Exam 3 Flashcards
anxiety
feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized
fear
reaction to a specific danger
levels of anxiety
mild, moderate, severe, panic
mild anxiety
everyday problem-solving leverage; grasps info more effectively; possible slight physical discomfort such as restlessness, irritability, or fidgety
moderate anxiety
selective inattention; clear thinking is hampered; problem solving is not optimal, sympathetic nervous system symptoms begin
severe anxiety
perceptual field greatly reduced; difficulty concentrating on environment; confused and automatic behavior; somatic symptoms increase; stay by pt side and dont leave alone
panic
markedly disturbed behavior like running, shouting, screaming, pacing; unable to process reality; impulsivity; may not be able to implement coping mechanisms or encourage certain behavior; do not leave pt alone
5 important properties of defense mechanisms
major means of managing unconscious conflict; they are for the most part unconscious; they are discrete from one another; they can be seen as part of many psychiatric disorders; they can be both adaptive and pathological
defense mechanisms
are automatic coping styles; protect people from anxiety; maintain self-image by blocking feelings conflicts and memories; can be healthy or unhealthy; are reversible
examples of healthy defense mechanisms
altruism, sublimation, humor, suppression, repression, displacement, reaction formation, somatization, undoing, rationalization
examples of immature defense mechanisms
passive aggression, acting-out behaviors, dissociation, devaluation, idealization, splitting, projection, denial
frequent co-occurring conditions with anxiety
depressive disorders, alcohol/drug use disorders, eating disorders, bipolar disorders, MDD
chronic anxiety can…
lead to increased risk for cardiovascular morbidity and mortality
types of anxiety disorders
generalized anxiety disorder, social anxiety disorder, panic disorder, specific phobias, agoraphobia, separation anxiety disorder
when diagnosing someone with an anxiety disorder…
need to rule out other medical causes and/or causes of anxiety d/t substance use
GAD- generalized anxiety disorder
hallmark feature is excessive worry out of proportion to event; nedd 3 associated symptoms of feeling on edge/restless, irritability, fatigue, concen. impairment (ADHD must be ruled out), sleep disturbances, muscle tension; causes change in social, occupational, or other areas of function;
difference between diagnosing children vs adults with GAD
adults need 3 associated symptoms where children need 1
comorbidities of GAD
depression, other anxiety disorders
gold standard of treatment for generalized anxiety disorder
SSRI/SNRI
social anxiety disorder
severe anxiety caused by exposure to social or performance situation; fear of saying something foolish or not being able to answer a question in class or eating in front of others or performing on stage or being among others; fear of public speaking is most common
panic disorders
feelings of terror; suspension of normal functioning; severely limited perceptual field; misinterpretation of reality; sudden onsets (not always in present of stress); often coupled with OCD; do not leave pt alone
s/s of panic attacks
palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nausea, feelings of choking, chills, hot flashes, GI symptoms
panic agoraphobia
intense and excessive level of anxiety and fear of being in places or situations where escaping is impossible; avoidance of feared places is common; avoiding behaviors become debilitating and life constricting
when someone arrives at the ED with panic…
assess for proper cardiac workup; referral is needed for potential diagnosis and treatment of anxiety disorder
specific phobias
intense fear or anxiety when in or anticipating presence of stimulus; person either avoids or tolerates with great discomfort; results in impairment in social, work, and relationships
agoraphobia
intense fear or anxiety about being in places/situations from which escape might b difficult or embarrassing or help may not be available in event of panic attack; situation is actively avoided, requires companion, or endured with intense fear/anxiety causing pt to become housebound; panic/anxiety is out of proportion to actual event/situation
situations/places must include 2 of the following
public transportation, open spaces, enclosed spaces, in line/crowd, outside of home alone
separation anxiety disorder
normal part of infant development 8 months - 18 months; fear that something will happen to attached person resulting in permanent separation
s/s of separation anxiety
GI disturbances and headaches most common in children
obsessive-compulsive disorder
obsessions are unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause significant anxiety or distress; compulsions are unwanted, ritualistic behavior that the individual feels driven to perform to reduce anxiety; exists as a continuum; mild compulsions are values in the US; not a diagnosis until begins to impair ones life
severe symptoms of OCD
center on dirtiness, contamination, germs; corresponding compulsions are cleaning and handwashing
most severe OCD symptoms
persistent thoughts of sexuality, violence, illness, and death
diagnoses related to OCD
body dysmorphic disorder, hoarding, trichotillomania, excoriation disorder
body dysmorphic disorder
preoccupation with an imagined defective body part, obsessive thinking about the body, impaired normal social activities either occupational or educational
hoarding
excessive collection of items considered worthless, individual is ashamed of failure to discard, disrupts life and causes distress, social isolation is common, unsafe living conditions
trichotillomania
pulling hair out of head, eyebrows, eyelashes, pubic area, axillae, limbs (anywhere on body); hair pulled in patches or singular; trichophagia is secretly swallowing the pulled hair
excoriation disorder
skin picking, mostly on the facial area, to deal with stress and relieve anxiety; damages to the skin; complications include pain, sores, scars, infections; trichotillomania can also occur
nursing problems related to anxiety
anxiety- self-monitors intensity, uses reduction techniques, maintains role performance; ineffective coping- identifies ineffective and effective patterns, asks for assistance and information, modifies as needed; chronic low self-esteem- verbalizes self-acceptance and increases confidence
planning related to anxiety
do not usually require inpatient; involves community-based interventions, encourage active participation in planning to increase positive outcomes; pt who experiences severe levels may not be able to participate in planning
nursing intervention for mild to moderate anxiety
therapeutic communication and listening- open ended questions, clarification, exploration; be aware of nonverbal communication; remain calm and nonjudgmental
nursing interventions for severe to panic anxiety
provide privacy; remain calm, speak quietly, softly; reduce environmental stimuli; provide for safety needs; reinforce reality; listen for themes; medications
psychopharmacology interventions for…
anxiety- first line is SSRIs and SNRIs for daily use; OCD- old TCA clomipramine (anafranil) and anxiolytics like benzodiazepines
how do benzodiazepines work?
agonize GABA (depress CNS); risk for dependence and tolerance; can cause sedation, ataxia, decreased cognitive function
other anxiety prescribed meds
antihistamines PRN like hydroxyzine (vistaril); anticonvulsants daily like gabapentin (neurontin), pregabalin (lyrica);’ antipsychotics in severe cases
behavioral therapy/techniques
relaxation techniques - deep breathing, guided imagery, progressive relaxation, autogenic training, self-hypnosis, biofeedback-assisted relaxation; behavioral therapy- aversion, flooding, systemic desensitization, exposure and response prevention, modeling, thought stopping
thought stopping example
snapping elastic on wrist to stop thinking and focus on the pain
evaluation of anxiety interventions
is pt able to recognize symptoms as related to anxiety, can pt use newly learned behaviors to manage anxiety, is pt taking care of self, is pt maintaining interpersonal relations, and is pt assuming usual roles?
trauma-related disorders in children
PTSD, reactive attachment disorder, disinhibited social engagement disorder
Types of adverse childhood experiences (ACEs)
physical abuse, physical neglect, household member with mental health issues, sexual abuse, loss of parent/divorce/abandonment, emotional abuse, emotional neglect, household member with substance abuse, household member who was incarcerated, witnessing domestic abuse
biological factors contributing to trauma related disorders
genetic- how individuals react to trauma; neurobiological- trauma dysregulates neural pathways that integrate emotional regulations and arousal, triggers hypoaroused stated causing dissociation, polyvagal theory; psychological factors- attachment theory; environmental factors- dependence on adults and systems, external factors that support or add stress
when assessing trauma-related disorders in children…
need to understand what the appropriate developmental level for the individual is
3 stages of intervention for trauma-related disorders: children and adults
stage 1- provide safety and stabilization; stage 2- reduce arousal and regulate emotion through symptom reduction; stage 3- catch up on development and social skills, develop a value system
interventions for children with PTSD
establish trust/safety, use developmentally appropriate language, teach relaxation techniques, use art/play to promote expression of feelings
PTSD in adults
re-experiencing the trauma, avoiding stimuli associated with trauma, persistent symptoms of increased arousal, alterations in mood
S/S of PTSD in adults
flashbacks, nightmares (ex. veterans avoiding 4th of july)
outcome identification/planning for PTSD adults
manage anxiety, increase self-esteem, improve ability to cope
implementation for PTSD in adults
stage 1- provide safety and stabilization; stage 2- reduce arousal and regulate emotion through symptom reduction; stage 3- catch up on development and social skills, develop a value system; psychodeducations; psychopharmacology
acute distress disorder
occurs immediately after highly traumatic event that can show S/S for 3 days; DX made within a month; after 1 month it either resolves or becomes PTSD
Acute distress disorder diagnoses
alterations in concentration, anger, dissociative amnesia, headache, irritability, nightmares
acute stress disorder implementations
establish therapeutic relationship, assist to problem solve, connect person to supports, collaborate for coordination of care, ensure and maintain safety, refer to licensed mental health provider, monitor response and/or adherence to treatment
advanced practitioner implementation for acute stress disorder
cognitive-behavioral therapy
adjustment disorder
precipitated by stressful event; debilitating cognitive, emotional, and behavioral symptoms that negatively impact normal functioning; responses to stressful event may include combinations of depressing, anxiety, and conduct disturbances
dissociative disorders…
occur after significant adverse experiences/traumas; individuals respond to stress with severe interruption of consciousness, unconscious defense mechanism; protect individual against overwhelming anxiety through emotional separation
types of dissociative disorders
depersonalization/derealization disorder, dissociative amnesia, dissociative identity disorder
depersonalization
focus on self; “I a not really me in a real world”
derealization
focus on outside world; “I am real, the world around me is not real”
dissociative amnesia
inability to recall important personal info; often of traumatic or stressful nature; commonly experience dissociative fugue
dissociative fugue
sudden unexpected travel and inability to recall ones identity; traveling with no memory
dissociative identity disorder
presence of two or more distinct personality states; each alternate personality has own patter of perceiving, relating to, and thinking about self and environment
assessment of dissociative disorders consists of…
history (HX of trauma?; avoid having pt recall events), moods, impact on pt and family, suicide risk, self-assessment
planning for dissociative disorders
Phase 1- establishing safety, stabilization, and symptom reduction; Phase 2- confronting, working through, and integrating traumatic memories; Phase 3- Identity integration and rehabilitation
implementation for dissociative disorders
psychoeducation, pharmacological interventions
schizophrenia spectrum disorders…
affect how a person thinks, feels, and behaves; not a mood disorder but a sensory disorder; primary psychotic disorder
psychotic disorders lead to abnormalities in 5 different symptomatic domains
delusions, hallucinations, disorganized thoughts, disorganized or abnormal motor behavior, and negative symptoms
what are secondary psychotic disorders
due to something such as substance abuse or diseases that affect the neurological system such as a brain tumor, dementia, neurological diseases, prescription meds (steroids), environmental toxins
risk factors for developing schizophrenia
alterations in brain structure, disruptions in brain’s neurotransmitter system, alterations to neural circuits caused by genetic and nongenetic factors
neurochemical contributing actors to schizophrenia
dopamine, serotonin, NMDA receptors, glutamate
physiological factors proving schizophrenia is disease of brain
neuroanatomical factors- decreased tissue volume, decreased brain volume, larger lateral and third ventricles, frontal lobe atrophy, more CSF
cultural considerations for schizophrenia
generally consistent; some symptoms can be interpreted differently such as some cultures commonly see hallucinations of a loved one after they pass which is normal; culture differ in attributions to mental illnesses
course of schizophrenia
prodromal phase, acute phase, stabilization phase, maintenance phaseprodro
prodromal phase of schizophrenia
s/s that precede the acute, fully manifested s/s of the disease (withdrawal, isolation, hyperfixations)
acute phase of schizophrenia
well developed symptoms grouped into 4 categories: positive symptoms, negative symptoms, cognitive symptoms, mood symptoms
stabilization phase of schizophrenia
period in which acute symptoms particularly “positive symptoms” decrease in severity
maintenance phase of schizophrenia
period in which symptoms are in remission although there might be milder symptoms still persisting (residual symptoms); for example some individuals will never not hear voices
positive symptoms of schizophrenia
symptoms added to a pt that is not normally present: hallucinations, delusions, bizarre behavior, paranoia, disorganized speech and thoughts
negative symptoms of schizophrenia
taken away from the patient: apathy, lack of motivation, anhedonia, avolition, blunted affect; harder to see negative symptoms
cognitive symptoms of schizophrenia
memory issues, inability to process social cues, impaired sensory perception, decreases ability to reason and problem sove, decreased focus/attention, disruption in social learning
mood symptoms of schizophrenia
depression, anxiety, dysphoria, suicidality
primary psychotic disorders other than schizohrenia
shizophreniform disorder, brief psychotic disorder, schizoaffective disorder, delusional disorder, substance/medication-induced psychotic disorder
schizophreniform disorder
essential features are identical to those of schizophrenia but shorter durationsbri
brief psychotic disorder
sudden onset of psychotic symptoms; need to treat the underlying cause to solve issue
schizoaffective disorder
considered part of the schizophrenia spectrum disorders and consists of the mood component of bipolar with the psychosis of schizophrenia
delusional disorder
involves non-bizarre delusions
substance/medication-induced psychotic disorder
caused by ingestion or withdrawal from a substance
when assessing fro schizophrenia and other psychotic disorders
need to rule out medical/substance induced psychosis, assess for command hallucinations, review pt beliefs, assess co-occurring conditions, inventory pt meds, determine family response to symptoms, assess pt interaction with family, review support system of pt
examples of nursing DX for schizophrenia/psychotic disorders
impaired perceptions (specify), hallucinations (specify), anxiety: panic levels, risk for suicide, impaired coping, social isolation, loneliness, self-esteem low, anxiety
outcome identification for schizophrenia/psychotic disorders
Phase I (Acute)- goal is pt safety and medical stabilization; Phase II (stabilizations) and Phase III (Maintenance)- improve functioning via participation in social vocational and self-care skills training as well as involvement in social groups , control anxiety and prevent relapse to psychosis
planning for schizophrenia.psychotic symptoms
Phase I (Acute)- brief hospitalization if pt is danger to self or others or pt refuses to eat or pt is too disorganize to provide self-care, aftercare needs and appropriate referrals, discharge planning; Phase II (Stabilization) and Phase III (Maintenance)- identify social interpersonal coping and vocational skills needed, teach relapse prevention, determine how/where needs can be best met in community
schizophrenia/psychotic disorders interventions
Phase I (Acute)- crisis intervention, acute symptom stabilization, med adherence, safety; Phase II (Stabilization) and Phase III (Maintenance)- meds, nursing interventions, community support, pt and family psychoeducation, health promotion/maintenance
when communicating with someone experiencing internal stimuli…
wait longer for pt to respond and think, repeat as necessary, use short phrases and concrete language
when suspecting a pt is hallucinating (Schizophrenia/psychotic disorders)…
watch for cues of hallucinations, ask pt directly if they are hallucinating, determine if voices are commanding harm (warn others who may be target if outpatient), document what pt states, accept that voices are real to pt but state you cannot hear them, stay with t and tell pt to tell voices to go away at times, help pt focus on one thing at a time, identify times/situations that hallucinations most prevalent, intervene once anxiety fear or agitation is noticed
when suspecting a pt is delusions (Schizophrenia/psychotic disorders)…
assess for need of external controls, be aware pt delusions represent way pt is experiencing reality, identify feelings, engage individual in yoga or exercise or walk, do not argue with pt, do not touch pt
when suspecting a pt is paranoia(Schizophrenia/psychotic disorders)…
place self bedside not face-to-face, avoid eye contact, use matter of fact/business-like approach, offer food/fluids in closed container, engage ot in reality-based non-competetive activities, observe for events that trigger delusions, use least restrictive measures if pt loses control
when pt demonstrating associative looseness…
dont pretend to understand and state when confused, verbalize implied, place difficulty on self not on pt, observe for recurring themes, emphasize here and now to pt and involve pt in simple reality based activities, tell pt what you do understand
benefits of providing practical education
increase persons ability to manage symptoms of disease, can instill hope, can promote wellness, can increase a person’s self-esteem
a therapeutic milieu provides…
emotional and physical safety, useful activities, resources for resolving conflicts, opportunities for learning social and vocational skills
antipsychotic medications
first generation/conventional antipsychotics and second generation/atypical antipsychotics
extrapyramidal side effects (EPS)
Tardive dyskinesia (irrversible), acute dystonia- neck and shoulder stiffness, akathisia- inability to stay still and may treat with beta blockers, pseudoparkinsonism- shuffling and drooling
additional side effects to antipsychotics
anticholinergic effects (drying out), anticholinergic delirium, neuroleptic malignant syndromes, drug induced liver problems
substitutes to antipsychotics drug therapy
antidepressants; benzodiazepines
program of assertive community treatment
designed for most marginally adjusted and poorly functioning patients; aim to prevent relapse, maximize social and vocational functioning, and keep individual in community
cognitive behavioral therapy methods for schizohrenia/psychotic disorders
recovery oriented cognitive therapy- target distress and disturbance by correcting self-defeating beliefs; cognitive remediation- use specific learning activities to improve cognitive skill; social skills training- train to improve social interactions, social cognition, self and illness management skills, community participation and workplace skills
Evaluation of treatment for schizophrenia/psychotic disorders
realistic, attainable, mutually agreed upon outcomes are more successful; critical for staff to remember change occurs over time; period may be prolonged for someone diagnosed with schizophrenia
Support resources for those with psychotic disorders
National alliance on mental illness (NAMI), national institute of mental health (NIMH), mental health America, mantalhelp.net, schizophrenia.com, schizophrenia and related disorders alliance of America (SARDAA), Janssen Canada
recovery model and recovery-oriented care
interventions toward pt strength and highest level of functioning/quality of life; defines recovery as process of change; four dimensions
4 dimensions of recover-oriented care for psychotic disorder pt
health- overcoming or managing your disease, home- having stable place to live, purpose- meaningful daily activities and resources to participate in society, community- having supportive relationships and hope
Evidence based psychosocial therapies for pt with schizophrenia and their families
Recovery after an initial schizophrenic episode Project (RAISE), The recovery model and recovery-oriented care, cognitive behavioral therapy
anger
emotional response to frustration of desires, threat to ones needs, or a challenge; anger is normal and is a continuum
aggression
motor counterpart of anger; goal-directed action or behavior resulting in verbal or physical attack; verbal or physical lashing out; may be appropriate if self protective or protecting someone else like family
violence
does not always have roots in anger but does have discrete intention of doing harm to specific group or person; defined as unjust unwarranted or unlawful display of verbal threats, intimidation, or physical force; intended to inflict harm
bullying
offensive, intimidating, malicious, condescending behavior designed to humiliate and terrorize; persistent systemic violence toward a person or group; done by a person with higher status
lateral bullying
bullying by a person of equal status
environmental/demographic correlations to violence
childhood aggression is strongest predictor of adult violence; setting fires, animal cruelty, conduct disorders are red flags; violence experienced in childhood; low socioeconomic status; poor populations; learned angry reactions; genetics; neurobiological factors/brain structure
assessment of angry individual
gather medical and psych HX from all possible sources (fam., friends, pt when calm); obtain HX of pt background and coping skills as well as pt perception of issue; does pt have HX of violence, substance abuse, or psychotic behavior
subjective assessment questions for angry individual
have you thought of harming someone else? have you ever seriously injured another person? what is the most violent thing you have ever done?
s/s preceding violence
angry, anxious, irritable affect, hyperactivity- most important predictor of imminent violence (slamming doors, restless, pacing), increasing anxiety and tension (clenching jaw or fist, rigid posture, tense facial expression, verbal expression), loud voice, intense eye contact, substance withdrawal, possession of weapon, paranoia
milieu characteristics conducive to violence
loud, overcrowding, staff inexperience, provocative/controlling staff, poor limit setting, staff inconsistency (staff splitting)
nursing diagnoses related to anger/violent pt
safety is always priority: risk for self-directed violence, risk for other-directed violence; ineffective coping, risk for stress overload, confusion, disturbed though processes, disturbed sensory perception
short term outcome identification for angry/violent individual
pt will display nonviolent behavior toward self and others, recognize when anger/aggressive tendencies are escalating and use new tension-reducing behavior, make plans to continue with long-term therapy to work on violence prevention strategies and to increase coping skills
long term outcome identification for angry/violent individual
pt and other remain free from injury, hostile and abusive behavior will cease, use of assertive and cognitive reasoning behaviors to replace aggressive behaviors is evident, variety of healthy anxiety reduction techniques will be used to keep anger in check, aggressive/violent impulse will be controlled
stages of violence
preassaultive- de-escalation approaches, assaultive- meds/seclusion/restraint, post-assaultive- seclusion/restraint
de-escalation techniques during pre-assaultive stage
emphasize you are on pt side, stand at angle to appear nonconfrontational, assess/provide for personal safety, appear calm and in control, do not speak while pt yelling, speak softly and nonjudgementally/nonprovocatively, show genuineness and concern, do not treat in humiliating manner, ask what will help pt now?
seclusion intervention
involuntary confined alone in a room; pt is physically prevented from leaving
restraints
physical or mechanical device that restricts freedom of movement; use least restrictive first
medication
IM injection of barbiturate, antihistamine, or antipsychotic depending on physicians orders or underlying conditions
reintegration interventions
monitor every 15 minutes face-to-face through locked window (constant face-to-face if under 14); gradual reintegration geared toward pt ability to handle increased stimulation; structured reintegration is moving from 4 point restrain to 2 point then out of seclusion and use time out periods to move slowly into milieu
alternatives to seclusion and restrain
no therapeutic value to seclusion or restrain, only used to protect pt from self harm and protect others; comfort rooms to self-isolate when anxious/stressed are great; trauma informed approach
steps to trauma informed approach
- safety, 2. trustworthiness and transparency, 3. peer support, 4. collaboration and mutuality, 5. empowerment voice and choice, 6. cultural historical and gender issues
post-assaultive stage interventions
assure quality of care, provide self care opportunity for staff, document the violent episode itself and the staff response
meds for acute aggression
benzodiazepines are first choice for episodic dyscontrol and incipient rage; 2nd gen antipsychotics fo emergencies
evaluation of aggressive/violent pt
was assessment accurate and thorough?, were DX applicable to assessment?, did nursing DX drive the interventions?, was plan comprehensible and individualized?, were interventions carried out properly?, was correct protocol used?, were quality improvement methods used for future?
interventions with pt with cognitive deficit
reality orientation, provide calm unhurried soothing responses, validation therapy (do not attempt reorientation if pt unable to perceive life situation), psychotherapy
planning for pt with anger/violence
watch own tone, choice of words, triggers, nonverbal communication to avoid impulsive emotion based responses that may be harmful
if verbal abuse is taking place with angry pt…
leave immediately and inform pt that you will return when pt is calmer, if unable pt leave then discontinue convo immediately and stop eye contact, respond positively to nonabusive communication
what is a substance use disorder
problematic pattern of substance use leading to clinically significant impairment or distress
risky drinking numbers
over 3 drinks in 1 day for women or up to 7 drinks a weeks; over 4 drinks in 1 day or up to 14 drinks a week for men
CNS depressants
benzodiazepines, barbiturates, alcohol
3 classes of drugs to seek detox from
alcohol, benzodiazepines, opioids
s/s of cns depressants intoxication
physical- slurred speech, incoordination, unsteady, drowsiness; psychological- disinhibition of sexual/aggressive drive, impaired judgement, impaired social/occupational function, impaired attention/memory, irritable
alcohol withdrawal
early signs develop within few hours and peak 24-48 hours then disappear
alcohol withdrawal symptoms
hyper alert, jerky movements, irritanility, startle easily, intense tremors, cramps, vomiting, increase in HR, HTN, febrile, grand mal seizures
delirium tremens
alcohol withdrawal delirium which is a medical emergency and causes tachycardia, diaphoresis, disorientation, agitation, visual/tactile hallucinations
alcohol overdose effects
cardiovascular or respiratory depression/arrest, coma, shock, convulsions, death
alcohol withdrawal meds
benzodiazepines, chlordiazepoxide (librium) or diazepam (valium), serax, phenobarbitol (NOT GIVEN WITH BENZOS),
alcohol withdrawal adjunct therapy
clonidine, beta blockers, calcium channel blockers to decrease BP HR and anxiety, thiamine, folic acid, theragran, ondansetron
meds given to maintain alcohol sobriety
disulfiram (antabuse)- causes violent reaction when mixed with alcohol; naltrexone (reVia, vivitrol)- reduces pleasant feelings of alcohol; acamprosate (campral)- reduces feelings of anxiety/tension
alcohol and nursing interventions
supportive care, replace electrolytes, seizure precautions, CIWA to assess alcohol withdrawal severity, symptom trigger policy (less meds given with less symptoms)
benzodiazepine withdrawal
short acting withdrawal symptoms can occur within 24 hours; long acting withdrawal symptoms can occur within 24-72 hours
benzodiazepine withdrawal symptoms
anxiety, insomnia, N/V, tremor, incoordination, restlessness, sweating, delirium, seizures (occur up to 2 weeks after)
opioid intoxication effects
physical- constricted pupils, decreased RR, drowsiness, hypotension, slurred speech, psychomotor retardation; psychological- initial euphoria followed by dysphoria and impairment of attention, judgment, and memory
opioid withdrawal effects
yawning, insomnia, irritability, rhinorrhea, panic, diaphoresis, cramps, N/V, muscle aches, chills, fever, lacrimation, diarrhea: flu like symptoms
opioid overdose
pinpoint pupils, respiratory depression/arrest, coma, possible dilation of pupils due to anoxia = triad of symptoms; cardiac arrest, shock, convulsions, death; treat with naloxone
meds to detox from opioids
methadone- reduces severe withdrawals and has long half life; buprenorphine (subutex)- opioid partial agonist with weaker opioid effects causing less chance of OD and helps to alleviate cravings; suboxone- buprenorphine with naloxone that is used for long-term treatment and as a later substitute; clonidine- treats anxiety, decrease BP, and decrease HR
adjunct treatment for opioid detox
ibuprofen for pain, hydroxyzine (atarax) for anxiety, trazodone for sleep, bentyl for abdominal cramps, loperamide for diarrhea, ondansetron for nausea; avoid benzos if possible
cocaine/crack
extracted from coca leaf; when smoked effects take 4-6 secons and last 5-7 minutes; causes anesthetic and stimulant effects; produces imbalance in neurotransmitters
cocaine/crack withdrawals
depression, paranoia, lethargy, anxiety, insomnia, N/V, sweating and chills
marijuana
from hemp plant; generally smoked; THC is active ingredient; causes depressant and hallucinogenic effects; desired effects are euphoria, detachment, and relaxation; long-term effects are lethargy, anhedonia, difficulty concentrating, loss of memory, motivational syndrome
nicotine
acts as stimulant, depressant, and tranquilizer; can lead to cancer, mouth cancer, emphysema, CV disease, adverse pregnancy outcomes
nicotine withdrawal symptoms
strong cravings, impaired concentration, nervousness, restlessness, irritability, impatience, increased appetite
pharmacological aids for nicotine cessation
patches, gum, lozenges, nasal sprays, inhalers; nicotine free products are varenicline (chantix) and bupropion (wellbutrin)
psychoactive drugs
aka club drugs: cause stimulation and hallucinogenic effects; MDMA, GHB, ketamine, rohypnol, methamphetamine, LSD
other common substances
mescaline, psilocybin, salvia are all similar to LSD; bath salts and cathinones are new psychoactive substances (NPS); inhalants like spray paint, glue, cigarette lighter fluid, propellant gas used in aerosols
initial assessment for substance use disorder
symptoms of brain injury can mimic intoxication; trauma victims should have tox screen or BAL
assessment guide for substance abuse
HX of pt substance abuse- amount, type of drug, pattern, dates, last use; med HX- coexisting conditions, current meds, mental status, HX of withdrawal, seizures, DT; psychiatric HX- comorbid psych conditions , HX of abuse (sexual or physical), HX of suicide or homicidal ideations or current SI; psychosocial HX- affected relationships from substance abuse, support system, legal issues, unable to meet role expectations
substance abuse guideline numbered
- ensure s/s not due to medical cause. 2. establish substance being used, route, pattern, quantity, last use. 3. assess fo overdose and potential for withdrawal. 4. asses SI. 5. assess for physical complaints. 6. explore pt interests in addressing susbtance abuse. 7. assess pt knowledge of resources or support system
helpful screening tests for identifying problem and extent of substance use
alcohol use disorders identification test (AUDIT), michigan alcohol screening test (MAST), CAGE- cut down, annoyed, guilty, eye opener/ease, clinical opiate withdrawal scale (COWS)
nursing DX for substance use disorder
vomiting/diarrhea- deficient volume, risk for electrolyte imbalance; audiovisual hallucinations, impaired judgement d/t substance withdrawal/intoxication- risk for violence to self/others, risk for injury; feelings of hopelessness- risk for suicide; excessive substance abuse affecting areas of life- defensive coping, ineffective relationship, risk for loneliness
nursing outcome identification related to substance use
free from injury while withdrawing, safety; attending groups/programs to stay sober, identifying cues/situations that pose relapse risk, positive substance free support system, identifying coping skills
nursing planning for substance abuse
attention to gender/age, social status, income, culture, substance use history, current condition; propose abstinence as treatment goal
nursiing implimentations for subatcne abuse
aim of treatment is self responsibility not compliance; choice of inpatient/outpatient depends on cost, availability, insurance; outpatient programs work best for those who are not employed and have social support; relapse prevention- identify triggers; strategies for relapse prevention- learn how to cope with threats to recovery
substance abuse nursing evaluation
judged by increased length of time in abstinence, decreased denial, functioning in occupation, improved relationships, ability to relate comfortably to other humans
recovery from substance abuse
recovery paradigm- emerges from hope and is person driven; psychotherapy using alternative coping to reduce reliance on substance; cognitive behavioral therapy- recognize and avoid triggers as well as offers coping strategies; group therapy; AA- 12 step program; residential programs- addiction and antisocial behavior
common types of abuse prevalent in all social strata
family violence and trusted authority figure violence
4 abuse categories
emotional, physical, sexual, neglect
child abuse
when a child is harmed by someone else; children younger than 4 are the most vulnerable
when assessing a child involved and child abuse…
reassure child di nothing wrong, do not pressure child to talk, nonthreatening and supportive experience, interview should not resemble a trial, children may express experience through dolls or drawing, do not suggest answers, do not promise confidentiality, do not react with shock
when interviewing child…
open-ended questions are most effective; how did this happen to you?, who takes care of you?, what do you do after school?, who are your friends? what happens when you do something wrong?
intimate partner violence
pattern of assault and course of behaviors that may include physical injury, psychologic abuse, sexual assault…
forms of teen abuse
extreme possessiveness, jealousy, stalking, manipulation, devaluation, humiliation, threatening suicide, unwanted touching, forcing intimacy or sex
different types of abuse seen in all age groups
intimate partner violence, teen abuse, child abuse, elder violence
cycle of violence
consists of three phases: tension-building, acute battering, honeymoon
3 common categories of elder violence
domestic, institutional, or self-neglect
the 5 kinds of elder abuse
physical abuse, emotional abuse- inflicting mental anguish, financial abuse- misuse of someones property and resources, neglect- failure to fulfill caretaking obligation or a self-neglect, sexual abuse
adult protective services
where reports or suspected elder abuse should be filed to
child protective services (CPS)
who to contact if children are being hurt or abused
mandated reporter for children and elderly
nurses are legally responsible for reporting child abuse to the appropriate child protective agency; social workers, medical and mental health professionals, teachers, childcare providers are also mandated reporters
