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124 Cards in this Set
- Front
- Back
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Milieu therapy
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assists in improving interpersonal skills, social functioning, performing ADL; focus on here & now; uses limit setting; involves client making decisions in own care; support privacy & autonomy; provide clear expectations
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Behavior modification
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change ineffective behavior patterns; focuses on the consequences of actions rather than peer pressure; uses positive & negative reinforcement; role modeling & teachnig new behavior
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Family therapy
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identifies entire family as client; concept of family as a system of parts forming whole; focus on patterns of interactions; identifying family roles; goal is to decrease family conflict and anxiety
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Crisis intervention
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directed at resolution of immediate crisis; crisis may develop when previously learned coping mechanisms are ineffective in dealing; individual usually in state of disequilibrium; if client is in panic state be very directive; goal is to return to precrisis level of functioning
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Purpose of therapeutic interaction
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allow clients autonomy to make choices when appropriate; give facts only-no opinions
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Forbidden phrases in client interaction
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you should, you'll have to, you can't, if it were me I'd, why don't you, I think you, it's the policy on this unit, don't worry, everyone..., why?, just a second, I know...
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Question of nurse-client confidentiality
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some information must be shared with other team memberes for the client's safety and optimal therapy
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Denial
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unconscious failure to acknowledge an event, thought, or feeling too painful for conscious awareness
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Displacement
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transference of feelings to another person/object
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Identification
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attempt to be like someone or emulate the personality/traits/behaviors
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Intellectualization
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using reason to avoid emotional conflicts
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Introjection
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incorporation of values or qualities of an admired person or group into one's own ego structure
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Isolation
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separation of unacceptable feeling/idea/impulse
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Passive-aggression
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indirectly expressing aggression toward others with a facade of overt compliance
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Projection
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attributing one's own thoughts or impulses to another person
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Rationalization
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offering an acceptable, logical explanation to make unacceptable feelings/behavior acceptable
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Reaction formation
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development of conscious attitudes & behaviors that are the opposite of what is really felt
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Regression
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reverting to an earlier level of development when anxious
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Repression
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involuntary exclusion of a painful thought or memory from awareness
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Sublimation
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substitution of an unacceptable feeling by a more socially acceptable one
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Suppression
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intentional exclusion of feelings & ideas
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Undoing
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communication or behavior done to negate a previously acceptable act
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Cognitive therapy
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replacing a client's irrational beliefs and distorted attitudes; short-term therapy
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Electroconvulsive Therapy
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electrically induced seizures for psych purposes; used for severe depression; may also be used for suicidal clients
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Nursing care for ECT
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avoid using the word "shock;" give anticholinergic 30 minutes before treatment to decrease secretions; give quick-acting muscle relaxant before to prevent muscle or bone damage; have emergency/crash cart in the room
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Nursing care after ECT
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maintain patent airway; check VS q15min; reorient after waking; common complaints: HA, muscle soreness, nausea
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Mild Anxiety
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associated with everyday life; increased levels of sensory awareness/alertness; thoughts are logical; cilent appears calm/controlled
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Moderate Anxiety
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motivate learning; be attentive/focus & problem solve; dulls perception of sensory stimuli; increased speech rate & volume; restlessness; may be converted into physical sx
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Severe Anxiety
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stimulates fight or flight; disorganized sensory stimuli; distorted perceptions; impaired concentration/problem-solving; selective attention; verbalization of emotional pain; causes tremors & increased motor activity
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Panic
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perception grossly distorted; unable to differentiate real from unreal; unable to concentrate or problem-solve; feel overwhelmed & helpless; lose control/ability to function; elicit behavior that may be angry/aggressive/withdrawn; immediate intervention
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Generalized Anxiety Disorder
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unrealistic, excessive, or persistent anxiety & worry about two or more life circumstances; neurobiochemical & psychodynamic theories
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GAD Assessment
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severe anxiety, motor tension, autonomic hyperactivity, vigilance & scanning (difficulty concentrating, etc), on edge, low self-esteem
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Panic disorders/phobias
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discrete periods of intense fear or discomfort; irrational fear of external object, activity, situation; chronic condition; transfers anxiety or fear from its source to a symbolic object, idea, situation
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Agoraphobia
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fear of crowds or open places
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Nursing assessment for panic d/o/phobia
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coping styles, autonomic hyperactivity, panic attacks that usually peak at 10min but can last up to 30 minutes; disruption in personal life; possible use of alcohol/drug
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Nursing interventions for panic d/o/phobia
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establish trust, safe environment, draw client's attention away from feared object/situation; discuss alternative coping strategies & encourage use; substitute positive thoughts; assist in desensitizing client; may use SSRIs; decrease intake of caffeine & nicotine
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OCD
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anxiety associated with repetitive thoughts (obsession) or irresistible impulses (compulsion)
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OCD Assessment
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coping styles to control anxiety; magical thinking; evidence of destructive/hostile/aggressive/delusional thought; intereference with normal activities; safety issues; recurring intrusive thoughts; recurring, repetitive behaviors
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OCD Interventions
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provide for physical needs; allow performance of compulsive activity with attention to safety; establish a routine; avoid punishing and criticizing; admin SSRIs/TCAs
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Zolpidem (Ambien)
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short-term treatment of insomnia; give with food 1-1.5h before bed
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PTSD Assessment
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anxiety; anxiety manifested in symptomatic behavior; responses to anxiety (shock, anger, panic, denial); self-destructive behavior; visible reminders of trauma
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Somatoform
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characterized by the expression of unexplained physical symptoms that have no physical basis; physical sx thought to be unconscious expression of internal conflict; occur more often in women; children may learn that physical complaints are acceptable coping strategy-secondary gain; may abuse analgesics without relief
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Somatization disorder
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recurrent somatic complaints with no medical pathology present
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Hypochondriasis
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belief in and fear of having a disease including misinterpretation of physical signs as proof of presence of disease
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Conversion disorder
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characterized by transferring a mental conflict into a physical sx for which there is no organic cause
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Somatoform Assessment
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preoccupation with pain/bodily function for 6 mos or more; history of doctor shopping; absence of emotional concern; elevated VS; fear of serious disease; excess use of analgesics; social/occupational impairment
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Somatoform interventions
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nonjudgmental attitude; help client identify needs met by sick role; encourage use of anxiety-reducing techniques
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La belle indifference
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lack of concern over physical illness
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Primary gain from somatoform
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decrease in anxiety from ability to deal with stressful situation
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Secondary gain from somatoform
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rewards obtained from the sick role
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Dissociative disorders
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alteration in the function of consciousness, personality, memory, identity; may be sudden/temporary or chronic/gradual; persons afflicted handle stress by splitting from the situation & going into fantasy state
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Psychogenic amnesia
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sudden temporary inability to recall extensive personal info; usually occurs after traumatic event; most common dissociative disorder
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Psychogenic fugue
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characterized by person suddenly leaving home/work with inability to recall his/her identity so this involves flight as well as loss of memory; rarely occurs; excess alcohol use may contribute
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Dissociative identity disorder
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presence of 2+ distinct personalities; personalities emerge during stress
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Depersonalization
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characterized by a temporary loss of one's reality & ability to feel/express emotions; client has fear of "going crazy;" client describes sense of "strangeness" in environment
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Nursing interventions with Dissociative disorders
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reduce environmental stimuli; stay with client during periods of depersonalization; demonstrate acceptance of client's behavior; document emergence of different personalities; implement suicide precautions if needed; encourage client to identify stressful situations that cause transition from one personality to another; help client identify effective coping
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Cluster A: Paranoid: Personality Disorder
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characterized by suspicious, strange behavior that may be precipitated by stressful event; may manifest as intense hypochondriasis
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Paranoid personality
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pervasive & long-standing suspiciousness; mistrusts others; projects blame for own problems onto others; hostile dialogue
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Schizoid personality
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socially detached, shy, introverted; avoids interpersonal relationships; emotionally detached, introverted, unresponsive, autistic thinking; says little, appears withdrawn
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Schizotypal personality
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interpersonal deficits; eccentricities; odd beliefs; socially isolated
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Interventions for Cluster A Personality Disorder
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est trust; be honest; follow through on commitments; avoid talking/laughing where client can see you but not hear you
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Cluster B: Dramatic, Emotional Personality Disoder
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antisocial, borderline, histrionic, narcissistic
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Antisocial personality
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aggressive, acting-out behavior with no remorse; clever & manipulative; emotionally immature & impulsive; ineffective interpersonal skills; belligerent
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Borderline personality
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disturbances regarding self-image & sexual/social/occupational roles; impulsive/self-damaging behavior, suicidal gestures; overly dependent on others; tends to view others as all good or all bad (splitting); self-critical/demanding/whiny/manipulative/argumentative
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Histrionic personality
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seeks attention by overreacting & exhibiting hyperexcitable emotions; overly dramatic, seeks attention; chaotic relationships; loud, excitable, overreactive, attempts to draw attention to self
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Narcissistic personality
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perceives self as all-powerful & important; critical of others; exaggerated feeling of self-importance & self-love; needs attention/admiration; preoccupied with power/appearance; exploits others
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Cluster C: Anxious, Fearful Personality Disorders
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avoidant; dependent; obsessive-compulsive
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Avoidant personality
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socially inhibited; feels inadequate; hypersensitive to criticism/rejection; longs for relationships
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Dependent personality
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unreasonable wishes & wants; expresses needs in a demanding, whining manner; passive without accepting responsibility for own behavior; low self-esteem; dependent on others to meet his/her needs
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Obsessive-Compulsive personality
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attempts to control self through the control of others or the environment; shows inattention to new facts or different viewpoints; cold & rigid to others; is a perfectionist/inflexible/stubborn; excessively neat & clean;
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Anorexia nervosa
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voluntary refusal to eat & maintain minimal weight for height/age; distorted body image & fear of obesity; 15-20% of those diagnosed die; associated with parent/child conflicts about dependency issues; possible causes: dysfunctional family system, unrealistic expectations, ambivalence of maturation & independence
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Assessment of Anorexia
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skeletal appearance, distorted body image, hair loss, dry skin, irregular heart beat, decreased pulse, decreased BP, amenorrhea, dehydration & F&E imbalance
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Interventions for Anorexia
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monitor weight/VS/electrolytes; provide structured/supportive environment; set time limit for eating; monitor after meals for vomiting; monitor activity level; devise behavior-modification; monitor activity & assess for weakness/fatigue/pathologic fractures
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Bulimia Nervosa
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eating d/o characterized by eating excessive amounts of food followed by self-induced purging by vomiting/misuse of laxatives/diuretics/fasting/excess exercise; usually report lack of control over eating & binging
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Nursing interventions for Bulimia
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monitor weight/VS/electrolytes; structured/supportive environment; assist client to learn strategies for coping; encourage expression of anger; promote family therapy
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Depressive disorders
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pathologic grief reactions ranging from mild to severe states
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Mild Depression
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feel sad; difficulty concentrating & performing usual activities; difficulty maintaining usual activity level
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Moderate Depression
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feelings of helplessness & powerlessness; decreased energy; sleep pattern disturbances; appetite/weight changes; slowed speech/thought/movement
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Severe Depression
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feelings of hopelessness/worthlessness/guilt/shame; despair; flat affect; indecisiveness; lack of motivation; change in physical appearance; suicidal thought; possible delusions/hallucinations; sleep/appetite disturbances; loss of interest in sexual activity; constipation
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Depression Assessment
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determine type of depression (exogenous/endogenous); determine degree of depression; determine current suicide risk; arrange lab tests
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Exogenous
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caused by a reaction to environmental or external factors
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Endogenous
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caused by internal biologic deficiency
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Depression interventions
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ask about feelings and plans to harm self; implement suicide precautions; monitor sleep/nutrition/elimination; assist with ADLs; initiate interaction with client; insist on participation in activities; observe for sudden elevation in mood; assist in identifying support system; encourage discussion of feelings; sit in silence if client isn't talkative
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Suicide Precautions
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obtain history (previous attempt is increased risk); be aware of major warning signs: giving away possessions & previously depressed client is suddenly happy
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Evaluate suicide intent
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directly as client about intent; ask about plans; identify method chosen--more lethal=greater risk of attempt; determine availability of method chosen
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Interventions for suicide
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express concern for client; tell client you'll share info with treatment team; offer hope; never leave suicidal client alone
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Bipolar Disorder
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manifested by mood swings involving euphoria, grandiosity, and inflated sense of self-worth; according to DSM-IV-TR client must have at least one episode of major depression--client may cycle
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Assessment of Bipolar
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assess nutrition/hydration; level of fatigue; danger to self/others
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Interventions of Bipolar
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maintain client's physical health, provide safe environment; decrease environmental stimulation; implement suicide precautions; consistent approach to minimize manipulative behavior; avoid giving attention to bizarre behavior; meet needs ASAP; provide small, frequent feedings of food that can be carried; praise self-control; promote family involvement
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Schizophrenia
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thought disturbance, altered affect, withdrawal from reality, regressive behavior, difficulty with communicatoin, impaired interpersonal relationships
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Catatonic schizophrenia
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stupor, rigidity, posturing, negativism, excitement, potential for violence
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Disorganized schizophrenia
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incoherence, flat/inappropriate affect, disorganized behavior, usunual mannerism, socially withdrawn, no delusions
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Paranoid schizophrenia
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systemized delusions/hallucinations related to single theme; ideas of reference; potential for violence if acting upon delusions
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Residual schizophrenia
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socially withdrawn; inappropriate affect; eccentric/peculiar behavior; absence of prominent delusions & hallucinationsn; no current psychotic behavior
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Undifferentiated
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prominent delusions & hallucinations; incoherence & grossly disorganized behaviors; failure to meet criteria for other types
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Assessment schizophrenia
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assess for thought process disturbance: symbolism, delusions, ideas of reference; note form of verbal communication; assess for disturbance in perception; assess for disturbance in affect; assess for disturbance in behavior; assess for disturbance in interpersonal relationships
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Interventions schizophrenia
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est trust; sit with mute clients; provide safe environment; assist with hygiene/ADL; matter of fact approach; use clear, simple, concrete terms; accept/support client feelings; reinforce congruent thinking; stress reality; avoid arguing or agreeing with inaccurate communications; set limits on behavior; avoid stressful situations; structure time for activities; encourage client to identify positive characteristics of self; praise socially acceptable behavior; avoid dependent relationship
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Delusional client
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encourage recognition of distorted reality; divert focus to reality; do not agree with/support delusions; avoid arguing about delusion; avoid physically touching client; admin antipsychotic drugs; admin antiparkinsonian drugs
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Hallucinating client
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protect client from injury that might result from following voices; avoid denying or arguing withclient about hallucination; discuss observations with client; make frequent but brief remarks to interrupt hallucinations; admin antipsychotic drugs; admin antiparkinsonian drugs
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Alcoholism Assessment
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patterns indicative of alcoholism; family history; dependency, yet resentfulness of authority; impulsive/abusive behavior; impaired judgment/memory loss; incoordination, slurred speech; mood varying between euphoria & depression; intoxication based on BAL; alcohol w/d sx; chronic alcohol related illness
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Symptoms of alcohol withdrawal
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begin shortly after drinking stops (4-6h); anxiety/nausea/insomnia/tremor/hyperalertness/restlessness; increase in all VS; DT may appear 12-36h after last drink: tachycardia, tachypnea, diaphoresis, marked tremors, hallucinations, paranoia; grand mal seizures
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Antabuse
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severe side effects occur if alcohol is consumed; teach client what to expect if alcohol is consumed; be aware that some alcoholics use the side effects to punish themselves for drinking
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Interventions for alcoholism
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safety, nutrition, hygiene, rest; provide care during withdrawal; implement suicide risk if necessary; rehab: direct, matter-of-fact attitude, confront manipulations, set firm limits, short-term goals, decrease loneliness, group/family therapy
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Child Abuse Indicators
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injuries not congruent with child's developmental age/skills; injuries not correlated with stated cause; delay in seeking medical care
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Assessment for Child Abuse
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bruises in unusual places; bruises/welts caused by belts/cords/etc; burns; whiplash injury; bald patches; fractures in various stages of healing; failure to thrive; torn/stained/bloody underclothes; genital lacerations; bedwetting; STDs; parent seeing child as different; parent using child to meet own needs; parent seldom touching/responding to child; child appearing frightened/withdrawn in presenceof parent/adult; family history of moving/unstable employment/marital discord/family violence; one parent answering all questions
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Interventions for Child Abuse
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nurses legally required to report all cases of suspected child abuse to the appropriate local or state agency; take photos of injuries; establish trust & care for physical problems; recognize own feelings of disgust/contempt for parents; support need for family therapy
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Intimate-Partner Violence
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usually a tension-releasing action; persons act more violently when drinking/drugs; relationship usually characterized by extreme jealously & issues of power & control ; often begins during pregnancy or occurs more frequently in pregnancy
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Assessment for Intimate-Partner Violence
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delay between time of injury & time of tx; anxious when answering questions about injury; ab injuries in pregnancy; looks to abuser for answers to questions related to injuries; depression/SI; feels responsible for provoking abuser; low self-esteem; abrasions/cuts/lacerations/sprains/black eyes; somatoform complaints; concurrent use of alcohol/drugs
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Interventions for Intimate-Partner Violence
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est trust; use nonjudgmental approach; treat physical injuries; document; provide crisis intervention; assist with referral to shelter if desired; assist with contacting authorities to press charges if desired; interview abused partner when abuser isn't present
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Elder Abuse
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an that causes injury or exploitation or neglect to older adult; underreported; majority of abuse is committed by spouses & children
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Assessment for Elder Abuse
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bruises on upper arms; broken bones caused by falls; dehydration/malnourishment; overmedication; poor hygiene; improper medical care; withdrawn behavior; behavior that may be demanding/belligerent/aggressive; repeated visits to health care agency for injuries & falls; injures that don't correlate with stated cause; misuse of money by children/guardian
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Rape/Sexual Assault
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act of aggression, not passion
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Assessment for Rape
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physical assessment; emotional status; coping behavior; support system; details of assault
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Interventions for Rape
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communicate nonjudgmental acceptance; provide physical care to treat injuries; give clear/concise explanations of all procedures to be performed; document using *exact* words; notify police & encourage victim to prosecute; collect/label evidence carefully in presence of witness; notify rape crisis team/counselor; allow discussion of feelings; advise of potential for venereal disease/pregnancy/HIV; provide info about care; support client/family/friends
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Delirium
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acute; usually reversible; recognized by sudden onset; occurs in response to specific stressors; treatment of choice is correction of causative disorder
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Dementia
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chronic; gradual, progressive onset; irreversible; judgment/memory/abstract thinking/social behavior affected; seen in: alzheimer, multiinfarctions (brain), huntington chorea, parkinson, MS, brain tumors, wernicke-korsakoff syndrome (chronic alcoholics)
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ADD
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developmentally inappropriate attention, impulsiveness, hyperactivity
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ADD Assessment
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physical assessment; more prevalent in boys; failure to listen/follow instruction; difficulty playing quietly/sitting still; disruptive/impulsive behavior; distractibility to external stimuli; excess talking; shifting from one unfinished task to another; underachievement in school
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ADD Interventions
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decrease environmental stimuli; set limits on behavior; safe/comfortable environment; initiate a behavior contract to help child manage own behavior; admin meds
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Conduct disorder
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antisocial behavior characterized by violation of laws, societal norms, & basic rights of others without feelings of remorse
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Oppositional defiant disorder
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characterized by behavior that fails to adhere to established norms, but doesn't violate the rights of others
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Conduct disorder assessment
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physical fighting, running away, lying, stealing, cruelty to animals, frequent truancy, vandalism, arson, use of alcohol/drugs
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Oppositional defiant disorder assessment
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argumentativeness, blaming others for own problems, defying rules/authority; using obscene language, acting resentful/vindictive
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Interventions for conduct/oppositional defiant disorder
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assess cues for escalating behavior; nonauthoritarian approach; avoid why questions; initiate a show of force with a child out of control; use a quiet room when external control is needed; clarify expressions/jargon; teach to redirect angry feelings; implement behavior modification; role-play new coping strategies
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