Exam 1 Mental Health Chapter 9

chapter 9 Working With an Individual Patient -Peplau defined nursing as “a significant, therapeutic, interpersonal process” -The nurse’s relationship with patients consists of a series of goal directed interactions through which t assess patients’ problems, elicits patient input, selects interventions of the patients’ choosing, and ev the effectiveness of care Therapeutic!Relationships! -The nurse offers presence and engages in a relationship to support the individual’s challenges and recog unique strengths -Caring is an essential component of nursing that promotes patients’ growth -Patients have a right to make decisions about their care -When patients start recognizing a problem, desire to change, and ask for assistance the nurse is able to with them on goals and plans -Coercion is not effective -Social communication consists of interactions whereby two individuals are talking about their own live -Therapeutic communication consists of the nurse focusing on the patients’ agenda and does not share p information -Nurse’s goal is to discover the patient’s story and perspective, to be curious -Some patients may misinterpret the nurse’s interest as a social relationship >remind the patients of the nurse’s rise and the need for friendship, love, and support Being!Therapeutic!vs.!Providing!Therapy! -Advanced practice nurses provide therapy in formalized,ongoing sessions that are process oriented -Therapeutic relationships take place to assist in discussing problems and practical solutions in brief en -Therapeutic relationships provide validation & feedback -Informal or recreational encounters give the nurse the opportunity to observe inappropriate social beha provide opportunities to demonstrate ways of handling situations -Sharing personal data can involve age, marital status, or title, by rarely personal problems -Brief self disclosure would be to help patients clarify their specific issues >facilitates comfort >honesty >openness >risk-taking >never burdens patients with the nurse’s problems Stages!of!Development!of!a!Therapeutic!Relationship! -In the stage of orientation, patients recognize needs and seek help; the nurse works actively to foster tr and to develop the relationship -In the identification & exploration stage, or working stage, clarification of perceptions and expectation the relationship takes place; patients become more motivated to take advantage of available resourc resolve problems -In the resolution stage, or termination stage, close attention is needed to avoid destroying the benefits from the relationship; focus is on the growth that occurred and on helping the patient develop self responsibility for setting new goals -The entire relationship is viewed by Peplau for promoting growth and a learning experience for the nu -Involves nurses learning about patients and their initial concerns and needs -Patients learn nurse roles -There is an identification of the problem that will be explored; the nurse collaborates with patient to d specific area to pursue -Nurses help the patient look at realistic options so the patient can make their own decisions -Trustworthiness is built when the nurse is honest -At admission patients may experience fear, grief regarding intentions, is consistent, and follows embarrassment, anger, ambivalence, confusion through with actions shame, guilt, etc. -Mutual respect and trust is crucial -Talk about emotions directly -Confidentiality is explained in terms of patient -Express empathy information being shared only with the immediate unit or program staff, consistent with HIPPA -Important for nurse to reach out and initiate -When patients lose control of their thoughts, conversations feelings, or behaviors, it is the nurse’s responsibility to take temporary control -Limit setting -Begins in orientation phase -Consistency, respect, affirmation, empathy, and staying with and holding the emotional distress of patien provide an emotional platform -Emotional support confirms patient’s worth and right as human beings and involves the nurse avoiding judgements of patients even when patients have made poor choices -When patients are ready, the work toward changing their thoughts, feelings, and behaviors can begin -Stabilization, reduction of distressing symptoms, and development of supportive relationships are goa -Nurse facilitates awareness, analysis, and interpretation through in depth exploration of issues and iden priority issues -Occurs as the nurse takes time to sit and engage with the patient -The nurse provides reassurance and support using a calm tone of voice with open, friendly body langu -Focusing on too many problems may overwhelm patients -Focus on manageable and changeable issues -Nurses assess a patients readiness to change and enhance motivation for change -Aucessful change can be accomplished through motivational interviewing (MI) -MI is an evidence based intervention that is patient centered >open ended question = clarify meaning and elicit patient’s emotion >reflective listening = used to enhance empathy and respect for the patient’s perspective >validation = used to enhance empathy and respect for the patient’s perspective -The struggle of change is called resistance -Ambivalence is important to explore because lasting change cannot occur until the patient endorses th necessity for change -Express empathy, roll with resistance, and support self-efficiacy -5 stages of change: 1. Precontemplation: no plan to change behaviors; does not identify the problem 2. Contemplation: identifies a problem and thinks about an action; ambivalence is a predominant fe 3. Preparation: imminently ready to work on change 4. Action: initiates a change 5. Meets goals & avoids relapsing -Focuses on more indirect outcomes of the nurse patient relationship, such as open communica -Nurse guides discussions to help patient identify for or more authentic expression of feelings themselves the specific changes in thoughts, feelings, ad behaviors that have occurred -Patients are encouraged to set priorities for these i issues and to establish reasonable time frames -Feelings might be positive, ambivalent, or negativ and may vary in degree -Patietns might experience anger or fear related to -For problems that need continuing attention after losing support discharge, referrals to appropriate resources are -Some patients might avoid any discussion of finalized termination Interactions!with!Selected!Behavior -Stay out of striking distance -Avoid touching patient without approval -Change the topic temporarily if a patient’s behavior is escalating -Suggest time out for the patient with fewer stimuli -Avoid entering a room alone with a patient who is not in control of his or her behavior -Leave temporarily if the patient is agitated and asking to be left alone -Call for staff assistance if the patient’s behavior escalates -The initial approach with patients who appear to be listening or talking with voices is to comment on th behavior: “You look as if you are listening to something. What do you hear?” -If the patient acknowledges hearing something that the nurse cannot hear, then the nurse can say, “Tell m you hear.” -The next step is assessment of hallucinations based on the content of the messages, which often reveals dynamics of the patient’s illness & typically revolves around themes of powerlessness, hatred, guilt, -After the content is known, focusing on how they make the patient feel may be helpful: “I know the voi important to you; can we talk about how the hallucinations make you feel?” -The nurse can also encourage the patient to utilize distraction as a method of dealing with hallucination distraction techniques involve the patient becoming engaged in more productive actinides, such as m or physical exercise -Patients are encouraged to share the meaning of the delusions: “Tell me more about what the delusion to you.” -Do not argue with the patient about delusions; it may strengthen the patients belief -Careful monitoring of patient to prevent harm to self or others -For patients with dementia or severe cognitive impairments, “ignore & distraction” may be more effec -Nurses must seek to understand the patients POV -Encourage patient to examine the effects or outcomes of their beliefs on their lives -Supportive confrontation assists the patient to examine the effect of maladaptive behavior on lives -Allowed & encouraged, verbally & nonverbally -Provide privacy -Nurse should be quiet & unobtrusive as possible -Offer opportunity to discuss the emotional experience that precipitated tears -Address what is happening or had happened in the nurse patient relationship -Limit setting us useful -A power struggle is useless -Help patients express their needs directly -Disturbed thought processes are occasionally evident in speech, especially if upset, confused, or psychotic -Typical approach is to clarify the meaning -Effective to key in their feelings and underlying themes rather than make sense of the content of their speech -Spend frequent & brief time intervals to offer support and build trust -Listen -Clarify -Verbalize thoughts to identify the underlying cause of the lack of cooperation -Discuss the causes, fears, and outcomes of the patient’s behaviors -The nurse’s role is to use therapeutic communication to increase trust -Ask patient to stop calmly -Let the patient know it makes you feel unsafe or afr -Remind the patient that the action is inappropriate -Set limits -Discuss the underlying need -The nurse should refrain from touching the patient sexual and boundary issues -Nurse is responsible for maintaining professional boundaries -Ask patient a patient before touching -Use patience, frequent contact, & empathy to assist the patient to recognize the need for change -Patient may not have energy to make the change quick -Improvement in personal hygiene, proper nutrition, & gradual increase in activities are encouraged -Major decisions are postponed until overwhelming em have subsided and thinking is more logical -Patient might be afraid of everyone -Communicate clearly, simply, & congruently -Misinterpretations should be clarified -Arguments over differences should be avoided -Offer rationales for rules, activities, occurrences, and noises -Encourage participation in the milieu; do not force patient to participate -Can be upsetting to other patients, staff, and themse -Might unintentionally harm self or others -Should be in a quiet area, with minimal auditory and visual stimulation -Nurse must remain calm, speak slowly and softly, & respect the patients’ personal space -Offer PRN medications as needed Nursing!Assessment Full name, gender, age, DOB, address, marital status, & names/ages of f members, partner, or SO Date & time of admission and type of admission Current problems as perceived by the patient; include stressor, dif with coping, developmental issues, “emergency behaviors”, fa history Dates, inpatient or outpatient, reasons for & types of treatment and thei effectiveness, current medications, and compliance Allergies, results of labs, x-rays, & exams Amount, frequency, duration of past & present use of prescriptions and illegal substances, date & time of use, and potential for withdrawal symptoms Sleep, intake, elimination, sexual activit work, leisure, self-care, hygiene Ethnicity, beliefs, practices, & religious preferences Amount of contact, nature & quality of relationships, and availability of su Type, condition, & appropriateness of clothing, grooming, clean physical condition, & posture Degree of cooperation, resistance, & engagement Friendliness, shyness, withdrawal Psychomotor agitation, restlessness, tics, tremors Amount, rate, volume, tone, mutism, slurring, stuttering To time, place, person, situation, LOC Immediate recall, recent, remote, amnesia, confabulation Education level, use of language & knowledge, abstract vs. co thinking, calculations Labels, blunted, flat, incongruent, or inappropriate Specific moods expressed or observed - euphoria, depression, anxiety, anger, guilt, fear Coherence, confusion, or vagueness Helplessness, hopelessness, suicidal or homicidal thoughts, phobias, obs denial, hallucinations, delusions, persecution, grandeur, influence, re nihilistic, suspiciousness, compulsion Ambivalence, circumstantiality, thought blocking, loose associations, flight of neologisms, world salad Degree of awareness of illness Soundness of problem solving and decisions Degree of motivation for treatment -Explore the following: >context or situation that precipitated the behavior >thoughts at the time -NANDA suggests a statement format that >feelings then and now has the following three: >behavior in the context 1. Risk for actual problem >behavior adaptive or dysfunctional 2. Contributing, causative, or etiolog >how does the current episode fit with the total picture factors >is a change needed 3. Defining characteristics or behavi >current MSE outcome -Nursing dx does not include medical dx -A goal or outcome specifies an adaptive behavior or replace dysfunctional behavior -The goal is achievable and measurable -Determine short term, realistic goals -Collaborate with the pa -An initial care plan might be updated at anytime, but begins with one or two behavior oriented problem suicide, aggression, escape, withdrawal or isolation, delusions, hallucinations, impulsive behavior) & problem, outcome, time contraint, and related nursing interventions -Keep in mind the patient’s unique problems and needs when forming interventions; focus particularly o structure, support, and symptom management” -Progress notes are either written or electronic & include patient statements and nurses observations, an plans; ensure continuity of care; evaluate effectiveness of treatment plans -Shift report should be concise, focused, and include an abbreviated list of the items included in the prog notes Evaluation -Goals should be specific, realistic, attainable, and measurable -If expecting too much change too soon, reassessment should occur -Evaluation determines patient referrals -Identify achieved outcomes -Identify outcomes to be addressed -Medication, including dosage and time -Follow up appointments with date & time -Referrals -Assess patient’s ability to read & understand discharge instructions -A process recording is a record of an encount with a patient that is as verbatim as possib -Includes nonverbal behaviors of nurse & pati as well as verbal interaction -Assessing & analyzing nurse communication -Identify patient themes -Evaluate effectiveness of interventions