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56 Cards in this Set

  • Front
  • Back
• Last resort if (imminent threat) dangerous to self or other
• Must try all other less restrictive methods first
• Immobilize one part of the body i.e. belt, strap etc.
• “If you don’t let me go out to smoke I will hit you?”: Not sufficient cause
• “If pt. has chair in air and trying to throw it at you.” Sufficient cause
• Posturing position = imminent threat
• Document behavior precisely.
• Destruction of property alone, NOT sufficient grounds for putting patient in restratints.
• Only o.k. if Pt. is exposing self or others to harm.
• Limit movement of person and prevent person from going out.
releasing a client who needs continued care
Advance directives
legal document that a competent individual may sign to convey wishes regarding future health care decisions.
behavioral expression of emotion. May be incongruent=inappropriate to situation or blunted/constricted (diminished) or flat (absence of emotional expression)
Restrains and Seclusion
• Violates pt. rights
• RN given authority if Pt. should be in restraints
• Need 1 hour to get Md order for restraints via phone.
• Md has 24-hours to sign order
• Should be 1 Md order for EVERY restraint episode (i.e. 3 restraints=3 Md order) for Behavioral restraints.
• Medical restraints (good for 24 hours)
• Must check adults (+ 18) 4 hours, teens 2 hours (9-18), children (< 9) 1 hour
• If adult > four hours is still aggressive, needs another order.
• No PRN orders for restraints.
fear of being in places or situations from which escape might be difficult.
Restless urgent need for movement. EPS side effects associated with some kinds of antipsychotic meds.
Restraints checks
• two fingers space
• check nail beds
• check color of skin
• always supine
• attach to bed frame/not rails
• criss-cross leg straps/keep legs closed
• within 1 hour- face to face assessment (clinician or Md)
• closely observe 1:1 (q15m VS checks- first hour, then hourly) and document.
• Document: Pt. still demonstrates agitation, continued need for restraints.
• Release and reposition pt. q30m or longer for extremities.
• Release 1 at a time.
Muscular weakness or loss of muscle movement. EPS side effects associated with some kinds of antipsychotic meds.
Debriefing for restraints
• Talk to patient > release: not a punishment, ask them why they were restrained? Try to prevent future incidence of restraint.
• Inability to communicate through speech, writing or signs caused by dysfunction of brain centers.
Inability to speak
An act that results in a persons fear and apprehension that they will be touched w/o consent. Threatening.
Physical harm
automatic thoughts
thoughts that occur rapidly. withouth rational analysis.
Admission in Psche ward
Physical and Mental assessment, long process.
Repeating action of another person. Imitating movement. w/Loose ego boundaries.
Parrot-like repetition (w/loose ego boundaries). i.e. "Hello" 'Hello" "How are you" "How are you?" "How are you" L=language.
absneces of speech (in MedSurg=organic) but in Psych - may be due to forgotten language i.e. demential/Altzheimers. When you talk to them, they just stare at you. They have forgotten words.
General feeling of well-being. Ex: you will be euphoric when you graduate RN school.
Mood higher than Euphoria. EX: pass NCLEX you will be elated.
Frequent change in mood WITHOUT external stimuli. EX: pt. is crying then suddenl laughs for no apparent reason or external stimuli.
Acongruent mood
When expression doesn't match mood. EX: Sad but laughing.
false sensory perception not associated wtih real external stimuli. May involve 5 senses. Sight, sounds, touch, smell, taste.
Blocking a sudden topic in a stream of thought.EX:Pt. is talking about rape incident and then stops and cannot remember.
Inability to talk (in MedSurg, physical) in Psych- refusal to speak. EX: Pt had heart surgery, really overwhelmed by event, Diagnosis: adjustment disorder w/major depression. Keep speaking to client.
Poverty of Speech
Using short sentences. How are you? Fine. How is your day O.K.
Associated Looseness
(flight of ideas)
Ideas are loosely connected. frequent change of topics withouth completing any topic but related. EX: I love my son. My son is as bright as the sun. Like the sunny oranges i California. The sunny place where tourist come to vist. Summer is a long way off. Summer break is fun.
Word salad
Mixture of word not related EX: Fruit, airplace, table.
NOT word salad-"Paper, pencil, pen" all r/t writing.
Clang association
Mixture of words with same sound. Run-Fun-Sun-Bun.
Use of phrases with same sound. "I went to heaven, I had 7, it became 11." "On the track, get a big mac..."
Beating around the bush. use a lot of idea to convey one concept or message. (like breaking up with guy... Over the past few days, I have observed...).
Use of ideas without arriving at a point. EX: Overuse ideas but never get message. "To all student, do what your mothers tell you, for the music of the world is the universal language and the peace of the human kind and to all of you- thank you." i.e. How are you today? very vague answer.
Inventing new words (not in dictionary). EX: a bracelet is a "wristlet."
Repetition of incoherant words. Gibberish. Worwozerah...Worwozerah...Worwozerah...
Repition of the SAME word or statement. Where is my purse? Where is my purse? Where is my purse?
Concrete thinking
Giving very concrete answers but not appropriate w/literal translation. "Why were you brought here to hospital?" "The ambulance brought me here." A rolling stone gathers no moss - because it is always rolling vs. abstract thinking "If you keep moving, you will not stagnate."
False belief that cannot be corrected by reason. Cannot argue or explain b/c patient believes it.
Persecutory delusions
Pt. believes "they are out to get me" about harm or ill intention. EX: pt. refuses to eat b/c believes food is poison.
Grandious delusions
Belief of power, greatness, possessions, importance. EX: I am Jesus Christ.
Ideas of reference
Events in the environment are referred to patient. i.e. I made it rain today b/c I wanted to stay inside. Pt. states, "All people are talking about me."
Control of influence
belief that one is under the control of a powerful being. John Nash in A Beautiful Mind, believed he was under control of FBI w/device implanted in arm
Somatic delusion
Belief of body part. My head is gone. I have a tumor- everything is negative.
belief of NON-existence. I have dissappeared. I have melted away, you cannot see me.
Belief that an important or popular person is in love with a patient. "I had to leave the hospital b/c the doctor fell in love with me."
Repetive or recurrent idea always in your mind.
Magical thinking
vs. delusional thinking. beyond reality. "I can make myself go to another place just by thinking about it."
Identify religion first. If behavior is appropriate to persons religion, NOT religiousity. i.e. moving head of bed toward sun part of religion. Making sign of cross in front of everyone and licking them IS religiousity. Blessing EVERYONE with holy water IS religiosity.
Irrational fear
Hallucination vs. Illusion
Hallucination - false perception (no external stimulus). Room is quiet, can hear baby crying.
Illusion- misinterpreted of actual stimulus. Carpters tapping. Pt. thinks they are soliders w/machine guns.
Most common hallluctions
Personalization vs. realization
Personalization - r/t to person losing reality.
EX: I am a rock, I cannot move. I am a robot.
Realization - r/t environment.EX: the world is gone, we have all turned into ghosts. I cannot feel, I am numb, I am a statue.
How to describe patient orientation
x 4. Person, time, place, situation.
Making up stories. Inventing stories to fill up memory gaps.
Abstract thinking
(is normal). If you ask them, they should be able to think abstractly.