Personality Disorder, Abg, Form And Eating Disorder

Answers to practice ABG's: #12 pH 7.4 = perfectly normal #1 pH 7.52 = alkalosis pCO2 60 = respiratory acidosis pCO2 40 = normal HCO3 30 = metabolic alkalosis HCO3 35 =metabolic alkalosis Two imbalances with complete compensation, so it Metabolic alkalosis (no compensation) is difficult to tell which is #2 pH 7.25 = acidosis the problem and which is the compensation. pCO2 60 = respiratory acidosis However, since only the kidneysare strong enough HCO3 27 = slight metabolic alkalosis in compensation to bring the pH back to perfectly Respiratory acidosis, and kidneys are beginning to normal, the primary problem has to be respiratory compensate (retain bicarb. Note that the pH has a long way to go before acidosis, with complete it comes back into compensation by the kidneys. normal range, so compensation has just begun.) #3 pH 7.25 = acidosis pCO2 40 = normal HCO3 12 = metabolic acidosis Personality Disorders Metabolic acidosis (no compensation) #4 pH 7.55 = alkalosis Personality disorders are stable patterns of experience pCO2 20 = respiratory alkalosis and behavior that differ noticeably from patterns that are HCO3 26 = normal considered normal by a person’s culture. Symptoms of a Respiratory alkalosis (no compensation) personality disorder remain the same across different #5 pH 7.29 = acidosis situations and manifest by early adulthood. These pCO2 20 = respiratory alkalosis symptoms cause distress or make it difficult for a person to HCO3 18 = metabolic acidosis function normally in society. There are many types of Metabolic acidosis with some compensation by the personality disorders, including the following: lungs (not very effective; has not returned pH to acceptable range yet) #6 pH 7.48 = alkalosis • Schizoid personality disorder: entails social pCO2 50 = respiratory acidosis withdrawal and restricted expression of emotions HCO3 34 = metabolic alkalosis Metabolic alkalosis with almost complete • Borderline personality disorder: characterized compensation by the lungs by impulsive behavior and unstable relationships, #7 pH 7.5 = alkalosis emotions, and self-image pCO2 20 = respiratory alkalosis HCO3 30 = metabolic alkalosis • Histrionic personality disorder: involves Combined respiratory & metabolic alkalosis#8 pH attention-seeking behavior and shallow emotions 7.18 = acidosis • Narcissistic personality disorder: pCO2 60 = respiratory acidosis characterized by an exaggerated sense of HCO3 26 = normal importance, a strong desire to be admired, and a Respiratory acidosis lack of empathy #9 pH 7.29 = acidosis pCO2 60 = respiratory acidosis • Avoidant personality disorder: includes social HCO3 35 = metabolic alkalosis withdrawal, low self-esteem, and extreme Respiratory acidosis with some compensation from sensitivity to negative evaluation kidneys #10 pH 7.48 = alkalosis • Antisocial personality disorder: characterized pCO2 20 = respiratory alkalosis by a lack of respect for other people’s rights, HCO3 34 = metabolic alkalosis feelings, and needs, beginning by age fifteen. Combined respiratory and metabolic alkalosis People with antisocial personality disorder are #11 pH 7.43 = normal deceitful and manipulative and tend to break the pCO2 35 = normal law frequently. They often lack empathy and HCO3 23 = normal remorse but can be superficially charming. Their Normal

behavior is often aggressive, impulsive, reckless, and irresponsible. Antisocial personality disorder has been referred to in the past as sociopathy or psychopathy.

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Somatoform disorders

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Somatization: The transference of mental experiences and

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states into bodily symptoms. Somatoform disorders: Characterized as the presence of physical symptoms that suggest a medical condition without demonstrable organic basis to account fully for them. The three central features of somatoform disorders are as follows:

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· Physical complaints suggest major medical illness but

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have no demonstrable organic basis.

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initiating, exacerbating, and maintaining the symptoms.

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· Psychological factors and conflicts seem important in

· Symptoms or magnified health concerns are not under the client’s conscious control. The five specific somatoform disorders are as followed: · Somatization disorder : Characterized by multiple physical symptoms. It begins by 30 years of age, extends over several years, and includes a combination of pain and GI, sexual, and pseudoneurologic

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symptoms.

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o Client’s jump from one physician to the next, or may see several providers at once in an effort to

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obtain relief of symptoms.

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competent.

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o They tend to be pessimistic about the medical establishment and often believe their disease could be diagnosed of the providers were more

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· Conversion disorder : Involves unexplained, usually sudden deficits in sensory or motor function (blindness, paralysis). These deficits suggest a neurological disorder but are associated with psychological factors. An attitude of la belle indifference, a seemingly lack of concern or distress, is the key feature. · Pain disorder : Pain is the primary physical symptom which is generally unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance. · Hypochondriasis : Preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). It is thought that clients with this disorder misinterpret bodily sensations or functions. · Body dysmorphic disorder : Preoccupation with an imagined or exaggerated defect in personal appearance such as thinking one’s nose is too large or teeth are crooked and unattractive. Symptoms of a somatization disorder · Pain symptoms : complaints of headache, pain in the abdomen, head, joints, back, chest, rectum; pain during urination, menstruation, or sexual intercourse. · GI symptoms : nausea, bloating, vomiting (other than pregnancy), diarrhea, or intolerance of several foods. · Sexual symptoms : Sexual indifference (don’t care to do

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the dirty), erectile or ejaculatory dysfunction, irregular

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menses, excessive menstrual bleeding.

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· Pseudoneurologic symptoms : Impaired coordination or balance, paralysis or localized weakness, difficulty

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swallowing or lump in throat, aphonia (loss of speech sounds), urinary retention, swollen tongue, hallucinations, double vision, blindness, deafness,

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seizures; disassociative symptoms such as amnesia; or

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loss of consciousness other than fainting. Related disorders:

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· Malingering : The intentional production of false or grossly exaggerated physical or psychological

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symptoms; it is motivated by external incentives such as avoiding work, evading criminal prosecution,

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obtaining financial compensation, or obtaining drugs. Their purpose is some external incentive or outcome that they view as important and results directly from their illness. People who malinger can stop the physical symptoms as soon as they have gained what they

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wanted.

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syndrome. Occurs when a person intentionally produces or feigns physical or psychological symptoms solely to

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· Factitious disorder : This is also known as Munchausen

gain attention. o Munchausen syndrome by proxy occurs when a person inflicts illness or injury to someone else to gain the attention of emergency medical personnel or to be a “hero” for saving the victim. This occurs most often in people who are in or familiar with medical professions, such as nurses, physicians, medical technicians, or hospital

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volunteers.

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provides, such as relief of anxiety, conflict, or distress.

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· Primary gain : Direct external benefits that being sick

· Secondary gains : Internal or personal benefits received from others because one is sick, such as attention from family members and comfort measures (being brought tea, receiving a back rub). Treatment: · Treatment focuses on managing symptoms and improving quality of life. · A trusting relationship helps to ensure that client’s stay with and receive care from one provider instead of “doctor shopping.” · SSRIs are commonly used for depression that may accompany somatoform disorders. Assessment · The nurse must investigate physical health status thoroughly to ensure there is no underlying pathology requiring treatment. It is important not to dismiss all future complaints because at any time the client could develop a physical condition that would require medical

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basic nutrition, and get no exercise. Nursing diagnoses

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· Client’s often have sleep pattern disturbances, lack

clients relax and reduce feelings of stress. This includes progressive relaxation, deep breathing, guided imagery, and distractions such as music. Problem-focused coping strategies help to resolve or change a client’s behavior or

The nurse should not attempt to confront clients about somatic symptoms or attempt to tell them that these symptoms are not

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attention.

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Emotion-focused coping strategies help the

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stress and physical symptoms.

situation or to manage life stressors. This

· In many cases, the client’s appearance brightens and they look much better as the assessment interview begins because they have the nurse’s undivided

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o The client will identify the relationship between

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· Ineffective coping

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includes learning problem solving methods. The nurse should help the client role play the above situations. · Ineffective denial o The client will verbally express emotional feelings

“real.” Encourage the client to write in a daily journal Limiting the time that clients can focus on physical complaints alone may be necessary.

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improve the client’s confidence in making

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relationships.

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· Disturbed sleep pattern

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· Anxiety o The client will demonstrate alternative ways to deal with stress, anxiety, and other feelings o The client will demonstrate healthier behaviors regarding rest, activity, and nutritional intake. The nurse explains that inactivity and poor eating habits perpetuate discomfort and that often it is necessary to engage in behaviors even though one doesn’t feel like it. · Fatigue · Pain

Eating disorders The distinguishing factor of anorexia includes an earlier age of onset and below-normal body weight; the person fails to recognize the eating behavior as a problem. Clients with bulimia have a latter age at onset and a near-normal body weight. They usually are ashamed and embarrassed by the eating disorder. Eating disorders appear to be equally common among Hispanic and white women and less common among African American and Asian women.

Anorexia Nervosa · A life-threatening eating disorder characterized by the client’s refusal or inability to maintain a minimally normal body weight, intense fear of gaining weight or “sick role.” becoming fat, significantly disturbed perception of the shape or size of the body, and steadfast inability or · Impaired social interactions refusal to acknowledge the seriousness of the problem o The client will follow an established daily routine or even that one exists. · Has experienced amenorrhea for at least 3 consecutive The nurse must help the client to establish cycles · Complaints of constipations and abdominal pain this that includes improved health behaviors. · Cold intolerance The challenge for the nurse is to validate the · Hypotension, hypothermia, bradycardia client’s feelings while encouraging him to o Intravascular volume is decreased; less blood to pump through heart, also due to excessive participate in activities. exercise The nurse should help the client plan social · Elevated BUN o Normal levels: 10-20 mg/dl contact with others, what to talk about (other o Urea is formed in the liver and is the end product than the client’s complaints), and can The nurse may have to explain to the family about primary and secondary gains; this will encourage relatives to stop reinforcing the

of protein metabolism. o In anorexia, the body has already used fat for energy; it is now breaking down muscles for energy—the reason for the elevated BUN · Decreased albumin o Normal levels: 3.5-5 g/dl o Measures amount of protein in the body; albumin is a protein formed in the liver. Albumin tests are a great indicator of nutritional status · Leukopenia and mild anemia o Not enough food and nutrients to replenish cells · Has a preoccupation with food and food-related activities · Can be divided into 2 subgroups: o Restricting subtype : lose weight primarily through dieting, fasting, or excessively exercising. o Binge eating and purging subtype : engage regularly in binge eating followed by purging. · Engage in unusual or ritualistic food behaviors o Refusing to eat around others o Cutting food into minute pieces o Not allowing the food they eat to touch their lips · Excessive exercise is common · Diagnosed between 14 and 18 years of age · Pleased with their ability to control their weight and may express this. · As the illness progresses, depression and lability in mood become more apparent · Isolate themselves · Believe peers are jealous of their weight loss and believe family and health care professionals are trying to make them “fat and ugly”. · Clients who use laxatives are at a greater risk for medical complications. · Autonomy may be difficult in families that are overprotective or in with enmeshment (lack of clear boundaries) exists. By losing weight, these clients have some control in their lives. · Have body image disturbance (page 409) · Can be very difficult to treat because they are often resistant, appear uninterested, and deny their problems. · Treatment: o Focusing on weight restoration o Nutritional rehabilitation o Rehydration Correction of electrolyte imbalances o Severely malnourished individuals may require TPN, tube feedings, or hyperalimentation to receive adequate nutritional intake. o Access to the bathroom is supervised to prevent purging as clients begin to eat more food.

o Weight gain and adequate food intake are most often the criteria for determining the effectiveness of treatment. o Amitriptyline (Elavil) and the antihistamine cyproheptadine (Periactin) in high doses (up to 28mg/d) can promote weight gain in inpatients. o Olanzapine (Zyprexa) has been used with success because of both its antipsychotic effect (on bizarre body image distortions) and associated weight gain. o Fluoxetine (Prozac) has shown some effectiveness in preventing relapse in clients whose weight has been partially or completely restored; close monitoring is needed because weight loss can be a side effect. · Family members often describe clients with anorexia as perfectionists with above average intelligence, dependable, eager to please, and seeking approval before their condition began. · Clients with anorexia appear slow, lethargic, and fatigued; they may appear emaciated, depending on the amount of weight loss. May be slow to respond and have difficulty deciding what to say. · Reluctant to answer questions fully because they do not want to acknowledge any problem. · Often wear loose clothing in layers · Seldom smile, laugh, or enjoy any attempts at humor Bulimia Nervosa · Characterized by recurrent episodes (at least twice a week for 3 months) of binge eating followed by inappropriate measures to avoid weight gain such as purging (vomiting, laxatives, diuretics, enemas, or emetics), fasting, or excessively exercising. · Engaging in binge eating secretly · Binging or purging episodes are often precipitated by strong emotions and followed by guilt, remorse, shame, or self-contempt. · Recurrent vomiting destroys tooth enamel, has dental caries and ragged or chipped teeth. Dentists are often the first health care professionals to recognize this. · Bulimia is typically diagnosed at 18 or 19. · Clients with bulimia are aware that their eating behavior is pathologic and go great lengths to hide it from others. · Clients with a co-morbid personality disorder tend to have poorer outcomes than those without. · Most are treated on an outpatient basis · Antidepressants are more effective than the placebos in reducing binge eating · Clients are often focused on pleasing others and have a history of impulsive behavior such as substance abuse and shoplifting as well as anxiety, depression, and personality disorders.

· May be underweight, overweight, but are generally close to expected body weight for age and size · Appear open and willing to talk; initially pleasant and cheerful as though nothing is wrong Nursing outcomes/interventions Imbalanced Nutrition: Less than/More than body requirements · The client will establish adequate nutritional eating Patterns Implement and supervise the regimen for nutritional rehabilitation o A diet of 1200-1500 calories is ordered, with gradual increases in calories until clients are ingesting adequate amounts for height, activity level, and growth needs. Start slowly—will have massive diarrhea o The client with anorexia may be critically malnourished. TPN through central line Electrolyte balance Tube feeds o A liquid protein supplement is given to replace any food not eaten to ensure consumption to ensure total number of calories prescribed o Must monitor meals and snacks and will sit at the table during eating away from the other clients A major goal is to first get them to the table o Diet beverages and food substitutions may be prohibited o Specified time may be set for consuming each meal and snack o Discourage clients from performing food rituals such as cutting food into tiny pieces or mixing foods in unusual combinations o Be alert for any attempts by client to hide or discard food o Must remain in view of staff for 1-2 hours to ensure they do not vomit; access to bathrooms is supervised. o Client is weighed daily on awakening and after they have emptied their bladder. Have the client wear a hospital gown each time they are weighed; they may attempt to place objects in their clothing to give the appearance of weight gain. o In bulimia, the clients should sit at a table in a kitchen or dining room. o Write out a grocery list, it is easier to follow a nutritious eating plan Ineffective coping · The client will eliminate use of compensatory behaviors such as excessive exercise and use of laxatives and

diuretics · The client will demonstrate coping mechanisms not related to food · The client will verbalize feelings of guilt, anger, anxiety, or an excessive need for control o Help the client recognize emotions such as anxiety or guilt by asking them to describe what they are feeling; allow adequate time for response. Do not ask “are you anxious? Sad?” because the client may quickly agree rather than struggle for an answer o Encourage self-monitoring (page 414); a behaviorcognitive approach Disturbed body image · The client will verbalize acceptance of body image with stable body weight o Help clients identify areas of personal strength that are not food-related broadens clients’ perceptions of themselves TIC disorders · Sudden, rapid, recurrent, non-rhythmic motor movement or vocalization · Stress and fatigue exacerbates tics · Treatment: Risperadol and Zyprexia · Complex vocal tics o Coprolalia : Use of socially unacceptable words, often obscene o Palilalia : Repeating own sounds or words o Echolalia : Repeating the last heard sound, word, or phrase Autistic disorder · Most prevalent in boys; identified no later than 3-years of age · Child has little eye contact, few facial expression, doesn’t use gestures to communicate · Does not relate to parents or peers, lacks spontaneous enjoyment, apparent absence of mood and emotional affect, can not be engaged in play or make believe · Repetitive motor behaviors such as hand-flapping, body twisting, or head banging · May improve as child acquires language skills · Short term impatient therapy is used when behaviors such as head banging or tantrums are out of control o Haldol or Risperadol may be effective (prn, of course) · Goals of treatment: o Reduce behavioral symptoms o Promotes learning and development o Language skills development