NCLEX RN Study Guide Module 4 | Integrity in psychosocial functioning

Other Free NCLEX RN Study Guides:

There are 8 Modules in NCLEX RN Study Guide. Here you can navigate all the NCLEX RN Study guide modules.

Table of Contents

let’s get started right away.

Psychosocial evaluations

Along with the physical assessment, a psychosocial assessment should also be carried out as part of the patient’s overall care plan.

This will include:

Experience with healthcare and any previous hospitalizations
Psychiatric history which includes any disorders, family history, if the patient has a history of violence, if they have attempted suicide, for example
A patient’s perception of their chief complaint should be ascertained
What their occupational and educational background is, for example, are they working or retired?
Social patterns relating to their family, friends, support system, and living situation should be ascertained
Sexual patterns should be discussed, in terms of orientation, sexual problems, and more
Finding out their interests and hobbies
If they are currently or in the past abused substances
Finding out their ability to cope and what stress reduction techniques they know
If they have suffered any physical, financial, sexual, or emotional abuse
Carrying out a cultural as well as a spiritual assessment and who that might impact their treatment

Cognitive assessments

Cognitive assessments should be carried out on those patients that show evidence of delirium, short-term memory loss, or dementia.

The most common way to do this is through a mini-mental state exam (MMSE) or a mini-cog test.

These are both covered in your coursework, so we won’t cover them in detail here.

Methods for assessing patient confusion

Here, the confusion assessment method can be used even by those who haven’t had any formal psychiatric training.

It’s used as a way to assess delirium progression and includes 9 factors.

Delirium is characterized by the following factors:

Onset: Sudden change in mental state
Attention: Often changing, inattentiveness, stable
Thinking: This is usually not very logical. Often topics are switched or the conversation rambles on
Consciousness level: Changes from being alert to almost coma-like
Orientation: The person is often disorientated when it comes to where they are, the time, or the person they are speaking to
Overall memory: Substandard
Disturbances in perception: This includes illusions and hallucinations
Psychomotor impairments: Can range from staring, not moving, or other forms of retardation to tapping, moving, picking, and other forms of agitation
Sleep-wake cycle: Reversed

As a way to measure anxiety-related symptomatology, the Hamilton Anxiety Scale can be used.

The test evaluates overall anxiety levels and the degree to which they are severe and includes somatic (physical) anxiety and physic (mental) anxiety.

You can read up more on it in your coursework.

As for depression, Beck’s Depression Inventory is a tool that’s widely utilized.

This takes the form of a self-reported questionnaire and again, your coursework will include further details about it.

Assessment: Suicide risk

These should be carried out and documented when a patient is admitted to hospital, on each change of shift and when they are discharged.

Assessment and documentation should include any signs related to helplessness, impulsive behaviors, feelings of hopelessness, anger, and guilt.

High scores indicate a higher risk of the chance of suicide.

Assessment: Alcohol usage

When trying to assess the severity of alcohol withdrawal in a patient, the Clinical Instrument for Withdrawal of Alcohol (CIWA) is used.

If the patient scores over 15, then they are experiencing severe withdrawal and will need to be admitted.

There are 10 categories to this assessment, each scored from 0 to 7, with category 10 scored from 0-4.

The categories are:

Vomiting and nauseous
Tremors
Paroxysmal sweats
Anxiety
Agitation
Tactile disturbances
Auditory disturbances
Visual disturbances
Headaches
Clouding/disorientation of sensorium

Neglect/abuse

Using patient history to define potential abuse indicators

Always be on the lookout for when a patient might be coming from a situation where they have been abused.

A patient’s overall history can give some indicators to this as well.

For example, they might not provide very revealing answers when it comes to the cause of their health problem, the explanations they give and the physical findings don’t match up and there’s a long period between sustaining an injury and then looking for medical help.

Information about their family can help in this regard as well, for example, if members have spent time in jail, if there is a history of violence, and other indicators.

Other indicators of abuse include:

Financial history: Patients may have turned their financial affairs over to another family member with a controlling personality
Family values and how the family is run
Relationships, particularly dysfunctional ones within the family

Another way to check for signs of abuse takes place during the collection of information about their patient history.

This specifically relates to their sexual history, their social history as well as during the psychological assessment.

Physical assessment abuse indicators

When carrying out a physical assessment, a nurse should always be looking for any indicators of abuse as well.

For a start, patients may show higher anxiety levels because they are being examined physically.

Other obvious indicators could include the presence of welts, bruises, scars, burns, black eyes, fractures, bleeding, lacerations, STDs, genital lacerations, and others.

Abuse could also be indicated if a patient is over or underweight, if they flinch when someone gets near them, if they have patches on their scalp where they’ve pulled out hair, and others.

Child neglect/lack of supervision

Children who are unsupervised or neglected are at risk and there are indicators to look out for which include:

The children are unkempt and dirty. They might wear broken clothes or those that don’t fit them and might even be covered in a lice infestation, for example
The children show signs of tiredness or fall asleep easily during the day
They have dental or medical problems that have not been attended to
They haven’t received their proper immunizations
They regularly miss health checkup appointments
They are underweight when compared to their peers

In the elderly, the neglect of their basic needs can also be a large problem.

If this is obvious, it should be reported to the relevant authorities.

For examples of what this neglect could include, you can consult your coursework.

Neglect and abuse in the elderly is also common and your coursework covers this thoroughly too.

Assessment: Domestic violence

Last in this section, we touch on domestic violence, something that women, men, and children can be subjected to.

Should this be suspected, the victims should be encouraged to report it.

There are many injuries that are associated with domestic violence including bruises, cuts, fractures, and more which are covered in full in your coursework.

Family dynamics

Types of families

Your coursework includes 10 different family types.

Let’s list what they are:

Nuclear family: Typical of 50 years ago, where the husband is the provider and the mom stays at home Only 7% of modern families are structured like this today.
Dual career/dual earner: Here both the parents work and this family type accounts for around 66% of all American families
Childless: Either by choice or through infertility, around 10% to 15% of American families fall into this type
Extended: Here, households are shared by multigenerational families or with other relatives and family and even friends.
Extended kin network: In this family type, there is a sharing of services, goods, childcare, and overall support between two nuclear families that live close together. This model is most often found in the Hispanic community
Single-parent: In our modern world, this has become one of the quickest growing family models. Here, either a mother or father take on the role of a single parent following a divorce or death of a spouse. In many cases, the single parent has never married. Often, the child will have very little contact with the parent they aren’t living with
Co-parenting/bi-nuclear: Two nuclear families exist in this particular family type with children spending time between the two who have a joint custody agreement over them. The benefit here is that children continue to have relationships with both parents
Step-parent: This is a common family type due to high divorce rates in America. Often, this can lead to conflict when a new child is born to the parent and step-parent
Cohabiting: Here, heterosexual couples are unmarried but living together. The overall relationship bias in this model can take on many forms. For example, some might be set up like the nuclear family. It’s just that the parties involved don’t want to get married for various reasons. Children can change the dynamic of the relationship based on whether they are planned or unplanned
Same sex: Here, marrying or cohabiting are the two most common options. There are various options when it comes to children too, for example, surrogates or sperm donation.

Family theory

The critical thing to cover when it comes to this section is different theories based on families.

First, we have family developmental theory.

The idea here is that over time, a family will go through different stages of development and when they do, these stages are related to certain tasks that are carried out.

These stages include:

Marriage
1st child born
Preschool children
School-age children
Teenagers
Launching adult children
The empty nest
Aging family

Second, we have the structural-functional theory.

Here, family serves society by fulfilling functions required for survival, since it is a social system.

These functions are:

Affective: Which sees each member being accepted and loved
Socialization and social placement: This teaches children how to maintain relationships and fit in with society
Reproductive: Having children so the family line can continue
Economic: Allocating and distributing family resources as necessary
Health care: This deals with ensuring that basic necessities are provided. This includes shelter and food but also teaching about and access to health care for basic hygiene

Third is family systems theory.

Here, in relation to other members of the family members, those within the system are understood. There is an interdependent relationship here too, so other members change to ensure equilibrium when there is a change experienced by another family member in the system. Within the system, specific roles are carried out by specific family members.

Functions and dynamics that affect families

There are various dynamics, such as lifestyle and cultural factors that will affect families.

Let’s touch on what they are, but they are well explained in your coursework.

Values
Roles
Decision making
Socio-economic factors

While it’s important to determine who the primary caregiver is for a patient, this can be complicated when in some situations, there isn’t one but multiple caregivers.

In this situation, there should still be one person considered as the primary person associated with the patient.

Impact and complications for multiple caregivers can include the following:

Poor communication regarding the condition of the patient and their needs
Confusion as a result of the caregiving and the different approaches used by the multiple caregivers
No bonds forming between the patient and their multiple caregivers as there would be if there was only one
Stress and anxiety levels are raised
Behavioral problems may result

Families: Functional coping strategies

When loved ones are in medical facilities, families can often struggle to deal with the stress and anxiety related to their illness and stay.

There are a number of coping strategies that families can use to help them cope in this situation.

These include:

The gathering of information, improving organization, collaborating on issues, and solving problems jointly
A strengthened family is the result of the stressful situation they find themselves in as family members draw together
Instead of trying to alter things that cannot be changed, the family accepts them
Open and direct communication occurs with children included, but information given to them is dependent on their age and understanding
Stress is deflected through the use of humor
Support also comes from outside of the family, including spiritual advisers, community agencies, and also extended family

Your coursework also covers dysfunctional coping strategies for families, and this deals with when families struggle with stressful situations.

This can include:

Using substances to cope which adds to overall dysfunction and can affect other family members
Frustration taken out on family members. This can be in the form of domestic violence in various forms
Not accepting that there is a problem or that dynamics within an immediate family aren’t what they were
Control is maintained within the family unit through the use of threats, aggression or not giving affection where needed
Certain family members get blamed for the stressful situation the family finds itself in

Attributes related to temperament

When it comes to temperament, there are nine attributes that you should be aware of:

Activity
Rhythmicity
Approach-withdrawal
Adaptability
Reaction intensity
Responsiveness threshold
Mood
Distractibility
Attention span and persistence

If you’d like to know a little bit more about these attributes, they are fully explained in your coursework.

Let’s discuss the different types of temperaments that are most often found:

Easy
Difficult
Slow-to-warm up

These are pretty self-explanatory, although you might not have heard of the third one.

This just means that the person doesn’t adapt to new situations quickly, can be moody, and are often shy while they generally have a low level of activity.

Parenting styles and their effects on children’s temperaments

There are four parenting styles that your coursework covers in this regard.

They are:

Authoritarian which is an autocratic style
Authoritative which is a democratic style
Indulgent which is a permissive style
Indifferent which is an uninvolved style

Therapeutic Relationships

Therapeutic communication

Communication has meaning, be it verbal or nonverbal.

When facilitating communication with the patient’s family, it should always be done with respect.

The process of facilitating communication with the patient or the family includes a number of techniques that you can use, which include:

Introduction
Encouragement
Empathy
Exploration
Orientation
Collaboration
Validation

Examples of these will be found in your coursework but they are pretty self-explanatory.

What should always be avoided is non-therapeutic communication in order to ensure effective communication at all times.

Non-therapeutic communication includes:

The use of cliches that ultimately are meaningless
Giving advice. Rather, a patient should ask and the carer then gives them the facts
An inappropriate approval that prevents a patient from communicating their actual feelings or anxieties
When asking why a patient behaved in a way that wasn’t directly related to their care
Passing negative judgments onto a patient
Directly disagreeing with a patient
Feelings of patients being undervalued when communicating with them
Making inappropriate responses
As a way to move on from uncomfortable topics, looking to change the subject

These are just some examples of non-therapeutic communication to give you an understanding of what should be avoided.

Communication: Patients with disabilities

Here are some guidelines when dealing with patients with disabilities when it comes to communication.

Never make the assumption that their cognitive abilities are impaired. Yes, some might be, but for the most part, they just have a physical disability, for example.
Respect and dignity are key aspects of how they should be treated
Always use a formal name when communicating with a patient, unless they ask you to call them by their first name
If communication is impaired in any way, always show patience
The patient will tell you what you can help them with when you offer them assistance
If a patient is in a wheelchair, sit down when possible as you communicate with them. This means they don’t have to strain their necks by looking up

Communication: Patients with cognitive disabilities

Respect and dignity are key at all times and in all communication
Always stick to concrete thoughts or ideas when communicating with these patients, and not abstract ones
Both words and sentences should be kept as short as possible. If necessary, you can rephrase the sentence if they don’t immediately understand
Patience in communication is key
Written communication may be the way some people with cognitive disabilities prefer to communicate
When giving instructions, only use a few at a time
Touch can be used to reassure them during communication

Communication: Patients with hearing problems or who are deaf

Communication should take place in as quiet an environment as possible
Touch or wave at the person to indicate that you want to communicate with them as a way of starting
Know which method of communication they would prefer, for example, writing, lip reading, etc.
When communicating, address the person directly
If an interpreter is helping, always keep your eyes on the person you are communicating with and not the interpreter
When communicating with someone that reads lips, always make sure you talk at a normal volume and speak normally and as clearly as possible
Always make sure the person understands what you have communicated to them

Communication: Patients with low vision or who are blind

Greet the person to start the process and when done, say goodbye so they know it’s over
Touch the arm of the person you are speaking to, if in a group
A normal volume level should be used
Provide them with information while communicating, for example, any obstacles that might be in their way while you walk with them
Direction can be given using a clock face and hands, for example, while eating, you can say their carrots are positioned at 6 o’clock.

Communication: Patients who have Parkinson’s disease

Usually, a patient with Parkinson’s disease will have trouble speaking properly.

In many cases, speech therapy can help them in this regard.

When dealing with them:

Give them the time they need to communicate. If you don’t understand, ask them to repeat what they have said
By teaching ways to encourage and facilitate communication with the patient, their family can be helped in this regard. Part of this is ensuring they help the patient carry out the various exercises a therapist will provide
Amplification devices can be suggested if the patient has a very low speech volume

While we won’t cover them in detail here, you should consult your coursework regarding communication with a patient on a ventilator, with those who have psychiatric problems, as well as with those who have had a stroke.

Cultural competence

On a daily basis, caregivers work with many different patients from many different cultures.

As a way to ensure they have cultural competence, they should:

Embrace diversity
Culturally assesses their own viewpoints
Understand the various dynamics between culture
Institutional culture should be recognized
Patient service should be adapted to diversity

An example of cultural competence would be dealing with Jehovah’s Witnesses who are in medical care as they would not want to receive certain blood products.

There are acceptable alternatives, however, for example, fractions from red cells, platelets, plasma, and white cells.

Other cultural considerations are necessary for Hispanic patients and those of middle eastern origin or Asians, for example, which is covered in your coursework.

Dealing with grief and loss

In this section, we start by looking at the Kubler-Ross model of grief

Five stages of grief according to Kubler-Ross

These are:

Denial
Anger
Bargaining
Depression
Acceptance

Depression v grief

In normal grief, we limit ourselves to the loss itself which, depending on the person suffering the grief, plays out in many different emotional responses.

From a social perspective, however, the person remains active and deals with other people, often looking for reassurance from them.

With depression, a person experiences sadness and preoccupation and for the most part, this will extend for a period of two months or longer and usually doesn’t take in one single event.

Often, depression will need to be relieved through professional intervention.

Dealing with patients and family who have experienced loss as a nurse

Loss is never an easy thing to deal with and can occur not only through death, but a loss of one’s health, a relationship, and even something like self-esteem.

Loss can be physical too, like someone losing their home in a fire, for example.

The grieving process affects people differently and is based on the overall severity of the loss, the coping mechanisms of the person experiencing it as well as their overall stability and maturity.

For those that have experienced grief and loss, the following nursing interventions should be used:

The way in which symptoms of loss and grief can be recognized should be taught to patients including empty feelings, lethargy, weakness, and others
Encourage the family or patient that, by accepting the loss, the healing process can start. They should also understand to recognize the pain that loss causes and ways in which they can adapt to the loss
Encourage them to attend counseling sessions if necessary

Helping patients who have received bad news

In a medical facility, the family of patients as well as the patients themselves will receive bad news, as an example, regarding their health.

When this happens, there should be a support team around them to help including those from the medical facility, like doctors and nurses as well as people from outside, like clergy, if pertinent.

When delivering bad news, it should always be done with the utmost privacy
The information shouldn’t be given all at once. By starting with an opening statement, you give the patient and their family time to comprehend what is being said
They should be allowed to react to the information given before providing them with more
This means that they should say when they want more information. Always give an answer to any question in the most simple terms possible. From time to time, information may need to be repeated
Therapeutic communication techniques can be used when providing the information to the patient or their family

Care: Palliative and hospice

While in this section on dealing with grief and loss, we need to talk about the difference between palliative care and hospice care.

With palliative care, the idea is to make the patient as comfortable as possible by keeping distressing symptoms under control and treating them.

Basically, there is no cure available to the patient and the aim is to control the discomfort a patient may experience, for example, pain from cancer.

Note, however, that palliative care can be for any patient with chronic disease and suffering.

A terminal disease diagnosis is not required.

Hospice care includes palliative care.

Here, the patient is dying and overall hospice care provides not only the patient with support but for their family too.

Here guidance is spiritual, psychological, and social while once the patient dies, bereavement support is provided to their families.

Psychosocial Pathophysiology

Intellectual disability and developmental delays

For this, diagnosis often depends on behavior analysis as well as studying performance results from standardized tests.

IQ is generally used to classify intellectual disabilities:

55 to 69: 85% of cases and considered mild
40 to 54: 10% of cases and considered moderate
25-39: Around 3% to 4% of cases and considered severe
Under 25: Around 1% to 2% of cases and considered profound

In all four of these categories, care provided to the individual is very different in each case and this is thoroughly explained in your coursework.

When dealing with a patient with an intellectual disability, it’s prudent to treat them with their developmental level and not their age in mind.

Personality disorders

When it comes to personality disorders these can be assessed using the DSM Classification Groupings which includes 10 disorders that are grouped into an A, B, or C cluster.

Cluster A: Here you would group people that show eccentric or odd behaviors, for example, It also includes those that are withdrawn from society or socially awkward
Cluster B: Here you would group people that show the following types of behaviors – dramatic, impulsive, erratic as well as highly emotional individuals
Cluster C: Here you would group people that have symptoms of anxiety or who are fearful

Bipolar disorder

In bipolar disorder, mood swings range from hyperactivity to depression.

As a result of the persons having distorted thoughts, they will also show impaired judgment.

Some people, when in a hypomanic stage, can become more creative, and function well.

This however, can also develop further, resulting in severe mania, hallucinations, psychosis, fast speed, and behavior that is increasingly erratic.

Following that, however, they fall into a deep depression.

These are the two basic symptoms to look for if you suspect a patient might be bipolar.

Depression

Patients that suffer from depression often are profoundly sad and will withdraw from society.

Depression can be brought on by something that happens to them, for example, the death of a loved one.

In other cases, patients might experience depressive episodes right throughout their lifetime as a result of a range of factors.

These could be environmental, biological, or even as a result of genetics.

When in a depressive episode, patients will have a sense of despair and hopelessness and won’t be interested in almost everything for an extended period of time, often two weeks or more.

Anxiety disorders

Anxiety can take on many forms but what you should know is Peplau’s four levels of anxiety which are:

Mild anxiety
Moderate anxiety
Severe anxiety
Panic

Symptoms of anxiety show themselves in various ways and include:

Cardiovascular symptoms
Respiratory symptoms
GI symptoms

There are physical symptoms too which include:

Neuromuscular symptoms, like shaking, fidgeting, pacing, easily scared, twitching eyelids, and more
Urinary tract symptoms like needing to urinate more and the feeling of needing to urinate as well
Skin symptoms such as sweaty palms, hot or cold sensations, pale or flushed face

Obsessive-compulsive disorder

OCD leads to an abnormally elevated anxiety response in people because of the various obsessions and compulsions those suffering from it have.

Obsession can include things like worrying about germs, a fear of dirt, getting some sort of disease, and many more.

Compulsions are more ritualistic in nature and include things like checking that doors are locked, arranging things in a certain order, hoarding, hand washing, and others.

OCD can often be found shared together with other psychological disorders that share comorbidities, for example, Tourette’s syndrome, depression, panic attacks, and others.

Panic attacks

Symptoms of panic attacks include:

Tremors
Fainting or dizziness
Pressure and sometimes pain in the chest
High levels of anxiety and even fear
Nausea
Vomiting
Hyperventilation
Heart palpitations
Dyspnea

Finding out the history of why a patient is having these attacks is critical as they can be associated with depression, agoraphobia, and even IPVA or intimate partner violence and abuse.

Should they reoccur often, these can become chronic panic disorders.

Along with panic attacks, check your coursework for details regarding post-traumatic stress disorder (PTSD).

This occurs to those who have experienced traumatic events, for example, military personnel but it doesn’t only happen to them.

Your coursework also covers another problem that many patients deal with in the form of stress which you can work through as well.

Suicide ideation

There are many reasons why someone may attempt suicide or think about it.

They may have a psychotic disorder, they may live in social isolation, they may be struggling with the death of a loved one, they may have a crisis they see no way out of or they may have severe depression.

Indications that someone may attempt suicide include:

They show signs of depression
They are hostile to others
They don’t have lots of close friends and struggle with peer relationships
They are suffering from post-crisis stress (a death, going through a divorce, failing college, etc)
They are withdrawn
Their behavior changes significantly (for example, they were very neat but are now unkempt)
They have other psychiatric problems (schizophrenia, bipolar)
They abuse drugs

Substance abuse

When it comes to substance abuse, you want to be aware of various indicators that help identify that someone could be abusing drugs, for example.

There are many physical signs including:

Fingers or lips having burn marks
Watery eyes
Extremely dilated or constricted pupils
Slow speech or slurring words
Tremors
A general lack of coordination
Severe weight loss
Dysrhythmias
Puffy face
Needle marks on their body

There are behavioral signs to look out for too including:

Mood swings, agitation, anger
Lying
Undertaking risky behavior
Not making set appointments
Blackouts
Short-term loss of memory
Confusion or disorientation
Excessive sleeping or even insomnia
No concerns about personal hygiene

Eating disorders

Many people suffer from eating disorders and if not treated, these can be particularly dangerous and could even result in death.

The two main eating disorders to consider are anorexia and bulimia.