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Transcript of NED Teaching
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Fetal Alcohol Syndrome
- Alcohol in pregnancy; Drinking alcohol during pregnancy;
- Fetal alcohol syndrome refers to growth, mental, and physical
problems that may occur in a baby when a mother drinks alcoholduring pregnancy.
- Alcohol crosses the placental barrier and can stunt fetalgrowth or weight, create distinctive facial stigmata,damage neurons and brain structures, which can result in
psychological or behavioral problems, and cause other physicaldamage.
- The main effect of FAS is permanent central nervous systemdamage, especially to the brain. Developing brain cells andstructures can be malformed or have development
interrupted by prenatal alcohol exposure; this can create anarray of primary cognitive and functional disabilities (includingpoor memory, attention deficits, impulsive behavior, and poorcause-effect reasoning) as well as secondary disabilities (forexample, predispositions to mental health problems and
drug addiction).
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Causes, incidence, and risk factors:
Using or abusing alcohol during pregnancy can cause the same risks
as using alcohol in general. However, it poses extra risks to thefetus. When a pregnant woman drinks alcohol, it easily passes
across the placenta to the fetus. Because of this, drinking alcohol
can harm the baby's development.
A pregnant woman who drinks any amount of alcohol is at risk,
since no "safe" level of alcohol use during pregnancy has beenestablished. However, larger amounts appear to increase the
problems. Binge drinking is more harmful than drinking small
amounts of alcohol.
Timing of alcohol use during pregnancy is also important. Alcohol
use appears to be the most harmful during the first 3 months ofpregnancy However, drinking alcohol anytime during pregnancy can
be harmful.
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Signs and Symptoms:
Poor growth while the baby is in the womb and after birth
Decreased muscle tone and poor coordination
Delayed development and significant functional problems in three
or more major areas: thinking, speech, movement, or social skills
(as expected for the baby's age)
Heart defects such as ventricular septal defect or atrial septal
defect. Structural problems with the face, including:
Narrow, small eyes with large epicanthal folds
Small head (microcephaly)
Small upper jaw Smooth philtrum ( groove in upper lip )
Smooth and thin vermillion (upper lip)
Micrognathia (small lower jaw)
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Diagnostic Tests/Exam:
A physical exam of the baby may reveal a heart murmur or other
heart problems. As the baby grows, there may be signs of delayed
mental development. There also may be structural problems of the
face and skeleton.
Tests include:
Blood alcohol level in pregnant women who show signs of being
drunk (intoxicated) Brain imaging studies (CT or MRI) shows abnormal brain
development.
Pregnancy ultrasound shows slowed growth of the fetus
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Treatment:
There is no cure or treatment for the disabilities of fetal alcohol syndrome
but there are certain protective factors that can be implemented to lessen
or prevent the development of secondary conditions associated with FAS.There is no medication or treatment that will reverse the symptoms of
fetal alcohol syndrome and the other disorders associated with alcohol-
related birth defects.
Management:a. Early Diagnosis
Children who are diagnosed early have more positive outcomes that those
who are not. The earlier a FAS child is placed in appropriate educational
classes and given essential social services, the more improved the
prognosis. Early diagnosis also helps family members and teachersunderstand the reactions and behavior of the FAS child, which can differ
widely from other children in the same situations.
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b. A Loving, Nurturing, and Stable Caretaking Environment
All children benefit from a loving, nurturing and stable home life.
But children with fetal alcohol syndrome have been found to be
more sensitive to disruptions, transient lifestyles and harmfulrelationships. To prevent the secondary conditions associated with
FAS, children who have fetal alcohol syndrome need support from
family and the community.
c. An Absence of Violence
Individuals with fetal alcohol syndrome who live in stable or
nonabusive households, or who do not become involved in youth
violence, are much less likely to develop long-term effects
associated with the condition than children who have been exposedto violence. Children with fetal alcohol syndrome may need to be
taught other ways of showing their anger or frustration.
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d. Involvement in Special Education and Social Services
Children who receive special education geared towards their
specific needs and learning styles are more likely to achieve their
developmental and educational potential. Children with fetal
alcohol syndrome show a wide range of behaviors and severity of
symptoms. Special education allows for individualized educational
programs. In addition, families of children with fetal alcohol
syndrome who receive social services, such as respite care or stress
and behavioral management training, have more positive outcomes
than families who do not receive such services.
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Prevention:
Avoiding alcohol during pregnancy prevents fetal alcohol syndrome.
Counseling can help prevent recurrence in women who have
already had a child with fetal alcohol syndrome.
Sexually active women who drink heavily should use birth control
and control their drinking behaviors, or stop using alcohol before
trying to conceive.
References:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001909/
http://en.wikipedia.org/wiki/Fetal_alcohol_syndrome
http://pregnancy.emedtv.com/fetal-alcohol-syndrome/treatment-of-fetal-alcohol-syndrome-p2.html
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Child and Adolescent DisordersLearning Objectives:
After discussing this chapter, the student will be able to:
1. Discuss the characteristics, risk factors, and family dynamics of
psychiatric disorders of childhood and adolescence such as AUTISM
and ADHD.
2. Apply the nursing process to the care of children and adolescentswith psychiatric disorders and their families.
3. Provide education to clients, families, teachers, caregivers, and
community members for young clients with psychiatric disorders.
4. Evaluate his or her feelings, beliefs, and attitudes about clients with
psychiatric disorders and their parents and caregivers.
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AUTISTIC DISORDER
Autistic disorder
Autistic spectrum disorder (ASD) is a condition that affects
how the brain functions. It affects how a person communicates
with, and relates to, other people. It also affects how they make
sense of the world around them. Autism affects information
processing in the brain by altering how nerve cells and
their synapses connect and organize; how this occurs is not well
understood.
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Cause:
a. Symptoms of ASD are caused by an abnormality in thedevelopment of the brain that occurs before, or soon after birth. Its
now known exactly what causes this abnormality.
b. Some evidence shows that having a defective gene may be a riskfactor in developing ASD. These genes may be inherited, and thechance of you having ASD if your brother or sister has it, is slightlyhigher than in the rest of the general population.
Hereditability contributes about 90% of the risk of a childdeveloping autism, but the genetics of autism are complex andtypically it is unclear which genes are responsible. In rare cases,autism is strongly associated with agents that causes birth defects.
c. Some research suggests that environmental factors such aspollution or viruses such as rubella (German measles) may triggerASD. However, ASD is not a result of anything that a parent hasdone either during pregnancy or after the child is born.
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Signs and Symptoms:
The first symptoms of ASD usually appear when the person is under
two - three years old, and last throughout life
Children with autism display little eye contact with and make few
facial expressions toward others; they do not use gestures to
communicate.
They do not relate to peers or parents.
They lack spontaneous enjoyment, have apparently no moods or
emotional affect, and cannot engage in play or make-believe with
toys.
There is little intelligible speech. These children engage in
stereotyped motor behaviors such as handflapping, body-twisting,or head-banging.
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have little or no interest in other people, and find it difficult make
friends.
not understand other peoples emotions, and prefer to spend time alone.
use odd phrases and use odd choices of words,
use more words than is necessary to explain simple things,
make up their own words or phrases,
play the same games over and over, or play with games designedfor children younger than themselves,
get upset if their daily routines are interrupted in any way
Prefers solitary or ritualistic play
Shows little pretend or imaginative play
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Treatment:
The goals of treatment of children with autism are:
to reduce behavioral symptoms and
to promote learning and development particularly the acquisition
of language skills.
Comprehensive and individualized treatment including
special education and language therapy is associated
with more favorable outcomes.
Pharmacologic treatment with antipsychotics such as haloperidol (Haldol) or
risperidone (Risperdal) may be effective for specific target symptoms such as
temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped
behaviors.
Currently, only Risperidone (Risperdal) is approved to treat children ages 5 -
16 for the irritability and aggression that can occur with autism. Other medicines
that may also be used include SSRIs, divalproex sodium and other mood stabilizers,
and possibly stimulants such as methylphenidate. There is no medicine that treats
the underlying problem of autism.
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References:
Psychiatric Mental Health Nursing, Edition 5 by Sheila L. Videbeck
pg. 484
http://en.wikipedia.org/wiki/Autism#Diagnosis
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002494/
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Attention deficit hyperactivity disorder (ADHD)
- is characterized by inattentiveness, overactivity, and impulsiveness.
- ADHD is a common disorder, especially in boys, and probably
accounts for more child mental health referrals than any other
single disorder.
- essential feature of ADHD is a persistent pattern of inattention
and/or hyperactivity and impulsivity more common than generally
observed in children of the same age.
Etiology:
Although much research is taking place, the definitive causes ofADHD remain unknown. A combination of factors, such as
environmental toxins, prenatal influences, heredity, and damage to
brain structure and functions, is likely responsible.
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Risk factors for ADHD include:
family history of ADHD;
male relatives with alcoholism; lower socioeconomic status;
Male gender; marital or family discord, including divorce, neglect,
abuse, or parental deprivation;
low birth weight; and various kinds of brain insult
SIGNS AND SYMPTOMS OF ADHD:
INATTENTIVE BEHAVIORS HYPERACTIVE/IMPULSIVE
BEHAVIORS
Misses details FidgetsMakes careless mistakes Often leaves seat, (e.g., during
a meal)
Has difficulty sustaining attention Runs or climbs excessively
Doesnt seem to listen Cant play quietly
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Has difficulty with organization Talks excessively
Avoids tasks requiring mental effort Blurts out answers
Often loses necessary things InterruptsIs easily distracted by other stimuli Cant wait for turn
Treatment:
The most effective treatment combines pharmacotherapy withbehavioral, psychosocial, and educational interventions.
The most common medications are Methylphenidate (Ritalin) and
an Amphetamine compound (Adderall)
The most common side effects of these drugs are insomnia, loss of
appetite, and weight loss or failure to gain weight. In therapeutic play, play techniques are used to understand the
childs thoughts and feelings and to promote communication.
Dramatic play is acting out an anxiety-producing situation such as
allowing the child to be a doctor or use a stethoscope or other
equipment to take care of a patient (a doll)
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APPLICATION OF THE NURSING PROCESS: ADHD
Assessment:
HISTORY
GENERAL APPEARANCE AND MOTOR BEHAVIOR
JUDGMENT AND INSIGHT
SELF-CONCEPT
ROLES AND RELATIONSHIPS
PHYSIOLOGIC AND SELF-CARE CONSIDERATIONS
Data Analysis and Planning:
Nursing diagnoses commonly used when working with children with ADHD
include the following:
Risk for Injury Ineffective Role Performance
Impaired Social Interaction
Compromised Family Coping
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Outcome Identification
Treatment outcomes for clients with ADHD may
include the following:
The client will be free of injury.
The client will not violate the boundaries of
others.
The client will demonstrate age-appropriate
social skills.
The client will complete tasks. The client will follow directions.
Intervention:
1. ENSURING SAFETY
For example, if the child was jumping down a flight of stairs, the adult might say,
It is unsafe to jump down stairs. From now on, you are to walk down the stairs,one at a time.If the childcrowded ahead of others, the adult would walk the child
back to the proper place in line and say, It is not OK to crowd ahead of others.
Take your place at the end of the line.
2. IMPROVING ROLE PERFORMANCE
For example, the adult might say, You walked down the stairs safely orYou did a
good job of asking to play with the guitar and waited until it was your turn.
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3. SIMPLIFYING INSTRUCTIONS
It helps to provide specific, step-by-step directions rather than give a
general direction such as Please clean your room. The adult could say,
Put your dirty clothes in the hamper. After this step is completed, the
adult gives another direction: Now make the bed. The adult assignsspecific tasks until the childhas completed the overall chore.
4. PROVIDING CLIENT AND FAMILY EDUCATION AND SUPPORT
CLIENT/FAMILY TEACHING FOR ADHD
Include parents in planning and providing care.
Refer parents to support groups.
Focus on childs strengths as well as problems.
Teach accurate administration of medication and possible side effects.
Inform parents that child is eligible for special school services.
Evaluation: Parents and teachers are likely to notice positive outcomes of treatment
before the child does. Medications are often effective in decreasing
hyperactivity and impulsivity and improving attention relatively quickly, if
the child responds to them. Improved sociability, peer relationships, and
academic achievement happen more slowly and gradually but are possible
with effective treatment.
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COGNITIVE DISORDERSLearning Objectives:
After reading this chapter, the student should be able to:1. Describe the characteristics of and risk factors for cognitive disorders.
2. Distinguish between delirium and dementia in terms of symptoms,
course, treatment, and prognosis.
3. Apply the nursing process to the care of clients with cognitive disorders.
4. Identify methods for meeting the needs of people who provide care to
clients with dementia.
5. Provide education to clients, families, caregivers, and community
members to
increase knowledge and understanding of cognitive disorders.
6. Evaluate his or her feelings, beliefs, and attitudes regarding clients with
cognitive disorders.
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Cognitive Disorder
is a disruption or impairment in these higher-level
functions of the brain. Disorders in which the central feature is the
impairment of memory, attention, perception, andthinking.
The primary categories of cognitive disordersare delirium, dementia, and amnestic disorders. All
involve impairment of cognition, but they vary with
respect to cause, treatment, prognosis, and effect on
clients and family members or caregivers.
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DELIRIUM
Delirium is a syndrome that involves a disturbance of consciousnessaccompanied by a change in cognition.
Associated features include:
Clouded sensorium no clear awareness of surroundings
Problems with attention
Disturbance in memory
Incoherent speech
Perceptual disturbances (e.g., hallucinations)
Cause / Risk Factors:
Delirium is most often caused by physical or mental illness and is usually
temporary and reversible. Many disorders cause delirium, includingconditions that deprive the brain of oxygen or other substances.
Causes include:
1. Alcohol or sedative drug withdrawal and drug abuse
2. Infections such as UTI or pneumonia (more likely in people who already have
brain damage from stroke)
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3. Physiologic or metabolic : Hypoxemia,renal or hepatic failure, dehydration, thiamine
or vitamin B12 deficiency, cardiovascular shock, and exposure to gasoline, paint
solvents, insecticides, and related substances
Types of Delirium:1. Hyperactive or hyperalert
the patient is hyperactive, combative and uncooperative.
May appear to be responding to internal stimuli
Frequently these patients come to our attention because they are difficult
to care for.
2. Hypoactive or hypoalert
Pt appears to be napping on and off throughout the day
Unable to sustain attention when awakened, quickly falling back asleep
Misses meals, medications, appointments
Does not ask for care or attention
This type is easy to miss because caring for these patients is not
problematic to staffs.
3. Mixed - a combination of both types just described. The most common
types are hypoactive and mixed accounting for approximately80% of delirium cases.
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SYMPTOMS OF DELIRIUM:
Delirium involves a quick change between mental states
(for example, from lethargy to agitation and back to lethargy).
Difficulty with attention
Easily distractible
Disoriented
May have sensory disturbances such as illusions,
misinterpretations, or hallucinations
Can have sleepwake cycle disturbances
Changes in psychomotor activity
may be slow moving or hyperactive
May experience anxiety, fear, irritability, euphoria,or apathy
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Treatment and Management:
The primary treatment for delirium is to identify and to treat any causal or
contributing medical conditions.
a. PSYCHOPHARMACOLOGY Clients with quiet, hypoactive delirium need no specific pharmacologic
treatment aside from that indicated for the causative condition.
Sedation to prevent inadvertent self-injury may be indicated. An antipsychotic
medication such as haloperidol (Haldol) may be used in doses of 0.5 to 1 mg
to decrease agitation.
b. OTHER MEDICAL TREATMENT
Adequate, nutritious food and fluid intake will speed recovery.
Intravenous fluids or even total parenteral nutrition may be necessary if a
clients physical condition has deteriorated and he or she cannot eat and drink.
If a client becomes agitated and threatens to dislodge intravenous tubing or
catheters, physical restraints may be necessary so that needed medical
treatments can continue.
Behavior modification to control unacceptable or dangerous behaviors
Reality orientation to reduce disorientaion.
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MOOD AND AFFECT
Clients with delirium often have rapid and unpredictable mood shifts. A wide
range of emotional responses is possible such as anxiety, fear, irritability,
anger, euphoria, and apathy. These mood shifts and emotions usually havenothing to do with the clients environment. When clients are particularly
fearful and feel threatened, they may become combative to defend
themselves from perceived harm.
THOUGHT PROCESS AND CONTENT
Thought processes often are disorganized and make no sense. Thoughts also
may be fragmented (disjointed and incomplete). Clients may exhibit delusions,
believing that their altered sensory perceptions are real.
SENSORIUM AND INTELLECTUAL PROCESSES
The primary and often initial sign of delirium is a altered level of consciousness
that is seldom stable an usually fluctuates throughout the day. Clients usually
are oriented to person but frequently disoriented to time and place. Clients cannot focus, sustain, or shift attention effectively, and there is
impaired recent and immediate memory . This means the nurse may have to
ask questions or provide directions repeatedly.
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Data Analysis:
The primary nursing diagnoses for clients with delirium are as follows:
Risk for Injury
Acute Confusion
Additional diagnoses that are commonly selected based on client assessment
include the following:
Disturbed Sensory Perception
Disturbed Thought Processes
Disturbed Sleep Pattern
Risk for Deficient Fluid Volume
Risk for Imbalanced Nutrition: Less Than Body Requirements
Outcome Identification:
Treatment outcomes for the client with delirium may include the
following:
The client will be free of injury.
The client will demonstrate increased orientation and reality contact.
The client will maintain an adequate balance of activity and rest.
The client will maintain adequate nutrition and fluid balance.
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Intervention:
PROMOTING THE CLIENTS SAFETY
Maintaining the clients safety is the priority focus of nursing interventions.
Medications should be used judiciously because sedatives may worsen
confusion and increase the risk for falls or other injuries
MANAGING THE CLIENTS CONFUSION
The nurse approaches these clients calmly and speaks in a clear, low voice. It is
important to give realistic reassurance to clients such as I know things are
upsetting and confusing right now, but your confusion should clear as you getbetter
Orient to reality
PROMOTING SLEEP AND PROPER NUTRITION
Monitor the clients sleep and elimination patterns and food and fluid intake.
Assisting clients to the bathroom periodically may be necessary to promoteelimination if clients do not make these requests independently.
It is also important for clients to have some exercise during the day to promote
nighttime sleep. Activities could include sitting in a chair, walking in the hall, or
engaging in diversional activities (as possible).
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SUMMARY OF NURSING INTERVENTIONS FOR DELIRIUM:
Promoting clients safety
Teach client to request assistance for activities (getting out of bed, going to bathroom).
Provide close supervision to ensure safety during these activities.
Promptly respond to clients call for assistance.
Managing clients confusion
Speak to client in a calm manner in a clear low voice; use simple sentences.
Allow adequate time for client to comprehend and respond.
Allow client to make decisions as much as able.
Provide orienting verbal cues when talking with client.
Use supportive touch if appropriate.
Controlling environment to reduce sensory overload Keep environmental noise to minimum (television, radio).
Monitor clients response to visitors; explain to family and friends that client may need to visit quietly
one on one.
Validate clients anxiety and fears, but do not reinforce misperceptions.
Promoting sleep and proper nutrition
Monitor sleep and elimination patterns. Monitor food and fluid intake; provide prompts or assistance to eat and drink adequate amounts of flood
and fluids.
Provide periodic assistance to bathroom if client does not make requests.
Discourage daytime napping to help sleep at night.
Encourage some exercise during day like sitting in a chair, walking in hall, or other activities client
can manage.
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Evaluation
Usually successful treatment of the underlying causes of delirium returns
clients to their previous level of functioning. Clients and caregivers or family
must understand what health care practices are necessary to avoid arecurrence. This may involve monitoring a chronic health condition, careful use
of medications, or abstaining from alcohol or other drugs.