review of concepts summary slides for exam

phases of nursing process evaluation

evaluating whether the desired outcomes have been achieved; identifying alternative plans of action

delusions

false fixed beliefs

Hallucinations

false sensory perceptions

PSYCH NURSING INTERVENTIONS symptom management

help patient to recognize, monitor, and manage/treat symptoms. Usually with medication

goal of intervention of hallucinations

help the patient increase awareness of the symptoms so that they can distinguish between psychosis and reality.

phases of nursing process nursing diagnosis

identifying areas for intervention

Milieu

(environment) therapy provides patients with opportunity to gain insight

Step 1 of Nursing process

Assessment

Nurse's Role in Therapeutic Community

Continual assessment of physical and psychological status Medication administration Development of a trusting relationship Setting limits on unacceptable behavior Patient education

____ keep anxiety within tolerable limits

Coping mechanisms

Mental Status Examination purpose

Detects changes or abnormalities in intellectual functioning, thought content, judgment, mood, affect

Mental status examination reflects what

Does not reflect patient's past or future evaluates patient's current state

Assessing Suicidal Ideation

Has patient wanted to harm himself/herself or someone else? Has patient made previous attempts to cause harm; if so, what events surrounded attempts? To judge patient's suicidal or homicidal risk, assess patient's plans, ability to carry out those plans (availability of method such as weapons, pills, rope, car) Determine level of supervision needed (close observation, 1:1 (staff member & pt.), Q 15 min. checks) Support systems available to patient

Crisis Assessment

Identify precipitating event/stressor person's perception support system and coping resources previous strengths and coping mechanisms, & if hospitalization is needed (for suicidal, psychotic, violent behaviors).

crisis definition

Internal disturbance from a stressful event or a perceived threat to self

crisis duration

Lasts 4-6 weeks

phases of nursing process assessment

MSE gathering & organizing data

ANA Clinical Practice Standards Goals of nurse client relationship

Maximize patient's positive interactions with the environment Promote a level of wellness; enhance self-actualization Promote and maintain integrated functioning

managing anxiety

Monitor the level protect patient modify environment decrease to manageable level prevent relapse

Predictors of Dangerousness - most mentally ill people are violent or victims of violence?

Most mentally ill people are not violent and are often the victims of violence

ANA Clinical Practice Standards _____is the vehicle for applying the nursing process

Nurse-patient relationship

medical diagnosis

Patient's health problem or disease state

Predictors of Violence

Previous violent behavior Psychosis Noncompliance with medications Current substance abuse Antisocial personality disorder Lack of perceived need for treatment/treatment effectiveness

nursing functions in milieu therapy

Provide structured environment Serve as emotional sounding board Diagnose conflicts, consequences of actions Facilitate adaptive change in behavior

Balancing factors in crisis

Realistic perception of the event Adequate situational supports Adequate coping mechanisms

Ego defense mechanisms function to

Unconscious process to protect against anxiety

PSYCH NURSING INTERVENTIONS structure

Unit milieu/environment (meets patient's level of functioning) clear, simple directions, setting limits on maladaptive behaviors)

nursing diagnosis

adaptive-maladaptive coping continuum of human responses to illness

Coping Mechanisms protect against

anxiety

phases of nursing process

assessment nursing diagnosis outcome identification planning implementation evaluation

Self-Concept 5 components

body image self-ideal role performance personal identity self-esteem

phases of nursing process implementation

carrying out the actions

Mental Status Examination - what type of approach

clinical rather than social approach

treatment stages + outcomes for: - crisis - acute - maintenance - health promotion

crisis --- stabilization acute - symptom relief with meds maintenance - improved functioning health promotion - optimal quality of life

Low Self-esteem

judgment of personal worth as inferior based on not achieving self-ideal

Therapeutic communication

keep it open, use verbal & non-verbal, active listening, silence, limit setting on behavior

goal of therapeutic community

learn adaptive coping, interaction, & relationship skills that can be generalized to other aspects of life.

For therapeutic Communication Techniques ____ is the foundation

listening

Therapeutic Communication Techniques

listening Use broad openings to encourage patient to communicate what is important to him/her Restate part of patient's statement Clarify vague ideas, thoughts Reflect on/validate patient's behavior, feelings

4 levels of anxiety

mild, moderate, severe, panic

PSYCH NURSING INTERVENTIONS support

nurse's emotional & physical presence (calmness) social (family/friends) instrumental/practical, spiritual nurse

milieu work is focused on

on realistic expectations decision making social behaviors in the "here and now"

Mental status examination is to psychiatric nursing what ____is to general medical nursing

physical examination

PSYCH NURSING INTERVENTIONS safety

physical, physiological, emotional (1:1 observation if necessary. Least restrictive environment)

phases of nursing process planning

planning actions to meet outcome criteria

Debriefing traumatic experiences

recall the events clarify traumatic experiences, ventilation of feelings to allow person to deal with the emotions.

Goal of Crisis Intervention

return to pre-crisis level

PSYCH NURSING INTERVENTIONS include

safety structure support symptom management medication management

Clozaril dose related risks for

seizures agranulocytosis

Kinesthetic hallucination

sensing movement while motionless

phases of nursing process outcome identification

setting outcome criteria

ANA Standards of Practice includes

standard 1 - 6 nursing process

PSYCH NURSING INTERVENTIONS medication management

target symptoms, potential side effects, treatment for side effects, patient teaching about side effects & how to recognize and treat them

Purposes of Therapeutic Communication

to allow the patient self-expression to promote healthy growth to understand the significance of the patient's problems to assist in the identification and resolution of the problems

Use ___ and ____ to develop therapeutic nurse patient relationship

trust & consistency

Therapeutic use of self

use one's personality consciously to establish relatedness & to structure nursing interventions.

Appraisal of stressor

what is pt.'s evaluation of the event or the meaning to the person?

Cenesthetic hallucination

•feeling body functions

outcome identification

•how will you know your interventions are successful/what does success or effectiveness look like?