EMOTIONAL DISORDER IN CHILDREN AND  Loss of any language or social skills at any

ADOLESCENCE age

CATEGORIES OF DISORDERS IN CHILDREN AND Treatment For Autism

ADOLESCENTS
1. Reduce behavioral symptoms
A. Pervasive Developmental Disorders
A. Reduce temper tantrums, aggressiveness,
1. Autistic Disorder self-injury, hyperactivity and stereotyped behaviors
2. Rett’s Disorder  Ex: Haloperidol (Haldol)
3. Childhood Disintegrative Disorder  Risperidone (Risperdal)
4. Asperger’s Disorder
B. Diminish self-injury, and hyperactive and
AUTISM obsessive behaviors
 Catapres (Clonidine)
 Also called mindblindedness  Anafranil (Clomipramine)
 Incidence: common in boys  ReVia (Naltrexone)
 Onset: not later than 3 years old
 Characteristic: impairment of reciprocal 2. Promote learning and development
interaction skills
  Special education: highly structured
Causes of autism program focusing on the development of
social skills, language, self-care and school
 Unknown performance
 An abnormality in the chemicals of the brain  Family therapy: Parental education
 A genetic factor
 An abnormality of the structure of the brain RETT’S DISORDER

Symptoms of Autism  Characteristic: Development of multiple deficit

after a period of normal functioning from birth
1. Difficulty with social interactions to 5 months
- unaffectionate  Incidence: girls
- prefer to be alone  Behavioral pattern: stereotyped (head banging,
- inappropriate attachment to objects tantrums, body twisting)
- lack of interest in the environment  Communication:
- inappropriate laughing or gingling  loss of expressive language
- may avoid eye contact  loss of receptive language
 Social interaction:
2. Difficulty with communication  loss of interest in social environment
- delayed or does not develop language
(echolalia) Differnce between RTT and Autistic Disorder
-does not use language to communicate
instead may use gestures RETTS SYNDROME AUTISM
-difficulty in expressing needs Common in girls (4:1) Common in boys
Loss of acquired language Delayed/ inappropriate
3. Stereotype behavior language development
 spin objects or self Loss of hand function Preserved hand function
 sustained repetitive motor movements Ataxia is common Ataxia is rare
o rocking Seizure is common Seizure is not common
o hand or finger flapping Abnormal chewing Normal chewing ability
o body twisting Microcephaly Normal head development
o Delayed physical growth Normal physical growth
 prefer sameness
 preoccupied usually with lights, moving objects CHILDHOOD DISINTEGRATIVE DISORDER
or parts of objects
 apparent insensitivity to pain  Also called Heller’s Syndrome and Dementia
 no real fear of dangers Infantialis
 Characteristic: marked regression in multiple
How is Autism Diagnosed??? areas of functions after at least 2 years of
normal growth and development
 For the first two years of life, the child should  Onset: 3 – 4 years old
be checked for the ff developmental deficits:  Incidence: common in boys
 12 months: No babbling, pointing, or  Behavioral pattern: stereotyped (headbanging,
gesturing tantrums, body twisting)
 18 months: No single word spoken  Communication: loss of previously acquired
 24 months: No two-word spontaneous spoken language
expressions  Social interaction: loss of previously acquired
social skills
  Motor development: loss of motor functions o Fidgets
(loss of bowel and bladder control) o run or climbs excessively
o often on the go
 NOTE: loss of skills may be gradual or occurs o talks excessively
rapidly over a period of 6 – 9 months o blurts out answers/interrupts
conversation
ASPERGER DISORDER o can’t wait for turns is markedly
affected
 Characteristic:
o severe impairment in social interaction FACTORS:
o have normal IQ and many (not all) may
exhibit exceptional skill or talent in a 1. Family history
specific area. -male relatives with antisocial personality
 Incidence: common among boys disorders or alcoholics
 Onset: appears to have a later onset -female relatives with somatization
 Etiology: unknown and may be a genetic disorders
 Behavioral pattern: 2. Low socioeconomic status
o Often viewed as eccentric or odd 3. Various kind of brain insults
because of their high functionality and 4. Male gender
naiveté. 5. Marital discord
o restricted and repetitive patterns of
behavior and idiosyncratic interest (ex: TREATMENT
fascination with remembering train
schedules of dates PSYCHOPHARMACOLOGY - use to reduce
 Communication: hyperactivity, inattentiveness, impulsivity and
o no language or cognitive delays lability of mood
o vocabularies may be extraordinary rich 1. CYLERT (Pemoline) - last drug to be
but extremely literal and have difficulty prescribed due to its hepatotoxicity (liver
using language in a social context damage)
 Social interaction: 2. ADDERAL (Amphetamine)
o severe impairment in social interaction 3. DEXEDRINE (Dextroamphetamine
o problem with empathizing and SE: insomnia, loss of appetite,
modulating social relationships this weight loss
may become noticeable when the child 4. STRATTERA (Atomoxetine)
enters school and may continue into  non-stimulant drug approved in
adulthood) 2002
 Mgt: Social skills training  an antidepressant (selective non-
epinephrine reuptake inhibitor)
B. Attention Deficit and Disruptive Behavior  SE: loss of appetite. N/V,
fatigability, abdominal distress
1. Attention deficit Hyperactive Disorders
2. Conduct Disorder NURSING INTERVENTION
3. Oppositional Defiant Disorder
1. Ensure safety of client and that of others
Attention Deficit Hyperactive Disorders - Stop unsafe behavior
- Provide close supervision
 Characterized by: hyperactivity, impulsivity, - Give clear directions about acceptable
distractibility, and unacceptable behavior
 Incidence: 2. Improved role performance
o Common among boys - Give positive feedback for meeting
o Usually identified and diagnosed when expectations
the child begins pre-School - Manage the environment (ex: provide a
 Etiology: unknown quiet place free of distractions for task
completion
Symptoms 3. Simplifying instructions/directions
- Get child’s full attention
 poor academic performance - Break complex tasks into small steps
 development of family and peer relationship is - Allow break
restrained due to disruptive and intrusive at 4. Structured daily routine
home which causes friction with siblings and - Establish a daily schedule
parents - Minimize changes
 Difficulty sustaining attention and 5. Client/family education and support
concentration - Listen to parent’s feelings and frustrations
o severe – 2 to 3 seconds
o mild – 2 to 3 minutes CONDUCT DISORDER
 Hyperactive and impulsive behavior
o inability to sit still
Persistent antisocial behavior in children and  They are less likely aggressive and have
adolescents that significantly impairs their ability to more normal peer relationship
function in social, academic or occupational functions  Are less likely to have persistent conduct
disorder or antisocial personality disorder
CONTRIBUTING FACTORS
1. Genetic vulnerability CLASSIFICATION
- More common in children who have a 1. MILD - child has less conduct problems that
sibling or parent with antisocial PD, cause to relatively minor harm to others
substance abuse, mood disorder and EX: lying, truancy, running away from
schizophrenia home
2. Neurochemical imbalances
3. Family functioning 2. MODERATE -Conduct problems increases as
-Ex: Marital discord, poor parenting, child does the amount of harm they cause to others
abuse and neglect Ex: vandalism, sexual harassment, use of
4. Environmental adversity weapons
-Ex: Inadequate housing, crowded
conditions, poverty 3. SEVERE - Conduct problems are greater with
considerable harm to others
RISK FACTORS Ex: rape, robbery, burglary, homicide, use
1. Poor parenting illegal substance
2. Poor peer relationship
3. Low academic achievement NURSING INTERVENTION
4. Low self-esteem
1. DECREASE VIOLENCE
PROTECTIVE FACTORS  Set limit on client’s inappropriate
1. Resilience behavior
2.Family support  Use behavioral contract
3. Positive peer relationship
4.Good health 2. INCREASE COMPLIANCE TO TREATMENT PLAN
 Provide consistency with client’s
CHARACTERISTICS treatment
1. AGRESSIVENESS TO PEOPLE  Provide routine schedule of ADL
 Bullies, threaten and intimidate others
 Often initiate fights 3. IMPROVE COPING SKILLS
 Often carry weapon with him  Teach client and practice problem solving
skills
 Sexual harassment  Behavioral therapy
 Physically cruel to persons  self-monitoring – Diary/Journal
 positive reinforcement of appropriate
 Have little empathy for others behavior
2. AGRESSIVENESS TO ANIMALS
 Physically cruel to animals 4. PROMOTE SELF-ESTEEM
3. DESTRUCTIVE TO PROPERTIES  encourage independency (making
 Intentionally destroy or damage other’s decision with guidance)
properties  Show acceptance, interest and respect
 Breaking into house, building or car
 Setting fire 5. PROMOTE SOCIAL SKILLS
4. OTHER CHARACTERISTICS  Teach age-appropriate social skills
 Stealing/shoplifting  Role-model and practice social skills

 Stow away 6. PROVIDE CLIENT AND FAMILY EDUCATION

 Stays out late at night
 Manipulative TREATMENT
 Often truant from school
 Liar *PRE-SCHOOL AGE
 -Parental education about growth and development
SUBTYPES OF CONDUCT DISORDER -Parental support during crisis
1. CHILDHOOD ONSET TYPE
- Involves symptoms before age 10 which *SCHOOL AGED CHILDREN – Family therapy
includes aggression towards others and -Parenting education
disturbed peer relationships -Social skills training to improve peer relationships
- Are more likely to have persistent conduct -Improve academic performance
disorder and to develop antisocial -Increase ability to comply with demands from
personality disorder authority figures

2. ADOLESCENT ONSET TYPE *ADOLESCENTS – Individual therapy

 No behavior of conduct disorder after -Conflict resolution
age 10 -Anger management
 -Teaching social skills 2.VOCAL:

OPPOSITIONAL DEFIANT DISORDER  clearing of the throat

 grunting
 Consist of uncooperative, defiant and hostile  Sniffing
behavior toward authority figures without major  snorting
antisocial violations  coughing
 Is diagnosed when behaviors are frequent and
intense and cause dysfunction in social, academic 3.COMPLEX VOCAL TICS
and work situations
 Incidence: Occur equally among boys and girls  COPROLALIA – use of unacceptable words
 25% of people with this disorder develop  PALILALIA – repetition of own words or
conduct disorder sounds
 10% are diagnosed as adult with antisocial  ECHOLALIA – repetition of words of others
personality disorders
TOURETTE’S DISORDER
C. Feeding and Eating Disorder
-Characterized by multiple motor tics and one or
1. PICA more vocal tics which occurs many time a day for
2. RUMINATION more than one year
3. FEEDING DISORDER OF INFANCY OR EARLY -Results to significant impairment in academic,
CHILDHOOD social and occupational functions
-More common in boys but rare
RUMINATION DISORDER -Identified by 7 years of age
-Some may have lifelong problems; others have no
-Characterized by regurgitation and re-chewing of symptoms after early adulthood
food
-Common in boys but rare CHRONIC MOTOR OR VOCAL TIC DISORDER
-Occurs most often during the first year of life
-Results to malnutrition, weight loss and even -Characterized by rapid, recurrent, uncontrollable
death in about 25% of affected infants movements or vocal outburst (but not both)
-To be diagnosed, the child has had the tics nearly
PICA every day for more than a year or had no tic-free
day longer than 3 months
-Characterized by ingestion of non-nutritive -More common than Tourette’s Syndrome
substance or objects.
 Ex:sand, paper, crayons, leaves, etc. TRANSIENT MOTOR TIC DISORDER
-Result to malnutrition
-Complications: intestinal obstruction and Characterized by single or multiple vocal or motor
infections, lead poisoning tics, but for no longer than 12 months

FEEDING DISORDER E. ELIMINATION DISORDER

-Characterized by persistent failure to eat 1. Ecopresis

adequately 2. Enuresis
-Equally seen in boys and girls
-Occurs most often during the first year of life 1. ENCOPRESIS - repeated passage of feces into
-Result to significant weight loss and in severe inappropriate places such as clothing or floor by a
cases, malnutrition and death child who is at least 4 years of age
2. ENURESIS - repeated voiding during the day or
D. TICS DISORDER night into clothing or bed by a child at least 5 years

1. TOURETTE’S DISORDER F. OTHER DISORDER

2. CHRONIC MOTOR TIC DISORDER 1. SEPARATION ANXIETY DISORDER
3. TRANSIENT TIC DISORDER 2. SELECTIVE MUTISM
3. REACTIVE ATTACHMENT DISORDER
4. STEREOSTYPE MOVEMENT DISORDER
5. LEARNING DISORDERS
TIC 6. COMMUNICATION DISORDERS
-Sudden, rapid, recurrent, non-rhythmic, 7. MENTAL RETARDATION
stereotyped motor movement or vocalization
SEPARATION ANXIETY DISORDERS
1. MOTOR:
 Blinking -Characterized by anxiety exceeding than
 neck jerking expected for developmental level related to
 Grimacing separation from the home or those to whom the
 shoulder shrugging child is attached
-More common in girls
 -Symptoms: depression, withdrawal, apathy, o Picking at skin/orifices
difficulty concentrating, fear that a family member
might die LEARNING DISORDER

ETIOLOGY  Learning disorder is diagnosed when a child’s

achievement in reading, mathematics or
 Overprotective parents of close family written expressions is below of that expected
relationship for age, formal education and intelligence
 Post-traumatic experience  -Reading and written expression disorders are
 Tend to run in family with anxiety disorders usually identified in grade one
 -Math disorder may be undetected until the
SELECTIVE MUTISM child reaches grade 5
 Characterized by persistent failure to speak  Effect of learning disorders:
in social situations where speaking is o Low self esteem
expected such as in school o Poor social skill
 Symptoms:  Management: Special education to promote
 Children are excessively shy, socially academic achievement
withdrawn, clinging, and have temper  Types of Learning Disorders
tantrums o 1. READING DISORDER
 Children may communicate by o 2. MATHEMATICS DISORDERS
gestures, nodding or shaking head or o 3. DISORDER OF WRITTEN EXPRESSION
one-syllable vocalization
 Rare and slightly more common in COMMUNICATION DISORDER
girls
1. EXPRESSIVE LANGUAGE DISORDERS
REACTIVE ATTACHMENT DISORDER 2. MIXED RECEPTIVE AND EXPRESSIVE DISORDERS
 Characterized by serious problems in emotional 3. PHONOLOGIC DISORDER
attachment to others and usually presents by 4. STUTTERING
age 5
 Etiology: EXPRESSIVE LANGUAGE DISORDER
 Traumatic loss of caregiver  characterized by impaired ability to
 Abuse communicate through verbal and non-verbal
 Repeated changes of care language.
 Parental neglect o Difficulty learning new words
Types: o Limited speech
o Incomplete and incorrect use of words
1. Inhibited type – child fails to initiate or
and sentences
respond to social interaction. May refuse cuddling
 The disturbance may be manifest clinically by
or close contact with others.
symptoms that include having a markedly
 Children with inhibited behavior shun
limited vocabulary, making errors in tense, or
relationships and attachments to
having difficulty recalling words or producing
virtually everyone. This may happen
sentences with developmentally appropriate
when a baby never has the chance to
length or complexity
develop an attachment to any
caregiver.
MIXED RECEPTIVE AND EXPRESSIVE DISORDERS
2. Disinhibited type - child lacks selectivity
 Characterized by:
in choice of attachment figures. May respond to
o problems of expressive language
parent or to a stranger in the same manner
o difficulty understanding (receiving) and
 this may happen when a baby has
multiple caregivers or frequent determining the meaning of words and
changes in caregivers. Children with sentences, Causes of Mixed receptive-
this type of reactive attachment expressive language disorder
disorder may frequently ask for help o a. Developmental – the disorder can be
doing tasks, have inappropriately present at birth
childish behavior or appear anxious. o b. Acquired – neurologic injury
STEREOTYPE MOVEMENT DISORDERS
PHONOLOGIC DISORDER
 Characterized by repetitive motor behavior o - characterized by problem in
that is non-functional and interferes with articulation
normal activities or results in self-injury STUTTERING
requiring medical treatment o - characterized by disturbance of the
 Often accompanies mental retardation normal fluency and time patterning of
 Stereotypic movements may include: speech
o Rocking o - mgt: speech therapy
o biting oneself
o Twirling objects/self MENTAL RETARDATION
o Biting fingernails
o Hand waving
Characterized by significant sub-average intellectual  Cognitive abilities include reasoning,
functioning (IQ) less than 70 judgment, perception, attention,
comprehension, and memory.
Significant limitations in two or more adaptive skill
areas such as: COGNITIVE DISORDER
A. Communication skills  Is a disruption or impairment in the higher level
B. Self care functions of the brain.
C. Academic functions  Cognitive disorders can have devastating
D. Social skills effects on the ability to functions in daily life.
E. Community functions  They can cause people to forget the names of
F. Self direction immediate family members, to be unable to
G. Health and safety perform daily household tasks and to neglect
H. ADL personal hygiene.
ETIOLOGY TYPES:
 A. Delirium
1. Genetic factors - Ex: Chromosomal  B. Dementia
abnormalities: increased/decreased  C. Amnestic Disorder
2. Acquired factors
A. Prenatal factors: DELIRIUM
 Infections  Is characterized by a disturbance of
 Radiation consciousness and a change in cognition that
 Toxins develops rapidly over a short period
 Drugs  Is usually begins abruptly following head
 Unknown cause trauma or a seizure; however, the onset may
B. Perinatal factors be slower if the etiology is metabolic. Duration
 Premature is usually brief and subsides upon recovery
 Anoxia condition.
 Brain damage
 infection DIAGNOSTIC CRITERIA
C. Postnatal factor
 Childhood diseases 1. Speech that is rambling, irrelevant, pressured,
 Accident and Incoherent.
 Hormonal problems 2. Impaired reasoning and goal-directed behavior.
 Infections 3. Disorientation of time and place.
 Anoxia 4. Extreme distractibility
 Environmental factors Anoxia 5. Psychomotor activity that fluctuates between
 Poisoning agitation and vegetative state,
 Birth defects such as cerebral 6. Interruption of sleep-wake cycle
palsy, deafness, blindness, etc. 7. Emotional instability or problems (fears, anxiety,
Environmental factors irritability)
 Anoxia 8. Sensory disturbances such as illusions,
 Poisoning misinterpretations, or hallucinations.
 Birth defects such as cerebral palsy,
deafness, blindness, etc. RISK FACTORS
CATEGORI OTHER IQ
ES NAME 1. MEDICAL CONDITION
Mild Moron 50-70 Educable  Delirium may be due to a general
Moderate Imbecile 35-50 Trainable medical condition such as systematic
Severe Idiot 20-35 Needs close infection, metabolic disorder, fluid and
supervision electrolyte imbalance, hepatic or renal
Profound Below 20 Needs disease, etc.
custodial 2. SUBSTANCE INDUCED
care  Symptoms may be attributed to side
effects of medication or drug abuse
Principles of Nursing care
Repetition 3. SUBSTANCE INTOXICATION
Role Modeling  Symptoms may occur following high
Restructuring doses of cannabis, cocaine,
hallucinogens, alcohol, anxiolytics, or
☺☺☺ narcotics.
4. SUBSTANCE WITHDRAWAL may occur after the
COGNITIVE DISORDER reduction or termination of a substance.
5) Delirium is a common post-anesthesia event
COGNITION
 Cognition is the brain’s ability to process, NURSING DIAGOSIS AND INTERVENTIONS
retain, and use information.
A. Risk for injury
- Promote client’s safety
  Client will return to previous levels of
1. Teach client to request assistance for activities functioning
(getting out of bed, going to the bathroom)  Client and caregivers or family must
understand health care practices to avoid
2. Provide close supervision to ensure safety during recurrence
performance of ADL  Ex: Monitor chronic health condition, use
medications carefully, or abstain from alcohol
3. Respond promptly to client’s call for assistance or other drugs.

B. Acute confusion TREATMENT

C. Disturbed sensory perception The primary treatment for delirium is to identify and to
treat any casual or contributing medical conditions
D. Disturbed thought processes 1. Antipsychotic drug
 Manage client’s confusion, disturbed  Haloperidol (Haldol) 0.5-1 mg to
thought process and misconceptions decrease agitation
 Sedatives and benzodiazepines should
1. Approach client calmly and speak in a clear low be avoided because they may worsen
voice and use simple words delirium

2. Allow adequate time for client to comprehend DEMENTIA

and respond Dementia is a mental disorder that involves multiple
cognitive deficits, primarily memory impairment and at
3. Allow client to make decision when able least one of the following cognitive disturbances:
 Aphasia- deterioration of language fxn
4. Provide orienting cues when talking to client  Apraxia- impaired motor fxn
such as calling client by name, placing calendar  Agnosia- inability to recognize
and clock in the client’s room, introducing self  Disturbance in executive functioning –
when talking inability to think abstractly

5. Use supportive touch if appropriate DIAGNOSTIC CRITERIA

6. Reduce environmental stimulation such as  Impairment of abstract thinking judgment

noises, tv, radio, visitors, etc. to reduce client’s and impulsive control
confusion  Disregard for rules of social conduct
 Neglect or personal appearance and hygiene
7. Provide well lighted environment to minimize  Altered language pattern
environmental misperceptions (illusions)  Personality change

E. Disturbed sleep pattern TYPES OF DEMENTIA

F. Risk for deficient fluid volume 1. Dementia of the Alzheimer’s type - insidious
and progressive deterioration in function due to
G. Risk for imbalanced nutrition: less than body neurotransmitter deficiency
requirement
 Promote sleep, proper nutrition, hydration 2. Vascular dementia - due to significant
and elimination, and activities cerebrovascular disease, caused by multiple
infracts in the cortex.
1. Monitor sleep pattern.
 Discourage daytime napping to help 3. Dementia due to HIV - related to brain
sleep at night infections with a range of symptoms from acute
delirium to profound dementia.
2. Monitor elimination pattern.
 Provide periodic assistance to 4. Dementia due to head trauma - Intellectual
bathroom if client does not make and memory difficulties due to post-trauma.
requests
5. Dementia due to Parkinson's disease
3. Monitor fluid and food intake. caused by a loss of nerve cells and decreased in
 Provide prompts assistance to eat and dopamine activity
drink adequate amounts of food and
fluids 6. Dementia due to Huntington’s disease -
damage from disease occurs in the areas of the
4. Encourage some exercise during day like sitting, basal ganglia and cerebral cortex. A profound state
walking in hall, or other activities client can of dementia and ataxia occurs within 5-10 years
manage onset.

EVALUATION 7. Dementia due to Pick’s disease - atrophy in

the frontal and temporal lobes of the brain.
 8. Dementia due to general medical disease: B. Disturbed sleep pattern
 Endocrine disorders
 Pulmonary disease C. Risk for deficient fluid volume
 Hepatic or renal failure
 Cardiopulmonary insufficiency D. Risk for imbalance nutrition: less than body
 Fluid and electrolyte imbalances requirements
-Promote adequate sleep, proper nutrition,
9. Substance-induced dementia- dementia hydration, elimination and hygiene , and activity
related to the persistent use of:
 Alcohol 1. Daily physical activity helps client to sleep at
 Inhalants night
 Sedatives, hypnotics and anxiolytics
Medication such as anticonvulsants. Toxin such as 2. Monitor food and fluid intake, bowel elimination
lead, mercury, carbon monoxide, insecticides, and patterns
industrial solvents.
3. Prepare desirable foods and foods client can
STAGES OF DEMENTIA self-feed; include fiber foods; sit with client while
eating
STAGE I (Mild) (FOLD)
last 2 – 4 years 4. Remind client to urinate; provide pads or diapers
 F – forgetfulness as needed; checking and changing them frequently
 O – occupational & social setting is less to avoid infection
enjoyable
 L – Losses objects frequently 5. Encourage mild physical activities such as
 D – difficulty finding words walking

STAGE II (Moderate) (COPRA) - may last several E. Ineffective role performance

years
 C – confusion is apparent F. Impaired social interaction
 O – oriented to person, time & place
 P – progressive memory loss G. Impaired verbal communication
 R – requires assistance to perform tasks
because the client losses ability to H. Impaired memory
live independently 1. Provide structured environment and routine
 A – ability to recall information is loss  Provide familiar surrounding and
(address, numbers) routine to help eliminate confusion

STAGE III (Severe) - nursing home care or 2. Provide emotional support

hospital facility  show acceptance, be kind and
 P – Personality changes respectful
-anger, irritability, loss of inhibitions,  convey reassurance by approaching
hypersexualities, vulgarities client in a calm and supportive manner
 O– obvious loss of memory as manifested by
aphasia, anomia, agnosia, etc  use supportive touch when
 W – wanders at night and difficulty to go appropriate and frustration from
back home (get lost) due to memory loss and memory loss
confusion
 E – Even name of spouse and children can’t
recall 3. Promote interaction and involvement
 R – requires assistance for ADL  Plan activities according to client’s
interest and abilities
NURSING DIAGOSIS AND INTERVENTIONS  Reminisce with client about the past
 If client is nonverbal, remain alert to
A. Risk for injury - Promote client’s safety nonverbal cues
 Employ techniques of distraction, time
1. Protect client against injury, meet physiologic away, going along and reframing to
needs and manage risk posed by the environment calm clients who are agitated,
because they can’t exercise normal caution in daily suspicious or confused
life.
 DISTRACTION – re-channeling client’s attention
2. Avoid environmental triggers such as strangers, and energy to a more neutral topic.
or changes in daily routine to prevent anxiety and
suspicion which may lead to agitation or erratic  TIME AWAY – involves leaving the client for a
behavior that compromise safety short period and then returning to them to re-
engage in interaction
3. Offer self and support in performance of ADL and
preserve client’s dignity
  GOING ALONG – means providing emotional memory term memory
reassurance to clients without correcting their impaired impaired, eventually
misperception or delusion destroyed
 Ex: “There’s no need to worry; the Speech May be slurred, Normal in early
children are just fine” rambling, stage, progressive
pressured, aphasia in later
 REFRAMING - offering explanations for events irrelevant stage
or situations Thought Temporarily Impaired thinking,
Ex: “The lady has many problems, and she processes disorganized eventually loss of
yells sometimes because she’s frustrated thinking abilities
Mood Anxious, Depressed and
TREATMENT fearful if anxious in early
1. Identify underlying cause and treat hallucinating; stage, labile mood,
 Ex: Vascular dementia – change diet, irritable; angry outburst in
exercise, control of hypertension or weeping later stage
diabetes
2. PSYCHOPHARMACOLOGY AMNESTIC DISORDER
a. Antidepressants – for depressive Symptoms
Amnestic disorder is a cognitive disorder characterized
b. Antipsychotics – to manage Sx of by disturbance in memory due to general medical
hallucinations, delusion & paranoia conditions’ physiological and substance effects
 HALOPERIDOL (Haldol)
 OLANZAPINE (Zyprexia) SIGNS AND SYMPTOMS
 RISPERIDONE (Risperdal)
 QUETIAPINE (Seroquel) C - Confusions
A – Attention deficit
c. Mood stabilizer to stabilize affective lability M – Memory deficit
and to diminish aggressive outburst Ex: Korsakoff Syndrome – alcohol induced
amnestic disorder that results from a
 LITHIUM CARBONATE chronic thiamine or Vit. B deficiency
 VALPROIC ACID (Depakote)
 CARBAMAZEPINE (Tegretol) ALZHEIMER’S DISEASE
 Alzheimer's disease is the most prevalent form
d. CHOLINESTIRASE INHIBITOR – to slow the of dementia characterized by memory loss,
progression of dementia deficit in thought processes, and behavioral
 ARICEPT (Donepezil) changes.
 5 -10 mg orally/day  The onset is insidious and course of disease
 monitor for nausea, diarrhea and progressive.
insomnia  Physiological studies indicate pathological
 Test stool periodically for GI bleeding degeneration of cholinergic neurons and
biochemical deficiency in the neurotransmitter
 COGNEX (Tacrine) system.
 40-160 mg orally/day divided into 4
doses RISK FACTORS
 monitor liver enymes for hepatotoxic
effects  Advanced age: one in twenty-six at age 65, two
 monitor for flu-like symptom out of five after age 85
 Female
 EXELON (Rivastigmine)  Head trauma
 3 – 12 mg orally/day divided into 2  Family history of Alzheimer's and/or Down's
doses Syndrome
 monitor for nausea, vomiting,
abdominal pain and loss of appetite DIAGNOSTIC CRITERIA

 REMINYL (Galantamine)  Stage 1: lasts 1-3 years

 16-32 mg orally/day divided into 2 a. Short-term memory loss
doses b. Decreased attention span
 monitor for nausea, vomiting, loss of c. Subtle personality changes
appetite, dizziness and syncope d. Mild cognitive deficits
e. Difficulty with depth perception
INDICATOR DELIRIUM DEMENTIA
ONSET Rapid Gradual or Insidious  Stage 2: lasts 2-10 years
Duration Brief (hours to Progressive a. Obvious memory loss
days) deterioration b. Confusion
Level of Impaired, Not affected c. Wandering behavior
consciousne fluctuates d. "Sundowning": behavior changes as sun
ss goes down, more confused
Memory Short term Short then long-
  Stage 3: lasts 5-15 years ◦ Making threats refusing to speak to
a. Increasing loss of expressive language
b. Loss of ability to care for self in ADLs ◦ ignoring the victim
c. Becomes more withdrawn
d. Loss of reasoning ability Economic Abuse
 Financial deprivation
 Stage 4: lasts 8-10+ years
a. Absent cognitive abilities Sexual Abuse
B. Disoriented to time and place  Marital rape
c. Absent communication skills  Sadism
d. Impaired or absent motor skills,  Incest
e. Bower and bladder, incontinence
f. Does not recognize family members or Victims of Abuse
self in mirror  1. Child
 2. Spouse
FACTS TO REMEMBER  3. Elder

 The client in the later stages of the disease will Characteristics of Violent Families
probably require long-term, protective care and 1.SOCIAL ISOLATION
assistance with ADI-s and other activities.  Members of violent family usually do not
 Families or caregivers also require support invite others into their home so that others
during this time. will not know the abuse.

☺☺☺ 2.ABUSE OF POWER AND CONTROL
 The abusive member almost always holds a
ABUSE AND VIOLENCE position of power and control over the
victim.
Abuse  The abuser is often the only family member
 Wrongful act against others by inflicting who makes decision, spends money, or
physical injury, and causing mental spends time outside the home with other
anguish /torture. people

Violence 3. ALCOHOL and OTHER DRUG ABUSE

 Unjust exercise of power, often resulting to  Substance abuse, specially alcoholism, has
physical injury and/or damaging properties been associated with family violence 50% –
90% of men who batter their domestic
Types of Violence partners have a history of substance abuse
1. Family or Domestic Violence
2. Community Violence 4.INTERGENERATIONAL TRANSMISSION PROCESS
 This means that patterns of violence are
Family/ Domestic Violence perpetuated from one generation to the
 It is a pattern of coercive behavior by a next through role modeling and social
member of the family, usually those who hold learning
position of power, to other member of the
family.
 This includes: Community Violence
◦ Physical abuse  refers to a wide range of events resulting to
◦ Psychological Abuse physical injury and damage to property. This
◦ Economic Abuse includes:
◦ Sexual Abuse ◦ riots
◦ gang wars
Physical Abuse ◦ war
 Inflictions of physical pain ◦ terrorist attacks,
◦ battering ◦ torture
◦ chocking ◦ bombing
◦ punching  usually happens without warning and
◦ homicidal comes as a sudden and terrifying events
◦ burning and can permanently destroy entire
◦ Restraining neighborhood
◦ hanging  may be intentional
◦ slapping
TYPES OF COMMUNITY VIOLENCE
Psychological Abuse
◦ name calling 1. Crime related events:
◦ belittling ◦ -rape - assault - homicide
◦ Screaming/yelling/shouting - murder
◦ Threatening 2. Exposure to community violence of children and
◦ destroying property adolescence:
 ◦ school shooting
◦ witnessing murder Indicators of Child Abuse
◦ living in a war zone -May withdraw from physical contact with adults
3. Interpersonal conflict – violent altercation -Head injuries (skull and facial fractures
between or among acquaintances -Bruises and welts in shapes of objects
-Child may protect abuser for fear of punishment
TYPES OF DOMESTIC VIOLENCE -Burns in different parts of the body
-Human bites
A. Child Abuse -Rope, burns from being tied
-Little eye contact with adults
 Intentional injury of a child by adults which -Inappropriate response to pain
includes: -Fractures in different stages of healing
◦ Ex: Physical abuse , Emotional abuse, -Internal injuries
Sexual abuse, Neglect
 Report suspected cases to authorities (R.A. Characteristics of Abusive Parents
7610 – anti-child abuse law)  Came from violent family
 Report cases to the barangay officers, DSWD  Have inadequate parenting skills
personnel, police within 24 hours  Have negative attitude towards the
management of the abused
PHYSICAL ABUSE – inflictions of physical pain  Are socially isolated
which includes:  Are emotionally immature
◦ Hitting an infant for crying or soiling his/her  also a victim of child abused
diaper
◦ Scalding with hot water B. Spouse Abuse
◦ Burning is maltreatment of one person by another in the
context of an intimate relationship:
◦ Biting
◦ Cutting -Husband and wife -Live-in partner
◦ Twisting limbs -Boyfriend and girlfriend -Same sex relationship

Emotional Abuse Cycle Spouse Abuse

 Verbal assaults such as blaming, screaming,
name calling and using sarcasm 1. TENSION-BUILDING PHASE
 Constant family discord/conflict - characterized by the onset and the beginning
 Emotional deprivation or withholding of of minor arguments, stony silence and repetitive
affection, nurturing and normal experiences complains of the husband
(acceptance, love, security and self-worth) - involves minor form of battering
 Exposure to parental alcoholism, drug use or
prostitution 2. ACUTE BATTERING INCIDENT
- characterized by intense violence inflictions of
Sexual Abuse physical injury, verbal demoralization and
 Involves sexual acts performed by an adult on threatening of the partner
a child younger than 18 years. - involves more serious forms of battering
 Incest 3. HONEYMOON STAGE
 Rape - characterized by the husband expressing
 Sodomy remorse and promises that the battering incident
 Molestation will no longer happen, becomes loving, and gives
 Exploitation such as making, promoting, or the wife hope that he will change
selling
 Pornography Characteristics of Abusive Husband
 Major characteristic: LOW SELF-ESTEEM
Neglect ◦ Has strong feeling of inadequacy
 Absent or lack of provision of things necessary ◦ Narcissistic
for the child’s growth and development ◦ Very controlling
◦ Irrational jealousy
A. Physical neglect: failure to provide ◦ Possessive (think that his wife is his
medical, dental or psychiatric care needed possession)
to prevent or threat physical or emotional ◦ Usually come from violent families
illness. ◦ Abused drugs and alcohol

B. Developmental neglect: failure to Characteristics of Abused Wife

provide emotional nurturing and cognitive  Most common characteristic: DEPENDENCY
stimulation needed to ensure freedom from  Low self-esteem (perceives herself as unable to
developmental deficits function without her husband)
 Feeling of inadequacy, accepting self-blame
C. Educational neglect: failure to provide  Fears leaving due to threats
education in accordance with the state’s  Feeling of powerlessness
education law -
  Depression and suicidal thoughts  Identify supportive people to assist in dealing
 Anxiety and recurrent nightmares with the crisis
 May result to alcohol or drug abuse  Involved client in mobilizing support systems
 Support decision making and active problem
C. Elderly Abuse solving
 It is the maltreatment of older adults, by the  Provide written information about community
family members or caretakers services and encourage to avail their services
 Victims are usually 75 years old and above,  Plan for follow-up care
and those who are debilitated.
 Elder-abused victims are often reluctant to RELATED DISORDERS OF VIOLENCE AND ABUSE
report abuse to protect the abuser which is
usually a family member and because of fear 1. Acute stress disorders
losing his/her support 2. Post-traumatic disorders
3. Dissociative disorders
Indicators of Elder Abuse
☺☺☺
1. PHYSICAL ABUSE
◦ Frequent unexplained injuries ANGER, HOSTILITY AND AGGRESSION
◦ Reluctance to seek medical treatment
◦ Disorientation ANGER
◦ Fear presence of family member or  Anger a normal emotional response when a
caregiver person is frustrated, hurt, afraid, threatened or
provoked.
2. PSYCHOLOGICAL/EMOTIONAL ABUSE  Anger can be a normal and healthy reaction
◦ Helplessness when situations or circumstances are unjust or
◦ Anger/agitation unfair, personal rights are not respected or
◦ Hesitance to talk openly realistic expectations are not met
◦ Withdrawal
◦ Depression RESPONSES TO ANGER
 1. POSITVE RESPONSE
3. FINANCIAL ABUSE  When anger is handled appropriately and
◦ Signatures on check that differ from the expressed assertively, it can be a (+) force that
elder helps a person to:
◦ Change in will or power of attorney  Resolve conflicts
◦ Missing valuables  Solve a problem
◦ Unusual concern by the caregiver over the  Make decisions
expense of the elder’s treatment and
expenses  2. NEGATIVE RESPONSE
 Anger becomes negative when the
4. NEGLECT person denies it, suppresses it, or
◦ Malnourished/ dehydrated expresses it inappropriately
◦ Poor environmental ventilation, lighting,  when anger is expressed
sanitation inappropriately or suppressed, it can
◦ Inadequate clothing cause:
 Emotional problem
◦ Poor personal hygiene  Physical problem
low self-esteem depression
5. SELF-NEGLECT headache stress ulcers
◦ Inability to manage ADL such as personal palpitations coronary artery
care, shopping, housework disease
◦ Lack of toilet facilities
NURSING INTERVENTIONS OF ANGER
◦ Unpaid personal finances and bills
◦ Failure to keep needed medical 1. Be a role model in expressing anger
appointments appropriately
◦ Living quarters infested with
animals/vermin 2. Encourage client to use assertive
communication (“I” statement)
NURSING INTERVENTIONS FOR VICTIMS OF Ex: “I feel angry when you interrupt me”
ABUSE
3. Role playing assertive communication technique
 Encourage expressions of feelings related to
the abuse 4. Provide activities that are not aggressive such as
 Allow client to discuss feelings and concerns walking or talking with another person
 Maintain confidentiality of information. Assure
client. 5. Encourage women to express their anger instead
 Offer self in seeking medical care for physical of suppressing them (anger suppression). This may
problem related to abuse
 result to somatic complaints and psychological B. ESCALATION
problems
 Client’s angry behavior escalates leading
RELATED DISORDERS WITH AGRESSION AND HOSTILITY toward loss of control
 Physiologic changes: pale or flushed face,
1. Paranoid delusion agitated
2. Auditory hallucination  Verbal aggression: yelling, swearing,
3. Dementia threatening, demanding
4. Delirium  Cognitive changes:
5. Intoxication with alcohol or other substances > inability to solve problem
6. Borderline personality > inability to think abstractly
7. Antisocial personality NURSING INTERVENTION
8. ADHD
1. Provide directions to the client in a calm, firm
HOSTILITY voice

 Hostility is also called verbal aggression 2. Instruct client to take time-out for cooling off in a
 It is an emotion expressed through: quiet area or in his/her room
 Verbal abuse
 Threatening behavior 3. Inform client that aggressive behavior is
 Lack cooperation unacceptable and that the nurse is there to help
 Violation of rules or norm client regain control
 Hostile behavior is intended to cause emotional
harm to other and it can lead to PHYSICAL 4. The nurse should obtain assistance from other
AGGRESSION staff members (initially 4-6) if client’s behavior
continues to escalate and should ready within sight
PHYSICAL AGGRESSION but not as close as the primary nurse (show of
force)
 Physical aggression is a behavior in which a
person attacks or injures another person and C. CRISIS
destructs properties
 Client loses physical and emotional control
STAGES OF HOSTILITY AND AGGRESSION  Verbal abuse
1. Triggering  Physical aggression
2. Escalation > throwing objects > kicking
3. Crisis > hitting > scratching
4. Recovery > biting
5. Postcrisis  Impaired judgment

A. TRIGGERING – when an events or NURSING INTERVENTION

circumstances initiates client to hostile or angry
response  Restrain and seclude client.
 R – Restlessness and irritability
 A – Anxiety or anger  Inform client that his/her behavior is out of
 M – Muscle tension, perspiration and control and that the staff is taking control to
rapid breathing provide safety and prevent injury
 P – Pacing
 Administer PRN medication if not taken earlier
NURSING INTERVENTION
1. Approach client in a non-threatening, calm  Perform close assessment of the client in
manner seclusion or restraint and documents the
actions
2. Convey empathy for the client’s anger or
frustration D. RECOVERY

3. Client express his/her angry feelings verbally,  Client regain physical and emotional control
suggesting that the client is in control and can  Lowering of voice
maintain that control  Decreased muscle tension
 Clearer, more rational communication
5. Use relaxation techniques  Physical relaxation

6. Resolve conflicts or problems that may exist NURSING INTERVENTION

7. Suggest client to retreat to a quiet place to 1. Encourage client to talk about the situation that
decrease stimulation triggered to aggressive behavior

8. Offering PRN medication 2. Help client to relax, perhaps sleep, and return to
a calmer state
  in making a smooth transition to
3. Help client explore alternatives to aggressive maintenance therapy with oral
behavior to avoid another aggressive episode Olanzapine

4. Assess staff members for any injuries and ☺☺☺

complete incident reports and flow sheets
SUBSTANCE RELATED DISORDER
5. Encourage other clients to talk about their
feelings regarding the incident  Substance use or abuse and related disorders
are a national health problem.
E. POSTCRISIS  It is estimated that over 15 million people in
the Philippines are dependent on alcohol and
 client attempts reconciliation with others and other drugs and 500,000 are between the ages
returns to the level of functioning before the of 9 and 12 years.
aggressive incident and its antecedents  However the actual prevalence of substance
 remorse abuse is difficult to determine precisely
 apologizes because many people meeting the criteria for
 crying diagnosis do not seek treatment.
 quiet
 withdrawn behavior List of commonly abused substance

NURSING INTERVENTION Hallucinogens

 Remove client from restraint or seclusion as  LSD
soon as client meets the behavioral criteria  Mescaline
 Discuss with client the behavior in a calm  Psilocybin
rational manner. Avoid being judgmental and
advising Opiods & Morphine Derivatives
 Resume client’s activities as soon as he/she  Codeine
can participate in milieu therapy  Fentanyl
 Heroin
TREATMENT  Morphine
 Opium
 Treatment for aggressive clients often focuses  Demerol
or treating the underlying or co-morbid
psychiatric diagnosis Stimulants
 LITHIUM  Amphetamines
 Effective in treating aggressive clients with  Cocaine
bipolar disorder, conduct disorder and mental  Ecstasy
retardation  Methamphetamine
 TEGRETOL (CARBAMAZEPINE)  Methylphenidate
 DEPAKOTE (VALPROATE)  Nicotine
 Use to treat aggression associated with
dementia, psychosis and personality disorders Cannabis
 RISPERDAL (RISPERIDONE)  Harshish
 ZYPREXA(OLANZAPINE)  Marijuana
 CLOZARIL (CLOZAPINE)
Depressants
 Use to treat aggression associated with  Barbiturates
dementia, brain injury, mental retardation and  Benzodiazepines
personality disorders  Flunitrazepam
 BEZODIAZEPINE  GHB
 To reduce irritability and agitation in older
adults with dementia but they can result in the Dissociative Anesthetics
loss of social inhibitions for other aggressive  Ketamine
clients thereby increasing rather than  PCP
decreasing their aggression
 HALDOL (HALOPERIDOL) Other Compounds
 ATIVAN (LORAZEPAM)  Anabolic Steroids
 Use in combination to decrease  Inhalants
agitation/aggression and psychotic symptoms
 VERZED (MIDAZOLAM) DSM –IV SUBSTANCE RELATED DISORDERS

 NOTE: When Olanzapine (Zyprexa) is given by A. Substance Intoxication

IM, it is effective in: B. Substance Abuse
 decreasing agitation C. Substance Dependence
 providing rapid tranquilization D. Substance Withdrawal

Substance Intoxication
  Recurrent use in situations that are
 The direct effect of substance after an physically hazardous
individual has used or has been exposed to the  Recurrent substance related legal
substance. problems
 Different substances affect individual in various  Continued use despite feeling
ways, but some of the effects seen in persistent or recurrent effects of the
intoxication might include substance
 Impaired judgement 1. Alcohol abuse
 Emotional instability 2. Amphetamine abuse
 Increase or decrease in appetite 3. Cannabis abuse
 Changed sleep pattern 4. Cocaine abuse
5. Hallucinogen abuse
Diagnostic Criteria 6. Inhalant abuse
 Symptoms never met criteria for substance 7. Opioid abuse
dependence. 8. Phencyclidine abuse
 Reversible substance-specific syndrome due to 9. Sedative, hypnotic, or anxiolytic abuse
the recent ingestion or exposure to a
substance Substance Dependence
 Clinically significant maladaptive behavioral or
psychological changes due to effect of When an individual persist in use of alcohol or other
substance on central nervous system, drugs despite problems related to use of the
developing during or shortly after use of substance.
substance
 Symptoms not due to general medical Diagnostic Criteria
condition, nor better accounted for by another
mental disorder  Maladaptive pattern of substance use leading
to clinically significant impairment or distress
1. Alcohol intoxication  Impairment manifested by three or more of the
2. Alcohol intoxication delirium following:
3. Amphetamine intoxication  tolerance
4. Amphetamine intoxication delirium  withdrawal
5. Caffeine intoxication  substance often taken in large amounts
6. Cannabis intoxication or over a longer period than was
7. Cannabis intoxication delirium intended
8. Cocaine intoxication  persistent desire or unsuccessful
9. Cocaine intoxication delirium efforts to cut down or control use
10. Hallucinogen intoxication  much time spent in activities necessary to
11. Hallucinogen intoxication delirium obtain the substance or use it
12. Opioid intoxication  reduction or cessation of important social,
13. Opioid intoxication delirium occupational, or recreational activities
14. Inhalant intoxication  use continued despite knowledge of having
15. Inhalant intoxication delirium persistent or recurrent physical or
16. Phencyclidine intoxication delirium psychological problem likely to have been
17. Sedative, hypnotic, or anxiolytic intoxication caused or exacerbated by the substance

Substance Abuse 1. Alcohol dependence

 Is the use of chemicals or material for non- 2. Amphetamine dependence
medical purposes with the intention of 3. Cannabis dependence
producing an altered state of consciousness 4. Cocaine dependence
sensorium, heightened sensory perception, or 5. Hallucinogen dependence
change in self-image. 6. Inhalant dependence
 It is manifested by: 7. Nicotine dependence
 repeated use of the substance and/or 8. Opioid dependence
 cognitive, behavioral, and 9. Phencyclidine dependence
psychological symptoms of 10. Sedative, hypnotic, or anxiolytic dependence
intoxication, withdrawal, anxiety and 11. Polysubstance dependence
delirium.
SUBSTANCE WITHDRAWAL
Diagnostic criteria Diagnostic Criteria

 Maladaptive pattern of substance use  Development of substance-specific syndrome

leading to clinically significant impairment or due to cessation or reduction in substance use,
distress previously heavy and prolonged
 Impairment manifested by three or more of the  Syndrome causing significant distress or
following occurring within a 12-month period: impairment in social, occupational, or other
 Recurrent use, resulting in failure to important areas of functioning
fulfill major role obligations at work,
school, or home 1. Alcohol withdrawal
2. Amphetamine withdrawal the most successful
3. Cocaine withdrawal methods of treatment.
4. Opioid withdrawal
5. Sedative, hypnotic, or anxiolytic withdrawal 2. PSYCHOLOGICAL TREATMENT
 a. Group therapy : Substance abusers
Substance-induced disorder are forced to confront their usage and
 Mood and anxiety disorders recognize the serious consequences
 Amnesia and psychosis that their use has on their body system
 Intoxication and withdrawal family and friends.
 Delirium and dementia  b. Behavioral therapy includes
 Sexual dysfunction and sleep disorders avoidance of the abused substance.
 Stress management and
Risk factors behavioral modification using
1. BIOLOGIC FACTORS positive and negative
 a. Genetics: Heredity factors play a role reinforcement are commonly
especially in alcohol abuse employed techniques
 b. Biochemical.- Alcohol may produce morphine  c. Counseling:
like substances in the brain leading to alcohol The goal of counseling or individual
addiction. therapy is to alleviate or reduce a
client's aversive life situation and to
2. PSYCHOLOGICAL FACTORS assist the client in putting the pieces of
 a. Development influence: Certain personality his/her life back together.
traits have been suggested to play a part In  Regression or relapse is a
both the development and maintenance of frequent problem because
dependence. often the underlying problem is
 They include impulsivity negative not resolved.
self-concept, weak ego, social 3. SOCIAL TREATMENT
conformity issues, and  Support group: The goal of this type of
introversion. social treatment is to decrease co-
dependent behavior and reinforce
3. SOCIOCULTURAL FACTORS appropriate behavior for the client and
 A. Social learning- Children is more likely to use family-
substances if their parents do so, modeling  Clients attend support groups
their behavior. Peer pressure also promotes such as Alcoholic Anonymous
substance abuse (AA) or Narcotics Anonymous
 b. Conditioning: Pleasurable effects from (NA) and family members may
substance use act as a positive reinforcement participate in the A1- Anon
for their continued use. group.
 c. Culture in ethnic influences: Some ethnic  These are other support groups
groups are more susceptible to substance available in many communities.
abuse, due to cultural acceptance. Members of these groups are
asked to share their
4. MENTAL ILLNESS: Clients with certain mental experiences as I give support
illnesses (e.g- bipolar disorder, schizopherenia) are without advice/ judgment to
vulnerable to substance abuse. other members during times of
crisis or relapse.
NURSING DIAGNOSIS COMMON IN CLIENT WITH
SUBSTANCE RELATED DISORDERS 4. PSYCHOPHARMACOLOGIC TREATMENT:
 Many approaches to substance abuse
1. Powerlessness treatment do not recommend the use
2. Risk to self or others of any drugs, even if prescribed. There
3. Altered thought processes are times, however, when they are
4. Anxiety prescribed.
5. Ineffective denial a. Benzodiazepine agents to manage
6. Ineffective individual coping withdrawal symptoms.
7. Spiritual distress
8. Disturbances in self-esteem b. Multivitamins, folic acid thiamine and
9. Altered role performance narcotic antagonist agents.
10. Ineffective family coping
c. Narcan for acute narcotic depression.
Therapeutic Nursing Interventions
d. Disulfiram is used to discourage impulsive
1. ENVIRONMENT TREATMENT (Milieu Therapy) alcohol use.
 Some clients may seek an inpatient  While taking antabuse client should not
treatment program for substance ingest substance containing alcohol
abuse and dependence. including cough syrup, fruitcake, or
 These are highly structured, cooking wine or they will feel very ill.
intensive programs which often
 e. If the symptoms of narcotic withdrawal are
severe: Moderate
 methadone hydrochloride
(Dolophine) is used to achieve  B. BAL 0.2% - 0.3% - Moderate (BAIT)
narcotic abstinence.  B – Blackouts
 Treatment is usually 10-40 mg.  A – Ataxia
in a single daily dose-  I – Impaired memory (confabulation)
 Restricted use of methadone  T – Tremors
during pregnancy and lactation
is key consideration. Severe
 C. BAL 0.3% and above – Severe (CAReS)
f. Anxiolytic agents such as:  C – Coma
 Chlordiazepoxide (Librium) are the  A – altered level of consciousness
drugs of choice for alcohol withdrawal.  Re – Respiratory depression
 S – Stupor
g. Anticonvulsant drugs, particularly:
 Phenytoin (Dilantin) or PHASES OF PROGRESSION OF ALCOHOLISM
Phenobarbital (Luminal) are given
for alcohol and sedative-hypnotic drug 1. PRE-ALCOHOLIC PHASE
withdrawal seizures.  starts with social drinking until
tolerance begins to develop
Therapeutic Nursing interventions 2. PRODROMAL PHASE
 B - blackout occurs
 Conduct a comprehensive health history with  A - alcohol becomes a need
physical assessment.  D - denial begins to develop
 Monitor vital signs during the withdrawal 3. CRUCIAL PHASE
period.  cardinal signs of alcoholism develops
 For example in the client with alcohol  loss of control over drinking
withdrawal monitor blood pressure 4. CHRONIC PHASE
every two hours for the first 12 hours,  the person becomes intoxicated all day
then every four hours for the next 24 to prevent symptoms of withdrawal
hours, followed by every six hours
unless it is unstable. EFFECTS OF ALCOHOL USE
 Early signs of withdrawal are anxiety,
anorexia, tremors and insomnia and may A. IMMEDIATE EFFECTS
begin up to eight hours after last intake
of alcohol.  ACUTE INTOXICATION (HILUS)
 Protect the clients from injury  H - high dose may cause stupor
 Assess for seizure and hallucination approach or coma
client calmly, Using soft voice keep light dim,  I - impaired attention and
allow a family member or friend stay with the memory
client. Reduce environmental stimulation and  L - lack of motor coordination
noise,  U - unsteady gait
 Assist the client with new learning problem  S - slurred speech
solving methods.
 Educate the client about stress reduction
techniques and alternative coping B. CHRONIC EFFECTS
mechanisms. 1. Gastrointestinal effects
 gastritis
Alcoholism  pancreatitis
 cirrhosis
 Chronic disorder characterized by excessive  Ascites
alcohol intake and interferes in the individual’s  esophagitis
health, economic and interpersonal  hepatitis
relationships.
 - first episode of intoxication is between 12 and 2. CNS EFFECTS
17 years of age  a. WERNICKE’S SYNDROME
 acute confusional state char by:
Levels of intoxication  P - peripheral neuropathy
 A - ataxia
Can be determined by blood alcohol level  D - delirium due to thiamine deficiency
 b. KORSAKOFF’ SYNDROME
Mild intoxication  chronic cognitive impairment characterized by
 A. BAL 0.1% – 0.2% - Mild Intoxication (SLUM) cerebral atrophy and memory loss related to
 S – Slurred speech and talkativeness Vit. B deficiencies
 L – Loss of inhibition
 U – Unsteady gait 3. Cardiovascular problems
 M - Motor incoordination  Examples:
  anemia  prevent or treat nutritional deficiencies
 alcoholic cardiac myopathy  4. Benzodiazepine – 50-100 mg repeat in 2-4
 thrombocytopenia hrs if necessary but should not exceed 300
mg/day
4. Reproductive problems  suppress the symptoms of abstinence
 Fetal Alcohol Syndrome in infants of alcoholic  V - Valium (Diazepam)
other  A - Ativan (Lorazepam)
 C – cardiac and genital abnormalities  L - Librium (Chlordiazepoxide)
 L – low birth weight  5. Naltrexone (Revia, Trexan)
 A – abnormal facial features  Use to reduce alcohol craving > 50
 M – microcephaly/ mental retardation mg / day for 12 weeks
 P – problems in vision, and hearing  Use for treatment of opioid abuse
(blocks the effects of opiates) >350
WITHDRAWAL SYMPTOMS OF ALCOHOLISM mg/week given in 3 divided doses for
 Withdrawal may take 1 -2 weeks opiate-blocking effect
 Safe withdrawal includes:  6. Dizulfiram (Antabuse)
 a. Benzodiazepine to suppress the  250-500mg/day for 1-2 weeks then
withdrawal symptoms 125-250mg/day as
 V - Valium (Diazepam) maintenance
 A - Ativan (Lorazepam)  help client to maintain abstinence
 L - Librium (Chlordiazepoxide) from alcohol
 A. 3 – 24 hrs after the last drink – called “The Adverse reactions:
SHAKES” or “Mild Tremors”  a. Mild:
 S – sweating  flushing
 A – anxiety /agitation  throbbing headache
 I – increased pulse and blood pressure  N/V
 N – nausea / vomiting  sweating
 T - tremors  b. Severe:
 B. 36 – 72 hrs after the last drink – results to  Hypotension
“DELIRIUM TREMENS”  confusion
 C - confusion  coma -
 I – increase body temperature  death
 S – seizures
 H – hallucination (48 hours) WHAT TO AVOID when in ANTABUSE therapy? (FASt
 A – agitation is extreme MOVE)
 D – diaphoresis
 F – food sauces made of wine
Behavioral Problems Commonly seen in  A – after shave lotion
Alcoholics  St – skin products
 M – mouth wash
D – Destructive and rebellious behavior  O – over the counter drugs
D – Dominant and critical behavior  V – vinegar
D – Difficulty with intimate relationships and  E – extract fruit flavored
tendency toward narcissism
D – Decreased self-esteem ☺☺☺

Defense mechanism common used by alcoholics GRIEF AND LOSS

Grief
1. Denial  A normal response to the experience of loss
 Ex: “ I don’t have a problem, I can quit  Refers to the subjective emotions
anytime I want”
2. Rationalization Mourning
 Ex: “If you have the problems I have,  Outward expression of grief
you’d drink too.  Rituals of mourning includes:
3. Projection > Having a wake
 Ex: “ Tom is the one who can’t hold his > arranging funerals
liquor” > holding religious ceremonies

Treatment Grieving/ Bereavement

 Refers to the process by which a person
 A. PHARMACOLOGY experience the grief.
 1. Folic acid (Folate) 1 – 2 mg/day  All people grieve when they experience life’s
 treat nutritional deficiency changes and losses
 2. Thiamine (Vit. B1) 100 mg/day
Anticipatory Grieving
prevent or treat Korsakoff-Wernicke’s
  When people grieve for an imminent loss or
Syndrome when there is a real possibility of loss or death
 3. Cyanocobalamin (Vit. B12) 25 – 50 mg/day in the near future
 1. Denial – shock and disbelief of loss
Disenfranchized Grief
 Grief over a loss that is not acknowledge 2. Anger – may be expressed toward God,
openly, mourned publicly or supported socially. relatives, friends or health provider
1. LOSS ITSELF IS NOT RECOGNIZED
- abortion - death of a pet 3. Bargaining – occurs when the person asks God
- job loss - separation/divorce for more time to delay the inevitable loss
- children living home
2. THE GRIEVER IS NOT RECOGNIZED 4. Depression – results when the person becomes
- same sex relationship aware of the loss
- extramarital relationship
- illegitimate child 5. Acceptance – occurs when the person shows
evidence of coming to terms with the event Ex:
Complicated Grieving death of loved one
occurs when person grieve for a prolonged period
or express feelings that seem out of proportion. STAGES OF GRIEVING (RODEBAUGH, SCHWINDT, &
VALENTINE)
People who are vulnerable to complicated grieving
1. REELING
1. Previous psychiatric disorders  person feels, shock, disbelief and
 Previous suicide threats or attempts denial
 Paranoid behavior 2. FEELING
2. Absent of support system  person experiences anguish, guilt,
 Ambivalent, dependent or insecure attachment profound sadness, anger resulting to
to the deceased person lack of concentration, sleep
3. Low self-esteem disturbances, appetite changes, fatigue
and general discomfort
Risk Factors Leading to Vulnerability to Complicated 3. DEALING
Grieving  person begins to adapt to the loss by
engaging in support groups, grief
 Death of a spouse or child therapy, reading and spiritual guidance
 Death of parent (particularly in early childhood 4. HEALING
or adolescence)  person integrates the loss as part of
 Sudden, unexpected and untimely death life, however healing does not imply
 Multiple deaths that the person has forgotten or
 Death by suicide or murder accepted the loss

Types Of Losses Responses of the Grieving Client

1.PHYSIOLOGIC LOSS – Ex: Loss of body parts, Loss 1.COGNITIVE RESPONSE

of sight/hearing  Questioning and trying to make sense
of the loss
2.SAFETY/ SECURITY LOSS  Attempting to keep the lost one
 Loss of safe environment (domestic or present
community violence)  Disruption of assumptions and belief
 Loss of psychological safety (trust, 2.BEHAVIORAL RESPONSE
breach of confidentiality, unfulfilled  Seeking or avoiding places and
promises) activities shared with lost one
 Ambivalent feeling (Keeping valuables
3. LOSS OF LOVE and a SENSE OF BELONGINGNESS of lost one while wanting to discard
 Death of loved one them)
 Separation from loved one/Rejection  Poor coping mechanism
 Illness ○ May abuse drugs or alcohol
○ May commit suicide or
4.LOSS OF SELF-ESTEEM homicide
 Any change in how the person is 3.EMOTIONAL RESPONSE
valued at work or in relationships.  Guilt over things not done or said in the
lost relationship
5.LOSS RELATED TO SELF- ACTUALIZATION  Anger, sadness, and anxiety are the
 An internal/external crisis that blocks predominant emotional experiences of
or inhibits strivings toward fulfillment loss
may threaten personal goals and  Feeling of hatred and revenge can be
individual potential expected when death has been due to
Ex: loss of pregnancy, losing the hope of extreme circumstances such as
marriage or having a family of one’s own suicide, murder or war
4.SPIRITUAL RESPONSE
Stages of Grieving - Finding explanations and meaning
through religious and spiritual beliefs.
 5.PHYSIOLOGICAL RESPONSE  Fear of separation from parents “wanted to
 Headache know who will take care of them”
 insomnia  Dying children may have regress behavior
 Loss of appetite
 indigestion School Age
 Weight loss  Have concept of time, causality and
 Palpitation irreversibility of death
 They fear of mutilation, pain abandonment
NURSING INTERVENTION FOR GRIEVING  Interested with death ceremony
 Feel/Interpret death as a punishment
1. PERCEPTION OF LOSS
 Explore client’s perception and Cultural and Spiritual Beliefs
meaning of his/her loss to help
alleviate the pain of what some would  Values, attitudes, belief and customs are
call the initial emotional response cultural aspect of a person’s life style
 Allow adaptive denial- this will help the  Spiritual or religious belief includes practices,
client gradually adjust to the reality of rites and rituals directed toward loss
loss experience and grieving

2. SUPPORT SYTEM
 Identify support system and assist
client to reach out for and accept
support.
 Make self available

3. COPING MECHANISM
 Encourage client to examine patterns
of coping in the past and present
situation of loss, and helping him/her
renew a sense of personal power

4. PROMOTE SELF-ESTEEM
 Encourage client to review personal
strength and personal power
 Encourage client to care for himself

5. USE EFFECTIVE COMMUNICATION

 Offer support and empathy (Respect
for client’s personal belief)
 Use broad opening
 Encourage description of perception
 Share observation
 Provide information

6. DEVELOP NURSE - PATIENT RELATIONSHIP

 Maintain trust and interpersonal skills
 Respect client’s unique grieving
process
 Be honest, trustworthy, dependable
and consistent

COPING REACTION TO DEATH THROUGHOUT THE LIFE

CYCLE REACTION OF CHILDREN TO DEATH

Infant and Toddler

 Live only at present
 Are concern with separation with mother,
afraid of being alone/being abandoned
 Can sense sadness from others and may feel
guilty due to magical thinking
 Healthy toddlers may insist on seeing other
long after the person’s death

Pre-school
 See death as temporary type of separation as if
it is a sleep separation
 See life as concrete, know the word death but
doesn’t know it’s finality