FC therapeutic communication.txt

• *to MODIFY the BODY IMAGE, CONCEPT of SELF, and RELATIONS to other PEOPLE and WORK.
• *to READJUST REALISTICALLY to the LIMITATIONS IMPOSED by the condition

• stage 1: transition from health to illness
• stage 2: acceptance of illness
• stage 3: convalescence

• TRANSITION from HEALTH to ILLNESS
• A.DEVELOPMENT of SYMPTOMS
• ----unpleasant sensations
• ----decrease in ability to function
• ----loss of vigor and stamina
• B. ANXIETY may be present
• Coping styles
• ---plunge into activity, work late, increase social activities
• ---passive, withdrawn, hoping symptoms will go away
• ---put off medical care, fear of diagnosis
• ---anxiety, guilt, shame, or denial are prominent
• C. if SYMPTOMS PERSIST, SEEK medical CARE
• ---ambivalent feelings (evident in canceled or missed appointments)
• ---may be non-compliant
• ---go from physician to physician
• D.If illness is SUDDEN or CATASTROPHIC, seeks IMMEDIATE attention
• ---fear of not getting timely help
• ---family fear (excessive demands, refusal to cooperate, suspicion of motive and methods of those trying to help)
• ---shock, disbelief, denial

• ACCEPTANCE of ILLNESS
• a.Recognizes and admits he is sick and in need of help from others
• b.Temporarily adopts patient role (dependence)
• c.Abdication from usual responsibilities and cooperation in the task of getting well
• d.Become preoccupied with self, symptoms, and treatment
• e.Interest in current events and even concern about family and friends may be limited
• f.May be seen as regressive (return to earlier forms of acting, feeling, and relating to others)
• g.Some regression may be useful (get rest, be waited on)
• h.For some, dependence may be threatening (deny illness, noncompliance)
• i.Serious acute illness (need a great deal of help from others).
• dependence may be overwhelming (both for patient and staff)
• j.May express anger, guilt, resentment
• k.May be critical of care and medical management, attacking the very people he depends on
• l.Nurse should recognize need and encourage expression of feeling without passing judgment, moralizing or arguing
• m.Feel helpless and hopeless
• n.Nurse should provide opportunity for decision-making and responsibility where possible
• o.Acute sense of loss
• p.depression: sadness, hopelessness, anger (mourning the loss of health, loss of body part or function, changes anticipated in job and family)
• q.stages of grief, denial/isolation, anger, bargaining, depressing, acceptance

• CONVALESCENCE
• a.Return to health and physical strength often precedes the patients feeling and acting well (remember there was a lag between being ill and accepting illness - this is a similar lag)
• b.Giving up dependent, regressive position; resuming adult responsibilities and normal relations
• c.Some are reluctant to give up role
• d.Some motivated, but hesitant (especially if involves major changes in work and family relations)
• e.Nurse may help by assuming role of adequate parent to teenager
• *relaxed protection, guidance, advice, encouragement
• *quietly retire to sidelines
• *ready to reassure, encourage experimentation
• *step in only when gross errors in judgment occur
• *patient will sense confidence of nurse

• the patient with a BODY IMAGE DISTURBANCE
• *Describes changes in thoughts and feelings about self.
• *Verbalizes acceptance of changes that have occurred.
• *Looks at, touches, and discusses changed body part.
• *Continues preexisting socialization pattern.
• *Engages in appropriate role functions.
• *Engages in recreational activities appropriate to limitations.
• *Maximizes use of remaining strengths.
• *Uses ALL available resources to improve functioning (or appearance) of body part.
• *Accepts offers of help.

• the patient with a SELF-ESTEEM DISTURBANCE
• *Demonstrates an improvement in personal appearance.
• *Verbalizes realistic perceptions of self.
• *Identifies at least 5 positive personal attributes.
• *Shares feelings about self with significant others.
• *Compares ideal self and perceived self.
• *Uses appropriate assertive and communication skills.
• *Demonstrates use of active rather than passive language pattern (e.g., says, I choose to, or, I choose not to).
• *Demonstrates increased social contacts and friendship networks.
• *Expresses satisfaction with own achievements.
• *Engages in positive talk about self.
• *Analyzes own behavior and its consequences.
• *Discusses options and alternatives when trying to solve problems.
• *Identifies ways of exerting control and influencing outcomes.

Successful adjustment to developmental phases, to meeting life crises, and to the experience of being ill

• the patient with ALTERED ROLE PERFORMANCE
• *Verbalizes realistic perception and positive acceptance of self in changed role.
• *Verbalizes understanding of role expectations and obligations associated with role.
• *Develops/lists realistic plans for adapting to new role or role changes.

• 1. communication is DYNAMIC and NECESSARY for social interaction
• 2. ALL BEHAVIOR TRANSMITS INFORMATION and is to be considered in the communication process
• 3. 60-80% of communication occurs via NON-VERBAL means.
• 4. ALL individuals have UNIQUE PATTERNS of communicating.
• 5. communication is INFLUENCED by AGE, CULTURE, DEVELOPMENTAL STAGE, COGNITION, ANXIETY, and STATE OF HEALTH
• 6. for communication to be EFFECTIVE, the MESSAGE SENT must be accurately RECEIVED.
• 7. an individual's HONEST, GENUINEness, EMPATHY, TRUST, RESPECT, and VALUE of individual DIFFERENCES facilitate communication.
• 8. highly elevated levels of ANXIETY decrease PERCEPTION

• 1. HUMAN NEEDS appear in a HIERARCHY from needs that are high in rank to those that are lower in IMPORTANCE at any given time
• 2. The PHYSIOLOGICAL needs usually must be MET BEFORE other needs; however, ALL needs INTERACT. (refer to MASLOW'S HIERARCHY)
• 3. HUMAN beings can HELP EACH OTHER meet their needs.
• 4. to be EFFECTIVE, a helper seeks to know how the PATIENT RANKS his/her NEEDS.
• 5. therapeutic relationships are based on RESPECT for the INDIVIDUALITY of the participants.
• 6. a major GOAL of a helping relationship is the PERSONAL GROWTH of the PARTICIPANTS. however, the PATIENT remains the PRIMARY FOCUS in the relationship.
• 7. a GOAL of all helping relationships is to aim for reaching the patient's HIGHEST ACHIEVABLE LEVEL of SELF-CARE
• 8. ALL behavior is MOTIVATED, and ALL behavior has MEANING.

• MASLOW'S HIERARCHY OF BASIC NEEDS
• PSYCHOLOGICAL Needs: biological needs i.e. oxygen, food, water, body temp.
• SAFETY Needs: in/security
• Needs of LOVE, AFFECTION, and BELONGINGNESS: giving/receiving love, affection, and the sense of belonging.
• Needs for ESTEEM: human need for stable, firmly based high level of self-repect and respect from others.
• Need for SELF-ACTUALIZATION: a need be and do what they were "born to do"

BASIC CONCEPTS

• Self-Concept
  
  








• Stress
  
  








• Stressors
  
  








• Anxiety

Adaptation and Coping

• SELF-CONCEPT
  
  





o An individual’s attitudes and beliefs about the physical and psychological self

o Guides life actions, expectations, and goals

o Develops and changes over time

Components of Self-Concept


o Personal Identity (or Self-image): Inner images that tell me who I am


o Self-Esteem: How I value/respect myself


o Role Performance: How I fulfill socially expected behaviors


o Body Image: How I perceive the size, appearance and physical functioning of my body and its parts

• Stress


















• ¡ Physiologic responses to internal and external demands

• Selye: Stress Activates Responses primarily in:

• Nervous system






• Endocrine system






• Immune system

• Stressors

• o Anything that causes stress
• o Stressors can be:
• Physical
• Chemical
• Emotional
• Developmental

• Ÿ
• Anxiety

o A common, pervasive feeling of dread accompanied by physical symptoms


o May be chronic, intermittent; ranges from mild to panic state


o Most often occurs in response to actual or perceived threat to:

• Biological integrity
• e.g. death, pain, injury

• Personal identity, e.g. loss of self-esteem,
• status, role performance

• Selye (General Adaptation Theory):
• Human beings are continually adapting to stress -- i.e. maintaining homeostasis/ability to function.
• Stress Tolerance – how much stress an individual is able to adapt to while maintaining normal function
• Resilience – how quickly an individual is able to recover from a stressful event

• Heredity
• Age
• Perception [Lazarus & Folkman]

• Lifestyle factors
• Chronicity of the stress
• (how long it has been going on)

Number and Severity of Stressors

*Self-protective cognitive and behavioral responses by an individual to manage a stressor which is perceived as a threat to health or safety


Goal of all coping behavior = stress and anxiety reduction



Principles of Coping


o Individuals cope in patterned ways


o The greater the variety of coping behaviors used by an individual, the more successful they are in dealing with stress


o Individuals are usually aware of their coping patterns



Coping Patterns


o Adaptive Coping:

• Problem-solving or emotion-regulation
• coping behaviors

o Maladaptive (Dysfunctional) Coping

• Coping behaviors which exacerbate stress or cause new stress

• Spirituality
• o Provides meaning, security and hope
• • Sexual Health
• o Multiple levels of the hierarchy of human needs

o gender/sexual identity

o sexual expression and sexual performance

• • Culture, Family and Community
  
  
  • Support System
  
  

• Crisis
  
  

o Overwhelming or life threatening event


o Usual adaptive, coping methods are ineffective


o Help is needed to regain homeostasis

• Physiologic Stressors
  
  

o Chronic illness/anxiety affect brain structures and immune system


o To maintain psychosocial integrity, client and family must successfully adapt to each stage of illness and recovery

• Family Context Factors
  
  



o Influence of family on learned behaviors

o Effects of early life stress

o Family system affected when one member is ill

o When family support is insufficient

• Cultural and Lifestyle Factors

o Culture Shock and cultural repression (military returns)


o Cultural Insensitivity or Misunderstanding

• o Lifestyle factors (workaholic)
• Use of substances

• Violence, Abuse, and Neglect
  
  




• Correlate to decreased stress tolerance, poorer psychosocial functioning

• Economic Factors
• employment status, insurance, expenses = HUGE impact

• Permission
• Limited Info
• Specific Suggestion
• Intensive Therapy

• Health and Social History

o Type and duration of stressors


o History of illness, including mental illness


o Medications used


o Coping ability and patterns


o Identify support system


o Sexual history if sexual function is involved


o PLISSIT model: sexual concerns

• Mental Status Assessment

o Cognitive Functioning (orientation, memory, knowledge, understanding, judgement)


o Affect (external observational appearance)


o Mood (patients internal emotional state, feelings)


o Psychomotor Behavior (voluntary movements/muscle activity assc. with mental process)

• • Lab tests are super important to ID physiological factors assc. with dilemma.
• • Standardized measures of intelligence, general personality traits, anxiety or depression, perception,
  • cognitive status, etc.
  
  
  
  
  
  • Nurse may administer some tests with dr.’s order e.g.
  • Mini-Mental State Scanning Tests
  
  
  

• Anatomical or Structural Changes
• CT: X-ray

• Biochemical Alterations (CNS Metabolites)
• * PET, MRI; MRSI

• Sensory Processing
• EEG

Laboratory Analysis

• Laboratory Tests

• Identify contributing physiological factors
• e.g. Thyroid function tests (TSH, T4), blood glucose level, serum analysis of drug levels

• • tell me about your concerns.
• • what have you been doing to manage your problem?
• • how well has this worked?
• • how can i help you?
• • PROBLEM ID BEGINS WITH PATIENT PERSPECTIVE.
• 
  
  
• Nursing Diagnoses




• o Problem Identification begins with patient’s perspective, if possible.

• • Goals and Outcomes
• o Cognitive Outcomes

Demonstrates improved memory, concentration, learning, etc.

o Affective Outcomes

Reports improved mood; affect improves

o Psychomotor Outcomes

Motor behaviors indicate positive changes

• Interventions

o The Helping Relationship; cultural, ethical and legal aspects


o Communication


o Drug Therapy


o Patient Teaching: Coping Skills


o Referrals


o Community Resources

• The Nurse-Client Relationship is a Helping or Therapeutic Relationship

o H. Peplau: In nursing practice, this is the one “core modality” which assists clients to maintain psychosocial integrity

o The therapeutic (helping) relationship is based on empathy, trust, respect, and healthy boundaries

o Differs from social relationships

• Client-focused (take self out of situation)
• Time-limited, boundaries are clear
• Goal-oriented, purposeful
• Nurse shares personal information only when helpful to client
• Promotes personal growth of the participants

• 1. Pre-Interaction Phase
• (preparing to meet patient)
• 2. Orientation Phase
• (starting/establishing the relationship)
• 3. Working Phase
• (developing/maintaining the relationship)
• 4. Termination Phase
• (ending/completing)

• communication
• space (personal)
• social organization (roles within community)
• time importance
• environmental control (perception of control)
• biological variation

• Confidentiality
• -- keeping secrets

Objectivity in documentation




o Culturally Competent Nurse-Client Relationship


o Based on recognition and valuing of differences and similarities


o Compromise is necessary component (nurse modifies care to meet client needs)

• o Good communication skills are essential for establishing and maintaining the nurse-client
• relationship

o Communication involves:

SENDER <-----> RECEIVER

encodes ------> message <-------- decodes


If the message is not received, no communication can take place.


o Effective Communication Means:


message sender intended to convey


reached intended receiver

was interpreted (decoded) accurately


receiver was able to respond in a meaningful way to indicate message was received (feedback)

o Verbal Communication


o Non-Verbal Communication (Metacommunication)


o Therapeutic Communication

• o Verbal Communication includes:
• Spoken words
• Written communication
• Language, vocabulary, slang and idioms

• o Non-Verbal Communication (Metacommunication) includes:
• Paralanguage
• Body language
• Humor
• Touch

Non-Verbal Communication is 60-80% of Communication

Paralanguage


Body language

• Humor
• Touch

Non-Verbal Communication is 60-80% of Communication

• Paralanguage or Vocal
• Cues
• Give meaning to the
• spoken word
• tone of voice
• emphasis
• pitch

• Kinesics or Body
• Language
• Posture
• Gestures
• Facial expression
• Attire, adornment
• Personal space
• (preferred closeness or distance)
• Humor
• Is both verbal and
• non-verbal

• Can decrease stress
• response

• Should be used
• appropriately

• Must be acceptable to
• client

• Touch
• Procedural (e.g. taking
• a B.P.)
• Non-Procedural
• Communicates connection
• Must be used
• appropriately

• Clients will not always
• welcome touch

• Nurse must be
• comfortable using it

• Techniques are
• deliberately selected

• Facilitates expression
• and identification of client’s thoughts and feelings

• Assists client to work
• through problems

• o
• Classifications include:

• -
• Anti-anxiety agents

• -
• Antipsychotic agents

• -
• Antidepressants

• -
• Mood-stabilizing agents

• -
• Acetycholine-potentiating
• drugs (for dementia)

• Utilize patient’s strengths
• Identify substitute coping behaviors that can be used to replace dysfunctional (ineffective) coping
• Teach new skills, if
• possible

• Skills may include:
• Relaxation techniques
• Positive self-talk

Lifestyle alterations: e.g. increase exercise, weight loss, etc

**can really help through a situation if time limited, but pt needs therapeutic communication**

Social Services

Pastoral Care

Case Management

Counseling

Senior Services

Religious/Spiritual Groups

Self-Help Groups

Teaching Groups

Evaluate via:


o Change in cognition, affect, or psychomotor behavior


o Client’s report (self-assessment)