Therapeutic Relationships and Patient Assessment

Chapter 7: The Nursing Process and Standards of Care

• The nursing process includes assessment, diagnosis, planning, implementation, and evaluation.
• Subjective assessment gathers information from the patient's self-report. This includes:
  • History of present illness (HPI)
  • Reasons for treatment (voluntary/involuntary)
  • Thought content and perceptions, including risk assessments for suicide and homicide
  • Hallucinations, delusions, illusions, obsessions, ruminations, and insight
  • Judgment and problem-solving ability
• Subjective assessment also includes:
  • Psychiatric history (age of onset, diagnoses, medication history, hospitalizations, suicide/self-harm, legal history, trauma)
  • Substance use history (caffeine, nicotine, controlled substances, illicit substances)
  • Social history (developmental, relationships, education, occupation, current living situation, support systems)
  • Medical and surgical history
  • Current medications
  • Allergies
  • Review of Systems (any relevant conditions outside the presenting concern)
• Objective assessment is based on observations and doesn't include subjective information. This includes:
  • Vital signs
  • Physical assessment
  • Diagnostic tests (labs, scans)
  • Results of screening tools
  • Mental status exam (MSE)

Mental Status Exam (MSE)

• Structured assessment used by healthcare professionals, particularly in mental health settings.
• Evaluates cognitive, emotional, and psychological functioning.
• Crucial for diagnosis, treatment planning, and monitoring progress.

Key Components of the MSE

• Appearance: Physical appearance, grooming, dress, and hygiene
• Behavior: Motor activity, eye contact, responsiveness, and general behavior during the interview
• Speech: Rate, volume, articulation, coherence (e.g., pressured, slurred, tangential)
• Mood and Affect: Reported emotional state (e.g., depressed, anxious), observed emotional expression (e.g., flat, labile, appropriate)
• Thought Process: Organization and coherence of thoughts (logical, flight of ideas, circumstantial)
• Thought Content: Delusions, obsessions, preoccupations, suicidal/homicidal ideation
• Perception: Sensory experiences (hallucinations, illusions)
• Cognition: Attention, concentration, memory, and orientation (person, place, time)
• Insight: Awareness and understanding of one's condition and need for treatment
• Judgment: Decision-making abilities and understanding of the consequences of actions

Chapter 8: Therapeutic Relationships

• Characterized by trust, respect, empathy, and collaboration
• Patient-centered care is fundamental
• Important components include dignity, respect, information sharing, and collaboration.
• Nurses must be clear and appropriate in setting boundaries.

Therapeutic Use of Self

• The conscious use of one's personality, experiences, and insights.
• Improves interpersonal skills and promotes self-awareness
• Essential for facilitating positive client outcomes and impactful therapeutic relationships

Concepts of Therapeutic Use of Self

• Self-Awareness: Recognizing one's values, beliefs, and experiences, understanding how these aspects influence the relationship.
• Authenticity: Being genuine in interactions, which builds trust and comfort for clients
• Empathy: Understanding and sharing the feelings of another, critical for creating a supportive environment.
• Boundary Setting: Maintaining professional boundaries essential for a focused therapeutic approach.
• Reflection and Supervision: Continual reflection on experiences and supervision to enhance effectiveness.
• Cultural Competence: Respecting diverse cultural backgrounds and tailoring interventions for specific client needs.

Chapter 9 Therapeutic Communication

• The purposeful, professional interaction between a healthcare provider, particularly a nurse or therapist, and a patient.
• Facilitates understanding, healing, and supports the patient.

Techniques in Therapeutic Communication

• Active Listening: Paying attention to both verbal and nonverbal cues.
• Empathy: Understanding and sharing the feelings of another.
• Open-Ended Questions: Encouraging detailed responses and elaboration.
• Clarification: Questioning to gain more understanding of the patient's message.
• Reflection: Mirroring back the patient's expressed thoughts and feelings.
• Silence: Allowing pauses for reflection and processing.
• Focusing: Directing the conversation to specific relevant concerns.
• Validation: Recognizing and affirming a patient's feelings and experiences.
• Humor: Using appropriate humor to reduce tension and build rapport.

Chapter 34: Therapeutic Groups

• Therapeutic groups bring together individuals with shared purposes.
• This promotes personal development and psychological growth. Some examples include DBT, AA, trauma groups, and grief groups.

Advantages of Group Therapy

• Multiple members can be treated simultaneously, reducing costs.
• Members learn from each other's experiences and knowledge.
• Therapeutic groups offer a safe space for practicing new communication and interaction skills.
• Groups can foster a sense of community and cohesiveness.

Disadvantages of Group Therapy

• Some members may feel their personal time is limited in larger groups.
• Confidentiality may be an issue depending on group size and member behaviors.
• Negative interpersonal dynamics can disrupt the effectiveness of a group
• Patient's opinions may be discouraged by group norms.

Curative Factors in Group Work

• Instillation of Hope: The leader and other members express optimism about the group's potential for improvement.
• Universality: Members realize they are not alone, that others share similar experiences.
• Imparting of Information: Members benefit from the knowledge and insights of others.
• Altruism: Members realize they can provide support to others, and this can contribute to self-esteem.
• Corrective Recapitulation of the Primary Family Group: Members have the opportunity to re-enact problematic interactions from the past, hopefully in a healthy manner.
• Development of Socializing Techniques: The group can help individuals learn and practice new social skills.
• Imitative Behavior: Members can observe and imitate the healthy behaviors of others.
• Interpersonal Learning: Members learn about their own behaviors through feedback from each other.
• Group Cohesiveness: A sense of belonging created within the group
• Catharsis: Emotions and feelings are acknowledged and processed through appropriate behaviors.
• Existential Factors: Group interactions support exploration of existential issues.

Group Leader Roles and Challenges

• Leading groups effectively is essential to their success.
• Therapists must perform specific roles, including providing support, instilling hope, and managing group processes.

Group Phases

• Preorientation Phase: Planning, preparing for meetings, and setting ground rules.
• Orientation Phase: Establishing trust and rapport.
• Working Phase: Establishing group goals, identifying themes, utilizing various strategies, providing support and confrontation when necessary.
• Termination Phase: Reviewing accomplishments, evaluating progress, and strengthening coping mechanisms.

Family Structure

• Nuclear Family: Two parents, married to each other and are the biological/adoptive parents of all children.
• Single-Parent Family: One parent is the biological/adoptive parent; child(ren).
• Unmarried Biological/Adoptive Family: Unmarried biological/adoptive parents and children.
• Blended/Step Family: A single parent and/or step-parent with children from previous relationships.
• Extended Family: Related adults are also members, such as grandparents, or adult siblings.
• Grandparent Family: One or more grandparents are raising the child(ren).
• Cohabitating Family: Partners/spouses but not legally married and children.
• Childless Family: Includes partners/spouses only.
• Other Family: Includes children living with adults who are not biological or adoptive parents (e.g., foster families).

Family Functions Management

• Management: Establishing rules, making decisions, and allocating resources.
• Power: Power dynamics and distribution within the family systems.
• Resources Allocation: Distribution of resources among family members.
• Finances: Financial considerations and accountability in the family system..

Family Functions: Boundaries

• Clear Boundaries: Expectations and limits are set; respect for each individuals' space.
• Diffuse Boundaries: Difficult to establish personal independence or space; lack of awareness of limits.
• Rigid Boundaries: Difficulty in engaging with other members of the family; significant resistance to change

Dysfunctional Family Communication

• Manipulation: Action intended to control or influence others, often in an underhanded or unfair way
• Distraction: Addressing irrelevant information or details to avoid dealing with the main issue
• Generalization: Making broad statements that don't consider individual circumstances, using universal terms
• Blaming: Placing blame instead of taking accountability.
• Placating: Seeking to please others, often to avoid conflict

Family Therapy Concepts

• Identified patient: A family member targeted as the root cause of the problem, even if that's not accurate.
• Triangulation: A third party (often a member of the family) is brought into a conflict between two other members; can be dysfunctional
• Behavior Violates Boundaries: Behavior is not healthy or positive in nature or in context.

Risk vs Benefit of Family Therapy

• Risks: Potential for emotional or physical harm.
• Benefits: Fosters healthier behaviors within the family, resolves conflicts, mobilizes family resources to address problems effectively.