Final Flashcards
interventions include using a directive approach, taking control of the situation, using a calm, firm voice for giving directions, directing the client to take a time-out in a quiet place, offering PRN medication, and making a “show of force.”
escalation phase,
experienced, trained staff can use the techniques of seclusion or restraint to deal quickly with the client’s aggression.
crisis phase,
, interventions include helping clients to relax, assisting them to regain self-control, and discussing the aggressive event rationally.
recovery phase
Wide perceptual field Sharpened senses Increased motivation Effective problem solving Increased learning ability Irritability
Restlessness Fidgeting GI "butterflies" Difficulty sleeping Hypersensitivity to noise
Mild anxiety
Perceptual field narrowed to immediate task
Selectively attentive
Cannot connect thoughts or events independently
Increased use of automatisms
Muscle tension Diaphoresis Pounding pulse Headache Dry mouth High voice pitch Faster rate of speech GI upset Frequent urination
Moderate anxiety
Perceptual field reduced to one detail or scattered details
Cannot complete tasks
Cannot solve problems or learn effectively
Behavior geared toward anxiety relief and is usually ineffective
Doesn’t respond to redirection
Feels awe, dread, or horror
Cries
Ritualistic behavior
Severe headache Nausea, vomiting, and diarrhea Trembling Rigid stance Vertigo Pale Tachycardia Chest pain
Severe Anxiety
Perceptual field reduced to focus on self Cannot process any environmental stimuli Distorted perceptions Loss of rational thought Doesn't recognize potential danger Can't communicate verbally Possible delusions and hallucination May be suicidal May bolt and run OR Totally immobile and mute Dilated pupils Increased blood pressure and pulse Flight, fight, or freeze
Panic
: characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and, occasionally, excessive religiosity (delusional religious focus) or hostile and aggressive behavior
Schizophrenia, paranoid type
: characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior
Schizophrenia, disorganized type
characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless and is not influenced by external stimuli. Other features include extreme negativism, mutism, peculiarities of voluntary movement, echolalia, and echopraxia.
Schizophrenia, catatonic type:
characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior
Schizophrenia, undifferentiated
: characterized by at least one previous, though not a current, episode; social withdrawal; flat affect; and looseness of associations
Schizophrenia, residual type
: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation
Ambivalence
: Fragmented or poorly related thoughts and ideas
Associative looseness
: Fixed false beliefs that have no basis in reality
Delusions
: Imitation of the movements and gestures of another person whom the client is observing
Echopraxia
Continuous flow of verbalization in which the person jumps rapidly from one topic to another
Flight of ideas:
: False sensory perceptions or perceptual experiences that do not exist in reality
Hallucinations
: False impressions that external events have special meaning for the person
Ideas of reference
: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic
Perseveration
: Tendency to speak very little or to convey little substance of meaning (poverty of content)
Alogia
: Feeling no joy or pleasure from life or any activities or relationships
Anhedonia
: Feelings of indifference toward people, activities, and events
Apathy
Restricted range of emotional feeling, tone, or mood
Blunted affect
: Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance
Catatonia
Absence of any facial expression that would indicate emotions or mood
Flat affect
: Absence of will, ambition, or drive to take action or accomplish task
Lack of volition
Mistrust and suspicions of others; guarded, restricted affect
** NI*
Serious, straightforward approach; teach client to validate ideas before taking action; involve client in treatment planning
Paranoid disorder
Detached from social relationships; restricted affect; involved with things more than people
NI*
Improve client’s functioning in the community; assist client to find case manager
Schizoid
Acute discomfort in relationships; cognitive or perceptual distortions; eccentric behavior
** NI **
Develop self-care skills; improve community functioning; social skills training
Schizotypal
Disregard for rights of others, rules, and laws
,** NI*
Limit setting; confrontation; teach client to solve problems effectively and manage emotions of anger or frustration
Antisocial personality disorder
Unstable relationships, self-image, and affect; impulsivity; self-mutilation
*** NI **
Promote safety; help client to cope and control emotions; cognitive restructuring techniques; structure time; teach social skills
Borderline personality disorder
Excessive emotionality and attention seeking
** NI***
Teach social skills; provide factual feedback about behavior
Histrionic
Grandiose; lack of empathy; need for admiration
**NI*
Matter-of-fact approach; gain cooperation with needed treatment; teach client any needed self-care skills
Narcissistic personality disorder
Social inhibitions; feelings of inadequacy; hypersensitive to negative evaluation
** NI***
Support and reassurance; cognitive restructuring techniques; promote self-esteem
Avoidant
Submissive and clinging behavior; excessive need to be taken care of
** NI*
Foster client’s self-reliance and autonomy; teach problem-solving and decision-making skills; cognitive restructuring techniques
Dependent
Preoccupation with orderliness, perfectionism, and control
** NI **
Encourage negotiation with others; assist client to make timely decisions and complete work; cognitive restructuring techniques
Obsessive-
compulsive
Pattern of depressive cognitions and behaviors in a variety of contexts
** NI**
Assess self-harm risk; provide factual feedback; promote self-esteem; increase involvement in activities
Depressive
Pattern of negative attitudes and passive resistance to demands for adequate performance in social and occupational situations
**NI*
Help client to identify feelings and express them directly; assist client to examine own feelings and behavior realistically
Passive-aggressive
nursing interventions include speaking calmly and nonthreateningly, conveying empathy, listening, offering PRN medication, and suggesting retreat to a quiet area
triggering phase
causes EXCESSIVE production of DOPAMINE
Schizophrenia
- hard time making decisions
Ambivalence
- fragmented or poorly related thoughts & ideas
- When you & the pt are talking about one topic & the pt goes off on a tangent with one word
Associative looseness
-fixed false beliefs
Delusions
- repetition of MOVEMENTS & GESTURES of another person the client is observing
Echopraxia
- repeating WORDS
Echolalia
- client jumps from one topic to another
• Many ideas in your head that all come out at once
Flight of ideas
- false impressions that external events have special meaning for that
person
• You believe everything refers to you
Ideas of reference
- verbal repetition of a sentence, word, or phrase
• Repetitive thought
Perseveration
- absence of will or drive to take action to accomplish tasks
Avolition
- acute, reactive psychosis for
Schizophreniform disorder
one or more bizarre delusions & the focus of the delusion is believable
• Delusion may be persecutory, erotomanic, grandiose, jealous, or somatic in content
Delusional disorder
- allows clients to practice & develop social skills
• Designed to help clients remediate or improve client’s deficits such as attention, memory, & information processing
• Help the client take the perspective of another person, rather than focus entirely on themselves
Cognitive enhancement therapy
- ideas that are related to another based on rhyming
• Ex:“IwilltakeapillifgoupthehillbutnotifmynameisJill,Idon’twanttokill”
Clang associations
- new words that have meaning to the pt
Neologisms
- repetition of words or phrases that may/may not have meaning to the listener
Verbigeration