Adult Nursing I - Exam #2

Inability to coordinate muscle activity during voluntary movements, resulting in shaky/tremor-like movements - lack of muscle coordination
loss of speech due to injury or illness
inability to perform purposeful movements or to use objects appropriately even when there is no impairment of motor functions
intimate space
0 to 1.5 feet from person, touching
personal space
The face-to-face distance people require to feel comfortable when talking with others
social space
4 to 12 feet - distances kept with strangers or acquaintances
public space
12 feet and beyond - speaking with someone in public
sharing the feelings of others (especially feelings of sorrow or anguish)
understanding and entering into another persons feelings
(psychoanalysis) the process whereby emotions are passed on or displaced from one person to another
the psychoanalyst's displacement of emotion onto the patient or more generally the psychoanalyst's emotional involvement in the therapeutic interaction
The act of filling in memory gaps by making up false memories
compounded rape reaction
Additional symptoms that go along with being raped such as depression, suicide, substance abuse, psychotic behavior
silent rape reaction
person is silent and tells no one about assualt
expressed rape reaction
expresses emotions such as crying, trembling, anger towards the rape
controlled rape reaction
emotions toward rape are controlled, client appears calm, feelings are masked, hidden
What type of emergency is suicide?
psychiatric emergency
Nursing priorities for suicide
watch the patient, 1 on 1 observation, maintain patient safety and safety of others
Psych nursing priorities
SAFETY first, then ABCs
Who is more likely to commit suicide?
older, middle aged men and teenagers. Men are more successful than women.
Who is more likely to be depressed?
single, divorced people. The very rich, the very poor
When does a person with severe alcoholism show signs of withdrawal?
within 4-12 hours after last drink. For example - person admitted to hospital at midnight would start to show signs around 4am
Blood alcohol level for intoxication?
100 mg/dL
How do you assess someone with alcohol withdrawal for tremors?
touch there arm - take their radial pulse to feel for fine tremors
Bipolar - mania considerations
provide high calorie finger foods throughout the day - mania leads to feeling of not being hungry and unable to sleep
MAOI considerations
Hypertensive crisis: avoid foods high in tyramine - aged cheese, pepperoni, wine, beer, liver, chocolate
Rittalin and Adderal considerations
medications are stimulants and appetite suppressors - children on these medications experience weight loss. Take medication early in the AM after a large breakfast (if taken before breakfast, child wont eat)
purpose of mini-mental exam
used to help distinguish between depression and dementia in the elderly
signs of child abuse
unexplained injuries, neglected appearance, child may be withdrawn or act out, child may flinch when sudden movements are made
signs of childhood incest in an adult
withdrawn, insomnia, unable to maintain healthy relationships with opposite sex, may be promiscuous, low self-esteem, lack of trust
what is transgenderism?
person identifies with the opposite sex, wants to become opposite sex
what is transvestic fetish?
enjoy dressing as the opposite sex - wearing lingerie, women's underwear, bras
When do we develop human sexuality?
from birth to 12 years old
Compulsion to achieve sexual arousal by touching or rubbing against a nonconsenting person in public situations
painful spasm of the vagina from contraction of its surrounding muscles - prevents penetration of penis into the vagina - common symptom in person who has experienced sexual abuse
painful intercourse
sexual pleasure through inflicting pain on others
sexual pleasure through receiving pain
Histrionic personality disorder
personality disorder - need to be center of attention, overly dramatic
Narcissistic personality disorder
characterized by a grandiose sense of self-importance, grandiose sense of power. Ex - Gaston from Beauty and the Beast. Kirk Branigan from Futurama
schizoid personality disorder
person is withdrawn, aloof, lacks emotional response
schizotypal personality disorder
personality disorder involving a pervasive pattern of interpersonal deficits featuring acute discomfort with, and reduced capacity for, close relationships, as well as cognitive or perceptual distortions and eccentricities of behavior.
use of nonhuman objects to achieve sexual arousal, sex with on-consenting adults, inflicting suffering or humiliation
Therapeutic nurse-client relationship
occurs when each individual views the other as being a unique human being, both have needs met by the relationship
phases of the therapeutic nurse-client relationship
pre-interaction phase, orientation (trusting) working phase, termination phase
Pre-interaction phase
obtain information about the patient from chart, others. Examine own fears about working with the client
Orientation (introductory) phase
creating an environment of trust and support, identify client's strengths and weaknesses, build rapport
Working phase
use problem solving model to work toward achieving goals, evaluate progress toward goal achievement, maintain trust and rapport - transference and countertransference occur during this phase
Termination phase
conclusion of relationship, plan of action developed for dealing with future situations established
Therapeutic use of self
The ability to use one's personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions
Six steps of the nursing process
assess, diagnose, outcomes, plan, interventions, evaluate
effective communication - restating
restating what the patient just said to make sure statement was understood
directs question back to patient to identify how they feel
non-therapeutic communication techniques
reassurance, rejecting, approving or disapproving, giving advice, defending, requesting an explanation, stereotyping
Active listening - SOLER
Sit quietly facing the client, Open body posture, Lean toward client, Eye contact, Relax
nurse care management
negotiates with several health care providers to obtain services for the client
Critical pathway of care (CPCs)
standard plans of care to achieve specific outcome, times, used by interdisciplinary team. Ex - PUP, prevention of DVTs
flushed face, clenched fists, speak in a low tone, yelling and shouting - may be part of the grieving process
verbal/physical threats, threats of homicide or suicide, disturbed thought process - intent!
Nursing priorities when dealing with anger/aggression management
maintain safety of others and self, be aware of past history of violence, diffuse person as anger, don't allow to escalate to aggression
prodromal syndrome
Behaviors: rigid posture, clenched fists and jaw, grim defiant affect, talking in a rapid raised voice, arguing and demanding, using profanity and threatening verbalization, agitation and pacing, pounding and slamming
acute, rapid change in cognitive function/consciousness. Impairment in memory, disoriented to time and place, hallucinations. Fight or flight responses with vital signs. Can be the result of fever, medications, infections, electrolyte imbalances
slow, progressive decline in cognitive function, personality change is common, impaired judgment and impulse control, loss of inhibition, , apraxia, aphasia, moodiness with sudden outbursts, incontinence
Primary Dementia
the result of organic brain disease. ex- Alzheimer's
Secondary dementia
occurs as a result of trauma, head injury, CVS
Causes of dementia
Alzheimer's, lewy's disease, Huntington's, HIV, alcohol withdrawal (lack of thiamine), MS, CJD,
loss of short term memory, unable to learn new information, confabulation (making up false stories to fill in memory gaps). Short term amnesia can be caused by ECT
wernicke's encephalopathy
severe thiamine deficiency
korsakoff's psychosis
confusion, loss of memory in alcoholics
withdrawal for short acting opioid (ex - heroin)
symptoms occur 6-12 hours after drug, last 5-7 days
withdrawal for long-acting opioid (ex - methadone)
symptoms occur 1-3 days after drug, last 10-14 days
withdrawal symptoms for short acting drugs (ex - demerol)
8-12 hours, last 4-5 days
Cluster A personality disorders
odd, eccentric behaviors - paranoid, schizoid, schizotypal
Cluster B personality disorders
dramatic, emotional, erratic - antisocial, borderline, histrionic, narcissistic
Cluster C personality disorders
anxious, fearful - OCD, avoidant, dependent
Severe depression
can't get out of bed - feel worse at the start of the day and gets better as the day progresses
Moderate depression
feel best at the start of the day, get worse as the day progresses
Dysthymic disorder
symptoms persist for two years or more with depressive symptoms not necessarily occurring every single day (but more so than not). No more than two symptom free months.
Major depressive disorder
disorder causing periodic disturbances in mood that affect concentration, sleep, activity, appetite, and social behavior, characterized by feelings of worthlessness, fatigue, and loss of interest that persist for 2 or more weeks
mild depression
part of the grieving process, anxiety, tearful, inability to concentrate but can still function
What are the 4 phases in the Cycle of Battering / Abuse?
Phase I - tension building phase, Phase II - battering incident, Phase III - honeymoon phase - calm, loving period
side effects of antipsychotics
EPS side effects, tremors, dry mouth, constipation, increased appetite and weight gain, ECG changes, hyperglycemia and diabetes
side effects of SSRIs
insomnia, headaches, agitation, weight loss, serotonin syndrome
examples of antipsychotics
risperidone, haldol, thorazine, clozapine
examples of anticonvulsants
dilantin (phenytoin), valproic acid
examples of ADHD medications
clonidine (catapress), Ritalin, adderal