Week 7; Mental Health Flashcards
MENTAL HEALTH IS DEFINED AS
“THE SUCCESSFUL ADAPTATION TO STRESSORS FROM THE INTERNAL OR EXTERNAL ENVIRONMENT, EVIDENCED BY THOUGHTS, FEELINGS, AND BEHAVIORS THAT ARE AGE-APPROPRIATE AND CONGRUENT WITH LOCAL AND CULTURAL NORMS.”
MENTAL ILLNESS IS DEFINED AS
“MALADAPTIVE RESPONSES TO STRESSORS FROM THE INTERNAL OR EXTERNAL ENVIRONMENT, EVIDENCED BY THOUGHTS, FEELINGS, AND BEHAVIORS THAT ARE INCONGRUENT WITH THE LOCAL AND CULTURAL NORMS AND INTERFERE WITH THE INDIVIDUAL’S SOCIAL, OCCUPATIONAL, OR PHYSICAL FUNCTIONING.”
INCOMPREHENSIBILITY:
THE INABILITY OF THE GENERAL POPULATION TO UNDERSTAND THE MOTIVATION BEHIND THE BEHAVIOR
CULTURAL RELATIVITY:
THE “NORMALITY” OF BEHAVIOR IS DETERMINED BY THE CULTURE.
CULTURE-BOUND SYNDROMES
SYMPTOMS ASSOCIATED WITH SPECIFIC CULTURES THAT MAY BE EXPRESSED DIFFERENTLY FROM THE AMERICAN CULTURE. MOST ARE CONSIDERED TO BE “ILLNESSES” AND MOST MAY HAVE LOCAL NAMES.
Therapeutic communication with mental health
THE NURSE-CLIENT RELATIONSHIP IS THE FOUNDATION ON WHICH PSYCHIATRIC NURSING IS ESTABLISHED. THE THERAPEUTIC INTERPERSONAL RELATIONSHIP IS THE PROCESS BY WHICH NURSES PROVIDE CARE FOR CLIENTS IN NEED OF PSYCHOSOCIAL INTERVENTION.
THE THERAPEUTIC NURSE-CLIENT RELATIONSHIP
- THERAPEUTIC NURSE-CLIENT RELATIONSHIPS CAN OCCUR ONLY WHEN EACH VIEWS THE OTHER AS A UNIQUE HUMAN BEING. WHEN THIS OCCURS, BOTH PARTICIPANTS HAVE NEEDS MET BY THE RELATIONSHIP. THERAPEUTIC RELATIONSHIPS ARE GOAL-ORIENTED AND DIRECTED AT LEARNING AND GROWTH PROMOTION.
OALS ARE OFTEN ACHIEVED THROUGH USE OF THE
PROBLEM-SOLVING MODEL.
- IDENTIFY THE CLIENT’S PROBLEM.
- PROMOTE DISCUSSION OF DESIRED CHANGES.
- DISCUSS ASPECTS THAT CANNOT REALISTICALLY BE
CHANGED AND WAYS TO COPE WITH THEM MORE
ADAPTIVELY. - DISCUSS ALTERNATIVE STRATEGIES FOR CREATING
CHANGES THAT THE CLIENT DESIRES TO MAKE. - WEIGH BENEFITS AND CONSEQUENCES OF EACH
ALTERNATIVE. - HELP CLIENT SELECT AN ALTERNATIVE.
- ENCOURAGE CLIENT TO IMPLEMENT THE CHANGE.
- PROVIDE POSITIVE FEEDBACK FOR CLIENT’S ATTEMPTS
TO CREATE CHANGE. - HELP CLIENT EVALUATE OUTCOMES OF THE CHANGE
AND MAKE MODIFICATIONS AS REQUIRED.
CONDITIONS ESSENTIAL TO DEVELOPMENT OF A
THERAPEUTIC RELATIONSHIP
*RAPPORT
*TRUST
*RESPECT
*GENUINENESS
*EMPATHY
PHASES OF A THERAPEUTIC NURSE-CLIENT
RELATIONSHIP
- PRE-INTERACTION PHASE
- ORIENTATION PHASE
- WORKING PHASE
- TERMINATION PHASE
PREINTERACTION PHASE
OBTAIN INFORMATION ABOUT THE CLIENT FROM CHART, SIGNIFICANT OTHERS, OR OTHER HEALTH TEAM MEMBERS. EXAMINE ONE’S OWN FEELINGS, FEARS, AND ANXIETIES ABOUT WORKING WITH A PARTICULAR CLIENT.
ORIENTATION (INTRODUCTORY) PHASE
CREATE AN ENVIRONMENT FOR TRUST AND
RAPPORT.
* ESTABLISH CONTRACT FOR INTERVENTION.
* GATHER ASSESSMENT DATA.
* IDENTIFY CLIENT’S STRENGTHS AND
LIMITATIONS.
FORMULATE NURSING DIAGNOSES.
* SET MUTUALLY AGREEABLE GOALS.
* DEVELOP A REALISTIC PLAN OF ACTION.
* EXPLORE FEELINGS OF BOTH CLIENT AND NURSE.
PHASE 3: WORKING PHASE
MAINTAINING TRUST AND RAPPORT IS KEY IN THIS PHASE.
* PROMOTE CLIENT’S INSIGHT AND PERCEPTION OF REALITY.
* USE PROBLEM-SOLVING MODEL TO WORK TOWARD
ACHIEVEMENT OF ESTABLISHED GOALS.
* OVERCOME RESISTANCE BEHAVIORS.
* CONTINUOUSLY EVALUATE PROGRESS TOWARD
GOAL ATTAINMENT.
COUNTERTRANSFERENCE and TRANSFERENCE
TRANSFERENCE:
OCCURS WHEN THE CLIENT
UNCONSCIOUSLY DISPLACES (OR “TRANSFERS”) TO THE
NURSE FEELINGS FORMED TOWARD A PERSON FROM THE PAST
COUNTERTRANSFERENCE:
REFERS TO THE NURSE’S
BEHAVIORAL AND EMOTIONAL RESPONSE TO THE CLIENT
PHASE 4: TERMINATION PHASE
- THERAPEUTIC CONCLUSION OF RELATIONSHIP
OCCURS WHEN - PROGRESS HAS BEEN MADE TOWARD ATTAINMENT OF
THE GOALS. - A PLAN OF ACTION FOR MORE ADAPTIVE COPING WITH FUTURE STRESSFUL SITUATIONS HAS BEEN ESTABLISHED.
- FEELINGS ABOUT TERMINATION OF THE RELATIONSHIP ARE RECOGNIZED AND EXPLORED.
Therapeutic communication technique:
USING SILENCE:
ALLOWS CLIENT TO TAKE CONTROL OF THE DISCUSSION, IF HE OR SHE SO DESIRES
Therapeutic communication technique:
ACCEPTING:
CONVEYS POSITIVE REGARD
Therapeutic communication technique:
GIVING RECOGNITION:
ACKNOWLEDGING, INDICATING AWARENESS
Therapeutic communication technique:
OFFERING SELF:
MAKING ONESELF AVAILABLE
Therapeutic communication technique:
GIVING BROAD OPENINGS:
ALLOWS CLIENT TO SELECT
THE TOPIC
OFFERING GENERAL LEADS:
ENCOURAGES CLIENT TO CONTINUE
PLACING THE EVENT IN TIME OR SEQUENCE:
CLARIFIES THE RELATIONSHIP OF EVENTS IN TIME
MAKING OBSERVATIONS:
VERBALIZING WHAT IS OBSERVED OR
PERCEIVED
ENCOURAGING DESCRIPTION OF PERCEPTIONS:
ASKING CLIENT TO VERBALIZE WHAT IS BEING PERCEIVED
ENCOURAGING COMPARISON:
ASKING CLIENT TO COMPARE SIMILARITIES AND DIFFERENCES IN IDEAS, EXPERIENCES, OR INTERPERSONAL RELATIONSHIPS
RESTATING:
LETS CLIENT KNOW WHETHER AN EXPRESSED STATEMENT HAS BEEN UNDERSTOOD
REFLECTING:
DIRECTS QUESTIONS OR FEELINGS BACK
TO CLIENT SO THAT THEY MAY BE RECOGNIZED
AND ACCEPTED
NONTHERAPEUTIC COMMUNICATION TECHNIQUES
GIVING REASSURANCE:
MAY DISCOURAGE CLIENT FROM FURTHER
EXPRESSION OF FEELINGS IF CLIENT BELIEVES THE FEELINGS WILL ONLY BE DOWNPLAYED OR RIDICULED
REJECTING:
REFUSING TO CONSIDER CLIENT’S IDEAS OR BEHAVIOR
APPROVING OR DISAPPROVING:
IMPLIES THAT THE NURSE HAS THE RIGHT TO PASS JUDGMENT ON THE “GOODNESS” OR “BADNESS” OF CLIENT’S BEHAVIOR
ROLE OF THE NURSE IN PSYCHIATRY/MENTAL
HEALTH
*TO ASSIST WITH THE CLIENT’S SUCCESSFUL ADAPTATION TO STRESSORS WITHIN THE ENVIRONMENT.
*GOALS ARE DIRECTED TOWARD CHANGE IN THOUGHTS, FEELINGS, AND BEHAVIORS THAT ARE AGE-APPROPRIATE AND CONGRUENT WITH LOCAL AND CULTURAL NORMS.
*THE NURSE IS A VALUABLE MEMBER OF THE INTERDISCIPLINARY TEAM, PROVIDING A SERVICE THAT IS UNIQUE AND BASED ON SOUND KNOWLEDGE OF PSYCHOPATHOLOGY, SCOPE OF PRACTICE, AND
LEGAL IMPLICATIONS OF THE ROLE.
BRIEF MENTAL STATUS EXAM
- ORIENTATION
- ATTENTION AND IMMEDIATE RECALL
- ABSTRACT THINKING
- RECENT MEMORY
- NAMING OBJECTS
- ABILITY TO FOLLOW SIMPLE VERBAL COMMANDS
- ABILITY TO FOLLOW SIMPLE WRITTEN COMMAND
- ABILITY TO USE LANGUAGE
- ABILITY TO CONCENTRATE
- UNDERSTANDING SPATIAL RELATIONSHIPS
SCORING:
30-21= NORMAL
20-11 MILD COGNITIVE IMPAIRMENT
10-0 = SEVERE COGNITIVE IMPAIRMENT
PSYCHOLOGICAL RESPONSES TO ANXIETY
- ANXIETY AND GRIEF HAVE BEEN DESCRIBED AS TWO MAJOR, PRIMARY PSYCHOLOGICAL RESPONSE PATTERNS TO STRESS.
- A VARIETY OF THOUGHTS, FEELINGS, AND BEHAVIORS ARE ASSOCIATED WITH EACH OF THESE RESPONSE PATTERNS.
- ADAPTATION IS DETERMINED BY THE EXTENT TO WHICH THE THOUGHTS, FEELINGS, AND BEHAVIORS INTERFERE WITH AN INDIVIDUAL’S FUNCTIONING.
ANXIETY
A DIFFUSE APPREHENSION THAT IS VAGUE IN
NATURE AND IS ASSOCIATED WITH FEELINGS OF
UNCERTAINTY AND HELPLESSNESS. ANXIETY VS FEAR, EXTREMELY COMMON IN OUR SOCIETY.
MILD ANXIETY IS ADAPTIVE AND CAN PROVIDE
MOTIVATION FOR SURVIVAL.
PEPLAU’S FOUR LEVELS OF ANXIETY
- MILD: SELDOM A PROBLEM
- MODERATE: PERCEPTUAL FIELD BEGINS TO DIMINISH
- SEVERE: PERCEPTUAL FIELD DIMINISHES GREATLY
- PANIC: THE MOST INTENSE STATE
AT THE MILD LEVEL OF ANXIETY
INDIVIDUALS EMPLOY VARIOUS COPING MECHANISMS TO DEAL WITH STRESS. A FEW OF THESE INCLUDE EATING, DRINKING, AND SLEEPING.
EGO STRENGTH IS TESTED
*COMPENSATION
*DENIAL
*DISPLACEMENT
*IDENTIFICATION
*INTELLECTUALIZATION
*INTROJECTION – (INTEGRATION)
*ISOLATION
*PROJECTION
ANXIETY AT THE MODERATE TO SEVERE LEVEL THAT REMAINS UNRESOLVED OVER AN EXTENDED PERIOD
CAN CONTRIBUTE TO A NUMBER OF PHYSIOLOGICAL DISORDERS.
EXTENDED PERIODS OF REPRESSED SEVERE ANXIETY CAN RESULT IN
PSYCHONEUROTIC PATTERNS OF BEHAVING.
EXTENDED PERIODS OF FUNCTIONING AT THE PANIC
LEVEL OF ANXIETY MAY RESULT IN __ AND OTHER PSYCHOTIC DISORDERS, SUCH AS
PSYCHOSIS.
INCLUDE SCHIZOPHRENIA, SCHIZOAFFECTIVE, AND DELUSIONAL DISORDERS.
PANIC –
SUDDEN, OVERWHELMING FEELING OF TERROR OR IMPENDING DOOM
PANIC DISORDER –
CHARACTERIZED BY RECURRENT PANIC ATTACKS, HE ONSET OF WHICH IS UNPREDICTABLE.
PANIC D/O- MANIFESTED BY:
INTENSE APPREHENSION, FEAR, OR TERROR
* PALPITATIONS
* SWEATING
* SENSATION OF SHORTNESS OF BREATH
* NAUSEA
* DIZZINESS
* CHILLS OR HEAT
* FEAR OF LOSING CONTROL
* DEREALIZATION
GENERALIZED ANXIETY DISORDER
PERSISTENT UNREALISTIC AND EXCESSIVE ANXIETY AND WORRY WHICH HAVE OCCURRED MORE DAYS THAN NOT FOR AT LEAST 6 MONTHS
PHOBIA
A PERSISTENT, INTENSELY FELT, AND IRRATIONAL FEAR OF A SPECIFIC OBJECT, ACTIVITY, OR SITUATION THAT RESULTS IN A COMPELLING DESIRE TO AVID THE STIMULUS.
OBSESSIVE-COMPULSIVE DISORDER
- OBSESSION – INTRUSIVE THOUGHTS THAT ARE RECURRENT AND STRESSFUL
- COMPULSION – REPETITIVE RITUALISTIC BEHAVIORS OR MENTAL ACTS THAT THE INDIVIDUAL FEELS DRIVEN TO PERFORM, WHICH ARE INTENDED TO REDUCE THE ANXIETY ASSOCIATED WITH THE OBSESSIVE THOUGHTS
DEFINITION OF CRISIS
A SUDDEN EVENT IN ONE’S LIFE, DURING WHICH
USUAL COPING MECHANISMS CANNOT RESOLVE
THE PROBLEM; THE CRISIS DISTURBS HOMEOSTASIS.
CHARACTERISTICS OF A CRISIS
- CRISIS OCCURS IN ALL INDIVIDUALS AT ONE TIME OR
ANOTHER AND IS NOT NECESSARILY EQUATED WITH PSYCHOPATHOLOGY. - CRISES ARE PRECIPITATED BY SPECIFIC IDENTIFIABLE EVENTS.
- CRISES ARE PERSONAL BY NATURE.
- CRISES ARE ACUTE, NOT CHRONIC, AND ARE RESOLVED IN ONE WAY OR ANOTHER WITHIN A BRIEF PERIOD.
- A CRISIS SITUATION CONTAINS THE POTENTIAL FOR PSYCHOLOGICAL GROWTH OR DETERIORATION.
PHASES IN THE DEVELOPMENT OF A CRISIS
1.
2.
3.
4.
- THE INDIVIDUAL IS EXPOSED TO A PRECIPITATING STRESSOR.
- WHEN PREVIOUS PROBLEM-SOLVING TECHNIQUES DO NOT RELIEVE THE STRESSOR, ANXIETY INCREASES FURTHER.
- ALL POSSIBLE RESOURCES, BOTH INTERNAL AND EXTERNAL, ARE CALLED ON TO RESOLVE THE PROBLEM AND RELIEVE THE DISCOMFORT.
- IF RESOLUTION DOES NOT OCCUR IN PREVIOUS PHASES, THE TENSION MOUNTS BEYOND A FURTHER THRESHOLD OR ITS BURDEN INCREASES OVER TIME TO A BREAKING POINT. MAJOR DISORGANIZATION OF THE INDIVIDUAL OCCURS, OFTEN WITH DRASTIC RESULTS.
TO A STRESSFUL SITUATION DEPENDS ON THREE FACTORS:
- THE INDIVIDUAL’S PERCEPTION OF THE EVENT
- THE AVAILABILITY OF SITUATIONAL SUPPORTS
- THE AVAILABILITY OF ADEQUATE COPING
MECHANISMS
CRISIS RESULTING FROM TRAUMATIC STRESS:
PRECIPITATED BY AN UNEXPECTED, EXTERNAL STRESSOR OVER WHICH THE INDIVIDUAL HAS LITTLE OR NO CONTROL AND FROM WHICH HE OR SHE FEELS EMOTIONALLY OVERWHELMED AND DEFEATED
MATURATIONAL/DEVELOPMENTAL CRISIS:
OCCURS IN RESPONSE TO A SITUATION THAT TRIGGERS EMOTIONS RELATED TO UNRESOLVED CONFLICTS IN ONE’S LIFE
CRISIS REFLECTING PSYCHOPATHOLOGY:
AN EMOTIONAL CRISIS IN WHICH PREEXISTING PSYCHOPATHOLOGY HAS BEEN INSTRUMENTAL
IN PRECIPITATING THE CRISIS OR IN WHICH PSYCHOPATHOLOGY SIGNIFICANTLY IMPAIRS OR COMPLICATES ADAPTIVE RESOLUTION
PSYCHIATRIC EMERGENCY:
A CRISIS SITUATION IN WHICH GENERAL FUNCTIONING HAS BEEN SEVERELY IMPAIRED AND THE INDIVIDUAL IS RENDERED INCOMPETENT OR UNABLE TO ASSUME PERSONAL RESPONSIBILITY
ANGER/AGGRESSION MANAGEMENT
- ASSESSING RISK FACTORS
- PREVENTION IS THE KEY ISSUE IN MANAGEMENT OF AGGRESSIVE OR
VIOLENT BEHAVIOR. - THREE FACTORS ARE IMPORTANT CONSIDERATIONS IN IDENTIFYING
EXTENT OF RISKS. - PAST HISTORY OF VIOLENCE
- CLIENT DIAGNOSIS
- CURRENT BEHAVIORS
- DIAGNOSIS/OUTCOME IDENTIFICATION
- PLANNING/IMPLEMENTATION
- EVALUATION
CRISIS INTERVENTION
- THE MINIMUM THERAPEUTIC GOAL OF CRISIS
INTERVENTION IS PSYCHOLOGICAL RESOLUTION OF THE INDIVIDUAL’S IMMEDIATE CRISIS AND RESTORATION TO AT LEAST THE LEVEL OF FUNCTIONING THAT EXISTED BEFORE THE CRISIS PERIOD. - A MAXIMUM GOAL IS IMPROVEMENT IN FUNCTIONING
ABOVE THE PRE-CRISIS LEVEL.
Suicide
- SUICIDE IS NOT A DIAGNOSIS OR A DISORDER; IT IS A
BEHAVIOR. - MORE THAN 90 PERCENT OF SUICIDES ARE BY
INDIVIDUALS WHO HAVE A DIAGNOSED MENTAL
DISORDER. - SUICIDE IS DEATH CAUSED BY INJURING ONESELF WITH THE INTENT TO DIE. A SUICIDE ATTEMPT IS WHEN SOMEONE HARMS THEMSELVES WITH THE INTENT TO END THEIR LIFE, BUT THEY DO NOT DIE AS A RESULT OF THEIR ACTIONS.
HEALTHY PEOPLE 2020 ON SUICIDE
- THE TARGET IS TO REDUCE SUICIDE RATES TO 10.2 PER 100,000 BY 2020
- SUICIDE RATES HAVE STEADILY INCREASED.
- SUICIDE RATES IN THE UNITED STATES HAVE INCREASED ABOUT 33% FROM 1999 TO 2019.
- SUICIDE RATES VARY BY RACE/ETHNICITY, AGE, AND OTHER POPULATION CHARACTERISTICS, WITH THE HIGHEST RATES ACROSS THE LIFE SPAN OCCURRING AMONG NON-HISPANIC AMERICAN INDIAN/ALASKA NATIVE AND NON-HISPANIC WHITE POPULATIONS.
- OTHER AMERICANS DISPROPORTIONATELY IMPACTED BY SUICIDE INCLUDE VETERANS AND OTHER MILITARY PERSONNEL AND WORKERS IN CERTAIN OCCUPATIONAL GROUPS.
MYTHS ABOUT SUICIDE
- PEOPLE WHO TALK ABOUT SUICIDE DO NOT COMMIT SUICIDE
- YOU CANNOT STOP A SUICIDAL PERSON
- ONCE A PERSON IS SUICIDAL, HE OR SHE IS SUICIDAL FOREVER
- IMPROVEMENT AFTER SEVERE DEPRESSION MEANS THAT THE SUICIDAL
RISK IS OVER - SUICIDE “RUNS IN FAMILIES”
- ALL SUICIDAL INDIVIDUALS ARE MENTALLY ILL.
- SUICIDAL THREATS SHOULD BE CONSIDERED MANIPULATIVE OR
ATTENTION SEEKING.
*PEOPLE USUALLY COMMIT SUICIDE BY TAKING AN OVERDOSE.
SUICIDE RISK FACTORS
- MARITAL STATUS
- THE SUICIDE RATE FOR SINGLE PERSONS IS TWICE
THAT OF MARRIED PERSONS. - GENDER
- WOMEN ATTEMPT SUICIDE MORE OFTEN, BUT MORE
MEN SUCCEED. - MEN COMMONLY CHOOSE MORE LETHAL METHODS
THAN DO WOMEN. - AGE
- RISK OF SUICIDE INCREASES WITH AGE, PARTICULARLY
AMONG MEN. - RELIGION
- AFFILIATION WITH A RELIGIOUS GROUP DECREASES RISK OF
SUICIDE. CATHOLICS HAVE LOWER RATES THAN DO
PROTESTANTS OR JEWS. - SOCIOECONOMIC STATUS
- INDIVIDUALS IN THE VERY HIGHEST AND LOWEST SOCIAL CLASSES HAVE HIGHER SUICIDE RATES THAN THOSE IN THE MIDDLE CLASS.
- ETHNICITY; WHITES ARE AT HIGHEST RISK FOR SUICIDE FOLLOWED BY NATIVE AMERICANS, AFRICAN AMERICANS, HISPANIC AMERICANS, AND ASIAN AMERICANS.
- PSYCHIATRIC ILLNESS: MOOD AND SUBSTANCE USE DISORDERS ARE THE
MOST COMMON PSYCHIATRIC ILLNESSES THAT PRECEDE SUICIDE. OTHER
PSYCHIATRIC DISORDERS THAT ACCOUNT FOR SUICIDAL BEHAVIOR
INCLUDE: SCHIZOPHRENIA, PERSONALITY DISORDERS, ANXIETY DISORDERS - SEVERE INSOMNIA IS ASSOCIATED WITH INCREASED RISK OF SUICIDE.
Suicide assessment
- PRESENTING SYMPTOMS/MEDICAL-PSYCHIATRIC
DIAGNOSIS - SUICIDAL IDEAS OR ACTS
- CURRENT IDEATION
- HISTORY OF ATTEMPTS
- INTENT
- PLAN
- MEANS
- VERBAL AND BEHAVIORAL CLUES
- INTERPERSONAL SUPPORT SYSTEM
ANALYSIS OF THE SUICIDAL CRISIS
- PRECIPITATING STRESSOR
- RELEVANT HISTORY
- LIFE-STAGE ISSUES
- PSYCHIATRIC/MEDICAL/FAMILY HISTORY
SUICIDE INTERVENTIONS
- INPATIENT PSYCHIATRIC UNIT SUICIDE PREVENTIONS
STRATEGIES ARE BEYOND SCOPE OF THIS CLASS;
HOWEVER, THE FOCUS IS ON SAFETY. - FOCUS IN THIS CLASS IS ON OUTPATIENT SETTING,
ALTHOUGH MANY OF THE INTERVENTIONS AND
RATIONALE IS THE SAME OR SIMILAR. - IF ON INPATIENT MEDICAL UNIT, USE FREQUENT CHECKS AND SITTER.
GUIDELINES FOR TREATMENT OF THE SUICIDAL
CLIENT ON AN OUTPATIENT BASIS
- CALL 911 - IF IMMEDIATE RISK
- TAKE TO EMERGENCY DEPARTMENT
- DO NOT LEAVE THE PERSON ALONE.
- ESTABLISH A NO-SUICIDE CONTRACT WITH THE CLIENT.
- ENLIST THE HELP OF FAMILY OR FRIENDS.
- SCHEDULE FREQUENT APPOINTMENTS.
- ESTABLISH RAPPORT AND PROMOTE A TRUSTING
RELATIONSHIP.
LIMIT THE “MEANS” – REMOVE GUN, PILLS
GUIDELINES FOR TREATMENT OF THE SUICIDAL
CLIENT ON AN OUTPATIENT BASIS (CONT’D)
- BE DIRECT AND TALK MATTER-OF-FACTLY ABOUT SUICIDE.
- DISCUSS THE CURRENT CRISIS SITUATION IN THE CLIENT’S
LIFE OR ANY TRIGGERS. - IDENTIFY AREAS OF SELF-CONTROL.
- REINFORCE POSITIVE COPING MECHANISMS AND
SUPPORT NETWORK - HAVE A PLAN FOR EMERGENCY INTERVENTION
- ADMINISTER ANTIDEPRESSANT MEDICATIONS AND
MEDICATION EDUCATION
TEACHING – FAMILY AND SUPPORT PERSONS
- TAKE ANY HINT OF SUICIDE SERIOUSLY.
- DO NOT KEEP SECRETS.
- BE A GOOD LISTENER.
- EXPRESS FEELINGS OF PERSONAL WORTH TO THE CLIENT.
- KNOW ABOUT SUICIDE INTERVENTION RESOURCES.
- RESTRICT ACCESS TO FIREARMS OR OTHER MEANS
OF SELF-HARM. - ACKNOWLEDGE AND ACCEPT THE PERSON’S FEELINGS.
- PROVIDE A FEELING OF HOPEFULNESS.
- DO NOT LEAVE THEM ALONE.
- SHOW LOVE AND ENCOURAGEMENT.
- SEEK PROFESSIONAL HELP.
- REMOVE CHILDREN FROM THE HOME IF NECESSARY.
- DO NOT JUDGE OR SHOW ANGER TOWARD THEM OR
PROVOKE GUILT
LONG TERM GOALS
- DEVELOP AND MAINTAIN A MORE POSITIVE SELF-CONCEPT.
- LEARN MORE EFFECTIVE WAYS TO EXPRESS FEELINGS TO OTHERS.
- ACHIEVE SUCCESSFUL INTERPERSONAL RELATIONSHIPS.
- FEEL ACCEPTED BY OTHERS AND ACHIEVE A SENSE
OF BELONGING.
EVALUATION
- RETURN TO GOALS AND DETERMINE IF THEY HAVE BEEN MET
- LONG TERM SAFETY
- CLIENT’S ABILITY TO NOTIFY SOMEONE IF THOUGHTS OF SUICIDE RETURN
- ESTABLISHMENT OF THERAPIST, FNP, MD FOR TREATMENT
- MEDICATIONS FOR DEPRESSION
APPLIED SUICIDE INTERVENTION SKILLS TRAINING (ASIST)
- ASIST IS A SUICIDE INTERVENTION SKILLS TRAINING PROJECT DEVELOPED BY LIVING WORKS
EDUCATION, INC. THE LIVING WORKS MATERIALS ARE DESIGNED TO CREATE LEARNING
EXPERIENCES THAT HELP COMMUNITIES PREVENT SUICIDE. - SUICIDE TALK (TELL, ASK, LISTEN, CARE) IS AN AWARENESS PROGRAM THAT CAN BE CUSTOMIZED
FOR 1-4 HOUR PRESENTATIONS. THIS TALK CAN BE GEARED FOR YOUTH, PARENTS, OR
PROFESSIONAL AUDIENCES. IT COVERS BASIC RECOGNITION SKILLS AND SELF-CARE.
THE ASIST WORKSHOP (FORMERLY THE SUICIDE INTERVENTION WORKSHOP) IS A TWO-DAY
WORKSHOP FOR COMMUNITY MEMBERS WHO WANT TO FEEL MORE COMFORTABLE, CONFIDENT
AND COMPETENT IN HELPING TO PREVENT THE IMMEDIATE RISK OF SUICIDE. - THIS TRAINING TEACHES PEOPLE HOW TO RECOGNIZE YOUTH WHO ARE AT POTENTIAL SUICIDE
RISK, INTERVENE WITH, AND REFER THEM ON TO PROFESSIONAL COUNSELING. OVER 200,000
INDIVIDUALS HAVE PARTICIPATED IN THIS TWO-DAY, HIGHLY INTERACTIVE, PRACTICAL, PRACTICE-
ORIENTED WORKSHOP.
Alzheimer disease (AD)
accounts for ~60–80% of all dementia cases in individuals age 65 and older
* Usually manifests after age 65
– Some individuals have symptoms as early as their 30s
* Survival time: 4–8 years after diagnosis
– Those diagnosed at younger ages may live up to 20 more years
– Patients spend more time in moderate stage of AD than in any other stage
* Caregiver burden
– Psychologic, physical, financial cost of caring for a person with AD
– Higher levels than in most other chronic illnesses
– Nurse must consider caregiver as well as patient
AD Patho
- Two basic types of AD with same sets of pathophysiologic changes
– Familial (early-onset AD)
▪ Inherited
– Sporadic (late-onset AD)
▪ No clear pattern of inheritance
▪ More common than early-onset AD - Pattern of progressive degenerative changes related to neuronal death
– Begins with neurons in limbic system, including hippocampus
– Spreads up and out toward cerebral surface
– Neuronal death in cerebral lobes produce a range of symptoms - As AD progresses
▪ Neurofibrillary tangles
▪ Amyloid plaques
AD Etiology
- Cholinergic hypothesis
– Lower acetylcholine production in brain → memory deficits
– Anticholinesterase inhibitors have only modest effect, tending not to support this
hypothesis - Amyloid hypothesis
– Incorrect processing of amyloid precursor protein → beta-amyloid → amyloid
plaques
– Amyloid plaques kill surrounding neurons, provoking inflammatory response - Tau hypothesis
– Abnormal tau proteins form neurofibrillary tangles instead of microtubule network
AD risk factors
- Nonmodifiable risk factors
– Age
▪ Advancing age: most prominent risk factor
– Sex
– Family history
– Genetic factors - Modifiable risk factors
– Cardiovascular risk factors
▪ Diabetes
▪ Midlife obesity, hypertension, hyperlipidemia
– Lifestyle risk factors
▪ Cigarette smoking
– Traumatic brain injury (TBI), depression, disordered sleep
AD prevention
- Increasing protective factors
– Reducing incidence of cardiovascular disease, other health problems
– Quitting smoking
– Increased levels of exercise - Other strategies
– Adopt a heart-healthy diet
– Consume alcohol moderately
– Stay socially active, connected with others
– Engage in activities that exercise cognitive function
– Use stress management techniques
AD s/s
- Symptoms emerge gradually, may be almost unnoticeable at first
- Most common first manifestation: subtle memory loss that becomes more apparent
over time - Other early signs
– Difficulty finding words and performing familiar tasks
– Impaired judgment and abstract thinking
– Disorientation to time or place
– Frequently misplacing things - Alterations go beyond changes associated with normal aging
- Diurnal changes
– Sundowning: pattern of diminished capacity in the evening - Changes in mood, personality
AD dx tests
- No definitive way to diagnose except brain autopsy after death
- Clinicians use differential diagnosis
– Ruling out other possible causes until AD remains as most likely diagnosis
– Standard laboratory tests
– Genetic testing in certain circumstances
▪ Individuals with a parent with early-onset AD
–If genetic testing reveals mutation, almost 100% chance of AD
▪ Individuals with Ap0E4 allele have 10- to 15-fold increased risk
▪ Lack of genetic findings does not mean a person will not develop AD - Biomarkers
– Physiologic, chemical, or anatomic measures associated with certain conditions
– Several are associated with AD
▪ Identification may facilitate early intervention and planning
AD pharm
- Medications are used to slow progression, treat associated symptoms
- Acetylcholinesterase (AChE) inhibitors
– Work by reducing acetylcholine breakdown
– Temporary stabilization of symptoms related to language, memory, reasoning
▪ Average of 6–12 months
– Some AChE inhibitors approved for early to moderate stages, donepezil
approved for all stages
▪ All AChE inhibitors act similarly
▪ Not all patients respond the same way
–About half see no delay in symptom progression
– Mild side effects
– Should not be stopped abruptly - NMDA receptor antagonists and combination agents
– Block effects of glutamate
– Do not reverse existing damage
– Slow rate at which new damage occurs
– Not prescribed until patient is in moderate to severe stages of AD
– Memantine: only FDA-approved NMDA receptor antagonist
– Combination of memantine and donepezil (AChE inhibitor) approved in 2014
– Side effects less common, milder than those of AChE inhibitors - Other medications used to treat symptoms
– Antipsychotics
– Selective serotonin reuptake inhibitor (SSRI) antidepressants
– Some evidence that these medications may increase risk of cognitive decline
non pharmacologic therapy
- Reality orientation
– Structured orienting to person, time, place, situation at regular intervals
– Verbal communication and use of visual cues
– Collaborative intervention involving all members of healthcare team
– Improve cognitive function when used with AChE inhibitors - Validation therapy
– Search for emotion or intended meaning in verbal expressions and behaviors
– Seemingly meaningless behaviors, speech have significance to current needs - Reminiscence therapy
– Purposely reflecting on past events
– Helps patients to retain long-term memory
– Comfort, self-esteem, identity purpose
– Can help to prevent isolation, withdrawal
Complementary therapies for AD
- Supported by empirical evidence of efficacy in promoting comfort, symptom relief
- Art therapy
– Music therapy
– Healing touch
– Reiki - Inconclusive evidence, associated with risks such as drug interactions, toxicity
– Antioxidant vitamins
– Gingko biloba
– Resveratrol
– Omega-3 fatty acids
– Medical foods such as tramiprosate, caprylic acid - No convincing evidence to date supporting use of dietary supplements
AD nursing process
Provide a safe, supportive environment that meets changing abilities and needs
* Support patient’s family members as they cope with physical and emotional demands
* Tools and techniques available
– Hartford Institute for Geriatric Nursing
– Alzheimers Association
– Agency for Healthcare Research and Quality
AD assessment
– Observe patient along with caregivers
– Patients with mild dementia might not show signs or symptoms
– Family members’ reports may provide first clue
– Signs of difficulty with self-care, difficulty focusing on simple tasks, difficulty
paying attention during patient interview, variable gait or changes in gait speed
– Patient interview
▪ Family history of AD, other dementias
▪ Medical history
▪ Medications, supplements
▪ Changes in cognition, memory, behavior
▪ Alterations in mood, sleep patterns, ability to perform ADLs
▪ Drug and alcohol use
▪ Exposure to environmental toxins
AD physical assessment
- Physical assessment
– Height, weight, vital signs, overall physical condition
– Possible signs of abuse, neglect, depression, malnutrition, elimination difficulties,
alterations in skin integrity - Mnemonic for conditions that mimic symptoms of dementia and AD
– D = Drugs and alcohol
– E = Eyes and ears
– M = Metabolic and endocrine disorders
– E = Emotional disorders
– N = Neurologic disorders
– T = Trauma or tumors
– I = Infection
– A = Arteriovascular disease - Cognitive mental status
– Mini-Mental Status Exam (MMSE): most common test to assess cognitive status - Functional status
– Ability to manage eating, dressing, cooking, managing housework, taking care of
finances
– Direct questioning of patient or family members
– Screening tools such as Functional Activities Questionnaire - Behavioral status
– Direct observation and questioning of patient, caregivers
– Inquire about events that precipitate behavior changes
– Screening tools
▪ Geriatric Depression Scale may be used to detect changes in mood
▪ BEHAVE-25 to elicit caregiver reports
AD caregiver
– Needs of caregiver
– Adequacy of living environment
– Screening tools
▪ Zarit Burden Interview
▪ Caregiver Role Strain Index
– Assess knowledge of effective caregiving interventions, capacity to use them in
current living environment
– Assess for cultural values, beliefs, practices, barriers to provision of care or
patient–family relationship
AD planning
- Goals may include that patient will
– Remain free from injury
– Use lists, calendars, other memory aids as needed
– Perform instrumental activities of daily living (IADLs) with caregiver assistance
– Exhibit reduced anxiety, agitation, restlessness
– Take all medications prescribed - Goals related to caregiver and family needs may include that the caregiver will
– Use respite care resources as needed
– Learn effective coping strategies for coping with stresses of supporting loved one
with AD
– Obtain sleep and nutrition needed to preserve personal health
