HESI MILESTONE 2 VERSION A BLUEPRINT HESI MILESTONE 2 VERSION A BLUEPRINT 100% CORR ECT/ HESI MILESTONE 2 VERSION A BLUEPRINT Best Revision Material 1. Schizophrenia care -: Establish trust and rapport, encourage the client to talk with you, be consistent in setting expectations, explain the procedures and be certain the client understands, give positive feedback for the client successes, show empathy, do not be judgemental, never convey to the client that you accept their delusions as reality. 2. Grief therapeutic response -: Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), active listening, and offering a supportive presence. Nursing Plans and Interventions: A. If needed, refer to grief counseling or a support group. B. Encourage activities that allow the individual to use past coping strategies to promote a feeling of self -worth and increased self -esteem. C. Encourage the individual to share his or her feelings. D. Encourage socialization with family peers and reminisce about significant life experiences. 3. Delirium care-: Know usual mental status and if changes noted are long-term, it probably represents dementia; if they are sudden/acute in onset, it is more likely to be delirium. Recognize and report symptoms immediately. Treatment of underlying causes is important - if untreated, it can lead to permanent, irreversible brain damage and death. The primary goals of nursing care for clients with delirium are: PROTECTION FROM INJURY, MANAGEMENT OF CONFUSION, AND MEETING PHYSIOLOG - ICAL AND PSYCHOLOGIC AL NEEDS. Ensure patient safety (fall risk) and manage behavioral problems. Alert the prescriber of nonessential medications. Nutritional and fluid intake must be monitored. A quiet and calm environment. Encourage visitors to touch and talk to patients. Assess/manage pain. 4. Alzheimer's hallucination -: Occurs in the late-middle to later stages of the disease process and is treated with antipsychotics such as Haldol HESI MILESTONE 2 VERSION A BLUEPRINT 5. Alcohol withdrawal -: Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse, and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizure s, or delirium, called delirium tremors. Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however, and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually accom - HESI MILESTONE 2 VERSION A BLUEPRINT plished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms. Nursing Plans and Interventions A. Maintain safety, nutrition, hygiene, and rest. B. Obtain a BAL on admission or when a client appears intoxicated after admission. C. Implement suicide precautions if assessment indicates risk. D. In general 1. Monitor vital signs, input and output (I&O), and electrolytes. 2. Observe for impending DTs. 3. Prevent aspiration; implement seizure precautions. 4. Reduce environmental stimuli. 5. Medicate with antianxiety medication, usually chlordiazepoxide (Librium) or lorazepam (Ativan) 6. Provide high-protein diet and adequate fluid intake (limit caffeine). 7. Provide vitamin supplements, especially vitamins B1 and B complex. 8. Provide emotional support. 6. Methadone -: Detoxification and maintenance therapy for opioid use disorder. Suppression of withdrawal symptoms during detox related to opioids such as heroin. It can cause respiratory depression. Do not give it to patients with acute or severe bronchial asthma. It is contraindicated for patients taking MAOIs. Methadone Overdose: A). Physical Assessment -Constricted pupils - Respiratory depression leading to respiratory arrest -Circulatory depression leading to cardiac arrest -Unconsciousness leading to coma -Death B). General Appearance -General physical and mental deterioration -Rapid tolerance -overdose likely if not monitored. -Impaired judgment 7. Aggression response -: The nurse must protect others from these clients' manipulative or aggressive behaviors. At the beginning of treatment, he or she must set limits on unacceptable behavior. The limit setting involves the following three steps: HESI MILESTONE 2 VERSION A BLUEPRINT Inform clients of the rule or limits. Explain the consequences if clients exceed the limit. State expected behavior. Nursing Plans and Interventions: Conduct and Defiant Disorders A. Assess verbal and nonverbal cues for escalating behavior so as to decrease outbursts. B. Use a nonauthoritarian approach. C. Avoid asking "why" questions. D. Initiate a "show of force" with a child who is out of control. E. Use a "quiet room" when external control is needed. F. Clarify expressions or jargon if meanings are unclear. G. Teach to redirect angry feelings to safe alternative, such as a pillow or punching bag. H. Implement behavior modification therapy if indicated. I. Role-play new coping strategies with client. 8. Duty to warn -: The obligation of a healthcare provider to warn third parties of potential threats or harm aimed at them by another individual. 9. Schizophrenia - treatment evaluation -: 1.) Clients should have decreased ag- itation, combativeness, and psychomotor activity. 2.) Decreased psychotic behaviors such as decreased hallucinations and delu- sions. 10. Anxiety drugs risk -: Most of these drugs are benzodiazepines, which are commonly prescribed for anxiety. Benzodiazepines have a high potential for abuse and dependence, so their use should be short -term, ideally no longer than 4 to 6 weeks. One chief problem encountered with benzodiazepines is their tendency to cause physical dependence. Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. This is especia lly a problem for clients with long -term benzodiazepine use, such as those with panic or generalized anxiety disorder. I am 100% convinced that this is the fact that three weeks after starting an anxiolytic, a patient is at a significantly higher risk of suicide due to increased energy and not wanting to go back to feeling anxious or depressed. It's mentioned both in Realize It and in the HESI prep 11. ADHD exam -: - Failure to listen/follow direction - Difficulty playing quietly/sitting still - Disruptive, impulsive behavior
