N212: Health Differences Across the Life Span 2

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NURSING 212 Health Differences Across the Life Span 2

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ACHIEVE TEST PREP Health Differences Across the Lifespan 2 Study Guide 1st Edition 10/9/2017

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Acknowledgements We would like to thank the authors for their patience, support, and expertise in contributing to this study guide; and Christina Wulff for her invaluable efforts in reading and editing the text. We would also like to thank those at Achieve Test Prep whose hard work and dedication to fulfilling this project did not go unnoticed. Lastly, we would like to thank the Achieve Test prep students who have contributed to the growth of these materials over the years. Copyright © 2017 by Achieve Test Prep All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review. Printed in the United States of America First Printing, 2012 Achieve Test Prep PO Box 10188 #29831 Newark, NJ 07101-3188 Tel: 888.900.8380 Visit the Achieve Test Prep website at http://www.achievetestprep.com/student

Health Differences Across the Lifespan 2 Study Guide

Table of Contents Chapter One: Care of Patients with Mental Health Problems................................................................ 4 1.1 General Assessment for Psychiatric Disorders ............................................................................... 5 1.2 Therapeutic Modalities..........................................................................................................................16 1.3 Roles of a Nurse ........................................................................................................................................18 1.4 Personality Disorders ............................................................................................................................21 1.5 Psychotherapy and Freud .....................................................................................................................26 1.6 Erik Erickson’s Development Tasks..................................................................................................30 1.7 Other Significant Theories and Therapies ......................................................................................32 1.8 Other Disorders........................................................................................................................................37 1.9 Pediatric Psychiatric Disorders..........................................................................................................42 1.10 Behavioral Psychotherapy .................................................................................................................48 Chapter One Practice Questions ................................................................................................................49 Chapter Two: Care of Patients with Impaired Cognitive Function ....................................................53 2.1 Delirium ......................................................................................................................................................53 2.2 Dementia.....................................................................................................................................................53 2.3 Alzheimer’s Disease ................................................................................................................................54 2.4 Wernicke Korsakoff Syndrome...........................................................................................................57 2.5 Pellagra........................................................................................................................................................57 2.6 Delirium Tremens (DTs) .......................................................................................................................58 Chapter Two Practice Questions ...............................................................................................................59 Chapter Three: Regulatory Mechanisms ....................................................................................................65 3.1 Excess Production of Hormones Disorders ....................................................................................65 3.2 Deficient Production of Hormones Disorders ...............................................................................75 3.3 Impaired Renal Function Disorders..................................................................................................79 Chapter Three Practice Questions ............................................................................................................86 Chapter Four: Metabolic Disorders ..............................................................................................................87 4.1 Metabolic Disorders in Response to Obstruction.........................................................................87 4.2 Metabolic Disorders in Response to Toxic Substances ..............................................................89 4.3 Metabolic Disorders in Response to Inadequate Production or Utilization of Secretions ............................................................................................................................................................................ 100 4.4 Drug Treatments................................................................................................................................... 106 Chapter Four Practice Questions............................................................................................................ 110 Appendix A: Practice Exam........................................................................................................................... 111 Appendix B: Answer Keys ............................................................................................................................. 139

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Health Differences Across the Lifespan 2 Study Guide

Chapter One: Care of Patients with Mental Health Problems 1.1 General Assessment for Psychiatric Disorders

©2017 Achieve Test Prep Page 5 of 140 Health History A psychiatric assessment is most commonly carried out for clinical and therapeutic purposes. Psychiatric assessments are also used to establish a diagnosis and formulation of the individual's problems, and to plan the individual's care and treatment. This may be done in a hospital (or in- patient) setting, in an ambulatory (or outpatient) setting, or in a community setting (as done in a home-based assessment). Subjective information is the information that is obtained from the patient’s point of view, such as his/her chief complaints, the history of the present illness, and the reason the patient is seeking health care. If possible, the chief complaints should be a standard part of any psychiatric assessment. The standard psychiatric history consists of biographical data (name, age, marital and family contact details, occupation, and first language), the presenting complaint (an account of the onset, nature, and development of the individual's current difficulties), and personal history (including birth complications, childhood development, parental care in childhood, educational and employment history, relationship and marital history, and criminal background). The history also includes an inquiry about the individual's current social circumstances, family relationships, current and past use of alcohol and illicit drugs, and the individual's past treatment history (current and past diagnoses and use of prescribed medication). The psychiatric history includes an exploration of the individual's culture and ethnicity, as cultural values can influence the way a person (and their family) communicates psychological distress and responds to a diagnosis of mental illness. Certain behaviors and beliefs may be misinterpreted as features of mental illness by a clinician who is from a different cultural background than the individual being assessed. The mental status examination (MSE) is another core part of any psychiatric assessment. The MSE is a structured way of describing a patient's current state of mind under the domains of appearance, attitude, behavior, speech, mood, thought process, thought content, perception, cognition (including orientation, memory, and concentration), insight, and judgment. The data is collected through a combination of direct and indirect means. This includes unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalized psychological tests. The purpose of the MSE is to obtain a comprehensive, cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning. The MSE is not to be confused with the mini-mental state examination (MMSE), which is a brief neuro-psychological screening test for dementia. The mini-mental state examination (MMSE) is a popular screening tool used to determine cognitive functioning. The MMSE is a reliable measurement containing thirty questions that are used to test basic cognitive functions such as attention, language production, orientation, language comprehension, and immediate memory. The average time it takes to complete the MMSE is five to ten minutes. People with normal cognitive functioning usually score high on the measurement, ranging from 27 to 30. The instrument is

Health Differences Across the Lifespan 2 Study Guide accurate in determining Alzheimer's disease and other forms of dementia in elderly populations. Panic Disorder Panic disorder is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress. These sensations often mimic symptoms of a heart attack or other life- threatening medical conditions. As a result, the diagnosis of panic disorder is frequently not made until extensive and costly medical procedures fail to provide a correct diagnosis or relief. Many people with panic disorder develop intense anxiety between episodes, worrying when and where the next one will strike. In some cases, panic attacks can become so debilitating that the person may develop agoraphobia because they fear another panic attack. To be diagnosed as having panic disorder, a person must experience at least four of the following symptoms during a panic attack: sweating, hot or cold flashes, choking or smothering sensations, racing heart, labored breathing, trembling, chest pains, faintness, numbness, nausea, disorientation, or feelings of dying, losing control, or losing one's mind. Panic attacks can occur in anyone. Chemical or hormonal imbalances, drugs or alcohol, stress, or other situational events can cause panic attacks, which are often mistaken for heart attacks, heart disease, or respiratoryproblems. During panic attacks remain calm, stay with the patient, offer reassurances, use short and clear sentences, and reduce environmental stimuli. When the level of anxiety is mild to moderate, explore possible causes of anxiety, teach signs and symptoms of escalating anxiety, and teach and reinforce appropriate coping mechanisms and strategies. Medications such as benzodiazepines and antidepressants treat panic disorders. Psychotherapy, known as cognitive-behavioral therapy, teaches patients how to view panic attacks differently and demonstrates ways to reduce anxiety. Obsessive-Compulsive Disorder People with obsessive-compulsive disorder (OCD) suffer intensely from recurrent, unwanted thoughts (obsessions) or rituals (compulsions), which they feel they cannot control. Rituals such as hand washing, counting, checking, or cleaning are often performed in hope of preventing obsessive thoughts or making them go away. Performing these rituals, however, provides only temporary relief, and not performing them markedly increases anxiety. Left untreated, obsessions and the need to perform rituals can take over a person's life. OCD is often a chronic, relapsing illness. Obsessions are intrusive, irrational thoughts or unwanted ideas and impulses that repeatedly well up in a person's mind. The person experiences disturbing thoughts over and over. Examples include, "My hands are contaminated; I must wash them,” "I may have left the gas stove on," and "I am going to injure my child." On one level, the sufferer knows these obsessive thoughts are irrational. But on another level, there is fear these thoughts are true. Trying to avoid such thoughts creates anxiety. Compulsions are repetitive rituals such as hand washing, counting, checking, hoarding, or arranging. An individual repeats these actions, perhaps feeling momentary relief, but without feeling satisfaction or a sense of completion. People with OCD feel they must perform these compulsive rituals or something bad will happen. ©2017 Achieve Test Prep Page 6 of 140

Health Differences Across the Lifespan 2 Study Guide Anxiety increases if obsessive thoughts and compulsions are interrupted. Depression and/or substance abuse may occur as a complication. Treatments include relaxation and cognitive behavioral techniques. Nurses should assist the patient to identify situations that increase anxiety, explore the meaning and purpose of thoughts and behavior, and support the patient in attempts to decrease obsessions and compulsions. Nurses should also conduct teaching immediately after the completion of a ritual when the patient is least anxious. Several medications have been proven effective in helping people with OCD including clomipramine, fluoxetine, fluvoxamine, and paroxetine. ECT has been used to treat depressive symptoms associated with OCD. Post-Traumatic Stress Disorder Post-traumatic stress disorder (PTSD) is an extremely debilitating condition that can occur after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that can trigger PTSD include violent personal assaults, such as rape or mugging, natural or human-caused disasters, accidents, or military combat. Clients with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms. Other signs and symptoms include emotional numbness and sleep disturbances, depression, anxiety, and irritability or outbursts of anger. Feelings of intense guilt are also common. Patients may exhibit apathy, social withdrawal and isolation, along with restlessness and amnesia for certain aspects of trauma. Treatments include providing a nonthreatening environment, encouraging the patient to discuss the traumatic event and associated feelings, and assessing and acknowledging feelings of guilt, grief, and shame. Nurses should encourage and reinforce appropriate coping strategies, teach new coping strategies, and assist the patient in resuming regular activities. Cognitive-behavioral therapy, group therapy, and exposure therapy, in which the patient repeatedly relives the frightening experience under controlled conditions to help him or her work through the trauma, have also been effective treatments. Medications, such as SSRIs, especially Zoloft (sertraline), seem to have some effect in treating PTSD. Phobias A phobia is a persistent, irrational fear of a specific object or situation. Phobias develop when an unconscious conflict is displaced onto an external object. It is also related symbolically to conflict. A diagnosis is often made when avoidance of feared stimuli drastically interferes with routine activities. There are several types of phobias, including: • Specific (simple) phobia: an unreasonable fear of specific circumstances or objects, such as traffic jams or snakes • Social phobia: extreme fear of looking foolish or unacceptable in public that causes people to avoid public occasions or areas ©2017 Achieve Test Prep Page 7 of 140

Health Differences Across the Lifespan 2 Study Guide • Agoraphobia: an intense fear of feeling trapped in a situation; a fear of being in a public place where escape might not be possible or help might not be available; fear of situations, such as crowds, standing in line, being on a bridge, and travelling in a plane, bus, train, or car • Specific phobia: an excessive fear of a particular object or situation Social phobia: This is extreme anxiety in social or public situations. It can produce a fear of being humiliated or embarrassed in front of other people. This problem may also be related to feelings of inferiority and low self-esteem, and can drive a person to drop out of school, avoid making friends, and remain unemployed. Although this disorder is sometimes thought to be shyness, it is not the same thing. Shy people do not experience extreme anxiety in social situations, nor do they necessarily avoid them. In contrast, people with social phobia can be at ease with people most of the time, except in particular situations. Often social phobia is accompanied by depression or substance abuse. Signs and symptoms include: • Finding blushing as painfully embarrassing • Feeling that all eyes are on them • Fear of speaking in public, dating, or talking with persons inauthority • Fear of using public restrooms or eating out • Fear of talking on the phone or writing in front of others Agoraphobia: This is the fear of being alone in public places from which there is no easy escape. Agoraphobia causes people to suffer anxiety about being in places or situations from which it might be difficult or embarrassing to escape (i.e. being in a room full of people or in an elevator). In extreme cases, a person with agoraphobia may be afraid to leave their house. Agoraphobia is frequently associated with panic disorder and is an anxiety disorder characterized by anxiety in situations where it is perceived to be difficult or embarrassing to escape. These situations can include, but are not limited to, wide-open spaces and uncontrollable social situations, such as being met in shopping malls, airports, and on bridges. The sufferer may go to great lengths to avoid those situations, and in severe cases, becoming unable to leave their home or safe haven. Although mostly thought to be a fear of public places, it is now believed that agoraphobia develops as a complication of panic attacks. Onset is usually between ages 20 and 40 years, and is more common in women. Approximately 3.2 million, or about 2.2% of adults in the US between the ages of 18 and 54, suffer from agoraphobia. Agoraphobia can account for approximately 60% of phobias. Studies have shown two different age groups at first onset: early to mid-twenties, and early thirties. In response to a traumatic event, anxiety may interrupt the formation of memories and disrupt the learning processes, resulting in dissociation. Depersonalization (a feeling of disconnection from one’s self) and derealization (a feeling of disconnection from one's surroundings) are other dissociative methods of withdrawing from anxiety. Standardized tools, such as panic and agoraphobia scale, can be used to measure agoraphobia and panic attack severity while monitoring treatment. ©2017 Achieve Test Prep Page 8 of 140

Health Differences Across the Lifespan 2 Study Guide Treatment includes cognitive therapy and graduated exposure or desensitization; anti-anxiety medications may provide short term relief of phobic anxiety. Nursing care includes accepting, but not supporting, phobia, exploring client’s perception of threats, discussing feelings that may contribute to irrational fears, and identifying strategies forchange. Depression and Mood Disorders Depression is a prolonged emotional state that affects a person’s life and personality. Change in mood is a normal and expected life occurrence; each person feels a range of emotions, such as joy, happiness, sadness, depression, anger, and fear. A person’s present feelings and moods with verbal and nonverbal behavioral cues are important. Mood disorders are characterized by changes in mood that range from depression to elation. Major depression is a loss of interest in life and a mood that transforms from mild to severe, which lasts at least 2 weeks. If uncontrolled, it results in disturbances in eating, sleeping, and functioning at work, home, and/or school. Withdrawal and decreased sociability, possible delusions and/or hallucinations with psychotic features if disorder progresses to severe depression is also a possibility. The term "depression" is ambiguous. It is often used to denote this syndrome, but may refer to other mood disorders or to lower mood states lacking clinical significance. Major depressive disorder is a disabling condition that adversely affects a person's family, work or school life, sleeping and eating habits, and general health. In the United States, around 3.4% of people with major depression commit suicide, and up to 60% of people who commit suicide had depression or another mood disorder. The diagnosis of major depressive disorder is based on the patient's self-reported experiences, behavior reported by relatives or friends, and a mental status examination. If depressive disorder is not detected in the early stages, it may result in a slow recovery and affect or worsen the person's physical health. Standardized screening tools such as major depression inventory can be used to detect major depressive disorder. The most common time of onset is between the ages of 20 and 30 years, with a later peak between 30 and 40 years. Typically, patients are treated with antidepressant medication and, in many cases, also receive psychotherapy or counseling, although the effectiveness of medication for mild or moderate cases is questionable. Hospitalization may be necessary in cases with associated self-neglect or a significant risk of harm to self or others. A minority are treated with electroconvulsive therapy (ECT). The course of the disorder varies widely, from one episode lasting weeks, to a lifelong disorder with recurrent major depressive episodes. Depressed individuals have shorter life expectancies than those without depression, in part because of greater susceptibility to medical illnesses and suicide. It is unclear whether or not medications affect the risk of suicide. Current and former patients may be stigmatized. Proposed causes include psychological, psycho-social, hereditary, evolutionary, and biological factors. Certain types of long-term drug use can both cause and worsen depressive symptoms. Psychological treatments are based on theories of personality, interpersonal communication, and learning. Most biological theories focus on the monoamine chemicals serotonin, norepinephrine, and dopamine, which are naturally present in the brain and assist communication between nerve cells. ©2017 Achieve Test Prep Page 9 of 140

Health Differences Across the Lifespan 2 Study Guide Signs and symptom include significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation, fatigue or loss of energy, diminished ability to think or concentrate, indecisiveness, social withdrawal, recurrent thoughts of death, suicidal ideation, with or without a specific plan. Bipolar Disorder Bipolar disorder, also known as manic depression, is an illness involving one or more episodes of serious mania and depression. The illness causes a person’s mood to swing from excessively “high” and/or irritable to sad and hopeless, with periods of a normal mood in between. Bipolar disorder typically begins in adolescence or early adulthood and continues throughout life. It is often not recognized as an illness and people who have it may suffer needlessly for years. Bipolar disorder can be extremely distressing and disruptive for those who have this disease, their spouses, family members, friends, and employers. Although there is no known cure, bipolar disorder is treatable and recovery possible. Individuals with bipolar disorder have successful relationships and meaningful jobs. The combination of medications and psychotherapy helps the vast majority of people return to productive, fulfilling lives. The presence of bipolar disorder indicates a biochemical imbalance which alters a person’s moods. This imbalance is thought to be caused by irregular hormone production or a problem with certain chemicals in the brain, called neurotransmitters, that act as messengers to our nerve cells. Lithium is effective in treating 60% of patients affected with bipolar disorder. Symptoms of mania include: • Excessive energy, activity, restlessness, racing thoughts, and rapid talking • Denial that anything iswrong • Extreme “high” or euphoric feelings; a person may feel “on top of the world” and nothing, including bad news or tragic events, can change this“happiness” • Easily irritated or distracted • Decreased need for sleep; an individual may last for days with little or no sleep without feeling tired • Unrealistic beliefs in one’s ability and powers; a person may experience feelings of exaggerated confidence or unwarranted optimism, which can lead to over ambitious work plans and the belief that nothing can stop him or her from accomplishing any task • Uncharacteristically poor judgment; a person may make poor decisions which may lead to unrealistic involvement in activities, meetings and deadlines, reckless driving, spending sprees, and foolish business ventures • Sustained period of behavior that is different from usual; a person may dress and/or act differently than he or she usually does, become a collector of various items, become indifferent to personal grooming, become obsessed with writing, or experience delusions • Unusual sexual drive • Abuse of drugs, particularly cocaine, alcohol, or sleepingmedications • Provocative, intrusive, or aggressive behavior; a person may become enraged or paranoid if his or her grand ideas are stopped or excessive social plans are refused ©2017 Achieve Test Prep Page 10 of 140

Health Differences Across the Lifespan 2 Study Guide Some people experience periods of normal mood and behavior following a manic phase, however, the depressive phase will eventually appear. This is a manifestation of an affective disorder. The patient will experience prolonged periods of sadness, feeling down, gloomy, or unhappy with no episodes of elation. There is a loss of interest in life and activities, feelings of hopelessness and helplessness, and suicidal thoughts. Acute depression is usually self-limiting and lasts from a few weeks (with treatment) to a few months. The most common age of onset is 25-44 with twice as many women being affected. Depressed clients, when severely ill, rarely commit suicide because they do not have the drive and energy to make a plan and follow it through when severely depressed. The danger period for suicide occurs when depression begins to lift. A no suicide contract may be helpful. Signs and symptoms of the depressive phase include: • Persistent sad, anxious, or emptymood • Sleeping too much or too little; middle of the night or early morning waking • Reduced appetite and weight loss, or increased appetite and weight gain • Loss of interest or pleasure in activities, includingsex • Irritability or restlessness • Difficulty concentrating, remembering, or makingdecisions • Fatigue or loss of energy • Persistent physical symptoms that don’t respond to treatment (such as chronic pain or digestive disorders) • Thoughts of death or suicide, including suicideattempts • Feeling guilty, hopeless, orworthless Dysthymia Dysthymia is a disorder with similar, but longer lasting and milder symptoms, than clinical depression. By the standard psychiatric definition, this disorder lasts for at least two years, but is less disabling than major depression. For example, victims are usually able to go on working and do not need to be hospitalized. Dysthymia is also known as neurotic depression. The concept was coined by Dr. Robert Spitzer as a replacement for the term "depressive personality" in the late 1970s. Dysthymia is a chronic disorder; sufferers may experience symptoms for many years before it is diagnosed, if diagnosis occurs at all. As a result, they may believe that depression is a part of their character, so they may not even discuss their symptoms with doctors, family members, or friends. The warning signs of dysthymia are: • Poor school/work performance • Social withdrawal • Shyness • Irritable hostility • Conflicts with family and friends • Physiological abnormalities • Sleep irregularities • Parents with major depression ©2017 Achieve Test Prep Page 11 of 140

Health Differences Across the Lifespan 2 Study Guide

©2017 Achieve Test Prep Page 12 of 140 Dissociative Disorder Dissociative disorders usually involve impairment of consciousness, memory, and perception. There is a sudden disruption in the patient’s consciousness, identity, or memory. Defense mechanisms of dissociation and repression are used. Possible etiologies include traumatic experiences or severe physical, sexual, or emotional abuse. With a dissociative identity disorder, aspects of the self may emerge as distinct personalities, with individual losing a sense of who he/she is. Multiple Personality Disorder This occurs when there is a presence of two or more distinct personalities or identities in one person. An alter is a personality state or identity that recurrently takes over the behavior of a person with DID; alters are personalities with different influences and power over one another and may represent different ages or gender. Each alter has a relatively enduring pattern of perceiving, relating to, and thinking about itself and the environment. Alters communicate with one another through the “executive” alter. Some alters share “co-consciousness”, aware of each other’s experience and behavior; others are aware only of their existence. “Switching” occurs by dissociating from one alter to another. The host personality is the primary identity that holds the person’s name; it is typically unaware of alters, but alters are typically aware of the host personality. The patient “loses track of time” when the alternate personality is present. Usually the patient is unable to give full account of childhood memories because of dissociation; the patient may appear forgetful and is often accused of lying. Mental status variations include blinking, eye rolls, headaches, and marked variations in speech. Other signs and symptoms include: • Disruption of identity characterized by two or more distinct personality states • Multiple mannerisms, attitudes, and beliefs • Pseudo seizures or other conversion symptoms • Somatic symptoms that vary across identities • Distortion or loss of subjective time (a long time) • Current memory loss of everyday events • Depersonalization, derealization, and depression • Flashbacks of abuse/trauma • Sudden anger without a justified cause • Frequent panic/anxiety attacks and unexplainable phobias Depersonalization Disorder Depersonalization disorder is a feeling of detachment or separation from one’s self, as if in a dream- like state. The patient describes his/herself as “detached from the body” or “being in a dream.” The patient feels strange or unreal, but is able to function during the experience. Distress about experiences may be reported and patients become depressed and anxious. Often the patient fears being “crazy”. Feelings may be accompanied by derealization, a feeling that the external world is unreal or strange. This disorder is most common in teenagers and young adults.

Health Differences Across the Lifespan 2 Study Guide Interventions include problem solving to reduce stress in general, stress management techniques, and “grounding” or focusing on external environment. Stress management and coping techniques should also be taught. Drug facilitated interviews using thiopental sodium (Pentothal) to recover memory can be used along with anti-anxiety medications, antidepressants, and antipsychotics (for extreme agitation). Individual or group therapy, and behavior modification are also effective interventions. In a nursing assessment, the client recounts the trauma or severe stress. Symptoms appear in adulthood after the stressful event. Symptoms can appear immediately or may be delayed for years. Dissociation is a defense mechanism in which experiences are blocked from consciousness so that affect, behavior, identity, memories, and/or thoughts are not integrated. Repression is a defense mechanism in which thoughts and feelings are kept from consciousness. The patient may report symptoms of depression or anxiety. Facial appearances and mannerisms may vary widely within one session or appearance may vary widely from day to day. A patient’s mood is anxious or depressed. Headaches are common with DID. Some may have amnesia for events. Feelings of detachment from self or environment and feelings of physical change in the body are common. Insight is impaired, and patients are unaware of memory impairment. Conversion Disorder A conversion disorder is a somatoform disorder in which a motor, sensory, or visceral function is lost and about which the client is usually indifferent. Symptoms do not have an underlying organic cause. Motor symptoms are autism, paralysis, and tremors. Sensory symptoms are blindness, deafness, and numbness. Visceral symptoms are urinary retention, breathing difficulties, and headaches. The client has no conscious control of this disorder. Reaction to painful memories and disagreeable desires appear as physical symptoms. One example is hysterical blindness which can occur after seeing a loved one die in an auto accident. Signs and symptoms include: • Gait disturbances, paralysis, pseudo-seizures, and tremors • La belle indifference (lack of concern about the symptom or limitation on functioning) • Hypochondriasis (persistent fear or belief that one has a serious illness) Somatization Disorder The onset is usually prior to age of 30 with symptoms of several years duration. Multiple physical complaints include four pain symptoms, two GI symptoms, sexual symptoms, and symptoms suggesting neurological disorders. Lifestyle changes are evoked by physical illness, affecting occupational, family, and community relationships, and self-care, resulting in disability and inability to work, thereby leading to financial struggles. The patient seeks treatment for physical symptoms. Interventions include long term medical management, treating physical symptoms conservatively, and a “matter of fact” approach. Antidepressants can be used if depressive symptoms present, but there is no drug therapy for anxiety symptoms. ©2017 Achieve Test Prep Page 13 of 140

Health Differences Across the Lifespan 2 Study Guide

©2017 Achieve Test Prep Page 14 of 140 Schizophrenia This is a serious disorder which affects how a person thinks, feels, and acts. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary, may be unresponsive or withdrawn, and may have difficulty expressing normal emotions in social situations. Contrary to public perception, schizophrenia is not split personality or multiple personality disorder. The vast majority of people with schizophrenia are not violent and do not pose a danger to others. Schizophrenia is not caused by childhood experiences, poor parenting, or lack of willpower, nor are the symptoms identical for each person. People with schizophrenia have a chemical imbalance of brain chemicals (serotonin and dopamine) which are neurotransmitters. These neurotransmitters allow nerve cells in the brain to send messages to each other. The imbalance of these chemicals affects the way a person’s brain reacts to stimuli, which explains why a person with schizophrenia may be overwhelmed by sensory information (loud music or bright lights), which other people can easily handle. This problem in processing different sounds, sights, smells, and tastes can also lead to hallucinations or delusions. Schizophrenic disorders are characterized by disturbances for at least 6 months in thought content and form, perception, affect, sense of self, volition (self-initiated behaviors), interpersonal relationships, and psychomotor behavior. Signs and symptoms include auditory hallucinations, disorganized thinking, or looseness of association. Negative behaviors include the absence of healthy behaviors including flat affect, apathy, anhedonia (inability to experience pleasure), avolition (inability to pursue goal directed behavior), alogia (poverty of speech), minimal self-care, ineffective social skills, and social withdrawal and isolation from concrete thinking. Positive symptoms focus on a distortion of normal functions and include delusions, hallucinations, disorganized speech, and grossly disorganized pacing, touching objects, or catatonic behavior. Types of schizophrenia include catatonic (least common), disorganized, and paranoid. Catatonia is a state of neurogenic motor immobility and behavioral abnormality manifested by stupor. It is associated with psychiatric conditions such as schizophrenia (catatonic type), bipolar disorder, post-traumatic stress disorder, depression, and other mental disorders, as well as drug abuse or overdose (or both). It may also be seen in many medical disorders including infections (such as encephalitis), autoimmune disorders, focal neurologic lesions (including strokes), metabolic disturbances, and abrupt or overly rapid benzodiazepine withdrawal. It can be an adverse reaction to prescribed medication. There are a variety of treatments available, but benzodiazepines are a first-line treatment strategy. Electro-convulsive therapy is also sometimes used. Antipsychotics are sometimes employed but require caution as they can worsen symptoms and have serious adverse effects. Disorganized schizophrenia is characterized by prominent disorganized behavior and speech and flat or inappropriate emotion and affect. Unlike the paranoid subtype of schizophrenia, delusions and hallucinations are not the most prominent feature, although fragmentary delusions and hallucinations may be present. A person with disorganized schizophrenia may also experience behavioral disorganization, which may impair his/her ability to carry out activities of daily living, such as showering or eating. The emotional responses of patients diagnosed with this subtype can often seem strange or inappropriate to the situation. Inappropriate facial responses may be common and behavior is sometimes described as silly, such as inappropriate laughter. The patient

Health Differences Across the Lifespan 2 Study Guide may also display complete lack of expressions and avolition (a lack of motivation). The major needs of schizophrenic patients are structure, diversion to distract them from disturbing thoughts, and stress reduction to minimize the severity of the disorder. Do not argue with or support a psychotic patient’s delusions. Paranoid schizophrenia patients believe others are out to get him or her. Patients may be hostile, suspicious, and aggressive. The patient has excessive feelings of importance and power over others. The patient may also have delusions that focus on religious content. The somatic type is when the patient has delusions fixed on an irrational belief about his or her body. The nihilistic type is when the patient has delusions of nonexistence. The persecutory type is when the patient has delusions that others are out to get him or her or are plotting against him or her. Thought broadcasting is when the patient believes that others can hear his or her thoughts. Thought insertion is when the patient believes that others have the ability to put thoughts in his or her mind against the his or her will. Interventions for schizophrenia include management of delusions and hallucinations, establishing a trusting and therapeutic relationship, encouraging expression of feelings and thoughts, and communicating with the patient using clear and direct statements. Nurses should provide an environment with a low degree of stimulation and express understanding of the patient’s belief about the delusion or hallucination but not share in it. Do not argue with the patient. Avoid physical contact or touching the patient, encourage the patient to verbalize feelings and thoughts openly, identify support symptoms, observe for self-destructive behaviors, provide opportunities for the patient that promote socialization and decrease isolation, involve the patient in setting realistic goals in a treatment plan, and provide daily living skills groups for patients to participate in. Anti-Social Personality This disorder involves individuals that exhibit inflexible and maladaptive responses to stress. Signs and symptoms include patients who are intelligent, charming, and self-centered, with a “con artist” inability to feel guilt or learn from past experience. Other symptoms are repeated lying and cheating, stealing, emotionally immature, lacking impulse control, and low frustration tolerance. Manipulation of others to fulfill wants and needs is another sign, and so is resisting authority, rules, and laws. Patients are often impulsive, lacking judgment, and using rationalization to justify behavior.

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Health Differences Across the Lifespan 2 Study Guide

©2017 Achieve Test Prep Page 16 of 140 1.2 Therapeutic Modalities Therapeutic modalities are modes of interventions that can be employed to help a patient. They involve non-pharmacological and pharmacological interventions. Milieu Therapy Milieu therapy uses all aspects of the hospital environment in a therapeutic manner. Patients are exposed to rules, expectations, peer pressure, and social interactions. Communication and decision making are encouraged. Opportunities are provided to enhance self-esteem and learn new skills and behaviors. The goal is to enable the patient to live outside the institutional setting. Few restraints are placed on the patient, but they are held responsible for their own actions. Milieu therapy is the treatment of the mental disorder or maladjustment by making substantial changes in a patient's immediate life circumstances and environment in a way that will enhance the effectiveness of other forms of therapy. The goal of milieu therapy is to manipulate the environment so that all aspects of the patient’s hospital experience are considered therapeutic. Within this therapeutic community setting, the patient is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life. Skinner outlined seven basic assumptions on which a therapeutic community is based: 1. The health in each individual is to be realized and encouraged to grow: All individuals are considered to have strengths as well as limitations. These healthy aspects of the individual are identified and serve as a foundation for growth in the personality and in the ability to function more adaptively and productively in all aspects of life. 2. Every interaction is an opportunity for therapeutic intervention: Within this structured setting, it is virtually impossible to avoid interpersonal interaction. The ideal situation exists for clients to improve communication and develop relationship skills. Learning occurs from immediate feedback of personal perceptions. 3. The patient owns his or her own environment: The patient makes decisions and solves problems related to government of the unit. In this way, personal needs for autonomy, as well as needs that pertain to the group as a whole, are fulfilled. 4. Each patient owns his or her behavior: Each individual within the therapeutic community is expected to take responsibility for his or her ownbehavior. 5. Peer pressure is a useful and a powerful tool: Behavioral group norms are established through peer pressure. Feedback is direct and frequent, so that behaving in a manner acceptable to the other members of the community becomesessential. 6. Inappropriate behaviors are dealt with as they occur: Individuals examine thesignificance of their behavior, look at how it affects other people, and discuss more appropriate ways of behaving in certain situations. 7. Restrictions and punishment are to be avoided: Destructive behaviors can usually be controlled with group discussion. However, if an individual requires external controls, temporary isolation is preferred over lengthy restriction or other harsh punishment.

Health Differences Across the Lifespan 2 Study Guide Goals of milieu therapy: • Manipulate the environment so that all aspects of patient’s hospital experience are considered therapeutic. • The patient is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life. • Achieve patient autonomy. Principles of milieu therapy: • To promote a fundamental respect for individuals (both patients andstaff). • To use opportunities for communication between the patient and staff for maximum therapeutic benefit. • To encourage patients to act at a level equal to their ability and to enhance their self-esteem (autonomy is reinforced). • To promote socialization. • To provide opportunities for patients to be part of unit management. • Individuals are held responsible for ownactions. • Peer pressure is utilized to reinforce rules andregulations. • A team approach is used. • Group discussions and temporary seclusions are favored approaches for actingout behavior. • The nurse’s function is to act in ways that consistently promote thesegoals. Therapeutic Nurse-Patient Relationship This is one of the most important aspects of nursing care. It requires the nurse to first assess his/her feelings about the patient and his/her condition. This way, the nurse can avoid negative attitudes that will conflict with patient care. The nurse must approach the patient in a nonjudgmental, supportive, and empathetic manner. The nurse must also be committed to walking with the patient through his/her crisis. Maintaining a neutral approach encourages the patient to verbalize and helps to establish a sense of trust that may enable the patient to change his/her dysfunctional behavior. In mental disorders, it is usually recommended that nursing exposure be limited to a few nurses. This allows the patient to establish trusting relationships with one or two nurses. The nurse must take care when the decision to use therapeutic touch is involved. Some disorders, such as depression or grief, welcome a friendly touch, while others with psychosis or paranoia may perceive touch as an act of aggression. When experiencing difficulty in communicating with a patient, it is important to ask direct, concrete questions that require concrete answers. Use open ended questions when interviewing the patient or trying to get more information. Peplau's theory explains the phases of interpersonal process, roles in nursing situations, and methods for studying nursing as an interpersonal process. The theory explains the purpose of nursing is to help others identify their felt difficulties. ©2017 Achieve Test Prep Page 17 of 140

Health Differences Across the Lifespan 2 Study Guide • Nurses should apply principles of human relations to the problems that arise at all levels of experience. • Nursing is therapeutic in that it is a healing art (assisting an individual who is sick orin need of health care). • Nursing is an interpersonal process because it involves interaction between two or more individuals with a common goal. • The attainment of a goal is achieved through the use of a series of steps following aseries of pattern. • The nurse and patient work together so both become mature and knowledgeable in the process. 1.3 Roles of a Nurse Technical definitions: • Person: A developing organism that tries to reduce anxiety caused by needs • Environment: Existing forces outside the organism and in the context of culture • Health: A word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living. • Nursing: A significant therapeutic interpersonal process. Nursing functions cooperatively with other human processes that make health possible for individuals in communities. The roles of a nurse: • Stranger: Receives the patient in the same way one meets a stranger in other life situations; provides an accepting climate that builds trust • Teacher: Imparts knowledge in reference to a need or interest • Resource person: Provides a specific needed information that aids in the understanding of a problem or newsituation • Counselor: Helps to understand and integrate the meaning of current life circumstances and provides guidance and encouragement to makechanges • Surrogate: Helps to clarify domains of dependence, interdependence, and independence and acts on the patient’s behalf as an advocate • Leader: Helps the patient assume maximum responsibility for meeting treatment goals in a mutually satisfying way The Four Sequential Phases in the Interpersonal Relationship 1. Orientation 2. Identification 3. Exploitation 4. Resolution ©2017 Achieve Test Prep Page 18 of 140