Final Stretch Flashcards
What is a self limiting state of disequilibrium/ struggle for equilibrium & adaptation
Crisis
Crisis is experienced as what?
An overwhelming emotional reaction
How long does a crisis last?
4-6 weeks
What is the goal crisis intervention?
Return individual to pre-crisis, level of functioning or higher
Crisis intervention is focused on what?
Current situation
Types of crisis
Maturational
Situational
Adventitious
Existential
What is a maturational crisis?
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
What is a situational crisis?
External “situation” causes crisis- happens to self
Example:
- job loss, death of a loved one, a divorce, physical or mental illness
What is an adventitious crisis?
Crisis of disaster: Larger in scale than situational: group
Example:
- natural disasters; floods, fires, earthquakes, etc.
- Mass shootings
- COVID
What is a existential crisis?
Questioning life’s purpose or spirituality
Seven stages of crisis intervention?
- 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
How many phases of crisis are there?
4
Phase 1 of crisis
- Conflict threatens self-concept
- Increased anxiety
- Stimulates Defense Mechanisms/ problem solving skills to lower anxiety.
Phase 2 of crisis
- defensive response fails/threat persists
- Anxiety escalates.
- Disorganized; can’t focus
- trial-and-error attempts to solve problems begin.
Phase 3 of crisis
- Trial-and-error attempts fail
- severe and panic levels anxiety
Phase 4 of crisis
- Problem is not solved after some time
- new coping skills: ineffective
- Anxiety overwhelms pt
- Serious illness: depression, hopelessness, violence, assess for suicidal thoughts.
Crisis
Pt assessment
- 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.
Crisis:
How do you assess pt’s perception of the trigger?
- 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?
Crisis interventions
- 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.
Crisis:
Strategies to build up resilience
- 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
Crisis intervention techniques
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
Phases of Critical Incident Stress Debriefing (CISD)
If tr s tr
Introductory
Fact
Thought
Reaction
Symptom
Teaching
Reentry
Crisis:
What happens in the introductory phase of CISD
overview of what happened;
- process
- confidentiality
- key members are identified
Crisis:
What happens in the fact phase CISD
what happened; facts only
Crisis:
What happens in the thought phase of CISD
what were you thinking when event happened
Crisis:
What happens in the reaction phase of CISD
what was your reaction; discuss feelings; most painful/ hardest to process
Crisis:
What happens in the symptom phase of CISD
what is everyone’s s/s, how’s it affecting your work
Crisis:
What happens in the teaching phase of CISD
Teach:
- resources; additional therapy
- s/s of PTSD
Crisis:
What happens in the reentry phase of CISD?
are you ok to go back to work?
being a paramedic, nurse, caretaker
Agnosia
Ability to name/recognize objects
Confabulation
Making up stories to fill in gaps of memory
Aphasia
Loss of ability to understand or express speech
Apraxia
Not being able to complete physical tasks because you don’t remember
Hypermetamorphosis
Having to touch things
Perseveration
Mind is on a hamster wheel; continuous thought
Delirium risk factors
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
Delirium onset
Sudden; hours- days
What causes Delirium
- Hypoglycemia
- Infection
- Fever
- Dehydration
- Hypotension
- Head injury
- Pain
- Change in environment
- Emotional stress
- B12 and folate deficiencies
- meds
Delirium S/S
- 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
Delirium, prognosis
Reversible; with proper in timely treatment
Delirium intervention
- 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
What is Dementia
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.
Dementia onset
Slow; months - years
What causes Dementia
Neurological disease
Alzheimer’s disease
Vascular disease
HIV
Chronic alcoholism
Vitamin B12 deficiency
Folate deficiency
Head trauma
Dementia S/S
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
Dementia prognosis
not reversible; progressive
Dementia interventions
Monitor client closely
Reorient Client
Positive feedback
Explain simply
Discourage suspiciousness
Avoid cultivation of false ideas
What is Huntington’s disease?
Progressive brain disorder
defective dominant gene on a chromosome 4
Huntington’s disease S/S
- 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
Huntington’s disease intervention
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
Huntington’s disease
Chorea meds
Atypical antipsychotics:
- Olanzapine
- Baclofin (muscle relaxer)
Huntington’s disease
Irritability Meds
Atypical antipsychotic
SSRI (less severe nonthreatening irritability)
Huntington’s disease
OCD thoughts- Meds
SSRIs
Creutzfeldt-Jakob Disease
Viral protein (Prion) found in CSF causes brain degeneration
- Spread by infected meat: MAD Cow disease
Creutzfeldt-Jakob Disease Labs
CSF proteins
EEG
MRI
Creutzfeldt-Jakob Disease S/S
Early stage
memory loss
visual impairment
dysphagia; speech disfunction
Creutzfeldt-Jakob Disease S/S
Within weeks
progressive dementia set in
Creutzfeldt-Jakob Disease S/S
1-2 years
Death
Creutzfeldt-Jakob Disease S/S
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
Creutzfeldt-Jakob Disease intervention
No treatment can slow or stop brain cell destruction
Vascular Dementia
Reduce blood flow/ oxygen/ nutrients to the brain causes a decline in thinking skills/ multiple small strokes
Vascular Dementia S/S
- 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
Vascular Dementia
Interventions
keep circulation good
- Don’t smoke
- Keep BP/ cholesterol/ blood sugar within limits
- Healthy, balanced diet
- Exercise
- Healthy weight
- Limit alcohol
Picks diseases
frontotemporal neurocognitive disorder
Picks disease (FTD) prognosis
5 years average lifespan after diagnosis
Picks disease (FTD) S/S
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
What causes Picks disease (FTD)
Unknown
Picks disease (FTD) onset
40s- early 60s
What is Lewy Body Disease
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.
Lewy Body Disease Prognosis
Average lifespan 5-7 years
Lewy Body Disease S/S
- 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
Lewy Body Disease interventions
None other than:
- self-care deficit
- meds to treat s/s
Lewy Body Disease Meds:
Treat thinking changes in Alzheimer’s
Cholinesterase inhibitor drugs
Lewy Body Disease Meds:
Treat behavioral symptoms in Alzheimer’s
Adverse affects of meds?
Antipsychotic drugs; use with caution. May cause:
- sudden changes in consciousness
- impaired swallowing
- acute confusion
- delusions/ hallucinations
- appearance or worsening of Parkinson’s symptoms.
Lewy Body Disease Meds:
- depression in Alzheimer’s disease
SSRIs
Most common type of dementia
Alzheimer’s disease
Alzheimer’s disease prognosis
Death 4-8 years after dx
Alzheimer’s disease risk factors
- Age: >65
- diabetes
- hypertension
- Hx: TBI
Alzheimer’s disease
Modifiable risk factors
behaviors that can be changed
- physical activity
- smoking
- education
- staying socially and mentally active
- blood pressure and diet
What causes Alzheimer’s disease?
- 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.
Alzheimer’s disease labs
CSF: for tau
MRI
CT scan
Beta-amyloid pet scan
Early s/s Alzheimer’s disease
- 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
Stages of Alzheimer’s disease
Mild
Moderate
Moderate to severe
Late: end stage
Alzheimer’s disease: S/S
Stage: mild
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
Alzheimer’s disease: intervention
Stage: mild
Discuss estate planning in this phase
Alzheimer’s disease: s/s
Stage: moderate
Confusion
- Memory losses apparent – may forget address &/or date
- ADL’s suffer
- Problems managing money, legal affairs
- Labile mood
- Withdraw from activities- socially isolate
Alzheimer’s disease: Interventions
Stage: Moderate
Needs day care / in-home assistance
Alzheimer’s disease: S/S
Stage: Moderate to Severe
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
Alzheimer’s disease: Interventions
Stage: Moderate to Severe
- 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
Meds for Moderate to severe stage Alzheimer’s disease
NMDA blocker: Memantine (Namenda)
- blocks NMDA receptors to block excessive glutamate, which has a toxic effect on neurons.
Alzheimer’s disease: S/S
Stage: Late: End Stage
- 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
Alzheimer’s disease: Interventions
Stage: Late: End Stage
- Require around-the-clock assistance with daily personal care
- Needs total care; incontinence common
Alzheimer’s disease prognosis
DX-death: 10 years, some people may live up to 20 years.
Alzheimer’s disease first line treatment medication
Cholinesterase inhibitors: increase ACh
- Donepezil (Aricept)
- Rivastigmine (Exelon)
- Galantamine (Razadyne)
Nursing implications:
- Take with food
- Bradycardia
- Fall risk
Antidote: Atropine
New Alzheimer’s disease med?
S/S?
Aducanumab
S/S:
- Headache
- Fall risk
- dizziness
- nausea
- confusion
- vision changes
- potential for allergic reactions
Addiction:
Prior to admission you need to know what 3 things
What was taken?
how much was taken?
when was it last taken?
What are the CNS depressants?
alcohol
benzodiazepines
barbiturates
One drink =
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
Low risk drinking amount
MEN: 18-65
- 4 per day
- 17 per week
WOMEN: 18-65 & AGES 66+
- 3 per day
- 7 per week
Blood Alcohol Levels: .05= S/S
X Drinks
1-2 drinks
changes in mood/ behavior
Legal blood alcohol content
.08 %
Blood Alcohol Levels: .10= S/S
X Drinks
5-6 drinks
voluntary actions, clumsy
Blood Alcohol Levels: .20= S/S
X Drinks
10-12 drinks
staggering, labile emotions
Blood Alcohol Levels: .30= S/S
X Drinks
15-18 drinks
confusion, stupor
Blood Alcohol Levels: .40= S/S
X Drinks
20-24 drinks
coma
Blood Alcohol Levels: .50= S/S
X Drinks
25-30 drinks
Death due to respiratory depression
Alcohol INTOXICATION S/S
- 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
When do Alcohol Withdrawal S/S start
Within a few hours after last drink
When do alcohol withdrawal s/s peak and disappear?
24-48 hours
Alcohol withdrawal s/s
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
Alcohol withdrawal interventions
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)
Tool developed to monitor withdrawal symptoms
CIWA scale
If the CIWA score is ______ for _____ long you should contact the HCP
> 17 for >4 hours
CIWA categories
- Visual Disturbances
- Auditory disturbances
- Nausea
- Clouding of the sensorium
- Headache
- Agitation
- Tactile Disturbances
- Tremor
- Vomiting
- Paroxysmal Sweats
- Anxiety
Write out the CIWA med/reassessment table
Gold standard medication: alcohol withdrawal
Benzodiazepines:
Short acting : lorazepam (Ativan)
Long acting : Chlordiazepoxide (Librium)
Medication for alcohol withdrawal
Lorazepam (Ativan)
Chlordiazepoxide (Librium)
Antabuse
Naltrexone
Route of lorazepam (Ativan)
PO, IV, IM
Route of chlordiazepoxide (Librium)
PO only
Antabuse (Disulfiram) use/ s/s / teaching
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
Naltrexone (ReVia) use/ MOA/ s/s
- 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
adjunct therapy: alcohol withdrawal
used along with benzodiazepines
- Hypertension: Systolic: >180hg or Diastolic: >100
—Metoprolol
—Clonidine
- Agitation: Delirium Protocol
—Haloperidol
Alcohol withdrawal:
Early/minor stage
- 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
Alcohol withdrawal:
Moderate stage
- 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
Alcohol withdrawal:
Severe stage
- 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
ALCOHOL RELATED MEDICAL PROBLEMS
pancreatitis
ulcers
cirrhosis
esophageal varices
cardiomyopathy
myopathies
malabsorption of vitamins
- folic acid
- vitamin B1 (thiamine)
- vitamin B12
Alcohol withdrawal labs
- AST/ ALT/ Bilirubin
- Lipase/ Amylase
Vitamins: - Folic acid
- Vitamin B1/ B12
Delirium tremens: alcohol withdrawal delirium
- 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
Delerium tremens s/s
delirium
disorientation
visual hallucinations
tactile hallucinations
illusions
paranoid delusions
agitation
raised vital signs
Wernicke-Korsakoff Syndrome
thiamine (B1) deficiency
Starts at Wernicke’s Encephalopathy
Turns into Korsakoff’s Psychosis
Wernicke’s Encephalopathy s/s
- ataxia; impaired coordination
- acute confusion; under-diagnosed
- Gait problems
- Problems with eye movement
—Nystagmus; eye jitter; seen in seizure disorder/ TBI
Wernicke’s Encephalopathy Treatment:
CIWA scale
Banana bag IV (B vitamins); first
Oral thiamine; after banana bag
Korsakoff’s Psychosis: “wet brain” s/s
- 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.
Tips for cutting down on alcohol use:
- Measure and count
- Set goals
- Pace and space
- Include food
- Avoid “triggers”
- Plan to handle urges
- Know how to say “no”
Opioid MOA
Increases dopamine; euphoria
Opioid prevalence
> males
Caucasian
Opioid drugs
fentanyl
hydrocodone
oxycodone
Percocet
Some prescription cough syrups
Heroin
What is used to determine opioid withdrawal severity
COWs scale
Opioid intoxication s/s
constricted pupils
decreased RR/BP
impaired memory/ judgment
drowsiness
slurred speech
Opioid interventions
Assess respirations
Do not abruptly stop opioid medicine; withdrawal can occur.
MATs: medication assisted treatments for substance use disorder
Detox Meds
Opioid detox meds/
Antidote
Methadone
Suboxone
naltrexone (ReVia)
Antidote: Naloxone
Marijuana labs
+ THC
- presumptive positive
Marijuana intoxication s/s
increased appetite
red eyes
relaxation/ euphoria
detachment/ dissociative symptoms
impaired memory & judgment
apathy
Marijuana dependence s/s
anhedonia
lethargy
Memory impairment
Difficulty concentrating
Marijuana withdrawal s/s
anxiety
cravings for drug
Insomnia
appetite loss
CNS stimulants
cocaine, amphetamines, caffeine
Stimulant intoxication s/s
Dilated pupils
Increased HR
Increased BP
Excessive motor activity
Euphoria
Paranoia
Stimulant withdrawal s/s
Depression; SI
Anergia
Anhedonia
Avolition
Addiction defense mechanisms
Denial:
- escaping unpleasant realities by ignoring their existence
Rationalization: Blame
- justifying illogical ideas, actions, or feelings by developing an acceptable explanation for unacceptable behavior.
Addictive cognitive distortions
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.
Substance abuse: ineffective coping/denial
Interventions
Assess + & - coping
Encourage pt to express feelings
Explore alternative coping strategies and ways to maintain sobriety (list)
Limit denial and rationalization
Recovery from addiction
Intervention
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
Addiction treatment programs
12 STEP PROGRAMS
RESIDENTIAL THERAPEUTIC COMMUNITIES
INTENSIVE OUTPATIENT (IOP) PROGRAMS: VA
FAMILY & MARITAL THERAPY:
RELAPSE
12 STEP PROGRAMS
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
RESIDENTIAL THERAPEUTIC COMMUNITIES
Betty Ford treatment center
INTENSIVE OUTPATIENT (IOP) PROGRAMS: VA
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
FAMILY & MARITAL THERAPY
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
RELAPSE intervention
common during recovery.
Explore this before it happens and afterwards.
Identify attitudes and situations that caused relapse
Somatic Symptom Disorder
- 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)
Somatic symptom disorder assessment
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
Somatic symptom disorder
Interventions
- 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)
Somatic symptom disorder
Therapies
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
Eating disorder process
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
Anorexia nervosa risk factors
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
Anorexia nervosa
Diagnostic criteria
- 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
Anorexia nervosa s/s
- 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
Anorexia nervosa interventions
- 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
Anorexia Nervosa meds
may improve weight, cognition, and body image
- Fluoxetine
- Olanzapine (Zyprexa)
Refeeding Syndrome Process
- 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.
Refeeding Syndrome s/s
- weakness
- mental confusion
- SOB
- cardiac arrest/failure
- seizures
- coma/death.
Refeeding syndrome intervention
monitor pt during feeding rehabilitation to avoid complications
Bulimia Nervosa diagnostic criteria
- 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
Bulimia nervosa interventions
- 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
Bulimia nervosa medications
SSRIs: fluoxetine (Prozac)
Binge eating disorder
Diagnostic criteria
- 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
Binge eating disorder interventions
Pt teaching:
- Alternative coping skills
- Improve social skills
- Problem solving skills
- Decision making skills.
Eating disorder cognitive distortions
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. ”
any type of sexual activity the victim does not agree to.
SEXUAL ASSAULT
RAPE
- is non consensual vaginal, anal, or oral penetration.
- ETOH is implicated in 69% of rapes
Drug-Induced Rape Prevention Act of 1996
- Up to 20 years imprisonment and fines to anyone administering a controlled substance to an unknowing victim
Drugs used in Rape
Gamma-Hydroxybutyrate (GHB): depressant;
- S/S: Amnesia, euphoria, hypotonia
Rohypnol: Benzo;
- S/S: Amnesia, decreased coord.
Ketamine: Anesthetic/ Hallucinogenic
- S/S: Amnesia,Analgesia, Cooperation
Sexual assault/ rape
Vulnerable individuals:
- 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
Sexual assault Perpetrators
- Antisocial PD
- Impulsive/ violent tendencies
- ACEs
- Hostility toward women
- Refuses to acknowledge acts of sexual assault
RAPE-TRAUMA SYNDROME
Acute phase: s/s
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
RAPE-TRAUMA SYNDROME
Long term: reorganization phase S/S
2 or more weeks after rape
- Nightmares/ flashbacks
- Phobias
- Anxiety
- Depression
- Insomnia
- Somatic symptoms
- Increased motor activity
- Increase emotional lability
Rape Assessment/Forensic examination
- 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
Rape intervention
- 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
Rape
Case management reassessment
- 24-48 hours afterwards
- 2, 4, and 6 weeks after
— Encourage pt to seek counseling and support groups
Rape Survivors are recovered if they:
- 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
GENDER DYSPHORIA s/s
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”
GENDER DYSPHORIA interventions
- Counseling
- Living as opposite sex with hormone therapy
- Progressive surgeries
Autism Spectrum disorder (ASD) Assessment
Assess what the child capable of
Autism Spectrum disorder (ASD) s/s
- 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
Autism Spectrum disorder (ASD) Meds
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
Asperger’s Disorder
High Functioning ASD
Asperger’s Disorder s/s
- 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?
ADHD
Persistent pattern of inattention, hyperactivity, and impulsiveness that is pervasive and inappropriate for developmental level
- Hyperactive type
- Inattentive type
- Combined type
ADHD s/s
- 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.
ADHD questionnaire
Vanderbilt Assessment Scales
ADHD Meds: Stimulants
- Methylphenidate (Ritalin): Short acting
— (Long acting: Concerta) - Amphetamine salts (Adderall)
ADHD stimulant MOA
- increase NE, DA & SR
- Increase focus and attention
ADHD stimulant s/s
- Restlessness
- insomnia- dont resolve
- Dry mouth
- Decreased appetite
- Weight loss
- Anorexia- dont resolve
- Headache- resolve
- Nausea, vomiting- resolve
ADHD med labs
Liver labs
ADHD Stimulant Nursing Implications
- 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
ADHD non stimulant drugs
Atomoxetine (Strattera)
Bupropion (Wellbutrin)
Guanfacine (Tenex)
Clonidine (Catapres)
Atomoxetine (Strattera) class
SNRI
Bupropion (Wellbutrin) MOA
Blocks neuronal uptake of SE, NE & DA
Guanfacine (Tenex)
Treats/ Drug class/ MOA/ s/s /
Nursing implications
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
Clonidine (Catapres)
Treats/ class/ MOA/ s/s nursing implications
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
Oppositional Defiant Disorder
ONSET
8yrs no later than early adolescence
Oppositional Defiant Disorder Prevalence
- > boys before puberty
- = in boys & girls after puberty
Oppositional Defiant Disorder S/S
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
Conduct disorder
- 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
Conduct disorder s/s
- 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
Tourette Disorder/ tic disorder
Characterized by multiple motor tics/ one or more vocal tics
Can suppress tics for brief periods, but can be lifelong
Tourette Disorder/ tic disorder Onset
around 6-7 years
Tourette Disorder/ tic disorder
Prevalence
> boys
Tourette Disorder/ tic disorder s/s
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
Tourette Disorder/ tic disorder Meds
- 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
Separation Anxiety Disorder
- Suffer great distress when faced with ordinary separations from major attachment figures
- May emerge after a change
Separation Anxiety Disorder onset
<18 yrs, commonly dx: 5-6yrs when the child goes to school
Separation Anxiety Disorder
Prevalence
> Girls
- Tends to runs in family
Separation Anxiety Disorder s/s
- Lot of anxiety about leaving; home
- School phobia; most children grow out of it
- Panic disorder: when kids grow up
Separation Anxiety Disorder
- focus on coping strategies
- Redirection
- Distraction
- Taper: parents stay with child less and less before leaving
- Therapies
Separation Anxiety Disorder
Therapies
- 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
Types of Neglect:
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
Physical Abuse
- 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.
shaken baby syndrome
Violent repetitive unrestrained acceleration-deceleration head and neck movements in children <3 years of age
shaken baby syndrome s/s
- Retinal hemorrhage
- Rib fractures-usually posterior
- Subdural Hematoma
- Mortality rate: High
—Survivors left with major neurological defect or developmental delay
Physical Abuse: Predisposing Factors:
PARENT characteristics
- 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
Physical Abuse: Predisposing Factors:
PARENT Behaviors
- 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
Physical Abuse: Predisposing Factors:
Child characteristics
- Young: Newborn - 1 year (70% fatalities < 3yrs)
— Parents don’t know what child wants - Physically disabled, hyperactive, premature, their own substance abuse
Physical Abuse: Predisposing Factors:
Child behavior
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
Physical Abuse: Predisposing Factors
Environmental characteristics
- Social isolation, poor support systems
- Chronic stress, poverty, low social economic stability, low income, substitute caregivers (daycare), housing instability
Sexual abuse:
Perpetrators Characteristics
- Most are trusted adult acquaintances
- Known acquaintance (non family) 50%
- Family Member
- Stranger
- Adolescents compromise 30% of perpetrators
Sexual Abuse
Victim: behavior S/S
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
Sexual Abuse
Victim: Medical S/S
- Pain
- Dysuria/enuresis
- Abdominal pain
- Somatic Complaints
- Bleeding
- Discharge
- STIs
- Pregnancy
Maltreated child interventions
- 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
Maltreated child: documentation
- 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
Maltreated child:
If contacting CPS: what should you do
Inform parents of process and what will happen
The cycle of violence phases
Tension- Building Phase
Serious Battering Phase:
Honeymoon Phase:
The cycle of violence:
Tension- Building Phase: s/s
Abuser/ victim
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
The cycle of violence:
Serious Battering Phase: s/s
Abuser/ victim
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
The cycle of violence:
Honeymoon phase: s/s
Abuser/ victim
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
Intimate Partner Violence (IPV)
- 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.
Assessment: IPV
- 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
IPV 3 questions to ask?
- 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
IPV victim characteristics
- 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
IPV perpetrator Characteristics
- 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
Intervention: IPV: communication with victim
- 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
IPV: Forensic issues
- 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)
IPV: Long-Reaching Effects
- 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.
When to report IPV?
When a patient is suspected to be suffering from a physical injury due to a firearm or assaultive or abusive conduct.
Who to report IPV to?
Local law enforcement agency in the jurisdiction where the injury was sustained
Time limit to report IPV?
- Phone report: immediately/ ASAP
- Written report: within two working days.
IPV: What must be included in the telephone and written report?
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
IPV medical record documentation
- 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
What do you do If the victim does not want a report to be made to local law enforcement:
- 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.
What to teach an IPV pt
- 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
Elder Abuse/ Neglect risk factors
- Age: 60+;
- Frailty; increased risk for sexual abuse
- Hx:
— depression
— Substance abuse
— dementia
— Psychiatric illness
Elder:
Physical abuse
Infliction of physical pain or injury
-Ex: slapping, bruising, sexually molesting, restraining
Elder:
Emotional abuse
Infliction of mental anguish
- Ex: humiliating, intimidating, threatening
Elder:
Financial abuse or exploitation
Misuse of someone’s property and resources by another person
Elder:
Neglect
Failure to fulfill a caretaking obligation to provide goods and services; may also include self-neglect; “granny dumping”
Elder:
Sexual abuse
Nonconsensual (either by refusal or incapacity to refuse) sexual contact
Elder abuse/neglect:
Perpetrator characteristics
- 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.
Red flags for elder abuse
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
Elder abuse/neglect
Interventions
- 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
Personality disorder risk factors
- family Hx
- Low SR/ excessive limbic system activity
- ACEs
Personality disorder characteristics
- 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
What are the 3 CLUSTERS OF DISORDERS
“A” = odd/eccentric cluster of disorders
“B” = dramatic cluster of disorders
“C” = anxious/fearful cluster of disorders
“A” = odd/eccentric cluster of disorders s/s
Paranoid
schizoid
schizotypal
“A” = odd/eccentric cluster of disorders:
Intervention
Redirect
“B” = dramatic cluster of disorders: S/S
Borderline
anti-social
narcissistic
histrionic
“B” = dramatic cluster of disorders:
Intervention
Set limits, Cognitive Behavioral Therapy (CBT)
“C” = anxious/fearful cluster of disorders: S/S
Dependent
obsessive-compulsive
avoidant
“C” = anxious/fearful cluster of disorders:
Interventions
Need assertiveness training, self-esteem, coping (encourage positive social networking)
SCHIZOTYPAL PERSONALITY DISORDER CLUSTER A
SCHIZOTYPAL PERSONALITY DISORDER CLUSTER A
Etiology
reduction in temporal lobe volume
SCHIZOTYPAL PERSONALITY DISORDER CLUSTER A
Intervention
- dependent on degree of decompensation
- strategies to increase self-worth
— social skills training;
— environmental management
— cognitive skills
Borderline PERSONALITY DISORDER cluster B: S/S
- 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)
Borderline PERSONALITY DISORDER cluster B:
Intervention
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
ANTISOCIAL PERSONALITY DISORDER CLUSTER B: s/s
- 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)
NARCISSISTIC CLUSTER B: s/s
- 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
AVOIDANT PERSONALITY DISORDER CLUSTER C: S/S
- 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
AVOIDANT PERSONALITY DISORDER CLUSTER C:
Interventions
- No negative criticism
- Identification of positive responses from others
- Exploration of previous achievements
- Exploration of reasons for self-criticism
- Social skills training
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER CLUSTER C: S/S
- 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
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER CLUSTER C: interventions
- Seek care for attacks of anxiety, spells of immobilization, sexual impotence, excessive fatigue
- Assessment: focus on patient’s physical symptoms
THERAPY GUIDELINES FOR PERSONALITY DISORDERS
- 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.
Personality Disorder Meds:
- SSRI’s: for depression
- Tegretol: impulsivity
- Lithium, anticonvulsants, or SSRI’s: aggression
