NUR 3105-002 Nursing Process & Therapuetic Communication

Chapter 7 & 9

Nursing Process: Assessment

Establish rapport

Obtain an understanding of the current problem (including psychosococial factors)

Assess for risks factors affecting the safety of the client and others

Perform a mental status examination

Briefly identify mitial goals for treatment

What information is obtained during nursing assessment?

Pertinent medical data like allergies and current medications

Recent Vital Signs and/or laboratory Data

Reviewing other providers documentation.

Collateral information from others like familu members or police

Standardized rating scales for common psychiatric symptoms

Client’s percepion of the problem

Psychosocial factors

Spiritual assesment: what gives your life meaning? Have your beliefs influenced how you take care of yourself

Example of open-ended questions?

“It sounds like you are in a lot of pain. What might some type of relief look like for you?’

“I’m wondering what have you treid to help manage your stress as work?’

“How do you usually cope when you’re feeling angry?”

Therapeutic Communication

Warm greetings, introduce yourself, open body language

• Should not physically touch the client; touch them with your words and body language

Ask one question at a time

• Allow the client enough time to answer your questions

• Start with simple, open-ended questions

Reflective listening displays empathy to the client.

“What I’m hearing”

“What it sounds like”

“I can imagine”

SOLER Principle: Non-Verbal Dimension: S

Face the interviewee squarely

SOLER Principle: O

Adopt an open posture

SOLER Principle: L

Lean toward the interviewee

SOLER Principle: E

Maintain good eye contact

SOLER Principle: R

Relaxed or natural in these behavior

Trauma-Informed Care (TIC)

The understanding that many clients have experienced trauma in their past

• A trauma is a harmful event an individual has experienced that can influence their well-being

The understanding that healthcare environments can be frightening for clients

• Power dynamic between client/provider and asking personal questions

• Vulnerable physical positioning, removal of clothing, and invasive procedures

TIC is..

The desire to create safe, welcoming, enviornments for clients that promote healing

• Ask and use client’s name and pronouns

TIC appraoch is centered around..

The 4 R’s

What are the 4 R’s of Trauma-Informed Care?

Realize the widesread effects of trauma and understand possible courses for healing.

Recognize the s/s’ of trauma in all individuals

Respond by fully incorporating knowledge about trauma into procedures and practices

Actively Resist re-traumitization