~ Alcohol & Substance Abuse ~

Substance Use Disorders Substance-Induced Disorders

Substance Abuse Substance Dependence Substance Intoxication Substance Withdrawal
Maladaptive pattern of Pattern leading to impairment * Reversible syndrome of * Development of substance-specific
repeated use. * Tolerance – ↑ amounts needed for effect physiologic & behavioral syndrome due to cessation/reduction
Consequences: * Withdrawal – physiologic & cognitive-behavioral Δs for lower Δs r/t substance effects of use that was heavy & prolonged
* Can’t fulfill social levels after heavy use * Due to CNS effect * Causes clinically significant distress
obligations * Compulsive use * Disturbances of mood, in social/occupational functioning
* Use in hazardous situations * Needing more than intended sleep-wake cycle, * Not due to general medical condition
* Recurrent * Unsuccessful efforts to “cut down” perception, attention, & are not better accounted by another
social/relationship * Lots of time spent to obtain substance thinking, judgment, mental disorder
problems * Continuing to use substance despite knowing associated adverse interpersonal behavior
Have never met criteria for effects & difficulties
substance dependence * Diagnosis associated w/every class of substance except caffeine.
~
Alcohol BAL & Behaviors Alcohol Withdrawal
* Can metabolize 1oz q 90min 0.05-0.15 * Hangover
° 95% broken down by liver, rest excreted thru lungs, kidney, skin * Initial Euphoria, Mood ° N/V, Gastritis, HA, Fatigue, Sweaty, Thirsty, Restless, Irritable,
* Effects lability, Cognitive Shaky, Vasomotor Instability
° CNS depressant absorbed in mouth, stomach, & small intestine disturbances, including: * Alcoholic Hallucinations
* Intoxication= BAL 0.10 ° ↓concentration, ° Auditory hallucinations 24-48h after
impaired judgment, * Generalized Sz
Long Term Effects sexual disinhibition ° ‘Rum Fits’ 2-3ds after. Prevented w/medical withdrawal program
* Hepatic 0.015-0.25 * Delerium Tremens (DT’s)
° Fatty liver syndrome, hepatitis, cirrhosis * Mood lability w/ other
° Severe memory disturbance, agitation, anorexia & Hallucinations
* Neuro outbursts, Slurred speech,
° Few days after drinking stops, last 1-5d.
Staggerd gait/ataxia,
° Wernike-Korsakoff syndrome, peripheral neuropathy,
Diplopia, Drowsiness
Marchiafava-Bignami syndrome, Central pontine myelinosis, * Minor
0.3
Cerebellar degeneration, Alcoholic amblypopia ° 6-12hrs after last drink
* Aggressive behavior,
* CV ° First agitation, then tremor, tachycardia, htn, diaphoresis, NVD,
Incoherent speech,
° Cardiomyopathy, hypokalemia, hypomagnesemia, hallucinationsmark beginning of major
Labored breathing,
hyperlipidemia, Δed fluid balance, Beriberi heart disease, * Major
Vomiting, Stupor
Hematologic abnormalities ° 2-3 Ds after, lasts 3-5d
0.4
* MSK ° Potentially life-threatening
* Coma
° Acute/Subclinical/Chronic alcoholic myopathy 0.5 ° Impending DT’stemp, severe diaphoresis, htn, tachycardia,
* GI * Severe Resp Depression confusion, disorientation, agitation, tremors, hallucinations,
° Gastritis, Esophagitis, Mallory-Weiss, Boerhaave’s, Nutritional * Death delusions
deficiency, N/Abd Pain, erratic bowel, GI hemorrhage, jaundice,
digestive tract CA, Glu intolerance
* Reproductive
° Impotence, Sterility, Gynecomastia, Anorgasmy, FAS
1
~
Blackouts Korsakoff’s Syndrome
* Not unconsciousness * Alcohol-induced persisting amnesic
* Retrograde amnesia – loss of short term disorder
memories & retention of remote memories * Short-term memory disturbance after
* Goes thru several days w/no memory of doing so. yrs of heavy alcohol intake – result of
* Person is not concerned & may cover up. thiamine deficiency.
* May appear late in disease process w/out * Result of damage to hippocampus
relationship to amount of alcohol consumed * W/out treatment, chronic &
irreversible
* Often use confabulations
Wernicke’s Encephalopathy
* Alcoholic encephalopathy
* Ataxia, 6th cranial nerve palsy,
nystagmus & confusion.
* Responds to parenteral
thiamine in early stages.
Fetal Alcohol Syndrome
* Fetus at risk in all trimesters.
* Just 3 drinks will cause damage
* Growth deficiency, heart defects,
malformed facial features, low birth wt,
hyperactivity & learning problems.
* Pretreatment possible
* 80% of children need care for life

~
Treatment Family Interventions Nursing Dx
Treatment of withdrawal BEAST * Chronic Pain
* Monitor fluids Boozing opportunitiesweddings, parties, trips. Be cautious, * Decisional Conflict
° give up to 3000 ml /d; if unable to drink, give IV don’t have to avoid, just don’t’ succumb * Disturbed sensory
* Ice packs for fever (esp for amphetamine/cocaine use) Enemy Recognitionrecognize enemy thoughts that booze is perception
* ↓ stimulation; quiet dark room good * Disturbed thought
* Point out reality Accuse the Beast of Malicebe angry at alcohol if it tempts you, processes
* Adequate Nutrition laugh at it * Dysfunctional Family
* Assess Δ in LOC Self-Control & Self Worth Remindersshow your beast you have Processes
* Protect skin integrity control, tell yourself you’re worthwhile * Fear
* Emotional support/community resources Treasuring your Sobrietyfocus on pleasures of life that are only * Impaired social
attainable in sobriety interaction
Meds * Ineffective Coping
* Administer mag sulfate – prevents sz S/S of Impending Relapse * Nutrition
* Administer vitamins, esp. B * Exhaustion, Dishonesty, Impatience, Argumentativeness,
* Benzodiazepines (Valium or librium) to prevent sz, also Dilantin Depression, Frustration, Self-pity, Cockiness, Complacency,
* Antabuse – must be alcohol free, no preparations w/alcohol Expecting too much from others, Letting up on discipline,
Wanting too much, Forgetting gratitude, “It can’t happen to me”,
* ReVia, Trexan
Omnipotence
° Blocks need to ingest alcohol. More success than antabuse
* Acamprosate (Campral)
° For maintenance of abstinence in alcohol when client is already abstinent.
° Alleviates psychological & physical distress
~

2
 Barbituates/Sedatives/Hypnotics
Barbituates
* High addictive, feel euphoric, relaxed
* Relieve pain, reduce anxiety & induce sleep,
cause CNS depression
* Action
° Partially metabolized in liver.
° Unmetabolized are active metabolites
stored in fatty tissue.
° Leads to cumulative effect, unsuspected
dependence & possible overdose.
° Often die from overdose, sometimes
w/alcohol
* Barbiturate withdrawal
° Unpleasant & life-threatening
° Deep sleep w/↓d respiration, coma &
sometimes death.
° Babies need withdrawal.
Anxiolytic Drugs (BZDs)
* Reduce anxiety w/out CNS depression
* Cause dependence, withdrawal syndrome
* Valium, Tranxene, Ativan & Xanax
* Δ balance of NTs, especially NE & GABA in
limbic system
* ↑ risk for abuse & physical dependence
w/tolerance, people “use more”
* Teens use barbiturates w/alcohol to get high –
CNS depression, dangerous
* Amphetamine users use barbiturates to
“come down”
* BZD withdrawal
° Autonomic hyperactivity (alterations in
vs & diaphoresis)
° Marked anxiety, agitation, insomnia,
depression & sz
° Need medical supervision
Cannibus
Opioids
Opioids: heroin, morphine
* Synthetics: Oxycontin, demerol,
codeine, methadone
* Analgesic qualities – after surgery
* Heroin alone is not dangerous –
infection from needles, etc is.
* Methadone treatment is successful
* ↑risk for HIV/AIDS because of IV
use
* “cutting” may cause poisoning
* Heroin overdose
° Signs: Constricted pupils,
euphoria, psychomotor
retardation, slurred speech, &
drowsiness
° Rx: Narcan – fast-acting
agonist that counteracts resp
depression
° Abd cramps, rhinorrhea &
lacrimation treated
w/belladonna alkaloids or
w/phenobarbital
* Withdrawal from opioids
° Within 12 hrs of last dose
° Severe 36 – 48 hrs
° Persons craves drug & often
terminates treatment
° Babies are treated for withdrawal
* Treatment
° Methadone treatment – is
addictive but lacks euphoria
° Clonidine given after methadone
is withdrawn
° Buprenex – alternative to
methadone
Amphetamines (Speed)
Amphetamines
* Uppers, counteract downers
* Δ judgment & obscure feelings
* Toxic, symptoms of paranoid
schizophrenia
* Mimic DA & NE
* Chronic use Δs thinking & behavior
* Resultant Δ in transport of DA
causes clinical severe psychiatric
symptoms
* Still used for appetite control,
depression, narcolepsy, minimal
brain dysfunctions,
* ADHD in children
* Users crave drugs & need ↑doses
* Crash may last up to several wks
* Overuse tied to stroke & death
* Diazepam IV ↓s tachycardia &
chance for convulsions
* Flashbacks
Methamphetamine
* Cheaper than cocaine
* Made at home
* Exposure is neurotoxic – extensive
neural damage
* Δs corpus callosum – skin lesions &
htn
* Enormous public health problem
Treatment of Amphetamines
* Thorazine combats physiologic
effects
* Valium ↓s tachycardia, chance of
convulsions
* Depression & anxiety in withdrawal
PCP
Cocaine
* Psychologically addicting
* Tolerance occurs
* No longer gives euphoria, but not taking it feels worse
* w/use DA is depleted
* User is chronically fatigued, irritable & anxious, even
confused & paranoid
* Suicide attempts, accidents & overdoses
* Mimics bipolar disorder & chronic anxiety disorder
Cocaine intoxication
* Low levels – like alcohol withdrawal:
° sweating, dilated pupils, psychomotor agitation &
↑ BP, HR
* ↑ doses – ↑ fever, arrhythmia, sz, hallucinations &
paranoid schizoprhenic syndrome. “cocaine bugs”
* Haldol combats psychotic symptoms
* Depletes DA
Cocaine detoxification
* Cold turkey
* Valium IV at slow rate
* Valium protocol
* TCAs to ↑ NTs in synapse
* Inderal given cautiously for tachycardia & htn
Crack
* Smoked cocaine
* Extremely addictive
* Rapid onset, intensely euphoric, then crash & smoke
more crack
* Recidivism 90%
* Symptoms: irritability, paranoia, depression, wheezing,
coughing blood, black phlegm
* Dysrhythmias cause death
* Crack babies are increasing
Hallucinogens
3
Cannabis (marijuana) HCT PCP (Phencyclidine) Treatment of PCP intoxication * LSD, peyote
* Stored in fatty tissues – detected for 6 wks * In ER, violent, psychotic & agitated * Valium for muscle spasms, sz & agitation * Cheap high
* Blood & urine for 2 wks * Person physically very powerful * Risperdal/Haldol for psychotic behavior * Bad trips – psychotic & fearful
* Analgesic * Between coma & violence * Don’t use phenothiazines. * Flashbacks – relive experience under
* Helps n & v in chemotherapy * Hallucinations common * Treatment focuses on protecting client & drug
* Dependence 10-15 yrs in adults, just a few yrs * Present as schizophrenia others from injury * May precipitate psychosis in teens
in children * Because illegal manufacture, never know what
they get.
~
Anorexia & Bulimia
Anorexia Bulimia Family Dynamics Nursing Dx Treatment

4
DSMIV DSMIV Family Systems Anorexia * Need 2-3L of
* Refusal to maintain body wt 85% norm * Recurrent binge eating * Boundaries enmeshed * Imbalanced nutrition-1st: fluid daily
* Intense fear of gaining wt * Recurrent vomiting, laxatives, diuretics, * Minimal privacy When pt. comes to * Weigh daily on
* Body image disturbed enemas, fasting, excessive exercise * Family overprotective treatment, in starvation. same scale
* Amenorrhea * Both above occur 2x/wk x3mo of child & entire Hormonal metabolic & * Observe for 1
* Self-eval unduly influenced by body family system emotional Δs hr after meals/
* Life-threatening shape/wt preoccupied w/food, * Ineffective individual bathroom
* Perfectionism, wt fear, significant wt. loss, eating, & rituals coping: unable to adapt to
body image disturbances, strenuous exercise, * Cycle begins w/skipping meals occasionally, w/eating do self-care, pursuit of Meds for Bulimia
peculiar food handling patterns, & reduction in overstrict dieting/fasting, amphetamines, * Difficulty w/conflict thinness. Independence vs. * SSRIs,
vital signs. hunger, fatigue & ↓ glu levels. resolution dependence particularly
* Hallmarks: rigidity & over control * Then binge eating (3500cal//hr) can last 8 * Marital conflict * Disturbed body image: Prozac, to deal
* Obsessive rituals for eating & exercising hrs results from how to unable to appraise own w/depression,
* Alone, at home, 1/ mo to several x/d care for anorexic body, underestimate bodily anxiety,
° Cutting food, chewing # of times,
inflexible exercise routine. * Usually junk or ↑cal foods child needs obsessions or
* Purge ingested foods – abuse laxatives & * Achievement & * Chronic low self-esteem impulse control
* Rules keep anxiety out of consciousness
awareness diuretics – means of regaining self-control performance oriented; from unrealistic behaviors
* Begins as way to stay thin – then a response body shape r/t expectations of self & * Use until 6
Anorexia behaviors to stress success & family others months after
* Hyperactive, over exercise ↑s wt loss * Not usually into exercise, but use street drugs focus on food, diet, symptoms have
exercise, &wt control Bulimia: stopped
* Reward & punish selves w/food & steal food & $ to support addiction
* Anxiety: r/t preoccupation * TCAs not as
* Need to please others
Assessment Comorbid Diseases w/body image effective
* Feel hopeless, helpless & effective
* Feelings of inadequacy, ↓ self-esteem & guilt * Anorexia & bulimia – ° Rise in anxiety signals
* Overcontrolled by parents – aim to gain some
* Shame over hidden behaviors depression binge-purge behavior
control – Praise for wt loss reinforce patterns * Deficient fluid volume
* Recognize that behaviors are bizarre * Circular
* Anxiety disorders: from vomiting &
Assessment: * Anxiety & unsatisfactory interpersonal
social phobias, OCDs purgatives
* Subjective data relationships
* Panic attacks when * Electrolyte
° Perception of obesity, regardless of wt * Impulsive, cannot delay gratification
behavior is imbalanceconfusion,
° Preoccupation w/exercise * Preoccupation w/food, wt & dieting
interrupted edema
* Objective data Objective assessment
* Conversion from * Ineffective coping: use
° Determine wt loss * Young females – average or above wt
anorexia to bulimia binge & purge, alcohol &
° Emaciated, sunken eyes, lanugo * More outgoing than w/anorexia
may be way to “hide” drug abuse, shoplifting
° Bradycardia, hypotension, arrhythmia * Impulsive & hoarding behavior * Compromised family
disorder
° Peripheral edema, hypothyroid-like * Hoarseness, esophagitis, “moth-eaten” teeth, coping: families see
symptoms (dry hair, hair loss) listlessness large parotid glands, abrasions on knuckles, themselves as unable to
° Laboratory Δs * Fluid volume deficit symptoms cope w/disorder – bulimic
* ↓K+, leading to arrhythmias behavior may be focus of
family
~
Suicide
Factors/Reasons for Assessment Relation to Depression Nsg Assessment & Intervention
5
Age & gender
* Adolescent – 3rd leading COD
* 17% consider suicide
* Males –Native Americans, white non-
Hispanics, Asian Pacific Islanders
higher than females
* Alcohol – adolescent males 17X more
likely to attempt suicides
Ethnicity
* Rate of depression ↑for Puerto Ricans
* ↓in Mexican-Americans & Cuan-
Americans when compared
w/depression for whites
* Annual suicide rates ↑for males
* Mexican-American & Puerto-Rican
male have ↓suicide rates than whites
* Depressed Asian-American youths 4X
more likely to display suicidal
behavior
* Depressed African-American females
reported more suicidal ideation than
male adolescents.
* Asian-Americans: if ↑ parental
conflict, 30X more likely to engage in
suicidal behavior than those
w/↓parental conflict
* African-Americans – 7X more likely if
parental conflict
Reason:
* terminal illness
* burden to others
* untenable family/personal situation
* punishment or exposure of
unacceptable behavior
~
Assessment ~couldn’t find it in slides or book~ Lethality Assessment Scale
* Cries for help-direct or indirect 1. No predictable risk
Signs: Suicide/Self-destructive behaviors * No notion, no h/o attempts, in close
* Give away possessions * Maladaptive measure to restore contact w/ significant others
* Make or Δ will equilibrium when overwhelmed- 2. Low risk
* Insurance policy try to take away unbearable * Considered suicide w/less lethal method.
* Cancel social engagements emotional pain No h/o attempt/recent serious loss, no
* Despondent, cry for no apparent reason * Suicide: 11th cause of death. ETOH, basically wants to live
* Feel hopeless * Seen a professional within the 3. Moderate risk
* Lose interest in friends, activities same month of suicide * Considered suicide w/ highly lethal
* Sudden recovery from depression method but has no specific plans/threats,
* Plan funeral Self-destructive behaviors or has one w/less lethal method. h/o less
* Nail biting, hair pulling, self- lethal attempts, reliance on drugs/meds
mutilating behaviors (scratching, for stress relief, weighing odds btw life-
Lethality assessment
cutting), smoking, driving death
* Attempt to predict likelihood of suicide.
recklessly, gambling, 4. High risk
* Evaluate client’s ability & intent
alcohol/drugs * Current highly lethal pan w/obtainable
* Get history of previous attempts
* Chronic – can hasten one’s death means; h/o previous attempts, unable to
* Ask Be clear & direct communicate w/friends; drinking; wants
* Never promise secrecy
Self-mutilation to die
* In all of your practice “never worry alone” * Persons w/early childhood abuse, 5. Very high risk
* Lethality of suicide methods neglect, trauma can’t process * Current highly lethal pan w/obtainable
° Less lethal feelings verbally & avoid means; h/o previous highly lethal
• Wrist cutting problems attempts, cut off from resources,
• House gas * Use self-mutilation to deal depressive, excess ETOH, threatened
• OTC meds (except ASA & Tylenol) w/anxiety & distress w/serious loss
° Highly lethal * Don’t see behaviors as
• Gun problematic until out of control Suicide precautions
* Associated w/suicidal ideation * Evenings, nights & wkends in hospital
• Barbiturates, sleep aids
* Important nursing responsibility
• Jumping
* Nursing observation single most
• ↑ASA & Tylenol
important factor
• Hanging
Removing suicidal status
• Car crash * Gradual removal & careful monitoring.
• Drowning * Slowly introduce dangerous objects
• Exposure to cold/Carbon monoxide * Monitor on antidepressant meds past 2-3
• Antidepressants wks
* Monitor client on ‘pass’
* Community resources
Somatoform Disorders/Psychosomatic Illnesses
Types Assessment
6
Biophysical Characteristics
* Unconscious transformation of emotions into physical
symptoms to deal w/stress
* Psychogenic pain just as hurtful as physical pain
* May respond to stress w/disruptions in sleep
Types
* Conversion disorder
° Impaired physical function related to expression of a
psychic conflict
° (Ie. Masterbate daily, arm paralyzed)
° Primary Gain-helps the person keep the psychologic
need/conflict out of conscious awareness
° Secondary Gain-helps person avoid a distressing,
uncomfortable, or pugnant activity while at the same
time receiving support from others
* Pain Disorder
° Pain experienced for no physiologic basis &
accompanied by psychological factors
° Pain is usually severe enough to disrupt several
functional areas.
° Results in unemployment, disability, &/or family
problems
° pt. looks for a Dr. to “cure” them
* Hypochondriasis
° preoccupation w/fear/belief of having a serious illness
that is not present on physical exam
* Body dysmorphic disorder
° preoccupation w/an imagined defect in physical
appearance that is exaggerated & out of proportion
° may lead to isolation
° important for plastic surgeon to screen for this
* Malingering
° Conscious falsification of illness, not considered a
psychiatric disorder
° Person deliberately fakes symptoms in order to benefit
° Have various motivations, including financial gain,
relief of work duties, or obtaining illicit drugs
° Obvious secondary gain(s)
* Factitious disorder (Munchausen)
° Similar to malingering, but pt has psychological need
to assume the sick role
° Deliberately produced
° Motivation: to assume the sick role in order to gain
attention and/or obtain medical treatment
* No obvious secondary gain
* Not under voluntary control
* Have unconscious motivation
* Primary gain is reduction of anxiety
* Client will present w/multiple complex problems.
* Utilize nursing process to systematically assess &
deliver care.
* Remain cognizant of your own values, beliefs, feelings,
& nonverbal behaviors.
* Clients will report physical symptoms for which there is
no evidence of physiologic cause.
* Always rule out physical causes for symptoms
* Be alert to responses indicative of la belle indifference
and/or the client who is overly dramatic & emotional
when symptoms are discussed.
* Careful interviewing reveals a stressful life event
w/which the client is not coping.
* Suggests that preoccupation w/somatic disorder is way
of avoiding underlying conflict
*
7
r
Sleep Disorders
Info In Maj. Depres. Disorder In Bipolar Disorder Treating Insomnia REM
“Good sleeper” can be identified three ways: * Insomnia of maintenance or * Sleep time significantly * Treatment for sleep disorders * Stage w/ most
* Self-defined early wakening type most reduced is complex dreaming
° say they get enough sleep to feel refreshed, common * Clients don’t complain of * Follow guidelines for good * Brain waves show a
have energy, fall asleep quickly * Insomnia is the most insomnia & can go w/out sleep hygiene level of cognitive
* Behaviorally defined commonly reported residual sleep * Utilize good sleep hygiene activity comparable to
° observe alertness during sedentary, repetitive symptom after remission * Reduced slow-wave sleep before taking sedative waking state, &
activity; note ability to fall asleep & final * Sleep pattern disturbance may * Reduced REM latency hypnotic medications physiologic functions
wakening at habitual rising time; utilize respond to antidepressant * Instil a sense of hope that are also heightened in
photographic serializing of movement during treatment sooner than other insomnia will improve, a state of activity
sleep symptoms client can manage it * Constitutes 75-85% of
* Sleep-Study Defined effectively sleep time
° Comprehensive sleep studies are conducted In Schizophrenia In Substance Abuse * Facilitate setting realistic * Almost total paralysis
in sleep labs: * Exacerbation of illness causes * Severe sleep disorder goals. of skeletal muscle
• polysomnogram significant sleep disruption during intoxication or * Teach normal developmental during REM, which
• multiple sleep latency test * Extreme sleep difficulty can withdrawal periods Δs in sleep patterns. prevents the acting out
* Persists even after * See treatment provider for of dream states
accompany severe anxiety
Guidelines for Good Sleep Hygiene * Heightened concern of prolonged abstinence of continued insomnia.
* Maintain regular sleep–wake schedule delusions & hallucinations some substances * Differentiate between myths
* Rise at the same time each d * Circadian cycle disrupted * Substance-induced mood & evidence-based practice.
* Go to bed when sleepy & relaxed * Reduction in REM sleep disorder characterized by * See physician for
* Maintain rituals in preparation for sleep * Do not experience REM sustained use of stimulants comprehensive PE to rule
* Control for temperature, lighting, noise rebound to stay awake or alcohol to out physical factors.
* Avoid stimulants before bed * Deficits in slow-wave sleep induce sleep * Interview bed partner.
* Focus on enjoying sleep that is achieved found in clients w/acute & * Determine if problem is
chronic schizophrenia positional or disappears
under certain circumstances.
* Treat underlying mental
health issues.
Sleep Dyssomnias
Primary Insomnia Narcolepsy Breathing-Related Primary Hypersomnia Circadian Rhythm Other Dyssomnias

8
* Difficulty initiating or * Condition where * Most common form is Sleep * Prolonged sleep & * Jet Lag Type-Δ time zone * Periodic Limb
maintaining sleep, or there is an Apnea excessive sleepiness so * Shift Work Type-night shift Movements-jerking
non-restorative sleep that almost ° Obstructive type-upper severe as to interfere * Delayed Sleep Phase Type- limbs
lasts for <1mo & does irresistible urge airway partially or totally w/function stay up/sleep in late * Restless Leg
not occur exclusively in to sleep collapses * Frequently seen in clients * Advanced Sleep Phase Type- Syndrome-
assoc w/another sleep or * followed by ° Client wakes to restore experience mental health early sleep, wake early disagreeable crawling,
mental disorder brief episodes of airway challenges itching * tickling
* Sleep meds may be deep sleep * Clients report difficulty staying sensation in legs
useful, but CBT is * Followed by a awake during day
superior sense of * Often obese w/thick neck &
refreshment snoring
* Tx: Lose wt, avoid alcohol,
change position, or remove
obstruction
~
Cognitive Behavior Therapy
Info Techniques Types

9
Based on:
* Principles of cognitive functioning
° What people think affects how they feel
° What people think is based on thinking
habits
° If we Δ our thinking, we can effect a Δ in
our feelings
* Principles of Behavior
° People do things
• When they are rewarded
• When something they don’t like is
removed
° People don’t do things
• When they get punished
• When something they like is taken away
from them
Concepts
* Attribution
° Assigning meaning to events
° Perceived causes that may not be accurate
° Depressed people attribute failure to
themselves & success to others.
° Expect a certain outcome & behave
consistently w/that expectation
° Feelings match the experience
* Modeling:
° Imitate people to get rewards we see
them getting
° Strive for level of skills that reward others
* Self-efficacy
° feeling effective thru one’s actions
° Learn when they practice new skills
° People who believe they can cope w/skills,
practice & observing outcome will gain
confidence & sense of self-efficacy.
~
Info
Cognitive therapy techniques
1.Identify thoughts that are
unrealistic, negative,
problematic
2.Examine their impact on
individual
3.Substitute positive or neutral
thoughts for problematic
thinking
Positive Imagery
* Thinking about how events
will happen positively –
promotes positive outcome
* Reframe past events
* Cognitive rehearsal
Mastery Imagery
* Shapes thoughts about being
in control of a particular
situation
Negative Imagery
* Help client predict what will
happen if Δs are not made
Attribution Restructuring
* Need to recognize how we
think & behave & to identify
problematic learning
* Each successive negative
experience breeds another
* Abandon intuitive strategies
Dementia Alzheimer’s Type DAT
Classical Conditioning
* People learn to associate a particular
feeling/state w/particular circumstance
conditioned stimulus for feeling
* Association between circumstance &
feeling strengthened thru repetition &
rehearsal.
* Goal of therapist to ↓ or eliminate the
association w/a particular feeling
Operant Conditioning
* People positively reinforced for certain
behaviors
* Learn to seek further positive
reinforcement
* Results from getting something
desirable or avoiding something
unpleasant
* Goal: to help ↑ positive reinforcement
thru more effective behavior
Rational Emotive Behavioral Therapy
* RET identifies & corrects irrational
beliefs
* Emphasizes cognitive causes of
emotional problems along w/ the
importance of taking personal
responsibility for maintaining health-
damaging thought habits & irrational
beliefs
* An irrational belief is one that lacks
reason & sound judgment
° I need someone
° Can’t Δ things
° If my family is upset, I am too
° I should always be able
° If things don’t go my way, it’s terrible
Dementia
Behavior Modification
* Focuses on problematic target behavior
° Antecedents (what came before)
° Precipitants (what appeared to
cause/provoke behavior)
° How is behavior expressed
° Timing
° Frequency
° Duration
° Personal strengths to be capitalized on
designing the plan
Response Prevention
* Identify lowest level of distress, walk thru,
replace w/adaptive behaviors
* Gradually, the client advances through their
hierarchy of distress, learning to develop
skills in responding competently in every step
Systematic Desensitization
* Graded exposures & response prevention
* Understand trigger, Substitute activity,
Recognize support
Thought Stopping
* Visualize a traffic stop sign
* Imagine hearing the word “stop”
* Imagine the tactile sensation of leaning up
against a closed door.
Dialectical Behavioral Therapy
* Assumes disorder in how client regulate
emotions & tolerates stress
* Teaches:
° Mindfulness
° Interpersonal effectiveness
° Emotional regulation
° Distress tolerance
Other Types
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* Functional declines in
multiple cognitive areas:
° Disorientation- time
first, then place &
person
° Memory
° Behavioral &
psychological symptoms
* Cortical : Dementia of
Alzheimer’s type (DAT)
* Subcortical: Huntington’s
or Parkinson’s disease
* Confabulation
° confused person’s
tendency to make up
response to question
when unable to
remember answer
° Attempt to save face, not
lying
* Labile affective behavior
especially if limbic system
involved
* Deterioration in social
skills
* Impulsive sexual behavior
* alteration in sexual
function – loss of erection
* Restlessness & agitation –
sundowning syndrome
DAT Pharmacological treatments for Dementia w/Lewy Bodies Creuzfeldt-Jakob Disease
5% in clinical settings from target symptoms: * 15-20% of dementias * Infectious, transmissible
reversible causes * Agitation, aggression & psychosis * Lewy bodies are abnormal degenerative dementia
* hyothyroidism, * Acetylcholinesterase inhibitors concentrations of protein that * Cell destruction & overgrowth in
nutritional deficiencies, slow progression of symptoms, do develop inside nerve cells cerebral cortex
or dementia syndrome not cure disease * Presents w/parkinsonism, * Rapid onset, involuntary
due to depression * ↑ Ach levels slow neuronal fluctuating confusion, disturbances movements
* Depression w/DAT most degradation of consciousness, falls, & * Iatrogenic – after corneal
common mood disorder ° Useful in mild to moderate psychiatric symptoms transplants & injection of human
in older adults stages * If give neuroleptics before growth hormone from cadavers
* Slow breakdown of Ach – diagnosis, can cause severe & even w/the disease
* Aphasia promotes function of Ach = fatal sensitivity to EPS side effects * Another form, similar to mad
* Anomia (can’t transmitting information from one * ↑risk for tardive dyskinesia & cow disease
remember words) cell to another. neuroleptic malignant syndrome :
* Agraphia (can’t put * In mild & moderate forms, more Can use Seroquel Pseudodementia
thoughts into words) Ach in CNS – memory & * Often overlaps w/DAT * Reversible cognitive impairments
* Alexia (can’t understand cognitive functioning improve seen in depression
written language) * Temporarily improve Frontotemporal Dementia * Clients fail to perceive their
* Apraxia (loss of neurotransmission & help * Previously known as Pick’s disease deficits
purposeful movement) memory deficits * Due to accumulation of cytoplasm
* Agnosia (can’t * Denial & confabulation may slow in brain Amnestic disorder
remember objects) getting to treatment * Leads to progressive loss of * Short & long-term memory
* Mnemonic disturbances judgment, disinhibition, social deficits, inability to recall or to
(memory loss) * Tacrine (Cognex) – didn’t really misconduct, apathy, loss of learn new information
* Visual (some auditory) help- caused liver toxicity, GI expressive language & * Causes: head trauma, hypoxia,
hallucinations symptoms & headache comprehension encephalitis, thiamine deficiency
* Agitated & erratic * Aricept – for all stages – fewer * Worsens rapidly & substance abuse
behaviors GI symptoms & headache
* Reminyl Vascular Dementia
3 distinct stages * Exelon * 19% of dementias
° Stage 1-2-4yrs * Namenda * Abrupt in onset, episodic
° Stage 2-Several yrs ° Safe, effective & well tolerated * Focal neurological signs
° Stage 3-1-2 yrs * Brain tissue destroyed by
intermittent emboli.
* Also w/htn, diabetes, &
cardiovascular disease affecting
other organs
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 Dementia
Nursing Diagnosis Interventions
* Impaired physical ability – gait Δs, hyperactivity * Dementia – minimize loss of self-care
* Self-care deficit (delirium & dementia) * Keep client safe
* Readiness for enhanced sleep – sundowning * Promoting Normal Motor Behavior
° Catnaps in d, wanders at night * Environmental –prevent falls
* Disturbed thought processes * Maintaining self-care
° Agnosia * Promoting adequate sleep
° Memory * Beer or wine preferable to hypnotics
° Orientation * Wander until tired
* Impaired verbal communication – aphasia, confabulation, confusion & paranoid * Low doses of risperdal/antianxiety w/caution
ideation * Mechanical restraints – last resort
* Risk for violence – linked w/impulsivity & unpredictability * Support Optimal Memory Functioning
* Ineffective role performance ° Gently orient, direct to fun activities
° from past role to dependence, regression ° Don’t test memory unless necessary
° Family experiences acute grief after diagnosis ° Use verbal & nonverbal cues together
* Disturbed sensory perception-Delirium Δs perception-can’t check reality * Promote Optimal Orientation
* Risk for situational Low Self-esteem ° Wear needed assistive devices
° Incontinence ° Familiar objects from home
* Imbalanced nutrition ° Orienting devices: clocks, calendars
° Call person by name, approach in clear view, simple directions
* Support conduct/impulse control
° Control stimulation/prevent sensory overload
* Make Δs slowly
* Avoid touching client
* View client as active member of family
* Lower anxiety by moving slowly, speaking clearly
* Manipulate environment: label bathroom, bedroom, post reminder notes,
* Reassure client that he is safe, don’t leave client alone w/out some stimulation
* Promote elimination
° put on schedule
° Use disposable underwear
° Avoid catheters

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Cluster A: Odd-eccentric
* Pervasive distrust, social detachment, &
impairment in social/occupational
functioning.
Paranoid personality disorder
* Suspiciousness & Mistrust (secret &
guarded)
* Rigidity – preoccupied w/their
perceptions
* Hypervigilance – ↑d state of watching
* Distortions of reality – Disagree
w/meaning of events, not events
themselves.
* Projection –Attribute their intolerable
motivations to others. (Concern about
harm may be wish to harm others)
* Restricted affect: Lack of emotional
affect & spontaneity
* Use intellectualization & rationalization
to avoid emotional experiences
* Exclusion: Because of suspiciousness &
antagonism, relationships w/others are
strained. They avoid him & reinforce
his suspicions
* May join counter-cultural groups
Schizoid Personality Disorder
* Detached & aloof social style
* Preference for solitary interests
* Choose occupations w/minimal social
involvement
* Indifference & humorlessness are
hallmarks
Schizo-typal Personality Disorder
* Suspicion
* Hard to maintain eye contact
* Don’t get humor
* Anxiety in social situations.
Types of Personality Disorders
Cluster B: Dramatic-Emotional
* Live in present – don’t make long-range plans
* Act decisively w/out consequences
* Unable to delay satisfaction
* Anger outbursts are self & other-directed
Borderline Personality Disorder
* Unstable interpersonal relationships, self-image,
& affect & are impulsive
* Psychotic under severe stress
* Impulsivity--I don’t know why, I just did it.
* Intense anger-tend to instigate problems in
therapeutic relationships
* Identity diffusion-hollow-can’t genuinely
experience feelings & emotions
* Unstable interpersonal relationships
* Splitting-inability to integrate contradictory
experiences. ‘all or none’
* Affective instability– intense mood fluctuations
* Feelings of emptiness & aloneness
* Self-damaging acts
* Distortions of reality
Histrionic Personality Disorder
* Tendency for dramatic, egocentric, attention-
seeking response patterns. Always “on stage”
* Craving for attention, activity & excitement
* Need constant love & attention-manipulate
others to hold on to them, highly inconsiderate &
lack empathy
* Competitive w/same sex, seductive w/opposite
* Sexual acting out
* Dysphoric mood
* Interested in imaginative pursuits, not analytic or
academic
* Look to authority figures for magical solutions
* Impaired health patterns – regression leads to
physical symptoms that call attention to
themselves
Narcissistic Personality Disorder
* Pattern of grandiosity, difficulty
regulating self-esteem, need
admiration from others which
determines their self-evaluation.
Boast about themselves
* Strong sense of entitlement
* When needs not met, feels rejected &
acts out
* Indifference towards others &
interpersonal manipulation
* Traits common in teen
* Kernberg: Chronic intense envy &
defenses against envy lead to
idealization & devaluation of others.
* Accusations of incompetence
* Demands for unattainable perfection
* Impaired sexual expression – perverse
fantasies & promiscuity may be
associated – Sex used for bartering
Antisocial Personality Disorder
* Pattern of disregard for & violation of
the rights of others
* Do not seek help, but are referred
because of criminal activity
* Manipulation used to control others &
interferes w/interpersonal
relationships.
* Drive to be “number one”
* Initially charming, tell you what you
want to hear
* Astute at identifying others’
vulnerabilities
* Impulsive, aggressive, lack of anxiety
* Need immediate gratification except
when planning things for their own
benefit.
Cluster C: Anxious-Fearful
Avoidant Personality Disorder
* Pattern of social withdrawal
w/sense of inadequacy, fear,
hypersensitivity to rejection
* Devalue their achievements
* Speech is slow
* Thought content serious
Dependent Personality Disorder
* unrealistic need to be cared for.
* Inability to make decisions & to
function independently
* Seek out others for guidance &
control
* Subordinate their desires to
others in order to maintain
relationships
* Friendly, helpful, indispensable
* When dominant personal is
unavailable, person experiences
intense anxiety
* SOs eventually respond w/anger
& resentment
Obsessive-Compulsive
Personality Disorder
* demonstrate fear & anxiety
about loss of control
* Perfectionism, preoccupation
w/details & hoarding behavior
* Attempts to keep world
predictable & organized
* Effort to keep order, little
attention to relationships
* Need to repeatedly check work,
not productive
* Aware of other’s expectations,
possible criticism, rules &
regulations
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~

Personality Disorders Planning/Intervention

Characteristics Cluster A: Odd-eccentric Cluster B: Dramatic-Emotional Cluster C: Anxious-Fearful
* Lack of insight – Impact * Maintain open style of questioning * Assessment: keep words & actions congruent * Aware of fear of rejection &
of behavior on others * Do not argue * Avoid getting into their manipulation dependency behaviors
* External response to * Because clients hold grudges & are quick to * Avoid doing for client what they can
stress – when threatened, attack, keep an eye on safety for you & other Manipulation do them self
try to Δ environment staff * Challenge – get needs met directly * Schedule regular session as a way to
rather than themselves * Respect Personal Space * Manipulate nurses into role of nurturers & anticipate client needs before client
* Failure to accept * Respect client’s preferences rescuers – remember, there is a life-long pattern demands attention thru inappropriate
consequences of their * Give feedback of victimizing & exploiting others responses
own behavior * Provide schedule & inform of Δs * Never make yourself available to this client * Point out when client negates own
* Manipulation – exploits * Help ID adaptive diversionary activities outside of the therapeutic relationship feelings/opinions
others for own good * Use role-playing to ID * Team approach to avoid splitting * Set realistic limits on what will/won’t
* Narcissism-entitled to feelings/thoughts/responses brought on by * Set limits on most problematic behavior to: be done
special favors stressful situations ° prevent escalation of negative behavior * Consider that client needs to realize that
* Impulsivity – act w/out * Use concrete, specific words ° establish boundaries yrs of denying satisfaction, working
considering * Respond to suspicious ideas by ‘it may be ° counteract resistance hard, restricting quality of life have not
consequences distressing,’ ‘you see him as vindictive’ * Teach clients relaxation brought expected rewards – leads to
* Teach to ask for what they want rather than act depression
* Impact 2 of following Aggressive behavior * Confront illogical perceptions of others
out
° Cognition * Paranoid, antisocial & borderline most likely * Boundaries provide structure that signifies * Learn to express true feelings in
° Affect * Limit setting & assertive behavior security to client counseling
° Interpersonal * Help to appreciate rights & needs of others * Use concerned, matter-of-fact approach * Help clients confront negative beliefs
relationships * Don’t personalize aggression * Set, communicate, & maintain consistent rules about themselves
° Impulse control * Thought-stopping techniques
* Do not argue, bargain, or rationalize
* Evident by early Guidelines for Angry Client * Identify their strengths
* Confront inappropriate behavior w/out
adulthood * Use calm, unhurried approach * Δ is influenced by:
anger/punitiveness/personalization
* Not result of other * Do not touch client * Be alert for flattery/verbal attacks ° Severity of emotional deprivation
mental disorders or SA * Use active listening ° Rigidity of personality structure
* May coexist w/major * Assure client staff will not allow him to hurt Impulsiveness ° Ego strength
mental disorders self or others * Safety maintenance ° Motivation to Δ
* Personality disordered * Discuss alternative means of releasing tension * Responsibility for actions, consequences ° Nurse’s skill & commitment
individual may become * Postpone discussion of consequences until * Self-destructive behavior ° Social support system that favor the
psychotic under stress under control * Don’t label “attention seeking” desired Δ
* Hold client responsible for behavior, remind of * Physical precautions
ability to make choices * Explain expectations & consequences

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 Complimentary & Alternative Medicine: Herbs
Herb Use Effectiveness & Safety
* Comparable to low dose benzodiazepines to short term tx of anxiety
Kava Anxiety/restlessness * Unsafe for long term/high doses
* Associated with liver failure

* Likely effective; effect is similar to that of Aricept

* Safe when used PO
Ginko Leaf Extract Dementia
* UNSAFE when used IV
* Warrants large-scale trials
* Safe PO, IV & IM and Short Term
* Evidence is contradictory-possibly as effective as Prozac and Zoloft, or
St. Johns Wort perhaps no more effective than placebo
Depression
* Unsafe in large doses (>1,800mg/day)
* Interferes w/ Rx meds by metabolizing them & transporting them out of
body
SAMe Depression * Possibly as effective as PO Tricyclic antidepressants
Encephalopathy (alcoholic) * Safe PO
Thiamine (B1)
Peripheral Neuropathy * Rare hypersensitivity when taken IM, IV
* Jet Lag & insomnia
Sleep Disturbance/
Melatonin/Valerian * Ineffective for work shift change adjustment
Insomnia
* Safe PO or IV
Omega- 3 fatty Dementia of Alzheimer’s
* Slows the cognitive and functional decline in Alzheimer’s
acids Type (DAT)

15
 Aggressive Behavior
Theories Rape Risks/Treatment Child Abuse
Intrapersonal theory * Crime of violence * Occurs in all socioeconomic classes * Child abuse:
* Rapists emotionally immature who are powerless * Not sex, but dominance & humiliation * Battering is epidemic ° Range from light
* Means of discharging anger & frustration * Videos & media sources make rape * Violent crime: victims have right to be slap to homicide
* Anger rape: physical violence & cruelty rapes occur more acceptable to men protected ° Message:
episodically as rage builds up * Rarely reported when women know * Sibling abuse: Don’t support or ignore 
* Power rape: command & master another person the attacker If small & weak,
* Sadistic rape: bondage & torture for excitement Nursing Role you deserve to
* Gang rape: # of perpetrators, part of ritual Rape trauma syndrome * Assess or intervene in consequences of be hit
* Date rape: forced by someone known to victim * Violent act against an innocent person violence & abuse 
* Changes lives forever * Can be active in prevent of rape & People who love
Interpersonal theory * May dissociate during attacks treatment of rape survivors you will hit you
* Perpetrator lacks interpersonal involvement * Support denial until ready to face * Can be key in intrafamily violence – it’s
* Preoccupied w/ self-fantasies reality * When detected, must comply w/ state laws appropriate
* Wish to dominate rather the be in mutually satisfying * Initial response agitated & for reporting 
relationship unpurposeful behavior * Provide Psychoeducation Violence
* Sees no need for consent * Followed by episodes of fear * Empower Victims appropriate if
* Anything that brings back experience ° Men/women equal, emphasize strength/ end is good
Social learning theory * Fear of follow-up investigation, etc. abilities, respect victim, alter destructive 
* Interpersonal violence acceptance makes rape a roles in family, state clear position about Violence is
higher incidence Physical injuries abuse, ID ways of dependence on abuser appropriate way
* Aggression learned from family & peers, culture & * Profuse bleeding, trauma to vital * Treat the Abuser of resolving
conflict
media. organs ° Group therapy. Responsibility placed on
* Contributes to a process of desensitization w/ * Vagina, rectum painful, swollen abuser. Learn effect of abuse on victims.
* Shaken baby
repeated exposure. * Tears of vaginal or rectal wall Violence is always a choice
* Viewers become numb to the pain, fear, & syndrome
* Throat traumatized from oral sex or
humiliation of sexual aggression For Rape: ° Most serious, yet
pressure
* Support defense mechanisms until client overlooked
Gender Bias Theory Long term consequences can cope ° 1/3 have serious
* Culture when men dominate political & economic * Depression in few weeks for about 3 * If unable to communicate – “Okay not now, brain injuries
activities maybe later” * Child neglect
months
* Women viewed as subservient, powerless, property * Thoughts of suicide * Share normal feelings like anxiety, fear, ° Act of omission
* Rape is to establish control of another person * May get MDD or obsessional thoughts guilt, etc. that results in harm
* Gender bias minimizes rape, blames victim, & about event * Encourage coping ° Lack of physical
excuses rapist * Flashbacks or violent dreams, future * When victim talks about rape, listen or emotional care
danger patiently * Homicide of child
Neurobiologic Theory * Rape in home disturbs normal feelings * “I know you handled the situation right ° Battering in
* Genes & NT contribute to violent behavior. of safety because you are still alive.” response to colic,
* Serotonin role in mood & aggressive behavior; if ↓= * Husband, live-in: must continue to * Identify & prioritize concerns toilet training
loss of temper, explosive rage interact & act as if normal * Focus on immediate problem difficulties

16
* Childhood abuse & neglect lead to permanent * May need celibacy or abstinence for * Restore control as you problem solve w/ ° Post partum
alterations some time victim depression primary
* Partner may reject person cause of
infanticide

Crisis Intervention
Info Defense Mechanisms Counseling

17
Crisis intervention
* Conceptual framework for
intervention that calls for
short-term action oriented
assistance, focused on
problem-solving
* Goal is to restore the
individual’ equilibrium
Crisis
* Turning point in person’s
life that result in new
equilibrium
* May be close to precrisis
state or positive or negative
* Positive:
° Gain skills
° New social network
° New-found problem-
solving skills
° Improved self-image
* Negative
° Lose skills
° Regress to earlier
developmental stage
° Develop socially
unacceptable behaviors
° Develop mental disorder
° Unsuccessful: anxious,
threatened & ineffective
Crisis is self-limiting
* Resolves in favorable or
unfavorable conclusion
* Although stress is not a
crisis, stress or an
emergency can precipitate a
crisis
* Crisis is not a mental
disorder
Resilience Ego Defense Mechanisms: ABCs
* ability to bounce back Compensation - Covering up weakness by emphasizing a more * Achieve contact
from difficult experiences desirable trait or by overachievement in a more comfortable area ° Introduce, emotional & physical
& continue to grow Minimization - Not acknowledging the significance of one’s safety
* Includes intrinsic behavior ° How would victim like to be called
biological & Sublimation - Displacement of energy associated w/more primitive ° Collect info about family, support,
psychological sexual or aggressive drives into socially acceptable activities friends
* Characteristics (become butcher) ° Assess if takes or needs meds
° Personality style Substitution - Replacement of a highly valued, unacceptable or
° ID victim’s feelings, reactions &
° Quality of interpersonal unavailable object by a less valuable, acceptable or available
perceptions
relationships object (Settle for similar, but less)
* Boil down problem
* It’s why all mistreated Undoing - Action or words design to cancel some disapproved
thought, impulses or acts in which the person relieves guilt by ° Briefly describe problem
children don’t have
making reparation (Child brings gift after spanked) ° What is most pressing problem
mental disorders in ° Review what you heard
adulthood
Old ones: ° Ask about similar crises in past
Denial – blocking out painful or anxiety-inducing events or feelings ° How did victim handle problem?
Risk factors
Displacement – discharging pent up feelings on people less * Cope (Predict & prepare)
* Intensity of exposure
dangerous than those who caused the emotion ° What does victim want to happen
* Preexisting psych
Dissociation – handling emotional conflicts, or internal, or external
symptoms ° Most important need
stressors, by a temporary alteration of consciousness or identity ° Formulate plan w/resources &
* Prior h/o traumatic Fantasy – symbolic satisfaction of wishes through non-rational
exposure timeline
thought ° Talk future & hope
* Family h/o Identification – unconscious assumption of similarity between ones
psych/anxiety/antisocial ° Connect to resource w/more long-
self & another
behavior term support
Intellectualization – separating emotion from an idea or thought,
* Early separation from because the emotional reaction is too painful
parents/Childhood abuse Planning & implementation
Introjection – acceptance of another’s values & opinions as one’s
* Poverty * Assess & understand human
own
* Cultural expectation that dependence needs
Projection – attributing one’s own unacceptable feelings & thought
prohibit asking for help * Collaborate w/person & significant
to others
* Degree of threat Rationalization – falsification of experience through the others
construction of logical or socially approved explanations of * Focus on immediate concrete
* Three balancing factors behavior contributing problems
important to successful Reaction formation – unacceptable feelings disguised by repression * Use actions appropriate to person’s
resolution of of the real feeling & by reinforcement of the opposite feeling level
disequilibrium Repression – unconsciously keeping unacceptable feelings out of * Consistent w/lifestyle & culture
° Perception of event awareness * Time-limited, concrete & realistic
° Situational supports Suppression – consciously keeping unacceptable feelings out of * Mutually negotiated
° Coping mechanisms awareness * Provide follow-up
18