NOTES VI - PSYCHIATRIC NURSING PART 4

NOTES VI - PSYCHIATRIC NURSING PART 4

PSYCHIATRIC D/O IN CHILDREN

•   MENTAL RETARDATION

•   PERVASIVE DEV’TAL D/O

–    AUTISM

–    RETT’S D/O

–    CHILDHOOD DISINTEGRATIVE D/O

–    ASPERGER’S D/O

–    PDD NOS

•   LEARNING D/O

–    READING

–    MATHEMATICS

–    WRITTEN EXPRESSION

–    ACADEMIC PROBLEM

–    LEARNING D/O NOS

 

•   MOTOR SKILLS D/O

•   COMMUNICATION D/O

–   EXPRESSIVE LANGUAGE

–   MIXED RECEPTIVE/EXPRESSIVE

–   PHONOLOGICAL

–   STUTTERING

–   SELECTIVE MUTISM

–   COMMUNICATION D/O NOS

•   MOV’T & TIC D/O

–   DEV’TAL COORDINATION

–   TRANSIENT TIC

 

–   CHRONIC MOTOR&VOCAL TIC

–   TOURETTE’S D/O

–   STEREOTYPIC MOV’T D/O

–   TIC D/O NOS

•   DISORDERS OF INTAKE & ELIMINATION

–   PICA

–   RUMINATION

–   FEEDING D/O

–   ENURESIS

–   ENCOPRESIS

–   OTHER: BULIMIA, ANOREXIA

 

•   ADHD & DISRUPTIVE BEHAVIOR D/O

–    ADHD

–    ADHD NOS

–    CONDUCT D/O

–    OPPOSITIONAL DEFIANT

–    CHILD ANTISOCIAL

–    DISRUPTIVE BEHAVIOR NOS

•   MOOD D/O

–    MJ DEPRESSIVE D/O

–    BIPOLAR I OR II

–    DYSTHYMIC

–    MIXED EPISODE

–    HYPOMANIC EPISODE

–    MOOD D/O DUE TO MEDICAL CONDITION

–    SUBSTANCE-INDUCED MOOD D/O

 

•   ANXIETY D/O

•   D/O OF RELATIONSHIP

–   SEPARATION ANXIETY

–   REACTIVE ATTACHMENT OF INFANCY OR EARLY CHILDHOOD

–   PARENT-CHILD RELATIONAL PROBLEM

–   SIBLING RELATIONAL PROBLEM

–   PROBLEMS RELATED TO ABUSE OR NEGLECT

MENTAL RETARDATION

•    an IQ below 70, significant limitations in two or more areas of adaptive behavior (i.e., ability to function at age level in an ordinary environment), and evidence that the limitations became apparent in before 18 y.o.

•    The following ranges, based on the Wechsler Adult Intelligence Scale (WAIS), are in standard use today:

•    Class                           IQ                            Terms

Profound                     Below 20                     Idiot

Severe                         20–34                          Imbecile

Moderate                     35–49                          Moron

Mild                            50–69

Borderline                   70–79

RETT’S D/O

•   Development is normal until 6-18 months, when language and motor milestones regress,

•   purposeful hand use is lost

•   Acquired deceleration in the rate of head growth (resulting in microcephaly in some)

•   Hand stereotypes are typical and breathing irregularities such as hyperventilation, breath holding, or sighing are seen in many.

•   Early on, autistic-like behavior may be seen

•   Common in females

CHILDHOOD DISINTEGRATIVE D/O or HELLER’S SYNDROME

•   CDD has some similarity to autism, but an apparent period of fairly normal development is often noted before a regression in skills or a series of regressions in skills.

•   characterized by late onset (>3 years of age) of dev’tal delays in language, social function and motor skills; skills apparently attained are lost

ASPERGER’S D/O

•    characterized by difference in language and communication skills, as well as repetitive or restrictive patterns of thought and behavior.

•    Signs: unable to interpret or understand the desires or intentions of others and thereby are unable to predict what to expect of others or what others may expect of them

–    Narrow interests or preoccupation with a subject to the exclusion of other activities

–    Repetitive behaviors or rituals

–    Peculiarities in speech and language

–    Extensive logical/technical patterns of thought

–    Socially and emotionally inappropriate behavior and interpersonal interaction

–    Problems with nonverbal communication

–    Clumsy and uncoordinated motor mov’ts

 

CHRONIC MOTOR/ VOCAL TIC

•   TIC is a sudden, repetitive, stereotyped, nonrhythmic, involuntary movement (motor tic) or sound (phonic tic) that involves discrete groups of muscles.

•   can be invisible to the observer (e.g. abdominal tensing or toe crunching)

TOURETTE’S D/O

•   characterized by the presence of multiple physical (motor) tics and at least one vocal (phonic) tic; these tics characteristically wax and wane

•   TTT: Neuroleptic medications

–   haloperidol (Haldol)

–   pimozide (Orap)

ADHD

Inattention:

•      Failure to pay close attention to details or making careless mistakes when doing schoolwork or other activities

•      Trouble keeping attention focused during play or tasks

•      Appearing not to listen when spoken to

•      Failure to follow instructions or finish tasks

•      Avoiding tasks that require a high amount of mental effort and organization, such as school projects

•      Frequently losing items required to facilitate tasks or activities, such as school supplies

•      Excessive distractibility

•      Forgetfulness

•      Procrastination, inability to begin an activity

•      Difficulties with household activities (cleaning, paying bills, etc.)

•      Difficulty falling asleep, may be due to too many thoughts at night

•      Frequent emotional outbursts

•      Easily frustrated

•      Easily distracted

Hyperactivity-impulsive behaviour

•      Fidgeting with hands or feet or squirming in seat

•      Leaving seat often, even when inappropriate

•      Running or climbing at inappropriate times

•      Difficulty in quiet play

•      Frequently feeling restless

•      Excessive speech

•      Answering a question before the speaker has finished

•      Failure to await one's turn

•      Interrupting the activities of others at inappropriate times

•      Impulsive spending, leading to financial difficulties

 

•   Frequently prescribed stimulants are methylphenidate (Ritalin and Concerta), amphetamines (Adderall) and dextroamphetamines (Dexedrine)

•   Feingold diet which involves removing salicylates, artificial colors and flavors, and certain synthetic preservatives from children's diets.

CONDUCT D/O

•   repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated,

–   AGGRESSION TO PEOPLE & ANIMALS

–   DESTRUCTION OF PROPERTY

–   DECEITFULNESS OR THEFT

–   SERIOUS VIOLATIONS OF RULES

• Beginning before age 13

OPPOSITIONAL DEFIANT

•    characterized by an ongoing pattern of disobedient, hostile, and defiant behavior toward authority figures that goes beyond the bounds of normal childhood behavior

•    Signs

–    Losing temper

–    Arguing with adults

–    Refusing to follow the rules

–    Deliberately annoying people

–    Blaming others

–    Easily annoyed

–    Angry and resentful

–    Spiteful or even revengeful

SUBSTANCE ABUSE

•   Excessive or unhealthy use of substances, such as alcohol, tobacco or drugs, or use of products such as food

•   Terms:

–    TOLERANCE: the declining effect of the same drug dose when it is taken repeatedly over time

–    HABITUATION: a psychological dependence of the use of a drug

–    ADDICTION: the biological and/ or psychological behaviors related to substance dependence

–    WITHDRAWAL SYMPTOMS: result from a biological need that develops when the body becomes adapted to having an addictive drug in the system; occurs when serum levels decrease

ADDICTION

•   ALCOHOL: blood alcohol levels of 0.1% (100mg alcohol/dl of blood) or higher

–    WITHDRAWAL

•  Anorexia

•  Anxiety

•  Easily startled

•  Hyperalertness

•  HPN

•  Insomnia

•  Irritability

•  Jerky mov’t

•  Possibly: hallucinations, illusions or vivid nightmares

•  Seizures (7-48 hrs after cessation)

•  Tachycardia

•  tremors

–   WITHDRAWAL DELIRIUM

• Agitation

• Anorexia

• Anxiety

• Delirium

• Diaphoresis

• Disorientation with fluctuating levels of consciousness

• Fever (100 to 103 F)

• Hallucinations and delusions

• Insomnia

• Tachycardia and HPN

–   Disulfiram (Antabuse) therapy

Nursing care

•    Obtain info about drug type and amount consumed

•    Assess v/s

•    Remove unnecssary obj from environment

•    Provide one-on-one supervision if necessary

•    Provide a quiet, calm environment with minimal stimuli

•    Maintain orientation

•    Ensure safety

•    Use restraints

•    Provide physical needs

•    Provide food and fluids as tolerated

•    Administer medications

•    Collect blood and urine samples for drug screening

SPOUSE ABUSE

•   Battering precipitates 1:4 suicide attempts of all women

•   Wives explain the injuries as being self-inflicted or accidental

•   Phases

–    Tension-building: series of small incidents that leads to beating

–    Acute beating phase: wife becomes object of assault behavior

–    Loving phase: batterer is remorseful and assures spouse that he will not harm her again. This leads to reconciliation.

 

•   Myths

–    They believe that if they try not to antagonize with their husband, he will change.

–    Efforts to coerce the wife out of the victim role can be fruitful.

•   Facts

–    Women stay in relationships with men who batter because they feel guilty or responsible of the husband’s behavior

–    Wife develops little sense of self-worth, immobilized and unable to remove self from the relationship.

•   Assessment: injuries, other evidence

•   Interventions: with consent

CHILD ABUSE

•PHYSICAL BATTERING

•EMOTIONAL

•SEXUAL

•NEGLECT

ELDERLY ABUSE

•   A variety of behaviors that threaten the health, comfort, and possibly the lives of the elderly, including physical and emotional neglect, emotional abuse, violation of personal rights, financial abuse, and direct physical abuse.

•   Commonly committed by care givers.

SEXUAL ABUSE

•   Components

–   Sexual Misuse: inappropriate sexual activity

–   Rape: there is actual penetration

–   Incest: refers to the relationship between the victim and abuser blood relative or step parent role

•   Interventions

–   Children: thru play or role playing with puppets

–   Prevention of further sexual abuse

»    next

COMPLETED SUICIDE

•   Self-inflicted death

 

•   LEVELS OF SUICIDE

–   Ideation: thought

–   Attempt: acted upon but failed

–   Completed

CHEMICAL RESTRAINT

•   CHEMICAL RESTRAINTS: Medications used to restrict the patient’s freedom of movement or for emergency control of behavior but are not a standard treatment for the px’s medical or psychiatric condition.

•   PHYSICAL RESTRAINTS: Are any manual method or physical or mechanical device attached to or adjacent to the px’s body that he or she cannot easily remove and that restricts freedom of movement or normal access to one’s body, material or equipment.

 

SECLUTION AND RESTRAINTS

•   SECLUTION: the involuntary confinement of a person alone in a room from which the person is physically prevented from leaving.

–   No therapeutic evidence other than a last resort to ensure safety.

–   Evidence suggest that it adds to further trauma and physical harm

 

•   GUIDELINES

–    All hospital staff who have direct contact with the px should have ongoing education and training in the proper use of seclusion and restraints and other alternatives

–    Physician or licensed practitioner should evaluate need within 1 hour after the initiation of this intervention.

–    Max of 4 hours for adults, 2 hours for ages 9-17, and 1 hour for children under 9 yrs

–    Orders may be renewed for 24 hrs before another face to face evaluation

–    Continuous assessment, monitoring and evaluation; recorded

–    Good nursing care

–    For both restrained and secluded: constant monitoring face to face or by both audio and video equipment.

–    Px should be released ASAP

OTHER GUIDELINES

•   SECLUSION

–    Room should allow observation and communication with px

–    Remove all items that px might use to harm self

–    Document: rationale, response to intervention, physical condition, nsg care, & rationale for termination

•   RESTRAINTS

–    Give support & reassurance

–    Position in anatomical position

–    Privacy is important

–    v/s & Circulation check

–    Should be released q 2hrs

–    Avoid tying to the side rails of bed

–    Assist in periodic change in body positions

 

TERMINATING THE INTERVENTION

•   As soon as met the criteria for release

•   Review with px the behavior that precipitated the intervention & px’s capacity to exercise control over behavior

•   DEBRIEFING: reviewing the facts related to an event & processing the response to them; can be used after any stressful event

THERAPEUTIC IMPASSES

•   Are blocks in the progress of the nurse-pt relationship

•   Provokes intense feelings in both the nurse and patient

–   RESISTANCE

–   TRANSFERENCE

–   COUNTERTRANSFERENCE

–   BOUNDARY VIOLATIONS

RESISTANCE

•   Reluctance or avoidance of verbalizing or experiencing troubling aspects of oneself

•   Eg: suppression or repression, intensification of sx, self-devaluation or hopelessness, intellectual inhibitions, acting out or irrational behavior, superficial talk, intellectual insight/ intellectualization, transference reactions.

TRANSFERENCE    

•   Unconscious response in which the px experiences feelings and attitudes toward the nurse that were originally associatated with other significant figures in his or her life.

–   HOSTILE TRANSFERENCE: anger and hostility, resistance

–   DEPENDENT TRANSFERENCE: submissive, subordinate and regards the nurse as a god-like figure; views relationship as magical

 

What do you do?

•LISTEN

•CLARIFY

•REFLECT

•EXPLORE/ ANALYZE

COUNTERTRANSFERENCE

•   Created by the nurse’s specific emotional response to the qualities of the patient; inappropriate in the context, content and intensity of emotion; nurses identify the px with individuals from their past, and personal needs

•   Types: Reactions of INTENSE

–   love or caring

–   Disgust or hostility

–   Anxiety, often in response to resistance by the px

 

•   Eg.

–    Difficulty empathizing

–    Feelings of depression before or after the session

–    Carelessness about implementing the contract

–    Drowsiness during the sessions

–    Encouragement of the px’s dependency

–    Arguments with the px

–    Personal or social involvement with the px

–    Sexual or aggressive fantasies toward the px

–    Tendency to focus on only one aspect or way of looking at information presented by the px

–    Attempts to help the px with matters not related to the identified nursing problems

–    Feelings of anger or impatience because of the px’s unwillingness to change

–    Dreams about or preoccupation with the px