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Psych mental Health Nursing Ch. 7-11 and 34
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  1. Therapeutic relationship
    an interaction between 2 people in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention
  2. Peplaues 6 subroles within the role of the nurse
    1. Stranger 2. The resource person 3. The leader 4. The teacher 5. The surrogate 6. The conselor
  3. Therapeutic use of self
    the ability to use ones personality consiously and in full awareness in an attempt to establish relatedness and to structure nursing interventions....it requires that the nurse have a great deal of slf awarness and self understanding about philosophical belief about life, death, and the overall human condition
  4. Beliefs
    • is an idea that one holds to be true and it can take several forms
    • -if the belief is acted in action it becomes a value
    • -rational-ideas are true by evidence that exis
    • - Irrational- idea that one hold as true despite the existence of the contrarary
    • - Faith- an idea that na individual holds as true which no objective evidenc exist
    • -Stereotype- a socially shared belief that describes a concept in an oversimplified ir undifferentiated matter
  5. Attitudes
    is a frame of reference around which an individual organizes knowledge about his/her world
  6. Values
    are abstractstandards positive or negative, that represents an individuals ideal goal. Ex. ideal mode of condact...different from values and beliefs because this are action oriented.
  7. Johari Window
    • It has 4 quadrants
    • 1. The open or public self- public and yoursself are aware of your part of self (upper Lf.)
    • 2. The unknowning self (upper Rt.)- part of the self that is known to others but remians hidden from the awarness from the individual
    • 3.The private self (lowe Lf.)- part of self that is known yo individual and not others
    • 4. The unknown self- unknown to both individual and others
  8. What are the conditions to develope a therapeutic relationship
    • *Rapport
    • *Trust
    • *Respect
    • *Genuineness
    • *Empathy
  9. Rapport
    • primary task
    • - implies special feelings on the part of both the client and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a non judgemental attitude.
  10. Trust
    one must feel condidence in that person's presence, reliability, integrity, veracity, and sincere desire to provide assistance when requested.
  11. Respect
    • is to believe in the dignity and worth of an individual regardless of his/hers unacceptable behaviors.
    • (unconditional positive regard), the nurse accepts the individual no matter how hes life style is, nurse will strive to understand the motivation behind the clients behavior, regardless how unacceptable it may be
  12. Genuineness
    • To be real
    • -to be open, honest, and real in interactions, when someone is genuine, there is congruence between what is felt and what is being expressed
  13. Empathy
    is the ability to see beyond outward behavior and ti understand the situation from the clients point of view, the nurse is able to accurately perceive and comprehend the meaning and revelance of the clients thoughts and feelings.
  14. Sympathy
    taking on the others needs and problems as if they were your own and becoming emotionally involved to the point of losing your objectivity
  15. Phases of a therapeutic nurse-client relationship
    • 1. The preinteraction phase
    • 2. The Orientation phase (Introductory)
    • 3. The working phase
    • 4. Termination phase
  16. The Preinteraction
    Nurse obtains necessary information about the client, from chart, significant other, health care team, to become aware(knowledge) about client, putting negative or other feeling to the side so nurse can meet client with a nonjudgemental attitude
  17. The Orientation phase (introductory phase)
    • 1. Here you build a rapport
    • 2. Build a contract for interventions that details the expectations and responsibilities of both the client and the nurse
    • 3. Gather asessement information, identify clients strenghts and limitation, nursing diagnose, goals
    • 4. Identify the clients strenght and limitations
    • 5. Formulate nursing dx
    • 6. Set realistic goals that are agreeable to both nurse and client
    • 7. Develope a plan of action that will establish goals
    • 8. Explore feelings of both the client and the nurse iin terms of the intro phase
  18. The working phase
    here the nurse should maintain the rapport that was established at the beginning, problem solving, overcoming resistance behavior on the art of the client as the level of anxiety rises responce ti discussion of painful issues,continously evaluate
  19. Transference
    • Client to the nurse
    • - the client unconsiously displaces or transfers feelings formed toward a person from the past , it can be triggered by apperance or personality
  20. Countertransference
    • nurse to client
    • - refers to the nurse behabioral and emotional responce to the client, triggered if the client reminds the nurse of someone in the past, or transference feeling from the client
  21. Type of boundaries in a relationship
    • 1. material boundaries- physical boundaries that can be seen, such as fences, border line
    • 2. Social boundaries- are established within a culture and define how individuals are expected to behave in social situations
    • 3. Personal boundaries- these are boundaries that individuals define for themselves, physical distance, emotional boundaries, such as how much can individual allow for other to disclose and intimate selves
    • 4. Professional boundaries- limit the outline exoectations for appropiate professional relationships with the clients, separate from a thereapeutic relationship
  22. Concerns related to professional boundaries
    • self disclosure- ok if benifits patient
    • gift giving- some cultures belief and value about appreciating and being thankful by gift giving, if gift is appropiate, nurse may choose to share it with staff that participated, money is never accepted but u can mention that they can donate to charity or something else
    • Touch- only professional touch, or appropiate therepeutic touch is accepted, asian and native amercian dont really like touch
    • Friendship or romantic association- romance not acceptable, nurse-client relationship should be professional.
  23. Preexistin conditions that impact communication
    • Values, attitudes, and beliefs
    • Culture or Religion
    • Social status
    • Gender
    • Age
    • Enviroment in which transaction is taking place
  24. Types of enviroment involve when communicating
    • Territoriality- is the innate tendency to own space
    • Density- the number o people within a given enviromental space
    • Distance- space to communicate
    • - intimate, personal, public, and social
  25. Four types of distance
    • Intimacy- the closet distance an individual would allow between themselves and others, 0-18inches
    • Personal- 18-40inches, reserved for interactions that are personal in nature such as close friends or collegues
    • Social- 4-12 in conversations within stranger or acquiantances,ex cocktail party
    • Public- exceed 12feet, include speaking in public, free to move around freely during this one
  26. Non verbal communication cues
    • Physical appearance and dress
    • Body movement and posture
    • Touch
    • Facial expression
    • Eye behavior
    • Vocual cues, or paralanguage
  27. Types of touch
    • Functional-Professional
    • Social polite
    • Friendship-warmth
    • Love-intamacy
    • Sexual arouse
  28. Paralanguage
    is the gestural component of the soken word. It consists of pitch, tone and loudness of spoken messege, the rate, pauses
  29. Therapeutic communication
    caregiver verbal and nonverbal techniques tha focus on the care recivers needs and advance the promotion of healing and change, it encourages exploration of feelings and fosterunderstanding of behavioral motivation, and its non judgemental , discourages defensiveness, and promotes trust
  30. Therapeutic communication techniques
    • Using silence
    • Accepting- Yes, I understand what you said (eye contact and nodding head)
    • Giving recognition- acknowleging and indicationg awareness ( Mr.J I notice that you made a ceramic ash tray in OT)
    • Offering self
    • Giving broad openings- What would u like to talk about today
    • Offering general leads- Yes I see go on
    • Placing the event in time or sequence-
    • Making observations- You seemed tense
    • Encouraging descriptionof perceptions
    • Encouraging comparasion
    • Restating
    • Reflecting- What do you think u should do
    • Focusing
    • Exploring
    • Seeking clarification and validation
    • Presenting reality
    • Voicing reality
    • Verbalizise the implied-
    • Attempting to translate words into feelings
    • Formulating a plan of action
  31. Non therapeutic techniques
    • Giving reassurance
    • Rejecting
    • Giving approval or disapproval
    • Agreeing and disagreeing
    • Giving advice
    • Probing
    • Defending
    • Requesting an explanation
    • Indicating the existence of an external source of power
    • Belittling feelings expressed
    • Making stereotyped comments
    • Using denial
    • Interpreting
    • Introducing and unrelated topic
  32. SOLER
    • Sit facing the client
    • Observe an open posture- legs and arms should remail uncrossed, suggesting that the nurse is open to talk ect...
    • Lean forward toward the client
    • Establishe eye contact
    • Relax- restlessnes can convey a feeling of discomfort and transfer to the client
  33. Feedback
    • its a method of communication for helping the client consider a modification of behavior
    • - it should focus on the behavior and not the client
    • - it should be descriptive rather than evaluative, specific rather than general, directed toward the behavior, impart info rather than advices, well timed vs delayed responce
  34. Outcomes from nursing process
    • Measureable , expected, patient focused that translate into observable behaviors
    • -they should be measureable and include time estimate, realistic to client capabilities
    • NIC-Nursing outcomes classifications
    • NOC- Nursing interventions classificationk,,
  35. Specific interventions that one can apply during care
    • Coordination of care
    • Health teaching and health promotion
    • Milieu therapy
    • Pharmacological, bio, and integrative therapies-incoporates knowledge of above with applied clinical skills to restore the patients health and prevent further disabilities
    • Prescriptive authority and treatment-accordance with state and federal laws and regulation
    • Psychotherapy- made by advance nurse
    • Consultation-advance practice RN cam provide consultation to influence the id plan, emhance the abilites of other clinicians to provide services for client and effect change
  36. Case management
    • the concept evolved with the advent of diagnosis related groups DRG's and shorter hospital stays
    • - here client is assign manger who can negotiate with multiple providers to obtain diverse services
    • - it helps clients....frail elderly, the very ill,,ect
  37. Managed care
    refers to the strategy employed by purchasers of health services who make determinations about various types of services in order to maintain quality and control costs. This type is more on how company saves money PPO and HMO
  38. Case Manafer
    • is responsible for negotiating wih multiple healthcare to obtain a variety of services for client.
    • -this includes RNs who have years of experience working, some places preferred a masters
  39. Types of documentation
    • Problem oriented- Plan of care
    • Focus charting- focus on one particular issue
    • Pie method- flow sheet,
  40. Problem Oriented recording
    • Subjective
    • Objective
    • Assessment- the nurse intepretation of tje subjective and objective data ( nursing diagnoses and outcomes)
    • Plan
    • Intervention
    • Evaluation
  41. Focus charting
    • main perspective has been changed from problem to focus
    • -DAR
    • - it can be the Nursing Dx, current client concern or behavior, significant change in the clientss status or behavior, sugnificant event in the clients therapy
    • Data
    • Action
    • Response
  42. PIE method
    • APIE
    • Assessment - at the beginning of each shift
    • Problem
    • Interventions
    • Evaluation
  43. Functions of groups
    • Socialization
    • Support
    • Task completion
    • Camararaderie- member of a group provide joy and pleasure that individual seek interaction with others
    • Informational
    • Normative
    • Empowerment
    • Governence
  44. Types of groups
    • Task group
    • Teaching group
    • Supportive/therapeutic groups
    • Self help groups
  45. Physical conditions that influence a group
    • Seating- there should be no barriers between the member and they are encourage to seat in different seats in every meeting
    • Size- 7-8 provide a favaroble climate
    • Membership- open or closed
    • -open groups member come and go
    • -end- members are there in a fixed time
  46. Reason why groups are helpful or curative
    • The instillation of hope- by observing the progress of others in the group with similar problems
    • Universality- individuals come to realize that they are not alone in the problem, feeling, thoughts they experienced
    • The imparting of information- is assimilated by a group members through mutual sharing and concerns for each other, providing assistance and support to others aswell
    • The corrective recapitulation of the primary family group- group members are able to reexperience early family conflicts that remain unresolved
    • The development of socialization techniques-
    • Imitative behavior-
    • Interpersonal learning
    • Group cohesiveness-member developes a sense of belonging that seperated I am into we are
    • Catharsis- individual may be able to express positive or negative feelings with the group
    • Existential factors- the individual member take direction of their own lives and to accept responsibility for the quality of their existence
  47. Phases of group development
    • Phase I- Initial or Orientation phase
    • Phase II- Middle or working phase
    • Phase III- Final or termination phase
  48. Leadership styles
    • Autocratic-have personal goals for the group, withhold some info from group that may interfere with achievement of their objective, Productivity is high and morale is low
    • Democratic- focuses on the member of the group, info is shared with the group, productivity is lower than autocratic and morale is high
    • Laissez-faire- allow member to do as they please, productivity and morale are both low
  49. Stages of family development
    • I The single young adult
    • II The newly married couple
    • III The family with young children
    • IV The family with adolescents
    • V The family launching grown children
    • VI The family later in life
  50. Th single young adult
    (I) family life cycle
    accepting seperation from parents and emotional and financial responsibility for self
  51. The newly married couple
    • Commiitment to new system
    • -formation of martial system
    • -realigment of relatioships with extended families and friends to include spouse
  52. The family with young children
    • -accepting new generation of members into the system
    • - adjusting martial system to make space for children
    • -joining in child rearing, financial and household tasks
    • -realigment of relationships wih extended family to include patenting and grandparenting roles
  53. The family with adolescence
    • increasing flexibility of family boundaries to permit childrens independence and grandparents increasing dependence
    • - shifting of parent/child relationship to permit adolescents of adult to adult relationships
    • -focus on midlife marital and career issues
    • -beggining shift toward concern for older generation
  54. The family launching grown children
    • accepting a multitude of exits from entries into the family system
    • -renegotiation of martial system as a dyad
    • -develop of adult -adult relationship between grown children and their parents
    • - realigment of relationships to include in laws and grandchildren
    • -dealing with disabilities and death of parents
  55. The family in later life
    • accepting the shifting of generational roles
    • -delaling with loss of spouse, siblings, oters
  56. Custodial parent vs the non costudial parents
    • - after the divorce the costudial parent must adjust to functioning as the single leader of an ongoing family while working tii rebuild a new social network
    • - after the divorce the noncustodial parent must find ways to continue to be an effective parent while remining outside the normal parenting roles
  57. Remarriage
    -about 3//4 of people divorce will remmaried
    -divorce rate is even higher for them
  58. In the traditional Jewish community, having children is seen as a scriptural and social obligation ...You should be fruitful and multiply, its a commandment of the TORAH
    -jewish take divorce very personal as a violation
  59. Asian cultures , sons are more highly valued than are daughters, younger siblings are expected to follow the guidance of oldest son thorughtout lives, olderst takes over when father dies, children are expected to be respectful of their parents and not to bring shame to the family no matter how they were treated
  60. Family functioning elements of assessment
    • - it assess whether the family is functional or non functional
    • Communicatin- making assumptions/Belittling feelings/failing to listen/ communicationg inderectly/presenting double -bind messages
    • Self concept reinforcement
    • Family member expectations
    • Handling differences
    • Family Interactional patterns
  61. Communication in the family
    • making assumptions- one assumes that the others will know what is meant by an action or an expression
    • Belittiling feeling- ignoring or minimizing another feelings when they are being expressed, this encourages the individual to withhold honest feelings to avoid being hurt by the negative response
    • failing to listen-
    • commnicating indirectly- _my dad)
    • double bind communication- a family member may respond to a direct request by another family member only to be revoked when its fullfilled
  62. Self- concept reinforcement
    • the manner in which children see and value themselves is influenced most signicantly influenced by the messege they recieve from member in the family ....messages that convey parise, approval, trust, appreciation, and confidence decision and that alllow member to pursue individual nnes
    • -Expressing denigrating remarks...putdown
    • -Withholding supportive messages- ex. the boy playing baseball
    • Taking over- this occurs when one family memberfails to permit another member to develop a sense of responsibilty and self worth
  63. Family member expectations
    • - they should be flexible allowing for change in the individual, comparasion should be avoided among members.
    • -ignoring individuality- ex. child wants to be a artist but parent want him to become a doctor
    • -demanding proof of love- iex. if u dont do this u dont love me
  64. Handling differences
    • * it is difficult to conceive 2 or more individuals living together who agree in everything all of the time
    • *individuals should be able to understand that is acceptable to disagree and deal witjh differences ina n open non attacking manner
    • -attaking
    • -avoiding
    • -surrendering
  65. Family Interactional patterns
    • it as to do in the way the family behaves, all families have develop recurring , predictable patterns of interacting over time...family rules
    • this rules are functional only if they are workable, are constructive, and promote the needs of all family members
    • Patterns that cause emotional discomforts- interactions can promote hurt and anger in family members, particulary individauls feel uncomfortable expressing feeling openly...ex never apologizing
  66. Bowens theorectical approach to family therapy is composed of 8 major concepts
    • Differentiation of self
    • triangles
    • nuclear family emotional process
    • family projection process
    • multigenerational transmission process
    • sibling position profiles
    • emotional cutoff
    • societal regression
  67. Milieu therapy
    a scientific structuring of the enviroment in order effect behavioral changes and to improve the psychological health and functioning of the individual
  68. Skinner 7 basic assumpions in which a therapeutic community is based
    • the health in each individual is to be realized and encourageed to grow
    • every interaction is an oppurtunity for therapeutic communication
    • the client own his/hers own enviroment
    • eact client owns his/hers behavior
    • peer pressre is a useful and powerful tool
    • innapropriate behaviors are dealt with as they occur
    • restrictions and punishments to be avoided
  69. Conditions that promote a thrapeutic community
    • basic physiological needs are fulfilled
    • the physical facilities are conductive to achievement of the goals of therapy- more homier
    • a democratic form of self government exists- problem solving and decision making by the client
    • responsibilities are assigned according to client capabilities
    • a structured program of social and worl related activities is schedule part of therapy...ex ecercise
    • community and family are included in the progra of therapy
  70. Crisis
    a sudden event in ones life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem
  71. 4 Phases of crisis
    • Phase I the individual is exposed to a precipitating stressor
    • Phase II when previous problem solving techniques do not relieve the stressor, anxiety increases further, coping techniques do not work an individual feels helpless
    • Phase III all possible resources, both internal and external are called on to resolve the problem and relieve the anxiety
    • Phase IV If non above listed above work than individual may reach the panic level, cognitive functioning are disordered
  72. Aguilera suggest that whether or not an individual experiences a crisis in response to a stressful situation depends upn the following 3 factors
    • The individual perception of the event- if the event is seen realistic than the individual will look for resources
    • The availability of situational support-without support the idividual feels everwhelmed and alone
    • -The availlability of adequate coping mechanism - better chances of resolving the problem if person as successful behavioral strategies that can help
  73. Baldwin 6 classes of emotional crisis
    • Dispositional crisis
    • Crisis of anticipated life
    • Crisis resulting from traumatic stress
    • Maturational/Developmental crisis
    • Crisis of reflecting psychopathology
    • Psychiatric emergencies
  74. Dispositionl crisis
    • an acute responce to an external situational stressor
    • - ex. of husband having problems with boss and takes it out on family
    • external source-boss
  75. Crisis of anticipated life transitions
    • Normal life-cycle transitions that may be anticipated but over which the individual may feel lack of control
    • ex. a stressor that can occur anytime during your life, such as John working more hr to compesate for wife not working after having the baby, he does poorly in school and begins to feel sick
  76. Crisis resulting from traumatic stress
    crises precipitated by unexpected external stresses over which the individual has little or no control and from which he or she feels emotionally overwhelmed and defeated
  77. maturational/ Development crises
    crises that occur in responce to situations that trigger emotions related to unresolved conflicts in ones life
  78. Crises reflecting psychopathology
    emotional crises in which preexisting osychopathology has been instrumental in precipitating the crisis or in which psychopathology significantly impairs or complicates adaptive resolution
  79. Psychiatric emergencies
    • crisis situations in which general functioning has been severly impaired and the individual rendered incompetent ir unable to assume personal responsibility
    • ex..acute suicidal individuals, drug overdoses, acute psychoses, uncontrolled anger...ect...
  80. Phases of crisis intervention: the role of the nurse
    • Phase I- Assessment
    • Phase II- Planning of therapeutic intervention
    • Phase III-Intervention
    • Phase IV- Evaluation of crisis resolution and anticipatory planning
  81. Borderline personality disorder
    • - a pervasive pattern of instability of interpersonal relationships, self image, and affects marked impulsivity begining by early childhood, individal seems to be in crisis most of the time, within minute,hrs, days...and most are depressive
    • -cannot be alone\
    • patterns of interaction
    • -clinging and distancing
    • -splitting
    • -manipulation
    • -self destructive behaviors
    • -impulsivity
  82. Borderline patterns of interactions
    • Clining and distancing-cling to another individual excessively no matter how they are treated and when that person leaves they feel betrated, angry..
    • Splitting- (primary ego defense mechanism)- it arises from their lack of achievement object constancy and its manifested by an inabilty to intergrate and accept both positive and negative feelings
    • Manipulation
    • Self destructive behavior- try to hurt themselves, hurt themselves ..ex.cutting themselvesor say they are going to kill themselvest to get what they want
    • impulsivity- behaviors associated include gambling, reckless driving, binging and purging, in response to perceived feeling of abondonment
  83. Mahlers theory 6 phases from birth to 36months
    • Phase I Birth- 1 month
    • -baby spends half awake and half sleep, main goal is to fullfillment of physio needs
    • Phase II Symbiotic phase- 1-5 months
    • -the child view the self as an extensio from parent figure
    • Phase III Differentation phase 5-10months
    • -child begins to recognize that hter is a seperation betweem self and parent figure
    • Phase 4 Practicing phase 10-16 months
    • increased locomotor functioning and the ability to explore the enviroment independently
    • Phase 5 16-2yrs
    • Rapprochement
    • -awarness of seperateness of the self becomes acute, child who wants to regain some lost closeness but not return to symbiosis phase (Emotional refueling) mother is there when child needs them so they can feel secured
    • Phase VI 24-36moths- a sense of seperation is established, seperation anxiety is resolved an the child sustaineds image of the loved object or person when out of sight

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