schizo3 nursing

  1. nx process- assessment
    • complex process- data various sources may be difficult to pull together
    • stadardized screening tools-
    • Global Assessment Functioning (GAF)= ability to perform ADL's self persevere, subjective 0-100
    • Brief Pyschiatric Rating Scale (BPRS) pos and neg symptoms assist in efficacy of tx. consist of 18 symptoms in 30 mins to complete
    • abnormal involuntary movement scale- tardative kinesia
  2. Assessment
    • complete H&P
    • CBC (anemia bc of meds), thyroid function test, LFT (antipsych meds), minerals, toxicology screen
    • neuro exam
    • neuropsychological test
    • MRI- fx identifies sudden brain chx
    • PET- fx determine brain activity
    • ¬†EEG- fx reveals electrical activity
  3. mental status exam
    • thought content--- delusions
    • thought process- loose assoc, word salad, tangebility
    • perception- hallucination (smiling, inapproriately turning head to listen, talking to no one there)
    • affect- inapproriate, flat, bland
    • sense of self- schizo [t experiences much confusion regarding his/her identity, echolia, echopraxia
  4. mental status exam 2
    • volition- inablity to initiate goal directed activity ambivalence (co-existing opposite emotions that interferes with ability to make simple decisions)
    • impaired interpersonal functioning- intrusion of personal space, emotional detachment, deteriorated appearance, regression to an earlier level of development
    • psychomotor behavior- anergia (laziness), waxy flexibility, posturing, pacing, rocking
  5. NANDA nursing diagnoses
    • impaired verbal communication r/t regression, withdrawal, poor concentration
    • social isolation r/t inablity to trust, poor concentration
    • disable family coping r/t lack of infomation and understanding pt's illness
    • disturbed thought processes r/t delusional thinking, impaired volition, inability to problem solve
  6. possible nx diagnoses
    • disturbed sensory perception r/t auditory/visual hallucination
    • impaired verbal communication r/t panic anxiety, unrealistic thinking
    • self care deficit r/t regression, withdrawal general deterioration in appearance and social manners
    • risk for self directed or other directed violence r/t suspiciousness, panic anxiety, command hallucination
  7. possible nx dx cont
    • ineffective health maintenance r/t inability to take responsibility for basic health practices, lack of knowledge re same
    • impaired home maintenance r/t unsafe, unclean disorderly, family expressing difficulty, maintaining their home in a safe comfortable condition r/t the pt
  8. outcomes- pt will
    • demonstate significant reduction in hallunication/delusions
    • demonstate absense of self mutilating, violent agressive behaviors
    • demonstrate reality based thinking and behaviors
    • engage in own hygience, grooming and adl skills
    • note: be flexible focus on maximizing pt functioning, setting realistic goals. very sensitive to change and failure. best is focus on things important to them ie personal power social expectation, self care, stability and coping with relapses
  9. the pt will:
    • socialize with peers and staff, participate in all groups
    • adhere to med regimen- honest open about what it will do s/e
    • verbalize an understanding of the role of med to reducing psychotic symptoms
    • demonstrate more functional coping and problem solving methods
    • participate in d/c planning with family
    • goals must be specific measurable, attainable, realstic, times and broken down into small steps, with inability to focus problem solve or reason task can be overwhelming, don't push them may increase anxiety, ie select one place of clothing- choosing an outfit can be a goal
  10. nx intervention
    • work on developing therapuetic relationships
    • socialization is the focus of tx plan include pt in activities that are supportive, non threatening, non competive, provide helpful feedback on how pt presents to others, can help if nurse attends grp with pt
    • the nx-pt relation is one of the most effective nx interventions..listen to pt, accepts them for who they are, understance their perspective, empowers the pt to achieve their highest level of functioning
  11. nursing intervention
    • attending groups with pt can help to meet short term goal of socialization
    • the nx care plan beginning p 351 addresses all of the pt potential needs, nx dx, with clearly written nx actions with rationales
  12. nurse role
    • be alert to avoid power struggles- no alterations w/pts
    • fam/others (if pt is returning home) must be included in tx planning and understand the goals, the interventions, in order to dec likelihood of recidivism relapse
    • provide explanation and rationales for all interventions
    • pt should set their own goals, go at their own pace- once stabilzed
  13. The four S of schizo
    • Stimulation- slowly and gradually introduces new routines, people and situations
    • Structure- provide daily routine, structure for waking dressing eating activity
    • Socialization- getting people in their lives to help with finances, healthcare, food, socializing
    • support- encourage to try new tasks, accompany to new places until they make new friends, feel comfortable
  14. nx interventions
    • assess and monitor for risk factors
    • reduce/minimize environmental stimulation
    • provide frequent time-outs and/or brief low- key interactions- sitting in group for like 10 mins
    • support and monitor prescribed medical and pyschosocial intervention
    • use clear concrete statements
    • determine precipitating factos that may excerbate the pts hallucinatory experiences-triggersm incre pt anxiety (med time, vistors, noise)
    • schizo need motherly attention on the unit
  15. nurse's role in tx
    • give positive feedback to pt for reality based perceptions, for not acting aggressive ways for approriate social interaction and group participation
    • educate pt/fam about symptoms, importance of medication adherence and continued use of therapeutic suppose after d/c
    • distract pt from delusion that exacerbate aggressive/potentially violent episodes, decrea anxiety
    • talk about real people, real things- talk about the weather etc. draw pt into reality based situation, thoughts
    • decreased anxiety- decre hallucinations, delusions
  16. what nurses do
    • accompany the pt to group activities (especially withdrawn pt) structured, simple, safe/less threatening groups-promote organized behavior
    • assist with personal hygiene, approriate dress, grooming until able to perform independently self-esteem,avoid power struggles
    • pt: i know this food is poisoned
    • nx: i understand it is frightening for you to believe this
  17. nursing role
    • establish routine time (decre anxiety since know what to expect) and goals for self care- helps to organize and promote reality in their world
    • spend planned time with pt each, engage in non challenging interactions, cases the pt into the community, helps develop NPR: they have experienced failures in relationships in the past and have a fear of rejection
    • assess pt's self concept
  18. what we do as nurses...
    • act as a role model for social behaviors in interactions, maintain good eye contact, approriate social distance, calm demeanor, helps pt identify appropriate social behavior
    • keep all appointments with pts develops trust
    • listen actively- allow pt/fam to express fears/anxieties, give support, empathy, emphasize clients
  19. nx interventions with anxious pyschotic pt
    • 1:1 interactions. calm voice and approach, quiet space or room
    • assess hallucinations command, determine triggers for hallu, use clear statements,
    • observe for signs of hallu like talking to oneself, looking around, startled response
    • do not touch without warning
    • even though i realize the voices are real to you i do not hear any voices speaking
    • distract- try to get them to do something else
  20. nx intervention with anxious pyscho pt 2
    intervention with delusions
    • do not argue with their false belief
    • do not focus on the content of the delusion other than to access the theme
    • focus on reality based aspects of the communication- assess feelings r/t delusions
    • protect them from self harm/harm to others
Card Set
schizo3 nursing
in memory