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What is important to remember about the nurse-client relationship?
- Basis of all psychiatric nursing treatment approaches
- Establishes an understanding in the client that the nurse-client relationship is
- with clear boundaries
What is the purpose of a review of the goals, roles, and focus of therapeutic communication?
Help patients to discover the truth about themselves, to make changes that will increase their satisfaction with life
What is the RN's role in therapeutic communication
Help patients clarify thoughts, feelings, needs and to take "response-ability" for co-developing strategies to increase their levels of health
What are the goals of therapeutic communication?
To assist the patient with...
- Communication of painful material
- Identiying self-defeating behavior patterns and replace them with functional, healthy patterns
What is the focus of therapeutic relationship?
Clients feelings, ideas and experience, their problems and needs
What are the types of relationships?
What are the basics of social relationships?
- Initiated for the purpose of friendship or meeting a goal
- Mutual needs are met
- Communication to give advice, give or ask for help
- Content of communication superficial
What are the basics of intimate relationships?
- Individuals have an emotional commitment
- Mutual needs are met
- Mutual goals
- Personal and intimate information shared
What are the basics of therapeutic relationships?
- Relationship consistently focused on the client's problems and needs
- Potential solutions to problems discussed
- Solution of client's choice implemented by client
- New coping skills develop
- Behavioral change encouraged
What are examples of detrimental Nurse-Client relationship?
- Nurse tries to get his or her own needs met
- Nurse tries to solve the client's problems
- Nurse takes the role of a friend or family member of the client
- Lack of boundaries in the relationship
What parts of genuineness are by the nurse are important in promoting change and growth in clients?
- Self-awareness of one's feelings
- Ability to communicate one's feelings
- Key in building trust
What parts of empathy by the nurse are important in promoting change and growth in clients?
- Feelings and ideas of client accurately perceived
- Accurate understanding of client's communication
- Understanding client's communication to help the client
- Empathy = Sympathy with understanding
What parts of positive self-regard by the nurse are important in promoting change and growth in clients?
- Respect communicated indirectly by actions
- Work seriously with client to develop personal resources
- Nonjudgmental focus on client's thoughts and feelings to understand behavior
What is important to remember about the boundaries of the nurse-client relationship?
- Client's needs are separated from the nurse's needs
- Client's role is different from that of the nurse
Nurses can blur boundaries when they...?
- Overly helpful
- Person unconsciously displaces onto individual in current life emotions and behaviors from childhood that originated in relationships with significant others
- Transference --> intensified with person in authority in current life
- Nurse displaces onto client feelings related to people in nurse's past
- Clients transference to nurse often results in countertransference in nurse
- Common sign of countertransference --> over-identification with the client
What are the phases or nurse-client relationship?
- 1. Preorientation phase
- 2. Orientation phase
- 3. Working phase
- 4. Termination phase
What are the parts of the orientation phase?
- 1. Trust
- 2. Parameters of relationship
- 3. Formal and informal contract
- 4. Confidentiality
- Termination begins
- (termination is hard!!)
What are the basics of the working phase?
- Maintain relationship
- Gather further data
- Promote clients --> problem-solving skills, self esteem, use of language
- Facilitate behavioral change
- Overcome resistant behaviors
- Evaluate problems and goals --> redefine them as necessary
- Promote practice and expression of alternative adaptive behaviors
What are the basics of the termination phase?
- Summarize goals and objectives achieved
- Review situations that occurred during time spent together
- Exchange memories that can validate the experience
- Feelings of guilt about termination of relationship common for novice caregiver
What are the factors that are beneficial to the nurse-client relationship?
- Consistent, regular, and private interactions with client
- Being honest and congruent
- Letting client set the pace
- Listening to client's concerns
- Positive initial attitues
What are some factors that can hamper the nurse-client relationship?
- Lack of nurse availability or lack of contact
- Lack of nurse self-awareness
- Nurse's negative feelings about client
Assessment Strategies and the Nursing process diagram
What things are part of the database in the assessment portion of putting together a psycho-social assessment?
- Psychosocial assessment
- Physical examination
- History taking
- Standardized rating scales
How do we verify data in a psycho-social assessment?
You dont really
Perception is reality, we verify thats how they feel
What are the two source types in data collection in the psychosocial assessment?
- Primary source --> client
- Secondary --> police records, charts, family members
What is important to remember regarding the personal consideration portion of the psychosocial assessment?
What age considerations are there in the psychosocial assessment?
- Adolescents --> challenging, demanding, angry
Regarding the process and content of the psychosocial assessment, the ____ and ____ is gathered
how and what
framework for nursing and therapeutic relationship
Gather of subjective and objective data
What are the important parts of the interview process of the psychosocial assessment?
- 1. Important to consider what is NOT said as well as what is said
- 2. Listen for areas of potential problems
- 3. Explore obvious symptoms in depth
- 4. Pay attention to subtleties
- 5. Assessment documented in specific and behavioral or factual terms, avoiding judgmental language
- 6. Look for incongruence and explore
- 7. Monitor own feelings and reactions. Intuitive feelings or "gut reactions" may signal subtle emotions or undercurrents of unexpressed emotions or issues.
What are the three structural components of the nursing diagnosis?
- Problem --> unmet need
- Etiology --> probable cause
- Supporting Data --> signs and symptoms
What are the basics of the goals for identifiable outcomes?
- Should be realistic and acceptable to client
- Stated in observable and measurable terms
- Sets a specific time goal should be achieved
- Short term and long term goals
- Written in positive terms
What is part of the planning phase of the interview process?
- Strive to use interventions that culturally relevant and compatible with health beliefs and practices
- Needs to be --> safe, appropriate, effective, individualized to client
What are the basic level interventions?
- milieu therapy
- self-care activities
- health teaching
- case management
- health promotion and health maintenance
What are the advanced practice interventions?
- Prescription of medication
What is part of the evaluation portion of the interview process?
- Need to relate to the actual goals identified
- Specific statements on how foals were met and approaching being met
- If not met what were the obstacles
What is needed if outcomes have not been achieved at desired level in the evaluation section?
- Additional data gathering
- Revised plan
What should the chart include and accurately document?
- Changes in condition
- Informed consent
- Reaction to medications
- Treatments and tests
- Response to treatments and tests
- Any untoward incidents
What are the parts of the mental status exam?
- A. Appearance
- B. Behavior
- C. Speech
- D. Emotional State
- E. Thought process
- F. Thought content
- G. Cognition
Mental Status Exam
- Grooming and Dress
- Level of hygiene
- Pupil dilation or constriction
- Facial expression
- Height, Weight, nutritional status
- Presence of body piercing or tattoos, scars, other
- Relationship between appearance and age
Mental Status Exam
- Excessive or reduced body movements
- Peculiar body movements --> scanning of environment, odd or repetitive gestures, LOC, balance and gait
- Abnormal movements --> tardive dyskinesia, tremors
- Level of eye contact (keep cultural differences in mind)
Mental Status Exam
- Rate: slow, rapid, normal
- Volume: loud, soft, normal
- Disturbances (articulation problems, slurring, stuttering, mumbling)
- Cluttering (rapid, disorganized, tounge-tied speech)
Mental Status Exam
Mood --> patient's self report of the current emotional experience. May ask patient to rate on a scale of 0-10. Include assessment of suicidality and/or homicidality, if indicated.
Affect --> Emotional tone of patient as observed by the nurse. Incongruence between mood and affect should be noted.
- Might want to include: interaction in interview
When assessing the emotional state, what other things might want to assess other than mood and affect?
- Mental status
- Euthymic - normal
- Euphoric - elated
- Labile - changeable
- Dysphoric - depressed, restless
What are examples of affect?
What is described in the thought process section of the MSE?
- Logical, organized, relevance and coherence of thoughts as demonstrated by word usage
- Can be organized, coherent, or have flight of ideas, neologisms, looseness of associations, thought blocking, circumstantiality
Flight of Ideas
rapid shift of ideas from topic to topic
Looseness of associations
relatedness of words or concepts diminished, may become incoherent (word salad)
response includes many irrelevant details, eventually reaches
goes off "on a tangent" leaving conversational goal behind
filling in memory gaps with made up stuff
meaningless rhyming of words or phrases as in "Look up at the star, I went to the bar. I drove the car. I'm stuck in the tar." Or single words as in "Mary, berry, fairy, carry." In a form of perseveration.
Mixture of meaningless words
repetition of own idea or phrase
repetition of own idea or phrase
inability to speak
What is described in the thought content section of the MSE?
- Perceptual disturbances
- Hallucinations (ie auditory, visual)
What is described in the cognition section of the MSE?
- Orientation: time, place, person
- LOC (alert, confused, clouded, stuporous, unconscious, comatose)
- Memory: remote, recent, immediate
- Fund of knowledge
- Attention: performance on serial sevens, digit span tests
- Abstraction: performance on tests involving similarities, proverbs
unable to generalize or ascertain overall meaning as when asked a proverb, "A rolling stone gathers no moss" will answer, "The stone is rolling too fast for the moss to stick to it."
Judgement and Insight
- Ability to solve problems
- Ability to make decisions
- Knowledge about self
- Awareness of:
- consequences of actions
What are the lifespan considerations for an elderly client?
- Assess for sensory impairments
- Assess for physical impairments
What are the lifespan considerations for children?
- Use play, drawing, dolls, story telling in assessment
- Special training needed to do assessments on children. We do not do our assessments on children in clinical
Wt are the components of the psychosocial assessment?
- General History and Information
- Presenting Problem
- Personal History
- Physical or Medical issues (Rx)
- Mental Status Exam
- Family History and Relationship
- Spiritual and Cultural Issues
What is in the general history and info section of the psychosocial assessment?
- Age and Sex
- Marital Status
- Living Arrangements
- DSM IV diagnosis (Axis I through V)
- Major signs and symptoms
What is included in the presenting problem and personal history section of the psychosocial assessment?
- Statement in client's words
- Recent difficulties
- Developmental level
- Emotional, Behavioral, Cognitive & Physical changes or issues
- Sexual patterns
- Substance use and abuse
- Methods of dealing with stress
What is included in the physical or medical issue section of the psychosocial assessment?
- Medical diagnosis
- How condition impacts person or family
- Diagnostic tests
What is included in the family history and relationships section of the psychosocial assessment?
- Use of drugs (current and past)
- Family history of physical or mental problems
- Family Life Cycle --> single, coupled, divorced, blended family
What is included in the spiritual and cultural section of the psychosocial assessment?
- Importance of religion or spirituality
- Influence on current life
- Who or what give client hope and meaning
- What cultural group does the client identify with
- What impact does client's culture have on current life and illness
- Alternative or complementary practices
What is involved in the clinical interview portion of the psychosocial assessment?
- Content and direction of the clinical interview are decided by the client
- This differs from the assessment interview!!!
- Employ therapeutic communication skills and active listening. They are acquired skills!
What is involved in the "How to begin and interview" section?
What are some possible phrases used in beginning an interview?
- “Where should we start?”
- “Tell me about what has been going on with you.”
- “What are some of the stresses you have been coping with recently?”
- “Perhaps you can begin by letting me know what some of your concerns have been recently.”
- “Tell me about your difficulties.”
What are some helpful guidelines in beginning a clinical interview?
- Speak briefly
- When you do not know what to say, say nothing
- When in doubt focus on feelings
- Avoid giving advice
- Do not rely on asking questions
- Pay attention to nonverbal clues
- Focus on the client
What are some common client behaviors?
- Asks nurse to keep a secret
- leaves before the session is over
- Interrupted by another client
- Communicates thoughts of suicide
- Does not want to talk
- Seeks to prolong the interview
- Gives the nurse a present
- Asks the nurse a personal question
What are some personal factors that affect communication?
What are some environmental factors that affect communication?
- Societal determinants
What makes up the verbal communication section of psychosocial assessment?
All words a person speaks or uses
Communicates --> beliefs and values, perceptions and meaning
- Convey --> Interest and understanding or insult and judgment
- messages clearly or conflicting or implied messages
- clear, honest feeling or disguised distorted feeling
What makes up nonverbal communication section of psychosocial assessment?
- 65% to 95% if a sent message
- Body behaviors
- Facial expressions
- Emotions expressed in the eyes
- Voice-related behaviors
- Observable autonomic physiological responses
- Personal appearance
- Physical characteristics
What are the Attending behaviors of communication?
- Culturally and individually appropriate
- Eye contact
- Body contact
- Vocal qualities
- Verbal tracking
What are some cultural considerations?
- Culture is more than race/ethnicity
- Race is not specific but one aspect of one's identity
- Race is significant because of racism and social beliefs
- Race may be significant due to physiologic differences in genetic makeup
What areas are problematic for interpreting messages when looking at cultural communication barriers?
- Communication styles
- use of eye contact
- perception of touch
- cultural filters
- time orientation
- view of a health care worker
What is cultural competence?
- Sensitivity to those issue
- Knowledge, attitude, attributes and skills
- Flexibility, empathy and & non-judgmental approach
What is are the areas of the cultural assessment?
- Role of the family
- who makes decisions
- who should be included in discussions,
- respecting confidentiality
- full disclosure
Avoid stereotyping --> may not identify with respective ethnic group
Cultural influences all aspects of life, especially illness and end of life
What are some tools for enhancing communication?
- Use of silence
- Active listening
- Clarifying techniques
Techniques to enhance communication
Silence --> not the absence of communication but transmitting and receiving messages
- Significant means to influence and be influenced
- No universal rule concerning silence
- Icy silence may be an expression of anger
- Giving the “silent treatment” is an insult
- May be an indication of emotional blocking
- Timing is essential
- Can communicate strength and support allowing client to regain composure & cont.
- Can be a moment of reflection for both
- If nurse feels compelled to fill every void with words, it is often due to their own anxiety, self-consciousness & discomfort
- Prolonged & frequent silence is not helpful
Techniques to enhance communication
- Observing client nonverbal behavior
- Listen to & understanding verbal message
- Understanding context of client’s life
- Listening to false notes (inconsistencies)
- Noticing verbal & nonverbal messages
- Communicates that client is not alone
- Enhances self-esteem
- S - Sit squarely facing the client (sort of)
- O - Observe an open posture
- L - Lean forward toward the client
- E - Establish eye contact
- R - Relax
What are some clarifying techniques to enhance communication?
- Paraphrasing --> restate in different words
- Restate --> mirrors overt and covert message
- Reflection --> may be a question or simple statement that conveys and observation that shows acceptance
- Exploring --> enables the nurse to examine important ideas, experiences or relationships
What are some ways to encourage conversation?
- Avoid misunderstandings "help me understand what you mean"
- Don't change the subject
- Encourage reminiscing
- Don't be afraid to acknowledge your feelings
What are some obstructive techniques?
- Asking excessive questions
- Giving approval or disapproval
- Asking "why" questions
What are some techniques to monitor or minimize?
Asking excessive questions: puts nurse in role of interrogator and conveys lack of respect
Giving false reassurance: underrates other person's feelings & belittles their concerns
- Giving Approval:
- Client can see as way to do the "right thing"
- Does something in order to please the nurse (get approval)
- May not lead to change in behavior but seeking of approval
Why should advising be avoided in communication practices?
- Rarely helpful
- Interferes with client's abliity
- to make decisions
- Can foster dependency
- Undermines sense of competence and adequacy
- Keeps nurse in control (feeling like strong one)
- Client may need information to help define problem of identity solutions
Why should the "why question" be avoided?
requesting an explanation
- implies criticism
- can be experienced as intrusive and judgemental
- serves to make client defensive
- more useful to ask what happened
Describe what is important about how stress leads to anxiety
- Produced by change in enviornment
- internal or external
- Individual perceives change as
Stress leads to a variety of psychological responses
Anxiety the most common response
What are the categories of anxiety?
Normal --> healthy life force necessary for survival
Acute or state anxiety --> crisis threatens sense of security
Chronic or trait anxiety --> Long-term anxiety (chronic fatigue or insomnia), Discomfort in relationships or poor job performance
What are the 4 levels of anxiety?
Important to identify which level if used in Nursing Diagnosis!
What are the properties of defense mechanisms?
- Manage conflict and affect
- Relatively unconscious
- Discrete from one another
- Ofen hallmarks of psychiatric syndromes, but reversible
- Adaptive as well as pathological
What are some defense mechanisms?
- Reaction Formation
take on attitudes or beliefs
one feeling from one person on to another
projection onto someone else how they feel