Exam 1 (3/3) Flashcards
CLEAR acronym for therapeutic communication
Clarify listen encourage explore empathize accept acknowledge reassure appropriately reflect feelings/thoughts show respect
why to Avoid “why” questions and how did that “make” you feel
implies outside source or that they aren’t in charge of their emotions
what to avoid in therapeutic communication
Refrain from giving advice
false reassurance
criticism
telling them what they “should do” to “fix things
boundaries with patient
not a social friendship but a professional helping relationship. Seeing patients socially is a definite boundary issue. Self disclosure should be limited
safety issues with communication
Milieu management is important role of psych nurse.
clients’ interactions with one another, practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems
Manage the environment, maintain safety, maintain therapeutic nature of the environment, and make sure all patients are safe.
Call for back up as needed.
Monitor boundary issues with all staff.
Maintain therapeutic interactions at all times.
Monitor response to medications, sleep/appetite, and report any side effects or medical probs.
Follow the treatment plan
Schizophrenia
One of the most debilitating psychiatric disorders with key symptoms of hallucinations, delusions, and disorganized thinking and behavior.
It is an enduring illness that usually requires antipsychotic medication and long term treatment.
patients can and do improve with proper treatment and support.
Know helpful interventions for hallucinations and delusions
Present your sense of reality
Do not argue
Convey empathy and recognition of patient’s feelings
Offer medication if needed
Distract them
Do not over focus on psychotic symptoms or ask irrelevant details
Do not use logic or reasoning
Nursing Process for Schizophrenia
Assessment
Diagnosis: think bio-psycho-social
Planning: outcome criteria, goals
Interventions: behavioral, medications, family education
Responding to the patient experiencing hallucinations
Responding to the patient experiencing delusions
Relapse prevention
Evaluation
s/s of schizophrenia
Positive: Hallucinations Command hallucinations Delusions (various types) Ideas of reference Loose associations and non-goal directed speech Thought insertion, withdrawal, broadcasting Word salad
Negative: Apathy- Social withdrawal Flat, blunted, or bland affect Anhedonia: lack of pleasure or joy Lack of volition- using own will
Other:
Anxiety
Insomnia
Religious and sexual preoccupation
Circumstantial (irrelevant) and tangential speech (totally irrelevant)
Poor grooming, hygiene, appearance
Poor appetite
Poor judgment
Poor insight
Catatonia- abnormal movement
Neologisms: made-up words that have meaning only to the client
Echolalia- repetition of vocalizations made by another person
Perseveration- repetition of the same response
Clang associations- groupings of words, usually rhyming words, that are based on similar-sounding sounds, even though the words themselves don’t have any logical reason to be grouped togethe
Family input with schizophrenia
ESSENTIAL AND ONGOING Refer to NAMI Do not blame them Teach them effective approaches Help them deal with eating and sleeping problems in the patient and what to do if patient becomes dangerous to self/others
safety issues with schizophrenia (Antipsychotic side effects)
command hallucinations to harm self or others, extreme agitation and paranoia, not eating/sleeping, poor hygiene, threatening other patients or staff, isolating most of time, unable to communicate well. May require involuntary commitment.
When a voluntary patient is made an involuntary patient
Voluntary patients can be made involuntary if they are insisting on leaving but dangerous to themselves and/or others and mentally disordered
Duty to warn
You do not need to contact anyone by yourself, but you should notify a supervisor about threats by patient to harm others
criteria for involuntary commitment
presence of mental illness
poses a danger to self or others
demonstrates severe inability to meet basic needs including food, clothing and shelter
requires treatment but unable to seek it voluntarily r/t the impact of the mental illness
rights of the involuntary patient
competent: right to refuse treatment, including medication
if made incompetent by judge: temporary or permanent guardianship, usually a fam member, appointed by court
guardian can sign informed consent, consider what the client would want
Least restrictive environment concept for treatment
verbal interventions (encouraging the client to calm down)
diversion or redirection
providing a calm, quiet environment
offering PRN medication (considered less than a physical restraint)
role of nurse with restraints
provider writes an order
time limits (18 > 4 hours, 9-17 2 hours, 8 < 1 hour)
if need continues, provider must reassess and rewrite order
assess
offer food and fluid
toileting
monitor VS
monitor for pain
document q 15-30 mins
nurse may apply restraints w/o order in an emergency
must be discontinues when pt is safer and quieter
antipsychotics purpose
Major tranquilizers used for psychoses (to reduce target symptoms of hallucinations, delusions), acute psychotic states, agitation, aka “neuroleptics”.
Antacids, caffeine, nicotine can reduce effectiveness
serious side effects of antipsychotics
extrapyramidal side effects (EPS)
Neuroleptic malignant syndrome (NMS)-can be lethal, and cause rhabdomyolysis (muscle breakdown releasing damaging proteins into blood). Hyperthermia, lead pipe rigidity, autonomic instability . May be confused with serotonin syndrome (overlapping symptoms; see medsafe.govt.nz or ncbi,nlm.nih.gov sites).
Agranulocytosis (deadly): Clozapine (wkly WBC labs)
Photosensitivity: use sunscreen
Orthostatic hypotension: arise slowly
Sedation- don’t combine with other sedating meds
Anticholinergic effects: constipation, urinary retention, increase fiber, fluids, note tooth decay
Seizures- lowers seizure threshold
Prolactin levels can increase
FDA black box warnings for use in patients with dementia
clozapine (Clozaril)
atypical antiphycotic - Used more frequently than conventional APs because of less movement disorders (EPS) and reduce positive and negative symptoms.
Side effects: : Substantial weight gain, diabetes, increased cholesterol, metabolic syndrome
can cause agranulocytosis (monitor WBC)
chlorpromazine (Thorazine)
conventional antipsychotic
block dopamine and are more effective for positive symptoms
MOVEMENT
Nursing: monitor for extrapyradmial effects: including dystonia (early in tx; sometimes after first dose; muscle spasms neck (torticollis), arching back (opisthotonus); can occlude airway; oculogyric crisis) akathisia (assess to determine if akathisia or anxiety (tx is very different)) pseudoparkinsonism (similar to Parkinson’s symptoms; akinesia; bradykinesia; cogwheel rigidity; gait disturbance; flat affect) tardive dyskinesia (irrev. and involuntary, oral, facial movements, writhing of trunk and limbs. Ingrezza-new tx.)- AIMS test
(old phenothiazine, low potency med)
haloperidol (Haldol)
conventional antipsychotic
block dopamine and are more effective for positive symptoms:
Nursing: monitor for extrapyradmial effects: including dystonia (early in tx; sometimes after first dose; muscle spasms neck (torticollis), arching back (opisthotonus); can occlude airway; oculogyric crisis) akathisia (assess to determine if akathisia or anxiety (tx is very different)) pseudoparkinsonism (similar to Parkinson’s symptoms; akinesia; bradykinesia; cogwheel rigidity; gait disturbance; flat affect) tardive dyskinesia (irrev. and involuntary, oral, facial movements, writhing of trunk and limbs. Ingrezza-new tx.)- AIMS test
high potency, less sedating, small doses used)
haloperidol decanoate (Haldol decanoate)
conventional
Long acting form of antipsychotics
aka “depot meds”
helps to decrease positive symptoms
thioridazine (Mellaril)
conventional antipsychotic
block dopamine and are more effective for positive symptoms:
Nursing: monitor for extrapyradmial effects: including dystonia (early in tx; sometimes after first dose; muscle spasms neck (torticollis), arching back (opisthotonus); can occlude airway; oculogyric crisis) akathisia (assess to determine if akathisia or anxiety (tx is very different)) pseudoparkinsonism (similar to Parkinson’s symptoms; akinesia; bradykinesia; cogwheel rigidity; gait disturbance; flat affect) tardive dyskinesia (irrev. and involuntary, oral, facial movements, writhing of trunk and limbs. Ingrezza-new tx.)- AIMS test
phenothiazines
fluoxetine (Prozac)
Antidepressant- SSRI
Most commonly used d/t least side effects. Can cause sexual probs, HA, dry mouth. Monitor for SI early in tx. Black box warning: younger than 24 years. Serotonin syndrome (hyperthermia, agitation, increased reflexes, increased BP and P, sweating, dilated pupils, shivering, diarrhea, muscle twitching; seizures) can result from combining ADs; herbals; dextromethorphan; others.
Do not mix MAOI and SSRI or SSNRI within 2-5 weeks of each other Serotonin Syndrome (can be confused with NMS)
doxepin (Sinequan)
antidepressant- TCAs
can cause cardiac dysrhythmias and lethal overdoses
orthostatic hypotension, anticholinergic effects, sedation
