Midterm #2 Flashcards
1
Q
What is continuum of care?
A
integrated system of care
*involves services & integrating mechanisms that guide people over time
physical/mental/social services with all levels of intensity
2
Q
3 major forces driving continuum of care
A
1) Decreased length of hospital stay
2) Movement towards more home care/community care e.g. increased family involvement in care
3) Regionalization
3
Q
2 goals of continuum of care
A
to provide seamless care from hospital to home
(pt/family educated on what to expect)
to maintain quality/continuity of patient care in different environments
4
Q
what is seamless care
A
is a smooth and safe transition of a patient from the hospital to the home.
5
Q
what is continuity of patient care?
A
personalized, continuous care that begins at point of entry into HC system until problems/needs resolved
6
Q
how to ensure continuity of patient care
A
interpersonal/interdisciplinary practice
collaboration/communication
focus on patient/family
7
Q
Regionalization history
A
emerged in 1993 in New Directions for Health BC
1996: downsized from 20 to 11
2002: downsized to 6 (5 geographical, 1 provincial)
8
Q
5 goals of regionalization
A
to integrate continuum of care concept
looks at unique health needs of each community
to promote collaboration/communication between agencies
to ensure patient-centered care via interdisciplinary teams
to reduce agency centeredness (decreasing cost/resource waste)
9
Q
How many stages are in discharge planning for nurses?
When does it begin?
A
4 stages
Begins upon admission
10
Q
Stage 1
A
The nurses role at first point of contact with hospital:
Involves:
admission assessment
full dimensional: home environment, social supports, preferences
getting to know patient
11
Q
Stage 2
A
Nurse as the patient advocate
Involves:
other HCP (referrals, family conference)
initial d/c date is decided
12
Q
Stage 3
A
Getting ready to go home
Nurse contacts community team
13
Q
Stage 4
A
Transition back home or to another facility
Involves other services: home health, patient, family, PT, OT etc.
14
Q
5 components of an effective discharge
A
1) occurs in stages
2) Inter-professional collaboration
3) Good timing and receipt of information
4) Clear communication (pt, family, PT, community resources)
5) “Close the loop” and “fill in the picture”
15
Q
5 Barriers to discharge planning
A
Time Cost Lack of motivation Patient being overwhelmed Communication barriers
16
Q
3 benefits to discharge planning for the patient/HCP
A
patient:
Improved quality of care -> improved outcome
Decreased hospital stays
Improved pt/family fears/anxiety
HCP:
Increased awareness of resources
Decreased frustration
More efficient use of professional time
17
Q
4 key objectives to delivery of home care*
A
1) Provide the support necessary for clients to remain in their own homes
2) Provide at-home services to clients who would otherwise require admission to hospital
3) Provide assisted living and residential care services to clients who can no longer be effectively supported in their own homes
4) Provide End of Life Care
18
Q
Home health philosophy
2 points
A
promote well-being, dignity, independence of both pt. & family
to offer support (not replace) and complement care provided by clients/families/community services
19
Q
4 Principles guiding home care philosophy
A
Ensure informed decision making
Clients have right to make own care decisions including right to ‘live at risk’
Care will *supplement/complement but NOT replace client’s efforts to care for self *
HHC services will promote the well-being, dignity and independence of clients
20
Q
3 triggers for home health:
A
D/C from hospital r/t acute event i.e. CVA
Worsening of chronic health condition requiring more care than available in home setting
Person with ongoing difficult health issues finding it more and more difficult to care for themselves at home.
21
Q
Who can make a referral for home care
A
Clients Family Physicians Concerned neighbours/friends The hospital
All referrals go through HHC office Intake nurse
22
Q
Home health intake process
Community vs. Hospital
A
Within Community:
All referral sent to HHC office intake nurse
Nurse screen referral & prioritizes it (1-3)
Nurse forwards referral to appropriate discipline
Within Hospital:
In hospital referalls made online
The Hospital Liaison Nurse will respond to discharge planning needs that arise
23
Q
Home health professionals involve..
A
Case Managers
Liaison Nurse ( formerly known as Hospital Case Managers)
Home Care Nurses(RNs & LPNs)
Social Worker/Palliative Social Worker
Rehabilitation Therapists (OT/PT)
24
Q
5 steps to case management?
A
- comprehensive assessment- I.D. strengths/weaknesses
- develop individualized care plan
- arrange various services
- monitor ongoing client needs
- re-assess/review care plan
25
purpose of long-term care
to assist adults with chronic health related issues to maintain optimal level of independent functioning
26
3 common health care resources that case managers use
Respite/Respite Beds
Community Health Workers
Residential Care
27
3 common community resources that case managers use
Family/friend support & other support groups
Life Line
Shopping Programs
28
7 functions of home care RNs
*Coordinate care
Assess
Teach
Support/counsel
Direct Care
Referrals
End of Life Care
29
home care LPN functions
Simple dressings
DOTs ( e.g..medication management, catheter care, eye drops, ostomy care)
30
What do rehab therapists do?
Includes OT and PT
```
Assesses:
safety in home
equipment needs
mobility/adaptive aids
falls prevention
post surgical therapy
```
31
What do social workers do?
Assisting with complex care needs of clients including:
financial assistance
housing issues
drug and alcohol issues
abuse issues
32
Criteria for costs of home health
Which program they are on
i.e. if the client is palliative they receive 6 months free service.
If the client is coming out of hospital they will likely get 2 weeks free
If the client is to receive services for an extended time then the charge is based on a financial assessment which will be made by HHC Case Manager.
33
Who is eligible to receive home care servies?
- Canadian Citizen/landed immigrant status
- BC residency
- Require care following D/C from hospital, care at home rather than hospital, or care because of a terminal illness
- Have a local doctor
We do not serve:
Persons whose primary handicap is developmental disability.
34
Who is eligible for subsidized services? (financial support)
Under 19 years of age
Lived in BC for 3 months
Canadian citizen or permanent resident status*
Unable to function independently d/t chronicity or terminal illness
35
what are DOT's?
Delegation of tasks
DOT’s are often for medication management, catheter care, eye drops, ostomy care
36
What is cognition?
| "PR-JIM"
Cognition refers to a system of interrelated abilities that allows us to be aware of ourselves/our surroundings
```
Perception
Reasoning
Judgment
Intuition
Memory
```
37
Types of cognitive disorders
Dementia
Delirium
Depression
38
What are amnestic disorders?
memory impairment not related to cognitive disorders
e.g. exposure to environmental toxins
substance abuse
head trauma
39
What is delirium?
An acute cognitive impairment
reversible
symptoms may differ
40
3 causes of delirium?
Medical conditions: acute crisis, Infections, F&E imbalances, hypoxia/ischemia
Medications & substances (surgical sedatives)
Elderly (65-75)
Unknown factors
41
4 types of delirium
hypoactive/mild (Lethargic/depressed, fatigued/drowsiness- highest mortality rate)
hypoactive/severe (more intense symptoms)
hyperactive (Psychomotor agitation, aroused/restless)
Mixed
42
Delirium interventions
Bed alarm
one-to-one
"soft" restraints (e.g. pelvic restraints, wrist constraints)
43
What is dementia
Global, *chronic* cognitive impairment
irreversible & progressive
Symptoms are the same no matter what the cause
44
5 types of dementia
```
Alzheimer’s
vascular dementia
dementias 2o to medical condition
dementias 2o to substance uses
dementias with mixed / unknown causes
```
*different dementias effect different areas of brain
45
Causes of dementia
anything that damages brain cells- depends on type of dementia
Multiple theories (plaques, tangles, cell death, genetics)
not a disease- but can occur as a result of diseases (CVA, Parkinson's, head trauma)
46
Hippocampus function
formation of memories (long-term)
shrinks in dementia
47
Parietal lobe function
sensation & sensory processing
48
Occipital lobe function
visual reception and interpretation
49
Cerebellum function
movement
| muscle coord
50
Temporal lobe function
Language
Learning
Short-term memory
51
Frontal lobe function
Thought processing
Language output
Programming of activities
Prioritization
Personality
Bheaviour
52
Difference between delirium/dementia/depression
** see chart
53
6 Risk factors for delirium
Age
Admission to new facility
pre-existing dementia
poly-pharmacy
changes in vitals
pain
54
Diagnostics for delirium
Note cognitive changes
review patient history
assessment
55
S&S of delirium
changes in:
A&O, focus, speech, language, memory
insomnia
social changes
fluctuating symptoms throughout the day.
56
3 priorities for delirium
Elimination or correction of underlying causes
Symptomatic measures e.g. treat cause of Delirium such as UTI
Supportive measures e.g. bring patient by nurses station
57
Interventions for delirium:
| physiological/psych/social
physiological: assessment, labs, meds, safety checks, avoid anticholinergics
psychological: MSE, reduce stimuli, non pharmacological comfort measures e.g. pets, warm blankets
social: family roles, social supports, providing information
58
Why avoid anticholinergics with delirium
further depresses the CNS
59
Delirium prognosis
Reversible if treated
Often causes lasting complications e.g. higher risk of developing dementia
60
Risk factors for dementia
Age (65+)
genetics
Down's syndrome/Parkinsons
Cardiac disease
Head trauma
lower socioeconomic status
lifestyle factors
exposure to viruses/environmental toxins
61
5 Diagnostics for Dementia
Aphasia: alterations in language/speech
Agnosia: failure to recognize/identify objects
Apraxia: impaired motor activity
Disturbance of executive functioning - Ability to think abstractly, plan, initiate, stop inappropriate behaviour
Significant decline in normal functioning
62
4 priorities with dementia
Delay cognitive decline
Attend to physical needs
Protect from harm
Support family members
63
Interventions for dementia
| psych/physical/social
Physiological interventions:
Promote self-care, monitor activity, nutrition, bowel/bladder, sleep/wake cycle, PRN meds
Psychological interventions:
Validation, tools for memory enhancement (pictures, whiteboard),
Social interventions: encourage participation, alter environment, home visits, create a home-style atmosphere
64
Alzheimers
| 4 points
memory/ADL impairments
effects all areas of brain
more common in women
the younger the age, the more rapid/severe
65
```
Vascular dementia
(3 points)
```
Symptoms dependent on area effected
Executive functioning goes early
Cerebrovascular lesions
Sudden onset & step wise progression
66
What medical conditions often result in dementia
AIDS
syphillis
Parkisons
Huntingdons
head trauma
hydrocephalus
meningitis
67
Substance induced dementia causes
drugs, alcohol, environmental toxins, Korsakoff's
68
Types of mixed dementia
Lewy body, frontotemporal lobe dementia
69
What does cognitive assessments involve?
```
MMSE
A&O (person,place,time)
Attention span
Speech
Appearance (appropriateness)
```
Ask family questions
Compare to baseline/chart
How well they attend to ADL's
Spatial recognition (unable to find front door)
70
What is poverty?
Material/social deprivation d/t political/public policies re: distribution of resources in the community
71
4 types of poverty
Absolute:
no resources to meet basic biological/physical needs
Relative:
standards/resources below average person
Low income cut-off line (*LICO*):
majority of income is spent on basic needs, strained compared to other average families
Core need:
Household falling below 1 or more standards: adequacy, suitability, affordability.
*Use 50% or more of TOTAL household income for rent
e.g. pay rent/bills or feed children
72
What does homelessness result in?
powerlessness
hopelessness
vulnerability
decreased resiliency
73
continuum of homelessness
from inadequate housing, to living in shelters, to absolute homelessness
74
Two categories of homelessness
Absolute (primary)
| Relative (secondary)
75
What is absolute homelessness
Totally without shelter of any kind
| Basic needs totally unmet
76
What is relative homelessness
Does not meet basic needs as defined by UN
```
protection from elements
secure/personal safety
Safe water/sanitation
access to employment/education/health care
affordable
```
77
4 types of homelessness
Chronic: long-term, engage in substance abuse, psychiatric problems
Periodic: temporary, leave home when tensions/pressures become intense
Temporary: result of crises from situational transition
At risk: too much of household income going to rent
78
Causes of homelessness
1) structural factors
2) personal factors
** see powerpoint for more specific
79
Structural factors resulting in homelessness
social safety-net cutbacks:
e.g. government policies/programs cut back on disability, EI
broader macro-economic & societal factors:
e.g. globalization, changed social contract, less job security, less affordable housing available
80
Personal factors resulting in homelessness
Morals (deserving poor vs. undeserving poor)...
| leading to various discourses*
81
What are discourses
the way which society chooses to make sense of phenomenon
82
Types of discourses r/t homelessness
Neo-liberal
| Conservatism
83
Neo-liberal discourses
Believe that government/state interferes with the operation of market/economy to provide benefits r/t welfare
84
Neo-liberal discourse history
1990- federal public policy changes
Chretien government withdrawal funding/involvement with affordable housing initiatives, more funding put towards business/trade
as a result increase in homelessness
85
Neo-conservatism discourse
Similar to neo-liberal discourse but adds moral tone by *attributing blame to those who are poor* (Campbell-BC, Klein-Alberta)
people living in poverty are responsible for themselves
other provinces express this more subtly via decreasing funding/not raising minimum wage
86
What does neo-conservative discourses result in
poor bashing
blaming the poor --> ostracism
disrespectful treatment
87
Types of discourses related to poverty
```
Moral underclass (MUD)
Social Integrationist (SID)
Redistributionist (RED)
```
88
MUD
believes that the underclass or socially excluded individuals are culturally different from mainstream
```
Impacts public policies re:
social assistance
minimum wage
EI eligibility
resulting in: difficult living conditions for those who rely on these services, "poor bashing" - stigmatization- adding psychological/social insult to the exisiting difficulties, become more dependent
```
89
SID
Believe in coercing non-working individuals into *paid-labour*
e.g. punitive workfare initiative programs across Canada
Hides issues of inequality of paid workers
e.g. ignores gender issues (men being paid more)
90
RED
Believe that poverty is caused by social exclusion
Believes that poverty can be reduced through benefit increases
Values *un-paid* work, and aims to increase power/resources
91
5 poverty/homeless theories
```
By choice/personality theory
Social disengagement/disaffiliation theory
Social disconnection theory
Housing/poverty theory
Poverty as social issue theory
```
92
3 social factors r/t poverty/homelessness
often are the breaking point resulting in homelessness
1) severe addiction/mental illness
2) Youth "aging out of care"
3) Family violence/social breakdown (women/youth)
93
What is a "harm reduction" approach
attempts to decrease the harms of illegal drugs
involves safety promotion, death/disability prevention, treating all individuals with respect/dignity/non-judgemental
94
What is insite
the only legal supervised drug injection site in North America
95
4 purposes of insite
- improve health of drug users: prevent overdose, drug transmission
- reduce harms associated with illegal drugs: discarded needles, crime
- increase access to social/health services by IV drug users
- reduce social/legal/incarceration costs associated with drug use
96
4 roles of outreach nurses
build relationship
primary nursing care
education
partnership & referrals to health/social systems
97
Examples of micro, meso, macro collaboration
READ ARTICLE (Insite)
98
Common homeless populations
adults
youth
sex-trade workers/MSWM
mentally ill
aboriginals
single parents (women & children)
99
5 common homeless health issues *adults*
psych episodes (as a result of medication lapses, chaotic lifestyle)
Infections- upper resp., TB
Impaired skin integrity: wound, abscess, cellulitis (as a result of poor injection technique, IV substance abuse etc.)
Scabies/lice/bed bugs
Malnutrition/dehydration/dental
100
3 common health issues in homeless *youth*
STD's/HIV/HCV
anxiety/fear/insomnia
depression/suicidal ideation
101
4 health issues in homeless *sex trade workers*
STD's/HIV/AIDS
unwanted pregnancies/unsafe abortions
GU infections/GI diseases
Risk-taking lifestyle
Rape
102
5 health issues in homeless *men who have sex with men*
STD's/HIV/AIDS
GI infections
Trauma: rape
Addiction
Discrimination/stigma
103
5 health issues in homeless *single parent mothers*
stress-anxiety-depression-insomnia
fear of children being taken away
self neglect-->malnutrition/dehydration
partner abuse
negative coping- substance abuse
104
5 health issues is homeless *children*
upper respiratory infections (2x more)
Skin disorders/infestations (4x more)
GI/GU problems (4x more)
Ear infections (2x more)
malnutrition- poor hygeine (dental issues)- emotional disorders
105
5 health issues in homeless aboriginals
- alcoholism/drug use
- lung cancer (second hand smoke)
- chronic wounds to lower legs/feet
- Trauma/rape/violent beatings
- STD's
106
5 common traumas treated in ER
```
Rape/IPA
Assault
Lacerations/contusions
MVA
Overdoses
```
107
negative factors impacting health of homeless people
increased morbidity rates in all dimensions -> leading to premature death
```
exposure to infection/diseases
stress-> triggering genetic disposition to diseases;
malnutrition-> chronic conditions
increased trauma/violence
poor living conditions
aggravated mental illness
substance abuse
```
108
Barriers to accessing health care
poverty (no fixed address)
no tax assessment- no care card (marginalization)
multiple diagnoses: mental illness/addiction
lack of transportation/fare
negative stereotyping/disrespect
fear of being caught for illegal activities
109
what is fear?
a cognitive response to a specific object that a person can identify
involves cognitive appraisal of a threatening stimuli
110
What does fear lead to
anxiety
111
What is anxiety
```
subjective feeling of:
uneasiness
tension
apprehension
dread
```
results from external threat to ones integrity
112
function of anxiety
to warn of potential threat/conflict/danger
113
main difference between anxiety/fear
anxiety has no identifiable object/cause, very subjective
114
Stages of anxiety
mild
moderate
severe
panic
115
Mild anxiety
Vitals stable -few physiological responses
Still able to focus- thoughts are controlled
Feel relatively relaxed/safe
116
Moderate anxiety
| e.g. writing a paper
Vitals elevate slightly - more muscle tension
More focused, optimal state for problem-solving
Feelings of readiness/challenge, learn new skills, energized
117
Severe anxiety
Fight or flight response- physiological responses (increased BP, increased BG, decreased blood flow to gut etc.)
Focus greatly narrowed - problem-solving is difficult, selective attention
Feel overwhelmed, detached, distortion of time, activity can increase (restlessness) or decrease
118
Panic anxiety
fight or flight continues until sympathetic nervous system activated and body reaches exhaustion:
BP drops, pale, disoriented
lack coord, limited sensation/perception, don't respond to stimuli
No focus, unable to problem solve, unrealistic, dissociation can occur
Feel helpless/angry/scared, may be extremely active or drawn
119
4 types of anxiety
ST-SF
Signal
Trait
State
Free-floating
120
What is signal anxiety
when a trigger is identified
e.g. balloon
121
What is trait anxiety
function of personality structure
e.g. "being an anxious person"
122
what is state anxiety
occurs in conflicting/stressful situations
123
What is free-floating anxiety
not associated with any idea or event
e.g. unsure of cause, wake up and just have feeling
124
5 types of anxiety disorders
```
Generalized Anxiety Disorder
Panic disorder
Phobias
PTSD & Acute Stress Disorder
OCD
```
125
population
more common in women
| late adolescents- mid 30's
126
Generalized anxiety disorder
Excessive anxiety and worry that occurs more days than not
127
Generalized anxiety disorder criteria
● At least 6 months of duration
● Presence of 3 of the following:
restlessness- edginess- irritability
muscle tension- sleep disturbance
fatigue- poor concentration
● Anxiety and worry that interfere with normal social and occupational functioning
128
Generalized anxiety disorder sx
- Difficult to control symptoms, lots of physical symptoms: chest pain, SOB, GI symptoms, migraines
- Make sure that it is not a result of substance abuse
129
What are panic attacks
A physical symptom of anxiety - not a psychiatric illness
Period of intense fear, discomfort, dread or doom
130
onset of panic attacks
abrupt, peaks in 10 mins
131
interventions for panic attacks
prevention
132
panic attack sx
```
has at least 4:
Racing heart-palpitations-chest pain
hot flashes- sweating - trembling
pain- nausea- dizziness- SOB
Fear of losing control, feelings of impending doom/death, trembling, depersonalization
```
133
Criteria for panic disorder
- reoccuring/unexpected panic attacks
- followed by:
concern for additional attacks
worry about implications of the attack
change in behaviour
134
Agoraphobia
anxiety about being somewhere where escape is difficult- avoid situations as a result
e.g. fear of open spaces/closed in spaces
135
What are specific phobias?
Fear of the presence/anticipation of a *specific object/situation*
exposure provokes anxiety/panic attack in attempt to avoid exposure
Recognize fear is excessive/unreasonable
136
Social phobia
Fear of social/performance situations that expose individual to scrutiny
Avoid these situations
only maintain relationships with familiar people
137
social phobia tx
psychotherapy
| SSRI
138
Symptoms of PTSD
Symptoms present for >1month and impairs function
```
Symptoms are reoccurant (nightmares)
Heightened arousal (irritation/anger outbursts)
Avoid situations
```
139
Acute stress disorder
| symptoms
Experience three symptoms of dissociation: numbing, detachment, dazed, derealization, depersonalization, dissociative amnesia
The symptoms of dissociation prevent the individual from adaptively coping with the trauma
140
what is dissociation
subjective sense of numbing/detachment
| reduced awareness of surroundings
141
Differences between acute stress disorder and PTSD
Acute stress disorder:
Short-term (2-30 days)
Unable to pursue everyday tasks
experience dissociation
142
obsession vs. compulsion
Obsession:
*unwanted thoughts/impulses/images* that cause anxiety
cannot be ignored-interferes with functioning
Compulsion:
* repetitive behaviours that the person feels driven to do in response to the obsession*
e. g. little girl washing hands repetitively
● Treated with behavioural therapy or medications (SSRIs, TCAs), suppress the thoughts
143
OCD tx
behavioural therapy
meds: SSRI, TCA
suppress thoughts
144
Nursing diagnoses for anxiety
Ineffective coping
Self-care deficit
Social isolation
Spiritual distress
145
Anxiety interventions
- Promote coping mechanisms/focus on strengths
- DB
- PRN medications
- Warm blanket
- Provide support
- Create a trusting/therapeutic relationship
- Sleep-wake patterns
- Decrease caffeine/stimulants
- Assertiveness
146
Common anxiety meds
```
● Benzodiazepines
Lorazepam, Clonazepam, Diazepam
- highly addictive
- increasing tolerance
- quick acting- onset/duration short
```
● SSRIs/SNRIs
Fluoxetine, Paroxetine, Sertraline, Venlafaxine
- onset 2 weeks
- may require PRN benzo in meantime
● TCAs
Clomipramine
● Other
Beta-blockers, Buspirone, Tegretol
147
```
Clozapine
class
action
onset/peak/duration
adverse effects
considerations
```
antipsychotic used with schizo/bipolar
action: binds to dopamine receptors in the CNS, blocks anticholinergic/apha-adrenergic activity
onset: unknown, peak:one week, duration: 4-12h
adverse effects: agranulocytosis (decreased WBC), neuroleptic malignant syndrome
Considerations:
- requires weekly monitoring every week for first 6 months
(standing/lying BP, vitals, sore throat, extra salivia, dizziness, nausea)
- use as last resort
148
What is metabolic monitoring
* see handout in adobe
149
What is an personality disorder
Axis II
pattern of inner experience/behavior that deviates markedly from expectations of culture
150
how is pattern of personality disorder recognized
Through cognition:
affect
interpersonal functioning
impulse control
151
types of disorders
Axis I- state disorders (short-term, associated with trauma)
Axis II- trait disorders (long-term, personality disorders)
152
Onset/duration/characteristics of personality disorders
onset: early (childhood-adolescent)
duration: long
characteristics: inflexible, pervasive, leads to distress/functional impairment
153
Causes of personality disorders
psychological
genetics: twins
neurochemical: serotonin levels/lack of opioid receptors
154
psychological factors
Freud: a result of unsuccessful completion of 5 psychosexual stages of development
object relations: improves ability to relate to others as personality develops, if unable to relate relationship to object then unable to develop healthy relationships
e.g. teddy bear and mom
155
Types of personality disorders
Cluster A
Cluster B
Cluster C
156
Cluster A personality disorders
odd & eccentric
paranoid personality disorder
schizoid personality disorder
schizotypal personality disorder
157
Cluster B personality disorders
dramatic & erratic
Antisocial
Borderline
Histrionic
Narcissistic
158
Cluster C personality disorders
anxious & fearful
dependent
avoidant
OCD
159
S&S of cluster A
difficulty relating to others
isolation
unusual ideas/perceptions
160
paranoid personality disorder
suspicious
difficulty with relationships- critical with others
difficulty expressing emotions
161
schizoid personality disorder
no desire for relationships
may seem cold/flat affect
162
schizoidtypal personality disorder
magical thinking
unusual perceptions/experiences
social anxiety
163
Nursing interventions for cluster A
```
build rapport/trust
be non-judgmental & accepting
reflect on situation
slow intro to social situations
role model
```
164
Cluster B S&S
dramatic approach to situations
difficulty maintaining relationships
impulsive
highly emotional
165
antisocial personality disorder
infancy-like behavior
crime & lack of remorse
aggressive
charming but manipulative
166
borderline personality disorder
fear of abandonment*
boredom/emptiness
unstable affect
splitting
167
histrionic personality disorder
draw attention to self
excessive emotions-rapid/shallow
over intimate
168
Narcissistic personality disorder
self-absorbed
put self higher and will exploit others to make self look/feel better
grandiose
169
nursing actions for Cluster B
identify primary nurse to avoid splitting
clear & concise communication
set mutual goals
set boundaries
170
Cluster C S&S
social inhibition
| internalize blame & emotions
171
dependent personality disorder
no coping mechanisms
| will use nurse/family member as coping mechanism
172
OCD
inflexible
perfectionist
cannot delegate tasks
fear of loss of control
173
avoidant personality disorder
isolation
big fear of rejection
fear of crowds/social situations
174
Treament for personality disorders
```
Team approach (know primary nurse)
Art/music
OT/recreation
Individual reflection
Family
```
175
What is milieu
getting involved with everyday tasks, routine, maintain consistency
176
3 common meds for personality disorders
Benzos (calm patient)
Antidepressants (monitor serotonin levels)
Anticonvulsants (stabilize mood)
177
cons of pharmacological tx
risk for poly-pharmacy
risk of substance abuse
risk of overdose
risk for dependency
178
Discharge planning for personality disorders
- safety
- arrange follow-up appointments
- acute sx management
- educations re: meds
- connect with resources
179
Bipolar onset
late teens- early 20's
180
Depression onset
mid 30's
181
Depression population
greater in caucasians, hispanics, lower socioeconomic groups
more often in women
182
Bipolar population
occurs more often in higher socioeconomic groups
183
What is a mood disorder?
often a comorbidity
a stress response to illness
a physiologic response to patho
" " to medication
184
What does mood disorders involve
bipolar
| depression
185
two types of depression
Major depressive disorder
| Dysthymic disorder
186
What is major depressive disorder
aka unipolar depression
episodic
5 sx present most of the day, every day, for at least 2 weeks
187
MDD sx
sx occur from result of disorder, not from substance/medical conditions/grief&loss
* depressed mood
* anhedonia (lack of interest in activity)
```
lack of energy
lack of concentration
low self-esteem
hopelessness
SI, suicide plan, attempt
ETC.
```
188
What is dysthymic disorder
chronic
low-level depression
depressed mood & at least 2 symptoms most of the day, nearly every day, for 2 years
189
dysthymic disorder sx
lack of appetite/overeating
insomnia/hypersomnia
hopelessness
low self-esteem
low energy
poor concentration
anger/irritability
190
Depression medications
TCA
Monoamine oxidase inhibitors
SSRI
191
what do TCA's do
block neuronal uptake of norepinephrine & serotonin
serotonin: contribute to well being/happiness
norepinephrine: concentration
192
what to MAOIs do
inhibits MAO-A in nerves
| increasing amount of norepinephrine/serotonin available for release
193
what do SSRI's do
inhibit serotonin reuptake
| intensify transmission at serotogenic synapses
194
When do bipolar disorders occur
when experience episodes of depression and mania/hypomania
195
types of bipolar
I- one or more manic episodes or mixed episodes
II- a clinical course of major depressive disorder followed by hypomania
196
what is a manic episode
persistent, elevated, irritable mood for one week, with at least 3 sx
197
manic sx
inflated self-esteem
chatty
decreased sleep
flight of ideas
distractability
goal directed activity
high-risk activities
198
what is hypomania
persistent, elevated, expansive irritable mood for 4 days, with at least 3 sx
199
what is clyclothymic disorder
2 years of hypomania/depressive periods without fulfilling criteria for an episode of mania/hypomania/MDD
200
Bipolar meds
```
Mood stabilizers (lithium)
anticonvlusants
```
201
how does lithium work
has a positive charge
202
how do anticonvulsants work
controls symptoms in acute manic episodes
| prevention for recurrent episodes of depression/mania
203
what is a crises
subjective response to a stressful experience
comprises stability/ability to cope/function
204
Venette's 4 defining characteristics of crisis
- Specific, unexpected, non-routine
- creates perception of threat
- creates uncertainty
- process of transformation: old system no longer working, need to change
205
5 components of a crisis (Rogers)
1) a hazardous/traumatic event
2) a vulnerable state
3) a precipitating (causative) factor
4) an active crisis state
5) a resolution of crisis
206
5 types of crises
external (situational): from events/circumstances in environment
internal (subjective)
phase-of-life (maturational): occurs during natural growth/development
disasters (adventitious)
psychiatric emergencies: sudden/serious psychological disturbance
207
5 risk factors for crises
- Experience multiple bio-psychosocial stressors
e. g. losses, unexpected transitions, unresolved problems, trauma
- Lack of resiliency/poor coping mechanisms
- Lack of social supports
- Chronicity
- Intensity of exposure
208
4 phases of crises development
| Caplan
Phase 1:
- Exposure to stressor
- Anxiety triggered
- Use of previous coping/problem solving mechanisms
Phase 2:
- Previous coping/problem-solving mechanisms fail
- Stressors persist & feelings of discomfort
Phase 3:
- Use internal/external resources to alleviate discomfort
- Fails- and anxiety escalates to panic
- May use new problem solving mechanisms - leading to resolution
Phase 4:
- if not resolved, major disorganization
- breaking point, cognitive function declines, emotions are unstable, irrational behavior, aggressive, self-harm
209
5 elements of crises that influence responses
1) predictability
2) duration
3) intensity
4) control
5) self-concept
210
5 barriers to crisis resolution
failure to learn from experience
mental issues
sociocultural considerations
secondary gain (external motivators e.g. missing work, obtain financial compensation)
therapist-patient boundary issues
211
what are crises interventions?
short-term/action-oriented/strategic interventions
focus on solving immediate holisit issues that result from crises
212
3 goals of crises intervention
to alleviate *acute distress*
restore independency
prevent psychological trauma
213
balancing factors for crises (for equilibrium)
have a realistic perception of event
social supports
coping mechanisms
if these factors not present disequilibrium continues and crises will continue
214
5 steps in crises intervention
1) assess individual & problem
2) plan therapeutic intervention
3) implement intervention
4) evaluation of resolution of crisis
5) anticipatory planning
215
step 1) assess individual & problem
gather hx/risk assessment
focused assessment of presenting problem
analyze problem: determine pre-crisis level of functioning/coping, assess support system, establish desired outcome
216
step 2) plan therapeutic intervention
select appropriate interventions that:
have a time limit
focus on strengths
uses past successful coping skills & new ones
uses social supports
217
step 3) intervention
- reality oriented
- establish relationship
- gain understanding of crises/cause/problem
- discuss feelings & validate
- encourage lengthy responses
- explore coping mechanisms
- identify social supports/ social resources
218
step 4) evaluation of crises resolution & step 5) anticipatory planning
- client summarizes changes/effectiveness of intervention
- states realistic plans for future
- reviews how this experience will help in the future
- referrals
- plan for similar experiences in the future
219
Roberts crises intervention model
crises assessment
establish rapport/relationship
identify major problems
deal with feelings/emotions
create/explore alternatives
action plan
follow up
220
3 main components of PTSD
re-experience of traumatic event:
dreams, acting/feeling, certain triggers result in distress
avoidance:
detachment, apathy, cannot recall events associated with event
hyperarousal:
insomnia, anger, lack of concentration, exaggerated startle response
221
PTSD risks
```
lack of support
lack of early tx/access to services
shame/guilt/self-doubt
other life stressors
underlying diseases
```
222
what does schizo do
distorts senses/cognition & disturbs thoughts/thought processes
difficult to determine what is real/what isn't
223
onset of schizo
men: late teens- early 20s
women: late 20s early 30s
occurs equally in men/women
224
cause of shiczo
biochemistry- excess dopamin
cerebral blood flow- entire brain "lit up" with schizo- unable to focus
molecular biology- increased ventricle size, loss of brain matter
genetic
225
what can alleviate/aggravate symtpoms
aggravates:
stress
drugs
alleviates:
nutrtion- vitamins/omega3 protects brain
226
What is schizo
a brain disease with specific symptoms d/t psychical & biochemical changes in brain
impacts thoughts/cognition
227
schizo tx
medications
228
schizo sx types
positive
negative
cognitive
depressive
229
positive sx
hallucinations/ delusions
bizarre behaviour/ agitation
disorganization
230
negative sx
lack of interest/motivation
lack of emotional activity (blunted affect)
impaired social skills
impaired concentration
231
cognitive sx
```
impaired:
memory
attention
focus
executive functioning
```
*associated with negative sx- apathy
232
depressive sx
anxiety/irritability
dysphoria (anguish)
suicide
233
perceptual disturbances in schizo
hallucinations/delusions
tangentiality (irrevelant responses)
poverty of thought (lack of thought)
loose association (unfocused)
234
Criteria for schizo
sx for at least 6 months
| 1 month includes 2 active-phase sx
235
active phase sx
hallucinations
delusions
disorginized behaviour
disorganized speech
236
5 types of schizo
paranoid
disorganized
catatonic
undifferentiated
residual
237
paranoid schizo
| sx/tx
sx:
delusions: believe someone is out to get them, grandiose
auditory hallucinations
intense/rigid/controlled interactions
tx:
respond well to medication
238
disorganized schizo
| sx/prognosis
```
sx:
regress & act like child/silly
disorganized speech/clanging/senseless laughter
grimacing/rocking/sexual behaviours
poor grooming/ADL's
social withdrawal
```
prognosis: poor d/t early permorbid hx
239
catatonic schizo
sx
prognosis
```
intense psychomotor disturbance
immobile, waxy flexibility
echopraxia (act like others), echolalia (repeat words of others), grimacing
fluctation between extremes
delusions in withdrawn state
```
prognosis: fair
240
undifferentiated schizo
| sx/onset/prognosis
psychotic manifestations are extreme
delusions/hallucinations/bizarre behaviour/disorientation/incoherence
fantasy content
onset: acute
prognosis: poor
241
residual schizo
cause:
sx:
prognosis:
results from at least one acute episode
free from positive sx but still has negative
may persist for years
```
unfocused
illogical thinking
blunted behaviour
social withdrawal
eccentric behaviour
```
prognosis: varies/unpredictable
242
4 warning signs of psychosis
mood: suspicious, depressed, anxiety, mood swings, irritability
thoughts: odd ideas, vague, lack of focus/recall
physical: insomnia, appetite, loss of energy
behaviour: lack of activity, social isolation, decreased work/school performance
243
population of psychosis
equal in men women
| onset usually late teens-young adults
244
risks for psychosis
```
genetics
drugs
abuse
trauma
stressful life events
failure to achieve developmental milestones
```
245
how does psychosis and cannabis relate
will create a poorer prognosis/functional outcome
increases risk of relapse
earlier age of onset
246
interventions that promote recovery from psychosis
```
stable living situation
strong social support
safe environment
goal oriented
understanding & insight
```
247
tx of psychosis
```
meds
relapse prevention
education
stress management
self management
lifestyle choices
social/life skills
family support/therapy/education
```
248
```
Quietapine (seroquel)
class
action
duration
adverse effects
```
mood stabilizer
antagonist for dopamine/serotonin
onset/peak unknown, duration 8-12h
adverse effects: neuroleptic malignant syndrome, cognitive impairment
249
Benztropine
| class
antiparkinsons agent
treats extrapyramidal side effects
action: blocks cholinergic activity in CNS which is partiall responsible for sx, restores balnace of neurotransmitters
250
what causes extrapyramidal S&S
blockage of dopamine or depletion of basal ganglia
251
what does dopamine do
ans and other animals. Some of its notable functions are in:
```
movement
memory
pleasurable reward
behavior and cognition
attention
inhibition of prolactin production
sleep
mood
learning
```
too little: parkinsons movement symptoms (rigidity, lack of coord, unable to stop movements)
too much: schizo symptoms
252
Fluphenazine Decanoate
class:
action:
onset:
class: antipsychotic
action: reduces dopamine in certain areas of brain
onset- 48-96 h
253
Olonzapine
class
indications
action
class: antipsychotic, mood stabilizer
for acute agitiation d/t schizo
action: antagonizes dopamine and serotonin in CNS
254
Antiprazole
class
indications
action
antipsychotic, mood stabilizer
for schizo/agitation
decreases dopamine/serotonin activity
