psyche - tourette's
TRANSCRIPT
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TOURETTES
SYNDROME
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Gilles de la Tourette Syndrome(TS) is one of a number of tic
disorders No biological test Evolve in childhood Standard diagnostic criteria used
Impairment defines the condition Diagnosis and Treatment take
time
TOURETTES SYNDROME
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ANATOMY OF TOURETTE
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The cause of TouretteSyndrome is unknown. Thebasic defect is thought tobe a biochemicalabnormality in the basalganglia of the brain.
E T I O L O G Y
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Genetically transmitted byautosomal dominant gene
Patient has 50% chance of passing
the gene to children. However,that genetic predisposition mayexpress itself as TS, as a milder ticdisorder or as obsessivecompulsive symptom with no ticsat all
In some cases TS may not beinherited and are identified asSporadic TS. The cause in these
instances is unknown
TRANSMISSION
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Onset before age 18 Multiple motor tics One or more vocal tics
Tics evolve in a progressive pattern Symptoms wax and wane* Duration longer than one year Absence of precipitating illness Observation of tics by knowledgeable person
*Relapsing Remitting MS. RRMS is identified by distinct periods of disease activity (relapses)followed by longer periods of disease inactivity (remission)
DIAGNOSTIC CRITERIA
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Chronic Motor or Vocal Tic Disorder
Transient Tic Disorder
Terms that may be used by doctors because theduration of the tics is less than one year
OTHER TERMS
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Affects BOYS 3 - 4:1 morethan GIRLS
Involuntary with limitedcapacity to suppress
Mean age of onset for tics 6 7 years
Affects 2% of the generalpopulation- a conservativeestimate since it is an underdiagnosed condition
TOURETTES SYNDROME
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Simple
Eye blinking
Facial Grimacing Shoulder shrugging
Head jerking
Arm thrusting
Nose twitching
Mouth opening
Eye rolling
SYMPTOMS
MOTOR TICS
Complex
Touching objects
Touching or Hittingself/others
Biting lips or arms
Scratching persistently
Twirling Foot tapping/dragging
Jumping
Hopping
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SYMPTOMS
VOCAL TICS
Simple
Throat clearing
Sniffing Grunting
Humming
Whistling Spitting
Squealing
Clenching teeth
Complex
Stuttering
Echolalia - Repeating ofanothers words
Palallia - Repeatingones own words
Copralalia - Speakingobscene word/phrases
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Writing Disorders
Reading Comprehension Disorders
Math Disorders
Visual-Motor Integration is almost always aproblem
Processing Speed and Efficiency Difficulties
LEARNING DISABILITIES
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Common NANDA nursing care plansDiagnosis:
Risk for self-directed or other-directed violence Impaired social interaction Low self-esteem
Goal: Minimize impairment
Maximize adaptive skills
Most important in planning:Encourage self-esteemPrevent depression
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Psychological Counseling
Behavioral Therapy
Medications
Alternative Therapies
Understanding and support from peers and
adults
TREATMENT FOR TS
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Drugs such as pimozide
(O
rap) and clonidine(Catapres) are used tocontrol tics.
MEDICA
TIONS
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Stress increases tics - Teach coping skills to handle stress;may need to avoid competition. Intensive involvement inenjoyable activities (sports, music) decreases tics and stressand calms.
Waxing and waning of symptoms of comorbidities and tics -Explain to parents, peers, teachers that student has very
limited control and that expression of tics and othersymptoms are involuntary as well as ever-changing andcoming and going
NURSING INTERVENTIONS
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Cognitive dulling, lethargy, seeming lack of interest,decrease in coordination - Could be due to medicationand/or depression. If worsening or severe, Inform thePhysician for reevaluation; Infrom Parents to allow extratime and attention for tutoring, studying, and testing.
Short temper and argumentative - Provide opportunity for
physical movement; encourage relaxation and body controltechniques as well as movement education to increase bodycontrol. Provide explanations to parents and peers.
NURSING INTERVENTIONS
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ADHD(ATTENTIONDEFICIT HYPERACTIVITYDISORDER)
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Arise in early childhood.
Onset before age seven.
Long lasting and evident for atleast six months
Affects 3-5% of all school agedchildren.
3:1 boys than girls
9:1 in clinical settings
A
DHD
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ETIOLOGY
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Primarily Inattentive Type ofSymptoms:
Fails to give close attention to
details or makes careless mistakes. Has difficulty sustaining attention. Does not appear to listen. Struggles to follow through oninstructions.
Has difficulty with organization. Avoids or dislikes tasks requiringsustained mental effort. Is easily distracted. Is forgetful in daily activities.
SYMPTOMS
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Primarily Hyperactive/Impulsive Typeof Symptoms:
Fidgets with hands or feet or squirmsin chair. Has difficulty remaining seated. Runs around or climbs excessively. Has difficulty engaging in activitiesquietly.
Acts as if driven by a motor. Talks excessively. Blurts out answers before questionshave been completed. Has difficulty waiting or taking turns. Interrupts or intrudes upon others.
SYMPTOMS
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There is no "cure" for ADHD, however, many treatment approachesmay alleviate or significantly decrease ADHD symptoms. As a result,improvements are evident in school/work performance,
relationships with others improve, and self esteem increases.
TREA
TMENT
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Stimulants Dosage (mg/day) NursingConsiderations
Methylphenidate (Ritalin)
Sustained release (Ritalin-SR Concerta Metadate-CD
10-60 in 3-4 divided doses
20-60 in the morning
Monitor for appetitesuppression or growthdelays.Give regular tablets after
meals.Alert client that full drugeffect takes 2 days.
Transdermal patch(Daytrana)
15 Wear patch for 9 hours effect lasts 3 hours afterremoval.
Dextroamphetamine
(Dexedrine)
Sustained release(Dexerine-SR)
5-40 in 2-3 divided doses
10-30 in the morning
Monitor for insomia.
Give last dose earlyafternoon.Monitor for appetitesuppresion.Alert client that full drug
effect takes 2 days.
PSYCHOPHARMACOLOGY
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Stimulants Dosage (mg/day) NursingConsiderations
Amphetamine (Adderall)
Sustained Release(Adderall-XR)
Pemoline (Cylert)
5-40 in 2-3 divided doses
10-30 in the morning
37.5-112.5 in the morning
Monitor for insomia.
Monitor for elevated liverfunction tests and appetitesuppressionAlert client that full drugeffect takes 2 days.
PSYCHOPHARMACOLOGY
Antidepressant (SNRI) Dosage (mg/day) NursingConsiderationsAntomoxetine (Strattera) 1.2 mg/kg/day in 1 or 2
divided doses (children 70 kg and adults)
Give with food.Monitor appetite forsuppression.Use calorie free beverages torelieve dry mouthMonitor for elevated liverfunction tests
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Risk for self directed or other directedviolence
Defensive coping
Impaired social interaction Ineffective coping
Low self esteem
Noncompliance
Anxiety (moderate to severe)
Compromised family coping
Imbalanced nutrition: Less than bodyrequirements
Ineffective family therapeutic regimenmanagement
Interrupted family processes
Risk for impaired parenting
COMMON NURSING DIAGNOSIS
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Set realistic expectations and limits because thepatient with attention deficit hyperactivitydisorder is easily frustrated
Always remain calm and consistent with the
child. Keep all your instructions to the child short and
simple.
Provide praise and rewards whenever possible.
Provide the patient with diversional activitiessuited to his short attention span.
Help the parents and other family membersdevelop planning and organizing systems to helpthem cope more effectively with the child's shortattention span.
NURSING INTERVENTIONS FOR ADHD
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Risk for self directed or other-directed violence
Observe clients behavior frequently.
Observe for suicidal behaviors: Verbal statements, such as statement going to kill myself
Determine suicidal intent and available means. Ask how where andwhen you plan to kill yourself
Obtain contract from client not to harm self and agreeing to seek outstaff when ideation occurs.
Help client to recognize when anger occurs and to accept thosefeelings
Act as a role model for appropriate expression of angry feelings.
Give positive reinforcement.
NURSING INTERVENTIONS
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NURSING INTERVENTIONS
Defensive coping
Encourage client to recognize and verbalize feelings of inadequacy and need for acceptance from others and to recognize how these feelings provoke defensive behaviors Provide immediate, fact, nonthreatening feedback for
unacceptable behaviors Help client identify situations that provoke defensiveness
Practice with role play for appropriate responses Give positive feedback for acceptable behaviors Evaluate and discuss with client the effectiveness of the new
behaviors and any modifications for improvement
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NURSING INTERVENTIONS
Impaired social interaction
Develop trust relationship
Give to the clients constructive criticism and positivereinforcement for clients efforts
Give Positive feedback to client
Provide group situations for client
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Ineffective coping
Provide safe environment for continuous large musclemovement, If client is hyperactive
Provide large motoric activities
Do not debate, argue, rationalize, or bargain with the
client. Explore with client and discus alternative ways of
handling frustration that would be most suited forclient
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Anxiety
Establish a trusting relationship
Maintain an atmosphere of calmness Offer support during times of
elevated anxiety, Use of touch iscomforting for some clients
When anxiety diminishes, help clientto recognize specific events that
preceded onset of anxiety. Provide help to client to recognize
signs of escalating anxiety On escalating anxiety provide
tranquilizing medication, as ordered
NURSING INTERVENTIONS