Unit 4- 60 questions

4.1 7 Questions
Grief- natural & normal reaction to loss, & it is part of the human experience.
Signs & symptoms of grief: physical distress, preoccupation w/ the image of the deceased, guilt, anger, hostile reactions, &
disruptions in normal patterns of conduct.
Physical: weakness, numbness, anorexia, feelings of choking, SOB, tightness in chest, dry mouth, GI disturbances.
Also fatigue, exhaustion, insomnia, crying are common. Link b/t grief & increased vulnerability to mental &
physical illness.
Cognitive: Preoccupation w. the deceased person (conversations w/ deceased). Normal grief, recognizes deceased
is not actually present. Difficulty concentrating (sometimes hallucinations), ruminating, fantasizing, confused.
Behavioral: inability to perform even basic activities of daily living, obsessive reflection, reminiscence, sense of
isolation, despair, hopelessness, crying, agitated, withdrawn, searching, avoidant.
Affective: sadness, guilt, loneliness, hopelessness, anger (most common).
Existential-disruption of life's certainties & questioning of beliefs.
Kubler-Ross stages:
Denial -refusal to believe
Anger- displaced or turned inward
Bargaining- promises made to delay the loss
Depression- full impact is felt
acceptance- resignation, peace, can move on
Hospice philosophy:
specialized care that focuses on comfort & quality of life rather than cure.
Spiritual Assessment:
the core values that underlie spiritual assessment are belief & meaning based upon the individual's view of life,
what is important & gives meaning to life.
What beliefs does the person have that give meaning & purpose to life?
What are imp. Symbols that reflect the beliefs?
How does the person's life story reflect or demonstrate these underlying themes?
Do any areas of the person's life story come into conflict w/ these underlying foundational beliefs?
Do any current situations or problems come into direct conflict w/ these beliefs?
Is the person able to consciously communicate these beliefs?
In what ways are these beliefs an unconscious part of the person's worldview?
Therapeutic communication: learned skill that involves both nonverbal & verbal communication. Enhance p/t growth.
therapeutic response to grieving persons
this must be a difficult time for you. I would like to sit here w/ you for a while
it's ok to feel anger or any other emotion at this time
most people experience these feelings during a loss
guilt is a common response when a loved one dies. Are you having any other feelings?
if you want to talk about your thoughts & feelings, I am here to listen
Do you have someone who can stay w/ you at home for a while?
Self-reflection:
knowing yourself allows you be therapeutic to others. Identifying ones own negative or unresolved issues. Johari
window:
Open known to self & others
Blind known only to others, unknown to self
Hidden known only to self, unknown to others
Unknown unknown to self or others
4.2 20 questions
Nursing process for dementia & delirium
assessment for p/ts
Environment:
positive & emotional environment free from distractions
maintain eye contact, speak clearly & directly to the p/t in a low tone.
Make sure their hearing aids or glasses are in place & working
Cognitive Assessment tools:
administer test in sections if p/t becomes tired, has short attention span or shows sings of anxiety.

Test p/t alone

MMSE
30 questions that assess orientation, registration, attention span, calulation, language recall, & perception.
Scores less than or equal to 24 indicate cognitive impairment.

dementia severity rating scale

assess elderly p/t's ability to function in the home

the Geriatric Depression Scale

simple yes or no ?s
for AD p/ts when able to comprehend the ?s
the Memory Impairment screen
4 item test
recommended for p/ts who belong to ethnic minorities b/c it doesn't show education or language bias

& the Mini-Cog.

3 item test for screening of dementia
test of executive functioning, visuospatial, & object recall
Functional Assessment Staging tool (FAST) identify specific stages of dementia.
Neurological Deficits:
amyloid plaques, neurofibrillary tangles, & fibrillary deposits in cerebral vessels.
PALMER:
perception & organization, attention span, language, memory, emotional control, & reasoning & judgment
(look under each heading pg 376-377)
Emotional Status:
mood & state of mind informal assessment each time nurse approaches a p/t
Depression Geriatric Depression Scale
Functional ability
Behavior people w/ dementia manifest their needs & discomfort w/ behaviors.
Physical Manifestations:
alteration in nutritional status inability to purchase & prepare food, lack of financial resources to buy food,
medical conditions that decrease the older p/t's appetite, or cognitive dysfunction that prevents the p/t from
remembering to eat.
Note any w.t changes
family need to monitor p/ts food intake dehydration
aspiration critical risk during stage 3 of AD aspiration pneumonia leads to death.
90-degree angle, keep chin toward the chest when swallowing rather than hyperextending the chin.
Thick liquids easier to swallow, sit 30 min after meal
changes in gait vision problems, neuropathy, general decrease of righting reflex.
Feel p/ts skin for temp.
incontinence in later stages of AD assess for potential environmental constraints (side rails, poor lighting &
wheelchair seatbelts)
Physical & lab exams
rule out neoplasia (brain tumors), metabolic disorders, systemic illnesses (hypertension, HIV, polypharmacy)
no lab test exists to confirm AD
test thyroid function, liver function, B12 & folate levels, complete blood cell count, serum blood, blood urea
nitrogen & creatinine levels.
MRIs, CT
Nursing dx, outcomes, interventions
Nursing dx:
risk: for aspiration, imbalanced body temp., infection, injury, powerlessness
Outcomes:
maintain health & safety w/ caregiver help
reach & maintain the highest functional level possible within his/her capacity
Nursing interventions:
inform all caregivers about the nx care plan
identify the p/ts current functional state, & encourage p/t to use his/her skills
keep all interactions w/ the p/t pleasant, calm, & reassuring

 do not ask the p/t to participate in ADLs when he/she is agitated

attempt to understand the p/ts feelings
simplify the verbal message & use no more than 5 or 6 words at a time
break down each task into separate components
repeat the message. Use same words.
Provide p.t w/ opportunity to make simple choices
avoid ?s for which the answer could be no
praise success , facilitate use of the p/ts remaining strengths
Stages of AD
stage 1: Mild 2-4 yrs
recent memory loss
cognitive loss in the following areas:
communication
calculation
recognition
anxiety & confusion
mild behavior problems, such as the inability to initiate & complete task
Neologisms
loss of interest & spontaneity & personality changes
depression
p/t, family, & caregivers might think it's normal aging
repetition of things, lose things easily, get lost frequently.
Require support & guidance
Stage 2: Moderate 2-10 yrs
symptoms increase
behaviors problems increase:
catastrophic reactions- sudden or gradual negative change in behavior caused by the inability to understand &
cope w/ environmental stimuli.
Sundowing- irritation or conclusion occurring during the afternoon or evening. R/t to reduced stimulation &
routine & tiredness from struggling to interpret the environment during the day.
Perseveration- repetitive verbalizations or motions or persistent repetition of the same idea in response to
different questions.
Sleep disturbances- restlessness & wandering
aimless pacing
confusion
incontinence, mild
hypertonia
hallucinates & becomes depressed & argumentative.
Require close supervision
Stage 3: Severe 1-3 yrs
symptoms increase
p/ts cannot use or understand words, unable to recognize themselves or others.
No longer able to care for themselves, total dependence on others
choking
emaciation
progressive gait disturbances that lead to nonambulatory status
total incontinence
immobility pneumonia, UTI, pressure ulcers
loss of ability to swallow aspiration death
caregiver makes all decisions about p/ts medical & social needs
Communication strategies:
Simplify the verbal message & use no more than 5 or 6 words at a time. Accompany words w/ visual or tactile
clues to decrease confusion & to increase the clarity of the message.
Break down each task into separate components to avoid confusion & frustration.
Repeat the message, if needed, & allow time for the p/t to respond. Use the same words. Do not go on to another

message until you are sure that the p/t understands the first one; do not leave & return to explain it in a different
way. Using these techniques will avoid or lessen such common behavior problems as catastrophic reactions &
sundowning, & they will prevent excess disability.
Meds:

acetylcholinesterase (AChE)- responsible for the breakdown of ACh cholinesterase inhibitors (drugs that inhibt
the action of AChE) improve symptoms of AD by increasing ACh in the synapses.
Goal improve symptoms & stop the progression of the disease
tacrine (Cognex)
1st cholinesterase inhibitor. Rarley used now b/c of its side effect profile, hepatic toxicity, & the need to take 4
doses/daily.
Donepezil (Aricept)
well tolerated, requires only 1/daily dosing.
Enhances cholinergic function by the reversible inhibition of the hydrolysis of ACh by AChE
effective when cholinergic neurons are intact overtime degeneration of neurons occurs, & the effect may
lessen.
GI side effects
rivastigmine (Exelon)
treats mild-moderate AD & PD
inhibits AchE selectively in the cortex & the hippocampus more than in other parts of the brain.
Tablet (2/daily), oral solution (2/daily), patch (effective, fewer SE compared to oral)
advantage for p/ts who do not respond to other anticholinergic drugs or who are in later stages of AD
side effects: nausea, vomiting, dizziness.
Galantamine (Razadyne)
newest AChE inhibitor reversible inhibitor of AChE
treats mild-moderate AD
effects nicotinic cholinergic receptors
decreases agitation & increases cognition.
Immediate release form requires 2/daily dosing extended release form allows for 1/daily dosing
memantine (Namenda) moderate-severe AD
alkaline agents (antacids) increase levels of memantine
blocks the excitotoxic effects of glutamate while allowing normal gultamate neurotransmission.
Pathological brain changes with AD:
accumulation of Amyloid Plaques (senile plaques/neuritic plaques) classic characteristics of AD interfere w/
cell-to-cell communication & result in decreased ACH.
Inflammation- proinflammatory cytokines (signaling proteins secreted by cells) are increased in p/ts' w/ AD.
Increase in neurofibrillary tangles
Lewy bodies & Lewy body disease neuronal cells or lesions w/ colored bodies that are found in the nuclei of the
midbrain.
Genetic mutations- 10%-40% of AD cases are genetic
NT deficiencies- cholinergic neurons normally decrease in # as people age, which makes less ACh available >
neurons that produce Ach are destroyed early during the course of AD.
Angiopathy & blood-brain barrier incompetence- capillary wall changes are often found in the brains of persons w/
AD.
4.3 20 questions (8 crisis, 12 Violence) :
Crisis intervention outcomes: 3 guidelines for outcome criteria
Congruent w/ c/ts needs:
needs
values
cultural expectations
Safety:
is c/t potentially suicidal or homicidal
how safe is the environment
Reduce anxiety:
so inner resources can be used
Interventions:

Express caring & consolation. Listen, observe, & encourage the expression of thoughts & feelings.
Assess the realities of the situation, & put tangible threats before those that are perceived & intangible to determine
the degree of the crisis & the types of interventions necessary.
Develop & begin to use an immediate plan for intervention that is based on the comprehensive, crisis-focused
nursing assessment & the crisis intervention model that best fits the p/ts needs & the type of crisis situation.
Coordinate w/ other agencies. This approach is essential, during large scale disasters w/ tangible threats such as
fires, earthquakes, wars, & acts of terror. Be familiar w/ resources that offer support w. basic needs such as foods,
clothing, shelter, & financial support. Have referral info & crisis hotline telephone #s available.
Anticipate future needs r/t to crisis, & develop a plan w/ the p/t for meeting these needs.
Barriers to interventions:
secondary gain crisis-focused assessment provides clues to this issue
failure to learn from from experience learned helplessness
Existing mental disorders cognitive impairment
therapist-patient boundary problems overidentification/countertransference
sociocultural considerations lack of resources, health insurance
Assessment:
First assess for suicidal or homicidal ideations or gestures
Box 21-2 pg 490
Types of crisis:
External (situational) crisis: loss of a job, death of a loved one, change in financial status, divorce, eviction or
foreclosure.
Internal (subjective) crisis: response to aging, loss, abandonment, or a breach of loyalty that results in profound
feelings of betrayal, fear or victimization. Also result from a threat to a deeply held belief or value, thereby
triggering spiritual distress or a loss of faith.
Phase-of-life (maturational) crisis: midlife crisis, child leaves home for first time for college or military, reduced
memory, loss of strength.
Disasters (adventitious) crisis: precipitated by a disaster that is not part of everyday life.
Natural disasters (earthquakes)
national or global disasters (war)
crimes of violence (rape)
Primary/Secondary/Tertiary interventions:
Primary:
promote mental health & reduce mental illness
Secondary:
prevent prolonged anxiety from diminishing
personal effectiveness
personality organization
Tertiary:
provide support to
facilitate optimal levels of functioning
prevent further emotional disruptions
Myths Battered Women: online not in the book
Women provoke battering or are masochistic
once a battered woman, always a battered woman
battered woman can always leave
Assessment/dx/interv. w/ elder, women, child abuse
Women:
anxious, frightened
depressed, passive
ashamed, embarrassed
poor eye contact
wt problems
looks to partner for answers
partner smothering, possessive
We often see women who have been hurt by their partners. Is your partner responsible for your injuries?

 Has your partner ever hurt you?

Have you noticed any pattern to this behavior, such as increase in frequency & severity?
Does he threaten to use or has he ever used a weapon to hurt you?
Children:
holistic approach
get as much info as possible w/o subjecting the child to unnecessary & repeated probing & questioning
complete physical exam if suspicious of child abuse
disheveled, malnourished
failure to thrive
fearful, watchful
asses relationship b/t child & caregiver
Do you know why you have come to see me?
What have you been told?
What kinds of games do you & (alleged abuser's name) play when your mom isn't around?
Are there any games that you & (alleged abuser's name) play that you don't like?
Elderly:
poor eye contact
anxious, fearful, passive
looks to caregivers for answers
poor hygiene
underweight, malnourished, dehydrated
physical needs not met
untreated medical conditions
Are you happy living w/ (the name of the suspected abuser)?
Please tell me about your financial assets & how they are managed?
Whom do you turn to when you are feeling down?
How are family disagreements handled in your household?
Has anyone ever hurt you or touched you when you didn't want to be touched?
nursing dx
risk: for self-directed & other-directed violence, injury
anxiety, fear, disabled family coping, powerlessness, caregiver role strain
outcome measures
evidence that the victim is no longer hurt or exploited
evidence that physical abuse has stopped
evidence that emotional abuse has stopped
nursing interventions & plan
Remind victims no one deserves abuser
know how to identify the partner's increasing levels of abuse leading to violence
identify supports including: family, friends, neighbors, local shelters, counselor, & others
memorize the address & phone # to police & the local abuse shelter
if they are afraid the abuser will approach them at work, notify the employer, as they may have a protocol for
violence
during a violent episode try to get a confined room if possible w/ a phone
ask a trusted neighbor to call the police if they hear the sounds of violence
Cycle of Violence:
Phase 1 (tension building):
major battering usually does not occur. Perpetrator establishes complete control usually by inflection of
emotional abuse.
Phase 2 (Acute battering):
tension can no longer be contained & acute battering occurs
Phase 3 (Honeymoon stage):
Perpetrator begs for forgiveness, promises never to do it again. Appears to have remorse, then tension
starts to build and cycle is repeated.
Safety Plan:
survival kit

 drivers license & ID for self & children such as birth certificates & SS cards
house & car keys if they do not have a car, plan a way to get to a police station or public shelter
insurance papers & other imp. Documents
cash & checkbook or credit cards
medical records
children's school records & books
meds
extra clothing
custody papers
imp. Personal items such as a fav. Toy or keepsake
a non-traceable (no GPS) cell phone
4.4 13 Questions
Assess/dx/interventions w/ anorexia & bulimia
all ED:
low self-esteem
compliance & conflict avoidance
sense of ineffectiveness Alexithymia (difficulty naming & expressing emotions) Interoceptive deficits
(inability to accurately identify & respond to bodily cues)
Anorexia Nervosa:
perfectionism
rigidity
risk & harm avoidance
Bulimia Nervosa: Alexithymia
impulsivity
emotional dysregulation- oversensitivity to & difficulty w/ modulating emotions & behavior
nursing dx
imbalanced nutrition
risk for injury
decreased cardiac output
chronic low self-esteem
disturbed body image
risk for imbalanced fluid volume
anorexia nervosa:
anxiety, disturbed body image, nutrition imbalance: less than body req., social isolation
bulimia nervosa:
ineffective coping, deficient fluid volume, chronic low self-esteem.
outcome criteria:
anorexia nervosa:
participate in therapeutic contact w/ staff
consume adequate calories for his/her age, ht, & metabolic needs
achieve a minimum normal w.t
maintain normal fluid & electrolyte levels
resume a normal menstrual cycle
demonstrate improvement in body image w/ a more realistic view of body shape & size
demonstrate more effective coping skills to deal w/ conflicts
manage family conflicts more effectively
verbalize awareness of underlying psychologic issues
achieve ideal body w.t
Bulimia nervosa:
participate in therapeutic contact w/ staff
consume adequate calories for his/her age
cease binge/purge episodes while in the inp/t setting & cease dieting
perceive body shape & w.t as normal & acceptable
interventions
provide safe, non-threatening environment

assess for risk of suicide

restore a minimum w.t & nutrition balance through a behavioral program
encourage the c/ts to express thoughts, feelings , & concerns about body & body image
assist the c/t to increase understanding of body image distortion
Anorexia Nervosa:
under supervision, re-feed, re-introduce health food plan
discuss need for food supplements (may include nasogastric feedings)
provide support w/ the above interventions
Bulimia Nervosa:
w/ supervision, eat meals provided by dietician
avoid purging by maintaining 1:1 nursing supervision post-meals
create a structured, supportive environment w/ clear, consistent, & firm limits
coordinate w/ dietician to construct a behavioral plan w/ specific w.t gain goals of approx. 3lbs/week, specific
eating foals of consuming 90-100% of meals.
Communication techniques:
sensitivity, thoroughness, sharp observation skills.
Refeeding:
close medical & nursing monitoring needed
refeeding w/ meals, supplements, nasogastric tube
w.t gain of 3lbs/week is safe
self starvation results in energy conserving metabolic changes, which shift quickly during refeeding process & is at
risk for refeeding syndrome
Procedure for severely malnourished (15% below ideal w.t)
not eating 90% of meals on day 1 receives dietary receives 3 dietary supplements on day 2
supplements continue daily until p/t eats 100% of their meal
if supplements are not finished on day 2 tube feeding will be started on day 3
tube feeding continues until 100% of all meals are eaten for 1 day
if p/t refuses tube feeding she will be discharged
Assess for edema, CHF, hypophosphatemia, & other serious electrolyte imbalance
Previous Modules 40 questions
1.3 2 rights
rights of c/ts
right to vote, manage financial matters, enter into contractual relationships, assert the constitutional right to
seek the advice of an attorney. Rights to send & receive unopened mail, wear one's rights to owns clothes,
receive visitors, keep & use personal possessions, & access to telephone.
Rights to be informed about potential risks, benefits, reasonable alternatives before giving consent to any
therapy, surgery or treatment, including meds.
Right to treatment
right to privacy & dignity, right to the least restrictive treatment & individual treatment plans.
Cannot keep an individual in a mental hospital w/ treatment
cannot detain individuals who are not dangerous w/ providing some mode of treatment
Right to refuse treatment
voluntary & involuntary p/ts have the right to refuse meds
during emergency situations, if there is potential danger, p/ts can be forcibly medicated. In the case of
involuntary p/t, as long a nurses follow due process guidelines as established & the administration complies w/
accepted professional judgment, meds can be given.
The right to refuse treatment is upheld if the p/t is involuntary & competent. Judge rules if incompetent.
2.1 4 questions alternative therapies, stress response, defense mechanisms, cognitive therapy
encompasses a broad range of healing philosophies, approaches, therapies & their accompanying theories &
beliefs.
More than 1800 approaches to healing in this field
NCCAM classified this into 7 broad categories
alternative medicine systems
traditional Chinese medicine, including acupuncture
folk medicine

 naturopathy
mind-body interventions
mediation
prayer
yoga
humor
exercise
hypnosis
pharmacologic & biologic-based therapies
vaccines & medicines not yet approved by mainstream medicine (animal cartilage, chelating chemicals)
herbal medications
Chinese herbals
American herbals
European herbals
diet, nutrition, supplements, & lifestyle changes
vitamins, minerals , supplements
vegetarian diets
ethnic-based diets
manipulative & body-based methods
chiropractic
acupressure
therapeutic touch
energy therapies
biofeedback
light therapy
bone-growth stimulation
Stress Response:
discuss the general adaptation syndrome according to Selye
stress- both as a response to noxious or stressful stimuli & as a stimulus that produces biologic, emotional, &
psychologic responses.
Distress (negative)- subjective response to internal or external stimuli that are threatening or perceived as
threatening to the self. Includes fatigue, pain, fear, and acute/chronic disease.
Eustress (positive)- nonspecific stress response that is associated w/ desirable events. Ex. Wedding, job promotion,
birth etc.
Psychologic stress- all processes, internal or external, that demand a cognitive appraisal of the event before a
response or the activation of any other system.
General adaptation syndrome- three stages of the individuals innate behavioral responses to any stress stimulus.
1. A brief alarm-fight-or-fight stage, which alerts the individual to the presence of stressful stimuli.
Reciprocal reaction b/t the autonomic nervous system, endocrine, and the immune system
release of hormone epinephrine from the sympathetic branch of the autonomic nervous system
places the person on alert
activation of the hypothalamic-pituitary-adernal axisresults in the release of cortisol
elevation of bp; tachycardia; constriction of blood vessels and the diversion of blood from
nonessential organs to the heart, brain, & skeletal muscles; increased blood sugar; dilated pupils;
increased muscle tone; increased alertness; and free-floating anxiety
fight or flight response
2. Resistance- body stabilizes & returns to normal homeostasis.
Stabilization
Hormonal levels return to normal
Parasympathetic nervous system activity
Adaptation to stressors

If the body does not adapt and the stressor continues to be prominent the individual enters the 3rd stage
3. Exhaustion- all the individual's resources are used & the individual is unable to adapt to the stressor.

Body becomes exhausted & Is unable to sustain the necessary changes that are activated during the
alarm stage.
Can manifest itself in the form of illness such as infections, headaches, hypertension, asthma attacks,
chronic fatigue syndrome, depression, anxiety disorders, & many other chronic conditions
increased physiological response as noted in the alarm reaction
decreased energy levels
decreased physiological adaptation
death
general inhibition syndrome (possum response)- person freezes or shuts down & is unable to respond
in any manner. Result of over-stimulation of the parasympathetic nervous system, & it is activated
automatically as a means of survival that has a paralyzing or numbing effect when a person is
facing a life-threatening event

Defense Mechanisms:
coping- use of resourcefulness & the ability to manage the stress of daily circumstances
conscious/unconscious adaptive/maladaptive
conscious mechanisms are sometimes learned unconscious mechanisms are often referred to as protective ego
defenses
adaptive conscious mechanisms-distractions such as reading, praying, meditating, using relaxation techniques, &
seeking social support.
Maladaptive conscious mechanisms- withdrawing from social contacts, changes in dietary habits, smoking, drug &
alcohol abuse, participating in other unhealthy behaviors & sudden outbursts of anger.
Unconscious ego defense mechanisms- repression, denial, rationalization, & regression. Often prevent the
individual from realistically appraising himself/herself, other people, or situations.
The goal is to use strategies that minimize unnecessary sources of stress & to promote effective adaptive responses.
People use these responses to protect their integrity. A response is often a temporary measure until the immediate
crisis is resolved or until the person is able to control the situation.
Cognitive therapy:
Help p/ts to reinterpret the meaning of body sensations. Used to treat p/ts w/ somatoform disorders & dissociate disorders.
P/ts ability to understand that physical symptoms are a response to thoughts or feelings that occur in daily life.
2.2 7 questions Application of the nursing process w/ the anxiety disorders & communication techniques
it is important for all nurses to identify dysfunctional manifestations of anxiety so that treatment can be
implemented promptly.
Nurses are the first HCP to come in contact with p/t's who are experiencing their first symptoms of panic disorders.
The p/t w/ agoraphobia sometimes comes to the attention of a nurse when the nurse is preparing a p/t for diagnostic
testing that includes a CT or MRI.
Most often p/ts w/ anxiety symptoms do not present w/ anxiety as their primary reason for seeking treatment.
Nurses who use an assessment tool that addresses each identified human response pattern will obtain cues from the
p/t who is experiencing anxiety that indicate further assessment.
thoroughly assess each p/t w/o considering the possibility that the p/t is feigning the physical symptoms.
Understand the possible anxiety precipitants of the somatic concerns will help the p/t to reduce his/her focus on the
physical sensations.
Diagnosis
nurse relies on info that is obtained during the assessment process.
Nurse identifies defining characteristics of the target dx from the p/t & together the nurse & p/t jointly identify
etiologic factors.
Etiologic factors influence the selection of the appropriate interventions.
Risk for suicide; anxiety; death anxiety; hopelessness: chronic pain (191+211)
Outcome Identification
somatization disorder: p/t will
construct an exercise program that includes anxiety reducing techniques
address 2 positive somatic responses (e.g, massage therapy, the satisfied feeling after a successful exercise
session.)
keep a journal to document somatic preoccupation & stressors, including intrusive thoughts & concerns
help the therapist to coordinate the info from the primary care provider & any other involved specialists.
Take meds as prescribed & be able to identify the rationales for the meds

contact the therapist for more frequent visits if somatization increases.

Dissociative identity disorder
: p/t will
alert the therapist or use a hotline such as or 1-800-273-TALK when feeling suicidal
respond to his/her name when addressed by a member of the treatment team
refer to himself/herself in the first-person pronoun form (e.g., I think)
identify periods of increasing anxiety
inform others about dissatisfaction in a nonthreatening manner
use assertive-response behaviors to meet his/her needs
keep a written journal to identify stressors & when the dissociation occurs.
Generalized anxiety disorder: p/t will
demonstrate a significant decrease in physiologic, cognitive behavioral, & emotional symptoms of anxiety.
Demonstrate the use of mindfulness meditation when experiencing symptoms of heightened anxiety
(concentrate on body; pay attention to the act of breathing; observe the act of breathing; meditation
discourages, p/t agrees to deal w/ the subject of the intrusive thought at a later time; p/t feels in control of
his/her body)
OCD: p/t will
participate actively in learned strategies to manage anxiety & to decrease OCD behaviors.
Demonstrate the ability to cope effectively when thoughts or rituals are interrupted.
PSTD: p/t will
demonstrate concern for personal safety by beginning to verbalize worries.
Assume a decision making role for his/her own health care needs

Planning
complex & varied
p/ts w/ severe BBD often require hospitalization to prevent a suicidal occurrence.
Treated in an outpatient setting, often w/ the use of different modalities, including individual psychotherapy, group
therapy, family therapy, art therapy.
Nurses provide p/ts & families w/ information about treatment alternatives, & they also provide comprehensive
discharge planning.
Implementation (interventions)
identify the degree of suicidal ideation & depression in p/ts w/ all types of anxiety & associated disorders.
Monitor your own level of anxiety, & make a conscious effort to remain calm. Anxiety is readily transferable from
one person to another. Individuals w/ somatoform illnesses have high risk.
Recognize that the p/ts use of relief behaviors focuses on somatic sensations as indicators of anxiety
more on pg 213
anxiety-reducing strategies include progressive relaxation techniques; mindfulness mediation
; slow deep- breathing exercises; focusing on a single object in the room; listening to soothing music or relaxation
tapes; visual imagery or nature r/t DVDs; exercise
Evaluation
if p/t does not make satisfactory progress, the nurse modifies either the expected outcomes or the interventions.
Examines all factors that relate to the outcomes.
Somatoform disorders & the dissociative disorders are chronic & enduring. It takes patience & support for the p/t
to determine the pattern of his/her behavior & to incorporate methods to initiate change.
2.3 2 Questions Sleep assessment, sleep disorders
Sleep assessment:
Obtain both subjective data from the affected individual & his/her bed partner
obtain comprehensive, objective and quantifiable data
Assess # of hrs of sleep per night
Time of day/night that the p/t goes to bed or falls asleep
any recent changes in established sleep patterns & routinesif changes reportedassess inhibiting/enhancing
factors
regularityregular/irregular
night time awakenings (describe)
napping (describe)
use of sleep aids or substances that disrupt sleep (e.g, stimulants, antidepressants, sleep meds, alcohol)
present stressors & those from recent or remote past

 objective data from the bed partner (e.g, snoring, apneic periods) or from parents (e.g, sleepwalking, nightmares)
Sleep disorders:
Primary sleep disorders (biologic disturbances)
Dyssomnias- occur as a result of abnormalities of the physiologic mechanisms that regulate sleep and wakefulness.
Abnormalities in amount, quality, or timing of sleep.
Insomnia- difficulty initiating or maintaining sleep or of experiencing nonresotrative sleep for a least 1 month.
Narcolepsy- sudden onset of brief sleep attacks that last 10-20 min. & typically take place 2-6x/day. They fall
asleep while engaging in meaningful activities such as driving a car, eating, or interacting w/ people. Not
common in children; generally initially recognized during puberty/adolescence.
Cataplexy- a common sign of Narcolepsy. Sudden loss of muscle tone & voluntary muscle movement.
Strong emotional experiences such as laughing or crying may cause this reaction.
Sleep paralysis- also reported in people w/ narcolepsy. Not able to speak or move just before the onset of
or upon awakening from a brief sleep attack. Some report hallucinations & experience vivid sensory
perceptual experiences either upon wakening (hypnopompic hallucinations) or when entering the brief
sleep episode (hypnagogic hallucinations).
Breathing-related sleep disorders-result from a sleep-related breathing condition such as obstructive or central
sleep apnea syndrome or central alveolar hypoventilation
obstructive sleep apnea- typically have some degree of narrowing or the complete obstruction of the upper
airway. Results in loud snoring and regular apneic periods during sleep that last for 10-30 sec. (sleep
apnea- absence of breathing)
Risk factor obesity & large neck circumference
Circadian Rhythm sleep disorder- sleep pattern disturbances w/ a persistent or recurrent pattern of sleep
disruption that result from a difference in an imposed sleep wake cycle & the individual's own circadian sleepwake pattern requirements.
Result from a delayed sleep phase, jet lag, shift work, or an unspecified source.
Parasomnias- occur as a result of the activation of physiologic systems at incorrect times during the sleep wake cycle,
thereby resulting in abnormal behavior or physiologic events during the sleep state. Abnormal behavior or events occurring
in association w/ sleep. More common among children.
Nightmare disorder takes place during the REM period late in the sleep cycle.
Fragmented sleep
frighting dreams that threaten their survival, security, or self-esteem.
Able to recall the nightmares in vivid details
Sleep terror disorder- experience of arousal during NREM sleep.
Awakening during the early part of the night due to extreme anxiety or panic.
Crying, screaming, and may appear disoriented
unable to recall the event
Sleepwalking disorder- (somnambulism)
engagement in walking, dressing, toileting, and driving while they are in a deep NREM stage of sleep.
Appears to be in a trance, and arousal is difficult.
Sometimes they wake up while performing complex tasks, but most frequently returns to sleep.
Unable to recall events that took place during the sleepwalking episode
Parasomnia not otherwise specified / due to General Medical Condition or substance use

Secondary sleep disorders (often result from a variety of psychiatric illness or medical conditions)
mood disorders
effects of substances- alcohol, stimulants (caffeine), amphetamines, cocaine, sedatives (opiates, hypnotics &
antianxiety meds)
general medical conditions (endocrine)
2.4 10 questions Mood disorders assessment/outcomes/interventions, communication techniques, risk for suicide, meds
Assessment:
nurses must maintain awareness of their own personal reactions to the p/t & the ways in which these reactions
affect the nurse-p/t relationship & subsequent care.
Mental status criteria

 Mood: the internal manifestation of a subjective feeling state

Affect: the external expression or manifestation of a feeling state
Temperament: observable differences in the intensity & duration of arousal & emotionality
Emotion: The experience of a feeling state
Emotional reactivity: tendency to respond to internal or external events w/ emotion
Emotional regulation: ability to control or modify the occurrence & intensity of feelings
Range of affect: the span of emotional expression experienced & displayed by an individual
Outcomes:
p/t will remain safe & free from harm
verbalize suicidal ideations & commit to a contact to not harm himself or herself or others
verbalize absence of suicidal or homicidal intent or plans
express the desire to live & not to harm others
report increased feelings of self-worth & confidence
more on pg 239
Interventions:
Interventions cover a wide range of biopsychosocial areas, w/ consideration of the effects of depression &
mania on the physiologic, cognitive, psychologic, behavioral, & social domains.
Interventions require nurse to maintain self-awareness & boundaries regarding their own reactions to p/ts b/c
p/t depression, irritability, anger, negativity, euphoria, & hyperactivity can readily influence nursing responses.
Be consistent, caring, concerned, empathetic, & genuine.
A knowledgeable, non demanding, & matter-of-fact approach is reassuring to p/ts & promotes their confidence
in the nurse.
Risk for suicide:
Be alert to suicidal ideation & intent among p/ts w/ depression & p/ts w/ mania who are cycling into depression or
whose insight & judgment are impaired. A high risk time is 1-6 weeks after the initiation of antidepressant therapy,
before therapeutic levels are reached.
Meds:
Tricyclic
Classification: Tricyclic antidepressants (TCAs) are a class of antidepressant medications that share a similar
chemical structure and biological effects.
Action: Tricyclic antidepressants increase levels of norepinephrine and serotonin, two neurotransmitters, and
block the action of acetylcholine, another neurotransmitter.
Side effects: blurred vision, dry mouth, constipation, weight gain or loss, low blood pressure on standing, rash,
hives, and, increased heart rate.
Use w/ MAOIs may increase risk of neuroleptic malignant syndrome, seizures. Hypertensive crisis, &
hyperpyrexia
use w. oral anticoagulants can result in bleeding. Use w/ clonidine can cause severe hypertension
herbal considerations: St. John's wort & SAM-e may increase the p/ts risk for serotonin syndrome.
Monoamine:
Antidepressants such as MAOIs ease depression by affecting chemical messengers (neurotransmitters) used to
communicate between brain cells. Like most antidepressants, MAOIs work by changing the levels of one or
more of these naturally occurring brain chemicals.
An enzyme called monoamine oxidase is involved in removing the neurotransmitters norepinephrine,
serotonin and dopamine from the brain. MAOIs prevent this from happening, which makes more of these brain
chemicals available. This is thought to boost mood by improving brain cell communication.
The most common side effects of MAOIs include: Dry mouth, Nausea, diarrhea or constipation, Headache,
Drowsiness, Insomnia, Skin reaction at the patch site, Dizziness or light headedness
Avoid caffeine, chocolate, & all tyramine-containing foods ( aged cheese) within several hrs of ingestion of
MAOIs b/c the combination may cause sudden & severe hypertension or hypertensive crisis
Third line agents after SSRIs & TCAs have been tried
signs of toxicity include increased headaches & palpitations
MAOIs should not be taken within 14 days of taking SSRIs
herbal considerations: parsley & St. John's wort pose some risk for serotonin syndrome

SSRIs
SSRIs block the reabsorption (reuptake) of the neurotransmitter serotonin in the brain.
SSRIs are called selective because they seem to primarily affect serotonin, not other neurotransmitters.
Side effects of SSRIs may include, among others: Nausea, Nervousness, agitation or restlessness, Dizziness,
Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction),
Drowsiness, Insomnia, Weight gain or loss, Headache, Dry mouth, Vomiting, Diarrhea
first-line antidepressant therapy
may cause fatal reactions w/ MAOIs by causing serotonin syndrome, hypertensive crisis, rigidity, &
neuroleptic malignant syndrome
serotonin syndrome- occur when medicines that are used to treat migraine headaches (5-hydroxytryptamine
receptor agonists, & medicines that are used to treat depression SSRIs & serotonin-norepinephrine reuptake
inhibitors (SNRIs) which are medicines from different classes) are used together
episodes of self-harm & potential suicidal behavior are reportedly higher in p/ts who are younger than 18.
use w/ caffeine increases agitation; use w/ alcohol increases sedation. Effectiveness is decreased w/ cigarette
smoking.
Should not be taken w/ lithium
herbal considerations: st. John's wort & SAM-e may cause serotonin syndrome. Use w/ ascorbic acid
(grapefruit juice) may alter the elimination of the drug & it's plasma concentration.
SNRIs
SNRIs block the absorption (reuptake) of the neurotransmitters serotonin and norepinephrine in the brain.
The most common side effects of SNRIs include: Nausea, Dry mouth, Dizziness, Excessive sweating
indicated for social anxiety disorder & general anxiety disorder
Venlafaxine is not approved for indications in children & adolescents b/c of the lack of efficacy & concerns
about increased hostility & suicidal ideation.
Mood stabilizers including lithium
Mood stabilizers balance certain brain chemicals (neurotransmitters) that control emotional states and
behavior.
effective for the treatment of mania in p/ts w/ bipolar disorders.
Most widely used is lithium
lithium acts as a salt within the body, & its blood levels are closely linked to the p/ts hydration & sodium
intake.
Side effects of lithium: neuromuscular &CNS effects (tremor, forgetfulness, slowed cognition), gastrointestinal
effects (nausea, diarrhea), weight gain, hypothyroidism & renal effects (polyuria).
blood levels of 0.6 mEq/L to 1 mEq/L more than 1.5 is toxic
lithium excreted through the kidneys, nurses need to use caution w/ p/ts w/ renal disease.
Herbal considerations: dandelion, goldenrod, juniper, & parsley increase lithium's effects & toxicity
Monitor p/t's sodium intake, b/c significant changes will alter lithium excretion. Black & green tea, coffee,
cola nut, guarana, plantains, & yerba mate may all decrease lithium levels.
Anticonvulsants
divided into 3 classes (first, second, & third generation) indicated for manic symptoms

Anticonvulsants work by calming hyperactivity in the brain in various ways. For this reason, some of
these drugs are used to treat epilepsy, prevent migraines, and treat other brain disorders.
They are often prescribed for people who have rapid cycling four or more episodes of mania and
depression in a year.
Anticoagulants used to treat bipolar disorder include: Depakote, Depakene (divalproex sodium,
valproic acid, or valproate sodium), Lamictal (lamotrigine) , Tegretol (carbamazepine)
Common side effects include: Dizziness, Drowsiness, Fatigue, Nausea, Tremor, Rash, Weight gain.
Used in place of lithium
abrupt withdrawal may cause seizures
labs=liver function, CBC w/ diff.
Antipsychotic
Antipsychotics are thought to work by altering the effect of certain chemicals in the brain, called dopamine,

serotonin, noradrenaline and acetylcholine.

atypical antipsychotics. These are sometimes called second-generation antipsychotics and include:
amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole.

typical well-established antipsychotics. These are sometimes called first-generation antipsychotics and
include: chlorpromazine, flupentixol, haloperidol, levomepromazine, pericyazine, perphenazine, pimozide,
sulpiride, trifluoperazine, and zuclopenthixol.
side-effects include: Dry mouth, blurred vision, flushing and constipation
Immediate treatment of psychotic behavior necessary to prevent exhaustion & infection due to body working
too hard. W/o treatment cardiac collapse can occur.
3.1 10 Questions Meds, outcomes/interventions, prodormal s/s, priority assessment
Prodromal: 1 month to 1 year before dx/S&S of this phase include
mood symptoms (anxiety, irritability, dysphoria, anguish)
cognitive symptoms (distractibility, concentration, difficulties, disorganized thinking)
obsessive behaviors
social withdrawal & role functioning deterioration
sleep disturbances
attenuated (weaker) positive symptoms (illusions, ideas of reference, magical thinking, superstitiousness)
Priority assessment:
subjective & objective plus secondary sources,
biological indicators
what p/t says in the interview p/ts w/ psychotic disorders have impaired processing of perceptual info.
Listen attentively to p/t & complete a physical exam
vital signs & nutrition, exercise, sleep patterns
schizophrenia metabolic syndrome ( cluster of findings that include increased visceral adiposity, measure by
circumference, hyperglcemia, hypertension, dyslipidemia) PHATS
disturbances in perception, thought, feelings & behavior imp. Categories for p/ts w/ shizophrenia
Outcomes/Interventions:
demonstrate an absence of suicidal behaviors or violent behaviors towards others
demonstrate absence of self-mutilating behaviors
demonstrate a significant reduction in hallucinations & delusions
demonstrate realty-based thinking & behaviors
more on pg 281
Interventions:
supplement the individuals ADL & instrumental activities of daily living
manage the environment
provide protection of the p/t, others, family members, & significant others
encourage self-management & manage relapse
Meds:
typical/conventional antipsychotic/1st generation
work by blocking the D2 dopamine receptors in the limbic region of the brain
Phenothiazines: Chlorpromazine (Thorazine) (first drug to treat psychosis in the 50s), Thioridazine (Mellaril),
Trifluoperazine (stelazine) & Fluphenazine (Prolixin)
most effective for treating positive psychotic symptoms only
has many side effects which causes clients to stop taking them
blocks dopamine in the motor centers (Extrapyramidal Nerve tract) causes movement disorders or
EPSincluding Tardive dyskinesia (a neurologic syndrome that consists of abnormal, involuntary,
irregular choreoathetoid movements of the muscles, the head, the limbs and trunk)
choreoathetosis is the occurrence of involuntary movements in a combination of chorea (irregular
migrating contractions) & athetosis (twisting & writhing)
-manifested by tongue protrusion, puffing of the cheeks, chewing or puckering of the mouth
-occurs rarely, but may be irreversible
AIM scale (autonomic involuntary movement scale)- performed not less than every 6 months when a p/t
is taking either typical or aytypical antipsychotics
then came Butyrophenons: Haloperidol (haldol)

others: Thiothixene (Navane)

Extrapyramidal symptoms: serious reactions that appear r/t to high dose of neuroleptic meds
Akathisia- subjective feeling of muscular discomfort that causes the p/t to become agitated, pace, alternately sit &
stand & feel a lack of control
Parkinsonian- muscle stiffness, cogwheel, rigidity, shuffling gate, perioral tremor, hypersalvation, & mask like
expression
acute dystonias-spasmodic movements caused by slow, sustained, involuntary muscle contractions such as:
torticollis (abnormal, asymmetrical head or neck position)
opisthotonos ( body is rigid & arches the back, w/ the head thrown backward)
oculogyric crisis ( prolonged involuntary upward deviation of the eyes)
EPS can involve the neck, jaw, tongue or entire body
Drugs of treatment:
Antiparkinson drug Benztropine (cogentin), trihexyphenidyl (Artane)
Acute emergencies Acute dystonic reactions, NMS (neuroleptic malignant syndrome)
Tardive dyskinesia life-threatening irreversible sweating, fever, unstable bp, stupor, muscle rigidity,
autonomic dysfunction, elevated CPK, excessive salvation, occurs in 1% but 10% die
other side effects of typicals:
anticholinergic (dry mouth, blurred vision, urinary retention, nasal congestion, constipation, ejaculatory
inhibition)
sedation (most common during early stage of treatment, need to avoid alcohol, antihistamines, & sleeping
aids)
postural hypotension
arrhythmias, palpitations, & prolonged QT intervals
lowered seizure threshold
weight gain increased risk for type II diabetes
photosensitivity & skin changes
poikilothermia loss of ability to regulate internal body temp. watch older adults in hot weather
galactorrhea & gynecomastia breast enlargement or tenderness
cholestatic jaundice
Atypicals- Clozoril (clozapine) was the first in the 90s
1st to effectively treat both + & - symptoms of schziophrenia
not used as a first resort due to risk for agranulocytosis ( bone marrow does not make enough of a certain type
of mature white blood cells (neutrophils)- regular & frequent serum lab testing required
used for refractory schizophrenia
other atypicals:
Seroquel (quetiapine)
Risperdal (risperidone)
Geodone (ziprasidone) problem prolonged QT interval
Zyprexa (olanzapine) similar to clozapine w/o the risks of agranulocytosis, does have high risk for
seizures- common side effect is gain weight
both serotonin + dopamine antagonists
work on + & - symptoms
fewer EPS side effects, but there still may be
less risk for tardive dyskinesia
cost more
elderly w/ dementia r/t to psychosis increased risk for death when taking these meds
black box warning contraindicated
mostly death r/t to cardiac failure/sudden death or infection (pneumonia)
3.2 3 Questions Family reactions, recovery, interventions
Interventions:
nurse focuses on treating & supporting the p/t through the drug withdrawal process detoxification. Focus on
education during stages of recovery.
FYI : cross-tolerance used to prevent withdrawal effects of drugs or alcohol. Ex. Ativan has a crosstolerance w/ alcohol b/c both affect the GABA receptors in the brain. It is used & gradually decreased to

manage withdrawal symptoms.

Family Reactions:
I have no clue, I hate this class.
Recovery:
psychotherapy
active involvement in a recovery program in addition to participating in individual or group therapies.
Addresses p/t's addiction as well as any comorbid disorders or life threatening behaviors.
Relapse prevention
help p/ts avoid or take control of situations in which relapse is possible.
Practices what to do if relapse occurs & develops a comprehensive plan to follow.
Harm reduction
techniques that help a person to change patterns of use to decrease the risk of harm & to adapt to a healthier
life-style.
Opiate replacements, needle-exchange programs
residential, half way house
provide living situations for c/ts who will need to totally reshape their lives, friends, social network, reconnect
w/ family & friends.
Outpatient care
teach the p/t to change & adjust to life w/o drugs while living in a real-life situation.
Community & faith based organizations
after-school programs, mentoring activities, sports
spirituality important to recovery for many individuals
3.3 2 questions borderline & antisocial disorder
Antisocial PD
irresponsible
failure to honor financial obligations, plan ahead or provide children w/ basic needs.
Involvement in illegal activities
lack of guilt
difficulty learning from mistakes
initial charm dissolves in coldness, manipulation, & blaming others
lack of empathy
irritability
abuse of substance
Epidemiology: APD usually diagnosed before 18 yrs, Hx, conduct disorder before 15 years; males
(characteristics in early childhood) more than females (characteristics evident by puberty); Many in SUD
programs or prison; incidence higher among lower socioeconomic populations; impulsive behavior common;
approx. 1% of U.S population 18 yrs or older.
Borderline PD
recurrent suicidal &/or self-mutilating behaviors
poor impulse control & engage in impulsive acts (gambling, binging, spending money, reckless driving, unsafe
sex).
Negative or angry affect
feeling emptiness or boredom
difficulty being alone or feelings of abandonment
difficulty identifying self
perception of people all good or bad
intense & stormy relationship
Epidemiology: condition diagnosed in 1.6% of population 18+ yrs; often hx of physical or sexual abuse,
neglect, hostile or conflictual experiences, & early parental loss or separation; more females than males.