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Study Notes for, The Patient-Doctor Relationship Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10thEd

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Study Notes for, The Patient-Doctor Relationship Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10thEd The Patient-Doctor Relationship Kaplan & Sadock's Synopsis... of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition EDIT Dr liza 140 366 660RAPPORT  An effective relationship is characterized by good rapport.  Rapport is the spontaneous, conscious feeling of harmonious responsiveness that promotes the development of a constructive therapeutic alliance.  It implies an understanding and trust between the doctor and the patient. Frequently, the doctor is the only person to whom the patients can talk about things that they cannot tell anyone else. Most patients trust their doctors to keep secrets, and this confidence must not be betrayed.  Patients who feel that someone knows them, understands them, and accepts them find that a source of strength. In his essay,Caring for the Patient Francis Peabody M D (1881-1927) a6 STRATEGIES RAPPORT  Ekkehard Othmer and Sieglinde Othmer defined the development of rapport as encompassing six strategies: (1) putting patients and interviewers at ease; (2) finding patients' pain and expressing compassion; (3) evaluating patients' insight and becoming an ally; (4) showing expertise; (5) establishing authority as physicians and therapists; and (6) balancing the roles of empathic listener, expert, and authority. As part of a strategy for increasing rapport, they developed a checklist (Table 1-1) that enables interviewers to recognize problems and refine their skills in establishing rapport. Empathy  Empathy is a way of increasing rapport. It is an essential characteristic of psychiatrists, but it is not a universal human capacity. An incapacity for normal understanding of what other people are feeling appears to be central to certain personality disturbances, such as antisocial and narcissistic personality disorders. Although empathy probably cannot be created, it can be focused and deepened through training, observation, and self-reflection. It manifests in clinical work in a variety of ways. An empathic psychiatrist may anticipate what is felt before it is spoken and can often help patients articulate what they are feeling. Nonverbal cues, such as body posture and facial expression, are noted. Patients' reactions to the psychiatrist can be understood and clarified.Transference  Transference is generally defined as the set of expectations, beliefs, and emotional responses that a patient brings to the patient doctor relationship.  They are based not necessarily on who the doctor is or how the doctor acts in reality but, rather, on repeated experiences the patient has had with other important authority figures throughout life. Transferential Attitudes  The patient's attitude toward the physician is apt to be a repetition of the attitude he or she has had toward authority figures. The patient's attitude can range from one of realistic basic trust, with an expectation that the doctor has P.2 the patient's best interest at heart, through one of overidealization and even eroticized fantasy to one of basic mistrust, with an expectation that the doctor will be contemptuous and potentially abusive. Countertransference  Just as the patient brings transferential attitudes to the patient-doctor relationship, doctors themselves often have countertransferential reactions to their patients. Countertransference can take the form of negative feelings that are disruptive to the patient-doctor relationship, but it can also encompass disproportionately positive, idealizing, or even eroticized reactions to patients. Just as patients have expectations for physicians for example, competence, lack of exploitation,Models of Interaction Between Doctor and Patient  The paternalistic model. In a paternalistic relationship between the doctor and patient, it is assumed that the doctor knows best. He or she will prescribe treatment, and the patient is expected to comply without questioning. Moreover, the doctor may decide to withhold information when it is believed to be in the patient's best interests. In this model, also called the autocratic model, the physician asks most of the questions and generally dominates the interview. The informative model. The doctor in this model dispenses information. All available data are freely given, but the choice is left wholly up to the patient. For example, doctors may quote 5-year survival statistics for various treatments of breast cancer and expect women to make up their own minds without suggestion or interference from them. This model may be appropriate for certain one-time consultations where no established relationship exists and the patient will be returning to the regular care of a known physician. At other times, the informative model places the patient in an unrealistically autonomous role and leaves him or her feeling the doctor is cold and uncaring. The interpretive model. Doctors who have come to know their patients better and understand something of the circumstances of their lives, their families, their values, and their hopes and aspirations, are better able to make recommendations that take into account the unique characteristics of an individual patient. A sense of shared decision-making is established as the doctor presents and discusses alternatives, with the patient's participation, to find the one that is best for that particular person. The doctor in this model does not abrogate the responsibility for making decisions, but is flexible, and is willing to consider question and alternative suggestions. The deliberative model. The physician in this model acts as a friend or counselor to the patient, not just by presenting information, but in actively advocating a particular course of action. The deliberative approach is commonly used by doctors hoping to modify injurious behavior, for example, in trying to get their patients to stop smoking or lose weight. Table 1-2 Assessment of Individual Illness Behavior  Prior illness episodes, especially illnesses of standard severity (childbirth, renal stones, surgery) Cultural degree of stoicism Cultural beliefs concerning the specific problem Personal meaning of or beliefs about the specific problem Particular questions to ask to elicit the patient's explanatory model:  What do you call your problem? What name does it have?  What do you think caused your problem?  Why do you think it started when it did?  What does your sickness do to you?  What do you fear most about your sickness?  What are the chief problems that your sickness has caused you?  What are the most important results you hope to i t tment?1. Functions Determining the nature of the problem  Objectives To enable the clinician to establish a diagnosis or recommend further diagnostic procedures, suggest a course of treatment, and predict the nature of the illness  SKILLS Knowledge base of diseases, disorders, problems, and clinical hypotheses from multiple conceptual domains: biomedical, sociocultural, psychodynamic, and behavioral  Ability to elicit data for the above conceptual domains (encouraging the patient to tell his or her story: organizing the flow of the interview, the form of questions, the characterization of symptoms, the mental status examination)  Ability to perceive data from multiple sources (history, mental status examination, physician's subjective response to the patient, nonverbal cues, listening at multiple levels)  Hypothesis generation and testing  Developing a therapeutic relationship (function II)2. Functions Developing and maintaining a therapeutic relationship Objectives The patient's willingness to provide diagnostic information  Relief of physical and psychological distress  Willingness to accept a treatment plan or a process of negotiation  Patient satisfaction  Physician satisfaction SKILLS Defining the nature of the relationship  Allowing the patient to tell his or her story  Hearing, bearing, and tolerating the patient's expression of painful feelings  Appropriate and genuine interest, empathy, support, and cognitive understanding  Attending to common patient concerns over embarrassment, shame, and humiliation  Eliciting the patient's perspective  Determining the nature of the problem  Communicating information and recommending treatment (function3.FUNGTIONS Communicating information and implementing a treatment plan OBJECTIVE Patient's understanding of the illness  Patient's understanding of the suggested diagnostic procedures  Patient's understanding of the treatment possibilities  Consensus between physician and patient about the above items 1 to 3  Informed consent  Improve coping mechanisms  Lifestyle changes SKILLS  Determining the nature of the problem (function I)  Developing a therapeutic relationship (function II)  Establishing the differences in perspective between physician and patientPredictable Reactions to Illness Intrapsychic  Lowered self image loss  Threat to homeostasis fear  Failure of (self) care helplessness, hopelessness  Sense of loss of control shame (guilt) Clinical  Anxiety or depression  Denial or anxiety  Depression Bargaining and blaming  Regression Isolation Dependency Anger Acceptance Common Interview Techniques  Establish rapport as early in the interview as possible.  Determine the patient's chief complaint.  Use the chief complaint to develop a provisional differential diagnosis.  Rule the various diagnostic possibilities out or in by using focused and detailed questions.  Follow up on vague or obscure replies with enough persistence to accurately determine the answer to the question.  Let the patient talk freely enough to observe how tightly the thoughts are connected.  Use a mixture of open-ended and closed-ended questions.  Don't be afraid to ask about topics that you or the patient may find difficult or embarrassing.  Ask about suicidal thoughts.  Give the patient a chance to ask questions at the end of the interview.  Conclude the initial interview by conveying a sense of confidence and, if possible, of hope.  Reprinted with permission from Andreasen NC, Black DW. Introduction Textbook of Psychiatry. Washington, DC: American Psychiatric Association, 1991.Character and Qualities of the Physician Imperturbability The ability to maintain extreme calm and steadiness Presence of mind Selfcontrol in an emergency or embarrassing situation so that one can say or do the right thing Clear judgment The ability to make an  Ability to endure frustration The capacity to remain firm and deal with insecurity and dissatisfaction  Infinite patienceThe unlimited ability to hear pain or trial calmly  Charity toward othersTo be generous and helpful, especially toward the needy and sufferingCharacter and Qualities of the Physician  The search for absolute truth To investigate facts and pursue reality  Composure Calmness of mind, bearing, and appearance  Bravery The capacity to face or endure events with courage  Tenacity To be persistent in attaining a goal or adhering to something valued  Idealism Forming standards and ideals and living under their influence  Equanimity The ability to handle stressful situations with an undisturbed, even temperThank youDEMENSIA, DELIRIUM, AMNESTIC DISORDER EDIT DR LIZA Delirium  Delirium is marked by short-term confusion and changes in cognition. There are four subcategories based on several causes: (1) general medical condition (e.g., infection); (2) substance induced (e.g., cocaine, opioids, phencyclidine [PCP]); (3) multiple causes (e.g., head trauma and kidney disease); and (4) delirium not otherwise specified (e.g., sleep deprivation). Dementia  Dementia is marked by severe impairment in memory, judgment, orientation, and cognition. The six subcategories are (1) dementia of the Alzheimer's type, which usually occurs in persons over 65 years of age and is manifested by progressive intellectual disorientation and dementia, delusions, or depression; (2) vascular dementia, caused by vessel thrombosis or hemorrhage; (3) other medical conditions (e.g., human immunodeficiency virus [HIV] disease, head trauma, Pick's disease, Creutzfeldt-Jakob disease, which is caused by a slow-growing transmittable virus); (4) substance induced, caused by toxin or medication (e.g., gasoline fumes, atropine); (5) multiple etiologies; and (6) not otherwise specified (if cause is Amnestic Disorder  Amnestic disorder is marked by memory impairment and forgetfulness.  The three subcategories are (1) caused by medical condition (hypoxia); (2) caused by toxin or medication (e.g., marijuana, diazepam); and (3) not otherwise specified.DSM-IV-TR Cognitive Disorders  Delirium Caused by a general medical condition Substance-induced From multiple etiologies Not otherwise specified Dementia Of the Alzheimer's type Vascular Dementia due to other general medical conditions Human immunodeficiency virus (HIV) disease Head trauma Parkinson's disease Huntington's disease Pick's disease Creutzfeldt-Jakob disease Other general medical conditions Substance-induced persisting dementia Multiple etiologies Dementia not otherwise specified Amnestic Disorders Caused by a general medical condition Substance-induced persisting amnestic disorder Not otherwise specified Cognitive disorder not otherwise specifiedNeuropsychiatric Mental Status Examination  1.General Description – General appearance, dress, sensory aids (glasses, hearing aid) – Level of consciousness and arousal – Attention to environment – Posture (standing and seated) – Gait – Movements of limbs, trunk, and face (spontaneous, resting, and after instruction) – General demeanor (including evidence of responses to internal stimuli) – Response to examiner (eye contact, cooperation, ability to focus on interview process) – Native or primary language  2,Language and Speech – Comprehension (words, sentences, simple and complex commands, and concepts) – Output (spontaneity, rate, fluency, melody or prosody, volume, coherence, vocabulary, paraphasic errors, complexity of usage) – Repetition – Other aspects  Object naming  Color naming3.Thought  Form (coherence and connectedness)  Content – Ideational (preoccupations, overvalued ideas, delusions) – Perceptual (hallucinations) 4.Mood and Affect  Internal mood state (spontaneous and elicited; sense of humor)  Future outlook  Suicidal ideas and plans  Demonstrated emotional status (congruence with mood) 5.Insight and Judgment  Insight – Self-appraisal and self-esteem – Understanding of current circumstances – Ability to describe personal psychological and physical status  Judgment6. Cognition  Memory – Spontaneous (as evidenced during interview) – Tested (incidental, immediate repetition, delayed recall, cued recall, recognition; verbal, nonverbal; explicit, implicit)  Visuospatial skills  Constructional ability  Mathematics  Reading  Writing  Fine sensory function (stereognosis, graphesthesia, two-point discrimination)  Finger gnosis  Right-left orientation  Executive functions  AbstractionCommon Causes of Delirium  Central nervous system disordeR= Seizure (postictal, nonconvulsive status, status) Migraine Head trauma, brain tumor, subarachnoid hemorrhage, subdural, epidural hematoma, abscess, intracerebral hemorrhage, cerebellar hemorrhage, nonhemorrhagic stroke, transient ischemia  Metabolic disorder =Electrolyte abnormalities,Diabetes, hypoglycemia, hyperglycemia, or insulin resistance  Systemic illness Infection= (e.g., sepsis, malaria, erysipelas, viral, plague, Lyme disease, syphilis, or abscess) Trauma Change in fluid status (dehydration or volume overload) Nutritional deficiency Burns Uncontrolled pain [Show More]

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