FINAL Flashcards
spirituality
- arises out each person’s unique life experiences
- his/her effort to find meaning and purpose
religion
- particular system of worship and faith
- organized system of beliefs and practice
- system of organized worship ascribing to a set of doctrines which the person practices
- only one way an individual may express their spirituality
global health
- examine global health issues
- develop solutions
- implement change both local and global level
-understand health equity and social justice concepts, in order to respond to pressing health and social challenges experienced by diverse populations worldwide
culture
“commonly understood as learned traditions and unconscious rules of engagement that people used to interpret experience to general social behaviour”
- shared pattern of learned values and behaviours
- transmitted overtime and distinguished the members of one group from another
- culture can include language, ethnicity, spiritual and religious beliefs, socioeconomic class, gender, sexual orientation, age, group history, geographic origin, and education, childhood, and life experiences
cultural group examples
- homeless
- aging families
- LBGTQ+ community
- students
- people with mental illness
- nurses
ethnicity
- refers to groups whose member share a social and cultural heritage
- sense of common identity
- share common values, language, history, physical characteristics, geographical space
- important: sense of common identity
- ex: irish, japanese, filipino
race
- common biological attributes shared by a group
- i.e. skin colour
cultural diversity
- first country to develop a multiculturalism policy (1971)
cultural safety
an outcome of nursing education that enables safe service to be defined by those who receive the service
6 Core concepts & principles
SELF-REFLECTIVE PRACTICE (IT STARTS WITH ME)
BUILDING KNOWLEDGE THROUGH EDUCATION
ANTI-RACIST PRACTICE (TAKING ACTION)
CREATING SAFE HEALTH CARE EXPERIENCES
PERSON-LED CARE (RELATIONAL CARE)
STRENGTHS-BASED AND TRAUMA-INFORMED PRACTICE (LOOKING BELOW
THE SURFACE)
Culturally Sensitive Care
- Being culturally knowledgeable
- Being client centered
- Being self reflective
- Recognizing conflict of client/ nurse values
- Facilitating client choice
- Incorporating client’s cultural preferences
- Accommodating client’s beliefs & practices
Conveying Cultural Sensitivity
- Address by last name (unless permission given)
- Introduce yourself, explain your role
- Use appropriate eye contact
- Be genuine and honest (about lack of knowledge)
- Respectful language (based on client’s preference and/ or acceptable norms)
- Do not make assumptions
- Respect the client’s values, beliefs and practices
- Show respect for client’s supports/ family
sociocultural theory
- interaction between people, social structure, relationships, and the “culture” in which they live, work and play
- human learning is a social process
- lev vysotsy: argued learning is based in interacting with other people, info integrated on the individual level
sociocultural assessment
PNUR VARIABLE ASSESSMENT GUIDE:
- Language and Communication Patterns: Verbal/ Nonverbal
- Cultural Roles and Expectations
- Social History: Family, Education and Work/ Finances
- Relationships/ Significant Others
- Health Beliefs, Habits and Practices
- Ethnicity and Race
social identity
Socio-demographic characteristics such as age, gender, group members (minority) and roles important to that person. Also viewed as self-concept, and includes:
- Social Status (age, sex, family status, occupation)
- Membership in groups (cultural, membership)
- Social labels (i.e. mentally ill, unemployed)
- Derived statuses (war veteran, recovering alcoholic)
- Social types (perceptions, attitudes as self defined).
- Personality identity (nickname, preferred name, title)
ecomap
- visual assessment; relationships, communities, work, education
- symbols used to express energy that flow from a person or family to other important people and elements of their environment (schools, church, etc)
genogram
is a concise visual depiction of the family structure and
relevant situational information used in nursing assessments
faith
- belief in something even when there is no evidence or proof
- can involve the belief in a God or doctrines of a religion
spiritual health
a feeling of generally alive, purposeful, and fulfilled
Assessing Spirituality Using the PNUR Variable Assessment Guide
- purpose/meaning
- interconnectedness
- faith
- religion
- forgiveness
- creativity
- transcendence
purpose and meaning
meaning: individual client when a search for insight and expression of underlying feelings regarding one’s philosophy of life, values, and beliefs about health and health challenges
- When an individual experiences an altered state of health, finding meaning within the experience may be difficult.
interconnectedness
- defined as an individual’s sense of love, belonging, and connection to self, others, a higher power, nature and the cosmos
faith
- belief in the unseen/unknown
- firm belief in ability to draw on spiritual resources with certainty despite any evidence or proof
forgiveness
- may not have meaning to all client groups
- clients will describe situations where either they cannot forgive themselves, others can’t forgive them, or they can’t others
- explore with client their ability to forgive others
- their openness to accept forgiveness from others as a starting point of “letting go” of past feeling of being hurt, angry, resentful, betrayed and/or devasted
creativity
activity producing a sense of peace, comfort, and soulfulness for the individual
transcendence
- process/experience beyond the usual sensory phenomena
- associated with classical mystic experiences of God
- not reserved for religious experience alone
- may be related to aesthetic reactions to art and music or the response to the majesty of creation (regarding a feeling of wonder or awe)
spiritual distress
disturbance in the person’s core value system, which provides strength, hope and meaning to life
how to support religious or spiritual practices
- holy days
- sacred writings
- spiritual symbols
- prayer/meditation
- beliefs:
diet nutrition
dress
birth & death
medical procedures
developmental variable
- growth
- development
- lifespan
- expected life events
- unexpected life events
- transition
adolescence
12-18 y/o
young adult
19-39 y/o
middle adult
40-64 y/o
older adult
65 y/o +
12-19 y/o normal development
- Physical changes: increase in bone & muscle growth
- hormone fluctuations = development of sex characteristics: puberty
- massive brain growth, pruning, poor impulse control
- self identity
- gender identity, peer relationships, sexuality, independence from family unit
- health risk
- MVA, violence, suicide, substance abuse, eating disorders, STIs, depression
20-39 y/o normal development
- careers
- marriage
- raising children
- physical changes: physcial growth is completed to 20 y/o, active (@ physical peak), avoid seeking help due to illness
- psychological changes: choosing occupation, pursing education, intimate, mature relationships, financial independence, parenthood, body image issues
- health risks: lifestyle habits, accidents, substance abuse, fertility issues, stress, pregnancy, mental illness
40-64 y/o normal development
- sandwich generation
- financial responsibilities
- balancing career & family against aging process
- physical: major physical: grey hair, wrinkles, metabolic change, decrease in hearing and vision, hormone fluctuations for both M/W (menopause)
- psychosocial: assisting children as they leave the nest, dealing with separation/divorce or death of a loved one
health risk: stress, anxiety, depression, obesity, long-term effects of poor lifestyle choices
65 y/o + normal development
- physical: Normal physiological changes in most body systems eg. Decreased muscle mass,
degenerative joint changes, lower cardiac output, decreased elasticity, etc. - psychosocial: Retirement, transitions & role change, social isolation (loss d/t death of friends,
loved ones), Maintaining sexual identity - health risks: Cancer, heart disease, delirium, dementia, arthritis, falls
Erikson’s Eight Stages of Social and Emotional Development
- Erikson believed personality develops in a series of stages.
- In each stage, each person needs to accomplish a particular task (challenge) in order to move onto the next stage
- Each stage builds upon the successful resolution of the previous developmental challenge
- According to Erikson’s theory, unsuccessful resolution of one stage will result in the chronic inability to master these tasks
Erikson’s Stages of Psychosocial Development: identity vs. role confusion
- adolescence (teens into 20’s)
- teenage work at refining a sense of self by testing roles and then integrating them to form a single identity, or they become confused about who they are
Erikson’s Stages of Psychosocial Development: intimacy vs. isolated
- young adult (20s-early 40s
- young adults struggle to form close- relationships and to grain the capacity for intimate love, or they feel socially isolated
Erikson’s Stages of Psychosocial Development: generativity vs. stagnation
- middle adult ( 40s-60s)
- middle-aged discover a sense of contributing to the world, usually through family and work, or they maybe feel a lack of purpose
Erikson’s Stages of Psychosocial Development: integrity vs despair
- late adults (late 60s+)
- when reflecting on his or her life, the older adult may feel a sense of satisfaction or failure
EE stage of adolescence 12-18 y/o
crisis is identity vs. role confusion
EE stage of young adulthood
Crisis is Intimacy vs. Isolation
EE stage of middle adulthood
Crisis is Generativity
vs. Stagnation
EE stage of late adulthood
Crisis is Integrity vs.
Despair
MAR
Medical administration record
what is documentation
- any written or electronically generated information about client that describes the care or service provided to that client
- nursing action, produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health record
purposes of documentation
- communication
- safe and appropriate nursing care
- professional and legal standards
BCCNM Professional standards (doc)
standard 2: competent, evidence-informed practice
- doc the application of the clinical decision-making process in a responsible, accountable and ethical manner
- applies documentation principle to ensure effective written/electronic communication
legal issues
- client’s record is permanent/legal document
- be used to provide evidence in court/coroner’s
- nurse must clearly document all nursing care given: care decision was based on assessment, and the nurse will continue to monitor, document, and report patient responses
- in court care not documented is not given
- freedom of information and protection of privacy act (FOIPPA)
Ethical issues
8: protects the confidentiality of all information gathered in the content of the professional relatoinship
#9: practices within relevant legislation that governs privacy, access, use
keeping records confidential
- computer passwords
-mindful of screens and papers - aware of agency policies: documenting sensitive info
- all written documentation is secured
RPN safeguard privacy, security, and confidentiality health records
documentation principles
- document care you personally provided
- only use agency-approved abbreviations
- never use pencil, black ink only
- document ASAP, chronological order, never prior
- follow proper protocol for errors, no erasing or white out
- document clear, concise, factual, objective, timely, and legible
- do not leave any blank spaces or lines
- add signature
what is a students initials for charting
DCPsycN
common doc forms
- initial assessment/admission forms
- nursing care plan
- flow sheets
- nursing notes
- interdisciplinary notes/history
- kardex
- incident reports (not part of the health record)
what is kardex
- purpose: make information readily available
- continuously updated (pencil)- not legal document
- content:
pertinent information/demographics
daily treatments-dressings
Dx procedures ie blood work
allergies
specific data: diet, assistance with transfer, walking aids, safety
Dx/goals
MH: status- certified, privileges, passes, clothes, pjs, obs level
breif shift summary
what do we chart
- status and health concern (assessment data)
- changes in MH status (MSE)
- nursing care/interventions
- completeness: reflect nursing process
- appropriateness: significant to assessment and care
- advocacy by nurse on behalf of client
- chart client responses and evaluate the effectiveness of the care provided
- effectiveness of medications and prn medications
types of charting/nurses notes
narrative: written chronologically in paragraph form in progress notes
problem-oritented/charting by exception: DARP/SOAP(IE)R- focuses on documenting only deviations from the norm, narrative format; often seen with checklist flowsheets
source oriented medical records: each discipline writes in a separate section of the chart (Dr’s , physio, dietician)
What is DARP
D: data eg: what is the pain? headache 9/10, LOTTARP
A: action eg: @ 11:10 650 mg
R: response eg: how did the pt respond? does the pt still have a headache
P: plan eg: what is next? follow up with pt
SOAP(IE)R
S: subjective (how does client feel)
O: objective (vital signs)
A: assessment (what is the clients status)
P: plan (does plan stay. the same or change)
I: Intervention (what occurred/what did nurse do)
E: evaluation (what is the clients outcome)
R: revision (what changes are needed)
only deviations
problems focussed
documenting tips
- familiarize style/type of docs used at the agency
- read documentation already contained
- balance relative details
- be objective state facts
- use patient’s words
- use current diagnosis
LATE ENTRIES: - follow agency policy
- write “late entry” after last recorded note
verbal reports
- concise and accurate
- state name and relationship to client
- state medical diagnosis, changes in nursing assessment, vital signs related to baseline, siginpificantly laboratory data, related nursing interventions
- have chart ready
- what does the staff ned to know
incident reports
purpose: document unusual unanticipated occurrences a risk management tool. Internal quality control only – standalone report/not in patient’s chart eg. medication errors, falls
-Identification of the client by name, initials, and hospital or identification number
- Date, time, and place of the incident
- Description of the facts of the incident (no conclusions or blame)
- Incorporation of the client’s account of the incident in quotes
- Identification of all witnesses
- Identification of any equipment by number and any medication by name and dosage
common errors to avoid (documenting)
- not dating, timing, and signing entries correctly
- illegible handwriting
- forgetting to chart important health info: allergies, medications given
- leaving blank lines in progress notes or blank spaces on forms
- using subjective language
- entering information into the wrong chart
- using inappropriate abbreviations
4 basic elements of normal movement/mobility
- body alignment (posture)
- joint mobility (ROM)
- balance
- coordination
range of motion
- max movement possible for joint
- varies:
age
health and overall activity level
genetics
general health status (baseline health) - active or passive
active ROM
- done first
- less intrusive
- uses patients own strength to create the movements through the joints
- ask patients to slowly move each joint through it’s full ROM (flexion/extension)
- tell pt to stop the movement and tell you if they experience any pain
passive ROM
- more intrusive
- manipulate the person’s joints for them
- tell the patient to relax and then support the joint and move it through it’s range of motion
- observe and compare each side of the body for symmetry, pain, inflammation, or stiffness
factors that impair mobility
- congenital or acquired postural abnormalities eg scoliosis
- damage to the CNS as it regulates voluntary movement
- impaired muscle development eg MS
- Direct trauma to the musculoskeletal system eg. fracture
- Inflammatory diseases eg. Rheumatoid Arthritis
- Bed rest or reduced activity tolerance
- Pain
- Medications
Rheumatoid Arthritis
- chronic (exacerbated/remission) inflammatory disease primarily impacts SYNOVIAL MEMBRANE but may impact other systems/organs (lungs/pericardium)
- both systemic/local effects eg inflamed knee
- cause: unknown (autoimmune disease, genetic/hereditary factors, infections) exacerbated by stress
- symptoms/assessment: inflammation
objective: heat, redness, swelling over joint, tenderness
subjective: pain, fatigue, report flare ups, morning joint stiffness
osteoarthritis
- degeneration of the joint that causes localized pain. deterioration of CARTILAGE in the joints = inflammation
- most common chronic condition of the joints
- risk factors: older than 65, increasing age, obesity, previous joint injury, overuse of the joint, weak thigh muscles, genes
symptoms: pain that worsens with activity, joint stiffness and loss of function, decreased ROM
signs: limited joint motion, crepitation
health promotion: encourage weight bearing exercies, increase Vit D and Ca intake; teach and encourage ROM exercises
osteoporosis (brittle bones)
- decreased density of bones and deterioration of bone tissue, leading to bone fragility, and increased risk for fractures
- bone mass is lost faster than it can be replaces
- common in hips, wrists, and spine
risk factors: gender (female), 65+, post-menopausal ( early menopause), ethnicity (caucasion/asian), history of fractures (from minor falls/injuries), family history, bone structure, body weight-thin, “small boned”, smoking, alcohol abuse
health promotion/prevention: diet, exercise, fall prevention
Immobility
- can lead to disuse osteoporosis
- muscle atrophy & deconditioning
- contractures
- stiffness and pain in the joints
- cardiovascular changes eg orthostatic hypotension
- metabolic changes eg loss of calcium, constipation
- respiratory complications eg atelectasis, pneumonia
- urinary changes eg increased risk for urinary stasis or renal calculi
- poor hygiene r/t immobility can lead to skin breakdown, and sustained pressure on joints can lead to pressure ulcers
hair assessment
- uniformity/thickness
- colour
- amount of hair (alopecia)
- body hair (lanugo)
- texture (oily/dry)
- scalp is free of lesions
- parasites (lice)
nail assessment
- texture: smooth, thick, thin
- colour: capillary refill, cyanosis
- cleanliness
- length eg: nail biting
- shape
- curvature
documenting and assessing wound (describing)
- type eg pressure ulcer
- size, shape and texture
- colour
- location/distribution
- surrounding skin
- elevation
- exudate/discharge
- odour
- measure height, width, and depth
bed sores
- pressure ulcer
- aka decubitus ulcer
4 stages of pressure sore (check slide 17: physiological-Integumen:musculo:mobil)
- epidermis
- dermis
- Subcutaneous fat
- bone
skin assessment (objective-inspection)
- colour: pallor (pale), erythema (red), cyanosis (blue), jaundice (yellow)
- redness, open wounds, lesions
- edema
- bruising, moles
- tattoos, marking eg birthmark
- rash, scratches/itchiness (itch is technically subjective)
- mucous membranes: pink, moist, intact
Skin assessment (objective- palpation)
- temperature-: use your hand and feel skin = indicates circulation/infection
- moisture: look for dryness, flaking; dehydration, eczema
- turgor: hydration status, age
- edema: swelling, fluid retention in tissues
- texture/thickness: smooth, rough, thin, uniform
client centered goals
- can be short or long term
- must be singular, observable, measurable, time-limited, mutual, and realistic
universal experience in the PNUR conceptual framework
- CRISIS* (Stress, Anxiety)
- COMFORT* (pain)
- HOPE* (hopelessness) LOSS (grief)
- POWER* (powerlessness)
- RESILIENCY* (coping, strengths)
- INTEGRITY (death, dying, acceptance)
what is stress
- stimulus, process, response, and a state
- stressors = stimuli
- stress = response or reaction TO stressors
- subjective
- internal and external causes
- response to demands that exceeds one’s ability to cope
- occurs on a continuum with anxiety and crisis
stress response
- physiological component
- cognitive component
- emotional component
physiological response:
- fight or flight
- general adaptation syndrome (selye)
Physiological response: general adaptation syndrome (selye)
- stage 1: alarm reaction
- stage 2: resistance stage
- stage 3: exhaustion stage
cognitive component
- considers the appraisal of stressors and how they influence the stress response
- cognitive appraisal theory (lazarus & folkman)
- cognitive triangle
Cognitive appraisal theory (lazarus & folkman)
- person is under stress only if they perceive themselves to be
- PRIMARY appraisal: what does this situation mean to me?
- SECONDARY appraisal: can i cope with it?
cognitive triangle (emotional component)
- triangle of: emotions, thoughts, and behavior
Anxiety
- apprehension or dread in response to internal or external stimuli that can be experienced in physical, emotional, cognitive, and or behavioural ways
- range: mild-severe/panic level
- BUT: is it normal? dangerous? adapative?
MILD anxiety
- Slight arousal that enhances perception, learning and productivity.
MODERATE anxiety
- Increased arousal with tension, nervousness and perception is narrowed.
SEVERE/PANIC (anxiety)
- It is consuming, poor focus, very uncomfortable and requires intervention.
- overpowering and frightening.
adaptive coping
- Strategies that minimize/reduce or eliminate the stress response.
- Strategies can be short- term/immediate, or longer term adaptations.
maladaptive coping
- May temporarily be “effective”, but cause longer term negative consequences and results in worsening distress.
- Defense mechanisms- denial, projection, regression etc.
comfort and the role of the RPN
- COMFORT IS CLOSELY RELATED TO CARING
- IT IS AN ESSENTIAL PART OF OUR ROLE AS RPN’S
- MAY INVOLVE CONSOLATION, SUPPORT OR ASSISTANCE TO PROMOTE WELL-BEING.
- DON’T CONFUSE IT WITH PITY!
- WHEN WE AREN’T SURE HOW TO COMFORT SOMEONE- ASK THEM!
hope
Hope is the anticipation of a continued good or of an improvement in, or lessening of something unpleasant
power
- The perception & process of gaining or maintaining control or influence over aspects on one’s environment.
- A client receiving mental health treatment can at times feel powerless.
- We must recognize & minimize the power differential inherent in our therapeutic relationships and our practices as RPN’s.
- The goal is to empower our clients by mobilizing their strengths.
types of crises
- DEVELOPMENTAL: retirement, empty nest, puberty
- SITUATIONAL:
- Illness
- Death of a loved one
- Separation or divorce
- Loss of job
- Moving
- Traumatic experience
- Unplanned pregnancy
crisis intervention: trying to restore the balance
- early intervention
- stabilization
- Facilitate Understanding
- problem solving
- encourage self reliance
role of RPN (crisis)
- Establish a therapeutic relationship
- Gather relevant data
- Bear witness to their pain
- Validate their feelings
- Provide education
- Teach new coping skills
- Offer hope – “I believe you will get through this”
concept of loss
-grief
- actual loss
- perceived loss
- bereavment
grief
The emotional response (subjective) to the perception of loss
actual loss
A loss of a person or object that can no longer be felt, heard, known or experienced
perceived loss
A loss that can’t be seen by others
bereavement
The response to the loss or death of a loved one
symptoms of grief
- Feel physically drained
- Can’t sleep
- Forgetful, can’t think clearly
- Appetite changes
- Physical symptoms: chest pains, headaches
- Poor concentration
- Senses or dreams about the deceased
- Guilt
- Tearfulness
- Sadness that comes in waves
factors that impact grieving
- Personality and temperament before the loss (external vs. internal locus of control)
- The degree of attachment with the person who died
-Culture & religious background
-Nature of the loss eg. sudden or traumatic - Presence of pre existing mental illness & coping skills
- The amount of support they have
- The number or previous losses person as experienced (grief is cumulative)
- The bereaved person feels responsible in some way for the loss
Normal Grief
- Self esteem intact
- Good days and bad days
- Maintains feelings of hope
- Able to experience pleasure
- Accepts comfort from others
- Physical symptoms are transient
Clinical Depression
- Self esteem is disturbed
- Feels persistent dysphoria
- Feelings of hopelessness
- Anhedonia is prevalent
- Does not respond to support from others
- Expresses chronic physical complaints
complicated grief
- stuck in the grieving process
- unhealthy mourning following a death
- lasts at least 6 months
- Pt doesn’t progress through the stages of grief
- Preoccupation with the deceased or death
- Recurrent intrusive images
- Avoidance of painful reminders of death
- Grief response continues to impact daily living
- Seek to isolate or avoid support systems
- Extreme feelings of guilt/ worthlessness
- Meet criteria for Major Depression
anticipatory grief
the emotional experience of the normal grief response before the loss actually occurs
role of RPN (grief)
- Assess the client’s stage in the grief process (gather an accurate baseline)
- Develop trust. Show empathy and unconditional positive regard.
- Provide ongoing support (friends, support groups…)
- Help client actualize the loss by talking about it. (reviewing events of the loss helps increase awareness)
- Help client identify and express feelings (repressed feelings of guilt/ anger can stall grieving)
- Understand and explain the normal grief process
- Be present and bear witness to their pain
- Identify maladaptive coping strategies (avoidance of pain can stall grieving)
concept of integrity
- latin word “integer” = whole and complete
- The quality of having an inner sense of ‘wholeness’ and consistency of character.
- You demonstrate a consistency in your values, beliefs and actions in all areas of your life.
- Satisfaction of attaining own life goals.
- Integrity contributes to trust and authenticity.
- Maintaining patient’s sense integrity is a key role of the nurse e.g. dying patient, grieving patient
medication administration
- preparing, giving, and evaluating the effectiveness of prescription and non-prescription drugs
role of RPN (med admin)
- knowledge about practice standards (BCCNM)
- education on drug being administering: what it does, works, normal dosages, why was it ordered?
- what could go wrong once you give it: side effects and contradictions for use
- any barriers to medication compliance: aware of why people may want to discontinue their meds
- nursing process: assessment of patient, create nursing diagnosis, planning (set client centered goals), perform interventions, evaluate if goals were met or not
BCCNM med admin
RPNS:
- responsible for admin. meds. within their scope
- knowledgeable about the effects, side effects and interactions of medications and take action as necessary.
- adhere to the “7 rights” of medication administration.
- administer only medications they themselves or a pharmacist have prepared, except in an emergency.
- do not pre-pour medication because it increases the likelihood of errors.
- take appropriate steps to resolve and report any medication administration error or near miss in a timely manner.
7 rights of med admin
- right medication
- right patient
- right dose
- right route
- right reason
- right time
- right documentation
what’re the additional rights (10 rights of med admin)
- right to refuse
- right patient education
- right evaluation
Pharmacology
study or science of drugs
- RPNs need to know about pharmacological principles so they can understand how each drug given will affect the patient (both beneficial and adverse effects)
drug names
- one medication can be known by up to 3 different names
- generic name
- trade name
- chemical name
generic name
- name given to the drug by the developer of the medication
- becomes the official name
- used in all formal publications
- eg acetaminophen, ibuprofen, dimenhydrinate
trade name
- aka brand name
- commercial name given to drug by manufacture
- vary in other countries
- eg tylenol, advil, gravol
chemical name
- describes the medications molecular structure
- eg N-acetyl-para-aminophenol is acetaminophen (generic name) or Tylenol (brand name)
drug classification
- the desired effect on the body system
- tells what type of drug it is
eg antipsychotic, antihypertensive
medication forms
- form of the med indicated the route of administration
- nurse must ensure they use the correct form of medication as this affects absorption and metabolization
eg tablet, ointment, suppository
eg Tylenol comes in many different forms such as tablets, capsules, liquid and suppositories.
Pharmacodynamics
study of what the drug does to the body
therapeutic effect
intended or expected effect on the body
eg tylenol will relieve a headache
side effect
unintended a secondary effects
eg morphine may cause a rash
adverse effect
serious, negative effects
eg gravol may cause hallucinations (rare)
toxic effect
a build up or accumulation of medication in the body - to the point it is poisonous
eg Lithium is used to treat bipolar disorder and major depressive disorder. Blood levels must be monitored several times a year to ensure chronic toxicity does not occur (this may happen over time if daily dose is just a little too high). Acute toxicity may occur if, for example, double doses are taken in error or on purpose.
contraindication
any characteristic of the patient
- disease state
- other medication
- pregnancy
= makes the use of the medication dangerous for them
pharmaceutics
-various medication forms/routes influence the way in which the body metabolizes a drug and the way in which the drug effects the body
eg
-Oral
- Sub-lingual
- Subcutaneously
- IM
- IV
- Transdermal
- Inhalation
- Topical
pharmacokinetics
how medication moves into, through and out of the body
- absorption, distribution, metabolism, and excretion
absorption (pharmacokinetics)
movement of the drug from the site of administration to the bloodstream
distribution (pharmacokinetics)
transport of drug in the body by the bloodstream to it’s site of action
metabolism (pharmacokinetics)
biological transformation or metabolic breakdown of a drug in the body
- liver
excretion (pharmacokinetics)
elimination of drugs from the body
- The kidneys are the primary way that drugs are eliminated from the body; to a lesser extent the bowel and liver are also responsible for elimination
parenteral
- IV
- IM
- subcutaneous
inhalation
- nebulizers
- nasal sprays
transmucosal
sublingual
gastroenteral
- PO
- suppositories
transdermal/topical
- patches
- creams
- ointments
onset action
- time it takes for the drug to elicit a therapeutic response
peak effect
- time needed for a drug to reach it’s meximum therapeutic response
duration of action
- length of time that the concentration is sufficient to elicit a therapeutic response (time it lasts before it wears off)
half- life
the time it takes for one half of the drug in the body to be eliminated from the body
drug schedule: schedule 1
needs prescription in order to sell
eg amoxicillin, sertaline
drug schedule: schedule 1A
Abuse potential drugs, require a triplicate/duplicate prescription in order to sell (MD keeps a copy, pharmacist a copy – to prevent forgeries and for prescription tracking purposes)
e.g. Tylenol # 3 (has 30 mg of codeine), fentanyl
drug schedule: schedule II
no prescription required but pharmacist supervises the sale (medications are kept behind the counter)
e.g. Tylenol # 1 - 8 mg of codeine, cough syrup with codeine
drug schedule: schedule III
Drugs that can be sold without a prescription by a pharmacist (medications are locked in grocery stores after pharmacy closes. If no pharmacist on duty, cannot sell the medications)
-e.g. hydrocortisone topical cream, Pepcid AC
drug schedule: schedule IV
prescription by pharmacist
drug schedule: unscheduled
no restriction on sale of this drug
e.g. Tylenol, Tums – available at 7/11, etc.
OTC medications SHOULD know
NSAIDS (Non-steroidal anti-inflammatory drugs)
ASA (Aspirin)
Advil (Ibuprofen)
Non-opioid Analgesics
Acetaminophen (Tylenol)
Anti-emetics
Dimenhydrinate (Gravol)
Antihistamines
Diphenhydramine (Benadryl)
natural health products (OTC)
Complementary medicines or traditional remedies based on premise that plants contain natural substances that can promote and alleviate illness. E.g. Marijuana, St. John’s Wort, Melatonin
advantages of natural health products
Adjunct therapy to support conventional pharmaceutical therapies.
disadvantages of natural health products
Drug-drug interactions
E.g. Evening primrose interferes with antipsychotic drugs
Allergic reactions
Adverse side effects
People believe they are safe due to “Natural” label
OTC nursing process (assessment)
Gather a comprehensive medication profile including:
- All medications your patient takes on a regular basis
- History of allergies
- Use of OTC and Natural Health Products
- Intake of alcohol, tobacco, caffeine
- Illicit drug use
- Past/ present health/ medication history
- Family history
- Client’s beliefs about their medications and their effectiveness
OTC nursing process (diagnosis)
- Developed from the assessment data through critical thought, analysis, creativity and accurate data collection.
- Nursing diagnoses related to medication therapy may include:
- Variance in Knowledge Base (knowledge deficit)
- Variance in Protection (risk of injury from over-medicating)
- Variance in Health Beliefs (non-adherence)
OTC nursing process (planning: goals & intervention)
- Goals are patient focused
- They include a time frame
- GOAL: Patient will take medication as prescribed on a daily basis, starting immediately.
OTC nursing process: intervention
- Interventions are based on evidenced based practice
- Interventions are done as independent nursing functions or as collaborative interdisciplinary care
- Nurse to discuss with patient the risks of not taking meds as prescribed
- Have pharmacist discuss side effect profile with patient and how to manage each side effect (this is often done by the nurse)
- Provide education on long term consequences of stopping medications abruptly
OTC nursing process: evaluation
- Includes monitoring whether or not the patient goal has been met or not
- Includes observing for therapeutic effects and adverse effects/toxicity of a medication
- If the goal is not met then nursing care plan will need to be revised
what is MSE
- A structured approach to assessing psychological, emotional, social and neurological functioning
– “An attempt to objectively describe the behaviours, thoughts, feelings, and perceptions of the patient throughout the course of the interview itself”
– Provides an overall picture of current mental health.
– Clinical knowledge, judgment, interpretation & communication skills are required to do it well.
– Uses a combination of observation (objective data) and questioning (subjective data).
how is MSE done
- during interview
- assess cognition
- Sensitive questions should be asked after more general, less sensitive topics are addressed & some rapport is established.
components of an MSE
1) Appearance and Behaviour
2) Mood and Affect
3) Speech
4) Thought Form/Process
5) Thought Content
6) Perception
7) Cognition
8) Insight and Judgment
9) Risk Assessment
MSE appearance (objective)
- Sex
– Apparent age (vs. chronological)
– Height/weight
– Ethnicity/race
– Grooming, hygiene
– Distinguishing features
– Eye colour, hair colour, length
MSE behaviour (objective)
– Psychomotor retardation or agitation
– Hyperactivity, restlessness, repetitive movements
– Eye contact (prolonged, intense, minimal, intermittent)
– Attentiveness
– Mannerisms, gestures
– General Attitude (uncooperative, cooperative, withdrawn, passive, inappropriate, suspicious, guarded, interested)
– Attitude towards the interviewer (neutral, positive, negative, dismissive, ambivalent, hostile, uncooperative, vague)
– “Client was pleasant and cooperative with the interview.”
MSE mood (subjective)
- “Good”, Happy, Cheerful, Euphoric, Elated
- Neutral, Calm, Peaceful
- “Okay”, “Blah”
- Depressed, Hopeless, Sad, Angry, Agitated
- Anxious, Nervous, Worried
– How are you feeling today?
– What word(s) would you use to describe
your mood?
– Do you experience highs and lows?
– Is there any pattern to these mood changes?
– Suicide/Self-Harm risk assessment
– Homicide/harming others assessment
– *What is your mood on a scale from 0 to 10?
MSE affect (objective)
– Elated, bright, animated
– Hostile, fierce, disgruntled
– Blunted, flat, downcast
– Restricted range
– Labile
– Euthymic*
– Note range of affect, appropriateness to context/situation, & congruency with stated mood
MSE speech (objective)
- Rate (average, slow, fast, pressured)
- Volume/tone (loud, average, soft, variable, monotone)
- Spontaneity/Hesitant
- Characteristics (accent, dialect, language)
- Response time (latency? Poverty of speech?)
- Speech production (unremarkable, incoherent, irrelevant, pressured, minimal, muttering, clear, slurred, appropriate inflection, hesitant, mute, poverty, echolalia)
MSE thought form/process (object & subjective)
- Thought process is determined by the flow of conversation and quality of thoughts. Essentially it is the “how” the person is thinking. It is how thoughts are formed and if they are easy to follow or not.
- Can only be determined through the patient’s speech and how they describe thinking.
- Logical, organized, goal directed.
- Illogical, disorganized, non-sensical.
- Racing thoughts
- Loose associations, tangential, flight of ideas
- Thought blocking or slow, hesitant.
- Neologisms (inventing new words)
MSE thought content (objective & subjective)
– Thought content is the “what” the client is thinking about.
– what topics they are spending their time thinking about.
– looking for bothersome thoughts, preoccupations or symptoms of psychosis, particularly delusions.
- can include persecutory, grandiose, religious, referential, thought control (broadcasting, insertion, withdrawal).
– looking for phobias or obsessions.
- “What do you spend most of your time thinking about?”
- “Do you worry about your safety?”
- “Do you ever feel as if there’s someone spying on you or out to get you in some way?”
- “Do you have any special powers or abilities?”
- “Do you have any specific fears?”
- “Are there certain thoughts that you ruminate over or spend your entire day thinking about?
- “Do these thoughts ever compel you to do something??”
MSE perception (objective & subjective)
- Hallucinations: auditory, visual, gustatory, olfactory, somatic/tactile
- Command hallucinations
- Illusions
- Objective data: responding to internal stimuli?
- Assess content of hallucinations, client’s interpretation/extent of belief in them being real, client’s reaction (positive vs. negative)
- Ways of coping?
cognitive functioning (objective & subjective)
- MMSE/Folstein
- Level of arousal (alert, drowsy)
- Orientation (person, place, time, situation)
- Concentration and attention
- Memory (short-term, recent, remote)
- Intellectual capacity/knowledge
- Abstraction/concrete
insight
- Awareness of situation, context
- Recognition of illness, need for help
- Understanding of factors contributing to illness
- Motivation to work on identified problems
- Stated as “full, partial, limited, impaired, no”
judgement
- The process one uses to reach a decision or take action.
- Ability to consider the pros and cons of decisions/choices
- “Poor judgment” may be demonstrated by impulsivity, engaging in actions with damaging consequences
risk assessment: risk to self
– Self-harm and suicide are not the same
– Ask routinely during initial assessment & periodically throughout treatment process.
– When a change in behaviour is noted that may indicate elevated risk.
– Following a major stressor.
– When we get ”clues” that the client may feel hopeless or be experience suicidal thoughts.
– Consider: suicidal thoughts, plan, intent, means, impulsivity, risk & protective factors (next slides)
– Suicide risk assessment tools can inform level of risk (low, moderate, high)
risk assessment: suicide risk factors
– Age
– Sex
– History of psychiatric disorder (including personality d/o)
– Current psychiatric diagnosis
– Characteristic symptoms: hopelessness, anger, depression, guilt, anxiety, insomnia, diminished attention/concentration
– Previous hx of suicidal behaviour.
– Hx of abuse, trauma
– Substance use
– Situational risk factors & life stressors (interpersonal conflict, recent changes, losses)
– Family hx of suicide & psychiatric disorders
– Living alone
– Social Relationship problems (isolation,
lack of support, conflict)
– Access to lethal means
– Physical health issues
suicide protective factors (individual factors)
– Strong sense of competence
– Sense of purpose
– Effective interpersonal skills
– Effective problem-solving skills
– Adaptive coping skills
– Self-understanding
– Optimistic outlook
– Religious affiliation
suicide protective factors (work factors)
– Sense of accomplishment
– Positive peer support and colleague
relationships
– Supportive, non-punitive work environment
– Professional development opportunities (e.g., career development, stress management workshops)
– Core values are present in the workplace (e.g., integrity, honesty)
– Access to employee assistance programs
suicide protective factors (family factors)
– Sense of responsibility to family.
– Relationships characterized by warmth and belonging.
suicide protective factors (community)
– Opportunities to participate
– Affordable, accessible supportive
resources
– Hope for the future
– Community self-determination and solidarity
psychosocial rehabilitation (PSR)
- mental health treatment philosophy or approach that promotes resilience, personal recovery, full community integration, and a sense of purpose and meaning for those who have been diagnosed with any mental health condition and/or addiction issue.
development of PSR: historical factors and influences
Deinstitutionalization (1970’s)
- Focus on community reintegration required shift in focus from pharmacology & therapy to life skills required to function in the community.
- Created a niche for non-medical professionals such as PSR support workers.
FOIPPA
freedom of information and protection of privacy act
FOIPPA: consistent purpose
- “continuity of care”
- we can share information with others (FOIPPA does not specify who) if that information is being shared for the same reason it was collected- to offer health care.
Privacy (BCCNP practice standard)
is the right of individuals to determine for themselves when, how, and to what extent information about themselves is communicated to others.
Confidentiality (BCCNP practice standard)
means ensuring that the personal and health information belonging to another individual is kept private, safe from access or use by or disclosure to people who are not authorized to have the information.
Form 4 (section 22)
- medical certificate
- detain 48 hours
- authority for anyone to take the individual to a designated facility
- second form 4 completed by different physician within 48 hours to further involuntary admission
failure = pt discharged or admitted as a voluntary pt - second form 4 valid up to one month from the initial admission
- pt should be informed when form 4 cert are completed
section 28 (I)
- police intervention
- give police authority to apprehend a person and take them to physician for examination
- doesnt mean arrested
- section 22: different criteria between officers and physicians
- officer must be satisfied on the basis of personal observation and/or info received from others that the person has a mental disorder and is acting in a manner that is likely to endanger their own safety or the safety of others
- safety = higher standard to meet than the criteria used by physicians
forms 9 & 10 (section 28 (3))
- Anyone who has reason to believe a person has a mental disorder and meets criteria for involuntary admission according to Section 22 can apply to a provincial court judge or justice of the peace to have a person apprehended for assessment by a physician.
- form 9: Application for Warrant (Apprehension of Person with Apparent Mental Disorder for Purpose of Examination) is completed by friend/family member or other individual and submitted to the judge.
- form 10: If the judge is satisfied the conditions are met, the judge may issue a warrant under Section 28 (4). giving police the authority to apprehend him or her.
form 20
- extended leave
- cert/invol intervention: treatment implications
pt rights under MHA: form 13
- to know the name and location of the facility.
- to know the reason why you are here.
- to contact a lawyer.
- to be examined regularly by a medical doctor to see if you still need to be an involuntary patient.
- to apply to the Review Panel for a hearing to decide if you should be discharged
- to apply to the court to ask a judge if your medical certificates are in order.
- to appeal to the court your medical doctor’s decision to keep you in the facility.
- to request a second medical opinion on the appropriateness of your medical treatment.
