Judgment Healthcare choices can reflect judgment . This can be a positive or negative reflection on an ability to reach a logical decision about a situation (Boyd, 2018). For example, the patient with diabetes who continues to consume a diet high in sugar is demonstrating poor judgment. Actions and behaviors are often signs of judgment capabilities. A manic patient may spend their life savings on a trip or a lottery ticket. However, once in the normal or melancholic state, the patient may have no memory of the incident. Proper evaluation of the mood state Safety Finally, an evaluation of safety is important in any mental status assessment. The essential areas to examine include safety of self and safety of others. The nurse should determine if the patient has thoughts or urges of intentional harm. When suicidal thoughts are noted, inpatient treatment must be considered. Assessing suicide risk consists of asking the patient about a suicide plan, suicidal intent, and the available means to harm oneself. A well-developed suicide plan with means at hand may necessitate forcing an involuntary hospital stay, whereas an impulsive episode of self-mutilating may be best treated by an intensive outpatient program with family supervision. For example, a hunter who thinks about shooting himself is at much higher risk than the office worker who doesn’t own or have access to a gun. Determining the lethality of the means available is also essential. Patients experiencing extreme emotional pain may also self- mutilate by cutting or burning their arms, legs, or other areas. Although this is not considered suicidal behavior, it is high-risk behavior that indicates significant emotional distress.
when the actions were carried out is an important part of the assessment. Conversely, the patient who recognizes that an increase in paranoia is a sign of decompensation and seeks out emergency treatment is demonstrating good judgment. A patient’s insight, or awareness of their own feelings, relates to the ability to display logical judgment (Boyd, 2018). Assessing and understanding a patient’s ability to make positive or negative choices is an important piece of planning effective mental healthcare. The nurse should also determine the degree of risk of harm to others. There are two distinct areas in which patients with a psychiatric disorder may lose their rights to confidentiality: a threat to harm or kill another person and the report of child or elder abuse (Halter, 2018; U.S Department of Health and Human Services, 2019). Duty to warn is an obligation to warn third parties when they may be in danger from a patient (Halter, 2018, p. 99; Duty to Warn). The nurse must use all means necessary to reasonably contact the individual at risk, including notifying the police. In most healthcare settings, there are policies to ensure the report is made accurately and documented appropriately. Across the United States, nurses are considered mandatory reporting agents when a patient offers knowledge of abuse, molestation, or neglect of vulnerable patients. The nurse is obligated to report this to the local Child Protective Services agency (Duty to Warn). However, there is a conflict between state and federal law when child abuse is revealed during drug and/or alcohol treatment, and a court order is required for disclosure (Halter, 2018). State laws vary and healthcare providers should be very clear on their respective state laws and facility policy in terms of confidentiality.
THE THERAPEUTIC RELATIONSHIP
patient that the interactions will take place over a specific period. This helps the patient plan for the termination phase so that complications are less likely to arise when the nurse- patient relationship ends. An example of an orientation-phase introduction is: Good morning, Mr. Jamison. I am Chris and I will be your nurse while you are a patient. I would like to arrange a time to meet this morning to discuss how we will work together to develop the plan of care for the next week. Together we will develop strategies to manage your depression and we will continue to meet daily to evaluate what you have accomplished before you are discharged. In the working phase, identification, exploitation, and resolution take place. During identification, the patient begins to identify with the nurse independently, dependently, or interdependently (Jones & Bartlett Learning, n.d.). It is during identification that the nurse reinforces the understanding of the meaning of the patient’s situation (Jones & Bartlett Learning, n.d.). During exploitation, the patient utilizes the nurse’s services based on personal needs, and once needs are resolved during resolution, mature goals emerge (Jones & Bartlett Learning, n.d.). During this working phase, the patient can practice new techniques or behaviors to manage thoughts, feelings, and behaviors that have contributed to their symptoms and created problems in relationships, occupational functioning, or interpersonal well-being. These skills and strategies can be practiced within the safety of the inpatient, partial hospital, or outpatient environment. The nurse helps to promote problem-solving skills, self-esteem, and behavioral changes. Unconscious thoughts and behaviors may arise in the working phase. It is important to address lingering or past issues to aid in the resolution of present symptoms. The patient learns about self , develops coping mechanisms, and tests new behaviors. During this phase, transference and countertransference often occur. Transference takes place when the patient unconsciously displaces feelings for another onto the nurse (Boyd, 2018). Likewise,
Hildegard Peplau applied Sullivan’s teaching to her own theory, which nurses still use today in practice. Peplau viewed the nurse- patient relationship as representative of the patient’s relationship with other important people in their life (husband, wife, mother, father, etc.). By analyzing the dynamic between the self and the patient, the nurse draws inferences about how the patient interacts with others and helps the patient to develop insight into these behaviors to promote change. Furthermore, Peplau applied Sullivan’s views on anxiety as a driving force behind behaviors and related these views to nursing practice and a patient’s ability to perceive and learn. For example, mild anxiety promotes learning, whereas severe or panic levels of anxiety prevent learning and distort perceptions (Keltner, 2014, p. 87). From her own research, Peplau developed the therapeutic model of the nurse-patient relationship and introduced this in 1952 in her book entitled Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing . Today, this framework is relevant as a basis of nurse-patient relationships. The nurse performs several roles while engaged in the relationship, including advocate, teacher, role model, and healer. Peplau saw these roles as significant in each phase of the nurse-patient relationship, all of which overlap and work together to facilitate interventions. There are traditionally three phases in the therapeutic relationship: the initiation (orientation) phase, the working phase, and the termination phase (Edberg, Nordmark, & Hallberg, 1995). Peplau (1952) identified five phases: orientation, identification, exploitation, resolution, and termination. In the orientation phase, the nurse establishes rapport and begins to discuss the parameters of the relationship. The nurse also collaborates with the patient to identify the problem and extent of intervention needed, and how the patient and the nurse will work together to find solutions (Jones & Bartlett Learning, n.d.). Here the nurse can discuss confidentiality while developing the plan of care. The nurse will also address termination of the relationship. This involves informing the
Book Code: ANCCUS3023
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