Mark Klimek NCLEX Review: Crutches, Canes, Walkers, Delusions, Hallucinations, Psychosis
Mark Klimek NCLEX Review: Crutches, Canes, Walkers, Delusions, Hallucinations, Psychosis, Psychotic and Non-Psychotic Hallucination, Illusion, Delusion
Crutches, Canes, Walkers
One of the major human functions is locomotion. Therefore, crutches, canes and walkers are tested on the NCLEX exam even though they are not really emphasized in school. Also, such knowledge is good for patient teaching. With that said, crutches, canes and walkers are devices used to help pts with an unstable gait, whose muscles are weak or who require a reduction in the load on weight-bearing structures
How do you measure the length of crutches?
• Measuring crutches is important for risk reduction when ambulating and to avoid nerve problems
• The length of a crutch is measured by
- Holding it vertically and placing the tip on the ground
- Having 2 to 3 finger widths between the pad and the anterior axillary fold
- The tip is located to a point lateral (6 inches) and slightly in front of foot (6 inches)
• Rule out landmarks on foot or say axilla!
• Handgrip measurement
- The angle of elbow flexion is 30 degrees
- The wrists should be at the level of the handgrip
How to Teach Crutch Gaits?
2-point gait—move a crutch and opposite foot together, then the other crutch with other foot together
• Together (Right leg & Left crutch) à Together (Left leg & Right crutch)
• For mild bilateral leg weaknesses
3-point gait—move (2 crutches & bad leg) together à Followed by unaffected leg
- The gait goes 3-1, 3-1, 3-1
- The affected (bad) leg is not on the ground
- The unaffected (good) leg is on the ground
4-point gait—move everything separately
- Move crutch à Move opposite foot à Followed by other crutch à Followed by opposite foot
- Right crutch à Left foot à Left crutch à Right foot
- 4-point gait is very slow but very stable
Swing-through is for non-weight bearing (amputees)
- Similar to 3-point gait
- The unaffected foot gets pass the tip of both crutches
- The person may be an amputee or does not bear weight on the leg at all
- Can move really fast.
When do you use these gaits?
• Use Even-point gait for even, odd-point gait for odd
• Use the even numbered gaits when weakness in the feet is evenly distributed
- 2-point for mild problems
- 4-point for severe
• Use the odd numbered gait when one leg is affected
- 3-point for one leg
• If patient cannot bear weight or amputation
- Swing-through
Example
A patient affected with early stages of rheumatoid arthritis. What gait should the patient use?
- Both legs affected (because it is a systemic disease)
- Early stage—mild
- 2-point gait
Example
A patient has left ATK (above the knee) amputation 2 days ago. What gait should the patient use?
- Non-weight bearing
- Swing-through
Example
Patient is first day postop, right knee, partial weight bearing allowed. What gait should the patient use?
- One leg affected
- Odd-numbered gait
- 3-point gait
Example
Patient is in advanced stages of ALS. What gait should the patient use?
- Bilateral leg weakness (because it is a systemic disease)
- Even-numbered gait
- Advanced stages = Severe
- 4-point gait
Example
Patient with left hip replacement, 2nd day postop on non-weight bearing instruction. What gait should the patient use?
- Non-weight bearing of 1 leg
- Swing-through gait
Example
Patient with bilateral (B/L) total knee replacement first day postop. Weight bearing is allowed. What gait should the patient use?
- Even-numbered gait = Bilateral
- Weight bearing
- First day postop = Severe
- 4-point gait
Example
Patient with bilateral total knee replacement 3 weeks postop. What gait should the patient use?
- Even-numbered gait = Bilateral
- Weight bearing
- 3 weeks postop = mild
- 2-point
Going Up and Down the Stairs with Crutches
- Remember this phrase: “Up with the Good, and Down with the Bad”
- When you go up the stairs, the good foot moves up first
- When you go down the stairs, the bad foot moves down last
But, no matter what: Both crutches always move with the bad leg
Cane
- Hold cane on the unaffected (strong) side
- Advance cane with the opposite side for a wide base of support
- Handgrip should be at the level the wrist
Walker
• Correct way to use a walker
- The walker is on the side of the patient, the patient “Picks it up … Sets it down … Walks to it”
- Once the walker is in front of the patient, the patient “Holds on to chair, Stands up, Then grabs walker”
• Don’t tie belongings to the front of the walker—Tie them to either side so it won’t tip over
• The NCLEX board does not like tennis balls or wheels on walker can create problem
Psychiatry
First thing to ask in a psych question is: “Is the patient psychotic or non-psychotic?”
The answer to this question will determine care plan, treatment, length of stay, legality, etc.
A Non-psychotic person has insight and is reality based. What kinds of answers do you pick for these people? What techniques do you use?
- Good therapeutic communication … Looks like a Med/Surge patient
- Examples of therapeutic communications:
- That must be very difficult/overwhelming for you
- How are you feeling?
- Tell me more about your …
- The exam is looking for “reflection, clarification, amplification, restatement, etc.”
The Psychotic person has no insight and is not reality based
They don’t think they’re sick—everyone else has the problem
- Examples are: delusions, hallucinations, illusions
Delusions, hallucination, and illusion are psychotic symptoms
• Delusions - a false, fixed belief or idea or thought. There is no sensory component. It is all in your head.
It is just a thought … 3 types of delusion
- Paranoid - People are out to get/kill me
- Grandiose - “I’m Christ” … “I am the President” … “I am the world’s smartest person”
- Somatic - Body part (I have x-ray vision, there are worms inside my arm)
• Hallucination—a sensory experience
- Auditory (1st m c)—voices telling you to harm yourself
- Visual (2nd m c)—I see bugs on the wall
- Tactile (3rd m c)—I feel bugs on my arm (Most common = m c)
- Gustatory (taste)
- Olfactory (smell)
• Illusion—a misinterpretation of reality. It is sensory
Differentiation between hallucination and illusion
• With illusion there is a referent in reality
- A referent is something that both the clinician and the patient can refer to … There is actually something there: The cord is a snake
• With hallucination, there is nothing there
Example
The patient staring at the empty wall says, “Listen, I hear demon voices.” Is that statement from the patient a hallucination and an illusion?
- There is no referent there
- This is a hallucination
Example
The same patient overhears nurses and doctors laughing and talking at the nursing station, and says, “I hear demon voices.” Is that statement from the patient a hallucination and an illusion?
- There is actually a referent (real people) there
- This is an illusion
Other examples
A patient looks with a blank stare and says, “I see a bomb.”
- This is a hallucination
A patient looking at the fire extinguisher on the wall and says look, “I see a bomb.”
- This is an illusion
How do you deal with these psychotic patients?
To deal with these psychotic patients, the first thing to ask is what type of psychosis the patient has?
There are 3 types of psychosis
1. Functional psychosis
2. Psychosis of dementia
3. Psychosis of delirium
1. Functional psychosis - they can function in everyday life
• 90% of the followings make up this category
• Chemical imbalance in the brain
• They are “Skeezo, Skeezo, Major, Manics”
- Schizophrenia, Schizoaffective disorder, Major depression (not depression), Mania
Example
- Bipolar = Depression and Mania
- Bipolar patients are psychotic in acute mania
2. Psychosis of dementia - what is their problem?
• Actual Brain destruction/damage
- Due to Alzheimer, stroke, organic brain syndrome
- Anything that says Senile/Dementia falls in the category
3. Psychotic Delirium - temporary, sudden, dramatic, episodic secondary to something else
• Loss of reality
- Due to UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs
Recap
Approach to Answering Psychiatric Questions
• First thing to ask is
- Is the patient non-psychotic? Or, is the patient psychotic?
• Patient is non-psychotic
- Address patient as you would address any Med/Surg patients Use therapeutic communication
• Patient is psychotic
- Next, ask if they are functional, demented, or delirious?
Functional = (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce these limits.
Demented = (1) Acknowledge their feeling, and (2) Redirect them—give them something they can do.
Delirious = (1) Acknowledge feeling, (2) Reassurance about safety and temporariness of their condition.
Functional Psychosis
Schizo, mood disorders thought process, and mania (chemicals out of whack)
- This patient has the potential to learn reality (no brain damage)
- Your role as a nurse—teach reality
- Use the 4-step process to teach reality:
(1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce these limits
What does this look like in a question?
1. The answer acknowledges patient’s feeling (look for the word “feel”)
You seem upset … That is so sad … It’s been so difficult … Tell me more about how you’re feeling
2. Now, present reality ... “I know you see that demon, but I don’t see a demon” … Or, “I am a nurse, this is hospital, this is your breakfast”
3. Set limit. ”We are not going to address that. Stop talking about…”
4. Enforce limit. “I see you’re too ill, so our conversation is over.” Ends the conversation. You’re not punishing the client by taking away privileges
Psychosis of dementia
- They cannot learn reality … Don’t present it! They can’t learn it! Thus, frustrates them, and may discourage you!
- Deal with their problems in 2 steps
(1) Acknowledge their feeling, and (2) Redirect them—give them something they can do
Do not confuse not presenting reality with reality orientation (Person, place, and time)
Reality orientation = Patient is oriented to person, place, and time
Example
Alzheimer lady is the lobby of waiting area of her nursing home. It is Sunday and she is all dressed up. You day to her, “Mrs. Smith, you are all dressed up.” She said, “Yeah! My husband is going to pick me up. We are going to church.” The problem is that the husband has been dead for 10 years.
- She has a false, fixed belief
- She is delusional (or she is psychotic)
- What do you say to her?
- First, acknowledge her … You say, “That sounds nice.” (acknowledging)
- Second, redirect her … You say, “Why don’t we sit down here and talk about church? …What church do you go to?” (redirecting)
- Don’t tell her husband is dead, which is presenting reality
Psychosis of delirium
- This is temporary, sudden, dramatic, episodic, secondary loss to reality
- Usually due to some chemical imbalance in the body
- Causes—UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs
- To manage these pts, treat the underlying cause
- Acknowledge feeling
- Reassure them of safety and temporariness of their condition
- They lost touch with of reality—Redirect them is futile
Example
A patient with schizoaffective disorder who points to 2 people talking across the room. The patient says, “Those people are plotting to kill me.” What would you say? What is the most important word in the vignette?
- Schizoaffective—psychosis
- I can see that would be frightening. They are not plotting.
- We are not going to talk about that. I can see you are too ill. We are ending the conversation
Example
A patient with Alzheimer disease who during your conversation points to 2 people talking across the room and says, “You see these people, they are plotting to kill me”
- Alzheimer Disease— category is dementia
- Acknowledge feeling— “I understand you seem to be scared”
- Redirect— Let’s go somewhere you feel safe
Example
A patient with delirium tremens who during your conversation points to 2 people talking across the room and says, “You see these people, they are plotting to kill me”
- Delirium tremens …
- “That must be scary”
- But you are safe. Your fear will go away when you get better
Psychotic symptoms
Loose associations
- Flight of Ideas: Rapid flow of though
- Word Salad: Throw words together and toss out … (Sicker than flight of ideas)
- Neologisms: Make it up
- Narrowed self-concept: When a psychotic refuse to change their clothes or leave the room.
Leave them alone
- This is a functional psychosis
- “Don’t make a psychotic do something they don’t want to do”
- Idea of reference: You think everyone is talking about you
Dementia hallmark: Memory loss, inability to learn
- Always acknowledge feeling
- 2nd step always begins with “Re” … Reassure, Redirect, Reality