MALADAPTIVE RLE

SMCG

Nursing Process

1. Assessment – Data collection (subjective and

objective)

2. Nursing Diagnosis – Identifying human

responses to health and illness

3. Planning – Setting patient goals and developing

interventions

4. Implementation – Executing nursing interventions

5. Evaluation – Measuring patient outcomes and

modifying care as needed

TYPES OF DATA

Subjective Data

Obtained from the client, family, or significant others

Information given spontaneously or during interview

Includes personal interpretations of symptoms

Objective Data

Information obtained through observation and

assessment techniques:

Inspection – Visual examination

Palpation – Using hands to assess the

body

Percussion – Tapping on the body to

assess internal organs

Auscultation – Listening to sounds (e.g.,

heart, lungs)

GORDON’S FUNCTIONAL HEALTH PATTERNS

Developed by Marjorie Gordon to standardize nursing

assessments.

Based on 11 functional health patterns common to all

humans

Helps identify functional strengths and dysfunctional

patterns

Defines health as optimal functioning

MENTAL STATUS ASSESSMENT

Used to establish a baseline, observe changes over

time, and document findings.

Areas of Assessment

General Observations – Appearance, behavior,

attitude

Orientation – Awareness of time, place, and self

 Mood & Affect

Mood: Overall emotional state (euthymic,

euphoric, dysphoric, labile)

Affect: External emotional expression (range,

intensity, stability)

Speech – Rate, tone, coherence

Thought Processes – Logic, organization,

delusions, hallucinations

Cognition – Memory, problem-solving

Insight vs. Judgment:

Insight – Awareness of one’s illness and emotions

Judgment – Ability to make logical decisions

OTHER ASSESSMENT TOOLS

Psychological Tests – Measures emotional and cognitive

states

Personality Tests – Evaluates personality traits and

disorders

Intelligence Tests – Assesses cognitive abilities

Diagnostic & Laboratory Exams – Identifies

medical causes of psychiatric symptoms

NURSING DIAGNOSIS

A nursing diagnosis identifies human responses to

illness.

Purpose of Nursing Diagnosis:

Helps prioritize nursing care

Enhances communication among healthcare

providers

 Aids in evaluating care effectiveness

DIFFERENCES BETWEEN NURSING & MEDICAL

DIAGNOSIS

Nursing Diagnosis Medical Diagnosis

Focuses on human

responses to illness

Focuses on diseases

(pathology)

Managed by nurses

independently

Managed by physicians

Can change as the

patient’s condition evolves

Remains the same while

the disease persists

TYPES OF NURSING DIAGNOSIS

Problem-Focused (Actual) Diagnosis

 Example: High risk for self-directed violence

related to depression, feeling of

worthlessness, anger turned inward

Risk Nursing Diagnosis

Example: Risk for Falls as evidenced by

dizziness and decreased lower extremity

strength

Health-Promotion Nursing Diagnosis

Focuses on improving overall well-being

Syndrome Diagnosis

A cluster of related nursing diagnoses

NANDA NURSING DIAGNOSES & NOC (Nursing

Outcomes Classification)

The NOC framework is used to evaluate patient

outcomes.

NOC Format:

Label Name

Definition

Measurement Scale

Indicators

Example of NOC Measurement Scales:

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

EXAMPLES OF NOC OUTCOMES

1. Bowel Continence (0500)

Definition: Control of stool passage

Indicators:

Maintains stool control

Ingests adequate fluids

Monitors stool consistency

2. Parent-Infant Attachment (1500)

Definition: Bond between parent and infant

Indicators:

Practices healthy behaviors during

pregnancy

Verbalizes positive feelings toward the

infant

 Responds to infant cues

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Nursing Process

Assessment – Data collection (subjective and objective)
Nursing Diagnosis – Identifying human responses to health and illness
Planning – Setting patient goals and developing interventions
Implementation – Executing nursing interventions
Evaluation – Measuring patient outcomes and modifying care as needed TYPES OF DATA Subjective Data  Obtained from the client, family, or significant others  Information given spontaneously or during interview  Includes personal interpretations of symptoms Objective Data  Information obtained through observation and assessment techniques:  Inspection – Visual examination  Palpation – Using hands to assess the body  Percussion – Tapping on the body to assess internal organs  Auscultation – Listening to sounds (e.g., heart, lungs) GORDON’S FUNCTIONAL HEALTH PATTERNS  Developed by Marjorie Gordon to standardize nursing assessments.  Based on 11 functional health patterns common to all humans  Helps identify functional strengths and dysfunctional patterns  Defines health as optimal functioning MENTAL STATUS ASSESSMENT  Used to establish a baseline, observe changes over time, and document findings. Areas of Assessment  General Observations – Appearance, behavior, attitude  Orientation – Awareness of time, place, and self  Mood & Affect  Mood : Overall emotional state (euthymic, euphoric, dysphoric, labile)  Affect : External emotional expression (range, intensity, stability)  Speech – Rate, tone, coherence  Thought Processes – Logic, organization, delusions, hallucinations  Cognition – Memory, problem-solving Insight vs. Judgment:  Insight – Awareness of one’s illness and emotions  Judgment – Ability to make logical decisions OTHER ASSESSMENT TOOLS Psychological Tests – Measures emotional and cognitive states  Personality Tests – Evaluates personality traits and disorders  Intelligence Tests – Assesses cognitive abilities  Diagnostic & Laboratory Exams – Identifies medical causes of psychiatric symptoms NURSING DIAGNOSIS  A nursing diagnosis identifies human responses to illness. Purpose of Nursing Diagnosis:  Helps prioritize nursing care  Enhances communication among healthcare providers  Aids in evaluating care effectiveness DIFFERENCES BETWEEN NURSING & MEDICAL DIAGNOSIS Nursing Diagnosis Medical Diagnosis Focuses on human responses to illness Focuses on diseases (pathology) Managed by nurses independently Managed by physicians Can change as the patient’s condition evolves Remains the same while the disease persists TYPES OF NURSING DIAGNOSIS  Problem-Focused (Actual) Diagnosis  Example: High risk for self-directed violence related to depression, feeling of worthlessness, anger turned inward  Risk Nursing Diagnosis  Example: Risk for Falls as evidenced by dizziness and decreased lower extremity strength  Health-Promotion Nursing Diagnosis  Focuses on improving overall well-being  Syndrome Diagnosis  A cluster of related nursing diagnoses NANDA NURSING DIAGNOSES & NOC (Nursing Outcomes Classification)  The NOC framework is used to evaluate patient outcomes. NOC Format:  Label Name  Definition  Measurement Scale  Indicators Example of NOC Measurement Scales: 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised EXAMPLES OF NOC OUTCOMES
Bowel Continence (0500) Definition : Control of stool passage Indicators :  Maintains stool control  Ingests adequate fluids  Monitors stool consistency
Parent-Infant Attachment (1500) Definition : Bond between parent and infant Indicators :  Practices healthy behaviors during pregnancy  Verbalizes positive feelings toward the infant  Responds to infant cues

Community Health Status (2701) Definition: Well-being of a community or population Indicators:  Participation in health programs  Compliance with health standards  Surveillance systems in place
Self-Esteem (1205) Definition : Personal judgment of self-worth Indicators :  Verbalizes self-acceptance  Maintains grooming and hygiene  Displays confidence Nurse-Client Communication Communication Process  Exchange of information  Takes place simultaneously verbal and non verbal communication The Four Communication Skills  Thinking  Listening  Speaking  Non-verbal Aspects of Communication  Referent - motivates one person to communicate  Sender - the one who convey the message  Message - the thought, idea, or emotion conveyed  Channel - how the message is sent  Receiver - physiological / psychological components  Feedback - the receiver's response to the sender  Influences - Culture, education, emotions, and other factors involved  Interpersonal variables - factors within both the sender and receiver that influence communication Levels of Communication  Intrapersonal Communication  occurs within an individual  self-talk, self-verbalization, or inner thought, self awareness and self concept  Interpersonal Communication  one on one interaction between two person  most frequently in used in nursing situation  results in exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth.  Transpersonal Communication  occurs within a person’s spiritual domain  communication with their “higher power”  prayer, meditation, religious rituals  Small Group Communication  occurs when a small number of persons meet  usually goal directed  Effective when they are cohesive and committed (Arnold and Bogggs, 2011)  Public Communication  interaction with an audience  Requires special adaptation in eye contact, gesture, voice inflection Process of exchange information  Verbal - words a person uses to speak  Context - Environment in which communication occurs  Non-verbal - Behavior that accompanies verbal context  Process - denotes all nonverbal messages  Congruency - saying and actions are congruent Privacy and Boundaries Proxemics - study of distance zones between people during communication  Intimate zone (0-18 inches) - comfortable for parents with young children, people who mutually desire personal contact, or people whispering.  Personal Zone (18-36 inches)- comfortable between family and friends who are talking.  Social Zone (4-12 ft) - acceptable for communication in social, work and business setting  Public Zone (1-25ft) - acceptable distance between a speaker and an audience, small group and other informal function Touch  Functional-professional touch - used in examination or procedures  Social-polite touch - used in greetings like handshake and air kisses  Friendship-warmth touch - involves a hug in greeting and arm thrown around the shoulder of a good friend  Love-intimacy touch- involve tight hugd and kisses between lovers or close relatives  Sexual-arousal touch- used by lovers Active listening - refraining from other internal mental activities and concentrating exclusively on what the client says Active Observation - watching the speaker’s nonverbal actions as he or she communicates Verbal Communication Skills  Concrete messages - specific and clear  Abstract messages - unclear patterns of words Therapeutic Communication- techniques facilitate interaction and enhance communication between patient and nurse Technique Rationale Examples Using silence Gives opportunity to collect and organize thoughts Accepting Conveys an attitude of reception and regard “yes I understand what you said” Giving recognition Acknowledging and awareness “ Isee you made your bed…” Offering self Making oneself available “I'll stay with you awhile….” Giving broad openings Allow the client take initiative “ tell me what you are thinking” Offering general leads Encourage the client to continue “Go on…” Placing the events in time or sequence Clarifies the relationship of events “what seemed to lead up to?” Making Verbalizing what is “I notice…”

 Vocal cues - voice volume, tone, pitch, intensity, emphasis, speed, pauses augment the sender’s message  Eye contact - looking into the other person’s eyes during communication, mirror of the soul, reflects our emotions  Silence - depressed and struggling to find the energy to talk, thoughtfully considering the question, not paying attention. Beginning therapeutic communication  Introduce and establish contract  Find patient-centered goals  Use directive or nondirective role appropriately, based on patient behavior Directive - asking direct yes/no questions Non-directive -using broad openings and open ended questions Goals of a therapeutic communication session  Establishing rapport  Identifying issues of concern and formulate a client- centered goal  Understanding the patient’s perception  Exploring the patients thought and feelings  Developing problem-solving skills  Promoting the patient’s evaluation of solution Components of Therapeutic nurse-patient relationship  Trust  Genuine interest  Empathy  Acceptance of person  Unconditional positive regard  Self-awareness  Values  Attitudes  Belief  Therapeutic use of self Establishing the therapeutic relationship  Orientation - begins when the nurse and client meet and ends when the client begins to identify problems to examine  Working phase  Problem identification - Client identifies the issues or concerns causing problems  Exploitation - nurse guides the client to examine feelings and responses  Transference - patients unconsciously transfer feelings  Countertransference - nurse responds to the patient based on his or her own unconscious needs and conflicts  Termination Phase - begins when the problems are resolved, and it ends when the relationship is ended Therapeutic Roles of the Nurse  Teacher  Caregiver  Advocate  Parent surrogate Acute Stress - is a mental health condition that occurs in response to experiencing or witnessing a traumatic event. It is characterized by significant psychological distress and functional impairment lasting from three days to one month after the trauma. SYMPTOMS AND DIAGNOSTIC CRITERIA  Intrusion Symptoms – Recurrent distressing memories, nightmares, or flashbacks related to the traumatic event.  Negative Mood – Persistent feelings of emotional numbness, detachment, or an inability to experience positive emotions.  Dissociative Symptoms – Altered sense of reality, memory lapses related to the trauma, or feeling detached from oneself.  Avoidance Symptoms – Avoidance of thoughts, people, places, or activities that remind the person of the event.  Arousal Symptoms – Hypervigilance, exaggerated startle response, sleep disturbances, irritability, and difficulty concentrating. Assessment  Has the person recently experienced a potentially traumatic event?  If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress?  Is there a concurrent condition? FOLLOW-UP AND MONITORING  Reassess the individual in 2–4 weeks if symptoms persist.  Provide immediate support if symptoms worsen or significantly impair daily functioning. Grief - is the emotional suffering people experience after a loss. Significant symptoms  Sadness, anxiety, anger, despair  Yearning and preoccupation with the loss  Intrusive memories, images, or thoughts of the deceased  Loss of appetite, energy, sleep problems  Social isolation and withdrawal  Medically unexplained physical complaints  Culturally specific grief reactions Prolonged Grief Disorder - Occurs when grief symptoms persist for an extended period (at least 6 months). Features:  Intense longing for the deceased.  Severe emotional pain.  Considerable difficulty with daily functioning. Common mental health issues after loss  Moderate-severe depressive disorder (DEP)  Psychosis  Self harm/Suicidal Ideation (SUI)  Harmful use of Alcohol and Drugs (SUB) Assessment of Grief  Has the person experienced a major loss?  Has the loss occurred within the last 6 months?  Are there concurrent symptoms that significantly affect daily functioning? Basic Management Plan

 DO NOT prescribe medications to manage symptoms of grief.  Provide Psychosocial Support  Strengthen social support.  Educate About Grief Follow-Up Plan  Encourage a 2–4 week follow-up if symptoms persist.  Continue support and monitoring. Moderate-Severe Depressive DIsorder Typical presenting complaints of moderate-severe depressive disorder:  Low energy, fatigue, sleep problems  Multiple persistent physical symptoms with no clear cause (e.g. aches and pains)  Persistent sadness or depressed mood, anxiety  Little interest in or pleasure from activities. Assessment 1  Does the person have moderate-severe depressive disorder? Core Symptoms:  Persistent depressed mood  For children and adolescents: irritability or depressed mood  Markedly diminished interest in or pleasure from activities (including reduced sexual desire) Additional Symptoms:  The person has experienced several of the following symptoms to a marked degree (or many to a lesser degree) for at least 2 weeks:  Disturbed sleep or excessive sleep  Significant change in appetite or weight (decrease or increase)  Beliefs of worthlessness or excessive guilt  Fatigue or loss of energy  Reduced ability to concentrate and sustain attention on tasks  Indecisiveness Impact on Daily Functioning:  Considerable difficulty in personal, family, social, educational, occupational, or other important domains. Diagnosis Criteria:  If A, B, and C are present for at least 2 weeks, moderate-severe depressive disorder is likely.  Presence of delusions or hallucinations may require adapted treatment; consult a specialist. Assessment 2  Other Possible Explanations for Symptoms Rule Out Concurrent Physical Conditions :  Anaemia, malnutrition, hypothyroidism, stroke, or medication side effects (e.g., mood changes from steroids). Rule Out History of Manic Episode(s):  Symptoms to assess:  Decreased need for sleep  Euphoric, expansive, or irritable mood  Racing thoughts; being easily distracted  Increased activity, energy, or rapid speech  Impulsive or reckless behaviors (e.g., excessive gambling, spending)  Unrealistically inflated self-esteem  Evaluate impairment in functioning or danger posed to self/others. Assessment question 3  Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for Self-Harm/Suicide Risk Psychosocial Interventions  Offer Psychoeducation  Offer psychosocial support as described in the  If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available:  problem-solving counselling  interpersonal therapy (IPT)  cognitive behavioral therapy (CBT)  behavioral activation Pharmacological interventions  CONSIDER ANTIDEPRESSANTS  Children < 12 years: Do not prescribe antidepressants.  Adolescents 12–18 years: Do not use antidepressants as first-line treatment. Offer psychosocial interventions first.  Adults:  Manage concurrent physical conditions before antidepressants  Consider antidepressants if no improvement after managing physical conditions.  ]Avoid if symptoms are normal reactions to loss.  Discuss and decide together whether to prescribe antidepressants: _Continue for 9–12 months after feeling well.**  Choose based on age, medical conditions, side-effect profile.  Adolescents (12 years and older): Consider fluoxetine if symptoms persist or worsen after psychosocial interventions.  Pregnant or Breastfeeding Women: Avoid antidepressants if possible. Consider lowest effective dose if no response to psychosocial interventions.  Avoid fluoxetine in breastfeeding.  Elderly People : Avoid amitriptyline if possible. **Cardiovascular Disease_* : Do not prescribe amitriptyline.*  Adults with Suicidal Thoughts:  First choice: Fluoxetine.  Limited supply if imminent self-harm risk. FOLLOW-UP  Schedule follow-up sessions per Principles of Management.  Second appointment within 1 week ; subsequent appointments based on the disorder's course.  Consider tapering off medication 9–12 months after symptom resolution ; reduce dose gradually over at least 4 weeks.

Epilepsy/Seizure - chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain Convulsive epilepsy - is characterized by seizures that cause sudden involuntary muscle contraction alternating with muscle relaxation, causing the body and limbs to shake or become rigid Presenting complaints of convulsive epilepsy  A history of convulsive movement or seizures Assessment  Does the person meet the criteria for convulsive seizure  convulsive movements lasting longer than 1- minutes  In the case of convulsive seizure, is there an acute cause  Follow up in 3 months to reassess  In the case of convulsive seizure without an identified acute cause, is this epilepsy?  (it is considered epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months

 follow up in 3 months if it is only 1 for 12

months Basic Management Plan  Educate the person and carers about epilepsy  Initiate or resume antiepileptic drugs  Continue medication until the person has not had a seizure for at least 2 years Follow up  At least once a month for the first 3 months  Meet every 3 months if seizures are controlled Stopping the antiepileptic medication if no seizure has occurred in the last 2 years Special management consideration for women with epilepsy  Give folate 5mg/day to prevent possible birth defects if she became pregnant  Phenobarbital or carbamazepine can be use for pregnant women but valproate and polytherapy should be avoided Intellectual Disability - is characterized by limitations across multiple areas of expected intellectual development (cognitive, language, motor and social skills) _They are vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments_** Presenting Complaints  Infants : poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing  Children : delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing  Adults : reduced ability to live independently or look after oneself and/or children  All ages : difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. Assessment  Does the person have intellectual disability  Review the person’s skill and functioning  Rule out visual impairment, hearing, malnutrition, epilepsy and problems in the environment  Are there associated behavioural problems Basic Management Plan  Offer psychoeducation  Promote community-based protection  Advocate for inclusion in community activities  If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Harmful Use of Alcohol and Drugs  Withdrawal - physical and mental symptoms that occur upon cessation or significant reduction of use  Dependence - damage to physical or mental health and/or general well-being Typical presenting complaints  Appearing to be under the influence of alcohol or drugs  Recent injury  Signs of intraveneous (IV) drug use  Requests for sleping tablets or painkillers

Assessment  Is there harm to physical or ment health and/or general well being from alcohol or drug use  amount and pattern of use  Triggers  Harm to self or others Basic Management Plan  Manage the harmful effects of alcohol or drug use  Assess the person’s motivation to stop or reduce the use of alcohol or drugs  Motivate the person to either stop or reduce the use of alcohol or drugs  Discuss various ways to reduce or stop harmful use  Offer psychosocial support Emergency management plan for life threatening alcohol withdrawal  Treat alcohol withdrawal immediately with diazepam(use typically until 3-4 days but no longer than 7 days)  Do not use antiepileptic drugs with withdrawal seizures  Address malnutrition  Maintain hydration Suicide Presenting Complaints  Feeling extremely upset or distressed  Profound hopelessness or sadness  Past attempts of self-harm Assessments  Has the person recently attempted suicide or self- harm?  Is there an imminent risk or suicide or self-harm  Are there concurrent condition associated with suicide or self-harm How to talk about suicide or self-harm  Create a safe and private atmosphere for the person to share thoughts  Use a series of questions where any answer naturally leads to another question  If the person has expressed suicidal ideas Basic Management plan  Provide medical care  Monitor the person continuously while they are still at imminent risk of suicide  Offer psychosocial support Follow up frequently in the beginning  Weekly for the first 2 month  Every 2 -4 weeks - if the patient improves

Nursing Assessment and Therapeutic Communication: A Comprehensive Guide, Study notes of Nursing

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 follow up in 3 months if it is only 1 for 12