MH Exam 5 Study guide
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Explain delusions, hallucinations, and delusions with paranoia
1.) A delusion is a fixed, false belief
2.) Hallucinations are sensory perceptions occurring in the absence of a stimulus
3.) Paranoia with delusions can occur in patients with paranoid schizophrenia and patients with drug induced psychosis
*Dual diagnoses clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychatric disorder should both be considered primary and receive simultaneous treatments.
Substance abuse withdrawal symptoms explanation
Substance dependence involves a lack of control over use. Patient develops tolerance and will experience withdrawal when intake is reduced or stopped.
In the early stages of narcotic withdrawal, the patient may have flulike symptoms without a temperature.
Withdrawal effects of CNS depressants: Cessation of prolonged heavy use of benzodiazepines, gluethimide, alcohol
- anxiety and irratibility
- tremors in hands, fingers, eyelids
- marked insomnia
- grand mal seizures
- (after 5-15 years of heavy use) - delirium
Withdrawal effects of CNS stimulants:
Cocaine and amphetamines
- agitation apathy
Withdrawal effects of opiates:
opium, heroin, Meriperidine (Demerol), Morphine, codeine, methadone, Hydromorphone (Dilaudid), Fentanyl (Sublimaze), Fentanyl analog
- runny nose
- Muscle aches
alcohol use disorder is the most common substance abuse problem in the US. A heavy drinker is described as a person who drinks every day and becomes intoxicated several times a month. There are about 2-3 men for every woman who becomes an alcoholic and 16-30 is the usual onset.
Asking a newly admitted patient with a history of alcohol abuse when the last time they had a drink is extremely important. The nurse needs to know when to begin looking for symptoms of withdrawal.
Illusions are common in early withdrawal from alcohol. The patient is misinterpreting a sensory perception.
Persons involved in AA should learn that the struggle will be life long and that it is done 1 day at a time.
considered a substance. Dependence (tolerance) potential is present. Withdrawal symptoms can occur with abstinence or reduction of use. Symptoms include: anxiety, craving poor concentration and headache.
the psychoactive drug in tobacco and dependence is considered the most common form of chemical dependence in the US today.
Cigarette smoke has more than 7000 chemicals and about 70 of those cause cancer. These chemicals alter mood, appetite, and alertness in ways users find pleasant and beneficial. Tobacco use is the leading cause of preventable deaths
What are the CNS depressants and stimulants?
- Depressants: alcohol, benzodiazepines, barbituates
- As patients withdrawal CNS depressants, the symptoms are similar. Generalized seizures are possible as well.
- Stimulants: cocaine, amphetamines, opiates, marijuana, hallucinogens, inhalants
- Patients that use inhalants may experience confusion, mouth ulcers and nose bleeds.
- Patients that have taken LSD may experience synesthesia (visions in sound), depersonalization and feelings of going "crazy"
Tolerance refers to needed higher and higher doses of a drug to produce the desired effect.
A habitual psychological and physiological dependence on the substance or practice beyone one's voluntary control
Symptoms and overdose effects of LSD use
The hallucinogenic effects produced by LSD results in flashbacks, and persistent perception disorder as well as hallucinations
- Intoxication effects are:
- Pupil dilation
- elevated TPR
- fear of going crazy
- paranoid ideas
- marked anxiety
- Overdose effects are:
- brain damage
Symptoms and overdose effects of inhalant abuse
- Intoxication effects:
- similar to alcohol
- slurred speech
- lack of inhibitions
- violent behavior
- Overdose effects:
- liver and brain damage
- heart failure
- respiratory arrest
- interferes with oxygen supply to vital organs
Important information to obtain in the assessment interview for substance abusers
- Current alcohol or other drug problems can be detected by asking two questions that are easily integrated into a clinical interview:
- 1.) in the past year, have you ever gotten drunk or used drugs more than you intended?
- 2.) Have you felt you wanted or needed to cut down on your drinking or drug use in the past year?
From these 2 questions, the nurse can then pinpoint specific drugs depending on the particular clinical situation. The nurse should ask questions in a straightforward, non judgmental fashion. Specific details include: names of drugs used, route, quantity, time of last use, and usual pattern of use.
Questions about alcohol or drug use should be asked as part of the assessment of any trauma. A urine toxicology screen or blood alcohol level measurement can be useful for assessment purposes.
Assessment strategies must include collection of data pertaining to both substance dependence and psychiatric impairment.
Once specific data are obtained, it is helpful to know if the person is abusing a substance or is actively dependent on the substance.
Important information to obtain in an assessment interview for chemically impaired patients
- Assess for severe or major withdrawal syndrome
- Assess for an overdose to a drug or alcohol that warrants immediate medical attention
- Assess the patient for suicidal thought or other self-destructive behaviors.
- Evaluate the patient for any physical complications related to drug abuse
How do you know if the treatment for substance abusers was successful
- Patient remains free from injury while withdrawing from the substance
- Patient is attending programs for treatment and maintenance of sobriety
- Patient is attending a relapse prevention progran during active course of treatment.
- Patient verbalizes cues or situation that pose increased risk of drug use.
- Patient has a stable group of drug free friends and socializing with them at least three times a week by (date)
- Patient demonstrates 1-3 new skills and dealing with trouble feelings (anger, loneliness, cravings, anxiety)
Nursing diagnoses for substance abusers
- Ineffective coping
- impaired verbal communication
- Social isolation
- Risk for loneliness
- Ineffective relationships
- Risk for suicide
Important notes to remember when dealing with a mass crisis situation.
The highest priority is safety. This can be assessed by asking the patient if they have thought of hurting themselves or others.
Immediately following a mass crisis situation, it is important that the victims have structure. Chaos is likely to occur so having a plan in place ahead of time and following that plan is crucial. Give clear instructions for people to follow so that they anxiety level may be reduced.
During a crisis is one time when the nurse may take a more active role by giving direction. Suggesting possible solutions to a patient experiencing crisis is important. The therapist must be open to the patient's situation.
What are strategies for crisis intervention?
Strategies of crisis intervention are directed toward the immediate cause of the crisis and area aimed at bolstering the emotional security and reestablishing equilibrium rather than focusing on underlying issues and long term resolutions. The goal is to return the individual to the pre-crisis level of functioning. Crisis intervention is by definition, short term
occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies.
Marriage, birth of a child, retirement are examples of maturational crises
arise from sources external to the individual such as a divorce and job loss.
Examples include: loss of job, death of a loved one, unwanted pregnancy, a move, change of financial status, divorce, severe physical and mental illness
occur when disasters such as natural disasters disrupt coping styles
Examples: national disasters, crimes of violence (rape, assault, murder in work place or school, bombings, spousal/child abuse)
Nursing diagnoses for a patient in crisis
Page 393 table 20-1
provides a systemic approach to guide departments and agencies at all levels of government, nongovernmental organizations and the private sector during disaster situations
Indicators of abuse - when to suspect some kind of abuse is going on
if a nurse suspects physical abuse/battery, the primary focus of assessment would be the physical injuries. Visible injuries need to be assessed and the possibility of further injury (internal) needs to be determined.
Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises and fractures as various stages of healing suggest the possibility of abuse. In older children vage complaints such as back pain may also be suspicious.
When a parent doesn't allow a child to attend school, it's considered neglect. The child's right to gain knowledge has been taken away.
Injuries such as concussion could suggest violence is involved. Other indicators would need to exist as well and the nurse would need to look for signs or fearfulness, depression, poor eye contact and a possessive significant other. The nurse should ask the significant other to leave the room and complete the assessment questioning. When the significant other will not leave or answers all the questions for the patient, the nurse should say this is a red flag, especially if all the other indicators are in place.`
How to recognize signs of emotional abuse
- Speech disorders
- lag in physical development
How to recognize signs of physical abuse
- unexplained burns, bruises or welts, broken bones, internal injuries, and bite marks.
- bald patches on scalp
- subdural hemorrhage
- retinal hemorrhage
how to recognize signs of sexual abuse
- difficulty in walking/sitting
- Torn, stained, or bloody underclothing
- Bruises or bleeding in external genitalia, vaginal or anal areas
- veneral disease, especially in preteens
- in boys, pain on urination or penile swelling or discharge
- foreign matter in rectum, vagina, or urethra
Nursing diagnoses for abused patients
- Risk for injury
- Safety is primary but others include:
- disabled family coping
- post-trauma syndrome
- impaired parenting
- acute pain
- delayed growth and development
- imbalanced nutrition: less than body requirements.
It is not a crime of sex. It's a crime of power, control and humiliation. The perpetrator wishes to subjugate the victim.
Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears and phobias occur in the long-term reorginization phase of rape trauma syndrome.
What is the nurse's role with victims of rape?
Along with assessment and other duties, the SANE, collect and presereve evidence, obtain the proper consent forms and provide prophylaxis medications for pregnancy and STDs.
The nurse must be careful when documenting. The terms used should not place blame on or show disapproval of the victim.
Educating rape victims
The telephone counselor establishes where the victim is and what has happened and provide the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until the immediate problems are solved. The victim remains anonymous. Counselors should remain empathic rather than sympathetic.
Due to the anxiety level of victims suffering from sexual assault, all educational materials should be provided in written format. These patients are unable to concentrate and therefore will not retain much of what is verbally said to them.
Explain the acute phase of rape trauma syndrome
Shock, numbness and disbelief
A person may appear self contained and calm and at other times cognitive function may be impaired, and the person may have difficulty making decisions, solving problems or concentrating. Or the person may cry, become hysterical, be restless or even smile.
Describe the long term phase of rape trauma syndrome
re-experiencing the trauma: recurrent nightmares about the rape, flashbacks, or uninvited, intrusive thoughts day/night
Social withdrawl: called "psychic numbing" and involves not experiencing feelings of any kind.
Avoidance behaviors and actions. Avoidance of all places and activities, as well as thoughts or feelings that could recall events about the rape.
increased psychological arousal chacteristics:exaggerated startle response, hypervigilance, sleep disorders, or difficulty concentrating.
Fears and phobias: fears of being alone, fear of sexual encounters, fear of the indoors/outdoors and just some examples
Nightmares and difficulty sleeping. Vivid nightmares of the event waking the individual and causing terror, disturbing sleep and preventing sleep.
Nursing diagnoses for intimate partner violence (IPV)
- Need immediate focus:
- Risk for violence
- Risk for injury
- Acute/chronic pain
- risk for trauma
- risk for self-directed or other-directed violence
- Need to be considered:
- social isolation
- disturbed sleep pattern
- disturbed personal identity
- risk for post-trauma syndrome
- disabled family coping
Important information about suicide
Up to 10% of patients with schizophrenia die from suicide, usually r/t depressive symptoms occurring in the early years of the illness
A person who's previously attempted suicide who has been on antidepressants, has an increase in energy and mood, needs to be watched closely. It may appear that the person is getting better but it is possible the person is still considering suicide and they now have more energy to complete the action.
During counseling with a person who has attempted suicide, the nurse helps the patient identify and develop effective coping skills. The nurse assists the patient to reduce the overwhelming effects of problems by prioritizing them.
When a patient successfully commits suicide while hospitalized, interventions should be aimed at helping the staff and patients come to terms with the loss. A community meeting should be scheduled to allow other patients to express feelings and request help if needed. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support.
Who is at risk for suicide?
People who attempted suicide have lower serotonin functioning. However, those who have completed suicide have the lowest levels.
Suicide has long been shown to cluster in some families - therefore family history is pertinent.
People who are psychotic are at a high risk for suicide, especially those who experience command hallucinations telling them to kill themselves or having delusions that they must die.
There is a trio of psychological-emotional factors often present when people become suicidal: hopelessness (lack of purpose), helplessness (lack of social supports) and feelings of worthlessness (lack of self-esteem or lack of love for self).
Suicide risk factors include:
- Presence of pain
- Previous suicide attempt
- History of mental disorder, particularly depression or alcohol or drug abuse
- Impulsive or aggressive tendencies
- Adverse life events, recent or expected loss
- feelings of hopelessness or isolation
- family hx of mental or substance abuse disorder
- family hx of suicide or attempts
- family violence, including physical/sexual abuse
- Exposure to suicidal behavior of others, including family, peers, newsworthy persons or fiction.
- Chronic physical illness, particulary if associated with chronic pain
- Native Americans have the highest suicide rate
Explain age as a risk factor for suicide
Suicide rates are increasing at the highest rate in the 14-24 y/o range. The data seems to point to increased rates of alcohol/drug use in depression among this age cohort.
The strongest risk factors for youth are substance abuse, aggression, disruptive behaviors, depression, and social isolation.
- Other risk factors for youth suicide:
- - Frequent episodes of running away
- - Frequent expressions of rage
- - family loss or instability
- - frequent problems with parents
- - withdrawal from family and friends
- - Expression of suicidal thoughts or talk of death or the afterlife when sad or bored.
- - Difficulty dealing with sexual orientation
- - Unplanned pregnancy
- - Perception of school, work, or social failure
Suicide victims and survivors
Survivors often feel that they are “going crazy” and need to be told that these feelings are normal. Survivors also need outlets for the undercurrent of anger against the deceased, who is responsible for the trauma, confusion, and pain inflicted on them. Unfortunately, few friends or family members of a person who has committed suicide seek counseling. Pronounced feelings of anger and guilt are common reactions. Within 6 months of the suicide, 45% of the survivors report mental deterioration, with symptoms of depression or posttraumatic stress disorder. Family members of the suicide victim exhibit a higher rate of suicide—4.5 times greater than the risk found in families in which no suicide occurred.
nursing diagnoses for suicide
- Most immediate:
- Risk for suicide (w/self-restraint from suicide being the ideal outcome)
- Other Nursing Dx:
- ineffective coping
- social isolation
- spiritual distress
- chronic low self esteem
- disturbed thought processes
- post-trauma syndrome
Communication techniques to use with aggressive patients
If the patient is approachable and the nurse can assess that they are escalating address them calmly and attempt to speak to them about their current feelings. Do not demand them to do anything at this point. Remain therapeutic and speak in a neutral/normal conversational tone.
Important information to know about aggressive patients
At times, especially on initial admission, a patient may need to be secluded to protect themselves and others on the unit. The nurse must immediately contact the physician to obtain a seclusion order and follow facility policy to ensure the safety of the patient.
The patient shouldbe given the opportunity to leave the area on his or her own free will. The nurse and patient can feel safe in a team setting. So it's ok to approach the aggressive pt with 3+ staff members present. if the nurse has to administer a medication to an aggressive pt they still need to attempt to provide privacy and the truthful information regarding the medicine. (What is it for and why it needs to be given)
If a person is assaulted, it is normal to initially have feelings or preoccupation with the incident, trouble sleeping and startle easily. If the person begins to have feelings of wanted revenge, assistance should be found.
Restraint and seclusion of aggressive patients
Seclusion “is the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving. It may only be used for the management of violent or self-destructive behavior” (APNA, 2007).
Restraint refers to (1) “any manual method, or mechanical device, material or equipment attached or adjacent to patient's body where they cannot move their arms, legs, body, or head freely” (Health Care Financing Administration [HCFA], 1999) or (2) “a drug or medication when it is used as a restriction to manage the person's behavior or restrict the person's freedom of movement and is not a standard treatment or dosage for the person's condition” (APNA, 2007).
The least restrictive means of restraint is always tried first and seclusion/restraint is used only after alternative interventions have been attempted (e.g., medications, verbal interventions, decrease in sensory stimulation, removal of a particular problematic stimulus, presence of a significant other, frequent observation, and use of a sitter who provides 24-hour one-to-one observation of the patient).
Signs and symptoms of increasing aggression
Expressions of anxiety and anger generally look similar. Both may involve increased demands, irritability, frowning, redness of the face, pacing, twisting of the hands, or clenching and unclenching of the fists. Changes in mood and behavior from quiet to talkative and loud, from talkative to silent and withdrawn, from calm to angry, or from depressed to elated also may occur. Box 24-1 identifies signs and symptoms that indicate the risk of escalating anger, which may in turn lead to aggressive behavior. Simple observation of these signs, however, does not provide the information necessary to determine the appropriate intervention.
Personality styles and aggressive behaviors
Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves.
Hospitals can be lonely, scary places for many people. Patients often feel that they are not being heard, and they may feel vulnerable, discounted, frightened, out of control of their situation, and tired. Some patients may have specific vulnerabilities for responding to their increasing anxiety and loss of autonomy through the use of violence. Therefore some patients with poor coping skills or mental or neurological problems may resort to anger, intimidation, or violence to obtain their short-term goals of feelings of control or mastery. For others, the anger occurs when limited or primitive attempts at coping are unsuccessful and alternatives are unknown. For these patients, anger and violence are particular risks in inpatient settings.
This is especially true for hospitalized patients with chemical or alcohol dependency who may be anxious about not having access to their substance of choice; they may have well-founded concerns that any physical pain will be inadequately addressed. Many patients with marginal coping also have personality styles that externalize blame. That is, they see the source of their discomfort and anxiety as being outside themselves; relief must therefore also come from an outside source (e.g., the nurse, medication).
Interventions begin with attempts to understand and meet the patient's needs
Nursing diagnoses for aggressive/violent patients
when anxiety escalates to levels at which there is a threat of harm to self or others, ineffective impulse control, risk for self-directed violence and risk for other-directed violence are primary diagnoses
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