Nur112 292 Final Exam Blueprint Spring 2018.

NUR112 292 FINAL EXAM BLUEPRINT SPRING 2018. Characteristics of Nurse-Client Relationship  Mutual respect  Client focused  Meets client’s needs  Emotional needs of nurse cannot interfere  Purposeful and goal oriented  Goals mutually established  Collaborative  Shared decision making  Promotes client’s independence  Agreement or contract is established  Boundaries are maintained Phases of the Nurse-Client relationship  Pre-interaction  begins before nurse meets client, nurse reviews data, considers personal feelings and thoughts  Orientation phase  introductory phase, initial encounter, develop trust, establish verbal contract and boundaries, collect data, formulate nursing diagnosis, develop goals, and initial plan of care  Working phase  Termination phase  end of the relationship, evaluate outcomes, express feelings about ending the relationship Conditions essential to developing a therapeutic relationship  Rapport  Trust  Respect  Genuineness  Empathy Transference  client transfers feelings and behavioral dispositions formed towards the nurse from past  Do you have a boyfriend?  Where do you live? Countertransference  nurses behavioral and emotional responses to the client  Poor boundaries  Nurse begins to interfere with patient’s health decisions Conditions that influence the nurse-client relationship Communication & Defense Mechanism Active listening  interactive process between nurse and client, understanding and being understood SOLER  Sit squarely facing client  Observe an open posture  Lean forward toward the client  Establish eye contact  Relax Verbal communication  vocabulary, denotative/connotative meaning, clarity, timing, relevance, pacing, intonation of voice Non-Verbal techniques  facial expression, eye contact, body posture, gestures, appearance, silence Assertive communication  promotes use of I statements, allows client to own feeling, client encouraged to make clear what he or she wants. Passive communication  personal needs are secondary to others, style is apologetic or complaining. Client Factors Nurse factors Religion and culture  Communication varies across cultures  Nurses should clarify personal preferences  Nurses needs to be sensitive and respectful Age/ Developmental level  Communication must be appropriate Emotional maturity  Self-awareness  Emotional intelligence Boundaries  Understand differences between professional and social relationships  Limit self-disclosure  “I am here to help you, this isn’t about me it about you” Touch  Use touch cautiously  Inform clients before touching them Aggressive communication  express needs but in a way that is disrespectful to others, hostile, angry, accusatory Therapeutic communication techniques Non-therapeutic communication techniques Silence reflecting Accepting focusing Recognition exploring Offering self clarifying Broad openings present reality General leads voice doubt Make observations state the implied Description of perceptions Comparisons Restating translate words into feelings Plan of action Reassurance clichés Rejecting denial Approving or disapproving interpreting Agree or disagree changing topic Giving advice Probing Defending Requesting explanations Indicate external source of power Minimize feelings ****** Assessment, mental status, interviewing: 1 Nursing Assessment:  Comprehensive and holistic o Physical o Psychological o Intellectual  executive functioning, illiteracy, capacity to intellectualize  How far did you go in your education?  Did you receive a GED?  Can you read? o Social  support system, social network o spiritual aspects  Evaluation ongoing; diagnosis and treatment plan evolve accordingly Preventive Intervention:  Primary  focuses on reducing the incidence of mental disorders; identify causes o Ex: education  Secondary  focuses on reducing the number of cases; screening; identify health needs; early treatment  Tertiary  focuses on reducing the severity of the mental disorder and its associated disabilities; rehabilitation; vocational training; symptom management; reduce long term effects Assessment:  First step in nursing process  defines client’s problem o why is it today you came in and asked for help? o What happened?  appropriate nursing diagnosis and plan of care  baseline level of functioning o on a scale of 1-10, how do you feel?  client’s self-assessment Psychiatric Nursing Interview  purpose: gather information necessary to understand and treat client  initial interview: focus on eliciting information to help staff provide safe environment  nursing interview: focus on client biopsychosocial history and current mental status  always remember ABC and safety  biopsychosocial history o assessment of client’s lifetime biologic, psychological, social functioning o identifying data o chief complaint o HPI o Psychiatric history  Have they been hospitalized before? o Alcohol and substance use history  High level of comorbidity between mental illness and alcohol or substance abuse o Medical and family history  Does mental illness run in the family?  Has anyone tried to take their life? o Developmental history  Erikson’s stages of development  Where you in special education? o Social history  Are you in touch with your family? o Occupational and education history  Do you have a job? Is it difficult for you?  Highest level of education? o Culture o Spirituality and values  Religion o Coping skills  Adaptive or maladaptive Mental Status Exam (MSE) BEST PICK  Behavior and general appearance  Emotions: mood and affect  Speech  Thought content and process  Perceptual disturbance  Impulse control  Cognition and sensorium  Knowledge, insight, judgement  evaluation of client’s present state  done every time you see the patient  requires little direct questioning  evaluate how client related to interviewer and to interviewing process  mood is client’s self-assessment; affect is observed state  Mood: do you feel happy, sad, mad?  Affect: what the nurse observes about a patient  observe rate, amount, style, tone of speech  impulse control: ability to delay, modulate, or inhibit expression of behaviors and feelings  observe LOC, orientation, concentration, memory  estimate client’s intellectual functioning  knowledge, insight, judgement related concepts  thought content: obsession, delusions, or homicidal thoughts  thought process: way in which the client thinks - Circumstantial, tangential, guarded, coherent  perceptions - Illusions: misinterpretations of true stimuli - Hallucinations  cognitive functioning: intellect - Attention and concentration o Test serial sevens, repeat a series of numbers forwards and backwards, spell WORLD backwards - Capacity for abstraction o Give 2 proverbs, explain how 2 items are similar (apple and orange) - Fund of knowledge o Name 5 large cities in the US, name current president - Insight o Ask can you tell me why you are in the hospital, what do you see as being your problem? - Orientation o Ask name, where they are, and date - Short-term memory o Repeat 3 names of objects immediately and after 5 minutes - Judgment o What would you do if there was a fire in the movie theater Conceptual models: 2 A conceptual model is a framework of related concepts Psychoanalytical model  Sigmund Freud  Levels of consciousness o Conscious, preconscious and unconscious  Structure of personality o Id, ego, and superego o Defense and coping mechanisms  Psychosocial development o Oral, anal, phallic, genital  Erikson’s Eight stages of man o Trust vs mistrust (0-1) o Autonomy vs shame and doubt (1-3) o Industry vs inferiority (6-12) o Identity vs role confusion (12-18) o Intimacy vs isolation (18-25) o Generativity vs stagnation (25-45) o Ego integrity vs despair (45 to death) Interpersonal model  Harry Stack Sullivan  Persons relationships with others  Need for satisfaction and security  Dynamisms  Anxiety as a central factor  Security operations  Self-concept Behavioral model  Classical conditioning (Ivan Pavlov)  IV behavior associated with an event  Operant conditioning (B.F. Skinner)  Voluntary behavior related to environment  Increasing a desired behavior o Positive (rewards behavior) reinforcement o Negative (avoid a negative stimulus) reinforcement  Decreasing a behavior o Punishment, response, cost, extinction Cognitive model  Distorted or negative thought patterns lead to maladaptive feelings and behaviors  Patterns of thinking are learned and become automatic  Perceived control affects response to stress (internal and external locus of control)  Tx: o Cognitive restructuring o Thought stoppage Neurobiological model  Molecular biology (neurons, NT, and receptors) o NT imbalance seen in all mental illnesses  Neurotransmitters  chemical signals that activate postsynaptic receptors o Acetylcholine, serotonin, dopamine, norepinephrine, GABA  Brain and nervous system are basic to understanding mental illness and disorders  Pharmacological tx o Put the NT in balance  Neuroplasticity  ability to adapt to environmental changes, learn, remember o Strengthening of synapses builds memories Genomics and Genetics A. Predict drug efficacy and adverse responses B. Explain why some medications have a delayed response C. Enhance understanding of NT systems Family therapy  family systems theory (Bowen) - Change in one aspect of the system affects the entire system  structural family theory (Minuchin) - Examines family organization and member interaction Milieu Therapy - The use of the environment as a therapeutic took o Ex: acute care floor – activities Legal-ethical principles: 2 Autonomy  patients right to make their own decisions  Always document reason of refusal, logistics, what you taught them, and that they know the risks associated with refusal of treatment Beneficence  to do good Justice  fair and equal Veracity  telling the truth Non-maleficence  to avoid causing harm Confidentiality  keeping patients information private Schizophrenia/psychosis: 6 (symptoms, etiology, medications, side effects, management, toxic effects, nursing diagnosis & interventions) Schizophrenia - Psychotic sx for at least 6 months - Not related to medical condition or substance abuse - Impaired social academic and occupational functioning - Can be single episode, episodic, continuous, in full or partial remission, never cured - Onset: late adolescence - Dopamine is out of balance in schizophrenia Types of schizophrenia - Paranoid o Suspicious, aloof, may be angry, argumentative, auditory hallucinations, later onset, better prognosis o Respond well to tx o Give them room - Disorganized o More disintegration of personality, incoherence, loose associations, giggling, bizarre behavior, impaired socialization and affect o Do not understand when you speak to them o Inappropriate language and argumentative - Catatonic o Extreme psychomotor retardation, mutism, thought blocking, waxy flexibility, impulsive movements, mild agitation o Move slowly and stiff - Undifferentiated o Bizarre behavior, hallucinations, and delusions Phases of schizophrenia - Prodromal (before disease is evident) o Functioning deteriorates over several months or years; negative symptoms appear - Active o Psychotic symptoms - Residual o Follows active phase o Resembles prodromal stage o May have acute exacerbations o Stabilized .