final study guide

loss

• invokes minor to complex thoughts, feelings and behaviors depending on the perceived relationship

  • Can occur suddenly and unexpectedly or be anticipated (e.g. elderly)

  • Stigmatic losses can affect coping (e.g. suicide, substance abuse, HIV)

grief

• intense, emotional reaction to the loss of a loved one; biopsychosocial response ​

  • Pain, sadness, anger, shock

bereavement

• the process of healing and learning how to cope with the loss​

  • First year after a loss is considered to be most difficult​

  • Important life events, holidays, birthdays and anniversaries also difficult​

  • Can last months, years, even a lifetime

integrative bereavement theory

• Shock and disbelief →

• Awareness of loss →

• Conservation-withdrawal → (turning point) 

• Healing →

• Renewal 

dual process model

• how we bounce between loss-oriented coping (focus on grief) and restoration oriented coping (focus on rebuilding life)

  • Loss Oriented Coping: focuses on the grief itself and the deceased person 

    • Processing emotions

    • reminiscing about the deceased

    • experiencing “grief work” to gradually process the loss 

  • Restoration Oriented Coping: deals with the secondary changes and adaptations that occur because of the loss 

    • Adjusting to new roles and responsibilities 

    • Returning to work/other daily tasks 

    • Socializing or making new connections 

    • Seeking out new experiences 

uncomplicated grief (+ interventions)

• Most common, lasts 6-12 weeks 

• Linear progression

• Natural, gradual profession through difficult emotions while still being able to continue everyday activities 

interventions:

• Most do not require clinical interventions (e.g. formal counseling/therapy)

• Find new meaning/purpose in their lives, maintain self-esteem and competency 

• Bereavement call, condolence call, memorial service 

anticipatory grief (+ interventions)

• Grief that occurs before a loss that is expected, such as when a loved one has a terminal illness. 

  • usually working with a family unit when dealing with this kind of grief.

interventions

• ddress emotional and functional impairment and loss 

  • Patient and family/loved ones grieving

  • Meaning of illness

  • Impact on self and relationships 

  • Financial issues 

• Denial may be an adaptive defense mechanism 

• Support groups for caregivers and patients

• Distraction exercises (‘the box’)

• Formal counseling 

traumatic grief (+ interventions)

• Grief that is complicated by the traumatic nature of the loss, such as a sudden or violent death

  • usually caused by external factors like violence, mutilation, or destruction, multiple deaths, own personal encounter with near death 

interventions

• Initially:

  • “I’m afraid I have some very bad news for you”

  • Give specific details

  • “I am so sorry”

  • Use the words “dead” or died”

  • Use victim’s name, not “body” or “the deceased”

  • Share positive things if known (“he did not suffer”)

  • Ask about contacting others

  • Guide through next steps

  • Know how to access medical or mental health care should family members experience a crisis reaction that is beyond your response capability

• After the incident:

  • Assessment will inform an individual care plan based on needs

  • Usually more difficult and prolonged

  • External factors may influence reactions and long-term outcomes

  • Assessment for suicide, depression & PTSD

  • Support groups, memorial services, formal counseling

complicated grief (+ interventions)

• frozen in the mourning state (> 1-6 months after a loss)

  • Also known as prolonged or persistent grief

  • more intense, long-lasting reaction that can be debilitating and impair daily functioning.

  • These individuals will usually need more bereavement support and mental health counseling

interventions

• Likely requires professional intervention (CBT, formal counseling, meds)

• Support groups, memorial service, condolence cards 

compassion fatigue

• Depletion of empathy

• Gradual loss of the ability to empathize with others and a feeling of being emotionally drained from constantly giving care.

• Physical, emotional, and mental exhaustion

• A response to chronic stress: It develops over time due to the continuous demands of caregiving, both paid and unpaid.

older adults mental status exam

• Mood and affect (depression is common)

• Thought process 

  • suspicious/delusional thoughts may characterize dementia (people are stealing, relative is an imposter, this is not my house)

• Cognition and intellectual performance 

  • Cognitive changes associated with delirium or dementia 

  • Abnormalities in consciousness, orientation, judgement are NOT related to age, but underlying neuro-pathologic changes 

• Behavioral changes (irritability, agitation, apathy)

  • Apraxia = inability to execute a voluntary movement despite normal muscle function ( → Alzheimer's, Parkinson’s, etc.)

• Stress and coping patterns (bereavement)

• Risk assessment (depression, suicide risk, firearms, substance/alcohol abuse, chronic medical conditions)

• Social assessment (activity level, functional status, community resources, spirituality)

• Quality of life (life has meaning/purpose)

• Legal status (elder abuse, advanced care directives)

meds that can contribute to dementia (older adults)

• opiates and synthetic narcotics

meds that can contribute to psychosis (older adults)

• digitalis, L-Dopa, reserpine, corticosteroids, barbiturates, isoniazid

meds that can contribute to depression (older adults)

• beta-blockers, chemotherapy drugs, sedative hypnotics

meds that can contribute to anxiety (older adults)

decongestants, bronchodilators, anticholinergics

Explain why older adults require careful monitoring and a stepwise approach for medication prescribing

• Pharmacokinetic changes associated with aging that increase risk of drug accumulation and toxicity

• An increased volume of distribution may result from the proportional increase in body fat relative to skeletal muscle with aging. 

• Decreased drug clearance may result from the natural decline in renal function with age, even in the absence of renal disease

• Larger drug storage reservoirs and decreased clearance prolong drug half-lives and lead to increased plasma drug concentrations in older people

stepwise approach to prescribing for older adults

• Review current drug therapy

• Discontinue unnecessary therapy

• Consider adverse drug events for any new symptom

• Consider nonpharmacologic approaches

• Reduce the dose

• Simplify the dosing schedule

• Prescribe beneficial therapy

BEERS criteria

• The criteria include over 50 medications designated in one of three categories: 

  • Meds that should always be avoided

  • Meds that are potentially inappropriate in older adults with particular health conditions or syndromes

  • Meds that should be used with caution

• Includes OTC meds, which nurses need to ask and educate about

• The American Geriatrics Society advises that clinicians must consider many factors in prescribing decisions

normal age-related changes in cognitive capacity in older adults

• Decreased sensory abilities

• Decreased pulmonary/immune function

• May sleep more or less when younger 

abnormal cognitive changes in older adults that are not age-related (may be due to underlying medical causes, medications, etc.)

• Insomnia ( → depression, interpersonal stress, loneliness)

• Sleep walking ( → Alzheimer’s dementia)

depression vs dementia

• Depression tends to be worse in AM, dementia worse in PM

• People with depression are generally more aware of their deficits than people with dementia

• People with depression maintain ability to complete ADLs*

examples of elder abuse

• Physical

• Sexual

• Emotional abuse

• Caretaker neglect

• Financial exploitation 

neurocognitive disorders

• Characterized by a decline in cognitive function from a previous level of functioning 

  • Acquired! (not present since early life)

• Based on deficits in cognitive domains: attention, executive functioning, learning and memory, language, perceptual-motor, social cognition

delirium

• Definition: disorder of acute cognitive impairment that is caused by a medical condition (e.g., infection), substance abuse, or multiple etiologies

  • Delirium may occur in any age group, it is most common among older adults. Delirium is often mistaken for dementia, which in turn leads to inappropriate treatment

characteristics of delirium

• Develops over a short time

• Usually reversible 

• Medical emergency

• Symptoms:

  • Impaired consciousness

  • Problems with attention/focus

  • Memory, orientation 

  • and language problems

delirium nursing assessment

• Rapid onset of global cognitive impairment 

• Mental status and LOC fluctuates throughout the day

• Thought content illogical, speech incoherent/inappropriate

• Difficulty focusing, remembering, disoriented 

• Behaviors: restless, agitated, lethargic/slow to respond 

interventions to eliminate or minimize the risk factors for delirium 

• avoid high risk meds

• treat infection/dehydration

• pain control

• O2

• regulate bladder/bowels

• nutrition

dementia

• chronic cognitive impairments and is differentiated by underlying cause, not by symptom patterns

  • Dementia can be further classified as cortical or subcortical to denote the location of the underlying pathology.

    • Cortical dementia (e.g. Alzheimer disease)

    • Subcortical dementia

characteristics of dementia

• Cognitive decline from previous level of functioning 

  • Attention

  • executive function

  • learning and memory

  • Language

  • perceptual-motor

  • social cognition

aphasia

• inability to understand or produce speech

apraxia

• inability to perform learned, purposeful movements despite having desire and physical capability to 

agnosia

brain cannot process or recognize sensory input (objects, faces, sounds)

nursing assessment (early signs) of dementia

• Forgets recently learned info or unable to recall later 

• Difficulty with everyday tasks (e.g. preparing a meal)

• Problems with language, substitute unusual words

• Disoriented to time and place, confused in own neighborhood

• Poor judgment, may dress inappropriately for weather

• Problems with abstract thinking

• Misplacing objects by putting them in unusual places

• Dramatic change in personality 

• Loss of initiative

Alzheimer's dementia

• degenerative, progressive, neuropsychiatric disorder that results in cognitive impairment, emotional and behavioral changes, physical and functional decline, and ultimately death

  • Early onset: < 65 years (less common, more rapid progression)

  • Late onset: > 65 years (more common)

  • Diagnosis based on clinical findings only

vascular dementia

• 2nd most common dementia 

• Caused by conditions that block or reduce blood flow to the brain

• Symptoms usually appear more suddenly than AD

parkinson dementia

• 75% of people with Parkinson Disease develop dementia

• May have overlapping pathology with AD

huntington dementia

• Genetically transmitted autosomal dominant disorder

• Frontal dementia = changes in behavior and personality, decreased attention

frontotemporal dementia

• Similar to AD, but has distinct patterns of brain atrophy and neuropathology

Lewy body dementia

• Creutzfeldt–Jakob disease, a rare, rapidly fatal, brain disorder

• Mad cow disease, a bovine disorder

• Progressive cognitive decline with visual hallucination, REM sleep disorder, and spontaneous parkinsonism characterize dementia, symptoms fluctuate and may resemble delirium

sundown syndrome

•  group of symptoms that can impact memory, thinking, personality, reasoning, behavior and mood often occurring later in the day; prevalent among individuals with dementia

  • Etiology: Impaired circadian rhythm, environmental (e.g. limited sunlight or overstimulation), physical illness or infection, chronic pain

complementary therapy

•  Nonmainstream techniques/interventions used alongside conventional medicine

  • Examples: acupuncture, aromatherapy, and massage therapy

alternative therapy

• Techniques/interventions used instead of conventional medicine

  • Examples: energy therapies (Reiki), supplements (Homeopathy), Traditional Chinese Medicine (TCM), and Ayurveda Medicine

integrative health

•  Combines conventional medicine with complementary therapies in a coordinated manner

  • Focuses on holistic care and wellness

  • Example: Using acupuncture alongside medication

gut-microbiota and mental health

• Gut microbiota includes bacteria, fungi, viruses, and other microorganisms

• Influences brain function through neurotransmitters, immune signaling molecules, and metabolic substances

brain-gut axis

• Interaction through neuroimmune, neuroendocrine, and vagus nerve pathways

• Healthy gut microbiota is essential for mental functioning

impact of western diet on mental health

• High intake of prepackaged foods, refined grains, and high-sugar drinks

• Associated with oxidative stress, neuroinflammation, and mental health problems

• reduces BDNF (which creates neurons)

impact of ultra-processed foods on mental health

• Examples: Salty packaged snacks, energy drinks, instant soups, flavored yogurts

• Promote neuroinflammation and disturb lipid metabolism

• a significant association was found between higher consumption of ultra-processed foods and an increased risk of developing depression or experiencing depressive symptoms

• a higher likelihood of depressive symptoms associated with greater consumption of ultra-processed foods

• a significant association between higher consumption of ultra-processed foods and increased odds of experiencing anxiety symptoms

omega-3 (supplement)

• improve memory, cognitive functions

lecithin (supplement)

Improves memory, cognition, functioning, mood in older adults + Alzheimer disease

L-tyrosine (supplement)

amino acid supplement used to boost dopamine and norepinephrine

St John’s Wort (Supplement)

• depression, pain, anxiety, insomnia, premenstrual syndrome

  • SE: interacts w/ serotonergic drugs, birth control pills, digoxin

Valerian (supplement)

• insomnia, nervousness

  • SE: headache, stomach upset, mental dullness, hepatotoxicity

Kava (supplement)

• anxiety reduction

  • SE: risk of severe liver injury, thrombocytopenia, leukopenia

saffron (supplement)

anti-inflammatory, antioxidant effects, improves cognition, reduces depression and anxiety symptoms, neuroprotective properties (Alzheimer’s)

thiamine (B1) supplement

• protects cognitive functioning in alcohol use disorder

folate (supplement)

improve depression

magnesium glycinate supplement

sleep initiation

preschoolers assessment

• May need different descriptors 

• Use of play and art to encourage verbalization and observe social/physical development 

school-aged assessment + communication

• Ensure understanding 

• Can tolerate limited periods of direct questioning 

• Competitive games and interests to engage 

• Ask about friends, interest, home, academics, aspirations, concerns 

adolescents assessment + communication

• Communicate respect, cooperation, honesty 

• Explain confidentiality limits and promote sense of control 

• Convey genuine interest 

• Also ask about sexual relations and drug/alcohol use 

egocentrism

individuals assume others share their thoughts, feelings, etc

clinical interview for pediatrics

• Self concept

• Social interaction

• General intelligence

• Fund of knowledge

• recent/remote memory

• Abstract reasoning and analogues

• Arithmetic calculations

• Writing and spelling ability 

• Reading

• Gross and fine motor skills 

safety assessment

• Have you ever hurt yourself?

• Have you thought about hurting yourself? 

• How would you hurt yourself?

• What do you think would have happened?

bibliotherapy

• using literature (e.g. books, poetry, etc.) as a supplement to help with mental health 

autism spectrum disorder characteristics

• Impairment in social interaction and communication (nonverbal, difficulty creating relationships)

• Abnormal and repetitive behaviors, interests, and activities (resistance to change, hypersensitivity to sensory input, fixed interests)

• Presentation in early childhood development 

• Limited and hindered everyday activities 

common co-occuring condition with autism

• Seizure disorder most common

• Other psychiatric: ID, language disorders, ADHD

autism development (+ risk factors, screening)

• Screening at ages 18 and 24 months 

• Male gender (males 4x more likely)

• genetic/chromosomal conditions (e.g. fragile X, older parents, mitochondrial disease)

• Prenatal exposure (valproic acid/Depakote, thalidomide)

ADHD characteristics (inattention vs hyperactivity/impulsivity)

• Inattention: > 6 symptoms of inattention present for >6 months and inappropriate for developmental level 

• hyperactivity/impulsivity: > 6 symptoms of hyperactivity-impulsivity present for >6 months and inappropriate for developmental level 

ADHD development (+ risk factors, course)

• risk factors

  • male (2:1 male to female ratio)

  • Genetics (1st degree relative)

  • History of childhood abuse or neglect

  • Low birth weight

  • Perinatal exposure to smoking, ETOH

  • Toxin (lead) exposure

• Symptoms must appear before age 12

• Remission may occur in adolescence or later 

• Hyperactivity generally remits first 

ADHD common comorbidities

• DMDD

• Learning disabilities

• Depression

• Anxiety

• OCD

• Tics

• ASD

ADHD medication - first line

•  stimulants (Ritalin, Concerta, Adderall)

ADHD med side effects that require immediate attention

• Priapism (persistent, painful erection without sexual stimulation) – medical emergency (discontinue med)

methylphenidate (Ritalin, Concerta)

• stimulant to treat ADHD

• FDA approved for > 6 years 

• Formulations: patch, tablets, capsules, liquid

amphetamine/dextroamphetamine (Adderall)

• stimulant to treat ADHD

• FDA approved for > 3 years 

• Formulations: tablets, capsules, liquids 

atomoxetine (Strattera) – norepinephrine reuptake inhibitor

non-stimulant to treat ADHD

• Side effects: GI upset, sedation, elevated HR/BP, suicidal ideation (!), severe liver injury, priaprim

• Take in morning unless sedation occurs 

guanfacine (Intuniv, Tenex) – alpha2 agonist

non-stimulant to treat ADHD

• Side effects: GI upset, headache, sedation, decreased BP/HR, overdose (!)

• Consistent adherence important 

• Tablets must be swallowed whole and taken at bedtime 

clonidine (capatapres) - alpha 2 agonist

non-stimulant to treat ADHD

Alzheimer's medications

• donepezil (Aricept)

• galantamine (Razadyne)

• memantine (Namenda)

• rivastigmine (Exelon)