PT20E Therapeutic Communications and Relationships
PowerPoint #3
Course Objective #1
• Define and describe the Psychotherapeutic Management Model according to the Diagnostic and Statistical Manual, (DSM) current edition.
Psychopathology
• Definition: the systematic study of mental disorders.
Psychotherapeutic Management Model
• Definition: Nursing care that balances the three (3) primary interventions used in care of D.D. and Psychiatric patients.
Psychotherapeutic Management Model
• Three (3) primary interventions:– Communicated Nurse-Patient Relationship (words)– Psychopharmacology (drugs)– Milieu management (environment)
Therapeutic Nurse-Pt. Relationship
• Communication skills
Psychopharmacology
• Psychotropic drugs:
Course Objective #4
• Relate why a psychopharmacologic understanding is important for the psychiatric technician
Importance of Psychopharmacology
• Assess response • Respond to side effects• Evaluate for desired results• Safely dispense• Teaching• Idiosyncratic reactions
Milieu Management
• Definition: Purposeful manipulation of the environment to promote a therapeutic atmosphere.
Course Objective #5
• Define milieu management and its six elemental components
Milieu Management• Components:– Safety– Structure– Norms– Setting limits– Balance– Environmental modifications
Safety
• Freedom from danger or harm
Structure
• Physical environment• Regulations• Schedules
Norms
• Expectations of behavior• Promote community
Beliefs
• Truths held by a culture
Values
• Deep feelings that determine what is considered good or bad.
Norms
• Society accepted rules
Setting Limits
• Clear & enforceable limitations on behavior
Setting Limits
–Behaviors:–Physical aggressiveness– Self-destructive acts– Lack of compliance–Use of alcohol or drugs– Elopement
Setting Limits
• Anticipate behavior!
Balance between Independence vs. Dependence
• Gradual process– too fast –Overwhelmed
Environmental Modifications• Changing the environment to promote mental
health– Physical arrangement– safety issues– orientation features
Course Objective # 2
• Describe the consequences of an imbalance in nursing care
Consequences of an Imbalance in Nursing Care
• Patient needs & setting
• Utilization
Influence
Consequences of an Imbalance in Nursing Care
• All components must be present if pt’s. are to fully benefit
Consequences of an Imbalance in Nursing Care
• Imbalance • compromise tx
Course Objective #3
• Relate the difference between therapy and being therapeutic.
Therapeutic vs. TherapyEducation
• Therapy – graduate-level psychiatric training
• Therapeutic – undergraduate-level psychiatric nurses
TherapeuticTasks
• Communication–Respect–Desire –Understanding –Active listening
Therapeutic
• Knowledge/skills • Each encounter is part therapeutic milieu
Therapeutic
• Real!–Problems – Solutions–Practice situations
Therapeutic
• Consistent• Spontaneous• Informal• Recreational
Therapy• Cure or manage the course of mental
disorder• Trained • Selective pt
Therapy
• Sessions– Formalized– On-going– Specific time, place, & length
• Specialized techniques
Therapeutic Nurse-Pt. Relationship
• Definition: A series of goal-directed interactions that focus on the patient– T, F, B’s – potential solutions
• Purposeful • Unique
Therapeutic Nurse-Pt. Relationship
• Client challenges: – Communicating–Relating– Functioning
Role of the Psych. Nurse
• Identify problems • Discover ways of meeting needs• Experience relationship
Characteristics of the TxN-PR
• Planned• Patient centered• Goal directed
Brief Encounters
• Brief encounters –Process feelings–Validation –Feedback
• Quickly
Course Objective #21 & 22
• List the stages of the therapeutic P.T.—patient relationships.
• Identify and describe the major tasks of each stage of the P.T.—patient relationship
Stages of TxNPR
• Orientation Stage• Working Stage• Termination Stage
Orientation stage• Establishing trust and rapport• Nurses learns– Concerns
• Patient learns– Role of the nurse
Orientation stage
• Create an environment – Honest – consistent, – keeps promises
• Clear, specific communications • Confidentiality explained
Orientation stage• Initiating conversations • Non-confrontational
Orientation stage• Establish a contract – Expectation– responsibilities
Orientation stage• Gather assessment information – intake interview• Needs• coping strategies• defense mech.• recurring thoughts, feelings, behaviors• awareness of problems• ability and motivation to change
Orientation stage• Gather
assessment information
• Defining goals–Prioritize
• Needs• Coping strategies• Defense mech. • Recurring T, F, B• Motivate to change
Orientation stage
• Management of emotions:– Fear of losing control– Feelings – Anger
Orientation stage• Feelings natural – Expression
• Empathy –Not alone–Hope
Orientation stage• Palliative coping mechanisms –Rest–Nutrition– Exercise–Meditation
Orientation Stage
• Teaching healthy ways to meet emotional needs–Coping skills–Challenging negative self-images
Orientation stage• Providing support: – Realistic hope• Abilities• Strengths
– Worth – Non-judgmental– Dependence independent
Orientation stage• Providing structure: • If the pt loses control – take temporary control
• If the patient is withdrawn– Spending time
• The major task of providing structure is – limit-setting
Orientation stage
• Crisis–Providing support–Managing emotions
Working Stage• AKA: – Learning Stage– Change Stage
• Problem-solving – Work toward change – Stabilization
Working Stage• Observation: –Describe the problem
Working Stage• Observation: –Describe the problem– “Participant Observer”• Nurses relationship
Working Stage• Analysis: – Encourages accuracy in pts
conclusions
Working Stage• Interpretation: –Change is necessary – Explore solutions
Working Stage• Planning: – formulating a plan– assists pts to solve their own problems– Encourage short-term, realistic,
achievable, daily goals
Working Stage• Testing out: –Trying out new behavior or
solution in a safe environment first –Rehearsal
Working Stage• Role playing – Practicing behaviors– Nurse • plays the role of persons with whom pts
are difficulty • assess communication & behavior
Working Stage• Evaluation–assess success
Working Stage• Feedback–Constructive
Working Stage• In-depth data collection: – Increased knowledge –Priority issues
Working Stage• Reality testing:–Presenting another point of view
Working Stage• Cognitive restructuring: –Cope with negative thoughts –more realistic conclusions • redefine • reinterpret • change perception
Working Stage• Supportive confrontation: –Challenging pt’s contradictions,– It challenges pts to •Meet their own needs • Be accountable for their own –Feelings–Behaviors–Decisions
Supportive Confrontation• Example:• Pt: “I went out drinking only once last
week. At least I’m trying to change.”• Nurse: “I can appreciate your effort, but
you agreed to abstain from alcohol completely.”
Working Stage• Writing/journaling: – Tool–Release emotions –Objective
• Letters
Working Stage• Promoting change: –Pt. initiated change –Support • Family & friends •Groups
–Motivated
Working Stage• Teaching new skills: –Desire + Know how – Small steps –Practice – Feedback
Termination Stage
• Evaluation & summary of progress: – ID changes – Long-term goals – Strengths & weaknesses
Termination Stage• Synthesizing what has occurred: –Progress – Indirect outcomes of TxPNR– Encouraged other relationships
Termination Stage• Referrals:–ID community resources–Written d/c instructions
Termination Stage• Discussion of termination:
Continuum of Care
• Definition: – levels of care through which a pt can
move depending on needs at the time
Course Objective # 25• List approaches and precautions to take with the
following patient experiencing:• Potential for violence, Hallucinating,
Delusional, With conflicting values, With incoherent speech, Manipulative, Crying, That are sexually inappropriate, Uncooperative or in denial, Depressed/apathetic, Suspicious, Hyperactive, Transference
Special Approaches/Precautions
• Brief encounters
Violent Behavior
• Keep your distance • Do not touch without approval• Change the topic • Suggest a “Time Out”
Violent Behavior
• Sit by the door –DO NOT BLOCK THE DOORWAY!
• Do not go into a room alone • Leave temporarily –Be aware of self-injury potential
• Call for assistance
Hallucinations• 1st –Comment –Assess the content • Powerlessness• Hatred• Guilt• Loneliness
Hallucinations• Do not focus on the hallucination–Activities &encounters
• “Do Not to act on commands”• “Tell staff”
Delusions• A fixed, false belief• not consistent with the person’s
intelligence and culture• unamenable to reason
Delusions• 1st –Clarify the meaning–Rarely discussed
• Do not arguing • Monitoring
Conflicting Values• Nurses vs. patients• Examine the effects of beliefs • Perspective
Incoherent Speech
• Clarify • Repeated questions anxiety• Frequent, brief support
Manipulation• Means to gain attention, sympathy,
control & dependence• 1st
–Address – Limit-setting –Help pts. to directly express their needs
Crying• Allowed & encouraged–Nrs – quite
• Stopped–Offer opportunity to talk
Sexual Innuendos or Inappropriate Touch
• Correct• Discuss• If continue– Limit-setting –Reassignments
Lack of Cooperation/Denial• ID the cause–Disturbances in thought process–Lack of insight–Disagreement –Fear
Lack of Cooperation/Denial• Discussed directly• Trust • Patience
Depressed Affect/Apathy/Psychomotor
Retardation
• Acknowledge feelings but discourage rumination
• Encourage– personal care
• Postpone major decisions
Depressed Affect/Apathy/Psychomotor Retardation
• Patience• Frequent contact• Empathy
Suspiciousness• Underlying – Fear
• Communicate – Clearly & simple – Avoid arguments – Rational
• Encourage participation– Do not force
Hyperactivity• Decrease stimulation• Physical activity• Remain calm• PRN meds?
Course objective #26
• Compare and contrast transference and counter-transference
Transference (pt)
• Unconscious emotional reaction • Patient Nurse• Based on past experiences
Transference (pt)• Positive –if pts view the nurses as helpful and
caring• Negative –interfere with treatment
Countertransference (nurse)• Unconscious emotional reactions –Nurse patient–based on the nurse’s past experiences– sympathetic –unable to confront the pt appropriately
Interventions• 1st
– Recognize • 2nd
–Discuss–Gently & directly
Course Objective #27
• Relate the nursing process to psychiatric nursing
What are the 5 steps of the nursing process?
• Assessment• Diagnosis• Planning• Implementation• Evaluation
Nursing process in psychiatric nursing…
• Patient centered• Individualized
Course objective #29 & 30
• Define and describe the following: Intake interview, Brief psychiatric rating scale, Nursing care plan, Process recording
• Define and give examples SOAP and narrative progress notes
Documentation
• Proof• Law
Types of Documentation• Progress Notes: –Assessing and analyzing
communication skills, identifying pt themes, and evaluating the effectiveness of interventions
Types of Documentation• S.O.A.P. Notes: –General narrative of basic nursing care
provided to the pt
SOAP Charting• S: • Subjective Data:–What the pt says: “___”–Reported
SOAP Charting• O: • Objective Data:–Direct observation
SOAP Charting
• A:• Assessment/Analysis: – interpretation –Conclusions– responses
SOAP Charting
• P:• Plan: –Actions / treatments
Types of Documentation
• Problem-oriented Recording (POR) –description of a specific intervention,
used for a specific problem and evaluates the pts response
P.I.E.Problem-oriented Charting
• P–Problem
• I– Intervention
• E– Evaluation
Types of Documentation
• Pt Care Plan: – Formal, written plan – Guides pt care • Diagnosis• Goals • Interventions
Types of Documentation
• Special Procedures Documentation:– Interventions implemented– Timely– Expected level of care
Intake Interview• Systematic • Mental Status Exam (MSE)• Assessments include:–Motivation to change–Coping strategies–Defense mechanisms–Recurring T, F, B’s
Course Objective #28
• List key members for a psychiatric treatment team.
Treatment Team• Psychiatrist: –MD– Specializes in psychiatry– Lead –Writes medical orders
Treatment Team• Psychologist: –PhD in psychology–psychological testing– individual therapy
Treatment Team• Clinical Social Worker: –D/C planning/placement– individual therapy – licensed
Treatment Team• MFT’s: –Marriage and family therapists–Run groups –Individual therapy
Treatment Team• Nursing Staff: –RN’s, LVN’s, PT’s: –manage the milieu–administer meds
Treatment Team• Activity Therapists: –Leisure skill –Activity therapy groups
Treatment Team• Occupational Therapists: –Training for work skills–ADL’s
Treatment Team• Patient: –Participate
Encouraging Description of Perceptions
• Perceptions are unique so it is important to learn how each person perceives a feeling or interprets situations and events.