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– A state of emotional, psychological and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept and emotional stability.(Videbeck) – Lifelong process of successful adaptation to a changing internal and external environments.
– A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress, increased risk of suffering, death, disability and loss of freedom. (Videbeck) – Loss of ability to respond to environment in ways that are in accord with oneself and society.
• • • • •
Accepts himself Perceives reality Mastery of self and environment Autonomy Unifying, integrated outlook in life
Theoretical Foundations
• Mental health-Psychiatric treatment integrates concepts and strategies from theories. • Theoretical Models are used as guides for treatments • These theories attempt to explain human behavior, health and mental illness
Theoretical Foundations
• Theoretical frameworks
– allow the systematic organization of knowledge – guide data collection – provide explanations for assessed behaviors – guide care plan development – provides rationales for interventions and – determine evaluation criteria – Guide research by providing assumptions to be tested.
Theoretical Foundations
PsychosexualPsychoanalytical Theory Psychosocial Theory Cognitive Theory Interpersonal Theory Sigmund FREUD Erik ERIKSON Jean PIAGET Harry Stack Sullivan
Moral Theory
Spiritual Theory
Theoretical Foundations
Behavioral Theories Humanistic Theories Psychobiology theory Pavlov and Skinner Maslow and Carl Rogers Neuroanatomy and physiology
Theories of Personality development
• • • • • • Freud's Psychoanalytic theory Erikson's Psychosocial theory Sullivan's interpersonal theory Piaget's Cognitive theory Fowler's Spiritual theory Kohlberg's Moral theory
• This theory supports the notion that EVERY human behavior is caused and can be explained • Freud believes that "repressed" sexual urges, desires, impulses or drives motivated much human behavior
Components of Personality 1. ID- part of a person that reflects BASIC or innate DESIRES, INSTINCT and SURVIVAL impulses 2. EGO- represents the REALITY aspect 3. SUPER-EGO- part that reflects MORALITY and ethical concepts, and values
Personality Stages and Functional Awareness 1. Conscious – perceptions, thoughts and emotion that exist in the person's awareness 2. Pre-conscious/Subconscious- Thoughts and emotions not currently in awareness but can be recalled with effort 3. Unconscious- thoughts, drives and emotions totally a person is Unaware
According to this theory, much of our behavior is motivated by our SUBCONSCIOUS thoughts or feelings
Five Stages of psychosexual development 1. Oral 2. Anal 3. Phallic or Oedipal 4. Latency 5. Genital
Phase Oral Anal Phallic Age Focus 0-18 months Site of gratification: Mouth 1 ½ - 3 years Site of gratification: Anus 3- 5 years Site of gratification: Genitals Site of gratification: (School Activities) Site of gratification: Genitals
Latency 6- 12 years Genital 12 & above
Phase Oral Anal Phallic Age Focus 0-18 months Major task: Weaning 1 ½ - 3 years Major task: Toilet training 3- 5 years Major task: Oedipal & Electra complex Major task : School activities Major task: Sexual intimacy
Latency 6- 12 years Genital 12 & above
Psychosexual model (Freud)
1. Oral a. 0-18 months b. Pleasure and gratification through mouth c. Behaviors: dependency, eating, crying, biting d. Distinguishes between self and mother e. Develops body image, aggressive drives
Psychosexual model (Freud)
2. Anal a. 18 months - 3 years b. Pleasure through elimination or retention of feces c. Behaviors: control of holding on or letting go d. Develops concept of power, punishment, ambivalence, concern with cleanliness or being dirty.
Psychosexual model (Freud)
3. Phallic/Oedipal
a. 3 - 6 years b. Pleasure through genitals c. Behaviors: touching of genitals, erotic attachment to parent of opposite sex d. Develops fear of punishment by parent of same sex, guilt, sexual identity
Psychosexual model (Freud)
4. Latency
a. 6 - 12 years b. Energy used to gain new skills in social relationships and knowledge c. Behaviors: sense of industry and mastery d. Learns control over aggressive, destructive impulses e Acquires friends
Psychosexual model (Freud)
5. Genital
a. 12 - 20 years b. Sexual pleasure through genitals c. Behaviors: becomes independent of parents, responsible for self d. Develops sexual identity, ability to love and work
Transference and Counter-transference • TRANSFERENCE is the clients feeling toward nurse arising from unconscious experiences with early significant others • COUNTER TRANSFERENCE is the nurse's feelings toward the patient arising also form previous experiences
The Freudian View of Mental Illness • All behavior has meaning • Mental illness and manifestations are caused by unconscious INTERNAL conflict arising from unresolved issues in early childhood • Ego defenses are utilized to relieve inner tension
Psychosocial Theory
• Theory that focuses on developmental task, focuses on EGO as this develops from social interaction • The developmental tasks are sequential and depend on prior successful mastery • An individual who fails to "master" the task at appropriate age may return to work on mastery
Psychosocial Theory
Use of the theory in Nursing • Assessment can be done focusing on the psychosocial development at specific age • Appropriate interventions can be selected based on task • Nurses can promote healthy behaviors and encourages hope that re-learning is possible
Erikson's Psychosocial theory
• • • • • • • • Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion Intimacy versus isolation Generativity versus stagnation Ego integrity versus despair
Psychosocial Model (Erikson)
1. Trust vs mistrust
a. 0 - 18 months b. Learn to trust others and self vs withdrawal, estrangement
2. Autonomy vs shame and doubt
a. 18 months - 3 years b. Learn self-control and the degree to which one has control over the environment vs compulsive compliance or defiance
Psychosocial Model (Erikson)
3. Initiative vs guilt
a. 3 - 5 years b. Learn to influence environment, evaluate own behavior vs fear of doing wrong, lack of selfconfidence, over restricting actions
4. Industry vs inferiority
a. 6 - 12 years b. Creative; develop sense of competency vs sense of inadequacy
Psychosocial Model (Erikson)
5. Identity vs role confusion
a. 12 - 20 years b. Develop sense of self; preparation, planning for adult roles vs doubts relating to sexual identity, occupational career
6. Intimacy vs isolation
a. 18 - 25 years b. Develop intimate relationship with another; commitment to career vs avoidance of choices in relationships, work, or life-style
Psychosocial Model (Erikson)
7. Generativity vs stagnation
a. 21 - 45 years b. Productive; use of energies to guide next generation vs lack of interests, concern with own needs
8. Integrity vs despair
a. 45 years to end of life b. Relationships extended, belief that own life has been worthwhile vs lack of meaning of one's life, fear of death
Interpersonal theory
• This concept focuses on interaction between an individual and his environment • Personality is shaped through "interaction" with significant others • We internalize approval or disapproval form our parents
Interpersonal theory
Personality has three SELF-SYSTEM 1. "Good Me" develops in response to behaviors receiving approval by parents/SO 2. "Bad Me" develops in response to behaviors receiving disapproval by parents/SO 3. "Not Me" develops in response to behaviors generating extreme anxiety in parents/SO and this is denied as part of oneself
Interpersonal theory
Mental Health is Viewed as: 1. Related to conflict or problematic interpersonal relationships 2. Past relationships, inappropriate communication and current relationship crisis are etiologic factors of mental illness
Interpersonal theory
Treatment of Mental illness: • Focuses on anxiety and its causes • Therapeutic relationship with client that is active and participative • Feelings and emotions are verbalized by the clients to modify problematic relationships
Interpersonal theory
Usefulness in Nursing • Nurse and client can participate in and contribute to the relationship that is therapeutic • This relationship can be used as a corrective interpersonal experience • Anxiety management
Interpersonal Model (Sullivan)
1. Infancy
a. 0 - 18 months b. Others will satisfy needs
2. Childhood
a. 18 months - 6 years b. Learn to delay need gratification
3. Juvenile
a. 6 - 9 years b. Learn to relate to peers
Interpersonal Model (Sullivan)
4. Preadolescence
a. 9—12 years b. Learn to relate to friends of same sex
5. Early adolescence
a. 12—14 years b. Learn independence and how to relate to opposite sex
6. Late adolescence
a. 14—21 years b. Develop intimate relationship with person of opposite sex
Cognitive Theory
• This theory focuses on the inborn development of thinking ability from infancy to adulthood • A person is born with a tendency to organize and to adapt to their environment • Mental illness is not directly discussed
Cognitive Theory
Usefulness of Cognitive theory in Nursing 1. This provides an understanding how an individual think and communicate. Nurse can provide intervention accordingly 2. Nursing interventions should be congruent to the age-specific cognitive level 3. Teaching strategies are modified according to cognitive process
• Sensori-motor (birth to 2 ) • Pre-operational (2-7)
– Preoperational preconceptual (2-4) – Preoperational intuitive (4-7)
• Concrete operational (7-12) • Formal operational (12 to adulthood)
Cognitive Theory (Piaget)
A. 0 - 2 years: sensorimotor -reflexes, repetition of acts B. 2 - 4 years: preoperational/preconceptual -no cause and effect reasoning; egocentrism; use of symbols; magical thinking C. 4 - 7 years: intuitive/preoperational -beginning of causation
Cognitive Theory (Piaget)
D. 7 - 11 years: concrete operations - uses memory to learn - aware of reversibility E. 11 - 15 years: formal operations -reality, abstract thought -can deal with the past, present and future
Behavioral Theory
• This concept describes a person's function in terms of identified BEHAVIORS • People learn to be who they are • Behavior can be observed, described and recorded • Behavior is subject to reward or punishment • Behavior can be modified by changing environment
Behavioral Theory
• The Classical Conditioning by Pavlov
– Learning can occur when a stimulus is paired with an unconditioned response – Conditioned responses happens when stimulus is present – Acquisition – gain of learned response – Extinction – loss of learned response
Behavioral Theory
• The Operant Conditioning by Skinner
– Rewards and punishments are utilized – Positive reinforcement- rewards – Negative reinforcement– Positive punishment – Negative punishment- withdrawing reward
Behavioral Theory
Mental Illness is viewed as: • Mal-adaptive BEHAVIORS are learned through classical and operant conditioning • Mal-adaptive behaviors can be changed by altering environment
Behavioral Theory
Application to Nursing 1. The nurse assess both adaptive and ,aladaptive behaviors 2. The nurse and client collaborate in identifying behaviors that need to change 3. Behavioral modification techniques are utilized by the nurse in the treatment of mental illness
Humanistic theory
• Human nature is positive and growth centered and existence involves search for meaning and truth • Maslow's theory of Needs are organized in a hierarchy
Humanistic theory
Mental illness in this framework 1. The failure to develop one's FULL potential leads to poor coping 2. Lack of self awareness and unmet needs interfere with feelings of security 3. Fundamental human anxiety is fear of death which leads to existential anxiety
Humanistic theory
Application of the theory to Nursing 1. NCR is based on positive regard, respect and empathy 2. Nurses assess the spiritual aspects of the client including religion, love and relationships 3. Through reflective listening and emphatic responses, the nurse helps the client gain self-understanding
• Stage 1 Age 2-3 • Description: – Punishment or obedience (heteronomous morality) – A child does the right things because a parent tells him or her to avoid punishment
• Stage 2 Age : 4-7 • Description: – Individualism – Child carries out actions to satisfy own needs rather than society's. The child does something for another if that person does something for him in return
CONVENTIONAL LEVEL level 2
• Stage 3 Age : 7-10 • Description: – Orientation to interpersonal relations of mutuality – A child follows rules because of a need to be a good person in own eyes and in the eyes of others
CONVENTIONAL LEVEL level 2
• Stage 4 Age : 10-12 • Description: – Maintenance of social order, fixed rules and authority – Child follows rules of authority figures as well as parents to keep the system working
POSTCONVENTIONAL LEVEL level 3
• Stage 5 Age :older than 12 • Description: – social contract, utilitarian law making perspective – child follows standards of society for the good of all people
POSTCONVENTIONAL LEVEL level 3
• Stage 6 Age :older than 12 • Descriptions: – universal ethical principle orientation – child follows internalized standards of conduct
• • • • • •
Establish rapport Obtain understanding of problem Assess for risk factors & psychological functioning Identify nursing diagnosis & goals Perform mental status examination Identify behaviors/beliefs/areas to be modified to effect positive change • Formulate a plan of care
• • • • • • • • • Previous Hospitalizations Educational Background Occupational Background Social Patterns Sexual Patterns Interest and Abilities Substance Use and abuse Coping Abilities Spiritual Assessment
• • • • • • • • Personal Information Appearance Behavior Speech Affect and Mood Thought Process Perceptual Disturbances Cognition
• Test to Assess Cognitive Function • Interpretation Any score over 24 (out of 30) is effectively normal. The normal value is also corrected for degree of schooling and age. Low to very low scores correlate closely with the presence of dementia, although other mental disorders can also result in abnormal findings of the MMSE testing. The presence of physical problems can also interfere with the interpretation. For example a patient that is physically unable to hear or read the instructions properly, or has a motor deficit that affects his writing and drawing skills.
Nature of Psychiatric Nursing
The DSM(DIAGNOSTIC STATISTICAL MANUAL)-TR (TEXT REVISION) IV- APA (AMERICAN PSYCHIATRIC ASSOCIATION)
– – – A taxonomy that describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research. Clinicians utilize this to diagnose psychiatric disorders. Purpose of DSM-TR:
1. Standard nomenclature/ classification 2. Defining characteristics 3. Underlying cause of disorders
Nature of Psychiatric Nursing
The DSM-TR IV : Multi Axis Classification AXIS I- Major Psychiatric Disorders AXIS II- Mental Retardation and Personality Disorders AXIS III- Current Medical Condition AXIS IV- Psychosocial and Environmental Problems AXIS V- Global Assessment of Function
Nature of Psychiatric Nursing
Historical People Worth Mentioning 1. Aristotle- the Humors 2. Freud- -Psychosexual theory 3. Kraeplin- symptomatic classification of mental disorders. 4. Bleuler- coined "schizophrenia"
Nature of Psychiatric Nursing
Psychiatric Nursing in the Philippines • GO and NGOs • Mental health programs
Nature of Psychiatric Nursing
Psychiatric Nursing in the Philippines
Mental Health State of well being, where a person can realize his potential. Mental Ill Health Disturbance of thought, feelings and behavior. Mental Disorder Medically diagnosable illness. Mental Hygiene Science which deals with measures employed to promote mental health.
Nature of Psychiatric Nursing
Scope of Nursing Practice • • Individual, family and community Healthy and ill person
Nature of Psychiatric Nursing
Self Awareness • The process by which the nurse gains recognition of his/her own feelings, beliefs and attitudes. (Videbeck) • Initial nursing activity to do before practicing psychiatric nursing.
Nature of Psychiatric Nursing
Self Awareness • This is accomplish through reflection, spending time deliberately focusing on how one feels and what one values or believes.
Mental Health Concepts
• Assessment (psychosocial processes )
– Appearance , behavior or mood – Speech , thought content and thought process – Sensorium – Insight and judgment – Family relationships and work habits – Level of growth and development
Common Behavioral Signs and Symptoms
1) Disturbances in perception
• • Misinterpretation of an actual external stimuli. False sensory perception in the absence of external stimuli.
Disturbances in thinking and speech Neologism
Coining of words that people do not understand.
Over inclusion of inappropriate thoughts and details.
Word salad
Incoherent mixture of words and phrases with no logical sequence.
Meaningless repetition of words and phrases.
Persistence of a response to a previous question.
• •
Pathological repetition of words of others.
Speech difficulty and disturbance Expressive , receptive or global
Magical thinking
• Primitive thought process thoughts alone can change events.
Autistic thinking
• Regressive thought process
Subjective interpretations not validated with objective reality.
Flight of ideas
• Shifting of one topic from one subject to another in a somewhat related way.
Looseness of association
• Incoherent ,illogical flow of thoughts(unrelated way).
Clang association
• Sound of word gives direction to the flow of thought.
• Persistent false belief,rigidly held.
• • • • Delusions of grandeur- special /important in a way Persecutory-threatened Ideas of reference-situation/events involve them Somatic- body reacting in a particular way
3) Disturbances of affect
• • • • • • • Disharmony between the stimuli and the emotional reaction. Severe reduction in emotional reaction. Absence or near absence of emotional reaction. Dulled emotional tone. Feeling of strangeness from one's self. Feeling of strangeness towards environment. Lack of sensory stimuli integration.
Blunted affect
Flat affect
4) Disturbances in motor activity
• Imitation of posture of others.
Waxy flexibility
Maintaining position for a long period of time.
Loss of balance.
Ataxia Akathesia
Extreme restlessness.
Uncoordinated spastic movements of the body.
Dystonia Tardive dyskenisia
Involuntary twitching or muscle movements.
Involuntary unpurposeful movements.
5) Disturbances in memory Confabulation
• • Filling of memory gaps 2nd time-like feeling
Déjà vu
Jamais vu
• Not having been to the place one has been before. Memory loss (inability to recall past events)
Retrograde-distant past Anterograde – immediate past Anomia – lack of memory of items
Therapeutic Relationships
• This is a nurse-client interaction that is directed toward enhancing the client's wellbeing (Isaacs) • A relationship established between a health care professional and a client for the purpose of assisting the client to solve his problems
Therapeutic Relationships
• The nurse- patient relationship is characterized by a helping process
– The nurse and client work together for his benefit – The nurse uses herself therapeutically and this is achieved by self-awareness
Therapeutic Relationships
• The nurse- patient relationship
– Respect the client and vale as individual – Holistic care – Maintain appropriate limits – Covey empathy not sympathy – Maintain honest and therapeutic communication – Encourage expression of feelings
Therapeutic Relationships
ELEMENTS OF THE THERAPEUTIC RELATIONSHIP • Contract • Boundaries • Confidentiality • Therapeutic Behaviors
Therapeutic Relationships
ELEMENTS OF THE THERAPEUTIC RELATIONSHIP Therapeutic Behaviors 1. Genuineness = sincerity and honesty 2. Concreteness= ability to identify client's feelings 3. Respect= shown through consideration of patient as unique being 4. Self- exploration and self disclosure
Therapeutic Relationships
PHASES OF THE THERAPEUTIC RELATIONSHIP 1. Pre-Interaction- Pre-orientation 2. Orientation- Interaction 3. Working 4. Termination
Therapeutic Relationships
Phase Nursing Activities
Nurse obtains data from secondary sources
Nurse establishes trust, assess client, establishes mutual agreement Nurse assists the client to meet goals and resolve problems
Interaction- Orientation Working
Nurse and client express feelings about termination, observes regressive behaviors and evaluates NCR
• Establishment of goals, rules, boundaries etc.. • Rapport is built • Identify expectations • Trust is gained • Assessment is done • Goals are defined • Contract is made
• Problems are identified • Solutions are explored, applied and evaluated • Nurse assists the client to develop coping skills, positive self concept and independence • Promote insight and the use of adaptive coping mechanisms
• Nurse terminates the relationship based on mutually agreed goals when these are already achieved • Focus of this stage is growth that has occurred • Client may become anxious and reacts • Nurses must help patient resolve the anxiety and ends the relationship professionally
Therapeutic Communication
• Therapeutic communication
– Dynamic process of exchanging information – Composed of verbal and non-verbal techniques that the nurse uses to focus on the client's needs
Therapeutic Relationships
Therapeutic communication : ELEMENTS 1. Sender- the source of message 2. Message- the information transmitted 3. Receiver- recipient of message 4. Feedback- receiver's response to the message
Therapeutic Relationships
NON VERBAL COMMUNICATION 1. Proxemics- the physical space between the sender and receiver 2. Kinetics- the body movements such as gestures, facial expressions and mannerisms 3. Touch- intimate physical contact
Therapeutic Relationships
NON VERBAL COMMUNICATION 4. Silence 5. Paralanguage- voice quality (tone, inflection) or how a message is delivered
Therapeutic Relationships
VERBAL COMMUNICATION • Use of therapeutic communication techniques • Effective communication should be therapeutic, appropriate, simple, adaptive, concise and credible
Therapeutic Communication
Open ended questions Focus on FEEELINGS State behaviors observed Reflect, restate, rephrase Neutral responses
Therapeutic Communication
Offering self Active listening Exploring Broad Openings I am here to help you Eye to eye contact Tell me more about…,. What do you want to talk about You seemed depressed
Making observation
Therapeutic Communication
Summarizing Voicing doubt Encouraging description of perception A few minutes ago, we were talking about.. Then… I find it hard to believe What are these voices telling you
Presenting reality
Seeking clarification
The sound is produced by the car No one is in the room I am not sure of what you mean
Therapeutic Communication
Verbalizing the implied Reflecting Restating Are you saying you want to kill yourself ? Do you think you should? P: I cant sleep at night N: You cant sleep at night ?
General leads
GO on… then…. Hmm….you were saying….
Lets talk more about what you think of your problems
Non-therapeutic communication
• These are blocks to communication • Usually, these are the common pitfalls of communicating non-therapeutically:
– Giving advise – Talking about self – Telling client is wrong – False reassurance – Cliché' – Asking 'Why'
Non-therapeutic communication
Making judgment False reassurance Invalidation Focusing on self You are wrong It's going to be alright I cannot talk now, I'm busy I am the best nurse to care for you
Changing the subject
P: I'm afraid of the surgery N: Ho many children do you have
Giving advice
If I were you, I will
Non-therapeutic communication
Agreeing Disapproving Defending Requesting explanation Yes I think you are right I don't want you to do that This hospital is the best "why"
Belittling feelings
There is the sun after the rain
P: I'm so depressed today N: everyone feels sad at times
PERSONAL= SOCIAL= PUBLIC= Distances Touching to 1 ½ ft 1 ½ to 4 ft 4 to 12 ft 12 to 15 ft
Psychiatric Nursing Process
• Applies to all clients • Utilizes unique process for psychological assessment • Similar to other types of nursing process approaches
Psychiatric Nursing Process
• Nursing ASSESSMENT Nursing History Physical Examination including the Neurological examination Laboratory Examination
Psychiatric Nursing Process
• Nursing ASSESSMENT
– Refers to the scientific process of identifying a patient's psychosocial problems, strengths an concerns – Interview is done to acquires broad information about a client
Psychiatric Nursing Process
– Level of consciousness – General appearance – Behavior – Speech – Mood and affect – Judgment – Memory – insight
Psychiatric Nursing Process
– Observation of mood and affect – Assessment of thought, sensorium and intelligence – Speech and content – Assess developmental status and family-culturalspiritual background
Psychiatric Nursing Process
– Emotional status – Cognitive assessment – Socio-cultural assessment
Psychiatric Nursing Process
• Physical Examination
– Observation for key signs
• Diagnostic Tests
– CT, MRI, PET, EEG – Laboratory tests= CBC, Electrolytes, Drug levels
Psychiatric Nursing Process
– Other diagnostic tests
• • • • • Beck depression inventory Minnesota multiphasic personality inventory Draw-a person test Sentence completion test Thematic aperception test
Psychiatric Nursing Process
• Nursing Diagnoses
– Anxiety – Ineffective coping- individual, family – Fatigue – Fear – Sleep pattern disturbance – Altered thought process – Etcetera
Psychiatric Nursing Process
• Nursing Objectives • Short term goals are set for immediate problems, feasible and within client's capabilities • Long term goals are related to discharge planning and prevention of recurrence of symptoms
Psychiatric Nursing Process
• Nursing Objectives: The client will:
– Participate in treatment program – Becomes oriented to three spheres and exhibit reality-based behaviors – Recognize reasons for behavior – Maintain self-care activities
Psychiatric Nursing Process
• Nursing Interventions
– Use of therapeutic communication – Therapeutic Groups – Psychotherapy: Family, Milieu, Behavioral modification, Crisis intervention, Psychopharmacology – Electroconvulsive therapy
Psychiatric Nursing Process
• Nursing Evaluation
– Determine if goals are met by collecting data and comparing them to baseline – Clients' behavior should demonstrate optimal orientation to reality and interaction with others appropriately
Treatment Modalities
1. 2. 3. 4. 5. 6. 7. Therapeutic Environment- Milieu Therapeutic Groups Crisis intervention Family therapy Behavioral modification Cognitive therapy Psychotherapy
Therapeutic environment
• Research has documented that the environment in which the mentally ill person is treated is a major factor in enhancing or impeding the therapeutic effects of other treatment modalities
Therapeutic environment
Characteristics of a Therapeutic environment 1. The clients' physical needs are met 2. The client is respected 3. Decision making authority is clearly defined 4. Client is protected from injury (self and others)
Therapeutic environment
Characteristics of a Therapeutic environment 5. Clients are allowed freedom of choice commensurate to his ability to decide 6. Nursing Personnel remain constant and assignments are stable 7. Emphasis is placed on social interaction between clients and staff
Therapeutic Modalities
Milieu therapy
– Total environment has an effect on the person's behavior- physical, emotional, relationships
Purposes of therapy 1. Improve client's behavior 2. Involve client in decision making 3. Increase autonomy and communication 4. Set structure of unit and behavioral limits
Therapeutic Modalities
Milieu therapy • The surrounding is made positive to effect behavioral changes in the prescribed directions • Goals of milieu therapy: to help patient develop sense of self-esteem, personal growth, improve ability to relate to others and return to the community better prepared
Therapeutic modalities
Milieu therapy
– The nurse involves the client in decision making – The nurse promotes the involvement of staff in care – Social skills are developed and sense of community is fostered
Therapeutic Groups
– A treatment approach in which the entire milieu is used as treatment – This includes the physical environment and the others clients
Therapeutic Groups
Group Therapy – Involves meaningful interaction between members of a group as they relate their personal experiences to each other – The main objective is for each group member to examine his own behavior and relationship. The group can influence to change his behavior and relationships
Therapeutic Groups
• Groups of clients meet with one or more therapists to work together to solve client problems
Therapeutic Groups
• Purposes
– To increase self-awareness – To improve interpersonal relationships – To make changes in behavior – To enhancing group teaching and learning
Therapeutic Groups
• Structure of the Therapeutic Group
– One leader chosen by the group – Members – Size is usually 10 – Physical arrangement – Time and place of meeting
Therapeutic Groups
Phases of group development 1. Beginning phase
– Info given, anxiety heightened
2. Middle phase
– Confrontation, cohesiveness, trust and selfreliance
3. Termination phase
– Goals of the group are achieved – Individuals leave the group when work is done
Therapeutic modalities
CRISIS • A disturbance caused by a precipitating event such as perceived loss, a threat of loss or a challenge that is perceived as a threat to self.
Therapeutic modalities
CRISIS Can be classified as to maturational crisis, situational crisis or adventitious crisis
– Maturational= role changes – Situational= loss of job, death – Adventitious= fires, earthquakes and floods – In a crisis, the person's usual methods of coping are INEFFECTIVE, resulting in increasingly greater levels of anxiety.
Therapeutic Modalities
• Characteristics of Crisis:
– It is sudden – It is short term may last for 4-6 weeks – Individualized – The person becomes dependent and overwhelmed
Therapeutic Modalities
Factors that can produce crisis • 1. Hazardous EVENTS • 2. Threat to the individual's equilibrium • 3. Inadequate coping skills
Therapeutic Modalities
• There are four PHASES of Crisis (DIDA)
– Denial – Increased Tension- when the person knows the existence of crisis and still continues ADL – Disorganization= pre-occupied and unable to perform function – Attempts to Reorganize= by mobilizing previous coping mechanisms
Therapeutic Modalities
– A technique of helping the person go through the crisis – To mobilize his resources – To help him deal with the here and now – A five step problem solving technique designed to promote a more adaptive outcome including improved abilities to cope with future crises
Therapeutic modalities
Goal of Crisis intervention: help the patient go back to his state of optimum level of functioning – IDENTIFY the problem- A solution is not possible unless the problem be identified. – LIST alternatives- all possible solutions to the problem need to be listed. – CHOOSE from among the alternatives- each options is carefully considered, and the alternative chosen is usually highly individualized, based on priorities and values of the person – IMPLEMENT the plan- the alternative is put into action. The nurse may need to support and encourage patient to take action – EVALUATE the outcome- the effectiveness of the plan is evaluated.
Therapeutic modalities
Family therapy • An approach in which the therapist focuses on the behavior of the entire family as a system instead of focusing on the pathology of one member
Therapeutic modalities
Family therapy
– – Focuses on the client as a 'family" Involvement of family members
Purposes of family therapy 1. Improve relationships among family members 2. Promote family functions 3. Resolve family problems 4. Help family find ways to cope with problems
Therapeutic modalities
Family therapy • Problems are identified by each family members and each discusses his/her involvement in the problem • Members discuss how problems affect them and they explore how to solve them
Therapeutic Modalities
Family therapy • The nurse functions to assess the family interactions, makes observations and encourages expression of feelings • Helping the family resolve the problem is the goal
Therapeutic Modalities
Behavioral Modification
– Therapy to change the unacceptable behavior to acceptable – The nurse determines the unacceptable behaviors and she identifies adaptive behaviors – Punishment is given to unacceptable behavior – Reward is given to acceptable behavior
Therapeutic Modalities
Behavioral Modification • Other Behavioral therapies 1. Self-control therapy 2. Aversion therapy 3. Desensitization 4. Modeling 5. Operant conditioning
Therapeutic Modalities
Cognitive therapy • An active, directive, time-limited approach • Therapeutic techniques are used to identify reality testing • The nurse helps the patient think and act more realistically and adaptively about his problems
Therapeutic Modalities
Play therapy
– Therapy with children in which they are helped to express themselves or their behavior through play
Therapeutic Modality: Psychotherapy
• A method of treating mental illness in which verbal and expressive techniques are used to help the person resolve inner conflict and modify behaviors
Therapeutic Modality: Psychotherapy
1. 2. 3. 4. 5. 6. Psychoanalysis Client centered therapy Rational emotive therapy Gestalt therapy Reality therapy Transactional analysis
Therapeutic Modality: Psychotherapy
1. Psychoanalysis
– THE therapist obtains information about the past and present experiences that have repressed in the person's subconscious mind – By learning the source of the problem, the problems can be brought to the conscious where the therapist helps the individual dealt with them
Therapeutic Modality: Psychotherapy
2. Client Centered therapy
– The therapist work with one client – Accepting, non-judgmental environment aimed at reducing the anxiety and reducing negative defenses – The patient is encouraged to express his feelings and increase self-awareness – When the person is aware of what he feels, he can work on improving behavior
Therapeutic Modality: Psychotherapy
3. Rational-Emotive therapy
– This is based in the assumption that a person's behavior is due to his own thinking – Problems arise as the person believes about eh events – The therapy aims to change the person's belief system
Therapeutic Modality: Psychotherapy
4. Gestalt Therapy
– The mind receives experiences as a whole – When the experience is complete, the problem will arise – The goal of the therapy is to help patients complete the experience through awareness
Therapeutic Modality: Psychotherapy
5. Transactional Analysis
– A group therapy method – Helps people "analyze" their transaction or interaction with others and guides them to the conclusion: I'm OK you are OK
Responses to Illness
• • • • Stress Anxiety Crisis Anger and hostility
Ego Defense Mechanisms
Unconscious Ego Defense Mechanism
• These are PSYCHOLOGIC adaptive mechanisms • Mental mechanisms that develop as the personality attempts to DEFEND itself, establishes compromises among conflicting impulses and allays inner tensions.
Unconscious Ego defense mechanism
• The unconscious mind working to protect the person from anxiety. • Releases tension .
Ego Defense Mechanisms
• Compensation • Covering up weaknesses by emphasizing a more desirable trait. • Attempt to ignore unacceptable realities by refusing to acknowledge them.
• Denial
Ego Defense Mechanisms
• Displacement • Discharging emotional reactions from one object to a LESS threatening object/person. • Imitation of someone feared or respected.
• Identification
Ego Defense Mechanisms
• Intellectualization • Use of rational explanations that remove from the event any personal significance and feelings. • Acceptance of other's norms as oneself.
• Introjection
Ego Defense Mechanisms
• Minimization • Not acknowledging the significance of one's behavior
• Projection
• Blame is attached to others or to environment for unacceptable thoughts, mistakes, etc
Ego Defense Mechanisms
• Rationalization • JUSTIFICATION of certain BEHAVIORS by faulty logic/reasons
• Reaction Formation
• Acting OPPOSITELY to the way they feel
Ego Defense Mechanisms
• Regression • Resorting to an earlier, more comfortable level of functioning that is less demanding • Unconscious mechanism of keeping threatening desires or thoughts from becoming CONSCIOUS
• Repression
Ego Defense Mechanisms
• Sublimation • Re-channeling of aggressive energies into socially acceptable activities
• Substitution
• Replacement of a highly valued object by a LESS valuable or acceptable and available object
Ego Defense Mechanisms
• Undoing • Actions or words designed to cancel some disapproved thoughts, impulses , or acts in which the person relieves GUILT by making reparation
Disturbances in 2 or more of the following: • Cognition (thinking about self, people, & events). • Affectivity (range, intensity, lability, & appropriateness of emotional response) • Interpersonal functioning • Impulse control
Type Paranoid Schizoid Schizotypal
Characteristics Suspicious & mistrust Hermitlike lifestyle, aloneness Similar to but less severe than those of schizophrenia
• Suspicious of others • Doubt trustworthiness or loyalty of friends & others. • Fear of confiding in others. • Suspicious, without justification, of spouse's or sexual partner's fidelity. • Interpret remarks as demeaning or threatening. • Hold grudges toward others. • Become angry & threatening when they perceive they are attacked by others.
• • • • • • •
Lacks desire for close relationships or friends Chooses solitary activities; a lifelong loner Little interest in sexual experiences Avoids activities Appears cold & detached Lacks close friends Appears indifference to praise or criticism
• Ideas of reference • Magical thinking or odd beliefs • Unusual perceptual experience, including bodily illusion • Odd thinking & vague, stereotypical, over elaborate speech • Suspicious • Blunted or inappropriate affect • Odd or eccentric appearance or behavior • Few close relationships • Excessive social anxiety
Type Antisocial
Disregard of others' rights without guilt Borderline Problems with self-identity, IPRs, mood shifts, & self-destructiveness. Narcissistic Over-evaluation of self, arrogance, & indifference to the criticism of others Histrionic Dramatic behaviors, attention seeking, & superficiality
• • • • • • • •
Deceitfulness as seen in lying or conning others Engages in illegal activities Aggressive behavior; violence Lack of guilt or remorse Irresponsible in work & with finances Impulsiveness Reckless disregard of safety for self or others Insensitivity
• Before age 15, these behaviors are diagnosed as conduct disorder. • DUI, substance abuse, domestic violence ie; child abuse, wife abuse. -> meet clients at court/prison • History is more important than mental status assessment. • Seems no conscience, irresponsible, immature & dependent. • Nursing care- set firm limits & be consistent in confronting behaviors & enforcing unit rules.
• Frantic avoidance of abandonment; real or imagined • Unstable & intense IPR; Identity disturbances • Impulsivity; Affective instability • Recurrent suicidal behavior or self-mutilating behavior – to express feelings of anger/frustration • Rapid mood shifts • Chronic feelings of emptiness • Transient dissociative & paranoid symptoms
• Uncertain about his self-image, career goals, personal values, & sexual orientation • Unhealthy R & in short-term intimate R • For client's impulsivity – Nurse's self awareness and set limit are important. • Pt alternates between overidealization & devaluation of individuals ie falls in love with the perfect person and shortly can find no redeeming quality in the formerly idealized person. • Manipulation & dependency commonly occur. Pt has great difficulty in being alone & therefore seeks intense but brief relationships • tend to view themselves as victims and assume little responsibility for their problems
• Grandiose self-importance • Fantasies of unlimited power, success, or brilliance • Believes he/she is special or unique; Needs to be admired • Sense of entitlement (i.e., deserves to be favored or given special treatment) • Takes advantage of others for own benefit • Lacks empathy • Envious of others or others are envious of him/her • Arrogant or naughty
• Family may complained "The pt never really seemed to see me as a person with my own thoughts and problems."
• • • • • • • •
Needs to be center of attention Displays sexually seductive or provocative behaviors Shallow, rapidly shifting emotions Uses physical appearance to draw attention Uses speech to impress others but is lacking in depth Dramatic expression of emotion Easily influenced by others Exaggerates degree of intimacy with others
Submissiveness, helplessness, fear of responsibility, & reliance on others for decision making. Timidity, social withdrawal behavior, & hypersensitivity to criticism.
Indecisiveness, perfectionism, inflexibility, & difficulty expressing feelings.
• Unable to make daily decisions without much advice & reassurance. • Needs others to be responsible for important areas of life. • Seldom disagrees with others because of fear of loss of support or approval. • Problem with initiating projects or doing things on own because of little self-confidence. • Performs unpleasant tasks to obtain support from others. • Anxious or helpless when alone because of fear of being unable to care for self. • Urgently seeks another relationship for support & care after a close R ends. • Preoccupied with fear of being alone to care for self.
• Avoids occupations involving interpersonal contact because of fears of disapproval or rejection. • Uninvolved with others unless certain of being liked. • Fears intimate Rs due to fear of shame or ridicule. • Preoccupied with being criticized or rejected in social situations. • Inhibited & feels inadequate in new interpersonal situations. • Believes self to be socially inept, unappealing, or inferior to others. • Very reluctant to take risks or engage in new activities due to possibility of being embarrassed.
• A pervasive pattern of social interaction, feeling of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in variety of context.
• Preoccupied with details, rules, lists, organization. • Perfectionism that interferes with task completion. • Too busy working to have friends or leisure activities. • Over conscientious & inflexible. • Unable to discard worthless or worn-out objects. • Others must do things his/her way in work or task related activity. • Reluctant to spend and hoards money. • Rigid and stubborn.
• • • • • • •
Anxiety High risk for self-mutilation Hopelessness Impaired communication Ineffective individual coping Self-esteem disturbance Social isolation
Nursing Care
• Nurse-Patient relationship – trust, empathy, authenticity • Focus on specific behaviors, distress to self or others or both & awareness of dysfunctional & self-defeating patterns • Case management – stress reduction & crisis intervention • Assertive training; Social skill training • Psychobiological therapy (with caution) • Milieu therapy – setting limits
• Personality traits -> individualization • Disorder = rigid, dysfunctional, distress • Distress come from others' reaction to or behaviors toward that person -> evoke interpersonal conflict • Usually have more than one DSM diagnosis • Long-term hospitalization is unnecessary • Limit setting – multidisciplinary work • Px - have a fairly good prognosis only with therapy
Substance-Related Disorders
Personal and societal toll Terminology & criteria for diagnoses Care plan and interventions
• Epidemiology - # 1 health problem in the US -> effects on cost, quality of life, society • Types - Alcohol, tobacco, other drugs ie opium, heroin, codeine, synthetic narcotics. • Cigarettes and alcohol – gateway drugs • History – medical use, social use, illegal use • Central nervous system (CNS) was affected • Substance dependency – Client experiences tolerance and withdrawal symptoms
• Prescribed medications
• Over-the-counter cough, cold, sleep, and diet medication. • Narcotics
– – – – Heroin Morphine Demerol Methadone.
– Ritalin – OxyContin
• Inhalants • Hallucinogen • Stimulants
– Marijuana, LSD, PCP… – Cocaine – Amphetamines
Other Substance & Trends
• Club drugs ie MDMA (ecstasy), GHB, Rohypnol,
ketamine, methamphetamine, LSD
• • • • •
CNS depressants ie. Valium, phenobarbital Steroids 1960 – hallucinogens, amphetamines 1970 – heroin, marijuana, sedatives 1980 – cocaine – injection, smoking
• Dependence
– physical & psychological
• Codependence
– an emotional, psychological and behavioral pattern of coping that an individual develops as a result of prolonged exposure to a dysfunctional pattern of behavior within the family. – The individual experiences difficulty with identity development and set in functional boundaries which lead to taking care of others rather than self.
• Tolerance
– May be influenced by the enzyme ie French
– A condition in which tolerance to one drug often results in a tolerance to chemically similar drugs. – Abstinence syndrome. – Physical signs and symptoms that occur when the addictive substance is reduced or withheld .
• Cross-tolerance
• Withdrawal
• Dual diagnosis • CAGE – cutdown, annoy, guilty, eye opener • Blackout
– The person appears to function normally while drinking but later is unable to remember what occurred. – It may last a few hours or several hours.
• Withdrawal from Cocaine -> anxiety and depression • hallucinogens do not produce physical dependence, so there are no withdrawal symptoms
A Continuum of Substance Use
Nonuse Social use • Social • Recreational • Medical Dependence •Physical •Tolerance •Withdrawal •Psychological •Compulsive use •Craving Addiction • Loss of control of ingestion • Using despite related problems • Tendency to relapse
• Biological theories
– Genetic predisposition
• Psychological theories
– Psychoanalytic theories – Interpersonal theories
• Family theories
– Family system theory
• Learning theories
– Positive effect of mood alternations – Media reinforcement – Peer pressures
• Psychosocial and behavioral factors increase the client's vulnerability to drug or alcohol abuse.
Age & Substance Use
Grade 8th Grade 12th Grade College Substance 1993 1993 2001 Alcohol 70 % 80 % ->92%(2001) 90% Cigarettes Marijuana Cocaine 44 % 10 % 2 % 63 % 37 % 8 %
Perinatal Concerns
• 25-30% of women expose their children to nicotine in utero • 3 out of every 5 women of childbearing age drink alcohol • 10% of women of childrearing age use an illicit drug • Substances = teratogens -> malformations in the fetus, intrauterine growth retardation, subtle mental and behavioral deficits.
Fetal Alcohol Syndrome (FAS)
• Low birth weight • Certain facial characteristics ie. microcephaly, microthalmia, short palpebral fissures, poorly developed philtrum, thin upper lip, short nose, small chin, flattening of the maxillary area • Neurological abnormalities ie developmental and/or intellectual delays; it is a preventable cause of mental retardation • Fetal Alcohol Effect (FAE)- Less severe cases
Other problems of FAS & FAE
• Other organs – heart, hearing, visual, dental, genital anomalies • Hyperactivity, poor coordination, short attention spans, dependency, social withdrawal, impulsivity… • Co-morbidity • Depression, anger, suicidal ideation, antisocial behaviors • Preventable health problem for children
Adolescent Substance Abuse
• • • • • • Health & social problem School drop-out Victim of abuse – child/parental, sexual Experienced trouble with law Suicide attempts Feelings of inferiority, history of mental problems
Signs of Adolescent Drug Use
• • • • • • • • Sudden behavioral changes Sweating, especially at night Needle marks Inebriation (intoxicated, drunk) Change in nutritional intake Nasal congestion Rhinorrhea with cocaine use School problems
Warning Ss of Teen Sub. Abuse
Physical Fatigue, health complaints, red/glazed eyes, lasting cough Emotional Personality, mood change, irritability, irresponsible behavior, depression… Family Arguments, breaking rules, withdrawing School Decreased interest, neg. attitude, drop in grades, absences, truancy Social Problems with law, changes to less problems conventional styles in dress and music
Prevention of Adolescent substance Use
• • • • • • • Positive role modeling Reinforce positive behaviors Support – cope with social pressure Establish normative expectations Help to anticipate pressures Involve in life skills training programs Open communication
Alcohol Abuse
• Body damage - brain cell -> neurological S/S Liver,
G-I, muscle, heart, sexual function …
• Blackouts – • Wernicke's syndrome - intact intellectual function
but poor memory, ataxia, confusion, vit B deficiency • Korsakoff's syndrome – disorientation
• Alcohol withdrawal syndrome (AWS) • Alcohol withdrawal delirium - Delirium tremens (DT) – confusion, disorientation,
hallucination, tachycardia, tremor, …
Wernicke's Encephalopathy
• Clouding of consciousness with an abrupt onset of confusion and mental status changes along with drowsiness. • Ocular motor abnormalities. • Ataxia of gait from weakness in limbs or coordination of muscles or poor balance
Korsakoff Syndrome
• Difficulty in acquiring new information or learning new skills • Lack of insight into their deficit • Amnesia • Impaired short term memory • Tendency for confabulation • Apathy • Inattention • Impaired fine motor skills • Impaired sense of smell • Talkative an repetitive behaviors
Treatment of WKS
• IV or IM thiamine • Medications – Cholinersterase inhibitors – Atypical antipsychotics – SSRI • Alcohol cessation • Dietary consumption
Clinical Description
• • • • • • • Denial Dependence – compulsive use Abuse – dysfunction in work, … Intoxication Withdrawal Delirium Psychotic disorders
• Denial – N's role - to question why they feel threatened to help them to gain insight. • Dependence – use of the drug is no longer under control, & continue to use despite adverse effects. • Abuse- recurrent use -> failure to manage work, school, or home roles, hazardous situation • Withdrawal – physiological, behavioral , cognitive, and affective symptoms that occur after reduction or discontinuance of a drug that has been used heavily over a long period of time. • Alcohol Withdrawal – tremulousness, nervousness, anxiety, anorexia, nausea, vomiting, insomnia, sleep disturbances, rapid pulse, high bp, profuse perspiration, diarrhea, fever, unsteady gait, difficulty concentrating, craving
Alcohol-related Disorders
Alcohol intoxication • Slurred speech • Incoordination • Unsteady gait • Nystagmus • Attention/ memory impairment • Stupor or coma Alcohol withdrawal Substance induced delirium • Nausea/vomiting • Impaired • Anxiety consciousness • Hallucination • Cognitive change • Sweating (memory, • Psychomotor disorientation, agitation hallucination) • Grand mal seizure • Short period of • Hand tremor time/fluctuates • Evidence of sub. abuse
• Detoxification – 3Ss– Secure environment – Sedation – Supplements
CNS Depressant - Narcotics
• Opioids – endorphin agonist, euphoria • Increasing pain threshold, reducing anxiety and fear • Decreased pulmonary ventilation/esp. elders • Respiratory depression in neonates/preg • Withdrawal is rarely fatal, but painful
– ie yawning, tearing, rhinorrhea, sweating, flushing, tachycardia, tremor, restlessness, irritability, muscle spasm, fever, nausea, diarrhea, vomiting, repetitive sneezing, abdominal cramps, backache
CNS depressant - Barbiturates
• Medical – relieve anxiety, produce sleep, anesthesia, epilepsy, soften withdrawal from heroin • Narrow therapeutic index • Classification- ultrashort (30'-3h), short (3-4h), intermediate (6-8h), long (10-12h) • Intoxication: unsteady gait, slurred speech, sustained nystagmus, confusion, irritability, insomnia • Tolerance
• Narrow therapeutic index- lethal dose being only slightly higher than the therapeutic dose • Barbiturates with short to intermediate duration have the highest abuse potential i.e. amobarbital( Amytal), pentobarbital (Nembutal), and seconbarbital (Seconal).
Stimulant - Cocaine
• Medical – relief for altitude sickness, anesthetics, • Block norepinephrine & dopamine reuptake • CNS & PNS effects – euphoria, alertness, anorexia, sexual stimulation • Derivatives: crack, rock • Physical dependence is less severe • Psychological dependence is intense • Highs (+ reinforcement) & lows ( - reinforcement) • Cocaine-induced depression, suicide • Death – caused by meta. & resp. acidosis, and hyperthermia, prolonged seizure, tachyarrhythmias
Stimulant - Amphetamine
• Speed, ice, crank, poor person's cocaine • Medical – ADD, narcolepsy, obesity • CNS effects – wakefulness, alertness, heightened concentration, energy, euphoria, insomnia, amnesia, restlessness, agitation, • PNS effects- palpitations, tachycardia, hypertension • Amphetamine-induced psychosis • Facilitate excretion by acidification of urine
• Natural & synthetic • Heighten awareness of reality or cause a terrifying psychosis-like reaction, distortions in body image, sense of depersonalization, loss of the sense of reality, panic, anxiety, confusion, paranoid reaction • Altered perception -> unable to perform simple tasks or lead to violent behaviors
Dual Diagnosis
• Comorbidity – 2 or more disorders in the same person • Dual diagnosis- 2 initial unrelated disorders that interact and cause increased manifestations of the other disorder • Personality disorders – higher incidence – 47% of antisocial; 2/3 of borderline; 4.5-15% above the norm in Schizophrenia
Etiology of Dual Diagnosis
• Substance use -> calmer, feel better, less anxious, decrease the intensity of hallucinations. • Compare with using antipsychotics – less uncomfortable side effects • Increase social acceptance, feeling of autonomy or power -> self-esteem
Tx for Dual Dx
• Multifaceted & multidisciplinary – case management, ind/gr therapy, skill training, vocational counseling, … • N-Pt Relationship – knowledgeable, skilled, nonjudgmental, empathic • Monitoring – S/s of withdrawal • Milieu therapy – set limits • Psychopharmacology - compliance
Impaired Professionals
• Incidence: 5% - chemical abuser • 8-10% (or higher) -chemically dependent • Common profile
– – – – – Family hx of sub abuse, depression, sexual abuse Academically and professionally successful Divorced Received professional treatment for sub abuse Regularly attends recovery self-help groups
• Report to supervisor immediately
Common Nursing Diagnoses
• Anxiety • Ineffective individual coping/ self-care • Altered health maintenance/ nutrition/ sensory-perception/ family process, • Risk for injury/infection • Impaired communication/ social interaction • Violence, potential for
Substance Abuse Problems Needing Collaboration
• 53% of drug abusers have at least 1 serious psychiatric problem
• 37% of alcohol abusers have at least 1 serious psychiatric problem
Pharmacological Treatment
• Alcoholism – Naltrexone (Trexan, ReVia) – – Disulfiram (Antabuse) – • Opiod addict – Methadone (Dolophine) – L-alpha Acetylmethadol (LAAM) – Naltrexone (Trexan, ReVia) – Clonidine
Pharmacological Treatment (II)
• Stimulant dependence –
– Dopaminergic drugs ie. Amantadine (Symmetrel), bromocriptine (Parlodel) – Anticonvulsants ie carbamazepine (Tegretol) – TCA ie desipramine (Norpramine)
• Hallucinogen dependence –
– Diazepam (Valium)
Supplementary Treatment
• Sedatives
– Benzodiazepine ie Librium, Valium – Phenobarbital
• • • • •
Thiamine (Vit B1) Folic Acid Magnesium sulfate Anticonvulsant Multivitamins
N-Pt Relationship
• • • • Trust - communication Support – minimizes anxiety Consistency – objective & nonjudgmental Continually assess
– Presence of predictable defense style – Psychophysiological responses
• Referral – local resources/ community agencies
Milieu Therapy
• Drug-free – safety, structure, norms, limit setting • Motivation – Dependency vs. face the consequences • 3Cs – Family members – did not cause the disease, – cannot control it, – cannot cure it • Belongingness – significant relationship, social skills,
Interdisciplinary Interventions
• • • • • • Breaking through defenses - denial Understanding and accepting the disorder Identification with peers Development of hope Re-socialization Developing self-esteem and self-worth
• Delirium is a serious and often undetected neuropsychiatric syndrome. • Failure to identify delirium can lead to longer hospital stays and increased morbidity and mortality.
Other Terms Applied to Delirium
• • • • • • Acute Brain Syndrome Acute Confusional State Metabolic Encephalopathy Toxic Psychosis Acute Brain Failure Altered Mental Status
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) The Themes One of the things I love about these colouring books are that they come in different themes. She's been sculpting organic volumes as long as I've known her and Aaron in school, and she always finds something new. That may be true, who can tell, but what he fails to mention is that the populism of the Bryan variety had a powerful effect on the mainstream of politics then as will Donald's populism have on today political realignment.
??Everything I have learned in life about leadership, about business, and about our incredible country tells me to pull every alarm in the house. This novel use of acoustic technology may lead to new ways to protect threatened and endangered species. By using this site, you consent to such processing and you warrant that all data provided by you is accurate.
We ship directly to our customers from centralized warehouses (sometimes directly from manufacturers). ??, Filed Under: Events, Movies, The Hunger Games The Hunger Games: Mockingjay Part 1 Trailer P September 15, 2014 &emsp. The perception you have (when the cargo door opens) is of a huge volume like a cathedral, says Gosselin.

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US political advisor says Trump and Putin likely to start things off on different footingWorld January 19, 8:14
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MOSCOW, November 9. /TASS/. Trucks of the Russian Emergencies Ministry carrying humanitarian cargo for Donbas have left their base near Moscow to head for southern Rostov region, where the 44th convoy for Donbas is being formed now, the ministry's press service told TASS on Monday.
"This morning, from the ministry's Noginsk (near Moscow) rescue center trucks left for the Rostov region, where they will become a part of another convoy with humanitarian aid for the Donetsk and Luhansk regions," the press service said.
In the southern region, the trucks from Noginsk and vehicles from Russia's other region will form a convoy, which is expected to leave for Donbas within days.
On Friday, Russia's Emergencies minister Vladimir Puchkov said at a meeting with the UN Deputy Secretary-General Stephen O'Brien "the humanitarian situations in the Donetsk and Luhansk regions remain very complicated." The minister said his authority had sent to the Ukrainian regions 43 humanitarian convoys with the cargo over 52,000 tons, which included food, medicines, essentials and everything necessary for sustainable work of all social facilities and of infrastructures.
"We have also supplied books for students and school pupils," he said. "And of course, by every humanitarian convoy we have been shipping equipment for our counterparts, fire brigades and rescuers, who in complicated situations are extinguishing fires and coping with emergencies." In sending the humanitarian convoys, the ministry complies fully with requirements of international documents on humanitarian aid, cooperates with the structures of the UN, the International Committee of the Red Cross and the Ukrainian counterparts.


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In an effort to better communicate with our members regarding weather related closings or other emergencies, our JCC is now using the Rained Out Text Message Alert System. Rained Out is being used in addition to JCC communications via social media platforms and our website. We recommend that all members with capabilities of receiving texts to subscribe to Rained Out. There is also an option to receive e-mail notifications through Rained Out.
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Phone 908-725-6994, Fax 908-725-9753


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Sixth graders are introduced to cultural history and diversity that is present in the community in which they live by examining secular and sacred celebrations. Students create scrapbooks to chronicle their family's celebrations.
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KINCARDINE, ONT. — They're rubbery, they squeak when you bite into them and they're as addictive as peanuts.
Mild-tasting, irregularly shaped cheddar cheese curds will become more widely available in major supermarkets throughout Ontario by the end of February.
Cheese curds are the first cheese solids produced in the cheese-making process.
Pine River Cheese, in Ripley just south of Kincardine, also plans to launch fresh and packaged curds and flavoured cheese specialties to the rest of Canada by the end of this year, says Vijay Kumar, general manager. It is one of the few farmer-owned co-operatives in Ontario.
Flavoured products will include caramelized cheddar cheese, Thai curry cheddar cheese and cheese fudge, a blend of cheddar cheese with chocolate. Thai curry cheddar cheese won first place under innovation products at Toronto's Royal Winter Fair in 2009 while chocolate cheese fudge won third place.
In the works are plans to provide its cheese products as private label brands in grocery stores across the country. This could mean a production increase by almost 50 per cent, he says.
Cheese curds are Pine River's top seller. But curd fans had to do without for 14 months after a fire put the plant out of commission in September 2010.
It was big local news when the first curds were produced in the new plant two months ago. A cheese curd alert was issued online to the waiting curd camp. Signs were posted outside and an announcement was made on local radio.
Just how addictive are cheese curds?
Kids are crazy about them. So are adults.
"I talked to a man who bought a package to take home, but he ate most of them in the car on the way home and had to drive back for more," says Kumar with a laugh.
Pine River, in operation since 1885, is one of a few cheese companies in Canada that makes cheese from 100 per cent Canadian milk.
Most cheese processed today is from modified milk ingredients used to cut costs, he says.
Cheese curds are a virgin market in Ontario and other provinces, says Kumar, who views them as becoming part of the snacking market that has grown by leaps and bounds in the last 15 years.
Most cheese companies tend to use curds for further processing, except for Quebec where they have become part of daily life as poutine, the gravy-topped, cheese curd concoction ladled over french fries, he says. Before the fire, Pine River supplied cheese curds to three different cheese companies in Ontario.
The co-op produces 23 varieties and nearly 100,000 kilograms a month when it is in full production.
Kumar expect it will take six to 10 months to get back in full swing with its complete cheese portfolio.
Here are two recipes using fresh cheese curds.
Fresh Cheese Curd Salad
If pomegranate seeds are unavailable, you can substitute 500 ml (2 cups) grape tomatoes.
750 ml (3 cups) spinach, trimmed
250 ml (1 cup) fresh cheese curds
250 ml (1 cup) red onions, thinly sliced
375 ml (1 ½ cups) pomegranate seeds, or to taste
Chopped fresh parsley, for garnish
2 ml (1/2 tsp) garlic, minced
2 ml (1/2 tsp) dried oregano
45 ml (3 tbsp) balsamic vinegar
10 ml (2 tsp) Dijon mustard
2 ml (1/2 tsp) salt
1 ml (1/4 tsp) ground black pepper
50 ml (1/4 cup) extra virgin olive oil
1. In a large bowl, combine spinach, cheese curds, red onions and pomegranate seeds.
2. In a small bowl, whisk together garlic, oregano, vinegar, mustard, salt and pepper. Gradually add oil, whisking until mixture emulsifies. Toss with salad. Sprinkle with parsley. Makes 4 servings.
Source: Suzanne Bourret
Comforting Pan Pizza with Cheddar Cheese Curds and Parmesan
500 g (1 lb) lean ground beef
1 sweet red pepper, chopped
50 ml (1/4 cup) water
125 ml (1/2 cup) chili sauce
250 ml (1 cup) diced zucchini
250 ml (1 cup) diced eggplant
125 ml (1/2 cup) diced red onion
250 ml (1 cup) diced mushrooms
15 ml (1 tbsp) tomato paste
30 ml (2 tbsp) minced fresh basil
500 g (1 lb) homemade or store-bought pizza dough
Cornmeal or flour
175 g (6 oz.) fresh cheese curds
50 ml (1/4 cup) grated Parmesan cheese
1. In a casserole on medium heat, cook ground beef thoroughly.
2. In a smaller casserole on medium heat, cook red pepper in water and chili sauce for 5 minutes or until tender. Puree to obtain a smooth sauce. Set aside.
3. Add zucchini, eggplant, onion and mushrooms to beef and cook for 4 to 5 minutes. Incorporate red pepper sauce, tomato paste and basil. Set aside.
4. Preheat oven to 200 C (400 F).
5. On a work surface, sprinkle a bit of cornmeal, then roll out pizza dough using a rolling pin. Dough must be large enough to cover the bottom and sides of a skillet roughly 30 cm (12 inches) in diameter and 2.5 cm (1 inch) deep.
6. Place dough in skillet and fill with beef-vegetable mixture.
7. Top with cheese curds, fold in any dough exceeding skillet edge, and bake for 30 minutes. Sprinkle with Parmesan and bake for another 5 minutes. Makes 6 to 8 servings. Serve with a spinach salad.
Nutritional information per serving when recipe serves 8: 362 calories; 23 g protein; 31 g carbohydrate; 16 g fat; 3.6 g fibre; 802 mg sodium.
Source: Dairy Farmers of Canada
How to use cheese curds:
• Use as a crunchy topping for salads and soups.
Melt in a skillet and top with red pepper jelly, sprinkled nuts or jalapeno peppers.
Add to omelettes.
Top nachos with curds and melt under broiler.
Make your own poutine.
Pack curds in school and work lunches.
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MS Excel News
Op-Ed: Scientists using MS Excel end up with research paper errors
Tim Sandle
Researchers who reviewed thousands of academic papers relating to genomics have found the data to contain errors and they have blamed this on Microsoft's spreadsheet software Excel.
Op-Ed: New MS Office for Cloud unveiled, but what about security?
Paul Wallis
Sydney - Microsoft is now selling the new Office due for release next year. It's basically an "Office Mobile" setup to be used as a Cloud app, with Skydrive saves direct on to a server. Fine, but why is nobody talking about security?
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At least they're not mocking men or making light of depressed robots. Nissan's latest marketing effort for the Altima has the auto company messing with patrons of entertainment venues. 200,000 sets of faux keys will be planted in clubs, bars, concert venues, and other congregation locations. The way the ruse works is that someone picks up the keys, and takes in a tidy little marketing message about the Altima's keyless ignition as they read the keychain. It's a great example of thinking outside
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13Anyone seen my keys? Check with Nissan
27Scooter sales hit the fast lane
- Joel Arellano
- May 15, 2006
- 27
Scooters have shot up in popularity alongside motorcycle sales as gas prices continue to hover around $3 a gallon. According to the Motorcycle Industry Council, sales went from 12,000 in 1997 to 113,000 in 2005 as people discovered the scooter's fuel-sipping100 mpg and its ability to zip through traffic snarls.
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- Most and least efficient car companies
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Military Tech Show: Could 3D Printing Change The Services?
3D printing is changing manufacturing and could be set to change the military.
The US is already using the technology to save money while the Royal Navy is testing a 3D-printed drone developed by Southampton University and made in Berkshire.
With NASA using one form of the technology to manufacture spare parts in space and Formula One teams using it to make safety-critical parts, the technology is reaching the stage where it is becoming a viable option for remote manufacture.
From 11th April the Military Tech Show is on Forces TV on Mondays at 7:30pm, Tuesdays at 1:30pm and Saturday lunchtimes at 12:15pm for two weeks.


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Helicobacter pylori and t(11;18) (q21;q21) translocation in gastric MALT lymphoma [Helicobacter pylori e presença de translocação t(11;18)(q21;q21) em pacientes portadores de linfoma MALT gãstrico]
Lima K.S.,Federal University of Minas Gerais |
Albuquerque W.,Federal University of Minas Gerais |
Arantes V.N.,Federal University of Minas Gerais |
Drummond-Lage A.P.,FCMMG |
Coelho L.G.V.,Federal University of Minas Gerais
Arquivos de Gastroenterologia | Year: 2014
Context - Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is clearly associated with Helicobacter pylori gastritis and can be cured with anti- H pylori therapy alone. The presence of t(11;18)(q21;q21) translocation is thought to predict a lower response rate to anti- H pylori treatment. Objective - To study the presence of t(11;18)(q21;q21) genetic translocation and its clinical impact in low-grade gastric MALT lymphoma Brazilian patients. Methods - A consecutive series of eight patients with gastric MALT lymphoma were submitted to gastroscopy, endoscopic ultrasound, histopathological examination, H pylori search and RT-PCR-based methodology. All patients received anti-H pylori treatment. Eradicated patients were followed-up every 3-6 months for 2 years. Results - Eight patients were studied. All patients had tumor involvement restricted to the mucosa or submucosa and seven patients had low-grade gastric MALT lymphoma. All infected patients achieved H pylori eradication. Histological tumor regression was observed in 5/7 (71%) of the low-grade gastric MALT lymphoma patients. The presence of t(11;18)(q21;q21) translocation was found in 4 (57%) of these patients; among them only two had histological tumor regression following H pylori eradication. Conclusion - RT-PCR is a feasible and efficient method to detect t(11;18)(q21;q21) translocation, being carried out in routine molecular biology laboratories. The early detection of such translocation can be very helpful for better targeting the therapy to be applied to gastric MALT lymphoma patients. Source
Frequency of psychoactive drug use among young pupils in university entrance courses [Frequência do uso de psicofármacos entre jovens estudantes que cursam pré-vestibular]
Cassimiro E.E.,FCMMG
Adolescencia e Saude | Year: 2012
Objective:This study explores the use of psychoactive drugs among pupils between 17 and 21 years old in university entrance courses, according to their selected academic fi elds. Methods: Forms were distributed to random classes at two leading university entrance schools, for voluntary completion by these pupils, preserving their anonymity. Results: The total sample consisted of 886 pupils, completing the forms in the presence of the researcher, who collected each form as it was completed. it was ascertained that 182 pupils take some type of psychoactive drug, separated into pharmacological groups, with anti-depressants being the most widely used. The highest rate was among the 21 year-olds, with no signifi cant statistical difference among their selected academic fi elds and psychoactive drug use. The chi-square test for independence indicates that taking psychoactive drugs and selected academic fi elds are not related (p-value: 0.117). Conclusion: This leads to the conclusion that psychoactive drug use is high among university entrance course pupils, refl ecting diffi culties in coping with increasingly keener competition, social and family pressures, doubts about choice of profession and other anxieties that might be age-related or could be linked to other factors. A serious problem of self-medication with psychoactive drugs was noted, despite restricted sales and retained prescriptions, which can have severe and unexpected consequences. Some questions were raised about the use of these drugs and the factors triggering their use. Source
Aramayo A.L.G.,University of Sao Paulo |
Lopes Filho G.J.,University of Sao Paulo |
Barbosa C.A.,University of Medical science of Minas Gerais |
Amaral V.F.,Federal University of Minas Gerais |
Costa L.A.,FCMMG
Acta Cirurgica Brasileira | Year: 2013
PURPOSE: To investigate abdominal wound healing using specific biomaterials in incisional hernias. METHODS: Incisional hernias were produced in 40 rabbits, after that they were reoperated with or without the use of meshes: PREMILENE® (PPL), ULTRAPRO® (UP), PROCEED® (PCD) or repairing without mesh (TRANSPALB). After 30 days a macroscopic and microscopic study of the part withdrawn from the abdominal wall was performed. RESULTS: Macroscopic: adhesion Area: PPL> UP and PCD (p = 0.031). Vascularization: PPL> UP and PCD (p = 0.001). PPL groups (p = 0.032) and PCD (p <0.001) showed greater meshes shrinkages when compared to UP. Microscopic: neutrophils: PCD> PPL, UP and TRANSPALB (p = 0.010); eosinophils: PPL> UP, and TRANSPALB PCD (p = 0.010); granulation tissue: PPL and PCD> UP and TRANSPALB (p <0.001); macrophages: PPL, UP and PCD> TRANSPALB (p <0.001); lymphocytes: PPL and PCD> UP (p = 0.009) and TRANSPALB (p <0.001); giant cells: PPL, UP and PCD> TRANSPALB (p <0.001); viscera adhered: PPL and UP> PCD and TRANSPALB (p <0.001). CONCLUSION: All types of meshes caused the formation of adhesions. The UP and PCD groups showed lower area and vascularization of the adhesions. The PPL and PCD groups showed higher meshes shrinkage and there was a predominance of acute inflammatory process in the PCD group. Source
Anatomic variation of the thoracic duct and absence of accessory hemiazygos and hemiazygos veins: Case report
Rodrigues D.S.,FCMMG |
Leao F.A.A.,FCMMG |
Siqueira S.L.,FCMMG |
Siqueira S.L.,Federal University of Minas Gerais |
And 5 more authors.
Journal of Morphological Sciences | Year: 2015
The thoracic duct is a lymph vessel extending from the abdomen to the base of the neck where it drains to one of the large veins in the region. Many cases are described in the scientific literature, regarding anatomical variations of the thoracic duct, from its origin, path, until its end, and the vast majority intended to relate variations in the last part of the duct. The reports related to variations of its path are very scarce. In a male cadaver dissection in the anatomy laboratory of the Faculdade de Ciências Médicas of Minas Gerais (FCMMG), an anatomical variation of the position of the thoracic duct was found. The thoracic duct was presented to the left of the aorta and spine, from its entry in the aortic hiatus of the diaphragm and chest throughout its length. There were also anatomical variations of interest in the venous circulatory system, such as the absence of the veins: hemiazygos and accessory hemiazygos, and the different location of the azygos vein, which was located to the left of the aorta. These variations have no relation to each other. The study of this variation is important because the knowledge of variations in the thoracic duct path allows lower rates of trauma and iatrogenic lesions in thoracic surgery, with possible serious complications, such as a chylothorax. © 2015, Brazilian Society of Anatomy. All rights reserved. Source
Seventh cervical nerve perforating the middle scalene muscle: A possible clinical and surgical application
Silva A.T.,FCMMG |
Gama H.V.P.,FCMMG |
Siqueira S.L.,Federal University of Minas Gerais |
Siqueira S.L.,Federal University of Ouro Preto |
And 3 more authors.
Journal of Morphological Sciences | Year: 2014
Introduction: In most of cases, the emergency of the nervous roots of the brachial plexus in the posterior cervical triangle occur between the anterior and middle scalene muscles. However, anatomic variations in the brachial plexus are not rare. Methods: In the laboratory of Human Anatomy of the "Faculdade de Ciências Médicas de Minas Gerais" 106 cadavers were dissected. There were dissected the cervical region of all of the cadavers bilaterally. Results: In routinely dissection in the laboratory of human anatomy of the "Faculdade de Ciências Médicas de Minas Gerais" we've found in the left cervical region of a male cadaver the ventral branch of the seventh cervical nerve (C7) perforating the substance of the middle scalene muscle. Conclusion: Professionals that work with this region on the practice must pay attention to this and other variations in the constitution of the brachial plexus in the clinic and surgical procedures to avoid complications. Source


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Located in Levernois, this air-conditioned villa features free WiFi. You can relax by the seasonal outdoor pool in the garden in fair weather.Accommodations in Levernois
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Featuring views of the sea and an indoor heated pool, Villa la Plain'itude is a holiday home situated in La Plaine-sur-Mer. The unit is 10 km from Pornic.Cheap sleeping La Plaine-sur-Mer
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눉Unfortunately, the air conditioner in the room is not great. It got very hot at night. We had to buy a fan!
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Trip Planner: USA / Maine / Mid Coast Maine / Prospect / Sightseeing / Penobscot Narrows Bridge
The Penobscot Narrows Bridge is a 2120ft long cable-stayed bridge that carries US 1/SR 3 over the Penobscot River. It connects Verona Island to Prospect, in the U.S. state of Maine. It replaced the Waldo–Hancock Bridge, built in 1931.Technical informationThe Penobscot Narrows Bridge is one of three bridges in the US constructed recently to utilize a cradle system that carries the strands within the stays from bridge deck to bridge deck, as a continuous element, eliminating anchorages in the pylons. Each epoxy-coated steel strand is carried inside the cradle in a one-inch steel tube. Each strand acts independently, allowing for removal, inspection and replacement of individual strands. The cable-stay system was designed with a system that uses pressurized nitrogen gas to defend against corrosion.In June 2007, six reference strands within three stays were replaced with carbon fiber strands – a first in the US. Monitoring on the strands will evaluate this material for future use in bridge designs. These engineering innovations helped the bridge appear in the December 2006 edition of Popular Science as one of the 100 best innovations of the year. The total project cost was $85 million.Penobscot Narrows Bridge is just one of the many highlights you can arrange to see using our world travel planner, Prospect Edition.
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28 days in United States BY A USER FROM UNITED STATES November, popular PREFERENCES: November ATTRACTION STYLE: Popular PACE: Medium 11 days in Mid Coast Maine BY A USER FROM UNITED STATES September, culture, beaches, historic sites, museums, shopping, slow & easy, popular PREFERENCES: September, culture, beaches, historic sites, museums, shopping ATTRACTION STYLE: Popular PACE: Slow & easy 7 days in Mid Coast Maine BY A USER FROM CYPRUS May, popular PREFERENCES: May ATTRACTION STYLE: Popular PACE: Medium
It's worth it to stop along and head up to the top of the bridge's viewing tower to take a gander at the Penobscot River. It is a great place to get panoramic views of Maine's wonderful fall foliage.
Matt L
I had no idea there was such a cool place along Route 1 until I happened to see it on Google Maps. The views from the top of the observatory are spectacular - 400 feet above the surrounding countrysid... more »
The observatory is 15' taller than the Empire State Building. There is an elevator which takes visitors to the top, then a short flight of stairs. There is even a handicapped access which will accommo... more »
Greg Anderson
Crossed this beautiful bridge on the way to Acadia and decided to check it out on the way back. You can buy a ticket and take an elevator to an observation deck at the top for 360 views. I would recommend taking a trip up to the top in the Fall for fantastic foliage views. For photogs, it's completely glass cased at the top so watch out for glare.
Gregory Dennis
Beautiful view. Friendly staff. Nice stop along the way up Maines coast.
Ryan Anderson
Worth a quick stop. Fort knox is more worth the time....
Katie Riley
Definitely a great place to stop! Don't just see the bridge visit Fort Knox also!
Timothy Ford Malone
The Bridge is a marvel of construction. The granite used in the towers was came from the same quarry that supplied granite used on the Washington Monument.
Best things to do in Prospect
Maine DaySail and the Schooner Timberwind
Visit for: 2h 30min
Acadia Zoo-Kisma Preserve
Visit for: 3h
Wild Acadia Fun Park & Water Slides
Visit for: 2h
Coastal Maine Botanical Gardens
Visit for: 4h
Mount Battie
Visit for: 3h 30min
Pemaquid Point Lighthouse
Visit for: 1h 30min
Hidden Gems©©
Boothbay Region Land Trust
Visit for: 2h 30min
Camden Snow Bowl
Visit for: 4h
Castle Tucker
Visit for: 1h 30min
Camden Hills State Park
Visit for: 3h
Schoodic Point
Visit for: 2h 30min
Moose Point State Park
Visit for: 3h
Kid Friendly Attractions©
Popham Beach State Park
Visit for: 3h
Reid State Park
Visit for: 3h
Great Wass Island Preserve
Visit for: 3h
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Indianapolis St Vincent Pediatric Nephrology Hypertension Center
About Search Results
YP - The Real Yellow PagesSM - helps you find the right local businesses to meet your specific needs. Search results are sorted by a combination of factors to give you a set of choices in response to your search criteria. These factors are similar to those you might use to determine which business to select from a local Yellow Pages directory, including proximity to where you are searching, expertise in the specific services or products you need, and comprehensive business information to help evaluate a business's suitability for you. "Preferred" listings, or those with featured website buttons, indicate YP advertisers who directly provide information about their businesses to help consumers make more informed buying decisions. YP advertisers receive higher placement in the default ordering of search results and may appear in sponsored listings on the top, side, or bottom of the search results page.
1. St. Vincent Pediatric Rehabilitation Center
1707 W 86th StIndianapolis, IN 46260
2. St. Vincent Pediatric Therapies
8220 Naab RdIndianapolis, IN 46260
3. St. Vincent Pediatric General Surgery
2001 W 86th StIndianapolis, IN 46260
4. St. Vincent Pediatric Adolescent Medicine
8402 Harcourt Rd Ste 320Indianapolis, IN 46260
5. St.Vincent Breast Center
8550 Naab Rd Ste 300Indianapolis, IN 46260
From Business: Breast care at St.Vincent is advanced, comprehensive and holistic. We treat each person with expert medical care and compassion, in the least invasive manner. Our g…
6. St.Vincent Orthopedic & Spine Center
2001 W 86th StIndianapolis, IN 46260
From Business: Whether you are seeking relief from chronic pain associated with aging joints, need care for a sports-related injury, or have been injured in an accident, you want …
7. Peyton Manning Children's Hospital At St. Vincent
8402 Harcourt RdIndianapolis, IN 46260
8. St Vincent Hospitals
1707 W 86th StIndianapolis, IN 46260
9. Children's Heart Center At St Vincent
8333 Naab Rd Ste 320Indianapolis, IN 46260
10. St. Vincent Developmental-Behavioral Pediatrics
301 E Carmel DrCarmel, IN 46032
11. St.Vincent Pediatric Therapies in Carmel
12425 Old Meridian StCarmel, IN 46032
12. St. Vincent Medical Group
2.5 hours on a Saturday morning. Very few patients. Nurse announced an hour into wait they now has 2 doctors so shouldn't be long. Workers are slow …
13. St.Vincent Headache Center
13430 N Meridian StCarmel, IN 46032
From Business: St.Vincent Headache Center aims at assisting patients with their headache problems through an array of treatment plans. Our hope is that together, your headache pro…
14. St.Vincent Immediate Care
9795 E 116th StFishers, IN 46037
From Business: The Immediate Care your family needs from the St. Vincent physicians you trust is available in three convenient northside locations. No appointment necessary.
15. St.Vincent Bariatric Center of ExcellenceMOVED
13500 N Meridian StCarmel, IN 46032
Staff is awesome! Dr.Inman will be a great surgeon! She has done these surguries for some time now. I trust her 100%. Im so excited!!
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