NURSING CONSIDERATION: 1. Consistency to build trust 2. Food: PACKED OR SEALED foods except canned goods: No metal 3.

Social Isolation no group session when schizophrenic Paranoid who is suspicious saying, This place is meant for bugs & prison, In order to encourage trust, the patient should be involved in the plan of care. 2. CATATONIC: With stereotyped position (catatonia) with waxy flexibility, mutism, bizarre mannerism. #1 Defense mechanism: Autism & mutism #1 Cardinal Sign of Catatonia waxy flexibility (cerea flexibilitas) Similar in children with autism, - Most dangerous/serious type of schizophrenia may die from dehydration PRIORITIZED NURSING DIAGNOSIS: 1. Fluid & Electrolyte Imbalance 2. Altered Nutrition less than body requirement 3. Self Care Deficit 3. DISORGANIZED: Another word is Hebephrenic. Characterized with inappropriate behavior: Silly crying, laughing, regression, transient hallucinations (Auditory). All behaviors are similar with toddlers since they are anal fixated. Developmental Stage FIXATION: Anal Fixation #1 Defense Mechanism: Regression & Fixation 4. UNDIFFERENTIATED or MIXED : Symptoms of more than one type of schizophrenia; has delusions & disorganized behavior but DOES NOT meet the criteria for the above sub types alone. The #1 drug of choice is Fluphenazine (Prolixin decanoate) 5. RESIDUAL: No longer exhibits overt symptoms, no more delusions but still has negative Undifferentiated type chronic schizophrenia must be referred to a program promoting social skills due to functional loss deficit. PRINCIPLES OF CARE 1.Maintenance of safety: Protect from altered thought processes. Respond to feelings, and not to delusions; Do not argue; Validate reality; remove from areas of tension Suspiciousness & paranoid patient is threatening to the staff, the action of an RN that shows a need for further teaching is when shegoes to the room of a pt. who yells, Everyone, out of here,

Appropriate action of RN to a Schizophrenic who yells loudly, talks to wall and saying Dont talk to me, bastard. includes walking towards the pt & ask him who he is talking to. 2. Meeting of physical needs: May have to be fed / bathe initially 3.Establishment and maintenance of therapeutic relationship: Engage in individual therapy; Promote trust; Encourage expression by verbalizing the observed; Offer presence-Tolerate long silences 4.Implementation of appropriate family, group, social or diversional therapies Patients with schizophrenia need activities that do not require interaction, so solitary activities are preferred over team activities. Admission assessment of a Schizophrenic client reveals auditory hallucination, and drinking more than 6 L of water daily for past weeks, priority focus should be hyponatremia. Desired efficacy of treatment in schizophrenic patient who is mute & immobilized includes standing up when RN enters the room. ANTIPSYCHOTICS

Another word: Neuroleptic / Major Tranquilizers USES: Schizophrenia, acute mania, depression and organic conditions; Non-psychiatric cases: Nausea and vomiting, preanesthesia, intractable hiccups. Antipsychotics can only decrease the positive symptoms of schizophrenia, but not the negative symptom such as ambivalence. Action: delusion, hallucinations, looseness of association to decrease levels of dopamine in the substantia nigra I. Phenothiazine Code: AZINE

Fluphenazine (Prolixin)* Acetophenazine (Tindal) Pherphenazine (Trilafon) Promazine (Sparine) Chlorpromazine (Thorazine)*#1 that causes photosensitivity/photophobia; Side effects: Causes also red orange urine In liquid form is usually put in a chaser Chaser: 60- 100 ml juice (prone or tomato); to prevent constipation & contact dermatitis; taken with straw (bite straw & sip) Mesoridazine (Serentil)

Thioridazine (Mellaril)* ceiling dose/day: 800 mg Adverse Effect: Retinitis pigmentosa Prochlorperazine (Compazine)* #1 commonly used anti emetic

3. Intermittent cold & warm compress 3. Constipation Nursing Interventions:

Compazine causes anticholinergic side effects Trifluoperazine (Stelazine) II. Butyrophenones Code: PERIDOL 1. Prevent constipation fiber (residue) AG or roughage, prune/pineapple/papaya juice/ fruits 2. OFI 3. exercise 4. Orthostatic Hypotension/Postural Hypotension - take BP in supine, Fowlers & standing position. Difference of BP 15-20 mm Hg below S/Sx: Pallor, dizziness Chlorprothixene (Taractan Thiothixene (Navane) IV. Atypical Antipsychotics Code: DONE / ZAPINE or APINE Olanzapine (Zyprexia) Clozapine (Clozaril) #1 that causes Agranulocytosis & Blood Dyscrasia I will need to monitor my blood level to continue my medication. shows a correct understanding of a patient while taking Clozaril. Loxapine (Loxitane) Prioritized Nursing Intervention: Risperidone (Risperidone) #1 drug for Korsakoffs psychosis Give (1) ice chips, (2) chewing gum, (3) sips of water Molindone (Moban) Aripiprazole (Abilify) newest antipsychotic drug SIX COMMON ANTICHOLINERGIC SIDE EFFECTS OF ANTIPSYCHOTICS ACUTE/COMMON SIDE-EFFECTS FOR PROLONGED USED OF ANTIPSYCOTICS Nursing consideration: Slowly change position. Told patient to dangle feet first before standing 5. Pan Photosensitivity (photophobia) Nursing Intervention: 1. Use sun glasses, sun block, long sleeves or/and umbrella Patients taking antipsychotic should be instructed to wear wide brimmed hat when going outside 6. Dan Dry mouth/ Xerostomia

Haloperidol (Haldol, Serenase)* #1 drug used for extreme violent behavior ; Instruct patient taking Haldol to wear sunscreen Droperidol (Inapsine) III. Thioxanthenes Code: THIXENE

Extrapyramidal Symptoms (EPS) Common Signs & Symptoms: Reversible side effect (except TARDIVE DYSKINESIA), which is a result of neurological dysfunction of the Extrapyramidal System.

(Anticholinergic effects are drug actions of antipsychotic drugs because they BLOCK MUSCARINIC CHOLINERGIC RECEPTORS) CODE: BUCO PanDan anticholinergic S/Es 1. Blurring of Vision - sympathetic reaction (dont operate machinery); Mydriatic pupil dilate sympa IOP dont use in glaucoma 2. Urinary Retention (Post Partum, Autonomic Dysreflexia, paraplegia) Nursing Interventions:

Patients taking with prolonged antipsychotic medications should always be assessed for symptoms of extrapyramidal symptoms. 1. Akathisia another word: Motor restlessness 1-6 wks Signs of motor restless: Foot tapping, finger fidgeting, cant sit down for more than 15 minutes and pacing back & forth. Patient is unable to remain still Drug of Choice: CODE: CBA #1 Cogentin (Benztropine Mesylate)

1. Provide Privacy give bed pan #2 Benadryl (Diphenhydramine Hcl) 2. Sounds of dripping water faucet

#3 Akineton (Biperiden Hcl) 2.Dystonia #1 cardinal Sign: Oculogyric crisis = involuntary rolling of eyeballs, neck shoulder, jaw and throat spasm (dysphagia) 2-5 days Drug of Choice: CODE: CBA #1 Cogentin (Benztropine Mesylate) #2 Benadryl (Diphenhydramine Hcl) #3 Akineton (Biperiden Hcl) 3.Pseudoparkinsonism - another word: Drug-induced Parkinsonism #1 sign: Pill-rolling tremors. Other signs: Mask-like face, flat affect, shuffling gait or festinating gait, cogwheel rigidity. DRUG OF CHOICE: #1 Artane (trihexyphenydyl) #2 Amantadine ( Symmetrel) can also be used in Chicken pox, also an ANTI VIRAL 4.Tardive Dyskinesia Starts with T: TONGUE (tongue rolling & tongue protrusion) lip smacking, tongue rolling, protrusion of the tongue, vermicular or vermiform tongue rolling irreversible. This is an EMERGENCY!!! Symptoms of tardive dyskinesia include fly catchers mouth, tongue thrusting, facial grimacing, puckering of cheeks, and drooling of saliva. --administer Artane, Benadryl, Cogentin, Antiparkinsonian drug 5. Akinesia absence of kinetic movements ANTI- EPS MEDICATION

#1 Cardinal Sign is High fever, tremors, tachycardia, tachypnea, sweating, hyperkalemia, stupor, incontinence, renal failure, muscle rigidity (Discontinue all drugs STAT; ventilation; hydration; nutrition; renal dialysis; hydrotherapeutic measures). Elevated blood pressure and diaphoresis are indicative of Neuroleptic malignant syndrome, which is a medical emergency. ANTIDOTE: Dantrolene (Dantrium) or Bromocriptine (Parlodel) Bromocriptine is both an Antiparkinsons & Anti prolactin

AFFECTIVE / MOOD DISORDERS MODELS OF CAUSATION: Genetic; Aggression turned inward; Objects loss; Personality disorganization; Cognitive: Hopelessness; Learned helplessnesshopelessness; Behavioral: Loss of positive reinforcement; Biological: Decreased serotonin and norepinephrine *; Life stressors; and Integrative: chemical, experiential, behavioral variables DEPRESSION

An abnormal extension or over elaboration of sadness and grief; oldest and most frequently described psychiatric illness; a pathologic grief reaction experienced by an individual who does not mourn The term depression is used in varied ways: a sign, symptom, syndrome, emotional state, reaction, disease or clinical entity. May be mild, moderate, severe, with (uncommon) or without psychotic features TYPES: 1. 2. 3. Depressive Disorders Manic-Depressive (Bipolar) Disorders Suicidal Behavior

CODE: PACABBA - Usually they are anticholinergic & antiparkinsonian drugs Procyclidine (kemadryl, kemadrin) Artane ( trihexyphenydyl) Cogentin (Benztropine mesylate) Akineton (biperiden Hcl) Bromocriptine (Parlodel) Benadryl (Diphenhydramine) Amantadine (Symmetrel) ADVERSE EFFECT OF ANTIPSYCHOTIC DRUGS:

BEHAVIORS COMMONLY ASSOCIATED WITH DEPRESSION a. Affective: Anger, anxiety, apathy, bitterness, hopelessness, helplessness, sense of worthlessness, low self-esteem, denial of feelings Physiological: Fatigue, backache, anorexia, vomiting, headache, dizziness, insomnia, chest pain, constipation, weight change, abdominal pains* Cognitive: Confusion, indecisiveness, ambivalence, inability to concentrate, pessimism, loss of interest, selfblame

b.

c.

Neuroleptic Malignant Syndrome RARE, LIFETHREATENING : (EXTREME EMERGENCY):

d. Behavioral: Altered activity level, over-dependency, psychomotor retardation, withdrawal, poor hygiene, agitation, irritability, tearfulness In a depressed patient, hostility is turned towards the self, while in manic patient, hostility is turned towards the environment. Depression in children results to anhedonia (energy loss & fatigue, decreased interest in previously enjoyed activities) like playing alone during recess. DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION: At least five of the following, most of the day, nearly daily, for 2 weeks: 1.Early morning depression 2.Loss of interest or pleasure (ANHEDONIA)* 3.Insomnia* 4.Psychomotor retardation (slow movt) 5.Fatigue or loss of energy (anemia) 6. Feelings of worthlessness & ambivalence (fear of death vs. fear living) * 7. Self care deficit* 8. History of suicide* 9. Weight loss or gain 10. Flat affect* 11. Constipation* PREDISPOSING FACTORS: 1. Single, Annulled & Divorced 2. Loss of loved one (situational crisis) 3. SAD Seasonal Affective Disorder common on winter season (Nov.-Feb.) or intimate months Seasonal depression occurs during winter and fall this is due to abnormal melatonin metabolism. Intervention for pt with seasonal affective disorder (SAD) during a depressed mood includes the use of broad spectrum light in high activity area. This produces high intensity color like broad day light. Also instruct the pt that the light source must be 3 ft away from the eye 4. Caucasians/Afro-Americans/Asians* 5. Alcoholics/Drug addicts* A 66 y/o American man, no hobby, no friend, retired 6 yrs ago, no money & has history of alcohol abuse is at risk for suicide

6. Protestants 7. Incurable Illness* 8. Post partum depression 9. Schizophrenia* Cognitive styles of suicidal patients: 1. Ambivalence. They have 2 conflicting desires at the same time: To live and to die. Ambivalence accounts for the fact that a suicidal person often takes lethal or near-lethal action but leaves open the possibility for rescue. 2. Communication. Some, people cannot express their needs or feelings to others, or when they do, they do not obtain the results they hope for. For them, suicide becomes a clear and direct, if violent, form of communication. Demographic Variables suicide rates are higher among the following: 1. Single people 2. Divorced, separated or widowed 3. People who are confused about their sexual orientation 4. People who have experienced a recent loss: divorce, loss of job, loss of prestige, loss of social status or who are facing the threat of criminal exposure 5. Caucasians, Eskimos and Native Americans 6. Protestants or those who profess no religious affiliation Clinical variables: 1. People who have attempted suicide before 2. People who have experienced the loss of an important person at some time in the past or the loss of both parents early in life, or the loss of or threat of their spouse, job, money or social position 3. People who are depressed or recovering from depression or a psychotic episode 4. Those with physical illness, particularly when the illness involves an alteration of body images or lifestyle 5. Those who abuse alcohol or drugs 6. Those who are recovering from a thought disorder combined with depressed mood and / or suicidal ideation ( hallucinations that tell them to kill or harm themselves) General guidelines the general task of the nurse is to work with the client to stop the constricted processing of suicidal thinking

long enough to allow the client and the family to consider alternatives to suicide. a. b. c. d. e. f. Take only threat seriously Talk about suicide openly and directly Implement basic suicide precautions: Check on the client at least every 15 minutes or require the client to remain in public place Stay with the client while all medications are taken Search the clients belongings for potentially harmful objects. Make the search in the clients presence and ask for the clients assistance while doing so

1. One-on-one nursing monitoring/intervention (never leave the client)* 2. Do not leave the patient for the 1st 24 hrs. (No suicide contract)* 3. Offering of self (best therapeutic communication)* 4. No metallic objects 5. No sharp objects 6. Needs stimulus bright room Rationale: to see suicidal acts 7. Avoid religious music (increases guilt) and love songs = nonsuggestive song is needed 8. Check for impending signs of suicide = sudden elevation of mood; #1 sudden mood swings A female patient who becomes euphoric for no apparent reason shows a behavior that indicates recovery from depression, which increases the risk for suicide. 9. Activities focus on self-care 10. Join group therapy

4. Check articles brought in by visitors 5. Allow the client to have regular food tray but check whether the glass or any utensils are missing when collecting the tray 6. Allow visitors and telephone calls unless the client wishes otherwise 7. Check that visitors do not potentially bring dangerous objects in the room IMPENDING SIGNS OF SUICIDE: 1. Sudden elevation of mood/sudden mood swings* When a depressed patient suddenly becomes cheerful, it means that the patient is recovering from depression and is in danger of committing suicide. 2. Giving away of prized possessions* 3. Delusion of Omnipotence (divine powers) Used by SS (Suicidal, Schizophrenia) 4. When the patient verbalizes that the 2nd Gen TCA is working. ( telling a lie) Suicidal attempts are common when client is strong enough to carry out a suicidal plan, usually 10-14 days after start of medication, and after ECT USUAL TIME FOR SUICIDE: 1. Early in the morning RATIONALE: The depression at this time is HIGH 2. In between nursing shifts RATIONALE: Nurses at this time are very busy NURSING DIAGNOSIS: (common) Risk/Potential for Injury Directed to Self STEP BY STEP PRIORITIZE NURSING INTERVENTIONS:

Depressed patients usually turn their hostile feelings towards themselves. Providing an activity that serves as an outlet for these aggressive feelings will make the patient feel less guilty. During family therapy, a mother asks, How long will my daughters have suicidal thoughts? appropriate response of the RN- Your daughter will go on to view suicide as a way of coping. 11. Monitor in giving medication do not leave patient after giving medication for 30 minutes. Check under the tongue & pillow 12. Monitor patient in CR, between shift & during endorsement 13. #1 Attitude Therapy: Kind Firmness 14. Step by step Tx: ANTIDEPRESSANT another word is THYMOLEPTICS 1st SSRI (Selective Serotonin Reuptake Inhibitor) 2nd Second Gen. TCA 3rd MAOI 4th ECT (last resort) 15. Meet physical needs: Promote eating, rest, elimination. Promote self-care whenever appropriate possible

16. Support self-esteem: Warm and consistent care Being patient with clients slowness

a. Induce sleep thru: 1. Warm bath (systemic effect) 2. Warm milk/banana (active substance: tryptophan) 3. Massage b. Give meds in single AM dose Antidepressants are best taken after meals

Simple tasks that increase success and self- esteem and imply confidence in capabilities Example: Self care activities that will not easily tire the patient. Rationale: Depressed patients have fatigue. 17. Decrease social withdrawal: Sit with client during quiet times; introduce to others when ready The priority focus for a suicidal patient in the ER with a slash in her wrist is her physiologic homeostasis. Assess attempt for suicide in a 16 y/o girl who is eating & sleeping poorly since break-up and saying, My life is ruined now. I. EFFECTS Action: Balance Serotonin gradual effect (usually 2 weeks) Effect: 2 wks. Code: XETINE/ODONE Fluoxetine HCl (Prozac) dry mouth (xerostomia) Paroxetine HCl (Paxil) Trazodone (Desyrel)) adverse effect: Priapism (prolonged use) Nefazodone (Serzone) Fluvoxamine (Luvox) Sertraline (Zoloft) causes GI upset (diarrhea, insomnia): always with meals Venlafaxine (Effexor) Citalopram (Celexia) Common Side Effects: 1. Weight Loss 2. Insomnia (single am dose) Nursing Considerations: 1. For insomnia: ANTIDEPRESSANTS or THYMOLEPTICS SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) Usually the FIRST LINE of drug. RATIONALE: FEWER SIDE

II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT

Action: Increases norepinephrine and/or serotonin levels in CNS by blocking their uptake by presynaptic neurons or it balances Serotonin & Epinephrine levels. Effect: 2-4 wks. Code: PRAMINE/TRYPTILLINE Clomipramine HCl (Anaframil) #1 for OCD* Imipramine (Tofranil)* the best drug for enuresis Amitryptilline (Elavil) Protryphilline (Vivactil) Maprotilline (Ludiomil) Norpramine (Desipramine) #1 antidepressant for elderly depression. RATIONALE: Fewer anticholinergic S/E Nortryptilline (Pamelor, Aventyl) Trimipramine ( Surmontil) Buproprion (Wellbutrin) 400 mg/day*(ceiling dose) EXCESS INTAKE: Grand mal seizure Doxepine (Sinequan) Amoxapine (Asendin) Common Side Effects: 1. Sedation (at night) 2. Weight gain Nursing Consideration: 1. Give meds at night

# 1 adverse effect cardiac dysrhythmias #1 screening test before taking TCA ECG When a depressed client taking TCA shows no improvement in the symptoms, the nurse must anticipate the physician to discontinue TCA after two weeks and start on Parnate.

Nursing intervention before giving the drug includes checking the BP. III. MAOI MONO AMINE OXIDESE INHIBITOR

2. Phentolamine (Regitine) also the #1drug for Pheochromocytoma (tumor in IV. ELECTROCONVULSIVE THERAPY (ECT)

ACTION: Psychomotor stimulator or psychic energizers; block oxidative deamination of naturally occurring monoamines (epinephrine, NOREPINEPHRINE, serotonin) CNS stimulation Effect: 2 weeks

ECT is passing of an electric current through electrodes applied to one or both temples to artificially induce a grand mal seizure for the safe and effective treatment of depression. ECTs mechanism of action is unclear at present Advantages:

CODE: PAMMANA Parnate (tranylcypromine) Marplan (Isocarboxacid)

Quicker effects than antidepressants; Safer for elderly; 80 % improvement rate of major depressive episode with vegetative aspects - Best therapy for major depression (last resort)

Mannerix (Moclobemide) *the newest MAOI Nardil (Phenelzine SO4) CONTAINDICATIONS: TYRAMINE + MAOI = HYPERTENSIVE CRISIS 1. Tyramine rich-food, high in Na & cholesterol Hypertensive Crisis 1. Aged cheese (except cottage cheese, cream cheese), Cheddar cheese and Swiss cheese are high in tyramine and should be avoided. 2. Canned foods such as sardines, soy sauce & catsup 3. Organ meats (chicken gizzard & liver) & process foods (salami/bacon) Na 3. Red wine (alcohol) 1. Temporary RECENT Memory Loss ANTEROGRADE amnesia 4. Soy sauce Intervention: Re-orient client to 3 spheres 5. Cheese burger 2. confusion/disorientation (usually 24 hours) 6. Banana, papaya, avocado, raisins (all over ripe fruits except apricot) 7. Yogurt, sour cream, margarine; 8. Mayonnaise 9. OTC decongestants 10. Pickled foods, Pickled herring women Foods contraindicated in MAOI therapy includes figs, bologna, chicken liver, meat tenderizer, , sausage, chocolate, licorice, yeast, sauerkrauts, Food safe to give includes fresh fish, Cream, Yogurt, Coffee, Chocolate , Italian green beans, sausage, yeast, Antidote: CALCIUM CHANNELBLOCKERS (-DIPINE) 1. Verapamil (Calan) 2. Neurologic problem Alzheimers, degenerative disorder 3. Brain tumor, weakness of lumbosacral spine Legal/Pre-Nursing Responsibilities: Preparation: Similar to preparing a client for surgery: 3. Headache 02 demand, cerebral hypoxia 4. Muscle spasm 5. Wt. gain (stimulate thalamic/limbic appetite) Contraindicated: 1. PPPP Post MI, Post CVA, pacemaker, pregnant 1. SSRi (Selective Serotonin Reuptake Inhibitor inhibitor) 2 wks 2. Antidepressants TCA 2nd Generation 2-4 wks 3. MAOi 2 wks 4. ECT (last resort) Side Effects: - Induction of 70-150 volts of electricity in).5-2secs. Then, it is followed by a grand-mal seizure lasting 30-60 secs. - 6-12 treatments, every other day - Before ECT a major depressed client undergo the ff meds: - Invasive

1. Informed Consent if client is guardian may sign the consent forms. 2. No metallic objects 3. No nail polish to check peripheral

coherent, if not a

REORIENT: Time, place (unit), person (nurse); Reassure regarding confusion and memory loss. Same RN before & after. B. BIPOLAR DISORDERS: With one or more manic episodes, with or without a major depressive episode 1. Bipolar, depressive: Most recent or current behavior displaying major depression 2. Bipolar, manic: Most recent or current behavior displaying overactive, agitated behavior 3. Bipolar, mixed: Rapid intermingling of depressed and manic behavior 4. Cyclothymania: Numerous occurrences of abnormally depressed moods over a period of at least 2 years MANIA - Mood that is elevated, expansive, or irritable. Manic behavior is a defense against depression since the individual attempts to deny feelings of unworthiness and helplessness. MANIC EPISODE: Neurotransmitter imbalance: 1. Norepinephrine* 2. Serotonin

circulation cornea

4. No contact lenses it may adhere to the 5. Wash & dry hair 6. Give following medications BEFORE ECT: a. Atropine sulfate anticholinergic

PRIMARY purpose to dry secretions and prevent aspiration SECONDARY purpose to prevent bradycardia (vagolytic) b. Phenobarbital (Luminal), Methohexital (barbiturate Na)- minor tranquilizer also an anticonvulsant c. Succinylcholine (Anectine) muscle relaxant LOC side-lying

7. Priority vs. to focus ABC; check RR 12 less; 8. Before ECT supine position; after ECT 9. Have patient VOID before giving ECT Nursing Diagnosis: 1. Risk for Airway Obstruction/aspiration 2. Risk for Injury 3. Impaired/Altered Cognition/LOC Nursing Intervention 5 S in Seizure 1. Safety (#1 objective) 2. Side-lying (#1 Position) 3. Side rails up 4. Stimulus (no noise & bright lights) 5. Support the head with a pillow AFTER the seizure

BEHAVIORS COMMONLY ASSOCIATED WITH MANIA A. Affective: Elation/ euphoria, lack of shame, lack of guilt, humorous, intolerance of criticism, expansiveness, inflated self-esteem* B. C. Physiological: Dehydration, inadequate nutrition, needs little sleep, weight loss* Cognitive: Ambitiousness, denial of realistic danger, distractibility, grandiosity, flight of ideas, lack of judgment. *

D. Behavioral: Aggressiveness, provocativeness, excessive spending, hyperactivity, poor grooming, irritability, argumentative* DIAGNOSTIC CRITERIA FOR A MANIC EPISODE: At least 3 of the following for at least 1 week: 1. Delusion of Grandeur over self-worth, inflated self-esteem RATIONALE: A defense to mask feelings of depression & inadequacies 2. Insomnia 3. Flight of ideas 4.Excessive involvement in pleasurable activities without regard for negative consequences

FIRST & TOP priority: Ensure a patent airway. Side-lying after removal of airway. Observe for respiratory problems Remain with client until alert. VS q 5 min until stable.

5. Flight of ideas talkative/pressured speech/pressure to keep talking Tell manic pt to speak more slowly to make a sense if he keeps on moving one subject to another. 6. Hyperactive & Distractibility 7. Easily Agitated 8. Manipulative 9. Increased Metabolism 10. Poor impulse control impulsive 11. Violent/aggressive/hypersexual 12. Pressured speech NURSING DIAGNOSIS: 1. Risk/ Potential for Injury directed to others /or to self 2. Fluid & Electrolytes Imbalances 3. Fluid Volume Deficit NURSING INTERVENTIONS: 1. Accept client; reject behavior 2. Provide consistent care 3. Set limits of behavior/external controls *One staff to provide controls *Do not leave alone in room when hyperactivity is escalating *Explain restrictions on behavior *Do not encourage performance/jokes *Approach in a calm, collected, non-argumentative manner 4. Distract and redirect energy: Choose physical activities using large movements until acute mania subsides (dancing, walking with staff) Meet nutritional needs: High-calorie FINGER FOODS and fluids to be carried while moving. Prone to become fatigue, so, give finger foods: potato chips, bread, raisin, and sandwich. SHORTCUT: ALL HIGH CALORIC & HIGH CARBOHYDRATE DIET or ALL BAKERY PRODUCTS!!! Tuna sandwich & apple are appropriate food for bipolar manic A Husband of 36 y/o bipolar manic type says, My wife hasnt eaten or slept for days. The RN should place a priority focus on physical condition. Encourage rest: Sedation PRN, short PM naps 9. Productive activities: Gardening, finger painting, household chores, Activity for Manic Bipolar includes raking leaves (quiet physical, constructive, productive) to increase self-esteem; competitive is not safe. 10. Less environmental stimulus: No bright lights, do not touch 11. Encourage OFI: Because of Lithium and increased metabolism 12. Check Lithium intoxication SELECTED SITUATIONS AND INTERVENTIONS: A. Disturbing the Group Session 1. Separate the patient from the group, REMEMBER dont touch the patient. Touching the patient may increase AGITATION. 2. Setting of limits matter of fact (#1 Attitude therapy for manipulative patients) Patient in acute manic phase begins to disrobe, appropriate nursing action includes removing patient from group meeting & accompany him to his room B. Aggressive Reaction 1. Decrease environmental stimulation A pt who is pt watching TV suddenly throws the pillows & chair, immediate action is to place pt in seclusion. Staff 1st used a lesser means of control for less success. Shows a documentation that indicates a pts right is being safeguarded during aggressive reactions. C. Violent Patients 1. Move to the door fast and call the crisis management team D. Swearing 1. Setting of Limits 2. Give avenues for verbalization/expression vs. Physical violence MOOD STABILIZERS (ANTIMANIC DRUGS): LITHIUM 7. Avoid ACTIVITIES that increases attention span such as chess, bingo, scrabble... 8. Avoid CONTACT SPORTS: Basketball, gym, strenuous activities & Increase perspiration!! ACCEPTABLE ACTIVITIES: Brisk walking, punching bag, raking leaves, tearing newspaper

For: (Mood disorder specifically Mania (Bipolar

Disorder)

USES: Elevate mood when client is depressed; dampen mood when client is in manic; used in acute manic, bipolar prophylaxis; ACTS by reducing adrenergic neurotransmitter levels in cerebral tissue through alteration of sodium transport affects a shift in intraneural metabolism of NOREPINEPHRINE Action: hyperactivity and balance or stabilize the mood Effect: 1 wk. CODE: LITH Lithium CO3 Eskalith, Lithane, Lithobid

A patient who is talking lithium must be placed in a normal sodium (3 gms.) , high fluid diet (3 L of water). This is done to facilitate excretion of lithium from the body. A. Increase Na = Lithium effect For hypernatremia AVOID Na CO3 Avoid taking soda and/or soda drinks When the lithium level falls below 0.5, the patient will manifest signs and symptoms of mania. B. Decrease Na = Lithium intoxication MORE dangerous!!!! AVOID the 2 dangerous D: diuretics & dehydration

Lithium Citrate Cibalith - S Avoid diuretics to prevent hyponatremia Therapeutic Serum Level: = 0.5-1.5 mEq (local/CGFNS) = 0.6 1.2 mEq (NCLEX) A. Early in therapy: Serum levels measured q 2-3 times per week; 12 hours after the last dose. Long-term: q 2-3 months. Before lithium is begun baseline RENAL, CARDIAC, and THYROID status obtained. Antidote: 1. DIAMOX (ACETAZOLAMIDE) carbonic anhydrase inhibitor (for open angle glaucoma) Avoid strenuous exercise/activities gym works Avoid sauna baths (EXCESSIVE PERSPIRATION) Avoid caffeine because it is a diuretic Stages in Lithium Intoxication I. Early/Initial/Mild: 1.5 mEq - Nausea, vomiting & anorexia - Diarrhea - Gross hand tremors - Abdominal cramps hypocalcemia metabolic alkalosis (Prolong vomiting metabolic acidosis) II. Moderate: 1.6 2.4 mEq Symptoms are 2x the initial signs III. Severe: hallucination 2. POA (Polyuria, Oliguria, Anuria) (Kidney problem) Lithium is nephrotoxic & teratogenic ARF 2.5 mEq 1. Nystagmus, tactile, olfactory & visual

2. MANNITOL (Osmitrol) osmotic diuretics Action to urine output, cerebral edema 3. MNGT. OF OVERDOSE: Induce emesis / lavage; airway; dialysis for severe intoxication 4. If patient forgets a dose, he may take it if he missed dosing time by 2 hours; if longer than 2 hours, skip the dose and take the next dose. NEVER DOUBLE A DOSE!!! Nursing Considerations: 1. 2. 3. 4. 5. 6. 7. 8. Before extracting Lithium serum level Lithium fasting 12 hrs check vital signs Avoid diuretics to prevent hyponatremia Avoid strenuous exercise/activities gym works Avoid sauna baths Avoid caffeine because it is a diuretic For hypernatremia AVOID Na CO3 Avoid taking soda and/or soda drinks OFI 3 L /day; Na 3mg/day

3. Grand Mal Seizure Cerebral hypoxia LOC COMA death PSYCHOSOMATIC / SOMATOFORM DISORDERS

A. PSYCHOSOMATIC DISORDERS: Without any organic or REAL physiological OBJECTIVE symptoms.

Emotional stress may exacerbate or precipitate an illness. The way an individual reacts to stress depends on his physiological and psychological make-up. Structural changes may take place and pose threat to life. Defense mechanisms include REPRESSION, PROJECTION, CONVERSION and INTROJECTION. Synergistic relationship exists between repressed feelings and overexcited organs. Somatoform disorders result in impaired social, occupational and other areas of functioning.

A. Can take the form of blindness, deafness, paralysis or any other physical conditions but with no organic basis. B. Client derives primary and secondary gains from the physical symptoms.

ASSESS FOR: TWO GAINS IN CONVERSION DISORDER Primary gain. REPRESSION: Keeps internal need or conflict out of awareness. SYMBOLISM: Symptom has symbolic value to client. Secondary gain. (Not connected to the primary gain) Additional advantages: Sympathy, attention, avoidance. Reinforces maladjusted behavior.

PSYCHOPHYSIOLOGIC DISORDER: with real symptoms! Physical symptoms whose etiologies are in part precipitated by psychological factors and may involve any organ system. Cardiovascular: Hypertension, Tachycardia NURSING INTERVENTION: Gastrointestinal: Peptic Ulcer, ulcerative colitis, Colic Respiratory: Asthma, Hyperventilation, Common colds, Hay fever Skin: Blushing, Flushing, Perspiring, Dermatitis Nervous: Chronic fatigue, Migraine headaches, Exhaustion Endocrine: Dysmenorrhea, Hyperthyroidism Musculoskeletal: Cramps Others: Obesity, hyperemesis gravidarum NURSING CARE: Holistic or TOTAL physical and emotional Understand that PHYSICAL SYMPTOMS ARE REAL and that the client is not faking and the TREATMENT OF PHYSICAL PROBLEMS DOES NOT RELIEVE EMOTIONAL PROBLEMS Develop nurse-client relationship: Respect the client and his problems. Help to express feelings, Allow client to feel in control Let client meet dependency needs. Dos: Divert attention from symptom; Provide social and recreational activities; Reduce pressure on client; Control environment Donts: Confront client with his illness; Feed into secondary gains through anticipating client needs. 2. HYPOCHONDRIASIS Preoccupation with an imagined illness with no observable symptoms and no organic changes. #1 Sign is DOCTOR SHOPPING: Inability to accept reassurance even after exhaustive testing activities as going from doctor to doctor to find cure. ASSESS FOR Preoccupation with body functions or fear of serious disease misinterpretation and exaggeration of physical symptoms Adoption of sick role and invalid life-style; signs of severe regression Lack of interest in environment history of repeated absences from work If the client is MALINGERING: Deliberately making up illness to prolong hospitalization; faking illness

Help to work through problems and learn new coping mechanism. TYPES OF SOMATOFORM DISORDERS / PSYCHOSOMATIC DISORDERS

Nursing Intervention: Show acceptance of the client. Prepare for, assist in complete medical workup to reassure client and rule and medical problems

1. CONVERSION DISORDER: Presence of physical symptoms with NO identified physical etiology. CHARACERISTICS: #1 Sign Labelle Indifference

 Psychotherapy, family therapy and group therapy: A combination of somatic and behavioral treatment modalities facilities treatment of the disorder. Meet physical needs giving accurate information and correcting misconception. Demonstrate friendly, supportive approach but NOT focusing on the illness. Provide diversionary activities that build selfesteem. Help client refocus on topics other than the illness. Assist client understand how he uses illness to avoid dealing with his problems.

Redirect clients attention away from self; increase socialization / diversional activities Support modalities of treatment: Abreaction: Assisting in the recall of past, painful experiences Hypnosis; cognitive restructuring Behavioral therapy Psychopharmacology: Anti-anxiety, antidepressant

Most appropriate intervention for Dissociative Personality Behavior includes encouraging to chart alternative personality. PERSONALITY DISORDERS

DEFENSE MECHANISMS IN SOMOTOFORM DISORDERS: Denial, Projection, Conversion, and Introjection DISSOCIATIVE DISORDERS

A. DEFINITION: Psychiatric disorder involving disruption in the usually integrated functions of consciousness, identity, memory, or perception of the environment; Client attempts to deal with anxiety by BLOCKING certain areas out of the mind or deeply REPRESSING traumatic events, or by PSYCHOLOGICAL RETREAT from reality; A condition NOT of organic origin and usually occurs as a result of some very painful experience ASSESSMENT FINDINGS: AMNESIA: Selective or generalized and continuous loss of memory FUGUE: State of dissociation involving amnesia and actual PHYSICAL FLIGHT transient disorientation where client is unaware that he has traveled to another location (Client does not remember period of fugue.) DEPERSONALIZATION: Alteration in perception or experience of self, sense of detachment from self, as if self is NOT REAL DISSOCIATIVE IDENTITY DISORDER ( MULTIPLE PERSONALITY): Donated by two or more personalities, each of which controls the behavior while in the consciousness

A. DEFINITION: Borderline state of personality characterized by defects in its development or by pathologic trends in its structure; premorbid personality of individuals resembling the compensatory mechanisms associated with the pathologic counterpart. PREDISPOSING FACTORS & CAUSATION 1. Biological predisposition malnutrition, neurologic defects & congenital predisposition 2. Development of maladaptive behavior 3. Freudian fixation GENERAL CHARACTERISTICS: 1. Denial 2. Maladaptive behavior inflexible 3. Minor stress poor tolerance mood disturbance 4. in reality 5. Not caused by physiological pattern - Attitude can be changed - Immature - do not adjust to environment 3 CLUSTERS OF PERSONALITY DISORDERS 1. Cluster A Disorders: Odd / Eccentric a. Paranoid b. Schizoid c. Schizotypal 2. Cluster B Disorders: Dramatic / Erratic a. Histrionic b. Narcissistic

NURSING IMPLEMENTATION: Assess what form the dissociative disorder is manifesting and degree of interference in ADL, lifestyle, and interpersonal relations Reduce anxiety-producing stimuli

c. Antisocial d. Borderline 3. Cluster C Disorders: Anxious/ Fearful a. Dependent b. Avoidant c. Passive Aggressive d. Obsessive Compulsive CLUSTER A: ODD / ECCENTRIC

- Ideas of reference or delusion of reference - Cold/aloof limit social contact=social anxiety - Peculiarity in speech but no looseness of association - may develop into schizophrenia or other psychotic disorders - Withdrawn, unattached, odd and eccentric,

A. Paranoid Personality Disorder CHARACTERISTICS: Code (MOST OF THEM STARTS WITH LETTER P) - suspicious, distrustful oral fixation - Loneliness suspicious/mistrust pathologic jealousy, hypersensitive #1 DEFENSE MECHANISM: Projection #1 NURSING DIAGNOSIS: Social Isolation #1NURSING CONSIDERATION/ INTERVENTIONS: 1. Passive Friendliness no eye contact, mo touch, no laughing/giggling, non whispering 2. Consistency 3. Proxemics: 7 feet away from the patient B. Schizoid Personality Disorder CHARACTERISTICS: - Socially distant, detached, low IQ - introvert, loner, aloof, humorless - avoids close relationships with family, friends, peers - Flat affect indifferent to praise - Functional when works alone; more interested on objects - #1 Defense Mechanism: Rationalization Shy, introverted since childhood but with fair contact with reality Autistic thinking, dreaming, emotional detachment, avoidance of meaningful interpersonal relationships, cold and detached #1 NURSING DIAGNOSIS: Social Isolation\ - Unable to postpone gratification, immature, irresponsible C. Schizotypal Personality Disorder - Similar with schizophrenia CHARACTERISTICS: - Odd, eccentric, lowest IQ - Magical thinking, e.g., superstitiousness, telepathy - Randomly acting out aggressive egocentric impulses on society; reckless, unlawful, disregard for right of others. - Steals, cheats, lies - Appears charming, intellectual, smooth talker - Antisocial patients have low tolerance to frustration. - Underdeveloped superego; lack of guilt, conscience and remorse; unable to learn from experience or punishment - Life-long disturbances that conflict with laws and customs - Diminished affective (blunted/inappropriate affect) and intellectual skills, vague, over elaborate speech - Frequent part of vagabond or transient groups of society #1 NURSING DIAGNOSIS: Social Isolation CLUSTER B: DRAMATIC/ ERRATIC A. Antisocial Personality Disorder - 15-40 y.o, mostly in males - History of conduct disorder (6-11 yo) THEORIES: Genetic/hereditary Physical/Sexual abuse Low socioeconomic status maladaptive behaviors CHARACTERISTICS: - Impulsive, aggressive, manipulative - Low self-esteem - lack remorse - hates rule/regulations, authority figures - coprolalia (bad words) - Kills, cheats, steals, rapes, destroys

NURSING INTERVENTION/CONSIDERATION: 1. SETTING OF LIMITS matter of fact, voice not high nor low, does not say please. Setting of limits prevent the patient from manipulating the nurse. 2. Consistency is a must regarding rules & regulation. Efficacy of treatment is achieved for an antisocial if the patient is able to respect nurses & other patients boundaries. Positive outcome for antisocial personality disorder includes adherence to rule of hospital unit Interventions that can be appreciated by antisocial include exchanging tokens for any privilege B. Borderline Personality Disorder - Mostly in females THEORIES: Faulty parent-child relationship; dysfunctional family Trauma; physical/sexual abuse (18 months) low ego Unfulfilled need of intimacy CHARACTERISTICS: - Impulsive, self-destructive, unstable - Self-mutilation & suicidal Therapeutic measure to prevent self-mutilation in borderline includes behavioral contract. The purpose of behavioral contract in borderline is to limit use of unhealthy defense mechanisms

- Intense, brief, unstable interpersonal relationships with impulsiveness, manipulation, physical fights and temper tantrums A borderline patient indicates an improvement when she state, I ran around the block rather than cutting myself. Borderline personality with a history of cutting her wrist shows an intense & a changeable affect during the middle phase of nurse-pt relationship. The patient says, "Youre a smart nurse. I want to be just like you. This statement shows Transference A patient borderline state, Youre a phony. You dont know what happened to me.Best response of the nurse will be, Ill ensure what is necessary will be done to you Intervention for borderline d/o includes setting of limits through saying, The policy of the unit is that, You cant leave in the unit in 1st 24 hrs. C. Histrionic Personality Disorder - More common in women, 2-3 % of the population THEORY: Llacks Electra complex (no father figure) Papas girl CHARACTERISTICS: - Emotional, dramatic, theatrical - wants to be the center of attention - Manipulative, Sexually seductive or provocative - Exaggeration of emotion, Style of speech is excessively impressionistic - Labile emotion, Positive: Creative, imaginative - Extroverted, manipulative, vain with behavior directed toward gaining attention to self; - Emotionally unstable; uses somatic complaints to avoid responsibility D. Narcissistic Personality Disorder - Usually Men - Another: Metrosexual

- Unpredictable behavior (gambling, shopping, sex, substance abuse) - Disturbance in self-concept: Identity - #1 DEFENSE MECHANISM: Splitting Youre the only nurse who understands me. This statement is shown in a patient with borderline behavior. - Identity disturbance with chronic feelings of emptiness (Anhedonia) - Marked mood swings and impulsive unpredictable behavior with potential for self-destruction.

CHARACTERISTICS: - Vanity in personal appearance - Exaggerated or grandiose sense of self-importance - Boastful, egotistical, superiority complex

- preoccupied with fantasies: Power, success, beauty - Excessive admirations; envies other, arrogant, lack of empathy -Overblown sense of importance, grandiosity; with strong need for attention and admiration from others CLUSTER C: ANXIOUS / FEARFUL A. Obsessive Compulsive Personality Disorder - More in women - Obsession irresistible thought, Compulsion irresistible action THEORIES: Genetic: Serotonin imbalance Anal fixation strict toilet training Overpowering mother CHARACTERISTICS: - Cardinal Signs: RITUALISTIC #1 DEFENSE MECHANISM: Undoing, Repression, Symbolization # 1 Ritual: handwashing Other Ritualistic behaviors: 4 Cs: Controlling perfectionism Collects or hoarding Cleaning Checking Rigid, over-conscientious, perfectionist, inflexible, cold affect Driven by obsessive concerns Sets high standards for self and others Preoccupied with details, rules and organization

the task. Question most likely to elicit response for treatment of compulsive hand washing includes asking how much has the symptom interfered with your daily activities? 2. Do not abruptly stop rituals 3. Setting of limits avoid manipulative and controlling behaviors 4. TX: Tricyclics antidepressants balance serotonin and norepinephrine Effects: 2-4 wks. Clomipramine (Anaframil) #1 drug of choice for OC Imipramine (Toframil) 2nd drug of choice

An oriented group therapy is indicated for OCD B. Dependent Personality Disorder - Most common personality disorder for Acute wife battering syndrome - Co-dependency enabling Statement of pt that indicates ability to care for self after being victim of domestic violence includes a statement like, I have a car key & money hidden outside the house. Battered wife should be referred to shelter Batterers are violent, loving & remorseful (dual personality) Wife batterer has low-self esteem Honeymoon episodes in acute wife battering syndrome showing statement of reconciliation includes, Mama, pls. get these red flowers. I love you & Ill never do it again. CHARACTERISTICS: - Submissive, clinging - lacks self-confidence, low self-esteem, helpless, good follower - Lacks self-confidence, helpless when alone, preoccupied with fear of being alone - Fails to make decisions and accept responsibility induces others to take responsibility A pt with Dependent personality who shows ineffective decision making should have

STEP TO STEP PRIORITY NURSING DIAGNOSIS: Altered Sleeping Patterns Altered Skin Integrity Ineffective Individual Coping PRIORITY NURSING INTERVENTIONS: 1. Give appropriate time to do rituals to decrease anxiety In OCD, intervention includes giving an extra hr to the pt to do the ritual before starting

setting of limits & make behavioral contract on its daily activities. C. Avoidant Personality Disorder CHARACTERISTICS: - Shy, timid, inferiority complex - avoid open forum - Over sensitive to rejection/criticism - Social withdrawal = inept - Depression, anxiety, anger are common - Withdrawn, loner, lacks self-confidence; with feelings of discomfort/timidity when with others -Unwilling to get involved with others and in situations where negative evaluation, rejection and failure are a possibility C. Passive Aggressive Personality Disorder CHARACTERISTICS: - insecure backbiter plastic - loves to procrastinate, cant finish a task - Patients with passive-aggressive personality expresses anger through passivity. #1 Defense Mechanism: Reaction formation. Goal of nurse in Passive Aggressive Personality includes verbalization of anger when needed Goal of Care for Passive Aggressive includes verbalization of feelings of anger when the need arises. COGNITIVE / ORGANIC MENTAL DISORDERS COGNITIVE/PSYCHIATRIC DISORDERS With organic etiology With deficits in COGNITION and MEMORY Effects: Changes in levels of functioning and disturbed behavior MOST COMMON AREAS OF DIFFICULTY (JOCAM)

C Confabulation (filling in memory gaps) A Affect (mood changes, depression, tearful, withdrawn) M- Memory (Impaired especially for names and recent events compensated by confabulation and circumstantiality) DELIRIUM VERSUS DEMENTIA

DELIRIUM- Acute in onset, Reversible , 1 sign: Clouding of consciousness or grandmal / tonic-clonic seizure, Causes: Hyperthermia, sepsis such as Encephalitis, meningitis, drug induced Withdrawal (alcohol & cocaine withdrawal) DEMENTIA- Chronic / Gradual in onset, irreversible , #1 Sign: Progressive memory loss, Causes: Unknown (idiopathic) SYMPTOMS OF DELIRIUM * Difficulty with attention * Easily distractible * Disoriented * May have sensory disturbances such as illusions, Misinterpretations or hallucinations * Can have sleep wake cycle disturbances * Changes in psychomotor activity * May experience anxiety, fear, irritability, euphoria, TYPES OF DEMENTIA

Picks Disease: Similar picture to DAT, but with frontal lobe symptoms (personality changes) and reactive gliosis. Vascular/Multi-infarct Dementia: Patchy cognitive deterioration (dependent on infarct site) appearing within 1 years of vascular injury; common in men and earlier in onset. Huntingtons Disease: Autosomal dominant (chromosome 4) disorder with both motor (chorea, gait disturbance, slurred speech) & cognitive changes (dementia) Creutzfeldt-Jacob Disease: Dementia due to prions (infectious particle without DNA or RNA); rapidly progressive from vague somatic complaints to ataxia, dementia then death. Parkinsons Disease: Dopamine in the basal ganglia & extra-pyramidal system causes tremors (pill-rolling & resting), bradykinesia, cogwheel rigidity, shuffling gait, mask-like fascies.

J Judgment (impaired) O Orientation (confused/disoriented; illusion/hallucination)

Progresses to depression & dementia, treated with Ldopa

Nursing care for the patient with dementia is geared towards maintaining existing functions by minimizing regression. Place an alarm signal to know that the pt is attempting to exit in a dementia client who used to wander away from acute facility. ALZHEIMERS DISEASE Degenerative disease of the central nervous system characterized by premature senile retardation. Degenerative disorder of the cerebral cortex. The etiology of Alzheimers disease is unknown

1.

Acetylcholine Alteration: Decrease in acetylcholine reduces the amount of neurotransmitter which results in disruption of cognitive process. Accumulation of Aluminum: Studies show that aluminum accumulates in damaged areas of the brain.

2.

3. Alterations in the Immune System: Antibodies are being produced in the brain which causes a reaction against self it is called autoimmune 4. Head Trauma: Head injuries 5.Genetic Factor: Pattern of inheritance

THREE STAGES OF ALZHEIMERS The most common non- traumatic cause of dementia is Alzheimers disease at 65, 10% of the population has Alzheimers; by 85, the percentage increases to half. Multi-infarct dementia is the second most common cause of non traumatic dementia. NATURE: Gradual, progressive; Onset: Usually after 65 (2-4%); may begin at 40-65; may die within 2 yrs or 8-10 yrs if with total care. The main pathology is the of presence of senile plaques that destroys neurons leading to decreased acetylcholine. The primary need of a patient with Alzheimers is Reorientation. Early stage (Forgetfulness Stage: Mild) The first symptom of Alzheimers disease is Progressive memory loss. This is followed by disorientation, personality changes, language difficulty, and other symptoms & dementia. The patient can compensate for the memory loss but the family may notice personality changes and mood swing. Recent memory is affected including the ability to learn new information. Managing daily living activities becomes progressively more difficult. The patient may notice difficulty balancing his checkbook and may forget where he put things. Forgetfulness: loose things; forget names, short-term memory loss, and the individual is aware of the intellectual decline. Early Confusion: Symptoms of confusion begins and concentration may be interrupted. Individual may forget major event in personal history such as birthday of his/her child: experience declining activity to perform task; individual may deny memory loss. Findings that are observed in the early stages of Alzheimers disease are inappropriate affect, disorientation to time, paranoia, memory loss, and an impaired judgment. * Response of nursing assistant to an Alzheimers patient that Needs Further Teaching includes a statement like, How many glasses of water did you drink today? - Anterograde amnesia. Middle stage (Wandering Stage/Sundown syndrome) The patient is increasingly disoriented and completely unable to learn and recall new information. He may wander or become agitated or physically aggressive. He may have bladder incontinence and may require assistance with activities of daily living. Individual may be unable to recall major life events even the name of spouse. Disorientation in the surroundings is common and the person may be unable to recall the day, season, and year. Sleeping becomes a problem. Symptoms worsen in the evening known as SUNDOWNING. Late stage (Kluver Bucy like Syndrome) The patient may be unable to walk and is completely dependent on caregivers. Hes totally incontinent of bowel and bladder. He may even be unable to swallow and is at risk for aspiration. Hes unable to speak intelligibly. In the late

4 CARDINAL SIGNS OF ALZHEIMERS 1. Agnosia sensoryinability to recognize objects/subjects Patient with agnosia is unable to recognize persons. 1st to forget: The name of an object 2nd to forget is the function of an object 2. Apraxia sensory-inability for purposeful movt. ex. Tremors 3. Amnesia 1st amnesia to appear: Anterograde amnesia recent memory 2nd amnesia to appear: Retrograde past Tx: Reminiscing Group Therapy 4. Aphasia sensory-inability for speech and communication Predisposing/Contributing Factors: Psychiatric Mental Health Nursing 3rd edition by Mary C. Townsend Exact cause unknown but several hypothesis were introduced; (pg 342-343)

stages of Alzheimers disease it is better to go along with the patients reality rather than confront him with logical reasoning. Asking close ended simple questions that relate to his reality is non-threatening and calming. Note that the nurses response in a way that is congruent is the main concern. The individual may not recognize family members. There may be problems of immobility. Nursing Diagnosis: Risk for trauma Nursing Intervention: 1. Milieu Therapy is needed: a CONSISTENT UNCHANGING & FAMILIAR ENVIRONMENT IS NEEDED to decrease chances of disorientation & confusion.In milieu therapy, patients plan and lead activities rather than the staff Millieu therapy involves scientific manipulation of the environment that can influence improvement patients behavior Store frequently used items within reach. Keep bed in unelevated position with soft padding if client has history of seizure and keep the rails up.

13. Wear the Medical Alert Bracelet (name, Address, Tel #, Diagnosis, Medication) 14. Avoid afternoon naps, avoid caffeine, TV & radio remote 15. REMEMBER THE 3 Cs for Alzheimers to DECREASE DISORIENTATION: Color, Calendar, Clock Nursing Diagnosis: Altered thought process Nursing intervention: 1. Frequently orient the patient to reality.

Sensory stimulation for elders helps to increase pts arousal 2. Keep explanation simple and use face-to-face interaction. Speak slowly and do not shout. In caring for elderly w/ Alzheimers use short & simple words & face him while you are talking. Discourage rumination of delusional thinking. Talk about real people and real events.

2. 3.

3.

4. Monitor for medication side effects. A confused Alzheimers patient who gets out of bed several times must be provided with a safe environment like placing a hand rails for the patient to hold. Bed of confused Alzheimers patient must always have its side rails up. 4. Assign room near nurses station. 5. Assist patient with ambulation. 6. Keep dim light on at night. Decrease environmental stimulus. 7. If patient is a smoker, stay with him/her at all times. 8. Frequently orient patient to time, place and situation. 9. If patient is prone to wander, provide an area in which the client is safe to wander. 10. Family counseling about Alzheimers disease includes checking that pt is wearing ID bracelet when going out at all times 11. Soft restrain may be required if the client is disoriented hyperactive as ordered by the physician. 12. Provision of simple, structured environment, choices Consistency and ROUTINE in care to increase security; Brief, frequent contacts; reinforce realityoriented comments Ample time and patience to allow client to talk / complete using associative patterns to improve recall: simplicity, focusing, repeating, summarizing. Allow REMINISCING of past life / exploits / achievements. Reminiscing helps lessen the patients loneliness. 5. Use soft tone, simple sentences, and a slow, calm manner when speaking to a person with Alzheimers disease. If he doesnt understand you, repeat yourself using the same words. Your nonverbal communication is more important than your actual spoken message. Dont a hurried tone, which will make the patient feel stressed. Move slowly and maintain eye contact. Nursing Diagnosis: Self-care deficit Nursing Intervention: 1. Identify self-care deficit and provide assistance.

Urinary incontinence in patient with Alzheimers can be controlled by decreasing fluid intake at night time 2. 3. 4. 5. 6. 7. Allow plenty of time for the patient to perform task. Provide guidance and support for independent actions by talking the patient through the task. Provide structure schedule of activities that does not change from day to day. ADLs should follow home routine as closely as possible. Provide clients nutritional needs, safety and security. Give foods high in carbohydrates to an Alzheimers who refuses to eat his meal

In an Alzheimers caregiver class, the nurse tells the student that the reason why pts do not take a bath is that they cant remember anymore if they have taken the bath already.

Screening Test: 1. 2. 3.

MS Brunner and Suddarth (pg 160)

Electroencephalography Computed tomography Magnetic Resonance Imaging

Ginkgo biloba, a plant extract, contains several ingredients that many believe can slow memory loss in people with Alzheimers disease, Research has shown that ginkgo produces arterial, venous, and capillary dilation, leading to improved tissue perfusion and blood flow. Adverse effects are uncommon but may include GI upset or using anticoagulants. EATING DISORDERS

Confirmative Test: Cerebral biopsy after death. Complication: 1. Infection 2. Malnutrition Best Drug: Anticholinesterase:Increases ACH (acetylcholine) levels Tacrine hydrochloride (Cognex) Donezepil (Aricept) Rivastigmine (Exelon) DRUG STUDY: No cure or definitive treatment exists for Alzheimers disease. However, three drugs, tacrine (Cognex), rivastigmine (Exelon), and donepizel (Aricept), have been approved by the Food and Drug Administration to improve cognitive function in patients with mild to moderate Alzheimers disease. Tacrine hydrochloride (Cognex)-monitor patient for liver toxicity Tacrine hydrochloride (Cognex)-enhances acetylcholine uptake in the brain, thus maintaining memory skills for a period of time. SUMMARIZED DRUGS USED TO TREAT DEMENTIA Tacrine (Cognex)- 40 160 mg orally per day divided into 4 doses; Monitor liver enzymes for hepatotoxic effects. Monitor for flu like symptoms. Donepezil (Aricept)- 5 10 mg orally per day; Monitor for nausea, diarrhea, and insomnia. Test stools periodically for GI bleeding. Rivastigmine (Exelon)- 3 12 mg orally per day divided into 2 doses; Monitor for nausea, vomiting, abdominal pain, and loss of appetite. Galantamine (Reminyl)- 16 32 mg orally per day divided into 2 doses; Monitor for nausea, vomiting, loss of appetite, dizziness, and syncope. BEST HERBAL DRUG FOR ALZHEIMERS: Enhancing memory with ginkgo biloba

#1 CAUSE: Unknown #1 Personality Disorder of Eating Disorders: Obsessive Compulsive Personality THEORIES OF CAUSATION: 1. Behavioral: Attention-seeking by rejecting foods; manipulation to gratify needs 2. Family interaction: Ambivalent feelings towards mother; overprotection, rigidity, lack of personal boundaries and independence; use of anorexia to avoid interpersonal conflicts. The issue of CONTROL is a central one for the client with anorexia nervosa. It is believed that symptoms are caused by stressor that the adolescent perceives as a loss of control in some aspect of her life. Controlling intake and weight gain is a way the client establishes a sense of control over her life. 3. Psychoanalytic: Regression to oral and anal developmental stage to avoid adolescent sexuality and independence 4. Medical: Genetic predisposition, increased catecholamines, hypothalamus dysfunction Anorexia- Amenorrhea, 15-20% ideal weight, Defective defense mechanism: Denial; Poor to fair prognosis; CHARACTERISTICS vegetarian - All are female - Adolescent 11-17 yo - hoards/collects food- strenuous exercise introvert. Patients with eating disorders are usually high achievers, perfectionist and preoccupied with food. OTHERS: Refusal to take meals dramatic weight loss. Anorexic patients usually suppress their appetite, which makes it difficult for the nurse to convince them to eat. Resistance to treatment; difficulty accepting nurturance & caring. Feelings of loneliness and isolation. Hypotension, bradycardia, hypothermia. Secondary sexual organ atrophy; amenorrhea. Reduced metabolism, reduced hormonal functioning; hypoglycemia; electrolyte imbalance; Hyperactivity; Constipation; Leukopenia ; Skin problem: Hyperkeratosis (overgrowth of horny layer of epidermis) Complications: #1 Cause of death: cardiac dysrrhythmia Hypokalemia ECG ST segment depression & Prominent U wave. STEP BY STEP NURSING DIAGNOSIS: 1. F/E imbalance

2. Fluid volume deficit hypovolemic shock 3. Altered Nutrition less than body requirement 4. Altered Body Image- Change of body image causes difficulty in self-esteem. Long term treatment for anorexia/bulimia includes outpatient family therapy sense of control over herself is a positive outcome in eating disorder. BULIMIA - Binge/purge syndrome; Binge eating: Eating increased amounts of high calorie food in a short period of time. 2 bingeeating episodes or more per week for 3 months ; fluctuation of body weight There is ACCEPTANCE; good prognosis acceptance(Bulimic patients are usually aware of their abnormal behavior) CHARACTERISTICS: - carbohydrate, caloric fast foods - 4 % are Boys - young adults - loves to cook -abuses laxatives/enema, extrovert. Complications: -esophageal varices , - dental carries, callous finger , - chipmunk face STEP BY STEP NURSING DIAGNOSIS: 1. F/E imbalance 2. Fluid volume deficit hypovolemic shock 3.Altered Nutrition less than body requirement

Preventing the patient from using the bathroom for 2 hours after eating, prevents the patient from inducing vomiting. Presence of anemia, hypotension, bradycardia, amenorrhea Interpersonal relationships

3. PROVIDE A STRUCTURED ENVIRONMENT that offers safety and comfort and helps DEVELOP INTERNAL CONTROL reduces need to control by self-starvation. 4. Help client accept eating problem and set realistic, attainable short-term goals 5. Provide support is developing better outlets for emotional expression; Encourage outside interests not related to food 6. Provide teaching on therapeutic diet: Balanced, calories restriction to effect WEIGHT GAIN (1-2 pound per week) 7. Offer PRAISE for progress; accept lapses (behavior modification) 8. Instruct and support in behavioral modification program: 1) Control speed of eating chewing food well; 2) Self monitoring w/ food diary; & 3) Praise/reinforce compliance Best discharge plan for anorexic teen includes attending a support group

NURSING INTERVENTION FOR EATING DISORDERS 1. DIETARY THERAPY restoration and stabilization of nutritional and fluid balance a. Feedings: Oral, IV or tubes; monitor hydration and electrolytes An anorexic patient with high urine specific gravity must be encouraged to have an increase fluid intake b. Caring and nurturance when possible c. Provide education 1) on growth & development and normal nutrition 2) Limit setting: Based on weight gain or loss, grant or restrict privileges; use behavioral contract to enforce limits 2. ASSESS AND EVALUATE: Weight and % of normal body weight loss; weighing 3x a week: Same time, clothing and weighing scale. Limit activity based on weight gain: For wt. Loss complete bed rest; gain less than 100 g- with bathroom privileges; more than 200 g- may ambulate in the hospital Eating patterns: Amount, type of foods, time and place of eating, whether food is forced or followed by vomiting; Provide surveillance 30 min. to 1 hr after meals

DRUG ADDICTION/NONALCOHOLIC SUBSTANCE ABUSE

SUBSTANCE ABUSE TERMS AND DEFINITTIONS a. ASSESSMENT FINDINGS History. Academic or job failures, marital failures, stealing to support habit, personality change, violent acting out Physical Examination: Malnutrition; abdominal cramps; diaphoresis, yawning, lacrimation, rhinorrhea 10 hours after the last opiate injection; needle marks on arms along path of a vein (wearing of long- sleeves); nasal discharge with nasal septum perforation (cocaine) Social: Inability to maintain ADL and fulfill role responsibilities and obligations

B. NURSING DIAGNOSES, POTENTIAL: Altered health maintenance/nutrition related to chemical dependence; lack of interest in food High Risk for Violence: Directed toward self or others related to feelings of suspicion or distrust; intake of mind-altering substances; misinterpretation of stimuli

Defensive Coping related to denial of problem; projection of responsibility or blame; rationalization of failures NON-ALCOHOLIC ABUSED SUBSTANCES

> Screening Questions for alcohol abuse: 1. When was the last time you have taken alcohol? 2. How much alcohol have you taken for the last 24-48 hrs? In a detoxification unit, the nurse asks the pt when was the last time he drink alcohol to determine the onset of alcohol withdrawal syndrome. Goal in alcohol detoxification includes maintaining maximum physical integrity during withdrawal period. Statement of a pt who is alcoholic and undergoing detoxification saying, I can quit whenever I want. shows denial CAGE SCREENING QUESTION FOR AN ALCOHOLIC

Another word for alcohol is Booze Brew GENERAL PRINCIPLES OF CARE: ALCOHOL DETOXIFICATION 3 As = Alcohol Withdrawal Aversion Therapy (Punishment) Antabuse (Disulfiram) = no effect unless mixed with alcohol Action: Inhibit Antabuse effect dehydrogenase Acetaldehyde

C cut down alcohol (Do you need to cut down alcohol?) A annoyed (Are you annoyed when someone will ask you Are you an alcoholic?) G guilty (Are you guilty of taking too much alcohol?) E eye opener (stimulant) Do you use an eye opener early in the morning to decrease the after effects of alcohol? 3 Stages of Alcohol Intoxication I. Alcohol Serum Level = 0.04 -0.05% unsteady gait > social & sexual inhibition II. ASL = 0.08-0.1 or 100 mg/dl > slurring of speech > Fruity odor similar to ketoacidosis > Legal intoxication III. ASL = 0.15-0.2 severe alcohol intoxication > 4 Common Complications with History of Alcoholism 1. Liver Cirrhosis 2. Gastritis inflammation 3. Pancreatitis 4. Wernickes Korsakoffs peripheral neuritis lack of Vit. B1 (thiamine) (Sx: Tingling sensation/numbness of extremities: Avoid electric blankets!) Wernickes psychosis is due to thiamine deficiency. >

> Dosage: Acute phase = 500 mg in 1st 2 wks. Maintenance Phase = 250 mg & >Prohibited Household items with alcohol: mouthwash, cough syrup/elixir, vinegar, fruitcake, shaving cream, astringent, and toner, acetone/nail polish Cough medicines and other over-the-counter medicines are alcohol-based and may cause antabuse reaction when it is combined with antabuse. Antabuse may worsen renal damage thus it is contraindicated for patients with renal problems. Effect of Antabuse with Alcohol 1. Nausea & Vomiting 2. Diarrhea 3. Intense headache 4. Abdominal cramps > Short term objective for an alcoholic: To stop/cut denial Long term objective: Abstinence (similar with STD/HIV/AIDS) > # 1 group therapy for Alcoholics (12 step recovery program AA (Alcoholic Anonymous) for victims of alcoholics: AL-ANON for alcoholic teens: ALATEEN Correct response of an RN to alcoholic patient who says, I dont want to attend group meeting, I dont need their alcoholic advice. Is a statement like, The group activity may not seem helpful to you but you can help them.

Confabulation or making up of stories is one of the initial manifestations of Korsakoffs syndrome. Two categories of Wernickes Korsakoffs: A. Wernickes Aphasia / Receptive Aphasia: Problems in interpretation (temporal lobe) B. Korsakoffs Psychosis irreversible (the best drug is Risperidone (Risperdal): It has Decrease extrapyramidal symptoms (EPS) 4 Stages of Alcohol Withdrawal I. Early/Initial Fine tremors, restlessness, tachycardia, diaphoresis, hyperventilation & nervousness Symptoms of alcohol withdrawal is observed when the cup rattles to the side when the patient stirs his coffee II. Hallucination #1 hallucination of Alcohol withdrawal is TACTILE

Delirium tremens is initially manifested by anxiety, restlessness, illusions, hallucinations and elevated vital signs. Observation indicating a need to be included during endorsement to next shift in an alcoholic patient in the ER include observations of becoming fearful (delirium tremens) DRUGS CAUSING DELIRIUM Anticonvulsants Antidepressants Antipsychotics Barbiturates Cardiac glycosides Hypoglycemic agents Narcotics (Inderal) Reserpine Anticholinergics Antihistamines Aspirin Benzodiazepines Cimetidine(Tagamet) Insulin Propranolol Thiazide diuretics

Nursing diagnosis for patient with delirium tremens who says, There are bugs in my bed crawling over me is Altered Thought Process 2. Visual hallucination Intervention: > Use lampshade to shadow (illusions) Leaving a light on the patients room will decrease visual hallucinations, which frequently occur in alcohol withdrawal syndromes. Shadow stimulates hallucination dont leave the patient (Offering of self)

MOST COMMON CAUSES OF DELERIUM 1. 2. COMMONLY USED ANTICONVULSANTS Valium (Diazepam) best drug for delirium tremens Librium (Clordiazepoxide)

Positive) outcome of Librium in alcoholic depressed woman includes an observation that client can pick an object on floor w/ smooth coordination 3. Klonopin (Clonazepam) 4. Phenytoin (Dilantin) best anticonvulsant for children SE: Gingival hyperplasia & red orange urine Intervention: Massage the gums & use soft bristle toothbrush Adverse Effect: Blood dyscrasia thrombocytopenia S/SX: Bleeding of the gums Lab test: Platelet count = 150,000-400,000; if 100,000-active bleeding

Assigning a staff to the patient promotes safety especially during withdrawal episodes. III. Pre-seizure/RUM FITS Impending signs of Seizure 1. Epigastric pain (early sign in 2. High pitch cry/projectile 3. Eye pain/periorbital pain usually in eclampsia 4. Headache & Aura- ICP 5. Restlessness cerebral hypoxia = & glucose IV. Delirium Tremens Active Seizure = Grand mal/Tonic-Clonic 02 (scotomas) eclampsia)

Special Considerations: The only COMPATIBLE I.V. Solution for Phenytoin (dilantin) is NSS (Normal Saline Solution) 5. Carbamazepine (Tegretol): Anticonvulsant neuralgia (tic douloureux) A/E: Agranulocytosis/neutropenia S/Sx: Sore throat - Neutrophils 54-56 % trigeminal

6. Valproic Acid (Depakene/Depakote) therapeutic serum level: 40-100 mcg. Adverse Reaction: Hepatotoxic (assess SGPT or ALT) 7. Ethosuccimide (zarontin)

1. 2. 3.

EXHIBITIONISM: Sexual gratification from exposing genitalia FETISHISM: Sexual gratification from an inanimate object (usually clothing material) substituted for the genitals FROTTEURISM: Sexual gratification from toughing or rubbing against a nonconsenting person (usually in crowds, public transportation) MASOCHISM: Sexual gratification from self-suffering used as an accompaniment of the sexual act or substitute for it

Chlordiazepoxide (Librium), multivitamins, thiamine and folic acid help decrease withdrawal symptoms. GENERAL PRINCIPLES OF CARE: DETOXIFICATION/OVERDOSE A. Maintain airway: Intubation (keep airway on hand), suction B. C. Start IV line Monitoring: BP, respiration, pulse, temperature, LOC

4.

5. PEDOPHILIA: Sexual gratification from children 6. SADISM: Sexual gratification from inflicting pain or cruelty to others used as an accompaniment of the sexual act or a substitute for it 7. TRANSVESTISM: Sexual gratification from wearing clothes of the opposite sex 8. VOYEURISM: Sexual gratification from watching the sexual play / act of others 9. ZOOPHILIA: Sexual gratification from animals C. SEXUAL DYSFUNCTION: Generalized or situational, acquired or lifelong inhibition or interference with any of the phases of the sexual responses which may be due to psychogenic factors alone or psychogenic and biologic combined. D. NURSING DIAGNOSES 1. Anxiety related to threat to security and fear of discovery 2. Anxiety related to conflict between sexual desires social norms 3. Sexual dysfunction related to actual or perceived sexual limitations 4. Sexual dysfunction related to inability to achieve sexual satisfaction without the use of paraphilic behaviors 5. Potential for infection related to frequent changes in sexual partners or sadistic or masochistic acts 6. Potential for injury / violence related to sexual behavior and retaliation for sexual behaviors E. GENERAL PRINCIPLES OF CARE

D. Prevent and control seizures; Keep in calm, quiet environment E. Check for trauma, protect from injury

A pt taking phencyclidine (PCP), shouts & walks back & forth, appropriate nursing intervention includes seclusion, staying w/ the pt, and decreasing stimuli. F. Administer ordered drugs; Detoxify / treat overdose NALOXONE (NARCAN) Pure antagonist to narcotics-induces withdrawal and stimulates respiration; DRUG OF CHOICE when in doubt the substance used because NALOPHINE (NALLIN), a partial antagonist to narcotics, will respiratory depression if barbiturates have also been used METHADONE drug substitute used for acute withdrawal and long-term maintenance; changes an illegal to a legal drug, which is administered under supervision. Antidepressants block the high from stimulant abuse

G. Nutrition: High-calorie, high-protein, high-vitamin SEXUAL DISORDERS / DYSFUNCTION 1. Acceptance NOT of the behavior but of the client who is in emotional pain 2. Protection of the client from others 3. Setting limits on the sexual acting out 4. Supporting of self-esteem: Avoidance of punitive remarks or responses

A. SEXUAL DISORDER: Deviations in sexual behavior; sexual behaviors that are directed toward anything other than consenting adults or are performed under unusual circumstances and are considered abnormal B. PARAPHILIA: Sexual fantasies or urges that are directed toward nonhuman objects, the pain to self or partner, or children and other nonconsenting individuals.

5. Provision of diversional activities PERVASIVE DEVELOPMENTAL DISORDERS CODE: ACA

2. 3. 4.

Set consistent and firm limits for his behavior Make physical contact on a regular basis. Accept the clients need to push but still maintain regular contact. Prevent acts of self-destructive behavior Provide appropriate therapy:

Autism, Conduct Disorder, Attention Deficit Hyperactive Disorder (ADHD), AUSTITIC DISORDER A. A type of developmental disorder for an unknown; probable underlying problem: failure to develop satisfactory relationships with significant adults - mostly males - talented in music or math - # 1 screening test DDST (Denver Developmental Screening Test) - Autism is usually diagnosed during the toddler stage. CHARACTERISTICS: 1. Blank stare 2. Repetitive movement: head banging padded room/helmet 3. Likes to follow bright moving objects 4. Catatonic 5. Temper tantrums 6. Clings to inanimate objects B. ASSESSMENT FINDINGS: 1. Disturbance in sense of self-identity, in ego system formation: Inability to distinguish between self and reality / environment speaks of self in the third person Withdrawal from reality. Lacks meaningful relationship with outside world; turns to inanimate objects and self-centered activities for security Personality alteration adaptive, inhibitory, steering mechanisms due to profound interference in intellect SEVERE AUTISM Severe apathy, Association looseness, Autistic thinking, Poor grasp of reality, Ambivalence, Poor communication skills, Poor interpersonal relations, Poor intellectual functioning

5.

Removal from home, if necessary; consistent loving home care is still favored over hospitalization; consistent care giver; never leave alone; and always provide safety. Psychotherapy: Play, group, individual therapy

Primary treatment goal to facilitate the recovery of an autistic child should include playing with blocks not with balls . Occupational Therapy #1 behavior modification #2 Behavior modification in an autistic child enables the nurse to modify the childs maladaptive behavior. Pharmacology: Tranquilizers and amphetamines to reduce symptoms Caring autistic children requires specialized skills. ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD) A. Disruptive behavioral disorder evident before 7 years old and lasting at least 6 months and characterized by hyperactivity and inattentiveness THEORIES: Norepinephrine,Serotonin

- #1 Screening Test DDST CHARACTERISTICS: 1. Hyperactive could not sit and stay in 15 minutes 2. metabolism fatigue 3. handwriting not legible 4. Easily agitated by noise & color (orange/yellow) ASSESSMENT 1. 2. 3. 4. 5. Severe inattentiveness with or without hyperactivity Short attention span Excessive impulsiveness Squirming and fidgeting Hyperactive could not sit and stay in 15 minutes metabolism fatigue

2. 3.

4. 5.

C. NURSING DIAGNOSIS: Potential for Injury D. NURSING IMPLEMENTATION: 1. Provide consistent, routine ADL in familiar environment

handwriting not legible Easily agitated by noise & color (orange/yellow)

CHILD ABUSE A. DEFINITION: Physical abuse and emotional neglect; may include sexual abuse B. CAUSE: Exact-unknown; Present in all socioeconomic levels ASSESSMENT:

NURISNG IMPLEMENTATION: 1. 2. 3. Set realistic, attainable goals Provide firm, consistent discipline with opportunities to experience satisfaction and success Provide a structured environmentWith a balance of energy expenditure and quiet time With learning experience utilizing childs ability With exercise in perceptual-motor coordination With LESS STIMULATION C.

Obvious physical injuries, disturbance on parent-child interaction (Absence of PROTEST on admission of a toddler is a sign of abuse.) Inconsistency of declaration of the type, location, cause of injury, discovery of undeclared / unreported fractures Malnutrition / failure to thrive / emotional neglect Sexual abuse signs: Genital bruises, lacerations; STDs History: Parents who were abused as kids

The priority needs of the child with ADHD are safety and provision of inadequate nutrition. Catching attention of a child with ADD includes getting him to look at his mom & give him simple directions. 4. Administer drugs as ordered: RITALIN (methylphenidate) or dextroamphetamine sulfate 5. #1 Therapy: Occupational Therapy using behavior modification DIET: caloric content finger foods Vitamin B Complex appetite Do not mix Caffeinated food/drinks with ACA/alcohol Tx: 1. RITALIN (Methylphenidate: BEST GIVEN AFTER BREAKFAST) Always with meals

Other characteristics of abusive parents: 1) Tend to be young, immature, dependent; 2) Low in self- esteem

3) Lacks identity 4) Expect child to provide them with love and care (PERSONAL ROLE THEORY of causation)

5) With incorrect concept of what the child is, and can do 6) With inadequate resources and support system Abusive parents usually have low-self-esteem and has little social involvement. Child abuse is common in the lower socio-economic class.

Ritalin, the drug of choice for ADHD causes growth suppression, insomnia and suppression of appetite. 1. Psychostimulant to increase attention span 2. Dextroamphetamine (Dexedrine) 3. Pemoline (Cylert) very hepatotoxic!!! 4. Stratera ( Atomoxetine) newest psychostimulant!! Contraindication: Do not give below 6 yo hepatotoxic SGPT Stratera, a drug for ADD/ADHD enhances catecholamine effect. Statement like, My son is able to accomplish his task better, indicates efficacy of the drug.

The interaction between the abuse child and a mother provides a clue to the kind of relationship that this child has with his mother. In working with the mother of abused child, therapeutic use of self requires self awareness initially, therefore the nurse has to deal with her feelings first. Attendance to a parenting class is a step towards learning parenting skills, which are lacking in abusive parents. D. POTENTIAL NURSING DIAGNOSES 1) Impaired Skin Integrity 2) Infective Family Coping E. NURSING IMPLEMENTATION o FIRST: Meet physical needs; treat injuries

MANDATORY: REPORTING of suspected cases to appropriate agency (SAVE EVIDENCES; TAKE PICTURES)

Rashes, sores, or lice on the elder Elder has an untreated medical condition is malnourished or dehydrated not related to a known illness Inadequate clothing

Notify the legal authorities about reports of a battered 7 y/o girl is part of the responsibilities of an RN EMOTIONAL SUPPORT to child: PLAY THERAPY to express feelings; NONJUDGMENTAL ATTITUDE toward parents ROLE MODELING for parents who are encouraged to care for child DOCUMENTATION of ACTUAL FINDIGNS not interpretation nor opinion

Indicators of self-neglect Inability to manage personal finances, such as hoarding, squandering, or giving away money while not paying bills Inability to manage activities of daily living such as personal care, shopping, housework Wandering, refusing needed medical attention , isolation, substance use Failure to keep needed medical appointments Confusion, memory loss, unresponsive Lack of toilet facilities, living quarters infested with animals or vermin

POSSIBLE INDICATORS OF ELDER ABUSE Physical abuse indicators Frequent, unexplained injuries accompanied by a habit of seeking medical assistance from various locations Reluctance to seek medical treatment for injuries, or denial of their existence Disorientation or grogginess indicating misuse of medications Fear or edginess in the presence of family member or caregiver

Warning indicators from caregiver Elder is not given opportunity to speak for self, to have visitors, or to see anyone without the presence of the caregiver Attitudes of indifference or anger toward the elder Blaming the elder for his or her illness or limitations Defensiveness Conflicting accounts of elders abilities, problems, and so forth Previous history of abuse or problems with alcohol or drugs.

Psychological or Emotional abuse indicators Helplessness Hesitance to talk openly Anger or agitation Withdrawal or depression

Financial abuse indicators Unusual or inappropriate activity in bank accounts

Signatures on checks that differ from the elders Recent changes in will or power of attorney when elder is not capable of making those decisions Missing valuable belongings that are no just misplaced Lack of television, clothes, or personal items that are easily affordable Unusual concern by the caregiver over the expense of the elders treatment when it is not the caregivers money being spent

Neglect indicators Dirt, fecal or urine smell, or other health hazards in the elders living environment