NUR 253 Exam 2 (2026/2027) COMPLETE QUESTIONS WITH VERIFIED CORRECT ANSWERS || 100% GUARANTEED PASS NEWEST VERSIONA+!!!

NUR 253 Exam 2 (2026/2027) COMPLETE QUESTIONS WITH VERIFIED CORRECT ANSWERS || 100% GUARANTEED PASS NEWEST VERSIONA+!!! GAS Three stages - ANSWER • Alarm or acute stress stage (flight or fight)( interaction between nervous and immune system) • Resistance or adaptation stage (usually stressors are successfully overcome) • Exhaustion stage (resources are depleted, stress may become chronic) NI for managing Stress - ANSWER • Measuring stress: - Social Readjustment Rating Scale (Holmes and Rahe) -Measures level of positive and negative stressful life events over a 1-year period • Recent Life Changes Questionnaire Four personal attributes people use to manage stress: - Health-sustaining habits (medical compliance, proper diet, relaxation, etc.) - Life satisfactions (work, family, hobbies, etc.) - Social supports - Effective and healthy responses to stress • Biofeedback: - Use of sensitive instrumentation gives exact information regarding muscle activity, brain waves, skin temperature, HR, BP, and other bodily functions • Deep breathing exercises: - Should be slow, deep, and even • Guided imagery: - Focusing on pleasant images to replace negative or stressful feelings Relaxation Techniques - ANSWER • Progressive relaxation: - Focusing on eliminating muscle contraction causes by anxious feelings which produce tense muscles • Meditation/mindfulness: - Training of the mind to develop greater calm and use that calm to bring penetrative insight into one's experience • Physical exercise: - Walking, yoga, cycling, aerobics, water exercise, dancing etc. • Cognitive reframing: - Changing ones perception of stress by reassessing the situation and replacing irrational beliefs • Journaling • Humor Levels of Anxiety - ANSWER • Mild anxiety - Everyday problem-solving leverage - Grasps more information effectively • Moderate anxiety - Selective inattention - Clear thinking hampered - Problem solving not optimal - Sympathetic nervous system symptoms begin • Severe anxiety - Perceptual field greatly reduced - Difficulty concentrating on environment - Confused and automatic behavior - Somatic symptoms increase • Panic - Most extreme level of anxiety - Markedly disturbed behavior—running, shouting, screaming, pacing - Unable to process reality; impulsivity generalized anxiety disorder - ANSWER - Excessive worry that lasts for months - Common worries are inadequacy in interpersonal relationships, job responsibilities, finances, and health of family members obsessive-compulsive disorder - ANSWER • Obsessions - Thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind • Compulsions - Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety • Obsessive-compulsive disorder - Behaviors exist along a continuum - Symptoms occurring on a daily basis - Pathological obsessions or compulsions cause distress - Rituals are time-consuming and interfere in normal routines, social activities, and relationships Pharmacological Interventions for Anxiety - ANSWER • Antidepressants •SSRI's considered first line which block reuptake of serotonin levels in the brain •Examples Paxil, Prozac, Lexapro, Luvox, and Zoloft • Anti-anxiety drugs •Benozodiazepines are most common b/c of quick onset •Use for short periods b/c of dependence •Monitor for SE such as sedation, ataxia, and decreased cognitive function Maturational Crisis – ANSWER - When new developmental stage is reached (Erickson) - Old coping skills no longer effective - Leads to increased tension and anxiety Examples - •Leaving home for the first time •Marriage •Birth of a child •Retirement •Death of a parent Situational Crisis - ANSWER Arise from events that are: •Extraordinary •External •Often unanticipated Examples - •Loss or change of job •Death of a loved one •Abortion •Change in financial status •Divorce •Mental illness Adventitous Cirisis - ANSWER caused by nature or humans and are not usual parts of everyday life -natural disaster, a national disaster, or a crime of violence. Examples - hurricane, plane crash, school shooting, physical/sexual assault - often results in acute stress disorder, PTSD, major depressive disorder Phase 1 of crisis - ANSWER ·Conflict or problem arises ·Self-concept threatened ·Increased anxiety ·Use of problem-solving techniques and defense mechanisms (sometimes resolves the problem) Phase 2 of Crisis - ANSWER Defense mechanisms fail Threat persists Anxiety increases Feelings of extreme discomfort Functioning disorganized Trial-and-error attempt to solve problem and restore normal balance Phase 3 of Crisis - ANSWER Trial-and-error attempts may fail Anxiety can escalate to severe level or panic Automatic relief behaviors mobilized (i.e., withdrawal and flight) Some form of resolution may be devised(i.e., compromising needs or redefining situation) Phase 4 of Crisis - ANSWER Problem is unsolved and coping skills are ineffective Overwhelming anxiety Possible serious personality disorganization, depression, confusion, violence against others, or suicidal behavior Modalities of Crisis Treatment - ANSWER Emergency rooms 24/7 Telephone hotlines Peer crisis services Crisis intervention teams (CITs) Crisis stabilization beds Short-term residential services Mobile Crisis Teams Assessment of crisis pt - ANSWER General assessment: •Important to assess for suicidal ideations and ask what can be done to make sure the client feels safe - Assessment of perception of precipitating event - Assessment of situational supports - Assessment of personal coping skills - Self assessment Phases of Group Development - ANSWER Orientation phase: - Rules - Expectations - Start and stop time and dates Working phase Termination phase Group Leadership Responsibility - ANSWER Initiating: - Get them going on time - Reiterate the topic or purpose of the meeting Maintaining: - Keep them on track Terminating: - Recapitulation - End on time Styles of Leadership - ANSWER Autocratic leader: - Do it my way or makes decisions independently Democratic leader: - Decide how to do it or make decisions as a group Laissez-faire leader: - Don't care how you do or when you do it just have it done on time Challenging Members - ANSWER Monopolizing member Complaining member who rejects help Demoralizing member Silent member Bipolar 1 disorder - ANSWER •This is the most severe bipolar disorder •Moods fluctuate from mania to deep depression (periods of normal functioning may alternate) •Bipolar 1 Disorder is characterized by at least one MANIC EPISODE Mania - ANSWER •Hallucinations and delusions •Extreme energy (no need to eat, sleep, etc.) •Risk taking behavior •Feeling euphoric and optimistic •Lasts at least a week •Is a psychiatric and physical emergency Bipolar 2 disorder - ANSWER •This is less severe than Bipolar 1 disorder •Moods fluctuate from hypomania to deep depression (periods of normal functioning may alternate) •Hypomania does not include hallucinations or delusions but is similar to mania in other symptoms to a lesser degree •The depression, however, can be very severe and that can include psychotic features cheeking/palming medication interventions - ANSWER -address underlying reasons for wanting avoid medications -seek to switch medication to a more difficult- to conceal form -long acting injectable forms need to be only take every 2-4 weeks(reduce episodes of medication-related conflict) Anosognosia interventions - ANSWER -establish trust and rapport -simple act such as offering patient gum everyday can increase comfort with staff -seek areas of commonality9what can both the patient/others agree upon) -agree to disagree about wether these issues do or do not indicate an illness but seek agreement they are a problem -patient may be aware of illness -involve patient in activities including peers who have gained insight despite once having had anosognosia Avoiding interaction with peers interventions - ANSWER -actively convey acceptance and meet patient where he is -regularaly engage with the patient, connect at interval/initially interact briefly about low anxiety topics like the weather -gradually increase the duration/frequency as more comfortable with interactions (short/frequent intervals) -offer encouragement to participate in anti activities without pressure " we would love to see you at the morning meeting" or "How about going for a walk with me" -Assure the patient that he generally has control over his choices"( if he becomes uncomfortable in group he can leave and try again another day) -reinforce each stop toward greater interaction " it was nice to see you in the morning meeting today" -Pet therapy may help patients increase comfort level with people Depression/hoplessness/despair interventions - ANSWER -engage with patient regularly -actively convey empathy and support "sometimes having a mental illness can be very discouraging... I wonder how you are feeling" -if he cannot identify his feelings suggest those that may apply " sometimes its hard to say what you're feeling do you feel sad, frustrated, or lost" -Validate the patients feelings understandable and assure that he is not alone -idenitfy options for coping with those feelings (keeping a journal or using a support group) -teach activities that reduce depression or use cognitive interventions, physical activity, self nurturing, getting support, spending more time outside Poor self esteem interventions - ANSWER -actively convey unconditional acceptance -engage regularly and supportively, guide patient to identify/express feelings -help the patient to recognize own positive traits/potential/accomplishments -educate the patient about how the illness may distort ones self view -guide the patient to question distorted beliefs/to replace these with a more realistic self-appraisal -arrange for interaction with individuals who also once experienced poor self-esteem but have since improved Fall risk interventions - ANSWER -walk with patient to assess gait, provide physical support when needed -Assess for orthostatic hypotension -ensure that patients is well hydrated and teach slow position changes -encourage used of handrails/seeking assistance when unsteady -guide patient to look ahead instead of down -locate patients room CLOSE TO NURSES STATION Choking risk intervention - ANSWER -assess all patient with difficulty to swallowing and identify cause -address causes that can be corrected -encourage smaller bites that are then thoroughly chewed -ensure patients are not rushed to complete meals -be available to monitor as needed Restlessness/agitation interventions - ANSWER -reduce excess stimulation (dim lights, low tv volume, redirect to less stimulating areas) -assess for EPS -explore patients feelings/perceptions that may contribute to akathisia -promote verbal expression of negative emotions to reduce desperation/distress -provide safe outlets for physical energy( walking, pacing, exercise equipment) -administer calming meds as needed Directed violence interventions - ANSWER -assess for hallucinations -engage regularly with patient -engender goodwil via supportive activités/strong therapeutic relationships -provide increased supervision when risk is present -place patients room near nurses station -make sure patient is taking medications -promptly de-escalate increasing tension -help patient feel safe and secure -promote communication and venting in a safe manner to reduce patients level of anxiety/desperation -teach patient coping skills -provide constructive diversion/outlets -relocate patient/targeted peer -only when necessary use restraints/seclusion -search for unsafe objects often Risk for self-directed violence interventions - ANSWER -assess for risk to self -suddenly brightening/worsening mood, terminating activities, giving away possessions -increased supervision when risk is present -place near nurses station -make unpredictable rounds -recieving medications theraputic communication techniques - ANSWER -concrete thinkers talk literal terms -counting out equivalent numbers of items -short (30 mins), frequent interactions Intervening with Hallucinations - ANSWER focus on learning or understanding the patient's experience and response during a hallucination; call the pt by name, speak simply and loudly enough to be understood during auditory hallucinations, present in a supportive manner, mainatin eye contact, redirect the pt's focus to your conversation if needed; increase sense of reality suicidal/commands require safety measure hallucinations interventions - ANSWER -watch for indicators ( eyes tracking, muttering/self talk, appearing distracted, intently watching vacant room) -assess for command hallucinations -ask about content of hallucinations -be alert to signs of anxiety -offer own perceptions "I do not hear any voices but that must be very frightening to you" -focus on here/now, simple projects/communciation -promote reality testing( have patient scan area to see if others are appearing frightening) -teach patient to compare perceptions to those trusted -"the voice you hear is part of your illness it cannot hurt you" -teach patient to question perception -avoid loud stressful areas -avoid negative/critical people -slow/deep breathing -tense/relax muscles -go for a walk, meditation, take a bath, listen to music) - listen to music/ tv -talk with others -read aloud -sing,whistle,hum -look to see if others are reacting -tell voices to go away -play musics-tell yourself no matter what you are safe intervening with delusions - ANSWER "it seems to you that people want to hurt you that must be very frightening, I will not hurt you and we can work together" -acknowledge and accept patients feelings -convey empathy -provide reassurance -avoid questioning delusions itself -help patient feel safer -NEVER TRY AND PROVE DELUSIONS IS INCORRECT -clarify misinterpetaions "it is true the doctors want to see you, he talks with all patients, would you feel more comfortable if I stayed with you" -be open, honest -"tell me more about someone trying to hurt you" -validate if part of it is real "yes there was a man at the nurses station, I did not hear him talk about you" -"although it is frightening for you It seem it would be hard for a small girl to hurt you" -if patient believes he is powerful, increase patients control "asking when patient wants to take his medication" - "I wonder if there might be any other explanation why others might be avoiding you, Instead of hating you might they just be busy" intervening with associative looseness - ANSWER -Do not pretend/allow patient to think that you understand when you don't -place the difficulty in understanding on yourself, not the patient "Im having trouble following what you are saying" -tell patient what you do understand -look for recurring issues/possible triggers "you've mentioned trouble with your brother several times, after your family visits, tell me about your brother and your visits with him" -summarize/paraphrase patients communication to clearer communication -give patient chance to correct anything that may be misunderstood SPEAK CONCISELY, CLEAR, CONCRETELY, IN SENTENCES RATHER THAN PARAGRAPHS UAP CANNOT SCHIZO - ANSWER NOT ALLOWED TO TAKE PATIENT TO BATHROOM CAN DO INVENTORY therapeutic milieu - ANSWER -engage in therapeutic activities -group activities may enhance function -drawing, writing journaling, listening to music enhance expression of feelings -do mechanical tasks -fold laundry DO NOT REASON education - ANSWER -causes, nature, symptoms, what to expect, how it is treated -relapse prevention -medications nurses do not - ANSWER hands in pockets fast movements arms crossed Therapies - ANSWER Group therapy -psychotherapy -CBT -psychoeducation -family therapy paranoia - ANSWER Patient will hate you do not take personal -do not laugh talk quietly -simple, sentences Substance abuse - ANSWER ARE NOT ILLNESS OF CHOICE -cravings -seeking and using regardless of consequences CHRONIC AND RELAPSING compromised executive function misusing - ANSWER using something for one thing when indicated for another ex: using Wellbutrin for weight loss instead of depression Abuse - ANSWER habitual use that falls outside medical use -alters mood and state of conscious Substance use disorder - ANSWER pathological use of a substance that leads to a disorder of use -impaired control -social impairment -risky use -physical effects (intoxication, tolerance, withdrawal) DSM-5 Criteria - ANSWER -alcohol -caffeine -cannabis -hallucinogen -inhalant -opioid -sedative, hypnotic,antianxiety meds -stimulant -tobacco Process addictions - ANSWER behaviors known to be addictive because they are mood altering COMPULSIVE ACTIONS -gambling -sexting -shopping -sexual activity -candy/eating HYPERFOCUSED ON TILL GET IS NOT ABLE TO FOCuS ON REST OF DAY Addiction - ANSWER Chronic, cycles of relapsing and remission -progressive and results in disability or death compulsive drug seeking behavior -motivated by cravings despite HARMFUL CONSEQUENCES THEY KNOW THEy ARE DESTROYING SELF BUT DO NOT CARE -create problem in functioning/relationships, emotional responses Intoxication - ANSWER in the process of using a substance to excess Tolerance - ANSWER person no longer responds to the drug in the way the person initially responded, takes higher dosage to feel effects Withdrawal - ANSWER Set of physiological symptoms after stopping use of drug -the more intense symptoms a person has the more likely they are to use again -cravings -sleep disruption -anxiety -depression table 22.1 commonly missued drugs - ANSWER -nicotine -alcohol -marijuana -hashish -heroin -opium -cocaine -amphetamine -methamphetamine -methylenedioxy- methamphetamine (MDMA) -flunitrazepam -GHB -ayahuasca -DMT -LSD -mescaline -psilocybin -ketamin -PCP -salvia -DXM -hallucinogens -anabolic steroids -inhalants,solvents, propellants, thinners, fuels -prescription pain relievers -prescription sedatives -prescription stimulants -methylphenidate Co-curring disorders - ANSWER any combination of two or more substance use disorder and psychiatric disorder identified in DSM5 serious mental illness indicates serious functional impairment substance use disorder risk factors - ANSWER -genetics -neurotransmitters -stressors -poverty -lack of parental supervision -poor educational resources -disadvantaged Neighborhoods -coping mechanisms -mental illness (self-medicate) caffeine - ANSWER associated with bipolar, eating disorders, sleep disorders effects begin as early as 15 minutes and last 6 hours long caffeine intoxication - ANSWER high doses of more than 250 mg -restlessness -nervousness -excitement -agitation -rambling speech -inexhaustibility physical -flushed face -diuresis -gastrointestinal disturbances -muscle twitching -tachycarida -cardiac arrhythmias Caffeine overdose - ANSWER overdose -fever -tachy/bradycardia -hypertension/hypotension -grand mal seizures -respiratory failure -dilated pupils -muscle rigidity -hyperreflexia/nause/vomiting -disorganized thinking, -delusions -hallucinations/seizures caffeine treatment - ANSWER -Hydration -gastric lavage -activated charcoal caffeine withdrawal - ANSWER -headache -irritablitiy -poor concentration -nausea/vomiting/muscle aches SYMPTOMS OCCUR WITHIN 12-24 HOURS PEAK IN 24-28 AND RESOLVE IN 1 WEEK Cannabis intoxication - ANSWER brighter colors, time goes by slowly motor skills are impacted for 8-12 hours two of the following symptoms are required -red eyes -increased appetite -dry mouth -tachycardia -hallucinations Delirium assessment - ANSWER PERFORM MEDICAL EVALUATION FIRST -information from family/friends -review medication history/drug use -any underlying illnesses/diseases -blood work -urinalysis -CBC/CRP -safety/fall risk -exit seeking -assess risk for poly pharmacy (using multiple drugs) delirium physical needs - ANSWER patient becomes disoriented -may wander or try and pull out IV lines -fall out of bed -want to go home or think hospital is home -SIMPLE ENVIRONMENT/CLEAR -Clocks/calendars -visual/auditory aides -interact with patient -poor self care= delirium assessment guidelines - ANSWER -dont assume confusion is bc of dementia - assess acute onset/fluctuating levels -assess ability to attend to immediate surroundings including nursing care -establish usual LOC -assess past cog impairment/other risk factors -identify disturbances/physiological abnormalities -VS, LOC, neuro signs -assess potential injury -maintain comfort measures (pain/cold/positioning) -mon factors that worsen/improve -assess availability of immediate med interventions to help prevent irreversible brain damage Mood and behavior of delirium - ANSWER -change drastically in short period -agitation/quiet delirious -no agitation= hypoactive -fear/anger/euphoria/depression/apathy -may strike out in fear and call for help or become calm next minute -erratic and fluctuating Nursing diagnosis delirium - ANSWER SAFETY IS PRIORITY -risk of injury if felt threatened -altered perception/hallucinations/delusions -fever/dehydration= risk for fluid imbalance Ask exploring questions -reduced clarity of awareness -reorient patient -impaired communication Planning delirium - ANSWER does patient have necessary visual/hearing aids -are family members able to stay with patient -does environment provide visual cues -has person experienced continuity of care Delirium interventions - ANSWER SFAETY -correct underlying disorder -monitor neuro status -avoid frustrating patient/quizzing with questions hard to answer -administer medications -monitor fluid and nutrition intake -assist with daily needs -physical restraints should be avoided as they cause increase in agitation -use family members in care -Maintain a WELL LIT/ HAZARD FREE environment -acknowledge fears/feelings -optimistic but realistic reassurance -provide information about what is happening/expected -limit need for decision making (no hard questions, simple easy) -accept patients perceptions/interpretations of reality -reorient patient to time place etc -APPROACH SLOWLY/FROM THE FRONT -address patient by name -always reintroduce self -simple/direct/descriptive statements -consistnet environment /daily routine -clocks/calendars/pictures -low stimulation NEVER LEAVE PATIENT ALONE Mild neuorcognitive disorder - ANSWER DO NOT INTERFERE WITH ACTIVITIES OF DAILY LIVING -if progressive may go to major -does not involve dementia/Alzheimers -decline is greater than expected at that age -requires more effort major neurocognitive disorder - ANSWER Significant decline in previous level of performance INTERFERE WITH ACTIVITIES OF DAILY LIVING -alzheimers/dementia -Alzheimers may be dementia but not all dementia is Alzheimers - SLOW ONSET -risks are genetics (first degree) -TBI -diabetes -hypertension Alzheimers - ANSWER most common cause of dementia -must distinguish difference between normal and memory deficit of AD -severe memory loss is NOT normal for older age Characteristics of Alzheimers - ANSWER early- difficulty remembering recent conversations, names or events, apathy, depression Middle- impaired communication , disorientation, confusion, poor judgement, behavioral changes late- difficulty speaking, swallowing and walking Alzheimers risk factors - ANSWER 65 years or older (late onset) -increasing age is greatest risk factor -genetics -cardiovascular disease -TBI Alzheimers modifiable risk factors - ANSWER education and engaging in mentally stimulating activities -physical exercise -social engagement -healthy diet -sufficient sleep Table 23.2 signs of Alzheimers disease - ANSWER -memory loss that disrupts daily life -challenges in planning or solving problems -difficulty completing familiar tasks -confusion with time or place -trouble understanding visual images or spatial relationships -new problems with words in speaking or writing -misplacing things or losing the ability to retrace steps -decreased/poor judgement -withdrawal from social and work activities -changes in mood/personality Mild stage of Alzheimers - ANSWER may go with mild neurocogntive disorders -loses energy/drive and initiative and has difficulty learning new things -may continue to work -depression may occur early in disease but resolves over time -Person and loved one notices memory lapses STILL ABLE TO FUNCTION INDEPENDENTLY -difficulties retrieving correct words or names -trouble remembering names when introduced to new people -challenges in performing tasks in social or work settings -forgetting material that one has just read -losing or misplacing a valuable object -increasing trouble with planning or organizing PERSONALITY/SOCIAL BEHAVIOR REMAIN INTACT -apathy is common Moderate stage of Alzheimers - ANSWER confuses words/ gets frustrated or angry or acts in unexpected ways such as refusing a bath (change in hygiene) SYMPTOMS BECOMES NOtICEABLE TO OTHERS -forget events or their personal history -become moody/withdrawn especially in socially or mentally challenging situations (temper outbursts) -unable to recall their own address or telephone number or where they graduated from highschool/ college -confused about where they are or what day it is -need help choosing proper clothing for season or occasion -change in sleep patterns -at risk for wandering/becoming lost -become suspicious or delusional or compulsive (repetitive behavior like hand writing) apathy continues (may not understand how others feel) agnosia (inability to identify familiar objects/.people) apraxia( need for repeated instructions/directions to perform simple tasks) Severe stage of Alzheimers - ANSWER lose the ability to respond to their environment, carry on conversation, eventually control of movement -say words or phrases but communicating becomes difficult -personality changes take place/ need extensive help with ADLS -require full time care -lose awareness of recent experiences and of surroundings -experiences changes in physical abilities (ability to walk/sit/ eat/ swallow) -increased difficulty in communicating -increase risk of infection (Pneumonia, can't swallow/sit still) -cannot remember location of toilet or unaware of prices of urinating/defecating assessment of Alzheimers - ANSWER It is PROGRESSIVE DETERIORATION OF COGNITIVE FUNCTIONING -as time goes on symptoms become more noticeable -at early stage person may be able to hide symptoms alzheimers symptoms - ANSWER Confabulation- creation of stories/answers in place of actual memories to maintain self-esteem (Sunday I went to lunch with my family, never actually happened) IS NOT LYING, used to protect EGO preservation- persistent repetition of a word/phrase/gesture Agraphia- EARLY, diminished ability to read or write Aphasia- loss of language ability, starts off unable to find word, ends with babbling/mutism Apraxia- loss of purposeful movement (person is unable to put clothes on properly) Agnosia- loss of sensory ability to recognize objects( recognize familiar sound, can't identify what apple is) Hyperorality- tendency to put everything into mouth and taste/chew Sundowning- tendency for individuals mood to deteriorate/ agitation increases in later part of day memory impairment -disturbances in executive functioning (problem solving, planning, organizing, abstract thinking) -diminution of emotional expression/ flat affect Alzheimers diagnostics - ANSWER MEDICALLY CLEARED FIRST pseudodementai- cognitive symptoms nurses be able to assess for depression, dementia, delirium -complete medical/psychiatric history -MSE -medication history -nutrition evaluation -history from family members -comorbidites -metabolic infections -suicide risk -family preparation/financial -prepare that end of life is near -support groups -assess for poly pharmacy ATLEAST 1 COGNITIVE ASSESSMENT PER SHiFT -assess for neglect/abuse/family needs Table 23.4 comparison - ANSWER DELIRIUM onset- sudden/ fluctuating over course of day cause/factors- underlying medical condition cognition- impaired attentionspan, memory deficit -disorientation, disturbances in perception, not related to other cognitive disorder or reduced arousal activity level- either increased or reduced, restlessness, sundowning, sleep wake cycle may be reversed emotional state- rapid swings, can be fearful anxious, suspicious, aggressive, hallucinations/delusions speech/language- rapid/inappropriate/incoherent/rambling prognosis- reversible with proper/timely treatment DEMENTIA onset- slowly over months/years cause/factors- Alzheimers disease/ vascular disease/ HIV/ neurological disease/ chronic alcoholism/ head trauma cognition- impaired memory, judgement,calculations/attention span/ abstract thing/agnosia activity level- Not altered, Sundowners emotional state- Flat/agitation speech/language- Incoherent, slow( can't find right words), inappropriate, rambling, repetitious Prognosis- Not reversible/progressive DEPRESSION onset- may have been gradual with exacerbations during crisis or stress Cause/factors- Lifelong history, losses, loneliness, crises, declining health, medical conditions cognition- difficulty concentrating, forgetfulness, inattention activity level- usually decreased/lethargy, fatigue, lack of motivation, may sleep poorly/awaken in early morning emotional state- slow/flat/low Prognosis- reversible with proper/timely treatment Nursing diagnosis Alzheimers - ANSWER SAFETY -may wander/put selves in danger -injuries from falls/accidents -burns -medication incorrectly taken -impaired communication -confusion -caregiver/family stress memory problems - ANSWER forgets appointments -forgets to change clothes/wash/go to toilet -forgets To eats/take medications -loses things disorientation problems - ANSWER -mixes day and night -mixes days of appointments -wears summer clothes in winter -forgets age -loses way around house -has difficulty recognizing visits/family/spouse need for physical help problems - ANSWER -dressing -washing/bathing -toileting -eating -performing house work -maintaining mobility risks in the home - ANSWER -falls -fires from cigs/cooking/heating -flooding -admission in strangers home -wandering risks outside of home - ANSWER -competence/judgement/risks at work -driving road sense -getting lost apathy problems - ANSWER -little conversation -lack of interest -poor self care Poor communication problems - ANSWER Dysphasia -unable to find correct words/interpret words Repetitiveness problems - ANSWER repetition of questions/stories -repetition of actions uncontrolled emotions problems - ANSWER -distress -agitation -anger/aggression -demands for attention uncontrolled behavior problems - ANSWER -restlessness day or night -vulgar table or toilet habits -undressing -sexual inhibition Incontinence problems - ANSWER -urine -feces -urination/defecation in wrong place Emotional reaction problems - ANSWER depression -anxiety -frustration/anger -embarrassment or withdrawal other -suspiciousness -hoarding/hiding Mistaken beliefs problems - ANSWER -still in paid work -parents or spouse alive -hallucinations decision making - ANSWER -indecisive -easily influenced -refuses help -make unwise decisions burden on family - ANSWER disruption of social life distress/guilt/rejection family discord Person-centered care approach Alzheimers - ANSWER -person is eventually lost to disease focuses on -preservation of personhood of people -patient centered care-personhood should remain and be honored -form meaningful relationships -maintain unique identity of person/promote well-being -RELATIONSHIPS MUST TAKE PRIORITY OVER TASKS Box 23.3 interventions for dementia management - ANSWER include family in planning/providing and evaluating care to extent desired identify and remove potential dangers in environment -assess risk for falls -assess tendency to wander -assess discomfort -assess pain determine and monitor cognitive deficits identify usual patterns of behaviors for sleep, medication use, elimination, food intake, self care -ascertain what is important to patient (values/beliefs/histories) -Provide frequent rest periods to prevent fatigue/sundowners/ reduce stress -monitor nutrition and weight -NORMAL MEAL TIMES TO ENCOURAGE SOCIALIZATION -introduce self and address patient by name -speak slowly -give one simple direction at a time in a respectful tone of voice -avoid frustrating by quizzing with orientation questions that cannot be answered -use distraction rather than confrontation -provide consistent caregivers/environment/ daily routine -low stimulation environment with adequate lighting -provide cutes such as current events season location names -select tvs/radios based on cognitive abilties/ interests -limit number of choices patient has to make (do you want orange juice instead of what do you want to drink) -place patients names on LARGE block letters in patients room/on clothing -use symbols rather than written signs to assist in locating room/bathroom/etc Dressing bathing interventions - ANSWER -have perform tasks within own capacity ( maintains self esteem) -have wear own clothes (maintains identity) -use clothes with elastics/velcros (minimizes confusion/eases independence) -label clothing with persons name/name of item( helps identify) -give step by step instructions (take this put one arm in now other arm, pull it over) - focuses on small pieces of information easily/promotes independence -water tank levels are set low to prevent scolding (impaired judgement) -if reluctant to perform self care ask again later( moods may be liable/ may forget) nutrition interventions - ANSWER Monitor food and fluid intake (lack of appetite/confusion) Offer finger foods that patient can take away from the dinner table (increases input throughout the day) Weigh patient regulary (monitors) During periods of hyperorality watch that patient does not eat non food items ( person puts everything in mouth) Bowel and Bladder function interventions - ANSWER -Begin bowel and bladder program early/ start with bladder (establishing same time of day for Bm/toileting) -early in morning, after meals/snacks/before bedtime can prevent incontinence -evaluate need for disposable diapers (prevents embarrassment/soiling) -label doors to rooms/bathrooms sleep interventions - ANSWER Maintain a calm atmosphere during day (reduces anxiety/promotes calm sleeping at night) expose patients to morning light/sunlight ( helps rest circadian rhythms) avoid using cholinerase inhibitor at bedtime (increased cortisol arousal) non medication options to promote sleep before medication discontinue medication once sleep schedule is established(reduces likelihood of injury) avoid antipsychotic use (increased stroke/mortality) NO RISPERIDAL avoid use of restraints (causes to become more agitated) Safe environment at home interventions - ANSWER gradually restrict use of motor vehicles remove throw rugs/objects in path minimize sensory stimulation if upset, listen/be supportive, ALLOW them to be upset, Gradually try and redirect/change topic label all drawers/rooms/label often used objects -install safety bars in bathroom -supervise while smoking Wandering interventions - ANSWER Place a mattress on the floor, or use a bed monitor. Brightly colored clothing if in hospital with names, unit and phone number Provide a MedicAlert bracelet with identification that cannot be removed Notify the police department with photographs, or alert the neighbors. If in the hospital, have the patient wear a brightly colored vest with the patient's identification printed on the back. Install complex locks on the door locks at the top of the door. encourage physical activity during day Explore feasibility of sensor devices or global positioning system (GPS). useful activities interventions - ANSWER Provide picture magazines or children books when reading capabilities diminish -provide simple activities that allow exercise of large muscles (groups/dance groups/walking) encourage group activities that are familiar/simple to perform (singing/dancing/reminiscing/clay/paint) Alzheimers integrative therapy - ANSWER -Nutrition may prevent and treat -Omge 3 fatty acid -fatty fish, flaxseed, canola oils Schizophrenia spectrum disorders - ANSWER Characterized by psychosis -altered cognition -altered perception -impaired ability to determine what is or is not real delusional disorder - ANSWER -delusions that have lasted 1 month or longer -grandiose/persecutory/somatic/referential themes WITHOUT PRESENCE OF PSYCHOTIC SYMPTOMS NOT SEVERE ENOUGH TO IMPAIR FUNCTIONING DO NOT TEND TO BEHAVE STRANGE OR BIZARRE Brief psychotic disorder - ANSWER SUDDEN ONSET OF AT LEAST ONE -delusions -hallucinations -disorganized speech -disorganzied or catatonic behavior MUST LAST LONGER THAN 1 DAY; NO LONGER THAN 1 MONTH schizophreniform disorder - ANSWER same as schizophrenia except symptoms last less than 6 months -impaired social or occupational function may or may not be apparent -return to previous level of functioning or may develop psychosis schizoaffective disorder - ANSWER INVOLVES -major depressive -Maniac -mixed episodes concurrent with symptoms that meet criteria for schizophrenia MUST NOT BE CAUSED BY ANY SUBSTANCE USE OR GENERAL MEDICAL CONDITION -assess for suicidal ideation due to mania + depression Substance induced psychotic disorder and psychotic disorder due to another medical condition - ANSWER illicit drugs, alcohol, medications or toxins induce hallucinations/delusions -can be caused by neurological disease, delirium , hepatic/renal disease SUBSTANCE USE AND MEDICAL CONDITIONS SHOULD ALWAYS BE RULED OUT BEFORE PRIMARY DIAGNOSIS OF SCHIZOPHRENIA CAN BE MADE Schizophrenia - ANSWER DEVELOPS GRADUALLY/ INSIDIOUSLY -begins 15 to 25 years of age PRECEDED BY PRODROMAL PHASE HAVE ATLEAST 1 PSYCHOTIC SYMPTOM -symptoms are severe enough to disrupt normal activities (school, work, family, social interaction/self care) -delay or stop achievement of developmental milestones -basic needs are often neglected -socialization/relationships are disrupted Male vs female schizophrenia - ANSWER males- between ages 15-25 associated with poorer functioning and more structural abnormality in brain women- have better prognosis, experience less structural changes in brain Schizophrenia comorbidities - ANSWER SUBSTANCE ABUSE- may be form of self medication treatment- form of coping Anxiety/depression/suicide- SUICIDE attempts are more common within 3 year diagnosis (earlier= greater risk), especially upon discharge after first episode Physical illness- cardiovascular disease/ metabolic syndrome greater risk for poor health maintenance behaviors Polydypsia- compulsive drinking of fluids /reduces odium levels /antipsychotic meds if sudden increase in psychotic symptoms think hyponatremia Schizophrenia risk factors - ANSWER -preexisting personality disorder (narcissism) -genetics -sleep deprivation -viral infections -birth injuries -environmental stressors -prenatal malnutrition -trauma -abnormal neural pruning that alters brain development Epigenetic factors (toxins/psychological trauma) -decreased dopamine anphetamines/cocaine can induce psychosis THE YOUNGER THE CHILD THE GREATER RiSK AS THEY DO NOT HAVE WELL DEVELOPED COPING SKILLS -brain structure abnormalities -prenatal stressors(infection during/after pregnancy) -father above 35 years of age -being brown in late winter/early spring Schizophrenia environmental factors - ANSWER -stress -sexual abuse -exposure to social adversity (poverty/crime) -foreign culture DSM-5 Criteria for Schizophrenia - ANSWER During a 1-month period, 2 (or more) of the following symptoms: Delusions Hallucinations Disorganized speech Disorganized behavior Negative symptoms -executive functioning is markedly low CONTINUOUS SIGNS OF DISTURBANCE PERSISTS FOR AT LEAST 6 MONTHS, INCLUDES AT LEAST ONE SYMPTOMS -schizoaffective is ruled out ( no major depressive/manic episodes Schizophrenia prognostic variables - ANSWER symptoms typically improve with medications but may not respond fully to treatment Less positive prognosis -slow onset -younger age (never able to create coping abilities) -longer duration between symptoms onset and first treatment -longer periods of untreated illness -more negative symptoms Prodromal phase of schizophrenia - ANSWER BEFORE ACUTE SYMPTOMS OCCUR -may experience mild changes in thinking/ reality testing/ mood -speech/thoughts may be odd -anxiety -DISORGANIZED SPEECH OR THOUGHT -Less socially engaged/adept -obsessive thoughts/compulsive behaviors -concentration at school or job performance/ social functioning may deteriorate -may feel "not right" or "something strange" is happening SYMPTOMS APPEAR 1-12 MONTHS BEFORE FIRST FULL EPISODE OF SCHIZOPHRENIA place safe interventions before psychosis occurs Acute phase of schizophrenia - ANSWER symptoms vary from few and mild to many and sibling -hallucinations, delusions, apathy, social withdrawal, diminished affect, anhedonia, disorganized behavior, impaired judgement/cognition RESULT IN FUNCTIONAL IMPAIRMENT CAN LAST SEVERAL MONTHS SAFETY RISK (INPATIENT) Stabilization phase of schizophrenia - ANSWER Symptoms diminish (stabilize) -movement toward previous level of functioning CAN LAST FOR MONTHS -outpatient or partial hospitalization program Maintenance/ residual phase of schizophrenia - ANSWER Condition has stabilized -new baseline is established Positive symptoms are usually significantly diminished or absent -negative/cognitive symptoms can continue to occur SCHIZOPHRENIA IS CHRONIC AND RELAPSING -each time little more baseline is lost Schizophrenia assessment - ANSWER -interview patient and observe behaviors -information from others -MSE -spiritual/cultural/biological/psychological/social/environmental elements Prodromal phase assessment - ANSWER EARLY ASSESSMENT iS KEY -reducing risk factors -enhancing social/coping skills -avoiding triggers -early treatment -supplemental essential fatty acids Positive symptoms - ANSWER Presence of symptoms that should NOT be present APPEAR EARLY/ DRAMATIC/PRECIPITATE TREATMENT IMPAIRED REALITY TESTING - hallucinations/delusions ALTERATIONS IN SPEECH associative looseness- thoughts are loosely connected Word salad- jumble of words meaningless to listener Clang association- words based on sounds/rhyme Neologisms- meaning to patient but not for listener/ create words that do not exist Echolalia- repetition of another words Circumstantiality- unnecessary details eventually reach point Tangentiality- wanders off topic, never gets to point Cognitive retardation- slowing of thinking/delay in responses Pressured speech/flight of ideas/symbolic speech thought blocking- reduction/stoppage of thought Thought insertion- belief someone else has inserted thoughts into head Thought deletion- thoughts have been taken or are missing Magical thinking - Reality can be changed simply by thoughts/actions Paranoia- irrational fear ALTERATIONS IN PERCEPTION Hallucinations- sensory/auditory/visual/olfactory/gustatory/ tactile Command hallucinations MOST SERIOUS- telling patient to do something (must be assessed) illusions- misinterpretations of environment depersonalization- feeling of being unreal or having lost one of body elements Derealization- environment has changed ALTERATIONS IN BEHAVIOR catatonia- increase/decrease in rate/amount of movement catalepsy- limbs remain in position they are placed Motor retardation- pronounced slowing of movement Motor agitation- excited behavior, running or pacing rapidly ( puts others at risk) stereotyped behaviors- repetitive behaviors that do not serve logical purpose Echopraxia- mimicking of movement of another Negativism- tendency to resist/oppose requests of others impaired impulse control- reduced ability to resist impulses (interrupting/throwing objects) (I Negative symptoms - ANSWER Absence of normal human qualities Anhedonia- reduced ability to experience pleasure Avolition- reduced motivation/goal directed behavior/difficulty beginning/sustaining goal directed behaviors Asociality- deceased desire for social interaction/discomfort during/social withdrawal Affective blunting -reduced/constricted affect Apathy- decreased interest in activated/beliefs Alogia- reduction in speech Affect- flat/blunted/constricted/inappropriate/bizarre ALL CAUSE POOR SOCIAL FUNCTIONING/ SOCIAL WITHDRAWAL -IMPAIR ABILITY TO INITIATE /MAINTAIN CONVERSATION/RELATIONSHIPS/SUCCEED IN SCHOOL OR WORK APATHY/AVOLITION RESULT IN DEFICIT IN BASIC ACTIVITIES Cognitive symptoms - ANSWER LEAD TO POOR JUDGEMENT/IMPAIRED COPING, LEARNING, MANAGE HEALTH, SUCCEED IN SCHOOL/WORK Concrete thinking- impaired ability to think abstractly, interpret things literally Nurses can communicate in more concrete terms Memory- impairment in short term memory/ability to learn give repetition/verbal reminders to help recall (picture of toothbrushes) Impaired information processing- delayed responses, misperceptions, difficulty understanding, inability to screen out external stimuli -reduce stimulation Impaired executive functioning- difficulty with reasoning, setting priorities, comparing options, placing things in logical order, planning/anticipating, interferes with problem solving skills Anosognosia- inability to realize one is ill, may cause patient to stop/resist treatment AFFECTIVE SYMPTOMS -altered experience/expression of emotions -unstable/erratic/labile mood -depression may signal and impending relapse / put at risk for suicide Schizophrenia assessment guidelines - ANSWER -ensure patient has had medical workup -assess for indication of medical problems that may mimic psychosis -assess for substance abuse disorders -complete an MSE -assess for hallucinations -DO NOT SAY WHAT ARE VOICES SAYING, SAY "WHAT DO YOU HEAR" it implies perceptions are real -assess when hallucinations began, content, how patient experiences them, what makes them worse/better, how patient responds, what patient does to cope -say "are you hearing a voice that is telling you to do something"/ " do you believe what you hear is real" -assess for delusions -assess for suicide risk -assess ADLS -assess medication regimen -assess families knowledge of/response to illness/symptoms Acute phase outcomes - ANSWER -patient safety and stabilization Stabilization phase outcomes - ANSWER -undestands illness/treatment -achieves optimal medication/psychosocial regimen -controls coping with symptoms and side effects -target negative and cognitive symptoms IMPROVE IN FUNCTION QUALITY OF LIFE ENHANCED Maintenance phase outcomes - ANSWER -focus on maintaining and increasing symptom control/optimal functioning MEDiCATION ADHERENCE EDUCATION ON DISEASE Acute phase planning - ANSWER hospitalization if danger to self/others -need to rapidly clarify diagnosis/initiate treatment Stabilization/maintenance phase planning - ANSWER education, support, skill training for patient/family -relapse prevention -each relapse increase dysfunction/deterioration -can contribute to despair/hopelessness/suicide risk -recognize signs of relapse ( reduced sleep, social withdrawal, worsening concentration) Interventions acute phase - ANSWER -theraputic mileu -monitor for suicide risk -medication education -psychoeducation POTENTIAL FOR PHYSICAL VIOLENCE interventions stabilization/maintenance phase - ANSWER -medication support -theraputic activites/structured -case management -support groups -essential family education Poor hygiene interventions - ANSWER -concisely/explicity identity expected hygiene -have patient try out each hygiene action while observing/assiting when needed -break tasks into smaller more manageable steps -use visual cues to prompt attention, putting toothbrush/towels in bathroom/ clean clothes on bed -suggest ways in which improved hygiene will benefit patient -guide patient to use napkin/towel around neck while eating -periodically remind patient and refocus hygiene tasks -reinforcing progress with verbal praise/concrete rewards (more privileges) Resistant to treatment interventions - ANSWER -meet patient where they are, acknowledge views/prefercbes without judgement -treat the patient with respect/actively convey empathy/care/support -establish trust by behaving in a constant/reliable manner -involve the patient collaboratively in planning treatment -explore concerns about treatment/suggest solutions -convey clear/concrete/confident manner your belief that the patient will benefit from treatment -Tie the treatment to the patients own goals (if patient believes that it will quiet voices or help him keep his jobs which are his goals) cannabis withdrawal - ANSWER within 1 week of stopping -irritability -anger -aggression -anxiety -restlessness -depressed mood -insomnia -weight loss physcial -abdominal pain -shakiness -sweating -fever -chills headache cannabis treatment - ANSWER abstinence and support -antianxiety meds hallucinogen use disorders - ANSWER Profound disturbances in reality -flashbacks -panic attacks -psychosis -delirium -mood/anxiety disorders HIGH ABUSE POTENTIAL hallucinogen intoxication - ANSWER -paranoia -impaired judgement -intensification of perceptions -depersonalizations -derealization physical -dilated pupils -tachycardia -sweating -palpitations -blurred vision -tremors -incoordination hallucinogen treatment - ANSWER talking patient down -Haldol PCP intoxication - ANSWER medical emergency-dangerous and violent side effects, belligerent, assaultive, impulsive, HTN, seizures, coma -nystagmus -hypertension -tachycardia -diminshed response to pain -ataxia -muscle rigidity -seizures -coma -hyperacusis hyperthermia PCP treatment - ANSWER CANNOT BE TALKED DOWN -benzos -mechanical cooling Inhalant use disorder - ANSWER -solvent for glue/adhesives -propellants -shaving cream -fuels cause SUDDEN SNIFFING DEATH FROM CARDIAC ARREST inhalation intoxication - ANSWER result in disinhibition/euphoria -fearfulness -illusions -hallucinations -distorted body image -apathy diminished functioning -impaired judgement -impulsive/aggressive behavior -nausea/anorexia -nystagmus -depressed reflexes -diplopia -stupor/unconciousness -amnesia DELIRIUM/DEMENTIA/PSYCHOSIS ARE SERIOUS SIDE EFFECTS Inhalants treatment - ANSWER abstinence resolves quickly -haldol Opioid use disorder - ANSWER Chronic relapsing disorder -impairment in life roles, interpersonal conflict, physically hazardous situations opioid intoxication - ANSWER psychomotor retardation, drowsiness, -euphoria slurred speech, altered mood, impaired memory and attention -pinpoint pupils MIOSIS -decreased bowel sounds -decreased RR/BP/HR -head nodding -calmness -analgesia -sedation -track marks/fresh injection sites opioid overdose - ANSWER respiratory arrest -unresponsiveness -slow RR -coma -hypothermia -hypotension/bradycardia -pinpoint pupils opioid overdose treatment - ANSWER aspirating secretions mechanical ventilation NARCAN, opioid withdrawal - ANSWER mood dysphoria nausea/vomiting/diarrhea -muscle aches/spasms -fever -anxiety -insomnia -tachycardia -hypertension -hyperthermia enlarged pupils (mydriasis) -hyperrelexia -sweating -increased RR -abdominal cramps -bone/muscle pain -watery eyes -runny nose -dilated pupils -yawning -bristling hairs -gooseflesh (piloerection) -spontaneous ejaculations BEGINS 8-12 hours lasts about 5 days opioid withdrawal treatment - ANSWER -Suboxone -Vivitrol opioid therapy - ANSWER continued abstinence -pharmacotherapy -cbt -family therapy -support groups Sedatives, Hypnotics, and Anti anxiety use disorder intoxication - ANSWER -slurred speech -incoordination -unsteady gait -nystagmus -impaired thinking -coma -inappropriate aggression -sexual behavior -mood fluctuation -impaired judgement overdose treatment - ANSWER -gastric lavage -activated charcoal -monitor vitals should be kept awake -Iv -mechanical ventialtion withdrawal of sedative/hypnotics/antianxiety - ANSWER -hyperactivity -tremor -insomnia -psychomotor agitation -anxiety -grand mal seizures Treatment -gradual reduction stimulant use disorder - ANSWER Amphetamines, cocaine or other stimulant drugs -euphoric feelings -high energy Stimulant Intoxication - ANSWER feel superhuman -elated,euphoric ,sociable -hypervigilant -sensitive -anxious -tense -angry -chest pain -cardiac arrhythmias -high/low BP -tachy/bradycardia -resp depression -dilated pupils -perspiration chills -N/V -weight loss -psychomotor agitation/retardation -weakness/confusion -seizures/coma stimulant withdrawal - ANSWER begin within few hours to days -tiredness -vivid nightmares -increased appetite -insomnia/hypersomnia -psychomotor retardation/agitation -impaired function -depression/suicidal thought stimulant withdrawal treatment - ANSWER -antipsychotics tobacco withdrawal - ANSWER Irritability, frustration, or anger Anxiety Difficulty concentrating Increased appetite Restlessness Depressed mood Insomnia tobacco treatment - ANSWER -medications -hypnotist -changing old routines -help lines Alcohol use disorder DSM-5 - ANSWER problematic pattern of alcohol use leading to clinically significant impairment/distress At least two of the following with 12 month period -often taken in larger amount of longer period of time -persistent desire/unsuccessful effect to cut down -great deal of time is pent in activities necessary to obtain -craving/strong desire/urge to use -recurrent alcohol use resulting in failure to fulfill major role obligations -continued use despite having persistent/recurrent social/interpersonal problems -recurrent use in physically hazardous situations important events are given up Binge drinking - ANSWER men- five or more drinks within 2 hours women- four or more drinks within 2 hours Heavy drinking - ANSWER women- 8 or more drinks in a week men- 14 or more drinks in a week Alcoholism - ANSWER Men - 4 drinks per day or 14 drinks in 7 days women- 3 drinks per day or 7 drinks in 7 days Alcohol use disorder comorbidity - ANSWER Bipolar, schizophrenia, antisocial personality disorder -major depressive disorder -increased risk of infections -genetics -social drinking -cultural Psychiatric disorders are 50-60% more likely to abuse alcohol (use it for self medication) Alcohol intoxication - ANSWER - Blood concentration of 80 to 100mg ethanol per deciliter of blood (mg/dL) - Quicker ingestion = higher levels of blood alcohol Alcohol withdrawal - ANSWER occurs after reducing or quitting alcohol after heavy/prolonged use BEGINS 6-8 hours after stopping -tremulousness(shakes) -jitters alcohol withdrawal mild-moderate - ANSWER BEGINS 6-8 hours Mild-moderate -agitation -lack of appetite -nausea/vomiting -insomnia -impaired cognition -tremors and mild perceptual changes -hypertension/tachycardia/fever Moderate alcohol withdrawal - ANSWER begins 8-10 hours after -psychotic and perceptual changes considered medical emergency due to risks of -unconsciousness -seizures -delirium Withdrawal alcohol seizures - ANSWER Occur 12-24 hours after stopping generalized seizures and tonic clonic alcohol withdrawal delirium - ANSWER delirium tremens DTS OCCURS IN FIRST 72 HOURS -MEDICAL EMERGENCY -result of medical problem such as pneumonia/renal disease/hepatic insufficiency/ heart failure -tachycardia -diaphoresis -fever -anxiety insomnia -hypertension -delusions/visual, tactile hallucinations -hepatitis/pancreatitis PREVENTION IS GOAL -correct dehydration -give Ativan Wernicke's encephalopathy - ANSWER From heavy use of alcohol over many years Short term memory problems MEDICAL EMERGENCY no treatment=death ACUTE/REVERSIBLE -thiamine deficiency -alcohol pickles brains Wernickes symptoms - ANSWER BLACKOUT altered gait -vestibular dysfunction -confusion -several ocular motility abnormalities -nystagmus/ orbital palsy/gaze palsy -aniscoria ( unequal pupil size) -hypovolemia -tachycardia -slurred speech -hypernatremia -cardiac dysrhythmias -tachypnea GIVE THIAMINE overtime results in korsakoffs Korsakoff's syndrome - ANSWER Chronic/irreversible -repeated wernickes leads to this -caused overtime -impaired memory -inappropriate behavior -impaired thinking -social skills affected blackouts - ANSWER excessive consumption of alcohol followed by episodes of amnesia Pregnancy - ANSWER Alcohol is most tetrogenic -alcohol during pregnancy= fetal alcohol syndrome -microcephaly -craniofacial malformations -limb/heart defects -low birth weight -increased risk of SIDS -fetal demise opioids - ANSWER men-overly emotional, very sensitive (increased estrogen) women- Increased fertility -relieve depression vulnerability of use - ANSWER decrease stress threshold -self medication -control panic/anxiety alcohol systemic effects - ANSWER Peripheral neuropathy Alcoholic myopathy and cardiomyopathy Esophagitis, gastritis, and pancreatitis Alcoholic hepatitis Cirrhosis of the liver Leukopenia Thrombocytopenia Cancer (head and neck) Routes of substance abuse administration - ANSWER -intranasal -trasndermal -rectal -IV= endocarditis -sublingual -oral Alcohol use disorder screening - ANSWER CAGE questionnaire C-cut down Annoyed Guilt Eye opener alcohol use assessment - ANSWER ASSESS WHEN THEIR LAST DRINK WAS any mental health symptoms -strengths -willingness to change -substance abuse -history of trauma family assessment -self assessment (personal thoughts/feelings) Alcohol use interventions - ANSWER Safety/sleep are first line interventions -gradual reintroduction of healthy foods/hydratopm -support/self care -identifying new coping skills/triggers -goal setting -administer medications -education on support groups/social activities -CBT/motivational interviewing -detoc -rehabilitation _AA Alcohol withdrawal interventions - ANSWER WITHDRAWAL WILL KILL SAFETY IS PRIORITY STAYS IN HOSPITAL FOR 72 hours -have seizure precautions (padded bed) -crash cart -suction/o2 CIWA score- shows how much Ativan to give at a time -subjective GIVE ATIVAN AS SCHEDULED plus need for PRN to prevent seizures ( not giving for behavior) if patient is asleep wake them up to give Ativan (safety preventing death) Alcohol withdrawal therapeutic management - ANSWER TYPICALLY STAYS CLEAN UNTIL NEXT STRESSFULL EVENT -not best time to teach them hard things educate on simple directions -coping skills/identify triggers -Educate on next relapse caused by stressed -educate them to use silence if confrontation at home occurs ALWAYS TELL THEM TO COME BACK IF THEY NEED HELP BECAUSE ALCOHOL WILL KILL THEM -always prepare them to have plan if something happens -be honest; tell them what is going to happen (they will drink and relapse at next stressful event) -ask if they have place to go when they have cravings -assess for support groups ( do they have somewhere to go where people will not be drinking) (AA, halfway houses, PHP, intensive outpatient programs,) Violence risk factors - ANSWER -trauma related -genetics -poverty -exposure -addiction/substance abuse -threat to self -neurotransmitters - lack of education Trauma informed care - ANSWER Ask what happened to you instead of why do you act like thus -past experiences depict future behavior PSYCHOANALYTICAL bad kids - ANSWER -setting fires -killing animals Delusion types - ANSWER Persecutory- belief that one is being singled out or harmed "Sarah believes her food is poisoned/ co workers are plotting to kill me" Referential- belief that events or circumstances that have no connection to you are somehow related to you "beliefs the birds songs are a secret message for him/ the radio is sending a secret message" Grandiose- one is powerful or important " I am god, the queen is my best friend" Erotomatic- belief that another person desires you romantically "Eric will marry me if his current wife would stop interfering" Nihilistic- major catastrophe will occur "giving away his belonging because a comet is going to hit earth" somatic- the body is changing in unusual ways "her heart is dead and rotting" Control- belief another person, group, external force controls thoughts or beliefs/feelings "covered his apartment walls with foil to block the aliens efforts to control his thought" NI for Bipolar 1 - ANSWER Your initial intervention is to physically stabilize: •Assess hydration and physical condition •Medicate Keeping an environment of decreased stimulation: •Clear and concise communication Reinforcing healthy patterns of sleep, eating and behavior: •Offer high calorie fluids frequently •Encourage frequent rest periods •Monitor I & O •Offer finger foods and high fiber foods NI Bipolar Disorder 2 - ANSWER •Encourage healthy patterns of eating, sleeping, etc. •Referrals to therapy •Medications as ordered Lithium - ANSWER •Lithium is a mood stabilizer •It takes 10 - 21 days to work, so other drugs may be used as an adjunct during this time •Lithium has a narrow therapeutic window and levels need to be drawn frequently •Fluid and sodium balance are important - dehydration, for example, may lead to toxicity. •Many drugs interact with Lithium •Long term use can cause hypothyroidism and goiter Lithium Toxicity - ANSWER •Normal range of Lithium: 0.6meq/L to 1.2meq/L •Beginning toxicity Levels over: 1.5meq/L •Severe toxicity Levels over: 2.0meq/L •Labs are drawn in the morning 10 - 12 hours after the last dose •Labs are monitored during initiation of Lithium and at any dose change until therapeutic levels are reached. After that, levels are drawn monthly. After about 6 months to 1 year of stability, the lab draws may go to every 3 months. Anticonvulsant Drugs - ANSWER •Anticonvulsant Drugs are also used as mood stabilizers Vaproates (Depakote and Depakene): •Monitor liver function, pancreatic function, platelet count, CBC's and drug levels. •Life threatening rashes may occur Carbamazepine (Tegretol): •Liver enzymes need to be monitored weekly for first 8 weeks •CBC's, pancreatic function, liver function, platelet count and drug levels need to be monitored ongoingly •Life threatening rashes may occur Lamotrigine (Lamictal): •Potential for life threatening rash •Monitor for liver toxicity and blood dyscrasias electroconvulsive therapy (ECT) - ANSWER •Painless, done under general anesthetic and paralytic agents also given •Airway must be closel