Reading the Medical Chart: Making Sense of Doctor's Orders

Because of rising concerns regarding patient safety, doctors are now being trained to improve on their handwriting and spell out their orders. But due to time or training constraints, some still continue to use old methods of making orders. Here are a few tips for nurses to make sense of the medical chart and the orders in them:

Know the Medical Chart Format

Some hospitals use a different method of making patient notes, but majority of doctors use the SOAP format. Knowing the sections of the chart will help you deduce what the doctor is trying to do for the patient

• The “S” portion on subjective complaints refers to the symptoms that patient’s experience.
• The “O” portion on objective findings refers to results of physical examination or laboratories as noted by the doctor.
• The “A” portion is the assessment or the doctor’s working diagnosis for the patient.
• The “P” portion on plan refers to the doctor’s orders on next steps including further diagnostic tests, medications, procedures, and other instructions for carrying out.

Know the Common Abbreviations

Some items in the chart cannot be understood, not because of handwriting, but because doctors abbreviate terms or use old Latin medical phrases. The Institute of Safe Medication Practices summarized a list of commonly misunderstood medical orders that should be avoided (https://www.ismp.org/tools/errorproneabbreviations.pdf). But in case they are used, here are descriptions of the most common abbreviations seen in medical charts:

Frequency	od - once a day bid - twice a day tid - three times a day qid - four times a day hs - at bedtime prn - as needed q - every (ex: q15m is every 15 mins, qh is every hour) d/c - discontinue
Laterality	AD / OD - right ear / right eye AS / OS - left ear / left eye AU / OU - both ears / both eyes
Descriptions with “-x”	sx - symptoms dx - diagnostics, or diagnosis bx - biopsy tx - treatment rx - medicines px - patient
Other names	PED - pediatric patient AP - attending physician
Body parts	heent - head, eyes, ears, nose, throat (also eent, ent) csf - cerebrospinal fluid abd - abdomen GB - gallblader KUB - kidney, ureter, bladder ing – inquinal
Physical exam tests or questions	BP - blood pressure HR - heart rate RR - respiratory rate EBL - estimated blood loss I&O - input and output ROM - range of motion LMP - last menstrual period
Laboratory tests	CBC - complete blood count PC - platelet count UA - urinary exam SE - stool exam CXR - chest xray AFB smear - acid fast bacilli smear ABG - arterial blood gas C/S - culture and sensitivity ECG – electrocardiogram
Conditions	UTI - urinary tract infection A/URTI - acute/upper respiratory tract infection CAP - community acquired pneumonia CA - cancer CAD - coronary artery disease CHF - congestive heart failure FBO - foreign body obstruction R/O - rule out (means a probable diagnosis, not yet certain)
Procedures	AP - appendectomy BKA - below knee amputation CPR - cardiopulmonary resuscitation I&D - incision and drainage
Other instructions	CBR - complete bed rest NPO - nothing per orem BRP - bathroom privileges DNR - do not resuscitate PT - physical therapy isol - isolation protocol vo - verbal order

Know the common orders for a specific case

Sometimes you can deduce the order from context clues. If the patient is suffering from pneumonia, then most likely antibiotics are given three times a day. If a diabetic patient is admitted for surgery, then pre-operatives laboratories are commonly comprehensive. If a patient is in critical condition in the ICU, then most likely monitoring is as often as every 15 minutes. Experience can also show you a doctor’s common patterns in treating their patients.

Don’t be Afraid to Ask for Help

But if you really can’t really understand the doctor’s orders, always ask for help. You can approach co-nurses or the actual doctor to help you understand what they want you to carry out. Never carry out an order that you are unsure of because this can be both harmful to the patient and the careers of yourself, the doctor, and the hospital. For cases like these, it is best to be safe than sorry.

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5 Ways Nurses Can Stay Safe

As healthcare workers, the first priority of nurses are the wellness and safety of their patients.

Nurses work in close proximity to people, helping patients move thus acquiring some injuries themselves.

Every nurses has the thinking that aches and pains do go with their job but taking care of the patients without the possibility of an injury should also be considered.

Lifting and transferring patients is the most common causes of back injury or muscle pain among nurses and this can cause not only your health but your career as well.

Below are five ways which nurses can do to stay safe as possible while carrying out their job as healthcare workers.

1. Know when’s the right time to exit.  Sometimes, a certain situation makes a nurse uncomfortable. If this is the case, call a co-nurse or simply step away.
2. Use available equipment or devices to help you do things easily. Don’t torture yourself. There are things nurses can use to perform other tasks with ease and avoid injury at the same time.
3. Protect yourself against needlesticks. Some diseases or illnesses can be acquired when pricked by needles that have come from carriers of pathogens. Extra precautions and proper procedures should be exercise by nurses when handling needles.
4. Always promote safety. Costly or not, having a safe work environment, especially in healthcare institutions is a must.
5. Practice cleanliness. Nurses must wear gloves and wash their hands often as they are exposed to patients’ bodily secretions which may contain infectious agents.

What can you add to these nurses?

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Working as an Ambulatory Care Nurse

Most people think that when you become a nurse, you only have one option. And that option is – to work in a hospital setting. That is not true. There are a lot of nursing fields and specialties where a nurse is required to work in a non-hospital setting. One of these specialties includes Ambulatory Care Nursing.

What is Ambulatory Care Nursing?

Ambulatory Care Nursing is a field of nursing that deals with patients on a preventive and maintenance level. Acute care is also included in ambulatory care nursing, but most of the time nurses deal with patients having long term needs. This field of nursing often makes nurses practice outside the hospital. They are often assigned in ambulatory clinics, community centers, schools, surgical units and so on.

Responsibilities of an Ambulatory Care Nurse

The ambulatory care nurse has lots of responsibilities. He/she may have to deal with a large amount of patients in the span of the day. The average interaction time between a patient and an ambulatory care nurse rarely extends past an hour. Despite the number of patients and the short interaction time, these nurses still have to perform basic nursing duties.  

These duties include the provision of health care to all sorts of patients with varied illnesses. The nurse may also function as a counselor and advocate for patients in need of psych and social assistance. He/she may also have to perform home based or telephone follow-ups for patients who cannot make it to clinics.

In an ambulatory care nursing, emphasis is placed on the importance of home care and patient education. That is why the nurse has to work as an effective educator. Patients need to learn to perform basic procedures on their own. It is also the nurse’s responsibility to translate complex procedures into terms the patient can easily understand. A patient education practices also extend to post and pre-op ambulatory surgical patients. They are also applied with individuals undergoing long term pain management.

Despite the seemingly complex duties of an ambulatory care nurse, a lot of individuals are still drawn to it. The main reason for that is the fact that these nurses work regular hours. The position eliminates the need for nurses to work on varying shifts from day to day. It is a great job for nurses that have growing families, those that go to school at night as well as those that maintain part-time night jobs.

Areas of Practice

Get rid of the notion that an ambulatory care nurse only works in a clinic. True, most ambulatory care nurses do find themselves in the clinical setting. But, there are various areas where an ambulatory care nurse can work. It may include working with paramedics in an ambulance or working as a school and company nurse. The job may also include working in a surgical or community setting. Ambulatory care nurses may also be called to provide home care to patients who need it.

Requirements and Qualifications

LOCALLY – There are no set rules and regulations in order to become an ambulatory care nurse in the Philippines. The main requirement is to be registered with the Professional Regulation Commission. Experience working in a hospital setting or otherwise may also be helpful in gaining a position in ambulatory care units.

Keep in mind that there are all sorts of ambulatory care units in the country. For Filipino nurses who want to work in surgical outpatient units, he/she must have a solid background as an operating room nurse. The same goes for other specialized areas in the ambulatory care nursing field.

US - In order to work in ambulatory care, the nurse must first garner a solid two years working as a registered nurse in any setting. For most states in the US, there is no other requirement. However, others require and prefer their ambulatory care nurses to be certified in the field. Certification is achieved by completing required number of work hours as an ambulatory care nurse. It also requires that a nurse earn a certain number of continuing education units in ambulatory care nursing. These units can be gained by attending seminars or post graduate conferences.

For other countries, the requirement is the same. The nurse applying for a position as an ambulatory care nurse must be an RN in the country. He/she must also have significant nursing experiences that will relate to the position he/she is applying for.

Work Opportunities in Ambulatory Care Nursing

LOCAL – There are a lot of work opportunities for local RNs in the ambulatory care nursing field. He/she may apply for work in physician clinics or with government community health centers. The opportunities are endless, but the nurse applicant has to have the competitive qualifications in order to get hired.

In the recent decade, more and more hospitals in the country have opened ambulatory care units. These units (especially government operated ones) rifle through immense numbers of patients daily. These patients may come for check-ups or for routine procedures.

Some local ambulatory care units deal with surgical patients. Most surgical ambulatory units deal with patients seeking minor surgery that have very little down time. A few minutes after the procedure, the patient is deemed well enough to get back on his/her feet and walk out of the unit.

THE US AND OTHER COUNTRIES – Work opportunities for ambulatory care nurses abroad can be very diverse. It can include everything from walking surgical centers, ambulances, pain managements units, mobile clinics, home care and home visits nursing, community centers, schools, work areas, etc. Some countries and American states require certification from their ambulatory care nurses. Nevertheless, most of the time only a regular license is required.

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Gastrointestinal Nursing

Gastrointestinal Nursing or GI Nursing is a very interesting nursing specialty. The nurse in this field is exposed to different GI conditions and diseases. GI Nurses can offer general, pediatric and geriatric care. GI patients may have life threatening cancers or simple and complex bowel obstructions and even contagious conditions bowel irritations.

 

Gastrointestinal Nursing is not an easy field to be in. It takes dedication and a strong stomach. Nurses in this specialty have to face bowel discharges on a daily basis. Most of the patients may have severe diarrhea and irritative bowel syndromes. Some patients may be fitted with shunts, ostomies or stomas that allow the passage of fecal matter. These patients’ require special care that only an experienced Gastrointestinal Nurse can give. Below you will find some of the responsibilities facing a GI nurse on a daily basis.

 

·         Assisting Physicians in Different GI Procedures – The Gastrointestinal nurse will often be called to assist the physician in procedures such as endoscopy, colonoscopy and other invasive operations. In cases like these, the nurse needs to be well versed in the different procedures. He/she has to know how to properly prepare the patient. He/she must also know how to assist the physician during the actual procedure. Aside from the procedures mentioned above, the GI nurse may also be called to perform enemas. Enemas are part of a patient’s preparation for various surgeries and other invasive operations.

 

·         Health Teaching/ Patient Education – A gastrointestinal patient may require several procedures that he/she may find foreign or new to him/her. This means that the said patient may require health teaching to help them cope with their new situation. Health teaching and Patient education may range from simple facts like: What to eat and what to avoid. It may also include more complex tasks such as cleaning an ostomy and a stoma. Patients in such a situation may be fearful to do certain procedures themselves. It is now up to the gastrointestinal nurse to help alleviate their anxiety. GI nurses must also look into involving other family members in the client’s care.

 

·         Standard Nursing Care/Procedures – Gastrointestinal Nursing is in essence just like any other nursing field. Nurses still have to perform basic nursing procedures that every patient needs. These include telemetry, medication and other basics.

 

GI Nursing with other Nursing Specialties

Gastrointestinal nurses have the option of furthering their knowledge of the GI field. They may choose to work with children or with senior citizen alone. They can also make a career out of administering anesthetics to their patients needing sedation for a procedure.

 

Sedation is important in some invasive GI procedures. Often anesthesiologists are the ones called to oversee the process. Nurse anesthesiologists can also be called induce sedation. This is seen as important crossover between two nursing specialties. In this manner the gastrointestinal nurse can also serve as a GI nurse anesthetist. The GI Nurse may also choose to specialize in Pediatric or Geriatric cases. This is another example of a nurses having more than one nursing specialty.

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The Pediatric Nurse

The Nursing profession has an infinite number of choices to offer its’ practitioners. A nurse can specialize in any area of nursing that he/she chooses. It may include working closely with the doctor as a Nurse Anesthetist. The nurse can also choose to be immersed in an adrenaline pumped Emergency Room. And if the nurse loves kids, he/she can choose to specialize as Pediatric Nurse.

What is Pediatrics and Pediatric Nursing?

Pediatrics is a branch of medicine that deals with infants, toddlers and adolescents. It is a specialized field that aims to maintain a child’s overall wellness as well as treat any underlying conditions be it acute or chronic. Pediatric Nursing is a special Nursing field where the nurse has constant contact with patients below a certain age. The diseases and disease processes that a nurse encounters may be the same as with adult patients, but the fact that he/she is working with children makes it an entirely different ball game.

To the layman, Children may seem like mini-adults. They may come to the conclusion that kids need the same care as adults do. But, the fact is that children have a different set of needs compared to adults. They may find it more difficult to understand the different procedures done to them. This means that pediatric nurses and doctors have to learn to understand kids better. They may also be called to use several methods that help children feel more at ease with their surroundings.

An effective pediatric nurse is important to a child’s confinement because he/she can help decrease the child’s stress levels. A pediatric nurse also helps in decreasing the trauma and negative long term effect that the hospital confinement may have on the child.

Tips on Dealing with Children:

Pediatric Nurses deal with children all the time. These kids may find it hard to understand that the different medical procedures they done to them are for their own good. More often than not, the nurse is met with an uncooperative child riddled with fear. The child may present with a certain degree of anxiety that affects him/herself, the parents as well as the people surrounding them. Below are a few tips and tricks that Pediatric nurses have been using for a long time. These tips held him/her deal with children better an as a result dramatically reduce the anxiety experienced by the child and his parents.

·         Child Friendly Terminologies: There are a lot of medical terminologies that a child may find difficult to understand. This often results in the child being afraid and uncooperative. The best solution for this situation is to explain the procedure in terms that the child understands. Teaching aides like puppets and fun diagrams may also be utilized.

·         Never lie to the Child: Often, parents and nurses tend to lie to children in order to get them to cooperate. They may say that a vaccine injection won’t hurt, when in fact it does. This results in the child being distrustful and fearful of the procedure more than he/she should. What parents and nurses should do is to tell the child the truth, they can say that: “The procedure may hurt a little, but it will just be like being bit by an ant”. That is a more effective way of dealing with the child because he/she will anticipate a little bit of pain instead of none at all.

·         Getting an adult in the game: Sometimes a child is afraid of routine procedures such as Blood Pressure measurement and Temperature taking. This fear can often be alleviated by allowing a parent or another adult undergo the procedure themselves. This way a child sees that there is nothing to be afraid of and he/she will cooperate better.

Other Individuals Involved in the Care of a Child

It is a well known fact that the Pediatric Nurse not only deals with the upset child. He/she also has to deal with the parents and other individuals involved in the child’s care. Often, parents and guardians can make a Pediatric Nurse’s task easier by helping to calm the child. But, sometimes their anxiety levels may be greater than that of the patient. In these kinds of situations the Pediatric Nurse also has to deal with the parents and adults involved in the child’s care.

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Becoming a Nurse Anesthetist

There is far more to the Nursing profession other than just being a regular RN. Nurses have the option to specialize in any field that they choose. One of these specialties includes becoming a Nurse Anesthetist.

For hundreds of years, nurses all over the world have been administering anesthetics and analgesics to their patients.

This was done under strict orders of Attending Physicians. Nurses themselves did not have the right to administer any medication on their own free will. Becoming a Nurse Anesthetist changes that.


Nurse Anesthetists enjoy a great degree of autonomy from other physicians when it comes to decision making. Even though their duties extend only to the Operating Room (OR) setting, they are now treated as equals and not as subordinates who merely take orders. This type of specialty is perfect for a nurse who is most comfortable in the OR setting.

 What is a Nurse Anesthetist?

A Nurse Anesthetist is a specially trained Registered Nurse. These nurses are in charge of administering the required anesthetics for a patient who is to undergo surgery. The Nurse Anesthetist is responsible for monitoring the patients Vital Signs throughout the entire operation. He/she is also the one to insert the necessary IV lines and artificial airways. These and a few others are the responsibilities handled by a nurse in this field.

 Requirements 

 The requirements for being a Nurse Anesthetist differ from country to country and from state to state. However, the basic principles of accreditation remain the same. A nurse who is interested in becoming a nurse anesthetist must undergo the necessary trainings. This may include taking some post graduate course as well as several hours of field experience.

The basic requirements of becoming a Nurse Anesthetist include:

•  A BSN (Bachelor of Science in Nursing) or any other appropriate degree


•  Applicant must be a registered nurse
  ·
•  Minimum of 1 year experience as a nurse in a hospital or clinical setting 

Some countries like the United States require that their Nurse Anesthetist undergo a special Nurse Anesthetist course in any accredited institution. This is also true for several European and Asian countries. 

 Certification and Licensure 

 After the necessary training and master’s courses have been completed, nurses may be required to take licensure examinations and apply for accreditation and certification. By doing so, nurses then earn the right to be considered as professional Nurse Anesthetist.

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Restraint Application

Definition

Restraint application is a technique of physically restricting a person’s freedom of movement, physical activity or normal access to his body. A physical restraint is a piece of equipment or device that restricts a patient’s ability to move. It is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.

The definition of restraint is based not on the equipment or device but rather on the functional status of the client. If the client cannot release himself from the device physically, then the said device is considered a restraint.

Purpose of Restraint Application

Restraints are used to control a patient who is at risk of harming him or her self and/or others. In some cases, restraints are also used for children who are not capable of remaining still when they are frightened or in pain during administration of medication or performing other procedures. However, using restraints in any health care facility should be used as the last option in dealing with patients.

When to use restraints?

Physical restraint should be used only when other, less restrictive, measures prove ineffective in protecting the patient and others from harm.

Types of Restraints

1. Soft restraints. This type of physical restraint device is used to limit movement of patients who are confused, disoriented or combative. The main goal of using this restraint is to prevent the patient from injuring him or her self and/or others.
2. Vest and Belt Restraints. In using this device full movement of arms and legs are permitted. This is used to prevent the patient from falling from bed or a chair.
3. Limb Restraints. Patients who are removing supportive equipments such as I.V. lines, indwelling catheters, NGTs and etc. are placed on limb restraints. This device allows only slight limb motion.
4. Mitts. This device prevents the patient from removing supportive equipment, scratching rashes or sores and injuring him or herself and/or others.
5. Body restraints. When patients become combative and hysterical they can be controlled by applying body restraints. This immobilizes almost all of the body.
6. Leather Restraints. This restraint is only used when soft restraints are not sufficient to control the patient and when sedation is either dangerous to the patient or ineffective.

Precautions of Restraint Application

1. Before applying restraints it is important to try other methods of promoting patient safety. Alternative methods that might be effective are reorientation of the patient to the physical surroundings, moving the patient’s room near to the staff members, teaching relaxation techniques in order to decrease anxiety and fear and decrease overstimulation.
2. Documentation of any alternative method used is extremely important. Restraint application should be documented thoroughly.\

Situations that Requires Restraint Application

1. Confused client tries to endanger him or herself
2. Confused client attempts to remove supportive equipments such as necessary tubes, IV lines or protective dressings.
3. The client is at risk for falls.
4. The client is suicidal.
5. The client poses harm or threat of inflicting harm to health care staff, other clients and/or visitors.
6. A child is unable to remain still during a minor surgical procedure.

Equipments

Soft restraints

• Vest restraint
• Limb restraint
• Mitt restraint
• Belt restraint
• Body restraint as needed
• Padding if needed (large gauze pads can be used)
• Restrain flow sheet (washcloth can be used)

Leather restraints

• Two wrist and two ankle leather restraints
• Four straps
• Key
• Large gauze pads – this is used to cushion each extremity
• Restraint flow sheet (washcloth can be used)

Restraint Application Key Steps

1. Make sure that the restraints are correct size for the patient’s build and weight.
2. Explain the need for restraint to the patient. Assure him or her that they are used to protect him from injury rather than to punish him. It is necessary to inform the patient of the conditions necessary to release him or her from restraints.
3. Restraints are ONLY used when all other methods have failed to keep the patient from harming himself or others. Restraints used should be least restrictive to the patient.
4. Obtain adequate assistance to manually restrain the patient.
5. After an hour of placing a restraint, the patient should be evaluated by a licensed independent practitioner and an order must be written for restraints.
6. The order must ne time limited: 4 hours for adults; 2 hours for patients ages 9 to 17 years old; 1 hour for patients younger than 9 years old.
7. The original order expires in 24 hours. Thus, the same order cannot be used the following day.
8. To promote safety and ensure the patient is not harmed with restraint application, the patient should be assessed every 2 hours or according to the facility policy.
9. In cases where the client consented to have his family informed of his care, the family should be notified of the use of restraints.

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Reality Therapy

Definition

Reality therapy is devised by William Glaser in 1965 which focuses on the person’s behavior and how that behavior keeps him or her from achieving life goals. The approach was developed while Glaser is working with persons with delinquent behavior, unsuccessful school performance and emotional problems. This therapy is considered a cognitive-behavioral approach to treatment.

Approach of Reality Therapy

William Glaser believed that people who are unsuccessful often blame their problems on other people, the system or the society. It is Glaser’s belief that these types of people can only find their own identities through a responsible behavior. The focus of approach of counseling and problem solving in reality therapy focuses on the here-and-now of the client and how to create a better future.

In this therapy, the individual is challenged to examine himself for ways in which his own behavior obstructs his attempts of achieving his life goal. The focus of Reality Therapy is to help counselees take ownership of their behavior and responsibility for the direction their lives take.

With reality therapy, whatever happened in our lives or what has been done in the past, the person can still choose behavior that will help him meet his needs more effectively in the future. It is believed that these needs that a person has to effectively meet are the following:

1. Power – this includes a person’s achievement and feeling worthwhile. Winning is also included here.
2. Love and belonging – this includes families, loved ones, relatives and groups.
3. Freedom – independence, autonomy, personal “space”
4. Fun – pleasure and enjoyment
5. Survival – nourishment, shelter

Process Involved in Reality Therapy

In practicing reality therapy, two major components should be considered:

• A trusting environment should be created.
• Therapeutic techniques should be utilized to help a person discover what they really WANT, reflect on their current activities and behavior and devise a new plan to fulfill that WANT effectively in the future.

The processes taking place in reality therapy are:

1. Developing a good RAPPORT with the client. To make the entire process effective, trust and rapport should be built at the beginning.
2. The current behavior (not the previous one) should be examined and evaluated by the client with the help of a psychotherapist. The therapist will ask the client to make a value judgment about his current behavior.
3. Help the client plan a new behavior that can be possibly done that works better than the current one.
4. The participant must make a commitment to carry out the plan.
5. There should be no punishment to be implemented. The therapist however, should stress to the client that there are no excuses and to never give up.

Summary of Facts about Reality Therapy

Focus of Reality Therapy: Help counselees take ownership of their behavior and responsibility for the direction their lives take.

Basic Premise of Reality Therapy: Regardless of what has happened to us in our lives, or what we have done in the past, we are living and making choices here and now.

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Psychiatric Mental Health Assessment

Definition

• Accuracy in assessment determines whether the following steps of the nursing process will produce accurate nursing diagnoses, palnning, and intervention.
• Psychiatric-mental health assessment is the gathering, organizing, and documenting of data about the psychiatric and mental health needs of the client and family.

Assessment

• The first step of the nursing process.

Interview

• The degree to which the interview is therapeutic, or helpful, to the client may determine the extent and honesty of the information shared by the client.
• Clients expect the interviewer to be an expert who is confident in the professional role, maintains confidentiality, demonstrates warmth and genuineness, is nonjudgmental toward them and their past or current behavior, and recognizes that clients are experts on themselves and their behavior.

Assessment Data

1. Subjective
   • Client’s current problem and reason for seeking help.
   • Past mental illness and treatment
   • Family history and mental illness
   • Medical history
   • Allergies to medications, foods, and other substances
   • Past and present medications and their effects
   • Past and present abuse
   • Substance abuse history
   • Educational and/or vocational history
   • Health habits
   • Safety issues
   • Cultural beliefs and practices
2. Objective
   • Behavior
   • Communication
   • Physical assessment
   • Laboratory or testing data
   • Mental status

Appearance

• Hygiene, grooming, appropriateness of clothing, posture, and gestures.

Behavior

• Eye contact, motor behavior, body language, behavioral responses to others and environment, volume and speed of speech, tone of voice, flow of words.

Affect and Mood

• Happy, sad, anxious, sullen, hostile, inappropriate for situation, silly, and range of emotions.

Orientation

• To person, place, time, situation, relationship with others.

Memory

• Immediate recall, recent and remote memory.

Sensorium or Attention

• Ability to concentrate on a task or conversation, perception of stimuli.

Intellectual functioning

• General fund of knowledge about the world, cognitive abilities such as a simple arithmetic.
• Ability to think abstractly or symbolically.

Judgement

• Decision making ability, especially regarding delay of gratification.

Insight

• Awareness of one’s responsibility for and analysis of current problem, understanding of how client arrived in current situation.

Thought Content

• Recurrent topics of conversation, themes.

Thought process

• Processing of events in the situation, awareness of one’s thoughts, logic of thought.

Perception

• Awareness of reality vs. fantasy, hallucinations, delusions, illusions, suicidal or homicidal ideation or plans.

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Phobias

Definition

• A phobia is an anxiety disorder characterized by obsessive, irrational, and intense fear of a specific object an activity, or a physical situation.
• The fear, which is out of proportion to reality, usually results from early painful or unpleasant experiences involving a particular object or situation.
• A phobia may arise from displacing an unconscious conflict on an object that is symbolically related.

image credit to: metro.co.uk

Types of Phobias

1. Agoraphobia
   • Fear of being in places or situations from which escape may be difficult or help may not be readily available.
2. Social Phobia
   • Also called Social Anxiety Disorder
   • Characterized by persistent fear of appearing shameful, stupid or inept in the presence of others.
3. Specific Phobia
   • Also called Simple Phobia
   • A persistent fear of a specific object or situation, other than of two phobias mentioned above.
   • Sub-categories:
     1. Injury-blood-injection
     2. Situational
     3. Natural environment
     4. Animals
     5. Other (fear of costumed character, space, etc)

Risk Factors

1. Learning theory
   • The belief that phobias are learned and become conditioned responses when the client needs to escape an uncomfortable situation.
2. Cognitive theory
   • Phobias are produced by anxiety-inducing self-instructions of faulty cognitions.
3. Life experiences
   • Certain life experiences, such as traumatic events, may set the sage for phobias later in life.

Signs and Symptoms

1. Withdrawal
2. High levels of anxiety
3. Inability to function and meet self-care needs
4. Inappropriate behavior used to avoid the feared situation, object or activity
5. Dysfunctional social interactions and relationships

Nursing Diagnoses

1. Anxiety
2. Powerless
3. Ineffective individual coping
4. Impaired verbal communication
5. Altered thought processes
6. Self-esteem disturbance
7. Impaired social interaction
8. Risk for injury

Therapeutic Nursing Management

1. Systematic desensitization
   • This process of gradual exposure to phobic object or situation aimed at decreasing the fear and increasing the ability to function in the presence of phobic stimulus.

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