NUR 322: Vulnerable Populations

Types of eating disorders

anorexia nervosa, bulimia nervosa, binge eating disorder

Eating disorder risk factors

interpersonal relationships, psychological influences (rigidity, ritualism, anxiety), environmental influences, participation in athletics

Anorexia nervosa

intense fear of gaining weight or becoming overweight. More common in women, voluntary refusal to eat, onset insidious, body weight < 85% of ideal weight

Anorexia nervosa: types

restricting, binge eating/purging

Anorexia nervosa: restricting

withdrawal from social situations where food might be, usually competitive/compulsive/obsessed about activities, participate in rigid or extreme exercise, some become hyperactive to lose weight

Anorexia nervosa: binge eating/purging

prone to vomit, excessive laxative use, eat normal in social setting, purge later, frequent dental problems, higher rate in impulsivity, abuse of substances

Overgeneralization

other girls do not like me because I am fat

All or nothing thinking

If i eat dessert, ill gain 50 lbs

Catastrophizing

my life is over if I gain weight

Personalization

when I go walking, i know everyone is looking at me

emotional resoning

I know I look bad because I feel bloated

Anorexia nervosa: findings

enlarged parotid glands, dental erosion, caries, langugo, thin bones, brittle hair, yellowed skin, pale, cool, calluses or scars on hands (russells), low BP, Temp, and pulse, irregular HB, HF, peripheral edema, severe constipation, infertility, dehydration, E imbalance, acidosis/alkalosis

Anorexia nervosa: labs

anemia, leukopenia, liver function, abnormal thyroid function, elevated cholesterol, decreased bone density, E imbalance ( low K, Na, Cl, estrogen, testosterone)

Anorexia nervosa: inpatient admission

weight loss 30+% of body weight over 6 months, unsuccessful weight gain, ECG chances, depression, SI, family crisis, psychosis, HR<40, SBP<70, temp<96.8, E disturbances

Milieu

reward for positive behavior, monitor exercise, purging, bathroom visits, encourage self care activities, participation with family, and small frequent meals

Anorexia nervosa: goals

increase weight by 2-3 lbs per week. Attain 90% of average body weight for height

Refeeding syndrome

fatal complication that occurs with malnourished patients. SLOW refeeding and fluid hydration. monitor E

Bulimia nervosa

large quantities of food consumed in short period (2 hrs), followed by inappropriate compensatory behaviors (purging, exercise, laxatives). Lack of control while eating, distress at overeating, usually normal or slightly above weight.

Bulimia nervosa: types

purging type, nonpurging type (exercise, laxatives, diuretics, enemas)

Bulimia nervosa: labs and assessment

low K, Na, Cl, ECG changes, menstrual irregularities, enlarged parotid gland, erosion of dental enamel, callusing of knuckles

Anorexia nervosa: key signs

very low weight, hormonal imbalance, constipation, lanugo

Bulimia nervosa: key signs

normal overweight, more likely to have E imbalance, GI problems do to binging and purging

Binge eating disorder

reoccurring episodes where large quantities of food is eaten over a short period with no compensatory behavior. Distress after episode and lack of control, commonly found in ages 46-55, weight gain usually leads to DM II, HTN, and cancer.

Eating disorder: NI

establish trust, create realistic goals for weight gain or loss, address cognitive distortions, monitor food intake, exercise patterns, and attempts to purge, teach meal planning, group therapy and referral to overeaters anonymous

Eating disorder: treatment

pharm (SSRI), cognitive behavioral therapy

Delirium: onset

abrupt

Delirium: course

acute, rapid (days hours)

Delirium: cause

typically other physical issue

Delirium: memory

short term impairment

Delirium: LOC

flucuates, lacks pattern

Delirium: thought content

logical, illogical, related to LOC

Delirium: speech

slurring/incoherent

Delirium: perception

possible, AH, VH, tactileH

Delirium: mood/affect

fear, anxious, frightened

Dementia: onset

slow, progressive

Dementia: course

chronic, months, years

Dementia: causes

primary D/O, eg, AD

Dementia: memory

STM impaired first, LTM fails at slower pace

Dementia: LOC

consistent, may confuse day or night

Dementia: thought content

not initially impaired, confusion yields difficult assessment

Dementia: speech

normal, may progress to aphasia

Dementia: perception

mis-identification of family/care providers. Delusions may be present

Dementia: mood/affect

wide ranging

Delirium acronym for causes

drugs, dehydration, depression, environment, E, endocrine, low oxygen, liver function, infection, retention of urine/stool, renal failure, ischemia, injury, under nutrition, metabolic issues, malnutrition, sleep deprivation, stroke

Delirium is a

MEDICAL EMERGENCY

Delirium: NI

prevent physical harm, perform comprehensive assessment, assist with proper health management o eradicate cause, use supportive measures to relief distress

Alzheimer's disease

most common form of dementia. insidious, loss of short term memory first manifestations.

AD: diagnosis

diagnosed after all other disorders ruled out. Based on clinical features. Autopsy of brain reveals extracellular deposition of amyloid beta protein, neurofibrillary tangles, senile plaques, and loss of neurons

AD: risk factor

age, head injury, cv disease, lower level of education, being female

AD: etiology

cholinergic deficit (acetylcholine), neural loss ( cerebral cortex, hippocampus, amygdala, forebrain), neurofibrillary tangles (due to separated tau protein fibers), beta amyloid plaques (oxidative stress, free radicals), genetics

AD: four As

amnesia, aphasia, apraxia, agnosia

amnesia

inability to learn new thigns

aphasia

expressive: inability to express thoughts in words

receptive: inability to understand what is said

apraxia

inability to carry out motor activities

agnosia

inability to recognize familiar objects or people

AD: screening

mini mental status exam, confusion assessment method, meelon champagne confusion scale, functional dementia scale, brief interview for mental status, functional assessment screening tool, global deterioration scale, blessed dementia scale (secondary source)

AD: stage 1

no impairment, preclinical AD

AD: stage 2

very mild cognitive decline, mild

AD: stage 3

mild cognitive decline, mild

AD: stage 4

moderate cognitive decline, moderate

AD: stage 5

moderately severe cognitive decline, moderate

AD: stage 6

severe cognitive decline, severe

AD: stage 7

very severe cognitive decline, severe

AD: mild stage

MMSE 20-30; decrease STM, work and name finding difficult, decision making, concentration, and judgment problems, difficulty performing usual activities, getting lost, repetitive questioning

AD: moderate stage

MMSE 10-19; apraxia, agnosia, aphasia, poor concentration, disorientation, blunted affect, delusions, ADL assistance, redirecting, lability, wandering, urinary incontinence, supervision, self absorption

AD: severe stage

MMSE 0-9; gait disturbance, B&B incontinence, bowel impaction, bed bound, difficulty swallowing, fetal position, 24- hr observation

Denial

client family refuses to believe changes are taking place

Confabulation

client makes up stories when questioned about events or activities that they do not remember, can be unconscious attempt to save self esteem

perseveration

avoids answering questions by repeating phrases or behavior

AD: classic behaviors

word finding difficulty, difficulty concentrating, misinterpreting the environment delusion, illusions, somatic preoccupations, misidentification, sundowning, loss of ability to care for oneself

AD: NI

articulate words clearly, calm approach, avoid arguing, go along with concern, provide prompts and reminders for patient with STML, provide reality orientation, provide structured environment, do not rush patient, do not shout, observe ADLs, set realistic goals, monitor physical needs, allow independence, intervene early

Mild to moderate AD: pharm

acetylcholinesterase, butyrylcholinesterase to terminate actions of acetylcholine

Goal to increase acetylcholine

Cholinesterase inhibitors: names

aricept (donepezil), exelon (rivastigmine), razadyne (galantamine)

Cholinesterase inhibitors: AW

GI distress and bradycardia, syncope

syncope

fainting

Cholinesterase inhibitors: CI

asthma, COPD

Namenda (memantine): class

AChE inhibitor and NMDA antagonist

Namenda (memantine): action

blocks NMDA receptor, interfering with pathophys of AD. Improves cognitive function.

Namenda (memantine): indication

moderate to severe AD

Too much glutamate causes

cell death because it is an excitatory neurotransmitter

Disorders in child and adolescents patients

neurodevelopmental, disruptive, impulse control and conduct, mood, anxiety, trauma and stressor related, feeding and elimination disorders

Etiology of disorders in children and adolescents

genetics, neurobiological, temperament, habitual coping, resilience, environmental, cutural

Risk factors for child experiencing a psychiatric disorder

severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, foster care, witnessing violence, abuse, bullying

Resilience of a child who has many risk factors

adaptability to change in environment, ability to form nurturing relationships with other adults, ability to distance self from emotional chaos, good social intelligence, good problem solving skills, ability tp perceive a long term future

Neurodevelopmental disorders

ADHD, autism, intellectual development, specific learning disorder

ADHD

inattention, hyperactivity, impulsivity, before 12 yo, more than one setting

ADHD: types

inattentive, hyperactive impulsive, combined

ADHD: stimulant meds

dextroamphetamine (Adderall), methylphenidate (Ritalin)

ADHD: nonstimulant meds

NE reuptake inhibitors (atomoxetine, bupropion, venlafaxine), alpha 2 agonists (clonidine, guanfacine)

Autism spectrum disorder

persistent deficits in social communication and interaction across multiple contexts, restricted and repeated behaviors interest, and activities, present in early childhood, significant impairment

Specific learning disorders

persistent difficulty in the acquisition of reading, writing, or math. Benefit from individualized education program

Intellectual development disorder

deficits in intellectual functioning, social function, managing age appropriate ADLs, functioning at school or work, and performing self care

Oppositional defiant disorder

negativity, disruptive, argumentative, defiant toward authority, hostile, angry, irritable, vindictive, refusal to accept responsibility for misbehavior, limit testing

Intermittent explosive disorder

recurrent behavioral outburst, verbal and physical aggression, at least 6 yo, recurrent episodic violent and aggressive behavior, aggressive overreaction to normal stressor followed by shame or regret

Conduct disorder

violates the rights of others, aggressive towards people and animals, destruction of property, deceitfulness or theft, serious violation of rules

Mood disorders

depression and anxiety

___ is the 3rd leading cause of death among adolescents

suicide

Disruptive mood dysregulation disorder (DMDD)

recurrent temper outburst that are severe and do not correlated with situation. 3+ outbursts a week in 2+ settings. Mood between outbursts is persistently irritable or angry most of the day.

Separation anxiety

child separed from or anticipating separation

PTSD

social withdrawal and may blame self for trauma. may start within one month of event, but sym may not appear for years. directly experiencing or witnessing a traumatic event