Module 4

Red flags for suicide in assessment

****Suddenly going from sad and depressed to happy and peaceful: -Often the decision to commit suicide gives a feeling of relief and calm. *****Patient gives away treasured possessions.

Ages for suicide

-3rd leading cause of death for adolescents, 15 to 24 years of age, and is the fastest growing group of suicides. - 2nd leading cause of death in young adults, 25 to 34 years of age. - 4th leading cause of death in young adults, 35 to 54 years of age. - 8th leading cause of death for persons 55 to 64 years

Cluster B

Cluster B are emotional, dramatic, erratic, flamboyant, poor impulse control and an unclear sense of identity. Manipulation is a common defensive mechanism; their behavior is always challenging.antisocial, borderline, histrionic, narcissistic personality.

Oppositional Defiant Disorder (ODD)

Oppositional Defiant Disorder (ODD) •Angry mood. •Defiant and headstrong behaviors. •Almost all children show symptoms found in ODD. However, for ODD to be diagnosed, the behaviors need to occur "more persistently and frequently."

Describe the need and rationale for postvention for family or friends of an individual who has completed suicide.

Post trauma debriefing should be initiated within 24-72 hours after the death. Natural feelings of denial and avoidance during the first 24h. Often lack normal mourning supports (which is normal). 45% of survivors report mental/emotional deterioration within 6 months. The ultimate goal of intervention is to reduce the trauma associated with the sudden loss. Can help lessen guilt, anger, pain, grief, and myriad emotions

90% of suicide completes had a diagnosable condition

-50%: Mood disorders, MDD, and bipolar disorder - 25%: Alcohol and substance abuse disorders - 10%: Psychoses -5%: Personality disorders -5%: Physical illness (E.g., traumatic brain injuries [TBI], epilepsy, terminal and/or painful diseases like cancer, AIDS, MS, Huntington's, and Parkinson's)

risk for suicide

-ACUTE risk of suicide is associated with anxiety, insomnia, and substance abuse -many people attempt to complete suicide often have poor critical thinking skills, troubled emotional lives (depression, anger, ax, guilt, boredom), and a low threshold for emotional pain YOUTH suicide: children or teenagers who lost a parent to suicide or 3 times likely to commit suicide. Hx of bullying/victimization, hx of family suicide Adolescents and young adults 14-24: substance abuse, aggression, disruptive behaviors, depression, and social isolation. Older Adults: social isolation, solitary living arrangements, widowhood, lack of financial resources, poor health, and hopelessness. ******Most older adults who commit suicide have visited their primary care physician the month before the suicide, sometimes that very day. ****Recognition and treatment of depression in the medical setting helps prevent suicide in older adults.

dependent personality disorder

-Belief in inability to survive if left alone -Excess need to be taken care of -Solicit caretaking through clinging and submission -Perversely, excessively submissive -Intense fear of separation and being alone -Tolerant of poor, even abusive relationships •If relationship does end, the individual has an urgent need to get into another -Inability to make decisions without excessive reassurance

avoidant personality disorder

-Feelings of low self-worth -Hypersensitive to criticism or rejection -Avoid situations requiring socialization; withdrawal -Fearful of disappointment or ridicule -Inhibited, reluctant to express irritation or anger, even when justified -Social phobia

Schizoid personality

-Flat affect, appearing indifferent to both praise and criticism -Unable to establish relationships -Restricted range of interpersonal emotions -Invest little energy in human relationships; conversely, may invest enormous energy in nonhuman interests (e.g., mathematics, astronomy, etc.); often connect more with animals -Often creative, original thinkers

narcissistic personality disorder

-Grandiose sense of personal achievement -Haughty sense of entitlement -Lack of empathy; exploiting others to meet own needs -Increasing attention seeking over time -Envious of others -Use of splitting, tantrums -Can be sadistic, with paranoid tendencies

Describe factors that can make it difficult to identify somatic symptom disorders

-Individuals are often seen in medical clinics and not psychiatric settings because the distressing symptoms present as primary physical in nature. -Actual diagnosed medical issues and somatic syndrome disorders can be present concurrently which can make diagnosis difficult.

historonic personality disorder

-Manipulative, insensitive -Dramatic, rapidly shifting, charming, flamboyant, and sexually seductive behaviors -Need to become and remain the center of attention, love, and admiration -Constant, sudden emotional shifts and lability -Superficial, shallow, short-lived relationships -Lack insight into cause of relationship failures

obsessive-compulsive personality disorder

-Orderliness, stubbornness, attention to detail -Indecisiveness -Emotional constriction -Pervasive pattern of perfection and inflexibility -Perseveration (persistent pursuit of an action even in the face of repeated failures) -High achievers -Superficial, rigidly controlled intimacy -Stinginess

antisocial personality disorder

-Persistent disregard for others -Persistent violation of others' rights -Absence of remorse for hurting others (callousness) -Sense of entitlement -Deceitfulness -Impulsiveness; risky behaviors to "feel alive"

paranoid personality disorder

-Pervasive, persistent, inappropriate suspiciousness and distrust of others (unjustified) -Present as hostile, irritable, injustice collectors; jealous, lacking warmth -May appear businesslike and efficient, but generate fear and conflict in others -Find malice in benign comments and behaviors (ideas of reference)

Discuss how staff psychological postmortem assessment postvention may contribute to improved coordination of care.

-Psychological postmortem assessment -Agency protocol analysis -Documentation completion ****A postmortem assessment can help the team to determine any changes that might be made in agency protocol to improve safety.

Develop realistic and measurable outcomes and interventions for clients with somatic symptom disorders and dissociative disorders

-Pt will verbalize clear sense of personal identity -Pt will report decrease in stress (using scale of 1-10) -Pt will report comfort with role expectations -Pt will plan coping strategies for stressful situations -Pt will refrain from injuring self

schizotypical personality

-Resembles schizophrenia but with no psychosis -Odd, eccentric behavior and speech -Cognitive perceptual distortions without psychosis -May display magical thinking and rituals -Give-and-take conversations difficult -Genuinely unhappy about lack of relationships -Social anxiety and unhappiness may increase over time

borderline personality disorder

-Unstable, intense relationships -Instability of affect; unstable, frequent mood changes -Emotional lability (shifting from anxiety, to irritability, etc.) -Poor impulse control; self-destructive; suicide-prone -Chronic depression -Projected identification -Emotional dysregulation -Splitting

Apply communication strategies (guidelines) when interviewing and assessing an older adult

1. Gather preliminary data before the session and keep questionnaires relatively short 2. Ask about often overlooked problems such as difficulty sleeping, incontinence, falling, depression, dizziness, sexual activity, drug or alcohol use, or loss of energy. Ask about often overlooked problems such as difficulty sleeping, incontinence, falling, depression, dizziness, sexual activity, drug or alcohol use, or loss of energy 3. Paste the interview to allow patient to formulate answers resist tendency to interrupt prematurely 4. Use simple choice questions if older patient has trouble coping with open ended questions 5. Begin with general questions like "How can I help you most of this visit," or "What's been happening?" 6. Be alert for information on patient's relationship with others, thoughts about family or coworkers, typical responses to stress, and attitudes towards aging, illness, occupation, and death. 7. Assess mental status for deficits in recent a remote memory and determine if confusion exists 8. Note all medication patients taking, assess side effects, efficiency, possible drug interactions, and if patients taking them regularly incorrectly 9. Determine how fast the pt condition has been changing and assess the extent of the patient's concerns 10. Include family or significant other in interview for added input, clarification, support, and reinforcement with patient's permission

Autism Spectrum Disorder

A disorder characterized by deficits in social relatedness and communication skills that are often accompanied by repetitive, ritualistic behavior. st demonstrate two or more of the following: •Stereotyped or repetitive speech, motor movements, and echolalia, and the repetitive use of objects •Excessive adherence to routines, rituals, or excessive resistance to change •Fixated interests that are abnormal in intensity •Hyporeactive or hyperreactive to the sense of joy or unusual interest in sensory aspects of the environment (e.g., indifference to pain, heat, cold) Deficits in: •Social and emotional reciprocity (unable to give & take) •Verbal and nonverbal communicative behaviors used for social interaction •Developing and maintaining relationships appropriate to the ***Observe for social deficits: bonding with parents, dislike of cuddling, poor eye contact ,lack of interaction with peers developmental level

Discuss important communication techniques and questions needed to promote safety with a suicidal patient or one at risk for suicide

ALWAYS ASK "ARE YOU THINKING OF KILLING OR HARMING YOURSELF?" Assess the precipitating event: "is there something difficult you're facing?" Assess risk factors and protective factors Assess history of suicide in self, or family history. The degree of hopelessness and helplessness and the lethality of the plan. Let the pt know crisis is temporary, unbearable pain can be survived, help is available, the pt is not alone. Nurse remains nonjudgemental and listens attentively ****Determine whether the patient's age, medical condition, or psychiatric diagnosis places the pt at a higher risk

Compare and contrast the behaviors seen in borderline personality disorder and narcissistic personality disorder

Borderline is a pervasive pattern of instability of interpersonal relationships, self image, and affects and marked impulsivity, beginning by early adulthood and present in a variety of contexts. Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships. Identity disturbances markedly and persistently unstable self image or sense of self. Impulsivity in at least two areas that are potentially self damaging -overspending money, sex, substance abuse, reckless driving, binge eating. Recurrent suicidal behavior, gestures, or threats, or self mutilating. Affective instability due to a marked reactivity of mood. Intense episodic dysphoria. Chronic feelings of emptiness. Inappropriate, intense anger, or difficulty controlling anger. Transient stress related paranoid ideations or severe dissociative symptoms. Narcissistic personality a maladaptive social response characterized by a person's grandiose sense of personal achievement. They consider themselves special and expect special treatment. Their arrogant and haughty and entitled. They lack empathy for the needs or feelings of others and exploit others to meet their own needs. They always blame others for the problems they have caused. Admired and envied by others for what appears to be a rich life. they require admiration, their attention seekers. Often envy others success or possessions. Fragile self-esteem, prone to depression, rejection. Defense mechanisms of splitting, exhibit tantrums, and can be sadistic with paranoid tendencies. Shallow superficial relationships, based on what others can do for them. Associated with anorexia nervosa, substance abuse, cocaine being the highest used.

conduct disorder

Childhood-onset conduct disorder can be seen as early as 2 years of age. *** More severe than ODD***. -Is physically aggressive, has poor peer relationships, shows little concern for others, and lacks guilt and remorse Adolescent-onset conduct disorder results in less aggression. > get in trouble with the law -Acts out misconduct with peer group (e.g., truancy, early-onset sexual behaviors, drinking, substance abuse, risk-taking behaviors) Assessment: lags or deficits in cognitive, psychosocial, and moral development > do they have remorse for the bad things they've done? these result in disruptive behaviors. •Quality of child-parent/caregiver relationship: -Bonding, anxiety, tension, and difficulty-of-fit between the parent and child's temperaments can contribute to these problems. •Parent or caregiver's understanding of growth and development and parenting skills: -Lack of knowledge contributes to the development of these problems

Cluster A

Cluster A they are seen as odd or eccentric, have been estrablished to have some relationship to schizophrenia. Individuals avoid interpersonal relationships, have unusual beliefs and may be indifferent to the reactions of others in their lives. Refuse responsibility of their own, blame others. Schizotypal, schizoid, paranoid personality.

Cluster C

Cluster C experience high levels of anxiety and outward signs of fear. Show inhibitors, mostly in he sexual sphere(shy and akward with potential sexual partners, impotence, or rigidity.) often fearful and reluctant to express irritation and anfer with others even when its justified. Paranoid, antisocial, borderline, narcissistic personalities who tend to blame others

ADHD

Combined Presentation, Predominantly Inattentive Presentation (formerly called ADD), Predominantly Hyperactive or Impulsive Presentation •Further assessed as mild, moderate, or severe and symptoms present prior to age 12 •Symptoms: Problems with concentration and focus, easily distracted, appearing not to listen, lack of follow- through, organizational and time-management challenges, and forgetfulness *Behavior modification, parent training, school accommodations, and pharmacologic agents that address inattention and hyperactive and impulsive behaviors •Special education programs that address academic difficulties •***Psychotherapy and play therapy to determine emotional problems that develop as a result of the disorder Methylphenidate (Ritalin) is the most widely used medication and available orally and as a transdermal patch (Daytrana)

Compare and contrast the etiologies and basic symptoms of somatic system disorders and dissociative disorders

Communication guidelines: gentle, supportive, build rapport Health teaching and health promotion: coping skills, stress management, techniques to interrupt a dissociative episode; journal to identify triggers Milieu Therapy: safe, quiet, structured, supportive Psychotherapy: most effective treatment (special training required) Pharmacologic, Biological, and integrative: mostly for co-morbid symptoms. Somatic: Characterized by the presence of multiple, real, and/or physical symptoms for which no evidence of medical illness is revealed. Accompanied by abnormal thoughts, feelings and reactions to these symptoms. ***Persistent preoccupation with and distress over physical symptoms. ***Client experiences symptoms of significant anxiety and life impairment ***Associated with increased health care use, functional impairment, provider dissatisfaction, psychiatric co-morbidity, and failed treatment response. Somatic etiology: genetic - 20% 1st degree female relatives of female patients; early trauma, parenteral somatization, early exposure to illness, perceived or real rejection from parenteral, difficulty expressing distress verbally. PHYSICAL SYMPTOMS. Dissociative: characterized by mental detachment from conscious awareness in reaction to abuse. Involve a disruption in the consciousness with a significant impairment in memory, identity, social functioning, or perceptions of self. Dissociative etiology: cause of DID protective response to past trauma, began at early age and has been severe and repetitive experiences (sexual, physical, emotional, or other traumatic) Prolonged detachment from caretaker affects limbic thus affecting neurotransmitters. genetic vulnerabilities can run in families. CONSCIOUSNESS, MEMORY, IDENTITY.

Explore areas in the assessment of suicide and symptoms that would raise concern for patient safety that may be unique to children or adolescents.

Depression in children/adolescents: It is important to note that depression in children sx such as sadness, crying, lack of energy, change in appetite or sleep patterns, negative or suicidal thoughts. They may display anger, isolation, a change in dress (dark clothing, hair covering face or eyes, poor grooming), a change in friends, use of drugs, listen to music with sad or violent thing. They may display anger, isolation, a change in dress (dark clothing, hair covering face or eyes, poor grooming), a change in friends, use of drugs, listen to music with sad or violent themes, sensitivity, poor school performance, physical complaints (HA/stomach ache), self harm such a cutting, or other acting out behaviors

Compare and contrast the differences between amnesia and fugue and give a brief clinical example of each

Dissociative Amnesia: psychologically induced memory loss and inability to recall important personal information after a severe stressor. Scenario: Bob's vehicle hits an improvised explosive device. He and his friend are thrown onto the sand. Bob's friend dies. A convoy passes 2 hours later. Bob is sitting by his friend, staring into space, and is unable to state who or where he is. Bob states that he doesn't remember the explosion. Dissociative Fugue: sudden, unexpected travel from a customary locale, and the inability to recall one's identity after a traumatic event. Scenario: Lin, 19 years old is admitted to the psychiatric unit after police found her wandering in Louisiana shopping mall parking lot. Lind does not recall who she is or where she lives. It's later found that Lin lives in Oregon, where her fiancé had cancelled their wedding 2 weeks earlier

Discuss the safety procedures/interventions for an acutely suicidal individual during the crisis period (prior & during hospitalization) and after the crisis period

During: -Follow institutional protocol -provide safe environment. -Keep accurate and thorough records of patient's behaviors. (physical and verbal) Establish frequent rapport and assess pt for their ability to seek out staff when struggling with suicidal thoughts. -Suicide precaution or suicide observation (one on one monitoring at arms length away) -Keep accurate and timely records and document patient's activity. -Construct verbal/written no suicide contract. After: -arrange for patient to stay with family/friends -weapons and pills are removed -encourage pt to talk freely about feelings -Encourage pt to avoid decisions during crisis -Contact family members; arrange for individual or family crisis counseling -If anxiety is extremely high or pt hasn't slept; anti anxiety or depressant may be prescribed. FOLLOW-UP Pyshcotherapy cognitive reframing: encourage patients to look into their negative thinking and reframe negative thinking into neutral objective thinking > cognitive reframing helps people look at the situations in ways that allow for alternative approaches

Identify communication guidelines and teamwork strategies when working with a client exhibiting the following behaviors: a. extreme manipulation; b. impulsiveness; c. aggression.

Extreme manipulation: assess your reactions toward the patient. assess the patients interactions. Set limits of any manipulative behaviors, such as arguing or begging. Intervene in manipulative behavior, be vigilant avoid discussing yourself or other staff with the patient. Assess own reaction towards pt. Impulsiveness: People with PDs are excessively dependent, demanding, manipulative, stubborn, or may self- destructively refuse treatment. • Nurses greatly enhance their ability to be therapeutic when they combine: Limit-setting Trustworthiness Dealing with manipulations Authenticity with their own natural style • Identify and discuss what precedes impulsive acts. • Explore effects on self and others. • Recognize cues. • Identify triggers. • Discuss alternative behaviors. • Teach or refer the patient for coping skills training (e.g., anger management, assertive skills) .

Describe the predisposing factors that put children and adolescents at risk for psychiatric disorders.

Genetic > temperament, autism, schizo, etc.., biochemical > decrease In NE & serotonin, developmental, environmental, and cultural factors.

Formulate three nursing diagnoses stating client outcomes with corresponding interventions for at least three child and adolescent psychiatric disorders

Hopelessness r/t feeling of abandonment, long-term stress. Interaction-assist the client to explore the meaning of his life, satisfaction with his life, and life goals. Anxiety r/t perceived threat to self concept interventions assess the psychological maturity of the individual. Impaired social interaction r/t communication barrier, insufficient skills to enhance mutuality. Interventions- use peer-mediated interaction to increase social interactions of children on the autistic spectrum.

For the following typical behaviors seen in borderline clients, discuss the nursing interventions and rationales: a. hostility; b. self-harm (e.g., safety risks); c. demanding behavior

Hostility clarify communication process, decrease acute conflicts, teach the patient and family adapted coping behaviors. Self harm keep eye contact, keep the patient and the staff safe, keep dangerous objects away from the patient. Demanding behavior -remain calm, engage in conversation to draw out the patients feelings, avoid arguing, set boundaries.

Formulate three nursing diagnoses stating client outcomes with corresponding interventions for a client with a borderline personality disorder.

Infective coping, labile, emotional control, impaired parenting, impaired social interaction, hopelessness, fear

Compare living wills, directives to physicians, and durable power of attorney for health care as they relate to the mental health patient

Living Wills: is a personal statement of how and where one wishes to die, and can be changed at any time by the individual > activated only when person is terminally ill and incapacitated Directive to Physician: a physician is appointed by the individual to service proxy. Many features parallel those of Living will, and designating the position as surrogate can particularly useful in cases of terminal ill when individual has no family. Unlike the Living Will, the directive to physician can be revoked early at any time without regard to patient competency Durable Power of Attorney for Health Care: differs from a Living Will in that a person is appointed to act as a patient's agent. Individuals do not have to be terminally ill or incompetent to allow the empowered individual to act on their behalf

Identify needed interventions that might provide quality improvement methods to help identify and prevent suicide for returning war veterans

More deaths in active duty are by suicide vs combat Risk behavior among returning veterans: -results in a disproportionate rate of death from accidents or unintentional poisonings. -common behaviors consistent with PTSD ****Veterans with TBI more likely to commit suicide***** psych eval needed before and after

Analyze the interrelatedness of biological determinates, chronic traumas and psychodynamic issues in the cause of personality disorders

Neurobiologic factors: Disturbed levels serotonin, abnormalities of prefrontal, cortico-striatal, & limbic networks. Aggressive, impulsive behaviors Affective instability Psychologic Influences: Childhood neglect is particularly damaging. Repeated cycles of trauma may reorganize the brain's cortical map, cognitive & behavior development & the unconscious. •Childhood trauma: -Excessively harsh and erratic discipline, alcoholic parent(s), and abusive and chaotic home life are risk factors for borderline PDs (BPDs) and antisocial PD's in particular. -Sexual abuse is a risk factor for a BPD.

Employ assessment guidelines including safety promotion for the older adult when performing a comprehensive geriatric assessment.

Older generations were raised to keep personal matters private and were taught not to be processed emotions in the same way as younger generation have been. One of the gifts the nurses can give their older patient is an understanding of this generational difference, and some gentle education guided by patient comfort level. A private and quiet setting is essential to a thorough assessment that touches on many personal topics, including sex and abuse. Additional measures include asking the patient what they would like to be called, positioning self at the same level, you using touch per patient comfort level, body language, I contact to convey warm in interest, and summarizing and inviting feedback or helpful.

Identify the causative factors and physiological effects of alcohol/substance abuse in the older adult compared with those on a younger adult

Older patients may have different definition or understanding of alcohol or substance abuse. Cocktail hours more common among older generations. As was generous prescribing Benzos. Elderly patients with substance-abuse use issues may have a long-term problem or newly developed addiction in response to life stressors. The loss of spells and distance from family they contribute to alcoholism. The lack of structure from work or raising a family may be in the impetus for a social drinker to advance to a problematic level of use. Older adults have an increased biological sensitivity to (decrease tolerance for) the effects of alcohol. Decrease tolerance is related to slower emptying of stomach contacts, slow metabolism including hepatic function, and an increase sensitivity to alcohol in the brain. As people age there is a decline in lean muscle mass and increase in fatty tissue that can contribute to increased blood alcohol levels. Age related changes such as decrease dexterity, balance, and flexibility can increase falls, burns or other incidents under the influence. *****Prognosis for the late-life problem drinker (i.e., person who has lived without recourse to alcohol and whose drinking is caused by a loss or stress) is excellent. •*****If the history of alcohol use is long and the patient meets the criteria for alcohol addiction, then a more rigorous treatment plan is required. •****Often the regimen includes detoxification in a 5- to 7-day inpatient unit. •Naltrexone (an opiate antagonist) is safe and effective for long-term treatment in older adults

Summarize the overt, covert, and behavioral clues and steps in evaluating the lethality of a suicide plan for an individual who is contemplating suicide

Overt: (OVER IT) "I can't take it anymore" "Life isn't worth living anymore" I wish I were dead" "Everyone would be better off if I died" Covert: (COVERING) "It's ok now. Everything will be fine" "Things will never work out" "I wont be a problem much longer" "Nothing feels good to me anymore, and probably never will" "How can I give my body to medical science?" Behavioral:*****Giving away prized possessions Writing farewell notes Making out a will Putting personal affairs in order Having global insomnia *****Exhibiting a sudden/unexpected improvement in mood after being depressed or withdrawn Neglecting personal hygiene Determine the lethality of the plan -how detailed is the plan? the more detailed the greater its lethal -how lethal is the proposed method? "guns, hanging, care crash -availability of means. Does the person have guns? access to a tall building?

Compare and contrast treatment modalities for children and adolescents

Parental involvement and support is critical for the child. Group therapy in young children takes the form of play. Milieu therapy therapeutic environment that facilitates growth, safety and positive change. Behavior modification and cognitive behavioral therapy rewarded behavior is more likely to be repeated. Removal and restraint are dangerous and controversial treatment modalities for children and adults. Therapeutic holding is nonpunitive in nature, or helmets to protect a patient during head banging can be used. Quiet room for a youth that needs to be removed from the situation for either self control or control by the staff. Time out is common method for intervening in disruptive or inappropriate behavior, both by parents, and in mental settings. Play therapy based on the notion that play is the work of childhood and the way a child learns to master impulses and adapt to the environment. Drawings can be evaluated fir inner conflict, family relationships and other stressors in the child's life. Dramatic play therapy also called psychodrama treatment modality that uses dramatic techniques to act out emotional problems, examine the experience develop new perspectives and try out new behaviors. Therapeutic games are ideal assessment tool for children who may have difficulty talking about their feelings and problems and also allow nonthreatening way to develop rapport. Bibliotherapy involved using children's books and literature to help the child express feelings in a supportive environment, gain insight into feelings and behavior, and learn new ways to cope with difficult situations. Therapeutic drawing allows children to spontaneously express themselves in artwork that captures thoughts, feelings and tensions they may be unable to express verbally. Music therapy instigates changes in both the physiology of the nervous system and social interactions. Movement and dance therapy is a direct expression of the self that helps the youth become more aware of feelings and thoughts, dissipate tensions, develop greater body awareness, improve or correct a distorted body image, improve coordination, and increase social interactions. Recreational therapy takes place off the unit and is often conducted by a recreational therapist with the assistance from the nursing staff.

Identify some concerting feelings that health care professionals frequently experience when working with individuals with personality disorders.

Patient's problems can overwhelm health care professionals. Intense feelings evoked in a nurse often mirror the feelings of a patient: -For example, a patient might tell a nurse, "You're inadequate and incompetent!" They may feel confused, helpless, angry, and frustrated. **frequent communication among staff & continuous availability of supervision & support are vital in times when behaviors, & effectiveness of staff members Patients are abusive of authority and successful in splitting staff in an attempt to defend against the patient's own feelings of frustration and powerlessness .When staff members are split, the result is conflict Untrained staff members may become vengeful in response to a sense of entitlement, manipulation, dependency, ingratitude, impulsivity, and rage

Describe "la belle indifference." Give a clinical example of this behavior

Patients highly distressed or show a lack of emotional concern. Episodes are typically brief but may become chronic. Some sx such as tremor my disappear when the pt is distracted.

Identify the major symptoms (relief behaviors) typically manifested in each of the somatic disorders and each of the dissociative disorders

Patients with many somatic complaints often become dependent on pain, GI problems, sexual dysfunction, fatigue, anxiety, and sleep medications. Dissociative episodes may be associated with recent use of alcohol or other substances such as cocaine, opioids, sedatives, or stimulants.

Explain the requirements for the use of physical and chemical restraints in the older adult

Physical restraints: •Physician's order must be obtained. •Restraint application must be time limited. •Attempts at alternative approaches must be documented. •Ongoing observation and assessment must be documented. •Care (e.g., provision of food and fluids, toileting, help with ADLs, response to attempted release) must be documented. -From The Joint Commission (TJC) guidelines should be used for emergency purposes only when there's a threat to the safety of the resident or others never as a means of controlling behavior or punishment Unfortunately, with restrictions on physical restraints and because of the lack of any FDA- approved medication, there has been an increase in off-label use of certain medications (particularly second-generation antipsychotics) as chemical restraints to control the behavior of elderly dementia patients, as well as to control the staff's working environment FDA issued black box warning's for use of antipsychotics and controlling behavior symptoms in elderly patients with dementia due to the dangers included increased risk for diabetes and CV events as well as doubled risk for mortality.

Explain the purpose of the different group interventions commonly used with older adults to meet their psychosocial needs

Re-motivation therapy: resocialize regressed and apathetic patients. Reawaken interest in the environment. Reminiscence therapy: share memories of the past. Increase self-esteem. Increase socialization. Increase awareness of the uniqueness of each. Pyschotherapy: alleviate psychiatric symptoms. Increase ability to interact with others in the group. Increase self-esteem. Increase ability to make decisions and function more independently.

Describe the roles of culture, religion, and socioeconomic status as they relate to suicidal risk

Religion: Judeo-Christian tradition: life is a gift; to take it is a sin. Shinto religion: suicide may be honorable Vulnerable groups: indigenous people, refugees, and LGBTQ persons. Higher suicide rates are seen among incarcerated and show who live through war. Protective factors: African Americans: Religion and extended family Hispanic Americans: Roman Catholicism and extended family (suicide considered a sin) Asian Americans: suicide rises with aging -suicide completes, 4x likelymen and increase w/ age -peaking after 75 -female suicide peaks after 55 -whites 2-3x more likely than African american -american Indian/ Alaska natives age 15-24, 2.5x higher than national group average

Explain how the characteristics of resilience can mitigate against etiological influences

Resiliency (toughness, able to recover quickly from difficulty) helps protect children and adolescents in a stressful situation. Temperament, problem-solving skills, and the support of a nurturing adult contribute to resiliency and successful navigation of stressful events.

Identify the risk factors for elder suicide and the nurse's role in prevention of suicide

Risk factors: hopelessness, uselessness/despair, widowhood, acute illnesses and intractable pain, status change, chronic illnesses, family history of suicide, chronic sleep problems, alcoholism, depression, and other losses. Losses may be personal, economic, social, or functional. Nurses play a vital role in prevention of older adults suicide due to their presents and every care setting and the trust patients place in them. Talking about suicide shouldn't be avoided but with all ages even more with elderly, communication to subject suicide must be approach gently. Just the word suicide can be upsetting and stigmatizing and people have different definitions for it. Examples of beginning approach maybe to ask the person if he or she is wishing not to be around, not to be alive, be with deceased loves ones, or no longer experiencing all the stressors. Helping the patient remember and talk about what here she has to live for, or what he or she would want to see in the future is helpful in alleviating suicide thoughts

Provide patient-centered care by discussing the implications as well as the risk factors identified in the Modified SAD PERSONS Scale when determining risk for suicide potential

Risk for suicide is immediately important. (Self-restraint from suicide is the hoped-for outcome) S: SEX > male 1 pt A: AGE 19-45 D: DEPRESSED/HOPELESSNESS > 2 P: PREVIOUS ATTEMPTS OR PSYCHIATRIC CARE E: EXCESSIVE alcohol OR DRUG USE R: RATIONAL THINKING LOSS (PYSCHOTIC OR ORGANIC ILLNESS S: SEPERATED, WIDOWED, DIVORCED O: ORAGANIZED PLA /SERIOUS ATTEMPT >2 N: NO SOCIAL SUPPORT A: AVAILABILITY OF LETHAL PLAN S: STATED FUTURE INTENT (DETERMINED TO REPEAT OR AMBIVALENT)

Anxiety in Children and Adolescents

Separation Anxiety Disorder: Developmentally inappropriate fear of separation from the person to whom the child is most attached. •Selective Mutism: Consistent failure to speak in situations where speaking is an expectation, although the child is able to speak at other times. •Specific Phobias, in Childhood: include fear of the dark, monsters, costumed characters, injections, water, and certain animals. Phobias occur in 5% of children and 16% of adolescents

Differentiate the significant differences between the bulk of the somatic symptom disorders and factitious disorder. Explain how this would affect your thought process while giving nursing care

Somatic symptom disorders: general medical conditions affected by stress or psychologic factors (no voluntary control of their symptoms) Factitious disorders: fabrication of symptoms or self-inflicted injury to assume the sick role (or inflicted on others) Different from malingering: faking injury for obvious (usually monetary) gain

Explain the defense mechanisms including splitting and why so prevalent with some groups of personality disorders

Splitting is the inability to integrate both the positive andthe negative qualities of an individual into one person. The patient tends to think extremes an individuals actions are all good or all bad. Seen either black or white

Describe the importance of the developmental theory when performing an assessment or providing care for child/adolescents. Give examples of developmental information you would gather.

The developmental theory is that a child's vulnerability to psychopathological conditions I the result of complex interactions between biological, psychological, genetic and environmental variables. Younger children are harder to diagnose than older children, because the boundaries between normal and abnormal behaviors are less distinct and children are less able to express themselves verbally. Intervention may be delayed until the child reaches school age and symptoms become more obvious. With a younger child you can have the child you can have the child draw, play games, and interactive play, such as puppets, or dollhouses, they are helpful for eliciting information from the children. The older child or adolescent should spend some time alone with the interviewer so the opportunity to disclose abuse is made available. • Mental status assessment is similar to that of adults except that the developmental level is considered. • Developmental assessment provides information about the child's current maturational level that, when compared with the child's chronological age, ******identifies developmental lags and deficits. • Denver II Developmental Screening Test is designed for infants and children up to 6 years of age.(Popular assessment)

Explain the concept of dissociation and the steps in dissociation in relation to early childhood trauma and/or sexual or physical abuse

When stress is intolerable for example, in severely abused child, the individual may develop dissociation to defend against the overwhelming pain and helplessness of the situation. In about half of the cases of depersonalization/derealization disorder, a recent traumatic antecedent cannot be identified. This may reflect a learned or biological etiology, but may also indicate a lack of recognition on the patient's part of abuse. Rather than an obvious incident of rape, for example, the trauma may have been a daily pattern of parental conflict. While these coping mechanisms first developed in childhood, they carry on to adulthood where they create difficulties in patient's life.

Review the effect of ageism in providing care to older adults and identify strategies to counter it

ageism: refers to deeply rooted negative attitudes or bias toward people because of their age. age prejudice: based on the notion that aging makes people increasingly unattractive, unintelligent, asexual, unemployable, and senile. age discrimination: actions and outcomes that reflect the bias towards the elderly. An example is hiring a younger inexperienced person over an elder seasoned employee with years of experience. Health care workers who deal on a daily basis with confused, ill, and frail older adults may tend to develop negative and biased view of them. The negative attitudes of most healthcare workers are often a reflection of stereotypical views of society. The rendering of medical care to older adults has been burdened with pessimism and professional at version. **Hearing and visual impairment, cognitive and memory deficits, child-resistant packaging, and an inability to afford medication all interfere strategies is to increase understanding of ageism by: -information about the aging process. -Discussion of attitudes relating the care of the older adult. -Sensitization of participants to their patient needs. -Use a valid and reliable assessment or specific to the older adult. -Use of online guidelines to prevent, identify, and manage geriatric syndromes. -Exploration of the dynamics of nurse-patient and staff- patient interactions, > grief loss and bereavement, ethical and legal issues, and communication

Compare and contrast the main characteristics of each of the three clusters of personality disorders

•Cluster A Disorders -Seen as "odd" or eccentric (strange/abnormal); have unusual beliefs -Avoid interpersonal relationships; often indifferent •Cluster B Disorders -Emotional reactivity, poor impulse control, manipulation -Unclear sense of identity •Cluster C Disorders -High anxiety and outward signs of fear -Inhibited, internalizing blame, even when not to blame