NURS 417 (Weeks 5, 6 & 7)
Trauma: Outcome Identification
1. The client will be physically safe. 2. The client will distinguish between ideas of self-harm and taking action on those ideas. 3. The client will demonstrate healthy, effective ways of dealing with stress. 4. The client will express emotions nondestructively. 5. The client will establish a social support system in the community.
Dementia: Cultural Considerations
- Clients from other cultures may find the questions difficult or impossible to answer. Such as
Conduct Disorder: Data Analysis and Planning
Nursing diagnoses commonly used for clients with conduct disorders include: - Risk for other-directed violence - Noncompliance - Ineffective coping - Impaired social interaction - Chronic low self-esteem
Define: Sodomy
- Anal intercourse - 12 states have laws that designate this as a crime, though such laws were invalidated by the Supreme Court in 2003
ADHD: Clinical Course in Adulthood
- 60% of children with ADHD have symptoms into adulthood. - Approximately 70% to 75% of adults with ADHD have at least one coexisting psychiatric diagnosis, with social phobia, bipolar disorder, major depression, and alcohol dependence being the most common
Define: Stereotyped Motor Behavior
- Hand flapping, body twisting, or head banging
Delirium: Assessment - History
- Often caused by medical illness, alcohol, or drugs. - Obtain a thorough history (from family if needed) - Should include alcohol, illicit drugs, OTC meds
Define: Exposure Therapy
A form of CBT, it is used to reduce anxiety and fear responses via gradual or simulated exposure to the anxiety-provoking stimulus. Best for Phobias and OCD
Drugs that Cause Delirium
Anesthesia Anticonvulsants Anticholinergics Antidepressants Antihistamines Antihypertensives Antineoplastics Antipsychotics Aspirin Barbiturates Benzodiazepines Cardiac glycosides Cimetidine (Tagamet) Hypoglycemic agents Insulin Narcotics Propranolol (Inderal) Reserpine Steroids Thiazide diuretics
Define: Callous and Unemotional Traits
Children with conduct disorder often exhibit callous and unemotional traits, similar to those seen in adults with antisocial personality disorder. They have little empathy for others, do not feel "bad" or guilty or show remorse for their behavior, have shallow or superficial emotions, and are unconcerned about poor performance at school or home.
Delirium: Assessment - Roles and Relationships
Clients are unlikely to fulfill their roles during the course of delirium. Most regain their previous level of functioning, however, and have no long-standing problems with roles or relationships.
Define: Aphasia
Deterioration of language function.
Elimination Disorders
Difficulty managing the elimination of bodily wastes, for example, difficulty controlling urination.
Define: Reminiscence Therapy
Discussing past activities and experiences with another individual or group.
Patient Health Questionnaire 9 (PHQ-9)
Further evaluates presence and severity of depression. Can be used for initial screening or follow up evaluation. Its available in primary care settings.
Define: Korsakoff Syndrome
Long-term use of alcohol that results in dementia is called Korsakoff syndrome or dementia. It was previously known as an amnestic disorder since amnesia and confabulation are common. Korsakoff's syndrome usually is found in the 40- to 70-year-old client with alcoholism and a history of steady and progressive alcohol intake. In time, this person develops a vitamin B1 (thiamin) deficiency that directly interferes with the production of the brain's main nutrient, glucose, resulting in the symptomatology of this syndrome. A client with this disorder has great difficulty with recent memory, specifically the ability to learn new information. Because of the inability to recall recent events, the individual fills in memory gaps with fabricated or imagined data (confabulation).
Define: Externalizing Behavior
Lying Cheating at school Swearing Truancy Vandalism Setting fires Bragging Screaming Inappropriate attention-seeking Arguing Threatening Demanding Relentless teasing Anger outbursts
ADHD: Data Analysis and Planning
Nursing diagnoses commonly used when working with children with ADHD include: - Risk for injury - Ineffective role performance - Impaired social interaction - Compromised family coping
Define: Internalizing Behavior
Prefers to be alone Withdraws Sulks Won't talk Is secretive Overly shy Stares in lieu of verbal response Physically underactive Somatic aches and pains Dizziness Nausea, vomiting, stomach problems Fatigue, lethargy Lonely Guilt feelings Nervous Crying spells Feels worthless, unloved
Define: Echolalia
Repeating the last word heard several times.
Race and ethnicity and disparities due to racism:
Risk of poorer mental health outcomes: - Increased risk for mood disorders, which might be caused by racial trauma, racism, microaggressions. These are less likely to receive diagnosis and treatment. - Black, Indigenous, and people of color are disproportionately misdiagnosed with schizophrenia. Risk of poorer physical/medical health: - Due to systemic racism, educational inequities, cultural/language barriers, and history mistreatment within the healthcare system, BIPOC may have lower health literacy and less frequency of health visits due to negative experiences. Intersection with classism: - Due to systemic racism resulting in limited occupational opportunities, BIPOC may have restricted or limited financial resources.
SBIRT
Screening, Brief Intervention, and Referral to Treatment
Define: Derealization
Sensation of being in a dream-like state in which the environment seems foggy or unreal.
Define: Executive Functioning
The ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior
Conduct Disorder: Onset and Clinical Course - Children
The childhood-onset type involves symptoms before 10 years of age, including physical aggression toward others and disturbed peer relationships. These children are more likely to have persistent conduct disorder and develop antisocial personality disorder as adults.
Delirium: Data Analysis
The primary nursing diagnoses for clients with delirium are: - Risk for injury - Acute confusion Additional diagnoses that are commonly selected based on client assessment include: - Disturbed sensory perception - Disturbed thought processes - Disturbed sleep pattern - Risk for deficient fluid volume - Risk for imbalanced nutrition: Less than body requirements
Define: Quality of Life (QoL)
The standard of health, comfort, and happiness experienced by an individual or group.
Dementia: Onset and Clinical Course
When an underlying, treatable cause is not present, the course of dementia is usually progressive. Dementia is often described in stages: Mild, Moderate and Severe
ADHD: Interventions - Promoting a Structured Daily Routine
- A structured daily routine is helpful. - The child will accomplish getting up, dressing, doing homework, playing, going to bed, and so forth much more readily if there is a routine time for these daily activities. - Children with ADHD do not adjust to changes readily and are less likely to meet expectations if times for activities are arbitrary or differ from day to day.
What is an Annual Wellness Visit (AWV)?
- An annual appointment with the primary care team to create and update a personalized prevention plan. - Available to all Medicare part B recipients over 65 and is not subject to co-pays. - AWV is not a comprehensive phsyical exam, and is not designed to manage acute health conditions.
Oppositional Defiant Disorder vs Acceptable Behaviors in Children
- A certain level of oppositional behavior is common in children and adolescents; indeed, it is almost expected at some phases such as 2 to 3 years of age and in early adolescence.
Types of Child Abuse
- Physical - Sexual - Emotional - Neglect
Physical Abuse Signs in Children
1. Bruises involving no breaks in skin integrity 2. Burns, usually due to immersion in hot water, contact with cigarettes, tying with a rope, or the application of a hot iron. 3. Lacerations, abrasions, welts, and scars noted on the lips, eyes, face, and external genitalia 4. Missing or loosened teeth 5. Skeletal injuries such as fractured bones, epiphyseal separation, or stiff, swollen, enlarged joints.
Rape: Assessment
1. Physical examination; preservation of evidence (rape kit/rape protocol) -Should occur before woman has showered, brushed her teeth, changed her clothes, or had anything to drink -If no report of oral sex, brushing teeth and drinking fluids can be permitted immediately. 2. Description of what happened. If they cannot do so, the nurse needs to ask gently with care. Rape kits and rape protocols are available at the ED, and provide the equipment and instructions needed to collect physical evidence. The physician or a specially trained sexual assault nurse examiner is primarily responsible for this step of the examination.
Chapter 22
1.Discuss the characteristics, risk factors, and family dynamics of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). 2.Apply the nursing process to the care of children and adolescents with ASD and ADHD and their families. 3.Provide education to clients, families, teachers, caregivers, and community members for young clients with ASD and ADHD. 4.Discuss the nurse's role as an advocate for children and adolescents. 5.Evaluate your feelings, beliefs, and attitudes about clients with ASD and ADHD and their parents and caregivers.
Define: Fugue Experience
The client usually moves to a new geographic location with no memories of the past, often assumes a new identity.
Define: Palilalia
A pathological condition in which words are rapidly and involuntarily repeated
Define: Hyperarousal
Being on guard or hyper vigilant
Define: Depersonalization
The client has a persistent or recurrent feeling of being detached from his or her mental processes or body.
Define: Dissociative Identity Disorder
- (formerly multiple personality disorder) - The client displays two or more distinct identities or personality states that recurrently take control of his or her behavior. - This is accompanied by the inability to recall important personal information. Ex: A normally calm client becoming aggressive and using abusive language at times.
Delirium: Treatment and Prognosis
- 1st you want to ID and treat any causal or contributing medical conditions - Almost always a transient condition that clears after cause is treated. - Some causes such as a head injury or encephalitis may leave the client with cognitive, behavioral or emotional impairments - Patients who've had delirium are at higher risk for future episodes
Dementia: Role of the Caregiver
- 34% of caregivers for those with dementia are 65+ - 2/3 of caregivers for htose with dementia are women - Over 1/3 are adult daughters. - Trend towards caring for family members at home is largely due to the high cost of institutional care, dissatisfaction with institution care, and difficulty finding suitable placements with clients with disruptive/difficult behaviors. - Other reasons include the desire to reciprocate for past assistance, to provide love and affection, to uphold family values or loyalty, to meet duty or obligation, and to avoid feelings of guilt. - Caregivers need to know about dementia and the care, and how the disease progresses. Education on how to - Caregivers deal with feelings of loss and grief - need an outlet, support groups - Caregivers' lives change drastically when caring for a loved one. - They experience role reversal, where they are caring for their parent like the parent caring for them, and role strain when the demands of providing care are overwhelming. - Caregivers should take opportunities to get assistance from other people and services. Take care of themselves.
What is the Mini-Cog?
- 5 minute assessment that measures executive function and memory - Classified moderate and severe dementia, with excellent accuracy, mild dementia with good accuracy, and mild cognitive impairment with modest accuracy. - This consists of 3-item recall and Clock-Drawing Test (CDT) - A total score of 3, 4, or 5 indicates lower likelihood of dementia but does not rule out some degree of cognitive impairment.
ADHD: Clinical Course to Adolescence
- 60% to 85% of children diagnosed with ADHD continue to have problems in adolescence. - Impulsive behaviors include cutting class, getting speeding tickets, failing to maintain interpersonal relationships, and adopting risk-taking behaviors, such as using drugs or alcohol, engaging in sexual promiscuity, fighting, and violating curfew. - Many have discipline problems serious enough to warrant suspension or expulsion from high school. - Low self-esteem and peer rejection, continue to pose serious problems
Autism: When diagnosed
- 80% of cases of autism are early onset, with developmental delays starting in infancy. - The other 20% of children with autism have seemingly normal growth and development until 2 or 3 years of age, when developmental regression or loss of abilities begins. - They stop talking and relating to parents and peers and begin to demonstrate behaviors previously described. - Once thought to be rare. - Current estimates are 1 in 59 children in the US have it, and 1-2% of children worldwide. - Genetic link. - Vaccines are not the cause.
Etiology: Frontotemporal Lobar Degeneration or Pick Disease
- A degenerative brain disease that particularly affects the frontal and temporal lobes and results in a clinical picture similar to that of Alzheimer disease. - Early signs include personality changes, loss of social skills and inhibitions, emotional blunting, and language abnormalities. - Onset is most commonly 50 to 60 years of age; death occurs in 2 to 5 years. - There is a strong genetic component, and it tends to run in families.
Etiology: Lewy Body Dementia
- A disorder that involves progressive cognitive impairment and extensive neuropsychiatric symptoms as well as motor symptoms. - Delusions and visual hallucinations are common. Functional impairments may initially be more pronounced than cognitive deficits. - Several risk genes have been identified, and it can occur in families, though that is less common than no family history.
Define: Dissociative Disorders
- A disruption in the usually integrated functions of consciousness, memory, identity, or perception. - Those w/ history of childhood physical and/or sexual abuse may develop dissociative disorders. - The goal with therapy is to reassociate and put consciousness back together. Includes: - Dissociative amnesia - Dissociative identity disorder - Depersonalization/derealization disorder
Stuttering
- A disturbance of fluency and patterning of speech with sound and syllable repetitions.
Posttraumatic Stress Disorder (PTSD)
- A disturbing pattern of behavior demonstrated by someone who has experienced, witnessed, or been confronted with a traumatic event such as a natural disaster, combat, or an assault. - Exposed to an event that posed actual or threatened death or serious injury and responded with intense fear, helplessness, or terror.
School Shooter Perpetrators
- A few people responsible for such violence have been diagnosed with a psychiatric disorder, often conduct disorder. - Often, however, this violence seems to occur when alienation, disregard for others, and little regard for self predominates.
Etiology: Alzheimer's Disease
- A progressive brain disorder that has a gradual onset but causes an increasing decline in functioning, including loss of speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions, hallucinations, inattention to hygiene, and belligerence. - It is evidenced by atrophy of cerebral neurons, senile plaque deposits, and enlargement of the third and fourth ventricles of the brain. - Risk for Alzheimer disease increases with age, and average duration from onset of symptoms to death is 8 to 10 years. - Research has identified genetic links to both early- and late-onset Alzheimer disease.
Define: Adjustment Disorder
- A reaction to a stressful event that causes problems for the individual. - Typically, the person has more than the expected difficulty coping with or assimilating the event into his or her life. - Financial, relationship, and work-related stressors are the most common events. - Symptoms develop within a month, lasting no more than 6 months. - At that time, the adjustment has been successful, or the person moves on to another diagnosis - Outpatient counseling or therapy is the most common and successful treatment.
Geriatric Depression Scale (GDS)
- A screening instrument used in clinical settings to assess depression in older people. It uses a yes and no answer format. - A score of 5+ is suggestive of depression and should warrant a follow-up comprehensive assessment. - A score 10+ is indicative of depression - More comprehensive and tailored to elderly population. - Gold standard.
Etiology: Parkinson's Disease
- A slowly progressive neurologic condition characterized by tremor, rigidity, bradykinesia, and postural instability. - It results from loss of neurons of the basal ganglia. - Dementia has been reported in approximately 25% (mild NCD) to as many as 75% (major NCD) of people with Parkinson disease and is characterized by cognitive and motor slowing, impaired memory, and impaired executive functioning.
Define: Adaptive Disclosure
- A specialized CBT approach developed by the military to offer an intense, specific, short-term therapy for active-duty military personnel with PTSD. - Incorporates exposure therapy as well as the empty chair technique, in which the participant says whatever he or she needs to say to anyone, alive or dead. - This is similar to techniques used in Gestalt therapy. - Despite the short six-session format, this approach seems well tolerated and effective in reducing PTSD symptoms and promoting post-trauma growth
Define: Autism Spectrum Disorder
- A spectrum of neurodevelopmental disorders characterized by disrupted social and language development (formerly referred to as autism). - 5 times more prevalent in boys than girls. - Usually Identified by 18 months and no later than 3yo. - Persistent deficits in communication and social interaction accompanied by restricted, stereotyped patterns of behavior and interests/activities. - May display little eye contact, make few facial expressions toward others, use limited gestures to communicate. - Limited capacity to relate to peers or parents. - May lack spontaneous enjoyment, express no moods or emotional affect, and may not engage in play or make-believe with toys. - Can be little intelligible speech. - These children engage in stereotyped motor behaviors. - These behaviors and difficulties are less prominent on the milder end of the autism spectrum and more pronounced on the severe end
Define: Posttraumatic Stress Disorder (PTSD)
- A stress disorder experienced by some people after a traumatic event and whose symptoms include persistent re-experiencing of the trauma, avoidance of anything associated with the trauma, and heightened arousal - A pattern of behavior following a major trauma beginning at least 3 months after the event or even months or years later. Symptoms include feelings of guilt and shame, low self-esteem, reexperiencing events, hyperarousal, and insomnia. - Clients with PTSD may also develop depression, anxiety disorders, or alcohol and drug abuse.
Define: Dissociation
- A subconscious defense mechanism that helps a person protect his or her emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory. - Can occur both during and after the event. - As with any other protective coping mechanism, it becomes easier with repeated use.
Define: Delirium
- A syndrome that involves a disturbance of consciousness accompanied by a change in cognition. - Usually develops over a short period, sometimes a matter of hours, and fluctuates throughout the course of the day. - Clients have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. - They also experience disturbances in the sleep-wake cycle, changes in psychomotor activity, and emotional problems such as anxiety, fear, irritability, euphoria, or apathy.
Define: Sluggish Cognitive Tempo (SCT)
- A syndrome that is not a DSM-5 diagnosis. - It includes daydreaming, trouble focusing and paying attention, mental fogginess, staring, sleepiness, little interest in physical activity, and slowness in finishing tasks. - Many of these are observed in children with ADHD; however, there is no hyperactivity or impulsivity—just the opposite. - This leads some to believe that it is separate for ADHD, while others believe it is a variant of ADHD. Investigation is ongoing
Violent Families: Abuse of Power and Control
- Abuser is almost always the person who holds power and control over the victim. - They exert not just physical power, but also economic and social control. - This might be the only family member who makes decisions, spends money, or spends time outside the home with others. - The abuser will belittle or blame the victim, often using threats and manipulation. - Violence escalates if the victim makes any moves towards independence or disobediance
Child Abuse: Clinical Picture
- Abusers often have minimal parenting knowledge or skills. - May not know/understand what their children need. - May be angry/frustrated because they are emotionally or financially unequipped to meet those needs. ** This does not explain every incidence of abuse ** - Many incidences of abuse/violence occur in family who seem to have everything, the parents are well educated, financially stable. - Are often immature, needy and incapable of meeting their own needs, much less those of a child. - The parent often views the child as property, without rights or feelings. - Sometimes the parent feels the need to have children to replace their own faulty bad childhood but the reality of having a child usually shatters those unrealistic expectations, when shattered, the parent reverts to what they learned growing up.
Violent Families: Intimate Partner Violence in Heterosexual Relationships
- Accounts for 14% of all homicides - 70% were females, 30% were males - In the US, half of all female homicide victims were killed by a current or former romantic partner. Only 16% were killed by a stranger. - Rates of IPV are increased during pregnancy - Men are sometimes hesitant to report victimization or may not consider behaviors such as shoving or slapping "abuse." - Nearly 1 in 4 women and 1 in 9 men are victims of IPV at some point in their lives. - Women are much more likely than men to be seriously injured as a result of IPV and to require medical treatment. - The reaction to IPV may differ by gender.
Related Disorders to PTSD
- Adjustment disorder - Acute stress disorder - Reactive attachment disorder - Disinhibited social engagement disorder
PTSD: Etiology - Ages
- Adolescents with PTSD are more likely to develop PTSD than children or adults. - Age, gender, type of trauma, repeated trauma are related to increased PTSD rates. - Adolescents with PTSD are at increased risk for suicide, substance abuse, poor social support, academic problems, and poor physical health. - Trauma-focused CBT can be delivered in school or community-based settings. It also has positive long-term effects both with PTSD and other comorbid conditions. - PTSD may disrupt biological maturation, contributing to long-term emotional and behavioral problems that require ongoing or episodic therapy to deal with relevant issues.
Child Abuse: Repercussions Later in Life
- Adults with a history of childhood sexual abuse are at a higher risk for depression, suicide attempts, marital problems, marriage to an alcoholic, smoking, alcohol abuse, chronic pain, and medically unexplained symptoms.
Assessment - Possible Indicators of Elder Abuse: Psychosocial Abuse
- Change in elder's general mood or usual behavior - Isolated from previous friends or family - Sudden lack of contact from other people outside the elder's home - Helplessness - Hesitance to talk openly - Anger or agitation - Withdrawal or depression
ADHD
- Affects 5% to 8% of school-aged children, with 60% to 85% having symptoms persisting into adolescence. - Up to 60% continue to be symptomatic into adulthood. - The ratio of boys to girls ranges from 2:1 in nonclinical settings to 9:1 in clinical settings. - To avoid overdiagnosis of ADHD, a qualified specialist, such as a pediatric neurologist or a child psychiatrist, must conduct the evaluation for ADHD. - Children who are very active or hard to handle in the classroom can be diagnosed and treated mistakenly for ADHD. - Some of these overly active children may suffer from psychosocial stressors at home, inadequate parenting, or other psychiatric disorders. - Essential to have a thorough and accurate diagnosis for ADHD. - There are other disorders and situations that may look similar to ADHD, such as bipolar disorder or behavioral acting out in response to family stress, such as divorce, parental mental disorders, and so forth. - A key feature of ADHD is the consistency of the child's behavior—every day, in almost all situations, and with almost all caregivers, the child demonstrates the problematic behaviors.
ADHD: Assessment - Self-Concept
- Again, this may be difficult to assess in a very young child, but generally, the self-esteem of children with ADHD is low. - Because they are not successful at school, may not have many friends, and have trouble getting along at home, they generally feel out of place and bad about themselves. The negative reactions their behavior evokes from others often cause them to see themselves as bad or stupid.
Behavioral Symptoms of Geriatric Substance Abuse
- Alientating loved ones, isolation - Strange odor of the body, breath or clothing - Changes in eating/sleeping habits - Deteriorating personal grooming habits - Drinking or using drugs in secret, even when medications or providers caution against it - Ritual use of drugs or alcohol
Elder Abuse: Perpetrators
- Almost always in the caregiver role, or the elder depends on them for something - Most cases occur when one older spouse is taking care of another. - This usually happens over many years after a disability causes the abused spouse to be unable to care for themself. - When the abuser is an adult child, the son is 2x as likely to be the abuser than the daughter - A psych disorder, or substance abuse problem may aggravate abuse of olders.
Conduct Disorder: Assessment - Self-Concept
- Although these clients generally try to appear tough, their self-esteem is low. - They do not value themselves any more than they value others. - Their identity is related to their behaviors such as being cool if they have had many sexual encounters or feeling important if they have stolen expensive merchandise or been expelled from school.
Etiology: Huntington Disease
- An inherited, dominant gene disease that primarily involves cerebral atrophy, demyelination, and enlargement of the brain ventricles. - Initially, there are choreiform movements that are continuous during waking hours and involve facial contortions, twisting, turning, and tongue movements. - Personality changes are the initial psychosocial manifestations followed by memory loss, decreased intellectual functioning, and other signs of dementia. - The disease begins in the late 30s or early 40s and may last 10 to 20 years or more before death.
Define: Cycle of Violence/Abuse
- An oft-cited reason for why abused partners find difficulty leaving the abusive relationship. - This is a pattern of behavior that starts with an episode of abuse or battery, then a period of regret, apologies, and promises. - The abuser will profess their love and may engage in over-the-top romantic behavior to convince them (honeymoon period). - The abused partner wants to believe their partner and hopes it was a one-time event. - After the honeymoon phase ends, tension starts to build again, with arguments, stony silence, or complaints from the abuser. - This ends with another violent episode, and the cycle continues.
Dementia: Assessment - Self-Concept
- Angry or frustrated with themselves for losing objects or forgetting important things. - May express sadness at their bodies for getting old and at the loss of functioning. - Soon they lose that awareness of self, which gradually deteriorates until they can look in a mirror and fail to recognize their own reflections.
Define: Bullying (In Schools)
- Another problem experienced at school, including verbal aggression; physical acts from shoving to breaking bones; targeting a student to be shunned or ignored by others; and cyberbullying involving unwanted e-mails, text messages, or pictures posted on the internet. - Adolescent suicide, substance use, self-harm ideation and actions, and moderate-to-severe symptoms of depression are correlated with bullying.
Conduct Disorder: Assessment - General Appearance and Motor Behavior
- Appearance, speech, and motor behavior are typically normal for the age group but may be somewhat extreme (e.g., body piercings, tattoos, hairstyle, clothing). - These clients often slouch and are sullen and unwilling to be interviewed. - They may use profanity, call the nurse or physician names, and make disparaging remarks about parents, teachers, police, and other authority figures.
Autism: Treatment
- Autism tends to improve, in some cases substantially, as children start to acquire and use language to communicate with others. - If behavior deteriorates in adolescence, it may reflect the effects of hormonal changes or the difficulty meeting increasingly complex social demands. - Autistic traits persist into adulthood, and most people with autism remain dependent to some degree on others. - Current research estimates that 20% of adults with ASD achieve most independent living outcomes, while 46% require substantial levels of support in most independent living outcomes. - Many continue to live with parents or adult relatives. - Manifestations vary from little speech and poor daily living skills throughout life to adequate social skills that allow relatively independent functioning. - Social skills rarely improve enough to permit marriage and child-rearing. - Adults with autism may be viewed as merely odd or reclusive, or they may be given a diagnosis of obsessive-compulsive disorder (OCD), schizoid personality disorder, or mental retardation.
ODD: Treatment
- Based on parent management training models of behavioral interventions. - These programs are based on the idea that ODD problem behaviors are learned and inadvertently reinforced in the home and school. - A hierarchy of problem behaviors is developed, and the most disruptive or problematic behaviors are targeted for intervention. - Parents ignore maladaptive behaviors, no negative attention. - Positive behaviors are rewarded and reinforced. - Therapy may help. - Medications don't really help, but ODD Is often comorbid so medications may help there. - ODD can be challenging, overwhelming and unrelenting.
ADHD: Interventions - Simplifying Instructions
- Before beginning any task, adults must gain the child's full attention. - Face the child on his or her level and use good eye contact. - The adult should tell the child what needs to be done and break the task into smaller steps if necessary. - This helps not overwhelm the child, and gives them feedback. - They also need breaks or opportunities to move around.
Neurodevelopmental Disorders: Self Awareness Issues
- Can be both rewarding and difficult. - Many disorders severely limit the child's abilities. - It may be difficult for the nurse to remain positive with the child and parents when the prognosis for improvement is poor. - Even in overwhelming and depressing situations, the nurse can positively influence children and adolescents, who are still in crucial phases of development. - The nurse can often help these clients develop coping mechanisms they will use throughout adulthood. - Working with parents is crucial. - Parents often have the most influence on how these children learn to cope with their disorders. - Must not be overly critical about how parents handle their children's problems until the situation is fully understood. - Caring for a child as a nurse is different from being responsible around the clock.
Etiology: Dementia related to Traumatic Brain Injury
- Can cause dementia as a direct pathophysiological consequence of head trauma. - The degree and type of cognitive impairment and behavioral disturbance depend on the location and extent of the brain injury. - When it occurs as a single injury, the dementia is usually stable rather than progressive. Repeated head injury (e.g., from boxing or football) may lead to progressive dementia.
Etiology: HIV related dementia
- Can lead to dementia and other neurologic problems; these may result directly from invasion of nervous tissue by HIV or from other acquired immunodeficiency syndrome-related illnesses such as toxoplasmosis and cytomegalovirus. - This type of dementia can result in a wide variety of symptoms ranging from mild sensory impairment to gross memory and cognitive deficits to severe muscle dysfunction.
IED: Onset
- Can occur at any time in life but is most common in adolescence and young adulthood. - More common in males than in females. - Many people with IED have a comorbid psychiatric disorder, most commonly substance use/abuse, ADHD, ODD, conduct disorder, anxiety disorders, and depression.
PTSD: Mental Health Promotion
- Can't avoid all traumatic events - One of the most effective ways of avoiding pathologic responses to trauma is effectively dealing with the trauma soon after it occurs. - In addition to first aid responders, counselors are often present to help people process the emotional and behavioral responses that occur. - Some can easily express feelings and talk, others are more reluctant to open up, and bottle things up. - Need accurate diagnosis: Stress immediately after an event is acute stress disorder, while PTSD is delayed in onset. - Some people may say they have PTSD but are self-diagnosed and may have autism spectrum disorder, a grief reaction, or other issues.
Elder Abuse: Assessment
- Careful assessment of elderly persons and their caregiving relationships is essential in detecting elder abuse. - Often, determining whether the elder's condition results from deterioration associated with a chronic illness or from abuse is difficult. Several potential indicators of abuse require further assessment and careful evaluation - These indicators by themselves, however, do not necessarily signify abuse or neglect. - The nurse should suspect abuse if injuries have been hidden, untreated or are incompatible with the explanation provided.
Dementia: Self Awareness Issues
- Caring for clients with dementia can be exhausting and frustrating. - Teaching is a major role for nurses, but teaching dementia clients isn't the same, the nurse often must repeat. - The nurse may get little to no positive response or feedback. - As dementia progresses, feelings of sadness may occur. The nurse must remain positive and supportive to clients and their families. - The progressive decline may last months or years, which adds to frustration and sadness. - The nurse may need to deal with personal feelings of depression and grief as the dementia progresses. - Talking to others helps
Etiology: Prion Diseases such as Creutzfeldt-Jakob Disease, Mad Cow and Kuru
- Caused by a prion (a type of protein) that can trigger normal proteins in the brain to fold abnormally. - They are rare, and only 300 cases per year occur in the United States. Creutzfeldt-Jakob disease - The most common prion disease affecting humans. - It is a CNS disorder that typically develops in adults aged 40 to 60 years. - It involves altered vision, loss of coordination or abnormal movements, and dementia that usually progresses rapidly (a few months). - The cause of the encephalopathy is an infectious particle resistant to boiling, some disinfectants (e.g., formalin, alcohol), and ultraviolet radiation. - Pressured autoclaving or bleach can inactivate the particle Mad cow disease and kuru -(seen largely in New Guinea from eating infected brain tissue) are other prion diseases.
ADHD: Etiology
- Causes remain unknown. - There may be cortical-arousal, information-processing, or maturational abnormalities in the brain. - Combined factors, such as environmental toxins, prenatal influences, heredity, and damage to brain structure and functions, are likely responsible. - Prenatal exposure to alcohol, tobacco, and lead and severe malnutrition in early childhood increase the likelihood. - Brain imaging shows possible decreased metabolism in the frontal lobes. - Studies have suggested decreased blood perfusion in the frontal cortex in children with ADHD, and frontal cortical atrophy in young adults with childhood ADHD. - Other studies showed decreased glucose in the frontal lobes of ADHD+ parents of children with ADHD - Genetic link - 1st degree relative with ADHD = increased risk of the disorder by 4-5x - There are also sporadic cases with no family history of ADHD
Dementia: Etiology
- Causes vary, though the clinical picture is similar for most dementias. - Sometimes no definitive diagnosis can be made until completion of a postmortem examination. - Metabolic activity is decreased in the brains of clients with dementia; it is not known whether dementia causes decreased metabolic activity or if decreased metabolic activity results in dementia. - A genetic component has been identified for some dementias, such as Huntington disease. - An abnormal APOE gene is known to be linked with Alzheimer disease. - Other causes of dementia are related to infections such as human immunodeficiency virus (HIV) infection or Creutzfeldt-Jakob disease.
Kleptomania
- Characterized by impulsive, repetitive theft of items not needed by the person, either for personal use or monetary gain. - Tension and anxiety are high prior to the theft, and the person feels relief, exhilaration, or gratification while committing the theft. - The item is often discarded after it is stolen. - More common in females and often has negative legal, career, family, and social consequences.
Define: Attention-Deficit/Hyperactivity Disorder (ADHD)
- Characterized by inattentiveness, overactivity, and impulsiveness. - Common disorder, especially in boys, and probably accounts for more child mental health referrals than any other single disorder. - The essential feature is a persistent pattern of inattention and/or hyperactivity and impulsivity more common than generally observed in children of the same age.
Conduct Disorder
- Characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others. - These children and adolescents have significantly impaired abilities to function in social, academic, or occupational areas. - Academic underachievement, learning disabilities, hyperactivity, and problems with attention span are all associated with conduct disorder. - Children with conduct disorder have difficulty functioning in social situations. - They lack the abilities to respond appropriately to others and to negotiate conflict, and they lose the ability to restrain themselves when emotionally stressed. - They are often accepted only by peers with similar problems.
Pyromania
- Characterized by repeated, intentional fire-setting. - The person is fascinated about fire and feels pleasure or relief of tension while setting and watching the fires. - There is neither any monetary gain or revenge or other reason, such as concealing other crimes, nor is it associated with another major mental disorder. - Pyromania as a primary disorder is rare. - Persons, if caught, become part of the legal rather than mental health system.
Stereotypic Movement Disorder
- Characterized by rhythmic, repetitive behaviors, such as hand waving, rocking, head banging, and biting, that appears to have no purpose. - Self-inflicted injuries are common, and the pain is not a deterrent to the behavior. - Onset is prior to age 3 years and usually persists into adolescence. - It is more common in individuals with intellectual disability. - Comorbid disorders, such as anxiety, ADHD, OCD, and tics/Tourette syndrome, are common and often cause more functional impairment than the stereotypic behavior
Conduct Disorder: Related Problems
- Children respond in different ways to environmental pressures and adversity. - Some children externalize their emotional issues by directing anger and frustration into aggressive or delinquent behavior, putting them at risk for diagnoses of ODD and conduct disorder. - Other children experiencing the same pressures may internalize their emotions, resulting in somatic complaints, withdrawal, isolative behavior, and problems with anxiety and depression. Externalizing behaviors and internalizing behaviors - These behavioral patterns correspond to the problems with self-regulation of emotions (internalizing) and behavior (externalizing).
ADHD: Treatment - Physiological and Self-Care Considerations
- Children with ADHD may be thin if they do not take time to eat properly or cannot sit through meals. Trouble settling down and difficulty sleeping are problems as well. - If the child engages in reckless or risk-taking behaviors, there may also be a history of physical injuries.
Autism: Until the mid 1970s
- Children with autism were usually treated in segregated, specialty outpatient, or school programs. - Those with more severe behaviors were referred to residential programs. - Since then, most residential programs have been closed; children with autism are being "mainstreamed" into local school programs whenever possible. - Short-term inpatient treatment is used when behaviors such as head banging or tantrums are out of control. - When the crisis is over, community agencies support the child and family.
Conduct Disorder: Assessment - History
- Children with conduct disorder have a history of disturbed relationships with peers, aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules (e.g., truancy, running away from home, staying out all night without permission). - The behaviors and problems may be mild to severe.
Chronic Motor or Tic Disorder
- Chronic motor or vocal tic differs from Tourette disorder in that either the motor or the vocal tic is seen, but not both. - Transient tic disorder may involve single or multiple vocal or motor tics, but the occurrences last no longer than 12 months.
Biological Symptoms of Geriatric Substance Abuse
- Chronic pain or health complaints with no cause - Unexplained nausea/vomiting - Extreme fatigue - Memory loss - Bloodshot eyes - Slurred speech - Poor coordination or loss of balance
Conduct Disorder: Assessment - Sensorium and Intellectual Processes
- Clients are alert and oriented with intact memory and no sensory-perceptual alterations. - Intellectual capacity is not impaired, but typically, these clients have poor grades because of academic underachievement, behavioral problems in school, or failure to attend class and to complete assignments.
Conduct Disorder: Assessment - Physiological and Self-Care Considerations
- Clients are often at risk for unplanned pregnancy and STDs because of their early and frequent sexual behavior. - Use of drugs and alcohol is an additional risk to health. - Clients with conduct disorders are involved in physical aggression and violence including weapons; this results in more injuries and deaths compared with others of the same age.
Conduct Disorder: Intervention - Promoting Social Interaction
- Clients may not have age-appropriate social skills, so teaching social skills is important. - Role model these skills to help clients practice appropriate social interaction. - ID what is not appropriate, such as profanity and name-calling, and also what is appropriate. - Clients may have little experience discussing the news, current events, sports, or other topics. - As they begin to develop social skills, the nurse can include other peers in these discussions. - Positive feedback is essential to let clients know they are meeting expectations.
Define: Depersonalization/derealization disorder
- The client has a persistent or recurrent feeling of being detached from his or her mental processes or body (depersonalization) or sensation of being in a dream-like state in which the environment seems foggy or unreal (derealization). - The client is not psychotic nor out of touch with reality.
Conduct Disorder: Community Based Care
- Clients seen in acute care settings only when their behavior is severe and only for short periods of stabilization. - Much long-term work takes place at school and home or another community setting. - Some clients are placed outside the parents' homes for short or long periods. - Group homes, halfway houses, and residential treatment settings are designed to provide safe, structured environments and adequate supervision if that cannot be provided at home. - Clients with legal issues may be placed in detention facilities, jails, or jail-diversion programs.
Points to Consider When Working with Traumatized Clients
- Clients who participate in counseling, groups, and/or self-help groups have the best long-term outcomes. It is important to encourage participation in all available therapies. - Clients who survive a trauma may have survivor's guilt, believing they "should have died with everyone else." Nurses will be most helpful by listening to clients' feelings and avoiding pat responses or platitudes such as "Be glad you're alive," or "It was meant to be." - Often clients just need to talk about the problems or issues they're experiencing. These may be problems that cannot be resolved. Nurses may want to fix the problem for the client to alleviate distress but must resist that desire to do so and simply allow the client to express feelings of despair or loss.
Dementia: Drug Therapy for Behaviors
- Clients with dementia demonstrate a broad range of behaviors that can be treated symptomatically. - Doses of medications are one-half to two-thirds lower than usually prescribed. - Antidepressants are effective for significant depressive symptoms; however, they can cause delirium. - SSRIs are used because they have fewer side effects. - Antipsychotics, such as haloperidol (Haldol), olanzapine (Zyprexa), risperidone (Risperdal), and quetiapine (Seroquel), may be used to manage psychotic symptoms of delusions, hallucinations, or paranoia, and other behaviors, such as agitation or aggression. - The benefit of antipsychotics must be weighed with the risks, such as an increased mortality rate, primarily from cardiovascular complications. FDA has not approved antipsychotics for dementia treatment, and there is a black box warning issued. - Lithium carbonate, carbamazepine (Tegretol), and valproic acid (Depakote) help stabilize affective lability and diminish aggressive outbursts. - Benzodiazepines are used cautiously because they may cause delirium and can worsen already compromised cognitive abilities. - Pimavanserin (Nuplazid) has been specifically FDA approved to treat delusions and hallucinations that some experience with Parkinson disease. One 34-mg capsule per day is the recommended dose. It is known to prolong the Q-T interval. - Both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia-related psychosis.
Delirium: Treatment and Prognosis - Psychopharmacology
- Clients with quiet hypoactive delirium need no specific drugs aside from what is needed to treat the cause. - Many clients though have persistent or intermittent psychomotor agitation, psychosis or insomnia that poses a risk to safety and interferes with treatment. - In these cases, sedation may be indicated. Haloperidol: (Antipsy) 0.5-1mg doses may be used to decrease agitation and psychotic symptoms, and facilitate sleep. - Can be used PO, IM, IV Lorazepam: (Benzo) Has been used historically but may worsen delirium, especially in the elderly. Only indicated for the treatment of sedative-hypnotic withdrawal or delirium induced by alcohol withdrawal.
ADHD Medications: Amphetamine Compounds (Adderall)
- Common medication - Stimulant used to treat ADHD. - Available in a sustained-release form taken once daily; this eliminates the need for additional doses when the child is at school.
Conduct Disorder: Cultural Considerations
- Concerns have been raised that "difficult" children may be mistakenly labeled as having conduct disorder. - Knowing the client's history and circumstances is essential for accurate diagnosis. - In high-crime areas, aggressive behavior may be protective and not necessarily indicative of conduct disorder. - In immigrants from war-ravaged countries, aggressive behavior may have been necessary for survival, so these individuals should not be diagnosed with conduct disorder. - Disruptive behavior disorders are the most frequent diagnoses for children world-wise
Psychological Symptoms of Geriatric Substance Abuse
- Confusion - Depression - Mood swings
Moderate Dementia
- Confusion is apparent, along with progressive memory loss. - Can no longer perform complex tasks but remains oriented to person and place. - Still recognizes familiar people. - Toward the end of this stage, the person loses the ability to live independently and requires assistance because of disorientation to time and loss of information, such as address and telephone number. - The person may remain in the community if adequate caregiver support is available, but some people move to supervised living situations.
Dementia: Assessment - History
- Considering the impairment of recent memory, clients may be unable to provide an accurate and thorough history of the onset of problems. Interviews with family, friends, or caregivers may be necessary to obtain data.
Oppositional Defiant Disorder (ODD)
- Consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations. - Diagnosed only when behaviors are more frequent and intense than in unaffected peers and cause dysfunction in social, academic, or work situations. - The disruptive, defiant behaviors usually begin at home with parents or parental figures and are more intense in this setting than settings outside the home. - Prevalance rate is estimated at 3% in US - More often in males, but in females rates are increasing. - Most authorities believe that genes, temperament, and adverse social conditions interact to create ODD. - Children with ODD have lower self-concept and lack competence in social situations.
Define: Oppositional Defiant Disorder
- Consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations. - More than what is expected at the child's age.
Treatment for PTSD
- Counseling, therapy (individual or in groups) for people with acute stress disorder helps to prevent progression to PTSD - Therapy is indicated for PTSD - Medications can help when targeting specific issues. - Combination of both therapies is best. - Inpatient treatment is not indicated, but short stays for severe crisis (SI, SA, Overwhelming flashbacks) might be needed. - CBT and other specialized therapy with CBT elements are the most common and successful types of formal treatment - Exposure therapy, adaptive disclosure, cognitive processing therapy.
Violent Families: Cultural Considerations
- DV affects families of all ethnicities, races, ages, national origins, sexual orientations, religions, and socioeconomic backgrounds. - However, a specific population is particularly at risk in the US - immigrant women. - The person may come from a culture that accepts DV - The person might believe they have less access to legal and social services. - If not a citizen, risk of deportation - Isolated by cultural dynamics that prevent leaving abuser, may not have resources - Language barriers may interfere with abilities to learn about rights, obtain resources, call 911
Violent Families: Intimate Partner Violence in Homosexual Relationships
- DV occurs in the same statistical frequency as in heterosexual relationships. - Victims receive fewer protections - 7 states define DV in a way that excludes same-sex victims. - 12 states have sodomy laws that designate sodomy as a crime, though those laws were invalidated by the Supreme Court in 2003 - The batterer has an additional weapon against the victim in the form of potentially outing them to friends, family, employers or community
Community Violence
- Death by homicide at school is < 3% - In recent years, multiple homicides by a single shooter are more common than 1-on-1 homicide at school - Students are trained on what to do if an active shooter comes to school - CDC has been working with schools to develop curricula that emphasizes problem-solving skills, anger management, and social skills development - In addition: Parenting programs that promote strong bond between parents/kids, along with conflict resolution and mentoring programs. - These tactics are showing promise
Delirium: Assessment - Self-Conecpt
- Delirium has no direct effect on self-concept, clients often are frightened or feel threatened. - Those with some awareness of the situation may feel helpless or powerless to do anything to change it. - If delirium has resulted from alcohol, illicit drug use, or overuse of prescribed medications, clients may feel guilt, shame, and humiliation, or think, "I'm a bad person; I did this to myself." - This would indicate possible long-term problems with self-concept.
Child Abuse: Assessment
- Detection and accurate identification are the first steps. - Burns or scalds may be ID'd by shape, such as cigarette marks, or may have a "stocking and glove" distribution, indicating scalding. - The parent of an infant with a severe skull fracture may say "they rolled off the couch," even if too young to do so or the injury is much too severe for such a short fall. - Bruises may have familiar, recognizable shapes (belt buckles or teeth marks) - Sexual abuse: the child might have UTIs, bruised, red or swollen genetalia, tears on the rectum or vagina, buising
Learning Disorders
- Diagnosed when a child's achievement in reading, mathematics, or written expression is below that expected for age, formal education, and intelligence. - Learning problems interfere with academic achievement and life activities requiring reading, math, or writing. - Reading and written expression disorders are usually identified in the first grade; math disorders may go undetected until the child reaches fifth grade. - 5% of children in US schools have a learning disorder. - Dropout ate is 1.5 times higher than average - Low self-esteem and poor social skills are common. - Adults with LD have problems with employment and social adjustment - Early ID = better outcomes
Delirium: Assessment - Thought Process and Content
- Difficult for the nurse to assess these changes accurately and thoroughly. - Marked inability to sustain attention makes it difficult to assess thought process and content. - Thought content in delirium is often unrelated to the situation, or speech is illogical and difficult to understand. - The nurse may ask how clients are feeling, and they will mumble about the weather. - Thought processes are often disorganized and make no sense. - Thoughts also may be fragmented (disjointed and incomplete). - Clients may exhibit delusions, believing that their altered sensory perceptions are real.
Speech Sound Disorder
- Difficulty or inability to produce intelligible speech, which precludes effective verbal communication.
Delirium: Assessment - General Appearance and Motor Behavior
- Disturbance of psychomotor behavior - Restless, hyperactive, picking at clothes, bedding, trying to get out of bed - Clients may be sluggish or lethargic - Speech may be affects, becoming less coherent, more difficult to understand. - Clients may perseverate on a single topic or detail, may be rambling and difficult to follow, or may have pressured speech that is rapid, forced, and usually louder than normal. - At times, clients may call out or scream, especially at night.
Delirium: Assessment - Psychological and Self-Care Considerations
- Disturbed sleep/wake cycles - May result in difficulty falling asleep, daytime sleepiness, nighttime agitation, or even a complete reversal of the usual daytime waking/nighttime sleeping pattern. - May ignore or fail to perceive internal body cues such as hunger, thirst, or the urge to urinate or defecate.
Dementia: Outcome Identification
- Does not involve regaining or maintaining abilities to function. The nurse must assess overall health status, and revise treatment outcomes periodically as the client's condition changes. - Psychosocial care involves a focus on the client's strengths and abilities for as long as possible. Keeping their independence for as long as possible, validating feelings, keeping client involved in the environment and dealing with behavioral disruptions respectfully. - The client will be free of injury. - The client will maintain an adequate balance of activity and rest, nutrition, hydration, and elimination. - The client will function as independently as possible given his or her limitations. - The client will feel respected and supported. - The client will remain involved in his or her surroundings. - The client will interact with others in the environment.
Dementia: Intervention - Communicating with Clients
- Don't interrupt clients or finish their thoughts for them, if the nurse doesn't understand they can ask the client - Watch for nonverbal behavior. - Sometimes it is necessary to use distraction, which involves shifting the client's attention and energy to a more neutral topic. This helps calm clients from a triggering situation. - Time away - involves leaving clients for a short period and then returning to them to re-engage in interaction. The client may no longer remember what they were doing before. - Going along - means providing emotional reassurance to clients without correcting their misperception or delusion. The nurse does not engage in delusional ideas or reinforce them, but he or she does not deny or confront their existence. - Reframing - Offer clients different points of view or explanations for situations or events. Because of their perceptual difficulties and confusion, clients frequently interpret environmental stimuli as threatening.
Neurodevelopmental Disorders: Mental Health Promotion
- Early detection and successful intervention are often the key to mental health promotion. - The SNAP-IV Teacher and Parent Rating Scale is an assessment tool that can be used for initial evaluation in many areas of concern such as ADHD, ODD, conduct disorders, and depression. - Such tools can identify problems or potential problems that signal a need for further evaluation and follow-up. - Insufficient knowledge about ASD and embarrassment or reluctance to have a child diagnosed with ASD are reasons that some parents are hesitant to have children evaluated if signs of developmental delays are present. - When any signs of developmental delay are detected, a thorough evaluation by a team of psychiatrists, pediatricians, physiotherapists, and neurologists can accurately identify the presence of ASD, intellectual disability, language impairment, motor developmental delays, or global developmental delays. - An accurate diagnosis and appropriate interventions are more likely to produce the best long-term outcomes that are available.
ADHD Medications: Methylphenidate (Ritalin)
- Effective in 70% to 80% of children with ADHD; it reduces hyperactivity, impulsivity, and mood lability and helps the child pay attention more appropriately. - Also available in a daily transdermal patch, marketed as Daytrana. - Available in a sustained-release form taken once daily; this eliminates the need for additional doses when the child is at school.
Define: Supportive Touch
- Effective with many clients. - Touch can provide reassurance and convey caring when words may not be understood. - Holding the hand of the client who is tearful and sad and tucking the client into bed at night are examples of ways to use supportive touch. - As with any use of touch, the nurse must evaluate each client's response. - Clients who respond positively will smile or move closer toward the nurse. - Those who are threatened by physical touch will look frightened or pull away from the nurse, especially if the touch is sudden or unexpected or if the client misperceives the nurse's intent.
Assessment - Possible Indicators of Elder Abuse: Emotional of Psychological Abuse
- Elder who is hesitent to talk openly to the nurse, or is fearful, withdrawn, depressed and helpless. - May be angry or agitated for no apparent reason. - May deny any problems despite evidence to the contrary
Patients with Delirium
- Elderly are most frequently diagnosed - 14-24% of people admitted to the hospital for general issues are delirious, which can worsen in the hospital - Delirium is reported in 10-15% of gen surgical patients, 30% of open-heart surgery patients, and more than 50% of those treated for fractures hips, 80% of those who are terminally ill - Causes of delirium are multiple stressors - Risk factors include increased severity of physical illness, older age, hearing impairment, decreased food and fluid intake, meds, baseline cognitive impairments - Children may be more susceptible to delirium
Define: Family Violence
- Encompasses spouse battering; neglect and physical, emotional, or sexual abuse of children; elder abuse; and marital rape. - In many cases, family members tolerate abusive and violent behavior from relatives they would never accept from strangers. - In violent families, the home, which is normally a safe haven of love and protection, may be the most dangerous place for victims.
Abuse Victims: Treatment and Intervention
- Every US state allows police to make arrests for DV, more than half of the states have laws requiring police to make arrests for some DV crimes. - Sometimes, the abuser is allowed to remain at home after talking with the police and calming down. - If an arrest is made, the abuser is sometimes only held for a few days or overnight. - Often, the abuser retaliates against their partner upon release. - Studies have shown that arrests may reduce short-term violence, but may increase long-term violence. - Shelters provide temporary housing and food for the abused partner and their children, however in many cities shelters are crowded, have waiting lists, and are only temporary. - This makes leaving difficult as the partner is often financially dependent. - In addition to physical issues - emotional and psychological issues are common. - Connection to community resources is crucial
Conduct Disorder: Elder Considerations
- Few studies have explored the prevalence of disorders such as IED or kleptomania in the elderly. - Individuals with behavior and/or anger issues that persist into adulthood may be viewed as "grouchy," "mean-spirited," or "difficult to get along with" by others. - If these problems are more pronounced or lead to legal consequences, there may be a diagnosis of personality disorder. - Little is known or formally studied in those without such a diagnosis.
Trauma: Intervention - Establishing Social Support
- Find support people or activities - The nurse can prepare a list - Problem-solving skills are hard at first - List should include a crisis hotline - The client needs to find things they can do to provide a diversion and a chance to get out of the house - The client needs to establish community supports to reduce dependency on health care professionals - Support groups
Mild Dementia
- Forgetfulness is the hallmark of beginning, mild dementia. - It exceeds the normal, occasional forgetfulness experienced as part of the aging process. - The person has difficulty finding words, frequently loses objects, and begins to experience anxiety about these losses. - Occupational and social settings are less enjoyable, and the person may avoid them. - Most people remain in the community during this stage.
Assessment - Possible Indicators of Elder Abuse: Physical Abuse
- Frequent, unexplained injuries accompanied by a habit of seeking medical assistance from various locations - Reluctance to seek medical treatment for injuries or denial of their existence - Disorientation or grogginess indicating misuse of medications - Fear or edginess in the presence of family member or caregiver - Cuts, lacerations, puncture wounds, bruises, welts or burns. - Burns can be cigarette burns, scaldings, acid or caustic burns, or friction burns of the wrists or ankles caused from being restrained by ropes, clothing, or chains.
Define: Child Abuse/Maltreatment
- Generally is defined as the intentional injury of a child. - It can include physical abuse or injuries, neglect or failure to prevent harm, failure to provide adequate physical or emotional care or supervision, abandonment, sexual assault or intrusion, and overt torture or maiming.
Delirium: Outcome Identification
- The client will be free of injury. - The client will demonstrate increased orientation and reality contact. - The client will maintain an adequate balance of activity and rest. - The client will maintain adequate nutrition and fluid balance. - The client will return to his or her optimal level of functioning.
Conduct Disorder: Etiology
- Genetic vulnerability, environmental adversity, & factors like poor coping interact to cause the disorder Risk Factors include poor parenting, low academic achievement, poor peer relationships, low self-esteem, Child abuse is an especially significant risk factor. Exposure to violence in the media and community is a contributing factor for the child at risk in other areas. Socioeconomic disadvantages, such as inadequate housing, crowded conditions, and poverty, also increase the likelihood of conduct disorder in at-risk children. Protective Factors include resilience, family support, positive peer relationships, and good health. - No specific gene marker has been identified, but the disorder is more common in children with a sibling with CD or a parent with antisocial personality disorder, substance abuse, mood disorder, schizophrenia, or ADHD.
Dementia: Community Based Care
- Half of the nursing home residents have Alzhermer disease or other dementia. - For every person with dementia in a nursing home, 2-3 with similar impairments are getting care in the community by family, friends or caregivers. - Programs and services have increased with the growing awareness of Alzheimer's disease - Home care is available through home health agencies, public health agencies, and visiting nurses. - These services provide bathing, food prep, and transportation along with other support for ADLs. - Adult day care centers provide supervision, meals, support, and activities - Respite care - offers in-home supervision of clients for the family to take a break. - Residential facilities are available for those who don't have caregivers at home, or who have progressed beyond what can be provided at home. - Skilled nursing home is sometimes indicated. - The provider, nurse or family can refer for these services.
Define: Elder Abuse
- Harm caused by: physical abuse, neglect, intimidation, cruel punishment, financial abuse, abandonment, deprivation of goods or services necessary to avoid physical harm or mental suffering of an elderly adult.
Shaken Baby Syndrome
- Has been documented in children up to 5 years of age. The result of a child being violently shaken. - The physical findings usually include bruising from being grabbed firmly along with major head injury, such as subdural hematoma or cerebral edema. - Nonfatal consequences include blindness due to retinal hemorrhage.
Etiology: Vascular Dementia
- Has symptoms similar to those of Alzheimer disease, but onset is typically abrupt, followed by rapid changes in functioning; a plateau, or leveling-off period; more abrupt changes; another leveling-off period; and so on. - Computed tomography or magnetic resonance imaging usually shows multiple vascular lesions of the cerebral cortex and subcortical structures resulting from the decreased blood supply to the brain.
Dissociative Disorders
- Have the essential feature of a disruption in the usually integrated functions of consciousness, memory, identity, or environmental perception. - This often interferes with the person's relationships, ability to function in daily life, and ability to cope with the realities of the abusive or traumatic event. - Varies greatly in intensity in different people, and the onset may be sudden or gradual, transient, or chronic. - Seen in clients with PTSD
Define: Grounding Techniques
- Helpful to use with the client who is dissociating or experiencing a flashback. - Reminds the client that he or she is in the present, is an adult, and is safe. - Validating what the client is feeling during these experiences is important: "I know this is frightening, but you are safe now." - In addition, the nurse can increase contact with reality and diminish the dissociative experience by helping the client focus on what he or she is currently experiencing through the senses: - "What are you feeling?" - "Are you hearing something?" - "What are you touching?" - "Can you see me and the room we're in?" - For dissociative symptoms, focus the client on the present. Ex, the nurse approaches the client and speaks in a calm reassuring tone. - First, the nurse calls the client by name and then introduces him or herself by name and role. - If the area is dark, the nurse turns on the lights. - Reorient the client as needed. - Ask the client to change positions and look around the room. - Getting them to move helps dispel the episode - Supportive touch may help, but ask - Use journaling to ID feeling sand their intensities, then find triggers to the flashbacks or dissociative episodes
PTSD: Etiology in Children
- History of parental major depression and childhood abuse. - Psychopathology in the parents results in a stress-laden environment for the child and is much more likely to end in a PTSD diagnosis. - These risks are diminished when postevent counseling occurs soon after the trauma. - Parental participation in treatment significantly enhances the benefits of CBT for traumatized children. - It also improved depressive symptoms commonly seen in parents
IED: Etiology
- IED is related to childhood exposure to trauma, neglect, or maltreatment. - Other potential etiologic factors include neurotransmitter imbalances, especially serotonin; plasma tryptophan depletion; and frontal lobe dysfunction. - Some have postulated that IED is correlated with adverse physical outcomes, such as coronary heart disease, hypertension, stroke, diabetes, arthritis, back/neck pain, ulcer, headache, and other chronic pain.
Elder Abuse: Bullying
- Identified in senior living facilities between residents. Verbal and social bullying is most common. - Both victims and perpetrators were reported having cognitive and physical disabilities. - Educational programs on safe interventions for bullying between residents are indicated.
Define: Role strain
- Identified when the demands of providing care threaten to overwhelm a caregiver. Indications of role strain include constant fatigue that is unrelieved by rest, increased use of alcohol or other drugs, social isolation, inattention to personal needs, and inability or unwillingness to accept help from others. - Caregivers may feel unappreciated by other family members, as indicated by statements such as "No one ever asks how I am!" In some situations, role strain can contribute to the neglect or abuse of clients with dementia.
Define: Ostracism
- Ignoring and excluding a target individual, has recently emerged as one of the more common and damaging forms of bullying. - The victim experiences threats to belonging, self-esteem, meaningful existence, and sense of control. - May pose an even greater threat to children's adjustment than bullying
Rape: Treatment and Intervention
- Immediate support is best - Expression of emotions (fear and rage) - Rape treatment centers (emergency services that coordinate psychiatric, gynecologic, and physical trauma services in one location and work with law enforcement agencies) are most helpful to the victim.
Dementia: Assessment - General Appearance and Motor Behavior
- Impaired ability to carry on meaningful conversations. - Aphasia - cannot name familiar objects or people. - Conversation becomes repetitive. - Speech becomes slurred, then loss of language function - Apraxia - Loss of ability to perform familiar tasks, cannot imitate the task even when demonstrated. - In the severe stage, they experience a gait disturbance that makes unassisted ambulation unsafe. - Uninhibited behavior, neglecting personal hygiene, showing familiarity with strangers, disregarding social conventions (inappropriate jokes, profanity etc)
Motor Skills Disorder (Developmental Coordination Disorder) Ignorethis
- Impaired coordination is severe enough to interfere with academic achievement or activities of daily living. - This diagnosis is not made if the problem with motor coordination is part of a general medical condition, such as cerebral palsy or muscular dystrophy. - Becomes evident as a child attempts to crawl or walk or as an older child tries to dress independently or manipulate toys such as building blocks. - Often coexists with a communication disorder. - Its course is variable; sometimes lack of coordination persists into adulthood. - Schools provide adaptive physical education and sensory integration programs to treat motor skills disorder - Emphasize inclusion of movement games such as kicking a football or soccer ball. - Sensory integration programs are specific physical therapies prescribed to target improvement in areas where the child has difficulties.
Cognitive Impairment in Older Adults
- In the US - over 6 million people aged 65+ are living with Alzheimer's Dementia, and 5+ million 71+ have cognitive impairment without dementia. - Risk for cognitive impairment and dementia increases with age. - However, cognitive impairment and dementia are not normal parts of aging.
Child Abuse
- In the US, each state defines child maltreatment, identifies specific reporting procedures, and establishes service delivery systems. - Although similarities exist among the laws of all states, there is also a great deal of variation. - For this reason, accurate data on the type, frequency, and severity of child maltreatment across the country are difficult to obtain. 2014 - 702,000 victims were identified from over 6.6 million reports. - 75% were neglect - 17% were physical abuse - 8% were sexual abuse - 6% were emotional/psychological maltreatment - An estimated 1580 died as a result of maltreatment, 70% of those were under 3yo.
Past Descriptions of Rape and its Perpetrators
- In the past, rape and its perpetrators were described in terms of motivation or dynamics (e.g., power, anger, opportunity). - Those categories weren't particularly useful since they were designed around the "rape by a stranger" idea, which is not usually the circumstance. - It is generally accepted that rape is not a sexual crime but rather the perpetrator's exertion of power, control, infliction of pain, or punishment for perceived wrongs.
Assessment - Possible Indicators of Elder Abuse: Self Neglect
- Inability to manage personal finances, such as hoarding, squandering, or giving away money while not paying bills - Inability to manage ADLs, such as personal care, shopping, or housework - Wandering, refusing needed medical attention, isolation, and substance use - Failure to keep needed medical appointments - Change in intellectual function: Confusion, memory loss, and unresponsiveness - Lack of toilet facilities, or living quarters infested with animals or vermin - Malnutrition, dehydration, rashes or sores on the body, odor of urine or feces, unable to keep medical appointments
ADHD: Risk Factors
- Include family history of ADHD; male relatives with antisocial personality disorder or alcoholism; female relatives with somatization disorder; lower socioeconomic status; male gender; marital or family discord, including divorce, neglect, abuse, or parental deprivation; low birth weight; and various kinds of brain insult.
Define: Disruptive Behavior Disorders
- Include problems with the person's ability to regulate his or her own emotions or behaviors. They are characterized by persistent patterns of behavior that involve anger, hostility, and/or aggression toward people and property. - ODD - Conduct Disorder - IED
Define: Sexual Abuse
- Includes assaults during sexual relations such as biting nipples, pulling hair, slapping and hitting, and rape. - 1 in 6 women and 1 in 14 men have experienced sexual violence by an intimate partner - Can involve exploitation such as making, promoting, or selling pornography, prostitution, trafficking
Autism Spectrum Disorder
- Includes disorders previously categorized as different types of pervasive developmental disorder (PDD), characterized by pervasive and usually severe impairment of reciprocal social interaction skills, communication deviance, and restricted stereotypical behavioral patterns. - Previous PDDs, such as Rett disorder, childhood disintegrative disorder, and Asperger disorder, are now viewed on a continuum called the autism spectrum. - Helps eliminate problems that existed when attempting to distinguish among these sometimes similar disorders. - Also, there is a great deal of difference among individuals diagnosed with autism, ranging from mild to very severe behaviors and limitations, which is easier to conceptualize along a continuum.
Causes of Intellectual Disability:
- Includes hereditary conditions such as Tay-Sachs disease or fragile X chromosome syndrome; early alterations in embryonic development, such as trisomy 21 or maternal alcohol intake, which cause fetal alcohol syndrome; pregnancy or perinatal problems such as fetal malnutrition, hypoxia, infections, and trauma; medical conditions of infancy such as infection or lead poisoning; and environmental influences such as deprivation of nurturing or stimulation. - In addition, the cause is sometimes unknown or not yet discovered.
Abuse: Self Awareness Issues
- Includes managing his or her own feelings and reactions about abuse, being willing to ask about abuse, and recognizing and dealing with any abuse issues he or she may have experienced personally.
Define: Psychological Abuse
- Includes name-calling, belittling, screaming, yelling, destroying property, and making threats as well as subtler forms, such as refusing to speak to or ignoring the victim.
Signs of Dementia
- Memory impairment - Difficulty learning new material, forgetting previously learned material - Initially, recent memory is impaired, such as forgetting where objects were placed, or food on the stove. - Later stages, remote memory is affected such as forgetting names of children, their own names, their jobs. - Clients may underestimate the risks associated with activities, or overestimate their ability to function. Ex. Driving - may cut drivers off, sideswipe cars, not slow down or stop when they should.
Child Abuse: Psychological Abuse
- Includes verbal assaults, such as blaming, screaming, name-calling, and using sarcasm; constant family discord characterized by fighting, yelling, and chaos; and emotional deprivation or withholding of affection, nurturing, and normal experiences that engender acceptance, love, security, and self-worth. - This often accompanies other types of abuse (e.g., physical or sexual abuse). - Exposure to parental alcoholism, drug use, or prostitution—and the neglect that results—also falls within this category.
Dementia: Assessment - Thought Process and Content
- Initially, ability to think abstractly is impaired - cannot plan, sequence, monitor, initiate, or stop complex behavior. - Loses ability to solve problems or take action in new situations. - Cannot generalize knowledge from one situation to another because they can not recognize similarities or differences. - Makes it impossible to keep working. - As dementia progresses, delusions of persecution are common, they might feel like people are stealing from them when objects or lost.
Dementia: Assessment - Mood and Affect
- Initially, anxiety and fear over the beginning losses of memory and cognitive functions. - May not express these feelings. - Mood becomes labile. - Emotional outbursts are common and pass quickly. - They may be angry, hostile even towards other people. - They may have catastrophic emotional reactions that may include verbal or physical aggression, agitation, wandering at night or other behaviors indicating a loss of personal control in response to environmental changes they don't understand. - Withdrawal symptoms of lethargy, apathy and pay little attention to the environment or the people in it. They appear to lose all emotional affect and seem dazed and listless.
Hazing
- Initiation rites, is prevalent in both high school and college. - Subjected to humiliating activities, or even illegal activities. - Negative consequences such as fighting; being injured; hurting other people; doing poorly in school; difficulty eating, sleeping, or concentrating; and experiencing feelings of anger, confusion, embarrassment, or guilt. - Most often associated with athletic teams, fraternities or other groups offering special status, prestige, recognition/admiration, and/or a sense of belonging. - The anticipation of these benefits helps lure students to participate, as well as the negative consequences that refusal may bring. - Alcohol consumption, humiliation, isolation, sleep deprivation, and sex acts are hazing practices common across students' groups.
Intervention Programs for Abusers
- Intervention programs may require abusers to undergo substance abuse treatment concurrently, so clients are required to remain sober and to submit to random drug testing. - Treatment centers will use a variety of approaches such as group therapy, solitary confinement, or attending Alcoholics Anonymous meetings.
Intimate Partner Violence and Stalking
- Intimate partner violence (IPV) is the mistreatment or misuse of one person by another in the context of an emotionally intimate relationship. - IPV may be suspected if a client exhibits unexplained bruising, broken bones, sexual assault, or a psychological/emotional trauma. - Stalking is a crime of intimidation in which perpetrators harass and terrorize their victims through behavior that causes fear or substantial emotional distress.
Language Disorder
- Involves deficit(s) in language production or comprehension, causing limited vocabulary and an inability to form sentences or have a conversation.
Communication Disorders
- Involves deficits in language, speech, and communication and is diagnosed when deficits are sufficient to hinder development, academic achievement, or activities of daily living, including socialization. - Communication disorders may be mild to severe. - Difficulties that persist into adulthood are related most closely to the severity of the disorder. - Speech and language therapists work with children who have communication disorders to improve their communication skills and to teach parents to continue speech therapy activities at home.
Define: Time Away
- Involves leaving clients for a short period and then returning to them to reengage in interaction. - Ex: The client may get angry and yell at the nurse for no discernible reason. The nurse can leave the client for about 5 or 10 minutes and then return without referring to the previous outburst. The client may have little or no memory of the incident and may be pleased to see the nurse on his or her return.
Tourette Disorder
- Involves multiple motor tics and one or more vocal tics, which occur many times a day for more than 1 year. - The complexity and severity of the tics change over time, and they experience almost all the possible tics described previously during their lifetime. - Significant impairment in academic, social, or occupational areas and feels ashamed and self-conscious. - This rare disorder (4 or 5 in 10,000) is more common in boys and is usually identified by 7 years of age. - Some people have lifelong problems; others have no symptoms after early adulthood
Intermittent Explosive Disorder (IED)
- Involves repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts, usually lasting less than 30 minutes. - During these episodes, there may be physical injury to others, destruction of property, and injury to the individual as well. - The intensity of the emotional outburst is grossly out of proportion to the stressor or situation. - A minor issue or occurrence may result in rage, aggression, and assault of others. - The episode may occur with no warning. - Afterward, the individual may be embarrassed and feel guilty or remorseful for his or her actions - But that does not prevent future impulsive, aggressive outbursts.
Child Abuse: Sexual Abuse
- Involves sexual acts performed by an adult on a child younger than 18 years. - Examples include incest, rape, and sodomy performed directly by the person or with an object, oral-genital contact, and acts of molestation such as rubbing, fondling, or exposing the adult's genitals. - Sexual abuse may consist of a single incident or multiple episodes over a protracted period. - A second type of sexual abuse involves exploitation, such as making, promoting, or selling pornography involving minors, and coercion of minors to participate in obscene acts.
Physical findings for a client suffering from IPV:
- Missing teeth and limited range of motion in an extremity. - Wearing clothes that are inappropriate for the weather could be an action to hide bruises or wounds. - Various wounds in different stages of healing could indicate repeated episodes of abuse. - An elevated blood pressure.
Define: Distraction/Redirection
- Involves shifting the client's attention and energy to a more neutral topic. Ex: The client may display a catastrophic reaction to the current situation, such as jumping up from dinner and saying, "My food tastes like poison!" The nurse might intervene with distraction by saying,"Can you come to the kitchen with me and find something you'd like to eat?" or "You can leave that food. Can you come and help me find a good program on television?" (redirection/distraction) Clients usually calm down when the nurse directs their attention away from the triggering situation.
Social Communication Disorder
- Involves the inability to observe social "rules" of conversation, deficits in applying context to conversation, inability to tell a story in an understandable manner, and inability to take turns talking and listening with another.
Define: Neglect
- Is malicious or ignorant withholding of physical, emotional, or educational necessities for a person's (child, elderly, dependent person) well-being.
Trauma: Intervention - Helping Promote the Client's Self-Esteem
- It is often useful to view the client as a survivor of trauma or abuse rather than as a victim. - It helps to refocus their views of themselves from being victims to being survivors. - Defining themselves as survivors allows them to see themselves as strong enough to survive their ordeal. - It is a more empowering image than seeing oneself as a victim.
Delirium: Assessment - Judgment and Insight
- Judgment is impaired. - Often cannot perceive potentially harmful situations or act in their own best interests. - Ex: They may try repeatedly to pull out IV tubing or urinary catheters; this causes pain and interferes with necessary treatment. - Insight depends on the severity of the delirium. - Clients with mild delirium may recognize that they are confused, are receiving treatment, and will likely improve. - Those with severe delirium may have no insight into the situation.
ADHD: Assessment - Mood and Affect
- Labile mood, possible verbal outbursts or temper tantrums. - Anxiety, frustration, and agitation are common. - The child appears to be driven to keep moving or talking and appears to have little control over movement or speech. - Attempts to focus the child's attention or redirect the child to a topic may evoke resistance and anger.
Conduct Disorder: Intervention - Decreasing Violence and Increasing Compliance with Treatment
- Limit setting is important. Limit setting involves the following three steps: 1. Inform clients of the rule or limit. 2. Explain the consequences if clients exceed the limit. 3. State expected behavior. - Providing consistent limit enforcement with no exceptions by all members of the health team, including parents, is essential. - Consequences must have meaning. - Behavioral contract will help by outlining expected behaviors, limits, and rewards - also helps avoid power struggles. - Must be consistent. - Time-out is not a punishment but an opportunity for the client to regain self-control.
Conduct Disorder: Assessment - Judgement and Insight
- Limited for developmental stage. - Clients consistently break rules with no regard for the consequences. - Thrill-seeking or risky behavior is common, such as use of drugs or alcohol, reckless driving, sexual activity, and illegal activities such as theft. - Clients usually blame others or society for their problems; they rarely believe their behavior is the cause of difficulties.
Trauma: Evaluation
- Long term treatment outcomes may take years to achieve - They usually make gradual progress in protecting themselves, learning to manage stress and emotions, and functioning in their daily lives. - Although clients learn to manage their feelings and responses, the effects of trauma and abuse can be far-reaching and can last a lifetime.
Dementia: Assessment - Sensorium and Intellectual Processes
- Lose intellectual function, then a complete loss of abilities. - Memory deficits (recent and immediate) are the initial and essential feature of dementia. - Eventually, it affects the ability to recognize close family members and even oneself. - Confabulation (make-up answers to fill in gaps) - Agnosia - Often lose visual-spatial relations (cannot draw or write) - Attention span, ability to concentrate impaired. - Chronic confusion Disorientation - Mild Dementia, just disoriented to time. - Moderate Dementia, disoriented to time and place. - Severe Dementia, disoriented to self. - Hallucinations - visual is most common.
Delirium: Intervention - Promoting Client's Safety
- Maintaining the client's safety is the priority focus of nursing interventions. - Medications should be used judiciously because sedatives may worsen confusion and increase the risk for falls or other injuries. - The nurse teaches clients to request assistance for activities such as getting out of bed or going to the bathroom. - If clients cannot request assistance, they require close supervision to prevent them from attempting activities they cannot perform safely alone. - If a client is agitated or pulling at IV lines or catheters, physical restraints may be necessary.
Child Abuse: Neglect
- Malicious or ignorant withholding of physical, emotional, or educational necessities for the child's well-being. - The most prevalent type of maltreatment - includes the refusal to seek health care for the child, or delay doing so; abandonment; inadequate supervision; reckless disregard for the child's safety; punitive, exploitive, or abusive emotional treatment; spousal abuse in the child's presence; giving the child permission to be truant; or failing to enroll the child in school.
Elder Abuse
- Maltreatment of older adults by family members, or others in a caregiver role. - May include physical abuse, sexual abuse, psychological abuse, neglect, self-neglect, financial exploitation, and denial of adequate medical treatment. - 1 in 10 over age 65 are injured, exploited, abused or neglected by their caregivers - Despite those numbers, few cases are reported - Perpetrators are likely living with the victim, related to the victim, and might have legal or psychological problems themselves. - Most victims are 75+, 60-65% are women. - Abuse is more likely if the elder has multiple chronic mental and physical health problems, and when dependent on others for food, medicare care, and ADLs.
Delirium: Intervention - Promoting Sleep/Proper Nutrition
- Monitor sleep and elimination patterns, as well as food and fluid intake. - May require prompting - Family may help - Assist to the bathroom periodically - Promote sleep balance - Discouraging daytime napping - Exercise can help
Define: Repressed Memories
- Many professionals believe that memories of childhood abuse can be buried deeply in the subconscious mind or repressed because they are too painful for the victims to acknowledge and that victims can be helped to recover or remember such painful memories. - Professionals may help the person remember or recover those memories of abuse. However, some believe there is a danger of inducing false memories of childhood sexual abuse through imagination in psychotherapy. - This so-called false memory syndrome has created problems in families when clients made groundless accusations of abuse. - Fears exist, however, that people abused in childhood will be more reluctant to talk about their abuse history because, once again, no one will believe them.
Dementia: Assessment
- May be confusing/complicated for clients. - Use simple explanations to explain as needed. - Clients may become confused or tire easily. - Take breaks in the interview, allow time to answer and use simple questions. - MSE - People w/ depression or psychosis may be able to perform these tasks correctly.
Conduct Disorder: Assessment - Mood and Affect
- May be quiet and reluctant to talk, or they may be openly hostile and angry. - Attitude is likely to be disrespectful toward parents, the nurse, or anyone in a position of authority. - Irritability, frustration, and temper outbursts are common. - Clients may be unwilling to answer questions or cooperate with the interview; they believe they do not need help or treatment. - If a client has legal problems, he or she may express superficial guilt or remorse, but it is unlikely that these emotions are sincere.
Elder Abuse: Treatment and Intervention
- May develop gradually as the burden of care exceeds the caregiver's physical or emotional resources. Relieving the caregiver's stress and providing additional resources may help correct the abusive situation and leave the caregiving relationship intact. In other cases, the neglect or abuse is intentional and designed to provide personal gain to the caregiver, such as access to the victim's financial resources. In these situations, removal of the elder or caregiver is necessary.
Delirium: Treatment and Prognosis - Other Treatment
- May need nutritious food and fluid intake such as IV fluids, parenteral nutrition if necessary. - Physical restraint may be nexessary if the client is agitated and threatening to dislodge IV tubing/catheters. - Restraints used only when necessary and stay in place for only as long as is warranted.
Define: Date Rape/Acquaintance Rape
- May occur on a first date, on a ride home from a party, or when the two people have known each other for some time. - It is more prevalent around or on college campuses. - The rate of serious injuries associated with dating violence increases with increased consumption of alcohol by either the victim or the perpetrator. - Alcohol is cited as a factor, along with the use of illegal drugs such as flunitrazepam (Rohypnol) or other "date rape drugs".
Define: Going Along
- Means providing emotional reassurance to clients without correcting their misperception or delusion. - The nurse does not engage in delusional ideas or reinforce them, but he or she does not deny or confront their existence. Ex: A client is fretful, repeatedly saying, "I'm so worried about the children. I hope they're OK," and speaking as though his adult children were small and needed protection. The nurse could reassure the client by saying, "There's no need to worry; the children are just fine (going along)," which is likely to calm the client. - The nurse has responded effectively to the client's worry without addressing the reality of the client's concern. - Going along is a specific intervention for clients with dementia and should not be used with those experiencing delusions whose conditions are expected to improve.
Conduct Disorder: Pharmacology
- Medications alone have little effect, but may be used in conjunction with treatment for specific symptoms. - For example, the client who presents a clear danger to others (physical aggression) may be prescribed an antipsychotic medication, such as risperidone (Risperdal). - Clients with labile moods may benefit from lithium or another mood stabilizer such as carbamazepine (Tegretol) or valproic acid (Depakote)
Medications for PTSD
- Medications for symptoms of insomnia, anxiety, hyperarousal - SSRI, SNRIs most effective - 2nd gen antipsychotics are next - Evidence of lacking for efficacy of benzodiazepines, though they are widely used in clinical practice
IED Treatment
- Medications, such as fluoxetine (Prozac); lithium; and anticonvulsant mood stabilizers such as valproic acid (Depakote), phenytoin (Dilantin), topiramate (Topamax), and oxcarbazepine (Trileptal). - SSRIs seem to reduce aggressive tendencies because serotonin deficiencies are often linked to causation. - Although these medications reduce aggressive impulses and irritability in many people, they do not eliminate the outbursts of IED. - Additional interventions can improve outcomes, such as CBT, anger management strategies, avoidance of alcohol and other substances, and relaxation techniques. - The best outcomes involve a combination of these interventions and treatment.
ADHD: Treatment - Strategies for Home and School
- Meds don't automatically work to improve their academic performance or help them make friends - Behavioral strategies - Educating parents and helping them with parenting strategies are crucial components. - Effective approaches include providing consistent rewards and consequences for behavior, offering consistent praise, using time-out, and giving verbal reprimands. - Additional strategies are issuing daily report cards for behavior and using point systems for positive and negative behavior. - Therapeutic play
ADHD: Treatment - Pharmacology
- Meds help decrease hyperactivity, impulsiveness improves attention. - Most common medications are methylphenidate (Ritalin) and an amphetamine compound (Adderall). - Dextroamphetamine (Dexedrine) and pemoline (Cylert) are other stimulants used to treat ADHD. - Giving during daytimes hours usually combats insomnia. - Eating a good breakfast w/ morning dose, and nutritious snacks later on help child maintain dietary intake. - 1st choice are stimulants, 2nd choice are antidepressants.
Violent Families: Social Isolation
- Members of the family keep to themselves, and do not invite others to the home or tell people what is happening. - Abusers threaten victims with greater harm if they reveal secret. - They make children keep secret out of fear, which prevents others from "interfering with private family business"
Common symptoms of depression:
- Mood of sadness, despair, emptiness - Negative, pessimistic thinking - Loss of ability to experience pleasure in life (anhedonia) - Low self-esteem - Apathy, low motivation, and social withdrawal - Excessive emotional sensitivity - Irritability and low frustration tolerance - Insomnia or hypersomnia - Disruption (mild to severe) in concentration or ability to make decisions - Suicidal ideation - Excessive guilt - Indecisiveness - Aches, pains, cramps
Enuresis and Encopresis
- More common in boys than in girls; 1% of all 5-year-olds have encopresis and 5% of all 5-year-olds have enuresis. - Encopresis can persist with intermittent exacerbations for years; it is rarely chronic. - Most children with enuresis are continent by adolescence; only 1% of all cases persist into adulthood. - Impairment associated with elimination disorders depends on the limitations on the child's social activities, effects on self-esteem, degree of social ostracism by peers, and anger, punishment, and rejection on the part of parents or caregivers. - Both elimination disorders respond to behavioral approaches, such as a pad with a warning bell, and to positive reinforcement for continence. For children with a disruptive behavior disorder, psychological treatment of that disorder may improve the elimination disorder
Abuse Victims: Assessment
- Most abused partners do not seek help directly. - Nurses may encounter abused people in emergency departments, clinics, pediatrician's offices - The nurse can make referrals, and contact appropriate health care professionals. - The nurse can offer caring and support throughout the visit (whether they are there for that or other medical problems). - Its important to ask everyone whether they feel safe at home or in their relationship - don't stereotype by asking only those who might be seen as "likely victims"
PTSD: Community Based Care
- Most care provided to people in the aftermath of traumatic experiences is done on an outpatient basis. - Individual therapy, group therapy, and self-help groups are among the most common treatment modalities. - In addition, both clients and families can implement many self-care interventions to promote physical and emotional well-being.
Bullying In Schools: Stats
- Nearly 1/3 of the U.S. students report they experience bullying, either as a target or as a perpetrator. - The frequency of bullying was highest among sixth through eighth graders. - Bullied children reported more loneliness and difficulty making friends, more likely to have poor grades and use alcohol and tobacco. C - Children with special physical health care needs are bullied more often, and children with chronic emotional, behavioral, or developmental problems are more likely to be victims of bullying.
What are the social determinants of health?
- Neighborhood and built environment - Health and health care - Social and community context - Education - Economic stability These can result in health disparities among older adults. - Approx 70% of health outcomes are affected It is important to practice from anti-oppression and social justice framework that utilizes cultural humility to have an understanding of how social identities intersect to affect a patient's health. - Note that two people from similar backgrounds can have completely different experiences and outcomes.
ADHD: Treatment
- No one treatment has been found to be effective for ADHD; this gives rise to many different approaches such as sugar-controlled diets and megavitamin therapy. - Parents need to know that any treatment heralded as the cure for ADHD is probably too good to be true. - ADHD is chronic; goals of treatment involve managing symptoms, reducing hyperactivity and impulsivity, and increasing the child's attention so that he or she can grow and develop normally. - The most effective treatment combines pharmacotherapy with behavioral, psychosocial, and educational interventions.
Elder Abuse: Reporting
- Nurses are mandated reporters. - Elders are often reluctant to report abuse, even when they can, because the abuse usually involves family members whom the elder wishes to protect. - Victims also often fear losing their support and being moved to an institution. - No national estimates of abuse of elders living in institutions are available. - However, under a 1978 federal mandate, ombudsmen are allowed to visit nursing homes to check on the care of the elderly. - These ombudsmen report that complaints of elder abuse are common in institutions, though not all complaints are substantiated.
Trauma: Self Awareness Issues
- Nurses must deal with their own personal feelings to best care for individuals affected by traumatic events. - If the nurse is overwhelmed by the violence or death in a situation, the client's feelings of being victimized or traumatized beyond repair are confirmed. - Conveying empathy and validating clients' feelings and experiences in a calm, yet caring professional manner is more helpful than sharing the client's horror. - When the client's traumatic event is a natural disaster or even a random violent attack, the nurse may easily support the client, knowing the client had nothing to do with what happened. - When the traumatized client causes a car accident that injured or killed others, it may be more challenging to provide unconditional support and withhold judgment. - Remaining nonjudgmental of the client is important but doesn't happen automatically.
PTSD Symptoms
- Occur 3+ months after trauma, which distinguished it from acute stress disorder - The onset can be delayed months or years. - Chronic in nature, though symptoms fluctuate in intensity/severity - Worse during stress - Can be exacerbated by other life events - Other disorders in addition to PTSD are common (depression, anxiety, sub abuse)
Define: Acute Stress Disorder
- Occurs after a traumatic event and is characterized by reexperiencing, avoidance, and hyperarousal that occur from 2/3 days to 4 weeks following a trauma. - It can be a precursor to PTSD. - Cognitive-behavioral therapy (CBT) involving exposure and anxiety management can help prevent the progression to PTSD. - Lasts from 3 days to 1 month
PTSD Ages
- Occurs at any age, including childhood - 60% of people at risk, such as combat veterans, victims of violence and natural disasters develop PTSD - 50% recover within 3 months - Severity and duration of the trauma, and proximity of the person to the event are the most important factors that affect the likelihood of developing PTSD - 1/4 of all victims of physical assault develop PTSD - 70% of rape victims develop it
Define: Reactive Attachment Disorder (RAD)
- Occurs before the age of 5 in response to the trauma of child abuse or neglect, called grossly pathogenic care. - The child shows disturbed inappropriate social relatedness in most situations. - Rather than seeking comfort from a select group of caregivers to whom the child is emotionally attached, the child with RAD exhibits minimal social and emotional responses to others, lacks a positive effect, and may be sad, irritable, or afraid for no apparent reason.
Define: Disinhibited Social Engagement Disorder (DSED)
- Occurs before the age of 5 in response to the trauma of child abuse or neglect, called grossly pathogenic care. - The child shows disturbed inappropriate social relatedness in most situations. i - The child with DSED exhibits unselective socialization, allowing or tolerating social interaction with caregivers and strangers alike. - They lack the hesitation in approaching or talking to strangers evident in most children their age. - Grossly deficient parenting and institutionalization are the two most common situations leading to this disorder ex. A child giving adults hugs just after meeting them
Dynamics of Rape
- Of men who commit rape, 50% are age 30+, 25% are 21-29. - 57% are white. - Alcohol is involved in 34% of cases. - Rape accompanies other crimes. - 75% of arrested rapists have criminal priors - Women who are raped are frequently in life-threatening situations, so #1 is to stay alive. - Sometimes efforts to fight or resist the attacker succeeds, other times it results in injury or death. - If the attacker has a weapon, the degree of submission is higher. - The rapist may also insert foreign objects into their victim's body or urinate on defecate on them.
Child Abuse: Perpetrators
- Often adults who were victims of abuse abused their children. - Fathers, stepfathers, uncles, older siblings and live-in partners of the child's mother often were the abusers of girls. - 75% of reported cases are father-daughter incest/rape! - Mother-son incest/rape were less frequent - 15 million women in the US are estimated to have been sexually abused as children, and 1/3 of all sexually abused victims were molested younger than 9. - Accurate statistics are difficult to obtain because many incidents are unreported, unknown or unacknowledged.
Delirium: Assessment - Mood and Affect
- Often have rapid and unpredictable mood shifts. - A wide range of emotional responses is possible, such as anxiety, fear, irritability, anger, euphoria, and apathy. - These mood shifts and emotions usually have nothing to do with the client's environment. - When clients are particularly fearful and feel threatened, they may become combative to defend themselves from perceived harm.
Dissociative Disorders: Treatment and Interventions
- Often in group or individual therapy in the community - Therapy focuses on reassociation or putting the consciousness back together. - Addresses trauma-based, dissociative symptoms. - Goals of therapy are to improve quality of life, improve functional abilities, and reduced symptoms. - Clients may be treated symptomatically, that is, with medications for anxiety or depression or both if these symptoms are predominant. - Clients with these disorders and PTSD are found in all areas of health care. These clients are only in acute care when in crisis. Treatment is usually short-term, then back to community-based treatment.
Intimate Partner Violence (IPV) - Perpetrators
- Often perpetrated by a husband against a wife - but the same patterns are seen between partners who are not married, same-sex partners and with wives who abuse their husbands. - The abuser often believes that the partner belongs to them, like property, and becomes increasingly violent and abuse if they show any signs of independence (job, leaving) - Typically the abuser feels inadequate, has low self-esteem, is emotionally immature, has poor problem-solving skills and social skills, is needy, irrationally jealous, and possessive. - The abuser may feel jealous of the partner's attention to the children and may abuse both the partner and the children. - This gives the abuser a sense of power and control, that they lack outside the home. - 1 in 4 women and 1 in 7 men report severe IPV from an intimate partner in their lifetime. - Pregnant people experience an increase in violence during pregnancy which leads to miscarriages, stillbirth and physical and psychological problems for the pregnant person.
Emotional Response of Sexually Abused Children
- Often, these children talk or behave in ways that indicate more advanced knowledge of sexual issues than would be expected for their ages. - They can be frightened and anxious and may either cling to an adult or reject adult attention entirely. - The key is to recognize when the child's behavior is outside what is normally expected for his or her age and developmental stage. - Seemingly unexplained behavior, from refusal to eat to aggressive behavior with peers, may indicate abuse.
What percent of eligible Medicare beneficiaries receive an Annual Wellness Visit (AWV)?
- Only 18.8% - This represents a significant gap in the health care services for the geriatric population.
Geriatric Substance Abuse
- Over 17% of older adults suffer from substance abuse disorder - One of the most commonly diagnosed and untreated conditions - Indistinct symptoms: the symptoms can mimic symptoms of medical comorbidities, depression, cognitive impairment - Decreased ability to metabolize drugs and alcohol, and have increased brain sensitivity to the intoxication.
PTSD: Etiology
- PTSD and acute stress disorder were thought of as anxiety disorders - Now their own categories, because there has to be a causative trauma or event that occurs prior to the development of the disorder, which is not the case with anxiety disorders - Effects of the trauma at the time (such as being directly involved, experiencing a physical injury, or loss of a loved one at the event) are more powerful predictors of PTSD for people. - Lack of social support, peri-trauma, dissociation, and previous psych history or personality factors can increase the risk of PTSD - Post-trauma counseling decreases risk
PTSD: Elder Considerations
- PTSD can be diagnosed at any age - Elderly people who fall and fracture a hip can get PTSD - Many elders went through wars such as WWII, Korean War, Vietnam etc - Often called Combat fatigue or shell shock - Vietnam vets are one of the first to be diagnosed with PTSD - PTSD has a negative impact on physical functioning and general health. - Chronic PTSD might be linked to premature aging and dementia.
Conduct Disorder: Mental Health Promotion
- Parental behavior profoundly influences children's behavior. - Parents who engage in risky behaviors, such as smoking, drinking, and ignoring their health, are more likely to have children who also engage in risky behaviors, including early unprotected sex. - Group-based parenting classes, as well as individual parent behavior therapy with the child, were both effective to deal with problem behaviors in children and improve parenting skills and confidence. - SNAP-IV tool helps to asses. - Early detection is key.
ADHD: Evaluation
- Parents and teachers are likely to notice positive outcomes of treatment before the child does. - Medications are often effective in decreasing hyperactivity and impulsivity and improving attention relatively quickly if the child responds to them. - Improved sociability, peer relationships, and academic achievement happen more slowly and gradually but are possible with effective treatment.
Conduct Disorder: Intervention - Providing Client and Family Education
- Parents may need help in learning social skills, solving problems, and behaving appropriately. - Often, parents have their own problems, and they have had difficulties with the client for a long time before treatment was instituted. - Parents need to replace old patterns such as yelling, hitting, or simply ignoring behavior with more effective strategies. - The nurse can teach parents age-appropriate activities and expectations for clients, such as reasonable curfews, household responsibilities, and acceptable behavior at home. - The parents may need to learn effective limit setting with appropriate consequences. - Parents often need to learn to communicate their feelings and expectation clearly and directly. - May need to let the child experience the consequences of bad behavior.
ADHD: Assessment - History
- Parents may report that the child was fussy and had problems as an infant, or they may not have noticed the hyperactive behavior until the child was a toddler or entered day care or school. - The child probably has difficulties in all major life areas such as school or play, and he or she likely displays overactive or even dangerous behavior at home. - Often, parents say the child is "out of control," and they feel unable to deal with the behavior. - Parents may report many largely unsuccessful attempts to discipline the child or change the behavior.
Delirium: Cultural Considerations
- People from different cultures may not be familiar with the typical tools used to assess memory such as US presidents - Others cultures may consider orientation to placement and location differently. - Jehovah's Witnesses do not celebrate birthdays, so they may have difficulty stating DOB - Nurse should make sure not to mistake these things
Severe Dementia
- Personality and emotional changes occur. - May be delusional, wander at night, forget the names of his or her spouse and children, and require assistance with ADLs. - Most people live in nursing facilities when they reach this stage, unless extraordinary community support is available.
Define: Therapeutic Play
- Play techniques are used to understand the child's thoughts and feelings and to promote communication. - Should not be confused with play therapy, a psychoanalytic technique used by psychiatrists. - Dramatic play is acting out an anxiety-producing situation such as allowing the child to be a doctor or use a stethoscope or other equipment to take care of a patient (a doll). - Techniques to release energy could include pounding pegs, running, or working with modeling clay. - Can help children to express themselves; for example, by drawing pictures of themselves, their family, and peers. - Useful when children are unable or unwilling express themselves verbally.
Dementia: Assessment - Judgement and Insight
- Poor judgment - Underestimate risks, unrealistically appraise their abilities - Cannot evaluate situations for risk/danger (wander outside in dead of winter) - Limited insight - May be aware of problems initially - Later, the concerns vanish and they have little to no awareness of the more serious deficits that have developed.
ADHD: Assessment - Judgment and Insight
- Poor judgment and impulsivity - May fail to see harm or danger - Assessing this is hard, but children with ADHD display more lack of judgment compared to the others. - Most young children with ADHD are unaware of their behavior being different and don't see how it harms others.
Assessment - Possible Indicators of Elder Abuse: Neglect
- Poor personal hygiene - Lack of needed medications or therapies - Dirt, fecal or urine smell, or other health hazards in the elder's living environment - Rashes, sores, or lice on the elder - The elder has an untreated medical condition or is malnourished or dehydrated not related to a known illness - Dehydration or malnourishment not linked with a specific illness. - Inadequate material items, such as clothing, blankets, furniture, and television
ADHD: Interventions - Improving Role Performance
- Positive feedback is needed when child meets expectation. - This reinforces desired behaviors and gives them a sense of accomplishment. - Managing the environment helps the child improve their ability to listen, pay attention, and complete tasks. - A quiet place with minimal noise and distraction is desirable. - At school, this may be a seat directly facing the teacher at the front of the room and away from the distraction of a window or door. - At home, the child should have a quiet area for homework away from the television or radio.
Geriatric depression:
- Prevalence is 5-13.5% (higher percentages for those in care homes and hospitals) - Not a normal effect of aging. - Frequently underdiagnosed, patients also resist treatment due to stigma. Increases the risk for: - Poor quality of life - Difficulties with ADLs - Physical comorbidities - Cognitive impairment - Institutionalization - Mortality
Define: Neurocognitive Disorder (NCD)
- Previously categorized as "adult cognitive disorders" in the DSM-5 such as dementia, delirium and amnestic disorders. - Those categories have been reconceptualized in the DSM-5 as neurocognitive disorders (NCDs). - This now includes delirium, major NCD, mild NCD, and their subtypes by etiology. - The term dementia is still used, even in the DSM-5, and also in the literature and by practitioners.
What are some barriers for Medicare recipients getting their Annual Wellness
- Sometimes PCPs do not have the time to meet the requirements of the visit (assessment and documentation of multiple different components) - Some patients might misunderstand the purpose of the AWV, and how it might differ from a regular visit. They may also have a negative view of the purpose of preventative care. - They may be unaware of the benefit.
Child Abuse: Treatment and Intervention
- Priority: Child safety and well-being (might involve removing the child from the home, which can be traumatic) - Thorough psychiatric evaluation is indicated. - Relationship of trust between the therapist and child is crucial. - Long-term therapy may be indicated depending on severity/duration of abuse and the child's response. Involves social work, psychiatry, psychology - Play therapy is best for a young child. - Social service agencies are in charge of reunification - based on whether the parents show benefit from treatment. - Family therapy may be indicated. Parents may require psychiatric/substance abuse treatment. - If reunification is not possible, short-term or foster care services may be indicated.
Dementia
- Progressive cognitive impairment with no change in the level of consciousness. - Involves multiple cognitive deficits such as aphasia, apraxia, agnosia, disturbances in executive functioning. - Must be severe enough to impair social or occupational functioning, and represent a decline from the previous functioning
Define: Restraining Order
- Protection order - Legally prohibits a person from approaching and contacting the filer. - Only limited protection - the abuser can easily violate the order and severely injure or kill the partner before the police get involved. - Some states have laws stating that they must remove firearms from the person, though the process is not clear in some states. - Most effective when combined with other interventions such as counseling, shelter, or talking with health care providers. - Those who have left abusive partners are more likely to be successful if their legal and psychological needs are addressed simultaneously.
Importance of Early Assessment and Screening
- Provides opportunity to ID problems early on. - If screening is negative, then you have a general baseline for the patient. - If screening is positive then further investigation is needed to find the cause. - Causes of cognitive impairment is not always due to dementia, and could be reversible or treatable. - Ex: Medication side effects, toxicity or metabolic problems, acute illness or infection, depression or other mood disorders
Neurodevelopmental Disorders
- Psychiatric disorders are not diagnosed easily in children. - Children often lack the verbal skills and abstract cognitive abilities to describe what is happening. - They are constantly changing and developing, children have a limited sense of a stable, normal self to allow them to discriminate unusual or unwanted symptoms from normal feelings and sensations. - Behaviors that are normal in a child of one age may indicate problems in a child of another age. - Children and adolescents experience some of the same mental health problems as adults, such as mood and anxiety disorders, and are diagnosed with these disorders using the same criteria as for adults.
Dementia: Intervention
- Psychosocial models for care - based on the approach that each client is a unique person and remains so, even as the disease's progression blocks the client's ability to demonstrate those unique characteristics. - Interventions are rooted in the belief that clients with dementia have personal strengths. - They focus on demonstrating caring, keeping clients involved by relating to the environment and other people, and validating feelings and dignity of clients by being responsive to them, offering choices, and reframing (offering alternative points of view to explain events). - This is in contrast to medical models of care that focus on progressive loss of function and identity. - Education for family members caring for clients at home and for professional caregivers in residential or skilled facilities is an essential component of providing safe and supportive care.
Define: Physical Abuse
- Ranges from shoving and pushing to severe battering and choking and may involve broken limbs and ribs, internal bleeding, brain damage, and even homicide.
Survivors of Rape: Aftercare
- Rape crisis centers, advocacy groups, and other local resources often provide a counselor or volunteer to be with the victim from the emergency department through longer-term follow-up. - The counselor acts as an advocate for the victim, and this type of unconditional support is often crucial to recovery - Therapy is indicated, helps the victim to regain a sense of control, relieve feelings of helplessness, dependency, and obsession with the assault, regain trust, improves functioning, assists with finding social support, dealing with feelings of guilt shame, and anger. - Group therapy is effective - Often takes 1 year or more
Conduct Disorder: Assessment - Roles and Relationships
- Relationships with others, especially those in authority, are disruptive and may be violent. - Verbal and physical aggression is common. - Siblings may be a target for ridicule or aggression. - Relationships with peers are limited to others who display similar behaviors; these clients see peers who follow rules as dumb or afraid. - Usually have poor grades, have been expelled, or have dropped out. - Unlikely that they have a job (if old enough) because they would prefer to steal. - Their idea of fulfilling roles is being tough, breaking rules, and taking advantage of others.
Dementia: Points to Consider When Working with Clients with Dementia
- Remember how important it is to provide dignity for the client and family as the client's life ends. - Remember that death is the last stage of life. The nurse can provide emotional support for the client and family during this period. - Clients may not notice the caring, patience, and support the nurse offers, but these qualities will mean a great deal to the family for a long time.
Neurodevelopmental Disorders: Points to Consider When Working with Children and Adolescents and Their Parents
- Remember to focus on the client's and parents' strengths and assets, not just their problems. - Support parents' efforts to remain hopeful while dealing with the reality of their child's situation. - Ask parents how they are doing. Offer to answer questions and provide support or make referrals to meet their needs as well as those of the client.
Points to Consider When Working with Clients with Disruptive Behavior Disorders and Their Families
- Remember to focus on the client's strengths and assets, as well as their problems. - Avoid a "blaming" attitude toward clients and/or families; rather, focus on positive actions to improve situations and/or behaviors.
Define: Dissociative Amnesia
- The client cannot remember important personal information (usually of a traumatic or stressful nature). - This category includes a fugue experience where the client suddenly moves to a new geographic location with no memory of past events and often the assumption of a new identity. - Amnesia about traumatic events is characteristic of dissociation.
Dementia: Mental Health Promotion
- Research continues on the risk factors for dementia - Elevated levels of plasma homocysteine are at increased risk for dementia. - Folate, vitamin b12, and betaine are known to reduce plasma homocysteine levels. - Clinical trials are in progress to test this. - Participating in brain-stimulating activities is less likely to develop Alzheimer's dementia. - Physical activity and having a social network during midlife = reduced risk for Alzheimer's later in life. - Healthy eating, physical activity, minimizing health risks helps decrease or delay cognitive decline.
Dementia: Intervention - Promoting Client Safety
- Safety considerations include - meeting physiological needs, managing environmental risks, protecting against injury - including against internal stimuli such as delusions and hallucinations. - They cannot accurately appraise the environment and their abilities; therefore, they do not exercise normal caution in daily life. - Assistance or supervision that is as unobtrusive as possible protects clients from injury while preserving their dignity. - May feel threatened, suspicious, or paranoid - leading to agitation or erratic behaviors that compromise safety. - Take clients to a calmer quieter place which can help reduce symptoms of agitation and anxiety.
Trauma: Intervention - Promoting the Client's Safety
- Safety is priority - Continually assess the patient's potential for self-harm or suicide, and take action - Provide safety measures when the client can't do so. - TO increase the client's sense of personal control, they must begin to manage safety needs asap. - The nurse can talk to the client about the difference between having self-harm thoughts and taking action on those thoughts; having the thoughts does not mean the client must act on them. - Gradually, the nurse can help the client find ways to tolerate the thoughts until they diminish in intensity.
ADHD: Interventions - Ensuring Safety
- Safety of child and others is priority. - Stop dangerous behaviors - Talking during the event is unlikely to succeed. - After the child is safe, the adult should talk to the child and express expectations for safe behavior. - Close supervision might be indicated. - Explanations should be short and clear. - State expectations clearly. - It is often necessary to act first to stop harmful behavior.
Warning Signs of Abused/Neglected Children
- Serious injuries such as fractures, burns, or lacerations with no reported history of trauma - Delay in seeking treatment for a significant injury - Child or parent giving a history inconsistent with severity of injury, such as a baby with contrecoup injuries to the brain (shaken baby syndrome) that the parents claim happened when the infant rolled off the sofa - Inconsistencies or changes in the child's history during the evaluation by either the child or the adult - Unusual injuries for the child's age and level of development, such as a fractured femur in a 2-month-old or a dislocated shoulder in a 2-year-old - High incidence of urinary tract infections; bruised, red, or swollen genitalia; tears or bruising of rectum or vagina - Evidence of old injuries not reported, such as scars, fractures not treated, and multiple bruises that parent/caregiver cannot explain adequately
Physical and Psychological Trauma of Rape
- Severe - Related medical problems include acute injury, STIs, pregnancy, and lingering medical complaints. - A study showed that women who had been raped rated themselves significantly less healthy, saw a provider 2x, and paid for medical costs 2x more than women who had not been - Many victims of rape experience fear, helplessness, shock, disbelief, guilt, humiliation, and embarrassment. - May avoid the place or circumstances of the rape, give up activities, experience depression, anxiety, PTSD, sexual dysfunction, insomnia and impaired memory - May contemplates suicide
Rape and Sexual Assault
- Sexual intercourse with a person against his or her will and without her consent, by force, fear of force, drugs, or intoxicants. - Crime of violence and humiliation of the victim expressed through sexual means. - Also rape if the victim is incapable of exercising rational judgment because of mental deficiency or because he or she is younger than the age of consent (which varies among states from 14 to 18 years) - Requires only slight penetration of the outer vulva or rectum; full erection and ejaculation are not necessary. - Forced acts of oral sex and anal penetration, although they frequently accompany rape, are legally considered sodomy, which is still sexual assault. - The person who is raped may also be physically beaten and injured.
Conduct Disorder: Intervention - Improving Coping Skills and Self-Esteem
- Show acceptance of clients as worthwhile individuals, even with bad behavior. - The nurse must be matter of fact about setting limits and must not make judgmental statements about clients - must focus only on the behavior. - Clients with a conduct disorder often have a tough exterior and are unable or reluctant to discuss feelings and emotions - a diary may help them ID and express their feelings. - The nurse can discuss these feelings with clients and explore better, safer expressions than through aggression or acting out. - Clients need to learn how to solve problems - which involves identifying the problem, exploring all possible solutions, choosing and implementing one of the alternatives, and evaluating the results
Define: Intergenerational Transmission Process
- Shows that patterns of violence are perpetuated from one generation to the next through role modeling and social learning. - Suggests that family violence is a learned pattern of behavior. Ex: children who witness violence between their parents learn that violence is a way to resolve conflict and is an integral part of a close relationship. - Stats show that 1/3 of abusive men are more likely to have come from violent homes where they witnessed abuse or were abused themselves. - Women who grew up in violent homes are 50% more likely to expect or accept violence in their own relationships. *** Not everyone though ***
Violent Families: Intergenerational Transmission Process
- Shows that patterns of violence are perpetuated from one generation to the next through role modeling and social learning. - This suggests that family violence is a learned pattern of behavior. - Ex: children who witness violence between their parents learn that violence is a way to resolve conflict and is an integral part of a close relationship. - Statistics show that 1/3 of abusive men are likely to have come from violent homes where they witnessed abuse or were abused themselves. - Women who grew up in violent homes are 50% more likely to expect or accept violence in their own relationships. ** Not all persons exposed to family violence, however, become abusive or violent as adults. Therefore, this single factor does not explain the perpetuation of violent behavior.
Characteristics of Violent Families
- Social isolation - Abuse of power and control - Alcohol and other drug abuse - Intergenerational transmission process
Delirium: Intervention - Managing Client's Confusion
- Speak in a clear, calm voice. It is important to give realistic reassurance to clients. - Facing clients while speaking helps capture their attention. - The nurse provides explanations that clients can comprehend, avoiding lengthy or too detailed discussions. - The nurse phrases questions or provides directions to clients in short, simple sentences, allowing adequate time for clients to grasp the content or respond to a question. - He or she permits clients to make decisions as they are able to and takes care not to overwhelm or frustrate them. - Orienting client with calendar/clock is helpful - Reduce sensory overload - Room should be well lit
ADHD Medications: Dextroamphetamine
- Stimulant used to treat ADHD. - Available in a sustained-release form taken once daily; this eliminates the need for additional doses when the child is at school.
ADHD Medications: Pemoline (Cylert)
- Stimulant used to treat ADHD. - Can cause liver damage, it is the last of these drugs to be prescribed.
Rape: Perpretrators
- Strangers - Acquaintances - Spouses - Persons of the same or opposite sex (though 7 states define this in a way that excludes same-sex victims of DV) - 28% committed by strangers, 7% for child victims - Date rape
Dementia: Intervention - Structuring the Environment and Routine
- Structured environment, established routines help reassure clients w/ dementia. - Familiar surroundings and routines help reduce confusion and frustration. - Does not mean forcing clients to conform to the setting or routines that others impose. - The nurse encourages the client to follow their usual routines and habits such as when/how they like to bathe. - Monitor and manage the client's tolerance of stimulation - when they're tired, hungry, stressed they tolerate less stimulation. - Progression of dementia = less tolerance for environmental stimuli. Need for quieter environment.
Violent Families: Alcohol and Other Drug Abuse
- Substance abuse, especially alcoholism is associated with family violence - This is not 'cause and effect' - but an abusive person is more likely to use substances. - The majority of victims of IPV report that alcohol was involved. - Women whose partners abused alcohol were more likely to be assaulted by their partners.
Conduct Disorder: Symptoms
- Symptoms are clustered in four areas: aggression to people and animals, destruction of property, deceitfulness, and theft, and serious violation of rules. - Callous and unemotional traits are similar to adults with an antisocial personality disorder. - Little empathy - Shallow and superficial emotions - Unconcerned about poor performance at home or school - Low self-esteem - Poor frustration tolerance and temper tantrums - Frequently associated with early onset of sexual behavior, drinking, smoking, use of illegal substances, and other reckless or risky behaviors. - In US 8% have Conduct disorder - Onset of conduct disorder behaviors before age 10 occurs primarily in boys; onset after age 10 occurs in girls and boys. - 30% to 50% of these children are diagnosed with antisocial personality disorder as adults
Conduct Disorder: Treatment in Adolescents
- Teens rely less on their parents and more on peers, so treatment for this age group includes individual therapy. - Many have some involvement with the legal system as a result of criminal behavior, and consequently, they may have restrictions on their freedom. - Use of alcohol and other drugs plays a more significant role for this age group; any treatment plan must address this issue. - The most promising treatment approach includes keeping the client in his or her environment with family and individual therapies. - The plan usually includes conflict resolution, anger management, and teaching social skills.
Large Scale Community Violence
- Terrorist attacks such as 9/11 has far-reaching effects on citizens. - Immediate aftermath, children were afraid to go to school, or have their parents leave them. - Adults had difficulty going to work, leaving home, using public transport, and flying. - 1 year later, 1 in 10 NY area residents suffered lingering stress and depression as a result - People reported higher relapse rates of depression and anxiety. - Prevalence rates of PTSD and depression remain elevated 15 years later. - Early intervention and treatment are key to dealing with victims of violence. - After several instances of school or workplace shootings, counseling, referrals, and ongoing treatment were instituted immediately to help those involved deal with the horror of their experiences. - Since 9/11 teams of physicians, therapists, and other health professionals (many associated with universities and medical centers) have been working with survivors, families, and others affected. - Despite such efforts, many people will continue to experience long-term difficulties
ADHD: Cultural Considerations
- The Child Behavior Checklist, Teacher Report Form, and Youth Self Report (for ages 11-18 years) are rating scales frequently used to determine problem areas and competencies. - These scales are often part of a comprehensive assessment of ADHD in children. - They are culturally competent and are widely used in various countries. - The ADHD-FX has also proved to be a valid, reliable, and culturally appropriate measure of functional impairment of at-risk students. - Parental beliefs about the causes and treatments of ADHD in their children may influence compliance with prescribed treatments. - Therefore, it is important to study, determine, and include parental, cultural beliefs to enhance effectiveness for children.
ADHD: Assessment - General Appearance and Motor Behavior
- The child cannot sit still in a chair and squirms and wiggles while trying to do so. - They may dart around the room with little or no apparent purpose. - Speech is unimpaired, but the child cannot carry on a conversation; he or she interrupts, blurts out answers before the question is finished, and fails to pay attention to what has been said. - Conversation topics may jump abruptly. - The child may appear immature or lag behind in developmental milestones.
ADHD: Assessment - Sensorium and Intellectual Processes
- The child is alert and oriented with no sensory or perceptual alterations such as hallucinations. - Ability to pay attention or to concentrate is markedly impaired - attention span may be as little as 2 or 3 seconds with severe ADHD or 2 or 3 minutes in milder forms of the disorder. - Assessing the child's memory may be difficult; he or she frequently answers, "I don't know," because he or she cannot pay attention to the question or stop the mind from racing. - Distractible and rarely able to complete tasks.
Define: Intellectual Disability
- The correct diagnostic term for what was once called mental retardation, a term often used in a disparaging manner to bully or ridicule individuals with impaired cognitive abilities. - The essential feature of intellectual disability is below-average intellectual functioning (intelligence quotient [IQ] <70) accompanied by significant limitations in areas of adaptive functioning such as communication skills, self-care, home living, social or interpersonal skills, use of community resources, self-direction, academic skills, work, leisure, and health and safety. - The degree of disability is based on IQ and cognitive functioning, often categorized as mild, moderate, severe, or profound.
Assessment - Possible Indicators of Elder Abuse: Warning Indicators from Caregiver
- The elder is not given an opportunity to speak for self, have visitors, or see anyone without the presence of the caregiver - Attitudes of indifference or anger toward the elder - Blaming the elder for his or her illness or limitations - Defensiveness - Conflicting accounts of elder's abilities, problems, and so forth - Previous history of abuse or problems with alcohol or drugs - May complain about how difficult caring for the elder is - incontinence, feeding, excessive costs of meds - Elder abuse is more likely when the caregiver has a history of family violence, or alcohol/drug problems
Autism: Treatment Goals
- The goals of treatment of children with autism are to reduce behavioral symptoms (e.g., stereotyped motor behaviors) and to promote learning and development, particularly the acquisition of language skills. - Comprehensive and individualized treatment, including special education and language therapy, as well as cognitive behavioral therapy for anxiety and agitation, is associated with more favorable outcomes.
Define: Intimate Partner Violence
- The mistreatment or misuse of one person by another in the context of an emotionally intimate relationship. - The relationship may be spousal, between partners, boyfriend, girlfriend, or an estranged relationship. - The abuse can be emotional or psychological, physical, sexual, or a combination (which is common).
Common Side Effects of ADHD Stimulant Medications
- The most common side effects of these drugs are insomnia, loss of appetite, and weight loss or failure to gain weight. - Stimulants raise BP and HR - Olivia
Mandatory Reporting of Child Abuse
- The nurse does not have to decide with certainty that abuse has occurred. - Nurses are responsible for reporting suspected child abuse with accurate and thorough documentation of assessment data. - All 50 states have laws, requiring nurses to report suspected abuse. - The nurse alone or in consultation with other health team members (e.g., physicians or social workers) may report suspected abuse. - In some states, that authority is Child Protective Services, Children and Family Services, or the Department of Health. - The number to call can be located in the local telephone book. - May remain anonymous if desired. - People who work in such agencies have special education in the investigation of abuse. - Questions must be asked in ways that do not further traumatize the child or impede any possible legal actions. - The generalist nurse should not pursue the investigation with the child; it may do more harm than good.
Rape: Treatment and Intervention: In the ED
- The nurse should allow the victim to proceed at his or her own pace and not rush through any interview or examination procedures - Giving as much control as possible back to the victim is important. Ways to do so include: - allowing him or her to make decisions when possible about whom to call - what to do next - what he or she would like done, and so on. - It is the victim's decision about whether or not to file charges and testify against the perpetrator. - The victim must sign consent forms before any photographs or hair and nail samples are taken for future evidence.
ADHD Medications: Atomoxetine (Strattera)
- The only nonstimulant drug specifically developed and tested by the FDA for the treatment of ADHD. - SNRI - Side effects in children during clinical trials were decreased appetite, nausea, vomiting, tiredness, and upset stomach. - In adults, side effects were similar to those of other antidepressants, including insomnia, dry mouth, urinary retention, decreased appetite, nausea, vomiting, dizziness, and sexual side effects. - Can cause liver damage, so individuals taking the drug need to have liver function tests periodically
Define: Rape
- The perpetration of an act of sexual intercourse with a person against his or her will and without her consent, whether that will is overcome by force, fear of force, drugs, or intoxicants. - Rape is a crime of violence and humiliation of the victim expressed through sexual means. - It is also considered rape if the victim is incapable of exercising rational judgment because of mental deficiency or because he or she is younger than the age of consent
Sleep Hygiene
- The practice of following good sleep habits to sleep soundly and be alert during the day. - Exercise enhances sleep, but the hours within 3 hours of bedtime should be avoided. - Naps should be avoided completely. Choosing new bedtimes and a new bedroom are not actions that are noted to improve sleep hygiene.
Delirium: Assessment - Sensorium and Intellectual Processes
- The primary and often initial sign of delirium is an altered level of consciousness that is seldom stable and usually fluctuates throughout the day. - Clients are usually oriented to people but frequently disoriented to time and place. - They demonstrate decreased awareness of the environment or situation and instead may focus on irrelevant stimuli such as the color of the bedspread or the room. - Noises, people, or sensory misperceptions easily distract them. - Cannot focus, sustain, or shift attention effectively, and there is impaired recent and immediate memory. - Frequently experience misinterpretations, illusions, and hallucinations. Both misperceptions and illusions are based on some actual stimuli in the environment; clients may hear a door slam and interpret it as a gunshot or see the nurse reach for an IV bag and believe the nurse is about to strike them.
Tic Disorders:
- Tic disorders tend to run in families. - Abnormal transmission of the neurotransmitter dopamine is thought to play a part in tic disorders. - Tic disorders are usually treated with risperidone (Risperdal) or olanzapine (Zyprexa), which are atypical antipsychotics. - It is important for clients with tic disorders to get plenty of rest and to manage stress because fatigue and stress increase symptoms.
Dementia: Intervention - Promoting Interaction and Involvement
- The psychosocial model of dementia care: the nurse or caregiver plans activities that reinforce the client's identity and keep him or her engaged and involved in the business of living. - The nurse or caregiver tailors these activities to the client's interests and abilities. - They should not be routine group activities that "everyone is supposed to do." - Often need the involvement of another person to sustain attention in the activity and to enjoy it more fully. - No activity often results in the client becoming restless/agitated. Clients engaged in activities are more likely to stay calm. - Activities such as music, dancing, pet therapy, aromatherapy, multisensory stimulation are things that can help maximize the client's involvement with the environment and enhance QoL. - Reminiscence therapy helps
Define: Stalking
- The repeated following, harassment, or threatening of an individual to frighten or cause him or her harm. - This may occur after a partner has left an abusive relationship, or could be "would-be lovers', doctors/providers stalked by patients, celebrities stalked by "fans". - 1 in 6 women, 1 in 19 men have been stalked
Encopresis
- The repeated passage of feces into inappropriate places such as clothing or the floor by a child who is at least 4 years of age either chronologically or developmentally. - It is often involuntary, but it can be intentional. - Involuntary encopresis is usually associated with constipation that occurs for psychological, not medical, reasons. - Intentional encopresis is often associated with oppositional defiant disorder (ODD) or conduct disorder.
Enuresis
- The repeated voiding of urine during the day or at night into clothing or bed by a child at least 5 years of age either chronologically or developmentally. - Most often, enuresis is involuntary; when intentional, it is associated with a disruptive behavior disorder. - Of children with enuresis, 75% have a first-degree relative who has had the disorder. - Most children with enuresis do not have a coexisting mental disorder. - Can be treated effectively with imipramine (Tofranil), an antidepressant with a side effect of urinary retention.
Dementia: Intervention - Providing Emotional Support
- Therapeutic relationship involves empathetic caring = kind, respectful, calm, reassuring, and paying attention to the client. - Clients with dementia often seem to ignore the nurse's efforts or respond with negative behavior, which can make it difficult for the nurse or caregiver to sustain caring behavior. - The nurse/caregiver must maintain the qualities of the therapeutic relationship. - Clients often need a lot of reassurance and patience. - The nurse can support the client by having a "we can do it together" approach and collaborate with the client.
ADHD: Assessment - Thought Process and Content
- There are generally no impairments in this area, though assessment can be difficult depending on the child's activity level and age or developmental stage.
Points to Consider When Working with Abused or Traumatized Clients
- These clients have many strengths they may not realize. The nurse can help them move from being victims to being survivors. - Nurses should ask all women about abuse. Some will be offended and angry, but it is more important not to miss the opportunity of helping the woman who replies, "Yes. Can you help me?" - The nurse should help the client focus on the present rather than dwell on horrific things in the past. - Usually, a nurse works best with either the survivors of abuse or the abusers themselves. Most find it too difficult emotionally to work with both groups.
ODD - Behavior
- They have limited abilities to make associations between their behavior and consequences of behavior—both negative and positive, indicative of a reduced sensitivity to reward and punishment. - Therefore, learning appropriate behavior and learning to refrain from inappropriate behavior are impaired. - They also exhibit impaired problem-solving abilities and deficiencies in attention, flexibility of thinking, and decision-making. - All of these problems are also present in children diagnosed with conduct disorder—to an even greater degree.
Dementia: Intervention - Promoting Adequate Sleep and Proper Nutrition, Hygiene, and Activity
- They need assistance to meet basic needs. - The nurse monitors I/Os - They may eat poorly due to limited appetite or distraction. - The nurse can give the client food they like, sit with the client at meals, have nutritious snacks available, minimizing distractions. - Cut up food if needed when its prepared, not in front of the client (protect dignity) - Finger foods may be best. - Low-calorie snacks might be indicated for clients who might eat too much or are trying to ingest inedible things - Enteral nutrition can be necessary when dementia is most severe, but not all families choose this - Adequate intake of fluids and foods = proper elimination. Its important to monitor output to ensure no complications arise. - Sanitary pads can help when the client is dealing with leakage. - Adult diapers or briefs are indicated for incontinence (not catheters which are prone to infection, reduce dignity, and can confuse the patient) - These need to be changed frequently to prevent infection, skin irritation and odors. - Balance rest & activity in the daily routine. Exercise helps with nighttime sleep, but the client needs to be prompted or encouraged to do so.
Dementia: Assessment - Physiological and Self-Care Considerations
- They often experience disturbed sleep-wake cycles; they nap during the day and wander at night. - Some ignore internal cues such as hunger or thirst; others have little difficulty with eating and drinking until dementia is severe. - May experience bladder and even bowel incontinence or have difficulty cleaning themselves after elimination. - They frequently neglect bathing and grooming. - Eventually, clients are likely to require complete care from someone else to meet these basic physiological needs.
Define: Honeymoon Period
- This period occurs after the violent episode. - The abuser showers the victim with gifts, apologies, promises. - This may last weeks or months initally, however as the relationship progresses, this begins to shorten and the severity of the injuries worsens. Eventually, its occurring several times a week or daily.
Conduct Disorder: Assessment - Thought Process and Content
- Thought processes are usually intact—that is, clients are capable of logical rational thinking. - Nevertheless, they perceive the world to be aggressive and threatening, and they respond in the same manner. - Clients may be preoccupied with looking out for themselves and behave as though everyone is "out to get me." - Thoughts or fantasies about death or violence are common.
Tics
- Tics are sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations. - Stress exacerbates tics, which diminish during sleep and when the person is engaged in an absorbing activity. - Common simple motor tics include blinking, jerking the neck, shrugging the shoulders, grimacing, and coughing. - Common simple vocal tics include clearing the throat, grunting, sniffing, snorting, and barking. - Complex vocal tics include repeating words or phrases out of context, coprolalia (use of socially unacceptable words, frequently obscene), palilalia (repeating one's own sounds or words), and echolalia (repeating the last-heard sound, word, or phrase). - Complex motor tics include facial gestures, jumping, or touching or smelling an object.
Self Neglect: Diagnosis
- To be diagnosed, the elder must be evaluated as unable to manage day-to-day life and take care of him or herself. - Cannot be established solely on the basis of family members' beliefs that the elder cannot manage his or her finances. - Ex: Just because he or she gives away large sums of money to a group or charity or invests in some venture of which family members disapprove.
Dependency in Abuse
- Trait most commonly found in abused partners who stay with their abusive partners. - They are often financially and personally dependent on the person, and find it extremely difficult to leave. - The abused partner often suffers from low self-esteem, and defines success by being able to "make it work" in the relationship. - There is also a very real fear that the abuser will kill them if they try to leave.
What are trauma and stressor related disorders?
- Trauma or event may affect a single individual, such as a person with a history of childhood abuse, a child newly diagnosed with type 1 diabetes, or an adult with an acute coronary syndrome such as a myocardial infarction or unstable angina. - Large numbers or groups of people may be affected by a traumatic event, such as war, terrorist attacks, or a natural disaster like a flood, hurricane, or tsunami. - Posttraumatic stress disorder (PTSD) is seen in countries around the world - Some people work through the experience - Others continue to have problems coping, managing stress, and emotions and daily activities.
Conduct Disorder: Evaluation
- Treatment is considered effective if the client stops behaving in an aggressive or illegal way, attends school, and follows reasonable rules and expectations at home. - The client will not become a model child in a short period; instead, he or she may make modest progress with some setbacks over time.
Conduct Disorder: Treatment in Children
- Treatment only has modest effectiveness. - Early intervention is more effective, and prevention is more effective than treatment. - Dramatic interventions such as incarceration or boot camp are not helpful - No one treatment is suitable for all ages. - Preschool programs such as Head Start help to lower rates of delinquent behavior - parental education about normal growth, stimulation for child, and parental support. - For school age children - the child, family, and school environment are the focus of treatment. - Techniques include parenting education, social skills training to improve peer relationships, and attempts to improve academic performance and increase the child's ability to comply with demands from authority figures. - Therapy is essential for school-aged children.
Dementia: Evaluation
- Treatment outcomes change constantly as the disease progresses. - The nurse must assess clients for changes as they occur & change outcomes & interventions as needed. - When a client is home - the nurse provides ongoing education to family members and caregivers.
Autism: Pharmacologic Treatments
- Treatment with antipsychotics, such as haloperidol (Haldol), risperidone (Risperdal), aripiprazole (Abilify), or combinations of antipsychotic medications, may be effective for specific target symptoms such as temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors. - Other medications, such as naltrexone (ReVia), clomipramine (Anafranil), clonidine (Catapres), and stimulants to diminish self-injury and hyperactive and obsessive behaviors, have had varied but unremarkable results. - There are no medications approved for the treatment of ASD itself. - Though in lecture they said Abilify and Risperdol are the only approved meds for Autism.
Exposure to Community Violence
- Tremendously affects children and young adults. - When children witness violence, they exp stress-related symptoms at increase with the amount of violence they see. - Leads to future problems - Addressing the problem of exposure to violence might help stop the cycle of violence and dysfunction -
Rape: Statistics
- Underreported crime, less than 1/2 of all rapes are estimated to be reported. - Underreporting is due to victims' feelings of shame, guilt, fear of further injury or fear of no legal recourse. - Victims can be any age, reported ages from 15 months to 82 years. - Highest incidence is in girls/women 16-24 years old. - Girls/women younger than 20 were the victims in 80% of rapes reported. - Most commonly occurs in the victim's neighborhood, often in or near the home. - Most are premeditated. - 50% of female victims minimize the assault, calling it a misunderstanding or lesser event - this is particularly true if the perp is known or in a position of power. Male rape is also significantly underreported. - Can occur between gay partners or strangers or in prisons (most prevalent) - 80,000 male inmates are assaulted each year, though that figure may be higher - 60% of the sexual assault is done by prison or jail staff - This is very violent and has dynamics of power and control.
PTSD Cultural Considerations
- Universal phenomenon - People leaving their countries due to political oppression have lower levels of resilience and poorer long-term outcomes. - Stronger sense of self and cultural identity are less frequently diagnosed with PTSD, and have better long-term outcomes when PTSD was present. - This might indicate that strong cultural identity and allegiance to culture contribute to resilience, and are highly positive factors. - Assessment and treatment can be culturally tailored. - Effective treatments, such as CBT, should be strengths-based, client-driven, and include the patient's culturally relevant beliefs about the illness, its symptoms, and how that intrudes in daily life.
Define: Intermittent Explosive Disorder (IED)
- Viewed as an impulse control disorder, it involves aggression toward people and property. - The age of onset for IED can occur after age 6, but is often diagnosed from adolescence to young adulthood
Assessment - Possible Indicators of Elder Abuse: Material Abuse/Financial Exploitation
- Unpaid bills - Standard of living below the elder's means - Sudden sale or disposal of the elder's property/possessions - Unusual or inappropriate activity in bank accounts - Signatures on checks that differ from the elder's - Recent changes in will or power of attorney when the elder is not capable of making those decisions - Missing valuable belongings that are not just misplaced - Lack of television, clothes, or personal items that are easily affordable - Unusual concern by the caregiver over the expense of the elder's treatment when it is not the caregiver's money being spent
Rights of Rape Victims
- Until recently, the rights of rape victims were often ignored. Ex: when they reported a rape to authorities, they often faced doubt and embarrassing questions from police officers. - The courts did not protect the rights of victims; for example, a woman's past sexual behavior was admissible in court even though the past criminal record of her accused attacker was not. - Laws to correct these problems have been enacted on a state-by-state basis since the mid-1980s and continue to be enacted. - Although the treatment of rape victims and the prosecution of rapists have improved in the past two decades, many people still believe that a woman provokes rape with her behavior and that the woman is partially responsible for this crime.
Define: Cyberstalking
- Use of electronic media to pursue harass, or contact another person who has not solicited the contact - Monitoring, following, intruding into another's social media, using a false identity, or tracking their location. - This has become more common in recent years, and is more difficult to detect the stalker. - According to PrepU - use of a cellphone to just call and text the person is called cyberstalking.
Define: Cognitive Processing Therapy
- Used successfully with rape survivors with PTSD as well as combat veterans. - Involves structured sessions that focus on examining beliefs that are erroneous or interfere with daily life, such as guilt and self-blame; for example, "It was my fault, I should have fought harder" or "I should have died with my fellow Marines;" reading aloud a written account of the worst traumatic experience; recognizing generalized thinking, that is, "No one can be trusted;" and regaining more balanced and realistic ways of appraising the world and themselves
ADHD: Onset
- Usually IDs when the child begins preschool/school. - As infants, they are often fussy and temperamental and have poor sleeping patterns. - Toddlers may be described as "always on the go" and "into everything," at times dismantling toys and cribs. They dart back and forth, jump and climb on furniture, run through the house, and cannot tolerate sedentary activities such as listening to stories. - Can be difficult to distinguish normal active behavior from excessive hyperactive behavior. - When school starts, the symptoms of ADHD interfere with behavior and performance. Fidgeting, not listening to teachers, interruptions, distractions. - Academic performance suffers because the child makes hurried, careless mistakes in schoolwork, often loses or forgets homework assignments, and fails to follow directions
ADHD: Treatment - Roles and Relationships
- Usually unsuccessful academically and socially at school. - Frequently disruptive and intrusive at home, which causes friction with siblings and parents. - Until the child is diagnosed and treated, parents often believe that the child is willful, stubborn, and purposefully misbehaving. - Measures to discipline have limited success; in some cases, the child becomes physically out of control, even hitting parents or destroying family possessions. - Parents find themselves chronically exhausted mentally and physically. - Teachers often feel the same frustration as parents, and day care providers or babysitters may refuse to care for the child with ADHD, which adds to the child's rejection.
Delirium: Evaluation
- Usually, successful treatment of the underlying causes of delirium returns clients to their previous levels of functioning. - Clients and caregivers or family must understand what health care practices are necessary to avoid a recurrence. - This may involve monitoring a chronic health condition, using medications carefully, or abstaining from alcohol or other drugs.
What services are covered by Medicare for an Annual Wellness Visit (AWV)?
- VItals - Health Risk Assessment - Medical/Family history review - Functional ability/safety assessment - Cognitive impairment assessment - Behavioral risks, depression, substance abuse assessment
Conduct Disorder: Course
- Variable. - Adolescent-onset type or mild problems can achieve adequate social relationships and academic or occupational success as adults. - Childhood-onset type or more severe problem behaviors are more likely to develop antisocial personality disorder as adults. - Even those who do not have antisocial personality disorder may lead troubled lives with difficult interpersonal relationships, unhealthy lifestyles, and an inability to support themselves.
ODD: Prognosis
- Varies by age of onset, symptom severity, and the presence of comorbid psychiatric disorders. - Early onset, more severe symptoms, and comorbid conditions are associated with poorer long-term outcomes. - Early onset is also associated with an increased risk for developing conduct disorder. - Children with this disorder can develop conduct disorder; some will be diagnosed with antisocial personality disorder as adults. - ODD is often comorbid with other psychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD), anxiety, and/or mood disorders that need to be treated as well.
Mood and Behavior Disturbances in those with intellectual disabilities:
- Vary among people with intellectual disabilities. - Some with intellectual disability are passive and dependent; others are aggressive and impulsive - Others may have minimal mood and behavior disturbances. - Children with mild-to-moderate intellectual disability usually receive treatment in their homes and communities and make periodic visits to physicians. - Those with more severe intellectual disabilities may require residential placement or day care services.
Clinical Picture of Abuse and Violence
- Victims can have physical injuries, but also psychological injuries with a broad range of responses. - Some clients are agitated and upset, others withdrawn and aloof. Anger/resentment are often suppressed (especially in cases of childhood sexual abuse) - Often, DV is undisclosed for months or years because of fear of their abusers. - Survivors often suffer in silence, feeling guilt and shame. - Children believe that they are at fault, and their life suffers as a result (missing school, not attending childhood, having issues throughout adolescence and adulthood). - Self esteem is low, and view themselves as unlovable. - Depression, SI/SA and marital and sexual difficulties occur
Dementia: Treatment and Prognosis
- When possible, treat the underlying cause of dementia to halt the progression of the disease. Ex. Vascular dementia - Changes to diet etc - Prognosis of progressive types of dementia vary, but all are progressive deterioration of physical and mental abilities till death. - In later stages, patients have minimal cognitive and motor function - For degenerative dementia, no direct therapies have been found to reverse the fundamental pathophysiological processes. - Levels of NTs such as ACh, Dopa, NE, and Serotonin are decreased in dementia. - This has led to attempts at replenishment therapy with acetylcholine precursors, cholinergic agonists, and cholinesterase inhibitors.
Feminist Theory
- Women have historically served as objects of aggression, dating back to when women and children were legally the property of men. - In 1982 the first married man was convicted of raping his wife, which meant the end of the notion that sexual intercourse could not be denied in the context of marriage.
Dementia: Assessment - Roles and Relationships
- Work performance suffers - Roles as spouse, partner, or parent deteriorate as clients lose the ability to perform even routine tasks or recognize familiar people. - Eventually, clients cannot meet even the most basic needs. - Inability to participate in meaningful conversation or social events limits relationships. - Clients become confined to the house or apartment - Close family members often begin to assume caregiver roles. - Grown children of clients with dementia experience role reversal. - Spouses or partners may feel as if they have lost the previous relationship and now are in the role of custodian.
Disruptive Behavior Disorders: Self Awareness Issues
- Working with parents and families is a crucial aspect of dealing with children with these disruptive behavior disorders. - Parents have the most influence on how these children learn to cope with their disorders. - The nurse's beliefs and values about raising children affect how they deal with children and parents. - The nurse may feel that the disruptive and/or aggressive behaviors, such as thinking that the client should be able to refrain from hostility and aggression through use of willpower. - It can be difficult to reconcile holding clients accountable for their behaviors while avoiding a purely punitive attitude. - Working with aggressive clients of any age may provoke anxiety and fears for personal safety in the nurse. May = angry feelings.
What is the Montreal Cognitive Assessment (MoCA)?
- a quick assessment to detect mild cognitive dysfunction; a score of 26 or above is considered normal - Test-retest reliability is excellent - Excellent inter-rater reliability - Criterion validity is excellent in its correlation with the MMSE
Delirium: Community-Based Care
Referrals for continued cognitive problems - Home health-care/visiting nurses - Rehabilitation program - Adult day care, residential care can provide care, rehab - Support groups for clients and family members to help them cope with changes in personality, and remaining cognitive and motor deficits
Define: Dementia
Refers to a disease process marked by progressive cognitive impairment with no change in the level of consciousness. It involves multiple cognitive deficits, initially, memory impairment, and later, the following cognitive disturbances may be seen.
Clinical Manifestations of PTSD
4 subcategories of symptoms of PTSD include: - Re-experiencing the trauma through dreams or recurrent and intrusive thoughts - Avoidance - Negative cognition or thoughts - Being on guard/hyperarousal - The person re-experiences the trauma also through reactions to external cues about the event - Feels a numbness, shows signs of increased arousal such as insomnia, hyperarousal, irratibility, angry outbursts. - Loses a sense of connection and control = avoidance - Seeks comfort/safety/security but actually becomes more isolated.
Define: Survivor
A person who has experienced sexual violence/trauma and has worked through the many issues and is going on with their lives.
Conduct Disorder: Onset and Clinical Course - Adolescent
Adolescent-onset type is defined by no behaviors of conduct disorder until after 10 years of age. These adolescents are less likely to be aggressive, and they have more normal peer relationships. They are less likely to have persistent conduct disorder or antisocial personality disorder as adults.
Aphasia, Apraxia, Agnosia and Disturbances in Executive Functioning in Dementia
Aphasia - Usually begins with the inability to name familiar objects or people and then progresses to speech that becomes vague or empty with excessive use of terms such as it or thing. - Clients may exhibit echolalia (echoing what is heard) or palilalia (repeating words or sounds over and over). Apraxia - May cause clients to lose the ability to perform routine self-care activities such as dressing or cooking. Agnosia - Frustrating for clients; they may look at a table and chair but are unable to name them. Disturbances in executive functioning - Evident as clients lose the ability to learn new material, solve problems, or carry out daily activities such as meal planning or budgeting.
Questions to Ask about Safety Note - The initial questions are designed to detect abuse, the latter questions are asked if warranted.
Ask when alone. - Do you feel safe in your relationships? - Are you concerned for your safety? - Are family or friends concerned for your safety? - Are your children (if any) safe? - Do you ever feel threatened? - If you felt threatened or unsafe, is there someone you can call? Night or day? - Do you have a safe place to go if you need to? - Do you have a plan if suddenly your situation becomes unsafe?
Conduct Disorder: Behaviors
Behaviors associated with conduct disorders fall into categories of aggression, destruction, deceit/theft, and rule violation, but they can vary in intensity. Mild: The child has some conduct problems that cause relatively minor harm to others. Examples include repeated lying, truancy, minor shoplifting, and staying out late without permission. Moderate: The number of conduct problems increases as does the amount of harm to others. Examples include vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity. Severe: The person has many conduct problems that cause considerable harm to others. Examples include forced sex, cruelty to animals, physical fights, cruelty to peers, use of a weapon, burglary, robbery, and violation of previous parole or probation requirements.
Psychotherapy for PTSD: Signs of Effectiveness and Ineffectiveness
Behaviors such as the ability to express grief and showing increased ability to cope with stress indicate that the client is well stabilized and that the therapy is successful. Voluntarily establishing contact with friends and family indicates that the client has started becoming social and is trying to become an active citizen in society. If the client reports feeling cautious in social settings, a sense of safety has not yet been achieved indicating further stabilizing is needed. Being extremely silent and preferring to remain isolated are symptoms related to PTSD. Persistence of these signs indicates ineffectiveness of the therapy.
Sexual Identity and disparities due to sexual prejudice:
LGBTQ+ Older Adults - At increased risk of limited support systems and isolation - Intersection to classism, due to systemic discrimination and limited occupational opportunities, might have lower socioeconomic status - May hesitate to access healthcare services due to past negative experiences and lack of LGBTQ+ affirming clinics.
Socioeconomic status and disparities related to classism:
Low socioeconomic status is associated with an increased risk for disease and mental distress. - Fixed income = barriers to paying bills, maintaining healthy diet, transportation Insurance - Limited coverage, denials - Limited access to specialty provider networks such as mental health, substance abuse, memory disorders
Dementia: Data Analysis
Many nursing diagnoses can be appropriate because the effects of dementia on clients are profound; the disease touches virtually every part of their lives. - Risk for injury - Disturbed sleep pattern - Risk for deficient fluid volume - Risk for imbalanced nutrition: Less than body requirements - Chronic confusion - Impaired environmental interpretation syndrome - Impaired memory - Impaired social interaction - Impaired verbal communication - Ineffective role performance - Disturbed thought processes and disturbed sensory perception would be appropriate for a client with psychotic symptoms. - Also nursing diagnoses associated with physiological status may be indicated (nutrition, hydration, elimination etc)
Define: Alzheimer disease
Disease of progressive cognitive deterioration
Dementia: Drug Therapy *These can slow disease progression for about 6 months.*
Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl, Razadyne, Nivalin) - Cholinesterase inhibitors - Have shown modest therapeutic effects and temporarily slow the progress of dementia. - No effect on the overall course of the disease. Tacrine (Cognex) - A cholinesterase inhibitor - It elevates liver enzymes in about 50% of clients using it. Lab tests to assess liver function are necessary every 1 to 2 weeks; therefore, tacrine is rarely prescribed. Memantine (Namenda) - NMDA receptor antagonist that can slow the progression of Alzheimer in the moderate or severe stages. Namzaric (memantine and donepezil) - A newer combination drug, has the actions of both cholinesterase inhibition and NMDA receptor antagonist
What is the nursing role in Annual Wellness Visits?
Educate patients, talk about health goals and priorities. - Support coordinated and comprehensive care with provider. Conduct portions of the AWV including: - Vitals - Health risk assessments - Medical/family history review - Advanced care planning - Med reconciliation - Behavioral health screenings - Identify and address barriers related to SDoH - Coordinate with healthcare team.
Define: Confabulation
Filling in gaps of memory with false information.
Ability status and disparities due to ableism:
Functional impairment: - Result in difficulty managing self care - Older adults may have limited access to supports (caregivers) Cognitive impairment: - Limited ability for decision making, planning care Technology access: - Older adults with 2+ chronic conditions are less likely to have a cell phone or use the internet Intersection with classism: - Limited occupational opportunities resulting in lower socioeconomic status = poorer health outcomes
Trauma/Abuse: Assessment - General Appearance, Motor Behavior and Mood and Affect
General Appearance and Motor Behavior - Assess client's behavior and appearance - Often hyperalert, easily startled. - May be uncomfortable if too close - May be anxious, agitated Mood and Affect - Wide range of emotions possible from intense feelings during a flashback, or when dissociating, may look numb with a vacant stare or speak in a different tone of voice
Define: Apraxia
Impaired ability to execute motor functions despite intact motor abilities. Ex: The nurse asks a client to pretend the client is brushing the client's teeth. The client is unable to perform the action. Upon examination, the nurse finds that the client possesses intact motor abilities.
Regarding communication with people with psychotic symptoms vs dementia:
It is important to remember that different interventions are indicated for dealing with psychotic symptoms, depending on the cause. People with dementia cannot regain their cognitive functions, so techniques like redirection or going along with the person are indicated. However, when psychotic symptoms are due to a treatable illness, such as schizophrenia, the nurse should not say or do anything to reinforce the notion that the delusions or hallucinations are real in any way. This would only interfere with or impede the client's progress.
Trauma/Abuse: Assessment - Judgement/Insight and Self-Concept
Judgment and Insight - Related to the duration of their problems with dissociation or PTSD - Client may not understand the relationship of past trauma to their current issues. - Others may be quite knowledgeable if they've progressed in treatment - Ability to make decisions or solve problems might be impaired Self-Concept - Low self-esteem - Low self worth/value - May believe they are bad people who deserved it - May feel like they are going crazy and are out of control, with no hope of regaining - May see themselves as helpless, hopeless and worthless
Trauma: Data Analysis
Nursing diagnoses commonly used in the acute care setting when working with clients who dissociate or have PTSD related to trauma or abuse include: - Risk of self-mutilation - Risk of suicide - Ineffective coping - Post-trauma response - Chronic low self-esteem - Powerlessness In addition, the following nursing diagnoses may be pertinent to clients over longer periods, although not all diagnoses apply to each client: - Disturbed sleep pattern - Sexual dysfunction - Rape-trauma syndrome - Spiritual distress - Social isolation
Child Abuse: Physical Abuse
Often results from unreasonable severe corporal punishment or unjustifiable punishment: - Hitting an infant for crying or soiling his or her diapers. - Intentional, deliberate assaults on children include burning, biting, cutting, poking, twisting limbs, or scalding with hot water. - The victim often has evidence of old injuries (e.g., scars, untreated fractures, or multiple bruises of various ages) that the history given by parents or caregivers does not explain adequately.
Abused/neglected children are at risk of:
Physical, emotional, and behavioral problems. - They may have problems getting along with others leading to fights. - Cognitive development may be impaired causing academic difficulties. - They are at risk for substance abuse such as cigarettes. - They may have low self-esteem and not want to participate in class.
Define: Vascular Dementia
Progressive cognitive decline associated with vascular infarcts.
Trauma/Abuse: Assessment - Roles/Relationships and Physiologic Considerations
Roles and Relationships - Difficulty with all kinds of relationships - Ability to take direction or be monitored causes issues at jobs - Ability to trust is compromised - Often times the client has quit work or been fired, may be estranged from family - Intrusive thoughts, flashbacks or dissociative episodes interfere with clients ability to socialize, so they avoid it, then keeps them from participating Psyiologic Consideration - Difficulty sleeping due to nightmares or anxiety - Overeating or a lack of appetite - Use of alcohol or drugs to attempt to sleep or block intrusive thoughts and memories
What are the components of SBIRT
Screening: Universal screening for quickly assessing use and severity of alcohol; illicit drugs; and prescription drug use, misuse, and abuse. - Identifies unhealthy use. Brief Intervention: Brief motivational and awareness-raising intervention given to risky or problematic substance users. - Focuses on education, increasing patient insight and awareness about risks, and enhances motivation towards change. Referral to Treatment: Referrals to specialty care for patients with substance use disorders
Dementia: Related Disorders
Substance/medication-induced mild or major NCD characterized by neurocognitive impairment that persists beyond intoxication or withdrawal. The deficits may stabilize or even show some improvement after a sustained period of abstinence. Korsakoff syndrome or dementia. It was previously known as an amnestic disorder since amnesia and confabulation are common. Long-term use of alcohol that results in dementia. Mild or major NCD due to another medical condition is caused by diseases such as brain tumor, brain metastasis, subdural hematoma, arteritis, renal or hepatic failure, seizures, or multiple sclerosis. Unspecified NCD is characterized by neurocognitive symptoms that cause the person distress or impairment, but do not meet the criteria for any other NCD. Neurocognitive deficits due to stroke, head injuries, carbon monoxide poisoning, or brain damage from other medical causes were previously classified as amnestic disorders.
Define: Reframing
Techniques to offer clients different points of view or explanations for situations or events. Because of their perceptual difficulties and confusion, clients frequently interpret environmental stimuli as threatening. Loud noises often frighten and agitate them. Ex: One client may interpret another's yelling as a direct personal threat. The nurse can provide an alternative explanation such as "That lady has many family problems, and she yells sometimes because she's frustrated. (reframing)" - Alternative explanations often reassure clients with dementia and help them become less frightened and agitated.
Define: Agnosia
The inability to recognize or name objects despite intact sensory abilities.
Elder Abuse: Clinical Picture
The victim may have: - Bruises or fractures - May lack needed eyeglasses or hearing aids - May be denied food, fluids, or medications - May be restrained in a bed or chair. - The abuser may use the victim's financial resources for his or her own pleasure while the elder cannot afford food or medications. - Abusers may withhold medical care from an elder with acute or chronic illness. - Self-neglect involves the elder's failure to provide for himself or herself.
Define: Abuse
The wrongful use and maltreatment of another person. - Statistics show that most abuse is perpetrated by someone the victim knows. - Victims of abuse are found across the life span, and can include partners or spouses, children, elderly parents.
Abuse Victims: Relationships
They have difficulty relating to others. - Trust is difficult, especially in authority figures. - Emotional reactions might be erratic, intense, unpredictable. - Intimate relationships may trigger extreme emotional responses. - Nurses should be sensitive to an abused client's need to feel safe, secure, and in control of their body. The nurse should take care to maintain the client's personal space, assess their anxiety level, ask permission before touching.
Trauma/Abuse: Assessment - Thought Process/Content and Sensorium and Intellectual Processes
Thought Process and Content - Client will relive the trauma - Experience intrusive, persistent thoughts that interfere with ADLs - Hallucinations or buzzing voices in their head - Self-destructive thoughts and impulses, SI - Revenge fantasies Sensorium and Intellectual Process - Oriented to reality except if the client is in a flashback or dissociative episode - May have memory gaps that are short or extensive, usually relating to the time of the abuse or trauma - Intrusive thoughts or ideas of self-harm often impair the client's ability to concentrate or pay attention
ADHD: Outcome Identification
Treatment outcomes for clients with ADHD may include: - The client will be free of injury. - The client will not violate the boundaries of others. - The client will demonstrate age-appropriate social skills. - The client will complete tasks. - The client will follow directions.
Conduct Disorder: Outcome Identification
Treatment outcomes for clients with conduct disorders may include: - The client will not hurt others or damage property. - The client will participate in treatment. - The client will learn effective problem-solving and coping skills. - The client will use age-appropriate and acceptable behaviors when interacting with others. - The client will verbalize positive, age-appropriate statements about self.
