Exam 4

Definition of Crisis

• Acute, time-limited event (4–6 weeks)

• Client cannot cope using usual mechanisms

• Client was previously mentally healthy

Key Concepts

• NOT pathological → normal response

• Personal perception matters

• Outcome:

  • Growth OR

  • Psychological deterioration

Common Characteristics of Crisis

• Sudden, unexpected event

• Perceived as overwhelming or life-threatening

• Loss of support/communication

• Sense of displacement

• Actual or perceived loss

Types of Crises

1. Situational (External)

• Unexpected life events

• Examples:

  • Divorce

  • Job loss/change

2. Maturational (Internal)

• Developmental transitions

• Require new coping skills

• Examples:

  • Marriage

  • Retirement

3. Adventitious (Disaster)

• Large-scale traumatic events

• Examples:

  • Natural disasters (hurricane)

  • Crimes, war

Assessment- crises

Key Assessments

• Suicidal or homicidal ideation (FIRST)

• Client’s perception of event

• Support system

• Coping skills

• Cultural/religious needs

Physical + Behavioral Findings

• Disorganization

• Anxiety/overwhelm

• Poor problem-solving

• Anger/aggression

Risk Factors- crises

• Unresolved losses

• Current stressors

• Mental/physical illness

• Fatigue or pain

• Developmental stage

🔹 Protective Factors

• Strong support system

• Previous coping experience

Phases of Crisis

Phase 1

• Anxiety ↑ → defenses activated

Phase 2

• Defenses fail → disorganization

• Trial-and-error coping

Phase 3

• Severe anxiety/panic

• Withdrawal or flight

Phase 4

• Overwhelming anxiety

• Possible:

  • Dissociation

  • Depression

  • Violence (self/others)

NURSING CARE (CRISIS)

PRIORITY INTERVENTIONS

• Ensure safety first

• Assess suicide/homicide risk

• Assist with hospitalization if needed

🔹 Initial Nursing Actions

• Identify problem

• Take active, directive role

• Help set realistic goals

• Focus on short-term solutions

🔹 Therapeutic Communication

• Stay with client

• Maintain eye contact

• Listen actively

• Ask about:

  • Feelings

  • Event

• Be:

  • Calm

  • Clear

  • Genuine

Avoid:

• False reassurance

• Nontherapeutic responses

🔹 Interventions

• Reduce anxiety

• Teach relaxation techniques

• Teach coping skills

• Encourage participation

🔹 Action Plan

• Short-term

• Realistic

• Focused on crisis

🔹 Debriefing

• Staff + client discussion post-crisis

• Example:

  • Critical Incident Stress Debriefing (CISD)

Levels of Care- crisis

Primary Prevention

• Prevent crisis

• Teach coping skills

Secondary Prevention

• During crisis

• Focus on safety

Tertiary Prevention

• Recovery phase

• Rehab, outpatient care

Medications (Crisis)

• Antianxiety:

  • Lorazepam, Diazepam

• Antidepressants:

  • Paroxetine, Fluoxetine, Bupropion

Client Education- crisis

• Use community resources:

  • Crisis hotlines

  • Support services

• Follow-up care is essential

ANGER MANAGEMENT

Key Definitions

• Anger:

  • Normal emotional response to frustration

• Aggression:

  • Verbal/physical attack

• Violence:

  • Intent to harm

🔹 Important Concept

• Clients with mental illness are:

  • More likely to harm themselves than others

Causes of Anger

• Underlying feelings:

  • Insecurity

  • Fear

  • Guilt

  • Rejection

• Can be secondary to:

  • Depression

  • PTSD

  • Anxiety

  • Grief

🔹 Comorbidities

• Depression

• Substance use

• Bipolar disorder

• PTSD

• Dementia

• Personality disorders

Stages of Aggression

1. Preassaultive

• Anxiety, tension

• Verbal aggression

• Hyperactivity

2. Assaultive

• Violence occurs

• May require:

  • Seclusion

  • Restraints

3. Postassaultive

• Recovery phase

• Debriefing

SECLUSION & RESTRAINTS

LAST RESORT ONLY

• Use only if:

  • Client is danger to self/others

🔹 Legal Requirements

• Provider order required:

  • Reason

  • Time limit

  • Type

  • Removal criteria

🔹 Monitoring

• Face-to-face eval within 1 hr

• Continuous monitoring (q15 min)

• NEVER leave alone

🔹 Nursing Responsibilities

• Check:

  • VS

  • Circulation

  • Skin integrity

• Provide:

  • Fluids, food, toileting

• ROM exercises q2 hr

• Document EVERYTHING

AGGRESSION ASSESSMENT

Risk Factors

• History of violence

• Poor impulse control

• Substance use

• Psychosis (hallucinations/delusions)

• Violent environment

🔹 Expected Findings

• Pacing, restlessness

• Loud/rapid speech

• Clenched fists

• Intense eye contact

• Aggressive posture

• Tachypnea

NURSING CARE (AGGRESSION)

De-escalation Key Actions

• Respond quickly

• Stay calm

• Maintain control

Communication

• Encourage verbal expression

• Use:

  • Silence

  • Reflection

  • Active listening

Environment

• Give personal space

• Nonthreatening posture

• Same eye level

Limit Setting

• Clear, direct instructions:

  • “I need you to stop yelling…”

• Offer choices

• Explain consequences

Other Strategies

• Physical activity (walking)

• “Show of force” if needed (staff presence)

🔹 If Escalation Continues

• Use medications

• Prepare for restraints if necessary

POST-INCIDENT CARE

🔹 Client Debriefing

• Discuss:

  • Triggers

  • Feelings

• Correct misperceptions

• Reinforce support

• Update care plan

🔹 Staff Debriefing

• Evaluate response

• Identify improvements

🔹 Documentation

• Behavior before/during incident

• Interventions used

• Client response

Medications (Aggression)

First-Line (Common)

• Atypical antipsychotics:

  • Olanzapine

  • Ziprasidone

🔹 Other

• Haloperidol

  • Monitor for:

    • EPS

    • Neuroleptic malignant syndrome

🔹 Additional Options

• SSRIs

• Mood stabilizers (Lithium)

• Benzodiazepines

family and community violence

Definition

• Violence = abuse of power by a stronger person over a weaker person

• Can occur:

  • Partner → partner

  • Parent → child

  • Child → parent

  • Caregiver → vulnerable adult

🔹 Key Concepts

• Usually involves control, intimidation, or injury

• Victims are often the least powerful

• Occurs across:

  • All cultures

  • All socioeconomic levels

CYCLE OF VIOLENCE

1. Tension-Building Phase

• Minor abuse:

  • Verbal abuse

  • Pushing/shoving

• Victim:

  • Feels anxious

  • Accepts blame

• Perpetrator:

  • May use substances

2. Acute Battering Phase

• Most violent stage

• Severe abuse occurs

• Victim:

  • May try to hide injuries

  • May seek help

3. Honeymoon Phase

• Perpetrator:

  • Apologizes

  • Promises change

• Victim:

  • Feels hopeful

  • Forgives

🔹 Important Pattern

• Cycle repeats

• Time between episodes shortens

• Violence worsens over time

TYPES OF VIOLENCE

Physical

• Hitting, kicking, strangling

• Shaken baby syndrome

🔹 Sexual

• Non-consensual contact

• Rape, incest, trafficking

🔹 Emotional

• Humiliation

• Threats

• Intimidation

🔹 Neglect

• Failure to provide:

  • Food

  • Emotional care

  • Education

  • Healthcare

🔹 Economic Abuse

• Withholding financial support

• Not paying bills despite having money

CHARACTERISTICS

🔹 Vulnerable Person (Victim)

• Low self-esteem

• Feelings:

  • Guilt, shame, helplessness

• Protects perpetrator

• Accepts blame

• May deny severity

🔹 Perpetrator

• Controlling, intimidating

• Poor impulse control

• Violent outbursts

• Low self-esteem

• Substance use history

• Often history of being abused

RISK FACTORS (violence)

General

• History of violence

• Substance use disorder

• Poverty

• Mental illness + stressors

🔹 High-Risk Situations

• Trying to leave relationship

• Pregnancy (↑ violence risk)

• Prior family violence

🔹 Children at Risk

• Age < 4 years

• Unwanted child

• Disability or “different”

🔹 Older Adults

• Dependent on caregiver

• Poor health

• Cognitive impairment

FAMILY VIOLENCE

Key Points

• Most violence occurs within families

• More likely toward:

  • Family members

  • Friends

  • NOT strangers

🔹 Important NCLEX Concept

• People with mental illness:

  • More likely to harm themselves than others

ASSESSMENT

🔹 Nursing Approach

• Ensure privacy

• Be:

  • Direct

  • Honest

  • Nonjudgmental

• Use open-ended questions

🔹 Legal/Ethical

• Must inform client if reporting is required

🔹 Forensic Nurse Role

• Collects evidence in:

  • Abuse

  • Sexual assault cases

AGE-SPECIFIC FINDINGS - violence

Infants Shaken Baby Syndrome

• Intracranial hemorrhage

• Findings:

  • Respiratory distress

  • Bulging fontanel

  • ↑ head circumference

  • Retinal hemorrhage

ANY bruising < 6 months = suspicious

🔹 Children Suspicious Findings

• Bruises:

  • Abdomen, back, buttocks

• Burns:

  • “Glove” or “stocking” pattern

  • Cigarette burns

• Fractures:

  • Spiral fractures

  • Multiple fractures

• Bite marks

• Head injury symptoms

🔹 Older Adults

• Injuries inconsistent with explanation

• Bruises, fractures, neglect

NURSING CARE- violence

PRIORITY

• Mandatory reporting (ALL states)

• Failure → legal consequences

🔹 Interventions

• Document:

  • Objective + subjective findings

• Treat injuries

• Make referrals

🔹 Safety Planning

• Identify triggers

• Provide:

  • Safe housing options

  • Shelters

🔹 Crisis Intervention

• Use during:

  • Family violence

  • Community trauma

COMMUNITY / MASS VIOLENCE

Examples

• School shootings

• Natural disasters

• Terrorism

🔹 Interventions Early

• Ensure safety

• Provide psychological first aid

• Reduce panic

Ongoing

• Restore:

  • Sleep

  • Routine

• Connect to:

  • Resources

  • Support systems

Critical Incident Stress Debriefing (CISD)

• Group therapy after trauma

• Includes:

  • Discussion of event

  • Emotional reactions

  • Coping strategies

SEXUAL ASSAULT

Definition

• Any forced or pressured sexual activity

• Includes:

  • Rape

  • Incest

  • Trafficking

Rape

• Nonconsensual penetration

• Crime of:

  • Power

  • Control (NOT passion)

🔹 Types

• Stranger

• Acquaintance (MOST common)

• Date rape

• Marital rape

Drug-Facilitated Assault

• Substances:

  • GHB (“liquid ecstasy”)

  • Flunitrazepam (“roofies”)

  • Ketamine

RAPE-TRAUMA SYNDROME

Initial Phase Expressed

• Crying, anger, hysteria

Controlled

• Calm, numb, confused

🔹 Long-Term Effects

• Guilt, fear, anxiety

• Depression

• Flashbacks

• Sleep disturbances

PTSD

• 1 month after trauma

• Symptoms:

  • Flashbacks

  • Hyperarousal

  • Avoidance

Acute Stress Disorder

3 days → 1 month post-trauma

Silent Rape Reaction

• No disclosure

• Signs:

  • Nightmares

  • Anxiety

  • Behavior changes

NURSING CARE (SEXUAL ASSAULT)

PRIORITIES

• Ensure safety

• Provide nonjudgmental care

• Assess for:

  • Suicide risk

🔹 Key Actions

• Obtain informed consent

• Use SANE nurse if available

• Collect forensic evidence

🔹 Evidence Collection

• Blood, swabs, hair, nails

• Document:

  • Injuries (photos/body maps)

  • Client statements (verbatim)

🔹 Medical Care

• Treat injuries

• STI prophylaxis

• Emergency contraception

🔹 Communication

• Encourage expression

• Do NOT ask “why”

• Reinforce:

  • “This is NOT your fault”

🔹 Support

• Contact support system (with permission)

• Provide emotional support

CARE AFTER DISCHARGE

🔹 Interventions

• Provide hotline numbers

• Written instructions

• Schedule follow-up

🔹 Therapy

• Individual therapy

• Group therapy

🔹 Important

• Follow-up compliance is often LOW → emphasize importance

INTERPROFESSIONAL CARE- sexual assault

Includes

• Case management

• Social services

• Legal system

• Shelters

🔹 Additional Support

• Parenting classes

• Stress management

• Problem-solving skills

substance use and addictive disorders

Overview

• Substance Use Disorders (SUD):

  • Repeated use of substances → clinically significant impairment (within 12 months)

  • Substances include:

    • Alcohol, caffeine, cannabis

    • Hallucinogens, inhalants

    • Opioids

    • Sedatives/hypnotics/anxiolytics

    • Stimulants, tobacco

• Behavioral (Process) Addictions:

  • Gambling, sex, shopping, social media, gaming

• Key Characteristics:

  • Loss of control

  • Continued use despite problems

  • High relapse rate

• Defense Mechanism:

  • Denial (VERY common)

    • “I can quit anytime”

🔹 Risk Factors

• Genetics (family history)

• Adolescents (immature judgment)

• Chronic stress (low socioeconomic status)

• Trauma (abuse, combat)

• Low self-esteem

• Poor coping skills

• Few relationships or achievements

• Risk-taking behaviors

🔹 Protective Factors

• Strong family/social support

• Positive self-esteem

• Caregiver involvement

• Community resources

• Employment

🔹 Cultural Considerations

• Higher alcohol use:

  • Some Native American/Alaska Native groups

• Lower alcohol use:

  • Some Asian populations

• Influenced by:

  • Alcohol metabolism

  • Cultural beliefs

  • Peer pressure

🔹 Assessment (Nursing History)

Use open-ended questions about:

• Substance type

• Frequency & pattern

• Amount used

• Age of first use

• Work/school changes

• Periods of abstinence

• Withdrawal history

• Last use

Review of Systems

• Blackouts

• Sleep issues

• Weight changes

• GI changes

• Chronic pain

• Stress

• Desire to cut down

🔹 Special Populations Young Adults (18–25)

• Highest use rates

• Early use → ↑ risk of disorder

Pregnancy

• Risks:

  • Prematurity

  • Low birth weight

  • Neonatal abstinence syndrome

Healthcare Workers

• Risk due to:

  • Stress + access to drugs

• Warning signs:

  • Overtime volunteering

  • Mood swings

  • Poor performance

  • Lying

Older Adults

• ↑ sensitivity to substances

• Risks:

  • Falls

  • Confusion

  • Memory loss

• Alcohol signs:

  • Incontinence

  • ↓ self-care

  • Dementia-like symptoms

• Polypharmacy ↑ adverse effects

🔹 Screening Tools

• MAST – Alcohol

• DAST / DAST-A – Drugs

• CAGE – Alcohol perception

• AUDIT

• CIWA-Ar – Alcohol withdrawal

• COWS – Opioid withdrawal

• SBIRT – Early intervention

Substance Categories

Opioids (Heroin, Morphine) Effects

• Euphoria, pain relief

Intoxication

• ↓ respirations ⚠ (can cause death)

• Slurred speech

• ↓ LOC

Antidote

• Naloxone

Withdrawal

• NOT life-threatening

• Flu-like symptoms:

  • Sweating, diarrhea, pain, insomnia

🔹 CNS Depressants Alcohol Intoxication

• Slurred speech

• ↓ motor skills

• Respiratory depression ⚠

• Chronic:

  • Liver disease, pancreatitis

Withdrawal ⚠

• Tremors, HTN, tachycardia

• Seizures

🚨 Alcohol Withdrawal Delirium (Delirium Tremens)

• 2–3 days after stopping

• MEDICAL EMERGENCY

  • Hallucinations

  • Severe HTN

  • Dysrhythmias

  • Death risk

Benzodiazepines / Barbiturates Intoxication

• Sedation

• Respiratory depression ⚠

Antidote

• Flumazenil (benzos only)

Withdrawal ⚠

• Seizures possible

🔹 Cannabis

• Effects:

  • Euphoria, increased appetite

• Risks:

  • Impaired motor skills (8–12 hrs)

  • Paranoia (high doses)

Withdrawal

• Irritability, insomnia, anxiety

🔹 Stimulants Cocaine Intoxication ⚠

• HTN, tachycardia

• Chest pain

• Seizures

• Death

Withdrawal

• Depression

• Fatigue

• Suicidal risk

Amphetamines

• Similar to cocaine

Withdrawal

• Depression, fatigue (NOT life-threatening)

🔹 Hallucinogens (LSD, PCP)

• Effects:

  • Altered perception

• Risks:

  • Panic, paranoia

Long-term

• Flashbacks (HPPD)

🔹 Inhalants

• Used by children/adolescents

• Effects:

  • Dizziness, confusion

  • Respiratory depression ⚠

🔹 Caffeine

• Intoxication (>250 mg):

  • Tachycardia, anxiety, insomnia

• Withdrawal:

  • Headache, fatigue

🔹 Nicotine Effects

• Relaxation

Long-term

• Cardiovascular disease

• Lung cancer

Withdrawal

• Irritability

• Cravings

• Increased appetite

Nursing Care- substance use

Priority = SAFETY

• Prevent injury

• Seizure precautions

• Monitor closely

🔹 Interventions

• Low-stimulation environment

• Frequent orientation

• Monitor:

  • VS

  • Neuro status

• Maintain:

  • Nutrition

  • Hydration

• Administer meds for:

  • Withdrawal

  • Detox

• Watch for covert use

🔹 Psychosocial Care

• Nonjudgmental approach

• Emotional support

• Educate family (codependency)

🔹 Promote Recovery

• Encourage:

  • Accountability

  • Coping skills

  • Emergency relapse plan

• Refer to 12-step programs:

  • AA, NA, Al-Anon

Interprofessional Care

🔹 Therapies

• CBT → change thinking/behavior

• ACT → acceptance + commitment

• Relapse prevention

• Group therapy

• Family therapy

🔹 Codependency

• Family enables behavior

  • Example: covering up for client

Medications- substance use tx

Alcohol Withdrawal

• Benzodiazepines (FIRST LINE)

  • Diazepam, Lorazepam

• Prevent seizures

🔹 Alcohol Abstinence

• Disulfiram

  • Causes severe reaction with alcohol ⚠

• Naltrexone

  • ↓ cravings

• Acamprosate

  • ↓ withdrawal discomfort

🔹 Opioid Use Disorder

• Methadone

  • Replacement therapy

• Buprenorphine

  • ↓ cravings

• Clonidine

  • ↓ withdrawal symptoms

🔹 Nicotine Cessation

• Bupropion

• Nicotine replacement:

  • Gum, patch, spray, lozenge

• Varenicline

  • ↓ cravings

  • ⚠ watch for suicidal thoughts

🔹 Antidotes

• Naloxone → opioids

• Flumazenil → benzodiazepines

Important Definitions

• Tolerance: need more for same effect

• Withdrawal: symptoms when stopping

• Abstinence syndrome: severe withdrawal

Treatment Goals

• Primary goal = Abstinence

• Long-term recovery:

  • Behavior change

  • Coping strategies

  • Support systems

opioids

• How Opioids Work: Opioids are prescribed for severe pain. They work by attaching to specific structures called opioid receptors located throughout the brain, spinal cord, and other body parts to dampen pain signals.

• Other Effects: Beyond pain relief, these drugs impact the brain's reward pathway by triggering the release of dopamine, which creates feelings of euphoria or a "high." They can also physically affect the body by slowing down breathing and reducing intestinal movement, which commonly leads to constipation.

• The Risks of Misuse: When taken as prescribed for short periods, these drugs are generally safe. However, using them in ways not intended—such as taking higher doses, using them recreationally, or sharing them—significantly increases the risk of serious health issues.

• Tolerance, Dependence, and Addiction:

  • Tolerance: The body becomes less sensitive to the drug over time, requiring higher doses to achieve the same pain relief.

  • Dependence: The body adapts to the drug, leading to physical withdrawal symptoms when use is stopped.

  • Addiction: A chronic brain disease characterized by overwhelming cravings and the inability to stop using the substance despite harmful consequences.

• Overdose: An overdose occurs when too much of the drug is consumed, potentially leading to confusion, unconsciousness, severe respiratory depression, and death.

• Seeking Help: The video emphasizes that addiction is a serious condition and encourages anyone struggling with opioid use or those seeking information to consult their healthcare provider for professional support.

opioids and withdrawal

• Why people use opioids: Opioids are powerful medications often prescribed for pain or used illegally (e.g., heroin). Beyond blocking physical pain, they produce a "rush" of pleasant feelings, which can lead to patterns of continued use.

• What is withdrawal: It is the body's reaction to the absence of a substance it has become accustomed to over time. As a person uses more of the drug to achieve the same effect, the body's reaction to stopping the drug becomes more severe.

• The physical sensation: While opioid withdrawal is not life-threatening, it is described as being extremely difficult to tolerate. Symptoms are often compared to a severe case of the flu and are essentially the opposite of the relaxed, pain-free state opioids provide.

• Common symptoms include:

  • Agitation, anxiety, and being short-tempered.

  • Disrupted sleep patterns.

  • Physical discomfort, including sweating, trembling, goosebumps, and muscle aches.

  • The return of original pain, often felt more intensely than before.

  • Digestive issues like nausea, vomiting, or diarrhea.

• The cycle of dependence: Because the withdrawal process is so painful, individuals may begin taking the opioid again simply to stop the symptoms, which often leads to a cycle of misuse and potentially opioid use disorder.

• A path forward: The video emphasizes that recovery is possible. If someone is struggling with opioid use or withdrawal, they are encouraged to talk to a healthcare provider. Effective treatment programs exist to help manage withdrawal symptoms safely and support individuals in reducing or stopping their use of opioids.

Addiction and the brain

• Addiction works in the brain's reward system

  • The brain relies on the substance to feel normal which makes stopping difficult

• The main neurotransmitter is dopamine

What is Substance Use Disorder

• Substance use disorder is a pattern of substance use that causes problems or distress

• Substance use disorder affects health relationships work or school safety daily functioning

• It can involve substances such as alcohol prescription medications illegal drugs nicotine or tobacco

Substance addictions

• Affect the brain and body in different ways

• But they all impact safety judgment health and daily functioning

other addictions

• There are many other addictions

• Look at compulsive behaviors

Why this matters in nursing - addiction

• Nurses care for clients with substance use disorder in many settings

  • Emergency Department medical surgical units behavioral health community and outpatient settings long term care maternal newborn care

• The substance may be a part of the bigger picture

• Substance use can affect safety judgment physical health mental health and treatment outcomes

Intoxication

Immediate effects of substance on brain and body

“under the influence”

Substance abuse

Over using

Tolerance

Takes more to feel the effects

Dependence

Body gets used to it

The five C's of addiction

Craving compulsion loss of control consequence coping

Withdrawl

How the body reacts when the substance is gone

Substance abuse is a complex health disorder

• Can be impacted by genetics mental health trauma environment stress and early exposure

Risk factors of substance abuse

• Risk factors don't guarantee addiction

• Family history of addiction

• Mental health disorders

• Trauma or abuse

• Peer pressure

• early substance exposure

• Poor support system

• Stress poverty or unstable environment

Protective factors of substance abuse

• Protective factors don't guarantee prevention

• Supportive family or relationships

• Positive coping skills

• School or work success

• Community support

• Healthy self image

• Access to resources and treatment

Warning signs and early clues for substance abuse

• Frequent falls

• Repeated ER visits

• Poor medication compliance

• Homelessness and instability

• Anxiety irritability

• Malnutrition

• Mood or behavior changes

• Decline in school or work performance

• Poor hygiene or self care

• Sleep or appetite changes

• Weight changes

• Tremors shakiness or sweating

• Frequent injuries or accidents

• missing appointments or poor follow through

• Relationship legal or financial problems

• Drug seeking behaviors

Nursing assessment substance abuse

• Substance history

  • What's used how much and how often

• Mood

• Withdrawal symptoms

• vital signs and level of consciousness

• nutrition

• Support systems

• Safety

  • Falls injury suicidal self harm violent situation

• make sure you know what they use when they last used if they're intoxicated or withdrawing if they're medically unstable or if they're safe

Therapeutic communication substance abuse

• nursing approach

• Be nonjudgmental

• Use a calm respectful tone

• Promote privacy and dignity

• Ask open ended questions

• use empathy

• Explain what you are doing and why

• Focus on safety and support not shame

• “tell me more”

• “ I'm here to keep you safe”

Alcohol use disorder

• Can affect the brain liver GI system heart nutrition and safety

• Will develop tolerance and dependence

• withdrawal can become life threatening

• s/s: Strong cravings for alcohol, Drinking despite harm to relationships, spending excessive time drinking, continuing despite worsening health, drinking in dangerous situations, failing responsibilities due to drinking, unsuccessful attempts to cut down, drinking more or longer than intended

CIWA

Measure acute alcohol withdrawal symptoms

at 48-72 hrs after alcohol withdrawal what s/s appears

Alcohol withdrawal delirium or delirium tremens

delirium tremens

• Tremors shakiness anxiety irritability nausea and vomiting headache tachycardia hypertension confusion and seizures

• delirium tremens: Life threatening emergency that requires immediate treatment and close monitoring

  • Monitor airway seizure precautions close vital signs monitoring medication support reduced stimulation keep room dark and quiet and safety precautions

disulfiram

• for AUD

• Inhibits alcohol metabolism

• Can cause an alcohol reaction if drinking alcohol while on it

  • Can cause nausea vomiting flushing tachycardia and intense feeling of unwell

  • used to deter

• Appropriate only if goal is abstinence of alcohol

Opioids and overdose

• Heroin oxycodone morphine fentanyl and methadone

• s/s: Drowsiness slowed breathing constricted pupils decreased level of consciousness

• red flags: Unresponsiveness pinpoint pupils blue Gray skin or lips low heart rate or bradycardia and respiratory depression

• worried about them stopping breathing

Opioid overdose emergency care

• Maintain airway

• support breathing

• administer oxygen

• Monitor vital signs

• Prepare or administer naloxone or Narcan as prescribed

• ensure patient safety

• Monitor for return of respiratory depression

  • Might have to give Narcan again

stimulants sedatives and Co occurring disorders

• stimulants

  • Cocaine methamphetamine

  • Agitation restlessness Tachycardia hyperactivity unable to sleep

• sedatives

  • Benzodiazepines

  • Drowsiness slurred speech poor coordination

• co-occurring disorders

  • Depression anxiety bipolar disorder or suicidal thoughts with alcohol use or substance abuse

lab tests for substance abuse or AUD

• Blood alcohol level

• Urine drug screen

• Liver function tests (ALT, AST, bilirubin)

  • See how alcohol is damaging the liver

• CBC

• electrolytes

  • alcohol affects electrolytes

• glucose

• magnesium

• kidney function

  • Organ damage dehydration malnutrition

Nursing interventions for AUD and substance abuse

• airway breathing circulation

• Frequent vital signs

• Neuro and mental status monitoring

• Monitor for withdrawal symptoms

• Hydration and nutrition

• Medication administration

• Calm low stimulation environment

• Reorientation as needed

• Assist with self care and ambulation

• Promote rest and sleep

Nursing safety precautions for AUD and substance abuse

• Fall precautions

• Seizure precautions

• Frequent observation (1:1)

• Safe environment

Patient education recovery and support for AUD and substance abuse

• Effects of substance use on the body

• Withdraw and relapse warning signs

• Medication teaching

• The importance of follow up care

• support groups and treatment options

• Healthy coping strategies

• Sleep nutrition and hydration

• Avoiding triggers when possible

Across the lifespan for AUD and substance abuse

• pregnancy, neonates, children

  • harm fetal growth and development and lead to complications

  • Fetal alcohol spectrum disorders and neonatal abstinence syndrome

• adolescents

  • Effects growth behavior learning development in adolescence

  • Developing brain especially vulnerable to poor decision making risk taking and long term addiction

• older adults

  • Harder to recognize

  • Increased risk for falls and confusion

  • Polypharmacy

Adverse Childhood Experiences (ACEs)

The video tells the life story of a child growing up in a home filled with violence, neglect, substance misuse, and emotional instability. It uses the child’s perspective to show how Adverse Childhood Experiences (ACEs) shape development, health, behavior, and future relationships.

Early Childhood: Fear, Instability, and Emotional Harm

The narrator begins as a young child who feels constantly frightened by parental fighting, shouting, and physical abuse. They long for basic affection—a cuddle, a bedtime story—but instead experience rejection and fear. This chronic emotional insecurity becomes the foundation for lifelong consequences.

The child witnesses domestic violence, sees a parent struggling with alcohol misuse, and watches the other parent cry despite taking medication. There is little money for food, clothing, or toys. The child becomes accustomed to fear, which gradually transforms into anger.

Biological and Developmental Impact

Doctors in the video explain that these experiences are ACEs—traumatic events that alter the developing brain and stress-response system. Because of constant stress, the child’s brain does not learn to regulate emotions effectively. Their body remains in a heightened state of alert, making it harder to relax or heal. Over time, this increases the risk of chronic diseases such as cancer, heart disease, and diabetes.

The video emphasizes that while physical abuse hurts, the deeper and more lasting damage is internal and invisible—changes in brain wiring, stress hormones, and emotional regulation.

Adolescence: Coping Through Risk and Aggression

As the child grows into adolescence, they turn to smoking, drinking, and fighting as coping mechanisms. They describe these behaviors as attempts to manage overwhelming emotions shaped by their ACEs. Violence feels normal because it mirrors home life.

School becomes a place of conflict rather than learning. The narrator gets into fights, skips classes, and feels disconnected from teachers who seem indifferent. They also become a parent at a young age, repeating the pattern of early pregnancy seen in their own family.

Adulthood Without Intervention: The Cycle Continues

In adulthood, the narrator faces significant health problems—diabetes and the expectation of future cancer. They have never held stable employment and have spent time incarcerated. Their relationships are strained, and they acknowledge hating their partner and even their children. Some of their children grow up with ACEs as well, continuing the intergenerational cycle.

The narrator recognizes that their life trajectory was set early and that their children are likely headed down the same path.

A Second Possible Path: Early Support and Intervention

The video then rewinds to show how the narrator’s life could have unfolded differently with early support.

As a baby, nurses notice the mother is struggling and offer help, explaining how important early childhood experiences are. When neighbors report domestic violence, police check on the child and ask how they feel. The parents receive support, the fighting decreases, and the hitting stops. The child finally receives affection and bedtime stories.

At school, a teacher notices emotional and behavioral struggles and connects the child with help to manage feelings. These small but meaningful interventions change the child’s developmental path.

Adulthood With Support: Breaking the Cycle

In this alternate future, the narrator becomes an adult who is married, employed most of the time, and raising children without repeating the harmful patterns they experienced. Their children grow up ACE‑free, giving the next generation a strong chance of remaining ACE‑free as well.

Public Health Message: ACEs Are Common and Preventable

The video concludes with key statistics:

• Nearly half of people in England and Wales experienced at least one ACE.

• One in ten experienced four or more.

Reducing ACEs would dramatically lower rates of smoking, binge drinking, violence, and chronic disease. The narrator calls on doctors, nurses, teachers, police, firefighters, and especially parents to become ACE‑aware. Understanding ACEs helps prevent them and supports those who have already experienced them.

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Adverse Childhood Experiences (ACEs): Impact on brain, body and behaviour

The video explains how a child’s earliest experiences shape the developing brain and influence lifelong health, behavior, and learning. It begins by establishing that genes provide the blueprint for brain development, but environmental experiences determine how that blueprint is expressed. Neural connections that are used frequently become stronger and more permanent, while those that are rarely used fade away. This interplay between nature and nurture forms the foundation for all future development.

Healthy vs. Harmful Early Experiences

The video distinguishes between different types of stress:

• Positive stress: everyday challenges like meeting new people or starting daycare. These experiences help children build coping skills and resilience.

• Tolerable stress: more serious events that can be buffered by supportive caregivers.

• Toxic stress: frequent, chronic, or intense stress without caregiver support.

Adverse Childhood Experiences (ACEs)—such as abuse, neglect, exposure to domestic violence, parental mental illness or addiction, and poverty—fall into the toxic category. These experiences can lead to long‑lasting changes in learning, behavior, and health.

How Toxic Stress Affects the Body

The stress-response system is designed to activate during danger: heart rate rises, cortisol and adrenaline surge, and the body prepares for fight or flight. Normally, this system shuts off once the threat passes or when a caregiver provides comfort.

With ACEs, the stress system stays activated for long periods. Without supportive adults to help regulate emotions, the child’s body struggles to return to baseline. This prolonged activation:

• Weakens the immune system

• Increases vulnerability to infection and chronic disease

• Disrupts normal brain development

Impact on Key Brain Regions

The video highlights three brain areas that are especially vulnerable to toxic stress:

1. Executive Function Center Responsible for planning, attention, problem‑solving, impulse control, and learning. Toxic stress disrupts its development, making it harder for children to focus, reason, and regulate behavior.

2. Emotional Center (the brain’s alarm system) Handles emotional processing and impulse control. Chronic stress makes this system overreactive, leading to emotional distress, heightened reactivity, and difficulty managing impulses.

3. Memory and Learning Center Supports memory formation and retrieval. Toxic stress interferes with learning and the ability to store and recall information.

As a result, children exposed to ACEs often show emotional dysregulation, impulsivity, learning difficulties, and increased risk for mental and physical health problems.

Epigenetics: How Experience Changes Gene Expression

The video explains that ACEs can influence gene expression through epigenetic mechanisms. Epigenetics does not change DNA itself but alters how genes function through chemical modifications.

The metaphor used is:

• Genes = hardware

• Epigenetics = operating system

Experiences such as stress, relationships, nutrition, and smoking can modify how genes are expressed. ACEs are associated with epigenetic changes affecting:

• Stress response

• Brain development

• Cognition

• Mental and physical health systems

Changes that occur early in development are more likely to be long‑lasting and may even be passed to future generations.

The Good News: Support Can Change Trajectories

Despite the risks, the video emphasizes that positive, supportive relationships at any stage of life can improve outcomes. Early intervention is especially powerful.

Warm, responsive caregiving—known as serve and return interaction—is highlighted as a key protective factor. This includes:

• Eye contact

• Responding to sounds, gestures, and emotions

• Shared activities like reading and play

Programs that help caregivers strengthen these skills can prevent many negative outcomes associated with ACEs and build strong foundations for healthy development.

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Protecting Our Elders: How to Spot and Stop Abuse

The video provides a clear, structured overview of elder abuse, emphasizing that it is a growing and often hidden problem affecting older adults across many settings. It defines elder abuse as any intentional harm, mistreatment, or neglect directed toward an elderly person, and stresses that it can take multiple forms—each with distinct warning signs and consequences.

Forms of Elder Abuse

The video outlines four major categories:

1. Physical Abuse

This includes any use of physical force—hitting, pushing, slapping, or improperly restraining an older adult. It also includes misuse of medications. Common indicators include unexplained bruises, cuts, fractures, or injuries inconsistent with the explanation given. Signs of neglect, such as dehydration or malnutrition, may also accompany physical abuse.

2. Emotional or Psychological Abuse

Emotional abuse involves behaviors intended to intimidate, control, or degrade an older adult. This may include threats, humiliation, manipulation, or isolation. Warning signs include depression, anxiety, withdrawal from social activities, sudden behavior changes, sleep disturbances, appetite changes, or difficulty concentrating.

3. Sexual Abuse

Sexual abuse includes any non‑consensual sexual contact, inappropriate touching, coercion, or forcing an older adult to engage in sexual acts. Signs may include genital injuries, bleeding, sexually transmitted infections, or abrupt personality changes such as increased aggression or agitation.

4. Financial Abuse

Financial exploitation involves the unauthorized or illegal use of an older adult’s money, property, or assets. Red flags include sudden changes in bank accounts, unexplained withdrawals, transfers to unfamiliar individuals, missing belongings, or unexpected changes to wills, powers of attorney, or financial documents.

👥 Who Is Most at Risk?

While anyone can experience elder abuse, the video highlights several factors that increase vulnerability:

• Social isolation

• Cognitive impairment, such as dementia

• Physical dependence on others for daily care

• Living in long‑term care facilities

• Living with family members who misuse drugs or alcohol

These conditions can reduce an elder’s ability to recognize abuse, report it, or escape harmful situations.

🧭 Preventing Elder Abuse

The video emphasizes that preventing elder abuse requires community awareness and proactive involvement. Key strategies include:

1. Educate Yourself

Understanding the types of abuse and their warning signs is the first step in recognizing when something is wrong.

2. Build Relationships and Reduce Isolation

Regularly checking in on older family members, neighbors, and friends helps build trust and reduces the isolation that often enables abuse.

3. Speak Up and Report Concerns

If abuse is suspected, the video urges immediate reporting to appropriate authorities such as local law enforcement or Adult Protective Services.

4. Support Independence

Encouraging older adults to stay active and engaged helps maintain their autonomy and reduces vulnerability.

5. Ensure Caregivers Are Qualified and Respectful

Whether care is provided by professionals or family members, caregivers should be properly trained and committed to treating older adults with dignity.

🧩 Final Message

The video concludes by stressing that preventing elder abuse is a shared responsibility. Families, communities, professionals, and government agencies must work together to create safe, supportive environments for older adults. Through awareness, vigilance, and compassionate action, elder abuse can be identified early—or prevented altogether.

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Child Abuse: Skeletal and Cutaneous Findings

The video provides a comprehensive overview of skeletal and cutaneous (skin) manifestations of physical child abuse, focusing on how to recognize, evaluate, and differentiate abusive injuries from medical conditions that may mimic them. It is designed to equip pediatric healthcare providers with the knowledge needed to identify red flags, conduct appropriate diagnostic workups, and fulfill their responsibilities as mandated reporters.

📊 Epidemiology and Scope

Child maltreatment is a widespread issue in the United States, with 4 million referrals annually. The highest rates occur in children under one year old, and nearly five children die every day from abuse. Among all forms of maltreatment:

• 75% are cases of neglect

• 17% involve physical abuse

• 8% involve sexual abuse

This video focuses specifically on physical abuse, particularly fractures and skin injuries, which are among the most common clinical presentations.

⚠ Risk Factors for Abuse

Risk factors fall into three categories:

Child-related factors

• Prematurity

• Chronic illness

• Developmental or physical disabilities

• Behavioral or emotional challenges

Caregiver-related factors

• Young parental age

• Substance or alcohol misuse

• Mental illness

• Unrealistic expectations of child behavior

Environmental factors

• Poverty

• Unemployment

• Low educational attainment

• Social isolation

• Single parenthood

• Presence of an unrelated adult male in the home

• History of intimate partner violence

The video emphasizes that child abuse crosses all socioeconomic, racial, cultural, and religious groups—no child is immune.

🩺 Clinical Red Flags

The most important indicator of possible abuse is a history that does not match the injury. Providers must assess whether the explanation is consistent, developmentally plausible, and appropriate for the child’s abilities.

Other red flags include:

• Delayed medical care

• Multiple injuries in different stages of healing

• Escalating severity of events

• Inappropriate caregiver affect

• Recent stressors or triggering events

In infants and toddlers, up to 20% of fractures are caused by abuse.

🦴 Skeletal Findings Common but nonspecific fractures

• Long bone fractures

  • May occur accidentally or abusively

  • Fracture pattern helps determine mechanism

    • Transverse: direct blow

    • Buckle: axial compression

    • Spiral: twisting force

Highly specific fractures for abuse

Especially concerning in children under one year:

• Classic metaphyseal lesions (CMLs)

  • Also called bucket handle or chip fractures

  • Caused by twisting/pulling forces

• Posterior rib fractures

  • Often from forceful squeezing of an infant’s chest

These injuries require significant force and are rarely accidental.

🩹 Cutaneous (Skin) Findings

90% of physically abused children present with skin findings, and sometimes a single bruise is the only sign.

Concerning bruise patterns

• Bruises in protected areas: torso, ears, neck, genitals, buttocks

• Bruises in non‑ambulatory infants (“those who don’t cruise rarely bruise”)

• Patterned injuries suggesting an implement:

  • Handprints

  • Bite marks

  • Loop marks from cords or belts

The video stresses that you cannot accurately date a bruise based on color.

Burns

• Accidental burns: irregular, asymmetric

• Intentional immersion burns: symmetric, sharply demarcated, uniform depth

  • Often involve lower limbs, perineum, or “glove and stocking” distribution

• Thermal burns may mirror the object used (e.g., cigarette, iron)

🔍 Diagnostic Workup

A thorough evaluation must distinguish accidental injuries, abusive injuries, and medical mimics.

Conditions that mimic abuse

• Rickets

  • Frayed metaphyses, osteopenia, bowed legs

• Osteogenesis imperfecta

  • Blue sclera, Wormian bones, family history

• Bleeding disorders

  • Easy bruising, abnormal bleeding history, family history

Laboratory evaluation

• Bone health labs: calcium, phosphorus, alkaline phosphatase, vitamin D, PTH

• CBC, platelets, coagulation studies

• Von Willebrand testing

• Factor VIII and IX levels

Imaging

• Skeletal survey for all children under two with suspected abuse

  • ~21 radiographs covering long bones, skull, spine, ribs, pelvis, hands, feet

  • High sensitivity with low radiation exposure

🛡 Management and Reporting

The first priority is medical stabilization. Next steps include:

• Notifying the hospital’s child protection team

• Reporting to Child Protective Services (mandated in all states)

• Contacting law enforcement when required

• Conducting a social evaluation

• Evaluating siblings for possible abuse

• Referring families for support with substance use or intimate partner violence

Medical students are also mandated reporters.

🌱 Prevention and Long‑Term Impact

Pediatricians play a crucial role in:

• Recognizing early “sentinel injuries”

• Providing anticipatory guidance during developmental stress points (e.g., toilet training)

• Building long-term supportive relationships with families

• Advocating for evidence‑based prevention programs

The consequences of physical abuse extend far beyond immediate injuries. Survivors have higher rates of:

• Depression

• Conduct disorders

• Substance abuse

One study found 80% of abused 21‑year‑olds met criteria for at least one psychological disorder. Nearly one-third of abused children later abuse their own children, perpetuating the cycle.

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what is trauma

Trauma is a deeply distressing or disturbing experience that overwhelms a person's ability to cope

Trauma can affect physical health mental health emotional regulation relationships and the sense of safety and trust

types of trauma

1. acute trauma: A one time event like an assault rape accident or disaster

2. chronic trauma: Repeated or ongoing trauma like an abuse neglect or domestic violence

3. complex trauma: Multiple or prolonged traumatic experiences often beginning in childhood

Common trauma responses

1. emotional/psychological: Fear anxiety depression shame guilt hypervigilance

2. physical/behavioral: Sleep issues chronic pain self harm substance use dissociation withdrawal

What is interpersonal violence

Intentional use of power control intimidation or force against another person

May include physical abuse emotional or verbal abuse sexual abuse financial abuse neglect or abandonment and stalking or intimidation

Types of interpersonal abuse

1. Physical abuse: Hitting slapping kicking choking burning

2. Emotional/psychological abuse: Threats humiliation control intimidation isolation

3. Sexual abuse: Unwanted or forced sexual activity

4. financial abuse: Controlling money stealing restricting access to funds

5. neglect/ abandonment: Failure to provide basic care safety or supervision

Who is at higher risk for interpersonal abuse

Children, older adults, pregnant individuals, people with disabilities, individuals with mental illness or substance use disorders, people who are socially isolated or financially dependent, LGBTQ plus individuals, Individuals with a history of trauma

Common characteristics of an abuser

Need for power and control, manipulation, jealousy or possessiveness, isolation of the victim, blaming others and the person being abused or minimizing abuse, lack of remorse, threats or intimidation, history of violence, substance misuse or poor impulse control

cycles of abuse

Why victims may not leave abusive situations

Fear of retaliation or death, financial dependence, children or custody concerns, emotional attachment or hope for change, shame or embarrassment, isolation from support systems, housing or transportation insecurity, trauma bonding

Domestic violence/intimate partner violence

May include physical violence sexual violence psychological abuse stalking reproductive coercion and financial control

Can occur in dating relationships marriage former partner relationships and all genders or relationship types

Indicators of neglect

Poor hygiene or dirty clothing

malnutrition or dehydration

untreated injuries or medical problems

frequent absences from school or appointments

inadequate supervision

unsafe living environment

developmental delays

pressure injuries or poor skin care

lack of needed medications or equipment

Indicators of sexual abuse

• physical: Bruising bleeding pain or injury to genital or anal areas, torn or bloody underclothing, recurrent STIs, pregnancy in a child or adolescent

• behavior: Fearfulness, withdrawal, sexualized behavior, regression, self harm, avoidance

Survivor presentation

A survivor may

minimize or deny abuse

appear fearful or withdrawn

avoid eye contact

be anxious or hypervigilant

have low self-esteem shame guilt PTSD depression or substance use

return to the abusive relationship

incest

Sexual abuse involving a family member or close relative

Especially traumatic because it involves violation of trust and safety, secrecy and fear, possibly a long duration, guilt confusion and loyalty conflict

possible effects of incest

Anxiety or depression, PTSD symptoms, self-harm, shame or secrecy, difficulty trusting others, sexual boundary issues, dissociation, eating disorders or substance use, relationship difficulties

Sexual assault

Any unwanted sexual contact or behavior without consent

Includes forced sexual contact attempted rape coercion drug facilitated assault assault by known or unknown individuals

Nursing priorities after sexual assault

Ensure immediate safety

Provide privacy and emotional support

Believe the survivor

Assess injuries

Explain options clearly

Preserve evidence if appropriate

Offer STI and pregnancy prevention resources

Refer to forensic services available

Sex trafficking

Use of force fraud or coercion to exploit a person for commercial sex acts

Victims may include children and adolescents runaway or homeless youth people with trauma histories individuals with substance use disorders people who are isolated or dependent on others

Red flags for sex trafficking

Accompanied by controlling person

cannot speak freely

no control of ID money or phone

frequent STIS or pregnancies

tattoos or branding

malnutrition injuries or exhaustion

fearful submissive or coerced answers

inconsistent story

multiple hotel and address changes

ACEs (Adverse childhood experiences)

Potentially traumatic events that happened before age 18

Examples include physical emotional or sexual abuse neglect witnessing domestic violence household substance use or mental illness parent separation or incarceration

ACE scoring

• each yes = 1 point → Higher the score equals higher long term health and psychosocial risk

• 0 = no reported ACE

• 1-3 = some increased risk

• 4 or more = Significantly increased risk

• ACE score is not a diagnosis it is a risk indicator

Nursing assessment

Assess privately

Look for injuries in different stages of healing

Observe for fear withdraw poor eye contact or hypervigilance

Notice if another person answers for the patient

Ask direct calm non judgmental questions

Consider patterns not just one isolated finding

What to ask and what to avoid

• helpful

  • Do you feel safe at home

  • Has anyone hurt threatened or controlled you

  • Has anyone made you feel afraid

• avoid

  • Why didn't you leave

  • Are you sure

  • Asking in front of the suspected abuser

  • Making promises you cannot keep

Mandatory reporting

Nurses are mandatory reporters for suspected abuse involving children older adults and vulnerable/dependent adults

Follow state law and facility policy, report suspicion not proof, Document objectively, and Prioritize safety