1
Q
physical environment needs of dementia
A
- light
- sound
- temperature
2
Q
subudural hematoma in older adults
A
have decreased brain size - more space to acommodate subdural bleed
Sx might now show for 3 days to a week later
3
Q
children and prescription medications
A
- metabolize and eliminate faster than adults
- can be prescribed as young as preschool age
- approved for syndromes not symptoms
- effectiveness and safety still clinical concerns
4
Q
coping mechanisms of personality disorders
A
- attempts to cope with anxiety r/t threatened or actual loneliness
- manipulative people view others as objects
- defenses protect against potentiaal psychological pain
- people w/ antisocial personality disorder use projection, splitting
5
Q
global elements of MI
A
- evocation
- collaboration
- autonomy/support
- empathy
- direction
6
Q
3 D’s
A
7
Q
cognitive deficits in Alzheimer’s
A
- cause significant impairment in social or occupational functioning
- represent significant decline from previous level of functioning
- gradual and worsen steadily
- not due to other causes
8
Q
adolescent non-suicidal self-injury
A
- differentiate suicide and self-destructive behaviors
- biting, cutting, hitting, burning
- intent
- relieve negative emotions, unpleasant thoughts/feelings
- release anger, tension, emotional pain
- provide security or control
- punishment
- set boundaries with others
- end depersonalization/derealization, flashbacks or racing thoughts
9
Q
LEAR(N)S
A
- naps
- limit daytime naps to
- limit naps to 3x per week
- none is best with insomnia complains - sleep restriction therapy
- when overnapping, reduce time in bed
- find out if someone is napping
- might be getting necessary hours of sleep, but need to add those to night, not day
10
Q
neurological comorbidities with depression in older adults
A
- post-CVA
- Alzheimer’s
- Parkinson’s and dementia with Lewy bodies
- Huntington’s
11
Q
window of tolerance
A
from baseline to fight/flight/freeze
shorted window in people with trauma - baseline is nearer to fight/flight threshold
12
Q
psycho-social needs of dementia
A
- affect
- assitsance matches ability
- diversional activities
13
Q
adolescents and sleep
A
- decreased total sleep time
- later bedtime, later wake time
- maturation of suprachiasmatic nucleus during puberty
- increased daytime sleepiness due to inadequate restorative needs
- restoration, physiologically
14
Q
diagnostic features of RLS
A
- urge to move limbs associated with paresthesias or dysesthesias
- symptoms start/worsen with rest
- partial relief with physical activity
- worsening of sx in evening/night
15
Q
social environment needs of dementia
A
- staff mix
- staff stability
- ward ambiance
- presence of others
16
Q
assessment of adolescent mental health
A
- family interview
- define problems, genogram, parental health, family interactions
- child interview
- mental state, fears, mood, sleep, hallucinations, development, play, physical exam
- other
- school, friends, bullying, psych tests, labs, neuroimaging
17
Q
depression in medically ill older adults associated with:
A
- amplified somatic Sx
- increased use of alcohol/sedatives
- increased use of health services
- interferene with medical care
- medical complications
- prolonged illness, length of stay
- excess disability
- risk of institutionalization
- increased mortality
18
Q
RASS scale -4
A
deep sedation: no response to voice, but movement or eye opening to physical stimulation
19
Q
Cluster A
A
- paranoid
- schizotypal
- schizoid
odd or eccentric in nature
20
Q
trauam: the disconnet
A
Your Experience vs Their Experience
- emotional and moody vs intense emotional pain
- impulsive vs immediate gratification
- self-injurious/suicidal vs relief of emotional pain
- manipulative vs desperate need to regulate
- dependent vs fear of rejection
- inflexible vs fear of internal disruption
21
Q
outcomes identification for personality disorders
A
- expected outcome: patient will obtain maximum interpersonal satisfaction by establishing and maintaining self-enhancing relationships with others
- short term goals progress from simpler to more complex behavior changes
- examples: develop goals with patient participation; consider ability to tolerate anxiety before setting goals
22
Q
personality disorder diagnosis
A
- symptoms are fixed and long lasting
- cannot change personality - use meds only to treat Sx
- appearance and severity can vary overtime
23
Q
worry time
A
- remove thoughts and cognitive activation of those thoughts far away from bedtime hours
- during day: write down thoughts and brainstorm solutions
- order priorities for attention during day
- practice problem solving strategies during day
24
Q
emotional dysregulation
A
- emotional world of trauamtized person is unexpected tidal wave of changing emotions
- easily triggered by external and internal stimuli
- when thoughts and perceptions intrude on fragile sense of equilibrium
- individual often not aware of triggers
25
phases of sleep
* NREM 1-4
* REM
26
non-pharmacological tx for adolescent mental health
* health education
* play therapy
* behavioral therapy
* family therapy
* group therapy
* individual therapy
* cognitive behavioral therapy
* milieu management
27
apraxia
impaired ability to carry out motor acticities despite intact motor function
28
ambivalence
* "I want to, but I don't want to"
* natural phase in process of change
* not pathological
* key issue to resolve for change to occur
* ambivalence = good
29
older healthy adults and sleep
decreased sleep efficiency of 3% each decade
REM decreases 2-3% also
30
RASS scale + 2
agitated: frequent non-purposeful movement, fights ventilator
31
ICSD sleep-wake disorders
* insomnia
* sleep-related breathing disorders
* hypersomnia
* circadian rhythm sleep dx
* parasomnias - disorders of arousal or REM
* sleep-related movement disorders - RLS, bruxism
* isolated symptoms
* others
32
sleep latency
* period of time when head hits pillow until you go into REM sleep
* important to have enough
* too short: REM sleep too early
* early awakening
* many reasons why sleep latency is shortened
33
epidimiology of delirium
* \> 7 million hospitalized/year
* rates of persistent delirium
* discharge 45%
* 1 mo 33%
* 3 mo 26%
* 6 mo 21%
* \>60% not recognized by healthcare system
34
contemplation
* person is aware that problem exists and seriously considering changing, but has not made commitment to take action.
* contemplators perform risk-reward analysis.
* ambivalence
* clinicians: tip decisional balance
35
cultural considerations in adolescent mental health
* not just about race/ethnicity
* SES, geographic locatio, acculturation vs assimilation
* avoid misdiagnoses by attending to relevant cultural factors
* acknowledge differences in emotional expression
36
depression cascade
37
mixed delirium
shift between hyper and hypoactive states
38
preparation
* individuals intending to take action and may practice some of the behaviors necessary
* clinicians: help determine course of action; develop plan
39
MDD & sleep
* impaired sleep continuity
* increased sleep latency and wakenings
* early morning awakenings
* more common in older patients
* REM abnormalities
* negatively impacted by antidepressants
* daytime sleepiness
* fatigue anergia r/t depression
* more common in young bipolar patients
40
RLS and PLMs
restless leg syndrome and periodic limb movements
occurring more commonly and recognized/Tx'd more
trigger = inactivity during daytime
41
characteristics of motivational interviewing
* guiding, more than directing
* dancing, rather than wrestling
* listening more than talking
* collaborative conversation
* evokes from person what he/she already has
* honors autonomy
42
adolescent psychosis
* psychotic dx
* schizophrenia
* schizoaffective
* delusional dx
* positive and negative symptoms
43
trauma spectrum disorders
dissociative disorders, PTSD, etc.
some believe that all psychological disorders have root in trauma, cumulative or overt
44
physiological needs of dementia
* nutrition
* hydration
* elimination
* oxygenation
* comfort
* rest
45
common nursing diagnoses for adolescent mental health
* risk for self-directed violence (#1 priority)
* chornic or situational low self-esteem
* ineffective coping
* anxiety
* risk for other-directed violence
* readiness for enhances family processes
46
emotional dysregulation in trauma survivor
* intensity of feelings has roots in past
* feelings may seem out of sync with here/now but not with there/then
* may feel fine one minute and tsunami of negative emotions the next
* may not have awareness to differentiate feelings of today and link to past
* vulnerable to abuse
47
reflective listening
* develop skill
* key to accurate empathy
* fundamental skill of MI
* to get ahead of patient
* when she's about to shut down
* determine what individual means and reflect back in a statement
* can have multiple meanings
* choose most likely
48
legal issues in adolescent mental health
* state-based regulation on treatment consent
* in PA, teens over 14 can receive mental health services w/o parental consent
* balance child/teen's rights to privacy/confidentiality with parent's desire for info
* mandatory disclosure issues
* plan to harm self/others
* physical or sexual abuse
* when in doubt, talk to someone
49
goal to promote adolescent mental health wellness
PET
P: prevention
E: early identification
T: treatment
50
mental health as we age
* exercise
* moderate 30 min 5x/week or 50 min 3x/week
* maintains cognition
* increases serotonin and mood
* education
* helpful for mental health long term - cognitively
* keeps mind active
* social engagement
* friends and family
* spirituality
* not necessarily an organized religion
51
treatment plan for personality disorders
* guide for intervention
* promotes consistency among treatment staff
* help patients and families understand disorders that cause maladaptive social responses
52
transference
* person transferring feelings and expectations from an important object in childhood onto present day relationships
* reflects individual's early experiences, shedding light on childhood relationships with important people
* brings individual's formative dynamics to helping relationship
* understanding of transference can help the helper better understand past experiences and how they impact patient's present
* understanding can help build more compassion
53
Staging of Alzheimer's
1. no cognitive/functional delcine
2. mild forgetfulness; some work difficulties
3. mild cognitive impairment, concentration prlblems, some difficulty at work
4. late confusional stage, increased denial of problems; withdrawal
5. poor recall of recent events; help with proper clothing, bathing
6. more advanced memory problems; ADL assistance needed
7. late dementia with loss of verbal abilities
54
sleep and newborn infants
no established circadian rhythm
sleep 16-20 hrs daily
NREM and REM established at ~ 3 mo
55
RASS scale -2
light sedation: briefly awakens with eye contact to voice
56
personality disorder treatment options
* psychotherapy (primary)
* engaging patients as collaborators
* one clinician in charge of care
* psychoeducation
* family involvement
* limited use of medication
57
continuum of social responses
* adaptive
* solitude
* autonomy
* mutuality
* interdependence
* in between
* loneliness
* withdrawal
* dependence
* maladaptive
* manipulation
* impulsivity
* narcissism
58
RASS scale +3
very agitated: pulls or removes tubes/catheters; aggressive
59
maintenance
* work to prevent relapse and consolidate gains
* clinician: identify strategies to prevent relapse
60
DMDD
* b/c of bipolar overdiagnosis
* Core
* chronic, severe, persistent irritability
* up to 12 yo with persistent irritability and frequent episodes of extreme behavioral dyscontrol
* severe recurrent verbal/behavioral temper outbursts
* out of proportion to situation/provocation
* typically develop unipolar depressive disorderes or anxiety, not bipolar
61
cycle of bonding
1. need to release painful material
2. mental health professional is safe source of intimate exposure
3. attachment to helper
paradox:
* in an effort to avoid abandoment, human faults/errors are overlooked or denied: necessary for survival
* in traumatized individual, they are intolerant of human faults/errors because it signifies danger
* when they used to overlook faults of abuser
62
adolescent suicide risk assessment
* Ask Suicide-Screening Questions (ASQ)
* past few weeks, wished you were dead?
* past few weeks, felt that you/family would be better off if you were dead?
* in past week, thoughts about killing self?
* tried to kill self? how? when?
63
implications of adolescent mental health disorders
* suicide-related injury and death
* unintended sexual health outcomes
* poorer physical and mental health, work performance and financial management in adulthood
64
reasons treatment is sought for adolescent mental health
* change in school performance
* aggressive beahvior (or other conduct issues)
* physical illness
* irritability
* withdrawal
* outside referral
* suicide attempt
65
insomnia and suicide
* depressed patient with sleep problems have increased suicidal behavior
* adolescents:
* increased suicidal behavior r/t
* sleep
* nightmares
66
narcissim
* may express frustration caused by lack/loss of recognition as:
* anger
* depression
* substance abuse
* other maladaptive behaviors
* fragile self-esteem
* drive to constantly search for praise, appreciation, admiration
67
NREM
non-rapid eye movement
75-80% of total sleep time
68
testing behaviors
* may have a template of how relationships "should be" and what interactions mean
* have to 'test' helpers to confirm relationship and reshape template
* confirm what is acceptable
* if they are cared about
* how consistent helper will be
* can manifest in testing behaviors throughout course of relationship
69
summarizing in MI
* allow individual to hear self a second time
* can reflect both sides of ambivalence
* one one hand, on the other
* summary of conversation up to that point
* can transition to new topic
70
DELIRIUM PS
D: drugs (added or removed)
E: eyes and ears (vision and hearing)
L: low oxygen
I: infections
R: retention (urine, stool)
I: ictal states
U: underhydration/nutrition
M: metabolic
P: pain
S: subdural
71
CEASE SAAD
to investigate hx of present depressive illness
C: crying
E: eating
A: anxiety
S: sleep
E: energy
S: sex
A: anhedonia
A: agitation
D: depressed mood
72
medication management of delirium
* use meds when:
* behaviors associated with psychotic thinking/perceptual disturbances pose safety risk or are distressing
* delirium interferes with needed medical therapies
* behavioral interventions fail
* DO NOT use meds as:
* substitue for detection, correction, elimination of underlying causes of delirium
* Use LOW doses over shortest possible time period
73
Cluster B
* antisocial
* borderline
* histrionic
* narcissistic
erratic, dramatic, emotional - most likely to attempt suicide
74
non-bendodiazepine hypnotics
* as effective as BZD and provide normal sleep architecture
* sleep changes not significantly changed with usual hypnotic doses
* anti-convulsant and muscle relaxant effect
* nextday hangover effects are minimal
* less liable to cause tolerance, dependence, rebound insomnia
* examples
* synota, nesta, rozerone (melatonin agonist)
75
adolescent borderline personality disorder
* most prevalent personality disorder
* highest suicide rate
* absence of separation-individuation during development
* can't separate completely from primary caretaker
* common Sx
* impulsive aggression
* clinging
* depression
* detachment and withdrawal
* setting boundaries and enforcing restrictions is key
76
differentiating delirium from depression and dementia
* cognitive impairment in dementia
* gradual
* \> 1 mo
* irreversible
* most are alert and able to maintain attention in early stages
* depression may present actuely with deficits in ability to sustain attention
* depression may present similar to hypo/hyper active delirium
* important to screen for depression in adults with a mixed picture
77
medication management of dementia behavior
* OBRA regulations limits med use
* HCFA has list of meds to avoid in elderly
* go low, go low
* frequent med reduction attempts
78
interpretation based on assumption
* can create disconnect between helper and client
* important information can be missed
* behaviors can continue and cause friction in relationship as opposed to becoming understood and ultimately resolved
79
general management of delirium
* multi-component interventions
* prompt recognition/treatment of underlying cause
* maximum supportive environment
* immediate medical Tx as necessary
* discontinuation or reduced doses of deliriogenic meds
* environmental interventions i.e. delirium room
80
NANDA-I diagnoses: personality disorders
* defensive coping
* chronci low self-esteem
* risk for self-mutilation
* impaired social interaction
* risk for violence
* self or other
81
how to make therapeutic relationship work with trauma patient
* be mindful
* be trustworthy (safe space, not trust)
* be consistent
* know yourself
* take care of yourself
* understand actual motivations behind behaviors, not your assumptions
82
depressive symptoms in adults
* mood
* depressed
* anhedonic
* suicide thoughts
* somatic
* sleep
* appetite
* psychomotor
* increased pain
* cognitive
* decreased concentration
* indecisiveness
83
implementation of treatment plan for personality disorders
* come for help with depression, anxiety, alcoholism, difficulties in relationships
* personality is NOT changed
* intrusive
* help patients change maladaptive thinking and behavior that result from personality traits
* treat co-morbidities
* involve patient in own care
84
RASS scale -1
drowsy: not fully alert, but has sustained awakening to voice
85
aphasia
language disturbance
86
NEECHAM confusion scale
* 9 item interactive observational scale
* 3 subscales
* processing
* behavior
* physiological control
* requires vital signs and pulse oximetry
87
mental status examination
* appearance and self-care
* psychomotor behvaior
* variant presentations of mood and affect
* withdrawal
* weariness
* comorbid anxiety
* thought content
* somatic preoccupations
* pain
* complaints r/t cognitive functioning
* psychosis
* suicide and death ideation
88
principles of milieu treatment
* establish control without option to escape involvement
* provide experienced, consistent staff
* implement clear structure with fiar, firm, consistently enforced rules
* provide support while patient learns to experience painful feelings, try out new behavioral responses
89
types of reflective statements
repeating
rephrasing
90
reinterpretation
thought: i cannot go to sleep no matter what i do
## Footnote
*one has not often lost control over daytime & nighttime routines, which in turn can greatly impact ability to go to sleep*
91
therapeutic relationship in trauma
* warmth and empathy crucial in helping relationship
* betrayal and rejection fears can disrupt the relationship
* understand:
* motivations behind behaviors of traumatized individual
* communications in relationship (transference)
* helpers own feelings and reactions (countertransference)
92
REM
rapid eye movement
20-25% sleep time
93
benzodiazepines and sleep
* induce GABA (inhibitory response) in brain
* CNS depression
* not for long term
* tolerance, dependence
* physical and physiological withdrawal syndrome
* examples
* valium, ativan, xanax, lorazepam
94
hypnopompic
hallucinations at beginning of sleep cycle
not psychotic illness
95
milieu therapy in personality disorders
* treated in community not inpatient because it is difficult and takes a long time to change maladaptive social responses
* can gain insight into behvaior
* focused on realistic expectations, decision-making, social behaiors in "here and now"
* sometimes hospitalized for self-destructive person with borderline
* antisocial person may require structured hospital environment with related limit setting to expect mature, responsible behavior
* not to control, but to work together towards change
* can make experience productive or counterproductive depending on how it is implemented
96
autism
* 1 in 68 or 14 in 1000
* 3-4X more in boys than girls
* impairment of communication, social sills, overregulated or repetitive behaviors
* assess for depression, anxiety
97
LE(A)RNS
* activity
* vigorous activity before 6pm (5 hrs before bedtime)
* bedroom for sleep and sex only
* computers/tvs OUT of bedroom
* no work in bed
* avoid cognitive activation near bedtime
* "worry time" scheduled during day
98
adolescent depression
* most common
* 14% major depressive episode before age 15
* distinct symptoms from adults
* children
* irritable mood, limited weight gain, withdrawal
* adolescents
* physical complaints, poor school performance, boredom/lethargy, risk-taking
* review medical hx and consider co-occurring dx
99
delirium superimposed on dementia
* collateral source report who also doesn't have dementia
* acute onset
* attention/disorganized thinking
* sleep-wake cycle disturbance
* change in level of consciousness
100
Stuart stress adaptation model
101
countertransference
* feelings that come up within helper in response to individual
* feelings that belong to you
* be aware of yourself, reactions, history
* can be used to understand how individiaul's effects on others where insight is lacking
* can help identify individual's feelings
* projection identification
102
RASS scale -5
unarousable: no response to voice or physical stimulation
103
responsibility lies with helper
* person receiving services ahs no code to uphold nor standard of behavior to violate
* responsibility lies in hands of helper
* role of helper carries inherent power
* role of client leaves person vulnerable
104
projection
putting issue on someone else - making it their fault
places responsibility for behavior outside of oneself
105
bright side of traumatic symptomology
* fear of abandonment = loyalty
* unstable relationshps = love of friendship
* unstable self-image = knowing yourself fully
* impulsivity = spontaneity
* suicidal behaviors = love of life
* self-mutilating behaviors = will to live/creativity
* intense feelings = emptahy/versatility
* chronic feelings of emptiness = love of activity
* intense anger = fiery spirit
* dissociation = capacity for protection and self preservation/love of memories
* paranoid ideation = trust/acceptance
106
stages of change
* precontemplation
* contemplation
* preparation
* action
* maintenance
* termination
* relapse
107
adolescent anxiety
* fear of separation
* highest during times of transition
* persistent anxiety disorders predict adult panic dx
* types
* panic
* phobias
* OCD
* PTSD
* generalized anxiety
108
impulsivity
* impulsive aggression is a hallmark of borderline personality disorder
* pivotal in
* self mutilation
* unstable relationships
* violence
* completed suicides
* can be frustrating
* behavior is defense against fear of loneliness, not consciously planned
* inability to plan, learn from experience
* poor judgment, unreliability
109
rephrasing
stay close to what client said, but substitute words or slightly rephrase
110
Confusion Assessment Method
Feature 1: acute onset of mental status change OR fluctuating course
AND
Feature 2: inattention
AND EITHER
Feature 3: disorganized thinking
OR
Feature 4: altered level of consciousness
111
FDA approved TX for bipolar
* acute
* lithium - hard with frail older adults b/c of narrow therapeutic range
* valproic acid (divalproex sodium)
* antipsychotics (olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone)
* mania and depressive episodes - quetiapine only
* maintenance
* lithium
* olanzapine
* lamotrigine
112
common infections that cause delirium
* UTI
* pneumonia
* skin cellulitis
* c. diff
* CNS infection
113
repeating
repeat portion of what client has said. may consit of one or two words
114
UTS and responding to pain
* not effectice at managing behavior of others
* respond to emotional pain with desperate behaviors seeking immediate relief
* do not use reason, respond to emotions through reflex
115
emotional regulation is psychosocial
* self regulation - being able to sit with painful feelings and self sooth - is learned
* begins in earliest relationships when feeling states are acknowledged and efforts to manage them come from caregiver
* responsibility for self-management increases as skills increase
* lack of skills contributes to emotional dysregulation
116
family involvement in personality disorders
* intimate relationships always affected - involve significant others in plan of care
* especially for manipulative patients who shit attention away from selves by creating conflict between family and staff
117
manipulation in personality disorders
* behavior in which people treat others as objects, form relationships, centered around control issues
* unaware of lack of relatedness, assumes interpersonal relationships are formed to take advantage of others
* little motivation to change becuase behavior has rewards
* cannot imagine intimate, sharing relationship
* believes in always maintaining control to avoid being controlled
* rational, premeditated way
* patience in carrying out plan
* acts from reason not reflex
* typical of borderline and antisocial
118
OARS
O: open-ended questions
A: affirm - accentuate positives, seek and acknowledge person's strengths and efforts - leads to change and builds relationship
R: reflective listening
S: summarize
119
personality disorders development through life cycle
* shaped by biology, social learning
* seed of personality = temperament
* hereditary, biological dispositions evidence from birth
* establishing strong affective bonds
* crucial to developing mature personality
120
resilience
* ability to withstand stress
* protective factors
* sense of autonomy
* adaptive distancing (family & past)
* understanding emotions of self & others
* responsive protective, stable, affectionate caregiving
* parenting that fosters competence
* positive self-esteem
* making friends and getting along with peers
121
SCN
* suprachiasmatic nucleus - regulates circadian rhythms in all organs
* receives input from retina nerve cells that act as brightness detectors
* detectors reset clock genes in SCN on daily basis
* SCN transmits messages to rest of brain (hypothalamus) and body to promote synchrony with external day-night cycle
* SCN also controls melatonin secretion
122
spirit of motivational interviewing
* underlying set of mind and heart within which MI is practiced
* includes partnership, acceptance, compassion, and evocation
* paradigm of strength that needs to be evoked rather than installing something new the client doesn't have
* not viewing them from a deficit perspective
123
dialetical behavior therapy
* form of CBT that is an effectice treatment for borderline personality
* uses behavior and cognitive techniques:
* psychological education
* problem solving
* training in social skills
* exercises in monitoring moods
* modeling by therapist
* homework assignments
* meditation
* reduces rates of suicide attempts, hospitalization for suicidal ideation, overall medical risk
124
sedatives
drug that reduces excitement, calms patient and is commonly used as anxiolytic in therapeutic doses
in larger doses: hypnosis (subject becomes passive and highly suggestible)
depresses CNS
125
LEA(R)NS
* routine
* regularize bedtime and wake time
* keep similar sleep-wake schedule through weekends
* develop beditime ritual and hour prior to bedtime
* relaxation techniques
126
personality definition
set of deeply ingrained, enduring patterns of thinking, feeling, behaving
127
primary progressive aphasia
* rare, ages 40-65
* decline in 1+ language: speaking/understanding, naming, reading, writing
* early: memory, reasoning, visual perception not affected
* funciton for routine activities intact
* increasing difficulty thinking of words
* substitue wrong word
* pronunciation mistakes
* talk around word
* problems reading and writing
* checks, directions
* difficulty understanding speech
* following conversations despite normal hearing
128
relaxation therapy
* reduce physiologic and cognitive arousal at bedtime
* techniques
* progressive muscle relaxation
* biofeedback
* breathing exercises
* yoga
* meditation
129
risks to helping relationship
* feelings that arise in helping relationship can be similar to those experienced early in life toward significant others
* transference
* what person experienced in past is expected in present, impacting current relationships
* shadows of individual's previous relationships can come alive in current ones
130
splitting
ex: i like this nurse, but not that one
manipulating to get what they want
borderlie or narcisstic - views people/objects as all good/bad
131
agnosia
failure to recognize or identify objects despite intact sensory function
132
personality disorders definition
set of patterns or traits that hidner a person's ability to maintain meaningful relationships, feel fulfilled, and enjoy life
usually begins in adolescence or early adulthood
133
personality disorder coping _resources_
* encouragement to seek help even with broad social network
* creative ways to express feelings
134
effects of delirium anticholinergics
See - blurred vision
Pee - urinary retention
Shit - constipation
Spit - dry mouth
Willy-nilly - confusion
Up-down - fall
135
behavioral assessment: reframing
essential for designing appropriate interventions
* suspend judgment
* avoid labeling
* collect cues
* behavioral assessment
136
biopsychosocial assessment of adolescent mental health
* developmental hx
* family hx
* stress and trauma hx
* strengths of child
* mental status exam
* general description
* emotional state
* experiences
* thinking
* sensorium and cognition
* relevant labs
137
reenacting the unresolved trauma
* when felings of abuse are triggered in current relationships, present situation can be perceived/responded to in same way as old trauma
* templates formed of early interactions used to understand current ones
* apparently safe/normal interactions may be perceived as potential danger
* thought that what is not remembered is reenacted until worked through
138
L(E)ARNS
* environment
* dark: no environmental light during sleep
* cool: too hot or too cold produces disruption
* increase body temp during day
* quiet: irregular sounds disrupt sleep
* regular sounds can be habituated to
139
hypnagogic
hallucination at end of sleep cycle
not psychotic illness
140
melatonin
hormone produced by pineal gland that is mainly secreted at night to consolidate circadian rhythms
only has limited direct effects on sleep
141
re-attribution
thought: every problem is r/t sleep
## Footnote
*sleep is not the cause of all of one's problems*
142
hypnotic
drug which produces sleep resembling natural sleep
in higher doses = general anesthesia
depresses CNS
143
DSM 5 Sleep disorders
* insomnia
* hypersomnolence
* narcolepsy
* breathing related sleep dx
* obstructive sleep apnea
* central sleep apnea
* sleep related hypoventilation
144
morbidity of insomnia
* increased risk for psychiatric dx
* decreased quality of life
* increased utilization of health care, increased cost
* absentesim, poor occupational performance
* cognitive decline
* motor vehicle accdients, occupational injuries
145
patients with unresolved traumatic symptomology (UTS)
* may respond to words/actions of helper as potential re-eneactment or re-experincing of trauma
* behaviors and expectations of others are dissected at unconscious level, constantly scanning for danger
* expectations may be high as they search for safety and proof of being cared for
* over and over again
* self protection and pain management = priority
* when perceiving danger, defensive behaviors employed
* understand what motivates individual's behavior and how they respond to environment can move client/helper relationship into positive direction
146
adolescents and prescription medications
* not children or adults
* SSRIs preferred over TCAs
* limit benzodiazepine due to drug use and effects on larning and memory
* lithium, abilify, seroquel for mania, aggression, conduct dx
* low dose antispychotics are effective
* watch for increased extrapryamidal side effects
* psychostimulants for ADHD
147
sleep efficiency
time in bed attempting to sleep (over) time in bed sleeping
stabilizes at 5 yo - why toddlers need naps
148
sleep & psychiatric disorders
* psych dx common in patients with sleep/wake Sx
* psych Sx common in patients with sleep dx
* sleep/wake problems risk factor for psych dx
* sleep disturbed in many psych dx
* sleep/wake disturbances provoke worst outcomes in patients with psych dx
149
ECT for bipolar
* for mania and depression
* for pharmacologically refractory or intolerant patients
* severe cases
* catatonia, mlancholia, psychosis
* bilateral electrode placement in manic, mixed
* unilateral in depression
150
adolescent bipolar dx
* high suicidality, psychosis, functional impairment
* diagnosis by history of \>1 mania episode
* hallmark signs
* sustained impulse control or conduct problems
* rapid cycle, mixed mania - decreased need for sleep
* 1/3 of 6-12 yo depressed children will develop bipolar
* chronic irritability may be first Sx in children
* differentiate from ADHD
* monitor suicide risk due to impulsivity and self-injurious behaviors
151
olanzapine and personality disorders
atypical antipsychotic
can reduce:
* anger
* impulsive aggression
* depression
* interpersonal sensitivity
152
RASS
Richmond Agitation and Sedation Scale
153
symptoms vs disorders
* symptoms - individual problem/manifestation
* sadness, anger, impulsivity, fear
* disorder
* group of symptoms that happen together
* classified via DSM
* treat symptoms not dx
154
motivational interviewing: clinical definition
a person-centered counseling style for addressing common problem of ambivalence about change
cognitive dissonace between:
* where one is
* where one wants to be
155
hypoactive delirium
* lethargy
* slowed speech
* decreased alertness
* apathy
156
dementia care planning
* advanced directives
* Alzheimer's association
* safe return or medic alert bracelet
* discuss delirium and depression
* discuss social engagement with caregiver
* encourage caregiver to ask for help
* discuss possibility of physical/verbal aggression as disease progresses
157
behavior management: mental health and aging
need driven behaviors - communicate an unmet need
* wandering
* repetitive questioning
* agitation
* restlessness
* combativeness
* sexually ianppropriate behavior
* incontinence
158
perceived meaning of progress in trauma victim
* progress = abandonment
* if i am perceived as being better, the important people helping me may leave me
* noting progress is important, but presentation is crucial
* regressions do not mean treatment failure
159
motivation and the change process
* patients not unmotivated
* enaging in behaviors that **others** think harmful OR not ready to engage in behaviors **others** think helpful
* belongs to individuals and process of change
* motivation can be enhanced or hindered by interactions with others
160
professionals using MI
* aim to help people explore and resolve their ambivalence about behavior change
* elicit from the person their own motivations for change
* assess readiness for change
161
adolescent conduct dx
* types of behaviors
* oppositional
* aggressive
* defiant
* largest group of psych dx
* more in boys
* family, biological, psychosocial factors
* limited guilt/remorse, delinquency
* 40% may develop antisocial personality dx
162
medications in personality disorders
* primarily for anxiety, mood swings, impulsive aggression
* Cluster A may need antipsychotics for subtle symptoms
* Cluster B may need mood-stabilizers or atypical antipsychotics for subtle biopolar
* Cluster C may benefit from serotonergic antidepressents for anxiety-related disorders
163
depressive symptoms in geriatrics
* mood
* weary, hopeless, angry
* anxious
* death ideation
* somatic
* increased pain
* Sx overlap with effects of medications and comorbidities
* cognitive: decreased...
* selective attention
* working memory/retrieval
* new learning
* processing speed
* executive function
164
adolescent suicide risk factors
* hx of previous attempts
* family hx of suicide
* hx of depression, mental illness
* somatic complaints
* alcohol/drug use
* stressful life event/loss
* easy access to lethal methods
* exposure to suicidal behavior of others
* incarceration
* sexual identity issues
165
(L)EARNS
* light
* use light to stabilize/shift sleep wake behaviors
* examples
* keep light on during day, don't lower lights until later evening hours
* decrease electronic light
* feed into SCN to provoke wakefulness
* increases adenosine which is opposite of melatonin (wake neurochemical)
166
cysto-cerebral connection
delirium caused by urinary retention
167
compared to hospitalized patients with no delirium, delirious patients have:
* higher mortality rates
* longer hospital stays
* higher propability of receiving long-term care after discharge
* higher probability of developing dementia at 48 mo
168
antisocial personality disorder
* 3% men, 1% women
* difficult to diagnose/treat
* diagnosis applied when
* consistently ignores social rules (after age 15)
* manipulative, exploitative, dishonest
* no sense of trust
* lacks remorse
* involved in criminal activity
* responsible for large portion of crime, violence, social distress
* childhood histories of abuse, neglect, absence of early emotional attachment
169
pharmacological treatment of adolescent mental health
* approved uses
* medication is FDA approved for use in tx of a specific disorder
* off label
* not approved for children/adolescents
* use best judgment
170
cumulative trauma
* unable to point to specific event
* no obvious fight/flight/freeze response
* repeated empathic parent/child fractures
* abuse disguised as joke
* name calling
* criticizing and judgment
* undermining
* occasional empathic fractures, resolved through positive communication, builds bonds
* invalidating environment
171
termination
problem ceases to be a problem
172
RASS scale +1
restless: anxious but movements not aggressive; vigorous
173
nursing assessment: medicines that suppress CNS
* also depress RR
* monitor if they are taking alcohol or other substances
* can die in their sleep
* very dangerous
* ex: Michael Jackson
174
hyperactive delirium
* increased psychomotor activity:
* rapid speech
* irritability
* restlessness
175
action
* modify behavior, experiences, environment to overcome problems
* clinician: help implement plan
176
elements of therapeutic alliance
* agreement on goals of treatment
* agreement on tasks
* development of a personal bond made up of reciprocal positive feelings
177
reasons for precontemplation stage
* reluctance: lack of knowledge or inertia. impact of problem not fully conscious
* resignation: lack of energy/investment. given up on possiblity of change. overhwelmed by problem.
* instill hope and explore barriers
* rationalization: why problem is not a problem - or only a problem for others. session feels like a debate.
* empathy and reflective listening
178
delirium defined
abrupt onset of a cluster of global, transient changes constituting disturbances in attention, cognition, psychomotor activity, level of consciousness, and/or sleep-wake cycle
179
depression DSM V
* MDD represents classic condition
* discrete episodes of \>2 wks duration involving clear-cut changes in affect, cognition, and neurovegetative functions and inter-episode remissions
180
key features of personality disorders
* inflexibile and maladaptive approach to relationships and environment
* individual's needs, perceptions, behavior foster cycles that promote unhelpful patterns and negative reactions from others
* coping skills are unstable and fragile
* lack of resilience when faced with stress
181
communicating with children
* therapeutic alliance with children and guardians
* communication by disorder type
* internalizing: child
* externalizing: parents
* stay away from problem-centered communication
* age-related norms/development
* familiar vocabulary
* needs in relation to immediate situation
* coping capacity
* nonverbal communication
* develop trust through honesty and consistency
182
nature vs nurture
* not either/or, both/and
* genetic predisposition to symptoms
* environmental triggers
* trauma
* led ingestion
* SES
183
adolescent ADHD
* 5-10%
* symptoms begin in infancy
* 50% undiagnosed
* more in boys than girls
* hallmarks
* attention deficits
* hyperactivity and impulsivity
184
borderline personality disorder
* 1-6% of general population
* most prevalent prsonality disorder (15-25%) in mental health settings
* women \> men
* characterized by polarized thinking...all or none, good or bad
185
insomnia definition
one or more required:
* difficulty initiating sleep
* difficulty maintaining sleep
* waking up too early
* sleep that is chronicaly non-restorative, or poor in quality
sleep difficulty despite adequate opportunity and circumstances for sleep
186
nursing functions in milieu therapy
* provide structured enviornment
* serve as emotional sounding board
* diagnose conflicts, consequences of actions
* facilitate adaptive change in behavior
* hold patients responsible for behavior
* communicate with staff for consistent messages
* encourage individuals to identify strengths and mobilize strengths for self-esteem via adpative defenses and positive coping skills
187
4 principles of MI
1. resist "righting reflex"
2. understand motivations of client
3. listen with empathy
4. empower the person
188
daytime impairments of insomnia
at least one reported:
* fatigue/malaise, attention, concentration, memory, social dysfxn, school performance problem, mood disturbance/irritability, daytime sleepiness, motivation/energy reduction
* 3x/week
* for at least 1 mo
189
similarities of dementia types
* usually older adults
* prior yo 65 = early onset
* usually genetic risk factor or TBI
* slow
* insidious
* irreversible
* progressive
190
trauma and manipulation
exerting shrewd or devious influence especially for one's own advantage
* shrewd = having or showing sharp powers of judgment, astute
* devious = showing skillful use of underhanded tactics to achieve goals
three conditions must be met:
* guiding the behaviour of someone
* in the direction one wants
* without the subject realizing it
191
decatastrophizing
thoughts: i will never be able to go to sleep, i haven't slept at all in a week
192
LEARN(S)
* substances
* no caffeine after 4 (noon preferrable)
* high variability in metabolism and response
* educate on types, amounts
* do not use ETOH for sleep
* preferred \> 5 hrs prior
* advances sleep latency and REM
* increase risk for early awakenings middle of night
* no smoking within hr before bed
* substances/medications - adjust times if needed
193
bullying
* negative effects can extend into adulthood
* direct vs indirect
* bullies usually mimic behavior seen at home
* teen victims suffer from depression, suicidal ideation, decreasing functioning
* perpetrators tend ot have adult delinquency
* cyber-bullying
194
RASS scale +4
combative: overly combative, immediate danger to staff
195
delirium background
* diagnosis is highly c linical and depends on clinician expertise, systematic screening, careful observation
* cardinal sign of geropsychiatric emergency
* promptly identified and addressed w/ biopsychosocial and environmental interventions
* progression to stupor and/or coma, seizures, death is possible
* early recognition + rapid management of underlying factors decreases severity and leads to improved outcomes
196
adolescent weight and body image problems
* anorexia, bulimia, obesity
* body dysmorphic dx
* special issues for children
* oral behaviors - nail biting, thumb sucking
* special issues for adolescents
* motivation: without, Tx is difficult
* cognitive skills: abstract and long-term thinking less developed
* interpersonal skills: communication difficulties
197
adolescent mental health background
* 1/2 lifetime mental illnesses begin by age 14
* 20% of youth affected by mental disorder at some point in lifetime
* in 2014, 2.8 mil youth (11.4%) had at least one major depressive episode in previous year
198
cognitive therapy of insomnia
* identify dysfunctional beliefs and attidues about sleep
* write down thoughts before sleep, use standardized scales
* explore validity of statements about sleep
* may be catastrophizing or have too high expectations
* approach beliefs, statements as hypothesis not absolute
* replace dysfunctional attitudes and beliefs about sleep with appropriate realistic goals
199
relationship dyad
* rescuer - victim
* victim - perpetrator
* perpetrator - rescuer
caused by a failed protector - victims angrier with failed protector than with abuser. can look different when failed protector was also abused
200
precontemplation
* no intention to change behavior in foreseeable future
* unaware or under-aware of behavior problem
* clinician: increase client's perception of risks w/ current behavior
201
what is trauma
any event in which individual experienced, witness, confronted with actual or threatened death/serious injury or a theat to physical integrity of self or others
* elicits strong emotional reactions
* experience overwhelems individual's capacity to cope with event
* signal fight, flight, freeze response
when traumatic event NOT processed:
* individual may remain aroused as thought fight, flight, freeze response is close to activation
202
sleep hygiene assessment
also: sleep hygiene promotion and sleep disorder Tx
L: light
E: environment
A: activity
R: routine
N: napping
S: substances
203
RASS scale 0
alert and calm
204
senile dementia - Alzehimer's type (SDAT)
* usually after age 65
* starts in medial temporal area - hippocampus and spreads
* loss of nerve cells, amyloid plaques, tau tangles
* begins with memory loss
* can't learn new info
* can't orient self
* later personality and behavior changes
* possible hallucinations and delusions later in stages
205
readiness ruler
* willing: the importance of change
* able: confidence for change
* ready: a matter of priorities
206
sleep disorders can cause psychiatric symptoms
* obstructive sleep apnea
* depression, anergia, fatigue, cognitive changes
* narcolepsy
* hallucinations, depression
* RLS
* paresthesias
* circadian rhythm dx
* social avoidance
15-30% w/ MDD have obstructive sleep apnea: severities correlate
207
Cluster C
* avoidant
* dependent
* obsessive-compulsive
anxious, fearful in nature
208
RASS scale -3
moderate sedation: movement or eye opening to voice (no eye contact)
209
depression overview
* depression and anxiety common response to loss and other stressors
* not inevitable with aging
* predisposing factors
* medical illness
* disability
210
triggers for abandonment
**Their Trigger vs Your Response**
* separation (object constancy) vs validation (transitional object)
* severe emotional distress vs your presence
* inconsistency vs stick to it
* progress vs note with caution
211
behavior management in children
* respond warmly to positive behaviors
* communicate approval
* ignore negative behavior when appropriate
* respond calmly/effectively when needed
* time outs when necessary
* 30-60 seconds per year of age
* nonpunitive - to help child regain control
* avoid negative remarks about child
212
relapse
clinician: help client recyle through stages of contemplation, preparation, and action again
213
DSM V of Alzheimer's
* development of multiple cognitive deficits manifested by impaired memory (long or short), can't learn new info, can't recall information previously learned, and distinguished by 1+ of the following:
* aphasia
* apraxia
* agnosia
* disturbance in executive functioning
214
adolescent suicide
* 2nd leading cause of death in males 10-24; 3rd in females 10-14 and 2nd in females 15-25
* suffocation and firearms most common
* visited HCP 3 months to 1 yr before death
* girls more likely to have ideation and attempt, boys more likely to die
* native american/alaskan native and hispanic youth have higher suicide-related fatalities and attempts
215
therapeutic relationships in personality disorders
* nurse must be accessible no matter what maladaptive social response patient is experiencing
* physically present with patient for interaction opportunities
* show genuine interst in patient, try to understand by clarifying meanings, validating perceptions
* support behavior change
* be empathic with focus on appropriate boundaries of relationship
* maintain patient safety
* facilitate patient participation in care
* select least restrictive intervention
* help patient assume responsibility for own actions
216
sleep and the value of exercise
* physically fit people adapt better to changes in work, sleep, life schedule
* exercise promotes sleep quality and duration
* combined with bright light, elevates mood and alleviates depresseive S/Sx
* daily exercise promotes transition from day work to evening and night work by promoting phase delays in circadian rhythm
217
mindfulness overview
temporarys tate of non-judgmental, non-reactive, present-centered attention and awareness that is cultivated during awareness and attention practice
enduring traits that can be described as dispositional pattern of cognition, emotion, behavioral tendency
* meditation
* intervention in therapy
* antidote to mind wandering and time travel
218
mindfulness traits
* act with awareness
* less reactive
* nonjugdmental
* development of ability to label and escribe with words the internal world
* self-observation
219
mindful moments
* nonconceptual
* nonverbal
* present-centered
* nonjudgmental
* participatory
* liberating
220
core of mindfulness
* awareness of awarness
* paying attention to intention
* awakened presence
* equanimity
* curiosity
221
the pause
* temporal pause from habitual automatic thoughts and responses
* redirects attitude of awareness of present experience with acceptance and compassion
* allows for awarness of changing vibrations of self and other
* enhances depth of attention, concentration, spaciousness in relationship
222
ways to be present
* physical - "being there": acts of care, tasks, technical interventions
* psychological - "being with": communication, listening, empathy
* therapeutic - mindful attentiveness, attunement, resonance
* awakened presence - embodied understanding of and interaction with things that are in the world
223
the breath
* object of awareness for mindfulness practices
* boundary between involuntary and voluntary, automatic and effortful
* interface between internal and external
* rhythm is repeated pattern where in-breath is followed by out-breath
* rhythm r/t to nervous sytem fxns and integration
224
forms of the mind
* spacious awarness
* concentrated awarness
* both forms are characteristics of conditioned phenomenon of consciousness
* pure awareness is an experience
225
spacious awarness
diffuse attention in present moment
expanisve with infinite space
226
concentrated awareness
focus of attention on object without distraction of other stimuli
227
mindfulness meditation
3 types:
* focused attention (FA): concentrative practice
* insight/open monitoring (OM): receptive practice
* loving, kindness, compassion: quality of attidue/emotion of tenderness, soothing, comfort, ease, care, connection
228
objects of awareness
* sensations, thoughts, feelings in "me"
* words, body, language, mood of the "other"
* flow of relationship, felt sense of connection or distance
229
mentalizing
constructing biographical and autobiographical narrative
making inferences about mental states
reflecting on meaning of mental states
230
overlap
* decentering
* awareness of mental states as representational
* nonjugmental
* acceptance
* compassion
* curiosity
231
mindfulness definition
attentiveness to mental states in self and others
bare attention
present-centered
232
components of compassion
* distress-sensitive
* sympathy
* distress-tolerance
* empathy
* non-judgment
* care for well-being of others
* create opportunities for growth and change with warmth
233
mindfulness in practice
* presence with awareness is critical in listening empathically and responding appropriately to others
* establishes rapport - worless experience of mindful attentiveness
* if one person is mindful, regulatory capacity of state is present for interpersonal system
* promotes well-being in body, mind, relationships
* therapeutic experiences that move an individual toward well-being promote integration
234
mindfulness experience
* reduces biases through specific forms of mental training that develop self-awareness
* increases ability to effectively manage or aler one's responses and impulses
* enhances development of positive relationship between self and other that transcends self-focused needs
* increases prosocial characteristics
235
clinical applications of mindfulness
* mindfulness-based stress reduction
* dialectical behavior therapy
* midnfulness-based cognitive therapy for depression
* acceptance and commitment therapy
* third-wave cognitive-behavioral therapies
* change r/t thought, feelings, impulses
* terminology overlapping mentalizing
* defusion, decentering, nonidentification
* stress reduction, anxiety, depression, BPD, substance abuse, eating disorders, psychosis
236
mindfulness conceptual overlaps
237
how mindfulness works
* attention regulation
* body awareness
* emotional regulation
* reappraisal
* exposure
* flexible sense of self
238
neurocognitive mechanisms of mindfulness
* intention and motivation
* attention and emotion regulation
* extinctio and reconsolidation
* prosociality
* nonattchment
* decentering
239
(mindless) vs mindful practice
* experiential avoidance
* cognitive fusion and projection into self conceptualization
* repertoire narrowing from personal narratives, old scripts, roles
* too much talk, not enough of action
* reinforcing avoidance
* insensitivty
* failure to link acceptance with values
240
mindless vs (mindful) practice
* fully present
* open to emotional content
* defused from judgment
* in touch with core values
* faciliate relationships qualities of warmth, resonance, openness, authenticity
* allows focus of mind and attention on internal world of another
* sparking sense of being "felt"
241
MAP
mindfulness awarness practice
* breath meditaiton
* mediation
* body/mind work
* intention with everyday activities
* loving kindness meditation
* insight dialogue
* concentration
* open monitoring
* equanimity
* presence
* loving kindness/compasion
242
mindfulness clinical training
* paying attention
* affect tolerance, emotional regulation, fearlessness
* practicing acceptance
* empathy and compassion
* equanimity and humility
* learning to see
* letting go and starting again
* epxosing narcissistic needs
* overcoming infatuation with theory/techniques
243
mindfulness training practices
* what brings you away
* being with discomfort
* breathing together
* embracing emotions that arise in therapy
* not worrying about me
* finding our profesional shadow
* beginner's mind
* three objects of awareness
244
G.R.A.C.E.
* Gathering your attention
* Recall your intention
* Attune to yourself, body, heart, mind
* Consider what will serve patient/colleague
* Enacting and ending
Psychiatric Nursing
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