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Spring 2016 Semester > Mental Health N4615 Module III > Flashcards

Mental Health N4615 Module III Flashcards

1
Q

What is Anger

A

it is a secondary emotion usually triggered by another feeling

in response to some preceived threat or unmet need.

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2
Q

Anger vs. aggression

A

anger is a feeling

where as

agression is a behvoior

agression becomes more likely when the angry, frustrated client feels ignored or discounted.

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3
Q

Aggression defined

A

Aggression is a harsh physical or verbal action that reflects rage, hositility with the potential to cause harm or destruction to

Self

others

property

Agressive behavior violates the rights of others.

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4
Q

What is the number one predictor of agressive behavior?

A

Past history of agressive behavior is the single best predictor of future behavior

increasing agitation is the most important predictor of imminent agression and violence.

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5
Q

Signs of Increasing Agitation

A
  • Restlessness, pacing, hyperactivity
  • Rapid breathing
  • Tensing of muscles
  • Tight jaw/clenching teeth
  • Shouting, cursing, making threats
  • Verbal abuse
  • Intense eye contact or avoidance of eye contact
  • Clenched or raised fist
  • Menacing posture
  • Kicking or punching walls
  • Picking up a weapon
  • Throwing objects
  • Stone silence
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6
Q

Psychiatric Conditions
Associated with Aggression & Violence

A
  • Dementia
  • Delirium
  • PTSD
  • Bipolar Disorder
  • Substance abuse
  • Antisocial Personality Disorder
  • Impulse-control disorders
  • Delusional disorder, persecutory type
  • Schizophrenia, paranoid type
  • ADHD, conduct disorder and oppositional defiant disorders in children
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7
Q

Medical Conditions
Associated with Aggression & Violence

A
  • Chronic pain
  • Neurological disorders
  • traumatic brain injury, seizure disorder, neurosyphillis, HIV encephalopathy
  • Endocrine disorders
  • thyroid, parathyroid and adrenal hormone imbalances
  • Metabolic disorders
  • chronic renal failure, hepatic encephalopathy, hyponatremia, lupus
  • Exogenous toxins
  • inhaled solvents, alcohol, amphetamines, hallucinogens, heavy metals
  • Vitamin deficiencies
  • folate deficiency, Wernicke’s/Korsakoff’s encephalopathy
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8
Q

What is the #1 nursing diagnosis for violent patients

A

Risk for other-directed violence

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9
Q

Principles to Remember When Planning Care for the Potentially Violent Client

A
  • Safety first!
  • Protect yourself
  • Maintain self-awareness and self-control
  • Focus on prevention
  • Always use the LEAST RESTRICTIVE intervention possible

Stop the Violence Before it Starts!

If it’s Predictable, it’s Preventable!

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10
Q

How to protect yourself in violent situations

A
  • Never see a potentially violent patient alone
  • Maintain a safe, comfortable distance from the patient
  • Avoid touching the client or invading his/her personal space
  • Maintain a non-aggressive, neutral stance
  • Be prepared to move quickly—Learn to scoot!
  • Identify an “escape route” and do not allow the patient to block your exit path
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11
Q

Use Therapeutic Communication Skills
to De-escalate the Situation

A
  • Speak in a calm, caring manner
  • Ensure that non-verbal messages are not defensive or provocative
  • Slow your cadence and lower the volume of your voice if/when patient escalates. Watch your tone!
  • Do not argue with the patient, shout, or belittle his feelings
  • Use open ended questions to explore issues, then reflect/paraphrase
  • Facilitate problem solving, but avoid telling the client what to do–unless limit setting becomes necessary
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12
Q

Set Limits When Necessary with an angry patient

A

Establish limits only when and where there is a clear need

Never set a limit you cannot enforce

Don’t use limit setting to threaten the patient

Establish reasonable and enforceable consequences or exceeding limits

Be consistent in enforcing limits

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13
Q

What is “the SET” Communication Principles to Verbally De-escalate and Set Limits

A

•Support

•Remind client that you are an ally and you have his/her best interests in mind - (“I care about you and I want to help you.”)

•Empathy

•Convey to client that you understand and care about his/her feelings - (“I can see how frustrating and distressing this is for you.”)

•Truth

•Clearly state the limit and tell the patient what you want him/her to do - (“I won’t let you hurt yourself or anyone else. I need you to put the chair down now, please.”)

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14
Q

If the violence continues to escalate

A

Assemble a Show of Force

Assign only one person to communicate with the patient - Continue to offer client opportunities to change behavior when possible -

Follow approved policies and procedures for doing a “takedown” if necessary

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15
Q

When is Involuntary medication necessary?

A
  • Requires “emergency declaration” by physician when ordered
  • Danger to patient or others must be imminent
  • Must document failure of less restrictive interventions
  • No “prns” allowed for emergencies

•Considered a “chemical restraint”

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16
Q

What is the 1st thing needed after an emergency seclusion?

A

Notify the health care provider to obtain a seclusion order.

This is a state law

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17
Q

When can you use Seculusion or Restraints

A

Considered “last resort” interventions.

Seclusion is used when there is risk of danger to others.

Restraints are used when there is risk of danger to self.

NEVER used for punishment or staff convenience

Both require MD order, declared emergency due to imminent danger to patient or others and failure of less restrictive interventions

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18
Q

Limits on seculsion or restraint

A
  • One hour for children
  • Two hours for adolescents
  • Four hours for adults
  • If longer use is indicated, intervention must be reordered
  • Patients must be evaluated face to face by physician or specially trained nurse within one hour of initiation
  • Patients in seclusion must be monitored at least q15 min.
  • Patients in seclusion who have also received sedation must be monitored continuously
  • Patients in restraints must be monitored continuously on 1:1 observation
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19
Q

What is the type of documentation (how it should be completed) that is required when someone is placed in seculsion or restraints

A
  • Behavioral Observations
  • Interventions
  • In the order they were done, least restrictive to most restrictive
  • Patient’s responses to interventions
  • Debriefing & patient’s response

•Patient education and response to education

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20
Q

What is Validation therapy

A

meeting the patient “where he/she is at the moment — acknowledging the patients wishes

ex. Cognitivly impaired patient want to go home…you would say “So you want to go home?”

Validation does not redirect, reorient or probe

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21
Q

What is the best medication to give a pt. thats agression continues to escalate?

A

Olanzapine (Zyprexa)

short acting antipsychotic useful in calming angry, aggrssive patients regardless of diagnosis.

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22
Q

What are the stages/cycles of domestic violence and their definition

A

Tension-building stage - characterized by minor incidents (pushing, shoving, and verbal abuse)…victim ignores or acepts the abuse for fear more will follow.

Acute battering state — abuser releases the built up tension by brutal beatings which result in injuries.

Honeymoon stage —characteized by kindness and loving behaviors, abuser is apologetic, remorseful and often give gifts to apologize — victim wants to believe the response and often agrees to drop any charges.

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23
Q

Prevention of Abuse

pg. 546 book

A

Primary prevention - measures taken to prevent occurence of abuse

Secondary prevention - involves early intervention in abusive situations to minimize disabling or long term effects.

Tertiary prevention - often occures in mental health settings, involves facilatating healing and rehabilitation. .

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24
Q

What are components of a “plan of escape”

A

- keep a phone fully charged

  • have number of nearest shelter
  • secure a supply of medications for self & childrens

- Assemble birth certificates, SS card, and licenses

- Determine a code word to signal when it’s time to leave.

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25
Q

What is Engagement

A

“involve one’s attention and pledge to do something”

They are focused on the task at hand / in what they are doing (heart & soul)

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26
Q

Healthcare Engagement

A

Actions individuals must take to obtain the greatest benefit from the health care services available to them.”

Behaviors of individuals relative to their health care that are critical and proximal to health outcomes, rather than the actions of professionals or policies of institutions.

Processes in which information and professional advice with own needs, preferences and abilities in order to prevent, manage and cure disease

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27
Q

Consequences of Non-Engagement

A
  • risk for poor health
  • perform specific health behaviors
  • without insurance
  • education
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28
Q

Complementary & Alternative Use

A

Non vitamin, non mineral supplements-18.9% in 2002 and unchanged from 2007 to 2012 (17.7%).

deep-breathing exercises were the second most commonly used complementary health approach in 2002 (11.6%), 2007 (12.7%), and 2012 (10.9%)

yoga, tai chi, and qi gong increased linearly over the three time points, beginning at 5.8% in 2002, 6.7% in 2007, and 10.1% in 2012

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29
Q

What is Mindfulness Based Therapy

A

A randomized controlled trial of mindfulness-based cognitive therapy for bipolar disorder.

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30
Q

Benefits of Vitamin B 12 & B 9

A

B12 -Cyanoboalamin

B9 folic acid

B 12 & B 9 - 60–74 years old with mild depressive symptoms in a RCT-no effect

B 12, B 9, & B 6 - Prevented depression post stroke (mean ages 45.8–76.6 years old).

Well – designed study showing benefit of l-methyfolate augmentation of antidepressant

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31
Q

Benefits of Omega 3

A

Fish: salmon, almonds & walnuts.

The data support an antidepressant effect of Ω3.

Low levels of Ω3 in depression & suicidal patients.

Bipolar depressive symptoms may be improved by adjunctive use of omega-3.

Not effective in mania.

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32
Q

Benefits of Ginkgo Biloba

A

Ginkgo biloba originates from the Maidenhair tree.

Neuroprotective

inhibits platelet activation

relaxes endothelium

inhibits cholinergic receptors

increases choline uptake in the hippocampus

antioxidant effects.

Small effect on cognitive decline in those already afflicted with certain types of dementia.

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33
Q

Benefits of Lemon Grass

A

Effect of Lemongrass Aroma on Experimental Anxiety in Humans.

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34
Q

Benefits of Lavender & Bergamot

A

Lavender and bergamot essential oils are antidepressants and relaxants,

Essential oils can be absorbed by inhalation into the olfactory pathway and from there to the brain. The scores on depression, anxiety, and stress decreased in the intervention group after the aromatherapy programme, but there was increased psychological distress in the control group. The results were consistent with those of previous studies, namely, that aromatherapy was able to relieve negative emotional symptoms

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35
Q

Tenants of Spiritual Care

A

We have care for the beginning of families, new parents, and infants

We nurture mothers and fathers, children, and youth.

We offer wisdom and understanding concerning life’s stresses, anxieties, and challenges; we face together the realities of evil, suffering, and death.

We address the power of guilt, hopelessness, and despair; we mark our boundaries and limits; we create meaningful and shared narratives of the world and of our life journeys

We seek to name and contain what is toxic, and we foster food and drink that promote health and well-being.

We have care also for the experience of aging and the end of life

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36
Q

Faith & Mental Illness

A

One in four persons sitting in our pews has a family member struggling with mental health issues

A majority of individuals with a mental health issue go first to a spiritual leader for help

Studies show that clergy are the least effective in providing appropriate support and referral information

Our faith communities can be a caring congregation for persons living with a mental illness and their family members

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37
Q

Faith / Religion & stress - immune systems

A

Studies have shown a positive correlation between spiritual practices and enhanced immune system function and sense of well-being

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38
Q

Strategies for Caregivers

A

Support

Respite care

Mini-relaxations

Nutrition

Exercise

Sleep

Annual check up

Spiritual care

Stress management

Resilience

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39
Q

Annual Self-care

A

Annual exam

Vitamin D - sunlight (get alot of it)

Eye exam

Dental exam

Blood pressure

Complete metabolic levels, complete blood count

Follow recommended treatments.

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40
Q

What is VOLUNTARY ADMISSION

A

no procedure – patient signs self in and can sign self out with 24 hr letter.

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41
Q

Two ways to start commitment

A

1) Go to judge — issues a MIW (mental illness warrant)

2) Call the police — Determine danger — APPOW (Apprehension by Police Officer Without a Warrant)

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42
Q

Comparison between

Voluntary & Involuntary committment

A

Voluntary

Patient signs a CONTRACT with facility allowing 24 hour hold before AMA release

Involuntary

Allows State of TX to hold citizen, against pt will, until psychiatric care provider deems no longer meets criteria or 90 days, whichever comes first

(Patient may invoke habeas corpus) in an attempt to get released.

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43
Q

INVOLUNTARY ADMISSION steps

A

> 1) EMERGENCY DETENTION – using EITHER: a MIW (Mental ill warrent) OR an APOWW (apprehension by Police Officer without warrent)2) evaluation by 2 physicians to make sure legal criteria are met3) (2 possibilities) release persons who do not meet criteria OR retain person and ensure legal representation4) probable cause hearing – this results in the OPC5) (2 possibilities) patient does not contest, judge reviews documents and, if legal rules followed commit patient to 90 days. OR – patient contests the commitment and has choices – (with or without their own lawyer) present their own case before the judge alone OR ask for a jury trial.

IF patient has already served 90 days and STILL meets criteria – there is another trial to commit for a longer period.( EXTENDED MENTAL HEALTH SERVICES)

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44
Q

Criteria for involuntary committment of

Mental Illness

A

1. Danger to Self

2. Danger to Others

3. Danger of deterioration of condition*

*Must be serious enough to cause substantial harm or death

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45
Q

What landmark suit establishes the “Duty to Warn” in many states?

A

Tarasoff v. Regents of the University of California

Pt. admitted to Doc intended harm to an ex-girlfriend… – Doc told the authorities…

Pt still let go… - then killed the ex.

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46
Q

What is delirium

A

Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation

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47
Q

What is amnestic syndrome

A

Amnestic syndrome involves memory impairment without other cognitive problems.

Just lost ur memory

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48
Q

What health problems are seen in

Dementia

A

Lewy body disease,

frontal-temporal lobar degeneration,

and Huntington’s disease.

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49
Q

What is Agnosia

A

Agnosia refers to the loss of sensory ability to recognize objects.

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50
Q

What is Aphasia

A

Aphasia refers to the loss of language ability.

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51
Q

What is Apraxia

A

Apraxia refers to the loss of purposeful movement

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52
Q

What is hyperorality

A

Hyperorality refers to placing objects in the mouth

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53
Q

What is Confabulation

A

Confabulation refers to making up of stories or answers to questions by a person who does not remember.

It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss.

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54
Q

What are the stages of Alzheimer’s disease

A

1) Preclinical Alzheimer’s disease

2) Mild cognitive decline

3) Moderately severe cognitive decline

4) Severe cognitive decline

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55
Q

Mild cognitive decline in Alzheimer’s

A

Mild cognitive decline (early-stage) Alzheimer’s

can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words.

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56
Q

Moderately severe cognitive decline in Alzheimer’s

A

In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date.

Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced.

The individual has difficulty with clothing selection

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57
Q

Severe cognitive decline in Alzheimer’s

A

personality changes may take place, and the patient needs extensive help with daily activities.

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58
Q

What are some of the diagnostic findings for Alzheimer’s

A

apolipoprotein E (apoE) malfunction,

neurofibrillary tangles,

neuronal degeneration in the hippocampus,

and brain atrophy

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59
Q

Four Key Concepts in the definition of a

Crisis

A

1) A Crisis is an Acute Time-Limited Phenomenon…a crisis will be resolved w/i 4-6 weeks after exposure to the stressor
2) A Crisis Results from Exposure to a Stressful Situation or Event
3) The Crisis Creates Emotional Distress…person in crisis feels anxious, overwhelmed and out of control
4) Existing Coping Skills Fail to Fix the Problem or Alleviate the Person’s Distress

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60
Q

Types of Crises

A
  • Maturational Crisis…Occurs when a person arrives at a new and predictable stage of development where previously used coping strategies are no longer effective or appropriate
  • Situational Crisis…critical life event from an external source. can change self - concept & esteem. (divorce, death of a loved one…job loss)
  • Adventitious Crisis… uplanned accidental or deliberate event not part of every day life. (Ie natural disasters / wars / murder / child abuse). —
  • Psychological first aid and crisis intervention are critical for persons of all ages after any adventitious crisis*
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61
Q

The Evolution of a Crisis

A
  • Phase I Person is exposed to a crisis event which triggers anxiety (robbery) - Anxiety stimulates the use of problem-solving strategies and defense mechanisms to decrease distress
  • Phase II Previously used coping skills fail to alleviate the problem (overload) - coping strategies become increasingly maladaptive as emotional distress increases

Phase III - Every internal and external resource is mobilized to solve the problem and relieve distress - Automatic relief behaviors such as withdrawal and flight are mobilized

Phase IV - The individual’s condition deteriorates as tension mounts, and “desperate measures” may be considered to alleviate distress (Suicide?)

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62
Q

What is Crisis Intervention?

A

A short-term helping process focused on resolution of the immediate problem through the use of personal, social and environmental resources

Crisis Intervention can be considered

“Psychological First Aid”

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63
Q

General Principles of Crisis Intervention

A

Safety First - Determine Whether There is an Immediate Need for External Controls — All Clients in Crisis Should be Assessed for Suicidal and Homicidal Ideation (thoughts)

Stabilization is the Goal - Restoring equilibrium and returning the client to the pre-crisis level of functioning is the objective

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64
Q

Basic Model for Crisis Intervention

A

Establish trust and develop rapport…Explore the patient’s feelings

Explore the problem…Find out what happened

Summarize both facts and feelings…“You feel x because of y.”

Focus on one problem…What does the patient want to change? What has to change in order for client to regain stability?

Explore resources and alternatives…Identify coping skills and resources

Develop plan of action…Consider contracting with client

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65
Q

Terminating with the Client in Crisis

A

Review accomplishments and discuss ways in which adaptive coping skills can be used to deal with crises in the future

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66
Q

Critical Incident Stress Debriefing

(CISD)

A

A group approach designed to help people who have been exposed to a crisis situation

Recent research suggests that it may not be as effective as once believed and may be harmful to

some people

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67
Q

Assualt def.

A

an intentional threat designed to make the victim fearful: produces reasonable apprehension of harm.

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68
Q

What is the concept of Justice

A

fair distribution of care, which includes treatment with the least restrictive methods

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69
Q

What is the concept of Beneficence

A

. Beneficence means promoting the good of others

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70
Q

What is the concept of Fidelity

A

Fidelity is the observance of loyalty and commitment to the patient.

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71
Q

autonomy def.

A

Autonomy is the right to self-determination, that is, to make one’s own decisions.

(e.g. acknowledging the pts right to refuse medicine promotes autonomy)

72
Q

Tort

A

A tort is a civil wrong against a person that violates his or her rights.

ex. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus, false imprisonment is a possible charge.

73
Q

battery def.

A

Battery is an intentional tort in which one individual violates the rights of another through touching without consent.

74
Q

competency def.

A

is the capacity to understand the consequences of one’s decision’s

Pt.s are considered legally competent until they have been declared incompetent through a formal legal proceeding.

75
Q

confidentiality def.

A

confidentiality of care and treatment remains an important right to all patients.

discussion or consultation involving a patient should be conducted discreetly and only w/individuals who have a NEED TO KNOW

Can only be released by the pt.’s written consent

The duty to warn a person whose life has been threatened by a psychiatric patient overrides the patient’s right to confidentiality.

76
Q

duty to warn

A

1974

Tarasoff v. Regents of the University of California..was a case in which the Supreme Court of California held that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient.

It is the health care professional’s duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional.

77
Q

false imprisonment def.

A

False imprisonment involves holding a competent person against his or her will.

Actual force is not a requirement for false imprisonment.

The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat.

78
Q

involuntary admission def.

A

is admission to a facility w/o the patients consent.

generally necessary when a person is in need of psychiatrict treatment, presents a danger to self or others, or is unable to meet his / her own basic needs.

Pts. can be kept involuntarily for up to 90 days, w/interim court apprearances. After that a panel reviews their cases.

79
Q

least restrictive environment def.

A

writ of habeas corpus and the least restrictive alternative doctrine are two of the most important concepts applicable to civil commitment cases.

Least restrictive mandates that the least drastic means be taken to achieve a specific purpose

ex. if someone is being treated for depression only on an outpatient basis….then hospitalization would be too restrictive and unnecessarily disruptive.

80
Q

malpractice def.

A

malpractice is an act or omission to act that breaches the duty of due care and results in or is responsible for a persons injuries.

81
Q

negligence def.

A

is the failure to use ORDINARY care in any professional or personal situation when you had a duty to do so.

ex. duty to drive safely…if you don’t and cause an accident, you could be changed with negligence.

82
Q

What are the five elements required to prove negligence?

A

1) duty

2) breach of duty

3) cause in fact

4) proximate cause

5) there were actual damages.

83
Q

patient rights def.

A

Pt.s right have been modified over time, but the following are some of the basic patient rights: pg 101 - 106

  • Right to treatment
  • Right to refuse treatment
  • Right to informed consent
  • Rights regarding involuntary admission and advance psychiatric directives
  • Rights regarding restraint and seclusion
  • Right regarding Confidentiality
84
Q

privileged communication def.

A

is that information / communication obtained between a patient / provider.

85
Q

right to privacy def.

A

is legally protected by HIPAA (Health Insurance Protability and Accountability Act)

Release of information without patient authorization violates the patient’s right to privacy.

86
Q

right to refuse treatment def.

A

Pts. may w/hold consent or withdrew constent to take medication at any time.

Commintment to a hospital facility does not mean they are forced to take medications….they retain their right to refuse treatment.

THE ONLY circumstance where medication will be forced is an emergency to prevent harm to self or others.

87
Q

right to treatment def.

A

Federal Statute 1964 - Hospitalization of the Mentally ill

All public hospitals are required to provide medical and psychiatric care to all persons admitted to a public facility.

O’Conner v. Donaldson (1975)

Court ruling that State cannot confine a non-dangerous individual who is able to survive in freedom by themself or w/help of family.

88
Q

restraint def.

A

a restraint can be any device, equipment or material that prevents or reduces movement of the pt.s arms/legs or head.

restraints can also be chemical or even one individual holding another (Therapeutic hold).

89
Q

Pervasive def.

A
90
Q

Conduct Disorder def.

A

Persistant pattern of behavior in which the rights of others are violated

Age appropriate societal norms/rules are disregarded

91
Q

Resilience def.

A

The ability to adapt & cope

Helps people to face tragedies, loss, trauma, & severe stress

92
Q

Temperament def.

A

The style of behavior a child habitually uses to cope w/ the demands & expectations of the environment

93
Q

Etiological risk factors for child/adolscent mental illness

A

Biological factors: Genetic & Neurobiological

  • Resilience, intelligence & supportive environment aid in avoiding development of mental disorders

Psychological factors: Temperament; fit w/ parents is crucial to development. Resilience

Environmental factors: Dependent on family; witness violence; neglect / sexual abuse; bullying

Cultural factors: Expectations; stigma follows throughout lifespan

94
Q

Risk factors that presents the highest chance for a child to develop a psychiatric disorder

A

Having a parent with a substance abuse problem has been designated an adverse psychosocial condition that increases the risk of a child developing a psychiatric condition.

Having a family history of schizophrenia presents a risk, but an alcoholic parent in the family offers a greater risk.

95
Q

Factors that increase resilience in children/adolscents

A

Child’s inborn strengths

Child’s success in handling stress in the environment

96
Q

Characteristics of a mentally

healthy child/adolscent

A
  • Trusts others & sees his/her world as being safe & supportive
  • Correctly interprets reality; makes accurate perceptions of the environment & one’s ability to influence thru actions (i.e. self-determination)
  • Behaves in developmentally appropriate way; doesn’t violate social norms
  • Has a positive, realistic self-concept & developing identity
  • Adapts to & copes w/ anxiety & stress using age appropriate behavior
  • Can learn/master developmental tasks & new situations
  • Expresses self spontaneously & creatively
  • Develops & maintains satisfying relationships
97
Q

Behavioral characteristics of children with

Pervasive Developmental Disorder

(Autism, Aspergers, PDD NOS)

A

Autism is primarily biogenetic

98
Q

Behavioral characteristics of children with

Tourette’s Disorder

A

A motor (neurodevelopment) disorder

Motor & verbal tics appearing between age 2 & 7

Tics change in location, frequency & severity over time

Tics cause marked distress, significant impairment in social & occupational functioning, & low self-esteem

Disorder is permanent; periods of remission may occur

Symptoms often diminish in adolescence & may disappear by early adulthood

Familial pattern in 90% of cases

Often co-exists w/ depression, OCD, & ADHD

Treated w/ antipyschotic meds: Hadol & Orap

99
Q

Behavioral characteristics of children with

Attention Deficit / Hyperactivity Disorder

A

Inattention

Impulsive

Hyperactive

Symptoms present before age 7

Symptoms must be present at home & school

Low frustration tolerance, temper outbursts

Poor school performance

Primarily biogenetic

100
Q

Nursing interventions for child

w/ADHD

A

“reduce loneliness and increase self-esteem.”

Because of their disruptive behaviors, children with ADHD often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness.

101
Q

Behavioral characteristics of children with

Separation Anxiety Disorder

A

Developmentally inappropriate levels of concern over being away from a significant other

May also be a fear that something horrible will happen to the other person resulting in permanent separation

Anxiety is so intense it distracts the pt from their norm activities, causes sleep disturbances & nightmares, is often manifested in GI disturbance & headaches

102
Q

Behavioral characteristics of children with

Conduct Disorder

A

Disruptive/impulsive control behavior disorder thought to be caused by parenting

Cruel bahvior to animals 1st then people

Violates rights & disregards norms (truancy before age 13, alcohol &/or heavy drug abuse, running away)

Aggressive & destructive (vandalism)

Deceitfulness

Pyromania and/or Kleptomania

Poor peer relationships; may be precursor to antisocial personality disorder

Meds for aggression, impulsivity & mood: Risperdal, Zyprexa, Seroquel, Geodon, & Abilify

103
Q

Behavioral characteristics of children with

Oppositional Defiant Disorder (ODD)

A

Disruptive behavior disorder thought to be caused by parenting

Angry & irritable; temper tantrums past usual age

Defiant & vindictive

Disregard for authority

Deliberately annoys & blames

Distructive (usually short of criminal)

Difficulty w/ home, school, peers

Not age limited but usually seen in preteens

Meds. not generally indicated but must treat comorbidity

104
Q

Disruptive Mood Dysregulation disorder

A

Frequent temper tantrums (verbal / behavioral outbursts) out of proportion to the situation & not developmentally age appropriate

Persistent irritable mood btwn outbursts

Dx given to children btwn ages 6 - 18 w/ no other medical/mental health dxs accounting for tempertantrums (i.e. autism)

105
Q

Disruptive mood management

A

Time-out

Quiet Room

106
Q

Behavioral characteristics of children with

Mood Disorders

(depression & bipolar disorder)

A

Core symptoms of depression in children/adolscents are same as for adults: sadness & anhedonia

Frequently assoc w/ anxiety & anger

Symptoms display differently in children/adolscents.

  • very young children cry
  • school age children are withdrawn
  • teens become irritable in response to feeling sad / hopeless

Generally, depressed children/adolscents display increased irritability, negativity, isolation, & w/drawl along w/ loss of energy.

Younger children may suddenly refuse to go to school.

Adolscents may engage in substance abuse or sexual promiscuity & become preoccupied w/ death or suicide.

Bipolar is more severe if starts in childhood/teens.

Youth w/ bipolar have more frequent mood switches, more mixed emotions, are sick more often, & have greater suicide attempts.

107
Q

General interventions for children/adolscents

A

Family therapy

  • specifical goals defined for ea family member

Group therapy - used for breavement, physical abuse, substance use, dating, or chronic illness (diabetes)

  • young child: play therapy
  • school-aged child: combines play, learning skills, & talking about activity; aids w/ social skills
  • adolscent: popular media event/personality used as basis for discussion

Behavioral therapy

  • behavior modification
  • rewards desired behaviors to reduce maladaptive behaviors
  • use least restrictive intervention

Cognitive-Behavioral therapy (CBT)

  • negative/self-defeating thoughts are replaced by more realistic & accurate appraisals
  • results in improved functioning
108
Q

Nursing interventions to alter behavior in

children/adolscents with mental illness

A

Physical problems have higher priority than mind/behavior problems

Parent training (positive parenting)

Behavioral therapies

Milieu therapy

Psychopharmacology

109
Q

What are the characterisitc’s of a time out

A

Time-out is designed so that staff can be consistent in their interventions.

Time-out may require going to a designated room or sitting on the periphery of an activity until the child gains self-control

110
Q

Teaching for parents of

children/adolscents with

mental illness

A

Predict & prevent

Act EARLY to stop escalation

Provide safety

Causes & prevention of non-genetic types of disorders

Parental expectations of behaviors

Behavioral control of socially unacceptable behaviors

111
Q

Psychoactive medications for

children/adolscents

A

Stimulants excite neurons responsible for focus

112
Q

Mental Health Assessment differences

for children vs. adults

A

Who is interviewed?

How is interview conducted?

Data collected:

113
Q

Psychosocial risk factors that

predispose children/adolscents

to Conduct Disorder

A

ADHD

Oppositional child behaviors

Parental rejection

Inconsistent parenting w/ harsh discipline

Early institutional living

Chaotic home life

Large family size

Absent or alcoholic father

Antisocial & drug-dependent family members

Association w/ delinquent peers

114
Q

Prevention strategies for

Conduct Disorder

A
115
Q

Parent teaching for managing

child’s behavior at home

A
  • Behavior modification - use it RIGHT or NOT AT ALL
  • Rewards occur ALL THE TIME but to effect change you MUST PLAN
  • Punishment is not allowed
  • Extinction - ignoring / not reacting to behavior will prevent the “reward”

*RNs don’t have time or relationship to use extinction

116
Q

Milieu characteristics for

children/adolscents with

ADHD and/or Disruptive Behavior Disorders

A

manage the milieu with structure and limit setting

117
Q

Medication class most commonly

prescribed for ADHD

& med side effects

A

Stimulants

Methyphenidate (Ritalin)

s/e…The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia

Weight loss has the potential to interfere with the child’s growth and development.

118
Q

What are some of the approaches valued by other cultures but not America?

A

Present orientation, interdependence, and a flexible perception of time are not valued in Western culture

These views are more predominant in other cultures

119
Q

What is a highly valued approach in Western Cultures, but not other cultures.

A

Directly confronting problems is a highly valued approach in the American culture but not part of many other cultures in which harmony and restraint are valued

American nurses sometimes mistakenly think that all patients should take direct action.

120
Q

What is Culutral competence?

A

Cultural competence is dependent on understanding the beliefs and values of members of a different culture.

A nurse who works with an individual or group of a culture different from his or her own must be open to learning about the culture.

121
Q

To provide culturally competent care,

A

identify strategies that fit within the cultural context of the patient

122
Q

What is valued in Hispanic Cultures

A

Hispanic individuals usually value relationship behaviors.

Their needs are for learning through verbal communication rather than reading and for having time to chat before approaching the task.

Many people from Central American cultures express distress in somatic terms

123
Q

How do Asian Americans express psychological distress

A

Asian Americans commonly express psychological distress as a physical problem.

The patient may believe psychological problems are caused by a physical imbalance.

The patient will probably respond best to a therapist who is perceived as giving.

124
Q

Communication techniques effective for Native American pt.s

A

Soft voice; break eye contact occasionally; general leads and reflective techniques.

Native American culture stresses living in harmony with nature. Cooperative, sharing styles rather than competitive or intrusive approaches are preferred;

thus, the more passive style described would be best received.

125
Q

W/an Asian pt. with mental illness, what type of intervention best fits this culture?

A

The Asian community values the family in caring for each other.

The Asian community uses traditional medicines and healers, including herbs for mental symptoms.

The Asian community describes illness in somatic terms.

The Asian community attaches a stigma to mental illness, so interfacing with the community would not be appealing

126
Q

What is the Western, biomedical prespective on health and illness?

A

The Western biomedical perspective holds the belief that sick people should be as independent and self-reliant as possible.

Self-care is encouraged; one gets better by “getting up and getting going.”

An ability to function at a high level is valued.

127
Q

What is a Culture-bound syndrome

A

Culture-bound syndromes occur in specific sociocultural contexts and are easily recognized by people in those cultures.

A syndrome recognized in parts of Southeast Asia is running amok, in which a person (usually a male) runs around engaging in furious, almost indiscriminate violent behavior.

128
Q

What is Wind Illness?

A

Wind illness is a culture-bound syndrome found in the Chinese and Vietnamese population.

It is characterized by a fear of cold, wind, or drafts. It is treated by keeping very warm and avoiding foods, drinks, and herbs that are cold.

Warm broth would be most in sync with the patient’s culture and provide the most comfort.

129
Q

Amoung different Cultures – are there difference in metabolic pharmacokinetics of pshychotrophic drugs?

A

YES

Cytochrome enzyme systems,

which vary among different cultural groups, influence the rate of metabolism of psychoactive drugs

130
Q

Know the following Culture-Bound Syndromes & the pts. heritage

A

Culture-Bound Syndromeheritage

  • Ataque de nervios Latin American
  • Ghost Sickness Navajo
  • Hwa-byung Korean
  • Susto Latin American
  • Wind Illness Chinese
131
Q

What is the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

A

The DSM-5 classifies disorders people have rather than people themselves

132
Q

“What is the most prevalent mental disorder in the United States?”

A

The 12-month prevalence for Alzheimer’s disease is 10% for persons older than 65 and 50% for persons older than 85.

133
Q

What is Clinical epidemiology?

A

A broad field that addresses studies of the natural history (or what happens if there is no treatment & the problem is left to run its course) of an illness, studies of diagnostic screening tests, & observational/experimental studies of interventions used to treat people w/ the illness or symptoms.

134
Q

What does Prevalence refer to?

A

The number of new cases

135
Q

What does Incidence refer to?

A

The number of new cases of mental disorders in a healthy population within a given period.

136
Q

What areas of care are promoted by QSEN

A

The key areas of care promoted by QSEN are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

137
Q

Body image in eating disorders

A

Perception is never reality

A distorted body image is DELUSIONAL

& will not chg w/ reasoning

(no nursing interventions will work)

138
Q

Eating disorder facts

A
  • Complex medical/psychiatric illness
  • Disease of control (pt can control eating)
  • Anorexia is 3rd most common chronic illness
  • Genetic, biological, behavioral, social, & psychological factors
  • Develop over time
  • Occurs across all socioeconomic & age groups
  • Bulimia is life-threatening; highest mortality rate of all mental illnesses
  • Causes are multifactoral
  • Global issue
139
Q

Anorexia Nervosa characteristics

A

Restricted calories w/ significantly low BMI

Low body wt (<85%)

Intense fear of gaining wt

Distorted body image

Extreme focus on shape / wt

Amenorrhea

Denial of illness (secretive)

140
Q

Types of Anorexia Nervosa

A

2 types:

  • Restricting - no consistent bulimic features
  • Binge-Eating - primarily restriction, some bulimic behaviors
141
Q

Anorexic issues

A
  • How can I appear perfect?
  • What is this feeling?
  • When I eat, I feel sick.
  • No energy
  • No sleep (not just insomnia)
  • No peristalsis
  • No appetite (not the same as hunger)
  • No control
  • No future
  • I HATE being me
  • Nobody can love ME the way I am
142
Q

Thoughts & behaviors assoc.

w/ Anorexia Nervosa

A
  • Terror of gaining wt; repeated re-weighting of self
  • Preoccupation w/ thoughts of food
  • View of self as fat even when emaciated
  • Peculiar handling of food; cutting into mini bites
  • Food portioning (eats sm amts of certain foods)
  • Pushing pieces of food around plate
  • Poss. development of rigorous exercise regimen / hyperactivity
  • Poss. self-induced vomiting, misuse of laxatives/diuretics
  • Cognition so distrubed that pt judges self-worth by his/her wt
143
Q

Personality traits of pt

w/ Anorexia Nervosa

A

Perfectionism

Obsessive thoughts & actions r/t food

Intense feelings of shame

People pleasing

Need to have complete control over their therapy

144
Q

Anorexia Nervosa assessment

A

Eating habits

History of dieting

Methods used to achieve wt control (restricting, purgeing, exercising)

Value attached to a specific shape & wt

Interpersonal & social functioning

Mental status & physiological parameters

145
Q

Physical presentation of

Anorexia Nervosa

A
  • Low body wt r/t caloric restriction / excessive exercise
  • Amenorrhea d/t low wt
  • Lanugo & thin, brittle hair d/t starvation
  • Cold extremities/cold intolerance/hypothermia d/t starvation
  • Peripheral edema d/t hypoalbuminemia & refeeding
  • Muscle weakening/letheragy d/t starvation & electrolyte imbalance
  • Constipation d/t starvation
  • Cardio abnormalities (hypotension, bradycardia, HF) d/t starvation & dehydration
  • Impaired renal function , low urine output, increased urine concentration d/t dehydration
  • Hypokalemia d/t starvation
  • Decreased bone density
  • Dry skin d/t dehydration
146
Q

Psychological presentation of

Anorexia Nervosa

A
  • Disturbed body image
    • excessive self-monitoring
    • describes self as fat despite emaciation
  • Ineffective coping
    • destructive behavior toward self
    • poor concentration
    • inability to meet role expectations
    • inadequate problem solving
  • Chronic low self-esteem
    • rejects positive feedback about self
    • reports feelings of shame
    • lack of eye contact
    • passive
    • indecisive behavior
  • Powerlessness
147
Q

Anorexia complications

A

Hormonal chgs

Cardiac issues (leaky heart valves, orthostatic pulse & BP chgs, prolonged QT, ST-T wave abnormalities) & arrhythmias

Edema (ankle & periorbital)

Electrolyte imbalances (lead to fatigue, weakness, letheragy)

Infertility

Bone density loss (osteoporosis)

Anemia

Neuro problems (peripheral neuropathy)

Death

148
Q

What is Refeeding?

A

Refeeding resulting in too-rapid weight gain & can overwhelm the heart, resulting in cardiovascular collapse.

Deadly complication of treatment involving metabolic alteration in serum electrolytes, vitamin defciencies, & sodium retention.

Focused assessment is a necessity to ensure the patient’s physiological integrity.

149
Q

Bulimia Nervosa characteristics

A

Cycle of bingeing/purging (1x per wk x 3 mo)

Feeling out of control

Compensatory behaviors (self-induced vomiting, excessive exercising, fasting, laxative/diuretic misuse)

Usually normal body wt

Self-image largely influenced by body image

150
Q

Types of Bulimia Nervosa

A

2 types:

  • Purging - self induced vomiting or laxative/diuretic misuse
  • Non-Purging - excessive exercising or fasting
151
Q

Bulimic issues

A
  • How can I appear perfect?
  • What is this feeling?
  • I eat to fill the void.
    • lack of emotion / emotional pain drives binge
  • I rid myself of food to get rid of the tension.
  • I HATE being this way. MAKE it STOP.
  • Nobody can love ME the way I am.
152
Q

Thoughts & behaviors assoc.

w/ Bulimia Nervosa

A
  • Binge eating behavior
  • Often self-induced vomiting (or laxative/diuretic use) after bingeing
  • Hx of anorexia nervosa in 1/4 - 1/3 of pts
  • Depressive signs & symptoms
  • Problems w/:
    • interpersonal relationships
    • self-concept
    • impulsive behaviors
  • Increase levels of anxiety & compulsivity
  • Poss. chemical dependency
  • Poss. impulsive stealing
  • Family relationships usually chaotic & lack nurturing
  • Life reflects instability & troublesome interpersonal relationships
153
Q

Bulimia Nervosa assessment

A

Are you satisfied w/ your eating habits?

Do you ever eat in secret?

154
Q

Physical presentation of

Bulimia Nervosa

A
  • Normal to slightly low wt r/t excessive caloric intake w/ purgeing or excessive exercise
  • Dental caries & tooth erosion r/t vomiting
  • Puffy cheeks / parotid swelling (enlarged salivary glands) d/t increased serum amylase levels
  • Gastric dilation / rupture r/t binge eating
  • Callused, ulcered, or scarred knuckles r/t vomiting
  • Swollen hands / feet (peripheral edema) d/t rebound fluid (seen w/ diuretic use)
  • Weakness & fatigue d/t electrolyte imbalances
  • Menstrual irregularities
  • Abdmonial pain
  • Sore throat
155
Q

Psychological presentation

of Bulimia Nervosa

A
  • Disturbed body image
    • obsession w/ body
    • denial of problems
    • dissatisfaction w/ appearance
  • Ineffective coping
    • obsessed w/ food
    • substance abuse
    • impulsive responses to problems
    • misuse of laxatives/diuretics/enemas
    • fasting
    • inadequate problem solving
  • Chronic low self-esteem
    • feelings of shame / guilt
    • views self as unable to deal w/ events
    • excessive seeking of reassurance
  • Powerlessness
    • loss of control w/ binge/purge cycle
  • Social isolation
    • absence of supportive significant other(s)
    • hides eating behaviors from others
    • reports feelign alone
156
Q

Bulimia complications

A

Tooth erosion, cavities, gum disease

Water retention / abd bloating

Low serum potassium

Irregular menstrual cycles

Swallowing problems & esophagus damage (perforation)

Salivary gland hypertrophy

Petechiae

Hematemesis

157
Q

Priority interventions for Bulimia Nervosa

A
  • Change dysfunctional eating behavoirs
  • Prevent use of dysfunctional compensation
    • monitor bathroom use after meals
    • ensure pt doesn’t purge or exercise w/o staff knowledge
  • Maintain physical integrity
  • Boost self-esteem
158
Q

What is the priority information that a nurse should provide for a pt. w/ binge-purge bulimia

A

How to recognize hypokalemia

Hypokalemia results from potassium loss associated w/ vomiting. Physiological integrity can be maintained if the pt can self-diagnose potassium deficiency & adjust the diet or seek medical assistance.

Self-monitoring of daily food & fluid intake is not useful if the pt purges.

159
Q

Binge Eating Disorder

(BED)

A

Recurring episodes (>/= 1x wk x 3 mo)

Feeling of shame, guilt, embarrassment & disgust

NO use of compensatory behavoirs

Common SE is obesity

160
Q

Psychological presentation

w/ BED

A
  • Disturbed body image
    • embarassment d/t wt gain
    • fear of negative rxn by others
    • attempts to hide wt gain
    • body dissatisfaction
  • Ineffective coping
    • eats as coping method
    • absence of other/more effective coping methods
    • eats when full
  • Anxiety
    • feelings of discomfort/dread
    • feelings of inadequacy
    • focused on self
    • increased wariness
    • irritability
  • Chronic low self-esteem
    • feelings of shame/guilt
    • views self as unable to deal w/ events
  • Powerlessness
    • loss of control of eating
  • Social isolation
    • absence of supportive significant other(s)
    • eats normally in presence of others
    • hides eating behaviors
    • reports feeling alone
161
Q

Avoidant/Restrictive Food Intake Disorder

(ARFID)

A

Individual restricts food intake & experiences significant associated physological / psychosocial problems but doesn’t met criteria for any other eating disorder.

  • difficulty digesting certain foods
  • avoids certain colors / textures of foods
  • eats only very small portions / no appetite
  • afraid to eat after freightening episode of choking / vomiting

Significantly low BMI; dependent on enteral feeding or experiencing nutritional deficiencies

No distortion of body image

Symptoms show up in infancy / childhood

162
Q

PICA

A

Ingestion of non-nutritive substances past toddlerhood

Varies w/ age & availability

Occurs in pregnancy, children, iron deficient adults, & institutionalized persons

Not culturally sanctioned

Not part of any other mental illness

Psych comorbidities: IDD, Austism, OCD, Schizophrenia, Trichotillomania (if hair ingested)

163
Q

Rumination Disorder

A

Repeated regurgitation of food

Regurgitate, re-chew, spit out or re-swallow

No GI or medical reason

Behavior is volitional (done willingly)

Occurs in secret

Not part of other mental illness/eating disorder

Psych comorbidities: IDD & generalized anxiety disorder

164
Q

Assessment in eating disorders

Daily physical assessments needed

A

Height, weight (blind wts), & muscle mass

Electrolytes

Cardiac function

Bradycardia, orthostatic hypotension

Amenorrhea

Mood changes

Use of enemas, laxatives, diuretics, diet pills

Dental caries, sore throat, calloused fingers

Cold intolerance

Hair loss

I & O

165
Q

Psychiatric comorbidity

of eating disorders

(co-existing psych & physical disorders)

A

Depression

Anxiety (r/t food)

OCD

Substance abuse

Personality disorders

Bipolar

Obesity

166
Q

Treatment goals for eating disorders

A

Refeed

Stabilize wt

Resolve cognitive distortions

Normalize eating

Treat comorbidities

Improve family relationships

Understand importance of balanced nutrition

Develop age-appropriate identity

167
Q

Treatment Team

A

Psychiatrist

Psychologist

RN

Dietician

Social Worker (family therapist)

Milieu therapist (PCT)

Art / Music / Recreational therapists

168
Q

Treatment of eating disorders

A
  • Restore pt to healthy wt
    • wt gain of 0.2 kg/day (slow & steady)
    • food intake must be increased slowly to prevent stressing heart
  • Treat psych issues r/t eating disorder
  • Reduce / eliminate behaviors or thoughts that lead to disordered eating; prevent relapse
    • Control issues: do NOT agrue over wt; emphasize HEALTH not wt.; avoid coerision
  • Behavior modification can help decrease manipulative behavior (CBT)
169
Q

Interventions for eating disorders

A

Medications:

  • Prozac (fluoxetine) or Zoloft (sertraline)
  • Zyprexa (olanzapine) - antipsychotic helps w/ distored thoughts

Psychotherapy (group & individual)

Behavior modification

  • promote behaviors that contribute to wt gain
  • limit wt-loss behaviors

Monitoring

  • physiological parameters (vitals, electrolytes)
  • wt routinely
  • daily caloric intake & fluid I&Os
  • restrict food to scheduled, pre-served meals/snacks
  • observe during & after meals/snacks
  • accompany to bathroom designated observation times; limit time spent in bathroom if not observed
  • limit physical activity

Support

  • use behavioral contracting w/ pt to elicit desired wt gain
  • reinforce wt gain & behaviors that promote it
  • assist pt to develop self-esteem compatible w/ healthy body wt

Promote increased independence

  • allow opportunity to make choices about eating & exercise as wt gain progresses

Remove anger / anxiety from eating situation (keep conversations light)

Well-balanced meals & adaquate calories (meal plans)

Be a role model

170
Q

Priority milieu interventions

A
  • Support restorative wt gain & normalization of eating patterns
  • Close supervision of pt’s eating
  • Prevention of exercise & purging
  • Strict adherence to menus
  • Observe pt during/after meals to prevent throwing away food or purging
  • Monitor all trips to the bathroom
  • Structured mealtimes (not flexible)
  • Regularly scheduled weighing
  • Privileges correlated w/ wt gain & trmt plan compliance
171
Q

Medication issues

with eating disorders

A
  • TCAs & SSRI - prevent relapse in Bulimia
  • Zyprexa - used to control anxiety; tends to cause wt gain
  • Antianxiolytic agents are contraindicated
  • Wellbutrin contraindicated in Bulimics
  • MAOIs are not indicated
  • Beta Blockers are contraindicated
172
Q

Psychiatric criteria for hospitalization

with eating disorders

A
  • Suicidal ideation or severely out of control, self-mutilating behaviors
  • Out of control use of laxatives, emetics, diuretics, or street drugs
  • Failure to comply w/ trmt contract
  • Severe depression
  • Acute psychosis
  • Family crisis or dysfunction

*pt must be physiologically stable to come to psych unit

173
Q

Physical criteria for hospitalization

with eating disorders

A
  • Wt loss > 30% over 6 mo. (severe malnutrition < 75% of normal body wt)
  • Rapid decline in wt
  • Inability to gain wt w/ outpt trmt
  • Physiologic instability
    • Severe hypothermia d/t loss of sub-Q tissue or dehydration (body temp < 36oC or 96.8oF)
    • Bradycardia (HR<40)
    • Hypotension (systolic < 70)
  • Electrolyte imbalances not corrected by oral supplmentation
    • hypokalemia
    • hyponatremia
    • hypophosphatemia
  • Cardiac dysrhythmias
174
Q

What is Acculturation

A

is learning the beliefs, values, and practices of a new cultural setting, which sometimes takes several generations

175
Q

What is enculturation

A

is a process where members of a group are introduced to the culture’s worldview, beliefs, values, and practices

Spring 2016 Semester (7 decks)

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