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Therapeutic Relationships
Learning Outcomes• Describe necessary components in the nurse-patient
relationship.• Explain the importance of values, beliefs, and attitudes
in the development of the nurse-patient relationship.• Describe the importance of self-awareness and
therapeutic use of self in the nurse-patient relationship.
• Describe the differences between social and therapeutic relationships.
• Describe and implement the phases of the nurse-patient relationship.
• Explain the negative behaviors that can diminish the nurse-patient relationship.
Therapeutic Relationships
• The ability to establish therapeutic relationships with patients is one of the most important skills a nurse can develop
• The therapeutic relationship is especially crucial to the success of interventions with clients requiring psychiatric care because the therapeutic relationship and the communication within it serve as the underpinning for treatment and success
• Therapeutic nurse-client relationships:– Trust– Genuine interest– Acceptance– Positive regard– Self awareness– Therapeutic use of self
Therapeutic nurse-patient relationship
• Purposeful and goal-directed– Directed towards the clients needs
• Has defined boundaries– Clients know what they can do and the nurse defines these
boundaries
• Is structured to meet the patient’s needs• Is safe, confidential, reliable, and consistent
– A social relationship between friends is subject matter, in a therapeutic relationship there is no social relationship, its all about the patient
• Nurse is responsible for initiating the nurse-patient relationship
Therapeutic Relationships (cont’d)• Components include:
– Trust• Builds when the client is confident in the nurse and when the nurse’s
presence convey integrity and reliability • Develops when the client believes that the nurse will be consistent in her
words and actions, can be relied on• Congruence (when words and actions match)
– Ex. Nurse has to leave for a meeting and says she will be back at 2 pm, and she is back by 2 pm
– Genuine interest• When the nurse is comfortable with herself, aware of her strengths and
limitation, and is clearly focused• Dishonest or artificial behavior: asking a question and not waiting for the
answer, talking over the client• Revealing personal information (biographical data, ideas, thoughts,
feeling) can enhance openness and honesty and allow for the client to share more information about themselves
– Empathy (not sympathy)• The ability of the nurse to perceive the meaning and feelings of the client
and to communicate that understanding to the client • Being able to put myself in the clients shoes (not poor you = sympathy)• “gift of self”: client – by feeling safe enough to share feelings; nurse – by
listening closely enough to understand
Therapeutic Relationships (cont’d)– Acceptance of person, not necessarily his or her behavior
• Nurse does not become upset or respond negatively to a client’s outburst, anger or acting out
• Avoiding judgment of the person no matter what the behavior but be clear and firm
– Unconditional positive regard • Appreciates the client as a unique worthwhile human being can
respect the client regardless of his or her behavior, background, or lifestyle
• Unconditional nonjudgmental attitude (don’t have to accept behavior)• Calling the client by name, spending time with the client, listening
and responding openly• Consider the client’s ideas and preferences • Attending – uses nonverbal and verbal communication techniques to
make the client aware that he is receiving full attention– Nonverbal: leaning toward the client, maintaining eye contact, being relaxed,
arms at side, interested but neutral attitude– Verbal: avoids communicating value judgments or negative opinions about
the client’s behavior
– Self-awareness and therapeutic use of self • Before the nurse can understand clients, the nurse must first know
herself• (Next slide )
Self-Awareness and Therapeutic Use of Self
• Self-awareness: process of understanding one’s own values, beliefs, thoughts, feelings, attitudes, motivations, strengths, and limitations and how one’s thoughts and behaviors affect others– Allows the nurse to observe, pay attention to and understand the subtle
responses and reactions of clients interacting with them
• Values: abstract standards that give a person a sense of right and wrong and establish a code of conduct for living– Hard work, honesty, sincerity, cleanliness, orderliness– Choosing – when the person considers a range of possibilities and freely
chooses the value that feels right– Prizing – when the person considers the value, cherishes it, and publicly
attaches it to herself– Acting – when the person puts the value into action
• Beliefs: ideas that one holds to be true– Ex. All old people are hard of hearing
• Attitudes: are general feelings or a frame of reference around which a person organized knowledge about the world
Therapeutic Use of Self• Therapeutic use of self: the nurse uses aspects of his or
her personality, experience, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients that are beneficial to clients– Nurses use themselves as a therapeutic tool to establish
therapeutic relationships with clients and to help clients grow, change, and heal
– Nurse’s personal actions arise from conscious and unconscious responses that are formed by life experiences and educational, spiritual and cultural values
– Johari window• Quadrant 1: open/public self – qualities one knows about self and others
also know• Quadrant 2: blind/unaware self – qualities know only to others• Quadrant 3: hidden/private self – qualities know only on oneself• Quadrant 4: unknown – an empty quadrant to symbolize qualities as yet
undiscovered by oneself or others
Establishing the Therapeutic Relationship• Therapeutic relationships are focused on the needs, experiences,
feelings, and ideas of the patient, not the nurse
• The therapeutic relationship consists of three phases:
– Orientation – begins when the nurse and client meet and ends when the client begins to identify problems to examine
– Working – divided into 2 sub-phases:
• Problem identification: client identifies the issues or concerns causing problems
• Exploitation: the nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive self image, this encourages behavior change and develops independence
– Termination – final stage in nurse-client relationship, begins when the problems are resolved, and it ends when the relationship is ended
• Client may feel the termination as an impending loss, often try to avoid termination by acting angry or as if the problem has not been resolved
Establishing the Therapeutic Relationship (cont’d)
• In the orientation phase:
– The nurse and patient meet
– Roles are established
– Purposes and parameters of future meetings are discussed
– Expectations are clarified
– Patient’s problems are identified
– Nurse builds trust with client
– Client shares preconceptions and expectations of nurse based on past experience
– Nurse helps client plan use of community resources and services
Establishing the Therapeutic Relationship (cont’d)• The working phase involves:
– Problem identification
o The patient identifies the issues or concerns causing problems
o Examination of the patient’s feelings and responseso Client fluctuates dependence, independence and
interdependence in relationship with nurse– Exploitation:
• Development of better coping skills and a more positive self-image, behavior change, and independence
• Client develops skill in interpersonal relationships and problem solving
• Client displays changes in manner of communication (more open, flexible)
Establishing the Therapeutic Relationship (cont’d)
• In the working phase, the nurse must be acutely aware of 2 common elements that can arise:– Transference: when patients unconsciously
transfer feelings they have for significant persons in their life onto the nurse
– Countertransference: when the nurse responds to the patient based on his or her own unconscious needs and conflicts
Establishing the Therapeutic Relationship (cont’d)
• The termination or resolution phase:– Begins when the patient’s problems are resolved– Ends when the relationship is ended – Deals with feelings of anger or abandonment that
may occur– Client maintains changes in style of communication
and interaction– Client shows positive changes in view of self
Behaviors That Diminish Therapeutic Relationships
• Inappropriate boundaries (relationship becomes social or intimate)
• Feelings of sympathy and encouraging dependency– Want them to be as independent as they can be
– You want to be empathetic and not sympathic
• Nonacceptance of the patient as a person because of his or her behaviors, leading to avoidance of the client, negative verbal responses or facial expressions of annoyance or turning away from the client
• Nurse self-awareness is the way to avoid such problems (obtain professional boundaries)
Therapeutic Roles of the Nurse in a Relationship• Teacher
– During the working phase the nurse my teach the client new methods of coping and solving problems, instruct about med regimen and availability of community resources
– To be a good teacher the nurse must feel confident about the knowledge he or se has and must know the limitations of that knowledge base
• Caregiver– Help them explore feelings, build trust, assist the client in problem solving and help
the client meet psychosocial needs– Help them to be able to talk with others– Help them with physical complaints– If the client requires physical care, the nurse needs to explain to the client the need
for touch so they don’t perceive it as intimacy or sexual • Advocate
– Act on client’s behalf, informs the client and then supports him in whatever decision he makes
– Make sure needs are met, not being taken advantage of, physically and psychologically safe, ensure privacy and dignity, promoting informed consent, preventing unnecessary exams and procedures, accessing needed services and benefits, ensuring safety from abuse and exploitation by a health professional or authority figure
• Parent surrogate– Many have very child like behaviors– May have to remind them to eat, bathe or actually feed or bathe them– Be very careful that it is a therapeutic type of reminder (be open, easy going,
nonjudgmental)– Be clear and firm and set limits or reiterate the previously set limits
Self-Awareness Issues
• Self-awareness on the nurse’s part is crucial to developing therapeutic relationships
• Values clarification, journaling, group discussions, and reading will assist with this process
• Developing self-awareness is a continual, ongoing process; the nurse needs to plan for self-growth
• Nurses need to learn to “care for themselves”– Balancing work with leisure time, building satisfying personal
relationships with friends, taking time to relax and pamper oneself
– Overly committed to work become burned out• Nurses who fail to take good care of themselves also
cannot take good care of clients and families
Therapeutic Communication
Learning Outcomes
• Describe the goals of therapeutic communication.• Identify therapeutic and non-therapeutic verbal
communication skills.• Discuss boundaries in therapeutic communication.
• The process people use to exchange information: – Verbal
• Words a person uses to speak
– Context • Environment in which communication occurs and can include the
time and the physical, social, emotional and cultural environment
– Nonverbal
• Behavior that accompanies verbal content such as body language, eye contact, facial expression, tone of voice, speed and hesitations in speech
– Congruency • Is what you are saying and your actions congruent• When verbal and nonverbal communications agree
– Incongruency• When verbal and nonverbal communications don’t agree• When what the speaker says and what he or se doesn’t agree
CommunicationCommunication
• Interpersonal interactions between the nurse and the patient during which the nurse focuses on the client’s specific needs to promote and effective exchange of information
• It focuses on the patient’s specific needs and is used to:
– Establish the therapeutic relationship
– Identify the patient’s most important concerns
– Assess the patient’s perceptions
– Facilitate the patient’s expression of emotions
– Teach the patient and family necessary self-care skills
– Recognize the patient’s needs
– Implement interventions designed to address the patient’s needs
– Guide the patient toward satisfactory and acceptable solutions
Communication (cont’d)Communication (cont’d)
Essential Components of Therapeutic Communication
• Privacy and respect for boundaries
– Therapeutic communication is most comfortable at 3 to 6 feet; should not be less than 18 inches
– Privacy is desirable but not always possible in therapeutic communication– An interview or conference room is optimal if the nurse believes this setting is
not too isolative for the interaction– Intimate zone – 0-18 inches, this space is comfortable with parents with
young children, intimate couples, whispering, invasion is threatening and produces anxiety
– Personal zone – 18-36 inches, comfortable between friends and family– Social zone – 4-12 feet, communication in social, work and business settings– Public zone – 12-25 feet, between speaker and audience, small groups, other
informal functions
• Touching
– Touch may be comforting and supportive – Touch also is an invasion of intimate and personal space – Nurse must evaluate whether the patient perceives touch as positive or
threatening and unwanted; never assume that touching a patient is acceptable
– Need to let them know when you are going to touch them: “I am going to take your dressing off now”, “I am going to touch you”
– Professional-functional – used when doing procedures– Social-polite – greeting, hand shake– Friendship-warmth – hug, arm around shoulder– Love-intimacy – tight hugs and kisses b/w lovers or close family– Sexual-arousal – touch used by lovers
Essential Components of Therapeutic Communication (cont’d)
• Active listening means refraining from other internal mental activities and concentrating exclusively on what the patient says
• Active observation means watching the speaker’s nonverbal actions as he or she communicates
• These are used to help the nurse to:– Recognize the issue that is most important to the client at
this time– Know what further questions to ask the client– Use additional therapeutic communication techniques to
guide the client to describe his perceptions fully– Understand the client’s perceptions of the issue instead of
jumping to conclusions– Interpret and respond to the message objectively
Verbal Communication Skills
• Use concrete messages
– Concrete messages are specific and clear (explicit and need no interpretation, use nouns instead of pronouns)
• What health symptoms caused you to come to the hospital today?
– Concrete messages elicit more accurate responses
– Many patients can’t understand if you do not use concrete words or messages
Verbal Communication Skills (cont’d)(NOTE: Refer to p. 107-111,table 6.1)
– Therapeutic communication – techniques facilitate interaction and enhance communication between patient and nurse
– Techniques that encourage the patient to discuss his or her feelings or concerns in more depth include:o Exploring – delving further into a subject
o “Tell me more about that”
o Focusing – concentrating on a single pointo “This point seem worth looking at more closely”
o Restating – clarification, repeating the main idea the client has stated to you
o Pt says “I can’t take this med” nurse says “you can’t take this med?”
o Reflecting – directing client actions, thoughts and feelings back to the client
o Pt “do you think I should tell the dr….”, nurse “do you think you should?”
o Make observations – verbalizing what the nurse perceives
o Have a client who is just sitting there and not interacting with anyone, ask them what is wrong with them
o “you appear tense”, “are you uncomfortable when…?”,
Verbal Communication Skills (cont’d)• Non-therapeutic communication includes:
– Advising – telling the client what to do• “I think you should…”, “why don’t you…”
– Agreeing – false fix ideal, indicating accord with the client, you don’t argue with them cause they do have that belief and you will not win, don’t agree with her delusions – voice doubt about the delusions
• Once you believe you are superman its hard to believe you can fly
– Reassuring – indicating there is no reason for anxiety or other feelings of discomfort, don’t tell them “everything will be ok”, cause you don’t know if it will be and if its not you don’t want them asking you why and blaming you
• “I wouldn’t worry about that”, “keep your chin up”
Nonverbal Communication Skills• Facial expression – connect with words to illustrate meaning
– Expressive – portrays person’s thoughts, feelings, needs– Impassive – face is frozen, emotionless– Confusing – opposite of what the person wants to convey
• Body language – gestures, posture, movements, body positions– Closed – legs crossed, arms folded– Accepting – face client, feet on floor, knees parallel, hands at side of
body, you can cross legs at ankle
• Vocal cues – voice volume, tone, pitch, intensity, emphasis, speed, pauses augment the sender’s message
• Eye contact – looking into the other person’s eyes during communications, mirror of the soul, reflects our emotions
• Silence – can mean different things– Client may be depressed and struggling to find the energy to talk– Client is thoughtfully considering the question before responding– Not paying attention– Rude for the nurse to jump in, be patient and give them time
Understanding the Meaning of Communication
• Messages often contain more meaning than just the spoken words
• The nurse must try to discover all the meaning in the patient’s communication, not only the literal meaning of the words– Ex. A pt with depression says “I’m so tired that I just can’t go
on” – It could mean fatigue associated with depression or that they
want to die
Understanding Context• Understanding the context of a situation gives the
nurse more information and reduces the risk of assumptions
• To clarify context, the nurse must gather information from verbal and nonverbal sources and validate findings with the patient– Ex. Pt says “I collapsed”– Could mean she fainted or felt weak and had to sit down OR
she could mean she was tired and went to bed
Understanding Spirituality
• Spirituality is a patient’s belief about life, illness, death, and one’s relationship to the health, universe
• The nurse must first assess his or her own spiritual beliefs– Nurse must remain objective and nonjudgmental regarding
the client’s beliefs and must not allow them to alter nursing care
• The nurse must remain objective and nonjudgmental• The nurse must assess the patient’s spiritual needs
– Also must guard against imposing her own on the client– Must ensure that the client is not ignored or ridiculed
because his beliefs and values differ from those of the staff
Cultural Considerations
• Culture – all the socially learned behaviors, values, beliefs and customs transmitted down to each generation
• The nurse must be aware of cultural differences in:
– Speech patterns and habits
– Styles of speech and expression
– Eye contact
– Touch
– Concept of time
– Health and health care
Goals of a Therapeutic Communication Session
• Establishing rapport by being empathetic, genuine, caring, and unconditionally accepting of the client
• Identifying issues of concern by actively listening, formulate a client-centered goal for the interaction
• Being empathetic, genuine, caring, and unconditionally accepting of the person
• Understanding the patient’s perception, in depth, foster empathy in the nurse-client relationship
• Exploring the patient’s thoughts and feelings
• Developing problem-solving skills
• Promoting the patient’s evaluation of solutions
Beginning Therapeutic Communication• Introduce and establish a contract
• Find patient-centered goals
• Use directive or nondirective role appropriately, based on patient behaviors– Directive – asking direct yes/no questions and using
problem solving to help the client develop new coping mechanisms to deal with present issues
• Used when the client is suicidal, experiencing crisis, or out of touch with reality
– Nondirective – using broad openings and open ended question to collect information and help the client to identify and discuss the topic of concern
• Client does most of the talking
Beginning Therapeutic Communication (cont’d)
• Phrase questions appropriately:– Ask for clarification– Manage patient’s avoidance of the anxiety-
producing topic– Avoid asking why
• Guide the patient in problem-solving and empower the patient to change– Identify the problem, brainstorm all possible solutions, select
the best alternative, implement the selected alternative, evaluate the situation, if dissatisfied with results select another alternative and continue the process
• Alert for inappropriate responses by nurse
Community-Based Care
• Nurses are increasingly caring for patients in the family unit and in communities
• Nurses need increased self-awareness and knowledge about cultural differences
• Nurses need self-awareness and sensitivity to the beliefs, behaviors, and feelings of others
• Nurses must collaborate with the patient and family as well as other healthcare providers – Assess relationships of the family
Self-Awareness Issues
• Nonverbal communication is as important as verbal• Ask colleagues for feedback• Examine your communication skills
Patient’s Response to Illness
Learning Outcomes
• Discuss individual characteristics and factors that influence a patient’s response to illness.
• Explain the nurse’s role working with patients of different cultural backgrounds.
• Describe cultural factors important in assessing and working with patients of different cultures.
Individual Factors• Age, stage of growth and development
– Diagnosed at a younger age has poorer outcomes than diagnosed at an older age because younger people have not had experiences of successful independent living or the opportunity to work and be self sufficient and have a less well developed sense of personal identity than older clients
– Lack understanding and ability to describe feelings• Genetics and biologic factors
– Some disorder have been linked genetically– Others that research has not proven are genetic, tend to appear
more frequently in families– Family history and background are important assessments
• Physical health and health practices– The healthier a person is the better they cope – Walking and stretching decrease negative effects to depression
and anxiety• Response to drugs
– Be alert to side effects and serum drug levels in clients from different ethnic backgrounds
Individual Factors (cont’d)• Self-efficacy (confidence)
– A belief that personal abilities and efforts affect the events in our lives– Experience of success in overcoming obstacles– Social modeling (observing successful people)– Social persuasion (persuading to believe in themselves)– Reduce stress, build physical strength, learn how to interpret physical sensation
positively• Hardiness
– Ability to resist illness when under stress– Commitment: active involvement in life activities– Control: ability to make appropriate decisions in life – Challenge: ability to perceive change as beneficial rather than stressful– Moderating or buffering effect on people experiencing stress
• Resilience and resourcefulness– Resilience: having healthy responses to stressful or risky circumstances – Resourcefulness: using problem solving abilities and believing that one can cope with
adverse situations• Spirituality
– Involves the essence of a person’s being and his beliefs about the meaning of life and the purpose for living
– Includes belief in God or a higher power, practice of religion, cultural beliefs and practices, relationship with the environment
– Serves as a primary coping device and a source of meaning, helps develop a social network
Interpersonal Factors• Sense of belonging
– Feeling of connectedness with or involvement in a social system or environment of which a person feels an integral part
– Maslow described a sense of belonging as a basic human psychosocial need that involves both feelings of value and fit
– Support systems: family, friends, coworkers, clubs, social groups, health care providers
• Social networks and social support– Social networks: groups of people whom one knows and with one feels
connected (can help reduce stress, diminish illness, positively influence ability to cope and adapt – emotional support)
– Social support: emotional sustenance that comes from friends, family members, health care providers who help a person when a problem arises (does not always provide emotional support)
– Client must feel connected to these in order for it to be positive (boost confidence, self esteem, assistance in problem solving
• Family support– Key factor in recovery, most important part of recovery even if not the
most positive– Nurse encourages family to support client while in hospital and should
identify family strengths such as love and caring
Cultural Factors• Beliefs about causes of illness• Culturally competent nursing care means being sensitive to
issues related to culture, race, gender, sexual orientation, social class, economic situation
• Factors in cultural assessment:– Communication (language, translator, nonverbal)– Physical space or distance (what distance is comfortable
for the client)– Social organization (family structure and organization,
religious values and beliefs, ethnicity, culture)– Time orientation (whether one views time as precise or
approximate – urgency, taking meds on time)– Environmental control (client’s ability to control
surroundings or direct factors in the environment)– Biologic variations (ethnicity – cause variations in
response to drugs, race – biologic variations based on physical makeup)
– Socioeconomic status and social class (status – income, education, occupation, influences a persons health, access to care, can afford meds; class – can be influence on social relationships, how people relate to each other, better than someone else)
Cultural Patterns and Differences
• Knowledge of expected cultural patterns provides a starting place for the nurse to begin to relate to persons from different ethnic backgrounds.
• Individual assessment of each person and family is necessary to provide culturally competent care that meets the client’s needs
Cultural Patterns and Differences (cont’d)• African Americans
– Usually family-oriented, but client makes own decisions– Conversation animated and loud– Comfortable with public affection
– Handshakes and direct eye contact convey interest and respect
– Silence may indicate lack of trust
– Church is important and a valued support system
– Prayers are an important part of healing
– View mental illness as a spiritual imbalance or punishment for sin
– Use folk remedies in conjunction with western meds
Cultural Patterns and Differences (cont’d)• Filipinos
– Greet others with smiles rather than handshakes– Facial expressions animated– Direct eye contact impolite, especially with authority
figures– Soft spoken, avoid expressing disagreement– Mental illness viewed as having religious and
mystical causes• Result of a disruption of the harmonious function of the
whole person and the spiritual world• Can include: contact with a stronger life force, ghosts,
souls of the dead, disharmony among wind, vapors, diet and shifted body organd
– Most are catholic, may want priest and dr– Ill assume passive role, eldest male in household
will make decisions after conferring with family members
Cultural Patterns and Differences (cont’d)
• Mexican Americans– Touching prevalent among family, but not
necessarily welcome from strangers• Handshake is ok
– Direct eye contact with authority figures avoided– Silence denotes disagreement– Illness comes from imbalance between person and
environment• Includes: emotional, spiritual, social and physical factors
– Catholic, observe the rites and sacraments of that religion
Nurse’s Role in Working With Clients From Various Cultures
• Nurse must learn about the client’s cultural values, beliefs, and health practices
– Best source of information is the client: o “How would you like to be cared for?”o “What do you expect (or want) me to do for
you?”o Religious beliefs and health practices
o Do you follow any dietary preferences or restrictions?o How can I assist you in practicing your religious or spiritual
beliefs?o What kinds of remedies have you tried at home?
o Client is more likely to share personal and cultural information if the nurse is genuinely interested in knowing and does not appear skeptical or judgment
Self-Awareness Issues• Maintain a genuine, caring attitude• Ask how you can promote or assist with spiritual,
religious, and health practices• Recognize your own feelings and possible prejudices• Remember that the patient’s response to illness is
complex and unique
Assessment
Learning Outcomes
• Identify the factors that influence the assessing of a mental health patient.
• Describe how to conduct a interview with a patient on a mental health unit.
• Explain the components used to gather information in the psychosocial assessment of a mental health patient.
• Identify other sources of data used in patient assessment.
Purposes of Psychosocial Assessment
• To construct picture of patient’s current emotional state, mental capacity, and behavioral function
• To form basis for plan of care • To establish clinical baseline to evaluate
effectiveness of treatment and interventions
Factors Influencing Assessment• Patient’s participation/feedback
– Requires active client participation– If the client is not able to fully help, the assessment will be incomplete or vague
• Patient’s health status– If pt is anxious, tired or in pain the nurse may have difficulty in getting the client’s full
participation in the assessment– Nurse needs to recognize these situations and allow the client to rest, receive meds
or be calmed before continuing the assessment• Patient’s previous experiences/ misconceptions about health care
– If they have had a bad experience before they may minimize or maximize their symptoms or problems or refuse to provide information in some areas
– Nurse must address the client’s feelings and perceptions to establish a trusting working relationship before proceeding with the assessment
• Patient’s ability to understand– Determine the client’s ability to hear, read, understand the language being used to do
the assessment– Important that the assessment reflects the health status no a result of poor
communication• Nurse’s attitude and approach
– If the client feels the nurse is short and curt or feels rushed or pressured, they may provide only superficial information or omit problems in some areas all together
– May also omit sensitive information if he feels the nurse is unaccepting, defensive or judgmental
How to Conduct the Interview• Provide a comfortable, private, safe environment
– Quiet place but still safe, may have another person present if the client is known to have threatening behavior
• Obtain input from family and friends (with patient’s permission)– If they give permission you can talk to others privately, some
family may not feel comfortable talking in front of the person– Clients may also not feel comfortable being along and need family
in the room with them– In suspected abuse or intimidation cases, nurse must talk to the
client privately at some point• Ask questions that are open-ended or closed-ended
as needed– Allows the client to begin as he feels comfortable, also gives the
nurse an idea about the client’s perception of his situation– Questions need to be clear, simple and focused on one specific
behavior or symptom– Nurse should use a nonjudgmental tone and language
• Especially about drugs or alcohol, sex behavior, abuse, violence
Content of the Assessment• History (background assessments)
– History, age, developmental stage, cultural & spiritual beliefs, beliefs about health and illness
• General appearance and motor behavior– Dress, hygiene, grooming, posture, eye contact, facial expression,
any unusual tics or tremors, speech for quality, quantity, abnormalities (neologisms: invented words that have meaning only for the client)
– Automatisms: repeated purposeless behaviors often indicative of anxiety (drumming fingers, twisting hair, tapping foot)
– Psychomotor retardation: overall slowed movements– Waxy flexibility: maintenance of posture or position over time
even when its awkward or uncomfortable• Mood and affect*
– Mood: client’s pervasive and enduring emotional state– Affect: outward expression of the client’s emotional state– Blunted affect: little or slow to respond facial expression– Broad affect: displaying full range of emotional expressions– Flat affect: no facial expression– Inappropriate affect: facial expression that is incongruent with
mood or situation, often silly or giddy regardless of circumstances– Restricted affect: displaying one type of expression usually
serious or somber– Labile: unpredictable rapid mood swings, from crying to euphoria
with no apparent stimuli; rapidly changing
Mood and Affect Assessment• Mood- is pervasive and sustained quality of person’s
emotional tone: described as euphoric, dysphoric, euthymic, or labile (rapidly changing)
• Affect- outward expression of emotion: described as blunted, flat, inappropriate/incongruent to verbal, appropriate, hyper-reactive, or restricted/constricted
• Thought process and content*– Process: how the client thinks– Content: what they actually say– Circumstantial thinking: eventually answers after giving
excessive unnecessary detail– Delusion: fixed false belief not based in reality– Flight of ideas: excessive amount and rate of speech
composed of fragmented or unrelated ideas– Ideas of reference: clients inaccurate interpretation that
general events are personally directed to him– Loose associations: disorganized thinking that jumps from
one idea to another with little or no evident relationship– Tangential thinking: wandering off the topic and never
providing the information requested– Thought blocking: stopping abruptly in the middle of a
thought, sometimes unable to continue the thought– Thought broadcasting: delusional belief that others can
hear or know what the client is thinking– Thought insertion: delusional belief that others are putting
ideas or thoughts into their head– Thought withdrawal: delusional belief that others are taking
the clients thoughts away and the client is powerless to stop it
– Word salad: flow of unconnected words that convey no meaning to the listener
Thought Processes and Content
• Thought process- how patient thinks• Thought content- what patient actually says• Common terms in assessing
– Delusions - (persecutory, paranoid, grandiose, somatic)– Hallucinations – are they hearing things, seeing things,
smelling things– Ideas of reference – feel like everything that is going on is
directed at you – if you are watching tv and they think they are getting special messages from the tv
– Loose associations – jump from one subject to another and there is no relation between thoughts
– Tangential thinking – can’t keep them on task, not able to stay on track
Thought Process and Content (cont’d)• Thought blocking – stopping abruptly when they are
talking to you• Thought broadcasting – think others can hear your
thoughts, that people can see what you are thinking• Thought insertion – feels that people or things are putting
thoughts into their mind• Thought withdrawal – feel that others are taking the
thoughts out of their head• Word salad – words that have no meaning in relation to
other things• Concrete thinking – inability to understand concrete
thoughts• Phobic - fears• Reality oriented – can they tell you the time, place, etc.
• Sensorium and intellectual processes– Orientation: recognition of person, place and time– Memory: ask about recent and remote memory (what
did you do yesterday?, what is the name of the current president?)
– Ability to concentrate: asking the client to perform certain tasks (spell the word world backwards, serial sevens – 100-7=?-7, repeat the days of the week backwards, perform a 3 part task)
– Abstract thinking: make association or interpretation about a situation or comment
– Hallucinations: false sensory perceptions or perceptual experiences that do not really exist
• Judgment and insight– Judgment: ability to interpret one’s environment and
situation correctly and to adapt one’s behavior and decisions accordingly
– Insight: ability to understand the true nature of one’s situation and accept some personal responsibility for that situation
• Self-concept– Way that one views oneself in terms of personal worth
and dignity– Ask client to describe himself and what characteristics
he likes and what he would change• Roles and relationships
– Nurse assesses the role the client occupies, satisfaction with those roles, whether the client believes he is fulfilling the roles adequately, client satisfaction with relationships or any loss of relationships
• Do you feel close to your family?, are your relationships meeting your needs for companionship or intimacy?
• Physiologic and self-care concerns– Emotional problems: effect eating and sleeping (under
stress: eat excessively or sleep longer hours)– Ask about any major health problems or prescription
meds they are taking, follows dietary recommendations, use of alcohol, drugs, OTC meds
Data Analysis
• After completing the assessment the nurse analyzes all the data to help in forming the patient’s plan of care
• Data assessment leads to the formulation of nursing diagnoses as a basis for care
• Other data may be gathered from the following– Psychosocial assessment – Psychological tests – Psychiatric diagnoses – Mental status exam
Psychological Tests
• Psychological tests are another source of data to use in planning care – Intelligence tests assess cognitive abilities and
intellectual functioning
– Personality tests evaluate self-concept, impulse control, reality testing, and major defense mechanisms
Psychiatric Diagnoses
• Based on the DSM-IV-TR multiaxial system:– Axis I: clinical disorders– Axis II: personality disorders, mental retardation– Axis III: general medical conditions– Axis IV: psychosocial and environmental problems– Axis V: global assessment of functioning (GAF)
Mental Status Exam
Focuses on the patient’s cognitive abilities:• Orientation to person, time, place, date, season, day
of the week• Ability to interpret proverbs• Ability to perform math calculations• Memorization and short-term recall• Naming common objects in the environment• Ability to follow multi-step commands• Ability to write or copy a simple drawing
Self-Awareness Issues
• Judgments are not part of the assessment process• Be open, clear, and direct when asking about personal
or uncomfortable topics • Examining one’s own beliefs and gaining self-
awareness is a growth-producing experience• The nurse must not allow personal beliefs to interfere
with the nurse–patient relationship and the assessment process
