Rebecca Sposato MS, RN
Physical examLabs, Neuro diagnostics, Review of systems
Mental Health Status ExamThinking patterns, Emotional affect, Perceptual disturbances, Speech, Appearance, Behavior, Safety/Harm
Psychosocial Home, family/friends, employment, income, substance use
Problem – what needs helpClinical judgmentNANDA diagnoses
Etiology – probable causeMedical, psychosocial, etc.‘related to . . .’
Supporting Data – objective signs and symptoms‘as evidenced by’
The maximum level of health that can be realistically achieved through nursing interventionsCustomized per patient situationNursing Outcomes Classification (NOC) -385 items in 7 categories
Set time period
Most places use standardized clinical plans and pathways
Safe, Compatible, Realistic, Individualized, Evidenced-Based
Nursing Interventions Classification (NIC) – 542 accepted interventions
Standard:Coordination of CareHealth Teaching/PromotionMilieu TherapyPharmacological, Biological
Advanced:PrescriptivePsychotherapyConsultation
Should be ongoing and criteria based
Reassess for outcomes and compare to goalIf they don’t match, review each standard and revise as needed
All parts of the patient’s environment are designed to contribute to sense of security, support and comfortSafety and protectionsUnit exhibits calm and positive
moodCommunicated rules and routinesCommunicated consequences for
behaviorConsistency and flexibility
Therapeutic use of self – the living part of the milieuPurposeful conscious use of
personality (words, actions and attitudes)
Every moment countsCommunicate trust on all levels
SafeReliableConsistentConfidentialBenevolent
Pre-orientation: internal state and beliefs
Orientation: Establish rapport - connectEstablish parameters – extent of
roleFormal/informal contract -
expectationsConfidentiality – terms of privacyTerms of termination – time period,
behavioral deal-breakers
Working:Problem-solving/coping skillsSubstance of therapy
TerminationResolution of the problemIncorporating therapy growth into the real life situation
Passing of the relationship
The nurse is an extension of the employer and profession
Clear limits Professional layer over nurse’s
personal needs and beliefs Transference and Counter-
transference: fitting the other person with pre-existing pattern of perception
Needs of patient identified and explored
Clear boundaries established
Use of problem-solving approaches
New coping skills developed
Behavioral change encouraged
Active Listening and silence: empathy Clarify statements: Summarize,
paraphrase, restate, reflect, explore Questions and Response: Open
ended vs. close ended Reality Testing: presenting reality,
stating the implied, voicing doubt, suggest alternatives
Excessive questioning – patient feels interrogated
Approval/disapproval – imply judgment
Advising – change should come from within
Asking ‘why’ – as a form of criticism
Believed to stem from the subconscious Less precise and more powerful then
verbal communicationVoice featuresBody/hand movementEye contactPersonal spaceCultural filters/interpretation
Classic Psychoanalysis and Psychodynamic Therapy– searches for greater understanding of unconscious processes’ contributions to thoughts, emotions and actionsLong-term - can be yearsOpen-ended – general improvementUnstructured – free associationLittle input/direction from the therapist
CBT- seeks to change distorted beliefs and habits and replace with logical and functional beliefs and habitsPreset time frameSpecific goal orientedHomework assignments
Introspective therapy about a person’s beliefs toward on event as the main contributor of one’s behavior and quality of lifeA: activating eventB: belief surrounding the eventC: consequences/emotions of their
actions
A: I must do well and please others to be good Leads to anxiety and depression Replace with self-acceptance
B: Others must treat me well and fair. If not they are bad and should be punished Leads to anger, passive-aggression Replace with other-acceptance
C: I must get what I want, when and how I want. If not, I can’t stand it Leads to self-pity, passivity,
intolerance Replace with life-acceptance
http://www.rebtnetwork.org/whatis.html, 2011
Without REBT With REBT
A: the kitchen is messy, and the sink is full of dishes
B: My roommate is a lazy slob
C: Resent the roommate and bicker about dishes
A: The kitchen is messy, and the sink if full of dishes
B ?
C ?
Derived from CBT by Dr. Linehan, to treat a person who is emotionally escalated and self destructive (originally suicidal borderline personality patients) to create ‘a life worth living’
Believes extreme behavior happen when emotional vulnerability occurs in an invalidating environment Individual TherapyGroup sessionsPhone Coaching
http://www.youtube.com/watch?v=9ZuwEWLHHHY
One: Out of control to in control of behavior Target 1: Decrease life threatening behaviors Target 2: Decrease behaviors interfering with
treatment Target 3: Decrease behaviors destroying quality
of life Target 4: Life/relationship skills
Two: Move to emotional shut down to full emotions Fill in middle of the emotional spectrum
Three: Strategies for life’s ordinary problems Four: Move to completeness/connectedness
http://behavioraltech.org/downloads/dbtFaq_Cons.pdf, 2011
SET – structured communication technique designed for speaking with an emotionally escalated personS: Support – established benevolent
intentionsE: Empathy – acknowledge/validate present
emotionT: Truth – realistic/honest assessment about
situation of concernhttp://www.youtube.com/watch?v=ckyGJr5DiJY&feature=related
(Keisman & Strauss, 1991)
Behavioral Tech LLC (2011). Retrieved from http://behavioraltech.org/resources/whatisdbt.cfm
Kreisman, J. & Straus, H. (1991) I Hate You; Don’t Leave Me. Harper Collins: New York
REBT Network (2011) retrieved from http://www.rebtnetwork.org/whatis.html