Exam 3 Flashcards
(163 cards)
1
Q
Autonomy
A
Respecting the rights of others to make their own decisions (e.g., acknowledging the patient’s right to refuse medication supports autonomy).
2
Q
Beneficence
A
The duty to act to benefit or promote the health and well-being of others (e.g., spending extra time to help calm an anxious patient).
3
Q
Justice
A
The duty to distribute resources or care equally, regardless of personal attributes (e.g., an intensive care unit [ICU] nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain aneurysm).
4
Q
Fidelity
A
Maintaining loyalty and commitment to the patient and doing no wrong to the patient (e.g., maintaining expertise in nursing skill through continuing nurse education).
5
Q
Veracity
A
The duty to communicate truthfully (e.g., describing the purpose and side effects of psychotropic medications in a truthful and non-misleading way)
6
Q
4 fundamental guidelines for MH Hospitalization
A
o Neither voluntary nor involuntary determines patient’s ability to make informed decisions about personal healthcare.
o Mental illness present
o The illness and its symptoms will result in an immediate crisis situation and other less-restrictive alternatives (i.e., outpatient care) are inadequate or unavailable.
o There is a reasonable expectation that the hospitalization and treatment will improve the presenting problems
7
Q
Nonmaleficence
A
Doing no harm to the patient (e.g., protecting confidential information about a patient)
8
Q
Voluntary Admissions
How to be admitted?
How to be released?
A
-apply in writing for admission
-individual can leave AMA (reevaluation can be done and make admission involuntary though)
9
Q
Involuntary Admissions 4 criteria
A
- Diagnosed with mental illness
- Danger to self or others
- Gravely disabled (unable to provide for basic necessities)
- In need of treatment and mental illness itself prevents voluntary help-seeking
10
Q
Two arguments patients can make to be released from involuntary commitment
A
i. Writ of habeas corpus: “formal written order” to “free the person; the procedural mechanism used to challenge unlawful detention by the government; hospital immediately submits to court and court decides
ii. Least restrictive alternative doctrine: mandates that care take the least drastic action to achieve a specific purpose i.e outpatient less restrictive than inpatient
11
Q
Involuntary admission process (5)
A
- Usually someone close to patient makes call to HCP, police, or mental health facility
- Formal application for admission is initiated
- Two physicians or combo of mental health professionals must certify that patient’s mental health status justifies detention and treatment
- Patient can get legal counsel and go to judge if they disagrees( arguments include writ of habeas corpus or least restrictive alternative doctrine)
- If not released by judge, patient can be kept 72 hours with formal hearing (For 3 days, patient gets basic care and learns about need for treatment)
12
Q
Emergency Commitment
Who is it used for? (2)
What is the primary purpose?
Length?
A
o Used for people who 1) are so confused they cannot make decisions on their own or (2) are so ill they need emergency admission
Primary purpose: observation, diagnosis, and treatment of patients who have mental illness or pose a danger to themselves or others
Length: 24 to 96 hours depending on the state. A court hearing is held and a decision is made for discharge, voluntary admission, or involuntary commitment.
13
Q
Unconditional release for Voluntary admission
What is it?
What if provider disagrees?
A
termination of legal patient-institution relationship by patient or provider
If provider disagrees, patient may be held 72 hours for involuntary admission or released AMA (against medical advice)
14
Q
Conditional release
What does it require?
What 3 things are evaluated during the time?
How does it differ for voluntary vs involuntary admitted?
A
requires outpatient for specified period of time
During time, individual evaluated for follow-through on medication regimen, ability to meet basic needs, and ability to reintegrate into community
o Voluntary admitted who are conditionally released cannot be readmitted without involuntary commitment process
o Involuntarily admitted who are conditionally released can be readmitted involuntarily based on original order
15
Q
Assisted outpatient treatment
What is it?
Who is it used for? (4)
How does it work?
Result of nonadherence?
A
court-ordered outpatient treatment; may occur post-discharge or straight from community to reduce or prevent relapse
- Used for those with hx of repeated hospitalizations, arrested for treatment nonadherence, Unlikely to participate in outpatient treatment and need treatment to prevent relapse; threat to self or others if relapse happens
-It is usually tied toward receipt of social welfare goods (disability benefits and housing) to improve adherence
-Nonadherence may lead to inpatient admission
16
Q
6 patient rights in MH setting
A
- Right to treatment (most fundamental; right to quality care)
- Right to refuse treatment (even if involuntarily committed)
- Right to Informed Consent
- Rights of Psychiatric Advance Directives
- Rights on Restraints and Seclusion
- Right to Confidentiality
17
Q
AMA discharge
When done?
What must patient do?
Why is it an ethical dilemma?
A
AMA release is if treatment seems beneficial but there is no compelling reason to seek an involuntary continuance of stay
Patient must sign a form indicating that they are leaving AMA. This form becomes part of the patient’s permanent record.
AMA is ethical dilemma because patient autonomy and right to refuse treatment clash with beneficence to protect patient
18
Q
5 rights under right to treatment
A
i. The right to be free from excessive or unnecessary medication
ii. The right to privacy and dignity
iii. The right to the least restrictive environment
iv. The right to an attorney, clergy, and private care providers
v. The right to not be subjected to lobotomies, electroconvulsive treatments, and other treatments without fully informed consent
19
Q
Right to refuse Psychopharmacological drugs
How does it work in emergencies?
How does it work in nonemergencies? (5 criteria)
A
i. In an emergency where harm to self or others may occur, institution can medicate person without a court order
ii. In nonemergencies, after a court hearing, person can be medicated if all the following are met:
1.Patient has serious mental illness
2. The person’s functioning is deteriorating and if the person is suffering or exhibiting threatening behavior
3. The benefits of treatment outweigh the harm
4. The person lacks the capacity to make a reasoned decision about the treatment
5. Less-restrictive services have been found inadequate
20
Q
Informed Consent
What is it?
What does it require of the patient?
When is it needed?
What is nurse’s role?
A
it is when person has been provided basic info on problem, purpose of treatment, risks, benefits, alternatives to treatment; likelihood of success before accepting to do a procedure
- Requires patient to have capacity and competence to voluntarily accept
- Generally needed for surgery, ECT, and use of experimental drugs or procedures; may be required for all medications in some facilities (the more intrusive or risky the procedure; the greater need for informed consent)
- Nurse role is to provide education and witness signature; provider gets consent
21
Q
Capacity
What is it?
When does it change?
Who decides if person has capacity?
A
Capacity: person’s ability to make an informed decision
- Fluid and can change rapidly
- Mental health providers may provide opinions about capacity.
22
Q
Competency
What is it?
When does it change?
Who decides if person has competency?
If someone is incompetent, who makes their decisions?
A
Competency: legal term related to the degree of mental soundness a person has to make decisions or to carry out specific acts
a. Competent until they have been declared incompetent
b. If found incompetent through formal legal proceeding, patient may be appointed a legal guardian or representative who is responsible for giving or refusing consent for the patient while always considering the patient’s wishes.
i. Order of selection usually (1) spouse or partner, (2) adult children or grandchildren, (3) parents, (4) adult siblings, and (5) adult nieces and nephews -> court-appointed person if no one available
23
Q
Psychiatric Advance Directives
What are they? When are they prepared?
6 things they may include
A
a way for patients with episode of severe mental illness to express treatment preferences; prepared while individual is well and identifies in detail their wishes and treatment choices
i. Designation of preferred physician and therapists
ii. Appointment of someone to make mental health treatment decisions
iii. Preferences regarding medications to take or not take
iv. Consent or lack of consent for ECT, medications, admission to MH hospital
v. Preferred facilities and unacceptable facilities
vi. Individuals who should not visit
24
Q
Restraints
Definition
What to assess before restraints?
A
any mechanical or physical device that reduces movement of patient including side rails and holding
-assess for physical origins of violence such as drug interactions and side effects; temp elevation, hypoglycemia, hypoxia, electrolyte imbalances which can all cause behavioral disturbances
25
Seclusion
What is it?
What does it not include?
Who is it for?
confinement alone or in an area and preventing from leaving including if unlocked door but make threats about what happens if they leave
1. Physical restraint in public room is not seclusion
2. Reserved for violent, self-destructive
26
Timeout
is not seclusion; this is when patient chooses or accepts a suggestion to spend time alone in specific area for certain amount of time; can leave at any time
27
Chemical Restraints (and how do they compare to mechanical restraints)
medications or doses of medication not used for patient's condition
Less restrictive than physical or mechanical but can impact patient’s ability to relate to environment
28
Restraints and least restrictive doctrine
5 less restrictive alternatives
What does CMS say about restraints in emergencies
i. In emergencies, CNS says less restrictive do not have to be used but need to be considered ineffective
ii. Least restrictive alternatives
1. Verbal intervention
2. Reducing stimulation
3. Actively listening
4. Providing diversion
5. Offering PRN medications
29
Documentation for Restraints and Seclusion (3 things included)
a. specific behaviors and mental state leading to restraint or seclusion
b. time the patient is placed in and released from restraint
c. 15–30-minute assessments for physical needs, safety (including protection from harm), and comfort
30
Orders for restraints and seclusion (4 notes)
- no PRN or standing orders for restraints
- renew every 4 hours (adults) for total of 24 hour (2 hours for children over 9-17; 1 hour for children under 9)
- After 24 hours, provider personally assesses the patient
- Restraint or seclusion is discontinued as soon as safer and calmer behavior begins and new order is required to reinstitute the intervention.
31
Confidentiality and Nurse-patient (3 tidbits)
- only patient can waive confidentiality (even in death)
- avoid conversations about patients in public places
- nurse does not have patient-nurse confidentiality like psychiatrists and attorneys (nurses must answer to the court)
32
4 exceptions to patient confidentiality (and what does failure to report lead to ?)
- Duty to warn (obligation to warn 3rd parties if they may be in danger from patient)
- Duty to protect (required to call and warn intended victim, victim family, or police to take necessary steps under the circumstances)- must assess and predict patient's level of danger and identify who they are threatening
- Child Abuse (all nurses are mandatory reporters; some states allow anonymous reporting)
- Older Adult and Dependent/Disabled Adult Abuse (required by most states to report)
Failure to report suspected abuse, neglect, or exploitation may result in misdemeanor
33
7 interventions for seclusions and restraints
o Staff in constant (do not leave patient alone)
o Monitor vital signs
o Assess range of movement
o Observe blood flow in hands/feet
o Observe that restraint is not rubbing
o Provide for nutrition, hydration, and elimination
o Continuously assess the need seclusion or restraint
34
Negligence
most common unintentional tort involving failure to use ordinary care in any professional or personal situation when there is duty to do so
35
5 elements to prove malpractice (and what each entails)
- Duty of care established (nurse represents self as capable of caring for psychiatric patient and accepts employment)
- Breach of duty (nursing performance below standard of care which exposes patient to unreasonable risk of harm; can be commission or omission)
- Cause in Fact (Actual cause aka if nurse did not do what they did, would injury have occurred?)
- Proximate cause (Legal cause aka determined by whether event was foreseeable; If average reasonable nurse could foresee injury that would result from action or inaction, injury was foreseeable)
- Damages (Pain and suffering; Actual damages (loss of earning, medical expenses, property damage); Incidental damage (deprivation of benefits like normal relationships)
36
Delirium
What is it?
6 cardinal symptoms
progressive and reversible acute cognitive disturbance with an underlying physiological cause that impairs lower-level cognition and can lead to permanent cognitive decline if not addressed
- impaired attention (inability to direct, focus, sustain, or shift)
- abrupt onset with fluctuating periods of lucidity and disorganized thinking
- disorientation (to time and place; not usually person)
- anxiety, agitation
- poor memory
- altered perceptions (visual hallucinations and illusions; delusions)
37
Delirium
Onset
Causes/ Contributing Factors
Cognition (4)
Activity level (4)
Emotional state
Speech and language (4)
Prognosis
Onset: sudden and fluctuates throughout day
Causes/ Contributing Factors: underlying medical condition (UTI, substances, medications)
Cognition: impaired attention, memory deficit, disorientation, perceptual disturbances
Activity level: increased or decreased; restless; sundowning; reversed sleep-wake cycle
Emotional state: rapid swings (fearful, anxious, suspicious, aggressive; hallucinate or delusions)
Speech and language: rapid, inappropriate, incoherent, rambling
Prognosis: reversible with proper treatment
38
Dementia
Onset
Causes/ Contributing Factors (5)
Cognition (6)
Onset: slowly over months and years
Causes/ Contributing Factors: Alzheimer's; vascular disease; HIV, chronic alcoholism; head trauma
Cognition: impaired memory, judgment, calculations, attention, abstract thinking, agnosia (inability to recognize things)
39
Dementia
Activity level (2)
Emotional state (2)
Speech and language (5)
Prognosis
Activity level: not altered; may have sundowning
Emotional state: flat (unresponsive in severe); agitation
Speech and language: incoherent, slow (difficulty finding the right word), inappropriate, rambling, repititious
Prognosis: not reversible; progressive
40
Depression
Onset
Causes/ Contributing Factors (5)
Cognition (3)
Activity level (3)
Emotional state (5)
Speech and language (3)
Prognosis
Onset: gradual with exacerbation during crisis or stress
Causes/ Contributing Factors: losses, loneliness, crisis, declining health, lifelong history
Cognition: difficulty concentrating, forgetfulness, inattention
Activity level: decreased (fatigue, lethargy); lack of motivation; poor sleep
Emotional state: extreme sadness, apathy, irritability, anxiety, paranoid ideation
Speech and language: slow, flat, low
Prognosis: reversible with proper treatment
41
Normal Aging vs Dementia
Normal Aging: Slight Forgetfulness (i.e sometimes forgetting names or appointments, but remembering them later)
What is the Alzheimer's symptom?
Memory loss that disrupts daily life
42
Normal Aging vs Dementia
Normal Aging: Making occasional errors when balancing a checkbook
What is the Alzheimer's symptom?
Challenges in planning or solving problems
43
Normal Aging vs Dementia
Normal Aging: Occasionally needing help to use the settings on a microwave or to record a television show
What is the Alzheimer's symptom?
Difficulty completing familiar tasks
44
Normal Aging vs Dementia
Normal Aging: Forgetting the day of the week but figuring it out later
What is the Alzheimer's symtom?
Confusion with time or place
45
Normal Aging vs Dementia
Normal Aging: Trouble understanding visual images or spatial relationships
What is the Alzheimer's symtom?
Vision changes related to cataracts
46
Normal Aging vs Dementia
Normal Aging: Sometimes having difficulty finding the correct word
What is the Alzheimer's symptom?
New problems with words in speaking or writing
47
Normal Aging vs Dementia
Normal Aging: Misplacing things from time to time and retracing steps to find them
What is the Alzheimer's symptom?
Misplacing things and losing the ability to retrace steps
48
Normal Aging vs Dementia
Normal Aging: Making a bad decision once in a while
What is the Alzheimer's symptom?
Decreased or poor judgment
49
Normal Aging vs Dementia
Normal Aging: Sometimes feeling weary of work, family, and social obligations
What is the Alzheimer's symptom?
Withdrawal from social and work activities
50
Normal Aging vs Dementia
Normal Aging: Developing specific ways of doing things and becoming irritable when routine is disrupted
What is the Alzheimer's symptom?
Changes in mood and personality
51
Mild Alzheimer's 8 hallmark symptoms
* Difficulties retrieving correct words or names
* Trouble remembering recent conversations, material just read (family may notice memory lapses)
* Challenges in performing tasks in social or work settings (still able to work)
* Losing or misplacing a valuable object
* Increasing trouble with planning or organizing
* Apathy
* Depression
* Personality is intact
52
Moderate Alzheimer's 8 hallmark symptoms
* Forget events or their personal history i.e be unable to recall their own address or telephone number or the high school/college from which they graduated
* Agnosia
* Behavior changes i.e become moody or withdrawn, especially in socially or mentally challenging situations
* Disorientation (confused about place and time)
* Need for help choosing proper clothing for the season or the occasion
* Wandering
* Change sleep patterns (may sleep during the day and becoming restless at night
* Paranoiac, agitated, and delusional or compulsive, for example, repetitive behavior like hand wringing
53
Severe Alzheimer's 6 hallmark symptoms
* Require full-time, around-the-clock assistance with daily activities and personal care
* Lose awareness of recent experiences and of their surrounding
* Apraxia so they need repeated instructions and directions for simple tasks
* Experience changes in physical abilities, including urinary incontinence ability to walk, sit, and eventually swallow,
* Have increasing difficulty communicating and speaking (difficulty responding to environment)
* Become vulnerable to infections, especially pneumonia
54
Alzheimer's and Symptoms
Confabulation (2)
Preservation
Agraphia
Confabulation: unconscious mechanism to protect ego involves creation of stories or answers in place of actual memories to maintain self-esteem; not lying b-c it is unconscious
Preservation: persistent repetition of word, phrase or gesture that continues after the original stimulus has stopped i.e repeatedly saying hello
Agraphia: early AD; diminished ability and eventual inability to read or write
55
Alzheimer's and Symptoms
Aphasia
Apraxia
Agnosia
Aphasia: the loss of language ability; from difficulty finding right word to few words to babbling or mutism
Apraxia: loss of purposeful movement in the absence of motor or sensory impairment which results in the inability to perform familiar and purposeful tasks.
-For example, in apraxia of dressing, the person is unable to put clothes on properly (e.g., putting arms in trousers).
Agnosia: loss of sensory ability to recognize familiar objects, sounds, sights (can be auditory, visual or tactile)
56
Alzheimer's and Symptoms
Hyperorality
Sundowning, or sundown syndrome
Memory impairment
Hyperorality: the tendency to put everything in the mouth and to taste and chew.
Sundowning, or sundown syndrome: tendency for an individual’s mood to deteriorate and agitation increase in the later part of the day, with the fading of light, or at night.
Memory impairment: initial difficulty remembering recent events -> deterioration of recent and remote memory.
57
9 Interventions around comfort and anxiety for Delirium
* Provide optimistic but realistic reassurance.
* Provide patient with information about what is happening and what can be expected.
* Accept patient’s perceptions or interpretation of reality and respond to the theme or feeling tone.
* Approach patient slowly and from the front and address patient by name.
* Always introduce self to patient when approaching.
* Communicate with simple, direct, and descriptive statements.
* Limit decision making if aggravates delirium
* Encourage significant others to remain with patient.
* Provide a consistent physical environment, daily routine, and caregivers.
58
5 Interventions around safety for Delirium
* Administer prn (as needed) medications for anxiety or agitation with caution.
* Physical restraints may increase symptoms and should be avoided if possible.
* Never leave a patient in acute delirium alone (family can watch)
* Maintain a well-lit, hazard-free, low-stimulation environment
* Encourage use of aids that increase sensory input (e.g., eyeglasses, hearing aids, and dentures).
59
3 Interventions around Orientation for Delirium
* Monitor neurological status on an ongoing basis
* Avoid frustrating the patient by quizzing with orientation questions that cannot be answered.
* Use environmental cues (e.g., signs, pictures, clocks, calendars, and color coding of environment) to stimulate memory, reorient, and promote appropriate behavior.
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4 basic Interventions for Alzheimer's Disease
- Provide emotional support to patient and family: Ascertain what is important to these patients, their values and beliefs, as well as their life histories. (unconditional positive regard is key)
- support caregivers: Include family members in planning, providing, and evaluating care
- assess and facilitate self - care: Identify usual patterns of behavior for such activities as sleep (provide rest periods), medication use, elimination, food intake, self-care
- Provide finger foods to maintain nutrition for patient who will not sit and eat.
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7 interventions for comfort care and anxiety management in Alzheimer's
- Introduce self and address patient by name when initiating interaction and speak slowly.
- Give one simple direction at a time in a respectful tone of voice.
- Use distraction, rather than confrontation, to manage behavior.
- Provide consistent caregivers, physical environment, and daily routine. (Limit number of choices patient must make so as not to cause anxiety.)
- Select television or radio programs based on cognitive processing abilities and interests.
- Place patient’s name in large block letters in room and on clothing, as needed.
- Use symbols, rather than written signs, to assist patient in locating room, bathroom, or other area.
62
What is the rationale for the following intervention for Dementia?
Gradually restrict use of motor vehicles
As judgment becomes impaired, the person may be dangerous to self and others.
63
What is the rationale for the following intervention for Dementia?
Minimize sensory stimulation.
Decreases sensory overload, which can increase anxiety and confusion.
64
What is the rationale for the following intervention for Dementia ?
If the person becomes verbally upset, listen and be supportive, allowing the person to be upset. Gradually try to redirect and change the topic.
Goal is to prevent escalation of anger. When attention span is short, the person can be distracted to more productive topics and activities.
65
What is the rationale for the following intervention for Dementia?
Label all rooms and drawers. Label often-used objects (e.g., hairbrushes and toothbrushes)
May keep the person from wandering into other people’s rooms. Increases environmental clues to familiar objects.
66
What is the rationale for the following intervention for Dementia?
Have the person wear medical alert bracelet that cannot be removed (with name, address, and telephone number). Provide police department with recent pictures.
The person can easily be identified by police, neighbors, or hospital personnel.
67
What is the rationale for the following intervention for Dementia?
If the person wanders during the night, put mattress on the floor.
Prevents falls when the person is confused.
68
What is the rationale for the following intervention for Dementia?
If the person is in the hospital, have the person wear brightly colored vest with name, unit, and phone number printed on back.
Makes the person easily identifiable.
69
What is the rationale for the following intervention for Dementia?
Put complex locks on top of door and use sensor devices.
Reduces opportunity to wander.In moderate and late Alzheimer-type dementia, ability to look up and reach upward is lost. Sensor devices provide warning if person wanders
70
What is the rationale for the following intervention for Dementia?
Encourage physical activity during the day.
Physical activity may decrease wandering at night
71
What to know about use of psychotropic drugs and Alzheimer's? (4)
- they increase risk of mortality from cardiovascular and infectious causes
- Antipsychotics, antidepressants, antianxiety, anticonvulsants are not FDA approved and are used off label
- Try to avoid but If used, start low, go slow, use smallest dose for shortest duration and discontinue if not effective
- Use as last resort to manage behavior
72
Donepezil
Mechanism of action
Use
Therapeutic Effect
Drug interaction
- Mechanism of action: Inhibit acetylcholinesterase from breaking down Ach
Use: all stages of AD including severe
Therapeutic Effect: small and short-lived improvements in cognitive function after 1 year but do not slow disease progression
Drug interactions: NSAIDs increase potential for GI bleeds and ulceration
73
8 adverse effects of Donepezil
temporary GI disturbances (Nausea, vomiting, diarrhea)
Insomnia
muscle cramps
fatigue
anorexia
urinary incontinence
rare is bradycardia or syncope
74
1. Which statement made by the primary caregiver of a person with dementia demonstrates an accurate understanding of providing the person with a safe environment?
a. “The local police know that he has wandered off before.”
b. “I keep the noise level low in the house.”
c. “We’ve installed locks on all the outside doors.”
d. “Our telephone number is always attached to the inside of his shirt pocket.”
c. “We’ve installed locks on all the outside doors.”
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2. Which statement made by a family member tends to support a diagnosis of delirium rather than dementia?
a. “She was fine last night but this morning she was confused.”
b. “Dad doesn’t seem to recognize us anymore.”
c. “She’s convinced that snakes come into her room at night.”
d. “He can’t remember when to take his pills or whether he’s bathed.”
a. “She was fine last night but this morning she was confused.”
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3. In terms of the pathophysiology responsible for both delirium and dementia, which intervention would be appropriate for delirium specifically?
a. Assisting with needs related to nutrition, elimination, hydration, and personal hygiene
b. Monitoring neurological status on an ongoing basis
c. Placing an identification bracelet on patient
d. Giving one simple direction at a time in a respectful tone of voice
b. Monitoring neurological status on an ongoing basis
77
4. What side effects should the nurse monitor for while caring for a patient taking donepezil (Aricept)? Select all that apply.
a. Insomnia
b. Constipation
c. Bradycardia
d. Signs of dizziness
e. Reports of headache
a. Insomnia
c. Bradycardia
d. Signs of dizziness
e. Reports of headache
78
5. What is the rationale for providing a patient diagnosed with dementia easily accessible finger foods thorough the day?
a. It increases input throughout the day
b. The person may be anorexic
c. It helps with the monitoring of food intake
d. It helps to prevent constipation
a. It increases input throughout the day
79
6. Ophelia, a 69-year-old retired nurse, attends a reunion of her former coworkers. Ophelia is concerned because she usually knows everyone, and she cannot recognize faces today. A registered nurse colleague recognizes Ophelia’s distress and “introduces” Ophelia to those attending. The nurse practitioner understands that Ophelia seems to have a deficit in her
a. Lower-level cognitive domain
b. Delirium threshold
c. Executive function
d. Social cognition ability
d. Social cognition ability
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7. After talking with her 85-year-old mother, Nancy became concerned enough to drive to her home and check on her. Her mother’s appearance was disheveled, her words were nonsensical, she smelled strongly of urine, and there was a stain on her dressing gown. Because she is a nurse, Nancy recognizes that her mother’s condition is likely due to
a. Early-onset dementia
b. A mild cognitive disorder
c. A urinary tract infection
d. Having skipped breakfast
c. A urinary tract infection
81
8. Lucia, 70 years old, recently underwent a major orthopedic surgical procedure. On postoperative day 3, she responds to the nurse who has been caring for her with affection. At other times, however, she tells the nurse to leave because she does not recognize her and asks to have another nurse care for her, specifically naming the nurse as the “nice one.” The most likely reason for Lucia’s behavior is that she is
a. Attention-seeking and manipulative
b. Showing signs of early dementia
c. Experiencing an acute delirium
d. Playing one staff member off against another
c. Experiencing an acute delirium
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9. Since his wife’s death 2 months earlier, Aaron, 90 years of age and in good health, has begun to pay less attention to his hygiene and seems less alert to his surroundings. He complains of difficulty concentrating, disrupted sleep, and lacks energy. His family has to remind and encourage him to shower, take his medications, and eat, all of which he then does. Which of the following responses would be most appropriate?
a. Reorient Mr. Smith by pointing out the day and date each time you have occasion to interact with him.
b. Meet with the family and support them to accept, anticipate, and prepare for the progression of his stage 2 dementia.
c. Avoid touch and proximity. These are likely to be uncomfortable for Mr. Smith and may provoke aggression when he is disoriented.
d. Arrange for an appointment with a mental health professional for the evaluation and treatment of suspected major depressive disorder.
d. Arrange for an appointment with a mental health professional for the evaluation and treatment of suspected major depressive disorder.
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10. Nurses caring for patients who have neurocognitive disorders are exposed to stress on many levels. Specialized skills training and continuing education are helpful to diffuse stress, as well as which of the following? Select all that apply.
a. Expressing emotions by journaling
b. Describing stressful events on Facebook
c. Engaging in exercise and relaxation activities
d. Having realistic patient expectations
e. Participating in a happy hour after work to blow off steam
a. Expressing emotions by journaling
c. Engaging in exercise and relaxation activities
d. Having realistic patient expectations
84
What is the rationale for the following intervention for Dementia?
Provide picture magazines and children’s books when the person’s reading ability diminishes.
Allows continuation of usual activities that the person can still enjoy; provides focus.
85
What is the rationale for the following intervention for Dementia?
Provide simple activities that allow exercise of large muscles.
Exercise groups, dance groups, and walking provide socialization, as well as increased circulation and maintenance of muscle tone.
86
What is the rationale for the following intervention for Dementia?
Encourage group activities that are familiar and simple to perform.
Activities such as group singing, dancing, reminiscing, and working with clay and paint all help increase socialization
87
7 characteristics of abusers
1. male dominance
2. need to be in power
3. pathological jealousy
4. controlling finances and friendship
5. Social isolation (see current relationship as closest they’ve had; poor social skills and lack social support)
6. substance abuse
7. Poor impulse control and coping skills
88
Nurse's role in IPV counseling (3)
- support victim
- counsel safety (develop safety plan)
- facilitate access to resources (safe houses and shelters offer protection so give patient the number to nearest one
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Safety Plan (4 notes)
- plan for rapid escape when abuse recure
- have important paperwork, destination, and transportation ready
- patient can identify signs of escalation and pick a particular sign that tells them it is time to leave
- If children, use a code word
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Clinical Picture of survivors of abuse (6)
-comorbid PTSD/ASD, MDD, anxiety, suicide
- impaired daily functioning
- low self-esteem
- sexual dysfunction
- somatic complaints
- recurrent and intrusive memories, dreams, flashbacks, and distress from cues that remind them of the assault.
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7 primary preventions for abuse
* Identify individuals and families that are high risk and reduce risk
* Provide health teaching
* Coordinate supportive services to prevent crisis
* Reduce stress
* Increase social support
* Increase coping skill
* Increase self-esteem
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5 secondary preventions for abuse (to reduce disabling and long-term effects)
* Establish screening programs for individuals at risk
* Participate in medical treatment of injuries resulting from violent episodes
* Coordinate community services to provide continuity of care
* Provide supportive therapy to reduce stress and depression
* Encourage support groups
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4 tertiary preventions for abuse (to facilitate healing and rehabilitation)
* Counseling individuals and families
* Provide support groups for survivors. Ex. legal advocacy
* Assist survivors in achieving optimal level of safety, health, and well being
* Complementary therapy, Example: Mindfulness based stress reduction (assist with healing process)
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Individual therapy and IPV
goal for survivor (3)
goal for perpetrator (2)
Goal for survivor: empowerment, ability to recognize and choose productive life options, development of solid sense of self by working through grief
- Can address feelings of depression, anxiety, somatization, PTSD
Goal for perpetrator: resolve psychopathological processes
- Most effective when court mandated
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Family therapy and IPV
Goal for perpetrator (4)
Goal for family
Why important?
When is conjoint therapy okay?
Goal: perpetrator will recognize destructive patterns of behavior, learn alternative responses, control impulses, and refrain from abusive behavior
Family goal: members of the family will openly communicate and learn to listen to one another.
- Abuse is symptom of family crisis so everyone needs attention, support, and understanding; family also needs support after IPV
- Conjoint therapy only if perpetrator has had individual therapy and demonstrated change AND consent of both parties
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Group therapy and IPV
Benefit for survivor (2)
Benefit for perpetrator
For survivor: Provides assurance that one is not alone and change is possible; Strengthens feelings of self-esteem and self-worth, and problem solving
For perpetrator: learn to recognize the thoughts preceding an abusive incident, responses to the thoughts, and interrupt negative feelings
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Most effective counseling approach in ED for sexual assault (5)
o Provide nonjudgmental care and optimal emotional support
o Convey confidential nature of visit
o Listen and let patient talk (a patient who feels listened to and understood no longer feels alone and can feel in control of situation)
o Separate vulnerability from blame (survivor may try to rationalize or blame their behavior for the incidence)
o Social support is key (Fewer somatic symptoms of stress if survivor is able to confide comfortably in at least one person, especially immediately after the assault)
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Date and acquaintance rape
non domestic relationships where the perpetrator is known to the victim (1 in 4 college women report this)
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8 do's of IPV interview
* Conduct the interview in private.
* Develop trust to make patient comfortable enough to self-disclose
* Be direct, honest, and professional
* Use language the patient understands. (ask about ways they solve disagreements or discipline methods rather than abuse or violence)
* Ask the patient to clarify words not understood.
* Be attentive but relaxed
* Inform the patient if you must make a referral to Children’s or Adult Protective Services, and explain the process.
* Use open-ended question that requiring descriptive response (also they are less threatening)
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7 Don'ts of IPV interview
* Try to “prove” abuse by accusations or demands.
* Display horror, anger, shock, or disapproval of the perpetrator or situation.
* Place blame or make judgments.
* Allow the patient to feel “at fault” or “in trouble.”
* Probe or press for answers the patient is not willing to give.
* Conduct the interview with a group of interviewers.
* Interrupt the patient
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3 Signs of abuse or neglect
-hesitant to talk
-fearful in presence of perpetrator
-tearful
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7 signs of physical abuse in child
- minor complaints (headaches, back pain, dizziness, accidents)
- overt signs (bruises, scars, burns, or wounds in various stages of healing in body parts that are usually covered or arms)--Any bruise on infant <6 months needs to be explored
- Shaken baby syndrome: leading cause of death from physical abuse in children under 2; signs include respiratory problems, bulging fontanels, retinal hemorrhage, CNS damage (seizures, vomiting, coma).
- In utero (Fetal alcohol spectrum disorders (brain damage and growth problems) & Neonatal abstinence syndrome (lasts days to weeks; includes irritability, difficulty soothing; long term hearing, vision, and learning difficulties)
- inconsistent explanations for injuries
- vague explanations
- minimization of seriousness
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4 Signs of Sexual abuse
- Sexualized behavior (acting out) in young children
- Sexual promiscuity or knowledge in older children
- PTSD symptoms (nightmares, somatic complaints, feelings of guilt)
- Adults sexually abused as child mainly report depression (other symptoms also reported)
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5 Signs of emotional abuse
*less obvious and more difficult to assess than other abuse*
- low self-esteem and feeling of inadequacy
- anxiety
- withdrawal
- learning difficulties
- poor impulse control
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3 signs of neglect
- Undernourished
- Dirty and poorly clothed
- Inadequate medical care (lack of immunizations and untreated medical or dental conditions)
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What is economic abuse? 2 signs
Failure to provide for the needs of the victim when adequate funds are available
-leaving bills unpaid
-preventing spouse from seeking job or education to promote dependency
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Assessment and IPV: Anxiety Findings (3)
- Agitation and borderline panic anxiety often present
- If severe to panic anxiety; use therapeutic techniques to lower anxiety first
- Chronic stress and severe anxiety may lead to hypertension, irritability, and GI disturbances
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Assessment and IPV: Coping Mechanism Findings (4)
- Flawed beliefs or myths are maladaptive coping mechanisms used
- Victim may withdraw from others due to despair, confusion, and shame-> social isolation
- Negative coping includes self- blame
- Positive coping includes looking at positives (i.e. seeing children again)
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Assessment and IPV: Support System Findings (2)
- Person usually in dependent position and perpetrator may isolate them from access to social support
- Notice nonverbal and verbal interactions between support system and patient
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Assessment and IPV: Suicide Potential Findings (3)
- May seem like the only option
- Risk increased by identity of abuser and frequency of abuse (immediate family and increased frequency)
- Means is usually overdose with combo of alcohol and other CNS depressants or sleeping medications
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Assessment and IPV: Homicide Potential
4 factors that place victim at greater risk
o The presence of a gun in the home
o Alcohol and drug misuse
o History of violence from perpetrator in other situations
o Extreme jealousy and obsessiveness on the part of the perpetrator
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Assessment and IPV: Substance use Findings (2)
- Person may self-medicate as way to escape intolerable situation (usually with CNS depressants (benzos) prescribed for stress-related symptoms
- If SUD present, do not discharge to abuser
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Documentation of IPV (5 tips)
- Ask patient to return in couple days if abuse just occurred for better pictures of bruises
- Ensure patient of confidentiality and power of record in legal action
- document Verbatim statements of who caused the injury and when it occurred.
- document a body map to indicate size, color, shape, areas, and types of injuries, with explanations
- Gather physical evidence of sexual abuse, when possible.
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4 Assessment guidelines for Rape Victim
1. Head-to-toe physical assessment including genital exam, observing for signs of injury (may be none)
- Explain procedure in reassuring and supportive way to avoid revictimization of the patient with another violation of their body
2. Evidence collection and preservation of legal evidence
- Includes blood, hair samples, oral swabs, nail swabs, scrapings, anal, genital, or penile swabs
3. Documentation of physical findings ( in narrative and pictorial form, use preprinted body maps, hand-drawn copies, or photographs; Include verbatim statements by the patient, detailed observations of emotional and physical status)
4. Treatment, discharge planning, and follow-up care
- Provide shower and change of clothes ASAP after exam and evidence collection
- Provide prophylactic treatment for STDs, emergency contraceptives
- Provide referral info and printed follow-up instructions
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Cycle of Violence: Tension building phase (3)
- begins with minor incidents, such as pushing, shoving, and verbal abuse.
- victim often ignores or accepts the behavior due to fear of escalation
- As the tension builds, both participants may try to reduce it (abuser via substance use, victim through minimization of tension)
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Cycle of Violence: Acute battering phase (4)
- when the tension peaks and becomes unbearable
- It is usually triggered by an external event, abuser’s emotional state; or victim provokes it to move on
- Victim may seek help or cover up abuse
- Abuse may be worsened by pregnancy or move toward independence
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Cycle of Violence: Honeymoon phase (3)
- period of calm after the abuse occurs
- Abuser usually demonstrates kindness and loving behaviors and makes promises to change
- The victim usually feels needed, loved, and hopes for change (often cancels plans to leave which were made during acute phase)
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Cycle of Violence
3 stages
How it changes over time?
Impact on victim
3 stages: tension building, acute battering, honeymoon
- Cycle repeats itself and honeymoon becomes briefer and other stages more intense
- cycle erodes victim’s self-esteem leading to depression, hopelessness, immobilization, and self-deprecation
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6 Interventions post-sexual assault
1. reduce anxiety with use of relaxation techniques and sleep
2. encourage help-seeking
3. reduce arousal and regulate emotions
4. encourage patient to develop narrative of event and the meaning of the event to them
5. gently suggest that person was not responsible for what happened
6. reassure that reactions to trauma do not indicate personal failure or weakness
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4 guidelines for personality disorders
- acknowledge the patient's feelings but set limits on bad behavior
- do not make empty threats. Set clear and realistic expectations
- setting firm limits and boundaries is very important.
- Know the facts before you act.
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How does intervention differ for “Sometimes, I just wish I could die” vs “I am going to kill myself.”
With the former, you would ask the patient to talk more about their feelings.
With the latter, you would immediately place them on 1:1 observation.
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Two treatment goals for personality disorders
- decrease the behaviors associated with the various disorders that affect function and interpersonal relationships.
- reduce the inflexibility that interferes with functioning and relationships
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Cluster A personality disorders
What are they?
Which personalities are included?
-odd or eccentric
- Paranoid, Schizotypal, Schizoid
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Cluster C personality Disorders
What are they?
Which personalities are included?
- anxious or fearful
- Avoidant, OCD personality disorder
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Cluster B personality Disorders
What are they?
Which personalities are included?
- dramatic, emotional, or erratic
- histrionic, narcissistic, borderline, antisocial
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Paranoid Personality Disorder: Characteristics (8)
* Longstanding distrust and suspiciousness of others
* believe that others want to exploit, harm, or deceive the person so anticipate hostility
* Relationship difficulties due to jealousy, controlling behaviors, and envious behaviors
* unwilling to forgive.
* Hypervigilant, oversensitive, guarded
* Provoke hostile responses by initiating a counterattack
* Exhibits self-destructive behaviors
* Projection is the dominant defense mechanism
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Paranoid Personality Disorder: Guidelines to Nursing Care (5)
* Strictly adhere to promises, appointments, and schedules due considering the degree of mistrust
* Being too nice or friendly may be met with suspicion.
* Give clear and straightforward explanations of tests and procedures beforehand.
* Use simple language and project a neutral but kind affect.
* Limit setting is essential when threatening behaviors are present.
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Paranoid Personality Disorder: Treatment (4)
* Psychotherapy – first line treatment
* Group therapy is threatening but may find role playing and group feedback helpful
* Diazepam for anxiety and agitation
* Severe agitation and delusions with FGAs, haloperidol or pimozide
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Schizoid Personality Disorder: Characteristics (8)
* Social withdrawal (Do not seek out or enjoy close relationships)
* Expressionless with restricted range of emotional expression (cold and indifferent)
* loners and poor academic performance
* inappropriate seriousness
* lack of spontaneity
* Approval nor rejection by others has an effect
* May have many imaginary friends or fantasies (aloof)
* depersonalized and detached
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Schizoid Personality Disorder: Guidelines to Nursing Care (5)
* avoid being too “nice” or “friendly.”
* Do not try to increase socialization
* Patients may be open to discussing topics such as coping and anxiety.
* Conduct a thorough assessment to identify symptoms that the patient is reluctant to discuss.
* Protect against ridicule from group members because of the patient’s distinctive interests or ideas.
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Schizoid Personality Disorder: Treatments (4)
* Psychotherapy is good because they tend to be introspective
* Group therapy not good first treatment choice but may be helpful later to overcome fears of closeness and feelings of isolation
* Antidepressants to increase patient’s pleasure in life (Bupropion)
* SGAs (risperidone or olanzapine) to improve emotional expressiveness
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Schizotypal Personality Disorder: Characteristics (8)
* Extreme anxiety in social settings
* Do not blend with the crowd (lengthy, abstract, overly detailed contributions to conversations)
* Magical thinking (belief they can do acts of god)
* Odd beliefs (overly superstitious)
* Strange speech patterns (rambling)
* Inappropriate affect
* Paranoia (overly suspicious and anxious of others; blame others for their social isolation)
* Hallucinations and delusions (less than in schizophrenia and brief)
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Schizotypal Personality Disorder: Guidelines to Nursing Care (4)
* Respect the patient’s need for social isolation.
* Be aware of the patient’s suspiciousness and use appropriate interventions.
* Help identify cognitive distortions
* Be aware that strange beliefs and activities, such as strange religious practices or peculiar thoughts, may be part of the patient’s life.
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Schizotypal Personality Disorder: Treatment (3)
* Often avoid treatment due to social anxiety and paranoia
* Goal is supportive care vs. alliance
* Low dose SGA (risperidone, olanzapine) for psychotic-like symptoms and day to day functioning (includes ideas of reference or illusions
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Difference between Schizophrenia and Schizotypal Personality Disorder
People with schizotypal personality disorder can be made aware of their suspiciousness, magical thinking, and odd beliefs.
Schizophrenia is characterized by far stronger delusions.
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Histrionic Personality Disorder: Characteristics (6)
* Excitable and dramatic yet high functioning
* Drama queens (Extroversion, flamboyance, colorful personalities)
* Limited ability to develop meaningful relationships due to partner smothering or insensitivity of histrionic
* attention-seeking behavior (self-centeredness, low frustration, tolerance, excess emotionality)
* Impulsive, flirtatious, provocative
* Difficulty regulating their feelings
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Histrionic Personality Disorder: Guidelines for Nursing Care (5)
* Know seductive behavior is a response to distress.
* Communication and interactions should always be kept professional; ignore flirtations
* Encourage and model the use of concrete and descriptive rather than vague and impressionistic language.
* Help patients to clarify their own feelings, as they often have difficulty identifying them.
* Teach and role model assertiveness.
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Histrionic Personality Disorder: Treatment (5 notes)
* Often do not believe they need psychiatric help
* Psychotherapy to help promote feelings clarification and expression (treatment of choice)
* Antidepressants for somatic or depressive symptoms
* Antianxiety for anxiety
* Antipsychotics for derealization or delusions
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Narcissistic Personality Disorder:
Main trait
6 other Characteristics
Main trait: antagonism via grandiosity and attention-seeking behaviors (Blame others for issues)
* Feelings of entitlement
* Lacks empathy and exploits others
* Exaggerated belief of one’s own importance(arrogance)
* Suffer from weak self-esteem
* hypersensitivity to criticism and rejection
* Feel intense shame and fear of abandonment
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Narcissistic Personality Disorder: Guidelines for Nursing Care (5)
* Nurses should remain neutral and recognize the source of narcissistic behavior—shame and fear of abandonment.
* Help identify goals and to develop a stronger self-identity.
* Role model empathy and practice how to engage in meaningful interaction.
* Avoid engaging in power struggles or becoming defensive in response to the patient’s disparaging remarks.
* Do not directly challenge grandiose statements.
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Narcissistic Personality Disorder: Treatment (4 notes)
* Less impairment in functioning and quality of life than other personality-based disorders
* Often difficult b/c pt must confront problem (often do not seek treatment)
* CBT for deconstructing faulty thinking
* Lithium for mood swings
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Borderline Personality Disorder
4 main features
Primary defense mechanism
3 other symptoms
Main features: emotional dysregulation, emotional lability, impulsivity, self-image distortions
Primary defense mechanism: splitting (inability to view both positive and negative aspects of others as part of a whole; people are either wonderful or horrible)
Others
- Self-destructive behaviors include ineffective self-soothing habits; chronic suicidal ideation
- Feelings of antagonism seen as hostility, anger, irritability-> physical violence or property damage
- May be psychotic during stress
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Borderline Personality Disorder Areas to Assess (8)
- Feelings of emptiness
- risky behaviors, such as reckless driving, unsafe sex, substance use, binge eating, gambling, or overspending
- Intense feelings of abandonment that result in paranoia or feeling spaced out
- Idealization of others and becoming close quickly
- tendency toward anger, sarcasm, and bitterness
- Self-mutilation and self-harm
- Sudden shifts in self-evaluation that result in changing goals, values, and career focus
- Intense, unstable romantic relationships
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Borderline Personality Disorder: Guidelines to Nursing Care (6)
* Nurse understands complaints originate from feeling of being threatened
* Be aware of manipulative behaviors such as flattery, seductiveness, instilling guilt
* Provide clear and consistent boundaries and limits
* Use straightforward and calm communication
* Be neutral and respond matter-of-factly
* Instruct patient to write down sequence of events leading to injuries and consequences before staff discusses the event
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Borderline Personality Disorder: Pharmacotherapy Treatment
Goals of pharmacotherapy (3)
5 categories of drugs and when are they used
- Geared toward maintenance of cognitive function, symptom relief, improved quality of life
- SSRIS, anticonvulsants, lithium for mood and emotional dysregulation
- Naltrexone, opioid antagonist, can reduce self-injurious behaviors
- SGAs control anger and brief episodes of psychosis
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CBT and Borderline Personality disorder (2)
- helps individuals identify and change inaccurate core perceptions of themselves and relationship problems
- reduces mood and anxiety symptoms including self-harm
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Dialectical Behavioral Therapy (DBT) and Borderline Personality disorder
What is it?
What is the goal?
What is its progression?
- evidence-based to treat chronically suicidal which combines CBT with mindfulness
Goal to increase pt’s ability to manage distress and improve interpersonal effectiveness skills to emphasize awareness of one’s thoughts and actively shape them
Begins with identification and interventions for suicidal behavior and progress to disruption of destructive behaviors
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Schema-focused therapy and Borderline Personality disorder
combines CBT with other therapies to focus on ways individuals view themselves; reframing schemas to fix dysfunctional self-image
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Antisocial Personality Disorder:
Main trait
6 other Characteristics
Primary: antagonistic behaviors such as deceitfulness, manipulative, hostile (sociopaths) for personal gain
* Callousness (profound lack of empathy) results in lack of concern about feelings of others, absence of remorse or guilt except in face of punishment ( Pattern of disregard for rights of others and their frequent violation)
* Disinhibited behaviors (criminal misconduct and substance misuse are common; inability to delay gratification)
* Little to no capacity for intimacy and exploit others (Adept at pretending to care or show concern if these behaviors help them manipulate and exploit others)
* Shallow, unexpressive, superficial affect
*intimidating and argumentative
*restless and easily bored
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Antisocial Personality Disorder: Guidelines to Nursing Care (5)
- Provide consistency, support, boundaries, limits and realistic choices
- Prevent or reduce untoward effects of manipulation (flattery, seduction, instillation of guilt of others)
- Assist patients in recognizing their feelings of anger, source, and identification of options to handle anger
- Listening and showing empathy can defuse an aggressive situation
- Help reduce anger and anxiety through physical outlets and therapeutic activities
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Antisocial Personality Disorder: Addressing Manipulation(2)
- Direct discussion of your concerns is best ( For example, nurse can say: “People enjoy hearing positive comments made by others about themselves. However, in the context of a nurse-patient relationship, these comments are not acceptable.”)
- For severe manipulation, address openly and include consequences in the form of rewards or penalties
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Antisocial Personality Disorder: Pharmacotherapy treatment (4 types and when used)
*no FDA approved*
- Mood stabilizers i.e lithium or valproic acid for aggression, depression, impulsivity
- SSRIs i.e fluoxetine and sertraline for irritability, anxiety, depression
- Benzodiazepines for anxiety w/ caution due to addiction
- Methylphenidate if comorbid ADHD
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Antisocial Personality Disorder: Psychological treatment (4 types and why helpful)
- CBT helpful b-c bond with psychotherapists
- Mentalization behavioral therapy: long-term treatment that supports individuals’ ability to recognize and understand their own and other people’s mental states
- Dialectical behavior therapy (DBT): regulating emotions and being mindful
- Group therapy helps to feel camaraderie
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Avoidant Personality Disorder:
Main trait
5 other characteristics
Main trait: low self-esteem related to poor functioning in social situations; feelings of inferiority compared with peers; Reluctance to engage in unfamiliar activities
* Extremely sensitive to rejection
* Feel inadequate
* Socially inhibited
* Failure of support system may lead to depression, anxiety, anger
* preoccupation with rejection, failure, and humiliation
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Avoidant Personality Disorder: Guidelines to Nursing Care (4)
* use a friendly, accepting, and reassuring approach.
* Being pushed into social situations can cause severe anxiety for these patients. (accept patient fears)
* Provide the patient with exercises to enhance new social skills but use these with caution because any failure can increase the patient’s feelings of poor self-worth.
* assertiveness training
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Avoidant Personality Disorder: Treatment (5 treatment options)
* Individual and group therapy
* Psychotherapy for trust and assertiveness training
* Beta blockers (atenolol) reduce ANS hyperactivity
* Antidepressants such as SSRI citalopram or SNRI venlafaxine reduce social anxiety
* Assertiveness training can help the person learn to express needs.
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Obsessive-Compulsive Personality Disorder:
Main trait
Defense mechanism
5 other Characteristics
Main: rigidity and inflexible standards for self and others
Defense mechanism: reaction formation
* Limited emotional expression
* Stubbornness, perseverance, and indecisiveness
* Preoccupation with orderliness, perfectionism, and control
* Constant goal-seeking behavior (self-defeating and goal-defeating because strict standards interfere with project completion)
* Solicitous, ingratiating with superiors; pompous, self-righteous with subordinates
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Obsessive-Compulsive Personality Disorder: Guidelines to Nursing Care (3)
* Guard against power struggles with these patients, as their need for control is very high.
* It is helpful to provide structure yet allow patients extra time to complete habitual behavior (patients have difficulty dealing with unexpected change)
* Help patients to identify ineffective coping and to develop better coping techniques.
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Obsessive-Compulsive Personality Disorder: Treatment (3 notes)
* Often seek help
* Group and behavioral therapy helpful
* Clomipramine (TCA) and fluoxetine (SSRI) help with obsessions, anxiety, depression
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Difference between OCD and Obsessive-compulsive personality disorder
OCD has obsessive thoughts and repetition or adherence to rituals. People are aware that these thoughts and actions are unreasonable.
Obsessive-compulsive personality disorder has an unhealthy focus on perfectionism. Such people “know” that their actions are right and feel comfortable with their self-imposed systems of rules.
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5 areas to assess for all personality disorders
1. Assess for suicidal or homicidal thoughts
2. Determine whether the patient has a medical disorder or another psychiatric disorder that may be responsible for the symptoms (especially a substance use disorder).
3. Take into account the person's ethnic, cultural, and social background.
4. Ascertain whether the patient experienced a recent important loss. (Personality disorders are often exacerbated after the loss of significant supporting people or in a disruptive social situation.)
5. Evaluate for a change in personality in middle adulthood or later, which signals the need for a thorough medical workup or assessment for unrecognized SUD
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1. A man is being abused by his wife whom he loves very much. He initially decided to leave his wife but ultimately changed his mind after she agreed to go to marriage counseling. What is the best response by the nurse?
A. You are making the right decision. If you need help, our facility is here to assist you.
B. I hope you have made the right decision. If you need help, our facility is here to assist you.
C. You should be careful when you return. If you need help, our facility is here to assist you.
D. Why are you returning to this dangerous situation? If you need help, our facility is here to assist you.
B. I hope you have made the right decision. If you need help, our facility is here to assist you.
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Borderline personality disorder
What is emotional dysregulation?
What is emotional liability?
What is impulsivity?
- Emotional dysregulation: poorly modulated mood; mood swings and difficulty managing painful emotions
- Emotional lability: rapidly moving from one emotional extreme to another (Includes out of proportion emotional responses; fear of separation; intense sensitivity to personal rejection)
- Impulsivity: act quick in response to emotions; may lead to damaged relationships or suicide
