2012

Competencies
y Given relevant case scenarios and questions students

will be able to ; y 1. Differentiate symptoms of somatoform disorders. (Communication skills) y 2. analyze life span issues affecting clients experiencing a somatoform disorders. (Bioethical principles) y 3. Delineate major treatment approaches for clients with somatoform disorders. (Creative thinking skills / Collaborative competencies)

Somatization is the transference of mental experiences and states into bodily symptoms. Somatoform disorders are the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis to account fully for them.

The three central features of somatoform disorders: y Physical complaints suggest major medical illness but have no demonstrable organic basis y Psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the symptoms y Symptoms or magnified health concerns are not under the client s conscious control

Five specific somatoform disorders:

y Somatization disorder: multiple physical symptoms;

combination of pain, GI, sexual, and pseudoneurologic symptoms y Conversion disorder: unexplained deficits in sensory or motor function associated with psychological factors; attitude of la belle indifference (lack of concern or distress)

y Pain disorder: pain unrelieved by analgesics;

psychological factors influence onset, severity, exacerbation, and maintenance y Hypochondriasis: preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia) y Body dysmorphic disorder: preoccupation with imagined or exaggerated defect in physical appearance

Onset and Clinical Course

y Symptoms usually onset in adolescence or early

adulthood y All the somatoform disorders are either chronic or recurrent y Clients will go from one physician or clinic to another, or they may see multiple providers at once in an effort to obtain relief of symptoms

Related Disorders
y Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms; it is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs y Factitious disorder occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention

(In malingering and factitious disorders, people willfully control the symptoms. In somatoform disorders, clients do not voluntarily control their physical symptoms.)

Somatoform Disorders
Not under voluntary control Have unconscious motivation Primary gain is reduction of anxiety

Factitious Disorders
Deliberately produced Motivation: to assume the sick role in order to gain attention and/or obtain medical treatment No obvious secondary gain

Malingering
Symptoms are consciously produced or feigned Have various motivations, including financial gain, relief of work duties, or obtaining illicit drugs Obvious secondary gain(s)

Related Disorders (cont d)

y Munchausen by proxy occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a hero for saving the victim

Somatoform Disorders
y Some symptoms: y Recurring, multiple, clinically significant somatic complaints y Colorful and exaggerated complaints lacking in factual information y Cause global impairment of functioning

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Etiology
y Psychosocial theories:
y Unconsciously expressing internalized stress through physical

symptoms (somatization) y Primary gains are achieved when the direct external benefits of being sick provide relief of anxiety, conflict, or distress y Secondary gains are obtained when the person receives internal or personal benefits from others because one is sick

y Biologic theories:

y Familial tendencies y Differences in the way body stimuli are regulated and interpreted

Causative Factors: Theories and Perspectives

y Major theories y Psychodynamic theories
y

Briquet s syndrome y Characterized by multiple dramatic medical complaints in the absence of a psychological basis y Later known as somatization disorder

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Causative Factors: Theories and Perspectives

y Major theories y Psychodynamic theories
y

Psychoanalytic theory y Symptoms represent a substitution for repressed instinctual impulses y Primary gain y Secondary gain

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Causative Factors: Theories and Perspectives

y Major theories y Psychosocial and stress factors
y

Substantial emotional distress expressing underlying depression, anxiety, and stress Females more likely to report ill health than males

18

Causative Factors: Theories and Perspectives

y Major theories y Psychosocial and stress factors
y

Incidence of reporting higher in low socioeconomic class and high emotional distress Sick role often accepted, validated, and reinforced within various social contexts

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Causative Factors: Theories and Perspectives

y Major theories y Attachment theory
y

Interpersonal stressors occurring during childhood increase likelihood of somatization disorders Maladaptive attachment behaviors are fixed and rigid, resulting in client s sensitivity to perceived or actual threats

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Causative Factors: Theories and Perspectives

y Major theories y Cognitive-behavioral theories
y

Dysregulation in perceptions of an event and psychological responses Exaggerated appraisal of risk, danger, and vulnerability to disease and illness

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Causative Factors: Theories and Perspectives

y Major theories y Neurobiological theories
y y

Familial patterns (genetics) Alterations in neuroanatomical structures and regional brain perfusion

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Causative Factors: Theories and Perspectives

y Major theories y Cultural considerations
y

Substantial role of cross-culture transition and psychological distress in somatization Immigrants worldwide experience significantly more stressful life experiences and are at a higher risk Other factors include gender, age, marital status, low educational and socioeconomic status

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Cultural Considerations

Specific Somatoform Disorders

y Somatization disorder y Core symptoms
y y y y

Detailed and complicated medical problems Tenacious in seeking medical attention Seeing more than one health provider at a time History of manipulative behaviors, impulsive, chaos, suicidal threats, unstable occupational and social functioning

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Specific Somatoform Disorders

y Somatization disorder y Treatment modalities
y y y

Nurse-client relationship is the cornerstone Determine history, severity, and duration of symptoms Identify level of functioning, present stressors, and coping patterns Instructions should be clear, empathetic, and nonconfrontational

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Specific Somatoform Disorders

y Conversion disorder y Prevalence
y y

Most frequently occurring of the somatoform disorders Affected persons range from early childhood into old age

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Specific Somatoform Disorders

y Conversion disorder y Core symptoms
y y

Unexplained physical manifestations Deficits affecting voluntary motor or sensory function

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Specific Somatoform Disorders

y Conversion disorder y Treatment modalities
y y y y

Cognitive-behavioral therapy Supportive therapy Avoid reinforcement of maladaptive coping behaviors Focus on development of effective stress management

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Specific Somatoform Disorders

y Pain disorder y Prevalence
y y

18 to 31 percent in sample populations 10 to 15 percent of Americans experience some form of occupational disability

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Specific Somatoform Disorders

y Pain disorder y Core symptoms
y y y

Pain in one or more anatomical sites Pain causes clinically substantial distress Pain is not accounted for by a mood, anxiety, or psychotic disorder

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Specific Somatoform Disorders

y Hypochondriasis y Core Symptoms
y y y

Fear of having a serious disease Exaggerated appraisal of risk or vulnerability to disease Benign bodily functions mistakenly associated with a suspected health hazard

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Specific Somatoform Disorders

y Hypochondriasis y Treatment modalities
y y

Cognitive-behavioral therapy Comprehensive mental and physical status examinations should be performed

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Specific Somatoform Disorders

y Hypochondriasis
y

Nurses should:
y y

Use an accepting and nonjudgmental approach Avoid reinforcing preoccupation with bodily functions and illness

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Specific Somatoform Disorders

y Body Dysmorphic Disorder (BDD) y Prevalence
y y

Remains obscure in community setting In clinical settings, 5 to 40 percent of clients with BDD also show signs of anxiety and depression disorders

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Specific Somatoform Disorders

y Body Dysmorphic Disorder (BDD) y Core symptoms
y

y y

Preoccupation with imagined defect y Thinning hair or facial scarring Some cognitive and memory deficits Obsessional thinking and compulsive behaviors

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Specific Somatoform Disorders

y Body Dysmorphic Disorder (BDD) y Treatment modalities
y y

Currently no mainstay treatment Pharmacologic interventions such as serotonin selective reuptake inhibitors (SSRIs) show promise Cognitive behavioral therapy to reframe negative thoughts and maladaptive behaviors

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Specific Somatoform Disorders

y Body Dysmorphic Disorder (BDD) y Treatment modalities
y

Nurses should:
y y

Use an empathic and sensitive approach Assess preoccupation with appearance and resulting emotional distress

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Related Disorders
y Chronic Fatigue Syndrome (CFS) y Prevalence
y y y

Prevalence is obscure Not listed as a somatoform disorder Vagueness of the symptoms may be variants of other somatoform disorders although may lack maladaptive processes

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Related Disorders
y Chronic Fatigue Syndrome (CFS) y Symptoms
y

Chronic fatigue, flulike symptoms, muscle pain, headaches, malaise lasting longer than 24 hours

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Related Disorders
y Chronic Fatigue Syndrome (CFS) y Treatment modalities
y y y y

Interdisciplinary approach necessary Stress management and relaxation activities Cognitive behavioral therapy Pharmacologic interventions

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Somatoform Disorders Across the Life Span

y Childhood y Possible contributor:
y

Impaired family dynamics y Over responsiveness y Limited autonomy y Rigidity y Overprotectiveness

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Somatoform Disorders Across the Life Span

y Childhood y High prevalence of comorbid anxiety and depressive disorders

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Somatoform Disorders Across the Life Span

y Adolescence y Body Dysmorphic Disorder
y y y

Emerges in adolescence Symptoms not always readily observed High prevalence of comorbid anxiety and depressive disorders

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Somatoform Disorders Across the Life Span

y Adulthood y Likely to affect client throughout lifespan y Holistic needs should be assessed

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Somatoform Disorders Across the Life Span

y Older adulthood y Likely to affect the adult throughout their lives y Treatment must be client-centered and age appropriate y Client s level of functioning will be impaired for years to come

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Treatment
y Treatment is focused on managing symptoms, improving quality of life, and improving coping skills y Antidepressants are sometimes used for accompanying depression y Referral to a pain clinic is helpful in pain disorder y Involvement in therapy groups to improve coping and express emotions verbally has shown some benefit

Application of the Nursing Process

Assessment y Investigate the client s physical health status to thoroughly rule out underlying pathology requiring treatment y History: client likely provides a detailed medical history; quite distressed about his or her health status (except the client with conversion disorder, who displays la belle indifference)

Application of the Nursing Process (cont d)

Assessment (cont d)
y General appearance and motor behavior: normal y Mood and affect: may be labile, shifting from sad and depressed (describing physical ailments) to bright and excited (describing trips to health care providers) y Thought processes and content: intact; content is about physical symptoms; vague in their description but use colorful, exaggerated terms

Application of the Nursing Process (cont d)

Assessment (cont d) y Sensorium and intellectual processes: alert and oriented y Judgment and insight: little or no insight; judgment may be affected by exaggerated responses to physical health concerns y Self-concept: low self-esteem, lack of confidence, difficulty coping

Application of the Nursing Process (cont d)

Assessment (cont d) y Roles and relationships: difficulty fulfilling family roles; few friends or social activities; may report lack of family support y Physiologic and self-care concerns: legitimate health concerns may include disturbed sleep patterns, poor nutrition, lack of exercise, overuse of prescription medications

Application of the Nursing Process (cont d)

Data Analysis
Nursing diagnoses include: y Ineffective Coping y Ineffective Denial y Impaired Social Interaction y Anxiety y Disturbed Sleep Pattern y Fatigue y Pain

Application of the Nursing Process (cont d)

Outcomes
The client will: y Identify the relationship between stress and physical symptoms y Verbally express emotional feelings y Follow an established daily routine y Demonstrate alternative ways to deal with stress, anxiety, and other feelings y Demonstrate healthier behavior regarding rest, activity, and nutrition

Application of the Nursing Process (cont d)

Intervention y Providing health teaching y Assisting client to express emotions y Teaching coping strategies
y Emotion-focused coping strategies (progressive relaxation, deep

breathing, guided imagery, and distractions) y Problem-focused coping strategies (learning problem-solving methods, applying the process to identified problems, and role-playing interactions with others)

Application of the Nursing Process (cont d)

Evaluation y Is the client making fewer visits to physicians with physical complaints? y Is the client using less medication and more positive coping techniques? y Are the client s functional abilities increased? y Does the client have improved family and social relationships?

Community-Based Care

y Make appropriate referrals, such as a pain

clinic for clients with pain disorder y Provide information about support groups in the community y Encourage clients to find pleasurable activities or hobbies

Mental Health Promotion

y Assist clients to deal with emotional issues

directly y Assist clients to continue gaining knowledge about themselves and their emotional needs

Self-Awareness Issues

y Deal with feelings of frustration y Be realistic about small successes y Validate client s feelings y Deal with feeling that client could do better

if he tried

Competencies
y 4. Differentiate different types of sleep disorders.

(Communication skills) y 5. develop a nursing care plan for clients presenting with sleep disorders. (Communication skills / Collaborative competencies / Creative thinking skills / Computer related competencies)

Biology and Physiology of Normal Sleep

y Sleep has restorative powers and promotes health y Physiological process is mediated by

neurotransmitters
y Serotonin y Norepinephrine y Dopamine

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Biology and Physiology of Normal Sleep

y Predictable pattern of brain activity during sleep y Two physiological states of sleep
y

Non-rapid eye movement (NREM) sleep y Four additional distinct electrophysiologic sleep occurs Rapid eye movement (REM) sleep

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Epidemiology of Sleep Disorders

y Prevalence y Problems vary
y y

40 to 50 percent of people intermittently have sleep problems 10 to 15 percent report chronic sleep problems

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Epidemiology of Sleep Disorders

y Prevalence y Insomnia
y

Perception of not sleeping well, including difficulty falling asleep, early awakening, and disrupted sleep

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Epidemiology of Sleep Disorders

y Prevalence y Chronic insomnia
y

Refers to insomnia that lasts more than three weeks Chronic lack of sleep Varies according to the person s normal sleep requirements

y Sleep deprivation
y y

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Epidemiology of Sleep Disorders

y Prevalence y Sleep apnea
y

Variety of disorders ranging from respiratory obstruction to cessation 10 percent of shift workers show significant sleep disturbances, fatigue, reduced productivity, and mood swings

y Shift work sleep disorder (SWSD)

y

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Causative Factors: Theories and Perspectives

y Biological factors y Linked to dysregulation in the hypothalamic-pituitaryadrenal axis y Neurotransmitters play roles in sleep regulation y Drugs and medical conditions that alter brain chemistry contribute to sleep disorders

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Causative Factors: Theories and Perspectives

y Psychiatric disorders y Mood, anxiety, and substance-related disorders can result from insomnia

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Causative Factors: Theories and Perspectives

y Psychiatric disorders y Mental illnesses that affect and are affected by disrupted sleep include:
y y y y

Alzheimer s disease Schizophrenia Bipolar I disorder Seasonal Affective Disorder (SAD)

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Causative Factors: Theories and Perspectives

y Nonpsychiatric medical conditions y Somatic illnesses associated with sleep disorders:
y y

Chronic fatigue syndrome Fibromyalgia

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Causative Factors: Theories and Perspectives

y Nonpsychiatric medical conditions y Other medical disorders affecting sleep:
y

Hypothyroidism y Excessive sleep Hyperthyroidism y Sleep deficit Nocturia y Interrupted sleep

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Causative Factors: Theories and Perspectives

y Cognitive and behavioral factors y Cognitive factors
y y y

Anxiety disorders Mood disorders Inability to sleep stems from worry

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Causative Factors: Theories and Perspectives

y Cognitive and behavioral factors y Behavioral factors
y y

Self-induced sleep deprivation due to hectic schedules Stress

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Causative Factors: Theories and Perspectives

y Psychosocial factors y Individuals worry and have trouble shutting down to sleep y Some major stressors that disturb sleep:
y y y

Starting college or a new job Marriage New baby

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Causative Factors: Theories and Perspectives

y Environmental factors y Noise in the sleep setting y Inability to achieve a dark room y Season of the year

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Causative Factors: Theories and Perspectives

y Environmental factors y Admission to a health care facility
y y y

Roommate issues Strangers (nurses and doctors) entering during night Poor temperature control

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Specific Sleep Disorders

y The Diagnostic and Statistical Manual of Mental

Disorders includes the following:

y Primary sleep disorders
y y y

Insomnia Dyssomnias Parasomnias

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Specific Sleep Disorders

y The Diagnostic and Statistical Manual of Mental

Disorders includes the following:

y Other sleep disorders:
y y y y

Restless leg syndrome (RLS) Periodic limb movement disorder (PLMD) Obstructive sleep apnea Upper airway resistance syndrome

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Developmental Perspectives
y Infancy and Childhood y Sleep varies significantly y GH is secreted during sleep
y

Results in growth and healing Nightmares Sleep terrors Sleepwalking

y Parasomnia is common:
y y y

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Developmental Perspectives
y Adolescence y Growth and development are major physiologic issues y Sleep disorders include:
y

Delayed sleep phase syndrome y Circadian rhythm disorder with late sleep onset and resultant desire to oversleep

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Developmental Perspectives
y Adolescence y Growth and development are major physiologic issues y Sleep disorders include:
y

Narcolepsy y Rare disorder of chronic daytime sleepiness, cataplexy, and sleep paralysis

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Developmental Perspectives
y Adulthood y Tasks of adulthood impact activities of daily living
y y

Marriage Employment y Attending, shift work Children y Sleep deprivation associated with young children Financial and work stressors

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Developmental Perspectives
y Older adulthood y 40 percent have some type of sleep disorder
y y y

Early morning wakening Disturbed sleep Daytime sleepiness

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Developmental Perspectives
y Older adulthood y Sleep patterns commonly result in less deep sleep
y

More problems may occur with healing, cell growth, and repair

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Treatment Modalities
y Pharmacologic and other biological interventions y Hypnotics
y

Benzodiazepines y Flurazepam (Dalmane)

y

Temazepam (Restoril)

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Treatment Modalities
y Pharmacologic and other biological interventions y Hypnotics
y

Nonbenzodiazepines y Zolpidem (Ambien)

y y

Zaleplon (Sonata) Eszopiclone (Lunesta)

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Treatment Modalities
y Pharmacologic and other biological interventions y Antidepressants (tricyclic)
y y

Doxepin (Sinequan) Imipramine (Tofranil) Trazodone (Desyrel) Nefazodone (Serzone)

y Antidepressants
y y

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Treatment Modalities
y Pharmacologic and other biological interventions y Anticonvulsants
y

Gabapentin (Neurontin)

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Treatment Modalities
y Complementary therapies y Dietary supplements
y

Melatonin y Modulates circadian rhythms Valerian y Increases gamma-aminobutyric acid Kava kava y Calms and relaxes without lasting sedation

96

Treatment Modalities
y Psychosocial Interventions y Deep breathing exercises
y

Help gain control of anxiety and stress Keeping a sleep diary

y Sleep hygiene stress management

y

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Treatment Modalities
y Psychosocial Interventions y Relaxation y Cognitive-behavioral therapies y Exercise y Balanced diet

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The Role of the Nurse

y The Generalist Nurse y Assesses client s holistic needs y Stresses activities that restore normal sleeping patterns

99

The Role of the Nurse

y The Generalist Nurse y Collects data concerning client s physical health
y y y

Vital signs Neurological status Relevant aspects of the mental status examination

100

The Role of the Nurse

y The Advanced-Practice Psychiatric Nurse y Understands causative factors of sleep disorders y Uses nursing process to:
y y y

Facilitate accurate diagnosis Decide appropriate interventions Assess treatment outcomes

101

The Role of the Nurse

y The Advanced-Practice Psychiatric Nurse y Pharmacological and non-pharmacological interventions

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The Nursing Process

y Assessment y Thorough evaluation crucial to accurate diagnosis of sleep disorders
y

Current sleep pattern, family history, substance abuse history, caffeine consumption, current medications (prescribed and over the counter) Difficulties falling asleep, staying asleep, or early awakenings

103

The Nursing Process

y Assessment y Thorough evaluation crucial to accurate diagnosis of sleep disorders
y

Appearance y Dark circles under eyes, fatigue, yawning Lifestyle habits

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The Nursing Process

y Nursing diagnoses y The correct nursing diagnosis is crucial

105

The Nursing Process

y Outcome identification y Client s goals may be very different than the nurses goals y Example:
y

Client will express feeling less fatigue and be able to tolerate performing specific activities of daily living (ADLs) within two weeks

106

The Nursing Process

y Implementation y Interventions that promote sleep
y y y y

Environment Cognitive-behavioral techniques to reduce distortions Medication administration Psychosocial interventions to strengthen coping skills and increase self-esteem

107

The Nursing Process

y Evaluation y Focuses on client responses y Development of coping skills y Increase in energy (self-report) and be able to perform ADLs

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