Exam 2 Flashcards
(167 cards)
1
Q
Epidemiology of Psychotic Disorders
A
About 1% of the population
Same percent is found internationally and across cultures
75% of all mental health expenditures
High Rates of Suicides 9-13% successful, 50% attempt
Life Span is 10 years less than average
2
Q
Course of Psychotic Disorders
A
Onset in adolescence to early adulthood
Premorbid predictive factors: deficiencies in attention, poor coordination, lack of emotional warmth, high ratio of angry, sad, and fearful expressions to joyful ones.
3
Q
Phases of Psychotic Disorders
A
Prodromal-before any active illness
Active- florid psychosis
Residual- Impairment between active episodes
Never go back to prodromal after first episode
4
Q
Pathogenesis of Psychotic Disorders
A
Genetics, Perinatal insult, cognitive deficits, biology (Neuroanatomy, neurotransmission)
5
Q
Cognitive Deficits of Psychotic Disorders
A
Consistent with frontal and temporal lobe dysfunction, more predictive of outcome then symptom severity, independent of acute phase symptoms (stable), May present premorbidly, more pronounced in higher cognitive function
6
Q
Mild Cognitive Impairment
15th Percentile
A
Perceptual Skills
Confrontation naming
7
Q
Moderate Cognitive Impairment
5th Percentile
A
Delayed recall and immediate memory
Distracted with irrelevant information
Visual Motor Coordination
8
Q
Severe Cognitive Impairment
>1st Percentile
A
Serial Learning
Executive function
Verbal Fluency
Working Memory
9
Q
CATIE Study
A
Clinical Antipsychotic Trials in Intervention Effectiveness
Cognitive Impairment: Present in almost all persons with schizophrenia, associated with poor functional outcomes, predicts poor work performance, more predictive of dysfunction than positive or negative symptoms
10
Q
Dopaminergic Tracks in the Brain
Mesocortical
A
Negative Symptoms
Cognitive Deficits
Attention Deficits
11
Q
Dopaminergic Tracks in the Brain
Mesolimbic
A
Positive Symptoms (Hallucinations, delusions, disorganized speech, and bizarre behavior)
12
Q
Dopaminergic Tracks in the Brain
Turberoinfundibular
A
Endocrine function
Temp Control
Sexual Arousal
Circadian Rhythms
13
Q
Dopaminergic Tracks in the Brain
Nigrostriatal
A
EPS
Tardive Dyskinesia
NMS
14
Q
Serotonin and Schizophrenia
A
Has modulating effect on dopamine
SGAs are combination serotonin/dopamine blocking agents
15
Q
Glutamate and schizophrenia
A
Is the major excitatory neurotransmitter in the brain
Of the eight genes for schizophrenia, all go through the glutamate pathways
May be potential pathway to improve cognitive function
16
Q
DSM Criteria for Schizophrenia
A
Two of the following: Delusions, Hallucinations, Disorganized speech, grossly disorganized behavior, negative symptoms
Significant decrease in functioning over significant period of time
Six months continuous disturbance and at least one acute episode
Not a mood disorder or caused by drugs
not autism
17
Q
Prevalence of Psychotic Symptoms
A
Delusions 90%
Auditory Hallucinations 50%
Visual Hallucinations 15%
Tactile Hallucinations 5%
18
Q
Level One insight about hallucinations
A
Hallucinations of stopped and person has full understanding of their pathological nature
19
Q
Level Two Insight about Hallucinations
A
Hallucinations have stopped, but the person believes they were real
20
Q
Level Three Insight about Hallucinations
A
Patient understands a contradiction between reality and hallucinations, but is unable to resolve the contradiction and may choose to keep quiet
21
Q
Level Four Insight about Hallucinations
A
Patient talks about hallucinations as real, but does not act on them
22
Q
Level Five Insight about Hallucinations
A
Patient accepts the hallucinations as “real” and acts accordingly
23
Q
Formal Thought Disorders
A
Tangentiality Claging Echolalia Self-Reference Neologisms Word Approximations Derailment Incoherence Poverty of Content
24
Q
Positive Symptoms of Psychotic Disorders
A
Hallucinations Delusions Thought Disorder Ideas of Reference Agitation Violance
25
Negative Symptoms of Psychotic Disorders
```
Blunted affect
Alogia
Asociality
Anhedonia
Avolition
```
26
What is recovery-oriented treatment?
A process of restoring or developing a positive and meaningful sense of identity apart from one's condition and then rebuilding a life despite or within the limitations imposed by that condition
27
Principles of Recovery-Oriented Services
```
Primacy of participation
Access and engagement
Continuity of care
Strengths-based assessment
Individualized recovery planning
Recovery Guides
Community Mapping and development
Identifying and addressing barriers to recovery
```
28
First Generation Antipsychotics (FGAs)
```
All have similar action and efficacy
Act by blocking dopamine
Vary from high potency to low potency
High potency have greater risk for EPS
-Haldol, Navane
Low potency have greater risk of sedation and orthostatic hypotension
-Thorazine, Melleril, Compazine
```
29
Second Generation Antipsychotics (SGAs or Atypicals)
First line treatment
Vary more in action than FGAs
All act on D2 - Same as FGAs
But some also act on 5HT in meso-cortical track and may have effect on negative symptoms
Lower risk of EPS
Greater risk of weight gain and metabolic syndrome
30
Some findings of SGAs from the CATIE study
account for 90% of the antipsychotic market in the US, In 2005 cot 10.5 billion, appear to have no greater benefit than FGAs, No difference in EPS, 3600-6000 more costly, Risk of weight gain and metabolic syndrome, Risk for TD 1-1.5%
31
Side Effects of Antipsychotic Drugs
```
Movement problems (EPS)
Weight Gain
Sedation
Neuroleptic malignant syndrome
Agranulocytosis
Anti-cholinergic
CNS depression
Lower seizure threshold
Photosensitivity
Elevated prolactin levels
ECG Changes
Elevated LFTs
Sexual Dysfunction
Temp Dysregulation
```
32
Acute Dystonia
Involuntary sustained muscle contraction
- Torticollis
- Oculogyric Crisis
- Can be very frightening
- Appears early in treatment
- Treated with diphenhydramine
33
Akathisia
```
Motoric Reslessness
Subjective sense of tension/restlessness
Can be extremely uncomfortable
Appears early to mid-treatment
Difficult to treat
```
34
Parkinsonism
Muscle rigidity
Tremor
Bradykinesia
Robotic gait
35
Tardive Dyskinesia
```
Lip smacking
Choreathetoid movements of limbs/trunk
Appears late in treatment
Can be permanent
Difficult to treat
Severe social disability
Assessed with AIMS
```
36
Anticholinergic side effects
```
Dry Mouth (Dry as a bone)
Blurred vision (Blind as a bat)
Flushed (Hot as the sun)
Memory, concentration difficulties (Mad as a hatter)
Urinary retention
Constipation
```
37
Neuroleptic Malignant Syndrome
```
Autonomic Dysregulation
Delirium, progressing to lethargy, stupor, coma
Muscle breakdown with increased CK
Rigidity
Shuffling gait
Psychomotor agitation
Termor
Incontinence
Pallor
```
38
Neuroleptic Malignant Syndrome Symptoms
```
Excitement
Diaphoresis
Rigidity
Hyperthermia
Tachycardia
Hypertension
```
39
Primary Nursing Diagnosis for Psychotic disorders
```
Risk for self-harm and/or harm to others
Disturbed thought process
Disturbed sensory perception
Impaired verbal communication
Social Isolation or impaired social interaction
Self-care deficit
Ineffective role performance
Impaired memory
Anxiety
Nonadherance
```
40
Nursing Interventions for acute psychotic phase
Management of hallucinations and delusions
-antipsychotic medication
Therapeutic Milieu
-Safety, structure, support, symptom management
41
Definition of Personality
ingrained, enduring, and habitual ways of psychological functioning that characterizes one's style
Attitudes, perceptions, habits, emotions, and behaviors.
42
Traits
enduring characteristics and features of a person
Introverison vs. Extroversion
60% Inherited
43
States
Condition of mind or temperament
Moods, Habits
40% of our personality is learned
44
DSM Criteria of PD
```
Inner experience and behavior that deviates markedly from the expectations of an individuals culture
Cognitive Distortions
Affectively
Interpersonal functioning
Poor Impulse control
```
45
Cognitive Distortions
all things black or all things white
| Ways of perceiving and interpreting self, others, and events
46
Common themes of all personality disorders
```
Adaptive inflexibility
Vicious Cycles
Cluelessness
Pathological Problem-Solving
Intense transference/counter-transference reactions
```
47
Paranoid PD
| Odd/Eccentric Cluster A
A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts
Male
48
Paranoid PD Features
They are tense, suspicious, guarded, self-righteous, petty, and vengeful. The bear grudges and demonstrate overt acts of violence. They are controlling and easily angered. they suspect without sufficient basis that others out to exploit, harm or deceive them. Is reluctant to confide in others out of fear that the information will be used against them.
49
Schizoid PD
| Odd/Eccentric cluster A
A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts
Does not enjoy close relationships , chooses solitary activities, little interest in sexual experiences
Male
50
Schizoid Features
Social detachment. They have little or no desire to be with people and are typically content to live a routine, quiet life. They are self- absorbed. Lack close friends or confidants other than first-degree relatives. Shows emotional coldness, detachment or flattened affect. Almost always chooses solitary activities.
51
Schizotypal PD
| Odd/Eccentric Cluster A
A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in variety of contexts
No sex ratio
52
Schizotypal PD Features
They are peculiar, highly eccentric, often bizarre in thought, appearance or behavior. They may look schizophrenic but will not meet criteria. Odd beliefs or magical thinking that influences behavior and is inconsistent with cultural norms
(Superstitious beliefs, telepathic)
53
Antisocial PD
| Emotional/Impulsive/Erratic Cluster B
There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years
54
Antisocial PD Features
They are pervasively dishonest, manipulative, exploitative and disloyal. They lack a well developed superego and experience little or no guilt when they break rules, violate laws, and shatter the lives of others. They are capable of experiencing intense insecurity and anxiety and tend to project their insecurity and anxiety by raising it in others. They are constantly irresponsible, lack remorse, anger and aggressiveness problems. They lie and con others for their personal profit
Male
55
Borderline PD
| Emotional/Impulsive/Erratic Cluster B
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts
Female
56
Borderline PD Features
Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships characterized by alternating between idealization and devaluation. Impulsive. Chronic feelings of emptiness. Inappropriate, intense anger, or difficulty controlling anger. They crave intimacy buy sabotage relationships by childish, overly demanding, jealous, possessive and verbally and physically abusive. They have primitive defense mechanisms most notably splitting, projection, and denial, they tend to self mutilate and are at high risk for suicide
57
Histrionic PD
| Emotional/Impulsive/Erratic Cluster B
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood, uncomfortable if he/she is not the center of attention
Female
58
Histrionic PD Features
Is uncomfortable when she/he is not the center of attention. Uses physical appearance to draw attention to self. Shows self dramatization, theatrically, and exaggerated expressions. They demand constant reassurance and gratification. They have rapidly changing and shallow moods. They are vain individuals who are phobic about aging. They can be talented, quick witted, beautiful, and a must at any party. they are seductive and provocative. Superficial and stormy relationships; lively.
59
Narcissistic PD
| Emotional, Impulsive, Erratic Cluster B
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, beginning by early adulthood and present in a variety of contexts
Male
60
Narcissistic PD Features
They believe that they are superior to just about anybody on the planet. They demand constant adulation and special treatment from everywhere they go. They have fantasies of perfection, may be preoccupied with envy and have a need for power, wealth prestige and attention. They are sensitive to shame and embarrassment. If you work for them they will take credit for you success and blame you for their failures. They project blame onto people and circumstances outside themselves.
61
```
Avoidant PD
(Anxious, fearful Cluster C)
```
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and presents in a variety of context.
No Sex Ratio
62
Avoidant PD Features
They are painfully, pathologically, shy persons who long for human contact but fear being criticized or judged, they often experience fear or panic in social situations. Views self as socially inept, socially unappealing or inferior to others. Is reluctant to take risks or engage in new activities.
63
Dependent PD
| Anxious, fearful cluster C
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of seperation, beginning by early adulthood
Female
64
Dependent PD Features
They see themselves as inadequate and have pervasive feelings of low self esteem and insecurity. They overcompensate of their perceived shortcomings by encouraging others to develop a strong dependency on them for emotional nurturance. They are profoundly passive and content with being in the passenger seat. They have great difficulty making everyday decisions without excessive amount of advice and reassurance. They urgently seek another relationship as a source of care and support when a close relationship ends.
65
Obsessive Compulsive PD Features
All about order and structure. Perfectionist and inflexible. Focus on detail. Unable to express affection; overly cold and rigid. Crippling preoccupation with trivial things. Very controlling and attend to lists and schedules. They are riddled with free floating anxiety and tend to keep this at bay by creating meticulously ordered, efficient environment. Devoted to work. Hard working and self-critical. Does not believe work is ever good enough. Judges others harshly. demands perfection from others.
66
Obsessive Compulsive PD
| Anxious, fearful Cluster C
Male
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency beginning by early adulthood and present in variety of contexts
67
Cognitive Disorders
A group of conditions characterized by the disruption of thinking, memory, processing, and problem solving.
General classifications include delerium, dementia and depression
68
Delirium
It is a neuro-psychiatric syndrome also called acute confusional state or actue brain failure that is common among the medically ill and often is misdiagnosed as a psychiatric illness which can result in delay of appropriate medical intervention
69
DSM Criteria for Delirium
Disturbance of consciousness
A change in cognition with no pre-existing conditions
Occurs over a short period of time, and tends to fluctuate during the day
Evidence that this could be caused by a physiological issue
70
Risk Factors for Delirium
```
Sensory Impairment
Immobilization
Medications
Aging
Chronic Renal or Hepatic Disease
Sleep Deprivation
Environment
Metabolic Derangement
Medical Illness
Stroke, tumor, vasculitis, trauma, demetia
Major Surgery
```
71
Clinical Characteristics of Delirium
```
Develops acutely
Fluctuating level of consciousness
Reduced ability to maintain attention
Disorganized thinking
Psychomotor agitation
Language difficulties
Altered sleep-wake cycle
Speech disturbances
Memory Dysfunction
Perceptions altered
```
72
Epidemiology and Delirium
approximately 40% of hospitalized elderly pts >65 yo
approximately 50% of pts post-hip fracture
approximately 30% of pts in surgical intensive care units
approximately 20% of pts on general medical wards
approximately 15% of pts on general surgical wards
73
Etiology of Delirium
```
Post-op states
Intoxication or withdrawal
Endocrine dysfunctions
Liver failure
Renal Failure
Pulmonary disease with hypoxemia
CVD
CNS pathology
Deficiency States (Vitamins)
Systemic infections
Trauma to the brain
Dehydration
Hypoglycemia
Electrolyte imbalances
```
74
Delirium Drug Related Causes
Anticholinergic medications, which block cholinergic transmitters in the brain, are thought to be the primary drug-related causes
OTC "home remedies" because many have anticholinergic effects
```
Analgesics
Steroids
Sedatives
Anticonvulsants
Antiarrhythmics
Anti-HTN
Antidepressants
```
75
Assessing Delirium
Delirium is based on careful assessment/observation and history
Obtain baseline, mental status
If you suspect delirium use valid/reliable assessment tool:
-Confusion Assessment Method (CAM)= cognitive function, attentiveness, mental status
-Mini Mental Status Exam-MMSE
routinely monitor delirium in all patients
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CAM (Confusion Assessment Method)
Feature 1 (Acute onset and fluctuating course) + Feature 2 (Inattention) + either disorganized thinking or altered consciousness
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Mini Mental Status Exam
Used to measure cognitive impairment
| Maximum score is 30, normal = 24-30, mild 20-23, moderate= 10-19, severe= 9-0
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Assess --> Think --> Intervene
Assess and monitor using reliable assessment tool
Identify causes and risk factors
Early mobility, control environment, etc.
79
Dementia
Not a specific disease, it is a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain. People with dementia have significantly impaired intellectual functioning that interferes with normal activities and relationships. They also lose ability to solve problems and maintain emotional control. They may experience personality changes and behavioral problems. Memory loss is a common symptom
80
DSM Diagnostic Criteria for Dementia
Memory impairment and one of the following: aphasia, apraxia, agnosia, executive dysfunction
The cognitive deficits cause significant impairment in social or occupational functioning and represent a decline from previous functioning
Hippocampus is the primary area affected
81
Vascular Dementia (Multi-Infarct Dementia)
Results from a small series of strokes, or changes in brains blood supply. These interfere with the function of daily activities and cause memory problems and slurred speech. Not reversible and there is no cure.
82
Lewy Body Dementia
Irreversible form of dementia. Associated with abnormal protein deposits in the brain, called lewy bodies. Symptoms are similar to Alzheimer's disease. However, visual hallucinations are predominate and parkinsonian features.
83
Frontotemporal Dementia (FTD)
Rare form of dementia clinically similar to alzheimer's. Affects the frontal and temporal lobes. Accumulation of Tau Protein, which aggregates into tangles. Which disrupts cell process and leads to death. Present with personality changes, disinhibition, loss of judgement and language disturbances.
84
Korasakoff Syndrome
Is a memory disorder which is caused by deficiency of vitamin B1, also called thiamine. The most common cause is related to long term abuse of alcohol.
85
Creutzfeldt-Jakob Disease
An infectious organism (prion or "slow virus") is responsible for this disease, whose symptoms include memory and behavioral problems and a loss of coordination. The disease progresses rapidly along with progressive deterioration and death within a year.
86
Chronic and Irreversible Dementia
| "Alzheimer's Disease"
Progressive brain disease that slowly destroys memory and thinking skills.
RF: Age, family Hx, head injury, fewer years of education, down's syndrome, environment (cholesterol, alcohol, obestiy, post-menopause, diabetes, herpes, heart conditions)
87
The Hallmarks of Alzheimer's Disease
Neurofibrillary Tangles
| Amyloid Plaques
88
Genetic Theory of Alzheimer's
```
Early Onset
Mutations of chromosomes 1, 14, 21
-Rare early-onset familial forms of demetia
-Down's syndrome
Late Onset AD
Apolipoprotein E4 on chromosome 19
-APOE*4 allele increases risk
Offspring have a 50/50 chance of developing
```
89
Neurotransmitter theory of Alzheimer's
Acetycholine is decreased
| Necessary for cognitive function
90
Early Stages of Alzheimer's
Insight into losses and failures- patient complains about memory problems; forgets where objects are; forgets names of people; not bad enough to affect work or social interactions; can mimic age related changes; loss of initiative; mood/personality changes; poor judgement; takes longer to perform routine chores; trouble handling money and paying bills.
MMSE= 27-24
91
Intermediate stages of Alzheimer's
Earliest clear cut deficits appear and others notice the changes in functioning, problems with short term memory; may get lost in car; loses objects more often; experience word finding difficulty, concentration and reading may be affected; some anxiety and denial of symptoms and may withdrawal from complex tasks.
MMSE= 24-18
92
Moderate Stage of Alzheimer's
Forgets more personal information such as address, name of high school, can't calculate well; repetitive statements and or movements; restless, especially in late afternoon and at night; occasional motor twitches or jerking; confabulation; may be suspicious; irritable or silly; can toilet and eat without help but needs help with clothing choices; can be paranoid, obsessive and experience sleep pattern disturbances.
MMSE= 18-11
93
Late Stage of Alzheimer's
Little capacity for self care; cannot communicate with words; loses weight; impulsive/intrusive and may touch everything; wandering and forgets family members; unaware of recent events, personal history diurnal rhythm disturbances, sleep reversal
MMSE= <10
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Terminal Stage of Alzeimer's
Loss of ability to ambulate; loss of ability to sit; patient is incontinent, requires help with toileting and feeding and all adl's, patient may have problems swallowing; weight loss worsens; infections can occur and are frequently the cause of death
MMSE= <5
95
Cholinesterase Inhibitor
```
Treatment of Alzheimer's
Donepezil
-Can delay home placement and progression
-5mg qd to 10mg qd
-SE: N/V, Diarrhea, weight loss
Galantamie
-Slowing progression
-4mg bid to max 12mg bid
-Same side effect as donepezil
```
96
NMDA Receptor Antagonists
Treatment of Alzheimers
-Blocks Glutamate; too much can cause cell death
Memantine
-Indicated for moderate to severe
-Start 5mg-20mg qd
-SE: Dizziness, constipation, coughing, headache
97
Atypical Antipsychotics
Used to treat agitation, aggression, hallucinations, thought disturbances, and wandering
Includes abilify, zyprexa, seroquel, risperdal, and geodon
New found increased risk of death for patients with dementia related psychosis, doctors still prescribe there drugs for low-risk patients but they are not FDA approved
98
Typical Antipsychotics
Haldol is used to treat agitation, aggression, hallucinations, thought disturbances and wandering. "effective' however side effects such as anticholinergic effects, extrapyramidal symptoms and sedation can be a problem
RULE Start low and go slow
99
Nursing Strategies for Dementia and AD
Monitor effectiveness and side effects of meds, provide appropriate cognitive enhancement techniques, ensure adequate rest and sleep, ensure adequate nutrition, ensure adequate elimination, ensure therapeutic and safe environment
100
Provide therapeutic communication strategies for dementia
Always identify yourself and call the person by name. Use short simple words and phrases, maintain face to face contact, provide validation of feelings and encourage reminiscing of the past. listen and identify underlying feelings that are conveyed.
101
Validation techniques for dementia
Involve addressing the feelings of a person with dementia rather than focusing on the facts or accuracy of what the person is saying
102
Address behavioral issues for dementia
Identify environmental stressors/triggers. Redirection techniques can work wonders when other communication techniques are not helpful.
103
Depression in Older adults
Persistent sad, irritable mood >2 weeks, marking diminished interest or pleasure in normal activities, significant weight loss/gain, insomnia, or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, recurrent SI or SIB, reduced ability to concentrate
104
Risk factors of older adult depression
```
Female gender
Widowed or divorced
Medical illness
Functional disability
Family/personal history
Social isolation
Life events
Caregiving strain
```
105
Elderly Suicide
Males are more likely to complete suicide than females, one elderly suicide every 101 minutes. One of the leading causes of suicide is depression.
106
Traumatic Brain Injury
is a complex injury with a broad spectrum of symptoms and disabilities that can be disabling and can adversely impact quality of life.
107
TBI includes at least one of the following after head injury:
- Any period of loss of consciousness
- Any altercation in mental state at the time of the accident
- Focal Neurological deficits that may or may not be transient
- Any loss of memory for events immediately before or after the accident
108
Leading causes and risk factors of TBI
Leading Causes: motor vehicle accidents, violence, firearms, blasts
Risk factors: Males, Ages 0-4, 15-19, and elderly (>75), AA, Military duties
109
Mild TBI
A brain injury can be classified as mild is loss of consciousness and/or confusion and disorientation lasts less than 30 minutes. About 75% of all TBI's are mild. Concussion is interchangeably with mild TBI. Length of hospital stay less than 48 hours, no abnormalities on CT or MRI scan. Glascow coma scale 13-15
110
Moderate TBI
Moderate brain injury is related to loss of consciousness for more than 30 minutes and less than 24 hours. There may be amnesia for 1-7 days related to the injury. Brain imaging may or may not reveal abnormalities. Glasgow coma scale 9-12.
111
Severe TBI
Severe brain injury is associated with loss of consciousness for longer than 24 hours. There is often objective evidence of brain in jury on brain scans and neurological exams. The deficits range from impairment of higher cognitive functions to comatose states. Long-term sequelae include - limited function of arms and legs, abnormal speech/language, visual deficits, emotional problems, and seizures. Glasgow coma scale 3-8.
112
Who is at risk for TBI?
Operation enduring freedom and operation iraqi freedom veterans
113
What type of exposures may cause TBI?
Blasts (IED, RPG, Mortar)
Vehicle Accidents / Crashes
Falls
Bullet/fragment wounds above the shoulder
114
Closed head injury
Skull intact, brain not exposed
| Coup, contracoup on impact
115
Open Head Injury
Open head injury where skull and dura matter are penetrated by object
116
TBI Psyical Signs and Symptoms
Headache, N/V, sensitive to light/noise, visual problems, fatigue, dazed, stunned, dizzy, balance issues.
117
TBI Cognitive S/Sx
Feeling mentally foggy, feeling slowed down, answers questions slowly, difficulty concentrating, forgetful of recent events, repeats questions, drop academic performance
118
TBI Emotional S/Sx
```
Irritability
Sadness/Depression
Personality change
Anxiety panic
More emotional
Less emotion
```
119
TBI Sleep S/Sx
Drowsy, sleeping more, sleeping less, difficulty falling asleep or staying asleep
120
Commonalities between PSTD and TBI
Irritability, Cognitive deficits, insomnia, depression, fatigue, anxiety
121
Recovery from Mild TBI
1st week - 90% or more endorse post concussive symptom
1 month = 50% fully recovered
3 months= 66% fully recovered
6-12 motnhs= 10% still symptomatic
Those who remain symptomatic at 12 months are likely to continue experiencing post concussive symptoms thereafter
122
Recovery from Moderate to Severe TBI
About 35-60% of persons with moderate to severe TBI will develop chronic neurobehavioral issues : impulsivity, agitation, social dis-inhibition, verbal/physical aggression and/or physical symptoms
123
What can nurses do to help TBI?
```
Screen for TBI
Education to veterans and families
Treatment of symptoms and co-morbidities
Referrals to other specialists as needed
Referral to polytrauma program
TBI Pilot program and community partners
```
124
The psychiatric Interview of children and adolescents
Sources of information: accurate assessment of the child requires gathering information from a variety of sources to obtain a picture of the child's functioning over time and in a variety of settings.
These include the parents, school, juvenile justice system, other agencies, cases works, records from pediatrician
Developmental history= go back to pregnancy, any complications during pregnancy, did they meet their developmental milestones
School Functioning
Family relationships
125
Special considerations in the evaluation of children and adolescents
Physical development = signs of maltreatment, abuse, neglect
Medical history
Mental status exam
Interviewing techniques
-Preschool aged: used prompts, books, drawings, puppets
-School aged: can articulate thoughts and feelings, ask about home life
126
ADHD
A neurobehavioral disorder of childhood. It is usually first diagnosed in childhood and often lasts into adulthood. Children with ADHD have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the results will be), and in some cases, are overly active.
127
DSM Criteria for ADHD
1) Symptoms of inattention or 2) symptoms of impulsivity-hyperactivity, or 3) both
Onset <7 years of age
Developmentally inappropriate
Cause of impairment in 2 or more settings
Cause significant impairment in social, academic or occupational functioning.
128
DSM Inattention symptoms for ADHD
| Has to have 6 of the 9
Inattention symptoms: fails to give close attention to details or make careless mistakes in schoolwork, work, etc., difficulty sustaining attention, does not seem to listen when spoken to directly, does not follow through on instructions and fails to finish schoolwork, chores, etc, difficulty organizing, avoids tasks requiring sustained mental effort, Loses things, easily distracted, forgetful
129
DSM hyperactivity-impulsivity symptoms for ADHD
| Has to have at least 6
Difficulty playing or engaging in activities quietly, always "on the go", talks excessively, blurts out answers, difficulty waiting in lines or awaiting turn, interrupts or intrudes on others, runs about or climbs inappropriately, fidgets with hands, feet, or squirms, leaves seat in class
130
Prevalence of ADHD
```
Continues to increase
Boys more likely than girls
Average diagnosed at 7yo
varies but state- MI 10th highest state
Most prevalent in AA children, then white, then latino
```
131
Comorbid Conditions with ADHD
```
Oppositional defiant disorder
Language disorders
Anxiety disorders
Learning difficulties
Mood disorders
Confuct disorders
Smoking
Substance use disorder
```
132
Research on ADHD
Results from a chemical imbalance or deficiency in neurotransmitters which regulate behavior
10-15% from a prenatal injury
3-5% from post natal injury
Linked to specific brain regions: frontal lobe, basal ganglia, cerebellum
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Genetics and ADHD
10-35% of the immediate family members of children with ADHD are likely to have this disorder, risk for siblings is 32%, if a parent has ADHD 57% chance the child will
Genetic forms of ADHD are associated with abnormalities at the dopamine re-uptake transporter gene and the DRD4 receptor gene
Strongly suggests a hereditary basis for this condition
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Neurotransmitter and ADHD
Dopamine and Norepinephrine have the best documented roles in attention, concentration, and associated cognitive functions such as learning and motivation.
Patients with ADHD have low levels of dopamine and/or norepinephrine
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Norepinephrine
Responsible for sustaining and focusing attention, mediating energy, motivation and interest
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Dopamine
Mediates cognitive functions such as verbal fluency, learning, executive functioning, sustaining, and focusing attention, and modulating behavior based on social cues.
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Psychosocial Treatment of ADHD
Modification of classroom environment, psychoeducation for patient and family members (support groups, coaching), Psychosocial/behavioral interventions, pharmacotherapy (stimulants, nonstimulants)
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Methylphenidate Products
| ADHD Medication
Ritalin, Ritalin LA, Concerta, Daytrana patch
| Expected pharmacological action- increases dopamine by blocking reuptake
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Sides effects of methylphenidate products
CNS stimulation, insomnia, restlessness, advice client to take medication in morning, unwanted weight loss/growth retardation, monitor clients weight, promote good nurition, cardiovascular effects (dysrhythmia, chest pain, high blood pressure) may increase the risk of sudden death in clients with heart problems
Monitor vital signs
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Amphetamine Products
| ADHD Medication
Adderall, Adderall XR, Vyvance
| Blocks dopamine reuptake and increases production of dopamine and norepinephrine
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Sides effects of Amphetamine products
(Same as methylphenidate) CNS stimulation, insomnia, restlessness, advice client to take medication in morning, unwanted weight loss/growth retardation, monitor clients weight, promote good nurition, cardiovascular effects (dysrhythmia, chest pain, high blood pressure) may increase the risk of sudden death in clients with heart problems
Monitor vital signs
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NonStimulant Products
| ADHD Medication
Atomoxetine
| Norepinephrine reuptake inhibitor, increases norepinephrine
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Side effects of Nonstimulant products
GI upset, mood swings, insomnia, weight loss and growth
Advise client to take medication in the morning, dosage may be reduced
Unwanted weight loss/growth retardation
Monitor weight, promote good nutrition, administer with meals
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Conduct Disorder DSM Criteria
A repetitive and persistent pattern of behavior in which either the basic rights of others or major age appropriate societal norms or rules are violated, resulting in a clinical significant impairment of functioning. For 12+ months. Shown by 3 or more of the following: frequent bullying, often starts fights, used a weapon that could have caused serious injury, physical cruelty to people/animals, theft with confrontation, forced sex upon another
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Etiology of conduct disorder
Exact cause is unknown
may have co-morbidity illness such as ADHD or depression
Brain damage
Child abuse
Genetic vulnerability
Trauma
Environmental factors such as lack of supervision or discipline, frequent changing of caregivers, parental rejection and neglect, etc.
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Treatment of Conduct Disorder
Family therapy, peer group therapy, medication, cognitive behavioral approaches, structural environments
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Prognosis of Conduct Disorder
antisocial personality disorder in adulthood is likely
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Anorexia Nervosa
Self starvation and excessive weight loss, the refusal to maintain minimally normal weight, extreme fear of gaining weight, distorted perception of body shape, feeling fat or overweight despite weight loss, amenorrhea
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Bulimia Nervosa
Characterized by a secretive cycle of binge eating followed by purging. Bulimia includes eating a large amount of food - more than most people would eat in one meal - in a short period of time, and then getting rid of the food and calories through vomiting, laxative abuse, or over-exercising.
Feeling out of control while eating, close to normal weight maintained
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Common behaviors associated with anorexia
Eat only "safe" good, usually those low in calories and fat, have odd rituals such as cutting food into small pieces and excessively chewing, spend more time playing with food than eating it, cook meals for others without eating, compulsive exercising, dramatic weight loss, dress in layers, denies there is problem, anxiety about gaining weight, consistent excuses to avoid mealtimes or situations involving food, preoccupation with weight, good, fat grams, and dieting, denial of hunger, spend less time with family/friends become isolated
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Complications due to anorexia nervosa
Bradycardia, hypotension, arrhythmias, hypokalemia, hypocalcemia, dehydration, amenorrhea, lanugo, dry skin, hair loss, hypoglycemia, hypothermia, edema, constipation, osteoporosis
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Genetics and Anorexia
Family studies have shown that first-degree relatives have a 6-10 times greater risk of developing AN than relatives of healthy controls.
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Hypothalamus and Anorexia
Key center for regulating hunger, dysregulation can cause hyposecretion of various hormones
- Low FSH and LH are responsible for menstrution, cause amenorrhea
- Low growth hormone results in stunted growth and osteoporosis
- Low thyroid stimulating hormone results in decreased energy and coldness
- Low cortical releasing hormone results in fatigue and depression
- Low leptin levels - this triggers the hypothalamus to stimulate appetite, low levels in anorexia and bullimia
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Neurotransmitters and Anorexia
Serotonin- Dysregulation of serotonin pathways
| Dopamine- Increased activity has been implicated in food repulsion, hyperactivity, weight loss, amenorrhea, and OCD
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Psychological Vulnerabilities and Anorexia
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Cognitive Features
-Misperception of body image
- Rigid all or nothing thinking
-Obsessive compulsive thoughts and rituals
-Perfectionism
-Difficulty expressing emotions
Control Issues
Family Issues
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Bulimia Nervosa and Epidemiology
About 4-20% of females
0.1-0.2% of males
Appears during late teens to mid-20s
Some estimates of up to 40% college women have tried purging
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Biological Factors of Bulimia
Serotonin- binging behavior is consistent with reduced serotonin function
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Psychological Factors of Bulimia
Control Issues = Out of control, hiding, self-esteem
Sexual Abuse
Neglect by family
Learned response to stress
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Common behaviors of Bulimia
Recurrent episodes of uncontrollable binge eating, become very secretive about food, spend a lot of time thinking about and planning next binge, takes repeated trips to bathroom, particularly after eating, steal food or hoard it in strange places, engage in compulsive exercising, abuse laxative and diuretics, anxiety escalates before eating
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Complications of Bulimia
Bradycardia, Arrythmias, hypokalemia, hypocalcemia, dehydration, irregular menses, Hoarseness, dental caries, enlarged parotid glands, tears in esophagus, hyponatremia, constipation, calluses on back of hands and knuckles from self-inducing vomiting
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Treatment of Eating Disorders
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Inpatient hospitalization
Nutrition Therapy=Education
Cognitive Therapy
Group Therapy
Family Therapy
Pharmacologic
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Eating disorder nursing diagnosis
Risk for injury related to electrolyte imbalance, imbalanced nutrition, anxiety, ineffective denial, decreased cardiac output, disturbed body image, chronic low self-esteem, ineffective coping
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Nursing interventions Eating Disorder
Monitor caloric intake, observe vital signs, EKG, BUN, Electrolytes, Creatinine, CBC, TSH, monitor activity, weigh daily with back to scale, lock bathroom door 1 hour after eating, do not allow patients to bargain with food, provide adequate nutrition and weight gain, encourage to verbalize thoughts and feelings, focus on control issues
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Eating Disorder Recovery Rates
50-70% recover, 20% partially recover, 10-20% develop chronic anorexia
60% had good outcome
29% had intermediate outcome
10% had poor outcome
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Low risk for suicide
No serious problems at school/home, took 5 ibuprofen after argument with girlfriend, impulsive, told mom 15 minutes after taking pills, occasionally feels down, no depression history, wants help resolving problems and is no longer considering suicide after interview
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Moderate Risk for Suicide
Wants to "get back" at parents, SI precipitated by recurrent fighting with parents and failing grades in school, current symptoms of depression for the last 2 months, difficulty controlling temper, binge drinking during weekends, cut wrists, called friend 30 minutes later
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High Risk for Suicide
Wants to be dead, sees no purpose in life, has a plan, access to firearm or pills, significant life stressors, history of prior attempts, hospitalized in the past, thrown out of house, marijuana daily, abuses alcohol, genetics
