PSYCH exam 3
Marijuana, hallucination (LSD and PCP), inhalants
Marijuana: ● Intoxication: euphoria, detachment, hallucinations/delusions, avolition (lack of motivation) ● Withdrawal: similar to tobacco Hallucinogens: LSD & PCP ● LSD ○ Intoxication: dilated pupils, diaphoresis, increased T/P/R, paranoia, depersonalization, anxiety/depression, hallucinations ○ OD: psychosis, brain damage, death ● PCP ○ Intoxication: nystagmus, increased T/P/BP, ataxia, rigidity, seizures, depersonalization, assaultive ○ OD: psychosis, respiratory arrest, hyperthermia, seizures Inhalants: ● Intoxication: excitement, drowsiness, agitation ● OD: CNS damage, death
implementation: opioid treatment
Methadone replacement ■ Synthetic opiates ■ Need to be titrated ■ Pregnant people need to have this ■ Daily medication ○ Levo-alpha Acetylmethadol (LAAM) addictive opioid blocking craving for heroin ■ Synthetic opiates ■ Need to be titrated ■ Longer acting—don't need to take everyday ○ Naltrexone non addictive and blocks opioid receptors ■ Blocks opiate receptors without activating them ■ Cannot have opiate in your system when you take the shot (can make you very sick) ○ Buprenorphine ■ Activate the receptor site enough where someone doesn't go through withdrawal tricks the body ■ They won't really get high from heroin
implementation: alcohol treatment
Naltrexone locks opiate receptors to decrease craving ■ Competes with opiate receptor sites to decrease the urge to drink and help people stay abstinent ■ Works even if they slipped up and already had a few beers ○ Acamprosate suppresses excitatory neurotransmitters and enhancing inhibitory transmission ■ Helps with physical stress ■ Helps maintain abstinence by decreasing cravings ■ Balances chemicals in the brain ○ Disulfiram ■ Makes them violently ill when they drink ■ Nasty drug for the liver so not good for patients with liver issues ■ Can't have ANYTHING with alcohol (wipes, topics, after shave)
nursing diagnosis and outcomes
Nursing diagnosis ● Risk for suicide, injury ● Problems with sleep ● Family ● Decreased cardiac output ● Impaired liver function Outcomes ● Withdrawal ○ Want to focus on safety ● Initial and active drug treatment ○ Identify triggers and risk for relapse ○ What do you have going on that we need to manage so you don't relapse ● Health maintenance ○ sober/clean one day at a time ○ For the rest of our lives
Children-
rare usually more severe symptoms, disrupts life/school
nursing diagnosis for schizo
self directed violence, social isolation (can worsen hallucinations and delusions), distorted thinking process, chronic low self-esteem
New with DSM 5
→ must have 2 of the following 5 symptoms (Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms) → 1 of the 2 symptoms must be from the first 3 listed (delusions, hallucinations, or disorganized speech) ○ Adults: difficulty with social, occupation, and family; self care also affected ■ Hygiene and nutrition are affected ■ Can be depressed and not care
○ Bleuler's signs of Schizophrenia:
■ Affect → flat, blunted, inappropriate or bizarre ■ Associative looseness → LOA, disorganized, thinking, and reasoning ■ Autism → delusion, hallucinations, neologisms, focused inward ● What reality is to them is different than it is to us ● Focused on themselves ■ Ambivalence → pathologic holding of opposing emotions, attitudes, ideas, wishes ● Ex: I want to go here, but I also want to go there ● Have a really hard time making decisions → even picking something off a menu can be hard for them
nursing process: assessment
■ Anxiety ● Observe and rate anxiety; if their anxiety is too high that cannot problem solve ● Higher anxiety= higher dysfunctional behavior ■ Coping ● "What can I do to help you?" "How do you cope when bad things happen?" ● Allow coping mechanisms to decrease anxiety ● Help them cope in ways that has helped before ■ Support systems ● "Who can you turn to?" "Do you feel comfortable talking to them about this?" ● Refer to group or 1 on 1 counseling ● essential for nurses to provide support while collecting and preserving legal evidence ■ S/S emotional trauma ● Disclosure, change in behavior, report inconsistent with physical findings ○ Understand there may be a psych disorder or something that is wrong with them if they are consistently reporting rape that aren't consistent with evidence ● Controlled style may throw off an untrained person ○ Just because they are acting one way don't assume they are okay (always follow up) ■ S/S physical trauma ● Abrasions, cuts, bite marks
positive symptoms ( alterations in behavior) **
■ Catatonia - increased or decreased movement ■ Motor retardation/Motor agitation ■ Echopraxia ● Repeating things you or others do, but not to be annoying ■ Stereotyped behavior - behavior with meaning only to person ● Not logical behavior ● Talked about pt who would stop & flick her hand for no reason → meant something to her, but didn't know why she did it ■ Waxy flexibility - holding position for long time ● Their arm was moved a certain way by someone for some reason (to take blood) and they keep their hand there even after done with blood draw ■ Negativism - resistance, doing opposite ● Active - if you ask someone to stand up and they lay down ● Negative - They do nothing ■ Impaired impulse control ● Talked about pt breaking in to a car because he wanted a piece of gum → couldn't control himself because he wanted the gum ■ Gesturing or posturing ● Could stay in 1 position for a long time → need to watch cardiovascular & neuro ■ Boundary impairment ● Impaired ability to sense where one's body or influence ends and another begins ● Ex: might stand too close or drink another person's beverage because it's near them so it must be theirs
cognitive symptoms
■ Cognitive development stops when s/s appear ■ Inattention - distractible ■ Imparied memory - forgetful, poor historians (noncompliance/adherence) ■ Poor problem solving and decision-making skills ■ Illogical thinking ● Don't see their "difference" and don't ask for help or seek help ● Anosognosia→ without insight; caused by illness itself → inability to realize one is ill ■ Impaired judgment- vulnerable with sex, alcohol, drugs, money ● May use marijuana to decrease anxiety but it is increasing dopamine and making schizophrenia worse ● People may use them for money
affective symptoms
■ Depression and other mood disorders are important to assess because they may... ● Signal an impending relapse ● Increase substance abuse ● Increase suicide risk ● Further impair functioning
negative symtpoms of Schizo **
■ Develop slowly & interfere most with person's adjustment & ability to cope ● More subtle than + symptoms ■ Contribute to poor social functioning and social withdrawal ■ Affect - flat or blunted, inappropriate, bizarre ● Often mood & affect do not match ■ Anergia - Abnormal lack of energy ■ Anhedonia - A reduced ability or the inability to experience pleasure ■ Avolition - Reduced motivation or goal directed behavior ● They will shower, but only after being told ■ Poverty of content ● Might talk a lot → but what they say is vague and doesn't contain a lot of message behind it ■ Poverty of speech ● Might get 1 or 2 word responses ● Nothing you did, just part of disease ■ Thought blocking ● Will stop mid sentence & completely forget what they were about to say ● Might think someone "stole" their thoughts
Etiology: Neurobiological
■ Family ● Runs in families- inheritance (especially vulnerable are sons of alcoholic fathers- 4x the rate even if not raised by the alcoholic father) ● Genetic-based insensitivity to alcohol→ an "inborn tolerance" ○ Gene influences + environmental conditions come together to result in alcohol-plus-multiple drug dependence ■ Dopamine ● Dopamine= motivation and survival ● Brain is wired to seek pleasure and repeat activities that bring pleasure and rewards ● Addictive drugs trigger short term release of high levels of dopamine (D1, D2, D3, D4, D5) and block transporters that remove dopamine → dopamine hangs around longer ○ Drugs release 10x more dopamine than eating or sex does ○ When there is a release of dopamine, we want it again ■ Receptors----impact of many and not enough! ● The more dopamine receptors you have the better (more dopamine receptors is a protective factor) ● High levels of dopamine stimulate brain circuits known to be reinforcing and involved with reward, motivation, memory, and inhibition control (addiction) ● Long term abuse of cocaine, alcohol, heroin, meth, and inhalants result in a reduction of the number of dopamine (D2) receptors even months after discontinuing ● Having more dopamine (D2) receptors in the brain may be an innate safeguard against the potential of becoming addicted ● Not enough dopamine receptors can lead to addiction→ may not get the pleasure of self-soothing or diminished boredom from activities non-addicted persons do ● Still want to hold people accountable even though it is partially biological
PTSD
■ If symptoms persist past 1 month ● Re-experience ● Avoidance ● Hyperarousal ○ Psychological effects of sexual assault ■ Long term psychological effects = Depression, suicide, anxiety, and fear ■ Difficulty with daily function, low self-esteem, sexual dysfunction ■ Victims of incest may expereience negative self-image, depression, eating disorders, personality disorers, self destructive behavior, substance miscuse ■ Commonly see hx of sexual abuse in psychiatric patients
positive symptoms (alterations in perception)
■ Illusions ● See something that is there, but interpreting it differently ● Ex: the microphone is actually in from of Amie, but pt sees it as a snake ■ Hallucinations ● Seeing or hearing something that is not there ● Auditory - 70% schizophrenics have at some point ○ Voices outside of head ○ Brain is activated as if external sounds ○ Misinterpretation of inner thoughts ○ Command hallucinations ■ Are they telling them to hurt themselves or others ■ We need to figure out what they're saying ■ Also need to assess if they can resist it ● Visual → usually seen with alcohol withdrawal & dementia ● Olfactory, Gustatory, Tactile ○ Olfactory - smelling something that is not there ○ Gustatory - tastes things that are not there ○ Tactile - feel something that is not there ■ Depersonalization - lost identity; "different/unreal" ● Dream like state ● Ex: body part does not belong to them or it has drastically changed ■ Derealization - environment changed ■ World seems bigger or smaller ■ Familiar surroundings seem strange
Positive symptoms (alterations in speech)
■ Note that their attention span is short ■ Looseness of Association (LOA) ● If I say lion → normal ppl think tiger → then think stripes ● Ppl w/ schizophrenia will go straight from lion to stripes → this makes stories they tell hard to follow ■ Neologisms ● Newly coined word or expression ● These words have meanings for the pt, but a different or nonexistent meaning for others ■ Echolalia - repeat, repeat, repeat ● Pathological repeating ■ Clang associations ● Will say words that rhyme or have similar sounds ● Meanings don't matter ■ Word Salad ● Words have no connection at all ■ Paranoia ● Safety is key w/ ppl w/ paranoia ● Can put them in dangerous situation → they think they need to protect themselves or others ■ Circumstantially ● Talk about everything except what you asked them ● Include unnecessary and often tedious details in conversation, but eventually get to the point ■ Tangentiality ● When the conversation goes off topic ● Ex: Start of by asking what brought them in to the hospital → they say brother → then start talking about their brother in law ● Never reach the point ■ Rapid or pressured speech ● Will talk & talk & talk ■ Flight of ideas ● Jumping from random topics with nothing in common ■ Thought broadcasting ● No filter ● Makes them want to isolate → this can increase their positive symptoms ■ Thought insertion/withdrawal/deletion ● Thought insertion = ppl think that the thought they have are not their own ○ Think someone has inserted thoughts into their brain ● Thought withdrawal/deletion = ppl think their thoughts have been taken
Phases of Schozophrenia
■ Phase I → Acute Phase: Onset/exacerbation → hospitalization ● Not safe, threat to themselves or someone else ● Can last several months ■ Phase II → Stabilization: Diminishing S/S → Partial hosp or group home ● Trying to get them back to baseline ● Teach them about med adherence & about the disease ● Teach their family about disease process ■ Phase III → Maintenance: Premorbid functioning → in community ● Rest of life ● Want them to be in the community ● Teach that they need a support system
phase i and ii
■ Phase I → experimental phase ● Do I like it and what it does? ● Can control mood swing by amount of intake ■ Phase II → relationship is developed, trust substance to do what you want it to ● Social/moderate drinkers ● Drinking regularly and appropriately ● Movement into harmful dependency can happen at any time (never "safe")
clinical picture: acute stress disorder
■ Psychological reaction to a serious trauma at increased risk for psychological problems as result of that trauma ■ Begins immediately after assault, typically at least 3 days and can be 1 month ■ Impact reaction: expressed or controlled ● Expressed: fearful, anxious, angry ● Controlled: in control of their emotions ○ Ex: girl getting raped and preserving evidence right after the event ○ Follow up care is very important (don't get false sense of hope) ■ Typically see shock, disbelief and denial initially; guilt, fear, anxiety, humiliation, fatigue, etc. ● Guilt is where interventions become important ● Help separate feelings of guilt vs vulnerability ○ May be thinking "I should have done this or that" in order to gain control over the situation, but it is not their fault ○ May blame drinking, doing drugs, or maybe they were out late → still not their fault ■ Vivid dreams, flashbacks, recurring images and response to stimuli
Tolerance and withdrawal
■ Tolerance: needing more of a substance to get effect ● Typically increased but later can decrease with alcoholism in particular ■ Withdrawal: physical symptoms with diminished use ● If you go through withdrawal then you are addicted ● No physical symptoms with LSD or PCP ■ Mood altering or psychoactive drug: alters the way one thinks, feels and acts ○ WHAT you drink, how MUCH you drink, WHEN you drink are all not as important as what HAPPENS when you drink...
physical status
■ Want nutrition balanced and observe for side effects of medications ■ Water intoxication→ assess fluid intake, weight gains (10 lbs +), increased urine output ■ Sleeping→ not sleeping can be a sign of early exacerbation; promote lifestyle that allows them to have good sleep ■ Personal hygiene→ skin/infection process ● May not seek help for skin problems ● Poor hygiene leading to skin breakdown ■ Pain → may not approach with pain so it is important to ask ■ All other systems and alcohol/drug use/nicotine
○ Schizophreniform
■ When someone has symptoms for < 6 months ■ Doctor is responsible for diagnosing this, not the nurse ■ Nurses care about how to respond to symptoms
Phase IV
■ → drinking to feel normal ● Drinking enough to feel like you used to when you weren't drinking at all ● So much emotional pain (projection, denial) ● Family, friends, employers become part of the delusional system ○ All are vulnerable to the effects of the disease ○ They aren't sure what IS reality, all trying to cope, everyone feels they are on a roller coaster ● Family role changes ○ The disease of alcoholism includes the alcoholic ○ Once you lose that role it is really hard to get it back ■ Ex. Young mom who is addicted to crack with 2 kids (in addiction, crack comes before the kids because of survival (dopamine)) → kids get neglected and are unsafe → changes mom's parental role and will be difficult getting that trust back from her 2 kids ○ Anger, shame, hurt, fear/uncertainty, loneliness, desire to be perfect, rebelliousness, apathy, guild ○ Family suffers, nobody escapes the pain ■ Without help and interventions, the family becomes codependent ● Over-responsible, guilty, controlling, obsessed in thinking about the situation, covering it up, making excuses, not taking care of self but taking care of everyone else, not feeling worthy, poor boundaries ■ Many co-dependents choose careers in health care professions ● Giving more of themselves than is necessary, seeking perfection, ignoring or repressing problems (nursing profession is attractive to these people because it involved caring for the most fundamental needs of others)
phase III
■ → harmful dependency ● Person slips behind "normal"; doesn't feel good about situation ● Pain and anxiety and low self esteem → rationalization ● Feels awful even when not drinking; chronic emotional pain; guilt; personality changes, priorities change, everything is "different" → seeing behavioral changes (not the person you recognize) ○ Geographic cure ○ Faulty Memory System: Delusional system develops ■ Blackout= not a pass out but severe memory impairment (does damage to the brain) ■ Euphoric Recall= don't remember the parts from last night were you acted like an ass or were embarrassing (only remembering good parts) ■ Repression= simply don't remember ● "I don't remember what happened at all last night" ● Signs of slipping into Phase III ○ Increased anticipation (you can't wait to get off work because you can drink/ can't wait for the weekend so you can drink) ○ Growing rigidity (get off work and go to the bar- becomes apart of your routine) ○ Drinking/suing more to achieve same effects (building a tolerance) ○ Amount of ingenuity to get "enough" (might be starting to spend what you got and be seeking ways to get more of what you need and want)
What is schizophrenia?
○ "split mind" - cognitive/emotional disconnect ■ It is NOT: DID (dissociative identity disorder)
clinical picture: addiction **
○ Addiction: primary, chronic disease of brain reward, motivation, memory, and related circuitry ■ Loss of behavioral control with craving and inability to abstain ■ Loss of emotional regulation→ unable to recognize the extent to which the addictions are creating serious problems in functioning, relationships, emotional responses ● They may become a person you don't even recognize ■ Loss of ability to identify problematic behaviors and relationships ○ Alcohol use disorders are medical conditions that doctors can diagnose when patient's drinking causes distress or harm
implementation: drug during detox
○ Alcohol withdrawal ■ Sedate with cross-tolerant drug (Benzodiazepine like lorazepam, diazepam) ■ Thiamine- prevent Wernicke's encephalopathy (confusion, memory loss, cranial nerve problems) hydration increases glucose metabolism- depletion of thiamine stores so replacement needed ■ Magnesium and multivitamins ● Help prevent deficiencies and complications ■ Anticonvulsants: carbamazepine ○ Benzodiazepine & Barbiturate withdrawal ■ CNS depression, hyperactivity of the CNS ○ Opiate withdrawal ■ Trazadone if can't sleep ■ Loose stools: imodium ■ Body aches: acetaminophen & ibuprofen ■ Meclizine for nausea ■ Clonidine: decreases withdrawal symptoms ■ Buprenorphine: partial opioid agonist that blocks withdrawal and suppresses heroin use
intervening with delusions
○ Build trust (open, honest, genuine, reliable) ○ Response to suspicion→ be matter of fact (not shocked), empathic, supportive, calm ○ Ask to describe ■ "Tell me more about people coming after you" - ask with balance because it can be anxiety provoking if they go on and on ○ Avoid arguing but voice doubt ■ "I find it difficult to believe..." ■ "Help me understand" ■ Once reality test hits they can label delusions- don't ever say you understand their delusions ○ Focus on feeling ■ "I would think you'd be (scared, sad, feel powerful) ○ Don't dwell on delusions- distract to reality ○ Watch for event that triggers anxiety or isolation that can lead to increased delusions and hallucinations ○ Validate if part of the delusion is real ■ "Yes, there is a doctor at the nursing station but I don't believe their phone call has anything to do with hurting you" ○ Involve family in teaching ■ Teach what it looks like when pt is being triggered ○ Teach coping techniques ■ Some people never lose a thought ● Ex. teaching a patient to go to their room to cope when they feel everyone is starting to look at them and start to get paranoid
● Planning/Implementation
○ Counseling ■ Non-judgemental, supportive, empathetic; watch countertransference ■ Use calm, matter-of-fact approach, talk to them at eye level ■ "You are safe here" keep repeating ■ Reinforce confidentiality ■ Trust building/consistency of staff- give choices and control ■ State observations ■ Let them talk; validate feelings ■ "You are not to blame" keep repeating to help separate blame from vulnerability ■ explain everything- may have to repeat because anxiety is high ○ Promotion of self-care ■ Give all info, follow-up instructions in written form due to anxiety (they are not in the optimal place for learning- make sure they have written info) ○ case management ■ Know the local resources to give to patient ■ Transition from victim to survivor ■ Without interventions, moves into PTSD and other psych issues
● Interventions for Looseness of Association (LOA)
○ Don't pretend to understand ■ "I am having a difficult time following you" ■ Don't say "You're not making any sense" ○ Look for recurring themes/topics ○ Focus on reality of environment and distract into activities
● Health teaching and promotion
○ Educate on illness ○ Resources for family ■ NAMI, SAMHSA, Wellness Recovery Action Plan (WRAP) ○ Develop a relapse prevention plan ■ Want them to do this while they are doing well and plan with their families ○ Set up individual, family, and group therapy ○ Teach coping strategies/ability to solve problems, social skills, importance of support system
● Etiology---how do people get it? How does Schizophrenia evolve? (diathesis stress model of schizo, biological)
○ Group of disorders with common but varying features ■ Scientists are trying to find out why ppl present with different symptoms ○ Brain chemistry, structure, and activity are different ○ Diathesis-Stress Model of Schizophrenia ■ Diathesis = genetic makeup ■ Stress = environmental trigger ● Used ex of pts sister committing sudicide and she was never the same since ○ Biological Factors ■ Genetic = 80% ● Multiple genes → different chromosomes → vulnerability ● Identical twin → 50% chance and 15% if fraternal ■ Neurobiologic ● Dopamine Theory → too much dopamine ○ Rationale for 1st gen meds ○ Cocaine, methylphenidate (Ritalin) and Levadopa → increase the activity of dopamine in the brain and in biologically susceptible person may precipitate schizophrenia's onset ○ Amphetamines → almost any drug of abuse, included marijuana → too much dopamine ● Other Neurochemical Hypotheses → not JUST dopamine → can also be serotonin ● Serotonin = rational for 2nd gen meds ● NMDA receptor → PCP (phencyclidine) intoxication → resembles schizophrenia & suggests glutamate has a role in causing schizophrenia ○ Glutamate - involved in information processing deficits ○ Acetylcholine may also play a role in psychosis ■ Brain structure abnormalities ● Structural abnormalities → disruption in communication pathways ● Pet scans, CT, & MRI → brain looks and functions differently ● Structural changes increase as disease progresses ○ In autopsy can see physical changes in brain ○ Will see reduced volume of gray matter → especially in temporal and frontal lobes
sexual assault- chapter 29 self awareness and why
○ Having self-awareness before encountering rape victim will better prepare you to give empathetic and effective care ○ Nurses are instrumental in not only providing holistic care but also helping preserve evidence
intervening with hallucinations
○ Monitor hallucinations and cues → pt won't usually tell you ○ Non-judgmental, non-threatening approach; focus on the patients experience and use empathy ○ Identify self; call patient by their name ○ Establish trust ○ Speak simply in voice louder than hallucination to get their attention ○ Ask directly "Are you hearing voices?" "Tell me what they are saying" ○ Don't argue or react or feed into hallucination ○ Offer own perceptions.focus on feeling ■ "I don't hear voices, but I know you do. It must be hard to have these voices..." ○ Divert/distract to reality gently ■ Get them involved in something else ○ Monitor anxiety ○ Involve family in teaching - teach them to interact with patient and hallucinations as the nurse should ○ Teach coping techniques to compete with the voices ■ Teach them to NOT say "you don't hear voices, they're not real" ■ Teach them that it's real for the patient
Chapter 22: addiction attitudes/self assessment
○ Nurses have professional responsibilities in treating patients and families who are victims of alcoholism and other addictions to the best of their knowledge and skill ○ Early recognition, diagnosis, and prevention have the same value and benefits for alcoholism and other substance-related addictions ○ No one is immune to substance-related and addictive disorders ○ We see a lot of judgment, people think addiction is a choice
● Physiologic (acute phase AND part of relapse prevention plan)
○ Nutrition (water intoxication) ○ Sleep ○ Elimination ○ Hygiene ○ Physical activity ○ Smoking ○ alcohol/drugs
comorbidity- ditto!!
○ Physiologic response to drug abuse can mimic s/s of psych disorders (ex. Cocaine and schizophrenia) ■ Run drug screen upon arrival to ER ○ S/S of psych disorder may lead to person self-medicating ○ Risk factors to substance use disorders are similar to psych disorders ■ Genetic vulnerabilities ■ Brain defects and pathways of the brain (brain circuitry and dopamine) ■ Environmental factors (early stress and trauma) ○ Men more likely than woman to commit suicide and more likely to have been drinking prior to committing suicide ○ Different routes to consider when doing an assessment ■ Intravenous→ looking for puncture marks called "tracks", most commonly on forearms ■ Intranasal→ assess sense of smell, nosebleeds, problems with swallowing, hoarseness and overall irritation of the nasal septum ■ Smoking→ assess resp and cardiac ■ Skin popping→ using drugs subq
etiology: psychological and sociocultural
○ Psychological ■ Addiction is a developmental disease → typically begins in childhood or adolescence (dangerous because the brain isn't fully developed till 25) ■ No addictive personality but psychodynamic factors do exist: ● Intolerance for frustration/pain ● Lack of success in life ● Lack of affectional/meaningful relationships ● Low self-esteem ● Risk taking propensity ■ Chronic stressors ○ Sociocultural ■ Socioeconomic stressors ■ Cycle of negative life events couples with low supports and negative role modeling ● Parenting practices→ sometimes parents use alcohol and drugs as a rite of passage, or say things like "I would rather have them do it in the house and be safe" → this can show an attitude that says this is normal and okay which might lead to issues for the kid ■ Parental and peer alcohol/drug use
Etiology ( psychological and environmental factors, prognostic considerations)
○ Psychological and Environmental Factors ■ Prenatal Stressors ● Birth & Pregnancy complications ● Trauma to pregnant mother → can alter a fetus & make them more susceptible to schizophrenia ■ Psychological stressors ● Can trigger a predisposed person ■ Environmental Stressors ● Sexual abuse ● Toxins (will not be tested on specific ones) ○ Prognostic Considerations ■ Remissions & Exacerbations (relapses) ● More often than not, this is treated and not cured ■ Roughly speaking ● ⅓ have single/few episodes ● ⅓ have frequent exacerbations ● ⅓ have few significant remissions ○ These pts are psychotic most of the time ○ Tend to need long term care & will not go back to community ■ Good prognosis → abrupt onset & good pre-morbid functioning ■ Poor Prognosis → Insidious onset, younger onset, time elapsed between s/s & treatment, longer time of being untreated, more neg s/s
● Rape Trauma Syndrome phases (what to expect short-term vs. long-term in recovery)
○ Rape-Trauma syndrome: sustained and maladaptive response to a forced, violent sexual penetration against the victim's will and consent ○ Refers to the physical and psychologial effects of rape ○ Short term: shame, guilt, helplessness, powerlessness, dependence etc. ○ Long term: depression, low self-esteem, anxiety, sexual identity issues, sexual dysfunction etc.
SANE
○ Sexual assault nurse examiners ○ Set up one-on-one with patient ○ Does rape kit if patient agrees to it (can do some parts, all, or none)
Epidemiology of addiction
○ Simply understand how prevalent these things are in society but here are some factors ○ Smoking a drug or injecting into a vein increases its addiction potential ○ The earlier a person begins to use a drug the more likely they are to progress to more serious abuse of the drug ○ Binge drinking→ drinking so much within about 2 hours that BAC reaches 0.08g/dL (consuming 4 or more drinks per occasion for women and 5 or more drinks per occasion for men) ■ Binge drinking leads to alcohol-impaired driving, interpersonal violence, risky sexual acitivty, unintended pregnancy ■ Most people who binge drink are not alcoholics or alcohol dependent ○ Drinking alcohol and energy drinks together leads to bad things (binging, sexual assult) ○ Use of pain medications can open the door to heroin use ○ Heroin dependency can start within 24 hours of use
diagnosis and outcomes
○ Situational low self-esteem, anxiety, disturbed personal identity, fear, social isolation, sexual dysfunction
● Sexual offenders and relationships with victims
○ Spousal (or marital) rape and acquaintance (or date) rape becoming higher in incidence ○ Sexual distress is more common amount women who have been sexually assaulted by intimates, and fear and anxiety are more common in those assaulted by strangers (depression occurs in both) ○ Acquaintance (or date) rape is typically combined with alcohol/drugs
best practice guidelines, Do NOT need to know date rape drugs
○ Stay with patient, consistency of staff is needed ○ Explain reasons for everything ○ Documentation is vital ○ Tell client he/she is not responsible for any bills ○ Provide private room ○ Notify police- needs to be reported but survivor does not have to prosecute ○ Let the patient know that showering will destroy the evidence
Comorbidity
○ Substance abuse & alcohol → more males, more psychotic s/s, violence, legal issues, more noncompliance ■ Substances do not mix well with schizophrenia ■ They increase dopamine and people with schizo already have too much dopamine ○ Nicotine → 60% → CV/resp problems ○ Anxiety, Depression Prevalent (Schizoaffective) ■ Suicide → 20% attempt & 10% succeed (5x that of general population) ■ Schizoaffective = have thought process of schizophrenia & mood disorder ○ Physical health illnesses → more common than in general pop. ■ Die 20 yrs prematurely due to CV disease & metabolic syndrome ■ Due to meds & poor health habits ■ CV → has a lot to do with the meds they take ● Increased BP, blood sugars, triglycerides, and higher body fat ○ Polydipsia → Compulsive drinking ■ 4-15 liters daily → fatal water intoxication (hyponatremia, confusion, worsening psychotic symptom, coma) ■ 20% of people with schizophrenia have insatiable thirst ■ Typically on long term anti-psychotic therapy ● SE of dry mouth ● Med induced inappropriate secretion of ADH, craving, compulsive behavior ■ Talked about pt who had seizure from drinking too much water ■ Can be caused by behavior as well as meds ■ If there is a sudden increase in psychotic symptoms (disorientation, restlessness, and fluctuating vital signs) → Hyponatremia should be considered
counseling and communication techniques
○ Trust building→ short frequent approaches to increase trust, keep promises, non-judgmental ○ Calm, quiet, matter of fact approach ○ Passive friendliness (neutral expression) ■ Over cheerfulness and smiley expression can increase paranoia ○ Use touch judiciously, if at all ○ Do not give multiple demands- keep it simply to avoid overwhelming ○ Always think- decrease anxiety for patient and me ○ Facilitating self-esteem ■ Call by name, sincere praise, ID strengths, involve in task they can be successful in ■ Praise them - ex: "I saw you went to group today"
Substance Use within Nursing Profession: what is abused, risk factors, early indicators, what do you do about it?
○ What is abused ■ Alcohol, followed by amphetamines, opiates, sedatives, tranquilizers, and inhalants ○ Risk factors ■ stress/lack of coping (12 hours shifts, rotating shifts) ■ Access ■ Attitude ■ Lack of education ● "It won't happen to me" ○ Early indicators ■ Isolating, prefers nights, prefers lack of supervision ■ Absent from work, tardiness before and after days off ■ Vague illnesses and sporadic work history ■ Offers to give meds, works extra hours, carries keys, med counts are off ○ What do you do about it? ■ Don't enable ■ Be alert to behaviors ■ Specific documentation: dates, times, events, consequences ■ Report to manager- responsible to assure job performance and client safety. Confront with plan of action
intoxication
○ process of using a substance to excess ■ Standard drink= 12 oz beer, 8 oz malt liquor, 5 oz wine, 1.5 oz "shot" distilled spirits/liquor (rum, gin, vodka, whiskey) ■ Moderate or "low-risk" drinking ● Men→ no more than 4 drinks on any single day AND no more than 14 drinks per week ● Women→ no more than 3 drinks on any single day AND no more than 7 drinks per week ● To stay low risk you must keep within the single-day and weekly limits; people who drink moderately may be less likely to experience an alcohol use disorder ■ Heavy drinking ● Men→ more than 2 drinks per day on average ● Women→ more than 1 drink per day on average
● Advance Practice Interventions: Psychotherapy for Survivor and Perpetrator evaluation
● Advance Practice Interventions: Psychotherapy for Survivor and Perpetrator ○ Survivor: benefits from individual and group work ○ Rapist: therapy needed if ever to change ● Evaluation ○ Wants to see absence of PTSD s/s ○ Don't want to see long-lasting disabilities ○ Manage depression and anxiety ○ Want to see them integrate experience without it controlling their life
Psychobiological Interventions---understanding of criteria and rationale with focus on ones for Alcohol and Opioid Treatment emphasized in class: AFFECTIVE and cognitve
● Affective ○ Therapeutic use of self ■ Self-awareness: accepting, non-judgmental open-ended questions, clarifying ■ Anxiety reducing strategies ■ Assertiveness, direct, matter of fact ■ Holds to limits set firmly ○ Facilitating expression of feelings- provides hope of recovery ■ State observations ■ Support all expression of feelings/empathic comments ■ Focus on here and now ■ involve ● Cognitive ○ Teach to think before acting impulsively ○ Teach problem-solving/decision making ○ Confrontation: focuses on the discrepancies between what person says and what they do ○ Describe message you are perceiving ○ Describe in the words of the client the perceived contradiction, distortion of reality, game, or evasion ○ Wait for response
nursing process- Assessment of patient with substance abuse behavior: (CNS depressants, CNS stimulants, Opioids, Marijuana, Hallucinogens, Inhalants) pt 2
● Alcohol withdrawal: very individualized ○ Dangerous and can be unsafe for others too because of hallucinations ○ Typically begins within 12 hours after abrupt stopping ○ Peak: 24-48 hours ○ Change in vitals: BP and P most indicative ○ Diaphoresis, tremors, agitation, N/V ○ SEVERE alcohol withdrawal→ Delirium tremens (DTs) ■ Usually peaks 48-72 hours and lasts 2-3 days ■ T: temp rises ■ T: tremors, really bad, sometimes can feel them, but not see ■ T: tachycardia, increased BP/N/V ■ T: terror, because of hallucinations and illusions, or misinterpret environment
Psychobiological Interventions---understanding of criteria and rationale with focus on ones for Alcohol and Opioid Treatment emphasized in class: behavioral, rapid prevention, selfhelp groups for client and family, evaluation
● Behavioral ○ Role play assertiveness ○ Reinforce accepting responsibility ● Relapse Prevention ○ HALT ■ Evaluates if you are hungry, angry, lonely, or tired ○ Lifestyle changes ● Self-help groups for Client and Family---how and why they work ○ AA (alcoholics anonymous) 12 step program ○ DA (drugs anonymous) and NA (Narcotics anonymous) ○ Gambling anonymous ■ Powerless over addiction life is unmanageable ■ Responsible for their recovery ■ Can't blame, they must face their problems and their feelings ● Al Anon ○ For families ● Al-a-Teen and Al-a-Tot ● Evaluation---how do we know if they are in recovery ○ Sense of hope and self-esteem ○ Consistent aversion- total abstinence ○ Substitute dependency ○ New social supports
implementation
● Hangovers! Primary prevention: don't drink so much ● General interventions during detox ○ Assess vitals, tremors, N/V, hallucinations/illusions ○ Careful physical assessments of systems ■ CIWA ○ Well-lit room ○ Decreased stimulation- but don't isolate ○ Suicide, elopement, seizure precautions ○ Smoking alert! ○ Encourage healthy eating, exercise and sleep ○ Monitor environment for substances
Opiates: Codeine, Oxytocin, Vicodin, Methadone, Diladudid, Morphine, Heroin
● Intoxication: pinpoint pupils, decreased pulse & respirations, drowsiness, impaired attention, judgment, & memory, suppression of pain ● OD: respiratory depression and arrest, coma, shock, convulsions, death ● Withdrawal: yawning, N/V/D, runny nose/eyes, muscle aches, chills/fever, panic (flu-like symptoms)
CNS stimulants: Cocaine, Crack, Methamphetamine
● Nicotine ○ Physical withdrawal: tremors, irritability ● Caffeine ○ Physical withdrawal: irritability, sluggish, headaches ● Cocaine, crack, bath salts ○ Intoxication: dilated pupils, increased pulse & BP, insomnia, grandiose, assaultive paranoia, hallucinations/delusions ○ OD: respiratory distress, ataxia, hyperpyrexia, seizures, coma, stroke, MI, death ○ Withdrawal: crash, fatigue/sleepiness, depression, apathy, craving- anxiety ● Bath salts ○ OD: sudden death or MI
outcomes ( phases, teamwork and safety, activities and group, working with an aggressive patient)
● Phase I→ structured evaluations (safety), meds, psycho education, support ● Phase II→ stabilization, education on meds, SE, disease process ● Phase III→ client and family teaching, relapse teaching, education on coping, adherence, cognitive/social skill enhancement ○ Many negative symptoms are addressed here because they are safe now ● Teamwork and safety ○ Protection from undue stress (control the environment, keep them involved but not overstimulated) ○ Therapeutic structure promotes faster recovery ● Activities/groups ○ Decrease withdrawal, enhance motivation, modify unacceptable behaviors, facilitate support and feedback from staff and peers, increase social competence ● Working with an aggressive patient ○ Least restrictive measures first ○ Aggression is coming from their symptoms→ some kind of response to hallucinations/delusions→ paranoia makes them the biggest safety risk ○ Impaired judgment and impaired impulse control ○ Interventions ■ More supervision (someone available to de-escalate) ■ Decreased stimulation ■ Make the patient feel safe ■ Diversional activities - get them involved in something else (distractibility)-- most likely some sort of solitary activity where they can still be in the environment
Signs of Intoxication, Withdrawal, OD Study those boxes in guided notes!
● Physical ● Cognitive ● Affective ● Behavioral
nursing process- Assessment of patient with substance abuse behavior: (CNS depressants, CNS stimulants, Opioids, Marijuana, Hallucinogens, Inhalants)
● Plan early for withdrawal intervention ● Better to give them medicine for a suspected withdrawal than to wait until they are withdrawing ● Ask open ended questions, matter of fact ○ Drug, what else do you use or prefer ○ Route ○ Last drink/drug ○ Attempts to quit and withdrawal symptoms ○ How much? How long? How often? ■ What happened is more important ○ Problems drugs have caused ○ Family history ■ Is it biological based ● CNS depressants ○ Alcohol, benzodiazepine, barbiturates ○ These 3 are cross-tolerant drugs and cause CNS depression ● Rule of thumb for withdrawal ○ Opposite of effect ■ Rebound hyperactivity ○ Not all addicted have physical withdrawal symptoms ■ Kindling can happen when someone didn't have help going through withdrawal ■ Some people quit cold turkey and nothing happens to them, they are fine, the next time they quit again it may be severe
Nursing process: Pre-psychotic Phase and Primary and Tertiary Prevention
● Pre-psychotic Phase: Early detection & treatment of symptoms is believed to lessen the risk or reduce the severity ○ Pre-psychotic (Prodromal)/Early Symptoms → month to yr prior ■ Deterioration of previous functioning → withdrawn, lonely, dep, vague plans ■ Anxiety s/s → phobias, obsessions, dissociations ■ Thought disorder s/s ● Poor concentration, mind wandering, "strange", detached, trust decreased, symbolism, preoccupied with religion, sexual identity issues, interest in metaphysical → ultimately delusions, and hallucinations → crisis and entry into health care system ○ Primary Prevention → Monitoring high risk, intervening to reduce stressors, teaching coping & social skills ■ Can't change if their parents have schizophrenia → can teach them how to deal with it ■ Want to monitor the high risk kids ■ Good prenatal treatment ○ Tertiary Prevention → recognizing early signs of relapse, keep on meds ■ Research → with each relapse of psychosis ■ Want them to recognize early signs of relapse ■ With each relapse → increase in deterioration ● Harder to get them back to baseline with each one
typical family response
● Sympathy → feel really bad for the addict ● Ignore→ "this isn't my problem" ● Ineffective confrontation ○ Tired of it→ confronting with anger ○ Person with addiction at risk for abuse ○ Thinking the person with the addiction is messing everything up and ruining the families lives ■ How does a person with substance use disorders and addiction get help? ● Spontaneous crisis: usually when the person hits rock bottom (this is dangerous) ○ Rock bottom is different for everyone, some people never meet it ○ Ex. jail, DUI, losing a partner, hepatitis/pancreatitis ● Structured intervention: purpose is to break down defenses when they are sober/clean and can think straight ○ Don't want to accept a person into rehab who is intoxicated
Etiology- demonstrate and understqnding of disease concept
● — there is no single cause of substance abuse, multiple factors contribute (social, biological, and psychiatric factors overlap) ■ Observable s/s in society ■ Primary→ not a symptom of a psychiatric or medical conditions ● "If a chemical causes a problem then the chemical is a problem" ■ Predictable, progressive course ● Always gets worse (could take a couple months, years, even decades) ■ Permanent or chronic ● No cure ● Periods of relapse and remissions ● Recovery is a process and lifetime commitment, every day ■ Fatal ● 12 years average shorter life span
General assessment: positive symptoms
● → Florid (fully developed) psychotic symptoms → admitted! ■ Most notable in society ■ Tend to respond better to meds ○ Alterations in thinking: Reality testing - themes ■ Should have them talk about delusions for a little bit and then try to get them back to reality → don't want them to get out of control with their story ■ Delusions - false fixed beliefs that can't be changed by reasoning → 75% experience this ● Control ○ Someone believes that someone is controlling them ● Ideas of Reference ○ When someone thinks that a random event is directly tied to them ○ Ex: 9/11 attacks had something to do with them ● Grandeur ○ Someone believes they are very important ○ Ex: think they are Jesus or Neapolitan ● Somatic ○ Body malformations ○ Ex: think their insides are rotting out ● Jealousy ○ Believe that their spouse is unfaithful ■ Concrete Thinking: ● If you ask what brought them in they'll respond "a car" ● If you say "the grass is always greener on the other side" → pt will respond "my neighbors grass is very green"
Epidemiology
● → No difference related to race, social status, or culture → 1% of general population; Males 1.4:1 and growing up in urban area ○ Onset - Abrupt onset with good premorbid functioning → more positive outcomes ○ Males ■ Early onset - 18-23 yrs ■ Poor premorbid adjustments ● Will see them doing weird things for a while before diagnosis ■ More structural abnormalities ■ More symptoms ○ Females ■ Later onset - 23-35 yrs ■ Okay premorbid adjustments ● More of an abrupt onset and will respond better to meds ■ Less structural abnormalities ■ Less symptoms → "better outcomes"
