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UNIT 1

What are the obstacles of therapeutic communication?


a) Resistance- lack of awareness of problems in order to avoid anxiety
b) Transference- unconscious assoc. NS with someone significant in his/her life.
c) Countertransference- Ns emotional response to a specific client.
d) Boundary violations- occurs when Ns enters into a personal/social relationship with client

What are the traits of therapeutic communication?


a) Genuineness- being consistent with both verbal and nonverbal behaviours
b) Positive Regard – respect and acceptance eg. addressing client by name they prefer, sitting and listening,
c) Empathy – ability to see things from the clients viewpoint
d) Trustworthiness- being responsible and dependable ex. Keeping commitments and promises
e) Clarity- be specific and clear
f) Responsibility- language involves the use of “I” statements when being assertive.
g) Assertiveness- the ability to express thoughts and feelings comfortably and confidently in a positive,
honest, and open manner.
Describe Mental Health:
MENTAL HEALTH consists of a person’s perceptions, thoughts, emotions, and behaviours

Discuss DSM-IV:
A. Clients diagnosis has 5 parts or AXIS:
1. AXIS I: Psychiatric Dx
2. AXIS II: Personality disorder or mental retardation
3. AXIS II: Medical dx
4. AXIS IV: Psychosocial stressors
5. AXIS V: Global Assessment of Fxning (GAF)- considered Psychologic, social and
occupational fxn on a hypothetical continuum of MENTAL HEALTH-ILLNESS.
B. What does GAF Measure? The client’s functional state @ the time of admission and within the last year

Safety is the top priority in mental health setting.


Discuss Client rights:
I. RIGHT TO TREATMENT:
A. People w/ mental illness have a right to tx.
B. State cannot detain individuals who are non-dangerous without providing some mode of tx.
C. MHN has professional obligations to help pts. Seek out and engage tx for mental illness 2 the least
restrictive level.

II. RIGHT TO REFUSE TX:


A. Voluntary and involuntary clients have the right to refuse medication.
B. During emergency situations, if there is potential danger, the client can be forcibly medicated
C. Right to refuse medication is upheld if client is involuntary and competent
What are the types of COMMITMENTS?
A. Voluntary – Those who want to be discharged must give written notice of intent to leave and must
be discharged within 3 days.
B. Emergency
C. Civil/judicial commitment- Legal basis

<<LEAST RESTRICTIVE ALTERNATIVE means providing MH tx in the least restrictive environment using
the least restrictive tx. >>

What is Duty to warn? Establishes responsibility of a treating MPH to notify an intended, identifiable victim.

Describe Neuroanatomy:

LOBE NORMAL FXN


FRONTAL  execution of voluntary motor fxn
 thought processes ex. Planning, abstract thought, decision making, critical thinking
 Intellectual insight, judgment
 Expression emotion
PARIETAL  Sensory and motor
 Interprets sensory information
 Right and left orientation
TEMPORAL  Hearing, connects with limbic system, allows connection of emotions, responsible for
language comprehension
OCCIPITAL  vision

III. ANTIPSYCHOTIC MEDICATIONS:


A. Also called NEUROLEPTICS – used for tx psychosis, behavioural problems in children, schizophrenia
etc. Controls symptoms like delusions, hallucinations and thought disorders Two types:
i. CONVENTIONAL or TYPICAL - block dopamine, acetylcholine and epinephrine
Phenothiazines (first generation) and non-phenothiazines ex. Haldol, Thorazine, Stelazine
a. Side effects: extrapyramidal symptoms, dry mouth, orthostatic hypotension
ii. UNCONVENTIONAL or ATYPICAL – blocks action of dopamine and serotonin. Ex. Clozaril,
Zyprexa, Risperdal, Abilify
1. Less side effects, few or no EPS
2. Work on negative and positive symptoms of schizophrenia
IV. ANTIDEPRESSANTS:
B. Partially block reuptake of norepinephrine and serotonin. 4 classes:
i. Selective Serotonin Reputake Inhibitors (SSRI’s)- work by inhibiting reuptake of
serotonin These treat major depressive disorder ex. Prozac, Zoloft, Paxil
ii. Tricyclic Antidepressant (TCA)- act by blocking the reuptake of Serotonin and
norepinephrine. This increases serotonin and norepinephrine in the nerve cell. These are
used to treat major depression.
iii. Side effects: orthostatic hypotension, sedation,
iv. Monoamine Oxidase Inhibitors- MAOI’s inhibit Monoamine oxidase enzyme----
result=increased availability neurotransmitter Ex. Nardil, Parnate
1. Side effects: HYPERTENSIVE CRISIS
2. Avoid foods with Tyramine
v. Atypical Antidepressant- used tx major depression and anxiety. Effects one or two of these
neurotransmitters: serotonin, norepinephrine, and dopamine. Ex. Wellbutrin, Cymbalta,
Effexor
a. Side effects: Headache, dry mouth, Seizures, suppress appetite
V. MEDICATIONS ALZHEIMERS DX:
A. Anticholinesteras inhibitors (AChe) are used tx Alzheimer’s dx.
B. Common inhibitors: Tacrin (Cognex), Donepezil (Aricept), Rivastigmine (Exelon)
C. M of A= increase acetylcholine concentration in CNS by inhibiting cholinesterase breakdown.

VI. ANTI-ANXIETY/ANXIOLYTIC MEDICATIONS:


A. Used to control anxiety and treat status epileptics; preoperative sedation, insomnia
B. Major group = benzodiazepines ex. Valium, Xanax...Buspar (non-benzodiazepine)—takes 4 weeks
C. M. Of. A= is to enhance the inhibiting action of Gamma-aminobutyric acid (GABA – an inhibitory
neurotransmitter in the CNS)
1. Side effects: Fatigue, dry mouth, sedation

VII. MEDICATION TREAT ATTENTION DEFICIT DISORDER:


D. Two types drugs used in tx ADHD:
i. Amphetamine- like drugs (psycho-stimulant) – Ritalin, Adderall, Concerta. Increases
release and blocks reputake of monoamines so more is available to inhibit an overactive part
of the limbic system.
VIII. MOOD STABILIZERS:
E. Used for tx. Bipolar disorder.
F. Eg. Lithium citrate and antiepileptic drugs (Tegretol, Depakote)
G. M. of. A= is alteration electrical conductivity in neuron
1. Side effects: Arrhythmias, Tremor, Polyuria,

a. GENERAL ADAPTATION SYNDROME: body’s response to stressful stimuli, which produces


biologic, emotional and psychological responses

b. What influences a person’s response to stress?


i. Age
ii. Past experience
iii. Lifestyle
iv. Culture
v. Developmental level
vi. Health status

c. Define DISTRESS: Subjective response to stimuli that are threatening or perceived as threatening.
Includes fatigue, pain, fear, or acute/chronic dx

d. Define EUTRESS: Stress response (nonspecific) assoc. with desirable events ex. Wedding, job
promotion, birth of child.

e. Define PSYCHOLOGIC STRESS: All processes of the person that require cognitive appraisal of the
event before a response
f. What is GIS? Activated automatically as response to survival; “POSSOM RESPONSE”.
Results overstimulation of PNS, activated by life threatening situations
g. Stages of GAS:

ALARM REACTION
alerts you to presence of stressful stimuli
•ANS releases EPINEPHRINE to alert body of stressor
fight or flight activates HPA AXIS (hypothalamus, pituitary gland, adrenal
gland) causes release of cortisol from adrenal glands
leads to increase BP, tachycardia, vasoconstriction of vessels,
increase in muscle tone, dilated pupils, increased alertness
and increase sugar levels etc.

RESISTENCE
stressor should be overcome in this stage
•Prolonged stage resistance mobilizes energy resources to
your body attempts to adapt to the stressor maintain adaptations

EXHAUSTION
if stressor isn't overcome, it will spread throught body causing dx
Exhaustion occurs when resources are used up and individual can no
BODY CAN'T MAINTAIN ADAPTATIONS
longer maintain adaptations leads to illness or death

I. COMPLEMENTARY AND ALTERNATIVE THERAPIES:


Holistic/alternative care beliefs strengthen individual’s inner resistance to dx, healing from within, or enhance
body’s innate healing powers
I. ALTERNATIVE THERAPY FIELDS:
A. Complementary and alternative medicine (CAM): 7 categories:
i. Alternative medicine systems
ii. Mind-body interventions
iii. Pharmacologic and biologic based therapies
iv. Herbal medicines
v. Diet, nutrition, supplements and lifestyle changes
vi. Manipulative and body-based methods
vii. Energy therapies<<Box 25-1 p. 573>>

ANXIETY DISORDERS:

I. What is anxiety? Feelings of uneasiness, uncertainty, apprehension or tension in response to an unknown


object or situation.
X. DEFENSE MECHANISMS:

EGO DEFENSE
MECHANISMS DEFINITION EXAMPLE
Conversion Unconscious expression of a mental conflict as a Woman experiences blindness after
physical symptom to relieve anxiety witnessing a robbery.
Denial Unconscious refusal to face reality. Woman denies that her marriage is
failing
Dissociation Separation and detachment of a strong, Male victim of car-jacking exhibits
emotionally charged conflict from one's symptoms of traumatic amnesia the
consciousness next day.
Identification Unconscious attempt to identify with personality Teenager dresses, walks, and talks
traits or actions of another to preserve one's self- like his favourite basketball player.
esteem
Projection Unconscious assignment of unacceptable thoughts Man who was late for work blames
or characteristics of self to others wife for not setting the alarm clock.
Rationalization Justification of one's ideas, actions, or feelings to Student states he didn't make the
maintain self-respect, prevent guilt feelings, or golf team because he was sick.
obtain social approval
Reaction-formation Demonstration of the opposite behaviour, attitude, Man who dislikes his mother-in-law
or feeling of what one would normally show in a is very polite and courteous toward
given situation her.
Suppression Voluntary rejection of unacceptable thoughts or Student who failed a test states she
feelings from conscious awareness isn't ready to talk about her grade.
Symbolization Use of external objects to become an outward An engagement ring symbolizes
representation of an internal idea, attitude, or love and a commitment to another
feeling person.

Nursing Assessment: Assess psychological, cognitive, and behavioural symptoms.


o Defense mechanisms used
o Mood
o Suicide potential
o Thought content and process
o Severity of subjective experience of anxiety
o Understanding of specific disorder

Nursing Interventions
Reducing Symptoms of Anxiety:
1. Maintain safety for the client and the environment
2. Assess own level of anxiety
3. Recognize the client’s use of relief behaviours
4. Inform client limiting caffeine, nicotine, and other CNS stimulants
5. Teach client to distinguish anxiety that is connected to identifiable sources
6. Instruct client to practice stress reduction techniques
7. Help client build on coping methods
8. Activate the client to identify support persons
9. Assist client gain control of overwhelming feelings and impulses
10. Help client structure quiet environment
11. Assess the presence and degree of depression and suicide ideation
12. Administer anxiolytics
XII. Types of ANXIETY:
i. Panic Anxiety: Recurrent unexpected anxiety attacks with thoughts of dread, impending
doom, death and fear of being trapped.
ii. Phobias: Client experiences panic attack in response to particular situations
Types: Agoraphobia – fear of being alone in public places, without escape, Social Phobia -
fear of social or performance situations. Eg. Speaking, eating in public
iii. Posttraumatic Stress Disorder (PTSD): Describes and individuals reaction to traumatic events
eg. Combat, sexual abuse, physical abuse, disasters, and grieving
a. Efforts to avoid thoughts, feeling, or conversation about the trauma
b. Efforts to avoid persons or places that evoke memories of trauma
c. Inability to remember important aspects of trauma
d. Diminished interest in significant activities
e. Restricted range of effect
f. A sense of impending doom.
1. Must have two of the following present:
a. Sleep disturbances, irritability or angry outbursts, difficulty concentrating,
Hypervigilance and exaggerated startle response.
iv. Acute Stress Disorder: Symptoms occur during or immediately after trauma
a. Develops three or more dissociative symptoms:
i. Subjective sense of numbing or detachment
ii. Absence of emotional responsiveness
iii. Feeling dazed (reduced awareness of surroundings)
iv. Derealisation (unreal feeling)
v. Depersonalization (feeling alienated)
vi. Dissociative amnesia
v. General Anxiety Disorder: Excessive anxiety and worry that is difficult to control
vi. Obsessive Compulsive Disorder:
1. Obsessions are recurrent and persistent thoughts, impulses or images
2. Individuals try to suppress the thoughts and impulses
3. Compulsions are repetitive behaviours that the person feels driven to perform in
response to an obsession
vii. Somatoform disorders: Characterized by physical symptoms that can’t be explained by
known physical mechanisms. They:
a. Involve multiple organs
b. have early onset and are chronic without signs of impairment
c. No laboratory evidence of medical condition
Types:
a. BODY DYSMORPHIC DISORDER-Preoccupation with imagined defect in
appearance in a normal-appearing person
b. CONVERSION DISORDER- Development of Neurologic disorder (blindness,
deafness, loss of touch, or pain sensation) or Involuntary motor function (aphonia,
impaired coordination, paralysis, or seizures).
c. HYPOCHONDRIASIS-Preoccupation with fears of having/ has a serious disease
despite appropriate medical tests and assurances to the contrary
d. SOMATIZATION DISORDER-History of many physical complaints before age 30.
History of pain in at least four different sites or functions
viii. Dissociative disorders:
a. Depersonalization disorder
b. Dissociative amnesia-One or more episodes of inability to recall important
information (usually of a traumatic or stressful nature)
c. Dissociative fugue-Sudden, unexpected travel away from home or one's
place of work with inability to remember past
XIII. COGNITIVE AND BEHAVIOURAL THERAPY:
a. Distorted and dysfxnal thinking causes psych disturbances expressed in mood and behaviour
b. GOAL: assist the client in beginning to I.D automatic thoughts and the feelings connected to them.

XIV. RATIONAL EMOTIVE THERAPY:


a. Precursor to cognitive behavioural therapy
b. Psychologic symptoms come from disturbed thinking—leads irrational beliefs not based in actual
fact- You are responsible for your irrational beliefs and thus mental disturbance

MEDICATIONS THAT TREAT ANXIETY:

XV. Anti-anxiety
A. Benzodiazapines
a. How it works: by enhancing the inhibitory action of GABA thus causing generalized CNS
depression
b. Therapeutic effect: relief of anxiety
c. Interactions: DO not use with MAOI’s, additive effect when taken with alcohol,
antihistamines
i. Diazapam (Valium)- 2-10mg 2-4x’s /dy
ii. Alprozolam (Xanax)- .25-.5mg 3x’s/dy
d. SE: dizziness, drowsiness lethargy, mouth dryness
o Treat overdose of benzo’s by:
a. Administering an antiemetic in conscious pt. and gastric lavage
in unconscious patient
B. Non-Benzodiazapine
a. How it works: decrease reputake of dopamine and increase serotonin in the CNS
b. Therapeutic effect: decrease depression
c. Interactions: grapefruit juice can cause toxicity, use with MAOI may cause HTN
1. Buspirone HCL (BusPAR) -5mg 2-3x/dy
d. SE: dry mouth, nausea, vomiting, agitation, headache, blurred vision, constipation
XVI. Antidepressant: 4 groups:
B. Tricyclic’s
a. How it works: blocks reputake of norepinephrine and serotonin
b. Interactions: do not use with MAOI and avoid concurrent use with SSRI’s
1. Amitriptyline (Elavil)-25mg 3x’s up to 200mg/dy
2. Imipramin (Tofranil)-25-50mg 3-4 up to 300mg/dy
c. SE: orthostatic hypotension, sedation, suicidal thoughts, blurred vision, dry mouth
C. SRRI’s:
a. How it works: blocks reputake of serotonin
b. Interactions: St. Johns wart causes central serotonin syndrome
1. Fluoxetine (Prozac)
2. Sertraline (Zoloft)
3. Paraxentine (Paxil)
c. SE: nervousness, sexual dysfunction, headache, insomnia
D. MAOI:
a. How it works: inhibiting monoamine oxidase causing a rise in neurotransmitters
b. Interactions: avoid foods withtyramines
1. Phenelzine Sulfate (Nardil)
2. Tranylaypromine Sulfate (Parnate)
c. SE: HYPERTENSIVE CRISIS s/s: headache, seizure, edema, chest pain, SOB, nausea,
vomiting, severe anxiety, unresponsiveness.
E. Atypical antidepressant:
a. How it works: effects serotonin, dopamine, and norepinephrine
b. Interactions: do not use w/ MAOI, should not be taken within 14dys of MAOI use
1. BuPropion (Wellbutrint)
2. Venlafaxine (Effecor)
3. Doloxetine (Cymbalta)
c. SE: headache, dry mouth, seizures, appetite suppression
F. Mood Stabilizers:
a. How it works: alters electrical conductivity of cell
b. Interactions: make sure have adequate Na intake for Lithium
1. Lithium
c. Monitor: therapeutic levels
G. Anti-epileptics:
a. How it works: increases inhibitory action of GABA
b. Interactions: increased CNS depression with consumption of alcohol
1. Divalproex sodium (Depakote)
2. Carbamazepine (Tegretol)
c. SE: agranulocytosis—so check WBC, sedation
d. Monitor: I/O
H. Beta-Blockers: Anti-anginals
a. How it works: blocks beta 1 receptors thus decreasing BP and HR
b. SHOULD NOT 50mg daily, Ccr=15-35mL/min
1. Atenolol (tenormin)- 50-200mg/dy
2. Propranolol (Inderal)- 40-100mg/dy
c. SE: fatigue, weakness, bradycardia, CHF, pulmonary edema
d. Monitor: vitals, I/O, daily weight, assess CHF. Take apical pulse before admin, if ,50bpm
do not administer
I. Antihistamines:
a. How it works: blocks effects histamine @ H1 receptor, creating CNS depression
b. Interactions: additive CNS depression with alcohol and antidepressants
1. Diphenhydramin (Benadryl)
2. Hydroxyzine HCL (Atarax)
3. Hydroxyzine Pamoate (Vistaril)
c. SE: dry eyes, constipation, dry mouth, and blurred vision, can decrease anxiety so asses
mood, mental status and behaviour.
J. Herbal Therapy:
a. Kava-Kava: used for anxiety
1. How it works: alters limbic system modulation of emotional processes
2. SE: dizziness, headache, drowsiness, extrapyramidal effects, HEPATIC
TOXICITY. When taken with Benzo’s additive CNS depression
b. Valerian: for anxiety
1. How it works: may increase concentrations of GABA
2. SE: drowsiness, headache
SLEEP DISORDERS:

I. Types:
a. Dyssomnias- abnormalities in amt, quality or timing of sleep
i. Insomnia- most common, difficulty initiating and maintaining sleep
ii. Hypersomnia-
iii. Narcolepsy- excessive daytime sleepiness, sudden onset sleep attacks. Can have cataplexy
(sudden loss muscle tone and involuntary muscle movement) or sleep paralysis
iv. Breathing-related sleep disorder-e.g sleep apnea
v. Circadian rhythm sleep disorder- e.g jet lag, shift work type and delayed sleep phase
b. Parasomnias- abnormal behaviour during sleep
i. Nightmare disorder- occurs during REM
ii. Sleep terror- occurs during non-REM
iii. Sleepwalking- typically ages 4-8, occurs during non-REM
II. NSG PROCESS:
a. Assessment: subjective and objective data sources and sleep hx
b. NSG DX:
i. Sleep deprivation
ii. Insomnia
iii. Ineffective bx
iv. Anxiety
v. Fatigue
vi. Ineffective coping
c. Outcome I.D
i. I.d primary causes sleep alteration
ii. Communicate interventions and implement them
iii. Demonstrate reduction sleep disturbance
iv. Participate discharge planning
d. Planning: participation multidisciplinary team
e. Implementation/Interventions:
i. Monitor sleep patter and id risks
ii. Have client keep sleep diary
iii. Develop hygiene plane
iv. Teach symptom management
v. Make environment quiet
vi. Help client i.d stressors
vii. Promote development coping skills
viii. i.d clients support system
ix. promote compliance medications
x. teach limit substances cause sleep disturbances
xi. educate about circadian rhythms
xii. refer sleep specialist
GRIEF:

I. Types:
a. Anticipatory grief- pre-mourning- grief assoc. With anticipation predicted death or developing
loss
b. Acute Grief- painful exper. After a loss
c. Dysfunctional grief- ex. PTSD. Lasts longer than other types and has greater disability ex.
Traumatic loss, complicated grief, chronic grief
d. Chronic sorrow- response to ongoing loss ex. Parents w/ disabled children.
II. Interventions:
a. Assess risk kill or harm self and others
b. Promote ns-relationship
c. Facilitate expression feelings related to loss
d. Help client understand relationship between self and lost person
e. Facilitate full expression grief
f. Promote interactions with others

COGNITIVE DISORDERS:

I. Types:
1. Dementia- It is the gradual and progressive deterioration of intellectual functioning.
2. Delirium- an acute state of confusion, disorientation to person and place, rapid onset and short
duration

SYMPTOMS DEMENTIA DELIRIUM


Judgment Impaired May be impaired
Mood Fluctuates Fluctuates (fluctuating consciousness)
Apathetic Reduced ability sustain attention
Memory Impaired Impaired
Cognition Disordered reasoning Disordered reasoning
Orientation Disoriented Disorientation
Thoughts Confused Confused
Suspicious Suspicious
Paranoid Incoherent
Perception No change Misinterpretations, Visual hallucinations and
delusions
Consciousness Normal Clouded
Speech Sparse Sparse or fluent
Repetitive Incoherent
Behavior Agitation Agitation
Wanders May wander
Insomnia Insomnia
Mental status Poor testing Poor testing
Progressively worsens Improves when medically stable
Inappropriate answers Improves with treatment
Activities of daily Deteriorate as dementia progresses Usually remain stable unless medically unstable
living
PROGNOSIS No return to pre-morbid function, chronic, Return to pre-morbid function if cause is
depends on cause as is generally insidious correctable and is corrected in time. Generally
in onset acute onset
II. STAGES OF ALZHEIMERS:
1. Stage1: Mild (2-4yrs)
i. Recent memory loss, neologisms
ii. Cognitive loss in:
1. Communicating
2. Calculating
3. Recognition
iii. Anxiety and confusion
iv. Mild behavioural problems
2. Stage2: Moderate
i. Stage1 symptoms increase
ii. Behavioural probs increase and include:
1. Catastrophic rxs
2. Sundowning- behavioural disturbance in the morning or evening
3. Preservation-excessive repetition
4. Aimless pacing
5. Wandering
6. Incontinence
7. Hypertonia
3. Stage3: Severe:
i. Stage2 symptoms increase
ii. Total incontinence
iii. Choking
iv. Emaciation
v. Total care needed
vi. Progressive gait disturbance leading to non-ambulatory status
III. NSG DX:
1. Risk aspiration
2. Imbalanced body temp
3. Infection
4. Injury
5. Physical mobility
6. Anxiety
7. Impaired verbal communication
8. Chronic confusion
9. Grieving
IV. OUTCOME IDENTIFICATION:
1. Maintain health and safety with caregiver help
2. Reach and maintain highest fxn level possible within capacity
3. Maintain best possible physical status
4. Participate therapeutic activity program
5. Participate planning for care
V. INTERVENTION:
1. Inform all caregivers nsg plan
2. i.d client current fxnal; state and encourage use of skills
3. set up structured routines
4. allow client time alone
5. remain flexible with schedule
6. keep all interactions with client calm and reassuring
7. do not ask client participate ADLs when agitated
8. attempt understand feeing
9. respond clients feelings and validate them
10. help client maintain self-esteem by keeping interactions at adult level
11. simplify verbal messages and provide simple choices
CRISIS INTERVENTIONS/RAPE-TRAUMA:

I. Types crisis:
a. External (situational)- external stressor which is apparent to another observer. Centres on real
events threaten health, shelter, loss loved one.
b. Internal (subjective) crisis- internal stressor threatens well being ex. Aging, loss independence
c. Phase-of-life (maturational) crisis-
d. Disaster (adventitious crisis)- man-made and natural disasters ex. Terrorism, tornados
II. 5 steps Crisis interventions:
a. Assess the individual and the problem:
i. Assess the individual and the problem- in the field and in office (physical safety principles,
medical hx, introduction and boundaries, chief complaint, hx present illness, family/social
hx, mental status, past medical & psychiatric hx, drug & alcohol hx, cultural and spiritual
issues, strengths and support, coping skills, GAF etc
b. Plan therapeutic intervention:
i. Express caring and consolation
ii. Assess reality of situation
iii. Develop and begin to utilize an immediate plan for intervention
iv. Coordinate w/ other agencies
v. Anticipate future needs related to crisis
c. Intervention
d. Resolution of the crisis
e. Anticipatory planning
III. 10 stages acute traumatic stress
i. Assess for danger/safety
ii. Consider mechanism of injury
iii. Address medical needs
iv. Evaluate level of responsiveness
v. Observe and identify who exposed
vi. Ground the individual
vii. Normalize the response
viii. Prepare for the future

DOMESTIC VIOLENCE:

I. Risk factors domestic violence:


a. Social isolation
b. Control by the abusive person
c. Alcohol and other drugs
d. Intergenerational transmission
e. Legal marriage or pregnancy
f. An attempt to leave the relationship
II. Interview questions: ask in private only: ask “SAFE” Questions
a. Have you ever been emotionally or physically hurt by your partner or someone important to you?
b. Within the last year, have you been hit, slapped, kicked, or physically hurt by someone? By whom?
How many times?
c. Within the last year, has anyone forced you to have sexual activity? Who? How many times?
d. Are you afraid of your partner or anyone else?
III. Rape-trauma syndrome:
a. Acute Phase:
i. Occurs immediately after the assault
ii. May lst for a few weeks
iii. Lifestyle disorganized
iv. Somatic symptoms are common
v. Reaction in cognitive, affective and behavioural functions
b. Long-term reorganization phase:
i. Intrusive thoughts
ii. Increased motor activity
iii. Increased emotional lability
iv. Fears and phobias
IV. Violence Interventions:
a. Follow your institutions protocol for sexual assault
b. Do not leave the person alone
c. Maintain a non-judgemental attitude
d. Ensure confidentiality
e. Encourage the person to talk, listen empathetically
f. Emphasize that the person did the right thing to save his/her life
g. Keep accurate records:
i. Physical trauma
ii. Ask permission to take photos
iii. Take verbatim statements as to clients reaction to rape
iv. Document emotional status
h. Explain everything that you are going to do before hand
i. Obtain medicolegal specimens with clients written permission
j. Alert client as to what he/she may experience during the long-term reorganization phase
k. Arrange for support follow-up, for ex.:
i. Support groups
ii. Group therapy
iii. Individual therapy
iv. Crisis counselling
V. Long-term effects rape:
a. Depression
b. Suicide
c. Anxiety
d. Fear
e. Difficulties with daily functioning
f. Low self-esteem
g. Sexual dysfunction
h. Somatic complaints
MOOD DISORDERS:

A. Leading cause of disease burden


i. Types:
1. Major depression
2. Dysrhythmic disorder- chronic low-level depression
3. Bipolar disorder-pattern of manic, hypomania and depressed episodes
4. Cyclothymic disorders- chronic mood disturbance
b. Nsg process:
i. Assessment- mood, affect and temperament
1. Mental status criteria
a. Mood
b. Affect
c. Temperament
d. Emotion
e. Emotional reactivity
f. Emotional regulation
g. Range of affect
ii. Nsg DX:
1. Activity intolerance
2. Anxiety
3. Constipation etc. Box 11-5
iii. Interventions:
1. Conduct a suicide assessment
2. Maintain a safe environ
3. Establish a rapport and demonstrate respect
4. Assist client verbalize feelings
5. Identify clients social support system and encourage client
6. Praise the client for attempt
7. Promote self-care
8. Assist s at alternate activities and interactions with others
9. Gently refuse to be part of secrecy agreements with the client
10. Monitor and implement strategies to ensure adequate fluid intake and output, food
intake and weight
11. Refer p.235
c. Pharmacology:
i. SSRI’s- citalopram (celexa), fluoxetine (Prozac), paroxetine (paxil), sertraline (Zoloft),
venlafaxine (Effexor)
ii. Atypical antidepressants
iii. TCA- amitriptyline (elavil), clomipramine (anafranil), imipramine (tofranil), desipramine
(norpramin),
iv. MAOI- phenelzine(Nardil), Parnate
v. Mood stabilizers: lithium and anticonvulsants Tegretol and Depakote
SUICIDE:

I. Assessment:
a. The observable behaviour of client e.g increased irritation, increase in energy
b. Hx from the client- gathering self-defeating coping patterns
c. Information from friends and family-
d. Hx suicidal gestures or attempts
e. MSE-disturbance concentration, memory, orientation
f. Physical exam-signs substance abuse, irritability, euphoria, slurred speech
g. Nurse’s intuition
II. Interventions:
a. Provide safety and prevent violence: ex. Safe environment, remove all weapons
b. Assist with improvement of coping skills
c. Enhance family and support system

EATING DISORDERS:

Sign/Symptoms:

1. Anorexia: Bulimia Nervosa:


a. Self-starvation 1. Recurrent episodes binge eating
b. Rituals/compulsive behaviours 2. Purging behaviours: self-induced vomiting, use
regarding food laxatives, diuretics, diet pills, ipecac, enemas,
c. Self-induced vomiting, laxatives, exercise, periods fasting
diuretics, or excessive exercise 3. Purging
d. Weight loss 15% below ideal 4. Hypokalemia
e. Amenorrhea 5. Alkalosis
f. Slow pulse 6. Dehydration
g. Cachexia-muscle wasting 7. Idiopathic edema
h. Lanugo 8. Hypotension
i. Constipation 9. Cardiac arrhythmias
j. Cold sensitivity 10. Cardiomyopathy
k. Denial seriousness 11. Hypogycemia
l. Irrational fear gaining weight 12. Constipation
m. Preoccupation food 13. Esophageal reflux
n. Delayed psychosexual development 14. Mallory-weiss syndrome
15. Dental enamel ersosion
16. Paratid gland enlargement
17. gastroparesis

Outcomes anorexia: Outcomes Bulimia:


1. participate therapeutic contact staff 1. participate therapeutic contact staff
2. consume adequate calories 2. maintain normal fluid and electrolyte levels
3. achieve normal weight 3. consume adequate calories
4. maintain normal fluid and electrolyte balance 4. cease binge/purge episodes
5. resume normal menstrual cycle 5. demonstrate effective coping skills
6. demonstrate improvement body image 6. Demonstrate age-approp. Boundaries
7. demonstrate effective coping skills 7. Verbalize improved body awareness
8. manage family conflicts 8. Normal perception of body weight and shape
III. Complications:
a. Electrolyte imbalance
b. Cardiac arrhythmias
c. Cardiac arrest
d. Diabetes mellitus
e. hypertension
IV. Interventions:
a. Provide safety
b. Assess suicide
c. Engage therapeutic relationship
d. Restore min. Body weight and nutritional balance
e. Create structured, supportive environment, with limits
f. Coordinate with dietician
g. Encourage client express thought, feelings, concerns body image
h. Con’t help client recall positive eating exper.
i. Assume caring matter of fact approach
j. P.400 for rest

SCHIZOPHRENIA:

I. Neurobiologic brain disorder, results impaired thoughts, perceptions, cog. Fxn, mood and motivation
II. Signs/symptoms and course:
a. Premorbid: contributing factors
b. Prodromal: one mth to 1yr before diagnosis:
i. Mood-Anxiety, irritability, dysphoria
ii. Cognitive- distractibility, concentration difficulties, disorganized think
iii. Obsessive behaviours and rituals
iv. Sleep disturbance
v. Weak positive symptoms
c. Psychotic phase:
i. Acute phase- pos. And neg. symptoms, unable to perform self-care
ii. Maintenance phase- able to care for self
iii. Stable phase- remission
III. Types:
a. Paranoid
b. Disorganized
c. Catatonic
d. Residual
e. Undifferentiated
IV. Positive symptoms:
a. Alterations perceiving: hallucinations (false perceptions), delusions (false beliefs), loss ego
boundaries
b. Alterations thinking: concrete thinking, loose associations, flight of ideas, ideas of reference, ideas
persecution, ideas grandiosity, ideas being controlled, though broadcasting, thought insertion,
thought withdrawal
c. Alterations speech: neologisms, echolalia, clang assoc, word salad, circumstantiality, tangential
(superficial speech)
d. Alterations behaviour: bizarre behaviour, agitation, waxy flexibility, stupor, negativity,
echopraxia, symbolism
V. Negative symptoms:
a. Cognitive: Poverty of speech (alogia), Poverty of thought. Thought blocking, Problems with
attention, memory, Impaired decision making/judgement, problem solving, Disorganized think
b. Behavioural: anhedonia, anergia, avolition, depression, hopelessness, social isolation, decreased
spontaneity, anxiety, irritability, drug abuse. Medical comorbidity
VI. NSG DX: bassed on assessment pos and neg symptoms
VII. NSG interventions:
a. for the agitated:
i. safety
ii. reduce stimulation
iii. brief, concise statements
iv. det. stressors
v. redirect
vi. prevent agitation
b. for those in acute crisis: crisis intervention, stabilization, safety and limit setting
c. for those in maintenance and stable phase: give small amts infor, i.d signs of relapse
VIII. Psychopharmacology:
a. Typical antipsychotics, which block dopamine, phenothiazines: treat positive symptoms
i. Ex. Thorazine, Mellaril, Navane, Stelazine, Haldol and Prolixin
ii. SE: anticholinergic- dry eyes, mouth, constipation, sedation, orthostatic hypotension,
lowered seizure thresholds, jaundice, ESP (use antiparkinson drugs...cogentin, artane),
dystonica, neuroleptic malignant syndrome, tardive dyskineasia
b. Atypical antipsychotics- block serotonin and norepinephrine. Work on pos and neg symptoms.
Produce metabolic syndromes (so check weights)
i. Ex. Clozoril (monitor for agranulocytosis and WBC), seroquel (quetiapine), Risperdal
(risperidone), geodon (ziprasidone), abilify(aripiorazole)
EPS S.E: Neuroleptic malignant syndrome:
 Akathsia  Fever
 Akinesia  Muscle rigidity
 Dystonias  Altered consciousness
 Acute distonic rx  Rapid breathin
 Pseudo parkinsonism  Stupor-coma
 Tardive dyskinesia  Excessive salivation
 Neuroleptic malignant syndrome  Elevated CPK

SUBSTANCE ABUSE:

 Support groups: AA, NA, CA Al-Anon, Al-a-teen, Adult children of alcoholics, inpatient, outpatient,
hospitalization, intensive outpatient, halfway houses.
Withdrawal from alcohol: Withdrawal from stimulants: Withdrawal from CNS
 Irritability, anxiety, agitation  Headache depressants:
 Insomnia  Anxiety  Cravings
 Diaphoresis  Restlessness  Abdominal
 Tremors  Cravings cramps
 Delirium  dreaming  Diarrhea
 Seizures  Depression  Nausea and
 Possible death  Decreased BP vomiting
 Psychomotor retardation  Bone/muscle pain
 Muscle spasm
 Tremor
 Chills
 Diaphoresis

IX. Signs/symptoms:

CNS Depressants: CNS stimulants: Hallucinogens:


 Decreased inhibitions  Euphoria  Panic attack/anxiety
 Impaired judgement,  Feelings impending doom  Psychosis
attention, memory  Agitation or combativeness  Delirium
 Drowsiness  Hallucinations/paranoia  Altered moods
 Slurred speech  Seizures  flashbacks
 Unsteady gate  Cardiovascular events,
 Hypotension palpitations, tachycardia,
 Bradycardia  Hypertension, irregular
 Pinpoint pupils rhythms, can lead to infarct
 Weak rapid pulse
 Depressed respirations
 Can lead com/death

X. Meds for withdrawal:


Tx emergency CNS Tx acute overdose Tx CNS intoxication:
depressant: alcohol:  Treat cardiac
 Life support  ABC’s symptoms
 Narcan (naloxone)  Thiamine  Benzo’s for
 Lavage or dialysis  Nutritional agitation and
 Control seizures glucose seizures
with  Clonidine  Antipsychotics for
phenobarbitol (catapress) for GI hallucinations
Tx CNS depressants symptoms
withdrawal symptoms:  Benzo’s
 Opiod substitution Long-term tx:
 Methadone  Antabuse
(dolophine)  Naltrexone
 Buprenorphine  Zofran and
(subutex) topamax—
 Naltrexone (ReVia) decrease cravings
 Suboxone-used for as well
maintenance
XI. Classes of drugs of abuse:
a. Cannabis-weed, pt, hashish
b. CNS depressants: alcohol, sedatives, hypnotics, anxiolytics
c. CNS stimulants: amphetamines, caffeine, cocaine, ephedra, Benzedrine, nicotine
d. Hallucinogens- LSD, Peyote, PCP, mescaline
e. Inhalants- glue, hydrocarbons, nitrates
f. Anabolic-androgenic steroids
g. OTC-antihistamines, sleeping pills, herbals, laxatives
h. Club drugs- ecstasy, ghb, rhohipnol, ketamine, methamphetamines
XII. Interventions SA:
a. Maintain airway, monitor vitals
b. Maintain safety
c. Observe s/s overdose, withdrawal, drug-drug interactions
d. Assess physiologic/Psychologic symptoms withdrawal
e. Initiate interventions to treat withdrawal symptoms
f. Provide emotional support
g. Support nutrition/metabolic needs
h. Refer nutritionist
i. Increase carb intake, offer straws and edible things to chew on
j. Initiate vit/mineral replacement etc.

PERSONALITY DISORDERS:

I. In General PD:
a. Higher death rates
b. Higher rates suicide attempts
c. Increased rates separation, divorce and involvement legal proceedings
d. Increased rate criminal behaviour, alcoholism, and drug abuse
II. 4 common characteristics:
a. Inflexibility, maladaptive response stress
b. Disability in working and loving
c. Ability cause interpersonal conflict in others
d. Capacity to irritate others
III. 4 maladaptive patterns:
a. Faulty perceptions
b. Emotional lability
c. Poor impulse control
d. Difficult interpersonal functioning
IV. Characteristics:
a. Repetitive maladaptive behaviour
b. Behaviour not recognized as abnormal so don’t seek treatment
c. Ability achieve developmental tasks are limited
d. Seek help only in crisis
e. Starts in adolescence
f. Maladaptive behaviour used fulfill need and bring satisfaction
V. General interventions:
1. Asses suicide ideation
2. Implement suicide precautions—every 15min
3. Establish contract for safety
4. Encourage attendance all group sessions
5. Assess for escalating anger or rage
6. Contract not to harm staff or others
7. Teach manage anger and impulsive feelings and behaviours
8. Discuss angry and aggressive feelings
9. Assess client for evidence self-mutilation.
s/s antisocial Interventions: s/s borderline Interventions:
personality: 1. Prevent/decrease personality; 1. Set limits
1. Hx antisocial effects manipulation 1. Relationship with 2. Provide
behaviour 2. Guard against being others intense boundaries
2. Deceitful, liar manipulated and aunstable and limits that
3. Aggressive 3. Set clear and realistic 2. Poor impulse are clear and
towards limits behaviour control consistent
others 4. All limits must be 3. Recurrent 3. Consistent
4. Lack remorse adhered to by all staff suidical/self staff: asses for
hurting others 5. Carefully document mutilation suicide and
5. Presents as objective physical 4. Attention self mutilating
charming, self- signs of seeking/manipula behaviour
assured and manipulation/ tive
adept aggression 5. No boundaries
6. Interacts 6. Outbursts odd
others through anger and
manipulation, hostility
aggressiveness 7. Intense and
and primitive rage
exploitation 8. Rapid idealization
7. Lack empathy and devaluation
or concern
VI. Etiology/factors:
a. Lower socioeconomic status
b. Substance abuse
c. Genetics