Mental Health N4615 Module III Flashcards
(175 cards)
1
Q
What is Anger
A
it is a secondary emotion usually triggered by another feeling
in response to some preceived threat or unmet need.
2
Q
Anger vs. aggression
A
anger is a feeling
where as
agression is a behvoior
agression becomes more likely when the angry, frustrated client feels ignored or discounted.
3
Q
Aggression defined
A
Aggression is a harsh physical or verbal action that reflects rage, hositility with the potential to cause harm or destruction to
Self
others
property
Agressive behavior violates the rights of others.
4
Q
What is the number one predictor of agressive behavior?
A
Past history of agressive behavior is the single best predictor of future behavior
increasing agitation is the most important predictor of imminent agression and violence.
5
Q
Signs of Increasing Agitation
A
- Restlessness, pacing, hyperactivity
- Rapid breathing
- Tensing of muscles
- Tight jaw/clenching teeth
- Shouting, cursing, making threats
- Verbal abuse
- Intense eye contact or avoidance of eye contact
- Clenched or raised fist
- Menacing posture
- Kicking or punching walls
- Picking up a weapon
- Throwing objects
- Stone silence
6
Q
Psychiatric Conditions
Associated with Aggression & Violence
A
- Dementia
- Delirium
- PTSD
- Bipolar Disorder
- Substance abuse
- Antisocial Personality Disorder
- Impulse-control disorders
- Delusional disorder, persecutory type
- Schizophrenia, paranoid type
- ADHD, conduct disorder and oppositional defiant disorders in children
7
Q
Medical Conditions
Associated with Aggression & Violence
A
- Chronic pain
- Neurological disorders
- traumatic brain injury, seizure disorder, neurosyphillis, HIV encephalopathy
- Endocrine disorders
- thyroid, parathyroid and adrenal hormone imbalances
- Metabolic disorders
- chronic renal failure, hepatic encephalopathy, hyponatremia, lupus
- Exogenous toxins
- inhaled solvents, alcohol, amphetamines, hallucinogens, heavy metals
- Vitamin deficiencies
- folate deficiency, Wernicke’s/Korsakoff’s encephalopathy
8
Q
What is the #1 nursing diagnosis for violent patients
A
Risk for other-directed violence
9
Q
Principles to Remember When Planning Care for the Potentially Violent Client
A
- Safety first!
- Protect yourself
- Maintain self-awareness and self-control
- Focus on prevention
- Always use the LEAST RESTRICTIVE intervention possible
Stop the Violence Before it Starts!
If it’s Predictable, it’s Preventable!
10
Q
How to protect yourself in violent situations
A
- Never see a potentially violent patient alone
- Maintain a safe, comfortable distance from the patient
- Avoid touching the client or invading his/her personal space
- Maintain a non-aggressive, neutral stance
- Be prepared to move quickly—Learn to scoot!
- Identify an “escape route” and do not allow the patient to block your exit path
11
Q
Use Therapeutic Communication Skills
to De-escalate the Situation
A
- Speak in a calm, caring manner
- Ensure that non-verbal messages are not defensive or provocative
- Slow your cadence and lower the volume of your voice if/when patient escalates. Watch your tone!
- Do not argue with the patient, shout, or belittle his feelings
- Use open ended questions to explore issues, then reflect/paraphrase
- Facilitate problem solving, but avoid telling the client what to do–unless limit setting becomes necessary
12
Q
Set Limits When Necessary with an angry patient
A
Establish limits only when and where there is a clear need
Never set a limit you cannot enforce
Don’t use limit setting to threaten the patient
Establish reasonable and enforceable consequences or exceeding limits
Be consistent in enforcing limits
13
Q
What is “the SET” Communication Principles to Verbally De-escalate and Set Limits
A
•Support
•Remind client that you are an ally and you have his/her best interests in mind - (“I care about you and I want to help you.”)
•Empathy
•Convey to client that you understand and care about his/her feelings - (“I can see how frustrating and distressing this is for you.”)
•Truth
•Clearly state the limit and tell the patient what you want him/her to do - (“I won’t let you hurt yourself or anyone else. I need you to put the chair down now, please.”)
14
Q
If the violence continues to escalate
A
Assemble a Show of Force
Assign only one person to communicate with the patient - Continue to offer client opportunities to change behavior when possible -
Follow approved policies and procedures for doing a “takedown” if necessary
15
Q
When is Involuntary medication necessary?
A
- Requires “emergency declaration” by physician when ordered
- Danger to patient or others must be imminent
- Must document failure of less restrictive interventions
- No “prns” allowed for emergencies
•Considered a “chemical restraint”
16
Q
What is the 1st thing needed after an emergency seclusion?
A
Notify the health care provider to obtain a seclusion order.
This is a state law
17
Q
When can you use Seculusion or Restraints
A
Considered “last resort” interventions.
Seclusion is used when there is risk of danger to others.
Restraints are used when there is risk of danger to self.
NEVER used for punishment or staff convenience
Both require MD order, declared emergency due to imminent danger to patient or others and failure of less restrictive interventions
18
Q
Limits on seculsion or restraint
A
- One hour for children
- Two hours for adolescents
- Four hours for adults
- If longer use is indicated, intervention must be reordered
- Patients must be evaluated face to face by physician or specially trained nurse within one hour of initiation
- Patients in seclusion must be monitored at least q15 min.
- Patients in seclusion who have also received sedation must be monitored continuously
- Patients in restraints must be monitored continuously on 1:1 observation
19
Q
What is the type of documentation (how it should be completed) that is required when someone is placed in seculsion or restraints
A
- Behavioral Observations
- Interventions
- In the order they were done, least restrictive to most restrictive
- Patient’s responses to interventions
- Debriefing & patient’s response
•Patient education and response to education
20
Q
What is Validation therapy
A
meeting the patient “where he/she is at the moment — acknowledging the patients wishes
ex. Cognitivly impaired patient want to go home…you would say “So you want to go home?”
Validation does not redirect, reorient or probe
21
Q
What is the best medication to give a pt. thats agression continues to escalate?
A
Olanzapine (Zyprexa)
short acting antipsychotic useful in calming angry, aggrssive patients regardless of diagnosis.
22
Q
What are the stages/cycles of domestic violence and their definition
A
Tension-building stage - characterized by minor incidents (pushing, shoving, and verbal abuse)…victim ignores or acepts the abuse for fear more will follow.
Acute battering state — abuser releases the built up tension by brutal beatings which result in injuries.
Honeymoon stage —characteized by kindness and loving behaviors, abuser is apologetic, remorseful and often give gifts to apologize — victim wants to believe the response and often agrees to drop any charges.
23
Q
Prevention of Abuse
pg. 546 book
A
Primary prevention - measures taken to prevent occurence of abuse
Secondary prevention - involves early intervention in abusive situations to minimize disabling or long term effects.
Tertiary prevention - often occures in mental health settings, involves facilatating healing and rehabilitation. .
24
Q
What are components of a “plan of escape”
A
- keep a phone fully charged
- have number of nearest shelter
- secure a supply of medications for self & childrens
- Assemble birth certificates, SS card, and licenses
- Determine a code word to signal when it’s time to leave.
25
What is Engagement
“involve one’s **attention and pledge** to do something”
They are focused on the task at hand / in what they are doing (heart & soul)
26
Healthcare Engagement
**Actions** individuals must take to obtain the greatest benefit from the health care services available to them."
**Behaviors** of individuals relative to their health care that are **critical and proximal** to *health outcomes*, rather than the actions of professionals or policies of institutions.
**Processes** in which information and professional advice with own needs, preferences and abilities in order to prevent, manage and cure disease
27
Consequences of Non-Engagement
- risk for poor health
- perform specific health behaviors
- without insurance
- education
28
Complementary & Alternative Use
**Non vitamin**, non mineral supplements-18.9% in 2002 and unchanged from 2007 to 2012 (17.7%).
**deep-breathing** exercises were the second most commonly used complementary health approach in 2002 (11.6%), 2007 (12.7%), and 2012 (10.9%)
**yoga, tai chi, and qi gong** increased linearly over the three time points, beginning at 5.8% in 2002, 6.7% in 2007, and 10.1% in 2012
29
What is **Mindfulness** Based Therapy
A randomized controlled trial of mindfulness-based cognitive therapy for **bipolar disorder**.
30
Benefits of Vitamin B 12 & B 9
**B12** -Cyanoboalamin
**B9** folic acid
**B 12 & B 9** - 60–74 years old with mild depressive symptoms in a RCT-no effect
**B 12, B 9, & B 6** - Prevented depression post stroke (mean ages 45.8–76.6 years old).
**Well** – designed study showing benefit of l-methyfolate augmentation of antidepressant
31
Benefits of Omega 3
**Fish**: salmon, almonds & walnuts.
**The data support** an ***antidepressant*** effect of Ω3.
**Low levels** of Ω3 in depression & suicidal patients.
**Bipolar depressive** symptoms may be improved by adjunctive use of omega-3.
***Not effective in mania.***
32
Benefits of Ginkgo Biloba
Ginkgo biloba originates from the Maidenhair tree.
**Neuro**protective
**inhibits** platelet activation
**relaxes** endothelium
**inhibits** cholinergic receptors
**increases** choline uptake in the hippocampus
**antioxidant effects.**
**Small** effect on cognitive decline in those already afflicted with certain types of dementia.
33
Benefits of Lemon Grass
Effect of **Lemongrass** Aroma on Experimental **Anxiety** in Humans.
34
Benefits of Lavender & Bergamot
Lavender and bergamot essential oils are **antidepressants and relaxants**,
**Essential oils** can be **absorbed** by inhalation into the **olfactory pathway** and from there to the brain. The scores on depression, anxiety, and stress decreased in the intervention group after the aromatherapy programme, but there was increased psychological distress in the control group. The results were consistent with those of previous studies, namely, that aromatherapy was able to relieve negative emotional symptoms
35
**Tenants** of Spiritual Care
**We** have care for the beginning of families, new parents, and infants
**We** nurture mothers and fathers, children, and youth.
**We** offer wisdom and understanding concerning life’s stresses, anxieties, and challenges; we face together the realities of evil, suffering, and death.
**We** address the power of guilt, hopelessness, and despair; we mark our boundaries and limits; we create meaningful and shared narratives of the world and of our life journeys
**We** seek to name and contain what is toxic, and we foster food and drink that promote health and well-being.
**We** have care also for the experience of aging and the end of life
36
Faith & Mental Illness
**One in four** persons sitting in our pews has a family member struggling with mental health issues
A majority of individuals with a mental health issue go **first** to a spiritual leader for help
*Studies show that **clergy** are the **least effective** in providing appropriate support and referral information*
Our **faith** communities **can be** a caring congregation for persons living with a mental illness and their family members
37
Faith / Religion & stress - immune systems
Studies have shown a **positive** correlation between spiritual practices and **enhanced** immune system function and sense of well-being
38
Strategies for Caregivers
**Support**
Respite care
Mini-relaxations
**Nutrition**
Exercise
**Sleep**
Annual check up
Spiritual care
**Stress management**
Resilience
39
Annual Self-care
**Annual exam**
Vitamin D - sunlight (get alot of it)
Eye exam
Dental exam
Blood pressure
Complete metabolic levels, complete blood count
**Follow recommended treatments**.
40
What is VOLUNTARY ADMISSION
**no procedure** – patient signs self in and can sign self out with 24 hr letter.
41
**Two** ways to **start** commitment
**1)** Go to judge --- issues a MIW (mental illness warrant)
**2)** Call the police --- Determine danger --- APPOW (Apprehension by Police Officer Without a Warrant)
42
Comparison between
Voluntary & Involuntary committment
**Voluntary**
Patient signs a CONTRACT with facility allowing 24 hour hold before AMA release
**Involuntary**
Allows State of TX to hold citizen, against pt will, until psychiatric care provider deems no longer meets criteria or **90** days, ***whichever comes first***
*(Patient may invoke habeas corpus)* in an attempt to get released.
43
INVOLUNTARY ADMISSION steps
> **1)** EMERGENCY DETENTION -- using EITHER: a **MIW** (Mental ill warrent) OR an **APOWW** (apprehension by Police Officer without warrent)
>
> **2)** evaluation by 2 physicians to make sure legal criteria are met
>
> **3)** (2 possibilities) release persons who do not meet criteria OR retain person and ensure legal representation
>
> **4)** probable cause hearing – this ***results*** in the **OPC**
>
> **5)** (2 possibilities) patient does **not contest**, judge reviews documents and, if legal rules followed commit patient to **90 days**. OR – **patient contests** the commitment and has choices – (with or without their own lawyer) present their own case before the judge alone OR ask for a jury trial.
IF patient has already served 90 days and STILL meets criteria – there is another trial to commit for a longer period.( **EXTENDED MENTAL HEALTH SERVICES**)
44
Criteria for involuntary committment of
Mental Illness
**1.** Danger to Self
**2**. Danger to Others
**3**. Danger of deterioration of condition\*
\*Must be serious enough to cause substantial harm or death
45
What landmark suit establishes the “Duty to Warn” in many states?
**Tarasoff v. Regents** of the University of California
Pt. admitted to Doc intended harm to an ex-girlfriend... -- Doc told the authorities...
Pt still let go... - then killed the ex.
46
What is **delirium**
Delirium is characterized by an abrupt onset of **fluctuating levels** of awareness, clouded consciousness, perceptual disturbances, and **disturbed memory and orientation**
47
What is amnestic syndrome
Amnestic syndrome involves **memory impairment** **without** other cognitive problems.
Just lost ur memory
48
What health problems are seen in
Dementia
Lewy body disease,
frontal-temporal lobar degeneration,
and Huntington's disease.
49
What is Agnosia
Agnosia refers to the loss of sensory ability to **recognize** objects.
50
What is Aphasia
Aphasia refers to the loss of **language** ability.
51
What is Apraxia
Apraxia refers to the **loss** of **purposeful** **movement**
52
What is hyperorality
Hyperorality refers to **placing objects** in the **mouth**
53
What is Confabulation
Confabulation refers to **making up of stories** or answers to questions by a **person** who **does not remember.**
It is a **defensive tactic** to protect self-esteem and **prevent others** from **noticing** **memory loss.**
54
What are the stages of Alzheimer's disease
**1)** Preclinical Alzheimer’s disease
**2)** Mild cognitive decline
**3)** Moderately severe cognitive decline
**4)** Severe cognitive decline
55
**Mild cognitive** decline in Alzheimer's
Mild cognitive decline (**early-stage**) Alzheimer's
can be diagnosed in some, but not all, individuals. Symptoms include **misplacing items** and **misuse of words.**
56
**Moderately severe** cognitive decline in Alzheimer's
In the moderately severe stage, deterioration is evident. Memory loss may include the **inability to remember addresses or the date**.
Activities such as driving may become hazardous, and frustration by the **increasing difficulty of performing ordinary tasks** may be experienced.
The individual has difficulty with clothing selection
57
**Severe cognitive** decline in Alzheimer's
**personality changes** may take place, and the patient needs extensive help with daily activities.
58
What are some of the diagnostic findings for Alzheimer's
apolipoprotein E (apoE) malfunction,
**neurofibrillary tangles,**
neuronal degeneration in the hippocampus,
and **brain atrophy**
59
Four **Key** Concepts in the definition of a
**Crisis**
1) **A Crisis is an Acute Time-Limited Phenomenon**...a crisis will be resolved *w/i 4-6* weeks after exposure to the stressor
2) **A Crisis Results from Exposure to a Stressful Situation or Event**
3) **The Crisis Creates Emotional Distress**...person in crisis feels anxious, overwhelmed and out of control
4) **Existing Coping Skills Fail to Fix the Problem or Alleviate the Person’s Distress**
60
Types of Crises
- **Maturational Crisis**...Occurs when a person arrives at a new and predictable stage of development where previously used coping strategies are no longer effective or appropriate
- **Situational Crisis**...critical life event from an external source. can change self - concept & esteem. (divorce, death of a loved one...job loss)
- **Adventitious Crisis**... uplanned accidental or deliberate event not part of every day life. (Ie natural disasters / wars / murder / child abuse). ---
* Psychological first aid and crisis intervention are critical for persons of all ages after any adventitious crisis*
61
The **Evolution** of a Crisis
- **Phase I** Person is exposed to a crisis event which triggers anxiety (robbery) - Anxiety stimulates the use of problem-solving strategies and defense mechanisms to decrease distress
- **Phase II** Previously used coping skills fail to alleviate the problem (overload) - coping strategies become increasingly maladaptive as emotional distress increases
**Phase III** - Every internal and external resource is mobilized to solve the problem and relieve distress - Automatic relief behaviors such as withdrawal and flight are mobilized
**Phase IV** - The individual’s condition deteriorates as tension mounts, and “desperate measures” may be considered to alleviate distress (**Suicide?**)
62
What is Crisis Intervention?
A short-term helping process focused on resolution of the immediate problem through the use of personal, social and environmental resources
Crisis Intervention can be considered
**“Psychological First Aid”**
63
General Principles of Crisis Intervention
**Safety First** - Determine Whether There is an Immediate Need for External Controls --- All Clients in Crisis Should be Assessed for Suicidal and Homicidal Ideation (thoughts)
**Stabilization is the Goal** - Restoring equilibrium and returning the client to the pre-crisis level of functioning is the **objective**
64
Basic Model for Crisis Intervention
**Establish trust and develop rapport**...Explore the patient’s feelings
**Explore the problem**...Find out what happened
**Summarize both facts and feelings**...“You feel x because of y.”
**Focus on _one_ problem**...What does the patient want to change? What has to change in order for client to regain stability?
**Explore resources and alternatives**...Identify coping skills and resources
**Develop plan of action**...Consider contracting with client
65
Terminating with the Client in Crisis
Review accomplishments and discuss ways in which adaptive coping skills can be used to deal with crises in the future
66
Critical Incident Stress Debriefing
**(CISD)**
A group approach designed to help people who have been exposed to a crisis situation
Recent research suggests that it may not be as effective as once believed and may be harmful to
some people
67
Assualt def.
an intentional threat designed to make the victim fearful: produces reasonable apprehension of harm.
68
What is the concept of Justice
**fair distribution of care**, which includes treatment with the least restrictive methods
69
What is the concept of Beneficence
. Beneficence means promoting the good of others
70
What is the concept of Fidelity
*Fidelity* is the observance of loyalty and commitment to the patient.
71
autonomy def.
Autonomy is the right to self-determination, that is, to make one’s own decisions.
(e.g. acknowledging the pts right to refuse medicine promotes autonomy)
72
Tort
A tort is a civil wrong against a person that violates his or her rights.
ex. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus, false imprisonment is a possible charge.
73
battery def.
Battery is an intentional tort in which one individual violates the rights of another through **touching** without consent.
74
competency def.
is the capacity to understand the consequences of one's decision's
Pt.s are considered legally competent **until** they have been declared incompetent through a formal legal proceeding.
75
confidentiality def.
confidentiality of care and treatment remains an important right to all patients.
discussion or consultation involving a patient should be conducted discreetly and only w/individuals who have a NEED TO KNOW
**Can only be released by the pt.'s written consent**
The duty to warn a person whose life has been threatened by a psychiatric patient **overrides** the patient’s right to confidentiality.
76
duty to warn
1974
Tarasoff v. Regents of the University of California..was a case in which the Supreme Court of California held that mental health professionals **have** a **duty** to **protect individuals** who are being threatened with bodily harm **by a patient**.
It is the health care professional’s duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional.
77
false imprisonment def.
False imprisonment involves holding a competent person against his or her will.
Actual force is not a requirement for false imprisonment.
*The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat.*
78
involuntary admission def.
is admission to a facility **w/o** the patients consent.
generally necessary when a person is in need of psychiatrict treatment, **presents a danger to self or others**, or is unable to meet his / her own basic needs.
Pts. can be kept involuntarily for up to 90 days, w/interim court apprearances. After that a panel reviews their cases.
79
least restrictive environment def.
writ of habeas corpus and the least restrictive alternative doctrine are two of the most important concepts applicable to civil commitment cases.
Least restrictive **mandates** that the least drastic means be taken to achieve a specific purpose
*ex. if someone is being treated for depression only on an outpatient basis....then hospitalization would be too restrictive and unnecessarily disruptive.*
80
malpractice def.
malpractice is an act or omission to act that breaches the duty of due care and results in or is responsible for a persons injuries.
81
negligence def.
is the failure to use **ORDINARY** care in any professional or personal situation when you had a duty to do so.
ex. duty to drive safely...if you don't and cause an accident, you could be changed with negligence.
82
What are the five elements required to prove negligence?
**1)** duty
**2)** breach of duty
**3)** cause in fact
**4)** proximate cause
**5)** there were actual damages.
83
patient rights def.
Pt.s right have been modified over time, but the following are some of the basic patient rights: pg 101 - 106
- **Right** to treatment
- **Right** to refuse treatment
- **Right** to informed consent
- **Rights** regarding involuntary admission and advance psychiatric directives
- **Rights** regarding restraint and seclusion
- **Right** regarding Confidentiality
84
privileged communication def.
is that information / communication obtained between a patient / provider.
85
right to privacy def.
is legally protected by HIPAA (Health Insurance Protability and Accountability Act)
Release of information without patient authorization violates the patient’s right to privacy.
86
right to refuse treatment def.
Pts. may w/hold consent or withdrew constent to take medication at any time.
Commintment to a hospital facility does not mean they are forced to take medications....they retain their right to refuse treatment.
***THE ONLY* circumstance where medication will be forced is an emergency to prevent harm to self or others.**
87
right to treatment def.
Federal Statute 1964 - **Hospitalization of the Mentally ill**
All public hospitals are required to provide medical and psychiatric care to all persons admitted to a public facility.
**O'Conner v. Donaldson (1975)**
Court ruling that State cannot confine a non-dangerous individual who is able to survive in freedom by themself or w/help of family.
88
restraint def.
a restraint can be any **device, equipment or material** that prevents or reduces **movement** of the pt.s **arms/legs or head**.
restraints can also be chemical or even one individual holding another (Therapeutic hold).
89
**Pervasive** def.
90
**Conduct** **Disorder** def.
**Persistant pattern** of behavior in which the **rights of others are violated**
Age appropriate societal **norms/rules are disregarded**
91
**Resilience** def.
The ability to **adapt & cope**
Helps people to face tragedies, loss, trauma, & severe stress
92
**Temperament** def.
The style of **behavior** a child **habitually uses to cope** w/ the demands & expectations of the environment
93
**Etiological risk factors** for child/adolscent mental illness
_Biological factors_: **Genetic** & **Neurobiological**
* Resilience, intelligence & supportive environment aid in avoiding development of mental disorders
_Psychological factors_: **Temperament**; **fit w/ parents** is crucial to development. **Resilience**
_Environmental factors_: Dependent on **family**; witness **violence**; **neglect / sexual abuse**; **bullying**
_Cultural factors_: **Expectations**; **stigma** follows throughout lifespan
94
Risk factors that presents the highest chance for a child to develop a psychiatric disorder
Having a parent with a substance abuse problem has been designated an adverse psychosocial condition that increases the risk of a child developing a psychiatric condition.
Having a family history of schizophrenia presents a risk, but an **alcoholic parent** in the family offers a greater risk.
95
Factors that increase **resilience** in children/adolscents
Child's **inborn strengths**
Child's **success in handling stress** in the environment
96
**Characteristics** of a mentally
**healthy** **child/adolscent**
* **Trusts** others & sees his/her world as being safe & supportive
* **Correctly interprets reality**; makes accurate perceptions of the environment & one's ability to influence thru actions (i.e. self-determination)
* **Behaves in developmentally appropriate way**; doesn't violate social norms
* Has a **positive**, **realistic self-concept** & developing identity
* **Adapts** to **& copes** w/ anxiety & stress using age appropriate behavior
* Can **learn/master developmental tasks** & new situations
* **Expresses self** spontaneously & creatively
* Develops & maintains **satisfying relationships**
97
Behavioral characteristics of children with
**Pervasive Developmental Disorder**
(Autism, Aspergers, PDD NOS)
Autism is primarily biogenetic
98
Behavioral characteristics of children with
**Tourette's Disorder**
A motor (neurodevelopment) disorder
**Motor & verbal tics** appearing between age 2 & 7
Tics change in location, frequency & severity over time
Tics cause marked distress, significant impairment in social & occupational functioning, & low self-esteem
Disorder is **permanent**; periods of remission may occur
Symptoms often diminish in adolescence & may disappear by early adulthood
**Familial pattern** in 90% of cases
Often co-exists w/ depression, OCD, & ADHD
Treated w/ antipyschotic meds: **Hadol & Orap**
99
Behavioral characteristics of children with
**Attention Deficit / Hyperactivity Disorder**
**Inattention**
**Impulsive**
**Hyperactive**
Symptoms present **before age 7**
Symptoms must be present at **home & school**
Low frustration tolerance, temper outbursts
Poor school performance
Primarily biogenetic
100
Nursing interventions for child
**w/ADHD**
*"reduce loneliness and increase self-esteem."*
Because of their disruptive behaviors, children with ADHD often receive negative feedback from parents, teachers, and peers, **leading to self-esteem** disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to **loneliness**.
101
Behavioral characteristics of children with
**Separation Anxiety Disorder**
***Developmentally inappropriate*** levels of concern over being away from a significant other
May also be a fear that something horrible will happen to the other person resulting in permanent separation
Anxiety is so **intense** it distracts the pt from their norm activities, causes sleep disturbances & nightmares, is often manifested in GI disturbance & headaches
102
Behavioral characteristics of children with
**Conduct Disorder**
Disruptive/impulsive control behavior disorder ***thought to be caused by parenting***
**Cruel bahvior** to animals 1st then people
Violates rights & disregards norms (**truancy** before age 13, **alcohol &/or heavy drug abuse**, **running away**)
**Aggressive** & destructive (**vandalism**)
**Deceitfulness**
**Pyromania** and/or **Kleptomania**
Poor peer relationships; may be precursor to antisocial personality disorder
Meds for aggression, impulsivity & mood: **Risperdal**, **Zyprexa**, **Seroquel**, **Geodon**, & **Abilify**
103
Behavioral characteristics of children with
**Oppositional Defiant Disorder (ODD)**
Disruptive behavior disorder ***thought to be caused by parenting***
**Angry** & irritable; **temper tantrums past usual age**
Defiant & **vindictive**
**Disregard for authority**
Deliberately **annoys & blames**
**Distructive** (usually short of criminal)
Difficulty w/ home, school, peers
**_Not_** age limited but usually seen in **preteens**
Meds. not generally indicated but must treat comorbidity
104
**Disruptive Mood Dysregulation** disorder
**Frequent temper tantrums** (verbal / behavioral outbursts) **out of proportion to the situation & not developmentally age appropriate**
**Persistent irritable mood** btwn outbursts
Dx given to children btwn **ages 6 - 18** w/ no other medical/mental health dxs accounting for tempertantrums (i.e. autism)
105
Disruptive mood management
Time-out
Quiet Room
106
Behavioral characteristics of children with
**Mood Disorders**
(depression & bipolar disorder)
Core symptoms of depression in children/adolscents are same as for adults: sadness & anhedonia
Frequently assoc w/ anxiety & anger
Symptoms display differently in children/adolscents.
* **very young** children **cry**
* **school age** children are **withdrawn**
* **teens** become **irritable** in response to feeling sad / hopeless
Generally, depressed children/adolscents display increased **irritability**, **negativity**, **isolation**, & **w/drawl** along w/ **loss of energy**.
Younger children may suddenly **refuse to go to school**.
Adolscents may engage in **substance abuse** or **sexual promiscuity** & become **preoccupied w/ death or suicide**.
**Bipolar** is **more severe** if starts in childhood/teens.
Youth w/ **bipolar** have **more frequent mood switches**, **more mixed emotions**, are **sick more often**, & have **greater suicide attempts**.
107
**General interventions** for children/adolscents
**Family therapy**
* specifical goals defined for ea family member
**Group therapy** - used for breavement, physical abuse, substance use, dating, or chronic illness (diabetes)
* young child: play therapy
* school-aged child: combines play, learning skills, & talking about activity; aids w/ social skills
* adolscent: popular media event/personality used as basis for discussion
**Behavioral therapy**
* behavior modification
* rewards desired behaviors to reduce maladaptive behaviors
* **use least restrictive intervention**
**Cognitive-Behavioral therapy (CBT)**
* negative/self-defeating thoughts are replaced by more realistic & accurate appraisals
* results in improved functioning
108
**Nursing interventions** to alter behavior in
children/adolscents with mental illness
**Physical problems** have higher **priority** than mind/behavior problems
Parent training (positive parenting)
Behavioral therapies
Milieu therapy
Psychopharmacology
109
What are the characterisitc's of a time out
Time-out is designed so that staff can be consistent in their interventions.
Time-out may require going to a designated room or sitting on the periphery of an activity until the child gains self-control
110
Teaching for parents of
children/adolscents with
mental illness
**Predict & prevent**
**Act EARLY** to stop escalation
Provide **safety**
**Causes & prevention** of non-genetic types of disorders
**Parental expectations** of behaviors
**Behavioral control** of socially unacceptable behaviors
111
Psychoactive medications for
children/adolscents
**Stimulants** excite neurons responsible for focus
112
Mental Health Assessment differences
for children vs. adults
Who is interviewed?
How is interview conducted?
Data collected:
113
Psychosocial **risk factors** that
predispose children/adolscents
to **Conduct Disorder**
ADHD
Oppositional child behaviors
Parental rejection
Inconsistent parenting w/ harsh discipline
Early institutional living
Chaotic home life
Large family size
Absent or alcoholic father
Antisocial & drug-dependent family members
Association w/ delinquent peers
114
**Prevention strategies** for
**Conduct Disorder**
115
**Parent teaching** for managing
child's behavior at home
* **Behavior modification** - use it **RIGHT** or NOT AT ALL
* Rewards occur **ALL THE TIME** but to effect **change** you **MUST** PLAN
* **Punishment** is **not allowed**
* **Extinction** - ignoring / not reacting to behavior will prevent the "reward"
\*RNs don't have time or relationship to use extinction
116
**Milieu** characteristics for
children/adolscents with
**ADHD** and/or **Disruptive Behavior Disorders**
manage the milieu with **structure** and **limit setting**
117
**Medication** class most commonly
prescribed for **ADHD**
& med side effects
**Stimulants**
Methyphenidate (Ritalin)
s/e...The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia
Weight loss has the potential to interfere with the child’s growth and development.
118
What are some of the approaches valued by other cultures but not America?
*Present orientation, interdependence, and a flexible perception of time* **are not** valued in Western culture
These views are more predominant in other cultures
119
What is a highly valued approach in Western Cultures, but not other cultures.
Directly confronting problems is a highly valued approach in the American culture **but not** part of many other cultures in which harmony and restraint are valued
American nurses sometimes mistakenly think that all patients should take direct action.
120
What is Culutral competence?
Cultural competence is dependent on understanding the beliefs and values of members of a different culture.
A nurse who works with an individual or group of a culture different from his or her own must be open to learning about the culture.
121
To provide culturally competent care,
identify strategies that fit within the cultural context of the patient
122
What is valued in Hispanic Cultures
Hispanic individuals usually value **relationship behaviors.**
Their needs are for learning through **verbal** communication rather than reading and for having time to chat before approaching the task.
Many people from Central American cultures express distress in somatic terms
123
How do Asian Americans express psychological distress
Asian Americans commonly express psychological distress as a **physical problem.**
The patient may believe psychological problems are caused by a physical **imbalance.**
The patient will probably respond best to a therapist who is perceived as giving.
124
Communication techniques effective for Native American pt.s
Soft voice; break eye contact occasionally; general leads and reflective techniques.
Native American culture stresses living in **harmony with nature.** Cooperative, sharing styles rather than competitive or intrusive approaches are preferred;
thus, the more passive style described would be best received.
125
W/an Asian pt. with mental illness, what type of intervention best fits this culture?
The Asian community **values** the **family** in caring for each other.
The Asian community uses traditional medicines and healers, including herbs for mental symptoms.
The Asian community describes **illness in somatic terms**.
The Asian community attaches a **stigma to mental illness**, so interfacing with the community would not be appealing
126
What is the Western, biomedical prespective on health and illness?
The Western biomedical perspective holds the belief that sick people should be as independent and self-reliant as possible.
Self-care is encouraged; one gets better by “getting up and getting going.”
An ability to function at a high level is valued.
127
What is a Culture-bound syndrome
Culture-bound syndromes occur in specific sociocultural contexts and are easily recognized by people in those cultures.
A syndrome recognized in parts of Southeast Asia is running amok, in which a person (usually a male) runs around engaging in furious, almost indiscriminate violent behavior.
128
What is Wind Illness?
Wind illness is a culture-bound syndrome found in the Chinese and Vietnamese population.
It is **characterized** by a **fear of cold, wind, or drafts**. It is treated by keeping very warm and avoiding foods, drinks, and herbs that are cold.
**Warm broth** would be most in sync with the patient’s culture and provide the most comfort.
129
Amoung different Cultures -- are there difference in metabolic pharmacokinetics of pshychotrophic drugs?
**YES**
Cytochrome enzyme systems,
which **vary** among different cultural groups, influence the rate of metabolism of psychoactive drugs
130
Know the following Culture-Bound Syndromes & the pts. heritage
## Footnote
**Culture-Bound Syndrome****heritage**
- Ataque de nervios Latin American
- Ghost Sickness Navajo
- Hwa-byung Korean
- Susto Latin American
- Wind Illness Chinese
131
What is the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
The DSM-5 classifies disorders people have rather than people themselves
132
“What is the most prevalent mental disorder in the United States?”
The 12-month prevalence for **Alzheimer’s disease** is 10% for persons older than 65 and 50% for persons older than 85.
133
What is **Clinical epidemiology**?
A broad field that addresses **studies** of the **natural history** (or what happens if there is no treatment & the problem is left to run its course) **of an illness**, studies of **diagnostic screening** tests, & observational/experimental studies of **interventions** used to treat people w/ the illness or symptoms.
134
What does **Prevalence** refer to?
The **number** of **new cases**
135
What does **Incidence** refer to?
The number of **new cases** of mental disorders in a healthy population **within a given period**.
136
What areas of care are promoted by QSEN
The key areas of care promoted by QSEN are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
137
**Body image** in eating disorders
Perception is never reality
A distorted body image is DELUSIONAL
& will not chg w/ reasoning
(no nursing interventions will work)
138
Eating disorder facts
* Complex medical/psychiatric **illness**
* Disease of **control** (pt can control eating)
* Anorexia is 3rd most common chronic illness
* Genetic, biological, behavioral, social, & psychological factors
* **Develop over time**
* Occurs across all socioeconomic & age groups
* Bulimia is **life-threatening**; highest mortality rate of all mental illnesses
* Causes are **multifactoral**
* **Global** issue
139
**Anorexia Nervosa** characteristics
Restricted calories w/ significantly low BMI
**Low body wt** (\<85%)
Intense **fear** of gaining wt
**Distorted** body image
Extreme focus on shape / wt
Amenorrhea
**Denial** of illness (secretive)
140
Types of Anorexia Nervosa
_2 types_:
* **Restricting** - no consistent bulimic features
* **Binge-Eating** - primarily restriction, some bulimic behaviors
141
Anorexic issues
* How can I appear perfect?
* What is this feeling?
* **When I eat, I feel sick**.
* **No energy**
* **No sleep** (not just insomnia)
* **No peristalsis**
* **No appetite** (not the same as hunger)
* **No control**
* **No future**
* I HATE **being me**
* Nobody can love ME the way I am
142
**Thoughts & behaviors** assoc.
w/ **Anorexia Nervosa**
* Terror of gaining wt; **repeated re-weighting of self**
* **Preoccupation w/ thoughts of food**
* View of self as fat even when **emaciated**
* Peculiar handling of food; cutting into **mini bites**
* **Food portioning** (eats sm amts of certain foods)
* Pushing pieces of food around plate
* Poss. development of **rigorous exercise** regimen / hyperactivity
* Poss. self-induced vomiting, misuse of laxatives/diuretics
* Cognition so distrubed that pt **judges self-worth by his/her wt**
143
**Personality traits** of pt
w/ **Anorexia** Nervosa
Perfectionism
Obsessive thoughts & actions r/t food
Intense feelings of shame
People pleasing
Need to have complete control over their therapy
144
Anorexia Nervosa **assessment**
Eating habits
History of dieting
Methods used to achieve wt control (restricting, purgeing, exercising)
Value attached to a specific shape & wt
Interpersonal & social functioning
Mental status & physiological parameters
145
**Physical** presentation of
**Anorexia** Nervosa
* **Low body wt** r/t caloric restriction / excessive exercise
* **Amenorrhea** d/t low wt
* **Lanugo** & thin, brittle hair d/t starvation
* **Cold** extremities/cold intolerance/hypothermia d/t starvation
* **Peripheral edema** d/t **hypoalbuminemia** & refeeding
* **Muscle weakening**/**letheragy** d/t starvation & electrolyte imbalance
* **Constipation** d/t starvation
* **Cardio abnormalities** (hypotension, bradycardia, HF) d/t starvation & **dehydration**
* **Impaired renal function** , **low urine output**, **increased urine concentration** d/t dehydration
* **Hypokalemia** d/t starvation
* **Decreased bone density**
* **Dry skin** d/t dehydration
146
**Psychological** presentation of
**Anorexia** Nervosa
* **Disturbed body image**
* excessive self-monitoring
* describes self as fat despite emaciation
* **Ineffective coping**
* destructive behavior toward self
* poor concentration
* inability to meet role expectations
* inadequate problem solving
* **Chronic low self-esteem**
* rejects positive feedback about self
* reports feelings of shame
* lack of eye contact
* passive
* indecisive behavior
* **Powerlessness**
147
Anorexia **complications**
**Hormonal chgs**
**Cardiac issues** (leaky heart valves, orthostatic pulse & BP chgs, prolonged QT, ST-T wave abnormalities) & **arrhythmias**
**Edema** (ankle & periorbital)
**Electrolyte imbalances** (lead to fatigue, weakness, letheragy)
**Infertility**
**Bone density loss** (osteoporosis)
**Anemia**
Neuro problems (**peripheral neuropathy**)
**Death**
148
What is **Refeeding**?
Refeeding resulting in too-rapid weight gain & can overwhelm the **heart,** resulting in cardiovascular collapse.
*Deadly complication* of treatment involving *metabolic alteration* in serum electrolytes, vitamin defciencies, & sodium retention.
**Focused assessment** is a necessity to ensure the patient’s physiological integrity.
149
**Bulimia Nervosa** characteristics
Cycle of **bingeing/purging (1x per wk x 3 mo)**
Feeling out of control
**Compensatory behaviors** (self-induced vomiting, excessive exercising, fasting, laxative/diuretic misuse)
Usually **normal body wt**
**Self-image largely influenced by body image**
150
Types of Bulimia Nervosa
_2 types_:
* **Purging** - self induced vomiting or laxative/diuretic misuse
* **Non-Purging** - excessive exercising or fasting
151
Bulimic issues
* How can I appear perfect?
* What is this feeling?
* **I eat to fill the void.**
* lack of emotion / emotional pain drives binge
* **I rid myself of food to get rid of the tension**.
* I HATE **being this way**. MAKE it STOP.
* Nobody can love ME the way I am.
152
Thoughts & behaviors assoc.
w/ Bulimia Nervosa
* Binge eating behavior
* Often self-induced vomiting (or laxative/diuretic use) after bingeing
* Hx of anorexia nervosa in 1/4 - 1/3 of pts
* Depressive signs & symptoms
* Problems w/:
* interpersonal relationships
* self-concept
* **impulsive behaviors**
* Increase levels of anxiety & **compulsivity**
* Poss. chemical dependency
* Poss. impulsive stealing
* Family relationships usually chaotic & lack nurturing
* Life reflects instability & troublesome interpersonal relationships
153
Bulimia Nervosa **assessment**
Are you satisfied w/ your eating habits?
Do you ever eat in secret?
154
**Physical** presentation of
**Bulimia** Nervosa
* **Normal to slightly low wt** r/t excessive caloric intake w/ purgeing or excessive exercise
* **Dental caries** & tooth **erosion** r/t vomiting
* **Puffy cheeks / parotid swelling** (enlarged salivary glands) d/t **increased serum amylase** levels
* Gastric dilation / rupture r/t binge eating
* **Callused**, **ulcered**, or **scarred knuckles** r/t vomiting
* Swollen hands / feet (peripheral edema) d/t rebound fluid (seen w/ diuretic use)
* Weakness & fatigue d/t electrolyte imbalances
* Menstrual irregularities
* Abdmonial pain
* **Sore throat**
155
**Psychological** presentation
of **Bulimia** Nervosa
* **Disturbed body image**
* obsession w/ body
* denial of problems
* dissatisfaction w/ appearance
* **Ineffective coping**
* obsessed w/ food
* substance abuse
* impulsive responses to problems
* misuse of laxatives/diuretics/enemas
* fasting
* inadequate problem solving
* **Chronic low self-esteem**
* feelings of shame / guilt
* views self as unable to deal w/ events
* *excessive seeking of reassurance*
* **Powerlessness**
* loss of control w/ binge/purge cycle
* **Social isolation**
* absence of supportive significant other(s)
* hides eating behaviors from others
* reports feelign alone
156
Bulimia complications
**Tooth erosion**, **cavities, gum disease**
**Water retention** / abd bloating
**Low serum potassium**
Irregular menstrual cycles
**Swallowing problems** & **esophagus damage** (perforation)
**Salivary gland hypertrophy**
**Petechiae**
**Hematemesis**
157
**Priority interventions** for **Bulimia Nervosa**
* **Change** dysfunctional **eating behavoirs**
* **Prevent** use of dysfunctional **compensation**
* monitor bathroom use after meals
* ensure pt doesn't purge or exercise w/o staff knowledge
* **Maintain physical integrity**
* **Boost self-esteem**
158
What is the priority information that a nurse should provide for a pt. w/ binge-purge bulimia
**How to recognize hypokalemia**
Hypokalemia results from potassium loss associated w/ vomiting. Physiological integrity can be maintained if the pt can self-diagnose potassium deficiency & adjust the diet or seek medical assistance.
Self-monitoring of daily food & fluid intake is _not_ useful if the pt purges.
159
**Binge Eating** Disorder
(BED)
**Recurring episodes** (\>/= 1x wk x **3 mo**)
Feeling of shame, guilt, embarrassment & disgust
_NO_ use of _compensatory behavoirs_
Common SE is **obesity**
160
**Psychological** presentation
w/ **BED**
* **Disturbed body image**
* embarassment d/t wt gain
* fear of negative rxn by others
* attempts to hide wt gain
* body dissatisfaction
* **Ineffective coping**
* *eats as coping method*
* absence of other/more effective coping methods
* *eats when full*
* **Anxiety**
* feelings of discomfort/dread
* feelings of inadequacy
* focused on self
* increased wariness
* irritability
* **Chronic low self-esteem**
* feelings of shame/guilt
* views self as unable to deal w/ events
* **Powerlessness**
* loss of control of eating
* **Social isolation**
* absence of supportive significant other(s)
* *eats normally in presence of others*
* hides eating behaviors
* reports feeling alone
161
**Avoidant/Restrictive Food Intake** Disorder
(ARFID)
Individual **restricts food intake** & experiences significant associated physological / psychosocial problems but *doesn't met criteria for any other eating disorder*.
* difficulty digesting certain foods
* avoids certain colors / textures of foods
* eats only **very small portions** / **no appetite**
* **afraid to eat** after *freightening episode of choking* / *vomiting*
Significantly **low BMI**; dependent on **enteral feeding** or experiencing nutritional deficiencies
**No distortion of body image**
Symptoms show up in infancy / childhood
162
## Footnote
**PICA**
Ingestion of **non-nutritive substances** past toddlerhood
Varies w/ age & availability
Occurs in pregnancy, children, iron deficient adults, & institutionalized persons
Not culturally sanctioned
Not part of any other mental illness
_Psych comorbidities_: IDD, Austism, OCD, Schizophrenia, Trichotillomania (if hair ingested)
163
**Rumination** Disorder
**Repeated regurgitation** of food
Regurgitate, re-chew, spit out or re-swallow
No GI or medical reason
Behavior is volitional (done willingly)
Occurs in secret
Not part of other mental illness/eating disorder
_Psych comorbidities_: IDD & generalized anxiety disorder
164
**Assessment** in eating disorders
_Daily_ physical assessments needed
Height, weight (blind wts), & muscle mass
Electrolytes
Cardiac function
Bradycardia, orthostatic hypotension
Amenorrhea
Mood changes
Use of enemas, laxatives, diuretics, diet pills
Dental caries, sore throat, calloused fingers
Cold intolerance
Hair loss
I & O
165
Psychiatric comorbidity
of eating disorders
(co-existing psych & physical disorders)
**Depression**
**Anxiety** (r/t food)
**OCD**
Substance abuse
Personality disorders
Bipolar
Obesity
166
**Treatment goals** for eating disorders
Refeed
Stabilize wt
Resolve cognitive distortions
Normalize eating
Treat comorbidities
Improve family relationships
Understand importance of balanced nutrition
Develop age-appropriate identity
167
Treatment Team
Psychiatrist
Psychologist
RN
Dietician
Social Worker (family therapist)
Milieu therapist (PCT)
Art / Music / Recreational therapists
168
**Treatment** of eating disorders
* Restore pt to **healthy wt**
* wt gain of **0.2 kg/day** *(slow & steady)*
* food intake must be increased slowly to prevent stressing heart
* Treat **psych issues** r/t eating disorder
* Reduce / eliminate **behaviors or thoughts** that lead to disordered eating; prevent relapse
* Control issues: do NOT agrue over wt; **emphasize HEALTH not wt**.; avoid coerision
* **Behavior modification** can help decrease manipulative behavior (CBT)
169
**Interventions** for eating disorders
Medications:
* **Prozac** (fluoxetine) _or_ **Zoloft** (sertraline)
* **Zyprexa** (olanzapine) - antipsychotic helps w/ distored thoughts
**Psychotherapy** (group & individual)
**Behavior modification**
* promote behaviors that contribute to wt gain
* limit wt-loss behaviors
**Monitoring**
* physiological parameters (vitals, electrolytes)
* wt routinely
* daily caloric intake & fluid I&Os
* restrict food to scheduled, pre-served meals/snacks
* observe during & after meals/snacks
* accompany to bathroom designated observation times; limit time spent in bathroom if not observed
* limit physical activity
**Support**
* use behavioral contracting w/ pt to elicit desired wt gain
* reinforce wt gain & behaviors that promote it
* assist pt to develop self-esteem compatible w/ healthy body wt
**Promote increased independence**
* allow opportunity to make choices about eating & exercise as wt gain progresses
**Remove anger** / **anxiety** from eating situation (keep conversations light)
Well-balanced meals & adaquate calories (**meal plans**)
Be a **role model**
170
Priority **milieu interventions**
* Support restorative wt gain & normalization of eating patterns
* Close supervision of pt's eating
* Prevention of exercise & purging
* **Strict adherence to menus**
* Observe pt during/after meals to prevent throwing away food or purging
* Monitor all trips to the bathroom
* **Structured mealtimes** (not flexible)
* **Regularly scheduled weighing**
* **Privileges** correlated w/ **wt gain** & **trmt plan compliance**
171
**Medication issues**
with eating disorders
* **TCAs** & **SSRI** - prevent relapse in _Bulimia_
* **Zyprexa** - used to control _anxiety_; tends to cause wt gain
* **Antianxiolytic** agents are **contraindicated**
* **Wellbutrin contraindicated** in _Bulimics_
* MAOIs are _not_ indicated
* **Beta Blockers** are **contraindicated**
172
**Psychiatric criteria for hospitalization**
with eating disorders
* **Suicidal ideation** or severely out of control, self-mutilating behaviors
* **Out of control use** of laxatives, emetics, diuretics, or street drugs
* **Failure to comply** w/ trmt contract
* **Severe depression**
* Acute **psychosis**
* **Family** crisis or dysfunction
\**pt must be physiologically stable to come to psych unit*
173
**Physical criteria for hospitalization**
with eating disorders
* Wt loss \> **30% over 6 mo**. (severe malnutrition \< 75% of normal body wt)
* Rapid decline in wt
* Inability to gain wt w/ outpt trmt
* Physiologic instability
* Severe hypothermia d/t loss of sub-Q tissue or dehydration (**body temp \< 36oC or 96.8oF**)
* Bradycardia (**HR\<40**)
* Hypotension (**systolic \< 70**)
* **Electrolyte imbalances** *not corrected by oral supplmentation*
* hypokalemia
* hyponatremia
* hypophosphatemia
* Cardiac **dysrhythmias**
174
What is Acculturation
is learning the beliefs, values, and practices of a new cultural setting, which sometimes takes several generations
175
What is enculturation
is a process where members of a group are introduced to the culture’s worldview, beliefs, values, and practices
