NCSBN – Lesson 4: Psychosocial Integrity Study Guide,100% CORRECT

NCSBN – Lesson 4: Psychosocial Integrity Study Guide Concepts of Mental Health Diagnosing & Treating Mental Illness • Neuroimaging through positron emission tomography (PET), computed tomography (CT) and magnetic resonance imaging (MRI) allow researchers and diagnosticians to study the brain. • The major neurotransmitters of the brain include norepinephrine, dopamine, serotonin and gamma-aminobutyric acid (GABA). • As a result of a better understanding of neurotransmitters and their functioning, medications are now more effective than ever before. • Currently, no type of genetic testing can tell whether a person will develop mental illnesses. Although familial and genetic factors are known to play a part in developing some mental illnesses such as bipolar disorder and schizophrenia, there is not enough evidence to know which gene variations contribute to the development of the illness or even the degree to which other factors contributed to it. Theories of Mental Illness There are various psychological theories about mental illness, including Sigmund Freud's Psychoanalytic Theory, Harry Stack Sullivan's Interpersonal Theory, Erik Erickson's Psychosocial Developmental Theory, cognitive behavioral theory and behavioral theory. Psychoanalytic Theory • Freud believed that only part of each persona's mental functioning is conscious and that treatment of mental illness involves helping the client become aware of the unconscious structures of the id, ego and superego. • Freud also believed that individuals unconsciously use defense mechanisms to cope with anxiety and defend the ego from conflicts between the id and the superego. Defence Mechanism s Primitive - Very effective short-term, but less effective over the long run - Often used by children Less Primitive Mature - Focused on helping a person cope and be at peace w/ themselves and those around them Denial • when someone treats obvious reality factors as though they do not exist because they are consciously intolerable Ex: A woman refuses to believe her child has been diagnosed with leukemia, and states, "she just has the flu." A functioning alcoholic denies he has a drinking problem, pointing out how well he functions in his job and relationships. Repression • an unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses, feelings or acts Ex. An adolescent "forgets" their appointment with a counselor to discuss final grades. Sublimation • diversion of unacceptable instinctual drives into personally and socially acceptable areas Ex. A young woman who hated school becomes a teacher. A person telling a lighthearted joke about a dark fantasy that secretly causes them great shame. Regression • retreating to an earlier and more comfortable emotional level of development. Ex. A 4-year-old insists on climbing into a crib with their younger sibling. After moving to a new home, a 5-year-old starts wetting the bed Displacement • involves transferring unacceptable feelings aroused by one object to another, more acceptable substitute Ex. Adolescent lashes out at his parents after not being invited to a party by his peers. A person who gets angry at his boss, but can't express his anger for fear of being fired, comes home and kicks the dog or starts an argument Compensation • An extra effort in one area is an attempt to offset real or imagined lack in another area; it helps reinforce a person's self-esteem and self-image Ex. A person who chain smokes or works out excessively in order to be able to boast about their fitness. In order to compensate for a lack of cooking skills, a person keeps an extremely organized and immaculate kitchen Acting out Intellectualization • use of thinking, ideas or intellect to avoid emotions. Assertiveness Ex. A parent becomes extremely knowledgeable about their child's diabetes yet denies having feelings about it. A wife of a substance abuser knows about enabling behaviors yet continues to report his absence on Monday morning as an "illness." Dissociation • walls off specific areas of the personality from consciousness. Ex. An adolescent jokes about failing grades as if they belong to someone else. People who have a history of any kind of childhood abuse often suffer from some form of dissociation. Rationalization • justifying behaviors, emotions and motives considered intolerable through acceptable excuses Ex. "I didn't get chosen for the team because the coach plays favorites." A woman who was head-over-heels in love with a guy, who then dumps her, says, "I knew he was a loser." Compartmentalization Undoing Projection • unconsciously projecting one's own unacceptable qualities or feelings onto others. Ex. A woman who is jealous of another woman's wealth accuses her of being a gold digger. A student who has sexual feelings towards a teacher tells her friends that the teacher is "coming on to her." Reaction formation • expressing unacceptable wishes or behavior by exhibiting opposite overt behavior. Ex. A recovered smoker preaches about the dangers of second-hand smoke. A woman who is very angry with her boss and would like to quit her job, instead is overly kind and generous toward her boss and expresses a desire to keep working there forever Interpersonal & Psychosocial Developmental Theories The Interpersonal theory was originally developed by Harry Stack Sullivan. The theory posits that personality develops according to the client's perception of how others view them and that a healthy personality is the result of healthy relationships. Hildegard Peplau, who is considered to be the "mother of psychiatric nursing," was influenced by this theory and wrote Interpersonal Relations in Nursing, which became the foundation for the nurse-client relationship. According to Peplau, the nurse-client relationship is one in which the client receives unconditional acceptance, the relationship between nurse and client is client-centered and the relationship is developed according to the client's perceived readiness. Psychosocial Developmental Theory The Psychosocial Developmental theory was developed by Erik Erikson. This theory extends Freud's work. Erikson believed that personality develops in a series of eight predetermined stages across the lifespan and that each stage involves a crisis or conflict: trust vs. mistrust, autonomy vs. shame and doubt, initiative vs. guilt, industry vs. inferiority, identify vs. role confusion, intimacy vs. isolation, generativity vs. stagnation and integrity vs. despair. Normal development is when a person successfully resolves the conflict; if the conflict is not resolved, then development is arrested at that stage. CBT – Cognitive Behavioural Therapy • is a type of psychotherapy based on the concept of pathological mental processing. The focus of treatment is on the modification of distorted cognitions and maladaptive behaviors. • focuses on the premise that a person's thoughts control their behavior. o If a client is feeling or behaving in an unwanted way, then it is important to identify the thoughts that are causing these feelings or behaviors. ▪ The goal of treatment is to have the client replace current thoughts with ones that produce a more desirable outcome. • The three major components of cognitive therapy are educational aspects, cognitive techniques and behavioral interventions. Behavioral Therapy • Behavioral theory believes that symptoms of mental illness are the result of learned behavior. Through the use of positive and negative reinforcement, unacceptable learned behavior can be replaced by a more desired behavior. Symptoms of phobias, sexual dysfunction and eating disorders are some of the mental illnesses currently treated using behavioral therapy. Assertiveness training and desensitization are also commonly used behavioral techniques. Religious & Cultural Awareness As health care becomes more complex, it is more important than ever to recognize and treat clients and their families or advocates as partners in their care. Patient- and family-centered care (PFCC) promotes effective partnerships with clients, families and health care professionals. This partnership leads to improved client safety, better health outcomes and increased patient (and staff) satisfaction. Religion & Spirituality Religion is an organized system of beliefs about a higher power. Spirituality relates to beliefs about the essence of being. Nurses should be familiar with some of the more common religious practices, including information about diet, daily prayer needs and beliefs surrounding death. Being open to learning about a client's religious beliefs can help a nurse better respect their client's health care preferences. Cultural Competence Cultural competence is a set of skills nurses need in order to provide client- and family-centered care. This involves obtaining accurate information from the client, including cultural practices used for health and healing, and developing a mutually acceptable and culturally-relevant treatment plan for each client problem. • Cultural Assessment Tools o There are a number of different mnemonic devices to help you conduct a cultural assessment, such as "LEARN" and "ETHNIC". You can use either of these acronyms to help you remember the steps of a culturally sensitive assessment: • Health Literacy o Clients need to know and understand information about their current health status. They also need to understand their prognosis and treatment protocol. Additionally, the client must be well informed about the processes and expectation of medical care, self-care and health promotion. o Nurses need to be aware that even under non-stressful circumstances, a client understanding what they or other health care providers are saying can be challenging. Understanding a person's health literacy will allow the nurse to share information in ways that clients can understand and in their preferred language. Helping to ensure that clients understand their plan of care, know how to take their medications and know how to take care of themselves at home is a nursing responsibility. Grief & Loss Loss • is a universal phenomenon that occurs across the lifespan. While we often think of the loss of significant others such as through death or divorce, there are a variety of types of losses, including: o Loss of an object o Loss of an environment, by moving to a new location, starting a new job or being admitted to a health care facility o Loss of an aspect of oneself, which may include loss of a body part, such as amputation of a limb or a physiologic or psychological function o A perception of loss that's felt by the person but intangible to others, such as "youth" o Situational loss, which is the result of an unpredictable event, such as a natural disaster • A person's response to loss depends on a number of factors, including personality, culture, previous experience with loss, values, the perceived value of the loss and the person's support system. Grief • Anticipatory grief o Mental anguish caused by the impending loss of a body part, a function or a loved one. o A person learns of impending loss and responds with processes of mourning, coping, interaction, planning and psychosocial reorganization. • Disenfranchised grief o A person experiences a loss that is not or cannot be openly acknowledged, publicly mourned or socially supported. • Complicated grief o Grief that is the result of a sudden loss. Theories of Grief Elizabeth Kubler-Ross (1969) Description Denial • Unconscious avoidance which varies from a brief period to the remainder of life • Allows one to mobilize defenses to cope • Positive adaptive responses; verbal denial or crying • Maladaptive responses; no crying, no acknowledgement of loss Anger • Expresses the realization of loss • May be overt or covert • Positive adaptive responses; verbal expressions of anger • Maladaptive responses; persistent guilt or low self- esteem, aggression, self-destructive ideation or behavior Bargaining • An attempt to change the reality of loss; a person bargains for treatment control; expresses the wish to be alive for specific events in the near future • Maladaptive responses; bargains for unrealistic activities or events in distant future Depression and Withdrawal • Sadness resulting from actual and/or anticipated loss • Positive adaptive response; crying, social withdrawal • Maladaptive responses; self-destructive actions, despair Acceptance • Resolution of feelings about death or other loss, resulting in peaceful feelings • Positive adaptive behaviors: may wish to be alone, limit social contacts, complete personal business John Bowlby () Four stages of separation and loss; individuals progress through these stages at their own pace, in any order, in an attempt to resolve their loss. 1. Shock and numbness 2. Searching and yearning 3. Disorientation 4. Reorganization and resolution Erich Lindemann (1944) Describes grief as a syndrome that includes a common range of physical symptoms, i.e., tightness of throat, shortness of breath and other pain, along with a range of emotional responses. Lindemann's research is based on a sample of primarily young survivors of sudden and traumatic loss. 1. Shock 2. Acute mourning 3. Resolution of grief William Worden (1991) Describes four tasks in the grieving process; once these tasks have been completed, grief is assumed to have been resolved. • To accept the reality of the loss • To work through the pain of grief • To adjust to the changed environment (in which the deceased is missing) • To emotionally relocate the deceased and move on with life Tagliaferre and Harbaugh (2002) • Expanded on Worden's model of grief • Proposed five tasks: o Acknowledge the loss o Feel the impact o Acquire temporary substitutes o Detach from the relationship o Reconstruct a new life Nursing Care The nurse should always remember that grieving is not a linear process. Everyone grieves in their own way and there is no time limit for how long a client grieves. Nursing care involves supporting the client and encouraging the client and/or significant other to express their feelings and concerns. Nurses should listen to the client and support effective coping mechanisms, problem-solving and decision-making efforts. Nurses can also provide resources to assist the client, including referrals to resources to help adjust to loss and bereavement. The nurse can utilize therapeutic touch as appropriate. The Nurse-Client Relationship A therapeutic relationship is one that is established between a health care professional and a client for the purpose of assisting the client with problem solving, grief counseling and teaching, regarding an illness or situation. The relationship consists of the nurse who possesses the skills and ability to provide counseling, crisis intervention and health teaching and the client, who is seeking help for a problem. Therapeutic interventions may be one-on-one, with a group and/or a family. The five basic characteristics of the nurse-client relationship include defining the relationship, goal-setting goals and establishing boundaries. Throughout the relationship, the nurse helps the client toward a resolution of the problem. • The first stage is when the nurse establishes trust and rapport with the client. • Many relationships begin with a contract that establishes the time, place and duration of the sessions. • During orientation, they outline problems and expectations, including goal-setting and a plan of action. o The nurse and client also establish the parameters for ending the relationship. • The client is usually anxious. The nurse can help alleviate the anxiety by encouraging the client to explore and talk about these feelings. Working Phase • Once the boundaries of the relationship are accepted by the client and the nurse, and a therapeutic relationship is established, the nurse and the client can begin to work on the client's problems. • The nurse will help the client identify insight into the problems and provide the client with adaptive coping and problem-solving skills. o An ongoing evaluation of the effectiveness of the interventions is discussed at every meeting. • The nurse uses therapeutic communication techniques and active listening skills. You can remember these skills using the acronym: SOLER. Termination Phase • The termination phase begins with the first session and ends when the identified treatment goals have been met. • This is the time when the nurse and client reassess the problem and evaluate outcomes. It is also the time to encourage clients to use what they have learned and be proactive about meeting their needs independently. • Occasionally, this is a difficult time for the client. Depending on the circumstances, the client may become too dependent on the nurse and the separation may bring up previous separation experiences and feelings of rejection, depression and/or abandonment. The nurse should reassure the client that it's natural to feel this way and encourage the client to express any thoughts and feelings about termination. Stress Management Stress is a universal phenomenon that requires change or adaptation so that the person can maintain equilibrium. Stress can be considered as any physical, chemical or emotional factor that causes bodily or mental unrest. Eustress or positive stress can help motivate people, improve performance and can even feel exciting. Eustress is usually short-term. Distress or negative stress causes anxiety or concern and is perceived to be outside of our ability to cope. It is an unpleasant feeling that decreases performance and can lead to mental and physical problems. A stressor is anything that causes the release of stress hormones. There is a list of potential stressors, which can conveniently be placed into one of two categories: physiological and psychological. Physical stressors may include disease or physical symptoms. Psychological stressors may include feelings of unexpressed anger, isolation and loss and poor body image. • Stage 1 – ALARM o When the body perceives a stressor, the body reacts with a fight-or-flight response. ▪ The stress response begins in the brain. When there's a perceived threat, the amygdala sends a distress signal to the hypothalamus. The hypothalamus oversees the stress response and will send a message to the pituitary gland and adrenal medulla. ▪ The adrenal medulla (part of the autonomic nervous system) works to maintain homeostasis. The adrenal medulla secretes the hormone epinephrine (adrenaline), which gets the body ready for a fight or flight response. ▪ Physiological reactions include: • Increased blood pressure • Tachycardia • Tachypnea • Increased respiratory rate • Increased blood pressure • Cold hands and feet ▪ Extra oxygen is sent to the brain, which increases alertness. Epinephrine also triggers the release of glucose and fats from temporary storage sites in the body, which supplies the body with energy. Sight, hearing and the other senses become sharper. ▪ The next phase of the stress response system includes a series of hormonal signals to maintain the sympathetic nervous system's response. The pituitary gland secretes adrenocorticotropic hormone (ACTH), which stimulates the adrenal glands to release cortisol. Cortisol allows the body to maintain a steady supply of glucose by releasing stored glucose from the liver. ▪ Stress also affects mood and the ability to think and process information. When someone is stressed, they may be irritable. Crying and feelings of inadequacy may also be part of the stress response. People may become forgetful and seem preoccupied. There's a tendency to make mistakes, which decreases productivity. They may even display poor judgement. o Adrenaline stimulates the sympathetic nervous system into action and reduces activity in the parasympathetic nervous system until the perceived threat is over. • Stage 2 – RESISTANCE o The body resists and compensates as the parasympathetic nervous system attempts to return to normal levels of functioning. The body remains on alert. • Stage 3 – EXHAUSTION o If the stressor or stressor continue, the body becomes exhausted. There's a decrease in the immune response, including a suppression of T-cells and dysfunction in the lymphatic system. The body is susceptible to disease and death. Managing Stress • Since stress is a normal part of life, it's impossible to eliminate all stress. Instead, clients should learn how to manage distress. • A balanced diet, adequate rest and regular physical activity helps anyone manage stress. Specific relaxation techniques include breathing exercises, medication, progressive muscle relaxation, guided imagery, yoga, biofeedback and prayer. • The nurse can use cognitive restructuring with the client to analyze the client's appraisal of stressors and then restructure his or her unrealistic or negative thinking. Crisis Intervention & Suicide Prevention Nurses will look for and assist clients and their families with events that can overwhelm their usual coping strategies. • Crisis Intervention o A crisis is an acute and temporary state of severe personality disorganization with an extreme state of emotional turmoil. The crisis occurs because the client's usual coping mechanisms and resources fail. ▪ A Crisis • There are four parts of a crisis. • First, the client must be in a vulnerable state. • Second, there is a precipitating event. o For example, the client could be going through a maturational crisis, a situational crisis involving a life change, loss of a loved one or a job, or extraordinary circumstances, such as an environmental disaster or war. • In the third or acute phase o the client temporarily loses control and may be in a panic state. o The client's emotional reactions are overwhelming, and thinking is scattered. o The client may not be able to make decisions or solve problems. o When the client loses all effective coping skills and cannot continue to function, this is referred to as an exhaustion crisis. ▪ The shock crisis is the result of a sudden external change that causes a release of emotions that overwhelms clients. • The fourth or last part of the crisis o is reorganization which takes place when a client is able to integrate pain or loss into a new way of coping. ▪ Nursing Care o Treatment is aimed at providing brief supportive interventions focused on the phase of crisis. o The objective is to help the client through the current crisis, allow free discharge of emotions and to enhance the client's cognitive thought processes. o Often the client will need pharmacologic therapy, such as an antidepressant or antianxiety medication. o To assist the client in crisis, the nurse can provide a quiet, restful environment. The nurse can empower the client to solve problems by allowing the client to express his or her feelings and emotions. The nurse can also correct any misperceptions about the crisis being experienced by the client and help the client identify support systems and alternative solutions. o Relaxation strategies, such as deep breathing and guided imagery can help the client to develop new coping skills. o Clients under stress may not be in full control of their emotions and may display emotional and physical outbursts, which is why the nurse must set consistent limits with the client and inform him or her of the consequences of violent behavior. Should the nurse ever feel threatened or unsafe, it is important to immediately call for assistance. • Suicide Prevention – SAD PERSONS can be used to assess risk o Suicide is a self-harming act intended to produce death. Some clients may have thoughts of ending their lives (suicidal ideation) or some may even have attempted suicide and failed. o More women attempt suicide than men, but men are more often successful. Suicide is the second leading cause of death in adolescents. Typically, clients diagnosed with depression and experiencing delusions and/or hallucinations are more prone to attempt suicide. Warning Signs • There are many warning signs of an intent to commit suicide. In addition to any previous suicide attempts or threats to commit suicide, many people who express hopelessness, helplessness and anger at themselves or the world are at a higher risk of attempting suicide and should be placed on suicide precautions. o SUICIDE PRECAUTIONS ▪ Started immediately by the medical or nursing staff when a client verbalizes and/or makes an overt suicidal attempt, including self- mutilation attempts or previous suicide attempts. ▪ Ask the client exactly how they would commit suicide ▪ Assess how lethal the attempt would be, and how quickly it could be carried out ▪ There are generally two levels of suicide precautions: o Minimal ▪ Staff will make visual contact with the client every 15 minutes and document ▪ The client will reside in a designated area to provide close observation during waking hours ▪ The client will sleep in an area where close observation can be provided ▪ Nursing staff will conduct a search for contraband each shift while client is awake; this must be documented ▪ All packages and clothes brought in to the client are carefully inspected by the nursing staff in the presence of the client ▪ Pass privileges or participating in off-unit activities are not allowed until the suicide precautions are discontinued ▪ Inspect the client's mouth after giving medication in tablet form to make sure it has been swallowed; liquid concentrates are preferable o Strict ▪ One-to-one supervision: o The client can never be more than an arm-length away (approximately six feet) o The client is accompanied by an assigned staff member during bathing, showering and shaving ▪ The staff member remains outside the bathroom door, with the door slightly ajar ▪ All attempts should be made to assign same-gender caregivers to the client ▪ During waking hours, the client will reside in a designated area ▪ The client will sleep in an area where close observation can be provided ▪ Remove all harmful objects from the environment: o The client will eat on the unit without sharp utensils (usually plastic) o Keep electrical cords to a minimum length o Keep all windows locked and if possible keep the client in a room with unbreakable glass in the windows ▪ Certain items of clothing, e.g., belts, drawstring pants, shoes with laces, etc., may be prohibited if these items present a potential danger ▪ Staff will conduct a client search for contraband each shift while the client is awake; this must be documented ▪ Pass privileges or participating in off-unit activities are not allowed until the suicide precautions are discontinued ▪ Inspect the client's mouth after giving medication in tablet form to make sure it has been swallowed; liquid concentrates are preferable • Other factors that can contribute to committing suicide include: o Loss of a job o Recent death of loved one o Unsatisfying interpersonal relationships o Making statements about how they would not be missed if they died o Expressing hopelessness about the future o Self-mutilation o Perceived lack of support o Low self-esteem o Drug and/or alcohol abuse • Anyone who puts their affairs in order, changes a will and begins giving away prized possessions should also be considered at high risk of suicide. Nursing Care • Treatment focuses on treating the condition that underlies the suicidal thoughts. • For any client at risk of suicide, the nurse should follow the organization's policy for suicide precautions. • Pharmacologic therapies include antidepressants, antianxiety medications and/or antipsychotics. If the client is receiving inpatient care, the nurse should check the client's mouth and ensure that he or she swallows any oral medications. Many medications are available in liquid oral forms, but these can easily be spit out. Better options are long- acting injectable medications (LAIs) for antipsychotics or sublingual or buccal forms of medications. • Nursing care can also involve encouraging appropriate expression of emotions, redirecting or setting limits on ruminations about suicide or previous attempts, helping the client explore stressors, coping mechanisms and alternative behaviors. Abuse, Maltreatment & Neglect Abuse is defined as any act or failure to act that results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm. When a mandatory duty to report violence exists, one must report and there is no excuse for not doing so. Failure to report, if you are required to do so, could result in professional disciplinary action. Abuse may be physical, sexual and/or emotional (psychological) and may involve neglect, abandonment and maltreatment. Child abuse, spousal or partner violence, older adult neglect and financial exploitation are all examples of abuse. Abusing substances also falls under the broad category of abuse. The Cycle of Abuse Many violent relationships follow a similar pattern. The pattern can occur all in one day or be spread out over weeks or months. • Phase 1 – Tension Building Phase o Tensions build over any issue, such as money, children or jobs. It usually begins with verbal abuse. The victim tries to do anything to please the abuser but eventually the tension moves into physical abuse. • Phase 2 – Acute Battering Incident o When the tension peaks, the physical violence begins. • Phase 3 – “Honeymoon” Phase o The abuser expresses remorse and tries to minimize the abuse. He (or she) may exhibit loving and kind behavior, which strengthens the bond between the abuser and the victim. Abusers & the Abused There are many theories about why someone abuses others or substances. There are biological theories, which are based on neurophysiological, biochemical and genetic influences. Psychological theories include the psychodynamic theory and learning theory. There are also sociocultural theories of abuse. • Abusers o As a general rule, abusers often blame the victim for provoking the violence. They are often jealous and controlling, demonstrate poor impulse control and have a low self-esteem. They are frequently victims of abuse themselves. • The Abused o Battered women (and men) often have low self-esteem and they may experience feelings of guilt, anger, fear or shame about being in an abusive relationship. They are usually isolated from family and other support systems by their abuser. • Findings o Physical symptoms of abuse include broken bones or dislocations, welts, bruises, burns and inappropriate bald spots from where hair was pulled from the scalp. There may be signs of being restrained around the wrists and ankles. With sexual abuse, there may be evidence of bruising or bleeding in genital or anal area; pain or itching in genital area; genitourinary infection; and evidence of sexual intercourse. o Findings of neglect include malnutrition, extremes in behavior and learning disorders in children, social isolation, unattended medical problems, lack of hygiene including unwashed and inappropriate dress. o In addition to physical abuse, abuse of older adults can also include unauthorized use of the older person's funds or property by a caregiver. o Domestic violence survivors are at higher risk of suicide. Nursing Care Nurses and other health care providers have a professional obligation to recognize, report and refer persons who are being abused. Evaluation of abuse for older adults should include an assessment of cognitive function. When abuse or neglect is suspected, the nurse should ensure the privacy of the victim and limit the number of different health care workers in the room. The nurse will provide information about any procedure before beginning, offer support and carefully document all signs of abuse or neglect. Crisis intervention involves removing the victim from the source of abuse and treating any injuries. Therapeutic Communication There is an art to explaining complex information so that it is understandable and meaningful to clients. Taking the time to talk and actively listen to clients helps reduce their anxiety and empowers them to be more actively involved in their care. Understanding and honoring clients' and their family's goals and preferences can also lead to better health outcomes and an enhanced quality of life. Therapeutic communication requires the nurse to consider the developmental level of the client, as well as his or her health literacy, emotional status and ability to speak and understand English. Therapeutic Communication Techniques Therapeutic communication in nursing reinforces the nurse-client relationship. Communication involves the verbal message (content) and the nonverbal message (process) and achieving congruence between the two. • Nonverbal Techniques o Acceptance – Recognizing the other person without inserting your own values o Listening – Consciously receiving the client's message, including listening actively, responsibly and seriously o Empathy – Experiencing another person's feelings temporarily; truly being with and understanding another through active listening o Using silence – Suspending talk for a therapeutic reason o Neutral response – Showing interest and involvement without saying anything else o Eye contact – Direct eye contact is acceptable Western behavior; it may not be appropriate for clients from some cultures • Verbal Techniques o Self-disclosure – Sharing personal information at an opportune moment to convey understanding or to role model behavior o Clarification – Putting into words the client's vague ideas or unclear thoughts to help the nurse understand, or to invite the client to explain o Restating – Repeating to the client the main thought the client expressed to indicate the nurse was listening and interested o Refocusing – Picking up on central topics or cues given by the client o Open-ended questions – Asking questions that facilitate communication and cannot be answered with a simple yes or no o Incomplete sentences – Encouraging the client to continue speaking, using phrases such as, "go on…" o Focusing – Helping the client to explore a specific topic Cross-cultural Communication • A difference in language impedes communication and has the potential to compromise safe and effective care. Therefore, health care organizations must offer interpretation and language resources so clients and families can understand and participate in their plan of care. Using professional interpretation services not only improves the quality of care, but also increases patient satisfaction and reduces health disparities. • The nurse should first make sure the interpreter can speak the dialect of the client and ensure that the interpreter's gender, age and cultural compatibility fits the topic to be discussed. For example, if the client is a female and a practicing Muslim, the interpreter should also be a female. After the nurse introduces the interpreter, the nurse should be sure to pose questions directly to the client, not the interpreter. It's also a good idea to ask for feedback from the client at regular intervals and provide an opportunity to ask questions or clarify information. Communicating with Clients with Hearing Loss • Findings of hearing loss may be subtle. If a hearing loss is not documented on the medical records, the nurse can suspect hearing loss is present if the client does not respond to direct questioning, responds inappropriately to questions and/or needs to have information repeated. • If the client normally wears a hearing aid, be sure the client is using it and it is turned on. The nurse should also keep background noise to a minimum and turn off competing sounds, like the radio or television. • Effective communication includes speaking slowly and distinctly while facing the client. There's no need to shout. Regardless of the client's ability to hear, it's always best to keep sentences short and simple and to repeat information as indicated. Using visual information can enhance the spoken word. Communicating with Clients after a Stroke It's always a good idea to approach clients from the side of intact field of vision and to remind them to turn their heads in the direction of visual loss to compensate for loss of visual field. The nurse should place objects within their client's reach, on the client's unaffected side. If the client is experiencing aphasia, it is helpful to understand the type of aphasia: • Global aphasia: The most severe form of aphasia where individuals cannot read, write or understand speech. • Broca's aphasia ("non-fluent" aphasia): Speech is limited mainly to short utterances of less than four words; the client may understand speech and be able to read but has limited writing ability. • Wernicke's aphasia ("fluent" aphasia): An inability to understand the meaning of spoken words and reading and writing is impaired; the client is able to speak but sentences do not hang together and speech may consist of mostly jargon. • Whether or not the client has aphasia or has trouble speaking, it is always helpful to ask simple questions that require only a yes or no responses. Communicating with Clients with Dementia • Clients with dementia often exhibit a wide variety of behaviors that can interfere with effective communication. Since clients with dementia are often very sensitive to the moods of others, the nurse should always try to remain calm and unhurried and remember to keep conversations short and focused. Consistency in responding to behavior problems is helpful. • Since the client has difficulty making decisions, it's best to offer two simple solutions. For example, instead of asking what the client wants to wear, the nurse can provide two wardrobe options. Asking questions that require only a yes or no response can be helpful. • Unlike other clients, reality orientation is not recommended. If the client insists they are going home today, the nurse can respond by saying, "that's wonderful…" despite knowing this is not true. The nurse will then redirect the client to the task at hand. In fact, if a 90-year-old client states she is going home to see her mother, it is cruel to remind her that her mother is dead and the client is never going home again. Nontherapeutic Communication Nontherapeutic communication minimizes the feelings of the client and impairs the nurse-client relationship. The following list includes examples of nontherapeutic communication. • Giving advice – This involves telling the client what to do or making decisions for the client. This implies that the client cannot handle life decisions. Examples of this include: o "Why don't you…" o "I think you should…" • False reassurance – In an attempt to reassure the client, the nurse uses clichés, pat answers or comforting statements, such as: o "I wouldn't worry about it…" o "Everything will be just fine." • Changing the subject – When the nurse inappropriately and randomly introduces a new topic. • Social response – Responding in a way that focuses attention on the nurse instead of the client; it is not goal-oriented on behalf of the client. • Invalidation – Ignoring or denying the client's thoughts or feelings. • Overloading – Talking rapidly, changing subjects or asking for more information than can be absorbed at one time. For example, the nurse asks two questions at the same time. • Underloading – This is when the nurse remains silent and unresponsive and doesn't pick up on cues. • Incongruence (also called a "double message") – The nurse's verbal and nonverbal messages contradict each other. For example, the nurse says, "Please stay calm" in a loud, high-pitched voice. • Value judgments – This is when the nurse would give an opinion or imply his or her own values by using words, such as "should," "ought," "good" or "bad." Anxiety Disorders An anxiety disorder is a condition in which a person has excessive fear and anxiety and related behavioral disturbances. Types of anxiety disorders include: separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder (GAD). Depression and substance abuse may occur with an anxiety disorder. • Etiology o Not known; may have a genetic link o Stress may contribute to the development of GAD • Findings o The main symptom of an anxiety disorder is frequent worry or tension for at least six months, even when there is little or no clear cause; usually related to family, other relationships, work, school, money and health. o Even when they are aware that their worries or fears are stronger than appropriate for the situation, a person with GAD still has difficulty controlling them. o Other symptoms include: problem concentrating; fatigue; irritability; problems falling or staying asleep or restless sleep; restlessness when awake; upset stomach; sweating; difficulty breathing; muscle tension. • Diagnostics o Physical exam and mental health assessment o Laboratory tests to rule out other conditions that may cause similar symptoms • Medical Intervention o Talk therapy o Medications: ▪ Antidepressants: • SSRIs: fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), citalopram (Celexa) • SNRI: venlafaxine (Effexor) is commonly used to treat GAD • Bupropion (Wellbutrin) • Ttricyclic antidepressants: imipramine (Tofranil) is prescribed for panic disorder and GAD • MAOIs: phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan) ▪ Anti-anxiety: buspirone (Buspar) for GAD ▪ Beta-blockers: propranolol (Inderal) for short term use for social anxiety ▪ Benzodiazepines: clonazepam (Klonopin) for social phobia and GAD, lorazepam (Ativan) for panic disorder, alprazolam (Xanax) for panic disorder and GAD o Stress and relaxation techniques such as yoga, acupuncture and kava • Nursing Care o Provide a non-demanding environment o Acknowledge the client's feelings o Do not force contact with a feared item or situation o Provide distracting activities o Use relaxation techniques o Identify triggers o Encourage the client to take responsibility for self-care o Client (and family) teaching: ▪ An overview about the nature of the illiness ▪ Management of the illness • Medication management • Sress management strategies • Teach ways to interrupt escalating anxiety ▪ Provide support services, including crisis hotline, support groups, individual psychotherapy Bipolar & Related Disorders A bipolar or related disorder is a condition in which a person has episodes of depression alternating with periods of being extremely happy or being cross and irritable; it includes changes in activity and energy as well as mood. Types of bipolar disorders include: bipolar I, bipolar II and cyclothymic. For many clients, episodes of depression are more common than episodes of mania. • Etiology o Not known; but it occurs more often in relatives of people with bipolar disorder o Affects men and women equally o Usually starts between ages 15-25 o Common triggers of a manic episode: childbirth, medications (antidepressants or steroids), insomnia and recreational drug use • Findings o A manic phase may last days to months. The client is: ▪ Easily distracted ▪ Little need for sleep and displays poor judgment ▪ Poor temper control ▪ Reckless behavior and lack of control (such as excessive drinking, drug use, sex with many partners or spending sprees) ▪ Expansive or irritable mood (racing thought, talking a lot, false beliefs about self or abilities) ▪ Very involved in activities o Depressive episodes are more common than mania and may include: ▪ Daily low mood or sadness ▪ Difficulty concentrating, remembering or making decisions ▪ Eating problems (loss of appetite and weight loss or overeating and weight gain) ▪ Fatigue or lack of energy ▪ Feeling worthless, hopeless or guilty ▪ Loss of pleasure in activities the client once enjoyed ▪ Loss of self-esteem ▪ Thoughts of death or suicide ▪ Trouble of getting to sleep or sleeping too much ▪ Pulling away from friends or activities • Diagnostics o Physical exam o Mental health assessment • Medical Intervention o Medications such as mood stabilizers, anticonvulsants and antidepressants can be administered to stabilize the client. o In addition, electroconvulsive therapy (ECT), support programs and cognitive behavioral therapy may be used in addition to medication treatment. o A severe manic or depressive episode typically results in hospitalization to stabilize the client. • Nursing Care o It is important for the nurse to implement measures to assist clients with their hyperactivity or agitation if they are in a manic state: ▪ Create a calming environment with little stimulation ▪ Limit the number of activities that may overstimulate the client ▪ Distract and redirect the client's energy o The nurse will also need to implement precautions to deal with manipulative behavior: ▪ Set limits, e.g., limit phone calls ▪ Use firm, consistent communication techniques ▪ Avoid extensive conversation o The nurse is responsible for meeting the client's needs for nutrition and rest, as well as administering medications safely. Finally, the nurse should help clients lower their denial and increase their self-awareness through reflection, role modeling, calling attention to the client's demanding behavior and instilling empathy. Depressive Disorders Depression is characterized by the presence of sad, empty, or irritable moods, accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function for weeks or longer. Types of depression include disruptive mood dysregulation, major depressive disorder, persistent depressive disorder (formerly called dysthymia) and premenstrual dysphoric disorder. Etiology • Exact cause is not known; most likely it is due to a combination of genetic, biological, environmental and psychological factors. • Alcohol or drug abuse, hypothyroidism or chronic pain, medications (steroids), sleeping problems and stressful life events are associated with depression. Findings • Client may present with agitation, restlessness and irritability, anger; becoming withdrawn or isolated; fatigue and lack of energy; feeling hopeless and helpless, worthless, guilty, self-hate; loss of interest or pleasure in activities that were once enjoyed; sudden change in appetite; thoughts of death or suicide; trouble concentrating; trouble sleeping or sleeping too much. • Severe depression can also be accompanied by hallucinations and delusions. Diagnostics • Physical exam and mental health assessment • Blood and urine test to rule out other medical conditions with symptoms similar to depression Medical Intervention • Medications – antidepressants: o SSRIs: fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro) o SNRIs: venlafaxine (Effexor) and duloxetine (Cymbalta) o bupropion (Wellbutrin) o tricyclics, tetracyclics, and MAOIs may also be used • Talk therapy: o Cognitive behavioral therapy – to teach how to fight off negative thoughts o Psychotherapy – to help to understand the issues that may be behind thoughts and feelings o Group therapy – to share with other who have like problems • Electroconvulsive therapy (ECT) o Light therapy – to relieve symptoms in the winter time (seasonal affective disorder or SAD) o Acupuncture, stress and relaxation techniques, massage, meditation, yoga, Tai Chi, Qigong, SAMe Feeding & Eating Disorders Eating disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food, significantly impairing physical health or psychosocial functioning. Types of eating disorders include pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa and binge-eating disorder. Serious medical complications can develop over time. Clients with anorexia may experience severe malnutrition, low potassium levels, heart problems and confusion. Clients with bulimia nervosa may experience constipation, dehydration, dental cavities, electrolyte imbalances, hemorrhoids, pancreatitis, swelling of the throat and tears in the esophagus. Etiology Risk factors for anorexia include having an anxiety disorder as a child; having a negative self- image; having certain social or cultural ideas about health and beauty; trying to be perfect or being overly focused on rules. The etiology of eating disorders is unknown. Findings • Anorexia Nervosa o Severely limited food intake o Client will cut food into small pieces and move them around the plate o Client may refuse to eat around other people o Obsessive exercising and using diuretics, enemas, laxatives and diet pills o Blotchy or yellow, dry skin covered with fine hair o Depression o Dry mouth o Extreme sensitivity to cold o Loss of bone strength, muscle wasting and loss of body fat ▪ DX • Laboratory tests to help find the cause of weight loss or to determine damage done by weight loss including albumin, bone density test, CBC, ECG, electrolytes, kidney function tests, liver enzyme tests, total protein, thyroid function tests and urinalysis. ▪ Medical Intervention • Often hospitalization may be needed; follow-up with day treatment program • Increasing social activity, reducing the amount of physical activity, using schedules for eating (nutritional rehabilitation) in addition to refeeding programs • Antidepressants such as the SSRI fluoxetine (Prozac) (regardless if the client is depressed or not) talk therapy, including cognitive behavioral therapy, group therapy, and family therapy; support groups • Bulimia Nervosa o Eating large amounts of high-calorie foods (usually in secret) o Forced vomiting o Cavities, gingivitis and worn enamel (due to vomiting) o Excessive exercise o Broken blood vessels in the eyes o Excessive use of laxatives, enemas or diuretics o Dry mouth o Russell's sign (cuts/calluses across tops of finger joints from forced vomiting) ▪ DX • Dental, physical and mental health exams and assessments, including family history, should be used to collect data. Clinicians administer tests such as Eating Disorder Examination (EDE) and Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS). Self-reports are also used, such as the Diagnostic Survey for Eating Disorders (DESD), Eating Attitudes Test (EAT) and the Eating Disorders Questionnaire (EDQ). ▪ Medical Intervention Nursing Care • A stepped approach, including support groups, cognitive behavioral therapy and nutritional therapy • Antidepressants such as the SSRI fluoxetine (Prozac) • Support groups, such as Overeaters Anonymous and American Anorexia/Bulimia Association • The nurse will establish adequate/appropriate nutritional intake and will correct any fluid and electrolyte imbalance. • The nurse will help encourage their client to develop a realistic body image and to improve self-esteem. The nurse is also responsible for providing support and involving significant others in the treatment program. It is also important for the nurse to work with other disciplines in developing a care plan. • Provide client (and family) teaching: o The nature and management of the illness o Causes of eating disorders and effects of illness on the body o Principles of nutrition o Importance of expressing fears and feelings o Alternative coping strategies, relaxation techniques, problem-solving skills o Correct administration of prescribed medications o Indication for and side effects of medications o When to contact a health care provider • Provide contact information for support services, such as Overeaters Anonymous, National Association of Anorexia Nervosa and Associated Disorders (ANAD), the American Anorexia/Bulimia Association, Inc. Neurodevelopmental Disorders Neurodevelopmental disorders are characterized by developmental deficits that produce impairments of personal, social, academic or occupational functioning; typically manifested before a child enters grade school. Types include intellectual disability (intellectual developmental disorder), global developmental delay, language disorders (including stuttering), autism spectrum disorder, attention-deficit hyperactivity disorder (ADHD), learning disorder and tic disorder. Diagnosis requires assessing both cognitive capacity (IQ) and adaptive functioning. Etiology The exact causes of autism spectrum disorder (ASD) are not known but are thought to be linked to abnormal biology and chemistry in the brain. Diet, digestive tract changes and mercury poisoning are also considered probable causes. Autism can be associated with other disorders of the brain, such as fragile X syndrome and tuberous sclerosis. The cause of attention deficit hyperactivity disorder (ADHD) is unknown as well but thought to be due to a combination of genetics and environmental factors. Findings Autism Spectrum Disorder • Autism spectrum disorder (ASD) clients have difficulty with pretend play, social interactions and verbal/non-verbal communication. • They are often overly sensitive in sight, hearing, touch, smell or taste. • ASD clients may have unusual distress when normal routines are changed, perform repeated body movements and show unusual attachments to objects. o Dx ▪ Complete physical and neurologic exam ▪ Hearing evaluation (for delay in language milestones) ▪ Blood lead test, genetic testing (for chromosome abnormalities) and metabolic testing ▪ Screening tests, such as the Checklist for Autism in Toddlers (CHAT) or the Autism Screening Questionnaire and evaluation of autism, using the Autism Diagnostic Interview-revised (ADI-R); Autism Diagnostic Observation Schedule (ADOS); Childhood Autism Rating Scale (CARS); Gilliam Autism Rating Scale; pervasive Developmental Disorders Screening Test-Stage 3 o Medical Intervention ▪ most successful when it is geared toward the client's particular needs. ▪ Applied behavior analysis (ABA) ▪ Medications to treat aggression, anxiety, attention problems, extreme compulsions, hyperactivity, impulsiveness, irritability, mood swings, sleep difficulties and tantrums: • Risperidone (Risperdal) – an antipsychotic approved to treat children ages 5-16 for irritability and aggression • SSRIs • Divalproex (Depakote) – an anticonvulsant also used to treat the manic phase of bipolar disorder • Mood stabilizers • Stimulants, such as methylphenidate (Ritalin, Concerta) ▪ Diet – some children respond to a gluten-free or casein-free diet ▪ Various therapies, including occupational therapy, physical therapy, speech-language therapy, vision therapy and sensory integration therapy and support groups Attention Deficit Hyperactivity Disorder (ADHD) Attention deficit hyperactivity disorder (ADHD): symptoms fall into three groups: • Inattentiveness • Hyperactivity • Impulsivity o Dx ▪ Complete physical and neurologic exam ▪ Diagnosis is based on a pattern of the symptoms ▪ Many children have at least one other developmental or mental health problem such as a mood, anxiety or substance use disorder, a learning disability or a tic disorder o Medical Interventions ▪ Effective treatment emphasizes partnership between the health care provider and the client. If client is a child, then parents and teachers are involved. • Set specific appropriate goals • Medication such as psychostimulants (stimulants), including methylphenidate (Ritalin, Concerta), amphetamine (Adderall), dextroamphetamine (Dexedrine), lisdexamfetamine dimesylate (Vyvanse) are used for treatment • Various therapies, including talk therapy, behavioral therapy (to teach healthy behaviors and how to manage disruptive behaviors) and support groups Nursing Care It is important for the nurse to maintain a consistent daily schedule, limit distractions and have clear and consistent rules for the client. The nurse will monitor the client's mental status and encourage, praise and reward independent behavior. • Client (and family) teaching: o The nature of the illness o Management of the illness o Medication management including side effects, length of time to take medication, what to expect from the medication and explain drug "holiday" for ADHD o Consult with your provider before taking any over-the-counter medication and before stopping medication o Importance of sleep and good nutrition • Promote problem-solving skills • Provide support services, including support groups; legal and financial assistance Obsessive-Compulsive & Related Disorders A client with an anxiety disorder may experience unwanted and repeated thoughts, feelings, ideas, sensations (obsessions) or behaviors that make them feel driven to do something (compulsions). Different types of anxiety disorders include obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding, trichotillomania disorder (hair pulling) and excoriation disorder (skin-picking). OCD does not usually progress into another disease but there can be long-term complications. For example, excessive hand washing can cause skin breakdown and compulsive hair pulling can lead to hair loss. Etiology The etiology is not known; however, factors that may play a role include head injury, infections and abnormal brain function. Findings Obsessions or compulsions cause major distress or interfere with everyday life; not doing the obsessive rituals can cause great anxiety; the person recognizes the behavior is excessive and unreasonable. Many people with OCD may have other psychiatric comorbid disorders, including mood and anxiety disorders, eating disorders or ADHD. Diagnostics Includes a physical exam, mental health assessment and utilizing the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to define range and severity of symptoms. Medical Intervention • Medications: o Tricyclic: clomipramine (Anafranil) is used to treat OCD o SSRIs: such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) o Antipsychotics: olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal) o Mood stabilizers: carbamazepine (Tegretol), divalproex (Depakote), lamotrigine (Lamictal) • Cognitive behavior therapy (exposure and response prevention or ERP) • Deep brain stimulation (when OCD does not respond to other treatments) Nursing Care When working with a client with OCD, it is important to promote a predictable, structured schedule and avoid engaging in any power struggles. The nurse will identify triggers to ritualistic behaviors, initially allow the behavior and then begin to limit it. Additionally, the nurse will provide positive reinforcement for non-ritualistic behavior. • Client (and family) teaching: o The nature of the illness o Management of the illness o Medication management, including side effects, length of time to take effect and what to expect • Stress management strategies and interventions to interrupt escalating anxiety • Support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial assistance Personality Disorders Clients with personality disorders present an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. These clients are pervasive and inflexible; the symptoms have an onset in adolescence or early adulthood, are stable over time, and lead to distress or impairment. Personality disorder types include general personality, paranoid personality, schizoid personality, schizotypal personality, antisocial personality, borderline personality, histrionic personality, narcissistic personality, avoidant personality, dependent personality, obsessive-compulsive personality. Complications include imprisonment, drug abuse, violence and suicide. Etiology The etiology is not known but may be related to genetic and environmental factors. For example, clients who have been subject to child abuse or alcoholic parents may be more at risk for developing a personality disorder. Personality disorders are diagnosed more often in men than women. The development of an antisocial personality disorder may be associated with childhood fire setting or cruelty to animals. Findings The client may be able to act witty and charming; be good at flattery and manipulating other people's emotions; break the law repeatedly; disregard the safety of self and others; have problems with substance abuse; lie, steal and fight often; show no guilt or remorse; are often angry or arrogant. Diagnostics Psychological evaluation is required to assess the history and severity of symptoms. Medical Intervention Personality disorders are difficult to treat; people usually start treatment when required by court action. Cognitive-behavioral treatment and medication may be helpful in treating symptoms of anxiety, anger and impulsiveness. Nursing Care The nurse's priority is to protect the client and others from harm and provide an environment that has low environmental stimuli to help the client remain calm. The nurse will also monitor the client's behavior and provide limits and a structured environment. Gradually the nurse will encourage appropriate expression of anger. • Client (and family) teaching: o The nature and management of the illness o Medication management, including side effects, length of time to take effect and what to expect • Relaxation techniques • Participation in therapy • Provide support services, including financial and legal assistance Schizophrenia Spectrum & Other Psychotic Disorders Schizophrenia is a lifelong condition that makes it hard to think clearly, to tell the difference between what is real and not real, to have normal emotional responses and to act normally in social situations. Clients with schizophrenia may present with abnormalities in one or more of the following: delusions, hallucinations and/or disorganized speech. Having schizophrenia increases the risk of developing problems with drugs or alcohol, physical illness (due to inactive lifestyle and medication side effects) or suicide. Etiology The etiology is not known not known; there may be a genetic factor. Schizophrenia affects about 1% of the world population and often clients are diagnosed in their late teens to early 20s. Findings Symptoms develop slowly over months or years. Early symptoms may include irritable or tense feelings, trouble concentrating and trouble sleeping. Later symptoms may involve bizarre behaviors, visual and audio hallucinations, isolation, reduced emotion, problems paying attention, delusions and "loose association." Diagnostics A physical exam and mental health assessment will be performed in addition to a brain scan (CT or MRI). Laboratory tests will assist the provider in ruling out other conditions with similar symptoms. Medical Intervention • Hospitalization will be necessary during acute episodes • Antipsychotics • Antiparkinsonism agents: used to counteract the extrapyramidal side effects (tardive dyskinesia) of many antipsychotic medications • Support programs, including family therapy • Behavioral techniques, such as social skills training and job training Nursing Care It is important for the nurse to establish a therapeutic relationship with the client by building trust, and being honest and dependable. The nurse should consistently monitor the client for signs of hallucinations and quickly orientate the client to reality when needed. The nurse should avoid touching the client without warning and give reco