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44 Cards in this Set
- Front
- Back
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Nursing Process how many steps
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6
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steps of nursing process
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assessment
diagnosis outcome identification planning implementation evaluation |
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headings of MSE
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identifying data
general description emotions thought process perceptional disturbances sensorium and cognitive ability impulse control judgement and insight |
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Identifying data
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name
age gender race/culture religious preference occupation/financial situation living arrangement significant other education level medical diagnosis chief complaint allergies dietary considerations |
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general description
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appearance
psychomotor behavior speech patterns general attitude |
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appearance
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8
grooming and dress hygiene posture height and weight level of eye contact hair color and texture evidence of scars, tattoos, other distinguishing skin marks evaluate appearance relative to age |
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psychomotor
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11
tics tremors gait agression mannerisms and gestures hyperactivity restlessness or agitiation rigidity echopraxia psychomotor retardations freedom of movement (range of motion) |
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speech pattern
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6
slowness or rapidity pressure of speech intonation volume studdering or other speech imparements aphasia |
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general attitude of process and examiner
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5
cooperative/uncooperative friendly/hostile/defensive uninterested/apathetic attentive/interested guarded/suspicious |
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emotions
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mood--pervasive emotional state
affect--emotional expression (look for appropriet and range) |
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mood
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8
anxious depressed/despair guilt labile elated euphoric fearful irritable |
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affect
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6
appropriate inappropriate labile congruence with mood constricted or blunted flat |
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thought process
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form of thought
content of thought |
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purpose of thought process
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productivity: stream of thought (amt and rate)
over production of ideas vs. thought blocking form of thought: answer questions, carry on goal oriented convo |
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form of thought
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13
flight of ideas associative loseness circumstantiality tangetiality neologisms concrete thinking clang assosications word salad perservation echolalia mutism poverty of speech ability to concentrate and disturbance of attention |
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content of thought
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delusions
suicidal or homicidal ideas obsessions paranoia/suspiciousness magical thinking religiousity phobias poverty of content |
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types of delusions
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8
thought broadcasting thought insertion ideas of reference persecutory grandious control or influence somatic nihilistic |
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perceptional disturbances
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hallucinations
illusions depersonalizations derealization |
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types of hallucinations
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5
auditory visual gustatory olfactory tactile |
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sensorium
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7
level of consciousness/aleartness orientation memory capacity for abstract thinking vs concrete thought intelligence visuospatial ability attention and concentrartion |
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types of memory
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recent
remote immediate confabulation |
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recent memory
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indivudual able to remember occurences of the past few days
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remote
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individual able to remember occurences of the distant past
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immediate
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ID 3 objects rest 5 min later
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confabulation
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individual fill in memory gaps with made up facts
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impulse control
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ability to control impluses
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judgement and decision making
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knowledge of self
ability to solve problems and make decisions good judgement |
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schizophrenia is a disturbance in
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congitive functioning
affect perception social and occupational functioning |
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DSM criteria for schizo
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Symptoms of at least two of the following during a one month period
Delusions Hallucinations Disorganized Speech Negative Symptoms Grossly Disorganized or Catatonic Behavior |
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types of schizo
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catatonic
paranoid disorganized undifferentiated residual schizoaffective disorder delusional disorder schizopreniform disorder brief psychotic disorder |
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catatonic
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characterized by motor behavior
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catatonic stupor
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psychomotor retardation
pt posturing or mute |
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catatonic excitement
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psychomotor agitation
out of control purposeless movements that have to be controlled to prevent hard to self or others |
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paranoic schizo
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paranoid dellusions
pt may be argumentative, hostile, agressive |
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disorganized schizo
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flat inappropriate affect
silliness or incongrous giggline social intereaction impared bizzare behaviour |
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undifferentiated schizo
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bizzare behavior that does not fit the discription of other types
hallucinations and dellusions prominant |
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residual schizo
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used to dx person with history of one schizophrenic episode with psychotic symptoms
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schizoaffective disorder
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includes elements of both psychosis and mood disorder.
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symptoms of mood disorder
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very low or high mood
sleep disturbances changes in energy and appetitie disrupted concnetration poor ADL |
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type 1 schizo
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acute onset
exaggeration of normal functioning percipitating factors > D2 in limbic system + symptoms no intellectual impairement |
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type 2 schizo
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chronic onset
more frequent genetic component impared intellectual functioning - symptoms hypodopaminergic process |
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positive symptoms
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aggitation
tension grandious ideas of reference exagerated cognition/bizzare behavior insomnia hallucinations/dellusions suspiciousness |
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negative symptoms
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poor hygiene and grooming
loss of drive enlarged cerebral ventricals attention devicit blunt affect impoverished speech anhedonia |
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recovery model includes
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developing hope
secure base and sense of self supportive relationships empowerment social inclusion coping skills meaning. |
