Autism

AUTISM VS. AD/HD

A 7 year old child has attention deficit hyperactivity disorder. The child is most likely to exhibit which of the symptoms? A. restlessness, decreased attention span and silence B. hyperactivity, failure to complete tasks and distractibility C. impulsiveness, anhedonia and shyness •

D. poor concentration, decreased attention span and somatic complaints

• Situation: A public health nurse during one of her home visits to a postpartum mother observed Noel, 5 years old sitting by himself in the corner of the room, rocking back and forth and spinning his toy occasionally. A child suffering from autism manifest one of the following behaviors: A. often shifts from uncompleted activity to another B. talks excessively C. may indulge in repetitive play with fingers and hands D. has difficulty playing quietly

• • • •

AUTISM

Living in their own world Appearance – flat (consistent) Behavior – ritualistic, repetitive Communication – echolalia, incomprehensible

NX: Impaired Verbal Communication Impaired Social Interaction Self Mutilation Risk for Injury

ADHD

Attention-deficit / hyperactive disorder –(I-HI) 7 years old and above • Duration: 6 months and above • • Requires 2 settings: home and school • • •

Appearance: Dirty child Behavior: Clumsy, hyperactive, impatient Communication: talkative, bursts out

• • • •

Structure Setting limits Schedule Safety

ADHD • Important to distinguish ADHD from normal, active behavior, behavioral signs of psychosocial stressors, inadequate parenting, or other psychiatric disorders such as bipolar disorder • Can persist into adulthood • Often diagnosed when child starts school

ADHD

• At school age, symptoms of ADHD begin to interfere significantly with behavior and performance: – Fidgets constantly – Makes excessive noise – Normal environmental noises are distracting – Cannot listen to directions or complete tasks – Blurts out answers before questions are completed – Hurried, careless mistakes in schoolwork – Loses or forgets homework assignments – Fails to follow directions – Peers may ostracize

Treatment

Combination of pharmacotherapy with behavioral, psychosocial, and educational interventions • (CARD)

• Stimulants: pemoline (Cylert) amphetamine compound (Adderall), methylphenidate (Ritalin), an dextroamphetamine (Dexedrine), and • Common side effects: insomnia, loss of appetite, and weight loss or failure to gain weight

• • • • •

Strategies for Home and School

Therapeutic play techniques Offering consistent praise Using time-out Giving verbal reprimands Helping with parenting strategies

• Providing consistent rewards and consequences for behavior • Issuing daily report cards for behavior • Give point systems for positive and negative behavior

Autism Etiology Growth & Development, brain anoxia, medications, Appearance genetic Clean, flat, act as deaf Behavior Ritualistic, insensitive to pain, no fear to death, uncuddly, point s to anything,

AD/HD Decrease glucose; early malnutrition; prenatal trauma; Dirty, low hereditary; self-esteem, social Clumsy, hyperactive, inattentive

Autism Communica Echolalia; tion giggling laugh NX Impaired verbal communication ; impaired social interaction; risk for injury (directed to Nursing Safety self) Priority

AD/HD Excessive talking, burst out in class Impaired social interaction; risk for injury (directed to others) safety

Nutrition

Treatment Milieu Activity Attitude therapy

Autism Increase nutrient requirement Antipsychotic drugs Stimulating environment Noncompetitive, monotonous Active friendliness

AD/HD Increase in calories, finger foods Ritalin, Dexedrine, Cylert Non- (C-A-RD) stimulating Quiet, noncompetitive Kind firmness

• The parents asked what are the side effects of Ritalin which was prescribed for Rico: • a. insomnia and palpitations • b. crying and uncontrolled eating • c. laziness and sleepiness • d. extreme obedience

• A 7-year old is hospitalized with a diagnosis of autism The nurse observes the child upon admission. Which of the following information regarding his behavior would confirm that he is an autistic child ? A. lack of interest in inanimate object B. dislike of routine C. unresponsive to others D. below average intelligence

• A child scores between 55 and 68 on standardized intelligent quotient (IQ) assessment test. The nurse is aware that this degree of intellectual impairment would be considered: a. mild b. severe c. profound d. moderate

Mental Retardation

Mental retardation • Subnormal general intellectual functioning which originates during the developmental period and is associated with impairment of either learning and social adjustment or maturation or both.  

• • • • • • • • •

Causes: 1. congenital numerical deficiency or abnormal arrangement of

brain cells 2. birth injuries due to pelvic disproportions, premature births or forceps delivery 3. infectious diseases e.g. german measles of the mother during the first 3 months of pregnancy 4. infectious diseases during childhood e.g. meningitis or encephalitis 5. endocrine deficiencies such as thyroid deficiency, known to be the cause of cretinism 6. exposure to environmental deprivation, with poor housing and economic and social conditions 7.  familial or hereditary causes 8. inborn errors of metabolism e.g. inability to metabolize proteins, carbohydrates or fats 9.  genetic defects e.g. abnormalities in the genes and chromosomes

Physical Appearance • small head; almond-shaped, downward slanted eyes; thick lips.short fat hands with usually one palmar line (simian crease); yellow complexion • tongue is flabby with deep groves and fissures • friendly and love to imitate others • acute leukemia is more prevalent in them • usually mouthbreathers and prone to respiratory infections • many die at an early age • Temper tantrums

Classification of mental retardation according to IQ CATEGORY

IQ

Borderline

68-85

mild

52-67

moderate

36-51

severe

20-35

profound

Under 20

Mild (Educable/Moron)

• Can develop social communication skills; minimal retardation in sensorimotor areas; often not distinguished from normal until late age (0-5 years) • Can learn academic skills up to approximately 6th grade until late teens. Can be guided toward social conformity, ‘educable’ (6-20 years) • Can usually achieve social and vocational skills adequate to minimum self-support but may need guidance and assistance when under unusual social or economic stress(21adult

Moderate (Trainable/Imbecile)

• Can talk or learn to communicate; poor social awareness; fair motor development, profits from training in self-help; can be managed with moderate supervision (0-5) • Can profit from training in social and occupational skills; unlikely to progress beyond second grade in academic subjects; may learn to travel alone in familiar places (6-20) • May achieve self-maintenance in unskilled or semi-skilled work under sheltered conditions; needs supervision and guidance when under mild social or economic stress

Severe(Imbecile)

• Poor motor development; speech is minimal; generally unable to profit from training in self-help; little or no communication skills (0-5) • Can talk or learn to communicate; can be trained in elemental health habits, profits from systematic habit training (6-20) • May contribute partially to self maintenance under complete supervision; can develop self-protection skills to a minimal useful level in a controlled environment (21-adult)

Profound (Idiot)

• Gross retardation; minimal capacity for functioning in sensorimotor areas;needs nursing care (0-5) • Some motor development present; may respond to minimal or limited training in self-help (6-20) • Some motor and speech development; may achieve very limited self-care; needs nursing care (21-adult)

Nursing Care • Help parents accept diagnosis of mental retardation • Consider the developmental/functional age, not the chronological age

• Teach parents/caregivers that they should:

– Protect the child from danger – Make the child as independent as his condition will permit – Teach the child to refrain from holding their mouths open as this gives them a dull appearance – Select attractive, well-fitting clothing, hairstyle and good hygiene practices – Eliminate the child’s undesirable social traits, e.g. touching their noses and ears, scratching – Refrain from scolding because it blocks learning – Recognize that temper tantrum as a child’s attempt to meet some underlying emotional needs

Nursing Care

• Teach parents/caregivers that they should: – When teaching the child: » Demonstrate » Use pictures for these are valuable teaching aids » Start teaching simple things, gradually progressing to complex learning experiences » Teach only one thing at a time » Repetition and patience are necessary virtues

Conduct Disorder

Conduct Disorder • A complicated group of behavioral and emotional problems in youngsters • Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms are violated • Appears in early or middle childhood as oppositional defiant behavior

4 Main Groupings: • • • •

Aggression to people and animals Destruction of property Deceitfulness, lying or stealing Serious violations of rules

Subtypes:

• Childhood-Onset Type

Symptoms before 10 years of age:

– Physical aggression toward others – Disturbed peer relationships – More likely to have persistent conduct disorder and to develop antisocial personality disorder as adults

• Adolescent-Onset Type

No behaviors of conduct disorder until after 10 years of age: – Less likely to be aggressive – Have more normal peer relationships – Less likely to have persistent conduct disorder or antisocial personality disorder as adults

Classifications:

• Mild- is applied if there are few, if any conduct problems in excess of those required for diagnosis, and if these cause only minor harm to others (ex.lying, truancy) • Moderate- applied when the number of conduct problems and effect on others are intermediate between “mild” and “severe” (ex.vandalism, bullying, aggression to animals) • Severe- when many conduct problems exist which are in excess of those required for diagnosis or the conduct problems causes considerable harm to others or property (ex. Crimes, arson)

Causes: • School-related factors • Parent psychological factors (maternal depression, paternal alcoholism, antisocial behavior) • Divorce, marital distress and violence • Family adversity • Parent-child interactions

Treatment:

• Early intervention is more effective; prevention is more effective than treatment: – – – – –

Preschool programs Parenting education Social skills training Family therapy Individual therapy

• Antipsychotics, lithium, or other mood stabilizers such as carbamazepine (Tegretol) or valproic acid (Depakote) for labile moods or aggressive behavior

Oppositional Defiant Disorder

Oppositional Defiant Disorder • A psychiatric behavior disorder that is characterized by aggressiveness and a tendency to purposely bother and irritate (pattern of stubbornness)

• • • • • • • • • •

Behavioral symptoms:

Losing one’s temper Arguing with adults Actively defying requests Refusing to follow rules Deliberately annoying other people Blaming others for one’s own mistakes or misbehaviors being touchy, easily annoyed Speaking harshly or unkind when upset Seeking revenge Having frequent temper tantrums

Treatment • Parent training • Giving medication if there is underlying other disorder • Caregiver should take frequent vacations

Separation Anxiety Disorder

• Excessive anxiety about separation from home or loved ones, exceeding what would be expected • Results from combination of:

– Temperament traits (passivity, avoidance, fearful or shy of novel situations) – Parenting behaviors that encourage avoidance as a way to deal with unknown situations Treatment: Parent education and family therapy

• The nurse is caring for several patients who have eating disorder. Based on appearance, how would the nurse distinguish bulimic patient from anorexic patients? • a. by their teeth • b. by the body size and weight • c. by looking Mallory-Weiss tears • d. the patients are indistinguishable upon physical examination

• The nurse is caring for a bulimic patients and an anorexic patient. What cognitive characteristic would be similar for both of these patients: • a. perfectionism, preoccupation with food • b. relaxed personality by preoccupied by food • c. no similarities • d. preoccupations with exercise

•

The nurse is aware that the signs and symptoms that would be most specific for diagnosing anorexia nervosa are: A. slow, pulse, 10% weight loss, and alopecia B. compulsive behaviors, excessive fears, and nausea C. excessive activity, memory lapses, and an increased pulse D. excessive weight loss, amenorrhea, and abdominal distention

EATING DISORDERS

ETIOLOGY

• Biological: increase levels of serotonin cause inhibited appetite; also to anxious, rigid and obssessional behaviors • Sociocultural: “slim is beautiful” • Family factors: twins • Cognitive and behavioral: staying slim is reinforced by attention given by other people • (Freud) 2 basic drives of humans: sexual and eating- considered nurturing; anorexics reject nurturing and the two appetites are repulsive

• Eating disorders can be viewed on a continuum: the anorexic eats too little, the bulimic eats chaotically, and the obese person eats too much. Eating disorders overlap: 50% • of clients with anorexia exhibit bulimic behavior, 35% of normalweight clients with bulimia have a history of anorexia. More than 90% of clients with • eating disorders are female.

Anorexia Etiology Psychological (Freudian); Socio-cultural; Manifestatio gender Lanugo, ns hypothermia, amenorrhea, Behavior Diet, diet, parotitis diet…die Fear of weight gain; preoccupation food Communica with Denial (knowledgeable tion in nutrition)

Bulimia Familial, internal Dao ming Su… Diet, diet, diet…vomit Binge eating; purging; still on diet Verbalization of body dysmorphic

Nx

Nx Priority Treatment / Therapy

Environment

Anorexia Nutrition Body Image disturbance Nutrition, promote selfesteem CBT; weight gain; behavioral modification / Kind Firmness Stay with the client one hour after eating; Don’t allow client to go to toilet at

Bulimia Imbalance nutrition more than or less than Nutrition; promote selfesteem CBT; weight gain; behavioral modification / Kind Stay Firmness with the client one hour after eating; Don’t allow client to go to

Anorexia Nervosa

• Refusal or inability to maintain a minimally normal body weight • Intense fear of gaining weight or becoming fat • Significantly disturbed perception of the shape or size of the body • Steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists

Anorexia Nervosa 85% or less of expected body weight Amenorrhea Preoccupation with food and food-related activities Restricting subtype loses weight dieting, fasting, or excessively exercising • Binge eating and purging subtype engages in binge eating followed by purging • • • •

Onset and Clinical Course • Typically begins between 14 and 18 years of age • Ability to control weight gives pleasure to the client • Client may feel empty emotionally and be unable to identify or express feelings • As illness progresses, depression and labile moods are common

Treatment: Anorexia Nervosa

Setting depends on severity of illness: • Medical management; risk of suicide is significant – – – – –

Weight restoration Nutritional rehabilitation Rehydration Correction of electrolyte imbalances Supervised access to a bathroom to prevent purging

Psychopharmacology Amitriptyline (Elavil) and the antihistamine cyproheptadine (Periactin) can promote weight gain. Olanzapine (Zyprexa) because of its effect on body image distortions Fluoxetine (Prozac) prevents relapse.

Psychotherapy Family therapy Individual therapy

Bulimia Nervosa

• Characterized by recurrent episodes of binge eating, then compensatory behaviors to avoid weight gain (purging, use of laxatives, diuretics, enemas, emetics, fasting, excessive exercise) • Binge eating is done in secret • Client recognizes behavior as pathologic, causing feelings of guilt, shame, remorse, or contempt • Usually normal weight

Onset and Clinical Course • Begins at about age 18 or 19 • Binge eating begins after an episode of dieting • Between binges, eating may be restrictive • Food is hidden in the car, desk at work, and secret locations around the house • Behavior may continue for years before it is discovered

Treatment: Bulimia Nervosa

Most clients are treated on outpatient basis: Cognitive-behavioral therapy Psychopharmacology

Antidepressants: desipramine (Norpramin), imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), phenelzine (Nardil), and fluoxetine (Prozac)

• Theodore begins to experience alcohol hallucinosis. The best nursing intervention at this time is to: A. keep the patient restrained in bed B. check the patients BP every 15 minutes and offer him juices C. provide a quite environment &administer medication as needed D. restrain the patient & check his BP every 30 minutes

• Which one of the following factors will ensure the ability of an alcoholic to abstain from alcohol? • A. family support system • B. can help himself • C. expresses regret about drinking too much alcohol • D. overcoming the denial that he has an alcohol problem

• The nurse is talking to the patient about amphetamine, cocaine and caffeine. How would the nurse classify this substance? • a. opiates • b. analgesics • c. stimulants • d. depressants

Which assessment findings indicate chronic cocaine use? • a. craving for sweets • b. lack of coordination • c. pinpoints pupil • d. nasal septum deterioration

CHEMICAL DEPENDENCE Alcohol Abuse Substance Abuse

Substance Dependence

• maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three or more of the following, occurring at any time in the same 12 month period – Tolerance – Withdrawal – Substance is often taken in larger amounts or over a longer period than intended – Persistent desire or unsuccessful effort to cut down – Time is spent in activities necessary to obtain the substance, use the substance or recover from its effects – Important social, occupational or recreational activities are given up or reduced because of substance use.

• Intoxication is use of a substance that results in maladaptive behavior • Withdrawal syndrome refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases • Detoxification is the process of safely withdrawing from a substance • Substance abuse is using a drug in a way that is inconsistent with medical or social norms and despite negative consequences • Substance dependence includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance

• Blackout drinking in which the person continues to function but has no conscious awareness of his or her behavior at the time nor any later memory of the behavior • As the person continues to drink, he or she often develops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect • After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol will intoxicate the person • The later course of alcoholism, when the person’s functioning definitely is affected, is often characterized by periods of abstinence or temporarily controlled drinking

Alcohol Abuse

Ethanol Alcohol dehydrogenase (enzyme)

hydrogen Bypass source of Energy in the liver

acetaldehyde(toxic) aldehyde dehydrogenase acetic acid (non toxic)

• One drink= 1 oz 86 proof “hard liquor”= 5 oz glass of table wine= 12oz can/bottle of beer • Legal limit= 5-6 drinks (non tolerant) • Beer=4% alcohol • Wine=12% alcohol • Liquor=40-50% alcohol • Healthy body can metabolize 10ml of alcohol every 90minutes • Tolerant drinker- 10-12 drinks before intoxication

CAGE QUESTIONNAIRE • Cutting Down –Have you ever felt you should cut down on your drinking? • Annoyance-Have people annoyed you by criticizing your drinking? • Guilty- Have you ever felt guilty about your drinking • Eye opener- Have you ever had a drink first thing in the morning to steady your nerves or get rid of hang-over? *2-3 yes answers to these questions strongly suggest dependence on alcohol

Alcohol Abuse • Alcohol is a legal substance • A central nervous system depressant • A disease that can be arrested but not cured. • Used with other substance

• • • • • • •

ALCOHOLISM

Intergenerational Transmission Awake but unaware Blackout Confabulation Denial, dependence Enabling, co-dependence Tolerance increases

• Detoxification - doctor

ALCOHOLISM

Avoid alcohol during therapy Aversion therapy Antabuse – disulfiram Belongings – check for alcohol, mouthwash, elixir etc. • B1 deficiency • Complication • • • •

– Wernicke’s Encephalopathy (Motor) – Korsakoff’s Psychosis (Mind)

• Delirium Tremens • Formication

Principles of Nursing Care • Provide a well-lighted room • DAT; Vitamin B1; Glucose • Monitor v/s • Long term therapy – Support system – • Alcoholic Anonymous • Alanon • Alateen

Principles of Nursing Care • Family therapy • Provide safety: alcohol free environment • Increase self-esteem • Resocialization

Common medications: • • • • • •

Antabuse Vit. B1 or thiamine Valium Magnesium sulfate Multivitamins anticonvulsants

Stages of Alcohol Withdrawal

• I 8 hours after the last drink

– Mild tremors, tachycardia, increased BP, diaphoresis, nervousness

• 2 8-12 hours after the last drink

– Gross tremors, hyperactivity, profound confusion, loss of appetite, insomnia, weakness disorientation, illusions, hallucinations and delusions

• 3 12-48 hours after the last drink

– * severe hallucinations, grand mal seizures

• 4 3-4 days after the last drink

– Delirium tremens, confusion, agitation, hallucinations, insomnia and tachycardia

CODEPENDENCY

• An over responsible behavior-doing for others what they just as well do to themselves • Women or wives of alcoholics • Codependent individuals find themselves: 1. Attempting to control someone else’s drinking 2. Spending inordinate time thinking about the alcoholic person 3. Covering up the person’s drinking or lying 4. Feeling responsible for the person’s

CODEPENDENCY

5. Feeling guilty for the alcoholic’s behavior 6. Avoiding family and social events because of concerns or shame about the alcoholic’s behavior 7. Allowing moods to be influence by the alcoholic 8. Assuming the alcoholic’s duties and responsibilities 9. Often bailing the alcoholic out of financial or legal problems

• . A young man is being assessed for early sign of narcotic withdrawal , which include: a. yawning and perspiring b. drowsiness and fruity odor to the breath c. syncope and pulse deficit d. bradycardia and headache

UPPERS AND DOWNERS

UPPER Cocaine Hallucinogens Amphetamines

DOWNERS Marijuana Alcohol Barbiturates Opiates Narcotics HEROIN CODEINE MORPHINE

Sedatives, Hypnotics, and Anxiolytics • Central nervous system depressants • Benzodiazepines alone, when taken orally in overdose, are rarely fatal, but the person will be lethargic and confused • Barbiturates, in contrast, can be lethal when taken in overdose. They can cause coma, respiratory arrest, cardiac failure, and death

• Withdrawal symptoms in 6 to 8 hours or up to 1 week • Withdrawal syndrome is characterized by symptoms opposite of the acute effects of the drug: – Autonomic hyperactivity (increased pulse, blood pressure, respirations, and temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitation; seizures and hallucinations occur rarely in severe benzodiazepine withdrawal

• Detoxification from sedatives, hypnotics, and anxiolytics is managed by tapering the amount of the drug

Stimulants (Amphetamines, Cocaine, Others)

Central nervous system stimulants Overdoses can result in seizures and coma Withdrawal occurs within hours to several days Withdrawal syndrome: – Dysphoria accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation; withdrawal symptoms are referred to as “crashing”--the person may experience depressive symptoms, including suicidal ideation, for several days • Stimulant withdrawal is not treated pharmacologically • • • •

Cannabis (Marijuana)

• Used for its psychoactive effects • Excessive use of cannabis may produce delirium or cannabis-induced psychotic disorder; overdoses of cannabis do not occur • Withdrawal symptoms:

– Insomnia, muscle aches, sweating, anxiety, and tremors

• Effects are treated symptomatically

Opioids • Central nervous system depressants • Overdose can lead to coma, respiratory depression, pupillary constriction, unconsciousness, and death • Withdrawal: – Short-acting drugs: begins in 6 to 24 hours; peaks in 2 to 3 days and gradually subside in 5 to 7 days – Longer-acting drugs: begins in 2 to 4 days, subsiding in 2 weeks

opioids stimulate opioid receptors endorphins (neurotransmitter mediating pain attracted) increase pain threshold euphoria (better than sex)

Heroin-more commonly abused narcotic (fat-binding) -becomes morphine in the brain, trapped, sustained euphoria Narcotics- risk for AIDS due to needle sharing

Respiratory depression

Sensitivity to CO2 stimulation by the medullary center for respiration – Primary cause of death PNS effects: constipation, decreased gastric, biliary and pancreatic secretions, urinary retention, hypotension, reduced pupil size Pinpoint pupils-sign of narcotics overdose AIDS- common because of needle sharing

Symptom pattern of respiratory depression: Person becomes stuporous Sleeps(Skin is wet and warm ) a coma develops, accompanied by respiratory depression and hypoxia skin becomes cold and clammy pupils dilate DEATH

• Withdrawal symptoms: – Anxiety, restlessness, aching back and legs, cravings, nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia

• Withdrawal does not require pharmacologic intervention • Administration of Naloxone (Narcan) is the treatment of choice • Methadone can be used as a replacement for heroin, serving to reduce cravings

Hallucinogens

• Distort reality and produce symptoms similar to psychosis, including hallucinations (usually visual) and depersonalization • Toxic reactions to hallucinogens (except PCP) are primarily psychological; overdoses as such do not occur. PCP toxicity can include seizures, hypertension, hyperthermia, and respiratory depression • Hallucinogens can produce flashbacks that may persist for a few months up to 5 years • Treatment is supportive:

– Isolation from external stimuli; physical restraints; (for PCP) medications to control seizures and blood pressure; cooling devices; mechanical ventilation

Drug

Length of Detoxifica Withdrawal acute tion Signs and detoxific agents symptoms ation Alcoho 3-5 days Librium, Anxiety, l Serax, sweats, Valium, tremors, VIstaril flushed face, irritability, sleepiness, Valiu Slow Librium, Agitation, confusion, m drug Valium insomnia, seizures, taper, up convulsions, delirium 2 ataxia, nausea, Pheno to Slow Librium, barbit weeks drug phenobar vomiting, hypertension al taper, 2- bital with postural 4 weeks hypotension, psychotic

Intoxicati on Loss of inhibition

Relaxatio n Euphoria None Natural Synthetic

Drug

Length of acute detoxific ation Heroin 3-5 days Morphi 3-5 days ne 3-5 days Demer 2 weeks ol + Metha done Amph etami nes

3-5 days

Detoxifica tion agents

Withdrawal Signs and symptoms

Intoxicati on

Methadon e or other tapering opiate or nonopiate withdraw al regimens

Yawning, dilated pupils, gooseflesh, vomiting, diarrhea, runny nose, and eyes, sleeplessness, anxiety, irritability, elevated blood General fatigue, pressure apathy, and pulse, craving depression, for narcotics drowsiness,

High ecstasy, relaxation , euphoria

Not required

irritability, paranoia

Rush, high fatigue

Drug

Length of Detoxifica Withdrawal acute tion Signs and detoxific agents symptoms ation Marijua 2-3 days Not Few signs of na (metaboli required withdrawal, tes craving for remain marijuana, the body general anxiety up to 2 and weeks) restlessness

Intoxicati on Euphoria, ecstasy with no anxiety

Withdrawal effects: Alcohol – tremors Narcotics – yawning Hallucinogens – perceptual / sensory disturbance Marijuana – amotivational syndrome Amphetamines - anxiety

Intervention: • • • • •

Behavioral Modification Detoxification Family Marital Therapy Self Help Groups Medication

Withdrawal Effects

• Perceptual and sensory disturbance ( hallucinogens )

• Amotivational Syndrome ( marijuana ) • Yawning ( narcotics ) • Anxiety ( amphetamine )

• Tremors ( alcohol )

Cardinal signs

• Narcotics: pupillary constriction, decreased BP • Stimulants: pupillary dilation, increased BP, paranoia • Hallucinogen : Bloodshot eyes, dry mouth, cravings for junk foods • Sedatives: tremors, sedation

Substance Abuse in Health Professionals

Warning signs of abuse include:

• Poor work performance, frequent absenteeism, unusual behavior, slurred speech, isolation from peers • Incorrect drug counts • Excessive controlled substances listed as wasted or contaminated • Reports by clients of ineffective pain relief from medications, especially if relief had been adequate previously • Damaged or torn packaging on controlled substances • Increased reports of “pharmacy error” • Consistent offers to obtain controlled substances from pharmacy • Unexplained absences from the unit • Trips to the bathroom after contact with controlled substances • Consistent early arrivals at or late departures from work for no apparent reason

• Situation: Mr. Albert, a 45 year old married man has been alcoholic for three years. He voluntarily sought admission to the rehabilitation center for detoxification. He started drinking when he was terminated from his work abroad. Due to his drinking problem, his family life deteriorated. The nurse identifies on eof the following as an appropriate nursing diagnosis: A. ineffective individual coping B. altered health maintenance C. ineffective family coping D. disturbance in self-esteem

• The nurse should be alert for signs of Korsakoff’s syndrome which are manifested in one of the following symptoms: A. delusions and ideas of reference B. hallucination and suspiciousness C. insomnia and confabulation D. delusions and flight of ideas

• Korsakoff’s syndrome is due. Mr. Albert is suited for what supplement? • A. ascorbic acid • B. Vitamin A • C. Thiamine • D. Vitamin D

• A treatment modality best suited for Mr. Albert is on eof the following therapies: • A. family therapy • B. marital therapy • C. behavior therapy • D. group therapy

• Marijuana is classified as: A. Hallucinogen B. narcotic C. sedative- hypnotic D. psycho-stimulant

A client informs his nurse therapist that he has been convicted for breaking and entering into homes and stealing women’s undergarments. Further questioning by the nurse reveals that the client requires these items in order to become sexually aroused. Based on this information, the nurse suspects the client is experiencing the psychosexual disorder of: A. voyeurism B. frotteurism C. fetishism D. sexual masochism •

• Answer: C • Rationale: Fetishism refers to the use of an object, foot apparel, for sexual arousal. Voyeurism involves the act of observing unsuspecting individuals, usually strangers, who may be naked or in the process of disrobing. Frotteurism involves intense, recurrent fantasies of, and/or actual touching and rubbing the genitalia against a nonconsenting person, in association with sexual arousal. The behavior usually occurs in crowded places, and the individual usually fantasizes an exclusive, caring relationship with the victim. Sexual masochism involves the act of being humiliated, bound, beaten and otherwise made to physically suffer for purposes of sexual stimulation.

Sexual Disorders

PARAPHILIA • A condition in which the sexual instinct is expressed in ways that are socially prohibited or are biologically undesirable

• Bisexuality sexual attraction to members of the opposite sex and the same sex • Masochism experiencing sexual attraction, urges or arousal when receiving pain (hypoxyphilia) • Sadism experiencing sexual attraction, urges or arousal when giving pain • Frotteurism pleasure from rubbing genitals against unconsenting victim • Pedophilia sexual pleasure with children below 13 • Necrophilia sexual pleasure with the dead • Voyerism experiencing intense pleasure from watching people undress • Transvestism cross dressing with the opposite sex • Transexualism going from one sex to another

•Telephone Scatologia •Zoophilia •Bestiality •Exhibitionism

Sexual Dysfunctions Excitement • Sexual aversion disorder • Hypoactive sexual desire • Erectile dysfunction Plateau • Premature ejaculation • Sexual arousal • Sexual Pain

Orgasm • Orgasm disorder

• Gender identity disorder

• • • 4. 5. 6. 7.

GENDER IDENTITY DISORDER

A strong and persistent cross-gender identification Involves discomfort with one’s sex or the gender role of that sex In Children: stated desire or insistence that he or she is the other sex In boys, dressing in female attire; in girls, wearing only masculine clothing. Make-believe play or fantasies of being the other sex Prefers playmates of the other sex.

In adolescents and adults: Stated desire to be the other sex Frequently passes as the other sex Desires to be treated as the other sex 5. Conviction that he or she has typical feelings and reactions of the other sex • 2. 3. 4.

SEXUAL ADDICTION • 50% or more of waking hours spent on sexual fantasies/activities • Impairs daily functioning • With or without a partner • Cycle- preoccupation, rituals, compulsion, shame & guilt, anxiety

Intervention Psychotherapy Individual therapy Group Psychotherapy Social skills training Treatment of co-morbid physical and psychiatric features • Hormonal treatments • Medications • Anti-androgen drugs (Medroxyprogesterone acetate and Cyproterone acetate) • • • • •

• In the initial interview with a 64-year old man who has primary dementia of the Alzheimer’s type and his wife , which of these data should be obtained in order to plan his care? a. his occupational skills b. his normal daily routine c. the quality of maternal relationship d. whether there is a history of dementia in his family

Which of the following nursing interventions minimizes confusion and disorientation in the patient with Alzheimer’s disease (AD)? A. reasoning with the patient B. using reality orientation C. following a regular routine D. using restraints to promote physical safety •

• Answer: C • Rationale: A calm, predictable environment which limits external stimuli and allows for a regular routine helps to support the patient’s cognitive function. Attempting to reason with the patient or using reality orientation may increase anxiety without promoting function. Using memory aids and offering clear and simple explanations may help to reduce confusion and disorientation while promoting security. Restraints are avoided if at all possible as they may increase agitation.

Delirium & dementia

Delirium

Delirium: a syndrome that involves disturbance of consciousness accompanied by a change in cognition • Acute and fluctuating • Difficulty paying attention, distractibility, and disorientation • Sensory disturbances include illusions, misinterpretations, hallucinations • Disturbances in sleep/wake cycle, anxiety, fear, irritability, euphoria, apathy

• Risk factors: hospitalization for general medical conditions, older acutely ill clients, severe physical illness, older age, and baseline cognitive impairment • Etiology: almost always results from an identifiable physiologic, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal

Psychopharmacology and Other Medical Treatment

• If quiet and resting, no medication needed for delirium • If experiencing psychomotor agitation, sedation with an antipsychotic may prevent inadvertent self-injury • Delirium induced by alcohol withdrawal is treated with benzodiazepines • Adequate food and fluid • Physical restraints only when necessary

Dementia

• Dementia involves multiple cognitive deficits, primarily memory impairment, and at least one of the following: – – – –

Aphasia Apraxia Agnosia Disturbance in executive functioning/Kluver-Bucy like syndrome (agraphia, hyperorality, hypermetamorphosis)

• Dementia is progressive

Treatment and Prognosis

• Acetylcholine precursors, cholinergic agonists, and cholinesterase inhibitors such as tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) temporarily slow the progress of dementia (CARE) • Alternatives: Gingko Biloba, Huperzine A, Melatonin

• Symptomatic treatment of behaviors such as delusions, hallucinations, outbursts, and labile moods, which vary among clients

Delirium Vs Dementia Etiology

Onset Course

Delirium Dementia Substance degenerative intoxication; medical condition, post-anesthesia Usually sudden Usually gradual Usually brief with Usually longreturn to usual term and level of progressive, functioning occasionally maybe arrested or

Population affected Sensorium Memory

Perception

Speech

Delirium Young and old alike Clouded Impaired; immediate, recent memory loss Illusion and Hallucinatio n Shadow and Incoherent monsters

Dementia Exclusive among elderly Clear Impaired; remote, recent memory loss Illusion Delusion Hallucination Difficult in finding words

Prognosis

Delirium Reversible

Manifestat Disoriented to ions time and place Emotionally unstable Speech is rumbling and irrelevant Extreme distractibility Sundowning

Dementia Irreversible Early: personality change, altered language pattern, neglect of personal appearance & hygiene Progressive: Wandering,

Delirium Interventi Safety ons Structure Set limits Communicate with simple words and in short phrases

Dementia Safety Consistency Clear verbal communicati on Reorientatio n to reality

Manifestations Memory loss

Nursing Responsibilities • Always re-orient patient as to time, person, place and activities being done. •Encourage patient to tell stories of earlier years. •Place familiar objects in surroundings.

Disorientation

• Make use of calendars, clocks and signs that are visible. •Provide proper functioning of eyeglasses and hearing aids. •Provide for presence of familiar personal objects in room.

Restlessness and agitation

Depression, mood lability

• Convey warmth and reassurance. •Orient to time, person and place. • Communication has to be simple, clear and direct. • should be •Expectations Assist in routine explained activities. simply and completely. • Involve patient in simple and repetitive tasks, especially one that involves helping someone..

Perceptual disturbances

Incontinence

• Orient to reality. • Decrease sensory stimuli. • assess source of perceptual disturbances and redirect attention to other things. • If severe, may give antipsychotic drugs. • Display pictures or signs on bathroom doors to provide visual clues. •Place patient near the toilet or supply a commode nearby. • Limit amount of fluid during night time.

Nursing Interventions • Always identify yourself and call the person by name. • Speak slowly; use face-to-face contact • Encourage reminiscing therapy • Keep the client’s room well lit and bring familiar objects from home. • Provide for safety measures (e.g. hot H20, medic alert bracelet, driving etc)

• End of Module 2

THANK YOU!

• . Countertransference is: • A. The patient’s feeling or reaction toward the therapist. • B. The therapist’s feelings or reactions towards the patient. • C. Underlying meaning in group interaction. • D. The content of an interaction

• . What is the number of treatments for ECT? • A. 2-3 times a week, 6 to 12 treatments B 5 times a week, 6 to 12 treatments • C 3-4 times a week, with hair spa & treatment • D. 3-6 treatments a week, 6 to 12 treatments •  

• Situation: Mercy, a 43 year old married woman was referred to the psychiatric clinic by her physician She has insomnia, anxiety, fatigue and loss of interest in her usual activities which started after her husband left her. • . This crisis is: • A. Situational • B. Adventitious • C. Developmental • D. Incidental

• The appropriate nursing diagnosis for Mercy is: • A. Impaired Social Interaction • B. Disturbed Thought process • C. Impaired Verbal Communication • D, Ineffective Individual Coping

• In crisis intervention, the nurse’s role should be: • A. Active and directive • B. Non-directive and passive • C. Firm and directive • D. Calm and non-aggressive

• Crisis Intervention therapy is characterized by one of the following features: • A. Focuses on solving the immediate problem • B Aims to resolve a situational crisis only • C. It is a long term process • D. Aims to correct a pathological state

• Situation: Joan, 40 years old, scheduled for mastectomy, starts to complain of palpitation, dizziness, nausea and cannot express what she wants. • Joan was given an antianxiety drug which is one of the following: • A. Imipramine (Tofranil) • B. Chlorpromazine (Thorazine) • C. Halloperidol (haldol) • D. Diazepam ( valium)

• A client with a diagnosis of schizophrenia repeatedly says to the nurse, “no moley jandu’. This is an example of: • A. echolalia • B concretism • C. a neologism • D. paleologic thinking

• When making an assessment of a client’s hallucination, the nurse realizes that the most common type of hallucination is: • A. visual • B. tactile • C. auditory • D. olfactory

• The best indication of effective crisis counseling for Mercy is she has: • A. Visited her relatives and friends • B. Worked through her feelings of grief over her son’s death • C. Resumed her previous routines and activities • D. Developed a closer relationship with her friends

• A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family relates that one day the client looked at a linen sheet on a clothesline and thought it was a ghost The nurse recognize that was: • A. an illusion • B delusion • C. confabulation • D. hallucination