NCLEX-PNPsychosocial Integrity

Concorde Career CollegeGarden Grove

Effective Communication Techniques

• Listen• Acknowledge• Give feedback• Be congruent• Clarify• Focus or defocus client• Validate• Reflect• Ask open-ended questions

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Effective Communication Techniques (continued)

• Encourage in nonverbal way• Restate• Paraphrase• Respond in neutral way• Use incomplete sentences• Minimize verbalization• Initiate broad statements• Use translator as needed

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Blocks to Effective Communication

• Make assumptions• Give advice• Change the subject• Use of social responses• Invalidate client• Use of false reassurances• Overload/underload conversation• Use of incongruent messages• Make value judgments

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Mental Health Assessment

• General appearance• Orientation• Affect, mood• Body movements• Speech • Thought processes – delusions• Perceptions – illusions, hallucinations• Memory• Religion, education, etc.• Judgment and potential for injury

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Mental Health Assessment

• Personality– Attitude and behavior– Patterns of adjustment

• Stress– Learned or conditioned behavior

• Anxiety – Perceived threat to self– Response to stress

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Defense Mechanisms

• Compensation• Conversion reaction• Denial• Displacement• Dissociation• Fantasy• Identification • Isolation • Projection

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Defense Mechanisms (contin.)

• Projection (scapegoating)• Rationalization• Reaction-formation• Regression• Repression• Restitution (undoing)• Sublimation

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Crisis Intervention

• Behaviors seen:– Denial– Anxiety– Shock– Anger– Withdrawal

• Phases of crises:– Increased anxiety and tension– Normal coping ineffective– Panic state– Personality changes– Resolution 9

Care in Crisis Intervention

• Try to understand feelings• Maintain safety• Enlist aid of others• Collaborate with health team members• Use non-verbal communication• Offer concrete assistance• Monitor progress and provide follow up

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Treatment for Crisis Intervention

• Group therapy• Family therapy• Environmental therapies• Psychotherapy• Somatic therapy

– Electroconvulsive therapy– Phototherapy (esp. Seasonal Affective Disorder)

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Grief and Loss

• Stages of Grieving – Denial and isolation– Anger– Bargaining– Depression– Acceptance

• Assessment– Previous coping mechanisms– Potential for violence– Changes in self– Changes in health maintenance

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Grief and Loss Intervention

• Provide support • Be aware of own feelings• Assess religious/spiritual beliefs• Assist client in saying goodbye• Provide medications as ordered

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Post-Traumatic Stress Disorder

• Symptoms– Introverted– Social withdrawal– Guilt and unfocused anger– Irritable and hostile– Low self-esteem– Sleep disturbances (insomnia, nightmares, etc.)– Depression– Substance abuse– Impaired relationships

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Post-Traumatic Stress Disorder

• Interventions– Educate about disorder– Non-stimulating/non-threatening environment– Provide support and protection– Encourage discussion of feelings– Set limits on behavior– Redirect aggressive or hostile behavior– Antianxiety medication

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Somatoform Disorders

• Characterized by reported physical symptoms with no organic cause

• Manifestations– Sensory– Motor– Visceral

• Nursing-– Redirect from manifestation– Encourage discussion of symptoms– Reinforce relaxation and stress reduction techniques– Schedule daily activities

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Somatoform Disorders

• Treatment– Antidepressants/antianxiety– Antipsychotic prn

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Hypochondriasis

• Preoccupied with health without organic cause• Seeks treatment from multiple providers• Nursing:

– Set limits and do not support manifestations– Help client express feelings– Administer SSRI’s, tricyclics, etc. as ordered

• Cognitive behavioral therapy

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Cognitive Mental Disorders

• Causes– Kidney or thyroid disease– Nutritional deficiencies– Meningitis– Syphilis– Benign trauma/tumor

• Dementia– Slow and progressive

• Delirium– Rapid change in consciousness

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Alzheimer’s Disease

• Non-reversible cognitive disorder• Progressive• Symptoms

– Sensory aphasia– Echolalia or palilalia– Behavior and motor function changes– Changes worsen with disease

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Cognitive Disorders: Nursing Care

• Assess memory loss and level of consciousness• Help client remain independent as much as

possible• Treat symptoms• Daily routine• Medications as ordered

– Assess for side effects

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Thought Process Disorders

• Delusions: false, fixed beliefs– Types

• Grandeur• Ideas of reference• Persecution• Somatic delusions• Thought broadcasting• Thought insertion• Thought withdrawal

• Hallucinations: sensory disturbance

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Thought Process Disorders

• Schizophrenia– Symptoms

• Cognitive impairment• Perceptual changes• Affective changes• Behavioral changes• Social changes

– Assessment• Mental functioning• Ability to function in society• Ability to care for self• Safety

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Thought Process Disorders

• Schizophrenia– Interventions

• Self-care activities• Counseling• Education• Neuroleptics/antipsychotics

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Depression

• Symptoms– Psychologically depressed mood– Appetite disturbance– Psychomotor retardation– Anxiety– Decreased self-esteem– Somatic complaints– Decreased or lack of interest in activities– Suicidal thoughts– Poor personal hygiene, posture, clothes

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Depression (continued)

• Interventions– Monitor physical activities– Thought processes – slowed, ruminative, blocking– Warm, supportive, repeated attention– Suicide precautions– Antidepressants– ECT– Psychotherapy– Requires long-term follow up

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Bipolar Disorder

• Symptoms (mania)– Flight of ideas– Elated, grandiose mood– Psychomotor excitement – Short attention span– Lack of attention to detail– Exaggerated response to stimuli– Restlessness

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Bipolar Disorder (continued)

• Interventions– Maintain physical status– Assess and assist with stabilization of thought processes– Decrease complications/hazards of abnormally inflated

self-esteem– Prevention of painful consequences– Adjunct therapy– Lithium

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Anxiety

• Symptoms– Muscle aches– Shakes– Palpitations– Dry mouth– Nausea/vomiting– Hot flashes– Chills – Polyuria– Difficulty swallowing

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Anxiety (continued)

• Counseling• Apply coping skills• Improve self-care• Milieu therapy• Antianxiety medications

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Panic Attack and Phobias

• Panic attack• Phobias

– Acrophophia– Agorophobia– Hematophobia– Mysophobia– Social phobias– Simple phobias– Claustrophobia

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Panic Attack and Phobias

• Interventions– Maintain calm milieu– Assurance staff will not belittle– Constructive activities– Promote safety– Promote social interaction– Do not attempt to interpret behavior– Monitor for panic attacks– Assess for suicidal thoughts– Document behavior changes

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Obsessive Compulsive Disorder

• Interventions– Provide time for ritual– Help problem solve– Role model appropriate behavior– Suicide precautions– Provide supportive environment with few changes– Monitor physical needs– Provide anti-anxiety meds and antidepressants– Document behavior changes

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Personality Disorders

• Borderline• Antisocial

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Suicide

• Symptoms– Improvement in mood and affect– Feelings hopelessness, helplessness, guilt, aggression– Gives away personal items– Progressive inability to cope– Usually follows series of “small” stressors– Talk about death and suicide– Difficulty sleeping

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Suicide (continued)

• Danger signs– Previous attempts– Change in personality– Change in mood– Giving away valued possessions– Getting things in order– Direct verbalizations– Long-term chronic illness– Alcoholism or drug abuse– Recurrent surgeries– Suicide note

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Suicide (continued)

• Interventions– Assessment extent of intent

• Thinking about it?• Plan?• Means?

– Suicide precautions– Offer support, safety– Treat underlying depression

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Eating Disorders: Anorexia

• Symptoms– Refusal to maintain body weight– Fear of becoming fat– Consumption of 200-400 calories/day– Denial of seriousness of low body weight– Absence of menarche– Excessive thoughts (i.e. exercise)– Sleep very little (2-3 hours/night)

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Eating Disorders: Anorexia

• Interventions– Education– Assess medications– Psychotherapy– Promote

• Positive self-concept• Healthy coping skills• Adequate nutrition

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Eating Disorders: Bulimia

• Symptoms– Binge eating with or without purging– Loss of control during eating– Recurrent inappropriate actions to avoid weight gain and

purging of calories– Fasting after binges– Excessive exercise for weight control– Self-esteem controlled by body shape/weight– Impulsiveness

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Eating Disorders: Bulimia

• Interventions– Promote healthy coping– Proper nutrition– Education: nutrition, exercise, sexuality– Assess medication– Psychotherapy

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Substance Related Disorders: Terms

• Substance abuse-> repeated use leading to significant impairment over 12 months

• Substance dependence-> tolerance, withdrawal, taken greater than prescribed, desire to control use, continued use despite problems caused

• Non-substance-related dependency-> dependence on behavior such as gambling or shopping

• Addiction-> loss of control despite continued problems

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Substance Use Disorders

• Risk factors– Culture– Family dysfunction– Personality disorder– Poverty and deprivation– Genetic predisposition– Excessive drug use– Presence of psychological conflict

• Diagnosis– Abuse of at least 1 month duration– Social complication– Dependence 43

Substance Use: Systemic Effects

• Stress• Sleep problems• Attempts to decrease use• CNS symptoms progress• Neurological system• Cardiopulmonary• GI• GU• Skin

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Substance Use Disorders (contin.)

• Interventions– Individual and group counseling– Support groups– Relationship skills– Self-care activities– Special care for dual diagnoses– Health promotion– Pharmacologic intervention– Delirium tremens management

• Safety

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Substances

• Heroine• Narcotics• Cocaine• Methamphetamines

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Abuse

• Causes– Tend to have low self-esteem – History of abuse– Abusers have personality disorders/poor relationships– Multiple stressors

Types– Physical– Emotional– Sexual– Neglect– Social isolation– Economic

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Abuse (continued)

• History– Delay in seeking care– Discrepancies in history– Multiple ER visits– Story vague and contradictory– Sudden change in behavior– Caregiver refuses visitors when client alone– Significant other or parent answers all questions– Dependent or co-dependent personality– Reliance on abuser

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Abuse (continued)

• Physical Examination– Multiple bruises in various stages healing– Suspicious burns – Apathetic child or adult– Poorly nourished child– Child who does not turn to parent for comfort– Unexplained vaginal/genital bruising or bleeding

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Abuse (continued)

• Treatment/Nursing care– Notify abuse hotline when suspected– Make adult feel safe to discuss concerns– Provide information about abuse and where to go for help– Ensure safety– Know your own thoughts/feelings about abuse– Remain nonjudgmental/show empathy– Know agency policy

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Abuse (continued)

• Prevention– Education– Build self-esteem and assertiveness skills– Eliminate co-dependent behavior– Reinforce violence NEVER option

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Sexual Assault (Rape)

• False concepts regarding rape:– Victim promiscuous– Victim provoked rape through mode of dress/actions– Only women are raped– Victims cant be raped against their will– Only young adults are raped

• Nursing interventions– Approach objective, nonjudgemental, empathetic– Provide safety and arrange exam by SANE– Collect evidence per law/policy– Stay with client– Arrange f/u STI’s 52

Alcohol Withdrawal

• Manifestations – Confusion with elevated vital signs– Nausea, vomiting, sensitivity to light– Shakiness, tremors, headache– Anxiety, mood swings, insomnia

• Nursing– Provide safety– Monitor VS– Initiate fluid and vitamin replacement– Administer medications as ordered

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Delirium Tremens

• Acute state of withdrawal– Within 72 hours up to 7-10 days after last drink

• Occurs in 5% patients• Manifestations

– Elevated BP, HR, RR– Sweating, N/V/D– Severe agitation, disorientation, confusion– Visual/auditory hallucinations– Seizures common 1st 24-48 hours

• Provide safety, meds, supportive care

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Pervasive Developmental Disorders: Autism

• Developmental areas affected-> social, interaction, language, behavior

• No single cause• Nursing Interventions->

– Monitor status– Administer medications– Facilitate communication between family– Creative therapy– Diet modifications– Client education/referrals

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Pervasive Developmental Disorders: Asperger’s

• Mild cognitive and/or language delay • Identified late in childhood• Affects ability to socialize and communicate

effectively with others• Typically awkward & all-absorbing in specific topics• Nursing interventions:

– Encourage one-on-one interactions– Use positive reinforcement to encourage desired

behavior– Administer medications – Client education/referrals

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Pervasive Developmental Disorders: Autism Manifestations

• Lack of interest in human contact

• Poor daily living skills• No social play• Repetitive movements• Develops rituals• Disturbed by change• Self-mutilation• Moves constantly• Rocking

• May be fascinated by parts of something

• May be sensitive to light/sound but insensitive to pain

• Late at talking• Developmental delays

by 30 months• Doesn’t make eye

contact

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Pervasive Developmental Disorders: Asperger’s Manifestations

• Engaging in long, one-sided conversations without noticing if other person is listening or trying to change the subject

• Unusual non-verbal communication• Obsession with 1 or 2 subjects• Appears not to understand, empathize with, or

sensitive to others’ feelings• Difficulty “reading” people or humor• Speaks monotonous, rigid, fast• Poor coordination

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Pervasive Developmental Disorders: Asperger’s

• Medications– Aripiprazole (Abilify) for irritability– Guanfacine (Intuniv) hyperactivity and inattention– Fluvoxamine (Luvox) depression or control of repetitive

behaviors (SSRI)– Risperidone (Risperdal) agitation and irritability

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Pervasive Developmental Disorders: Attention Deficit Hyperactivity Disorder

• Chronic conduct disorder usually diagnosed in children

• Characterized by lack of attention, impulsiveness, excessive hyperactivity

• Nursing interventions->– Encourage effective communication– Assess safety and intervene prn– Initiate education techniques– Administer medications (stimulants)– Reinforce compliance/consistency– Referrals as needed

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Pervasive Developmental Disorders: Attention Deficit Hyperactivity Disorder

• Manifestations – Difficulty concentrating– Easily distracted– Poor attention span– Failure to complete tasks– Problems organizing tasks/activities– Avoids/dislikes tasks that require sustained mental effort– Impulsive actions without thought of possible

consequences

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State Law: Commitment of Clients with Psychiatric Conditions

• Involuntary commitment– Must prove:

• Client mentally ill• Danger to self or others

– Can be held 48-72 hours– If determined to still exist = hold 30 days

• Otherwise = released

• Voluntary commitment– Can refuse participation or treatment– Not guaranteed insurance to pay

• Mentally ill have right to TREATMENT

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Informed Consent Required for:

• Electroconvulsive therapy• Medications• Seclusion • Restraints

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Client Rights• Right to receive or refuse treatment• Access to stationery and postage• Receipt of unopened mail• Visits by health care provider, attorney, or clergy• Daily interaction with visitors or phone access• Right to have or spend money• Storage space for personal items• Right to own property, vote, and marry• Right to make wills and contracts• Access to educational resources• Right to sue, or be sued, including challenging one’s

hospitalization64

Any questions?

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