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WILKES NSG 526 EXAM
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Primary prevention - Actually preventing the thing Secondary Prevention - early identification and treatment Tertiary prevention - Avoiding complications Norms are considered - The right patterns of behavior for a society Crisis is - a time limited response lasting 4 to 6 weeks What initiates a crisis - A crisis is initiated by internal or external demands that are perceived as a threat to a persons physical or emotional functioning. Precipitating event is stressful and unusual or rare. maturational crisis - Describes unfavorable person-environmental relationships that relate to maturational events such as leaving home for the first time, completing school or accepting the responsibility of adulthood. Situational Crisis - Occurs whenever a specific stressful event threatens a person's biopsychosocial integrity and results in some degree of psychological disequilibrium Aventitious Cirsis - Initiated by an unexpected unusual events that can affect an individual or a multitude of people. National and natural disasters. During an adventitious crisis (e.g., flood, hurricane, forest fire) that affects the well-being of many people, the interventions of the PMH-APRN will be a part of the community's efforts to respond to the event. Goal for people experiencing crisis - To return to pre-crisis level of functioning. Role of APRN in Crisis - he role of the PMH-APRN is to provide a framework of support systems that guide the client through the crisis and facilitate the development and use of positive coping skills. Assess risk of homicide/suicide/self-injury
Assess coping skills
Individuals in this group should be moved away from the main triage area. o Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances Psychological Assessment - Assess the victim for behaviors that indicate a depressed state, presence of confusion, uncontrolled weeping or screaming, disorientation, or aggressive behavior. Ideally, the PMH-APRN should assess the coping strategies the victim uses to normally manage stressful situations. ABC's of Psychological First Aid - The ABCs of psychological first aid include focusing on A (arousal), B (behavior), and C (cognition). When arousal is present, the intervention goal is to decrease excitement by providing safety, comfort, and consolation. When abnormal or irrational behavior is present, survivors should be assisted to function more effectively in the disaster and when cognitive disorientation occurs, reality testing and clear information should be provided. After initital assessment the PMH- APRN should - support the development of resilience, coping, and recovery while providing technical assistance, training, and consultation Goals of care - include helping the victims prioritize and match available resources with their needs, and preventing further complications, monitoring the environment, disseminating information, and implementing disease control strategies Debriefing - May be helpful but is no longer considered essential Explanation of anticipated behaviors and reactions - helps the patient gain control and improve coping Social Assessment: - The PMH-APRN should maintain a calm demeanor, obtain and distribute information about the disaster and the victims, and reunite victims and their families. In addition, there is a need to monitor the news media's impact on the mental health of the victims of the crisis Assess for economic distress, access to shelter, food, etc ASD/PTSD support - Providing a safe environment is the priority for any client who is a victim of a serious crime/assault
ASD duration - 2 days to 1 month ASD: Focus on - Meet immediate needs o Build therapeutic alliance o If distressed, limit to immediate care o Complete psych assessment Focus on reexperiencing, avoidance or numbing, hyperarousal, dissacociation o Goals of treatment: Reduce the severity of symptoms, Prevent or treat trauma-related comorbid conditions, Improve adaptive functioning by promoting resilience, Prevent relapse, Integrate the trauma into the patient's life experience, Prevent the development of PTSD Psychological First Aid in ASD - The key features of PFA are empathy, compassion, stabilizing the patient by reducing distress, and connecting the individual with resources o The frontline treatment for patients with ASD is multiple session, trauma-focused cognitive behavioral therapy o Do something, instead of nothing (Pleasure promoting activities) Factors that increase risk of PTSD: - Factors that appear to increase the risk for developing PTSD among individuals with ASD include female gender, prior exposure to traumatic events, low levels of social support, stressful life events in year prior to trauma, a personal or family history of psychopathology, and experiencing new stressors after the original trauma factors and interventions to prevent the development of PTSD focus on - preventing or treating new stressors, reducing distress, modulating arousal, managing pain, and treating depression. Propranolol, opioid, psychotherapy Primary Feature of PTSD: - disturbance of memory, in which memories of the traumatic event are not processed and integrated with other information, so they are reexperienced Overall treatment goal for PTSD - is to enable patients to regain control of their emotional responses and to place the trauma in the larger perspective of their lives as an event that happened at a certain time and that is unlikely to recur.
Schizotypical PD - ideas of reference; magical thinking or odd beliefs; perceptual distortions; vague, stereotyped speech; frightened, suspicious, blunted affect; distant and strained social relationships. These clients tend to be frightened and suspicious in social situations. o Explanations can ease their anxiety. Cluster B - Dramatic, Emotional, Erratic Borderline Personality symptoms - Unstable, intense relationships; identity disturbances; impulsivity; self-mutilation; rapid mood shifts; chronic emptiness; intense fear of abandonment; splitting; and anger Inability to tolerate perceived rejection BPD Major defense - A major defense is splitting (alternating between idealizing and devaluing). Self Mutilation in BPD - Self-mutilation and suicide-prone behavior are often-used impulsive self-destructive behaviors. Self mutilation occurs: - because a client may feel that pain is better than not feeling anything, it also results from feelings of abandonment, it can be a manipulative gesture, and it is also happens when a safety plan has been put in place. Self mutilation is mainly due to: - fear of abandonment or the increase of independence Note: - If a client with BPD who was making progress but recently had an anxiety producing situation arise and now cut herself is that even though this behavior is dysfunctional, it is mostly the patient's best effort to cope Best response from PMH-APRN in BPD - The best response by the PMHNP when speaking with a client with BPD who has been in counseling for management of self-harm behaviors who now wants to cut themselves is to assist the client to identify an appropriate coping strategy Anger in BPD - Anger is intense and pervasive and help with anger management is an important intervention Other focuses of BPD Management - Relationship building, safety, and limit setting are other foci. Clients with BPD have not successfully - achieved the developmental stage of separation-
individuation during which a child normally develops a sense of self, a permanent sense of significant others (object constancy), and integration of seeing both bad and good components of self Projective Identification: - falsely attribute to others their own unacceptable feelings, impulses, or thoughts Boundries and BPD - Respecting a client's boundaries is important in establishing a therapeutic relationship with a patient with BPD. Risk Factors for BPD - sexual abuse, parental separation, biological component (A decrease in serotonin activity and an increase in α2-noradrenergic receptor sites may be related to the irritability and impulsiveness; an increase in dopamine may be responsible for transient psychotic states) DBT/ Mindfulness - DBT is a psychosocial treatment developed by Marsha M. Linehan specifically to treat individuals with borderline personality disorder. DBT includes: o Individual component in which the therapist and client discuss issues that come up during the week, recorded on diary cards and follow a treatment target hierarchy. During the individual therapy, the therapist and client work towards improving skill use. Often, skills group is discussed and obstacles to acting skillfully are addressed. DBT targets behaviors in a descending hierarchy: Decreasing high-risk suicidal behaviors Decreasing responses or behaviors (by either therapist or client) that interfere with therapy Decreasing behaviors that interfere with/reduce quality of life Decreasing and dealing with post-traumatic stress responses Enhancing respect for self Acquisition of the behavioral skills taught in group
Suicide gestures may result in client entry into the health care system. o A thorough assessment of suicide potential must be undertaken, and support offered in the form of clear parameters of psychotherapy. Cluster C - Anxious & Fearful Dependent PD - nability to make daily decisions without advice and reassurance, need of others to be responsible for important areas of life, anxious and helpless when alone, and submissive. Solicit care taking by clinging. Fear abandonment if they are too competent. Experience anxiety and may have co-existing depression. Know the cluster! (C) Avoidant PD - Social inhibition, feelings of inadequacy, hypersensitivity to criticism, preoccupation with fear of rejection and criticism, and self-perceived to be socially inept. Low self-esteem and hypersensitivity grow as support networks decrease. Demands of workplace often overwhelming. Project that caregivers will harm them through disapproval and perceive rejection where none exists. Nurses can teach socialization skills, provide positive feedback, and build self-esteem. OCD - Preoccupied with rules, perfectionist, too busy to have friends, rigid control, and superficial relationships. Complains about others' inefficiencies and gives others directions. Assessment of a Child (8 Questions) - Behaviors that are possible indicators of a mental illness in a 3-year-old child: o Most psychiatric disorders in children are multifactorial.
Understand that children from different cultures develop at different rates. Most children will adopt the same world view as their parents (ex. If a child was brought up by parents who thought the world was hostile, they would most likely adopt this view as they grow older. The psych NP needs to foster a child's healthy characteristics and existing environmental supports no matter how negative (ex a child lives in a homeless shelter). Therapeutic drawing is a helpful technique if a child feels self-blame regarding their parent's divorce. Establishing a therapeutic alliance is important because acceptance and trust convey a feeling of security in an adolescent. Objective observations help the most in evaluating outcomes of child therapy. Play Therapy - Play therapy is important because it allows the child to play out their fears and frustrations. Play therapy is child-centered and typically builds on the foundation of the psychodynamic, object-relations, and attachment theories. Used for children 3 years or older Nondirective play is normally viewed as the best way to begin play therapy. Structured play is rarely used until nondirective play has enabled a full assessment of relevant themes and issues, and the child's trust around anxiety-laden issues has been developed. Useful for catharsis, abreaction (assimilate previous experiences that have been traumatic or painful), role-play Interventions include reflection (commenting) and interpretation (after rapport developed)
themes and issues, and the child's trust around anxiety-laden issues has been developed. Useful for catharsis, abreaction (assimilate previous experiences that have been traumatic or painful), role-play Interventions include reflection (commenting) and interpretation (after rapport developed) Cognitive Therapy (1 question) Understand schemas o Individuals with BPD develop dysfunctional beliefs and maladaptive schemas leading them to misinterpret environmental stimuli continuously, which in turn leads to rigid and inflexible behavior patterns in response to new situations and people Cognitive therapy is the modality that prioritizes a client's schema. 7 and older Bibliotherapy (2 questions) Bibliotherapy uses books and a librarian as resources. When children listen to or read a story, they unconsciously identify with the characters and experience a catharsis of feelings. Family Therapy (Systems) (1 question) Family therapy can promote the greatest change in an adolescent's behavior. Know different family styles such as "closed Family". The Developmental Theoretical approach describes a family's progression through the lifecycle. Flooding (1 question) Know an example of flooding in a child. Adolescent education on substances (1 question) When conducting a counseling session for a group of at-risk adolescents on drug use, it is important to have their peers involved in teaching some of the problem-solving skills. Child Protective Services (1 question) Reporting requirements for Child Protective Services and the Health Professional
Oppositional Defiant Disorder (1 question) Event interpretation should be included for problem solving therapy for a child with conduct disorder. The primary treatment of oppositional defiant disorder is family intervention using both direct training of the parents in child management skills and careful assessment of family interactions. Nursing Theorists - Freud - Psychodynamic Erikson - Developmental Piaget - Cognitive Fairbairn, Winnicott, Klein, Mahler, Stem - Object-relations Bowlby and Ainsworth - Attachment Skinner - Behavioral/learning Bower - Family Remotivation/Reminiscence Therapy - Validation therapy advocates that, rather than trying to bring the person with dementia back to our reality, it is more positive to enter their reality. o Once the person has experienced severe short-term memory loss and can no longer make sense of the present, they are likely to go back to the past to resolve unfinished conflicts, relive past experiences or to retreat from the present. o Acknowledge and empathize with with the feelings behind the behavior. Reminiscence therapy and life review are useful interventions for elders who are experiencing self-esteem disturbance, grief, hopelessness, powerlessness, altered role performance, and social isolation. o Reminiscence uses the recall of past events, feelings, and thoughts to facilitate pleasure, quality of life, adaptation to present circumstances, or distraction. o Life review is a structured process involving the recall of past events in one's life in an
strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons.
