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Therapeutic communication, anxiety and defense mechanism


Social interaction impaired, Anxiety, Ineffective, individual coping, Self esteem disturbance …

Social interaction impaired, Anxiety, Ineffective, individual coping, Self esteem disturbance

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  • 1. Therapeutic Communication, Anxiety and Defense Mechanism Submitted By :
  • 2.
    • Assessment
    • Appearance, behaviour or mood
      • Well groomed, relaxed
      • Self-confident, self accepting
    • Speech, thought content and thought process
      • Clear, coherent
      • Reality based
    • Sensorium
      • Oriented
      • Good memory
      • Ability to abstract
  • 3.
    • Insight and judgment
    • Family relationships and work habits
      • Satisfying interpersonal relationships and work habits
      • Ability to trust
      • Ability to copy effectively with stress
    • Level of growth and development
  • 4.
    • Analysis
    • Potential support system or stressors
      • Church or community support
      • Family
      • Socioeconomic resources
      • Education cultural norms
    • Potential risk factors
      • Family H/O mental illness
      • Medical history
    • Satisfaction of basic human needs
  • 5.
    • Potential nursing diagnosis
    • Social interaction impaired
    • Anxiety
    • Ineffective individual coping
    • Self esteem disturbance
    • Implementation
    • Therapeutic communication
      • Listening to and understanding client while promoting clarification and insight
  • 7.
    • Goals
    • To understand clients message verbal and non verbal
    • To facilitate verbalization of feelings
    • To communicate understanding and acceptance
    • To identify problems, goals and objectives
    • Guidelines
    • Nonverbal communication constitutes 2/3 of all the communication
    • It gives most accurate reflection of attitude
    • Key points : say nothing and listen
    • Observe physical appearance, body movement, posture, gesture and facial expression
    • Maintain eye contact, physical distance
    • Use therapeutic touch
    • Person’s feelings and what is said may be incongruent
  • 8.
    • Therapeutic responses
    • Using silence
    • Use general leads or broad openings : what would u like to talk about. go on….
    • Clarification : Give me one example, tell me more…
    • Reflecting : it sounds like u r feeling angry, are you saying…
  • 9.
    • Avoid
    • Close ended questions, yes or no : how many children u have
    • advice giving : why don’t u ….
    • Responding to questions that r related to client in an embarrassed or concrete way : nurses r not allowed to go with their patients
    • Arguing or responding in a hostile manner
    • “ why” questions : why u did not take ur medication
    • Being judgmental : u were wrong to do that
  • 10.
    • Treatment modalities for mental illness
    • Biological
    • Emotional problem is an illness
    • Cause may be inherited or chemical in origin
    • Medications and ECT
    • Psychoanalytical
    • Anxiety results when there is conflict between id and ego
    • Defense mechanisms form to ward off anxiety
    • Therapist helps the patient to become aware of unconscious thoughts and feelings
    • he helps him to understand anxiety and defenses
  • 11.
    • Milieu therapy
    • Providing a therapeutic environment will help increase patients awareness of feelings, increase sense of responsibility and help him to return to community
    • Client plans social and group interactions
    • Group therapy
    • Relationship is recreated among group members
    • Members meet regularly with a leader to form a stable group
    • Members learn new ways to cope with stress and develop insight into their behaviors with others
  • 12.
    • Family therapy
    • Problem is a family problem not an individual one
    • Therapist treats the whole family
    • Help members to develop their own sense of identity
    • Activity therapy
    • Important group interactions occur when group members work on a task together
    • Organized group activities r created to promote socialization and increase self esteem
  • 13.
    • Play therapy
    • Children express themselves more easily in play than in verbal communication
    • Choice of colors, toys, interaction with toys reflects child’s situation in family
    • Provide materials and toys to facilitate interaction with child, observe play, and child to resolve problems through play
  • 14. Behavior therapy and behavior modification
    • Psychological problems r result of learning
    • Deficiencies can be corrected through learning
    • Operant conditioning : use of rewards to reinforce positive behavior
    • Desensitization used to treat phobias. Patient slowly adjusts to threatening objects
  • 15.
            • ANXIETY
    • Feeling of dread or fear in the absence of an external
    • threat or disproportionate to the nature of threat
    • Assessment
    • Cardiovascular
    • Increased pulse, BP, respiration
    • Palpitations, chest discomfort or pain
    • Perspiration, flushing and heat sensations
    • Cold hands and feet
    • headache
  • 16.
    • Gastrointestinal
    • Nausea, Vomiting, Diarrhea
    • Belching, heart burns, cramps
    • Musculoskeletal
    • Increased muscle tension and tendon reflexes
    • Increased generalized fatigue
    • Tremors jerking of limbs
    • Unsteady voice
    • Intellectual
    • Poor comprehension, poor concentration, selective attention
    • Impaired problem solving
    • Unable to communicate : distorted, disconnected thought and impaired logic
    • Rapid high pitched speech
  • 17.
    • Social and emotional
    • Feelings of helplessness and hopelessness
    • Feelings of increased threat, dread, horror, anger and rage
    • Use of defense mechanisms and more primitive coping behaviors such as
      • shouting, arguing, hitting , kicking
      • crying, rocking, curling up and withdrawal
  • 18.
    • Analysis
    • Definition
    • Feeling of dread or fear in the absence of an external threat or disproportionate to the nature of threat
    • Predisposing conditions
    • Prolonged unmet needs of dependency, security, love and attention
    • Stress threatening security or self esteem
    • Unacceptable thoughts or feelings surfacing to consciousness eg rage, erotic impulses, flashbacks
  • 19. Levels of anxiety Mild : high degree of alertness, mild uneasiness Moderate : heart pounds, skin cold and clammy, poor comprehension Severe : hallucinations and delusions Panic : inability to see and hear, inability to function
  • 20. Assess level of anxiety
    • Look at body language, speech patterns, facial expressions, defense mechanism and behavior used
    • Distinguish levels of anxiety
    Nursing interventions in anxiety
  • 21. Keep environmental stresses low when anxiety is high
    • Pleasant, attractive uncluttered environment
    • Provide privacy if presence of other patients is stimulating
    • Provide physical care when necessary
    • Avoid offering several alternatives or decisions when anxiety is high
    • Intervene if anxiety is severe or panic
    • Provide brief orientation to unit or procedures
    • Provide written information to read when anxiety is lower
  • 22. Assist client to cope with anxiety more effectively
    • Acknowledge anxious behavior: reflect and clarify
    • Always remain with client
    • Assist client to clarify own thoughts and feelings
    • Encourage measures to reduce anxiety eg exercise, activities, talking with friends, hobbies
    • Assist client to recognize his strengths and capabilities realistically
    • Provide therapy to develop more effective coping and interpersonal skills eg individual or group
    • May need to administer antianxiety medications
  • 23. Maintain accepting and helpful attitude towards client
    • Use an unhurried approach
    • Acknowledge client’s distress and concerns about problem
    • Encourage clarifications of feelings and thoughts
    • Evaluate and manage own anxiety when working with the client
    • Recognize the value of defense mechanisms and realize that client is attempting to make the anxiety tolerable in the best possible way
    • Acknowledge defense but provide reality
    • Do not attempt to remove a defense mechanism at any time
  • 24. Anxiety disorders Type Assessments Nursing Mx PHOBIA
    • Apprehension, anxiety, helplessness when confronted with phobic situation
    • Acrophobia – heights
    • Claustrophobia –closed spaces
    • Agoraphobia - open spaces
    • Avoid confrontation and humiliation
    • Do not focus on getting patient to stop being afraid
    • Systematic desensitization
    • Relaxation techniques
    • antidepressants
  • 25. Type Assessments Nursing Mx OCD Obsession- repetitive, uncontrollable thoughts Compulsion - repetitive uncontrollable acts e.g. rituals
    • Accept ritualistic behavior
    • Structure environment
    • Provide for physical needs
    • Offer alternative activities esp ones using hands
    • Guide decisions, minimize choices
    • Encourage socialization
    • Group therapy
    • Clomipramine (anafranil)
    • Stimulus -response prevention
  • 26. Type Assessments Nursing Mx Conversion hysteria Physical symptoms with no organic basis- blindness, paralysis, Convulsions without loss of consciousness “ La belle indifference” Stocking and glove anesthesia
    • Diagnostic evaluation
    • Discuss feelings rather than symptoms
    • Promote therapeutic relationship
    • Avoid secondary gain
  • 27.
          • Defense mechanisms
    • Denial : an alcoholic says he does have an alcoholic problem
    • Displacement : yelling at dog when angry with boss
    • Projection: blaming others
    • Undoing : apologizing excessively
    • Compensation : small person excel in sports
  • 28. Substitution : marrying someone who looks like previous significant other Introjection : blaming oneself when angry with others Repression : inability to remember a traumatic event (unconsciously) Reaction formation : being good to someone u don’t like
  • 29. Regression : bedwetting, babytalk Dissociation : detachment of painful emotional conflict from consciousness Suppression : deciding not to deal with something unpleasant until next day
  • 30.
    • Assessment
    • Stages of crisis
    • Denial
    • Increased tension, anxiety
    • Disorganization, inability to function
    • Attempts to reorganize
    • Attempts to escape the problem pretends problem doesn’t exist, blames others
    • General reorganization
  • 31.
          • Precipitating factors
    •      Development
    • 1) Birth, adolescence
    • 2) Midlife, retirement
    •     Situational
    • 1) Natural disasters
    • 2) Financial loss
    • Threats of self- concept
    • 1) Loss of job
    • 2) Failure at school
    • 3) Onset of serious illness
  • 32.
    • Analysis
    • Characteristics
    • Temporary state of disequilibrium precipitated by an event
    • Self-limiting – usually 4-6 weeks
    • Crisis can promote growth and new behaviors
    • Potential diagnoses
    • Individual coping ineffective
    • Powerlessness
    • Grieving, dysfunctional
    • Plan/Implementations
    • Goal-directed, focus on the here and now
    • Focus on client’s immediate problems
  • 33.
    • Explore nurse’s and client’s understating of the problem
    • Define the event (client may truly not know what has precipitated the crisis)
    • Confirm nurse’s perception by reviewing with client
    • Identify the factors that are affecting problem-solving
    • Evaluate how realistically client sees the problems or concerns
    • Help client become aware of feelings and validate them
    • Acknowledge feelings
    • Avoid blaming client
    • Encourage ventilation
    • Tell client he will feel better but it will take 1 or 2 months
  • 34.
    • Develop a plan
    • Encourage client to make as many arrangements as possible, avoid dependence
    • Write out information as comprehension is impaired
    • Maximize clients situational supports
    • Find new coping skills and manage feelings
    • Focus on strengths and present coping skills
    • Encourage client to form new social outlets
    • Facilitate future planning
    • Ask client “what would u like to do?”, “where would u like to go from here?”
    • Give referrals family and vocational counseling
  • 35. Situational crises Grieving patient Dying patient Rape trauma A S S E S S M E N T
    • Stages of grief
    • Shock and disbelief
    • Awareness of the pain of loss
    • Restitution
    • Actual grief period- 4 to 8 weeks
    • Usual resolution within 1 year
    • Long term resolution over time
    Stages of dying DABDA
    • Stages of crises
    • Acute reaction lasts 3-4 weeks
    • Reorganization is long term
    • Common responses to rape
    • Self blame, embarrassment
    • Anxiety, insomnia
    • Phobia fear of violence
    • wish to escape, move, relocate
    • Psychosomatic disturbances
  • 36. Grieving patient Dying patient Rape trauma A N A L Y S I S Potential Problems Family guilt, anger, anxiety Patient anger, withdrawal, guilt, anxiety, loss of role
    • Avoidance behavior
    • Inability to express feelings when in denial
    • Feelings of guilt
    • Withdrawal, lonely, frightened
    • Anxiety of patient and family
    • Fears, panic reactions, generalized anxiety
    • Guilt, inability to cope
    • Current crises may reactivate old unresolved trauma
    • Follow emergency protocol
    • Be alert for internal injuries
  • 37. Nursing interventions
    • Grieving patient
    • Apply crises theory
    • Focus on here and now
    • Provide support to family
    • Provide family privacy
    • Encourage verbalization of feelings
    • Facilitate expression of anger and rage
    • Emphasize strengths increase ability to cope
    • Support adjustments to illness loss of body part
  • 38.
    • Dying patient
    • Keep communication open
    • Let patient know he is not alone
    • Provide comforting environment
    • Provide privacy
    • Physical care
    • Give sense of control and dignity
    • Respect patient’s wishes
  • 39.
    • Rape trauma
    • Write out Tx and appointments for client
    • Record all information in chart
    • Refer for legal assistance, support psychotherapy
    • Follow up regularly until client is improved
  • 40.
    • Assessment
    • Exposure to traumatic event : rape, murder, fire
    • Response to trauma causes intense fear
    • Recurrent or distressing recollection of event
    • Distressing dreams or nightmares
    • Acting or feeling like the trauma is recurring (flashbacks)
    • Hyper vigilance and exaggerated startle response
    • Irritable or outbursts of anger
    • Avoidance or numbing
  • 41.
    • Analysis
    • Duration of symptoms is atleast one month
    • Syndrome can emerge months to years after traumatizing event
    • Biological changes due to impact of stressor and excessive arousal of sympathetic nervous system
  • 42.
    • Planning
    • 1. Help client integrate the traumatic experience
    • Encourage client to talk about painful stored memories
    • have client recall images of traumatic event with as much detail as possible: flooding
    • use empathetic responses to the expressed distress
    • remain nonjudgmental
    • allow client to grieve over losses
  • 43.
    • Assist client to challenge existing ideas about event and substitute more realistic thoughts and expectations
    • Point out irrational thinking to the client
    • Help client recognize the limits of his control over the stressful event
    • 2. Assist client with emotional regulations
    • Help client label his feelings and find ways to express them safely
    • Teach stress management techniques
  • 44.
      • Involve client in anger Mx program
    • Recognize anger as normal feeling
    • Teach time out or other ways of walking away from problematic situations involving anger
    • Teach nonintrusive communication techniques
        • speak in first person
        • Move away from object of anger
        • Cognitive restructuring eg using thoughts like this person cannot make me lose control
  • 45.
    • Develop a schedule of regular physical activity with client: walking, running
    • Use empowering strategies such as keeping a journal of disturbed thoughts and feelings in response to flashbacks or other problems
    • Teach methods to reduce sleep disturbances
    • regular bedtime
    • Use bed for sleeping and lovemaking exclusively. No TV or reading
    • Do not lie in bed sleepless for more than half an hour: get up and move around and then come back to bed
  • 46.
    • 3. Enhance the clients support systems
    • Refer to self help group
    • Include family and friends in psychoeducational activities
    • Explore opportunities for socialisation
    • 4. Educate client regarding the recovery process
    • Assess for and treat substance abuse
    • Administer antidepressants
  • 47. Thanks