SJDC ADN Class of 2008: April 2007

1. What communication techniques work best for clients rendered immobile by anxiety?
Clients with panic anxiety are out of control so they need to know that they are safe from their own impulses. Firm, short, and simple statements are useful. Use a low pitched voice, speak slowly and with repetition. Reinforce reality if distortions occur, listen for themes in communication (Varcarolis pg 216).
• Maintain a calm manner, and remain with the patient who is experiencing the severe to panic anxiety attack
• Minimize environmental stimuli (move to a quieter setting)
• Use clear simple statements and repetition in a low-pitched voice while speaking slowly
• Reinforce reality if distortions occur while listening for themes in communication
• Attend to physical and safety needs when necessary (warmth, fluids, pain, etc.)
• Safety is an overall goal, a “show of force” or use of physical limits may need to be implemented
• Provide opportunities of exercise to help dissipate tension
• Offer high caloric drinks to someone who is constantly moving and pacing
• Assess need for meds or seclusion after other interventions have failed
• If hypercapnia occurs, instruct client to take slow, deep breaths. Breathe with the patient to obtain cooperation.
• Keep expectations minimal and simpleSee also table 14-2 page 233, and table 14-5 page 237

2. What techniques are used by a crisis nurse that might not be used in a traditional therapeutic setting?
The nurse must be willing to take an active, even directive role in intervention; this is in direct contrast to what occurs in conventional therapeutic interventions, which stress a more passive and nondirective role for the practitioner (Varcarolis pg 459).
• The following are important assumptions when working with a client in crisis: The person is in charge of their life; the person is able to make decisions; the crisis counseling relationship is one between partners.
• See Table 22-4 page 465, and Box 22-1 #8 page 459

3. Differentiate between primary and secondary crisis interventions.
Primary care promotes mental health and reduces mental illness to decrease the incidence of crisis. The nurse will work with the client to recognized potential problems, teach specific coping skills and evaluate life changes to decrease the negative effects of stress.
Secondary care establishes intervention during an acute crisis to prevent prolonged anxiety from diminishing personal effectiveness and personality organization. The nurse’s primary focus is to ensure the safety of the client. Then the nurse will assess the clients problem, support systems, and coping styles to lessen the time a person is mentally disabled during a crisis (Varcarolis pg 465).

4. Describe characteristics of clients manifesting escalation of aggressive behavior.
Hyperactivity: most important predictor of imminent violenceIncreasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self,Verbal abuse, profanity and argumentativeness.Loud voice: change in pitch, or very soft voice forcing others to strain to hearintense eye contact or avoidance of eye contact (Varcarolis pg 493).
• Recent acts of violence, including property violence
• Stone silence
• Alcohol or drug intoxication
• Possession of a weapon or object that may be used as a weapon
• Milieu characteristics conducive to violence: overcrowding; staff inexperience; provocative or controlling staff; poor limit setting; Arbitrary revocation of privileges

5. Discuss techniques used when staff needs to administer IM medication to an aggressive client.
A team with about five staff members is gathered and organized before approaching the client. They are equipped with medication and the right size restraint. Each member knows which limb to secure or task to perform. The team leader explains to the client in a matter of fact manner exactly what the team is about to do and why. Often the client will cooperate at this point, if not the team remains calm and acts as quickly as possible to restrain the client. Once restrained the nurse administers the IM injection (benzodiazepine, major tranquilizer, or antihistamine). The nurse provides an explanation to the client of the medication. Throughout the whole process the team leader continues to relate to the client in a calm, steady voice, communicating decisiveness, consistency and control (Varcarolis pg 496).
• The nurse’s role is to provide an explanation to the client for the medication and to make sure the client is properly restrained so that the medication can be safely administered.
• The team leader continues to relate to the client in a calm, steady voice, communicating decisiveness, consistency, and control.
• Prior to medication administration, the client needs to be restrained and in doing so each team member needs to have proper training
• The approach needs to be organized with each team member knowing what their role is
• Also make sure to appropriate sized equipment is ready
• The team leader explains to the client in a matter-of-fact manner exactly what the team is about to do and why; this may provoke the client to cooperate or move into a seclusion room
• Refer to Box 24-3 page 497 for some other guidelines to restraint.

6. Describe aspects of a unit milieu that decreases likelihood of violent behavior.
The following are to be avoided to decrease likelihood of violence:Overcrowding.Staff inexperience.Provocative or controlling staff.Poor limit setting.Arbitrary revocation of privileges (Varcarolis pg 493).
• You want to make sure that the environment provides enough space for clients to prevent overcrowding.
• There also needs to be a balance between structure and quiet time
• Staff should be provided education in verbal de-escalation techniques
• Counseling of staff regarding the use of punitive and arbitrary approaches to clients
• The need to look for escalating events and how to provide immediate intervention to prevent overt violence (deescalating techniques, restraints/seclusion, and/or medication)
• Provide the client with the tools via psychotherapeutic approaches to the client new skills for handling anger.
• See box 24-2 page 496 for deescalating techniques, and refer to questions 5 and 6

7. Discuss reasons for seclusion and restraint as well as priority actions by a nurse caring for a client who has been restrained and secluded.
Seclusion or restraint is used in the following circumstances:
Ø Alternative interventions have been tried (documented) and failed. These include; verbal intervention, behavioral care plan, medication, decrease in sensory stimulation, removal of problematic stimulus, presence of significant other, frequent observation, and one-on-one observation of client.
Ø The client presents clear and present danger to self or
Ø The client presents a clear and present danger to others or
Ø The client has been legally detained for involuntary treatment and is thought to pose an escape risk or
Ø The client requests to be secluded or restrained.Priority actions by the nurse caring for a restrained or secluded client include:
Ø Be sure to receive or maintain an updated Physician’s Order for the restraint.
Ø Have nurse in constant attendance.
Ø Complete written record every 15 minutes.
Ø Release limb from restraint every 2 hours.
Ø Stretch limb through range of movement.
Ø Monitory vital signs, observe blood flow.
Ø Observe that restraint is not rubbing.
Ø Provide for nutrition, hydration, and elimination.
Ø Closely monitor client to determine the client’s ability to reintegrate into the unit activities (Varcarolis pg 497).

8. Differentiate between child abuse and neglect.
Child abuse is a broad category, which includes battering, neglect, physical endangerment, and sexual abuse.
Child neglect is either physical (failure to provide medical, dental, or psychiatric care needed to prevent or treat physical or emotional illnesses), developmental (failure to provide emotional nurturing or the physical or cognitive stimulation needed to ensure freedom from developmental deficits), or educational (failure to provide education in accordance with state law) (Varcarolis pg 511,786).
• Physical violence: is the infliction of physical pain or bodily harm
• Sexual violence: is any form of sexual contact or exposure without consent, or in circumstances in which the victim is incapable of giving consent (childhood sexual abuse destroys an individual’s positive self-concept and can interfere with the learning of self care skills)
• Emotional violence: is the infliction of mental anguish and take the form in the following; terrorizing through verbal threats; demeaning an individuals self worth; directing blatant or subtle hostility and hatred; persistently ignoring an individuals needs; consistently belittling and criticizing an individual; with holding warmth and affections; threatening an individual with abandonment or institutionalization.
• Neglect: can be physical, developmental, or educational.
• Physical neglect: failure to provide the medical, dental, or psychiatric care needed to prevent or treat physical or emotional illness
• Developmental neglect: failure to provide emotional nurturing and the physical and cognitive stimulation needed to ensure freedom from development deficits
• Educational neglect: when a child’s caretakers deprive the child of the education available in accordance with the state’s education laws.

9. Describe the cycle of violence and assessment priorities for a nurse caring for a victim of physical abuse.
Periods of intense violence alternate with periods of safety, hope, and trust during three phases known as the cycle of violence.
Ø Tension building stage is characterized by minor incidents such as pushing, shoving, and verbal abuse.
Ø Acute battering stage involves a serious battering incident where the perpetrator releases the build-up tension by brutal and uncontrollable beatings.
Ø Honeymoon Stage is characterized with kindness and loving behaviors. The perpetrator feels remorseful, is apologetic, brings gifts and makes promises to change
(Varcarolis pg 511).
Assessment priorities for a victim of physical abuse include
Ø A series of minor complaints such as headaches, back trouble, dizziness, accidents or falls.
Ø Bruising, scars, burns, and wounds around head face, chest, arms, abdomen, back, buttocks and genitalia.
Ø Be wary if the explanation does mot match the injury or if the client minimizes the seriousness of the injury, a high index of suspicion is key.
Ø Bruises on an infant younger than 6 months is suspicious, shaken baby syndrome is frequently overlooked and manifest as an abnormal pulmonary examination, or head circumference greater then 90th percentile.
Ø Nonverbal responses are also important such as hesitation or lack of eye contact (Varcarolis pg 514).
o Escalating-deescalating: conditions of anger and fear escalate until an incident of violence takes place, after which there is a defusing of tension and a brief feeling of safety; victims over time believe that the beatings are deserved and accept blame.
• Important interviewing guidelines are listed in box 25-4 page 512
• Priorities that should take place are initially started with safety and addressing any signs/ symptoms of the traumatic injuries that were inflicted during the incident. Should utilize the “Abuse Assessment Screen” found on page 517, figure 25-2
• Assess for potential problems in vulnerable families
• Physical, sexual, and/or emotional abuse and neglect, and economic maltreatment in family should be assessed
• Observe what family coping patterns are present
• Assess the client’s support system
• Assess for drug/ alcohol abuse
• Are there any suicidal or homicidal ideation
• Is post traumatic stress disorder present?
• Appropriate agencies need to be contacted to handle the matter.

10. Know the priority nursing diagnoses for clients with Alzheimer’s disease who may be suffering from abuse.
Risk for injury related to helplessness as evidenced by signs of violence
Page 510, table 25-3 on page 518.
• Elderly adults may become vulnerable because they are in poor mental and/pr physical health, or are disruptive (i.e. an Alzheimer client)
• There is a dependency need upon caretakers which places the client at risk for abuse.
• Refer to questions 8 and 9 for addition information
• View page 518, under Nursing diagnosis for potential Dx in the Elderly
• Some might include: Risk for injury; Anxiety; Fear; Disabled family coping; Interrupted family process; pain related to physical injuries.
• See also box 25-3 page 518 for potential nursing Dx in family violence

11. Differentiate between mild, moderate, severe, and panic levels of anxiety in victims of abuse.
Mild anxiety occurs in the normal experience of everyday living, the person’s ability to perceive reality is brought into sharp focus. A person may display physical symptoms such as slight discomfort, restlessness, irritability, or mild tension relieving behaviors.
Moderate anxiety causes perceptual field to narrow and some details are excluded from observation. The person will see, hear, and grasp less information than normal. Physical symptoms include tension, pounding hearth, increased pulse and respiration rate along with mild somatic symptoms.
Severe anxiety causes the perceptual field to be greatly reduced. The person may focus on one particular detail or many scattered details. Behavior is autonomic and the person may complain of increased severity of somatic symptoms along with trembling, pounding heart and hyperventilation.
Panic Level anxiety is the most extreme form and results in markedly disturbed behavior. The person is not able to process what is going on in the environment and may lose touch with reality (ie screaming or hallucinations) (Varcarolis pg 213-215).

12. Discuss priority assessments and discharge instructions for rape victims in emergency departments.
Assessment guidelines include
Ø Assess psychological trauma. Write down verbatim statements of the client.
Ø Assess level of anxiety
Ø Assess physical trauma. Use a body map and ask permission to take photos
Ø Assess available support system. Often partners or family members do not understand the trauma of rape and may not be the best supports to draw on.
Ø Identify community supports (attorneys, support groups, therapists) ect
Ø Encourage the client to tell his or her experience. Do not press the client to tell (Varcarolis pg 536).
Because the ramifications of rape are experienced for an extended time after the acute phase discharge instructions must include information for follow-up care. In addition information on likely physical concerns, emotional reactions, legal matters, victim compensation, and ways that the family and friends can help should be provided. Everything must be in writing since the amount of verbal information the client can retain may be limited due to anxiety. (Varcarolis pg 537-538).

13. Describe key features of the following disorders:
Anxiety disorders: Anxiety becomes a problem when it interferes with adaptive behavior, causes physical symptoms, or exceeds a tolerable level. The client with an anxiety disorder will use rigid, repetitive, and ineffective behaviors to try and control anxiety. The anxiety is so high that it interferes with personal, occupational, or social functioning (Varcarolis pg 228).
Ø Agoraphobia: Intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing, or in which help might not be available if a panic attack occurred. Feared places are normally avoided. This avoidance behavior can be debilitating and life constricting. (Varcarolis pg 234).
Ø Obsessive-compulsive disorder: Obsessions or compulsions cause marked distress to the individual, rituals are performed to relieve anxiety. The rituals are time consuming and interfere with normal routine, social activities, and relationships with others. Obsessions are thoughts, impulses, or images that persist and recur, so that they cannot be dismissed in the mind (think of a song stuck in your head). Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety (this decreases the anxiety temporarily until the compulsive act needs to be repeated). Table 14-4 page 235 shows common traits. These clients are humiliated by their acts but they cannot control it. (Varcarolis pg 234).
Ø Post-traumatic stress disorder: Repeated re-experiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others. Symptoms often begin within 3 months after the trauma but a delay of years is not uncommon. Post-traumatic stress disorder: characterized by repeated re-experiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others with intense fear, helplessness, and horror. Usually 3 months after the event occurred and has a couple of key features: Persistent re-experiencing (flashbacks); persistent avoidance of stimuli associated with the trauma; experience persistent numbing of general responsiveness (detached from others, feeling empty inside); also a persistent increased arousal (difficulty sleeping, difficulty concentrating, hypervigilance, or startled responses). There are issues of trust, and also chemical abuse involved. (Varcarolis pg 236).
Ø Social phobias: (Social anxiety disorder) is a severe anxiety or fear provoked by exposure to a social situation or a performance situation. Fear of public speaking is the most common social phobia (Varcarolis pg 234).
Ø Panic attacks: Sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom. The feelings of terror present are so severe that normal function is suspended. People experiencing panic attacks believe they are losing their minds or having a heart attack. Usually come out of the blue. (Varcarolis pg 232).
Somatoform disorder: Physical symptoms suggest a physical disorder for which there is no demonstrable base. There is a strong presumption that the symptoms are linked to psychobiological factors (Varcarolis pg 253).
Ø Conversion disorder: Development of one or more symptoms or deficits suggesting a neurological disorder (blindness, deafness, loss of touch) but which is NOT due to a general medical condition, a malingering or factitious disorder and is not culturally sanctioned. Symptoms are associated with psychological factors and are initiated or exacerbated by psychological stressors. They are not caused by a substance. Significant impairment is present (Varcarolis pg 255).
Ø Hypochondriasis: For at least 6 months preoccupation with fears of having a serious disease, these persist despite appropriate medical tests and reassurances. Other disorders are ruled out (somatic delusional disorders) and significant impairment in social or occupational functioning or marked distress is present (Varcarolis pg 255).
Ø Somatoform pain disorder: Pain in one or more anatomical sites which causes significant impairment in occupational or social functioning or marked distress. The pain is associated with psychological factors and is not intentionally produced or feigned (Varcarolis pg 255)
.Ø Body dysmorphic disorder (BDD): Preoccupation with some imagined defect in appearance, or excessive concern over a minor defect that is present. Preoccupation causes significant impairment and is not better accounted for by another mental disorder (Varcarolis pg 255).
Personality disorders: An enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (Varcarolis 275-276).
Ø Paranoid: Distrust and suspiciousness towards others, based on the belief (unsupported by evidence) that others want to exploit, harm, or deceive the person. They are hyper-vigilant, anticipate hostility and may provoke hostile responses. They are difficult to interview and, underneath the surface, are quite anxious about being harmed (Varcarolis 280).
Ø Schizoid: Is emotionally detached and does not seek out or enjoy close relationships (Varcarolis 280)
Ø Schizotypal: Odd beliefs lead to interpersonal difficulties. The client has an eccentric appearance and shows evidence of magical thinking or perceptual distortions. The client cannot understand the usual interpersonal cues in social situations and thus relates to others inappropriately. The person is more likely to seek psychiatric help then those with Schizoid PD because of the intense anxiety felt in social relationships (Varcarolis 280).
Ø Borderline: Instability in affect, identity, and relationships. Individuals desperately seek relationships to avoid feeling abandoned however often drive others away because of their excessive demands. Multiple dramatic suicidal gestures may be present and risk of suicide is increased (Varcarolis 282).
Ø Narcissistic: Arrogance with a grandiose view of self-importance. The person has a need for constant admiration along with a lack of empathy for others. Underneath the surface of arrogance they feel intense shame and fear that if they are bad they will be abandoned and are afraid of their mistakes (Varcarolis 284).
Ø Histrionic: Emotional attention-seeking behavior, in which the person needs to be the center of attention. The person is impulsive and melodramatic and may act flirtatious or provocative to get the spotlight (Varcarolis 282).
Ø Dependent: Extreme dependency in a close relationship with an urgent search to find a replacement when one relationship ends. The person has difficulty making independent decisions and are constantly seeking reassurance. Their submissiveness makes them vulnerable to abusive relationships. (Varcarolis 284).
Ø Obsessive-compulsive: Perfectionism with a focus on orderlineness and control. The person becomes so preoccupied with details and rules that they may not be able to accomplish a given task. They do not have full blown obsessions or compulsions but do not have insight about their own difficult behavior (Varcarolis 286).

14. Describe complications of re-feeding syndrome in clients with anorexia nervosa.
A potentially catastrophic treatment complication in which the demands of a replenished circulatory system overwhelm the capacity of a nutritionally depleted cardiac muscle, which results in cardiovascular collapse (Varcarolis 308).

15. Discuss binge-purge syndrome and likely triggering factors.
This typically has a binge eating behavior (eating till they are literally stuffed) followed by self induced vomiting (laxatives and diuretics can also be used). There are depressive signs and symptoms and have problems with: Interpersonal relationships; problems with self concept; and problems with impulsive behavior. There is increased level of anxiety and compulsivity, possible chemical dependence, and compulsive stealing. They can be found to have 5-8 episodes per night of the binge eating followed by the purging.
• Refer to table 17-1 for phenomena surrounding bulimia on page 303, also refer to box 17-1 on page 304 for some medical complications

16. Name some physical assessment findings in the client with severe anorexia nervosa.
Low weight, amenorrhea, yellow skin, lanugo, cold extremities, peripheral edema, muscle weakening, constipation, hypotension, bradycardia, heart failure, kapokalemia, anemic pancytopenia, and decreased bone density (Varcarolis 302).

17. Describe the defense mechanism of splitting and circumstances that provoke its use.
Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. Aspects of self or others tend to alternate between opposite poles either all good or all bad. This defense mechanism is prevalent in personality disorders, especially the borderline ones (Varcarolis pg 282).
• Splitting usually takes place when a client tries to be manipulative to get there way and will use flattery, seductiveness, even instilling guilt to get there way. The second the nurse does not provide what the client desires then splitting takes place. Staff splitting can occur because of the clients which is why it is important to have supervision over the staff to monitor for splitting and have debriefing once a week to prevent it.
• Read Case study and plan of care 16-1 on page 290 to get a better picture of a borderline client

18. List pertinent client education for those who are prescribed alprazolam (Xanax) for acute anxiety disorders.
The medication reduces the ability to handle mechanical equipment, do not drink alcohol or take other anti-anxiety drugs because depressant effects can be potentiated and avoid caffeine. Avoid becoming pregnant because the drug increases the risk for congenital anomalies, do not breast feed because the drug can be excreted in the milk. Cessation may cause withdrawal symptoms, take with food or shortly after to reduce gastrointestinal discomfort. Antacids delay absorption, cimetidine interferes with metabolism, alcohol and barbituarates can cause increased sedation (Varcarolis pg 246).

19. Name a drug that might be prescribed for the social phobia – fear of public speaking.
Antidepressant Selective serotonin reuptake inhibitors are the first line treatment for anxiety disorders because they have a more rapid onset of action and fewer problematic side effects then alternatives. Keltner mentions Paroxetine (Paxil) and Sertraline (Zoloft) specifically. Fluoxetine (Prozac) is our prototype drug in that class (Keltner pg 251).

20. Discuss the drug buspirone (Buspar) and contrast it with the drug diazepam (Valium) for those clients with anxiety.
Buspirone (Buspar) is a nonbezodiazepine anxiolytic used to treat anxiety disorders. It does not cause dependence and so can be used by clients with known substance abuse problems. It does however take 2-4 weeks for full effects; it may be used for long-term treatment and must be taken regularly. In contrast diazepam (Valium), an anxiolytic benzodiazepine has a rapid onset of action but has the potential for dependence. It can cause sedation, impair performance, and is associated with falls in elderly. It is ideal for short periods until other medication or treatments reduces symptoms (Keltner pg 237).
• Buspar is a drug that reduces anxiety without having strong sedative-hypnotic properties
• It is much better tolerated than benzodiazepines because it does not induce sleepiness.
• Since it is not a CNS depressant, it will not have adverse affects with other depressants
• It seems to act as an antagonist to presynaptic serotonin receptors, thus stopping the negative feedback mechanism which usually stops the secretion of serotonin. By stopping this feedback, there is a greater amount of serotonin in the synaptic cleft. Which presumably accounts for its benefit of decreased anxiety.
• Valium is a benzodiazepine which acts as a depressant and can cause significant adverse affects if mixed with other depressants.
• This drug works by binding to GABA receptors to help increase the infinity of GABA, thus increasing the affects of GABA (only works if GABA is present, unlike Buspar which does not have this stipulation).

SJDC ADN Class of 2008

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