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Special Populations and Psychiatric Emergencies

Special Populations and Psychiatric Emergencies. PVN123 – Mental Health Nursing. Objectives. Identify characteristics / treatment/ and nursing interventions for the following: Common mental health issues for children and adolescents Mood disorders MDD Dysthymic Disorder

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Special Populations and Psychiatric Emergencies

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  1. Special Populations and Psychiatric Emergencies PVN123 – Mental Health Nursing

  2. Objectives • Identify characteristics / treatment/ and nursing interventions for the following: • Common mental health issues for children and adolescents • Mood disorders • MDD • Dysthymic Disorder • Bipolar disorder • Anxiety Disorders • Substance Abuse • Eating Disorders) • Behavioral Disorders ( • ADHD • oppositional defiant disorder • conduct disorder • Pervasive Developmental Disorders • Autism • Identify elements / client characteristics / nursing role and nursing interventions for mental health emergencies • Crisis Management • Suicide • Family and Community Violence • Abuse • Rape • Community violence and disasters

  3. Mental Health Nursing Issues for the Child and Adolescent

  4. Issues for Children and Adolescents • Mental health issues not always easy to diagnose • Treatment may be delayed or less than adequate • Children can’t describe what is happening • Wide variety of behaviors considered normal development • Hard to determine if behavior is a mental health problem • May have comorbid conditions

  5. Issues for Children and Adolescents • Children’s behavior is considered problematic if: • Interferes with home, school, peer interactions • Considered pathologic if: • Not age appropriate • Deviation from cultural norms • Causes impairment in adaptive functioning

  6. Common Mental Health Disorders (children and adolescents) • Mood disorders (including suicide) • MDD • Dysthymic Disorder • Bipolar disorder • Anxiety Disorders • Substance Abuse • Eating Disorders (primarily females) • Behavioral Disorders (ADHD, oppositional defiant disorder, conduct disorder) • Pervasive Developmental Disorders • autism

  7. Good Mental Health Characteristics (children and adolescents) • Ability to interpret reality • Correct perception of environment • Positive self-concept • Appropriate coping with stress and anxiety • Developmental skills mastery • Spontaneous self-expression and creativity • Satisfying relationships with others

  8. General Risk Factors • Genetic • Biochemical • Social and environmental • Cultural and ethnic • Degree of resiliency • Trauma or traumatic event

  9. Mood Disorders Children and Adolescents Depression

  10. Risk Factors • Family history of depression • Physical or sexual abuse or neglect • Homelessness • Disputes, conflicts and rejection • High-risk behavior • Learning disabilities • Chronic illness

  11. Clinical Manifestations – Mood Disorders • Feelings of sadness • Decreased appetite • Nonspecific health complaints • Solitary play or work • Appetite changes leading to weigh changes • Disturbed sleeping patterns • Irritable • Aggressive • High-risk behavior • Poor school performance / dropping out • Poor concentration • Hopelessness about the future • Sense of helplessness • Suicidal ideation

  12. Anxiety Disorders Children and Adolescents Separation Anxiety PTSD

  13. Anxiety Disorders • Exist when: • Normal growth and development are disrupted by anxiety • Anxiety so serious that child cannot function normally • Separation Anxiety Disorder • Excessive anxiety when separated from home or parents • Can develop into phobias(fear of school/being left alone • Depression may be concurrent • May progress to panic disorder or phobia • PTSD • Can be caused by experience of a traumatic event • Often respond in phases • Begins with arousal lasting a few minutes to 1-2 hours • 2 weeks when child attempts to cope using defense mechanisms • 2-3 months when child may develop clinical findings • Failure to cope >>>>> may lead to obsessing about the even

  14. Risk Factors and Clinical Manifestations (anxiety disorders) Risk Factors Manifestations (PTSD) Anxiety Depression Phobia Conversion reactions External display of anxiety Irritability Aggression Poor academic performance Somatic complaints Belief that life will be short Problems sleeping • Specific stressor • Death • Illness • Move • Abuse/assault

  15. Behavior Disorders Children and Adolescents ADHD Oppositional Defiant Disorder Conduct Disorder Pervasive Developmental Disorders Autism

  16. ADHD • To be diagnosed as ADHD • Behaviors present before age 7 • Present in more than one setting • Inability to control behaviors that require sustained attention • Types • Combined (most common) • ADHD predominately attentive • Difficulty paying attention • Doesn’t appear to listen • Easily distracted • ADHD predominately hyperactive-impulsive • Fidgeting • Unable to sit still • Excessive talking • Trouble waiting for turn • Interrupting • Disregard for consequences of behavior • May put child at risk for injury • Behaviors often receive negative attention from adults and peers

  17. Oppositional Defiant Disorder • Recurrent pattern of the following behaviors • Negativity • Disobedience • Hostility • Defiant behaviors (especially toward authority) • Persistent stubbornness • Argumentative • Limit testing • Unwilling to compromise • Refuse to accept responsibility for behavior • Misbehavior usually demonstrated at home and directed toward someone the child knows • Do not see themselves as defiant • See behavior as response to unreasonable demands • May exhibit • Low self esteem • Mood lability • Low frustration threshold • Can develop into conduct disorder

  18. Watch a Video Oppositional Defiant Disorder on WTNH 8 • http://www.youtube.com/watch?v=LYhkFxfL72w

  19. Conduct DisorderContributing Factors • Parent rejection / neglect • Difficult temperament in infancy • Inconsistent child-rearing practices • Harsh discipline • Physical or sexual abuse • Lack of supervision • Early institutionalization • Frequent change of caregivers • Large family • Associating with delinquent peers • Parent history of psychological illness

  20. Conduct DisorderClinical Manifestations • Lack of remorse / care for feelings of others • Bullies / threatens / intimidates others • Believes that aggressive behavior is justified • Low self esteem • Irritability • Temper outbursts • Reckless behavior • Signs of suicidal ideation • Concurrent learning disorders and cognitive impairment • Demonstration of physical cruelty • Has used a weapon that could cause injury • Destroys property belonging to others • Has run away from home • Lying / shoplifting / truant from school

  21. Pervasive Development Disorders (Autism Spectrum Disorder) • Complex neurodevelopment disorder • Etiology unknown • Wide spectrum of behaviors • Affects ability to communicate with others • Cognitive / language development delayed • Characteristics include: • Inability to maintain eye contact • Repetitive actions • Strict observance of routines • Usually observed before the age of 3 years • Wide variability in functioning (poor to high) • Inability to perform self care • Inability to communicate and relate to others • Ability to function at near normal levels

  22. Watch a Video • The Brain of an Autistic child + Temple Grandin • http://www.youtube.com/watch?v=2o6KYIw2yww

  23. Watch a Video Temple Grandin - Thinking in Pictures • http://www.youtube.com/watch?v=l58MffRIJUQ

  24. Watch a Video Temple Grandin: The world needs all kinds of minds • http://www.ted.com/playlists/9/all_kinds_of_minds.html

  25. Other Disorders in Children • Mental Retardation • IQ less than 70 • Learning Disorders • Difficulty in getting and using essential skills • Listening • Speaking • Reasoning • Performing math • Writing • Communication Disorders • Expressive • Receptive • Combination of both • Treated with • Speech/language therapy • Adaptive communication devices • Hearing aids • Sign language

  26. Clinical ManifestationsBehavioral Disorders • Clinical findings worsen in: • Situations that require sustained attention • Group situations with less structure • Usually occur in: • School • Church • Home • Recreational activities

  27. Clinical ManifestationsADHD • Inattention • Impulsivity • hyperactivity

  28. Clinical Manifestations Autism • Sensory integration dysfunction • Sleep disorders • Digestive disorders • Feeding disorders • Epilepsy • allergies

  29. Clinical ManifestationsMental Retardation • Significant limitations • Communication • Self care • Home living • Self-direction • Social skills • Community • Work • Leisure • Academic achievement • Health • Safety

  30. Nursing Care – Assessment • Nursing History • Mother’s pregnancy and birth history • Sleeping / eating/ elimination patterns • Recent weight loss or gain • Achieved developmental milestones • Allergies • Current meds • Peer and family relationships • School performance • History of abuse • Parent’s perceptions of child’s behaviors • Family history (all current members of household) • Substance abuse / misuse • Tobacco • Alcohol • Drugs • Home and school safety • Actual / risk for self injury • Depression / suicidal ideation • Includes plan / lethality of plan / means to carry out the plan • Availability of weapons in the home • Complete physical assessment including mental status examination

  31. Nursing Care - Prevention • Help children adopt a realistic view of their bodies and improve overall self-esteem • Identify and reinforce positive coping skills • Monitor for safety at home • Emphasize use of seat belts • Encourage using protective gear for high-impact sports • Provide education on contraceptives / STD transmission • Encourage abstinence • Open lines of communication with adolescents to discuss sexual issues and practices • Encourage children and families to seek professional help

  32. Intervention for children engaging in high-risk behaviors • Instruct client/family about factors that contribute to substance dependency (make referrals) • Inform client/family about support groups • Eating disorders • Substance abuse • General adolescent support • School and community resources • Request referrals to social services when indicated • Discuss use and availability of hot-lines

  33. Intervention for children with Anxiety Disorders • Emotional support • Accepting use of regression and other defense mechanisms • Offer protection • During panic levels of anxiety • Reinforce cognitive-behavioral therapy techniques • Relaxation • Thought stopping • Implement methods to: • Increase self esteem • Feelings of achievement • Assistance with working through traumatic events • Encourage group therapy

  34. Interventions for Behavioral Disorders • Calm/firm/respectful approach • Use modeling • Demonstrate desired behavior • Obtain child’s attention before giving instructions • Short/ clear explanations • Set clear limits for unacceptable behavior • Identify physical activities • For child to use energy and obtain success • Help parents develop a reward system • Focus on strengths / not just problems • Provide a safe environment • Provide positive feedback • Identify issues that result in power struggles • Assist to develop effective coping mechanisms • Encourage participation in group, individual, family therapy • Administer medication and monitor for side effects • Antipsychotics • Mood stabilizers • Anticonvulsants • antidepressants

  35. Interventions for Autism • Request referral for early intervention • Determine emotional and situational triggers • Provide structured environment • Monitor behavior to ensure safety • Consult with parents • Provide consistent / individualized care • Encourage parents to assist with plan of care • Short/concise developmentally appropriate communication • Identify and reward desired behaviors • Role model social skills • Encourage verbal communication • Limit self-stimulating or ritualistic behaviors • Provide alternative play activities • Give notice before changing routines

  36. Common MedicationsChildren and Adolescents • Prozac (fluoxetine) • SSRI • Elavil (amitriptyline) • Tricyclic antidepressant • Atypical antidepressants • BuSpar (buspirone • Wellbutrin (bupropion) • CNS Stimulants • Concerta, RitalinSR (methylphenidate) • Strattera (atomoxetine HCl) • NSRI

  37. Other Care • Learning Disabilities • Individual approach • Generally treated in the school system • Interdisciplinary method • Special education • Speech therapy • Physical therapy • Resource teachers • Communications Disorder • Treated with wide variety of modalities • Speech/language therapy • Adaptive communication devices • Hearing aids • Sign language

  38. Client Outcomes • Client will achieve maximal level of physical, cognitive, and social development • Client is able to communicate effectively • Client and family verbalize the need for information and support • Client verbalizes improved mood • Client develops realistic goals for the future • Family identifies strategies for managing behaviors

  39. Quick Quiz! A school-age child is being evaluated for ADHD. The nurse should expect to find which of the following in this child? A. inability to maintain eye contact B. easily distracted C. anxiety about separation from parent D. self-mutilation

  40. Quick Quiz! A nurse is observing an adolescent for clinical findings of conduct disorder. The nurse should expect to observe which of the following? (select all that apply) _____ hostility _____ frequent lying _____ easy distraction _____ activities that break the law _____ careless mistakes _____ cruelty to neighborhood pets _____ poor eye contact

  41. Psychiatric Emergencies Crisis Management Suicide Family and Community Violence

  42. Watch a Video Child Mental Health Crisis In The Emergency Room http://www.youtube.com/watch?v=GR_6ZTSm_2A

  43. Watch a Video Psychiatric Emergencies http://www.youtube.com/watch?v=M5HW2O_gJWw

  44. Psychiatric EmergenciesCrisis Management • Crisis • Acute / time-limited (4-6 weeks) event • Client has emotional response that cannot be managed with normal coping mechanisms • Characteristics: • Sudden event with little time to prepare • Perceives event as life threatening or disrupting • Lost / decrease in communication with significant others • Sense of displacementfrom familiar • Actual or perceived loss • Types of crises: • Situational / external • Unanticipated loss or change experienced in real life events • Maturational / internal • Achieving new developmental stages that require learning additional coping mechanisms • Adventitious • Occurrence of natural disasters / crimes / national disasters

  45. Risk and Protective Factors • Accumulation of unresolved loses • Current life stressors • Concurrent mental and physical health issues • Excessive fatigue or pain • Age and developmental age • Support system • Prior experience with stress or crises

  46. Nursing History • Include: • Presence of suicidal or homicidal ideation • Client’s perception of precipitating event • Cultural or religious needs of client • Support system • Present coping skills

  47. Manifestations at Phase of Crisis • Phase 1 • Escalating anxiety • Activates increased defense mechanisms • Phase 2 • Anxiety continues to escalate • Defense mechanisms fail • Functioning becomes disorganized • Client resorts to trial and error attempts to resolve anxiety • Phase 3 • Trial and error method fails • Client’s anxiety escalates to severe / panic • Leads to fight or flight response or withdrawal behavior • Phase 4 • Overwhelming anxiety • Leads to anguish or apprehension • Feelings of powerlessness • Feelings of being overwhelmed • Dissociative symptoms • Depersonalization • Detachment from reality • Depression • Confusion • Violence (against others or self)

  48. Nursing Care - Crisis • Initial Interventions • Identify the problem / assist with resolution • Take active / directive role with client • Help client set realistic goals • Provide for client safety • Recommend hospitalization for those with suicidal or homicidal thoughts • Prioritize! • Physical needs first • Strategies to decrease anxiety • Therapeutic nurse/client relationship • Stay with the client • Listen and observe • Make eye contact • Ask questions / draw out patient’s feelings • Ask questions related to event • Be genuine and caring • Communicate clearly • Avoid false reassurance • Reinforce relaxation techniques • Encourage use of coping skills • Assist with development of an action plan • Short term (no longer than 24-72 hours • Focused on the crisis • Realistic and manageable

  49. Medication / Education / Outcomes • Medications • Antianxiety meds • Antidepressant meds • Client Education • Encourage use of support agencies • Request referral for follow up care • Outcomes • Client is able to make decisions between two or more options • Client is able to manage anxiety with relaxation techniques • Client returns to pre-crisis level of function • Client has learned new coping skills and uses them

  50. Quick Quiz! • Scenario: • A nurse on a medical-surgical unit is caring for a client who was admitted from the emergency unit 24 hours ago. The client was involved in a motor vehicle crash. The client has multiple lacerations and fractured pelvis and radius. The client’s adolescent son was killed in the crash. • What type of crisis did the client experience? • Which of the following medications should the nurse anticipate administering to the client? • A. Lithobid • B. Paxil • C. Risperdal • D. Haldol

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