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1. an individual can be looked at as the sole person or in the context of their family. When the pt is seen as part of the family system or the family is the patient, some behaviors and thoughts are better understood.

1. Prior to 1950's therapy was focused on the individual as the patient.

2. Mid 1900's social workers began to look at families of juvenile delinquents to better understand them; John Bowlby met with a family and observed their interaction.

3. 1954, foundational research on communication in schizophrenic patient families led by Greg Bateson, Jay Haley, John Weakland and Don Jackson.

a.) symptomatic behavior may serve to maintain homeostatic balance of a family.

b..) identified patient role of family member as "the problem" one who manifests symptoms of familial disturbance.

c.) double bind - an interactional pattern involving conflicting messages by using different levels of abstraction and leaving child with "no win" option of responding, feeling trapped.

1. Considered the founder of family therapy

2. Bowen's first impression of families that he saw was shock over extreme emotionality. He saw feelings rule over thinking in interaction and coined the term, "undifferentiated ego mass".

3. A key goal of therapy is to clarify and distinguish thought process and feelings of family members.

4. A premise of family systems is that the family is a homeostatic system. A change in functioning of one of the family members results in a change of the functioning of others.

1. The family is the primary system to which a person belongs. It is the most powerful system to which a person may ever belong. The family relationships provide the primary context of human development. The family is the emotional system of 3 or more generations.

1. Biological- parents related / one parent related / neither related (adoption)

2. Marital status - single / married / cohabiting

3. Sexual orientation - heterosexual / gay

4. Gender roles - traditional / nontraditional

1. Couple formation, Joining Families

2. Becoming parents, families with young children

3. Families with adolescents

4. Launching children, moving on

5. Families later in life

6. Launching the single young adult

1. Discuss what happens at your family cycle stage

2. What are positive things that can occur?

3. What are some challenges at this stage?

4. What are things that the family should be prepared to do so that they proceed well through this stage?

1. Differentiating Self in relation to family

2. Developing intimate peer relationships

3. Establishing self in work and finances

4. Couple identity

5. Realigning relationships with extended families

6. Shifting parent-child relationships

7. Refocusing midlife marital and career issues

8. Dealing with death and disability

1. Management - decisions made re:power, clear rules made, finances, and relations with those outside family *what is the hierarch*

2. Communication - healthy communication patterns have clear straight messages, not manipulative and members are free to express emotions while they are able to control expression.

3. Emotional support (self-concept reinforcement) - there is a general attitude of concern and affection, emotional and physical needs usually met; affection vs. conflict/anger

4. Socialization - families model and teach social skills. Children learn from family and apply to society. healthy families adapt to changing needs of members.

5. Boundaries - emotional barriers that protect and enhance the integrity of individuals and families; semipermeable membrane that filters input and output HIERARCHAL BOUNDAIRES.

1. Boundaries

2. Differentiation - a psychological state of being in which someone is able to maintain their sense of self, identity, thoughts and emotions when emotionally or physically close with others, particularly within intense or intimate relationships.

3. Triangulation - a significant relation between 2 people goes between cycles of closeness and distance; if anxiety rises during conflict, a third person or thing (i.e. drinking) is drawn to reduce tensions.

1. Nuclear family emotional process - emotional forces in families that operate over years in recurrent patterns such as, emotional distance between spouses or projection of problem onto children.

2. Multigenerational transmission process - family patterns are reenacted through generations.

1. Scapegoating - displacing blame of family dysfunction onto the least powerful member.

2. Hierarchy function - of power and its structure in families, delegation of roles.

3. Sociocultural Context- assessing family with respect to influences of religion, ethnicity, class, race, sexuality, and gender.

1. Bowen - describes boundaries between individuals and their families; all families are on a continuum of emotional fusion --- differentiation.

2. degree of differentiation is the degree that one resolved emotional attachment with family of origin, formed unique identity AND maintains a healthy connection.

3. A differentiated person can maintain separation between thought and emotion.

4. A person subject to fusion experiences high emotional intensity, anxiety in relationship; they are too close, enmeshed or blended.

5. A differentiated person is less subject to triangulation and reactive to polarities (purser/distancer or over/underfunctioning) because they are able to address conflict upfront.

1. The function of boundaries are to protect individuals and subsystems from intrusion so they can be autonomous.

2. Describes boundaries as either "diffuse or rigid" with resultant "enmeshment or disengagement" in relationship.

3. Diffuse boundaries are too open, allowing too much outside interference.

4. Rigid boundaries do not allow enough communication, support, or affection between family/subsystem.

5. The goal is to realign coalitions by strengthening or weakening boundaries (i.e. parental dyad strengthened)

6. Appreciates the interlocking nature of subsystem boundaries, has a social system component.

1. Assess the family according to their:

2. Family life cycle stage

3. Social cultural context- the influence of religion, gender, race, economic class, sexual orientation and ethnicity will impact how a families approaches issues. A nurse needs to be sensitize to the specific family values, rules, and roles that are normal for the family's.

4. Multigenerational issues - a more comprehensive picture is achieved if the nurse sees the family in the context of at least 3 generations. Are their patterns of addiction, poor coping with loss, affairs and secrets? Is there family awareness and openness to discussing these issues?

1. Is family hierarchy healthy according to developmental needs of individuals in family? (i.e. management, roles, boundaries between levels of hierarchy)

2. Does family demonstrate emotional support, appropriate congruent communication and appropriate boundaries within and outward from family system? (look at relating and relationships)

3. Are dyads respected and supported in system? (versus viewed as a threat or ignored, or utilized against scapegoat)

4. Is differentiation among all family members encouraged? (freedom to be self and discuss varied perspectives)

1. Genogram - identifies at least 3 generations, sex, dates of birth, marriages, divorces, sibling order, conflictual relationships, illnesses, geographical location, and critical events.

2. Focused interview to find out how family operates and family members perceptions.

3. Observation of family interactions

4. Nurse should engage in self-assessment and peer supervision to maintain objectivity.

1. Coping, compromised family

2. family, interrupted

3. Family processes: alcoholism, dysfunctional

4. Dysfunctional grieveing

5. Impaired parenting

6. Knowledge deficit

7. Ineffective sexual patterns

8. Caregiver role strain

1. Family therapy, psychoeducational family therapy, self-help/support groups

2. Communication principles:

a.) non-blaming manner to promote openness, RN should ask how each member feels affected and what they consider to be a solution.

b.) be clear and understandable with info to all family members; allow them to decide what to do with information

c.) the perspective of every family member needs to be heard.

1. Families of an Alcoholic

2. How has each member adapted to the alcoholic's behavior? role vs. the person

3. Codependency

4. Educate re: illness, risk factors for children, recovery

5. Resources- support groups for alcoholic, spouse and children

6. Reorganize family.

1. Teach about the mental illness

2. Teach skills to decrease emotional expression; improve communication

3. Teach members to have balanced perspective of their responsiblity

4. Encourage family to express feelings of loss

5. Take care of self, do not neglect own needs

6. Be aware of support services. ie NAMI

1. One if 4 women (22.3%) have been a victim of severe physical violence by an intimate partner, while 1 in 7 men (14%) have.

2. 1 in 6 women (15.2%) have been stalked, 1 in 19 men (5.7%)

3. Nearly 3 in 10 women and 1 in 10 men in the US experienced rape, physical violence and/or stalking and report a related impact on their functioning. Is this skewed related to men and fear of reporting.

4. IPV resulted in 2,340 deaths in 2007, (14% of all homicides) of these deaths, 70% were females and 30% were males.

5. Estimated 15-25% of pregnant women abused.

1. There were 678,932 victims of child abuse and neglect reported to CPS in 2013.

2. The youngest children, under 3yrs old, most vulnerable- 27% of reported victims. Nationally, fourth-fiths(79.5%)- neglected; 18% physically abused; 9% sexually abused and 8.7% psychologically maltreated.

3. CPS reports may be underestimate the true occurrence of abuse and neglect. a non-cps study estimated that 1 in 4 children experience some form of child maltreatment in their lifetimes.

4. About 1,520 children died from abuse and neglect in 2013.

1. 7.6%-10% of study (elderly) participants experienced abuse in the prior year.

2. Data from state of APS agencies show an increasing trend in the reporting of elder abuse.

3. Despite the accessibility of APS in all 50 states (whose programs are different), as well as mandatory reporting laws for elder abuse in most states, an overwhelming number of cases go undetected and untreated each year.

4. In the only national study that attempted to define the scope of elder abuse, the vast majority of abusers were family members (90% approx) most often adult children, partners and others.

1. From violent homes where abuse witnessed and/or experienced.

2. Strong feelings of inadequacy

3. Easily threatened by any independence from him

4. Strives to keep victim dependent, isolated

5. Aggression is bully, intimidation, violence.

6. Perceive women as property

7. highest incidence in ETOH and crack abuser

8. identification -> testing behavior -> dehumanization

1. At least 50% grew up in violent homes

2. Dependence

3. Low self-esteem

4. Usually adhere to feminine role stereotype

5. Isolated from support system

6. Feel guilt, fear, anger, shame

7. Pregnancy increases risk

8. Learned helplessness

1. Build up phase - increased tension

2. Stand-over phase - control/fear

3. Explosion

4. Remorse Phase - justification/minimization/guilt

5. Pursuit phase - pursuit and promises/helplessness/threats

6. Honeymoon phase - enmeshment/denial of previous difficulties

1. cycle has evolved over time.

2. Basic boundaries are not clearly identified and enforced from the onset of the relationship. Possessiveness for example is accepted as "loving" or cherishing behaviors'. disrespect or teasing is accepted as joking. Differentiation is a threat to the abuser.

3. Much emotional abuse and control over the victim has occurred by the time physical abuse has become a pattern. The victim does not like abuse but has, to some level, accepted that it is their own fault. The victim agrees with the justification passionately verbalized by the abuser.

1. In the beginning stages hope is held out that the abuser will stop . He may make promises to change but remains unclear what that means. After a while, the victim learns to endure the abuse and not challenge it; a survival mentality pervades.2. The abuser projects responsibility onto the victim who “deserved” the consequence of punishment. Rarely does the abuser acknowledge that they have a problem or that they are out of control. Their behavior is rationalized. They have a perspective on women roles and how “love” should be demonstrated.3. Disagreement with them is viewed as more detrimental than any physical means to maintain control.

1. Abuser is extremely dependent on the victim and will not accept the thought of them being apart from him.

2. It is unlikely that the abuser will gain insight until he is apart from the victim AND is externally forced to get help into facing his extremely unhealthy way of relating, it require undoing of entreched pattern of behavior and belief system.

1. Abuser's form of love: love = control, agreement with the "head" of family, no challenging, total submission. In the event control is challenged, extreme measures are justified/ appropriate to maintain order in home.

2. Real love = mutual respect (desire to see each other at best) voluntary trust in the other, desire to know the person as they are, general attitude/expression of support/acceptance, comfort with differentiation of self and other, freedom to disagree, and express self, anger expressed with respect to boundaries; sadness or fear not met with control but openness.

1. Communicate safety now and presence. be aware of victims fear and tendency to self-blame.

2. Encourage, but don't force feeling expression and assault account.

3. Explain process of assessment clearly and simply. Give rationale for steps. Obtain informed consent before photographing the patient.

4. Assessment includes verbal account, emotional response, full view of skin, wounds, palpation, colposcopy(cervix) exam, collection of fluid, tissues, and detailed gynecological history of the victim for past: infections, STDs and pregnancy.

5. Nurse should offer the morning after pill if the patient's pregnancy test is negative.

1. Abusive parents were usually victims and exposed to violent homes.

2. Stressors contribute towards physical and emotional abuse-poverty, overcrowding, lack of support, unemployment, substance abuse, mental disorders, lack of knowledge of normal childhood development.

3. Those with increased vulnerability as victim's are "difficult" children - premature, mentally retarded, physically disabled, hyperactive.

1. accidental discovery of a significant skin injury

2. Multiple injuries of various stages

3. No history offered, or a changing or contradictory history for the injuries

4. Injuries inconsistent with the child's stage of development.

5. Injuries in different systems

6. Suspicious attitude int he parents/child

1. Parent - excessive criticism of the child, lack of empathy, unrealistic expectations for the child, preoccupation with their needs rather than those of the child, excessive control of the child, accusing another child of causing injury, visibly under the influence of alcohol or drugs

2. Child - hypervigilance, fear, passivity, aggressiveness, mistrust, depressed look.

1. In infants, any bruises on the face and buttocks should be considered nonaccidental until proven otherwise.

2. Injuries to children's upper arms (caused by efforts to defend themselves), the trunk, the front of their thight, the sides of their face, their ears and neck, genitalia, stomach, and buttocks more likely to be nonaccidental injuries.

3. Marks the shape of fixed objects

1. Location - buttock, between, legs, ankle, wrist, palm ,soles

2. Symmetrical as opposed to "splash"

3. Full thickness to muscle or bone possibly

4. Sharp demarcations as in glove of sock

5. Older neglected and infected wounds

6. Shape of an instrument

7. Numerous, various stages of healing.

1. Subdural hematomas usually seen in ages <24 months, peak incidence at 6 months, nonspecific s/s - raised ICP with vomiting, seizures, stupor, or coma. It may be associated with shaking the baby violently or with an extreme blow to the head ,such as occurs when children are thrown against a hard object.

2. Retinal hemorrhages - hallmark of shaken baby syndrome, rarely associated with some other MoI.

3. Internal organ injuries are second only to head trauma as the most common causes of death in child abuse. Nonaccidental internal injuries usually involve structures below the diaphragm. In most cases of abdominal organ injury there are no external signs of trauma. This is due to the pliability of the abdominal wall and its ability to absorb trauma without showing bruises.

4. Skeletal series should be completed to note various fractures in different stages of healing.

1. appears malnourished

2. confined in one area for extensive time

3. poor hygiene; in babies diapers not changed for extended periods

4. babies - very irritable, cry often

5. frequent school absences

6. role reversal - child becomes parent

7. poor peer relationships

1. Elder abuse - act or omission which results in harm of threatened harm to the welfare of an elderly (65 yrs old or older)

2. physical abuse, physical neglect(dehydration, malnutrition, pressure ulcers, poor adls), emotional abuse, finacial/material abuse.

1. Sexual Abuse is defined as non-consensual sexual contact of any kind. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It includes but is not limited to unwanted touching, all types of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photographing.

2. S/s of SA include: bruises around the breasts/genitals, unexplained venereal disease, unexplained vaginal/anal bleed, torn clothes, report of being sexually assaulted/raped.

1. BE PRIVATE - hear victim, alleged abuser accounts separately.

2. BE NONTHREATENING AND SUPPORTIVE: give time for answers, use OPEN ENDED QUESTIONS REQUIRING DESCRIPTIVE RESPONSES FOLLOWED BY MORE DIRECT SPECIFIC QUESTIONS.

3. BE FOCUSED SO THAT IT IS CLEAR WHAT BEHAVIORS OCCURED(WHAT EXACTLY DID THE ABUSER DO AND SAY)?

4. after assessment get perspective of hx or prior violence.

5. Be prioritized. stay in tune with pt, basic physiological current emotional needs.

6. Be documented. cite all physical behavioral verbal indications of abuse, charting needs to be precise. Remain objective

1. Promote trusting relationship. Do not force answers. For children, offer play for expression. Explain your purpose as a professional is to help provide safety and assistance. Do not give false assurances to victims.

2. Speak to caregivers/possible abusers privately. REMAIN NEUTRAL, DO NOT JUDGE. Assess their understanding of appropriate discipline, care and supervision. In a supportive manner, asses risk factors, stressors and attitude towards victim.

1. For adult victim, assure confidentiality and that any changes are to be made by them. THEY HAVE TO INITIATE THE PROCESS.

2. Assess clients level of insight first. Clarify that abuse is NEVER acceptable. It is NEVER their fault.

3. Clearly explain legal process to adult victim. Teach safety resources. tessacs

4. Provide writeen information in a discrete manner. Ask patient to name 2 emergency contacts/phone numbers prior to discharge. DEVELOP A DETAILED SAFETY PLAN WITH THE VICTIM. (safe house as concrete plan, long term goal dealing with empowerment issues.

1. For child and elderly who are suspected abuse victim. REPORT TO AUTHORITIES IS MANDITORY/LAW (in hospital contact social worker on call, state child welfare service or elder abuse hotlines)

2. FAILURE TO REPORT SUSPECTED CHILD/ELDER ABUSE IS SUBJECT TO CHARGES FINE AND POSSIBLE JAIL.

Section 19-3-304 of the Colorado Revised Statues(C.R.S.) outlines the persons required by law toreport child abuse and/or neglect. It is a class 3misdemeanor in Colorado for a mandatedreporter to fail to report suspected child abuse orneglect or knowingly makes a false report and ispunishable under law.•Call 1-844-CO-4-Kids or 1-844-264-5437

1. Sharing mutual responsibility with the legal system in order to protect victims legal, civil and human rights, to proect the consitutional rights of perpretrators of criminal acts, and the families of both.

1. Sexual Assault Nurse Examiner (SANE)

2. Forensic Psychiatric Nursing Speciality

3. Correctional/Institutional Nursing

4. Nurses in ICU or ED: PHYSICAL/PSYCHOSOCIAL ASSESSMENT WITH FOCUS ONVIOLENCE, ABUSE ASPECTS, AWARENESS OF HOW TOCOMMUNICATE AND CHART IN THESE CASES– Gathering appropriate evidence and preserving properly– Treating victims with full care- physical, legal, psychosocialneeds– Maintaining rights for perpetrators

1. Historically, eating disorders have been viewed from different perspectives. none of these have been proved to be casual.

2. Feminist perspective - viewpoint of the fashionable and desirable has grown to be skewed since 16th to 21st century.

3. Sociocultural - eating is a social activity

4. Familial - illness enables avoidance of spousal issues; families have enmeshed boundaries with overly restrictive controlling perfectionistic parents > children seeks control via eating pattern.

5. Biological - a neurochemical - possible decrease in 5-ht, NE in bulimia; possible high CSF opioids in anorexia; b. possible genetic predisposition and chromosomal link. c. possible neuro-endocrine abnormalities related to hypothalamus (anorexic)

•1. Anorexia is a disease of malnutrition. Primarily restriction (although there are anorexics that do engage in binge-purge, they are malnourished) occurs which relates to perfectionistic/controlling inclinations. Medical complications relate to starvation and possibly dehydration.•2. Bulimia is a disease of binge-purge pattern. The binge-purge cycle is connected to triggers that elicit extreme anger/ feelings of rejection/ low self esteem “stuffed” then purged. Medical complications relate to electrolyte imbalance and fluid shifts (hypovolemia) depending on severity of purging.

• DEFINITION- eating disorder characterized by purposeful lossof weight far beyond the normal range.SYMPTOMS OF ANOREXIA intense fear of becoming obese disturbance in body image Weight loss of at least 15 percent of expected bodyweight (adjusted i.e.100 +4 lbs for each inch over 5feet) Refusal to maintain normal weight Cessation of menstrual cycle Hyperactivity Fasting Repetitive rituals and obsessions Binging/ purging: vomiting, laxative use (for somepatients)

SOCIALIZATION- withdrawal from family/ social relationships; reduced social activities as illness progressesMOOD- depression increases as lack building block for NT’s ; decreased thyroid function> depressionCOGNITION- perfectionism; stubborn; cog. distortions; late disease> cognitive delay and poor functioningINTEGUMENTARY- grayish cast; fragility, dryness; eventual loss of subcutaneous tissue contributes to hypothermia and development of lanugoCARDIAC- hypotension, bradycardia eventual weakeningof cardiac muscle> exercise intolerance, anemia andperipheral edema from hypoalbuminemia, possible cardiac failure (r/t weak myocardium or refeeding)

RENAL- dehydration> possible renal failure; hematuria, proteinuriaGI- cavities; oral lesions r/t poor nutrition; severeconstipation r/t decreased digestive activityMUCULOSKELETAL- Hypocalcemia; Osteopenia and early osteoporosis; decreased protein intake> muscle wastingREPRODUCTIVE- amenorrhea chronically disruptsreproductive cycle> possible infertility

• Recurrent episodes of binge eating– Large amount of food in a discrete period– Sensed lack of control, cannot stop• Recurrent inappropriate compensatorybehavior to prevent weight gain (purge-self-induced vomiting; abuse oflaxatives, diuretics or other medications;fasting; or excessive exercising)• These occur once weekly for 3 months• Persistent over concern with body shapeand weight– Purging/nonpurging types

1. Behavioral - impulsive behaviors, stealing

2. Mood - denial of anger, rejection, surface happy but report depression

3. Cognitive - distortions; people pleasing; extreme shame

4. Dental - erosion of enamel related to vomiting; caries/cavities

5. Sialadenosis - swelling of salivary / parotid glands related to increased activity of amylase; infection

6. Integumentary - Russell's sign scars on top of hand

7. GI - weight usually normal (or slightly more/less); Mallory Weiss tears related to purging, gastric dilation/rupture; rectal prolapse; diarrhea/constipation

1. Cardiac:

2. Electrolyte imbalance (hypokalemia, hypomagnesia, hyponatremia) = cardiac dysrhythmias

3. Hypovolemia -> syncopal episode and

4. Cardiomyopathy related to Ipecac (vomit syrup) intoxication

5. Renal - extended hypovolemic and/or electrolyte imbalances -> renal failure, hematuria, proteinuria.

6. Neuro - seizures related to electrolyte imbalances.

1. Low self-esteem

2. Body image disturbance

3. Preoccupation with food

4. Dieting, thinness = key to sucess, mean of obtaining control

5. Perfectionistic

6. Interoceptive defect-

7. Alexithymia - inability to describe and identify own emotions.

1. Overgeneralizations/Magnification - overestimation of significance of undesirable events.

2. Dichotomous thinking - viewing situations as all or nothing, black/white/ extremism

3. Personalization - over interpretation of events as having personal significance; self refence

4. Superstitious thinking- believing cause and effect relationship in non contingent events.

• Nutrition, less than body requirements (anorexia)• Fluid volume deficit/ Electolyte imb. (bulimia, both)• Decreased Cardiac Output• Risk for Injury• Risk for self harm (both, anorexic later)• Constipation/ Diarrhea• Self esteem disturbance (both)• Body image disturbance (both)• Ineffective coping/ denial (both)• Dysfunctional family process (both)

• For hospitalized patient, the medical needs andsafety r/t injury addressed first (cardiac: V.S.,EKG,electrolyte monitoring; seizure; renal fx {monitor output,hydration} anemia, syncope; suicidal prec. if pertinent. )• Weight restoration to at least 75% ideal body wt.• Normalization of eating habits-– Precise meal times– Adherence to menu (set by staff initially then pt. input)– Observation of eating pattern by staff– Regular weigh-ins, consistent time– Close monitoring of pt. to avoid purging– Education in nutrition only at prescheduled times

1. Provide safe environment

2. Engage client in therapeutic alliance to encourage expression of thoughts/ feelings (after binge help reflect on feelings prior; was this a response to a stressor?) avoid focus on food, body in social discussion.

3. Enact nutritional behavioral program to restore minimum safe weight.

4. Caution rapid refeeding leads to CHF/overload if weak cardio

5. Reward based vs. punishment = pt. already self punitive

6. Create structured supportive environment

7. Pt. must remain in milieu, CO for bathroom.

1. Assist in identifying issues of low self-esteem, family issues, body image distortion, cognitive distortions and physical symptoms.

2. Teach about dynamics of disorder:

For bulimic: felt failure/stressor>binge>purge>attempt to control, For anorexic: lack of control>perfection>restrict>felt control

3. Teach to record/self monitor diet and binge episodes

4. Record/self monitor weight, new foods introduced, response to progression

5. Teach family about illness, control issues and conflict avoidance

6. Milieu and family therapy

1. Client will eat 75% of meals and gain 2-3 pounds within first week of treatment.

2. Client will maintain electrolytes in normal range for 5 consecutive days.

3. Client will attend groups 2x day and engage in 1:1 with RN/SW to discuss treatment plan.

4. Client will begin to correlate eating pattern have served as a tool to manage emotions.

1. Client will discuss various aspects of self-image aside from weight/appearance and express balanced perspective (strengths and weaknesses)

2. Client will express emotions about issues relevant to life (family relationships, school, friends, fear of future)

3. ***Client will verbalize insight into use of food*** control emotions and express self-acceptance

4. Client will verbalize new coping, increased socialization, involvement in new interests, commit to talk about struggle with weight issues when arise, versus focus on controlling weight and hide emotions.

1. Rapid onset, possibly reversible if treated

2. Last hours - weeks

3. LOC altered (stupor to hypervigilant), changes

4. Distractible, rambling, illusions, hallucinations possible

5. RAPIDLY CHANGING PERSONALITY

6. AGIATION

7. Vital sign changes (autonomic response)

8. Emergency: assess and define acute cause and treat

1. Gradual onset, progressive, irreversible

2. Chronic

3. LOC intact

4. Aphasia, apraxia, agnosia

5. Defenses employed

6. GRADUAL PERSONALITY CHANGE

7. AGITATION in later stages, tied to loss of control

8. Vitals Stable

9. Assessment involves determining level of impairment /stage and naming disease

1. Delirium due to a general medical condition (i.e. malnutrition, respiratory status)

2. Post operative conditions

3. Substance-induced delirium

4. Substance-intoxication delirium

5. Substance- withdrawal delirium

6. ex: alcohol, electrolyte imbalance, endocrine imbal, infection/sepsis, drug induced, hepatic, abnormal, seizure, trauma

1. Assess and report rapid changes in LOC use family as collaborative source for pt. norm.

2. Monitor VS changes, med eval, detail neuro status, cardiac status and report for further eval./assessments (ex. cultures, LP, MRI)

3. Implement safety precautions - falls, agitation (pulling drains/IVs etc) decreases stimuli

4. Advocate for treatment of cause utilize respiratory MD for intervention.

1. Defined by a loss of previous levels of cognitive, executive, and memory function in a state of full alertness.

2. Symptoms: impairment exists in abstract thinking, judgement, and impulse control. Conventional rules of social conduct are disregarded. Personal appearance and hygiene are neglected. Language may or may not be affected. Personality change is common.

1. Aphasia - inability to express thoughts in correct words

2. Apraxia - inability to do simple tasks

3. Agnosia - inability to identify familiar objects or people

4. Agraphia - inability to read or write

5. Hyperorality - putting everything in mouth, pulling, feeling

6. Hyper metamorphosis - touch everything, pulling, feeling

7. Irritability and moodiness, with sudden outbursts over trivial issues.

8. Wandering away from the home area

9. Inability to care for personal needs independently from difficulty cooking, dressing to inability to severe (forget to swallow)

10. Incontinence

1. Alzheimer's Disease (AD) is the most common form of dementia.

2. Alzheimer's disease (AD) accounts for 50% to 60% of all cases of dementia.

3. AD affects 1:8 people >= 65 yrs old.

45% >= 85 yrs old (90% of AD pts are over 75 yrs old)

1. Etiologies may include

2. Beta amyloid accumulation

3. Acetylcholine alterations

4. Plaques and tangles

5. Increased tau in CSF

6. Genetic factors

7. Cardiovascular disease

8. Social engagement, diet

9. Head trauma

1. Stage 1 - no apparent symptoms

2. Stage 2 - forgetfulness

3. Stage 3- mild cognitive decline

4. Stage 4- mild to moderate cognitive decline; confusion

5. Stage 5 - moderate cognitive decline; early dementia

6. Stage 6 - moderate-to-severe cognition decline; middle dementia

7. Stage 7 - severe cognitive decline; late dementia

8. Stage 1 = preclinical Stages 3-4: mild neuorcog. DO mild cog impairment. Stage 5-7: major neurocog. DO; dementia

1. The client history: areas of concern to be addressed:

2. type, frequency, and severity of mood swings

3. personality and behavioral changes

4. catastrophic emotional changes

5. catastrophic emotional reactions

6. cognitive changes

7. language difficulties

8. Orientation to person, place, time, situation; appropriateness of social behavior; current and pas use of medications, drugs, and alcohol, client and family history of specific illness.

1. assess for diseases that can induce confusion, loss of memory, and behavioral changes

2. neurological examination: assess mental status, alertness, muscle strength, reflexes, sensory perception, language skills, and coordination

3. Psychological tests to differentiate between dementia and pseudodementia (depression)

4. Labs: risk of infection / sepsis, hepatic and renal dysfunctions, electrolyte imbalances, diabetes, endocrine disorders, nutritional deficiences.

1. Electroencephalogram (EEG)

2. Computed tomography (CT) scan

3. Positron emission tomography (PET)

4. Magnetic resonance imaging (MRI)

5. Lumbar puncture to examine cerebrospinal fluid (CSF)

1. Risk for trauma

2. Disturbed thought process

3. Impaired verbal communication

4. Impaired memory

5. Disturbed sensory-perception

6. Risk for other-directed violence

7. Self-care deficit

8. Situational low self-esteem

9. Grieving

1. The client has not experienced physical injury

2. Has not harmed self or others

3. Has maintained reality orientation to the best of his or her capability

4. Discusses positive aspects about self and life

5. Fulfills activates of daily living with assistance

1. Caregivers should focus on client's perceived need (searching for ?, hungry? BR?) Versus immediately correcting client.

2. Caregivers SHOULD BE AWARE OF EMOTIONAL TONE, RESPECT EMOTIONS AND VALIDATE, (restate/reflect, validate) then steer conversation to related topic of interest to allow client to verbalize what is important to them.

1. Interventions need to be client specific

2. Protection of self and others THINK CHECKLIST:

3. near RN station, frequent observation, minimize clutter, make safe space, decrease stimuli, bed (railing, pads, position facing alarm ON), monitor lower functioning for ability to swallow, need of mitts, bed restraints one to one observation, assist with ambulation, bladder/bowel training schedule.

4. Every time before leaving room, review client needs (call bell, urinal, TV, water pitcher, photos)

1. Minimizing confusion / communication

2. be clear, slow (don't rush!, only one topic at time), face to face

3. Repeat calmly, kindly and utilize matching nonverbal

4. Do not argue with client, listen and affirm pt.

5. Keep familiar personal and orientating items in open: pictures, books, blankets, calendar, posted names, places, signs

6. Preferred music background; bring familiar topics during shift

7. Consistent routine and staff (do not overwhelm or push new people into situations prematurely)

8. Use symbols and nonverbals when able, do not rely on words

9. Distractions/interruption IS appropriate in the event client is wandering or touching/ putting things in mouth.

1. Establish calm supportive nurturing environment utilizing order (not cluttered) music, visual cues- photos, pictures AND printed signs, appropriate TV for pt, basic needs consistently addressed, understanding of each pt. needs/ family interests.

1. Nature of illness: possible causes, what to expect, symptoms

2. Management of illness: ways to ensure client safety, how to maintain reality orientation, provide assistances ADLs, nutritional information, difficult behaviors, medication administration, matters related to hygiene and toileting.

3. Support services: financial assistances, legal assistances, caregiver support groups, respite care, home health care.

1. Cholinesterase Inhibitors: for mild/ early cognitive impairment, slows progression by maintaining ACh in synapse. (Donepezil/Aricept, higher dose can be used later too, Rivastigmine/Exelon, Galatamine/Razadyne, Physostigmine, Tacrine/Cogex* avoid liver damage.

2. NMDA receptor antagonist- for moderate to severe cognitive impairment, Memantine (namenda)

3. For agitation - ALL antipsychotic medications have warning by FDA that death risk is increased. Some MDs use Risperdal and Zyprexa as well as Seroquel in aggressive pts.

1. Pharma Agents for depression by dementia:

2. SSRIs: often considered 1st line due to favorable SE profile

3. Tricyclic antidepressants: often avoided due to anticholinergic and cardiac SEs

4. Trazodone(Desyrel): good choice for clients with insomnia

5. Dopaminergic agents: helpful in treatment of severe apathy.

1. For anxiety (should not be used routinely for prolonged periods)

2. Chloradiazepoxide (librium)

3. Alprazolam (xanax)

4. Lorazepam (ativan)

5. Oxazepam (serax)

6. Diazepam (valium)

1. For sleep disturbances, short-term therapy only

• Flurazepam (Dalmane)• Temazepam (Restoril)• Triazolam (Halcion)• Zaleplon (Sonata)• Ramelteon (Rozerem)• Eszopiclone (Lunesta)• Trazodone (Desyrel)• Mirtazapine (Remeron)

1. Generalized anxiety disorder (GAD)

2. Panic DO

3. Phobias

4. Obsessive compulsive DO (OCD)

5. Body dysmorphic DO

6. Post traumatic stress DO (PTSD)

7. Somatic Symptom DO (SSD), Illness anxiety DO

1. Excessive anxiety/worry (time consideration = 6months) interrupts life, causes distress/ impairs functioning.

2. Feelings of restlessness, "on edge"

3. Easily fatigued / decreased sleep

4. Difficulty concentrating / "blank"

5. Irritable

6. Increased muscle tension

7. Tends to be chronic, fluctuating course of illness

1. Unexpected onset

2. Trembling or shaking

3. Sensations of SOB, smothering

4. Choking feeling

5. Chest pain or discomfort

6. Dizziness or lightheadness

7. Chills or hotflashes

8. Paresthesia

9. Fear of dying, losing control, going crazy, impending doom, terror

10. Panic DO VARIABLE course of illness and intensity/number of attacks a month

1. Pt will recognize / verbalize signs of increased anxiety.

2. Pt understand ways to interrupt escalation

3. Demonstrate specific techniques that prevent escalation of anxiety.

4. Demonstrate specific relaxation techniques that will be incorporated into life.

1. Therapeutic communication: stay matter of fact, calm, stay with pt.

2. Speak clearly, simply

3. Decrease environmental stimuli

4. Assess for need of anxiolytics/ evaluate response of meds (versus just giving meds immediately or withholding when appropriate)

5. When anxiety decreases, explore w/ client symptoms, causative factors.

6. Teach symptoms and relaxation techniques and practice

1. Anticipatory; persistent, irrational fear of object or situation.

2. In specific phobias, persons anticpate harm or losing control: animal type, natural environment, blood injection/injury, situational (cars)

1. Pt will function adaptively in presence of stimuli without panic (Long term goal)

2. Pt will discuss experience with phobia

3. Pt will demonstrate techniques to keep anxiety manageable with stimulus present

4. Pt will verbalize specific plan to FACE stimuli and maintain calmness during

1. Assess pt. perception and symbolism of phobic stimulus

2. Discuss aspects of phobic stimulus in relation to pts life what can / cannot change.

3. Enter treatment options of coping strategies and level of avoiding stimuli. FLOODING OR SYSTEMATIC DENSENSITIZATION

4. Discuss underlying issues- self esteem, empowerment, issues related to irrational response.

1. New DSM 5 grouping of disorders to include: Obsessive compulsive disorder

2. body dysmorphic disorder

3. hoarding disorder

4. hair pulling / skin picking disorders

5. recurrent obsessions or compulsions that interfere with life (bc of time 1 hr to leave home) and distressed imposed)

6. pt is aware behavior unreasonable and excessive (not children) but it RELIEVES ANXIETY

7. ex. washing, cleaning, counting, demanding assurances.

1. DSM 5 groups BDD with OCD

2. Preoccupation with some imagined defect in physical appearance

3. Preoccupation is extreme but not delusional

4. May socially isolate to avoid all people which severely restricts activity/schedule.

1. INTIALLY, allow time for rituals, do not judge or deny

2. Assess anxiety provoking situations, precipitants to ritualism. Explore purpose of behavior

3. Structured schedule, incorporating time for ritual. Assist with decisions (do not take over!)

4. Gradually limit time for rituals, increasing other activities and positive reinforcement for other activities.

5. Teach pt to interrupt rituals / obsessions along with Relaxation techniques.

1. Pt will name / discuss topics / situations that are stressors for them

2. Pt will manage OCD symptoms by utilizing limiting skills such as fixed amt. time given to compulsivity's. Pt will demonstrate relaxation techniques / behaviors.

3. Pt will verbalize self acceptance and discuss underlying struggles with self esteem, empowerment, relationship etc.