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Nursing diagnosis for anxiety
- Anxiety (moderate, severe, panic)
- Ineffective coping
- Deficient diversional activity
- Social isolation
- Ineffective role performance
- Disturbed thought process
- Post-trauma syndrome
- Sleep deprivation
- Chronic low self-esteem
- Spiritual distress
- Self-care deficit
- Impaired skin integrity
- Imbalanced nutrition: less...
- Imbalanced nutrition: more...
Prioritization of nursing interventions for personality disorders
Prioritization of nursing interventions for manipulative pt
Prioritization of nursing interventions for schizotypical personality disorders
Types of defense mechanisms
- Reaction Formation(overcompensation)
What is denial?
Escaping unpleasant realities by ignoring their existence
What is regression?
In the face of overwhelming anxiety, the return to an earlier, more comforting (although less mature) way of behaving
What is displacement?
Transfer of emotions associated with a particular person, object, or situation to another person, object, or situation that is non threatening
What is projection?
The unconscious attributing of one'sown intolerable wishes, emotions, or motivations to another person
What is conversion?
An unconscious defensr mechanism in which anxiety is expressed as a physical symptom that has no organic cause
What is somatization?
The expression of psychological stress through physical symptoms
What is idealization?
Emotional conflicts or stressors are dealt with by attributing exaggerated positive qualities to others
What is altruism?
Emotional conflicts and stressors are dealt with by meeting the needs of others
What is rationalization?
Justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener
What is reaction formation (overcompensation)?
S/S of mild anxiety
- Slight discomfort
- Mild tesion relieving behaviors- nail biting, foot/finger tapping, fidgeting
S/S moderate anxiety
- Hampered ability to think clearly
- Learning/problem solving still take place
- Pounding heart
- Increased pulse & respiratory rate
- Mild somatic symptoms- gastric discomfort, headache, urinary urgency
S/S severe anxiety
- Perceptual field greatly reduced
- Learning/problem solving not possible
- Sense of impending doom or dread
- Increased severity of somatic symptoms- headache, nausea, dizziness, insomnia
- Pounding heart
S/S panic level of anxiety
- Unable to process what is going on in environment
- Loss of touch with reality
- Hallucinations or false sensory perceptions
Interventions mild-moderate anxiety
- Be calm
- Ask open-ended questions
- Give broad openings
- Explore/seek clarification
- Closing off unrelated topics
- Not bringing up irrelevant topics
- Recognize pt's distress
- Be willing to listen
- Evaluate effective past coping mechanisms
- Help pt identify anxiety
- Anticipate anxiety-provoking situations
- Use nonverbal language to demonstrate interest (lean forward, eye contact, nod)
- Encourage pt to talk about feelings or concerns
- Focus on pt concerns
- Ask questions to clarify what is being said
- Help pt identify thoughts/feelings before onset of anxiety
- Enourage problem solving with pt
- Develop alternative solutions to a problem
- Explore behaviors that have worked in the past to relieve anxiety
- Provide outlets for working off excess energy
Interventions severe-panic levels of anxiety
- Maintain a calm manner
- Always remain with pt experiencing acute severe to panic level of anxiety
- Minimize environmental stimuli
- Use clear and simple statements and repetition
- Use low-pitched voice; speak slowly
- Reinforce reality if distortions occur
- Listen for themes in communication
- Attend to physical & safety needs as needed
- Physical limits may need to be set-speak in firm, authoritative voice
- Provide opportunities for exercise
- When person is constantly moving or pacing, offer high-calorie fluids
- Assess need for meds or seclusion after other interventions have been tried unsuccessfully
What is agoraphobia?
Fear of open spaces
What is acrophobia?
Fear of heights
What is claustrophobia?
Fear of closed places
What is xenophobia?
Fear of strangers
What is mysophobia?
Fear of germs or dirt
What is social phobia?
- Social anxiety disorder
- Severe anxiety or fear provoked by exposure to a social situation or a performance situation
- Fear of public speaking is most common
What is PTSD?
Repeated re-experiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others, to which individual responded with intense fear, helplessness, or horror
Major features of PTSD
- Persistent re-experincing of the trauma through recurrent intrusive recollections of the event, dreams, and flashbacks
- Persistant avoidance of stimuli associated with the trauma, which results in the individual's avoiding talking about the event or avoiding activities, people, places that arouse memories of the trauma
- After the trauma, experience of persistent numbing of general responsiveness, as evidenced by individual's feeling detached or astranged from others, feeling empty inside, or feeling turned off to others
- After the trauma, experiencing of persistent symptoms of increased arousal, as evidenced by irritability, difficultyn sleeping, concentrating, hypervigilance, or exaggerated startled response
What is OCD?
- Typically involve issues of sexuality, violence, contamination, illness, or death
- Time consuming rituals that interfere with normal routines, social activityies, and relationships with others
- thoughts, impulses, or images that persist and recur so they cannot be dismissed from the mind and the ritualistic behaviors that an individual feel driven to perform in an attemp to reduce anxiety
What is thought stopping?
Teaches client to consciously say "stop" to maladaptive thoughts
What is hypochondriasis?
- Misrepresenting innocent physical sensations as evidence of a serious illness
- Marked by severe distress, impqirmeent in ability to function in personal, social, and occupational roles
What is body dysmorphic disorder (BDD)?
- Preoccupation with an imagined "defective body part" results in obsessional thinking and compulsive behavior
- Highly distressing and impairing disorder
What is a fugue state and what evidence supports it in an assessment?
- An altered state of consciousness involving both memory loss and travel away from or from one's usual work locale-involves both flight and forgetfulness
- Can the pt remember recent and past events?
- Is pt memory clear and complete or partial and fuzzy?
- Is pt aware of gaps in memory?
- Do the pt's memory place the self with a family, in school, in an occupation?
- Does pt ever lose time or have blackouts?
- Does pt find themselves in places with no idea how they got there?
What is dissociative identity disorder?
What is a high priority assessment for this diagnosis?
- Formerly known as multiple personality disorder
- The presence of two or more distinct personality states that recurrently take control of behavior
What is conversion disorder?
- Marked by symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition
- Dysfunction does not correspond to current scientific understanding of the nervous system and they are judged because of psychological factors
Difference btwn somatoform disorder and dissociative disorder
- Dissociative disorder is an altered mind-body connections and believd to be related to stree and anxiety
- Consciousness is altered whereas thinking, feeling, and perceptions are less impaired
- Somatoform disorders are characterized by the presence of physical symptoms in the absence of pathology or known pathophysiology
- Somatization disorder
- Conversion disorder
- Pain disorder
- Body dysmorphic disorder
- Dissociative amnesia
- Dissociative fugue
- Dissociative identity disorder
- Depersonalization disorder
Questions to ask when assessing a dissociative disorder
How to help pt with depersonalization disorder and feeling mechanical, dreamy, floating
Types of emotions nurses feel when dealing with somatoform disorders
Can antisocial clients be manipulative? What are other characteristics of antisocial persons?
What is limit setting?
The reasonable and rational setting of parameters for pt behavior that provide control and safety
What are boundaries?
- Those functions that maintain a clear distinction among individuals with a family or group and btwn family members and the outside world
- May be clear, diffuse, rigid, or inconsistent
What are paranoid personality disorders?
- Characterized by a pattern of distrust and suspiciousness
- Individual interprets other peoples motives as threatening
- See chart p 180
What is a borderline personality disorder?
- Characteristic lack of affect
- Lack of a sense of identity and instability in relationships
- Experience overwhelming needs, internal and external, that they seek to have met in relationships, but their excessive demands, unstable anger, and impulsive behavior drive people away
What is paaranoid PD?
Characterized by long-standing problems in behavior, mood, perception, and relationships
What is histrionic PD?
Characterized by excessive emotionality and attention-seeking behaviors that are dramatic and egocentric
What is avoidant PD?
Marked by social inhibition, feelings of inadequacy, and sensitivity to potential rejection or criticism
What is narcissistic PD?
- Individual typically demonstrates grandiosity and the need for constant adoration by others
- Exaggerates their importance and accomplishments
What is splitting?
- Primitive defense mechanism characterized by an "all or none" mentality
- There is no recognition that a person may have both good and bad qualities
What feelings may a nurse experience when caring for a client with depression?
What should nurse teach pt and family to report when giving an SSRI for treatment of depression?
What is dysthymia?
- Characterized by a chronically depressed mood occuring most of the day, more days than not, for at least a 2yr period
- During periods of depressed mood, at least two or more of the other symptoms of depression must be present
- Disorder does not usually affect social or occupational functioning
What is anhedonia?
The inability to experience pleasure
What are the vegetative signs of depression?
- Alterations in those activities necessary to support physical life and growth
- Changes in easting patterns: 60-70% report anorexia
- Changes in sleep patterns: cardinal sign; insomnia; light sleep prolongs the agony of depression over 24hr
- Changes in bowel habits: constipation seen with psychomotor depression
- Interest in sex declines: loss of libido
- Pain: 2/3 depressed people report pain with or without reporting psychological symptoms
What should pt avoid when taking an MAOI?
What is the time frame btwn taking an MAOI and an SRI? If taken too close what crisis can occur?
What are some statements that show treatment plans are effective with depression?
What are some statements that show treatment plans are effective with anxiety?
What are some statements that show treatment plans are effective with personality disorders?
What are some statements that show treatment plans are effective with somatoform disorders?
What are some statements that show treatment plans are effective with dissociative disorders?
What are proper foods for pt with depression, with nursing diagnosis of imbalanced nutrition < body requirements?
What are proper foods for pt with anxiety, with nursing diagnosis of imbalanced nutrition < body requirements?
- For pt constantly pacing or moving, offer high-calorie fluids
- Dehydration and exhaustion must be prevented
What pt needs to be watched most closely for depression?
How do you approach and what do you do for a client that is depressed and cannot perform ADL's?
What can ECT do to your short term memory?
Short term memory deteriorates further during a treatment course, but most often resolves within a few weeks after final treatment
Pre and Post procedure Prep for ECT
- Prior to test, pt should sign informed consent, which may be withdrawn verbally at any time. May only be done involuntarily with a court order.
- NPO at mn before procedure
- All jewelry and dentures removed
- Empty bladder
- Procedure should be carried out with resuscitation equip and staff on hand
- Pt given anesthetic and neuromuscular blocker to relax skeletal muscles
- 100% O2 administered while unable to breathe
- As soon as unconscious and paralyzed, psychiatrist applies electrodes to head and delivers 70-150volts to brain for 0.1-1sec
- Generalized seizure produced and lasts 30-60sec
- Pt responsive approx 15min p treatment and fully recovered 1-2hr later
- Monitor VS and assess orientation and alertness
Foods to be avoided on a Tyramine restricted diet; interact with MAOI's
- Aged cheese
- Smoked fish
- Some dietary supplements
- Some beers
- Red wine
- Caffeinated beverages
- Fava beans
What is serotonin syndrome (causes and symptoms)?
- Rare, life-threatening associated with the SSRI's
- Thought to be related to overactivation of the central serotonin receptors, caused by either too high a dose or interaction with other drugs
- Symptoms: abdominal pain, diarrhea, seating, fever, tachycardia, elevated blood pressure, AMS, myoclonus (muscle spasma), increased motor activity, irritability, hostility, and mood change
- Severe manifestation can include hyperpyrexia, cardiovascular shock or death
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