9-15 notes NUR 314
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This 10 page Class Notes was uploaded by Megan Dineen on Tuesday September 15, 2015. The Class Notes belongs to NUR 314 at Illinois State University taught by Amie in Fall 2015. Since its upload, it has received 28 views. For similar materials see Mental Health and Psychiatric Nursing in Nursing and Health Sciences at Illinois State University.
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Date Created: 09/15/15
Mennonite College of Nursing Illinois State University NUR 314 Psychiatric Mental Health Nursing 9 Guided Notes Trauma StressorRelated and Dissociative Disorders Chapter 16 Tuesday September 15 2015 Be kinder then necessary Everyone is ghting a battle unknown SelfAssessment see EBP p 307 Need to know where you stand in regards to the situation Many of us have our own stressors and trauma in life Easy for us to re ect our feelings onto the patient 0 Countertransference Need to lead with empathy instead of sympathy 0 Hard to be empathetic if we are struggling with things ourselves Can be very complex TraumaRelated Disorders in Children A lot of trauma begins with children Integrated Trauma Informed Care 0 Trauma informed care Recognize and seek out to understand what happened to the child rather than focusing what is wrong with the child 0 Abuse and neglect o Witnessing violence onvasive medical procedures and illnesses oquotquotf you can understand these you can understand why they are reacting to you and the situation the way that they are If you see something wrong with them you won t be able to approach them therapeutically Clinical Picture 0 Post Traumatic Stress Disorder PTSD 1 disorder in regards to children Changes in play Negative thoughts and guilt Detachment or estrangement Aggression sleep problems 0 Reactive Attachment Disorder quotInhibited emotionally withdrawnquot p 305 o Disinhibited Social Engagement Disorder quotno normal fear of strangersquot p 305 o Epidemiology o PTSD rates high if witness violence 0 Very high if they have witnessed violence Especially if it is a family member involved Comorbidity o Other disorders increase vulnerability to PTSD 0 Have an increased risk that makes them more vulnerable Poverty Altered family structure Learning disabilities Chronic illnesses Sleep problems Depression Substance abuse 0 Etiology 0 Biological Factors Gene c a Prenatal maternal stress ll Stress when baby prevents brain from regulating stress a Parental nurturing mediates stress absence leads tol problems with concentration direction and p 306 you get vulnerable behaviors such as impulse problems a Some children are just born compromised and highly more vulnerable to stress Neurobiological in 1st 5 years key with brain development a Trauma causes a quotdysregulation that disrupts the integration ofneura networksquot p 306 I quotparasympathetic response triggers hypoarousal state with dysregulation of hypothalamic pituitary adrenal axisquot dissociation a disconnection from the disorder a See quotpolyvagal theoryquot on page 306 Interesting but not vital to know 0 Psychological Factors Attachment Theory relationship with rst caregiver imprints baby for life How caregiver works with client is an imprint for life 0 Environmental Factors quotdependency of child plus neuroplasticityincreases vulnerability to life experiencesquot p 307 I Neuroplasticity brain can be molded in different ways Resilience needed positive adaptation Application of the Nursing ProcessResiliency needed Nurses help ID and foster qualities to keep at risk children from developing PTSD Assessment History of present illness Developmental history Developmental Assessment Neuro Assessment Medical History Family History Mental Status Assessment includes characteristics of play Data Collection Interviewing screening testing observing and interacting structured questionnaires by parents and teachers Developmental Assessment Looks at maturational level and chronological age to ID lags and De cits Includes Denver II Developmental Screenings Diagnosis Risk for impaired parentchild attachment Risk of delayed development Outcomes Identi cation Implementation Remember we are mandated reports in suspected listen to your gut Staged model of treatment for trauma Stage I safety and stabilization Stage II reducing arousal and regulating emotions by working with emotions and memories Stage III development of coping and social skills Don t need to know stages just want to understand the basic concept of it 0 Want to be sure they re safe reduce their emotions and make sure they can cope quotWindow of Tolerancequot balance between sympathetic and parasympathetic response We help our clients learn to quotself regulatequot o How muchwhat they can handle 0 Interventions with children Box 161 Focus on caring relationship development and trust Anxiety reduction relaxation soothing techniques Teach about feelings normalcy and expression dealing with grief about trauma Teach coping strategies art and play therapies storytelling Early intervention is key 0 Advanced Practice Interventions CBT Cognitive behavioral therapy Helping the person to change their thinking through actions Eye movement desensitization and reprocessing EMDR p 310 Not on the exam nice to know Advance practice technique Think about traumatic event clinician has them tap their nger or follow a light and that simultaneous doing something causes a rebooting of your brain Low risk for client and cheap 0 Psychopharmacology Use in combination with other therapies 0 Evaluation 0 They should have more ability to self regulate TraumaRelated Disorders in Adults Post Traumatic Stress Disorder Major Features Reexperiencing trauma ashbacks dreams recollections Sit there doing nothing and then out of nowhere the ashback comes Avoidance of stimulidetachment numbing Helps them become numb to the pain Blocks negative AND positive feelings Persistent symptoms of increased arousalirritability difficulty sleeping difficulty concentrating hypervigilance or exaggerated startle re ex Alterations in moodchronic depression p 310 Active and passive suicidal ideation Violence to self and others 0 Epidemiology 0 5590 have experienced traumatic event quot8 develop PTSDquot p 310 0 And just because they have PTSD does not mean they are weak and if they don t have PTSD it doesn t mean their experiences weren t bad 0 Diagnosed a month or years after exposure 0 Average onset is 23 years More women outside of military WHY 0 Domestic violence sexual assault vulnerability of women in some cultures the dependency of women Comorbidity o quotThe more adverse childhood experiences ACE experienced the more both medical and mental illness occurs later as adultsquot 0 Depression Anxiety Dissociative amp Sleep Disorders and SA substance abuse disorders 0 Etiology Biologicalsee children Application of the Nursing Process See Case Studv 161 0 Assessment 0 Initial screens PTSD Checklist or Primary care PTSD Screen 0 SymptomsD functional impairment 0 Medical and psychiatric history including meds o Suicideviolence Active and passive suicide cutting violence to others all very common 0 SupportsCoping strategies Substances 0 Diagnosis 0 Interrupted family function Ineffective coping Social isolation Self esteem Risk for suicide Risk for selfharm Anxiety OOOOOO O Hopelessness Outcomes Identi cation see 311 for generic ideas 0 Interventions with adults 0 0 00000 Therapeutic relationship nonjudgmental acceptance Need selfawareness Validate feelingssituation with empathic comments Empathic comments c I can t even imagine o It must be really hard 0 It must be scary Indicates you are listening and connecting on emotional level Use all anxiety decreasing strategies Breathing techniques Relaxation techniques Guided imagery Calm soft noises strong structure environment Increased structure decreases anxiety Expand coping strategies including CBT and helping them think Intervene to decrease hopelessness amp guilt Teach quotNOT responsible for event responsible for copingquot Involve with others sharing experiences Psychoeducational Include family Taught how it manifests interpersonal and occ problems SA quotNormal reaction to abnormal eventquot Psychopharmacology SSRI amp SNRI TCA amp Clonidine CatapresPrazosin Minipres Inderal Advanced Practice Interventions o EMDR Psychotherapy Behavioral therapy Group Therapy 0 EBP interventions 0 Evaluation 0 Sleeping more less cutting etc takes time 2 TraumaRelated Disorders in Adults Acute Stress Disorder ASD Traumatic event followed by 8 of 14 symptoms during or after event Sense of numbing Derealization Inability to remember at least one aspect of event Intrusive memories Recurrent distressing dreams Feeling event is reoccurring Intense prolonged distress or physiological reactivity Avoidance of thoughts or feelings about event Sleep disturbances Hypervigilance Iirritable angry or aggressive o Exaggerated startle re ex o Agitation or restlessness V Diagnosed 3 days to 1 month after event V See Considering Culture p 316 for an example 0 Interesting but will not be tested on 0 Diagnosis Posttrauma syndrome see page 313 o Comorbid acute stress disorder 0 Outcomes Identi cation 0 Implementation 0 Establishing relationship 0 Maintain safety 0 Helping person problem solve One at a time 0 Connecting to supports They are not alone 0 Educa ng 0 Advanced Practice Intervention CBT EMDR o Medications are rarely the answer 0 Evaluation TraumaRelated Disorders in Adults Adjustment Disorder V Less intensityie loss empty nest move retirement V Diagnosed immediately or within 3 months V quotcognitive emotional and behavioral symptoms that negatively impact functioningquot p 315 quotdepression anxiety and conduct disturbancesquot p 315 V Individual interventions but may include Antidepressants 0 Finding support building selfesteem dealing with anxiety of new life situation V Not usually seen on a locked psychiatric unit Dissociative Disorders V Trauma quotinterruption in consciousnessquot p 315 V Dissociation dissociation is unconscious o Emotional separation or disconnect 0 Memory consciousness seIf identifv and perception Cannot tell what is reality and what is not They do not have delusions or hallucinations Are not psychotic but may act like they are c Epidemiology 0 Less common 0 Very common to have depersonalization however Comorbidity o Dissociative amnesia depression anxiety depersonalization trance states SA PD Dissociative fugue Dysphoria anxiety grief guilt suicidal or aggressive impulses PTSD SA Dissociative Identity Disturbance somatization disorder BPD APD SA 0 Etiology 0 Environmental Factors All dissociative disorders are believed to be linked with traumatic life events some form of this will be on test Panic disorders vs dissociative disorders Dissociative disorders something big happened in their life 0 Panic disorders nothing big happened 0 Biological Factors Genetic more common among rstdegree relatives quotreated to stress reactivityquot Neurobiological limbic system development may be faulty due to trauma allowing experiences to be detached from memory Early trauma and lack of attachment may affect neurotransmitter o Psychological Factors Learning theory learned method for avoiding stress and anxiety and tuning outquot The more quottuning outquot is used the more likely to be automatic 0 Under their control individually based on cultures 0 Cultural Factorssome culture bound disorders look like dissociative disorders 1 DepersonalizationDerealization Disorder ConsciousnessPerception Disruption in consciousness and perception Depersonalization Persistent or recurrent alteration in perception of selfone s own reality is temporarily lost realitytesting remains intact not psychotic Feels 39dreamy or detached from body Feel like their body is oating away from their head See themselves differently Derealization focus on outside world bigger or smaller 0 Everything around you changes in perception 0 See the environment differently 2 Dissociative Amnesia 0 Memory Inability to recall important personal info of a traumatic or stressful naturemore pervasive than forgetfulness Three types generalized localized amp selective o Disruption of memory 0 Traumatic event and person cannot remember it 0 You think they are suppressingrepressing it but it is something bigger than that Not because of a head injury but because of the trauma of it o Dissociative Fugue Memory and Identity Inability to recall identity and info about the past plus travel away from customary locale fugue 0 They don t have memory of the event and they are travelling away from 0 Can forget who you are or where you live and travel to other places 3 Dissociative ldentitv Disorder 0 Multiple Personality Disorder Identity 2 or more distinct alternative altars or sub personality states that take control of behavior Each altar has its own pattern of perceiving relating to and thinking about self and environment p 317 o Altars quotcome outquot with stress 0 Most pervasive most uncommon Used to be called multiple personality disorders 0 NOT schizophrenia 0 Client is not psychotic but there are two or more sub personality states 13 are dissociative disorders all go along with trauma Application of the Nursing Process for all Dissociative Disorders All other etiologies must be ruled out before DID diagnosis Dissociative Experience Scale Dissociative Disorders Interview Schedule 0 Assessment 0 History Gathering of eventsmedical history trauma historyln DID Assess for differing sets of memories about childhood incidents of finding strange clothing in closets o Mood Depression often triggers clients to seek help DID Mood shifts Fugue and Amnesia victims may seem indifferent or perplexed Signi cant Never know what mood is going to show per personality 0 Impact on Patient and Family irratic behavior dysfunction occupational problems reliability Issues signi cant chaos Significant impact 0 Suicide Risk Alwavs assess O High suicidal risk because of the struggle with helplessness hopelessness power and control Some personalities may be stronger than others Identity and Memory Amnesia amp fugue Ask about Identify of self amp bh know where they are lose time DID look for gaps in memory used of third person when communicating Diagnosis Disturbed personal identity Ineffective role performance Outcomes Identi cation Table 161 Planning baby steps 0 O 0 Phase 1 stabilization Phase 2 working through to integrate memories Phase 3 identity integration Implementation See Table 162 0 000 00000 SPEP to ensure client safety Milieu Management Structured simple routine Keep oriented Do not ood person with data regarding past events Have them slowly piece their past together Assess anxiety and teach stressreducing methods Assist with decision making as necessary Encourage to do things for self decrease learned helplessness Help client see consequences of using dissociation to cope Help client to identify triggers leading to dissociation Important Helps them to see what pushed them over Psychoeducation Coping and stress management Grounding Techniques focus on here and now mindfulness 0 Don t want mind to wanter Journaling Why Increase awareness of feelings and ID triggers of dissociative events Need for ongoing therapy for patient and family Pharmacological Interventions No Antidissociation drugs but use anti depressants and antipsychotics to decrease hyperarousal and intrusive thoughts Advanced Practice Interventions I Somatic Therapy Sensorimotor psychotherapy talking therapy with movement focused on physical sensations dance therapy Evaluation safe decreased anxiety new coping strategies stress handled without dissociation means the personalities have been integrated Takes much time Fa15dc 10
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