THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUES EXAMPLESUsing silence

Accepting YesHh hmmI follow what you saidNodding

Giving Recognition Good morning, Mr. S.You look nice today

Offering Self I’ll sit with you a whileI’m interested in your comfort

Giving Broad Openings Is there something you would like to talk about?Where would you like to begin?

Offering General Leads/Facilitation Go onTell me about it

Placing the Event in Time or Sequence

Was this before or after?When did this happen?

Making Observations You seem tenseAre you uncomfortable when you.

Encouraging Description of Perception

What is happeningTell me

Encouraging Comparisons Was this something like?Have you had similar symptoms.

Restating Client: I can’t sleep, I stay awake all night.Nurse: You have difficulty sleeping?

Reflecting Client: Do you think I should tell the doctor?Nurse: Do you think you should.

Focusing This symptom seems worth discussing a little bit more.

Exploring Tell me more about...Would you describe it more fully?

Seeking Clarification I’m not sure that I follow....What would you say is the main point of what you said?

Voicing Doubt Isn’t that unusual?Really?

Consensus Validation Tell me whether my understanding agrees with yours?

Collaboration Perhaps together we can figure this out.

Summarizing Have I got this straight?You’ve said thatDuring the past 15 minutes we’ve discussed.

TECHNIQUES FOR COMMUNICATING WITH ELDERLY CLIENTS

I. Factors Influencing Communication with the Elderly

Client Factors

A. Anxiety:Many elderly clients may function continually at a high level of anxiety. Thus,

the increased stress of a new situation may lead to intense arousal, impairing the elderly person’s ability to communication effectively.

B. Sensory Deprivation:Hearing loss is a widespread problem among the elderly. Its affects men more

than women and occurs in some 30% of all elderly. Hearing loss is potentially the most difficult sensory loss for the elderly client. Although 80% of the elderly have fair to adequate vision, some visual problems may occur.

C. Cautiousness:Older clients tend to make few errors of commission but are likely to make errors

of omission. When taking a history, the nurse must be aware that elderly clients may omit important aspects of their illnesses. Elderly clients take longer to respond to inquires.

D. Persistent Themes:The elderly client may concentrate on particular themes:

Somatic Concerns: Clients may spend much time complaining of ailments or recounting detailed histories of bodily functions. At a time when friends and loved ones have died and sensory input is decreased, the body, in many ways, keeps the client company. It is, therefore quite usual for the elderly client to be somatically oriented.

Loss Reactions: The elderly client may spend considerable time discussing the many losses experienced in later life. These include loss of friends and loved ones, loss of activities, and loss of self esteem.

Life Review: There is tendency in the elderly to reflect and reminisce. This is a normal process brought about by disillusion and realization that death is approaching.

Fear of Losing Control: Many elderly clients agonize over the loss of physical and mental functions, including physical strength, bowel and bladder control, motor functions, and especially, the ability to regulate one’s thoughts and emotions. One of the greatest fears of late life is the fear of “going crazy”.

Death: The elderly are not, as a rule, obsessed with approaching death. It nevertheless, is a frequent topic of conservation. The major fear is of being alone at the end of life.

Nurse Factors:

A. Attitudes toward the Elderly:It is quite common to find fears of aging and death among members of our youth

oriented society. The recognition of such fears and of the nurse’s personal feelings about these issues is of utmost importance in establishing effective communication with the elderly.

B. Lack of Understand:The nurse must attempt to separate myths about aging from reality. For example,

the labeling and stereotyping of the elderly may be a significant barrier to communication. The elderly are especially sensitive to being labeled “senile”, “mentally ill”, for “hypochondriac”. The nurse should try to empathize with the elderly client. Putting your self in the other person’s shoes is an ability not easily taught by text books and can only be learned through personal experiences.II. Techniques of Effective Communication

Approach the Elderly Client with Respect:The nurse should knock before entering the client’s room and approach the client from the front. Greet the client by surname, (Mr. Smith, Mrs. Rose) rather than by given name (Johnny, Mary), unless the client wishes to be addressed by a given name.

Position Yourself Near the Elderly Client:The nurse should be close enough to the client to be able to reach out and touch the client if desired. The most comfortable arrangement of chairs for both parities is at a 45 degree angle to each other. If possible, chairs should be the same height and the nurse should not stand or walk during the conservation.

Speak Clearly and Slowly:The elderly client may have a hearing problem or may not understand a nurses’

accent. Clarity of speech and the use of simple sentences is most effective in communicating with an elderly client.

Inquire Actively and Systematically into the Problem Presented:The nurse should inquire into common physical symptoms of later life (such as

visual and auditory defects, falls, and weight loss) and typical psychosocial problems (death of a loved one, change in living arrangements, recent retirement, financial setback, feelings of decreased self esteem, hopelessness, and anxiety).

Pace the Interview:The elderly client must be give enough time to respond to the nurses questions.

The elderly are not, as a rule, uncomfortable with silences, which give them an opportunity to formulate answers to questions, and to elaborate on certain points. A slow and relaxed pace in the interview will do much to decrease anxiety.

Pay Attention to Nonverbal Communication:The nurse should be alert for changes in facial expression, gestures, postures, and

touch as auxiliary methods of communication in the elderly. These nonverbal signs can provide considerable information about conditions such as depression or anxiety.

Touch:Touch may also be an effective way to relax and make contact with the elderly

client. As a rule, the elderly are less inhibited about physical touch. Holding the client’s hand or resting your hand on his arm may be very reassuring.

Be Realistic but Hopeful:Nurses who work with the elderly often deny the problems of later life. But

neither the client nor the nurse believe phrases like “You’ll live to be a hundred”, or “It’s nothing to worry about”, and the nurse should avoid using them. The nurse should never abandon all hope for an elderly client, but should work in the here and now. Avoiding unrealistic expectations, three pain free days may be most rewarding to the client dying of cancer, a fact too often overlooked.

TOPIC: TECHNIQUES FOR COMMUNICATING WITH CHILDREN

Age Group Characteristics Communication TechniquesToddlers Limited vocabulary &

verbal skillsMake explanations brief and clear. Use child’s own vocabulary words for basic are activities (urinate = pee pee, tinkle), learn and use self name of child. Get to know child first before approaching child. Show you can be a friend with mommy.

Speaks in phases Rephrase child’s message in a simple complete sentence: avoid baby talk.

Kinesthetic Allow ambulation when possible. Put child in a wagon if child is not mobile.

Struggling with issues of autonomy and control

Allow child some control. Reassure child if he or she displays some regressive behavior. (Example: If child wets his pants, say, “We will get a dry pair of pants and let’s find something fun to do”). Allow child to express anger and to protest about his care (Example: Say “it’s OK to cry when you are angry or hurt). Allow to sit up or walk, as often as possible and as soon as possible after intrusive or hurtful procedures, say, “It’s all over and we can do something more fun”).

Fear of Bodily Injury Show hands (free of hurtful items) and say. “There is nothing to hurt you. I came to play/talk.

Egocentrism Allow child to be self oriented and accepted. Use distraction if another child wants the same item or toy rather than expect child to share.

Direct Questions Use non-directive approach. Sit down and join the parallel play of child.

Separation Anxiety Accept protesting when parents leave. Hug, rock the child, and say “You miss mommy and daddy, They miss you too.”

Preschoolers Speaks in sentences but unable to comprehend abstract ideas.

Use simple vocabulary; avoid lengthy explanations. Focus on the present. Use play therapy and drawings.

Unable to tolerate direct eye to eye contact.

Use some eye contact. Sit or stoop and use slow, soft tone of voice.

Short attention span and imaginative stage

Use play therapy. Use sensory data. Use music.

Concrete sense of humor Tell corny jokes and laugh with childNeed for control Provide for many choices. “Do you want

to get dressed now or after breakfast?”School Age Developing ability to

comprehendInclude child in concrete explanations about condition, treatment, protocols. Use draw a person. Use sensory information in giving explanations.

Increased responsibility for health care.

Reinforce basic care activities in teaching.

Increased need for privacy. Respect privacy; knock on door before entering room: tell client when and for what reasons you will need to return to his/her room.

Early Adolescent

Increased comprehension about possible negative threats to life or body integrity, yet some difficulty in adhering to long term goals.

Verbalize issues about treatment protocols requiring giving up immediate gratification for long term gain. Explore alternative options.

Confidentiality Reassure about confidentiality of your

discussion, but clearly state limits of confidentially.

Struggling to establish Allow participation in decision making.identify and be independent Actively listen. Accept regression.

Avoid judgmental approach. Use clarifying and qualifying approach.

Beginning to demonstrate abstract thinking.

Use abstract thinking, but look for nonverbal clues that indicate lack of understanding.

Uses colloquial language Touch your dialogue with the use of some of client’s own words.

Sexual Awareness and maturation

Offer self and willingness to listen. Provide value free, accurate information.

Example of a Therapeutic Conversation Expressing Empathy

Client: I can't believe the terrible job I did on that project.

Clinician: You seem too feel a deep sense of shame about your project.

Client: Yes, I do feel ashamed. I just always screw things up.

Clinician: You're sounding really frustrated with yourself.

Client: Yes, I am. I mean, it's not just at my job. I screwed up my relationship with my son. I screwed up my exercise program by stopping only two weeks into it.

Clinician: You're blaming yourself for all those things. Help me understand that better. I wonder if you ever feel like you screwed things up in our work together.

Client: Yes, I did. Remember when I called you at home when my sister had hurt herself again and was admitted to the hospital? I was so upset and really felt like I needed to talk to you even though it was not a scheduled appointment.

Clinician: Sounds like you felt like that wasn't okay with me. I wonder how you thought I reacted to the call?

Client: Well, you didn't sound annoyed. I remember you tried to help me. Still, I felt I had done a stupid thing.

Example of a Similar Conversation, Expressing Sympathy

In this example, instead of the therapeutic skill of empathy, the "clinician" expresses sympathy, which further entrenches the client in a downward spiral of bad feelings. This example is given to show the importance of empathy in the therapeutic alliance.

Client: I can't believe the terrible job I did on that project.

Clinician: I'm sorry you did so poorly.

Client: Yes, I am too. I guess I just don't have a good work ethic. I should just accept that this job is above me.

Clinician: That's really a shame.

Client: Yes, I really needed this higher salary. My wife and kids are kind of depending on me.

Clinician: How unfortunate that you might let them down like that.

Empathy is an essential part of the therapeutic conversation. Sympathy, on the other hand, is not.

Example of a Therapeutic Conversation

Clinician: One thought you had was that your son was failing out of school. What led you to have that thought?

Client: Well, he wouldn't show me his report card. It makes me think he failed something.

Clinician: He may have. Does he have a history of failing classes?

Client: No. He usually gets "As" and "Bs."

Clinician: So this is the first time you have suspected that he may have failed a class?

Client: Yes.

Clinician: And what is your definition of "failing out of school?"

Client: I guess it would be someone who has failed several classes so that the person was not asked back to the school.

Clinician: And does that sound like your son?

Client: No, I guess I overreacted when I said he was failing out of school.

Clinician: And what about your thought that you are to blame for his behavior? What led you to think that?

Client: I'm his parent. Aren't I the biggest influence in his life?

Clinician: Yes, your role certainly is an important one. How might you have encouraged your son to fail out of school?

Client: I don't know what you mean.

Clinician: I wonder if you have failed out of school yourself.

Client: No, of course not.

Clinician: Perhaps you condone failure, or didn't try to teach him that school success is important?

Client: No. Just the opposite. I have very strong feelings about the importance of education. I always tried to show my son by example how to succeed.

Clinician: I'm confused, then, about how you may have caused him to fail.

Client: I guess I was just feeling bad and wanted to find an explanation. But I can see that I certainly never taught him to fail.

Restating

Restating what the patient has said shows him that the nurse has listened to and understands what he has articulated. It may also give the patient a new perspective on his situation.

Patient: "I won't ever be able to use this electric wheelchair!" Nurse: "You're concerned that you won't be able to use the devices on your new wheelchair."

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Open-Ended Question

In this scenario, the psychiatrist asks the patient an open-ended question to facilitate the opportunity for a broad response. As opposed to a closed-ended question, this type of communication avoids the perception of judgment and allows the patient to speak what is truly on his mind regarding the topic.

Psychiatrist: "What kind of relationship did you have with your mother?" Patient: "She was horrible to me but good to my brother and I was the one who tried to please her."

A closed-ended question may be non-therapeutic in this circumstance:

Psychiatrist: "Did you have a good relationship with your mother?" Patient: "It was all right."

Stating Observations

The therapist may make an observation when he notices that the patient isn't talking about how he feels. This may help the patient verbalize his feelings, explains NurseReview.org.

Therapist: "You seemed angry with your son today." Patient: "Yes, he really hurt my feelings by telling people that I'm crazy. Who does he think he is? I worked 12 hours a day putting him through school and now he treats me like this."

Acceptance

The doctor may use verbal and nonverbal cues to convey unconditional acceptance of the patient's feelings. This allows the patient to feel understood and comfortable to continue to explain her feelings. Not arguing with the patient's point of view gives her the opportunity to fully consider the issue without feeling defensive.

Patient: "I am so disappointed that my husband put me in this nursing home." Doctor: "I understand." The doctor makes eye contact with the patient and nods his head. Patient: "I guess I can sort of understand it. His arthritis keeps him in a lot of pain, making it hard for him to take care of me."

Silence

Being silent gives the patient an opportunity to consider his thoughts, explains Michael Zychowicz, a Mount Saint Mary College faculty member. The psychologist shows the patient her support by sitting quietly with him as he collects his thoughts, fostering the therapeutic relationship.

The psychiatrist is silent or says, "I will sit quietly with you; I can tell you have something serious on your mind."

Therapeutic Technique

1. Offering Self

making self-available and showing interest and concern. “I will walk with you”

2. Active listening

paying close attention to what the patient is saying by observing both verbal and non-verbal cues.

Maintaining eye contact and making verbal remarks to clarify and encourage further communication.

3. Exploring

“Tell me more about your son”

4. Giving broad openings

What do you want to talk about today?

5. Silence

Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say more.

6. Stating the observed

verbalizing what is observed in the patient to, for validation and to encourage discussion

“You sound angry”

7. Encouraging comparisons

asking to describe similarities and differences among feelings, behaviors, and events.

“Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?”

8. Identifying themes

asking to identify recurring thoughts, feelings, and behaviors. “When do you always feel the need to check the locks and doors?”

9. Summarizing

reviewing the main points of discussions and making appropriate conclusions. “During this meeting, we discussed about what you will do when you feel the

urge to hurt your self again and this include…”

10. Placing the event in time or sequence

asking for relationship among events. “When do you begin to experience this ticks? Before or after you entered grade

school?”

11. Voicing doubt

voicing uncertainty about the reality of patient’s statements, perceptions and conclusions.

“I find it hard to believe…”

12. Encouraging descriptions of perceptions

asking the patients to describe feelings, perceptions and views of their situations. “What are these voices telling you to do?”

13. Presenting reality or confronting

stating what is real and what is not without arguing with the patient. “I know you hear these voices but I do not hear them”. “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.

14. Seeking clarification

asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is unclear.

“I am not familiar with your work, can you describe it further for me”. “I don’t think I understand what you are saying”.

15. Verbalizing the implied

rephrasing patient’s words to highlight an underlying message to clarify statements.

Patient: I wont be bothering you anymore soon. Nurse: Are you thinking of killing yourself?

16. Reflecting

throwing back the patient’s statement in a form of question helps the patient identify feelings.

Patient: I think I should leave now. Nurse: Do you think you should leave now?

17. Restating

repeating the exact words of patients to remind them of what they said and to let them know they are heard.

Patient: I can’t sleep. I stay awake all night. Nurse: You can’t sleep at night?

18. General leads

using neutral expressions to encourage patients to continue talking. “Go on…” “You were saying…”

19. Asking question

using open-ended questions to achieve relevance and depth in discussion. “How did you feel when the doctor told you that you are ready for discharge

soon?”

20. Empathy

recognizing and acknowledging patient’s feelings. “It’s hard to begin to live alone when you have been married for more than thirty

years”.

21. Focusing

pursuing a topic until its meaning or importance is clear. “Let us talk more about your best friend in college” “You were saying…”

22. Interpreting

providing a view of the meaning or importance of something. Patient: I always take this towel wherever I go. Nurse: That towel must always be with you.

23. Encouraging evaluation

asking for patients views of the meaning or importance of something. “What do you think led the court to commit you here?” “Can you tell me the reasons you don’t want to be discharged?

24. Suggesting collaboration

offering to help patients solve problems. “Perhaps you can discuss this with your children so they will know how you feel

and what you want”.

25. Encouraging goal setting

asking patient to decide on the type of change needed. “What do you think about the things you have to change in your self?”

26. Encouraging formulation of a plan of action

probing for step by step actions that will be needed. “If you decide to leave home when your husband beat you again what will you do

next?”

27. Encouraging decisions

asking patients to make a choice among options. “Given all these choices, what would you prefer to do.

28. Encouraging consideration of options

asking patients to consider the pros and cons of possible options. “Have you thought of the possible effects of your decision to you and your

family?”

29. Giving information

providing information that will help patients make better choices. “Nobody deserves to be beaten and there are people who can help and places to

go when you do not feel safe at home anymore”.

30. Limit setting

discouraging nonproductive feelings and behaviors, and encouraging productive ones.

“Please stop now. If you don’t, I will ask you to leave the group and go to your room.

31. Supportive confrontation

acknowledging the difficulty in changing, but pushing for action. “I understand. You feel rejected when your children sent you here but if you look

at this way…”

32. Role playing

practicing behaviors for specific situations, both the nurse and patient play particular role.

“I’ll play your mother, tell me exactly what would you say when we meet on Sunday”.

33. Rehearsing

asking the patient for a verbal description of what will be said or done in a particular situation.

“Supposing you meet these people again, how would you respond to them when they ask you to join them for a drink?”.

34. Feedback

pointing out specific behaviors and giving impressions of reactions. “I see you combed your hair today”.

35. Encouraging evaluation

asking patients to evaluate their actions and their outcomes. “What did you feel after participating in the group therapy?”.

36. Reinforcement

giving feedback on positive behaviors. “Everyone was able to give their options when we talked one by one and each of

waited patiently for our turn to speak”.

Avoid pitfalls:

1. Giving advise2. Talking about your self3. Telling client is wrong4. Entering into hallucinations and delusions of client5. False reassurance6. Cliché7. Giving approval8. Asking WHY?9. Changing subject10. Defending doctors and other health team members.

Non-therapeutic Technique

1. Overloading

talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time.

“What’s your name? I see you like sports. Where do you live?”

2. Value Judgments

giving one’s own opinion, evaluating, moralizing or implying one’s values by using words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.

“You shouldn’t do that, its wrong”.

3. Incongruence

sending verbal and non-verbal messages that contradict one another. The nurse tells the patient “I’d like to spend time with you” and then walks away.

4. Underloading

remaining silent and unresponsive, not picking up cues, and failing to give feedback.

The patient ask the nurse, simply walks away.

5. False reassurance/ agreement

Using cliché to reassure client. “It’s going to be alright”.

6. Invalidation

Ignoring or denying another’s presence, thought’s or feelings. Client: How are you? Nurse responds: I can’t talk now. I’m too busy.

7. Focusing on self

responding in a way that focuses attention to the nurse instead of the client. “This sunshine is good for my roses. I have beautiful rose garden”.

8. Changing the subject

introducing new topic inappropriately, a pattern that may indicate anxiety. The client is crying, when the nurse asks “How many children do you have?”

9. Giving advice

telling the client what to do, giving opinions or making decisions for the client, implies client cannot handle his or her own life decisions and that the nurse is accepting responsibility.

“If I were you… Or it would be better if you do it this way…”

10. Internal validation

making an assumption about the meaning of someone else’s behavior that is not validated by the other person (jumping into conclusion).

The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood.

Other ineffective behaviors and responses:

1. Defending – Your doctor is very good.2. Requesting an explanation – Why did you do that?3. Reflecting – You are not suppose to talk like that!4. Literal responses – If you feel empty then you should eat more.5. Looking too busy.6. Appearing uncomfortable in silence.7. Being opinionated.8. Avoiding sensitive topics9. Arguing and telling the client is wrong10. Having a closed posture-crossing arms on chest

11. Making false promises – I’ll make sure to call you when you get home.12. Ignoring the patient – I can’t talk to you right now13. Making sarcastic remarks14. Laughing nervously15. Showing disapproval – You should not do those things.

One of the most important skills of a nurse is developing the ability to establish a therapeutic relationship with clients. For interventions to be successful with clients in a psychiatric facility and in all nursing specialties it is crucial to build a therapeutic relationship. Crucial components are involved in establishing a therapeutic nurse-patient relationship and the communication within it which serves as the underpinning for treatment and success. It is essential for a nurse to know and understand these components as it explores the task that should be accomplish in a nurse-client relationship and the techniques that a nurse can utilize to do so.

TRUST

Without trust a nurse-client relationship would not be established and interventions won’t be successful. For a client to develop trust, the nurse should exhibit the following behaviors:

Friendliness Caring Interest Understanding Consistency Treating the client as human being Suggesting without telling Approachability Listening Keeping promises Providing schedules of activities Honesty

GENUINE INTEREST

Another essential factor to build a therapeutic nurse-client relationship is showing a genuine interest to the client. For the nurse to do this, he or she should be open, honest and display a congruent behavior. Congruence only occurs when the nurse’s words matches with her actions.

EMPATHY

For a nurse to be successful in dealing with clients it is very essential that she empathize with the client. Empathy is the nurse’s ability to perceive the meanings and feelings of the client and communicate that understanding to the client. It is simply being able to put

oneself in the client’s shoes. However, it does not require that the nurse should have the same or exact experiences as of the patient. Empathy has been shown to positively influence client outcomes. When the nurse develops and utilizes this ability, clients tend to feel much better about themselves and more understood.

Some people confuse empathizing with sympathizing. To establish a good nurse-patient relationship, the nurse should use empathy not sympathy. Sympathy is defined as the feelings of concern or compassion one shows for another. By sympathizing, the nurse projects his or her own concerns to the client, thus, inhibiting the client’s expression of feelings. To better understand the difference between the two, let’s take a look at the given example.

Client’s statement:

“I am so sad today. I just got the news that my father died yesterday. I should have been there, I feel so helpless.”

Nurse’s Sympathetic Response:

“I know how depressing that situation is. My father also died a month ago and until now I feel so sad every time I remember that incident. I know how bad that makes you feel.”

Nurse’s Empathetic Response:

“I see you are sad. How can I help you?”

When the nurse expresses sympathy for the client, the nurse’s feelings of sadness or even pity could influence the relationship and hinders the nurse’s abilities to focus on the client’s needs. The emphasis is shifted from the client’s to the nurse’s feelings thereby hindering the nurse’s ability to approach the client’s needs in an objective manner.

In dealing with clients their interest should be the nurse’s greatest concern. Thus, empathizing with them is the best technique as it acknowledges the feelings of the client and at the same time it allows a client to talk and express his or her emotions. Here a bond can be established that serves as a foundation for the nurse-client relationship.

Therapeutic Communication Techniques Examples

1. Using silence The client says: "We drink and smoke a lot here." The student thinks…how can that be…drinking alcohol in a state hospital? But says nothing…using silence…the client then says: "yes we drink a lot of cokes and smoke a lot."

2. Accepting "Yes" or "I follow what you said" 

3. Giving Recognition "I notice you combed your hair."

4. Offering self "I'll sit with you awhile."

5. Using Broad Openings "What would you like to talk about?"  

"Tell me what's bothering you."

6. Using General Leads (using neutral expressions to encourage continued talking by the client)

"Go on.    " Ummm..I am listening" 

"Tell me about it"

7. Placing he event in time or sequence "Was this before or after…?" 

"What seemed to lead up to…?"

8. Making Observations "You appear tense" 

"I notice you are biting your lips."

9. Encouraging Description of Perceptions "What do you think is happening to you right now…?"

10. Restating Client: "I can't sleep. I stay awake all night." 

Nurse: "You have difficulty sleeping" 

11. Reflecting Patient: "Do you think I should tell the doctor?" 

Nurse: "Do you think you should tell the doctor?"

12. Focusing "This point seems worth looking at more closely." 

"You said something earlier that I want you to go back to."

13. Exploring "Would you describe that more fully."

14. Giving Information "My name is…I am a student nurse.."

15. Seeking Clarification "What would you say is the main point of what you said?"

16. Presenting Reality "Your mother is not here…I am a nurse." 

Patient: "Did you bring my car today?" 

Nurse: "No, you do not have a car. I drove my car

here today."

17.. Voicing Doubt "That's hard to believe." 

"Really?"

18. Seeking Consensual Validation  

19. Verbalizing the Implied  

20. Encouraging Evaluation (asking for the client's view of the meaning or importance of something)

"How important is it for you to change this behavior?" 

21. Attempting to Translate Into Feelings " From what you say, I suspect you are feeling relieved."  

22. Suggested Collaboration  "Let's see if we can figure this out.."

23. Summarizing " Let's see, so far you have said..."

24. Encouraging Formulation of a Plan of Action "What will it take to reach your goal of not hitting anyone?" 

25. Identifying themes  ..asking client to identify recurrent patterns in thoughts, feelings, and behaviors

 "So what do you do each time you drink too much and it's time to go home?"  What is the major feeling you have about all men?"

  Nursing Process in Psychiatric Nursing

Mrs. Jyoti Beck, RN, RM,DPN RINPAS, Ranchi, India This page was last updated on March 8, 2011

Outline

Introduction Assessment Nursing Diagnosis Outcome Identification Planning Implementation Evaluation Components of Assessment Sample of Nursing Care Plan

References

Introduction

The nursing process is an interactive, problem-solving process. It is systematic and individualized way to achieve outcome of nursing care.

The nursing process respects the individual’s autonomy and freedom to make decisions and be involved in nursing care.

The nursing process is accepted by the nursing profession as a standardfor providing ongoing nursing care that is adapted to individual client needs.

The nurse and the patient emerge as partner in a relationship built on trust and directed toward maximising the patient’s strengths, maintaining integrity, and promoting adaptive response to stress.

In dealing with psychiatric patients, the nursing process can present unique challenges.

Emotional problems may be vague, not visible like many physiological disruptions.

Emotional problems can also show different symptoms and arise from a number of causes. Similarly, past events may lead to very different form of present behaviours. Many psychiatric patients are unable to describe their problems.

They may be highly withdrawn, highly anxious, ,or out of touch with reality.

Their ability to participate in the problem solving process may also be limited if they see themselves as powerless.

Nursing process aims at individualized care to the patient and the care is adapted to patient’s unique needs. Nursing process the following steps;

Assessment Nursing Diagnosis

Outcome Identification

Planning

Implementation  and

Evaluation

Assessment

Individualized care begins with a detailed assessment as soon as the patient is admitted. In the Assessment phase, information is obtained the patient in a direct and structured manner through observation, interviews and examination. Initial interview includes an evaluation of mental status. In such cases, where the patient is too ill to participate in or complete the interview, the behaviour the patient exhibits to be recorded and reports from  family members if possible, can obtained. Even when the initial assessment is complete, each encounter with the patient involves a continuing assessment .The ongoing assessment involves what patient is saying or doing at that moment.

HEALTH HISTORY AND PHYSICAL ASSESSMENT

1. Client’s complaint, present symptom and focus of concern2. Perceptions and expectations3. Previous hospitalizations and   mental health treatment4. Family history5. Health beliefs and practices6. Substance use7. Sexual history8. Abuse9. Spiritual10. Basic needs (diet, exercise, sleep, elimination)11. Sociocultural12. Coping patterns13. Self-esteem14. Medical Examination15. Diagnostic Investigations 16. Mental Status Examination

Subjective Data Objective Data

Name and general information about theclient

Client’s perception of current stressor orproblem

Current occupational or work situation

Any recent difficulty in relationships

Any somatic complaints

Physical exam Behavior Mood and affect Awareness Thought processes Appearance Activity Judgment Response to

environment

Current or past substance use

Interests or activities previously enjoyed

Sexual activity or difficulties

Perceptual ability

When the nurse investigates a patient’s specific behaviour, it is valuable to explore the following,

Situation that precipitated that behaviour What the patient was thinking at that moment?

Whether that behaviour makes any sense in that context?

Whether the behaviour was adaptive or dysfunctional?

Whether a change is needed?

If the nurse has to interview the patient she should select a private place, free from noise and distraction and interview should be goal directed. Although the patient is a  regarded as a source of validation , the nurse should also be prepared to consult with family members or other people  knowledgeable about the patient. This is particularly important when the patient is unable to provide reliable information because the symptoms of the psychiatric illness. She should gather Information from other information sources, including health care records, nursing rounds, change- of shifts, nursing care plans and evaluation of other health care professionals.

Nursing Diagnosis

After collecting all data, the nurse compares the information and then analyses the data and derives a nursing diagnosis.

A nursing diagnosis is a statement of the patient’s nursing problem that includes both the adaptive and maladaptive health responses and contributing stressors.

These nursing problems concern patient’s health aspects that may need to be promoted or with which the patient needs help.

A nursing diagnosis may be an actual or potential health problem, depending on the situation.

The most commonly used standard is that of the North

American Nursing Diagnosis Association (NANDA).

A nursing diagnostic statement consists of three parts:

Health problem Contributing factors

Defining characteristics

The defining characteristics are helpful because they reflect the behaviour that are the target of nursing intervention .They also provide specific indicators for evaluating the outcome of psychiatric nursing interventions and for determining whether the expected goals  of the nursing care were met.

Example:

If a patient is making statements about dying, he is isolative, anorexic, cannot sleep and wants to die. Then the nursing diagnosis can be-

Helplessness, related to physical complaints, as evidenced by decreased appetite and verbal cues indicating despondency.

Fatigue related to insomnia, as evidenced by  an increases in physical complaints and disinterest in surroundings.

Social isolation , related to anxiety, as evidenced by withdrawal  and  uncommunicative behaviour.

Outcome Identification

The psychiatric mental health nurse identifies expected outcomes individualised to the patient.  Within the context of providing nursing care, the ultimate goal is to influence health outcomes and improve the patient’s health status. Outcomes should be mutually identified with the patient, and should be identified as clearly as clearly and determine the effectiveness and efficiency of their interventions.

Before defining expected outcomes, the nurse must realize that patient often seek treatment with goals of their own. These goals may be expressed as relieving symptoms or improving functional ability. The nurse must understand the patient’s coping response and the factors that influence them. Some of these difficulties in

defining goals are as follows-

The patient may view a personal problem as someone else’s behaviour.

The patient may express a problem as feeling, such as “I am lonely” or “I am so unhappy”.

Clarifying goals is an essential step in the therapeutic process. Therefore the patient nurse relationship should be based upon mutually agreed goals. Once the goals are a greed on they must be stated in writing .Goals should be written in behavioural terms, and should be realistically described what the nurse wishes to accomplish within a specific time span. Expected outcomes and short term goals should be developed with short tem objectives contributing to the  long term expected outcomes.

Example of short term goals:

At the end of the two weeks patients will stay out of bed and participate in activities

At the end of the one week patient will sleep well at night.

At the end of the one week patient will eat properly and maintain weight.

Planning

As soon as the patient‘s problems are identified, nursing diagnosis made, planning nursing care begins.

The planning consists of:

Determining priorities Setting goals

Selecting nursing actions

Developing /writing nursing care plan

In planning the care the nurse can involve the patient, family, members of the health team. Once the goals are chosen    the next task is to outline the plan achieving them. On the basis of an analysis, the nurse decides which problem requires priority attention or immediate attention. Goals stated indicates as to what is to be achieved if the identified problem is taken care of. These

can be immediate short-term and long- term goals. The nursing action technique chosen will enable the nurse to meet the goals or desired objectives. For example, the short-terms for a depressed patient is  "to pursue him or her take bath”. The nursing action may be  “The nurse firmly direct the patient  to get   up and finish her/his bath before 8 O’ clock. On persuasion the patient takes bath. This is an example of selection of the nursing action. Writing or recording of the problems, goals, and nursing actions is a nursing care plan.

Implementation

The implementation phase of the nursing process is the actual initiation of the nursing care plan. Patient outcome/goals are achieved by he performance of the nursing interventions. During the phase the nurse continues to assess the patient  to determine  whether interventions are effective. An important part of this phase is documentation. Documentation is necessary for legal reasons because in legal dispute “if it wasn’t charted, it wasn’t done". The nursing interventions are designed to prevent mental and physical illness and promote, maintain, and restore mental and physical health. The nurse may select interventions according to their level of practice. She may select counselling, milieu therapy, self-care activities, psychological interventions, health teaching, case management, health promotion and health maintenance and other approaches to meet the mental health care needs of the patient.

To implement the actions, nurses need to have intellectual, interpersonal and technical skills.

Nursing actions are of two types-

1. Dependent nursing action: Action derived from the advice from the psychiatrist. For example, giving medicines.

2. Independent nursing actions: This is based on nursing diagnosis and plan of care, pursuing the patient to attend to personal hygiene.

Evaluation

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.

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 –have I done everything for my patient? 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.

Components of Assessment

Mental Status Examination Appearance

Dress, grooming, hygiene, cosmetics, apparent age, posture, facial expression.

Behaviour/activity

 Hyperactivity or hyperactivity, rigid, relaxed, restless, or agitated motor movements, gait and coordination, facial grimacing, gestures, mannerisms,, passive , combative, bizarre.

Attitude

Interactions with interviewer: - Cooperative, resistive, friendly, hostile, ingratiating

Speech-Quantity: - poverty of speech, poverty of content, volume.

Quality: - articulate, congruent, monotonous, talkative, repetitious,  spontaneous, circumstantial, confabulation, tangential and pressured

Rate:-slowed, rapid

Mood and affect

Mood (Intensity depth duration):- sad, fearful, depressed, angry, anxious,  ambivalent, happy, ecstatic, grandiose.

Affect (Intensity depth duration) :- appropriate, apathetic, constricted, blunted, flat, labile, euphoric.

Perception

Hallucination, illusions, depersonalization, derealization, distortions

Thoughts

Form and content-logical vs. illogical, loose associations,  flight of ideas, autistic, blocking., broadcasting, neologisms,  word salad, obsessions, ruminations, delusions, abstract  vs. concrete

Sensorium and Cognition

Level of consciousness, orientation, attention span, , recent and remote memory, concentration, , ability to comprehend and process information, intelligence

Judgment

Ability to assess and evaluate situations makes rational decisions, understand consequence of behaviour, and take responsibly for actions

Insight

Ability to perceive and understand the cause and nature of own and other’s situatio

Reliability

Interviewer’s impression that individual reported  information accurately and completely

Psychosocial Criteria

Internal:-Psychiatric or medical illness, perceived loss such as loss of self concept/self-esteem

External:-Actual loss, e.g. death of loved ones, diverse, lack of support systems, job or financial loss, retirement of dysfunctional family system

Coping skills

Adaptation to internal and external stressors, use of functional, adaptive coping mechanisms,  and techniques,

management of activities of daily living

Relationships

Attainment and maintenance of satisfying, interpersonal relationships congruent with developmental stages, including sexual relationship as appropriate for age and status

Cultural

Ability to adapt and conform to present norms, rules, ethics.

Spiritual (Value-belief)

Presence of self-satisfying value-belief system that the individual regards as right, desirable, worthwhile, and comforting

Occupational

Engagement is useful, rewarding activity, congruent with developmental stages and societal standards (work, school and recreation)

Sample of Nursing Care Plan

Sample of Nursing Diagnoses (As per NANDA- North American Nursing Diagnosis Association)

 Nursing Diagnosis Analysis

1 Risk for injury related to accelerated motor activity

Accelerated motor activity or impulsive actions

2 Disturbed thought process related to impaired judgement associated with manic behaviour

Judgement impaired , mood of elation (patient is using inappropriate dress and bizarre dressing)

3 Self-care deficit (unkempt appearance)  related to

Unable to take time for self-care  is, dishevelled and unkempt

hyperactivity

4 Impaired  verbal communication –flight of ideas related to accelerated thinking

Accelerated speech with flight of ideas (thought speeded up causing rapid speech and flight of ideas, excessive  planning  for activities

5 Ineffective  coping related to  elated expressive mood

Euphoria, elation, cheerfulness( an exaggerated sense of well being)

6 Disturbed thought process –grandiosity related to  elevated mood

Grandiosity-inflation self-esteem

7 Ineffective coping related to emotional liability  associated with manic behaviour

Emotional  labiality (unstable mood moves from cheerfulness to irritation easily with little irritation

8 Disturbed thought process –related to delusion of  grandeur

Grandiose delusions (Belief that well known political religious, or entertainment leader)

9 Disturbed thought process decreased attention span and difficulty in concentration  related to accelerated thinking

Short attention  span, difficulty in concentrating , easily disturbed

10 Risk for violence related to hostile and angry behaviour

Hostile comment and complaints

11 Impaired verbal communication related to pressure of speech

Accelerated thinking, highly responsive to environmental stimuli, accompanying flight of ideas

12 Nutrition: less than

body requirements, imbalanced

Weight loss (less food intake associated with depression which

Nutrition: more than body requirements, imbalanced

Nutrition: risk for more than body requirements, imbalanced

contributes to loss of appetite with weight loss/weight gain following pharmacological management/possible wieght gain

13 Self-care deficit-neglect of personal hygiene  related to depression

Neglect of personal hygiene (feeling of worthlessness  associated with depression which contribute to lack of interest in personal hygiene

14 Health Maintenance, ineffective –psychomotor retardation related to depression

Extreme slowness in performing activity

15 Risk for violence- self-directed, related  to depression

Bruises, cuts, scars, (possible destructive  behaviour or abuse by others)

16 Anxiety –neurological symptoms related to depression

Extreme nervousness (possible response to loss with symptoms to those of anxiety)

17 Risk for violencerm Suicidal feeling  (Hopelessness contributes to total despair

18 Sensory perceptual alteration –disorientation about time, place, and person  related to increased anxiety

Confusion or disorientation

19 Ineffective coping –obsessive thinking related to  anxiety

Anxiety (Increased anxiety unapparent and discharge  through  obsessive thinking)

20 Impaired Social interactions Lacks ability to develop warm 

–inability to form warm, meaningful relationships, related to compulsive behaviour

relationship ( has limited ability to express emotion)

21 Ineffective coping –compulsion related to need for excessive cleanliness)

Excessive cleanliness (Over  emphasis for cleanliness and neatness)

22 Potential for self harm related to poor impulse control associated with substance abuse)

Poor impulse control

23 Potential for self-harm related to marked disorientation , disorganization, and confusion

Disorientation, disorganization  and confusion (If marked , patient is at high suicidal risk)

24 Distarbance of self-concept-insecurity related to suspiciousness

Insecurity, oversensitive, Failure to meet needs results in mistrust and  insecurity

25 Potential for violence  directed towards others related t perceived  threat or injustice to himself

Anger and hostility –may become physically violent (Overly concerned with protecting himself from environment : overly sensitive)

25 Ineffective individual coping persecutory feeling related to mistrust

Feeling of being misjudged , conspired against, spied upon , followed , poisoned, dragged, obstructed in achieving long term goals.

Nursing Diagnosis: Risk for violence, self directed.

Risk factors-Chronic illness, retirement, change in marital status

Patient Outcome Nursing Intervention with Rationale

Evaluation

Patient will not harm himself

 

Patient will refrain from suicidal threats or behaviour gestures.

He will deny any plans for suicide

Observe patient’s behaviour during routine patient care. Close observation is necessary to protect from self harm.

Listen carefully suicidal statements and observe for non-verbal indications of suicidal intent. Such behaviours are critical clues regarding risk for self harm.

 

Ask direct questions to determine suicidal intent , plans for suicide, and means to commit suicide .Suicide risk increases when  plans and means exists

Patient remained safe, unharmed.

 

 

Absence of verbalized or behavioural indications of suicidal intent by the patient.

 

Patient denies active suicide plans

Nursing Diagnosis: Ineffective individual coping, related to response crisis (retirement), as evidence by isolative behaviour, changes in mood, and decreased sense of well-being.

Patient Outcome

Nursing Intervention with Rationale

Evaluation

Patient will identify positive coping strategies, such as structuring leisure time.

 

Patient will combine past effective coping methods with newly acquired coping strategies

Develop trusting relationship with patient to demonstrate caring and, encourage patient to practice new skills in a safe therapeutic setting.

                             

Praise patient for adaptive coping. Positive feedback encourages repetition of effective coping by patient

Patient expresses trust in nurse-patient relationship.

 

 

Patient discusses plans for use of past and newly learned coping methods.

Nursing Diagnosis: Self-care deficit (grooming, dressing, and feeding) related to manic hyperactivity, difficulty in concentrating and making decisions: as evidenced by inappropriate dress, and dysfunctional eating habits.

Patient OutcomeNursing Intervention with Rationale

Evaluation

Patient will dress appropriately for age and status.

 

 

 

Patient will eat and drink adequately to sustain fluid balance and  proper nutrition.

Offer assistance for selecting clothing and grooming to provide input and direction for appropriateness of dress and hygiene to preserve self-esteem and avoid embracement. 

Encourage and remind patient to drink fluid and to eat food to focus the patient on necessary feeding activities , to prevent dehydration and starvation.

Provide recognition and positive reinforcement for feeding/dressing accomplishments to reinforce appropriate behaviours and enhance self-esteem.

Patient dresses self appropriately and maintains hygiene.

 

 

 

Patient eats and drinks fluids necessarily to maintain physical health.

 References:

1. Ladwig, A.(1999).Nursing Diagnosis Handbook, A Guide for Planning Care. Section 1:5

2. Kapoor, B. (1994). A Text Book for Psychiatric Nursing: Chapter5, Page 223-224.

3. Foortinash, Hoolodey-Warrant. Psychiatric Mental Health

Nursing, 1996: Chapter 20, page 279, 482.

4. Gail.W.Stuart, Michal T. Laraiya. Principles and Practice of Psychiatric Nursing 1998: Chapter 10, Page 178.

5. Katherine N Fortinash, Patrica N Hooliday-Worret. Psychiatric Nursing Care Plans 1991: Chapter 1, Page 1.

     

 

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History Quiz-I

Psychiatric Nursing History Quiz-II

 

                

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The first use of convulsive therapy for the treatment of a psychiatric disorder in modern times is attributed to

A. Ladislaus von Meduna

B. A. E. Bennett

C. Egas Moniz

D. Kurt Schneider

Answer Key

2. The first therapeutic use of electrically induced seizures in the treatment of mental disorders is related to

A. Harold Sackeim

B. Luigi Bini and Ugo Cerletti

C. D. Goldman

D. G. Holmberg and S. Thesieff

Answer Key

3. The sequece of administration of medications in anesthesia for ECT is:

A. Atropine---thiopentone/methohexitol---succinylcholine

B. Succinylcholine---atropine---thiopentone/methohexitol

C. Atracurium---succinylcholine---atropine

D. Atropine--- succinylecholine---thiopentone/methohexitol

Answer Key

4. As per the current evidence, which statement is NOT correct?

A. Bilateral ECT is superior in efficacy to unilateral ECT.

B. Unilateral ECT is more likely to cause cognitive deficits.

C. Brief-pulse ECT delivery is associated with decreased cognitive deficits.

D. Unilateral ECT is administered to the non-dominant hemisphere

Answer Key

5. Which of the following drugs is associated with lower seizure thresholds when administering ECT?

A. Lithium

B. Anticonvulsants

C. Benzodiazepines

D. Barbiturates

Answer Key

6. What is the minimum seizure duration required for effectiveness of ECT?

A. 1 to 3 seconds

B. 5 to 10 seconds

C. 30 to 90 seconds

D. 180 to 200 seconds

Answer Key

7. What is the best accepted placement of electrodes in unilateral ECT?

A. Bifrontotemporal

B. Paritotemporal

C. Occipital

D. D'Elia position

Answer Key

8. What is considered as the gold standard for confirmation of seizure in ECT?

A. Cuff method

B. Electroencephalography (EEG)

C. Electromyogram (EMG)

D. Galvanic Skin Response (GSR)

Answer Key

9. What is the average mortality rate with ECT (modified)?

A. 3-4 per 100,000

B. 10-25 per 100,000

C. 10-20 per 10,000

D. 50-60 per 1000,00

Answer Key

10. Factors predisposing to postictal confusional state include, all EXCEPT:

A. Sine wave ECT

B. High-dose ECT

C. Existing CNS disease

D. Multiple ECT

E. A younger age group

Answer Key

11. Which is the best unit for quantification of ECT stimuli?

A. Millicoulombs (mC)

B. Joules

C. Watts

D. Volt

Answer Key

12. Which of the following is NOT a recommended preparation for ECT procedure?

A. Informed consent in writing

B. Pre-ECT investigations

C. Morning bath, cleaning the oil from the head, overnight fast

D. Premedication with an anticholinergic agent

E. Administration of an anticonvulsant 30 minutes before ECT

Answer Key

13. The most common indication of ECT is:

A. Schizophrenia

B. Generalized Anxiety Disorder

C. Manic episodes

D. Major depression

Answer Key

14. rTMS is found to have antidepressant properties when applied to

A. Temporal– parietal regions of the cortex

B. Dorsolateral prefrontal cortex (DLPFC)

C. Occipital cortex

D. Parieto-occipital cortex

Answer Key

15. The most persistent adverse effect of ECT is

A. Retrograde amnesia

B. Fractures

C. Seizures

D. Hypertension

Answer Key

ANSWER KEY

1. A 2. B 3. A 4. B 5. A

6. C 7. D 8. B 9. A 10. E

11. A 12. E 13.D 14. B 15. A

Reference

1. Andrade C. Electrical Aspects of ECT. in Handbook of Psychiatry by Bhugra D, Ranjith G, Patel V. Byword Viva Publishers, New Delhi, 2005.

2. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry. 9th ed. Hong Kong :William and Wilkinson Publishers ;1998.

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