004 Mark Klimek

The transcription discusses the importance of understanding crutches, canes, and walkers for medical exams. It emphasizes measuring crutches correctly to prevent nerve damage and teaching different crutch gates for walking. The four types of crutch gates are explained: two-point, three-point, four-point, and swing-through. The even-for-even and odd-for-odd rule is highlighted for determining when to use each crutch gate based on the number of affected legs. An example is given for applying this rule to different medical conditions. Alright, we're going to start out with Crutches, Canes, and Walkers on page 17. Any questions? Any questions? Probably just went over to the left. Yeah, we did. Crutches, Canes, and Walkers. One of the major areas of human functioning is locomotion, and so they do test it. So certain things show up on boards with greater frequency than what you might expect them to, and locomotion is one of those. And so to test that, they test casts, traction, canes, crutches, walkers, things that were really probably not emphasized in your school much, were they? That wasn't a major emphasis, I doubt. But on boards, people will always say, like, well, I'm surprised at how many things I had about traction or about casts or about things like that. And that's because one of the eight areas of human functioning they test is locomotion. So you do have to note some of these things. Plus, there are also really good areas for patient teaching because a lot of boards is teaching. What do you teach? What's your goal? What's the teaching? And then it's also risk reduction, you know, as far as reducing risk to skin, risk for mobility problems and that. So let's talk about crutches. The first thing is, how do you measure crutches? The reason why they want you to know how to measure crutches correctly is for risk reduction, so that you don't cause nerve damage. The first thing is the length of the crutch. How do you measure the length of the crutch? It's two to three finger widths below the anterior axillary fold to a point lateral to and slightly in front of the foot. Now, what they'll do is they'll say something like, you know, you see an RN or an LPN or an A measuring a person for crutches. You notice they're doing all of the following. What would you correct? And you have to pick something where they're doing it wrong. Or they'll say, which one shows the right? And you have to pick out the correct. The deal is that they'll often write sets of instructions where you're measuring from the wrong point to the wrong point. For example, they'll say, to get the length of a crutch, you measure from the axilla. You don't measure from the axilla. You measure two to three finger widths below the anterior axillary fold. So they'll give you the wrong upper point. Or they'll say, you measure to the heel. You don't measure to the heel. You measure to the little toe. You don't measure to the little toe. In other words, you don't measure to any landmark on the foot. You measure to a point lateral to and slightly in front of the foot. So if any of the answers say axilla or any landmark on your foot, they are incorrect. They are wrong. Rule them out. So any instructions with a landmark on the foot or, say, axilla, they're wrong instructions for how long the crutches need to be. Letter B, the next thing you have to measure is the hand grip. The hand grip can be adjusted up and down. And what you need to know there is when the hand grips are properly placed, the angle of elbow flexion will be about 30 degrees. So those are the two things that they're all about with crutch measuring, the length and the angle of elbow flexion when you put the hand grips properly in place. Those are the only two things you need to know about measuring crutches. The next part of it is how to teach crutch gates. Because you're supposed to be able to educate people on how to walk with crutches. There are four crutch gates, two-point, three-point, four-point, and swing-through. Now, how do you teach each of them? Two-point gate is rather simple. These names are really obvious. You shouldn't forget these names because these names tell you exactly what you're doing with one or two, with one exception, maybe. In two-point gate, pretend my arms are crutches, all right? In two-point gate, you move a crutch and the opposite foot together, followed by the other crutch and the other foot together. And so you kind of walk like this. Two things, two things, two things, two things, two things. So it goes two, two, two, two, two. Well, if you were going two, two, two, two, two, what would you name the gate? Two-point, does that make sense? Because in two-point, you're moving two things together. What two things? A crutch and the opposite. It's always crutch and opposite. So that's real simple to teach. In three-point gate, you're moving two crutches and the bad leg together. Two crutches and the bad leg. So how many things is that? Three. So it goes, if this is my bad leg, it goes three, one, three, one, three, one. So what would you call a crutch gate that goes three, one, three, one, three, one? Three-point, seems logical. So what are you moving together in two-point? How many are you moving together in two-point? How many are you moving together in three-point? So how many do you move together in four-point? Four. No. Because that would be, what would that look like? That would look like this. Right? And if you can do that, you don't need crutches. So obviously that falls apart. So you move two things together in two-point. You move three things together in three-point. But in four-point, you move everything separately. So how many things do you have? Well, you have two legs and two crutches. Two plus two equals four. So how does four-point go? Well, four-point goes like this. You move a crutch, any crutch, just pick a crutch. But once you move that crutch, now you're locked in. Your sequence is now locked in. So now what must you move? The opposite foot followed by the other crutch followed by the other foot. So one, two, three, four. One, two, three, four. That's four-point game. It's very slow, but very stable. We'll be talking about that in the next case, because that's exactly the next thing we need to tell you. Because you do have to know that. Okay. Swing-through, on the other hand, is for non-weight-bearing. For example, amputations where you can't bear weight on the stomach. Or whenever they say non-weight-bearing. What swing-through is, is you've seen it. I can't illustrate it because I don't really have crutches. But it's where you can't bear weight on this leg, and so you clamp the crutches, all right? And then you swing-through, you see? And then you just, and you never put this leg down. You've seen it. They kind of whoosh, whoosh, whoosh, and they just follow. And that's exactly what they do. They just swing it. And it actually can be really fast. Have you seen people go pretty fast with this? They just move. And that leg never touches down. Okay. So when do you use swing-through? Non-weight-bearing. I did have a student who called me after she took her test, and she said, that crutch stuff was on there, but what you taught me didn't help. Oh, okay. Rather accusatory, but hey, whatever. And I said, well, why didn't it help? And she said, well, you were telling us about the different crutch case. And she said, the one that gave me nothing you taught us helped. And I said, well, what did they tell you? And she said, well, he had an amputation. So I didn't know which crutch case to use. And I said, well, what do you mean you didn't know? She says, well, two-point wouldn't work, three-point wouldn't. She says, and then swing-throughs were non-weight-bearing. And I said, well, amputation, you can't bear weight. Do you see what I'm saying? Why do people make those kinds of mistakes on tests? They're not thinking. Why are they not thinking? They're anxious. And they're not taking steps to manage that anxiety. Now, I will never tell a student, when you take this test, don't be anxious. That's stupid. You can't tell a person not to be anxious. Because they're going to be anxious as whatever they're going to be. Well, you have to teach them how to what? Manage the anxiety. And she wasn't managing the anxiety. And I'm thinking, you know, but if you think about it, could you really do three-point? You know, one, two, three. You can't do that with an amputation. You have to do swing-through. Now, what if they said they had an amputation with a prosthetic device? Could you bear weight? Yeah. Okay. Letter D on the next page. This is what you asked, which is when do you, when do they use these? In what situation do they use these? You also have to know that. Now, this is easy. Because there's a little saying we often use, and that's even for even, odd for odd. Even for even, odd for odd. Now, how does that work? Well, let's plug it in. Letter D, number one. Use the even-numbered dates, which are what? Two and four, correct? When the weakness is evenly distributed. That's even for even. Meaning use an even-numbered date when you have an even number of legs messed up. Use two-point for a mild problem and four-point for a severe problem. So generally answering your question, when do you use four-point? With severe bilateral weaknesses. When do you use a two-point date? Mild bilateral weaknesses. Because if you, see, what my point is this, is if they give you a question about what crutch gate will you teach, all you have to do to get it right is ask yourself how many legs are affected. If it's an even number of legs, which would be what? Two. Then pick two or four. Even for even. Okay, D, number two here, use the odd-numbered gate, and there's only one odd-numbered gate, and that is three, when one leg is odd. That's the odd for odd. So if you say, how many legs are affected? One. Well, what kind of a number is one? Even or odd? Odd. So pick the odd-numbered gate, which is three. But if you have two legs affected, is that an even or an odd number? Even. So pick an even-numbered gate, two or four. Two for a mild, four for a severe. And if they can't bear weight, you go swing through, and if they're an amputation, you go swing through. So I'm going to give you some examples, and I want you to tell me which crutch gate you would teach, all right? And I just want you to write it down. Number one, early stages of rheumatoid arthritis. Early stages of rheumatoid arthritis. Left above the knee, amputation. First day, post-op, right knee replacement. Partial weight-bearing allowed. Partial weight-bearing allowed. Right or left? Did I say left or right? Right. Right toe-and-knee replacement, first day, post-op, partial weight-bearing allowed. Advanced, advanced stages of amyotrophic lateral sclerosis, ALS. Advanced ALS. Left hip replacement, second day, post-op, non-weight-bearing allowed. Second day, post-op, non-weight-bearing. And just write down the crutch gate you're going to teach. Next one, bilateral total knee replacement. Bilateral total knee replacement. First day, post-op, weight-bearing allowed. Bilateral total knee replacement. First day, post-op, weight-bearing allowed. And last patient, bilateral total knee replacement. Three weeks, post-op. Okay. So do you have your crutch gates down? Okay, what's it read? What's the first one? Two. Two. Why two? Did I tell you how many legs were affected? No, but it was a systemic disease. And what should you assume is a systemic disease? Both legs. So is two an even or odd number? Even. So you would have picked two or four. Why did you pick two? Early. Okay, then what was the next one? Swing through. Then what? Three. Then which one? Four. Everybody's sitting there like, are you just not answering? Is everybody getting four? Okay, then swing through, then four, then two. Did you get those? Any questions about any of them? Okay, good. Just remember, even for even, odd for odd. All right, stairs, going up and down stairs with crutches, letter E. Going up and down stairs. Again, it's going to be patient teaching. Remember the saying, up with the good, down with the bad. Up with the good, down with the bad. In other words, when you go upstairs with crutches, go up with your good. That means leading with your good. So what goes first, crutches or the foot? Foot. Foot, so crutches go up. Second, up with the good, up with the good. See that? Third, down with the bad, down with the bad. See that? Down with the bad. But it actually makes sense. But could you go up with the bad? Okay, let's put the crutches up first. Okay, now the crutches are up. Okay, now how do I? See, you can't get up because the crutches are there. And when you come down, would you really lead with your good leg? You know, that would throw you. You'd be talented. That's what it does. It just throws you down. So it's always up with the good, down with the bad. And the crutches always move with the bad leg. Canes. Hold the cane on the strong side. People hold cane incorrectly, notoriously. If I have a weak right leg, a weak right leg, in which hand do I hold the crutch? The left. But I advance it with the bad leg. So when you walk with crutches appropriately, you're walking like this, but this is your bad leg. You're going like this. And see, when you put your crutch down, you have a nice wide base of support, which keeps you upright. When people do it wrong, they hold the cane on the bad side. And what they do is, here's the bad leg, here's the cane, and they go like this. When they go like that, it's a point. So they have to shift their weight over that base of support. And then they walk back, and they go like this. And if you see anybody doing that, what do you know? They have the cane where? Wrong hand, they need to switch it over and walk correctly. So whenever you see people walk in that way, they're wrong. Even if they are a television doctor. Okay, I will correct people in the mall. I've been known to do that. That's why my daughters will never walk with me. I embarrass them. Now I want somebody to say, hmm, interesting, how have you been taught to use that cane? See, I see that you're actually using it incorrectly. Sometimes they listen, sometimes they don't. But nurses, once you're a nurse, it corrupts you, doesn't it? You're different now that you're a nurse. One of the things that my daughters also, they won't walk with me in a hotel hallway. Because what do I do when I go down a hotel hallway? Because you do it too. You're walking down a hotel hallway and this is you. What are you doing? You're looking in the room, aren't you? As a nurse, you cannot go down a hallway and not look in the room. So I'm looking in all these open doors like this, and my daughters are going, Dad, stop looking in the room. My response is, if they didn't want me looking in the room, they should have closed the door. Can you do this? Can you walk by an open door without looking in? I mean, you may have been able to before you were a nurse, but you can't do it now that you're a nurse. It's unavoidable. Try to walk down a hallway next time in a hotel and say, I will not look in any empty rooms. You'll go nuts. It'll drive you crazy. Okay. Walkers. Pick them up, set them down, walk to them. Pick them up, set them down, walk to them. In other words, it's slow. Yeah, it's slow. No big deal. They pick it up, they set it down, they walk to it. They're supposed to pick it up, set it down, walk to it. Pick it up, set it down. What do they do? They go like this, and then they go. Right? They don't do the right. They don't do it right. Okay, and number two, if they must tie their belongings to the walker, have them tie it to the sides, not the front. Why? Tipping over. What's that? I didn't hear you. Okay. If they must tie their belongings to the walker, have them tie belongings to the side of the walker, not to the front of the walker. So even though it is done by 99% of everybody you see, boards does not like stuff tied onto the front of walkers. All right? And boards doesn't even like wheels on walkers or tennis balls on walkers. You see? Even though it's done. Any questions about crutches, canes, and walkers? Just a little refresher, because I figured that if you got a question about that and you hadn't had it in a long time, it might throw you, when it's very simple and very easy to master. All right, let's totally switch gears on page 19 and talk about delusions, hallucinations, and illusions. In other words, some psych. Let's talk psych. Do you see where your first point, letter A, says neurosis versus psychosis? I want you to cross out the word neurosis, and I want you to put non-psychotic, so that the statement now says non-psychotic versus psychosis. Because this is probably one of the most important points I could talk to you about in psych. Because this is probably the most common reason why people with whom I work miss psych questions. Because right out of the gate, they turned left instead of turning right. They went the wrong way out of the gate. And the reason why they go the wrong way out of the gate on a psych question is, the very first thing you have to do to get a psych question correct is decide, is my patient non-psychotic or psychotic? That's the first thing you must do in a psych question. You must decide, am I dealing with a psychotic or a non-psychotic? Why does that matter? How many think that might be an important point? Exactly. It's huge. It'll determine treatment. It'll determine goals. It'll determine prognosis. It'll determine medication. It'll determine length of stay. It'll determine legalities. It'll determine everything. So if you don't even know if you're working with a psychotic versus a non-psychotic, how in the world do you expect to get the question correct? And you won't. You may guess right once in a while, but over the long haul, you're going to do horrible. So the very first thing you must do, and I want you to start doing it, whenever you take a psych question, what's the first question you'll ask yourself? Is the patient psychotic or non-psychotic? Now let's talk about those differences. Number one, a non-psychotic person, wherever you see the word neurotic, just replace it with non-psychotic. A non-psychotic person has insight and is reality-based. A non-psychotic person, yes, they're emotionally ill. Yes, they have emotional distress. Yes, they have mental and behavioral disorders. But they are not psychotic. They have insight. Insight means they know what's wrong with them. They know they have a problem. They know what the problem is. They know how it's messing up their life. And they are reality-based, meaning what they're believing, seeing, hearing, smelling, feeling, tasting is what you believe in, hearing, seeing, smelling, feeling, tasting. So these people are mentally distressed and emotionally distressed, but they're not psychotic. So how do you treat these people? What kinds of answers do you go and select? Now, if you've been doing psych questions right, you know what I'm talking about. So what do you pick? What kind of answers do you pick in that case? What techniques do you use in that case? You guys never made this differentiation when you take psych tests? What was that? The question is, the first thing you have to do when you get a psych question is decide if your patient is a psychotic or a non-psychotic. And if you find out, if you say, oh, this is a non-psychotic patient, then what approaches, what kinds of answers, what kinds of techniques, what kinds of approaches do you look for as being the right answer for this non-psychotic, mentally disturbed patient? Good therapeutic communication. What do I mean by that? Good therapeutic communication. Why? Because isn't that what you do for everybody? Do you do that for med-certified patients? Do you use good therapeutic communication skills with med-certified patients? Do you use good therapeutic communication skills with pediatric clients? Do you use it with L.D. clients? Community health clients? So the point is this. If a person is mentally disturbed, mentally distressed, emotionally disordered, but they are non-psychotic, the right answer is the right answer that would be right for everybody and anybody that just displays really good communication skills. Like, tell me more about what you're experiencing right now. Or, that must be very difficult. Or, all that has happened has been fairly overwhelming for you. Or, how are you feeling right now? Or, you know, those kinds of things. Tell me more about what do you mean by? Can you explain to me more fully about? See, those are answers. Have you ever had those questions where they give you a med-certified patient and ask you what would you say, and they're just testing reflection, clarification, amplification, restatement? Remember those therapeutic communication skills you learned in basic nursing that you use with everybody? Well, that's what you want to do with a non-psychotic. There's nothing special that you're supposed to do or know differently with a non-psychotic than any med-certified OB patient. So if they say to you, Alice is depressed, and she says, I hate this depression, it's ruining my life, I have absolutely no energy to do anything. Now, is she psychotic or non-psychotic? How did you know she was non-psychotic? She recognized her problem. She had insight, so that makes her. But she is depressed. So what would you say? Well, you wouldn't use any real fancy sick psych strategies. You would just say to her, well, how are you feeling right now? Or what is currently causing distress for you? Or how much energy do you have today? Do you have enough energy? You know what I mean? Whatever you would ask anybody else is good communication skills. So how hard of a question is a psych question for a patient with a psych problem who is non-psychotic? Is it hard or easy? It's easy because you're just going to use good, general, therapeutic communication. And there's nothing special you were supposed to have known about. Now, however, let's talk about the next group, the psychotics. Letter B, or number 2. The psychotic person has no insight and is not reality-based. In other words, they don't know they're sick. They think everybody else has the problem, not them. Have you ever met these people? What do they say about themselves? I'm not sick. Who do they blame? Everybody's got, you know, it's the doctor, it's the nurses, it's my neighbors, it's my wife. So you have to understand that psychotics don't think they're sick. And if they say they're sick, because I've heard psychotics say, I'm a schizophrenic, undifferentiated type. And they'll even quote the ICDA code for insurance purposes. But yet then they say that the Martians are causing all their problems in life. Well, that's not insight. Because insight means you know you're sick and you know how it's messing up your life. Well, they may be able to state the disease, but that doesn't mean they have insight. Do you hear that? How many have heard psychotics tell you that they've actually told you their diagnosis, but they have no insight? Now, these people are treated very differently, because what does not work with these people? Good therapeutic communication skills. Because that assumes that people are rational, reality-based, and know they have a problem. Well, these people don't have any of that. So what you've got to memorize is unique, specific strategies, which I will teach you on the next page. But for right now, let's move into symptoms. Delusions, hallucinations, and illusions are psychotic symptoms. Only psychotic people get these. Non-psychotics do not have delusions, non-psychotics do not have hallucinations, and non-psychotics do not have illusions. So the minute your patient has a delusion, they have crossed the line, and they are now in the camp of psychotics. So, remember Alice that was depressed, that I talked about a couple of minutes ago? If they said, Alice is depressed, she says, I can't stand this depression, it's ruining my life, what symptoms would you expect? You've got some questions? What symptoms would you expect in this lady? Select all that apply. Okay, would you pick decreased anxiety? Select all that apply. Okay, would you pick decreased energy level? Psychomotor retardation, meaning everything kind of slows down. Delusions of persecution? No. That would be totally out the window. Why? Because she is non-psychotic, and non-psychotics don't have delusions, hallucinations, and illusions. So you could automatically rule that out. Now, if they are psychotic, you rule those in, because they do have those. So let's talk about these psychotic symptoms in depth, because I'm going to teach you what they are and then how to treat them. The first psychotic symptom is a delusion. A delusion is a false, fixed, F-I-X-T-D, fixed. Which means they don't change it. A false, fixed idea or belief. There is no sensory component. With a delusion, you're not hearing, feeling, taking, seeing, smelling, anything. It's all up here. You're thinking it. You're not feeling it. You're not sensing it at all. It's just a thought. Now, there are three types of delusions. The first is a paranoid delusion, which is a false, fixed belief that people are out to harm you. Like the police are out to kill me. The mob is out to kill me. My wife is having me committed so she can run off with the psychiatrist. The kids are lying about me so they can get my house. The neighbors are shining lasers on me to hurt me. That kind of stuff. Grandiose delusion is a false, fixed belief that you are superior. So this is where you think you're Christ or Muhammad or Genghis Khan or, you know, whoever. Or you generically think that you're the world's smartest person. You're the world's greatest person. The future of the universe hinges on you. Those are all grandiose thoughts. The third type of delusion is a somatic, which is a false, fixed belief about body. About a body part. About your body. In other words, I have x-ray vision. I can melt stone with my eyes. My brain is a Martian superconducting proton accelerator. There are worms inside my arm. My body is hollow. You're pregnant, you're 83, and you're male. You know, those are delusions, somatic delusions. Now, hallucinations. How are hallucinations different? A hallucination is a false, fixed sensory experience. You see, with this illusion, there was no sensation going on. With hallucination, it's purely sensory. You see, hear, feel, taste, smell, all those things. So how many senses do we have? We have five. So how many types of hallucinations? We have one for each sense. The most common hallucination is letter A. Auditory. An auditory. A-U-D-I-T-O-R-Y. Auditory hallucination, where you hear things. And primarily, there are voices telling you to hurt yourself. So the most common hallucination is an auditory hallucination, and the most common auditory hallucination is voices telling you to harm yourself. That is by far and away the most common hallucination reported. The next most common hallucination is a visual, which is seeing things that are not there. The third most common is tactile, T-A-C-T-I-L-E, which is feeling things that are not there. And the last two are gustatory, G-U-S, and then the word cat, C-A-T, and then O-R-Y, gustatory, which is smelling, or tasting, I'm sorry, tasting things that are not there. And the last one is olfactory, O-L and then the word factory, which is smelling things that are not real. So you have auditory, visual, tactile, gustatory, olfactory. The first three are the most common in that order. The most common is auditory, second most common is visual, third most common is tactile. The last two, gustatory and olfactory, are relatively rare, and you don't usually hear of them much. So let's turn the page and talk about an illusion. What is an illusion? Well, an illusion is a misinterpretation of reality. A misinterpretation of reality. You're misinterpreting what's going on. It is a sensory experience. Sensory. Well, that's what's great, because now what two are we going to confuse? Because they're both sensory. Hallucinations are sensory, right? And illusions are sensory. Well, that's bad, because now how are you going to tell them apart? And that's what that next part says, number two. Differentiation between illusions and hallucinations. In other words, how do you tell the difference between a hallucination and an illusion? Here's how you tell the difference. With illusions, there is a reference in reality. With an illusion, there is a reference in reality. Now let's talk about what that means. A reference. R-E-F-E-R-E-N-T. R-E-F-E-R-E-N-T. Reference. What a reference is, is something to which a person refers when they say something. So, with an illusion, there is a reference. There's actually something there. They just misinterpret what it is. With a hallucination, there is absolutely nothing there. So, it's probably best understood by illustration. If a client says, Listen, I hear demon voices. Listen, I hear demon voices. Of what is that an example? That is a hallucination. Why? It was sensory, and there was nothing there. What about this example? A client overhears nurses and doctors laughing and talking at the nurses' station and says, Listen, I hear demon voices. Now, they said the exact same thing. Of what is that an example? Why is that an illusion? It was the same thing. They said the exact same thing. The question bothered to tell you that there was actually real people talking, making real sounds, but they misinterpreted it. In that case, it's an illusion. What's this? During your interview, a client stares at the wall and says, Look, I see a bomb. They stare at the wall and say, Look, I see a bomb. B-O-M-B Hallucination or illusion? Hallucination. What about this? During your interview, the client looks at the fire extinguisher on the wall and says, Look, I see a bomb. What's that? That's an illusion. Why? Was there something there? Was there a reference? Was there something in reality to which they referred? Yes, that was the fire extinguisher. Is it really going to be hard to spot an illusion on the test? Why is it going to be easy? Because they're going to add a whole bunch of words, a whole big sentence, telling you there was actually something there. When you see all that there, you go, Oh, that's an illusion. So it's sort of like an illusion is a hallucination with a reference, basically. Now, the bigger question is letter E. How do you deal with these psychotic symptoms in a psychotic patient? When dealing with a patient experiencing psychotic symptoms such as illusions, hallucinations, and illusions, the first thing you, the nurse, must ask yourself is, What is their problem? In other words, what kind of psychosis do they have? I hope you guys were taught that there are basically three types of psychosis. Were you taught that? If you weren't, I don't understand how you're supposed to answer questions. Because these three different types are huge differences. The first type of psychosis is what they call a functional psychosis. Now, you don't have to know the names of all of these. You just have to know there are three types and what they mean. The first type of psychotic is a functional psychotic. And what do you suppose that means? Functional. They can function in everyday life. They can have a family, a marriage, a relationship, a job. They live alone, take care of themselves, pay their bills, pay their taxes. They can function. But they are what? Psychotic. They can function, but they're psychotic. Now, there are four diseases that make up 90% of this category. And they are what I call the schizoschizomajor manic. The schizoschizomajor manic. Now, what are those? Schizo for schizophrenia. The second schizo is schizoaffective disorder. I hope you've heard of that. The third one is major depression. Major depression, not depression. You understand, depression is not psychotic. Major depression is psychotic. So it has to have major there. And then manic. People that are acutely manic. So are bipolars functional? Yes. But are they always psychotic? No. They're only psychotic in what phase? The manic phase. The rest of their life they're... In fact, you guys could be bipolar and I wouldn't even know it. Because I'll be bipolar for all I know. So what are the four functional psychoses? Schizo, schizo, major, manic. Now, the next psychotic is the psychosis of dementia. Dementia. So what's these people's problem? Why are they psychotic? Why do they not know reality and have no insight? Why do dementia clients not know reality and why are they not having insight? Why do they lack insight? Well, why is the memory messed up? Thought I heard it. Brain damage. Actual damage to the brain. The brain is actually damaged. Now, in the functional, is the brain damaged? No. It's just the chemicals are out of balance and they haven't learned adaptive behavior as well. But in this case with the dementia, there's actual brain damage. And that's why they're psychotic. The brain damage. These would be people like Alzheimer's. Did you ever know anybody that after a stroke they're kind of psychotic after a stroke due to the damage? That would be this. Have you heard of organic brain syndrome? That would fall under this category. Anything that says senile or dementia falls in this category. And lastly, number three. The third type of psychotic is psychotic delirium. Delirium. D-E-L-I-R-I-U-M. D-E-L-I-R-I-U-M. Delirium. And we'll talk about these people. But here's the deal. What's the first thing you must do to get a psych question correct? Psychotic or non-psychotic? If you decide they're non-psychotic, what answer do you pick? The best good therapeutic communication response. It would be true for anybody. If you decide that they are psychotic, then what step must you take? Decide which of the three categories that person falls in. Are they functional? Are they dementia? Are they delirious? Because you're going to use different approaches for each of these. Because not all psychotics are the same. So let me illustrate how you're going to answer questions differently. Letter F. Let's talk about the functional psychotic. Does this person have brain damage? No. So number one, this patient has the potential to learn reality. Why can they learn reality? They don't have any damage. They can learn it. They might need some meds to balance some chemicals, and then you might need to set some structure. If they can learn it, they can improve. If they can learn it, what's your role as a nurse? If they can learn reality, what is your role as a nurse? Teach reality. So how do you teach reality? You use the four-step process that's here. This four-step process is the way we teach reality to a functional. First step, acknowledge feeling. Second step, present reality. Third step, set a limit. Fourth step, enforce the limit. Now, that isn't good enough for me just to tell you that. I need to illustrate to you how that would look in a question. Because BORS doesn't say what's the first thing you do, A, acknowledge feeling. They don't say that. They say what's the first thing you'll say, and they'll give you four quotes, and you're supposed to pick out the one that acknowledges the feeling or the one that presents reality or the one that sets a limit. How do answers look like that acknowledge feeling? If you said, oh, I've got to look for an answer that acknowledges their feeling, what would it look like? How would you spot it? What would it say? Usually the word feel is in the answer, yes. So you say, or you can even specify a feeling, couldn't you? If you don't say the word feel, usually there's a specification of a feeling. For example, you say, I see you're angry. Or, you seem upset. Or, that must be distressing. Or, that's so sad. Or, all that has happened has been so devastating. Or, tell me more about how you're feeling right now. See, all of those go to what? Feeling. And that's the first thing you do. How many have noticed that in psych, if you're between a couple of answers and one of them is talking about feeling, if you pick it, you're usually more right than wrong. Have you noticed that? Because what are you doing? Acknowledging their feeling, which is the very first thing you should always do with a functional. Secondly, you present reality. What does presenting reality look like? Well, it has different forms. One of the classic forms of presenting reality says, I know that blank is real to you, but I do not blank. Do you see what I'm saying? I know that you see that demon, but I do not see a demon. Do you see what I'm saying? I know you, I understand those voices are real to you, but I do not hear any voices. Do you see what I'm saying? I understand that you think that the mafia is out to kill you, but in reality, no one is going to harm you. Do you see that? That's one format. The other format of presenting reality is just to tell them what is real. I am a nurse, this is a hospital, and this is your breakfast. Do you see what I'm saying? So you can either tell them what actually reality is, or you can just say, I know that's real to you, but I do not. Both of those are acceptable formats for presenting reality. Either one is good, but it's not the first thing you did. The second thing you did. Setting a limit. What setting a limit looks like is, when you set a limit, the answer will say something like, that topic is off limit in our conversation. Or, when we talk together, we are not going to address that problem, or we're not going to talk about that. And sometimes it can go all the way and be as extreme as, stop talking about. That would be all right, to tell them to stop talking about those aliens. Stop talking about the voices. And you can be that strong. You can be the strong enough to say, we're not going to talk about those voices. So you can be that directive and that strong. And then enforcing the limit usually takes the format of saying something like, I see you're too ill to stay reality-based so our conversation is over. That's enforcing the limit. Enforcing the limit is ending the conversation. Enforcing the limit is not taking away a privilege. See, that's punishing. Does everyone understand the difference between enforcing a limit and punishing them? What are you doing when you punish somebody? What actions do you take to punish? What would be bad answers that would be construed as punishing? Because you told them to stop talking about the voices, right? And they keep talking about the voices. You violate the limit. So what would be a bad way to enforce it? Such as? Yeah, since you can't follow the rules, you lose your telephone privileges. You lose your refrigerator privileges. You're going to be restricted to your room. No, that's not enforcing the limit. That's punishing them. The only enforcement is ending the conversation. That's the enforcement. Why is that appropriate? Why is it good to end a conversation with them when they are not reality-based and won't stay reality-based? You're not going to accomplish anything and by continuing to talk, what are you reinforcing? The non-reality. So how does it go? Well, let's talk about this. You have a patient who says to you, and he's schizophrenic. Does that matter, schizophrenic? Why does that matter? It throws him in what category? Functional. And you know to do the four-step functional process. He says, schizophrenic says to you, I'm going to kill you all. You're all going to be dead by morning. I'm going to slit your throats, and I'm starting with you. Okay? Rather paranoid, violent, delusional thinking. What's the first thing you say to him? What's that? Right. You can say, I understand you're upset, or you can say, I see you're angry. I wouldn't say, how do you feel right now, because I think I know. You know, I mean, sometimes they give you enough data in the question to kind of know what they're feeling like. Okay, so, I see you are upset. Then what do you do? What did I tell you to do next? Okay, but they're not going to say present reality. Give me a quote. In this case, you'd say, I see you are upset, but he didn't talk about bugs. That's the only problem. That is presenting reality, but he didn't say that. He said he was going to kill us all. We're all going to be dead by morning. He's going to split our throats, and he's going to start with me. Unacceptable behavior. Okay, and I think that's a great answer. I think we could go better with talking about it more positively than negatively. Rather than saying, you're not going to kill anybody, I would say, we're all going to be kept safe. So, I would present the reality. If you're between two things, sometimes, Derek, it comes down to, one is stated positively, and one is stated negatively, and you always want to... Yeah, rather than saying, you're on a fluid, you're only allowed to have 10 cc's at breakfast time, you say, you can have 10 cc's at breakfast time. You know what I mean? They always like you to state it positively. Like with diet, it's better to emphasize what they can have than what they cannot have. With mobility, it's better to tell them what they can do. And so, in every way, if you're between two answers, one is positive, one is negative, go with the positive. Does that make sense? In this case, Derek said, killing is inappropriate and not going to happen in this situation. Versus, I see you are upset, but everybody is going to be kept safe while we're here. This isn't safe. You see, it's the same thing, only stated more positively. It's presenting the reality of what's going to happen. No one is going to get killed, right? Okay, then what do you say? We're not going to talk about that kind of stuff. We're just back to those kinds of ideas, although they are real to you, are off limits in our conversation. So then he keeps talking about it. I'm going to kill you. I'm going to slit your throat. I've got this knife. I'm going to shank you. What do they say? What do you then say? I see you're too ill. It's a reality-based conversation, so our conversation is over. And in reality, in real life, when I work psych, I then offer them a tranquilizer. I say, and we have some medication that can help you control those things. Would you like some? You know, and that kind of thing. A lot of times they do. And I always like to say that because I like to say, I see you're too ill. I love to say that because what's it telling them about their experience? That that is a symptom of their illness and they're gaining. I'm hoping to teach them that it's not them. It's their illness. And they need to recognize what's ill means and what's healthy means. And so I always love to say, I know that's a symptom of your illness, but as you know, I see you're too ill to have a reality-based conversation. So we're done now. But I always like to say, but we have medication to help you with those symptoms. Now again, what am I reinforcing? It's a symptom. This is a symptom of your illness. And it's controllable. And we have meds for it. So comply with it. Do you know what I mean? Because noncompliance is the number one reason why psych patients are readmitted to facilities. Right? So I always find that and I say, and they say, well, what medication? Well, like Xanax. Well, I don't like that. Okay, well, we have this. Okay, well, I'll have some of that, I guess. And it works out about one-third of the time. When you say one-third of the time, it's very good. Oh, it's a lot. I mean, that's pretty good for a psych hospital. One-third compliance rate. So then they do well. Okay? So that's a good way to go. Do you get the, do you understand the process? Acknowledge feelings, present reality, set a limit, enforce it. However, if they have psychosis of dementia, who are these people? Dementia. Senile, Alzheimer's, brain injuries, organic brain syndrome, post strokes. Number one says, this patient has a brain problem, structural brain problem, and cannot learn reality. They cannot learn reality. Do you think that makes any difference? Yeah. What about the functional? What's the high, what's the positive point about functional? They can learn reality. What's the best for a dementia? They can't learn it. Do you think that difference is minor or major? That's a major difference. Do you see why you have to differentiate which of the three categories your psychotic falls into? Because it makes a huge difference in how you deal with it. Well, how do you deal with a dementia, a psychotic dementia, a person who has brain damage, and they can't learn reality? Well, number one, you do two steps. The first step is you acknowledge their feeling, and the second step is you redirect them. You redirect them. So what am I telling you you don't do? Present reality. Why is presenting reality for a dementia not appropriate? They can't learn it. And you keep trying to teach something that they can't learn. It's ridiculous. It's going to frustrate them, anger them, discourage you. You can't. They can't learn it. It's impossible. So don't try. So what do you do? You redirect them, and redirect means to channel them from something they cannot do to something that they can do. Why do you not set limits on their bizarre communication? It's just plain mean, isn't it? That's just mean. Now, I do want to caution you guys. Here's where a lot of people go wrong, and they get confused, and there shouldn't be any cause for confusion, if you understand it. With your dementias, like your Alzheimer's and your senile, when you work with them on the unit, what do they tend to get all the time? What's a problem they always have? You ever worked with elderly dementias? What's a problem they constantly have every day related to, because they forget? Where they are, where their room is, what day it is. Okay? Now, that is not psychosis. At that point, they are not psychotic. They're just forgetting. Now, when they're having delusions, hallucinations and illusions, what are they at that point? Psychotic. Okay, now, here's the thing. I told you what technique is not appropriate for a dementia client when they're experiencing psychotic symptoms. What is not appropriate? Presenting reality. Don't confuse that with reality orientation. What is reality orientation? What does that mean when you see the phrase reality orientation? Tell them person, place and time. Is that appropriate with dementia? Yes. Reality orientation is always appropriate with dementia. Is presenting reality appropriate with dementia? No. Do you see the problem with our language that confuses people? Presenting reality versus reality orientation. Two totally different things. Can you do reality orientation with a dementia? Yes. Because you're just dealing with loss of memory. Can you do presentation of reality to dementia patients? No. Can you keep that straight? Because a lot of people are going to confuse that and I don't want you to confuse it. Let me illustrate my point here. You have a patient with Alzheimer's. Does that matter? In the question, does that phrase matter? Yes. Why? It threw them in the dementia category. We knew they were psychotic now and it threw them in the dementia category. So you've got a patient with Alzheimer's. She's in the waiting room, the lobby of the nursing home. She's all dressed up. It's Sunday. You say to her, Mrs. Smith, you're all dressed up. She says, yes, my husband's picking me up. We're going to go to church. Okay. Problem. Husband has been dead for ten years. So she has a what? She thinks her husband is alive but he's been dead. So she has a what? True or false? False. Fixed. Belief. So she has a what? Delusion. So she is delusional. So at this point, she is what? Psychotic. What do you say to her? So what would be the first thing you'd say to her? My husband's coming to pick me up. We're going to church. What does it say to do? Okay. Says to acknowledge feelings. In this case, what would that look like? What's that? There's no feeling there, though. No, I wouldn't say, are you? I would say, that sounds exciting. Or that sounds like an exciting thing to do. Or that sounds fun. Or that sounds interesting. Don't always ask. See, a lot of times with these questions, they tell you stuff so that you are supposed to recognize the feeling. So don't always ask, what are you? Are you? Just say, I see you are happy. I see you are sad. What if it fits? Those are much better answers. Do you see what I'm saying? Because you can say, how are you feeling? I say, well, I think I'm feeling. You know what I mean? But if you say, I see you're acknowledging it. Do you understand? What's the difference between exploring feeling and acknowledging feeling? What is the difference? Or is there no difference? There's a difference, okay? What does explore feeling mean? Digging, trying to find out what it is. Acknowledge means you already know you're just acknowledging with them that you see that that's what they are. And that's what we're doing here. Got it? Okay, then what would you say? She says, you're going to church, husband and driving. That sounds like an exciting thing to do. Yeah, and she said, why don't we grab some breakfast while we're waiting? Now, that's redirection. But I don't know if it's the best one because she would say, but if I go to breakfast, I'll miss him. He won't, he'll miss me. Do you see what I'm saying? And so, I think it's good but I think that you could probably say something like, well, why don't we sit down here and talk about what's going to happen at church today? Do you see what I'm saying? So, while we wait. So, she sits down and then you start saying, well, what church do you go to? Who's your pastor? Who's your priest? What do you like about the service? Do you have friends there? Does your family go there? What are you doing now? It's all what? Reinforcement of intact memory. And isn't that good with dementia? And pretty soon, you start getting her turned from church to family. You see, and then you say, do you have any grandkids? And then you get talking about the grandkids and then you say, do you have any pictures? Right? And they say, yeah, could I see the pictures? Well, I don't have them with me. Well, where are they? In my room. Could you show me? Okay. Now, she's leading you back to the room to show the pictures. She's long forgotten about church and husband and you're not having a fight. You see how you do it? You kind of just redirect them into things. So, that's the way you go. What would be the wrong answer to say to her? That sounds exciting. But your husband's been dead. That's called presenting reality and that's appropriate for us. Schizo, schizomajormatic, but it stings for a dementia. Do you see where one answer, the best answer for one is the worst answer for the other. That's why you've got to know which one you're dealing with or you're not going to know what to answer. Are you seeing this? Okay, let's talk about the third kind of psychotic and that's the psychotic delirium. Description of this psychotic delirium. This is a temporary, sudden, dramatic, secondary loss of reality. And it's usually due to some chemical imbalance in the body. So, it's temporary, it's sudden, it's dramatic, it's episodic, it's secondary and it's usually due to some chemical imbalance in the body. Now, how is that different than functional? It's temporary. What else is different about than this than functional? It's sudden. How is this different than dementia? It's temporary. It's sudden. It's secondary. You see? So, it's different. Now, who are these people? These would be people that are crazy for the short term because of something else causing them to be crazy. For example, have you ever seen anybody go crazy or psychotic because they're on a particular drug? They have a drug reaction and it makes them lose touch with reality. Have you ever seen that? Yeah. Tagamet will do it. It's obvious. It's as innocuous as Tagamet can do it. Another area is people that are high on uppers. You know, intoxicated on uppers. They'll be this way or withdrawing from diners will be this way. So, delirium tremens would do this. Cocaine overdose. Methamphetamine overdose. Have you ever... What are some other chemical situations where you've seen people act crazy? It's temporary. It's due to some other imbalance in their body. What's that? Post-op psychosis is due to withdrawing from a downer. Because what's an anesthetic agent? A downer. What are the pain meds? Downers. When you withdraw from the downers, everything goes up and you have this. Particularly in the elderly. If you have an elderly patient who's had anesthesia and a PCA pump, the third post-op day into that fourth post-op day, they can go wacky crazy for about 48 hours. Just plan on it. And then they'll come right out of it. But they will be loony as a tune. So, don't start zapping them full of tranquilizers or you'll confuse them and they'll end up in a nursing home when they would have come out of it in 48 hours. And gone home. Who else? Post-op's a classic. What else? Yeah, I see you. Psychosis can do it with the sensory deprivation can cause it. What else? A UTI, an occult hidden urinary tract infection in the elderly. Classic. Any occult infection, but the UTIs in the elderly are the major ones. Have you heard of thyroid storm? That's another one. Have you heard of adrenal crisis? Another one. So those are your... I even think roid rage to some extent could be classified something like that if they're actually seeing, hearing, hallucinating and you know, if they're that bad. It can be that. Well what's the good news for these people? It's temporary. So really what's the focus of managing these people? Removing the underlying cause and keep them safe. So what is the two steps? Acknowledge what? Feeling. And then reassure. Reassure. Of what two things are you reassuring them? That it's temporary, it will go away and they will be kept safe. So reassure them of safety and that it will go away. Why don't you present reality? They're not going to get it. Why do you not redirect them? Because it's not going to work. It's just reassure. Reassure. Let me give an example with all three. Functional, dementia, delirium. And show you how the answer changes. One of the things they do on boards is they change this type of psychosis and they look to see if you change your answer when they change the type of psychosis or do you always go with present reality, present reality, present reality no matter who you're with which is the wrong way to go. Okay, here we go. You have a patient with schizoaffective disorder who points to two people talking at a table across the room. It's got the picture. Schizoaffective. They're pointing to two people talking at a table across the room and they say those people are plotting to kill me. What would you say? Well, what's the most important word in that whole question? Schizoaffective. Why is schizoaffective the most important word? Because it throws them in the category of functional psychotic. So what's the first thing you say to that person in that context? Those two people over there are plotting to kill me. I see you are frightened or scared of that. It must be frightening. Then what would you say? Okay, but they don't say reality. You've got to know what it's going to look like. What is it? What is it going to look like? What is it going to say? Those people are not plotting to kill you. We're all safe. That's called presenting reality. Then what do you say to that person? Furthermore, we're not going to discuss this. And if they keep doing it, what do you say? So you can talk about the two people over there. I see you're too ill to have a conversation so we're finished. Maybe you can have a reality-based conversation. Those are all appropriate. Do you see the four steps? Okay, let me give you another question. No, not necessarily. No, not necessarily. So that is not the priority at that point in time. The priority is presenting the reality, setting the limit. Now if they're escalating and they're starting to do it, there was no escalation in that question. What about this? You have a patient with Alzheimer's disease who during your conversation points to two people sitting at a table and says, you see those people they're plotting to kill me. What's the most important word in that question? Why Alzheimer's? It puts them in what category? Dementia. So now you know you're going to acknowledge feeling and redirect. So how would we then do it? What would be the answers? C, you seem scared. That must be frightening. Now what? Redirect. That's actually changing the subject. And redirection is not changing the subject. Redirection is going with what they're talking about but getting it achieved in a right way. Exactly. See, that would be better than, they will have both of those there. What was your answer? Let's go, we all like why. Let's go somewhere where we can, where you can feel safe. Versus, what did you say? Let's go eat. Let's go eat lunch. Why would A be better than B? A is more relevant to what they're feeling and what they're talking. B says, B kind of, it kind of ignores it but it's better than presenting reality. You see what I'm saying? And that's why they would put A with B because B is a good answer but A is better. Do you understand that? Okay, what about this question? A client with delirium tremens says to you, you see those two people over there at the table? They're flying to kill me. What's the most important word in that question? Delirium. Delirium tremens. So that makes them delirious. So what do you say? I see you're scared and don't say I promise. Well just say, you are safe. Just say, you are safe and that will go, that feeling will go away when you get better. You see that? You are safe. That's a symptom of your illness that will go away when you get better. Now, could you say to the first person with schizoaffective, would it be okay to say, I see you're frightened, I'll keep you safe and that will go away when you get better? No, because they didn't learn anything, right? And you can't say it will go away when you get better to an Alzheimer's because it's permanent. So do you see where the good answer for one is a bad answer for the other? How many of you in your psych questions have up to this point basically treated all psychotics the same? Do you understand now there are three varieties and the answers are different? Have you ever had this experience in taking psych questions because a lot of people do. Like for example, you'll get a question that says, the patient is hallucinating, what are you going to do? And you go, oh, I'm going to present reality. So you pick present reality, you go back to the rationale that says, no, you should redirect the patient. And you go, oh, hmm, that's interesting. So then you take some more psych questions and about 30 questions later you get another question about hallucinations, right? And they say, what are you going to do about this hallucination? And you go, oh, I know, it's what? Redirect, because that's what it was last time. So you pick redirect, you go back to the answers and they say, no, you should reassure the patient. And you go, what? I wish you'd make up your mind. Last time you said that. So you take some more psych questions and about 30 questions later you get another question about hallucinations and it says, what are you going to do about this hallucination? And you go, well, it's either redirect or reassure. I don't know which one. They keep changing and I don't understand this. And then you go back and forth and back and forth and finally after 20 minutes you finally just pick one and you say, well, I'm picking reassure because that's what it was the last time. You go back to the rationale and what does it say? That's what I said the first time and you said I was wrong. What's going on here? Why do they always keep changing the answer in psych? Have you ever felt that in a psych question? Well, why do they keep changing the answer in psych? Because they're changing the patient. And when they change the patient, you change your answer. That first one that said redirect, what was probably the patient's problem? Redirect, what was probably the problem? Dementia. The second one which was reassure was probably a what? Delirium. The third one which was reality was probably a? Functional and you completely missed the point and you're trying to figure out what's the pattern? What's the pattern? That's the pattern. Does that make sense to you? Do you think you understand how you're going to see the pattern now? Question. What happens when you consider personality disorders in psych? What happens if we have a patient with a personality disorder or do not? Personality disorders are not considered psychosis. They're considered to be access to baseline factors that come along with just like mental retardation is not considered to be psychosis. So, they are not going to classify as borderline personality. What you do with a borderline personality is probably more than anything else is talk. If I got a question about not a borderline but any personality disorder I would probably use good therapeutic communication skills. Now, are they sick? Some of them are really sick little puppies but they're not classically psychotic. Do you understand what I'm saying? The only ones where I would really use the presentation of reality is with the There are three personality disorders going clusters. There's clusters. Three clusters. ABN. Okay. Thank you. I kept thinking ABD, ABN, ABC. It's ABN. The letters ABN are an abbreviation for what word? ABN. Abnormal. So, I tell people the really abnormal personality disorders are the ABN. Antisocial, borderline, and narcissistic. Those are the real sick. The histrionics, the obsessive-compulsive, the dissociative, the schizoid, they're no big deal. But your ABN, your antisocial, your borderline, and your narcissistic, they're the real sick personality disorders. They're the ones that have real problems. And that's where I would probably treat them more like a functional. But for most personality disorders, I would just use good communication skills, basically. The reason why I like the functional protocol for the ABN is I end up setting what? Limits. And with an ABN, an antisocial, a borderline, and a narcissist, you've got to set limits. And I like it with them. Because I like to set those limits on those people. Oh, heaven. Oh, you mean the multiaxial obsessive axis? One, two, three, four, five. That would not be essential knowledge for you to know. That would be a question that would be hard. But axis one is the primary site disease. Axis two is only really two things. Mental retardation and personality disorder. Really, that's about all there ever is to put an axis to. Three is medical conditions. Not psychosis, like diabetes, whatever. Four is psychosocial factors like unemployed, recently divorced, newly married, just had a baby. You know, those kinds of things. And five is a score. It ranges from zero to a hundred. It's a number. Like thirty-five, fifty-two. And it's an estimation of how high your function. A hundred being perfect psychological functioning like me. And a zero being completely disorganized personality. So it's that. One is your primary diagnosis. Two is two things. One is your primary diagnosis. Two is two things. Retardation and personality. Three is medical. Four is psychosocial. And five is a score. But that's all I really want you to know. I haven't heard people reporting that those are on there. Okay. Hopefully, has this changed the way you're going to look at psych questions? So what's the first big task you have with a psych question? Psychotic or non-psychotic. If you know it's non-psychotic, use what? If it's psychotic, you have further work, you have to divide it into what? Three. Four. The three, the first step, for all three, the first step is what? Acknowledge feeling. The second step always starts with the letters R-E. Reality, redirect, reassure. And now, isn't it true, now when you think back on psych questions, isn't it true that most psych questions, one answer will be reality, B will be redirection, C will be reassurance, and D will be ignoring. And you see the games I've been playing all this time? Alright. Let's talk about three more psychotic symptoms and we'll take a break. Loosening of association. Loosening of association is the fancy way of saying your thoughts aren't wrapped too tight. In other words, your thoughts are all over the map. Loosely associated. Loosely associated. The first one is flight of ideas. This is when you go from thought to thought to thought to thought. You actually make phrases. You actually say phrases that are coherent. But the phrases are not tightly connected. In other words, each phrase by itself is coherent. But the phrases together are not coherent. Do you understand that? Flight of ideas. Whereas word salad they are sicker. They can't even make a phrase that's coherent. They just babble random words. So who's sicker? Flight of ideas or word salad? Word salad. Neologism means making up imaginary words. So they'll say you're a Brinslebick or you're a Shabazniak or the Crenulacs are attacking. They're making up all these new words. Robin Williams makes a fortune on humor based on loosening of association. He can do flight of ideas at the drop of a hat. He can remember Mork and Mindy that dates me. Probably you guys don't even know what I'm talking about. Unless you watch Nick at night. But he used to say Nanu Nanu and Shazbat. Those were never in the script. He just neologistically did that on the spot and said oh that's cool let's add that in. You know because he just completely did you ever see him do just dream of consciousness? He can just do it like good morning Vietnam all that flight of ideas stuff going on. So that's sort of it. He's also bipolar. That's why he makes like six movies in two years and you don't see him for three. Currently you're not seeing him but he will come out in a year and a half with three movies to be released that he made in three days. Okay narrow self-concept. Narrow self-concept is when a psychotic and that's key psychotic when a psychotic refuses to leave their room or change their clothes. If you've got a psychotic who will not leave the room and not change their clothes and I would say it is a functional psychotic. The reason why they're doing it is why? Why is a functional psychotic refusing to change their clothes and refusing to leave their room? Why? Although that could be an issue. Paradigm can be another explanation but it's not the number one. Think of narrow self-concept. What would that mean? What's that? That would be worse sense of that would be low self-esteem. This is narrow self-concept. Your self-concept is how you define who you are and how they define who they are is extremely narrow meaning they define who they are based on what two things. Where they are and what they're wearing. So if you the reason why they refuse to change their clothes and leave the room is they don't know who they are unless they are wearing those things in that room. And that's why they won't change because it's terrifying. So as a nurse would you make a functional psychotic who is refusing to leave their room and change their clothes would you make them do it? Why? If you made them do it they would cease to know who they were you would have a panic escalation somebody would get hurt. So you do not do that. So when do you what do you tell them when they refuse to leave their room and change their clothes and leave the room until you feel comfortable or until you're ready. It's a perfect world so they can stay there for 30 years if that's the case. Don't say well they can't stay I mean that won't work because what if it's three weeks and they still don't feel comfortable they won't be able to stay in the hospital that long. Hey it's a perfect world yes they can stay. However once they say this a Mrs. Jones has been depressed since her last child went to college three months ago. She has no energy to do the housework she has lost her job because she didn't have the energy to get up and go to work. She says I hate the way I feel I am going to kill myself and things don't get better because this depression is ruining my life please help me. She is refusing to leave her room or eat her breakfast or do her daily hygiene care. What do you do? Okay but now you are taking the four step process for a psychotic and this lady is a what? She is a non-psychotic she is a non-psychotic she is a non-psychotic she is a non-psychotic she is a non-psychotic she is a non-psychotic she is a non-psychotic she is a non-psychotic she just said depression. She had insight right? If they don't say major it isn't major. They have to specify major. So what do you use? Good therapeutic communication skills. But what do you say? 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