HABACON, Gabrielle Anne J.

BSN 3-5

ADPIE AND THERAPEUTIC COMMUNICATION Factors influencing Assessment:

 Client Participation/Feedback
 Client’s Health Status
o Severity of condition
o How mild is the condition
 Client’s Previous Experiences
/Misconceptions about Health care
o Reluctant
o Was forced to get treatment
 Client’s ability to understand
o Cognitive problems
 Nurse’s attitude and approach
 Environment
o Set-up
NURSING PROCESS
o Input from family and friends

PSYCHIATRIC ASSESSMENT

- “Psychosocial Assessment”
- “Mental health Statis Examination”
- General examination on medical and
psychiatric areas to conduct a clear
picture of the client’s emotional state,
mental capacity, and behavioral
function.
o History
o Gen. Appearance and Motor
Behaviors
o Mood and Affect
o Thought process and content
o Sensorium and Intellectual
Process
o Judgement and Insight
STEP 1: Assess
o Self-Concept
STEP 2: Diagnose o Role and relationships
o Physiologic Concerns
STEP 3: Outcome Identification
Reminder!
STEP 4: Planning
During assessment, patient may
STEP 5: Intervention
exhibit various form of disturbances which
STE[ 6: Evaluation may alter the assessment phase.

ASSESSMENT Immediate management for evident

Involves the collection, organization,
and analysis of information about the client’s
health. (Used as a baseline data for diagnosis
and intervention)
disturbances is proved to handle the
manifestation immediately so that it will not
hamper with data collection, ensure the
safety of both the professional and the

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HABACON, Gabrielle Anne J.
BSN 3-5

patient and continue the therapeutic o Does the client appear to be

relationship. his or her stated age?
- Posture
HISTORY
- Facial Expression
A. Client’s History - Eye contact
- Client and family history (pertinent to - Unusual movement
client’s condition)
MOTOR DISTURBANCES
o Has the client experienced
similar difficulties in the past? AUTOMATISM
o Has the client been admitted
- Reflexive/repeated purposeless
to the hospital? What was the
behaviors or rituals often indicates
experience?
anxiety
o What other problems/illness
- Mannerisms
does the family members
- e.g. drumming fingers, tapping foot
have?
B. Age PSYCHOMOTOR RETARDATION
- Chronological age and Developmental
- Overall slowed movements.
age
o Chronological: according to WAXY FLEXIBILITY
birth
o Developmental: according to - Maintains an awkward or
uncomfortable posture/position over
developmental tasks
time.
C. Cultural and Spiritual Considerations
- Make accurate assumption about APRAXIA
psychological functioning
- Defines a person’s role in society - General involuntary purposeless
o Western: Adulthood = muscle movements.
independence, good eye - e.g. tremors
contact ECHOPRAXIA
o Eastern: Adulthood: (3)
generational living; extended - Imitation and repetition of
family; importance of values movements of other people.
D. Past developmental and medical - e.g. kumamot ka on the same spot,
history gagayahin din nila

COMPULSION

GENERAL APPEARANCE AND MOTOR - Impulse that mandates a person to

BEHAVIOR act in repetition.
- Two types:
A. Dress, Hygiene, Grooming o DIPSOMIA (compulsive
- Ability to perform self-care according alcohol consumption)
to age o KLEPTOMANIA (compulsion to
o Is the client appropriately steal)
dressed for his or her age and
the weather? AGITATION
o Is the client unkempt or - Emotional tension with restless motor
disheveled? behavior.

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HABACON, Gabrielle Anne J.
BSN 3-5

HYPERKINESIS - Repetition of words/phrases without

stimulus.
- Extreme motor restlessness and
agitation. PERSEVERATION

TIC - Repetition of answers to various

question; only 1 answer.
- Automatic, unconscious spasmodic
and intermittent twitching. CLANG ASSOCIATION

SPEECH AND COMMUNICATION - Rhyming words without meaning.

- Speech quantity, quality and rate AFFECT AND MOOD

o Does the client talk nonstop?
o Does the client perseverate?
(stuck on 1 topic)
o Are responses limited to “yes”
or “no” with no elaboration?
o Is the content speech relevant
to the question?
o Is the rate fast or slow?
o Is the tone audible or loud?
o Does the client speak in a
rhyming manner?
SPEECH DISTURBANCES
NEOLOGISM
- Coining of new words; assigning a
new meaning.
MOOD
- Imitation and repetition of
movements of other people.
AFFECT
- Expression of emotional state
o “I’m depressed.”
o “I’m elated.”
o On the scale of 1 to 10, 1
being depressed and 10 being
most depressed, where would
you place yourself right now?
o Check consistency of the
mood, affect, and situation.
AFFECT

WORD SALAD BLUNTED

- Blending of words without - Little or slow response of facial

comprehensible thought. expression.

CIRCUMSTATIALITY BROAD

- Exaggerated and insignificant details; - Display of full range of emotional

too many details but only 1 meaning responses.

ECHOLALIA FLAT

- Imitation and repetition of words of - No facial expression.

other people
INAPPROPRIATE
PRESSURED SPEECH
- Incongruent expression with mood or
- Increased amount, rate, loudness of situation.
speaking.
RESTRICTED
VERBIGERATION
- Display one type of expression.

LABILE

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HABACON, Gabrielle Anne J.
BSN 3-5

- Unpredictable and rapid mood o IDEAS OF REFERENCE (other

swings. action is directed to himself;
gossip)
PLEASURE AFFECT
o GRANDEUR (exaggeration of
- Positive or heightened emotion not importance/powerful)
aligned with idea. o EROTOMATIC (someone
- 2 classifications: like/loves them)
o EUPHORIA (sense of physio- o SOMATIC (body is diseased,
emotional well-being) abnormal, or changed)
o ELATION (increased sense of
JUDGEMENT
joy, confidence, and motor
activity) - Ability to interpret one’s environment
and situation correctly and adapt
THOUGHT PROCESS AND CONTENT
one’s behavior and decisions
THOUGHT PROCESS: how the client thinks. accordingly.
o If you found a cellphone left
THOUGHT CONTENT: what the client says.
in table, what would you do?
o Assess if the client makes
INSIGHT
sense (related, logical)
o Assess if the client is - Ability to understand the true nature
preoccupied of one’s situation and accept some
personal responsibility for that
THOUGHT PROCESS DISTRUBANCES
situation (strength and weaknesses)
AVOLITION o Blaming others for their own
behavior
- Feel of powerless/ no will in making o Not accepting a responsibility
decisions. over a behavior
FLIGHT OF IDEAS MEMORY
- Increased amount and rate of speech - Ability to remember both recent and
with unrelated ideas. remote memory.
LOOSE ASSOCIATION o Do you have any memory
problems?
- Disorganized thinking; jumps from 1 o What did you do yesterday?
idea to another. o What is the name of the
TANGENIAL THINKING current president?
o Who was the president
- Wandering off the topic and never before that?
provide information. o What is your social security
DELUSIONS number?

- False belied of the real environment. MEMORY DISTURBANCES

- Classifications: AMNESIA
o PERSECUTORY (others are out
to get him or persecute him) - Failure to recall in part or in whole
previous experiences
- 2 types:

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HABACON, Gabrielle Anne J.
BSN 3-5

o RETROGRADE (Events prior to o Do you feel close to your

a traumatic experience) family?
o ANTEROGRADE (events in the o Are your relationships
most recent occurrence) meeting your need?
o Can you meet your sexual
ANOMIA
needs satisfactorily?
- Failure to name objects, persons, or o Have you been involved in
items. any abusive relationship?

AGRAPHIA
PSYCHOLOGICAL TEST
- Failure to express oneself in writing.
- Another source of data for the nurse
AGNOSIA
to use in planning and care for the
- Failure to perceive and recognize patient.
objects by sensory impressions. - Types:
o Intelligence tests
CONFABULATION o Personality tests
- Unconscious attempt to fill in the gaps
INTELLIGENCE TEST
or missing details.
- Designed to evaluate client’s cognitive
SENSORY PERCEPTION
abilities and intellectual functioning.
- False sensory perceptions or
perceptual experience that does not
exist.
o Hallucinations (-) stimulus
auditory, visual
o Illusions (+) stimulus

CONCENTRATION
PERSONALITY TEST
o Spell the words backwards
o Sequential activities - Test that reflects the client’s
o Begin with number 100, personality in areas such as self-
subtract 7 and so on (serial concept, impulse control, reality
sevens) testing and major defenses.

SELF-CONCEPT

- Way one views oneself in terms of

personal worth and dignity.
o Description of his/her
characteristics
o What do you or how do you
solve when you have a
problem? DIAGNOSIS
o What works to deal with
anger or disappointment? - Identification of specific patient
needs, health alteration, mental
ROLES AN RELATIONSHIPS

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HABACON, Gabrielle Anne J.
BSN 3-5

illness, or other related psychological - Application, use and carrying out the
problems. therapeutic task under each objective.
- Provides a clear condition where the o Therapeutic Communication
goal is directed. o Therapeutic Relationship
o Psycho-therapeutics
NURSING DIAGNOSIS
o Psycho-pharmacology
- NANDA taxonomy
PRINCIPLES OF COMMUNICATION
P-E-S -> Problem – Etiology – S/Sx
“Process of exchange of information”

NURSE = PATIENT
DIAGNOSTIC AND STATISTICAL MANUAL
(DSM)

- Developed by the American

Psychiatric Association (APA)
- Multi-axial system of evaluating
patients based on manifestation
criteria.

DSM V (5th Ed.)

- Distress (comfort or painful

manifestation)
- Disability (Impaired function nor COMMUNICATION
ability to perform task) VERBAL COMM.
- High risk of suffering death, pain, and
disability - Use of words to speak and convey a
- Loss if independence or freedom message.
o CONTENT
Section 1: Coverage on how to use DSM-V  Literal words that a
Manual person speaks.
Section 2: Diagnostic Criteria to classify o CONTEXT
disorders and codes.  Environment which
communication
Section 3: Emerging measures and models. occurs.
 Physical, social,
emotional, cultural
PLANNING environments.
- Process of setting objectives to NONVERBAL COMM.
achieve the goal.
- Behavior that accompanies verbal
o Safety > physiologic
content indicates thoughts, feelings,
OUTCOME IDENTIFICATION and values
o PROCESS
- Goals set by correcting the problems
 All nonverbal used by
identified in the diagnosis.
speaker to give
o General -> specific
meaning and context
IMPLEMENTATION

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HABACON, Gabrielle Anne J.
BSN 3-5

(congruent or - Comforting and supportive measure

incongruent) for the client.
- Check if the client is welcoming
THERAPEUTIC COMMUNICATION
because it is an invasion of intimate
- Interpersonal interaction between the and personal space.
nurse and the client focusing on the o Functional-Professional
client’s specific needs to promote  Used in exams and
effective exchange of information to procedures
understand and empathize with the o Social-Polite
client’s experience.  Used in greetings
- Goals: o Friendship-Warmth
 Establish a therapeutic  Greeting friends and
relationship relatives
 Identify the most important o Love-Intimacy
client concern (client-  Holding hands
centered goal) o Sexual-Arousal
 Assess the client’s perception  Used by lovers
of the problem, behaviors/
messages of the involved ACTIVE LISTENING
people and client’s thoughts - Refraining from other mental
and feelings about the activities and concentrating
situation, others and the self. exclusively on what the client says.
 Facilitate client’s expression
of emotions. ACTIVE OBSERVATION
 Teach the client and family - Watching the nonverbal actions as the
necessary self-care skills. person communicates.
 Recognize the client’s needs. - First step in therapeutic interaction to
 Implement interventions to develop insights about the client.
address the client’s needs.
 Guide the client towards plan USING CONCRETE MESSAGES
of action.
- Using words as clear as possible so
- PRIVACY AND RESPECTING
the client can understand the
BOUNDARIES:
message.
A. Proxemics
- Study of distance zones between CONCRETE MESSAGES
people during communication.
- Explicit words; needs no further
o Intimate zone (0-18 in)
explanation.
 Parents, loved ones
o What health symptom caused
o Personal zone (18-36 in)
you to come to the hospital?
 Family and friends
o Social zone (4-12 ft.) ABSTRACT MESSAGES
 Social, work, business
- Unclear patterns often contain figures
o Public zone (12-25 ft.)
of speech that are difficult to
 Speaker and
interpret; requires interpretation.
audience, informal
o Your clinical performance has
functions
to improve.
B. Touch

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HABACON, Gabrielle Anne J.
BSN 3-5

THERAPEUTIC RELATIONSHIP

- Nurse-client interaction directed

towards enhancing the client’s well-
being grounded by empathy to
achieve a goal.
- Focuses on the needs, experiences,
feelings, and ideas of the client only.

Hildegard Peplau’s Interpersonal Process

- Elements:
o Contract
 Agreement that sets
the condition of the
relationship
o Boundaries
 Establish the
relationship as
therapeutic.
o Confidentiality
 Respecting the
client’s right to keep
private any
information about
his/her mental and
physical health.
o Self-Disclosure
 Revealing personal
information such as
biographical and
personal ideas,
thoughts and feelings
about oneself.

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