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Hocking MH1
Nursing Process of care: Physical and Behavorial
| Question | Answer |
|---|---|
| Avolition | Lack of energy, Contentment to just sit and do nothing, lack of motivation, goal directed behavior |
| Anergia | decreases energy, interest, drive. |
| Akinesia | Slow Heavy movements |
| Posturing | Assume uncomfortable positions for an extended time |
| Waxy flexibility | Assume posture/ position placed in |
| Repetitive Movement Behaviors | Walking, Rocking, pacing, echopraxia, echolalie, perseveration |
| Echopraxia | repetitive actions of others |
| Echolalia | Repeats whats heard, mocking or mimicing others |
| Perseveration | Repeats same words or phrase. |
| What would you do with a suspicious person regarding nutrition? | Allow options that requireclient to open or break seal of food on their own. Oranges, bananas, packaged food that requires a seal to be broken, bottled water. |
| A client is being admitted to the unit who is diagnosed with schizophrenia and currently undergoing a level of high anxiety, where would you assign a room to this patient? | End of the hall, zero stimuli, quiet area without a roommate if possible. |
| Interventions during hyperactivity in a client with schizophrenia regarding milieu. | Room assignment, decrease stimulation, assess for environmental safety concerns, offer support to other clients. |
| Interventions for the team during hyperactivity in client with schizophrenia. | Get back up staff to show support, develop safety plan,contact PCP for emergency medication and restraint and seclusion orders, be consistent to build trust and set safe secure limits, create a calm and safe milieu. |
| Basic Needs (complete sentence) | Are frequently compromised and require attention. |
| Interventions regarding sleep in a client with hyperactivity in schizophrenia. | Offer a clear structured daily routine with energy outlets and rest periods, assess sleep habits, in the acute phase rest is needed and necessary, explore and facilitate a sooting bedtime routine. |
| Interventions regarding ADL's in a client experiencing schizophrenia with hyperactivity. | Assess and support as needed, create a safe private environment to do daily hygiene, encourage the person to feel safe (don't force) to complete personal hygiene, coach one step at a time if needed, help to gradually increase involvement in care. |
| Intervention regarding negativism in a client with schizophrenia. | State expectations and follow through. "Would you like to take your shower before lunch or after lunch?" |
| Intervention regarding catatonia in a client with schizophrenia. | Careful assessment, follow a routine of care explain and act as if client is responding , be clear,assess track and record holistic needs, offer food, fluid, elimination, ROM, ADL support, slowly coach through activities when able, sit in silence. |
| Intervention regarding paranoia | Inform other staff, get PRN meds, Offer reg contacts, Always introduce self and role (don't touch in this phase) Acknowledge fear,discomfort, explain routine, no group involvement initially, give person control of as much as possible. |
| Interventions when dealing with anxiety the nurse will | Always assess for and help decrease anxiety,Help recognize emotions, needs of care,facilitate grieving, listen Normalize, empathize, help develop routines, help develop and use supports. |
| Mild Anxiety | Comforting |
| Moderate Anxiety | Uncomfortable |
| Sever Anxiety | Condemning (saying really mean things) |
| Panic | Conquering |
| Most common type of disturbed sensory perceptions | Auditory and visual |
| Depersonalization | Feels alienated detached from body, person feels disconnected from others and self. |
| Types of Sensory perceptual disturbance | Illusions, hallucinations, depersonalizations. |
| Illusions | Misinterpret reality stimuli ( saw a leaf fly aacross the road and you think its a chipmunk) Mind tricks. |
| Hallucinations | Impaired sensory experiences,without apparent stimuli, same stages of anxiety, many kinds as senses. |
| Loose Associations | Thoughts without apparent connections. (jumping from one topic to another. |
| Tangential Circumstantial | Gives many nonessential details (acute confusion) |
| Concrete thinking | Literal, factual,( What brings you to the hospital?.....The bus) |
| Clang Associations | Rhyming |
| Word Salad | Random words together that are real and made up,makes no sense, hard to respond to theses types of comments. |
| Perseveration or Ruminations | Repetitive words and thoughts |
| Verbigeration | Repeat meaningless words |
| Thought Problems | Blocking, Broadcasting, Withdrawal, Insertion |
| Blocking | Thoughts stop |
| Broadcasting | Others hear thoughts |
| Withdrawal | Others withdrawal thoughtss |
| Insertion | Others insert thoughts. |
Created by:
smithk11593
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