Running head: THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

Therapeutic Encounter and Healthy History

Natalie R. Selkirk
Trent University
NURS 1020

1) Communication Facilitators and Barriers:

Establishing a therapeutic relationship is crucial when obtaining information; especially
personal information from a resident. Trust, respect and honesty are the key components in
establishing therapeutic relationships (Registered Nurses Association of Ontario [RNAO], 2002).
Nurses can use a variety of different strategies and interpersonal skills to professionally initiate,
maintain and end nurse-resident relationships. Before beginning this assignment I completed
research about communication techniques; the RNAO provided an extensive list of effective
techniques that I utilized, including listening, silence, open-ended questions and statements,
restating, reflecting, seeking clarification and validation, focusing, summarizing, awareness of
verbal and non-verbal communication, and awareness of cultural differences related to
communication (RNAO, 2002). To initiate conversation with a resident, I always introduced

THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

myself by my name, my role and my purpose for being there (College of Nurses of Ontario
[CNO], 2006). As MC has been diagnosed with dementia it was crucial for me to give her
sufficient time to fully process questions and respond (CNO, 2006). In addition to this, active
listening was crucial for me to collect all required information (CNO, 2006). A major barrier for
me was verbal communication. MC is able to communicate, however often times her sentences
and train of thought are unrelated to the topic/question posed. Therefore, actively listening and
fully engaging in the conversation was crucial when trying to decipher the meaning of what was
being said. When communicating with MC I found that I needed to modify my communication
style by making the questions more simple and straight forward due to her developmental stage
and cognitive impairment (CNO, 2006). Another barrier for me was her cognitive impairment
due to her diagnosis of dementia. When I was unable to get information from MC herself I
utilized other resources including the PSWs, nurses and her chart/binder. Overall I feel as though
I was successful in obtaining information for my therapeutic encounter and health history. By
combining verbal and non-verbal techniques, approaching MC herself and approaching other
employees when required, I was able to obtain all of the information.
2) Health History and Nursing Goal:
A. Data Collection
1. Age (yr)
2. Gender
3. Developmental State
73 years old
DOB:
09/03/1943

Female

Integrity versus despair:

the final stage of the Erik
Eriksons psychological
stages. MC is in her late
adulthood stage of life,
which includes reflecting
back on life events.
Overall MC states she is
fairly satisfied with the life
she lives, however regrets
the events that have lead to

4. Health State
MC presents with
various diagnoses;
these medical
conditions reduce
her overall health
state.
Alert and oriented x0
Subjective view:
MC says that she is

5. Sociocultural
Orientation
MC was born and raised
in Jamaica and now
resides in Canada.

THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

her moving into LTC, thus
feeling some despair. MC
can be cognitively
unstable (mainly due
dementia and
hallucinations/paranoia).
Her level of alertness (e.g.
place and time) varies and
she sometimes displays
mumbled speech that can
be hard to understand.
(Appendix D)
6. Healthcare system
factors, e.g., medical,
diagnostic and treatment
modalities

7. Family
system factors

Medical diagnoses
include: dementia,
gastroesophageal disease
(GERD), hyperlipidemia,
hypertension and
glaucoma.

MC is widowed.

MC has a history of and

can experience
hallucinations and
paranoia.
Treatment modalities
include: medications as
per physicians orders and
treatments as per
nursing/physicians order
MC has a good appetite;
attends all meals in the
dining hall. Generally eats
a majority of food (may
need to be
prompted/encouraged).

MC reports
having a family
(however when
asked, does not
discuss the topic
any further).

8. Patterns of
living, including
activities
regularly
engaged in.
MC performs
own morning
care; requires
some guidance
and prompting.

doing a lot better

than she used to be.
She spent a long
time in the hospital a
few years ago and
believes that her
health is increasing.

9. Environmental
factors

10. Resource
availability and
adequacy

MC has a 2-person
bedroom.

MC does not
regularly engage in
recreational
activities provided
by Centennial Place.

Although MC resides
in a 2-person
bedroom, MC has
MC spends a
access to her own
great deal of time private washroom.
at the bus stop.
MC has a
MCs room is located
relative that
MC states that
near the nursing
works at
she does not
station; reportedly due
Centennial Place. actively
to her wandering and
MC often speaks participate in the hallucinations.
of going back to activities
provided by
visit family in
MC does not use bed
Centennial Place, rails.
Jamaica (birth
however MC will
country).
go if encouraged.
MC appears to like to
keep her comb in a
MC is observed
specific drawer in her
to keep to herself bathroom.
for most of the
day (unless
MC resides in the
encouraged).
secure unit of
Centennial Place.
MC enjoys

MC requires some
prompting form
HCPs, however is
quite independent a
majority of the time.

MCs family does

not appear to be a
major resource.

THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

spending time in
her room with
the television on.
MC states to
roam around
throughout the
day.
Recreation,
social and
religious
activities as per
MCs wishes.
B. Universal Self-Care Requisites. There are 8 universal self-care requisites common to
men, women and children.
1. Air
2. Water
3. Food
4. Elimination
Vital Signs
Intake & Output
Appetite
Urine
BP: 116/62 T: 36.1 P: 88
-Fluid intake appears to be -Appetite is normal
-Continent bladder
R: 14 O2 Sats: 99%
adequate
-Food preferences:
-Wears pull-up brief as a
-Pulse was strong and
-MC always micturates
Cheerios, Rice Krispies,
precaution
regular
during morning routine
soup, chicken, potatoes,
-No catheter
beef,
poultry,
fish,
eggs,
Breath sounds
-MC appears hydrated,
-No reports of difficulty
hot
dogs,
cheese,
yogurt,
presenting
no
signs
of
-MC does not report a
with voiding (on regular
ice-cream, raw fruit,
dehydration
cough
basis)
cooked
vegetables,
white
-Breath sounds were clear -Drink preferences: juice,
-Urine appears to be light
bread, pasta, rice,
milk and coffee
upon inspiration and
yellow with no sediment
pancakes,
etc.
expiration
Edema
or odour (on regular basis)
Feeding
precautions
Colour, pedal pulse
-Does not show signs of
-Reported signs of UTI
-Normal
diet,
regular
edema
(Mar. 7, 2016). Presenting
-Feet observed to be
texture
with delirium type
normal in colour
Intake & Output
-Met: All water criteria
symptoms and increased
-Food
intake
appears
to
be
frequency
-Met: All air criteria met
adequate (attends dining
-Requires supervision with
hall for all meals)
toileting
Oral status care
Bowel movement
-MC has dentures. Oral
-Continent bowel
status appears to be good.
-No reports of having
Note: tends to sleep in her issues with regular bowel
dentures
movements
-Bowel movements are
-Met: All food criteria met usually type 3 or 4
according to the Bristol
Stool Scale (Appendix A)

THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

5. Activity/Rest

Mobility
-No mobility/ambulation
devices
-Independent for mobility;
may need some verbal
guidance
-Morse Fall Scale: MC
presents with a moderate
risk for falls (e.g. was on
fall watch the week of
March 14, 2016)
(Appendix B)
Assistance required
-Requires supervision with
dressing
-Independent for
transferring
ROM
-MC appears to have good
ROM in the upper body
-Displays some limited
ROM in the lower body
(e.g. walks with a slight
limp)
Positioning
-Independent for
positioning
Sleep/rest patterns
-MC does not nap
throughout the day
-Reported to have overall
good sleep pattern (on
occasion MC wanders and
paces)

-Unmet: MC can have

episodes of incontinence,
showed symptoms of a
UTI and requires
supervision while toileting
6. Solitude/Social
7. Prevention of hazards 8. Promotion of human
to human life and
functioning and
Interaction
functioning and welldevelopment in social
being.
groups and human desire
to be normal.
Communication pattern
Cognitive orientation,
Medical regimen
judgment, memory
-Interacts with other
-Pain control: PRN (as
residents, PSWs and
-Cognitive orientation and needed)
nurses at meal times
judgment varies; alert and -Skin care: normal bathing
-Communication with MC oriented x0 (e.g. believes it schedule. Washes face
is realistic for her to travel every morning
can be difficult due to
to Jamaica, believes she is -Wound: no wounds
mumbled phrases and
waiting at the bus stop
dementia
present
waiting to travel to the
Isolation
Awareness/ Management
mall, etc.)
-MC can be social and
of Disease Process and
-Memory
impaired
at
isolated at times (e.g. will
Self-Care
communicate with others, times; MC has been
-Potential risks: due to
however may also keep to diagnosed with dementia
dementia and history of
Dysphagia
herself even while in
paranoia and
public areas)
-No reports of dysphagia
hallucinations MC is
or risk for dysphagia
-Does not engage in
sometimes unaware of her
scheduled recreational
Communication tips
true surroundings
activities at Centennial
-Remove any distractions
-Future care needs: will
Place unless prompted
need continued care in the
-Allow MC time to
Relationships
future (e.g. continued care
process requests and
for dementia and diabetes).
-Widowed
questions
MC is not fully aware of
-Appears to be receptive
-Orient yourself to be at
her condition as she often
with HCPs
eye level with MC
states how she will be
-Appears to cooperate with Transfers
moving back home
HCPs
-Independent for
(Jamaica) once she Is
transferring
completely better
-Unmet: communication
Restraints
-Medical treatment: MC
can be difficult due to
-No restraints used (e.g. no
will continue to need
mumbled phrases and
bed rails, etc.)
medical care (multiple
dementia, does not often
diagnoses)
engage in scheduled
-Unmet: alert and oriented
-Relationship with
recreational activities and
x0, memory impairment
caregivers: MC appears to
does not appear to have
and dementia
have good relationships
close familial relationships

THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

Braden Scale
-No reports of pain (4)
-Rarely moist (4)
-Walks occasionally (3)
-No limitation in mobility
(4)
-Nutrition appears
adequate (3)
-No apparent problems
with friction and shear (3)
-According to the Braden
Scale, MC appears to be at
low risk for pressure soars
(23)
(Appendix C)
-Unmet: MC poses
moderate risk for falls (has
been placed on fall watch),
requires supervision with
dressing and displays
some limited ROM in
lower extremities

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with all her caregivers
Developmental stage
-Challenges: not fully
aware of her medical
diagnoses, may pose risk
in the future
-Hygiene challenges: no
reports of difficulty with
hygiene
-Frailty: no significant
reports of frailty
Promotion of normalcy
-Lifestyle continuity:
should be encouraged to
remain as independent as
possible as this will
continue to help promote a
healthy lifestyle
-Meaningful activities:
MC does not appear to
engage in many
meaningful activities. Her
room does have some
meaningful items (e.g.
pictures, etc.)
Adaptive self-image
-Self-image: states that she
views herself as being
much healthier than she
used to be (had a long stay
in the hospital and was in
poor condition) under
the impression that she is
healthier than she is
-Anxiety/mood: mood
varies
-Grief and loss: reports of
some grief about residing
in LTC, does not always
feel that she belongs or
that this is her true home
Lifestyle adjustment
-Adaptation to LTC: no
significant opinions about
her move to LTC; has

THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

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however mentioned that
she plans to move at some
point. Does not appear that
she has had a successful
lifestyle adjustment (e.g.
can be isolated, does not
participate in recreational
activities, etc.)
-Unmet: displays potential
risk for Awareness/
Management of Disease
Process and Self-Care, not
fully aware of medical
diagnoses, varying moods
and unsuccessful lifestyle
adjustment

C. Nanda Nursing Diagnosis:

Risk for impaired social interaction related to lack of self-promoted involvement in
scheduled social/recreational activities and cognitive impairment associated with diagnosis of
dementia. Thom, Centena, Behenck, Marini and Heidt (2014) determine that impaired social
interaction is a common NANDA (North American Nursing Diagnosis Association) diagnosis.
Furthermore. Thom et al. (2014) report a significant association between impaired social
interaction and socialization enhancement as an intervention. Nursing interventions related to
socialization enhancement include: refining interpersonal care, assisting with activities of daily

THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

living, promoting skills for behaviour modification, exercise promotion and self concept/worth
enhancement (Thom et al., 2014).

References

College of Nurses of Ontario (CNO). (2006). Therapeutic Nurse-Client Relationship, Revised

2006. Toronto, ON.
Registered Nurses Association of Ontario (RNAO). (2002). Nursing Best Practice Guideline:
Establishing Therapeutic Relationships. Toronto, ON.
Thom, E. D. S., Centena, R. C., Behenck, A. D. S., Marini, M., & Heldt, E. (2014).
Applicability of the NANDAI and Nursing Interventions Classification Taxonomies to

THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

Mental Health Nursing Practice. International journal of nursing knowledge, 25(3),
168-172.

Appendix A

THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

https://www.gutsense.org/constipation/normal_stools.html

Appendix B

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THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

https://www.pinterest.com/pin/507006870526439036/

Appendix C

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THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

https://www.pinterest.com/pin/381539399659531651/

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THERAPEUTIC ENCOUNTER AND HEALTH HISTORY

Appendix D

https://www.pinterest.com/pin/71635450299516564/

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