Addictions
When caring for a patient experiencing alcohol withdrawal, what areas (types of questions) might the nurse ask to obtain assessment information for the CIWA?
CIWA is assessing the following areas:
questions should be framed in a way to gather information to complete a CIWA score
Anxiety is classified into what categories?
How might a patient present in each level?
Mild: special attention; increased sensory stimulation; motivational--Anxiety is not bad, but rather a warning sign.
Moderate: something
definitely wrong; nervousness/agitation; difficulty concentrating; able to be redirected
Severe: trouble thinking and reasoning; tightened muscles; increased vital signs; restless, irritable, angry
Panic: fight, flight, or freeze response; increased vital signs; dilated pupils; cognitive processes focusing on defense
What are positive symptoms associated with schizophrenia? (think of examples of how a patient may present)
What are negative symptoms associated with schizophrenia? (think of examples of how a patient may present)
Positive symptoms are "adding" to the situation
Negative symptoms are "taking away" from the situation
Interventions for a client with Antisocial Personality Disorder include?
limit setting, confrontation, teach effective problem solving, manage emotions of anger and frustration, be consistent and firm with the plan of care, provide immediate positive feedback for desired behaviors
What class of medication may be helpful for patients experiencing anger/frustration?
Antipsychotics
Examples:
Olanzapine
Ziprasidone
Risperdone
Stimulant (meth, cocaine, etc) abuse can lead to patients experiencing what types of complications?
Hallucinations
Violence/Aggression (potential for violence)
Impaired judgment
Severe to panic levels of anxiety
When caring for a patient with severe or panic level anxiety, what is the main priority for the nurse?
What type of medication would the nurse anticipate being ordered?
Safety- stay with the patient. remind them they are safe and use short, direct sentences
Benzo's are used for short-term, immediate relief
what is the AIMS scale?
How often should it be completed?
•Screens for symptoms of movement disorders
•Observe client in several positions and judge severity of symptoms
•Rate each symptom on 0 to 4 scale
•0 if not observed and 4 if severe
•If “stable” repeat every 3-6 months to detect symptoms of tardive dyskinesia
•Increased score indicates development of symptoms
•Should have baseline AIMS assessment prior to starting antipsychotic treatment
Major considerations for clients with Borderline Personality Disorder include?
Safety- high risk of self harm and accidental suicide
Staff splitting-- set limits and refer all questions to their assigned staff member
Help the client to cope without feeling the need to "act out" or dramatize the situation
Stick to a schedule/structure/routine
What are the various antianxiety medications and their typical onset?
Diazepam (Valium)- Fast
Alprazolam (Xanax)- Intermediate
Chlordiazepoxide (Librium)- Intermediate
Lorazepam (Ativan)- Intermediate
Clonazepam (Klonopin)- Slow
Oxazepam (Serax)-Slow
Opioid abuse is treated with what medications? how is it managed?
Buprenorphine (also the idea is to taper the patient off of it)
Clonidine can be used to manage autonomic symptoms (n&v, diarrhea)
Clients also benefit from peer support and outpatient therapy to determine the underlying cause of their substance abuse
Obsessions are classified as?
Compulsions are classified as?
A short term goal for a patient being treated for OCD is?
Obsessions = thoughts
Compulsions = behaviors
Short term goal = reduction in compulsions
Neuroleptic Malignant Syndrome (NMS)
What are clinical manifestations?
Treatment includes?
F: Fever
E: Elevated CPK/WBC
V: Vital signs instability
E: Encephalopathy
R: muscle Rigidity
Treatment includes aggressive treatment of symptoms: antipyretics to treat hyperprexia; dantrolene to reduce muscle spams; IV fluids for dehydration
Nursing interventions for a client with dependent personality disorder include?
Encourage independence
help clients express feelings of grief and loss over the end of a relationships while fostering autonomy and self-reliance, help clients identify their strengths and needs, cognitive restructuring techniques, teach problem-solving and decision-making
What are some of the various education points to make with clients starting on Benzo's?
•Safety measures: orthostatic hypotension, risk for falls, respiratory depression, sedative
•Avoidance of alcohol and caffeine
•Avoidance of abrupt discontinuation- could experience withdrawal (life-threatening)
•Drug may lose its effectiveness over time
•Do not take with antacids
•Do not become pregnant while taking
•Avoid breast-feeding
•Take with food to avoid GI upset
Medications used to help patients maintain sobriety from alcohol include?
•Disulfiram (Antabuse)- helps with impulse drinking d/t long lasting effects, when mixed with alcohol the patient will have violent physical reactions
•Naltrexone (Vivitrol)- reduces desired pleasant feelings by blocking release of endorphins, also blocks cravings
•Acamprosate (Campral)- reduces unpleasant symptoms of abstinence and decreases cravings
Other disorders related to OCD include?
•Self-soothing behaviors:
–Excoriation (skin picking)
–Onychophagia (nail biting)
–Trichotillomania (hair pulling)
•Reward-seeking behaviors:
–Kleptomania (compulsive stealing)
–Oniomania (compulsive buying)
–Hoarding (excessive acquisition)
–Pyromania (fire setting)
•Disorders of body appearance and function:
–Body dysmorphic disorder (preoccupation with slight or even imagined physical imperfection)
–Body identity integrity disorder (feeling alienated from a part of the body to the extent of seeking amputation of the identified body part)
•Excoriation AKA dermatillomania
–Skin picking
–Leads to medical complications
–May require medicine, surgery, plastic surgery to treat
•Onychophagia
–Nail biting
–Onset is in childhood- behavior decreases by age 18
–SSRI antidepressants for treatment
•Trichotillomania
–Repetitive, chronic hair-pulling
–Distress and functional impairment
–Common onset in childhood, comorbidities with anxiety and depression
Hallucinations are based in what?
examples include?
Delusions are based in what?
Examples include?
Hallucinations:
•Command- voices demanding the client to take action (auditory)
•Visual- seeing images that don’t exist, second most common type
•Olfactory- smelling specific smells or odors
•Tactile- bugs crawling, electricity in body, touch (rare without alcohol w/d)
•Gustatory- taste lingering in the mouth
•Cenesthetic- feels body processes usually not able to be felt (urine formation)
Delusions:
•Persecutory/Paranoid- belief others are planning to harm the client, “others”
•Grandiose- client claims to be related to famous people, belief they are famous
•Religious delusions- coming of Christ or another significant religious figure
•Somatic- vague and unrealistic beliefs about the client’s bodily functions
•Sexual- belief that sexual behaviors are known to others
•Referential- belief that television shows, music, etc. have special meaning for client
What are the various types of personality disorders and what characteristics make up each one?
Cluster A
•Odd or eccentric behaviors
•Paranoid personality disorder
•Schizoid personality disorder
•Schizotypal personality disorder
Cluster B
•Erratic or dramatic behaviors
•Antisocial personality disorder
•Borderline personality disorder
•Histrionic personality disorder
•Narcissistic personality disorder
Cluster C
•Anxious or fearful behaviors
•Avoidant personality disorder
•Dependent personality disorder
•Obsessive personality disorder
First-Generation Antipsychotics:
Side Effects?
Nursing interventions for potential side effects
•Can cause extrapyramidal side effects (EPS) due to the blockage of D2 receptors
•Acute dystonia, Akathisia, Pseudoparkinsonism, Tardive dyskinesia
•May adjust dose, change drug, or add oral anticholinergic (benztropine)
- monitor for weight gain (may start metformin to help control weight gain and potential diabetes)
- monitor for seizures
- monitor NMS (FEVER)
- monitor for prolactin elevation (gynecomastia, galactorrhea)
Withdrawal from alcohol can be seen within what time frame?
8-12 hours
It usually peaks within 24-48 hours after the last drink ( or decreased consumption)
A main goal for a client with OCD includes?
limiting the time spent on the compulsions
Example: if they typically take 1 hour to complete their morning routine, maybe have them aim for 45 minutes (it should lesson the number of times they are doing the compulsive behavior)
Tardive Dyskinesia (TD) - clinical manifestations include?
Treatment includes?
Involvuntary tonic movement- usually spams in the face and jaw
Tounge and lip-smacking
Uncontrollable biting, chewing or sucking motions
STOP Medication!
Medications are same as with EPS - benztropine, trihexyphenidyl, diphenhydramine
The goal with any personality disorder is what?
Helping to treatment the symptoms of the type they are diagnosed with-- there is no "cure" or medication; rather management of the behaviors
signs of EPS include?
Treatment of EPS would include what immediate medication administration?
Tardive dyskinesia (TD) - involuntary muscular spasms of the face and jaw, lip smacking, or unusual tongue movements,
Acute Dystonia: severe spasms of the muscles of the tongue, head and neck, fixed upward deviation of the eyes, severe back spams
Akathisia: internal restlessness, inability to site still ( pacing, fidgeting)
Pseudoparkinsonism: stiffening of muscular activity, shuffling gait, tremors,
Prevention is essential- patients should begin with benztropine when starting antipsychotics
Treatment may include: benztropine IV/IM or diphenhydramine IM/IV