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8/7/2019 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


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


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.

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