there is no point to life. This crisis can result from major depression, trauma, loneliness, seeking meaning and/or general dissatisfaction with life Terminal Illness: Many people with terminal illnesses that have no hope of improving their situation based on current science and medicine may become depressed. Chronic pain: If you have chronic pain, it means that you have had daily pain that has persisted for between three and six months. This pain often impairs your ability to function throughout the day and can affect mobility, the ability to perform certain tasks, and even a person's mental health. Although pain levels differ among chronic pain sufferers, one thing that they all have in common is an inability to escape the daily discomfort associated with their pain. Financial Problems: People who are struggling financially sometimes see no end in sight to their debt and bills. Prescription drugs: The side effects of various prescription drugs such as antidepressants can result in suicidal ideation.
Monoamine Oxidase Inhibitors (MAOI's) - what is the action? Side effects?
Monoamines are a type of organic compound including the neurotransmitters such as dopamine, norepinephrine, and serotonin. Monoamines oxidase is an enzyme that metabolizes (break down) monoamines such as dopamine, norepinephrine, and serotonin. Inhibitors that block the enzyme, inhibiting the destruction of norepinephrine, dopamine and serotonin. These are used for depression when other drugs have failed. S/E: Constipation, dizziness, orthostatic hypotension. Contraindications: hypertensive crisis with OTC cold & weight remedies, birth control, herbal supplements, and foods containing tyramines (fermented, picked, aged, dried, wines, and beer.
What is the difference between mood and affect?
Mood (subjective) sustained emotional tone (what person tells you (I'm crabby) Affect (Objective) behavioral expression of emotion (What you see)
Types of elder abuse and examples
Neglect (most common) • Malnutrition • Omission of medication • Urine burns • Inappropriate dress (for the weather) Physical • Welts, bruises, fractures Financial • Unpaid bills • Cashing checks without authorization Sexual • Assault • Jokes • Inappropriate comments Psychological/emotional • Ignoring (calls for help) • Threatening • Isolating (restricting phone calls, mail, visitors, or even outings)
What is neurosis?
Neurosis is an extended period of repressed severe anxiety can result in psychoneurotic patterns of behaving—called neurosis. Neurosis is a psychiatric disturbance (mild mental illness) characterized by excessive anxiety. It is expressed outwardly or through our defense mechanisms. It sometimes appears a symptom without disease. Symptoms of stress (depression, anxiety, obsessive behavior, hypochondria)
What Neurotransmitter deficiency occurs with ETOH-? Psychological? Sociocultural?
Neurotransmitter-Dopamine Psychological-Tolerance of stressors, low self-esteem, depression Sociocultural-cultural attitude, Society and family attitude toward alcohol, kids learn from what they see, peer pressure, cultural expectance and acceptance. Dopamine is the brain chemical present in regions of the brain that regulate motivation, emotion, cognition or learning, and the ability to experience pleasure and pain. All drugs directly or indirectly affect the limbic (reward) system. The reward system consists of the ventral tegmental area (VTA), the nucleus accumbens, and part of the cerebral cortex. The first time an individual uses a substance, the neurons in the reward pathway release an unusually large amount of dopamine, which exaggerates feelings of pleasure. The neurons in the reward pathway communicate through electrical signals that are passed from one neuron to another across the synapse. Dopamine is then released into the synapse, crosses to the next neuron, and binds to that neuron's dopamine receptor. It is this binding that produces the initial unnatural intense feelings of pleasure. Because of this flood of neurotransmitters, the neurons try to regulate the level of dopamine in the brain either by reducing the number of dopamine receptors or by synthesizing less dopamine. Eventually, dopamine's ability to stimulate the reward center becomes very ineffective, and the individual is encouraged to increase the amount of the drug to raise dopamine levels to normal or higher levels; this vicious cycle of taking increasing amounts of the drug to even feel "normal" begins the cycle of tolerance to the drug and eventual dependence or addiction. Alcohol and other central nervous system (CNS) depressants act on GABA receptors.
What does the nurse assess for ETOH? ---physical manifestations?
Objective: History: Including family, past alcohol experiences (1st drink, jobs, conflicts) Current or existing experiences: divorce, job, $$ Cage questionnaire, Cut Down, Annoyed, Guilty, EYE OPENER Have you ever thought you should cut down on your drinking? Has anyone ever annoyed you by criticizing your drinking? Have you ever felt guilty about your drinking? Have you ever had to have an EYE OPENER—drink 1st thing in the morning? ****2 or more positive answers suggests drinking may be causing problems**** Important to know when last drink was so can have an idea when symptoms will happen Subjective: Physical problems—ascites (stomach distention) Decreased albumin: Alcohol consumption depletes protein production Increased pressure in portal veins (fluid goes into peritoneal space) Jaundice-caused form alcoholic hepatitis: yellowing of the skin Malnourished: Alcohol had no caloric benefits and it inhibits absorption and usage of vital nutrients such as thiamine (vitamin B1), vitamin B12, folic acid, and zinc. Toxicity screen: A toxicology screen is a test that determines the approximate amount and type of legal or illegal drugs that you've taken. It may be used to screen for drug abuse, to monitor a substance abuse problem, or to evaluate drug intoxication or overdose. The results of a toxicology screen are usually positive or negative. A positive test result means that a drug or multiple drugs are present in the body. Blood alcohol content test: A blood alcohol test measures the amount of alcohol (ethanol) in your body. Alcohol is quickly absorbed into the blood and can be measured within minutes of having an alcoholic drink
What is discontinuation syndrome? When can it occur?
Occurs or approx. 2 weeks following discontinuing an antidepressant that blocks SERT. Solution: Tapering off Discontinuation Syndrome -More likely with a longer duration of treatment and a shorter half-life of the treatment drug F -flu-like symptoms (h/a, n/v, chills, dizzy, diarrhea, fatigue) I -insomnia N -n/v I -imbalance (gait, dizzy) S -sensory (parenthesis, "brain zap") H -hyperarousal (anxiety) All classifications of antidepressants have varying potential to cause discontinuation syndrome.
What is serotonin syndrome? What are some of the symptoms?
One rare and life-threatening event associated with the SSRIs is serotonin syndrome. This is thought to be related to overactivation of the central serotonin receptors, caused either by too high a dose or by interaction with other drugs. **May occur with St. John's Wort) Symptoms include abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, altered mental state (delirium), myoclonus (muscle spasms), increased motor activity, irritability, hostility, and mood change. Severe manifestation can induce hyperpyrexia (excessively high fever), cardiovascular shock, or death. Restlessness -agitation Confusion, mania, hallucinations; loss of consciousness Seizure, coma, death Loss of coordination -Overactive reflexes ↑HR/BP Nausea -vomiting -diarrhea Fever -sweating -shivering
What are some verbal (overt/covert), behavioral, and emotional assessment cues that would warrant concern? Give an example of an overt and covert clue when assessing suicide.
Overt: obvious/someone says it straight out. "I'm going to kill myself". Covert:" you won't see me again"/ I won't be around much longer"/subtle hinds) Behavioral: Giving away belongings, neglecting hygiene, self-mutilation (cutting), withdrawn Emotional: sudden or unexpected improvement in mood (made decision to kill themselves) Take every threat seriously.
Severe Anxiety?
PSYCHONEUROTIC RESPONSE (INJURED): More intense thoughts, feelings, and behaviors of greater frequency •Perceptual field is greatly diminished •Concentrates on one detail or many extraneous details •Focused on self; Not aware of the environment • Attention span extremely limited • Learning and problem-solving not possible • Has difficulty completing even a simple task • May appear dazed and confused • Has purposeless activity
Panic Anxiety?
PSYCHOTIC RESPONSE: (ILL)-Significant impairment in daily life (school, family, work, social) •Extreme level of anxiety •Disturbed behavior •Not capable of processing what is happening in the environment •Lose contact with reality •Disorganized or irrational thinking •Cannot problem-solve •Experiences: terror, immobility or severe hyperactivity/flight, dilated pupils, unintelligible speech, severe shakiness, sleeplessness, severe withdrawal
What does the acronym "PADDLE" stand for?
Paddle is a risk assessment mnemonic for suicide risk. P-Previous attempts A-Alcohol, drug use, agitation D-Depression D-Development of plan L-Loss of hope, lack of support E-Expressed suicidal thoughts, exhausted
4 phases of alcohol consumption.
Phase 1: The Pre-Alcoholic Phase (Drinks a beer after work) •Use of alcohol to reduce every day stress •Seen as an acceptable way to cope with stress •Tolerance develops, and the amount required for same effect increases. Phase 2: The Early Alcoholic Phase (sneaking drinks, gulping them down, defensive, denial) •Begins with blackouts/brief periods of amnesia •Alcohol is no longer a source of pleasure •Drug that is required by the person •Behaviors: Sneaking a drink, rapid gulping, preoccupation with drinking •Individual feels guilty and becomes defensive •Excessive use of denial and rationalization Phase 3: The Crucial Phase (body needs it, withdrawal-willing to risk it all) •Person has lost control •Physiological evidence is preset •Binge drinking: several hours to several days •Individual extremely ill; sickness, Loss of Consciousness •Anger and aggression are common •Drinking is their total focus; willing to risk loss things that are important to them •Individual losses: Job, Marriage, Family, Friends, Job, Self-respect Phase 4: The Chronic Phase (Drunk more than sober) •Emotional and physical disintegration •Usually intoxicated more than sober •Profound helplessness: self-pity
Give examples of each type of abuse.
Physical abuse -Slapping, Punching, Hitting, Pushing, Restraining, Biting, Throwing, Burning Sexual abuse -Any form of sexual contact or exposure (without consent or inability to give consent). May escalate into sexual assault or rape. Emotional abuse- Threatening (Terrorizing with verbal threats & Threatening an individual with abandonment), Humiliating, Intimidating, Isolating, Demeaning the individual's worth with putdowns Ignoring the individual's needs, Belittling and criticizing Neglect- Failure to do something Physical neglect-failure to provide medical, dental, or psychiatric care or failure to provide adequate food, shelter, and clothing Developmental neglect-failure to provide emotional nurturing or absence of physical and cognitive stimulation Financial neglect -NOT letting a person use their own money to meet their physical, emotional or personal needs. Educational neglect- Deprivation of education available in accordance with state's educational laws Safety neglect- not putting a child in a care seat, leaving a child unattended in a hot care or near water
Physical & Emotional Symptoms of Severe Anxiety?
Physical symptoms: headaches, palpitations, insomnia, hyperventilation, nausea, insomnia Emotional symptoms: confusion, dread, horror, sense of impending doom
How does primary differ from secondary and that from tertiary --and what are the responsibilities of the nurse in each?
Primary- prevention strategies that include providing information and education to at-risk populations Secondary- management of the suicide crisis. Ask the client to agree to a no-suicide contract, which is a verbal or written agreement that the client makes to not harm himself, but instead to seek help. Tertiary- interventions with the family or friends of a person who committed suicide.
Who are the target populations for primary, secondary, and tertiary interventions for suicide?
Primary--- Teaching elementary school students conflict resolution skills; programs that improve parent-child relationships Secondary— Perfecting depression detection and treatment in primary healthcare of the elderly Tertiary— Implementation of psychotherapy immediately after patients have been assessed in emergency services due to a suicide attempt and/or Survivor support.
What nursing diagnosis might be appropriate for a patient with substance abuse?
Risk for Injury Altered Nutrition Ineffective Coping
What are some nursing diagnosis?
Risk for injury Ineffective coping Pain, Powerlessness, spiritual distress, Anxiety, and many more...
What does the acronym "SAD PERSONS" stand for?
S-Sex A-Age D-Depression P-Previous Attempts E-ETOH R-Rational thinking loss S-Separated, widowed, or divorced O-Organized plan or serious attempt N-No social support S-Stated future intent
What does S-A-L-T mean in relation to a suicide assessment?
S-Specific plan A-Availability of method L-Lethality T-Time
How often should a suicide assessment be performed?
Screening can be applied either universally or selectively. A universal screening program is applied to everyone in a population regardless of whether they are thought to be at a higher risk than the average person. For example, a universal screening program might include every patient visiting a primary care office.
Describe secondary nursing interventions for suicide.
Secondary -After attempt or threat has been made ◦Risk assessment (early diagnosis) ◦Crisis intervention-acute care setting (prompt treatment) •Physical needs •Safety (make sure pt isn't pocketing meds, check q15min) •Develop a supportive trusting relationship—will help patient open up •Suicide precautions •Accurate and timely documentation (very important) All team reviews of status, names of team members. Decisions R/T changes in restriction levels. Statements from client R/T self-harm Responses to phone calls, visitors, passes--All searches •Referral/community connections (need support when they leave)
What are some alcohol withdrawal nursing interventions?
Seizure precautions Create quiet environment Monitor BP, Pulse, Temp, Resp Rate, O2 sat, neuro, labs, nutrition Fluids (if electrolyte imbalance)—hypokalemia, hypocalcemia Medications Benzodiazepines-Librium, Valium, Ativan--(bind to GABA receptor sites----causing a calming effect) Thiamine 100mg IV or PO Folic Acid (IV, IM, Sub Q) Multi-vitamin (MVI) Malnourished Magnesium Sulfate-seizure threshold CIWA protocol depending on score Important to know when last drink was so can have an idea when symptoms will happen
Types of Atypical Antidepressants.
Serotonin + Norepinephrine Reuptake Inhibitor (SNRI) Block presynaptic serotonin and norepinephrine transmitters which then blocks the reuptake: venlafaxine (Effexor) S/E: Headache, nervousness, insomnia, decreased appetite, sexual dysfunction, inappropriate secretion of antidiuretic hormone, hyponatremia duloxetine (Cymbalta) S/E: Nausea, diarrhea, anorexia, sexual dysfunction, hypertension, palpitations, increased blood pressure, urinary frequency/retention, inappropriate antidiuretic hormone, hyponatremia Serotonin-Norepinephrine Disinhibitos (SNDI)-mirtazapine (Remeron) Increase norepinephrine and serotonin transmission by blocking presynaptic a2-nor-adrenergic receptors S/E: Dry mouth, abnormal dreams, confusion, sedation, influenza-like symptoms, hypotension Norepinephrine--Dopamine Reuptake Inhibitors (NDRI)--bupropion (Wellbutrin) It inhibits dopamine-norepinephrine reuptake, and inhibits nicotine, acetylcholine receptors which reduces addictive factors. S/E: Anxiety, insomnia, nausea, headache, dizziness, anorexia Serotonins Antagonist/Reuptake Inhibitors (SARI)-trazadone (Desyrel) Alters the effects of serotonin in the CNS: S/E: has potent a-adrenergic blocking properties so it can cause priapism (painful prolonged penile erection) Each of these drugs inhibit uptake of the various neurotransmitters in the brain
Know the difference between a panic attack and heart attack? How do you rule this out? What are the test? What are the labs? Meds?
Signs and symptoms of both are: chest pain, palpitations, numbness of hands, diaphoresis, elevated BP, P, R (hyperventilation vs. SOB) To rule out Heart attack: O2 check O2-if low deliver oxygen to increase O2sat above 95% Monitor mental capacity and LOC (low O2 can cause issues here) EKG—looking for any abnormalities or cardiac event that could of took place Meds: Nitro vs anxiolytic: Nitro would help to dilate vessels within the heart to allow oxygenation of the blood to perfuse the heart better. Would see positive responses if truly a cardiac event. Labs: Creatinine phosphokinase CK-MB and/or Troponin— Cardiac enzymes. These labs with show cardiac muscle damage and breakdown with these labs. May also draw a CBC chemistry panel electrolytes and glucose
What s/s would you expect to see in stage 1, stage 2, and stage 3 post-alcohol withdrawal? What are the time frames?
Stage 1: mild-(6-8 hours post-alcohol) Nervousness, flushed face, tremors, anorexia, insomnia, tachy, nausea, vomiting, mild anxiety, headache, and diaphoresis. Stage 2: moderate (24-72 hours post-alcohol) Nervousness, flushed face, tremors, anorexia, insomnia, tachy, nausea, vomiting, mild anxiety, headache, and diaphoresis. PLUS---Confusion, hallucinations, HTN Stage 3: severe (48-96 or 72-96 hours post-alcohol) Nervousness, flushed face, tremors, anorexia, insomnia, tachy, nausea, vomiting, mild anxiety, headache, and diaphoresis, Confusion, hallucinations, HTN PLUS.... 5% who suffer from withdrawal---DT's (Delirium Tremens)—sudden and severe mental change Grand mal seizures, delirium, severe HTN, tachy, hallucinations, elevated temp, profuse diaphoresis. Arterial pH rises due to hyperventilation; elevated O2 consumption ***Cardiac arrest and respiratory failure can occur***
Subjective signs of depression
Subjective--Physical Assessment & History • Little or no eye contact • Sad/flat affect • Monotone voice • Poor hygiene • Weight change • Slumped posture • Crying • Slow movement • Thought processes • Inability to think
Elder abuse assessment—subjective and objective
Subjective: • "Has anyone hurt you?" • "Does anyone yell at you or threaten you?" • "Tell me about... (open-ended questions) • "What is a typical day like for you?" • "How are your finances managed?" Objective: • Malnutrition • Poor hygiene--explainable STI's • Omission of medication/over medication • Welts, bruises, fractures • Depression, withdrawn • Interaction between caregiver and client
How is anxiety different that stress?
Stress is the precursor to anxiety. Stress is caused by an existing stress-causing factor or stressor. Anxiety is stress that continues after that stressor is gone. Stress can come from any situation or thought that makes you feel frustrated, angry, nervous, or even anxious. Anxiety is closely related to fear.
11. What does a nurse assess with a patient with anxiety? Subjective vs Objective manifestations
Subjective: •Identify anxiety-producing situations (cause specific to the individual) •Coping strategies •Identify defense mechanism •Support system (family, friends) •Duration Objective: What physical signs (fidgeting, nail biting, cigarette smoking, shaking legs)
What are the assessments-subjective and objective- with domestic abuse?
Subjective: •Reports "accidents" (I fell...etc.) •Injuries don't reflect nature of "accident" •Nurse: Ask... "Does your partner... threaten you, hit you, prevent you from leaving/working, destroy things you care about, watch every move..." *Do not use the word ABUSE* •Avoid asking "why" questions (Ex. why don't you just leave him?) -- They will not open up to questions that seem accusing Objective: •Physical Injury: face, head, genitals •Embarrassed--no eye contact •Partner reluctant to leave room-- •Delay in seeking treatment (partner may have control over them, or victim may be embarrassed and feel the violence may be her fault)
What is suicide attempt, suicide gesture, suicide threat, and suicide ideation? Give an example of each. What does lethality mean?
Suicide attempt: (lethal method) includes all willful, self-inflicted, life-threatening attempts that have not led to death. Suicide gesture: (non-lethal method) Superficial (cutting of wrist) causing minimal harm Suicide threat: (talk, but no action) verbal or nonverbal threats of suicide—without action Suicide ideation: thoughts of passive or active suicide (means a person is thinking about self-harm) Complete suicide: Death Lethality---level of wrist: Gunshot & hanging—high Gun shot—low
What are the theories of suicide? What does psychobiological mean? Is there a genetic link? Biochemical-what system is there an issue in? What neurotransmitter is usually involved?
Suicide is not a diagnosis or a disorder. It is a behavior—An act of desperation. Most individuals do not want to die, they just don't know how to go on living with their mental and/or physical pain. Psychobiological— the interpretation of personality, behavior, and mental illness in terms of adaptive responses to biological (illness or disease), social (Experiencing loss of relationships with society /losing a job, breakup, etc.), cultural (Considering self-inflicted death as honorable -Eastern culture), and environmental factors. Genetic Link: No real genetic link except serotonin related genes. Suicide has long been shown to cluster in some families; therefore, family history is pertinent. Biochemical: **serotonin related genes Neurotransmitter: Decreased levels of serotonin have been found in people with depression, impulsive disorders, a history of suicide attempts, and in the brains of suicide victims. Low threshold for emotional pain. Everything is such a struggle for them. Copycat/glamourizing. 10% leading cause of death in Wisconsin:2 out of 3 suicide deaths seen a PCP 1 month before suicide
Generalized Anxiety Disorder (GAD)
Symptoms: impair work, social or personal functioning • 6 months: excessive anxiety and worry • Trouble controlling these feelings • 3 or more of the following symptoms: o restless o edgy/irritable o tire easily o trouble concentrating o increased muscle tension o Insomnia
What are some examples of primary prevention of domestic abuse?
Teaching adolescents about dating violence
What is the guideline intervention for a SAD PERSONS risk assessment of 5-6? 7-10?
The SAD PERSONS scale was developed as a screening tool for suicide. An individual receives one point as applicable in each category that follows. These points are then totaled to determine the risk factors for suicide. 0-2 Treat at home with follow-up care (Low Risk) 3-4 Closely follow-up and consider possible hospitalization (Moderate Risk) 5-6 Strongly consider hospitalization (High Risk) 7-10 Hospitalize (Very High Risk)
What does half-life mean and how would you figure that?
The amount of time required for half (50%) of the drug to be eliminated from the body The longer the ½ life the better for the patient—more sedating but better withdrawal experience. 100 mg drug with ½ life of 12 hours 12 hours=1-hour ½ life=50mg 24 hours=2-hour ½ life=25 mg 36 hours=3-hour ½ life=12.5 mg
What are psycho-physiological responses and what does that mean
The physiological response is an automatic reaction that triggers a physical response. The psychological response is either a conscious or subconscious defense mechanism utilized to deal with stressful situations or stimuli
What are some intervention strategies used for substance abuse?
Therapy---Individual or group Treatment programs: Impatient (more positive results) and outpatient Medications: Antabuse(Disulfiram)—prevent impulse drinking Antidepressants- helps treat underlying issues
What is somatic symptom disorder?
To somatize is the tendency to experience and communicate physical symptoms in response to psychological distress. These somatic symptoms are related to significant distress and impairment. Although there are times that medical tests repeatedly demonstrate no medical basis, people continue to seek relief from their somatic symptoms that are causing significant distress and/or dysfunction; however, according to the DSM-5, "Somatic symptom disorders can also be diagnosed along with medical disorders" •physical symptoms of anxiety with no demonstrable organic pathology. •Psychological factors role in onset, severity, exacerbation, or maintenance of symptoms (sometimes pain, neurological, blind, deafness, sexual dysfunction) •They are the result of high levels of stress, can come and go
Describe the continuum of depression. Give examples and differences between each.
Transient Depression--life's everyday disappointments (feeling sad, having the blues, crying) Mild Depression-Normal grief response (anger, anxiety, guilt, helplessness, sadness, tearfulness, restlessness—associated with the loss of a significant other) Moderate depression- Dysthymic disorder Severe depression- Major depressive disorder
Who is normally the victim in elder abuse?
Usually White females >70 y/o
How would we assess for suicidal tendencies? What would we ask?
Verbal and Non-verbal clues: •Verbal -overt and covert (overt: obvious/someone says it straight out) vs (covert:" you won't see me again"/ I won't be around much longer"/subtle hinds) •Behavioral: Giving away belongings, neglecting hygiene, self-mutilation (cutting), withdrawn •Emotional: sudden or unexpected improvement in mood (made decision to kill themselves) Needs to be part of routine Nursing Assessment Don't be afraid to ask about suicidal thoughts "Are you feeling depressed, sad, or discouraged?
Indicators of Mild Anxiety?
Verbalization Changes: Increased questioning Motor activity changes: Mild restlessness, sleeplessness Perception and attention changes: Increased alertness, uses learning to adapt Respiratory and circulatory changes: None Other changes: None
Indicators of Severe Anxiety?
Verbalization changes: Communication difficult to understand Motor activity changes: Increased motor activity, inability to relax. Fearful facial expression. Perception and attention changes: Inability to focus or concentrate. Easily distracted. Learning severely impaired Respiratory and circulatory changes: Tachycardia, hyperventilation Other changes: Headache, dizziness, nausea
Indicators of Panic Anxiety?
Verbalization changes: Communication may not be understandable Motor activity changes: Increased motor activity, agitation, trembling, poor motor coordination. Unpredictable responses Perception and attention changes: Perception distorted or exaggerated. Unable to learn or function Respiratory and circulatory changes: Dyspnea, palpitations, choking, chest pain, or pressure Other changes: Feeling of impending doom. Paresthesia, sweating
Indicators of Moderate Anxiety?
Verbalization changes: voice tremors and pitch changes Motor activity changes: tremors, facial twitches, and shakiness. Increased muscle tension. Perception and attention changes: Narrowed focus of attention, able to focus but selective inattentive. Learning is slightly impaired Respiratory and circulatory changes: slight increase in respiratory and heart rate Other changes: Mild gastric symptoms (butterflies in the stomach)
What is Wernicke's encephalopathy, --what happens/ what are the symptoms? how is it treated?
Wernicke's Encephalopathy (WE) is a neurological disorder caused by thiamine deficiency (B-1), typically from chronic alcoholism or persistent vomiting, marked by mental confusion, abnormal eye movements, and unsteady gait. Bleeding in the lower section of the brain (including the thalamus and hypothalamus) is what causes the symptoms of WE. Triad of symptoms: ophthalmoplegia (ocular disturbance), ataxia (failure of muscle control in arms/legs) , and confusion Severe mental confusion, and difficulty with muscle coordination Onset considered a medical emergency Treatment: Thiamine administered immediately If treated early, Korsakoff psychosis or Wernicke-Korsakoff Syndrome (WKS) can be avoided.
What is wernick-korsakoff syndrome? It's cause?
Wernicke-Korsakoff Syndrome (WKS): Usually found in alcoholics, WKS is a type of brain disorder caused by a lack of vitamin B-1. The syndrome is two separate conditions that can occur at the same time. It is the combination of Wernicke's encephalopathy and Korsakoff's psychosis.
synergistic effect?
When some drugs are taken together, the effect of either or both drugs is intensified or prolonged.
antagonistic effect?
combine drugs to weaken or inhibit the effect of one of the drugs
Describe primary nursing interventions for suicide.
education, inform public, QPR (Question: any thoughts of suicide; Persuade: persuade them to seek help; Refer: If they need help—Get it NOW! Refer NOW—suicide hotline)
Appropriate Anxiety?
feeling nervous when wanting to impress somebody. Anxiety we all feel
Describe tertiary nursing interventions for suicide.
help the family/friends left behind after person committed suicide or patient who survived suicide attempt. Encourage them to talk about the suicide and their loved one Be aware of guilt or blaming of family members Allow expression/problem-solving: reorganizing family/social structures Discuss both positive and negative aspects of relationship with suicide victim Essential components of the grieving process Utilize support systems (talk them through the denial, anger, bargaining, depression, acceptance)
tolerance?
is a need for higher and higher doses of a substance to achieve the desired effect and/or to prevent withdrawal symptoms.
withdrawal?
occurs after a long period of continued use and signifies a physical dependence. physiological and psychological signs and symptoms associated with stopping.
What are the conditions for violence?
• A perpetrator • A vulnerable individual • A crisis situation
addictive dependence?
refers to a more complex process. Previously, addiction focused on physical "dependence" and "uncomfortable withdrawal."
abuse?
refers to the habitual use of a substance that falls outside of medical necessity or social acceptance and is used for the single purpose of altering one's mood, emotion, or state of consciousness. The abuse of a substance all too often results in adverse effects to the abuser and often to others.
Who are victims of violence?
• Children • Spouse/ Domestic partner • Elderly
What emotions that would be concerning?
sudden or unexpected improvement in mood (made decision to kill themselves)
Threatening Anxiety?
the anxiety we feel when somebody in the car in front of us stops suddenly and we need to react quickly to avoid an accident
Profile of a victim of domestic abuse?
• Low self-esteem • Views relationship as male-dominant • Accept blame for batterers' actions • Feelings of guilt, anger, fear and shame • Isolated from support systems • Grew up in an abusive home • Impaired decision making • Other risk factors...
Secondary considerations when prescribing antidepressants?
• Neurotransmitter specificity • Family history of response • Cost
What would be some nursing interventions? Are nurse's mandatory reporters?
• Physical needs of child • SAFETY!!! #1---child safety • Report • Obligation to report • DOCUMENT -use body map • Teach • Do not try to prove abuse • Do not accuse • Do not be judgmental
Examples of Defense Mechanisms?
• Rationalization -justifying • Regression -moving back to a previous stage • Repression -exclusion with awareness • Denial -rejects fact
Panic Anxiety Adaptations?
• Sense of Impending doom • Terror • Bizarre behavior • Shouting • Screaming • Running about wildly • Clinging to anyone or anything from which a sense of safety and security is derived • Hallucination/ Delusions • Extreme withdrawal
With depression, what neurotransmitters are affected?
• Serotonin • Norepinephrine • Dopamine
Primary considerations when prescribing antidepressants?
• Side effect profile (e.g., sexual dysfunction, weight gain) • Ease of administration • Past response • Safety and medical considerations • Specific depressive symptoms (e.g., anxiety, irritability, hypersomnia, insomnia) • Medical considerations (diabetes, high cholesterol, cardiac disease)
What target symptoms do antidepressants improve?
• Sleep disturbance • Appetite disturbance (decreased or increased) • Fatigue • Decreased sex drive • Psychomotor retardation or agitation • Diurnal variations in mood (often worse in the morning) • Impaired concentration or forgetfulness • Anhedonia (loss of ability to experience joy or pleasure in living)
What are some objective signs of sexual abuse in children?
• Withdrawn behavior • Inappropriate knowledge of sexual behavior • Bleeding and/or bruising of genitalia • Drug abuse and truancy (in adolescents) • Frequent UTI • Regression (thumb sucking or bed wetting)
Nursing interventions for Panic Anxiety?
•#1 = patient safety •Quiet environment •Do not leave patient alone •not a good time to try to educate the patient •Call patient 1st (therapeutic communication) meds are not the 1st line of treatment.
How would you assess someone with depression? -give specifics you would ask about
•Always assess patient's risk of harm to self or others (SUICIDE) •Thorough medical and neurological exams •Assess history of depression (types of therapies they've used and how they worked) •Assess support systems, family and significant others •Assess need for information /referrals •Assess for any events that might have "triggered" a depressive episode (lost job, divorce)
What is depression? What does it affect?
•An alteration in mood that is expressed by feelings of sadness, despair, and pessimism. •Loss of interest in usual activities. •Somatic symptoms may be evident. •Changes in appetite and sleep patterns are common. Depression is a "whole Body" disorder: It affects: Intellectual, Emotional, Physical, Social, Occupational, Environmental, and Spiritual. Depression causes a lot of physical symptoms
How does the naltrexone work?
•Blocks the reaction of alcohol. (Won't get drunk) •Reduces the desired pleasant feeling "High" •Blocks release of endorphins r/t alcohol intake •Blocks drug cravings
What is ECT? How do we prepare patients for this procedure?
•Brief application of electric current to the brain •Induces a seizure •Thought to alter chemical imbalances •70-90% patients demonstrate a (+) response •Used when severe depression is unresponsive to other forms of therapy •Maintenance treatments
What information should be included when teaching a patient about taking disulfiram Antabuse?
•Can start medication 12 hours after last drink •If choosing to drink, wait 14 days after the last dose of Antabuse •Have patient wear a medical alert bracelet •Patient is to avoid: hand sanitizers, tooth paste, mouth wash, cough syrup, or anything with alcohol in the ingredients. •**Read labels carefully**
Describe the honeymoon stage? What does the abuser do in the stage? What about the victim?
•Characterized by kindness and loving behaviors •Perpetrator--feels remorse and is apologetic, may bring presents, flowers, jewelry, candy, makes promises, "It won't happen again, I promise.", tells the victim how much she is loved - "I did it because I love you so much." •Victim believes the promises and drops any legal proceedings •Honeymoon stage will fade away as tension rebuilds •Cycle of violence continues without intervention
Physical signs and symptoms of depression
•Chronic fatigue •Lack of energy •Sleeping too much or too little •Weight gain or loss •Loss of motivation •Substance abuse •Unexplained aches and pain symptoms
1How is depression diagnosed? What are some of the test/labs used to rule out other things?
•Complete blood count (CBC) & Electrolytes •↑Calcium -fatigue, anorexia •↓Potassium -fatigue, muscle weakness •Serum toxicology screen •Thyroid function tests •CT scan or MRI of brain •Electroencephalogram (EEG) •Psychometric tests: self-reporting
What is brain hyperexcitability? What symptoms occur?
•Consumed alcohol enters the bloodstream and affects the neurotransmitters. •Alcohol affects GABA, the inhibitory transmitter, and enhances sedative effect. •Alcohol affects the central nervous system, and acts as a depressant. •Body attempts to compensate for depressant effect =increases excitability of neurons
What are some characteristics of shaken baby syndrome?
•Convulsions •Irritability •Fixed Pupils •Sleepiness/inactivity •Vomiting •Swelling of the head •Pooling of blood in the eyes-Retinal hemorrhages /detachment
Moderate Anxiety Adaptations?
•Defense Mechanisms employed •Adaptive or Maladaptive •Used consciously/unconsciously as a protective device •Are discrete from one another •Are often hallmarks of psychiatric syndromes •Are reversible
What are some different types of depression and explain them.
•Dysthymia •Major Depressive Disorder •Premenstrual Dysphoric Disorder (mood swings, decreased interest doing things wk prior to menses) •Substance/Medication-Induced Depressive Disorder (direct result of the physiological effects of meds) Also associated with the withdrawal from substances—drugs, alcohol, etc. •Depressive Disorder Due to Another Medical Condition (direct consequence of another medical condition)
Severe anxiety adaptations?
•Extended periods of repressed severe anxiety can result in psychoneurotic patterns of behaving--Neurosis •Neuroses-psychiatric disturbances, characterized by excess anxiety o Expressed outwardly or through Defense Mechanisms •Psychoneurotic Responses to Anxiety o Anxiety Disorders o Somatic Symptom Disorder
Thoughts of depression?
•Frequent self-criticism •Impaired memory and concentration •Indecisiveness •Confusion •Thoughts of death and suicide
Predisposing factors for depression?
•Genetic-increase prevalence-genetic predisposition •Biochemical -neurotransmitters •Hormonal -estrogen/progesterone •Medication side effects: Chemo, steroids, anxiolytics, Accutane •Nutritional deficiencies: B1, B6, B12, Fe, Folic Acid •Neurological Disorders -CVA, Alzheimer's, Parkinson's •Physiological Conditions -Lupus, cardiovascular disease, congestive heart failure, MI, Infections, metabolic disorders
Risk factors of elder abuse?
•History of mental illness (within the abuser or the victim) •History of family violence •Shared living arrangement •Dependency on both the victim and abuser •Limited financial resources •Stressful life events on abuser's part •Isolation or poor health or cognitive impairment of the victim.
Treatment options for depression?
•Individual Psychotherapy •Cognitive Behavioral Therapy •Group Therapy •Family Therapy •Medical management of Depression-antidepressants **especially if suicidal--may need other options such as ECT--electro consultant therapy
What nursing interventions need to be done for ECT?
•Informed consent (must be done by MD and confirmed completion by the nurse) •Assessment-Vital signs •Remove dentures •Atropine -Robinul (glycopyrrolate) - to eliminate parasympathetically mediated dysrhythmias. However, such agents increase heart rate and myocardial workload and may increase risk of cardiac adverse events •Teach o Short-term memory loss o Problems learning • Post-treatment o Headache, muscle pain, nausea
Why doesn't the victim leave?
•Love (Loves the abuser) •Hope (hope that the relationship will change) •Fear (Fear that the abuser's threats will become reality) •Some women don't realize that they are being abused. •May have cultural or religious beliefs. Financial problems or feel loyalty to them
What are neurotransmitters and what do they do? Explain the function and how?
•Messengers that travel between one brain cell and another •Chemical signals that neurons use to talk to each other •Help determine how we feel, think and act Dopamine- Involved in cognition, motivation, and movement: Controls the emotional responses in the brains reward and pleasure center--treatment: depression and mood Norepinephrine- The neurons call noradrenergic neurotransmitters. Plays a role in regulating mood--excessive norepinephrine is associated with manic symptoms. Treatment: depression and mood Serotonin- Helps regulate mood, arousal, attention, behavior, and body temperature. Treatment: depression and anxiety 3 neurotransmitters thought to be involved with major depression. Scientist believe there is a chemical imbalance in the neurotransmitters that results in a clinical state of depression.
What happens in the tension building stage? What do the victims try to do?
•Minor incidents •Pushing and shoving •Verbal abuse -yelling, swearing, criticizing •Victim accepts behavior-rationalization •Victim tries to calm abuser •Victim fears more severe abuse •Perpetrator rationalizes abusive behavior is acceptable •May last several weeks -months
What nursing interventions are the nurse's priority concern?
•Patient's safety •Prompt treatment of physical injuries •Thorough exam and assessment to search for other injuries
What are the different types of abuse?
•Physical abuse- Infliction of pain or bodily harm (normally if being physically abused--they are more likely to be emotionally abused too) Potential for long-term physical deformities, potential for internal damage, acute painful tissue damage, bone damage, and even death •Sexual abuse - Any form of sexual contact or exposure without consent or inability to give consent (may escalate into sexual assault or rape) •Emotional abuse- Infliction of mental anguish •Neglect-failure to do something---Types of neglect: physical, developmental, financial, educational, safety
Name 5 characteristics that create a high risk for suicide.
•Psychosis, substance abuse •poor problem-solving skills •impulsive •low threshold for pain place people at high •risk for suicide when overwhelmed
How does Acamprosate work?
•Reduces the bad s/s of abstinence (anxiety, tension, dysphoria-uneasiness) •Cuts down on cravings
Objective signs of depression
•Sad/flat affect--crying •little or no eye contact •monotone voice •poor hygiene--slumped posture •Slow movement & thought processes •Being agitated or unable to settle
Emotional signs of depression?
•Sadness •Anxiety •Guilt •Anger •Mood swings •Feelings of helplessness and hopelessness •Irritability
What interventions could be done for depression?
•Safe environment •Therapeutic relationship •Contract with patient to report suicidal idealizations •Communication (reframe, silence, open-ended) •Referral -SS, spiritual, community services •Education--self-care activities (sleep, exercise) •Pharmacological/medical treatment •*rapport - trust - respect - genuineness - empathy
What interventions can a nurse do for someone with anxiety?
•Safety •Physical needs: fluids, rest, nutrition •Communication: Firm, short and simple statements: Slow low-pitched voice: Reinforce reality •Environment--Quiet, minimal stimulations •Psychosocial: emotion vs. symptoms •Psychotherapy: family, behavioral, cognitive restructuring •Problem solving/coping strategies •Medication teaching
What kind of behavior would we look for that would be concerning?
•Self-destructive: Aggression, Self-Mutilation, Addictions •Verbal clues •Giving away valued possessions •Arrange all their business and personal affairs •Acquiring a gun •Isolation or withdrawal from family
What happens in the acute battering stage? Why is this the most violent stage?
•Shortest and most violent •Perpetrator releases built-up tension by brutal and uncontrollable beatings •Trigger often an external stressor •Uncontrollable degree of destructiveness inflicted on the victim •Severe injuries may occur •Victim may or may not fight back or call for help •Batterer justifies actions •Victim depersonalizes the incident
Examples of causes of anxiety. Biological? Psychological? Social? Physiological factors?
•Stress at work. •Stress from school. •Stress in a personal relationship such as marriage. •Financial stress. •Stress from an emotional trauma such as the death of a loved one. •Stress from a serious medical illness. •Side effect of medication. •Use of an illicit drug, such as cocaine. Biological---Genetic factors Psychological-- How different people react to stressors. Social--What we learn from our environment. (be a good role model for your children) Physiological factors-- Illness or Diseases (terminal disease (cancer), heart disease, high blood pressure, irritable bowel, kidney or liver dysfunction) Irregularities in neurotransmitters--Neurotransmitters are chemical that facilitates the communication between neurons: Can be excitatory (stimulate firing of neuron) or Inhibitory (suppress that neuronal firing). If someone lacks GABA they can suffer from anxiety issues.
What are the stages of the cycle of battering?
•Tension Building (stress builds) •Acute Battering Incident--most violent stage and shortest stage (teaching her a lesson) •"Honeymoon" (victim feels loved and needed) •Cycle repeats (more severe and violent the times it occurs)
What might be the significance of the child's response to the father?
•The increase in crying may indicate she is fearful of her father •Normally, a preschool-aged child calms with the nurturing acts of a parent •Do not arrive at any premature conclusion that is not substantiated with reasonable fact •The child may prefer to be soothed by the mother
What are some nursing interventions? Give examples of what to say to an individual. What to look for?
•Treatment of physical injuries--1st thing (stop bleeding...etc.) •Provide safe environment--keeping abuser out of the room •Documentation-document what they say and what we see. Get consent for photographs •Encourage verbalization--be non-judgmental and build rapport •Provide referral to shelters •Encourage decision-making •Teach •*Safety plan •*Safety signal with neighbor •*Emergency bag •*Phone #s •*Documents •*Exit plan •Even though he is not abusive to the children, the abuse they witness is still harmful to the child •Teach the cycle of abuse--because sometimes she starts to normalize that behavior. IT Isn't normal
Nursing interventions-what do nurse do? Are nurse's mandatory reporters for the elderly?
•Treatment of physical problems**most important •Safety**most important •Documentation: quotes, discrepancies, body map, photos (consent for photos) •Ombudsman—advocate for elder patients in nursing homes (TEACH)
What is tyramine?
•Tyramine is released from proteins in certain foods with fermenting, aging, smoking & pickling •Tyramine is a building block of norepinephrine. •Excessive amounts of norepinephrine can lead to a hypertensive crisis -stroke -cardiac arrhythmia--death •Normally, Tyramine is deactivated by MAO in the gut wall & liver •But... if the patient is taking an MAOI's, the drug will inhibit MAO so that it can't get rid of excess tyramine