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.
So when we look at
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.
So what are our learning outcomes?
We wanna be able to intervene helping to
restore our patient's ability
to evaluate their reality correctly.
Again there is a lot of reasons why
our patients loose touch with reality.
May be it's their disease process.
May be they came in
with the mental illness.
May be it's because they
are struck in the hospital room.
May be it's the medications
that we have given them.
So again it is my role to be able
to intervene and get them back
in touch with their reality.
I also need to understand treatment
plans specific to
each patient's needs.
And making sure that I understand
the plan for the patient
and keep them oriented
to their surroundings.
So let's start off with
the typical NCLEX question.
A patient's spouse reveals ongoing infidelity
in her relationship.
A nurse identifies that the
patient is at increased risk for:
A. Ineffective protection.
Or D. Knowledge deficit.
Now with this question you may be
thinking that the patient is at risk
for all of these and you
would probably be correct.
And what we are looking for is
looking at Maslow's hierarchy of needs.
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.
And to answer this question
it would be C. Injury.
We wanna prevent injury.
So in general
What should we do as nurses?
1. We have to know how to
help patient achieve and maintain
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.
But we are going to help them achieve
and maintain behavioral self control.
We are also going to be able
to identify the characteristics of
altered mental processes.
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.
We think more about
physical, lungs and heart.
So again sometimes it will help to
go back and review your psych book.
And look at those behaviors that
might give me some kind of clue
that there is a behavioral problem going on.
And then be familiar with
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.
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.
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.
Combative-aggressive kind of behaviors.
In reaction to may be a
new diagnosis and reaction
to been told that "your loved
one has a terminal illness".
Again we don't know how people coped before.
But we can help them get
through these kind of situations
to keep them safe
as well as ourselves.
it's so easy to let our
mind kind of run away with us
and we know that about patients.
We know that when they are giving may
be some bad news or some troubling news.
Or because they come in may
be abusing alcohol or drugs
that way can become
disoriented very easy.
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.
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".
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.
Denial of illness: This happens all
the time. Nobody wants to be told
that they have an illness,
especially, chronic illness.
And so a normal process would be a denial.
But if this denial is keeping them
from taking care of themselves.
Keeping them from being compliant
with the medical diagnosis,
with medical processes, with getting
them medications fill and taken.
Again then that is where
it is causing them harm.
So being able to pick up on
those kind of behaviors as well.
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.
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.
And then manipulation.
We have all had patients. I am sure even in
nursing school when you are in clinical setting.
Patient's that are manipulators.
Again some people that
is their personality.
But for other people it is a
way to try to get control of behavior.
May be they have lost
control of their reality.
And behavioral and manipulation is the only way
that they feel like that they can gain control.
And then noncompliance. Again
Why they are non-compliant?
There are host of reasons.
But as a nurse doing my assessment
and asking the right questions
using therapeutic communication
to get to the root.
Sometimes they will tell me
why they are noncompliant.
And may be has nothing to
do with my initial assumptions.
Disorientation is a
big nursing diagnosis.
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.
Making sure they know the
time a day and the time
on of the clock and what
day of the week it is.
Because being in a room, being ill
is having your sleep patterns
change will cause a disorientation.
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".
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.
Altered mood states: Again
being upset 1 minute and
noncompliant in another or
despondent at an another time.
All these coping mechanisms
that I can help my patient at work through.
Impaired ability to perform
self-maintenance activities: Again
as a nurse I want to promotes
self care as much as possible.
Sometimes when patients
come in to the hospital
because of their disease process.
Or may be because of an injury.
The way that they took care of
themselves before has been altered.
But as a nurse it is my
goal to make sure that they can
care of themselves as much as possible.
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.
And then altered sleep patterns. That goes
along with being in the hospital period.
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.
So again don't forget about
allowing for constant sleep
uninterrupted sleep, So that
our patients can stay oriented.
And then altered perceptions of surroundings
A lot of times it's just medication
that we give our patients.
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.
Introduce yourself when you
come into the room each time.
So that they have a
concept of what's going on.
More nursing diagnosis. Noncompliance:
Sometimes this diagnosis kind
be just thrown at the people
and we really don't understand
why they are noncompliant.
But it's definitely
a nursing diagnosis.
That has goals attach to it to help
the patient become more complaint.
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.
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?".
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.
Is this patient causing violence
to themselves or to others?
I need to watch those patients
that are gonna be prone for that.
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.
And again like I mentioned that earlier
I may not know how people coped
before they came into the hospital.
But I can help with educating them
on new coping mechanisms. That they
can then use later on in life.
Altered thought processes:
Those with noncompliance and those with
not taking care of yourselves
as things start adding up.
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.
To our normal 20-30 years old may
be not as bad. But be thinking
about your 50, 60, 70 years old.
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.
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.
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.
I am also using things like
there were TV shows will help
bring them to a time reality.
Develop open and honest relationship.
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.
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.
Demonstrate respect: Again
respecting your patient
for no matter what kind of behavioral problems
they come in with. However they are coping.
Not making fun of them.
Not degrading them.
But again showing them respect
and that you are there to help
and not to make things worse.
Having clearly verbalizing expectations.
Setting goals with your patients.
Not just telling your patient
"how things are going to be?".
But setting realistic
goals and expectations.
So that you are on the same page with the
patients. So that the patient knows that you have
their best interest at heart.
And then verbalize
acceptance of the patient.
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.
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.
Encourage patient to assume
responsibility for their own behavior.
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.
Positive reinforcement: We think of
this a lot of times with our pediatric
patients. But it works just
as well with our adult patients.
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.
Encourage group therapy if appropriate.
And knowing psycho-nursing,
they do a lot of group
therapy and that works
for a lot of people.
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.
Preventing injury for a patient, their
families, other patients and for ourselves.
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.
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".
But a lot of times we can.
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.
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.
Good luck on NCLEX.