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A strong sense of dread accompanied by physical symptoms and autonomic nervous system responses.
Anxiety
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Anxiety is determined by a persons ability to deal with stressors....examples
- adaptability
- support
- coping mechanisms
- genetics
- presence of neurotransmitters
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tension of day to day living, the individual has an alert perceptual field and can motivate learning
mild anxiety
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focus is on immediate concerns, perceptual field is narrowed, and the individual exhibits selective attention
moderate anxiety
ie taking an exam
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focus is on specific detail, perceptual field is greatly reduced
sever anxiety
ie witnessed a car accident
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individual experiences a sense of awe, dread and/or terror. Individual has lost control and there is a disorganization of the personality
Panic anxiety
ie devastating earthquake
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generalized anxiety disorder
when a person has excessive worrying about every day things. This occurs more days than not for at least 6 months.
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S/S of Generalized Anxiety Disorder
- interference with ability to function-
- difficulty concentrating
- irritability
- muscle tension
- cant complete tasks
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Nursing Interventions for Generalized Anxiety Disorder
- cognitive therapy (explore feelings/thoughts and learning new ways to respond to stimuli)
- teach relaxation techniques
- teach thought stopping
- help patient to discuss irrational fears
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Panic Disorder
presence of recurrent, unexpected panic attacks. After the first attack the person will have a persistent concern about having another panic attack (anticipatory fear)
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Panic Disorder is:
Characterized by-
Physical symptoms-
characterized-disorganized thinking, feelings of terror, helplessness and non purposeful behavior
physical-dizzy, derealization, nausea, chest pains, SOB, hyperventilation
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Nursing interventions for panic disorder
- stay with patient
- talk in a calm quiet voice
- ask if have any distractors that relieve their physical symptoms
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Phobias
an exaggerated behavioral response to an old fear that no longer is an adaptive coping mechanism.
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Main coping mechanism for phobias?
avoidance...it is used to take the threat away, but it makes the anxiety worse cuz the patient eventually becomes for dependent on others.
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Nursing Interventions for phobias
- help the client learn to function in the presence of the phobic object without experiencing panic anxiety
- assist the client to overcome fear of leaving their home
- teach relaxation techniques
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Obsessions
unwanted repetitive and intrusive thoughts, impulses or images that interfere with ADL's and cause distress.
Theme-contamination/dirt, violence/safety, blasphemous thoughts and thoughts about one's own performance
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Compulsions
recurrent, irrational and infinitely repetitive behaviors USED TO DECREASE ANXIETY.
Behaviors include: hand washing, cleaning, checking, counting, repeating words, hoarding objects
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When does OCD occur?
when a person has a fear that's pushed out of their consciousness...anxiety occurs which causes compulsive thinking. The person gets a feeling of inadequacy. Those feelings are displaced on to an object or item and it creates a symbolic event. This symbolic event (compulsion) is used as an attempt at being able to control something which will in turn bring down their anxiety level.
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Nursing interventions for OCD
- Id the underlying emotion behind the compulsion
- help the pt recognize whats going on prior to the compulsion (triggers)
- Later in therapy....relaxation techniques, reinforce positive behaviors and alter diet to not include caffeine/alcohol
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Post Traumatic Stress Disorder
follows exposure to extreme trauma. Emotional response to the event involves intense fear, helplessness or horror.
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What determines the extent of PTSD?
- type of traumatic experience
- age of traumatic experience (older has more coping skills)
- recovery environment (with family or away)
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What's RAN for PTSD?
- R-reliving the event through nightmares or repetitive thoughts
- A-autonomic Arousal (fight or flight)
- N-numbing (person is emotionless)
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Nursing Interventions for PTSD
- obtain accurate history from significant others about the traums
- stay with pt during flashbacks/nightmares
- let pt talk about trauma at their own pace
- assist pt to try and comprehend trauma
- discuss feelings of vulnerability and their "place" in the world
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What's the best type of drug for panic disorders? Name them
Benzodiazepines-has the most immediate action
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Teaching for Benzos
- best for short term use
- high abuse potential
- withdrawals will occur if don't maintain steady state
- don't drink alcohol-additive effect
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Which medication is best for GAD and addictive disorders?
Buspar
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Positive about Buspar....and negative?
- Positive-no risk for physical dependence
- Negative-takes 2 weeks to start working
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2 Anti Depressants that treat anxiety
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What drug is good for treating GAD, OCD and PTSD?
SSRI's
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What treats GAD and agoraphobia?
Imipramine (Tricyclic Anti Depressant)
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What treats OCD?
Clomipramine (Tricyclic Anti Depressant)
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What drug is good for treating situational and performance anxiety?
Beta Blockers....decreases palpitations and heart rate
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What is used to sedate an anxious person?
Vistaril-antihistamine
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General Nursing Interventions for all anxiety disorders
- consider their anxiety level prior to trying to teach
- teach anxiety reduction techniques
- safety, safety, safety
- assist pt with problem solving
- encourage proper diet and rest/sleep
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How long does it take for alcohol to start depressing our CNS? Peak effect?
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Weird things chronic alcohol use causes
- peripheral neuropathy
- myopathy
- Wernickes encephalopathy
- korsakoffs psychosis
- cardiomyopathy
- leukopenia
- thrombocytopenia
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Wernicke's encephalopathy
- serious form of THIAMIN deficiency
- paralysis of ocular muscle
- diplopia
- ataxia
- somnolence stupor
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Korsakoffs psychosis
- seen with chronic alcohol use
- syndrome of confusion
- loss of recent memory
- confabulation
Permanent
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What does alcohol overdose look like?
- N/V
- shallow respirations
- cold, clammy skin
- weak, rapid pulse
- coma
- death
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What does Alcohol Withdrawal look like?
- seizures
- hallucinations
- irritability
- anxiety
- insomnia
- tremors
- sweating
- tachy
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When do alcohol withdrawal symptoms start?
seizures?
hallucinations?
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What do Delirium Tremors look like?
- confusion
- disorientation
- hallucinations
- tachy
- extreme tremors
- agitation
- diaphoresis
- fever
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When do DT's start and how long do they last?
usually 2-3 days after last drink, but can be as long as 14 days after
last about 5 days
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What kind of hallucinations does a person see with DT's?
visual and tactile
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How do you treat withdrawals and DT's?
- Vitamin and Mineral replacement
- meds to prevent hyper excitability and seizures
- protect from injury
- monitor fluids
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Meds that prevent hyper excitability and seizures
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Main given to people with alcohol problems....
Thiamin
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Antabuse
Helps to detox a person from alcohol
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How does antabuse work? Teaching?
- will cause person to have bad N/V if drink while on this medication
- teach pt to stay away from all alcohol, including:
- mouthwash, aftershave and perfume
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How long is the "wash out" period for antabuse?
14 days
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What will happen if a person drinks a lot of alcohol while on antabuse?
- SOB
- throbbing head
- low BP
- seizures
- death
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What does Naltrexone treat? How?
opiate and alcohol dependency
It is an abstinence promoter and relapse reducer (for alcohol) by blocking euphoric response to substance
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What is the name of the drug that a person takes after they have withdrawn from alcohol that:
reduces relapse severity
low risk for abuse
can be used safely with other meds
Campral
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What's the CAGE assessment?
- Asking the patient....
- Cut down-Have you ever felt you should cut down?
- Annoyed-Do you feel annoyed when people talk to you about drinking?
- Guilt-Have you ever felt guilty about your drinking?
- Eye Opener-Have you ever needed an eye opener?
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CIWA
Clinical Institute Withdrawal Assessment
- N/V
- Tremor
- Sweating
- Anxiety/Agitation
- Tactile/Auditory/Visual disturbances
- headache
- clouding of sensorium
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Examples of Sedative-hypnotic or Anxiolytics
CNS depressants-include barbituates, non barbiturate hypnotics and anti anxiety agents
Rohypnol/Roofies/Flunitrazepam/GHB
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How do sedative-hypnotic or anxiolytics work?
depress CNS (brain, nerves, muscles and heart)
level of depression depends on dose and potency(mild to death)
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What is used to get a person off of sedative-hypnotic or anxiolytics?
long acting barbituates or phenobarbital
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What are opiate narcotics?
- heroin
- morphine
- codeine
- dilaudid
- demerol
- vicodin
- oxycodone
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CNS effects of opiates
- euphoria/mood change/mental cloud
- papillary constriction
- respiratory depression
- antitussive-suppresses cough center
- N/V
- constipation
- hypotension
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What do you treat opiate OD with?
Narcan
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S/S or opiate OD
- shallow breathing
- shallow pulse
- clammy skin
- pulmonary edema
- respiratory distress
- convulsions/coma/death
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S/S of withdrawal for opiates
- terrible craving
- chills/sweats
- goose bumps
- abdominal pain/cramps/diarrhea
- runny nose
- irritability
- tearfulness
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Withdrawal treatment of opiates
- phenobarbital
- muscle relaxants
- anti diarrheal agents
- additional benzos
- clonidine
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Why do you give a person withdrawing from opiates clonidine?
it suppresses the opiate withdrawal symptom and is non addicting when used with Methadone
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2 ways to detox a person on opiates
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How does Buprenorphine work with detoxing a person from opiates? What must a person have to take this med?
must do in an office and it is less powerful than methadone and safer with fewer side effects.
addiction certificate
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How does methadone work?
prevents withdrawal from opiates by filling opiate receptor sites.
Must decrease the dose
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Dysfunctional family
- feelings are shut down
- needs/wants go unmet
- secrets
Denial is prevalent, walking on eggshells
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Co dependency
partner stays in a relationship with substance abuser and becomes the care taker. All effort goes in to taking care of the other, thus they fail to fully take care of themselves
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Enabling behavior
consciously or unconsciously facilitating the behavior of the substance abuser. It perpetuates the problem and and facilitates denial
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Hero in a dysfunctional family
- oldest
- shift of parent/child relationship by child taking on parents role
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What does a hero have a hard time with later in life?
transitioning in to an adult role
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Scapegoat in a dysfunctional family
the person the family blames for all of their problems
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What usually happens with the scapegoat?
- they get in to trouble at school
- family goes in to counseling and they find out about the alcoholic because the scapegoat got in to trouble
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Lost child in a dysfunctional family
they fly under the radar and do anything not to get hurt
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Mascot in a dysfunctional family
jokster....learn to break the tension in the family
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substitution therapy
the use of various medications to decrease the intensity of symptoms in an individual who is withdrawing.
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confabulation
a memory disturbance characterized by information that appears to be made up rather than true....fill in the gaps with lies
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Criteria for substance abuse
recurrent use of a substance resulting in failure to fulfill major role obligations at work, school and home
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Criteria for substance dependence
- evidence of tolerance
- evidence of withdrawal symptoms
- substance is taken in larger amts or longer than intended
- pt spends lots of time trying to obtain substance
- important social/occupation are given up cuz of substance
- substance is used even though problems are occurring
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Pre alcoholic
use of alcohol to relieve every day stress and tension in life
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Early alcoholic
- begins with blackouts
- alcohol is no longer a source of pleasure or relief
person starts to sneak drinks and feels guilty when drinks and becomes defense when talked to about drinking habits
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Crucial phase of an alcoholic
binge drinking-lasts hours to weeks
loss of job, marriage, family, friends and self respect
loss of control and physiologic dependence
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Chronic phase of an alcoholic
- helplessness and self pity
- person is now intoxicated more than sober
- life threatening physical manifestations in all body systems
- if abstain from alcohol-hallucinate, tremors, convusions, panic, and agitation
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How long since the last drink for Antabuse?
minimum of 12 hrs.
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dependency
compulsive or chronic requirement for a substance....if don't have it will experience physiological or psychological distress
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Who has the highest rate of alcoholism?
Euro Americans
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What is implicated in 70% of violent crimes?
alcohol
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What do Mexicans abuse the most?
alcohol
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What do Puerto Ricans and Cubans abuse the most?
Pot and coke
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Who has the lowest rate of substance abuse?
Asian Americans
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What culture has 3x the national average when it comes to alcoholism?
Native Americans
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Substance abuse and fetus/newborn
alcohol
cigs
marijuana
- alcohol-leading cause of preventable birth defects
- cigarettes-low birth weight and resp. problems
- marijuana-low birth weight and small heads
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What happens to the baby with Fetal Alcohol Syndrome?
- facial deformities
- hearing loss
- visual problems
- growth retardation
- cognitive problems/learning disabilities
- heart and kidney defects
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suppression vs. repression
- suppression is voluntary
- repression is involuntary
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4 types of involuntary committments
- mentally ill in need of treatment
- emergency commitment (behavior clearly trouble to self or others)
- involuntary outpatient (court ordered)
- gravely disabled client (cant basic necessities for self)
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Emergency restraints details
- Dr. must be notified within 1hr of restraing
- then.....order must be reviewed by Dr. within 4 hrs.
- In person re-evaluation at 8 hrs.
If pt no longer in restraints when verbal order expires, Dr. must reevaluate within 24 hrs.
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Charge for restraints/secluding pt without Dr. order?
false imprisonment
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Writ of habeus corpus
judicial review-go before judge and state why shouldn't be kept in a 5250
a person may request 1 per hold, they can choose to do this instead of probable cause hearing
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The doctor says I am not pregnant, but I know I am
somatic delusion
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I am made of chocolate and my families going to eat me
nihilistic delusion
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Example of magical thinking
patients thoughts have control over things or people
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concrete thinking
literal interpretation and lack of abstract thinking
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stereotypies
repetitive or ritualistic movement or utterance
rocking
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neologisms
inventing new words
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clang associations
rhyming all of the time
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word salad
a group of words put together randomly
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comfort drug for N/V
Zofran
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If somebody is in withdrawal from alcohol and has a CIWA score of 8....what do I do?
give 2mg or lorazepam and thiamine
below 8...nothing
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What do Sedative-hypnotics and anxiolytics do to a persons sleep?
decreased time in REM...but when in withdrawal, their dreaming becomes vivid and excessive
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Withdrawal from what substances can kill you?
- alcohol
- sedative-hypnotics
- anxiolytics
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When will you see withdrawal symptoms with sedatives-hypnotics and anxiolytics?
10-14 days after abstinence....must wean off slowly
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What is phenobarbital?
an anticonvulsant
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Difference btwn Buprenorphine and Methadone?
Buprenorphine is done in an office and Methadone can be taken at home or wherever
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antidote for benzo OD
Flumazenil
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nystagmus
tweeking eye when drunk
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agoraphobia
anxiety about being in places or situations from which escape would be difficult or embarrassing or in which help might no be available in the event of a panic attack
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What's the most common phobia and how do they deal with it?
agoraphobia....avoidance
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fear
a vital response to physical and emotional danger...intellectual and cognitive response
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coping behaviors
conscious attempts to protect oneself from the emotional pain of anxiety....may be ineffective or effective
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defense mechanisms
unconscious attempts to manage anxiety also may be adaptive or maladaptive
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Sociocultural information and anxiety
- women have it more often
- minority and poor children are at risk
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Elderly and benzos
- need to be reduced to protect kidney and liver functioning
- they cause cognitive impairment in them
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Utilize nursing process and critical thinking to plan, implement and evaluate care for pts with anxiety disorders
- stay with pt
- reassure safety
- maintain calm nonthreatening matter of fact approach
- simple words
- consider level of anxiety when doing pt teaching
- anxiety reduction techniques
- help with problem solving
- encourage nutrition, sleep and rest
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depersonalization
a sense of unreality or self estrangement
seeing oneself from a distance, like in a dream
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derealization
perception that the environment has changed....things seem unreal, smaller, fuzzy or out of focus.
Familiar objects become strange
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