Ego Defense Mechanism

1. Compensation - over achievement in one area to offset real or perceived deficiences in another area
2. Conversion - expression of an emotional conflict through the development of a physical symptom, usually sensorimotor in nature
3. Denial - failure to acknowledge an unbearable condition; failure to admit the reality of a situation, or how one enables the problem to continue
4. Displacement - ventilation of intense feelings toward persons less threatening than the one who aroused those feelings
5. Dissociation - dealing with emotional conflict by a temporary alteration in consciousness or identity
6. Fixation - immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage
7. Identification - modeling actions and opinions of influential others while searching for identity, or aspiring to reach a personal, social, or occupational goal
8. Intellectualization - separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions
9. Introjection - accepting another person's attitudes, beliefs, and values as one's own
10. Projection - unconscious blaming of unacceptable inclinations or thoughts on an external object
11. Rationalization - excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect
12. Reaction Formation - acting the opposite of what one thinks or feels
13. Regression - moving back to a previous developmental stage in order to feel safe or have needs met
14. Repression - excluding emotionally painful or anxiety provoking thoughts and feelings from conscious awareness
15. Resistance - overt or covert antagonism toward remembering or processing anxiety-producing information
16. Sublimation - substituting a socially acceptable activity for an impulse that is unacceptable
17. Substitution - replacing the desired gratification with one that is more readily available
18. Suppression - conscious exclusion of unacceptable thoughts and feelings from conscious awareness
19. Undoing - exhibiting acceptable behavior to make up for or negate unacceptable behavior

Tips:
- Anxiety is where all behaviors originated/motivated from
- All behaviors have meaning
Primal Impulse:
a) Libido - life instinct
b) Mortido- death instinct
5 Therapeutic variables:
1. Containment - safety; protect patient from harm
2. Structure - predictable; trust in patient; reduce anxiety of the patient
3. Support- unconditional acceptance
4. Trust- knowledge of patient
5. Involvement - volatile ; easily changed; degree of exposure of patient to others
How to treat patients:
1. Active friendliness - seeks friendship, needs assistance with ADL, severely withdrawn patients; with poor self-esteem, catatonic, no demand attitude; 1:1 relationship with a nurse
2. Passive friendliness - paranoid; suspicious patients
3. Kind firmness - suicidal support; set limits
4. Matter of fact - consistency, limit setting, manipulative; borderline
5. No demand attitude - highly agitated, assaultive
- Energy field by Virginia Henderson- aura through touch theraphy (for infant and demented patients only)
- Lex Taliones- castration fear; punishment
- Hostility is verbal attack
- Aggression is physical attack
- Always restate when answering questions
- Never blame hospital policy in answering questions
- Crisis is 4 weeks impairment
- Crisis can be resolved in 6 weeks
- Adventitious crisis could be manmade
- Counter transference is when a nurse is impaired
- Marplan, Isocarboxacide; no tyramine except cream and cottage cheese
- Easily startled are PTSD; dissociative disorder; hyperthyroidism
- Agranulocytosis - (MAOI) High fever, increased BP, infection, low WBC
- Carbamazepine is a lithium substitute
- ABCD of Psychiatry is A for appearance ; B for behaviour ; C for communication D for diagnostics
- Id is the desire for pleasure, superego is the conscience and ego balances everything
- Insight opens gateway to reality
- The best thing a nurse can offer is self and the understanding of client's situation without prejudice
- There is a renal problem when the output is <400ml/d
- Anorexia has problem during anal stage; perfect; suicidal
- Bulimia has problem during oral stage; pharyngitis; Russel's sign
- Mania's best activities are tetther ball and pingpong
- Schizophrenic's best activities are picnic, bridge to reality,neutral topic, non-competitive
- Depressed activities are gardening and acting out
- Paranoid activity is board games
- Dysthemia is a minor depression (major depression is usually at least 2 weeks)
- Hypomania is a minimania
- Euphoria is an intensed mania
-Cyclothemia is a minibipolar
Somatotoform Disorder:
-Conversion-labelle indifferance; projection; reaction formation
- Pain disorder - severe misperception
-Hypochondriasis-fear of getting multiple disorders/ill; misinterprets body sensation
-Body dysmorphic disorder- exaggerate perceived facial defect ; imagined defects; body perception
-Malingering - tells lie for own benefit
-Factitious disorder- invent own sickness
-Maunchausen's- self-diagnosed disease
-Maunchausen's by proxy- others are being diagnosed as sick
Reasons for diagnosis: Primary gain- to reduce anxiety
Secondary gain- avoidance of anxiety
Dependence- hold on to props

Stress- has 3 sources : body, thoughts and environment. Major types are: physical and psychological.

4 Dimensions of Stress Management:
1. Spiritual - prayers, religions, meditation, forgiveness and faith
2. Mental - positive self-talk, visual imagery, creative hobbies and reading
3. Emotional - social support system, touch, use of colors, music, humor and laughter
4. Physical - simple muscle tension relief, sports or exercise, rest and sleep, massage, nutrition, balance work and play

10 Minutes Stress Management- do nothing; laugh out loud; tune in; think happiness ; hit the road; breath easy and rise relaxed

HOSPITAL SETTING:

FOCUS CHARTING-Patient centered not task oriented

Focus-
What is the focus of my care
What is the concern of this particular patient

DATA-
What is the patient's objective and subjective data base from the stated focus
What does the patient tell you
What are the findings which indicates action to be taken
What do you see, hear, touch or smell
What are the key pieces of data that helps determine which action to take
What is the basis for your choice of appropriate goal to resolve the focus
ACTION-
What action did you initiate
Did you initiate standard care
Did you start a teaching and treatment protocol
RESPONSE-
What happened to the patient
What is the result of the action or intervention to the patient
What are the patient's outcome
Does the current status matches the desired outcome



Sample charting:

Focus Charting-a method for organizing health information in a patient's record. It is a systematic approach to documentation using nursing terminology to describe individual's health status and nursing actions.

Focus:

- Abnormal lab results
- Admission
- Airway impairment
- Allergic reaction
- Anxiety
- Aspiration
- Cardiovascular
- Central line therapy
- Chest tubes
- Code (whit, blue, and pink, etc.)
- Cognitive impairment
- Confusion
- Comfort
- Constipation
- Coping
- CNS Status
- Dehydration
- DNR / Therapeutic choices
- Dialysis
- Discharge
- Edema
- Falls
- Fatigue
- Family dynamics/Concerns
- Fluid balance
- Fever
- GI status, GU status
- Health teaching
- Hemorrhage/ Bleeding
- High risk/suicidal
- Hypotension
- Hypertension
- Hypothermia
- Hyperthermia
- Incontinence
- Infection
- Isolation
- Mental/ Emotional status
- Nausea/Vomiting
- Neurovascular
- Musculoskeletal
- Pain control
- Physician / Visit /Assist / Notified
- Physical status
- Respiratory status
- Restraints
- Skin integrity/Wound care
- Spiritual interventions
- Swallowing
- Substance abuse
- Teaching
- Telemetry
- Transfer
- Vital signs
- Wound care

Focus
- a key word or category from a nursing diagnosis. A collaborative problem on the plan of care (action plan). Example : skin integrity, coping, activity tolerance, self-care deficit
- a current individual concern or behavior. Example : nausea, chest pain, pre-op teaching, hospital admission
- a sign or symptom of (possible) importance to the nursing and /or medical diagnosis or treatment plan. Example : fever, constipation, hypertension, incontinence , lethargy
- an acute change in a patient's condition. Example: respiratory distress, seizure, fever, discomfort
- a significant event in a patient's care. Example : begin treatment regimen (oxygen), change in diet, catheterization
- a keyword or phrase indicating compliance with a standard care or agency policy. Example : self medication, teaching plan,transition


Components of a Focus note:

DATA - subjective or objective information, supporting the stated focus or describing observations at the time of significant events

ACTION - nursing interventions performed, planned to be performed, and/or protocols and procedures initiated

RESPONSE - description of individual's response to medical and/or nursing care. Statement that the Action Plan of Care outcomes have been attained or are progressing toward attainment

Example:

Need: Comfort/ Relief of pain

Data- complaining continuous sharp pain in mid-abdominal incision area. Crying. "I need something for pain now! " Stated pain on a scale of 10.

Action- medicated with Demerol 75 mg IM in LUOQ of left buttock. Repositioned on right side with pillow on abdomen to help splint wound.

Response- patient stated comfort 30 minutes later and rated pain 3 on a scale of 10---Noted by nurse

General Survey:
- appearance of the patient, condition- when seeing the patient
- any IVF or medications attach to the arms of the patient
- current vital sign of the patient

Example:
- approached sitting on bed, awake, responsive, coherent with ease in respiration, with O2 at 2 lpm, with an IVF of 4 plr 1l + 8.25 meq KCl @ 66ugtts/min infusing wellat the right arm. V/S: BP=110/70 mmHg ,PR = 100 bpm, RR = 26c pm, T= 36.8 degree Celsius/axilla
- followed by F-DAR
- after writing F-DAR ,at the end of the shift write again your general observation/survey of the patient condition


Focus: Hyperthermia


Data - increase in body temperature above normal range to T= 38 degree Celsius/axilla
- flushed skin and warm to touch

Action 9:00 am
- TSB done
- instructed SO to let the patient wear loose clothing, provide blanket when shivering, drink lots of fluid and include Vitamin C such as orange in his diet
- provided an opportunity for the patient to rest
- due meds given

Response 1:00 pm
- patient kept rested
- T= 36.7 degree Celsius

Focus 1 : Ineffective Breathing Pattern

Data:
- increase respiratory rate of 24 cpm
- use of accessory muscle to breath
- presence of nonproductive cough

Focus 2 : Hyperthermia

Data:
- skin warm and flush to touch
- increased body temperature of T= 37.7 degree Celsius/axilla

Focus 3 : Fatigue

Data:
-less movement noted with the verbalization of ," I feel tired , I can not sleep well !"

Action : 9:00 am
- monitored V/S and noted
- regulate IVF and charted
- morning care done
- assessed patient needs and performed handwashing before handling the patient
- advised SO to always stay on patient bedside
- promote proper ventilation and a therapeutic environment
- elevated the head of the bed (moderate high back rest)
- due meds given
9:30 am
-TSB done
- instructed SO to provide blanket and let the patient wear loose clothing

Focus: Discharge Plan (2:00 pm)

Data 1:
Discharge Order given by: Dr.Name/Time
M - medications - advised SO to give the ff. meds at the right time, dose, frequency and route
E - encouraged to maintain cleanliness of the house and surroundings
T - advised to go to follow-up consultations on prescribed time
H - encouraged to do chest tapping to facilitate mobilization of secretion
O - observed for signs of super infections such as fever, black fury tongue and foul
odor discharges
D -diet - encouraged to eat fresh vegetables and fish
S - spirituality - advised to continue praying to God and hear mass on Sunday

4:00 pm 0out of the room per wheelchair with improved condition

Dicharge plan for patient who undergo Surgery
H - health teaching
A - anticipatory guidance
S - spirituality
M - medications
I - incision in care
N - nutrition
E - environment











NURSES NOTES

SURNAME:De la Cruz AGE: 29 HOSPITAL NO. 2000
Given Name:Maria SEX: F WARD : OB
Middle Name: Juan CS : M BED NO. 3

DATE/ A. DATA B. /ACTION /C. RESPONSE
SHIFT/ FOCUS / Assessment / Nursing Diagnosis/TIME / Nursing Intervention TIME/ TIME/ Evaluation


6-22-09 /Adm /- admitted a 29 y/o /- placed comfortably / - patient seems in
8- 4 shift/ postpartum G2P2 per at her room/ pain and is
1:00 pm / stretcher accompanied /nervous
by relatives
Comfort / - adult diaper intact and /- perineal hygiene /- for compliance
with minimal vaginal bleeding/ emphasized
1:10 /V/S/ - BP- 120/80 PR- 80
T- 37 C RR- 20
IVF /- with D5LR with 10 units/ - checked for signs/ - negative phlebitis
Oxytocin @ 1000 cc / of infiltration and infusing well
Nut /- on DAT/ - advised to eat/ - taken with fair nutritious food appetite
and on sitting
position
H/T / - upon child's rooming-in/ - advised strict /- verbalize
breastfeeding understanding
-/ proper cleaning /- for compliance
of the umbilicus
given

gtts factor IVF

1L - gtts - ugtts
24 hr - 10 - 42
20 - 12 - 50
18 - 14 - 56
16 - 16 - 63
14 - 18 - 71
12 - 21 - 83
10 - 25 - 100
8 - 31 - 125
6 - 42 - 167