FC therapeutic communication.txt

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nikkiknak
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39240
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FC therapeutic communication.txt
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2010-10-03 16:10:28
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NURSING therapeutic relationships
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nursing level 1 ACC test 3 therapeutic relationships module
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  1. STAGES of ILLNESS and EFFECT on ROLE FUNCTIONING: TASKS DURING ILLNESS
    • *to MODIFY the BODY IMAGE, CONCEPT of SELF, and RELATIONS to other PEOPLE and WORK.
    • *to READJUST REALISTICALLY to the LIMITATIONS IMPOSED by the condition
  2. STAGES of ILLNESS and EFFECT on ROLE FUNCTIONING: STAGES
    • stage 1: transition from health to illness
    • stage 2: acceptance of illness
    • stage 3: convalescence
  3. STAGES OF ILLNESS: STAGE 1
    • TRANSITION from HEALTH to ILLNESS
    • A.DEVELOPMENT of SYMPTOMS
    • ----unpleasant sensations
    • ----decrease in ability to function
    • ----loss of vigor and stamina
    • B. ANXIETY may be present
    • Coping styles
    • ---plunge into activity, work late, increase social activities
    • ---passive, withdrawn, hoping symptoms will go away
    • ---put off medical care, fear of diagnosis
    • ---anxiety, guilt, shame, or denial are prominent
    • C. if SYMPTOMS PERSIST, SEEK medical CARE
    • ---ambivalent feelings (evident in canceled or missed appointments)
    • ---may be non-compliant
    • ---go from physician to physician
    • D.If illness is SUDDEN or CATASTROPHIC, seeks IMMEDIATE attention
    • ---fear of not getting timely help
    • ---family fear (excessive demands, refusal to cooperate, suspicion of motive and methods of those trying to help)
    • ---shock, disbelief, denial
  4. STAGES OF ILLNESS: STAGE 2
    • ACCEPTANCE of ILLNESS
    • a.Recognizes and admits he is sick and in need of help from others
    • b.Temporarily adopts patient role (dependence)
    • c.Abdication from usual responsibilities and cooperation in the task of getting well
    • d.Become preoccupied with self, symptoms, and treatment
    • e.Interest in current events and even concern about family and friends may be limited
    • f.May be seen as regressive (return to earlier forms of acting, feeling, and relating to others)
    • g.Some regression may be useful (get rest, be waited on)
    • h.For some, dependence may be threatening (deny illness, noncompliance)
    • i.Serious acute illness (need a great deal of help from others).
    • dependence may be overwhelming (both for patient and staff)
    • j.May express anger, guilt, resentment
    • k.May be critical of care and medical management, attacking the very people he depends on
    • l.Nurse should recognize need and encourage expression of feeling without passing judgment, moralizing or arguing
    • m.Feel helpless and hopeless
    • n.Nurse should provide opportunity for decision-making and responsibility where possible
    • o.Acute sense of loss
    • p.depression: sadness, hopelessness, anger (mourning the loss of health, loss of body part or function, changes anticipated in job and family)
    • q.stages of grief, denial/isolation, anger, bargaining, depressing, acceptance
  5. STAGES OF ILLNESS: STAGE 3
    • CONVALESCENCE
    • a.Return to health and physical strength often precedes the patients feeling and acting well (remember there was a lag between being ill and accepting illness - this is a similar lag)
    • b.Giving up dependent, regressive position; resuming adult responsibilities and normal relations
    • c.Some are reluctant to give up role
    • d.Some motivated, but hesitant (especially if involves major changes in work and family relations)
    • e.Nurse may help by assuming role of adequate parent to teenager
    • *relaxed protection, guidance, advice, encouragement
    • *quietly retire to sidelines
    • *ready to reassure, encourage experimentation
    • *step in only when gross errors in judgment occur
    • *patient will sense confidence of nurse
  6. OUTCOME CRITERIA FOR SELECTED PSYCHOSOCIAL DIAGNOSES: BODY IMAGE DISTURBANCE
    • the patient with a BODY IMAGE DISTURBANCE
    • *Describes changes in thoughts and feelings about self.
    • *Verbalizes acceptance of changes that have occurred.
    • *Looks at, touches, and discusses changed body part.
    • *Continues preexisting socialization pattern.
    • *Engages in appropriate role functions.
    • *Engages in recreational activities appropriate to limitations.
    • *Maximizes use of remaining strengths.
    • *Uses ALL available resources to improve functioning (or appearance) of body part.
    • *Accepts offers of help.
  7. OUTCOME CRITERIA FOR SELECTED PSYCHOSOCIAL DIAGNOSES: SELF-ESTEEM DISTURBANCE
    • the patient with a SELF-ESTEEM DISTURBANCE
    • *Demonstrates an improvement in personal appearance.
    • *Verbalizes realistic perceptions of self.
    • *Identifies at least 5 positive personal attributes.
    • *Shares feelings about self with significant others.
    • *Compares ideal self and perceived self.
    • *Uses appropriate assertive and communication skills.
    • *Demonstrates use of active rather than passive language pattern (e.g., says, I choose to, or, I choose not to).
    • *Demonstrates increased social contacts and friendship networks.
    • *Expresses satisfaction with own achievements.
    • *Engages in positive talk about self.
    • *Analyzes own behavior and its consequences.
    • *Discusses options and alternatives when trying to solve problems.
    • *Identifies ways of exerting control and influencing outcomes.
  8. PSYCHOSOCIAL INTEGRITY
    Successful adjustment to developmental phases, to meeting life crises, and to the experience of being ill
  9. OUTCOME CRITERIA FOR SELECTED PSYCHOSOCIAL DIAGNOSES: ALTERED ROLE PERFORMANCE
    • the patient with ALTERED ROLE PERFORMANCE
    • *Verbalizes realistic perception and positive acceptance of self in changed role.
    • *Verbalizes understanding of role expectations and obligations associated with role.
    • *Develops/lists realistic plans for adapting to new role or role changes.
  10. PRINCIPLES related to COMMUNICATION
    • 1. communication is DYNAMIC and NECESSARY for social interaction
    • 2. ALL BEHAVIOR TRANSMITS INFORMATION and is to be considered in the communication process
    • 3. 60-80% of communication occurs via NON-VERBAL means.
    • 4. ALL individuals have UNIQUE PATTERNS of communicating.
    • 5. communication is INFLUENCED by AGE, CULTURE, DEVELOPMENTAL STAGE, COGNITION, ANXIETY, and STATE OF HEALTH
    • 6. for communication to be EFFECTIVE, the MESSAGE SENT must be accurately RECEIVED.
    • 7. an individual's HONEST, GENUINEness, EMPATHY, TRUST, RESPECT, and VALUE of individual DIFFERENCES facilitate communication.
    • 8. highly elevated levels of ANXIETY decrease PERCEPTION
  11. PRINCIPLES related to THERAPEUTIC RELATIONSHIPS
    • 1. HUMAN NEEDS appear in a HIERARCHY from needs that are high in rank to those that are lower in IMPORTANCE at any given time
    • 2. The PHYSIOLOGICAL needs usually must be MET BEFORE other needs; however, ALL needs INTERACT. (refer to MASLOW'S HIERARCHY)
    • 3. HUMAN beings can HELP EACH OTHER meet their needs.
    • 4. to be EFFECTIVE, a helper seeks to know how the PATIENT RANKS his/her NEEDS.
    • 5. therapeutic relationships are based on RESPECT for the INDIVIDUALITY of the participants.
    • 6. a major GOAL of a helping relationship is the PERSONAL GROWTH of the PARTICIPANTS. however, the PATIENT remains the PRIMARY FOCUS in the relationship.
    • 7. a GOAL of all helping relationships is to aim for reaching the patient's HIGHEST ACHIEVABLE LEVEL of SELF-CARE
    • 8. ALL behavior is MOTIVATED, and ALL behavior has MEANING.
    • MASLOW'S HIERARCHY OF BASIC NEEDS
    • PSYCHOLOGICAL Needs: biological needs i.e. oxygen, food, water, body temp.
    • SAFETY Needs: in/security
    • Needs of LOVE, AFFECTION, and BELONGINGNESS: giving/receiving love, affection, and the sense of belonging.
    • Needs for ESTEEM: human need for stable, firmly based high level of self-repect and respect from others.
    • Need for SELF-ACTUALIZATION: a need be and do what they were "born to do"
  12. Basic Concepts for Understanding Clients’
    Psychosocial Needs
    BASIC CONCEPTS











    • Self-Concept








    • Stress








    • Stressors








    • Anxiety













    Adaptation and Coping













  13. Basic Concepts for Understanding Clients’
    Psychosocial Needs: SELF CONCEPT













    • SELF-CONCEPT






    • o An individual’s attitudes and beliefs about the physical and psychological self


















      o Guides life actions, expectations, and goals


















      o Develops and changes over time











    Components of Self-Concept


    o Personal Identity (or Self-image): Inner images that tell me who I am


    o Self-Esteem: How I value/respect myself


    o Role Performance: How I fulfill socially expected behaviors


    o Body Image: How I perceive the size, appearance and physical functioning of my body and its parts
  14. Basic Concepts for Understanding Clients’
    Psychosocial Needs: STRESS

















    • Stress

















    • ¡ Physiologic responses to internal and external demands















    • Selye: Stress Activates Responses primarily in:















    • Nervous system





    • Endocrine system





    • Immune system















    • Stressors








    • o Anything that causes stress
    • o Stressors can be:
    • Physical
    • Chemical
    • Emotional
    • Developmental
  15. Basic Concepts for Understanding Clients’
    Psychosocial Needs: ANXIETY
    • Ÿ
    • Anxiety


    o A common, pervasive feeling of dread accompanied by physical symptoms


    o May be chronic, intermittent; ranges from mild to panic state


    o Most often occurs in response to actual or perceived threat to:


    • Biological integrity
    • e.g. death, pain, injury

    • Personal identity, e.g. loss of self-esteem,
    • status, role performance
  16. Adaptation To Stress
    • Selye (General Adaptation Theory):
    • Human beings are continually adapting to stress -- i.e. maintaining homeostasis/ability to function.
    • Stress Tolerance – how much stress an individual is able to adapt to while maintaining normal function
    • Resilience – how quickly an individual is able to recover from a stressful event
  17. Individual’s Stress Tolerance and Resilience are influenced by a variety of factors:
    • Heredity
    • Age
    • Perception [Lazarus & Folkman]


    • Lifestyle factors
    • Chronicity of the stress
    • (how long it has been going on)


    Number and Severity of Stressors
  18. COPING
    *Self-protective cognitive and behavioral responses by an individual to manage a stressor which is perceived as a threat to health or safety


    Goal of all coping behavior = stress and anxiety reduction



    Principles of Coping


    o Individuals cope in patterned ways


    o The greater the variety of coping behaviors used by an individual, the more successful they are in dealing with stress


    o Individuals are usually aware of their coping patterns



    Coping Patterns


    o Adaptive Coping:

    • Problem-solving or emotion-regulation
    • coping behaviors


    o Maladaptive (Dysfunctional) Coping









      • Coping behaviors which exacerbate stress or cause new stress








  19. Factors Which Maintain Psychosocial Integrity








      • Spirituality
    • o Provides meaning, security and hope
      • Sexual Health
    • o Multiple levels of the hierarchy of human needs

    o gender/sexual identity

    o sexual expression and sexual performance

      • Culture, Family and Community

      • Support System

  20. Risk Factors to Maintaining Psychosocial Integrity







    • Crisis












    o Overwhelming or life threatening event


    o Usual adaptive, coping methods are ineffective


    o Help is needed to regain homeostasis






    • Physiologic Stressors






    o Chronic illness/anxiety affect brain structures and immune system


    o To maintain psychosocial integrity, client and family must successfully adapt to each stage of illness and recovery







    • Family Context Factors




    • o Influence of family on learned behaviors






      o Effects of early life stress






      o Family system affected when one member is ill






      o When family support is insufficient









    • Cultural and Lifestyle Factors








    o Culture Shock and cultural repression (military returns)


    o Cultural Insensitivity or Misunderstanding


    • o Lifestyle factors (workaholic)
    • Use of substances







    • Violence, Abuse, and Neglect




      • Correlate to decreased stress tolerance, poorer psychosocial functioning

    • Economic Factors
    • employment status, insurance, expenses = HUGE impact
  21. sexual history: PLISSIT model
    • Permission
    • Limited Info
    • Specific Suggestion
    • Intensive Therapy
  22. Psychosocial Assessment







    • Health and Social History








    o Type and duration of stressors


    o History of illness, including mental illness


    o Medications used


    o Coping ability and patterns


    o Identify support system


    o Sexual history if sexual function is involved


    o PLISSIT model: sexual concerns








    • Mental Status Assessment








    o Cognitive Functioning (orientation, memory, knowledge, understanding, judgement)


    o Affect (external observational appearance)


    o Mood (patients internal emotional state, feelings)


    o Psychomotor Behavior (voluntary movements/muscle activity assc. with mental process)
  23. Psychological Screening Tools
      • Lab tests are super important to ID physiological factors assc. with dilemma.
      • Standardized measures of intelligence, general personality traits, anxiety or depression, perception,
      • cognitive status, etc.




      • Nurse may administer some tests with dr.’s order e.g.
      • Mini-Mental State Scanning Tests








      • Anatomical or Structural Changes
      • CT: X-ray










      • Biochemical Alterations (CNS Metabolites)
      • * PET, MRI; MRSI








      • Sensory Processing
      • EEG





    Laboratory Analysis





    • Laboratory Tests







    • Identify contributing physiological factors
    • e.g. Thyroid function tests (TSH, T4), blood glucose level, serum analysis of drug levels
  24. Nursing Diagnoses and Goals for Psychosocial Needs
      • tell me about your concerns.
      • what have you been doing to manage your problem?
      • how well has this worked?
      • how can i help you?
      • PROBLEM ID BEGINS WITH PATIENT PERSPECTIVE.


      • Nursing Diagnoses



      • o Problem Identification begins with patient’s perspective, if possible.

        • Goals and Outcomes
      • o Cognitive Outcomes

      Demonstrates improved memory, concentration, learning, etc.

      o Affective Outcomes

      Reports improved mood; affect improves

      o Psychomotor Outcomes

      Motor behaviors indicate positive changes
    • Therapeutic Interventions to Assist Clients with
      Psychosocial Needs



        • Interventions

      o The Helping Relationship; cultural, ethical and legal aspects


      o Communication


      o Drug Therapy


      o Patient Teaching: Coping Skills


      o Referrals


      o Community Resources





      • The Nurse-Client Relationship is a Helping or Therapeutic Relationship










    • The Nurse-Client Relationship is a Helping or Therapeutic Relationship
      o H. Peplau: In nursing practice, this is the onecore modality” which assists clients to maintain psychosocial integrity

      o The therapeutic (helping) relationship is based on empathy, trust, respect, and healthy boundaries

      o Differs from social relationships

      • Client-focused (take self out of situation)
      • Time-limited, boundaries are clear
      • Goal-oriented, purposeful
      • Nurse shares personal information only when helpful to client
      • Promotes personal growth of the participants





      • phases of a working relationship


















      • 1. Pre-Interaction Phase
      • (preparing to meet patient)
      • 2. Orientation Phase
      • (starting/establishing the relationship)
      • 3. Working Phase
      • (developing/maintaining the relationship)
      • 4. Termination Phase
      • (ending/completing)
    • the helping/THERAPEUTIC relationship
      text pp49
      • communication
      • space (personal)
      • social organization (roles within community)
      • time importance
      • environmental control (perception of control)
      • biological variation
    • Ethical and Legal Aspects
      • Confidentiality
      • -- keeping secrets

      Objectivity in documentation




      o Culturally Competent Nurse-Client Relationship


      o Based on recognition and valuing of differences and similarities


      o Compromise is necessary component (nurse modifies care to meet client needs)
    • Interventions: Communication
      • o Good communication skills are essential for establishing and maintaining the nurse-client
      • relationship



      o Communication involves:

      SENDER <-----> RECEIVER

      encodes ------> message <-------- decodes


      If the message is not received, no communication can take place.


      o Effective Communication Means:


      message sender intended to convey


      reached intended receiver

      was interpreted (decoded) accurately


      receiver was able to respond in a meaningful way to indicate message was received (feedback)
    • Modes of Communication









      o Verbal Communication


      o Non-Verbal Communication (Metacommunication)


      o Therapeutic Communication

      • o Verbal Communication includes:
      • Spoken words
      • Written communication
      • Language, vocabulary, slang and idioms

      • o Non-Verbal Communication (Metacommunication) includes:
      • Paralanguage
      • Body language
      • Humor
      • Touch


      Non-Verbal Communication is 60-80% of Communication
    • o Non-VerbalCommunication (Metacommunication) includes:
      Paralanguage


      Body language


      • Humor
      • Touch



      Non-Verbal Communication is 60-80% of Communication



      • Paralanguage or Vocal
      • Cues
      • Give meaning to the
      • spoken word
      • tone of voice
      • emphasis
      • pitch



      • Kinesics or Body
      • Language
      • Posture
      • Gestures
      • Facial expression
      • Attire, adornment
      • Personal space
      • (preferred closeness or distance)
      • Humor
      • Is both verbal and
      • non-verbal


      • Can decrease stress
      • response


      • Should be used
      • appropriately


      • Must be acceptable to
      • client


      • Touch
      • Procedural (e.g. taking
      • a B.P.)
      • Non-Procedural
      • Communicates connection
      • Must be used
      • appropriately


      • Clients will not always
      • welcome touch


      • Nurse must be
      • comfortable using it
    • Therapeutic Communication “Talk with a Purpose”:
      • Techniques are
      • deliberately selected


      • Facilitates expression
      • and identification of client’s thoughts and feelings


      • Assists client to work
      • through problems
    • Interventions: Psychoactive Drug Therapy
      • o
      • Classifications include:


      • -
      • Anti-anxiety agents


      • -
      • Antipsychotic agents


      • -
      • Antidepressants


      • -
      • Mood-stabilizing agents


      • -
      • Acetycholine-potentiating
      • drugs (for dementia)
    • Other Nursing Interventions:
      Patient Teaching: Coping Skills















      • Utilize patient’s strengths
      • Identify substitute coping behaviors that can be used to replace dysfunctional (ineffective) coping
      • Teach new skills, if
      • possible
    • Other Nursing Interventions:
      Coping Skills: Stress Reduction


























      • Skills may include:
      • Relaxation techniques
      • Positive self-talk

      Lifestyle alterations: e.g. increase exercise, weight loss, etc
    • Referrals and Community Resources














      **can really help through a situation if time limited, but pt needs therapeutic communication**

      Social Services

      Pastoral Care

      Case Management

      Counseling

      Senior Services

      Religious/Spiritual Groups

      Self-Help Groups

      Teaching Groups
    • Evaluation of Interventions
      Evaluate via:


      o Change in cognition, affect, or psychomotor behavior


      o Client’s report (self-assessment)

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