HESI MILESTONE 2 VERSION A
BLUEPRINT
Schizophrenia care-
Establish trust and rapport, encourage the client to talk with you, be consistent in setting
expectations, explain the procedures and be certain the client understands, give positive
feedback for the client successes, show empathy, do not be judgemental, never convey to the
client that you accept their delusions as reality.
Grief therapeutic response-
Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression, and Acceptance (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 individual to use past coping strategies to promote a
feeling of self-worth and increased self-esteem.
C. Encourage the individual to share his or her feelings.
D. Encourage socialization with family peers and reminisce about significant life experiences.
Brainpower
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Delirium care-
Know usual mental status and if changes noted are long-term, it probably represents dementia;
if they are sudden/acute in onset, it is more likely to be delirium. Recognize and report
symptoms immediately. Treatment of underlying causes is important - if untreated, it can lead 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 PHYSIOLOGICAL AND PSYCHOLOGICAL
NEEDS.
Ensure patient safety (fall risk) and manage behavioral problems.
Alert the prescriber of nonessential medications.
Nutritional and fluid intake must be monitored.
A quiet and calm environment.
Encourage visitors to touch and talk to patients.
Assess/manage pain.
Alzheimer's hallucination-
Occurs in the late-middle to later stages of the disease process and is treated with
antipsychotics such as Haldol
Alcohol withdrawal-
Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of
alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse, and blood
pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may
progress to transient hallucinations, seizures, or delirium, called delirium tremors. Alcohol
withdrawal usually peaks on the second day and is over in about 5 days. This can vary,
however, and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually accomplished with
the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium),
or diazepam (Valium), to suppress the withdrawal symptoms.
Nursing Plans and Interventions
A. Maintain safety, nutrition, hygiene, and rest.
B. Obtain a BAL on admission or when a client appears intoxicated after admission.
C. Implement suicide precautions if assessment 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 lorazepam
(Ativan)
6. Provide high-protein diet and adequate fluid intake (limit caffeine).
7. Provide vitamin supplements, especially vitamins B1 and B complex.
8. Provide emotional support.
Methadone-
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 Overdose:
A). Physical Assessment
-Constricted pupils
- Respiratory depression leading to respiratory arrest
-Circulatory depression leading to cardiac arrest
-Unconsciousness leading to coma
-Death
, B). General Appearance
-General physical and mental deterioration
-Rapid tolerance-overdose likely if not monitored.
-Impaired judgment
Aggression response-
The nurse must protect others from these clients' manipulative or aggressive behaviors. At the
beginning of treatment, he or she must set limits on unacceptable behavior. The limit setting
involves the following three steps:
Inform clients of the rule or limits.
Explain the consequences if clients exceed the limit.
State expected behavior.
Nursing Plans and Interventions: Conduct and Defiant Disorders
A. Assess verbal and nonverbal cues for escalating behavior so as to decrease 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 control is needed.
F. Clarify expressions or jargon if meanings are unclear.
G. Teach to redirect angry feelings to safe alternative, such as a pillow or punching bag.
H. Implement behavior modification therapy if indicated.
I. Role-play new coping strategies with client.
BLUEPRINT
Schizophrenia care-
Establish trust and rapport, encourage the client to talk with you, be consistent in setting
expectations, explain the procedures and be certain the client understands, give positive
feedback for the client successes, show empathy, do not be judgemental, never convey to the
client that you accept their delusions as reality.
Grief therapeutic response-
Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression, and Acceptance (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 individual to use past coping strategies to promote a
feeling of self-worth and increased self-esteem.
C. Encourage the individual to share his or her feelings.
D. Encourage socialization with family peers and reminisce about significant life experiences.
Brainpower
Read More
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:15
Full screen
Delirium care-
Know usual mental status and if changes noted are long-term, it probably represents dementia;
if they are sudden/acute in onset, it is more likely to be delirium. Recognize and report
symptoms immediately. Treatment of underlying causes is important - if untreated, it can lead 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 PHYSIOLOGICAL AND PSYCHOLOGICAL
NEEDS.
Ensure patient safety (fall risk) and manage behavioral problems.
Alert the prescriber of nonessential medications.
Nutritional and fluid intake must be monitored.
A quiet and calm environment.
Encourage visitors to touch and talk to patients.
Assess/manage pain.
Alzheimer's hallucination-
Occurs in the late-middle to later stages of the disease process and is treated with
antipsychotics such as Haldol
Alcohol withdrawal-
Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of
alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse, and blood
pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may
progress to transient hallucinations, seizures, or delirium, called delirium tremors. Alcohol
withdrawal usually peaks on the second day and is over in about 5 days. This can vary,
however, and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually accomplished with
the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium),
or diazepam (Valium), to suppress the withdrawal symptoms.
Nursing Plans and Interventions
A. Maintain safety, nutrition, hygiene, and rest.
B. Obtain a BAL on admission or when a client appears intoxicated after admission.
C. Implement suicide precautions if assessment 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 lorazepam
(Ativan)
6. Provide high-protein diet and adequate fluid intake (limit caffeine).
7. Provide vitamin supplements, especially vitamins B1 and B complex.
8. Provide emotional support.
Methadone-
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 Overdose:
A). Physical Assessment
-Constricted pupils
- Respiratory depression leading to respiratory arrest
-Circulatory depression leading to cardiac arrest
-Unconsciousness leading to coma
-Death
, B). General Appearance
-General physical and mental deterioration
-Rapid tolerance-overdose likely if not monitored.
-Impaired judgment
Aggression response-
The nurse must protect others from these clients' manipulative or aggressive behaviors. At the
beginning of treatment, he or she must set limits on unacceptable behavior. The limit setting
involves the following three steps:
Inform clients of the rule or limits.
Explain the consequences if clients exceed the limit.
State expected behavior.
Nursing Plans and Interventions: Conduct and Defiant Disorders
A. Assess verbal and nonverbal cues for escalating behavior so as to decrease 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 control is needed.
F. Clarify expressions or jargon if meanings are unclear.
G. Teach to redirect angry feelings to safe alternative, such as a pillow or punching bag.
H. Implement behavior modification therapy if indicated.
I. Role-play new coping strategies with client.
