Study Guide Exam 1:

Autonomy:

Autonomy: emphasizes the status of persons as autonomous moral agents whose rights to determine their destinies should always be respected.

Acetazolamide (Diamox):

- To prevent AMS, discuss use of acetazolamide (diamox)- is a carbonic anyhydrase inhibitor and it acts by causing a bicarbonate diuresis, which rids the body of excess fluid, and induces metabolic acidosis. The acidotic state increases respiratory rate; It is a sulfa drug so ask about allergy to sulfa before administering Classification- Therapeutic: Anticonvulsants, antiglaucoma agents, diuretics, ocular hypotensive agent Pharmacologic: Carbonic anhydrase inhibitors Indications- Lowering of intraocular pressure in the treatment of glaucoma. Management of acute altitude sickness. Edema due to HF. Adjunct to the treatment of refractory seizures Pharmacokinetics- Absorption: Dose dependent; erratic with doses 10 m g/kg/day. Distribution: Crosses the placenta and blood-brain barrier; enters breast milk. Protein Binding: 95%. Metabolism and Excretion: Excreted mostly unchanged in urine. Contraindications/Precautions Contraindicated in: Hypersensitivity or cross-sensitivity with sulfonamides may occur; Hepatic disease or insufficiency; Use Cautiously In: Chronic respiratory disease; Electrolyte abnormalities; Gout; Renal disease; Diabetes Adverse Reactions/Side Effects CNS: depression, fatigue, weakness GI: anorexia, metallic taste F and E: hyperchloremic acidosis Neuro: paresthesias Interactions Drug-Drug: Excretion of barbiturates, aspirin, and lithium isqand may lead to decreased effectiveness. Route/Dosage: PO (Asults)- Altitude sickness—250 mg 2- 4 times daily started 24- 48 hr before ascent, continued for 48 hr or longer to control symptoms Nursing Implications: Assessment ● Observe for signs of hypokalemia (muscle weakness, malaise, fatigue, ECG changes, vomiting). ● Assess for allergy to sulfonamides. ● Altitude Sickness: Monitor for decrease in severity of symptoms (headache, nausea, vomiting, fatigue, dizziness, drowsiness, shortness of breath). Notify health care professional immediately if neurologic symptoms worsen or if patient becomes more dyspneic and rales or crackles develop.

Assault and Battery:

Assault- An act that results in a person's genuine fear and apprehension that he or she will be touched without consent. Battery- The unconsented touching of another person. - These charges an result when a treatment is administered to a client against his or her wishes and outside of an emergency situation. - Harm or injury need not have occurred for these charges to be legitimate. Examples Include: - Locking an individual in a room - Taking a client's clothes for purposes of detainment against his or her will - Retaining in mechanical restraints a competent voluntary client who demands to be released

Genuineness:

Genuineness: Refers to the nurse's ability to be open, honest, and "real" in interactions with the client. May call for a degree of self-disclosure on the nurse's part.

Burns (ER):

Go by ABC's Airway, Breathing, Circulation, Disabled, Exposure

Involuntary Commitment:

Involuntary hospitalization results in substantial restrictions of the rights of an individual, the admission process is subject to the guaruntee of the 14th amendment to in which "citizens protection against the loss of liberty and ensures due process rights" They are made for various reasons and most states commonly cite the following criteria: 1. In an emergency situation (for the client who is dangerous to self or others) 2. For observation and treatment of mentally ill persons 3. When an individual is unable to take care of basic personal needs ("Gravely disabled")

Feedback:

Method of communication that helps the client consider a modification of behavior. - Feedback should be descriptive rather than evaluative and focused on the behavior rather than the on the client.

Black Widow:

Pathophysiology: - Found in every state except Alaska - Found in cold, damp environments like outdoor log piles, vegetation, and rocks - Carry neurotoxic venom - Hourglass pattern is more prominent on females than males - In most cases, the symptoms do not progress beyond a local reaction in the sea of the bite Assessment: - Venom produces a syndrome known as latrodectism- Veom causes neurotransmitter release from nerve terminals S&S- Severe abdominal pain, muscle rigidity & spasm, hypertension, and N&V are common - Muscle spasms involve the large muscles of abdomen & back - Other problems include: facial edema, ptosis (eyelid dropping), diaphoresis, weakness, increased salivation, respiratory difficulty, and parathesias - Effects of bite generally heal within a few days First Aid/Prehospital Care: - Monitor for evidence of systemic toxicity - Support ABC's - Applying an ice-pack because cold application decreases the action of the neurotoxin. Hospital: - Monitor vitals, especially BP & resp - Opioids and muscle relaxers may be given such as diazepam (Valium) - Provide tetanus - Antivenom is available although it can cause anaphylaxis & serum sickness but its effective in treating severe reactions - Antivenom is also given to pregnant women because they may have uterine contractions

De-Escalation:

Refers to behavior that is intended to escape escalations of conflicts. It may also refer to approaches in conflict resolution. Escalations of commitment are often hard from spiraling out of proportions without specific measures being taken.

Snake Bite:

Snake Bite Prevention: - Do not keep venomous snakes as pets - Be extremely careful in locations where snakes may hide (tall grass, rock piles, ledges and crevices, woodpiles, brush, boxes, and cabinets - Snakes are most active on warm nights - Don protective attire such as boots, heavy pants, and leather gloves - When walking or hiking, use a walking stick or trekking poles - Inspect suspicious areas before placing hands and feet in them - DO NOT harass any snakes you may encounter - Be aware that newly dead or decapitated snakes can inflict a bite for up to an hour after death because f the persistence of the bite reflex - Do not transport the snake with the victim to the medical center for identification purposes, instead take a photo Pit Viper: - A heat-sensing pit - A triangular head that indicates the presence of venom glands and elliptical pupils - Two retractable, curved fangs that have canals for venom flow - Up to three sets of developing "replacement" fangs behind the primary fangs - Pit vipers can regulate the amount of venom through their fangs - Pit viper envenomination can lead to impaired tissue integrity from local tissue necrosis and massive tissue swelling, intravascular fluid shifts & hypovolemic shock, pulmonary edema, renal failure, hemorrhagic complications from disseminated intravascular coagulation (DIC), & death. First Aid/ Pre-Hospital: - Immobilize the affected extremity in a position of function with a splint may help limit the spread of venom - Keep person warm, don't offer alcohol because it can cause the venom to spread through vasodilaton - Do not incise or suck the wound, apply ice to it, or use a tourniquet- these actions are ineffective and can worsen the patient's outcome. Hospital Care: - Supportive care includes supplemental oxygen, two large-bore IV lines, and infusion of crystalloid fluids such as normal saline solution or LR. - Apply continuous cardiac output and BP monitoring - Opioids are given to minimize pain from bite - Provide tetanus prophylaxis - Anticipate obtaining specimens for coagulation profile, CBC, creatinine kinase, & type and crossmatch for possible blood transfusions - Accurately acess the development of tissue edema measure and record Q15 - Contact the regional poison control central so that toxicologists an provide specific advice for antivenom dosing Coral Snake: - Found in Southeastern and Southwestern US - Contain two toxins: a nerve toxin and a muscle toxin - Remember, "Red on yellow can kill a fellow" but "red on black, venom lack" (Only applies to coral snakes in US) - The physiological effect is to block neurotransmission, which produces weakness, cranial nerve deficits (ptosis, diplopia, swallowing difficulty) - the venom is spread via the lymphatic system; swelling is mild - Toxic effects of their venom may be delayed up to 13 hours Early S&S: - N&V - Headache - Pallor - Abdominal Pain Assess for neurological manifests: - Parathesias (Painful Tingling) - Numbness - Mucle fasiculations - Total flaccid paralysis may occur- may have difficulty breathing, speaking, and swallowing. - Clotting disorders do not occur - Muscle toxin in venom can cause an elevation in creatinine kinase level from muscle breakdown and produce myoglobinuria (release of muscle myoglbulin into the urine) First Aid/ Pre-Hospital: - Identify snake first because so many resemble coral snake - Even if snake isn't identified treatment is done - The treatment of choice is to limit the spread of venom by use of pressure immobilization techniques - Extremity is encircled snugly with an elastic bandage or roller gauze to impede lymphatic flow - The bandage shouldn't be removed until the victim is managed at an acute care facility Hospital Care: - Continuous cardiac care, BP, Pulse, and are admitted to critical care - Coral snake antivenom is no longer manufactured in the US because supportive care seems to be most effective

Debriefing Session:

Stand down/Debrief- happens after causality- assess supplies, equipment, medicine, and explores feelings

Biopsychosocial:

The biopsychosocial model is a broad view that attributes disease outcome to the intricate, variable interaction of biological factors, psychological factors, and social factors.

Protected Health Information:

1. Names 2. Postal Address info (Except State) 3. All elements of dates (Except Year) 4. Telephone Numbers 5. Fax Numbers 6. Email 7. SS# 8. Medical Record Number 9. Health Plan Beneficiary Numbers 10. Account Numbers 11. Certificate/License Numbers 12.Vehicle Identifiers & Serial Numbers 13. Device Identifiers & Serial Numbers 14. Web Uniform Resource Locators (URLs) 15. IP Address 16. Biometric Identifiers (Finger & Voice Prints) 17. Full face photographic images 18. Any other unique identifying number, code, etc.

Disaster Medical Assistance Team:

- A DMAT is a group of professional and para-professional medical personnel (supported by a cadre of logistical and administrative staff) designed to provide medical care during a disaster or other event. NDMS recruits personnel for specific vacancies, plans for training opportunities, and coordinates the deployment of the teams. - DMATs are designed to be a rapid-response element to supplement local medical care until other Federal or contract resources can be mobilized, or the situation is resolved. DMATs deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours while providing medical care at a fixed or temporary medical care site. The personnel are activated for a period of two weeks.

CroFab (Crotalidae Polyvalent Immune):

- Contraindicated if the patient is allergic to papaya or papain which is used during the manufacturing process of CroFab Give CroFab cautiously in patients who have: - Previous allergy to antivenom therapy - A hypersensitivity to bromelain (pineapple-derived enzyme) or sheep protein - Prior CroFab therapy for a past envenomation (patients can become sensitized to the foreign sheep protein) - Pregnancy - Sensitivity to mercury-containing products (the antivenom contains mercury) - Should be given to patients ASAP with the optimal timing within 6 hours - If symptoms aren't controlled an additional 4-6 vials may be administered - Once symptoms are controlled 2 more vials are adminsitered every 6 hours for a total of 18 hours - The recommended initial dose is 4-6 vials infused over 1 hour - During the first ten minutes, the infusion should be slow (25-50mL/hr) - Monitor for rash, hives, difficulty breathing

Anxiety:

- Diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness Peplau has described 4 types of anxiety: Mild: Seldom a proble; Associated with tension experienced in response to everday life; Sharpens the senses; Increases motivation for productivity; Learning is enhanced Mechanisms that help with mild anxiety: - Sleeping - Eating - Smoking - Crying - Nail-Biting - Fidgeting - Drinking - Laughing Inappropriately Moderate: Level of anxiety increases; Perceptual field diminishes; Moderately anxious individual is less alert; Attention span and ability to concentrate decreases; Increased muscular tension; Severe: Concentration centers on one particular detail only; Attention span is extremely limited;Physical symptoms include- - Headaches - Palpitations - Insomnia Emotional Symptoms Include- - Confusion - Dread - Horror - Extended periods of repressed severe anxiety can result in psychoneurotic patterns of behaving. Neurosis is no longer considered a separate category of mental disorder Common Characteristics of people with Neuroses: - Aware they are experiencing distress - Aware that their behaviors are maladaptive - Unaware of possible pyschological causes of distress - Feel helpless to change their situation - Experience no loss of contact with reality Panic: Most intense state; Unable to focus on even one detail; Hallucinations or delusions may occur; A feeling of terror may occur as well; Individuals may be convinced they are having a life-threatening illness or fear they are "going crazy"; Leads to physical exhaustion - Individuals with panic anxiety are not capable of processing what is happening & may lose contact with reality Psychosis- A severe mental disorder characterized by gross impairment in reality testing Following are common characteristics of pyschoses: - Exhibit minimal distress (Emotional tone is flat, bland, or inappropriate) - Unaware thei behavior is maladaptive - Unaware of any psychological problems - Exhibiting a flight from reality into a less stressful world or into one in which they are attempting to adapt

Frostbite:

- Main risk is exposure to cold - Wet clothing - Poor insulator First Degree: - Least severe type - Involves increased BF of the involved area and edema formation Second Degree: -Large fluid-filled blisters - Partial-thickness skin necrosis Third Degree: - Appears as small blisters containing fluid - Affeted body pat is cool, numb, blue, and doesn't blanch - Necrosis occurs and debridement is required Fourth Degree: - Most severe - No blisters or edema - Numb, cold, and bloodless - Gangrene develops which may require amputation First Aid/ Prehospital: - Recognition is key Early signs: White, waxy skin for light and dark skin; - Superficial frostbite is managed by body heat Hospital: - For all degrees, rapid rewarming in a water bath at a temp of 104-108F is indicated to thaw the frozen part - Severe pain occurs so opioids are used - When rewarming is complete, handle the injured part carefully and elevate above heart - Do not rub the frostbitten area - compare unaffected to affected area to assess for pallor - Assess pulses and muscle weakness - Frostbite destroys tissue therefore a patient needs a tetanus if the one they have is expired - Apply loose non adherent sterile dressings & avoid compression

Water Safety:

- Observe people who cannot swim and are in or around water - Never swim alone - Test the water depth before diving head-first; and never dive into shallow water - Avoid alcoholic bevarages when swimming and boating - Ensure that the water rescue equipment such as life jackets, flotaton devices, and rope is immediately available when around water

Stress Debriefing:

- Provides a formal systematic review and analysis after an event. Two types of debriefings occur following a mass casualty event or period. • Critical incident stress management programming addresses pre-crisis through post-crisis interventions for small to large groups, including communities. • Critical incident stress debriefing (CISD) teams provide small group sessions for staff to promote effective coping strategies. • A team is composed of two to three specially trained individuals who come together quickly when called to deal with the emotional needs of health team members after a particularly devastating or disturbing incident. • The team leader typically has background in a mental health/behavioral health field. • The second type of debriefing is an administrative function directed at analyzing the hospital or agency response to an event soon afterward. An administrative review of staff and system performance is done to determine opportunities for improvement in the emergency management plan. • The goal of this type of debriefing is to evaluate the implementation of the emergency preparedness plan so that changes can be made. • Representatives from all groups that were involved in the incident come together for discussion.

Proactive nursing actions in an effort to avoid nursing malpractice: "Avoiding Liability"

- Responding to the patient - Educating the patient - Complying with the standard of care - Supervising care - Adhering to the nursing process - Documenting carefully - Following up by evaluating the care that was given

Least-Restrictive Alternative:

- Talking Down (Verbal Intervention) is usually tried to be used first - Second would be chemical such as tranquilizing patient. - Third would be mechanical restraints or seclusion room (Most often avoided)

DSM-5 Criteria for Developing a Mental Illness:

- The psychological factors may exacerbate symptoms of, delay recovery from, or interfere with treatment of the medical condition. The condition may be initiated or exacerbated by an environmental situation that the individual perceives as stressful. Measurable pathophysiology can be demonstrated. It is thought that psychological and behavior factors may affect the course of almost every major category of disease, including, but not limited to, cardiovascular, gastrointestinal, neoplastic, neurological, and pulmonary conditions.

The Health Insurance Portability and Accountability Act:

- Under this law, individuals have the right to access their medical records to have corrections made to their medical records, and to decide with whom their medical information may be shared.

Standards of Psychiatric-Mental Health Clinical Nursing Practice for a Nurse Generalist:

1. Assessment: Psychiatric/Mental health RN collects health data pertinent to patient's health and situation. 2. Diagnosis: Psychiatric/Mental health RN analyzes assessment data to determine diagnoses or problems, including level of risk. 3. Outcomes Identification: Psychiatric/Mental health RN identifies expected outcomes for a plan individualized to the patient or situation. 4. Planning: Psychiatric/Mental health RN develops a plan that prescribes strategies and alternatives to attain expected outcomes. 5. Implementation: Psychiatric/Mental health RN implements the identified plan. - Coordination of Care: Psychiatric/Mental health RN coordinates care delivery - Health Teaching and Health Promotion: Psychiatric/Mental health RN employs strategies to promote health and safe environment. - Milieu Therapy: Psychiatric/Mental health RN provides, structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other health-care clinicians. - Pharmacological, Biological, and Integrative Therapies: Psychiatric/Mental health RN incorporates knowledge of pharmacological, biological, and complementary interventions with applied clinical and complementary interventions with applied clinical skills to restore the patient's health and prevent further disability. - Prescriptive Authority & Treatment: Psychiatric/Mental health RN uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations. - Psychotherapy: Psychiatric/Mental health RN conducts individual, couples, group, and family psychotherapy using evidence-based psychotherapeutic frameworks and nurse-patient therapeutic relationships. - Consultation: Psychiatric/Mental health RN provides consultation to influence the identified plan, enhance the abilities of other clinicians to provide services for patients, and effect change. 6. Evaluation: Psychiatric/Mental health RN evaluates progress toward attainment of expected outcomes.

Arthropod Bites:

Arthropod Bites & Sting Prevention: - Wear protective gloves, including gloves and shoes when working in areas known to harbor venomous arthropods (Bees, Wasps, Scorpions, Spiders) - Cover garbage cans. Bees and wasps are attracted to it - Use screens in windows and doors to prevent flying insects from entering - Inspect clothing, shoes, and gear for insects before putting them on - Shake out clothing and gear that's been on the ground - Consult an exterminator to control arthropod populations in and around the home - Eliminate insects that are part of the arthropods food source - Do not place your hands where you cannot see - Avoid handling insects or keeping them as pets - DO not swat insects, wasps, and africanized bees because they can send chemical signals that alert others to attack - Carry an Epi-pen and antihistamines with you if you are allergic to bee or wasp stings Bees & Wasps: • Potential for anaphylactic reaction • Emergency care to remove stinger and apply ice pack • Advanced emergency hospital care to ensure airway, breathing, circulation • "EpiPen" administration especially valuable for allergic patients • Insect stings can produce a wide range of reactions from discomfort at the sting site to severe pain and life-threatening anaphylaxis in allergic individuals. • Single bee and wasp stings cause local reactions unless the person is allergic to them. Reactions are more severe with multiple stings and may be fatal because venom doses have cumulative toxic effects. • The person who is stung by a bee or wasp first has a local reaction of immediate pain and a wheal-and-flare skin reaction. • Swelling can be extensive and involve an entire limb or body area. Systemic effects can then develop based on the venom load and the person's sensitivity to the venom. • All patients who have sustained multiple stings (particularly more than 50) are observed in an emergency care setting for several hours to monitor for the development of toxic venom effects. • Anaphylaxis is evidenced by respiratory distress with bronchospasm and laryngeal edema, hypotension, deterioration in mental status, and cardiac dysrhythmias. • Epinephrine is the drug of choice for bee and wasp sting allergic reactions, followed by an antihistamine drug. • Teach anyone who develops an allergic reaction to bee or wasp stings to always carry a prescription epinephrine auto-injector and wear a medical alert tag or bracelet.

Behavioral Adaptation Responses to Anxiety:

At the mild level, individuals employ various coping mechanisms to deal with stress. A few of these include eating, drinking, sleeping, physical exercise, smoking, crying, laughing, and talking to persons with whom they feel comfortable. • At the mild to moderate level, the ego calls on defense mechanisms for protection, such as - Compensation - Denial - Displacement - Identification - Intellectualization - Introjection - Isolation - Projection - Rationalization - Reaction formation - Regression - Repression - Sublimation - Suppression - Undoing • Anxiety at the moderate to severe level that remains unresolved over an extended period can contribute to a number of physiological disorders, e.g., migraine headaches, irritable bowel syndrome, and cardiac arrhythmias. • Extended periods of repressed severe anxiety can result in psychoneurotic patterns of behaving, e.g., anxiety disorders and somatoform disorders. • Extended periods of functioning at the panic level of anxiety may result in psychotic behavior. • Examples of psychotic disorders include schizophrenia, schizoaffective disorders, and delusional disorders.

Chlorpheniramine (Phenetron):

Classification Therapeutic: Allergy, cold, and cough remedies, antihistamines Indications- Relief of allergic symptoms caused by histamine release, including: Nasal allergies, Allergic dermatoses. Management of severe allergic or hypersensitivity reactions Action- Antagonizes the effects of histamine at H2-receptor sites; does not bind to or inactivate histamine Pharmacokinetics- Absorption:Well absorbed following oral and parenteral administration. Distribution: Widely distributed. Minimal amounts excreted in breast milk. Crosses the blood-brain barrier. Metabolism and Excretion: Extensively metabolized by the liver. Contraindications/Precautions- Contraindicated in: Hypersensitivity; Acute attacks of asthma Use Cautiously in: Angle-closure glaucoma; Liver disease Adverse Reactions/Side Effects- CNS: drowsiness EENT: blurred vision CV: hypertension Interactions- Drug-Drug: Increases CNS depression with other CNS depressants, including alcohol, opioid analgesics, and sedative/hypnotic Route/Dosage: PO (Adults): 4 mg q 4- 6 hr or 8- 12 mg of extended-release formulation q 8- 12 hr (not to exceed 24 mg/day). Subcut, IM, IV (Adults): 5- 40-mg single dose (not to exceed 40 mg/day). Nursing Implications: Assessment- ● Assess allergy symptoms (rhinitis, conjunctivitis, hives) prior to and periodically during therapy. ● Monitor pulse and BP before initiating and throughout IV therapy. ● Geri: Assess for adverse anticholinergic effects

Diphenhydramine (Benadryl):

Classification Therapeutic: Allergy, cold, and cough remedies, antihistamines, antitussives Indications- Relief of allergic symptoms caused by histamine release including: Anaphylaxis, Seasonal and perennial allergic rhinitis, Allergic dermatoses Action- Antagonizes the effects of histamine at H1-receptor sites; does not bind to or inactivate histamine. Significant CNS depressant and anticholinergic properties Pharmacokinetics- Absorption: Well absorbed after oral or IM administration but 40- 60% of an oral dose reaches systemic circulation due to first-pass metabolism. Distribution:Widely distributed. Crosses the placenta; enters breast milk. Metabolism and Excretion: 95% metabolized by the liver. Contraindications/Precautions- Contraindicated in: Hypersensitivity; Acute attacks of asthma Use Cautiously in: Severe liver disease; Angle-closure glaucoma; Seizure disorders; Prostatic hyperplasia; Adverse Reactions/Side Effects CNS: drowsiness GI: Anorexia, Dry Mouth Route/Dosage: IM, IV (Adults): 25- 50 mg q 4 hr as needed (may need up to 100-mg dose, not to exceed 400 mg/day). PO (Adults and Children 12 yr): Antihistaminic/antiemetic/antivertiginic—25- 50 mg q 4- 6 hr, not to exceed 300 mg/day. Nursing Implications: Assessment- ● Diphenhydramine has multiple uses. Determine why the medication was ordered and assess symptoms that apply to the individual patient. ● Prevention and Treatment of Anaphylaxis: Assess for urticaria and for patency of airway. ● Allergic Rhinitis: Assess degree of nasal stuffiness, rhinorrhea, and sneezing

Lorazepam (Ativan)

Classification- Therapeutic: Anesthetic adjuncts, antianxiety agents, sedative/hypnotics Pharmacologic: Benzodiazepines Indications- Anxiety disorder (oral). Preoperative sedation (injection). Decreases preoperative anxiety and provides amnesia. Action- Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter Pharmacokinetics- Absorption: Well absorbed following oral administration. Rapidly and completely absorbed following IM administration. Sublingual absorption is more rapid than oral and is similar to IM. Distribution: Widely distributed. Crosses the blood-brain barrier. Crosses the placenta; enters breast milk. Metabolism and Excretion: Highly metabolized by the liver Contraindications/Precautions- Contraindicated in: Hypersensitivity; Cross-sensitivity with other benzodiazepines may exist; Comatose patients or those with pre-existing CNS depression Use Cautiously in: Severe hepatic/renal/pulmonary impairment; Myasthenia gravis; Depression; Psychosis Adverse Reactions/Side Effects CNS: dizziness, drowsiness, lethargy Interactions- Drug-Drug: Additive CNS depression with other CNS depressants including alcohol, antihistamines, antidepressants, opioid analgesics Route/Dosage PO (Adults): Anxiety—1- 3 mg 2- 3 times daily (up to 10 mg/day). Insomnia— 2- 4 mg at bedtime Nursing Implications: Assessment ● Conduct regular assessment of continued need for treatment

Dexamethasone (Dexpak)

Classification- Therapeutic: Anti-inflammatories (steroidal) Indications- Used systemically and locally in a wide variety of chronic diseases including: Inflammatory, Allergic, Hematologic, Endocrine Action- In pharmacologic doses, suppresses inflammation and the normal immune response. Has numerous intense metabolic effects Pharmacokinetics- Absorption: Well absorbed after oral administration. Sodium phosphate salt is rapidly absorbed after IM administration. Absorption from local sites (intra-articular, intralesional) is slow but complete. Distribution: Widely distributed, crosses the placenta, and appears to enter breast milk. Metabolism and Excretion:Mostly metabolized by the liver. Contraindications/Precautions- Contraindicated in: Active untreated infections (may be used in patients being treated for tuberculous meningitis); Use Cautiously in: Chronic treatment (will lead to adrenal suppression; use lowest possible dose for shortest period of time); Stress (surgery, infections) Adverse Reactions/Side Effects: CNS: depression, euphoria, CV: hypertension Derm: acne,pwound healing, ecchymoses, hirsutism, petechiae. Interactions- Drug-Drug: increased risk of hypokalemia with thiazide and loop diuretics, amphotericin B, piperacillin, orticarcillin. Hypokalemia mayqrisk of digoxin toxicity. Route/Dosage- PO, IM, IV (Adults): Airway edema or extubation—0.5- 2 mg/kg/day divided q 6 hr; begin 24 hr prior to extubation and continue for 24 hr post-extubation. Nursing Implications: ● Monitor intake and output ratios and daily weights. Observe patient for peripheral edema, steady weight gain, rales/crackles, or dyspnea

Nifedepine (Procardia)

Classification- Therapeutic: Antianginals, antihypertensives Pharmacologic: Calcium channel blockers Indications- Management of: Hypertension (extended-release only), Angina pectoris, Vasospastic (Prinzmetal's) angina Action- Inhibits calcium transport into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction Pharmacokinetics- Absorption: Well absorbed after oral administration, but large amounts are rapidly metabolized (primarily by CYP3A4 enzyme system), resulting in decreased bioavailability (45- 70%); bioavailability is increased (80%) with long-acting (CC, PA, XL) forms. Distribution: Unknown. Protein Binding: 92- 98%. Metabolism and Excretion:Mostly metabolized by the liver. Contraindications/Precautions Contraindicated in: Hypersensitivity; Sick sinus syndrome; 2nd- or 3rd-degree AV block (unless an artificial pacemaker is in place); Use Cautiously in:Severe hepatic impairment ( decreased dose recommended); History of porphyria; Severe renal impairment Adverse Reactions/Side Effects- CNS: headache CV: Arrhythmia, HF, Peripheral Edema Derm: flushing Interactions- Drug-Drug: Rifampin,rifabutin, phenobarbital, phenytoin, orcarbamazepine may significantly decrease levels and effects Nursing Implications: Assessment ● Monitor BP and pulse before therapy, during dose titration, and periodically during therapy.Monitor ECG periodically during prolonged therapy. ● Monitor intake and output ratios and daily weight & for skin rashes

Diazepam (Valium):

Classification- Therapeutic: antianxiety agents, anticonvulsants, sedative/hypnotics, skeletal muscle relaxants (centrally acting) Pharmacologic: benzodiazepines Indications: Adjunct in the management of: Anxiety Disorder, Athetosis, Anxiety relief prior to cardioversion (injection), Stiffman Syndrome, Preoperative sedation, Conscious sedation (provides light anesthesia and anterograde amnesia). Treatment of status epilepticus/uncontrolled seizures (injection). Skeletal muscle relaxant. Pharmacokinetics: Absorption: Rapidly absorbed from the GI tract. Absorption from IM sites may be slow and unpredictable. Well absorbed (90%) from rectal mucosa. Distribution: Widely distributed. Crosses the blood-brain barrier. Crosses the placenta; enters breast milk. Metabolism and Excretion: Highly metabolized by the hepatic P450 enzymes. Interactions Drug-Drug: Alcohol, antidepressants, antihistamines, and opioid analgesics. kava-kava, valerian, or chamomile can increase CNS depression Contraindications/SE: Use Cautiously in: Severe renal impairment; History of suicide attempt or drug dependence; Debilitated patients Adverse Reactions/Side Effects CNS: dizziness, drowsiness, lethargy RESP: Respiratory Depression Dosage: Antianxiety- PO (Adults): 2- 10 mg 2- 4 times daily. IM, IV (Adults): 2- 10 mg, may repeat in 3- 4 hr as needed. Skeletal Muscle Relaxation- PO (Adults): 2- 10 mg 3- 4 times daily. PO (Geriatric Patients or Debilitated Patients): 2- 2.5 mg 1- 2 times daily initially IM, IV (Adults): 5- 10 mg; may repeat in 2- 4 hr (larger doses may be required for tetanus). IM, IV (Geriatric Patients or Debilitated Patients): 2- 5 mg; may repeat in 2- 4 hr (larger doses may be required for tetanus). NURSINGIMPLICATIONS Assessment ● Monitor BP, pulse, and respiratory rate prior to and periodically throughout therapy and frequently during IV therapy.

Fluphenazine Decanoate:

Classification: Therapeutic: Antipsychotics Pharmacologic: Phenothiazines Indications- Acute and chronic psychoses. Action- Alters the effects of dopamine in the CNS Pharmacokinetics- Absorption: Well absorbed after PO/IM administration; salt in sesame oil has delayed onset Distribution: Widely distributed. Crosses the blood-brain barrier. Crosses the placenta; enters breast milk. Metabolism/Excretion: Highly metabolized by the liver; undergo enterohepatic recirculation Contraindications/Precautions- Contraindicated in: Hypersensitivity; Cross-sensitivity with other phenothiazines may exist; Use Cautiously in: Cardiovascular disease; Parkinson's disease; Angle-closure glaucoma; Myasthenia gravis; Adverse Reactions/Side Effects CNS: Neuroleptic Malignant Syndrome, Extrapyramidal reactions DERM: Photosensitivity Hemat: Agranulocytosis Interactions Drug-Drug: Concurrent use with drugs that prolong the QT interval, including antiarrhythmics, pimozide, erythromycin, clarithromycin, fluoroquinolones, methadone, and tricyclic antidepressants may increase the risk for arrhythmias; Route/Dosage Fluphenazine Decanoate IM (Adults): 12.5- 25 mg initially; may be repeated q 3 wk. Dose may be slowly increase as needed (not to exceed 100 mg/dose). Nursing Implications: Assessment ● Assess mental status (orientation, mood, behavior) before and periodically during therapy. ● Monitor BP (sitting, standing, lying), ECG, pulse, and respiratory rate before and frequently during the period of dose adjustment.

Nursing Outcomes:

Comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions.

Mass Casualty:

Mass casualty: - Local medical capabilities overwhelmed - May require collaboration of multiple agencies and health care facilities to handle crisis • The main difference between multi-casualty event and mass casualty (disaster) event is based upon the scope and scale of the incident and the number and severity of victims or casualties. • For all mass casualty events, the goal of emergency preparedness is to define ways to meet the extraordinary need for hospital beds, staff, drugs, personal protective equipment, supplies, and medical devices, such as mechanical ventilators.

Ego Defense Mechanisms:

Denial Definition: Refusing to acknowledge the existence of a real situation or the feelings associated with it. Example: A woman drinks alcohol every day and cannot stop, failing to acknowledge that she has a problem. Displacement Definition: The transfer of feelings from one target to another that is considered less threatening or that is neutral. Example: A client is angry at his doctor, does not express it, but becomes verbally abusive with the nurse. Identification Definition: An attempt to increase self-worth by acquiring certain attributes and characteristics of an individual one admires. Example: A teen-aged boy who required lengthy rehabilitation after an accident decides to become a physical therapist as a result of his experiences. Sublimation Definition: Rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive. Example: A mother whose son was killed by a drunk driver channels her anger and energy into being the president of the local chapter of Mothers Against Drink Drivers Rationalization Definition: Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors. Example: John tells the rehab nurse, "I drink because it's my way I can deal with my bad marriage and my worse job." Compensation Definition: Covering up a real or perceived weakness by emphasizing a trait one considers more desirable. Example: A physically handicapped boy is unable to participate in football, so he compensate by becoming a great scholar. Reaction Formation Definition: Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors. Example: Jane hates nursing. She attended nursing school to please her parents. During career day, she speaks to prospective students about the excellence of nursing as a career. Regression Definition: Responding to stress by retreating to an earlier level of development and the comfort measures associated with that level of functioning. Example: When 2-year-old Jay is hospitalized for tonsillitis he will drink only from a bottle, although his mother states he has been drinking from a cup for 6 months. Intellectualization Definition: An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning,and analysis. Example: Susan's husband is being transferred to his job to a city far away from her parents. She hides anxiety by explaining to her parents the advantages associated with the move. Introjection Definition: Integrating the beliefs and values of another individual into one's own ego structure Example: Children integrate their parents' value system into the process of conscience formation. A child says to a friend, "Don't cheat. It's wrong." Isolation Definition: Separating a thought or memory from the feeling tone or emotion associated with it. Example: Without showing any emotion, a young woman describes being attacked and raped. Projection Definition: Attributing feelings or impulses unacceptable to one's self to another Example: Sue feels a strong sexual attraction to her track coach and tells her friend, "He's coming on to me!" Repression Definition: Involuntarily blocking unpleasant feelings and experiences from one's awareness Example: An accident victim can remember nothing about the accident. Suppression Definition: The voluntary blocking of unpleasant feelings and experiences from one's awareness. Example: Scarlett O'Hara says, "I don't want to think about that now. I'll think about that tomorrow." Undoing Definition: Symbolically negating or canceling out an experience that one finds intolerable. Example: Joe is nervous about his new job yells at his wife. On his way home he stops and buys her some flowers.

Psychiatric Emergency Crisis:

Describe four phases in the development of a crisis: Phase 1: Individual is exposed to a precipitating stressor. - Anxiety increases; previous problem-solving techniques are employed. Phase 2: When previous problem-solving techniques do not relieve the stressor, anxiety increases further. - Individual feels great discomfort & coping mechanisms no longer work & helplessness prevails. Phase 3: All possible, both internal and external, are called on to resolve the problem and relieve the discomfort. - Individual may try to vie the problem from a different perspective or even to overlook certain aspects of it. Phase 4: If resolution does not occur in previous phases, Caplan states that "the tension mounts beyond further threshold or its burden increases over time to a breaking point. Major disorganization of the individual with drastic results often occurs. - Anxiety may reach panic levels. Cognitive functions are disordered, emotions are labile, and behavior may reflect the presence of psychotic thinking. 1Identify types of crises that occur in people's lives: Dispositional crisis: an acute response to an external situational stressor Crisis of anticipated life transitions: normal life-cycle transition that may be anticipated but over which the individual may feel a lack of control Crisis resulting from traumatic stress: precipitated by an unexpected, external stressor over which the individual has little or no control and from which he or she feels emotionally overwhelmed and defeated Maturational/developmental crisis: occurs in response to a situation that triggers emotions related to unresolved conflicts in one's life Crisis reflecting psychopathology: an emotional crisis in which preexisting psychopathology has been instrumental in precipitating the crisis or in which psychopathology significantly impairs or complicates adaptive resolution Psychiatric emergency: a crisis situation in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility

Scorpion:

Pathophysiology: - Found in many states in the US - Inject venom through tail - Potentially fatal systemic response from bark scorpion Assessment: - Venom is neurotoxic so symptoms can result from cranial nerve and/or skeletal muscle involvement - Severe systemic manifestations such as excessive salivation, hyperactivity, higher fever, hypertension, GI disorders, tachycardia, pulmonary edema, and nervous system involvement - Symptoms begin immediately and can become fatal within 12 hours - Pain and parathesias can remain for up to 2 weeks Hospital: - First priority is vitals and continuous monitoring for several hours - Provide O2 and IV fluid replacement - Appy ice pack to the sting to control pain - Give analgesics and sedative agents with caution in the nonintubated - Potent opioids, benzos, and barbitruates can cause loss of airway reflexes - Contact poison control asap to assist with patient management

Hypothermia:

What are patients with severe hypothermia at risk for? - Cardiac arrest so avoid using external rewarming with heating devices because it is dangerous and contraindicated. • Occurs at core body temp <95º F (35º C) Categories by severity: - Mild: 90-97º F (32-36º C) - Moderate: 82-90º F (28-32º C) - Severe: Below 82º F (<28º C) Common causes: - Cold water immersion - Acute illness - Traumatic injury - Shock states - Immobilization - Cold weather (homeless & outdoor workers) - Advanced age - Selected meds (phenothiazines, barbitruates) - Alcohol intoxication - Malnutrition - Hypothyroidism - Inadequate clothing Key Features: Mild: - Shivering - Dysarthria (Slurred Speech) - Decreased Muscle Coordination - Impaired cognition (Mental Slowness) - Diuresis (Shunting of blood to major organs) Moderate: - Muscle Weakness - Increased loss of coordination - Acute confusion - Apathy - Incoherence - Possible stupor - Decreased clotting (Caused by impaired platelet aggregation and thrombocytopenia) Severe: - Bradycardia - Severe hypotension - Decreased respiratory rate - Cardiac arrhythmias (Possible ventricular Fibrillation or Asystole) - Decreased neuro reflexes - Decreased pain responsiveness - Acid-base imbalance First Aid/ Pre-hopsital Care: - Pt needs to be sheltered - Undergo passive and external rewarming - Have victim drink warm high-carb liquids - If heating blanket is used monitor skin every 15-30 min Hospital Care: • Prevent ventricular fibrillation • Horizontal position • Maintenance of ABCs • After-drop: Continued decrease in body temp atfer the victim is removed from environment, caused by return of blood from the periphery to the central circulation • Extracorporeal rewarming methods - Remember that drugs accumulate without obvious therapeutic effect and potentionally led to drug toxicity as effective rewarming is underway - Consider withholding IV drugs except vasopressors until core temp is above 86F - If they are in ventricular fibrillation or pulseless ventricular tachycardia- one defibrillation attempt is appropriate - Defibrillation may be ineffective unil the core temp is 86F • Core rewarming methods for moderate hypothermia include administration of warm IV fluids, heated oxygen or inspired gas to prevent further heat loss via the respiratory tract, and heated peritoneal, pleural, gastric, or bladder lavage. • Avoid using active external rewarming with heating devices because it is dangerous and contraindicated due to rapid vasodilation. • The patient who is severely hypothermic is at high risk of cardiac arrest. The treatment of choice is extracorporeal rewarming methods such as cardiopulmonary bypass, hemodialysis, or continuous arteriovenous rewarming.

Brown Recluse:

Pathophysiology: - Aka "Fiddleback" & "Violin Spider" - Medium sized and light brown - Shy and hide in areas that are dark and secluded (boxes, basements, sheds, garage) - The only evidence left may be impaired tissue integrity from a skin lesion or a necrotic wound - Systemic effects from the injected toxin, commonly referred to as loxoscelism Assessment: - Cause cell damage - Painless or stinging when bitten - The center of the bite becomes bluish-purple - Eschar eventually forms - Tissue integrity is impaired by an open wound or ulcer that can remain for weeks or months - Some may develop rash, fever, chills, n&v, malaise, and joint pain. - In worst cases, hemolytc reaction, pulmonary edema, cardiovascular collapse, and death can occur Intervention: - Apply cold compress (Cold helps decrease the enzyme activity of the venom and may limit tissue swelling and necrosis - Topical antiseptic and sterile dressings are necessary - Tetanus prophylaxis - Debridement may be needed as well as skin grafting Some patents develop loxoscelism: Manifestations include: - Fever and Chills - N&V - Renal Failure - Hemolytic Anemia (Destruction of RBC) - Thrombocytopenia (Low platelets) - Disseminated Intravascular Coagulation - Death

Stages of Grief:

Kubler-Ross Stages of Grief: Denial- Stage of shock and disbelief - Response may be "No, this can't be true"; - Protective mechanism that allows individual to cope Anger- Stage where they question, "Why me?" and "It's not fair!" - Envy and resentment towards those unaffected occur - Anger may be directed at family, friends or even God Bargaining- Stage where they bargain and say things like, "God, I promise I will go to church every Sunday if you help me or bring said lost thing back." - Usually not visible to others, as the individual makes promise to oneself and God - Sometimes the promise is associated with one's own guilt for not having helped Depression- Stage where the impact of the loss is fully experienced. - Sadness and depression prevail - This stage differs from pathological depression in that is represents advancement toward resolution than fixation Acceptance- Stage that brigs a feeling of peace - It is a time of quiet expectation and resignation - Focus is on reality of the loss Maladaptive Grief Responses: Prolonged response: - Characterized by an intense preoccupation with memories of the lost entity for many years after the loss; - Behaviors associated with the stages of denial or anger are manifested, and disorganization of functioning and intense emotional pain Delayed/inhibited response: - Individual becomes fixed in the denial stage or the grieving process. - Emotional pain associated with the loss is not experienced; but anxiety disorders may be evident (Phobias, Somatic Symptom Disorders, Insomnia, Anorexia) - May remain in denial for years until triggered Distorted response: - Individual is fixed in the anger stage of grieving - All normal behaviors of grieving such as helplessness, hopelessness, sadness, and guilt are exaggerated

Stress:

Mental Health: is defined as "The successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms." Mental Illness: is defined as "Maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and interfere with the individual's social, occupational, or physical functioning." Physical and Psychological Responses to Stress: Physical Responses: • Hans Selye defined stress as "the state manifested by a specific syndrome which consists of all the nonspecifically induced changes within a biologic system." • "Fight-or-flight" syndrome Selye's General Adaptation Syndrome: 1. Alarm reaction stage- Beginning of "fight or flight" 2. Stage of resistance- Person tries to adapt to the stressor; if adaptation occurs then the third stage is prevented or delayed. Physiological symptoms may occur. 3. Stage of exhaustion- Occurs when the person is exposed to the stressor for a prolonged exposure. The adaptive energy is depleted, and the individual can no longer regain energy. (Diseases of adaptation- Headaches, Mental Disorders, Coronary Artery Disease, Ulcers, Colitis) • Anxiety and grief have been described as two major, primary psychological response patterns to stress. • A variety of thoughts, feelings, and behaviors are associated with each of these response patterns. • Adaptation is determined by the extent to which the thoughts, feelings, and behaviors interfere with an individual's functioning.

Anaphylaxis:

Pathophysiology: - Stings can produce an array of symptoms - Bumblebees, Hornets, and Wasps are capable of stinging repeatedly when disturbed - Honeybees can only sting once - Africanized bees are known as "Killer Bees" as they travel in swarms and chase their victims - Try to outrun and don't try to go underwater as they will wait until you come up for air - Keep mouth and eyes covered if possible Assessment: - Local wheal-and-flare skin reaction and pain - Systemic effects can then develop based on sensitivity Venom effects: - Generalized Edema - N&V - Diarrhea - Destruction of red and white blood cells & platelets - Damage to blood vessel walls - Acute kidney injury - Renal Failure - Live rinjury - Multi-organ system failure First Aid/ Prehospital: - Quick removal of stinger (Tweezers is best) - Determine allergy to bees/wasps - Inject with Epi and then antihistamine - Call 911 to transport patient Hospital: - Advanced life support - O2 administration is needed - Cardiac and BP monitoring - If epi fails IM, give to patient with IV bolus slowly - Bronchospasm will be treated with albuterol - Toxin in venom may outlast the initial doses and pt may need repeated doses for hours or days

Orientation:

Phases of a Therapeutic Nurse-Client Relationship: Pre-interaction phase: • Obtain information about the client from chart, significant others, or other health team members • Examine one's own feelings, fears, and anxieties about working with a particular client Orientation (introductory) phase: • Create an environment for trust and rapport • Establish contract for intervention • Gather assessment data • Identify client's strengths and limitations • Formulate nursing diagnoses • Set mutually agreeable goals • Develop a realistic plan of action • Explore feelings of both client and nurse Working phase: • Maintain trust and rapport • Promote client's insight and perception of reality • Use problem-solving model to work toward achievement of established goals • Overcome resistance behaviors • Continuously evaluate progress toward goal attainment - Transference: occurs when the client unconsciously displaces (or "transfers") to the nurse feelings formed toward a person from the past - Countertransference: refers to the nurse's behavioral and emotional response to the client Termination phase: • Therapeutic conclusion of relationship occurs when - Progress has been made toward attainment of the goals - A plan of action for more adaptive coping with future stressful situations has been established - Feelings about termination of the relationship are recognized and explored

Roberts' Seven-Stage Crisis Intervention Model:

Roberts' Seven-Stage Intervention Model- Stage & Intervention Stage I: Psychosocial and Lethally Assessment - Conduct rapid biopsychosocial assessment Stage II: Rapidly Establish Rapport - Counselor uses genuineness, respect, and unconditional acceptance to establish rapport with the client - Skill such as good eye contact, nonjudgmental attitude, flexibility, and maintaining a positive mental attitude are important. Stage III: Identify the major problems or crisis precipitants - Identify precipitating event that led client to seek help at present time - Identify other situations that led up to the precipitating event - Prioritize major problems with which the client needs help - Discuss the client's current style of coping, and offer assistance in areas where modification would be helpful in resolving the present chaos future crises Stage IV: Deal with feelings and emotions - Encourage client to vent feelings. Provide validation. - Use therapeutic communication techniques to help the client explain his or her story about current crisis situation - Eventually, and cautiously, begin to challenge maladaptive beliefs and behaviors, and help the client adopt more rational and adaptive options. Stage V: Generate and explore alternatives - Collaboratively explore options with client - Identify coping strategies that have been successful for the client in the past - Help the client problem-solve strategies for confronting current crisis adaptively. Stage VI: Implement and action plan - There is a shift at this stage from crisis to resolution - Develop a concrete plan of action to deal directly with the current crisis - Having concrete plan restores the client's equilibrium and psychological balance - Work through the meaning of the event that precipitated the crisis. How could it have been prevented? What responses may have aggravated the situation? Stage VII: Follow-Up - Plan a follow-up visit with the client to evaluate the post-crisis of the client - Beneficial scheduling of follow-up visits include 1-month and 1-year anniversaries of the crisis event.

Crisis Communication:

The goal of a crisis intervention is the resolution of the immediate crisis. Its focus is on the supportive, with the restoration of the individual to his pre-crisis level of functioning or possibly to a higher level of functioning. The therapist's role is direct, supportive, and that of an active participant. Identify the role of the nurse in crisis intervention: Nurses respond to crisis situations on a daily basis. Crises can occur on every unit in the general hospital, in the home setting, the community health-care setting, schools, offices, and in private practice. Nurses may be called on as crisis helpers. Apply the nursing process to clients' experiencing crises: Assessment: - Asking pt. to describe the event - Determine when it occurred - Assess individual's physical and mental status - Determine if the individual has experienced this stressor before. If so, what coping methods were used? - Assess suicide/homicidal ideations - Assess adequacy of support systems Nursing Diagnoses that may be used: - Ineffective Coping - Anxiety (Severe-Panic) - Risk for self- or other-directed violence - Rape-trauma syndrome - Post-Trauma syndrome - Fear Planning: - Nurse selects appropriate nursing actions for the identified nursing diagnoses. -Resources for support are identified Intervention: - Actions emphasized in phase 2 are implemented Interventions that are the focus of nursing in crisis intervention: - Use reality-oriented approach. Focus of the problem is on the here and now - Remain with individual - Establish a rapid working relationship by showing unconditional acceptance, by active listening, and by attending to needs - Set firm limits on aggressive, destructive behaviors - Clarify the problem that the individual is facing - Help the individual determine what he or she believes Evaluation of Crisis Resolution and Anticipatory Planning: To evaluate outcome of crisis intervention, a reassessment is made to determine: - Have positive behavior changes occurred - Has the individual developed more adaptive coping strategies - Has the individual grown from the experience by gaining insight

Therapeutic Communication:

Therapeutic Communication Techniques: Using Silence- Give client opportunity to collect and organize thoughts, to think through a point, or to consider introducing a topic of greater concern Accepting- Conveys an attitude of reception and regard Giving Recognition- Acknowledging and indicating awareness; better than complimenting Offering Self- Making oneself available on an unconditional basis; increasing client's feeling of self-worth Giving Broad Openings- Allows client to take the initiative in introducing the topic; Emphasizes the importance of the client's role in he interaction Offering General Leads- Offers the client to continue Placing the Event in Time or Sequence- Clarifies the relationship of events in time so that the nurse and client can view them in perspective Making Observations- Verbalizing what is observed or perceived; This encourages the client to recognize specific behaviors and compare perceptions with nurse Encouraging Description of Perceptions- Asking the client to verbalize what is being perceived; often used with clients experiencing hallucinations Encouraging Comparison- Asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships. This helps the client recognize life experiences that tend to recur as well as those aspects of life that are changeable Restating- Repeating the main idea of what the client has said. This lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue, or to clarify if necessary. Reflecting- Questions and feelings are referred back to the client so that they may be recognized and accepted, and so that the client may recognize that his or her point of view has value- a good technique to use when the client asks the nurse for advice. Focusing- Taking notice of a single idea or even a single word; works especially well with a client who is moving rapidly from one thought to another. This technique is NOT therapeutic, however, with the client who is very anxious. Focus should not be pursued until the anxiety level has subsided. Exploring- Delving further into a subject, idea, experience, or relationship; especially helpful with clients who tend to remain on a superficial level of communication. However, if the client chooses not to disclose further info, the nurse should refrain from pushing into an area that obviously causes discomfort. Seeking Clarification & Validation- Striving to explain that which is vague or incomprehensible ans searching for mutual understanding. Clarifying the meaning of what has been said facilitates and increases understanding. Presenting Reality- When the client has a misperception of the environment, the nurse defines reality or indicates his or her perception of the situation for the client. Voicing Doubt- Expressing uncertainty as to the realty of the client's perceptions; often used with clients experiencing delusional thinking. Verbalizing the Implied- Putting into words what the client has only implied or said indirectly; can also be used with the client who is mute or is otherwise experiencing impaired verbal communication. Attempting to Translate Words into Feelings- When feelings are expressed indirectly, the nurse tries to "desymbolize" what has been said and to find clues to the underlying true feelings Formulating a Plan of Action- When a client has a plan in mind for dealing with what is considered to be stressful, it may serve to prevent anger from escalating Nontherapeutic Verbal Communication Techniques: Giving Reassurance- Indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings; may discourage the client from further expression or feelings if he or she believes they will only be downplayed or ridiculed. Rejecting- Refusing to consider or showing contempt for the client's ideas or behavior. This may cause the client to discontinue interaction with the nurse for fear of further rejection. Approving or Disapproving- Sanctioning or denouncing the client's ideas or behavior; implies that the nurse has the right to pass judgment on whether the client's ideas or behaviors are "good" or "bad," and that the client is expected to please the nurse. The nurse's acceptance of the client is then seen as conditional depending on the client's behavior. Agreeing or Disagreeing- Indicating accord with or opposition to the client's ideas or opinions; implies that the nurse has the right to pass judgment on whether the client's ideas o opinions are "right" or "wrong." Agreement prevents the client from later modifying his or her point of view without admitting error. Disagreement implies accuracy, provoking the need for defensiveness on the part of the client. Giving Advice- Telling the client what to do or how to behave implies that the nurse knows what is best and that the client is incapable of any self-direction. It nurtures the client in the dependent role by discouraging independent thinking. Probing-Persistent questioning of the client; pushing for answers to issues that the client does not wish to discuss. This causes the client to feel used and values only for what is shared with the nurse and places the client on the defensive. Defending- Attempting to protect someone of something from verbal attack. TO defend what the client has criticized is to imply that he or she has no right to express ideas, opinions, or feelings. Defending does not change the client's feelings and may cause the client to think the nurse is taking sides against the client. Requesting an Explanation- Asking the client to provide the reasons for thoughts, feelings, behaviors, and events. Asking "Why" a client did something or feels a certain way can be very intimidating, and implies that the client must defend his or her behavior or feelings. Indicating the Existence of an External Source of Power- Attributing the source of thoughts, feelings, and behaviors to others or to outside influences. This encourages the client to project blame for his or her thoughts or behaviors on others rather than accepting the responsibility. Belittling Feelings Expressed- When the nurse misjudges the degree of the client's discomfort, a lack of empathy and understanding may be conveyed. The nurse may tell the client to "perk up" or "snap out of it." This causes the client to feel insignificant or unimportant. When one is experiencing discomfort, it is no relief to hear that others are or have been in similar situations. Making Stereotyped Comments- Cliches and trite expressions are meaningless in a nurse-client relationship. When the nurse makes empty conversation, it encourages a like response from the client. Using Denial- Denying that a problem exists blocks discussion with the client and avoids helping the client identify and explore areas of difficulty. Interpreting- With this technique the therapist seeks to make conscious that which is unconscious, to tell the client the meaning of his or her experience. Introducing an Unrelated Topic- Changing the subject causes the nurse to take over the direction of the discussion. This may occur in order to get to something that the nurse wants to discuss with the client or to get away from a topic that he or she would prefer not to discuss. Non-verbal behaviors: S: Sit squarely facing client O: Observe an open posture L: Lean forward toward client E: Establish eye contact R: Relax

Transference:

Transference: occurs when the client unconsciously displaces (or "transfers") to the nurse feelings formed toward a person from the past

Altitude-Related Illnesses:

• Also known as high altitude disease (HAD) • Acclimatization • Acute mountain sickness (AMS) • High altitude cerebral edema (HACE)- Key sign is ataxia (defective muscle coordination) • High altitude pulmonary edema (HAPE) First Aid/ Pre-Hospital: - Most important intervention is descent to lower altitude - Descent of even 1600 feet may improve - Plan a slow descent to allow for acclimatization - Learn to recognize clinical manifestations - Avoid overexertion and overexposure to cold; rest at present altitude before ascending further - Ensure adequate hydration and nutrition - Avoid alcohol and sleeping pills when at high altitude - For progressive or advanced acute mountain sickness (AMS), recognize symptoms and implement a descent; provide O2 at high concentration - To prevent AMS, discuss use of acetazolamide (diamox)- is a carbonic anyhydrase inhibitor and it acts by causing a bicarbonate diuresis, which rids the body of excess fluid, and induces metabolic acidosis. The acidotic state increases respiratory rate; It is a sulfa drug so ask about allergy to sulfa before administering - Protect skin and eyes from sun's UV rays and wear sunscreen with SPF 30 and high quality sunglasses • High altitude, especially an elevation above 5000 feet, can produce a range of physiologic responses in the body and can be fatal, primarily due to hypoxia. But millions of people worldwide who ascend to or live at altitudes above 2500 feet are at risk for acute and chronic mountain sickness. • High altitude illnesses, also known as high altitude disease (HAD) or altitude sickness, causes pathophysiologic responses in the body as a result of exposure to low partial pressure of oxygen at high elevations. • The priority for care of the patient is descent to a lower altitude. • Acetazolamide (Diamox, Apo-Acetazolamide) is the drug of choice for prevention and treatment of mild altitude-related illness. • Teach patients best practice strategies for preventing, recognizing, and treating altitude-related illnesses. HAPE: • Most common cause of death associated with high altitude • Manifestations: Poor exercise tolerance, persistent cough, cyanosis of lips, tachycardia, tachypnea

Lightning Injuries:

• Lightning is responsible for multiple injuries and deaths each year. • The best way to prevent lightning injuries is to avoid places where lightning is likely to strike. • Lightning causes central nervous system and cardiovascular complications, as well as skin burns. A classic finding is an immediate but temporary paralysis that affects the lower limbs to a greater extent than the upper limbs. • Both the cardiopulmonary and central nervous systems are profoundly affected. • The most lethal initial effect of massive electrical current discharge on the cardiopulmonary system is cardiac arrest. • Apnea results in hypoxia-induced ventricular fibrillation.

Drowning:

• Prevention is key • Safe rescue of victim • Airway and cardiopulmonary support interventions • CPR if necessary • Gastric decompression • Support of body systems Assessment/ Care for Drowning Victims: - Makeup and quantity of the water aspirated is important - Aspiration of both salt and fresh water causes surfactant to wash out of the lungs - Salt-Water is a hypertonic fluid and also creates an osmotic gradient that draws protein-rich fluid from the vascular space into the alveoli (Drowning inside body) - Victim's outcome may be negatively affected by contaminants such as chemicals, algae, microbes, sand, and mud - Duration and severity of hypoxia are tow most important factors - Hypothermia might offer some protection to the hypoxic brain by reducing cerebral metabolic rate First Aid/ Prehospital: - Priority is removing from water - Spine stabilization - Airway clearance - Ventilatory support DO NOT attempt to get the water from the patient's lungs, deliver abdominal or chest thrusts only if airway is obstructed Hospital Care: - CPR is important as well as O2, endotracheal intubation, and defibrillation

Nurse-Client Relationship:

• Therapeutic nurse-client relationships can occur only when each views the other as a unique human being. When this occurs, both participants have needs met by the relationship. • Therapeutic relationships are goal-oriented and directed at learning and growth promotion • Goals are often achieved through use of the problem-solving model: - Identify the client's problem. - Promote discussion of desired changes. - Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively. - Discuss alternative strategies for creating changes the client desires to make. - Weigh benefits and consequences of each alternative. - Help client select an alternative. - Encourage client to implement the change. - Provide positive feedback for client's attempts to create change. - Help client evaluate outcomes of the change and make modifications as required. Essential Conditions for a Therapeutic Relationship to Occur: • Rapport: Implies special feelings on the part of both the client and nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. • Trust: To trust another, one must feel confidence in that person's presence, reliability, integrity, veracity, and sincere desire to provide assistance. • Respect: Show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior. • Genuineness: Refers to the nurse's ability to be open, honest, and "real" in interactions with the client. May call for a degree of self-disclosure on the nurse's part. • Empathy: Ability to see beyond outward behavior and to understand the situation from the client's point of view. It also means that you remain emotionally separate from the other person, even though you can see the patient's viewpoint. One of the most important characteristics of a therapeutic relationship.

Disaster Preparedness:

• To maintain disaster preparedness skills, hospital personnel and disaster teams participate in emergency training and drills or an actual event at least twice yearly. • One of the drills or events must involve community-wide resources and an influx of actual or simulated patients to assess the ability and effectiveness of collaborative efforts and command structures, and must use an "all-hazards approach." • This approach must address all credible threats to the safety of the community that could result in a disaster situation.

Serum Sickness:

• Type III hypersensitivity reaction • Develops in 3 to 21 days as skin rash • Progresses to fever, joint pain, pruritus (itching) • Mild to moderate allergic reactions can occur; anaphylaxis rare

Describe ethical issues relevant to psychiatric/mental health nursing:

• Utilitarianism: an ethical theory that promotes action based on the end result that produces the most good (happiness) for the most people • Kantianism: suggests that decisions and actions are bound by a sense of duty • Christian ethics: Do unto others as you would have them do unto you. • Natural law theories: Do good and avoid evil. Human knowledge of the difference between good and evil directs decision making. • Ethical egoism: Decisions are based on what is best for the individual making the decision. • Ethical dilemmas are situations that require individuals to make a choice between two equally unfavorable alternatives. • Taking no action is considered an action taken. • Autonomy: emphasizes the status of persons as autonomous moral agents whose rights to determine their destinies should always be respected. • Beneficence: refers to one's duty to benefit or promote the good of others. • Nonmaleficence: abstaining from negative acts toward another; includes acting carefully to avoid harm • Justice: principle based on the notion of a hypothetical social contract between free, equal, and rational persons. The concept of justice reflects a duty to treat all individuals equally and fairly. • Veracity: principle that refers to one's duty to always be truthful. • The right to refuse medication • The right to the least restrictive treatment alternative