NCM 117-Care of Clients with Maladaptive Patterns of Behavior (Acute and Chronic)

Flashcards on Legal and Ethical Issues in Mental Health Nursing

Voluntary Admission

The client willingly enters and consents to treatment, retaining all civil rights and the option to discontinue treatment.

Involuntary Inpatient Admission

The client is institutionalized against their will, typically posing a threat to self or others, lacking capacity for basic needs, or being seriously mentally ill but refusing treatment.

Confidentiality

Client information is privileged and must be treated with utmost confidentiality.

Informed Consent

Client must be adequately informed about care and treatment and provide consent for treatment.

Right to Refuse Treatment

All clients have the right to refuse treatment, including those committed involuntarily.

Seclusion

Isolating a person in a room where he is physically prevented from leaving.

Restraints

Use of chemical or mechanical devices to control a client’s physical activity, requiring a physician’s order (except in emergencies, where an order must be obtained afterward).

Incompetence

To be determined by the court. If proven incompetence, a legal guardian is appointed.

Autonomy

Freedom to make choices about one’s life.

Beneficence

Requires nurse to act in ways that benefit clients.

Nonmaleficence

Requires nurse to act in manner to avoid causing harm to client.

Veracity

Practice of telling the truth.

Confidentiality

Nondisclosure of information with which one is entrusted.

Justice

Fair,equitable and appropriate treatments.

Fidelity

Faithfulness and practice of keeping promises.

Stress

Generalized, nonspecific response of the body to any demand, change, or perceived threat, whether positive or negative.

Stressors

Circumstances or events that elicit stress response and may be real or anticipated.

MILD Stress (+1)

Increased alertness to inner feelings or environment initiates action

MODERATE Stress (+2)

Narrowing of ability to perceive - concentrate in one specific thing

SEVERE Stress (+3)

Ability to perceived is further reduced - focused on small scattered details

PANIC Stress (+4)

Complete disruption of the ability to perceive takes place, personality disintegration

Crisis

Temporary state of disequilibrium by an event, usually self- limiting 4-6 weeks

Crisis: Precipitating Factors

Developmental, situational, and threats to self- concept

THERAPEUTIC NURSE – CLIENT RELATIONSHIP

Contract, Boundaries, Confidentiality, Therapeutic Nurse Behavior, Phases

Phases: Preinteraction

Develop self-awareness of feelings and fears, conduct a self-assessment of professional assets and limitations, Research any information available, Review records, Plan meeting with client/patient

Phases : ORIENTATION

Developing trust and open communication > patient should know the nurse > make a contract for termination, Assessing the client’s reason for seeking help or hospitalization Establishing mutually “agreed –upon” goals Developing a therapeutic contract Formulating nursing diagnosis

Phases: WORKING

Planning outcomes and related interventions to meet goals and to assist the client, Facilitating expression of thoughts and feelings, Exploring problems, Encouraging constructive coping measures, Practicing and evaluating more adaptive behaviors, Working through resistant behaviors/therapies

Phases: TERMINATION

Evaluating therapeutic outcomes, expressing feelings about termination, observing for regressive behavior, and evaluating the nurse-client relationship.

MENTAL RETARDATION CAUSES

Infection and intoxication, Injury to the brain suffered during the prenatal,natal,or postnatal, Inadequate nutrition and metabolic or endocrine disorders, Chromosomal abnormalities Low birth weight or prematurity.

NORMAL IQ

90 to 110 IQ

BORDERLINE IQ

71 to 89 IQ

MILD IQ

50/55 to 70 IQ

EDUCABLE

Mental age of 8 to 12 years. read and write, do arithmetic, vocational skill, and function in society

MODERATE IQ

35/40 to 50/55 IQ

Trainable

Mental age of 3 to 7 years. activities of daily living, social skills; work in a sheltered workshop

SEVERE IQ

below 20/25 to 35/40 IQ

Barely trainable

Mental age of 1 to 2 years; Totally dependent ;needs custodial care

PROFOUND IQ

below 20/25 IQ

Mental age of young infant

Mental age of young infant; Requires total care

Mental Retardation CLINICAL FINDINGS

Infant fails to suck; head lag after 4 -6 mos. of age; slow in learning; slow to respond to new stimuli; slow or absent speech development, May repeat words (echolalia); abstract ability is limited, Lack power of self- appraisal; does not learn from mistakes, Cannot carry out complex instructions, Does not relate to peers; more secure with adults; comforted by physical touch, Short attention span, but usually attracted to music

Mental Retardation NURSING CARE

Consider the developmental age Teach simple steps for habit formation Ensure each step is learned completely before teaching the child another step Praise accomplishment Hospital routines be based on normal routine Keep discipline simple (acceptable behavior rather than developing judgment). Promote Routine, Repitition, Reinforcement

LEARNING DISORDERS ETIOLOGIC FACTORS

No one definitive cause has been established. Learning disorders (LD) are frequently found in association with variety of medical conditions (lead poisoning, fetal alcohol syndrome, fragile X syndrome). Genetic predisposition, perinatal injury, neurologic and general medical conditions

LEARNING DISORDERS CLINICAL FINDINGS

Disorders of written expression and mathematics commonly occur in combination with reading disorder. Demoralization, lower self esteem, and deficits in social skills maybe associated. School drop out rate for children or adolescent with LD is approximately 1.5 times the average. Employment difficulties and social adjustment are noted in adolescence and adulthood. Disorder may persist into adulthood

LEARNING DISORDERS NURSING CARE

Activities consistent to disorder, Diagnostics evaluation, Guidance and supervision, Maintain routine based on the child’s usual schedule, Consistent and firm limits behavior, Trusting relationship with child and family

MOTOR SKILLS DISORDER ETIOLOGIC FACTORS

No definitive cause for motor impairment has been established , No specific neurologic disorders are present. Lack of coordination can continue through adolescence and adulthood

MOTOR SKILLS DISORDER CLINICAL FINDINGS

A marked impairment in the development of motor coordination that interferes with academic achievement or activities of daily living, First noted when child attempts motor task such as running, holding a knife and fork, buttoning clothes, or playing ball games, Performance in daily activities requiring motor coordination is substantially below than expected for chronological age and measured IQ

MOTOR SKILLS DISORDER NURSING CARE

Prevention of injury, exercise, emphasize abilities and achievements, help parents to cope

PERVASIVE DEVELOPMENTAL DISORDERS (AUTISTIC DIORDERS) ETIOLOGIC FACTORS

No definitive cause has been established. Failure to develop satisfactory relationships with significant adults, regardless of the cause, appears to be an underlying problem

PERVASIVE DEVELOPMENTAL DISORDERS (AUTISTIC DIORDERS) CLINICAL FINDINGS

An alienation or withdrawal from reality, usually evident before age 3, A severe disturbance in the child’s feeling of self identity. Inability to differentiate between self and environment, A conflict between self and reality, Interference with intellect may be so profound, child appears to be mentally retarded, Turning to inanimate objects and self centered activity for security.

AUTISTIC DIORDERS THERAPEUTIC INTERVENTIONS

Psychotherapy (play, group, or individual therapy , medications: neuroleptics, stimulants, and lithium provide some reductions of symptoms, Removal from the home situation/ day school situations

AUTISTIC DIORDERS NURSING CARE

Consistent routine, Consistent familiar environment, Use picture and letter boards, Consistent and firm limits, Prevents act of self- destructive behavior, Self-boundaries - using child’s name and personal pronouns and identifying belongings.

ATTENTION - DEFICIT HYPERACTIVITY DISORDER (ADHD) ETIOLOGIC FACTORS

no known cause; Evident before 7 years of age; lasting at least 6 months

ATTENTION - DEFICIT HYPERACTIVITY DISORDER (ADHD) CLINICAL FINDINGS

Inappropriately inattentive, Excessive impulsiveness, Short attention span; easy distractibility, Squirming and fidgeting, Hyperactivity may or may not be present

ATTENTION - DEFICIT HYPERACTIVITY DISORDER (ADHD) THERAPEUTIC INTERVENTIONS

Methylphenidate hydrochloride (Ritalin) is frequently used, Although dextroamphetamine sulfate (Dexedrine) may be also given, Pemoline ( Cylert )

ATTENTION - DEFICIT HYPERACTIVITY DISORDER (ADHD) NURSING CARE

Balance between energy expenditure and quiet time, attainable goals, less stimulation (play only one after another)

TIC DISORDERS DATA BASE

Gross motor movement disorders

TIC DISORDERS BEHAVIORAL / CLINICAL FINDINGS

Involuntary, uncontrolled, multiple, rapid movements of muscles such as eye blinking, twitching, and head shaking that occur in bouts throughout the day, Involuntary production of sounds such as throat clearing, grunting, barking, or the utterance of socially unacceptable words is usually associated with Tourette’s disorder, Can be controlled for short duration; not usually present during sleep; increase during time of stress, More common in males than in females

TIC DISORDERS THERAPEUTIC INTERVENTIONS

Medications such as sedatives or DILANTIN may be prescribed

TIC DISORDERS NURSING CARE

Accept behavior as uncontrollable, Identify precipitating factors, Help the child to see as worthwhile person, Established trust always, Promote independence, Be realistic and truthful

Delirium

Disorientation, acute, young adults,clouded sensorium, reversible, good prognosis

Dementia

Impairment of memory, chronic , elderly, clear sensorium, irreversible, poor prognosis

Amnestic disorder

Disturbance in memory related to medical and substance abuse

DELIRIUM

Syndromes from which the client usually recovers, because the changes may be reversible & temporary

DELIRIUM Stressors

Infection, Trauma to head, Circulatory disturbances Metabolic and Multiple etiologies

DELIRIUM CLINICAL FINDINGS

Delirium and its accompanying confusion, hallucinations, and delusions, Disorientation and confusion as to time, place, identity, Memory defects for both recent and remote events and facts, Slurring of speech may occur along with an indistinct pronunciation or use of words, Tremors, incoordination, imbalance and incontinence may develop. Physical symptoms may occur such as gastrointestinal problem

DELIRIUM NURSING CARE

Reduce causative agent, Prevent further damage, Diet high in calories, protein, and vitamins, Sedative as prescribed, Safe environment

DEMENTIA

Dementia may be progressive, static, or remitting

DEMENTIA Stressors

prenatal injury or malformation infections trauma circulatory disturbances nutritional deprivation damage may results from generalized diseases damage resulting from pressure of brain tumors

DEMENTIA CLINICAL FINDINGS

Memory impairment (recall or learning), Aphasia (language disturbance), Apraxia (impaired motor activities), Agnosia (inability to recognize familiar objects), Amnesia/memory loss (disturbance in planning, organizing, sequencing).

DEMENTIA Types

Alzheimer’s disease, Vascular Dementia Pick’s disease Creutzfeld-Jakob diease Parkinson’s disease Huntington’s disease

DEMENTIA NURSING CARE

Toilet frequently, Feed the client, Protect client from self and environment, Support independence, Emphasize on preventing further damage

AMNESTIC DISORDERS DATA BASE

Disturbance in memory related to medical condition (head trauma). Disturbance in memory related to persistence effects of substances (drug abuse, medication, or toxin exposure

AMNESTIC DISORDERS CLINICAL FINDINGS

Impaired ability to learn new information. Difficulty recalling previously learned information or past events. No evidence of anxiety related to traumatic event. Impaired social and occupational functions

AMNESTIC DISORDERS Nursing Care

Provide safety, Orient the patient, Provide support

Anxiety

Feeling of dread or fear in the absence of external threat or disproportionate to the nature of the threat

Mild Anxiety

Level of Anxiety: more alert than usual, mild uneasiness

Moderate Anxiety

Level of Anxiety: heart pounds, skin cold and clammy, poor comprehension

Severe Anxiety

Level of Anxiety: hallucinations, delusions

Panic Anxiety

Level of Anxiety: inability to see and hear, inability to function

Phobia

Most common form of anxiety disorder.it is an irrational fear of an object, activity or situation that is out of proportion to the stimulus and results in avoidance of the identified object, activity or situation internal source of fear expressed to an external source

Agoraphobia

Fear of being alone in public places

Social phobia

Compelling desire to avoid situations in which others may criticize a person

Specific phobia

Excessive fear of an object, an activity or a situation that leads a person to avoid the cause of that fear

Post - traumatic stress syndrome ASSESSMENT

Exposure to traumatic event (e.g.combat, rape, murder, fire, other catastrophe Response to trauma causes intense fear or horror Recurrent or distressing recollections of event- images, thoughts, feelings

Post - traumatic stress syndrome ANALYSIS

Duration of symptoms is at least 1 month Syndrome can emerge months to years after traumatizing event Biologic changes due to impact of stressor and excessive arousal of sympathetic nervous system

Post - traumatic stress syndrome NURSING CONSIDERATIONS

Help to integrate the traumatic experience Encourage c to talk about painful stored memories Be nonjudgmental Allow grieving over losses, Help label his feelings, Stress management program Anger management program, Journal of disturbed thoughts and feelings Reduce sleep disturbances, Regular physical activities with client Support systems

Somatization disorders

rule out physical illness first, Clients focus on body symptoms,Interventions: encourage to recognize, label, & work through feelings & emotions, encourage to engage in relationship, stimulate verbalization use of relaxation techniques

Conversion disorder

Lost or altered body functioning related to psychological conflict/need, Interventions: Don’t focus on physical symptoms, Minimize sick role behavior, Encourage performing ADL, Reinforce personal strength, Explore relation. with others, feeling’s & conflicts Help identify what needs are met by symptoms Help identify other ways to meet needs

Hypochondriasis

Preoccupation with fear of illness or belief that one has illness based on physical signs, No evidence of illness on physical exam Symptoms do not result from panic attack, Interventions: explore the needs being met by symptoms, explore alternative ways without manipulation explore feelings & conflicts, help relate feelings & conflicts to physical sx. do not reinforce sick role

DISSOCIATIVE DISORDERS

Disruption in integrative functions of identity, memory, or consciousness Types dissociative identity disorder/multiple personality disorder Dissociative amnesia individual Group & Family Psychotherapy expand self-awareness Increased self-esteem

DEPRESSION ASSESSMENT

Suicidal preoccupation, negative view of self, world and future, poverty of ideas, dysphoric; depressive

DEPRESSION ANALYSIS

Response to real or imagined loss Anger and aggression directed toward self, results from feelings of guilt about negative or ambivalent feelings, Incorporation of a loved one or hated object/person to one’s ego

DEPRESSION NURSING CONSIDERATIONS

Provide for physical needs, Assess signs of suicidal ideation, Promote feelings of expression, Constructive activities/monotonous and promote socialization, Encourage client to listen to himself and assume more of his decision making, Promote opportunities for autonomy and self – actualization, Promote self-esteem

BIPOLAR DISORDER

Definition : components of both depression and elation (manic- depressive), milder symptoms of both mania and depressionSymptoms of depression alternating with short periods of normal mood.

BIPOLAR DISORDER Mood

Elevated Irritable

BIPOLAR DISORDER Speech

Loud- rapid Rhyming Clanging May cause

BIPOLAR DISORDER Nursing Care

Lithium carbonate Non-stimulating activities Non-competitive activities Finger foods Hydration