The Nursing Blog for All Nursing Students

BUY NOW VIAGRA CIALIS !!!

2012-07-08T18:12:00.000-07:00

USPS - Fast Delivery Shipping 1-4 day USA
Best quality drugs
Worldwide shipping
Professional packaging
100% guarantee on delivery
Best prices in the market
Discounts for returning customers
FDA approved productas
350000+ satisfied customers

http://mrcut.drugspoul.ru

BUY NOW VIAGRA CIALIS !!!

2012-03-31T12:11:00.000-07:00

http://bugho.pillssaud.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-21T18:41:00.000-08:00

http://knsqa.drugsqual.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-11T20:27:00.000-08:00

http://yobvu.cymedic.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-11T16:58:00.000-08:00

http://pdqeu.lymedic.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-10T03:25:00.000-08:00

http://fovwg.drugspump.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-10T01:45:00.000-08:00

http://mcciu.drugsspro.ru

Max-Gentleman Enlargement*Pills

2012-02-09T22:28:00.000-08:00

http://pbjd.sunear.ru

MaxGentleman Enlargement Pills have been featured across major media outlets around the world, including ESP and Fox News, with dozens of positive reviews.
This is the only Male enlargement supplement that has been PROVEN in clinical trials to enlarge your penis – safely, quickly, and importantly – PERMANENTLY.
Here were the results in 5,000 randomized male subjects who took MaxGentleman for 6 months:

* Increase in penis length by 1-3 inches
* Increase in penis width by 20%.
* Aids in preventing Premature Ejaculation.
* Achieved longer, rock hard erections
* All gains in penis length and width were 100% permanent

MaxGentleman Enlargement pills are also:

* 100% Herbal, 100% Safe
* Doctor Approved and Recommended!
* The only Penis Enlargement pill PROVEN in clinical trials
* No Expensive Doctor Visit Required
* Very Discrete packaging and billing
* 100% Satisfaction & Money Back Guarantee
* 3 FREE Bottles Of MaxGentleman
* Secure State of the Art SSL Encryption.

========================================================

BUY NOW VIAGRA CIALIS !!!

2012-02-08T17:14:00.000-08:00

http://eiilx.pillsclub.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-08T02:41:00.001-08:00

http://pibat.pillstimb.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-07T16:08:00.000-08:00

http://gwoit.pillstimb.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-06T20:18:00.000-08:00

http://szeeq.cianpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-06T16:29:00.000-08:00

http://zdswg.talkpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-05T19:00:00.000-08:00

http://ntvaf.saipills.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-05T02:12:00.000-08:00

http://iwsbz.etdoctor.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-05T01:44:00.000-08:00

http://bomvk.ildpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-03T22:41:00.000-08:00

http://brfsa.aydoctor.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-02T19:56:00.000-08:00

http://qscll.pillsle.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-02T15:46:00.000-08:00

http://ywdez.pillsja.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-01T17:32:00.000-08:00

http://hxivh.drugshele.ru

BUY NOW VIAGRA CIALIS !!!

2012-02-01T13:33:00.000-08:00

http://vcotg.drugsshap.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-31T17:54:00.000-08:00

http://gadjy.pillschai.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-31T02:50:00.001-08:00

http://btkkz.flaxpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-30T21:00:00.000-08:00

http://asgww.pillsfind.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-29T16:12:00.000-08:00

http://swsbf.ertdrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-28T20:58:00.000-08:00

http://kouaw.tusdrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-28T17:25:00.000-08:00

http://aytna.onydrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-28T05:50:00.000-08:00

http://knzqh.drugspeac.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-27T21:31:00.000-08:00

http://tsjyx.onpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-26T21:19:00.000-08:00

http://rygca.drugshate.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-26T15:26:00.000-08:00

http://dncvd.drugsmini.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-26T00:03:00.000-08:00

http://kwaau.drugscou.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-25T19:49:00.000-08:00

http://cfuwy.drugsact.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-25T00:23:00.000-08:00

http://khnbe.riadrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-24T23:27:00.000-08:00

http://ztdjd.eardrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-24T18:54:00.000-08:00

http://cypur.urydrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-24T02:27:00.000-08:00

http://kyhfu.hopdrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-22T20:54:00.000-08:00

http://cqlkv.derdrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-22T19:33:00.000-08:00

http://vslwy.masdrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-22T16:55:00.000-08:00

http://iumjw.yampills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-21T17:29:00.000-08:00

http://lshuw.pplypills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-20T18:02:00.000-08:00

http://bavxb.pillsroom.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-19T18:05:00.000-08:00

http://yvrnw.pillssle.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-19T15:54:00.000-08:00

http://uhmgp.pillslad.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-18T23:29:00.000-08:00

http://ajbfj.pillsnitr.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-18T18:02:00.000-08:00

http://amhil.pillsdepo.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-18T12:52:00.000-08:00

http://obkdo.pillscir.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-17T23:48:00.000-08:00

http://bxtgc.okedrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-17T19:33:00.000-08:00

http://xhjuv.pillsacti.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-17T16:11:00.000-08:00

http://svwpa.ortdrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-17T07:33:00.001-08:00

http://cjchk.iskdrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-16T16:22:00.000-08:00

http://vwxdh.itishpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-16T00:03:00.000-08:00

http://rabqj.clepills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-15T23:32:00.000-08:00

http://gxtjw.drugsgall.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-15T22:29:00.000-08:00

http://xjucp.ndopills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-15T09:10:00.001-08:00

http://ktdob.roomdrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-14T17:11:00.000-08:00

http://xmvhb.ramicdrugs.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-14T06:12:00.000-08:00

http://takvz.umbpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-14T01:05:00.001-08:00

http://etefk.relpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-13T23:29:00.000-08:00

http://dksjw.pillssple.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-13T04:22:00.000-08:00

http://kybdx.medictra.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-12T22:52:00.001-08:00

http://mrlmo.medicres.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-12T20:30:00.000-08:00

http://vztpq.nsepills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-08T22:47:00.000-08:00

http://gnezm.firpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-07T22:09:00.000-08:00

http://suuha.ifypills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-07T13:11:00.000-08:00

http://ezqjt.suspills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-06T18:38:00.000-08:00

http://mfojh.nelpills.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-05T23:32:00.000-08:00

http://vywcm.pillspum.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-05T17:23:00.000-08:00

http://nsqse.pillssha.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-05T10:46:00.000-08:00

http://rzzzn.pillsmat.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-05T00:43:00.000-08:00

http://idwqe.pillstal.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-04T12:37:00.000-08:00

http://iskzl.pillscro.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-04T03:48:00.000-08:00

http://szzdb.pillskey.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-03T20:24:00.000-08:00

http://zotqs.pillsriddl.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-03T09:57:00.001-08:00

http://fhqir.pillsmous.ru

BUY NOW VIAGRA CIALIS !!!

2012-01-02T22:50:00.000-08:00

http://yasem.pillsocta.ru

Canadiana Pharmacy , Save Money !

2012-01-01T23:59:00.000-08:00

http://ouhpq.pillslarc.ru

Canadiana Pharmacy , Save Money !

2012-01-01T23:27:00.000-08:00

http://eaizg.pillsdiffe.ru

Canadiana Pharmacy , Save Money !

2012-01-01T20:37:00.001-08:00

http://slhak.pillsfoxg.ru

Canadiana Pharmacy , Save Money !

2012-01-01T07:57:00.000-08:00

http://szlex.pillsjapan.ru

Canadiana Pharmacy , Save Money !

2011-12-31T18:01:00.000-08:00

http://vfqtl.pillscolo.ru

Canadiana Pharmacy , Save Money !

2011-12-31T10:25:00.000-08:00

http://afjgp.partdrugs.ru

BUY NOW VIAGRA + CIALIS !

2011-12-30T22:53:00.001-08:00

http://azknp.doctorab.ru

Canadiana Pharmacy , Save Money !

2011-12-30T13:18:00.000-08:00

http://xoawy.pillsgrou.ru

BUY NOW VIAGRA + CIALIS !

2011-12-30T06:04:00.000-08:00

http://upeij.doctorsm.ru

BUY NOW VIAGRA + CIALIS !

2011-12-30T00:52:00.000-08:00

http://bbtjm.doctorhy.ru

BUY NOW VIAGRA + CIALIS !

2011-12-29T20:48:00.000-08:00

http://mqegc.medicpat.ru

BUY NOW VIAGRA + CIALIS !

2011-12-29T14:43:00.000-08:00

http://xgawt.medicpai.ru

BUY NOW VIAGRA + CIALIS !

2011-12-29T01:07:00.000-08:00

http://kczqd.medicfib.ru

BUY NOW VIAGRA + CIALIS !

2011-12-28T20:30:00.000-08:00

http://tdjok.medicrav.ru

BUY NOW VIAGRA + CIALIS !

2011-12-28T15:29:00.000-08:00

http://stptm.medicdes.ru

Canada Pharmacy (Holiday Discount)

2011-12-28T08:51:00.001-08:00

http://myyxu.medicbre.ru

( DISCOUNT 20% )BUY NOW VIAGRA & CIALIS

2011-12-28T03:02:00.001-08:00

http://xfyhg.medicsna.ru

( DISCOUNT 20% )BUY NOW VIAGRA & CIALIS

2011-12-27T12:49:00.000-08:00

http://hyurr.medicbot.ru

( DISCOUNT 20% )BUY NOW VIAGRA & CIALIS

2011-12-27T03:46:00.000-08:00

http://lyarz.medicswi.ru

( DISCOUNT 20% )BUY NOW VIAGRA & CIALIS

2011-12-27T03:07:00.000-08:00

http://zfwxd.medicdre.ru

( DISCOUNT 20% )BUY NOW VIAGRA & CIALIS

2011-09-04T02:48:00.000-07:00

http://rxwvc.medicmar.ru

anxiety part I

2008-10-17T11:22:00.001-07:00

Anxiety

Miss Thomas – Monday 10/06/08

Anxiety

Mild

Moderate

Severe

Panic

Anxiety may be differentiated from fear in tat the former is an emotional process, whereas fear is cognitive

Introduction

Increase BP, dry mouth, tight throat, muscle tremors, urinary frequency, sweaty palms,

Anxiety disorders most common type of all psychiatric illnesses

More common in women than men

Minority children and children from lows socioeconomic environments at risk a familial predisposition probably exists

Anxiety disorders cont.

How much is too much?

Heightens alertness senses aware mild anxiety

May be considered abnormal

If anxiety is out of proportion to the situation that is creating it

Anxiety interfere with social, occupational or other important areas of functioning

7 major anxiety disorders

Panic

Agoraphobia

Specific phobias

Social phobias

Generalized anxiety disorder (grouped with panic)

OCD

Post traumatic stress disorder

Panic disorder

Characterized by recurrent panic attacks, onset of which are unpredictable, and manifested by intense apprehension, fear or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort

RN having a panic attack (video on youtube)

Generalized Anxiety disorder

Characterized by chronic, unrealistic, and excessive anxiety and worry

Causes of Anxiety

Threat

Danger –crime, war, bad, weather

Self-esteem- at clinical when you don't feel confident, how you look

Separation- not easy to be separated from loved one

Values – when we face losing freedom in our country

Unconscious influences – repressed, fear of coming out of closet

More causes of Anxiety

Conflict – divided into 3 categories

1.Approach-approach – two dinner invitations for same night, you want to go to both

2. Approach-avoidance – take a new job, want job, but have anxiety about job don't want it

3. Avoidance –avoidance – two alternatives bad – painful illness face surgery – both options are painful

Fear – irrational beliefs ie. making a speech

Unmet needs – Maslow's hierarchy – if basic needs not met, ie shelter, food, water

Physiology – illnesses that may have anxiety component, mitral valve prolapse, COPD, asthma, pulmonary edema (not able to breathe)

Individual differences – well known that people react differently to different situations, ie social, etc

Diagnosis/outcome identification

Anxiety related to real or perceived threat to biological integrity or self-concept

Powerlessness related to impaired cognition

Anxiety: Must have one have

Physiological sx increased HR, BP, SOB

Emotional sx apprehension, nervousness, lack of self confidence

Cognitive – poor orientation, inability to concentrate, lack of awareness of surrounding, forgetfulness
pg 12 carpenito

Powerlessness related to impaired cognition

Overt or covert expressions of dissatisfaction about inability to control situation

These both are part of anxiety

Outcomes

The client is able to recognize signs of escalating anxiety

Is able to intervene so that anxiety does not reach level of panic

The client is able to discuss long term plan to prevent panic/ anxiety when stressful situations occur

Practices techniques of relaxation daily

Engages in physical exercise 3x week

Performs activities of daily living independently

Experiences satisfaction with independent functioning

Is able to maintain anxiety at a manageable level without use of medication

Is able to participate in decision-making thereby maintaining control over life situation

Verbalizes acceptance of life situation over which he or she has no control

Nursing actions

Recognize own anxiety and calm down

Calming tension

Showing love

Help to help someone having a panic attack breathing exercises

Identify causes

Ie snake, shark,

Intervention categories

Biblical interventions

Biological interventions (meds)

Behavioral interventions

Environmental interventions

Encourage action

Individual psychotherapy

Cognitive therapy

404-407 in book

Biblical interventions

Rejoice – call to mind the promises of God

Gentleness & kindness– reduces anxiety

Pray-take even the small details to God, thanksgiving

Think – lock truth onto your mind, stop with negative thoughts, positive thoughts, scriptures

Act

Prevent anxiety – trust God that He looks out for our well-being, focus on others

Medication

Anxiolytics – benzodiazepines – effective for panic attacks

Xanax (alprozolam), Valium (diazepam), Ativan (lorezepan)

Safer than sedatives, are addictive, undesireable for long period

Used prn

Need to know generic and brand name

Problem – physical dependence and tolerance

Abuse

Can not abruptly discontinue use

**know common and trade names for all drugs**

More meds

Non benzodiazepines –(also are anxiolytics)

Buspar

Ambien

More meds

Antidepressants

Tricyclic not used a lot

Elevil (amytryptyline) and Tofranil (imipramine)

SSRI (?effectiveness)

Antihypertensives –propanalol and clonidine (reduce cardiac effects, high BP, sweaty palms)

5 HTP (tryptophane) natural herbal

Exercise

Progressive muscle relaxation

By Edmund Bourne

Phobias

Agoraphobia-without hx of panic disorder: assessment

Fear of being in places or situations from which escape might be difficult or in which help might not be available if a limited-symptom attack or panic-like symptoms should occur

Ie. claustrophobia: elevators

Another name for fear see core concept on 387 endured with marked distress, more common in women and in 20's.

Phobias cont

Specific phobia: Assessment

Excessive fear of situations in which the person might do something embarrassing or be evaluated negatively by others (giving a speech)

Social phobias: assessment

Specific phobia: assessment – marked, persistent, and excessive or unreasonable fear when in the presence of or when anticipating and encounter with a specific object or situation

DSM-IV-TR subtypes

Animal type

Natural environment type

Blood injection injury type

Situational type

Other type

See book 389 table 17-2

Phobias (cont)

1. Learning theory

Fears are conditioned responses and thus are learned by imposing rewards for appropriate behaviors (learned from a parent) classical conditioning

2. cognitive theory

Anxiety is the product of faulty cognitions or anxiety inducing self-instructions

Negative self-statements

Irrational beliefs

Diagnosis: outcome identification

Phobias (cont)

Cognitive theory

Anxiety is the product of faulty cognitions or anxiety-inducing

Fear related to causing embarrassment to self in front of others, to being in a place from which one is uncapable to escape or to a specific stimulus

feelings of dread, fright, apprehension, alarm – major defining characteristics

minor defining characterisitics – cry

pg 161 carpenito

minor characteristics:

cry

aggression

escape

hypervigilence

Social isolation related to fears of being in a place form which one is unable to escape

expressed feelings of aloneness, rejections, desire more contact with people

phobia: they are isolated at home due to phobia (guy who works in high rise can't take elevator)

Outcome

Functions adaptively in the presence of the phobic object or situation without experiencing panic or anxiety

Demonstrates techniques that can be used to maintain anxiety at a manageable level

Voluntarily attends group activities and interacts with peers

Discusses feelings tat may have contributed to irrational fears

Verbalizes a future plan of action for responding in the presence of the phobic object of ritualization without developing panic anxiety

Nursing care of the client with a phobia is aimed at

Helping the client learn to function in the presence of the phobic object without experiencing panic anxiety

Assisting the client to over come fear of leaving home alone

Establish trust – use calm approach

Provide safe environment

Let's face it

Exposure therapy

Real life desensitization –systematic desensitization

Involves unlearning the connection between the phobic situation and an anxiety response

Reassociating feeling of relaxation an calmness with that particular situation

See 406

Behavior therapy "implosion therapy"

Creating a hierarchy

A series of steps that brings you incrementally closer to being in the feared situation

Making the most of exposure therapy

Rely on support person

Be wiling to take risks

Cope with resistance

Be willing to tolerate some discomfort

Avoid flooding and be willing to retreat

Plan for contingencies

Trust you own pace

Reward yourself for small successes

Learn to cope with the early stages of panic

Use positive coping statements

Meds for phobias

Anxiolytics – benzodazepines

Have been shown to reduce symptoms but not the first line treatment

Antidepressants SSRI's Paroxetine and sertraline are used for social anxiety disorder

Antihypertensives – beta blockers propanalol and atenolol (stage fright – sweaty palms,)

Evaluation

Reassessment if conducted to determine whether the nursing actions have been successful in achieving the objectives of care.

Obsessive-Compulsive disorder (OCD)

Assessment data

Recurrent obsessions or compulsions that are severe enough to be time consuming or to cause marked distress or significant impairment

Obsessions:

Unwanted intrusive persistent ideas, thoughts impulse or images that cause marked anxiety or distress

Compulsions: unwanted repetitive behavior patterns or mental acts that are intended to reduce anxiety, not to provide pleasure or gratification

Etiological implications of OCD

Psychoanalytical theory

Clients with OCD have weak, underdeveloped egos

Aggressive impulses are channeled into thoughts and behaviors that prevent the feelings of aggression from surfacing and producing intense anxiety fraught with guilt

Learning theory

Conditioned response to a traumatic event

Passive avoidance

Active avoidance

Biological aspects

Neurobiological disturbances may play a role

Neuroanatomy

Abnormalities in various regions of the brain have been implicated in the neurobiology of OCD

Physiology

Electrophysiological, sleep electroencephalogram, and neuroendocrine studies have suggested that there are commonalities between depressive disorders and OCD

Biological aspects (cont)

Biochemical

Read about 384 read **** neuro pathways / chemicals

OCD – diagnosis

Ineffective coping related to underdeveloped ego, punitive superego, avoidance learning, possible biochemical changes

Ineffective role performance related to need to perform rituals evidenced by inability to fulfill usual patterns of responsibility

Outcomes

The client is to maintain anxiety at a manageable level without resorting to the use of ritualistic behavior

Is able to perform ADL independently

Verbalizes understanding or relationship between anxiety and ritualistic behavior

Demonstrates more adaptive coping strategies

Thought stopping – put rubber band on wrist – pop rubber band, relaxation techniques, physical exercises

Postpone worry

Client is able to resume role-related

Nursing care helping the client learn new, more adaptive coping strategies without resorting to obsessive-compulsive behaviors

Helping

Talk to them after compulsion is over when anxiety is lowest

Avoid punishing

Establish routine

Gradually decrease time for performance of ritual

Meds

Antidepressants

SSRI's fluoxetine, paraoxetine

Sertraline – Zoloft

Fluvoxamine

Selexa -

Know s/e

Headaches,

Sleep disturbances

Restlessness

2-4 weeks to be effective

Evaluation

Reassessment is conducted to determine

Posttraumatic stress disorders

assessment

Development of characteristics sx

Following exposure to an extreme traumatic stressor involving a personal threat to physical integrity or to the physical integrity of others

Reexperiencing (flashback) a traumatic event

Sustained high level of anxiety or arousal

Or a general feeling of numbness or responsiveness

Intrusive recollections or nightmares of the event are common

Self-destructive behavior

Psychosocial theory

The traumatic experience

Severity & duration of the stressor

Extent of preparation before onset

Exposure to death

Numbers affected by life threat

Amount of control over recurrence

Location where trauma was experienced

Individual

Degree of ego strength

Effectiveness of coping resources

Presence of pre-existing psychopathology

Outcomes of previous stressor.trauma

Behavioral tendencies

Recovery environment

Availability of social supports

Cohesiveness of & protectiveness of family and friends

Attitudes of society regarding the experience

Cultural & subcultural influence

Learning theory

Negative reinforcement

Behavior patterns drugs/ alcohol numb themselves from stress

Avoidance behavoiors

Cognitive theories

World view violated them

Biological aspects

It has been suggested that a person who has experienced previous trauma is more likely to develop symptoms after a stressful life event

Outcome

Posttrauma related to distressing event considered to be outside of the range of usual human experience

Complicated grieving related to the loss of self as perceived before the trauma or other actual or perceived losses incurred during or after the event

Outcomes

The client can acknowledge the traumatic even the impact it has had on his or her life.

Is experiencing fewer flashbacks, intrusive recollections and nightmare than he or she was on admission

Get enough sleep

The client:

Verbalizes community resources form whom e or she may seek assistance in times of stress

Attends support group ** most important

Nursing care is aimed at providing assistance with integration of the trauma into his her persona

Renewing meaningful goals

Renewing significant relationship

Progressing through grief process

Devel9oping a sense of optimism and hope for futre

Actively listen\

Assess suicide risk

Assist client to dev. objectivity about event & encourage group therapy** most important

Meds SSRI's first line of tx

Paraxeiine – Paxil

Sertraline – Zoloft

Anxiolytics – use is discouraged because of abuse

Benzos

Antihypertensives

Others

Group therapy

Has proven to be effective for PTSD sufferers

Share experiences

Talk about problems of social adaptation

Discuss options for managing

Evaluation

Reassessment

Nature of the illness

Client/family education read in book

What is anxiety?

What might it be related to?

What is OCD

What is PTSD

Sx of anxiety disorders

Management of illness

Meds

Adverse effects

Length of time to take effect 2-4 wks

What to expect from med

Stress management

Teach way to interrupt escalating anxiety

Teach relaxation techniques

Crisis hotline

Support groups

Individual psychotherapy

anxiety

2008-10-17T11:21:00.001-07:00

Anxiety-related disorders

Miss Thomas Friday 10/10/08

Evidence does exist to support the presence of organic pathology or a known pathophysiological process

Somatoform: characterized by physical symptoms suggesting medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to account for them.

Pain disorder: predominant disturbance in pain disorder is severe and prolonged pain that causes clinically significant distress or impairment in social, occupational or other areas of functioning (chronic pain that affects their functioning).

Hypochondriasis: a preoccupation with the fear of contracting or the belief of having a serious disease

The fear becomes disabling and persists despite reassurance that no organic pathology can be detected

Do Doctor-shopping

Conversion disorder

A loss of or change in body function resulting from a psychological conflict the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism ie. blindness, seizures,

La belle indifference

Ways to reduce pain/anxiety

Focus activities away from pain

Exercise

Reaffirm that tests reveal no pathology

Dissociative disorders

Dissociative amnesia: inability to recall important personal data that is too extensive to be explained by ordinary forgetfulness, onset can follow stress,

Dissociative fugue: very rare

thyroid

2008-10-17T11:16:00.001-07:00

Thyroid

Affects: Metabolism, CV fxn, GI fxn, and neuromuscular fxn.

Body temperature – control at 98.6. endocrine system will work to help this

Must have iodine to work

Hyper/hypo most common disorders

Deficiency predisposes to hyperpthyroidism

Grave most common hyperthyroidism

Associated with myasthenia gravis & pernicious anemia

Goiter with graves, flushed moist skin, nervousness and weight loss,

Exopthalmos due to impaired venous draining from orbit – leading to increased deposits of fat & fluid in retro-orbital tissues – upper eyelids retracted & elevated, won't close at night, watch for corneal ulcers, need to tape shut at night.

Pretibial myexedema – dry waxing swelling in front of shin bone.

Heart rate up to 150, temp 105, can be caused by surgery which increase can touch thyroid and stimulate release of hormones, infection, trauma,

Treatment: prevent death

Diagnostic studies

TA test – eleveated in graves

TSH

Radioactive iodine uptake test

Treatment

Improve 1-2 weeks after initial therapy.

After 4-8 week good results, 6 months spontaneous remission

Target thyroid not affect that in circulation

Long term iodine therapy not effective in controlling hyperthyroidism

Radioactive iodine limit thyroid tissue and can result in hypothyroidism

Beta adrenergic – treat heart palpitations

Nutritional management

Avoid highly seasoned food & caffeine so as not to speed up more

Thyroidectomy – performed if thyroid is enlarged to the point is putting pressure on the trachea or esophagus

May be total or subtotal removal

Subtotal: leave enough of gland to produce hormone

Total requires life-long replacement

Thyroid surgery

Fowler – prevent aspiration

Chronic & home management

Will have periods of hypothyroidism after surgery

Fine window to watch for both

Thyroid enlargement

Calorie intake reduced substantially

Iodine need for thyroid fxn

And seafood 2x week

Regular exercise to stimulate thyroid

At first biweekly visits for a month then 2 x year to assess fxn for rest of life to make sure not develop hypothyroidism

Thyroid nodules

Usually hard and painful, diagnosed by thyroid scan iodine 131

Tumor that show up are called hot nodules and need to be removed

Thryoiditis

Acute due to bacterial/ fungal infections,

Hashimoto's – chronic- insidious onset, chronic autoimmune where cells replaced by fibrous tissue

Subacute:

Chronic:

Hashimoto's

Hyperthyroidism TX

Thyroid crisis/storm

Extreme state of hyperthyroidism (rare)

Due to improved diagnosis and tx

Usually effects people with untreated hyperthyroidism

This is a life-threatening condition (usually caused by surgery to neck)

Thyroid storm

The rapid increase in metabolic rate that results from the excessive TH causes the manifestations of thyroid storm

Manifestations include temp from 102 F to 106F increased HR, BP, GI sx agitation, tremors,

Can progress to death, so rapid tx is essential

Tx with cooling blanket, replace fluid, electrolytes, maintain respiratory status, monitor HR,

Hyperthyroidism

Monitor vitals, SOB, skin – cap refill, maintain cool, quiet environment, balance rest/activity periods

Disturbed sensory perception visual: turn lights low, artificial tears, cover eyes, head of bed at 45 to drain eyes, report vision changes,

Nutrition:

Disturbed body image – can lose hair, fatigue, sweating

Hypothyroidism: cretinism

Adult – atrophy of gland

Primary hypothyroidism

Caused by congenital defects in the gland loss of thyroid tissue following treatment for hyperthyroidism, thyroiditis, or iodine deficiency

Secondary hypothyroidism

Results from pituitary TSH deficiency or peripheral resistance to thyroid hormones

Has a slow onset with manifestation occurring over months or even years

Treatment will cause reversal of sx.

Clinical manifestations of both types with adult onset

Goiter, fluid retention and edema, decreased appetite, weight gain, constipation, dry skin, dyspnea, pallor, hoarseness & muscle stiffness

Infant onset

Appear normal at birth due to circulating hormones of mother in bloodstream,

Look for large infant fails to thrive & long gestational period

Excessive sleeping, skin lips enlarged, feeding respiratory difficulties, squint due to peri-orbital edema screened for test heel stick T4 & TSH

Causes irreversible dwarfism & mental retardation

If caught in time, will develop normally

Childhood manifestations

Generalized muscle hypertrophy

Adulthood

Slowing of body processes, personality changes, fatigue, lethargy, severity depends on degree of hormone deficiency,

Myxedema

Triggered by acute illness or trauma, edema due to water retention in muco-protein deposits in interstitial spaces – have puffy tongue, voice hoarse, husky, peri-orbital edema, sub normal temperature, hypotension, ventilation, can progress to point that they need ventilator until you stabilize them.

Hashimotos thyroiditis

Most common cause of goiter

Autoimmune disorder

Antibodies develop and destroy thyroid tissue

Get a goiter

Functional thyroid tissue is replaced with fibrous tissue and TH level decrease

Decreased thyroid hormone in early stages of disease prompt gland to enlarge & cause goiter

Treatment:

Comfortable warm environment due to slower metabolism, prevent skin breakdown, avoid sedatives, when giving hormones monitor CV status,

Nursing diagnosis

Decreased cardiac output, constipation

Risk for impaired skin integrity – dry rough skin, decreased circulation to peripheral slow wound healing, keep in warm environment, frequent rest period, high fiber diet,

Thyroid cancer

Very rare

Palpable firm nontender nodule in the thyroid

Tx is subtotal or total thyroidectomy

Parathyroid – 4 glands on back of thyroid

Increased levels of hormone act on kidney to increase reabsorption of calcium and increased phosphate excretion

Primary pg 547

Occur when there is hyperplasia or an adenoma in one of the parathyroid glands

This interrupts the normal regulatory mechanism between serum CA and PTH secretion and increase the absorption of ca in the GI tract

Secondary

Is a compensatory response by the parathyroid glands to chronic hypocalcemia

Characterized by an increased secretion of PTH

Tertiary

Results from hyperplasia of the parathyroid gland and a loss of response to serum CA levels

Most often seen in pt with chronic renal failure

Diagnostic

CA & phos opposite

Treatment

Mithracmycin anti hx agent to lower CA levels

IV saline

Inderal used to inhibit

Surgery – same post op as with thyroid surgery

Major complication is tetany due to calcium

Unpleasant tingling around mouth, hands

Hypoparathyroidism

Lack of PTH causes hypocalemia and an elevated blood phosphate level

Most common is removal of parathyroid gland

Clinical manifestations

Therapeutic management

Know s/sx tetany

Nursing management

Hyperparathyroidism