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PSYCHE - Tourette's

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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

    NURSING INTERVENTIONS

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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


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