question

3 qualities needed to guide a person toward effective social and interpersonal functioning

answer

1) stable and realistic sense of self 2) System for interpreting social situations and understanding of relational motives/actions of others 3) Capacity to serve self and others

question

Realistic sense of self

answer

Recognition that we may have flaws: a way of managing conflict in social situations

question

Personality Disorders (PD)

answer

Personality traits are exaggerated and rigid to the point that they cause dysfunction in their relationships

question

Common characteristics of all people with PD

answer

1) Inflexible and maladaptive responses to stress; individuals have difficulty responding flexibility and adaptively to the environment and to the changing demands of life 2) They often are unable to cope w/ stress and react by using manipulative behaviors (exposes the disorder) -Tend to overreact

question

PD shared common characteristics (cont)

answer

*Disability in working and loving, generally more serious and pervasive than the similar disability found in other disorders *pts. with PDs assume that everyone thinks and functions as they do= within relationships, they do not see their behavior as a problem **Not do they see a need to make changes/accommodate to others

question

Prevalence and Co-Morbidity

answer

~9-16% of the general population meet criteria for PD -In the population diagnosed w/ a psychiatric disorder, 30%-50% have a co-occuring PD -Is associated with emotional, social and occupational disability

question

PD emerges

answer

-in adolescence -personality traits are present from infancy

question

Gentic factors in PD

answer

PDs are historically considered to be environmentally mediated -research supports a more dominate role in genetics -In a twin study those who were raised apart, identical twins were found to have more similar personality traits than fraternal twins

question

Psychological influences(PD)

answer

-Childhood neglect is particularly damaging childhood trauma -Excessively harsh and erratic disciple, alcoholic parents, and abusive/chaotic home like are risk factors for Borderline PDs (BPDs) and antisocial PDs in particular -sexual abuse is a risk factor for BPD

question

Predisposing Factors

answer

The theory of object relations suggest that the basis for the borderline problem lies in the ways the child separates from her -phase 5 (18-25 months) Rapprochement phase, awareness of separateness from the mother increases. This is frightening -theory suggest that the individual with borderline personality is fixed in the rapproachment phase of development -this fixation occurs when the both begins to feel threatened by the increasing autonomy of her child and so withdrawals her emotions

question

Predisposing factors CONT

answer

The child comes to believe in the following way: " to grow up and be independent= bad child -to stay immature and dependent= good child Mom withholds nurting from the bad; child

question

Cultural considerations

answer

Native and African Americans, young adults, low socioeconomic status, and those who are divorced, separated, widowed, and never married

question

Low rates of antisocial PDs in

answer

-Taiwan, China, Japan, Jewish families -Might be attributed to strong family ties.

question

Summarize four characteristics that people with a PD share.

answer

-The difficult patient is almost always an individual with a PD. -PD is among one of the disorders most frequently treated by psychiatrists. -Initial focus of treatment is a usually a co-occurring disorder, such as anxiety disorder, depressive disorder, substance abuse disorder, or eating disorder.

question

Characteristics that people with PD share

answer

-mild to severe -Impairments in personality functioning include identity, self direction, and empathy/intimacy -Impairments are not solely due to the effects of substances o the general medical condition -Patients do not see behavior as a problem they blame others Pts. believe they are normal; it is the others who have the problem

question

Characteristics of pts. with PD: Close Relationships are Desired but often fail b/c

answer

-Avoidance and fear of rejection blurring of boundaries -Insensitibity to the needs of others demanding the fault finding -Inability to trust -Lack of accountability -Intense interpersonal conflict

question

Characteristics that people with PDs share

answer

-relationships that may lead to violence to self or to another -capacity to "get under the skin" -Suffering -Rarely reaching potential -Bizarre, anxious, withdrawn, and manipulative actions

question

CO-occuring conditions that are present in people with a PD

answer

-PDs often co-occur with substance abuse, somatic symptoms disorders, eating disorders, post-raumatic stress orders (PTSD), or general medical conditions -Patients with PDs do not believe that a problem exists; consequently they rarely enter treatment for the disorder alone

question

Primitive defenses- are attempts to control inner chaos

answer

-Especially true of BPDs and antisocial PDs - Nurses deal with these PDs most often in all medical settings -Exhibit outrageous and troublesome behavior -Those with a PD are unable to use the higher level defense mechanisms (e.g. creativity, productivity)

question

Primitive/immature defenses

answer

-Ambivalence and poor impulse control "Ego weakness" results in: Splitting, dissociation, psychotic thinking *Blurred personal boundaries: Closeness seems similar to a fusion of boundaries where one person begins and one leaves off *Needs are experienced as rage. *Sexuality and dependency are confused with aggression. *Intense and inappropriate behaviors uproot relationships: -are no less disruptive in health care settings. Slide 23 identifies primitive defenses (see Figure 13-1).

question

Affects (primitive defenses)

answer

Unmodulated: rage, envy, shame

question

Behaviors in pts. with PD (Primitive)

answer

-Attacking, clinging, lying, identity (diffusion/boundary violation -Impulsitivity -Passive- aggression/masochism -Irrationality -Selfishness -Cruelty -Suicide

question

Congitions (Primitive Defenses)

answer

Vague self good/bad split Entitlement/need=want wish is reality no=yes Selective perception self as empty

question

Defenses (Primitive Defenses)

answer

splitting dissociation psychotic denial primitive idealization Omniopotence/devaluation projective identification

question

Splitting (BPD)

answer

Splitting- the inability to integrate both positive and negative qualities of an individual into one person -The individual tends to think in extremes (i.e) an individual's actions and motivations are all good or all bad with no middle ground

question

Borderline (BPDs) behaviors

answer

Borderline: -emotional instability -separation insecurity -depression (chronic) -fear feelings of abandonment -Excessive demands, impulsive behavior, -uncontrolled anger -Stormy relationships -Idealization and Devaluation -Self-mutilation and prone to suicide splitting

question

Narcissistic (PDs)

answer

Attention seeking antagonism Grandiosity expectation of special treatment lack of empathy exploit, blame, and envy -shallow, superficial and tantrums -Manipulation -Splitting

question

Three Clusters of PDs

answer

Characterized by similar behavior patters: *Cluster A: Odd or eccentric *Cluster B: Dramatic, emotional, erratic (requires team approach to be more successful) *Cluster C: Anxious or fearful

question

Cluster B: Dramatic, Emotional, Erratic, flamboyant

answer

Cluster B disorders appear to share dramatic, erratic, flamboyant, or erratic behaviors as part of their presenting symptoms: Antisocial- "sociopaths" Borderline -Narcisstic -Histrionic

question

Cluster B: dramatic, emotional, erratic

answer

Antisocial and Borderline

question

Overlap of Cluster B personality disorders and other mental health disorders

answer

-Substance use -depression -eating disorders -manipulation

question

Manipulation

answer

A common defense mechanism among these disorders, and their behaviors are always challenging -Disorders include: antisocial, borderline, history, and narcissistic personality disorders -• Verbally, pts with antisocial personality disorder may be charming, engaging, and uncanny in their ability to find just the right angle to lure a person into the intrigue with the intent to exploit them for money, favors, or more sadistic purposes

question

Antisocial Personality disorder: Pathological personality traits

answer

Characterized by deceit, manipulation, revenge, and harm to others with an ABSENCE of remorse for hurting others

question

People with antisocial PD:

answer

have a sense of entitlement; they believe they have the right to hurt others, take what they want, treat others unfairly, destroy property of others, and so on (callousness) -No restraint on their behavior, nor do they feel any sense of responsibility for their actions -lack regard for te law and right of others and have a history of persistent lying, using aliases, conning others for personal profit or pleasure, and stealing (deceitfulness)

question

Antisocial PD

answer

pts. with antisocial PD do count on others to conform to the social norms

question

Antisocial Personality Traits: verbal

answer

charming -Engaging -Uncanny in their ability to find just the right angle to lure a person into their intrigue with the intent to exploit them for money, favors, or more sadistic purposes (manipulation)

question

Common events in pts. with Antisocial personality disorder

answer

Promiscuity Reckless disregard for the safety of others failiur to honor work or financial commitments Drunk driving -Their lives are marked by irresponsibility and unreliability

question

Pts. with antisocial personality disorder may have a history of:

answer

violence -Partner abuse -Child abuse -Anger in response to minor slights Vindictive behavior toward others that can result in physical or emotional pain -general reckless disregaurd for the safety of others

question

Antisocial Personality Disorders (Dramatic, emotional, erratic) - Mneumonics for Diagnosing CORRUPT

answer

(CORRUPT) (C) Cannot conform to law (O) Obligations ignored (R) Reckless disregard for safety (R) Remorselessness (U) Underhanded (Deceitful) (T) Temper (irritable ; aggressive)

question

Borderline Personality Disorders (IMPULSIVE)

answer

Impulsive Moodiness Paranoia or dissociation under stress Unstable self-image Labile intense relationships Suicide gestures Inappropriate anger Vulnerability to abandonment

question

Borderline Personality Disorders (DESPAIRER)

answer

Disturbance of identity Emotionally labile Suicidal behavior Paranoia or dissociation Abandonment (Fear of) Impulsive Relationships unstable Emptiness (feelings of) Rage (inappropriate)

question

• A pt. with BPD can experience dissociative states under stress

answer

o Recurrent suicide attempts/self-mutilation make suicide a significant risk in these pts o Their frequent use of the defense of splitting not only strains personal relationships but also creates turmoil in health care settings o Splitting- the inability to integrate both positive and negative qualities of an individual into one person o Tends to think in extremes

question

Gale's medical history (from previous admissions) indicates an Axis I diagnosis of depressive disorder and an Axis II diagnosis of BPD. Based on these diagnoses, which of the following will be your best initial intervention as you begin your shift? A) Allow Gale to act out her frustrations since she is newly admitted. B) Immediately set strict limits so that Gale knows who is in control. C) Instruct a mental health technician to monitor Gale on a 15-minute basis. D) Introduce yourself, and let Gale know that you will be her nurse during your shift.

answer

D) is correct; have to start with a therapeutic relationship

question

Gale tells another nurse on the unit, "You are the only decent person here. You really care, and my nurse is really cold." This nurse is new to the unit and does not know how to answer. What would be your best response to Gale if you were in this position? A) "You seem concerned about how you are being treated here on this unit." B) "You have just not learned to trust people; your nurse is a good person." C) "Your personality disorder is causing you to be angry and distrustful." D) "You need to understand that all the staff here are very caring."

answer

A is correct

question

In applying SELF-CARE, identify some of the feelings that are experienced by health care professionals when working with a person with a personality disorder.

answer

*Patient's problems can overwhem health care professionals -Intense feelings evoked in a nurse often mirrors the feelings of a patient: -for example, a pt. might tell a nurse, "You're inadequate and incompetent!" Health care professionals may feel confused, helpless, angry, and frustrated

question

In applying self-care, identify some of the feelings that are experienced by health care professionals when working with a person with a PD

answer

-pts. are abusive of authority and successful in splitting staff in attempt to defend against the patients own feelings of frustration and powerlessness -when staff members are split, the result=conflict -Untrained staff members may become vengeful in response to a sense of entitlement, manipulation, dependency, ingratitue, impulsive, and rage

question

(cont'd): In applying self-care, identify some of the feelings that are experienced by health care professionals when working with a person with a PD.

answer

*Nurse/other health care professionals should practice self-health management, which includes acknowledging and accepting their own emotional responses -Health care professionals should ensure personal well-being

question

Discuss how you would use teamwork and COLLABORATION when working with a patient who is extremely manipulative.

answer

-Have frequent communications among staff members -Set limits on pts. behavior -all staff should consistently enforce limits

question

Discuss how you would use teamwork and collaboration when working with a patient who is extremely manipulative

answer

-Provide necessary support when behavoir of pts. starts to affect confidence, feelings, behaviors, and effectiveness of staff members -assess your own reactions toward the patent -Have discussion with peers

question

Managing Behaviors

answer

-Assess the pt. for a short period before labeling him/her as manipulative -Set limits on manipulative behaviors: *arguing/begging *using flatery or seductiveness *Instilling guilt and clinging *Constantly seeking attention -*pitting one person, staff member, or group against another *Frequently disregarding the rules *Constant engaging in power struggles

question

Managing Behaviors Cont.

answer

Behaviors should be objectivly documented (e.g. time, date, circumstances) -Provide clear boundaries and consequences -Enforce consequences AVOID: -Discussing youself or other staff members with pt. -Promising to keep a secret -Accepting gifts from a pt. -Doing special favors for pt.

question

In planning patient-centered care with a patient who has impulsive behaviors, identify four communication guidelines you would use

answer

Communication guidelines: -People with PDs are excessivly dependent, demanding, manipulative, stufforn, or may self-distructively refuse treatment

question

Communication guidelines: Nurses greatly enhance their ability to be therapeutic when they combine: (Impulsive behavior)

answer

Limit-setting Trustworthiness Dealing with manipulations Authenticity with their own natural style

question

Interventions for Impulsive Behavior

answer

Identify and discuss what precedes impulsive acts -Explore effects on self and others -Recognize cues -Identify triggers* -Discuss alternative behaviors -Teach or refer thept. for coping skills training (e.g., anger management, assertive skills)

question

Personality Disorders: Assessment Guidelines

answer

Assess suicidal/homicidal thoughts -Determine whether the pt. has a medical disorder or another psychiatric disorder -View the assessment of personality functioning from within ethnic, cultural, and social backgrounds -Ascertain recent and important losses -Evaluate for changes in personality in middle adulthood or later: may signal an unrecognized substance use disorder -Be aware of strong negative emotions that pts. evoke

question

Therapy

answer

-Creating a therapeutic relationship is difficult. -Most health care providers have experienced interrupted therapeutic alliances. -Suspiciousness, aloofness, and hostility will set up failure. -Guarded and secretive style produces an atmosphere of combativeness. -When patients blame or attack others, the nurse needs to understand the context of the complaints. -Attacks spring from a feeling of being threatened. -The more intense the complaints, the greater the fear of potential harm and loss.

question

Therapy cont.

answer

-Psychotherapy -Psychodynamic psychotherapy -Cognitive-behavioral therapy

question

Dialectical Behavior Therapy

answer

*Primary focus: -Stabilizing patient, achieving behavioral control, regulating emotions, developing distress tolerance skills, and constantly using crisis interventions *Target behaviors include decreasing: -Life-threatening suicidal behaviors -Therapy-interfering behaviors -Quality-of-life interfering behaviors **Is extremely effective in helping patients gain hope and a quality of life**

question

Systems Training for Emotional Predictability and Problem Solving (STEPPS)

answer

-Systems training for emotional predictability and problem solving (STEPPS) is a new supplement approach in the treatment of BPD. -Offers a 20-week manual-driven progra -Reduces the intensity of the core aspects of BPD. -Does not reduce hospital utilization and suicidal ideation. -Reduces suicide attempts and visits to the emergency department.

question

Pharamcologic Therapies for PD

answer

-Medications are not available for the treatment of PDs per se -treating symptoms is helpful **Benzodiazepines** (maintenance dosing) for anxiety are NOT appropriate because of the potential for abuse and overdose; they may be used in emergency situations** Medications with low toxicity are appropriate

question

Pharmacologic Therapies Cont

answer

**Selective serotonin reuptake inhibitors (SSRIs)—treat co-morbid depression and panic attacks. ** *Trazodone and venlafaxine—have low toxicity in overdose. *Carbamazepine—targets impulsivity and self-harm. *Lithium, anticonvulsants, SSRIs—minimize aggression. *Atypical antipsychotics—help with psychotic features.

question

On day 4 of Gale's inpatient stay, she is still refusing oral medications. She has another impulsive outburst and slaps another patient on the back of the head. She is placed in seclusion and medicated. Which of the following medications would most likely be given? A) Haloperidol and anxiolytic tablets immediately placed under the tongue to dissolve B) Haloperidol and an anxiolytic via an immediate intramuscular injection C) Carbamazepine given every 4 hours for aggression D) Lithium given every 4 hours for aggression control

answer

B

question

Medications for Acute aggression

answer

Atypical antipsychotics *IM risperdone, olanzapine, ziprasidone) or high potency typical neuroleptics (IM haperidol) are first line treatments for acute aggression and psychosis induced violence

question

Benzodiazepines (lorezapam)

answer

often the first choice for acute aggresive eppisodes, especially in episodic dyscontrol and incipient rage episodes

question

Atypial Antipsychotics

answer

have fewer s/e -not avalable in short-acting IM for if a pt. refuses to take oral medication

question

Olonzapine

answer

short acting IM injectable- meany caveats for use should only be used if the person has shown previous dystonic or sever extraparmadial symptoms from IM haloperidol, person needs an antipsychotic but has pre-existing cardiac disease

question

Outcomes

answer

**Outcomes should be realistic, modest, and obtainable** -Criteria might include the following: Minimizing self-destructive behaviors Reducing manipulating behaviors Linking consequences to behaviors Initiating alternatives to prevent crisis Ongoing management of emotions Creating lifestyle that prevents regression

question

After experiencing a social rejection, which patient is most likely to need a nursing plan to monitor self-destructive behavior? 1.Mr. A., who has been diagnosed with obsessive-compulsive PD 2.Ms. B., who has been diagnosed with borderline PD 3.Mr. C., who has been diagnosed with paranoid PD 4.Ms. D., who has been diagnosed with schizoid PD

answer

2 is correct chronic depression is common in DPD, high emotional sensitivity, acute responsiveness, and slow return to normal as "emotional dysregulation) **this cycle may lead to feelings of deadness, panic, and fury as well as self- mutilation and suicide prone behaviors irritability short lived but intense (emotional lability)

question

Pts with Borderline Peronality disorder (BPD)

answer

can expereince dissociates states under stress recurrent suicde attempts or self mutilation make suicide a risk in these pts. their frequent use of the defense of SPLITTING not only strains personal relationships but problems in the health care setting

question

For the nurse working with patients with PDs, which nursing intervention must be an ongoing priority? 1. Offering professional advice 2.Probing for etiological factors 3.Encouraging diversional activity 4.Setting appropriate limits

answer

4 is correct

question

When nurses are caring for a patient with a PD, which of the emotional states listed below are they likely to experience themselves? Select all that apply

answer

1.Anger 2.Confusion 3.Frustration 4.Helplessness 1,3

question

s/sx of people with PD

answer

Crisis, high levels of anxiety anger and aggression, child, elder, or spouse abuse -Withdrawal, paranoia -Depression -Difficulty in relationships, manipulation, dysfunctional family processes -Failure to keep medical appointments, late arrival for appointments, failure to follow prescribe medical procedure or medication regimen

question

Attention Deficit Hyperactivity Disorder

answer

Affects 5%-10% of children and adolescents it is difficult to diagnose before age of 4 years -exhibits excessive gross motor activity that becomes less pronounced as the child matures -Is identified when the child has difficulty adjusting to elementary school, which is when a child is expected to control his or her behavior

question

Behaviors are considered pathologic when they

answer

o Are not age appropriate o Deviate from cultural norms o Create deficits or impairments in adaptive functioning

question

• Concept: Resiliency

answer

o Many children and adolescents grow up threatened by poverty, neglect, natural disasters, physical or mental illness, homelessness, or abuse or, in general, are known as children at "high risk." o Many children and adolescents grow up threatened by poverty, neglect, natural disasters, physical or mental illness, homelessness, or abuse or, in general, are known as children at "high risk." • More available resources than nonadapting children • Average or better-than-average intellectual skills • Good parenting or mentoring figure • Less vulnerable to stress

question

Surgeon General and treatment of children/adolesences

answer

o Estimated two thirds of all young people with mental health problems are not receiving the help they need. o Psychiatric disorders continue into adulthood, and approximately 75% of all 21-year-old young adults with mental disorders had previous problems. o Surgeon General report identified barriers to treatment of children and adolescents and noted a lack of: • Clarity about the why, when, and how of screening • Coordination of funding and eligibility systems • Resources • Mental health providers • Adequate reimbursement

question

Symptoms of ADHD

answer

-Inattention -Hyperactivity -Imulsivity

question

Causes of ADHD

answer

-No known cause exists. Predisposing factors include the following: -Family history; chaotic family life such as parental rejection, inconsistent parenting, harsh discipline, and out-of-home placements; frequent shifting of parental figures; large family; absence of father or presence of an alcoholic father - Prenatal or perinatal influences (e.g., intrauterine exposure to toxic substances such as drugs, alcohol, nicotine), low birth weight, postnatal influences (central nervous system [CNS] trauma, infections) -Brain scans reveal underdeveloped and inactive frontal lobes.

question

A method of modifying the disruptive behavior of a child that will be perceived by the child as punishment is:

answer

Therapeutic holding Planned ignoring Restructuring Seclusion

question

The nurse who is working in the emergency department usually assesses adult patients, but tonight she is responsible for assessing the suicidal potential of a 13-year-old adolescent. In this assessment, which topic must be explored that is different from such an assessment in the adult?

answer

Presence of distorted perceptions about suicide and death Presence of ideas about seriously hurting self or causing death Circumstances at the time suicidal thoughts are experienced Identification of feelings such as depression, anger, guilt, and rejection

question

Assessment of ADHD

answer

o Mental status assessment is similar to that of adults except that the developmental level is considered. See page 503 o Developmental assessment provides information about the child's current maturational level that, when compared with the child's chronological age, identifies developmental lags and deficits. o Denver II Developmental Screening Test is designed for infants and children up to 6 years of age.

question

Nursing Diagnosis: ADHD

answer

Risk for other-directed violence Risk for caregiver role strain (discuss in class) Defensive coping Risk for injury Impaired social interaction Ineffective coping Chronic low self-esteem Disturbed thought processes

question

METHODS OF COLLECTING DATA

answer

o Interviewing, testing, observing, and interacting o Histories from parents and caregivers o Questions answered about life at home and school o Free to describe current problems o Games, drawings, puppets, and free play used for children unable to respond to a direct approach o Important observations of interactions among child, adolescent, caregiver, and siblings

question

Mental Health Assessment Questions

answer

o What is the level of emotional and intellectual maturity? o What are the child or adolescent's particular strengths? o What particular weaknesses and strengths are present? o What stresses are affecting the child or adolescent? o How do stressors affect children or adolescents at any particular stage of life? o How did gender-specific challenges affect the expression of illness and its treatment?

question

Intellectual disability

answer

o Deficits such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience

question

• Nursing Diagnosis: Intellectual Developmental Disorder

answer

o Fear o Personal identity disturbed o Defensive and ineffective coping o Delayed growth and development—self-care deficit o Impaired verbal communication and social interaction deficits o Risk for: • Impaired parent or child attachment • Injury • Self-mutilation • Self- or other-directed violence

question

Deficits in general mental abilities

answer

o Daily activities such as communication, functioning at school or at work, personal independence, and impairment in adaptive functioning

question

Implementation

answer

Assess the parent or caregiver's knowledge (teaching). Explore the effects of behaviors on family life. Discuss the family or caregiver's support system. Discuss realistic behavioral goals. Plan activities that are geared to abilities for success. Offer positive recognition and feedback when a child succeeds. Provide educational information about medications. Refer the parent or caregiver to the appropriate support group.

question

Interventions

answer

Behavior modification and pharmacologic agents that address inattention and hyperactive and impulsive behaviors Special education programs that address academic difficulties Psychotherapy and play therapy to determine emotional problems that develop as a result of the disorder

question

Pharmacolgic Interventions: ADHD

answer

*Psychostimulants—a sluggish frontal lobe is thought to be a causative factor of the disorder. *Methylphenidate (Ritalin) is the most widely used medication and is available orally and as a transdermal patch *(Daytrana). *Concerta is an extended-release Ritalin that allows for once-daily dosing. *Adderall is a combination of *dextroamphetamine and amphetamine that also calms; it comes in an extended-release form.

question

Pharmacologic Interventions: ADHD

answer

Thirty percent of children with ADHD (the "inattentive type") are thought to have a totally different kind of neurologic disorder. Alternatives and adjuncts include: *Clonidine hydrochloride: Improved symptoms in children 6 to 17 years of age. *Quanfacine HCl: Treats aggression and insomnia. *Tricyclic antidepressants (TCAs) or bupropion HCl

question

Tourette's Disorder

answer

Are stereotyped, rapid, and involuntary recurring motor movements that include excessive blinking, facial grimacing, shoulder shrugging, and head turning. Tics wax and wane over time and are usually in response to stress, excitement, fatigue, and anxiety. Tourette's disorder is the most serious of tic disorders and involves motor and verbal tics that cause significant impairment in social and occupational functioning.

question

Tourettes's:

answer

May appear by age 2 years -average onset is b/w 6-7 years of age -Duration is usually lifelong with periods of remission -Usually involves the head but can also involve torso and limbs -Vocal tics include words and sounds (e.g. barks, grunts, yelps, clicks, snorts, sniffs, coughs) Coprolalia, the uttering of obscenities, is present in less than 10% of cases -Affects 4-5 in 10,000 and is more common in males

question

Tourette's Disorder: Assessment

answer

-Symptoms include obsessions, compulsions, hyperactivity, distractibility, and impulsivity. Low self-esteem is common, feeling ashamed, self-conscious, and rejected by peers. Fear of tics in public situations limits activities. -CNS stimulants increase the severity of tics: Children with co-existing ADHD must have their medication carefully monitored.

question

Nursing Diagnosis: Tourette's Disorder

answer

-Anxiety -Impaired social interaction -Chronic low self-esteem -Social Isolation

question

Implementation: Tourette's Disorder

answer

Focus of the treatment is helping the child, family, and school understand and cope with tic behaviors. Is managed on an outpatient basis unless tics severely impair the child's ability to function at home or school. Inpatient and day hospitalization is needed for a complete evaluation and pharmacologic intervention. Clonidine HCl and guanfacine HCl are the most effective drugs. Mild co-occurring obsessive-compulsive disorder (OCD) is responsive to cognitive therapy.

question

Disruptive, Impulsive, and Conduct Disorders

answer

Oppositional Defiant Disorder (ODD) Angry mood Defiant and headstrong behaviors Almost all children show symptoms found in ODD. However, for ODD to be diagnosed, the behaviors need to occur "more persistently and frequently.

question

Assessment

answer

Quality of child-parent/caregiver relationship: Bonding, anxiety, tension, and difficulty-of-fit between the parent and child's temperaments can contribute to these problems. Parent or caregiver's understanding of growth and development and parenting skills: Lack of knowledge contributes to the development of these problems. Lags or deficits in cognitive, psychosocial, and moral development result in disruptive behaviors

question

Conduct Disorder

answer

-Childhood-onset conduct disorder can be seen as early as 2 years of age. Is physically aggressive, has poor peer relationships, shows little concern for others, and lacks guilt and remorse. -Adolescent-onset conduct disorder results in less aggression. Acts out misconduct with peer group (e.g., truancy, early-onset sexual behaviors, drinking, substance abuse, risk-taking behaviors).

question

Assessment Guidelines: ODD and Conduct Disorder

answer

Assess: Seriousness of disruptive behavior Possible hospitalization or residential placement Levels of anxiety, aggression, hostility, and impulse control During the interview: Have support available in case hostility escalates. Position self in a safe spot. Assess moral development: the ability to understand the effects of hurtful behavior on others, to empathize with others, and to feel remorse.

question

Nursing Diagnosis: Disruptive Disorders

answer

Fear Defensive coping and ineffective coping Delayed growth and development and self-care deficits Disturbed personal identity Impaired verbal communication and social interaction Risk for impaired parent and child attachment Risk for injury Risk for self-mutilation Risk for self-directed or other-directed violence

question

Implementation

answer

Protect from harm, and provide for needs. Provide immediate nonthreatening feedback for unacceptable behaviors. Provide immediate positive feedback for acceptable behaviors. Increase the ability to control impulses using role play. Foster identification with positive role models. Foster the development of realistic self-identity. Provide education and guidance for parents and caregivers.

question

Anxiety Disorders

answer

Are the most common mental disorders of childhood and adolescence, affecting 13% of youth 9 to 17 years of age. Have a genetic vulnerability. Anxiety in children and adolescents may be displayed in more somatic complaints such as stomach aches and headaches (as opposed to adults). Agoraphobia, generalized anxiety disorder, panic disorder, specific phobia, and a social phobia may develop through adulthood.

question

Separation Anxiety Disorder

answer

-Experience extreme anxiety when separated or anticipating separtion from fmilial surroudings -Panic is overwhelimg and excessive -if not treated, extreme anxiety can persist and lead to panic disorder with agoraphobia later in life -Depressed mood often accompanies anxiety

question

Assessment Guidelines: Anxiety Disorders

answer

Quality of child-parent/caregiver relationship Recent stressors and severity Parent's or caregiver's understanding of developmental norms, parenting skills, handling of problematic behaviors: Lack of knowledge contributes to increased anxiety. Assessment of whether regression has occurred Assessment of physical, behavioral, and cognitive symptoms of anxiety

question

Assessment Guidelines: Separation Anxiety Disorder Cont.

answer

Assess child's previous and current ability to separate from parent or caregiver: Separation and individuation process may not be completed, or the child may have regressed. Assess for the presence of anxiety problems in the parent or caregiver: In addition to genetic issues, anxiety and depression can be "contagious." Assess parental response to child's anxiety: Increased attention reinforces behavior.

question

Nursing Diagnosis

answer

Anxiety Fear Delayed growth and development Impaired parenting Ineffective coping

question

Implementation: Anxiety Disorders

answer

Medications are only used if psychotherapy is unsuccessful or anxiety levels are incapacitating. SSRIs have proved to be the most effective. Foster developmental competencies and coping skills. Protect from panic levels of anxiety. Accept regression, and give emotional support

question

Implementation: Anxiety Disorders Cont.

answer

Offer positive reinforcements (hugs, praise) for small victories the child is able to accomplish. Negative reinforcement may increase anxiety. Increase self-esteem and feelings of competence in the ability to perform, achieve, and influence the future. Help accept and work through traumatic events or losses.

question

Therapeutic Modality Definitions Class Acitivity

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Dramatic play Movement/dance Music Therapy Recreational therapy Therapeutic drawing family involvement group therapy behavior modification milieu therapy therapeutic games time out therapeutic holding removal and restraints

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Sigmund Freud's 5 of the most important properties of defense mechanisms:

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o Defenses are a major means of managing conflict and affect o Defenses are relatively unconscious o Defenses are discrete from one another o Although defenses are often the hallmarks of major psychiatric syndromes, they are reversible o Defenses are adaptive as well as pathological

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Denial

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• Involves escaping unpleasant realties by ignoring their existence

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Splitting

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• Pts. with BPD • Aspects of the self and of others tend to alternate b.w opposite poles • Their frequent use of the defense splitting not only strains personal relationships but also creates turmoil in health care settings • It is the inability to integrate both positive and negative qualities of an individual into one person • Individual tends to think in extremes

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Reaction formation

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• Phenomenon: obsession • Purpose: anxiety-producing unacceptable thoughts or feelings are kept out of awareness by the opposite feeling or idea • Example: pt. with strong aggressive feelings toward husband repeatedly thinks the opposite to keep hostile feelings out of awareness

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Denial

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An unconcious protective defense against the terrifying reality of losing one's place in the world

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Neurocognitive Disorders: Three (3) Main Categories

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1) Delirium 2) Demetia (a maor neurocognitive disorder) 3) Mild nurocognitive disorders

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Delirium Prevalance

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-Is present in 60% of nursing home residents who are 75 years of age or older. -Approximately 75%-85% of people with a terminal illness develop delirium near death.

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Delirium: Co-morbidity

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Always exists secondary to another medical condition or substance use.

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Delirium

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-Occurs more often in older adults -Causes are surgery, drugs, UTIs, pneumonia, cerebrovascular disease, and CHF

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Delirium: Essential Feature

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disturbed consciousness coupled with cognitive difficulties (thinking, memory, attention, and perception) -sundown syndrome (increased confusion in evening hours)

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Delirium: Clinical Picture

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Disturbances in consciousness occur. Change in cognition occurs. Develops over a short period. Is common in hospitalized patients, especially older adults. Is always secondary to another physiologic condition. Is a transient disorder. If the underlying condition is corrected, then complete recovery should occur.

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Delirium: Assessment (4 cardinal features)

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-Acute onset and fluctuating course -Inattention -Disorganized thinking -Disturbance of consciousness

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Delirium Assessment

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Cognitive and perceptual disturbances (illusions, hallucinations) -Physical needs Mood and physical behaviors

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Delirium Assessment Guidelines

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*Determine fluctuating levels of consciousness. *Interview the family to determine the patient's normal level of consciousness and cognition. *Review medical findings and diagnostic data to help determine any underlying conditions. *Assess vital and neurologic signs. *Determine the patient's risk for injury. *Assess the need for comfort measures. *Assess the availability of an immediate medical intervention to prevent brain damage.

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Delirium- Causes (I WATCH DEATH)

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Infection Withdrawl Acute metabolic Trauma CNS pathology Hypoxia Deficiencies Endocrineopathies Acute vascular Toxins or drugs Heavy metals

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Delirium- Life- threatening causes (WWHHHIMPS)

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Wernicke's encephalopathy Withdrawl Hypertensive crisis Hypoperfusion/hypoxia of the brain Intracranial process/infection Metabloic/meningitis Poisons Status epilepticus

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Delirium- Deliriogenic medications (Mneumonic for diagnosing: ACUTE CHANGE IN ME)

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Antibiotis Cardiac Drugs Urinary incontinence drugs Theolophyline Ethanol Corticosteroids H2 blockers Antiparkinsonian drugs Narcotics Geriatric psychiatric drugs ENT drugs Insomnia drugs NSAIDS Muscle relaxants Seizure medicines

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Delirium: Common Symptoms

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>Autonomic hyperactivity (increased vitals) >Hypervigilance (constantly alert or scanning room) >Labile mood swings >Agitation and/or anger

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Delirium: perception, disturbances, cognitive/perceptual

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*Perception of the environment is abruptly disrupted. *Disturbance in consciousness occurs (awareness of time, place, and person). *Cognitive and perceptual disturbances include: -Illusions (false perception of real stimuli) -Hallucinations (primarily visual and tactile

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Delirium: NURSING DIAGNOSIS

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Risk for injury Acute confusion Deficient fluid volume Insomnia and sleep deprivation Impaired verbal communication Fear Self-care deficit Disturbed thought process

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Delirium: Planning/Implementing

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-Medical management is directed toward identifying and treating any underlying cause. -Nursing implementations are directed toward patient safety. -Communicate in simple and concrete phrases. -Use reality-orientation aids (clocks, calendars). -Maintain the same staff, if possible. -Encourage family members to be supportive

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Communication Guidelines (Delirium)

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Keep distractions to a minimum. Always identify yourself. Speak slowly with short, simple words. Focus on one piece of information at a time. Talk with the patient about familiar things in life. Reinforce reality when the patient is delusional. Have the patient wear eyeglasses or hearing aids. Use reality-orientation tools such as clocks, calendars, a well-lit room, and family pictures.

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Delirium: Implementation

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-Prevent physical harm caused by confusion, aggression, or fluid and electrolyte imbalance. -Perform a comprehensive nursing assessment to aid in identifying the cause. -Assist with proper health management to eradicate the underlying cause. -Use supportive measures to relieve distres

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Delirium: Outcomes Identification

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Patient will return to premorbid level of functioning. Patient will remain safe and free from injury while in the hospital. Patient will be oriented to time, place, and person. Patient will be free from falls and injury.

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**Delirium: Evaluation Long-term outcomes include:**

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LONG-TERM OUTCOMES: Patient will remain safe pt. will be oriented to time,place, and person -Underlying causes will be identified

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**Delirium: Evaluation: Short-term goals**

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SHORT-TERM GOALS Are related to the ongoing changing condition of patient -Are the vital signs stable? -Have the pts. skin turgor and gravity remained normal?

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Physical safety needs of patients with Delirium

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-Wandering, pulling out IVs and foley catheters, and falling out of bed are common dangers that require nursing intervention -confusion magnifies the inability to recognize reality -Physical environment should be made as simple and clear as possible objects s/a clocks and calendars can maximize orientation to time -nurse should interact with pt. whereby they are awake- short periods of social interaction help reduce anxiety and misconceptions

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Biophysical safety (Delirium)

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autonomic signs- *tachycardia *sweating *flushed face *dialted pupils *elevated BP hypervigilange- when pts. are extraordinarily alert and their eyes constantly scan the room; may have difficulty falling asleep **important that nurses assess all medications b/c the nurse is in a position to recognize any drug reactions or potential interactions before delirium actually occured**

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Assessment of Delirium guidelines

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1) Assess for fluctuating levels of conciousness, key to delirium 2) Interview family or other caregivers to establish pts. normal LOC, and cognition 3) Assess for past confusional states 4) Identify other disturbances in medical status (infection, dyspnea, edema, presence of jaundice) 5)Identify elecroencephalographic, neuroimaging, or laboratory abnormalaties documented in the pts. records 6) Assess vital signs, LOC, and neurological signs 7) Assess potential for injury (falls, wandering) 8) assess need for comfort measures (address pain, cold, improve positioning) 9) monitor factors that worsen or improve symptoms 10) Assess for avalablility of immediate medical interventions to help prevent irreversible brain damage 11) remain nonjudgemental, confer with other staff readily when questions arise

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Dementia: Major Neurocognitive Disorder

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Is marked by impaired cognitive function and by slowly deteriorating social and occupational functioning, although the levles of alterness are generally not disturbed

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Dementia

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Cognitive functioning progressively deteriorates, and global impairment of the intellect develops. No change in consciousness occurs. Memory, thinking, and comprehension are difficult. Majority of dementias are irreversible.

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Cognitive impairment involves the four "A's"- defense mechanisms

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*Amnesia (memory impairment) *Aphasia (loss of language ability) *Apraxia (loss of purposeful movement in the absence of motor or sensory impairment) *Agnosia (loss of sensory ability to recognize objects)

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Primary Dementia

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Irreversible Progressive Not secondary to any other disease Example: AD

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Secondary Dementia

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Result of some other pathologic process Example: Acquired immunodeficiency syndrome (AIDS)-related dementia

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People with dementia often:

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-Have difficulty finding the right words. -Use familiar words repeatedly. -Invent new words to describe things (neologisms) . -Lose their train of thought. -Rely on nonverbal gestures.

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outcomes for pts. with Dementia

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-Pt. will remian safe and free from injury while in hospital during periods of lucidity, pt. will be oriented to time, place, and person with the aid of nursing interventions, s/a the provision clocks, calendars, maps (orienting information) Pt. will remain free from falls and injury whle confused with the aid of nursing safety measures Pts. tubes (e.g NG tube, IV, O2) will remain in place with aid of nurse, family, and/or medication as needed **b/c LOC changes throughout the day, pt. needs to be checked for orientation (time,place, person) frequently during different times of the day

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Communication guidelines for AD (primary type of dementia)

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Always identify yourself. Call the person by his or her name at each meeting. Speak slowly. Use short, simple words and phrases. Maintain face-to-face contact. Be near the patient when talking, one or two arm lengths' away. Focus on one piece of information at a time. Talk with the patient about familiar things. Encourage reminiscing about happy times. When the patient is delusional, acknowledge the patient's feelings and reinforce reality. Do not argue or refute delusions. Have the patient wear eyeglasses or a hearing aid. Keep the patient's room well lit. Have clocks, calendars, and personal items (e.g., family pictures, Bible) in clear view. Reinforce the patient's pictures, nonverbal gestures, X's on calendars, and other methods to present reality.

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If a patient gets into an argument with another, separate the individuals. After approximately 5 minutes, explain your intervention.

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If the patient is verbally aggressive, then acknowledge the patient's feelings and shift the topic to a familiar ground (e.g., "I know this is upsetting for you, because you always cared for others").

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Reducing stress can be facilitated by

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Realistic understanding Establishing realistic outcomes Maintaining good self-care

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Common Risk factors in AD

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Higher rates of diabetes and hypertension are found in those with AD than found in those who do not develop AD. Lower educational levels increases the risk for AD. Socioeconomic levels factor into the above statistics. Adequate medical care (e.g., past head traumas) is lacking. Poor diet, obesity, and insulin resistance History of head injury First-degree relative of a person with AD Family history Vascular factors Inflammatory markers Hypertension

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Safe environment when caring for a patient with AD or teaching family members

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Gradually restrict the use of a car. Remove throw rugs and other objects. Minimize sensory stimulation. If verbally upset, give support and change the topic. Label rooms, drawers, and often-used objects. Install safety bars in the bathroom. Supervise the patient when he or she smokes. History of seizures exists; educate the family on seizure management.

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Wandering: INTERVENTIONS FOR THE SAFE ENVIRONMENT

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Wandering Place a mattress on the floor, or use a bed monitor. Provide a MedicAlert bracelet with identification. Notify the police department with photographs, or alert the neighbors. If in the hospital, have the patient wear a brightly colored vest with the patient's identification printed on the back. Install complex locks on the door and locks at the top of the door. Explore feasibility of sensor devices or global positioning system (GPS).

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Useful Activities: interventions for the safe environment when caring for a pt. with AD

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Provide picture magazines and children's books when reading ability diminishes. Provide simple activities that exercise large muscles. Encourage group activities that are familiar and simple to perform. Encourage physical activity during the day.

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Hallucinations: nursing interventions for

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nurse should initially should try and understand what the voices are saying or telling the person to do suicidal/homicidal messages necessitate initation of safety measures for all members of the health care team nurse should approach pts. who are hallucinating in a nonthreatening nonjudemental manner during acute phase- maintain eyecontact

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Stages of Alzheimer's Disease (Dementia)

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Stage 1 (mild) - forgetfulness Stage 2 (moderate)- confusion Stage 3 (moderate to severe)-Ambulatory dementia Stage 4 (late)- end stage

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Stage 2 (moderate) Dementia

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shows progressive memory loss; short term-memory impaired, memory difficulties interfere with all abilities withdrawn from social activities shows declines in instramental activities (ADLs) s/a money management, legal affairs, transportation, cooking, house keeping -Denial common; fears "losing his/her mind" -Depression common; frightened b/c aware of deficits; covers up for memory loss through confabulation -Problems intensified when stressed, fatiged, out of own environment -Ill commonly need "day care" or in home assistance is needed at this time

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stage 2: Moderate Alzheimer's disease

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-Often person with moderate AD cannot remember address or the date memory gaps in persons history that may fluctuate from one moment to the next -Hygiene suffers, and the ability to dress appropriately is affected (e.g may not fasten zipper (apraxia) -Mood becomes labil -may have bursts of paranoia, anger, jealousy, and apathy care and supervision become full time jobs for family members

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Autism Spectrum Disorders (ASDs)

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o ASDs combine what the DSM-5 called Pervasive Developmental Disorders (PDD) Not Otherwise Specified, such as autistic disorder and Asperger's syndrome. o Significant evidence supports the genetic transmission of ASD. (CDC, 2010) o Must demonstrate two or more of the following: o Stereotyped or repetitive speech, motor movements, and echolalia, and the repetitive use of objects o Excessive adherence to routines, rituals, or excessive resistance to change o Fixated interests that are abnormal in intensity o Hyporeactive or hyperreactive to the sense of joy or unusual interest in sensory aspects of the environment (e.g., indifference to pain, heat, cold) o Deficits in Spectrum disorders • Social and emotional reciprocity • Verbal/nonverbal communicative behaviors used for social interaction • Developing and maintaining relationships appropriate to the developmental level

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Symptoms of ASPs

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social skills: • Avoids eye contact'resists physical contact • Plays alone • Flat or inappropriate facial expressions • Noes not respond by to name by 12 months of age

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Communication

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• Delayed speech and language skills • Echolalia (repeats words and phrases over and over) • Plays with toys the same way every time • Gets upset about minor changes (furniture moved around) • Obsessive interests

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ODD

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o Angry mood o Defiant and headstrong behaviors o Almost all children show symptoms found in ODD. However, for ODD to be diagnosed, the behaviors need to occur "more persistently and frequently."

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Assessment of ODD

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o Quality of child-parent/caregiver relationship: o Bonding, anxiety, tension, and difficulty-of-fit between the parent and child's temperaments can contribute to these problems. o Parent or caregiver's understanding of growth and development and parenting skills: o Lack of knowledge contributes to the development of these problems. o Lags or deficits in cognitive, psychosocial, and moral development result in disruptive behaviors

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Conduct disorder (CD)

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• Is a serious behavioral and emotional disorder characterized by a persistent pattern of behavior in children and adolescents in which the rights of others and societal rules are violated • Child/adolescent acts out these patters of behaviors all in one setting and is considered forerunner of antisocial/ asocial personality disorder • Childhood-onset conduct disorder can be seen as early as 2 years of age

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Conduct disorder Cont

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o Irritable temperament, inattentiveness, impulsivity) which can later lead to conduct disturbances o As these children reach elementary school age aggressive tendencies with adults and peers continue to not follow social mores and lack the ability to solve the psychosocial issues. These children are physically aggressive, has poor peer relationships, shows little concern for others, and lacks guilt and remorse poor compliance o They misperceive the intentions of others as being hostile and believe their aggressive responses are justified o They try to project a tough image, but often lack self esteem and a low tolerance for frustration, show irritability, and have temper outbursts

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Assessment for ODD and conduct disorders

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o Assess: • Seriousness of disruptive behavior • Possible hospitalization or residential placement • Levels of anxiety, aggression, hostility, and impulse control o During the interview: • Have support available in case hostility escalates. • Position self in a safe spot. **Assess moral development: the ability to understand the effects of hurtful behavior on others, to empathize with others, and to feel remorse**

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Nursing Diagnosis: Disruptive Disorders

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o Fear o Defensive coping and ineffective coping o Delayed growth and development and self-care deficits o Disturbed personal identity o Impaired verbal communication and social interaction o Risk for impaired parent and child attachment o Risk for injury o Risk for self-mutilation o Risk for self-directed or other-directed violence

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Older ADULTS AND MEDS

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• Prescription and Over-the-Counter Drug use and Abuse o Older adults use prescription and OTC drugs at a higher rate than the general population. o Increased sensitivity increases medication-related adverse events such as increased sedation, delirium, confusion, and falls resulting in hip fractures. o Medication-related adverse events are especially prevalent with long-acting benzodiazepines and anticholinergic medications. o Prescription drug abuse by older adults went from 0.7% to 3.5% during 1992 to 2008. o Older adults will abuse two or more drugs (multidrug abuse).

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Physical restraints

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Physician's order must be obtained • Restraint application must be time limited • Attempts at alternative approaches must be documented • Ongoing observation and assessment must be documented • Care (e.g., provision of food and fluids, toileting, help with ADLs, response to attempted release) must be documented o From the Joint Commissions (TJC) Guidelines

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dystonia

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• A common EPS that involves muscle cramps of head and neck • Contractions of tongue, face, neck, and back (tongue and jaw first)

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Tactile Hallucinations

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• Delirious individuals may become terrified when they "see" giant spiders crawling over the bed

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Aphasia

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• Loss of language ability • Progresses with the disease (alzheimers) • Initially the person has difficulty finding the correct word, then is reduced to few words, and then babbling/mutism

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Apraxia

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• Loss of purposeful movement in the absence of motor or sensory impairment • Person is unable to perform once-familiar and purposeful tasks • E.g. person loses the ability to walk (apraxia of gait) • Apraxia of dressing= the person is unable to put on clothes properly

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Agnosia

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• Loss of sensory ability to recognize objects • Person may lose the ability to recognize familiar sounds (auditory angosia) s/a the ring of the telephone, a car horn • Loss of this ability extends to the inability to recognize familiar objects (visual/tactivle agnosia) s/a glass, magazine, pencil, or toothbrush

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