Mental Health Countertransference (Notes)

Module Topic Countertransferenc e Defense mechanism Table 3.1 Notes Countertransference�Nurse’s feelings & response toward the pt. based on the nurse’s past relationships and experiences. Ex: giving patients special attention bc they remind the nurse of their grandma. e Transferencethe patient displaces onto the nurse attitudes or feelings from their past. Defense Mechanisms� methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events. TYPES: e Avoidance avoiding people, places, situations associated with distressing thoughts/feelings. n Compensation Focusing on strengths vs perceived weaknesses. Ex: student who struggles academically focuses on sports. n Conversion develops physical symptoms in response to stress. No underlying injury or medical cause. lDenial Refusing to accept the reality of the situation tDisplacement Transfer of feelings from one target to another. - Ex: a pt distressed about dx yells at his nurse. n Dissociation Disconnecting from reality n IntellectualizationAvoiding emotions associated with a stressful event by focusing on facts/logic. - Nurse nervous about new job in ICU focuses on how it will help her career )Identification (Introjection) Adopting the beliefs/behaviors of another person. n ProjectionAttributing your own thoughts/feelings onto someone else - i.e. nurse who dislikes her coworker insists that “she hates me” n RationalizationTrying to justify unacceptable behavior with a logic-based explanation. - i.e. student who cheats on test states: “I don’t really need to know that information anyway” n Reacting Formation Expressing the opposite feelings/behavior from what is actually felt. - Boy is mean to a girl that he actually likes. n Regressionreverting to an earlier development level in response to stress. - Despite being potty trained, sibling wets the bed in response to their new baby brother. n RepressionInvoluntary blocking of unpleasant feelings. g SplittingFailure to recognize positive and negative attributes of an individual (“all or nothing” mentality). Common with borderline personality disorder n Sublimination Unacceptable impulses are transformed into socially acceptable behaviors - Taking out anger by hitting a punching bag n Suppression Conscious (voluntary) blocking of unpleasant feelings g Undoing Attempt to “cancel out” an unacceptable thought/behavior. - i.e. manager is excessively harsh on employee, and then goes out of her way to be overly nice and praise the employee. Therapeutic milieuplanning Therapeutic milieu-planning---the setting. We don’t want the patients in their rooms, we want them in the group therapy rooms. y Milieu therapy involves pts interactions with each other, practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group. #1 goal= SAFETY and protection for all pts and promoting social interaction. Therapeutic Community or Milieu. Sullivan envisioned the goal of treatment as the establishment of satisfying interpersonal relationships. The therapist provides a corrective interpersonal relationship for the client. Sullivan coined the term participant observer for the therapist’s role, meaning that the therapist both participates in and observes the progress of the relationship. milieu therapy, developed by Sullivan, involved clients’ interactions with one another, including practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems. Today, inpatient hospital stays are too short for pts to develop meaningful relationships with one another. Therefore, the concept of milieu therapy receives little attention. Management of the milieu, or Sleep deprivation environment, is still a primary role for the nurse in terms of providing safety and protection for all clients and promoting social interaction. Goal of sleep= 6-8 hours. priority = safety S&S confusion, lethargy, slow reactions sleep meds are a last cool room to sleep Sleep Hygiene Measures ● Establish a regular schedule for going to bed and arising. ● Avoid sleep deprivation, and the desire to “catch up” by excessive sleeping. ● Do not eat large meals before bedtime; however, a light snack is permissible, even helpful. ● Avoid daytime naps, unless necessitated by advanced age or physical condition. ● Exercise daily, particularly in the late afternoon or early evening, as exercise before retiring may interfere with sleep. ● Minimize or eliminate caffeine and nicotine ingestion. ● Do not look at the clock while lying in bed. ● Keep the temperature in the bedroom slightly cool. ● Do not drink alcohol in an attempt to sleep; it will worsen sleep disturbances and produce poorquality sleep. ● Do not use the bed for reading, working, watching television, and so forth. ● If you are worried about something, try writing it down on paper and assigning a designated time to deal with it—then, let it go. ● Soft music, relaxation tapes, or “white noise” may be helpful; experiment with different methods to find those that are beneficial for you. Tardive dyskinesia irreversible syndrome of permanent involuntary movements caused by long-term use of antipsychotics Look over schizophrenia notes Tardive dyskinesia�㹪late appearing, abnormal and involuntary movements (lip smacking, tongue protrusion, chewing, blinking, grimacing, choreiform movements of the limbs. Irreversible once it appears S NMS Potentially fatal idiosyncratic reaction to an antipsychotic drug. Medical emergency S/S: - Rigidity (jaw) Neuroleptic malignant syndrome-med - - High fever Unstable VS Stop antipsychotics s Can give meds benzo, tropentin, dantrolene S&S: rigidity, high fever, autonomic instability—high Bp, diaphoresis and pallor; delirium, Know this and EPS—no high fever Civil rightspsychiatric clients BOX 9.1 Patient’s Bill of Rights ● To be informed about benefits, qualifications of all providers, available treatment options, and appeals and grievance procedures ● Least restrictive environment to meet needs ● Confidentiality ● Choice of providers ● Treatment determined by professionals, not third-party payers ● Parity ● Nondiscrimination ● All benefits within scope of benefit plan ● Treatment that affords greatest protection and benefit ● Fair and valid treatment review processes ● Treating professionals and payers held accountable for any injury caused by gross incompetence, negligence, or clinically unjustified decisions n Voluntary Admission Patient requests admission and may sign out at any time. right to make phone calls, right to refuse meds, have the right to petition to leave. The nurse wants to find out why the pt wants to go home. n Involuntary Hospitalization Admission without consent if the pt poses a risk to self, others, or is gravely disabled. The pts can be released when they no longer pose a threat to self or others. Group treatment A person can be detained in a psychiatric facility for 48 to 72 hours on an emergency basis until a hearing can be conducted to determine whether or not they should be committed to a facility for treatment for a specified period. Many states have similar laws governing the commitment of clients with substance abuse problems who represent a danger to themselves or others when under the influence. In group therapy, members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in return. Group rules are established, which all members must observe. Being a member of a group allows the client to learn new ways of looking at a problem or ways of coping or solving problems and also helps him or her learn important interpersonal skills. clients often receive feedback on how others perceive and react to them/their behavior. This is extremely important information for many clients with mental disorders, who often have difficulty with interpersonal skills. Results of group therapy include: ● Gaining/learning new info ● Gaining inspiration or hope ● Interacting with others ● Feeling acceptance and belonging ● Becoming aware that one is not alone and that others share the same problems ● Gaining insight into one’s problems and behaviors and how they affect others ● Giving of oneself for the benefit of others (altruism) Psychotherapy group�㹪 members learn about their behavior & make positive changes in their behavior by interacting and communicating with others as a member of the group. Open Groups�㹪 Ongoing and run indefinitely, allowing members to join or leave the group as needed. Closed groups�㹪 Structured to keep the same members in the group for a specified number of sessions. Refusal of treatment Clients receiving mental health care retain all civil rights afforded to all people except the right to leave the hospital in the case of involuntary commitment. They have the right to refuse treatment, to send and receive sealed mail, and to have or refuse visitors. Depressed adolescent-rapport Peer groups---adolescents want to fit in Brains aren’t fully developed so they don’t think about consequences Nurse worries about suicide attempts because they are impulsive. Nurse needs to build a trusting rapport. Want to listen to the pt and build trust. The therapeutic relationship focuses on the needs, experiences, feelings, and ideas of the client only. The nurse who has self-confidence rooted in self-awareness is ready to establish appropriate therapeutic relationships with clients. Suicide-Maslow POC Hierarchy of Needs– safety is #1 priority Constant monitoring Remove dangerous items Plans, means, etc Assessment of Suicide or Harm toward Others The nurse must determine whether the depressed or hopeless client has suicidal ideation or a lethal plan. Likewise, if the client is angry, hostile, or making threatening remarks about a family member, spouse, or anyone else, the nurse must ask whether the client has thoughts or plans about hurting that person. When a client makes specific threats or has a plan to harm another person, health care providers are legally obligated to warn the person who is the target of the threats or plan. The legal term for this is duty to warn. Anxietycommunication Goal is to get the pt out of severe and panic anxiety to mild/moderate so we can process stuff with them. Decrease stimuli Short, simple directions, focus on breathing Reassure the patient is safe Crisis interventionempathy s Maturational/ developmental crisis predictable normal course of life s Situational crisis unanticipated, sudden events---loss of job, loved one, physical/emotional illness. s Adventitious crisis natural disasters, terrorist attacks, riots, violent crimes. Crisis intervention includes a variety of techniques based on the assessment of the individual. Directive intervention s sassess the pt’s health status and promote problem-solving. - offering the person new info, knowledge, or meaning; - raising pt’s self-awareness by providing feedback about behavior; - directing pt’s behavior by offering suggestions or action. Supportive interventions�㹪dealing with the pt’s needs for empathetic understanding. - encouraging the pt to identify and discuss feelings serving as a sounding board for the person - affirming the person’s self-worth.. y Empathy ability of nurse to perceive the meanings and feelings of the pt and to communicate that understanding to the pt Clarificationcommunication Stress & angertherapeutic response Insight-judgment s Catharsis not something we want for pts with anger issues Teach the pt S/S when they are about to have an angry episode Work on awareness with the client Components of the mental status exam. Insight�㹪 patient’s understanding of their own illness. the ability to understand the true nature of one’s situation and accept personal responsibility for that situation. example of poor insight: a pt who places all blame on others for his own behavior, saying “It’s my wife’s fault that I drink and get into fights because she nags me all the time.” This pt isn’t accepting responsibility for their drinking and fighting. Judgement�㹪 Is the patient able to make good decisions? Judgment refers to the ability to interpret one’s environment and situation correctly and to adapt one’s behavior and decisions accordingly. Problems with judgment may be evidenced as the client describes recent behavior and activities that reflect a lack of reasonable care for self or others. example, the client may spend large sums of money on frivolous items when he or she cannot afford basic necessities such as food or clothing. Risky behaviors such as picking up strangers in bars or engaging in unprotected sexual activity may also indicate poor judgment. The nurse may also assess a client’s judgment by asking the client hypothetical questions, such as “If you found a stamped addressed envelope on the ground, what would you do?” Mental status nurse will collect objective data by observing the patient and the patient's behavior. (appearance, posture, movement, hygiene and grooming, clothing/dressed, behavior[LOC], eye contact and facial expressions, speech, orientation, attention span, memory) Mental Status Exams include: Orientation to person, time, place, date, situation Ability to interpret proverbs Math calculations Memorization and short-term recall Naming common objects in the environment Ability to follow multistep commands Loss of hope Anger management CH 11 Ability to copy a simple drawing. HUGE red flag of risk of suicide rAnger strong, emotional response to a real or perceived provocation. results when a person is frustrated, hurt, or afraid. y Hostility verbal aggression n Physical Aggression attack/injury to another person or destruction of property. - Meant to harm or serve as a punishment Cognitive Behavioral Therapy Techniques: - Distraction - Problem-solving - Reframing Assertive Communication - Person uses “I feel” statements that express feelings and are specific to the situation. - “I feel angry when you interrupt me” - Appropriate expression of anger - Want people to be able to tell us what is triggering their anger Catharsis - activities that provide a release for anger. - May engage in aggressive activities such as hitting a punching bag, or screaming - Not recommended for people with anger issues in mental health. For these patients, we want to focus on assertive communication. n Suppression we do not want suppression. Common in women. Not healthy; so we want to encourage assertive communication because we want to alleviate those symptoms Suppressing anger can lead to high BP and coronary artery disease Employee Threat— safety Shouting Client Phases of escalation: TRIGGERING PHASE - An event that initiates the pt’s response, which is often anger and hostility - Can ask the pt to take a time-out - S/S: pacing, irritable, restless ESCALATION PHASE pt’s responses represent escalating behaviors that indicate movement toward a loss of control. - Can lead to physical aggression, loses the ability to perceive events accurately; - S/S: pale or flushed face, yelling, swearing, clenched fists, threatening gestures. - Nurse must take control—direct pt to take a timeout, state that aggressive behavior is not acceptable. CRISIS PHASE - During an emotional and physical crisis, the pt loses control - Kicking, hitting, spitting, throwing objects, screaming, inability to clearly communicate - Seclusion, restraint, 4-6 staff to restrain RECOVERY PHASE - Pt. regains physical and emotional control - Lowering voice, decreased muscle tension - Staff debriefszvn x s POSTCRISIS PHASE - Pt. attempts reconciliation with others and returns to the level of functioning before the aggressive incident & its antecedents May feel embarrassed, guilty, quiet, withdrawn tCode of conductoutlines acceptable and inappropriate/unacceptable behavior. TELLS US HOW WE NEED TO ACT AND CONDUCT OURSELVES. Have to provide education and training to all employees Verbally de-escalate the patient PRIORITY IS TO GET THE PATIENT CALM* - Encourage verbal expression - Convey empathy - Ask the patient to go take a “time out” to calm down in a quieter area---when we see “time out” on a test, it is not a punishment, it is a break - Offer PRN meds Know phases of anger and key components Trigger--- pick up on early signs of anxiety—pacing Escalate—verbal; not rational -Crisis—the worst it is going to get; physical ---the nurse must take control in this phase. Show of force-one person talks, and 4-6 ppl are on standby Recovery---remorse; debriefing—what happened, recap. s Postcrisis how we are going to make sure it doesn’t happen again. Caffeine addiction withdrawal-POC Overdose-action Alcohol withdrawalhospitalization Make sure the other patients are safe, decreasing lights, short, simple directions Pt will experience; headaches, irritable, shakes, nauseous, cranky Drink caffeine in moderation, 8oz per day Priority is safety; ABCs; we need orders to give meds e Benzos antidote flumazenil e Opioids antidote naloxone s Alcohol withdrawals benzos: lorazepam, chlordiazepoxide, dizepam; e Tylenol antidote acetylcysteine Symptoms begin 4-12 hours after cessations or marked reduction of alcohol intake. Peaks: 2nd day and is over in about 5 days. May last up to 1-2 weeks. S S&SHand tremors, diaphoresis, increased HR & BP, anxiety, agitation, n/v, double vision, hallucinations, delirium tremens. - Withdrawal symptoms are the opposite symptoms of what the drug/alcohol did - Alcohol causes CNS depression, so everything goes back up when it is taken away #1 Goal = Safe withdrawal—Hospital for 3-5 days **. WE WANT THE PT IN THE HOSPITAL BECAUSE PATIENTS CAN DIE FROM WITHDRAWAL x Tx Benzodiazepines= drug of choice (lorazepam) We give benzos because they work fast. We want to prevent seizures and delirium tremens Assessment: CIWA-AR Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-AR) EBP Tool to assess the severity of alcohol withdrawal ▪ 10 items, each evaluated independently then aggregated to yield a score correlating with severity of alcohol withdrawal, scores used for medication protocol ▪ Frequency of assessment is based upon MD order, severity of withdrawal sx and whether meds were given for withdrawal ▪ Max score of 64 Classification: Sleeping medications Look at realizeit* Mild: Less than 8 Moderate: 8-15 Severe: Greater than 15 Can be habit forming Take 30 mins before bed and go to bed Not to be taken every night Have to get 6-8 hours of sleep because they can have a “hangover” effect No alcohol, no benzos, no OTC, no antidepressants Alcohol abuse codependent behaviors e Codependencemaladaptive coping pattern on the part of family members/others resulting from a prolonged relationship with the person who uses substances. Enabling is a type of codependent behavior---seems helpful on the surface but perpetuates substance use. Alcohol detoxification action Catapres-alcohol withdrawal Disulfiram (Antabuse) Example: a wife who continually calls in to her husband’s job to report that he is sick when he is really drunk or hungover prevents the husband from having to face the true implications and repercussions of his behavior. What appears to be a helpful action really just assists the husband in avoiding the consequences of his behavior and to continue abusing the substance. The patient should always be taken to the hospital to detox from alcohol. Detox may cause death if not treated correctly. Prevent seizures and delirium tremens CIWA assessment Benzos given to suppress withdrawal symptoms Clonidine (Catapres) treats HTN Treats n/v/d, muscle aches, anxiety and restlessness. The BP will rise during withdrawal and clonidine given Info on pg 34 Disulfiram (Antabuse)—is used to help maintain abstinence from alcohol. n adverse reaction facial and body flushing from vasodilation, throbbing headache, sweating, dry mouth, severe hypotension, confusion, coma, N/V, sweating and even DEATH Avoid products containing ETOH: cough syrup, hand sanitizer, mouth wash, perfume, aftershave, lotion, vinegar, vanilla, peppermint and other extracts. Symptoms can be unpleasant up to 1-2 weeks after last dose of Antabuse Alcohol detox Disulfiram�㹪 used to help maintain abstinence from alcohol. Benzodiazepines �㹪 used for alcohol withdrawal because they are the safest withdrawal and they prevent relapse - Need IV fluids especially if vomiting IV bolus-mL Stress behavior Anxiety cognitive behavioral techniques three stages of reaction to stress: ● Alarm reaction stage, stress stimulates the body to send messages from the hypothalamus to the glands (such as the adrenal gland, to send out adrenaline and norepinephrine for fuel) and organs (such as the liver, to reconvert glycogen stores to glucose for food) to prepare for potential defense needs. ● Resistance stage, the digestive system reduces function to shunt blood to areas needed for defense. The lungs take in more air, and the heart beats faster and harder so that it can circulate this highly oxygenated and highly nourished blood to the muscles to defend the body by fight, flight, or freeze behaviors. If the person adapts to the stress, the body responses relax, and the gland, organ, and systemic responses abate. ● Exhaustion stage occurs when the person has responded negatively to anxiety and stress; body stores are depleted or the emotional components are not resolved, resulting in continual arousal of the physiological responses and little reserve capacity. With stress, we want pts to cope well with stress. Want to help manage and know what is a healthy level of stress. Cognitive Behavioral Therapy (CBT) focuses on: Positive Reframing - Turning negative messages into positive ones - Pt creates positive messages for use during panic episodes. - Instead of: “my heart is racing I feel like I’m going to die” the pt thinks: “I can do this. This is just anxiety, and it will go away” Decatastrophizing - Making more realistic appraisal of the situation Pt uses distraction techniques to stop focusing on the negative thoughts. Splashing cold water on face, snapping self with rubber band, shouting Assertiveness Training - Helps pt. take control over life situations - Learn to negotiate interpersonal situations & foster self-assurance - Using “I” statements to ID feelings and communicate concerns Anxiety-intervention Systematic desensitization NURSING INTERVENTIONS - Self-awareness of anxiety level - Assessment of pt anxiety level - Assessing--- the patient’s perceptions and their past experiences The nurse must first assess the person’s anxiety level to determine the intervention. Therapeutic Responses - Open ended vs. closed-ended questions--* always want open-ended - Assessing--- the patient’s perceptions and their past experiences - “Tell me more” Mild Anxiety no direct intervention. - Teaching can be effective when the pt is mildly anxious. - This is the stage where learning & motivation are effective Moderate Anxiety pt’s attention can wander. - Use short, simple sentences - Redirect the pt to the topic if goes off on a tangent. Stop to make sure the pt is still taking info in correctly. Severe Anxiety - Pt can’t pay attention or take in info. - Nurse goal: lower the pt’s anxiety level to moderate or mild before proceeding with anything else. - Stay with the person because anxiety can worsen when alone - Using a calm, low, soothing voice - Helping pt take deep even breaths to lower anxiety. Panic Anxiety - Safety is #1 concern - Nurse keeps talking to the person to comfort, even if pt cant’t process the info - Go to a small, quiet, non-stimulating environment - Reassure the pt that anxiety will pass and they are safe. - Stay with pt until panic stops. - If the patient doesn’t calm down Depressionstructured lifestyle Depressionincreased energy Depression-plans for harm What other disorder goes with anxiety disorders? Agoraphobia Want to try and maintain a healthy lifestyle Provide a consistent, structured environment. Let the pt know what is expected of them Set goals Consistency and structure can reassure the pt. Meds will take 4-6 weeks to take effect. We worry about increased energy because it is a risk of suicide. The risk for suicide may increase as clients begin taking antidepressants. Although suicidal thoughts are still present, the medication may increase the client’s energy, which may allow the client to carry out a suicide plan. Thoughts Plan---Means (how lethal is their plan?) tIntent ( ● Suicidal ideation means thinking of suicide. ● People with increased rates of suicide include single adults, divorced men, adolescents, older adults, the very poor or very wealthy, urban dwellers, migrants, students, whites, people with mood disorders, substance abusers, people with medical or personality disorders, and people with psychosis. ● The nurse must be alert to clues to a client’s suicidal intent—both direct (making threats of suicide) and indirect (giving away prized possessions, putting their life in order, making vague goodbyes). suicide lethality assessment involves determining the degree to which the person has planned his or her death, including time, method, tools, place, person to find the body, reason, and funeral plans. ● Nursing interventions for a client at risk for suicide involve keeping the person safe by instituting a no-suicide contract, ensuring close supervision, and removing objects that the person could use to commit suicide. Coping -past success Look at what has worked well for the pt in the past Focus on the pt’s strengths Want to build up positives and strengths Depression-activity Anhedonia, not going to work, late, can look like they are very laxy but we know they are feeling so down that they have no drive and don’t know how to come out of this. Look over ECT�㹪 reserve as a last resort after meds have failed. Bipolar-coping lithium levels: 0.5-1.5 Bipolar Disorder→ mood fluctuates to extremes of mania and/or depression, as described previously. - TOO MUCH norepinephrine Characteristics ● ● ● ● ● ● Pressured speech rapid talking Flight of ideas rapid thoughts Cycling---experience altering episodes of mania and depression at least 4 times in a year Euphoria Inflated self-esteem Excessive involvement in pleasure-seeking or risk-taking activities Nursing Care - #1 safety - Control the environment—make sure the pt is safe and the environment is quiet, calm, and free from stimuli. - Offer small meals, snacks - If manic, encourage small periods of rest - Set limits and redirect when being inappropriate Assess for suicide Frequent monitoring to make sure pt is safe Make sure pt is dressed appropriately Periodically manage lithium, and assess lithium levels T(x) Lithium: Therapeutic levels: 0.5-1.5mEq/L Lithium toxicity: over 1.5; n/v/diarrhea If they don’t take lithium, they take anticonvulsants—Depakote, Depression-suicide #1 PRIORITY (safety) -Assess for ideation -one-to-one supervision -”no suicide contract” -encourage client to talk about feelings/ identify positive aspects about self -provide safety (no harmful objects) Assessment Plan- is there a plan? have the means to carry out plans? when? History- any attempts of suicide in the past? How many times? Was the client accidentally rescued? Psychosocial- is a client alienated from others? substance abuse? any recent losses or physical illness? lifestyle changes? Suicidal Cues-giving away personal possessions -canceling social engagement -taking out/changing insurance companies -making out/changing will -feelings of hopelessness/ difficulty concentrating -loss of interest in activities -sudden deterioration in school, work performance -client inquiries poisons, guns, or other lethal objects -client statements indicating an intent -sudden calmness or improvement in a depressed client Tricyclicsmedication schedule TCAs are the oldest antidepressants. They treat symptoms of hopelessness, helplessness, anhedonia, inappropriate guilt, suicide ideation, and mood variations. These meds have a lag period of 10-14 days before reaching a serum level that starts to alter symptoms. They take 6 weeks to reach their full effect. They have a long serum half-life, so there’s a lag period of 1-4 weeks before steady plasma levels reached and symptoms start to decrease. Contraindicated in impaired liver function and myocardial infarction. S OD S&S hallucinations, confusion, agitation, hyperpyrexia, increased reflexes. Seizures, coma, and cardiovascular toxicity can occur with ensuing tachycardia, decreased output, depressed contractility and AV block. Lithium-creatinine Less common in older adults. Used for BPD Lithium is bad for the kidneys.; s Lithium therapeutic levels 0.5-1.5 Remember, lithium acts as a salt. We want to monitor fluids and electrolytes. Monitor kidney labs—creat: normal is 0.6-1.2; BUN 7-20 valproate (Depakote)monitoring lab Depress-bulimia & K Anorexia-faintingfemale adolescent Eating disorder- y Lithium toxicity will be flu-like symptoms n/v/d, tinnitus Mood stabilizers Use: mania with BPD, seizures, migraines s Therapeutic levels 50-125 Need to monitor liver labs, ammonia, platelets, and bleeding times. Bulimia may cause hypokalemia, hyponatremia Anorexia is more common in females ages 14 to 18 YO All about control—preoccupied with a certain size and weight Distorted body image Perfectionists Assessment 5 assess History ▪ Anorexia: perfectionists, eager to please ▪ Bulimia: history of impulsive behavior o General appearance and motor behavior ▪ Anorexia: slow, lethargic, emaciated, low BP, low temp, ▪ Bulimia: generally close to expected weight for size o Mood and affect: labile moods; sad, anxious, worried; with bulimia, initially pleasant and cheerful o o o o o o o NSG221.10.01.0 5 Anorexia NSG221.10.01.0 5 Bulimia priority NSG221.10.02.0 3 OCD-action Thought process and content: preoccupation with food or dieting Sensorium and intellectual processes: signs of starvation in malnourished clients with anorexia Judgment and insight ▪ Anorexia: limited insight, poor judgment about health status ▪ Bulimia: ashamed of behaviors Self-concept: low self-esteem Roles and relationships: unable to fulfill roles Physiological and self-care considerations (see Table 20.2) ANOREXIA NERVOSA— - Age: 14-18 YO (ADOLESCENTS) - Life threatening because the body starts to compensate—muscle wasting - Intense fear of being fat—extreme calorie counting - Distorted body image - Refusal to eat= low BMI and body weight - Low self-esteem - Amenorrhea Managing F/E Safety (Maslows) medication treatment for eating disorders antihistamine - promote weight gain antidepressants- effectiveness in preventing relapse antipsychotics- address bizarre body image distortions The nurse sets time limits for the OCD rituals The patient will start to experience anxiety.. we will see hand wringing, pacing, Nurse: orientate to reality, slowly lower time they are allowed to focus on their rituals. TREATMENTS FOR OCD Cognitive Behavioral Model: “If I think, it will happen” According to the cognitive model, the person believes that "if I think, it will happen." Therefore, the client wants to control the client's own thoughts. This client tries to be perfect and has intolerance for uncertainty. The client feels threatened by the thoughts. All this causes an increased anxiety in the client leading to some compulsive ritualistic behavior. As per the cognitive model, the client's thoughts are influenced by an inflated sense of responsibility. This may be a result of strict moral or religious upbringing. Exposure Therapy�㹪 assisting the pt in confronting the situations and stimuli that they usually avoid. n Response Prevention focus on delaying or avoidance performance of rituals. The person learns to tolerate the thoughts and the anxiety and to recognize that it will recede without the disastrous imagined consequences. deep breathing and relaxation�㹪can also assist the person with tolerating and eventually managing the anxiety. Progressive relaxation- Doesn’t involve a therapist, no equipment, can happen anywhere. Eliminates muscle contraction and helps decrease anxiety. EX) Close your eyes and take a deep breathe IV-ml remaining IV-ml/hr IVvolume to infuse Paranoia assessment Self-mutilationassess Anxiety, schizophrenia, Paranoid personality disorder, schizotypal personality disorder. Want to make sure their thoughts don’t include hallucinations where they are hearing voices to hurt themselves or others Read in realize it/book Non-suicidal self injury Happens with borderline personality disorder Antisocial personality disorder CLUSTER B rAntisocial Personality Disorder think serial killers, the grinch, - “psychopath” - Aggressive, impulsive, and manipulative - Can come off as very charming—they know what people want to hear - Disregard for the rights & safety of others - History of acts of cruelty, abusive parents, stealing, illegal activity, lying, cheating, stealing - Don’t care about morals, values, norms - Average or above average IQ - Risks of violence when they are rejected, challenged, etc. - No empathy—only care about self Nursing Intervention o Therapeutic relationship; promoting responsible behavior - Limit setting, Confrontation o Problem-solving; control of emotions - Taking time-outs o e Enhancing role performance don’t get involved in a power struggle. Set limits. We want to give them positive feedback. Auditory hallucinations Delusions-respond Echolaliaintervention Primary nursing intervention is dismissal intervention. Teach the pt. to talk back to the voices forcefully. This may help eliminate the auditory hallucinations. Should be done in private. Must find out if the patient is experiencing command hallucinations Do not challenge the pt, but use reality orientation. Don’t openly confront the delusions or argue Establish and maintain reality Use distraction techniques RN teaches positive self-talk, thinking, and ignore delusional beliefs Focus on safety and reality orientation Echolalia is part of the unusual speech patterns in patients with schizophrenia Echolalia�㹪 patient repeats/imitates what the other person is saying. During admission—we may have to get info from family. Document as poverty of speech. Document what we see, do objective assessment, let the provider know, and document exactly what we are seeing and hearing Schizophrenia-key features S/S present longer than 6 months Positive or Hard Symptoms (Think as we are adding) Ambivalence: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation Associative looseness: Fragmented or poorly related thoughts and ideas Delusions: Fixed false beliefs that have no basis in reality Echopraxia: Imitation of the movements and gestures of another person whom the client is observing Flight of ideas: Continuous flow of verbalization in which the person jumps rapidly from one topic to another Hallucinations: False sensory perceptions or perceptual experiences that do not exist in reality Ideas of reference: False impressions that external events have special meaning for the person Perseveration: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic Bizarre behavior: Outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior Negative or Soft Symptoms (Think as we are taking away) Alogia: Tendency to speak little or to convey little substance of meaning (poverty of content) Anhedonia: Feeling no joy or pleasure from life or any activities or relationships Apathy: Feelings of indifference toward people, activities, and events Asociality: Social withdrawal, few or no relationships, lack of closeness Blunted affect: Restricted range of emotional feeling, tone, or mood Catatonia: Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance Flat affect: Absence of any facial expression that would indicate emotions or mood Avolition or lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks Inattention: Inability to concentrate or focus on a topic or activity, regardless of its importance Meds will help control the symptoms Too much dopamine Meds will block dopamine production (1st gen) 1st Gen Antipsychotics (Typical) (* can be given as a long lasting injectable) Dopamine Antagonists�㹪 1st gen blocks dopamine. Treat positive symptoms Haloperidol (Haldol)* Fluphenazine (Prolixin)* Thiothixen* Chlorpromazine Nursing interventions--- GET EKG BEFORE AND AFTER ADMINISTRATION 2ND GEN ANTIPSYCHOTICS (ATYPICAL) (* can be given as a long lasting injectable) Dopamine and Serotonin Antagonists Serotonin treats the negative symptoms Risperidone* Paliperidone* Olanzapine* Aripiprazole* Clozapine--- agranulocytosis; risk for infection Quetiapine Nursing intervention: Need to obtain WBC and Neutrophil counts. monitor Blood glucose levels Adverse: leukopenia More sedation with 2nd gen High risk for developing diabetes Agranulocytosis Clozaril-WBC Haldol-taper clozapine 2ndcgen antipsychotic treats both positive and negative symptoms. Adverse effect: - Agranulocytosis�㹪 the bone marrow isn’t producing enough WBCs. Can be fatal - Pt is at risk for infection. S/S: Fever, malaise, sore throat, leukopenia Must check the WBC count for s/s of infection--- weekly blood draws for the first 6 months *haloperidol (Haldol)* 1st gen antipsychotic - Blocks dopamine Treats positive symptoms of schizophrenia. Taper dosage to avoid EPS Extrapyramidal Side Effects�㹪 reversible movement disorders that are induced by neuroleptic meds. EPS includes: dystonic reactions: spasms in discrete muscle groups, such as neck muscles or eye muscles; protrusion of tongue. Parkinsonism: shuffling gait, masklike faces, muscle stiffness. Akathisia: restless movement, pacing, inability to remain still. Tx for EPS - diphenhydramine (Benadryl) - benztropine (Cogentin) IM Seclusion Risperdal-teach Look over in drug book Restraints and seclusion are used as a LAST resort. Seclusion is a form of restraint. Goal: for patient to regain control Must have an order from the Dr. Time in restraints is based on age of the patient Not a form of punishment, used to keep the patient safe. Has to be directly observed every 15 mins Can only use seclusion in mental health Risperidone—2nd gen Have to be careful because it can elevate blood glucose levels, and can cause gynecomastia Long acting injectable Adverse: elevated blood glucose levels, weight gain, cardiac issues Teaching: good oral care, need adequate fluid intake but don’t want them washing out their meds, weight management, preventing diabetes. Geodon-tardive dyskinesia Zyprazadone (Geodon) - Tardive dyskinesia�㹪late appearing, abnormal and involuntary movements (lip smacking, tongue protrusion, chewing, blinking, grimacing, choreiform movements of the limbs. Irreversible once it appears Adult-generativity Erikson's stage 7, the adult's ability to care for another person. Middle adulthood (35-65) -Fulfilling life goals that involve family, career, and society -ability to give care for others (successful) -Self absorption; inability to grow as a person (unsuccessful) IPV abuse-legal responsibility IPV�㹪 Intimate Partner Violence Nurses are mandatory reporters for children and elderly. No mandatory reporting for domestic violence—if adults do not want to press charges they don’t have to. Unless it is a situation where the police are involved and the wife is hospitalized(?) ❖ Treatment and interventions o Laws related to domestic violence; arrest o Restraining order/protection order o Recognition of stalking o Shelters o Individual psychotherapy/counseling, group therapy, support and self-help groups o Treatment for PTSD Spousal abuse V IPV Intimate Partner Violence ❖ Mistreatment or misuse of one person by another in context of emotionally intimate relationship Psychological abuse (emotional) can be overt or subtle. Physical abuse: shoving, pushing, battering, choking Sexual: assaults during sexual relations, rape Rates higher among women Increased rates during pregnancy Domestic violence occurs in same-sex relationships with same statistical frequency. o Victims have fewer protections. Violent episode → honeymoon period → tension-building phase → violent episode We see more abuse when the person tries to become independent. Child abuse-action Inconsistency in stories, injuries, delayed medical treatment, bruises in unusual places and bruises/wounds in various stages of healing; fractures that pt didn’t seek tx for; poor hygiene; NURSES ARE MANDATORY REPORTERS OF ANYONE UNDER THE AGE OF 18YO. - Always try to get the child away from the suspected abuser to ask questions ❖ Detection and accurate identification are the first steps (see Box 12.3- see speaker notes). ❖ Report suspected child abuse o Nurse does not have to decide for certainty if abuse occurred. ❖ Treatment and intervention o Child’s safety and well-being is a priority. o Psychiatric evaluation o o o o Domestic violenceelder Recording Psychological trauma Therapy may be indicated over significant period. Approach depends on the age of a child. Social services involvement Family therapy/requirements for parents Kids that are sexually abused with act out acts with other kids or when they are playing. ❖ Maltreatment of older adults o Physical, sexual, psychological abuse o Neglect of self-neglect o Financial exploitation o Denial of adequate medical treatment ❖ Estimated 10% of population over age 65 abused by caregivers. ❖ 60% to 65% of victims are women. ❖ People who abuse elders almost always in caretaker role or elders depend on them in some way. ❖ Most cases when one older spouse is taking care of another ❖ Bullying between residents in senior living facilities ❖ Elders often reluctant to report abuse o Want to protect family members o Fear losing support ❖ Clinical picture: variable depending on the type of abuse Assessment Treatment and intervention o Caregiver stress relief o Additional resources o Possible removal of elder or caregiver Abuse is more likely when the elder has multiple chronic mental and physical health problems and when he or she is dependent on others for food, medical care, and various activities of daily living. The victim may have bruises or fractures; may lack needed eyeglasses or hearing aids; may be denied food, fluids, or medications; or may be restrained in a bed or chair. Rape kits, keeping the patient’s clothing, Posttraumatic stress disorder (PTSD)�disturbing pattern of behavior demonstrated by someone who experienced, witnessed, or been confronted with a traumatic event such as a natural disaster, combat, or an assault.\ Adjustment disorder�reaction to a stressful event that causes problems for the person. The person has more than the expected difficulty coping with or assimilating the event into their life. Financial, relationship, and work-related stressors are most common. symptoms develop within a month, lasting no more than 6 months. Acute stress disorder occurs after a traumatic event and is characterized by reexperiencing, avoidance, and hyperarousal that occur from 3 days to 4 weeks following a trauma. It can be a precursor to PTSD. Cognitive–behavioral therapy (CBT) involving exposure and anxiety management can help prevent the progression to PTSD Repression Reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) occur before the age of 5 in response to trauma of child abuse or neglect, called grossly pathogenic care. The child shows disturbed inappropriate social relatedness in most situations. Rather than seeking comfort from a select group of caregivers to whom the child is emotionally attached, the child with RAD exhibits minimal social and emotional responses to others, lacks a positive effect, and may be sad, irritable, or afraid for no apparent reason. The child with DSED exhibits unselective socialization, allowing or tolerating social interaction with caregivers and strangers alike. They lack the hesitation in approaching or talking to strangers evident in most children their age. Grossly deficient parenting and institutionalization are the two most common situations leading to this disorder Rape A crime of violence and humiliation of the victim expressed through sexual means. Rape can occur between strangers, acquaintances, married persons, and persons of the same sex. Most rapes premeditated Goal: Preserve evidence Prevent infection Preventative care for pregnancy Rape kit permission PTSD- safety It is the victim’s choice to officially report the rape as a crime. Dx: there’s usually a stressful event. IF the person is not over the even within 3 months and hasn’t coped or moved on. Tx underlying cause. - Can happen to anybody who experienced something stressful Violence on a larger scale - PTSD and depression - Can become violent - Startle easily Safety is a priority. Nurse must continually assess the pts potential for self-harm or suicide and take action. NSG interventions: discuss self-harm thoughts, help the client develop a plan for going to a safe place when having destructive thoughts or impulses. PTSD- document Are they having flashbacks? How are they coping?; Dx 6 months after the trauma Abuse-question Screen pts alone, reassure the pt is safe, what is happening is not right or their fault Addiction Motivation to change Addiction- relapse Want to motivate pt to change and let them know what their addiction is physically doing to their body - Replace bad habit with a new healthy habit Worry about it when they start reverting to behaviors—hanging out with people who drink, Alcohol withdrawalaction Heroin - history Prevent seizures, and delirium tremens—if they have a history it will happen again Anxiety- panic OCD- referral Antipsychotic-POC Aggressioncommunication tCOWS assessment very bad flu like symptoms, Antidote naloxone e Review meds we can give on the powerpoints Panic is the most severe level. Stay with the patient and reassure they are okay. Want to bring the anxiety from panic to mild-moderate level and then we can proceed with interventions. Will need to do outpatient therapy. Main use is for schizophrenia, but we can give for behavior, agitation, aggression, DISTORTED thought process (eating disorders, bipolar, etc) Limit setting; Pick up on early warning signs; Don’t threaten/intimidate, but let them know that there are limits