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63 Cards in this Set
- Front
- Back
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Demetia develops slowly and impairment in memory without impairment in consciousness. Most are irreversible unless they are secondary to another disease.
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delirium
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Priority Diagnosis RISK FOR INJURY. SAFETY IS IMPORTANT! Supportive interventions that lower anxiety are also important.
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Identify priority diagnosis with regards to delirium
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Will return to premorbid level of functioning, wil remain safe and free of injury, during periods of lucidity, client will be oriented to A0X3 by using clocks, calendars, etc. Client will remain free of falls and injury while confused.
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Identify outcome criteria with regards to high priority delirium diagnosis.
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Initiate eye contact, introduce self, address patient distinctly by name and speak slowly, give one simple direction at a time, speak in a clear, low, respectful tone. Use distraction, rather than confrontation to manage behavior, provide unconditional posotive regard, avoid touch and proximity if this causes stress and anxiety. Provide rest periods, avoid frustrating patient by quizzing them about orientation, provide cues such as current events,seasons, locations, etc.
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Apply nursing interventions with agitated elderly patients, particularly in critical units.
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_______are errors in perception of sensory stimuli. For example: a person may mistake folds in the bed as white rats or the cord on the window blind for snakes. The stimulus is a real object in the environment, however it is misinterpreted and often becomes the object of the clients projected fear.
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illusions
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reflect the misinterpretation of the clients cognitive stimuli FOR EX: You ppl are all alike, all in on the FBI plot to destroy me.
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delusions
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cant recognize family or objects, needs repeated instructions and directions to perform the simple tasks (advanced apraxia). Total care is necessary, even a nursing agency.
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stage 3
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inability to read or write, put thing sin mouth hyperorality, touching everything in sight , (hypermetamorphosis) Death is secondary to choking and infection.
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stage 4
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hyperalert, jerky movements, irritability, startle easily, subjective distress, shaking inside, grand mal seizures
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alcohol wihdrawal symptoms
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tachycardia, sweat, htn, disorientation, clouding of consc, visual or tactile hallucinations, hyperexcitec to lethargic, delusion, paranoid behaviors, fever 100-103 degrees.
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Assess for signs and symptoms that indicate alcohol-withdrawal delirium
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DRUG OF CHOICE: Librium, provides safe withdrawal, anticonvulsant effects, also Valium. (serax and ativan too)
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Medicate patient experiencing alcohol withdrawal and priority interventions
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Kind warm supportive manner can allay anxiety and provide a sense of security. Necessary to orient them to place and time. Encourage friends and family one at a time can increase orientation and minimize confusion, clarify illusions, demonstrate accepting attitude and showing strong support for efforts of recovery. Therapeutic leverage, making abstinence worthwhile.
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Apply therapeutic communications with alcohol dependent patient.
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Offer behavioral, cognitive, and dynamic structure needed in recovery. 3 principles: Indivi with addictive behaviors are powerless over their addiction, and their lives are unmanageable. Althought they are not responsible for their disease, they are responsible for their recovery. They can no longer blame people, places and things for their addiction, they must face their problems and feelings.
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Know principles of Alcoholic Anonymous
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Naltrexone (Trexan, Revia) lox toxicity, few side effects, does not produce dependence.
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Identify medication to maintain abstinence that would most likely be prescribed for patients with either alcoholism or opioid addiction
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Operational principles centered around acceptance of the disease model of addiction, including pragmatic methods for avoiding enabling behaviors. Expect a client to have a dual diagnosis, treatment is successful when staff work as a team and are empathetic and hopeful, addiction programs both need a dual focus, which requires appropriate training for staff. Substance use disorder and psych disorder are both considered primary and need simultaneous treatment, Recovery occurs in stages, and treatment should be matched to clients needs and level of motivation. Outcomes must be individulalized to support progress in small steps over a long period of time.
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Educate spouse about principles of alcoholism rehabilitation program
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Address behaviors that almost all subs. abusers have in common, including dysfunctional anger, manipulation, impulsiveness, and grandiosity. Validate and empathize, warm and accepting manner. Point out realities. VALIDATING AND EMPATHIZING, ENCOURAGING THE CLEINT TO SHARE PAIN, ENCOURAGING EXPRESSIONS, Using therapeutic leverage (making sobriety and abstinence worthwhile), encouraging evaluation, pointing out realities, validating the clients perception, clarifying and encouraging the client to be specific not global on details.
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Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol dependence
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Residential programs that encourage abstinence, development of social skills, and elimination of antisocial behavior. Therapeutic communities also help.
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Identify which treatment approach for patient with antisocial behavior when treated several times for substance dependence.
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S/s dilation of the pupils, dryness of the oronasal cavity, and excessive motor activity. Antipsychotics, fever reducing, diazepam, ammonium chloride. If chest pain, irregular pulse or hx of heart problems, go to ER immediately.
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Identify the priority nursing intervention when caring for a patient after an overdose of amphetamines.
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N/V, tachycardia, sweating, anxiety or irritability, tremors in hands, fingers, eyelids, marked insomnia, grand mal seizures.
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Assess for symptoms of withdrawal from central nervous system depressants
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Constricted pupils, decreased respiration, drowsiness, slurred speech, psychomotor retardation.
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Assess for symptoms an individual who recently injected heroin.
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(colors are heard, sounds are seen)
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Assess for symptoms who are on LSD and experiencing synesthesia.
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depression, paranoia, lethargy, anxiety, insomnia, nausea and vomiting, sweating and chills, signs of the body struggling to regain its normal chemical balance.
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Assess for symptoms of amphetamine abuse.
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Used with motivated clients who have shown the ability to stay sober. Classical conditioning by causing the person to avoid alcohol when mixed with drug. When taken together, facial flushing occurs, sweating, throbbing headache, neck pain, tachycardia, respiratory distress, decrease in b/p, and nausea and vomiting.
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Teach patient about disulfiram (antabuse)-- multiple answers may apply.
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Client safety: external controls may be applied for protection of the person in crisis if the person is suicidal or homicidal. Anxiety reduction: anxiety reduction techniques are used, so that inner resources can be mobilized. Take initial steps to make client feel safe an lower anxiety.
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Identify priority assessments and concerns during crisis intervention.
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Nurse needs to be needed, Nurse sets unrealistic goals for patient, Nurse has difficulty dealing with the issue of suicide, Nurse has difficulty terminating the nurse-patient relationship.
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Recognize potential unrealistic expectations of the nurse during crisis situations.
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New developmental stage is reached, Old coping skills no longer helpful, Ineffective defense mechanisms until new coping skills develop. EX: Marriage, new baby, retirement. Professional intervention may be indicated.
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maturational
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Arise from events that are, Extraordinary, External, Often unanticipated. EX: loss of job, death, abortion, divorce, mental illness. Resolution of grief associated with loss.
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situational
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Unplanned and accidental, Natural disaster, National disaster, Crime of violence. Critical incident debriefing and
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adventitous
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Listen carefully, make eye contact, frequent feedback to make sure you understand, summarize what client says at the end. Encourage expression of feeling in non-destructive manner, feeling of support and hope to diminish anxiety, indicate that help is available, genuine interest and support.
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Apply therapeutic communication techniques with client in crisis.
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Ineffective coping, Outcome: uses effective coping strategies: reports increase in psychologic comfort, verbalizes sense of control, functions well in precrisis level or higher.
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Identify priority nursing diagnoses and outcome criteria with regards to crisis and disaster.
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discus concerns of behavior with pt. Identify undesirable pt behavior, discuss what is desirable in a given situation or setting, establish consequences for occurrence and non-occurrence of desired behaviors, communicate established behavioral expectations and consequences to patient in language that is easily understood and nonpunitive, refrain from arguing and bargaining, monitor for occurrence and nonoccurrence of desired behaviors, modify behavioral expectations and consequences as needed to accommodate reasonable changes in pts situation.
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manipulative behavior
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Assidting the pt to mediate impulsive behavior through application of problem-solving strategies to social and interpersonal situations. Assit pt to identify the problem or situation that requires thoughtful action and course to possible action and their costs and benefits, teach pt to cue himself or herself to stop and think before impulsive behavior. Assist to evaluate the outcome of the chosen course of action, provide positive reinforcement for successful outcomes, encourage pt to self-reward for positive outcomes, provide opportunities for patient to practice problem solving (role playing) within the therapeutic environment. Encourage pt to practice problem solving in social and interpersonal situations outside the therapeutic environment.
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impulsive behavior
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Limit setting and confrontation about negative behavior is better accepted by the client if the staff first employs empathetic mirroring (ex: reflecting back to the client an understanding of the clients distress without a value judgement). For example, the nurse can listen to a clients emotional complaints about the staff and the hospital without correcting any errors but rather by simply noting that the client feels truly hurt. Showing empathy may also decrease aggressive outbursts if the client feels that the staffare trying to understand feeling of frustration.
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Apply the principle of empathetic mirroring
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Uses conflict resolution methods EX: exhibits receptiveness and sensitivity to to others, cooperates with others, uses assertive behaviors as appropriate, use confrontation as appropriate. accepts respossibility for actions EX: develops action plan, obtains needed support, self-initiates goal directed behavior, expresses that [erformance will lead to desired outcome.
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Identify outcome criteria for patient with manipulative behaviors.
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Has the primary feature of emotional detachment
Pt does not seek out or enjoy close relationshipts May be able to function in a solitary occupation but shows indifference to praise or criticism from others Depersonalization may occur as a result of the persons limited interactions with others Can be a precursor to schizophrenia or delusional disorder, and there is inc prevalence of the d/o in fam w/ a hx of schizophrenia or schizotypal personality disorder Genetic predisposition to shyness. Often raised in a cold and neglectful atmosphere in which they may conclude that relationships are unsatisfying and unnecessary |
schizoid characterisctics
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Characterized by distrust and suspiciousness toward others based on the belief (unsupported by evidence) that others want to exploit, harm , or decieve the person
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paranoid
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Eccentric and odd behavior- such as social isolation and detachment
Unusual levels of suspiciousness- perceptual distortions Magical thinking Cognitive impairment Ppl who meet dx for cluster A experience severe illness effects and are generally resistant to tx. Firmly believe in their interpretation of events |
cluster a pd
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Genetically linked- predisposition is set into motion by a childhood environment of inconsistent parenting, significant abuse, and extreme neglect.
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antisocial
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consistent disregard for others through exploitation and repeated unlawful actions
Clear hx of conduct disorder in childhood and individuals show no remorse for hurting others Neglect responsibilities, tell lies, and perform destructive or illegal acts w/o developing any insight into predictable consequences Individuals don’t voluntarily seek psych care for symtoms of the PD- usually its court – reffered evaluation |
antisocial
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Borderline: Thought to develop as a result of early abandonment, which results in an unstable view of self and others
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borderline
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Most well known and dramatic of the personality disorders
Severe impairments in functioning, a high mortality rate , extensive utilization of services from hc system Marked instability in emotion regulation, interpresonal relationships, impulsivity, identity or self image distrotions, and unstable mood Ineffective and harmful self soothing habits, such as cutting, promiscous sexual behavior, and numbing w/subs are common and may result in unintentional death SPLITTING- the primary defense or coping style used; it’s the inability to incorportate both positive and negative aspects of oneself or others into a whole image Believed to be partly a result of the persons failed experiences w/adult personality integration and likely is influenced by exposure to earlier pschological, sexual or physical trauma |
borderline
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Projection is the dominant defense mechanism – they blame others for their short comings.
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paranoid
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Unaccepatable feelings or behaviors are kept out of awareness by the developing the opposite behavior or emotion. EX: a person who hates kids, becomes a boy scout leader.
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reaction formation aka overcompensation
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JUSTIFYING illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener.
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rationalization
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manipulative, exploitave of others, aggressive, callous towards others
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antisocial
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shows seperation anxiety, manifest ideas of reference,
impulsive (suicide, self mutilation) engages in splitting MANUPULATIVE |
BORDERLINE
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reclusive, avoidant, uncooperative
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schizoid
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Experienced nurses working in disaster situations can become overwhelmed when witnessing catastrophic loss of human life (acts of terrorism, plane crashes, skool shootings) and or mass destruction of ppls homes and belongings ( floods, fires, tornadoes). Researchers finda that mental health care providers may experience psychological distress from working with traumatized populations a phenomenon of secondary traumatic stress
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vicarious traumatization
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o Avoid being too nice or too friendly
o Don’t try to inc socialization o Perform thorough dx assessment as needed to identify symptoms of d/o the pt is reluctant to discuss |
schizoid nursing interventions
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Avoid being too nice or too friendly
Give clear and straightforward explanations of tests and procedures beforehand o Use simple, clear lang avoid ambiguity o Project a neutral but kind affect o Warn about any changes s/e of med and reasons for delay. Such interventions may help allay anxiety and minimize suspiciousness . a written plan may help encourage cooperation |
paranoid interv
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set realistic goals, use clear action words
Be aware of manipulative behavior (flattery, seductiveness, instilling of guilt) Provide clear and consistent boundaries and limits Use clear and straightforward communication When behavioral probs emerge, calmly review the therapeutic goals and boundaries of tx Avoid rejection or rescuingAssess for suicidal and self mutilating behaviors, especially during times of stress |
bordeline inteventions
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try to prevent or reduce untoward effects of manipulation ( flattery, seductiveness, instilling of guilt)- clear and realistic limits on specific behavior, ensure that limits are adhered by all staff, carefully document signs of manipulation or aggression, document behaviors (time, dates, circumstances) provide clear boundaries and consequences
o Be aware that antisocial pts can instill guilt when they are not getting what they want. Guard against being manipulated through feelings of guilt o Subs abuse is best handled through a well-organized tx program b4 counseling and other forms of therapy are started |
antisocial interventions
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Provides support for those who have experienced a severe crisis and are now recovering from a disabling mental state
Rehabilitation centers, sheltered workshops, day hospitals, outpatient clinics Primary goals: facilitate optimal level of functioning and prevent further emotional disruptins Social and community facilities that provide structured environments that can help prevent problem situations |
tertiary care
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Establishes intervention to prevent prolonged anxiety from diminishing personal effectiveness and personality organization.
Nurses primary focus is safety, then assess the problem- support system- coping styles Care lessens the time a pt is mentally disabled during a crisis Safety, support system, prevention of future anxiety attacks that could lead up to a crisis, improve coping strategies. |
secondary care
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Promotes mental health and reduces mental illness to decrease the incidence of crisis
Reduce stimuli Nurse can: Work w/ pt to recognize potential probs by evaluating the pt experience of stressful life events Teach the pt specific coping skills Assist the pt in evaluating the timing or reduction of life changes to dec the negative effects of stress as much as possible |
primary care
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consciousness itself is ALTERED in a dramatic way, whereas thinking, feeling, and perceptions are less impaired.
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dissociative
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Physical symptoms suggest a physical disorder for which there are no demonstrable base, there is also a strong presumption that the symptoms are linked to psychobiological factors. The client with somatoform disorder comlplains of somatic distress but RETAINS NORMAL PATTERNS OF THINKING AND FEELING OVERALL.
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somatoform
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Less concerned and less anxious, “oh well”. These patients have an association to childhood physical/sexual abuse. Socioeconomic factors related are lower income and education levels, residence in rural areas, military service, especially in combat zones. SEEK SECONDARY GAINS. INVOLUNTARY BEHAVIOR.
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conversion
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These clients usually manifest paralysis, blindness. EX: the client who demonstrates paralysis of an arm can be expected to eat using the other arm. The client who is experiencing blindness can be told at what numbers on an imaginary clock the food is located on the plate and encouraging to feed himself or herself. These strategies are effective in reducing secondary gain.
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conversion
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tend to lead rather simpler lives, rarely calling attention to themselves. After a few weeks to months, they may remember their identities and become amnesic for the time spent in fugue state. Assessment: may be disoriented to time, place and maybe person. ASK: Do you ever lose time or black out? Do you find yourself in place you have no idea how you got there?
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assess for fugue state
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Less concerned and less anxious, “oh well”. These patients have an association to childhood physical/sexual abuse. Socioeconomic factors related are lower income and education levels, residence in rural areas, military service, especially in combat zones. SEEK SECONDARY GAINS. INVOLUNTARY BEHAVIOR.
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conversion
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These clients usually manifest paralysis, blindness. EX: the client who demonstrates paralysis of an arm can be expected to eat using the other arm. The client who is experiencing blindness can be told at what numbers on an imaginary clock the food is located on the plate and encouraging to feed himself or herself. These strategies are effective in reducing secondary gain.
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conversion
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tend to lead rather simpler lives, rarely calling attention to themselves. After a few weeks to months, they may remember their identities and become amnesic for the time spent in fugue state. Assessment: may be disoriented to time, place and maybe person. ASK: Do you ever lose time or black out? Do you find yourself in place you have no idea how you got there?
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assess for fugue state
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