Coping Styles-automatic psychological process that protect the individual against anxiety.

The patient may or may not be aware. Style

Denial Displacement Identification Intellectualization

Description
Unconscious failure to acknowledge an event, or feeling The transference of feeling to another person or object Attempt to be like someone or emulate the traits of another Using reason to avoid emotional conflicts

Example
Pt. dx with cancer tells her family all the tests were negative After being scolded by boss, a man kicks the dog for barking A teen boy dresses like his favorite singer Wife of a drug user understands her husband has a problem but calls his workplace to tell them he is sick. A young man deals with a business client in the same fashion that his father deals with his clients. An ER nurse is able to care for injured pts by isolating or separating her feelings related to the pt An employee is late to a meeting and disrupts others after being reminded of being late A student who has sexual feelings for a teacher tells her friends the teacher is coming on to her A student who does poorly in a course says it was poorly taught and the content was not important anyways. A person who dislikes animals volunteers for a humane society After moving, a 6 year old starts wetting the bed A young man whose mother died cannot tell you how old he was or the year she died A student who feels too small to play football becomes a swimmer

Introjection

Incorporation of values of an admired person into ones own ego Separation of an unacceptable feeling, idea, or impulse. Indirectly expressing aggression toward others Attributing ones own thought to another person Offering an acceptable, logical explanation to make unacceptable feelings/behaviors acceptable Development of conscious attitudes and behaviors that are opposite of what is really felt Reverting to an earlier level of development The INVOLUNTARY exclusion of painful thoughts Substitution of an unacceptable feeling by a more socially acceptable one

Isolation

Passive-aggression

Projection

Rationalization

Reaction formation

Regression Repression Sublimination

Suppression Undoing

The INTENTIONAL exclusion of feelings Communication/behavior done to negate a previously unacceptable act

The student nurse focuses all his attention on school to avoid problems at home A person who used to hunt now is head of a committee for protection of animals

Types of Treatment Modalities

1. Milieu Therapy use of people, resources, and activities to assist in improving
interpersonal skills, social functioning, and ADLs. Here & Now. Help patient deal with realities of today rather than focusing on past. Requires limit setting and allow patient to make decisions in his/her care. Uses sharing, cooperation, and compromise. Support patient privacy and autonomy. Behavior modification Used to change ineffective behavior patterns and focuses on consequences of actions. Uses positive reinforcement to strengthen behavior and negative reinforcement to decrease behavior (ex: ignoring, timeout). Be a good role model and teach new behaviors. Family therapy Entire family is client. Make sure you identify if there are any life scripts (living out parents dreams) or self-fulfilling prophecies. Goal is to decrease family conflict and anxiety. Crisis Intervention Directed at the resolution of an immediate crisis. Patient is usually in a state of equilibrium. Focus on problem, not cause. Identify support system, fast-coping patterns used in other situations. The goal is to return client to precrisis level. Cognitive Therapy Directed at replacing clients irrational beliefs. Focused on problem solving. Short-term. Electroconvulsive Therapy (ECT) Electrically induced seizures to psychiatric purposes. Used with severely depressed patients, acutely suicidal, when rapid

2.

3. 4.

5.

6.

response is needed, when patient has extreme agitation, or has poor response to other medications. Also used for bipolar clients who are rapid cyclers (more than 4 a year). 2-3 times a week for 3-4 weeks. Teach client what treatment involves, avoid using the word shock. An anticholigeric is usually given 30 min before to dry oral secretions. A quick acting muscle relaxant is given to prevent bone or muscle damage. Requires informed consent. Reorient client after. Side effects: confusion, disorientation, memory loss. 7. Group Interventions used with two ore more clients who share common goal or issue. Includes orientation where patients may be anxious and have superficial interactions and may test the nurse to see if they can be trusted. Working phase is where problem is identified and is the beginning of problem solving. The termination phase, clients may be have anger or joy and you evaluate the experience. Groups are good because they help patient learn socializing behaviors, let them know they arent alone, opportunity for feedback.

HESI HINTS:

Avoid the words good, bad, right, wrong, and nice. Do not say these phrases: You should. You cant. If it were me. I think. Why dont you Just because the focus is on clients psychological needs, do not ignore physiologic needs. Ex: schizophrenic pt complains of chest paintake B/P.

Anxiety- decreased GABA. discomfort, tension, apprehension when a person feels a threat.
Responses to stress are increased HR and B/P, shallow respirations, tight feeling in throat, anorexia, palmar sweating. 1. Mild a. Associated with daily life. Motivates learning. b. Increased alertness. c. Client is able to concentrate and problem solve, client is calm. 2. Moderate a. Patient is attentive and able to focus and problem solve. b. Dulls perceptions, client is hesitant and begins to become restless c. Speech rate and volume increase d. May show physical symptoms like nausea, headache, diarrhea 3. Severe a. Fight or flight b. Perceptions are distorted, impairs concentrations c. Patient focuses on only one detail d. Results in verbalization of emotional pain e. Causes tremors, pacing. 4. Panic a. Client is unable to tell real from unreal b. Unable to concentrate, causes loss of logical thinking, overwhelmed feeling c. May be angry and aggressive or withdrawn, may cry d. Immediate intervention! Generalized Anxiety Disorders: unrealistic, excessive anxiety (lasting 6+ months) about two or more life circumstances. Previously learned coping skills are inadequate to deal with this anxiety. Usually demonstrate, restlessness, shakiness, SOB, dizziness, diaphoresis, sleep disturbances, irritability, low self esteem. Help patient recognize anxiety and identify the stressor. Encourage exercise, deep breathing, relaxation, decrease environmental stimuli (away from nurses station). Phobias irrational fear of object, activity, or situation. Clients usually use displacement, projection, repression, and sublimination. Panic attacks usually peak at 10 minutes but can last up to 30. Patient may use drugs/alcohol to decrease anxiety. After trust is established, use desensitization. Teach patient thought replacement, and relaxation. Expose client to feared stimuli and offer support. Provide positive reinforcement. Administer antianxiety meds and SSRI as needed. Obsessive Compulsive Disorder Anxiety associated with repetitive thoughts (obsession) or impulses (compulsions). Patients fear losing control. Patients typically use repression, isolation, undoing, magical thinking (belief that ones thoughts can control other people). Interference with normal activities is common. Safety is important with repetitive actions (washing hands = infection). Explore feelings about behavior, avoid punishing, establish routine, avoid reinforcing

behavior, limit amount of time for ritual, administer antianxiety med and SSRI as needed. Best time for interaction is after a client completes ritual. Clomipramine (Anafranil) Post-Traumatic Stress Disorder severe anxiety results from traumatic experience. Patient may have intrusive thoughts, flashbacks, nightmares, detachment, shock, anger, panic, denial, self destructive behavior. Provide nonthreatening environment, actively listen, assess suicide risk, encourage group with others who have similar traumatic event, administer antianxiety meds and antipsychotics as needed.

Antianxiety Drugs: Benzodiazapines: Libruim, Valium, Serax, Xanax, Ativan Side effects: sedation, drowsiness, ataxia, habituation. Implications: administer at bedtime to alleviate daytime sleepiness, dont combine with other CNS depressants, gradually taper off, use only as short term. Nonbenzodiazapines: Ambien can cause daytime drowsiness. Give with food 1 hour before bed BuSpar- can cause dizziness, takes several weeks to be effective.

Somatoform Disorders
* Expression of unexplained physical symptoms. More common in women. Children may learn that physical complaints are an acceptable coping strategy and are rewarded by attention (secondary gain). These clients may abuse analgesics without relief from pain (Doctor shopping). Patients have preoccupation with pain of body for at least 6 months, vital signs may be elevated in a panic attack. Be nonjudemental, record pain with attention to what precipitate onset, divert attention away from pain, reward patient for not focusing on physical symptoms. 1. Somatization Disorder a. Recurrent complaints for which frequent medical attention is sought but no pathology is present. EX: client with chest pain has normal ECG. 2. Hypochondriasis a. Belief that he/she has disease, misinterpret physical signs. EX: client with rash that is minor thinks he has lupus. 3. Body Dismorphic Disorder a. Image of defective body part 4. Conversion Disorder a. Characterized by transferring a mental conflict into a physical symptom. EX: blindness, paralysis, seizure, false pregnancy. *Terms: La belle indifference lack of concern over physical illness. Primary gain a decrease in anxiety resulting from the ability to deal with a stressful situation. Secondary gain the rewards obtained from the sick role, like sympathy, or dismissal from certain responsibilities.

Dissociative Disorders
* Involve alteration in the function of consciousness, personality, memory, and identity. May be sudden and temporary or gradual and chronic. These patients handle stress by splitting from the situation and going into a fantasy state. Patients tend to have depression, insomnia, mood swings, impaired functioning. Reduce patients environmental stimuli, stay with client during

depersonalization. Avoid giving clients with dissociative disorders too much information about past events at one time. 1. Psychogenic fugue a. Person suddenly leaving home or work with the inability to recall his or her identity. Excessive use of alcohol may contribute to this state. 2. Dissociative Identity Disorder a. Presence of two or more distinct personalities within a person. These tend to emerge during stress. 3. Depersonalization a. Temporary loss of ones reality and the ability to feel and express emotions. Client fears going crazy.

Personality Disorders
** With patients with PD, focus on their strengths and accomplishments, set limits, reinforce independence, encourage socialization. People with PD, are comfortable with their decisions and believe they are right and the world is wrong, they have very little motivation to change. 1. Cluster A: Paranoid (Suspicious, strange behavior that may be precipitated by stressful event. May manifest as intense hypochondriasis). Determine degree of antitrust, anxiety, and suspiciousness. Determine whether delusions are present. Follow through on commitments, assess situations that provoke aggression and anxiety. Avoid confrontation over delusions, engage in noncompetitive activities that require concentration. a. Paranoid personality i. Displays pervasive and long standing suspiciousness. Mistrusts others, is in touch with reality, uses hostile dialogue, appears tense and distant. b. Schizoid personality i. Socially detached, shy, introverted. Avoids relationships, has autistic thinking, appears withdrawn. Humorless and shows little expression. c. Schizotypal personality i. Has odd beliefs and is eccentric. Socially isolated. 2. Cluster B: Dramatic, Emotional a. Antisocial personality i. Shows aggressive, acting out behavior with no remorse. Clever and manipulative, ineffective interpersonal skills. Humiliating, belligerent towards others. Cold, and insensitive. b. Borderline personality i. Has disturbances regarding self image and sexual and social roles. Shows impulsive, self damaging behaviors. Overly dependent on others. Unable to problem solve or learn from experience. Tends to view others as all good or all bad (splitting). Is self critical, demanding, and impulsive. c. Histrionic personality i. Seeks attention by overreacting. Overly dramatic and tends to exaggerate. Has chaotic relationships. Is loud, immature, selfcentered, dependent on attention from others. d. Narcissist personality i. Perceives self as all powerful, critical of others, needs attention and admiration, exploits others, talks about self all the time.

3. Cluster C: Anxious, fearful a. Avoidant personality i. Socially inhibited, feels inadequate, overly sensitive to negative criticism, and rejection. b. Dependent personality i. Unreasonable wishes and wants, whining. Is passive and doesnt accept responsibility for consequences of actions, low self esteem, unable to make decisions. c. Obsessive Compulsive personality i. Attempts to control self through control of environment. Cold and rigid to others, is a perfectionist, inflexible. Excessively neat and clean.

Eating Disorders
Anorexia voluntary refusal to eat and maintain minimal body weight. A distorted body image and fear of becoming obese drives excessive exercise and diet. It is often associated with parentchild conflicts about dependency, feel that weight is only thing they can control. Weight loss, apathy about physical condition, skeletal appearance, distorted body image, hair loss, irregular heartbeat, amenorrhea, dehydration, hypokalemia, odd handling of food, yellow skin, cold extremities. Interventions: Monitor weight on regular schedule, vital signs, and electrolytes. Structured environment especially during meals, time limit for eating, monitor after meals for vomiting, use positive reinforcing, monitor activity level, praise for weight gain rather than food intake, assess for water loading prior to weighing, meal contract, lock bathrooms, teaching about meals at restaurant, administer antidepressants as needed. HESI HINT: Do not allow anorexic patients to plan or prepare food for unit based activities. This reinforces self control. Bulimia characterized by eating excessive amounts of food following by purging, laxatives, fasting, or diuretics. Mallory-weiss syndrome (tears in the esophagus) and Russell signs (calluses on hand from induced vomiting). Normal to low body weight, hyponatremia, dental cavities, sore throat, hoarse voice. Interventions: monitor weight, electrolytes, structured environment especially around meals, monitor after meals for purging, encourage expression of anger, use positive reinforcement, discuss ways to stop vomiting and laxative use, administer antidepressants as needed. HESI HINT: patients with bulimia often use syrup of ipecac to induce vomiting, if this is not vomited and is absorbed, cardiotoxicity may occur, so assess for edema and breath sounds.

Mood Disorders **Depression

-Norepinephrine & serotonin Symptoms of depression: 1. Mild a. Sadness, difficulty concentrating and performing activities, difficulty maintaining usual activity level

2. Moderate a. Feelings of helplessness, powerlessness, decreased energy, sleep pattern disturbances, appetite and weight changes, slowed speech. 3. Severe a. Feelings of hopelessness, worthlessness, guilt, despair, flat affect, lack of motivation, change in physical appearance, suicidal thoughts, possible delusions or hallucinations, loss of interest in sexual activity, constipation. Major Depressive Disorder-one of these symptoms must be present most of the day, nearly every day for at least 2 weeks. (Anhedonia- loss of interest, numbness, diminished ability to make decisions, insomnia, weight loss, sleep disturbance, financial problems, withdrawal from family, poor concentration). Usually worse in the morning. Dysthymia- a chronic, low level depression. Symptoms are less severe than MDD. Pt. must have had a depressed mood and at least 3 of the following symptoms for most of the day nearly every day for 2 years for adults, 1 year for children. (Depressed mood, irritability, hopelessness, poor appetite, low self esteem, guilt, chronic fatigue, social withdrawal). Cannot have any manic episodes. Seasonal Affective Disorder- October-November and March-April. Must be evident for 2 consecutive years. Assessment of Depression: Determine type of depression (Exogenous-caused by reaction to external factors or Endogenous- caused by internal biological deficiency). Determine degree of depression, current suicide risk, lab tests (DST-indirect marker of depression, considered positive if DST cortisol level is >5. HESI HINT: children with depression often present with headaches and stomachaches. Interventions for depression: ask client about plans to harm self, implement suicide precautions if necessary, monitor sleep and eating pattern, initiate interaction with client, don not give client choice about participating, observe for sudden elevation in mood as this may indicate increased suicidal risk, administer antidepressants as needed, return when promised, comment on signs of improvement by noticing behavior. Suicidal Patient: Obtain history, look for risk factors, be aware of warning signs of impending attempt like giving away possessions, suddenly elevated mood. Ask client if he/she ever thinks about harming themselves, if they have a plan, what is their plan. Express concern to patient, tell client you have to tell other staff, offer client hope, stay with client, help promote self-esteem and control by assisting with hygiene. HESI HINT: most important intervention is to sit quietly next to client, offering support with your presence. Antidepressant Medications: 1. SSRI

a. Used for depression, anxiety, panic disorder, aggression, anorexia, OCD b. Low incidence of anticholinergic effects c. Faster onset than TCA = better pt. compliance d. Serious side effects: central serotonin syndrome = look at other patients meds that contain serotonin. Symptoms: drowsiness, heaahce, insomnia, sexual dysfunction, allergic rash, elevated B/P, tachycardia, hostility, mood change. Severe symptoms: fever, cardiovascular shock. Discontinue medications and notify physician. e. Do not take with MAOIs. Must have 14 days between switching MAOI to SSRI f. Do not change or miss dose g. Effective 2-4 weeks after starting. h. Ex: Citalophram, Prozac, Paxil, Zoloft. 2. New Atypical a. Used for depression, With trazodone for insomnia, dementia b. May cause fatal reaction with MAOIs c. Safer than MAOIs. d. Effective 2-4 weeks after starting. e. Elderly are more sensitive to effects f. Herbal considerations: St. Johns wort may increase serotonin syndrome. g. Ex: Cymbalta, Wellbutrin 3. Tricyclic Antidepressants a. Used for depression and morbid fantasies. b. Takes 10-14 days to work or longer c. Start with low dose, slowly increase d. Use 6-12 months to prevent relapse e. Side effects: anticholinergic effects, sedation, poor concentration, orthostatic hypotension f. Adverse reactions when taken with MAOI, oral contraception, anticoagulants, antihypertensives. g. Administer at bedtime b/c of sedative effect. h. Dont give if pt had recent MI, glaucoma, seizure, pregnancy. i. May give total daily dose at night to help pt sleep. j. Ex: Elavil, Sinequan, Tofranil, Norpramin. Second Line Antidepressants 1. MAOI a. Used for depression, Phobias, and Anxiety. b. Signs of toxicity are palpitations and headache. c. Should not be taken 14 days of taking SSRI d. Avoid all tyramine containing foods (avocados, yogurt, processed meats, aged cheese, liver, yeast, chocolate, soy sauce, bananas, red wine, beer, beef and chicken), can cause hypertensive crisis

e. Side effects: orthostatic hypotension, tachycardia, (hypertensive crisis: severe headache, chest pain, sweating, vomiting, increased B/P), stroke, convulsions, death. f. Dont give if patient has hx of stroke, CHF, hypertension g. Do not use with tricyclics = can cause hypertensive crisis. h. Ex: Nardil, Emsam, Marplan.

**Bipolar Disorder
1. Affective disorder that is manifested by mood swings involving euphoria, grandiosity, inflated sense of self-worth. 2. Bipolar 1- one or more manic episode and one or more depressive episode 3. Bipolar 2- less severe. One or more hypomanic episode and one or more depressive episode. 4. Mania- abnormally and persistently elevate mood for one week. Three of the following must be present: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, hallucinations, flight of ideas, bizarre colorful dress, easily irritated. 5. Full Blown Mania- excessive spending, dont complete anything, promiscuous, financial strain, loud, CLANG ASSOCIATIONS- putting words together b/c of rhyming. 6. Fact splitting and manipulation can break staff. Use communication to prevent! 7. Interventions: use 15-20 min segments, be prepared for personal putdowns and avoid arguing or becoming defensive, encourage noncompetitive physical activities that use large muscle groups, reduce stimuli, provide nutrition, hygiene, be consistent use avoid manipulation, use frequent and brief contact to decrease anxiety, limit setting, dont give attention to bizarre behavior like dress, small frequent feedings (finger food), praise self-control, administer lithium, sedatives, and antipsychotics as needed. Mood Stabilizing Drugs: Lithium Carbonate 1. Used for Bipolar disorder, especially in manic phase. 2. Requires therapeutic drug monitoring. Weekly blood draws. Therapeutic level is 0.8-1.4 HESI HINT: blood levels should be drawn 12 hours after last dose. 3. Requires renal function assessment and monitoring 4. Adverse reactions: nausea, fine hand tremor, weight gain, hypothyroidism, polyuria. 5. Reduces euphoria, flight of ideas, and grandiose. 6. Teach patient early symptoms o toxicity, keep salt usage consistent, dont use with diuretics. 7. Long term use of Lithium- hypothyroidism, impairment of kidneys to concentrate urine.

8. Dont use Lithium with pts who are pregnant, have brain damage, renal or thyroid disease, or are breastfeeding Expected Side Effects Fine hand tremor Polyuria Mild thirst Weight gain Early Toxicity 1.5 Muscle weakness Slurred speech N/V Polyuria Advanced Toxicity 1.5 2.0 Coarse hand tremor GI upset Confusion Incoordination Severe Toxicity 2.0 - 2.5 Ataxia Blurred vision Seziures Coma or death 2.5+ Arrhythmia Incontinence Oliguria low urine output Death

Thought Disorders
1. Schizophrenia A psychiatric disorder characterized by thought disturbance, altered
affect, withdrawal, regressive behavior, poor communication. Increased dopamine. a. Catatonic i. Stupor decrease in reaction to environment ii. Rigidity iii. Waxy flexibility iv. Negativism b. Disorganized i. Incoherent ii. Flat or inappropriate affect iii. Unusual mannerisms iv. Disorganized behavior v. No delusions are present c. Paranoid i. Delusions, hallucinations or both. ii. Ideas of reference (misconstruing events and remarks by giving them personal significance) iii. Potential for violence if delusion are acted upon d. Residual i. Withdrawn ii. Inappropriate affect iii. Eccentric behavior iv. No current psychotic behavior e. Undifferentiated i. Prominent delusions and hallucinations ii. Incoherent iii. Failure to meet any other criteria. 2. Assessment for Schizophrenia: Interpret internal and external stimuli, assess for delusions, ideas of reference, looseness of association, tangential speech (giving nonessential details), echolalia (repeating what is heard), neologism (creating new words), word salad (jumbled), hallucinations, affect. 4 As: Autism, Affect, Associations, Ambivalence.

Positive symptoms- initial symptoms. Most common cause of hospitalization.

a. Hallucinations b. False beliefs c. Paranoia d. Echoliah e. Word salad Negative symptoms- lack of normal functioning. develop over time. f. Withdrawal g. Flat affect h. Anhedonia i. Lack of energy j. Poor eye contact
Interventions: sit with mute clients, safe environment, matter-of-fact & non judgmental approach, clear, simple terms, stress reality, avoid arguing, set limits, structure time for activities, praise socially acceptable behavior, avoid fostering dependent relationships, teach medication compliance and therapy. HESI HINT: do not argue, logic does not work with these clients, it only increases their anxiety. Do not agree that you hear voices, but acknowledge your observation of the client. For delusional clients: encourage reality, divert focus from delusional thought, do not support delusion, avoid touching client. For hallucinating clients: protect from injury, avoid arguing, discuss observations, make frequent but brief remarks to interrupt hallucination. Antipsychotics:

1. Traditional a. Phenothiazines i. Used to control hallucinations, delusions, bizarre behavior. ii. Target positive symptoms iii. Less expensive iv. High incidence of Tardive Dyskinesia v. Adverse reactions: drowsiness, orthostatic hypotension, anticholinergic, photosensitivity. HESI HINT: wear sunglasses and protective clothing for photosensitivity. vi. Extraparamidal side effects = akathisia (inability to sit still), dystonia (repetitive movements or abnormal postures), tardive dyskinesia (involuntary movements of the tongue, lips, face, trunk, and extremities). vii. Takes 2-3 weeks for effect. viii. Keep client supine after administration and change positions slowly. ix. Ex: Thorazine, Prolixin, Vesprin, Moban b. Nonphenothiazines i. Used to control psychotic behavior ii. Less sedative than phenothiazines iii. Can cause severe extrapyramidal reactions, lekocytosis, anticholinergic effects. iv. Ex: Haldol, Taractan, Navane, Orap (Touretts syndrome)

2. Atypical a. Used for positive & negative symptoms of schizophrenia w/o significant EPS. b. Less side effects c. Adverse reactions: Risperdal can cause neuroleptic malignant syndrome (fever, muscular rigidity, altered mental status), dizziness, GI upset. Zyprexa can cause weight gain, agitation, and EPS. Seroquel can cause drowsiness, headache, EPS, anticholinergic effects. Clozaril can cause agranulocytosis, neuroleptic malignant syndrome.e d. Target positive and negative symptoms e. Ex: Clozaril, Zyprexa, Seroquel, Risperdal Side Effects of Antipsychotics and Interventions:
Aganulocytosis Thrombocytopenia Parkinsonism (1-4 wks after initiation) Akathisa (1-6 wks after initiation) Dystonia (1-2 days after initiation) Sore throat Bruises easily Rigidity, pill rolling hand movements, tremors, masklike face Restlessness, agitation, pacing, cant sit still Limb and neck spasms, jerky movements, rigidity Protect from infections, provide comfort like gargle for sore throat, lozenges. Safety Administer anticholinergic drugs like Cogentin Rule out anxiety, ask if pt is restless, Inderal Emergency treatment with IM anticholiergic drug. Have respiratory emergency equipment handy. Benadryl and Cogentin. Teach to report early symptoms, no effective treatment but Vitamin E has shown benefits Stay out of sun, wear sun glasses and protective clothing. Discoloration will disappear within 6 months after drug is discontinued Transfer to medical facility for hydration, nutritional support. Notify HCP stat Encourage sips of water, chewing sugarless gum, increase fiber, change positions slowly.

Tardive Dyskinesia

Involuntary tongue and lip movements, movements of trunk Exposed skin turns blue and color changes in eyes

Photosensitivity

Neuroleptic Malignant Syndrome Serotonin Syndrome Anticholinergic Effects

High fever, tachycardia, increase respirations, rigidity Confusion, disorientation Dry mouth, blurred vision, constipation, urinary retention, orthostatic hypotension

Antiparkinson Drugs: 1. Artane & Cogentin 2. Used on EPS to reduce symptoms

Substance Abuse
Signs of abuse: dilation of pupils, paranoia, hallucinations, dryness of oronasal cavity, abnormal vital signs. Tolerance need for higher and higher doses to get desired effect. Withdrawalsymptoms from stopping or reducing. Alcohol Abuse drinking pattern that interferes with all areas of life. Antabuse is given to chemically dependent clients. Used as a deterrent to drinking alcohol. Teach client not to use any products with alcohol in them while taking this medication. Naltrexone can also be used. It reduces craving for up to 72 hours, but dont give until symptoms are present. Alcohol Withdrawal Just a few hours after stopping Signs peak in 24-48 hours then disappear Anxiety, insomnia, tremors, increased vs, grand mal seizure. Frequent reorientation, simple instructions Alcohol Withdrawal Delirium Medical emergency Can result in death Peaks 2-3 days after stopping, lasts 2-3 days. Hallucinations, disoriented, agitated, delusions, anxiety.

Cocaine & Crack Can cause violent behavior. Withdrawal: depression, disturbed sleep, lethargy, psychomotor agitation. Overdose: tachycardia, pupil dilations, cardiac arrhythmias, chills. Opiates Morphine, codeine, opium, heroin. Withdrawal: diaphoresis, dilated pupils, abdominal cramps, n/v. Overdose: constricted pupils, respiratory depression, unconsciousness, death. Treatment: Methadone (only medication that is safe for pregnant women). It blocks craving and effects. Marijuana THC Euphoria, relaxation, detachment, lethargy, difficulty concentrating, memory loss. Hallucinogens LSD, magic mushrooms, PCP, angel dust, horse tranquilizers. Blank stare, uncoordinated movement, rigidity, violence, loss of control. Overdose: panic, psychosis. Benzodiazepines Valium, Ativan Withdrawal: tremors, agitation, anxiety, grand mal seizures.

Overdose: drowsiness, confusion, hypotension, coma, death.

Childhood and Adolescent Disorders

1. Attention Deficit Hyperactive Disorder a. Inappropriate attention, impulses, and hyperactivity. b. Failure to listen to instructions, difficulty sitting still, disruptive, distracted by external stimuli. c. Decrease stimuli, set limits, initiate behavior contract. d. Concerta, Ritain. 2. Conduct Disorder a. Aggression to people and animals b. Serious violation of rules c. Violates rights of others d. Poor peer relationships e. No guilt or remorse f. Act out in peer group g. Frequently progresses to adult antisocial personality disorder. 3. Oppositional Defiant Disorder a. Stubborn b. Refusal to accept blame c. Test limits d. No serious violation of others e. Most evident at home f. Avoid asking why questions, quiet room, behavior modification, role-playing, planned ignoring, change activity, set limits. 4. Autism a. Abnormal left brain function (logic, language, reason) b. Impairment in coordination, cant name objects, repetitive language, no interest in others, poor eye contact, aversion to affections, rigid adherence to routine, sing song speech. c. Prognosis r/t developmental and language skills 5. Aspergerss a. High functioning autism b. Mild mental retardation c. No significant delays in development d. Restrictive and repetitive behavior, delay in motor sills, poor social sills, no empathy 6. Tourettes a. 2-10 years old b. Impairment in social and occupational functioning. c. Motor tics: blinking, touching, skipping, tongue protrusions d. Verbal tics: barks, grunts, clicks, snorts.

Delirium Acute process that if treated is usually reversible. Sudden onset. Can be a response to a stressor like infection, drug reaction, sleep deprivation, head trauma, intoxication. Treat cause

Dementia Cognitive impairment Gradual onset, irreversible. judgment, memory, and behavior are affected. Most commonly seen in Alzheimers but can be seen in Huntingtons, Parkinsons, and Wernicke-Korsakoff syndrome.

Assessment for Delirium and dementia: easily distracted, confusion, disorientation, hallucinations, sudden anger, loss of memory, confabulation (making up responses to fill in lost memory), slurring speech, decreased personal hygiene, sleep deprivation, daynight reversal, incontinence. HESI HINT: confabulation is not lying it is used by patient to reduce anxiety and protect ego. Interventions: safe environment, reorient client, simple and direct statements, mark the bathroom, provide support, assist with ADLs.

Alzheimers
-Acetylcholine Stage 1- Mild, forgetfulness Stage 2- Moderate, confusion Stage 3- Moderate to severe, ambulatory dementia Stage 4- Late, end stage. S/S: Confabulation (making up answers to reduce anxiety), Perseverations (repetition of a phrase or behavior), Aphasis (loss of language), Apraxia (loss of movement), Agnosia (loss of sensory ability to recognize objects) Medications for Alzheimers: 1. Acetyl Cholinesterase Inhibitors a. Cognex can cause elevated liver enzymes. b. Aricept c. Exelon d. Reminyl e. Concerta f. Adderal g. Teach patient NOT to take anticholinergic medications, take with meals to avoid upset, do not discontinue abruptly.

Grief
Stages: Avoidance- denial is present, detached feeling. Confrontation-active mourning, disorganization, despair. Reestablishment- decrease in symptoms, recovery. S/S: chest tightness, shock, disbelief, yearning. Types of Grief: 1. Anticipatory- predicted death, hospice clients, terminal illness 2. Dysfunctional grief continues beyond normal limits, PTSD, greater disability 3. Acute- occurs right after loss, wont last forever 4. Chronic- response ongoing loss, chronic illness.

Sleep Disorders
Dyssomnia trouble going to sleep or maintaining sleep. a. Insomnia b. Narcolepsy c. Breathing related 2.Parasomina a. nightmare b. sleep terror cant recall. c. sleep walking Moderate signs Apathy Withdrawal Fatigue Weight loss Psychomotor agitation Aids Dementia Complex: Acute psychotic signs Delusions hallucinations Mania

Theories
Freud Oral Anal Phallic Latency Genital 0-1 2-3 3-5 6-12 13+ Feeding Bowel training, ego develops, reality Value, guilt, morals, superego Mastery of previous skills, friends Mature sexually

Erickson: Stage Basic Conflict Important Events Infancy (birth Trust vs. Feeding to 18 months) Mistrust Outcome

Children develop a sense of trust when caregivers provide reliabilty, care, and affection. A lack of this will lead to mistrust. Early Autonomy vs. Toilet Training Children need to develop a sense of Childhood (2 to Shame and personal control over physical skills and a 3 years) Doubt sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt. Preschool (3 to Initiative vs. Exploration Children need to begin asserting control 5 years) Guilt and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt. School Age (6 Industry vs. School Children need to cope with new social and to 11 years) Inferiority academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority. Adolescence Identity vs. Social Teens need to develop a sense of self and (12 to 18 years) Role Relationships personal identity. Success leads to an Confusion ability to stay true to yourself, while failure leads to role confusion and a weak sense of self. Yound Intimacy vs. Relationships Young adults need to form intimate, Adulthood (19 Isolation loving relationships with other people. to 40 years) Success leads to strong relationships, while failure results in loneliness and isolation. Middle Generativity Work and Adults need to create or nurture things Adulthood (40 vs. Stagnation Parenthood that will outlast them, often by having to 65 years) children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world. Maturity(65 to Ego Integrity Reflection on Older adults need to look back on life and death) vs. Despair Life feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair

Piaget: Sensori-motor (Birth-2 yrs) Differentiates self from objects Recognizes self as agent of action and begins to act intentionally: e.g. pulls a string to set mobile in motion or shakes a rattle to make a noise Achieves object permanence: realizes that things continue to exist even when no longer present to the sense Pre-operational (2-7 years) Learns to use language and to represent objects by images and words.Thinking is still egocentric: has difficulty taking the viewpoint of others. Classifies objects by a single feature: e.g. groups together all the red blocks regardless of shape or all the square blocks regardless of color Concrete operational (7-11 years) Can think logically about objects and events Formal operational (11 years and up) Can think logically about abstract propositions and test hypotheses systematically.Becomes concerned with the hypothetical, the future, and ideological problems