Exam 3 Review Pointers

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This is what we got from Nelson ….. do you have more? more?   12 questions –  questions –  clinical  clinical picture for borderline and antisocial, know how they do splitting, manipulate, how do you communicate & manage their behavior

Borderline Personality Disorder These people are between neurosis (highly anxious) and psychosis (loss of reality) 

Clinical Picture: Always in crisis Affect –  Affect  –  extremely  extremely intense Liable behavior (can change in days, hours or minutes)

Stuck in “rapprochement phase” where child is learning independence but still desires maternal symbiosis 

Periodic anxious agitation or inappropriate outburst Chronic depression (rage turned inward) Inability to be alone

Was probably abandoned or neglected as a child 

How do we communicate and manage:

They interact with others by:


Clinging or distancing Clinging –  Clinging  –  dependant,  dependant, helpless, childlike o  with “good” people NOTE if they they can‟t be with theses people, this is when they cut themselves (self-mutulation)  Distancing –  Distancing  –  hostile,  hostile, angry, and devaluing o  of the “bad” people  people    seeing people as all good (if one is Splitting –  seeing fulfilling pt‟s needs) or all bad (if one is not

  o  o  o  o  o  o  o 

fulfilling pt‟s needs).  needs).  Will be loving and your best friend one o  shift and curse you the next –  next  –  tell  tell them “I‟m the same person I was yesterday.”  yesterday.”   playing one individual against Manipulating –  playing another to gain favor or avoid abandonment. They know how to act the way you want o  them to act to get their way o  Will steal your money, clothes Will curse you out and threaten your job o  Will use projection –  projection –  my  my doctor put me on o  the wrong medicine Will belittle you, lie, spit, threaten, refuse, o  selectively mute, cry, smile ingraciatingly,

   o  o  o 

give gifts Self-Destructive Behavior  –  –  cutting,  cutting, scratching or burning oneself, may also include suicide attempts (but usually with a safety net), to elicit a rescue response from the “good”  person who may not be giving giving their full attention –  poor  poor impulse control that Impulsivity  –  includes drug abuse, gambling, promiscuity, reckless driving, binging and purging Other Nursing Diagnosis: Risk for self-mutilation r/t parental emotional deprivation Dysfunctional grieving r/t maternal deprivation during rapprochement phase of development internalized as a loss, with fixation in anger stage of grieving process Impaired social interaction r/t extreme fears of abandonment and engulfment Disturbed personal identity r/t underdeveloped ego Anxiety r/t unconscious conflicts based on fear of abandonment Chronic low self-esteem disturbance r/t lack of positive feedback


Observe frequently w/o being obvious Get safety contract –  contract –  pt  pt will seek staff if desire to muti. is felt Matter-of-fact demeanor and care if self-mutilation self-mutilation occurs Encourage discussing what were feelings prior to self-mutil. Be a role model Give positive reinforcement for good behavior Remove all dangerous objects Put on one-to-one assignment if needed

Nurs Diag: DYSFUNCTIONAL GRIEVING   Show accepting attitude


Always be honest Help identify root of anger, anxiety & have them talk about it Release pent up emotions with large muscle exercise Explain normal grieving process & help pt recog. where he is Set limits on acting out behaviors, making clear what the consequences are o  Make sure all staff knows care plan and is consistent




Encourage pt to examine behaviors Show your available but don‟t allow allo w dependent behavior Positive reinforcement for independent behavior Rotate staff –  staff –  no  no dependence, more different person interaction o  Explore how fear of abandonment by clinging interferes w/satisfactory relationships

o o

Ms. Nelson says most important interventions: Get behavior contract All staff must know about contract & be consistent When pt gets anxious, get them by themselves and help them put a name to their feelings Help them identify what it is that makes them anxious and break the pattern Do not circum to splitting “I‟m the same person I wass yesterday.”  wa yesterday.”  Safety issues Set limits, set goals and follow across board

If cutapply themselves, beand verysay noncha nonchalant lant about it: getthey a 4x4, p ressure pressure “well, I guess we‟ll have to get some stitches on this” –  if  if you  panic or feed into it, this response makes them do it again.



Antisocial Personality Disorder These pt had absence of parenting discipline 

Clinical Picture:

Always rescued, never suffered consequences of their actions 

You will not often see this pt in a clinical setting unless under court order for clinical psychological evaluation Will find commonly in prisons, jails and rehabilitation services

They interact with others by: Socially irresponsible   No regard for the law o No o Does not conform to social norms Exploitative –  Exploitative  –   o  Will not work because they find ways to manipulate people for money instead of actually working o  Will scam people out of money Guiltless, no shame in unacceptable treatment of others o Will be polygamist Total disregard for rights of others Cold, calculating, intimidating with  brusqueness and belligerence Can appear cheerful, charming and gracious when things are going their way st Easily provoked to attack and their 1   response is to demean and dominate Have contempt for weak and underprivileged Primary defense mechanism is  projection because they justify their own action as „had to do it‟ to avoid unjust  persecution Unable to delay self gratification Thrill seekers, immune to danger  No warmth, compassion, or empathy and find these traits in other suspicious Other Nursing Diagnosis: Risk for other-directed violence r/t rage reactions, negative role-modeling, inability to tolerate frustration Defensive coping r/t dysfunctional family system Chronic low self-esteem r/t repeated negative feedback resulting in diminished self-worth Impaired social interaction r/t negative role modeling and low self-esteem Deficient knowledge (self-care activities to achieve and maintain optimal wellness) r/t lack of interest in learning and denial of need for information

They usually have history of ADHD or conduct disorder during childhood 

How do we communicate and manage:  Nurs Diag: RISK FOR OTHER-DIRECTED VIOLENCE

  Convey accepting attitude –  attitude –  it not the pt you don‟t like, it‟s



o o

the behavior Develop trust, be honest, keep all promises Maintain low level of stimuli   low lighting, few people, simple décor, low noise level   staff maintains calm attitude Observe frequently w/o being obvious Remove dangerous objects Help client identify root of anger Encourage verbalization of hostile feelings Explore alternation ways to handle frustration   Channel into lrg motor skill exercise Have sufficient staff for show of strength

    o  o  o  o


  o  o

If  pt Talk get out of hand down down –   –  one  onedotothe onesteps 


 

Tranquilize Restraints –  ck Restraints –   ck q 15 min


  Make pt aware of unacceptable behavior by confronting o  Do not coax, rather set norms   DO NOT “You should do…”  do…”    DO “You will be expected to…”  to…”  o  Set up reward system –  system –  giving  giving rewards for positive behavior o

and withholding reward for bad behavior –  behavior –  with  with increasing time frame ie. at first 2 hrs of good behavior gets a reward, then 4 hrs gets reward, etc…  etc…  o  Provide milieu environment so pt will get feedback from  peers on behavior also





When behavior occurs, help client obtain insight as to why it bad is bad Convey, it‟s not you that is unacceptable, it‟s the behavior  

Ms. Nelson says most important intervention: Confront that inappropriate behavior Provide activity Be firm and consistent Use one head nurse Use reward system, o  give reward with good,



confront when badand withhold reward Help client learn to delay gratification



6 questions –  questions –  schizoid,  schizoid, schizotypal, paranoid –  paranoid –  what’s the clinical picture, nutrition, medication compliance, stay in reality These are all Personality Personality Disorders: Disorders: Cluster A: Behaviors described as odd odd or eccentric: Schizotypal Clinical picture: Bland, inappropriate affect Aloof, apathetic

Schizoid Clinical picture:

These arebecause not normally found clinicalpeople settings they are ablein to function in the world Cold and aloof Indifferent to others Work alone  No need for emotional ties Much energy in intellectual pursuits In crowd –  crowd –  shy,  shy, anxious or uneasy Inappropriately serious about everything, difficulty w/lightheartedness  No spontaneity Bland affect Anhedonia How to handle/treat: Give these pts their space Help develop social skills if possible, this can be accomplished be getting them in a group if possible Childhood: Bleak, cold, unempathic and without nurturing

Magical thinking Ideas of reference Delusions (not pure per Ms. Nelson) Depersonalization Bizarre speech patterns o  Vague, digressive, tangential, not pertinent to topic Talk and gesture to themselves Under stress, may go psychotic with hallucinations, illusions, and delusions, usually these break with reality are brief, this is when they are hospitalized How to handle/treat: Keep stress level down –  down –  calm  calm environment Watch for anxiety to avoid danger dange r to self and others Risk for injury is implied Nurs. Diag. Help them develop social skills if possible Childhood: Families were impassive, indifferent, formal Early companions may have shunned, overlooked, rejected and disgraced

Paranoid Clinical picture: Constantly on guard Hypervigilant Ready for threat (real or imagined) Trusts no one Constantly tests honesty Oversensitive Misinterprets minute clues, magnifies and distorts them

Important in understanding tendencies of violence: Uses projection to blame others for shortcomings. Envious of successful people. They are not successful because of unfair treatment. Threats, usually imagined, cause feelings of intense desire for reprisal and vindication and possible loss of control

Ms. Nelson says: these people are violent; they the y are the ones that will hurt you.

How to handle/treat:  Never lie! Always make everything very clear (so that it cannot later be construed as an untruth), even give in writing

Childhood: Antagonistic or harassing parents  Needs not met or inconsistent inconsistent in the “trust vs. vs. mistrust” developmental phase, paranoia is learned defense from this


   Any communication answer on the test shou should ld be Respectful, Emp Empathetic, athetic, Stay in Re Reality ality …ie. Mr. Doe, I know those (bugs, whatever) are very scary to you, but I’m not seei seeing ng them  Problems with a patient patient - have community mee meeting ting with staff to a address ddress how to manage the client –  client –  establish  establish the consistent care plan

 KNOW NARCAN (nalaxone) Narcan (naloxone)

ReVia (naltrexone) and Revex (nalmefene) are also narcotic antagonist whose prototype is naxalone. They can be used in place of Narcan for opiod overdose, but do not work as well. These two drugs can also be used in the treatment of alcohol dependence as a substitution drug to keep pt from relapsing back into drinking

narcotic antagonist use for opiod overdose o  overdose due to medical use or recreational use o  give to reverse excessive respiratory depression (and other depressive effects)   give IV 0.4 mg, may increase q 2-3 min up to 10 mg if necessary (opiate overdose)   give IV 0.1-0.2 mg, may repeat q 2-3 min up to 3 doses if necessary (postoperative opiate depression   watch for bleeding problems, associated with abnormal coagulation   will reverse analgesic effects of pain medication, which are opiods, like morphine (so Dr. Fire says be prepared for pt to be mad and curse you) 

cause the symptoms of opiate withdrawal for opiate dependent pt, these symptoms   will should start to diminish 20-40 minutes after use and usually disappear within 90 this is due to an extremely short half-life of Narcon and is not a treatment for withdrawal therapy or narcotic abstinence syndrome

Give alcoholics diets high in carbs and high calorie to keep body for using its protein  stores Don‟t forget to give them thiamine and folate also

 DT’s are very common for 10 10 year alcoholics, w will ill occur in 4 4-12 -12 hours, can happen within 30 minutes  Alcohol intoxication intoxication occurs at 100-200 mg/dl, mg/dl, death at 400-70 400-700 0 mg/dl (pg 417)  Pt with hallucinations hallucinations –   –  don’t reinforce (feed (feed into it) show reality  Pt using CNS stimulants stimulants are reality based so those that overdose an and d then in the windi winding ng down stage, they know that it is wrong and will be filled with quilt –  quilt –  watch  watch for suicide  Any detoxing pt –  pt –  watch  watch for suicide Withdrawal from zanax and alcohol (not together) can kill you, w/d from other substance covered just make you want to die…..well, feel real bad    Know how to detox an alcoholic


  Detoxing an alcoholic

Refer to: Psychiatrist  Neurologist Cardiologist Internist  Nutritionist

Remember withdrawal symptoms may appear within 4-12 hours h ours of stopping drinking Ck VS q 4 hrs h rs for 24 hours, q 8 hrs for next nex t 48 hours, bid for days 4 4-7 -7 Ck I&O until day 6, along with skin turgor, color of mucus membranes Ck w/d symptoms through day 4 when they will start to ease o  Tremors, n/v, tachycardia, sweating, high BP, seizures, insomnia, hallucinations (often tactile) delirium  –   o  Complication may include alcohol withdrawal delirium –    altered mental state from coma to violence Start pt on high dose of o f Librium (200 mg) to lessen withdrawal symptoms o  Librium (chlordiazepoxide) is an anxiolytic benzodiazepine   Can also use Serax = benzodiazepine or Tegretol = mood stabilizing anticonvulsant o  Reduce dose by 20-25% each day until symptom (160 mg day 2, 120 mg day 3, 80 day 4, 40 day 5, 0 day 6) Labs: o  Also give Librium prn Blood alcohol level Give Maalox ac & hs Drug screen (urine & Give thiamine (100 mg), multivitamin, and folate (1 mg) q day (teach also)  blood)  Nutrition (teach also) Chem. 7 Urinalysis o  Day 1 - Bland, fluid Chest x-ray o  Day 2-3 frequent, small, easy digested foods ECG o  Days 4-7 high protein, high carbohydrate diet 

Toxicology tests –  tests –  know the first thing they’ll do is get you to pee in in  a cup, then they’ll draw blood  Alcohol withdrawing pt has hallucinations hallucinations - commonly have ttactile actile hallucinati hallucinations ons such as bugs crawling on skin  Ask 2 questions –  questions –  “when is the last time you had a drink?” and “how much do you drink?” (I can’t rem remember ember when you need to ask th these ese questions….w questions….will ill find out more)  more)  o  Anytime a patient is admitted to a cl clinic inic or actually any hospital hospital if long term alcohol use is suspected because they will have withdrawals and you need to be  prepared with an order for Librium.  Page 3 on Part II the ND –  ND –  “Imbalanced…..” and “Risk for…” (last 2 slide on page). Test questions on both….how do you deal with these  these   Imbalanced nutrition nutrition less than body requirements/fluid volume deficit r/t drinking or taking drugs instead of eating: Consult dietician I&O and daily weight Monitor protein intake of client with impaired liver function Restrict sodium intake to minimize fluid retention Provide small frequent feedings of nonirritating

Risk for infection r/t malnutrition and altered immune condition:

Didn‟t find anything on this directly, the previous care  plan would apply to balance balance the patient‟s patient‟s nutrition. Teaching abstinence to reverse effects of alcohol, which can cause leukopenia, a condition that impairs the immune system. How alcohol caused leukopenia is not understood.


 Alcohol has no nutritional nutritional value wha whatsoever tsoever


  Page 4 on Part II the ND –  ND –  “Low self…..” and “Deficient …” (first 2 slide on page). Test questions on  both….how do you deal with these  these  Low self-esteem r/t weak ego, lack of positive feedback Spend time with client and develop trust Get pt involved in activities they will be successful in Provide positive reinforcement for small s mall accomplishments Focus on strengths; minimize failures Encourage group attendance Refer to AA o 

Assist with behaviors requiring change Teach assertiveness and effective communicati communications ons

Deficient knowledge (effects of substance abuse on the body) r/t to denial of problems with substances evidenced by abuse of substances: Assess client‟s level of knowledge and readiness to learn Include significant others in teaching Provide information about physical effects of alcohol on body

Teach about disulfiram

 Detoxification –   Detoxification  –  Administer  Administer substitution therapy –  therapy –  give  give methadone for opioids  AA is the best organization organization to prevent recid recidivism ivism (relapsing into d drinking) rinking) st

Pg 13, 1  sli  slide de … Know disulfiram (antabuse)  (antabuse)  quit drinking o  Usually don‟t give unless client demonstrates that he is ready to quit drinking Teach –   –  take nothing w/alcohol, not alcoholic beverages, not cough syrup, don‟t even wipe the o  Teach skin with an alcohol wipe vasodilation –  skin  skin turns red o  Causes vasodilation –  o  Also can use Revia or Revex --- understand what these do for test Disulfiram produces a sensitivity to alcohol which results in a highly unpleasant reaction when the patient under treatment ingests even small amounts of alcohol. Disulfiram blocks the oxidation of alcohol at the acetaldehyde stage. During alcohol metabolism after disulfiram intake, the concentration of acetaldehyde occurring in the blood may be 5 to 10 times higher than that found during metabolism of the same amount of alcohol alone. Accumulation of acetaldehyde in the blood produces a complex of highly unpleasant symptoms referred to as the disulfiramalcohol reaction. This reaction, which is proportional to the dosage of both disulfiram and alcohol, will persist as long as alcohol is being metabolized. Disulfiram does not appear to influence the rate of alcohol elimination from the body. Disulfiram plus even small amounts of alcohol produces flushing, throbbing in head and neck, throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating, thirst, chest pain, palpitation, dyspnea, hyperventilation, tachycardia, hypotension, syncope, marked uneasiness, weakness, vertigo, blurred vision, and confusion. In severe reactions, there may be respiratory depression, cardiovascular collapse, arrhythmias, myocardial infarction, acute congestive heart failure, unconsciousness,, convulsions, and death. The intensity of the reaction may vary with each individual but is generally unconsciousness  proportional to the the amount of disulfiram and alcohol alcohol ingested. In the sensitive sensitive individ individual, ual, mild reactions may occur when the  blood alcohol concentration concentration is increased to as little little as 5 to 10 mg/100 mg/100 mL. At a concentration of 50 m mg/100 g/100 mL symptoms are usually fully developed, and when the concentration reaches 125 to 150 mg/100 mL unconsciousness may occur. The duration of the reaction is variable. It can last from 30 to 60 minutes in mild cases, up to several hours in more severe cases, or as long as there is alcohol remaining in the blood. Teach patient that the reaction can occur with any amount of alcohol ingestion ingestion or on skin. This includes; liquid liquid cough and cold preparations, vanilla extract, aftershave aftershave lotions, colognes, mouthwash mouthwash,, nail polish remover, isopropyl alcohol. Nurse should be aware not to use alcohol wipes on the skin and not to use flushes that contain alcohol as a preservative.

Other tidbits throughout note with *KNOW* note by them:


  Opiod abuse and dependence patients –  patients –  opiods  opiods cause constipation, listen to bowel sounds to make sure no paralytic illeus Onset of withdrawal symptoms depends on the half-life of the drug from which the  person is withdrawing Cirrhosis is where regular liver cells are replaced by fibrous scar tissue that when  palpated feels like a rock. This can be an effect of long term alcohol abuse. Cirrhosis side effects include ascites. ascites. This is cause by bloo blood d flow in the liver ccausing ausing the liver to sweat from portal hypertension. hypertension. This liquid is third spa spaced ced into the abd abdominal ominal cavity. Confabulation is when an alcohol making up activities to replace the periods of blackout. This happens during Korsakoff‟s psychosis.  psychosis.  Paresthesia is a prickly sensation in the extremities and is a characterization of alcohol caused peripheral neuropathy

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