Exam 1 Flashcards
When can you apply restraints?
As a last resort if patient is a danger to others/self
How often do you check/reevaluate restraints
Q2h, check for circulation and comfort every 15 minutes
Do you have to have a doctors orders to apply restraints?
Yes, must have a rationale and interventions used prior to application. If an emergency apply restraints and obtain a written order ASAP.
What should a nurse consider before using restraints?
Verbally intervening, reducing stimulation/triggers, actively listening, providing diversion, offering PRN meds
What does the mental status examination include?
Appearance, behavior, cognition, speech, mood, harm self/others, perceptual disturbance, disordered thoughts
Appearance
Grooming and dress, level of hygiene, pupil dilation or constriction, facial expression, height, weight, nutritional status, relationship between appearance and age, clothes, hygiene, tattoos/scars
Behavior
Excessive or reduced body movements, peculiar body movements (scanning the environment, odd or repetitive gestures, LOC), abnormal movements (tardive dyskinesia, or tremors), level of eye contact (keep in mind cultural differences), anxious, guarded, sit still, anger
Tardive dyskinesia
Caused by long-term use of neuroleptic drugs. It causes repetitive involuntary stiff, jerky movements of your face and body that you can’t control
Cognition
Orientation (person, place, time), LOC (alert, confused, clouded, stuporous, unconscious, comatose), memory, fund of knowledge, insight, judgment
Immediate memory
Give the person a thing to remember then in a few minutes ask them to repeat those things
Recent memory
Remembering things that brought them to the hospital, knowing birthday and name, the nurse needs to ask questions that the nurse can validate
Remote memory
In dementia this is the last to go, patient seen to go back to their childhood
Ideas of harming self or others
Suicidal or homicidal history and current thoughts, presence of a plan, means to carry out the plan, opportunity to carry out a plan
Speech
Rate (slow, rapid, normal), volume (loud, soft, normal), disturbances (articulation problems, stuttering, slurring, mumbling)
Mood
Subjective data, ask the patient, Sad, labile, euphoric
Affect
Objective; what do we see
Flat, bland, animated, angry, withdrawn, appropriate to context
Perceptual disturbance types
Illusions, hallucinations, auditory, visual, tactile, olfactory, gustatory, command hallucinations
Illusions
Something is there but it’s being misperceived. It’s an environmental stimuli
Hallucinations
Are not really happening and not caused by the environment
Auditory
Hearing things
Visual
See things that are not there
Tactile and olfactory
Feeling things that are not there and smelling things that are not there
Gustatory
Taste random things
Command hallucinations
Voices in a patient’s head that tells them to do something such as hurt a specific person or hurt themselves because the voices told them to
Disordered thoughts
Thought process is how they are thinking and idea it makes sense (disorganized, coherent, flight of ideas neologisms, thought blocking, circumstantiality) Thought content is what the person is thinking about(delusions, obsessions) Word salad (random words in a sentence and the sentence does not connect or make sentences)
What do you rule out before assuming psychiatric
Physical medical diagnoses
Assessment data
Physical, psychosocial and mental status Presenting problem History of illness Family history Medical history Social history
Psychosis
Symptoms in which make it difficult for a person to distinguish what is real and not real
What kind of personality is schizophrenia?
A deteriorating personality
Blueler’s four A’s of schizophrenia
Affective disturbance
Autism
Associative looseness
Ambivalence (mixed emotions)
Schizophreniform
Same as schizophrenia except that duration of signs is less than 6 months and social functioning may not be impaired
Schizoaffective disorder
Signs meet criteria or schizophrenia but the person also has a depressed, manic, or mixed episode as well
What are the neurotransmitters involved with schizophrenia
Dopamine, glutamate, serotonin, and GABA
Dopamine
High levels of overactive dopamine glands associated with schizophrenia. Involved in fine muscle movement and in integration of emotions and thoughts, involved in decision making
Glutamate
Excitatory neurotransmitter that is elevated. Plays a role in learning and memory
Serotonin
A brain catecholamine that plays an important role in mood, sleep, sexuality, appetite and metabolism. Elevated levels cause altered perception, attention, mood, aggression, sexual drive, appetite, sleep, and mood behavior
GABA
Inhibitory Neurotransmitter than had reduced levels in schizophrenia. Plays a role in aggression, excitation, and anxiety. Has a role in pain perception and also may impair cognition and psychomotor functioning.
Positive signs
What the patient experiences. Hallucinations, delusions, associative looseness, circumstantiality (conversation is derailed by unnecessary and tedious details), agitation, bizarre behavior
Negative signs
Physical manifestations of patient
Uncommunicative, withdrawn, expresses feelings of rejection or aloneness, talks about self as bad or no good, feels guilty because of bad thoughts, anergia (lack of energy), anhedonia (people lost interest and pleasure that were usual happy events for them), loss of motivation, blunted affect, abolition (don’t have any goals), unable to initiate tasks
