A 7-year old is hospitalized with a diagnosis of autism The nurse observes the child upon admission. Which of the following information regarding his behavior would confirm that he is an autistic child ?
Situation: A public health nurse during one of her home visits to a postpartum mother observed Noel, 5 years old sitting by himself in the corner of the room, rocking back and forth and spinning his toy occasionally.
A child suffering from autism manifest one of the following behaviors:
A. often shifts from uncompleted activity to another
B. talks excessively
C. may indulge in repetitive play with fingers and hands
P -P roviding consistent rewards and consequences for behavior
I -I ssuing daily report cards for behavior
G -G ive point systems for positive and negative behavior
Decrease glucose; early malnutrition; prenatal trauma; hereditary; social Etiology Clumsy, hyperactive, inattentive Behavior Dirty, low self-esteem, Appearance AD/HD safety Nursing Priority Impaired social interaction; risk for injury (directed to others) NX Excessive talking, burst out in class Communication
Eating disorders can be viewed on a continuum: the anorexic eats too little , the bulimic eats chaotically , and the obese person eats too much.
Eating disorders overlap: 50% of clients with anorexia exhibit bulimic behavior, 35% of normal-weight clients with bulimia have a history of anorexia.
More than 90% of clients with eating disorders are female.
Verbalization of body dysmorphic image Denial Communication Diet, diet, diet…vomit Binge eating; purging; still on diet Diet, diet, diet…die Fear of weight gain; preoccupation with food (knowledgeable in nutrition) Behavior Dao ming Su… Lanugo, hypothermia, amenorrhea, parotitis Manifestations Bulimia Anorexia
Stay with the client one hour after eating; Don’t allow client to go to toilet at once Stay with the client one hour after eating; Don’t allow client to go to toilet at once Environment Imbalance nutrition more than or less than Nutrition Body Image disturbance Nx CBT; weight gain; behavioral modification / Kind Firmness CBT; weight gain; behavioral modification / Kind Firmness Treatment / Therapy Nutrition; promote self-esteem Nutrition, promote self-esteem Nx Priority Bulimia Anorexia
Withdrawal symptoms in 6 to 8 hours or up to 1 week
Withdrawal syndrome is characterized by symptoms opposite of the acute effects of the drug:
Autonomic hyperactivity (increased pulse, blood pressure, respirations, and temperature), hand tremor , insomnia, anxiety, nausea, and psychomotor agitation; seizures and hallucinations occur rarely in severe benzodiazepine withdrawal
Detoxification from sedatives, hypnotics, and anxiolytics is managed by tapering the amount of the drug
Dysphoria accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation; withdrawal symptoms are referred to as “crashing”--the person may experience depressive symptoms, including suicidal ideation, for several days
Stimulant withdrawal is not treated pharmacologically
Distort reality and produce symptoms similar to psychosis, including hallucinations (usually visual) and depersonalization
Toxic reactions to hallucinogens (except PCP) are primarily psychological; overdoses as such do not occur. PCP toxicity can include seizures, hypertension, hyperthermia, and respiratory depression
Hallucinogens can produce flashbacks that may persist for a few months up to 5 years
Treatment is supportive:
Isolation from external stimuli; physical restraints; (for PCP) medications to control seizures and blood pressure; cooling devices; mechanical ventilation
Agitation, insomnia, convulsions, ataxia, nausea, vomiting, hypertension with postural hypotension, psychotic Anxiety, sweats, tremors, flushed face, irritability, sleepiness, confusion, seizures, delirium Withdrawal Signs and symptoms Librium, phenobarbital Librium, Valium Librium, Serax, Valium, VIstaril Detoxification agents Loss of inhibition 3-5 days Alcohol None Natural Synthetic Slow drug taper, 2-4 weeks Phenobarbital Relaxation Euphoria Slow drug taper, up to 2 weeks Valium Intoxication Length of acute detoxification Drug
General fatigue, apathy, depression , drowsiness, irritability, paranoia Yawning , dilated pupils, gooseflesh, vomiting, diarrhea, runny nose, and eyes, sleeplessness, anxiety, irritability, elevated blood pressure and pulse, craving for narcotics Withdrawal Signs and symptoms Not required Methadone or other tapering opiate or non-opiate withdrawal regimens Detoxification agents High ecstasy, relaxation, euphoria 3-5 days 3-5 days 3-5 days 2 weeks + Heroin Morphine Demerol Methadone Rush, high fatigue 3-5 days Amphetamines Intoxication Length of acute detoxification Drug
Withdrawal effects: Alcohol – tremors Narcotics – yawning Hallucinogens – perceptual / sensory disturbance Marijuana – amotivational syndrome Amphetamines - anxiety Few signs of withdrawal, craving for marijuana, general anxiety and restlessness Withdrawal Signs and symptoms Not required Detoxification agents Euphoria, ecstasy with no anxiety 2-3 days (metabolites remain the body up to 2 weeks) Marijuana Intoxication Length of acute detoxification Drug
Q: Situation: Mr. Albert, a 45 year old married man has been alcoholic for three years. He voluntarily sought admission to the rehabilitation center for detoxification. He started drinking when he was terminated from his work abroad.
Due to his drinking problem, his family life deteriorated. The nurse identifies on eof the following as an appropriate nursing diagnosis:
Q: A client informs his nurse therapist that he has been convicted for breaking and entering into homes and stealing women’s undergarments. Further questioning by the nurse reveals that the client requires these items in order to become sexually aroused. Based on this information, the nurse suspects the client is experiencing the psychosexual disorder of:
Rationale : Fetishism refers to the use of an object, foot apparel, for sexual arousal. Voyeurism involves the act of observing unsuspecting individuals, usually strangers, who may be naked or in the process of disrobing. Frotteurism involves intense, recurrent fantasies of, and/or actual touching and rubbing the genitalia against a non-consenting person, in association with sexual arousal. The behavior usually occurs in crowded places, and the individual usually fantasizes an exclusive, caring relationship with the victim. Sexual masochism involves the act of being humiliated, bound, beaten and otherwise made to physically suffer for purposes of sexual stimulation.
Rationale : A calm, predictable environment which limits external stimuli and allows for a regular routine helps to support the patient’s cognitive function. Attempting to reason with the patient or using reality orientation may increase anxiety without promoting function. Using memory aids and offering clear and simple explanations may help to reduce confusion and disorientation while promoting security. Restraints are avoided if at all possible as they may increase agitation.
Secondary Insomnia- inability to initiate or maintain sleep or nonrestorative sleep due to a psychiatric disorder such as depression, anxiety or schizophrenia; general medical or neurologic disorders; pain and abuse
Jet Lag : sleepiness and alertness that occur at an appropriate time of day relative to local time; occurring after repeated travel across more than one time zone
Narcolepsy: overwhelming sleepiness in which the individual experiences irresistible attacks of refreshing sleep, cataplexy (loss of muscle tone) and/or hallucinations or sleep paralysis at the beginning or end of sleep disorders.
Nightmare Disorder : repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely frigthening dreams, usually involving threats to survival, security or self-esteem
Situation: Mercy, a 43 year old married woman was referred to the psychiatric clinic by her physician She has insomnia, anxiety, fatigue and loss of interest in her usual activities which started after her husband left her.
A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family relates that one day the client looked at a linen sheet on a clothesline and thought it was a ghost The nurse recognize that was: