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.