VIOLENCE AND ABUSE

Signs of sexual abuse in a child

o May exhibit behavioral extremes
Aggressive
Overly submissive
Child-like
Regressive
o Child fears the parent/caretaker
o May exhibit severe depression, withdrawal, or suicidal behavior
o May present with sexual acting out or prostitution
o Inappropriate seasonal dress
o Telling sexually explicit stories
Signs that an adolescent has been sexually abused
o May present with sexual acting out or prostitution
o Inappropriate seasonal dress
o Telling sexually explicit stories
o Nightmares and flashbacks
Cycle of violence phases
o Tension building stage
Marked by verbal abuse and minor physical assaults (hitting, slapping)
Abuser often reduces tension with alcohol or drugs; has minor explosions
Victim blames self, feels helpless, and displays compliance
o Acute battering stage
Marked by brutal beating
Abuser and victims experience unbearable tension
Victim may try to cover up incident or look for help
o Honeymoon stage
Abuser exhibits loving behavior, feels sorry, makes promises to changes,
and brings gifts
Victim is trusting, hoping for change, desperately wants to believe
partners promises, and stays due to feelings of guilt or being to blame
Both the victim and the abuser are in denial
Period of most danger in a domestic abuse situation
o When the individual being abused leaves
Nursing assessment of elderly abuse victims
o Difficult to identify due to embarrassment or inability to report, as well as the fear
of abandonment or escalation of violence
o Abuse occurs in the physically or mentally impaired
o Individual may present as aggressive or submissive
o Malnutrition
o May have been an abuser themselves
o Increased risk for suicide due to feeling like a burden

Feelings of the nurse when caring for an abuse victim

o Strong negative feelings about the abuser
o Intense, protective feelings towards the victim
o Anger at the woman for staying in the abusive relationship
What should the perpetrator do instead of acting out violently?
From a crises intervention perspective - what do we want to know (assess) when a rape
victim enters the emergency room?
o Determine coping mechanisms as soon as possible such as support systems
o Obtain an informed consent to collect rape evidence
o Assess suicidal risk by asking if the individual is thinking about committing
suicide
What is most important to educate the rape victim about upon discharge from the
emergency room?
o Keep follow-up appointments with rape victim advocate after discharge
o Give referral information for community groups as follow-up and long-term
therapy
o Reassure victim that abuse is not their fault
MOOD DISORDERS

What is bipolar disorder?

o Alternating moods between depression and euphoria
o Onset is usually before age 30
What does ECT treat?
o Used to treat bipolar disorder when a rapid response is needed to prevent suicide
in the severely depressed, or there is a poor response to antidepressant
psychotherapy
SSRI side effects and precautions
o Side effects:
Drowsiness
Insomnia
Anxiety
Nervousness
Sexual dysfunction
Abdominal pain
Diarrhea
Hyperactivity
Restlessness
May interfere with blood, liver, and renal functions
o Precautions:
Risk for suicidal ideation
Interacts with digoxin and warfarin and OTC herbs
Tricyclic side effects and precautions

o Side effects:
Dry mouth
Nausea
Increased suicidal ideations
o Precautions:
Risk for suicide by overdose
Risk for heart problems
MAO inhibitors: Side effects and dietary precautions
o Side effects:
Interaction with Tyramine, an amino acid that stimulate the release of
epinephrine and norepinephrine
Urinary retention
Hypertensive crisis marked by sudden severe increase in blood pressure
which exceeds 200/130
Severe headaches
Cardiac arrythmias
Nose bleeds
Muscle twitches (can lead to convulsions as well as a coma)
o Dietary precautions:
Beer and red wine
Chocolate
Pepperoni/salami
Aged cheeses
Sour cream
Broad beans
Avocados
Yogurt
Bananas
Length of time to see effectiveness of antidepressants
Precautions when discontinuing antidepressants
All interventions in major depressive disorder
o Monitor intake of food and fluids
Client will eat 50% of meals within 2 days
Loss of appetite = priority focus
o Weigh daily
o Maintain schedule of regular activities
o Remove potentially harmful articles
o Contract with client to report suicidal feelings
o Assist with dressing, feeding, and hygiene
o Encourage verbalization of feelings
o Accept clients negativity without judging
o Dont attempt to cheer the client up, because its not effective and may make the
client worse

This is due to the fact that they cant meet the expectations
Results in further depression and guilt
o Give appropriate positive feedback to increase self esteem
o Avoid excessive cheerfulness
o Medical management:
Electroconvulsive therapy
Administration of antidepressants as ordered
o Limit group activities until patient can respond appropriately
Too challenging and individual doesnt have enough energy
Facilitate completion of one task at a time; form a small group
Etiology and biochemistry of mood disorders
o Biochemical imbalances
o Serotonin deficiency
o Neurotransmitter deficiencies
Symptoms of major depression and biopolar disorder
o Hyperactivity that leads to physical exhaustion
o Flamboyant dress and makeup; excessive spending
o Sexual acting out and impulsive behavior
o Appearance of an inflated self esteem
o Flight of ideas with the inability to finish one thought before jumping to another
o Loud, domineering, and manipulative
o High degree of distractibility
o Dehydration and nutritional deficits
o Delusions of grandeur
o Hostility and aggression
o Decreased sleep
Lithium administration levels
o Initial dose = 600 mg TID for maintenance of serum level (1.0-1.5 mEq/L)
Take serum levels biweekly
o Maintenance dose = 300 mg TID/QID to maintain serum levels between 0.4-1.0
mEq/L
Check blood levels monthly
o Toxicity occurs with serum leels higher than 2.0 mEq
Signs of lithium toxicity
o Tremors
o Nausea
o Vomiting
o Thirst
o Polyuria
o Diarrhea
o Confusion
o Coma
o Seizure

o Cardiac arrest
Use of anticonvulsants in mood disorders
Educational interventions in medication noncompliance
Signs and symptoms of mania
o Elation and aggression
Signs of impending suicide
o Changes in personal habits
o Changes in personality
o Use of alcohol and other drugs with increased intake
o Bodily complaints and self-deprecating comments
o Giving away personal belongings
o Making out wills and putting things in order
o Decreased interpersonal interaction
High risk time for suicide attempt
o Within the first 2 years after an attempt (60-70% try again)
o Elderly
o Third leading cause of death in teens
o When patient is getting better and the depression is lifting
Assessment for suicide
o Usually preceded by a crisis or patient is morbidly depressed
o Thoughts, threats, attempts are a cry for help
o Risk taking behaviors in adolescents
o 75-80% give clues before committing suicide
o Hopelessness highly correlates with suicide
o Alcohol and drugs and poor impulse control are closely associated with suicide
o Ask directly if client has thoughts of hurting self
o Ask if there is a plan to hurt self
o Determine lethality of plan
The more lethal the plan, the more likely it is that the person will follow
through with the attempt
o Determine if client has the means to hurt self
o Assess ability for no harm contract and ability to communicate when suicidal
feelings increase
SCHIZOPHRENIA

Etiology and biochemistry

o Unknown etiology
Genetic basis of causation is the most popular theory, because
schizophrenia does in fact run in families
Psychosocial theory
Schizophrenia is attributable to a psychotic break from exposure to
high stress levels and continuous disordered communication

Interpersonal theory
Results from intense, unrelieved anxiety in interpersonal
relationships
Psychoanalytical theory
Freud blamed it on the motherly figure
Hallmark = Break from reality
o Biochemistry:
Genetic difference in nervous system
Altered brain circuits related to cerebral abnormalities
Overactive basal ganglia
Imbalance between dopamine and seratonin, especially an excess of
dopamine
Define: idea of reference, delusion, hallucination, signs of hallucinations, grandiosity,
echolalia, word salad, loose associations, waxy flexibility
o Idea of reference
o Delusion: False belief absent of external stimuli; inconsistent with individuals
own knowledge and experiences; disorder of thought content with presence of
strong beliefs that are misinterpretations of reality
o Hallucination: false sensory perceptions involving all senses, no presence of
external stimulus, and hearing voices making commands or insults
o Signs of hallucinations
Laughing/talking to no one
Nodding/tilting head as if listening
Darting eyes/mumbling
Ask: Are you hearing voices right now?
o Grandiosity
o Echolalia: A parrot-like repetition of speech heard from others
o Word salad
o Loose associations: jumbled illogical thinking manifested in loosely associated
speech
o Waxy flexibility: Symptomatic of excessive negativism, stand in one position for
hours on end, and limb/body will remain passively in position in which it is
placed
Positive and negative symptoms of schizophrenia
o Positive (hard):
Hallucination
Delusions
Disorganized thinking
Paranoia
Withdrawal from reality
o Negative:
Lack of motivation
Impaired social interaction

Flat or silly affect

Regression
Withdrawal
Social isolation
Paranoid schizophrenia activities
Catatonic interventions
o Special needs
Nutrition
Rest
Elimination
ADLs
Highest priority: Fluid and electrolyte balance
Strict fluid intake
Agranulocytosis: What is it? What are the signs, monitoring methods, and interventions?
o Seen with atypical antipsychotics such as Ciozaril
o Sore throat, fever, malaise, and mouth sores
o WBC monitoring weekly
Always maintain baselines so you know where you started
o Discontinue medication and notify physician immediately in presence of above
symptoms
Side effects of antipsychotics: What are signs of extrapyramidal side effects? What is
pseudo parkinsonism and what are the signs? What is neuroleptic malignant syndrome
and what are the signs and treatment?
o Extrapyramidal
Dystonic reactions
Uncoordinated spastic movements
Facial grimacing
Opisthotonous: Unusual posturing/tonic arching of entire body
Torticollis: Neck muscle contractions that draw the head to one
side
Fixed upward gaze = occulogyric crisis
Neuroleptic malignant syndrome
Hyperthermia up to 107 degrees F
Muscle rigidity (hard as a board)
Tachycardia
Fluctuations in blood pressure
Diaphoresis
Altered consciousness which leads to a coma
Life threatening and potentially fatal
Laboratory status
o High creatinine phosphokinase

Notify physician immediately and prepare to send patient to the

emergency room
Akathesia
Motor restlessness/excessive walking
Continuous agitation
Complaints of the feeling of jumping out of their skin
Akinesia
Complete or partial loss of muscle movement
Parkinson reactions
Muscle rigidity
Muscle tremors/intention tremors
Increased salavation/drooling
Shuffling gait
Blank, mask-like facial expression
Treatment: Anticholinergics
Cogentin
Symmetral
Benadryl
Artane
SOMATOFORM DISORDERS

Symptoms of each and the reasons why they develop

o Somatization disorder
Symptoms:
Complaints of multiple physical symptoms affecting multiple body
systems
Complaints are chronic, but fluctuate over time
Present with exaggerated and inconsistent medical histories
History of seeking medical attention
There may be coexisting symptoms of anxiety and depression
o Conversion disorder
Symptoms:
Sudden onset or impairment in sensory or motor functioning
Impairment/deficits include: Blindness, deafness, loss of touch,
paralysis, and seizures
There is close relationship between a distressing/traumatic event
and the development of symptoms
Defense mechanisms are repression and conversion
o Pain disorder
Symptoms:

Pain in one or more anatomic sites unrelieved by analgesics

Causes marked by distress
Pain is severe and prolonged
Difficulty sleeping secondary to pain
Sleep and pain medications must be administred as ordered
o Body dysmorphic disorder
Symptoms:
Preoccupation with imagined or exaggerated defect in appearance
Clients obsess about minor nonexistent abnormalities such as
wrinkles, spots on skin, facial asymmetry, hair, breasts, genitals,
buttocks, hands, feet, etc.
Clients are excessively self-conscious about the imagined defect
o May cause social isolation/homebound
o Interferes with educational, social, and occupational
functioning
o In severe forms the patient is at risk for suicide
Self-esteem issues: May make statements about being ugly
Frequently seeks out medical treatment to correct defect
What is a fugue state and what are the assessment parameters?
Depersonalization disorder: What is it? What are the signs and symptoms?
Feelings of the nurse when caring for a client with this disorder
PERSONALITY DISORDERS

Antisocial signs, symptoms, and interventions

Paranoid personality signs and symptoms
Borderline signs, symptoms, and behavior
EATING DISORDERS

Anorexia nervosa: What is it? What are the signs and symptoms? What are the primary
problems? What personality traits are present? What assessment and intervention
methods are involved?
Bulimia nervosa: What is it? What are the signs and symptoms? What are the primary
problems? What personality traits are present? What assessment and intervention
methods are involved?
COGNITIVE DISORDERS

What is the difference between delirium and dementia?

What are the interventions for delusions?
MEDICATIONS

Tofranil
Nardil
Elavil
Lithium
Tegratol
Thorazine
Clozaril
THERAPEUTIC COMMUNICATION/RESPONSES