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5th Quarter:
Unit 2
| Question | Answer |
|---|---|
| Define anesthesia. | A state of depressed central nervous system activity, marked by depression of consciousness, loss of responsiveness to stimuli and/or muscle relaxation. |
| General anesthesia | Loss of sensation, consciousness, and reflexes. |
| What method of anesthesia is used for a patient undergoing major surgery that will require complete muscle relaxation? | General anesthesia |
| Local anesthesia | Loss of sensation without loss of consciousness. |
| What type of anesthesia blocks transmission along nerves, providing for loss of autonomic function & muscle paralysis in a specific area? | Local anesthesia |
| What are some risk factors for general anesthesia complications? | Family Hx of malignant hyperthermia, respiratory disease, cardiac disease, gastric contents, preop use of alcohol/illicit drugs. |
| What are some risk factors for local anesthesia complications? | Allergy to ester-type anesthetics, alterations in peripheral circulation. |
| What are the three phases of general anesthesia? | Induction, maintenance, emergence. |
| What happens during the induction phase of general anesthesia? | Preop meds are given, IV lines are started, placed on monitors, airway is secured. |
| What happens during the maintenance phase of general anesthesia? | Surgery is performed, airway is maintained. |
| What happens during the emergence phase of general anesthesia? | Surgery is completed, assistive airway devices are removed. |
| What two classifications of anesthetics are used during general anesthesia? | Injectable & Inhaled |
| What are inhaled anesthetics? | Volatile gases/liquids that are dissolved in O2. |
| Inhalation anesthetics | -ane. (Also Nitrous Oxide) |
| How are inhalation anesthetics eliminated? | Primarily through exhalation. |
| Classes of adjunct meds | Opioids, benzodiazepines, anticholinergics, antiemetics, sedatives, neuromuscular blocking agents. |
| Adjunct opioids: Fentanyl (Sublimaze), Sufentanil (Sufenta) | Used for sedation & analgesia. |
| Adjunct benzodiazepines: Diazepam (Valium), Midazolam (Versed) | Used for amnesia & anxiety reduction. |
| Adjunct anticholinergics: Atropine, Glycopyrrolate (Robinul) | Used to dry up excess secretions, reduce risk of aspiration. |
| Adjunct antiemetics: Promethazine (Phenergan) | Used for n/v reduction, reduce risk of aspiration. |
| Adjunct sedatives: Pentobarbitol (Nembutal), Secobarbital (Seconal) | Used for amnesia & sedation. |
| Adjunct neuromuscular blocking agents: Succinylcholine (Anectine), Vecuronium (Norcuron) | Used for muscle relaxation in surgery & airway placement. |
| What are three main methods of administering local anesthesia? | Topical, local infiltration, regional nerve block. |
| Topical local anesthesia | Applied directly to skin or mucous membranes. |
| Local infiltration anesthesia | Injected directly into tissues, where a surgical incision will be made. |
| Regional nerve block anesthesia | Injected into/around specific nerves. |
| What are the four types of regional nerve block anesthesia? | Spinal, epidural, bier, peripheral. |
| Spinal anesthesia | Injected into subarachnoid space CSF. Provides autonomic, sensory, and motor blockade. |
| Epidural anesthesia | Injected into epidural space in thoracic/lumbar areas of spine. Sensory pathways are blocked, motor function remains. |
| Bier anesthesia | IV injection of anesthetic into extremity following mechanical exsanguination w/ a tourniquet, providing analgesia & bloodless surgical site. |
| Peripheral anesthesia | Injection of anesthetic into specific nerve for analgesic & anasthetic use. |
| Examples of local anesthetics: | Procaine (Novocain), Lidocaine (Xylocaine). |
| What vasoconstrictor may be administered, with local anesthesia, to prolong effects & decrease effect of systemic toxicity? | Epinephrine |
| When would you not want to use epinephrine along with local anesthesia, to prolong effects & decrease effect of systemic toxicity? | With distal injuries, such as a finger, due to decreased circulation. Prolonged vasoconstriction can l/t tissue necrosis. |
| Observations for systemic absorption of local anesthesia: | Restlessness, excitement, seizures, tachycardia, tachypnea, HTN. |
| Anesthesia complication s/sx: Myocardial depression | Bradycardia, hypotension, cyanosis, edema. |
| Anesthesia complication s/sx: Anaphylaxis | Cardiac failure, allergic symptoms, abnormal v/s. |
| Anesthesia complication s/sx: Malignant hyperthermia | Tachycardia, tachypnea, hypercarbia, dysrhythmias. |
| Anesthesia complication s/sx: ANS systems blockade | Hypotension, bradycardia, n/v. |
| Anesthesia complication s/sx: CSF leakage | HA |
| After Versed admin, BP drop, HR increase, what will surgeon request? | 500 mL NS bolus |
| What is a priority assessment after administering nitrous oxide? | O2 sat |
| What is the most dangerous possible adverse reaction of inhalation anesthetics? | Malignant hyperthermia. |
| Conscious sedation | Administration of sedatives/hypnotics to point where pt is relaxed enough that minor procedures can be performed w/o discomfort, while pt can respond to verbal stimuli, retain reflexes, is easily arousable, and independently maintains airway. |
| Who can administer conscious sedation? | Only a qualified provider, or a RN under the direct supervision of said provider. |
| What is the RNs role with a pt under conscious sedation? | Continuously monitor pt, remaining present with no other responsibilities, before, during and immediately after procedure. |
| Drugs used for conscious sedation: | Opioids, anesthetics, benzodiazepines. |
| Equipment needed within immediate reach, during conscious sedation: | Crash cart, ECG monitor, BP monitor, O2 monitor, thermometer, stethoscope, O2 & supplies, airways, suction, IV supplies. |
| After sedation, RN should continually monitor: | LOC, cardiac rhythm, respiratory status, v/s. |
| How long is the RN to monitor and record v/s & LOC after completion of procedure? | Until pt is fully awake and all assessment criteria return to pre-sedation levels. |
| Typical discharge criteria, post anesthesia: | LOC as on admission, v/s stable for 30 - 90 minutes, able to C&DB, able to take oral fluids, no n/v, no SOB, no dizziness. |
| Complications that may arise from conscious sedation: | Airway obstruction, respiratory depression, cardiac arrhythmias, hypotension, anaphylaxis. |
| Airway obstruction d/t conscious sedation | Insert airway, suction. |
| Respiratory depression d/t conscious sedation | Give O2 & reversal agents. |
| Cardiac arrhythmias d/t conscious sedation | Set up 12 lead ECG, antidysrhythmics, fluids. |
| Hypotension d/t conscious sedation | Fluids, vasopressors. |
| Anaphylaxis d/t conscious sedation | Epinephrine |
| Preop takes place from: | Time patient is scheduled for surgery until transferred to OR. |
| Who obtains informed consent? | The provider. |
| Preop teaching should include: | Pain management, DB&C, ambulation/leg & foot exercises to prevent DVT. |
| Purpose of urinalysis | To rule out infection. |
| Purpose of T & C | Transfusion readiness. |
| Purpose of CBC | Infection/immune status. |
| Purpose of Hgb & Hct | Fluid status, anemia. |
| Purpose of electrolyte levels | Hypo/hyperkalemia. |
| Purpose of serum creatinine | Renal status. |
| Purpose of pregnancy test | Fetal risk of anesthesia. |
| Purpose of chest x ray | Heart and lung status. |
| Purpose of 12 lead ecg | Baseline heart rhythm, dysrhythmias. |
| Preop diagnoses | Deficient knowledge, anxiety, anticipatory grieving, ineffective individual coping. |
| What is the RNs role in informed consent? | To clarify any information that remains unclear after the provider's explanation, and witness client's signature, after acknowledging consent. |
| Preop education should include what about cigarette smoking? | None for 24 hrs preop. |
| How long will pt be NPO before a surgery with general anesthesia? | At least 6 - 8 hours. |
| How long will pt be NPO before a surgery with local anesthesia? | 3 - 4 hours. |
| What items should be removed prior to surgery? | Eyeglasses/contacts, jewelry, dentures, prosthetics, makeup. Hearing aid removed last, in OR. |
| Possible complications of sedatives (benzodiazepines & barbiturates): | Respiratory depression, drowsiness, dizziness. |
| Possible complications of narcotics: | Respiratory depression, drowsiness, dizziness. |
| Possible complications of IV infusions (NS, LR): | Cardiac abnormalities (especially in CHF), hypernatremia. |
| Possible complications of GI meds: | Alkalosis, cardiac abnormalities, drowsiness. |
| What are the three areas of the surgical suite? | Unrestricted, semi restricted, restricted. |
| Unrestricted area: | Street clothes & scrubs, holding area & staff areas. |
| Semi restricted area: | Surgical attire required, corridors & support areas. |
| Restricted area: | Full surgical gear, OR. |
| Role of the scrub nurse | Monitor aseptic technique, handle surgical equipment for surgeon, remain sterile during procedure. |
| Role of the circulating nurse | Plan & coordinate intraoperative care, maintain documentation, report off to PACU. |
| Intra Op nursing diagnoses | Risk for perioperative injury, impaired skin integrity, impaired tissue integrity, risk for infection. |
| What areas of surgical attire are considered sterile? | 2 inches below neck to the waist. From wrist to elbow. |
| Anesthesia may mask what type of reaction? | An anaphylactic reaction. |
| Malignant hyperthermia | Caused by certain anesthetics. High body temperature & rigid skeletal muscles. (other: tachy, hypotension, cyanosis, myoglobinuria). |
| Response to malignant hyperthermia | Stop administration. Intubate. 100% O2. IV Dantrolene. Cooling techniques. Monitor cardiac and renal. |
| Who is responsible for transferring patient from OR to PACU? | Anesthesiologist. |
| What are the main priorities of care immediately post-op? | Airway patency & ventilation. |
| Post-op patients who received general anesthesia need frequent assessment of: | Respiratory status. |
| Post-op patients who received epidural/spinal anesthesia need frequent assessment of: | Motor and sensory function. |
| Risk factors for post-op complications: | Immobility, anemia, hypovolemia, older age, respiratory disease, immune disorder, DM, coagulation defect, malnutrition, obesity. |
| What five categories are scored in the Aldrete scoring system? | Activity, Consciousness, Respiration, Color, Circulation. |
| What criteria indicate readiness for discharge from PACU? | Aldrete of 10, stable v/s, no evidence of bleeding, return of reflexes, wound drainage minimal/moderate, UO of at least 30 mL/hr. |
| Post-op nursing diagnoses | Impaired gas exchange, ineffective airway clearance, ineffective breathing pattern, risk for infection, acute pain, altered tissue perfusion, impaired tissue integrity, n/v, urinary retention, constipation. |
| How should a patient be positioned in the PACU? | Supine w/ head flat, to prevent hypotension. |
| If the patient is unconscious/comatose, what position should he be placed in? | On his side, to prevent aspiration. |
| When do we raise the head of the bed? | When patient is fully reactive, to aid in respiratory expansion. |
| When should we elevate a clients legs? | When shock develops. |
| How often do we monitor pain and RR post-op? | Every 30 minutes. |
| A patient without a catheter should void: | at least 200 mL within 6 hr of surgery. |
| How long is a patient NPO post-op? | Until gag reflex and peristalsis return. |
| How can we assess presence of peristalsis? | Monitor for bowel tones and flatus. |
| What is the progression of drainage? | Sanguineous to serosanguineous to serous. |
| Complication: Airway obstruction | Monitor for choking, noisy irregular resps, decreased O2 sat, and cyanosis. |
| Complication: Hypoxia | Monitor O2 sat. O2 as prescribed, C&DB. |
| Complication: Hypovolemic shock | Monitor for decreased BP & UO, increased HR, slow cap refill. Admin fluids & vasopressors as indicated. |
| Complication: Paralytic ileus | Monitor bowel tones, encourage ambulaion, advance diet as tolerated. |
| Complication: Wound dehiscence/evisceration | Monitor risk factors. If occurs, stay with pt, cove with sterile towel/dressing moistened with sterile saline, DO NOT ATTEMPT TO REINSERT ORGANS. |
| -ectomy | removal of |
| -orrhaphy | repair of |
| -ostomy | to form a new opening |
| -otomy | make an incision/cut into |
| -plasty | surgical repair of |
| -oscopy | visualization |
| Surgeries are classified by: | TPAPER: Timing, purpose, anatomical site, physical setting, extent, risk. |
| Minor surgery | Simple procedure with little risk. General/local anesthesia. |
| Major surgery | Greater risk, more extensive. May involve risk to life. |
| Minimal access | Laparoscopic |
| Open procedure | Part of body opened. |
| Simple procedure | Very defined anatomical location. |
| Radical procedure | Dissection of tissue beyond the immediate operative site. |
| Purpose of surgery | D.C.CRAP: Diagnostic, Curative, Cosmetic, Restorative/reconstructive, Ablative, Palliative. |
| Elective surgery | Planned. To improve quality of life, physically/psychologically. (cataract/breast augmentation) |
| Urgent surgery | Unplanned. Need to be done in 24 hr, if not, long term consequences. (Appendectomy) |
| Emergent surgery | Unplanned. Must be done now, to preserve life and limb. (Ruptured aneurysm) |
| Ambulatory surgery | Pt comes in in a.m. and leaves same day. |
| Same-day surgery | Pt comes in in a.m., goes to unit following surgery. |
| Cardiovascular changes associated with aging: | Loss of Lg artery elasticity. Myocardial changes. Lt ventricular hypertrophy. Calcification of valve leafs. Hemodynamic alterations. HR decreases. Orthostatic hypotension. |
| What is the result of Lt ventricle hypertrophy? | Increase in systolic BP > increased stretch > becomes less elastic > heart failure. |
| What is the result of respiratory changes in older patients? | Decrease tidal volume, decreased vital capacity, decreased O2 & CO2 exchange, decreased aerobic capacity. |
| What contributes to the fall in cardiac response & reserve as we age? | A decline in sympathetic responsiveness. |
| Albumin | 3.5 - 5.0 g/100 mL |
| What organs are primarily responsible for drug excretion? | Kidneys |
| As we age, plasma renin concentration & activity decline by 30 - 50%, which leads to: | A decrease in plasma concentration of aldosterone > decrease in Na+ > increase in K+ = Hyperkalemia |
| Hyperkalemia sx | WEAKNESS, nausea, DIARRHEA, HYPERACTIVE GI, muscle weakness & PARALYSIS, arrhythmias, DIZZINESS, postural hypotension, OLIGURIA. |
| Hypokalemia sx | ANOREXIA, n/v, FATIGUE, DECREASED LOC, LEG CRAMPS, muscle weakness, ANXIETY, IRRITABILITY, arrhythmias, postural hypotension, COMA. |
| Hypernatremia sx | CONFUSION IF SEVERE, F, TACHYCARDIA, LOW BP, postural hypotension, DEHYDRATION, POOR SKIN TURGOR, DRY MUCOUS MEMBRANES/TONGUE, FLUSHED. |
| Hyponatremia sx | N/V, ABDOMINAL CRAMPS, DIARRHEA, HA, DIZZINESS, CONFUSION, FLAT AFFECT, DECREASED DBP, INCREASED HR, postural hypotension, DECREASED DTR. |
| What organ metabolizes drugs? | Liver |
| Hypothermia | A decrease in core body temp to 35 C |
| Complications of anesthesia in the elderly | Inhibit reflexes to make heat, cause dysrrhythmias, metabolic acidosis, hyperglycemia, coma. |
| What is always the first priority? | Airway |
| Conscious sedation | Administration of sedative/hypnotic to the point where pt is relaxed enough for minor procedure to be performed w/o difficulty. |
| What is key with conscious sedation? | Pt can respond to verbal stimuli and protect airway independently. |
| What meds are used for conscious sedation? | Morphine, fentanyl, dilaudid, versed. |
| Procedures that may require conscious sedation: | Endoscopy, lumbar puncture, cardio version, wound care, minor surgery, placement/removal of implanted devices/catheters/tubes, bone marrow aspiration, reduction/immobilization of fractures. |
| Prior to conscious sedation: | H&P, education, NPO, IV access, informed consent, attach monitor, remove dentures. |
| What range do you want a patient to stay in, according to the Ramsay Sedation Scoring System? | 2 - 3 |
| When using the modified Aldrete scoring system, how do we know a patient has recovered from anesthesia? | If the score is 9 or greater. |
| How do you dress for the OR? | From head to toe. |
| What is the physiological result of anxiety on a surgery patient? | Increased HR, Increased BP, Increased gastric acid production. |
| Common pre-op diagnostic tests | EKG, CBC, lytes, PT, PTT, T&C, CXR, PFT, ABGs, UA, BUN, creatinine, glucose, liver panel. |
| RBC | 4.2 - 6.2 million/mm3 |
| WBC | 5,000 - 10,000/mm3 |
| Hgb | F: 12 - 16 g/100 mL M: 14 - 18 g/100 mL |
| Hct | F: 37 - 47% M: 42 - 52% |
| Ca++ | 8.5 - 10.5 mg/100 mL |
| Cl- | 100 - 106 mEq/L |
| K+ | 3.5 - 5.0 mEq/L |
| Mg++ | 1.5 - 2.0 mEq/L |
| Na+ | 135 - 145 mEq/L |
| pH | 7.35 - 7.45 |
| PO2 | 75 - 100 mm Hg |
| PCO2 | 35 - 45 mm Hg |
| HCO3 | 22 - 26 mmo/L |
| BUN | 8 - 25 mg/dL |
| Creatinine | 0.5 - 1.6 |
| PT (coumadin) | 22 - 26 seconds (therapeutic) |
| PTT (heparin) | 60 - 70 seconds (therapeutic) |
| What ASA classes are good for conscious sedation? | 1 & 2 |
| At what point in the perioperative time will a patient be most teachable? | At the time of the preadmission interview. |
| What effect does increased stress have? | It increases blood sugar which delays wound healing. |
| Nursing Diagnoses r/t surgery | Anxiety, Risk for ineffective airway clearance, risk for ineffective peripheral tissue perfusion. |
| What is the purpose of the "time out"? | Correct patient, correct procedure, correct surgical site, correct patient position, correct implants/x-rays, equipment available. |
| Goals of anesthesia | Loss of consciousness, analgesia, eliminate normal reflexes, relax skeletal muscles, cause amnesia, maintain physiological stability. |
| 4 anesthesia stages | 1. Analgesia 2. Excitement 3. Surgical Anesthesia 4. Medullary Depression |
| What stage of anesthesia do you not want to linger at? | Stage 2, Excitement. Will have most complications here. |
| There are 3 planes to Stage 3 of anesthesia, what are they? | 1. Regular resps, no lid reflex. 2. Fixed, dilated eyes, decreased intracostal muscle activity. 3. Intercostal muscle paralysis. 4. Cessation of spontaneous respiration. |
| What happens in stage 4 of anesthesia, the medullary depression stage? | Respiratory & Circulatory collapse. |
| IV agents for induction: | Barbiturates, non barbiturates, benzodiazepines, opioids, muscle relaxants. |
| Maintenance anesthetics | IV or inhaled. |
| What is the reversing agent for Benzodiazepines? | Romazicon |
| What medication is used when intubating? | Succinylcholine (Anectine) Fast acting. Effects gone in minutes. |
| What anesthetics are most titratable? | Inhaled gases. |
| What acts as a carrier for the inhaled gases? | O2 |
| How soon does a pt awaken after cessation of inhaled gases? | 15 - 20 minutes |
| Reglan | Stimulates gastric emptying |
| Amides (Lidocaine) | Used locally. Long & intermediate acting. |
| Esters (Novocain) | Used locally. Long & short acting. Less effective & more likely to cause an allergic reaction. |
| What is done to relieve a spinal HA? | Blood patch. |
| When numbness goes above T4, what happens? | Pt experiences respiratory complications. |
| What do we document and score in relation to an epidural? | Sensation level, drip rate, side effects, sedation level, and mentation level. |
| If an epidural and PCA are oredered simultaneously, what should the RN do? | Question the order. |
| Possible complications of surgery | Arrest, laryngospasm, n/v, aspiration, hyper/hypotension, hypoxia, anaphylaxis, malignant hyperthermia. |
| Why might a patient with Parkinson's need anticholinergics? | To manage secretions. |
| PACU assessments | V/S, respiratory, cardiovascular, neurologic, UO, skin integrity, pain/pca. |
| What requirements must be met in order for discharge from PACU? | Minimu Aldrete score of 10. Stable v/s. No evidence of bleeding, return of reflexes, UO at least 30 mL/hr. |
| Post-op complications: Respiratory | Airway obstruction, atelectasis, pneumonia, pulmonary embolism. |
| Post-op complications: Cardiovascular | Venous thrombosis, fluid imbalance, hyper/hypotension, dysrhythmias. |
| Post-op complications: GI | Hiccups, n/v, abdominal distension, paralytic ileus, stress ulcer, abdominal compartment syndrome. |
| Post-op complications: Renal | Urinary retention. |
| In the event of respiratory depression: | O2 & reversal agents. |
| In the event of hypotension: | Fluids & vasopressors. |
| In the event of anaphylaxis: | Epinephrine |
| Surgical risks | The higher the score the greater the risk. |
| Epidural catheter placement: T5 - T7 | Thoracotomy |
| Epidural catheter placement: T8 - T10 | Abdominal incision |
| Epidural catheter placement: L3 - L4/5 | Orthopedic surgery |
| Neuroendocrine response to surgery | Increased norepinephrine, increased aldosterone, increased glucocorticoid (increased ICP), Increased ADH. |
| Metabolic response to surgery | Starvation: Increased metabolism, decreased intake. Anorexia: Stress response, glucose needs met w/ stored glycogen. Increased fat metabolism. |
| What causes hypothermia in surgery? | Anesthesia & environment. This is a normal response. |
| During anesthesia sensations leave & return in this order: | Movement, touch, pain, warmth, cold. |
| If sensation of cold is lost: | Too much anesthesia has been given. |
| How do we monitor for respiratory complications, post-op? | Listen to lung sounds, RR, O2 sats, color, mentation. |
| How do we monitor for cardiovascular complications, post-op? | HR, BP, peripheral pulses, color, warm feet, JVD, EKG. |
| Dissociative disorders | A disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment. |
| Dissociative disorders most often begin: | In late childhood or early adolescence. |
| Dissociative disorders affect: | Women more than men. |
| The four types of dissociative disorders: | Amnesia, fugue, DID, depersonalization. |
| Dissociative amnesia | Inability to recall important personal information, usually of a traumatic/stressful nature, too extensive to be explained by normal forgetfullness. |
| Dissociative fugue | Inability to recall some/all of one's past, along with loss of identity/formation of a new identity. Occurs w/ sudden, unexpected, purposeful travel away from home. |
| Dissociative identity disorder | Characterized by two or more identities/personalities that alternatively take over the person's behavior. |
| Depersonalization disorder | Persistent/recurrent sense of detachment from one's body/mental processes and often a feeling of being an outside observer in one's own life. |
| Dissociative amnesia: Etiology | Overwhelming stress, may be from traumatic life events, accidents, disasters that are experienced or witnessed. |
| Dissociative amnesia: Sx | MEMORY LOSS FOR A PERIOD OF TIME. Pt may become confused/depressed after an episode. |
| Dissociative amnesia: Tx | Supportive environment, sense of safety. |
| Localized dissociative amnesia | Most common. Cannot recall any incident associated w/ traumatic event for a specific time after the event. |
| Selective dissociative amnesia | Able to recall certain instances of traumatic event. |
| Generalized dissociative amnesia | Memory completely gone. Whole life and identity. |
| Continuous dissociative amnesia | Total inability to remember, even the present. |
| Systematized dissociative amnesia | Can't remember something that applies to a specific category. |
| Dissociative fugue: Etiology | Overwhelming stress, desire to escape responsibility or embarassment. |
| Dissociative fugue: Sx | New identity & complex social interactions for hours to months. In progress, asymptomatic to an outsider. When ends: depression, discomfort, grief, shame, suicide, aggression. |
| Dissociative fugue: Tx | Most episodes are brief and self-limiting and require no intervention. |
| Dissociative Identity Disorder: Etiology | Ovewhelming stress, lack of nurturing, sexual/physical abuse. |
| Dissociative Identity Disorder: Sx | Amnesia r/t identities, high incidence of suicide attempts. Comorbidities: depression, anxiety, phobias, eating disorders, PTSD. Pt can hear inner conversation of other personalities. Fluctuating leves of function. Severe HA/bodily pain. Time loss. |
| Derealization | Experiencing familiar people & surroundings as if they are unfamiliar & strange/unreal. |
| Dissociative Identity Disorder: Tx | Psychotherapy, hypnosis, cognitive-behavioral therapy. |
| Depersonalization disorder: Etiology | Overwhelming stress, such as childhood abuse. |
| Depersonalization disorder: Sx | May feel unreal, estranged from self, or dreamlike. May have chronic anxiety about perception of world. |
| Depersonalization disoder: Tx | Often resolves on own, when stress is resolved. Meds for anxiety/depression. Cognitive-behavioral therapy. |
| Things to assess with dissociative disorders | Memory gaps, Ox3, knowledge of identity, mood, affect, behavior, cognition & thought processes, sleep pattern, ETOH/drug use, suicide risk. |
| Dissociative nursing diagnoses | Impaired adjustment, anxiety, ineffective coping, interrupted thought processes, impaired memory, risk for self/other violence. |
| What environment is best for dissociative disorders? | A safe, structured one (milieu therapy). |
| A personality disorder is an enduring pattern of inner experience & behavior that: | is pervasive, maladaptive, inflexible. Onset in adolescence/early adulthood. Stable over time. Leads to distress/impairment. |
| What four common characteristics to all personality disorders share? | Inflexibility/maladaptive response to stress. Disability in social & professional relations. Tendency to provoke interpersonal conflict. Capapcity to cause irritation/stress to others. |
| What effect do the maladaptive behaviors of a person with a personality disorder have? | They are not felt as uncomfortable to the person. |
| Three groups of personality disorders | A: Odd/eccentric B: Dramatic/emotional/erratic C: Anxious/fearful |
| What defense mechanisms are used by people with personality disorders? | Repression, suppression, regression, undoing, splitting. |
| Splitting | Inability to incorporate positive and negative aspects of self/others into a whole. People seen as all good, or all bad. |
| Cluster A | Paranoid, schizoid, schizotypal. |
| Paranoid personality | Distrust & suspiciousness toward others, based on unfounded belief that others are out to get them. |
| Schizoid personality | Emotional detachment, disinterest in close relations, indifference to praise/criticism. Often uncooperative. |
| Schizotypal personality | Odd beliefs l/t interpersonal difficulties, eccentric appearance, magical thinking. |
| Cluster B | Antisocial, borderline, histrionic, narcissistic. |
| Antisocial personality | Disregard for others w/ exploitation, repeated unlawful actions, deceit, failure to accept personal responsibility. |
| Borderline personality | Instability of affect, identity & relations. Fear of abandonmet, splitting behaviors, manipulation, impulsive. Self-mutilition, may be suicidal. |
| Histrionic personality | Emotional attention-seeking behavior, person needs to be center of attention, often seductive & flirtatious. |
| Narcissistic personality | Arrogance, grandiose view of self importance,need for constant admiration, often sensitive to criticism. |
| Cluster C | Avoidant, dependent, obsessive-compulsive |
| Avoidant personality | Social inhibition & avoidance of all situations that need interpersonal contact, despite wanting close relations, d/t extreme fear of rejection. Very anxious in social situations. |
| Dependent personality | Extreme dependency in a close relationship, urgent search to find new one if it ends. Most frequently seen personality disorder, in clinical setting. |
| Obsessive-compulsive personality | Perfectionism, focus on orderliness & control, so much so that pt may not be able to accomplish a given task. |
| Assessment of personality disorders should include: | Full medical hx, Hx/presence of suicidal/homicidal/agressive ideations, Meds, ETOH/drug use, legal hx, Hx of physical/sexual/emotional abuse. |
| Personality disorder diagnoses | Anxiety, defensive coping, ineffective coping, hopelessness, noncompliance, risk for self/other directed violence, risk fo suicide. |
| Limit-setting & consistency are important with: | Borderline or antisocial personality disorders. |
| Assertiveness training & modeling are important with: | Dependent or histrionic personality disorders. |
| What personality disorders tend to isolate themselves? | Schizoid & schizotypal. (This need for isolation should be respected) |
| Milieu therapy | Aimed at affect management in group context. Includes coping skills, psychoeducational, & socializing groups. |
| Dialectical behavior therapy is used for: | Borderline personality disorder. |
| Ego alien | Acting as we know we shouldn't, and feeling uncomfortable about it. |
| Psychotic disorders | Out of touch with reality. Don't think have a problem, won't seek help. Meds can help clear thinking. |
| Anxiety disorders | Pt knows they have this. Will seek help. |
| General characteristics of personality disorders | Inadequate motivation to change, impulsive, egocentric, immediate gratification, unreliable, insincere, lack of remorse, poor judgement, poverty of affective emotions, unable to form close relations. |
| Ego syntonic | Feels normal to pt, get upset at people that criticize them. |
| Freudian Theory | Problem w/ development in genital stage. Can't determine strengths, weaknesses, goals, skills. |
| Erickson | Life span |
| Sullivan | Through age 21 |
| Mahler's Theory of Object Relations | Through 36 months. Differentiation, practicing, rapproachment, consolidation. |
| Differentiation: 5 - 10 months | Recognition of separateness from mother figure. |
| Practicing: 10 - 16 months | Explores the world, still very dependent on mother figure. |
| Rapproachment: 16 - 24 months | Trying to branch out, away from mother figure, still need nearby for emotional security. |
| Consolidation: 24 - 36 months | Sense of separateness established. Child begins to retain quality of relationship even if mother figure not near. |
| Theory of Integration | Object constancy, Integration |
| Object constancy | Decipher personality from other's personality. |
| Integration | Understanding people have good & bad in them. |
| Decreased serotonin leads to | Increased aggression. |
| Brainwaves observed in people with personaity disorders: | Are slower. |
| Personality disorder Tx goals | Short-term problem solving. No cure. |
| Schizophrenia is a group of psychotic disorders that affect: | Thinking, behavior, emotions, and the ability to perceive reality. |
| The term psychosis refers to what? | The presence of delusions, hallucinations, or disorganized speech or catatonic behavior. |
| Schizophrenia comorbidities | Substance abuse, nicotine dependence, depression, suicidal ideation, and anxiety disorders. |
| Diagnosis of schizophrenia requires two or more of these characteristic symptoms for a large portion of a month | Hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. |
| Additional diagnostic tools for schizophrenia | Social/occupational dysfunction, continuous signs for 6 mo or more, s/sx not r/t drug abuse/medical condition, prominent delusions/hallucinations must be present if pervasivie developmental disorder exists. |
| What diagnostic studies are used to help diagnose schizophrenia? | PET scan, CT, MRI and neurotransmitter studies. |
| Positive Symptoms | Hallucinations, delusions, disorganized speech, bizarre behavior. |
| Which symptoms are most easily identified? | Positive symptoms |
| Negative symptoms | Affect - blunted/flat, alogia, avolition, anhedonia, anergia. |
| What symptoms are more difficult to treat? | Negative symptoms |
| Alogia | Poverty of thought/speech. |
| Avolition | Lack of motivation in activities & hygiene. |
| Anhedonia | Lack of pleasure/joy. |
| Anergia | Lack of energy. |
| Cognitive symptoms | Disordered thinking, unable to make decisions, poor problem-solving, difficulty concentrating, memory deficits. |
| Depressive symptoms | Hopelessness, suicidal ideation. |
| How is paranoid schizophrenia characterized? | By suspicion toward others. |
| Common symptoms of paranoid schizophrenia: | Hallucinations, delusions, other-directed violence. |
| How is disorganized schizophrenia characterized? | By withdrawal from society & very inappropriate behaviors. |
| Which type of schizophrenia is frequently seen in the homeless population? | Disorganized schizophrenia. |
| Common symptoms of disorganized schizophrenia: | Loose associations, bizarre mannerisms, incoherent speech, less organized hallucinations/delusions than in paranoid. |
| How is catatonic schizophrenia characterized? | By abnormal motor movements. |
| What are the two stages of catatonic schizophrenia? | Withdrawn & excited. |
| Common symptoms of the withdrawn stage of catatonic schizophrenia: | Psychomotor retardation, waxy flexibility, pt has extreme self-care needs. |
| Common symptoms of the excited stage of catatonic schizophrenia: | Consant movement, unusual posturing, incoherent speech, may be danger to self/others. |
| How is residual schizophrenia characterized? | Active symptoms no longer present, but pt has two or more "residual" symptoms. |
| Common symptoms of residual schizophrenia: | Anergia, anhedonia, avolition, withdrawal from social activities, impaired role function, speech problems, odd behaviors. |
| What are the characteristics of undiferrentiated schizophrenia? | Any positive or negative symptoms may be present. Bizzarre behavior that doesn't meet criteria of other types. |
| Schizoaffective disorder | Schizophrenia and an affective disorder. |
| Ex. of affective disorder | Depression, mania. |
| Brief psychotic disorder | Symptoms last from 1 day - 1 month. |
| Schizophreniform disorder | Symptoms like schizophrenia for 1 - 6 months. Social/occupational dysfunction may/may not be present. |
| Shared psychotic disorder (Folie a Deux) | One person begins to share the delusional beliefs of another. |
| Secondary (induced) psychosis | Brought on by a medical disorder or by use of chemical substances. |
| What brain abnormalities may have a link to schizophrenia? | Enlarged lateral cerebral ventricles, cerebellar atrophy, atrophy of frontal lobe, increased fissure size on brain surface. |
| Acute phase of schizophrenia | Periods of both positive & negative symptoms. |
| Maintenance phase of schizophrenia | Acute symptoms decrease in severity. |
| Stabilization phase of schizophrenia | Symptoms in remission |
| When does schizophrenia become a problem? | When symptoms interfere with interpersonal relationships, self-care, and ability to work. |
| Delusions | False fixed beliefs that cannot be corrected by reasoning & are usually bizarre. |
| Types of delusions: | Ideas of reference, persecution, grandeur, somatic delusions, jealousy, being controlled, thought broadcasting, thought insertion, thought withdrawal, religiosity. |
| Ideas of reference | Misconstrue trivial events & attach personal significance to them. |
| Persecution | Feel singled out for harm by others. |
| Grandeur | Believe self to be all powerful & important. |
| Somatic delusions | Believe body is changing in unusual way. |
| Jealousy | May feel spouse is sexually involved with someone else. |
| Being controlled | Believe force outside own body is controlling it. |
| Thought broadcasting | Believe that thoughts heard by others. |
| Thought insertion | Believe that others' thoughts are being inserted into their mind. |
| Thought withdrawal | Believe that thoughts have been removed by outside agency. |
| Religiosity | Obsessed with religious beliefs. |
| Alterations in speech: | Flight of ideas, neologisms, echolalia, clang association, word salad. |
| Flight of ideas | Associative looseness. Each sentence related to another topic. |
| Neologisms | Made up words that only have meaning to the pt. |
| Echolalia | Pt repeats words spoken to them. |
| Clang association | Meaningless rhyming of words. |
| Word salad | Words jumble together with little meaning/significance to listener. |
| Alterations in perception | Hallucinations, personal boundary difficulties. |
| Hallucinations | Sensory perceptions that have no apparent external stimulus. |
| Types of hallucination | Auditory, visual, olfactory, gustatory, tactile. |
| Personal boundary difficulties | Disenfranchisement with one's own body, identity, and perceptions. |
| Two types of personal boundary difficulties: | Depersonalization & derealization. |
| Alterations in behavior | Extreme agitation, stereotyped behaviors, automatic obedience, wavy flexibilty, stupor, negativism, echopraxia. |
| Stereotyped behaviors | Motor patterns that had meaning to pt but now are mechanical and lack purpose. |
| Automatic obedience | Responding in a robot-like manner. |
| Wavy flexibility | Excessive maintenance of position |
| Stupor | Motionless for long time periods; coma-like. |
| Negativism | Do the opposite of what is requested. |
| Echopraxia | Purposeful imitation of movements made by others. |
| Schizophrenia diagnoses | Ineffective coping, self-care deficit, risk for other/self-directed violence, disturbed thought processes, impaired verbal communication. |
| Interventions - schizophrenia | Milieu therapy, psychotherapy, therapeutic communication, trusting relationship, encourage participation & development of social skill. |
| Atypical antipsychotics | Current meds of choice, treat both pos & neg sx. Risperdal, Zyprexa, Seroquel, Geodon, Abilify, Clozaril. |
| Typical antipsychotics | Mainly pos sx. Haldol, Loxitane, Thorazine, Prolixin. |
| Antidepressants used to treat depression in schizophrenic pts | Paxil |
| Anxiolytics/benzodiazepines used to treat anxiety in scizophrenic pts | Ativan & Klonopin. |
| A nursing diagnosis appropriate for a pt in the acute stage of paranoid schizophrenia | Disturbed thought processes. |
| What are the two hallmark symptoms of schizophrenia? | Hallucinations & delusions. |
| Dereism | Mental activity based on fantasy, not reality. |
| Thought blocking | Sudden stopping in train of thought, or in the middle of a sentence. |
| ______ will have periods of remission, but no cure. | Schizophrenia. |
| How do hallucinations occur? | Begin softly, build to a peak, then go away softly. |
| What stage do we want to first recognize schizophrenia? | With negative symptoms. |
| What is a negative symptom? | The absence of what is considered normal. |
| What symptoms are mainly the reason that schizophrenics can't live independently? | Negative symptoms. |
| Positive symptoms: Formal thought disorders | Disorders of the stream of thought, disorders of the form of thought, disturbances of thought content, disorders of perception. |
| What is a positive symptom? | An addition to what is considered normal. |
| Disorders of the stream of thought | Bombarded with thoughts without the ability to filter them. |
| Disorders of the form of thought | How thoughts are structured, pt never gets to the point. |
| Disturbances of thought content | Delusional thinking most common. |
| Bleuler's Four A's | Association, Affect, Ambivalence, Autistic thinking. |
| Bleuler: Association | Fragmented, rapid subject changes. |
| Bleuler: Affect | Blunted, flat, inappropriate, labile. |
| Bleuler: Ambivalence | Simultaneously holding two different attitudes. |
| Bleuler: Autistic thinking | Intrusion of private fantasy world into thinking. |
| Epidemiology: Schizophrenia | Age of onset > in females, paranoid type earlier in males, female fetus exposed to influenza > risk. |
| How many schizophrenics will attempt suicide? | 50% and 13% will succeed. |
| Command hallucination | "hearing" requests to harm someone. |
| Non-command hallucination | "heaing" a radio that isn't on. |
| Paranoid schizophrenia per Kim | Less neur/cognitive impairment. Better prognosis. Danger to self/others. Persecutory, grandiose delusions. Auditory hallucinations. Sudden onset triggered by stress. |
| What type of schizophrenia is most successfully treated? | Paranoid schizophrenia |
| Disorganized schizophrenia per Kim | Severe personality disintegration. Silly/childish/inappropriate social function. Word salad. Grimace, grunt, posturing. Unable to complete ADLs. Poor prognosis. |
| Catatonic schizoprenia per Kim | Stupor/excitement. Psychomotor disturbance. Echopraxia/echolalia. Dramatic, abrupt onset. Bizarre delusions. |
| Undifferentiated schizophrenia per Kim | No clear connect to other type. Inappropriate affect. Mix of pos & neg sx. Fragmented thought. Severely disturbed sleep (nightmares). |
| Residual schizophrenia per Kim | One acute episode, now free of prominent pos sx. Some neg sx. May last years. Emotionally blunt. Social withdrawal. Eccentric behaviors |
| What hallucinations are most common? | Auditory |
| Schizophrenia discharge criteria | Absence of suicidal ideation. Verbalize control/absence of hallucinations. ID stressors. Support system. Accept referral. Accept responsibility for actions & self-care. Verbalize coping strategies. |
| The four S's of schizophrenia | Stimulation, structure, socialization, support. |
| Stimulation | Slow, gradual introduction to routines, people, places & events. |
| Structure | Routine expectations in waking, dressing, eating, activities. |
| Socialization | Introduce people in life to help with finances, health, food, etc. |
| Support | Encouragement to try new things, accompany to new places. |
| EPS can be treated with: | Antiparkinsonian meds (artane, cogentin). |
| EPS | Dystonia, Akathisia, Pseudoparkinsonism, Akinesia, Tardive dyskinesia, torticollis, Oculogyric crisis. |
| Dystonia | Involuntary muscle contractions that cause abnormal/painful movements/positioning. |
| Akathisia | Syndrome combines a feeling of restlessness with repetitive movement. |
| Pseudoparkinsonism | Shuffling gait, tremors, drooling, mask-like facial expression. |
| Tardive dyskinesia | Potentially irreversible, involuntary movement of muscles in face, tongue, trunk, extremities. |
| Torticollis | Acute dystonic reaction involving neck muscles. |
| Oculogyric crisis | Acute dystonic reaction involving muscles that control eye movement. |
| Neuroleptic malignant syndrome | Life threatening neuro disorder from adverse reaction to neuroleptic/antipsychotic meds. |
| Sx of neuroleptic malignant syndrome | Muscle rigidity, F, autonomic instability, cognitive changes (delirium). |
| How is neuroleptic malignant syndrome diagnosed? | Elevated CPK levels. |
| CPK | < 150 U/L |
| De-escalating aggression | Manage environment. Show confidence. Encourage verbalization. Use non-verbals. Personalize & show concern. Use disengagement breakaways. Use removal, seclusion, restraints. |
| Neuroleptic malignant sydrome Tx | Supportive measures, withdraw medication. |
| Antipsychotic medications are most effective when used along with: | Milieu therapy. |
| Waxy flexibility | Condition in which pt allows body parts to be placed in uncomfortable/bizarre positions. |
| Paranoid | Pervasively and unjustifiably suspicious. |
| Schizoid | Emotionally cold & aloof. |
| Schizotypal | Oddities of thought or perception. |
| Antisocial | Behavior causes conflict with society. |
| Borderline | Impulsive, unpredictable, self-damaging. |
| Histrionic | Overly dramatic and reactive. |
| Narcissistic | Grandiose sense of self importance. |
| Avoidant | Hypersensitive to rejection. |
| Dependent | Passively subordinates own needs. |
| Obsessive-compulsive | Over-meticulous, stubborn |
| Alterations in liver functon d/t cirrhosis | Increased: ALT, AST, ALP, bili, PT & INR, ammonia, creatinine. Decreased: albumin, protein, CBC, WBC, platelets. |
| Albumin & protein may be decreased d/t | a lack of hepatic synthesis |
| Creatinine may be increased d/t | Decreased renal function, secondary to liver disease. |
| Urine specific gravity | 1.005 - 1.030 |
| Preliminary labs | UA, T&C, CBC, Hgb, Hct, PT, INR, PTT, lytes, creatinine, pregnancy, ABG, chest x-ray |
| Myxedema coma | Significantly decreased RR, decreased CO, worsening cerebral hypoxia, stupor, hypothermia, bradycardia, hypotension. |
Created by:
NataschAnn
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