theory exam 1 Flashcards
actual (problem that is present) or potential (at risk for)
o Actual: powerlessness, social anxiety
o Potential: suicidal, self harm
• Explanation of the diagnostic and statistical manual (DSM-5)
• Use of the DSM-5 in the mental health delivery system
nursing diagnosis in the nursing process
o Patient notices how you at and reminds them of something from their past
transference in therapeutic relationship
- Nurse is reminded of something by the patient
* Seek clinical supervision to maintain objectivity
counter transference in therapeutic relationship
- initial
- working
- termination
phases of therapeutic relationships
maybe we can compromise
• Rational part of our personality
Ego
Psychoanalytic Theory of Freud
Theories of personal development
want to do that now
• Concerned with instant gratification of basic physical needs/urges
• Unconsciously
• Take ice cream from stranger for itself – doesn’t care that it’s rude
Id
Psychoanalytic Theory of Freud
Theories of personal development
it’s not right to do that
• Concerned with rules and morals
• Like our conscious
Superego
Psychoanalytic Theory of Freud
Theories of personal development
– Trust vs Mistrust – find hope – infancy (0-1 ½ )
– Autonomy vs Shame – find will – early childhood (1 ½ - 3)
– Initiative vs Guilt – find purpose – play age (3-5)
– Industry vs Inferiority – find competency – school age (5-12)
– Ego identify vs Role confusion – find fidelity – adolescence (12-18)
– Intimacy vs. Isolation – fine love – young adult (18-40)
– Generativity vs Stagnation – find care – adult (40-65)
– Ego integrity vs Despair – find wisdom – maturity (65+)
eriksons psychosocial stages
a. Tension with day to day stressors/events
b. Sharpens your senses
mild anxiety
anxiety levels of Peplau
a. Attention span and concentration decrease. Increase in muscle tension/restlessness
moderate anxiety
anxiety levels of Peplau
a. Perception is diminished. Get headaches, palpitations
severe anxiety
anxiety levels of Peplau
panic attack
panic anxiety
anxiety levels of Peplau
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
5 stages of grief of Kubler-Ross
- Suppression – purposely try to block it out
- Repression – involuntary blocking it out
- Rationalization – make your own reason to justify your doings
- reaction formation – you’re afraid but put yourself out there to do that thing
- Regression – going backwards
- Denial – refuse to acknowledge the real situation
- Displacement – putting feelings onto someone else
- Undoing – purposefully doing opposite of action to cancel it out
- Projection – pass blame on someone else
- Sublimation – rechanneling impulses that aren’t acceptable into activities that are tolerable
- Intellectualization – attempt to avoid expressing emotions associated with a stressful situation
- Identification – try to identify with someone you admire
function of defense mechanisms/coping mechanisms for stress
elevated or expansive irritable mood where motor activity comes frenzy and excessive
a. Abnormal elevated mood for one week, large increase in activity/energy, decrease need for sleep (3 hours or less), overly talkative, fight of ideas, money sprees, hypersexual activity, thought process is extreme goal driven
mania
5 levels of bipolar disorder
last 4 days and not as extreme as mania
a. Increase in activity, decrease need for sleep, etc
hypomania
5 levels of bipolar disorder
fluctuations in your everyday mood – baseline mood
eurthymia
5 levels of bipolar disorder
neurosis where you go though a loss of contact of reality
a. Depressed mood, weight loss, insomnia, poor appetite, low energy
dysthymia/depression
5 levels of bipolar disorder
depression neurosis that impairs social ability
a. See suicidal thoughts/attempts, no self esteem, hopelessness, helplessness and worthlessness
major depression
5 levels of bipolar disorder
- Clinical course with 1 or more manic episodes—manic episode or history of manic episode required to make Bipolar I Disorder diagnosis
- Manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes
- “Mixed episodes”—include both manic and major depression symptoms
bipolar 1 disorder
- Characterized by a clinical course of recurring mood episodes consisting of one or more major depressive episode
- The major depressive episode must last at least 2 weeks, and the hypomanic episode must last at least 4 days to meet the diagnostic criteria
bipolar 2 disorder
• Characterized by 1 or more major depressive episodes without history of manic, mixed or hypomanic episodes
• Severe depression symptoms present during same 2-week period and represent a change from previous level of functioning
o Depressed mood, weight loss, fatigue, suicidal thoughts/attempts
• Depressed mood and/or loss of interest or pleasure in addition to other symptoms of severe depression
Major depression disorder
• Protect individuals in manic phase of illness from their ambitious buying, entertaining, business schemes
• Protect from risk for injury due to poor judgment and hyperactivity
o Decrease risk for injury by reducing stimuli
• Attend to nutritional, hydration, and sleep deficit needs
• Set necessary behavioral limits
• Monitor response to medications
nursing interventions for manic S/S
- Assume that individuals who have major depression are potentially suicidal
- Assess suicide potential and intervene
- Ask directly regarding suicidal thoughts/plans
- Place on suicide precautions with 10-15 minute checks or constant 1:1 observation
- Maintain environmental safety and vigilance
- Provide supportive measures if vegetative signs of depression are present
nursing interventions for depression
- ECT is believed to increase levels of norepinephrine and serotonin, resulting in decrease in depression
- Treatment modality for depressed individuals, especially if acutely suicidal or not responding to antidepressant medications
- Memory loss and temporary confusion post ECT
- Medications used prior to and during ECT
- Contraindications
- Nursing care pre-ECT and post-ECT
electroconvulsive therapy
- Procedure used to treat depression by targeting certain cells in the brain
- Involves use of short pulses of magnetic energy to stimulate nerve cells in the brain, similar to the electrical activity observed with ECT
- Unlike ECT, the electrical waves generated by TMS do not result in generalized seizure activity
transcranial magnetic stimulation
history of suicide/experiencing violence/abuse, lack of support system, risky behaviors, bullied, stigma to getting help, talks about dying, change in personality/sleeping/eating, feelings of loss of contro
warning signs of suicide in children
- Instill sense of hope in the future while acknowledging the individual’s current pain and despair
- Values and attitudes of nurse influence assessment and interventions
- Provide safe, secure environment
- Institute suicide precautions per policy
- Establish therapeutic relationship with patient
- Verbalize care and concern for patient
- Promote problem-solving and decision-making
- Goal: person will talk about but not act upon suicidal feelings/plans
- Hospitalize if person is at significant risk to attempt suicide
intervention strategies for suicidal individual
- Individual treatment needs: Provides each patient with sufficient space/privacy, allow communal dining/activities (alone time/group time)
- Self governance/community meetings: Encourage group, but don’t force them come
- Progressive levels of responsibility: Accountable for missing group/participating – promotes achievement but know regression may occur
- Variety of meaningful activities: Groups go along with what there is more of like depression, abuse
- Links with patient’s family
- Links with the community: Involving treatment with family, helps complete therapy and discharge process
- Effective working relationships among staff
- Humanistic staff: See better outcomes/positive attitude if working together
8 elements of therapeutic milieu
• Organization of patients therapeutic external environment can cary as patient demonstrates that he/she is more able to make decisions, behave responsibily and tolerate stress
how mileu is manages
- Nurse creates, manages, maintains, and coordinates the milieu 24/7
- Includes traditional structured nursing responsibilities
- Includes unstructured aspect, referred to as the therapeutic use of self
role of nurse in therapeutic milieu
- Using interpersonal relationships to help patients learn to trust, to acquire self confidence and self esteem, and to progress from dependence to independence
- Using all milieu activities to help patients learn interpersonal skills
- Identifying illness-maintaining patterns of interaction and avoid reaffirming them
- Encouraging patients to try out health-promoting behaviors
- Affirming and strengthening patient’s adaptive or successful interactions
- Communicating what is expected of patient and what is permitted
- Informing patient about what is happening, what is going to happen, and why
therapeutic use of self
- Helps individual gain empowerment and allow them to control their care decisions
- STEPS ON PAGE 323-325
recovery model
o Helps patient develop a tool box (tools, strategy, coping skills to manage S/S: journal, music, exercise),
o daily maintenance (what needs to be done to reach level),
o triggers
o early warning signs
o things are breaking down/getting worse (identify that situation has worsen and they need to seek health – have headaches, hallucinations, bizarre behaviors),
o crisis planning (caregiver steps in to help because they are no longer able to)
o Step process where a person is able to monitor/manage distressing symptoms in daily life
o Steps on pages 323
wellness recovery action plan (WRAP)
o Focus on persons self determination in recovery
psychological recovery model
- Hope
- Empowerment – focus on strengths and the things you can do
- Self responsibility
- Connection
- Meaningful life
5 components of recovery
- How one thinks determine how one feels/behaves
- Goals: series of 5 steps – find evidence to support thoughts, substituted realistic behaviors for biased and help learn to identify/alter dysfunctional beliefs
cognitive therapy :aaron beck
• Arbitrary Inference – patient comes to conclusions without evidence/facts to support it
o Sent wedding gift and didn’t receive thank you so assumed they didn’t like the gift
• Overgeneralization – sweeping conclusions – all or nothing
o Man submitted article and didn’t get accepted – believes no journal will accept his work
• Dichotomous Thinking – views situations in black in white, all/nothing, good/bad
o Man writes article, editor asked him to rewrite parts of it, man thinks he’s a bad write
Automatic thoughts
• Selective Abstraction – conclusion based on selected portion of evidence – usually negative
o Perfectionists – student has 3.98 GPA, gets accepted to everything, but is mad she didn’t receive a 4.0
• Magnification – exaggerating negative significance of events
o Woman overhears friend is having a party, she wasn’t invited, assumes she doesn’t like her
• Minimization – undervaluing positive significance of event
o Grandma calls daughter, says she’s sorry she cant but will call her, grandma feels unloved even though she’s calling her but cannot attend
automatic thoughts
• Catastrophic Thinking – always thinking the worst ill occur without thinking of possibility of a positive outcome
o 1st day of job, asked to write a letter, came back with an error, she thinks she will be fired
• Personalization – person takes complete responsibility for everything without think of contributing factors
o Man is selling product and talked with her for 2 hours and she said no, so he thinks he’s a awful salesman’s even though she really doesn’t have the money
automatic thoughts
- Didactic/educational aspect – therapists giving educations/informational/homework
- Purpose: to help patient become their own therapists – gain knowledge through assignments
- Cognitive techniques – recognizing/modifying cognitive errors (automatic thoughts) and core beliefs (schemas)
- Behavioral intervention – helps clients learn more adaptive behaviors
techniques of cognitive therapy
• Recognizing and then modifying automatic thoughts by:
o looking at other alternatives
o Allow patient to see other possibilities
• examining evidence for and against the automatic thought
o Helping patient find facts to support automatic thought (positive or negative)
• Decatastrophizing – helping patient examine validity of their automatic thought, also helping them cope adaptively moving beyond the crisis
• Recognizing and then modifying automatic thoughts by:
• reattribution of adverse events to circumstances outside self
o Many patients blame themselves for adverse – changing it from internal to external
• using the “Daily Record of Dysfunctional Thoughts” DRDT
o Log where patients rate automatic thoughts, rate intensity and formulate resolutions
• cognitive rehearsal – uses mental imagery to uncover positive thoughts
cognitive techniques used in cognitive therapy
- Behavioral rehearsal – use of role play to rehearse situation and modify maladaptive behavior
- Task assignments – 1 task is broken down to subtasks and each subtask is given a goal – then work to accomplish each subtask one at a time
- Distraction – use this to redirect patient thinning/divert negative thoughts
- Relaxation exercises – helping them relax/think through thinks
- Social skills training – train social skills to redirect automatic thoughts
- Thought stopping techniques – use this in cognitive therapy to help patient stop automatic thought – spell out the word stop, and it changes their thought process
behavioral interventions for cognitive therapy
substance use disorder definition
addition to substance
substance induced disorder definition
intoxication, withdrawal, other substance/med induced mental disorder
- Impaired control – needing larger amounts to receive desire effect
- Social impairment
- Risky use – amount could be hazardous to patients health
- Tolerance – need more to reach desire effect
- Withdrawal
substance use disorder - 1st cateogry
• Detects alcohol use disorder o Have you felt you should CUT down o Have you felt ANNOYED by criticism o Have you felt GUILTY o Have you taken a drink 1st thing in the morning (EYE-OPENER) to steady nerves
CAGE questionnaire
• Intoxication—problematic behavioral, psychological and cognitive changes
o Mood, impaired judgment, occurs shortly after use of substance
• Withdrawal—behavioral, physiological and cognitive changes
o Start after abruptly stopping or decreasing it tremendously
• Substance/Medication-Induced Mental Disorders—mental disorder associated with substance intoxication or withdrawal
o Occur within 1st month or dose
substance induced disorder
- Pre-alcoholic – use to relieve stress
- Early alcoholic phase – hiding, trying to keep use secretive – consists of black outs,
- Crucial phase – person has loss control of alcohol use and they contemplate if they should risk losing everything – know problem is there and what they could lose but cannot stop
- Chronic phase – feeling helping, pity, suicidal thoughts/attempts, life threatening physical conditions WERNICKE-KORSAKOFF: related to thymine deficiency
alcohol use disorder
- Recent ingestion of alcohol: BAL 100-200
- Clinically significant problematic behavior or psychological changes that developed during, or shortly after, alcohol use
- Signs and symptoms, e.g. slurred speech, unsteady gait, nystagmus, impaired attention or memory
- Stupor or coma can occur
alcohol intoxication
- Occurs after stopping or greatly reducing alcohol use following a period of heavy and prolonged use
- Signs and symptoms, e.g. increased blood pressure and pulse, sweating, hand tremor, insomnia, nausea or vomiting, transient hallucinations or illusions, psychomotor agitation, anxiety, generalized tonic-clonic seizures
- Can start 4-12 hours after last drink – especially if someone is used to blacking out then waking up and starting that cycle again
alcohol withdrawal
- A patient who meets the criteria for both alcohol withdrawal and delirium is considered to have Withdrawal Delirium (Delirium Tremens)
- Criteria for Delirium: Decreased attention and awareness; Disturbance in attention, awareness, memory, orientation, language, visuospatial ability, perception, or all of these abilities that is a change from the normal level for the individual and fluctuates in severity during the day
- DTs are the most severe form of alcohol withdrawal
alcohol withdrawal delirium (DELIRIUM TREMENS) (DT)
- Occur after stopping or reduction in prolonged, heavy drinking—can occur a week to 10 days after cessation of drinking
- DTs are a medical emergency requiring vigorous treatment
- Major treatment goals for Alcohol Withdrawal Delirium are to control agitation, decrease the risk of seizures, and decrease the risk of injury and death
- Supportive care includes reorienting to person, place and time; providing reassurance; frequent monitoring of vital signs; and ensuring adequate hydration
alcohol withdrawal delirium (DELIRIUM TREMENS) (DT) 2
more and more alcohol is needed to achieve the desired effect
physical tolerance
ability to mask the effects of alcohol – walk a straight line, not slur words, function reasonably normally
behavioral tolerance
- Goal: The individual with the alcohol problem assumes full responsibility for decision to use alcohol
- Medications may include use of Thiamine, Multivitamins, Anxiolytics, Anticonvulsants
- Antabuse— a medication occasionally used as adverse conditioning treatment
- Take this med when they’re in process of recovery so they don’t drink – any drink of alcohol = nasty GI symptoms
treatment of alcohol problems
- Scores on the CIWA-Ar range from 0 to 67
- Scores lower than 8 indicate mild withdrawal symptoms that rarely require use of medications
- Scores of 8-15 indicate moderate withdrawal symptoms likely to respond to modest doses of benzodiazepines
- Scores higher than 15 indicate severe syndromes that require close monitoring to avoid seizures and alcohol withdrawal delirium
clinical institute withdrawal assessment of alcohol scale
- Important to be aware of feelings related to Alcoholism and Drug Abuse
- Keep in mind that all substance dependent persons suffer from a negative self concept
- Avoid reinforcing this negative self concept through non-therapeutic treatment of chemically dependent individuals
nurses responses to alcoholism/drug abuse*
- Enabler
- Hero – child that tries to bring positive attention through school and take away the negative attention
- Scapegoat – troublemaker in school – get attention away from alcoholic
- Lost Child – isolated, keep to themselves due to embarrassment
- Mascot – tries to bring light to a negative situation
impact on family
• 2 or more S/S for the past 6 months
o Positive: delusions, hallucinations, disorganized speech, grossly disorganized behavior (inappropriate dress)
Positively there when you don’t want them to be, behaviors there when they should be – adding on S/S on a normal level
o Negative: anhedonia (showing lack of pleasure), apathy, poverty of speech
Taking away normal behaviors – lack of interest there
• Disturbance in thinking, feeling and social relations
schizophrenia
o Presence of the schizo S/S (previous slide) for less than 6 months. (1 day-6 months)
brief psychotic disorder
o 1 month-6 months:
schizophreniform disorder
o S/S of schizophrenia, but affect that resembles mood disorder (bipolar, depressed/manic episode)
o Affect determines what diagnosis will be when admitted to hospital
schizoaffective disorder
o Presence of delusions for at least 1 month and doesn’t include any hallucinations or bizarre behaviors
Erotomaniac: thinking someone is in love with them, like a celebrity
Grandiose: patient believes they have inflated worth, powder, or knowledge
jealous: believe their partner is unfaithful
persecutory: one is being evilly treated – someone is plotting against them
somatic: belief they have a medical condition
mixed: no certain theme, a cluster of delusions
delusional disorder *
o Present with mutism, repetitive movements, agitation, echolalia (mimicking of sound/repeat what they hear) and echopraxia (repetitive copying of movements, see someone stretching so they copy it)
catatonia
false, fixed, personal belief
delusion
o Auditory – most common in terms of a voice
Dog barking, sounds, music, command (telling them to hurt themselves or others)
o Visual – see images of people, shadows, flashes of light
o Tactile – feel something is crawling under their skin
o Gustatory – tastes something, usually unpleasant
o Olfactory – any sort of smell
hallucinations *
o Essential features: inattention, impulsiveness, hyperactivity
o Manifestations: distractibility, excitability, impulsivity, and excessive physical activity
Motor activity: fast talking, no control over actions/thoughts
Overlook their mistakes by rushing through things, don’t check over work
Difficulty with long lectures/long periods of time, following instructions
Appear not to be listening when spoken to
Blurt out answers, interrupting
o Cause: genetic and environmental factors
High lead levels, diet considerations (food dyes), sugar
o Nursing interventions
Decrease environmental stimuli, setting clear limits while protecting from injury (hyperactivity), improving social interaction and self esteem, completing task expectations
attention deficit hyperactivity disorder
o Characterized by a pattern of behavior in which a child:
o violates the basic rights of others
o violates major age-appropriate societal norms or rules, such as aggression to people or animals, destruction of property, theft, etc.
o Manifested by antisocial behavior in the form of physical aggression and violence against another person; violation of the rights of others; stealing, lying and truancy; use of illegal substances; sexual permissiveness; projecting blame; anger control and school performance problems
o Nursing intervention:
Protecting others from patient’s physical aggression
Improving social interaction and self esteem
Holding patient accountable for behavior
Recognizing behaviors that precede onset of aggression and intervening before violence occurs
conduct disorder
o Characterized by a pattern of negativistic, hostile, and defiant behavior without the more serious violations of the basic rights of others that are seen in Conduct Disorder
o Oppositional attitude usually directed at home, but may not be evident at school or the community
o Nursing interventions
Peer pressure (why do you talk to your mom that way), use of B. Mod plan, help set realistic goals, limit manipulative behavior
oppositional defiance disorder ODD
o I.Q. 70 or lower o Deficits in adaptive functioning o Causes--many predisposing factors Medical conditions, meningitis, autism o Nursing interventions Working 1 task at a time to get self care, social interaction, group activities, risk for injury, o Nursing involvement with family o Behavior modification
intellectual disability
o Physiological changes that occur secondary to extreme weight loss: amenorrhea, lanugo hair, hypotension, bradycardia, hypothermia, constipation, polyuria, and electrolyte imbalances that may be life threatening
o treatment approaches:
Behavior modification to restore weight and nutritional status
STG: Patient will cooperate with nutritionally sound re-feeding program resulting in a weight gain of 2 pounds/week, more is too hard on CV system
Psychotherapy to deal with unresolved psychological problems
anorexia
o Family characteristics–families may be disorganized, in conflict and characterized by confusing sex role expectations for women
o Behaviors of bulimic–enormous grocery bills and many cavities (acid from throw up)
o Physiologic complications
Dehydration, electrolyte imbalance, erosion of tooth enamel, increase work load on heart or lungs
o Treatment:
Out-patient psychotherapy which may involve an eating disorder program
Sit with patient 1/2 hour after meals if purging history
May need to treat concurrent substance abuse problem along with treatment of bulimia
bulimia
