The Nurse Client Relationship & Therapeutic Communication
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| TYPES OF RELATIONSHIPS | SOCIAL / INTIMATE RELATIONSHIPS
THERAPEUTIC RELATIONSHIPS
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| SOCIAL / INTIMATE RELATIONSHIPS | Mutual, considers both sets of goals, needs & feelings
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| THERAPEUTIC RELATIONSHIPS | Client focused Exists for and because of needs & goals of the client Patients often get bored with talking about themselves and will try to talk about you
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| FACTORS THAT ENHANCE GROWTH IN OTHERS | 1.Positive Regard
2.Genuineness
3.Empathetic vs. Sympathetic
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| Empathy | 1. Direct identification with, understanding of, and vicarious experience of another person's situation, feelings, and motives.
2. The projection of one's own feelings or emotional state onto an object or animal.
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| Sympathy | the sharing of another's emotions, esp of sorrow or anguish; pity; compassion.
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| BOUNDARIES | Role of nurse and client should be well defined.
Needs of client are separated from those of the nurse.
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| Blurring of Boundaries | -Social or intimate context
-Focus on needs of nurse
-Over-helping
-Controlling
-Narcissism-Excessive love or admiration of oneself.
-Over-identification
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| PHASES OF THE NURSE CLIENT RELATIONSHIP | Phase One
Pre-Interaction Phase
Phase Two
Orientation Phase (Assessment, Diagnosing & Planning)
Phase Three:
Working Phase (Implementation / Intervention)
Phase Four:
Termination Phase (Evaluation)
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| Therapeutic Communication Between the Nurse & Patient | An exchange of information that facilitates a POSITIVE relationship.
Involving the patient in his or her own care.
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| Goal of Therapeutic Communication: | -Obtaining or providing information
-Developing trust
-Showing caring
-Exploring feelings
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| Main points of therapeutic Communication | Ask opened ended questions.
Avoid "why" questions
Use silence, wait for pt to respond.
Encourage pt to share & express of feelings.
Focus on pts feelings.
Support the pts expression of feelings.
Value a pts feelings.
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| Communication Rules to Follow | Rule # 1 - Always clarify message.
Rule # 2 - Be aware of non-verbal cues.
Rule # 3 - When we communicate poorly it causes frustration, loss of respect and errors.
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| APPLICATION of Therapeutic Communication Skills Tactics to DO: | Validate what you are hearing
Use silence
Use active listening
Use of touch
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| APPLICATION of Therapeutic Communication Skills Tactics to Avoid: | NO-argue, challenge, give false reassurance, coerce client into treatment, give approval/ praise
Becomes tied to pt pleasing the nurse
NO-Give Advice, NO Why Questions This implies criticism, can feel intrusive & judgmental-makes pt defensive
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| Anger & Aggression | is harmful to the body systems if prolonged
Myth -“ Getting it all out ” is a useful way to diminish anger
TRUTH - Expressions of anger can lead to Increased anger & Negative physiologic changes.
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| Theories of Anger Behavioral Theory | Emotions are learned responses
Anger and aggression offer Rewards
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| Theories of Anger Cognitive Theory | Event → Thought → Emotion → Behavior
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| Theories of Anger Biological Theory | Correlated with physiologic signs, medical conditions, genetics
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| Feelings that Underlie Anger | Discounted
Embarrassed
Frightened
Frustrated
Found Out
Guilty
Humiliated
Hurt
Ignored
Inadequate
Insecure
Not Heard
Out of Control of Situation
Rejected
Threatened
Tired
Vulnerable
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| Nursing Assessment of Anger & Aggression | Past & Present Hx
background information, culture & childhood environment
-Assess usual coping methods
-Assess meaning of current situation to patient
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| S/sx to identify Anxiety/Irritation before it escalates | increased volume & rate of speech, rigid posture, increased demands, irritability, frowning, reddened face, pacing and/or twisting, jaw clenching, fists, wringing hands, staring with narrowed eyes into the eyes of another (crazy eyes).
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| Anger - Nursing Diagnosis | Ineffective Coping
Risk for Violence Directed at Self or Others
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| Anger GOALS / PLAN | Pt will demonstrate one new constructive method for coping with anger by (date, end-of-shift).
Pt will discuss issues before acting out his anger when he begins to feel angry.
Pt will refrain from injury to self & others.
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| Anger Nursing Interventions | Understand pts verbal & non-verbal cues
Understand pts triggers
Help pt identify thoughts that increase anger
Be aware of pts past aggressive behavior
Acknowledge pts distress to reduce their anxiety
Validate pts anger
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| Anger feelings | Name the underlying feelings leading to anger
Be respectful and apologize when appropriate.
Indicate a willingness to search for solutions.
Use clear & concrete communication.
Be respectful.
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| Working with an angry pt | Do not reinforce the behavior.
Understand your own responses to pt behavior
Set Limits on abusive behavior/language
Be prepared for escalation
-Seclusion
-Restraints
Rule of thumb:
always use the least restrictive approach FIRST !
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| Stress Reduction Methods | Group or social supportCreative imagery
Thought stopping
Meditation
Yoga
Biofeedback
Breathing exercises
Time management
Self-hypnosis
Proper nutrition
Regular exercise
Relaxation response
-Quiet environment
-Passive attitude
-Comfort positio
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| Evaluation of anger | Has pts agitation, aggressiveness or anger:
Diminished?
Resolved?
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| Group Interventions Functions of a Group: | -Socialization
-Support
-Task completion
-Camaraderie
-Information sharing
-Normative
-Empowerment
-Governance
Clients can learn from each other
Support that they find often brings about changes in them
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| MHN wants to strive | We want to strive to empower patients to be involved in their own recovery; be their hope when they have none.
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| Types of Groups Task Groups | accomplishing a specific task with a specific outcome
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| Teaching Groups | Leader has knowledge and shares with others who need it
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| Therapeutic groups | Therapeutic groups focus on interaction between group members; leader keeps them on track and facilitates productive group interaction;
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| Group therapy | typically led by psychologists, advanced degree nurses, social workers
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| Self-Help Groups | Leader is a member and likely has same issue as other group members
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| Physical Conditions that influence Group Dynamics Space | Open space without barriers in seating
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| Physical Conditions that influence Group Dynamics Size | Group size 2-15 depending on the topic
7-8 patients is best according to research; too much lose control; too few not enough interaction
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| Group Membership Open-ended groups | members leave and join at any time
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| Closed-ended groups | all group members join at same time and task is met and group comes to end
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| Curative Factors of Groups | Instilling Hope
Other members with similar problems discuss their ways of overcoming issues
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| Universality | I’m not alone
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| Imparting information | Learning from each other
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| Altruism | concern for the welfare of othersSomeone helps someone else with their problem
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| Corrective recapitulation | Corrective recapitulation of the primary family group
Re-experience conflicts in safe place and get feedback
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| Development of socializing techniques | Helps people get to socialize correctly
Imitative behavior
Interpersonal learning
Group cohesiveness - sense of belonging
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| Catharsis-expressing feelings safely | express feelings + or – in a public setting
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| Catharsis in medicine | Purgation, especially for the digestive system.
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| Catharsis in psychology | Psychology
a. A technique used to relieve tension and anxiety by bringing repressed feelings and fears to consciousness.
b. The therapeutic result of this process; abreaction.
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| Phases of Group Development Phase I | Initial or Orientation phase-Establish rules and goals
-Promotion of trust
-Members are superficial and overly polite
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| Phases of Group Development Phase II | Middle or Working phase-Productively work on tasks
-Leader becomes more of a facilitator
-Member cohesiveness exists
-Conflict is managed by group members
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| Phases of Group Development Phase III | Final or Termination phase
-Group members may feel a sense of loss
-Some members have feelings of abandonment
-Grief for previous losses may be triggered
-Discussion of feelings of loss
-Reminisce about group accomplishments
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| As group nears completion | Old behaviors may come back because of sense of loss due to end of group
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| Autocratic leadership | focus is on the leader
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| Democratic leadership | focus is on the members
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| Laissez-faire leadership | there is no focus
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| Group Member Roles | Members play one of three types of roles within a group:
-Task roles
-Maintenance roles
-Individual (personal) roles
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| Psychodrama | A type of group therapy that employs a dramatic approach
Members become “actors” in life-situation scenarios
Protagonist: Selected to portray life situation
Other members: Play roles of people whom the protagonist has unresolved issues
Dir-grp l
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| Family Therapy | Focus is on treatment of family as a unit
. Family therapy is a form of psychotherapy that involves all the members of a nuclear or extended family.
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| Family Therapy Goal | is to identify and change relationship patterns that are:-Problematic
-Maladaptive
-Self-defeating
-Repetitive
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| Genograms | A family tree diagram that represents the names, birth order, sex, and relationships of the members of a family. Therapists use genograms to detect recurrent patterns in the family history and to help the members understand their problem(s).
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| Nurses Role in Group Interventions | Nurses in psychiatry lead therapeutic groups such as:
-Educational
-Assertiveness training
-Parenting
-Transition to discharge
-Other therapeutic groups
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| psych nursing minimum training | MSN in psych nursing as minimum training for group psychotherapy
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| Community Mental Health Nursing Public Health Model Primary Prevention | reducing incidence of mental disorders within the population; any intervention done with a group that is at risk for a problem
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| Community Mental Health Nursing Secondary Prevention | the problem has occurred; how can the course of the problem be shortened or how can the problem be controlled
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| Community Mental Health Nursing Tertiary Prevention | the disease is present; can’t shorten; can’t control symptoms; how do we prevent bad outcomes and promote maximum function
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| Maturational Crisis 1. Adolescence | Identity v Role confusion
Self esteem, body image, what will I do for career, what are my ideals and values; sexuality; drug and alcohol exposure
Primary Prevention
educational; DARE program
Secondary Prevention
Alcoholics anonymous, Narcotics Anon
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| Maturational Crisis 2. Marriage | One of the most common crises in America
Primary Prevention
premarital classes and counseling sessions
Secondary Prevention
Marriage counseling; to prevent divorce, abuse, homicide, suicide, etc…
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| Maturational Crisis 3. Parenthood | Total responsibility for a human being that can do nothing for itself; sleep patterns are disturbed; economic challenges
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| Maturational Crisis Parenthood Primary Prevention | teaching child development and parenting skills while parents to be are pregnant; provide day care resources
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| Maturational Crisis Parenthood Secondary Prevention | parents aren’t coping well with new parenting duties; getting counseling to prevent bad outcomes; such as abuse; neglect; homicide; etc..
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| Maturational Crisis 4. Midlife | Aging; relationships with kids and parents change; body changes; hormonal changes
Primary Prevention
teaching stress management techniques; medications for hormonal changes
Secondary Prevention
Counseling if there are issues
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| Maturational Crisis 5. Retirement | Negative feelings about lack of productivity; financial issues
Primary Prevention
financial planning; hobbies;
Secondary Prevention
helping remain independence with activities; exercise programs
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| Situational Crisis 1. Poverty | Neglect medical health; nutritional deficiencies; correlation between poverty and mental health issues
Primary Prevention
Educating unemployed about resources
Secondary Prevention
Community shelters; food banks
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| Situational Crisis 2. High rate of life change events | Spouse dies; child dies; sibling dies
Primary Prevention
Education of support groups; encouraging family and friends to be supportive; hospice
Secondary Prevention
Helping patients work through grieving process; and in support groups
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| Situational Crisis 3. Environmental conditions | Tornados, floods, tsunamis,
Primary Prevention
Alerts
Secondary Prevention
Getting resources like red cross to come in to assist
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| Situational Crisis 4. Trauma | Traumatic events; experiences outside the normal range of human experience; military combat; assault victims; POW; tortured vicitms; kidnappee; hostage
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| Situational Crisis Trauma Primary prevention | Teaching vulnerable populations to defend themselves and to escape those situations
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| Situational Crisis Trauma Secondary prevention | Self defense class to avoid another abuse; counseling
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| Tertiary Mental Health Care Individuals with severe and persistent mental illness -Historical and epidemiological aspects | Approximately 100,000 persons with mental illness reside in public mental hospitals
Deinstitutionalization of persons with chronic mental illness began in the 1960s
Large segments of people with chronic mental illness are left untreated
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| Mental health illnesses related to age | Many mental health illnesses don’t show themselves until adolescence or later
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| The Homeless Population | Approximately 25 to 33% of homeless pop suffers from some form of mental illness
Interfering Factor – residential instability
Hlth Issus:
Alcoholism is common
Thermoregulation
Tuberculosis on the rise
Dietary deficiencies
STDs
Spl hlth nds of HL c
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| Community Resources for Homeless Types of resources available: | -Homeless shelters
-Healthcare centers and store-front clinics
-Mobile outreach units
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| Tertiary Community Services Treatment alternatives | -Community mental health centers
-Assertive Community Treatment (ACT)
-Day-evening treatment/Partial hospitalization programs
-Community residential facilities
-Psychiatric home health care
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| Care for the Caregiver | Rest / relaxation periods
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