Fundamentals · Unit 3

🧠 Unit 3

Psychosocial Integrity · 5 topics

My own notes. Rewritten from scratch — nothing here is copied from a review module.

Ch 32Therapeutic Communication

Therapeutic communication is purposeful, patient-centered talk that invites the patient to keep going rather than shutting them down. Exam questions are usually a single quoted nurse response, and the right answer nearly always reflects feelings, seeks clarification, or offers presence. The wrong answers reassure falsely, advise, or redirect to the nurse.

Core techniquesNamed therapeutic techniques include active listening, offering self, using silence, broad openings, open-ended questions, restating, reflecting, clarifying, focusing, exploring, making observations, presenting reality, verbalizing the implied, and summarizing. Reflection turns the question back to the patient's own feeling rather than supplying an answer.

Named barriersNontherapeutic blocks include giving false reassurance, giving advice, asking why, changing the subject, offering personal opinions, using clichés, defending, disagreeing or challenging, requesting explanations, minimizing feelings, and giving approval or disapproval. Any response that begins with the word I about the nurse is suspect.

Why why failsWhy questions demand a justification the patient may not have and put them on the defensive. Replace why did you stop taking it with tell me what happened when you took the medication.

Empathy versus sympathyEmpathy acknowledges and names the patient's feeling while keeping the focus on them; sympathy shifts focus to the nurse's own feelings and pity. Saying that sounds frightening is therapeutic, while I feel so sorry for you is not.

Silence and touchDeliberate silence gives the patient time to organize thoughts and often produces the most important disclosure of an interview, so resist filling it. Touch is powerful but culturally variable, so use it sparingly and stop if the patient stiffens or withdraws.

Nonverbal presenceSit at eye level, keep an open posture without crossed arms, lean slightly forward, maintain culturally appropriate eye contact, and stay relaxed. When verbal and nonverbal messages conflict, the nonverbal message is the more accurate one.

Relationship phasesThe nurse-patient relationship moves through preinteraction, orientation where you set boundaries and goals, working where problems are addressed, and termination where you summarize progress and address feelings about ending. Do not introduce new issues in the termination phase.

Aphasia adaptationsWith expressive (Broca) aphasia the patient understands but cannot produce words, so use yes or no questions, picture or letter boards, and allow generous time without finishing sentences. With receptive (Wernicke) aphasia comprehension is impaired, so use short simple sentences, gestures, and demonstration.

Sensory impairmentFor hearing loss, face the patient in good light, get their attention first, speak in a lower pitch at a normal or slightly slower rate, and reduce background noise rather than shouting. For visual impairment, announce yourself on entering, describe the environment, and say when you are leaving.

Interpreters and handoffUse a trained medical interpreter rather than a family member and never a child, and speak directly to the patient in the second person while the interpreter conveys it. For clinician-to-clinician reporting, use a structured format covering the situation, background, assessment, and recommendation.

The best answer almost always reflects the patient's feeling or asks them to say more; it never reassures, advises, or moves the conversation to the nurse.

Never offer false reassurance such as everything will be fine or do not worry, because it dismisses the patient's concern and ends the conversation.

SOLER for attending behavior: Sit squarely, Open posture, Lean forward, Eye contact, Relax.

Ch 33Coping

Coping covers the physiology of stress, how people appraise threat, the defense mechanisms they use, and the four levels of anxiety with matched nursing actions. Exam items usually give you a behavior and ask you to name the defense mechanism or the anxiety level. The intervention changes completely between moderate and panic anxiety.

General adaptation syndromeSelye described three stages: alarm, in which sympathetic fight-or-flight activation raises heart rate, blood pressure, glucose, and pupil size; resistance, in which the body stabilizes and attempts to adapt; and exhaustion, when resources are depleted and illness or death can follow.

Appraisal modelLazarus described primary appraisal, where the person judges whether an event is a threat, harm, or challenge, and secondary appraisal, where they inventory the resources available to handle it. Stress is the gap between demand and perceived resources, which is why the same event overwhelms one person and not another.

Two coping stylesProblem-focused coping changes the stressor itself through information seeking, planning, or action and works best when the situation is controllable. Emotion-focused coping manages the distress instead, through reframing, relaxation, or seeking support, and is appropriate when the stressor cannot be changed.

Common defense mechanismsDenial refuses to acknowledge reality, repression pushes it out of awareness involuntarily, regression retreats to earlier behavior, projection attributes one's own feelings to someone else, rationalization invents acceptable reasons, and displacement redirects feeling onto a safer target.

Healthy versus harmfulSublimation channels unacceptable impulses into socially useful activity and is considered the most mature mechanism, while compensation offsets a weakness with a strength. Any mechanism is adaptive short term but becomes maladaptive when it persists, distorts reality, or blocks needed treatment.

Mild and moderate anxietyMild anxiety widens the perceptual field, sharpens the senses, and is the state in which learning happens best. Moderate anxiety narrows focus to the immediate concern with selective inattention, and the patient can still be redirected, so this is the level at which teaching should be kept simple and focused.

Severe and panic anxietySevere anxiety reduces perception to scattered details, produces headache, nausea, trembling, and hyperventilation, and requires direction rather than teaching. Panic involves loss of rational thought, disorganization, and possible hallucination or immobility; stay with the patient, use short simple directive statements, reduce stimuli, and ensure safety.

Crisis characteristicsA crisis is an acute, time-limited state, usually resolving in about four to six weeks, that occurs when usual coping fails. Types are situational, such as job loss or diagnosis; maturational or developmental, tied to life transitions; and adventitious, arising from disaster, violence, or mass trauma.

Crisis interventionIntervention is directive and focused on the immediate problem, not on personality change, and the goal is returning the person to at least the precrisis level of functioning. Establish safety first, identify the precipitating event, mobilize supports, and set concrete short-term steps.

Practical stress reductionTeach diaphragmatic breathing, progressive muscle relaxation, guided imagery, meditation, journaling, regular physical activity, adequate sleep, and use of support systems. Nurses themselves are at risk for burnout and compassion fatigue and should use debriefing and employee assistance resources.

Match the intervention to the anxiety level: teach at mild to moderate anxiety, but at severe to panic levels stop teaching, reduce stimuli, stay present, and give short directive instructions.

Never leave a patient in panic-level anxiety alone, and never assume that asking directly about suicidal thoughts will plant the idea; asking directly is required and does not increase risk.

General adaptation syndrome is Alarm, Resistance, Exhaustion.

Ch 34Self-Concept and Sexuality

Self-concept is how a person perceives themselves, built from identity, body image, role performance, and self-esteem, and any of the four can be disrupted by illness or treatment. Sexuality is treated as a normal dimension of health that nurses are expected to raise, not avoid. Test items focus on recognizing body image disturbance and responding without judgment.

Four componentsSelf-concept is made up of personal identity, body image, role performance, and self-esteem. Identity is who I am, body image is how I perceive my physical self, role performance is how well I meet expectations attached to my roles, and self-esteem is my judgment of my own worth.

Stressors and warning signsBody image is most threatened by amputation, mastectomy, ostomy creation, burns, scarring, paralysis, and hair loss, while role performance suffers with job loss, chronic illness, retirement, and divorce. Warning signs are behavioral: refusing to look at or touch a stoma or surgical site, declining to participate in self-care, avoiding mirrors, making global negative self-statements, withdrawing from visitors, or fearing rejection by a partner.

Nursing approachAccept the patient's feelings without arguing them out of the perception, encourage verbalization, and let them set the pace for viewing and handling the affected area. Reinforce realistic strengths and progress rather than offering blanket compliments, involve the partner or family when the patient consents, and refer to peer support groups.

Sexuality terminologyBiological sex, gender identity, gender expression, and sexual orientation are four separate concepts and do not predict one another. Use the name and pronouns the patient states, document the legal name where required, and ask rather than assume the gender of a partner.

Response cycleThe classic sexual response cycle is excitement, plateau, orgasm, and resolution, with desire added as a preceding phase in later models. Dysfunction is generally classified by the phase affected, which is why the history asks where in the sequence the problem occurs.

PLISSIT frameworkPLISSIT stages the discussion as Permission to raise the topic, Limited Information, Specific Suggestions, and Intensive Therapy. Staff nurses commonly work at the first two levels and refer onward for the last, but giving permission is the step most often skipped.

Taking the historyEnsure privacy, ask matter-of-factly using open-ended questions, normalize the topic by explaining you ask all patients, and avoid reacting with surprise. Do not assume the patient is heterosexual, partnered, monogamous, or sexually inactive because of age or disability.

Treatment effectsMany drug classes impair libido or function, including beta blockers and other antihypertensives, SSRIs, antipsychotics, opioids, and many chemotherapy agents; alcohol also impairs function. Patients often stop these medications silently, so ask before assuming nonadherence is forgetfulness.

Activity after cardiac eventsTeach that sexual activity may generally resume when the patient tolerates moderate exertion, such as climbing two flights of stairs, without chest pain or dyspnea, and to choose a rested, comfortable time rather than after a heavy meal or alcohol. Report chest pain, palpitations, or dyspnea that persists after activity.

Inappropriate behaviorIf a patient makes sexual advances, respond calmly, name the behavior specifically, state clearly that it is unacceptable, and describe what will happen if it continues. Stay professional, do not joke it away, and document and report the incident.

Signs of body image disturbance are behavioral before they are verbal: the patient who will not look at or touch the altered body part is telling you the diagnosis.

Never give nitrates to a patient who has taken a phosphodiesterase-5 inhibitor for erectile dysfunction within the manufacturer-specified window, because the combination can cause profound, life-threatening hypotension.

PLISSIT: Permission, Limited Information, Specific Suggestions, Intensive Therapy.

Ch 35Cultural and Spiritual Nursing Care

This topic asks you to individualize care rather than apply group traits, and to distinguish culture, ethnicity, race, and religion. The safest exam answer nearly always involves asking the patient about their own beliefs and practices instead of acting on what is typical for a group. Spiritual care is presence and facilitation, not persuasion.

Key definitionsCulture is learned, shared patterns of belief and behavior; ethnicity is shared heritage and identity; race refers to socially assigned physical characteristics; and religion is an organized system of faith practices, while spirituality is the broader search for meaning and connection. A person can be deeply spiritual without being religious.

Attitudes to avoidEthnocentrism is believing your own culture is superior, cultural imposition is forcing your values onto a patient, and stereotyping is assuming an individual holds every trait of a group. A generalization is a starting hypothesis you verify with the patient, which is the difference that makes it acceptable.

Cultural humilityCompetence is treated as a lifelong process rather than an endpoint, requiring self-awareness of your own biases, knowledge, skill in assessment, direct encounters, and genuine desire. The practical version is asking the patient what matters to them and what they want you to know about their care.

Assessment domainsStructured cultural assessment commonly examines communication style, personal space needs, social and family organization, orientation to time, sense of control over environment and health, and biological variations such as differing drug metabolism and disease prevalence.

Communication normsEye contact, touch, silence, and comfortable conversational distance all vary culturally; direct eye contact may signal respect in one group and disrespect in another. In some families the elder or a designated relative is the expected decision maker, and honoring that is not the same as bypassing the patient's autonomy.

Interpreter standardsUse a trained medical interpreter, offer one at no cost, and avoid family members and especially children, who may filter or omit information. Face and address the patient directly, use short segments, and document that an interpreter was used and their identifier.

Dietary and fasting practicesCommon patterns include kosher and halal preparation with avoidance of pork, avoidance of beef in Hinduism, vegetarianism, and religious fasting periods. Fasting matters clinically for diabetes management, medication timing, and preoperative instructions, so plan with the patient rather than overriding the practice.

Treatment-affecting beliefsSome patients refuse blood transfusion on religious grounds while accepting alternatives such as volume expanders or cell salvage, and some prefer prayer to conventional treatment. Verify each patient's specific wishes in writing, notify the provider, and support the informed refusal of a competent adult.

End-of-life customsPractices vary in who may touch the body, the gender of the caregiver, the speed of burial, willingness to permit autopsy or organ donation, and required rituals or prayers. Ask the family what they need before performing postmortem care rather than after.

Spiritual distressRecognize it in questioning the meaning of suffering, anger at a higher power, expressions of abandonment or hopelessness, refusal to participate in previously meaningful practices, or requests to see clergy. Interventions are presence and active listening, arranging chaplain or clergy visits, protecting time and privacy for prayer, and permitting religious objects at the bedside.

When a question offers a culturally typical assumption and an option that asks the patient about their own preferences, the assessment question is always the answer.

Never impose your own religious or cultural beliefs, and never pray with or for a patient in your own tradition unless they specifically request it.

FICA spiritual assessment: Faith, Importance, Community, Address in care.

Ch 36Grief, Loss, and Palliative Care

This topic covers types of loss and grief, the recognized stage and task frameworks, the difference between palliative and hospice care, and the physical signs of imminent death. Exam answers favor presence and listening over fixing, and comfort over cure. Know that stage models describe common experiences, not a required sequence.

Types of lossLoss can be actual, meaning recognizable by others, or perceived, meaning felt internally and easily overlooked; it may be situational, arising from an unexpected event, or maturational, tied to normal development. Anticipatory grief begins before the loss occurs and can either ease or complicate later mourning.

Types of griefUncomplicated grief gradually softens and allows functioning to return. Complicated or prolonged grief remains intense and disabling well beyond expected time. Disenfranchised grief is loss that society does not openly acknowledge, such as a pregnancy loss, a pet, an ex-partner, or a stigmatized death, and it is a major risk factor for complicated grief.

Kubler-Ross stagesThe five described responses are denial, anger, bargaining, depression, and acceptance. They are not sequential, not universal, and not a goal; a patient may skip stages, revisit them, or never reach acceptance, and pushing someone toward the next stage is not therapeutic.

Other frameworksBowlby described phases of numbing, yearning and searching, disorganization and despair, and reorganization. Worden reframed grief as four active tasks: accepting the reality of the loss, processing the pain, adjusting to a world without the person, and finding an enduring connection while moving forward. Engel described shock and disbelief, developing awareness, restitution through rituals, and resolution.

Palliative versus hospicePalliative care focuses on symptom relief and quality of life and can start at diagnosis alongside curative or life-prolonging treatment, at any age and any stage. Hospice is a subset for patients with a limited prognosis, commonly certified at about six months or less, where the goal shifts fully to comfort; both use interdisciplinary teams.

Advance directivesA living will documents desired treatments, a durable power of attorney for health care names a decision maker, and code status or portable medical orders translate wishes into actionable orders. The nurse's role is to confirm documents are present, current, and accessible, and to advocate that they be followed, without steering the patient's choice.

Signs of approaching deathExpect decreasing level of consciousness, cool mottled extremities as circulation centralizes, irregular Cheyne-Stokes breathing with apneic periods, decreased urine output, loss of sphincter control, and noisy respirations from pooled secretions. Hearing is thought to persist longest, so continue speaking to the patient and avoid bedside conversation you would not want overheard.

Symptom managementManage terminal secretions with repositioning, elevating the head, and an anticholinergic agent rather than deep suctioning, which is distressing and ineffective. Give opioids around the clock rather than as needed for persistent pain, titrate to comfort, and start a bowel regimen with the first opioid dose; fear of hastening death is not a reason to undertreat pain.

What actually helpsSit down, be silently present, let the person retell the story as many times as needed, and use open acknowledgment such as tell me about them. Avoid clichés like they are in a better place, at least it was quick, or I know how you feel; offer concrete practical help and expect grief to resurface on anniversaries and holidays.

Postmortem careConfirm whether the death is a medical examiner or autopsy case before removing any tubes or lines, since they must stay in place if it is. Approach organ and tissue donation through the designated trained requestor, then close the eyes, position the body in alignment with the head slightly elevated, replace dentures promptly, clean the body, and allow the family unhurried time with any rituals they request.

Grief stages are descriptive, not prescriptive; the correct nursing action is to meet the patient where they are and stay present rather than move them toward acceptance.

Never tell a grieving person how they should feel, that you know how they feel, or that it is time to move on; and never withhold ordered opioids from a dying patient out of fear of addiction or of hastening death.

DABDA: Denial, Anger, Bargaining, Depression, Acceptance.