Nursing Interventions ^*denotes collaborative interventions

Rationale

Review with the client the events that have led to increases in psychiatric symptoms or hospitalizations.

The client may not recognize the relationship between the need for hospitalization, particular health behaviors, and recurrence of the illness.

^*Engage the client in mutual goal-setting, such as avoiding hospitalization, becoming more satisfied with his or her life, meeting needs, and so forth.

The client’s willingness to participate is increased if he or she values the reasons for doing so.

Use an assertive approach when attempting to engage the client in a particular activity.

A positive attitude is conveyed with this approach. The client may respond to a tentative approach with a negative answer, and there will be no opportunity to proceed.

Be directive with the client, and do not ask “yes/no” questions or questions that require a choice. For example, say “It is time for group,” rather than “Do you want to go to group?”

The client is likely to respond “no” to “yes/no” questions because of the negativism he or she feels, or it may simply seem easier not to do something.

Use a behavioral approach when teaching skills.

A behavioral approach decreases reliance on the client’s verbal skills and ability to think abstractly and provides the client with the experience of doing the skill rather than simply hearing about how to do the skill.

Model the skill or behavior for the client.

Modeling provides a clear, concrete example of what is expected.

Coach the client to replicate the skill or behavior.

Coaching allows shaping—a behavioral procedure in which successive approximations of a desired behavior are positively reinforced—toward successful completion of the target behavior.

Prompt the client to continue practicing the skill or behavior. Reinforce success with verbal praise and tangible rewards, such as a soda, a snack, and so forth.

The client may need reminders because of a lack of interest or initiative. Coupling verbal praise with tangible rewards is the most successful means of reinforcement. It helps the client perpetuate the behavior or skill until it becomes part of his or her daily routine.

Teach the client a basic problem-solving sequence. It may help to write the steps.

Problem solving in a methodical fashion may be a skill the client has never had, or it may have been impaired by the illness.

Help the client establish a daily schedule. Writing on a daily or weekly calendar is usually helpful. Once the client agrees to a particular appointment or activity, instruct the client to write it on the calendar.

A written schedule provides a visual aid to which the client can refer. Once the client has written it on the calendar, it is more likely that he or she will follow through, much as with a written contract.

Assess the client for living skills that are absent or need improvement. Include hygiene, grooming, shopping, obtaining housing, budgeting, using telephones and transportation, cooking, and ability to call a doctor or other agencies for service.

A variety of skills are needed for independent living. It is imperative to identify deficient areas as the initial step of the learning process.

^*Teach the client about cooking and requirements for adequate nutrition. Referral to a dietitian may be indicated.

The client may have little or no knowledge of nutritional needs or food preparation skills.

Have the client demonstrate skills if possible. If skills are assessed verbally, avoid asking “Do you know how to…?” Rather, say “Tell me how you…?”

Areas such as hygiene or grooming are easily assessed by the client’s appearance, but skill demonstration may be necessary in areas such as use of telephone or transportation. If you ask the client if he or she has a particular skill, the response may be “yes” because the client is embarrassed at not having the skill or because the client mistakenly believes that he or she has the skill.

Teach skills in the client’s own environment when possible. For example, if you are teaching how to do laundry, use the laundromat the client will use regularly.

Transferring or generalizing knowledge from one situation to another may be difficult for the client.

Instruct the client about signs of physical illness that require medical attention. Give specific parameters, such as a “fever of 102° F.”

Specific indicators are easier for the client to recognize because the client’s judgment often is ineffective.

^*Assist the client to identify the clinic or physician services that he or she will contact if physical illness occurs.

It is easier to choose health care providers when the client is well, before an urgent situation develops. Knowing who to call when a need arises will help the client follow through.

^*Encourage the client to discuss with his or her physician any difficulties with medications or needs for changes before the client initiates changes on his or her own.

This strategy allows the client to participate in managing his or her health and to meet perceived needs regarding medication changes.

Tell the client that if he or she does alter the pattern of medications without professional help, you would like him or her to report this honestly.

It is more important to have accurate information on which to base decisions than to create the illusion of a “good” patient.

Give the client positive feedback for attempts in the self-care area and for honesty in reporting.

Even if attempts at self-care are unsuccessful initially, it is important to reinforce the client’s sense of personal control over his or her life and honesty in relationships with health care providers.

^*Teach the client and the family and significant others, if any, about the client’s illness, treatment, and safe use of medications.

The client and significant others may have little or no knowledge of the client’s illness, treatment, or medications.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Teach the client appropriate interactive and social skills. Describe and demonstrate specific skills, such as eye contact, attentive listening, nodding, and so forth. Discuss basic manners (please, thank you), especially in making requests. Discuss topics appropriate for casual social conversation, such as the weather, local events, news, and so forth.

The client may have little or no knowledge of social interaction skills. Use of basic manners will result in more successful interactions for the client. Modeling provides a concrete example of the desired skills.

^*Assist the client to approach someone and ask a question or make a request. Use real-life situations, such as seeking assistance in a store, asking directions, or renting an apartment.

Asking questions is an essential skill in daily life. Using real situations makes the exercise more meaningful for the client.

^*Role-play situations in which the client must accept “no” to a request and in which the client must appropriately refuse a request from someone else.

Low frustration tolerance makes hearing a negative answer difficult for the client. Clients frequently comply with requests from others, and then regret doing so because they are unable to refuse in a socially appropriate manner.

Practice giving and receiving compliments with the client. Make sure compliments are sincere.

Chronically mentally ill clients rarely notice things about other people without practicing that skill. Receiving compliments can be awkward due to low self-esteem.

Facilitate the client’s practicing interactions, requests, and conversations with other clients as well as staff.

Varying the client’s exposure to others in social situations can help build the client’s confidence and comfort level in approaching and dealing with other people.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Encourage the client to develop leisure habits, such as reading the newspaper or watching television at a certain time each day. It may be beneficial for the client to write these activities on a daily schedule.

Lack of interest or past pleasure experiences causes clients to be reluctant to try activities. Establishing habits or a schedule eliminates the need to make a decision about whether or not to pursue an activity each day.

Introduce the client to activities that are suitable for one person, such as drawing, solitaire, reading, writing, or sketching in a journal.

The client needs to have some leisure activities to pursue independently for those times when other people are not available.

Assist the client in identifying and trying activities that are free or low cost, such as taking walks, attending free concerts, and so forth.

Chronically mentally ill clients usually have limited financial resources. The cost of movies, bowling, or independent transportation can be prohibitive.

Facilitate client’s interactions and relationships with other clients as well as staff.

Varying the client’s exposure to others in social situations can help build the client’s confidence and comfort level in approaching and dealing with other people.

^*Facilitate the client’s interactions with others outside the hospital setting. If a drop-in center or other service is available, accompany the client to acquaint him or her with others. Plan a group activity that three or four clients attend.

It is important for the client to establish a social network because professionals cannot meet all of the person’s needs. The client is not likely to form relationships independently.

^*Assist the client in finding a suitable volunteer activity or an activity involving helping other people, animals, or the environment. Refer to vocational services as appropriate.

Many clients resist doing things just for fun because these activities do not provide a sense of productivity or making a contribution. Feeling useful or needed enhances self-esteem and provides an opportunity for praise or recognition from others.