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WHAT SUBSTANCE IN THE BRAIN IS DISRUPTED BY SUBSTANCE ABUSE
SLEEP CYCLE, NUTRITION, JUDGEMENT, HYGIENE
SUBSTANCE ABUSE COMMONLY DISRUPTS THESE ASPECTS IN INDIVIDUALS
WHAT IS A COMMON COMORBIDITY DURING SUBSTANCE ABUSE
WHAT ARE SUBSTANCES ABUSERS ALSO AT HIGH RISK FOR?
GENETIC; FOR CHILDREN OF ALCOHOLICS
IN ADDITION TO ENVIRONMENTAL, PHYSICAL, DEVELOPMENTAL, AND PSYCHOSOCIAL FACTORS FOR ADDICTION, WHAT OTHER ASPECT IS LINKED TO ADDICTIVE PERSONALITY?
SUBSTANCE ABUSE THEORY: CERTAIN PSYCHODYNAMIC FACTORS ARE PART OF THE ADDICTIVE PERSONALITY. SUCH AS: • LACK OF TOLERANCE, FRUSTRATION, AND PAIN • LACK OF SUCCESS IN LIFE • LACK OF AFFECTIONATE, MEANINGFUL RELATIONSHIPS PATIENTS HAVE A LOW SELF ESTEEM, LACK OF SELF-REGARD, RISK TAKING PROPENSITY, FREQUENT DEPRESSION, AND PASSIVITY. UNABLE TO RELAX, DETER GRATIFICATION, AND COMMUNICATE EFFECTIVELY
SUBSTANCE ABUSE THEORY: PATIENT DISCOVERS THE EUPHORIC STATE, ROUTINELY SEEKS IT TO “ESCAPE”, AND CONTINUES TO ABUSE IN SPITE OF THE DIRE CONSEQUENCES. TREATMENT INVOLVES IDENTIFICATION OF STRESSORS IN THE PATIENT’S LIFE
SUBSTANCE ABUSE THEORY: STATES THERE IS DIFFERENCES IN THE RATE OF SUBSTANCE ABUSE AMONG VARIOUS GROUPS. CULTURE HAS AN IMPACT. ABUSERS FIND A SENSE OF BELONGING WITHIN THE SUBSTANCE ABUSE CULTURE
b.) tolerance *Tolerance is described as needing increasing greater amounts of a substance to receive the desired result to become intoxicated or finding that using the same amount over time results in a much-diminished effect. Intoxication is the effect of the drug. Withdrawal is a set of symptoms patients experience when they stop taking the drug. Addiction is loss of behavioral control with craving and inability to abstain, loss of emotional regulation, and loss of the ability to identify problematic behaviors and relationships.
Erik is a 26-year-old patient who abuses heroin. He states to you, “I’ve been using more heroin lately. I told my provider about it and she said I need more and more heroin to feel the effect I want.” You know this describes: a.) intoxication. b.) tolerance. c.) withdrawal. d.) addiction.
c.) Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities.
*The more common co-occurring medical conditions are hepatitis C, diabetes, cardiovascular disease, HIV infection, and pulmonary disorders. The high comorbidity appears to be the result of shared risk factors, high symptom burden, physiological response to licit and illicit drugs, and the complications from the route of administration of substances. Most substance abusers do have medical comorbidities. There is research such as the 2001-2003 National Comorbidity Survey Replication (NCS-R) showing the correlation between medical comorbidities and psychiatric disorders. It is more likely that medical comorbidities negatively affect substance addiction in that they cause added symptoms, stress, and burden.
Which of the following is true regarding substance addiction and medical comorbidity? a.) Most substance abusers do not have medical comorbidities. b.) There has been little research done regarding substance addiction disorders and medical comorbidity. c.) Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. d.) Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.
b.) Cody will be medically stabilized while in the hospital. *If the patient has been abusing substances heavily, he will begin to experience physical symptoms of withdrawal, which can be dangerous if not treated. The priority outcome is for the patient to withdraw from the substances safely with medical support. Substance use disorder outcome measures include immediate stabilization for individuals experiencing withdrawal such as in this instance, as well as eventual abstinence if individuals are actively using, motivation for treatment and engagement in early abstinence, and pursuit of a recovery lifestyle after discharge. The first option is an unrealistic time frame. It is not likely that the patient will make a total commitment to abstinence within this time frame. Although a leave of absence may be an option, the immediate need is to make sure the patient goes through drug and alcohol withdrawal safely.
Cody is a 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months. He is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for Cody’s treatment plan while in the hospital? a.) Cody will return to a predrug level of functioning within 1 week. b.) Cody will be medically stabilized while in the hospital. c.) Cody will state within 3 days that he will totally abstain from drugs and alcohol. d.) Cody will take a leave of absence from college to alleviate stress.
a.) Readiness to change and support system
*The plan will take into account acute safety needs, severity and range of symptoms, motivation or readiness to change, skills and strengths, availability of a support system, and the individual’s cultural needs. The other options may be factors but are not the priority factors in planning interventions for the patient as much as the patient’s perceived need for change and having others who can lend support outside the hospital.
The treatment team meets to discuss Cody’s plan of care. Which of the following factors will be priorities when planning interventions? a.) Readiness to change and support system b.) Current college performance c.) Financial ability d.) Availability of immediate family to come to meetings
d.) “It helps prevent relapse by reducing drug cravings.”
*Naltrexone is used for withdrawal and also to prevent relapse by reducing the craving for the drug. The other options do not accurately describe the action of naltrexone.
Cody is preparing for discharge. He tells you, “Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?” Which response is appropriate teaching regarding naltrexone? a.) “It helps your mood so that you don’t feel the need to do drugs.” b.) “It will keep you from experiencing flashbacks.” c.) “It is a sedative that will help you sleep at night so you are more alert and able to make good decisions.” d.) “It helps prevent relapse by reducing drug cravings.”
d.) withdrawal. Withdrawl is a condition marked by physical and psychological symptoms that occur when a drug that has been taken for a long time is stopped or drastically reduced in dosage.
A syndrome that occurs after stopping the long-term use of a drug is called a.) amnesia. b.) tolerance. c.) enabling. d.) withdrawal.
The effects of opiates can be negated by a narcotic antagonist such as naloxone.
The only class of commonly abused drugs that has a specific antidote is the a.) opiates. b.) hallucinogens. c.) amphetamines. d.) benzodiazepines.
d.) the need to take larger amounts of a substance to achieve the same effects.
With regard to substance abuse, tolerance is defined as the need to take higher and higher doses of a drug to achieve the desired effect.
The term tolerance, as it relates to substance abuse, refers to a.) the use of a substance beyond acceptable societal norms. b.) the additive effects achieved by taking two drugs with similar actions. c.) the signs and symptoms that occur when an addictive substance is withheld. d.) the need to take larger amounts of a substance to achieve the same effects.
d.) exert a calming effect.
Benzodiazepines act by binding to α-aminobutyric acid-benzodiazepine receptor sites, producing a calming effect.
Benzodiazepines are useful for treating alcohol withdrawal because they a.) block cortisol secretion. b.) increase dopamine release. c.) decrease serotonin availability. d.) exert a calming effect.
b.) enabler. An enabler is one who helps a substance-abusing client avoid facing the consequences of drug use.
A person who covertly supports the substance-abusing behavior of another is called a(n) a.) patsy. b.) enabler. c.) participant. d.) minimizer.
a.) denial. Believing that one can control drug use, despite addiction to the substance, is based on denial (escaping unpleasant reality by ignoring its existence).
A client who is dependent on alcohol tells the nurse, “Alcohol is no problem for me. I can quit anytime I want to.” The nurse can assess this statement as indicating a.) denial. b. ) projection. c. ) rationalization. d.) reaction formation.
d. )Supervisory staff should be informed as soon as possible in both cases.
If indicators of impaired practice are observed, the observations need to be reported to the nurse manager. Intervention is the responsibility of the nurse manager and other nursing administrators. However, clear documentation (specific dates, times, events, consequences) by co-workers is crucial. The nurse manager’s major concerns are with job performance and client safety. Reporting an impaired colleague is not easy, even though it is our responsibility. To not “see” what is going on, nurses may deny or rationalize, thus enabling the impaired nurse to potentially endanger lives while becoming sicker and more isolated. Impairment can occur whether the nurse is under the influence of alcohol or a narcotic drug.
What is the ethical obligation of the nurse who sees a peer divert a narcotic, compared with the ethical obligation when the nurse observes a peer who is under the influence of alcohol? a. )The nurse should immediately report the peer who is diverting narcotics and should defer reporting the alcohol-using nurse until a second incident takes place. b. )Neither should be reported until the nurse has collected factual evidence. c. ) No report should be made until suspicions are confirmed by a second staff member. d. )Supervisory staff should be informed as soon as possible in both cases.
b. )GHB The drugs most frequently used to facilitate a sexual assault (rape) are flunitrazepam (Rohypnol, “roofies”), a fast-acting benzodiazepine, and gamma-hydroxybutyrate (GHB) and its congeners. These drugs are odorless, tasteless, and colorless; mix easily with drinks; and can render a person unconscious in a matter of minutes. Perpetrators use these drugs because they rapidly produce disinhibition and relaxation of voluntary muscles; they also cause the victim to have lasting anterograde amnesia for events that occur.
A young woman reports that although she has no memory of the event, she believes that she was raped. This raises suspicion that she unknowingly ingested a. ) LAAM b. )GHB c. )ReVia d. ) Clonidine
c. )The client must strive to maintain abstinence. Abstinence is the safest treatment goal for all addicts. Abstinence is strongly related to good work adjustments, positive health status, comfortable interpersonal relationships, and general social stability.
In helping an addicted individual plan for ongoing treatment, which intervention is the first priority for a safe recovery? a.) Ongoing support from at least two family members must be secured. b. )The client needs to be employed. c. )The client must strive to maintain abstinence. d. )A regular schedule of appointments with a primary care provider must be set up.
a. ) lacrimation, rhinorrhea, dilated pupils, and muscle aches. Symptoms of opioid withdrawal resemble the “flu”; they include runny nose, tearing, diaphoresis, muscle aches, cramps, chills, and fever.
Symptoms that would signal opioid withdrawal include a. ) lacrimation, rhinorrhea, dilated pupils, and muscle aches. b. )illusions, disorientation, tachycardia, and tremors. c.) fatigue, lethargy, sleepiness, and convulsions. d.) synesthesia, depersonalization, and hallucinations.
c.) Barbiturates Withdrawal from central nervous system depressants is complicated, requiring carefully titrated detoxification with a similar drug. Abrupt withdrawal can lead to death REF: Page 416
Which of the drugs used by a polysubstance abuser is most likely to be responsible for withdrawal symptoms requiring both medical intervention and nursing support? a.) Opiates b.) Marijuana c.) Barbiturates d.) Hallucinogens
a.) tremors. Tremors are an early sign of alcohol withdrawal.
REF: Page 414
Nursing assessment of an alcohol-dependent client 6 to 12 hours after the last drink would most likely reveal the presence of a.) tremors. b.) seizures. c.) blackouts. d.) hallucinations.
d.) observation for hyperpyrexia and seizures.
Hyperpyrexia and convulsions are dangerous symptoms seen in central nervous system stimulant overdose.
REF: Page 414
A client has been using cocaine intranasally for 4 years. When brought to the hospital in an unconscious state, nursing measures should include a.) induction of vomiting. b.) administration of ammonium chloride. c.) monitoring of opiate withdrawal symptoms. d.) observation for hyperpyrexia and seizures.
a.) Blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min
Opiate overdose results in lowered blood pressure with a rise in pulse rate along with respiratory depression.
REF: Page 416
Which assessment data would be most consistent with a severe opiate overdose? a.) Blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min b.) Blood pressure, 120/80 mm Hg; pulse, 84 beats/min; respirations, 20 breaths/min c.) Blood pressure, 140/90 mm Hg; pulse, 76 beats/min; respirations, 24 breaths/min d.) Blood pressure, 180/100 mm Hg; pulse, 72 beats/min; respirations, 28 breaths/min
b.) Stimulation and anesthetic effects
Cocaine exerts two main effects on the body, both anesthetic and stimulant.
REF: Page 413-415 (Table 22-1)
Cocaine exerts which of the following effects on a client? a.) Stimulation after 15 to 20 minutes b.) Stimulation and anesthetic effects c.) Immediate imbalance of emotions d.) Paranoia
c.) abstain from the use of mood-altering substances.
Abstinence is a highly desirable long-term goal/outcome. It is a better outcome than short-term goal because lapses are common in the short term.
REF: Page 422
An appropriate long-term goal/outcome for a recovering substance abuser would be that the client will a.) discuss the addiction with significant others. b.) state an intention to stop using illegal substances. c.) abstain from the use of mood-altering substances. d.) substitute a less addicting drug for the present drug.
a.) The client has a high tolerance to alcohol. A nontolerant drinker would evidence staggering, ataxia, confusion, and stupor at this blood alcohol level.
REF: Page 416
A client was in an automobile accident and while there is the odor of alcohol on his breath, his speech is clear, and he is alert and answers questions posed to him. His blood alcohol level is determined to be 0.30 mg%. What conclusion can be drawn? a.) The client has a high tolerance to alcohol. b.) The client ate a high-fat meal before drinking. c.) The client has a decreased tolerance to alcohol. d.) The client’s blood alcohol level is within legal limits.
b.) obtaining an order for seclusion and close observation.
Aggressive, violent behavior is often seen with PCP ingestion. The client will respond best to a safe, low-stimulus environment such as that provided by seclusion until the effects of the drug wear off. Talking down is never advised because of the client’s unpredictable violent potential. Naltrexone is an opiate antagonist.
REF: Page 414
A client brought to the emergency department after phenylcyclohexylpiperidine (PCP) ingestion is both verbally and physically abusive, and the staff is having difficulty keeping him and themselves safe. The nursing intervention that would be most therapeutic is a.) taking him to the gym on the psychiatric unit. b.) obtaining an order for seclusion and close observation. c.) assigning a psychiatric technician to “talk him down.” d.) administering naltrexone as needed per hospital protocol.
c.) “Most over-the-counter cough syrups are safe for me to use.”
The client taking disulfiram has to avoid hidden sources of alcohol. Many cough syrups contain alcohol.
REF: Page 427 (Table 22-9)
A teaching need is revealed when a client taking disulfiram (Antabuse) states, a.) “I usually treat heartburn with antacids.” b.) “I take ibuprofen or acetaminophen for headache.” c.) “Most over-the-counter cough syrups are safe for me to use.” d.) “I have had to give up using aftershave lotion.”
c.) result from lack of good situational support.
Relapses can point out problems to be resolved and can result in renewed efforts for change.
REF: Page 425
The most helpful message to transmit about relapse to the recovering alcoholic client is that lapses a.) are an indicator of treatment failure. b.) are caused by physiological changes. c.) result from lack of good situational support. d.) can be learning situations to prolong sobriety.
WHICH TYPE OF ABUSED SUBSTANCE IS CONSIDERED THE “LAUGHING” DRUG?
LOSS OF CONSUMPTION CONTROL, CONTINUED USE DEPITE PROBLEMS, TENDENCY TO RELAPSE
ADDICTION IS CHARACTERIZED BY WHICH 3 ASPECTS
BIOLOGICAL, PSYCHOLOGICAL, SOCIOCULTURAL, GENETIC
4 RISK FACTORS TIED INTO SUBSTANCE ABUSE
GATHER DATA, NOTIFY NURSE MANAGER, DO NOT CONFRONT
IF INDICATORS OF IMPAIRED PRACTICE ARE OBSERVED BY ANOTHER NURSE, WHAT IS THE OBSERVER’S RESPONSIBILITY?
NURSE MANAGER, NURSING ADMINISTRATORS
INTERVENTION OF A NURSE ABUSING IS WHOSE RESPONSIBILITY?
MAKE NOTIFICATION TO NEXT LEVEL IN CHAIN OF COMMAND
IF NOTIFICATION IS MADE AND THE NURSE NOTICES NO ACTION HAS BEEN TAKEN, WHAT IS NECESSARY?
PROTECT PATIENTS, GET NURSE TREATMENT, RETURN NURSE TO PRACTICE OF POSSIBLE
WHAT IS THE MAIN GOAL OF INTERVENTION?
• MEDICATION WASTING / NOT GETTING WASTING COUNTER-SIGNED • PATIENT COMPLAINS OF INEFFECTIVE PAIN CONTROL • COMES IN EARLY / STAYS LATE • VOLUNTEERS FOR ADDITIONAL SHIFTS • USES BATHROOM A LOT • SLOPPY CHARTING • ↑ ABSENTEEISM • FREQUENT JOB CHANGES / LOSS • JOB RELATED ACCESS • CRIMINAL RECORD
SYMPTOMS FOR AN IMPAIRED NURSE
THE DRUG OF CHOICE GIVEN TO DECREASE ALCOHOL WITHDRAWAL SYMPTOMS, STABILIZE VITAL SIGNS, AND PREVENT SEIZURES/DT’S
FOR ALCOHOL WITHDRAWAL PATIENTS, WHAT DRUG IS GIVEN TO TREAT HALLUCINATIONS (TACTILE, VISUAL, AUDITORY, OLFACTORY)
FOLIC ACID, THIAMIN, MULTIVITAMINS
WHAT IS ALSO GIVEN TO ALCOHOL WITHDRAWAL PATIENTS TO ADDRESS MALNUTRITION
WHICH DRUG, WHICH BLOCKS OPIOD RECEPTORS, IS ALSO GIVEN TO ALCOHOL WITHDRAWAL PATIENTS TO DECREASE THE PLEASANT, REINFORCING EFFECTS OF ALCOHOL?
WHICH DRUG, WHICH LOWERS BP, IS GIVEN IN COMBINATION WITH THE ABOVE MED AND IS A NON-OPIOD SUPPRESSOR OF WITHDRAWAL SYMPTOMS
WHICH SCALE IS UTILIZED TO IDENTIFY SYMPTOMS AND DETERMINE SEVERITY OF ALCOHOL WITHDRAWAL?
A SCORE OF ABOVE ___ ON THE CIWA SCALE MANDATES TREATMENT
A SCORE ABOVE ___ INDICATES SEVERE WITHDRAWALS
WHAT IS THE ONLY MEDICATION CURRENTLY APPROVED FOR THE TREATMENT OF A PREGNANT OPIOD ADDICT
WITHIN A COUPLE HOURS AFTER CESSATION
EARLY SIGNS OF ALCOHOL WITHDRAWAL APPEAR:
ALCOHOL WITHDRAWAL SIGNS PEAK AFTER:
ALCOHOL WITHDRAWAL DELIRIUM PEAKS AFTER:
WHAT WAS TAKEN, WHEN LAST TAKEN, HOW MUCH
WITH A NEWLY ARRIVED SUBSTANCE ABUSE PATIENT, WHAT QUESTIONS ARE THE NURSING PRIORITY WITH REGARD TO THE SUBSTANCE?
AS A PRECAUTION, A NURSE HANDLING A WITHDRAWAL PATIENT SHOULD MONITOR FOR WHAT PHYSICAL REACTION?
WHICH DRUG FOR ALCOHOL ABUSE WORKS ON THE CLASSICAL CONDITIONING PRINCIPLE OF INHIBITING IMPULSIVE DRINKING. CAUSES UNPLEASANT PHYSICAL EFFECTS IF ALCOHOL IS CONSUMED
THE NEGATIVE EFFECTS ASSOCIATED WITH ALCOHOL CONSUMPTION / EXPOSURE
WHAT SHOULD THE PATIENT BE EDUCATED ABOUT WHEN ON ANTABUSE?
role in inhibition, reduces aggression, excitation, anxiety (decrease = anxiety disorder, schizo)
GABA Neurotransmittersare responsible for?
THE NEED FOR HIGHER AND HIGHER DOSES TO ACHIEVE THE DESIRED EFFECT
OCCURS AFTER A LONG PERIOD OF CONTINUED USE; STOPPING OR REDUCING USE RESULTS IN SPECIFIC PHYSICAL AND PSYCHOLOGICAL SIGNS AND SYMPTOMS
TRANSITORY RECURRENCE OF PERCEPTUAL DISTURBANCE CAUSED BY A PERSON’S EARLIER HALLUCINOGENIC DRUG USE. RANGE FROM MILD/PLEASANT TO FRIGHTENING
THE INTENSIFIED OR PROLONGED EFFECT WHEN DRUGS ARE TAKEN TOGETHER
COMBINING DRUGS TO WEAKEN OR INHIBIT THE EFFECT OF ONE OF THE DRUGS
A CLUSTER OF BEHAVIORS OFTEN MANIFESTED BY PERSONS LIVING WITH A SUBSTANCE ABUSING INDIVIDUAL. EXHIBIT OVER-RESPONSIBLE BEHAVIOR, DOING FOR OTHERS WHAT THEY COULD DO FOR THEMSELVES
NECESSARY WHEN A PERSON IS SUBSTANCE ABUSING AND HAS A PSYCHIATRIC ILLNESS
• MENTALLY ILL AND SELF MEDICATES • DEPRESSED ADDICT BECAUSE OF ALCOHOLISM
WHEN A PERSON IS SUBSTANCE ABUSING AND HAS A PSYCHIATRIC ILLNESS IT MUST BE DETERMINED WHICH CONDITION IS PREDOMINANT. MUST DISTINGUISH BETWEEN PERSON WHO IS:
HOW MUST A DUAL DIAGNOSED PATIENT’S CONDITIONS BE TREATED
THE TERM FOR THE ABUSE OF TWO TYPES OF SUBSTANCES
WHICH TYPE OF DRUG IS NOT SAFE WHEN TREATING AN ADDICTED PATIENT
ALCOHOL ABUSE IS LOW IN THIS CULTURE DUE TO A BIOLOGICAL DEFICIENCY IN ALDEHYDE DEHYDROGENASE; AN ENZYME THAT BREAKS DOWN ALCOHOL ACETALDEHYDE?
WHICH GENDER HAS LOWER SUBSTANCE ABUSE RATES?
1.) Control addictive and impulsive behaviors.
A nurse is teaching a group of clients about addiction. One client says he can stop drinking whenever he wants. The nurse concludes that this client does not yet understand that addiction is a disease in which individuals primarily lose ability to do which of the following? (1 point) 1.) Control addictive and impulsive behaviors.
2.) Act sober even if they are not.
3.) Think logically about their addictive behaviors.
4.) Recognize that addictive behavior is harmful to themselves and others.
c.) “Your son has probably seen changes in you when you were drinking.”
After orienting the client to the addiction treatment unit, the nurse suggests that the client invite his 13-year-old son to the family sessions. The client questions why the son needs to participate, because he has not seen his father drunk. What is the best response by the nurse? (1 point) a.) “Your son probably knows that you are an alcoholic.”
b.) “Thirteen-year-olds are old enough to start learning about the effects of alcohol.”
c.) “Your son has probably seen changes in you when you were drinking.”
d.) “It’s good that you have concern for your underage son.”
4.) Feeling that nurses’ knowledge about drugs protects them from drug dependency
The nurse conducts an in-service session about impaired nursing practice. The nurse evaluates that the teaching was effective when one of the nurses says that the most influential risk for impaired nursing practice is which of the following? (1 point) 1.) Thinking that professionals are not at high risk for substance dependency
2.) Having grown up in a dysfunctional family
3.) Having a tendency to involve self in codependent professional and personal relationship
4.) Feeling that nurses’ knowledge about drugs protects them from drug dependency
A male client comes to day treatment surrounded by an intense odor of alcohol. The client staggers when walking but insists that that he has not consumed any alcohol. The nurse concludes that this behavior constitutes which of the following? (1 point) 1.) Rationalization
4.) “Perhaps they have noticed that your drinking creates consequences for you.”
A female alcohol-dependent client who has cardiomyopathy tells the nurse that she is certain that her family and friends are against her. The client goes on to say, “They stay on my back about my drinking and say I could die from it.” What would be the best response by the nurse? (1 point) 1.) “Anyone saying this to you must have a problem with his or her own drinking.”
2.) “Although their intentions are good, they have no right to judge another person’s drinking.”
3.) “Do you think they may be jealous that you can drink more than they can?”
4.) “Perhaps they have noticed that your drinking creates consequences for you.”
1.) Sobriety issue and depression at the same time
A client who is recovering from alcoholism presents in the psychiatric unit and tells the admitting nurse she is very depressed and has a hard time staying sober. The nurse concludes that the most likely treatment sequence for this client will be which of the following? (1 point) 1.) Sobriety issue and depression at the same time
2.) Sobriety issue before the depression
3.) Depression before the sobriety issue
4.) Depression after the sobriety issue has been resolved
4.) Once an individual has achieved sobriety, he or she continues to be at risk for relapse into drinking.
5.) People learn to change negative attitudes and behaviors into positive ones.
As part of the clinical experience, a student nurse is required to attend an Alcoholics Anonymous (AA) meeting and write a report about what was learned. What information would the student include in the report about the twelve-step program? (Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected. (1 point) 1.) A Higher Power will protect individuals if they feel like using.
2.) Once an individual learns how to be sober, he or she can graduate from attending meetings.
3.) Acceptance of being an alcoholic will prevent urges to drink, since it represents giving up one’s denial.
4.) Once an individual has achieved sobriety, he or she continues to be at risk for relapse into drinking.
5.) People learn to change negative attitudes and behaviors into positive ones.
The nurse working in the maternal care area is reinforcing physician health teaching about the risks of substance use during pregnancy. When questioned by the client, the nurse should reply that which drugs are most likely to lead to significant physical, cognitive, and developmental problems for any infant? (1 point) 1.) Cocaine
“Inhaling fumes from paints and wood stains may cause a disulfiram reaction.”
Having requested it as part of a comprehensive treatment program, the client is to receive disulfiram (Antabuse). Which statement should the nurse include when teaching the client about this drug? (1 point) “Taking disulfiram will reduce your physical craving for alcohol.”
“Eating inadequately cooked seafood may lead to disulfiram resistance.”
“Inhaling fumes from paints and wood stains may cause a disulfiram reaction.”
“If you consume alcohol while taking disulfiram, rapid intoxication will occur.”
HALLMARK SIGN OF SUBSTANCE ABUSE
• DYSFUNCTIONAL ANGER • MANIPULATIVE • IMPULSIVE
BEHAVIORS ASSOCIATED WITH SUBSTANCE ABUSE
DEPRESSION & SUICIDE
COMMON IN PATIENTS WHETHER SOBER OR INTOXICATED
THE TERM FOR THE ATTEMPT TO CONTROL THE ADDICT’S BEHAVIOR
CHANGES IN MOOD AND BEHAVIOR, IMPAIRED JUDGEMENT
BLOOD ALCOHOL LEVEL of 50 mg/dL Effects?
ATAXIA; LEGAL LEVEL OF IMPAIRMENT IN MOST STATES
BLOOD ALCOHOL LEVEL of 100 mg/dL Effects?
DEPRESSED FUNCTION OF ENTIRE MOTOR AREA OF BRAIN; ATAXIA, STAGGERING, EMOTIONAL LABILITY
– CULTURAL BELIEFS AND PRACTICES – SPIRITUAL AND RELIGIOUS BELIEFS
CULTURAL BELIEFS AND PRACTICES
– to be assessed in order to plan care around the clients beliefs and practices
SPIRITUAL AND RELIGIOUS BELIEFS
SPIRITUALITY – refers to a client’s internal values, sense of morality, and how he views the purpose of life. RELIGION – refers to a client’s beliefs according to an organized set of patterns of worship and rituals
This affects the way in which a client finds meaning, hope, purpose , and a sense of peace.
MENTAL STATUS EXAMINATION (MSE)
– LEVEL OF CONSCIOUSNESS – PHYSICAL APPEARANCE – BEHAVIOR – COGNITIVE AND INTELLECTUAL ABILITIES
LEVEL OF CONSCIOUSNESS
ALERT – responsive and able to fully respond by opening her eyes and attending to a normal tone of voice and speech. – answers spontaneously and appropriately LETHARGIC – open her eyes and respond BUT drowsy and falls asleep readily STUPOROUS – vigorous or painful stimuli to elicit a brief response ex.) pinching a tendon or rubbing sternum – might not be able to respond verbally COMATOSE – unconscious and does not respond to painful stimuli DECORTICATE RIGIDITY – flexion and internal rotation of upper-extremity joints and legs DECEREBRATE RIGIDITY – neck and elbow extension, wrist and finger flexion
– personal hygiene – grooming – clothing choice EXPECTED FINDINGS: – well-kempt – clean – dressed appropriately for the given environment
assessment of voluntary and involuntary body movements, and eye contact MOOD: – information about the emotion that she is feeling AFFECT: – objective expression of mood, such as: – FLAT AFFECT – LACK OF FACIAL EXPRESSION
COGNITIVE AND INTELLECTUAL ABILITIES
– orientation to time, person, and place. – memory both recent and remote IMMEDIATE: – ask client to repeat – a series of numbers – a list of objects RECENT: – ask client to recall recent events – visitors from the current day – purpose of mental health appointment or admission REMOTE: – ask client to state a VERIFIABLE fact from his past – DOB – Mother’s maiden name
CLIENT’S LEVEL OF KNOWLEDGE – what he knows about his current illness or hospitalization CLIENT’S ABILITY TO CALCULATE – if he can count backward from 100 in serials of 7 CLIENTS ABILTY TO THINK ABSTRACTLY – if he can interpret a cliché – the ability to interpret a higher level of thought process PERFORM AN OBJECTIVE ASSESSMENT OF THE CLIENT’S PERCEPTION OF HIS ILLNESS
CLIENT’S JUDGEMENT BASED ON HIS ANSWER TO A HYPOTHETICAL QUESTION
CLIENT’S RATE AND VOLUME OF SPEECH, AS WELL AS THE QUALITY OF HIS LANGUAGE
STANDARDIZED SCREENING TOOLS
– MINI-MENTAL STATE EXAMINATION – GLASGOW COMA SCALE
MINI-MENTAL STATE EXAMINATION (MSE)
ASSESSMENT A CLIENT’S COGNITIVE STATUS – ORIENTATION to time and place – ATTENTION SPAN and ability to calculate by counting backward by seven – REGISTRATION and recalling of objects – LANGUAGE – naming of objects – following of commands – ability to write
GLASGOW COMA SCALE
– used to obtain baseline assessment – eye, verbal, and motor response is evaluated and a number value based on the response is assigned – highest value possible is 15 – indicated that the client is awake and responding appropriately – a score of 7 or less – indicate a client is in a coma
– CHILDREN AND ADOLESCENTS – OLDER ADULTS
CHILDREN AND ADOLESCENTS
MENTAL HEALTH DIAGNOSES
SERIOUS MENTAL ILLNESS
ROLE AND LIFE CHANGES
THERAPEUTIC STRATEGIES IN THE MENATL HEALTH SETTING
– COUNSELING – MILIEU THERAPY – PROMOTION OF SELF-CARE ACTIVITIES – PSYCHOBIOLOGICAL INTERVENTION – COGNITIVE AND BEHAVIORAL THERAPIES – HEALTH TEACHING – HEALTH PROMOTION AND HEALTH MAINTENANCE – CASE MANAGEMENT
– using therapeutic communication skills – assisting with problem solving – crisis intervention – stress management
– orienting the client to the physical setting – identifying rules and boundaries of the setting – ensuring a safe environment for the client – assisting the client to participate in appropriate activities
PROMOTION OF SELF-CARE ACTIVITIES
– offering assistance with self-care tasks – allowing time for the client to complete self-care tasks – setting incentive to promote client self-care
– administering prescribed medication -providing teaching to the client/family about medications – monitoring for adverse effects and effectiveness of pharmacological therapy
– Nausea, fatigue, thirst, polyuria, and fine hand tremors – Weight gain – Hypothyroidism – Early signs of toxicity: diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination – possible renal impairment
– Therapeutic level range from 0.5 to 1.5. – Excreted by the kidneys. Maintain adequate serum levels – Assess electrolytes, especially sodium. – Baseline studies of renal, cardiac and thyroid status must be obtained before therapy is begun – Teach the client early symptoms of toxicity. If drug is continued, coma, convulsions, and death may occur. – instruct client to keep salt usage consistent – Use with diuretics is contraindicated. Diuretic-induced sodium deletion can increase levels causing toxicity.
– To minimize risk of severe rash, give low dosage, 25-50 mg/day initially, then gradually increase to maintenance dose of 200 mg/day (alone) or 100 mg/day (w/ valproate) or 400 mg/day (w/ Carbamazepine)
– perception of own health beliefs about illness and wellness – activity/leisure activities, how a pt passes time – substance use or disorder – stress level and coping abilities (coping strategies, support systems) – cultural beliefs and practices -spiritual beliefs
Assessment: Mental Status Examination (MSE) – Level of consciousness
– Alert – pt is responsive and able to fully respond – Lethargy – pt is able to open eyes but is drowsy – Stupor – pt requires vigorous or painful stimuli; unable to respond verbally – coma – no response can be achieved – decorticated rigidity –> flexion and internal rotation of upper extremity joints and legs – decerebrate rigidity –> neck and elbow extension, wrist and finger flexion
Assessment: Mental Status Examination (MSE) – Physical appearance
– personal hygiene, grooming, clothing choice; is client well kept, clean, and dressed appropriately
Assessment: Mental Status Examination (MSE) – behavior
– mood –> gives info about emotion and feeling – affect –> objective expression of mood
Assessment: Mental Status Examination (MSE) – Cognitive and intellectual abilities
– assess orientation to time and place, memory recent and remote – immediate –> ask client to repeat a series of numbers – recent –> recall recent events – remote –> fact from the past that is verifiable – assess client level of knowledge, ability to calculate, ability to think abstractly, -perform objective assessment of illness – assess judgement based on a hypothetical question – assess rate and volume of speech
Assessment: Standardized Screening Tools
– Mini-Mental State Exam -Glasgow Coma Scale – baseline assessment of pts level of consciousness (highest value is 15, 7 or less =coma)
Considerations across the Lifespan: Children and Adolescents
Assessment – temperament, social and environmental factors, cultural and religious concerns and developmental level Mentally healthy children should trust others, view the world as safe, interpret their environments, master developmental tasks, appropriate coping skills Assess mood, anxiety, development, behavioral, eating disorders and risk for self-injury or suicide
Considerations across the Lifespan: The older adult – Assessment
Functional ability; economic and social status; environmental facts; physical assessment
Considerations across the Lifespan: The Older adult – standardized assessment tools
Geriatric depression scale Michigan alcoholism screening test Mini-Mental Status Exam Pain Assessments
Considerations across the Lifespan: The older adult – conducting assessment
– private, quiet space with enough lighting – make an intro, and determine pt’s name preference – stand or sit at the client’s level to conduct the interview – Use touch to communicate caring as appropriate – Include questions about difficulty sleeping, incontinence falls or other injuries -Include the family and significant others as appropriate – obtain detailed medication history – after interview summarize and ask for feedback from client
Therapeutic Strategies in the mental health setting: Counseling
Therapeutic communication skills; help with problem solving; stress management
Therapeutic Strategies in the mental health setting: Milieu therapy
helps pt build adaptive coping interact more effectively and strengthen relation skills; orienting the client to the physical setting; identifying rules and boundaries of the setting; ensuring a safe environment for pt
Therapeutic Strategies in the mental health setting: Promotion of self-care activities
Offer assistance with self-care tasks; allow time for the client to complete self-care tasks; setting incentives to promote self-care
Therapeutic Strategies in the mental health setting: Psychobiological interventions
Give medications; providing teaching to the client/family about medications; monitoring for adverse effects and effectiveness
Therapeutic Strategies in the mental health setting: Cognitive and behavioral therapies
some definitions emphasise positive psychological well-being
a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.
What is mental health? For example, the World Health Organization has defined mental health as:
連續的Mental health is seen as a continuum, ranging from having good mental health to having mental illness. A person will vary in their position along this continuum at different points in their life. A person with good mental health will feel in control of their emotions, have good cognitive functioning and positive interactions with people around them.
ranging, spectrum, scope
what is psychosis?
(adj)風波 There are severe disturbances in thinking, emotion and behaviour.
In the world of medicine, the Alzheimer’s condition is considered to be the enemy of mental health. Sleep deprivation or the lack of sleep is also a factor that is recognized when concerning the healthy state of one’s mind. In various studies, sleep disorders have been linked to several mental degenerative diseases. To expand on that point, “researchers reported that biomarkers for amyloid beta (A?), the plaque-building peptides associated with Alzheimer’s disease, increase over time in elderly adults with OSA in proportion to OSA severity. Thus, individuals with more apneas per hour had greater accumulation of brain amyloid over time.” Based on the data from the studies that reported the increase of Alzheimer’s in patients with sleep apnea, there is a potential positive correlation between how the sleep cycle functions and how susceptible an individual is for contracting the issue. In recent years, much study has been dedicated to the discovery of how Alzheimer’s is formed. Other professionals claim that “Alzheimer’s disease (AD) pathogenesis is widely believed to be driven by the production and deposition of the amyloid-beta peptide (Abeta).” Over time, the buildup of these hazardous plaque cells inhibits the normal functions of the mind. Plaque is well known for clogging the arteries and veins of the bloodstream and cardiovascular system. Today, plaque or amyloid beta peptide is a candidate for the position of the leading cause for dementia and Alzheimer’s level dementia. In fact, “for many years, investigators have been puzzled by the weak to nonexistent correlation between the amount of neurotic plaque pathology in the human brain and the degree of clinical dementia.” By understanding how the Alzheimer’s condition functions, individuals concerned about the issue have more of an opportunity to put their own minds at ease. Beyond this, understanding the functions of plaque and Amyloid Beta will only further the knowledge of those wishing to avoid Alzheimer’s.
What is Amyloid Beta?
The plaque found in the bloodstream of an individual’s body is used to prevent infections as well as provide a barrier from the external elements trying to enter the body. In some instances, plaque can become harmful under some conditions, mainly because of how it constricts the flow of blood. Due to the rise of Alzheimer’s related issues, more attention is being brought to what is considered the most contributing factors of Alzheimer’s. To gain some perspective, “AD is a neurodegenerative disorder that afflicts approximately five million older Americans. OSA is even more common, afflicting from 30 to 80 percent of the elderly, depending on how OSA is defined.” The bodies defense systems are much weaker in elderly individuals, making them more likely to produce a plaque related issue. The elderly are more easily influenced by the common issues that move throughout the world, and these issues include heavy plaque buildup. Plaque particles function as scales or platelets flowing the bloodstream, bunching together when repairing the body. To expand on this, “plaques form when protein pieces called beta-amyloid clump together. Beta-amyloid comes from a larger protein found in the fatty membrane surrounding nerve cells.” In a sense, beta amyloid plaque cells are an isotope spawning from their more useful and helpful counterparts. Beta amyloid plaque cells work incredibly different from the bodies normal plaque cells. For example, “the most damaging form of beta-amyloid may be groups of a few pieces rather than the plaques themselves. The small clumps may block cell-to-cell signaling at synapses. They may also activate immune system cells that trigger inflammation and devour disabled cells.” As opposed to blocking harmful bacteria, beta amyloid plaque cells do the opposite of what is necessary for a functional body. The next question that researchers asked involved the relationship between amyloid beta cells and the progression of Alzheimer’s.
How Does Amyloid Beta Influence Alzheimer’s?
Today, sleep disorders have grown to be recognized as a serious threat to one’s health, despite how harmless these conditions may appear. The process of sleep consists of a few different steps, each step helping to create adequate rest. Sleeping conditions such as sleep apnea and sleep walking can be more harmful to one’s condition than anticipated. In fact, “Several studies have suggested that sleep disturbances might contribute to amyloid deposits and accelerate cognitive decline in those at risk for AD,” said senior author Ricardo S. Osorio from the New York University School of Medicine.” The studies behind sleep disturbances believe to have found a link between the amount of plaque buildup in an individual and their risk for developing Alzheimer’s disease. Despite this beneficial discovery, there is still some speculation as to how accurate these findings are. Plaque buildup is known to cause several issues, yet Alzheimer’s disease is a more complicated health condition than most individuals realize. Furthermore, “the purpose of this study was to investigate the associations between OSA severity and changes in AD biomarkers longitudinally, specifically whether amyloid deposits increase over time in healthy elderly participants with OSA.” OSA is a more aggressive form of sleep apnea, creating more health-related issues for the individuals with said condition. Patients also need to understand that even the most basic forms of sleep apnea can cause a severe plaque buildup if left untreated. Sleep apnea restricts blood flow, thus impeding the natural movements of the blood platelets in the bloodstream. One study found “that more than half the participants had OSA, including 36.5 percent with mild OSA and 16.8 percent with moderate to severe OSA.” Each of the participants in the study conducted above were elderly individuals; the most likely people to contract a dementia related disorder. Since sleep apnea causes plaque buildup and OSA is more harmful than the normal amount of sleep apnea, it can be understood that plaque buildup can be a major cause for Alzheimer’s. After learning how plaque buildup functions, a patient at risk for Alzheimer’s or even normal sleep apnea has more of an opportunity to find a positive treatment method.
How can Amyloid Beta and Alzheimer’s be treated?
If the Alzheimer’s condition is linked to sleep disorders such as sleep apnea or OSA, then the treatment methods are clear. Staying healthy in the present is one of the best opportunities an individual has for preventing conditions such as Alzheimer’s and dementia. Essentially, it is the small things that an individual does every day that culminate into a healthy lifestyle. On another note, “the high prevalence of OSA the study found in these cognitively normal elderly participants and the link between OSA and amyloid burden in these very early stages of AD pathology.” It is the elderly that take a major portion of the damages caused by dementia related conditions. However, it is the early signs of a health condition that allow an individual to lead a healthy life. For example, overcoming issues such as sleep apnea puts an individual at a greater chance for health and survival. To treat sleep apnea, “the CPAP, dental appliances, positional therapy and other treatments for sleep apnea could delay cognitive impairment and dementia in many older adults.” The purpose of the CPAP machine is to provide more airflow to the lungs and more oxygen to the bloodstream as a result. When the bloodstream works the way it was designed to, the amount of plaque platelet buildup is normalized as well. With a normal plaque concentration, the ability to develop Alzheimer’s is greatly decreased.
Alzheimer’s is a condition that slowly wipes away the mental state of its victims. This condition is not always simple to recognize, but it can be prevented under the correct circumstances. Because of this issue, there have been a plethora of studies dedicated to sleep disorder prevention and Alzheimer’s dementia prevention. For example, one study showed that “deposited Abeta is more easily cleared from the brain in animal models and does not show the same physical and biochemical characteristics as the amyloid found in AD.” If this condition can be cleared more easily in less evolved animals, it is only a matter of time before research catches up with technology. Within the human body there are several anomalies that cause certain health conditions to occur. To expand upon thus, “the composition of these pools of Abeta reflects different populations of amyloid deposits and has definite correlates with the clinical status of the patient.” Alzheimer’s may cause an individual to forget who they are, but there is always an element of that individual remaining inside of themselves. This element is called hope, and it is incredibly useful in the world of medical research. Without hope, not even a potential link between plaque and Alzheimer’s can be found.
But also having positive individuals surrounding them and understanding their issues can produce an even bigger response in their recovery. Offering that support no matter how little can assist an individual in their own positive thinking and their journey to mange any hurdles to may have to cross. 1. 2 It is reported that 1 in 4 people suffer with some form of mental illness within the UK. The definition of the exact cause of mental illness is unknown.
However, due to extensive research undertaken in this area, it largely became apparent that 1 Sarah Goulding Health & Social Care Level 3 biological, social, and psychological factors contribute to an individual’s mental wellbeing and mental health problems. In order to identify with the illness, knowledge of the causes of such is of importance.
Biological factors Neurotransmitters are chemicals within the body that convey messages from one brain cell to another. In definition; they assist the nerve cells within the brain to communicate with each other. A dysfunction or lack of communication with the brains nerve cells may cause abnormal functioning with in the brain.
This means that it may not work in the way in which it is designed to. The consequences of this can therefore origin symptoms of mental illness. Mental illness can in some cases also be hereditary. It is believed that this is due to a defect in the genes passed through family generations. It is not just one gene that defines mental illness; it would concern a combination of genes. However, it must be noted that in the case of these genes having been passed down, it does not mean that the individual with develop the illness.
This could be triggered by a range of factors for example; the way in which the genes combine and react and factors concerning biological, social, and psychological interactions. These are not the only biological factors that may influence mental health; defect to the brain, injury, pre natal damage, substance abuse, poor nutrition and infection may all have effect in the development of mental illness. Social factors Social factors can play a large part in the development of mental illness. This includes reasoning such as educational levels, social interactions, work pressures, the communities in which the individual lives, their emotional support, relationships, their upbringing and even poverty.
It is believed that this could be due to the level of the individual’s comprehension of circumstance. Social factors can present individuals with a level of vulnerability with regards to mental health issues. Psychological factors 2 Sarah Goulding Health & Social Care Level 3 Psychology relates to the mind and emotions and includes concern to the emotional wellbeing of an individual. The emotional state of an individual can, in some cases, cause imbalance and trigger the causes of mental health issues.
Factors of which may include; psychological trauma, the loss of a loved one, neglect, and the ability to relate. Most of which is believed to have effect on mental health when occurrence happens at a young age. 1. 3 As with all illness and general day to day life issues, mental health and wellness comes with each individual having varied levels of resilience. There are many types of risk factors and protective factors that can influence this level of resilience. This can affect the individual’s tendency to manage.
Understanding each individual’s barriers can be a way forward in the assistance to overcome their issues. Risk factors increase the probability of issues occurring; they can create vulnerability in an individual and can heed their management and/or recovery. Risk factors can also worsen their mental wellbeing or mental health issues. Such factors can arise in many forms and can be biological or psychological. Influences of such factors may arise from parental control, relationships, working environments or school environments, outside influences such as media, and the community in which they live.
Feelings of inequality, discrimination and seclusion can all cause jeopardy in the recovery and management of mental health and wellbeing. Protective factors are characteristics in an individual that help them to deal with things in a more effective manner therefore eliminating occurrences creating factors of risk. Protective factors can be described as a safeguard of stress and can be drawn up in such situations. Individuals of inclusion, value, and support from their surrounding family, piers, and friends, are more empowered with the ability to protect.
This then connects with the importance of understanding mental wellness and mental illness. Assisting a suffering individual with the feeling of empowerment and assisting them to build up their protective factors will in turn help them on their road to recovery. 2. 1 3 Sarah Goulding Health & Social Care Level 3 There are various steps an individual can take to look after themselves and promote personal mental health and wellbeing. Steps researched and developed by the New Economics Foundation include; human connection, to be active, to take notice, to learn, and to give.
There are wide views and extensive research available to collaborate with their findings which suggest that human interaction, in any form, may it be speaking to someone new, listening when people speak to you no matter of interest, listening to someone’s thoughts and feelings or even just giving a colleague a lift to work can divert and promote a person’s mood.
This can in turn act as a stepping stone and assist as a protective factor in an individual suffering with mental health issues. Also, being active has been proven on many occasions to lower rates of depression and anxiety which is in some cases a leading factor of mental health issues. Learning new things can promote pride and improve self esteem and self worth.
Not only this but learning can be undertaken in activities therefore promoting social engagements. These are only a few examples further information can be found at www. mind. org. uk. 2. 2 Help and support from influences surrounding an individual with mental health issues can help them to aim positively and actively boost determination. Assistance in this way has proven to provide confidence in supporting personal mental wellbeing and mental health. There are many ways in which you can help no matter the significance; the small things make the biggest differences.
For example; show interest in the individual, listen to what they have to say and engage in conversation. Find out what theirs likes are, their strengths and weaknesses. Talk about their whole life, their family, their hobbies, places they like to go. Don’t just focus on the illness; the illness is not the person. Be alert and look out for signs of distress, ask them how they feel. Promote and undertake activities, or just offer help with small jobs.
These are only to name a few. Knowing that people care, knowing that people are looking through the illness and getting to know the real person can offer great support and promote self confidence. It is all about helping others to help themselves. 2. 3 Self help skills, to an individual with mental health issues, are the key to living an actively manageable lifestyle.
The aim of encourage mental wellbeing and mental 4 Sarah Goulding Health & Social Care Level 3 health is to promote growth in the individual whilst aiming towards recovery and wellness. Developing a strategy to follow presents you with the tools needed to strive forward and overcome any hurdles that may need to be crossed along the way.
To elaborate on the meanings of this, WRAP will be used as example. WRAP is a wellness recovery plan developed by individuals with mental health and other various health issues. The way in which this was done was by identifying on a personal level what makes them feel ‘well’. This is then used as a wellness tool. The objective is to promote wellbeing, relieve symptoms and provide an individual with the means to overcome.
Tools such as talking to a friend, focus exercises, sleeping, writing, listening to music, looking through old pictures, making a list of accomplishments, and doing something for someone else, are amongst the list of the most commonly used tools. Having the tools there to assist with avoidance regarding triggers of mental issues is also a supporting factor. Having these tools to hand in a binder or in a box organised in a personal way to each individual is a key element to their success.
Having a wellness tool box is not the only element to the success of mental health and wellbeing. Others include; a daily maintenance plan, identifying triggers, action planning, identifying early warning signs and crisis planning. Having someone there to help create this action plan focusing on the points developed by WRAP gives encouragement and supports them to promote the health and wellbeing in a positive and manageable way.
If you would like more information this can be found at www. mentalhealthrecovery. com/wrap 2. 4 Describe key aspects of local, national or international strategy to promote mental wellbeing and mental health within a group or community. 2. 5 Evaluate a local, national or international strategy to promote mental wellbeing and mental health within a group or community. References http://www. who. int/mental_health/en/ http://www. webmd. com/anxiety-panic/mental-health-causes-mental-illness 5 Sarah Goulding Health & Social Care Level 3
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1. Which data gathering technique is employed during the assessment phase of the nursing process? A. Asking the client to rate mood after administering an antidepressant B. Asking the client to verbalize understanding of previously explained unit rules C. Asking the client to describe any thoughts of self-harm D. Asking the client if the group on assertiveness skills was helpful
ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. The other three options are employed during the evaluation phase of the nursing process.
2. Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems? A. Medical history is of little significance and can be eliminated from the nursing assessment. B. Assessment provides a holistic view of the client including biopsychosocial aspects. C. Comprehensive assessments can be performed only by advanced practice nurses. D. Psychosocial evaluations are gained by subjective reports rather than objective observations.
ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities.
3. Which nursing diagnosis should a nurse identify as being correctly formulated? A. Schizophrenia R/T biochemical alterations AEB altered thought B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance C. Depressed mood R/T multiple life stressors D. Developmental disability R/T early-onset schizophrenia AEB hallucinations
ANS: B The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the client’s condition, facilitating the choice of interventions.
4. Which expected client outcome should a nurse identify as being correctly formulated? A. Client will feel happier by discharge. B. Client will demonstrate two relaxation techniques. C. Client will verbalize triggers to anger by end of session. D. Client will initiate interaction with one peer during free time within 2 days.
ANS: D The statement “Client will initiate interaction with one peer during free time within 2 days.” is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.
5. Which statement regarding nursing interventions should a nurse identify as accurate? A. Nursing interventions are independent from the treatment team’s goals. B. Nursing interventions are solely directed by written physician orders. C. Nursing interventions occur independently but in concert with overall treatment team goals. D. Nursing interventions are standardized by policies and procedures.
ANS: C The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client’s care.
6. Within the nurse’s scope of practice, which function is exclusive to the advance practice psychiatric nurse? A. Teaching about the side effects of neuroleptic medications B. Using psychotherapy to improve mental health status C. Using milieu therapy to structure a therapeutic environment D. Providing case management to coordinate continuity of health services
ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy.
7. A nurse charts “Verbalizes understanding of the side effects of Prozac.” This is an example of which category of focused charting? A. Data B. Problem C. Action D. Response
ANS: D “Verbalizes understanding of the side effects of Prozac.” is an example of the response category of focused charting. The response is a description of the client’s reaction to any part of medical or nursing care.
9. Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)? A. CIWA scale B. GGT C. MMSE D. CAPS scale
ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels which may be an indication of alcoholism.
10. What is being assessed when a nurse asks a client to identify name, date, residential address, and situation? A. Mood B. Perception C. Orientation D. Affect
ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the client’s orientation. Assessment of the client’s orientation to reality is part of a mental status evaluation.
11. What is the purpose when a nurse gathers client information? A. It enables the nurse to modify client behaviors related to personality disorders. B. It enables the nurse to make sound clinical judgments and plan appropriate client care. C. It enables the nurse to prescribe the appropriate medications. D. It enables the nurse to assign the appropriate Axis I diagnosis.
ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical judgments and plan appropriate care. The nurse should complete a thorough assessment of the client including information collected from the client, significant others, and health-care providers.
13. The following outcome was developed for a client: “Client will list five personal strengths by the end of day 1.” Which correctly written nursing diagnostic statement most likely generated the development of this outcome? A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements B. Self-care deficit R/T altered thought processes C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt
ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written.
15. A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client’s problem? A. The client will avoid daytime napping and attend all groups. B. The client will exercise, as needed, before bedtime. C. The client will sleep 7 uninterrupted hours by day four of hospitalization. D. The client’s sleep habits will improve during hospitalization.
ANS: C The outcome “The client will sleep 7 uninterrupted hours by day four of hospitalization.” is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.
16. The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement? A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. B. The client has a history of four suicide attempts in adolescence. C. The client expresses hopelessness and helplessness and isolates self. D. The client has disorganized thought processes and delusional thinking.
ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of a risk for suicide nursing diagnosis. Disorganized thoughts and delusional thinking would lead to the development of an altered thought process nursing diagnosis.
17. A student nurse asks an instructor how best to develop nursing outcomes for clients. Which reply by the instructor most accurately answers the student’s question? A. “Use the Nursing Interventions Classification (NIC) as a reference for nursing outcomes.” B. “Look at your client’s problems and set a realistic, achievable goal.” C. “Use the Nursing Outcomes Classification (NOC) as a reference for nursing outcomes.” D. “Copy your standard outcomes from a nursing care plan textbook.”
ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions.
18. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client’s problem? A. Altered thought processes B. Altered sensory perception C. Anxiety D. Chronic confusion
ANS: B The nursing diagnosis altered sensory perception accurately reflects the client’s symptoms of hearing things that others do not. A nursing diagnosis describes a client’s condition and facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes.
19. A nurse is evaluating the effectiveness of teaching after instructing a group of clients on joint replacement. In the evaluation step of the nursing process, which learning domain is the most difficult to measure? A. Normative domain B. Affective domain C. Cognitive domain D. Psychomotor domain
ANS: B Affective knowledge is the most difficult to evaluate because of differences in values, cultures, and attitudes.
20. A client is recovering from abdominal surgery. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse? A. Assessing the client’s level of pain B. Assessing and documenting the client’s vital signs C. Assessing skin turgor and hydration status D. Assessing incisional site for serosanguineous drainage
ANS: A Pain will distract the client and interfere with the learning process.
21. During the implementation phase of the nursing process, a nurse is teaching an adult with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? A. Using repetition B. Speaking directly face-to-face C. Employing the use of sign language D. Providing large-print materials
ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing.
22. A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation? A. Provide warm milk and a backrub. B. Give a sleep medication. C. Hold a relaxation group before bedtime. D. Review the client’s normal sleep pattern.
ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client’s health or situation. In this situation, the nurse must initially determine the client’s normal sleep patterns in order to evaluate if a true problem exists.
23. An instructor overhears a student say, “That family seems to disagree more than agree. The family seems to be dysfunctional.” To further assess the family’s situation, which would be an appropriate instructor reply? A. “Families who disagree can be a challenge to the treatment team.” B. “You seem very critical of the family. Do you believe that you are unable to help them?” C. “Let’s bring the family in for an educational session to improve their communication.” D. “What appears to trigger family disagreements?”
ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client’s health or situation. In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts.
24. Which nursing response would be appropriately used in the evaluation phase of the nursing process? A. “If I were in your situation, I would not repeat a behavior that has caused problems.” B. “What do you think needs changing, and what do you want to do differently?” C. “What exactly will it take to carry out your plan, and what else do you need to do?” D. “This new approach seems to work for you.”
ANS: D In the evaluation phase of the nursing process, the nurse evaluates progress toward attainment of the expected outcomes.
25. A client diagnosed with major depressive disorder states, “Why should I keep trying to get a job? I mess up everything I do.” Which correctly written nursing diagnosis best reflects the content and mood themes in this client’s statement? A. Hopelessness R/T poor job performance B. Risk for impaired adjustment R/T inadequate social skills AEB isolation C. Altered role performance R/T the fear of failure AEB not seeking employment D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred
ANS: C An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it doesn’t as of yet exist. The client’s statement indicates that role performance is altered due to the fact that fear of failure prevents seeking employment.
26. During an intake interview, which question would assist the nurse in gathering data about the client’s judgment? A. “What brought you to the hospital? Do you know what day and season it is now?” B. “On a scale of 1 to 10, how would you rate your stress level?” C. “What does the phrase ‘a rolling stone gathers no moss’ mean to you?” D. “If you found a stamped, addressed envelope in the street, what would you do?”
ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client’s health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment based on the client’s action choice.
27. An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals? A. “What do you think needs to change about how you express anger?” B. “How did you feel after attending the anger management session?” C. “On a scale of 1 to 10, please rate your current level of anger.” D. “What bothers you about the actions of others when you get angry?”
ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation.
28. The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview? A. “Appears uncooperative. Exhibits characteristics of depression.” B. “Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression.” C. “States, ‘I don’t need to be here.’ when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission.” D. “Unwilling to respond openly during interview.”
ANS: C Documentation occurs in the implementation phase of the nursing process. All charting entries to the client’s legal record should be objective and based on assessed data. Implications and generalizations should be avoided.
29. A client is assigned the nursing diagnosis of impaired social interaction R/T socio-cultural differences AEB client stating, “Although I’d like to, I don’t join in because I don’t speak the language so good.” Which correctly written outcome addresses this client’s problem? A. The client will collaborate with nursing staff to set specific goals by day 3. B. The client will participate in one group activity of choice by day 2. C. The client will express a desire to interact with others. D. The client will become increasingly independent by discharge.
ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation.
30. The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted? A. The client who is experiencing tremors and has a need for medication adjustment B. The client who is experiencing anxiety and a sad mood after separation from spouse C. The client who is a single parent and hears voices stating, “Kill your infant son” D. The client who argued with her boyfriend and inflicted a superficial cut on her arm
ANS: C In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client’s health or situation. These data are prioritized to meet client needs with an emphasis on safety.
31. Which of the following nursing interventions fall within the standards of psychiatric-mental health clinical nursing practice for a nurse generalist? (Select all that apply.) A. Assist clients to perform activities of daily living. B. Consult with other clinicians to provide services for clients and effect system change. C. Encourage clients to discuss triggers for relapse. D. Use prescriptive authority in accordance with state and federal laws. E. Educate families about signs and symptoms of alcohol dependence and withdrawal.
ANS: A, C, E Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric-mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority.
32. Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.) A. Client outcomes are specifically formulated by nurses. B. Client outcomes are not restricted by time frames. C. Client outcomes are specific and measurable. D. Client outcomes are realistically based on client capability. E. Client outcomes are formally approved by the psychiatrist.
ANS: C, D The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others.
33. After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? (Select all that apply.) A. Medical judgments related to the psychiatric disorder B. Unmet client needs present at the moment C. Supporting data that validate the diagnosis D. Outcomes that will be targets for nursing interventions E. Statements of client problems of a functional nature
ANS: B, C, E A nursing diagnosis is a statement of a client’s functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it does not as yet exist.
persistent pattern of inattention and/or hyperactivity impulsivity that interferes with functioning or development
Diagnostics Criteria for ADHD
Inattention Hyperactivity and Impulsivity
Etiology – ADHD
Sx presents before age 7 Must have 6 or more symptoms persisting at least 6 months Sx present in two or more settings Impairment in social, academic, occupational setting
Inattention – Characteristics
Deficit in: 1. Attention 2. Sustaining attention 3. Listening 4. Following through instruction 5. Organizing tasks and activities 6. Interest in activities require mental effort Also: 7. Loses things necessary for tasks/activities 8. Often forgetful
Hyperactivity – Characteristics
1. Fidgets hands/feet or squirm in seat 2. Hard to remain seated 3. Runs/climbs excessively 4. Hard to play or engage in activities quietly (loud) 5. “On the go” or “driven by the motor” 6. Talk excessively.
Impulsivity – Characteristics
1. Blurts out answer before question finished 2. Difficulty waiting turn 3. Interrupts or intrudes
Food substances (dyes, additives, etc.) play role in ADHD?
85% comorbidity of ADHD & psych disorders. All can be treated concurrently, except in …….
Substance abuse Bipolar disorder
ND r/t ADHD
1. Risk for injury r/t impulsive, accident-prone, inability to perceive self harm 2. Low self-esteem r/t dysfunctional family system and negative feedback 3. Non-compliance (with task expectations) r/t low frustration tolerance and short attention span
ND #1 – GOAL Risk for injury r/t impulsive, accident-prone, inability to perceive self-harm
Free from injury
ND #1 – INTERVENTIONS Risk for injury
1. Safe environment ~ Remove hazardous items 2. Identify risk-for-injury behaviors & institute consequences ~ Aversive reinforcement –> modify behavior 3. Provide adequate supervision ~ Safety is priority
ND #2 – GOALS Low Self-esteem
1. Independently direct own care/ADLs 2. Increased self-worth (verbalizing positive statements about self; less demanding behavior) 3. Identify factors lead to low self-esteem 4. Verbalize view of self-worth 5. Self-confidence (setting realistic goals & activity, and participate in life situation) 6. Participate in treatment program to promote self-evaluation
ND #2 – INTERVENTIONS
1. Realistic goals ~ Unrealistic goals –> set up for failure –> diminishes self-esteem 2. Plan activities for successful opportunities ~ enhances self-esteem 3. Unconditional acceptance & positive regard ~ affirmation of worth-while ct –> increase self-esteem 4. Immediate recognition & positive feedback/reinforcement ~Enhance self-esteem & increased desire behavior
ND #3 – GOALS Non- compliance
1. Participate and cooperate in therapeutic activities 2. Able to complete task s willingly and independently/minimum assistance
ND #3 – INTERVENTIONS Non-compliance
1. Free distractions environment ~ highly distractible even with minimal stimuli 2. One-to-one assistance for simple and concrete instructions ~ unable assimilate complicated and abstract information 3. Ask to repeat instructions ~ repetition –> identify level of comprehension 4. Establish goals to complete part of task, rewarding each task ~ short term goals –> not overwhelming; reward –> increase self-esteem & incentive 5. Gradually decrease assistance given while assuring assistance available if deemed necessary ~ independent & security
Meds for ADHD
Amphetamines: Vyvanse Dexedrine Adderall Should be used cautiously with comorbid condition: Cardiac & drug abuse Black box warning: sudden death
Meds for ADHD – other
Buproprion (Wellbutrin) Cautious with comorbid: seizures, bulimia, anorexia
S/E for ADHD Meds
Over-stimulation Restlessness Insomnia
Insomnia r/t ADHD Meds – Interventions
1. Prevent injury 2. Low stimulation – Quiet environment 3. Administer last dose at least 6 hours before bedtime
Anorexia/wt loss r/t ADHD Meds – Interventions
1. Take med immediately after meals 2. Weigh regularly
Tolerance/withdrawal r/t ADHD Meds
1. Rapidly developed 2. Drug holiday (at MD advice) to eval effectiveness and necessary continuation 3. No abrupt stop – Withdrawal S/E: N/V, abd cramping, HA, fatigue, weakness, mental depression, suicidal ideation, increased dreaming, psychotic behavior
CONDUCT DISORDER (CD) – specific
Violation of the basic rights for others
Family influences in CD
1. Parental rejection 2. Inconsistent mgmt/Harsh discipline 3. Early institutional 4. Frequent shifting of parental figures 5. Large family size 6. Absent father 7. Parents with antisocial PD/alcohol dependence 8. Marital conflict or divorce 9. Inadequate communication 10. Parental permissiveness
Diagnostic Criteria CD
1. Aggression to People or animals 2. Destruction of Property 3. Deceitful or Theft 4. Serious violations of rules
Aggression to People or animals
1. Bullies, threatens/intimidates 2. Initiatives physical fights. 3. Used weapon (bat, brick, knife, etc.) to harm others 4. Physically cruel to people/animals 5. Stole while confronting a victim 6. Sexual forced
1. Broken into other’s house/car/etc. 2. Lies to obtain goods/favors or avoid obligations 3. Stole items without confrontation
Serious violations to the rules
1. Beginning before 13 of age, stays out despite parental prohibitions 2. Run away from home for long period of time 3. Truant from school before 13
~ The pattern behavior manifested by the presence of three or more of these criteria in the past 12 months with at least one criterion present in the past 6 months. ~ Cause clinically impairment in social, economic and occupational functioning ~ Addtl: tobacco/liquor/non-prescribed drugs use; sexually active (early); low self-esteem; tough guy image; poor frustration tolerance; irritability, frequent temper outbursts; NOT anxiety, depression sx; ADHD is common.
ND #1 – Conductive Disorder (CD)
Risk for Other-Directed r/t characteristics of temperament, peer rejection, negative parental role models, dysfunctional family dynamics.
ND #1 – CD – Goals
1. Discuss feelings of anger 2. Will not harm others/property
ND #1 – CD – Intervention
1. Observe behavior frequently through routine activities ~ aware of agitation –> prevent/interven before violence occur 2. Redirect violent behavior with physical outlets for suppressed anger/frustration ~ Release excess energy/anger –> feeling of relaxation 3. Express anger and act as role model for anger expression ~ create anger –> effective to deal with it 4. Sufficient staff –> show strength ~ evidence of control over situation & security for staff 5. Tranquilizing medications or mechanical restraints/isolation ~ ensure safety
ND #2 – CD
Defensive Coping r/t low self-esteem and dysfunctional family system
ND #2 – CD – Goals
1. Verbalize personal responsibilities for difficulties experienced in interpersonal relationships 2. Accept responsibility for own behaviors without being defensive
ND #2 – CD – Interventions
Apervasive and sustained emotion that colours one’s perception of the world and how one functions.
Normal variations in mood: – Sadness – Euphoria – Anxiety
Variations occur in response to specific life experiences and are time limited
Not normally associated with significant functional impairment
Major Depressive Disorder (MDD)
One or more depressive episodes
Depressed mood or a loss of interest or pleasure in nearly all activities AND 4 or the following 7 additional symptoms:
1. Disrupted sleep patterns 2. Appetite (weight) changes 3. Poor concentration 4. Loss of energy 5. Psychomotor agitation or retardation 6. Excessive guilt or feelings of worthlessness Suicidal ideation
Can include: – psychotic features – melancholic features: – atypical features – catatonic features – Postpartum onset – Seasonal features (seasonal affective disorder [SAD])
presence of disorganized thinking, delusions (of guilt or being punished for sins, horrible disease or body rotting, poverty, bankruptcy), or hallucinations (usually auditory)
includes vegetative symptoms such as overeating and oversleeping
unresponsiveness and psychomotor retardation
seasonal effectiveness disorder
episodes of depression begin in the fall/winter and remit in the spring
there is reduced cerebral metabolic activity
this disorder is characterized by anergia, hypersomnia, overeating, weight gain and a craving for carbs; it responds to light therapy
short-duration depressive episode
depressive affect with at least four of the eight symptoms of MDD that persists more than four days but less than fourteen days
diathesis-stress model of depression
takes into the interplay of biology and life events in the development of depressive disorders
early life trauma may result in sensitization of the corticotropin-releasing factor (CRF) circuits to even mild stress in adulthood –> exaggerated stress response
the underlying assumption is that a person’s thoughts will result in emotions; if a person looks at his or her life in a positive way, the person will experience positive emotions
people may acquire a psychological predisposition due to early life experiences where negative predispositions can be reactivated during times of stress
Beck’s cognitive triad
1. A negative, self-deprecating view of self 2. A pessimistic view of the world 3. The belief that negative reinforcement (or no validation for the self) will continue in the future
*realizing that one has an ability to interpret life events in positive ways provides and element of control over emotions and, therefore, over depression
Learned helplessness theory of depression
although anxiety is the initial response to a stressful situation, it is replaced by depression if the person feels no control over the outcome
Children – depression
– Similar manifestations to those seen in adults
– Less likely to experience psychosis (auditory hallucinations more common than delusions)
– More likely to have anxiety and somatic symptoms
Adolescents – depression
– mood may be irritable rather than sad
– risk for suicide highest in mid-adolescents (15+)
Older adults – depression
not a normal part of aging!
loss of ability to experience joy or pleasure in living
occurs in almost 97% of people living with depression
constant pacing or wringing of hands
slowed movements and somatic complaints of headaches, malaise, backaches)
vegetative signs of depression
alterations in those activities necessary to support physical life and growth
e.g. change in BM and eating habits, sleep disturbances, lack of interest in sex
Nursing Phases of treatment and recovery from MD
1. acute phase: – 6-12 weeks and directed at reduction of depressive symptoms and restoration of psychosocial/work function
2. continuation phase: – 4-9 months is directed at prevention of relapse through pharmacotherapy, education, and depression-specific psychotherapy
3. maintenance phase: – one year or more is directed at prevention of reoccurrences of depression
**keeping the pt. a functional and contributing member of the community after recovery from the acute phase is the goal**
Selective serotonin reuptake inhibitors (SSRIs)
recommended as first-line therapy for most types of depression; they block the neuronal uptake of serotonin increasing availability in the synaptic cleft
they have relatively low adverse effects (no dry mouth, blurred vision, urinary retention; effective in depression with anxiety features and with psychomotor agitation
sometimes used to treat anxiety, OCD and panic disorders
a syndrome thought to be related to over activation of the central serotonin receptors, caused by either too high a dose or interaction with other drugs
symptoms include abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, altered mental state, myoclonus, increased motor activity, irritability, hostility and mood change
risk is highest when used in conjunction with MAOIs
inhibit the reuptake of norepinephrine and serotonin presynaptically
have sedative effects likely due to blockage of histamine receptors with a 10-14 day onset with full effects maybe 4-8weeks; choosing is based on what has worked for pt or not;
similar to antipsychotic agents, therefore anticholinergic actions are similar – dry mouth, blurred vision, tachycardia, constipation, urinary retention, GERD
Administering at night is beneficial because: 1. most TCAs have sedative effects; 2. the minor adverse effects occur while sleeping, increasing drug adherence
the enzyme responsible for breaking down norepinephrine, serotonin, dopamine and tyramine in the brain
Monoamine oxidase inhibitors (MAOIs)
anti-depressants that prevents the amines from becoming activated that breakdown NE, serotonin, dopamine and tyramine resulting in mood elevation
tyramine is of concern, as increased levels can cause high BP, hypertensive crisis and eventually cerebrovascular accident
particularly effective for atypical depression, panic disorder, social phobia, generalized anxiety, OCD, PTSD and bulimia
– Mechanism of action unknown
– Effective treatment for severe depression Treatment-resistant depression or so severely ill that rapid treatment is required
– Several contraindications
– Appears to be more effecitve in older adults RNs role: patient education and monitoring
at least one episode of mania alternates with major depression; psychosis may accompany the manic episode
hypomanic episode(s) alternate with major depression; psychosis is not present
hypomania tends to be euphoric; depression tends to put people at higher than average risk for suicide
more common in women
depression without episodes of mania
1. mood; 2. behaviour; 3. thought processes and speech patterns; and 4. cognitive function
has three phases, which guide panning of care:
1. acute 2. continuation (4-9mos) 3. maintenance
mild to moderate state in which people have voracious appetites for social engagement, spending, activity, and even indiscriminate sex; constant activity and a reduced need for sleep
flight of ideas
a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations or plays on words
inflated self regard, is apparent in both the ideas expressed and behaviour
the stringing together of words because of their rhyming sounds, without regard to their meaning
Symptoms of manic and depressive episodes
effective in the treatment of bipolar I acute and recurrent manic and depressive episodes and inhibits about 80% of acute manic and hypomanic episodes within 10-21 days
Indicated for reducing: – elation, grandiosity, and expansiveness – flight of ideas – irritability and manipulation – anxiety
To a lesser extent, this drug controls: – insomnia – psychomotor agitation – threatening behaviour – distractibility – hyper sexuality – paranoia
Often supplemented with olanzapine to prevent exhaustion/cardiac collapse and has a narrow therapeutic level 0.4-1.0 (toxic) therefore fluid levels and sodium levels are watched
2 longterm affects: – hypothyroidism – impairment of the kidneys’ ability to concentrate urine
Anticonvulsant drugs: Bi-polar treatment
Do not support the Kindling Theory, but are thought to be:
– superior for continuously cycling patients – more effective when no family hx of bipolar – effective at dampening affective swings in schizoaffective pts – effective at diminishing impulsive and aggressive behaviour in some non psychotic pts – helpful in cases of alcohol and benzo withdrawal – beneficial in controlling mania (within 2 weeks) and depression (within 3 weeks or longer)
an anticonvulsant chemically related to valproic acid; useful in treating lithium non responders in acute mania, rapid cycles, in dysphoric mania or have not responded to carbamazepine and preventing future mania
Liver fun and platelet count must be monitored; can cause drowsiness/dizziness and increase SI
normal dose: 50-100mcg
an anticonvulsant used with treatment-resistant bipolar for rapid cycling and severely paranoid, angry pts experiencing mania (dysphoric)
can cause bone marrow suppression and liver inflammation, therefore liver fxn and platelet count should be monitored weekly for up to 8 weeks
Clonazepam and lorazepam
anti-anxiety drugs useful in the treatment of acute mania in some pts who are resistant to other treatments
effective in managing psychomotor agitation seen in mania
AVOID: substance abusers
Olanzapine, risperidone, and quetiapine
atypical anti-psychotics that have sedative properties and seem to have mood-stabilizing properties and may be better tolerated and prevents mania relapse more effectively than lithium
the act of taking one’s own life
used to describe potentially self-injurious actions with a nonfatal outcome for which there is evidence that a person intended to kill him/herself
e.g. self harm, SI, desire to hasten death, risky behaviour, suicide threats
– complex pattern of characteristics, largely outside of the person’s awareness
– distinctive patterns of perceiving, feeling, thinking, coping and behaving
– emerges within bio-psychosocial framework
– an enduring pattern of deviant inner experiences and behaviours
– differ from cultural expectations; pervasive, inflexible and stable
Features: – Mistrustful, avoid relationships that cannot control. Incidents are often misinterpreted as having sinister or hidden meaning.
– These people are blind to their own behaviours; they are often hypercritical and attribute these traits to others (projection)
Management: – Nurse-client relationship may be difficult to establish (mistrust) – Need to use therapeutic communication technique such as acceptance, confrontation, and reflection, etc. – Goal is to examine problematic area and gain another view of the situation. – Associated anxiety may be treated with psychotropics –> May be treated with anti-anxiety meds or a low dose Seroquel
Features: – eccentric (unconventional & slightly strange) – pattern of social and interpersonal deficits, no close friends – odd beliefs, ideas of reference – when psychotic, symptoms mimic schizophrenia
Nursing interventions: – similar to that with schizo – provide social skills training – reinforcing and modelling socially appropriate behaviour
1. Borderline personality disorder
2. Antisocial personality disorder
3. Histrionic personality disorder
4. Narcissistic personality disorder
Borderline personality disorder (BPD)
Features: – pervasive patterns of instability of interpersonal relationships, self-image, and affects, as well as marked impulsivity that begins by early adulthood and is present in a variety of contexts – they appear more competent then they really are – when personal expectations are not met, they experience various emotions such as intense shame, self-hate, self directed anger, etc. – live from crisis to crisis (soap opera)
Affective instability: – rapid and extreme shifts in mood
Identity disturbance: – personality is poorly developed
Unstable interpersonal relationships: – fear of abandonment, insecure attachments
the primary defence or coping style used by people with BPD; the inability to incorporate positive and negative aspects of oneself or others into a whole image
e.g. individual may tend to idealize another person (friend, lover, nurse) at the start of a new relationship, hoping that this person will meet all of his or her needs; but the first disappointment, the individual quickly shifts to devaluation, despising the other
Interventions for BPD
1. Dialectical Behavioural Therapy (DBT) 2. Sleep enhancement 3. Prevention and treatment of self-injury 4. Establishing boundaries and limitations 5. Management of dissociative states 6. Behavioural Interventions 7. Pharmacological
Antisocial personality disorder
Features: – pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence – behaviourally impulsive and interpersonally irresponsible – fail to adapt to the ethical and social community standards – interpersonally engaging, but in reality lack empathy; lack of remorse – easily irritated, often aggressive directed at others
Interventions: – Milieu interventions – establish clear boundaries
Histrionic personality disorder
Features: – attention seeking, life of the party, uncomfortable w/single relationship – women: dress seductively – men: dress “macho” – become depressed when not centre of attn
Interventions: – help develop a sense of self w/out validation of others – ensure that the pt does not become dependant on the mental health system – reinforce personal strengths – encourage the pt to act autonomously
Narcissistic personality disorder
Features: – grandiose, inexhaustible need for admiration and lack of empathy – believe that they are superior, unique, special – they define the world through their own self-centred view
1. Avoidant personality disorder
2. Dependent personality disorder
3. Obsessive-compulsive personality disorder
Avoidant personality disorder
Features: – avoiding interpersonal contacts and social situations – perceiving themselves as socially inept
Interventions: – focus on refraining negative criticism; explore previous achievements of success
Dependent personality disorder
Features: – submissive pattern – cling to others to be taken care of
Intervention: – support these individuals to make their own decisions
Obsessive-compulsive personality disorder
**different than OCD**
Features: – not as many obsessions or compulsions – described as “not fun” – rigidity, perfectionism, and control are part of the clinical picture
Prolonged exposure, adaptation no longer possible; diseases of adaptation occur
Two major responses to stress
Anxiety and grief
Apprehension that is vague in nature; characterized by uncertainty and helplessness
Peplau’s four stages of anxiety
Mild, moderate, severe, panic
Emotional, physical, and social responses to loss
Kubler-Ross — Five Stages of Grief
Denial, anger, bargaining, depression, acceptance
Keeping a “stiff upper lip”; stuck in denial stage of grief; ambivalent feelings about lost one, outside pressure to continue life, perceived lack of coping mechanisms
Dysfunctional in management of daily living; fixed in anger stage of grief; anger turned inwards, can lead to depression
Maintaining personal possessions aimed at keeping lost one alive, unable to perform ADLs, refusing to participate in family gatherings, setting place at table for loved one long after death
Can only occur when person is able to remember both the good and bad qualities of partner
Anna Freud’s Ego Defense Mechanisms
Mild to moderate states of anxiety; adaptive or maladaptive
Covering up real or perceived weakness by emphasizing a trait one considers more desirable; physically handicapped boy cannot play football, compensates by becoming a great scholar
Refusing to acknowledge existence of/feelings about situation; woman drinks alcohol every day but doesn’t realize that she has a problem
Transfer of feelings from target to another; client is angry with doctor, does not express it, then becomes verbally abusive towards nurse
Making excuses or formulating logical reasons to justify unacceptable feelings/behaviors; man tells rehab nurse “I drink because it’s the only way to deal with my bad marriage and worse job”
Preventing unacceptable/undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts/behaviors; girl hates nursing and only went to school to please parents, but speaks to prospective students about excellence of nursing as a career
Responding to stress by retreating to earlier level of development for comfort measures; 2-year-old boy is hospitalized for tonsillitis and will only drink from bottle even though he has been drinking from cup for 6 months
Attempt to increase self-worth by acquiring characteristics of an individual one admires; teenaged boy who went through lengthy rehabilitation after accident decides to become physical therapist
Attempt to avoid expressing actual emotions about situation by using logic, reasoning, and analysis; woman’s husband is being transferred with his job to a city far away from woman’s parents, and she explains to her parents the advantages of moving
Integrating beliefs and values of another person into one’s own ego structure; child integrates parents’ value system by saying to another kid, “Don’t cheat, it’s wrong.”
Separating thought or memory from the feeling tone or emotion associated with it; a young woman describes being attacked and raped without showing any emotion
Attributing feelings/impulses unacceptable to one’s self to another person; girl feels strong sexual attraction to her track coach and tells her friend, “He’s coming on to me!”
Involuntary blocking unpleasant feelings and experiences from one’s awareness; an accident victim can remember nothing about the accident
Rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive; a mother whose son was killed by a drunk driver channels anger and energy into being president of local chapter of MADD
Voluntary blocking of unpleasant feelings and experiences from one’s awareness; Scarlett O’Hara says, “I don’t want to think about that now. I’ll think about that tomorrow.”
Symbolically negating or canceling out an experience that one finds intolerable; Man in nervous about new job and yells at wife, then stops and buys her flowers on the way home
Freud’s Personality Theory
Stages of development; birth to 5 years is the most important in the formation of basic character
Freud’s Three Components of Personality
Id, ego, superego
Instinct driven, “pleasure principle”; “I found this wallet, I will keep the money”, “Mom and Dad are gone, let’s party!”, “I’ll have sex with whomever I please, whenever I please.”
Rational self, “reality principle”; “I already have money. Maybe the person who owns this needs it”, “Mom and Dad said no friends over while they are away. Too risky”, “Promiscuity can be very dangerous.”
“Perfection principle”; “It is never right to take something that doesn’t belong to you”, “Never disobey your parents”, “Sex outside of marriage is always wrong”
Freud’s Three Mental Concepts and Operations
The conscious mind, the preconscious mind, and the unconscious mind
The conscious mind
Memories within awareness
Forgotten memories that can be recalled
The unconscious mind
Memories you are unable to bring to memory
Freud’s Stages of Personality Development: Birth to 18 months
Oral Stage – relief of anxiety through oral gratification
Freud’s Stages of Personality Development: 18 months to 3 years
Anal stage – independence and control, focus on excretory function (potty training)
Freud’s Stages of Personality Development: 3-6 years
Phallic Stage – identification with parent of same gender, sexual identity, focus on genital organs
Freud’s Stages of Personality Development: 6 – 12 years
Latency – sexuality repressed, relationships with same gender peers
Freud’s Stages of Personality Development: 13- 20 years
Genital – libido reawakened as genital organs mature, relationships with opposite gender
Sullivan’s Personality Theory
Individual behavior and personality development are the result of interpersonal relationships
Sullivan’s major personality concepts: Anxiety
Emotional discomfort we all try to avoid; develops when we can not satisfy our needs of achieve interpersonal security
Sullivan’s major personality concepts: Satisfaction of needs
All needs (water, food, warmth, tenderness, rest, sexual expression) must be met for an individual to have interpersonal security
Sullivan’s major personality concepts: Interpersonal security
A state where needs are met and the person has a sense of total well being
Sullivan’s major personality concepts: Self-system
Security measures to prevent anxiety e.g. “good me” or our response to positive feedback; “Bad me” or our response to negative feedback, increases our anxiety; “Not me”, a denial of situations that cause intense anxiety, horror, dread
Sullivan’s Stages of Development: Birth to 18 months
Infancy – relief of anxiety through oral gratification
Sullivan’s Stages of Development: 18 months to 6 years
Childhood – learning to delay personal gratification without undue anxiety
Sullivan’s Stages of Development: 6-9 years
Juvenile – learning to form satisfactory peer relationships
Sullivan’s Stages of Development: 9-12 years
Preadolescene – learning to form satisfactory relationships with persons of same gender
Sullivan’s Stages of Development: 12-14 years
Early adolescene – learning to form satisfactory relationships with persons of opposite gender; sense of identity
Sullivan’s Stages of Development: 12-21 years
Late adolescence – Establishing self-identity, intimate opposite-gender relationship
Erikson’s 8 Stages of Life
Focuses on social processes on the development of personality; when person struggles with developmental tasks
Erikson’s 8 Stages of Life: Infancy (Birth – 18 months)
Trust vs. Mistrust – develop basic trust in mothering figure, learn to generalize it to others
Erikson’s 8 Stages of Life: Early childhood (18 months – 2 years)
Autonomy vs. Shame and Doubt – gain some self-control and independence within environment
Erikson’s 8 Stages of Life: Late childhood (3-6 years)
Initiative vs. Guilt – develop a sense of purpose, ability to initiate and direct own activities
Erikson’s 8 Stages of Life: School age (6-12 years)
Industry vs. Inferiority – self-confidence by learning, competing, performing successfully, and receiving recognition from family and peers
Erikson’s 8 Stages of Life: Adolescence (12-20 years)
Identity vs. Role Confusion – integrate tasks mastered in previous stages into secure sense of self
Erikson’s 8 Stages of Life: Young adulthood (20 to 30 years)
Intimacy vs. Isolation – form intense, lasting relationship to another person, cause, institution
Erikson’s 8 Stages of Life: Adulthood (30-65 years)
Generativity vs. Stagnation – achieve life goals while considering welfare of future generations
Erikson’s 8 Stages of Life: Old age (65+)
Ego Integrity vs. Despair – review one’s life, derive meaning from positive and negative events, achieving positive sense of self-worth
individuals who refuse to maintain weight for their height; fear of gaining weight
some restrict food intake, where others binge eat and purge
individuals who binge eat and then compensate with behaviours such as self-induced vomiting, fasting, excessive exercise and using medications such as laxatives and diuretics
Binge Eating Disorder
individuals who engage in repeated episodes of binge eating but do not regularly use compensatory behaviours
Eating Disorder NOS
includes disorders that do not meet the criteria for either anorexia, bulimia or binge eating, which are all characterized by a significant disturbance in the perception of body shape and weight
Eating Disorders – epidemiology
Most eating disorders begin in early teens to mid-20s
Many people with disordered eating patterns do not present for help
Statistics do not reflect the magnitude of the problem
Eating disorders Co-morbitities
Depression and anxiety disorders (particularly social phobias) are common co-morbidities
Incidence of OCD is as high as 25% in individuals with anorexia nervosa
Personality disorders may occur in 42-75% of individuals with eating disorders
Link exists between trauma and eating disorders
Anorexia – Nursing Assessment
General: – Physical: Electrolytes, weight, hair, skin, pulse, temperature – Perception of the problem – Eating habits – History of dieting – Methods to achieve weight loss/control – Value attached to weight – Social functioning – Mental status
Anorexia Nervosa – thoughts and behaviours
– terror of gaining weight – preoccupation w/food – view of self as fat even when emaciated – peculiar handling of food –> cutting food into small bits / pushing pieces of food around plate – possible development of rigorous exercise regimen – possible self-induced vomiting, use of laxatives and diuretics – cognition so disturbed that individual judges self-worth by weight
Criteria for hospital admission – eating disorders
Physical: – weight loss, <85% below ideal
- rapid decline in weight w/food refusal
- inability to gain weight w/outpatient treatment
- temperature <36
- HR <40 bpm
- BP <90/60
- severe dehydration
- glucose <60mg/dL
- hepatic, renal or cardio organ compromise
- risk for suicide
- failure to comply w/treatment contract
- severe depression or other disorder
- family crisis or dysfunction
Anorexia Nervosa – Nursing Interventions
Acute: – medical stabilization including electrolyte imbalances/ideal body weight
Psychosocial: – weight-restoration program – milieu therapy –> cognitive distortion recognition
Pharmacological: – SSRIs are helpful in reducing OC behaviour – Antipsychotics (chlorpromazine) helpful for delusional or overactive pts – Atypical antipsychotics (olanzapine) help in improving mood and decreasing obsessive behaviour
Bulimia Nervosa – Nursing Assessment
General: – Often at or slightly below or above ideal body weight – Physical: Enlargement of parotid glands, dental erosion, electrolytes, dehydration – Social functioning – Mental status
Bulimia Nervosa – Nursing Interventions
Acute: – CBT used to normalize eating habits is the gold standard
Pharmacological: – Antidepressants
Milieu management: – stopping the cycle of binging and purging
Pharmacological: – SSRIs helpful in short-term, but clients often regain weight once med is d/c
Which female patient should the nurse recognize as having the highest risk to have or develop bulimia nervosa? The one who:
a. grew up in an underserved area b. lives in a society influenced by Eastern cultural beliefs c. is 20 years old d. is Asian Canadian
c. is 20 years old; Bulimia nervosa is rarely seen in children younger than 12, whereas anorexia nervosa may start as early as 7-12.
The degree of public services has not been linked as a predisposing factor for bulimia nervosa. Women living in industrialized nations influenced by Western culture are more predisposed to eating disorders than those influenced more strongly by Eastern cultural beliefs. There has not been much research that has focused on eating disorders and ethnicity; however, there is some evidence that Canadian Jewish women and Aboriginal women are at greater risk for developing an eating disorder than their non-Jewish and non-Aboriginal counterparts.
The nurse is caring for a 16 year old female patient with anorexia nervosa. What should the initial nursing intervention be upon the patient’s admission to the unit?
a. build a therapeutic relationship b. increase the patient’s caloric consumption c. involve the patient in group therapy to build a support group d. self-assess to decrease tendencies toward authoritarianism
d. self-assess to decrease tendencies toward authoritarianism; Without self-assessing, the nurse may inadvertently blame the patient for her health problems and assume a parental role rather than a therapeutic one. The nurse must first self-assess to become aware of personal feelings about the patient’s condition and then proceed to act in a therapeutic manner.
For the duration of the patient’s stay, building a therapeutic relationship will be important, but it is not the initial nursing intervention. For the duration of the patient’s stay, having a plan to increase the patient’s caloric consumption will be important, but it is not the initial nursing intervention. For the duration of the patient’s stay, involving the patient in group therapy to build a support network will be important, but it is not the initial nursing intervention.
The nurse is caring for a patient with bulimia. Which nursing intervention is appropriate?
a. monitor patient on bathroom trips after eating b. allow patient extensive private time with family members c. provide meals whenever the patient requests them d. encourage patient to select foods that she or he likes
a. monitor patient on bathroom trips after eating; Close observation of patients includes monitoring all trips to the bathroom after eating to prevent self-induced vomiting.
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Although family contact is important, extensive family time would interfere with the patient participating in the therapeutic activities on the unit. The milieu of an eating-disorder unit is purposefully organized to assist the patient in establishing more adaptive behavioural patterns, including normalization of eating. Providing meals whenever the patient requests them is not consistent with the normalization of eating. The highly structured milieu includes precise mealtimes, adherence to the selected menu, observation during and after meals, and regularly scheduled weigh-ins. Encouraging the patient to select foods that she likes does not support the normalization of eating and may not meet all the patient’s daily nutritional requirements.
The nurse is admitting a pt who weights 45kg, is 167 cm tall, and is below ideal weight. The pts BP is 130/80, pulse is 72, potassium is 2.5mmol/L, and ECG is abnormal. Her teeth enamel is eroded, her hands are visibly shaking, and her partied gland is enlarged. The pt states, “I am really worked up about coming to this unit.” What is the priority nursing diagnosis?
a. Powerlessness b. Risk for injury c. Imbalanced nutrition: less than body requirements d. Anxiety
b. Risk for injury; Although all diagnoses listed are appropriate to consider within the plan of care, the priority is Risk for injury related to the low potassium value, mildly elevated blood pressure, and abnormal ECG, which indicates hypokalemia. If left untreated, multiple complications— including cardiac arrhythmias and eventual respiratory depression—can occur.
Although Powerlessness is an appropriate nursing diagnosis, it is not the priority diagnosis. Although Imbalanced nutrition: Less than body requirements is an appropriate nursing diagnosis, it is not the priority diagnosis. Although Anxiety is an appropriate nursing diagnosis, it is not the priority diagnosis.
The nurse is planning care for a patient with an eating disorder. What outcomes are appropriate? Select all that apply.
a. the patient will experience a decrease in depression b. the patient will identify four methods to control anxiety c. the patient will collect different kinds of cookbooks. d. the patient will identify two people to contact if suicidal thoughts occur
a, b, d. Patients with eating disorders are very likely to have depression, anxiety, higher suicide rates, and problems with substance abuse. Therefore, decreasing depression, controlling anxiety, and having a support system in place are reasonable outcomes for planning care. Patients with eating disorders are very likely to have depression, anxiety, higher suicide rates, and problems with substance abuse. Therefore, decreasing depression, controlling anxiety, and having a support system in place are reasonable outcomes for planning care.
4 C’s of substance use disorder
Compulsive Use Cravings Continued Use – despite serious consequences Can’t Stop
ABCDE – substance use disorder
– Inability to consistently ABSTAIN
– Impairment in BEHAVIOURAL control
– CRAVING or hunger for drugs or rewarding experiences
– DIMINISHED recognition of significant problems with one’s behaviours and interpersonal relationships
– A dysfunctional EMOTIONAL response
The nurse is caring for a patient with an addictive disorder who is currently drug-free. The patient is experiencing repeated occurrences of vivid, frightening images and thoughts. Which term would the nurse use to document this finding?
a. tolerance b. flashbacks c. withdrawal d. synergistic effect
c. flashbacks; Flashbacks occur in a drug-free state and involve visual distortions, time expansion, loss of ego boundaries, and intense emotions. Often flashbacks are mild and perhaps pleasant, but at other times, individuals experience repeated recurrences of frightening images or thoughts.
Tolerance occurs when a patient’s physiological reaction to a drug decreases with repeated administration of the same dose. Withdrawal causes physiological changes as blood and tissue concentrations of a drug decrease in individuals who have maintained heavy and prolonged use of a substance. The term synergistic effect is used when drugs are taken together and the effect of either or both drugs is intensified.
Which condition would the nurse be most concerned about when caring for a patient who abuses alcohol?
a. cirrhosis of the liver b. suicidal potential c. Wernicke’s encephalopathy d. Korsakoff syndrome
b. suicidal potential; Safety is always the priority when caring for patients. Ensuring safety includes completing a suicide risk assessment.
Although the patient may develop or present with cirrhosis, the nurse must first plan care for prevention of self-harm. Wernicke’s encephalopathy may develop, but the nurse must first plan care for prevention of self-harm. Korsakoff syndrome is not the priority of care.
Which patient response to the question “Have you ever drunk more alcohol or used more drugs than you meant to?” should immediately cause the nurse to assess further?
a. No, I have never used drugs or alcohol. b. I have drunk alcohol before but have never let myself get drunk. c. I figured you’d ask me about that. d. Yes, I did that once and will never do it again.
c. I figured you’d ask me about that; Automatic responses such as “I figured you’d ask me about that” serve as red flags that further assessment must be done right away to provide clarification.
Further assessment would be appropriate through the context of the general assessment; however, alcohol and drug use would not be the immediate priority.
Which patient behaviours should the nurse suspect as related to alcohol withdrawal?
a. hyper alert state, jerky movements, easily startled b. tachycardia, diaphoresis, elevated BP c. peripheral vascular collapse, electrolyte imbalance d. paranoid delusions, fever, fluctuating levels of consciousness
a. hyper alert state, jerky movements, easily startled; Patients who are exhibiting hyperalertness and jerky movements and who startle easily are most likely in a state of alcohol withdrawal, a condition that peaks in 24 to 48 hours after cessation or reduction of alcohol intake and then rapidly and dramatically disappears unless the withdrawal process progresses to alcohol withdrawal delirium.
Tachycardia, diaphoresis, and elevated blood pressure are associated with alcohol delirium and are considered a medical emergency and can result in death if not treated. Peripheral vascular collapse and electrolyte imbalance are associated with alcohol delirium and are considered a medical emergency and can result in death if not treated. Paranoid delusions, fever, and fluctuating levels of consciousness are associated with alcohol delirium and are considered a medical emergency and can result in death if not treated.
A patient at your community mental health centre smokes up to a half a pack of cigarettes daily but has tried with limited success to cut back over the past two weeks. Today he asked the pharmacist about the various products that could aid his attempts to quit smoking in time for him to manage a long overseas flight next month and travel with friends who are allergic to smoke. What phase of change is this patient demonstrating?
a. pre contemplation b. contemplation c. preparation d. action
c. preparation; This patient is demonstrating the preparation stage of change. He already has some experience with change and is further trying to change or “testing the waters” by inquiring about pharmacological products to aid his efforts and plans to act within the next month.
At the precontemplative stage, people are not intending to take action in the foreseeable future, but this patient has a set goal. Patients who are demonstrating contemplation would still be ambivalent about change, or “sitting on the fence,” and not preparing for a change within the next month. Patients who are involved in the action phase of behaviour change are already working toward desired behavioural change, including modification of environment, experiences, or behaviour. This patient is not yet at this stage.
result from changes in the brain and are marked by disturbances in orientation, memory, intellect, judgement, and affect; range from minor – major
a cognitive disturbance characterized by inattention, disorganized thinking, and a fluctuating mental status; should be considered a medical emergency, and immediate attention given to prevent irreversible and serious damage
A 73 year old woman with pneumonia becomes agitated after being admitted to the ICU through the ER. She continually tries to leave her bed despite being too weak to walk. Her vital signs are erratic, her thinking seems disorganized. During her first 24 hours in ICU, the patient varies from somnolent to agitated, and from laughing to angry. Her daughter reports that the patient “was never like this at home.” What is the most likely explanation for the situation?
a. pneumonia has worsened the patients early-stage dementia b. the patient is experience delirium secondary to the pneumonia c. the patient is sundowning due to the decreased stimulation of the ICU d. the patient does not want to be in the hospital and is angry that staff will not let her leave
b. the patient is experiencing delirium secondary to the pneumonia; Delirium is always secondary to other disorders or causes (such as medications or fever), develops over a short period of time, and presents with emotional lability, unstable vital signs, fluctuating levels of consciousness, disorientation, and disorganized thinking—all of which exist in this case.
While pneumonia may result in hypoxia, which could aggravate the symptoms of dementia, the patient’s daughter reports that this behaviour is out of the ordinary. Sundown syndrome is the development or worsening of behavioural problems due to reduced sensory input and relative lack of orientation aids (e.g., lighting) and is characterized by increasing disorientation as nightfall proceeds. In this case, the patient’s behavioural changes are occurring and changing in a manner seemingly unrelated to the time of day (e.g., persisting through a 24-hour period). The patient may well be angry about being hospitalized, but anger would be an unlikely explanation for the constellation of symptoms and the patient’s overall levels of mental deterioration since admission.
Interventions appropriate for a hospitalized patient experiencing delirium include which of the following? Select all that apply.
a. immediately placing the patient in restraints if she begins to hallucinate or act irrationally or unsafely b. assuring that a clock and a sign indicating the day and date is displayed where the patient can see it easily c. being prepared for possible hostile responses to efforts to take vital signs or provide direct physical care d. preventing sensory deprivation by placing the patient near the nurses’ station and leaving the television and multiple lights turned on 24 hours per day e. anticipating that the patient may try to leave if agitated and providing a secure environment with direct observation to prevent wandering f. promoting normalized sleep patterns by encouraging the patient to remain awake during the day and facilitating rest at night
b, c, e, f. Clocks and other items that help orient the patient can prevent or decrease the disorientation. While not prone to violence, patients experiencing dementia may misinterpret the nurse’s intentions and respond aggressively with little or no warning, so to increase staff’s safety, use caution when the patient is agitated. Speaking with the patient for frequent, brief periods allows for frequent reassessment and reorientation opportunities. It also helps to prevent isolation and disorientation without overstimulating the patient. The risk of elopement should be anticipated, and antielopement precautions, such as direct observation or electronic monitors, should be implemented. Sleep patterns can become disrupted due to sleeping during the day (from sedation or boredom), which, in turn, interferes with sleep at night and increases the risk for sundowning; therefore, interventions that normalize sleep cycles are therapeutic.
Restraints tend to increase the patient’s fear and resistance and should not be used unless all other options for reassuring the patient’s safety have failed. Hospitals tend to provide excess stimulation, particularly if the patient is in a high-traffic area such as the nurses’ station. Some lighting is helpful in reducing disorientation, but leaving the TV on 24 hours and placement near the station exposes the patient to excess noise and stimulation, which can be disorienting.
Which statement about dementia is accurate?
a. the majority of people over age 85 are affected by dementia b. disorientation is the dominant and most disruptive symptom of dementia c. people with dementia tend to be distressed by it and complain about its symptoms d. hypertension, diminished activity levels, and head injury increase risk for dementia
d. hypertension, diminished activity levels, and head injury increase risk for dementia; Many factors can contribute to dementia in vulnerable persons, including diet, diminished physical and mental activity, and cardiovascular risk factors such as hypertension.
Even among those aged 85 and older, the majority of persons are not significantly affected by dementia, whose primary characteristics include the gradual, progressive loss of memory, cognitive functioning, and decision-making abilities. Although disorientation tends to result at some point in dementia, it is not usually the most dominant or fundamental feature of dementia. Dementia develops insidiously, and most persons with it fail to notice its development and tend to minimize or conceal the presence of symptoms rather than complain or seek assistance.
describes experiences that may overwhelm a person’s capability to cope
(1980) diagnostic criteria include a hx of exposure to a traumatic event of actual or threatened death, serious injury or sexual violation; exposure must result from: – directly experiencing the traumatic event – witnessing the traumatic event in person – learning that the traumatic event occurred to a close family member or close friend – experiencing first-hand repeated or extreme exposure to aversive details of the traumatic event
Symptoms (clusters): – re-experiencing (intrusive thoughts, flashbacks) – avoidance (triggers, people, feelings) – negative alterations in cognitions and mood (depression, change in beliefs) – alterations in arousal (reactivity, dissociative identity)
or sometimes called DESNOS = disorders of extreme stress, not otherwise specified
impairments related to: 1. affective functioning: heightened emotional reactivity, outbursts, consciousness/dissociative states when under stress
2. self functioning: persistent beliefs about oneself as diminished, worthless, pervasive feelings of shame and guilt
3. relational functioning: disordered attachment, difficulty sustaining relationships, feeling close to others
Important in treating alzheimer’s
Important in treating schizophrenia.
Important in treating anxiety
Important in treating depression
Important in treating depression, bipolar, mood symptoms
Teach methods to avoid orthostatic hypotension, warn about delayed initial response & prolonged effect after discontinuing drugs; teach about s/e, monitor mood & affect, should be taken only as prescribed, do not give at bedtime, monitor for hypertensive crisis, avoid OTC cold medications, allergy medications, diet preparations
*Risk for Serotonin Syndrome if taken with SSRI
Lithium Carbonate (Lithane, Eskalith, Lithobid)
Use of Lithium
7-10 days, treats: elation, flight of ideas, irritability, manipulativeness, anxiety, insomnia, psychomotor agitation, threatening or assaultive behavior, distractibility in Bipolar patients
Buspirone (buspar): binds to primarily serotonin receptors and dopamine receptors
Action of Anxiolytics
CNS depressant potentiates the effects of the powerful inhibitory neurotransmitter gamma-amniobutyric acid (GABA) in the brain, producing a calamative effect in 7-10 days.
Use of Anxiolytics
To treat anxiety.
Pre-op sedation, status epilepticus, acute alcohol withdrawal, mild muscle relaxant
Common S/E of Anxiolytics
Conusion, h/a, agitation, oversedation, constipation, decreased libido, urinary retention, hypersensitivity, dry mouth, blurred vision, ACH side effects
Nursing Considerations for Anxiolytics
Withdraw drugs slowly, not safe for use in pregnancy, watch for changes in liver fx, paradoxical excitement, mood and affect, avoid use with alcohol or other CNS depressant, use carefully with renal or hepatic failure or glaucoma, give withfood, no driving or operating machinery until you know your reaction
Antipsychotic; prevents vomiting but ^QTC
Antipsychotic; old drug
long acting injectables
Atypical antipsychotic; watch out for neutropenia, king of antipsychotics
atypical antipsychotic; OD associated with Post-injection Delirium Sedation Syndrome (easy to OD)
atypical antipsychotic; no weight problem, approved for autism
As a future Social Worker it is important to be aware of the policies that may impact the community in which we serve. By being aware of these policies a social worker can prepare to provide services to the population for which one serves. A social worker must advocate for the good of the community and the people within that community. As the Mayor of Biloxi you are also in a position where you must advocate for or against policy initiatives for the good of the people for which you serve. Therefore, it is important that you join me in supporting S. 195 or the “Mental Health in Schools Act of 2013.” Part A: Legislation and Political Context: What is the “Elevator Speech” Overview?
The purpose of the Mental Health in Schools Act of 2013 is to amend the Public Health Service Act to revise and extend projects relating to children and violence to provide access to school-based comprehensive mental health programs. This piece of legislation seeks to revise, increase funding for, and expand the scope of the Safe Schools-Healthy Students program in order to provide access to more comprehensive school-based mental health services and supports. It will also provide for comprehensive staff development for school and community service personnel working in the school, and provide for comprehensive training for children with mental health disorders, for parents, siblings, and other family members of such children, and for concerned members of the community.
The Bill was introduced in the Senate on January 31st, 2013 and was referred to the Committee on Health, Education, Labor, and Pensions. The bill was introduced by Senator Al Franken (D-MN) and has 11 Co-sponsors (10 Democrats, 1 Independent), none of which represent any of the four districts in the state of Mississippi. BILL TEXT URL:
http://napolitano.house.gov/sites/napolitano.house.gov/files/images/mental_health_in_schools_act_2011.pdf Part B: Problem Analysis: Why is this Bill/Policy Important? Why Should the Mayor Care? On behalf of the Substance Abuse and Mental Health Services Administration (SAMHSA), Pamela Hyde testified before the Senate Health, Education, Labor, and Pensions Committee Hearing on “Assessing the State of America’s Mental Health System” January 24, 2013. She stated that, “Half of all lifetime cases of mental and substance use disorders begin by age 14 and three-fourths by age 24.6”. If proper treatment and support services are not provided to people with mental health conditions or substance abuse disorders, they may experience crisis situations which can affect families, schools and communities. Less than one in five children and adolescents with diagnosable mental health and substance use problems receive treatment. That is why last week, the President announced initiatives to ensure that students and young adults receive treatment for mental health issues.
Enacting the Mental Health in Schools Act will make it possible to identify and provide treatment for mental health and substance abuse issues early, before the development of crisis situations, such as the Newtown tragedy. It would also provide us with the resources to help communities understand and implement the prevention approaches proven to be effective in stopping issues from developing in the first place. The social problems this Bill seeks to impact, as stated in the original Bill (Mental Health in Schools Act of 2011) and on Congresswoman Napolitano’s website, “Approximately one in five U.S. children and adolescents have a diagnosable mental disorder.” (American Academy of Pediatrics), Serious emotional or behavioral disorder that is severe enough to cause substantial impairment in functioning at home, at school, or in the community effects approximately one in ten children. It is estimated that seventy-five percent of those children do not receive specialty mental health services.
Formal partnerships with community mental health providers to deliver mental health services are reported in only half the schools across the United States. There must be access to resources that provide family centered, culturally and linguistically appropriate supports and services available if schools are going to respond to the mental health needs of its students. In a recent study one-third of school districts reported decreased funding for school mental health services, and at the same time two-thirds of school districts reported increased need for such services. Seventy percent of adolescents with mental health problems do not receive care (Journal of Adolescent Health, volume 38). Suicide is the 3rd leading cause of death for youth ages 15-24 (National Institute of Mental Health report). Among young people aged 10-14 years old, suicide rates have doubled in the last two decades (American Foundation for Suicide Prevention). More than half of federal and state prison inmates have a diagnosable mental health problem (U.S. Department of Justice). Children with mental health issues make $10,400 less per year as adults (Journal of Social Science and Medicine).
Four in ten currently unemployed parents say they have seen behavioral changes in their children due to their unemployment (NY Times/CBS Poll). Behavioral and emotional problems decreased among 31 percent of youth with mental health issues after 6 months of receiving mental health care (SAMHSA report) Within one year of entering a mental health program, youth attending school regularly increased from seventy-five percent to eighty-one percent, and those receiving passing grades increased from fifty-five percent to sixty-six percent (SAMHSA report). The number of students involved in violent incidents decreased by fifteen percent within three years of instating mental health programs (SAMHSA report). Sixteen percent of students report lower depression, twenty-one percent lower anxiety, and thirty-eight percent have better behavior after one year (SAMHSA report). Two thirds of school districts reported that the need for mental health services had increased since the previous year, and one third reported that funding for mental health services had decreased in that time (Foster et al., 2005).
State mental health programs were cut nationally by four percent in 2009, five percent in 2010, and at the time of this report were estimated to be cut by more than eight percent in 2011 (Stateline.org July 19 2010). According to the National Alliance on Mental Illness the cuts between 2011 and 2012 amounted to between 10.4 percent in Mississippi and 39.3 percent in South Carolina in ten of the states who made the highest cuts. The Mental Health in Schools Act can assist thousands of children with mental health issues. The cost of counseling them is low compared to the harm caused by suicide, crime, and lifetimes of missed opportunities. Providing the children in our communities with the help they deserve opens up new possibilities for them and their families. Our community is not confined to a geographical area, but to the children in need of the services this Bill will provide.
The Mental Health in Schools Act legislation will ease problems by: providing professional help for youth suffering from mental health issues; addressing mental health problems when students are young instead of waiting until they have drifted into drug use, crime, depression, or suicide; keeping costs low, because mental health costs are very little compared to the costs placed on social services and the prison system when mental health is neglected; saving lives by funding mental health professionals who can identify at-risk youth and counseling students before suicide risk becomes an issue. According to her biography on her webpage, Congresswoman Grace Napolitano has successfully implemented this program within her previous congressional district since 2001. The program is currently operating in 11 local schools. The program has proven to be tremendously successful in helping students overcome mental health issues and improving quality of life for them and their families. The Mental Health in Schools Act seeks to expand this model nationwide to provide more students with the benefits of on-site mental health care. Part C: Existing resources to Deal with Problem
The National Alliance on Mental Illness (NAMI) offers many support and education programs for Americans affected by mental illness to help them have a better quality of life. Some of these programs are the NAMI Helpline which is an information and referral service, the Education, Training and Peer support Center which provides free education and support programs for individual, family members, providers and the general public. There are State and Local NAMIs that are made up of volunteer leaders who work in communities across the nation to raise awareness and provide free education, advocacy and support group programs.
While the resources are there, they are not enough to ensure a child gets the proper care. Behavioral health care delivered in a primary care setting can help to minimize discrimination and reduce negative attitude about seeking services. It is believed that this will help alleviate the fear people have about getting mental health treatment and improve overall health outcomes. Increased funding for these programs will make them more available to the people who need them most. It would also be helpful to introduce a community based education program to raise awareness for the already existing resources families have available to them. Part D: Stakeholders: Getting Down to Details
Jurisdiction encompasses most of the agencies, institutes, and programs of the Department of Health and Human Services, including the Food and Drug Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, the Administration on Aging, the Substance Abuse and Mental Health Services Administration, and the Agency for Healthcare Research and Quality. The Committee also oversees public health and health insurance statutes to address emerging threats and changing patterns in the healthcare industry Some of the groups supporting legislation are: Mental Health at the National Institutes of Health, The President’s New Freedom Commission on Mental Health, The National Council for Behavioral Health, The Substance Abuse and Mental Health Service Administration (SAMHSA). Other supporters of this legislation might be Teachers Unions, Parent Teacher Organizations, State and National School Board Associations, and the American Federation of Teachers. When the Bill was introduced by U.S. Rep. Grace Napolitano, a California Democrat, in 2011, most Republicans opposed it due to the cost of implementing the program. The Bill would provide up to $200 million in competitive grants of up to $1 million each. The cost is certainly a concern but even more concerning is the number of children suffering with mental illness.
Editor: National Alliance on Mental Illness. (2013) Retrieved February 16, 2013, from http://www.nami.org/Template.cfm?section=Find_Support H.R. 751–112th Congress: Mental Health in Schools Act of 2011. (2011). Retrieved February 16, 2013, from http://napolitano.house.gov/sites/napolitano.house.gov/files/images/mental_health_in_schools_act_2011.pdf Hyde, P. S.: Substance Abuse and Mental Health Services Administration. (2013). Testimony Before the Senate Health, Education, Labor, and Pensions Committee Hearing on “Assessing the State of America’s Mental Health System.” Retrieved from http://www.help.senate.gov/imo/media/doc/Hyde1.pdf Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602. Sheryl H. Kataoka, M.D., M.S.H.S.; Lily Zhang, M.S.; Kenneth B. Wells, M.D., M.P.H. (2002) Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status. Am J Psychiatry; 159:1548-1555. 10.1176/appi.ajp.159.9.1548 S. 195–113th Congress: Mental Health in Schools Act of 2013. (2013). In www.GovTrack.us. Retrieved February 16, 2013, from http://www.govtrack.us/congress/bills/113/s195
Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12-4725. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.