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Continuation of the Nursing Process

ECT (electroconvulsive therapy) has been used for over 50 years to treat various psychiatric conditions. It involves inducing a seizure through electrical stimulation of the brain. Common side effects include temporary memory loss and confusion. Nursing interventions involve explaining the procedure, monitoring the client during and after treatment, and providing support and structure to minimize confusion. Psychotherapy can promote confidence and functioning through trust and communication. Individual and group therapies are used, with the latter involving clients interacting to benefit each other. Complementary therapies like yoga, meditation, and herbal medicines are also used in psychiatric treatment.

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NCM 105 PSYCHIATRIC-MENTAL HEALTH NURSING-PART 2 Psychiatric Nursing Practice – The Nursing Process Lectured by Leila T. Salera, RN, MD, DPSP
ECT – ELECTROCONVULSIVE THERAPY
ECT  Has been used continuously for more than 50 years  The induction of a grand mal seizure through the application of electrical current to the brain  Duration of seizure should be at least 25 seconds (Sadock and Sadock)  Most clients require an average of 6 to 12 treatments  Some may require up to 20 treatments  Administered usually every other day, three times per week  Performed on an inpatient basis for those that require close observation and care (suicidal, agitated, delusional, catatonic, or acutely manic) ( Townsend Chapter 22; Student Guide, pages 53 to 56)
ECT  Indications: a. Major depression – not often the treatment of choice but is considered only after a trial of therapy with antidepressant medication has proven ineffective b. Mania – rarely used for this purpose; for those who do not tolerate or fail to respond to lithium or other drug treatment, or when life is threatened by dangerous behavior or exhaustion c. Schizophrenia – can induce remission in some clients with acute schizophrenia, particularly if it is accompanied by catatonic or affective symptomatology; no value among clients with chronic shizophrenia ( Townsend Chapter 22; Student Guide, pages 53 to 56)
ECT  Other conditions it is being used: a. Neuroses b. OCD – obsessive compulsive disorder c. Personality disorder d. Postpartum psychoses  Mechanism of action (theories) a. Electrical stimulation results in significant increases in the circulating levels of several neurotransmitters (serotonin, NE, and dopamine) which are affected by antidepressant drugs b. May also result in increases in glutamate and GABA ( Townsend Chapter 22; Student Guide, pages 53 to 56)
ECT  Side effects a. Temporary memory loss and confusion (most common) b. Permanent memory loss (?) c. Occasional cardiac dysrhythmias d. Brain damage – 2 per 100,000 treatments ( Townsend Chapter 22; Student Guide, pages 53 to 56)
ECT  Nursing interventions prior to ECT a. Explain the procedure b. NPO for 8 hours (after midnight) c. Have consent signed d. Ensure labs and diagnostic examinations are all done results available: CBC, urinalysis, X-ray e. Empty bowel and bladder f. Take vital and record signs approximately 1 hour prior to treatment is scheduled g. Client should remain in bed with side rails up ( Townsend Chapter 22; Student Guide, pages 53 to 56)
ECT  Nursing interventions prior to ECT h. Client should be changed into a hospital gown i. Administer premedications 30 minutes prior to treatment – atropine or glycopyrolate (anticholinergics) IM j. Remove anything conductive k. Stay with client to allay fears and anxiety l. Maintain a positive attitude m. Encourage verbalization of feelings n. Ensure airway patency o. Restraints as necessary ( Townsend Chapter 22; Student Guide, pages 53 to 56)
ECT  Nursing interventions during ECT a. Provide suctioning as needed b. Assist anesthesiologist with oxygenation as required c. Observe readouts on machines monitoring vital signs and cardiac functioning d. Provide support to the client’s arms and legs during the seizure e. Observe and record the type and amount of movement induced by the seizure ( Townsend Chapter 22; Student Guide, pages 53 to 56)
ECT  Nursing interventions after ECT f. Allow the client to verbalize fears and anxieties related to receiving ECT g. Stay with the client until he or she is fully awake, oriented, and able to perform self-care activities without assistance h. Provide the client with a highly structured schedule of routine activities in order to minimize confusion ( Townsend Chapter 22; Student Guide, pages 53 to 56)
PSYCHOTHERAPY
PSYCHOTHERAPY  Any procedure that promotes the development of courage, inner security and self confidence making the person more functional  Most important element is trust and communication  A form of mental exploration that should be individualized ( Student Guide, pages 58 to 60)
INDIVIDUAL PSYCHOTHERAPY  Method of bringing about change in a person by exploring his or her feelings, attitudes, thinking, and behavior  Involves one-to-one relationship between the therapist and the client  Therapist’s theoretical beliefs strongly influence his or her style of therapy  Nurse or other health care provider who is familiar with the client may be in a position to recommend a therapist or a choice of therapists (Videbeck pages 56 to 61)
GROUP THERAPY  Clients participate in sessions with a group of people  The members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in return  Group rules are established, which all members must observe, which vary according to the type of group (Videbeck pages 56 to 61)
GROUP THERAPY  The therapeutic results of group therapy include the following: a. Gaining new information, or learning b. Gaining inspiration or hope c. Interacting with others d. Feeling acceptance and belonging e. Becoming aware that one is not alone and that others share the same problems f. Gaining insight into one’s problems and behaviors and how they affect others g. Giving of oneself for the benefit of others (altruism) (Videbeck pages 56 to 61)
GROUP THERAPY  Psychotherapy groups 1. Family therapy 2. Family education 3. Education groups 4. Support groups 5. Self-help groups (Videbeck pages 56 to 61)
PSYCHOTHERAPY GROUPS  Goal: for members to learn about their behavior and to make positive changes in their behavior by interacting and communicating with others as a member of a group  Often formal in structure, with one or two therapists as the group leaders  Two types a. Open groups – ongoing and run indefinitely, allowing members to join or leave the group as they need to b. Closed groups – structured to keep the same members in the group for a specified number of sessions; members decide how to handle members who wish to leave the group and the possible admission of new group members (Videbeck pages 56 to 61)
PSYCHOTHERAPY GROUPS-FAMILY THERAPY  A form of group in which the client and his or her own family members participate  The goals include understanding how family dynamics contribute to the client’s psychopathology, mobilizing the family’s inherent strengths and functional resources, restructuring maladaptive family behavioral styles, and strengthening family behavioral styles, and strengthening family problem-solving behaviors  Can be used both to assess and to treat various psychiatric disorders (Videbeck pages 56 to 61)
PSYCHOTHERAPY GROUPS-FAMILY EDUCATION  A unique 12-week Family-to-Family Education Course developed by the National Alliance for the Mentally Ill (NAMI)  Taught by trained family members, the curriculum focuses on schizophrenia, bipolar disorder, clinical depression, panic disorder, and obsessive- compulsive disorder  Discusses clinical treatment of these illnesses and teaches knowledge and skills that family members need to cope more effectively (Videbeck pages 56 to 61)
PSYCHOTHERAPY GROUPS-EDUCATION GROUPS  Goal is to provide information to members on a specific issue-for instance, stress management, medication management, or assertiveness training  The group leader has expertise in the subject area and may be a nurse, therapist, or other health professional  Usually scheduled for a specific number of sessions and retain the same members for the duration of the group (Videbeck pages 56 to 61)
PSYCHOTHERAPY GROUPS-SUPPORT GROUPS  Organized to help members who share a common problem to cope with it  The group leader explores members’ thoughts and feelings and creates an atmosphere of acceptance so that members feel comfortable expressing themselves  Often provide a safe place for members to express their feelings of frustration, boredom, or unhappiness and also discuss common problems and potential solutions (Videbeck pages 56 to 61)
PSYCHOTHERAPY GROUPS-SELF-HELP GROUPS  Members share a common experience, but the group is not a formal or structured therapy group  Professionals organize some self-help groups, many are run by members and do not have a formally identified leader  Examples: Alcoholics Anonymous (AA), Parents Without Partners, Gamblers Anonymous, and Al- Anon (a group of spouses and partners of alcoholics)  Some have national headquarters and Internet websites  Most have a rule of confidentiality (Videbeck pages 56 to 61)
COMPLEMENTARY AND ALTERNATIVE THERAPIES  Alternative medical systems – yoga, herbal medicines, acupuncture, etc…  Mind-body interventions – meditation, prayer. Mental healing, and creative therapies that use art or music  Biologically based therapies – use substances found in nature, such as herbs, food, vitamins  Manipulative and body-based therapies – therapeutic massage and chiropractic or osteopathic manipulations  Energy therapies – two types: a) biofield therapies, intended to affect energy fields that are believed to surround and penetrate the body (therapeutic touch, qi gong, Reiki) and b) bioelectric-based therapies, involving use of electromagnetic fields, such as pulse fields, magnetic fields, and AC or DC fields (Videbeck, pages 56 to 61)
PSYCHIATRIC REHABILITATION  Involves providing services to people with severe and persistent mental illness to help them to live in the community  Often called community support programs  Focuses on the client’s strengths, not just on the illness  Client actively participates in program planning  Programs are designed to help the client manage the illness and symptoms, gain access to needed services, and live successfully in the community (Videbeck, pages 56 to 61)
PSYCHOSOCIAL INTERVENTIONS  Nursing activities that help enhance the client’s social and psychological functioning and improve social skills, interpersonal relationships, and communication (Videbeck, pages 56 to 61; Student Guide, pages 58 to 59 and 72 to 82)
COMMUNITY-BASED CARE – WHO/DOH  Mental Health Sub-Programs A. Wellness of Daily Living B. Extreme Life Experiences C. Mental Disorder D. Substance Abuse Disorder (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE – WHO/DOH  Home care is advocated  Acute cases are referred to the National Center for Mental Health (NCMH) or hospitals with psychiatric facilities for proper management  They are screened and after a few days they are assessed and discharged if they can be managed at home  Cases needing continuing supervision and care may be confined  A team from the NCMH follow up their discharged patients in the provinces (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE- WELLNESS OF DAILY LIVING  Wellness of Daily Living – The process of attaining and maintaining mental well-being across the life cycle through the promotion of healthy lifestyle with emphasis on coping with psychosocial issues  Objectives: 1. To increase awareness among the population on mental health and psychosocial issues 2. To ensure access of preventive and promotive mental health services  (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE- EXTREME LIFE EXPERIENCES  Objectives: 1. To differentiate between critical incident and extreme life experiences 2. To identify situations which may be extreme life experiences 3. To categorize/prioritize the extreme life experience which may be the concern of mental health 4. To identify programs that could address psychosocial consequences and mental health issues of persons with extreme life experiences  (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE- MENTAL DISORDER  Objectives: 1. Promotion of mental health and prevention of mental illness across the lifespan and across sectors (children and adolescents, adults elderly, and special population such as military, OFWs, refugees, persons with disabilities)  (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In mental health promotion 1. Participate in the promotion of mental health among families and the community 2. Utilize opportunities in his/her everyday contacts with other members of the community to extend the general knowledge on mental hygiene 3. Help people in the community understand basic emotional needs and the factors that promote mental well being 4. Teach parents the importance of providing emotional support to their children during critical periods in their lives like first day in school graduation, etc…  (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In prevention and control 1. Recognize mental health hazards and stress situations as unemployment, divorce or abandonment of children, vices, long standing physical illness, all of which make heavy demands on the emotional resources of the persons concerned 2. Recognize pathological deviations from normal in terms of acting, thinking and feeling and make early referral so that diagnosis and treatment could be done early. 3. Be aware of potential causes of breakdown and when necessary take some possible preventive action.  (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In prevention and control 4. Help the family to understand and accept the patient’s health status and behavior sp that all its members may offer as much support in the readjustments to home and community 5. Help patient assess his/her capacities and his/her handicaps in working towards a solution of his/her problem 6. Encourage feeling of achievement by setting health goals that patient can attain 7. Encourage the patient to express his/her anxieties so that fears and misconceptions can be cleared up  (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In prevention and control 8. Impart information and guidance about the treatment scheme of the patients, the desired and undesirable effect of the tranquilizers, psychiatric emergency management and other nursing care  (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  Rehabilitation 1. Initiate patient participation in occupational activities best suited to patient’s capabilities, education, experience and training, capacities and interest 2. Encourage and initiate patients to partake in activities of CIVIC organization in the community through the cooperation of the patient’s family 3. Advise the family about the importance of regular follow-up at the clinic 4. Make regular home visits to observe patients’ conditions during conversation and follow-up of medication  (Public Health Nursing in the Philippines, 2007, pages 231)
COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In research and epidemiology 1. Participate actively in epidemiological survey to be aware of the size and extent of mental health problems in the community and to organize a program for better preventive, curative and rehabilitative measures.  (Public Health Nursing in the Philippines, 2007, pages 231)
STANDARD 6 - EVALUATION  The psychiatric-mental health nurse evaluates progress toward attainment of expected outcomes  The continuous or ongoing phase of nursing process is evaluation.  Nursing care is a dynamic process involving change in the patient’s health status over time, giving rise to the need of new data, different diagnosis, and modifications in the plan of care. (Videbeck, page 10; The Internet)
STANDARD 6 - EVALUATION  When evaluating care the nurse should review all previous phases of the nursing process and determine whether expected outcome for the patient have been met.  This can be done checking: 1. Have I done everything for my patient? 2. Is my patient better after the planned care?  Evaluation is a feed back mechanism for judging the quality of care given.  Evaluation of the patient’s progress indicates what problems of the patient have been solved, which need to be assessed again, replanted, implemented and re- evaluated. (Videbeck, page 10; The Internet)
AREAS OF PRACTICE  Basic-Level Functions a. Counseling b. Milieu therapy c. Self-care activities d. Psychobiologic interventions e. Health teaching f. Case management g. Health promotion and maintenance  Advanced-Level Functions a. Psychotherapy b. Prescriptive authority for drugs (US) c. Consultation and liaison d. Evaluation e. Program development f. And management g. Clinical supervision (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Student concerns are normal  Usually do not persist once the students have initial contacts with clients  Some common concerns and helpful hints for beginning students: “What is I say the wrong thing?” - No one magic phrase can solve a client’s problems; likewise, no single statement can significantly worsen them - Listening carefully, showing genuine interest, and caring about the client are extremely important (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “What will I be doing?” - In the mental health setting, many familiar tasks and responsibilities are minimal - Physical care skills or diagnostic tests and procedures are fewer than those conducted in a busy medical- surgical setting - The student must deal with his or her own anxiety about approaching a stranger to talk about very sensitive and personal issues - Development of the therapeutic nurse-client relationship takes time and patience (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “What if no one will talk to me?” - Students sometimes fear that they will be rejected by the client - Some clients may not want to talk, or are reclusive, but may show that same behavior with experienced staff - Students should not see such behavior as a personal insult or failure (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “Am I prying when I ask personal questions?” - Personal questions should not be the first thing a student says to the client - These issues usually arise after some trust and rapport have been established - Ask sincere questions (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “Ho will I handle bizarre or inappropriate behavior?” - It is important to monitor one’s facial expressions and emotional responses so that clients do not feel rejected or ridiculed - The nursing student instructor and staff are always available to assist the student in such situations - Students should never feel as if they have to handle situations alone (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior?” - Some clients have difficulty recognizing or maintaining interpersonal boundaries - When client seeks contact of any type outside the nurse-client relationship, it is important for the student (with the assistance of the instructor or staff) to clarify the boundaries of the professional relationship (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior?” - Likewise, setting limits and maintaining boundaries are needed when a client’s behavior is sexually inappropriate - Initially, the student might be uncomfortable dealing with such behavior, but with practice and the assistance of the instructor and staff, it becomes easier to manage (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior?” - It is also important to protect the client’s privacy and dignity when he or she cannot do so (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “Is my physical safety in jeopardy?” - Actually, clients hurt themselves more often than they harm others - Staff members usually closely monitor clients with a potential for violence for clues of an impending outburst - When physical aggression does occur, staff members are specially trained to handle aggressive clients in a safe manner (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “What if I encounter someone I know being treated in the unit?” - It is essential that the client’s identity and treatment be kept confidential - If the student recognizes someone he or she knows, the instructor must be notified, and the instructor will decide on the situation - Always reassure client that all will be kept confidential and the student will be reassigned (Videbeck, pages 11 to 12)
STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “What if I recognize that I share problems or backgrounds with clients?” - No easy way to answer this question - We do not always know why some people have serious emotional problems, while others do not, and yet they have similar life experiences - Self-awareness is key (Videbeck, pages 11 to 12)
SELF-AWARENESS  The process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes  In nursing, being aware of one’s feelings, thoughts, and values is a primary focus  What would you do if you were assigned to a client who just had an abortion, and you are strong believer of anti-abortion?  Will your personal feelings and beliefs interfere with your work?  The nurse needs to discover him/herself and what he/she believes before trying to help others with different views (Videbeck, pages 11 to 12)
SELF-AWARENESS- POINTS TO CONSIDER  Keep a dairy or journal that focuses on experiences and related feelings  Talk with someone you trust about your experiences and feelings  Engage in formal clinical supervision. Even experienced clinicians have a supervisor with whom they discuss personal feelings and challenging client situations to gain insight and new approaches  Seek alternative points of view. Put yourself in the client’s situation and think about his or her feelings, thoughts, and actions (Videbeck, pages 11 to 12)
SELF-AWARENESS- POINTS TO CONSIDER  Do not be critical of yourself (or others) for having certain values or beliefs. Accept them as a part of yourself, or work to change those values and beliefs you wish to be different (Videbeck, pages 11 to 12)
THERAPEUTIC RELATIONSHIPS  The ability to establish therapeutic relationships with clients is one of the most important skills a nurse can develop  The therapeutic relationship is especially crucial to the success of interventions with clients requiring psychiatric care because the therapeutic relationship and the communication within it serve as the underpinning for treatment and success (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Trust  Genuine interest  Empathy  Acceptance  Positive regard  Self awareness and Therapeutic use of self (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Trust 1. Trust is built in the nurse-client relationship when the nurse exhibits the following behaviors: a. Caring b. Openness c. Objectivity d. Respect e. Interest f. Understanding g. Consistency h. Treating the client as a human being i. Suggesting without telling j. Approachability k. Listening l. Keeping promises m. Honesty (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Trust 2. Congruence – occurs when words and actions match  Genuine interest 1. The client perceives this when the nurse is comfortable with him/herself and is aware of his strengths and limitations, and is focused 2. A client with mental illness can detect when someone is exhibiting dishonest or artificial behavior (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Empathy 1. The ability to perceive the meanings of feelings of the client and to communicate that understanding to the client 2. Being able to put him/herself in the client’s shoes  Acceptance 1. The nurse does not become upset or respond negatively to a client’s outbursts, anger, or acting out 2. Avoiding judgment (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Positive regard 1. The nurse is able to appreciate the client as a unique worthwhile human being 2. The nurse can respect the client regardless of his or her own behavior 3. Unconditional nonjudgmental attitude  Self-awareness 1. The nurse must first know him/herself before he or she can attend to a client 2. What are your values, attitudes, and beliefs? (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Therapeutic use of self 1. Self-awareness has been developed 2. The nurse can use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Genuine interest Client: “I’m so confused! My son just visited and wants to know where the safety deposit box key is.” Nurse: “You’re confused because your son asked for the safety deposit box key?” (using reflection) or Nurse: “Are you confused about the purpose of your son’s visit?” (using clarification)
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Acceptance Client: puts his arm around the nurse’s waist Appropriate response conveying acceptance but not allowing the inappropriate behavior of the client to continue: “ Sir, do not place your hand on me. We are working on your relationship with your girlfriend and that does not require you to touch me. Now, let’s continue.” Inappropriate response: “ Sir, stop that! What’s wrong with you? I am leaving, and maybe I’ll return tomorrow.”
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Positive regard Client: I was so mad, I yelled and screamed at my mother for an hour.” Which conveys positive regard or are appropriate responses by the nurse? a. “Well that didn’t help did it?” b. “I can’t believe you did that.” c. “What happened then?” d. “You must really be upset.”
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Positive regard Client: I was so mad, I yelled and screamed at my mother for an hour.” Which conveys positive regard or are appropriate responses by the nurse? a. “Well that didn’t help did it?” b. “I can’t believe you did that.” c. “What happened then?” d. “You must really be upset.”
COMPONENTS OF A THERAPEUTIC RELATIONSHIPS  Therapeutic use of self - Johari Window 1. A “words portrait” of a person in four areas 2. Each area indicates how well that person knows him/herself and communicated with others  Patterns of knowing - Nurse theorist Hildegard Peplau (1952) identified preconceptions, or ways one person expects another person to behave or speak, as a roadblock to the formation of an authentic relationship (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
TYPES OF RELATIONSHIPS  Social relationship – primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task  Intimate relationship – involves two people who are emotionally committed to each other  Therapeutic relationship – focuses on needs, experiences, feelings, and ideas of the client only (Videbeck pages 86 to 87) (Student Guide pages 59 to 69)
ESTABLISHING THE THERAPEUTIC RELATIONSHIP  Phases: 1. Orientation phase 2. Working phase a. Problem identification subphase b. Exploitation subphase 3. Termination phase (Videbeck pages 87 to91) (Student Guide pages 59 to 69)
ESTABLISHING THE THERAPEUTIC RELATIONSHIP  Phases: 1. Orientation phase a. Begins when then nurse and client meet and ends when the client begins to identify problems to examine b. The nurse establishes the roles, the purpose of meeting, and the parameters of subsequent meetings c. Identifies client’s problems d. Clarifies expectations (Videbeck pages 87 to 91) (Student Guide pages 59 to 69)
ESTABLISHING THE THERAPEUTIC RELATIONSHIP  Phases: 2. Working phase a. Problem identification subphase – the client identifies the issues or concerns causing problems b. Exploitation subphase – the nurse guides the client to examine feelings and responses and develop better coping skills and a more positive self-image, to encourage behavior change and develop independence (Videbeck pages 87 to 91) (Student Guide pages 59 to 69)
ESTABLISHING THE THERAPEUTIC RELATIONSHIP  Phases: 3. Termination phase a. Also known as the resolution phase b. The final stage of the nurse-client relationship c. It begins when the problem is resolved d. Ends when the relationship is ended (Videbeck pages 87 to 91) (Student Guide pages 59 to 69)
THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION  Therapeutic communication - Is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information - Helps the nurse understand and empathize with the client’s experience (Videbeck, page 98 to 116)
THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION  Therapeutic communication - Goals: 1. Establish a therapeutic nurse-client relationship 2. Identify the most important client concern at that moment (the client-centered goal) 3. Assess the client’s detailed actions as it unfolds 4. Facilitate the client’s expression of emotions 5. Teach the client and family necessary self-care skills 6. Recognize the client’s needs 7. Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution (Videbeck, page 98 to 116)
THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION  Therapeutic communication - Privacy and Respecting Boundaries 1. Privacy is desirable, but not always possible in a therapeutic communication 2. Proxemics – the study of distance zones between people during communication a. Intimate zone – 0 to 18 inches between people; parents and young children, people who mutually desire personal contact b. Personal zone – 19 to 36 inches; between family and friends who are talking c. Social zone – 4 to 12 feet; acceptable for communication in social, work, and business settings d. Public zone – 12 to 25 feet; speaker and audience, small groups, and other informal functions (Videbeck, page 98 to 116)
THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION  Therapeutic communication 1. Verbal communication – uses concrete messages and abstract messages 2. Non-verbal communication – body language, eye contact, facial expression, tone of voice, speed and hesitations in speech, grunts and groans, and distance from the listeners (Videbeck, page 98 to 116)
THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION  Therapeutic communication 1. Touch a. Functional-professional touch b. Social-polite touch c. Friendship-warmth touch d. Love-intimacy touch (Videbeck, page 98 to 116)
THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION  Therapeutic communication 1. Concrete messages – the words are explicit and need no interpretation 2. Abstract messages – requires interpretation by the listener like figure of speeches (Videbeck, page 98 to 116)
THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION  Therapeutic communication Concrete messages “What health problems caused you to come to the hospital today?” Abstract messages “How did you get here?” The terms “how” and “here” are vague. To an anxious client who is not thinking clearly: “Where am I?” or “The ambulance brought me here?” (Videbeck, page 98 to 116)
THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION Therapeutic communication Abstract (unclear): “Get the stuff from him.” Concrete (clear): “He’ll be home today at 5pm, and you can pick up your clothes at that time.” Abstract (unclear): “Your clinical performance has improved.” Concrete (clear): “To administer medications tomorrow, you’ll have to be able to calculate dosages correctly by the end of today’s class.” (Videbeck, page 98 to 116)
THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION  Non-Therapeutic communication a. Should be avoided b. These responses cut off the communication and make it more difficult for the interaction to continue c. Asking “why” questions may be perceived as criticism by the client, conveying a negative judgment from the nurse (Videbeck, page 98 to 116)
THERAPEUTIC COMMUNICATION TECHNIQUES  Accepting – indicating reception, you are listening and you have followed the train of thought “Yes” or “I follow what you said” or simply nodding  Broad opening – allowing the client to take the initiative in introducing the topic, makes the client feel that he or she has the lead interaction “Is there something you’d like to talk about?”  Consensual validation – searching for mutual understanding, for accord in the meaning of the words; to avoid any misunderstanding “Tell me whether my understanding of it agrees with yours.”
THERAPEUTIC COMMUNICATION TECHNIQUES  Encouraging comparison – asking that similarities and differences be noted “ Was it something like…?”  Encouraging description of perception – asking the client to verbalize what he or she perceives “What is happening?’  Encouraging expression – asking the client to appraise the quality of his or her experiences “Tell me more about that.”  Focusing – concentrating on a single point “Of all you’ve mentioned, which is the most troublesome?”
THERAPEUTIC COMMUNICATION TECHNIQUES  Formulating a plan of action – asking the client to consider kinds of behavior likely to be appropriate in the future  General leads – giving encouragement to continue  Giving information – making available the facts that the client needs  Giving recognition – acknowledging, indicating awareness “Good morning, sir.” “I noticed that you’ve combed your hair.”
THERAPEUTIC COMMUNICATION TECHNIQUES  Making observations – verbalizing what the nurse perceives “You appear tense.”  Offering self – making oneself available “I’ll stay here with you for a while.”  Placing event in time or sequence – clarifying the relationship of events in time “When did this happen?”  Presenting reality – offering for consideration that which is real “I see no one else in the room.”
THERAPEUTIC COMMUNICATION TECHNIQUES  Reflecting – directing the client actions, thoughts, and feelings back to the client Client: “Do you think I should tell the doctor…?” Nurse: “Do you think you should?”  Restating – repeating the main idea expressed Client: “I can’t sleep. I stay awake all night.” Nurse: “You have difficulty sleeping.”  Seeking information – seeking to make clear that which is not meaningful or that which is vague Nurse: “I’m not sure I follow.” Nurse: “Have I heard you correctly.”
THERAPEUTIC COMMUNICATION TECHNIQUES  Silence – nurse says nothing but maintains eye contact  Suggesting collaboration – offering to share, to strive, and to work with the client to his or her benefit Nurse: “Let’s go to your room, and I’ll help you find what you’re looking for.”  Summarizing – organizing and summing up that which has gone before Nurse: “Have I got this straight.” Nurse: “You’ve said that…”
THERAPEUTIC COMMUNICATION TECHNIQUES  Translating into feelings – seeking to verbalize client’s feelings that he or she expresses only indirectly Client: “I’m dead.” Nurse: “Are you suggesting that you feel lifeless?”  Verbalizing the implied – voicing what the client has hinted or suggested Client: “I can’t talk to you or anyone. It’s a waste of time.” Nurse: “Do you feel that no one understands?”  Voicing doubt – expressing uncertainty about the reality of the client’s perceptions Nurse: “Really?”
NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Advising – telling client what to do Nurse: “I think you should….” or “Why don’t you…?”  Agreeing – indicating accord with the client  Belittling feelings expressed – misjudging the degree of the client’s discomfort  Challenging – demanding proof from the client  Defending – attempting to protect someone or something from verbal attack Nurse: “This hospital has a fine reputation.” or “I am sure your doctor has your best interests in mind.”
NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Disagreeing – opposing the client’s ideas  Disapproving – denouncing the client’s behavior or ideas; implies that the nurse has the right to pass judgment  Giving approval – sanctioning the client’s behavior or ideas; tends to limit the client’s freedom to think, speak, or act in a certain way, which could lead to the client acting a certain way just to please the nurse  Giving literal responses – responding to a figurative comment as though it were a statement of fact Client: “They’re looking in my head with a TV camera.” Nurse: “Try not to watch TV.” or “What channel?”
NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Indicating an existence of an external source – attributing the source of thoughts, feelings, and behavior to others or to outside influences Nurse: “What made you say that?” – implies that the client is compelled to think a certain way  Interpreting – asking to make conscious that which is unconscious, telling the client the meaning of his or her experience. The client’s thoughts and feelings are his own, hidden meaning are not meant for the nurse to discover, only the client knows. Nurse: “What you really mean is…” or “Unconsciously, you’re saying…”  Introducing an unrelated topic – changing the subject Client: “I’d like to die.” Nurse: “Did you have visitors this evening?”
NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Making stereotyped comments – offering meaningless clichés or trite comments Nurse: “It’s for your own good.” or “Just have a positive attitude and you’ll be better in no time.”  Probing – persistent questioning of the client Nurse: “Tell me about this problem. You know I have to find out.” or “Tell me your psychiatric history.”  Reassuring – indicating there is no reason for anxiety or other feelings of discomfort Nurse: “Everything will be alright.”
NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Rejecting – refusing to consider or showing contempt for the client’s ideas or behaviors’ This closes the chances of exploration, and the client may feel personally rejected along with feelings or ideas Nurse: “Let’s not discuss….” or “I don’t want to hear about…”  Requesting an explanation – asking the client to provide reasons for thoughts, feelings, behaviors, events. There is a difference between this and asking the client to describe what is occurring or has taken place, and usually a “why” question is intimidating Nurse: “Why do you think that?” or “Why do you feel that way?”
NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Testing – appraising the client’s degree of insight, which forces the client to recognize his or her problem. Helpful to the nurse, but not to the client Nurse: “Do you know what kind of hospital this is?” or “Do you still have the idea that….?”  Using denial – refusing to admit that a problem exists. This implies that the nurse dismisses the seriousness of the situation Client: “I’m nothing.” Nurse: “Of course you’re something – everybody’s something.” Client: “I’m dead.” Nurse: “Don’t be silly.”

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Continuation of the Nursing Process

  • 1.
    NCM 105 PSYCHIATRIC-MENTAL HEALTH NURSING-PART2 Psychiatric Nursing Practice – The Nursing Process Lectured by Leila T. Salera, RN, MD, DPSP
  • 2.
  • 3.
    ECT  Has been used continuously for more than 50 years  The induction of a grand mal seizure through the application of electrical current to the brain  Duration of seizure should be at least 25 seconds (Sadock and Sadock)  Most clients require an average of 6 to 12 treatments  Some may require up to 20 treatments  Administered usually every other day, three times per week  Performed on an inpatient basis for those that require close observation and care (suicidal, agitated, delusional, catatonic, or acutely manic) ( Townsend Chapter 22; Student Guide, pages 53 to 56)
  • 4.
    ECT  Indications: a. Major depression – not often the treatment of choice but is considered only after a trial of therapy with antidepressant medication has proven ineffective b. Mania – rarely used for this purpose; for those who do not tolerate or fail to respond to lithium or other drug treatment, or when life is threatened by dangerous behavior or exhaustion c. Schizophrenia – can induce remission in some clients with acute schizophrenia, particularly if it is accompanied by catatonic or affective symptomatology; no value among clients with chronic shizophrenia ( Townsend Chapter 22; Student Guide, pages 53 to 56)
  • 5.
    ECT  Other conditions it is being used: a. Neuroses b. OCD – obsessive compulsive disorder c. Personality disorder d. Postpartum psychoses  Mechanism of action (theories) a. Electrical stimulation results in significant increases in the circulating levels of several neurotransmitters (serotonin, NE, and dopamine) which are affected by antidepressant drugs b. May also result in increases in glutamate and GABA ( Townsend Chapter 22; Student Guide, pages 53 to 56)
  • 9.
    ECT  Side effects a. Temporary memory loss and confusion (most common) b. Permanent memory loss (?) c. Occasional cardiac dysrhythmias d. Brain damage – 2 per 100,000 treatments ( Townsend Chapter 22; Student Guide, pages 53 to 56)
  • 10.
    ECT  Nursing interventions prior to ECT a. Explain the procedure b. NPO for 8 hours (after midnight) c. Have consent signed d. Ensure labs and diagnostic examinations are all done results available: CBC, urinalysis, X-ray e. Empty bowel and bladder f. Take vital and record signs approximately 1 hour prior to treatment is scheduled g. Client should remain in bed with side rails up ( Townsend Chapter 22; Student Guide, pages 53 to 56)
  • 11.
    ECT  Nursinginterventions prior to ECT h. Client should be changed into a hospital gown i. Administer premedications 30 minutes prior to treatment – atropine or glycopyrolate (anticholinergics) IM j. Remove anything conductive k. Stay with client to allay fears and anxiety l. Maintain a positive attitude m. Encourage verbalization of feelings n. Ensure airway patency o. Restraints as necessary ( Townsend Chapter 22; Student Guide, pages 53 to 56)
  • 12.
    ECT  Nursing interventions during ECT a. Provide suctioning as needed b. Assist anesthesiologist with oxygenation as required c. Observe readouts on machines monitoring vital signs and cardiac functioning d. Provide support to the client’s arms and legs during the seizure e. Observe and record the type and amount of movement induced by the seizure ( Townsend Chapter 22; Student Guide, pages 53 to 56)
  • 13.
    ECT  Nursing interventions after ECT f. Allow the client to verbalize fears and anxieties related to receiving ECT g. Stay with the client until he or she is fully awake, oriented, and able to perform self-care activities without assistance h. Provide the client with a highly structured schedule of routine activities in order to minimize confusion ( Townsend Chapter 22; Student Guide, pages 53 to 56)
  • 15.
  • 16.
    PSYCHOTHERAPY  Any procedurethat promotes the development of courage, inner security and self confidence making the person more functional  Most important element is trust and communication  A form of mental exploration that should be individualized ( Student Guide, pages 58 to 60)
  • 17.
    INDIVIDUAL PSYCHOTHERAPY  Methodof bringing about change in a person by exploring his or her feelings, attitudes, thinking, and behavior  Involves one-to-one relationship between the therapist and the client  Therapist’s theoretical beliefs strongly influence his or her style of therapy  Nurse or other health care provider who is familiar with the client may be in a position to recommend a therapist or a choice of therapists (Videbeck pages 56 to 61)
  • 18.
    GROUP THERAPY  Clientsparticipate in sessions with a group of people  The members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in return  Group rules are established, which all members must observe, which vary according to the type of group (Videbeck pages 56 to 61)
  • 19.
    GROUP THERAPY  The therapeutic results of group therapy include the following: a. Gaining new information, or learning b. Gaining inspiration or hope c. Interacting with others d. Feeling acceptance and belonging e. Becoming aware that one is not alone and that others share the same problems f. Gaining insight into one’s problems and behaviors and how they affect others g. Giving of oneself for the benefit of others (altruism) (Videbeck pages 56 to 61)
  • 20.
    GROUP THERAPY  Psychotherapy groups 1. Family therapy 2. Family education 3. Education groups 4. Support groups 5. Self-help groups (Videbeck pages 56 to 61)
  • 21.
    PSYCHOTHERAPY GROUPS  Goal: for members to learn about their behavior and to make positive changes in their behavior by interacting and communicating with others as a member of a group  Often formal in structure, with one or two therapists as the group leaders  Two types a. Open groups – ongoing and run indefinitely, allowing members to join or leave the group as they need to b. Closed groups – structured to keep the same members in the group for a specified number of sessions; members decide how to handle members who wish to leave the group and the possible admission of new group members (Videbeck pages 56 to 61)
  • 22.
    PSYCHOTHERAPY GROUPS-FAMILY THERAPY A form of group in which the client and his or her own family members participate  The goals include understanding how family dynamics contribute to the client’s psychopathology, mobilizing the family’s inherent strengths and functional resources, restructuring maladaptive family behavioral styles, and strengthening family behavioral styles, and strengthening family problem-solving behaviors  Can be used both to assess and to treat various psychiatric disorders (Videbeck pages 56 to 61)
  • 23.
    PSYCHOTHERAPY GROUPS-FAMILY EDUCATION  Aunique 12-week Family-to-Family Education Course developed by the National Alliance for the Mentally Ill (NAMI)  Taught by trained family members, the curriculum focuses on schizophrenia, bipolar disorder, clinical depression, panic disorder, and obsessive- compulsive disorder  Discusses clinical treatment of these illnesses and teaches knowledge and skills that family members need to cope more effectively (Videbeck pages 56 to 61)
  • 24.
    PSYCHOTHERAPY GROUPS-EDUCATION GROUPS  Goalis to provide information to members on a specific issue-for instance, stress management, medication management, or assertiveness training  The group leader has expertise in the subject area and may be a nurse, therapist, or other health professional  Usually scheduled for a specific number of sessions and retain the same members for the duration of the group (Videbeck pages 56 to 61)
  • 25.
    PSYCHOTHERAPY GROUPS-SUPPORT GROUPS  Organizedto help members who share a common problem to cope with it  The group leader explores members’ thoughts and feelings and creates an atmosphere of acceptance so that members feel comfortable expressing themselves  Often provide a safe place for members to express their feelings of frustration, boredom, or unhappiness and also discuss common problems and potential solutions (Videbeck pages 56 to 61)
  • 26.
    PSYCHOTHERAPY GROUPS-SELF-HELP GROUPS  Membersshare a common experience, but the group is not a formal or structured therapy group  Professionals organize some self-help groups, many are run by members and do not have a formally identified leader  Examples: Alcoholics Anonymous (AA), Parents Without Partners, Gamblers Anonymous, and Al- Anon (a group of spouses and partners of alcoholics)  Some have national headquarters and Internet websites  Most have a rule of confidentiality (Videbeck pages 56 to 61)
  • 32.
    COMPLEMENTARY AND ALTERNATIVE THERAPIES Alternative medical systems – yoga, herbal medicines, acupuncture, etc…  Mind-body interventions – meditation, prayer. Mental healing, and creative therapies that use art or music  Biologically based therapies – use substances found in nature, such as herbs, food, vitamins  Manipulative and body-based therapies – therapeutic massage and chiropractic or osteopathic manipulations  Energy therapies – two types: a) biofield therapies, intended to affect energy fields that are believed to surround and penetrate the body (therapeutic touch, qi gong, Reiki) and b) bioelectric-based therapies, involving use of electromagnetic fields, such as pulse fields, magnetic fields, and AC or DC fields (Videbeck, pages 56 to 61)
  • 35.
    PSYCHIATRIC REHABILITATION  Involvesproviding services to people with severe and persistent mental illness to help them to live in the community  Often called community support programs  Focuses on the client’s strengths, not just on the illness  Client actively participates in program planning  Programs are designed to help the client manage the illness and symptoms, gain access to needed services, and live successfully in the community (Videbeck, pages 56 to 61)
  • 36.
    PSYCHOSOCIAL INTERVENTIONS  Nursing activities that help enhance the client’s social and psychological functioning and improve social skills, interpersonal relationships, and communication (Videbeck, pages 56 to 61; Student Guide, pages 58 to 59 and 72 to 82)
  • 37.
    COMMUNITY-BASED CARE –WHO/DOH  Mental Health Sub-Programs A. Wellness of Daily Living B. Extreme Life Experiences C. Mental Disorder D. Substance Abuse Disorder (Public Health Nursing in the Philippines, 2007, pages 231)
  • 38.
    COMMUNITY-BASED CARE –WHO/DOH  Home care is advocated  Acute cases are referred to the National Center for Mental Health (NCMH) or hospitals with psychiatric facilities for proper management  They are screened and after a few days they are assessed and discharged if they can be managed at home  Cases needing continuing supervision and care may be confined  A team from the NCMH follow up their discharged patients in the provinces (Public Health Nursing in the Philippines, 2007, pages 231)
  • 39.
    COMMUNITY-BASED CARE- WELLNESSOF DAILY LIVING  Wellness of Daily Living – The process of attaining and maintaining mental well-being across the life cycle through the promotion of healthy lifestyle with emphasis on coping with psychosocial issues  Objectives: 1. To increase awareness among the population on mental health and psychosocial issues 2. To ensure access of preventive and promotive mental health services  (Public Health Nursing in the Philippines, 2007, pages 231)
  • 40.
    COMMUNITY-BASED CARE- EXTREMELIFE EXPERIENCES  Objectives: 1. To differentiate between critical incident and extreme life experiences 2. To identify situations which may be extreme life experiences 3. To categorize/prioritize the extreme life experience which may be the concern of mental health 4. To identify programs that could address psychosocial consequences and mental health issues of persons with extreme life experiences  (Public Health Nursing in the Philippines, 2007, pages 231)
  • 41.
    COMMUNITY-BASED CARE- MENTALDISORDER  Objectives: 1. Promotion of mental health and prevention of mental illness across the lifespan and across sectors (children and adolescents, adults elderly, and special population such as military, OFWs, refugees, persons with disabilities)  (Public Health Nursing in the Philippines, 2007, pages 231)
  • 42.
    COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In mental health promotion 1. Participate in the promotion of mental health among families and the community 2. Utilize opportunities in his/her everyday contacts with other members of the community to extend the general knowledge on mental hygiene 3. Help people in the community understand basic emotional needs and the factors that promote mental well being 4. Teach parents the importance of providing emotional support to their children during critical periods in their lives like first day in school graduation, etc…  (Public Health Nursing in the Philippines, 2007, pages 231)
  • 43.
    COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In prevention and control 1. Recognize mental health hazards and stress situations as unemployment, divorce or abandonment of children, vices, long standing physical illness, all of which make heavy demands on the emotional resources of the persons concerned 2. Recognize pathological deviations from normal in terms of acting, thinking and feeling and make early referral so that diagnosis and treatment could be done early. 3. Be aware of potential causes of breakdown and when necessary take some possible preventive action.  (Public Health Nursing in the Philippines, 2007, pages 231)
  • 44.
    COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In prevention and control 4. Help the family to understand and accept the patient’s health status and behavior sp that all its members may offer as much support in the readjustments to home and community 5. Help patient assess his/her capacities and his/her handicaps in working towards a solution of his/her problem 6. Encourage feeling of achievement by setting health goals that patient can attain 7. Encourage the patient to express his/her anxieties so that fears and misconceptions can be cleared up  (Public Health Nursing in the Philippines, 2007, pages 231)
  • 45.
    COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In prevention and control 8. Impart information and guidance about the treatment scheme of the patients, the desired and undesirable effect of the tranquilizers, psychiatric emergency management and other nursing care  (Public Health Nursing in the Philippines, 2007, pages 231)
  • 46.
    COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  Rehabilitation 1. Initiate patient participation in occupational activities best suited to patient’s capabilities, education, experience and training, capacities and interest 2. Encourage and initiate patients to partake in activities of CIVIC organization in the community through the cooperation of the patient’s family 3. Advise the family about the importance of regular follow-up at the clinic 4. Make regular home visits to observe patients’ conditions during conversation and follow-up of medication  (Public Health Nursing in the Philippines, 2007, pages 231)
  • 47.
    COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES  In research and epidemiology 1. Participate actively in epidemiological survey to be aware of the size and extent of mental health problems in the community and to organize a program for better preventive, curative and rehabilitative measures.  (Public Health Nursing in the Philippines, 2007, pages 231)
  • 48.
    STANDARD 6 -EVALUATION  The psychiatric-mental health nurse evaluates progress toward attainment of expected outcomes  The continuous or ongoing phase of nursing process is evaluation.  Nursing care is a dynamic process involving change in the patient’s health status over time, giving rise to the need of new data, different diagnosis, and modifications in the plan of care. (Videbeck, page 10; The Internet)
  • 49.
    STANDARD 6 -EVALUATION  When evaluating care the nurse should review all previous phases of the nursing process and determine whether expected outcome for the patient have been met.  This can be done checking: 1. Have I done everything for my patient? 2. Is my patient better after the planned care?  Evaluation is a feed back mechanism for judging the quality of care given.  Evaluation of the patient’s progress indicates what problems of the patient have been solved, which need to be assessed again, replanted, implemented and re- evaluated. (Videbeck, page 10; The Internet)
  • 50.
    AREAS OF PRACTICE  Basic-Level Functions a. Counseling b. Milieu therapy c. Self-care activities d. Psychobiologic interventions e. Health teaching f. Case management g. Health promotion and maintenance  Advanced-Level Functions a. Psychotherapy b. Prescriptive authority for drugs (US) c. Consultation and liaison d. Evaluation e. Program development f. And management g. Clinical supervision (Videbeck, pages 11 to 12)
  • 51.
    STUDENT CONCERNS  Studentconcerns are normal  Usually do not persist once the students have initial contacts with clients  Some common concerns and helpful hints for beginning students: “What is I say the wrong thing?” - No one magic phrase can solve a client’s problems; likewise, no single statement can significantly worsen them - Listening carefully, showing genuine interest, and caring about the client are extremely important (Videbeck, pages 11 to 12)
  • 52.
    STUDENT CONCERNS  Somecommon concerns and helpful hints for beginning students: “What will I be doing?” - In the mental health setting, many familiar tasks and responsibilities are minimal - Physical care skills or diagnostic tests and procedures are fewer than those conducted in a busy medical- surgical setting - The student must deal with his or her own anxiety about approaching a stranger to talk about very sensitive and personal issues - Development of the therapeutic nurse-client relationship takes time and patience (Videbeck, pages 11 to 12)
  • 53.
    STUDENT CONCERNS  Somecommon concerns and helpful hints for beginning students: “What if no one will talk to me?” - Students sometimes fear that they will be rejected by the client - Some clients may not want to talk, or are reclusive, but may show that same behavior with experienced staff - Students should not see such behavior as a personal insult or failure (Videbeck, pages 11 to 12)
  • 54.
    STUDENT CONCERNS  Somecommon concerns and helpful hints for beginning students: “Am I prying when I ask personal questions?” - Personal questions should not be the first thing a student says to the client - These issues usually arise after some trust and rapport have been established - Ask sincere questions (Videbeck, pages 11 to 12)
  • 55.
    STUDENT CONCERNS  Somecommon concerns and helpful hints for beginning students: “Ho will I handle bizarre or inappropriate behavior?” - It is important to monitor one’s facial expressions and emotional responses so that clients do not feel rejected or ridiculed - The nursing student instructor and staff are always available to assist the student in such situations - Students should never feel as if they have to handle situations alone (Videbeck, pages 11 to 12)
  • 56.
    STUDENT CONCERNS  Somecommon concerns and helpful hints for beginning students: “What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior?” - Some clients have difficulty recognizing or maintaining interpersonal boundaries - When client seeks contact of any type outside the nurse-client relationship, it is important for the student (with the assistance of the instructor or staff) to clarify the boundaries of the professional relationship (Videbeck, pages 11 to 12)
  • 57.
    STUDENT CONCERNS  Somecommon concerns and helpful hints for beginning students: “What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior?” - Likewise, setting limits and maintaining boundaries are needed when a client’s behavior is sexually inappropriate - Initially, the student might be uncomfortable dealing with such behavior, but with practice and the assistance of the instructor and staff, it becomes easier to manage (Videbeck, pages 11 to 12)
  • 58.
    STUDENT CONCERNS  Somecommon concerns and helpful hints for beginning students: “What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior?” - It is also important to protect the client’s privacy and dignity when he or she cannot do so (Videbeck, pages 11 to 12)
  • 59.
    STUDENT CONCERNS  Some common concerns and helpful hints for beginning students: “Is my physical safety in jeopardy?” - Actually, clients hurt themselves more often than they harm others - Staff members usually closely monitor clients with a potential for violence for clues of an impending outburst - When physical aggression does occur, staff members are specially trained to handle aggressive clients in a safe manner (Videbeck, pages 11 to 12)
  • 60.
    STUDENT CONCERNS  Somecommon concerns and helpful hints for beginning students: “What if I encounter someone I know being treated in the unit?” - It is essential that the client’s identity and treatment be kept confidential - If the student recognizes someone he or she knows, the instructor must be notified, and the instructor will decide on the situation - Always reassure client that all will be kept confidential and the student will be reassigned (Videbeck, pages 11 to 12)
  • 61.
    STUDENT CONCERNS  Somecommon concerns and helpful hints for beginning students: “What if I recognize that I share problems or backgrounds with clients?” - No easy way to answer this question - We do not always know why some people have serious emotional problems, while others do not, and yet they have similar life experiences - Self-awareness is key (Videbeck, pages 11 to 12)
  • 62.
    SELF-AWARENESS  The processby which the nurse gains recognition of his or her own feelings, beliefs, and attitudes  In nursing, being aware of one’s feelings, thoughts, and values is a primary focus  What would you do if you were assigned to a client who just had an abortion, and you are strong believer of anti-abortion?  Will your personal feelings and beliefs interfere with your work?  The nurse needs to discover him/herself and what he/she believes before trying to help others with different views (Videbeck, pages 11 to 12)
  • 63.
    SELF-AWARENESS- POINTS TOCONSIDER  Keep a dairy or journal that focuses on experiences and related feelings  Talk with someone you trust about your experiences and feelings  Engage in formal clinical supervision. Even experienced clinicians have a supervisor with whom they discuss personal feelings and challenging client situations to gain insight and new approaches  Seek alternative points of view. Put yourself in the client’s situation and think about his or her feelings, thoughts, and actions (Videbeck, pages 11 to 12)
  • 64.
    SELF-AWARENESS- POINTS TOCONSIDER  Do not be critical of yourself (or others) for having certain values or beliefs. Accept them as a part of yourself, or work to change those values and beliefs you wish to be different (Videbeck, pages 11 to 12)
  • 65.
    THERAPEUTIC RELATIONSHIPS  Theability to establish therapeutic relationships with clients is one of the most important skills a nurse can develop  The therapeutic relationship is especially crucial to the success of interventions with clients requiring psychiatric care because the therapeutic relationship and the communication within it serve as the underpinning for treatment and success (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
  • 66.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Trust  Genuine interest  Empathy  Acceptance  Positive regard  Self awareness and Therapeutic use of self (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
  • 67.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Trust 1. Trust is built in the nurse-client relationship when the nurse exhibits the following behaviors: a. Caring b. Openness c. Objectivity d. Respect e. Interest f. Understanding g. Consistency h. Treating the client as a human being i. Suggesting without telling j. Approachability k. Listening l. Keeping promises m. Honesty (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
  • 68.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Trust 2. Congruence – occurs when words and actions match  Genuine interest 1. The client perceives this when the nurse is comfortable with him/herself and is aware of his strengths and limitations, and is focused 2. A client with mental illness can detect when someone is exhibiting dishonest or artificial behavior (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
  • 69.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Empathy 1. The ability to perceive the meanings of feelings of the client and to communicate that understanding to the client 2. Being able to put him/herself in the client’s shoes  Acceptance 1. The nurse does not become upset or respond negatively to a client’s outbursts, anger, or acting out 2. Avoiding judgment (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
  • 70.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Positive regard 1. The nurse is able to appreciate the client as a unique worthwhile human being 2. The nurse can respect the client regardless of his or her own behavior 3. Unconditional nonjudgmental attitude  Self-awareness 1. The nurse must first know him/herself before he or she can attend to a client 2. What are your values, attitudes, and beliefs? (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
  • 71.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Therapeutic use of self 1. Self-awareness has been developed 2. The nurse can use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
  • 72.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Genuine interest Client: “I’m so confused! My son just visited and wants to know where the safety deposit box key is.” Nurse: “You’re confused because your son asked for the safety deposit box key?” (using reflection) or Nurse: “Are you confused about the purpose of your son’s visit?” (using clarification)
  • 73.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Acceptance Client: puts his arm around the nurse’s waist Appropriate response conveying acceptance but not allowing the inappropriate behavior of the client to continue: “ Sir, do not place your hand on me. We are working on your relationship with your girlfriend and that does not require you to touch me. Now, let’s continue.” Inappropriate response: “ Sir, stop that! What’s wrong with you? I am leaving, and maybe I’ll return tomorrow.”
  • 74.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Positive regard Client: I was so mad, I yelled and screamed at my mother for an hour.” Which conveys positive regard or are appropriate responses by the nurse? a. “Well that didn’t help did it?” b. “I can’t believe you did that.” c. “What happened then?” d. “You must really be upset.”
  • 75.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Positive regard Client: I was so mad, I yelled and screamed at my mother for an hour.” Which conveys positive regard or are appropriate responses by the nurse? a. “Well that didn’t help did it?” b. “I can’t believe you did that.” c. “What happened then?” d. “You must really be upset.”
  • 76.
    COMPONENTS OF ATHERAPEUTIC RELATIONSHIPS  Therapeutic use of self - Johari Window 1. A “words portrait” of a person in four areas 2. Each area indicates how well that person knows him/herself and communicated with others  Patterns of knowing - Nurse theorist Hildegard Peplau (1952) identified preconceptions, or ways one person expects another person to behave or speak, as a roadblock to the formation of an authentic relationship (Videbeck pages 80 to 86) (Student Guide pages 59 to 69)
  • 79.
    TYPES OF RELATIONSHIPS Social relationship – primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task  Intimate relationship – involves two people who are emotionally committed to each other  Therapeutic relationship – focuses on needs, experiences, feelings, and ideas of the client only (Videbeck pages 86 to 87) (Student Guide pages 59 to 69)
  • 80.
    ESTABLISHING THE THERAPEUTIC RELATIONSHIP Phases: 1. Orientation phase 2. Working phase a. Problem identification subphase b. Exploitation subphase 3. Termination phase (Videbeck pages 87 to91) (Student Guide pages 59 to 69)
  • 81.
    ESTABLISHING THE THERAPEUTIC RELATIONSHIP Phases: 1. Orientation phase a. Begins when then nurse and client meet and ends when the client begins to identify problems to examine b. The nurse establishes the roles, the purpose of meeting, and the parameters of subsequent meetings c. Identifies client’s problems d. Clarifies expectations (Videbeck pages 87 to 91) (Student Guide pages 59 to 69)
  • 82.
    ESTABLISHING THE THERAPEUTIC RELATIONSHIP Phases: 2. Working phase a. Problem identification subphase – the client identifies the issues or concerns causing problems b. Exploitation subphase – the nurse guides the client to examine feelings and responses and develop better coping skills and a more positive self-image, to encourage behavior change and develop independence (Videbeck pages 87 to 91) (Student Guide pages 59 to 69)
  • 83.
    ESTABLISHING THE THERAPEUTIC RELATIONSHIP Phases: 3. Termination phase a. Also known as the resolution phase b. The final stage of the nurse-client relationship c. It begins when the problem is resolved d. Ends when the relationship is ended (Videbeck pages 87 to 91) (Student Guide pages 59 to 69)
  • 84.
    THERAPEUTIC AND NON-THERAPEUTICFORMS OF COMMUNICATION  Therapeutic communication - Is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information - Helps the nurse understand and empathize with the client’s experience (Videbeck, page 98 to 116)
  • 85.
    THERAPEUTIC AND NON-THERAPEUTICFORMS OF COMMUNICATION  Therapeutic communication - Goals: 1. Establish a therapeutic nurse-client relationship 2. Identify the most important client concern at that moment (the client-centered goal) 3. Assess the client’s detailed actions as it unfolds 4. Facilitate the client’s expression of emotions 5. Teach the client and family necessary self-care skills 6. Recognize the client’s needs 7. Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution (Videbeck, page 98 to 116)
  • 86.
    THERAPEUTIC AND NON-THERAPEUTICFORMS OF COMMUNICATION  Therapeutic communication - Privacy and Respecting Boundaries 1. Privacy is desirable, but not always possible in a therapeutic communication 2. Proxemics – the study of distance zones between people during communication a. Intimate zone – 0 to 18 inches between people; parents and young children, people who mutually desire personal contact b. Personal zone – 19 to 36 inches; between family and friends who are talking c. Social zone – 4 to 12 feet; acceptable for communication in social, work, and business settings d. Public zone – 12 to 25 feet; speaker and audience, small groups, and other informal functions (Videbeck, page 98 to 116)
  • 87.
    THERAPEUTIC AND NON-THERAPEUTICFORMS OF COMMUNICATION  Therapeutic communication 1. Verbal communication – uses concrete messages and abstract messages 2. Non-verbal communication – body language, eye contact, facial expression, tone of voice, speed and hesitations in speech, grunts and groans, and distance from the listeners (Videbeck, page 98 to 116)
  • 88.
    THERAPEUTIC AND NON-THERAPEUTICFORMS OF COMMUNICATION  Therapeutic communication 1. Touch a. Functional-professional touch b. Social-polite touch c. Friendship-warmth touch d. Love-intimacy touch (Videbeck, page 98 to 116)
  • 89.
    THERAPEUTIC AND NON-THERAPEUTICFORMS OF COMMUNICATION  Therapeutic communication 1. Concrete messages – the words are explicit and need no interpretation 2. Abstract messages – requires interpretation by the listener like figure of speeches (Videbeck, page 98 to 116)
  • 90.
    THERAPEUTIC AND NON-THERAPEUTICFORMS OF COMMUNICATION  Therapeutic communication Concrete messages “What health problems caused you to come to the hospital today?” Abstract messages “How did you get here?” The terms “how” and “here” are vague. To an anxious client who is not thinking clearly: “Where am I?” or “The ambulance brought me here?” (Videbeck, page 98 to 116)
  • 91.
    THERAPEUTIC AND NON-THERAPEUTICFORMS OF COMMUNICATION Therapeutic communication Abstract (unclear): “Get the stuff from him.” Concrete (clear): “He’ll be home today at 5pm, and you can pick up your clothes at that time.” Abstract (unclear): “Your clinical performance has improved.” Concrete (clear): “To administer medications tomorrow, you’ll have to be able to calculate dosages correctly by the end of today’s class.” (Videbeck, page 98 to 116)
  • 92.
    THERAPEUTIC AND NON-THERAPEUTICFORMS OF COMMUNICATION  Non-Therapeutic communication a. Should be avoided b. These responses cut off the communication and make it more difficult for the interaction to continue c. Asking “why” questions may be perceived as criticism by the client, conveying a negative judgment from the nurse (Videbeck, page 98 to 116)
  • 93.
    THERAPEUTIC COMMUNICATION TECHNIQUES  Accepting – indicating reception, you are listening and you have followed the train of thought “Yes” or “I follow what you said” or simply nodding  Broad opening – allowing the client to take the initiative in introducing the topic, makes the client feel that he or she has the lead interaction “Is there something you’d like to talk about?”  Consensual validation – searching for mutual understanding, for accord in the meaning of the words; to avoid any misunderstanding “Tell me whether my understanding of it agrees with yours.”
  • 94.
    THERAPEUTIC COMMUNICATION TECHNIQUES Encouraging comparison – asking that similarities and differences be noted “ Was it something like…?”  Encouraging description of perception – asking the client to verbalize what he or she perceives “What is happening?’  Encouraging expression – asking the client to appraise the quality of his or her experiences “Tell me more about that.”  Focusing – concentrating on a single point “Of all you’ve mentioned, which is the most troublesome?”
  • 95.
    THERAPEUTIC COMMUNICATION TECHNIQUES  Formulating a plan of action – asking the client to consider kinds of behavior likely to be appropriate in the future  General leads – giving encouragement to continue  Giving information – making available the facts that the client needs  Giving recognition – acknowledging, indicating awareness “Good morning, sir.” “I noticed that you’ve combed your hair.”
  • 96.
    THERAPEUTIC COMMUNICATION TECHNIQUES  Making observations – verbalizing what the nurse perceives “You appear tense.”  Offering self – making oneself available “I’ll stay here with you for a while.”  Placing event in time or sequence – clarifying the relationship of events in time “When did this happen?”  Presenting reality – offering for consideration that which is real “I see no one else in the room.”
  • 97.
    THERAPEUTIC COMMUNICATION TECHNIQUES Reflecting – directing the client actions, thoughts, and feelings back to the client Client: “Do you think I should tell the doctor…?” Nurse: “Do you think you should?”  Restating – repeating the main idea expressed Client: “I can’t sleep. I stay awake all night.” Nurse: “You have difficulty sleeping.”  Seeking information – seeking to make clear that which is not meaningful or that which is vague Nurse: “I’m not sure I follow.” Nurse: “Have I heard you correctly.”
  • 98.
    THERAPEUTIC COMMUNICATION TECHNIQUES Silence – nurse says nothing but maintains eye contact  Suggesting collaboration – offering to share, to strive, and to work with the client to his or her benefit Nurse: “Let’s go to your room, and I’ll help you find what you’re looking for.”  Summarizing – organizing and summing up that which has gone before Nurse: “Have I got this straight.” Nurse: “You’ve said that…”
  • 99.
    THERAPEUTIC COMMUNICATION TECHNIQUES Translating into feelings – seeking to verbalize client’s feelings that he or she expresses only indirectly Client: “I’m dead.” Nurse: “Are you suggesting that you feel lifeless?”  Verbalizing the implied – voicing what the client has hinted or suggested Client: “I can’t talk to you or anyone. It’s a waste of time.” Nurse: “Do you feel that no one understands?”  Voicing doubt – expressing uncertainty about the reality of the client’s perceptions Nurse: “Really?”
  • 100.
    NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Advising– telling client what to do Nurse: “I think you should….” or “Why don’t you…?”  Agreeing – indicating accord with the client  Belittling feelings expressed – misjudging the degree of the client’s discomfort  Challenging – demanding proof from the client  Defending – attempting to protect someone or something from verbal attack Nurse: “This hospital has a fine reputation.” or “I am sure your doctor has your best interests in mind.”
  • 101.
    NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Disagreeing– opposing the client’s ideas  Disapproving – denouncing the client’s behavior or ideas; implies that the nurse has the right to pass judgment  Giving approval – sanctioning the client’s behavior or ideas; tends to limit the client’s freedom to think, speak, or act in a certain way, which could lead to the client acting a certain way just to please the nurse  Giving literal responses – responding to a figurative comment as though it were a statement of fact Client: “They’re looking in my head with a TV camera.” Nurse: “Try not to watch TV.” or “What channel?”
  • 102.
    NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Indicatingan existence of an external source – attributing the source of thoughts, feelings, and behavior to others or to outside influences Nurse: “What made you say that?” – implies that the client is compelled to think a certain way  Interpreting – asking to make conscious that which is unconscious, telling the client the meaning of his or her experience. The client’s thoughts and feelings are his own, hidden meaning are not meant for the nurse to discover, only the client knows. Nurse: “What you really mean is…” or “Unconsciously, you’re saying…”  Introducing an unrelated topic – changing the subject Client: “I’d like to die.” Nurse: “Did you have visitors this evening?”
  • 103.
    NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Makingstereotyped comments – offering meaningless clichés or trite comments Nurse: “It’s for your own good.” or “Just have a positive attitude and you’ll be better in no time.”  Probing – persistent questioning of the client Nurse: “Tell me about this problem. You know I have to find out.” or “Tell me your psychiatric history.”  Reassuring – indicating there is no reason for anxiety or other feelings of discomfort Nurse: “Everything will be alright.”
  • 104.
    NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Rejecting– refusing to consider or showing contempt for the client’s ideas or behaviors’ This closes the chances of exploration, and the client may feel personally rejected along with feelings or ideas Nurse: “Let’s not discuss….” or “I don’t want to hear about…”  Requesting an explanation – asking the client to provide reasons for thoughts, feelings, behaviors, events. There is a difference between this and asking the client to describe what is occurring or has taken place, and usually a “why” question is intimidating Nurse: “Why do you think that?” or “Why do you feel that way?”
  • 105.
    NON-THERAPEUTIC COMMUNICATION TECHNIQUES  Testing– appraising the client’s degree of insight, which forces the client to recognize his or her problem. Helpful to the nurse, but not to the client Nurse: “Do you know what kind of hospital this is?” or “Do you still have the idea that….?”  Using denial – refusing to admit that a problem exists. This implies that the nurse dismisses the seriousness of the situation Client: “I’m nothing.” Nurse: “Of course you’re something – everybody’s something.” Client: “I’m dead.” Nurse: “Don’t be silly.”