Mental Health & Crisis Management

1. A pregnant patient receives the news that she has low iron according to the complete blood count (CBC) lab results. The patient panics and worries that there is something wrong. Your response to the patient is:

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2. A newborn is delivered by Cesarean Section and weighs 4000 gms. As the nurse caring for the newborn you will complete the following action: Question 40 options: Avoid skin to skin with mother Heel stick for blood glucose Recommend formula feeding as a supplement Refrain from covering the newborn’s head with a hat to avoid overheating Mental Health & Crisis Management

3. Fertility Awareness Methods are best utilized by:

4. The purpose of applying pressure to the anus and perineal area with a sterile towel during the delivery of the fetal head is:

5. A patient in labour and delivery is hemorrhaging after the vaginal delivery of a 2800 gm newborn. You know that the most likely cause of hemorrhage is: Question 31 options:  Uterine atony Lacerations to the perineum and birth canal Placental abruption Retained palcental tissue

6. A pregnant patient reports having upper epigastric pain, a headache and pitting edema. You know that these are all symptoms of: Question 27 options: Preeclampsia Fatty liver disease Seizure disorder of pregnancy Eclampsia

7. When palpating a contraction, what criteria is the nurse assessing regarding the contraction?

8. you are assessing a non-hispanic black, 35 years old multipara at 24 weeks gestation. Mental Health & Crisis Management

9. You are coming onto shift and have been assigned Room #3. You receive report that the newborn in Room #3 is 39 weeks gestation, Large for gestational age, pink and feeding well. When you observe the newborn you see that the newborn weighs 3000 gms, is covered in lanugo and is feeding well. This observation concludes that: Question 14 options: The newborn is actually large for gestation age The newborn is actually intrauterine growth restricted The social worker needs to be contacted. The newborn is less than 39 weeks gestation

10. An newborn is delivered vaginally at 36 weeks gestation. You are aware that this newborn may :

11. The fetus has engaged and Mom has been pushing for 4 hours. The physician encourages an epidural to give Mom a rest. When the baby is finally delivered vaginally you notice the following:

Alcohol related disorders and Clinical Institute Withdrawal for Alcohol (CIWA-AR) Scale

 

Alcohol is the only drug for which exact objective measures of intoxication (BAL) currently exist.

 

Alcohol content varies from product to product; nevertheless, a drink is a drink is a drink, with 1.5 ounces of liquor (40% alcohol), a 12-ounce bottle of beer (5% alcohol), and a five-ounce glass of table wine (12% alcohol) all containing the same amount of ethanol. Thus all affect human physiology in a consistent manner as measured by blood alcohol content (BAC), although there are distinct differences between men and women (Table 18-5). Differences in effects from person to person produced by beverage alcohol do not generally result from the type of drink consumed, but rather from the person’s size, previous drinking experiences, and rate of consumption. A person’s feelings and activities and the presence of other people also play a role in the way the alcohol affects behaviour.

 

Assessing the patient’s behaviour can assist the nurse in (1) ascertaining whether the person accurately reported recent drinking and (2) determining level of intoxication and possible tolerance, as patient behaviours may indicate greater or lesser levels of tolerance. As tolerance develops, a discrepancy is seen between the BAL and expected behaviour: a person with tolerance to alcohol may have a high BAL but minimal signs of impairment. Alternatively, a person who is highly sensitive to alcohol or compromised medically may have a low BAL but demonstrate a high level of intoxication. Mental Health & Crisis Management

 

Alcohol poisoning

Is a state of toxicity that can result when an individual has consumed large amounts of alcohol either quickly or over time. It can produce death from aspiration of emesis or a shutdown of body systems due to severe CNS depression. Signs of alcohol poisoning include an inability to rouse the individual, severe dehydration, cool or clammy skin, respirations less than 10 per minute, cyanosis of the gums or under the fingernails, and emesis while semiconscious or unconscious. Refer to Table 18-2 for important assessment and treatment information regarding alcohol intoxication and poisoning.

 

Alcohol Withdrawal

The early signs of alcohol withdrawal, a physical reaction to the cessation or reduction of alcohol (ethanol) intake, can develop within a few hours of the last intake. Symptoms peak after 24 to 48 hours and then rapidly and dramatically disappear unless the withdrawal progresses to alcohol withdrawal delirium.

 

Severity of withdrawal tends to be dose related, with heavier drinkers experiencing more severe symptoms. Withdrawal severity is also related to age, with those over 65 years of age experiencing more severe symptoms. During withdrawal, the patient may appear hyperalert, manifest jerky movements and irritability, startle easily, and experience subjective distress often described as “shaking inside.”

 

Grand mal seizures may appear 7 to 48 hours after cessation of alcohol intake, particularly in people with a history of seizures. Careful assessment, including this history and any other risk factors, followed by appropriate medical and nursing interventions can prevent the more serious withdrawal reaction of delirium.

 

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) provides an efficient, objective means of assessing alcohol withdrawal to prevent under- or overtreating patients with benzodiazepines.

 

Alcohol withdrawal delirium

Also referred to as delirium tremens (DTs), is a medical emergency that can result in death in 20% of untreated patients. It is an altered level of consciousness that presents with seizures following acute alcohol withdrawal. Death is usually due to cardiopathy, cirrhosis, or other comorbidities requiring mechanical ventilation.

 

The state of delirium usually peaks 48 to 72 hours after cessation or reduction of intake, although it can peak later, and lasts 2 to 3 days. Features of alcohol withdrawal delirium include the following:

 

• Autonomic hyperactivity (tachycardia, diaphoresis, elevated blood pressure)
• Severe disturbance in sensorium (disorientation, clouding of consciousness)
• Perceptual disturbances (visual or tactile hallucinations)
• Fluctuating levels of consciousness (ranging from hyperexcitability to lethargy)
• Delusions
• Anxiety and agitated behaviours
• Fever (38°C to 39°C)
• Insomnia
• Anorexia

 

Detoxification or Alcohol Withdrawal Treatment

 

Acamprosate (Campral) was approved by Health Canada in 2008 to treat people who had been alcohol dependent, had stopped drinking, and wished to remain abstinent. In randomized, double-blind, placebo-controlled trials, though without active comparators, acamprosate in conjunction with psychosocial therapy was generally significantly better than placebo plus psychosocial interventions in improving various key outcomes, including the proportion of patients who maintained complete abstinence from alcohol, the average duration of abstinence duration, and the total number of nondrinking days. Acamprosate is believed to effect a reduction in one’s intake of alcohol through suppression of excitatory neurotransmission and enhanced inhibitory transmission (Lehne, 2014; Plosker, 2015).

Naltrexone (ReVia), an agent used in reversing the effects of opioid addiction, is sometimes used in the treatment of alcohol dependency, especially for those with intense cravings and somatic symptoms. Naltrexone works by blocking opioid receptors, thereby interfering with the mechanism of reinforcement and reducing or eliminating the alcohol craving (Vuoristo-Myllys, Lipsanen, Lahti, et al., 2014). Long-acting injectable forms with the brand names Vivitrex or Vivitrol, Naltrel, and Depotrex are being tested and show promise as having relatively stable plasma levels, allowing for more sustained effects (Gordon, Kinlock, Vocci, et al., 2015; Knopf, 2016).

 

Topiramate

Similar to acamprosate, topiramate (Topamax) is purported to decrease alcohol cravings by inhibiting the release of mesocorticolimbic dopamine, which has been associated with alcohol craving. Currently topiramate is still not approved for use with alcohol-dependent persons, although preliminary findings indicate that it has a beneficial effect in individuals with a typology of craving characterized by drinking obsessions and automaticity of drinking (Guglielmo, Martinotti, Quatrale, et al., 2015).