Week Twelve Flashcards
Self Concept
Ones mental image of oneself
Self esteem
Ones judgement of one’s own worth; how one’s standards and performance compare to others and to one’s ideal self
Personal (self) identity
The conscious sense of individuality and uniqueness that is continuously evolving throughout life. Ex. Name, sex, age, race, occupation, talent, roles
Body image
How a person perceives the size, appearance, and functioning of the body and its parts
Role performance
How a person in a particular role acts in comparison to the behaviors expected of that role
What are the four components of self-concept?
Personal identity, body image, role performance, and self-esteem
What would a person with strong sense of personal identity exhibit?
A person with a strong sense of personal identity would exhibit the integration of all parts of their lives to define themselves such as body image, role performance, and self esteem.
What would a person with a healthy body image exhibit?
A concern for both health and appearance.
What is role mastery?
Persons behaviors meet social expectations
What is global self esteem?
How one likes oneself as a whole
What is specific self esteem?
His much one approves of a certain part or aspect of oneself
What are the key factors that can influence self concept?
Stage of development, family and culture, stressors, resources, past history of successes and failure, illness
What are the behaviors associated with low self esteem?
Avoids eye contact, stooped posture, unkempt appearance, overly critical of self, overly critical of others, hesitant soft speech, unable to accept positive remarks about oneself, apologizes frequently, feels helpless/hopeless/powerless, lack of goals, many negatives
What are the behaviors associated with high self esteem?
Positive thinking, able to identify strengths, able to set attainable goals, able to provide positive reinforcement and feed back, able to take pride or acknowledge when goals are met, maintaining a sense of humor, able to acknowledge skills, positive relationships, emotional strength, spiritual strength
How does an RN go about assessing self concept?
Creating a therapeutic environment by establishing rapport, be aware of self attitudes and judgments, gather information on personal identity, body image, role performance, and self-esteem
Define disturbed body image
Confusion in mental picture of one’s physical self
Define risk for situational low self esteem.
At risk for developing negative perception of self worth in response to a current situation (specify situation)
Define situational low self esteem
Development of a negative perception of self worth in response to a current situation (specify situation)
Defining characteristics for situational low self esteem
Evaluation of self as unable to deal with events, evaluation of self as unable to deal with situations, expressions of helplessness, expressions of uselessness, indecisive behavior, non assertive behavior, self negating verbalizations, verbally reports current situational challenge to self worth
R/t for situational low self esteem
Behavior inconsistent with values, developmental changes, disturbed body image, failures, functional impairment, lack of recognition, loss, rejection, social role changes
Risk factors for risk for situational low self esteem
Behaviors inconsistent with values, decrease in control over environment, developmental changes, disturbed body image, failures, functional impairment, history of abandonment, history of abuse, history of learned helplessness, history of neglect, lack of recognition, loss, physical illness, rejections, social role changes, unrealistic self expectations
Tnis situational low self esteem
Assess for s/s of depression and potential suicide/violent behavior and if present notify appropriate resources and act stat, assess for underlying stressors, assess for unhealthy coping mechanisms, assist pt in indigo citation of problems or contributing factors (make change and offer options), identify strengths, resources available, and previous positive effective coping, accept patient where he or she is, teach positive coping, support and encourage problem solving strategies, encourage self evaluation, provide psycho-education to family, provide validation for pt, acknowledge social stigma, work to address/present a positive outlook, identification of self strengths, and set realistic goals
TNIs for risk for situational low self esteem
identify environmental/developmental factors that increase the risk for low self esteem, especially in children and adolescences, utilize resources as available and appropriate, assess previous experience with health care and coping, assess low and or negative affect, encourage to maintain highest level of functioning, utilize respect and therapeutic relationship to set realistic goals, and have the client involved in planning care
Defining characteristics of disturbed body image
behaviors of acknowledgement of one’s body, behaviors of avoidance of one’s body, behavior’s of monitoring one’s body, non-verbal response to actual change in body appearance, structure, function, non-verbal response to perceived change in body, verbalization of feelings that reflect an altered view of one’s body, verbalizations of perceptions that reflect an altered view of one’s body appearance
r/t for disturbed body image
biophysical, cognitive, cultural, development changes, illness, illness treatment, injury, perceptual, psychosocial, spiritual, surgery, trauma
TNIs for disturbed body image
employ psychosocial questions in assessment to identify clients at risk for disturbed body image, if identified as at risk for disturbed body image utilize a standardized tool to further assess and gather data, utilize resources as appropriate (provide a list of recources to client/family), allow opportunity for client/family to voice concerns, fears, feelings, offer support through positive unconditional regard, and non-judgemental acceptance, acknowledge negative feelings expressed, encourage the client to discuss interpersonal and social conflicts that may arise, explore opportunities to assist the client to develop a realistic perception of his/her body image, encourage client to write a narrative description of their changes, encourage client to involvement in planning care and treatment, take cues from the client regarding their readiness to look at body/wound, and utilize their questions/comments as a means to provide teaching, encourage the client to engage in health promotion behaviors as able and appropriate
Aphasia
the partial or total loss of ability to express or understand speech or written words
What are the five senses?
visual, auditory, olfactory, tactile, gustatory
Signs of Sensory Deprivations
excessive yawning, drowsiness, sleeping, decreased attention span, difficulty concentrating, decreased problem solving, impaired memory, periodic disorientation/general confusion, preoccupation with somatic c/o, hallucinations/delusions, crying, annoyance with small matters, depression, apathy, emotional lability
Sensory Deprivation Definition
Low or lack of meaningful stimuli
Sensory Overload Definition
Inability to process or manage the amount of intensity of sensory stimuli
Signs of Sensory Overload
c/o fatigue, sleeplessness, irritability, anxiety, restlessness, periodic or general disorientation, decrease problem-solving, task performance, increase in muscle tension, scattered attention and racing thoughts
Contributing Factors for Sensory Deprivation
sensory input is interrupted (blindness, deafness, paralysis), lack of environmental stimulation, lack of social input, lack of light and lack of visual stimulation
Who is at risk for developing sensory deprivation?
unable to process stimuli, prolonged bedrest/mobility restrictions, private room/isolation precautions/home bound, sensory alterations (eyes bandaged), limited social contacts (few visitors), different culture
What nursing actions can be taken for those at risk or those with sensory deprivation?
encourage use of sensory aid (glasses, hearing aid), maintain meaningful interactions with client, call the client by name and touch client, provide meaningful environmental stimuli, increase tactile stimulation (textured objects, back rub, foot care, hair wash), encourage social interaction, encourage mental stimulation and use self-stimulating techniques (signing etc.), encourage environmental changes
Contributing factors Sensory Overload
increased quantity or quality of internal stimuli (N, pain, anxiety, dyspnea), increased quantity or quality of external stimuli (noise, light, procedures), inability to distinguish stimuli selectively
Clients at risk for developing Sensory Overload
Busy/noisy environment (ICU, room near nurse’s station, being closely monitored), machinery (o2, telemetry, IV pumps), acutely ill, presence of pain or discomfort, CNS disturbances or decrease in cognitive ability, roommate
Nursing actions for those at risk or experiencing sensory overload
quiet, calm subdued environment, control pain, provide orienting cues, plan care to allow uninterrupted periods of rest and sleep (private room if available), establish a routine of care, communicate in a calm, unhurried manner, provide information and client teaching at appropriate level, reduce noxious odors, ask client to ask questions and ventilate feelings, teach client stress-reducing techniques
What are the factors affecting sensory function?
developmental stage, culture, stress, medication and illness, lifestyle & personality
Nursing Assessment Nursing History Component for Sensory
can interview client as well as family or significant others, focus is on sensory perceptions, functioning, any deficits and on any potential problems
Nursing Assessment Mental Status Component for Sensory
Level of consciousness, orientation, attention span, and memory, mini-mental status exam
Nursing Assessment Physical Exam Component for Sensory
to determine whether the senses are impaired, visual acuity and visual fields, hearing acuity, olfactory sense, gustatory sense, tactile sense
Nursing Assessment Environment Component for Sensory
Is there appropriate and meaningful stimuli in the environment? does the environment pose any safety risks?
Nursing Assessment Social Support Component for Sensory
does the client live alone? who visits and when? any signs indicating social deprivation? who provides social contact with this person? important for social stimulation, assistance, support, opportunity to discuss feelings and fears
Behaviors of Visually Impaired
poor coordination, squinting, under or over-reaching for objects, persistent repositioning of objects, impaired night vision, accidental falls
What are some sensory aids to visually impaired?
sunglasses, contact lenses, eyeglasses, magnifying glass, seeing-eye dog, well lighted areas, large print, braille
Nursing Implications for Care of Contact Lenses
facilitate clients who normally care for their clients themselves. contact solution is to be kept sterile.
Nursing Actions for Visually Impaired
identify yourself, stay within the client’s field of vision, avoid loud voice tones, explain what you will be doing before you touch a client, explain environmental sounds, let client know when you enter and when you leave, do not rearrange furniture or belongings, set up tray for meals and offer assistance, when ambulating give client elbow, never leave client alone in unfamiliar place, allow independence, provide suitable recreation
Behaviors of Hearing Impaired
blank look, decreased attention span, lack of reaction to loud noises, increased volume of speech, position of head toward sound, smiling & nodding when someone speaks, lip reading, writing, relying on non-verbals, complaint of ringing in ears
Sensory Aids for Hearing Impaired
hearing aid, amplifier (phone), telecommunication device for the deaf, sign language, flashing alarm clocks and smoke detectors, lip reading, hearing guide dog
Nursing Actions for Hearing Impaired Clients
decrease background noises when speaking, face clients and make sure light shines on your face and that client can see lips, talk at moderate rate in normal tone of voice, do not shout, position in good ear if applicable, refrain from small talk, use longer phrases to facilitate understanding, choose words wisely, use writing and gestures, be sure hearing aids are in and on and glasses on if client has these, never do anything unexpected from behind, never leave client in complete darkness, be sure you have client’s attention before speaking
Nursing Implications regarding Care of a Hearing Aid
hearing aids require regular cleaning of the ear-mold, regular replacement of batter, can be switch on and off, volume can be adjusted, ear-molds typically require adjustment ever 2-3 years
Define Acute Confusion
Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time
Defining Characteristics for Acute Confusion
fluctuation in cognition, fluctuation in level of consciousness, level of consciousness, psychomotor activity, hallucinations, increased agitation, increased restlessness, lack of motivation to follow through with goal-directed behavior or purposeful behavior, lack of motivation to initiate goal-directed behavior or purposeful behavior, misperceptions
Define Chronic Confusion
Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behavior
Defining Characteristics of Chronic Confusion
altered interpretation, altered personality, altered response to stimuli, clinical evidence of organic impairment, impaired long-term memory, impaired short-term memory, impaired socialization, long-standing cognitive impairment, no change in level of consciousness, progressive cognitive impairment
Reality Orientation
A communication modality used to make a client aware of reality. The purpose is to restore a sense of reality, improve level of awareness, promote socialization, evaluate the client’s independent functioning, and/or minimize confusion.
Guides for Reality Orientation
time, date, and place during conversation, reference to clocks, calendars and other reality props, do not reinforce or support misconceptions, call the client by name, introduce oneself, redirect if client rambles, encourage independence and provide client with choice, make sure client has necessary sensory or mobility aids, reward even small changes in behavior that indicate progress, repeat info as necessary, give directions and explanations in short sentences with concrete times, maintain consistency in routine and care providers as able, provide visual cues (family photos and possessions in room, written schedule name outside room)
Wandering Strategies
doors/windows locked, door alarms, ID bracelets, provide adequate exercise, do not restrain , do not argue c person who wants to leave and instead go with them, let the person wander in enclosed areas, assess any underlying cause (pain, toileting)
Agitation Strategies
calm, quiet approach, ensure congruency b/w caregiver verbal and non-verbal behavior, determine cause of behavior and remove cause, individualized music therapy, consistency of care givers, provide for client’s and other’s safety
Define Hallucinations
Seeing, hearing, or otherwise experiencing something that is not present in objective reality
Hallucinations Strategies
do not argue c person, identify yourself & purpose for being there, reassure, acknowledge that the person is experiencing something you are not experiencing, do not challenge the hallucination as unreal, do not leave client alone while a hallucination is being experienced or immediately afterward, avoid sedatives or hypnotics
Define Sundowning
A state of disorientation and agitation that occurs at night in institutionalized people who are oriented during the day. It is a temporary state of confusion that cycles with the sun.
Sundowning Strategies
calm environment late in day, treatments/activities should be done early in the day, do not restrain, encourage exercise and activity early in the day, promote urinary and bowel elimination, do not try to reason with the person, do not ask the person to tell you what is bothering him or her, provide adequate lighting, assess underlying physiologic causes (delirium)
