Nursing care plans

Question 1

What would be the rationale for this nursing intervention: Suicide assessment and reduce situations that can lead to increased thoughts of suicide

Answer 1

By conducting a thorough assessment we can explore with the patient situations where he/she is at increased risk and try put measures in place to manage that situation i.e risk increases when alone and drinking alcohol

Question 2

What would be the first nursing intervention based of this nursing objective: Reduce risk of suicide

Answer 2

Suicide assessment and reduce situations that can lead to increased thoughts of suicide

Question 3

What would be the first objective/goal based of this nursing diagnosis: Increased risk of suicide related to low mood and loss of employment

Answer 3

Reduce risk of suicide

Question 4

What do Psychotherapeutic interventions include?

Answer 4

Client-motivated interventions such as: Self-management techniques

Question 5

What are some nursing interventions for the key concern of: Dehydration

Answer 5

Monitor and document fluid intake, Provide high cal fluids frequently throughout shift, and frequently remind the person to drink

Question 6

What are some nursing interventions for the key concern of: Impaired sleep

Answer 6

Monitor and document sleep pattern, provide low stimulus environment, monitor caffeine intake and reduce, and PRN sedatives as prescribed

Question 7

What are some nursing interventions for the key concern of: Malnutrition

Answer 7

Monitor and document fluid intake, Provide high cal finger foods frequently throughout the shift, frequently remind the person to eat, and provide a low stimulus environment for meal times

Question 8

What are the 3 possible objectives for this nursing diagnosis for John: Potential for exhaustion related to reduced sleep secondary to elevated mood.

Answer 8

1. Johns sleep will restore to baseline level (8 hours per night)
2. John will feel rested on waking
3. John will have rest periods during the day

Question 9

What are 5 interventions for enhancing johns sleep?

Answer 9

1. Promote sleep hygiene (utilise pyjamas, linen on bed, sleep in bed, ADLs prior to bed ect)
2. Provide low stimulus environment
3. Encourage rest during the day/quiet activity
4. Utilise PRN sedation
5. Limit screen time

Question 10

What are some nursing interventions for elevated mood?

Answer 10

Low stimulus environment, use a firm and calm approach, set limits, and adopt a consistent approach amongst the nursing care team

Question 11

What are some nursing interventions for irritability?

Answer 11

Use a firm and calm approach, do not engage in arguments, set limits, and access risk to self or others regularly

Question 12

What are some nursing interventions for thought disorder?

Answer 12

Assess content and extent of thought disorder and document regularly, assess degree to which thought disorder impacts on ADLs, use clear and simple language, and reduce environmental stimulus

Question 13

What are some nursing interventions for delusions?

Answer 13

Assess the risk of the delusional thinking to self and others, attempt to understand the content of the delusional thinking, do not agree or argue with ideas presented, and reduce environmental stimulus

Question 14

What are 3 nursing interventions for an objective of: “Nigel will remain safe and continue to resist the impulse of suicide”

Answer 14

1. Regular assessment of risk factors in a collaborative manner that allows nigel to continue to hold responsibility.
2. Develop trust through regular 1:1s to allow nigel to share his thoughts feelings.
3. Identify strategies that help nigel to remain safe and seek help when necessary, and ensure nigel is aware of the rationale for each and how they work to keep him safe

Question 15

What would be the rationale for this nursing intervention: Identify strategies that help nigel to remain safe and seek help when necessary, and ensure nigel is aware of the rationale for each and how they work to keep him safe

Answer 15

This gives nigel other options encouraging him to use other strategies and identify the rationale for them and evaluate their efficiency. Giving him control over the situation and enhancing hope that things can change.

Question 16

What would be the rationale for this nursing intervention: Develop trust through regular 1:1s to allow nigel to share his thoughts feelings.

Answer 16

This allows nigel time to express his thoughts and voice his concerns and fears. This is vital as we gain an understanding of the details of his experience and how it influences his behaviour.

Question 17

Is a nursing diagnosis also a medical diagnosis?

Answer 17

NO

Question 18

What is a nursing care plan?

Answer 18

A plan based on symptoms related to a medical diagnoss, it identifys realistic treatment goals and works towards a positive recovery while promoting autonomy and considering holistic care and cultural considerations

Question 19

Nursing care plans draw on the patients what?

Answer 19

Strengths

Question 20

How might someone who is described as ‘stubborn’ use this as a strength?

Answer 20

They may be described as driven or determined

Question 21

What is involved in a nursing diagnosis?

Answer 21

Identifying and prioritising an issue and the cause of that issue even if they dont have a medical diagnosis yet for example increased blood pressure related to dehydration

Question 22

What is the formula for a nursing diagnosis?

Answer 22

Issue related to cause

Question 23

How do we making an objective/goal in a nursing care plan?

Answer 23

Using the S.M.A.R.T framework for example: James will have a bowel motion at least every second day for the next seven days

Question 24

What is an example of an intervention for laxative use?

Answer 24

To take all prescribed laxatives and use PRN laxatives if BNO after two days

Question 25

What would be a rationale for using laxatives?

Answer 25

E.g “Current use of prescirbed laxative regime is designed to promote peristalsis and soften stools to make bowel motions easier to pass”

Question 26

What are the principles of recovery?

Answer 26

Hope, journey, supportive environent, refining who they are, active/ongoing process, non-linear journey, learning, educating + managing internal/external stigma

Question 27

What is the rationale for therapeutic communication as an intervention for psychosis and schizophrenia?

Answer 27

How nurses communicate with people who experience psychosis and schizophrenia-type conditions plays a vitally important role in their recovery. People with positive relationships with their nurses and other carers are more likely to experience recovery outcome. Working together as a team and using statements like ‘we’ and ‘us’ will help inspire collaboration. A formal or ‘stiff’ approach has been shown to be negatively related to effectivenes

Question 28

What is a specific nursing intervention for: Weight gain, especially with clozapine, olanzapine and chlorpromazine

Answer 28

Stress the importance of activity and exercise and accompany the person, if possible, to overcome lethargy. Assess current dietary intake and suggest modifications if required. Be aware not to blame the person for the challenges in managing the effects of medication.

Question 29

What is a specific nursing intervention for: Parkinsonian effects: blank, mask-like expression, drooling, tremor, muscle rigidity, stiffness and shuffling gait

Answer 29

Reassure the person that these adverse reactions subside with time. Monitor for parkinsonian effects and administer anticholinergics as prescribed and prn. Be open with the person about the limited value of additional medication in managing some side effects

Question 29

What is a specific nursing intervention for: Akathisia, which may disturb both sleep and rest with the incessant urge to move the limb and to change position

Answer 29

Report this to the medicine prescriber, who might need to review the antipsychotic if adverse reactions cannot be tolerated. Anticholinergics might ameliorate adverse reactions.

Question 30

What is a specific nursing intervention for: Neuroleptic malignant syndrome, which is serious and life-threatening; usually develops quickly but could occur any time the person is taking a higher potency typical antipsychotic (e.g. haloperidol)

Answer 30

Cease antipsychotic immediately and refer to a medical practitioner. Nursing care consists of vigilance for the syndrome in those who are taking high-potency drugs such as haloperidol; hydration; monitoring; and reduction of body temperature. (This is a medical emergency that literature suggests has a mortality rate between 3% and 27%, with a lowering trend since the advent of atypical antipsychotic medications (Modi et al. 2016). Symptoms are hyperthermia, severe motor rigidity, disturbances in levels of consciousness, cardiovascular functioning, blood pressure, sweating, pyrexia, hypotension, tachycardia, stupor and muscular rigidity)

Question 31

What is a specific nursing intervention for: Tardive dyskinesia (TD; ‘late-occurring movement disorder’), a devastating, irreversible adverse reaction to long-term conventional antipsychotic medication (e.g. haloperidol) but less frequently atypical antipsychotics

Answer 31

Effects range in severity from mild to incapacitating and include: uncontrollable coarse tremor; spasm-like movements of the body, arms and legs; rolling of the tongue; and smacking of the lips. TD continues after cessation of antipsychotics and is often made worse by administering antiparkinsonian drugs such as benztropine. Refer involuntary movements to the medical practitioner to cease, lower or taper off the dose and assess.

Question 32

What is a specific nursing intervention for: Acute dystonic reaction (spasm) – muscle spasms in the trunk and neck (opisthotonos and torticollis); eyes can roll up uncontrollably (oculogyric crisis); life-threatening when muscles of the larynx spasm and occlude the airway

Answer 32

This is a medical emergency demanding swift nursing intervention. Acute dystonic reactions respond swiftly to intravenous, intramuscular or oral (route depends on the level of acuity) administration of antiparkinsonian drugs such as benztropine, followed by careful observation. In the case of laryngeal spasm, the person may require airway support and oxygen therapy until it resolves.