Mental Health Nursing: Understanding Presence, Authenticity, and Patient Safety, Exams of Nursing

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NURS 3016 FINAL EXAM STUDY GUIDE THE PSYCHIATRIC NURSE PATIENT RELATIONSHIP The Psychiatric Nurse Patient Relationship • Some attributes of mental health o o Spirituality is one of the highest defense mechanisms we have ▪ Enormous comfort for people especially around loss • Influences that can have an impact on an individual’s mental health o • Mental health continuum of biologically based disorders o o Psychosis – patients we will be seeing in inpatient units o Patients cannot be admitted unless they are imminently a danger to themselves and others • Key to Recovery in Severe Mental Illness o Literature Review of 35 studies exploring the lived experience of persons with severe mental illness disclosed their painful isolation and desire for normalcy. o Key to recovery is: ▪ Social life and involvement in meaningful activities • All behavior has meaning ▪ Relationships with others based on understanding, trust, acceptance, and valuing of the individual. • Patient is expert in own area of illness • Patient empowerment is key ▪ Treated with respect and given opportunities to be involved in their treatment ▪ “These are remarkably ordinary aspirations that reveal how conspicuously absent these everyday life experiences may be for persons with severe mental illness and how this void may contribute to their experience of suffering. And, while medication will do little to alleviate this kind of suffering, nursing is poised to respond with understanding.” • Definition of a Therapeutic Relationship o Focus on client issues, problems, and concerns o Therapeutic Communication Techniques used to identify and explore needs, set goals, assist in development of new coping skills, encourage behavioral change ▪ Focus on the positives (how have you been managing, etc.) o Presence and authenticity are key elements when working with those who suffer ▪ Patients will know if you are not listening to them ▪ Need to be an active participant • Establishing a Therapeutic Alliance o “Psychiatric nurses need to be clear that their role demands both action and stillness. We should not discount the everyday activities of PMH nurses that bring patients ease during difficult times. Nurses will need to find room for presence so that there is space for the patient's story to emerge.” ▪ Its okay to sit in silent – time to think of what to say and what to do o RESPECT ▪ Dress and conduct self professionally ▪ Don’t want to trigger patients by our appearance ▪ Want to convey professionalism and our role o SINCERITY ▪ Be warm but not disingenuous ▪ Be honest o EMPATHY • Social Class and Psychiatric Nursing Care o How does access to psychiatric care vary with social class? o How do social factors, age, gender, occupational status, and race influence the therapeutic alliance between nurses and patients? o Is coerciveness associated with treatment of patients according to social class or age? • Culture and Psychiatric Nursing Care o Evaluating the cultural context of the patient’s illness ▪ Cultural degree of stoicism • “What do you think caused your symptoms? Why did these symptoms start when they did? How would you describe the severity?” ▪ Cultural beliefs about the specific problem • “What do you fear most about your symptoms? What are the chief problems you believe your symptoms have caused for you, your family, partner, work colleagues, etc...?” ▪ Personal meaning or beliefs about treatment • “What kind of treatment do you think you should receive? • “ What have you done to treat or manage your symptoms?” • “What are the most important results you hope to achieve from treatment?” • Boundary Blurring o Relationship slips into a social context o Nurse behavior meets personal needs at expense of client: ▪ Underhelping ▪ Overhelping ▪ Controlling ▪ Narcissism ▪ Transference ▪ Countertransference • Definition of Transference and Countertransferece o Transference ▪ Client’s unconscious displacement of feelings for significant people in the past onto the nurse in the current relationship o Countertransference ▪ Nurse’s emotional reaction to the client based on significant relationships in the nurses’ past ▪ Can be positive or negative feelings ▪ Maybe conscious or unconscious • Countertransference in the Nurse-Patient Relationship o Clues to Countertransference ▪ Intense feelings regarding the patient • Anger, fear, guilt, disgust, sympathy or sexual attraction ▪ Difficulty paying attention ▪ Dreading contact with the patient ▪ Becoming preoccupied ▪ Departing from usual routine of nursing care o Disclosing Personal Information ▪ Try to explore the interest or concern in the patient’s inquiry about personal information o Physical Boundaries ▪ Rule of thumb, avoid touching o Gifts ▪ Graciously accept handmade gifts from children, decline personal gifts from adults • Countertransference and Quality of Care o Sources of emotional influence on clinical performance ▪ Ambient induced • Transitory emotional states • Environmental • Stress, fatigue • Other influences ▪ Clinical situation induced • Counter transference • Fundamental attribution error • Specific emotional biases ▪ Endogenous • Circadian, infradian, seasonal mood variation • Mood disorders • Anxiety disorders • Emotional dysregulatory states o Diagnostic Overshadowing ▪ RNs were given a hypothetical scenario of a patient with chest pain who was on no meds, or on psych meds • No meds – 50.6% of RNs predicted patient had MI • Psych meds – 35% of RNs predicted patient had MI ▪ Iatrogenic events higher for patients with schizophrenia • Schizophrenic patients 2X more likely to have post-op sepsis or respiratory failure; deep venous thrombosis or pulmonary embolism; and infections • Hospitalized schizophrenic patients more likely to die from adverse events than patients with no psych hx o Implications for Nursing Practice ▪ Recognize that emotional influences can adversely impact clinical performance and patient safety ▪ Clinical teaching must promote openness and discussion of emotional feelings about patients to develop emotional awareness, tolerance and non-judgmental listening ▪ Students need to develop self-understanding on how their emotional bias or countertransference influences clinical decision-making and quality of patient care ▪ Nurse managers must promote an workplace environment that supports and sustains mental health of nursing staff • Violence: Warnings o Restlessness/hyperactivity o Signs of anxiety and tension o Profanity, argumentativeness o Loud voice or stony silence o Intense glaring eye contact o Intoxication o Carrying a dangerous object o Recent acts of violence • Care with Least Restrictive Alternatives o Patient Rights Movement in Mental Health has consistently championed the development of gentle, voluntary, empowering and holistic alternatives to seclusion and restraint. o Nursing staff must use interventions for the least amount of time and in the least restrictive way, taking into consideration the patient's history, preferences and cultural perspective. • De-Escalating Techniques o Move to a “safe” place – Avoid being trapped in a corner o Avoid audiences – have staff ask other patients or visitors to move from the area o Allow greater body space than normal o Assess situation; identify stressors and what client sees as his need o Pay attention to non-verbal behavior such as body posture and eye contact o Assess for own personal safety –never approach a patient alone o Stay calm, lower your voice o Calm the patient before trying to solve the problem o Questions about the “facts” rather than the patient’s feelings can assist in de-escalating o Speak clearly and briefly, attempt to negotiate options and avoid threats o Don’t argue, encourage reasoning • Primary Prevention: Patient Specific Triggers o Being touched o Being isolated o Feeling crowded o Particular time of day or year o Loud noise or Yelling o Not having control or input o Being around men or women • Secondary Prevention: Patient Preferences to Reduce Agitation o Voluntary time out in your room or comfort room o Watching TV, reading, writing in journal, listening to calming music o Sitting by the nurses station or pacing the halls o Talking with another patient, friend, nursing staff o Exercise or going for a walk o Punching a pillow or deep breathing exercises o Putting hands in cold water , ice on wrist or cold face cloth o Wrapping up in a blanket • Secondary Prevention: Sensory Approaches to Reduce Agitation o Watching fish in an aquarium(sight). o Listening to calming music (sound). o Smelling lavender, vanilla, or orange (smell). o Squeezing a stress ball or using a weighted blanket(touch). o Eating, salty, sour, or sweet foods (taste) • Evidence Based Practice: Nursing Interventions to Reduce Agitation o Study Interventions: ▪ Traditional group • Alone time or quiet time • Increased super vision • One on one staff time o Conditions to release medical/nursing records by Subpoena ▪ Must have signed release signed by client and attorney ▪ Disclosure falls under laws pertaining to harm to self or others ▪ Subpoena is valid ▪ Document in the medical record and with the client precisely what information was released o Testimonial Privilege ▪ Applies confidentiality principles to court proceedings ▪ Some states extend testimonial privilege to psychotherapists. If there are no provisions in the state nurse practice act, the nurse should exercise testimonial privilege unless ordered to release information by the court • Confidentiality in Group Psychotherapy o Only 32% of group therapists explicitly discussed the risks of disclosure by other group members o Group psychotherapists must clearly define confidentiality, it’s importance at the first group session and subsequent sessions. o Inadvertent disclosures and deliberate infractions must be addressed in the group. • Mandatory Reporting o Duty to Warn AKA Tarasoff ▪ Massachusetts and Rhode Island Statues • If a patient has a history of physical violence known to the licensed health care provider, and the provider has a reasonable basis to believe that there is a clear and present danger the patient will harm the victim, there is a duty to warn. o Duty to Warn ▪ Massachusetts Statues • Requires the licensed health care professional to “reasonably identify” the potential victim • Document in the client’s record,date, times and specific communication in your phone calls to the police and potential victim(s) • Keep copies of certified letters and receipts validating delivery in the medical record • Mandatory Reporting of Abuse o Types of Abuse ▪ Abandonment • “ Willful forsaking of an elder or dependent adult by anyone having care or custody of that person under circumstances in which a reasonable person would continue to provide care ▪ Neglect • “ Failure to assist a child, elder or dependent adult in personal hygiene, to prevent malnutrition to provide medical care, etc ▪ Physical • Assault, unreasonable physical restraint, deprivation of food or water, medication or isolation without authorization ▪ Sexual • Rape, lewd and lascivious acts upon a child, sexual exploitation • Mandatory Reporting of Elder and Child Abuse o Must immediately make an oral report to DSS o Must file a 51 A within 48 hours with DSS o Document in the client record date, time, protective agency staff contacted and nature of communication. o Follow notification protocols for 51A in the clinical agency o DSS will request your name, address, phone number, relationship to abuse victim o Action taken to treat, shelter or assist the victim o Any prior knowledge of previous injuries or neglect o Specifics about the nature and extent of the abuse or neglect • Confidentiality and Treatment of Minors o School Records ▪ Parents of minors or students who are 18 have the right to review their educational record ▪ An exception maybe counselor case notes and notes by the school nurse • Confidentiality and Treatment of Minors o Parents have a legal right to access mental health records o Formation of a therapeutic relationship is founded upon trust that the nurse will respect the child or adolescent’s right to privacy. o The nurse can not provide minors with a guarantee of blanket confidentiality. At outset of forming the nurse-patient relationship, information that will be disclosed needs to be discussed among the nurse, child/adolescent, and parents o Never keep a secret!! Don’t make that promise (I want to hear what you have to say, but I have to share it with other members of the treatment team) • Justification for Hospital Admission o Clear risk of client danger to self and others o Dangerous decompensation of long term treatment client o Failure of community-based treatment/need for structure o Medical need of psychiatric or non-psychiatric nature • Goals for Acute Hospitalizaion o Prevention of self-harm o Prevention of harm to others o Crisis stabilization and return to community o Initiation/modification of psychotropic medications o Brief, specific problem solving to promote compensation o Rapid planning for outpatient therapy • Psychiatric Hospital Admissions o I. Conditional Voluntary Admission – 3 days notice to leave o II. Involuntary Admission (Commitment) ▪ Types of Procedures • Judicial • Administrative • Agency ▪ Nature & Purpose of Involuntary Admission • Observational or temporary • Emergency • Long-term (formal) o III. Doctrines that apply to all admissions ▪ Habeus Corpus ▪ Least restrictive alternative • Massachusetts Laws: Seclusion & Physical Restraint o Legal requirements ▪ Direct evaluation by MD ▪ MD order expires at 3 hours ▪ Telephone orders expire at 1 hour ▪ Patient must be fully clothed ▪ Staff must directly observe patient at all times ▪ Must be evaluated by physician every 6 hours ▪ Staff must document every 15 minutes safety checks o Patient must be released for 10 minutes every 2 hours from 8am to 8 pm, and every 4 hours from 8 pm to 8 am o Documentation on DMH triplicate form with space for patient comments o Minors may only be restrained or secluded in DMH authorized facilities o No minor maybe secluded for more than 2 hours o Human Rights Committee and Commissioner review all documentation regarding the use of seclusion and restraint including patient comments every month • Massachusetts DMH Seclusion/Restraint Regulations o Nursing Assessment Documented on DMH form ▪ Document safety checks q15 minutes - ▪ Vital signs ▪ Circulation, Body Alignment, and Comfort ▪ Changes in Mental status o Nursing Care Documented on DMH form ▪ Nutrition ▪ Hydration ▪ Elimination o Signature and title of nursing staff required for every safety check documented on DMH restraint form • Massachusetts Laws: Chemical Restraint o Nursing Assessment and Documentation ▪ Precipitating behavior ▪ Less restrictive alternatives tried and result ▪ Ongoing observations ▪ MD direct assessment and order ▪ Telephone orders only permissible if written in as part of the treatment plan • Ethical Principles o Beneficence ▪ Promoting good o Autonomy ▪ The right to make one’s own decisions o Justice ▪ Treating others fairly and equally o Fidelity ▪ Doing no wrong to the client; observance of loyalty and commitment to the client o Veracity ▪ Telling the truth • Ethical Complaints in Psychiatry o Sexual Misconduct 44% o Insurance and Fee Problems 15% o Nonsexual Dual Relationships 13% o Child Custody Evaluation 11% • ANA Psychiatric Standard 1: Nursing Assessment o Psychiatric History ▪ Identifying information • Name, age, sex, race, marital status, occupation, prior psyche. diagnosis or hospital admission • Use the DSM-V (Manual developed by APA to help us develop criteria that patient must meet to have diagnosis of a major mental illness) ▪ Presenting problem or Chief complaint • In the patient’s own words, in quotes • Do not make assumptions about why the patient is seeking treatment • Note if the patient’s description of the chief complaint differs from significant others ▪ Brief recent history • When were the symptoms first noticed, how severe are they, are the symptoms persistent or episodic? • How are the symptoms affecting all areas of social, physical and psychological functioning • Any recent changes in medical status? o First thing you want to do: rule out if a medical illness in which a symptom can appear through behavior (hypothyroidism) • Any recent changes in use of alcohol or drugs? o Co-occurring alcohol or drug related use or misuse o Alcohol is a CNS depressant (can confuse the mental status picture of patients, especially those with major depressive disorder) ▪ Goal is to determine what specifically were the precipitants.. ▪ How did social supports or coping mechanisms breakdown to trigger crisis? • That’s where therapeutic relationship starts o Family History ▪ Genogram • Highlight dates of losses including deaths, separations, divorce, miscarriages o If history of suicide who found the victim? What did the family tell the patient about the suicide? • Highlight incidence of psychiatric and medical illnesses. o Note treatment especially psychopharmacology ▪ Any history of alcohol or substance abuse? ▪ Explore role relationships among family members, parenting styles, customs, and religious rituals • Any history of physical, sexual or emotional abuse? ▪ Goal is to understand the meaning of the patient’s behavior in the context of the family relationships, culture and genetic history o Personal History ▪ Childhood Development • Early childhood memories, dreams, important events • Adaptation to school, socialization with peers, separation from family • Childhood injuries, illnesses ▪ Adolescent Development • Peer relationships • Sexuality and intimacy • Autonomy and independence • Alcohol or substance abuse o Brain continues to develop until you’re 30 years old o Assessment in a Cultural Context ▪ QUESTION on ATAQUENERVIOS ▪ History, class and status ▪ Traditions including religious, rituals and superstitions ▪ Values such as personal relationships, morality, work and time ▪ Family systems including sex roles, parental roles, and how the family is defined (ie- matriarchal, blood lineage, etc.) ▪ Influence of class and ethnicity on behavior, attitudes and values ▪ Knowledge of help-seeking behaviors ▪ Role of language, speech patterns and communication styles ▪ Knowledge of the impact of social services ▪ Knowledge of informal helping networks o Use of “Ad Hoc” interpreters (e.g.,bilingual hospital staff, friends or family) ▪ May impede disclosure of sensitive material and contribute to distortions or errors. ▪ Errors occur more often among acutely ill patients and may lead to over- or underestimation of psychopathology ▪ Compromised disclosure may yield fewer referrals for follow-up care potentially impacting treatment and health outcomes. ▪ Difficult because of the personal nature of psychiatric nursing ▪ To the degree possible use professional translators o Use of Professional interpreters ▪ Facilitates disclosure of sensitive material ▪ Leads to greater patient satisfaction and self-understanding, thereby reinforcing the cornerstones of high-quality psychiatric care. o Implications for Psychiatric Nursing Practice ▪ Nurses rated communication as “poor” or “fair” in 84% of evaluations without an interpreter and 72% with ad hoc interpreters, but only 6% with professional interpreters ▪ Bilingual nurses were less likely than professional interpreters to say they could not follow the patient instead asserting their opinion that the patient was psychotic. o Spiritual Assessment ▪ What role does religion/spirituality play in your life? ▪ Does faith help you in stressful situations? ▪ Do you pray/meditate? ▪ Who or what supplies you with strength and hope? ▪ Has your illness affected religious/spiritual practices? ▪ Do you participate in any religious activities? ▪ Do you have a spiritual advisor or member of the clergy available? ▪ Is there anyone I can contact to help put you in touch with your church/place of worship? o Assess Resilience within a Strength Based Model ▪ #1 – Purpose • What is it about your life that gives you the most meaning? • What do you do every day that others value and/or depend on you for? • What do you hope for in your life? o Assess Resilience within a Strength Based Model ▪ #2 Perseverance • What kinds of things have you worked hard at in your life? • When you have experienced difficult times, how would you say you’ve gotten through them? • Figure out the patient’s natural support system o Assess Resilience within a Strength Based Model ▪ #3 Equanimity • Individuals who focus in disappointments or regrets overlook the positive aspects of their life • What is your overall outlook on life? o Alcohol abuse o Male gender o Poor functional status o Depression o Pain o Increased BUN/Creatine ratio  Medication Risk Factors for Delirium o Medications  Polypharmacy & drug/drug interactions, increase in doses, OTC or ETOH interactions  Medications with Anticholinergic Properties  Tricyclic antidpressants – amitriptyline, doxpin, imipramine  First generation antipsychotics – chlorpromazine, thioridazine  Olanzapine  Paroxetine  Corticosteroids  Benzodiazepines  Withdrawal from medications, especially opioids  Poor pain management  Risk Factors for Delirium in Hospitalized Older Adults o > 70 years old o MMSE <24/30 o Mobility or ADL impairment o Vision impairment o Hearing impairment o Dehydration  Evaluation of Risk Factors for Delirium post op Precipitant Evaluation considerations Environmental factors - Inadequately controlled pain Physical examination - Sleep disturbance Review of medical records, including nursing notes - Use of physical restraints - Use of bladder catheterization - Poor vision and/or hearing Infection - Urosepsis Physical examination - Pneumonia Urinalysis and blood cell count - Line sepsis Chest radiograph - Bacteremia Blood, sputum, and urine cultures - Surgical site infection Imaging of surgical site if indicated o  Nursing Assessment of Delirium o Assess for risk factors  1. Baseline or pre-morbid cognitive impairment  2. Medications review  3. Pain  4. Metabolic disturbances (i.e., hypoglycemia, hypercalcemia, hyponatremia, hypokalemia)  5. Dehydration (physical signs/symptoms, intake/output, Na+, BUN/Cr)  6. Infection (fever, WBCs with differential, cultures)  7. Environment (sensory overload or deprivation)  8. Impaired mobility  Evidence Based Assessment Screens for Delirium o General delirium screening instruments  Confusion assessment method (CAM) – short form  Delirium symptom interview (DSI)  Nursing Delirium Screening Scale (NuDESC) o Intensive care unit screening instruments  Confusion assessment method for the intensive care unit (CAM-ICU)  Intensive care delirium screening checklist  Screen for symptoms of delirium with CAM (Confusion assessment method) o Hyperactive (3 or more)  Restlessness  Anger/irritability  Combativeness  Uncooperative  Wandering  Distractibility  Persistent thoughts  Swearing  Euphoria  Fast or loud speech o Hypoactive (4 or more)  Unawareness  Lethargy  Decreased alertness  Staring  Sparce, slow speech  Apathy  Decreased motor activity  Nursing interventions: delirious older adult o First and Foremost:  Eliminate or minimize risk factors  Administer medications judiciously; avoid high-risk medications.  Prevent/promptly and appropriately treat infections.  Prevent/promptly treat dehydration and electrolyte disturbances.  Provide adequate pain control.  Maximize oxygen delivery (supplemental oxygen, blood, and BP support as needed).  Use sensory aids as appropriate.  Regulate bowel/bladder function.  Provide adequate nutrition.  Nursing best practices to promote use of beers criteria o Nursing assessment includes a comprehensive medication evaluation of prescription, non-prescription medications as well as complementary treatments. o Medication evaluation should be repeated at each transition of care and end of life. o Polypharmacy should be avoided to minimize drug-drug interactions and adverse events. o Post the Beers criteria I and II where medications are ordered or dispensed o Incorporate the Beers criteria I and II into electronic medication ordering systems o Evaluate falls, agitation and injury to assess if the patient had been prescribed a medication contained in the Beers I and II criteria.  Evidence based practice: Beers Criteria o o  Nursing best practices to promote use of beers criteria o Medications on Beers I and II criteria should be re-evaluated and safer alternatives considered. o Promote the use of nonpharmacologic alternatives to manage behavioral symptoms o Educate patient and family about importance of adhering to prescribed treatment and about drug interactions with over the counter medications and alternative treatments. o Evaluate and monitor laboratory data. Use the Cockcroft-Gault Formula to determine if creatine clearance is low and whether medication should be prescribed in a reduced dose. For women multiply answer by 0.85. o (140 – age in years) X lean body weight in kg o serum creatinine in mg/dl X 72  Nursing interventions: delirious older adult o Know the distinguishing characteristics between depression, dementia and delirium o Monitor vital and neurological signs o Keep head of bed elevated o Provide clocks, calendars  Nursing interventions: communicating with delirious patient o Have client wear glasses, hearing aids o Clarify reality if hallucinations or illusions persist o Ignore insults o Call client by name and identify self o Use face-to-face contact o Use short, simple, concrete phrases o Explain what’s to be done  Nursing interventions: delirious older adult o Provide appropriate sensory stimulation:  quiet room; adequate light;  one task at a time; noise-reduction strategies o Facilitate sleep:  back massage, warm milk or herbal tea at bedtime;  relaxation music/tapes;  avoid awakening patient o Foster familiarity:  encourage family/friends to stay at bedside;  bring familiar objects from home;  maintain consistency of caregivers;  minimize relocations o Maximize mobility  Ambulate at least 2 X / day if appropriate  Avoid restraints and urinary catheters o Minimize invasive interventions o Pain control with scheduled acetaminophen if appropriate o Nutritional and fluid replacement o Reassure and educate family  Evidence Based Pharmacologic Recommendations for Delirium o Antipsychotic or benzodiazepines should not be prescribed to patients with post-operative delirium who are not agitated or threatening substantial harm to self or others o Antipsychotics at the lowest effective dose for the shortest possible duration maybe prescribed to patients who are severely agitated or threatening harm to self or others o Benzodiazepines should not be prescribed as a first line treatment for the agitated or threatening patients with delirium, except to treat ETOH withdrawal  Summary: Nursing Interventions for Delirium  Persecutory delusions (most commonly a delusion of theft)  Paranoid  Somatic  Capgras syndrome (misidentification of spouse or family member or home)  Grandiosity  Hallucinations  More prone to verbal outbursts, aggression and agitated behaviors  Nursing Diagnosis o Imbalanced Nutrition o Self-Care Deficit o Impaired Swallowing o Constipation; Bowel Incontinence o Impaired Urinary Elimination o Risk for Impaired Skin Integrity o Impaired Physical Mobility o Pain and Comfort Management o Impaired Memory o Disturbed Thought Processes o Chronic Confusion  Nursing interventions: Dementia o Biologic  Check skin for dehydration  Monitor for electrolyte imbalances  Provide well-balanced meals individualized to patient’s need  Assess for pain and provide comfort measures  Allow for naps, use of night time activities to decrease restlessness o Social  Reinforce communication with others, social remarks and gestures  Institute pet or stuffed animal therapy  Maintain simple, consistent routines  Minimize environmental distractions  Institute protective measures o Psychological  Communicate slowly and clearly  Encourage expression of negative feelings  Distract from hallucinations  Distract from situations that produce catastrophic reactions  Identify triggers for delusions/not confront  Behavioral changes in Dementia: Sundown syndrome o Characteristics  Agitation, confusion, anxiety, and aggressiveness in late afternoon, in the evening, or at night. o Risk Factors  Sundown syndrome is highly prevalent among individuals with dementia. o Etiology  Impaired circadian rhythmicity, environmental and social factors, and impaired cognition.  Neurophysiological factors include the degeneration of the suprachiasmatic nucleus of the hypothalamus and decreased production of melatonin  Nursing interventions: Sundown syndrome o Rule-out medical etiology   Pain, incontinence, constipation o Side-effect of medications or caffeine o Restrict daytime sleep o Sleep hygiene o Regular exposure to morning sunlight, bright lights in afternoon and early evening o Regular mild exercise and daily physical activity o Calming music o Aromatherapy  Behavioral changes in dementia: Agitatoin o Rule-out medical etiology  Toxic reactions, infections, pain o Interpersonal Interventions  Brief, frequent goal-directed interactions with primary care giver  Use of touch, close eye contact, low caring voice, linking nonverbal behavior to unmet needs o Calming music during mealtimes o Towel bathing instead of shower bathing o Hand massage for 10 minutes  Nursing interventions Biologic domain: Agitation o Antipsychotics  FDA issued a “Black Box” warning of increased mortality with atypicals in demented patients(4-05) o Antidepressants  When symptoms of depression, anxiety or irritability are prominent o Mood Stabilizers  If the behavioral agitation in dementia represents a form of organic mania, anticonvulsants may be effective based on their mood-stabilizing properties. o Benzodiazepines: Short-acting  If anxiety and tension are a major component of the agitation. o Psychopharmacology in the Older Adult  Decreased Liver Function  Need lower doses  Are more likely to develop side-effects  Impaired cognition affects adherence o Use of pill boxes o Calendar o Enlist assistance of family members  Nursing intervention in Biologic Domain: Goals of Psychopharmacology o Symptomatic stabilization o Preservation of function o Slowing of inevitable decline in cognition o Slowing appearance and severity of behavioral disturbances o Slowing onset and rate of functional impairment o Slowing emergence of declining behaviors o Delaying emergence and onset of agitation, aggressive behavior, violent behaviors, and psychosis o Preservation of function and activities of daily living o Delaying institutionalization o Delaying requirement for antipsychotic use o Coast savings o Preservation of ABCs reduces cost of comorbid conditions  Psychopharmacology for Alzheimer’s o CHOLINESTERASE INHIBITORS – 1st Line Mild to Moderate Alzheimer’s  Donepezil (Aricept)  Galantamine (Razadyne)  Rivastigmine (Exelon)  Tacrine (Cognex)  check ALT every 2 weeks o N-METHYL-D-ASPARTATE RECEPTOR ANTAGONIST- Moderate to Severe Alzheimer’s  Memantine (Namenda)  Nursing interventions in Psychological domain o Evidence based practice for care of the elderly  Life Review Therapy  Pet Therapy  Exercise Therapy  Music Therapy  Horticultural Therapy  Remotivation Groups  Reminiscence Group Therapy  Nursing interventions: Life Review Therapy o Childhood  Birthplace, any special about town or school, pets, favorite activities, religious rituals o Adolescence  Special friends, hobbies, sports, school interests o Young adult  First car, military, college, marriage o Adult  Work and family, travel, hobbies, o Older Adult  Leisure pursuits, community, favorite foods, losses  Nursing interventions in Psychological Domain o Decrease sensory stimulation but avoid social isolation  Structured daily routine  Schedules, calendars, clocks, keeping priced possessions in same place  Use creative means to avoid physical restraint  “Sheltered Freedom” - space to move about freely both indoors and outdoors  Nursing care concerns in Social domain o Memory impairment o Disorientation, mistaken beliefs o Needs physical help o Risk for injury o Apathy o Poor Communication o Repetitiveness o Uncontrolled emotion, behavior o Incontinence o Poor decision making o Burden on family o Community Nursing Homes  Difficulty in communication 40%  Delusions and Hallucinations 38%  Restlessness, P/A Behaviors 38%  Demanding interactions 36%  Socially objectionable 36%  Disruptive 34%  Aggressive 26%  Wandering/noisy 24%  Nursing interventions: Social domain o Behaviors that Burn-Out Family Caregivers  Incontinence  Personality Conflicts  Falls  Physically aggressive behavior  Inability to walk unaided  Daytime wandering  Sleep disturbance  Evidence based practice: PLST model of care for dementia o Maximize safe function by supporting losses  Limit choices on the bases of ability, avoid teaching new skills  Schedule rest periods o Provide unconditional positive regard  Use distraction or acceptance rather than argument or confrontation o Use anxiety and avoidance to gauge activity and stimulation levels  Record activities and time of day associated with increased anxiety o Interpret repeated behaviors as expressions of anxiety  Provide comfort items like a family photo, pillow or soothing object o Modify environment to enhance safety  Assess environment for hazards or barriers  Minimize use of physical restraints o Provide referrals to community resources for assistance with care, respite and support groups  Psychiatric Disorders Related to Acute and Chronic Medical Illness o Psychiatric disorder may be the first manifestation of a primary disease o Depressive symptoms are an intrinsic part of endocrine disorders, metabolic disturbances, malignancies, viral infections, inflammatory disorders, and cardiopulmonary conditions o Malignancies associated with anxiety and depression o Cardiac disease associated with precipitated depressive syndromes in 20%-50% of patients and anxiety disorders in up to 80%  Major depressive disorder in the older adult o Epidemiology  15% of all nursing home residents o Risk Factors  Widow and chronic medical illness o Clinical Features  Hypochondriasis and somatic complaints  Feelings of worthlessness, low self-esteem  Refusal to eat, agitation, psychotic features  Nursing Best Practices: Screen with Geriatric Depression Scale o Choose the best answer for how you have felt over the past week: o 1. Are you basically satisfied with your life? YES / NO o 2. Have you dropped many of your activities and interests? YES / NO o 3. Do you feel that your life is empty? YES / NO o 4. Do you often get bored? YES / NO o 5. Are you in good spirits most of the time? YES / NO o 6. Are you afraid that something bad is going to happen to you? YES / NO o 7. Do you feel happy most of the time? YES / NO o 8. Do you often feel helpless? YES / NO o 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO o 10. Do you feel you have more problems with memory than most? YES / NO o 11. Do you think it is wonderful to be alive now? YES / NO o 12. Do you feel pretty worthless the way you are now? YES/ NO o 13. Do you feel full of energy? YES / NO o 14. Do you feel that your situation is hopeless? YES / NO o 15. Do you think that most people are better off than you are? YES / NO  Nursing assessment: Dementia vs. Depression o Depression vs. Dementia o Duration Short Long o Symptoms Worse in a.m. Worse in p.m. o Family Hx MDD Yes No o Family Hx Dementia No Yes o Aware of deficits Yes No o Ability to do ADLs Yes No  Suicide and the older adult o Epidemiology  1 out of every 5 suicides committed by person 65 years or older  Highest rate for any age group o Risk Factors  Over 85 years old, male, white, own a firearm  Likely to visit primary care giver 1 month prior to suicide  Physical and psychiatric illness  ECT for Treatment of MDD in the Older Adult o ECT preferred over psychopharmacology if:  Catatonic, delusional or psychotic  Co-morbid medical conditions  Hypertension, coronary artery disease and conduction disturbances o  Mild anxiety o Perceptual field heightened o Grasps what is happening o Identifies disturbing things o Can work toward a goal o Can examine alternatives o Experiences slight discomfort o Restlessness, irritability o Mild tension relieving behaviors  Moderate anxiety o Perceptual field narrows o Selective inattention o Needs to have things pointed out o Problem solving ability moderately impaired o Benefits from guidance o Shaky voice, concentration difficult o Sympathetic nervous system symptoms o Somatic complaints  Severe anxiety o Perceptual field greatly reduced o Attention scattered o Self-absorbed o Can’t attend to events or see connections o Perceptions distorted o Feelings of dread/doom o Sympathetic nervous system symptoms o Confusion, purposeless activity  Panic level anxiety o Unable to focus on environment o Terror, emotional paralysis o Hallucinations/delusions o Muteness, severe withdrawal o Immobility or extreme agitation, severe shakiness o Disorganized, irrational thinking o Unintelligible speech o Sleeplessness  Defenses against anxiety o Manage conflict and affect o Are relatively unconscious o Are discrete from one another o Are often hallmarks of psychiatric syndromes o Are reversible o Are adaptive as well as pathological  Neurotransmitters and anxiety o Norepinephrine  Increase: mania, anxiety states, schizophrenia  Decrease: depression o Serotonin  Increase: anxiety states  Decrease: depression o GABA  Increase: reduced anxiety  Decrease: anxiety disorders, schizophrenia  Epidemiology of anxiety disorders o Lifetime prevalence of anxiety and phobic disorders is 17.5% o Incidence of panic attacks is 10% of general population o Lifetime prevalence of OCD is 2 - 3% and is consistent across cultures  Epidemiology: anxiety disorders and gender o Women 2 X more likely to have an Anxiety Disorder than Men  Anxiety and medical symptoms o 10-27% of primary care patients have anxiety derived complaints o Cardiac  tightness, pain, tachycardia o Respiratory  shortness of breath, hyperventilation o Neurological  headache, dizziness o GI  diarrhea, nausea, vomiting, urinary frequency  DSM V criteria for GAD o Excessive anxiety or worry for 6 months associated with:  Restlessness  Fatigue  Poor concentration  Irritability  Muscle tension  Sleep disturbance  Nursing assessment biological domain: anxiety disorders o Questions for Differential Diagnosis  Are there metabolic, endocrine, cardiorespiratory or neurologic comorbid conditions?  When was the onset?  What is the medical treatment? Any side-effects noted?  Any family history of medical conditions associated with anxiety?  Nursing assessment: anxiety disorders o Differentiating Medical Conditions  Cardiac  CHF, MI, Angina, Mitral Valve Prolapse  Dietary  Caffeine (Coke,Surge, herbal teas)  Endocrine  Hyperthyroidism, hypoglycemia, Cushings  Respiratory  Asthma, COPD, pulmonary embolism  Inflammatory  Lupus  Deficiency states  B12, Anemia  Nursing Assessment Biological Domain: Anxiety Disorders o Laboratory Tests  Thyroid screen ( in anxiety)  Parathyroid (  in anxiety)  Cardiac Enzymes(AST  in heart failure)  Akathisia (s.e. of antipsychotics)  Anticholinergic toxicity(tricyclics)  Bronchodilators (theophylline)  Nursing assessment: anxiety disorders o Laboratory Tests  Bicarbonate ( with hyperventilation)  Catacholamines ( panic)  ACTH ( in Cushings)  Fasting Blood Sugar ( panic & anxiety)  Phosphorus ( panic & hyperventilation)  Nursing Assessment Biological Domain: Anxiety Disorders o Tests for Cardiac Function  Echo, Halter  Monitor, EKG  10 - 40% of patients with panic disorder have mitral valve prolapse  Bronchodilators (theophylline)  Nursing assessment: anxiety disorders o ETOH use significant contributor to symptoms of anxiety  4 X more prevalent in panic disorders  3.5 X more prevalent in OCD  2.5 X more prevalent phobias o Substance Abuse mimics Anxiety  Cocaine  Amphetamines  LSD  Nursing Assessment Biological Domain: Anxiety Disorders o Differentiating Drug Induced  ETOH withdrawal  Over the counter diet pills  Psychostimulants (cocaine, amphetamines) o Laboratory Tests  Urine and or serum toxic screen  Nursing Assessment Psychological Domain: Anxiety Disorders o History  Onset of symptoms  Typically, late teens to early 20s  >40 years greater likelihood of organic cause o Duration and Course  Anxiety disorders  intermittent or persistent  Situational reactions  self-limiting o Mental Status Exam  Speech  rapid and pressured (or) sparse  Cognition  uncontrolled worry, obsessions  Affect  uneasiness, dysphoria  Behavior  limited mobility, flight, compulsions  DSM-V Criteria for Panic Disorder o Discrete period of intense fear in which the following symptoms develop abruptly and peak within 10 minutes  Palpitations, chest pain, tachycardia  Sweating, trembling, dizziness  Derealization, depersonalization, fear of losing control  Culture Related Diagnostic Issues in Panic Disorder o DSM-V Note: Culture specific symptoms should not count as symptoms of panic disorder. Examples include:  Trung gio (“hit by the wind”)  Vietnamese individual who has a panic attack after walking out into a windy environment  Ataque de nervios (“attack of nerves”)  Latin American who exhibit uncontrollable screaming or crying  Khyal (“soul loss”)  Cambodians who experience depersonalization or derealization  Differentiating GAD and Panic Disorder o History of Chief Compliant  Panic Disorder seek treatment earlier  Panic Disorder are more disabled by symptoms  Panic Disorder have an abrupt onset  25% of patients with GAD develop panic disorder o Family History  Panic Disorder  20-25% of 1st degree relatives  5 X > concordance in mono vs. dizygotic twins  Anxiety Disorder  No familial pattern  Prognosis of Panic Disorder o 10 - 20% have chronic course o 30 - 40% have full remission o 50% have persistent, mild symptoms which do not interfere with normal daily functioning  DSM-V Criteria for Phobias o Agoraphobia  Panic attack triggered by intense fear about being in places where escape maybe difficult, open spaces or outside the home o Specific Phobia  Anxiety or panic attacks associated with specific object o Social Phobia  Marked and persistent fear in social or performance situations  Nursing Interventions Psychological Domain: Anxiety Disorders o Acute Phase  Decrease somatic and affective symptoms of anxiety o Stay with client o Reassure you will not leave o Low pitched voice; speak slowly, o Maintain a calm manner o Use clear, simple statements and repetition o Meet physical and safety needs o Minimize environmental stimuli o Walk or pace with client o Assess for prn medication o Correct cognitive distortion (i.e., catastrophizing) o Listen for themes o Encourage discussion of antecedent events and triggers o Encourage to link behavior to feelings o Encourage relaxation techniques, breathing control o Assess for efficacy of medication  Biologic, Psychological and Social Domain Outcomes for Panic Disorders o Biologic:  Decreased number and severity of panic attacks  Decreased use of pathogenic substances  Improved nutritional status  Improved sleep  Increased utilization of breathing control and relaxation techniques  Improved physical condition o Social:  Decreased avoidance  Increased number of interpersonal relationships  Decreased number of life stressors  Increased time management skills  Increased family knowledge of disorder  Increased family support  Increased social contract o Psychological  Decreased catastrophic interpretations  Increased sense of control  Increased self-esteem  Increased assertiveness  Increased management skills  Improved symptom management and relapse prevention skills  Obsessive-Compulsive Disorders o Epidemiology  Lifetime prevalence of OCD is 2 -3%  2/3 rd. have onset ฀ 25 years old  15% have onset ฀ 35 years old  35% of first degree relatives have OCD  Equal prevalence men and women o Onset and Course  50 - 70% abrupt onset after stressful event  20 - 40% chronic or deteriorating course  Co-morbidity in OCD o Depression: 66% o Simple phobia: 22% o Social phobia: 18% o Eating disorder: 17% o Alcohol dependence: 14% o Panic disorder: 12% o Tourette syndrome: 7%  Epidemiology: Obsessive Compulsive Disorders o Cultural Context  Rates of OCD similar across all cultures  OCD symptoms reflect characteristics of culture  Muslims  - Compulsive ablution (washing) & religious rituals  Japanese  - Courtesy, need for symmetry o Biological Factors  Genetic  Twins and family studies suggest significant genetic component  Biological  Dysregulation of serotonin o Behavioral Factors  Fear or anxiety becomes a learned response to events that are noxious or anxiety producing.  Compulsions and obsessions are a conditioned mechanisms to neutralize anxiety o Psychodynamic Factors  Undoing  Reaction Formation  Neurotic defense mechanisms: Undoing o Neutralize wish by channeling anxiety into a compulsive activity is an attempt to prevent or undo the consequences that the patient irrationally anticipates from a thought or impulse  Differentiating Obsessions and Compulsions o Obsessions  A recurrent and intrusive thought, feeling or sensation  Most Common Obsessions  Contamination  45 %  Pathological Doubt  42 %  Somatic  36 %  Need for Precision  31 % o Compulsions  A conscious, standardized, recurrent behavior.  80% recognize that compulsion is irrational.  Most Common Compulsions  Checking  63 %  Counting  36 %  Washing  50 %  Asking or Confessing  18 %  Nursing Assessment Biological Domain: OCD o #1 Priority : Skin Integrity Maintenance  Excessive washing  Dermatitus or Eczema  Excessive brushing  Blooding Gums  Ritual hair pulling (trichotillomania)  Alopecia  Repeated visits to PCP for self or child  Nursing Assessment Psychological Domain: OCD o Mental Status  Mood and Affect  Anxious dread accompanies obsessions  50% present depressed  Thought Processes and Content  Obsession intrudes persistently into person’s conscious awareness  Obsession is recognized as ego-alien (irrational)  Behavior  50% do not resist compulsion o Decrease Rate of Compulsive Behaviors with Behavior Therapy  Response Prevention  Patients are taught to prevent themselves from engaging in ritualistic behavior  Graduated Exposure Therapy  Patients face the feared situation repeatedly and are given positive reinforcement o Decrease Rate of Obsessions with Behavior Therapy  Thought Stopping  Concentrate on unwanted thoughts and then loudly yell “STOP”. At the same time use aversive intervention like snapping a rubber band around the wrist.  Refocus on a pleasurable thought or activity o Decrease Rate of Compulsive Behaviors with Behavior Therapy  Response Prevention  Patients are taught to prevent themselves from engaging in ritualistic behavior  Graduated Exposure Therapy  Patients face the feared situation repeatedly and are given positive reinforcement o Decrease Rate of Obsessions with Behavior Therapy  Thought Stopping  Concentrate on unwanted thoughts and then loudly yell “STOP”. At the same time use aversive intervention like snapping a rubber band around the wrist.  Refocus on a pleasurable thought or activity o Decrease Intrusive Thoughts with Rational Emotive Therapy  Daily Mood Log  Describe event or situation in which obsessive-compulsive behavior occurred (Repeated handwashing in public restroom)  Specify and rate emotions (i.e., Fear and Panic, 90)  Specify and rate automatic, negative thoughts ()’m going to be infected with an STD, 90)  Identify distortions (Magnification)  Write a rational response – Cue Card - to automatic thoughts ( I can’t be infected with an STD by touching things in a restroom)  Nursing Interventions Biological Domain: OCD o Decrease Rate of Obsessions and Compulsions with Psychopharmacology  SSRIs to maximum dose for minimum of 10 - 12 weeks  FDA approved medications to treat OCD: fluvoxamine, (Luvox), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil)  TCAs to maximum dose  Clomipramine (Anafranil), Imipramine (Tofranil)  Summary Nursing Interventions OCD o Anticipate needs, especially for information o Focus on client rather than on rituals o Monitor nutrition/sleep; encourage meals/rest o Avoid hurrying client o Do not arbitrarily forbid rituals; give positive reinforcement for non-ritualistic activity o Psychoeducation: medication, interrupting obsessive thoughts  DSM-V Pathological Personality Traits o 1. Manipulativeness o 2. Callousness o 3. Deceitfulness o 4. Hostility  Anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. o 5. Risk taking  Engagement in dangerous, risky, and potentially self-damaging activities o 6. Impulsivity  Acting on the spur of the moment in response to immediate stimuli o 7. Irresponsibility  Disregard for—and failure to obligations or commitments; lack of respect for—and lack of follow-through on—agreements and promises.  Diagnostic Features of Personality Disorders o Abnormal, inflexible behavior patterns of long duration, traced back to adolescence and early adulthood o Pervasive across a broad range of personal and social situations o Deviate in the following:  Cognitive abilities (schema)  Affectivity and emotional stability (emotions)  Interpersonal functioning/self-identity  Impulse control and destructive behavior  Epidemiology Borderline Personality Disorder o 0.4%-2.0% prevalence in general populations o In clinical populations, BPD is most frequently diagnosed personality disorders o Mostly women (77%) o Mean age of diagnosis is mid-20s o Coexistence of personality disorders with Axis I disorders (mood, substance abuse, eating, dissociative, and anxiety disorders)  Etiology of Borderline Personality Disorder: BioSocial Theories o Marsha Linehan (1997) o Emotional dysregulation is biologically based and due to a combination of the following risk factors  Genetics  Intrauterine abnormalities  Early childhood events that are traumatic o Invalidating environment  Trivializes, disregards, blames or punishes the person for their emotional dysregulation  Clinical Features Borderline Personality Disorder o Cyclical Phenomenon  As the individual becomes more emotionally reactive and behavorily dysregulated, the environment becomes more invalidating o Adaptive inflexibility: rigidity in interactions with others o Tenuous stability: exaggerated emotions and unable to cope with normal stressful events o Vicious circles: because of inflexibility, generate and perpetuate dilemmas  Clinical Course: Borderline Personality Disorder: o Many children and adolescents show symptoms similar to those with BPD o Symptoms begin in adolescence o By early adulthood, exhibit a pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity o Interpersonally irresponsible o Fail to adapt to the ethical and social standards of community o Interpersonally engaging, but in reality lack empathy o Easily irritated, often aggressive  Epidemiology and Risk Factors: Antisocial Personality Disorder o 0.2% to 3% of the population o Age of onset -- exhibit antisocial behavior before 15 o Men more often diagnosed o Present in all cultures o Comorbid with alcohol and drug abuse  Etiology: Antisocial Personality Disorder o Biologic  Genetic component -- 5X more common in first degree relatives  Biochemical -- not well understood o Psychological  Insecure attachments  Difficult temperament o Social  Chaotic families  Abuse  Nursing Assessment and Nursing Diagnosis o Psychological  Homicidal ideation  Impulsivity  Aggression  Substance abuse/use o Social  Legal/probation issues  Family dysfunction  Unemployment  Incarceration o Nursing Diagnosis  Risk for Violence  Ineffective Role Performance (unemployment)  Ineffective Coping  Impaired Communication  Impaired Social Interactions  Nursing Interventions: Antisocial Personality Disorder o Set clear, realistic limits on specific behavior o All limits adhered to by all staff o Document objective physical signs of manipulation or aggression o Provide clear boundaries, consequences o Guard against letting client make you feel guilty o Guard against being manipulated o Assess for substance abuse and withdrawal  Childhood and Adolescent Suicide o Epidemiology  Leading cause of death after accidents in adolescents o Risk Factors  2/3rds have had MDD   Victims of bullying, incest and sexual abuse  Male suicide attempts more often fatal  Females make more suicide attempts  Nursing Assessment of Childhood Suicide o Risk Assessment  Never ignore threats, hints, and continued comments about destroying self which appear inconsequential or attention-getting.  Take seriously all recent losses including pets, significant objects, extreme shame or guilt and other traumatic events  If child or adolescent has a well thought out plan, do they have the means? Most common method is guns for males and overdose for females  Carefully assess for physical signs of self-mutilation or abuse o Developing a Therapeutic Alliance  Begin interview by discussing neutral topics (i.e. age, school interests), then gather history on chief complaint, symptoms, family issues  Interview adolescent alone, child with parents only if not disruptive. Children under 13 have difficulty reporting mood over time.  Use vehicles for expression for latency age child (drawing, playing with dolls) o Mental Status  Assess Suicidality  Did you ever feel so upset that you wished you were dead?  Did you ever do something dangerous so you would get hurt?  What do you think will happen if you die?  Have you ever thought about killing yourself? How specifically?  Nursing Interventions for Major Depression in Children o Safety and Prevention of Self Harm o Improve Social Role Functioning  School Performance - MDD maybe misdiagnosed as learning disorder  Social Skills Training - Use of “buddy” for modeling  Cognitive Restructuring - Teaching children helpful thinking skills  Peer Relationships  Assertiveness Training - Role playing  Treatment for Depressed Teens o Treatment for Adolescents with Depression Study (TADS)  Taking benefits and harms into account, combined treatment appears superior to monotherapy with antidepressants as a treatment for major depression in adolescents.  Adolescents receiving fluoxetine alone had higher rates of suicidal thinking (15%) than those receiving CBT alone (6%).  Adolescents receiving fluoxetine and CBT had a 8% rate of suicidal thinking  Treatment Resistant Depression in Adolescents o 40% of Depressed Adolescents do not respond to antidepressants  55% switched to another SSRI or SNRI with an average of 9 sessions of CBT responded  41% switched to only another SSRI or SNRI responded  Venlafaxine (Effexor) was associated with the most side-effects including skin rashes and cardiovascular effects  Use of sedative-hypnotic sleep medication was associated with poorer outcomes. Sleep hygiene interventions were associated with improvement  No difference in suicidality among all the groups  Children with Obsessive-Compulsive Disorder o Onset  1/3 of adults developed OCD as children  Males are more likely to have a prepubertal onset  Females more likely to have onset at puberty o Differential Diagnosis  Tourette’s  beta-hemolytic streptococcus infection  Sydenham’s chorea (autoimmune inflammation of the basal ganglia triggered by a bacterial infection)  Clinical Features of OCD in Children o Obsessions  Concern about Bodily Wastes, Dirt or Germs  43%  Fear of Death of Loved One  24%  Orderliness  17%  Preoccupation with religious rituals  13% o Compulsions  Excessive washing and grooming  85%  Ritualistic behavior  51%  Checking behaviors  46%  Hoarding and collecting  11%  Nursing Interventions with OCD in Children o Decrease intrusive thoughts and ritualistic behavior  1st Line Treatment: Cognitive-Behavioral Approaches (40- 60% enduring reduction in symptoms)  Exposure with response prevention o Putting hands in dirt (obsession) and refraining from handwashing (compulsion) to neutralize and extinguish anxiety  2nd Line treatment: Psychopharmacology (29-44% reduction in symptoms)  FDA approved for OCD in child: fluvoxamine (> 8 yrs), fluoxetine (> 7 yrs), sertraline (> 6 yrs.) paroxetine. clomipramine (Anafranil)  DSM- V Disruptive Behavior Disorders in Children & Adolescents o Oppositional Defiant Disorder  Angry/Irritable Mood  Argumentative/Defiant Behavior  Vindictive/spiteful  Onset: as early as preschool, may precede onset of Conduct Disorder o Conduct Disorder  Aggression to People and Animals  Destruction of Property  Deceitfulness or Theft  Serious Violations of Rules  Onset: Prior to age 10  DSM-V Disruptive Behavior Disorders in Children & Adolescents o Intermittent Explosive Disorder  Behavioral outbursts that can be either verbal or physical  Magnitude of outburst grossly out of proportion to precipitant and typically last less than 30 minutes  Unlike Disruptive Mood Dysregulation disorder, there is not evidence of a persistent negative mood state  Onset: After age 6  Evidence Based Practice: Disruptive Behavior Disorders o Best Practice Recommendation  “The use of risperidone led to a reduction in aggression and conduct problems in children and youths with disruptive behavior disorders after six weeks of treatment, and the medication appeared safe.”  Multimodal psychotherapy is most effective in children with less psychopathology, functional impairment and when parents exhibit less narcissistic and impulsive traits. Only half of the children diagnosed with DBD responded to multimodal treatment  Childhood Mania: Differential Diagnosis o Unlike ADHD or Conduct Disorder, Manic Children have:  Episodic rather than chronic manifestation of symptoms.  Described as angry, irritable and moody  Sleep disturbances  Children have rage episodes and are not consolable  60% inappropriately diagnosed with ADHD  20-40% children diagnosed with Major Depression will develop Bipolar Disorder  Nursing Care of Childhood Mania o Epidemiology  Prevalence in adolescence is 1% o Onset  12 years of age o Risk Factors  High rates of affective disorder and 1st and 2nd degree relatives  Bipolar Disorder in Adolescence o Grandiosity and inflated self-esteem o Flight of ideas, paranoia and racy thoughts o Unrestrained involvement in pleasurable activities  (i.e., hypersexuality) o Intensity of symptoms, risk-taking behaviors and psychotic symptoms require hospitalization  Other Childhood Mental Health Disorders o Tic Disorders  Motor tics: quick, jerky movements  Phonic tics: repetitive throat clearing, grunting, or other noises or complex sounds such as words, parts of words, or possibly obscenities o Tourette’s disorder: motor & phonic tics  Onset: around age 7 years  Boys affected three times more often than girls  OCD also frequently occurring  Psychopharmacologic interventions  Antipsychotics (haloperidol, pimozide, atypical antipsychotics)  Alpha-adrenergic agonists (clonidine)  Elimination Disorders o Enuresis  involuntary excretion of urination after an age of attainment of bladder control  most common in boys  etiology unknown  limit fluid intake in evening  behavioral treatment -- pad, buzzer o Encopresis  soiling clothing with feces or depositing feces in inappropriate places  more common in boys  usually not a result of physical problems