Question Of The Day: Mood, Adjustment, and Dementia Disorders

Q. The nurse meets with the client and his wife to discuss depression and the client's medication. Which of the following comments by the wife would indicate that the nurse's teaching about disease process and medications has been effective?

A. "His depression is almost cured."
B. "He's intelligent and won't need to depend on a pill much longer."
C. "It's important for him to take his medication so that the depression will not return or get worse."
D. "It's important to watch for physical dependency on Zoloft."

Correct Answer: C
Explanation: Improved balance of neurotransmitters is achieved with medication. Clients with endogenous depression must take antidepressants to prevent a return or worsening of depressive symptoms. Depression is a chronic disease characterized by periods of remission; however, it is not cured. Depression is not dependent on the client's intelligence to will the illness away. Zoloft is not physically addictive.

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5 Best Summer Test Prep Tips for the NCLEX

During the summer, most people prepare for BBQ’s, parties, and beach days. If you are a nursing student or a new graduate nurse, however, you are most likely preparing for the following semester or to take your NCLEX exam. Here are some tips to help prepare you for the NCLEX or a test of any kind during the summer season:

1. Begin test prep by reading ahead    

If you are preparing for the following semester, see if you can snag a course outline from someone has just taken the course or if you can get it from the professor or from the campus bookstore. If you are able to get your hands on the assigned reading, it may be helpful to start skimming through the reading over the summer when you have more time. We are all familiar with the heavy reading load professors place on us during the semester, so if you have the time during the summer to get a head of the game, go for it!

2. Set a summer schedule  

Set up a summer study schedule that you know you will be able to stick with. During the summer, you may get caught up on fun summer activities and events and may be working long hours. Try to devote an hour or two a day to studying and preparing for the NCLEX or the upcoming semester.

3. Do practice NCLEX questions

Do as many practice NCLEX questions as you can. The best way to prepare for any nursing test is to reinforce your knowledge and critical thinking skills through the use of practice questions. The questions that provide rationales and explanations are great as they can help you understand why you are getting questions wrong.

4. Assess yourself   

Take practice tests throughout the summer to help give yourself an idea of where you stand with the content. While studying the general concepts is good, practicing is the best way to see what specific areas you need to focus on.

5. Study with a friend   

Studying with a fellow nursing friend is a great way for both of you to challenge and assess yourself on content. For example, if you know that you struggle with med math (which will follow you all throughout nursing school and your career) try and review med math problems with someone that excels in math.  

If you follow the above listed steps and create your own study groove, you are sure to be on the path for success. Remember, everyone studies differently, so some of the suggestions listed may work for you and others may not. Test prep during the summer doesn’t have to be overwhelming—by sticking to a schedule, studying in small increments, and reinforcing what you know, you will be successful on your exam.

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4 Things Nurses Should Never Say to Patients

Believe it or not, simple words can truly affect a nursing patient’s experience in the hospital. You may have the best of intentions, but certain topics or comments can negatively affect a patient’s sense of confidentiality, personal beliefs, and emotions.

When working as registered nurse with long shifts and multiple clients, it is easy to forget what it’s like to be a patient. A little empathy and imagining what it is like to be a patient will help you to remember what to say or not to say. Here are a few things to avoid to help you uphold quality care:

1. Nurses should never complain about another caregiver

Inevitably in your career, you may come across co-workers with different opinions than your own. These differences can and should be used to complement each other and strengthen a team. Unfortunately, though, they can also escalate making a stressful work environment.

In your frustration, it’s easy to let a negative comment slip a about another registered nurse in front of a patient, causing them to lose confidence or feel suspicious of any future caregiver. When a person feels ill they naturally feel vulnerable to the nurses who care for them.

If you truly feel something was done incorrectly that could have endangered the patient or negatively affected their experience, make it known to that caregiver outside of the patient’s presence. You can also discuss the issue with your nurse manager.

2. Save personal conversations for between shifts

Hopefully, you will have a great relationship with many of your fellow nurses because you will be spending a lot of time with them. You’ll naturally want to discuss personal issues such as relationships in your life, how the local sports team did last weekend, or your evening plans.

Just remember, there’s a time and place for everything. When interacting with a patient, they should be your only focus. While in a patient’s room, whether it’s performing a procedure or even just helping to dress or turn a patient, it can be easy for nurses to start discussing these topics over the patient’s head. This may cause the patient to feel as if their needs aren’t being met.

It’s best to catch up with coworkers outside of the patient’s room, during lunch, or before or after your shift.

3. Keep your personal and religious beliefs to yourself

As a nursing patient’s caregiver you have a position of power. Imagine being in a hospital, in a hospital gown, dependent on one person for all personal care, medications, and communication with the medical staff. I’ve been in situations where patients have expressed to me that their bedside nurse or caregiver expressed their own opinions on healthcare choices or expressed religious or political beliefs that made them uncomfortable.

Part of nursing is caring for the patient as a whole that includes honoring their own traditions as well as empowering them to make informed decisions about their healthcare by providing objective information. Your role as a registered nurse is to simply be the messenger and help translate medical terminology for the patient. That translation should remain objective.

4. Never act too busy to give a client attention and care

As a registered nurse, you will often feel like you are being pulled in ten different directions. If you work as a bedside nurse, you may have up to five patients or more, depending on the specialty and acuity of the clients. It can be a challenge to meet all the needs of just one patient, let alone all of them.

When a patient is in pain or scared or just needs help getting to the bathroom, they are not thinking about the four other clients you have to manage. It is NOT OK to tell a patient, “I’m too busy right now, you will just have to wait.” You have resources—use them. Ask a coworker who may not be as busy to help. Ask one of the nursing techs to assist you.

Either way, the most important thing is to communicate to the patient appropriately. For example, “I understand that you need pain medication. I am in another patient’s room. I will be able to bring the medication to you in 10 minutes.” Or “I understand that you need to go to the bathroom right now. I have asked the nurse tech to come to your room as soon as possible.”

Your words carry a lot of weight for your patients. You have an important duty as a registered nurse to honor each patient’s autonomy by respecting their beliefs and creating a healing environment for their care.

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Question Of The Day: Neurosensory Disorders

Q. When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

A. Trendelenburg's
B. 30-degree head elevation
C. Flat
D. Side-lying



Correct Answer: B
Explanation: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

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5 Tips for New Nurses to Avoid Feeling Overwhelmed and Overworked

As a new nurse, it’s relatively easy to feel overwhelmed with the job. Transitioning from books to actual patients is not as easy as it sounds. Aside from feeling pressured to deliver well, the fast-paced environment can make you feel the need to catch up. Unfortunately, working fast doesn’t always mean quality work. It can also make you question if you’ve taken the right path. Trust me, I’m with you on this one.

To help cope with the stress of becoming a new nurse, here are some tips you can use on your next shift:

1. Pace yourself.

To beat your self-doubt, it’s a wise move if you can work at your own pace. It doesn’t necessarily say that you have to work real slow but starting out with what you know, particularly during an emergency, can make you an asset rather than the team’s liability. It can also help you build more confidence to tackle on complex tasks as you continue to learn.

“I prefer new nurses who step on their game. However, if you’re not thoroughly acquainted with that defibrillator yet, I’d like you to let somebody else do the job if we have an emergency. Any delay can cause us our patient’s life. We can always do the orientation at another time,’ an ER head nurse said.

2. Go to work prepared.

One of the things that can make you feel overwhelmed is the idea that you “may probably not complete a task correctly.” Instead of always worrying, it can help if you prepare beforehand. Graduating nursing school and getting your license don’t mean you can stop studying. Reviewing your notes and researching about a topic you’re not thoroughly familiar with can help ease your nerves the next time you encounter the same task or case.

3. Do not give up just yet.

The pressure of working as a new nurse can be too much to handle. As a matter of fact, it’s one of the most frequent reasons why they quit their jobs. If ever you’re feeling this way, I suggest you hold on. It took me several months before I was comfortable with my work as a Delivery Room nurse.

There are a lot of things that can affect how fast or slow you adjust to your working environment. These can involve the people you work with, your unit, your patients, and the general working atmosphere. Once you get comfortable with these things, you’ll just probably laugh at yourself for all the unnecessary things you’re worrying about today.

4. Relax.

One of the best ways to beat stress is to relax. Not de-stressing, particularly after a very busy shift, can make you feel burnt out and unhappy about your work in the long run. To help you stay motivated, it’s best if you can find an activity that you like, such as biking or even taking cooking classes. It doesn’t have to be an expensive hobby. As a matter of fact, getting a good rest or taking a short walk in the park can help you stay happy with your work.

5. Find passion in what you do.

As most people say, nursing is not just a profession, but it’s a calling. Not everyone feels compelled to serve other people as much as we do. If your heart and mind are not in tune with this calling, it’s easy to lose interest in the job.

To be an experienced nurse, you have to find the passion for the work you do. There are a lot of subspecialties within the profession in which you can explore. If you’re comfortable with kids, it can help if you get a job that deals with pediatrics instead. In case you like teaching, you can work on being a clinical instructor. Being a nurse doesn’t necessarily mean you’re limited to hospital work.

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Question Of The Day: Gastrointestinal Disorders

Q. Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?

A. The client will be maintained on bed rest for several days.
B. Ambulation is restricted by the presence of drainage tubes.
C. The operative incision is near the diaphragm.
D. The presence of a nasogastric tube inhibits deep breathing.

Correct Answer: C
Explanation: The incisions made for upper abdominal surgeries, such as cholecystectomies, are near the diaphragm and make deep breathing painful. Incentive spirometry, which encourages deep breathing, is essential to prevent atelectasis after surgery. The client is not maintained on bed rest for several days. The client is encouraged to ambulate by the first postoperative day, even with drainage tubes in place. Nasogastric tubes do not inhibit deep breathing and coughing.

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Question Of The Day: Antepartum Period

Q. A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. Which of the following should the nurse do upon the client's arrival?

A. Position the client in a supine position.
B. Auscultate breath sounds every 4 hours.
C. Monitor the vital signs every 4 hours.
D. Admit the client to a quiet, darkened room.

Correct Answer: D
Explanation: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible. Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour.

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Top 10 Nursing Specialties Nurses Would Want to Pursue

The nursing profession has been expanding for years already; you would be surprised with the number of nursing specialties that exists today. Despite the nursing shortage in some countries, the trend for nursing specialties never goes out of style. More and more registered nurses pursue studies in their fields of interests, leading to more competent and competitive nurses around the globe. Notwithstanding the salary (which is pretty much terrific), the satisfaction that a nurse gets from being a nurse specialist draws them to further their studies and perform in their fields of interests. We compiled a list of 10 nursing specialties that a nurse wants to enter, so take a pick and see where it might take you.

1. Nurse Anesthetist

Nurse anesthetists are highly competent and skilled nurses who collaborate with anesthesiologists during surgeries.

Nurse Anesthetist is one of the most sophisticated and complex nursing specialty in the field of nursing. Nurse anesthetists are highly competent and skilled nurses who collaborate with anesthesiologists during surgeries. They specialize in the administration of anesthesia for surgical, obstetrical, and trauma operations. There is an increasing need for nurse anesthetists because more and more rural hospitals are being erected, and almost all surgical anesthesias are administered solely by nurse anesthetists.

How to Become One: To become a certified nurse anesthetist, you have to obtain a bachelor’s degree in nursing and become a licensed nurse. Next, finish a master’s degree and obtain more than a year’s experience from an acute care facility then take a certification exam to become a certified nurse anesthetist.

Why to Pursue This: Most experienced nurses, especially operating room nurses, want to pursue this path because it gives them more precise and detailed knowledge of the nervous system. They yearn for a more challenging task and being a nurse anesthetist would surely satisfy this thirst. The salary is humungous, of course. You may earn up to $154, 390 annually.

2. Nurse Researcher

Nurse Researchers are considered as detail-oriented and very organized. A nurse researcher must possess strong writing skills for writing grant proposals and clinical study reports. They conduct researches that improve nursing practices and standards and also discover cures to diseases.

How to Become One: To become a nurse researcher, obtain a bachelor’s degree in nursing then become a licensed nurse and take up your master’s in nursing. Having a doctorate in nursing is a plus because it can create more opportunities of studies for you.

Why to Pursue This: Nurses who have the passion for writing and discovering new things usually pursue this specialty. It gives them the opportunity to embrace their interests and at the same time be a nurse in the profession. Engaging in experiments also may excite your mind, and you will just find yourself having fun in this specialty. The salary also attracts the nurses because you can earn up to $95,000 annually.

3. Nurse Midwife

A nurse midwife aids the pregnant woman during her labor stages, and she can also handle deliveries.

The maternal and child nursing community is slowly booming today. The demand for maternal nurses shot up because of the increase in the number of women who are giving birth in hospitals. A nurse midwife aids the pregnant woman during her labor stages, and she can also handle deliveries.

How to Become One: One should have a Bachelor’s degree in Nursing and be a licensed nurse. The nurse also would have to obtain one or two years experience in obstetrics, and then complete a nurse-midwife education. After obtaining this, you can apply for certification from a certification council specific only for nurse midwives.

Why to Pursue This: Nurses want to become nurse-midwives because they can hit two birds with one stone: they can still function as a nurse and also deliver babies even without a physician’s present. The salary is also attractive at $ 92,229 annually.

4. Clinical Nurse Specialist

These nurses can work across all fields in a clinical setting. Their work requires a lot of research too, but they also get to work side by side with a patient. Clinical nurse specialists can also prescribe medicines, so when there is no doctor around, you can try to consult with the local nurse specialist for some of your minor diseases, and they would prescribe medicine for you.

How to Become One: First, you have to finish your degree in Nursing and secure your license. You would also have to complete a master’s degree which gives emphasis in clinical practice.

Why to Pursue This: If you are fond of being hands-on with your patients and love working in the actual clinical setting, this would be the job for you. You would also get your mind at work when you reach the research stage. Mind you, the salary is $93, 901 annually. You would certainly love to be one!

5. Critical Care Nurse

Being a critical care nurse requires more extensive knowledge of different medical conditions and should be very detail-oriented when it comes to their patients.

Nurses in the critical care area work in close collaboration with specialists, for they are carefully monitoring each critical patient’s status. The most that are assigned to a critical care nurse would be two patients per shift. They would have to experience a wide variety of diseases, so being a critical care nurse requires more extensive knowledge of different medical conditions and should be very detail-oriented when it comes to their patients.

How to Become One: Obtain your Nursing degree and license first. Experience in the critical care area is a must so you can apply for a critical care certification exam. Once this is passed, to keep your certificate current, you would need to attend continuing education courses as required by your institution.

Why to Pursue This: You would be caring for a patient more closely, and you would be able to see all the changes the patient would undergo as time moves on. You would get to see the effects of your interventions and the medical interventions, and would have more understanding of disease conditions more than a regular nurse has.

6. Family Nurse Practitioner

If most of us have family physicians, it is time to know that nurses have a field that specializes in family care too. These are the nurse practitioners, and they can examine, diagnose, and prescribe medications for common disease conditions of the family.

How to Become One: Completion of a bachelor’s degree in Nursing and obtaining your license are the first steps. Complete a master’s degree, and then apply for your family nurse practitioner certification from the American Nurses Credentialing Center or the American Academy of Nurse Practitioners.

Why to Pursue This: If you are more inclined to help families through their journey towards their wellness, then this would fit you like a tee. You would be the go-to of every family when they have disease conditions, and you would get to monitor each member’s health and wellness. The salary is also pretty attractive at $94, 407 annually.

7. Nurse Manager

Nurse Managers supervise the registered nurses under them and also acts as the bridge between the staff nurses and the management. They facilitate every nurse with their patients and can also be found at the bedside, but they also handle disciplinary works and higher lever tasks.

How to Become One: Finish your bachelor’s degree in nursing and then take management classes. Obtain your license and experience in working in a clinical setting. Complete a master’s degree in healthcare or business administration. Lastly, pass the proper certification exam from the American Organization of Nurse Executives.

Why to Pursue This: When you are born with the leadership skills and also active in supervising every group interactions you had at nursing school, then you can develop and become a nurse manager. A nurse manager must have the skills for patient care and the managing skills too. The salary would be at $93, 371 annually.

8. Nurse Case Manager

Nurse case managers focus on one disease for every person. They obtain information including the history, present illnesses, and practices of the patient that lead to the present disease condition.  They work in a primary care setting to monitor the treatment and coordinate the care of their patient with other healthcare providers.

How to Become One: Complete your bachelor’s degree in Nursing and secure your license. You can take your master’s degree with emphasis on health conditions and illnesses. Then, gain your certification from the Case Management Society of America and pursue continuing education to maintain the certificate.

Why to Pursue This: If you have the penchant for details and health conditions, then you would find your fit at being a case manager. You would be getting to know the patient more than giving care and treatment, and this could be quite fulfilling once you have achieved all your goals for their health. The salary could also motivate you at $85, 000 annually.

9. Neonatal Nurse

These nurses specialize in the care of neonates, newborns who are 28 days old and below. They administer medications, perform procedures, and deliver oxygen to neonates especially the premature ones.

How to Become One: Obtain your degree in nursing first, and then secure your license. You must also have an experience in working in the neonatal care unit and finish your master’s degree.

Why to Pursue This: Most would answer that they would pursue this specialty because they love babies. You would not only care for healthy babies, but you would also have the chance to care for neonates who are critically ill. Estimated annual salary for neonatal nurses is $ 91,000.

10. Nurse Educators

They are responsible for the education that we had at nursing school. They teach student nurses all they need to know to become a nurse and also supervise them during clinical duties in hospitals they are affiliated in. This is currently the highest nurse specialty in demand across all states.

How to Become One: Obtain your bachelor’s degree in nursing and secure your nursing license. You also have to complete a master’s degree. A doctorate is not necessary, but higher positions are given to those who have doctorate degrees. You would also need to pass a nursing educator’s certification exam from the National League of Nursing or other professional nursing organizations.

Why Pursue This: This is a very fulfilling specialty because you would be giving the students their foundations on how to become an efficient nurse. You would teach them all they need to know until they become your colleagues and you would be able to see the fruit of your labor when they become registered nurses like you. The salary is also competitive at $83,000 annually.

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Question Of The Day: Mood, Adjustment, and Dementia Disorders

Q. A nurse is facilitating mandated group therapy for clients who have sexually abused children. Children who are victims of sexual abuse are typically:

A. from any segment of the population.
B. of low socioeconomic background.
C. strangers to the abuser.
D. willing to engage in sexual acts with adults.


Correct Answer: A
Explanation: Victims of childhood sexual abuse come from all segments of the population and from all socioeconomic backgrounds. Most victims know their abuser. Children rarely willingly engage in sexual acts with adults because they don't have full decision-making capacities.

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Question Of The Day: The Nursing Process

Q. A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved?

A. The entry should include clearer descriptions of the client's mood and behavior.
B. The entry should avoid mentioning cognitive or psychosocial issues.
C. The entry should list the specific reasons that the client was upset.
D. The entry should specify the subsequent interventions that were performed.

Correct Answer: A
Explanation: Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.

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7 Ways Nurses Can Treat Their Feet Right

Your feet literally carry you through life, bear your weight and take you places. As a nurse, you are constantly on your feet, from eight hours to sixteen-hour shifts.  The importance of the feet cannot be over-stated. Despite their importance, the feet are often neglected. So what can you do to treat your feet right?

Pedicure and Foot Baths

Taking care of your feet is important. Make sure you wash your feet when you shower, and be sure to give them a good scrub when you take a bath. You can buy a foot bath with a massage function to target your feet in particular. Bathe your feet with Epsom salt or other organic bath salts for an extra enjoyable bath. Add a few drops of organic lavender essential oil for a relaxing scent that also fights foot fungus.

After properly washing your feet, you will want to trim and file your toenails regularly. Taking good care of your feet prevents in-grown toenails. In-grown toenails are hellishly painful, so taking easy steps to avoid them will prevent unnecessary pain. Besides, effective feet care routine that you turn to a regular habit will leave you with gorgeous, sandal-ready feet when the summer comes!

Reflexology and Foot Massage

Have you ever had a foot massage? There’s almost nothing more heavenly. Take things a step further, and you have reflexology: foot massage geared toward relieving certain ailments in the body. The principle behind reflexology is that the foot is like a map for the entire body. One part of the foot corresponds to a body part, such as the edge of the foot connects via nerve endings to the spine. If you massage certain areas, you can sometimes trigger healing of a body part. Massage the arch of the right foot to target your liver and aid in detoxification.

Make Your own Foot Cream

To make your foot cream, simply combine coconut oil with a few drops of peppermint oil. The peppermint and coconut oils are antibacterial and anti-fungal and help to combat foot odor. They also leave the feet feeling silky, moisturized and refreshed -especially after a long day on your feet!

Rest Your Feet

After a hard day on the job, you will not want to underestimate the importance of rest! Give your feet a nice foot bath, massage your feet and then put them up! Not on the table necessarily, but on a comfortable foot rest. This will help blood flow and circulation to your feet that will soothe them and help prevent soreness.

Magnesium

Did you know that an effective way to take your vitamins is via the skin? Try a magnesium spray right on your feet and legs. This prevents soreness and soothes your muscles after a hard day. This is an often overlooked part of foot care that you should incorporate into their daily routine. You will feel so much better, more relaxed and just plain healthier!

Intensive Foot Care

If you suffer from calluses, you are not alone. It is completely common among nurses because they walk constantly. They are painful and unsightly though, so of course, you want to take care of them! Here’s an easy way to do it.

Take a foot bath in Epsom salt. Scrub at the calluses with a pumice stone. After that, rinse your feet in apple cider vinegar. Repeat the process. At night, apply a foot creme consisting of peppermint oil and coconut oil to the affected area. Cover the area with a bandage and see how much softer your feet will become! Your calluses will be gone in days if you repeat this process regularly.

Don’t Cheat your Feet!

The feet are among the most important parts of the body. Like the roots of a tree, they support us, and we should repay them with tender care. Make foot care a part of your daily beauty routine and be sure to get plenty of rest for your feet. Massage your feet often, whether at home or work.

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Question Of The Day: Respiratory Disorders

Q. A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

A. Endotracheal suctioning
B. Encouragement of coughing
C. Use of a cooling blanket
D. Incentive spirometry

Correct Answer: A
Explanation: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

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Question Of The Day: Neurosensory Disorders

Q. A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

A. Sit with the client for a few minutes.
B. Administer an analgesic.
C. Inform the nurse manager.
D. Call the physician immediately.

Correct Answer: D
Explanation: The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.

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The Importance of Branding for Nurses

Erica MacDonald RN, BSN, MSN

Are you satisfied with your nursing career? Are you feeling so confident in your current employment that you don’t ever plan to switch jobs? Or, are you ready for a career change such as job role, or even trying out a different specialty such as nurse entrepreneurship?

What is Personal Branding?

No matter what point you are at in your nursing career, utilizing “branding” can make a huge difference at work or in your business. As a nurse, you probably think that “branding” is a marketing activity only used by businesses. However, the savvy nurse understands personal branding vs. business branding.


Business branding requires many skills which you will learn if you decide to become a nurse entrepreneur. However, personal branding is useful to all nurses. Your personal brand should be the expression of the unique “you”. It highlights who you are and what you have to offer the world. Just a few of the elements of personal branding can include: your personality, values, skills, dress, communication style, and your in-person & online reputation.

Can Branding Advance Your Nursing Career?

Personal branding can be part of the secret sauce to growing your network, obtaining promotions, becoming known in your specialty, and it might help you earn more money. Even if your current nursing job seems perfect, things can change. (After all, in nursing, the one constant is change.) Your facility could downsize, be bought, shut down, or a major life event could occur. As you approach retirement or desire a less demanding job, you might decide to start calling the shots (a personal brand can become an excellent jumping off point to start building a business brand). Personal branding can serve as a buffer and springboard in your career.

Build Your Brand

Have I convinced you yet? If so, get started creating your brand with these practical tips:

1. Know Yourself.

Others can’t possibly get to know the unique “you” if you don’t know yourself. Who are you? What are your life priorities and goals? What do you want to contribute to the world? If you can’t specifically and truthfully answer these questions, you have some self-reflection work to do.

2. Be You.

Be who you really are. People can sniff out a “fake” quickly. Don’t waste your time building a fake personal brand. Building a brand that is not congruent with who you really are is not effective.

3. Manage Your Online Reputation.

Seriously. This is IMPORTANT. The first thing people will do when they meet you is “Google” you. Appearing professional online is crucial in the development of your brand. This includes monitoring what others are posting about you, too.

Remember, what you do in the privacy of your home is your business (you just might want to make sure the cell phones are put away). However, being controversial, opinionated, or overly personal online can send a negative message about your brand. (I can hear your doubts now. But, I thought you just said in the last tip to “Be You”. What if being personal and opinionated is part of who I am? True, you are… who you are. BUT, you can be your authentic self without exposing every nuisance of your personality to your 500 Facebook friends, potential colleagues, clients, and employers.)

Before, you push the publish button, remember that you are not a reality TV star. Please don’t post like one. A social media post can live in infamy. Positive and professional are often key elements in building a desirable brand online. (Also, you might want to clean up your social media profiles & posts in order to present the best possible image, especially if you are searching for a new job.)

Medical professionals, should not take pictures of wounds, x-rays, or anything else that belongs to a patient. Definitely do not post it online. Even if it lacks personal identifiers, it still could be recognized. In fact, the more unusual the picture, the more likely it could be identifiable to others. Just don’t do it! Besides ethical violations, future employers probably won’t hire you.

4. Hand Out Business Cards.

You need “business cards” for networking even if you are traditionally employed and do not own a business. Business cards are visual, tangible, and memorable (if they are done right). Many people tend to hang onto them. Plus, it looks professional to hand them out when meeting new people. Take your career seriously and other people will too.

5. Become an Expert.

Whatever nursing specialty you are in or want to move into, become an expert in it (or at least a niche within that specialty). For example, if you are a medical or surgical nurse, you can become the “go to” person for questions about labs, medications, or patient positioning. Just pick an area you love within your specialty and learn to be great at it. Trust me, others will notice.

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Question Of The Day: Gastrointestinal Disorders

Q. A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?

A. Lean beef.
B. Air-popped popcorn.
C. Hot chocolate.
D. Raw vegetables.

Correct Answer: C

Explanation: With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be acceptable.

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Gaining the Courage to Get Back to Your Nursing Career

It is sometimes necessary to take some time out from work. This may be due to family reasons like having a baby, or you may take time out to travel or take care of a loved one. There are several reasons why people take time away from work, and it may last from less than a year to several years.

Many people feel overwhelmed by emotions when it comes to returning to work. Often, if the reason you left was to give birth or take care of a loved one, you may feel hesitant about leaving them.

It takes courage to return to work without feeling overwhelmed.

There are some things that you can do to prepare yourself.

◉ Take a Refresher Course

A refresher course can be very helpful if you have been away from work for over one year. These courses focus on skills like medication administration, critical thinking, phlebotomy basics, and other skills that people tend to do poorly when they have not been using them for a while.
Refresher courses may be offered at a community college near you that teaches nursing. You just have to look around for them.

◉ Update Your CEU’s and License

Update the Continuing Education Units that your state requires. If your license has expired, contact your board of nursing to make sure you get the information that you need to update your license. Some of these courses are free online. Make sure that whatever course you choose to do is accredited; otherwise, you will waste your time and money.

◉ Improve and Update Your Resume

Update your resume. You can do this by listing any accomplishments and awards that you may have received since you last worked on your resume. Update any new skills and licenses or degrees. There are lots of resume templates online that you can use. You may also consider contacting a professional to help you update your resume.

◉ Consider Applying to Your Old Job

Your old job may be a good option for you to apply to. Give your old employer a phone call and discuss your intentions. Follow this up with a cover letter telling him or her what value you bring to the institution.
If you want a change and do not want to go back to your old employer, then you should apply to several other places.

◉ Make Connections

It’s important to make connections that may inform you of where you can get a new job. Joining forums is one way of knowing where to find jobs and learning about the job market.

Linked In forums for nurses are a good place to begin. Get in touch with old colleagues, and tell them that you are job hunting. They can be a great help as well.

Getting back to nursing after being away can cause some anxiety, but once you prepare yourself, it is not that hard.

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Question Of The Day: The Neonate

Q. A woman who has recently immigrated from Africa who delivered a term neonate a short time ago requests that a "special bracelet" be placed on the baby's wrist. The nurse should:

A. Tell the mother that the bracelet is not recommended for cleanliness reasons.
B. Apply the bracelet on the neonate's wrist as the mother requests.
C. Place the bracelet on the neonate, limiting its use to when the neonate is with the mother.
D. Recommend that the mother wait until she is discharged to apply the bracelet.

Correct Answer: B
Explanation: The nurse should abide by the mother's request and place the bracelet on the neonate. In some cultures, amulets and other special objects are viewed as good luck symbols. By allowing the bracelet, the nurse demonstrates culturally sensitive care, promoting trust. The neonate can wear the bracelet while with the mother or in the nursery. The bracelet can be used while the neonate is being bathed, or if necessary and acceptable to the client removed and replaced afterward.

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The Nursing Entrepreneur's Toolbox

Nurse Entrepreneurs spend years preparing for the right opportunity to use their nursing education, expertise, and experiences to start businesses. We turn the elements of the nursing process into blueprints for starting ventures within the healthcare industry. Assessing analyzing, planning, implementing, and evaluating clients are transferrable skills that make up the entrepreneurial mindset. The nursing process and the right opportunity is a recipe for successful nursing business ventures.

I’m scared! I am thinking about starting a business! I am a future nursing entrepreneur…I think? When I think of entrepreneurs, I am reminded of three characters in the Wizard of Oz. The scarecrow, lion, and tin man wanted a brain, courage, and a heart. These are the three tools of an entrepreneur. I need the Wizard!

Nurse Entrepreneurs spend years preparing for the right opportunity to use their nursing education, expertise,and experiences to start businesses. We turn the elements of the nursing process into blueprints for starting ventures within the healthcare industry.Assessing analyzing, planning, implementing, and evaluating clients are transferrable skills that make up the entrepreneurial mindset. The nursing process and the right opportunity is a recipe for successful nursing business ventures.

Webster’s dictionary defines opportunity as “an advantageous occasion”. An opportunity is not advantageous unless the entrepreneur feels some level of passion for an idea, and a personal connection.Like the tin man in the Wizard of Oz, the heart of the entrepreneur drives motivation and the ability to think outside of one’s environment where the opportunity presents itself.

The brain is the command center for which all things are controlled. In the Wizard of Oz, the scarecrow wanted a brain. The entrepreneurs brain power keeps them on the track to success. The brain is a culmination of a person’s life experiences, personal beliefs and values, and education both formal and informal. Altogether it shapes how the entrepreneur analyzes, develops, and implements an idea.

For the entrepreneurial mindset nurses have “heart” and“brain” covered. Nurse entrepreneurs are increasing in various areas in the health care industry demonstrating creativity, business know-how and the ability to identify niche markets and consistent customer bases. Nurses entrepreneurs are branching out into coaching, teaching/training, public speaking, writing/editors, software developers, and day care to name a few.

I believe I found my opportunity. I am passionate about developing nurse leaders for the future. I guess that is why I teach nursing leadership and management to nursing students. Providing courses on relevant topics for nursing leaders is not only an opportunity,but a passion for developing future nurse leaders.

As a future nurse entrepreneur, a barrier for me would be overcoming self-doubt. Internally, self-doubt is also an objection that requires intervention. The entrepreneur that lacks confidence or courage likeOz’s lion will fail even before they begin. They spend too much time thinking about why it “won’t work” instead of mitigating the “what ifs.” These negative thoughts prevent them from seeing the big picture, and often the fear of failure paralyzes the ability tomove forward.

Perhaps turning the lion’s quest for courage into a positive acronym can provide a box of tools for potential entrepreneurs lacking courage. L-I-O-N.


L is for leaning forward. It takes less energy to lean forward than backwards. Just about all motivational speakers talk about the positive aspect of leaning forward. We lean into the wind when walking or when there something we want to listen to. Leaning forward helps the entrepreneur to approach a new venture with a singular focus. You are not dwelling on the past if you are facing forward.

I is for intervention. No one expects an entrepreneur to know everything about starting a business. New entrepreneurs tend to try to go it alone and view asking for help as a sign of weakness. There are thousands of entrepreneurs in the world. Pick one and start asking questions. Entrepreneurship is a team sport and like baseball you are only alone when you get up to bat. Until then,you have the support of team members and fans.

O is for opposite direction. It is okay to make a U turn if you are facing the wrong way. Just because you start off in one direction, you may need to offramp to a new destination. The beauty of entrepreneurship is that it is a journey with many twists, turns, and detours. Approach it like the adventure itis and be prepared for anything.

N is for natural. Let the idea come simple and unrehearsed. If you are forcing yourself to come up with an idea, it not for you and you will spend more time talking yourself out of the idea than with the idea. Noticed I did not say “into” the idea. You should not have to talk yourself into anything. It takes courage to stand up to people who want to reshape your idea into something they really want to do. An idea should fit and feel like a pair of well-worn slippers.

At the end of the Wizard of Oz story,the characters realized that what they were looking for was inside each of the mall the time. The scarecrow had a brain, the lion showed courage, and the tin man demonstrated emotion and passion. The wizard is in all of us. We don’t need to go to the land of Oz to see the Wizard. Now where is that yellow brick road to entrepreneurship?

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Question Of The Day: Antepartum Period

Q. An anxious young adult is brought to the interviewing room of a crisis shelter, sobbing and saying that she thinks she is pregnant but does not know what to do. Which of the following nursing interventions is most appropriate at this time?

A. Ask the client about the type of things that she had thought of doing.
B. Give the client some ideas about what to expect to happen next.
C. Recommend a pregnancy test after acknowledging the client's distress.
D. Question the client about her feelings and possible parental reactions.

Correct Answer:  C
Explanation: Before any interventions can occur, knowing whether the client is pregnant is crucial in formulating a plan of care. Asking the client about what things she had thought about doing, giving the client some ideas about what to expect next, and questioning the client about her feelings and possible parental reactions would be appropriate after it is determined that the client is pregnant.

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Question Of The Day: Mood, Adjustment, and Dementia Disorders

Q. A client who took an overdose of Tylenol in a suicide attempt is transferred overnight to the psychiatric inpatient unit from the intensive care unit. The night shift nurse called the primary health care provider on call to obtain initial prescriptions. The primary health care provider prescribes the typical routine medications for clients on this unit: Milk of Magnesia, Maalox and Tylenol as needed. Prior to implementing the prescriptions, the nurse should?

A. Ask the primary health care provider about holding all the client's PM prescriptions.
B. Question the primary health care provider about the Tylenol prescription.
C. Request a prescription for a medication to relieve agitation.
D. Suggest the primary health care provider write a prescription for intravenous fluids.

Correct Answer: B
Explanation: The nurse should question the Tylenol order because the client overdosed on Tylenol, and that analgesic would be contraindicated as putting further stress on the liver. There is no need to hold the PM Milk of Magnesia or Maalox. There is no indication that the client is agitated or needs medication for agitation. There is little likelihood that the client needs an IV after being transferred out of an intensive care unit, as the client will be able to take oral fluids.

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4 Personality Disorders Nursing Care Plans

Personality is defined as the differences in the characteristic patterns of behaving, feeling and thinking of an individual.

A personality disorder is a type of mental illness in which a person’s personality traits have become rigid, inflexible, maladaptive and can hinder the person’s perception and association to situations and people. This can cause significant problems and restriction in the family, social activities, school, employment and other functional roles.

Nursing Care Plans

The nursing care plan varies according to the kind of personality disorder, its severity, and life situation. A collaborative intervention is needed to make sure all of the clients social, medical and psychiatric needs are met.

The goals of the nurse for clients with personality disorders focus on establishing trust, providing safety and comfort, teaching basic living skills and promoting a responsible behavior.

Here are four (4) nursing care plans (NCP) for personality disorders:

Risk For Self-Mutilation

Risk For Self-Mutilation: At risk for deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain.

Risk factors

➨ Desperate need for attention.
➨ Emotionally disturbed or battered children.
➨ Feelings of depression, rejection, self-hatred, separation anxiety, guilt, and depersonalization.
➨ History of self-injury.
➨ History of physical, emotional, or sexual abuse.
➨ High-risk populations (BPD, psychotic states).
➨ Impulsive behavior.
➨ Inability to verbally express feelings.
➨ Ineffective coping skills.
➨ Mentally retarded and autistic children.

Possibly evidenced by

➨ Fresh superficial slashes on wrists or other parts of the body.
➨ Intense rage focused inward.
➨ Signs of old scars on wrists and other parts of the body (cigarette burns, superficial knife/razor marks).
➨ Statements as to self-mutilation behaviors.

Desired Outcomes

➨ Patient will be free of self-inflicted injury.
➨ Patient will participate in impulse control training.
➨ Patient will participate in coping skills training.
➨ Patient will seek help when experiencing self-destructive impulses.
➨ Patient will discuss alternative ways a client can meet demands of current situation.
➨ Patient will express feelings related to stress and tension instead of acting-out behaviors.
➨ Patient will sign a “no-harm” contract that identifies steps he or she will take when urges return.
➨ Patient will respond to external limits.
➨ Patient will participate in the therapeutic regimen.
➨ Patient will demonstrate a decrease in frequency and intensity of self-inflicted injury.
➨ Patient will demonstrate two new coping skills that work for the client for when tension mounts and impulse returns.

Nursing Interventions	Rationale
Assess client’s history of self-mutilation: ➨ Types of mutilating behaviors. ➨ Frequency of behaviors. ➨ Stressors preceding behavior.	Identifying patterns and circumstances surrounding self-injury can help the nurse plan interventions and teaching strategies suitable to the client.
Identify feelings experienced before and around the act of self-mutilation.	Feelings are a guideline for future intervention (e.g., rage at feeling left out or abandoned).
Explore with the client what these feelings might mean.	Self-mutilation might also be: ➨ A way to gain control over others. ➨ A way to feel alive through pain. ➨ An expression of self-hate or guilt.
Secure a written or verbal no-harm contract with the client. Identify specific steps (e.g., persons to call upon when prompted to self-mutilate).	Client is encouraged to take responsibility for healthier behavior. Talking to others and learning alternative coping skills can reduce frequency and severity until such behavior ceases.
Set and maintain limits on acceptable behavior and make clear client’s responsibilities. If the client is hospitalized at the time, be clear regarding the unit rules.	Clear and nonpunitive limit setting is essential for decreasing negative behaviors.
Be consistent in maintaining and enforcing the limits, using a nonpunitive approach.	Consistency can establish a sense of security.
Use a matter-of-fact approach when self-mutilation occurs. Avoid criticizing or giving sympathy.	A neutral approach prevents blaming, which increases anxiety, giving special attention that encourages acting out.
After the treatment of the wound, discuss what happened right before, and the thoughts and feelings that the client had immediately before self-mutilating.	identify dynamics for both client and clinician. Allows the identification of less harmful responses to help relieve intense tensions.
Work out a plan identifying alternatives to self-mutilating behaviors. ➨ Anticipate certain situations that might lead to increased stress (e.g., tension or rage). ➨ Identify actions that might modify the intensity of such situations. ➨ Identify two or three people whom the client can contact to discuss and examine intense feelings (rage,self hate) when ther arise.	Plan is periodically reviewed and evaluated. Offers a chance to deal with feelings and struggles that arise.

Chronic Low Self-Esteem

Chronic Low Self-Esteem: Long standing negative self-evaluation/feelings about self or self-capabilities.

May be related to

➨ Avoidant and dependent patterns.
➨ Childhood physical, sexual, psychological abuse and/ or neglect.
➨ Dysfunctional family of origin.
➨ Lack of realistic ego boundaries.
➨ Persistent lack of integrated self-view, with splitting as a defense.
➨ Shame and guilt.
➨ Substance abuse.

Possibly evidenced by

➨ Evaluates self as unable to deal with events.
➨ Excessively seeks reassurance.
➨ Expresses longstanding shame/guilt.
➨ Hesitant to try new things/situations.
➨ Longstanding or chronic self-negting verbalizations; expressions of shame and guilt.
➨ Overly conforming, dependent on others’ opinions, indecisive.
➨ Rationalizes away/ rejects positive feedback and exaggerates negative feedback about self.

Desired Outcomes

➨ Patient will identify one skill he or she will work on to meet future goals.
➨ Patient will identify two cognitive distortions that affect self-image.
➨ Patient will identify three strengths in work/school life.
➨ Patient will reframe and dispute one cognitive distortion with nurse.
➨ Patient will set one realistic goal with nurse that he or she wishes to pursue.
➨ Patient will state a willingness to work on two realistic future goals.
➨ Patient will identify one new skills he or she has learned to help meet personal goals.
➨ Patient will demonstrate ability to reframe and dispute cognitive distortions with assistance of a nurse/clinician.

Nursing Interventions	Rationale
Assess with clients their self perception. Target different areas of the client’s life: ➨ Strengths and weaknesses in performance at work/school.daily-life tasks. ➨ Strengths and weaknesses as to physical appearance, sexuality, personality.	Identify with client with realistic areas of strength and weaknesses. Client and nurse can work on the realities of the self-appraisal, and target those areas of assessment that do not appear accurate.
Maintain a neutral, calm, and respectful manner, although with some clients this is easier said than done.	Helps client see himself or herself as respected as a person even when behavior might not be appropriate.
Review with the client the types of cognitive distortions that affect self-esteem (e.g., self-blame, mind reading, overgeneralization, selective inattention, all-or-none thinking).	These are the most common cognitive distortions people use. Identifying them is the first step to correcting distortions that form one’s self-view.
Teach client to reframe and dispute cognitive distortions. Disputes need to be strong, specific, and nonjudgmental.	Practice and belief in the disputes over time help clients gain a more realistic appraisal of events, the world, and themselves.
Work with client to recognize cognitive distortions. Encourage client to keep a log.	Cognitive distortions are automatic. Keeping a log helps make automatic, unconscious thinking clear.
Keep in mind clients with personality disorders might defend against feeling of low-self-esteem through blaming, projection, anger, passivity, and demanding behaviors.	Many behaviors seen in PD clients cover a fragile sense of self. Often these behaviors are the crux of clients’ interpersonal difficulties in all their relationships.
Discourage client from making repetitive self-blaming and negative remarks.	Unacceptable behavior does not make the client a bad person, it means that the client made some poor choices in the past.
Discourage client from dwelling on and “relieving” past mistakes.	The past cannot be changed. Dwelling on past mistakes prevents the client from appraising the present and planning for the future.
Discuss with client his or her plans for the future. Work with client to set realistic short-term goals. Identify skills to be learned to help client reach his or her goals.	Looking toward the future minimizes dwelling on the past and negative self-rumination. When realistic short-term goals are met, client can gain a sense of accomplishment, direction, and purpose in life. Accomplishing goals can bolster a sense of control and enhance self-perception.
Focus questions in a positive and active light; helps client refocus on the present and look to the future. For example. “What can you do differently now?” or “What have you learned from that experience?”.	Allows client to look at past behaviors differently, and gives the client a sense that he or she has choices in the future.
Give the client honest and genuine feedback regarding your observations as to his or her strengths, and areas that could use additional skills.	Feedback helps give clients a more accurate view of self, strengths, areas to work on, as well as a sense that someone is trying to understand them.
Do not flatter or be dishonest in your appraisals.	Dishonesty and insincerity undermine trust and negatively affect any therapeutic alliance.
Set goals realistically, and renegotiate goals frequently. Remember that client’s negative self-view and distrust of the world took years to develop.	Unrealistic goals can set up hopelessness in clients and frustrations in nurse clinicians. Clients might blame the nurse for not “helping them,” and nurses might blame the client for not “getting better”.

Impaired Social Interaction

Impaired Social Interaction: Insufficient or excessive quantity or ineffective quality of social exchange.

May be related to

➨ Biochemical changes in the brain.
➨ Disruptive or abusive early family background.
➨ Genetic factors.
➨ Immature interests.
➨ Unacceptavle social behavior or values.

Possibly evidenced by

➨ Alienating others through angry, clinging, demeaning, and/or manipulative behavior or ridicule toward others.
➨ Destructive behavior toward self or others.
➨ Dysfunctional interaction with peers, family, and/or others.
➨ Observed use of unsuccessful social interaction behaviors.

Desired Outcomes

➨ Patient will identify and express feelings as they occur with nurse.
➨ Patient will identify two personal behaviors that are responsible for relationship difficulties within two weeks.
➨ Patient will identify one specific area that requires change.
➨ Patient will verbalize decreased suspicions and increased security.
➨ Patient will begin to demonstrate an increase in nonviolent behaviors as evidenced by a reduction in reported outbursts.
➨ Patient will begin to demonstrate a reduction in manipulative behaviors as evidenced by nurse/staff.
➨ Patient will state that he or shes is willing to continue in follow up therapy.
➨ Patient will keep follow-up appointments.
➨ Patient will demonstrate, with the aid of the nurse/clinician, the ability to identify at least two unacceptable social behavior (manipulation, splitting, demeaning attitudes, angry acting out) that client is willing to change.
➨ Patient will work with the nurse/clinician on substituting positive behaviors for those unacceptable behaviors identified earlier on an ongoing basis.

Nursing Interventions	Rationale
Set limits on any manipulative behaviors: ➨ Arguing or begging. ➨ Flattery or seductiveness. ➨ Instilling guilt, clinging. ➨ Constantly seeking attention. ➨ Pitting one person, staff, group against another. ➨ Frequently disregarding the rules. ➨ Constant engagement in power struggles. ➨ Angry, demanding behaviors.	From the beginning, limits need to be clear. It will be necessary to refer to these limits frequently, because it is to be expected that the client will test these limits repeatedly.
Expand limits by clarifying expectations for clients in a number of settings.	When time is taken in initial meetings to clarify expectations, confrontations, and power struggles with clients can be minimized and even avoided.
In a respectful, neutral manner, explain expected client behaviors, limits, and responsibilities during sessions with nurse clinician. Clearly state the rules and regulations of the institution, and the consequences when these rules are not adhered to.	From the beginning, clients need to have explicit guidelines and boundaries for expected behaviors on their part, as well as what client can expect from the nurse. Clients need to be fully aware that they will be held responsible for their behaviors.
Monitor own thoughts and feelings constantly regarding your response to the PD client. Supervision is strongly recommended for new and seasoned clinicians alike when working with PD clients.	Strong and intense countertransference reactions to PD clients are bound to occur. When the nurse is enmeshed in his or her own strong reactions toward the client (either positive or negative), nurse effectivess suffers, and the therapeutic alliance might be threatened.
Collaborate with the client, as well as the multidisciplinary team, to establish a reward system for compliance with clearly defined expectations.	Tangible reinforcement for meeting expectations can strenthen the client’s positive behaviors.
Assess need for and encourage skills training workshop.	Skils training workshops offer the client wats to increase social skills through role play and interactions with others who are learning similar skills. This often acts as a motivating factor where positive feedback and helpful suggestions are readily available.
Problem solve and role play with client acceptable social skills that will help obtain needs effectively and appropriately.	Over time, alternative ways of experiencing interpersonal relationships might emerge. Take one small skill that client is willing to work on, break it down into small parts, and work on it with the client.
Understand that PD clients in particular will be resistant to change and that this is symptomatic of PDs. This is particularly true in the beginning phases of therapy.	Responding to client’s resistance and seeming lack of change in a neutral manner is part of the foundation for trust. In other words, the nurse does not have a vested interest in the client “getting better.”. The nurse remains focused on the client’s needs and issues in any event.
Intervene in manipulative behavior. ➨ All limits should be adhered to by all staff involved. ➨ Objective physical signs in managing clinical problems should be carefully documented. ➨ Behaviors should be documented objectively (give times, dates, circumstances). ➨ Provide clear boundaries and consequences. ➨ Enforce the consequences.	Client will test limits, and, once they understand that the limits are solid, this understanding can motivate them to work on other ways to get their needs met. Hopefully, this will be done with the nurse clinician throughout problem-solving alternative behaviors and learning new effective communication skills.

Ineffective Coping

Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

May be related to

➨ Failure to intend to change behavior.
➨ Intense emotional state.
➨ Lack of motivation to change behaviors.
➨ Negative attitudes toward health behavior.
➨ Neurologic factors.
➨ Trauma early in life (physical, emotional, or sexual abuse).

Possibly evidenced by

➨ Anger or hostility.
➨ Demonstration of nonacceptance of health status.
➨ Dependency.
➨ Dishonesty.
➨ Extreme distrust to others.
➨ Failure to learn or change behavior based on past experience or punishment.
➨ Failure to achieve an optimal sense of control.
➨ Intense emotional dysregulation.
➨ Manipulation of others.
➨ Poor judgment.
➨ Superficial relationship with others.

Desired Outcomes

➨ Patient will identify behaviors leading to hospitalization.
➨ Patient will have an increased in frequency of expressing needs directly without ulterior motives.
➨ Patient will learn and master skills that facilitate functional behavior.
➨ Patient will demonstrate an increase in impulse control.
➨ Patient will demonstrate a use of a newly learned coping skill to modify anxiety and frustration.
➨ Patient will demonstrate decreased manipulative, attention speaking behaviors.
➨ Patient will not act out anger toward others while hospitalized.
➨ Patient will remain safe while hospitalized.
➨ Patient will spend time with the nurse and focus on one thing he or she would like to change.
➨ Patient will state that he/she will continue the treatment on an outpatient basis.
➨ Patient will talk about feelings and perceptions and not act on them at least twice.
➨ Patient will focus on one problem and work through the problem-solving process with the nurse.
➨ Patient will practice the substitution of functional skills for times of increased anxiety with the nurse.

Nursing Interventions	Rationale
General Interventions for All Personality Disorders:
Review intervention guidelines for each personality disorder in this chapter.	All clients are individuals, even within the same diagnostic category. However, guidelines for specific categories are helpful for planning.
Identify behavioral limits and behaviors that are expected.	Client needs clear structure. Expect frequent testing of limits initially. Maintaining limits can enhance feelings of safety in the client.
Identify what the client sees as the behaviors and circumstances that lead to the hospitalization.	Ascertain client’s understanding of behaviors and responsibility for own action.
Ascertain from family/friends how the person interacts with significant people. Is the client always withdrawn, distrustful, hostile, have continuous physical complaints?	Identifying baseline behaviors helps with setting goals.
Approach the client in a consistent manner in all interactions.	Enhances feelings of security and provides structure. Exceptions encourage a manipulative behavior.
Refrain from sharing personal information with the client.	Open up areas for manipulation and undermines professional boundaries.
Be aware of flattery as an attempt to feed into your needs to feel special.	Giving into client’s thinking that you are “the best” or “the only one” can pit you against other staff and undermine client’s need for limits.
Do not receive any gift from the client.	Again, clouds the boundaries and can give the client the idea that he or she is due special consideration.
If the client becomes seductive, reiterate the therapeutic goals and boundaries of treatment.	The client is in the hospital/clinic for a reason. Being taken in by seductive behavior undermines effectiveness of the treatment.
Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on.	Institutional policies provide structure and safety.
Be very clear about the consequences if policies/limits are not adhered to.	Client needs to understand the consequences of breaking the rules.
When limit or policies are not followed, enforce the consequences in a matter-of-fact, nonjudgmental manner.	Enforces that the client is responsible for his or her own actions.
Make a clear and concrete written plan of care so other staff can follow.	Helps minimize manipulations and might help encourage cooperation.
If feasible, devise a care plan with the client.	If goals and interventions are agreed upon, cooperation with the plan is optimized.
If the client becomes hostile or projects blame onto you or staff, project a neutral, calm demeanor, and avoid power struggles. Focus on the client’s underlying feelings.	Defuses tension and opens up productive interaction.
When appropriate, try to understand underlying feelings prompting inappropriate behaviors.	Often acting out behaviors stem from underlying feelings of anger, fear, shame, insecurity, loneliness, etc. Talking about feeling can lead to problem solving and growth for the client.
Some clients might attempt to instill guilt when they do not get what they want. Remain neutral but firm.	Nurses often want to be seen as “nice” However, being professional and maintaining limits is the better therapeutic approach.
Keep goals very realistic and go in small steps. There are no overnight successes with people with personality disorders.	It can take a long time to positively change ingrained, life-long, maladaptive habits; however, change is always possible.
Work with the client on problem-solving skills using a situation that is bothering the client. Go step by step: ➨ Define the problem. ➨ Explore alternatives. ➨ Make decisions.	Client might not know how to articulate the problem. Helping identify alternatives gives the client a sense of control. Evaluating the pros and cons of the alternatives facilitates choosing potential solutions.
When the client is ready and interested, teach client coping skills to help defuse tension and trouble feelings (e.g., anxiety reduction, assertiveness skills).	Increasing skills helps the client use healthier ways to defuse tensions and get needs met.
Guard against personal feelings of frustration and lack of progress.	Change if often very slow and may seem to take longer than it actually is. Nurture yourself outside the job. Keep your “bucket” full of laughter and high regard from family and friends.
Understand that many people with personality disorders do not stay with the treatment and often come to facilities because of crisis or court order.	Even short encounters with therapeutic persons can make a difference when a client is ready to learn more adaptive ways of living his or her life.
Give the client positive attention when behaviors are appropriate and productive. Avoid giving any attention (when possible and not dangerous to self or others) when client’s behaviors are inappropriate.	Reinforcing positive behaviors might increase the likelihood of repetition. Ignoring negative behaviors (when feasible) robs client of even negative attention.
Borderline Personality Disorder (BPD):
Assess for self-mutilating or suicide thoughts or behaviors.	Self-mutilating and suicide threats are common behaviors for clients with BPD.
Assess for self-mutilating or suicide thoughts or behaviors.	Self-mutilating and suicide threats are common behaviors for clients with BPD.
Clients with BPD can be manipulative.	Consistent limit setting helps provide structure and decrease negative behaviors.
Encourage the client to explore feelings and concerns (e.g., identify fears, loneliness, self-hate).	Client is used to acting out feelings.
Be nonjudgmental and respectful when listening to client’s feelings, thoughts, or complaints.	Clients have an intense fear of rejection.
Use assertiveness when setting limits on client’s unreasonable demands for attention and time.	Firm, clear, nonjudgmental limits give client structure.
Interventions often call for responses to client’s intense and labile mood swings, irritability, depression, and anxiety:	Many of the dysfunctional behaviors of BPD clients (e.g., parasuicidal, anger, manipulation, substance abuse) are used as “behavioral solutions” to intense pain.
Irritability, anger: Use interventions early before anxiety and anger escalate.	Clients with BPD are extremely uncomfortable and want immediate relief from painful feelings. Anger is a response to this pain. Intervening early can help avoid escalation.
Depression: Client might need medications to help curb depression. Observe for side effects and mood level.	Most clients with BPD suffer profound depression.
Anxiety: Teach stress-reduction techniques such as deep breathing relaxation, meditation, and exercise.	Clients experience intense anxiety and fear of abandonment. Stress reduction techniques help the client focus more clearly.
Provide and encourage the client to use professionals in other in other disciplines such as social services, vocational rehabilitation, social work, or the law.	Clients with BPD often have multiple social problems. Often they do not know how to obtain these services.
Clients with BPD benefit from coping skills training (e.g., anger management skills, emotional regulation skills, interpersonal skills). Provide referrals and/or involve professional experts.	Client learns to refine skills in changing behaviors, emotions, and thinking patterns associated with problems in living that are causing distress and misery.
Clients with BPD often drop out of treatment prematurely. However, when they return, they can still draw upon what they have learned from previous encounters with health care personnel.	Clients might become impatient and leave, then return in a crisis situation. It is a good thing when they are able to tolerate longer periods of learning.
Treatment of substance abuse is best handled by well-organized treatment systems, not by an individual nurse/clinician.	Keeping detailed records and having a team involved with each client can minimize manipulation.

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