420 Exam 3

Progression of Dementia

Reversible stressors that could cause dementia - Subdural hematoma - Tumor (especially meningioma) - Cerebral vasculitis - Hydrocephalus Identify, treat underlying stressors promptly Involves structural and neurochemical brain changes from: - Trauma - Infection - Cerebrovascular disruptions - Substance use, or unknown cause

BEFORE SEXUAL ASSAULT NURSE EXAMINERS (SANE)..

Longer patient wait times, public waiting room Multiple testaments -average patient tells their story 10 -12 times to individuals who have nothing to do with the case MDs not specially trained in injury identification or evidence collection The newest intern in the department did the exam for "experience"

AIDS Dementia Complex

One third of people with HIV develop AIDS dementia complex, usually in late stages of the disease Symptoms: slowed thinking, severe forgetfulness, difficulty performing multistage complex tasks (ADLs) May include muscle control and eventually social withdrawal, apathy, depression

Anorexia Nervosa

Onset usually between the ages of 14 and 18 Denial early on; depression and lability and isolation with progression and can lead to paranoia or mistrust Medical complications oMusculoskeletal (muscle wasting, minerals come out of bones & teeth, osteoporosis) oGI (delayed gastric emptying, abd pain, constipation, bloating, gas, diarrhea) oCardiac (alterations in electrolytes like hypokalemia, bradycardia, hypotension, arrhythmias) oMetabolic, reproductive (hypothyroidism s/s, stop menstruating, low glucose & decreased insulin sensitivity, low temp., difficulty developing secondary sex characteristics and low FSH and LH, amenorrhea) oNeurologic (fainting, vision problems, abnormal tase sensation, apathetic depression, sleep disturbance, swelling of facial glands) oDerm (dry/cracking skin, lanugo, edema, acrocynaosis) oHematologic (leukopenia, anemia, thrombocytopenia, hypercholesterolemia, hypercarotenemia) Treatment: often difficult; client is resistant, uninterested, denies problem (anxiety about gaining weight) Medical management oWeight restoration (slowly)/nutritional rehabilitation > pre-selected diet (decide what they are going to eat the night before, plan meals and stick to them) > slow, gradual increase in caloric intake; access to bathroom supervised to prevent purging oCaution - refeeding syndrome (when someone is starving, if they eat too much it can cause CV collapse and kill them b/c of rapid electrolyte and fluid shifts) oRehydration/correction of electrolyte imbalances Psychopharmacology (antidepressants like amitrptyiline/elavil or antihistamine like cypropheptadine/periactin): olanzapine/zyprexa for body image disturbance and weight gain, fluoxetine/prozac to prevent relapse Psychotherapy oFamily therapy oIndividual therapy (coping, self-esteem, relationships, assertiveness, functioning) oCBT (address body image disturbance, perfectionism, mood intolerance, self-esteem, and interpersonal difficulties)

TRAUMA NEGATIVELY AFFECTS PATIENTS' HEALTHCARE ENGAGEMENT

1. Avoidance of medical services - 40% of women IPV victims delayed medical care in the past year 2.Non-adherence to treatment - Poor self-care, poor memory and confusion - "Problem behaviors" can be symptoms of trauma or coping skills 3.Postponing medical services until condition is much worse - More likely to present in a crisis 4.Misuse of medical treatment services - ex. overuse of ER Services and misuse of prescriptions meds

Behaviors in Dementia

Loss of intellectual abilities, interferes with usual social or occupational activities Impairment of memory, judgment, abstract thought Onset of dementia usually gradual, without clouding of awareness seen with delirium May result in progressive deterioration or may stabilize Personality changes often occur

WHAT IS TRAUMA INFORMED CARE?

1.A program, organization or system that is trauma-informed •Realizes the prevalence of trauma and taking a universal precautions position •Assume all patients may be trauma survivors, and treat accordingly 2.Recognizes how trauma affects all individuals involved with the program, organization, or system, including its own workforce 3.Responds by putting this knowledge into practice 4.Resists retraumatization Notes •Give relaxed, unhurried attention •Talk about concerns and procedures before doing anything (ex. asking patient to disrobe, asking prior to touch a patient, explaining what you are going to do and why) •Give as much control and choice as possible to the patient •Validate any concerns as understandable and normal •Allow a support person or other staff person to be present in the room •Be mindful of possible stress reactions. (becoming stiff, cringing, pulling away, startling, crying should not be ignored) •Universal Precautions: Assume all patients may be trauma survivors, and treat accordingly

FORENSIC NURSES/SEXUAL ASSAULT NURSE EXAMINERS

A forensic nurse is a nurse who provides specialized care for patients who are victims and/or perpetrators of trauma(both intentional and unintentional). Forensic Nurses are nurses first and foremost. However, the specialized role of forensic nurses goes far beyond medical care; forensic nurses also have a specialized knowledge of the legal system and skills in injury identification, evaluation and documentation. After attending to a patient's immediate medical needs, a forensic nurse often collects evidence, provides medical testimony in court, and consults with legal authorities.

WHAT HAPPENS DURING A SAFE EXAM?

ABC's 1. we are nurses first! 2. medical conditions take priority over forensic examination 3. patients are triaged and should receive medical screening and/or treatment as needed without delay WHAT IS INVOLVED IN A SAFE EXAM? •Medical history •Labs •Physical exam •Collect evidence (Swabs, clothing) •Photos/body diagrams •Medications •Advocacy and follow up planning

Types of Dementia

AD AD plus dementia with Lewy bodies Vascular dementias, or multi-infarct dementia Vascular dementias with AD Dementia with Lewy bodies Parkinsonian dementia AIDS dementia complex Frontal lobe dementia Corticobasal degeneration, or supranuclear palsy

Learning Disorders

Achievement in reading, mathematics, written expression below expected for child's age, formal education, level of intelligence > often do really well in one domain like math and then poor in another like writing Interference with academic achievement, life activities, development of self-esteem, social skills Early identification, intervention, no coexisting problems associated with better outcomes > special education classes

REPORTING

All 50 states have some mandatory reporting - They are all different PENNSYLVANIA MANDATORY REPORTING 1. Child abuse > All known or suspected child abuse must be reported 2. Elder/vulnerable adult abuse > Persons who abuse elders are almost always in a caregiver role, or the elders depend on them in some way (often older spouse) > Must be reported if you are a healthcare worker in a facility providing care to these individuals 3. Other > Injuries caused by a firearm or other deadly weapon > Injury caused in violation of "any law" - With an exception for IPV to not be reported without the victim's consent ****

Dementia

Alzheimer disease (AD): most common dementia, accounting for approximately 70% of cases - More than 5 million people in the United States have AD - AD is NOT a normal part of aging Implications - Early-onset AD associated with more rapid course - Involves more genetic predisposition compared with late-onset AD - Behavioral change slow in early and late stages of AD and rapid in middle stage - AD is fifth leading cause of death after age 65

Elder Considerations

Approximately 30% to 60% of elders in treatment began drinking abusively after age 60. Risk factors for late -onset substance include chronic illness that causes pain - long-term use of prescription medication (sedative-hypnotics, anxiolytics) - life stress, loss, social isolation, grief, depression - an abundance of discretionary time and money Physical problems associated with substance abuse develop rather quickly **

Eating Disorders and Nursing Process Application

Assessment oHistory - Anorexia: perfectionists, eager to please, seeking approval - Bulimia: history of impulsive behavior or anxiety/depression, but also eager to please and avoid conflict oGeneral appearance and motor behavior - Anorexia: lethargic, fatigued, emaciated (may layer loose clothing to hide this), slow to respond, limited eye contact - Bulimia: generally close to expected weight for size, may have a lot of dental carries from vomiting oMood and affect: labile moods; sad, anxious, worried; (with bulimia initially seem pleasant and cheerful) oThought process and content: preoccupation with food or dieting; paranoia others are trying to make them fat; delusional body image disturbance oSensorium and intellectual processes: signs of starvation in malnourished clients with anorexia (confusion, slow mental process, impaired concentration and attention) oJudgment and insight - Anorexia: limited insight, poor judgment about health status (don't see problem) - Bulimia: ashamed of behaviors oSelf-concept: low self-esteem oRoles and relationships: unable to fulfill roles; withdraw from others; may fail school; hide stuff from those around them oPhysiological and self-care considerations (excessive exercise, sleep disturbances, dental problems & mouth sores from vomiting)

Conduct Disorder and Nursing Process Application Application

Assessment oHistory: disturbed peer relationships, aggression toward people or animals, destruction of property, deceitfulness, theft, truancy, running away, staying out all night, destroying property, lighting things on fire oGeneral appearance and motor behavior: typical for age group; may be extreme (body piercing/tattoos); slouch and are sullen/sulky oMood and affect: quiet, reluctant to talk; openly hostile, angry; disrespectful; not cooperative in interview; don't think they need help; insincere guilt/remorse oThought process and content: perceive the world to be aggressive/threatening; thoughts/fantasies of death oSensorium and intellectual processes: poor grades because of academic underachievement oJudgment and insight: limited; rule breaking; risky behavior; lack insight & blame others oSelf-concept: tough appearance; low self-esteem oRoles and relationships: disruptive, possibly violent; poor school/work performance oPhysiological and self-care: often at risk for unplanned pregnancy, STDs; drug use; injuries/deaths b/c of violence Data analysis/nursing diagnoses - Risk for other-directed violence - Noncompliance - Ineffective coping - Impaired social interaction - Chronic low self-esteem Outcome identification oNo injury to others or damage to property oParticipate in treatment oLearn effective problem-solving and coping skills oUse age-appropriate and acceptable behavior when interacting with others oVerbalize positive, age-appropriate statements about self Interventions oDecreasing violence/increasing compliance with treatment > Limit setting with consistent enforcement, state expected behavior and consequences > Behavioral contracting of expected behaviors; time-out oImproving coping skills, self-esteem (diary) oPromoting social interaction (role model and practice social skills, positive feedback) oProviding client and family education > Identify age-appropriate behaviors > Provide routine schedule Evaluation

ADHD and Nursing Process Application

Assessment oHistory: fussy as infant; "out of control"; difficulties in all major life areas; overactive oGeneral appearance and motor behavior: inability to sit still; inability to carry on conversation (interrupts, blurts out answers); abrupt jumping from topic to topic, developmentally immature oMood and affect: possibly labile, anxiety, frustration, agitation, outburst/tantrums, anger when trying to redirect oThought process and content (generally no impairment) oSensorium and intellectual processes: impaired ability to pay attention or concentrate, distract easily and rarely complete tasks oJudgment and insight: poor; impulsive (fail to perceive danger) oSelf-concept: low self-esteem; negative reactions to behavior make them feel bad or stupid oRoles and relationships: academic, social problems oPhysiological and self-care: may be thin; trouble settling down; sleeping problems; may engage in reckless behavior Data analysis/nursing diagnoses oRisk for injury (monitor them closely; might jump off high places or run into traffic b/c impulsivity) oIneffective role performance oImpaired social interaction oCompromised family coping Outcome identification oFree of injury oNo violation of others' boundaries oDemonstrate age-appropriate social skills oComplete tasks oFollow directions Interventions oEnsuring safety (stop negative behavior, give direct instructions, close supervision) oImproving role performance (positive feedback, manage environment to quiet free of distractions) oSimplifying instructions (allow breaks, break complex tasks into simple small steps) oPromoting structured daily routine oProviding client and family education and support Evaluation

Cultural Considerations

Attitudes vary in different cultures. - Muslims do not drink alcohol. - Wine is an integral part of Jewish religious rites. - Some Native American tribes use peyote (hallucinogen) in religious ceremonies. Genetic traits of certain ethnic groups as predisposing to or protective against alcoholism Variations in enzymatic activities among Asians, African Americans, whites (ex: flushing of face & neck occurs in Asians when consuming even small amounts of alcohol) Alcohol abuse: a part in the five leading causes of death for Native Americans and Alaska Natives Japan: alcohol not regarded as a drug; no religious prohibitions against drinking; excessive alcohol consumption is widely condoned at parties, business functions, and at home, and few Japanese people go for alcohol treatment Russia: high rates of alcohol abuse, suicide, and cigarette smoking in male population

Onset and Clinical Course

Average age for first episode of alcohol intoxication is adolescence (15) > Episodes of "sipping" as early as 8 years old > Pattern of more severe difficulties emerges in mid-20s to mid-30s (ex: breakups, arrest, medical problems, interference w/ school or work) Blackout (use to forget; sign of abuse and dependence > person continues to function but has no conscious awareness of his or her behavior at the time or any later memory of the behavior Tolerance (needs more alc to produce effect) Periods of abstinence or temporarily controlled drinking - Followed by escalation of alcohol use and subsequent crisis; cycle continues For many, substance use is chronic illness. - Remissions and relapses - Relapse rates 60% to 90%; nearly half of individuals relapsing in the year after treatment - Highest rates for successful recovery—abstinence and high level of motivation to have a substance-free lifestyle, and who actively work on relapse prevention Spontaneous remission (someone who just stops using substance on their own without treatment) Poor outcomes associated with earlier age at onset, longer periods of substance us, and serious psych illness Increases risk of suicide Related Disorders (addictions) - Gambling disorder - Caffeine and tobacco additions - Computers/phones/ gaming - Substances can induce symptoms similar to other mental illness diagnoses (avolition w/ cannibis, low self-esteem, psychosis/hallucinations like schizophrenia with methamphetamine, alcohol mimics depression, mania like in bipolar disorder)

Sedatives, Hypnotics, and Anxiolytics

Barbiturates, nonbarbiturate hypnotics, and anxiolytics (Benzos) > Benzodiazepines and barbiturates common Intoxication and overdose - CNS depressants - Intensity depends on drug - Intoxication symptoms: slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, stupor - Barbiturate overdose possibly lethal**(phenobarbital worse than benzos like ativan); coma, respiratory arrest, cardiac failure, death > Treatment in an intensive care unit is required using lavage or dialysis to remove the drug from the system and to support respiratory and cardiovascular function Onset of withdrawal dependent on half-life of drug - Symptoms opposite of drug's acute effect > autonomic hyperactivity (increased pulse, blood pressure, respirations, and temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitation > seizures and hallucinations may occur in severe benzo withdrawal - Can be life-threatening! Detoxification via drug tapering slowly

Behaviors Associated with Delirium

Behavioral response to widespread disturbances in cerebral metabolism Involves sudden decline from previous level of functioning, usually considered a medical emergency Often results from advanced age and medications or medical procedures Disturbances Caused by Delirium - Consciousness - Attention - Cognition - Perception - Motor ability

Brain Dysfunction

Maladaptive cognitive responses possible at any age In some people, cognitive responses do not develop fully or may deteriorate once developed Generally childhood maladaptive cognitive responses are called developmental disabilities or mental retardation

Etiology

Biologic factors - Genetic vulnerability (60% developed alcohol dependence if parents had alcoholism) - Neurochemical influences (dopamine is targeted by substances; it is seen as a reward in limbic system so they want to keep using; some people have an alteration/don't have a cap to this reward so they can't control themselves b/c they keep seeking the reward) Psychological factors - Family dynamics (inconsistency in the parent's behavior, poor role modeling, and lack of nurturing) - Coping styles (anxiety or keeping them up and alert) Social and environmental factors - Cultural factors (is it normal to have a glass of wine w/ dinner), - Social attitudes, peer behaviors - Laws, cost, availability > Urban areas where drugs are readily available also have high crime rates, high unemployment, and substandard school systems that contribute

Etiology of Eating Disorders

Biologic factors 1. Genetic vulnerability - May be related to a certain personality type or groups of MH disorders (mood, anxiety, OCD) 2. Disruptions in the nuclei of the hypothalamus relating to hunger and satiety (lateral hypothalamus = decreased eating and sensory stimuli, ventromedial hypothalamus = excessive eating, weight gain, decreased responsiveness to satiety) 3. Neurochemical changes (low norepinephrine, serotonin); not known if these changes cause disorders or are result of eating disorders Developmental factors oStruggle for autonomy, identity, control (puberty) oOverprotective or enmeshed families (control issues; can control eating) oBody image disturbance (discrepancy between one's body image and the perceptions of others; dissatisfaction w/ one's body) oSelf-perceptions of the body (very different from reality; ex: being overweight) Family influences (family dysfunction, childhood adversity, abuse/neglect**, parental control/overprotectiveness) Sociocultural factors (media, pressure from others, athletes, bullying) Risk factors - Biologic: obesity, dieting at early age, possible serotonin and norepineprhine disturbances and chromosome 1 susceptibility in bulimia only, - Developmental/ Sociocultural: control/autonomy issues, developing identity, dissatisfaction w/ body image, lack of family support or parental maltreatment, can't deal w/ conflict, cultural ideal of being thin, self-perception of being fat Cultural Considerations - Increased prevalence in industrialized countries - Most common in the United States, Canada, Europe, Australia, Japan, New Zealand, South Africa, other developed industrialized countries - Equal among Hispanic and Caucasian women - Less common among African American and Asian women

Interventions: Traumatic Brain Injury

Brain injuries do not heal like other injuries Recovery is a functional recovery involving many aspects of cognition A collaborative, interprofessional team approach that includes the family is required Rehabilitation should begin as soon as possible after the injury

TRAUMA HARMS PHYSICAL AND MENTAL HEALTH

CDC and Kaiser Permanente collaboration •17,000 people over 10 year period beginning in 1995-1997 •Long-term effects over lifespan •Aim to fill scientific gaps in the conceptual pyramid Findings: increases in ACE (ADVERSE CHILDHOOD EXPERIENCES) score increases proportionately with higher rates of... 1.Chronic diseases 2.Mental health disorders 3.Risky behaviors 4.Other negative outcomes (e.g. unintended pregnancies, intimate partner violence) ACE score of above 4 (out of possible 10) is associated great increases in... 1. Chronic diseases: •2-4x risk of Hypertension •& Diabetes •2.4x risk of Liver Disease •4x risk of COPD 2. Mental illness •12x risk of Suicide •4x risk of Depression 3. Risky behaviors •7x risk of Alcoholism •2x risk of Smoking Note: Disease risk is not only modulated by risky behaviors •Patient with ACE score of 7 has 30-70% increased risk of ischemic heart disease as an adult with no evidence of risk taking behaviors

Stimulants (Amphetamines, Cocaine)

CNS stimulants (Amphetamines, Cocaine) Intoxication and overdose - High or euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic or repetitive behavior, anger, fighting, and impaired judgment - Elevated blood pressure and pulse, dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmia - Seizures, coma with overdose (and possibly CV like MI) > Treatment with chlorpromazine (Thorazine), an antipsychotic, controls hallucinations, lowers blood pressure, and relieves nausea Withdrawal - Onset within hours to several days; NOT life-threatening - Primary symptom is marked dysphoria (sadness, may sleep for days) - "Crashing"; loss all energy & motivation; may have suicidal ideation & depressive symptoms - Not treated pharmacologically (does not become physically dependent on stimulant so can be taken off, don't require medical detox) ** Stimulants - Methamphetamine - Particularly dangerous - Highly addictive - Causes psychotic behavior - meth psychosis - schizophrenia - Brain damage related to use - possibly from substance used to make it - liquid fertilizer (look different like face and teeth changes and age/deteriorate quickly)

Categories of Drugs

Categories of Drugs - Alcohol - Sedatives, hypnotics, and anxiolytics - Stimulants (common) - Cannabis - Opioids - Hallucinogens (also common) - Inhalants > treat based on pt's symptoms > designer drugs is when they alter the chemical breakdown slightly to make a similar drug to an existing one to make it legal; not controlled by FDA Diagnostic Classes of Substance Abuse - Intoxication (under influence of substance; maladaptive behavior**) - Withdrawal syndrome (stop using substance; can have physical and psychological symptoms) - Detoxification (substance leaving body; safe withdrawal) - Substance abuse (using substance in way not intended to be used despite negative consequences; creates problems in person's life) - Substance dependence (you become dependent on it and use it for example to decrease anxiety, when you stop using it you experience withdrawal) - Substance use (abuse and dependence) - Tolerance (have to use more of substance to achieve desire effect)

Disruptive Behavior Disorders

Characterized by persistent patterns of behavior that involve: oAnger oHostility oAggression > All of these towards people and/or property Oppositional defiant disorder (ODD) Conduct disorder Intermittent explosive disorder (IED) > occur after age 6 Related disorders: oKleptomania—impulsive, repetitive theft of items not needed by the person oPyromania—repeated, intentional fire-setting

Pharmacological Options and Target Symptoms

Cholinesterase inhibitors: apathy, psychosis (delusions, hallucinations), agitation, anxiety, nighttime behavior; positive effects on cognition, ADLs, global functioning NMDA antagonist: severe dementia Antipsychotics: psychosis, hostility, aggression, agitation, violent behavior Serotonergic agents: psychosis, agitation Antidepressants: depressive symptoms, anxiety disorders, insomnia ß-Blockers, benzodiazepines, estrogen: anxiety/agitation Anticonvulsants: agitation, aggression, mood swings

Community-Based Care

Community-Based Care - Hospital admission only for medical necessity (dangerously low weight, electrolyte imbalances, or renal, cardiac, or hepatic complications) - Community settings oPartial hospitalization or day treatment programs oIndividual or group outpatient therapy oSelf-help groups Mental Health Promotion - Education of parents, children, young people about strategies to prevent eating disorders - Healthy People 2020—increase in comprehensive school education (unhealthy dietary patterns and inadequate physical injury) - National Eating Disorders Association guidelines > Get rid of the notion that a particular diet, weight, or body size will automatically lead to happiness and fulfillment > Learn about eating disorders > Challenge idea that fat means bad and thin means good; avoid categorizing foods as food or bad (balanced diet) > Stop judging self and others based on weight > Limit time on social media (don't listen to "ideals") > Surround self w/ positive people - Screening questions > How often do you feel dissatisfied with your body shape or size? > Do you think you are fat or need to lose weight, even when others say you are thin? > Do thoughts about food, weight, dieting, and eating dominate your life? > Do you eat to make yourself feel better emotionally and then feel guilty about it? Self-Awareness Issues - Feelings of frustration when client rejects help. - Being seen as "the enemy" if you must ensure that the client eats. - Dealing with own issues about body image and dieting. - Be empathetic and nonjudgmental.

Substance Abuse Treatment

Concept: medical illness that is progressive and chronic, characterized by remissions and relapses Treatment models: - Hazelden Clinic model (serenity prayer, groups, ??) - 12-step program of Alcoholics Anonymous (self-help group) > first step: admit you are powerless over alcohol > recognize higher power > make list of persons harmed and make amends Individual, group counseling (education about substances and their use, problem-solving techniques, and cognitive techniques to identify and modify faulty ways of thinking) Treatment settings (medically supervised detox in hospitals, outpatient clinics for day/evening programs, halfway houses, residential settings) Pharmacologic treatment: safe withdrawal; prevent relapse - Medications help manage withdrawal or cravings, but is not a specific treatment for substance abuse - Ex: ativan, librium, methadone, nalaxone, b12 / folate / thiamine

Behaviors in Dementia continued.

Confabulation: confused person's tendency to make up answers when unable to remember - Do not view as lying or attempt to deceive - May be way to save face in embarrassing situations Aphasia: difficulty finding the right word Apraxia: inability to perform familiar skilled activities Agnosia: difficulty in recognizing well-known objects, including people Amnesia: significant memory impairment in absence of clouded consciousness or other cognitive symptoms Patients with dementia may have disturbed sleep, demonstrate labile affective behavior Some deterioration in social skills possible Impulsive sexual advances may occur, with decreased inhibition, impaired judgment

Eating Disorders and Nursing Process Application Application continued

Data analysis/nursing diagnoses - Imbalanced nutrition: Less than/more than body requirements - Ineffective coping - Disturbed body image - Chronic low self-esteem - Others: deficient fluid volume, constipation, fatigue, and activity intolerance Outcome identification oEstablish adequate nutritional eating patterns oEliminate compensatory behaviors (excessive exercise, laxatives, diuretics, purging) oDemonstrate coping mechanisms not related to food oVerbalize feelings of guilt, anger, anxiety, excessive need for control oVerbalize acceptance of body image with stable body weight Interventions oEstablishing nutritional eating patterns (inpatient treatment if severe; gradually increase caloric intake) > monitor meals; sit w/ them & observe the client following meals and snacks for 1 to 2 hours > monitor daily weights first thing in morning only wearing gown (be careful of waterloading or stuffing things in pockets to weight more; might do blind weights so person can't see) > offer liquid protein supplement if client is unable to complete meal oIdentifying emotions, developing coping strategies (self-monitoring for bulimia; identify behavior patterns and then implement techniques to avoid or replace them; keep diary of food and emotions and eating behaviors) > sometimes emotions come out through somatic complaints > they often have difficulty identifying and expressing feelings (alexithymia) > relaxation, distraction oDealing with body image issues > identify strengths > recognize benefits of a more near-normal weight oProviding client and family education > laxative abuse, harmful effects of binging and purging, set realistic goals > avoid talking only about weight or food, don't try to force them to eat, Evaluation

Adaptive Cognitive Responses

Decisiveness Intact memory Complete orientation Accurate perception Focused attention Coherent, logical thought

Communication Disorders

Deficit in language, speech, communication severe enough to hinder development, academic achievement, or ADLs, including socialization Language disorder is deficit in production or comprehension of language (limit vocabulary and ability to form sentences or have conversation) Speech sound disorder (difficulty or inability to produce intelligible speech) Stuttering (disturbance of fluency and pattern of speech w/ sound and syllable repetitions) Social communication disorder (inability to observe social rules of conversation like taking turns listening and talking, deficit in applying context to conversation)

Other Dementias

Dementia with Lewy bodies (DLB): second most common form of degenerative dementia Lewy bodies: neurofilament material in brainstem, thalamus, basal ganglia of patients with dementia Associated with atypical Parkinson disease Huntington disease Parkinson disease

IS ALCOHOL A "DATE RAPE" DRUG?

Does it impair your judgment and motor skills? When impaired, might a person not be able to fend off or escape an assault? Does severe drinking lead to unconsciousness and/or temporary loss of memory? YES. Alcohol is the most common "date rape" drug. Drugs used to impair consent Most commonly found: •Alcohol (most common) •Gammahydroxyburerol(GHB) •Ketamine •Ecstasy/Molly •Benzodiazepines •Opioids HOW WOULD I KNOW IF A PATIENT WAS DRUGGED? - n/v - dizziness, disorientation, unconciousness - loss of inhibition - amnesia - overly intoxicated compared to usual limitis

Opioids

Desensitization to pain, euphoria, well-being Morphine, codeine, hydromorphone, oxycodone, methadone, oxymorphone, hydrocodone, heroin, fentanyl, and normethadone (may use methadone or Buprenorphine for abstinence and slowly weaning off) Intoxication: apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory Overdose: coma, respiratory depression, pupil constriction, unconsciousness, death (life-threatening) - Administer Naloxone; reverses toxicity Withdrawal - Initially anxiety, restlessness - N/v, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia - Symptoms cause significant distress, but do not require pharmacologic intervention to support life (not life-threatening) or bodily functions (will tell you they're dying and they need something but don't need it) - Short-acting drugs (e.g., heroin): onset in 6 to 24 hours; peaking in 2 to 3 days and gradually subsiding in 5 to 7 days - Longer acting drugs (e.g., methadone): onset in 2 to 4 days, subsiding in 2 weeks

Motor Skill Disorders

Developmental coordination disorder oImpairment in coordination severe enough to interfere with academic achievement or ADLs > maybe can't kick ball but still develop normally otherwise oOften coexisting with communication disorder Adaptive physical education, sensory integration to foster normal growth, development Stereotypic movement disorder oCharacterized by rhythmic, repetitive behaviors oSelf-inflicted injuries are common, pain is not a deterrent to the behavior.

Conduct Disorder

Diagnosed with this before 18; if it continues past this it is antisocial personality disorder Persistent behavior that violates social norms, laws, rules, rights of others (aggression to people & animals, destroying property, deceitfulness and theft, serious violations of rules) Impaired functional abilities in social, academic, and occupational areas (academic underachievement, learning disabilities, hyperactivity, issues w/ attention span, difficulty socializing w/ others) Callous and unemotional traits (no remorse or empathy, shallow emotions, not concerned about performance at home or school) > low-self esteem, poor frustration tolerance, temper outbursts Frequently associated with reckless/risky behaviors Classification: - mild (relatively minor harm to others; ex: lying, shoplifting, staying out late, truancy) - moderate (vandalism, conning others, running away, verbal bullying/intimidation, drinking, sexual promiscuity) - severe (cruelty to animals, physically harming others, rape, burglary/robbery) Related behavior problems - externalizing (lying, cheating, swearing, truancy, vandalism, setting fire, screaming, attention-seeking, fighting) - internalizing (withdrawing, sulking, not talking, somatic pain, n/v and stomach upset, fatigue, anxiety, low self-esteem, crying)

Interventions: Orientation

Disorientation common but nursing interventions can help In a facility, it is helpful to mark patient rooms with large, clearly printed signs indicating occupant's name Allow patient to have a personal space, some favorite belongings A light in the room at night helps patient remain oriented, decreases nighttime agitation Large clocks, calendars, newspapers help Reality orientation includes attention to dimensions of time, place, person

Behaviors in Delirium

Disorientation in some or all three spheres: time, place, person Thought processes disorganized, poor judgment, little decision-making ability Stimuli may be misinterpreted, resulting in illusions and distortions of reality Hallucinations Assaultive or destructive behavior Labile affect Also may note loss of usual social behavior, resulting in acts such as undressing, playing with food, grabbing at others Delirious patients tend to act on impulse Other behaviors may be specifically related to physical cause of behavioral syndrome

Traumatic Brain Injury

Disruption of normal brain function that occurs when the skull is struck, suddenly thrust out of position, or penetrated Symptoms may appear right away or may not be present until days or weeks or months after the injury TBI can affect a single, specific region of the brain (focal injury), be distributed throughout the brain (diffuse injury), or both TBI is classified into three categories based on time of lost consciousness > Mild - less than 30 minutes > Moderate - more than 30 minutes but less than 24 hours > Severe - more than 24 hours Concussion is often used interchangeably with mild TBI

WHAT NOT TO DO WHEN THEY SAY YES...

Do NOT: - Judge their choices - Ask why they don't leave or doubt them / tell them to leave or imply they are at fault - Call the police without the patient's knowledge (and consent in most cases) - Ignore / not acknowledge the disclosure - Minimize the impact of violence - Express outrage w/ perpetrator - Recommend couple's counseling SUPPORTING SURVIVORS: WHAT NOT TO SAY - "You should definitely report immediately and go get a rape kit." - "You are definitely in an abusive relationship." - "That does not sound like rape to me..." - "Your partner is crazy, you need to break up with them." - "Were you drunk? Were you using the buddy system?" or "What did you do to set them off?" - "So what happened after that, and what happened after that?"

WHAT TO DO WHEN THEY SAY YES...

Do: - Be nice; respect their decisions - Validate experiences and emotions; believe victim; listen and affirm what they same - Tell them they deserve to be safe and that you are concerned about their safetu - Let them know they are not alone > that your office / hospital /etc. is a place to find safety > that there are resources in the community to help provide safety (support group or individual counseling, shelter, police) POSITIVE DISCLOSURE: ONE LINE SCRIPTS - "I am so sorry this is happening. It is not okay, but it is common. You are not alone." - "This is not your fault. Nothing you did caused this. Someone else made a choice to hurt you." - "What you're telling me makes me worried about your safety and health." - "Would you like me to explain options and resources that other patients have found helpful?" - "Some people find talking to an advocate or counselor to be helpful." - "What else can I do to be helpful? Is there another way I can be helpful?"

Mental Health Promotion for ADHD

Early detection and successful intervention Early detection of potential problems (SNAP-IV Teacher and Parent Rating Scale) > asks about attention, ability to listen to directions and complete tasks, impulsivity/anger, communication skills, frequent movements, and other reckless behaviors Dr. Andrew Wakefield: damaging medical hoax (autism caused by vaccines; some people believe that people don't really have ADHD and we just need to work with them?) Nurse's Role in Health Promotion: Early intervention may include collaborating with oSchool psychologist oPediatrician oPhysiotherapist oTeacher oNeurologist oFamily oSpeech therapist oOT Self-Awareness Issues - Recognize own beliefs about parenting, how they differ from others. - Focus on child's and parents' strengths, not just problems. - Support parents; efforts to remain hopeful. - Ask parents how they are doing.

Traumatic Brain Injury effects

Effects of TBI are physical, cognitive, affective, and behavioral Following TBI a person is at risk for many psychiatric disorders—depression, generalized anxiety disorder, panic disorder, agoraphobia, posttraumatic stress disorder About half of all people with TBI also experience chronic pain Comorbid psychiatric illnesses predict poorer health outcomes and quality of life Many people with TBI make a full recovery Others have long-lasting cognitive and behavioral changes that limit their ability to work and live a functional and productive life Multiple TBIs are cumulative in the damage that can occur so that mild cases can become severe Quality and Safety Alert!!!! > Risk for suicide is 2 to 4 times greater for individuals with TBI > Even mild brain injury increases suicide risk

Elimination Disorders

Encopresis: repeated passage of feces into inappropriate places (child at least age 4) oOften involuntary (associated w/ constipation) but can be intentional (associated w/ ODD or conduct disorder) Enuresis: repeated urination during day or night in clothes or bed after age 5 oMost often involuntary oIntentional enuresis associated with disruptive behavior disorder More common in boys than girls Recognize: typically it is not usually on purpose; don't discipline them for behavior (use bladder/bowel protocols) > educate families not to be punitive

Oppositional Defiant Disorder

Enduring pattern of uncooperative, defiant, disobedient, hostile behavior toward authority figures; no major antisocial violations (don't hurt others, have remorse, get along w/ peers just distrustful of authority figures) Certain level of this behavior common in children and adolescents - ex: inconsistent & unpredictable behavior, erratic work-leisure patterns, critical of self and others, ambivalent/verbal aggression towards parents acceptable Limited ability to make connection between behaviors and consequences (reduced sensitivity to reward & punishment) > impaired problem-solving & decision making ** > "the teacher just gave me an F b/c he hates me" Varied prognosis Treatment (no real meds) —parent management training models of behavioral interventions (don't be too punitive, establish trust but also set firm consistent limits and consequences) > behaviors are learned & reinforced at home & school > ignore maladaptive behaviors DO NOT give attention and reward positive ones

Conduct Disorder continued

Etiology: interaction of genetic vulnerability, environmental adversity, factors such as poor coping Risk factors: Grows up with abuse, parents/siblings with personality disorders, parents who are very punitive or inconsistent, substance abuse disorders in family or prenatal, low self-esteem and/or academic achievement, poor peer relationships, marital discord, early use of alcohol/drugs or sex, exposure to violence in media/community Protective factors: Caring, nurturing family, good health, positive peer relationships, resilience Treatment: oMust be geared toward developmental age oEarly intervention/prevention; parenting education, social skills training, family therapy, individual therapy, medications (in conjunction with treatment; antipsychotic like Risperdal or mood stabilizer like Tegretol***) > empathy development skills; encourage expression of feelings (anger might cover up other emotions)

Restlessness and Agitation

Extreme agitation at night sometimes called sundowning syndrome Probably results from tiredness at day's end combined with fewer orienting stimuli: planned activities, meals, contact with people Causes of agitation - Physical and medical problems - Environmental stresses - Sleep problems - Psychiatric disorders

Opioid Crisis

Five point program includes: - Access: Better prevention, treatment, and recovery services - Data: Better data on the epidemic - Pain: Better pain management - Overdoses: Better targeting of overdose-reversing drugs - Research: Better research on pain and addiction

Stages of Dementia: Stage III: Severe - 1-3 years

Fragmented memory No recognition of familiar people No recognition of self in mirror Uses words improperly Depends on others for basic activities of daily living Reduced mobility

Pharmacological Approaches

Generally must use medications with care when treating persons with dementia Each medication has unintended consequences, including increased cognitive disability Risk-benefit analysis is always a part of the decision process in using psychotropic medication

DOCUMENTING INJURIES

Head-to-toe exam Document ALL findings Size, location, color May be used in court! WHAT'S IN THE EVIDENCE KIT? - reference sample - oral swabs - fingernail swabs - vaginal swabs - anal/perianal swabs - miscellaneous/debris/trace evidence - underwear/clothes

Inhalants

Intoxication: neurologic, behavioral symptoms - anesthetics, nitrates, and organic solvents, ex: gasoline, glue, paint thinner, and spray paint Acute toxicity - Anoxia (lack of O2), respiratory depression, vagal stimulation, dysrhythmias - Death possible from bronchospasm, cardiac arrest, suffocation, or aspiration No withdrawal or detoxification - Frequent users report cravings Symptomatic treatment of related disorders (ex: lung damage) > support respiratory and cardiac functioning until substance is removed from the body

HEALTHCARE PROVIDERS PLAY AN IMPORTANT ROLE IN HELPING (OR HURTING) TRAUMA VICTIMS

Healthcare professionals are a crucial resource for survivors of trauma and violence •Most survivors do not seek mental health help, and instead come into primary care practices with complaints of somatic symptoms (ex: HA) •Victims of IPV more likely to disclose to physicians and healthcare providers (50%) than others, especially primary care physician compared to other providers (86%) But healthcare settings can also be retraumatizing for patients •e.g.: Invasive procedures, state of undress, lack of control, state of vulnerability or powerlessness, gender of provider Routine screening and counseling for interpersonal and domestic violence is recommended by many health and medical organizations: •Institute of Medicine (2011) •Health and Human Services Administration (2011) •American Nurses Association (1991) •American Medical Association (1992) •...and is reimbursed by Affordable Care Act WOMEN WHO TALKED TO THEIR HEALTH CARE PROVIDER ABOUT ABUSE WERE: 4 times more likely to use an intervention (i.e., hotline, advocate, counselor, protection order) AND 71% of those who used an intervention reported it being extremely or very useful

INTIMATE PARTNER VIOLENCE:DEFINITION AND STATISTICS

IPV: mistreatment or misuse of one person by another in the context of an emotionally intimate relationship; physical, sexual, or psychological harm by a current or former partner or spouse 1 in 3-4 women and 1 in 4-7 men reports lifetime IPV 4% of women report past year physical IPV IPV Homicide - 40-50% of women who are murdered are murdered by a current or former partner [vs. ~5-10% of men] - 75% of women killed by partners had a hx of IPV Consequences - STIs - flashbacks, PTSD, disturbed sleep - bladder/kidney infections, PID - unintended pregnancy - Anxiety, depression, suicide

Attention-Deficit/Hyperactivity Disorder (ADHD)

Inattentiveness**, overactivity, impulsiveness > Persistent pattern* of inattention and/or hyperactivity and impulsivity (consistent in almost all situations and w/ almost all caregivers child demonstrates problematic behaviors) Often diagnosed when child starts preschool or school (b/c this is when they use more structure and they don't adapt well) Behaviors - Fidgeting, noisy, disruptive (may not sit still during activities, even ones they like they are in and out of seat) - Unable to complete tasks, failure to follow directions (easily distracted) - Blurting out answers, lost or forgotten homework - Unable to take turns and constantly interrupts others Possible ostracize/ridicule by peers Etiology oCause unknown: possible cortical-arousal, information-processing, or maturational abnormalities in the brain oOther theories: environmental toxins (ex: lead poisoning), prenatal influences, heredity, damage to brain structure and functions oParental exposure to drugs (tobacco), lead, severe malnutrition oDecreased metabolism in frontal lobes (essential for attention, impulse control, organization, goal-directed activity) > slight genetic link associated w abnormalities in catecholamine and serotonin metabolism

TRAUMA IS DEFINED BY 3 KEY COMPONENTS AND CAUSED BY A VARIETY OF EXPERIENCES

Individual trauma results from an event, series of events, or set of circumstances > experienced by an individual as physically or emotionally harmful or life threatening > lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being (guilt/shame, low self-esteem, problems at school and work, difficulty with relationships) Many experiences cause trauma 1. Abuse (cycle of abuse followed by apologizing) •Sexual/physical/emotional abuse or assault •Victim or witness to domestic, interpersonal, or community violence 2. Loss •Death/Abandonment •Neglect •Natural or manmade disasters •War, terrorism or political violence •Forced displacement 3. Chronic Stressors •Poverty •Racism, historical trauma •Community trauma •System-induced trauma and retraumatization Characteristics of Violent Families - Social isolation (don't invite others over or tell anyone) - Abuse of power and control (verbal, physical, financial) - Alcohol and other drug abuse - Intergenerational transmission process (patterns of violence are perpetuated from one generation to the next through role modeling and social learning)

Interventions: Socialization and Structured Activities

Interventions that may help: discussion groups with set agendas, exercise groups to promote physical activity, reality orientation groups, sensory stimulation, parties appropriate to time of year or that recognize important events (birthdays) Other structured activities may be recreational (sorting) or physical (walking) Refer to other members of treatment team, especially occupational, recreational, art, music, and dance therapists, as indicated

Alcohol

Intoxication and overdose - CNS depressant: relaxation/loss of inhibitions - Slurred speech, unsteady gait, lack of coordination, and impaired attention, memory, judgment, concentration - Aggressive behavior or display of inappropriate sexual behavior; blackout - Overdose: vomiting, unconsciousness, respiratory depression > Treatment: gastric lavage or dialysis to remove the drug and support of respiratory and cardiovascular functioning in an intensive care unit; Acamprosate can be used for detox > Will eventually have consequences like Wernicke encephalopathy, cirrhosis, ascites, pancreatitis, myopathy, esophagitis, hepatitis, leukopenia, thrombocytopenia, Korsakoff psychosis Withdrawal - CIWA - Onset within 4 to 12 hours after cessation or marked reduction of alcohol intake; usually peaks on the second day and complete in about 5 days - Symptoms: coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, n/v - Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium (DTs). - Withdrawal can be life-threatening. > we will give thiamine (prevent or to treat Wernicke- Korsakoff syndrome) and b12 b/c they can get depleted - Benzodiazepines for safe withdrawal (dose based on CIWA score); tapering > ex: Valium, Ativan, Librium > may add tegretol or dilantin if we think they are going to seize > Total scores less than 8 indicate mild withdrawal, scores from 8 to 15 indicate moderate withdrawal (marked arousal), and scores greater than 15 indicate severe withdrawal.

Interventions: Family and Community

Many people with dementia live in communities with their families When hospitalization occurs, need careful discharge planning to help family prepare to bring patient home See practical recommendations in Box 22-9

Depression and Dementia (+Disorientation)

May misinterpret depression in elderly as dementia Pseudodementia: reversible cognitive impairment caused by psychiatric disorder: depression Aggression in patients with dementia strongly linked to depressive symptoms Treatment of depression may prevent, manage physically aggressive behavior Disorientation - Common behavior related to dementia, with time orientation usually affected first, then place and person - Can be distressing to patient, who may be aware of this difficulty and embarrassed or frightened

Maladaptive Cognitive Responses

May occur episodically or be continual May be reversible or progressive deterioration in functioning - Inability to make decisions - Impaired memory and judgment - Disorientation - Misperceptions - Decreased attention span - Difficulties with logical reasoning

MEDICAL & FORENSIC HISTORY

Medical: •History (Focus on ob/gyn, psych -risk for suicide/homicide) •Medications & allergies Forensic: •History of the assault •What exactly was done to you This guides the SANE to know where to look for and collect evidence from. POTENTIAL LABS 1. Blood •Syphilis •Alcohol level •Hep B/C •HIV •Chempanel/CBC •Drug facilitate panel 2. Urine Sample •Pregnancy test •Gonorrhea/chlamydia •Drug screening •Drug facilitated panel

Interventions: Wandering

Medications may cause agitation and restlessness Wandering may meet patient's need for attention or desire to get away Decrease environmental stress, especially at night, when many people have decreased stress tolerance Provide safe areas where patients can move about freely

Substance Abuse

National health problem Actual prevalence of substance abuse difficult to determine (people lie/hide it) Detrimental effects - Alcohol is a causal factor in more than 200 disease and injury conditions - Absenteeism at work and high use of benefits - Prenatal exposure (fetal alcohol syndrome, neonatal abstinence syndrome increasing meaning babies who are in withdrawal b/c pregnant mom used drugs) - Increased violence

Interventions: Pharmacological Approaches

No cure for AD, but goal of AD research is to identify agents that prevent occurrence, defer onset, slow progression, or improve disease symptoms - Cholinesterase inhibitors may improve cognitive symptoms or temporarily reduce cognitive decline Donepezil (Aricept), galantamine (Razadyne), rivastigmine (Exelon): approved to maximize function of cholinergic neurons by inhibiting enzyme acetylcholinesterase (AChE) - Allow greater acetylcholine concentration in brain, improving cholinergic function - Exelon patch (rivastigmine transdermal system): only skin patch available to treat mild to moderate forms of AD Tacrine (Cognex): first cholinesterase inhibitor to receive approval as specific treatment for cognitive symptoms of AD but it causes liver toxicity problems and is seldom used - Because AChE is primary gastrointestinal motility-enhancing transmitter, nausea, anorexia, diarrhea common Memantine (Namenda), first N-methyl-D-aspartate (NMDA) receptor antagonist approved for moderate to severe dementia - May be combined with cholinesterase inhibitor for severe dementia

Attention-Deficit/Hyperactivity Disorder (ADHD) treatment

No one treatment effective Goals: managing symptoms, reducing hyperactivity and impulsivity, increasing child's attention Combination of medications, behavioral, psychosocial, and educational interventions (self-regulation like time-out) Medications oStimulants: methylphenidate (Ritalin), amphetamine compound (Adderall) > side effects: insomnia, loss of appetite, weight loss oAntidepressants (SNRI**) as second choice (Atomextine/strattera) > side effects n/v, decreased appetite, upset stomach > give w/ food, monitor LFTs for liver damage Home and school strategies oConsistent rewards and consequences > Praise > Time-out > Verbal reprimands > Daily report cards for behavior & using point systems oTherapeutic play > Dramatic play (act out anxiety-provoking situation) > Creative play (help express themselves)

Neurodevelopmental Disorders (exam 3 starts here****) > ALSO LOOK AT THE MED CHART IN CANVAS (specifically stimulants?)

Not diagnosed as easily in children as in adults (kids progress at different paces and kids can't always express or verbalize what is going on like their feelings) oLack of abstract cognitive abilities and verbal skills oConstantly changing and developing Similar problems as in adults such as mood (may look a little different than in adults; present as irritability), anxiety, and eating disorders (especially at ages like 12 & 13) Usually diagnosed in infancy or childhood; sometimes in adolescence Intellectual disabilities (often occur w/ other mental illnesses; impaired cognitive functioning ex: IQ less than 70 and limitations in functioning like communication, self-care, work, etc.) oMild (function well independently, have jobs, etc. just need a little structure), moderate (need more structure and supervision but can still function), severe (need a lot of structure) oDifferent causes (fragile X syndrome*, tay sachs disease, trisomy 21, problems during fetal development or birth like infections or trauma, etc.) > we don't hospitalize or institutionalize people for intellectual disabilities, just teaching structure at home etc.

Stages of Dementia: Stage II: Moderate - 2-10 years

Obvious memory problems Gets confused about recent events Decreased ability to perform activities of daily living Argues easily Seems anxious and depressed Paces Noticeable behavioral difficulties Close supervision needed

Autism Spectrum Disorder continued

Once thought to be rare (often used to be confused with intellectual disabilities) Genetic link (fragile X) Controversy with MMR vaccine oResearch has concluded no relationship Tendency to improve with acquisition and use of language ** Traits persist into adulthood Treatment goals: reduce behavioral symptoms, promote learning and development especially language (doesn't cure autism) Treatment: Special education, language therapy; antipsychotic medications (Haldol, Abilify, Risperdal) for specific target symptoms Related disorders oTic disorders oChronic motor or tic disorder oLearning disorders oMotor skills disorder oCommunication disorders oElimination disorders

WHY SANES?

One nurse to write up a single statement: •Prevents conflicting reports •Minimizes re-traumatizing the patient Photo documentation of injuries Systematic evidence collection Provide patient advocacy and trauma-informed care •Implementation of things like showers, clothing, & separate waiting rooms in ED settings SANEs trained in testifying in court SANE TRAINING (ADULT/ADOLESCENT) •40 Hours classroom training •16 hours clinical > Demonstrate foundational knowledge and skills needed to complete the essential functions of a SANE-A

Bulimia Nervosa

Onset: late adolescence or early adulthood (average age of 18-19 years) Binge eating frequently begins during or after dieting (might be a little overweight, but often normal weight) > purging can be excessive exercise or laxative use Between binging and purging episodes, clients may eat restrictively, choosing salads and other low-calorie foods Clients aware eating behavior is pathologic; go to great lengths to hide (ex: store food in secret) > self-monitoring can be effective b/c they are aware Complications - electrolyte imbalances (can cause seizures), GI (hemorrhage, chronic constipation or diarrhea), esophageal varices (enlarged veins from vomiting) Treatment oCBT (most effective; interrupt thinking and behaviors in cycle of dieting then binging then purging and dysfunctional thoughts about food and body image) oPsychopharmacology: antidepressants (SSRIs) > desipramine (Norpramin), imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), phenelzine (Nardil), and fluoxetine (Prozac) > Contraindicated w/ Wellbutrin b/c electrolyte imbalances

Eating Disorders

Overview - We have to eat to survive - Social and enjoyable - Obesity a problem in US - Anxiety about weight and image - Eating disorders are not new (fasting, self-starvation from early in history; not recognized); in 1960s became medical dx View on continuum: anorexia (eating too little); bulimia (eating chaotically; sometimes too much and then purging); obesity (eating too much) Categories oAnorexia nervosa > Restricting subtype (dieting, fasting, excessive exercise) > Binge eating and purging subtype (different than bulimia, still restricting food but when they do eat it's a large amount and then purging, still underweight) > Fear of gaining weight, disturbed perception of body image, body weight less than normal > Physical problems (amenorrhea, constipation, cold sensitive, lanugo, loss of body fat, muscle atrophy, hair loss, dry skin, dental caries, pedal edema, bradycardia and arrhytmias, orthostasis, enlarged parotid glands, hypothermia, electrolyte imbalances like hyponatremia and hypokalemia) oBulimia nervosa (recurrent episodes of binge eating followed by inappropriate compensatory behaviors to avoid weight gain, such as purging, fasting, or excessively exercising; often followed by shame or self-contempt; still normal weight but have dental caries and destroyed enamel) Related disorders oBinge eating disorder (without purging, often overweight) oNight eating syndrome (wake up in middle of night and binge eat 50% of daily calories; often obese) oPica (eating non-nutrient food substances like lead paint) and rumination (regurgitation of food, spit out and rechew and re-swallow that food) oOrthorexia nervosa (preoccupation or obsession w/ healthy eating; look at labels for everything) Comorbid Disorders - Mood disorders (depression) - Anxiety disorders - Substance abuse - OCD - Linked to neglect and sexual abuse

ANONYMOUS REPORTING AND NON-REPORTING

PATIENTS DO NOT HAVE TO REPORT TO THE POLICE IN ORDER TO HAVE A SEXUAL ASSAULT EXAM WHY ANONYMOUS REPORTING - not emotionally ready - poor social support - embarassed/ashamed - fear of retaliation/personal safety - reasons different for each person Any person age 18 and older* With no mandated reporting to law enforcement •*Under 18 may be required to report as child abuse based on state level policies •*Some vulnerable adult mandatory reporting laws will also supersede this Access to forensic medical evaluation and treatment Kits held various lengths of time (days to indefinitely based on jurisdiction) Anonymous reporting = jurisdiction has a way to test kits without ID Non-report = kits are held but not tested

ADVOCACY and Discharge

PREVENT STDS •Treatment for STDs by CDC Guidelines > HIV testing offered PREVENT PREGNANCY •Patients have the option to take Plan B or Ella within 120 hours of unprotected intercourse ** ADVOCACY •Lethality assessment •Arranges safe housing and transportation •Connect to legal resources (police, SA legal organizations) •Follow up with community or hospital-based advocacy DISCHARGE •Referral for follow up care •Patient may be offered a shower, clean clothes, or other basic comfort measures It often takes 1 year or more for survivors of rape to regain previous levels of functioning.

Mental Health Promotion for conduct disorder

Parenting classes > Assist parents to lower their own risky behaviors > Behavior therapy with parent and child Early detection of potential problems (SNAP-IV Teacher and Parent Rating Scale) Self-Awareness Issues - Recognize own beliefs and values about raising children. - Be aware of feelings about child's disruptive behaviors. - Focus on client's and family's strengths, not just problems. - Avoid a "blaming" attitude. Medications - Go to https://ocde.us/SPED/Documents/Quick%20Reference%20-%20Drugs.pdf ***

Interventions: Communication

Patients may be frustrated when constantly confronted with evidence of failing memory Direct conversational focus to topics patient initiates: memories of the past Deal with misperceptions of the present gently, diplomatically Make requests one step at a time; if repeating, state request in exactly the same way Nonverbal communication skills also important; verbal and nonverbal communication must be congruent Touch and nonverbal techniques can reassure Encourage humor, reminiscence, talking with family members—pictures or music may help Make patient's daily schedule predictable, unhurried, but flexible if needed Use distraction, diversion, decreased stimulation if patient becomes agitated

Decreasing Agitation

Patients may become agitated when doing something unfamiliar or unclear Explain expectations simply, completely If patient refuses to participate in an activity, continued insistence usually leads to increased agitation and sometimes loss of behavioral control, resulting in catastrophic response Best approach may be to wait a few minutes and then return to see if patient will agree to request Patient may think staff was too controlling and power struggle developed, or request made too abruptly

Intermittent Explosive Disorder

Repeated episodes of impulsive, aggressive, violent behavior; angry verbal outbursts not proportional to situation; may occur with no warning (usually lasting less than 30 minutes) > May physically injure others and self or property > May feel guilty after outbursts; this does not prevent future outbursts Most common in adolescence and young adulthood Etiology - Comorbid psychiatric disorders (substance abuse, ADHD, ODD, conduct disorder, anxiety, depression) - Associated w/ childhood trauma, neglect, maltreatment - Neurotransmitter imbalance (serotonin) - Plasma tryptophan depletion - Frontal lobe dysfunction Treatment 1. Psychopharmacology oFluoxetine (prozac) oLithium oAnticonvulsant mood stabilizers (Depakote, Dilantin, Topamax, Trileptol) oSSRI antidepressants (reduce aggressiveness) 2. Cognitive-behavioral therapy 3. Anger management 4. Relaxation techniques 5. Avoidance of alcohol and other substances

Autism Spectrum Disorder

Pervasive, usually severe impairment of reciprocal social interaction skills, communication deviance, restricted stereotypical behavioral patterns > some behaviors look similar to intellectual disabilities; sometimes can be difficult to differentiate > behaviors are consistent and pervasive across different areas of their lives Previous PDDs (pervasive developmental disorders like autism or rett disorder) now viewed on continuum called autism spectrum in DSM5 Range from mild (aspergers) to severe behaviors and limitations Present by early childhood (18 months to 3 years); more prevalent in boys > 18 months: time they get their immunizations Behaviors - Little eye contact; may be uncomfortable w/ touch - Few facial expressions, limited gestures to communicate - Limited capacity to relate to peers or parents - Lack of spontaneous enjoyment, express no moods or emotional affect - Inability to engage in play or make-believe with toys - Little intelligible speech; Delayed speech and language skills (echolalia) - Stereotyped motor behaviors like hand flapping, body twisting, or head banging > Not responding to own name by 1 year (e.g., appears not to hear) > Doesn't show interest by pointing to objects or people by 14 months > Doesn't play pretend games by 18 months > Prefers to be alone (doesn't seem to get separation anxiety) > Obsessive interests (gets stuck on one toy or one idea) > Upset by minor changes in routine > Repeats words or phrases over and over (echolalia); answers are unrelated to questions > Flaps hands, or rocks or spins in a circle > Unusual reactions to sounds, smells, or other sensory experiences

THE PATIENT AS A CRIME SCENE

Physical examination should occur before the victim has showered, brushed teeth, douched, changed clothes, or had anything to drink EVIDENCE ON THE BODY - removing clothing carefully (if needed) - cut away from obvious stains or holes - don't remove ligatures unless restricting breathing or circulation - if ligature must be removed before SANE arrives - cut away from the know or fastening - photograph or diagram before altering if possible PRESERVING EVIDENCE:CHAIN OF CUSTODY •Dry clothing in separate PA P E Rbags -one item per bag > related to contamination of evidence •Don't shake out clothing •If clothing comes to us already bagged: > Leave as is > Transport with patient to the SANE •Dry all evidence before packaging > Wet evidence = moldy = no good evidence L

Conclusion

Population of individuals with altered cognitive responses is growing Delirium common in hospitalized patients, particularly in ICUs, geriatric psychiatry units, emergency departments, alcohol treatment units, oncology units

CONNECT TO THE SPECIFIC KIND OF VISIT: SRH

Pregnancy tests: Anytime patients come in for a pregnancy test, we ask them all whether the sex they had was consensual. Was this something you wanted to do? STI testing: Anytime patients come in for STI/HIV testing, we always ask if they feel comfortable talking with their sexual partners about condom use. Birth control options: Do you feel safe asking your sexual partners to use protection? DEPRESSION AND ANXIETY: "Could your relationships be contributing to these feelings?" SUBSTANCE USE: Has anyone pressured you to drink or use drugs? Has what's going on with your partner made you feel like drinking/using more? - In addition to survivors using substances to cope with trauma, perpetrators may also use substances to coerce, control or harm victims.

Vascular Dementia

Previously called multi-infarct dementia; caused by disrupted cerebral blood supply 1. Hemorrhage, hypoperfusion (cardiac arrest, hypotension), ischemic stroke, postsurgical complications 2. Vasculitis from autoimmune (lupus) or infectious (neurosyphilis, Lyme) diseases or with hypertensive vascular disease

Diagnosis & Outcomes for Dementia

Primary NANDA-I Nursing Diagnoses - Acute or chronic confusion - Impaired social interaction - Diagnosis should consider underlying stressors and patient behaviors - Most cognitive impairment disorders are physiological, so nurse should consider patient's physical needs, age, psychosocial behavioral problems Outcome for patient with maladaptive cognitive responses: patient will achieve optimum cognitive functioning Goals: improved ability to process information or optimum use of abilities the patient retains (if impairment irreversible) - Make goals realistic to avoid frustration - Update, modify nursing goals as needed Planning - Life-threatening problems always receive highest priority for nursing intervention - Protection of safety almost always a concern - Direct mental health education toward the family, who are often caregivers for these patients - See Table 22-8

Hallucinogens (ex: ectasy, Phencyclidine = PCP, LSD)

Reality distortion; symptoms similar to psychosis including hallucinations (usually visual), depersonalization - Cause increased pulse, blood pressure, and temperature; dilated pupils; and hyperreflexia Intoxication: maladaptive behavioral/psychological changes, anxiety, depression, paranoid ideation, ideas of reference, fear of losing one's mind, and potentially dangerous behaviors No overdose; toxic reactions are primarily psychological PCP toxicity: seizures, hypertension, hyperthermia, respiratory depression - Medications to control seizures and blood pressure - Cooling devices (hyperthermia blankets) - Mechanical ventilation No withdrawal syndrome - Some report a craving for the drug Flashbacks possible for few months up to 5 years

Memory

Remote memory: recall of events, information, and people from the distant past Recent memory: recall of events, information, and people from the past week or so Immediate memory: recall of information or data to which a person was just exposed

Stages of Dementia: Stage I: Mild - 2-4 years duration

Repeats words or action Has trouble remembering names and common objects Gets lost easily Loses things Beginning problems in activities of daily living Subtle personality changes Shows lack of interest in usual activities

CUES INTERVENTION FOR IPV ASSESSMENT AND REFERRAL

Review limits of Confidentiality - Discuss confidentiality (Duty to warn refers to the responsibility of a counselor or therapist to inform third parties or authorities if a client poses a threat to themselves or another identifiable individual) CRIPTS: DISCLOSING LIMITS OF CONFIDENTIALITY WITH MINOR PATIENTS - "Before I get started, I want you to know that everything here is confidential, meaning I won't talk to anyone else about what is happening unless you tell me that you are being hurt physically or sexually by someone or planning to hurt yourself " Universal Education & Empowerment (offer safety information and encourage sharing) - Provide universal education on consensual sex, healthy relationships, harm reduction - "We've started giving this card to all our patients so they know how to get help for themselves or so they can help others" > NORMALIZE conversation > UNIVERSAL intervention Direct assessment for IPV - Do you feel safe in your relationships? Are you or your family/friends concerned for your safety? - Do you ever feel threatened and if you do is there someone you can call or a place you can go to? - Do you have a plan if suddenly your situation becomes unsafe? If IPV is disclosed: - Harm reduction strategies - Warm referral to advocacy services (support) If IPV is not disclosed: - Information on resources THINGS TO REMEMBER: •Focus on prevention in addition to intervention. •All patients have access to information on IPV services, not just those who disclose. •Disclosure is not the goal •Violence advocates are key members of the health care team through warm referrals.

Coping Mechanisms: Dementia

Some patients use denial and attempt to pursue their usual daily routine, making light of memory lapses, or using some environmental resources to cope Regression often used to cope with advanced dementia, involves deterioration in mental function

Interventions: Sensory Enhancement

Soothing music based on personal preference can calm, reduce agitation Aromas of essential oils from plants or flowers can positively affect mood, sleep, stress in people with dementia Massage or touch therapy may comfort

Interventions for Dementia

Stressors do not present immediate threat to life, so highest priority to nursing care to help patient maintain optimum level of functioning: - Adjust routines to focus on person, not task - Adjust interaction and communication strategies, ensure person receives message - Change reactions, responses to behavior - Monitor, adjust environment

Dual Diagnosis

Substance abuse + another psychiatric illness Estimated 50% of people with a substance abuse disorder also have mental health diagnoses Successful treatment, relapse prevention strategies (see Nursing Care Plan) - Healthy, nurturing, supportive living environments - Help with fundamental life changes, such as finding job, abstinent friends - Connections with other recovering people - Treatment of comorbid conditions Clients identified the need for - stable housing - positive social support - using prayer or relying on a higher power - participation in meaningful activity - eating regularly, getting sufficient sleep, looking presentable

Tic Disorders

Sudden, rapid, recurrent, nonrhythmic stereotyped motor movement (like blinking, cough, jerking neck, etc.) or vocalization (clear throat, snort, bark/grunt or complex like repeating words) > exacerbated w/ stress Treatment with atypical antipsychotics (olanzapine/zyprexa or risperidone) > sometimes tics can be developed after an infection (giving broad spectrum antibiotics can help) ** Tourette disorder: multiple motor tics, one or more vocal tics Chronic motor or tic disorder: either motor or vocal tics, not both

Substance Abuse and Nursing Process Application

The Simple Screening Instrument for Alcohol and Other Drugs (SSI- AOD) Assessment - History: chaotic family life, family history, crisis that precipitated treatment (physical problems or development of withdrawal symptoms while being treated for another condition); often seek treatment b/c other people tell them to - General appearance and motor behavior normal; may be anxious or apprehensive - Mood and affect: tearful; expressing guilt, remorse; angry; sullen; quiet; unwilling to talk; irritable; may seem fine if in denial - Thought process and content: minimize substance use; blaming others; rationalization; denial - Sensorium and intellectual processes: intact - Judgment and insight: poor judgment; impulsivity; limited insight; may still believe he or she can control substance use - Self-concept: low self-esteem; problems identifying and expressing feelings; difficulty coping without using substance - Roles and relationships: often strained; may have legal issues; absenteeism and poor work performance - Physiological considerations: poor nutrition; sleep disturbances; liver damage; HIV infection; lung or neurologic damage Data analysis/nursing diagnoses - Related to physical health status > Imbalanced nutrition: Less > Risk for injury > Diarrhea > Excess fluid volume > Activity intolerance > Self-care deficits - Related to substance use > Ineffective denial > Ineffective role performance > Dysfunctional family processes: Alcoholism > Ineffective coping Outcome identification - Abstain from alcohol and drug use - Express feelings openly and directly - Accept responsibility for own behavior - Practice nonchemical coping alternatives - Establish an effective aftercare plan Interventions: Detoxification is the initial priority; safety, nutrition, fluids, elimination, and sleep - Health teaching for client, family (it is an illness, abstinence is not a matter of willpower, any alcohol or even prescribed meds can be abused, decrease codependent behavior, set realistic goals) - Addressing family issues (codependence/enabling by helping them get avoid consequences of using or making excuses for them or doing things for them that they can do for themselves, shifting roles) - Promoting coping skills > role-play difficult situations > relaxing, exercising, listening to music, or engaging in activities to reduce anxiety > focus on the present, not the past; set goals - If it is a chemically impaired professional tell supervisor* Evaluation: absitinence

Cannabis (Marijuana)

Used for psychoactive effects Medical applications (lowering intraocular pressure in glaucoma, n/v in chemo patients, anorexia and weight loss of AIDS, seizure control) Intoxication - Lowered inhibitions, relaxation, euphoria, increased appetite - Symptoms of intoxication include impaired motor control, impaired judgment, conjunctival injection (bloodshot eyes), dry mouth, hypotension, and tachycardia - Delirium, cannabis-induced psychotic disorder - No overdose No clinically significant withdrawal syndrome - Possible symptoms of insomnia, muscle aches, sweating, anxiety, tremors