Pred ATI Review 4
Standardized screening tools MMSE pg. 4
1. Mini Mental State Examination ( MMSE ) : is used to objectively collect data about a client's cognitive status by evaluating the following : - Orientation to time and place - Attention span and ability to calculate by counting backward by seven - Registration and recalling of objects - Language, including naming of objects, following of commands, and ability to write 2. Glasgow Coma Scale : is used to obtain baseline data of client's LOC and for on going evaluation.
GCS ( Glasgow Coma Scale )
A score of less than 8 = comatose - Abnormal posturing indicates comatose
RELAXATION TECHNIQUES PG.50 - meditation - guided imagery - breathing exercises - progressive muscle relaxation - physical exercise = causes a release of endorphins that lower anxiety and reduce stress PROTECTIVE FACTOR AGAINST STRESS : practicing spiritual or religious beliefs ( meditating or praying ) - having a strong, active social support network - being optimistic about future
Acute stress response = pg. 49 - depressed immune system - increased BP - unhappiness * MINDFULNESS = decrease the client's stress * ASSERTIVE COMMUNICATION = allow the client to assert her feelings and then make a change in the situation
Offering general leads
Allows the nurse to take the direction of the dicussion
Negative symptom of schizophrenia
Apathy ( deficits in the client's ability to experience emotions. Apathy is . negative symptom of schizophrenia manifested by a loss of interest in one's surroundings). -Anhedonia ( loss of interest in daily activities and the inability or lack of capacity to experience pleasure in general .
Nonverbal communication pg. 16
Appearance Posture Gait Facial expressions Eye contact Gestures Sounds Territoriality Personal Space Silence
Manifestations of Histrionic personality disorder
Attention- seeking behaviors -Extremely dependent and easily influenced by others - Seductive behavior
Recreational therapist
Can promote therapies like art and music to help and enhance preserve mental health.
Characteristics of therapeutic comunication
Client centered; not social or reciprocal Purposeful, planned, goal- directed Building rapport Trust Respect Genuineness Empathy
Schizoprenia + priority nursing actions?
Conduct an abnormal involuntary movement scale test ( AIMS test ). - AIMS ( abnormal involuntary movement scale test ) is a DATA collection tool used to guide medication therapy for clients who are prescribed antipsychotic medications.
DSM-5 ( Diagnostic and Statistical Manual of Mental Disorders )
DSM-5: - establishes diagnostic criteria for mental health disorders - Assist nurses in planing, implementing, and evaluating care for clients who have mental health disorders. - Identifies expected findings for mental health disorders
Manifestations of Bulimia nervosa to expect
Dental caries ( which can lead to tooth erosion). Dental caries are caused by the increased acid in the stomach that is found in the vomitus of clients who purge repeatedly.
Manifestations of alcohol withdrawal
Diaphoresis Insomnia Increased HR Increased yawning
Justice
Distributing care or resources equally among the clients or groups of clients. - Fair & equal treatment for all
Reinforcing discharge teaching w/ client on ALPRAZOLAM , priority instructions?
Do not drive until your reaction to the medication is determined. (Do not drive or handle major mechanical equipment while taking alprazolam ). -Take alprazolam w/ a light . snack to reduce GI discomfort.
What info to ask a client when gathering info on psychosocial info?
Do you have a hobby that you enjoy? ( nurse should ask questions regarding the client's interest and hobbies when gathering psychosocial information
Mechanical restraint documentation
Document the following: - how much water was offered and how often it was offered - A description of client verbal communication -Dosage and time of medication administration
Beneficence
Doing good or causing good to be done; kindly action
Nonmaleficence Ethical and legal issues Pg. 9
Doing no harm to clients
Veracity
Duty to tell the truth. ( nurse should uphold this ethical principle when administering a new medication to a client by explaining the therapeutic effects as well as the adverse effects. This action promotes a trusting relationship between the nurse and the client, which enhances the nurse's primary commitment to the client of providing optimum, quality care.
Mental Status examination
EX of Q: what is the date and where are you living -How are an apple and an orange alike? a method of objectively assessing a client's behavior and functioning in a number of spheres, with particular attention to the symptoms associated with psychological disturbance
Summarizing
Enables the nurse to bring together important points of discussion to enhance understanding
Countertransference
Is an emotional response toward the client by the nurse. This response might be related to the nurse's past unresolved feelings or relationships. These feelings can interfere with a nurse client therapeutic relationship. In order to correct the situation of countertransference, the nurse must recognize personal reactions to the client in an attempt to work through these feelings.
Fidelity
Loyalty and faithfulness to the client and to one's duty.
Posttraumatic stress disorder
May experience: - flashbacks ( so they may receive therapy that treats flashbacks)
Cognitive THERAPY Pg. 40 - Cognitive refraiming - Priority restructuring = teaches client to prioritize differently to reduce the number of stressors. - Journal keeping -Assertiveness training -Monitoring thoughts
Modeling pg. 40 Operant conditioning Systematic desensitization Aversion therapy Meditation , guided imagery , diaphragmatic breathing , muscle relaxation , biofeedback = behavioral therapy to control pain , tension , and anxiety - BIOFEEDBACK = uses mechanical device to promote voluntary control over autonomic functions pg. 40 - flooding = planned exposure to an undesirable stimulus in an attempt to turn off the anxiety response. - Response prevention - thought stopping = instructing a client to say "stop" when anxiety occurs is an example of thought stopping
Psychological intervention an example
Monitoring adverse effects of medication
Example of small group communication
Nurse's discussion of client information with members of the health care team is an example of this
Nurse is preparing to obtain consent from a client who has a tibia fracture. The client received IV morphine sulfate prior to arrival on the unit and is scheduled for surgery. Which of the following actions should the nurse take first?
OBTAIN CONSENT FROM A RELATIVE of the client. ( the client has been given an opioid medication that can alter his ability to understand. COnsequently, this client is NOT LEGALLY able to provide consent. The nurse should obtain consent from a relative or health care proxy. )
Phases and tasks of a therapeutic relationship pg. 26
Orientation Working Termination
PACT = Program of Assertive Community Treatment
PACT group works with clients who are nonadherent with traditional therapy ( ex: client in home setting who keeps "forgetting" his injection
Therapeutic tools: Pg. 39 - Free association = spontaneous , uncensored verbalization of whatever comes to a client's mind ( Ex: saying the first thing that comes to my mind) - Dream analysis and interpretation - Transference - Hypnosis
PSYCHOTHERAPY pg. 39 - Psychodynamic psychotherapy - Interpersonal psychotherapy - Cognitive Therapy - Behavioral Therapy - Cognitive behavioral therapy - Dialectical behavior therapy = a cognitive behavior therapy for clients who have personality disorder and exhibit self injurious behavior.
Positive symptoms of schizophrenia
Paranoia Echolalia Delusions
Manifestations of Anorexia Nervosa
Peripheral Edema ( d/t hypoalbuminemia and weight loss) Hypotension Bradycardia Amenorrhea ( resulting from fluid & electrolyte imbalance) Lanugo ( resulting from starvation) Yellow skin ( resulting from carotenemia) - A BMI of 17 or LESS ( BMI range for a person of average weight and height is 20 to 24.9
Time limit for seclusion
Pg. 11 complete documentation every 15 to 30 mins or facility protocol ** Nurse can use seclusion or restraints without first getting a written prescription if it is an emergency situation but the nurse must get a written prescription within a specified period of time (usually 15 - 30 mins ).
Bipolar disease + Hx of mania indication that client is relapsing
Pressured speech ( rapid or pressured speech, provocative behavior and insomnia are indicators of potential replapse in a client who has bipolar disorder and a history of mania. ) -Weight loss
Manifestations of paranoid personality disorder
Projects blame on OTHERS ( rather than taking responsibility for their own actions ).
Seclusion and Restraint Pg. 10- 11
Provider should prescribe seclusion or restraint for the shortest duration necessary and only if less restrictive measures are not sufficient. They are for the physical protection of the client , other clients and or staff. Less restrictive measures : - Verbal interventions telling the client to calm down - Diversion or redirection - Providing a calm and quiet environment Pg. 10-11
Manifestations of antisocial personality disorder
Repeated physical aggression
Stuporous client
Requires vigorous or painful stimuli to elicit a response - Stuporous = is a client that is NOT alert
Confidentiality
Respecting the client's privacy regarding personal issues.
Autonomy
Respecting the client's right to make her own decision. -client must accept the consequences of decisions made. The client must also respect the decision of others
MDD SAD seasonal affective disorder PMDD premenstrual Persistent depressive disorder pg. 71
SSRIs ( citalopram , fluoxetine , sertraline ) pg. 73 Tricylic antidepressant ( amitriptyline , imipramine , nortriptyline ) pg. 73 MONOAMINE OXIDASE INHIBITORS ( phenelzine ) pg. 73 ATYPICAL ANTIDEPRESSANT ( bupropion, trazadone ) pg. 73 SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS ( venlafaxine , duloxetine ) pg. 73 St. John's wort pg. 73 Light therapy pg. 73
OCD + continually washes hands
Schedule times for the client to wash her hands during the day. ( providing schedule is a type of response prevention and can DECREASE anxiety by allowing the client to know in advance when hand washing can be performed. )
Manifestations of borderline personality disorder
Self- mutilation through cutting Reckless driving
Manifestations of SEROTONIN SYNDROME
Serotonin syndrome = life threatening syndrome and is caused b an over activation of the central serotonin receptors. - this is r/t taking an SSRI and trazadone along with St. John's wort. Manifestations: - Hypertension tachycardia vomiting abdominal pain mental status changes
MSE ( Mental Status Examination )
Tests of LOC - Alert - Lethargic - Stuporous - Comatose ( there are abnormal posturing in the client who is comatose) * Decorticate Rigidity : Flexion and INTERNAL rotation of upper extremity joints and legs * Decerebrate rigidity: Neck and elbow extension , wrist and finger flexion
Validation therapy
This strategy validates client's feelings and emotions, even when they don't coincide with reality. The nurse should also attempt to integrate redirection techniques without the client realizing he is being redirected.
DISULFIRAM
Tx: alcoholism causes nausea and vomiting ( if he drinks) , HA, palpitations when mixed with alcohol Report respiratory distress - Can be used as an AVERSION therapy. B/c it pairs maladaptive behavior with unpleasant stimuli to promote a change in behavior
Modeling = demonstration followed by a client imitation of the behavior GROUP THERAPY pg. 43 Phases of group development: 1. Orientation phase = -the nurse should identify the purpose of the group , - the nurse should set the tone of the group, including an expectation of confidentiality -the nurse should discuss the termination of the group in the 2. Working phase = - the nurse should identify informal roles that other members in the group often assume 3. Termination phase
Types of families: Pg. 44 - Nuclear families - single parent families - adoptive families - Blended families - Cohabiting families - extended families - other families Types of discipline Pg. 45 - Reasoning - Scolding - Behavior modification - Consequences - Corporal or physical punishment
Aversion therapy
Used for clients who have PARAPHILIC disorders that are not responsive to other treatment measures.
TMS = TRANSCRANIAL MAGNETIC STIMULATION = noninvasive therapy uses magnetic pulsations to stimulate the cerebral cortex of brain. pg. 54-55 FOR: - approved by FDA to treat: MDD clients that do NOT respond to pharmacological treatment CONSIDERATIONS: pg. 54 -Prescribed DAILY for 4 to 6 weeks - can be performed as outpatient - each session is 30 - 40 mins - client is alert during procedure COMPLICATIONS: pg. 54 - mild discomfort , tingling sensation - monitor for lightheadedness - seizures are RARE
VAGUS NERVE STIMULATION pg. 55 = VNS = electrical stimulation through the vagus nerve to the brain through a device that is surgically implanted under the skin on the client's chest . Believed to increase levels of neurotransmitters FOR: Depression that's resistant to pharmacological treatments and ECT - APPROVED BY FDA CONSIDERATIONS: -performed as an outpatient - around the clock programmed pulsations, usually for 30 seconds every 5 min - therapeutic antidepressant effects usually take several weeks to achieve - assist provider in getting informed consent COMPLICATIONS: - voice changes , hoarseness, throat/ neck pain and dysphagia - dyspnea is possible
Generalized anxiety disorder , appropriate statements by the nurse?
We will demonstrate for you how to use relaxation techniques ( to decrease feelings of anxiety in clients who have generalized anxiety disorders). Ex: Progressive relaxation , deep breathing exercises.
Restating
allows the nurse to repeat the main idea expressed f
Mechanical restraints
are warranted to protect the client from self-destructive behavior. - Restraints are CONTRAINDICATED as a method of discipline - Restraints are CONTRAINDICATED as a method of punishment
Social worker
assist client with building a support structure to help promote and preserve mental health, including contacting day treatment centers ad arranging for financial and other community resources.
Manifestations of OCD
being preoccupied with details. - Ritualistic behavior
Tort
civil wrongdoing, in which monetary damages can potentially be awarded to the plaintiff ( injured party ) and collected from the defendant ( responsible party ) . Example of torts: 1. False Imprisonment : Confining a client to a specific area, such as a seclusion room. 2. Assault : making a threat to a client's person such as approaching the client in a threatening manner 3. Battery : touching client in a harmful or offensive way
Focusing
concentrates the attention on one single point
Milieu therapy
creates an environment that is supportive, therapeutic & safe. Pg. 25 - began as an effort to provide an environment conducive to the treatment of children who have mental illness. * Goal: while in this therapeutic environment, the client will learn the tools necessary to cope adaptively, interact more effectively and appropriately and strengthen relationship skills. The hope is that the client will use these tools in all other aspects of his life.
Reminiscence therapy
encourages the client to reflect on and think about the past. This therapy most often takes place in a group setting where older adults clients share significant past events with their peers.
Feedback
gives information to clients about how others perceive them and helps them consider changing their behavior
Systemic desensitization therapy
is a cognitive and behavioral intervention = a planned , progressive exposure to anxiety- provoking stimuli. During this exposure, relaxation techniques suppress the anxiety response.
RESPONSE PREVENTION Therapy
is used to limit ritualistic acts for clients who have OCD.
Art Therapy
like drawing or listening to music can assist a client with recognition and expression of specific feelings.
Denial
pretending the truth is not reality to manage the anxiety of acknowledging what is real
Reflecting
refers questions and feeling back to clients so they realize that their point of view has value. This technique is used most often when clients ask the nurse for advice.
Echolalia
repetition of words spoken by someone else, a positive symptom of schizophrenia
electroconvulsive therapy ( ECT )
short term memory problems are temporary side effects of ECT treatment.
Witness on the consent form ( informed consent form ) means
that the person or nurse confirms that the client was the one who signed the consent form.
MMSE
the use of mental questionnaire assists in identifying deterioration in mental status and brain damage which are findings associated with cognitive disorders
Paranoia
unfounded fear of others and is a positive symptom of schizophrenia
Transference
when a client views the nurse as having characteristics of another person who has been significant to his personal life, such as his ex girlfriend
Classical psychoanalysis
-focuses on PAST relationships to identify the cause of the anxiety disorder. - A therapeutic process that requires many sessions over months to years - Focuses on identifying and resolving the cause of the anxiety rather than changing behavior - Assesses unconscious thoughts and feelings
Restraints : monitoring and interventions
- restraint should be tied to a NONMOVABLE part of bed frame where it will not tighten when the bed is raised or lowered - restraint should be secured using a QUICK RELEASE KNOT - should be left loose enough for ROM and with enough room to fit 2 fingers between device and client - client should NOT be left unattended without the restraint. Type of frequency of care= - ROM - neurosensory checks - removal integumentary checks
Restraints
- use of restraints without an order is considered FALSE imprisonment - use only as last resort , nurse should consult with provider to obtain a written order stating WHY the restraint is necessary and for how long - If a nurse uses restraints in an emergent situation, a face to face assessment is to be done within 1 hr by the provider -prescription must include: reason, type, location , how long the restraint may be used, type of behaviors demonstrated by client that warrant use of restraint. - Prescription and renewal are limited to 4 hour for an adult, 2 hr for clients age 9-17 1 hr for clients younger than 9 y.o. Prescriptions may be renewed if needed, with a maximum 24 consecutive hr. - safety should be checked and documented 15-30 min based on facility policy - bony prominences should be padded and neurosensory checks should be performed Q 2 hrs.
Stress management pg. 49 GAS = general adaptation syndrome = the body's response to an increased demand * 1st stage = INITIAL ADAPTIVE BEHAVIOR ( aka fight or flight mechanism )
* ACUTE STRESS ( fight or flight ) pg. 49 - apprehension - unhappiness or sorrow - decreased appetite - increased respiratory rate, HR, CO & BP - increased metabolism and glucose use - depressed immune system * PROLONGED STRESS ( maladaptive response ) - chronic anxiety or panic attacks - depression , chronic pain, sleep disturbances - weight gain or loss - increased risk for MI, stroke - poor diabetes control, HTN , Fatigue , irritability , decreased ability to concentrate - increased risk for infection
ROLES pg. 44
* Maintenance roles = members who take on these roles tend to help maintain the purpose and process of the group. ( ex: harmonizer = attempts to prevent conflict in the group ). * Task roles = members take on various tasks within the group process ( ex: recorder who takes notes and records what occurs during each session ) * Individual roles = prevent teamwork bc individuals take on roles to promote THEIR OWN AGENDA . ( Ex: recognition seeker = boasts about personal achievements , a dominator = tries to control other members )
* Triangulation = is when a 3rd party is drawn into a relationship with 2 members whose relationship is unstable. * Group Process = a verbal and nonverbal communication that occurs within the group during group sessions * Subgroup = a small number of people within a larger group who function separately from that group * Hidden agenda = is when some group members have a different goal than the stated group goals. The hidden agenda is often disruptive to the effective functioning of the group.
* Placation = is the dysfunctional behavior of taking responsibility for problems to keep peace among family members * Manipulation = the dysfunctional behavior of suing dishonesty to support an individual agenda * Blaming = the dysfunctional behavior of blaming others to shift focus away from the individual's own inadequacies. * Distraction = the dysfunctional behavior of inserting irrelevant information during attempts at problem- solving.
Levels of prevention pg 32
* Primary intervention = promotes HEALTH and PREVENTS mental health problems from occurring ( Nurse assist with community education program to teach the community about certain techniques for better mental health) * Secondary prevention = focuses on EARLY detection of mental illness (example: screening tools) * Tertiary prevention = focuses on REHABILITATION and PREVENTION of further problems in clients who have previous diagnosis ( Nurse assist leading a support group for clients who have completed a substance use disorder program.
Reaction formation : pg. 22 overcompensating or demonstrating the opposite behavior of what is felt - Displacement : shifting feelings related to an object, person, or situation to another less threatening object, person, or situation - Sublimation : dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression.
-
Barriers to effective communication p.g 17
- Asking irrelevant personal questions - Offering personal opinions - Giving advice - Giving false reassurance - Minimizing feelings - Changing the topic - Asking " why " questions - Offering value judgements - Excessive questioning - Responding approvingly or disapprovingly
Reinforce teaching about healthy sleep habits
- Avoid consumption of caffeine bc it can promote insomnia . - Avoid taking naps in the day time to enhance night time sleep patterns and minimize the amount of time the client needs to take ALPRAZOLAM .
BRAIN STIMULATION THERAPIES pg. 53 , 73 - electroconvulsive therapy ECT - transcranial magnetic stimulation TMS - vagus nerve stimulation VNS
- ECT = use electrical current to induce brief seizure activity while the client is anesthetized - 2 to 3 X per week for 6 to 12 treatments - Does NOT cure depression FOR: - MDD major depressive disorder Pg 53 - Schizophrenia spectrum disorders - Acute manic episodes - BIPOLAR disorder with rapid cycling CONTRAINDICATIONS for ECT Pg. 53 - cardiovascular disorder - cerebrovascular disorders COMPLICATIONS of ECT pg. 54 - ADMIN SUCCINYLCHOLINE = to reduce the risk for injury during induced seizure activity, a muscle relaxant
Community Mental health Center, nurse should be ready to provide
- Educational groups - Medication dispensing programs - Individual counseling - Family therapy
Therapeutic nurse- client relationship
- Goal oriented - encourages POSITIVE behavioral change - Establishes a termination date
Somatization behaviors
- Increased anxiety about health concerns that can't be explained medically.
Manifestations of Opioid intoxication
- Lethargic - Euphoria - Drowsiness - Slurred speech
Manifestations of marijuana intoxication
- May be socially withdrawn - Impaired judgment - minimal coordination - Substandard reaction times
Anxiety pg. 22 -23 mild, moderate, severe , panic-level
- Moderate anxiety : decreases problem solving and can hamper the client's ability to understand information. Vital signs can increase somewhat and the client is visibly anxious pg. 23 - Mild anxiety: client's ability to understand information actually INCREASE - Severe anxiety : causes restlessness , decreased perception, and an inability to take direction - during panic attack : the person is completely distracted, unable to function and can lose touch with reality.
Anxiety disorder
- can use COGNITIVE REFRAMING techniques - cognitive reframing = helps the client look at irrational cognitions ( thoughts ) in a more realistic light and to restructure those thoughts in a more positive way.
Major depressive disorder
- can use FREE ASSOCIATION as a therapeutic tool
FLOUXETINE
- do NOT DC abruptly bc this can cause the client to exhibit manifestations of withdrawal
Intimate partner violence , nursing actions?
Encourage the client to develop a safety plan. ( to aid in escaping further violence if necessary ). - Another nursing action that should be a priority is to treat the client's injuries. The nurse should support the client's decision to seek treatment, and the nurse should ask the client if he/she needs assistance with making a report. But it is the client's choice whether or not to report the incident to authorities. Members of the health care team might be required to report intimate partner violence themselves if the client has been assaulted by a weapon or if rape has occurred, depending on individual state laws. - Nurse should interview the client privately without the partner present
Manifestations of antisocial behavior
Exploiting others
Group therapy session + client is having difficulty staying seated and states loudly to the therapist, " I know more than you do about the people in this room!" Nurse should identify that which of the following findings is the likely explanation for the client's behavior?
HYPOMANIA ( clients with hypomania exhibit excessive energy and a decreased need for sleep. These clients are easily distracted in a group setting and have a pretentious, grandiose sense of self. )
Manifestations of cocaine use
Hypertension Mental alertness Tachycardia Dilated pupils
Withdrawal manifestations smoking cessation course
I will probably feel irritable within 24 hours of my lat cigarette. Irritability craving difficulty concentrating Weight gain ( d/t increased appetite) Decrease in HR and BP -Nicotine withdrawal manifestations do NOT go away within 10 days but can last for WEEKS or months! Symptoms typically starts within 24 hours of the last cigarette or nicotine use
