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44 Cards in this Set

  • Front
  • Back
S/S of OCD (obessive complusive disorder)
repeated rituals,
anxiety occurs if obbessions or complusions are resisted,
N/I of OCD
Identify problems
DO Not interupt complusive behaviors,
allow pt to perform rituals unless cause harm to oneself,
make schedule to distract
encourage verbilization of compulsive disorder.
S/S of Phobic Disorder
irrational fear of object or situation that a person recogniaes as unreasonable,
Panic level anxiety if object or situation cannot be avoided,
defense mechansiem are repression and displacemnt
N/I of Phobic Disorder
Stay with client while anixety is high,
Identify the anxiety
allow client to speak about the object or situation
Desensatize by gradually introducing feared object or situation,
DO NOT FORCE contact with object or situation
What is agraphobia
fear of being alone in a public place where escape maybe difficult
What is Social Phobia
fear of situation in which one might be embarrsed or criticized, and fear of making a fool out of oneself
S/S of PTSD (post traumatic stress disorder)
After expiercing a psychological traumatic event, the indivdual reexpierences the event via recurrent dreams or flashbacks,
Emotional numbness, detachment, anxiety, sleep disturbance, hyperviligence, guilt, poor concentration
Desensitation through gradual exposure,
Instruct pt in relaxation techniques,
Provide individual therpy that address loss of control issue or anger issue,
Support groups,
S/S of dissociative disorder
- disruption in integrative function of memory, consciounes or identity.
- Associated to exposure to a traumtic event
N/I of dissociative disorder
- Develop a trusting relationship with client
- Encourage verbal expression of painful exposure, anxities or concerns
- Explain methods of coping
- Identify sourses of conflict
- Focus on clients strengths and skills
- Provide nondemandinf simple routines
Types of Dissociative Disorders
- Multiple personality, Amnesia, Fugue, Depersonilation Disorder
What is multiple personality
- 2 or more fully developed distinct and unique personalits within the person
- personalitites may take full control of the client one at a time
- Personalities may or may not be aware of each other.
What is amnesia
- Inability to recall important personell information because it is anxiety provoking
- memory imparment may be partial or almost complete
What is Fugue
- Assumption of a new identity in a new enviorment
- disorder may occur suddenly
What is depersonlation Disorder
- altered self perception in which one's own reality is lost or changed
S/S of Ulcerative Collitus
- Anorexa, wt loss, Malise, Abd tender and cramping, severe diahreha may contain blood and mucus, dehydration and electoylite imbalance, anemia, vit K deficiency, increased bowels ounds
N/I of ulcerative collitis
- Acute Phase: NPO status, IV and elctrolyte possibly TPN
- restrict pt activity to reduce insestinal activity
- monitor bowel sounds
- After acute phase diet progress from clear liquid to low residue diet
- Avoid gas forming foods
- Administer bulk forming agents to decrease diahrea
- Administer drugs to prevent infection and reduce inflamation
What is Ulcerative collitis
- Inflamotry disease of bowel that results in poor absorption of nutrients
- colon becomes endemtious and may develop bleeding lesions and ulcers
- scar tissue develops and causes loss of elasticity
What is Gastric Ulcer?
- Ulceration in Mucosal wall of the stomach, that is accessiable to gastric secretions erosion may extend through the muscle
- Predisposing factors are stress, smoking, use of cortisteriods, NSAIDS, alcohol, HX of Gastitis
- Complaints of hemmorage, perforation and pyloric obstruction
S/S of Gastic Ulcer
Gnawing sharp pain on or left of the midepigastric region 1-2 hours after eating.
- Nausea and Vomiting
- Hematemesis
N/I of Gastric Ulcer
- Monitor vital signs and for signs of bleeding
- Adminster small frequent bland feedings
- Admin. histamines to reduce secretion of Gastic Acid
- Admin. Antacids
- Admin Anticholergenics to reduce gastric motility
- Admin. mucosal barrir protectants as prescribed 1 hour before meal
What is Aneroxia Nervosa
- Onset is often associated with stressful life event.
- pt. intensely fears obestity
- body image is distorted has a disruppted self concept
- preoccupied with foods that prevent weight gain
- can be life thearting
- self induced wt. loss greater than 15% of normal weight for age and ht.
S/S of Aneroxia Nervosa
- vary depending on severity of illness
- wt loss greater than 15% of normal weight
- Bradycardia, hypotension, cold intolerance, hypothermia, dry skin, constipation, ABD pain
- psychological manifestations include perfectionistic and OCD with high performance expectations
- anxiety increased exersice activity, inhibited or destructive social interactions
N/I of Aneroxia Nervosa
- Asses pt. nutrional status
- Establish contract concerning the diet plan
- Assist pt. in Identifying preceptors of the eating disorder
- Encourage behavior modifications technique
- record I & O
- set time limit on meal time
- weight pt daily
- asses and limit pt activity level
What is Bulimia Nervosa
- Pt indulges in eating binges followed by purging behavior
- most pts remain within normal wt limits but are dominated by eating related conflict
- use of self induced vomiting, excessive laxatives, diuritics, fasting, excessive exercise
S/S of Bulimia Nervosa
- Preoccupied with body weight
_ consumes high calorie food in secret
- Binge Purse syndrome
- Lower self esteem
- Poor interpersonal relationship
- mood swings
N/I of Bulemia Nervosa
- same as aneroxia
- nutrional plan
- balanced diet
What is schizophrenia
- group of mental disorders charterised by psychotic factors, inablity to trust others, disordered thought process, and disrupted interpersonal relationships
- Disturbance in affect, mood, behavior, and thought process
Factors related to schizophrenia
Genetic - if one parent is affected 19% child will, if both parents affected 39% child will
- Biochemical , Dopamine, Norepi, seratonin may have a role
- psychosocial factors , interpersonal theory proposes lack of a warm nutring relationship in early years of life
S/S of schizophrania
Disheveled apperance, body image disturbance, preoccupied with somatic complaints
- cataonic posturing, catatonic excitment, movements may be repetative, motor activity increase
- mistrust, view world as unsafe and threating display feelings of helpness, anixety, anger
- compulsive rituals, abnormal thought process
Nursing Diagnosis for Schizophrania
- alterted thought process related to perceptual and cognitive distortions
- social isolation related to inability to trust
- risk for activity intolerence related to adverse reactions to meds
- risk for violence self directer or toward others
N/I of schiophrania
- provide pt with honest and consistent feedback
- avoid challenging the content of pts behavior
- focus on pts behavior
- administer meds
Evaluate outcome criteria for pts with schiophrania
- exhibits improvded reality orientation, concentration and attention span
- communicates with family and shift in a clear manner without evidence of loose thinking
- maintain personell hygine
What is Autisem
- severe mental disorder before the age of 3
- Impairment in recprocal social interaction, and in verbal and non verbal communication
- cause unkown and prognosis is poor
S/S of Autisem
- Disturbance in the rate and apperance of physical and social and language
- Abnormal responce to body sensations
- Abnormal ways of relatiting to poeple or objects
- Child may play happy alone for hours but disturb him and he will throw a temper tamtron
- Language disturbance often includes repiption of preverously heard words
N/I of Autestic Child
- Determine childs routine and habits and preferences and maintain
- Facilitate communication through picture board
- Evalualte for safety
- Monitor for stress and anxiety
- Initiate referrels to special programs
S/S of paranoid Disorder
- suspcious and mistrustful
- emotionally distant
- distorts reality
- poor insight
- Hyperviligence
- Low self esteem
- Evasive
Nursing Diagnosis for pts with paranoid Disorder
- Alterted thought process to perceptual and cognitive distortions
- Social Isolation related to inablity to trust
- Risk for activity intolerence related to adverse reactions
- Ineffective individual coping related to misinterpretation
- Risk for violence
N/I for paronia Pts
- Assess suicie risk
- Dimish suspcious behavior
- Establish trusting relationship
- Promote increased self esteem
- Follow through on commitment made to pt
S/S of hostility
- Hx of violence or self harm
- poor impulse control and low tolerence of frustration
- defiant argumtation
- verbal thearts
- Increase in pacing and agitated
- muscle rigitidy
- flushed face
- glaring
- Loud voice
N/I of hostility
- Acknowledge Anger
- Set limits on behavior
- listen actively and assist pt to deal with consequences of anger
- provide safety for expressing anger and to safety of others
Clues for suicidal reaction
- giving away personel, special or prized possesions
- cancelling social engagments
- taking out or changing insurance policies
Assesment of sucidial reaction
- Does pt have a plan
- Pt of Hx of attempts,
- psychosocial
N/I of sucidial reaction
- Initiate suicude precautions
- remove harmful object
- do not leave pt alone
- provide nonjudgemental attitutde
- provide contract
- keep pt active