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.