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Unit 2 .............................pptx
- 1. Unit 2 Tools ofPsychiatric Nursing therapeutic communication and relationship PREPARED BY SANIA TAZEEN PRINCIPAL ABDALI INSTITUTE OF NURSING AND HEALTH SCIENCES
- 2. Objectives By theend of the session, students will be able : Discuss significance of communication skill Describe techniques that facilitate or impede therapeutic communication. Discuss nature, purpose and process of mental health assessment Begin to analyze clinical findings that indicate mental health problems in selected clients.
- 3. INTRODUCTION The nurse-clientrelationship is the foundation on which psychiatric nursing is established. The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention. Mental health providers need to know how to gain trust and gather information from the patient, the patient's family, friends and relevant social relations, and to involve them in an effective treatment plan. Therapeutic use of self is the instrument for delivery of care to clients in need of psychosocial intervention. Interpersonal communication techniques are the “tools” of psychosocial intervention.
- 5. THERAPEUTIC NURSE-CLIENT RELATIONSHIP Therapeuticrelationships are goal- oriented and directed at learning and growth promotion. Series of interactions between the nurse and the patient in which the nurse assists the patient to attain positive behavioral change
- 6. Therapeutic Use ofSelf Definition - ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions. Nurses must possess self-awareness, self-understanding, and a philosophical belief about life, death, and the overall human condition for effective therapeutic use of self.
- 7. REQUIREMENTS FOR THERAPEUTIC RELATIONSHIP Rapport Trust Respect Genuineness Empathy
- 8. PHASES OF ATHERAPEUTIC NURSE- CLIENT RELATIONSHIP Pre-interaction phase Orientation/Introductory Period Working Termination
- 9. Pre-interaction phase Beginswhen the nurse is assigned to a patient Phase of Nurse-Patient Relationship in which the patient is excluded as an actual participant Nurse feels certain degree of anxiety
- 10. Orientation/Introductory Period Includesall of what the nurse thinks and does before interacting with the patient Tasks include data gathering, planning for the first interaction Major task is to develop self-awareness
- 11. Working It ishighly individualized More structured than the orientation phase The longest and most productive phase of the nurse- patient relationship Limit-setting is employed Tasks include planning and implementation Major task is identification and resolution of the patient’s problems
- 12. Termination It isa gradual weaning process It is a mutual agreement It involves feelings of anxiety, fear and loss It should be recognized in the orientation phase Tasks include evaluation Major task is to assist patient to review what has been learned and to transfer his learning to his relationship with others
- 13. THERAPEUTIC COMMUNICATION TECHNIQUES Usingsilence - allows client to take control of the discussion, if he or she so desires Accepting - conveys positive regard Giving recognition - acknowledging, indicating awareness Offering self - making oneself available Giving broad openings - allows client to select the topic Offering general leads - encourages client to continue
- 14. Placing theevent in time or sequence - clarifies the relationship of events in time Making observations - verbalizing what is observed or perceived Encouraging description of perceptions - asking client to verbalize what is being perceived Encouraging comparison - asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships Restating - lets client know whether an expressed statement has or has not been understood Reflecting - directs questions or feelings back to client so that they may be recognized and accepted Focusing - taking notice of a single idea or even a single word
- 15. Exploring -delving further into a subject, idea, experience, or relationship Seeking clarification and validation - striving to explain what is vague and searching for mutual understanding Presenting reality - clarifying misconceptions that client may be expressing Voicing doubt - expressing uncertainty as to the reality of client’s perception
- 16. Verbalizing theimplied - putting into words what client has only implied Attempting to translate words into feelings - putting into words the feelings the client has expressed only indirectly Formulating plan of action - striving to prevent anger or anxiety escalating to unmanageable level when stressor recurs
- 17. THERAPEUTIC COMMUNICATION AND PROBLEM-SOLVING Goals are often achieved through use of the problem-solving model: Identify the client’s problem. Promote discussion of desired changes. Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively. Discuss alternative strategies for creating changes the client desires to make.
- 18. Weigh benefitsand consequences of each alternative. Help client select an alternative. Encourage client to implement the change. Provide positive feedback for client’s attempts to create change. Help client evaluate outcomes of the change and make modifications as required.
- 19. LISTENING TO THEPATIENT To listen actively is to be attentive to what client is saying, both verbally and nonverbally. Several nonverbal behaviors have been designed to facilitate attentive listening. S – Sit squarely facing the client. O – Observe an open posture. L – Lean forward toward the client. E – Establish eye contact. R – Relax.
- 20. NONTHERAPEUTIC COMMUNICATION TECHNIQUES Givingreassurance - may discourage client from further expression of feelings if client believes the feelings will only be downplayed or ridiculed Rejecting - refusing to consider client’s ideas or behavior Approving or disapproving - implies that the nurse has the right to pass judgment on the “goodness” or “badness” of client’s behavior Agreeing or disagreeing - implies that the nurse has the right to pass judgment on whether client’s ideas or opinions are “right” or “wrong” Giving advice - implies that the nurse knows what is best for client and that client is incapable of any self-direction Probing - pushing for answers to issues the client does not wish to discuss causes client to feel used and valued only for what is shared with the nurse
- 21. Defending -to defend what client has criticized implies that client has no right to express ideas, opinions, or feelings Requesting an explanation - asking “why” implies that client must defend his or her behavior or feelings Indicating the existence of an external source of power - encourages client to project blame for his or her thoughts or behaviors on others Belittling feelings expressed - causes client to feel insignificant or unimportant Making stereotyped comments, clichés, and trite expressions - these are meaningless in a nurse-client relationship Using denial - blocks discussion with client and avoids helping client identify and explore areas of difficulty Interpreting - results in the therapist’s telling client the meaning of his or her experience Introducing an unrelated topic - causes the nurse to take over the direction of the discussion
- 22. CONCLUSION Effectivecommunication is the core skill in mental health care in primary care settings. Self-awareness and ability to collaborate with other health care providers are also skills that will facilitate accurate inquiry into the patient's true concerns and the context in which they occur
- 23. Mental Status Examination MSE is a cross-sectional, systemic documentation of the quality of mental functioning at the time of interview. It serves as a baseline for future comparison and to follow the progress of the patient.
- 24. The Purpose ofMental Status Examination Provides baseline information regarding a person’s mental state at the time of interview Helps identify who may need a more comprehensive psychiatric assessment To assist with diagnosis
- 25. To guide interventions Toevaluate patient’s progress To inform the risk assessment To support discharge planning Structured approach to understand the psychological state of patients
- 26. History Individual Identification Identify the presenting problem History of present illness Personal History Previous Medical History Drug History Family History.
- 28. Appearance & Behavior Apparent age Hygiene Dressing Cleanliness Posture Gait Facial expressions Eye contact General status of health & Nutrition
- 29. Motor activity It describespatients physical movement. It includes Level of psychomotor activity: lethargy, tense, restless/ agitated Type of activity: tics, grimaces, tremors Unusual gesture/ mannerism: compulsion
- 30. Speech Rate, Volume,and Amount etc. Rate: rapid/slow Volume: Loud/ soft Amount: paucity, muteness and pressured Characteristics: Stuttering, slurring of words or unusual accent.
- 32. Neologisms: thecreation and use of new words that are only understood by the speaker (e.g., Pepsidiction = Pepsi + addiction, Spritependency = Sprite + dependency) Word salad: incoherent thinking expressed as a sequence of words without a logical connection Example: “They’re destroying too many cattle and oil just to make soap. If we need soap when you can jump into a pool of water, and then when you go to buy your gasoline, my folks always thought they should get pop but the best thing to get is motor oil and money.”
- 33. Motor activity Thisis concerned with the patient physical movement Level of activity: Lethargic, tense, restlessness, agitation Type of Activity: Tics, Grimaces, or tremors Unusual gestures or mannerisms: Compulsion
- 34. Behavior (Interaction during Interview Calm and cooperative Hostile Irritable Guarded Apathetic Defensive Suspicious
- 35. Mood and Affect Mood is patients self report of prevailing emotional state (internal feeling) e.g. How are you feeling today? The answer may be sad, fearful, hopeless, euphoric or anxious Affect is patients apparent emotional tone (external emotional response) Mood and effect may be congruent or incongruent
- 36. Mood The patient’s selfreport of prevailing emotional state and reflects the patient’s life situation. Refers to the patient's subjective assessment of their emotions when asked how they feel. Is subjective feeling of: Sadness Fearfulness Anxiety Anger Euphoria Happiness Guilt
- 37. Affect Objective emotionaltone or objective expression of emotional feelings Refers to the physician's objective assessment of a patient's emotions conveyed both verbally and nonverbally during an interview Appropriate Flat Blunted Smiling Calm Anxious Irritable
- 38. Experiences Perceptions Perception involvesthe organization, identification and interpretation of sensory information to understand the world around us. Abnormalities of perception are a feature of several mental health conditions.
- 39. Perception Hallucinations: False sensory impressionin the absence of any external stimulus Visual (Sight) Auditory (Sound) Tactile (Touch) Olfactory (smell) Gustatory (Taste)
- 40. Illusions: False perceptionor false responses to a sensory stimulus. Misperception of a real external stimulus. Depersonalization: The patient feels that they are no longer their ‘true’ self and are someone different or strange. Derealization: A sense that the world around them is not a true reality
- 41. Thinking Thought Content What theperson is actually thinking (Ideas & beliefs). Thought content refers explicitly to what an individual is thinking about (i.e., main themes and beliefs) and is usually evaluated based on the presence of: Delusion Obsession compulsions Phobia Suicidal and homicidal ideation
- 42. Thought Content Delusions Delusionsare fixed, false beliefs (unrelated to one's religious beliefs or culture) that are maintained despite being contradicted by reality or rational arguments. Types of delusion Persecutory Delusion (others are deliberately trying to wrong, harm, or conspire against another) Grandiose delusion (an exaggerated sense of one’s own importance, power, or significance)
- 43. Somatic Delusion(physical sensations or medical problems, belief that one’s body or body parts are diseased or distressed) Religious delusion (false belief that the person has a special link with God) Paranoid delusion (The patient has an exaggerated distrust of others and is suspicious of their motives.) Delusion of reference The patient believes that normal events are of special importance to them (e.g., an individual might feel that a television reporter is talking about them).
- 44. Thought Content Contd… Suicidal and homicidal ideation Suicidal ideation: any type of thoughts that an individual has regarding ending their own life Homicidal ideation: thoughts regarding ending someone else's life Obsessions and compulsions Obsession: A repetitive, persistent, intrusive, and unpleasant thought or urge that causes severe distress and anxiety. Compulsion: Ritualistic, repetitive behaviors (e.g., touching, washing) or mental act (e.g., counting, repeating a word silently) carried out in an effort to relieve urges and decrease obsession- related distress.)
- 45. Thought Content Contd… Phobias A specific phobia is a persistent (≥ 6 months) and intense fear of one or more specific situations or objects (phobic stimuli). Some common examples of phobias includes: Agoraphobia (fear of unknown places and situations) Claustrophobia (fear of enclosed places) Arachnophobia (fear of spiders) Hematophobia (fear of blood) Can be assessed by asking the patient whether they are scared of anything and how long this fear has affected them
- 46. Thinking Thought process Ishow of the patient self expression, is observed through speech. It is “how” of the patients self expression. It comprise patterns of forms of verbalization rather than content. It includes Circumstantiality – excessive or irrelevant details Tangentiality –similar to circumstantiality but person never returns to the central point. Word salad – words & phrases lack comprehension and totally unrelated
- 47. Flight ofideas: over productive speech characterized by rapid shifting from one topic to another and fragmented ideas Loose association: Lack of logical relationship between thoughts and ideas vague, diffuse and unfocused Neologism: New word/ word created by patient Thought blocking: sudden halt in the train of thought or in the middle of the sentence Perseveration: involuntary, excessive continuation or repetition of a single response, idea or activity
- 50. Sensorium and Cognition Sensorium: Theevaluation of sensorium assesses a patient's level of consciousness and their orientation to person, place, and time. Cognition: It is the mental process of gaining knowledge and understanding via thinking, experiencing, and sensing, and includes many aspects Level of Consciousness Awake Confusion Drowsiness Unconsciousness Orientation Person Place time
- 51. Cognition Memory: ability torecall events, people, and information Remote: distant past Recent: past week or so Immediate: a person just exposed to
- 52. Cognition Level ofconcentration and calculation Concentration is the patient’s ability to pay attention during the course of interview Calculation is the ability to do simple math
- 53. Cognition Abstract Thoughts: Thepatient can be given example of proverbs and its interpretation Patient can also be asked for similarities and difference between two objects Abstract thinking: Abstract thinking is assessed by asking similarities or giving proverbs to interpret.
- 54. Cognition Judgement: Capacityto make sound, reasoned and responsible decisions use of standard hypothetical questions More useful to relate to person’s own self- care, recent/current situation or behavior Judgment: Assess clients problem solving abilities via giving scenarios
- 55. Insight Insight: Assessclients understanding of his illness Awareness/understanding of problems and their implications Recognition of illness and benefits of treatment Motivation to change - ambivalence to commitment
- 56. REFERENCES Stuart GW,Lararia MT. Principles and practices of psychiatric nursing (8th edn) Mosby publications; Missouri, 2005. Epstein RM, Borrell F, Caterina M . Communication and mental health in primary care. In New Oxford Textbook of Psychiatry (Edrs. Gelder MG, López-Ibor JJ, Andreasen NC), Oxford University Press, 2000. Antai-Otong, D . (2003). Psychiatric Nursing : Biological & behavioral concepts. Texas : Thomson Learning Boyd, M. A. (2002). Psychiatric nursing: Contemporary practice (2nd ed.). Philadelphia: Lippincott. Moher.W,K. (2006). Psychiatric- mental health nursing. (6th ed). Philadelphia: Lippincott. Stuart, G. W., & Laraia, M. T. (2005). Principles and practice of psychiatric nursing. (8th ed.). St. Louis: Mosby. Varcarolis, E.M., Carson, V. B., Shoemaker, N. C. (2006). Foundation of psychiatric mental health nursing: a clinical approach. (5th ed). Saunders