UNIT 3 ■ Care of Patients With Psychiatric Disorders interventions, and rationales for each. Some institutions use a case management model to coordinate care (see Chapter 6 for more detailed explanation). In case management models, the plan of care may take the form of a critical pathway. Concept Care Mapping NURSING DIAGNOSIS: DIsTuRbED THOugHT PROCEssEs RELATED TO: Inability to trust, panic anxiety, possible hereditary or biochemical factors EVIDENCED BY: Delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract, or conceptualize; extreme suspiciousness of others OuTCOME CRITERIa NuRsINg INTERVENTIONs RaTIONaLE Short-Term Goal TABLE 15–2 | CARE PLAN FOR THE PATIENT WITH SCHIZOPHRENIA—cont’d
1. Patient must understand that you do not view the idea as real. ■■ Is the patient able to verbalize positive aspects about self, past accomplishments, and future pros- pects, including a desire to live? ■■ Can the patient identify areas of life situation that are controllable? 2. Arguing with the patient or denying the belief serves no useful purpose, because delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded. 3. Discussions that focus on the false ideas are purposeless and useless and may even aggravate the psychosis. ■■ Is the patient able to participate in usual religious practices and feel satisfaction and support from them? ■■ Is the patient seeking interaction with others in an appropriate manner? ■■ Does the patient maintain reality orientation with no evidence of delusional thinking? ■■ Is the patient able to concentrate and make deci- sions concerning own self-care? 4. To decrease patient’s suspiciousness: a. Familiar staff and honesty pro- motes trust. ■■ Is the patient selecting and consuming foods suffi- ciently high in nutrients and calories to maintain weight and nutritional status? ■■ Does the patient sleep without difficulty and wake feeling rested? ■■ Does the patient attend to personal hygiene and grooming? ■■ Have somatic complaints subsided? Treatment Modalities Interpersonal Psychotherapy b. Patients with suspicious ideation often perceive touch as threatening and may respond in an aggressive or defensive manner. c. Patient may have ideas of refer- ence and believe he or she is being talked about. Real Nurses, Real Advice shares Research has documented the importance of close, satisfactory attachments in the prevention of depres- sion with over double the risk among those with the lowest quality of social relationships (Teo et al., 2013). With this concept in mind, interpersonal psy- chotherapy focuses on the client’s current interper- sonal relations. Interpersonal psychotherapy with the depressed person proceeds through three phases. 360 and family members? ■■ Is the patient able to verbalize feelings and behav- iors associated with each stage of the grieving pro- cess and recognize own position in the process? ■■ Have obsession with and idealization of the lost object subsided? ■■ Is anger toward the lost object expressed appro- priately? ■■ Does the patient set realistic goals for self?
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Therapeutic Communication Icon identifies helpful interventions and guidance on how to speak with patients. Look for this icon in Care Plan sections.
■■ By the end of 2 weeks, patient will recognize and verbalize that false ideas occur at times of in- creased anxiety. Long-Term Goals ■■ By time of discharge from treatment, patient’s verbaliza- tions will reflect reality-based thinking with no evidence of delusional ideation. ■■ By time of discharge from treatment, the patient will be able to differentiate between delusional thinking and reality. The role of patient teacher is important in the psy- chiatric area, as it is in all areas of nursing. A list of topics for patient and family education relevant to depression is presented in Box 16–5. Evaluation of Care for the Depressed Patient 3. Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk about real events and real people. 4. If patient is highly suspicious, the following interventions may be helpful: a. Use same staff as much as possible; be honest and keep all promises. In the final step of the nursing process, a reassess- ment is conducted to determine whether the nursing b. Avoid physical contact; ask the pa- tient before touching to perform a procedure, such as taking a blood pressure. c. Avoid laughing, whispering, or talk- ing quietly where patient can see but cannot hear what is being said. d. Provide canned food with can opener or serve food family style. “The anhedonia, psychomotor retardation, and anergia in acute depression can make assessment a challenge. It’s important to offer hope to a client who may be uncer- tain about how to navigate their present state of deep depression and to remain diligent while not making e. Mouth checks may be necessary following medication administration to verify whether the patient is actually swallowing the pills. f. Provide activities that encourage a one-to-one relationship with the nurse or therapist. g. Maintain an assertive, matter-of- fact, yet genuine approach. the patient feel pressured to speak. Paraphrasing what the patient has said to you conveys understand- ing and provides validation. Open-ended questions encourage the patient to elaborate rather than just answer ‘yes’ or ‘no.’” —Larry Johnson, RN The concept map care plan is an approach to plan- ning and organizing nursing care (see Chapter 6). It is a diagrammatic teaching and learning strategy that allows visualization of interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments. An example of a concept map care plan for a patient with depression is presented in Figure 16–3. Patient and Family Education 1. Convey acceptance of patient’s need for the false belief but indicate that you do not share the belief. 2. Do not argue or deny the belief. Use “reasonable doubt” as a thera- peutic technique: “I understand that you believe this is true, but I person- ally find it hard to accept.” Real Nurses, Real Advice
UNIT 3 ■ Care of Patients With Psychiatric Disorders
Real People, Real Stories: Dr. Fred Frese
Author's review (if needed) Dr. frese: Like one time when they perceived I was spend- ing too much time interacting with patients, they assumed I was “going off again,” and next thing I knew, they called a “blue alert” and wanted to hospitalize me. But that time, the medical director just told me to take some time off. I never did find out why they called that blue alert. Initials Date OK Correx ISBN# 2/C Karyn: So you haven’t been hospitalized for a very long time, and you are internationally renowned for all of your work and advocacy in the field of mental health. What do you think has contributed most to your recovery? Date Check if revision 7678 11/19/18 Editor's review Initials Date OK Correx 2nd color PMS Dr. frese: Not always. It seemed like even among my cow- orkers, when something strange happened, they thought it was something wrong with me. Karyn: What do you mean by “something strange”? me. During the last attempt to hospitalize me, I actually escaped and ran away, even though I was in pretty bad shape. Karyn: So since you were knowledgeable about the laws, you could essentially be your own self-advocate and argue your case, so to speak? Dr. frese: Yes, and by that time, I was in grad school and had secured a job at what is now the Department of Men- tal Health and Addiction Services. I remember I was living in the hallway of some university housing, and one of the students, who saw me day after day just hanging around and not really doing anything, suggested that I might be eligible for a government job because of my military back- ground. When I applied, the receptionist saw my history of mental health commitments and said I would never get the job, but I did. The last time I went to the hospital, I went voluntarily because I knew I needed more medica- tion, but they thought I needed to be hospitalized and I didn’t; so I ran away. Karyn: Sounds like you were managing a lot of stuff—grad school, working—and, at the same time, episodically strug- gling with symptoms of illness. You were working in the field of mental health, too. Was the work environment supportive? Dr. frese: No, I haven’t been hospitalized since I got mar- ried. I think that has been central in my recovery: having a person who you trust to give you feedback and let me know when I need more medication. Karyn: What role do medications play in recovery? Dr. frese: It’s very individual. We need more research to identify who, among people with schizophrenia, will benefit most by continuous medication versus episodic, reduced doses, or no medication. Genetic research is hopeful, but we’re not there yet. It’s hard to advise any individual what to do without knowing their individual cir- cumstances, and even knowing, it can be very hard.
Author Dr. frese: I was 25 when I had my first episode. I was in the Marines and—I know I had seen the movie The Manchurian Candidate previously—and I began to think that the Vietnamese were using the same strategies from the movie to control us. When I let my commanding of- ficer know my theories, I was hospitalized involuntarily, and for the next 10 years I was in and out of hospitals— mostly involuntarily—taking various medications, living many different places, and not employed. Karyn: Were you getting any treatments or intervention that you thought were helpful to your recovery? Fig. # Artist B /W 4/C Dr. frese: Well, at that time it was thought that schizophre- nia was not an illness from which one could recover. Even recently, I’ve heard some folks who have a family member with schizophrenia say, “There’s no way that anyone with this illness can get better.” But that’s starting to change, and now that the government, through SAMHSA (Sub- stance Abuse and Mental Health Services Administration) is backing the recovery model approach, I think healthcare will improve. I remember being told that my brain was going to progressively deteriorate and that I would never be able to function on my own. All in all, I probably spent about a year of my life in hospitalizations. Once the laws changed and I knew you had to be of imminent harm to yourself or others in order to be hospitalized involuntarily, I talked some of the health professionals out of admitting Townsend UF15_01 GW-CO X People with schizophrenia continue to be disenfranchised, misunderstood, and stigmatized. Even within healthcare, evidence has shown that some settings have been very hostile to people with severe mental illnesses. One way to begin combating stigmatization of people with mental illness is to get to know them personally. Dr. Fred Frese is a licensed psychologist and an internationally renowned speaker, writer, and advocate in the field of mental illness. Karyn: Could you share a little bit about your history with the illness of schizophrenia? 31/01/22 7:55 PM
d. Suspicious patients may believe they are being poisoned and re- fuse to eat food from an individu- ally prepared tray. e. Suspicious patients may believe they are being poisoned with their medication and attempt to discard the tablets or capsules. f. Competitive activities are very threatening to suspicious patients. helpful tips from practicing nurses to help students navigate clinical situations and provide the best possible care to their patients. g. Patients with suspicious ideation are prone to distrust and are hypervigi- lant of peoples’ behavior and com- munication. Approaches that are overly directive or cheerful may in- crease the patient’s suspiciousness.
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Real People, Real Stories features interviews with patients and provides a model for effective therapeutic communication.
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