HESI MILESTONE retake
Establish trust and rapport, encourage
the client to talk with you, be consis-
tent in setting expectations, explain the
procedures and be certain the client un-
derstands, give positive feedback for the Schizophrenia care-
client successes, show empathy, do not
be judgemental, never convey to the
client that you accept their delusions as
reality.
Allow the 5 steps of grieving: Denial,
Anger, Bargaining, Depression, and Ac-
ceptance (DABDA), active listening, and
offering a supportive presence.
Nursing Plans and Interventions:
A. If needed, refer to grief counseling or
a support group.
B. Encourage activities that allow the in-
Grief therapeutic response-
dividual to use past coping strategies to
promote a feeling of self-worth and in-
creased self-esteem.
C. Encourage the individual to share his
or her feelings.
D. Encourage socialization with family
peers and reminisce about significant life
experiences.
Know usual mental status and if changes
noted are long-term, it probably repre-
sents dementia; if they are sudden/acute
in onset, it is more likely to be delirium.
Recognize and report symptoms imme-
diately. Treatment of underlying causes
is important - if untreated, it can lead Delirium care-
to permanent, irreversible brain damage
and death.
The primary goals of nursing care for
clients with delirium are: PROTECTION
FROM INJURY, MANAGEMENT OF
CONFUSION, AND MEETING PHYS-
, HESI MILESTONE retake
IOLOGICAL AND PSYCHOLOGICAL
NEEDS.
Ensure patient safety (fall risk) and man-
age behavioral problems.
Alert the prescriber of nonessential med-
ications.
Nutritional and fluid intake must be mon-
itored.
A quiet and calm environment.
Encourage visitors to touch and talk to
patients.
Assess/manage pain.
Occurs in the late-middle to later stages
of the disease process and is treated Alzheimer's hallucination-
with antipsychotics such as Haldol
Symptoms of withdrawal usually begin 4
to 12 hours after cessation or marked
reduction of alcohol intake. Symptoms
include coarse hand tremors, sweat-
ing, elevated pulse, and blood pres-
sure, insomnia, anxiety, and nausea or
vomiting. Severe or untreated withdraw-
al may progress to transient hallucina-
tions, seizures, or delirium, called delir-
ium tremors. Alcohol withdrawal usual-
ly peaks on the second day and is
over in about 5 days. This can vary, Alcohol withdrawal-
however, and withdrawal may take 1
to 2 weeks. Safe withdrawal is usual-
ly accomplished with the administration
of benzodiazepines, such as lorazepam
(Ativan), chlordiazepoxide (Librium), or
diazepam (Valium), to suppress the with-
drawal symptoms.
Nursing Plans and Interventions
A. Maintain safety, nutrition, hygiene, and
rest.
B. Obtain a BAL on admission or when
, HESI MILESTONE retake
a client appears intoxicated after admis-
sion.
C. Implement suicide precautions if as-
sessment indicates risk.
D. In general
1. Monitor vital signs, input and output
(I&O), and electrolytes.
2. Observe for impending DTs.
3. Prevent aspiration; implement seizure
precautions.
4. Reduce environmental stimuli.
5. Medicate with antianxiety medication,
usually chlordiazepoxide (Librium) or lo-
razepam
(Ativan)
6. Provide high-protein diet and ade-
quate fluid intake (limit caffeine).
7. Provide vitamin supplements, espe-
cially vitamins B1 and B complex.
8. Provide emotional support.
Detoxification and maintenance therapy
for opioid use disorder.
Suppression of withdrawal symptoms
during detox related to opioids such as
heroin.
It can cause respiratory depression.
Do not give it to patients with acute or
severe bronchial asthma.
It is contraindicated for patients taking
MAOIs. Methadone-
Methadone Overdose:
A). Physical Assessment
-Constricted pupils
- Respiratory depression leading to res-
piratory arrest
-Circulatory depression leading to car-
diac arrest
-Unconsciousness leading to coma
-Death
, HESI MILESTONE retake
B). General Appearance
-General physical and mental deteriora-
tion
-Rapid tolerance-overdose likely if not
monitored.
-Impaired judgment
The nurse must protect others from
these clients' manipulative or aggressive
behaviors. At the beginning of treatment,
he or she must set limits on unaccept-
able behavior. The limit setting involves
the following three steps:
Inform clients of the rule or limits.
Explain the consequences if clients ex-
ceed the limit.
State expected behavior.
Nursing Plans and Interventions: Con-
duct and Defiant Disorders
A. Assess verbal and nonverbal cues for
escalating behavior so as to decrease
Aggression response-
outbursts.
B. Use a nonauthoritarian approach.
C. Avoid asking "why" questions.
D. Initiate a "show of force" with a child
who is out of control.
E. Use a "quiet room" when external con-
trol is needed.
F. Clarify expressions or jargon if mean-
ings are unclear.
G. Teach to redirect angry feelings to
safe alternative, such as a pillow or
punching bag.
H. Implement behavior modification ther-
apy if indicated.
I. Role-play new coping strategies with
client.
Establish trust and rapport, encourage
the client to talk with you, be consis-
tent in setting expectations, explain the
procedures and be certain the client un-
derstands, give positive feedback for the Schizophrenia care-
client successes, show empathy, do not
be judgemental, never convey to the
client that you accept their delusions as
reality.
Allow the 5 steps of grieving: Denial,
Anger, Bargaining, Depression, and Ac-
ceptance (DABDA), active listening, and
offering a supportive presence.
Nursing Plans and Interventions:
A. If needed, refer to grief counseling or
a support group.
B. Encourage activities that allow the in-
Grief therapeutic response-
dividual to use past coping strategies to
promote a feeling of self-worth and in-
creased self-esteem.
C. Encourage the individual to share his
or her feelings.
D. Encourage socialization with family
peers and reminisce about significant life
experiences.
Know usual mental status and if changes
noted are long-term, it probably repre-
sents dementia; if they are sudden/acute
in onset, it is more likely to be delirium.
Recognize and report symptoms imme-
diately. Treatment of underlying causes
is important - if untreated, it can lead Delirium care-
to permanent, irreversible brain damage
and death.
The primary goals of nursing care for
clients with delirium are: PROTECTION
FROM INJURY, MANAGEMENT OF
CONFUSION, AND MEETING PHYS-
, HESI MILESTONE retake
IOLOGICAL AND PSYCHOLOGICAL
NEEDS.
Ensure patient safety (fall risk) and man-
age behavioral problems.
Alert the prescriber of nonessential med-
ications.
Nutritional and fluid intake must be mon-
itored.
A quiet and calm environment.
Encourage visitors to touch and talk to
patients.
Assess/manage pain.
Occurs in the late-middle to later stages
of the disease process and is treated Alzheimer's hallucination-
with antipsychotics such as Haldol
Symptoms of withdrawal usually begin 4
to 12 hours after cessation or marked
reduction of alcohol intake. Symptoms
include coarse hand tremors, sweat-
ing, elevated pulse, and blood pres-
sure, insomnia, anxiety, and nausea or
vomiting. Severe or untreated withdraw-
al may progress to transient hallucina-
tions, seizures, or delirium, called delir-
ium tremors. Alcohol withdrawal usual-
ly peaks on the second day and is
over in about 5 days. This can vary, Alcohol withdrawal-
however, and withdrawal may take 1
to 2 weeks. Safe withdrawal is usual-
ly accomplished with the administration
of benzodiazepines, such as lorazepam
(Ativan), chlordiazepoxide (Librium), or
diazepam (Valium), to suppress the with-
drawal symptoms.
Nursing Plans and Interventions
A. Maintain safety, nutrition, hygiene, and
rest.
B. Obtain a BAL on admission or when
, HESI MILESTONE retake
a client appears intoxicated after admis-
sion.
C. Implement suicide precautions if as-
sessment indicates risk.
D. In general
1. Monitor vital signs, input and output
(I&O), and electrolytes.
2. Observe for impending DTs.
3. Prevent aspiration; implement seizure
precautions.
4. Reduce environmental stimuli.
5. Medicate with antianxiety medication,
usually chlordiazepoxide (Librium) or lo-
razepam
(Ativan)
6. Provide high-protein diet and ade-
quate fluid intake (limit caffeine).
7. Provide vitamin supplements, espe-
cially vitamins B1 and B complex.
8. Provide emotional support.
Detoxification and maintenance therapy
for opioid use disorder.
Suppression of withdrawal symptoms
during detox related to opioids such as
heroin.
It can cause respiratory depression.
Do not give it to patients with acute or
severe bronchial asthma.
It is contraindicated for patients taking
MAOIs. Methadone-
Methadone Overdose:
A). Physical Assessment
-Constricted pupils
- Respiratory depression leading to res-
piratory arrest
-Circulatory depression leading to car-
diac arrest
-Unconsciousness leading to coma
-Death
, HESI MILESTONE retake
B). General Appearance
-General physical and mental deteriora-
tion
-Rapid tolerance-overdose likely if not
monitored.
-Impaired judgment
The nurse must protect others from
these clients' manipulative or aggressive
behaviors. At the beginning of treatment,
he or she must set limits on unaccept-
able behavior. The limit setting involves
the following three steps:
Inform clients of the rule or limits.
Explain the consequences if clients ex-
ceed the limit.
State expected behavior.
Nursing Plans and Interventions: Con-
duct and Defiant Disorders
A. Assess verbal and nonverbal cues for
escalating behavior so as to decrease
Aggression response-
outbursts.
B. Use a nonauthoritarian approach.
C. Avoid asking "why" questions.
D. Initiate a "show of force" with a child
who is out of control.
E. Use a "quiet room" when external con-
trol is needed.
F. Clarify expressions or jargon if mean-
ings are unclear.
G. Teach to redirect angry feelings to
safe alternative, such as a pillow or
punching bag.
H. Implement behavior modification ther-
apy if indicated.
I. Role-play new coping strategies with
client.
