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NUR 140 > Final (Nursing Interventions & Action) > Flashcards

Final (Nursing Interventions & Action) Flashcards

1
Q

Healthy Outcomes Stress

A

Coping strategies (mechanisms)
Family/Social Support
Positive thoughts and responses by individuals

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2
Q

Nursing Interventions Stress

A 
Rapid focused assessment
Develop trust and rapport
Offer reassurance and support
Identify precipitating stressor/problem(s)
Encourage verbalization of experience and associated feelings
May need to challenge (gently) maladaptive beliefs/behaviors
Discuss stages of grieving
Assess coping strategies
Explore new coping strategies
*Problem solve
*Develop a plan
*Implement a plan
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3
Q

Rapid focused assessment

Nursing Interventions Stress

A

Physical
Psychological
Level of anxiety
S/H I/P/M

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4
Q

Develop trust and rapport

Nursing Interventions Stress

A

Active Listening

Unconditional acceptance, Genuine, Non-judgmental

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5
Q

Offer reassurance and support

Nursing Interventions Stress

A

Reality oriented approach – here and now

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6
Q

Identify precipitating stressor/problem(s)

Nursing Interventions Stress

A

Discourage lengthy discussions and
rationalizations
Prioritize patient’s problems/concerns

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7
Q

Encourage verbalization of experience and associated feelings
Nursing Interventions Stress

A

Clarify the problem (perceptions)

Validate feelings and emotions

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8
Q

Assess coping strategies

Nursing Interventions Stress

A

What has been used?

What was the outcome?

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9
Q

Develop a plan

Nursing Interventions Stress

A

Present and future options

Identify support systems

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10
Q

Implement a plan

Nursing Interventions Stress

A

Seek support from others

Family, friends, community resources

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11
Q

Goals Stress

A

Relief/decrease in anxiety
Restoration of function
Personal growth

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12
Q

Therapeutic Communication

A 
Using silence
Accepting
Giving recognition
Offering self
Giving broad openings
Offering General Leads
Placing Events in time Sequence
Making Observations
Encouraging Descriptions of Perceptions
Encouraging comparison
Restating
Reflecting
Focusing
Exploring
Presenting reality
Voicing doubt
Verbalizing the implied
Attempting to translate words into feelings
Formulating plan of action
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13
Q

Nontherapeutic Communication

A 
Giving reassurance
Rejecting
Approving or disapproving
Agreeing or disagreeing
Giving advice
Probing
Defending
Requesting an explanation
Indicating the existence of an external source of power
Belittling feelings expressed
Making stereotyped comments
Using denial
Interpreting
Introducing an unrelated topic
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14
Q

Techniques for dealing with aggression

A 
Talking down
Physical outlets
Medications
Call for assistance
Restraints
Observation and documentation
Ongoing assessment
Staff debriefing
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15
Q

Verbal Intervention Tips and Techniques - Do

A 
Remain Calm
Isolate the situation
Enforce limits
Listen
Be aware of nonverbals
Be consistent
Ignore challenge questions
Be nonthreatening
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16
Q

Verbal Intervention Tips and Techniques - Don’t

A 
Overreact
Provide an audience
Change them
Ignore
Communicate emotion
Make false promises
Get in a power struggle
Be threatening
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17
Q

Avoiding Liability

A 
Respond to the patient needs with compassion and respect
Educate the patient
Comply with the standard of care
Supervise care
Adhere to the nursing process
Document carefully and objectively
Follow-up and evaluate care provided
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18
Q

Professionalism in Nursing

A

Respond to the patient needs with compassion and respect
Protect patient’s health, safety and rights
Develop and maintain a good interpersonal relationship with patient and family
Maintain competency, personal and professional growth

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19
Q

Risk for Spiritual Distress

A

“At risk for an impaired ability to experience and integrate meaning and purpose in life through a connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself”

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20
Q

Risk for Spiritual Distress Interventions

A

Aimed at helping the patient achieve meaning and purpose in life that reinforces hope, peace, contentment, and self-satisfaction

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21
Q

Goals of Cognitive Therapy

A
  1. Monitor his or her negative, automatic thoughts.
  2. Recognize the connections between cognition, affect,
    and behavior.
  3. Examine the evidence for and against distorted
    automatic thoughts.
  4. Substitute more realistic interpretations for these
    biased cognitions.
  5. Learn to identify and alter the dysfunctional beliefs
    that predispose him or her to distort experiences.
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22
Q

Techniques to help a client recognize a cognitive distortion

A

Socratic Questioning/dialogue
Guided relaxation
Role play/ behavioral rehearsal

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23
Q

Techniques to modify cognitive distortions

A 
Generating Alternatives
Examining the evidence
Decatastrophizing
Reattribution
Dysfunctional Thought recordings
Cognitive rehearsal
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24
Q

Indications for Cognitive Therapy

A 
Depression
Panic disorder
Generalized anxiety disorder
Social phobia
Obsessive-compulsive disorder
Posttraumatic stress disorder
Eating disorders
Substance use disorders
Personality disorders
Schizophrenia
Couple’s problems
Bipolar disorder
Illness anxiety disorder
Somatic symptom disorder
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25
Q

Role of the Nurse in Cognitive Therapy

A

Cognitive therapy requires an understanding of educational principles and the ability to use problem- solving skills to guide clients’ thinking through a reframing process

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26
Q

Dialectical Behavioral Therapy (DBT) Intervention

A

Avoid “always” and “never”
Accept that change is constant
Appreciate differences
Current treatment for borderline personality disorder

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27
Q

Positive Therapies Clinical handout

A

These are tools for your tool box when you go to clinical.
The core philosophy is to build on what is strong and positive with your client. Work with your client to recognize their strengths, gifts, and positive coping skills.

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28
Q

Positive therapies

A 
Well being therapy
Healing therapies
Positive Psychotherapy
Identify signature strength
Gratitude Visit
Gratitude Therapy
Daily Affirmations
Build strengths to foster hope
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29
Q

Nursing Assessment - Schizophrenia

A

Impaired personal functioning

Impaired relationships

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30
Q

Impaired personal functioning

Nursing Assessment Schizophrenia

A

Unable to meet role expectations

Deterioration in appearance

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31
Q

Impaired relationships

Nursing Assessment Schizophrenia

A

Intrusive

Isolate

32
Q

Nursing Problems - Schizophrenia

A 
Risk for violence (self or other)
*Disturbed thought processes
*Disturbed sensory perceptions
Impaired verbal communication
Self-care deficits
Social isolation
Ineffective health/home maintenance
Disabled family coping
33
Q

Goals (Patient) - Schizophrenia

A 
Remains safe
Communicates with others
Completes ADLs
Interacts satisfactorily with others
Reports control over hallucinations
Perceives environment realistically
Verbalizes logical thought processes
34
Q

Risk for Violence (self or others)

Nursing Interventions - Schizophrenia

A

Reassure patients they are safe
Protect from physical harm as they respond to the altered perceptions
Encourage verbalization of fears
Contract for safety
Intervene at early sign of anxiety, agitation

35
Q

Disturbed Thought Process

Nursing Interventions - Schizophrenia

A

Validate belief of patient, but that you do not share belief
Avoid arguing with patient or deny the false belief
Present reality

36
Q

If patient is suspicious

Nursing Interventions - Schizophrenia

A 
Consistent staff
Keep promises
Avoid physical contact
Monitor communication with others
Food, medication
Avoid competitive activities
37
Q

Disturbed Sensory Perceptions (Hallucinations)

Nursing Interventions - Schizophrenia

A 
Observe for and determine type
Develop trusting relationship
Calming techniques
One-to-one interactions
Do not reinforce perception, orient to reality
Use distraction techniques
Active involvement in activity
Correlation of anxiety to hallucinations
38
Q

Communication

Nursing Interventions - Schizophrenia

A 
Promote verbal communication
Pay close attention and monitor for “themes” to understand the message
Seek clarification
Teach assertive communication
Promote social interaction and activity
Group therapy
Promote social skills
39
Q

Self Care Deficits

Nursing Interventions - Schizophrenia

A 
Explore adaptive coping strategies
Enhance self esteem
Encourage self care activities
Acknowledge achievements
Positively reinforce independence
Prevent relapse
Educate regarding relapse triggers (physical, personal, and community stressors)
40
Q

Health Maintenance

Nursing Interventions - Schizophrenia

A

Promote medication adherence
Involve the patient in medication-based treatment decisions
Teach patient how to report and manage side effects
Discuss patient’s expectation of the medications
Provide hope
Involve the family/caregiver

41
Q

Coping with socially inappropriate behaviors

Nursing Interventions - Schizophrenia

A

Loss of ego boundaries leads to bizarre and inappropriate behaviors.
Protect the patient from retaliation
Reintegrate the patient into the Milieu

42
Q

Family/Caregiver Teaching - Schizophrenia

A

Discuss basic nature of disorder
Help families identify their initial response to the diagnosis
Acknowledge families for supporting treatment of the ill family member
Encourage family participation in psycho- educational programs
Provide contact information for NAMI

43
Q

Nursing Problems - Bipolar

A 
Risk for self-directed violence
Complicated grieving
Low self-esteem
Hopelessness
Self-care deficit
Imbalanced nutrition
Disturbed sleep pattern
Social isolation or Impaired social interaction
44
Q

Injury/Suicide Prevention

A 
Observe frequently/Close Observations
Evaluate level of suicide intent
Remove sharp/dangerous objects from
Intervene at first sign of increased agitation
Remain calm; Spend time with patient
Have sufficient staff on hand
Encourage verbalization of feelings including anger
Contract for safety
45
Q

Unresolved / Complicated Grief Nursing Interventions

A 
Develop trust
Encourage expression of anger
Teach positive coping strategies to release anger
Teach about normal grief
Assess spiritual needs
Encourage use of support groups
46
Q

Self-Esteem Enhancement for Depression

A

Identify and focus on strengths
Encourage independence
Teach assertiveness skills
Teach use of “I” statements
Encourage involvement in activities they can be successful
Recognize and praise small accomplishments

47
Q

Self Care Deficit: Adequate Nutrition and Sleep

A 
Assess calorie needs and food preferences
Provide high protein, high calorie finger foods & drinks
Record I & O - Assess Weight
Assess activity level
Monitor sleep patterns
Promote adequate sleep
Teach relaxation techniques
Encourage daily hygiene
48
Q

Increased Socialization for Depression

A

Make brief but frequent interactions
Spend time with patient, in silence if necessary
Attend activities with patient at first
Reinforce social skills and self-confidence

49
Q

Improved social interactions for Bipolar

A

Keep environmental stimuli to a minimum
Set limits on inappropriate behavior
Do not argue, bargain or try to reason
Provide positive reinforcement for expected behavior
Help patient identify positive aspects of self
Help patient accept consequences of behavior

50
Q

Patient/Family Teaching - Nature of illness

Depression

A

Signs of relapse

51
Q

Patient/Family Teaching - Management of illness

Depression

A

Medications - side effects, lab work, compliance
Assertiveness techniques
Anger management
Coping Strategies

52
Q

Patient/Family Teaching Depression

A

Complications of Medication Non-Compliance
Alcohol and/or drug abuse may be used as a strategy to “self-medicate.”
Personal relationships, work, and finances may suffer as a result of mood swings.
Suicidal thoughts and behaviors are very real complications.

53
Q

Family Teaching - Support services

Depression

A 
NAMI
Crisis hotline
Support groups
Legal/financial assistance
Suicide hotline
54
Q

What can I do as the nurse? Adolescent Disorders

A

Safety
Establish trust
Acceptance of child separate from behavior
Immediate positive feedback for acceptable behavior
Redirect violent behaviors into positive outlets
Role play
Behavioral reinforcement
Structured activities - starting with lower expectations and progressing
Identification of feelings
Limit setting
Consistent discipline

55
Q

What am I looking for? Adolescent Disorders

A

No physical harm to self or others
Appropriate interactions with others
Positive self concept
Follows rules without becoming defensive
Fewer demanding behaviors
Cooperation and completion of tasks
Demonstrates self- control by managing tics
Able to accept directions without becoming defensive
Decreased anxiety upon separation from caregiver

56
Q

Self assessment - Addiction

A

Nurses must begin relationship development with an individual who abuses substances by examining own attitudes and personal experiences with substances

57
Q

Common Assessment tools - Addiction

A

Clinical Institute Withdrawal Assessment of
Alcohol Scale, Revised (CIWA-Ar)
Michigan Alcoholism Screening Tool (MAST)
CAGE

58
Q

Nursing Problems - Addiction

A 
Denial
Ineffective CopingAlternate Strategies
Nutrition - Less than Body Requires
Infection
Low Self Esteem
Deficient Knowledge
Injury
Suicide
59
Q

Detoxification - Addiction

A

Provide safe and supportive environment

Administer substitution therapy

60
Q

Intermediate Care - Addiction

A

Provide explanations of physical symptoms
Promote understanding and identify causes of substance dependency
Help patient accept use of substance as a problem
Provide education and assistance to patient and family

61
Q

Rehabilitation - Addiction

A

Encourage continued participation in long- term
treatment
Promote participation in outpatient support system.
Assist patient to identify alternative sources of satisfaction
Provide support for health promotion and maintenance.

62
Q

Nature of the Illness

Patient/Family Education - Addiction

A

Ways in Which Use of Substance Affects Life

Effects (of Substance) on the Body

63
Q

Management of the Illness

Patient/Family Education - Addiction

A 
Activities to substitute for (substance) in times of stress
Relaxation techniques:
– Progressive relaxation
– Tense and relax
– Deep breathing
Problem-solving skills
Essentials of good nutrition
64
Q

Abuse and Neglect Nursing Problems

A 
Rape-trauma syndrome
Powerlessness
Delayed growth & development
Fear
Low self esteem
Acute Confusion
Ineffective Coping
Risk for self directed violence
Disturbed sleep pattern
65
Q

Abuse and Neglect Nursing Interventions

A

Reassure client they are in a safe place
Display empathy that this has happened
Instill that they are not to blame for abuse
Provide privacy during interview and physical exam
Explain all procedures (photography)
Treat injuries/diseases
Listen to them, support open communication
Maintain a non-judgmental attitude
Establish trust
Encourage expression of feelings : fear, loss of control, powerlessness, grief
Assure client of confidentiality
Assist with decision making
Avoid ‘rescuing’ the client
Provide information for available resources
Help them contact support systems
Promote self esteem and self worth
Review coping strategies

66
Q

Dementia and Delirium Nursing Interventions

A 
Protect from harm
Provide safe, secure, structured environment
Maintain calm, quiet environment
Low level stimuli
Consistency of staff
Maintain routines
Engage in social and leisure activities
Reorient to time place situation
Label objects
Ask one part questions
Give simple explanations
Speak slowly and distinctly
Hearing aids/glasses
Assist with ADLs as needed
67
Q

Anxiety Nursing Interventions

A

Stay with client, reassure client they are safe
Provide caring, non judgmental environment
Unconditional positive regard
Low stimuli environment
Calm, quiet, clear communication
Review sign and symptoms of escalating anxiety
Identify/teach adapt coping strategies
Thought stopping, relaxation, exercise

68
Q

OCD Nursing Interventions

A

Identify events/situations that trigger increase in anxiety and initiate ritualistic behaviors
Acknowledge relationship of anxiety to behaviors.
Initially, meet client’s dependency needs, then encourage independence.
Initially, allow plenty of time for ritual. Then gradually limit amount of time.
Use positive reinforcement for non- ritualistic behaviors

69
Q

Body Dysmorphic Disorder Nursing Interventions

A

Assess client’s perception of body
Help client see that body image is distorted or out of proportion in relation to significance of actual anomaly
Involve client in activities that reinforce a positive sense of self not based on appearance

70
Q

PTSD Nursing Interventions

A 
Reassurance of safety
Encourage expression feelings
Integration of the trauma into persona
Progress through the grief process
Develop a sense of optimism and hope for the future
71
Q

Anxiety Disorders Education of patient/family

A

Nature of illness
Management of illness - Medication, Stress
Relaxation techniques
Support services

72
Q

Somatic disorders Nursing Interventions

A

Non judgmental approach
Assist with self care as need
Review medical testing and assessment with client
Limit time discussing physical complaints/deficits
Gradually withdraw attention from physical complaints
Identify gains by client

73
Q

Dissociative Disorders Nursing Interventions

A

Nursing care for the patient with a dissociative disorder is aimed at restoring normal thought processes.
Assistance is provided to the patient in an effort to determine strategies for coping with stress by means other than dissociation from the environment.

74
Q

ED Nature of illness Family Education

A

Symptoms of eating disorders
Causes of eating disorders
Effects of the illness or condition on the body

75
Q

ED Management of the illness Family Education

A 
Principles of nutrition
Ways patient may feel in control of life
Importance of expressing fears and feelings, rather than holding them inside
Alternative coping strategies
Relaxation techniques
Problem-solving skills
76
Q

ED Healthy Outcomes Predictors of Success

A

Coping with emotional issues adaptively
Reaching ideal body weight and maintaining
Behavioral change are made by the patient and family members.

NUR 140 (7 decks)

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