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