Suicide: 1. Assess.

Main elements of the assessment should include: how detailed is the plan, how lethal is the plan, (guns, hanging, CO, staging a car crash) all extremely lethal. And the availability of means, do they have a gun? Etc. 2. D/C teaching: let the family know the red flags to look out for such as pt goes suddenly from sad and depressed to happy and peaceful. This is often after the decision to commit suicide. See the patient giving away prized possessions. Give knowledge to significant others of potential suicide ideation (e.g. increasing withdrawal, preoccupation, silence, and remorse). Give the family and patient knowledge of community resources that they could use for support during crisis. Delirium & Dementia: 5. Four As: a. Amnesia: memory impairment: initially recent events, then with time it is recent and remote memory. b. Aphasia: loss of language ability, reduced to babbling c. Apraxia: Unable to perform once-familiar and purposeful tasks. Unable to dress. d. Agnosia: loss of ability to recognize objects. e. Also: disturbances in executive functioning: planning, organizing, abstract thinking. 6. Physical needs: a. Delirium: Patient will try and go home,wandering, pulling out IV lines, foley caths, and falling out of bed are all common dangers. Since the individual is having difficulty processing stimuli in the environment, it should be made very simple and clear as possible. Objects such as clocks and calenders can maximize orientation. Eye glasses, hearing aids, and adequate lighting can help to interpret what is going on. Rn should interact with patient whenever awake, short periods of interaction help to reduce anxiety and misperception. Risk for injury is always present, and the overall out-come is that the patient will return to the premorbid level of functioning. b. Dementia: Families who have a member with dementia are faced with an exhaustive list of issues that need addressing. The family should be tought to have a realistic understanding of the disease so that their expectations are realistic, establishing realistic outcomes for the patient and recognizing when they are achieved: ex. pt feeds self with spoon, maintaining good self-care: family needs to protect themselves from the negative effects of stress by obtaining adequate sleep and rest, eating a nutritious diet, exercising, engaging in relaxing activities, and addressing their own spiritual needs.

c. Safe Milieu in the home: 1 Restrict use of the car, remove throw rugs and other objects in walking paths, minimize sensory stim, if patient becomes upset listen attentively then give support and change the subject, label all rooms and drawers and often used objects: toothbrush, install safety bars in bathroom, supervise pt when they are smoking, educate family on seizure precautions. 2 Wandering: put mattress on the floor to prevent falls, have them wear a medicalert bracelet, alert police and neighbors about the wandering, have them wear a bright vest with the phone number printed on back, put complex locks on tops of doors, encourage physical activity in daytime to decrease wandering at night. 3 Useful activities: provide picture magazines and childrens books when the patients reading ability diminishes, provide simple activity to work on the large muscles, encourage group activities that are familiar and simple. Do not neglect cognitive function; some stimuli will help minimize feelings of alienation.

7. Consistency of approach (orientation) a. it's best to be consistent with the nursing staff, have routines set up, etc. to facilitate patient func. For orientation you must reorient the patient constantly, using things like clocks, calendars, family pictures. And every time you come in contact with the patient, you have to introduce yourself, and you have to teach the family to do the same. b. Interventions for patient with Delirium: 1 Reduce underlying factors causing delirium, introduce self at the beginning of each meeting, face to face contact, short simple concrete phrases, explain what you are going to do before doing it, encourage friends and family one at a time to take a supportive role, maintain a low stim and well lit environment, hprovide clocks and calenders, familiar faces minimize confusion so try and assign the same staff, if hallucinations/illusions are present clarify reality, inform patient of progress during lucid intervals, ignore insults, use limit setting to stop abusive behaviors. Addictive disorders:1. Alcohol withdrawal delirium MULTIPLE RESPONSE: Treatment a. Bza to ease withdrawal (Librium) b. Vit B1 c. Anti-convulsant d. Monitor VS e. Propanolol

2. Withdrawalsymptoms develop when patient has already been admitted: (risk for falls and seizures are increased as well) they are: a. Anxiety b. Insomnia c. Delusions d. Delirium e. Tactile hallucination f. Visual hallucination 3. CNS decrease in intoxication, CNS increase in withdrawal! 4. Marijuana: kids want to use it because it causes euphoria, detachment, and relaxation. It is a depressant, a hallucinogen, increase anxiety and paranoia. Anxiety Disorders: 1. OCD: Ego-dystonic: it's maladptive way to control anxiety, therefore the patient has to connect to what's causing the anxiety, one way to do this is to discuss with the pt the event that precipitate his/her rituals. 2. Panic disorder: Axis 1, they believe they are losing their minds and having a heart attack. Usually accompanied by palpations, chest pain, diff breathing, nausea, feeling of choking, chills and hot flashes. This typically occurs suddenly, not necessarily in response to stress, are extremely intense, lasts a matter of minutes and then subsides. Pt communication is to realize these feelings are real to the patient, so do not minimize their feelings. 3. PTSD: Signs: flashbacks, avoid stimuli associated with trauma, feelings of emptiness. Increased startle response. Pt is not able to connect with problem, so to have the patient connect with a trigger is a positive outcome. When they realize what it is that is bothering them. Personality Disorder: 1. Antisocial: Chronically irresponsibly and unreliable: lie and steal, no remorse. 2. Paranoid: They are always suspicious. 3. Borderline: difficulty controlling emotion, use splitting, self-inflicted injury for attention because of the fear of being abandoned. 4. COMM FOR ALL: using limit setting: straight to the point, be firm and clear, Tell the patients that their manipulation will not work, accept that the patient is sick but do not accept bad behavior, trustworthiness, use of the point system to increase positive patient behaviors.

5. Difficulty creating therapeutic relationship: give patient choices, orient patient to reality, teach behaviors that build on existing skills, use patients strengths. Anorexia & Bulimia: 1. Communication guidelines: avoid authoritarianism , build a therapeutic relationship (difficult with anorexia because they are terrified of gaining weight, exactly what you want them to do), in bulimia it is a little easier because they ae ego dystonic and know what they are doing is wrong. Acknowledge the patients difficulty with gaining weight, and address underlying emotions, by switching from the patients feelings to their emotion. 2. Differences between Anorexia and Bulimia: a. Anorexia: family: perfectionists, very thin, always dehydrated, lanugo, amenorrhea, proteinuria, oligouria, osteoporosis, degeneration of liver. b. Bulimia: family: chaotic, around normal body weight, esophageal tears, Russells sign, antisocial behavior, erosion of teeth, parotid gland enlargement, cardiomyopathy. 3. Long term outcome: enhanced body image, immediate goal is stabilization. Autism & ADHD: 1. Autism: Use consistency approach with these patients, they need to learn to trust one care taker. This builds on the relationship and increases the functioning of the patient. 2. ADHD: Meds to use: psychostimulants: calms down the patient so they are able to focus, adverse effects of these are loss of appitite, sleep and growth. The best way to avoid these effects is to administer after a full breakfast!