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Final Stretch Flashcards

1
Q

What is a self limiting state of disequilibrium/ struggle for equilibrium & adaptation

A

Crisis

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2
Q

Crisis is experienced as what?

A

An overwhelming emotional reaction

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3
Q

How long does a crisis last?

A

4-6 weeks

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4
Q

What is the goal crisis intervention?

A

Return individual to pre-crisis, level of functioning or higher

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5
Q

Crisis intervention is focused on what?

A

Current situation

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6
Q

Types of crisis

A

Maturational
Situational
Adventitious
Existential

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7
Q

What is a maturational crisis?

A

Difficulty in a new developmental stage
Example:
- having a child leave home to attend college
- Birth of a child
- Death of your aged parents
- Teenagers confused about what college to get into

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8
Q

What is a situational crisis?

A

External “situation” causes crisis- happens to self
Example:
- job loss, death of a loved one, a divorce, physical or mental illness

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9
Q

What is an adventitious crisis?

A

Crisis of disaster: Larger in scale than situational: group
Example:
- natural disasters; floods, fires, earthquakes, etc.
- Mass shootings
- COVID

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10
Q

What is a existential crisis?

A

Questioning life’s purpose or spirituality

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11
Q

Seven stages of crisis intervention?

A
  • Plan and conduct crisis management: SI assessment
  • Establish rapport
  • Identify major problems: what is the #1 problem/ trigger
  • Deal with feelings/ emotions
  • Explore alternative: reframe cognitive distortions
  • Develop/ formulate an action: tell pt what to do/ what’s important
  • Crisis resolution
  • Follow up
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12
Q

How many phases of crisis are there?

A

4

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13
Q

Phase 1 of crisis

A
  • Conflict threatens self-concept
  • Increased anxiety
  • Stimulates Defense Mechanisms/ problem solving skills to lower anxiety.
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14
Q

Phase 2 of crisis

A
  • defensive response fails/threat persists
  • Anxiety escalates.
  • Disorganized; can’t focus
  • trial-and-error attempts to solve problems begin.
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15
Q

Phase 3 of crisis

A
  • Trial-and-error attempts fail
  • severe and panic levels anxiety
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16
Q

Phase 4 of crisis

A
  • Problem is not solved after some time
  • new coping skills: ineffective
  • Anxiety overwhelms pt
  • Serious illness: depression, hopelessness, violence, assess for suicidal thoughts.
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17
Q

Crisis
Pt assessment

A
  • SI/ HI/ plans
  • Trigger
  • Ability to identify trigger; perception
  • Understanding of the situation
  • Coping skills
  • Support system; local support systems
  • Religious and cultural beliefs: churches provide food, housing, clothing.
  • Need for psychiatric treatment or hospitalization.
  • Need for primary, secondary, or tertiary intervention.
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18
Q

Crisis:
How do you assess pt’s perception of the trigger?

A
  • Has anything upsetting happened to you within the past few days or weeks?
  • What was happening in your life before you started to feel this way?
  • Has anything traumatic happened in the past and is still bothering you?
  • What leads you to seek help now?
  • Describe how you are feeling right now
  • How does this situation affect your life?
  • What would need to be done to resolve this situation?
  • What type of help do you think you need?
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19
Q

Crisis interventions

A
  • Empathy
  • Listen
  • Calming (therapeutic communication)
  • Hope (instill hope)
  • Empowerment
  • lower anxiety
  • Connectedness (support systems)
  • assist in crisis coping
  • acceptance of the situation
  • Set realistic goals
  • Help pt formulate a plan
  • Strategies to build up resilience
  • Pt safety
  • Schedule regular follow-up to assess progress.
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20
Q

Crisis:
Strategies to build up resilience

A
  • Build social support
  • CBT to reframe perception
  • Teach pt change is part of life, it does not=powerlessness
  • Empower pt to identify goals and take action
  • Spiritual support (MSHP)
  • Self-care:
    —Cultivate insight/self-awareness
    —encourage positive view of self,skills developed, gain self—-worth, strength, resilience hope, see big picture
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21
Q

Crisis intervention techniques

A

Goal: quick resolution
- Catharsis: release of feelings
- Clarification
- Suggestion: use CBT to reframe perception
- Reinforcement of behavior: (positive reinforcement)
- Support of defenses: gently encouraged or discouraged
- Raising self-esteem: empowers pt to problem solve
- Exploration of solutions: to immediate crisis

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22
Q

Phases of Critical Incident Stress Debriefing (CISD)

A

If tr s tr

Introductory
Fact
Thought
Reaction
Symptom
Teaching
Reentry

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23
Q

Crisis:
What happens in the introductory phase of CISD

A

overview of what happened;
- process
- confidentiality
- key members are identified

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24
Q

Crisis:
What happens in the fact phase CISD

A

what happened; facts only

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25
Q

Crisis:
What happens in the thought phase of CISD

A

what were you thinking when event happened

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26
Q

Crisis:
What happens in the reaction phase of CISD

A

what was your reaction; discuss feelings; most painful/ hardest to process

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27
Q

Crisis:
What happens in the symptom phase of CISD

A

what is everyone’s s/s, how’s it affecting your work

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28
Q

Crisis:
What happens in the teaching phase of CISD

A

Teach:
- resources; additional therapy
- s/s of PTSD

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29
Q

Crisis:
What happens in the reentry phase of CISD?

A

are you ok to go back to work?
being a paramedic, nurse, caretaker

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30
Q

Agnosia

A

Ability to name/recognize objects

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31
Q

Confabulation

A

Making up stories to fill in gaps of memory

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32
Q

Aphasia

A

Loss of ability to understand or express speech

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33
Q

Apraxia

A

Not being able to complete physical tasks because you don’t remember

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34
Q

Hypermetamorphosis

A

Having to touch things

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35
Q

Perseveration

A

Mind is on a hamster wheel; continuous thought

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36
Q

Delirium risk factors

A

DAMP SNIDS
- Dementia
- Age; young children/older adults
- Medication; polypharmacy; anesthesia
- Pain; uncontrolled/ perfusion problems

  • Sleep disturbances
  • Number of co-occurring conditions; comorbidity
  • Infection
  • Depression
  • Substance/alcohol use
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37
Q

Delirium onset

A

Sudden; hours- days

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38
Q

What causes Delirium

A
  • Hypoglycemia
  • Infection
  • Fever
  • Dehydration
  • Hypotension
  • Head injury
  • Pain
  • Change in environment
  • Emotional stress
  • B12 and folate deficiencies
  • meds
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39
Q

Delirium S/S

A
  • Altered LOC
  • Mood swings
  • Anxiety
  • Paranoid
  • Aggression
  • Hallucinations/delusions
  • Speech: rapid, inappropriate, incoherent, rambling
  • Activity: fluctuates
    —Sundowners
  • cognition: fluctuates
    —Impaired
  • memory
  • Judgment
  • Calculations
  • Attention span
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40
Q

Delirium, prognosis

A

Reversible; with proper in timely treatment

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41
Q

Delirium intervention

A
  • Consistent caretakers
  • Monitor continuously
  • Assess LOC every 2-4 hours
  • Reorient
  • Distract (redirect) pt from harmful behaviors
  • Use short, simple, concrete phrases to communicate
  • Keep room well lit
  • Explain procedures, simply
  • Comfort needs: pain, thirst, hunger, elimination
  • Glasses & hearing aides
  • Provide clocks & calendars
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42
Q

What is Dementia

A

Characterized by multiple cognitive deficits, including memory, and develops over a long period of time. May be secondary, due to a medical condition, or primary.

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43
Q

Dementia onset

A

Slow; months - years

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44
Q

What causes Dementia

A

Neurological disease
Alzheimer’s disease
Vascular disease
HIV
Chronic alcoholism
Vitamin B12 deficiency
Folate deficiency
Head trauma

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45
Q

Dementia S/S

A

LOC: not altered
Impaired:
- memory
- judgment
- calculations
- attention span
- thinking
- Agnosia: Doesn’t recognize family or objects
- Anxiety
- Anger
- Aggression
- Delusions
- Paranoid
- Catastrophic reactions
- Flat affect

Activity: not altered; (sundowners)
- Impaired motor ability
- Wandering
Speech:
- incoherent
- Slow
- Inappropriate
- Rambling
- Repetitious

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46
Q

Dementia prognosis

A

not reversible; progressive

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47
Q

Dementia interventions

A

Monitor client closely
Reorient Client
Positive feedback
Explain simply
Discourage suspiciousness
Avoid cultivation of false ideas

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48
Q

What is Huntington’s disease?

A

Progressive brain disorder
defective dominant gene on a chromosome 4

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49
Q

Huntington’s disease S/S

A
  • Chorea: Uncontrolled movements of the arms, legs, head, face and upper body
  • Impaired Judgement
  • Impaired attention span
  • Impaired Memory
  • Impaired planning and organization
  • anxiety
  • anger
  • irritability
  • Obsessive compulsive behavior: person repeats same question and activity over and over
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50
Q

Huntington’s disease intervention

A

Interventions: manage symptoms; Meds
No Cure
Support group: pts feel normal/ not alone
Huntington’s Disease Society of America (HDSA)
HDSA at 800.345.4372

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51
Q

Huntington’s disease
Chorea meds

A

Atypical antipsychotics:
- Olanzapine
- Baclofin (muscle relaxer)

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52
Q

Huntington’s disease
Irritability Meds

A

Atypical antipsychotic
SSRI (less severe nonthreatening irritability)

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53
Q

Huntington’s disease
OCD thoughts- Meds

A

SSRIs

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54
Q

Creutzfeldt-Jakob Disease

A

Viral protein (Prion) found in CSF causes brain degeneration
- Spread by infected meat: MAD Cow disease

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55
Q

Creutzfeldt-Jakob Disease Labs

A

CSF proteins
EEG
MRI

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56
Q

Creutzfeldt-Jakob Disease S/S
Early stage

A

memory loss
visual impairment
dysphagia; speech disfunction

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57
Q

Creutzfeldt-Jakob Disease S/S
Within weeks

A

progressive dementia set in

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58
Q

Creutzfeldt-Jakob Disease S/S
1-2 years

A

Death

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59
Q

Creutzfeldt-Jakob Disease S/S

A

Rapid progression is one of the most important clue
A MAD DR. - MJ-TP
- apathy
- mood swings
- Agitation
- Depression
- Disorientation
- Rapidly worsening confusion

Impaired:
- memory
- judgment
- thinking
- planning

Activity:
- Difficulty walking
- Muscle stiffness
- Muscle twitches; involuntary jerky movements

Eyes:
- double vision
- hallucinations

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60
Q

Creutzfeldt-Jakob Disease intervention

A

No treatment can slow or stop brain cell destruction

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61
Q

Vascular Dementia

A

Reduce blood flow/ oxygen/ nutrients to the brain causes a decline in thinking skills/ multiple small strokes

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62
Q

Vascular Dementia S/S

A
  • Confusion
  • Disorientation
  • Trouble speaking / understanding speech
  • Physical stroke symptoms; sudden headache
  • Difficulty walking; poor balance
  • Numbness or paralysis on one side of the face or the body
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63
Q

Vascular Dementia
Interventions

A

keep circulation good
- Don’t smoke
- Keep BP/ cholesterol/ blood sugar within limits
- Healthy, balanced diet
- Exercise
- Healthy weight
- Limit alcohol

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64
Q

Picks diseases

A

frontotemporal neurocognitive disorder

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65
Q

Picks disease (FTD) prognosis

A

5 years average lifespan after diagnosis

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66
Q

Picks disease (FTD) S/S

A

reflect area of brain affected Behavior, Personality, Language
- Memory loss; advanced FTD
- Behavior changes; first noticeable s/s
- Speech difficulties
- difficulty making sense when they speak
- Difficulty understanding the speech of others
- Difficulty reading

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67
Q

What causes Picks disease (FTD)

A

Unknown

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68
Q

Picks disease (FTD) onset

A

40s- early 60s

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69
Q

What is Lewy Body Disease

A

faster acting than Alzheimer’s
- Protein deposits (Lewy bodies) in the brain stem (and other parts of the brain) deplete Dopamine and Acetylcholine causing Parkinson’s-like physical symptoms and Alzheimer’s-like cognitive symptoms.

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70
Q

Lewy Body Disease Prognosis

A

Average lifespan 5-7 years

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71
Q

Lewy Body Disease S/S

A
  • Changes in thinking and reasoning.
  • Memory loss- less prominent than in Alzheimer’s
  • Fluctuating cognition that is delirium-like.
  • Trouble interpreting visual information
  • visual hallucinations.
  • REM sleep behavior disorder; acting out dreams.
  • slowness of movement
  • resting tremor/ rigidity.
    Malfunctioning (“automatic” (autonomic) nervous system):
  • sweating, BP/ HR, digestion and sexual response
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72
Q

Lewy Body Disease interventions

A

None other than:
- self-care deficit
- meds to treat s/s

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73
Q

Lewy Body Disease Meds:
Treat thinking changes in Alzheimer’s

A

Cholinesterase inhibitor drugs

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74
Q

Lewy Body Disease Meds:
Treat behavioral symptoms in Alzheimer’s
Adverse affects of meds?

A

Antipsychotic drugs; use with caution. May cause:
- sudden changes in consciousness
- impaired swallowing
- acute confusion
- delusions/ hallucinations
- appearance or worsening of Parkinson’s symptoms.

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75
Q

Lewy Body Disease Meds:
- depression in Alzheimer’s disease

A

SSRIs

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76
Q

Most common type of dementia

A

Alzheimer’s disease

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77
Q

Alzheimer’s disease prognosis

A

Death 4-8 years after dx

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78
Q

Alzheimer’s disease risk factors

A
  • Age: >65
  • diabetes
  • hypertension
  • Hx: TBI
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79
Q

Alzheimer’s disease
Modifiable risk factors

A

behaviors that can be changed
- physical activity
- smoking
- education
- staying socially and mentally active
- blood pressure and diet

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80
Q

What causes Alzheimer’s disease?

A
  • Microscopic changes in the brain begin long before the first signs of memory loss
  • Role of plaques and tangles in damaging and killing nerve cells
    — Protein fragments called beta-amyloids deposit plaques that build up in the spaces between nerve cells.
    —Twisted fibers of a protein called tau build up into Tangles inside cells.
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81
Q

Alzheimer’s disease labs

A

CSF: for tau
MRI
CT scan
Beta-amyloid pet scan

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82
Q

Early s/s Alzheimer’s disease

A
  • Memory loss that disrupts daily life
  • Challenges in Planning or solving problems
  • Difficulty completing family tasks
  • Confusion with time or place
  • Trouble understanding visual images and spatial relationships
  • New problems with words in speaking or writing
  • Misplacing things and losing the ability to retrace steps
  • Decreased or poor judgment
  • Withdrawal from work or social activities
  • mood/ personality Changes
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83
Q

Stages of Alzheimer’s disease

A

Mild
Moderate
Moderate to severe
Late: end stage

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84
Q

Alzheimer’s disease: S/S
Stage: mild

A

Forgetfulness
symptoms not easily noticeable
- short-term memory loss
- puts things in odd places; loses them
- Uses memory aids: sticky notes
- Denial of problems common

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85
Q

Alzheimer’s disease: intervention
Stage: mild

A

Discuss estate planning in this phase

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86
Q

Alzheimer’s disease: s/s
Stage: moderate

A

Confusion
- Memory losses apparent – may forget address &/or date
- ADL’s suffer
- Problems managing money, legal affairs
- Labile mood
- Withdraw from activities- socially isolate

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87
Q

Alzheimer’s disease: Interventions
Stage: Moderate

A

Needs day care / in-home assistance

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88
Q

Alzheimer’s disease: S/S
Stage: Moderate to Severe

A

Ambulatory dementia
- Doesn’t recognize family or objects (agnosia)
- Forgets how to do activities such as walking, eating (apraxia).
- Shows ADL deficits:
— Wandering
— Depression resolves as awareness of losses diminish

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89
Q

Alzheimer’s disease: Interventions
Stage: Moderate to Severe

A
  • May need placement in skilled care facility
  • Needs total assistance for all activities of daily living
  • Take away car keys- assess ability to drive
  • dont ask open ended questions; Ask yes no questions
  • Limit options
  • Avoid arguing
  • Talk to them in front of them
  • Don’t have multiple conversations
  • Limit outside noises
  • Sundowners: appropriate rest periods, go outside to burn off energy, increase lighting in home in the evening, sleep routine
  • Meds
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90
Q

Meds for Moderate to severe stage Alzheimer’s disease

A

NMDA blocker: Memantine (Namenda)
- blocks NMDA receptors to block excessive glutamate, which has a toxic effect on neurons.

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91
Q

Alzheimer’s disease: S/S
Stage: Late: End Stage

A
  • Exhibits hypermetamorphosis & hyperorality
  • Does not recognize self anymore
  • Forgets how to eat, swallow, chew
  • Loses ability to talk & walk
  • Prone to complications of immobility like pneumonia
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92
Q

Alzheimer’s disease: Interventions
Stage: Late: End Stage

A
  • Require around-the-clock assistance with daily personal care
  • Needs total care; incontinence common
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93
Q

Alzheimer’s disease prognosis

A

DX-death: 10 years, some people may live up to 20 years.

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94
Q

Alzheimer’s disease first line treatment medication

A

Cholinesterase inhibitors: increase ACh
- Donepezil (Aricept)
- Rivastigmine (Exelon)
- Galantamine (Razadyne)

Nursing implications:
- Take with food
- Bradycardia
- Fall risk

Antidote: Atropine

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95
Q

New Alzheimer’s disease med?
S/S?

A

Aducanumab
S/S:
- Headache
- Fall risk
- dizziness
- nausea
- confusion
- vision changes
- potential for allergic reactions

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96
Q

Addiction:
Prior to admission you need to know what 3 things

A

What was taken?
how much was taken?
when was it last taken?

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97
Q

What are the CNS depressants?

A

alcohol
benzodiazepines
barbiturates

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98
Q

One drink =

A

A 12 ounce can/ bottle of beer 5% Alcohol
A 5-ounce glass of wine 12% alcohol
A shot of Hard Liquor 1.5 ounces 40% Alcohol

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99
Q

Low risk drinking amount

A

MEN: 18-65
- 4 per day
- 17 per week
WOMEN: 18-65 & AGES 66+
- 3 per day
- 7 per week

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100
Q

Blood Alcohol Levels: .05= S/S
X Drinks

A

1-2 drinks
changes in mood/ behavior

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101
Q

Legal blood alcohol content

A

.08 %

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102
Q

Blood Alcohol Levels: .10= S/S
X Drinks

A

5-6 drinks
voluntary actions, clumsy

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103
Q

Blood Alcohol Levels: .20= S/S
X Drinks

A

10-12 drinks
staggering, labile emotions

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104
Q

Blood Alcohol Levels: .30= S/S
X Drinks

A

15-18 drinks
confusion, stupor

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105
Q

Blood Alcohol Levels: .40= S/S
X Drinks

A

20-24 drinks
coma

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106
Q

Blood Alcohol Levels: .50= S/S
X Drinks

A

25-30 drinks
Death due to respiratory depression

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107
Q

Alcohol INTOXICATION S/S

A
  • slurred speech
  • incoordination
  • staggering; unsteady gait
  • drowsiness
  • Decreased vital signs
  • inhibitions lowered resulting in impulsive sex and aggression
  • impaired judgment; role function
  • Impaired attention/memory
  • Irritability
  • social problems
  • occupational problems
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108
Q

When do Alcohol Withdrawal S/S start

A

Within a few hours after last drink

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109
Q

When do alcohol withdrawal s/s peak and disappear?

A

24-48 hours

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110
Q

Alcohol withdrawal s/s

A

DIC I SAID SHCVATTAANV 😮‍💨

  • Delirium
  • illusions
  • confusion
  • Increased BP & HR
  • Seizures
  • anorexia
  • insomnia
  • Disorientation
  • Sweating
  • Headache
  • Clouded senses
  • Visual disturbances
  • Audio disturbances
  • Tactile disturbances
  • Tremors
  • Anxiety
  • Agitation
  • Nausea
  • Vomiting
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111
Q

Alcohol withdrawal interventions

A

Calm, quiet, reassuring atmosphere
Frequent reorientation
- Assess CIWA
- Monitor for seizures
- VS Q 2-4 hours
- Psycho-social support
- Medication
— Benzodiazepines
— clonidine
— thiamine/ multivitamins
- relapse prevention
— Antabuse (Disulfiram)
— Naltrexone (ReVia)

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112
Q

Tool developed to monitor withdrawal symptoms

A

CIWA scale

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113
Q

If the CIWA score is ______ for _____ long you should contact the HCP

A

> 17 for >4 hours

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114
Q

CIWA categories

A
  • Visual Disturbances
  • Auditory disturbances
  • Nausea
  • Clouding of the sensorium
  • Headache
  • Agitation
  • Tactile Disturbances
  • Tremor
  • Vomiting
  • Paroxysmal Sweats
  • Anxiety
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115
Q

Write out the CIWA med/reassessment table

A
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116
Q

Gold standard medication: alcohol withdrawal

A

Benzodiazepines:
Short acting : lorazepam (Ativan)
Long acting : Chlordiazepoxide (Librium)

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117
Q

Medication for alcohol withdrawal

A

Lorazepam (Ativan)
Chlordiazepoxide (Librium)
Antabuse
Naltrexone

118
Q

Route of lorazepam (Ativan)

A

PO, IV, IM

119
Q

Route of chlordiazepoxide (Librium)

A

PO only

120
Q

Antabuse (Disulfiram) use/ s/s / teaching

A

Aversion therapy: helps prevent relapse by discouraging impulsive drinking

When ingested with alcohol causes:
- Nausea, vomiting, headache, flushing

S/S: metallic aftertaste, dermatitis, hypotension, nausea, vomiting

Alcohol is in: Paint fumes, cough syrup, after shave, alcohol in food, hand sanitizers, mouthwash, vinegar

Pt teaching:
- Pt should be alcohol free for 14 days
- Hidden sources of alcohol

121
Q

Naltrexone (ReVia) use/ MOA/ s/s

A
  • Diminishes alcohol cravings/ Doesn’t allow benefits of alcohol
    Used in the acute recovery phase of alcohol dependence
  • First 12 weeks

S/S:
- nausea, abdominal pain, constipation, dizziness, headache, anxiety, fatigue

  • Block the effect of opiates
    — Can precipitate Narcotic withdrawal in patients using opioid drugs or pain medication
122
Q

adjunct therapy: alcohol withdrawal

A

used along with benzodiazepines
- Hypertension: Systolic: >180hg or Diastolic: >100
—Metoprolol
—Clonidine
- Agitation: Delirium Protocol
—Haloperidol

123
Q

Alcohol withdrawal:
Early/minor stage

A
  • Can occur 2 hr after stopping or reducing use
  • Usually develops within 7-48 hr
    S/S: peak 24-48 hr
  • Elevated BP/ HR
  • Sweating
  • G.I. symptoms
  • Headache
  • Hand tremors
  • Feeling shaky inside
  • Jerky movement
  • Ataxia
  • Startled easily
  • Irritability
  • Seizures
124
Q

Alcohol withdrawal:
Moderate stage

A
  • Appears 7 - 48 hrs after stopping or reducing use
  • Can continue for 5-7 days
    S/S: Worsening of earlier stage s/s
  • Continued elevation of all vital signs
  • Vomiting
  • Clammy skin
  • Anxiety
  • Mood lability
  • Combativeness
  • Hallucinations
  • Illusions
125
Q

Alcohol withdrawal:
Severe stage

A
  • Can start in the same timeframe as above
  • Make progress to delirium tremens (DTs)
    S/S:
  • All above symptoms plus seizures
  • Awareness symptoms
  • Disorientation and confusion
  • Agitation and irritability
  • Paranoia and disinhibition
126
Q

ALCOHOL RELATED MEDICAL PROBLEMS

A

pancreatitis
ulcers
cirrhosis
esophageal varices
cardiomyopathy
myopathies
malabsorption of vitamins
- folic acid
- vitamin B1 (thiamine)
- vitamin B12

127
Q

Alcohol withdrawal labs

A
  • AST/ ALT/ Bilirubin
  • Lipase/ Amylase
    Vitamins:
  • Folic acid
  • Vitamin B1/ B12
128
Q

Delirium tremens: alcohol withdrawal delirium

A
  • Starts 2-3 days after last drink when withdrawal process has not been managed well
  • Medical emergency
  • Death due to
    — cardiac problems
    — aspiration pneumonia
    — hyperpyrexia
129
Q

Delerium tremens s/s

A

delirium
disorientation
visual hallucinations
tactile hallucinations
illusions
paranoid delusions
agitation
raised vital signs

130
Q

Wernicke-Korsakoff Syndrome

A

thiamine (B1) deficiency

Starts at Wernicke’s Encephalopathy
Turns into Korsakoff’s Psychosis

131
Q

Wernicke’s Encephalopathy s/s

A
  • ataxia; impaired coordination
  • acute confusion; under-diagnosed
  • Gait problems
  • Problems with eye movement
    —Nystagmus; eye jitter; seen in seizure disorder/ TBI
132
Q

Wernicke’s Encephalopathy Treatment:

A

CIWA scale
Banana bag IV (B vitamins); first
Oral thiamine; after banana bag

133
Q

Korsakoff’s Psychosis: “wet brain” s/s

A
  • 20% mortality
  • Permanent loss of ability to learn and remember
  • Confabulations; making stuff up
  • Avoid large glucose intake:
    —B1 is a coenzyme in glucose metabolism; ingesting large amounts of glucose during a period of thiamine deficiency exacerbates an existing Wernicke’s Encephalopathy.
134
Q

Tips for cutting down on alcohol use:

A
  • Measure and count
  • Set goals
  • Pace and space
  • Include food
  • Avoid “triggers”
  • Plan to handle urges
  • Know how to say “no”
135
Q

Opioid MOA

A

Increases dopamine; euphoria

136
Q

Opioid prevalence

A

> males
Caucasian

137
Q

Opioid drugs

A

fentanyl
hydrocodone
oxycodone
Percocet
Some prescription cough syrups
Heroin

138
Q

What is used to determine opioid withdrawal severity

A

COWs scale

139
Q

Opioid intoxication s/s

A

constricted pupils
decreased RR/BP
impaired memory/ judgment
drowsiness
slurred speech

140
Q

Opioid interventions

A

Assess respirations
Do not abruptly stop opioid medicine; withdrawal can occur.
MATs: medication assisted treatments for substance use disorder
Detox Meds

141
Q

Opioid detox meds/
Antidote

A

Methadone
Suboxone
naltrexone (ReVia)

Antidote: Naloxone

142
Q

Marijuana labs

A

+ THC
- presumptive positive

143
Q

Marijuana intoxication s/s

A

increased appetite
red eyes
relaxation/ euphoria

detachment/ dissociative symptoms
impaired memory & judgment
apathy

144
Q

Marijuana dependence s/s

A

anhedonia

lethargy
Memory impairment
Difficulty concentrating

145
Q

Marijuana withdrawal s/s

A

anxiety

cravings for drug
Insomnia
appetite loss

146
Q

CNS stimulants

A

cocaine, amphetamines, caffeine

147
Q

Stimulant intoxication s/s

A

Dilated pupils
Increased HR
Increased BP
Excessive motor activity
Euphoria
Paranoia

148
Q

Stimulant withdrawal s/s

A

Depression; SI
Anergia
Anhedonia
Avolition

149
Q

Addiction defense mechanisms

A

Denial:
- escaping unpleasant realities by ignoring their existence
Rationalization: Blame
- justifying illogical ideas, actions, or feelings by developing an acceptable explanation for unacceptable behavior.

150
Q

Addictive cognitive distortions

A

All or nothing thinking:
- inability to deal with parts of a situation.
Selective Inattention:
- only paying attention to parts of a situation or conversation.
Conflict minimization:
- reducing the importance of an issue
Manipulation:
- getting people to do what you want.

151
Q

Substance abuse: ineffective coping/denial
Interventions

A

Assess + & - coping
Encourage pt to express feelings
Explore alternative coping strategies and ways to maintain sobriety (list)
Limit denial and rationalization

152
Q

Recovery from addiction
Intervention

A

AIM = self- responsibility, not compliance
- Support and kindness
- Reinforce disease concept
- Set limits
- Maintain consistency
- Provide information about addiction as a chronic disease
- Encourage family therapy

153
Q

Addiction treatment programs

A

12 STEP PROGRAMS
RESIDENTIAL THERAPEUTIC COMMUNITIES
INTENSIVE OUTPATIENT (IOP) PROGRAMS: VA
FAMILY & MARITAL THERAPY:
RELAPSE

154
Q

12 STEP PROGRAMS

A

Philosophy that addicted people are:
- Powerless over their addiction
- Not responsible for disease but responsible for recovery
- Can’t blame anyone else for your problems.
- Believe in a higher power

155
Q

RESIDENTIAL THERAPEUTIC COMMUNITIES

A

Betty Ford treatment center

156
Q

INTENSIVE OUTPATIENT (IOP) PROGRAMS: VA

A

Patient go there for a few hours of the day
- While family is at work
- So that patient is not alone to give into impulses

157
Q

FAMILY & MARITAL THERAPY

A

life is often very dysfunctional due to client’s drug use. Need to rebuild trust & learn to live together. Also must change codependence patterns in family

158
Q

RELAPSE intervention

A

common during recovery.
Explore this before it happens and afterwards.
Identify attitudes and situations that caused relapse

159
Q

Somatic Symptom Disorder

A
  • Symptoms cannot be explained medically
  • Modifiers – pain
  • Illness Anxiety Disorder (hypochondriasis)
  • Hx of physical complaints begin before age 30, resulting in seeking treatment
  • Symptoms described in exaggerated terms
  • Impaired social/ occupational functioning; pts seek medical care from many providers
  • Complaints of physical symptoms for which there is no physical explanation
  • Extreme distress/dysfunction
  • Abnormal thoughts, feelings and behaviors associated with symptoms
  • Symptoms are not controlled or caused
    — If the patient can control symptoms or creates them: Malingering
    — Factitious Disorder Imposed on Self/or Other (formerly Munchausen Syndrome also by proxy)
160
Q

Somatic symptom disorder assessment

A

Physical exam with appropriate medical tests
Assess
- PQRST of symptoms
- ability to perform ADLs
- safety risk of symptoms
- voluntary control of s/s
- Pt thought process / ability to communicate feelings
- Type and amount of medication pt is using
- ACEs/ risk of SI
- support network
- Secondary gains
- Cognitive style

161
Q

Somatic symptom disorder
Interventions

A
  • Offer explanations during diagnostic tests
  • Redirect focus: away from symptoms to feelings or neutral topic
  • Reinforce strengths/ promote independence
  • Spend time with the patient when they are not having complaint
  • Teach assertive communication
  • Stress reduction techniques (promote healthy coping mechanisms)
162
Q

Somatic symptom disorder
Therapies

A

Cognitive therapy:
- helps patient see how they express feelings physically
Behavior therapy:
- incentives to help patients control symptoms
Family therapy:
- places patient’s symptoms in perspective and improves interpersonal interaction
Milieu therapy:
- rejection increases symptoms, shift conversation away from symptoms (redirect), reinforce strengths, matter of fact approach to managing symptoms
Alternative coping mechanisms

163
Q

Eating disorder process

A

1.) Normal eating
2.) Development of risk factors
- low self esteem
- Dieting
—Parental attitudes
—Body dissatisfaction
- Media ideal bodies
3.) Partial-syndrome Eating Disorder
- Binge eating
- Serious dieting
4.) Full- syndrome Eating Disorder
- increase in frequency and severity of:
—Binge eating
—Purging
—Starvation
5.) Treatment

164
Q

Anorexia nervosa risk factors

A

Increased BMR
overexercising; elite athlete
Low self-esteem
body dissatisfaction
feelings of ineffectiveness

Family:
- Overprotective
- enmeshed
- rigid boundaries
- inability to solve conflicts

Protective factor:
- Healthy eating attitudes, acceptance of body size
- Positive self-evaluation

165
Q

Anorexia nervosa
Diagnostic criteria

A
  • Onset: early adolescence; chronic condition with relapses
    — Body image distortion
    — Drive for thinness
    — Interoceptive awareness
    — Perfectionism
    — Guilt and anger
  • Females affected 10 times more often than males
  • More common among Hispanics and whites
  • Possible medical complications
  • Characterized: excessive dieting/purging/exercise that leads to severe weight loss (less than 85% of normal)
  • Pathological fear of gaining weight or becoming fat
  • Body image disturbance
  • Judges self-worth by weight
  • Absence of three or more menstrual cycles
    — Restricting type
    — Binge-eating and purging type
166
Q

Anorexia nervosa s/s

A
  • Low weight
  • Lanugo (goes away when nutritionally rehabilitated)
  • Yellow skin
  • Cold extremities
  • Peripheral edema
  • Low BP, P, and Temperature
    —Ex: SBP < 70, Pulse < 40, K < 3
  • Regular H/As
  • “diet talk” to start each day
  • Avoids eating with certain people/eat what they want to eat with certain people
  • Forces oneself to exercise even when tired or injured
  • Judge people based on what they are eating
  • Only meets people for coffee or tea (no calories)
  • Will only eat out when they know everything that is in the meal
    Makes excuses for canceling plans
    Will not eat out with people
167
Q

Anorexia nervosa interventions

A
  • Recognize terror of gaining weight; be empathetic
  • Develop a therapeutic alliance
  • Teach self care activities
  • Teach new coping skills
  • Improve social skills
  • Improve decision-making skills
  • Family/ individual/ cognitive therapy
  • Milieu therapy
    — focuses on normalizing eating and addressing issues related to the illness.
  • Refeeding; increase weight (Weight goal is 90% of ideal)
    — Addresses only acute complications; electrolyte imbalance/ cardiac problems
    — Precise meal times
    — Adherence to menu
    — observation during & after meals
    — scheduled weights
    — Tie privileges to weight gain
    MEDS
168
Q

Anorexia Nervosa meds

A

may improve weight, cognition, and body image
- Fluoxetine
- Olanzapine (Zyprexa)

169
Q

Refeeding Syndrome Process

A
  • Prolonged fasting; depletes intracellular minerals as the body tries to conserve muscle and protein.
  • Normal amounts of food; Increases BMR/ protein & fat synthesis.
  • Body does not have enough intracellular minerals or electrolytes to meet demands;
  • Dramatic shift of fluids/ electrolytes causes serious complications.
170
Q

Refeeding Syndrome s/s

A
  • weakness
  • mental confusion
  • SOB
  • cardiac arrest/failure
  • seizures
  • coma/death.
171
Q

Refeeding syndrome intervention

A

monitor pt during feeding rehabilitation to avoid complications

172
Q

Bulimia Nervosa diagnostic criteria

A
  • Binge eating at least once a week for at least 3 months
  • Compensatory behaviors:
    — Purging: vomiting or use of laxatives, diuretics, or emetics
    —Nonpurging: fasting or overexercising
  • No severe weight loss/ amenorrhea
  • Self evaluation unduly influenced by weight (“feel fat”)
    — ego-dystonic; patients feel shame
    — very sensitive to attitudes of others
173
Q

Bulimia nervosa interventions

A
  • Nutrition and healthy eating
  • clarification of misconceptions about food
  • Educate about eating disorder/ effects on body
  • Sleep management
  • Relaxation techniques
  • Alternate coping
  • Assertiveness
  • Boundary and limit setting
  • Psychoeducation
  • Behavioral techniques: cue elimination; self-monitoring
  • CBT and IPT
  • Group therapy
  • Strict monitoring of:
    — food intake; before & after
    — bathroom visits
    medication
174
Q

Bulimia nervosa medications

A

SSRIs: fluoxetine (Prozac)

175
Q

Binge eating disorder
Diagnostic criteria

A
  • Recurrent episodes of binge eating and sense of lack of control
  • Marked distress over binge eating
  • may eat alone to hide behavior
  • Not synonymous with obesity
176
Q

Binge eating disorder interventions

A

Pt teaching:
- Alternative coping skills
- Improve social skills
- Problem solving skills
- Decision making skills.

177
Q

Eating disorder cognitive distortions

A

Overgeneralization
- (a single event affects unrelated situations):
- “I was happy at size 4. I must get back to that weight.”

All-or-nothing thinking
- (reasoning is absolute and extreme, unable to find a balanced position):
- “If I eat 1 popsicle, I must eat 5. ”

Catastrophizing:
- (consequences are magnified unreasonably):
- “If I gain weight, my weekend will be ruined.”

Personalization:
- (over interprets events as being personal):
- “I know everyone is watching me eat.”

Emotional reasoning:
- (emotions determine reality):
- “I know I’m fat, because I feel fat. ”

178
Q

any type of sexual activity the victim does not agree to.

A

SEXUAL ASSAULT

179
Q

RAPE

A
  • is non consensual vaginal, anal, or oral penetration.
  • ETOH is implicated in 69% of rapes
180
Q

Drug-Induced Rape Prevention Act of 1996

A
  • Up to 20 years imprisonment and fines to anyone administering a controlled substance to an unknowing victim
181
Q

Drugs used in Rape

A

Gamma-Hydroxybutyrate (GHB): depressant;
- S/S: Amnesia, euphoria, hypotonia

Rohypnol: Benzo;
- S/S: Amnesia, decreased coord.

Ketamine: Anesthetic/ Hallucinogenic
- S/S: Amnesia,Analgesia, Cooperation

182
Q

Sexual assault/ rape
Vulnerable individuals:

A
  • Gender: Women; > rate sexual assault
  • Age: 16-19; > rate sexual assault
  • Older adults; Cognitively or functionally impaired
  • Drug/ ETOH use
  • High risk behavior
  • Poverty
  • Culture: Native American women highest rate
183
Q

Sexual assault Perpetrators

A
  • Antisocial PD
  • Impulsive/ violent tendencies
  • ACEs
  • Hostility toward women
  • Refuses to acknowledge acts of sexual assault
184
Q

RAPE-TRAUMA SYNDROME
Acute phase: s/s

A

ER: Immediately after - two weeks.
Expressed style:
- pt explains situation in an expressive way; hysterical
Controlled style:
- Pt explains situation in a self contained; calmed; masked affect/ flat, numb
- Emotional s/s: fear, guilt, shock, numb
- Physical s/s: insomnia, nightmare, decreased appetite, pain/ discomfort

185
Q

RAPE-TRAUMA SYNDROME
Long term: reorganization phase S/S

A

2 or more weeks after rape
- Nightmares/ flashbacks
- Phobias
- Anxiety
- Depression
- Insomnia
- Somatic symptoms
- Increased motor activity
- Increase emotional lability

186
Q

Rape Assessment/Forensic examination

A
  • Don’t leave pt alone
  • Assess anxiety level
  • Assess Support system
  • Assess Coping mechanisms
  • Assess s/s physical trauma; Injuries to face head, neck, & extremities
  • Explain and get consent to take photos/videos and specimens
  • Make a body map to identify size, color, and location of injuries
  • Determine location, what happened, safety, help needed
  • Explain all procedures before doing them
  • Explain the forensics specimens you plan to collect; inform patient that specimens can be used for identification and prosecution of the rapist
    — Do not use lube when collecting specimens
    — Example:
    — - Debris in head, hair and pubic hair
    — - Skin from underneath nails
    — - Semen samples
    — - Blood
    — - Urine sample (if date rape drug is suspected)
  • Do not wash, change clothes, douche, brush teeth, eat, or drink.
  • Encourage patient to consider treatment and evaluation for sexually transmitted infections before leaving ED
  • Offer prophylaxis to pregnancy
  • All data must be carefully documented
    — Verbatim statements
    — Detailed observation of physical trauma
    — Detailed observation of emotional status
    — Results from the physical examination
    — All lab test should be noted
  • Offer support follow up:
    — Rape counselor
    — Support group
    — Group Therapy
    — Individual therapy
    — Crisis counseling
187
Q

Rape intervention

A
  • Have someone stay with the patient while he or she is waiting to be treated in the ED
  • Approach patient in a non-judge mental manner
  • Do not use judgemental language:
    — Reported not alleged
    — Declined not refused
    — Penetration not intercourse
    — Describe the behavior not “no acute distress”
  • Confidentiality
  • Explain to the patient the signs and symptoms that many people experience during the long term phase
  • Listen and let the patient talk. Do not press the patient to talk.
  • Stress that the patient did the right thing to save his or her life
  • Help the victim separate issues of vulnerability from blame.
  • Provide referrals and follow-up information
  • Avoid showing anger.
  • Hotline: #988
188
Q

Rape
Case management reassessment

A
  • 24-48 hours afterwards
  • 2, 4, and 6 weeks after
    — Encourage pt to seek counseling and support groups
189
Q

Rape Survivors are recovered if they:

A
  • Eat according to pre-rape pattern
  • sleep well
  • Are calm, relaxed
  • Show minimal strain in relationships with family & friends
  • Are generally positive about themselves
  • Free from somatic reactions
190
Q

GENDER DYSPHORIA s/s

A

disparity between biological and psychological sexual identity
Gender identity is established by 18 months
Cause not known
S/S: Cross dressing; Often men- “Drag queen”

191
Q

GENDER DYSPHORIA interventions

A
  • Counseling
  • Living as opposite sex with hormone therapy
  • Progressive surgeries
192
Q

Autism Spectrum disorder (ASD) Assessment

A

Assess what the child capable of

193
Q

Autism Spectrum disorder (ASD) s/s

A
  • social relation issues
  • Lack of development in social interaction/ communication
    — Little interest in people
    — Doesn’t respond to interaction attempts
    — May dislike affection/ physical contact
  • Delayed and deviant language, or concrete thinking
    — Language may be absent
    — absent/ inappropriate facial expressions/gestures; social smile absent
  • Minor changes in environment can be cause resistance and hysterical behavior
    — Repetitive rocking
    — Hand flapping
    — Repetitive verbalizations: saying the same thing over and over
    — Insistence on sameness: same shoes, clothes, food etc.
    — Self-injurious behavior: banging head on wall
    — Diet abnormalities, eating only a few specific foods
    — Sensory issues with textures and clothes: tags on clothes can be problematic
194
Q

Autism Spectrum disorder (ASD) Meds

A

Antipsychotics:
- Risperidone (risperdal)/ Aripiprazole (abilify)
— aggression
— deliberate self injury
— temper tantrums and labile moods 5-17 years old

SSRIs:
- Fluoxetine (Prozac) and Sertraline (Zoloft)
— improve anxiety or obsessive traits

Methylphenidate (Ritalin):
- inattention, impulsivity, and overactivity

Clonidine(Alpha 2 agonist):
- reduces hyperactivity, self-stimulation, and irritability

Buspirone and trazodone:
- reduce agitation

195
Q

Asperger’s Disorder

A

High Functioning ASD

196
Q

Asperger’s Disorder s/s

A
  • Severe/ sustained impairment in social interaction
  • Restricted/ repetitive patterns of behavior, interests, and activities
  • Normal intelligence
  • Good verbal skills
  • low performance
  • Intense interest in things; almost like obsession
  • Social deficits:
    — Inappropriate initiation of social interactions
    — Inability to respond to social cues
    — Concrete in interpretation of language
    — Stereotypic behavior?
197
Q

ADHD

A

Persistent pattern of inattention, hyperactivity, and impulsiveness that is pervasive and inappropriate for developmental level
- Hyperactive type
- Inattentive type
- Combined type

198
Q

ADHD s/s

A
  • Problems with concentration such as making careless mistakes, difficulty remaining focused, being easily distracted, etc.
  • May also avoid tasks that require sustained mental effort, misplace items, and tend to be messy.
  • Children may fidget, run or climb when not appropriate, interrupt, or talk excessively. Excessive motor activity.
  • Boundless energy
  • As adults, this may present as an internal restlessness more than as physical impulsivity.
199
Q

ADHD questionnaire

A

Vanderbilt Assessment Scales

200
Q

ADHD Meds: Stimulants

A
  • Methylphenidate (Ritalin): Short acting
    — (Long acting: Concerta)
  • Amphetamine salts (Adderall)
201
Q

ADHD stimulant MOA

A
  • increase NE, DA & SR
  • Increase focus and attention
202
Q

ADHD stimulant s/s

A
  • Restlessness
  • insomnia- dont resolve
  • Dry mouth
  • Decreased appetite
  • Weight loss
  • Anorexia- dont resolve
  • Headache- resolve
  • Nausea, vomiting- resolve
203
Q

ADHD med labs

A

Liver labs

204
Q

ADHD Stimulant Nursing Implications

A
  • Give in AM
    — Administer last dose at least 6 hours before bed.
    — May need to take melatonin for insomnia
    — Create good sleep routine
  • High Calorie meals (breakfast) and snacks
    — Monitor Weight weekly & growth
    — Monitor anorexia and weight loss
  • Monitor for med abuse/ compliance
  • Don’t stop abruptly
    — Drug holidays:
    —-Tapering off drug during summers/ winter break when drug isn’t needed.
    —-Given child time to catch up in growth: eat/ gain weight
  • Uses cautiously in pts w/ turrets
  • Assess mental status changes: stimulation and aggressiveness, can cause psychosis
205
Q

ADHD non stimulant drugs

A

Atomoxetine (Strattera)
Bupropion (Wellbutrin)
Guanfacine (Tenex)
Clonidine (Catapres)

206
Q

Atomoxetine (Strattera) class

A

SNRI

207
Q

Bupropion (Wellbutrin) MOA

A

Blocks neuronal uptake of SE, NE & DA

208
Q

Guanfacine (Tenex)
Treats/ Drug class/ MOA/ s/s /
Nursing implications

A

Treats:
- ADHD/ insomnia

Class:
- antihypertensive/ alpha agonist

MOA:
- stimulates CNS A2 receptors
- Decreases fight or flight

S/S:
- Decreases BP
- Decreases motor tension
- Decreases motor tone
- Decreases adrenaline
- Sedation

Nursing implications:
- Monitor BP/ HR
- Give at night
- Monitor weight
- Liver labs

209
Q

Clonidine (Catapres)
Treats/ class/ MOA/ s/s nursing implications

A

Treats:
- ADHD, PTSD, alcohol withdrawal/ insomnia

Class: antihypertensive

MOA:
- stimulates CNS A2 receptors
- Decreases fight or flight

S/S:
- Decreases BP
- Decreases motor tension
- Decreases motor tone
- Decreases adrenaline
- Sedation

Nursing Implications:
- Monitor BP/ HR
- Give at night

210
Q

Oppositional Defiant Disorder
ONSET

A

8yrs no later than early adolescence

211
Q

Oppositional Defiant Disorder Prevalence

A
  • > boys before puberty
  • = in boys & girls after puberty
212
Q

Oppositional Defiant Disorder S/S

A

Egosyntonic
Passive aggressive behaviors
- Disobedience
- Stubbornness, unwilling to compromise
- Procrastination
- Resistance to directions
- Angry outbursts
- Low frustration tolerance
- Tendency to blame others
- Test limits
- School: fights/ truancy/ poor grades

213
Q

Conduct disorder

A
  • A pattern of behavior that is repetitive and persistent in which the basic rights of others or age appropriate societal norms are violated.
  • Develop into antisocial personality disorder; >in boys
  • Hx of oppositional defiant disorder; likely
214
Q

Conduct disorder s/s

A
  • Repeated serious violations of the rules
  • Violate rights of others
  • Four main behaviors:
    — Aggressive behavior that harms people or animals
    — Lacks feeling of remorse
    — Destruction of property
    — Deceitfulness or theft
    —- Stealing, lying, truancy common, break laws
215
Q

Tourette Disorder/ tic disorder

A

Characterized by multiple motor tics/ one or more vocal tics
Can suppress tics for brief periods, but can be lifelong

216
Q

Tourette Disorder/ tic disorder Onset

A

around 6-7 years

217
Q

Tourette Disorder/ tic disorder
Prevalence

A

> boys

218
Q

Tourette Disorder/ tic disorder s/s

A

cause distress / interfere with social and occupational functioning

Physical tics:
- Simple: blinking, neck jerking, shrugging shoulders, facial grimacing
- Complex: squatting, hopping skipping, running out of room

Vocal tics: squeaking, barking, grunting, cursing

219
Q

Tourette Disorder/ tic disorder Meds

A
  • Clonidine: first line treatment; less S/S Extended release forms
  • Guanfacine: Last longer less sedating than clonidine

Antipsychotic:
- Haldol
- Off label: Risperidone, olanzapine and Ziprasidone

220
Q

Separation Anxiety Disorder

A
  • Suffer great distress when faced with ordinary separations from major attachment figures
  • May emerge after a change
221
Q

Separation Anxiety Disorder onset

A

<18 yrs, commonly dx: 5-6yrs when the child goes to school

222
Q

Separation Anxiety Disorder
Prevalence

A

> Girls
- Tends to runs in family

223
Q

Separation Anxiety Disorder s/s

A
  • Lot of anxiety about leaving; home
  • School phobia; most children grow out of it
  • Panic disorder: when kids grow up
224
Q

Separation Anxiety Disorder

A
  • focus on coping strategies
  • Redirection
  • Distraction
  • Taper: parents stay with child less and less before leaving
  • Therapies
225
Q

Separation Anxiety Disorder
Therapies

A
  • Group therapy; takes the form of play
  • Talk therapy; as children get older
  • Milieu therapy
  • Behavior therapy
  • CBT
  • Play therapy; allows kid to adapt to environment
  • Dramatic play therapy; psychodrama; act out emotional problems
  • Games
  • Bibliotherapy; using children’s books/ literature
  • Music therapy
  • Movement/dance therapy
  • Recreational therapy
226
Q

Types of Neglect:

A

Physical neglect: depriving someone of physical needs
- Deprivation of food, clothing, shelter, supervision, medical care, and education

Emotional neglect:
- Lack of affection, attention, and emotional nurturance

Emotional abuse
- Destroys or impairs child’s self-esteem

227
Q

Physical Abuse

A
  • Deliberate infliction of physical injury on a child
  • Shaken baby syndrome

S/S
- Bruises and welts usually in clusters
- Fractures especially spiral and in different stages of healing,
- Subdural hemorrhages
- Missing patches of hair
- Injuries in a distinct pattern like a shoe print
- Unexplained burn or small circular scars from cigarette burns.

228
Q

shaken baby syndrome

A

Violent repetitive unrestrained acceleration-deceleration head and neck movements in children <3 years of age

229
Q

shaken baby syndrome s/s

A
  • Retinal hemorrhage
  • Rib fractures-usually posterior
  • Subdural Hematoma
  • Mortality rate: High
    —Survivors left with major neurological defect or developmental delay
230
Q

Physical Abuse: Predisposing Factors:
PARENT characteristics

A
  • Younger Age, single parent, unrelated partner (step parents)
  • Low self-esteem, poor parenting knowledge, poor role model (maybe they were abused as a kid)
  • Substance abuse, unresolved mental health problem
  • Problem bonding with child
  • History of abuse or other trauma
231
Q

Physical Abuse: Predisposing Factors:
PARENT Behaviors

A
  • Are evasive when asked about injury
  • Seek care at different facilities; far from home
  • Provide an explanation for the injury that isn’t credible/ reasonable/possible/ doesn’t make sense
    —Developmentally the child couldn’t have done this
  • Dominates the conversation when the child is being interviewed
    — They want to give details and tell the story
232
Q

Physical Abuse: Predisposing Factors:
Child characteristics

A
  • Young: Newborn - 1 year (70% fatalities < 3yrs)
    — Parents don’t know what child wants
  • Physically disabled, hyperactive, premature, their own substance abuse
233
Q

Physical Abuse: Predisposing Factors:
Child behavior

A

Child Behavior:
Wary of adult contact
Apprehensive when children cry; tells other kids not to cry
Fearful of parents or don’t want to go home
Extremely aggressive or markedly withdrawn, depressed
Insistent on keeping arms and legs covered: wearing long sleeves/ pants in summer
Exhibits self destructive behaviors, act out
Responds as if numb to pain; not flinching/ crying during shots

234
Q

Physical Abuse: Predisposing Factors
Environmental characteristics

A
  • Social isolation, poor support systems
  • Chronic stress, poverty, low social economic stability, low income, substitute caregivers (daycare), housing instability
235
Q

Sexual abuse:
Perpetrators Characteristics

A
  • Most are trusted adult acquaintances
  • Known acquaintance (non family) 50%
  • Family Member
  • Stranger
  • Adolescents compromise 30% of perpetrators
236
Q

Sexual Abuse
Victim: behavior S/S

A

Behavioral
- Difficulty sitting/walking; painful
- Bleeding bruising pain of genital area
- Low self esteem/Self Injury
- Anxiety/Depression/SI
- School Problems
- Sexual knowledge beyond age
- Nightmares; PTSD
- Eating disorders; because controlling what they eat is. Something they can control
- STIs
- Masturbating
- Self-destructive behaviors

237
Q

Sexual Abuse
Victim: Medical S/S

A
  • Pain
  • Dysuria/enuresis
  • Abdominal pain
  • Somatic Complaints
  • Bleeding
  • Discharge
  • STIs
  • Pregnancy
238
Q

Maltreated child interventions

A
  • Adopt a nonthreatening relationship with the parents
  • Understand child does not want to betray his/her parents
  • Detailed history and thorough physical examination pertaining to the incident
  • The use of dolls or drawing might help child to tell how the injury or accident happened.
  • Evidence of maltreatment
    — Pattern or combination of indicators that arouse suspicion and further investigation
    — Child and caregiver histories of events do not match
    — Inconsistent or incongruent behaviors
  • Accurate records
239
Q

Maltreated child: documentation

A
  • physical evidence
  • body map
  • Detail: shape, color, size, measurements
  • photos
  • Exact words of child
  • Trained personnel
  • Interview:
    — Be honest & direct
    — Interview child away from parents if possible
    — Don’t be judgemental; no blame
    — Don’t try to prove accusations
240
Q

Maltreated child:
If contacting CPS: what should you do

A

Inform parents of process and what will happen

241
Q

The cycle of violence phases

A

Tension- Building Phase
Serious Battering Phase:
Honeymoon Phase:

242
Q

The cycle of violence:
Tension- Building Phase: s/s
Abuser/ victim

A

Abuser:
- Edgy, has minor explosions
- May become verbally abusive
- Minor hitting, slapping, and other incidents begin
Victim:
- Feels tents and afraid like “walking on eggshells”
- Feels helpless, becomes compliant, accepts blame

243
Q

The cycle of violence:
Serious Battering Phase: s/s
Abuser/ victim

A

Abuser:
- may try to cover up the injury or may look for help
- May not remember incident

Victim:
- tention becomes unbearable; the victim may provoke an incident to get it over with
- Remember incident
- Goes to ER at this time

244
Q

The cycle of violence:
Honeymoon phase: s/s
Abuser/ victim

A

Abuser:
- Loving behavior, such as bringing gifts and flowers, and doing special things for the victim
- Contrite, sorry. Make promises to change.

Victim:
- Trusting, hoping for change
- Wants to believe partner’s promises
- Charges are often dropped in this phase; CA state doesn’t drop the charges

245
Q

Intimate Partner Violence (IPV)

A
  • A pattern of assault and behaviors; may include physical injury, psychologic abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, and threats between current or former partners of an intimate relationship
  • IPV: Pregnancy
    — IVP is the leading cause of injury-related deaths during pregnancy.
    — Birth defects and infant deaths are frequent outcomes of abuse during pregnancy.
246
Q

Assessment: IPV

A
  • Pts most often seen in the ED; or physician’s office or clinic.
  • If injuries don’t match the explanation
  • if the patient minimizes the abuse, then suspect IPV.
  • If IPV is suspected, then complete a physical history, including an X-ray study and a neurologic examination.
  • Rape may be part of the abuse—evaluate, especially if the woman is pregnant, exposed to sexually transmitted diseases (STDs), or has signs of infection or trauma
  • Signs of abuse may include burns, bruises, scars, and other wounds in various stages of healing, particularly around the head and neck.
  • Physical examination includes assessing:
    — Internal injuries—concussions, perforated eardrums, abdominal injuries, eye injuries, and strangulation marks on the neck
    — Broken (fractured) bones—arms, pelvis, ribs, clavicle, legs, or jaw
  • Examination might reveal burns from cigarettes, acids, scalding liquids, or appliances.
  • Presenting signs might include high anxiety, stress, and the complaint of insomnia, chest pain, back pain, dizziness, stomach upset, trouble eating, and severe headache, among others.
  • Assessment for post traumatic stress disorder (PTSD) should be part of the evaluation
247
Q

IPV 3 questions to ask?

A
  • Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?
  • Do you feel safe in your current relationship?
  • Is there a partner from a previous relationship who is making you feel unsafe now?
  • Are there children at home? Are they being hurt

Assess:
- Support
- SI
- Coping strategies
- Substance abuse

248
Q

IPV victim characteristics

A
  • Does not ask to be beaten and does not enjoy it.
  • Does not usually initiate; usually in self-defense
  • Lives in terror
  • powerlessness
  • low self-esteem
  • Loses sense of self
  • Isolated; few friends/ family
  • Keeps violence and pain a secret
  • Subject of extreme and irrational jealousy
  • verbally and physically abused
  • psychologically destroyed
  • Believes what the abuser says is true.
  • Lives in fear for their life/ children’s lives
  • Depression; due to economic and emotional dependency.
  • Substance abuse risk
  • Believes if they do or says “the right thing,” the abuse will stop.
  • Believes if they don’t do anything “wrong,” the abuse will not happen.
    -may need permission to leave house
  • SI/ HI risk
249
Q

IPV perpetrator Characteristics

A
  • Denial/ Blame
  • Emotional abuse: Belittles, criticizes, insults, uses name calling, and undermines
  • Control through isolation: Limits contact/ activity with family/ friends
  • Tracks victims; time away, mileage on the car, stalking,
  • Escorts victims to work, school, etc.
  • Control through intimidation: threats; Instills fear
  • Breaks things, destroys property, abuses pets, displays weapons, threatens children, and threatens homicide or suicide
  • Physical, sexual, and psychological abuse
  • Controls the money. May force victim to miss work.
  • Makes all the decisions; defines the role in the relationship,
  • Treats victim like a servant
  • Brought up in an abusive home.
  • Low sense of self
  • Poor impulse control
  • Limited tolerance for frustration
  • No guilt; lack concern
  • Appears: well-adjusted
  • Possessive
  • jealous
  • Believes in male supremacy
  • Substance Use disorder; not the cause of the abuse; it is an excuse
  • Those with dyssocial tendencies; more lethal
  • treatment not highly effective
250
Q

Intervention: IPV: communication with victim

A
  • See pt alone; without partner present, at least part of the exam
  • Ask the pt if someone is hitting/ hurting them (or their children) —either a current or past partner, or anyone else
  • Ask if pt feels safe in their current relationship
    — Red Flag: partner reluctant to leave pt
251
Q

IPV: Forensic issues

A
  • Identify pt interest in pressing charges.
  • If yes, then give verbal or written information on:
    — Local attorneys who handle spouse abuse cases
    — Legal clinics and/or battered women’s advocates
  • If the patient is not ready to take action at this time, provide a list of community resources:
    — Hotlines, shelters, battered women’s groups
    — Battered women’s advocates
    — Aid to Families with Dependent Children (AFDC)
252
Q

IPV: Long-Reaching Effects

A
  • Children are vulnerable to feelings of responsibility, guilt, emotional distress, behavioral regression, somatic complaints, PTSD, alcohol or drug abuse, and more.
  • Children are also likely to be abused.
  • Children are likely to model the actions they see around; violence.
253
Q

When to report IPV?

A

When a patient is suspected to be suffering from a physical injury due to a firearm or assaultive or abusive conduct.

254
Q

Who to report IPV to?

A

Local law enforcement agency in the jurisdiction where the injury was sustained

255
Q

Time limit to report IPV?

A
  • Phone report: immediately/ ASAP
  • Written report: within two working days.
256
Q

IPV: What must be included in the telephone and written report?

A

The report must include the following:
A. Pt name
B. Pt location
C. Character and extent of injuries
D. Perpetrator name; identity
Report form OCJP 920: Suspicious Injury Report Form to make the report

257
Q

IPV medical record documentation

A
  • Use quotations
  • Name of perpetrator
  • Time of injury
  • Time pt was seen in ER
  • A map of the pt’s body showing and identifying injuries and bruises
  • Location, number, types, characteristics of injury
  • A copy of the reporting form in the chart
  • Who was informed of case; who you’ve told about incident
  • Any comments regarding Hx of domestic violence
258
Q

What do you do If the victim does not want a report to be made to local law enforcement:

A
  • Health practitioners are required to report if the terms of the law are met, whether or not the patient consents to a report.
  • Assess reasons why
  • Advocate for pt needs/ concerns with the authorities.
259
Q

What to teach an IPV pt

A
  • Move to a room with more than one exit
  • Avoid rooms with potential weapons (e.g., kitchen knives).
  • Know the quickest route out of the home/ workplace.
  • Inform neighbors about abuse/ ask them to call the police when they hear a disturbance.
  • Have a code word with kids, family, and friends.
  • Know community resources; HOTLINE: 800-799-7233
  • Have a safe place to leave to
  • Pack a bag beforehand with:
    — Essential clothes and valuables
    — Prepaid phone card, cell phone, address book, and a 1-month supply of medications
    — Cash
    — Keep this packed bag hidden but easy to grab quickly
  • Include legal documents:
    — Birth certificates, social security card, photo identification, passports, welfare identification, green card, marriage certificate, restraining orders, health insurance papers, medical cards, school records, account numbers, rental agreements, and house deed registration, etc
260
Q

Elder Abuse/ Neglect risk factors

A
  • Age: 60+;
  • Frailty; increased risk for sexual abuse
  • Hx:
    — depression
    — Substance abuse
    — dementia
    — Psychiatric illness
261
Q

Elder:
Physical abuse

A

Infliction of physical pain or injury
-Ex: slapping, bruising, sexually molesting, restraining

262
Q

Elder:
Emotional abuse

A

Infliction of mental anguish
- Ex: humiliating, intimidating, threatening

263
Q

Elder:
Financial abuse or exploitation

A

Misuse of someone’s property and resources by another person

264
Q

Elder:
Neglect

A

Failure to fulfill a caretaking obligation to provide goods and services; may also include self-neglect; “granny dumping”

265
Q

Elder:
Sexual abuse

A

Nonconsensual (either by refusal or incapacity to refuse) sexual contact

266
Q

Elder abuse/neglect:
Perpetrator characteristics

A
  • Closely resembles the perpetrator in IPV or child abuse.
  • May not be cruel or insensitive, but under extreme stress.
  • Often times is a caregiver;
    — a middle-aged child of the elder
    — financially dependent on the elder
    — Dealing with mental illness/ substance abuse/ inability to cope.
267
Q

Red flags for elder abuse

A

Similar to IPV but include the following:
- Fear of being alone with caregiver
- Caregiver is angry or aggressive toward the elder
- Obvious malnutrition
- Bedsores or skin lesions
- Begging for food
- Needs medical and/or dental care
- Left unattended for long periods
- Reports of abuse and neglect
- Passive, withdrawn, and emotionless
- Concern over finances and missing valuables, personal belongings are missing, another person’s name is added to the clients bank account

268
Q

Elder abuse/neglect
Interventions

A
  • possible removal of the victim from the home
  • Check the individual state for laws regarding elder abuse. CA: Healthcare providers are mandated reporters
  • Contact APS.
  • family meetings; to identify stressors.
  • Notify community agencies:
    — Support group for elder and abuser
    — Meals on Wheels
    — Daycare for seniors and respite services
    — Visiting nurse services
    — Encourage abuser’s use of counseling
269
Q

Personality disorder risk factors

A
  • family Hx
  • Low SR/ excessive limbic system activity
  • ACEs
270
Q

Personality disorder characteristics

A
  • Pattern of inner-experience / behavior that:
    — deviates from expectation of the individual’s culture
    — is pervasive / inflexible
    — is stable over time
    — leads to distress or impairment.
    — tend to be rigid and maladaptive
    — egosyntonic
  • Pts Misinterpret the world
  • Inappropriate emotional responses
  • Impulse control problems
271
Q

What are the 3 CLUSTERS OF DISORDERS

A

“A” = odd/eccentric cluster of disorders
“B” = dramatic cluster of disorders
“C” = anxious/fearful cluster of disorders

272
Q

“A” = odd/eccentric cluster of disorders s/s

A

Paranoid
schizoid
schizotypal

273
Q

“A” = odd/eccentric cluster of disorders:
Intervention

A

Redirect

274
Q

“B” = dramatic cluster of disorders: S/S

A

Borderline
anti-social
narcissistic
histrionic

275
Q

“B” = dramatic cluster of disorders:
Intervention

A

Set limits, Cognitive Behavioral Therapy (CBT)

276
Q

“C” = anxious/fearful cluster of disorders: S/S

A

Dependent
obsessive-compulsive
avoidant

277
Q

“C” = anxious/fearful cluster of disorders:
Interventions

A

Need assertiveness training, self-esteem, coping (encourage positive social networking)

278
Q

SCHIZOTYPAL PERSONALITY DISORDER CLUSTER A

A
279
Q

SCHIZOTYPAL PERSONALITY DISORDER CLUSTER A
Etiology

A

reduction in temporal lobe volume

280
Q

SCHIZOTYPAL PERSONALITY DISORDER CLUSTER A
Intervention

A
  • dependent on degree of decompensation
  • strategies to increase self-worth
    — social skills training;
    — environmental management
    — cognitive skills
281
Q

Borderline PERSONALITY DISORDER cluster B: S/S

A
  • Unstable relationships
  • Sense of emptiness
  • Impulsive suicide attempt
  • Helping patients deal with their unstable emotions and impulsive behavior is a key to improving their lives (use CBT)
  • Self-mutilation (cutters)
  • Fear of abandonment (may present as attention seeking)
  • “Splitting” (manipulative)
282
Q

Borderline PERSONALITY DISORDER cluster B:
Intervention

A

DIALECTIC BEHAVIOR THERAPY (DBT)
- Problem solving
- Exposure techniques
- Skills training (emotional regulation, interpersonal - effectiveness, core mindfulness, distress tolerance, and self- management skills)
- Contingency management
- Cognitive modification
- Mindfulness

283
Q

ANTISOCIAL PERSONALITY DISORDER CLUSTER B: s/s

A
  • Violate the rights of others, with no remorse
  • Lack empathy
  • Violent or manipulative to get desires met
  • On the unit, limit setting is a key intervention (because they are manipulative)
284
Q

NARCISSISTIC CLUSTER B: s/s

A
  • Grandiose with an inexhaustible need for attention
  • Lacking empathy; feelings of superiority, specialness, or uniqueness; self-centered view; sense of entitlement
  • Epidemiology: 6.2%; men > women
  • Etiology: little evidence of biologic factors; possible result of parents’ overvaluation and overindulgence of a child
  • Nursing management: nurse self-awareness; focus on coexisting responses to other health care problems
285
Q

AVOIDANT PERSONALITY DISORDER CLUSTER C: S/S

A
  • Avoidance of social situations
  • Timid, shy, hesitant, fear of criticism, and feelings of inadequacy
  • Extremely sensitive to negative comments and disapproval
  • Engagement in interpersonal relationships only when they receive unconditional approval
  • Assessment: lack of social contacts, a fear of being criticized, evidence of chronic low self-esteem
286
Q

AVOIDANT PERSONALITY DISORDER CLUSTER C:
Interventions

A
  • No negative criticism
  • Identification of positive responses from others
  • Exploration of previous achievements
  • Exploration of reasons for self-criticism
  • Social skills training
287
Q

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER CLUSTER C: S/S

A
  • Different from OCD; no obsessions and compulsions but pervasive pattern of preoccupation with orderliness, perfectionism, and control
    — Completely devoted to work
    — Uncomfortable with unstructured leisure time
    —Formalized leisure activities
  • Need to control others
  • Difficulty making decisions and completing tasks because they become so involved in the details
  • Tense, joyless mood
288
Q

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER CLUSTER C: interventions

A
  • Seek care for attacks of anxiety, spells of immobilization, sexual impotence, excessive fatigue
  • Assessment: focus on patient’s physical symptoms
289
Q

THERAPY GUIDELINES FOR PERSONALITY DISORDERS

A
  • Staff needs to be consistent in approach (always refer them to their own nurse for their needs)
  • Egosyntonic: rarely come on own for help
  • Change happens slowly – large changes are unrealistic
  • Difficult to form a therapeutic relationship
  • Tend to be suspicious and hostile
  • Need sense of control – giving options may enhance compliance
  • Milieu: groups force pt to interact appropriately with others, also makes visible their own behaviors.
290
Q

Personality Disorder Meds:

A
  • SSRI’s: for depression
  • Tegretol: impulsivity
  • Lithium, anticonvulsants, or SSRI’s: aggression

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