here is preivous
1. A pregnant patient receives the news that she has low iron according to the complete blood count (CBC) lab results. The patient panics and worries that there is something wrong. Your response to the patient is:
2. A newborn is delivered by Cesarean Section and weighs 4000 gms. As the nurse caring for the newborn you will complete the following action: Question 40 options: Avoid skin to skin with mother Heel stick for blood glucose Recommend formula feeding as a supplement Refrain from covering the newborn’s head with a hat to avoid overheating
3. Fertility Awareness Methods are best utilized by:
4. The purpose of applying pressure to the anus and perineal area with a sterile towel during the delivery of the fetal head is:
5. A patient in labour and delivery is hemorrhaging after the vaginal delivery of a 2800 gm newborn. You know that the most likely cause of hemorrhage is: Question 31 options: Uterine atony Lacerations to the perineum and birth canal Placental abruption Retained palcental tissue
6. A pregnant patient reports having upper epigastric pain, a headache and pitting edema. You know that these are all symptoms of: Question 27 options: Preeclampsia Fatty liver disease Seizure disorder of pregnancy Eclampsia
7. When palpating a contraction, what criteria is the nurse assessing regarding the contraction?
8. you are assessing a non-hispanic black, 35 years old multipara at 24 weeks gestation.
9. You are coming onto shift and have been assigned Room #3. You receive report that the newborn in Room #3 is 39 weeks gestation, Large for gestational age, pink and feeding well. When you observe the newborn you see that the newborn weighs 3000 gms, is covered in lanugo and is feeding well. This observation concludes that: Question 14 options: The newborn is actually large for gestation age The newborn is actually intrauterine growth restricted The social worker needs to be contacted. The newborn is less than 39 weeks gestation
10. An newborn is delivered vaginally at 36 weeks gestation. You are aware that this newborn may :
11. The fetus has engaged and Mom has been pushing for 4 hours. The physician encourages an epidural to give Mom a rest. When the baby is finally delivered vaginally you notice the following:
Alcohol related disorders and Clinical Institute Withdrawal for Alcohol (CIWA-AR) Scale
Alcohol is the only drug for which exact objective measures of intoxication (BAL) currently exist.
Alcohol content varies from product to product; nevertheless, a drink is a drink is a drink, with 1.5 ounces of liquor (40% alcohol), a 12-ounce bottle of beer (5% alcohol), and a five-ounce glass of table wine (12% alcohol) all containing the same amount of ethanol. Thus all affect human physiology in a consistent manner as measured by blood alcohol content (BAC), although there are distinct differences between men and women (Table 18-5). Differences in effects from person to person produced by beverage alcohol do not generally result from the type of drink consumed, but rather from the person’s size, previous drinking experiences, and rate of consumption. A person’s feelings and activities and the presence of other people also play a role in the way the alcohol affects behaviour.
Assessing the patient’s behaviour can assist the nurse in (1) ascertaining whether the person accurately reported recent drinking and (2) determining level of intoxication and possible tolerance, as patient behaviours may indicate greater or lesser levels of tolerance. As tolerance develops, a discrepancy is seen between the BAL and expected behaviour: a person with tolerance to alcohol may have a high BAL but minimal signs of impairment. Alternatively, a person who is highly sensitive to alcohol or compromised medically may have a low BAL but demonstrate a high level of intoxication.
Is a state of toxicity that can result when an individual has consumed large amounts of alcohol either quickly or over time. It can produce death from aspiration of emesis or a shutdown of body systems due to severe CNS depression. Signs of alcohol poisoning include an inability to rouse the individual, severe dehydration, cool or clammy skin, respirations less than 10 per minute, cyanosis of the gums or under the fingernails, and emesis while semiconscious or unconscious. Refer to Table 18-2 for important assessment and treatment information regarding alcohol intoxication and poisoning.
The early signs of alcohol withdrawal, a physical reaction to the cessation or reduction of alcohol (ethanol) intake, can develop within a few hours of the last intake. Symptoms peak after 24 to 48 hours and then rapidly and dramatically disappear unless the withdrawal progresses to alcohol withdrawal delirium.
Severity of withdrawal tends to be dose related, with heavier drinkers experiencing more severe symptoms. Withdrawal severity is also related to age, with those over 65 years of age experiencing more severe symptoms. During withdrawal, the patient may appear hyperalert, manifest jerky movements and irritability, startle easily, and experience subjective distress often described as “shaking inside.”
Grand mal seizures may appear 7 to 48 hours after cessation of alcohol intake, particularly in people with a history of seizures. Careful assessment, including this history and any other risk factors, followed by appropriate medical and nursing interventions can prevent the more serious withdrawal reaction of delirium.
The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) provides an efficient, objective means of assessing alcohol withdrawal to prevent under- or overtreating patients with benzodiazepines.
Also referred to as
delirium tremens (DTs), is a medical emergency that can result in death in 20% of untreated patients. It is an altered level of consciousness that presents with seizures following acute alcohol withdrawal. Death is usually due to cardiopathy, cirrhosis, or other comorbidities requiring mechanical ventilation.
The state of delirium usually peaks 48 to 72 hours after cessation or reduction of intake, although it can peak later, and lasts 2 to 3 days. Features of alcohol withdrawal delirium include the following:
• Autonomic hyperactivity (tachycardia, diaphoresis, elevated blood pressure)
• Severe disturbance in sensorium (disorientation, clouding of consciousness)
• Perceptual disturbances (visual or tactile hallucinations)
• Fluctuating levels of consciousness (ranging from hyperexcitability to lethargy)
• Delusions
• Anxiety and agitated behaviours
• Fever (38°C to 39°C)
• Insomnia
• Anorexia
Acamprosate (Campral) was approved by Health Canada in 2008 to treat people who had been alcohol dependent, had stopped drinking, and wished to remain abstinent. In randomized, double-blind, placebo-controlled trials, though without active comparators, acamprosate in conjunction with psychosocial therapy was generally significantly better than placebo plus psychosocial interventions in improving various key outcomes, including the proportion of patients who maintained complete abstinence from alcohol, the average duration of abstinence duration, and the total number of nondrinking days. Acamprosate is believed to effect a reduction in one’s intake of alcohol through suppression of excitatory neurotransmission and enhanced inhibitory transmission (
Lehne, 2014;
Plosker, 2015).
Naltrexone (ReVia), an agent used in reversing the effects of opioid addiction, is sometimes used in the treatment of alcohol dependency, especially for those with intense cravings and somatic symptoms. Naltrexone works by blocking opioid receptors, thereby interfering with the mechanism of reinforcement and reducing or eliminating the alcohol craving (
Vuoristo-Myllys, Lipsanen, Lahti, et al., 2014). Long-acting injectable forms with the brand names Vivitrex or Vivitrol, Naltrel, and Depotrex are being tested and show promise as having relatively stable plasma levels, allowing for more sustained effects (
Gordon, Kinlock, Vocci, et al., 2015
;
Knopf, 2016
).
Similar to acamprosate, topiramate (Topamax) is purported to decrease alcohol cravings by inhibiting the release of mesocorticolimbic dopamine, which has been associated with alcohol craving. Currently topiramate is still not approved for use with alcohol-dependent persons, although preliminary findings indicate that it has a beneficial effect in individuals with a typology of craving characterized by drinking obsessions and automaticity of drinking (
Guglielmo, Martinotti, Quatrale, et al., 2015
).
Introduction to this week’s topic
The language we use has a direct and profound impact on those around us. The negative impacts of stigma can be reduced by changing the language we use about substance use.
Two key principles include:
· Using neutral, medically accurate terminology when describing substance use
· Using “people-first” language, that focuses first on the individual or individuals, not the action (e.g. “people who use drugs”)
It is also important to make sure that the language we use to talk about substance use is respectful and compassionate.
· People who use drugs
· Instead of “addicts” use people who use drugs
· Instead of “junkies” use people with a substance use disorder
· Instead of “users” use people with lived/living experience
· Instead of “drug abusers” use people with lived/living experience
· Instead of “recreational drug user” use person who occasionally uses drugs
· People who have used drugs
· Instead of “former drug addict” use people who have used drugs
· Instead of referring to a person as being “clean” use people with lived/living experience or people in recovery
· Drug use
. substance/drug use
. substance use disorder/ opioid use disorder
. problematic [drug] use
. [drug] dependence
. Instead of “substance/drug abuse” or “substance/drug misuse” use:
This document was created in discussion with people with lived and living experience, through existing research and documentation from other organizations trying to address stigma. This is not an exhaustive list. Furthermore, as a result of the evolving discussion around the best language to use to accurately discuss substance use, this list will likely be revised.
Anxiety disorders
A common problem
Anxiety disorders are the most common mental health illnesses, affecting one in ten Canadians.
In the clinical setting, anxiety disorders often co-exist with other mental health problems such as depression, eating disorders and substance use disorders. This is particularly the case if anxiety disorders are left untreated.
However, when we work on managing the anxiety, the overall functioning, quality of life and well being of that person improves. Thus showing that anxiety can be a big part of the problem, but its treatment is also a big part of the solution.
It is very important to manage anxiety before it escalates further.
Levels of anxiety
1.
Mild anxiety, which occurs in the normal experience of everyday living, allows an individual to perceive reality in sharp focus. A person experiencing a mild level of anxiety sees, hears, and grasps more information, and problem solving becomes more effective. Physical symptoms may include slight discomfort, restlessness, irritability, or mild tension-relieving behaviours (e.g., nail biting, foot or finger tapping, fidgeting, wringing of hands).
2. Moderate Anxiety, As anxiety increases, the perceptual field narrows, and some details are excluded from observation. The person experiencing
moderate anxiety
sees, hears, and grasps less information and may demonstrate
selective inattention
, in which only certain things in the environment are seen or heard unless they are pointed out. While the person’s ability to think clearly is hampered, learning and problem solving can still take place, although not at an optimal level. Physical symptoms of moderate anxiety include tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (gastric discomfort, headache, urinary urgency). Voice tremors and shaking may be noticed. Mild or moderate anxiety levels can be constructive because anxiety may signal that something in the person’s life needs attention or is dangerous.
3. Severe Anxiety, The perceptual field of a person experiencing
severe anxiety
is greatly reduced. A person with severe anxiety may focus on one particular detail or many scattered details and have difficulty noticing his or her environment, even when it is pointed out by another. Learning and problem solving are not possible at this level, and the person may be dazed and confused. Behaviour becomes automatic (e.g., wringing hands, pacing) and is aimed at reducing or relieving anxiety. Somatic symptoms such as headache, nausea, dizziness, and insomnia often increase; trembling and a pounding heart are common; and the person may hyperventilate and experience a sense of impending doom or dread.
4.
Panic
, the most extreme level of anxiety, results in noticeably disturbed behaviour. Someone in a state of panic is unable to process what is going on in the environment and may lose touch with reality, even experiencing hallucinations, or false sensory perceptions (e.g., seeing people or objects not really there). Physical manifestations may include pacing, running, shouting, screaming, or withdrawal, and actions may become erratic, uncoordinated, and impulsive. These sorts of automatic behaviours are used to reduce or relieve anxiety, although such efforts may be ineffective. Acute panic may lead to exhaustion.
Mood disorders and schizoaffective disorders
Overview1
Mood disorders affect about 10% of the population. Everyone experiences “highs” and “lows”, but people with mood disorders experience them with greater intensity and for longer periods of time.
Depression is the most common mood disorder; a person with depression feels “very low.” Symptoms may include: feelings of hopelessness, changes in eating patterns, disturbed sleep, constant tiredness, an inability to have fun, and thoughts of death or suicide.
People with bipolar disorder have periods of depression and periods of feeling unusually “high” or elated.
Some examples of mood disorders include2:
Prolonged and persistent periods of extreme sadness.
Depression that includes alternating times of depression and mania.
A form of depression most often associated with fewer hours of daylight in the far northern and southern latitudes from late fall to early spring.
A disorder that causes emotional ups and downs that are less extreme than bipolar disorder.
Mood changes and irritability that occur during the premenstrual phase of a woman’s cycle and go away with the onset of menses.
A long-term (chronic) form of depression.
A disorder of chronic, severe and persistent irritability in children that often includes frequent temper outbursts that are inconsistent with the child’s developmental age.
A persistent depressed mood and a significant loss of pleasure in most or all activities that’s directly related to the physical effects of another medical condition.
Depression symptoms that develop during or soon after substance use or withdrawal or after exposure to a medication.
Schizoaffective Disorder
verview3
The two types of schizoaffective disorder — both of which include some symptoms of schizophrenia — are:
· Bipolar type, which includes episodes of mania and sometimes major depression
· Depressive type, which includes only major depressive episodes
Schizoaffective disorder may run a unique course in each affected person, so it’s not as well-understood or well-defined as other mental health conditions.
Untreated schizoaffective disorder may lead to problems functioning at work, at school and in social situations. People with schizoaffective disorder may need assistance and support with daily functioning.
·
Anxiety and Mood Disorders
Mood Matters: What you need to know about ANXIETY AND MOOD DISORDERS
·
Bipolar Disorder
Mood Matters: What you need to know about BIPOLAR DISORDER
·
Depression
Mood Matters: What you need to know about DEPRESSION
·
Early Psychosis and Young People
Mood Matters: What you need to know about EARLY PSYCHOSIS and YOUNG PEOPLE
·
Obsessive Compulsive Disorder (OCD)
Mood Matters: What you need to know about OBSESSIVE COMPULSIVE DISORDER
·
Perimenopause / Menopause
Mood Matters: What you need to know about PERIMENOPAUSE / MENOPAUSE
·
Postpartum Depression
Mood Matters: What you need to know about POSTPARTUM DEPRESSION
·
Premenstrual Dysphoric Disorder (PMDD)
Mood Matters: What you need to know about PREMENSTRUAL DYSPHORIC DISORDER (PMDD) and PREMENSTRUAL SYNDROME
·
Rapid Cycling
Mood Matters: What you need to know about RAPID CYCLING
·
Seasonal Affective Disorder (S.A.D.)
Mood Matters: What you need to know about SEASONAL AFFECTIVE DISORDER (S.A.D.)
·
Seniors and Depression
Mood Matters: What you need to know about SENIORS and DEPRESSION
·
Suicide
Mood Matters: What you need to know about SUICIDE and MOOD DISORDERS
·
Teen Depression
Mood Matters: What you need to know about TEEN DEPRESSION
Perry: Maternal Child Nursing Care in Canada
Chapter 36:
The Infant and Family
Case Study 24: Child Abuse
1. Jamie is 6 months old and was brought to the emergency department by her mother. In your assessment of Jamie, you find multiple bruises in different stages of healing and decreased range of motion in the left leg.
As the nurse in the emergency department, what should you do?
(a) Call the division of family services.
(b) Maintain confidentiality of physical data until Jamie’s mother signs admission papers.
(c) Obtain a thorough patient and family history.
(d) Obtain a serum sample for a CBC.
2. Jamie is 6 months old and was brought to the emergency department by her mother. In your assessment of Jamie, you find multiple bruises in different stages of healing and decreased range of motion in the left leg.
Jamie has been diagnosed with a fractured femur. During your interview with Jamie’s mother on the nature of the fracture, which one of the following statements made by Jamie’s mother would cause you to suspect abuse?
(a) “Jamie got her leg caught in the crib bars and it twisted.”
(b) “Jamie hurt herself while crawling.”
(c) “I can’t remember Jamie falling or hurting herself.”
(d) “Jamie fell out of her car seat because I didn’t have it secured properly.”
3. Jamie is 6 months old and was brought to the emergency department by her mother. In your assessment of Jamie, you find multiple bruises in different stages of healing and decreased range of motion in the left leg.
The criterion that is most important for causing the nurse to suspect child abuse is which one of the following?
(a) Appropriate parental concern for the degree of injury.
(b) Absence of the parents for questioning about the child’s injury.
(c) Parental concern about health problems other than the ones associated with the possible abuse.
(d) Incompatibility between the history given and the observed injury.
Case Study 25: Infant Growth and Development
1. Elizabeth is a 6-month-old female delivered at 40 weeks of gestation weighing 3400 g. She now weighs 6800 g. You are discussing infant growth and development with Elizabeth’s mother. Elizabeth’s mother is concerned that her baby is not gaining enough weight. You can assure her and provide anticipatory guidance. Which of the following statements should you make to Elizabeth’s mother?
(a) Elizabeth is gaining weight well. At 6 months an infant is expected to have doubled her birth weight. At 1 year the weight should triple.
(b) Elizabeth is gaining weight well. At 6 months an infant is expected to have tripled her birth weight. At 1 year the weight should quadruple.
(c) Elizabeth is gaining weight well. At 6 months an infant is expected to have doubled her birth weight. At 1 year the weight should quadruple.
(d) Elizabeth is not gaining weight as expected. At 6 months an infant is expected to have tripled her birth weight. At 1 year the weight should quadruple.
2. Elizabeth’s mother says the infant reaches for her food. She asks if it is acceptable to let the baby feed herself. Which is the most appropriate response?
(a) Grasping occurs during the first month as a reflex and gradually becomes voluntary. By 4 months, infants can hold their bottle, as well as grasp their feet and pull them to their mouth.
(b) Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. By 6 months, infants can hold their bottle, grasp their feet and pull them to their mouth, and feed themselves a cracker.
(c) Grasping occurs during the first 4 to 5 months as a reflex and gradually becomes voluntary. By 7 months, infants can hold their bottle, grasp their feet and pull them to their mouth, and feed themselves a cracker.
(d) Grasping occurs during the first 6 to 8 months as a reflex and gradually becomes voluntary. By 9 months, infants can hold their bottle, grasp their feet and pull them to their mouth, and feed themselves a cracker.
3. Elizabeth’s mother is aware of the importance of play for children. What games and interactions should you recommend?
(a) Encourage the infant to play with push-pull toys.
(b) Hang mobiles with black and white designs above the crib.
(c) Place an unbreakable mirror where the infant can see herself.
(d) Point to body parts and name each one.
Chapter 36: The Infant and Family
Case Study 26: Health Problems of Infants
1. Sara is a formula-fed, 1-month-old infant who weighed 3200 g at birth. She is gaining weight well and appears healthy. Sara’s mother looks exhausted and states she is concerned, frustrated, and feels like she is not a good mother.
Sara’s mother explains that the baby begins to cry early in the evening and continues to cry for hours. The crying started about a week ago. She is worried there is something wrong with the baby; nothing she does seems to help. The nurse recognizes this description of paroxysmal abdominal pain. Which one of the following is the most appropriate response to the mother’s concerns?
(a) Tell her to ignore the crying for as long as possible before picking the baby up.
(b) Provide support to the parent. Stress that despite the crying and obvious pain, the infant is doing well.
(c) Encourage the mother to be more responsive to the child in order to prevent the crying episodes.
(d) Change the child’s formula to a soy-based product.
The correct answer is (b).
Paroxysmal abdominal pain (or colic) is reported in many infants, and despite the stress it causes for parents, results in no long-term health problems for the child. Discuss possible treatments for soothing Sara with her mother, including reviewing her formula type, placing the infant on a hot water bottle, and so on.
2. Sara’s mother has heard about a condition called sudden infant death syndrome (SIDS) and asks the nurse how she can protect her baby. The nurse should recommend one of the following:
(a) Place Sara to sleep on her back.
(b) Place Sara to sleep on her stomach.
(c) Recommend the use of a home monitor to assess for apneic episodes.
(d) Place Sara to sleep on her side, with soft pillows for support.
The correct answer is (a).
Many studies have linked sleep position with an increased risk of SIDS. For this reason, it is recommended that parents put their baby to sleep on its back. Do not put anything soft, loose, or fluffy in the baby’s sleep space (this includes pillows, blankets, comforters, stuffed animals, and other soft items), as these may increase the baby’s risk for suffocation.
Key Points
· Biological development of the child encompasses proportional changes; sensory changes, including binocularity, depth perception, and visual preference; maturation of biological systems; fine motor development; and gross motor development.
· Erikson’s theory of psychosocial development (birth to 1 year) is concerned with acquiring a sense of trust while overcoming a sense of mistrust.
· Piaget’s theory of cognitive development, as it applies to the infant, focuses on the sensorimotor phase, which includes the use of reflexes, primary circular reactions, secondary circular reactions, and coordination of secondary schemata and their application to new situations.
· Development of body image begins in infancy; by 1 year of age, infants recognize that they are distinct from their parents.
· Social development of the infant is guided by attachment, language development, personal-social behaviour, and participation in play.
· Temperament influences the type of interaction that occurs between the child and parents and siblings.
· Parents are faced with many concerns, including selecting an appropriate day care, limit-setting and discipline, thumb-sucking and pacifier use, teething, and choice of infant shoes.
· Breast milk provides optimal nutrition for the infant during the first six months; gradual introduction of solid food occurs during the second six months. Commercial iron-fortified infant formula is a safe alternative to human milk. Whole milk is not recommended until after 1 year of age.
· Common sleep problems that develop during infancy—and that are easily prevented—are associated with night crying and feeding. Nurses should instruct the parents, after careful assessment, in strategies to deal with the specific problem.
· Cleaning the teeth regularly in early childhood and appropriate dietary intake promote good dental health.
· Recommended routine immunizations include those for hepatitis B virus, hepatitis A virus, diphtheria, influenza, tetanus, pertussis, polio, measles, mumps, rubella, pneumococcus, meningococcus, chickenpox, and haemophilus influenzae type B.
· Recommended immunizations for selected groups of children are rotavirus and human papillomavirus vaccines.
· Because injuries are a major cause of death during infancy, parents should be alerted to the possibility of aspiration of foreign objects, suffocation, falls, poisoning, burns, motor vehicle injuries, and bodily damage, as well as preventive actions needed to make the environment safe for infants.
· Treatment of colic may involve change in feeding practices, correction of a stressful environment, behaviour modification, and support of the parent.
· Growth failure, or failure to thrive (FTT), may occur in children who have a chronic illness, or it may occur in a family environment in which healthy-infant feeding practices are poorly managed or understood. FTT is not always associated with a pattern of a disturbed maternal–infant relationship.
· Factors that place the infant at high risk for sudden infant death syndrome (SIDS) include prone sleeping position, soft bedding, sleeping in a noninfant bed with an adult or older child, and maternal prenatal smoking.
· Positional plagiocephaly can be easily prevented by allowing the awake infant to have periods of tummy time and by alternating the infant’s head position during sleep.
· The primary nursing responsibility in care associated with sudden infant death is educating the newborn’s family about the risks for SIDS; modelling appropriate behaviours in the hospital, such as placing the infant in a supine sleep position; and providing emotional support of the family that has experienced a SIDS loss.
· Infants with apparently life-threatening events are carefully evaluated for clues to the underlying cause.
· Home apnea or cardiorespiratory monitors do not prevent SIDS.
Questions on Toilet Training
1. Matt is a healthy 2 1/2-year-old boy whose mother asks the nurse for advice about toilet training. Matt’s mother is expecting her second child in 4 months and has no previous experience with toilet training.
Which one of the following should the nurse do first?
(a) Ask Matt if he wants to learn to use the toilet.
(b) Discuss the signs that indicate Matt is ready to begin toilet training.
(c) Encourage Matt’s mother to initiate toilet training after the birth of the new baby.
(d) Assess the mother to determine why she has waited so long to begin toilet training.
1. The correct answer is (b).
(a) “Negativism,” the persistent negative response to requests, is a characteristic of toddlers in their quest for autonomy. Asking a toddler a “yes or no” question will often result in a “no” response. Therefore, asking Matt if he wants to learn to use the toilet is not the most accurate way to assess his readiness.
(b) Both physical ability and complex psychophysiological factors are required for toilet training readiness. One of the most important responsibilities of nurses is to help parents identify the readiness signs in their child. According to the Canadian Paediatric Society, 5 markers signal a child’s readiness to toilet train: motor, language, social milestones, demeanour, and relationship with the parents. According to some experts, physiological and psychological readiness is not complete until age 22 to 30 months.
(c) The addition of a new baby to the family often involves changes that are resented by the toddler. The first few weeks at home with a newborn and toddler can be challenging enough for the parents and should not be complicated with the task of toilet training.
(d) This is a normal time to consider toilet training. The mother is requesting advice on toilet training at an appropriate age for her toddler.
2. Matt’s mother tells the nurse that she can’t afford to buy a potty chair. She explains that they are saving money because they will soon have the added expense of another child. What is the most appropriate response for the nurse to make?
(a) Suggest ways to toilet train Matt without a potty chair.
(b) Refer the family to social services for financial assistance.
(c) Recommend postponing toilet training until they can afford a potty chair.
(d) Have Matt sit on a regular toilet to assess whether his feet will touch the floor.
2. The correct answer is (a).
If a potty chair is not available, many other methods can be used to assist the child in toilet training. Having the child sit facing the toilet tank, or placing a small bench under the child’s feet can provide added support when his feet do not touch the floor.
3. Matt is brought to the clinic 4 1/2 months later because he has an ear infection. The nurse asks about his toilet training. His mother says, “He has done real well, except since the baby came he has wanted to wear diapers instead of underpants. I have been letting him wear diapers. He takes them on and off to use the toilet. I hope that is okay.” What is the most appropriate response from the nurse?
(a) Assess why the mother decided to let Matt wear diapers.
(b) Recommend that the mother put Matt back into underpants immediately.
(c) Reassure the mother that regression such as this is common in toddlers after the birth of a sibling.
(d) Explain to the mother that negativism like this is common in toddlers who are toilet trained before they are ready.
3. The correct answer is (c).
(a) Sibling rivalry may cause a toddler to revert to more infantile forms of behaviour. The mother is demonstrating an understanding of this response in her toddler, and allowing him to express his feelings. The nurse should support the mother’s actions rather than assessing further.
(b) The toddler’s regression is a common sign of his feelings and will pass as he learns to accept the changes in his lifestyle. This expression should not be suppressed by making the child wear his underpants.
(c) Reassure the parent that the period of regression will pass when the toddler learns to accept the changes in his lifestyle.
(d) The regression demonstrated by the toddler is a common form of communicating angry feelings following the addition of a newborn to the family. This should not be interpreted as a lack of toilet training readiness.
· The toddler stage, extending from 12 to 36 months, is a period of intense exploration of the environment.
· Biological development during the toddler years is characterized by the acquisition of fine and gross motor skills that allow children to master a wide range of activities.
· Although most of the physiological systems are mature by the end of toddlerhood, development of certain areas of the brain is still occurring, allowing for greater intellectual capacity.
· Locomotion is the major gross motor skill acquired during toddlerhood, followed by increased eye–hand coordination.
· Specific tasks in the psychosocial development of a toddler include differentiating self from others, tolerating separation from parent, coping with delayed gratification, controlling bodily functions, acquiring socially acceptable behaviour, communicating verbally, and interacting with others in a less egocentric manner.
· According to Erikson, the major developmental task of toddlerhood is acquiring a sense of autonomy while overcoming a sense of doubt and shame.
· In Piaget’s sensorimotor and preconceptual phases of development, the toddler experiments by incorporating the old learning of secondary circular reactions with new skills and applies this knowledge to new situations. There is the beginning of rational judgement, an understanding of causal relationships, and discovery of objects as objects.
· Preconceptual thought is characterized by egocentrism, centration, global organization of thought processes, animism, and irreversibility.
· Language is the major cognitive achievement in toddlerhood.
· The most striking characteristic of language development during early childhood is the increasing level of comprehension.
· Development of body image occurs with increasing motor ability, at which point toddlers recognize the importance and capacity of body parts.
· The two phases of differentiation of self from significant others are separation and individuation.
· Parental concerns during the toddler years include toilet training; coping with sibling rivalry; limit-setting and discipline; and dealing with temper tantrums, negativism, and regression.
· Effective discipline techniques for toddlers include reward, ignoring, and time-out.
· Nutrition is important during the toddler stage because eating habits established in this period have lasting effects in subsequent years.
· Regular dental examinations, fluoride supplementation, removal of plaque, and provision of a low-sucrose diet promote optimum dental health.
· Because of increased locomotion, toddlers are at high risk for sustaining injuries. Fatal injuries are primarily a result of motor vehicle accidents, drowning, and burns.
Answers
to Questions
Amanda is a healthy 4-year-old child who presents for her yearly well child visit. Amanda’s mother is concerned because the toddler has trouble going to sleep.
1. What is an appropriate reply for the nurse to initially make regarding Amanda’s mother’s concern?
(a) Some children have trouble going to sleep.
(b) Bring the child into your bed to make it easier for her.
(c) Allow the child to stay awake beyond her usual bedtime.
(d) Try eliminating naps so she is more tired at bedtime.
Sleep disturbances are common during the preschool years, and may be due to a variety of factors. Recommendations for handling sleep disturbances should be offered only
after
a thorough assessment of the problem.
2. Her mother continues to explain that about 1 to 4 hours after Amanda is asleep, she hears Amanda screaming and thrashing in her bed, but the toddler does not wake up. What does this behaviour best describe?
(a) Nightmares
(b) Sleep terrors
(c) Restlessness
(d) Convulsions
Sleep terrors usually happen during non-REM sleep, about 2-3 hours after the child initially falls asleep when sleep transitions from the deepest stage of non-REM sleep to lighter REM sleep, a stage where dreams occur.
3. The appropriate intervention for this sleep disturbance is which one of the following?
(a) Sit with the child and offer comfort and protection.
(b) Observe the child without interfering and provide safety.
(c) Bring the child into your bed.
(d) Try to wake the child.
The best way to handle a sleep terror is to wait it out patiently and ensure that the child doesn’t get hurt while he or she is moving around. Most children experiencing sleep terrors will settle down and return to sleep on their own in a few minutes. It’s best not to try to wake a child during a sleep terror, because these attempts often don’t work, or if they do, can cause confusion and disorientation for the child, and may make it more difficult to settle the child down and go back to sleep.
Answers
1. What is an effect of childhood abuse?
a) Anxiety
b) Low self esteem
c) Difficulty trusting people
d) Depression
e) All the above
2. The most common type of childhood abuse is:
a) Physical
b) Neglect
c) Psychological
d) Sexual
e) They are all about equal
3. What is psychological (emotional) abuse?
a) A child looking for support from his or her parents
b) Any behaviour inflicted that could cause bodily harm
c) Any behaviour inflicted for the sexual gratification of the offender.
d) Any behaviour inflicted on a child that causes mental or emotional anguish or deficits
4. In which of the following cases would you suspect Munchhausen by proxy?
a) Child is repeatedly brought in for medical care for alleged problems that cannot be documented
b) Sudden infant death syndrome
c) There are other explanations for the child’s symptoms.
d) The parent fails to try to resuscitate child and blames this behavior on shock.
5. Risk factors of neglectful parents include all of the following EXCEPT
a) Poverty
b) Substance abuse
c) Prior referrals
d) Caregiver absence
6. Child neglect has a specific definition so it can be easily identified, intervened upon, and when necessary, prosecuted?
a) True
b) False
7. Which is known as the most basic and destructive element of all forms of child abuse?
a) Physical abuse
b) Psychological maltreatment
c) Sexual abuse
d) Neglect
Chapter 37: The Preschooler and Family
Key Points
· The preschool years consist of the period from 3 to 5 years of age, a time considered critical for emotional and psychological development.
· Biological development in the preschool period is characterized by mature body systems and refinement in gross and fine motor behaviour, as evidenced by activities such as running, riding a tricycle, and drawing.
· According to Erikson, acquiring a sense of initiative is the chief psychosocial task of the preschooler. Development of the superego occurs during this period, as conscience begins to emerge.
· According to Piaget, the preschool age is characterized by intuitive (or prelogical) thinking and a move toward logical thought processes through advanced, complex learning; language; and understanding of causality.
· The seeds of moral development are planted during the preschool period. According to Kohlberg, these children are in the stage of naive instrumental orientation, in which they are concerned with satisfying their own needs and, less frequently, the needs of others.
· Social development includes further separation–individuation; more sophisticated language; greater independence; and more complex, imaginative forms of play.
· Areas of special concern to parents during the preschool period are the preschool and kindergarten experience, sex education, fears, stress, and speech problems.
· In selecting an early learning program, parents should inquire about daily activities, teacher qualifications, accreditation, student–staff ratio, safety, meals, fees, and health practices.
· Two rules that govern how parents answer questions about sex and other sensitive issues are to find out what the children know and to be honest.
· Fears constitute a great part of the preschool period; fear of objects or potential annihilation and parent-induced fears are common.
· Preschool aggression may result from frustration, modeling behaviour, and reinforcement.
· Hesitancy or dysfluency in speech patterns is a normal characteristic of language development. Speech problems can occur when parents express excessive concern over this pattern.
· Health promotion continues to be directed toward proper nutrition, adequate sleep, proper dental care, and injury prevention.
· Child maltreatment may take the form of physical abuse or neglect, emotional abuse or neglect, or sexual abuse.
· Parental, child, and environmental characteristics are criteria that may predispose children to maltreatment.
· Identification of abuse entails securing evidence of maltreatment, taking a history pertaining to the incident, and assessing parental and child behaviours.
· The reported incidence of sexual abuse has increased in the past decade; common forms are incest, molestation, rape, exhibitionism, child pornography, child prostitution, and pedophilia.
Questions & Answers on School Age Injury Prevention
1. Patrick is an active 7-year-old who lives with his parents and 2 younger siblings in a house in the suburbs of a small city. He enjoys being outside and riding his bike.
What is the most common cause of severe injury and death in the school-age child?
(a) Burns
(b) Drowning
(c) Motor vehicle accidents
(d) Cancer
See your textbook for recommendations on how to help reduce the incidence of these injuries in the school-age child.
2. What is the most effective way to support accident prevention?
(a) Purchase new equipment.
(b) Supervise all activities.
(c) Educate the child and family.
(d) Hang posters in the school.
The most effective means of injury prevention is education of the child and family about the hazards of risk taking and the improper use of equipment.
3. Patrick always asks his mother why he can’t ride in the front seat of the car beside her. At what age can a child be allowed to ride in the front passenger seat of cars with airbags?
(a) 11 years
(b) 12 years
(c) 5 years
(d) 16 years
The Canadian Pediatric Society’s (2008) position statement on motor vehicle safety advises that the rear vehicle seat is the safest place for children under the age of 13 years. Children should use specially designed care restraints until they are 145 cm in height or are 8 to 12 years old, and they should not sit in the front seat until they are 12 years of age.
Questions and Answers on Interviewing Adolescents
A father brings his 15-year-old son, John, to the clinic for his sports physical examination. This is the first time you have met the family. According to his chart, John has not had a health assessment in 4 years. There have been a lot of changes in the household. The father reports that he is now the primary care provider since he lost his job over 1 year ago. The mother lives with the family, but works long hours and is unavailable for child care issues.
John seems nervous to answer questions when his father is present. When performing a health history on an adolescent what is the best action for you to take?
John should be offered the opportunity to have the history and assessment done in privacy without the presence of his father. Frequently adolescents are more willing to discuss their concerns with an adult outside the family, and they often welcome the opportunity to interact with a nurse. Confidentiality is of great importance and an adolescent’s disclosures do not have to be shared unless they indicate a need for intervention.
During the family assessment interview, John states that the changes at home have not affected him. However, with his father out of the room, John reports that his father has taken control of his life. He is not allowed to spend time with his peers outside of sports activities; he feels his father is very controlling. Which of the following is not helpful in assessing the family function?
A. Observation of the father’s and John’s responses toward each other.
B. Assessment of the role John has in decision making.
C. Examination of only John’s specific concerns and reactions.
D. Evaluation of family communication patterns.
Assessment of family function is concerned with how the family members behave toward one another and with the quality of the relationships. Assessment includes observation of all family members’ responses to each other; inquiry into individual member’s control over others in the family; clarity of boundaries of power between parents and children; assessment of communication patterns; and acknowledgment of expression of feelings and individuality.
Questions on Teen Smoking
Danielle is a 17-year-old female in Grade 12. She and her friends started smoking 2 years ago, at age 15. Danielle is aware of the risks associated with smoking, but she and her friends think it is cool to smoke, and “besides, everybody is doing it.”
Which of the following is the most appropriate nursing intervention to discourage teen smoking?
(a) Ignore the issue because teens never listen to adults.
(b) Lecture on the effects of smoking on growth and development.
(c) Promote programs that include peers, parents, mass media, and community organizations.
(d) Provide models of smoke-filled lungs to the schools.
Identify the most common reason that teenagers start smoking.
(a) Peer pressure
(b) Relaxation
(c) Curiosity
(d) Family history
Chapter 38: The School-Age Child and Family
Key Points
· Middle childhood, also known as the school years, is the period of life that extends from 6 to 12 years of age.
· Although growth is slower than in previous years, there is a steady gain in height and weight, with maturation of body systems; primary teeth are lost and replaced by permanent teeth.
· A major task during the middle school years is developing a sense of industry or accomplishment (Erikson).
· Piaget’s period of concrete operations refers to the school-age period, when children are able to use their thought processes to experience events and actions, and to make judgements based on reasoning.
· The child develops a conscience and is able to understand and adhere to rules and standards set by others.
· Entertaining different points of view, becoming sensitive to cultural norms, and forming peer friendships are important features of social development during the school years.
· Co-operative play, team activities, and the acquisition of skills are prime elements of play during the school years; rules and rituals assume greater importance.
· Parental concerns during middle childhood include lying, cheating, stealing, bullying, and school achievement.
· The availability of junk foods, irregular family meals, and schedules of working parents often interfere with optimal nutrition and may lead to obesity.
· Activities involving physical movement should be encouraged; sedentary activities, such as watching television or playing video games for long periods of time, are contributing to health problems in this age group.
· Dental care is important during this time; potential dental problems include caries, periodontal disease, malocclusion, and dental injury.
· Increased socialization and media exposure make the school years an ideal time for sex education.
· Ideally, school health programs include health appraisal, emergency care, safety education, lifestyle support, recommended immunizations, communicable-disease control, counselling, guidance, and health education with adjustment to individual student needs.
· Injury prevention is directed toward safety education, provision of safe play areas and equipment, and supervision of sports activities.
· Alterations in growth and maturation may be manifested as short or tall stature, or delayed sexual development.
· Behaviour problems in middle childhood can result from attention deficit hyperactivity disorder, enuresis, school phobia, recurrent abdominal pain, childhood depression, conversion reaction, and childhood schizophrenia.
· Eating disorders are being seen in younger children; an index of suspicion is important to diagnosis.
· Education related to appropriate uses of social media is important.
Perry: Maternal Child Nursing Care in Canada
Chapter 39: The Adolescent and Family
Key Points
· The pubescent growth spurt that begins around age 10 in girls and age 12 in boys signals the beginning of adolescence.
· Biological development during puberty is characterized by increased activity of the pituitary gland, which results in sexual maturity and the appearance of secondary sex characteristics.
· Development of body image is closely tied to body changes and social interactions.
· According to Erikson, the major developmental crisis of adolescence is establishing a sense of identity.
· Cognitive development in adolescence includes abstract thought, thinking beyond the present, logical reasoning, and a sense of idealism.
· According to Kohlberg’s theory of moral development, adolescents begin to question existing moral values and learn to make their own choices.
· Spiritual development is characterized by the questioning of one’s family’s values and ideals and a move toward more philosophical thinking.
· Adolescent relationships with parents may be strained; the influence of the peer group increases, and intimate relationships assume importance.
· Teenagers demonstrate a wide variety of interests, and their increased physical and cognitive skills allow them to engage in increasingly difficult and complex activities.
· Adolescents’ emotions fluctuate.
· Nutritional needs may not be met by teenagers’ eating habits, such as snacking and irregular mealtimes.
· Motor vehicle injuries are the primary cause of death from injury in the adolescent years.
· The rapid changes, growth, and stress accompanying the transition to adulthood may predispose adolescents to faulty problem solving.
· The most common health problems related to the female reproductive system during adolescence involve menstrual dysfunction.
· Eating disorders observed in middle and late childhood are obesity, anorexia nervosa, and bulemia nervosa.
· Tobacco smoking is a widespread problem among teenagers.
· Reasons for smoking include social pressure and mass-media influence.
· The substances used by children and adolescents are alcohol, marijuana, narcotics, central nervous system depressants, central nervous system stimulants, hydrocarbons and fluorocarbons, and mind-altering drugs.
· Suicide, the deliberate act of self-injury with the intent to kill, may occur because of difficulties coping with stress, disturbed family environment, substance use or dependency, or mental health disorder.
· No threat of suicide by an adolescent should be ignored or challenged.
Anonymous self
–
help support groups
Addiction may be expressed in individuals regardless of their age, gender, sexual orientation, socioeconomic status, education, culture, or occupation. Addiction is the most prevalent of all mental conditions, the leading preventable cause of death and disease globally. For these reasons, it has been argued that addiction is the most important illness of our time (Els, 2007). Yet addiction is often neglected and undertreated in Canadian society. There are significant barriers (e.g., stigma and resources) for persons with addiction to overcome in order to access the treatment they need, and these systemic barriers may be as intractable as the disease of addiction itself. Individuals affected with addiction are often alienated and isolated from both their family and communities.
Spirituality (which is not to be confused with religion) has a close relationship with the field of addiction treatment; individuals who have recovered from addiction often mention spiritual experiences or motivation as a major contributory factor in their recovery. Spirituality can be defined as the relationship between an individual and the sacred (numinous), perhaps represented by a transcendent higher being (or higher power) or force (or mind of the universe). This relationship is personal to the individual and does not require affiliation with any organized religion; religion is not necessary for an individual to develop his or her spirituality or, for that matter, to recover from addiction. Spirituality is an integral dimension of the Twelve Step tradition of Alcoholics Anonymous (AA).
Twelve-step programs emphasize the conceptualization of addiction as an incurable, progressive disease that has spiritual, cognitive, and behavioural components. Alcoholics Anonymous (AA) was the first 12-step self-help group and started in the mid-1930s by William Wilson (“Bill W.”) and a physician. The AA movement has become a worldwide fellowship of people with problems (current or past) related to alcohol, which provides support, individually and at meetings, to others who seek help. The only criterion for entry into AA is the “desire to quit drinking.” Many treatment programs discuss concepts from AA, hold meetings at treatment facilities, and encourage patients to attend community meetings when appropriate. They also encourage continuing use of AA and other self-help groups as part of an ongoing plan for continued abstinence. Twelve-step methods firmly endorse the need for abstinence and are considered by followers as lifelong programs of recovery with success attained 1 day at a time. The importance of recognizing and relying on a “higher power,” or a power greater than the individual, is a central element of these programs.
Members of 12-step groups can attend meetings on a self-determined or prescribed schedule that, if necessary, may be every day or even twice a day. Periods associated with high risk of relapse (e.g., holidays, weekends, family functions) are particularly appropriate times for attending meetings.
A sponsor who is compatible with the patient can be particularly supportive and offer guidance through the recovery process, particularly during periods of high stress or increased craving. The benefits from 12-step groups occur through the interplay of social interactions, prescribed behaviours, and mobilized psychological process.
There is strong evidence that social support for abstinence is an important element to its success. Consistent support is also found for the benefit of two specific prescribed behaviours: meeting attendance and engagement in the program and being a sponsor. The evidence is mixed about the relative importance of spiritual/religious changes for explaining increased abstinence (Cavacuiti, Vasic, McCrady, & Tonigan, 2011). Inclusion in 12-step groups is considered a routine part of addiction treatment in most settings. However, an individual’s refusal to participate in a self-help group is nonsynonymous with his or her resistance to treatment in general. Self-help groups are not beneficial for all people, and some persons may not embrace the spiritual dimension of the program.
Alternative programs for sobriety, although not as widely available, have been developed to address this problem, such as Women for Sobriety and Secular Organizations for Sobriety. There are now more than 60 different 12-step fellowships available worldwide, including Alcoholic Anonymous, Cocaine Anonymous, Narcotics Anonymous, Dual Recovery Anonymous, Sex Addicts Anonymous, among others. They do not solicit members, engage in political or religious activities, make medical or psychiatric diagnoses, engage in education about addiction to the general population, or provide mental health, vocational, or legal counselling.
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer
–
Alcoholics Anonymous (AA)
· Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem
· It is nonprofessional, self-supporting, multiracial, apolitical, and available almost everywhere
· There are no age or education requirements
· Membership is open to anyone who wants to do something about his or her drinking problem
· THE TWELVE STEPS OF ALCOHOLICS ANONYMOUS A.A.’s Twelve Steps are a group of principles, spiritual in their nature, which, if practiced as a way of life, can expel the obsession to drink and enable the sufferer to become happily and usefully whole”
Narcotics Anonymous (NA)
· Narcotics Anonymous is a global, community-based organization with a multi-lingual and multicultural membership
· NA was founded in 1953, and our membership growth was minimal during our initial twenty years as an organization
· Since the publication of our Basic Text in 1983, the number of members and meetings has increased dramatically
· Today, NA members hold nearly 67,000 meetings weekly in 139 countries
For further information please visit
https://na.org/
(optional)
To view a copy of the “Institutional Group Guide” please visit
https://www.na.org/admin/include/spaw2/uploads/pdf/handbooks/IGG
(optional)
Al-Anon and Alateen
· AlAnon is a mutual support program for people whose lives have been affected by someone else’s drinking
· By sharing common experiences and applying the Al-Anon principles, families and friends of alcoholics can bring positive changes to their individual situations, whether or not the alcoholic admits the existence of a drinking problem or seeks help
· Alateen, a part of the Al-Anon Family Groups, is a fellowship of young people (mostly teenagers) whose lives have been affected by someone else’s drinking whether they are in your life drinking or not
· By attending Alateen, teenagers meet other teenagers with similar situations. Alateen is not a religious program and there are no fees or dues to belong to it
ResouRces
n
n
n
n
Download this card and additional resources at http://wwww.sprc.org
Resource for implementing The Joint Commission 2007 Patient
Safety Goals on Suicide http://www.sprc.org/library/jcsafetygoals
sAFe-T drew upon the American Psychiatric Association
Practice Guidelines for the Assessment and Treatment of
Patients with Suicidal Behaviors http://www.psychiatryonline.com/
pracGuide/pracGuideTopic_14.aspx
Practice Parameter for the Assessment and Treatment of Children and
Adolescents with Suicidal Behavior. Journal of the American Academy
of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s
AcKNoWLeDGMeNTs
n Originally conceived by Douglas Jacobs, MD, and developed as
a collaboration between Screening for Mental Health, Inc. and
the Suicide Prevention Resource Center.
n This material is based upon work supported by the Substance
Abuse and Mental Health Services Administration (SAMHSA) under
Grant No. 1U79SM57392. Any opinions/findings/conclusions/
recommendations expressed in this material are those of the
author and do not necessarily reflect the views of SAMHSA.
National Suicide Prevention Lifeline
1-800-273-TALK (8255)
HHS Publication No. (SMA) 09-4432 • CMHS-NSP-0193
Printed 2009
SAFE-T
Suicide Assessment Five-step
Evaluation and Triage
1
IDeNTIFY RIsK FAcToRs
Note those that can be
modified to reduce risk
2
IDeNTIFY PRoTecTIVe FAcToRs
Note those that can be enhanced
3
coNDucT suIcIDe INQuIRY
Suicidal thoughts, plans,
behavior, and intent
4
DeTeRMINe RIsK LeVeL/INTeRVeNTIoN
Determine risk. Choose appropriate
intervention to address and reduce risk
5
DocuMeNT
Assessment of risk, rationale,
intervention, and follow-up
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
www.samhsa.gov
Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical
change; for inpatients, prior to increasing privileges and at discharge.
1. RISK FACTORS
3 suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior
3 current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality
disorders, conduct disorders (antisocial behavior, aggression, impulsivity)
Co-morbidity and recent onset of illness increase risk
3 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations
3
3 Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real
or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation
3 change in treatment: discharge from psychiatric hospital, provider or treatment change
3 Access to firearms
Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization
2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk
Internal: ability to cope with stress, religious beliefs, frustration tolerance
external: responsibility to children or beloved pets, positive therapeutic relationships, social supports
3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent
Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever
Plan: timing, location, lethality, availability, preparatory acts
Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions
Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious.
Explore ambivalence: reasons to die vs. reasons to live
3
3
3
3
3
3
* For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition
* Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above
3
3
4. RISK LEVEL/INTERVENTION
Assessment of risk level is based on clinical judgment, after completing steps 1–3
Reassess as patient or environmental circumstances change
RISK LEVEL RISK/PROTECTIVE FACTOR SUICIDALITY POSSIBLE INTERVENTIONS
High
Psychiatric diagnoses with severe
symptoms or acute precipitating event;
protective factors not relevant
Potentially lethal suicide attempt or
persistent ideation with strong intent or
suicide rehearsal
Admission generally indicated unless a significant
change reduces risk. Suicide precautions
Moderate
Multiple risk factors, few protective
factors
Suicidal ideation with plan, but no intent
or behavior
Admission may be necessary depending on risk
factors. Develop crisis plan. Give emergency/crisis
numbers
Low
Modifiable risk factors, strong protective
factors
Thoughts of death, no plan, intent, or
behavior
Outpatient referral, symptom reduction.
Give emergency/crisis numbers
(This chart is intended to represent a range of risk levels and interventions, not actual determinations.)
5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant
others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plan should include roles for parent/guardian.
Opioids and Clinical Opiate Withdrawal Score (COWS)
Box 18-2
Canada’s Fentanyl Public Health Crisis
Developed in 1959 for use as a general anesthetic, fentanyl is therapeutically used to provide physical and emotional relief from acute pain, principally for palliative care patients or those with long-term chronic pain who experience breakthrough pain when using other less potent opioids. It has rapid onset and short duration of action; thus it is primarily administered transdermally in a hospital setting to make its use more convenient for those who are severely ill, with each patch designed to slowly release the potent substance over 72 hours.
In
2017
, illicit street use of the potent licit synthetic opioid fentanyl became a national public health crisis, with overdose deaths in Canada reaching new levels. A decade before, a less potent licit synthetic opioid oxycontin had likewise become a public health issue, which led to its use being prohibited but without the development of a concurrent treatment strategy for those who had become addicted. In fact, during this time the Harper government appealed all the way to the Supreme Court of Canada in an attempt to shutter the nation’s lone supervised injection site; after losing that appeal, the government introduced legislation creating additional barriers to opening any new facility anywhere in Canada.
Historically, whenever a psychoactive substance is prohibited, in its void an alternative arises (Csiernik,
2016
). Unfortunately in this case the prohibition of oxycontin, which was accompanied by its manufacturer, Purdue Pharma, paying a $600 million fine for product misbranding, led to an increase in heroin use. However, heroin is both expensive and illicit, whereas fentanyl, a synthetic drug that is 3 times as potent as uncut heroin and 100 times as potent as morphine, is both far cheaper to manufacture and can be legally produced in nations such as China. Across Canada, the cheaper fentanyl was being mixed with heroin, and at times cocaine, so that less of the expensive drug needed to be used and thus drug dealers could increase their profit margins. Combining the two drugs in street-level labs, however, often creates “hot spots” where more fentanyl is incorporated into the mix and thus the risk of overdose is further increased. Along with fentanyl, another synthetic opioid, even more potent, carfentanil began to be used for this purpose, again increasing the likelihood of each injection leading to an overdose.
Canada is facing a national opioid crisis. The growing number of overdoses and deaths caused by opioids, including fentanyl, is a public health crisis. This is a complex health and social issue that needs a response that is comprehensive, collaborative, compassionate and evidence-based.
Since January 2016 there have been:
· 15,393
Apparent opioid-related deaths
, or 11 per day
· 19,377
Opioid-related poisoning hospitalizations
, or 13 per day
While lower numbers of opioid-related harms have been noted in
2019
compared to
2018
, trend analysis indicate no significant decrease and rates have remained high.
Rate of opioid-related harms per 100,000 population
|
Harm |
2016 | 2017 | 2018 | 2019 |
| Apparent opioid-related deaths |
8.6 |
11.3 |
11.9 |
10.2 |
| Opioid-related poisoning hospitalizations |
16.8 |
18.4 |
17.6 |
15.2 |
According to available opioid-related poisoning hospitalization data in 2019:
· 4,435 opioid-related poisoning hospitalizations occurred between January and December of which 62% were accidental;
Among accidental opioid-related poisoning hospitalizations:
· 3 in 5 were male;
· 49% were among young and middle aged adults (20-49 years);
· 46% were among older adults (≥ 50 years);
· 25% involved fentanyl or fentanyl analogues;
· 28% involved one or more types of non-opioid substances;
According to available Emergency Medical Services (EMS) data in 2019:
· More than 21,000 EMS responses for suspected opioid overdoses occurred between January and September;
Based on available data from 9 provinces and territories;
· 3 in 4 were male;
· 75% were among young and middle aged adults (20-49 years);
· 22% were among older adults (≥ 50 years);
Under the Joint Statement of Action to Address the Opioid Crisis, Health Canada committed to take new action across the Health Portfolio.
The Health Portfolio’s actions to address the opioid crisis complement the Government of Canada’s overall approach to drug policy, which is:
· collaborative
· compassionate
· comprehensive
· evidence-based
These values are reflected in our Canadian drugs and substances strategy. Led by the Minister of Health, this strategy is a balanced and health-focused approach to drug policy, involving:
· a strong foundation in evidence
· the restoration of harm reduction
· prevention
· treatment
· enforcement
The Government of Canada is committed to taking action on Canada’s opioid crisis through a targeted public health response and through:
· Prevention
· Treatment
· Harm reduction
· Enforcement
Actions in these areas will be supported by a strong evidence base.
As with alcohol, a protocol has been established to assist with opioid withdrawal. The Clinical Opiate Withdrawal Scale (COWS) was developed for buprenorphine/naloxone induction, though it can also be used in a variety of clinical settings such as assessing acute opioid withdrawal during an opioid detoxification, methadone maintenance, or methadone treatment, as well as during the treatment of chronic pain
Methadone (Metadol) is a synthetic opioid that blocks the craving for and effects of opioids. It has to be taken every day, produces high physical and psychological dependency, and, when stopped, produces withdrawal symptoms that those in withdrawal have equated to the pain of bone cancer at its peak. Therefore for methadone to be effective, the patient must take a dose at a prescribed level that will prevent withdrawal symptoms, block drug craving, and block any effects of illicit use of short-acting opioids.
Methadone inhibits ascending pain pathways and alters the perception of and response to pain, and although it has morphine-like actions and cross-tolerance, it does not produce euphoria for opioid users when given orally. This has led to its current primary use in substitution therapy for opioid-dependent individuals. However, tolerance and withdrawal do readily occur in methadone users, though their development is much slower than with other opioids. Methadone’s side effects include weight gain, constipation, numbness in the extremities, and, for some, hallucinations when they first begin to use the substance.
Buprenorphine is a partial µ-opioid receptor agonist and, in combination with the opioid antagonist naloxone in a 4 : 1 ratio, is used as an alternative to methadone in opioid drug substitution. When this combination drug known as Suboxone is taken sublingually, it takes from 2 to 10 minutes to dissolve. Used in this manner, the naloxone exerts no clinically significant effect, leaving only the opioid agonist effects of buprenorphine. However, if a patient attempts to inject Suboxone, the opioid antagonism of naloxone causes the user to go into withdrawal. This nearly immediate physical response greatly reduces the abuse potential of the compound drug. Suboxone users report more clarity of thinking, greater confidence, and lower stigma compared to those using methadone. However, Suboxone, like methadone, produces physical dependency and, as with all opioid substances, can slow and even stop respiration, though it is less likely than methadone to produce an overdose (
Orman & Keating, 2009
;
Tanner, Bordon, Conroy, et al., 2011
).
Naltrexone (ReVia) was originally developed as an opioid antagonist, and as a relatively pure antagonist, it blocks the euphoric effects of opioids well. It has low toxicity and few adverse effects and does not produce dependence, as it is not a psychoactive substance itself. A single dose provides an effective opioid blockade for up to 72 hours. Taking naltrexone three times a week is sufficient to maintain a fairly high level of opioid blockade. For many patients, long-term use results in gradual extinction of cravings.
Clonidine (Catapres) was initially marketed for high blood pressure, but it was also found to be an effective somatic treatment, combined with naltrexone, for some chemical-dependent individuals. Clonidine is a nonopioid suppresser of opioid withdrawal symptoms and as such does not produce physical dependency when used regularly. A Cochrane review found clonidine to be more effective than placebo for the management of withdrawal from heroin or methadone, though methadone is associated with fewer adverse effects than clonidine (Gowing, Farrell, Ali, et al., 2014).
SAFE-T Protocol with C-SSRS (Columbia Risk and Protective Factors) – Recent
Step 1: Identify Risk Factors
C-SSRS Suicidal Ideation Severity Month
1) Wish to be dead
Have you wished you were dead or wished you could go to sleep and not wake up?
2) Current suicidal thoughts
Have you actually had any thoughts of killing yourself?
3) Suicidal thoughts w/ Method (w/no specific Plan or Intent or act)
Have you been thinking about how you might do this?
4) Suicidal Intent without Specific Plan
Have you had these thoughts and had some intention of acting on them?
5) Intent with Plan
Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?
C-SSRS Suicidal Behavior: “Have you ever done anything, started to do anything, or prepared to do anything to end your
life?”
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t
swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or
actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
If “YES” Was it within the past 3 months?
Lifetime
Past 3
Months
Activating Events:
□ Recent losses or other significant negative event(s) (legal,
financial, relationship, etc.)
□ Pending incarceration or homelessness
□ Current or pending isolation or feeling alone
Treatment History:
□ Previous psychiatric diagnosis and treatments
□ Hopeless or dissatisfied with treatment
□ Non-compliant with treatment
□ Not receiving treatment
□ Insomnia
Other:
□ ___________________
□ ___________________
□ ___________________
Clinical Status:
□ Hopelessness
□ Major depressive episode
□ Mixed affect episode (e.g. Bipolar)
□ Command Hallucinations to hurt self
□ Chronic physical pain or other acute medical problem (e.g. CNS
disorders)
□ Highly impulsive behavior
□ Substance abuse or dependence
□ Agitation or severe anxiety
□ Perceived burden on family or others
□ Homicidal Ideation
□ Aggressive behavior towards others
□ Refuses or feels unable to agree to safety plan
□ Sexual abuse (lifetime)
□ Family history of suicide
□ Access to lethal methods: Ask specifically about presence or absence of a firearm in the home or ease of accessing
Step 2: Identify Protective Factors (Protective factors may not counteract significant acute suicide risk factors)
Internal:
□ Fear of death or dying due to pain and suffering
□ Identifies reasons for living
□ ___________________
□ ___________________
External:
□ Belief that suicide is immoral; high spirituality
□ Responsibility to family or others; living with family
□ Supportive social network of family or friends
□ Engaged in work or school
Step 3: Specific questioning about Thoughts, Plans, and Suicidal Intent – (see Step 1 for Ideation Severity and
Behavior)
C-SSRS Suicidal Ideation Intensity (with respect to the most severe ideation 1-5 identified above) Month
Frequency
How many times have you had these thoughts?
(1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each day
Duration
When you have the thoughts how long do they last?
(1) Fleeting – few seconds or minutes (4) 4-8 hours/most of day
(2) Less than 1 hour/some of the time (5) More than 8 hours/persistent or continuous
(3) 1-4 hours/a lot of time
Controllability
Could/can you stop thinking about killing yourself or wanting to die if you want to?
(1) Easily able to control thoughts (4) Can control thoughts with a lot of difficulty
(2) Can control thoughts with little difficulty (5) Unable to control thoughts
(3) Can control thoughts with some difficulty (0) Does not attempt to control thoughts
Deterrents
Are there things – anyone or anything (e.g., family, religion, pain of death) – that stopped you from wanting to die or acting on
thoughts of suicide?
(1) Deterrents definitely stopped you from attempting suicide (4) Deterrents most likely did not stop you
(2) Deterrents probably stopped you (5) Deterrents definitely did not stop you
(3) Uncertain that deterrents stopped you (0) Does not apply
Reasons for Ideation
What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way
you were feeling (in other words you couldn’t go on living with this pain or how you were feeling) or was it to get attention,
revenge or a reaction from others? Or both?
(1) Completely to get attention, revenge or a reaction from others (4) Mostly to end or stop the pain (you couldn’t go on
(2) Mostly to get attention, revenge or a reaction from others living with the pain or how you were feeling)
(3) Equally to get attention, revenge or a reaction from others (5) Completely to end or stop the pain (you couldn’t go on
and to end/stop the pain living with the pain or how you were feeling)
(0) Does not apply
Total Score
Source: The Columbia Lighthouse project. (2021). SAFE-T with C-SSRS. https://cssrs.columbia.edu/documents/safe-t-c-
ssrs/
Step 5: Documentation
Risk Level :
[ ]
High Suicide Risk
[ ]
Moderate Suicide Risk
[ ]
Low Suicide Risk
Clinical Note:
Your Clinical Observation
Relevant Mental Status Information
Methods of Suicide Risk Evaluation
Brief Evaluation Summary
Warning Signs
Risk Indicators
Protective Factors
Access to Lethal Means
Collateral Sources Used and Relevant Information Obtained
Specific Assessment Data to Support Risk Determination
Rationale for Actions Taken and Not Taken
Provision of Crisis Line 1-800-273-TALK(8255)
Implementation of Safety Plan (If Applicable)
Step 4: Guidelines to Determine Level of Risk and Develop Interventions to LOWER Risk Level
“The estimation of suicide risk, at the culmination of the suicide assessment, is the quintessential clinical judgment, since no study has identified
one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior.”
From The American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors, page 24.
RISK STRATIFICATION TRIAGE
High Suicide Risk
? Suicidal ideation with intent or intent with plan in past month (C-SSRS
Suicidal Ideation #4 or #5)
Or
? Suicidal behavior within past 3 months (C-SSRS Suicidal Behavior)
Initiate local psychiatric admission process
Stay with patient until transfer to higher level of care is
complete
Follow-up and document outcome of emergency psychiatric
evaluation
Moderate Suicide Risk
? Suicidal ideation with method, WITHOUT plan, intent or behavior
in past month (C-SSRS Suicidal Ideation #3)
Or
? Suicidal behavior more than 3 months ago (C-SSRS Suicidal Behavior
Lifetime)
Or
? Multiple risk factors and few protective factors
Directly address suicide risk, implementing suicide
prevention strategies
Develop Safety Plan
Low Suicide Risk
? Wish to die or Suicidal Ideation WITHOUT method, intent, plan or
behavior (C-SSRS Suicidal Ideation #1 or #2)
Or
? Modifiable risk factors and strong protective factors
Or
□ No reported history of Suicidal Ideation or Behavior
Discretionary Outpatient Referral
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Treating Women Who Have Experienced
Intimate Partner Violence
Intimate partner violence (IPV) is one of the most common form of violence against women. It could be
physical, sexual, and emotional abuse and controlling behaviors by an intimate partner and occurs in all settings
and among all socioeconomic, cultural and religious groups. IPV may lead women to negative health
consequences, including mental health disorders. Therefore, it is important to implement IPV screening and
counselling safely and effectively throughout the health care delivery system. It can be achieved by educating
health care professionals in IPV screening and counseling techniques.
The following sections discuss screening, safety assessment, treatment options and best practices in treating
women who have experienced IPV.
Screening for IPV Survivors in Mental Health Settings
Women with mental health symptoms or disorders (depression, anxiety, post-traumatic stress disorders (PTSD),
self-harm/suicide attempts) should be screened for IPV in health care settings as part of best clinical practice.
Survivors should be evaluated for safety and homicide risk and undergo a general health screening. Other areas
to assess include history of substance abuse/misuse and social support.
In 2007, the Centers for Disease Control and Prevention released the screening tool Intimate Partner Violence
and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings: Version , that is
widely used by providers.
Safety Assessment
A vital role for health care providers is to assess the safety of a survivor and develop a plan to ensure immediate
safety of the survivor. Health care providers may connect survivors to a nurse, social worker, advocate,
community resource, or health care workers who are trained in violent prevention.
Suicide Assessment
Studies have found a link between the number of previous traumatic events and the risk of attempting suicide.
Mental health providers should conduct a suicide risk assessment in all interactions with IPV survivors. Mental
health care providers should:
o Conduct the assessment in a private, confidential space.
o Provide interpreters as needed.
o Discuss the reasons for assessment with your patients. It will reduce their fear, anxiety and the
risk of aggression.
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o Describe with as much detail as possible what is happening or going to happen which will
increase a sense of control and decrease fear and anxiety.
o De-brief with staff involved in the process.
o Work with the patient on a safety plan. This will increase a sense of control and collaboration.
o Focus on coping strategies for risky situations. It will help survivors identity and reinforce
strengths, social supports and motivations to seek help. Available safety planning resources can
be found at http://www.sprc.org/resources-programs/patient-safety-plan-template
Danger Assessment
Every year 1,500-1,600 women in the US are killed by their intimate partners. About 1 in 5 women killed or
severely injured by an intimate partner had no previous warning; the fatal or life-threatening incident was the
first physical violence they had experienced from their partner. The following tools are used to help determine
this risk.
x The Danger Assessment is a widely validated tool that determines the level of danger an abused woman
has of being killed by an intimate partner.
o It consists of two sections: a calendar and a 20-item scoring instrument. The calendar records
the severity and frequency of IPV during the past year.
o The 20-item instrument uses a weighted system to score yes or no responses to risk factors
associated with intimate partner homicide.
o The tool is available in English, Spanish, Portuguese and French. Training and certification are
available in many forms including an online version.
o It is also available in the form of a smartphone application for users who want to learn about the
level of risk in their current relationships.
x The Danger Assessment-Revised (DA-R) is a tool that was also found to predict re-assault in abusive
female same-sex relationships. This tool is also available, and it predicts only re-assault, not lethality.
x The Lethality Screen for First Responders is an assessment tool that was developed using the Danger
Assessment as a guide. The instrument is currently being used by law enforcement in Maryland.
x Training options for the Danger Assessment are available at:
https://www.dangerassessment.org/TrainingOptions.aspx
Treatment
Psychotherapies
Psychotherapies may be used to address the multiple stressors of IPV survivors, including the immediate need
for safety and resources, loss of an intimate relationship, social isolation, and parenting issues.
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The following psychotherapies that have demonstrated effectiveness in large randomized controlled trials for
PTSD.
Cognitive Behavioral Therapy (CBT)
Present-focused non-exposure Cognitive Behavioral Therapy (CBT) helps people attain safety while helping to
reduce trauma/PTSD symptoms and substance misuse. It can be delivered in the group and individual formats, in
both adults and adolescents.
Seeking Safety, an evidence-based, integrative treatment approach is often used to help IPV survivors attain
safety from trauma and PTSD. The key principles of Seeking Safety are:
1. Safety as the overarching goal (helping patients attain safety in their relationships, thinking, behavior,
and emotions)
2. Integrated treatment (focus on both trauma and substance abuse)
3. A focus on ideals to counteract the loss of ideals in both trauma and substance abuse
4. Four content areas: cognitive, behavioral, interpersonal, case management
5. Attention to clinician processes (clinicians’ emotional responses, self-care, etc.)
STAIR (Skills Training in Affective and Interpersonal Regulation)
STAIR is an evidence-based skills-focused CBT for PTSD treatment. STAIR was initially developed for individuals
with PTSD related to childhood abuse (though not formally tested in IPV survivors). It can be implemented in
both individual and group modalities. While this psychotherapy can be complemented with an exposure
component, it is primarily focused on reframing cognitions that have emerged as a result of a traumatic
experience. STAIR focus on:
1. Psychoeducation about the impact of trauma on emotions and relationships
2. Emotion regulation skills
3. Effective expression of negative emotions
4. Interpersonal skills related to appropriate assertiveness
5. Development of flexibility in regard to interpersonal expectations, actions and reactions. Treatment also
includes recognition of achievements during treatment and exercises in self-compassion.
Interpersonal Psychotherapy (IPT)
IPT has been shown to be an effective non-exposure-based treatment for PTSD. Many PTSD symptoms reflect
interpersonal difficulties such as emotional withdrawal from relationships and individuals, sometimes resulting
in interpersonal hypervigilance. IPT directly addresses these areas by focusing on four interpersonal areas:
1. Grief, role disputes (disagreements with significant others)
2. Role transitions (changes in life circumstances)
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3. Interpersonal deficits (persistent loneliness)
4. Social supports to improve well-being
Cognitive Processing Therapy (CPT)
CPT is an effective treatment for reducing PTSD and depression symptoms following interpersonal victimization,
including physical and sexual assault. CPT focuses on:
1. Education of PTSD symptoms
2. Effect of traumatic events
3. Connections between trauma-related thoughts, feelings, and behaviors
4. Remembering the traumatic event and experiencing the emotions associated with it
5. Ability to challenge maladaptive thoughts about the trauma
6. Reduction of negative thinking patterns and motivation to learn new, healthier ways of thinking
7. Exploration of how core themes have been impacted by trauma.
Eye movement desensitization reprocessing (EMDR)
The EMDR integrates techniques from cognitive behavioral, psychodynamic, and body-oriented therapy.
Processes identified in EMDR include mindfulness, somatic awareness, free association, cognitive restructuring,
and conditioning. These processes may interact to create the positive effects achieved with EMDR. The therapy
is conducted without detailed descriptions of traumatic events.
HOPE (Helping to Overcome PTSD through Empowerment)
It is a short-term non-exposure CBT specifically developed for battered women with PTSD living in domestic
violence shelters. The therapy focuses on stabilization, safety, and empowerment. HOPE focuses on the
following:
x Immediate physical and emotional risks
x PTSD symptoms, behaviors, and cognitions that interfere with achieving shelter and treatment goals
x PTSD symptoms and behavioral and cognitive patterns that interfere with quality of life
x Post-shelter goals and safety.
Relapse Prevention and Relationship Safety (RPRS)
RPRS addresses IPV and relationship safety and reduces drug use, PTSD, depression, and risky sexual
behaviors. Treatment is culturally specific to low-income Black and Latina women.
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The program does not try to pressure women into leaving the abusive relationship. It focuses on
empowerment and safety tactics, within or outside of the relationship.
Grady Nia Project
It is a culturally competent intervention developed for low-income African American IPV survivors who are also
suicidal. Nia derives its name from the Kwanza term that means purpose. It focuses on intrapersonal factors
and women s support networks and communities. The program aims to help women:
1. Build skills and enhance self-efficacy
2. Increase social connectedness
3. Decrease trauma-related distress through gender focused, Afrocentric empowering practices
4. Access comprehensive mental health care
Cognitive Trauma Therapy for Battered Women (CTT-BW)
CTT-BW was developed for IPV survivors who had no desire to reconcile with their abusive partners. The
intervention includes psychoeducation about PTSD, stress management, and components to address:
1. Trauma-related guilt about failed relationships, effects on children, decisions to stay or leave
2. Histories of other traumatic experiences
3. Risk for subsequent re-victimization
4. Negative beliefs about self
The intervention also helps survivors with strategies for best interacting with former partners around child
custody and visitation
Psychopharmacologic Treatment
x Psychopharmacological treatment can be used when treating mental health consequences of IPV, such
as mood and/or anxiety symptoms
x Antidepressants, anxiolytics, and hypnotics are used to treat major depressive disorders (MDD) and
PTSD associated with IPV. Combination of CBT and antidepressants is often used for treating PTSD.
x A full list of pharmacological interventions and psychotherapies can be viewed at “Systematic Review of
Trauma-Focused Interventions for Domestic Violence Survivors.”
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Best Practices
IPV survivors may feel misunderstood and unsupported during their interactions with mental health
professionals. Labeling survivors with psychiatric conditions may cause them to feel as though their abusive
situation is not understood. This may lead to mistrust of health care providers.
Using a trauma-informed model, health care providers can ensure a positive engagement between patients and
providers. Trauma-informed principles include: 1) Acknowledgement; 2) Safety; 3) Trust; 4) Choice and Control;
4) Compassion; 5) Collaboration; and a 6) Strengths-based Focus.
x Mental health providers should build a therapeutic relationship based on respect, trust and safety. The
following are recommendations for treating survivors:
o Conduct interviews in private, confidential spaces.
o Provide language interpreters, if needed.
o Frame and ask questions and statements with empathy and nonjudgment.
o Be mindful of the language or communication you use. (See glossary in Table 1 which can serve
as a tool to improve communication.)
o Try not to discuss too quickly the trauma that survivors endured. It can increase the risk of
dissociation and feeling overwhelmed.
o Conduct a suicide risk assessment and danger assessments.
o Focus on a collaborative approach. After appropriate concerns are obtained, other service
providers should be involved in the patient s care.
o Consider incorporating culturally sensitive care to survivors.
o Document all interactions, especially those in which the survivor presents psychological distress,
dissociative symptoms or substance misuse.
x If survivors are ready to leave their partners, mental health providers should connect them with
available resources that can provide multidisciplinary support in this process. These resources include
crisis hotline, shelters, legal services, and community organizations.
x It is important to inquire about their children s safety at home. Law mandates mental health providers
to report child maltreatment.
x Providers may discuss the dangers of exposing children to an abusive environment and ways to handle
child protective services re-referrals, if needed.
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Table 1. IPV and Trauma-Sensitive Practices -Strengths-based Language
Deficit-based/Inappropriate Language Strengths-based Language
Domestic dispute, crime of passion,
anger issues, wife beating
Intimate-Partner Violence (IPV): violence between intimate partners
regardless of whether they cohabitate/are married or still in a
relationship in an ongoing pattern of coercive control perpetrated by
one partner over another
Victim, Battered Woman Survivor: Person who has experienced IPV regardless of gender.
It s a personal matter.
It s private; it s between the two of
you.
I not your fa l Tha was a crime It s important to reinforce
that IPV was wrong in a non-judgmental way
So, you re here because you ve been
abused?
Build a rapport naming the abuse or the r i or experience. If the
survivor is describing abuse without naming it, take time to listen and
validate before providing psychoeducation on abuse: What you re
describing sounds like abuse. It s not okay that he/she said/did those
things to you.
perpetrator, batterer, abuser,
wife beater, offender
It is more helpful to refer to the behavior rather than characterizing a
person and defining them by using those terms. It is suggested to use
languages such as beha ed ab i el or ab i e par ner
He s a bad guy/she is a bad woman.
He she s evil; I don t know how he/she
can live with himself.
Some survivors have powerful attachments to their abusive partners
and/or feel preoccupied with discussing or seeking treatment for
their partner.
So, it was just a misunderstanding. Abusive partners generally minimize and deny the abuse and blame
survivors for the abuse. Survivors may come to believe that they are
at fault, that they are too sensitive or that they deserved the
abuse. Never assume that the violence or abuse is not serious.
Why did you allow him/her to do that
to you? Why didn t you fight back?
Recognize and reinforce that the r i or struggles leaving a
relationship. Do ask What did he/she do to o
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Why didn t you just leave?
You chose to stay.
Some of the survivors may not be willing or able to leave their
abusive partners. Some may not want to leave their abusive partners
though they want the violence to stop.
Do ask What were the reasons you felt you couldn t leave? What
gave you the courage to leave?
Really? Did that really happen that
way?
Believe survivors. IPV survivors may already have experienced
minimization and invalidation of their experience. It s important not
to overtly question their narrative, especially the first time they share
it with you.
You are mentally ill Avoid pathologizing survivors. When discussing possible psychiatric
diagnoses and treatment with IPV survivors, keep in mind that
abusive partners often use such language to belittle survivors (e.g.
mental health coercion).
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Appendix
Traumatic Brain Injury (TBI)
x TBI is a form of acquired brain injury that occurs when a sudden trauma causes damage to the brain. TBI
can result when the head suddenly and violently hits an object, or when an object pierces the skull and
enters brain tissue.
x The prevalence of TBI in IPV survivors seeking emergency shelter or presenting to the Emergency
Department ranges from 30% to 74%.
x Mild to severe TBI can cause irreversible physical and mental health consequences.
x Individuals who experience IPV are more likely to have multiple TBIs. As these accumulate, the
likelihood of recovery dramatically decreases. (For more information and resources on TBI please visit
http://www.ninds.nih.gov/disorders/tbi/tbi.htm).
x Some individuals may not lose consciousness and still have significant sequelae because of the TBI.
x Mental health providers may be unaware of TBI in their patients. Subtle injuries may not be evident with
brain imaging but still, lead to significant impairment. Therefore, proper referrals for evaluation and
services should be given when TBI is suspected in IPV survivors.
x Patients with significant neurologic sequelae may need to apply for long term disability.
x A brief screening tool for TBI is available at:
http://www.doj.state.or.us/victims/pdf/traumatic_brain_injury_and_domestic_violence
Non-fatal Strangulation (Choking)
x Non-fatal strangulation (choking) is one of the most lethal forms of IPV as it can lead to temporary loss
of consciousness and sometimes death. Strangulation accounts for 15-20% of deaths associated with IPV
in the United States
x Symptoms of strangulation include nausea, vomiting, lightheadedness, headache, involuntary urination
and/or defecation, as well as difficulty in breathing, speaking, or swallowing.
x Individuals who have been strangled may appear normal after the event. Therefore, a physical
examination for strangulation injuries in survivors may be necessary.
x Non-fatal strangulation is a felonious assault in most states and may be considered an attempted
homicide.
x Patients need to be educated about the seriousness of strangulation, risk of homicide and long-term
consequences of strangulation.
x Mental health providers should connect strangulation survivors to advocacy organizations to receive
help to understand legal rights.
AMERICAN PSYCHIATRIC ASSOCIATION | DIVISION OF DIVERSITY AND HEALTH EQUITY | © 2019
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x Training on non-fatal strangulation response is available at The Training Institute on Strangulation
Prevention (Institute) a program of Alliance for HOPE International:
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Chapter 39
The School-Age Child and Family
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Promoting Optimal
Growth and Development
“School age” generally defined as ages 6 to 12 years
Physiologically begins with shedding of first deciduous teeth; ends at puberty with acquisition of final permanent teeth
Gradual growth and development
Progress with physical and emotional maturity
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Fig. 39-1. Middle childhood is the stage of development when deciduous teeth are shed.
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Biological Development
Height increases by 5 cm/year.
Weight increases by 2 to 3 kg/year.
Males and females differ little in size.
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Maturation of Systems
Increase in bladder capacity
Heart smaller in relation to rest of body
Immune system increasingly effective
Increase in bone ossification
Physical maturity not necessarily correlated with emotional and social maturity**
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Prepubescence
Defined as two years preceding puberty
Typically occurs during preadolescence
Varying ages from 9 to 12 (girls about 2 years earlier than boys)
Beginning of puberty at age 10 in girls and age 12 in boys
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Psychosocial Development
Relationships centre around same-sex peers.
Freud described it as the “latency” period of psychosexual development.
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Psychosocial Development—cont.
*Erikson; A sense of industry or stage of accomplishment
Eagerness to develop skills and participate in meaningful and socially useful work
Acquisition of sense of personal and interpersonal competence
Growing sense of independence
Peer approval strong motivator
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Psychosocial Development—cont.
Erikson; inferiority
Feelings may derive from self or social environment.
Sense of inferiority arises if child is incapable or unprepared to assume the responsibilities associated with developing a sense of accomplishment.
All children feel some degree of inferiority regarding skill(s) they cannot master.
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Cognitive Development
Piaget; concrete operations
Uses thought processes to experience events and actions
Develops understanding of relationships between things and ideas
Is able to make judgements based on reason (“conceptual thinking”)
Masters the concept of conservation
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Fig. 39-3. Common examples that demonstrate the child’s ability to conserve (ages are only approximate).
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Moral Development
Kohlberg; development of conscience and moral standards
Age 6 to 7: Reward and punishment guide choices.
Older school-age children are able to judge an act by the intentions that prompted it.
Rules and judgements become more founded on needs and desires of others.
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Spiritual Development
Children think in very concrete terms.
Children begin to learn the difference between natural and supernatural.
Religious rituals comfort them.
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Social Development
Importance of the peer group
Identification with peers a strong influence in child gaining independence from parents
Gender roles strongly influenced by peer relationships
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Social Relationships
Clubs and peer groups
Formation of formalized groups
Bullying (incidence doubles from 2002-2012)
CHI, 2013.
Relationships with families
Parents primary influence in shaping child’s personality, behavior, and value system
Increasing independence from parents primary goal of middle childhood
Children not ready to abandon parental control
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Social Relations cont’d
Relationships with families
Parents primary influence in shaping child’s personality, behavior, and value system
Increasing independence from parents primary goal of middle childhood
Children not ready to abandon parental control
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Play
Rules and rituals
Team play
Quiet games and activities
Ego mastery…conscious decision making
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Developing a Self-Concept
Definition: a conscious awareness of a variety of self-perceptions (e.g., abilities, values, appearance)
Importance of significant adults in shaping child’s self-concept
Positive self-concept leading to feelings of self-respect, self-confidence, and happiness
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Fig. 39-6. School-age children take pride in learning new skills.
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Developing a Body Image
Generally children like their physical selves less as they grow older.
Body image is influenced by significant others.
Increased awareness of “differences”
may influence feelings of inferiority (e.g., hearing or visual defects).
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Coping With Concerns Related to
Normal Growth and Development
School experience
Second only to the family as socializing agent
Transmission of values of the society
Peer relationships becoming increasingly important
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Coping With Concerns Related to
Normal Growth and Development—cont’d
Teachers
Parents
Latchkey children
Limit-setting and discipline
Dishonest behaviour
Stress and fear
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Promoting Optimal Health
During the School Years
Nutrition
Importance of balanced diet to promote growth
Quality of diet related to family’s pattern of eating
“Junk-food” concerns…obesity rates
Journal List Health Promot Chronic Dis Prev Canv.36(9); 2016 Sep
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Sleep and Rest
Average 9.25 hours per night by about age 12 but highly individualized
May resist going to bed at ages 8 to 11
12 years and up generally less resistant to bedtimes
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Exercise and Activity
Sports
Controversy regarding early participation in competitive sports
Concerns with physical and emotional maturity in competitive environment
Acquisition of skills
Generally like competition
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Fig. 39-7. The activities engaged in by school-age children vary according to interest and opportunity. A: Little League competitors. B: Playing tug-of-war.
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Dental Health
Eruption of permanent teeth
Good dental hygiene
Trauma
Prevention of dental caries
Periodontal disease
Malocclusion
Dental injury
Dental avulsion—replacement or reattachment
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Fig. 39-8. Sequence of eruption of secondary teeth.
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Sex Education
Sex play as part of normal curiosity during preadolescence
Middle childhood as ideal time for formal sex education
Lifespan approach
Information on sexual maturity and process of reproduction
Effective communication with parents
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Nurse’s Role in Sex Education
Treatment of sex as normal part of growth and development
Questions and answers
Differentiation between “sex” and “sexuality”
Values, problem-solving skills
Open for communication with parents
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School Health
Responsibilities of parents, schools, and health departments
Ongoing health maintenance through assessment, screening, and referrals
Routine services, emergency care, safety and communicable disease control, counselling and follow-up care
Need to increase knowledge of health and health habits
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Injury Prevention
Motor vehicle crashes as most common cause of severe injury and death in school-age children—pedestrian and passenger
Bicycle injuries—benefits of bike helmets
Appropriate safety equipment for all sports
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Stress Fractures
Occur as result of repeated muscle contraction
Seen most often in repetitive weight-bearing sports
Common symptoms
Sharp, persistent, progressive or deep, dull ache
Pain over the involved bony surface
Diagnosis based on clinical observation, possibly bone scan
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Therapeutic Management
of Stress Fractures
Rest—alleviation of repetitive stress that initiated symptoms
Training with alternative exercise regimens
Physical therapy, cryotherapy, cold whirlpools
Rx: nonsteroidal anti-inflammatory medications for discomfort
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Nurse’s Role in Sports
for Children and Adolescents
Evaluation for activities
Prevention of injury
Treatment of injuries
Rehabilitation after injuries
Instruction to student and parents
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Altered Growth and Maturation
Often are the result of simple physiological (“constitutional”) delay
Endocrine dysfunction
Chromosome abnormalities
Chronic disease (e.g., malabsorption, asthma)
Stress
Poor nutrition
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Tall Stature
May cause anxiety, perceived social handicap among some patients
Gender perceptions related to height
Use of estrogens to control height if initiated before menarche
Use of hormone therapy controversial
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Short Stature
May be first manifestation of serious disorder
May be of no consequence to health
Most common cause worldwide: inadequate nutrition
Also chronic disease, endocrine dysfunction, primary gonadal failure
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Sex Chromosome Abnormalities
Most caused by altered number of sex chromosomes
Most due to nondisjunction
Cognitive impairment less common
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Turner Syndrome
Absence of one of the X chromosomes (45,X)
Females
Manifestations
Infertile
Short stature
No secondary sex characteristics
Webbed neck, widely spaced nipples, low posterior hairline and edema of the hands and feet
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Klinefelter’s Syndrome
Most common of all chromosome abnormalities
Presence of one or more additional X chromosomes (47,XXY most common)
Occurs in males
Rarely seen before puberty
Failure of adolescent virilization
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Klinefelter’s Syndrome—cont.
May not be diagnosed until person presents for infertility
Azoospermia, small testes
Defective development of secondary sex characteristics
Cognitive impairment of varying degrees, behavioural problems, possibly gross motor difficulties
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Attention Deficit Hyperactivity
Disorder and Learning Disability
ADHD: inattention, impulsiveness, and hyperactivity
LD: a heterogeneous group of disorders with difficulties in acquisition and use of listening, speaking, reading, writing, reasoning, math, and/or social skills
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Diagnostic Evaluation
Quality of motor activity
Developmentally inappropriate inattention, impulsivity, and hyperactivity
Wide variation of severity
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Battery of Tests for LD
and ADHD
IQ
Hand–eye coordination
Visual and auditory perception
Comprehension
Memory
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Therapeutic Management
of ADHD
Medication
Environmental manipulation
Classroom
Family education and counselling
Behavioural and/or psychotherapy for child
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Medications for ADHD
Stimulants
Dexedrine
Ritalin
Tricyclic antidepressants
Clonidine
Guanfacine
Norepinephrine transport inhibition
Atomoxetine
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Enuresis
Bed-wetting
More common in boys
Usually ceases between 6 and 8 years of age
Diagnosis
Developmental age of more than 5 years
Two times per week or more for three months
May have urgency, frequency
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Enuresis—cont.
Organic causes
Structural defects
Urinary tract infection, impaired kidney function, chronic renal failure
Neurological deficits, endocrine disorders (diabetes)
Sickle cell disease
Bladder volume of 300 to 350 mL sufficient to hold a night’s urine
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Treatment for Enuresis
Drugs
Tofranil
Oxybutynin
Desmopressin (DDAVP ®)
Bladder training
Fluid restriction in evenings
Interruption of sleep to void
Conditioned-reflex response device
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Posttraumatic Stress Disorder (PTSD)
Development of characteristic symptoms following exposure to extremely traumatic experience or catastrophic event
May function adequately but have foreboding regarding the future
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PTSD: Response to the Event
Initial response
Intense arousal; lasts one to two hours
“Fight or flight” response
Second phase
Lasts approximately two weeks
Denial, period of quiescence
Third phase
Appear to get worse; lasts two to three months
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PTSD Symptoms
Depression, anxiety, conversion reactions
Phobic symptoms, repetitive actions
Flashbacks common
Inquiry about what has happened
Nursing care management
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School Phobia
Defined as extreme reluctance to attend school for a sustained period of time as a result of severe anxiety or fear of school-related experiences
Also called “school refusal” and “school avoidance”
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Impact of Social Media
Benefits include entertainment, development of communication and technological skills.
Risks include cyberbullying, sexual predators.
Children need parental monitoring with participation and discussion of their children’s online activity.
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Center for Deployment Psychology | Uniformed Services University of the Health Sciences
4301 Jones Bridge Road, Bldg. 11300‐602, Bethesda, MD 20814‐4799
www.deploymentpsych.org
Columbia Suicide Severity Rating Scale (C‐SSRS)
Availability
All four versions of the scale can be accessed from the Columbia University Medical Center’s Center for Suicide
Risk Assessment website at http://www.cssrs.columbia.edu/. The C‐SSRS is included in the battery of measures
available within the Behavior Health Data Portal (BHDP). The BHDP is a software platform used to measure and
examine patient‐level clinical outcomes in military behavioral health clinics.
What is the scoring range?
The C‐SSRS is made up of ten categories, all of which maintain binary responses (yes/no) to indicate a presence or
absence of the behavior. The ten categories included in the C‐SSRS are as follows: Category 1 – Wish to be Dead;
Category 2 – Non‐specific Active Suicidal Thoughts; Category 3 – Active Suicidal Ideation with Any Methods (Not Plan)
without Intent to Act; Category 4 – Active Suicidal Ideation with Some Intent to Act, without Specific Plan; Category 5 –
Active Suicidal Ideation with Specific Plan and Intent; Category 6 – Preparatory Acts or Behavior; Category 7 – Aborted
Attempt; Category 8 – Interrupted Attempt; Category 9 – Actual Attempt (non‐fatal); Category 10 – Completed Suicide.
A yes/no binary response is also utilized in assessing self‐injurious behavior without suicidal intent. The outcome of the
C‐SSRS is a numerical score obtained from the aforementioned categories.
Scoring the C‐SSRS
What does it measure?
The Columbia Suicide Severity Rating Scale (C‐SSRS) is a measure used to
identify and assess individuals at risk for suicide. Questions are phrased for
use in an interview format, but can be completed as a self‐report measure
if necessary. The C‐SSRS measures four constructs: the severity of ideation,
the intensity of ideation, behavior and lethality. It includes “stem
questions,” which if endorsed, prompt additional follow‐up questions to
obtain more information. There are four versions of the scale available,
including:
1. Lifetime/Recent version, which allows practitioners to gather a
lifetime history of suicidal ideation and/or behavior.
2. Since Last Visit version for assessment of suicidal thoughts and
behaviors since C‐SSRS was last administered.
3. Screener version, a shortened version of the full form (3‐6
questions) most commonly used in clinical triage settings.
4. Risk Assessment Page, which provides a checklist of protective and
risk factors of suicidality.
About the C‐SSRS
Oct 2016
Center for Deployment Psychology | Uniformed Services University of the Health Sciences
4301 Jones Bridge Road, Bldg. 11300‐602, Bethesda, MD 20814‐4799
www.deploymentpsych.org
What are the clinical cutoffs, if any?
There are no specified clinical cutoffs for the C‐SSRS due to the binary nature of the responses to items. When an item is
endorsed, the clinician must pose follow‐up inquiries to obtain additional information. The following table can inform
safety monitoring and treatment planning when patients endorse suicidal ideation, suicidal behavior, or both:
Outcome Item Endorsement C‐SSRS Categories
Suicidal ideation “Yes” Categories 1‐5
Suicidal behavior “Yes” Categories 6‐10
Suicidal ideation & behavior “Yes” Categories 1‐10
How should a provider interpret results?
Interpretation of the C‐SSRS can take place on an itemized level, a categorical scale, or overall severity of suicidal
ideation and behavior. Specific ratings can be derived from the C‐SSRS, such as the suicidal behavior lethality scale,
suicide ideation score, and the suicidal ideation intensity rating. Ultimately, interpretation will be derived from a
thorough clinical assessment, client history, and clinical expertise.
How should providers use the results in treatment planning?
Providers should use the C‐SSRS as a measure of suicidal ideation, intent, or plan, and past suicidal behavior. It can be
used to guide appropriate therapeutic intervention and to facilitate safety monitoring and planning. In addition, the C‐
SSRS can be utilized to measure treatment progress over time and to assess continued difficulties with suicidality which
should be targets of treatment.
References:
Mary E. Nilsson, M.E., Suryawanshi, S., Gassmann‐Mayer, C., Dubrava, S., McSorley, P., and Jiang K. (2013).
Columbia–Suicide Severity Rating Scale Scoring and Data Analysis Guide. Retrieved from
http://www.cssrs.columbia.edu/documents/ScoringandDataAnalysisGuide_Feb2013
Posner, K., Brown, G.K., Stanley, B., Brent, D.A., Yeshiva, K.V., Oquendo, M.A., Currier, G.W., Melvin, G., Greenhill, L.,
Shen, S., & Mann, J.J., (2011). The Columbia‐suicide severity rating scale: Initial validity and internal consistency
findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266‐
1277. doi: 10.1176/appi.aip.2011.10111704
Posner, K. (n.d.). Columbia‐Suicide Severity Rating Scale (C‐SSRS) Columbia University Medical Center; Center for Suicide
Risk Assessment. Retrieved from http://www.cssrs.columbia.edu/
Posner, K. (n.d.). Columbia‐Suicide Severity Rating Scale (C‐SSRS) Columbia University Medical Center;
Center for Suicide Risk Assessment. Retrieved from
http://www.cssrs.columbia.edu/clinical_practice.html
Naval Center for Combat & Operational Stress Control. (n.d.). Behavioral health data portal (BHDP). Retrieved May 4,
2015, from http://www.med.navy.mil/sites/nmcsd/nccosc/technology/bhdp/index.aspx
June 2014
Using the C‐SSRS in Practice
Chapter 37
Toddler and the Family
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Promoting Optimal
Growth and Development
Ages 12 to 36 months
Intense period of exploration
Terrible ‘2’s’
GOAL for Parents?
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Biological Development
Weight gain slows to 1.8 to 2.7 kg/year.
Birth weight should be quadrupled
by 2½ years.
Height increases about 7.5 cm/year.
Growth is steplike rather than linear.
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Sensory Changes
Visual acuity of 20/40 acceptable
Hearing, smell, taste, and touch increasingly well developed
Uses all senses to explore environment
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Maturation of Systems
Most physiological systems relatively mature by the end of toddlerhood
Upper respiratory infections, otitis media, and tonsillitis common among toddlers
Voluntary control of elimination
Sphincter control: ages 18 to 24 months
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Gross and Fine Motor
Development
Mobility
Improved coordination: between ages 2 and 3
Fine motor development
Improved manual dexterity: ages 12 to 15 months
Throw ball: by 18 months
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Psychosocial Development
Erikson; developing sense of autonomy
Autonomy vs. shame and doubt
Negativism
Ritualization—sense of comfort
Id, ego, superego or conscience
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Toddler response
All typically developing toddlers push for their independence.
♦ Each child has a unique timetable for this burst of “negativism”, but many parents will notice an increase in this difficult behavior around 18 months and again around 30 months.
♦
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Toddler Response
A common toddler response to frustration is a temper tantrum.
♦ Toddlers are having their own struggle, as they try to balance their need for independence with their need for dependence.
♦ Toddlers often respond with a loud “NO!” almost automatically, even when they really mean, “yes”.
♦ Toddlers often forget the rules parents set, so they make the same mistakes over and over again.
♦ The purpose of the toddler’s negativism is not to be disrespectful. He is attempting to assert him- self as an individual, separate from his parents.
♦ “Difficult” behavior during the toddler years will not last a lifetime. When parents allow their toddler to assert his independence in acceptable ways, the toddler can pass through this stage and move to the more cooperative, reasonable preschool stage.
♦ Older toddlers can be taught, with patience and understanding, the basics of appropriate social behavior.
Tips for parents…
♦ Keep your sense of humor when dealing with your toddler. It can be a joy to watch your toddler try new skills and practice his newfound independence.
♦ Don’t ask questions that will require a “yes” or “no” answer. The toddlers will undoubtedly say “NO!” For example, instead of “Would you like oatmeal for breakfast?” say, “Would you like hot or cold cereal?”
♦ Stay focused on the positive behaviors your toddler exhibits, as she explores her world and learns new skills.
♦ Continue to remind yourself that toddlers won’t learn all the “right”
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Toddler Response
Difficult” behavior during the toddler years will not last a lifetime. When parents allow their toddler to assert his independence in acceptable ways, the toddler can pass through this stage and move to the more cooperative, reasonable preschool stage.
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Toddler Response
Toddlers often forget the rules parents set, so they make the same mistakes over and over again.
♦ The purpose of the toddler’s negativism is not to be disrespectful. He is attempting to assert him- self as an individual, separate from his parents.
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Autonomy vs Shame & Doubt Group 2 Period 5
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YouTube clip
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Cognitive Development
Piaget; sensorimotor and preoperational phase
Awareness of causal relationships between two events
Learning of spatial relationships
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Piaget’s Preoperational Stage.mov
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YouTube Clip
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Invention of New Means
Through Mental Combinations
Imitation of behaviours
Domestic mimicry and gender role behaviour
Concept of time still embryonic
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Fig. 37-2. Domestic mimicry and gender-role behaviour are common during toddlerhood.
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Preoperational Phase
Phase begins about age 2.
Transition occurs between self-satisfying behaviour and socialized relationships.
Preconceptual phase is a subdivision of the preoperational phase.
Preoperational thought implies children cannot think in terms of operations.
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Spiritual Development
Spiritual routines can be comforting.
Religious teachings and moral development influence toddler behaviour.
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Development of Body Image
Refer to body parts by name.
Recognize gender differences by age 2.
Avoid labels about physical appearance
Dr. Robin Berman Labels are Limits
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Development of Gender Identity
Exploration of genitalia common
Gender identity formed by age 3
Gender roles understood by toddler
Evident in much of their imitative play
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Girl toys vs boy toys: The experiment – BBC Stories
YouTube Clip
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Social Development
Differentiation of self from mother and significant others
Separation
Individualization
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Fig. 37-3. Transitional objects, such as a fuzzy stuffed animal, are sources of security to a toddler.
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Language
Increasing level of comprehension
Increasing ability to understand
Comprehension much greater than the number of words a toddler can say
At age 1 uses one-word sentences (holophrases)
By age 2 uses multiword sentences by stringing together two or three words
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Personal Social Behaviour
Toddlers develop skills of independence.
Skills for independence may result in tyrannical, strong-willed, volatile behaviours.
Skills include feeding, playing, dressing, and undressing self.
(back to autonomy vs. doubt)
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Fig. 37-6. To minimize sibling rivalry, parents should include the toddler during caregiving activities.
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Fig. 37-4. Young children enjoy dressing up.
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Play
Magnifies physical and psychosocial development
Interaction with others becoming more important
Parallel play
Related to emerging linguistic abilities
Tactile play
Selection of appropriate toys
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Coping With Concerns Related to
Normal Growth and Development
Toilet training
Sibling rivalry
Temper tantrums
Negativism
Regression
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Toddlers regulate their behavior to avoid making adults angry
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YouTube Clip
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Assessing Readiness
for Toilet Training
Can get to potty chair
Able to stay dry for several hours
Can balance while sitting on potty
Receptive language skills
Expressive language skills to communicate need to use potty
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Fig. 37-5. A: Sitting in reverse fashion on a regular toilet provides additional security to a young child. B: Children may begin toilet training sitting on a small potty chair.
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Promoting Optimum Health
During Toddlerhood
Nutrition
Ritualism
Nutritional counselling
Dietary guidelines; Canada’s Food Guide
Sleep and activity
Dental health
Regular dental examinations
Removal of plaque
Fluoride
Low-cariogenic diet
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Fig. 37-7. Young children can participate in toothbrushing, but parents need to brush all the child’s teeth thoroughly.
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Fig. 37-8. The most effective cleaning of the teeth is done by parents.
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Fig. 37-9. Nursing caries. Note extensive carious involvement of maxillary primary incisors.
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Injury Prevention
Motor vehicle injuries: car seat safety
Drowning
Burns
Poisoning
Falls
Aspiration and suffocation
Bodily damage
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Fig. 37-10. A: Convertible car safety seat in forward-facing position. B: Use of locking clip.
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Fig. 37-11. Lower anchors and tethers for children (LATCH). A, Flexible two-point attachment with top tether. B, Rigid 2-point attachment with top tether. C, Top tether.
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Anticipatory Guidance
Understanding toddlers is fundamental to successful childrearing.
Nurses can assist parents in facilitating tasks and meeting the needs of children.
Provide opportunities for parents to express their feelings.
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Stress, coping and Anxiety
Stress
Severe stress is unhealthy and can weaken biological resistance to psychiatric pathology in any individual
Stress is especially harmful for those who have a genetic predisposition to mental illness/mental disorders
While an understanding of the connection between stress and mental illness is essential in the psychiatric setting, it is also important when developing a plan of care for any patient, in any setting, with any diagnosis
Imagine having an appendectomy and being served with an eviction notice on the same day – How well could you cope with either situation, let alone both simultaneously?
The nurse’s role is to intervene to reduce stress by promoting a healing environment, facilitating successful coping, and developing future coping strategies
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Stress Response –
Lazarus (2012)
The body responds the same physiologically regardless of whether the stress is real or only perceived as a threat and whether the threat is physical, psychological, or social
Lazarus (2012) describes these reactions as distress and eustress:
Distress is a negative, draining energy that results in anxiety, depression, confusion, helplessness, hopelessness, and fatigue
Distress may be caused by such stressors as a death in the family, financial overload, or school or work demands
Eustress is a positive, beneficial energy that motivates and results in feelings of happiness, hopefulness, and purposeful movement
Eustress may be the result of a much-needed vacation, being called in for an interview, the birth of a baby, or buying a new car
Eustress could lead to a depletion of physiological resources if sustained
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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SOME REACTIONS TO ACUTE AND PROLONGED (CHRONIC) STRESS
ACUTE STRESS CAN CAUSE PROLONGED (CHRONIC) STRESS CAN CAUSE
Uneasiness and concern Anxiety and panic attacks
Sadness Depression or melancholia
Loss of appetite Anorexia or overeating
Suppression of the immune system Lowered resistance to infections, leading to an increase in opportunistic viral and bacterial infections
Increased metabolism and use of body fats Insulin-resistant diabetes
Hypertension
Infertility Amenorrhea or loss of sex drive
Impotence, anovulation
Increased energy mobilization and use Increased fatigue and irritability
Decreased memory and learning
Increased cardiovascular tone Increased risk for cardiac events (e.g., heart attack, angina, and sudden heart-related death)
Increased risk for blood clots and stroke
Increased cardiopulmonary tone Increased respiratory problems
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Neurotransmitters involved in the stress response
Serotonin is a brain catecholamine that plays an important role in mood, sleep, sexuality, appetite, and metabolism
One of the main neurotransmitters implicated in depression
During times of stress, serotonin synthesis becomes more active
This stress-activated turnover of serotonin is at least partially mediated by the corticosteroids, and researchers believe this activation may dysregulate (impair) serotonin receptor sites and the brain’s ability to use serotonin
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Assessing Coping Styles
People cope with life stressors in a variety of ways, and a number of factors can act as effective mediators to decrease stress in our lives.
Rahe (1995) identified four discrete personal attributes (coping styles) people can develop to help manage stress:
1. Health-sustaining habits (e.g., medical compliance, proper diet, relaxation, adequate rest and sleep, pacing one’s energy)
2. Life satisfactions (e.g., occasional escapism, reading, movie watching, work, family, hobbies, humour, spiritual solace, arts, nature)
3. Social supports (e.g., talk with trusted friends, family, counsellors, or support groups)
4. Effective and healthy responses to stress (e.g., work off anger through physical activity, go for a walk, dig in the garden, do yoga)
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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POSITIVE AND NEGATIVE RESPONSES TO STRESS
POSITIVE AND NEGATIVE RESPONSES TO STRESS
POSITIVE STRESS RESPONSES NEGATIVE STRESS RESPONSES
Problem solving—figuring out how to deal with the situation Avoidance—choosing not to deal with the situation, letting negative feelings and situations fester and continue to become chronic
Using social support—calling in others who are caring and may be helpful Self-blame—faulting oneself, which keeps the focus on minimizing one’s self-esteem and prevents positive action toward resolution or working through the feelings related to the event
Reframing—redefining the situation to see both positive and negative sides, as well as the way to use the situation to one’s advantage Wishful thinking—believing that things will resolve themselves and that “everything will be fine” (a form of denial)
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Anxiety and Anxiety Disorders
Anxiety
Anxiety is a universal human experience and is the most basic of emotions
Defined as a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat
Normal anxiety is a healthy reaction necessary for survival
Provides us with energy to carry out everyday tasks and strive toward goals; motivates us to make and survive change; and prompts constructive behaviours, such as studying for an examination, being on time for a job interview, preparing for a presentation, and working toward a promotion
The common element of anxiety disorders is that those affected experience a degree of anxiety so high that it interferes with personal, occupational, or social functioning
All anxiety-related disorders tend to be persistent and are often disabling
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Levels of anxiety
Mild Anxiety
Occurs in the normal experience of everyday living, allows an individual to perceive reality in sharp focus
A person experiencing a mild level of anxiety sees, hears, and grasps more information
Physical symptoms may include slight discomfort, restlessness, irritability, or mild tension-relieving behaviours (e.g., nail biting, foot or finger tapping, fidgeting, wringing of hands)
Moderate Anxiety
As anxiety increases, the perceptual field narrows, and some details are excluded from observation
The person experiencing moderate anxiety sees, hears, and grasps less information and may demonstrate selective inattention, in which only certain things in the environment are seen or heard unless they are pointed out
Physical symptoms of moderate anxiety include tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (gastric discomfort, headache, urinary urgency)
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Levels of anxiety
Severe Anxiety
The perceptual field of a person experiencing severe anxiety is greatly reduced
A person with severe anxiety may focus on one particular detail or many scattered details and have difficulty noticing his or her environment, even when it is pointed out by another
Learning and problem solving are not possible at this level, and the person may seem confused
Behaviour becomes automatic (e.g., wringing hands, pacing) and is aimed at reducing or relieving anxiety
Somatic symptoms such as headache, nausea, dizziness, and insomnia often increase; trembling and a pounding heart are common; and the person may hyperventilate and experience a sense of impending doom or dread
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Neurotransmitters involved in anxiety
Norepinephrine
Implicated in anxiety disorders because of its effects on the systems associated with the physical sensations of anxiety—the cardiovascular, respiratory, and gastrointestinal systems via stimulation of the sympathetic arm of the autonomic nervous system
Serotonin [5-hydroxytryptamine (5-HT)]
Indirectly implicated in the aetiology of anxiety disorders in that drugs that facilitate serotonergic neurotransmission are effective in treating anxiety and panic symptoms
Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs) are efficacious treatments
Panic
The most extreme level of anxiety
Results in noticeably disturbed behavior
Someone in a state of panic is unable to process what is going on in the environment and may lose touch with reality, even experiencing hallucinations, or false sensory perceptions (e.g., seeing people or objects not really there)
Physical manifestations may include pacing, running, shouting, screaming, or withdrawal, and actions may become erratic, uncoordinated, and impulsive
These sorts of automatic behaviours are used to reduce or relieve anxiety, although such efforts may be ineffective
Acute panic may lead to exhaustion
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Clinical picture
Anxiety exerts a powerful influence on the mind and body. The experience of anxiety is an underlying factor in several disorders, including:
Acute stress disorder
Anxiety disorder not otherwise specified
Anxiety due to medical conditions
Depersonalization/derealization disorder
Generalized anxiety disorder
Obsessive-compulsive disorder and related disorders
Panic disorders
Phobias
Post-traumatic stress disorder
Somatic symptom disorder
Substance-induced anxiety disorder
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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GENERIC CARE PLAN FOR GENERALIZED ANXIETY DISORDER
Nursing diagnosis: Ineffective coping related to persistent anxiety as evidenced by fatigue and irritability.
Outcome: Patient will maintain role performance.
SHORT-TERM GOAL INTERVENTION RATIONALE
1. Patient will state that immediate distress is decreased by end of session. 1a. Stay with patient. 1a. Conveys acceptance and ability to give help
1b. Speak slowly and calmly. 1b. Conveys calm and promotes security
1c. Use short, simple sentences. 1c. Promotes comprehension
1d. Assure patient that you are in control and can assist him or her. 1d. Counters feeling of loss of control that accompanies severe anxiety
1e. Give brief directions. 1e. Reduces indecision; conveys belief that patient can respond in a healthy manner
1f. Decrease excessive stimuli; provide quiet environment. 1f. Reduces need to focus on diverse stimuli; promotes ability to concentrate
1g. After assessing level of anxiety, administer appropriate dose of anxiolytic agent if warranted. 1g. Reduces anxiety and allows patient to use coping skills
2. Patient will be able to identify source of anxiety by (date). 2a. Encourage patient to discuss preceding events. 2a. Promotes future change through identification of stressors
2b. Link patient’s behaviour to feelings. 2b. Promotes self-awareness
2c. Teach cognitive therapy principles:
• Anxiety is the result of a dysfunctional appraisal of a situation.
• Anxiety is the result of automatic thinking. 2c. Provides a basis for behavioural change
2d. Ask questions that clarify and dispute illogical thinking 2d. Helps promote accurate cognition
2e. Have patient give an alternative interpretation. 2e. Broadens perspective; helps patient think in a new way about problem or symptom
3. Patient will identify strengths and coping skills by (date). 3a. Have patient identify what has provided relief in the past. 3a. Provides awareness of self as individual with some ability to cope
3b. Have patient write assessment of strengths. 3b. Increases self-acceptance
3c. Reframe situation in ways that are positive. 3c. Provides a new perspective and converts distorted thinking
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Putting together – stress and anxiety
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Obsessive Compulsive Disorder
Neuroses are characterized by anxiety, depression, or other feelings of unhappiness or distress that are out of proportion to the circumstances of a person’s life.
Includes Diseases: Obsessive–compulsive disorder
Obsessive-Compulsive Disorder (OCD)
Severe obsessions or compulsions that interfere with life
Obsessions:
Unwanted thoughts, intrusive
Persistent thoughts, impulses, or images that cause anxiety and distress
Fear of contamination
Compulsions:
Repetitive behaviours performed in a ritualistic way that relieve anxiety
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Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
OCD
Obsessions create anxiety, and compulsions are performed to reduce anxiety
Common compulsions:
Washing, cleaning, checking, counting, repeating actions
Ordering, making confessions, and requesting assurances
If sequence is disturbed, person experiences anxiety
Most common obsessions:
Fear of contamination, resulting compulsion toward hand washing
Dissociation: a breakdown in integrated functions of memory, consciousness, perception of self, environment, or sensory and motor behaviour
Depersonalization: loss of sense of personality
Coexists with Tourette’s syndrome
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Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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COMMON OBSESSIONS AND COMPULSIONS
TYPE OF OBSESSION EXAMPLE ACCOMPANYING COMPULSION
Losing control Fear of acting on an impulse to harm oneself Praying to prevent harm to oneself
Harm Fear of being responsible for something terrible happening Checking that nothing terrible happened
Checking that you did not make a mistake
Perfectionism Need for symmetry—concern about evenness
Inability to decide whether to keep or discard things Rereading or rewriting
Putting things in order or arranging things until it “feels right”
Collecting items that results in significant clutter in the home (hoarding)
Contamination Environmental contaminants (radiation, oil, or lead)
Germs or viruses Cleaning household items in a certain way to remove contaminants
Washing hands excessively
Religious obsessions Concern with offending God
Excessive concern with morality Praying to seek forgiveness
Repeatedly touching or kissing religious objects
Replaying interactions with others and repeatedly reviewing every remark to determine if you said anything wrong
Other obsessions Concern about getting a disease, such as cancer, colitis, or diabetes Checking some parts of your physical condition or body
Superstitious ideas Repeating activities in “multiples” (e.g., doing a task three times because three is a “good,” “right,” or “safe” number)
Source: Halter, M. J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A clinical approach (2nd edition). Elsevier.
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Lisa-Marie Woodley (LW) –
Nursing Management: Biologic Domain
26
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Assessment for multiple physical symptoms
Physical fears
Physical consequences of compulsions
Nutrition and sleep status
Dermatologic lesions secondary to hand washing
Nursing Management: Psychological Assessment
27
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Type and severity of obsessions and compulsions
Degree to which the OCD symptoms interfere with patient’s daily functioning
Consider using rating scales
Suicide assessment
Psychological Interventions
28
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Response prevention
Thought stopping
Relaxation techniques
Cognitive restructuring
Cue cards
Psychoeducation
Nursing Management: Social Domain
29
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Consider sociocultural factors and patient’s ability to relate to others
In the hospital, unit routines are carefully and clearly explained to decrease patient’s fear of unknown
Recognize significance of rituals
Assist patient in arranging schedule
Marital and family support are important
Other Anxiety Disorders
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Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
Specific phobia
General Anxiety Disorder
Social phobia
Acute stress disorder
Chapter 35
The Infant and Family
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Promoting Optimal
Growth and Development
Biological development
Proportional changes
150–200 g weight is gained per week until age 5–6 months.
Birth weight doubles by age 6 months.
Birth weight triples by age 1 year.
Height increases by 2.5 cm per month for 6 months.
Growth occurs in “spurts” rather than following a gradual pattern.
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Fine Motor Development
Grasp object: ages 2 to 3 months
Transfer object between hands: age 7 months
Use pincer grasp age: 8 months crude, 11 months refined
Remove objects from container: 11 months
Build tower of two blocks: 12 months
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Fig. 36-1. Crude pincer grasp at 8 to 10 months.
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Gross Motor Development
Head control: well established by 4–6 months
Rolling over: ages 5 to 6 months
Sitting: 7 months; 8 months unsupported
Moving from prone to sitting position: 10 months
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Fig. 36-2. Head control while pulled to sitting position. A: Complete head lag at 1 month. B: Partial head lag at 2 months. C: Almost no head lag at 4 months.
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Fig. 36-3. Head control while prone. A: Infant momentarily lifts head at 1 month. B::Infant lifts head and chest 90 degrees and bears weight on forearms at 4 months. C: Infant lifts head, chest, and upper abdomen and can bear weight on hands at 6 months. Note how this position facilitates turning from abdomen to back.
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Fig. 36-4. Parachute reflex.
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Fig. 36-5. Development of sitting. A: Back is completely rounded, and infant has no ability to sit upright at 1 month. B,:At 2 months, infant exhibits more control; back is still rounded, but infant can sit up momentarily with some head control. C: Back is rounded only in lumbar area, and infant is able to sit erect with good head control at 4 months. D: Infant can sit alone, leaning on hands for support, at 7 months. E: Infant sits without support at 8 months. Note the transferring of objects that occurs beginning at 7 months.
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Gross Motor Development—cont.
MOBILITY
Cephalocaudal direction of development
Crawling age: 6 to 7 months
Creeping age: 9 months
Walk with assistance: 11 months
Walk alone: 12 months
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Fig. 36-6. Development of locomotion. A: Infant bears full weight on feet by 7 months. B: Infant can maneuver from sitting to kneeling position. C: Infant can stand holding onto furniture at 9 months. D,:While standing, infant takes deliberate step at 10 months. E: Infant crawls with abdomen on floor and pulls self forward, and then, F, creeps on hands and knees at 9 months.
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Pulls themselves into a standing position
Understand the word “No”
May sleep-in with parents in certain cultures
6 teeth (Age in months -6)
Can have water liberally
What else happens at 12 mos?
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Psychosocial Development
Erikson phase I
Acquiring sense of trust while overcoming sense of mistrust
Birth to 1 year
Food intake most important social activity during first 3–4 months
Next modality reaching out through grasping
More active stage next, including biting
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Erikson Interview 9:50
https://www.youtube.com/watch?v=FpOtpuBnjbo
Start at 9:50.
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Cognitive Development
Piaget theory (1952)
Sensorimotor phase
Birth to 1 month: reflex stage
1 to 4 months: primary circular reactions
Reflex vs. Voluntary acts
4 to 8 months: secondary circular reactions
Deliberate movements for response reaction
Imitation
Play
Affect
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Piaget Sensorimotor
Stage 1-4 only
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Development of Body Image
Concept of object permanence
By end of first year recognize that they are distinct from parents
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Fig. 36-7. Nine-month-old infant actively searches for object hidden behind pillow.
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*
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Fig. 36-8. Nine-month-old infant enjoying own image in mirror.
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*
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Social Development
Attachment
Reactive attachment disorder
Separation anxiety
Stranger fear
Language development
Play
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*
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Fig. 36-9. Behaviors related to fear of strangers include clinging to the parent and turning away from the stranger.
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*
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Coping With Concerns Related to Normal Growth and Development
Separation and stranger fear
Alternative child care arrangements
Limit-setting and discipline
Thumb-sucking and use of a pacifier
Teething
Infant shoes
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*
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Promoting Optimum Health During Infancy
First 6 months of life (0-6)
Breast milk should be only food.
Second 6 months of life (6-12)
Selection and preparation of solid foods
Introduction of solid foods
Weaning from breast or bottle
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*
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Sleep and Activity
Infants are naturally active.
Walkers, swings, and playpens are not necessary.
Sleep problems must be managed.
Concept of “graduated extinction” is of value in managing nighttime crying.
?Ferber method
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*
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Dental Health
Maternal dental health
Cleaning initiated at eruption of primary teeth
Fluoride at 6 months
Prevention of dental cavities
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
*
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Fig. 36-10. Sequence of eruption of primary teeth. *Range represents ±1 standard deviation, or 67% of subjects studied.
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
*
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Immunizations
Schedule for immunizations (Birth to 6 mos)
Recommendations for routine immunization
Hepatitis A and B viruses
Diphtheria (throat/ respiratory system)
Tetanus (motor neurons)
Pertussis (Whooping cough)
Polio (viral/ fecal-oral route/paralysis
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*
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Immunizations—cont.
Routine immunizations
Measles, mumps, rubella (Current outbreak in BC)
blindness
encephalitis, an infection that causes brain swelling
extreme dehydration
ear infections
pneumonia
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*
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Evidence-based research
The World Health Organization (WHO) reports that in 2017, there were 110,000 measles deaths globally, mostly among children under the age of five. However, measles vaccination resulted in an 80 per cent drop in measles deaths between 2000 and 2017 worldwide, which prevented an estimated 21.1 million deaths.
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
*
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EBR cont’d
Despite the positive impacts vaccination has had in combatting one of the most highly contagious and serious diseases, the WHO has declared vaccine hesitancy one of the top 10 threats to global health in 2019. They wrote, “Vaccine hesitancy … threatens to reverse progress made in tackling vaccine-preventable diseases.”
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*
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Vaccinations cont’d
Pneumococcus
Haemophilus influenzae type B
Varicella (chickenpox)
Influenza
Meningococcus
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*
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Immunizations—cont.
Recommendations for selected immunizations
Selected groups of children
Rotavirus and human papillomavirus
Reactions
Contraindications and compliance
Administration
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*
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VAERS
Vaccine Adverse Event Reporting System
To report any adverse reactions after administration of any vaccine
Vaccine Information Statements
Information statements that must be given
to parents before administration of given vaccines
Provision of updated information for parent or guardian of child being vaccinated
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*
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Injury Prevention
Aspiration of foreign objects
Suffocation
Motor vehicle injuries
Falls
Poisoning
Burns
Drowning
Bodily damage
Shaken baby syndrome
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*
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Fig. 36-11. A rear-facing infant car restraint that is approved by Transport Canada and placed in the back seat provides the best protection.
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
*
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Fig. 36-12. Safety demonstration board. Clockwise from lower left: Two types of cabinet latches, a shock guard for an electrical outlet in use, and two types of outlet covers (the one with the white cover has passive devices that automatically cover the outlet when a plug is removed).
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*
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Fig. 36-13. Infants can find hazardous electrical wires.
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*
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Feeding Difficulties
Regurgitation and “spitting up”
Colic (paroxysmal abdominal pain)
Therapeutic management
Growth failure
Terms organic failure to thrive (FTT) and nonorganic FTT no longer much used
FTT classified according to categories
Diagnostic evaluation
Prognosis
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*
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Fig. 36-14. The “colic carry” may be comforting to an infant with colic.
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*
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Fig. 36-15. Consistent nursing contact is important in developing trust in infants with failure to thrive.
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*
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Positional Plagiocephaly
“Back to Sleep” campaign since 1999
Front to play
Diagnostic evaluation
Therapeutic management
Nursing care management
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*
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Fig. 36-16. A, Plagiocephaly. B, Helmet used to correct plagiocephaly.
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*
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Disorders of Unknown Etiology
Sudden infant death syndrome (SIDS)
Etiology
Nursing care management
Finding the infant
Arriving at emergency department
Returning home
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*
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Apnea and Apparent
Life-Threatening Events
Apnea—unexplained respiratory pause of 20 seconds
Diagnostic evaluation of ALTEs
Therapeutic management
Theophylline or caffeine to stimulate respiration
Home apnea monitors
Family support
CPR training
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*
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Fig. 36-17. Electrode placement for apnea monitoring. In small infants, one fingerbreadth may be used.
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*
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Next Week: Toddler & the Family
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*
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Depressive Disorders
Week 11 – Part 1
1
Major depressive disorder (MDD) – Introduction
One of the most common psychiatric disorders
Almost 1 in 8 adults (12.6%) have identified symptoms that met the criteria for a mood disorder at some point during their lifetime
Major depressive disorder, or major depression, is characterized by a persistently depressed mood lasting for a minimum of 2 weeks
The length of a depressive episode may be 5 to 6 months
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
2
Major depressive disorder (MDD) – Introduction
About 20% of cases become chronic (i.e., lasting more than 2 years)
While depression begins with a single occurrence, most people experience recurrent episodes
People experience a recurrence within the first year about 50% of the time and within a lifetime up to 85% of the time
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
3
Clinical Picture:
Major Depressive Disorder
Depressed mood, impairing functioning with:
Emotional
Cognitive
Physical, and
Behavioural symptoms
And experienced for over 2 weeks
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
4
Clinical Picture (Cont.)
Major depressive disorder, with subtypes:
Psychotic features
Melancholic features
Atypical features
Catatonic features
Postpartum onset
Seasonal features (seasonal affective disorder [SAD])
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
5
Video
Video link: https://www.youtube.com/watch?v=1RXnE2tyHdw
6
MDD
The diagnosis for MDD may include one of the following specifiers to describe the most recent episode of depression:
Psychotic features
Indicates the presence of disorganized thinking, delusions (e.g., delusions of guilt or of being punished for sins, somatic delusions of horrible disease or body rotting, delusions of poverty or going bankrupt), or hallucinations (usually auditory, voices berating person for sins)
Melancholic features
This outdated term indicates a severe form of endogenous depression (not attributable to environmental stressors) characterized by severe apathy, weight loss, profound guilt, symptoms that are worse in the morning, early morning awakening, and often suicidal ideation
Atypical features
Refers to dominant vegetative symptoms (e.g., overeating, oversleeping). Onset is younger, psychomotor activities are slow, and anxiety is often an accompanying problem, which may cause misdiagnosis.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
7
MDD
Catatonic features
Marked by nonresponsiveness, extreme psychomotor retardation (may seem paralyzed), withdrawal, and negativity
Postpartum onset
Indicates onset within 4 weeks after childbirth. It is common for psychotic features to accompany this depression
Seasonal features (seasonal affective disorder [SAD])
Indicates that episodes mostly begin in fall or winter and remit in spring
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
8
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
9
Etiology
(Biological factors)
Genetic
Certain genetic markers seem to be related to depression when accompanied by early childhood maltreatment or a history of stressful life events
There is no gene directly related to the development of the mood disorder
There is a genetic marker associated with depression in the context of stressful life events
Biochemical
Two of the main neurotransmitters involved in mood are serotonin (5-hydroxytryptamine [5-HT]) and norepinephrine
Serotonin is an important regulator of sleep, appetite, and libido
Dysfunction can result in sleep disturbances, decreased appetite, low sex drive, poor impulse control, and irritability
Norepinephrine modulates attention and behaviour – it is stimulated by stressful situations, which may result in overuse and a deficiency of norepinephrine
A deficiency, an imbalance or an impaired ability to use available norepinephrine can result in apathy, reduced responsiveness, or slowed psychomotor activity
Stressful events
10
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
10
Etiology
(Biological factors)
Hormonal
Most widely studied in relation to depression has been hyperactivity of the hypothalamic–pituitary–adrenal axis
People with major depression have increased urine cortisol levels and elevated levels of corticotrophin-releasing hormone
Ensure blood testing on TSH levels
Inflammation
While we do not believe that inflammation causes depression, research indicates that it does play a role
Support for this belief includes the finding that about a third of people with major depression have elevated inflammatory biomarkers in the absence of a physical illness
Also, people who have inflammatory diseases have increased risk for major depression
Diathesis–stress model
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
11
Etiology
(Psychological factors)
Cognitive theory
The underlying assumption is that a person’s thoughts will result in emotions.
If a person looks at their life in a positive way, the person will experience positive emotions, but negative interpretation of life events can result in sorrow, anger, and hopelessness
Beck and Rush (1995) found that people with depression process information in negative ways, even in the midst of positive factors
Three thoughts constitute Beck’s cognitive triad:
A negative, self-deprecating view of self
A pessimistic view of the world
The belief that negative reinforcement (or no validation for the self) will continue in the future
Realizing that one has an ability to interpret life events in positive ways provides an element of control over emotions and, therefore, over depression
Learned helplessness
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
12
Nursing Process
(Assessment)
Assessment tools
The Patient Health Questionnaire-9 (PHQ-9), a short inventory that highlights predominant symptoms of depression
Many clinicians also use the mnemonic SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor activity, and suicidal thoughts) to guide their assessment
Assessment of suicide potential
The most dangerous aspect of MDD is a preoccupation with death
A patient may fantasize about funeral or experience recurring dreams about death
Beyond these passive fantasies are thoughts of wanting to die
As a whole, all of these nihilistic thoughts are referred to as suicidal ideation
These thoughts may be relatively mild and fleeting, or persistent and involve a plan
Suicidal ideation, especially that in which the patient has a plan for suicide and the means to carry the plan out, represents an emergency requiring immediate intervention
Suicidal thoughts are a major reason for hospitalization for patients with major depression
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
13
Nursing Process
(Assessment)
Key assessment findings
A depressed mood and anhedonia (loss of ability to experience joy or pleasure in living) are the key symptoms of depression
Psychomotor agitation may be evidenced by constant pacing and wringing of hands
The slowed movements of psychomotor retardation, however, are more common
Somatic complaints (e.g., headaches, malaise, backaches) are also common
Vegetative signs of depression—alterations in those activities necessary to support physical life and growth (e.g., change in bowel movements and eating habits, sleep disturbances, lack of interest in sex)—are universally present
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
14
Nursing Process
(Cont.)
Areas to assess
Affect
Thought processes
Mood
Feelings
Cognitive changes
Physical behaviour
Communication
Religious beliefs and spirituality
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
15
Nursing Process
(Cont.)
Age considerations
Children and adolescents
Older adults
Self assessment
Feeling what the patient is feeling
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
16
Nursing Process
(Cont.)
Nursing diagnosis
Risk for suicide—safety is always the highest priority
Hopelessness
Ineffective coping
Social isolation
Spiritual distress
Self-care deficit
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
17
Nursing Process
(Cont.)
Outcomes identification
Recovery model
Focus on patient’s strengths
Treatment goals mutually developed
Based on patient’s personal needs and values
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
18
Nursing Process
(Cont.)
Planning
Geared toward:
Patient’s phase of depression
Particular symptoms
Patient’s personal goals
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
19
Nursing Process
(Cont.)
Implementation
Three phases
Acute phase (6 to 12 weeks)
Continuation phase (4 to 9 months)
Maintenance phase (1 year or more)
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
20
Nursing Process
(Cont.)
Counselling and communication
Health teaching and health promotion
Promotion of self-care activities
Milieu management and teamwork
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
21
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
22
Psychopharmacology
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Antidepressants
Selective serotonin reuptake inhibitors (SSRIs)
First-line therapy
Indications
Adverse reactions
Potential toxic effects
23
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Psychopharmacology
(Cont.)
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Tricyclic antidepressants (TCAs)
Neurotransmitter effects
Indications
Adverse effects
Toxic effects
Adverse drug interactions
Contraindications
Patient and family teaching
24
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Psychopharmacology
(Cont.)
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Monoamine oxidase inhibitors (MAOIs)
Neurotransmitter effects
Indications
Adverse/toxic effects
Interactions
Drugs
Food
Contraindications
25
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
26
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
27
Other Treatments
for Depression
Electroconvulsive therapy (ECT)
Transcranial magnetic stimulation
Vagus nerve stimulation
Deep brain stimulation
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
28
Complementary and Integrative Therapies
Light therapy
St. John’s wort ** CAUTION – taking with other medications – MANY contraindications
Exercise and outdoor activity
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
29
Advanced-Practice Interventions
Psychotherapy
Cognitive-behavioural therapy (CBT)
Interpersonal therapy (IPT)
Time-limited focused psychotherapy
Behaviour therapy
Group therapy
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30
30
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Nursing Process
(Cont.)
Evaluation
Suicidal ideation
Intake
Sleep pattern
Personal hygiene and grooming
Self-esteem
Social interaction
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
31
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Post-partum depression (PPD)
Post-Partum Depression
Post-partum depression (PPD), also called post-natal depression, is a type of mood disorder associated with childbirth
Onset is typically between one week and one month following childbirth (can occur any time in the first year post-partum)
PPD can also negatively affect the newborn child
While the exact cause of PPD is unclear, the cause is believed to be a combination of physical and emotional factors
These may include factors such as hormonal changes and sleep deprivation
While most women experience a brief period of worry or unhappiness after delivery, post-partum depression should be suspected when symptoms are severe and last over two weeks
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Postpartum Depression: What You
Need to Know
Mayo Clinic. (2015, October 15). Postpartum depression: what you need to know. Retrieved from https://www.youtube.com/watch?v=fBYYr_kEjmo
34
Diagnostic criteria
The criteria required for the diagnosis of post-partum depression are the same as those of non-childbirth related major depression or minor depression. The criteria include at least five of the following nine symptoms, within a two-week period:
Feelings of sadness, emptiness, or hopelessness, nearly every day, for most of the day or the observation of a depressed mood made by others
Loss of interest or pleasure in activities
Weight loss or decreased appetite
Changes in sleep patterns
Feelings of restlessness
Loss of energy
Feelings of worthlessness or guilt
Loss of concentration or increased indecisiveness
Recurrent thoughts of death, with or without plans of suicide
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
35
Risk
Factors
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
36
Prior episodes of post-partum depression
Bipolar disorder
Family history of depression
Psychological stress
Complications of childbirth
Lack of support
Substance use disorder
Mayo Clinic Minute: Understanding postpartum depression
Mayo Clinic. (2018, February 20). Mayo clinic minute: Understanding postpartum depression. Retrieved from https://www.youtube.com/watch?v=pGk4pd8_ezY
37
Treatment
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
38
Treatment for PPD may include counseling or medications
Types of counseling that have been found to be effective include:
Interpersonal psychotherapy (IPT)
Cognitive behavioural therapy (CBT), and
Psychodynamic therapy
Tentative evidence supports the use of selective serotonin reuptake inhibitors (SSRIs)
Post-Partum Psychosis
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
39
Post-partum psychosis is not a formal diagnosis
Widely used to describe a psychiatric emergency that appears to occur in about 1 in a 1000 pregnancies
Symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations and delusions begin suddenly in the first two weeks after delivery; the symptoms vary and can change quickly
It is different from post-partum depression and from maternity blues
It is important not to confuse psychosis with other symptoms that may occur after delivery, such as delirium.
Delirium typically includes a loss of awareness or inability to pay attention
Post-Partum Psychosis
Half of women no risk factors; but a prior history of mental illness, especially bipolar disorder, a history of prior episodes of post-partum psychosis, or a family history put some at a higher risk
Post-partum psychosis often requires hospitalization, where treatment is antipsychotic medications, mood stabilizers, and in cases of strong risk for suicide, electroconvulsive therapy
The most severe symptoms last from 2 to 12 weeks, and recovery takes 6 months to a year
Women who have been hospitalized for a psychiatric condition immediately after delivery are at a much higher risk of suicide during the first year after delivery
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
40
Postnatal Psychosis: The stigma of mothers with mental illness
The Feed SBS. (2018, April 12). Postnatal Psychosis: The stigma of mothers with mental illness. Retrieved from https://www.youtube.com/watch?v=JUFRZ6PgfQE
41
Other Depressive Disorders
Disruptive mood dysregulation disorder
Persistent depressive disorder (dysthymia)
Premenstrual dysphoric disorder
Substance/medication induced depressive disorder
Depressive disorder due to another medical condition
Depression and grieving
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
42
Disruptive Mood Dysregulation Disorder
A disorder characterized by severe and recurrent temper outbursts that are inconsistent with developmental level
This disorder was introduced in 2013 in response to an alarming number of children and adolescents being diagnosed with bipolar disorder
A bipolar diagnosis resulted in exposure to powerful medications that probably were not helping and a lifelong label of serious mental illness
The most compelling reason to change this diagnostic practice was that most of the young people who received a diagnosis of bipolar disorder did not go on to exhibit classic bipolar symptoms as adults
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
43
Disruptive Mood Dysregulation Disorder
In fact, most children and adolescents once diagnosed with bipolar disorder actually converted to major depressive disorder or an anxiety disorder in adulthood
The basic symptoms of disruptive mood dysregulation disorder are constant and severe irritability and anger in individuals between the ages of 6 and 18
Onset is before age 10
Temper tantrums with verbal or behavioural outbursts out of proportion to the situation occur at least three times a week
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
44
Other Depressive Disorders
Persistent depressive disorder (dysthymia)
Is diagnosed when feelings of depression occur most of the day, for the majority of days
These low-level depressive feelings last at least 2 years in adults and 1 year in children and adolescents
In addition to depressed mood, individuals with this disorder have at least two of the following: decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness
Premenstrual dysphoric disorder
A relatively new addition to the diagnostic system for psychiatry
Referring to a cluster of symptoms that occur in the last week before the onset of a woman’s period
Premenstrual dysphoric disorder causes problems severe enough to interfere with the ability of a woman to work or interact with others
Symptoms decrease significantly or disappear with the onset of menstruation
The prevalence of premenstrual dysphoric disorder is about 2% to 6% of menstruating women
Symptoms cease after menopause, although they may return with hormone replacement therapy
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
45
Other Depressive Disorders
Substance/medication induced depressive disorder
Depressive disorder due to another medical condition
Depression and grieving
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
46
Bipolar Disorders
Week 11 – Part 2
Clinical Picture
Bipolar disorder is marked by shifts in mood, energy and ability to function
Course is variable and symptoms can range in severity and duration:
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
2
Bipolar I disorder
Marked by severe shifts in mood, energy, and inability to function
Periods of normal functioning may alternate with periods of illness (highs, lows, or a combination of both)
Experience at least one manic episode
Manic episodes usually alternate with depression or a mixed state of anxiety and depression
Mania
is a period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extreme goal-directed activity or energy
these periods last at least 1 week for most of the day, every day
symptoms of mania are so severe that this state is a psychiatric emergency
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
3
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
4
Bipolar II disorder
Experience at least one hypomanic episode and at least one major depressive episode
Hypomania
Like mania, hypomania is accompanied by excessive activity and energy for at least 4 days and involves at least three of the behaviours listed under Criterion B in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Unlike mania, psychosis is never present with hypomania
Psychotic symptoms may, however, accompany the depressive side of the disorder
Hospitalization is rare
However, the depressive symptoms can be quite profound and may put those who suffer from it at particular risk for suicide
Underdiagnosed and is often mistaken for major depression or personality disorders, when it actually may be the most common form of bipolar disorder
A source of significant morbidity and mortality, particularly due to the occurrence of severe depression
Anyone with major depression should be assessed for symptoms of hypomania because these symptoms are frequently associated with a progression to bipolar disorder
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
5
Cyclothymic Disorder
Symptoms of hypomania alternating with symptoms of mild to moderate depression for at least 2 years in adults and 1 year in children
Hypomanic and depressive symptoms do not meet the criteria for either bipolar II or major depression, yet the symptoms are disturbing enough to cause social and occupational impairment
As part of the spectrum of bipolar disorders, cyclothymic disorder may be difficult to distinguish from bipolar II disorder
Individuals with cyclothymic disorder tend to have irritable hypomanic episodes
Some people experience rapid cycling and may have at least four changes in mood episodes in a 12-month period
The cycling can also occur within the course of a month or even a 24-hour period
Rapid cycling is associated with more severe symptoms, such as poorer global functioning, high recurrence risk, and resistance to conventional somatic treatments
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
6
Other Bipolar Disorders
Several other bipolar and related disorders are included in the DSM-5. They include:
Substance/Medication-Induced Bipolar and Related Disorder
Bipolar and Related Disorder Due to Another Medical Condition
Other Specified Bipolar and Related Disorder
Unspecified Bipolar and Related Disorder
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
7
Epidemiology
Often misdiagnosed (confused with unipolar depression)
Lifetime risk is 4%
Age of onset of bipolar I is 18 years, and for bipolar II, 20 years
Bipolar I—more common in males
Bipolar II—more common in females
Cyclothymia—usually begins in adolescence or early adulthood
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
8
Etiology
Biological factors
Genetic (strong heritability)
Neurobiological
Neuroendocrine/Hormonal
Psychological factors
Environmental factors
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
9
Biological factors – Genetic
Bipolar illnesses tend to run in families, and the lifetime risk for individuals with an affected parent is 15% to 30% greater
Recent research suggests that there may be an overlap between rare genetic variations linked to bipolar disorder and those implicated in schizophrenia and autism
Some evidence suggests that bipolar disorders are more prevalent in adults who had high intelligence quotients (IQs), and who were particularly verbal, as children
People with bipolar disorders appear to achieve higher levels of education and higher occupational status than individuals with unipolar depression
The proportion of patients with bipolar disorders among creative writers, artists, highly educated men and women, and professionals is higher than in the general population
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
10
Biological factors – Neurotransmitters
Neurotransmitters (norepinephrine, dopamine, and serotonin) have been studied since the 1960s as causal factors in mania and depression
One simple explanation is that having too few of these chemical messengers will result in depression and having an oversupply will cause mania
Proportions of neurotransmitters in relation to one another may be more important
Receptor site insensitivity could also be at the root of the problem—even if there is enough of a certain neurotransmitter, it is not going where it needs to go
Mood disorders are most likely a result of interactions among various chemicals, including neurotransmitters and hormones
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
11
Biological factors – Brain Structure and Function
Structural neuroimaging techniques (e.g., computed tomography [CT] and magnetic resonance imaging [MRI]) provide still pictures of the scalp, skull, and brain
Structural imaging is useful in viewing bones, tissues, blood vessels, tumours, infection, damage, or bleeding
Functional neuroimaging techniques (e.g., positron emission tomography [PET], functional MRI [fMRI], and magnetoencephalography [MEG]) provide measures related to brain activity
With bipolar disorder, functional imaging techniques reveal dysfunction in the prefrontal cortical region, the region associated with executive decision making, personality expression, and social behaviour
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
12
Biological factors – Brain Structure and Function
Dysfunction is also evident in the hippocampus, which is primarily associated with memory, and the amygdala, which is associated with memory, decision making, and emotion
Dysregulation in these areas results in the characteristic emotional lability, heightened reward sensitivity, and emotional dysregulation of bipolar disorder
These abnormalities may be due to grey matter loss in these areas
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
13
Biological factors – Neuroendocrine
The hypothalamic–pituitary–thyroid–adrenal (HPTA) axis has been the object of significant research in bipolar disorder
Hypothyroidism is one of the most common physical abnormalities associated with bipolar disorder
In both manic and depressive states, peripheral inflammation is increased –the inflammation tends to decrease between episode
The role of estrogen in bipolar disorder is also under review – childbirth is known to be associated with the onset of mood and anxiety disorders
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
14
Biological factors – Neuroendocrine
Estrogen studies have shown that women with postpartum psychosis have very low levels of estrogen and improve after estrogen replacement therapy
Selective estrogen receptor modulators (e.g., tamoxifen) have also been shown to produce antimanic effects. Further research in this area is required
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
15
Environmental factors
Bipolar disorder is a worldwide problem that generally affects all races and ethnic groups equally, but some evidence suggests that bipolar disorders may be more prevalent in upper socioeconomic classes – the exact reason for this finding is unclear
The educational levels of individuals with unipolar depressive disorders, on the other hand, appear to be no different from those of individuals with no symptoms of depression within the same socioeconomic class
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
16
Environmental factors
Stressful family life and adverse life events may result in a more severe course of illness in these individuals
Stress is also a common trigger for mania and depression in adults
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
17
Psychological Factors
With the advent of improved neuroimaging techniques and treatment advances, psychological theories are largely dismissed
Mania was once thought to be a defence against underlying anxiety and depression
Mania was also thought to help individuals tolerate loss or tragedy, such as the death of a loved one
Psychodynamic theorists believed that a faulty ego uses mania when it is overwhelmed by pleasurable impulses such as sex or feared impulses such as aggression
An overactive and critical superego being replaced with the euphoria of mania has also been suggested as the cause
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
18
Application to the nursing process
Assessment
Mood
Behaviour
Thought processes and speech patterns
Flight of ideas
Clang associations
Grandiosity
Cognitive functioning
20
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Self-Assessment
Manic patient
Can be manipulative at times
Demanding
Splitting
Staff member actions
Frequent staff meetings to deal with patient behaviour and staff response
Set limits consistently
21
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Assessment Guidelines
Bipolar Disorder
Danger to self or others
Need for protection from uninhibited behaviours
Need for hospitalization
Medical status
Coexisting medical conditions
Family’s understanding
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
22
Nursing Diagnosis
Risk for injury
Risk for violence
Other-directed
Self-directed
Ineffective coping
23
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Outcomes Identification
Acute phase
Prevent injury
Continuation phase
Relapse prevention
Maintenance phase
Limit severity and duration of future episodes
24
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Planning
Acute phase
Medical stabilization
Maintaining safety
Self-care needs
Continuation phase
Maintain medication adherence
Psychoeducational teaching
Referrals
Maintenance phase
Prevent relapse
25
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Implementation
Acute phase
Depressive episodes
Manic episodes
Continuation phase
Prevent relapse with follow-up care
Maintenance phase
Prevent recurrence
26
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Pharmacological Interventions
Lithium carbonate
Indications
Therapeutic and toxic levels
Therapeutic blood level: 0.6 to 1.2 mEq/L
Toxic blood level: 1.5 mEq/L and above
Maintenance therapy
Contraindications
Adverse effects and toxicity (see Table 14.4 in text)
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
27
Drugs Used for the Treatment of Seizures
Divalproex sodium (Epival)
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
28
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Drugs Used for the Treatment of Anxiety and Psychosis
Clonazepam (Rivotril)
Lorazepam (Ativan)
Atypical antipsychotics
Olanzapine (Zyprexa)
Risperidone (Risperdal)
29
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Other Treatments
Electroconvulsive therapy (ECT)
Milieu management and teamwork
Support groups
Health teaching and health promotion
30
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Advanced-Practice
Interventions
Psychotherapy
Cognitive-behavioural therapy (CBT)
Interpersonal and social rhythm therapy
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
31
Evaluation
Evaluate outcome criteria
Reassess care plan
Revise care plan if indicated
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
32
! 294 J Postgrad Med October 2008 Vol 54 Issue 4
Women survivors of intimate partner violence
and post-traumatic stress disorder: Prediction
and prevention
DeJonghe ES, Bogat GA1, Levendosky AA1, von Eye A1
ABSTRACT
A considerable body of research has demonstrated that women who are abused by their male romantic partners
are at substantially elevated risk for the development of post-traumatic stress disorder (PTSD). This article
reviews recent literature regarding intimate partner violence (IPV) and resultant PTSD symptoms. The article
is intended to be an introduction to the topic rather than an exhaustive review of the extensive literature in
this area. Factors that enhance and reduce the risk for PTSD, including social support, coping styles, and types
of abusive behavior experienced, are described. In addition, the unique risks associated with IPV for women
who have children are discussed. Prevention efforts and treatment are briefly reviewed.
KEY WORDS: Domestic violence, intimate partner violence, post-traumatic stress disorder, violence against
women
Department of Psychology
and Sociology, California
State Polytechnic University
Pomona, Pomona, CA , USA ,
1Department of Psychology,
M ichigan State University,
East Lansing, MI, USA
Correspondence:Correspondence:
Dr. Erika S. DeJonghe
E-mail:
esdejonghe @ csupomona. edu
Received : 02-04-08
Review completed : 10-05-08
Accepted : 18-06-08
PubMed ID : 18953149
J Postgrad Med 2008;54:294-300
www monline.comS ymposium
T here are numerous forms of violence to which women can be exposed. This article will focus on womenís
experiences of intimate partner violence (IPV, defined here as
menís violence toward their female partners). We will discuss
how IPV leads to post-traumatic stress symptoms as well as
preventive interventions and treatment for this group of women.
In addition, we will discuss how IPV affects those women who
are pregnant or are mothers. The current article is intended to
provide the reader with a broad overview of research on IPV and
post-traumatic stress disorder (PTSD). Articles in peer-reviewed
journals and more recent research were given preference for
citation whenever possible.
Rates and Types of Intimate Partner Violence
Intimate partner violence is a serious problem that results
in significant costs to individuals, the healthcare system,
and society. About 20-64% of all violence against women is
from romantic partners,[1,2] and more than half of the women
experiencing IPV live with children under age 12.[3] Particularly
troubling is that IPV is a common experience of women who
are pregnant or raising children.[4] In such cases, not only are
women negatively affected, but also are their developing fetuses
and children.[5]
Post-traumatic Stress Disorder
as a Consequence of Intimate Partner Violence
Intimate partner violence can be life-threatening for some
women, but more commonly results in injuries, immune
disorders, difficulty in sleeping, and gastrointestinal problems.
The mental health impairments associated with IPV include
depression, low self-esteem, psychological distress, and
PTSD.[6-11] Post-traumatic stress disorder is a syndrome of
intrusive re-experiencing, avoidance and emotional numbing,
and hyperarousal symptoms that occurs in some individuals
in the aftermath of a traumatic event.[12] A traumatic event
is defined as experiencing or witnessing an event involving
threat to life or physical integrity that results in feelings of fear,
helplessness, or horror.
Among all women, not just those who experience IPV, PTSD is
usually associated with multiple other mental health problems.
Cross-sectional survey research examining prevalence of PTSD
in a sample of young Germans (14-24 years old) indicates that
the vast majority (87.5%) of persons meeting the criteria for
PTSD have at least one additional diagnosis and that PTSD is
significantly correlated with almost all other mood and anxiety
disorders.[13] The same authors so found that diagnoses such as
J Postgrad Med October 2008 Vol 54 Issue 4 295 !
somatoform disorders, and social and simple phobias, tended
to precede traumatic events, whereas depressive disorders,
agoraphobia, and substance dependence tended to occur at
the same time or after the trauma. When PTSD is chronic, it
is comorbid with depression more than half the time.[14,15]
The prevalence of PTSD among battered women is high,
ranging from 45-84%.[8,10,16,17] Numerous studies find a dose-
response relationship between IPV and PTSD: the more types
of IPV experienced (e.g., physical, sexual, or emotional abuse),
the greater the number of the womanís PTSD symptoms.
[18] Research also found that depressive symptoms, somatic
complaints, and PTSD symptoms were higher in pregnant
women, at a hospital in India, who reported a history of IPV
and sexual coercion compared to those who did not.[19] Similarly,
in another study, both physically and psychologically abused
women displayed higher rates of PTSD, depressive, and anxiety
symptoms, as well as thoughts of suicide when compared to
nonabused controls.[20]
Why Does Intimate Partner Violence Result in
Post-traumatic Stress Disorder?
Recent research suggests that neuroendocrine dysregulation
may play a role in why PTSD results from IPV. Similar to other
stressors, IPV activates the biological stress system, of which the
predominant component is the hypothalamic-pituitary-adrenal
stress axis (HPA axis), which produces cortisol. Cortisol levels
naturally increase with stressful stimuli and help organisms
cope with transient stressors by altering metabolism and
neural function. However, chronic activation of this system for
prolonged periods of time can damage physiological functions,
lower immunity and inflammatory responses, and, importantly,
lead to psychological problems, such as PTSD, that are related
to the inability to cope with stress. In fact, chronic activation
of this system can be neurotoxic. In other words, it can inhibit
the growth of neurons and alter the activation of neural
circuits.[21,22] Recent research has suggested that these cortisol-
induced brain changes are related to the emotional response
that adults and children have to stressful situations.[23]
Few studies have examined whether womenís exposure to IPV
influences their HPA axis functioning. Extant studies suggest
that it does[24,25] and that cortisol levels are sometimes further
associated with PTSD and/or depression within IPV-affected
samples.[23,26] Currently, it is not clear whether those who
experience PTSD, compared to those who do not, have higher
or lower levels of cortisol. For example, Miller et al.[27] in a review
of the literature, describe how characteristics of a stressor (e.g.,
threat to physical integrity, trauma) affect cortisol secretion.
Interestingly, for most people, HPA activity increases with
subjective distress, but in those who have PTSD, researchers
generally find their HPA activity is lower.[26,28,29] For example, Olff
et al.[30] compared plasma cortisol levels in people who did and
did not have PTSD. Severity of PTSD symptoms was negatively
related to cortisol levels. However, other researchers found that
IPV-victimized women with prior or current PTSD had higher
cortisol levels across the day as compared to victimized women
without PTSD.[23] Clearly, the relationship between changes in
cortisol levels and the development of PTSD has not been fully
elucidated; further research is needed in this area.
Risk Factors for the Development of
Post-traumatic Stress Disorder
There are several factors that increase the likelihood that
women will develop PTSD as a result of experiences of IPV.
First, PTSD from childhood abuse is known to increase the risk
of repeated victimization in adulthood.[31,32] Childhood abuse
also appears to increase the likelihood that negative mental
health consequences will emerge if a woman is victimized by
a partner. Koopman and colleagues[33] found that depressive
symptoms were strongly associated with childhood physical
and sexual abuse among a sample of women who were IPV
victims. Lewis and colleagues[34] found that childhood emotional
abuse mediates the relationship between childhood exposure
to family violence and PTSD which results from adult IPV
victimization.
Second, the nature of the abusive behavior itself may place
women at increased risk of PTSD. Sexual abuse often occurs
in conjunction with other types of IPV and, when it does,
increases risk for PTSD and other serious mental health
consequences.[35] Partner rape has been associated with PTSD,
depression, and suicidal ideation.[35] Sexual assault by a partner
(vs. a nonpartner) is the stronger predictor of PTSD[36] and
sexual aggression by a partner is a stronger predictor of negative
mental health outcomes than is physical abuse.[37] And, Pico-
Alfonso et al.[20] found that for IPV associated with PTSD, the
co-occurrence of sexual abuse was associated with increased
depression and suicide attempts.
Third, the timing and exposure to IPV affects womenís
mental health. In our research, we found that a history of
exposure to IPV as well as IPV during pregnancy is negatively
related to womenís mental health symptoms across diagnostic
categories.[6] The number of partners and the timing of this
exposure had different effects. Those experiencing chronic IPV
(across both partners and time) had the worst outcomes. Women
who experienced IPV recentlyóduring their pregnancies and in
the year prior to pregnancy with their current partnersóhad the
next worst outcomes. In other research, current IPV predicted
PTSD symptoms (especially avoidance), with psychological
abuse contributing variance over and above physical abuse.[34]
Protective Factors for the
Development of Post-traumatic Stress Disorder
While the risk of PTSD is high among women who are victims
of IPV, not all women develop these symptoms. Several
factors have been associated with women who are resilient to
developing trauma symptoms when they experience IPV; these
include social support and specific personal characteristics.
Much research indicates that social support helps mitigate
the influence of IPV on womenís mental health. For example,
social support may have both a direct effect on mental health
in the context of IPV[38,39] as well as moderate the relationship
between IPV and poor mental health outcomes.[40-42] Similarly,
DeJonghe, et al.: PTSD and intimate partner violence !
! 296 J Postgrad Med October 2008 Vol 54 Issue 4
tangible social support moderates the relationship between
IPV and PTSD symptoms.[43] Martin and Hesselbrock[44] found
that social support enhanced the capacity for resilience among
incarcerated women with histories of victimization. Finally,
Leone et al.[45] compared help-seeking in victims of intimate
terrorism (the repeated, severe abuse of one person by his/her
romantic partner) vs. situational couple violence. Those women
experiencing intimate terrorism were more likely to seek formal
help, but rates of informal help-seeking were equivalent.
Personal characteristics have also been associated with resilience
among women experiencing IPV. In a study of survivors of
violent trauma (including IPV), several personal characteristics,
including control, commitment, goal-orientation, self-esteem,
adaptability, social skills, and humor were associated with
greater general levels of mental health, as well as lower PTSD
severity.[46] In addition, particular intrapersonal coping
mechanisms can attenuate the negative mental health
consequences of IPV. Reviere et al.[47] found that, among a
sample of low-income, African-American women, those who
attempted suicide were more likely to use coping strategies
that focused on accommodating abusers. Those who did not
attempt suicide used coping strategies focused on leaving the
relationship or avoiding harm. In particular, engagement coping
(such as goal- or solution-oriented behaviors) seems to predict
better outcomes as compared to disengagement coping, such as
avoidance.[37] Finally, specific cognitions and/or cognitive styles
have been associated with resilience to IPV. For example, Calvete
et al.[48] found that cognitive schemas of disconnection and
rejection mediated the link between violence and depression.
Among survivors of childhood abuse, persistence of PTSD
symptoms was related to perceptions of the intensity of
negative emotions and fear of these negative emotions.[49] And,
finally, Feldner and colleagues[50] found that anxiety sensitivity
moderated the relationship between traumatic events (not
specifically IPV) and PTSD symptoms.
Intimate Partner Violence and Mother ’s Pregnancy
During pregnancy, women are at elevated risk of becoming
victims of IPV, placing both the woman and her developing fetus
at risk. Based on a systematic review of published prevalence
data for partner abuse during pregnancy, Gazmararian and
colleagues report that the incidence of physical abuse during
pregnancy may be as high as 20% among women seeking prenatal
care.[51] Importantly, the high rates of IPV during pregnancy are
confounded by womenís age. Younger women are more likely
to experience IPV[52] and also more likely to become pregnant.
During pregnancy, research suggests that the stress associated
with IPV and the resultant psychological disorders that occur
may negatively affect the developing fetus. Women survivors of
childhood intrafamilial maltreatment and sexual trauma may
be particularly likely to experience high PTSD levels across
gestation, due to psychosexual triggers associated with pregnancy
and maternity care.[53,54] They are also more likely to have
comorbid conditions and associated features that complicate
recovery and may be as disruptive to perinatal and parenting
outcomes as PTSD itself: affect (emotion) dysregulation and
interpersonal reactivity.[55,56] For example, Seng and colleagues[57]
found that lifetime victimization was associated with PTSD
in pregnant women, and the PTSD symptom count of these
women was significantly negatively associated with perinatal
outcomes. In our research, IPV experienced during pregnancy
was associated with greater likelihood of premature labor, later
entrance into prenatal care, greater utilization of healthcare
resources, and more prenatal substance use.[58] Seng et al.[59]
also found that PTSD diagnosis was associated with pregnancy
and birth complications. Rosen et al.[60] found that prevalence
of prenatal IPV was two times as high among women who gave
birth to low birth-weight infants as compared to those with
normal birth-weight infants.
Intimate Partner Violence and Children
Although not the focus of this article, it is important to note
that when mothers are victims of IPV, their children are often
affected. More than half the women who experience IPV live
with children under age 12.[61] Multiple studies indicate that
about 20-25% of children report witnessing incidents of IPV
between their parents.[62-64]
Intimate partner violence may affect children even before they
are born. Prenatal IPV has been associated with compromised
infant attachment to mothers at six months[65] and at age
one.[66] In our own research, we found that women who had
been abused during their pregnancies had significantly more
negative thoughts and expectations about their unborn babies
than did nonabused women.[67] We also examined the stability
of these maternal representations of caretaking (i.e., how
mothers thought about their relationships with and care for their
infants) from pregnancy to one year postpartum.[68] Women
who changed from positive to less positive representations were
more likely to be abused during pregnancy than were nonabused
women. And, women with more negative prenatal schemas were
more controlling and hostile with their infants at one year.[69]
Once born, the effects of maternal IPV victimization may be
seen beginning in infancy. Our research indicates that at age
one, infants exposed to IPV were more reactive to adult anger
than those who were not exposed[70] and were likely to exhibit
trauma symptoms.[71] Preschool and school-age children also
exhibit trauma symptoms as a result of witnessing IPV.[72-76] And
a recent meta-analysis indicated that effect sizes for trauma
symptoms occurring as a result of IPV exposure were greater
than those for other forms of internalizing behaviors.[77] Of
course, problems other than PTSD or trauma symptoms occur
when children are exposed to IPV. Recent meta-analyses find
an increased risk of behavioral and emotional problems among
children living in households with IPV.[77,78]
Impaired parenting may result from IPV, and it has been
hypothesized as one of the causal mechanisms that influence
child outcomes. Much research has documented the deleterious
effects of parental depression on parenting behavior and
childrenís functioning across many age ranges.[79-84] Depression
contributes to less optimal caretaking behaviors because the
motherís attention and interest in the child is reduced[85,86]
! DeJonghe, et al.: PTSD and intimate partner violence
J Postgrad Med October 2008 Vol 54 Issue 4 297 !
DeJonghe, et al.: PTSD and intimate partner violence !
and she is not available to assist the child with emotion
regulation.[86,87] English et al.[88] found that caregiver functioning
(including depression) was a mediator between IPV and child
outcomes between the ages of four and six. The studies did
not test for PTSD, so although there is a large literature
examining the effects of depression on parenting, the effects
on parenting of PTSD alone or with depression have been rarely
examined.[89-91]
Prevention of Intimate Partner Violence
Efforts to prevent the occurrence of IPV and the resultant
PTSD include both broad-based and targeted interventions
with adolescents prior to the onset of violence between
romantic partners. Cornelius and Resseguie[92] reviewed current
intervention programs for adolescent dating violence. Although
most programs are able to produce changes in attitudes and
beliefs about dating violence, changes in behavior are either
not assessed or, when assessed, not maintained over time.
For example, Foshee and colleagues[93] implemented a dating
violence prevention program with eighth and ninth graders
that focused on changing behavioral norms, gender stereotypes,
conflict resolution styles, and altering cognitive factors
associated with help-seeking for those in dating relationships.
At a one-year follow-up, the authors found changes in beliefs
and attitudes toward dating violence but no significant change
in dating violence behaviors. Thus, further research is needed
to ascertain effective preventive interventions for IPV.
Treatment of Post-traumatic Stress Disorder
Efforts to mitigate trauma symptoms once they emerge have
been effective. Among adults suffering from PTSD, several
psychotherapy treatments have received empirical support. (For
a review see the article of Bisson and Andrew.[94]) Treatments
categorized as ìprobably efficaciousî by the American
Psychological Associationís Division of Clinical Psychology[95]
include exposure therapy,[96,97] stress inoculation treatment,[96]
and eye movement desensitization and reprocessing[98]; however,
whether rapid eye movement is a key ingredient in treatment
is debatable.[99] In addition to these psychotherapies, medical
treatment may be helpful. For example, selective serotonin
reuptake inhibitors have effectively treated PTSD.[100]
Newer treatments specifically targeted for violence against
women are currently being developed. For example, in contrast
to a purely ìexposure-basedî intervention, cognitive processing
therapy is an evidence-based 12-session manualized treatment
for PTSD.[101,102] This treatment was specifically developed
for rape and sexual assault victims, but it has been used with
individuals experiencing other types of trauma (e.g., war
veterans).[103] Therapy clients write about their memories of
the traumatic incident and the impact it has had on their lives.
These narratives are read aloud during treatment sessions so
that distorted cognitions involving depression, guilt, and anger
can be challenged.
Some research has examined the efficacy of treating acute stress
disorder (ASD) so that PTSD does not develop.[104] The ASD
symptoms are similar to those of PTSD, but they only last up
to four weeks after a traumatic event. About 80% of people
experiencing ASD will go on to develop PTSD.[105] A six-session
cognitive behavioral therapy treatment for ASD, following motor
vehicle accidents, industrial accidents, and nonsexual assaults,
prevented the development of chronic PTSD at six months[106]
and four years after the event.[107] To date, this intervention has
not been tested with women who experience IPV.
However, it is important to note that not all preventive
treatments for PTSD are effective. Many recent review articles
indicate that at least one popular treatmentópsychological
debriefing, in which individuals are encouraged to engage in
discussion about the critical incidentómay actually increase
or maintain symptoms.[108-110]
Conclusion
It is clear that women who experience IPV are at considerable risk
of developing PTSD. The effects of IPV on victims are profound.
Factors such as victimization during childhood, sexual abuse by
a partner, type of abuse (e.g., sexual, physical), and timing of
abuse (chronic, recent) may increase the probability that women
will develop PTSD. When considering the effects of IPV on
women, practitioners must also be mindful of how the IPV and
the womanís experiences of it may affect families and children.
However, there are factors that reduce the chance that women
will develop PTSD as a result of IPV experiences. Social support
and proactive coping styles may reduce the likelihood that
PTSD will develop, and recent research suggests that effective
psychological and pharmacological treatments are available.
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Psychother Psychosom 2003;72:176-84.
Source of Support: Nil, Confl ict of Interest: Not declared.
! DeJonghe, et al.: PSTD and intimate partner violence
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“The goal of a suicide assessment is not to predict suicide, but rather to…appreciate the basis for suicidality, and to allow for a more informed intervention”
– (Jacobs, Brewer, & Klein-Benheim, 1999, p. 6).
The assessment of suicide risk is commonly based on the identification and appraisal of warning signs as well as risk and protective factors that are present. Information relevant to the person’s history, chronic experience, acute condition, present plans, current ideation, and available support networks can be used to understand the degree of risk.
Suicide risk assessment is a multifaceted process for learning about a person, recognizing and addressing his or her needs and stressors, and working with him or her to mobilize strengths and supports. While suicide risk assessment tools are a part of this process, these should be used to support the assessment process, rather than to guide it.
Risk factors and warning signs
Risk factors may be associated with a person contemplating suicide at one point in time over the long term, whereas warning signs are those factors that, in the immediate future (i.e., minutes and days), may set into motion the process of suicide (Rudd, 2008). Warning signs present tangible evidence to the clinician that a person is at heightened risk of suicide in the short term; and may be experienced in the absence of potentiating risk factors.
It is important to recognize that risk may still be high in persons who are not explicitly expressing ideation or plans, searching for means, or threatening suicidal expressions. Persons who may be truly intent on ending their lives may conceal warning signs. Thus, it is vital that all warning signs are recognized and documented during the risk assessment process
Protective factors
Protective factors are those that may mitigate risk of suicide.
· Strong connections to family and community support
· Skills in problem solving, coping and conflict resolution
· Sense of belonging, sense of identity, and good self-esteem
· Cultural, spiritual, and religious connections and beliefs
· Identification of future goals
· Constructive use of leisure time (enjoyable activities)
· Support through ongoing medical and mental health care relationships
· Effective clinical care for mental, physical and substance use disorders
· Easy access to a variety of clinical interventions and support for seeking help
· Restricted access to highly lethal means of suicide
Principles of risk assessments
Principle 1: The therapeutic relationship
The primary principle for maintaining a person-centered risk assessment is the establishment of a therapeutic relationship with the person (APA, 2003). This relationship should be based on active listening, trust, respect, genuineness, empathy and responding to the concerns of the person (RNAO, 2009). Maintenance of openness, acceptance, and willingness to discuss his or her distress can help minimize feelings of shame, guilt, and stigma that the person may experience.
Principle 2: Communication and collaboration
Effective communication and collaboration are crucial for ensuring that suicide risk assessment remains thorough, consistent, and effective in addressing a person’s risk throughout his or her journey through the system (e.g., from the emergency room to the community, from one professional to another). Communication and collaboration are essential for obtaining collateral information about a person’s distress and maintaining his or her safety. To support the person throughout his or her recovery process, it is essential to maintain good communication and collaboration:
· With the person;
· With the person’s informal support network; and
· Within and between the care teams supporting the person.
Principle 3: Documentation in the assessment process
Documentation is a key process for ensuring the efficacy of suicide risk assessment. After initial and ongoing assessments, chart notes should clearly identify the person’s level of risk (based on warning signs, potentiating factors, and protective factors) and plans for treatment and preventive care. Chart notes should be augmented with structured assessments, including relevant risk assessments, previous psychiatric history, previous treatment received, and concerns expressed by family or friends. In settings where behaviours can be easily observed (e.g., hospital), documentation should also include information about the person’s specific thoughts and behaviours to further help appraise risk.
Documentation should include information about current and historical suicidal and purposeful self-harming expressions. Even if the expressions occurred several years previously, it is necessary to explore the circumstances around that incident and the person’s reaction to it, in case a similar situation arises. For both current and historical suicidal expressions, details about timing, method, level of intent, and consequences of the expressions should be documented.
Documentation during transitions Studies have shown that persons who have been discharged from in-patient psychiatric care are at particularly higher risk of suicide than the general population (Ho, 2003; Hunt et al., 2009; Goldacre et al., 1993). The transition from the safety of the hospital setting back into the community is a vulnerable period. Discharge planning may improve this transition to the community and reduce the risk for suicide once the person has left in-patient psychiatric care.
A thorough suicide risk assessment is essential when considering the timing of discharge. If the crisis has not been addressed, the person has not fully de-escalated, or the person cannot (or will not) agree to formulate a safety plan, try to negotiate a safety plan with the person. Suicidal ideation, low mood or hopelessness should not be present at time of discharge. Offer concrete choices (e.g., “Do you think staying in hospital would be helpful, or would returning home with a family member feel safer?”) to provide autonomy to the person to choose the treatment/discharge option that feels most safe for him or her. Relying on how the person has previously managed in the community (or while in hospital) is not a fail-safe indicator of how he or she will respond when back in the community. The person will need preparation for reintegrating, crisis contact numbers, and a timely appointment with a professional to address these items. Persons who self-discharge following a suicide crisis should be red-flagged for close monitoring. Follow-up appointments should incorporate the same suicide risk management practices as those used for discharge planning (Bergmans et al., 2007; Hunt et al., 2009).
Persons in hospital or the emergency department for suicidality should be discharged with a specific safety plan on how to stay safe once he or she returns to the community. Strategies for staying safe, early warning signs, grounding techniques, coping strategies and crisis contact numbers that were discussed during the intervention should be included in the safety plan.
Principle 4: Cultural awareness
Clinicians and health care professionals performing suicide risk assessments need to be aware of culture and its potential influence on suicide. In some cultures for instance, suicide is considered taboo and is neither acknowledged nor discussed. This creates a challenge not only for the clinician assessing for suicidality, but also for the person of that culture who may be struggling with suicidal thoughts and unable to discuss or disclose those thoughts or feelings to members of their same ethnic community. It should be considered a sign of strength for persons whose culture does not accept or discuss suicide to disclose suicidal ideation. Intra-cultural beliefs regarding suicide can be further confounded by age (e.g., youth, adult, elder), sex, and/or religious beliefs.
It is important to consider and be aware of this diversity in beliefs and the potential impact on risk of suicide. Whenever possible, talking with the person, family, or others about specific cultural beliefs toward suicide will aid the risk assessment process and help develop an approach to prevention with the person that is in line with his or her beliefs.
It is estimated that 90% of people who die by suicide are experiencing depression, another mental health illness, or a substance use disorder, all of which are potentially treatable (Government of Canada, 2016). About 15% of patients who have major depression or bipolar disorder (during the depressed phase) will die by suicide (Brendel, Breezing, Lagomasino, et al., 2016). Loss of relationships, financial difficulty, and impulsivity are contributing factors in this population.
Suicide risk is 50 times higher among patients with schizophrenia than among the general population, especially during the first few years of the illness, and suicide is the leading cause of early death among those with the illness. About 40% of all patients—and 60% of males—with schizophrenia attempt suicide at least once. Up to 10% of these patients die by suicide, usually related to depressive symptoms rather than to command hallucinations or delusions. The more risk factors that are present, the higher is the risk for suicide.
Patients with alcohol or substance use disorders also have a higher suicide risk. Comorbidity of substance abuse and depression or antisocial personality disorder is also associated with increased risk. Up to 15% of those with alcohol or substance abuse die by suicide (Sadock, Sadock, & Ruiz, 2017).
Approximately every 40 seconds, a human life ends as a result of suicide (World Health Organization, 2014). Nursing students and practising nurses at all levels encounter individuals suffering from the pain and hopelessness that all too frequently culminate in some type of suicidal expression. These individuals can be identified in inpatient settings, in outpatient treatment settings, and in the community. Studies have shown that 83% of people who die by suicide had received inpatient or outpatient health services in the year before their death (Ahmedani, Simon, Stewart, et al., 2014), with 45% consulting a primary care physician within a month before death (Turecki & Brent, 2016). This highlights the important role clinicians have in identifying risks and preventing these suicides.
The term bullycide was coined by Marr and Field (2000) to refer to suicidal expressions in response to bullying. In a larger survey across Canada it was found that 1 in 5 teens has seriously considered suicide in the last 12 months, with twice as many girls as boys reporting having considered suicide. Of this group, nearly half reported that they did not speak to anyone about suicide (47%) and that they had formulated a plan (46%).
Bullying, relationship problems, and body and self-image problems are all related to suicidal thoughts in this group (
Kids Help Phone, 2016
).
Substance related disorders
Dual Diagnosis
Concurrent disorders
Week 10
Key Terms
Use
Drinks alcohol, swallows, smokes, sniffs or injects
Abuse-harmful use
Using a legal/illegal substance in the not prescribed way/not intended way
Dependence
Use despite adverse consequences
Addiction
A chronic often relapsing brain disease that causes compulsive substance seeking and use
Withdrawal
Adverse physical and psychological symptoms that occur when use has stopped
Detoxification
Process of safely and effectively withdrawing a person from an addictive substance
Relapse
Recurrence of alcohol- or drug- dependent behaviour in person who had previously been abstinent
Intoxication
The development of aa reversible substance-specific syndrome due to the recent ingestion of (or exposure to) a substance
Clarification: Addiction/Substance use disorder interchangeable*
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
Herie, M., Godden, T., Shenfield, J. & Kelly, C. (2010). Addiction an information guide. Retrieved from https://www.camh.ca/-/media/files/guides-and-publications/addiction-guide-en ?la=en&hash=F1BFB1ED194D54A9FCF892116BFE745818169A56
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Introduction – What is addiction/ substance use disorder?
Link: https://www.youtube.com/watch?v=LNk8J5AFsFg
3
Addiction
The term “addiction” is commonly used in such a “vague way”, there have been many attempts to define it more clearly
The following provides a good definition for addiction
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors. . . . It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving (Savage et al., 2003)
Source: Herie, M., Godden, T., Shenfield, J. & Kelly, C. (2010). Addiction an information guide. Retrieved from https://www.camh.ca/-/media/files/guides-and-publications/addiction-guide-en ?la=en&hash=F1BFB1ED194D54A9FCF892116BFE745818169A56
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Distinguishing Between an Addiction and Compulsive Behaviour
Addiction must include three elements:
biological, psychological, and social (see Figure 18.1)
Compulsive behaviours do not have the biological element,
only the psychological and the social
Without the biological risk different concerns for policy and practice are present
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
5
The Process of Addiction Development
Addiction development
No contact
Experimentation
Integrated use
Excessive use
Addiction (with features of tolerance and withdrawal)
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Substance Classifications
Alcohol
Caffeine
Cannabis
Hallucinogens
Inhalants
Opioids
Sedatives
Hypnotics
Anxiolytics
Tobacco
Other substances
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Epidemiology
Prevalence of alcohol use for Canadians over age 15 years is 78%
Drug use by youth 15 to 24 years of age is higher than for adults 25 years and over
Binge drinking among Canadian men is ranked as the highest in the world
Of the three categories of pharmaceuticals, opioid pain relievers were the most commonly used in 2017
Overall smoking prevalence has fallen to 15% of the population
The rate of death due to alcohol for Indigenous people in Canada is twice that of the general population
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Epidemiology/ Comorbidity
The combination of a psychiatric comorbidity and substance use disorder is called a concurrent disorder
Of those with Anxiety Disorders, 24% have concurrent substance use disorders
27% of people with Major Depressive Disorder have concurrent disorders
47% of those with Schizophrenia have concurrent disorders
56% of those with Bipolar Disorders experience a concurrent disorder
Copyright © 2019 Elsevier Inc. All rights reserved
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Medical Comorbidities
Wernicke’s (alcoholic) encephalopathy: an acute and reversible condition
Korsakoff’s syndrome: a chronic condition with a recovery rate of only about 20%
Fetal Alcohol Spectrum Disorder
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
10
Etiology
Characterized by use, abuse, and physical and psychological dependence, and also by certain behaviours:
Loss of control of substance consumption
Continued substance use despite associated problems
Cravings and a tendency to relapse after efforts to change behaviour
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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The Brain & Addiction
The most complex body organ, the brain, is impacted by substance use in 3 central areas:
The brain stem
This controls basic bodily functions, including breathing, sleeping, and heart rate
The cerebral cortex
This controls executive functions, such as decision-making, planning, and sensory information processing
The limbic system
This is the body’s emotional reward circuitry and controls our ability to experience pleasure and motivation for survival sustaining activities, which is activated by drugs of abuse (NIDA, 2014)
Source: Drugabuse.com. (2013). What causes addiction? Retrieved from https://drugabuse.com/causes-of-addiction
12
Neurotransmitters
The main systems that seem to be involved in substance abuse are the endorphin, catecholamine (especially dopamine), serotonin, endocannabinoid, and GABA systems
Cocaine, amphetamines, and lesser stimulants increase levels of norepinephrine, serotonin, and dopamine
Opioid drugs act on endorphin receptors with a secondary effect on dopamine
Alcohol and other CNS depressants will act on GABA receptors and, as a result, increase the bioavailability of glutamate, norepinephrine, and dopamine
Hallucinogens act to varying degrees on serotonin, whereas marijuana acts on endocannabinoids
Dopamine
The brain registers all pleasures in the same way, whether they originate with a psychoactive drug, a monetary reward, or a satisfying meal
In the brain, pleasure has a distinct signature: the release of the neurotransmitter dopamine in the nucleus accumbens, a cluster of nerve cells lying underneath the cerebral cortex (see illustration)
Dopamine release in the nucleus accumbens is so consistently tied with pleasure that neuroscientists refer to the region as the brain’s pleasure center
Source: Drugabuse.com. (2013). What causes addiction? Retrieved from https://drugabuse.com/causes-of-addiction
Helpguide.org. (2019). Understanding addiction: How addiction hijacks your brain. Retrieved from https://www.helpguide.org/harvard/how-addiction-hijacks-the-brain.htm
14
Dopamine
All drugs of abuse, from nicotine to heroin, cause a particularly powerful surge of dopamine in the nucleus accumbens
Addictive drugs provide a shortcut to the brain’s reward system by flooding the nucleus accumbens with dopamine
The hippocampus provides memories of this rapid sense of satisfaction, and the amygdala creates a conditioned response to certain stimuli
Source: Drugabuse.com. (2013). What causes addiction? Retrieved from https://drugabuse.com/causes-of-addiction
Helpguide.org. (2019). Understanding addiction: How addiction hijacks your brain. Retrieved from https://www.helpguide.org/harvard/how-addiction-hijacks-the-brain.htm
15
Tolerance
Over time, of using substances the brain adapts in a way that actually makes the sought-after substance or activity less pleasurable
Addictive drugs and behaviors provide a shortcut, flooding the brain with dopamine and other neurotransmitters
Addictive drugs, for example, can release 2 to 10 times the amount of dopamine that natural rewards do, and they do it more quickly and more reliably
In a person who becomes addicted, brain receptors become overwhelmed
Source: Helpguide.org. (2019). Understanding addiction: How addiction hijacks your brain. Retrieved from https://www.helpguide.org/harvard/how-addiction-hijacks-the-brain.htm
16
Tolerance
The brain responds by producing less dopamine or eliminating dopamine receptors—an adaptation similar to turning the volume down on a loudspeaker when noise becomes too loud
As a result of these adaptations, dopamine has less impact on the brain’s reward center
People who develop an addiction find that, in time, the desired substance no longer gives as much pleasure
Therefore, take more of it to obtain the same dopamine “high” because the brain has adapted—an effect known as tolerance
Source: Helpguide.org. (2019). Understanding addiction: How addiction hijacks your brain. Retrieved from https://www.helpguide.org/harvard/how-addiction-hijacks-the-brain.htm
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Psychological factors
Fundamental to this perspective is the belief that people will repeat any behaviour that brings pleasure or reward and will discontinue any behaviour that brings them discomfort or punishment
If a drug brings pleasure or relief in a stressful situation, reduces anxiety or fear, or provides status or popularity in an insecure or lonely situation, its use will become a repeated behaviour
This is what the treatment process attempts to accomplish in terminating an individual’s misuse or abuse of a substance
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Psychological factors
Another prominent psychological theory is personality theory
Human personality traits have been grouped into five categories: extraversion, agreeableness, conscientiousness, emotional stability and openness to experience
Of these five, it is the extraversion trait that has been most closely associated with excessive substance use, particularly the attribute of impulsivity
The literature generally shows personality does not predict illness, with research continuing in this area
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
19
Psychological factors
A third long-established psychological perspective on addiction is based in psychodynamic theory
This view arises from the early work of Freud, although Freud, himself, did not devote much attention to addiction in his extensive writings, despite his own drug dependency to tobacco and cocaine
Freud stated that alcoholism may be due to the inability to successfully resolve issues among the three components of the self: the id or instinctual striving for at times pleasure and at other times pain relief, the superego or conscience, and the ego or coping component of the person
Failure of the ego to resolve issues between conscience and basic instincts can lead to maladaptive coping responses, including use of psychoactive drugs
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
20
Psychological factors
A fourth perspective is attachment theory, which focuses on long-term emotional bonds
The core idea of attachment theory is that primary caregivers who are available and responsive to an infant’s needs allow the child to develop a sense of security, which some label as love, enabling the child to explore their environment in a confident manner, knowing that they are protected
Children who are securely attached as infants tend to develop stronger self-esteem and are more sociable and self-reliant as they grow older
Attachment theory views addiction as an attempt to fill the empty space left by the lack of a secure attachment due to deprivation during childhood, including painful, rejecting, or shaming relationships
Excessive drug use, then, is seen as an individual’s attempt to self-repair psychological deficits and fill an emptiness from childhood
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
21
Common question: Why do people keep ‘using’?
Substance use/ abuse can be hard to change
One thing that makes change so difficult is that the immediate effects of substance use tend to be positive
People may feel good, have more confidence and forget about problems
People may come to rely on the effects of substances to bring short-term relief from difficult or painful feelings
Biological and psychological
theories combined
Source: Herie, M., Godden, T., Shenfield, J. & Kelly, C. (2010). Addiction an information guide. Retrieved from https://www.camh.ca/-/media/files/guides-and-publications/addiction-guide-en ?la=en&hash=F1BFB1ED194D54A9FCF892116BFE745818169A56
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Common question: Why do people keep ‘using’?
The effects of substances can make problems seem less important, or make it seem easier to talk and to be with others
People may come to believe that they cannot function or make it through the day without a particular substance
Continued substance use, especially heavy use, can cause changes in the body and brain. If people develop physical dependence and then stop using, they may experience distressing symptoms of withdrawal
Biological and psychological
theories combined
Source: Herie, M., Godden, T., Shenfield, J. & Kelly, C. (2010). Addiction an information guide. Retrieved from https://www.camh.ca/-/media/files/guides-and-publications/addiction-guide-en ?la=en&hash=F1BFB1ED194D54A9FCF892116BFE745818169A56
23
PICTURE: http://www.bing.com/images/search?view=detailV2&id=1FCC36EFC65069422FAD141F6FA29517BBA98F8D&thid=OIP.yl-O3Ej977f5epjkTI_p-QHaFb&mediaurl=http%3A%2F%2Fwww.soulshepherding.org%2Fwp-content%2Fuploads%2F2010%2F05%2FCycle-of-Addiction &exph=889&expw=1214&q=addiction+cycle&selectedindex=0&adlt=strict&ajaxhist=0&vt=0
24
Clinical course of addiction
Research suggests, most patients struggling with addictions will have one or more relapses during their process of recovery
Substance related reminders: smells, sounds, sights, or thoughts
Treatments focus on identifying triggers and possible reasons for current cravings and using this as an outcome measure to signal of possible relapse
Highly stigmatized!
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
25
Personal reflection
What stigmas are attached to addiction?
PICTURE: http://www.bing.com/images/search?view=detailV2&id=E8B7D5DD9E96C127FB684808D394466DF1524AD2&thid=OIP.4rzKxRYkDqmLu6_KgAydoAHaFj&mediaurl=http%3A%2F%2Fmooc.employid.eu%2Fwp-content%2Fuploads%2F2017%2F03%2FReflection &exph=768&expw=1024&q=personal+reflection&selectedindex=6&adlt=strict&ajaxhist=0&vt=0&eim=1,6
26
Stigma of addiction/ substance use
Stigma is another reason why the rates of substance use problems may be higher than studies suggest
Stigma marks substance use problems as “shameful” and makes people want to hide their addiction
Stigma also affects the families of people with addiction
It makes them hide the problem or pretend it isn’t there at a time when families need support
Source: Herie, M., Godden, T., Shenfield, J. & Kelly, C. (2010). Addiction an information guide. Retrieved from https://www.camh.ca/-/media/files/guides-and-publications/addiction-guide-en ?la=en&hash=F1BFB1ED194D54A9FCF892116BFE745818169A56
27
What can we do about stigma?
One simple way you can help is to choose to talk about “people with substance use problems” rather than about “addicts,” “alcoholics,” “junkies”
Try this approach whether you are talking about another person or about yourself
When you do this, you put the person ahead of the problem
You are giving the person with an addiction the support and understanding it takes to recover
Source: Herie, M., Godden, T., Shenfield, J. & Kelly, C. (2010). Addiction an information guide. Retrieved from https://www.camh.ca/-/media/files/guides-and-publications/addiction-guide-en ?la=en&hash=F1BFB1ED194D54A9FCF892116BFE745818169A56
28
Application of the nursing process
Application of the
Nursing Process
Screening
CAGE
Acute Withdrawal Assessment
Clinical Institute Withdrawal for Alcohol (CIWA-AR)
Clinical Opiate Withdrawal Score (COWS)
Family assessment
Codependence
Self-assessment
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Assessment
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
30
CAGE screening
The four questions to be asked in the screening process are remembered by the mnemonic CAGE:
Have you felt you ought to Cut down on your drinking, substance use, or behaviour?
Have people Annoyed you by criticizing your drinking, substance use, or behaviour?
Have you felt Guilty about your drinking, substance use, or behaviour?
Have you had a drink (or used another substance or behaviour) first thing in the morning to steady your nerves or get yourself going for the day (an Eye-opener)?
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
31
Acute Assessment Process
Assess for:
Acute intoxication
Severe or major withdrawal syndrome
Overdose of a drug or alcohol that warrants immediate medical attention
Suicidal thoughts or other self-destructive behaviours
Physical complications related to drug abuse
Motivation to change
Knowledge of community resources for alcohol and drug treatment
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
32
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
33
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
35
Assessment of
Readiness to Change
The Transtheoretical Model of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
36
Nursing Process
(Cont.)
Nursing diagnosis
Outcomes identification
Planning
Identifying problem
Setting a goal
Determining the interventions that will accomplish the goal
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
37
Nursing Process
(Cont.)
Implementation – care continuum for substance abuse
Detoxification (detox)
Rehabilitation
Halfway houses
Other housing
Partial hospitalization
Intensive outpatient (IOP) treatment
Outpatient treatment
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Levels of prevention
Primary – eg., alcohol labelling policy; cigarette taxation
Secondary – eg., harm reduction practices (supervised injection sites, managed alcohol program); relapse prevention support
Tertiary – detox and recovery/rehabilitation programs
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
39
Nursing Process
(Cont.)
Implementation
Motivational interviewing
Counselling (individual and family)
Relapse prevention support
Psychobiological interventions
Pharmacological
Health teaching and health promotion
Evaluation
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Motivational Interviewing
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
41
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Establish rapport
Set the agenda
Assess readiness to change
Sharpen the focus
Identify ambivalence
Elicit self-motivating statements
Handle resistance
Shift focus and transition
Dual Diagnosis/Concurrent Disorders
Drug use problems and mental health: Comorbidity explained
Link: https://www.youtube.com/watch?v=5RbEotf0jqI
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Dual Diagnosis (Concurrent Disorders)
An individual suffers from one substance-related disorder and a mental health disorder
Many possible combinations
Most complex and difficult clinical scenarios in health care
Likely to be stigmatized, socially marginalized, experience high degrees of relational problems, and are likely to be involved in the criminal justice system
Tend to fall through the cracks
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Dual Diagnosis (Concurrent Disorders)
Epidemiology
50% of persons with addiction also suffer from a mental disorder
20% of persons with mental illness also suffer from substance-related disorders
Affect young and old adults
18.5% prevalence of concurrent disorders
Co-occurrence is strongly associated with antisocial and challenging behaviour, legal involvement, and risk of suicide or self injurious behaviours
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Treatment Approaches
Screening should include both substance-related disorders, and other mental health disorders
No single approach or set of interventions
Treatment of each disorder simultaneously
Treatment matching
Indications for hospitalization
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Care for a patient who is suicidal and risk assessments
https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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Introduction
Source: Government of Canada. (2019, July 17). Suicide in Canada. Retrieved from https://www.canada.ca/en/public-health/services/suicide-prevention/suicide-canada.html
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Approx. 4,000 deaths by suicide per year
Every day, an average of approximately 11 Canadians die by suicide
1/3 of deaths by suicide are among people 45-59 years
Suicide is the second leading cause of death among youth and young adults (15-34 years)
Suicide rates are approx. 3x higher among men compared to women
Every day an average of 10 Canadians die by suicide
For every person lost to suicide, many more experience thoughts of suicide or suicide attempts
What populations are at higher
risk for suicide?
In Canada, the following groups have higher rates or risk of suicide:
Men and boys
Individuals serving federal sentences
Survivors of suicide loss and survivors of a previous suicide thought/intent/expression
Youth (15 to 24 year olds)
second leading cause of death for youth
Source: Government of Canada. (2019, July 17). Suicide in Canada. Retrieved from https://www.canada.ca/en/public-health/services/suicide-prevention/suicide-canada.html
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What populations are at higher
risk for suicide?
In Canada, the following groups have higher rates or risk of suicide:
Some First Nation and Métis communities, especially among youth
Women have higher rates of self-harm
**Self-harm can be a risk factor for suicide
Thoughts of suicide and suicide-related expressions are more frequent among LGBTQ youth in comparison to their non-LGBTQ peers. This refers to those who identify as lesbian, gay, bisexual, trans, Two-Spirit or queer/questioning youth
Source: Government of Canada. (2019, July 17). Suicide in Canada. Retrieved from https://www.canada.ca/en/public-health/services/suicide-prevention/suicide-canada.html
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Canadian Statistics
Source: Government of Canada (2020, March 4). Suicide in Canada: Key statistics (infographic). Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/suicide-canada-key-statistics-infographic.html
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Thoughts
11.8% report thoughts of suicide in their lifetime
2.5% report thoughts of suicide in the past year
Plans
4.0% report having made suicide plans in their lifetime
7% of people in lowest income quintile vs. 3% of people in highest income quintile
Key terms
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Suicide or death by suicide
Terms used to describe the act of taking one’s own life.
Suicidal expressions
Is the term used to describe potentially self-injurious actions with a nonfatal outcome for which there is evidence that a person intended to end their life
Examples of suicidal expressions include self-harm, suicidal ideation, desire to hasten death, risky behaviour, and suicide threats
Suicidal expressions may or may not result in injury
Nonsuicidal self-injury
Is characterized by self-harming with no intent to die
Stigma
Several terms used in association with suicide add to the stigma and alienation experienced both by people with suicidal ideation (referred to as self-stigma) and by survivors of suicide
Terms such as committed suicide, failed suicide, and successful suicide are avoided
Words like commit and attempt evoke connotations of criminality, which are inappropriate and potentially stigmatizing to suicidal individuals and those touched by suicide
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Stigma
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Failure and success in this regard are equally disrespectful and distort what could never be considered a success
For these reasons, the neutral and factual expression “died by suicide” or “death by suicide” is preferred
Changing the language that we use to describe suicide and suicidal expressions is a first step in addressing the ways in which nurses can sensitively and empathically begin working with individuals who are suicidal
Video: Suicide Myths and Facts (no sound)
Centre for suicide prevention. (2017, April 4). Suicide Myths and Facts. Retrieved from https://www.youtube.com/watch?time_continue=81&v=Lgt0IH1JCJ8&feature=emb_title
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Video: “I jumped off the golden gate bridge”
BuzzFeed. (2015, December 9). I jumped off the golden gate bridge. Retrieved from https://www.youtube.com/watch?v=WcSUs9iZv-g
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Risk factors
&
Warning signs
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Warning Signs
The American Association of Suicidology (AAS) uses the mnemonic IS PATH WARM to assist people to recognize and identify the warning signs of suicide
I Ideation
S Substance use
P Purposelessness
A Anxiety or agitation
T Trapped
H Hopelessness or helplessness
W Withdrawal
A Anger
R Recklessness
M Mood changes
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Note that, although patients who exhibit protective factors may still have expressions or death from suicide, multiple protective factors generally contribute to patient resilience in the face of stress and adversity
Protective Factors
Children in the home, except among those with postpartum psychosis
Responsibility to others
Pregnancy
Personal, social, cultural and religious beliefs that discourage suicide and support self-preservation
Life satisfaction
Reality testing ability
Positive coping skills
Positive social support
Positive therapeutic relationship
Hope for the future
Self-efficacy
Supportive living arrangements
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Application of the nursing process
Application of the
Nursing Process
Assessment
Verbal and nonverbal clues
Overt statements
Covert statements
Lethality of suicide plan
Assessment tools
SAD PERSONS scale
C-SSRS Scale
Self-assessment
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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Taking Seriously –RNAO
Registered Nurses Association. (2009). Assessment and care of adults at risk for suicidal ideations and behaviours. Retrieved from https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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All verbal and non-verbal expressions that may convey an expression of dying are taken seriously
The patient is assessed for suicide risk. Here are some suggestions to ask your patient if they are suicidal:
“Are you thinking about ending your life?”
“Are you suicidal?”
“Do you have a plan to take your own life?”
“Do thoughts of death or suicide enter your mind?”
The assessment is documented and communicated to the appropriate members of the health care team
Based upon the assessment, appropriate interventions are initiated
The score is calculated from ten yes/no questions, with one point for each affirmative answer:
This score is then mapped onto a risk assessment scale as follows:
0–4: Low
5–6: Medium
7–10: High
SAD Scale
IMAGE REFERENCE: https://www.bing.com/images/search?view=detailV2&id=6EB9E7C21A3CAF607995C1BD9DEC85EA1E07C254&thid=OIP.us1aJsea4RYj1ymvRyaUMgHaKo&mediaurl=http%3A%2F%2Fwww.ebmedicine.net%2Fspaw%2Fuploads%2FaboutUs%2FModified%2520SAD%2520PERSONS%2520Scale%2520Emergcency%2520Medicine%2520Practice.JPG&exph=619&expw=431&q=sad+scale&selectedindex=0&ajaxhist=0&vt=0&eim=0
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The Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS)
Supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask
The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs
Users of the tool ask people:
Whether and when they have thought about suicide (ideation)
What actions they have taken — and when — to prepare for suicide
Whether and when they attempted suicide or began a suicide attempt that was either interrupted by another person or stopped of their own volition
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Application of the
Nursing Process
Diagnosis
Risk for suicide
Outcomes identification
Suicide self-restraint
Implementation
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
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Risk Assessment
Presence of risk factors
Lack or presence of protective factors (e.g. spirituality, hope, future orientation, cultural and/or spiritual factors)
Suicidal intent
Plan
Lethality
Access to means
Timeframe
Hope –what has stopped from acting? What gives hope?
Previous expressions
Registered Nurses Association. (2009). Assessment and care of adults at risk for suicidal ideations and behaviours. Retrieved from https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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Interventions
IMAGE REFERENCE: https://www.bing.com/images/search?view=detailV2&id=4CB122F60B330F9ADE8480428B6EA514ADB46A01&thid=OIP.fDA9uz56vH84u5_LnGZZ7AHaD_&mediaurl=http%3A%2F%2Fsouthcentralhealth.com%2Fwp-content%2Fuploads%2F2014%2F01%2FSuicide_prevention &exph=350&expw=650&q=suicide+help&selectedindex=2&ajaxhist=0&vt=0&eim=0
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Nursing Interventions
Taking seriously all statements made by the patient that indicate, directly or indirectly, a wish to die by suicide, and/or all available information that indicates a risk for suicide
Working toward establishing a therapeutic relationship with patients at risk for suicidal ideation & expressions
Working with the patient to minimize the feelings of shame, guilt and stigma that may be associated with suicidality, mental illness and addictions
Provides care in keeping with the principles of cultural safety/cultural competence
5. Assessing and managing factors that may impact the physical safety of both the patient and the interdisciplinary team
Registered Nurses Association. (2009). Assessment and care of adults at risk for suicidal ideations and behaviours. Retrieved from https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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Nursing Interventions (cont’d)
6.
Recognizing key indicators that put an individual at risk for suicidal expressions, even in the absence of expressed suicidality. For individuals who exhibit risk indicators, the nurse conducts and documents an assessment of suicidal ideation and plan
Assessing for protective factors associated with suicide prevention
Obtaining collateral information from all available sources: family, friends, community supports, medical records and mental health professionals
Mobilizing resources based upon the patients assessed level of suicide risk and associated needs
Ensuring that observation and therapeutic engagement reflects the client’s changing suicide risk
Registered Nurses Association. (2009). Assessment and care of adults at risk for suicidal ideations and behaviours. Retrieved from https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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Nursing Interventions (cont’d)
Working collaboratively with the patient to understand their perspective and meet their need
Using a mutual (patient nurse) problem-solving approach to facilitate the patients understanding of how they perceive their problems and generate solutions
Fostering hope with your patient
Being aware of current treatments to provide advocacy, referral, monitoring and health teaching interventions, as appropriate
Registered Nurses Association. (2009). Assessment and care of adults at risk for suicidal ideations and behaviours. Retrieved from https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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Nursing Interventions (cont’d)
Identifying people affected by suicide that may benefit from resources and supports, and referrals as required
The nurse may initiate and participate in a debriefing process with other health care team members as per organizational protocol
Seeking support through clinical supervision when working with adults at risk for suicidal ideation and expressions to become aware of the emotional impact to the nurse and enhance clinical practice
Registered Nurses Association. (2009). Assessment and care of adults at risk for suicidal ideations and behaviours. Retrieved from https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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Inpatient Care and Acute Treatment
Source: Austin, W., Kunyk, D., Peternelj-Taylor, C. & Boyd, M. (2018). Psychiatric & Mental health nursing for Canadian practice (3rd ed.). Lippincott Williams & Wilkins
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Protect patient from suicide and establish treatment of underlying psychiatric disorder
Objectives of hospitalization:
Maintain patient’s safety.
Decrease the level of suicidal ideation.
Initiate treatment for underlying disorder.
Evaluate for substance abuse.
Reduce level of social isolation.
https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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Biologic Interventions
Source: Austin, W., Kunyk, D., Peternelj-Taylor, C. & Boyd, M. (2018). Psychiatric & Mental health nursing for Canadian practice (3rd ed.). Lippincott Williams & Wilkins
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Ensuring safety
Protocol for safety
Engaging in a therapeutic relationship
Observing patient regularly
Removing dangerous objects
Somatic therapies
Medications
ECT (we will cover this next week)
Substance use treatment
Assisting with Treatment of Substance Use
Psychological Interventions
Source: Austin, W., Kunyk, D., Peternelj-Taylor, C. & Boyd, M. (2018). Psychiatric & Mental health nursing for Canadian practice (3rd ed.). Lippincott Williams & Wilkins
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Evaluating patient’s ways of thinking about problems and generating solutions
Cognitive interventions
Developing plans to prevent future suicide expressions/thoughts
Social Interventions
Source: Austin, W., Kunyk, D., Peternelj-Taylor, C. & Boyd, M. (2018). Psychiatric & Mental health nursing for Canadian practice (3rd ed.). Lippincott Williams & Wilkins
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Help patient develop social skills that can be used in engaging others
Identify family and friends who are willing to be supportive
The nurse can be one of the supportive individuals if successful in establishing a professional therapeutic relationship
Therapeutic Dialogue
Suicide Safety Planning
What is it?
What are the steps?
Video – World Suicide Prevention Day 2019: You Make Today Better
TWLOHA. (2019, September 9). World Suicide Prevention Day 2019: You Make Today Better. Retrieved from https://www.youtube.com/watch?v=xFu8IXDSy1s
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https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0
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Safety Planning – Introduction
A safety plan is a document that supports and guides someone when they are experiencing thoughts of suicide, to help them avoid a state of intense suicidal crisis
When developing the plan, the person experiencing thoughts of suicide identifies:
their personal warning signs,
coping strategies that have worked for them in the past, and/or strategies they think may work in the future,
people who are sources of support in their lives (friends, family, professionals, crisis supports),
how means of suicide can be removed from their environment, and
their personal reasons for living, or what has helped them stay alive
Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
NOTES for voiceover:
Suicidal thoughts can burden people and hold them hostage. Experiencing these thoughts is to experience “absolute darkness, hopelessness, pain,” and nothing matters but stopping that pain.
When is a safety plan written?
A safety plan is written when a person is not experiencing intense suicidal thoughts. It may be written after a suicidal crisis, but not during, as at this time an individual can become overwhelmed with suicidal thoughts and confusion and may not be able to think clearly. A safety plan is written when a person has hope for life, or even can consider the possibility of life, so that they can identify their reasons for living, and positive actions they can take to prevent their thoughts from becoming intense and overwhelming.
A safety plan can be developed in one sitting by the person with thoughts of suicide together with you, their caregiver or friend, or over time. The plan can change as the circumstances for the individual change and can be revised accordingly.
Why does it work?
A safety plan is an assets-based approach designed to focus on a person’s strengths. Their unique abilities are identified and emphasized so they can draw on them when their suicidal thoughts become intense. The goal is to draw upon their strengths during subsequent recovery and healing processes (Xie, 2013). Personal resources are another integral safety plan component. Drawing on strengths is the entry-level activity; reaching out for help may also become necessary (Xie, 2013; Bergmans, personal communication, 2019).
The safety plan is organized in stages. It starts with strategies the individual can implement by themselves at home and ends with 24/7 emergency contact numbers that can be used when there is imminent danger or crisis.
The person with thoughts of suicide can verify, along with their caregiver or friend, whether coping skills are feasible, as well as whether or not the chosen contact people are appropriate (Bergmans, personal communication, 2019).
When implemented, safety plans become self-strengthening. For people who experience recurring suicidal thoughts or crises, one strength becomes knowing they have weathered the storm before and have navigated their way out.
Is a safety plan the same as a no-suicide contract?
A no-suicide contract is different from a safety plan in that it is “an agreement, usually written, between a mental health service user and clinician, whereby the service user pledges not to harm himself or herself” (McMyler & Prymachuk, 2008, p.512). It was introduced in 1973 by Robert Drye, Robert Goulding and Mary Goulding. Mental health service users are expected to seek help when they feel they can no longer honour their commitment to the contract (Rudd, Mandrusiak & Joiner, 2006).
The no-suicide contract has been widely used by clinicians working with patients at risk of suicide (Rudd, Mandrusiak & Joiner, 2006). However, there is a lack of evidence to support contracts as clinically effective tools. Both service users and clinicians have voiced strong opposition to their use. Moreover, important ethical and conceptual issues in the use of such contracts have been identified, including the potential for coercion from the clinician for their own protection and the ethical implications of restricting a service user’s choices when they may be already struggling for control. A strength-based approach like a safety plan, on the contrary, not only encourages the service user’s input and agency, it is a true partnership with the physician or caregiver, bound by hope (McMyler & Prymachuk, 2008; Rudd, Mandrusiak & Joiner, 2006).
Source: Centre for Suicide Prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
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Step 1: List warning signs that indicate a suicidal crisis may be developing
Guiding question(s) for the person thinking about suicide
What (situations, thoughts, feelings, body sensations, or behaviours) do you experience that let you know you are on your way to thinking about suicide, or that let you know you are mentally unwell generally?
Think about some of the more subtle cues
Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
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Step 2: List the coping strategies that can be used to divert thoughts, including suicidal thoughts
Guiding question(s) for the person thinking about suicide
What (distracting activity, relaxation or soothing technique, physical activity) helps take your mind away from thought patterns that feel scary or uncomfortable, or thoughts of suicide?
Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
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Step 3: List the places and people that can be used as a distraction from thoughts of suicide
Guiding question(s) for the person thinking about suicide
Where can you go to feel grounded, where your mind can be led away from thoughts of suicide? Who helps take your mind away from these thoughts?
Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
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Step 4: List all the people that can be contacted in a crisis, along with their contact information
Guiding question(s) for the person thinking about suicide
Who among your friends, family, and service providers can you call when you need help (when your thoughts become overwhelming or you’re thinking about suicide)?
Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
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Step 5: List mental health providers and the hours they can be reached, as well as 24/7 emergency contact numbers that can be accessed in a crisis
Guiding question(s) for the person thinking about suicide
Who are the professionals you’ve worked with who can be helpful to you in a crisis? What other professionals or organizations could you call?
Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
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Step 6: List the steps to be taken to remove access to means of suicide from the environment
Guiding question(s) for the person thinking about suicide
What could be used in your environment (home, work)? How have you thought about dying by suicide before, and how can you make that method more difficult to access?
Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
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Step 7: List important reasons to live, or how/why that person is still alive
Guiding question(s) for the person thinking about suicide
When do you feel most at ease during the day? Who do you love? What do you enjoy doing? What did you used to enjoy doing? What is important to you, or used to be important to you? What has kept you alive up until now?
Note: These reasons can become apparent through conversation with the person, and through the process of a suicide intervention. You may need to identify these for the person, based on what they’ve told you.
Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
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How to implement a Safety Plan
Keep in mind that the safety plan is not written in stone: it can be revised as often as is needed. The plan can be reviewed at any time, and especially if the person experiencing thoughts of suicide has found any portion of it ineffective in helping them cope with their thoughts. For example, if one contact person was found to be difficult to get in touch with on several occasions, or if a coping strategy is no longer effective or accessible
Source: Centre for Suicide Intervention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/
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Once complete, the person who has had thoughts of suicide should keep copies of the safety plan in an accessible place
The safety plan needs to be accessible to ensure the person can always find it when they are experiencing intense thoughts of suicide
Each step in the safety plan plays a role in supporting the person with thoughts of suicide
Video – Tomorrow needs you
TWLOHA. (2018, September 10). World Suicide Prevention Day 2018. Retrieved from https://www.youtube.com/watch?v=aEzUMnBHHK0
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IMAGE REFERENCE: https://www.bing.com/images/search?view=detailV2&id=D3CC55A82520F7963EE5A944F8D467B85B2D6455&thid=OIP.dzXHl-7e8OtDl3Kmughj0AHaIy&mediaurl=https%3A%2F%2Fi.pinimg.com%2Foriginals%2Fc4%2Fcb%2Fbf%2Fc4cbbfdb56385356aa78faa5b3d4924a &exph=593&expw=500&q=people+will+not+remember+what+you+said&selectedindex=8&ajaxhist=0&vt=0&eim=0
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IMAGE REFERENCE: https://www.bing.com/images/search?view=detailV2&id=D8B6DDD73F6741781F978EF3569556BCDC2AFC0F&thid=OIP.Vh-1Ooife93hj_50FS-WQQHaFD&mediaurl=http%3A%2F%2Fwww.quotesvalley.com%2Fimages%2F70%2Fman-can-live-about-forty-days-without-food-about-three-days-without-water-about-eight-minutes-without-air-but-only-for-one-second-without-hope &exph=275&expw=403&q=man+can+live+40+days+without+food&selectedindex=6&ajaxhist=0&vt=0&eim=0
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Canadian – Help Resources
9-1-1
Kids Help Phone: 1-800-668-6868
Text CONNECT to 686868
Chat Services [6 pm–2 am EST]: www.kidshelpphone.ca
Trans Lifeline: 1-877-330-6366
Hope for Wellness Help Line: 1-855-242-3310
Online chat: www.hopeforwellness.ca
Indian Residential Schools Crisis Line: 1-866-925-4419
Canada Suicide Prevention Service: 1-833-456-4566 [24/7]
Source: Government of Canada (2020, March 4). Suicide in Canada: Key statistics (infographic). Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/suicide-canada-key-statistics-infographic.html
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Chapter 38
The Preschooler and Family
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Promoting Optimal
Growth and Development
The preschool period: ages 3 to 5 years
Preparation for most significant lifestyle change—going to school
Experience of brief and prolonged separation
Use of language for mental symbolization
Increased attention span and memory
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
*
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Biological Development
Physical growth slows and stabilizes.
Body systems mature and stabilize; child can adjust to moderate stress and change.
Muscle development and bone growth are still not mature.
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
*
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Gross and Fine Motor Behaviour
Gross motor: walking, running, climbing, and jumping well established by 36 months
Refinement in eye–hand and muscle coordination
Drawing, artwork, dressing
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
*
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Fig. 38-1. A 3-4-year-old child has sufficient balance to stand or hop on one foot.
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
*
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Psychosocial Development
Erikson; developing sense of initiative
Initiative vs. Guilt
Chief psychosocial task of preschool period
Feelings of guilt, anxiety, and fear may result from thoughts that differ from expected behaviour
Development of superego (conscience)
Learning right from wrong; moral development
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
*
Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Initiative Vs. Guilt
Bethany Geltner YouTube video
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Initiative
Sense of initiative is strengthened when they are allowed to try out new skills with little risk of disapproval and disappointment, and by being given the independence and reinforcement to play. Play creates a social group of children where they learn to engage and cooperate with others to achieve shared goals.
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Guilt
Being threatened, criticized and punished excessively by adults can lead to development of a sense of guilt among children.. This may affect their social interactions negatively and may also hinder their creativity. However, some guilt is deemed necessary for them to learn self-control and feel the significance of conscience. A balance between initiative and guilt must therefore be achieved.
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Cognitive Development
Readiness for school
Readiness for scholastic learning
Typically ages 5 to 6 years
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Cognitive Development—cont.
Piaget; preoperational phase
Spans 2 to 7 years
Divided into two stages
Preconceptual phase: ages 2 to 4
Intuitive thought phase: ages 4 to 7
Shifts from egocentric thought to social awareness
Able to consider other viewpoints
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Jean Piaget Pre-operational Stage Experiment (By: C & E)
YouTube video
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Cognitive Development—cont.
Language continues to develop.
(Incessant talking at age 3)
(Stammering, stuttering can be normal)
Concept of causality begins to develop.
Concept of time is incompletely understood.
Use of “magical thinking” is frequent.
(usually age 5)
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Theory of Moral Development
Kohlberg;
Premoral/conventional/post conventional ladder
Can only progress to next step once you are finished the stage you are in
“Heinz”
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Heinz Dilemma
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Heinz Dilemma
Heinz’s wife was dying from a peculiar type of cancer, and the doctors said a new drug might be able to save her. The drug had been discovered by a local chemist and Heinz tried desperately to buy some, but the chemist was charging ten times the money it cost to make the drug and it was much more than the Heinz could afford.
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Even after help from family and friends, Heinz could only raise a fraction of the cost for the drug. He explained to the chemist that his wife was dying and asked if he could have the drug for a cheaper price or pay the rest of the money later. The chemist refused, saying that he had discovered the drug and was going to make money from it. The husband was desperate to save his wife, and he was wondering what he should do.
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Points to Ponder…
Should he steal the drug?
Should he steal the drug and face the consequences?
Should he obey the law and not steal the drug, only to let his wife die?
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Premoral
Obedience vs. Punishment
Reasoning based on physical consequence of action
Rules fixed and absolute
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Conventional
Good Boy & Good Girl
The child is ‘good’ based on what is perceived as others as good…So now the child is aware of others perceptions and is influenced by others
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Post Conventional
Social Contract
Self-chosen principles direct thinking based on individual rights and justice for he greater good
Heinz…was protection of life more important than maintaining Law and Order?
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School-Aged view of Heinz Dilemma
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Spiritual Development
Knowledge of faith and religion learned from significant others and religious practices
Development of conscience strongly linked to spiritual development
May misinterpret illness as punishment from God
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Development of Body Image
Increasing comprehension of “desirable” appearances
Awareness of racial identity, differences in appearances, and biases
Poorly defined body boundaries
Fear that if skin is “broken” all blood and “insides” can leak out
Intrusive experiences frightening (Dr/ Dentist)
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Development of Sexuality
Child forms strong attachment to opposite-sex parent while identifying with same-sex parent.
Modesty becomes a concern.
Sex-typing occurs.
Sex role limitation occurs, with child “dressing up like Mommy or Daddy.”
Sexual exploration is more pronounced.
Questions arise about sexual reproduction.
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Social Development
Separation–individuation process completed
Overcoming stranger anxiety and fear of separation from parents
Still need parental security and guidance
Security from familiar objects
Play therapy beneficial for working through fears, anxieties, and fantasies
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Language
Major mode of communication and social interaction
By age 6, can use all parts of speech correctly
Define simple things…i.e. ball is round and an toy…not just ‘red’ or ‘ball’
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Fig. 38-2. Preschool children enjoy friends and often use nonverbal messages to communicate.
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Personal–Social Behaviour
Self-dressing
Willing to please
Have internalized values and standards
of family and culture
May begin to challenge family’s code of conduct
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Fig. 38-3. Most preschoolers are able to dress themselves but need help with more difficult items of clothing.
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Play
Associative play (watching and conversing without interacting)
Imitative play (role play)
Imaginative play—imaginative playmates
Dramatic play (play out a part or ‘role’)
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Fig. 38-4. Preschoolers enjoy play activities that promote motor skills such as jumping and running. Water play is an exciting activity for preschooler.
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Imitation
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Imitation
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Coping With Concerns Related to
Normal Growth and Development
Preschool and kindergarten
Developmental screening tool to assess readiness for school
Importance of infection control in
school setting
Introduction of child to school
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Fig. 38-6. Thorough hand washing is the single most effective method of preventing infection.
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Sex Education
Find out what children know and think.
Be honest.
Discuss masturbation.
Sexual exploration and sexual curiosity are common.
Formal edu. usually starts at Age 10
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Fears
Dark
Being left alone
Animals (e.g., snakes, large dogs)
Ghosts
Sexual matters
Objects or people associated with pain
Animism – spiritual essence to natural phenomena
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Stress
Realization that minimal amounts of stress can be beneficial
Parental awareness of signs of stress
in child’s life
Prevention of stress
Scheduling adequate rest
Preparing child for upcoming changes to maximize coping strategies
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Stress Symptoms in Children
Start at 1:05.
YouTube Video
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Aggression
Behaviour that attempts to hurt person or destroy property
May be influenced by biological, sociocultural, and familiar variables
Factors that increase aggressive behaviour: gender, frustration, modelling, and reinforcement
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Speech Problems
Dysfluency (inability to say word)
Dyslalia (problems with articulation)
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Promoting Optimal Health
During the Preschool Years
Nutrition
Caloric requirements dependent on age and gender
Fluid requirements approximately
100 mL/kg/day, depending on activity and climate
Food fads, strong tastes common
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Fig. 38-7. Preschool-age children enjoy helping adults and are more likely to try new foods if they can assist in the preparation.
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Sleep and Activity
12 hours of sleep per night, infrequent naps
Free play encouraged
Emphasis on fun and safety
– current debate re: increasing # of organized activities
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Sleep Problems
Thorough assessment of sleep problems
Nightmares
Sleep terrors
Encourage consistent bedtime routine
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Dental Health
Eruption of deciduous teeth complete
Professional care and prophylaxis
Fluoride supplements
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Injury Prevention
Safety education
Increase in pedestrian motor vehicle accidents
Development of long-term safety behaviours
Wearing protective equipment
*bike safety
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Anticipatory Guidance—
Care of Families
Child care focus shifts from protection
to education.
Children begin questioning previous teachings of parents.
Children begin to prefer companionship
of peers.
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Child Maltreatment
Intentional physical abuse (20%) or neglect (34%)
Emotional abuse (9%) or neglect
Sexual abuse of children (3%)
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Types of Neglect
Physical neglect
Deprivation of food, clothing, shelter, supervision, medical care, and education
Emotional neglect
Lack of affection, attention, and emotional nurturance
Emotional abuse—destroy or impair child’s self-esteem
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Physical Abuse
Deliberate infliction of physical injury on child
Shaken baby syndrome
Violent shaking of infant or young child
Munchausen syndrome by proxy
Factitious disorder by proxy or medical child abuse
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Factors Predisposing
to Physical Abuse
Parental characteristics
Social isolation, young parents, single parents
Characteristics of the child
Disabled, preterm, and under 3
Environmental characteristics
Divorce, poverty, unemployment
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Sexual Abuse
No universal definition exists.
Sexual abuse and exploitation in Canada involves using a child for sexual purposes.
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Sexual Abuse—cont.
Incest
Molestation
Exhibitionism
Child pornography
Child prostitution
Pedophilia
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Characteristics of Abusers
and Victims
Typical abuser is male whom victim knows, but may be anyone.
All socioeconomic backgrounds can be involved.
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Nursing Care of the
Maltreated Child
Identify abusive situations as early as possible.
Obtain history pertaining to incident.
Evidence of maltreatment includes:
Pattern or combination of indicators that arouse suspicion and further investigation
Protect child from further abuse
Prevent abuse.
END HERE
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School Age
Group Work
Puberty
Body Image
Erkison/Piaget
Moral Development
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Adolescent
Erikson/Piaget
Peer Relationships
Obesity
Sleep and Rest
Injury Prevention
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Anger, Aggression & Violence
Abuse & interpersonal violence
Defining Key Terms
Anger
strong uncomfortable emotional response to a provocation that is unwanted and incongruent with one’s values, beliefs or rights; “ it is a feeling”
Aggression
verbal statement against someone intended for intimidation; “ is a behaviour, an action”
Violence
a physical act of force intended to cause harm to a person or an object and conveys a perpetrator’s point of view
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Anger
Introduction
Anger is “a strong, uncomfortable emotional response to a provocation that is unwanted and incongruent with one’s values, beliefs, or rights”
Anger is usually described as a temporary state of emotional arousal, in contrast to hostility, which is associated with a more enduring negative attitude
Anger is part of the fight/flight response; although anger is portrayed as a bad emotion that always leads to aggression, this is often not the case
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Introduction
Some of the words used interchangeably with anger include annoyance, frustration, temper, resentment, hostility, hatred, and rage
In addition, the word angry is used to describe both a transient emotional state and a personality trait
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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The experience of anger
An internal event that involves thoughts, images, and bodily sensations
Can serve as a warning that demands are greater than available resources
The meaning of angry episodes develops from the beliefs held about anger and the interpretation given to the episode and these are shaped by influences such as culture, language, and gender
Anger is a normal human emotion; it is the dysfunctional expression of anger that may be threatening to the self or others
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Expressions of anger
Verbal (e.g., yelling) and motor behaviours (e.g., stomping one’s foot) are involved in the expression of anger
Difficulties in expressing anger have been associated with psychiatric disorders
“Anger turned inwards” has been implicated as a contributor to mood disorders, especially depression
Several medical disorders have linked with the suppression of anger, including essential hypertension, migraine headaches, psoriasis, rheumatoid arthritis, and Raynaud’s disease
Behavioural expressions of anger vary
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Chris Mackey Psychology. (2018, December 12). Managing anger and aggression. Retrieved from https://www.youtube.com/watch?v=a29nKy8wsdE
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Violence
Introduction
While anger is an emotion, aggression and violence are actions
Aggression is defined as “verbal statements against someone that are intended to intimidate or threaten the recipient”
A study of verbal aggression on psychiatric units indicated that the types of verbal aggression by prevalence were abusive language, shouting, threats, expressions of anger, and racist comments
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Introduction
Violence is defined as “a physical act of force intended to cause harm to a person or an object and to convey the message that the perpetrator’s point of view is correct and not the victim’s”
Aggression and violent behaviour reflect a continuum from suspicious behaviour to extreme actions that threaten the safety of others or result in injury or death
Research focused on inpatient psychiatric units has found that higher levels of aggression were associated with clients detained under mental health legislation (Bowers et al., 2011), high client turnover, unit doors being locked, and higher staffing ratios
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Increasingly, the complexity of aggression and violence occurring in health care settings is being recognized
A systemic perspective of aggression and violence in mental health care has been proposed that identifies four related phenomena:
environmental (e.g., layout of the unit, noise level)
intrapersonal/client (e.g., age, gender, trauma, diagnosis)
clinician (e.g., skills, stress level, attitude towards aggression)
mental health care system (e.g., policies, cultural factors, control orientation)
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Theories
This section discusses some of the dominant theoretical explanations for anger, aggression, and violence. A single model or theory cannot yet fully explain anger, aggression, and violence; instead, the nurse must choose the most useful models for explaining a particular client’s experience and for planning interventions
Theories of aggression
Biological
Caused by developmental difficulties, malnutrition, toxins, tumors, trauma
Damage to cerebral cortex
History of abuse/ family violence
“ Emotional circuit”
limbic system, cerebral
cortex, frontal and
temporal lobe.
Neurochemical and low serotonin
Psychological
Aggression or violent behaviour are instinctual impulses and events in the environment that stimulate instinctual urges
Protect against a threat
Behavioural
Violence originates internally
People experience anger as a result of feeling that goal is being blocked or interference with achieving it
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer
Halter, M.J., Pollard, C.L., & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd Ed.). Milton, ON: Elsevier.
Townsend, M.C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based practice (8th Ed.). Philadelphia, PA: F.A. Davis
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Neurochemical Model & Low Serotonin Syndrome
In recent decades, knowledge has increased about the complex role of neurotransmitters in human behaviour
Serotonin is a major neurotransmitter involved in mood, sleep, and appetite
Low serotonin levels are associated not only with depression but also with irritability, increased pain sensitivity, impulsiveness, aggression, vulnerability to alcoholism, and obsessive– compulsive behaviour
People with a history of aggressive behaviour have been found to have a lower-than-average level of serotonin
Studies of humans with known aggressive tendencies, such as violent offenders, have repeatedly shown lower-than- average concentrations of 5-hydroxyindoleacetic acid (5-HIAA), the major metabolite for serotonin
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Theories of aggression
Social Learning
Children learn anger and aggression
Learn that it gets them what they want
Sociocultural
Violent behaviour has multi determinants i.e. social expression in family and peer settings
Influenced by gender
The Social Learning Theory, developed by Albert Bandura in 1977 suggests that individuals model behavior they witness. This theory has been the most relevant theory to criminology. Bandura asserted that aggression must explain three aspects:
1) “how aggressive patterns of behavior are developed;”
2) “what provokes people to behave aggressively.”
3) “what determines whether they are going to continue to resort to an aggressive behavior pattern on future occasions.”
The theory is a combination of the Social Control Theory and the Social Learning Theory in that it emphasizes a weak societal bond and learning that encourages deviant behavior. This theory is meant to examine all of the influential factors an individual may experience throughout his/her life.
This theory is more of a developmental theory which suggests that societal, learning, and delinquency factors all contribute to an individuals involvement in organized crime. The theory further states that individuals with weak social bonds will form other bonds with other delinquents who share the same poor values.
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Violence
Creates a critical challenge to the safety, well-being, and health of the clients and others in their environment
Nurses should always assume an organic component (drugs, alcohol, psychosis, or delirium) underlying the aggression in clients presenting with disorganized impulsive or violent behaviors, until proven otherwise
Client body language offer clues to escalating anxiety, particularly agitation, threatening gestures, or darting eye movements
Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders — Chapter 16
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Violence
Treatment of violent clients consists of immediately providing a safe, non-stimulating environment for the client
Often clients calm down if taken to an area with less sensory input
The client should be checked thoroughly for potential weapons and physically disarmed, if necessary*** Note this should only be done by authorized personnel/police – SAFETY for all is priority
Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders — Chapter 16
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Predictors of Violence
History
Previous episodes of aggression/rage or violence
Escalating irritability
Intruding angry thoughts
Fear of losing control
Additional factors: brain injury, substance abuse
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
Townsend, M.C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based practice (8th Ed.). Philadelphia, PA: F.A. Davis
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Nursing Management
Mental health and aggression
Many clients who have mental health problems do not behave aggressively or violently
To develop a means of predicting aggressive and violent behaviours, some researchers have attempted to determine the relationship between medical diagnosis and violence
Others have focused on the role of a person’s history in predicting violence or examined demographics, client characteristics, and unit climate
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Mental health and aggression
Although media attention highlights violence related to mental illness, research shows that “the mentally ill as a group pose little risk of violence”
Persons with severe mental illness, such as schizophrenia or bipolar depression may be at a slightly higher risk for violent behaviour but they are overwhelmingly more likely to be victims of violent crime (prevalence 6 to 23 times greater than others)
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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While the following is a great learning example for the management of anger and aggression, please note the video does have some aggression
I am here if you would like to debrief after or watch together. Please do not hesitate to talk to me if this is triggering or if there is anything you would like to discuss
Remember you are NEVER alone!
BJC HealthCare. (2014, July 8). Do this, not that! Providing care for medical patients with psychiatric issues. Retrieved from https://www.youtube.com/watch?v=UgLb7sPslUo
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TABLE 20-1
Behavioral Indicators of Potential Violence
Behavioral Categories Potential Indicators
Mental status Confused
Paranoid ideation
Disorganized
Organic impairment
Poor impulse control
Motor behavior Agitated, pacing
Exaggerated gestures
Rapid breathing
Body language Eyes darting
Prolonged (staring) eye contact or lack of eye contact
Spitting
Pale, or red (flushed) face
Menacing posture, throwing things
Speech patterns Rapid, pressured
Incoherent, mumbling, repeatedly making the same statements
Menacing tones, raised voice, use of profanity
Verbal threats
Affect Belligerent
Labile
Angry
Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders — Chapter 16
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BOX 20-3 – De-escalation Tips for Mental Health Emergencies
• Use a nonthreatening stance—open, but not vulnerable. Have the client “take a seat”
• Eye contact—not constant, brief to show concern
• Commands—brief, slow, with simple vocabulary, only as loud as needed, repeat as needed
• Movement—not sudden, announce actions when possible, keep hands where they can be seen
• Attitude—calm, interested, firm, patient, reassuring, respectful, truthful
• Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the client “I understand you are seeing or feeling this, but I am not”
• Remove distractions, upsetting influences
• Keep the client talking/focused on the here and now
Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders — Chapter 16
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BOX 20-3 – De-escalation Tips for Mental Health Emergencies
• Allow verbal venting within reason
• Be sensitive to personal space/comfort zone
• Remove client to a quiet space; remove others from immediate area (avoid the “group spectators”)
• Give some choices or options, if possible
• Set limits if necessary
• Limit interaction to just one professional and let that person do the talking
• Avoid rushing—slow things down
• Give yourself an out; do not put the client between yourself and the door
Arnold, E. &Boggs, U.K. (2016). Interpersonal relationships: Professional communication skills for nurses (7th ed.). St. Louis, Missouri: Saunders — Chapter 16
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Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Planning & implementing interventions
The following assumptions are important to consider in planning interventions:
The nurse and client collaborate to find solutions and alternatives to aggressive and violent outbursts
Anger is a normal emotion
All people have the right to express their anger
All people have a responsibility to express their anger in a way that does not, emotionally or physically, threaten or harm others
In most instances, the person who behaves aggressively or violently can assume responsibility for the behaviour
The nurse views the client from the perspective of acknowledging that the client has solved problems before and is only temporarily in need of help
The nurse understands that norms for behaviour are created within the context of a particular environment and are influenced by the client’s history and culture
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
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Planning & implementing interventions
Nurses who work collaboratively with potentially violent clients must also keep in mind that they can take certain actions to minimize personal risk:
Using nonthreatening body language
Respecting the client’s personal space and boundaries
Positioning themselves so that they have immediate access to the door of the room in case they need to leave the room
Choosing to leave the door open to an office while talking to a client
Knowing where colleagues are and making sure those colleagues know where they are
Removing or not wearing clothing or accessories that could be used to harm them, such as scarves, necklaces, or dangling earrings
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
31
Abuse &
Interpersonal Violence
Types of Abuse
Abuse of Women
2 to 4 million cases per year
Highest risk 18 -24, over 65 pregnant and have a history of childhood victimization
Types battery, rape sexual assault, stalking
Abuse of Men
Sexual assaults of men are higher in resent years.
Males also inflected with emotional and physical abuse
Abuse of Children
Child Neglect (43%)
Physical Abuse (31%)
Sexual Abuse (10%)
Incest
Non-family members
Pedophilia
Emotional abuse
Rejecting; Isolating; Terrorizing; Ignoring; Corrupting
Munchausen syndrome by Proxy
Secondary abuse: Children of battered women
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
Townsend, M.C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based practice (8th Ed.). Philadelphia, PA: F.A. Davis
33
9 Types of Interpersonal Violence
Physical
Sexual
Psychological
Emotional
Spiritual
Cultural
Verbal
Financial
Abuse
34
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Cycle of Violence
Deliberate and systematic
Used to gain control
Intentional
Type of violence chosen
Rage
Cool/calculating
Pattern of escalation
35
Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
Townsend, M.C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based practice (8th Ed.). Philadelphia, PA: F.A. Davis
Epidemiology and comorbidity
One of the most important public health issues in Canada
Comorbidity
Secondary effects of violence
Depression
Suicidal ideation
Chronic post-traumatic stress symptoms
Dissociation
Interpersonal disturbances
Substance abuse
Revictimization
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
36
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Ecological model
Identifies risk factors:
Poverty
Social isolation
Alcohol/substance abuse
Access to firearms
And conditions:
A perpetrator
A person vulnerable to abuse (e.g., child, woman, older adult, mentally ill, or physically challenged person)
A crisis situation
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
37
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Characteristics of perpetrators
Consider their own needs more important than the needs of others
Poor social skills
Extreme pathological jealousy
May control family finances
Dominance, power, and control are the primary drives
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
38
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Characteristics of vulnerable persons: Women
Pregnancy may trigger or increase violence
Violence may escalate when makes move toward independence
Greatest risk for violence when the woman attempts to leave the relationship
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
39
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Characteristics of vulnerable persons: Children
Younger than 3 years
Perceived as different
Remind parents of someone they do not like
Product of an unwanted pregnancy
Interference with emotional bonding between parent and child
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
40
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Characteristics of vulnerable persons: Older adults
Poor mental or physical health
Dependent on perpetrator
Female, older than 75 years, living with a relative
Older adult father cared for by a daughter he abused as a child
Older adult woman cared for by a husband who has abused her in the past
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
41
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Application of the nursing process
Assessment
General assessment
Interview process and setting
Self-assessment
Should include:
Violence indicators
Level of anxiety and coping responses
Family coping patterns
Support systems
Suicide or homicide potential (or both)
Drug and alcohol use
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
42
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Application of the nursing process
Diagnosis
Risk for injury
Risk for violence
Outcomes identification
Abuse protection
Abuse recovery
Implementation
Reporting abuse
Counselling—safety plan
Case management
Therapeutic environment
Promotion of self-care activities
Health teaching and health promotion
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
43
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
Prevention of abuse
Primary prevention
Measures taken to prevent the occurrence of abuse
Secondary prevention
Early intervention in abusive situations to minimize their disabling or long-term effects
Tertiary prevention
Facilitating the healing and rehabilitative process
Providing support
Assisting survivors of violence to achieve their optimal level of safety, health, and well-being
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
44
Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
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