nursing 261 unit 1 mental health nursing fall...

Nursing 261 Fall 2007 1

Nursing 261 Unit 1Mental Health Nursing

Fall 2007

Nursing 261 Unit 1Nursing 261 Unit 1Mental Health Nursing Mental Health Nursing

Fall 2007Fall 2007Linda Linda ServidioServidio MSN, RN, BCAPN MSN, RN, BCAPN

CNE Professor, NursingCNE Professor, Nursing

Mental Health NursingWelcome to the world of mental health nursing. By this time you have been introduced to some new material and reviewed previously learned information in the Introduction To Mental Health Nursing Packet.

You’re on the Way-Rolling Out the Carpet to Welcome You~~~

How Does the Handout Help!!!

The Unit 1 handout will be a helpful guide during lecture. Reviewing the packet prior to lecture & answering the learning activities will help you assess your mastery of the content.Ask questions; be an active learner~~~ Take charge of your learning do not let it take charge of you; Participate in success workshops on campus. Complete WEBCT activities, learning packets, quizzes etc.~~~~

Lecture 1Week 1

Psychiatric AssessmentMental Status Examination

• A ppearance• S peech• M emory/Mood• T houghts• P erception• O rientationMnemonic• Always Send Mail

Through Post Office

Check Yourself

When completing the MSE of a client, which would the nurse assess? Select all that apply:Orientation (1)Mood & affect (2)Effects of medication (3)Employment status (4)Speech patterns (5)Thought content (6)

Acute IllnessHas a rapid onset Generally of symptoms and lasts only a relatively short timeExamples: Acute psychosis due to drugs, illusions, confusion due to translocation phenomena

Chronic IllnessA broad term that encompasses many different mental alterations where the person often feels little hopeExamples: schizophrenia, depression, anxiety disorders

Carpenito, 2002 Nursing Diagnoses

Making accurate nursing diagnoses takes knowledge and practice. If the nurse uses a systematic approach to nursing diagnosis validation, the accuracy will increase.

North American Nursing Diagnosis Association (NANDA)

.risk for injury.social isolation.risk for loneliness.ineffective parenting.ineffective family processes

NANDAineffective coping.risk for violence.defensive coping.ineffective denial.decisional conflict.self-care deficit.body image disturbance.self-esteem disturbance

NANDApersonal identity disturbance .self-mutilation, risk for.sleep pattern, disturbed.hopelessness.powerlessness.knowledge deficit.thought processes, disturbed

NANDA.anxiety.sensory –perceptual, disturbed .ineffective protection

.ineffective cerebral perfusion

NANDA.imbalanced nutrition .risk for aspiration.fatigueimpaired gas exchange.impaired verbal communication

Selected Nursing Interventions (NIC)American Psychiatric Nurses’ Association

Behavior management: over-activity/inattentionBehavior management: self-harm Body image enhancementCalming technique

Selected Nursing Interventions (NIC)American Psychiatric Nurses’ Association

Anxiety reductionAbuse protection Active listeningAnger control assistanceSocialization enhancementConflict mediation

NICCognitive restructuringComplex relationship buildingCoping enhancementCounselingCrisis interventionDelusion/

hallucination management

NICSubstance use treatment alcohol/drugs Substance use treatment: drug/alcohol withdrawalSuicide preventionSupport system enhancement

NICSeclusionSelf-awareness enhancementSelf-esteem enhancementSleep enhancementMutual goal settingSafety surveillance

NICNutrition managementPhysical restraintPresenceReality orientationRelaxation therapyLearning readiness enhancement

NICGrief work facilitationGuilt work facilitationHallucination managementHope instillationRole-enhancement

NICImpulse control trainingLimit setting Milieu therapyMood managementMedication managementInfection protectionAirway management

NICElopement precautionsEnvironmental management: violence prevention/protectionFamily therapyForgiveness facilitation

Defense Mechanisms: A Review

All Defense Mechanisms share three common properties :

They can operate unconsciously. They can distort, transform, or falsify

reality is some way.The changing of perceived reality allows for a lessening of anxiety, reducing the psychological tension felt by an individual.

Anna Freud

Ego Defense Mechanisms A Review

The ego is trapped between numerous anxieties which threaten its stability at any given moment, it utilizes defense mechanisms to overcome the sense of dread and get on with lifeRationalizationProjection

Defense Mechanisms

DisplacementRepressionDenialUndoingDepersonalizationDissociation

Check Yourself????

A client is diagnosed with cancer but does not talk about or acknowledge the diagnosis. Which defense mechanism is the client using?1. Denial2. Undoing3. Projection4. Rationalization

Check Yourself

A client who has been sexually assaulted states “ I felt like I was outside my body” while it as happening? Which defense is being displayed?1. Depersonalization2. Rationalization3. Suppression4. Reaction formation

Check Yourself????

A client had a fight with his wife and the next afternoon comes home with flowers and reservations for the dinner. Which defense mechanism is the client displaying?1.Regression2.Denial3.Identification4.Undoing

Check Yourself????A client relates angrily that his family thinks he is selfish and that is why he cannot get ahead in life. Which defense mechanism is the client using?1. Denial2. Rationalization3. Undoing4. Regression

Check Yourself

What behavior is the nurse likely to see when a client demonstrates dissociation as a defense mechanism? 1. Ambivalence2. Loneliness3. Forgetfulness4. Grandiosity

Check Yourself????

A client is angry at the physician and “tells the nurse this is the worst care ever received; this is an example of which defense mechanism?1.Blocking2.Denial3.Displacement4.Undoing

Check Yourself????

A client who attempted suicide following a long history of abuse remarked to the nurse why is everyone so concerned, what happened , Which defense mechanism is the client displaying?1.Repression.2.Substitution.3.Reaction formation.4.Compensation.

Check Yourself

A young man who is extremely aggressive accuses others in the office of verbally abusing colleagues. Which defense mechanism is the client displaying?1. Reaction formation2. Projection3. Depersonalization4. Rationalization

Now Comes Anxiety

Anxiety-Could You Be Specific:

Anxiety can occur under many guises that are not readily recognized by the nurse or practicing clinician. Clients may experience anxiety as the result of a specific medical condition (e.g., thyroid disease,), changes in employment, lifestyle, or trauma (Post Traumatic Stress Disorder etc).

Anxiety, The Stress Response & Illness

Acute Stress

Acute stress constitutes the reaction to an immediate threat, commonly called the “fight or flight.”

Chronic StressChronic Stress occurs when the situation is ongoing or continuous, such as chronic illness of a family member or job related/family responsibilities.

Things are Good~~~

When the perception of the stressful situation is changed, the stimulation to the autonomic nervous system decreased.

The Anatomy of Anxiety

These disorders encompass mind-body interactions in which the brain, in ways still not well understood, sends various signals that heighten the patient’s awareness, indicating a serious problem in the body.

Nursing 161F ear is a response to external stimuliA nxiety is a response to internal conflict Remember: FreudP anic is an extreme level of anxiety/interferes with functioning

Plain Talk about Anxiety Disorders-Myth Busters

Myth: All anxiety disorders cause psychological symptoms, but only panic attacks cause physiologic symptoms.

Panic Attack

Panic attacks occur suddenly with no warning. The attack usually lasts about 10-15 minutes. They are time limited.During the attack the person feels like they are smothering, dying, and have an urgent need for assistance, chest pain, suffocation, nausea…….

NORMAL VS. ABNORMALAnxiety may become pathological when:

No real threat exists, or threat has passedIt is likely to be an internal conflictIt is of greater-than-expected intensityIt prevents fulfillment of rolesIt interferes with daily/social activitiesIt affects overall quality of lifeDefense mechanisms overused

Panic DisorderRecurrent frequent panic attacksPersistent thoughts of another attackWorry about the implication of the attackAvoidance behaviorPanic attacks are not better accounted for by another mental disorder or physical disorder

ContinuedReality: Both physiologic (repression) and psychological symptoms accompany all levels of anxiety, from mild to severe.

Post traumatic Stress DisorderStill Anxiety

Defense Mechanisms:RepressionDisplacement

So What Is It Then???An anxiety response to any extreme stressor resulting from witnessing a serious traumatic event: combat, murder, torture, natural disasters, sexual assault, battering, imprisonment .

Chronic Symptoms 3 months or longer

Recurrent, intrusive, distressing memoriesNightmares/Flashbacks/IrritabilityIntense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic eventFeelings of detachment or estrangement from others

Symptoms (continued)

Sense of a shortened future (does not expect to have a career, marriage, children, nor a normal life span)Feeling of detachment or estrangement from othersExaggerated startle responseOutbursts of anger

Symptoms

HypervigilanceExaggerated startle responseAnger outbursts towards self or othersInability to recall aspects of the traumaAvoidance behaviors of activities, places, or people that arouse memories of the traumaDepersonalization

During a flashback, the person feels as though he or she is reliving the traumatic experience.

No Thanks for the Memories and the Anxieties

Although the patient may be unable to recall specific aspects of the traumatizing event, he/she may experience it in flashbacks, dreams, or thoughts when cues to the event occur.

Nursing Interventions

Immediate

Serenity Now

Immediate Care So What do Nurses Do??

Promote safety & comfort

Safe environmentSleep enhancement

Explain the importance of adequate sleep-Facilitate sleep-wake cycles

Regulate environmental stimuliKeep a client away from crowds, bright light, & noise.Monitor participation in fatigue-producing activities during wakefulness (pacing, crying)

Inform before touching until (startle reflex)

Assess physical status; food, hygiene, sleep(comfort measures)

Safety Surveillance/Security EnhancementProtect from ridiculeBe aware of tone, tempo, volume, pitch & inflection of the voiceCalm, reassuring voice

PresenceRemain with the client during the acute reaction/panic attack/ or post-trauma responseDisplay interest.Avoid insincere expressions of reassuranceOffer to contact support systems

Anxiety ReductionHelp the client to focus on relaxation techniques.Remind the client that the attacks are time limited.

Survivor GuiltGuilt is believed to serve three keyfunctions:

Effecting self-punishment Preventing the event from becoming meaningless Shattering self and competence Donna Marzo, Psy.D.

Nursing Interventions-Serenity Now!!!

Guilt Work FacilitationHelp the client recognize that guilt is a universal reaction to catastrophic events “Others that have had similar experiences have shared similar reaction's.”

Delving into GuiltGuilt interferes with healing…cannot see self progression or PTSD as a survivor!Families and significant others interfere with healing as they cast doubt on events such as rape or battering~~~

Grief Work Facilitation

Support progression through grievingCommunicate acceptance of discussing lossAssist to develop personal coping strategiesAssist in identifying modifications needed in lifestyle

Communicating with the Grieving Client

Client: “It has been so hard since I have been back from the war, you know I lost my brother; he was my best friend. We did everything together.”Nurse: "Tell me what a typical day has been like for you since returning home and the death of your brother.”Nurse: “I hear what you are saying; I know they cannot substitute for him but, who are your other friends?”

Check yourself~~~~~``A client whose significant other recently died shows signs of grief resolution when he or she:A. Relates that things could have been different with time.......!B. Discusses positive and negative aspects of the relationship.C. Makes excuses for deficiencies in the relationship.D. Expresses anger toward the deceased

Check Yourself~~~~~~~~Which is a correct statement when attempting to distinguish normal grief from clinical depression?A. In clinical depression, lack of interest in life is prevalent.B. In normal grieving, the person has generalized feelings of guilt.C. The person who is clinically depressed relates feelings to a specific loss.D. In normal grieving, there is a persistent state of sadness.

Forgiveness FacilitationIdentify beliefs that may hinder/help in “letting go” of an issueIdentify source of the distressExplore forgiveness as a processUse empathy

Communication enhancement/Active ListeningRecognize the client’s needs, & facilitate expression of feelings. Ex. Tell me more… I am interested in hearing about….

Self Esteem EnhancementIncrease personal judgment & worth

(value what the person thinks, feels), “How do you feel about what is happening now.”

Identify (if possible) what happened before the panic attack when the client is able to focus to make connections between, people, places and things~~~Monitor frequency of self-negating verbalizations ex. John; this might have been the best you could do under the circumstances…

Nursing Interventions?

Assist the client to see themselves as a survivor (PTSD)Remain non-judgmentalGive positive feedback for expressing feelings regardless of what the feelings are at this time. Positive behavior that is reinforced tends to be repeated.Encourage new challenges-empowerment

Substance use Awareness/preventionDetermine substances UsedDiscuss effects of substance use on identified concerns; family relationships, depression, anxiety, sleep disturbances

Counseling/Coping EnhancementRecognize how behavior effects others. Identify any differences between the client’s point of view & what happened (PTSD).Do not debate someone else's experience. If they say_____ happened, do not argue with their statement.

Provide factual information concerning diagnosis, treatment, and prognosisFoster constructive outlets for angerEncourage the client to identify a realistic description of change in role and relationships

Note: Your client may feel better if he/she understands the their survival may have been due to chance alone.Support Group/Role EnhancementEstablish a social support: the list should include local crisis centers, hotlines, friends, and family.

Nursing InterventionsIdentify themes (hopelessness, anger, distrust)Explore-reason for self-criticism_ “John you believe that you could have stopped the sniper invasion?” “Mary you believe you could have stopped the rapist.” Cast doubt-not challenge!!!!!Foster constructive outlets for anger

Journaling

Anxiety Disorder Memory Jogger:

For treatment to be successful, all stressors linked to the onset must be identified!!!

Delving into DepersonalizationMyth: A person who experiences dissociation/depersonalization after a traumatic event can consciously control the feeling.Reality: Depersonalization/Dissociation occurs because the a traumatic event has overwhelmed the person’s ability to cope using any other method. It is beyond conscious control.

ABC’s of DepersonalizationA: Altered perception of selfB: Belief that one is observing oneself from outside the bodyC: Characteristics of the body are perceived as altered or detached-outside self

Myths Busters

Myth: With posttraumatic stress disorder, patients who frequently talk about their trauma tend to relive the traumatic experience.Reality: Talking about the trauma with a mental health professional can help the patient acknowledge the traumatic event, learn coping strategies, and obtain support during the recovery process.

Practice to PassA client being admitted to a medical-surgical unit asks why many of the assessment questions are related to anxiety? How should you respond to the client’s concern?An anxious client verbalizes some interest in attending a support group. What specific action should you take to refer this client to the group?

Communicating: Anxious Client

Client; Glancing away, crossing and uncrossing legs. “I’m sorry that I seem so anxious. I don’t know what I’m to say…”Nurse: I’ll just sit with you until group begins. I want to listen to whatever you would like to say, or we can just sit here quietly.”Nurse: “It is often difficult to know where to begin. Perhaps you could tell me a little about yourself.”

PracticeWhich is the best intervention for a client experiencing a panic level of anxiety?

a. Leave the client alone in a quiet roomb. Increase environmental stimulic. Presence.d. Ask questions to determine the precipitating factor.

PracticeWhen assessing an apparently anxious client, questions about anxiety should be:

a. Abstract and non-threatening.b. Avoided until anxiety disappears.c. Avoided until the client brings up the subject.d. Specific and direct

Mind Jogger

What type of life situations might trigger a panic attack?What impact do anxiety disorders have on a person’s life style?Persons with PTSD may experience a

general lack of trust in others (T/F)

Check Yourself

When working with a person who is anxious, what is the priority overall outcome of nursing interventions?1. Set limits on anxiety.2. Increase the person’s awareness.3. Protect the person from anxiety.4. Engage them in psychotherapy.

Check YourselfYour client whose army reserve unit was called to fight in Desert Storm witnessed his best friend dying from a wound during an implosion. John says to you, “I can’t figure out why God took my friend instead of me.” From this statement, the nurse anticipates that John has:A. Repressed angerB Survivor guiltC. Intrusive thoughtsD. Spiritual distress.

Check yourselfThe best outcome for a client learning about relaxation techniques is that the client will:A. Confront the source of anxiety directly.B Experience anxiety without feeling overwhelmed.C Reports no anxietyD. Suppresses feelings.

Check Yourself

A client reports having no memory of escaping from a building destroyed in an explosion. The nurse evaluates this client is using which defense mechanism?_____??????????

Anxiety

Hint: Common physiological responses to anxiety include increased heart rate and blood pressure; rapid shallow respirations; dry mouth, tight feeling in the throat; tremors, muscle tension; anorexia; urinary frequency, a palmer sweating.

Hint-Anxiety

Hint: Anxiety is very contagious & is easily transferred from client to nurse AND nurse to client. FIRST, the nurse must assess his/her own level of anxiety & remain calm. A calm nurse assists the client to regain control & increase feelings of security.

Hint: Post-traumatic stress disorder

Assess suicide risk.Assist the client to develop objectivity about the event and problem solving regarding possible means of controlling anxiety related to the events.Encourage group therapy with other clients who have experienced the same or related traumatic events.

Agree or Disagree

Antianxietymedications are not a cure for anxiety, but a temporary means to reduce anxiety.

Pharmacological ManagementAnxiolytics-)Anti-anxiety agents)Benzodiazepines-Non-Benzodiazepines(Mental Health

Nursing Text-WEBCT & video in class)

General Outcomes

Reduce anxietyEnhance copingMaintain role performanceFocus on problem-identificationDemonstrate healthy ways of dealing with stressInterpret & respond to messages objectively

Personality Disorders

Odd-EccentricDramatic-ErraticAnxious-Fearful

Personality

The totality of a person’s unique biopsychosocial characteristics that consistently influences inner experience and behavior across the lifespan.

DefinitionPersonality disorders: a disorder characterized by personality patterns that are inflexible, enduring, pervasive, maladaptive and cause significant functional impairment or subjective distress.

DefinitionBe prepared for defensiveness. Clients suffering from a personality disorder are not likely to recognize it in themselves.

Personality Changes & Physical Illness

Note: Be aware that a personality change may be the first sign of a serious neurological, endocrine, or other medical illness-which may be reversible if detected early.

General Diagnostic Criteria DSM-IV-TR

Personality disorders manifest symptoms in two or more of the following areas:Cognition: way of perceiving & interpreting.Affect: the range, intensity, & appropriateness of emotionality. Interpersonal functioning.Behavior: patterns of day-to-day behavior and impulse control.

General Diagnostic criteria (continued)

The enduring pattern is inflexible and pervasive across a broad range of personal and social situationsThe enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioningThe pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood

General Diagnostic Criteria (continued)

The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorderThe enduring pattern is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. head trauma)

So What Do Personality Disorders have in common??????

1. A deeply ingrained, inflexible, maladaptive trait. (the definition)

2. Extreme difficulty in adjusting to social and occupational relationships; the capacity to annoy others

So What Do Personality Disorders have in common??????

3. Exclusive use of rigid and dysfunctional social behaviors that are consistent throughout life.

4. Varied Affective Responses (dramatic, erratic, impulsive)

5. Lack of awareness that others view their life as troublesome

MythsMyth: If someone with a personality disorder seems healthy, that means he/she is capable of changing behavior.Reality: With a personality disorder, personality traits are fixed and not easy to change.

Antisocial Personality Disorder

Myth: Most people with an antisocial personality disorder are powerful and are always “out for me, me, me!!Reality: They see themselves as victims & seek revenge. No responsibility for actions.

Antisocial Assessment

A Abuses substancesN No satisfying interpersonal T Tends to manipulate othersI Irresponsible & exploitativeS Social norms are disregardedO Obnoxious toward others

Antisocial Memory Jogger

C Cold & callousI Intimidates others/ImpulsiveA ArgumentativeL Legal problems

Borderline-Unstable, Unhappy

Practice to Pass

A client with a borderline personality tends to label people as all good or bad. What is this an example of?

Borderline Personality Disorder

Mothering a baby is appropriate. But mothering a client with a borderline personality disorder does more harm than good.

Borderline Personality Disorder

Intense/unstable relationshipsImpulsiveUnpredictableUnstable self-imageManipulativeSelf-mutilationSplitting

Think??????

What happens if a borderline is not the center of attention~~~~~

Self mutilation

Remember: Movie Fatal AttractionNot meant to be lethal-But Could Tend to become involved in self-

destructive relationships that are a no-win, unstable & very

INTENSE~~~

Communicating with a Self-mutilating Client

Client: “It gets to the point that I feel numb inside and cutting makes me feel alive. I hate crying so now the blood has become my tears.”Nurse: Can you tell me more about how that helps you? ”I am having difficulty understanding.Nurse: “Can you tell me what other ways besides cutting you tried to deal with the “numbness?.”

Nursing Interventions Cluster B

• Be patient as clients display emotional & erratic behavior-non judgmental.

• Limit setting to avoid power struggles and manipulation

state the behavioral limitidentify the consequenceidentify the desired behavior

Nursing Interventions Cluster B

• Safety is always the first priority of care-protect from self-mutilation & accidental suicide from impulsivity

delaying gratificationdecatastrophizing

Therapy, individual & familyFrequent staff conferences to support plan of care

Practice to Pass

What are the basic principles supporting the intervention of limit setting?Why is it important withdraw your attention as much as possible if the client acts out while still attending to safety needs?

Communicating with the Manipulative Client

Client: “You better give that meal to me right now if you know what’s good for you.”Nurse: “ I hear that you want to eat right now; however, there are more adaptive ways to communicate your need/s………

Practice to Pass

Why is impulse-control training crucial to the effective nursing management of some individuals diagnosed with a personality disorder?In what way could self-mutilation be described as a manipulative behavior?

Critical Thinking Question

A 22-year-old woman is admitted to the unit with major depression and borderline personality disorder. She mutilates herself, and she is anorexic. What are the nurse’s priorities?

Critical Thinking!!!!

The nurse should monitor a client admitted with a borderline personality disorder for what self-destructive behavior______?

General Outcomes

Refrain from self-inflicted injury, impulsive behaviors-toward-self & othersRestrain from assault, combative, destructive &/or manipulative behaviors toward othersAdapt & trust in non-family caregivers

Personality disorders

Hint: Personality disorders are long-standing behavioral traits that are maladaptive responses to anxiety and cause difficulty in relating and working with other individuals. NCLEX-RN questions often test personality disorder content by describing management situations.

Personality disorders

Hint: Individuals with a personality disorder are usually comfortable with their disorder & believe that they are right & the world is wrong.These individuals usually have any very little motivation to change. Think of them as a CHALLENGE!

Lecture 2Week 2

Terminology

Anger: Normal emotional response to the perception of frustrationRestraint: Physical/chemical /mechanical control of a client to prevent injury to self or othersSeclusion: Process of placing a client alone in a specially designed room for protection and close observation.Catharsis: Activities that are supposed to provide a release for strong feelings such a anger, rage etc.

TerminologyActing OutAn immature defense mechanism in which the person deals with emotional conflict or stress by actions rather than reflection or feelings; the person is trying to feel less powerless or helpless by acting out.Hostility: Also called verbal aggression, is an emotion, expressed through verbal abuse, lack of cooperation, violation of rules or normsImpulse control: The ability to delay gratification and to think about one’s behavior

AssessmentUnit milieuHistory of violenceHow does the client handle angerPsychosis/Substance AbuseHow does the client handle disappointment

Five phase Aggression Cycle

TriggeringAn event or circumstance in the environment initiates the client’s response, which is often anger or hostility.Symptoms: restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, anger

Escalation

Client’s responses represent escalating behaviors that indicate movement toward a loss of controlPale or flushed face, yelling, swearing, agitated, threatening, demanding clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly

Crisis

During a period of emotional and physical crisis, the client loses control.Loss of emotional and physical control, throwing, objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, inability to communicate clearly

Recovery

Client regains physical and emotional controlLowering of voice; decreased muscle tension, clearer more rational communication; physical relaxation

Postcrisis

Client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedentsRemorse: apologies; crying: quiet, withdrawn behavior

Nursing InterventionsTriggering phase

Calming technique/Anxiety ReductionVerbal Interventions (discover

source of distress): Talk to clientTake an attitude of caring/non-

threatening Active listening

Quiet areaPRN medications or as needed

Nursing InterventionsEscalation Phase

Limit Setting: establishing parameters of desirable & acceptable client behavior refrain from arguing or bargaining

.communicate established expectationsConflict Mediation

.provide private neutral area. Offer guidance as parties voice concerns

Nursing Interventions (cont)

Environmental Management: Violence protection/prevention

Take a position outside the client’s personal space but keep in visual space

Make sure the door of a room is readily accessible-if in a closed area

Seclusion/restraint (obtain adequate staff) to prevent injury to self/othersPharmacological management-rapid sedation

Communicating with the Angry Client

• Client: “There is now way you people are going to treat me like that ! Who do you think you are?

• Nurse: “Tell me what is going on.• Nurse: “How can I help you?””

Seclusion

• To give the client the opportunity to regain physical and emotional self-control

• Short-term use of restraint or seclusion is permitted only when the client is imminently aggressive and dangerous to himself or herself or to others.

Criteria for removal of restraints or Seclusion

• As soon as possible, staff members must inform the client of the behavioral criteria that will be used to determine whether to decrease or to end the use of restraint or seclusion

• Criteria may include the client’s ability to verbalize feelings and concerns rationally

Criteria for removal of restraints or Seclusion

• To have decreased muscle tension• To demonstrate self control• To make no verbal threats• Special Note: Remember to offer

support to clients family, who may be angry or embarrassed when the client is restrained or secluded.

Pharmacology-AgitationAtypical antipsychotics such as clozapine(Clozaril), risperidone(Risperdal), and olanzapine (Zyprexa)

PharmacologyHaloperidol (Haldol) and lorazepam for clients with psychoses Ziprasidone(Geodon)Benzodiazepines for agitation

Anger Control AssistanceClients learn ways to identify & monitor their own anger cuesActive listening.

Talk it out rather then act it out.

Practice to PassWhy is it important to assess a client in restraints frequently?

Critical Thinking QuestionsWhy is it important for other clients to share their opinions & reactions to the seclusion & restraint of another client?What are some contradictions to seclusion /restraint?How many staff members are needed legally when placing an acting out client in restraints or seclusion? Check Textbook~~~~~ pg 198 (2nd ed) 184 (3rd ed) Why?

Practice to Pass

A client is pacing in the hallway with clenched fists and a flushed face. He is yelling and swearing. Which phase of the aggression cycle is he in.

A. AngerB. Triggering.C. Escalation.D. Crisis.

Practice to PassWhen planning the care of clients experiencing aggression the nurse incorporates the principle of "least restrictive alternative," meaning that less restrictive interventions must be tried before more restrictive measures are employed. Which would the nurse consider to be the most restrictive?a. Tension reduction strategies.b. Haloperidol (Haldol) given orally.c. Voluntary quiet room or "time-out." d. Haloperidol (Haldol) given intramuscularly.

Critical Elements

Anger is a normal human emotion that may be expressed assertively, passively, and or aggressively (physical acting out).Tension reduction, medications, seclusion, or restraints become necessary interventions for aggressive clients in crisis.

Critical Elements

Verbal and physical aggression especially assault and battery, require safe, immediate interventions based on the principle of the least restrictive alternative.The best predicator of future violence

is a history of violent behavior.

General Outcomes

Developed personal judgment of self-worthRestrain from assault, combative, or destructive behavior towards others

General Outcomes

Comply with treatment team recommendationsDescribe his or her feelings & concerns without aggressionContract for safetyRefrain from behaviors that are intimidating or frightening to others

Schizophrenia:

Schizophrenia is considered the most common and disabling of the psychotic disorders. Although it is a psychiatric disorder, it stems from a physiological malfunctioning of the brain. This disorder affects all races, and is more prevalent in men than in women.

Onset of Schizophrenia:

The onset of schizophrenia may occur late in adolescence or early in adulthood, usually before the age of 30. Although the disorder has been diagnosed in children, approximately 75% of persons diagnosed as having schizophrenia develop the clinical symptoms between the ages of 16 and 25.

Schizophrenia

The burden of psychiatric conditions has been heavily underestimated. Disability caused by active psychosis in schizophrenia produces disability equal to quadriplegia.

- National Institutes of Mental Health, 2003

Schizophrenia/Chronic Mental Illness

• Schizophrenia is one of a cluster of related psychotic brain disorders of multiple-etiologies.

• Schizophrenia is a combination of disordered thinking, perceptual disturbances, behavioral abnormalities, affective disruptions, and impaired social competency.

Subtypes of Schizophrenia

• Paranoid-Persecutory delusions

• Catatonic-Inappropriate body postures (waxy flexibility), withdrawal, mute

Assessment

MotorBehaviorSpeechGeneral appearanceThought process and content

HallucinationsDelusions

RelationshipsSelf-conceptPhysiologic and Self-care considerationsSleep patternsSensoriumJudgment

Two major dimensions of psychopathology

• Researcher ( Andreasen, 2000) outlined two comprehensive dimensions of psychopathology in schizophrenia:

1.The disorganization dimension2. The psychotic dimension

Disorganization Dimensionloose associationsneologisms poverty of thought

Disorganized BehaviorPsychomotor retardationBizarre posturingWaxy flexibility

Disorganized Behavior (cont) Affect

Inappropriate-smile or giggle for out of context Reduced emotional expression: flat or blunted

Psychotic Dimension

Delusions: persecutory, grandiose, somatic (body), religiousHallucinations: auditory, visual, tactile, olfactory, gustatory

Hallucination

• The voices are telling me that I am the devil and should die because I am bad

• The people are laughing at me because I did not complete my plan

• Note: Perceptual impressions without external stimuli

HallucinationsAuditory: hearing sounds, voicesVisual: involve seeing images that do not exist at all such as lights, dead people, frightening pictures

Hallucinations

Olfactory: involve smell or odors.

Noted more in neurological disorders

HallucinationsTactile: refer to sensations such as electricity running through the body or bugs crawling on the skin. Noted more in withdrawal syndrome.Gustatory: involves a taste lingering in the mouth

Delusion

The FBI sent me to help the countryWhen I speak everyone should be silentElectricity is placing thoughts in headNote: False, Fixed Belief…

Delusion of Grandeur

Examples of Psychotic Dimension

1.____ Persecution

2.____ Grandiosity

3.____ Thought broadcasting

4._____Thought insertion

A. “The radio is electronically placing thoughts in my head.”

B. You can hear what is going on in my mind

C. I hold secrets so my neighborhood wants me dead

D. Within one month I will be president.

Nursing interventions

Communication enhancement:Communicate with the client

using clear, direct statements. Avoid abstract comments & metaphors such as it is 10 p.m. it is time to “hit the hay.”

Give the client time to respond.Ask the question the 2nd time

the same way to avoid confusion

Nursing interventionsEnvironmental Management/Behavior

ManagementProvide an environment with a low

degree of stimulation & safe for clients and others.Communicate risk to other care providersAnticipate trigger situations visitors, noise, other clients

Nursing InterventionsSelf-Care AssistanceDetermine individual need for assistance; teach is short segments.Provide cognitive enhancing techniques (up-to date calendars, clear directions, pictures if needed)Assist with ADL’s/Nutrition as needed during acute phase, later facilitate care to empower the client

Nursing interventions

Delusion/Hallucination ManagementProvide reality testing & focus on

reality.If the client is experiencing a

hallucinations/delusions, provide a room with adequate lighting & minimal stimuli

Nursing Interventions(cont)

maintain consistent routine

assign consistent caregiver

monitor for medication side effects

Nursing interventions (cont)

Express to the client that you understand that the or she believes the delusions or hallucination but you do not share the delusional belief or hallucination.

Collaborate with the multidisciplinary team.

Support system enhancement:Educate the family/significant

other regarding the chronic nature of the illness. Self-Responsibility Facilitation

Determine whether client has adequate skills prior to making client responsible

Encourage the client to participate in unit activities in a gradual manner (1:1, 1: 2 then others.)

Violence preventionMinimize stressful interactions.

Assess & treat substance abuse.Avoid ridicule which can escalate to

violence

Initially; assess theme of hallucination/delusion, eventually if not responsive to treatments distract to an activity in reality

Don’t touch the client without informing-this could be perceived as threatening; however Remember: they do need care~~

Psychopharmacology (Mental Health Nursing text & supplemental packet)) anti-psychotic medications and Adjunctive Medications-WEBCT-Quiz & Matching

Communicating-Ideas of Reference/Suspicion

Client: “What did you mean by that remark? People are always making fun of me.”Nurse: “That remark was not meant for you. It was directed toward everyone in the group.”

Check Yourself

The nurse needs to do ongoing assessment when a client is on haloperidol (Haldol) due to which significant side effects? Select All that apply:1.Diarrhea2.Constipation3.Orthostatic hypotension4.Decreased appetite5.Elevated blood pressure6.Urinary retention

Practice to Pass~~ Alternate Format Question?

The nurse caring for a client diagnosed with schizophrenia administers what classification of drugs to treat hallucinations_________?

Memory Jogger

To remember the major needs of schizophrenic clients, think SDS:S tructure-because they tend to have too little in their livesD iversion-to distract them from troubling thoughtsS tress reduction-to minimize the severity of the disorder

Outcomes

Meet developmental tasksReceive, interpret & express messages appropriatelyUse coping strategies in a functional adaptive mannerEat adequate amounts of different food groups

Outcomes

Achieve control over distorted thoughtsMaintain social supportsPromote personal safetyComply with prescribed facility & treatment regimens

Practice

What are considered nursing priorities when a client is experiencing psychosis?Schizophrenia is generally considered a chronic condition, which needs long-term management. What are some nursing interventions that may decrease relapse potential?

Critical thinking QuestionsWhy do you think the rate of substance abuse is so high among individuals with schizophrenia?A client is admitted agitated, talking to himself and frightened by those around him. He screams “they are out to kill me! Don’t let them kill me.” This symptom is:___regression ___neologism___ delusion

Questions

A schizophrenic patient who has been taking a typical antipsychotic for 5 years is exhibiting involuntary movements of the tongue and mouth. The nurse interpret these findings as: a. Dystoniab. Tardive dyskinesiac. Akathisiad. Parkinsonism

Practice to Pass

A client diagnosed with schizophrenia is thought to be having hallucinations. The most common type of hallucination involves which of the following senses?

a. Auditory.b. Olfactory.b. Tactile.d. Visual.

Critical Thinking Questions

As you begin your shift s the charge nurse in an acute care psychiatric unit, you are informed in shift change report of a new client admission. The client has a psychiatric diagnosis of schizophrenia, paranoid type. What types of symptoms might you anticipate?

Critical Thinking Questions

What are the priorities of care?

Critical Thinking Questions (cont)

Why is it important initially to seek information from the client (if possible) regarding the content of the delusions/hallucinations?

Yourself

• Perceptual perception without external stimuli is_______________!!!!!!!!

• When assessing a client with schizophrenia which findings would the nurse most likely note:A. Inappropriate affectB. DelusionsC. Bizarre behaviorD. Panic attacks

Practice to PassA client is sitting in the corner of the dayroom tilting his head to one side as if he is hearing something, but no one is nearby. The nurse suspects an auditory hallucinations. Which would the nurse ask first?a. "Are you seeing someone near you other than me?“b. "What are you hearing right now.“c. "What is going on with you right nowd. "Do you want to go to the recreation room?"

Hint: Observe for increased motor activity and/or erratic response to staff and other clients. The client may be experiencing an increase in command hallucinations. When this occurs, there is an increased potential for aggressive behavior. Think-Medication!Hint: When evaluating client behaviors, consider the medications the client is receiving. Exhibited behaviors may be manifestations of schizophrenia or a medication reaction.

Schizophrenia/Psychosis

Hint’s continuedHint: Do not argue with a client about delusions or hallucinations. Logic does not work; it only increases the client’s anxiety. Be matter-of-fact and divert delusional thoughts to reality.

Just the Facts:

The most common delusional themes in the person with schizophrenia tend to be related to themes of persecution, religious ideas, or body references.

Hints (continued)

Trust is the basis for all interactions with these clients. Be supportive and non-judgmental. Stress increases anxiety thus increases delusional behavior. Homeless people without shelter or housing have a sense of isolation & rejection & possibly multiple medical needs.

Lecture 3Week 3

Mood Disorders/Affective DisordersMania & Depression

Mood Disorder Statistics:By the year 2020, mood disorders are

estimated to be the second most important cause of disability worldwide. (World Health Organization 2004)

Depression/ Manic Assessment

Sleep disturbancesInterestEnergyConcentration/distractibilityAppetitePsychomotor functionSuicidal Ideation

Practice AssessmentDepression/ Mania/Both

Finds self sleeping all the time ____Does not want to take time to eat ____Feels really “great.” ____ Jumps from topic to topic ____Catastrophizing ____Lack of interest in life ____Thinks of self as powerful ____

Assessment (continued)

Pressured speech _____Flamboyant dress _____Difficulty thinking & focusing _____Unintentional weight change _____Recurrent thoughts of death _____Feels overwhelmed in life _____Fells unworthy of care _____

PracticeA client exhibiting euphoria, hyperactivity, & distractibility is unable to remain seated at mealtimes long enough to eat an adequate of food. Which food would the nurse expect to include in the client's plan of care?

a. Cheeseburger & apple.b. Steak & baked potatoc. Beef stew and diet soda.d. Hot dog, & carrots

Practice to Pass

A client with depression is being moved from one room to another. As the nurse you would ensure that you:

a. Check all belongings during the room change.b. Send another client to help for socialization.c. Allow the freedom to move from room to

room without supervision. d. Have the family work with the client on

gathering personal items.

Safety: Crisis ManagementBehavioral management: underactivity/overactivity

limit setting-sleep & rest are needed-impulse control-self-restraint-personalization: tendency to self-reference

external events without basis

Nursing Interventions (continued)

Behavioral: Communication Enhancement-active listening (listen, clarify, one topic or

question) Environmental Management: comfortCreate an environment that fosters privacyInitiate screening for environmental hazards

Communicating with the Depressed Client

Client: Looking down at her hands in her lap, shoulders slumped, “I have been very sad since Christmas time.” (It is now February)Nurse: “ It sounds like it has been difficult for you to have these feelings such a long time…..

Nursing Interventions (continued)-decrease environmental stimuli-identify the theme of the conversation in

an attempt to communicate (this is difficult with flight of ideas)-validate, clarify, re-state, focus, “I know that your thoughts are coming fast, let’s go back to…”

Socialization enhancement:-communicate understanding with intent to

help (begin with solitary activities, then 1: 1, 1:2 ; schedule non-intellectual activities such as leatherwork, sanding, help on the unit, walking, drawing: avoid competitive games)

-facilitate the response-reward the effort-communicate with the client to decrease

loneliness-short frequent visits

Behavioral: Coping Enhancement-Problem-solving

Nutrition management: Reestablish eating patterns:small frequent feedingshand held foods

Guilt Work Facilitation-Respond to persistent irrational beliefs

and catastrophizing with realistic, non-challenging evidence: What could you have done differently? Mary, you believe that everything that happens in your family was caused by you? Jim, What is the worst that can happen if you try………….or do?????

Nursing Interventions (cont)Self-Esteem Enhancement-Review past joys and successesConvey your confidence in client’s abilitiesLong term treatmentMedicationsCounselingSupport

Mood Management• early warning signs of

depression/suicide• education is part of responsibility for

wellness

Therapies

Electroconvulsive therapyModifies the chemical milieu, or

environment, of the neurotransmitters believed to contribute to depression Preparation similar to minor proceduresCheck for history & physicalInformed consent

Nursing Responsibilities for ECT

No food or drink the morning of treatmentVoids before procedureRemoves dentures, loose clothing

Nursing Responsibilities for ECT

Vital signsPosition on side after the procedureUsually 3 treatments 3 time a week for six-weeksConfusion is of concern to client. This may persist for weeks or months. Reassure client & family that memory will return

TherapiesPharmacological Management: Antidepressants, Mood-Stabilizers (AntimanicMedications), Anticonvulsants in Psychiatry (Mental Health Nursing text & supplemental packet-WEBCT)

Check YourselfA nurse is caring for a client with a major depressive disorder who is undergoing electroconvulsive treatments. While planning the post procedure care, the priority nursing interventions is_______.The nurse is preparing a client for electroconvulsive therapy. What is a priority for the nurse to assess from the client’smedical record (consent is there)_____?

Check yourself~~~~Which should the nurse include in the plan of care for a client taking an antidepressant pharmacological agent?1. Encourage the client to drink low-calorie beverages.2. Instruct the client to take the drug on an empty stomach.3. Inform the client that urinary frequency is an adverse reactions.4. Monitor the client for bradycardia prior to administration.

Check Yourself~~~

Anticonvulsants are prescribed for your client with not history of seizures. The nurse concludes that the client is taking the anticonvulsant drug to treat?1. Major depression2. Bipolar disorder3. Anxiety disorder4. Delirium.

Practice to Pass

Which interventions used to treat depression has been supported by research findings to improve overall health??A. Exercise.B. Support groups.C. Music therapy.D. Medications.

Practice to Pass

A nurse education a client about possible signs of lithium carbonate (Eskalith) toxicity should instruct the client to report which adverse reactions? Select all that apply?1. Weight gain.2. Vomiting3. Diarrhea4. Fine tremor5. Abdominal pain

Practice to PassA client states, “ I can’t believe my mother gave me her depression!” Is this statement accurate, and what is your best response to the client?Assessment of a client with a mood disorder is often done in 15-to 20 minute segments. Discuss the rationale behind these timedsegments.

Practice to Pass

You are admitting a client to the inpatient unit. The client is in a manic state exhibiting flight of ideas, disinterest in food, irritability, and rapid mood swings. The client has been unable to sleep for the past three nights and stays awake pacing the floor.

Practice to Pass

-Identify at least 3-5 questions you will ask during your initial interview?Hint: MedicationHint: SleepHint: Food-List three main priorities of care for this client?

Memory Jogger Interventions

C onsult with staffO bserve the suicidal clientM aintain personal contactP rovide a safe environmentA ssess for clues to suicide R emove dangerous objectsE ncourage expression of feelings

Affective/Mood Disorders

Hint: Depressed clients have difficulty hearing and accepting compliments because of their lowered self-concept. Comment on signs of improvement by noting the behavior, e.g., “I noticed you combed your hair today.” Not, “You look nice today.”

Affective/Mood Disorders

Hint: The most important sign and symptom of depression is a depressed mood with a loss of interest or pleasure in life. Other symptoms include:Significant change in appetite often accompanied by a change in weight-either weight loss or gain

Affective/Mood DisordersHint

Insomnia or hypersomniaFatigue or a lack of energyFeelings of hopelessness, worthlessness, guilt, or over-responsibilityLoss of the ability to concentrate or think clearlyPreoccupation with death or suicide

The nurse knows depressed clients are improving when they begin to take an interest in their appearance or begin to perform self-care activities that were previously of little or no interest.

Manic clients can be very caustic toward authority figures. Be prepared for personal “put downs.”Avoid arguing or becoming defensive.

What activities are appropriate for a manic/depressed client? Non-competitive physical activities that require the use of large muscle groups.Where should a manic client be placed on the unit? Make every attempt to reduce stimuli in the environment. Place the client in a quiet part of the unit.

When dealing with a depressed client, the nurse should assist with personalhygiene tasks and encourage the client to initiate grooming activities even when he/she does not feel like doing so-helps promote self-esteem and a sense of control.

HintAn important nursing intervention for the depressed client is to sit quietly with the client. When answering NCLEX-RN questions, remember that you are working at Utopia general and there is plenty of time and staff to provide ideal nursing care.

HintDo not let the realities of the clinical situation deter you from choosing the best nursing intervention. The best intervention is to sit quietly with the client, offering support with your presence.

General Outcomes

Maintain interest in lifeSustain social supportComply with prescribed treatment regimensMaintain role performanceConcentrate on specific stimulusAdjust to prevailing emotional tone in response to circumstances

SuicideFinancial Problems, Pain, Hardship, Loss, Loneliness, Poor health, Relationship problems, Misunderstanding, Hopelessness, HelplessnessFear

Review at a glance

Suicidal ideation: the person is having thoughts about killing himself or herself.Ambivalence: simultaneous holding of two emotions: wanting to live and die.

Of Special Note~~~

Note: clients when lifting from depression appear happy, cheerful, and content; thus the ambivalence is over and the person is content to DIE````

SuicideSuicide is associated with disappointments or unfulfilled needs, feelings of hopelessness & helplessness ambivalence (conflicts between survival & unbearable stress, a narrowing of perceived options & a need to escape).Unable to see any other way of improving the present situation.

Shneidman 1996

SUICIDE

Suicide may be the culmination of self-destructive urges that have resulted from:

the client’s desiring to escape a perceived intolerable psychological state

or life situation. The client may be asking for help by attempting suicide, seeking attention or

attempting to manipulate someone with suicidal behavior.

• Schultz & Videbeck 2002

Review at a glanceDirect suicide: conscious , voluntary, life-ending acts (hanging, shooting, suffocation)Indirect suicide: unconscious hidden desires to die manifested in risky behavior such as walking at night in a known crime area, or not taking medication that is needed for a chronic illness

Assessment-Populations at RiskSexAgeDepressionPrevious attempts

Psychologic Commonalities of Suicide

The common purpose of suicide is to solve a program. The health care professional must assist the suicidal person to identify the life problem that needs to be solved or changed.The common goal of suicide is death.The common stimulus of suicide is intolerable physiological or psychological pain, along with the decision not to experience that pain.

Continue

The common stressor in suicide is frustrated psychological needs, such as achievement, affiliation, autonomy, harm avoidance, shame avoidance.The common emotions of suicide are helplessness, hopelessness and loneliness.

Continue

The common cognitive state is ambivalence (the wish to live or the wish to die).The common interpersonal act is the communication of intention.The common consistency in suicide is lifelong patterns of failure, stress, duress and threats to self-esteem.

Assessment-Populations at RiskLethality assessment (SAL)How fast will a person die??S specificityA valibility of meansL lethality of method

Support systemsAcute or chronic illness

Assessment-Populations at Risk

Substance abuseOther mental disorders

Nursing Alert: Never ignore any suicidal ideation, regardless of how trivial or subtle it may seem and regardless of the client’s intent or emotional status.

Nursing Priority

Nursing Alert: Be aware of special times when a client might be suicidal (e.g. when there is less staff available, or during a busy day or crisis on the unit; asking questions about rounds and staff routine~~~~

Acknowledge how difficult and painful recent losses must be (It’s sounds like it has been rough for you lately).”Supervision: One-to-one, no-suicide contract, suicide precautions.Monitor and restrict visitors as needed.Support groups.

Nursing InterventionsFocus on the healthy side (”You seem to be asking for help, I am glad you did that.)Ask for their ideas about the solutions to the current situation.NO –Belts

MatchesRazorsCords

Ask directly do you plan to hurt yourself? (Authoritative role to stay safe).Express genuine concern and a desire

to work with the caller or client in person (“I am interested in helping you, what we can do together.”)

Nursing InterventionsGive callers your complete attention.Assess lethality (plan, method, rescue).Remember SAL

General Outcomes

Identify personal health threatsRefrain from gestures and attempts at self-harmMake choices amongst alternativesEncourage social support as toleratedGenerate, test, & evaluate realistic plans to address underlying issuesCreate a list of positive attributes

Practice to Pass

Identify four client statements that might indicate a subtle message about suicidal ideation.

Practice to Pass

Suicide is a high risk among clients with dual diagnoses. Which of these dual diagnoses, when linked with suicidal intention, is considered part of a "deadly triangle" ?

a. Mania & drug abuse.b. Alcohol abuse & delirium.c. Depression & substance abuse.d. Personality disorders and drug abuse.

Practice to PassThe nursing staff of the psychiatric inpatient unit maintains a safe milieu by monitoring the clients at designated times. A client with suicidal ideations & feeling unable to contract for safety is considered as high risk .The nursing staff must be prepared to implement:a. Every 15 minutes checks.b. One-to-one observations.c. Having family stay with the client.d. Placing the client in seclusion.

Lecture 4Week 4

Substance-related Disorders/Dual diagnosis/Delirium-

The recurrent use of a drug that results in a failure to manage work, school, or home roles, or in hazardous situations such as driving a car, or legal and interpersonal problems

Check Yourself!!!!

The main nursing goal with clients diagnosed with substance abuse disorders is to:A. Establish a trusting relationship.B. Set limits on distorted thinking.C. Quickly establish parameters for self care.D. Facilitate group activities.

Chemical Abuse

Chemical dependency is a serious health

problem. For People with mental illness, chemical dependency can be

a catastrophic life problem.

Vaccaro, 1999

Chemical Abuse

According to the National Mental Health Association

39% of all people diagnosed as mentally ill abuse either alcohol or drugs

National Mental Health Association 2004

Abuse of any Substance Means Trouble

Dangers:

Dependence- need to continue taking a substance, despite serious results Abuse-drug use leading to legal, social, & medical problems

Dangers continued

Tolerance-the need for an ever-increasing dosage to achieve the same effectOverdose- an excessive use of a drug resulting in an adverse reaction which can be possibly be fatal

Dangers (cont)

Withdrawal: an uncomfortable syndrome that occurs when tissue and blood levels of the abused substance decrease in a person who has used that substance heavily over a prolonged period

Dangers (cont)Withdrawal symptoms may cause the person to resume taking the substance to relieve the symptoms, thereby contributing to repeated drug use

Dangers (cont)

Intoxication: a reversible substance-specific syndrome caused by ingestion of or exposure to that substance

Poly drug dependence

Involves the regular us of three or more substances over a period of at least 6 months.

Classification of common abused substances

• CNS depressants AlcoholOpioids

OpiumHeroinMorphine

Anxiolytics(Valium)Librium

Central Nervous Stimulants

• Amphetamines • Dextroamphetamine(Dexedrine)

• Cocaine (crack,coke, root, snow)

• Note: Crack has been labeled the most addictive drug. It is a potent form of cocaine.

Hallucinogens• Hallucinogens

• phencyclidine (PCP)

Mescaline, lysergic acid (LSD)

• Smoked with Marijuana

Cannabinoids• Cannabinoids • Cannabis (marijuana)

• Hashish (hash)

Check YourselfThe nurse documents which clinical manifestations to be anticipated in a client who is experiencing cannabis intoxication?Select all that apply1. Anorexia2. Dry mouth3. Euphoria4. Bradycardia5. Sensation of slowed time6. Drowsiness

The Maze of Assessment

Phase 1 (acute crisis)Phase 2 (sequeale of substance abusePhase 3 (rehabilitation)

Nursing Interventions-Acute Crisis

Drug intoxication/withdrawal/overdose, care focuses on:Maintaining the client’s vital functionsEnsuring safety

• physical• psychological

Acute Phase

Easing discomfortMedication administrationAnxiety reductionDelusion/hallucination/illusion management

Acute Phase

Presence/Anxiety reduction/Calming techniquesManagement of Sensory-perceptual alterationsCommunication enhancement-What is the clients perception of the events~~~

Interventions

Cooling measures-hyperthermia Gastric lavage (decreased drug absorption) Antianxiety/antipsychotic for agitationNarcan-opoid overdose-repeat dosing due to short duration of action of Narcan then the opoid.

Interventions

Environment manipulation-illusionsno dark roomwell litno shadows

Anti-hypertensive for severe hypertensive crisisFluid monitoringSeizure precaution

What Does the Person Look Like-Opoid

Intoxication: euphoria, apathy, decreased sensation of pain, impaired attention & memory, sedation, psychomotor retardation, facial flushing, bradycardia, hypotension Chronic Use: scarred veins (tracks), hepatitis B,C,D, AIDS, drug-seeking behaviors, constricted pupils,malnourishment

CNS depressants: CNS Depressant Withdrawal

Neuroexcitation occurs when CNS depressants are abruptly withdrawan; rebound norepinephrine & dopamine stimulation accounts for the withdrawal symptoms

What Does the Person Look Like

Withdrawal: 6-8 (8-12) hours, reach a peak in the 2nd or 3rd day, and disappear in 7-10 days. after the last dose. Symptoms are distressing, but medically benign, & include nausea, vomiting, muscle aches, cramping, lacrimation, rhinorrhea, sweating, fever, & insomnia, drug craving, pupillary dilation.

Check Yourself

After collecting data on a client suspected of being in opoid withdrawal, which symptoms should the nurse expect?1. Slurred speech2. Decreased blood pressure3. Psychomotor retardation4. Diarrhea5. Muscle aches6. Rhinorrhea

What Does the Person Look Like

Overdose: Medical emergency Respiratory PerilPulmonary edema, respiratory depression, aspiration pneumonia, & hypotension, bilateral crackles, unconsciousness, & death

Central Nervous Stimulants: What Happens

When CNS stimulants are abruptly withdrawn, excitatory neurotransmitters are profoundly depleted and severe dysphoria & depression occur. The “rush” or “high” experienced with these drugs probably results from high levels of dopamine in the brain areas that regulate feelings of pleasure.

CNS Stimulants Abuse

Intoxication: increased energy, euphoria, extreme vigilance, hostility, impaired judgment, hypertension, tachycardia, dilated pupils, insomnia, decreased appetite, nausea, vomiting, cardiac arrhythmias, myocardial infarction, weight loss, intracranial hemorrhage.Chronic use: cardiovascular accidents, nasal perforation (crack).

CNS Stimulant Abuse

• Withdrawal: depression, psychomotor retardation, fatigue (crashing)

• Overdose: cardiac arrhythmias, headache, convulsions, tachycardia, coma, possible death from cerebral hemorrhage or cardiac arrhythmias

Check YourselfThe nurse is caring for a client who is experiencing cocaine intoxication. Which symptoms would indicate that the client’s condition is deteriorating? Select all that apply:1. Chest pain2.Hypertension3.Restlessness4.Tachycardia5.Anxiety

Hallucinogen Abuse What Does The Person Look Like

Intoxication: intensified perceptions, including heightened response to color, textures, & sounds, dilated pupils, & tachycardia, “panic reactions” (“bad trip”) hypertension, impulsive behaviors, aggression, garbled speech.

Hallucinogen Abuse

Chronic Use: Flashbacks (transient spontaneous repetition of a previous hallucinogenic experience occurring in the absence of substance use)

Check Yourself

Which would the nurse identify as a realistic short-term goal to be accomplished in 2-3 days for a client with delirium? The clienta. Explains the experience of having the delirium.b. Regain a normal sleep-wake cycle.c. Becomes oriented to time place and person.d. Establishes normal bowel and bladder function.

Hallucinogen Abuse

Withdrawal: craving for the drug most prominent withdrawal symptomOverdose: Seizure, respiratory, depression, convulsions, death

Check YourselfThe priority nursing intervention in caring for a client experiencing flashbacks from hallucinogenic intoxication include:1. assisting the client with anxiety reduction.2. exploring relapse triggers.3. providing intrapersonal skills training.4. teaching the client the medical consequences.

Anxiolytic Abuse What Does the Person Look Like

Intoxication: slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, stupor. Chronic Use: drowsiness, lack of motivation, clouded thinking, memory loss, changes in personality, increased risks of accidents, rebound insomnia & anxiety,

Withdrawal: occur 3-4 days after the drug is stopped: last 5-7 days this is a medical emergency: seizure peril: nervousness, hypertension, delirium, nausea, vomiting, & abdominal pain, hallucinations Treatment: seizure precautions, long-acting benzodiazepines may be used in withdrawal substitution therapy

Overdose: Lethargy, coma, aspiration pneumonia, profuse diaphoresis, hypotension, abnormal pupil size and response, pulmonary edema, rhonchi, crackles

Alcohol Abuse-What Does the Person Look Like

Intoxication: Aggressiveness, impaired judgment, impaired attention, irritability, euphoria, depression, emotional lability, slurred speech, lack of coordination, unsteady gait, nystagmus, flushed face, loss of inhibitions. Overdose: Nausea, vomiting, shallow respirations; cold clammy skin; weak, rapid pulse; coma; possible death

Chronic Use:Peripheral NeuropathyWernicke”sEncephalopathy Korsakoff’spsychosis Alcoholic cardiomyopathyEsophagitis

Gastritis PancreatitisAlcohoic HepatiitsCirrhosis of Liver, Esophageal varicesHepatic encephalopathyKidney Failure

Alcohol Abuse-What does the Person Look Like

• Withdrawal: Tremors, nausea/vomiting, malaise, weakness, sweating, hypertension, anxiety, depressed mood, irritability, delirium, illusions, hallucinations, insomnia, major motor seizures, tachycardia in excess of 100 beats per minute indicating impending-Alcohol Withdrawal Delirium

Deadly Delirium-Tremens

Note: Deadly 24-72 hours after the last drink.Severe agitation, dramatic increases in pulse, respirations, & blood pressure, seizures, coma, deathOverdose: Nausea, vomiting, shallow respirations; cold, clammy skin; weak, rapid pulse; coma; possible death

Check Yourself

A client admits to opiate use. How long would the nurse expect the drug effects could last?A. 2-4 hoursB. 4-6 hoursC. 3-5 daysD. 11 to 18 days

Check Yourself~~~

The nurse should anticipate which behaviors in a client experiencing alcohol withdrawal? Select all that apply:1. Hypertension2. Tinnitus3. Pupil constriction4. Tachycardia5. Sedation6. Startles easily

Check Yourself

Which would the nurse eliminate from the diet of a client who abuses alcohol?A. Milk.B. Caffeine.C Orange Juice.D. Eggs.

Communicating with a Substance-client in Withdrawal

Client: “I feel so terrible. My muscles are twitching, I feel like “I’m going to throw up, I’m dizzy and weak, and my heart is pounding. Nurse: “I’m going to take your vital signs now. We will take care of you’re physical symptoms to keep you safe and take steps to ensure that you are more comfortable.”

Interventions for Rehabilitation Phase

• Anatbuse: disulfram inhibits complete alcohol breakdown in the body; when alcohol is taken with disulfram, acute hypersensitivity occurs

• Symptoms: include flushing, severe nausea & vomiting, dizziness, and hypotension. Acts as a psychological deterrent to prevent client form using alcohol

• Naltrexone (ReVia)• Opioid receptor antagonist; blocks brain

reward pathway reduces pleasurable response to opioid & alcohol

• Acamprosate calcium (Campral)Exact action not understood acts with

glutamate and GABA neurotransmitter systems in the CNS to restore balance between neuronal excitation and inhibitions that may be altered by chronic alcohol exposure

Goal: abstinence from alcohol

• Methadone (Dilophine): synthetic opioid; provides non-euphoric state, freedom from physiologic craving for heroin

• Self-help groups• Partial-hospitalization

• Out-patient counseling• Medical detoxification units• Long-term residential programs (3-6

months)• Community Based Education • Family support• No wrong door to treatment

Invest in resultsCommit to qualityChange attitudesBuild partnerships

Communicating –Substance-Abusing Client in RehabilitationClient: “I don’t need to spend a lot of time talking to you about this stuff. I’m not going to take coke again, and you can bet on that.”Nurse: “I hear that you have no intentions of using cocaine again, and that is good. I would like to help to make certain that you have the support available to you when you feel like you are could go back to drugs.”

Know what defense mechanisms chemically dependent clients use. Denial & rationalization & projection are thethree most common defense mechanisms used-their use must be confronted so accountability for the client’s own behavior can be developed.

3 Coping Styles that Contribute to Substance Abuse Maintenance

Rationalization:falsifying experiences by contrived, socially acceptable, and logical explanations: Example: “Sure I got a little angry with my boss. Everyone comes in late to work, so why does he have to pick on me all the time?”

ProjectionA defense mechanism in which the individual attributes to other people impulses and traits that he himself has but cannot accept. It is especially likely to occur when the person lacks insight into his own impulses and traits."

An aggressive man accuses other’s of being aggressive.

Denial

Denial: Escaping unpleasant realities by ignoring their existence.Example: “I’m sick of everyone thinking I drink too much. I can control my drinking whenever I want…and stop whenever I want.”

What type of therapy is used with chemically dependent clients? Group therapy is effective as well as support groups such as Alcoholics Anonymous, Narcotics Anonymous, etc.

Check YourselfThe nurse is preparing to teach a class to a group of new graduate nurses on substance use disorders. Which should the nurse include in the class? 1. A client with a substance dependence must take the same drug to relieve withdrawal symptoms2. A substance abuse disorder is both a physical and psychological disorder.3. A client who is motivated and has a substance dependence can overcome the addiction by stopping the substance.4. A substance must be abused over a long period of time before an addiction develops.

What basic needs have priority when working with chemically dependent clients? Safety: Nutrition: Psychological needs are priority. Alcohol & drug intake has superseded the intake of food for these clients.

What behaviors are expected during withdrawal? Specific to the substance.In the alcoholic, delirium tremens (DTs) occurs 22-72 hours after the last intake of alcohol. Know the symptoms.

Opiates withdrawal symptoms begin 6-8 hours after the last dose and reach their peak intensity within 48-72 hours; can last in body 3-7 days.Cocaine withdrawal after approximately 24 hours referred to as the (crash).

Hint (cont)

What medications can the nurse expect to administer to chemically dependent clients” In treating alcohol withdrawal?

Hint (cont)

Librium, an antianxiety agent is commonly used.

Hint (cont)

Antabuse is often used as a deterrent to drinking alcohol. Client teaching should include the effects of consuming any alcohol while on Antabuse. Encourage the client to read all labels of over-the-counter medications that may contain may contain small amounts of alcohol.

Memory Jogger’s

** Memory jogger: SPEED helps when assessing a client for amphetamine use (sweating, psychotic behavior, exhaustion, everything up (hyperthermia, hypertensiontachycardia, dilated pupils)

Memory Jogger

**Memory jogger (weed) MarijuanaW Wacky behaviorE EuphoriaE Elevated heart rateD Distorted sense of time

Memory Jogger

**CrackC cardiac arrestR respiratoryA auditory, visual, & olfactory

hallucinationsC coma and confusionK razy actions (irritable & psychotic

behavior)

Memory Jogger (PCP)Think: Angel Dust

A AmnesiaN NystagmusG Gait ataxiaE EuporiaL lack of perception (depth ,

distance)

Memory Jogger

D Delusions and distortionsU Unpredictable effectsS Sudden behavior changesT Tachycardia

Memory Jogger

LSD (Acid)*** A Arrhythmias and abdominal cramps

C ChillsI Illusions and increased

salivationD Diaphoresis, distortions

Pharmacology Hint

There are always questions on the NCLEX-RN. Here are some tips: Know common side effects for drug groups. For example:Antianxietyagents=sedation, drowsiness, dependence.

Hint (cont)

• Antipsychotic agents=photosensitivity, need to wear protective clothing, sunglasses, extrapyramidal effects (EPS); tardivedyskinesia is permanent!

• Antidepressant agents=anticholinergic effects, postural hypotension, MAO inhibitors=hypertensive crisis!

Hint (cont)

• Antipsychotic agents=photosensitivity, need to wear protective clothing, sunglasses, extrapyramidal effects (EPS); tardivedyskinesia is permanent!

Hint (cont)

• Monitor serum lithium levels carefully. The therapeutic range is between 0.5-.2/1.5mEq/L.

• The therapeutic and toxic levels are very close in reading. Signs of toxicity are evident when lithium levels are more than 1.5mEq/L. Blood levels should be drawn 12 hours after the LAST dose. About 5-7 days after therapy is initiated.

Emotional Needs of the Critically Ill Client

Patients need to feel that their circumstances and feelings are appreciated and understood by the health care team member without criticism or judgment. . . . If patients feel that the attention they receive is genuinely caring and tailored to meet their needs, it is far more likely that they will develop trust and confidence in the organization”

Benner’s model

Lack of charting of our practices and clinical observations deprives nursing theory of the uniqueness and richness of the knowledge embedded in expert clinical practice.”

Novice, Advanced Beginner, Competent, Proficient and Expert.

• Novice: no background understanding of situation exists. Context free rules & attributes are required for safe performance at this level. Example is a first year nursing student.

Novice, Advanced Beginner

Advanced Beginner: has enough experience to grasp aspects of (but not attributes) and recurrent meaningful components of the situation. Demonstrates marginally acceptable performance. Example is a new graduate.

Competent

Able to determine which aspects of situations are important and which can be ignored. Demonstrates conscious and deliberate planning with an increased level of efficiency. An expert judge is needed to ascribe this level.

Proficient

Able to perceive the situation as a whole, performance is guided by principals and rules of conduct. Nurse recognizes salient conditions and has an intuitive grasp of situation based on understanding.

Expert:

Able to focus on the accurate region of the problem of the situation because judgment is based on understanding of theory. Effectiveness of practice not hindered by any wasted regard of alternative diagnosis or solutions. An expert judge is needed to ascribe this level.

Domains of NursingHelping roleTeaching coaching roleDiagnostic and patient-monitoring roleEffective management of rapidly changing situations

Organizational and work-role competencies

First a nurse will identify with another nurse telling the story, an emotional response will be generated, which causes the receiving nurse to internalize the message (Benner, 1984).

Administering and monitoring therapeutic interventions and regimensMonitoring and ensuring the quality of health care practices

Connection, Concern, Possibilities.

• Caring creates “an enabling condition of connection and concern, which sets up the possibility of giving and receiving help.” (Benner & Wrubel, 1984)

Caring

• Their study revealed that caring (Chinn & Kramer, 1999):

Determines what matters to people.

Establishes what is stressful to people.

Explore rationale’s to support or reject the following statements:

“It is imperative that nurses be aware of the symptoms of both depression & anxiety, and routinely screens clients who display characteristics of either.”

“Nurses must keep up with rapid changes in healthcare and continue to provide excellent patient care.”

Practice to Pass

• Which question by the nurse in a general medical setting would be best to obtain information to assess for depression?

a. "So, how have things been going lately.“b. "You look sad, is something wrong?c. "How are you feeling about your

hospitalization?”d. "Are you depressed about this illness?"

The End~~~~~~~~~~~~

• Congratulations & Thanks

References

• Benner, P. (1983). Uncovering the knowledge embedded in clinical practice.

• Image: The Journal of Nursing Scholarship, 15(2), 36-41.

• Benner, P. (1984). From Novice to Expert: Excellence and Power in clinical nursing

• practice. Menlo Park, CA: Addison-Wesley. • Benner, P. (2000). The Wisdom of our practice.

American Journal of Nursing

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