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322 Exam 1 Materials - Lecture notes for exam 1
Behavioral Health Nursing (NSG-322)
Grand Canyon University
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Exam 1 Materials
Topic 01: Foundations of Behavioral Health Nursing
Brief Historical Overview of Mental Health Care Mental illness was often viewed as demonic possession o People were beaten, banished, and/or institutionalized Psychiatric nursing was recognized in late 1800s but wasn’t taught in nursing schools until the 1950s Increased knowledge of the neurobiology of mental functioning helped o Psychotropic drugs – first developed in the early 1950s 1963 - Community Mental Health Center Act o Push towards community care rather than institutionalization when possible o Gained momentum after World War II & increased rates of ‘shell shock’ (later termed post-traumatic stress disorder, or PTSD)
The Mental Health Continuum Normal functioning > common, mild, reversible distress > significant functional impairment > clinical disorder, severe persistent functional impairment Mental health encompasses more than what many people consider psychiatric symptoms
Stigma: the mark of disgrace associated with a particular circumstance, quality, or person
Psychiatric Mental Health Nurses A common misconception about psychiatric nurses o Because they “just talk” and/or “just pass meds,” psych nurses lose their “real” nursing skills This stigmatizes psychiatric nurses What is the reality? o Effective therapeutic communication is a skill that must be learned o Client in the psychiatric unit often have complex medical/health care needs in addition to often invisible mental health symptoms
Mental Health Concepts Holistic practice: the integration of both scientifically knowledge and caring arts (essence of nursing) Nursing process: assessment/data gathering, nursing diagnosis, interventions, outcome evaluation DSM-5: the official manual for psychiatric medical diagnosis Provides standardized nomenclature and language Presents defining characteristic or symptoms to differentiate diagnoses (specifies diagnostic criteria for disorders) Assists in identifying the underlying causes of disorders Includes many medical disorders that have psychiatric components
Multidisciplinary Treatment Team
The psychiatric–mental health registered nurse implements the identified plan. This is considered basic level nursing. Advanced Practice Level: PMH-APRN Role (also described as advanced level nursing, master’s degree-prepared, may be licensed as psychiatric mental health nurse practitioners or clinical nurse specialists) o Prescriptive Authority and Treatment o Psychotherapy o Consultation What is the difference between a psychiatrist & a psychologist? Psychiatrist: can give medications! The person who can make prescriptions o They can also do counseling, but the main difference is the ability to give medications Psychologist are doctoral prepared (essentially they studied mental health, but are not able to give medications)
Standards of Practice for Psychiatric Nursing Established consistent nursing expectations o Developed jointly by: American nurses associations (ANA) American psychiatric nurses association (APNA) International society of psychiatrists mental health nurses (ISPN) Follow the nursing process o The 6 standards following the nursing process: Assessment Diagnosis (Nursing) Outcome identifications Planning Implementations Evaluation Provides guidance o Certificate criteria o Legal definition of psychiatric nursing o National council of state boards of nursing licensure examination (NCLEX-RN) competencies
Therapeutic Strategies in the Mental Health Setting Advances practice RN’s o Counseling and psychotherapy o Prescribing medications ALL RN’s o Provide a safe therapeutic environment (milieu therapy) o Promote self-care (psycho educational groups) o Administer medications o Health teaching on social skills and coping skills
with the gratification of your patients physical, emotional and spiritual need through your knowledge and skill that may be inadvertent, thoughtless or even purposeful, while attempting to meet a special therapeutic need of the patient. Boundary crossings can result in a return to established boundaries, but should be evaluated by the nurse for potential adverse patient consequences and implications. Repeated boundary crossings should be avoided. Boundary violations can result when there is confusion between the needs of the nurse and those of the patient. Such violations are characterized by excessive personal disclosure by the nurse, secrecy or even a reversal of roles. Boundary violations can cause distress for the patient, which may not be recognized or felt by the patient until harmful consequences occur. A nurse’s use of social media is another way that nurses can unintentionally blur the lines between their professional and personal lives. Making a comment via social media, even if done on a nurse’s own time and in their own home, regarding an incident or person in the scope of their employment, may be a breach of patient confidentiality or privacy, as well as a boundary violation. Professional sexual misconduct is an extreme form of boundary violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the patient. Professional sexual misconduct is an extremely serious, and criminal, violation.
Transference and Countertransference Example of Transference: - Essentially the patient had an experience, and they are transferring that experience to you when you are walking into the room, even though you were not a part of it, that is transference -The action of transferring something or the process of being transferred Example of Countertransference: -The emotional reaction of the analyst (nurse) to the subjects contribution -A redirection of a psychotherapists feelings toward a client - Behind the counter
Trauma-Informed Care: Incorporating SAMHSA’s Six Principles of a Trauma Informed Approach to Care Students: please review this information in more detail on your own time (outside of class), and let your instructor know if you have questions about any of this information.
Trauma-Informed Approach and Trauma-Specific Interventions SAMHSA's six key principles of a trauma-informed approach and trauma-specific interventions address trauma’s consequences and facilitate healing. Trauma-Informed Approach According to SAMHSA’s concept of a trauma-informed approach, “A program, organization, or system that is trauma-informed: - Realizes the widespread impact of trauma and understands potential paths for recovery; - Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
- Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
- Seeks to actively resist re-traumatization."
- A trauma-informed approach can be implemented in any type of service setting or organization and is distinct from trauma-specific interventions or treatments that are designed specifically to address the consequences of trauma and to facilitate healing.
A trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures. These principles may be generalizable across multiple types of settings, although terminology and application may be setting- or sector-specific:
- Safety
- Trustworthiness and Transparency
- Peer support
- Collaboration and mutuality
- Empowerment, voice and choice
- Cultural, Historical, and Gender Issues From SAMHSA’s perspective, it is critical to promote the linkage to recovery and resilience for those individuals and families impacted by trauma. Consistent with SAMHSA’s definition of recovery, services and supports that are trauma-informed build on the best evidence available and consumer and family engagement, empowerment, and collaboration.
Trauma-Specific Interventions Trauma-specific intervention programs generally recognize the following: The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery The interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers
Admission and Treatment Types of mental health admissions to treatment o Voluntary admission Inpatient Outpatient o Emergency involuntary hospitalization Limited observational Inpatient o Involuntary commitment Long term Inpatient or outpatient Concept of due process in civil (involuntary) commitment o Writ of habeus corpus
Prohibit any disclosure without a court order Federal law supersedes state laws, although compliance with the state law may be maintained under the following: If a court order is obtained pursuant to the regulations If a report can be made without identifying the abuser as a patient in an alcohol and drug treatment program If the report is made anonymously (some states do not allow anonymous reporting)
Elder Abuse Reporting Statutes o Each U. state has a system in place for reporting elder abuse and a definition of “elder” adult. o It is NOT mandatory to report elder abuse in all states. Because state laws vary, nurses are responsible to become familiar with the requirements of the state(s) in which they practice.
Dependent / Vulnerable Adult Abuse Reporting Laws also apply to dependent adults. In most states, a person who is required to report suspected abuse, neglect, or exploitation of a disabled adult and who willfully does not do so is guilty of a misdemeanor. Dependent adults are protected by law from physical or fiduciary neglect or abandonment. Laws require a person to report the knowledge of or the reasonable suspicion of mental abuse or suffering. Adult Abuse Reporting: This is not mandatory in all states. In fact, the concept of a vulnerable or dependent or elderly adult varies from state to state. We will look at this in more detail in Topic 08: Crisis Nursing
Seclusion: is the involuntary confinement of a person alone in a room or areas from which the person is physically prevented from leaving Restraint: is any manual method, physical a or mechanical device material, or equipment that immobilizes or reduces the ability of a person to move his or her arms, legs, body or head freely
Seclusion and restraint were once perceived as therapeutic practices in the treatment of people with mental and/or substance use disorders. Today, these methods are viewed as traumatizing practices and are only to be used as a last resort when less-restrictive measures have failed and safety is at severe risk. Seclusion is defined as the involuntary, solitary confinement of an individual. Restraint refers to any method, physical or mechanical device, or material or equipment that immobilizes or reduces an individual’s ability to freely move his or her arms, legs, body, or head. A drug or medication also might be used to restrict behavior or freedom of movement. Studies have shown that the use of seclusion and restraint can result in psychological harm, physical injuries, and death to both the people subjected to and the staff applying these techniques. Injury rates to staff in mental health settings that use seclusion
and restraint have been found to be higher than injuries sustained by workers in high-risk industries. Restraints can be harmful and often re-traumatizing for people, especially those who have trauma histories. Beyond the physical risks of injury and death, it has been found that people who experience seclusion and restraint remain in care longer and are more likely to be readmitted for care. Subsequently, trauma-informed care has emerged as an approach to care that prevents the re-traumatizing of these individuals. Studies suggest that restraints and seclusion can be harmful and is often re-traumatizing for an individual who has suffered previous trauma (SAMHSA, n. as citing NASMHPD, 2009). .. is a common misconception that seclusion and restraint are used only when absolutely necessary as crisis response techniques. In fact, seclusion and restraint are most commonly used to address loud, disruptive, noncompliant behavior and generally originate from a power struggle between consumer and staff. The decision to apply seclusion or restraint techniques is often arbitrary, idiosyncratic, and generally avoidable (SAMHSA, n. as citing Haimowitz, Urff, & Huckshorn, 2006; SAMHSA n., as citing NASMHPD, 2003; SAMHSA, n. as citing SAMHSA, 2003). Moreover, some studies indicate that seclusion and restraint use leads to an increase in the behaviors that staff members are attempting to control or eliminate (SAMHSA, n. as citing Jones & Timbers, 2002; SAMHSA, n. as citing Magee & Ellis, 2001; SAMHSA, n. as citing Natta, Holmbeck, Kupst, Pines & Schulman, 1990). Conversely, it is important to note that programs that have reduced or eliminated seclusion and restraint have realized a number of positive outcomes including reduced youth and staff injuries, reduced staff turnover, higher staff satisfaction, reduced lengths of stay, sustained success in the community after discharge, and significant cost savings (SAMHSA, n. as citing LeBel & Goldstein, 2005; SAMHSA, n. as citing LeBel, in press). PRN restraints are ILLEGAL do not use them in your practice
Seclusion, Restraint Nurses in psychiatric settings may encounter provocative, threatening, or violet client behavior o Use of restraint and seclusion may be necessary until a client demonstrates safer behavior Nurses in the psychiatric setting should understand o Intentional torts or battery and assault o False imprisonment Use of seclusion or restrain is permitted only o When a written description order is given by a provider for a specific restrictive intervention o The prescription includes a specific time limit for the intervention and criteria for release The clients condition is reviewed and documented regularly, per state law and facility policy (e., continuous observation with documentation every 15 minutes)
Note that assessment and documentation time frames for children who are secluded or restrained are generally less than every 15 minutes (state laws vary; some require every- 5-minute assessment and documentation for pediatric clients at certain ages). Since there are differences in the requirements based on ages and state laws, you are expected to learn that by law, documentation must be completed at least every 15 minutes during any restrictive intervention (seclusion or restraint).
Factors that can Impede Communication Personal factors including: o Emotional and social factors o Cultural and language differences o Lifestyle differences o Cognitive factors Environmental factors including o Physical factors o Societal factors Relationship Factors in Communication Symmetrical relationship: o Equal/lateral: friends or colleagues Complementary relationship: o Unequal: difference in status and power, such as between a nurse and patient or between a teacher and student o Characterized by inequality (one participant is superior to the other).
Verbal versus Nonverbal Communication Communication: roughly 10% verbal and 90% nonverbal o Spoken word: represents the public self. Can be straightforward comments or can be used to distort, conceal, deny or disguise true feelings o Nonverbal behaviors: covers a wide range of human activities from body movements to response to the messages of others Double messages: are conflicting messages or mixed messages Doubling bind messages: sent to create meaning: can be defensively used to hide what is actually going on; the intent is to create confusion
Effective (Therapeutic) Communication Skills Active listening o Active listening helps strengthen the patient’s ability to use critical thinking to solve problems. By giving the patient undivided attention, the nurse communicates that the patient is not alone. o Active listening includes: o Observing the patient’s nonverbal behaviors o Listening and understanding the patient’s verbal message o Listening and understanding a person in the social context, and listening for “false notes”
o Providing feedback: Most people want (in communication) the other person to be there for them psychologically, socially, and emotionally. Clarifying techniques Paraphrasing: restating, reflection of feelings Exploring Projective questions (“what if...”) Presupposition questions (the “Miracle Question”)
Therapeutic Communication Using silence Accepting Giving recognition Offering self Offering general leads Giving broad openings Placing the events in time and sequence Making observations Encouraging description of perception Encouraging comparison Restating Reflecting
Exploring Giving information Seeking clarification Presenting reality Voicing doubt Seeking consensual validation Verbalizing the implied Encouraging evaluation Attempting to translate into feelings
Suggesting collaboration Summarizing Encouraging formulation of plan Focusing
Nontherapeutic Communication Techniques Asking excessive questions Giving approval- agreeing Disapproving- disagreeing Giving premature advice Asking why questions
Minimizing feelings Being falsely reassuring Making value judgements Changing the subject Extensive use of silence
Theories and Therapies In the late 1800s, psychological models and theories arose to provide the structure for considering developmental processes possible explanations about how we think, feel, and behave Theorists believed if complex workings of the mind could be understood, then they could be treated. Therapies evolved from these models and theories.
Freud’s psychoanalytic theory Foundation for the psychodynamic understanding of human behavior Freud believed that adult personality develops based on a person processing of early childhood experiences within developmental stages Basic concept: o Most human suffering is determine during childhood development Resulting therapy: psychoanalysis
Initially in the nurse-patient relationship, the nurse may act as a surrogate parent if the patient is in a developmental stage of infancy or adolescence. During the working phase power shifts away from the nurse to the patient as the patient becomes more independent with personal care (exploitation phase). During this time, the nurse starts activating the discharge plan and acts primarily as an educator and leader. The final phase: Termination phase. This phase allows the nurse and patient to disengage from the nurse-patient relationship altogether. During this time, the nurse summarizes the discharge plan and helps the patient organize actions to progress toward new socially interdependent relationships. According to Peplau, the termination of the nurse-patient relationship enhances the patient’s ability to become more self-reliant in leading a productive healthier life.
Behavioral Theories & Therapies Therapies derived from conditioning o Behavior modification o Systematic desensitization o Aversion therapy o Biofeedback Implications for nursing Altering targeted client behaviors and behavior management
Cognitive Theories & Therapies Cognitive-behavioral therapy (Beck) o Identifies and tests distorted beliefs (cognitive distortions) Client learns to change way of thinking Corrected thinking process leads to improved behaviors
A-B-C Theory of Cognitive Therapy The ABC theory of cognitive therapy is a valuable tool to help individuals recognize: o Automatic thought which can issue in a situation o Beliefs: thoughts/feelings about the automatic thought o Consequence of belief: challenge the belief with rational evidence (reframe)
Behavioral Health Treatment: Inpatient vs. Outpatient Settings INPATIENT 24-hour nursing care Locked units (for safety) Crisis response teams Residential treatment programs State acute care systems General hospital psychiatric units Private psychiatric hospital (acute care)
OUTPATIENT
Primary care providers (PCPs) Patient-centered medical homes Primary care medical homes Community mental health centers Psychiatric home care Individual or group outpatient treatment Intensive outpatient programs
Specialty treatment setting Pediatric psychiatric care
Forensic psychiatric care Veterans administration centers/homes Telehealth for psychiatry and/or counseling services Geriatric psychiatric care
Eating disorders treatment centers (inpatient/outpatient) Alcohol and drug abuse treatment (inpatient/outpatient) Self help options
Topic 2: ANXIETY & SOMATIC DISORDERS
What is anxiety? Anxiety is a subjective emotional state, often with feelings of: o Apprehension o Uneasiness o Uncertainty o Dread Anxiety is a normal emotion which helps us recognize real problems and solve them. In its healthy form, anxiety helps you perform at your best ability when you’re adjusting to, say, a new job or an exam Anxiety is a universal human experience Anxiety is not normal when it lasts well beyond a specific stressful event or when it interferes with a person’s day-to-day ability to function in life When behavior is recognized as dysfunctional, the nurse can initiate anxiety-reducing interventions As anxiety decreases, dysfunctional behavior generally also decreases Dysfunctional behavior is often a protective defense mechanism against anxiety
Types of anxiety Normal o A healthy life force necessary for survival Pathological o Differs from normal anxiety in Duration Intensity Impact on functioning (even after the threat is resolved) Acute o A short term response precipitated by A perceived imminent loss or A potential threat Chronic o A long term response Chronic anxiety usually begins in childhood
In what ways can anxiety manifest in people? How do you notice that anxiety affects you? Is this how anxiety will affect your clients? Anxiety: Anxiety is viewed on a continuum with increasing levels of anxiety leading to decreasing ability to function.
o Irritable bowel syndromes o Reduced immune response Contributing factors include: o Family history of anxiety-related disorders o Imbalances of serotonin, norepinephrine, and GABA o Existence of other medical or mental health challenges or diagnoses Anxiety may be worsened by medical conditions o Cultural approach to anxiety and stress (e., gender, ethnicity, social, race)
Anxiety Caused by Medical Conditions Symptoms of anxiety may be direct physiologic result of a medical condition: o Respiratory o Cardiovascular o Endocrine o Neurologic o Metabolic Evidence must be present in the clients history, physical examination, and/or laboratory findings for a providers to diagnose the medical condition
Medical causes for anxiety symptoms (differential diagnoses or ddx) must be ruled out prior to any psychiatric diagnosis of an anxiety or anxiety-based disorder, according to the diagnostic guidelines in the DSM-5. Anxiety disorders are inappropriate timing of sympathetic reaction (fight or flight)
Defense Mechanisms: protect people from painful awareness of feelings and memories that can provoke overwhelming anxiety
Healthy defenses: Altruism: emotional conflicts and stressors are addressed by meeting the needs of others. Unlike self sacrificing behavior, in altruism, the person receives gratification either vicariously or from the response of others Sublimation: an unconscious process of substituting constructive and socially acceptable activity for strong impulses that are not usually considers acceptable. Often these impulses are sexual or aggressive. A man with strong hostile feelings may choose to become a butcher or he may participate in rough contact sports Humor: humor makes life easy. An individual may deal with emotional conflicts or stressors by emphasizing the amusing or ironic aspects of the conflict or stressor through humor Suppression: is the conscious denial of a disturbing situation or feeling
Intermediate defenses: Repression: the exclusion of unpleasant or unwanted experiences, emotions, or ideas from consciousness awareness UNCONSCIOUSLY. Examples include forgetting the name or a former boyfriend or girlfriend, or forgetting an appointment to discuss poor
grades. Repression is considered the cornerstone of the defense mechanisms and it is the first line of psychological defense against anxiety. Displacement: transfer of emotions associated with a specific person, object, or situation to another person, object, or situation that is non-threatening. Example: the boss yells at the man, the man yells at his wife, the wife yells are the child and the child kicks the cat Reaction formation: unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion. Example: a person who harbors hostility toward children becomes a boy scout leader Somatization: occurs when repressed anxiety is demonstrated in the form of physical symptoms that have no organic cause. It can be an unconscious way of avoiding a situation that is anxiety provoking or an indirect way to communicate the need for help in a more socially acceptable manner, Example: it is considered “acceptable” to ask for help when you are “physically” sick. Undoing: is performing an action to make up for a previous behavior. Example: giving a gift to “undo” an argument. A pathological example of undoing is compulsive hand washing, this can be viewed as cleansing oneself of an act to thought perceived as unacceptable Rationalization: consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations for the behavior Example: “everybody cheats, so why shouldn’t i?” Rationalization is a form of self deception
Immature defenses: Passive aggression: can be seen when an individual deals with emotional conflict or stressor by indirectly and unassertively expressing aggression toward others. The appearance of compliance masks covert resistance, resentment and hostility. In passive aggression, the aggression toward others may be expressed through procrastination, failure, inefficiency, or passivity. These types of behaviors occur when the individual feels unable to directly express displeasure or disagreement Acting out behaviors: in acting out, an individual address emotional conflicts or stressors by actions rather than reflections or feelings. A person may lash out in anger verbally or physically to distract the self from threatening thoughts or feelings. Acting out can make a person feel temporarily less helpless or vulnerable. By lashing out at other, an individual can transfer the focus from person doubts and insecurities to another person or object, Acting out behaviors are a destructive coping style Dissociation: a disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment is known as dissociation. This defense mechanism is usually only seen with severe stressors Devaluation: occurs when emotional conflicts or stressors are handled by attributing negative qualities to self or others. When devaluing another, the individual then appears good by contrast Idealization: emotional conflicts or stressors are addressed by attributing exaggerated positive qualities to others. Idealization can be an adaptive aspect of the development of the self. Children who grow up with parents they can respect and idealize develop healthy standards of conduct and morality. When people idealize and overvalue a person in a new relationship, disappointment can occur when the object of the idealization turns out to be a human,
comprehend the environment, able to identify the cause of anxiety
what is happening, selective Inattentiveness; can attend to more with assistance from others Ability to learn Can effectively work towards goals and problem solve
Problem solving not optimal; will benefit from the guidance of others Physical May have slight discomfort Urinary frequency and urgency, headache, backaches, insomnia, increases respiration, increase heart rate, muscle tension Behavioral Restlessness, irritability, impatient, foot or finger tapping, fidgeting
Voice tremors and pitch changes, difficulty concentrating, repeats questions, very shaky pacing, banging on tables/doors/walls
ANXIETY CHARACTERISTICS by LEVEL Severe anxiety Panic Perceptual field Greatly reduced, can focus on specific details, scattered attention, completely self absorbed, blocking out the environment
Extremely narrow. Unable to focus, may lose touch with reality
Ability to learn Unable to relate events and details unable to problem solve
Disorganized reasoning, unable to learn.
Physical Dizziness, nausea, headache, insomnia, tachycardia, hyperventilation
Extreme psychomotor activity, dilated pupils, insomnia, increased heart rate, hyperventilation, inability to speak or form sentences Behavioral Feelings of dread, confusion, and doom; loud rapid speech, may make threats or demands
Sever shakiness, sleeplessness, social withdrawal, possible hallucinationS or delusions, often results in emergency room visit due to c/o cardiac, hyperventilation symptoms
Clients with panic anxiety have extreme psychomotor activity, which can lead to exhaustion. Nursing interventions: Provide a quiet environment Provide gross motor activities, (tension reduction) walking, exercising. Evaluation of the effectiveness of interventions allows for determination of resolution or revision of the approach to the client in any setting. The sudden onset of extreme apprehension and fear, is associated with feelings of impending doom. A panic attack is the abrupt onset of intense fear or discomfort that reaches a peak within minutes and includes at least four of the following symptoms: - Palpitations, pounding heart, or accelerated heart rate - Sweating - Trembling or shaking - Sensations of shortness of breath or smothering - Feelings of choking - Chest pain or discomfort - Nausea or abdominal distress - Feeling dizzy, unsteady, light-headed, or faint - Chills or heat sensations - Paresthesia (numbness or tingling sensations) - Derealization (feelings of unreality) or depersonalization (being detached from oneself) - Fear of losing control or “going crazy” - Fear of dying Since many of the symptoms of panic disorder mimic those of heart disease, thyroid problems, breathing disorders, and other illnesses, people with panic disorder often make many visits to emergency rooms or doctors' offices, convinced they have a life-threatening issue. Can not problem-solve and have poor grasp of event occurring in the environment. They are unable to control their actions, therefore safety of the client and others are a concern. Clients with panic anxiety have extreme psychomotor activity, which can lead to exhaustion. Nursing interventions: Provide a quiet environment Provide gross motor activities, (tension reduction) walking, exercising. Evaluation of the effectiveness of interventions allows for determination of resolution or revision of the approach to the client in any setting.
Panic attacks Done in sudden minutes (maybe an hour) super fast. When it goes away the client is not necessarily to terms with their condition, but the fear of sudden death is gone.
The sudden onset of extreme apprehension and fear, chin reaches a peak within minutes, and associated with feelings of impending doom Must included at least four of the following symptoms to meet DSM-5 diagnostic criteria o Palpitations, pounding heart or accelerated heart rate o Sweating
o Trembling or shaking o Sensations of SOB or smothering
322 Exam 1 Materials - Lecture notes for exam 1
Course: Behavioral Health Nursing (NSG-322)
University: Grand Canyon University
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