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Behavioral Interventions

by Diana Shenefield, PhD
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    00:01 Welcome, my name is Diana Shenefield. The topic we are gonna cover today is Behavioral Interventions and in the NCLEX review that falls under the heading of Psychosocial Integrity.

    00:14 So when we look at behavioral interventions you want to go back and look at your psych books and look at therapeutic communication. And being able to assess escalating behaviors and how to de-escalate those behaviors.

    00:31 So what are our learning outcomes? We wanna be able to intervene helping to restore our patient's ability to evaluate their reality correctly.

    00:41 Again there is a lot of reasons why our patients loose touch with reality.

    00:45 May be it's their disease process.

    00:47 May be they came in with the mental illness.

    00:49 May be it's because they are struck in the hospital room.

    00:53 May be it's the medications that we have given them.

    00:56 So again it is my role to be able to intervene and get them back in touch with their reality.

    01:02 I also need to understand treatment plans specific to each patient's needs.

    01:07 And making sure that I understand the plan for the patient and keep them oriented to their surroundings.

    01:15 So let's start off with the typical NCLEX question.

    01:18 A patient's spouse reveals ongoing infidelity in her relationship.

    01:24 A nurse identifies that the patient is at increased risk for: A. Ineffective protection.

    01:31 B. Pain C. Injury.

    01:35 Or D. Knowledge deficit.

    01:38 Now with this question you may be thinking that the patient is at risk for all of these and you would probably be correct.

    01:44 And what we are looking for is looking at Maslow's hierarchy of needs.

    01:49 And what would be the first thing that we would want to choose that would be at the bottom of the hierarchy of needs, the most important.

    01:57 And to answer this question it would be C. Injury.

    02:00 We wanna prevent injury.

    02:03 So in general What should we do as nurses? 1. We have to know how to help patient achieve and maintain behavioral self-control.

    02:14 A lot of times we don't know what patients are like before they come into our presence. Whether it's a physician's office? Whether it is the hospital or nursing home, an outpatient clinic? And so not knowing the kind of behavioral coping skills that they had before sometimes makes its hard as nurses to be able to intervene and to be able to pick up.

    02:35 But we are going to help them achieve and maintain behavioral self control.

    02:41 We are also going to be able to identify the characteristics of altered mental processes.

    02:47 What are the signs and symptoms I am going to look for when somebody is escalating in their behavior? Again a lot of times we don't think about those things when we are taking care of patients at the bedside.

    02:59 We think more about physical, lungs and heart.

    03:02 So again sometimes it will help to go back and review your psych book.

    03:07 And look at those behaviors that might give me some kind of clue that there is a behavioral problem going on.

    03:15 And then be familiar with behavioral interventions.

    03:18 And you may be saying to yourself, "Why I am not gonna work in psych hospital? Why would I need to know that?" You don't have to spend much time on a med search floor or in the ER to know that all nurses need these skills.

    03:31 So what are common behavioral problems that we need to be watching for? And anger is one of a med at top of the list; because, people that are angry sometimes aren't thinking clearly.

    03:42 And also anger can cause injury and so making sure that we keeping ourselves safe as long as our patients and other patients are in the units.

    03:51 Combative-aggressive kind of behaviors.

    03:54 In reaction to may be a new diagnosis and reaction to been told that "your loved one has a terminal illness".

    04:02 Again we don't know how people coped before.

    04:05 But we can help them get through these kind of situations to keep them safe as well as ourselves.

    04:13 About confusion/disorientation, it's so easy to let our mind kind of run away with us and we know that about patients.

    04:22 We know that when they are giving may be some bad news or some troubling news.

    04:26 Or because they come in may be abusing alcohol or drugs that way can become disoriented very easy.

    04:33 And so what can I do as a nurse to keep them in touch with the reality and to pickup on those signs before escalates to a violent behavior.

    04:43 Sometimes these patients will show their behavioral problems with being demanding and you got out to the nursing station and people be "oh that patient always wanting something".

    04:55 But is there a reason. Is that the only way that the patient knows how to cope with what's going on? Again if I can understand that may be I can help that patient work through that process.

    05:07 Denial of illness: This happens all the time. Nobody wants to be told that they have an illness, especially, chronic illness.

    05:15 And so a normal process would be a denial.

    05:18 But if this denial is keeping them from taking care of themselves.

    05:22 Keeping them from being compliant with the medical diagnosis, with medical processes, with getting them medications fill and taken.

    05:30 Again then that is where it is causing them harm.

    05:34 So being able to pick up on those kind of behaviors as well.

    05:38 And then dependence. Is the patient become depended to where they can't take care of themselves? Or refuse to take care of themselves? And if they were a very independent person before you know what has caused them to just give up and have somebody else make decisions for them.

    05:55 And then hostility. Can we goes along with the anger? There is everything that make them hostile. Do they just do not want to be in the hospital? Or don't want that IV? Again looking at reasons and is an ineffective coping.

    06:10 And then manipulation.

    06:11 We have all had patients. I am sure even in nursing school when you are in clinical setting.

    06:16 Patient's that are manipulators.

    06:18 Again some people that is their personality.

    06:21 But for other people it is a way to try to get control of behavior.

    06:25 May be they have lost control of their reality.

    06:28 And behavioral and manipulation is the only way that they feel like that they can gain control.

    06:33 And then noncompliance. Again Why they are non-compliant? There are host of reasons.

    06:39 But as a nurse doing my assessment and asking the right questions using therapeutic communication to get to the root.

    06:46 Sometimes they will tell me why they are noncompliant.

    06:50 And may be has nothing to do with my initial assumptions.

    06:55 Disorientation is a big nursing diagnosis.

    06:59 We know that there is a reason why when we go in the patient's room we are always orienting the person, place and time.

    07:05 Making sure they know the time a day and the time on of the clock and what day of the week it is.

    07:10 Because being in a room, being ill is having your sleep patterns change will cause a disorientation.

    07:18 And that what is that disorientation do as far as risk of falls and inability to concentrate? Altered behavioral patterns: Again sometime people will say, "that person never acts like that".

    07:31 Why? Why is it that their behavioral patterns have been altered? Is it a way of coping? So don't forget about that is a nursing diagnosis as you are trying to set goals for that patient.

    07:42 Altered mood states: Again being upset 1 minute and noncompliant in another or despondent at an another time.

    07:51 All these coping mechanisms that I can help my patient at work through.

    07:56 Impaired ability to perform self-maintenance activities: Again as a nurse I want to promotes self care as much as possible.

    08:04 Sometimes when patients come in to the hospital because of their disease process. Or may be because of an injury.

    08:10 The way that they took care of themselves before has been altered.

    08:14 But as a nurse it is my goal to make sure that they can care of themselves as much as possible.

    08:19 So don't forget about this as a nursing diagnosis as work with the patient towards goals and how they can get back to as much self-independence as possible.

    08:30 And then altered sleep patterns. That goes along with being in the hospital period.

    08:34 But we know that the less amount of sleep that you get the more in pain you are. The more anxious you are which leads to more disorientation.

    08:43 So again don't forget about allowing for constant sleep uninterrupted sleep, So that our patients can stay oriented.

    08:53 And then altered perceptions of surroundings A lot of times it's just medication that we give our patients.

    08:58 And/or I am struck in this room and it seems like it is always dark nothing changes. Does that help to alter our perception of what's going on? So again making sure as nurses that we keep our patients oriented to what we are doing. Explain all procedures.

    09:15 Introduce yourself when you come into the room each time.

    09:19 So that they have a concept of what's going on.

    09:23 More nursing diagnosis. Noncompliance: Sometimes this diagnosis kind be just thrown at the people and we really don't understand why they are noncompliant.

    09:32 But it's definitely a nursing diagnosis.

    09:34 That has goals attach to it to help the patient become more complaint.

    09:38 Denial: Again if they are denying their illness, if it's a normal part of a denial and they are moving through it to the next normal. But if they are struck in that denial it can lead to noncompliance.

    09:52 Decisional conflict: If you have the patient that just can't make a decision even if it's just about "what to have for breakfast in the morning?".

    10:00 Is it a way that they are showing that they are not coping and what can i do as a nurse to help move them to do that? Risk for self-directed violence: Again now we have got our safety and our risk for injury.

    10:13 Is this patient causing violence to themselves or to others? I need to watch those patients that are gonna be prone for that.

    10:21 Defensive coping: Again if I don't know how to cope then sometimes the way that I do in that reacting the things aren't normal and healthy.

    10:31 And again like I mentioned that earlier I may not know how people coped before they came into the hospital.

    10:37 But I can help with educating them on new coping mechanisms. That they can then use later on in life.

    10:45 Altered thought processes: Those with noncompliance and those with not taking care of yourselves as things start adding up.

    10:55 Have you been in the hospital for 3-4 days and now you have kinda loss touch of what day of the week it is? What's going on outside? Those kind of things happen and they happen suddenly.

    11:06 To our normal 20-30 years old may be not as bad. But be thinking about your 50, 60, 70 years old.

    11:13 Be watching for that sundowner syndrome. Be watching for that loss of reality when they have been in a room for a long periods of time.

    11:23 So what are our interventions? What can I do as a nurse to help people bring back to reality well keeping a routine? And a lot of times in a hospital we are kind of push to have our routine to more rigid then other places.

    11:37 But again knowing and telling the patient when you are coming in when they are getting their medicines. That helps keep them in a sense of time, a sense of time of day.

    11:46 I am also using things like there were TV shows will help bring them to a time reality.

    11:54 Develop open and honest relationship.

    11:56 This sometimes is a lot easier said than done. If your patient only in the hospital for 24 hours, it's very hard to have an open relationship But again being honest. Making sure they know "what you are doing?" , "when you are doing?". Explain all procedures and being as honest as you can with a time frames.

    12:15 They are going to X-Ray. Is it ever than they hours? Is it sometime today? Is it this evening? Again helping them know that you are trying to stay to a schedule and then you are being as honest as possible.

    12:29 Demonstrate respect: Again respecting your patient for no matter what kind of behavioral problems they come in with. However they are coping.

    12:37 Not making fun of them. Not degrading them.

    12:40 But again showing them respect and that you are there to help and not to make things worse.

    12:46 Having clearly verbalizing expectations. Setting goals with your patients.

    12:50 Not just telling your patient "how things are going to be?".

    12:54 But setting realistic goals and expectations.

    12:57 So that you are on the same page with the patients. So that the patient knows that you have their best interest at heart.

    13:03 And then verbalize acceptance of the patient.

    13:06 Sometimes patient do and say things that go against that may be "what I believe? Or what I would act in a certain circumstance?" But if I show acceptance then let's that patient know again that I care. And may be those shares some more things with me that I can help them work through these behavioral problems.

    13:25 And then good role modeling. Again if I am snickering or doing things that may be aren't respectful then my patient isn't either.

    13:34 Encourage patient to assume responsibility for their own behavior.

    13:37 Again they do need to take responsibility and how I do that has a lot to do with therapeutic communication by now accusing. But in helping them to see their actions and what they are actions doing to themselves and others.

    13:53 Positive reinforcement: We think of this a lot of times with our pediatric patients. But it works just as well with our adult patients.

    14:01 And then orienting our patient to reality. Again all the time "What day of the week is it?" "Is it sunny outside?" "Is it raining outside?" "What time a day is it?" A constant, every time you walk in to the room making sure they know who you are what your purpose is.

    14:17 Encourage group therapy if appropriate.

    14:19 And knowing psycho-nursing, they do a lot of group therapy and that works for a lot of people.

    14:25 So again is that appropriate for your patient? Even if you are not the one setting up the group therapy. Do you know who your resources are to get that patient into that group therapy? Prevent injury is always at the top of our list.

    14:37 Preventing injury for a patient, their families, other patients and for ourselves.

    14:43 And consulting the appropriate resources. Again knowing who your resources are? Makes a big difference in the kind of help that you are gonna give your patient.

    14:52 So in closing, again a lot of time a lot of nurses don't feel like "we are capable of being able to intervene when behavioral problem show up".

    15:01 But a lot of times we can.

    15:03 We can by showing respect and acceptance of the patient and by active listening to what's going on in their lives and trying to put ourselves in their shoes.

    15:13 We can have open honest communication and a lot of times we can help de-escalate patients before may cause injuries to themselves or others.

    15:23 Good luck on NCLEX.


    About the Lecture

    The lecture Behavioral Interventions by Diana Shenefield, PhD is from the course Psychosocial Integrity. It contains the following chapters:

    • Behavioral Interventions
    • Common Behavioral Problems
    • Nursing Diagnoses
    • Behavioral Interventions

    Included Quiz Questions

    1. "You seem restless; tell me what is happening“
    2. "You need to stop that behavior now.“
    3. “You will need to be placed in seclusion”
    4. "You will need to be restrained if you do not change your behavior“
    1. Initiate confinement measures
    2. Acknowledge the patient’s behavior
    3. Assist the patient to an area that is quiet
    4. Maintain a safe distance with the patient
    1. Decreased blood pressure
    2. Increased respiratory rate
    3. Increased muscle tension
    4. Decreased peristalsis

    Author of lecture Behavioral Interventions

     Diana Shenefield, PhD

    Diana Shenefield, PhD


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