Psych.

Lecture 01
Basic concepts of mental health. Behavior: o

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Is the manner in which the person performs any or all the activities of daily living.

Mental health is ones ability to cope w/ and adjust to the recurrent stresses of everyday living.

The nurse can expect to use mental health nursing principles in a variety of health care settings.

Basic mental health concepts are useful in understanding a pt.s behaviors responses to disease and dysfunction.

M.I is evidence by a pattern of behaviors that is conspicuous threatening and disruptive of relationships or deviates from acceptable behaviors

The nurse has the responsibility of assessing and intervening while maintaining a caring relationship of trust w. the pt.

HX Thought to be possesses by evil spirits. o Shamans (Medicine Men) Focused in removing evil spirits thru Tx uncalled for. Unsuccessful Abandoned to die alone or die by starvation attacked by wild animals. Early Christians o o o Punished for sins Possessed by devil Witchcraft Tx 17th & 18th o o Worse Late 18th England o o o Asylum built Nurturing atmosphere Psychiatry became separate branch of medicine. Exorcisms Physical punishments Imprisonment

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US o Penn. Hosp. 19
th

Tx mental illness.

o o

Flourishing of institutions and asylums Overcrowding and bureaucracy brought decline of care provided by institutions.

Dorothea Dix o appalled by the care of mental health Millions of dollars towards the develop. Of mental hosp.

Linda Richards o First Psychiatry RN/Training.

DR. Philippe Pinel o o o o o Recognized mental illnesses Name to behaviors Document illness Case Studies Advocate for humane care

20

th

o o

Ushered in the reform of mental healthcare Committee for Mental Hygiene (1909) Prevention of mental illness and the removal of the stigma of mental illness

1930S o Electroconvulsive therapy (ECT) & Insulin Shock therapy o Developed and used to Tx: schizophrenia

Frontal Lobotomy Tx and eliminate: violent behavior

Physical restraints: Check pt. q. 30min.

Hydro-Therapy Hot or cold water to see if behavior changed.

1940s o National Health Act and the establishment of National Institute of Mental Health.

1950s o Intro. to Psychotherapeutic drugs.

1960s -1970s

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o Changes in mental health Tx and environment

OBRA 1981 o Reduced funding for the mental health system and put the monies into block grants for the comm. to use.

Deinstitutionalization was rapid o Putting many mental ill pt.s from state institutions to the streets.

21st o practiced in a variety to settings public health home health care facilities outpatient settings acute care hosp.

Mental Health Continuum On the illness end, the person is rarely in touch w/ reality, but on the healthy side, the person demonstrates a high lvl. of wellness Assess. Of components of mental health o o o Positive self-concept Awareness of responsibility for ones behavior and its consequences. Maintenance of satisfying interpersonal relationships.

Basic Concepts R/T to Mental Health Adaptability to changes Effective Comm. Awareness and acceptance of emotions and their expressions Recognition and use of supportive system. The point at which a person is deemed to be mentally ill is determined by the behavior exhibited as well as the context in which the behavior is observed Results from an inability to cope w/ an overwhelming situation. Personalities: o The relatively consistent sort of attitudes and behaviors to and individual o o o patterns of mental traits woven together

Influenced by genetics and interactions w/ the envr. Individuals internal and external patterns of adjustment to life. EE Provided a framework for understanding personality development If given a task is not mastered then a set of behaviors can be predicted.

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o SF ID: Functions on a primitive lvl. and is aimed primarily at experiencing pleasure and avoiding pain. Ego: Functions to integrate and mediate between self and the rest of the envr. Superego: The moralistic censoring force; develops from he ego in response to reward or punishment from others. Self-Concept: o This is the framework of reference the individual uses for all he/she knows and experiences o o Includes all perceptions and values During development: Stress o o Is the nonspecific response to the body to any demand made on it. An individuals response to stressful situations or events is often of learned or conditioned behavior. o Stressors Ex: o Physical, social, spiritual;, economic, chemical. Basic perception of who he is, knows, and how others react to him.

Mental health nursing concerns itself w/ behavior, particularly a persons response to stressors.

Anxiety o A MAJOTR COMPONETS TO ALL HEALTH DISTURBAMCEAS o o o o o This is vague a feeling of

Mild forms ready to the body to meet stressful demands Severe forms interfere w. daily activities Problem solving and constructive Immobilized coping skills and result of emotional chaos. Influenced by: How the person views the stressors The number of stressors being handled at one time Previous exp. w/ similar situations Magnitude of change the event represents for the individual.

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Motivation o The gathering of personal resources or inner drive to complete a task or reach a goal May be generated by: Perceived reward Perceived threat of punishment.

The motivation to participate in care helps the pt recover quickly Frustration: o o This involves anything that interferes w/ goal-directed activity. Some ppl. Are more flexible and adaptable than others

Conflict: o The mental struggle; conscious or unconscious

Adaptation and Coping: o o Individuals ability to adjust to changing life situations using various strategies Coping responses: uses to reduce anxiety on by stress May be conscious or unconscious Activity that are not used to on a daily basis.

Defense Mechanisms o o Table 34-1, pg. 1129 (a lot of time reading this) Unconscious intra-psychic reactions that offer protection to the self from a stressful situation. o o Behaviors patters that protect the individual against a real or perceived threat Blocking conscious awareness of threatening feelings.

Illness Behaviors This is the state of homeostatic imbalance When a person doesnt feel well, the body saying, pay attention to my needs. Crisis: o Turning point in life when patterns of living must be modified to prevent disorganization. Some individuals have difficulty coping w. an illness or crisis. Behavior is learned, and individuals bring their learned behavior patterns into the health care setting. Common behaviors: o Denial

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o o o o Anxiety Shock Anger Withdrawal

Crisis Intervention RN Intervention o o o Provide accurate info. That aids in realistic perception of the situation Encourage venting of feelings Identify family support and adequate coping mechanisms.

Req. for communication: One way: o Very little response from receiver. Two Way o Both sender and receiver Group center therapy. Lecturing class.

Assertive Comm. o Takes into account feelings and needs of the pt.

Aggressive Comm. o Interacting w/ another in an overpowering and forceful manner to meet ones own needs at the expense of others.

Establishing a Therapeutic Relationship Interaction in which the nurse demonstrates caring, sincerity, empathy, and trustworthiness. Trust is essential to effective nurse-patient interaction. Personal Space Involves pt. in all areas of nursing process.

Non-Therapeutic Prevents pt. from becoming a mutual partner in the relationship and may place the pt. on passive role. Non-verbal Therapeutic Comm: Just listen o o Blocks to Comm: Hardest method; most effective Conveys interest and caring

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False reassurance Giving Advice False assumptions Value judgments Clichs Defensiveness Asking for explanations Changing the subject

Quiz: What does bx mean? Manner of how they preform ADLs

What does mental health concepts cope w/ everyday. How do you classify a person who is mentally ill? Context in which the behavior that is observed.

Superego is the moral compass Freud: Component of personality that is focused on reality: o Ego

Infants personality falls in which category o ID

Psych. Lecture 02
Care of the of the pt. w/ a Psch. Disorder Key Terms: Though Disorders Pressure of Speech Loose Assoc. aka Derailment Flat Affect Hallucinations Word Salad (Incoherence)

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Every nurse should have a basic understanding of mental illnesses. Neurosis Ineffective coping with stress that causes mild interpersonal disorganization. o o o Pt. has insight that he has a psych. Problem Remain oriented to reality May have some degree of distortion of reality. Nervousness Emo. Upset Compulsions Obsessiveness & phobias Tx. Psychosis Out of touch with reality Severe personality deterioration Impaired perception & judgment Hallucinations & delusions *Pt. does not recognize having a psychiatric illness. o Auditory Hallucinations o Tx. Hosp. required with follow up out pt. care Voluntary or involuntary (repeated voices) Outpatient setting

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Most often admitted on an involuntary status (5150), which is a legal hold, 3 days bed hold. DSM-4 Published by the American Psych. Assoc. Arranged into 5 categories* o Axis 1 o All major psych. Disorders Depression, Schizophrenia, anxiety, and substance related disorders. Axis 2 o Axis 3 o General medical conditions that are potentially relevant to the understanding or management of the persons mental disorder Axis 4 o Psch. And Envr. Disorders that affect the Dx, Tx, and prognosis of mental disorder Axis 5 o Global Asses. Of functioning that rates the overall psychological functioning of the person MD Makes a dx based in stated criteria Rn Interventions & approp. Meds prescribed for conditions under Axis 1, 2, 3 Axis 4 asses stressors Altogether; facilitate holistic care Death of spouse Brain injury Personality disorders & developmental disorders Pg. 136 5250: 14 Days 5270: 30 Days

Organic Mental Disorders

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Differ from other mental disorders Cognitive or intellectual abilities affected o Dementia & Delirium

Thought Process Disorders Bizarre, non-reality based thinking*

Schizophrenia Gross distortion of reality Disturbance of language and comm. Withdrawal from social interaction Disorganization & fragmentation of thought perception and emo. Reaction* o Sky is green, or son posed by demons (So, beat the hell of them) One of the most profound disability mental illness seen Young adult Strikes both sexes = 1% of the pop. Will experience schizophrenia in their lifetime. A chronic disorder with residual disability in functioning* Emo. And financial family devastation Can be aggravated by stress in life Not the same as multiple personalities Inappropriate emo. Response Bizarre behavior Impaired Comm* o CM Different brain structure Brain tissue change noted o Risk Factors Having fam hx. Exposure to viruses in the womb Stressful life circumstances Older paternal age Taking psychoactive drugs during adolescence. Left ventricle larger than right. Cerebral cortex smaller

Excess amounts of neurotransmitter dopamine and glutamate.

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Five subtypes o o o o o Disorganized Paranoid Catatonic* Undifferentiated Residual Disorganized Flat or inappropriate affect, incoherence, prognosis is poor Delusions, auditory hallucinations Prognosis good with tx Catatonic Features stupor, negativism, rigidity, excitement, posturing, Prognosis id fair. Delusions, hallucinations Prognosis: Fair S/s assoc. with schizophrenia without displaying evidence of gross disorganizations, incoherence, delusions, & hallucinations Prognosis: o Poor Paranoid

Undifferentiated

Residual

Nclex (Ch. 63; betta wun!) Pg. 934; Figure 63-1

Behaviors in Schizophrenia o o o Positive or negative Cognitive Symptoms Depressive or other mood symptoms (63-1) Positive: Better response to medications Delusions Hallucinations Disordered thinking Blunted Emo. Responses

Negative

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Anhedonia Delusions: False, fixed belief that cannot be corrected by feedback and is not accepted as true by others. Pt. starts with false premise; believing its true; reality Very difficult for pt. to accept whats true* Types: Grandeur: o I am god Event has special personal meaning Some one is out to get them False belief pertaining to body function or image. Thought broadcasting: o Their ideas are known to others Ideas are put in their mind by others Their thoughts are being removed from their mind Hallucinations *Types: Sensory experience without a trigger Auditory, most often experienced *Visual *Olfactory *Tactile Box. 35-1 Thought insertion: o Thought withdrawal o Ideas of reference: o Persecution: o Somatic: o Inability to experience happiness or joy Lack of non-verbal expressions of emotions Laughing when given news about a death, etc* Flat affect Bizarre posturing or behaviors

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Dx o o Presence of at least 2 of these disorders Significant impairment in the ability to work, attend school, or preform normal daily tasks o Sign last for at least 6 months. Marked by acute episodes of psychosis alternating with pterions of relatively normal function* 1 Prodromal phase 2 Prepsychotic Phase 3 Acute Phase 4 S/S Vary Disturbances in thought, perception, emo & behavior are apparent Often loses contact with reality & is unable to function in most basic ways. Quiet; passive behavior Prefers to be alone Hallucination & delusions may be present Odd, suspicious, or eccentric behavior patterns are noted. Family reports theyve changed into a stranger. Often begins in adolescence and begins with lack of energy or motivation Affects become blunted Beliefs & ideas become odd Disordered thinking Presence of emo. Liability Speech is difficult to follow May complain of physical problems Magical thinking or believing that ones thoughts control events that occur* 4 stages: o

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Residual Phase Symptoms to prodromal phase Follows acute phase After residual phase, there often is a period od remission where the pt. is able to experience some relief of symptoms & to manage some basic activities in life. Prognosis and Tx of Schizophrenia Fair to poor Number of psychotherapies to allow pt. to self expression. Antipsychotic drug therapy to control disorder/ symptoms Milieu therapy (Environment) Psychotherapy Antipsychotic Drugs o Risperdal, Zyprexia, Albilify (Doesnt have as many SE as Haldol) Long term social support* Prognosis o Variable: o Depends on extent of symptoms and response to Tx/meds. Longer & more difficult to return to baseline May be reluctant to seek & continue with Tx Each relapse o Paranoid type Complications o o o o o o o o o o Suicide Depression Threat to self and society. Poverty Homelessness Family conflicts Inability to work/ attend school Health problems from antipsychotic medications Being a victim or perpetrator of violent crime Heart disease, often r/t heavy smoking. Establish therapeutic comm.

RN Interventions o

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o o o o o Reality orientation Reduce anxiety Manage positive behaviors Manage negative behaviors Med Management Box 63-14 Conventional;/ typical antipsychotic Haloperidol (Haldol) o Block dopamine receptors to cause sedation; mechanism unknown. SE: (Box 35-3) Akethesia To Reduce EPS or ^: Stop drug, parenteral diphenhydramine, antiparkinson drugs Dystonia Sedation Parkinsonian Effects Tardive Dyskinesia Dry Mouth Table 35-3 Provide symptomatic control; not cure SE: Postural hypotension Sedation Photosensitivity Autonomic reactions

Thioridazine (Mellaril) Fluphenazine (Prolixin) Clozapine (Clozaril) Risperidone (Risperdal) Olanzapine (Zyprexa) o Not in Geri Pt. Quetiapine (Seroquel)

New Generation

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o Major Mood Disorders Severe & Emo. Responses Other symptoms assoc. with depressed or manic states* Is a prolonged emo. That affects a persons psyche. Extremes ranges from depression to maniac Hereditary factors o 60-80% Insufficiency of norepinephrine & serotonin exist in depressed pts. *Maniac pts. Have increased norepinephrine (opposite ^^^) o Both maybe result of hereditary or envr. Factors such as stress or brain tumors. o Most people experience both in their lifetime, but those with a mood disorder suffer for months or years without relied.* Major depression o Unipolar 1/20 People Women 2x than men Insufficiency of norepinephrine and serotonin. S/S o o o o o o o o Exaggerated feeling of sadness Despair Lowered self esteem Pessimism Multiple physical complaints Guilty Feelings Anxiety Isolation Repeating, severe depressive episodes lasting more than 2 years Dysthymic disorder? Daily moderate depression lasting more than 2 years. Gain wt (30/month)

Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invenga)

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o Suicide 8th leading cause of death Overdoses Refusing medical care Auto accidents Teen suicide is on the rise Highest rate of suicide is among the older white male population.* Not accepted in our culture To prevent suicide: o One must recognize the warning signals & learn the kind of actions that can often be aver it* Do contracts 1-1 Check pt. q 15min Make sure all meds are swallowed Injectables if pt. refuses oral forms Monitor pt. during meals Keep track of utensils and dinnerware Make frequent therapeutic verbal contact.* Tx Antidepressants ECT Last resort Italy, 1930s Muscle relazants and anesthesia now part of therapy Relieve depression, mania, schizoaffective disorders 10 over several weeks. Headache 2-4 weeks to start effective will make bipolar pts. manic Lithium, depakote For safety Suicidal Thoughts

Mood Stablizers Individual or family group therapy

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Bipolar Disorder Manic Hypomanic o o o o Can be engaging, outgoing, and charming Achieving and successful Can be a very productive member of the community in this state Unfortunately..can accelerate. o Excessive feeling Euphoria Talking rapidly Flight of ideas Unrealistic beliefs of abilities No sleep Poor judgment Denial that anything can go wrong. Increased Sex Drive Obnoxious or provocative behavior Death from exhaustion can occur Mood swings with manic episodes May alternate with episodes of depression Symptoms of mania Psychomotor overactivity* No periods of normal function with this condition Thought to be a muted version of bipolar disorders Many pts. Progress to Bipolar disorders. Phototherapy Sudden shift of emo Confusion upon awakening Short-term akenesia

50% are prone to falling under depression again

Cyclothymic Disorder SAD Postpartum Depression Prozac (Fluozetine)

o SSRIS o

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o Zoloft (Sertraline) o o o Effexor Celexa Paxil Increasing amount of serotonin available

Bupropion (Wellbutrin) Trazadone o Inhibit serotonin uptake by the cells, therefore increasing serotonin in the synapse

Tricyclic o Amitriptyline o o Activates nortriptyline Amoxapine Desipramine HCL Nardil Parnate Triazolopyradines

MOAIs o o o

Serotonin Syndrome Agitation Blood pressure fluctuations TACHYCARDIA Hyperthermia Akethesia

Interventions for Bipolar Establish relationship If manic o Cannot stay focused Slower physical reponse Depressed o Avoid o NUT Avoid anthing competitivie Communications

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o Do not remove salt from diet if on lithium B/C Toxicity Above 1.3 meq Nausea, vomiting, diarrhea, drowsiness, muscle weakness, ataxia Antimanics Mania TBL o 7-10 days to achieve

Antianxiety Se PTSD War people, flashbacks emo. Detachment Insomnia Sever anxiety with addictions 3 types o Acute o Within 6 months and last about 6 months Symptoms last 6 months or longer Symptoms that start after 6 moths after the event Chronic o Delayed Drowsiness, muscle weakness Ativan Valium Xanax Buspar

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TX o o o o Antidepressants Antiseizures Cognitive Behavioral o event Desensitization Debriefing may serve to prevent PTSD from occurring if right after the

Chapter 35 cont Anxiety disorders: a normal response to stress or threat, a state or feeling of -apprehension -Uneasiness -Agitation -Uncertainty -Fear resulting from the anticipation of some threat or danger -Often described by type Levels of anxiety -Mild: can be positive -Moderate: selective inattentiveness occurs -Severe: focus is on minute or scattered details; all behavior is at relieving the anxiety Types of anxiety -Signal anxiety: a learned response to an event such as test taking -Free-floating anxiety: associated with feelings of dread that cannot be identified Anxiety Trait -A leaned aspect of personality -Anxious reactions to a relatively non-stressful event -Pts respond faster and more strongly to stress -Are slower to level off than normal Generalized anxiety disorders -Characterized by a high degree of anxiety and/or avoidance behavior -Tends to worry or fret over many things -Finds it difficult to concentrate on the task at hand -Excessive worry or anxiety about multiple issues which lingers 6 months or more can indicate generalized anxiety disorder

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Anxiety disorders -Panic/phobia: (panic) an acute, intense and overwhelming anxiety accompanied by a degree of personality disorganization such as being unable to solve problems or think clearly. Symptoms occur abruptly and peak within 10 mins Symptoms: heart palpitations or accelerated hr -seating -trembling or shaking -feelings of dyspnea or choking -cp -nausea or abd distress -feeling dizzy or faint -fear of losing control or going crazy -fear of dying -parestheasia -chills or hot flashes Tx: focus on educating the pt on the nature of the disorder4 -assisting the pt in developing better coping mechanisms -pharmaceutical agents -emotional support and reassurance are important as well (phobia): different than a normal fear -irrational fear in which the pt tends to dwell on the object of the phobia -may recognize the fear but still unable to control paralyzing anxiety (NCLEX 63-2) -Obsessive-compulsive: 2 features 1:obsessions- thoughts that are recurrent, intrusive and senseless, anxiety producing and distressful in that the thoughts are uncomfortable 2:Compulsions: behaviors that are performed in response to an obsessive thought. They are repetitive, ritualistic behaviors such as checking the locks 10 times. The pt may recognize the behavior is absurd but is still compelled to perform the ritual to relieve tension -pt may find it hard to express his emotions. Depression is often seen in these pt -stopping the repetitive act results in extreme anxiety. Isolation and undoing are mechanisms often employed to avoid anxiety -interpersonal relationships and occupations suffer due to the time consuming behaviors -activity addictions like compulsive gambling, sexual promiscuity, excessive internet use and overeating are common TX: psychopharmacology

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-antianxiety: has sedative/hypnotic effects (ativan, valium, xanax, buspar) side effects of drowsiness, muscle weakness -minor tranquilizers -help individuals experiencing moderate to sever anxiety -drugs in this category are commonly abused -Post-traumatic stress disorder (PTSD): a response to an intense traumatic experience that is beyond the usual experience that is beyond the usual range of human experiences such as war, rape, major auto accidents, observing someone tortured or being tortured, witnessing a violent death -may occur acutely after the event or months later -may evoke feelings of terror and helplessness -may repeatedly relive in dreams or flashbacks -flashbacks may be triggered by a stimulus that resembles the experience or on the anniversary of the event Behaviors: emotional detachment -gulit about being a survivor -amnesia of the event -insomnia -irritability -difficulty concentrating -wariness -physical response to severe anxiety occurs with each relived episode. Depression and substance abuse may be associated with PTSD* Types: 1- Acute: symptoms occur within 6 months of the event and last about 6 months 2- Chronic: symptoms last 6 months or longer 3- Delayed: symptoms that start after 6 months after the event TX: -antidepressants or antiseizure meds -cognitive therapy -behavioral therapy: desensitization -debriefing may serve to prevent PTSD from occurring if right after the event Somatoform disorders: characterized by persistent worry or complaints regarding physical illness without supporting physical findings Psychophysiological disorders

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Psychophysical illness -more recent term -stess-related problems resulting in physical signs and symptoms Nrsg interventions -recognize the anxiety -provide activities that limit the amount of time for the destructive behavior -reduce the anxiety quickly -admin antianxiety meds as ordered -remain with the pt -establish a written contract with the pt to decrease with frequency of compulsive behaviors gradually Eating disorders -anorexia nervosa -bulimia nervosa Personality disorders: inflexible/maladaptive patterns of behavior or thinking -associated with significant impairment of functioning Characterized by: -lack of insight, concrete thinking, poor attention, unable to understand consequences of behavior, distorted selp-perception by hatred or idealizing self -impaired relationships -projects own feelins onto others -poor impulse control -inflexible behavioral response patterns -cannot handle change Types: Narcissistic personality: me-me-me Dependent personality: needs others Paranoid personality: out to get me Borderline personality: I hate you dont leave me Antisocial personality: non sociable Obsessive-compulsive personality Schizotypal personality: highly thoughts, perceptions, speech and behavior Schizoid personality: severe introvert Avoidant personality

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Histrionic personality Sexual disorders: normal sexual behavior difficult to define due to: -cultural influences -Religious institutions -Societies laws -Affects an individuals belief of what is acceptable and unacceptable sexual behavior Adaptive sexual behaviors: occur in private between 2 consent adults -satisfying and not forced on each other Maladaptive sexual behaviors: harmful sexual actions to self or others -may be performed publicly and sometimes without the others consent Sexual orientation: the preference of the individual Herterosexual Homosexual Dyspareunia: painful intercourse Hypoactive sexual desire Premature ejaculation Paraphilias: unusual acts of sex for pleasure (most not legal) Pedophilia: unnatural desire for sexual relationships with children by an adult Exhibitionism (flashing): exposing genitals to a stranger to achieve arousal Voyeurism: sexual gratification by observing nude people and others having sex Frotteurism: sexual arousal by rubbing against or touching a non-consenting person Fetishism: sexual arousal with non living objects, usually an article of clothing; may be followed by masturbation Sexual sadism: inflicting mental or physical pain on others to enjoy sex ex: spanking, stabbing, strangulation Sexual masochism Transvestic fetishism: wearing clothing of the opposite sex Transsexualism: a persistent desire to the body of the opposite sex Gender identity disorder: conflict of biological sex identity and gender perception -person believes he or she was born in the body of the incorrect sex Biologic sex change -psychological counseling -hormone tx -major surgical procedures; not reversible

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Nurses must be aware of own attitudes and values about sexual behavior -careful of nonverbal messages -must not affect quality of pt care Therapeutic interventions: -depends on type or disorder -most treated as outpatients -these can be very complex -may require the skill of specially trained physicians, nurses, or therapists Psychotherapy -milieu therapy: using physical and social environment to effect positive change (can be done in hospital or residential care center -cognitive therapy: focuses on breaking negative thought patterns and developing positive feelings about memories or thoughts Group therapy: used in a hospital setting or day tx programs, a group of pt with similar problems gain insight through discussion and role playing -initial stage: superficial communication -working stage -termination stage: members reflect (NCLEX box 62-5) Play therapy: may be used to help children express themselves by using toys such as puppets as their spokesperson of feelings Hypnosis: a technique used to help the person recover deeply repressed emotions and speed recovery, also been used to help change habits such as smoking Psychoanalysis: developed by freud , a long term and intense form of therapy that allows the pt to bring unconscious thoughts to the surface Free association: speaking thoughts without censorship Adjunctive therapies -occupational therarpy -Recreational therapy -Music therapy -Magnetic -Art -Hydrotherapy

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-These allow expression of feelings, help increase self-esteem and promote positive interaction and reality orientation, may be group or individual Alternative therapies -use of natural or herbal meds has gained tremendous popularity -control and manufacture of these meds fo not fall under the law of the US food and drug admin St. Johns wort: tx mild depression Valerian root: antianxiety Chamomile: sedative -quality and quantity vary from manufacturer to manufacturer -claims and clinical studies are not always consistent -nurse should ask about the use of herbs when obtaining drug history Older adult considerations -experience significant sensory changes in hearing, vision, with related behavioral changes that are often mistaken for disorientation -social isolation is frequently caused by physical or financial limitations -increased issues with dying and grief may affect the coping ability and result in anxiety, fear or depression* -relocation can cause stress which can result in behavioral changes -hopelessness and helplessness are common and may lead to loss of will to live, and even to suicide -reminiscence and life review are effective techniques to help older people to cope c changing life circumstances -alcoholism is common as it may be used as a means to cope

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