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NCM 105

PSYCHIATRIC-MENTALHEALTH

NURSING-PART 2Psychiatric Nursing Practice The Nursing Process

Lectured by Leila T. Salera, RN, MD, DPSP


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ECT ELECTROCONVULSIVE THERAPY


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ECT

Has been used continuously for more than 50 years

The induction of a grand mal seizure through theapplication 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 perweek

Performed on an inpatient basis for those that requireclose observation and care (suicidal, agitated,delusional, catatonic, or acutely manic)

( Townsend Chapter 22; Student Guide, pages 53 to 56)


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ECT

Indications:

a. Major depression not often the treatment of choicebut is considered only after a trial of therapy withantidepressant medication has proven ineffective

b. Mania rarely used for this purpose; for those who donot tolerate or fail to respond to lithium or other drugtreatment, or when life is threatened by dangerousbehavior or exhaustion

c. Schizophrenia can induce remission in some clients

with acute schizophrenia, particularly if it isaccompanied by catatonic or affectivesymptomatology; no value among clients with chronicshizophrenia



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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



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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



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ECT

Nursing interventions prior to ECT

a. Explain the procedure

b. NPO for 8 hours (after midnight)

c. Have consent signedd. 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 hourprior to treatment is scheduled

g. Client should remain in bed with side rails up



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ECT

Nursing interventions prior to ECT

h. Client should be changed into a hospital gown

i. Administer premedications 30 minutes prior totreatment atropine or glycopyrolate

(anticholinergics) IMj. Remove anything conductive

k. Stay with client to allay fears and anxiety

l. Maintain a positive attitude

m. Encourage verbalization of feelingsn. Ensure airway patency

o. Restraints as necessary( Townsend Chapter 22; Student Guide, pages 53 to 56)


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ECT

Nursing interventions during ECT

a. Provide suctioning as needed

b. Assist anesthesiologist with oxygenation as

requiredc. Observe readouts on machines monitoring vital

signs and cardiac functioning

d. Provide support to the clients arms and legs

during the seizuree. Observe and record the type and amount of

movement induced by the seizure



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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



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PSYCHOTHERAPY


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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)


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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

Therapists 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)


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GROUPTHERAPY

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



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GROUPTHERAPY

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 ones problems and behaviors and

how they affect others

g. Giving of oneself for the benefit of others (altruism)



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GROUPTHERAPY

Psychotherapy groups

1. Family therapy

2. Family education

3. Education groups4. Support groups

5. Self-help groups



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PSYCHOTHERAPYGROUPS

Goal: for members to learn about their behavior and tomake positive changes in their behavior by interactingand communicating with others as a member of a group

Often formal in structure, with one or two therapists asthe group leaders

Two typesa. 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 samemembers in the group for a specified number of

sessions; members decide how to handle memberswho wish to leave the group and the possibleadmission of new group members



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PSYCHOTHERAPYGROUPS-FAMILYTHERAPY

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 clients psychopathology,

mobilizing the familys 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



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PSYCHOTHERAPYGROUPS-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 membersneed to cope more effectively



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PSYCHOTHERAPYGROUPS-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)


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PSYCHOTHERAPYGROUPS-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 problemsand potential solutions



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PSYCHOTHERAPYGROUPS-SELF-HELP

GROUPS

Members share a common experience, but thegroup 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 ofalcoholics)

Some have national headquarters and Internetwebsites

Most have a rule of confidentiality(Videbeck pages 56 to 61)


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COMPLEMENTARYANDALTERNATIVE

THERAPIES

Alternative medical systems yoga, herbal medicines,acupuncture, etc

Mind-body interventions meditation, prayer. Mentalhealing, 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, qigong, Reiki) and b) bioelectric-based therapies,involving use of electromagnetic fields, such as pulsefields, magnetic fields, and AC or DC fields

(Videbeck, pages 56 to 61)


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PSYCHIATRICREHABILITATION

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 clients 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



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PSYCHOSOCIALINTERVENTIONS

Nursing activities that help enhance the clients

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)


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COMMUNITY-BASEDCARE 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)


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COMMUNITY-BASEDCARE WHO/DOH

Home care is advocated

Acute cases are referred to the National Center forMental Health (NCMH) or hospitals with psychiatricfacilities for proper management

They are screened and after a few days they areassessed and discharged if they can be managed athome

Cases needing continuing supervision and care maybe confined

A team from the NCMH follow up their dischargedpatients in the provinces



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COMMUNITY-BASEDCARE- WELLNESSOF

DAILYLIVING

Wellness of Daily Living The process of attainingand maintaining mental well-being across the lifecycle through the promotion of healthy lifestyle withemphasis 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 promotivemental health services



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COMMUNITY-BASEDCARE- 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 personswith extreme life experiences



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COMMUNITY-BASEDCARE- NURSING

RESPONSIBILITIES

In mental health promotion1. Participate in the promotion of mental health among

families and the community

2. Utilize opportunities in his/her everyday contacts withother members of the community to extend the general

knowledge on mental hygiene3. Help people in the community understand basic

emotional needs and the factors that promote mentalwell being

4. Teach parents the importance of providing emotional

support to their children during critical periods in theirlives like first day in school graduation, etc (Public Health Nursing in the Philippines, 2007, pages 231)


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RESPONSIBILITIES

In prevention and control1. Recognize mental health hazards and stress situations

as unemployment, divorce or abandonment ofchildren, vices, long standing physical illness, all ofwhich make heavy demands on the emotional

resources of the persons concerned2. Recognize pathological deviations from normal in

terms of acting, thinking and feeling and make earlyreferral so that diagnosis and treatment could be doneearly.

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)


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RESPONSIBILITIES

In prevention and control4. Help the family to understand and accept the patients

health status and behavior sp that all its members mayoffer as much support in the readjustments to homeand community

5. Help patient assess his/her capacities and his/herhandicaps in working towards a solution of his/herproblem

6. Encourage feeling of achievement by setting healthgoals that patient can attain

7. Encourage the patient to express his/her anxieties sothat fears and misconceptions can be cleared up



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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)


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RESPONSIBILITIES

Rehabilitation1. Initiate patient participation in occupational activities

best suited to patients capabilities, education,experience and training, capacities and interest

2. Encourage and initiate patients to partake in activities

of CIVIC organization in the community through thecooperation of the patients family

3. Advise the family about the importance of regularfollow-up at the clinic

4. Make regular home visits to observe patientsconditions during conversation and follow-up ofmedication



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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 andrehabilitative measures.



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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 patients 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)


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STANDARD 6 - EVALUATION

When evaluating care the nurse should review allprevious phases of the nursing process and determinewhether expected outcome for the patient have beenmet.

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 thequality of care given.

Evaluation of the patients progress indicates what

problems of the patient have been solved, which need tobe assessed again, replanted, implemented and re-evaluated.

(Videbeck, page 10; The Internet)


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AREASOFPRACTICE

Basic-Level Functionsa. 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 liaisond. Evaluation

e. Program development

f. And management

g. Clinical supervision



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STUDENTCONCERNS

Student concerns are normal

Usually do not persist once the students have initialcontacts 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 clients problems;likewise, no single statement can significantlyworsen them

- Listening carefully, showing genuine interest, andcaring about the client are extremely important



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STUDENTCONCERNS

Some common concerns and helpful hints for beginningstudents:

What will I be doing?

- In the mental health setting, many familiar tasks andresponsibilities are minimal

- Physical care skills or diagnostic tests and proceduresare 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 andpersonal issues

- Development of the therapeutic nurse-client relationshiptakes time and patience



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STUDENTCONCERNS


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



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STUDENTCONCERNS


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



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STUDENTCONCERNS

Some common concerns and helpful hints forbeginning students:

Ho will I handle bizarre or inappropriate behavior?

- It is important to monitor ones facial expressions

and emotional responses so that clients do not feelrejected or ridiculed

- The nursing student instructor and staff are alwaysavailable to assist the student in such situations

- Students should never feel as if they have to handlesituations alone



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STUDENTCONCERNS


What happens if a client asks me for a date ordisplays sexually aggressive or inappropriate

behavior?- Some clients have difficulty recognizing or

maintaining interpersonal boundaries

- When client seeks contact of any type outside thenurse-client relationship, it is important for the

student (with the assistance of the instructor orstaff) to clarify the boundaries of the professionalrelationship



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STUDENTCONCERNS


What happens if a client asks me for a date ordisplays sexually aggressive or inappropriate

behavior?- Likewise, setting limits and maintaining boundaries

are needed when a clients behavior is sexuallyinappropriate

- Initially, the student might be uncomfortable dealing

with such behavior, but with practice and theassistance of the instructor and staff, it becomeseasier to manage



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STUDENTCONCERNS


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 clients privacy and

dignity when he or she cannot do so



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STUDENTCONCERNS


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



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STUDENTCONCERNS


beginning students:

What if I encounter someone I know being treated in

the unit?

- It is essential that the clients 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



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STUDENTCONCERNS


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



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SELF-AWARENESS

The process by which the nurse gains recognitionof his or her own feelings, beliefs, and attitudes

In nursing, being aware of ones feelings, thoughts,and values is a primary focus

What would you do if you were assigned to a clientwho just had an abortion, and you are strongbeliever of anti-abortion?

Will your personal feelings and beliefs interfere withyour work?

The nurse needs to discover him/herself and whathe/she believes before trying to help others withdifferent views



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SELF-AWARENESS- POINTSTOCONSIDER

Keep a dairy or journal that focuses on experiences andrelated feelings

Talk with someone you trust about your experiences and

feelings

Engage in formal clinical supervision. Even experiencedclinicians 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

clients situation and think about his or her feelings,

thoughts, and actions



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SELF-AWARENESS- POINTSTOCONSIDER

Do not be critical of yourself (or others) for havingcertain values or beliefs. Accept them as a part of

yourself, or work to change those values and

beliefs you wish to be different



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THERAPEUTICRELATIONSHIPS

The ability to establish therapeutic relationshipswith 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 requiringpsychiatric care because the therapeutic

relationship and the communication within it serve

as the underpinning for treatment and success


(Student Guide pages 59 to 69)


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COMPONENTSOFA THERAPEUTIC

RELATIONSHIPS

Trust Genuine interest

Empathy

Acceptance

Positive regard

Self awareness and Therapeutic use of self



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RELATIONSHIPS

Trust1. 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



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RELATIONSHIPS

Trust2. Congruence occurs when words and actions

match

Genuine interest

1. The client perceives this when the nurse iscomfortable with him/herself and is aware of hisstrengths and limitations, and is focused

2. A client with mental illness can detect whensomeone is exhibiting dishonest or artificialbehavior



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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 clients shoes Acceptance

1. The nurse does not become upset or respond

negatively to a clients outbursts, anger, or acting out

2. Avoiding judgment(Videbeck pages 80 to 86)


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RELATIONSHIPS

Positive regard1. 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 behavior3. Unconditional nonjudgmental attitude

Self-awareness

1. The nurse must first know him/herself before he or

she can attend to a client2. What are your values, attitudes, and beliefs?



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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 perceptionsto establish relationships with clients



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RELATIONSHIPS

Genuine interestClient: Im so confused! My son just visited and

wants to know where the safety deposit box keyis.

Nurse: Youre confused because your son asked forthe safety deposit box key? (using reflection)

or

Nurse: Are you confused about the purpose of yoursons visit? (using clarification)

COMPONENTS OF A THERAPEUTIC


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RELATIONSHIPS

Acceptance

Client: puts his arm around the nurses 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, lets

continue.Inappropriate response:

Sir, stop that! Whats wrong with you? I am leaving,

and maybe Ill return tomorrow.



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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 didnt help did it?

b. I cant believe you did that.

c. What happened then?

d. You must really be upset.



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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 didnt help did it?

b. I cant believe you did that.

c. What happened then?

d. You must really be upset.



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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) identifiedpreconceptions, or ways one person expects anotherperson to behave or speak, as a roadblock to the

formation of an authentic relationship




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TYPESOFRELATIONSHIPS

Social relationship primarily initiated for thepurpose 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



ESTABLISHING THE THERAPEUTIC


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ESTABLISHINGTHETHERAPEUTIC

RELATIONSHIP

Phases:

1. Orientation phase

2. Working phase

a. Problem identification subphase

b. Exploitation subphase

3. Termination phase

(Videbeck pages 87 to91)




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RELATIONSHIP

Phases:1. Orientation phase

a. Begins when then nurse and client meet and endswhen the client begins to identify problems to

examineb. The nurse establishes the roles, the purpose of

meeting, and the parameters of subsequentmeetings

c. Identifies clients problems

d. Clarifies expectations





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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)




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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



THERAPEUTIC AND NON THERAPEUTIC FORMS


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THERAPEUTICANDNON-THERAPEUTICFORMS

OFCOMMUNICATION

Therapeutic communication

- Is an interpersonal interaction between the nurse

and the client during which the nurse focuses on

the clients specific needs to promote an effective

exchange of information- Helps the nurse understand and empathize with the

clients experience

(Videbeck, page 98 to 116)

THERAPEUTIC AND NON-THERAPEUTIC FORMS


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OFCOMMUNICATION


- 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 clients detailed actions as it unfolds

4. Facilitate the clients expression of emotions

5. Teach the client and family necessary self-care skills

6. Recognize the clients needs

7. Guide the client toward identifying a plan of action to a

satisfying and socially acceptable resolution




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OFCOMMUNICATION

Therapeutic communication- Privacy and Respecting Boundaries

1. Privacy is desirable, but not always possible in a therapeuticcommunication

2. Proxemics the study of distance zones between peopleduring communication

a. Intimate zone 0 to 18 inches between people; parents andyoung children, people who mutually desire personal contact

b. Personal zone 19 to 36 inches; between family and friendswho are talking

c. Social zone 4 to 12 feet; acceptable for communication in

social, work, and business settingsd. Public zone 12 to 25 feet; speaker and audience, small

groups, and other informal functions




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OFCOMMUNICATION

Therapeutic communication1. Verbal communication uses concrete messages

and abstract messages

2. Non-verbal communication body language, eye

contact, facial expression, tone of voice, speedand hesitations in speech, grunts and groans, anddistance from the listeners




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OFCOMMUNICATION


1. Touch

a. Functional-professional touch

b. Social-polite touch

c. Friendship-warmth touch

d. Love-intimacy touch




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THERAPEUTICANDNON THERAPEUTICFORMS

OFCOMMUNICATION


1. Concrete messages the words are explicit and

need no interpretation

2. Abstract messages requires interpretation by the

listener like figure of speeches




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OFCOMMUNICATION


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?




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OFCOMMUNICATION


Abstract (unclear): Get the stuff from him.

Concrete (clear): Hell 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, youll have to be able to calculate

dosages correctly by the end of todays class.




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OFCOMMUNICATION

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



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THERAPEUTICCOMMUNICATIONTECHNIQUES

Accepting indicating reception, you are listeningand 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 clientfeel that he or she has the lead interaction

Is there something youd like to talk about?

Consensual validation searching for mutualunderstanding, for accord in the meaning of the

words; to avoid any misunderstandingTell me whether my understanding of it agrees with

yours.


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Encouraging comparison asking that similaritiesand differences be noted

Was it something like?

Encouraging description of perception asking the

client to verbalize what he or she perceivesWhat is happening?

Encouraging expression asking the client toappraise the quality of his or her experiences

Tell me more about that.

Focusing concentrating on a single point

Of all youve mentioned, which is the mosttroublesome?


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Formulating a plan of action asking the client toconsider kinds of behavior likely to be appropriate

in the future

General leads giving encouragement to continue

Giving information making available the facts thatthe client needs

Giving recognition acknowledging, indicating

awareness

Good morning, sir.

I noticed that youve combed your hair.


96/105


Making observations verbalizing what the nurseperceives

You appear tense.

Offering self making oneself available

Ill 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.


97/105


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 cant sleep. I stay awake all night.

Nurse: You have difficulty sleeping.

Seeking information seeking to make clear thatwhich is not meaningful or that which is vague

Nurse: Im not sure I follow.

Nurse: Have I heard you correctly.


98/105


Silence nurse says nothing but maintains eyecontact

Suggesting collaboration offering to share, to

strive, and to work with the client to his or her

benefitNurse: Lets go to your room, and Ill help you find

what youre looking for.

Summarizing organizing and summing up that

which has gone beforeNurse: Have I got this straight.

Nurse: Youve said that


99/105


Translating into feelingsseeking to verbalize clientsfeelings that he or she expresses only indirectly

Client: Im dead.

Nurse: Are you suggesting that you feel lifeless?

Verbalizing the implied voicing what the client hashinted or suggested

Client: I cant talk to you or anyone. Its a waste of time.

Nurse: Do you feel that no one understands?

Voicing doubt expressing uncertainty about the reality

of the clients perceptionsNurse: Really?

NON-THERAPEUTICCOMMUNICATION


100/105

TECHNIQUES

Advising telling client what to doNurse: I think you should. or Why dont you?

Agreeing indicating accord with the client

Belittling feelings expressed misjudging the

degree of the clients discomfort Challenging demanding proof from the client

Defending attempting to protect someone orsomething from verbal attack

Nurse: This hospital has a fine reputation. or I amsure your doctor has your best interests in mind.



101/105

TECHNIQUES

Disagreeingopposing the clients ideas Disapprovingdenouncing the clients behavior or

ideas; implies that the nurse has the right to pass

judgment

Giving approvalsanctioning the clients behavior orideas; tends to limit the clients 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: Theyre looking in my head with a TV camera.

Nurse: Try not to watch TV. or What channel?



102/105

TECHNIQUES

Indicating an existence of an external sourceattributing the source of thoughts, feelings, and behaviorto others or to outside influences

Nurse: What made you say that? implies that the clientis compelled to think a certain way

Interpreting asking to make conscious that which isunconscious, telling the client the meaning of his or herexperience. The clients thoughts and feelings are hisown, hidden meaning are not meant for the nurse todiscover, only the client knows.

Nurse: What you really mean is or Unconsciously,

youre saying Introducing an unrelated topic changing the subject

Client: Id like to die.

Nurse: Did you have visitors this evening?



103/105

TECHNIQUES

Making stereotyped comments offeringmeaningless clichs or trite comments

Nurse: Its for your own good. or Just have a

positive attitude and youll 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.



104/105

TECHNIQUES

Rejecting refusing to consider or showing contempt forthe clients ideas or behaviors This closes the chances

of exploration, and the client may feel personally

rejected along with feelings or ideas

Nurse: Lets not discuss. or I dont 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, andusually a why question is intimidating

Nurse: Why do you think that? or Why do you feel that

way?



105/105

TECHNIQUES

Testingappraising the clients degree of insight, whichforces the client to recognize his or her problem. Helpfulto the nurse, but not to the client

Nurse: Do you know what kind of hospital this is? or Doyou still have the idea that.?

Using denial refusing to admit that a problem exists.This implies that the nurse dismisses the seriousness ofthe situation

Client: Im nothing.

Nurse: Of course youre something everybodyssomething.

Client: Im dead.

Nurse: Dont be silly.

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