In “The Final Phase”, patients in the Day Room need to be assessed for level of stress and assigned a nursing action. Select each patient from below to view his or her current exhibited behaviors. After you have viewed each patient, select the patient with the highest acuity, then assign acuity level. Afterwards, you will select appropriate nursing action. After nursing action actions are assigned, you will return to Dayroom to repeat process until all patients have been addressed. Use definitions below to determine appropriate acuity and nursing action Mild/ Normal Stress Is considered to be healthy and is accomplished by a level of mild anxiety. With some assistance, coping with daily life is achievable. Nursing actions include: • Allowing expression of feelings • Employ empathy in communication • Demonstrate active listening • Help patient identify problems • Assist in problem solving • Evaluate, explore results, plan is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m Moderate Stress Lingers and continues to influence the person's life. The person experiences feelings of being overwhelmed and troubled. Nursing actions include: • Offer a cool beverage • Respect need for personal space • Actively dialogue with patient to share feelings • Create activities for distraction • Explore alternative coping mechanisms • Help patient focus on the here and now Pacing, avoids eye contact – offer cool beverage Avoids eye contact, “I don’t know what to do” – respect personal space Th Severe Stress Occurs when the person's stress level has not been reduced and is now more obvious. Negative behaviors begin to intrude such as somatic complaints, agitations, and anger. Nursing actions include: • Begin limit setting • Make simple and direct statements • Describe behavior needed • Notify MD and administer medication • Remove other patients from day room • Explain consequences of behavior Shouting loudly, refusing to follow directions – begin limit setting Hyperextended neck, swearing – remove others from day room sh Panic level Results in a person that is physically and emotionally exhausted from stress. The ability to cope and exert self-control is virtually non-existent. Nursing actions include: • Assess potential for injury to self/others • Conduct debriefing of unit community • Call for therapeutic team support • Call Physician for onsite assessment • Conduct debriefings of staff and patient post-containment Throwing objects - Therapeutically contain patients. Full flight/fight mode, gross motor skills at highest level – conduct debriefing on unit community This study source was downloaded by 100000766988704 from CourseHero.com on 10-04-2021 22:10:35 GMT -05:00 https://www.coursehero.com/file/68827644/Day-Room-Assessment-Helppdf/ Powered by TCPDF (www.tcpdf.org)