The flashcards below were created by user
BSNwannabe
on FreezingBlue Flashcards.
-
Nursing diagnosis for anxiety
- Anxiety (moderate, severe, panic)
- Fear
- Ineffective coping
- Deficient diversional activity
- Social isolation
- Ineffective role performance
- Disturbed thought process
- Post-trauma syndrome
- Sleep deprivation
- Fatigue
- Hopelessness
- 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
- Denial
- Regression
- Displacement
- Projection
- Conversion
- Somatization
- Idealization
- Altruism
- Compensation
- Rationalization
- 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
- Restlessness
- Irritability
- 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
- Tension
- Pounding heart
- Increased pulse & respiratory rate
- Perspiration
- Mild somatic symptoms- gastric discomfort, headache, urinary urgency
-
S/S severe anxiety
- Perceptual field greatly reduced
- Learning/problem solving not possible
- dazed/confused
- Hyperventilation
- Sense of impending doom or dread
- Increased severity of somatic symptoms- headache, nausea, dizziness, insomnia
- Trembling
- 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
- Erratic
- Uncoordinated
- Impulsive
-
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
-
Somatoform disorders
- Somatization disorder
- Conversion disorder
- Hypochondriasis
- Pain disorder
- Body dysmorphic disorder
-
Dissociative disorders
- 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
- Pepperoni
- Salami
- Avocados
- Figs
- Bananas
- Smoked fish
- Protein
- Some dietary supplements
- Some beers
- Red wine
- Caffeinated beverages
- Chocolate
- Fava beans
- Ginseng
-
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
|
|