Suddarth's Textbook of Medical-Surgical Nursing, 13th Edition + Brunner & Suddarth's Textbook of Medical-Surgical Nursing Study Guide, T13th Edition: exam 4 nursing 3 Flashcards
Crises are universal experiences
Crisis represents struggle for
equilibrium and adjustment when problems seem unsolvable
Presents
both danger to personality organization as well as opportunity for
personal growth
Concept of Crisis
acute, time-limited event experienced as overwhelming emotional reaction
CRISIS
: assistance in coping for those in crisis. Interventions used are broad, creative and flexible
CRISIS INTERVENTION
Higher level of functioning
Same level of functioning
Lower
level of functioning
Crisis is self-limiting (4 to 6 weeks)
Resolution of crisis:
person will emerge at
return individual to previous level of functioning
Deal with
person’s present problems: “here and now”
Nurse takes active,
directive role when intervening
Important to set realistic goals
Goal of crisis intervention
Related to identified developmental stages occurring throughout
life
Each new stage requires new coping mechanisms
Examples
Marriage, birth of a child, retirement
Maturational: TYPES OF CRISIS
Arises from external rather than internal source; usually
unanticipated
Examples
Loss of job, death of loved one,
change in financial status, divorce
Situational: TYPES OF CRISIS
Crisis or disaster not part of everyday life
Arise
from
Natural disaster (floods, fires, earthquakes)
National
disaster (acts of terrorism, war, riots, airplane crashes)
Crime
of violence (rape, assault, murder in workplace/school, bombing in
crowded areas, abuse)
U.S.: 460 major disasters from 1990-2000
Adventitious : TYPES OF CRISIS
person is confronted by conflict or problem that threatens self-concept and causes anxiety
PHASE 1 OF CRISIS
if usual defensive response fails and threat persists, anxiety continues to rise
PHASE 2 OF CRISIS
if trial-and-error attempts fail, anxiety can escalate to panic levels
PHASE 3 OF CRISIS
if problem is not solved and new coping skills are ineffective,
anxiety can overwhelm person
Serious personality disorganization,
depression, confusion, violence against self/other can occur
PHASE 4 OF CRISIS
Patient’s perception of precipitating event
Perception critical:
one person’s minor irritation can be another’s major
problem
Assess patient’s situational supports
Does stressful
event also affect patient’s family/support systems?
Assess
patient’s personal coping skills
Evaluate patient’s anxiety level
and use of defense mechanisms
Nursing Process: Assessment Guidelines
Risk for self- or other-directed violence, Spiritual distress, Hopelessness, Anxiety (moderate, severe, panic), Disturbed thought processes, Ineffective coping, Risk for post-trauma syndrome
Outcomes identification
Outcomes need to realistic
Patient
and family need to be involved in identifying outcomes
Outcomes
need to be congruent with patient’s values, cultural expectations
Planning
Nurse plans interventions via variety of
modalities
Disaster nursing, mobile crisis units, group work,
health education and crisis prevention, victim outreach programs,
telephone hotlines
Implementation
Nurse can intervene for individual, group, or
community
Questions important
How much has crisis affected
person’s life?
How is state of disequilibrium affecting patient’s
significant others?
Goals of intervention: patient safety,
anxiety reduction
Assess for suicidal or homicidal thoughts
Ensure patient
safety
Listen carefully to patient’s perceptions of
problem
Use directive and creative approaches in intervening
Common Nursing Interventions for Patient in Crisis
Identify patient support systems and mobilize these
Plan with
patient interventions acceptable
Plan regular follow-up to assess
patient’s progress toward established goals
Common Nursing Interventions for Patient in Crisis
Primary
Promote mental health and decrease incidence of crisis
Secondary
Interventions to prevent prolonged anxiety and
personality disorganization
Tertiary
Support for those who
have experienced severe crisis and are recovering
Goal:
facilitate optimal level of functioning
Levels of Nursing Care for Crisis Intervention
used in following situations
Debrief staff following patient
suicide
Help staff/students following incident of school
violence
Debrief rescue personnel who responded to disaster
Critical Incident Stress Debriefing (CISD)
Performed 4-8 weeks after initial interview
Successful
intervention characterized by:
Patient’s anxiety and ability to
function has returned to pre-crisis level
Questions to
ask
Is patient safe?
Has patient developed adaptive
coping?
Has patient maintained optimum level of function?
Nursing Process: Evaluation
Individuals with depression experience great personal pain and
suffering
Depression common to all ages, races, and both
sexes
Vulnerability to depression can be related to genetics and
life stressors
Concept of Depression
Fourth leading cause of disability in U.S.
Lifetime prevalence
of major depressive disorder is 16.6%
More common in women
Prevalence
Frequently with other psychiatric disorders
Anxiety disorders,
schizophrenia, substance abuse, and eating disorders
Increases
with presence of medical disorder
Comorbidity
Children as young as age 3 have been diagnosed with
depression
Adolescents have increased incidence
Often
associated with substance abuse and antisocial behaviors
Older
adults (>65) increased incidence
Increased suicide rate occurs
with depression in this age group
Depressive Disorders: Developmental Aspects
Genetics
Twin and adoptive studies point to genetic
factors
Biochemical factors: multiple neurotransmitters (NT) may
be involved
Monoamine NT (serotonin, noradrenaline)
Research
focused on role of dopamine, acetylcholine, and GABA
receptors
Stressful life events can deplete NTs
Biological Theories Related to Depressive Disorders
Neuroendocrine factors
Hyperactivity of
hypothalamic-pituitary-adrenal cortex axis implicated
Increased
cortisol secretion
Dexamethasone suppression test (DST) helps
determine cortisol oversecretion
Imaging results
CT and MRI
scans show ventricle enlargement, cortical atrophy, sulcal widening
Biological Theories Related to Depressive Disorders
Psychodynamic factors: stress-diathesis model
Early life trauma
sensitizes stress pathways in brain, increasing vulnerability to
depression
Cognitive theory: Aaron Beck
Automatic negative
thoughts (of self, future and the world) related to
depression
Learned helplessness: Martin
Seligman
Individual’s perception of lack of control over
stressful life events leads to depression
Other Theories Related to Depressive Disorders
Manifested by emotional, cognitive, physical, and behavioral symptoms
occurring nearly every day for at least a 2-week period
Symptoms
represent a change in functioning
Major Depressive Disorder (MDD)
DSM-IV-TR diagnosis can include specifiers
Psychotic features;
catatonic features; melancholic features; postpartum onset; seasonal
affective disorder (SAD); atypical features
Major Depressive Disorder (MDD)
Emotional and cognitive symptoms: depressed mood,
feelings of
worthlessness and guilt,
anhedonia, hopelessness,
decreased concentration,
recurrent thoughts of death/suicide
PHYSICAL
weight gain or loss,
insomnia or
hypersomnia,
increased or decreased motor activity,
anergia,
constipation
Major Depressive Disorder: Common Symptoms
Characterized by chronic depressive syndrome usually present for most
of day, more days than not, for at least a 2-year period (APA,
2000b)
Not usually severe enough for hospitalization unless
person becomes suicidal
Onset is usually early childhood, teenage
years, or early adulthood
Dysthymic Disorder: DD
Use any of the multiple standardized depression screening tools
available
Evaluate patient for suicidal ideation
Determine
presence of emotional, cognitive, and physical symptoms of
depression
Determine presence of other medical conditions
contributing to depression
Nursing Process: Assessment Guidelines: DEPRESSION
Determine history/current support system
Ascertain recent
“triggering event” related to loss
Determine cultural
beliefs/spiritual practices related to mental health treatment
Nursing Process: Assessment Guidelines: DEPRESSION
Common nursing diagnoses assigned
Risk for suicide,
Hopelessness, Ineffective coping, Social isolation, Self-care
deficit
Outcomes identification
Important to include
specific goals for patient safety and outcomes related to
vegetative/physical signs of depression
Nursing Process: Diagnosis and Outcomes Identification: DEPRESSION
Planning
Geared toward specific phase of depression and
particular symptoms exhibited
Implementation
Focus
interventions on specific symptoms with priority related to suicide
prevention
Teach patient and family about symptoms of depression,
treatment, and medication
Focus on predischarge counseling to
alleviate tension on family system
Nursing Process: Planning and Implementation: DEPRESSION
Understand that patient may need more time to reply to
communication
Silence/sitting with patient can be
therapeutic
Allow time for patient to respond
Make
observations related to patient/situation or environment
Avoid
platitudes
Listen carefully for covert messages and question
directly about suicide
Communication Guidelines for Patient with Depression
Milieu therapy
Structured hospital environment
helpful
Follow protocol for suicide
prevention
Psychotherapy
Cognitive-behavioral (CBT) and
interpersonal (IPT) therapies used
Group therapy
Helps
decrease feelings of isolation, hopelessness, helplessness and alienation
TREATMENT FOR DEPRESSION
Advantage
Can help alter withdrawal, vegetative symptoms,
activity level; improve self-concept
Drawback
Can take 1-3+
weeks to note improvement
Safety considerations
Concerns
about relationship between use of antidepressant drugs and suicide;
however, no conclusive evidence to support this
Treatment for Depression: Antidepressant Medications
Action: inhibit reuptake of norepinephrine and serotonin by
presynaptic neurons
Dose: start low and gradually
increase
Common adverse reactions
Dry mouth, blurred vision,
constipation, and urinary retention
Sedation
Potential
dysrhythmias, hypotension, myocardial infarction
Treatment for Depression: Tricyclic Antidepressants (TCAs)
Action: selectively block neuronal uptake of serotonin
Common
adverse reactions
Agitation, anxiety, sleep disturbance, tremor,
sexual dysfunction, headache, weight changes, nausea, diarrhea, dry
mouth
Potential toxic effect
Serotonin syndrome (SS):
potentially fatal reaction when more than one antidepressant used
Treatment for Depression: Selective Serotonin Reuptake Inhibitors (SSRIs)
Symptoms
Hyperactivity, severe muscle spasms, tachycardia
leading to cardiovascular shock, hyperpyrexia, hypertension, delirium,
seizures, coma, death
Treatment
Stop offending
agents
Provide respiratory, circulatory support in intensive care
environment
Use medications to reverse excess serotonin:
cyproheptadine, methysergide, propranolol
Symptoms and Treatment of Serotonin Syndrome (SS)
Action: affect variety of NTs including those affecting serotonin and
norepinephrine
Advantage
Can target unique populations of
depressed individuals
Can be used to treat other conditions
Treatment for Depression: Newer Atypical Agents
Action: enhance NTs at synapse by preventing the enzyme monoamine
oxidase from breaking them down
Common adverse
reactions
Hypotension, sedation, insomnia, changes in cardiac
rhythm, muscle cramps, sexual impotence, anticholinergic effects,
weight gain
Potential toxic reaction
Hypertensive crisis
Treatment for Depression: Monoamine Oxidase Inhibitors (MAOIs)
Can occur when monoamine oxidase inhibition prevents the breakdown of
tyramine, which is used by the body to make
norepinephrine
Preventing hypertensive crisis involves
maintaining a special diet (low tyramine) and avoiding medications
that contain ephedrine/other psychoactive substances
Hypertensive Crisis and MAOIs
Electroconvulsive therapy (ECT)
Course of treatment: 2 or 3
treatments/week for total of 6 to 12 treatments
For patients not
responding to antidepressants or for depression with
psychosis
Potential adverse reactions
Initial confusion and
disorientation on awakening from treatment
Memory deficits
Treatment for Depression: Somatic Treatments
Vagus nerve stimulation: long-term implanted treatment device
approved by FDA for patients with treatment-resistant
depression
Action: not well understood, affects neurotransmitters
implicated in depression
Device implanted in upper chest that
sends electrical signals to left vagus nerve in the neck at regular intervals
Treatment for Depression: Somatic Treatments
Light therapy
First-line treatment for seasonal affective
disorder (SAD)
Action: suppresses nocturnal secretion of
melatonin, which seems to have beneficial effect on depression
Treatment for Depression: Integrative Therapies
Plant with antidepressant properties
Not regulated by
FDA
Research suggests effective in mild depression
ST JOHNS WART
Research indicates mood elevation and decreased depression occurs with moderate exercise
EXCERSISE
Evaluate short-term indicators and outcome criteria
Reduction in
suicidal thoughts
Able to state alternatives to
suicide
Decrease in severity of emotional, cognitive and
vegetative/physical symptoms of depression
Nursing Process: Evaluation; DEPRESSION
M- Meds = Nitroprusside, Morphine
A - Airway
D - Decrease
preload ( nitroglycerin IV)
D - Diuretics ( Lasix)
O -
Oxygen
G - Blood Gases (ABGs)
PULMONARY EDEMA - MADDOG
Formerly called manic-depressive illness
Characterized by two
opposite poles
Euphoria
Depression
Chronic, recurring,
life-threatening illness
Individuals experience interpersonal,
occupational difficulties even during remission
Associated with
highest lifetime suicide rate among psychiatric disorders
Concept of Mood Disorders: Bipolar Disorder
At least one episode of mania alternating with major
depression
Psychosis may accompany manic episode
Bipolar I
Hypomanic episode(s) alternating with major depression
Not
accompanied by psychosis
Bipolar II
Hypomanic episodes alternating with minor depressive episodes
TYPES OF BI POLAR DISORDER : Cyclothymia
Rapid cycling (four or more episodes in 12-month period
TYPE OF BI POLAR DISORDER : Specifier from DSM-IV-TR






Lifetime prevalence in U.S. estimated at 3.9%
First episode
commonly occurs between ages 18 and 30
Prevalence
Substance use disorders, personality disorders, anxiety disorders,
attention deficit hyperactivity disorder
Medical conditions:
cardiovascular, cerebrovascular, metabolic disorders
Comorbidity
Genetics
Twin, family, and adoptive studies support strong
genetic component
Specific genes identified on chromosome 13
associated with bipolar disorder
Biological Theories Related to Bipolar Disorders
Neurobiological factors
Hypothalamic-pituitary-thyroid-adrenal
axis dysfunction implicated
Neuroanatomical
factors
Dysregulation in prefrontal cortex and medial temporal
lobe implicated
Biological Theories Related to Bipolar Disorders
Psychological influences
Stressful life events
Families
characterized by high expressed emotion most associated with
relapse
Cultural considerations
More prevalent in higher
socioeconomic classes
Higher rates noted among creative writers,
artists, highly educated men and women
Other Theories Related to Bipolar Disorders
Periods of abnormal and persistently elevated mood for at leas:
4 days for hypomania
1 week for
mania
Hypomania
Episode associated with decreased
function
Hospitalization not required
BI POLAR DISORDER
Episode associated with marked impairment in
function
Hospitalization necessary
BI POLAR MANIA
Mood symptoms
Unstable euphoric mood, intense feeling of
well-being, mood may change to irritation and anger when
thwarted
Behavioral symptoms
Excessive hyperactivity,
involved in pleasurable activities with painful consequences, sexual
indiscretion, excessive spending of money, mode of dress/makeup may be
outlandish, bizarre
Bipolar Disorder: Common Symptoms
























Physical symptoms
Nonstop activity, minimal food intake, little
or no sleep
Can lead to exhaustion and even death
Cognitive symptoms (thought processes)
Poor
concentration, problems with verbal memory, sustained attention and
executive functioning (may persist even in remission)
Flight of
ideas: continuous flow of accelerated speech with abrupt changes from
topic to topic usually based on understandable associations
Disorganized and incoherent speech with content often
sexually explicit and grossly inappropriate
Clang associations:
stringing together of words because of rhyming sounds
Grandiose
persecutory delusions
Bipolar Disorder: Common Symptoms
Determine if patient dangerous to self or others
Presence of
physical exhaustion
Poor impulse control
Uncontrolled
spending of money
Determine medical symptoms
Dehydration, infections
Nursing Process: Assessment Guidelines ; BI POLAR
Determine presence of other medical/psychiatric
conditions
Determine if hospitalization is
necessary
Determine patient’s and family’s understanding of
disorder, treatment, medications, support groups
Nursing Process: Assessment Guidelines: BIPOLAR
Common nursing diagnoses
Risk for injury, Risk for self- or
other-directed violence, Risk for suicide, Ineffective coping,
Disturbed thought processes, Interrupted family processes, Impaired
verbal communication, Imbalanced nutrition: less than body requirements
Nursing Process: Diagnosis and Outcomes Identification: BIPOLAR
Outcomes identification
Acute phase: goal is prevention of
physical injury and decrease in symptoms manifested
Continuation
of treatment phase: goal is relapse prevention
Maintenance phase:
goal is relapse prevention and limiting severity of future episodes
Nursing Process: Diagnosis and Outcomes Identification
Planning
Geared toward particular phase of mania as well as
other co-occurring issues (e.g., risk of suicide, risk of violence,
family/legal crisis, substance abuse, risk-taking behaviors, medical compliance)
Nursing Process: Planning and Implementation: BI POLAR
Implementation
Directed toward establishing therapeutic
alliance
Acute phase implementations related to safety in
hospital environment, establishment of controls and medical stabilization
Nursing Process: Planning and Implementation : BIPOLAR
Use firm, calm approach
Use short, concise
statements
Remain neutral; avoid power struggles
Be
consistent
Important with firm limit setting
Hear and act on
legitimate complaints
Firmly redirect energy into appropriate channels
Nursing Communication Guidelines for Patient with Bipolar Disorder
Seclusion and restraints may be used if patient becomes dangerously
out of control and other least restrictive measures
failed
Purposes: reduces overwhelming stimuli, protects patient
and others from injury, prevents destruction of property
Use of seclusion/restraint associated with complex
legal, ethical, and therapeutic issues
Follow well-established
institutional protocols for use of these measures
Treatment for Bipolar Disorders: Milieu Therapy
Used for lifetime maintenance therapy
Lithium carbonate:
first-line treatment for mania
Therapeutic blood level must be
reached for drug to be effective (usually takes 7-14
days)
Maintenance/therapeutic blood levels between 0.4 and 1.3
mEq/L
Used in combination with antipsychotics or antianxiety
medications in initial acute mania
Treatment for Bipolar Disorders: Mood Stabilizers
Adverse reactions
Related to lithium toxicity—fine line between
therapeutic and toxic levels
Lithium toxicity ranges from mild to
moderate and severe symptoms depending on blood level
Severe
symptoms include ataxia, ECG changes, clonic movements, seizures,
coma, and death
Major long-term risks include hypothyroidism and kidney
impairment
Necessity for periodic thyroid and renal function tests
Treatment for Bipolar Disorders: Lithium Carbonate
Patient and family teaching important
Continue drug therapy to
prevent relapse
Maintenance of normal diet with normal salt and
fluid intake (1500-3000 mL/day)
Lithium decreases sodium
absorption and low sodium levels/dehydration cause lithium
toxicity
Stop taking lithium and call physician if symptoms of
dehydration develop from sweating and/or nausea, vomiting, diarrhea
Treatment for Bipolar Disorders: Lithium Carbonate
Adjunct to lithium as well as treatment for patients not responsive
to lithium
Commonly used drugs
Carbamazepine (Tegretol),
divalproex (Depakote), lamotrigine (Lamictal)
Adverse effects of
individual antiepileptic drugs vary but include such problems as
sedation, agranulocytosis, hepatitis, life-threatening rash
Treatment for Bipolar Disorders: Antiepileptic Medications
Can be used to subdue severe manic behavior in patients who are
treatment resistant to usual medications
May also be used in
patients who are suicidal
Treatment for Bipolar Disorders: Electroconvulsive (ECT) Therapy
Cognitive-behavioral therapy
Cognitive restructuring effective
in decreasing affective symptoms, increasing social functioning, and
reducing relapse
Interpersonal and social rhythm therapy
(IPSRT)
Focuses on resolution of interpersonal problems and
prevention of further disputes
Treatment for Bipolar Disorders: Psychotherapy
Family-focused therapy
Treatment approach focusing on
communication within family, communication skills, and education to
prevent relapse
Treatment for Bipolar Disorders: Psychotherapy
Short-term and
intermediate evaluation focused on goal attainment such
as:
Are patient’s vital signs stable?
Is
patient well hydrated ?
Is patient able to control behavior or
respond to external controls?
Does patient sleep at least 5
hours per night?
Does family have understanding of illness and treatment?
Nursing Process: Evaluation: BIPOLAR
Long-term evaluation focused on goal attainment such as compliance with medication regimen, resumption of functioning in community, and family
Nursing Process: Evaluation; BIPOLAR
















complete or incomplete disruption in the continuity of bone
structure
Complete: a break across the entire cross section of
the bone, can be displaced
Incomplete: break through only a part
of the cross section
Comminuted: several bone
fragments
Closed: simple, no break in the skin
Open:
compound, complex; skin or mucous membranes compromised
Fractures
Pain: continuous, increase in severity until mobilized, muscle
spasms
Loss of function: unable to function properly, abnormal
movement
Deformity: displacement
Shortening: long bones,
extremity appears shorten compared to other
extremity
Crepitus
Localized edema and ecchymosis
Abnormalities: Fractures: ASSESSMENTS
First immobilize the body part, splinting; assess neurovascular
status before and after splinting
Open fracture: cover wound with
sterile dressing to prevent further contamination
Reduction:
restoration of the fracture fragments
Closed: manipulation and
manual traction
Open: surgical approach
Immobilization:
after reduction, bone fragments are immobilized by external or
internal fixation/cast/traction
Abnormalities: Fractures: Management
Nursing Management
Closed: Education, page 1163 Chart
43-1
Cast Care Page 1109 Chart 41-4
Open: Prevent infection
of the wound, soft tissue, and bone and promote healing
Risk for
osteomyelitis, tetanus, gas gangrene
External fixation:
elevation, neurovascular assessment, pin care
Abnormalities: Fractures
Shock: hypovolemic shock from hemorrhage
Fat embolism: fracture
of long or pelvic bones, crush injuries; fat gobules may diffuse from
the marrow into the vascular compartment, can occlude
vessels
Onset is rapid: Hypoxemia, neurologic compromise,
petechial rash
Management: respiratory support
Compartment
Syndrome: a sudden and severe decrease in blood flow to the tissue
distal to an area of injury; ischemic necrosis
Report of severe,
unrelenting pain, worse with ROM, pallor, pulselessness, paresthesia,
paralysis
Emergency: measures to restore tissue perfusion (fasciotomy)
Complications:
DVT/PE
Delayed union, malunion, nonunion
Avascular Necrosis
of bone: bone loses its blood supply and dies
Complex Regional
Pain Syndrome: painful sympathetic nervous system problem: severe
burning pain, local edema, stiffness
Heterotopic Ossification:
abnormal formation of bone
Abnormalities: Fractures: Complications
uses a pulling force to promote and maintain alignment to an injured
part of the body
Must be continuous to be effective
Skeletal
traction is never interrupted
Weights are not removed unless
intermittent traction is ordered
Any factor that can reduce the
effective pull or alter is eliminated
Patient must be in good
body alignment in the center of the bed
Ropes must be
unobstructed
Weights must hang freely and not rest on the
bed
Knots in the rope or the footplate must not touch the pulley
or foot of the bed
TRACTION
Skin: pulling force is applied by weights that are attached to the
client with Velcro, tape, straps, boots, cuffs,
2-3.5kg
Buck’s
Skeletal: continuous traction, passing a
metal pin or wire through the bone, ropes and weights are attached the
end of the pin
Nursing Management:
Maintain
traction
Maintain Position
Prevent skin
breakdown
Assess Neurovascular
TRACTION


























Concept of Mood
Disorders: Bipolar Disorder
• Formerly
called manic-depressive illness
• Characterized by two opposite
poles
• Euphoria
• Depression
• Chronic, recurring,
life-threatening illness
• Individuals experience interpersonal,
occupational difficulties even during remission
• Associated
with highest lifetime suicide rate among psychiatric
disorders
Types of Bipolar Disorders
**Know this
•
Bipolar I
• At least one episode of mania alternating with major
depression
• Psychosis may accompany manic episode
• One
episode
• Bipolar II
• Hypomanic episode(s) alternating
with major depression
• No psychosis
• Cyclothymia
•
Hypomanic episodes alternating with minor depressive episodes
•
Duration 2 years, pt is very irritable, mind raises, thought are so
quickly
• Specifier from DSM-IV-TR
• Rapid cycling (four
or more episodes in 12-month period)
Bipolar Disorders: Prevalence and Comorbidity
•
Prevalence
• Lifetime prevalence in U.S. estimated at 3.9%
•
First episode commonly occurs between ages 18 and 30
**A lot of
people are suffering with this disorder**
• Comorbidity
•
Substance use disorders, personality disorders, anxiety disorders,
attention deficit hyperactivity disorder
• Medical conditions:
cardiovascular, cerebrovascular, metabolic disorders
Biological Theories Related to Bipolar Disorders
• What are
some reasons?
• Genetics
• Twin, family, and adoptive
studies support strong genetic component
• Specific genes
identified on chromosome 13 associated with bipolar disorder
•
Substance abuse
• Metabolic disorder: electrolyte
imbalance
• What is going on in this phase
• Neurobiological
factors
• Hypothalamic-pituitary-thyroid-adrenal axis dysfunction
implicated
• Neuroanatomical factors
• Dysregulation in
prefrontal cortex and medial temporal lobe implicated
Other Theories Related to Bipolar Disorders
• Psychological
influences
• Stressful life events
• Families characterized
by high expressed emotion most associated with relapse
•
Hyperactive, can’t sleep
• Poor nutrition
• Cultural
considerations
• More prevalent in higher socioeconomic
classes
• Higher rates noted among creative writers, artists,
highly educated men and women
Bipolar Disorder
• Periods of abnormal and persistently
elevated mood for at leas:
• 4 days for hypomania
• 1 week
for mania
• Hypomania
• Episode associated with decreased
function
• Hospitalization not required
• Mania
•
Episode associated with marked impairment in function
•
Hospitalization necessary
Bipolar Disorder: Common
Symptoms
• Mood symptoms
• Unstable euphoric mood, intense
feeling of well-being, mood may change to irritation and anger when
thwarted
• Behavioral symptoms
• Excessive hyperactivity,
involved in pleasurable activities with painful consequences, sexual
indiscretion, excessive spending of money, mode of dress/makeup may be
outlandish, bizarre
• Physical symptoms
• Nonstop activity,
minimal food intake, little or no sleep
• Can lead to exhaustion
and even death
• Cognitive symptoms (thought processes)
•
Poor concentration, problems with verbal memory, sustained attention
and executive functioning (may persist even in remission)
•
Flight of ideas:
• continuous flow of accelerated speech with
abrupt changes from topic to topic usually based on understandable
associations
• Disorganized and incoherent speech with content
often sexually explicit and grossly inappropriate
• Clang
associations: stringing together of words because of rhyming
sounds
• ”like a rapper”
• Grandiose persecutory
delusions
• **We bring them back to reality**
• I’m god, I’m
the king of England, believe he is Michael Jackson
Nursing Process: Assessment Guidelines
• Determine if
patient dangerous to self or others
• Presence of physical
exhaustion
• Poor impulse control
• Agitation
•
Uncontrolled spending of money
• impulsiveness
• Determine
medical symptoms
• Dehydration, infections
• Determine
presence of other medical/psychiatric conditions
• Determine if
hospitalization is necessary
• Determine patient’s and family’s
understanding of disorder, treatment, medications, support groups
Nursing Process: Diagnosis and Outcomes Identification
•
Common nursing diagnoses
• Risk for injury, Risk for self- or
other-directed violence, Risk for suicide, Ineffective coping,
Disturbed thought processes, Interrupted family processes, Impaired
verbal communication, Imbalanced nutrition: less than body
requirements
• Outcomes identification
• Acute phase: goal
is prevention of physical injury and decrease in symptoms
manifested
• Continuation of treatment phase: goal is relapse
prevention
• Maintenance phase: goal is relapse prevention and
limiting severity of future episodes
• Planning
• Geared
toward particular phase of mania as well as other co-occurring issues
(e.g., risk of suicide, risk of violence, family/legal crisis,
substance abuse, risk-taking behaviors, medical compliance)
•
Implementation
• Directed toward establishing therapeutic
alliance
• Acute phase implementations related to safety in
hospital environment, establishment of controls and medical
stabilization
Nursing Communication Guidelines for Patient with
Bipolar Disorder
• Use firm, calm approach
• Use short,
concise statements
• Tell them what they are doing wrong
•
Remain neutral; avoid power struggles
• Don’t fight/argue with
them
• Be consistent
• Important with firm limit
setting
• Neutralize the situation
• Hear and act on
legitimate complaints
• Address their problems
• Firmly
redirect energy into appropriate channels
• In manic phase: give
them to do an exercise/activity/to neutralize them
Treatment for Bipolar Disorders: Milieu Therapy
• Seclusion
and restraints may be used if patient becomes dangerously out of
control and other least restrictive measures failed
• Purposes:
reduces overwhelming stimuli, protects patient and others from injury,
prevents destruction of property
• Use of seclusion/restraint
associated with complex legal, ethical, and therapeutic issues
•
Follow well-established institutional protocols for use of these measures
Treatment for Bipolar Disorders: Mood Stabilizers
• Used for
lifetime maintenance therapy
• Lithium carbonate: (Adam
book)
• first-line treatment for mania
• Given once they
reach the Therapeutic blood level must be reached for drug to be
effective (usually takes 7-14 days)
• 0.4 and 1.3 Normal
Maintenance/therapeutic blood levels between
• > 1.5 Early
toxicity: N &V, diarrhea, thirst
• 1.5to 2.0 Advance
toxicity: EKG changes, mental confusion
• 2 to 2.5 life
threatening: severe EKG changes, seizures, death, use carbamazepine
• Hepatotoxic and heart
• Make sure pt. is getting adequate
salt diet and monitor labs/ Lithium is a salt
• Used in
combination with antipsychotics or antianxiety medications in initial
acute mania
Treatment
• **know the changes in
toxicity
• Adverse reactions
• Related to lithium
toxicity—fine line between therapeutic and toxic levels
• Lithium
toxicity ranges from mild to moderate and severe symptoms depending on
blood level:
• Severe symptoms include ataxia, ECG changes,
clonic movements, seizures, coma, and death
• Major long-term
risks include hypothyroidism and kidney impairment
• Necessity
for periodic thyroid and renal function tests
Patient and family
teaching important
• Continue drug therapy to prevent
relapse
• Maintenance of normal diet with normal salt and fluid
intake (1500-3000 mL/day)
• Lithium decreases sodium absorption
and low sodium levels/dehydration cause lithium toxicity
• Stop
taking lithium and call physician if symptoms of dehydration develop
from sweating and/or nausea, vomiting, diarrhea
Treatment for Bipolar Disorders: Antiepileptic Medications
•
Adjunct to lithium as well as treatment for patients not responsive to
lithium
• Commonly used drugs
Carbamazepine (Tegretol),
divalproex (Depakote), lamotrigine (Lamictal)
o Adverse effects
of individual antiepileptic drugs vary but include such problems as
sedation, agranulocytosis, hepatitis, life-threatening rash
Electroconvulsive (ECT) Therapy
• Can be used to subdue
severe manic behavior in patients who are treatment resistant to
usual medications
• May also be used in patients who are suicidal
Psychotherapy
• Cognitive-behavioral therapy
• Cognitive
restructuring effective in decreasing affective symptoms, increasing
social functioning, and reducing relapse
• Interpersonal and
social rhythm therapy (IPSRT)
• Focuses on resolution of
interpersonal problems and prevention of further disputes
•
Family-focused therapy
• Treatment approach focusing on
communication within family, communication skills, and education to pre
Fractures
complete or incomplete disruption in the continuity of
bone structure
1. Complete: a break across the entire cross
section of the bone, can be displaced
2. Incomplete: break
through only a part of the cross section, most common in children
(greenstick fracture)
3. Comminuted: several bone
fragments
4. Closed: simple, no break in the skin
5. Open:
• Immobilization: after reduction, bone fragment is immobilized
by external or internal fixation/cast
• compound, complex; skin
or mucous membranes compromised
• A cast can’t be put until the
inflammation is gone/goes down
Grade I: clean wound less than 1
cm long
Grade II: larger wound w/o extensive soft soft tissue
damage or avulsions
Grade III: Highly contaminated
Hip Fracture
Expected finding:
• Shortening and
Displacement, reports pain in the hip and groin or in the medial side
of the knee
• adducted, and externally rotated
Pain
•
in the hip and groin or in the medial side of the knee.
**high
mortality rate (die from complications)
Abnormal findings
• Neurovascular, venous
thromboembolism
• Pulmonary complications:
o atelectasis,
pneumonia
• skin breakdown, and loss of bladder control
(incontinence or retention
Late complications include infection,
nonunion, and AVN.
Management
• First immobilize the body part, splining:
keeping stable
• Buck’s extension traction, a type of temporary
skin traction
• Displaced femoral neck fracture is an emergency
and must be repaired within 24 hours
• GOAL: manage pain during
first 24 to 48 hrs, prevention secondary problems
• Deep
breathing every 1 to 2 hrs
• Thigh-high anti-embolism stockings
or pneumatic compression devices
• REPOSITION: to the uninjured
side, placing pillow b/w legs (abducted/separated), proper alignment
and supported while turning
• PROMOTE EXERCISE: use overbed
trapeze, on first day of postop transfer pt. to chair, physical
therapy, the safe use of assisted device
Assess neurovascular status before and after splinting
•
Capillary refill
• Pulses
• Color
• Temperature
• **This will tell me if I got a complication of the fracture
Pelvic Fracture:
Expected finding;
• ecchymosis;
tenderness over the symphysis pubis, anterior iliac spines, iliac
crest, sacrum, or coccyx; local edema; numbness or tingling of the
pubis; and inability to bear weight without
discomfort
Pain
• Continuous, increase in severity until
mobilized, muscle spasms (begin within 20 minutes after the injury)
Abnormal findings:
• Hemorrhage and shock
• Absence of
pulses (dorsalis pedis and peripheral pulses)
Stable: treated
with few days of bed rest
• Fluids, dietary fiber, ankle and leg
exercises, deep breathing and skin care educe the risk of
complications
• RISK: Paralysis of the ileus, bowel sounds
Unstable “open book”
• Immediate treatment in the emergency
department
• stabilizing the pelvic bones and compressing
bleeding vessels with a pelvic girdle
• an external binding and
stabilizing device
Assessment
• Loss of function: unable to function properly,
abnormal movement (pain contributes)
• Deformity: displacement,
angulation, or rotation (when compare with the uninjured
extremity)
• Shortening: long bones, extremity appears shorten
compared to other extremity
• Crepitus: crumbling sensation (can
be feel or heard)
• Localized edema and ecchymosis: as a result
of trauma and bleeding into the tissues
• may develop within an
hour, depending on the severity of the fracture
Management
•
First immobilize the body part, splinting; assess neurovascular status
before and after splinting
• Open fracture: cover wound with
sterile dressing to prevent further contamination
• Reduction:
restoration of the fracture fragments
• Closed: manipulation and
manual traction
• Open: surgical approach
• Immobilization:
after reduction, bone fragments are immobilized by external or
internal fixation/cast/traction
Nursing Management
Closed: Education, page 1163 Chart
43-1
1. Describe approaches to control swelling and pain:
o
elevate extremity to heart level; take analgesics as
prescribed
2. Report pain uncontrolled by elevation and
analgesics
o (may be an indicator of impaired tissue perfusion or
compartment syndrome)
3. Describe management of immobilizing
device or care of incision
4. Consume diet to promote bone
healing
5. Demonstrate ability to transfer
6. Use mobility
aids and assistive devices safely
7. Avoid excessive use of
injured extremity; observe prescribed weight-bearing limits
8.
State indicators of complications to report promptly to primary
provider
o uncontrolled swelling and pain; cool, pale fingers or
toes
o paresthesia; paralysis
o signs of local and systemic
infection
o signs of venous thromboembolism
o problems with
immobilization device
9. State possible delayed complications of
fractures
o delayed union; nonunion; avascular necrosis
o
complex regional pain syndrome, formally called reflex sympathetic
dystrophy syndrome
o heterotopic ossification
10. Describe
gradual resumption of normal activities when medically cleared, and
discuss how to protect fracture site from undue stresses
Cast Care Page 1109 Chart 41-4
1. Describe techniques to
promote cast drying
o do not cover cast; expose cast to
circulating air
o handle damp plaster cast with palms of
hands
o do not rest the cast on hard surfaces or sharp edges that
can dent soft cast
2. Describe approaches to controlling swelling
and pain
o elevate immobilized extremity to heart level, apply
intermittent ice bag if prescribed, take analgesic agents as
prescribed
3. Report pain uncontrolled by elevating the
immobilized limb and by analgesic agents
o may be an indicator
of impaired tissue perfusion—compartment syndrome or pressure
ulcer
4. Demonstrate ability to transfer
o from a bed to a
chair
5. State indicators of complications to report promptly to
primary provider (e.g., uncontrolled swelling and pain; cool, pale
fingers or toes; paresthesia; paralysis; purulent drainage staining
cast; signs of systemic infection; cast, splint, or brace
breaks)
6. Describe care of extremity following cast, splint, or
brace removal
o skin care, gradual resumption of normal
activities to protect limb from undue stresses, management of swelling
Open: Prevent infection of the wound, soft tissue, and bone and
promote healing
• Risk for osteomyelitis, tetanus, gas
gangrene
• External fixation: elevation, neurovascular
assessment, pin care
ORIF VS OREF
Open Reduction with Internal Fixation
(ORIF)
Priorities
o Elevation
o The keep the pt. leg
in abducted position
o open surgical procedure to repair and
stabilize a fracture
o Pin care/keep it nice and clean
o
Internal fixation devices
metallic pins, wires, screws,
plates, nails, or rods
Open Reduction External Fixation
(OREF)
o Elevate and Ice
o Keep the swelling down
o
Support the extremities
o Immobilization is accomplished by
external fixation
bandages, casts, splints, continuous
traction, and external fixators) or internal fixation.
Complications:
• Shock: hypovolemic shock from
hemorrhage
• Fat embolism: 02 FIRST PRIORITY
o fracture of
long or pelvic bones, crush injuries; fat globules
o may diffuse
from the marrow into the vascular compartment, can occlude
vessels
Onset is rapid: Hypoxemia, neurologic compromise,
petechial rash, hypoxia and tachypnea
headache and mild
agitation to delirium and coma
Management: respiratory
support
• Compartment Syndrome: 5 p’s
o Pain, pallor,
pulseless, paresthesia, paralysis
o a sudden and severe decrease
in blood flow to the tissue distal to an area of injury; ischemic
necrosis
• Report of severe, unrelenting pain,
o worse with
ROM (hallmark sign) intensifies with dorsiflexion of the wrist of the
affected extremity
o pallor, pulselessness, paresthesia,
paralysis
• IF complications: splint may be loosened or removed
(cut in half longitudinally)
• maintaining limb alignment, and
the extremity must then be elevated no higher than heart level to
maintain arterial perfusion
Emergency: measures to restore tissue perfusion (fasciotomy)
DVT/PE
• Delayed union, malunion, nonunion
• Avascular
Necrosis of bone: bone loses its blood supply and
dies
Infections: Always is a late sign
• Complex Regional
Pain Syndrome: painful sympathetic nervous system problem: severe
burning pain, local edema, stiffness
• Heterotopic Ossification:
abnormal formation of bone
Traction
• Traction: uses a pulling force to promote and
maintain alignment to an injured part of the body
• Must be
continuous to be effective
• Skeletal traction is never
interrupted
• Weights are not removed unless intermittent
traction is ordered
• Any factor that can reduce the effective
pull or alter is eliminated
• Patient must be in good body
alignment in the center of the bed