EGO DEFENSE MECHANISM

1. Compensation- Overachievement in one area to offset real or perceived deficiencies in

another area
ex • Napoleon complex: diminutive man becoming emperor.
• Nurse with low self-esteem working double shifts so her supervisor will like her
2. Conversion- Expression of an emotional conflict through the development of a physical
symptom, usually s ensorimotor in nature
• Teenager forbidden to see X-rated movies is tempted to do so by friends and develops
blindness, and the teenager is unconcerned about the loss of sight.
3. Denial- Failure to acknowledge an unbearable condition; failure to admit the reality of a
situation or how one enables the problem to continue
• Diabetic person eating chocolate candy
• Spending money freely when broke
• Waiting 3 days to seek help for severe abdominal pain
4. Displacement- Ventilation of intense feelings toward persons less threatening than the one
who aroused those feelings
• Person who is mad at the boss yells at his or her spouse.
• Child who is harassed by a bully at school mistreats a younger sibling.
5. Dissociation- Dealing with emotional conflict by a temporary alteration in consciousness or
identity
• Amnesia that prevents recall of yesterday’s auto accident
• Adult remembers nothing of childhood sexual abuse.
6. Fixation- Immobilization of a portion of the personality resulting from unsuccessful
completion of tasks in a developmental stage
• Never learning to delay gratification
• Lack of a clear sense of identity as an adult
7. Identification- Modeling actions and opinions of influential others while searching for
identity, or aspiring to reach a personal, social, or occupational goal
• Nursing student becoming a critical care nurse because this is the specialty of an instructor
she admires
8. Intellectualization- Separation of the emotions of a painful event or situation from the facts
involved; acknowledging the facts but not the emotions • Person shows no emotional
expression when discussing serious car accident.
9. Introjection- Accepting another person’s attitudes, beliefs, and values as one’s own
• Person who dislikes guns becomes an avid hunter, just like a best friend.
10. Projection- Unconscious blaming of unacceptable inclinations or thoughts on an external
object
• Man who has thought about same-gender sexual relationship, but never had one, beats a
man who is gay.
• Person with many prejudices loudly identifies others as bigots.
11. Rationalization- Excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or
loss of self-respect
• Student blames failure on teacher being mean.
• Man says he beats his wife because she doesn’t listen to him.
12. Reaction formation -Acting the opposite of what one thinks or feels
• Woman who never wanted to have children becomes a supermom
.• Person who despises the boss tells everyone what a great boss she is.
13. Regression- Moving back to a previous developmental stage to feel safe or have needs
met
• Five-year-old asks for a bottle when new baby brother is being fed.
• Man pouts like a 4-year-old if he is not the center of his girlfriend’s attention.
14. Repression- Excluding emotionally painful or anxiety-provoking thoughts and feelings
from conscious awareness
• Woman has no memory of the mugging she suffered yesterday.
• Woman has no memory before age 7, when she was removed from abusive parents.
15. Resistance- Overt or covert antagonism toward remembering or processing anxiety-
producing information
• Nurse is too busy with tasks to spend time talking to a dying patient.
• Person attends court-ordered treatment for alcoholism but refuses to participate.
16. Sublimation-Substituting a socially acceptable activity for an impulse that is unacceptable
 • Person who has quit smoking sucks on hard candy when the urge to smoke arises.
17. Substitution- Replacing the desired gratification with one that is more readily available
• Woman who would like to have her own children opens a day care center. 18.
Suppression- Conscious exclusion of unacceptable thoughts and feelings from conscious
awareness
• Student decides not to think about a parent’s illness to study for a test.
• Woman tells a friend she cannot think about her son’s death right now.
19.Undoing-Exhibiting acceptable behavior to make up for or negate unacceptable
behavior
• Person who cheats on a spouse brings the spouse a bouquet of roses.
• Man who is ruthless in business donates large amounts of money to charity

Grief refers to the subjective emotions and affect that are a normal response to the
experience of loss. Grieving, also known as bereavement, refers to the process by which a
person experiences the grief.
TYPES OF LOSSES
One framework to examine different types of losses is Abraham Maslow’s hierarchy of
human needs. According to Maslow (1954), a hierarchy of needs motivates human actions.
The hierarchy begins with physiologic needs (food, air, water, sleep), safety needs (a safe
place to live and work), and security and belonging needs (satisfying relationships). The next
set of needs includes self-esteem needs, which lead to feelings of adequacy and confidence.
The last and final need is self-actualization, the ability to realize one’s full innate potential.
When these human needs are taken away or not met for some reason, a person experiences
loss. Examples of losses related to specific human needs in Maslow’s hierarchy are as
follows:
• Physiologic loss: Examples include amputation of a limb, a mastectomy or hysterectomy, or
loss of mobility.
• Safety loss: Loss of a safe environment is evident in domestic violence, child abuse, or
public violence. A person’s home should be a safe haven with trust that family members will
provide protection, not harm or violence. Some public institutions, such as schools and
churches, are often associated with safety as well. That feeling of safety is shattered when
public violence occurs on campus or in a holy place.
• Loss of security and a sense of belonging: The loss of a loved one affects the need to love
and the feeling of being loved. Loss accompanies changes in relationships, such as birth,
marriage, divorce, illness, and death; as the meaning of a relationship changes, a person may
lose roles within a family or group.
• Loss of self-esteem: Any change in how a person is valued at work or in relationships or by
him or her self can threaten self-esteem. It may be an actual change or the person’s
perception of a change in value. Death of a loved one, a broken relationship, loss of a job,
and retirement are examples of change that represent loss and can result in a threat to self-
esteem.
• Loss related to self-actualization: An external or internal crisis that blocks or inhibits strivings
toward fulfillment may threaten personal goals and individual potential. A person who wanted
to go to college, write books, and teach at a university reaches a point in life when it becomes
evident that those plans will never materialize. Or a person loses hope that they will find a
mate and have children. These are losses that the person will grieve
Theories of Grieving
Kubler-Ross’s Stages of Grieving Elisabeth Kubler-Ross (1969) established a basis for
understanding how loss affects human life. As she attended to clients with terminal illnesses,
a process of dying became apparent to her. Through her observations and work with dying
clients and their families, Kubler-Ross developed a model of five stages to explain what
people experience as they grieve and mourn:
1. Denial is shock and disbelief regarding the loss.
2. Anger may be expressed toward God, relatives, friends, or health care providers.
3. Bargaining occurs when the person asks God or fate for more time to delay the inevitable
loss.
4. Depression results when awareness of the loss becomes acute.
5. Acceptance occurs when the person shows evidence of coming to terms with death. This
model became a prototype for care providers as they looked for ways to understand and
assist their clients in the grieving process.
WHAT IS THERAPEUTIC COMMUNICATION?
Therapeutic communication is an interpersonal interaction between the nurse and the client
during which the nurse focuses on the client’s specific needs to promote an effective
exchange of information. Skilled use of therapeutic communication techniques helps the
nurse understand and empathize with the client’s experience. All nurses need skills in
therapeutic communication to effectively apply the nursing process and to meet standards of
care for their clients. Therapeutic communication can help nurses to accomplish many goals:
• Establish a therapeutic nurse–client relationship.
• Identify the most important client concern at that moment (the client-centered goal).
• Assess the client’s perception of the problem as it unfolds. This includes detailed actions
(behaviors and messages) of the people involved and the client’s thoughts and feelings about
the situation, others, and self.
• Facilitate the client’s expression of emotions.
• Teach the client and family necessary self-care skills.
• Recognize the client’s needs.
• Implement interventions designed to address the client’s needs.
• Guide the client toward identifying a plan of action to a satisfying and socially acceptable
resolution.

Privacy and Respecting Boundaries Privacy is desirable but not always possible in
therapeutic communication. An interview or a conference room is optimal if the nurse believes
this setting is not too isolative for the interaction. The nurse also can talk with the client at the
end of the hall or in a quiet corner of the day room or lobby, depending on the physical layout
of the setting. The nurse needs to evaluate whether interacting in the client’s room is
therapeutic. For example, if the client has difficulty maintaining boundaries or has been
making sexual comments, then the client’s room is not the best setting. A more formal setting
would be desirable.
Proxemics is the study of distance zones between people during communication. People feel
more comfortable with smaller distances when communicating with someone they know
rather than with strangers (DeVito, 2008). People from the United States, Canada, and many
Eastern European nations generally observe four distance zones:
• Intimate zone (0 to 18 inches between people): This amount of space is comfortable for
parents with young children, people who mutually desire personal contact, or people
whispering. Invasion of this intimate zone by anyone else is threatening and produces
anxiety.
• Personal zone (18 to 36 inches): This distance is comfortable between family and friends
who are talking.
• Social zone (4 to 12 feet): This distance is acceptable for communication in social, work,
and business settings.
• Public zone (12 to 25 feet): This is an acceptable distance between a speaker and an
audience, small groups, and other informal functions (Hall, 1963).

The therapeutic communication interaction is most comfortable when the nurse and client are
3 to 6 feet apart. If a client invades the nurse’s intimate space (0 to 18 inches), the nurse
should set limits gradually, depending on how often the client has invaded the nurse’s space
and the safety of the situation.

Touch
 As intimacy increases, the need for distance decreases. Knapp (1980) identified five types
of touch:
• Functional-professional touch is used in examinations or procedures such as when the
nurse touches a client to assess skin turgor or a masseuse performs a massage.
• Social-polite touch is used in greeting, such as a handshake and the “air kisses” some
women use to greet acquaintances, or when a gentle hand guides someone in the correct
direction.
• Friendship-warmth touch involves a hug in greeting, an arm thrown around the shoulder of
a good friend, or the backslapping some men use to greet friends and relatives.
• Love-intimacy touch involves tight hugs and kisses between lovers or close relatives.
• Sexual-arousal touch is used by lovers.

Active Listening and Observation

To receive the sender’s simultaneous messages, the nurse must use active listening and
active observation. Active listening means refraining from other internal mental activities
and concentrating exclusively on what the client says.
Active observation means watching the speaker’s nonverbal actions as he or she
communicates.
Peplau (1952) used observation as the first step in the therapeutic interaction
Active listening and observation help the nurse to
• Recognize the issue that is most important to the client at this time.
• Know what further questions to ask the client.
• Use additional therapeutic communication techniques to guide the client to describe his or
her perceptions fully.
• Understand the client’s perceptions of the issue instead of jumping to conclusions.
• Interpret and respond to the message objectively

Using Concrete Messages

When speaking to the client the nurse should use words that are as clear as possible so that
the client can understand the message. Anxious people lose cognitive processing skills—the
higher the anxiety, the less the ability to process concepts—so concrete messages are
important for accurate information exchange. In a concrete message, the words are explicit
and need no interpretation; the speaker uses nouns instead of pronouns—for example, “What
health symptoms caused you to come to the hospital today?” or “When was the last time you
took your antidepressant medications?” Concrete questions are clear, direct, and easy to
understand.

Abstract messages, in contrast, are unclear patterns of words that often contain figures of
speech that are difficult to interpret. They require the listener to interpret what the speaker is
asking. For example, a nurse who wants to know why a client was admitted to the unit asks,
“How did you get here?” This is an abstract message: the terms how and here are vague

Using Therapeutic Communication Techniques

Therapeutic Communication Examples Rationale
Technique
Accepting—indicating “Yes.” “I follow what you
reception said.” Nodding
Broad openings—allowing “Is there something you’d like
the client to take the initiative to talk about?”
in introducing the topic “Where would you like to
begin?”
Consensual validation— “Tell me whether my
searching for mutual understanding of it agrees
understanding, for accord in with yours.” “Are you using
the meaning of the words this word to convey that…?”
Encouraging comparison— “Was it something like…?”
asking that similarities and “Have you had similar
differences be noted experiences?”
Encouraging comparison— “Tell me when you feel
asking that similarities and anxious.” “What is
differences be noted happening?”
“What does the voice seem
to be saying?”
Encouraging expression— “What are your feelings in
asking the client to appraise regard to…?”
the quality of his or her “Does this contribute to your
experiences distress?”
Exploring—delving further “Tell me more about that.”
into a subject or an idea “Would you describe it more
fully?” “What kind of work?”
Focusing—concentrating on “This point seems worth
a single point looking at more closely.”
“Of all the concerns you’ve
mentioned, which is most
troublesome?”
Formulating a plan of action “What could you do to let
—asking the client to your anger out harmlessly?”
consider kinds of behavior “Next time this comes up,
likely to be appropriate in what might you do to handle
future situations it?”
General leads—giving “Go on.” “And then?”
encouragement to continue “Tell me about it.”
Giving information— making “My name is….” “Visiting
available the facts that the hours are….”
client needs “My purpose in being here
is….”
Giving recognition— “Good morning, Mr. S.….”
acknowledging, indicating “You’ve finished your list of
awareness things to do.”
“I notice that you’ve combed
your hair.”
Making observations— “Are you uncomfortable
verbalizing what the nurse when…?”
perceives “I notice that you’re biting
your lip.
Offering self—making oneself I’ll sit with you awhile.”
available “I’ll stay here with you.” “I’m
interested in what you think.”
Placing event in time or “What seemed to lead up
sequence—clarifying the to…?”
relationship of events in time “Was this before or after…?”
“When did this happen?”
Presenting reality— offering “I see no one else in the
for consideration that which room.”
is real “That sound was a car
backfiring.” “Your mother is
not here; I am a nurse.
Reflecting—directing client Client: “Do you think I should
actions, thoughts, and tell the doctor…?” Nurse: “Do
feelings back to client you think you should?”
Client: “My brother spends all
my money and then has
nerve to ask for more.”
Nurse: “This causes you to
feel angry?”
Restating—repeating the Client: “I can’t sleep. I stay
main idea expressed awake all night.”
Nurse: “You have difficulty
sleeping.”
Client: “I’m really mad, I’m
 really upset.”
Nurse: “You’re really mad
and upset.”
Seeking information— “I’m not sure that I follow.”
seeking to make clear that “Have I heard you correctly?”
which is not meaningful or
that which is vague
Silence—absence of verbal Nurse says nothing but
communication, which continues to maintain eye
provides time for the client to contact and conveys interest.
put thoughts or feelings into
words, to regain composure,
or to continue talking
Suggesting collaboration— Perhaps you and I can
offering to share, to strive, discuss and discover the
and to work with the client for triggers for your anxiety.”
his or her benefit “Let’s go to your room, and
I’ll help you find what you’re
looking for.”
Summarizing—organizing “Have I got this straight?”
and summing up that which “You’ve said that….” “During
has gone before the past hour, you and I have
discussed….”
Translating into feelings— Client: “I’m dead.”
seeking to verbalize client’s Nurse: “Are you suggesting
feelings that he or she that you feel lifeless?” Client:
expresses only indirectly “I’m way out in the ocean.”
Nurse: “You seem to feel
lonely or deserted
Verbalizing the implied— Client: “I can’t talk to you or
voicing what the client has anyone. It’s a waste of time.”
hinted at or suggested Nurse: “Do you feel that no
one understands?”
Voicing doubt—expressing “Isn’t that unusual?” “Really?”
uncertainty about the reality “That’s hard to believe.”
of the client’s perceptions

Avoiding Nontherapeutic Communication

Techniques Examples
Advising—telling the client what to do “I think you should….”
“Why don’t you….”
Agreeing—indicating accord with the client “That’s right.”
“I agree.”
Belittling feelings expressed—misjudging the Client: “I have nothing to live for… I wish I
degree of the client’s discomfort was dead.”
Nurse: “Everybody gets down in the dumps,”
or “I’ve felt that way myself.”
Challenging—demanding proof from the “But how can you be president of the United
client States?”
“If you’re dead, why is your heart beating?”
Defending—attempting to protect someone “This hospital has a fine reputation.”
or something from verbal attack? “I’m sure your doctor has your best interests
in mind.”
Disagreeing—opposing the client’s ideas “That’s wrong.” “I definitely disagree with….”
“I don’t believe that.”
Disapproving—denouncing the client’s “That’s bad.”
behavior or ideas “I’d rather you wouldn’t….”
Giving approval— sanctioning the client’s “That’s good.”
behavior or ideas “I’m glad that….”
Giving literal responses—responding to a Client: “They’re looking in my head with a
figurative comment as though it were a television camera.” Nurse: “Try not to watch
statement of fact television” or “What channel?”
Indicating the existence of an external source “What makes you say that?” “What made you
— attributing the source of thoughts, feelings, do that?”
and behavior to others or to outside “Who told you that you were a prophet?”
influences
Interpreting—asking to make conscious that “What you really mean is….” “Unconsciously
which is unconscious; telling the client the you’re saying….
meaning of his or her experience
Introducing an unrelated topic—changing the Client: “I’d like to die.” Nurse: “Did you have
subject visitors last evening?”
Making stereotyped comments—offering “It’s for your own good.” “Keep your chin up.”
meaningless clichés or trite comments “Just have a positive attitude and you’ll be
better in no time.”
Probing—persistent questioning of the client “Now tell me about this problem. You know I
have to find out.” “Tell me your psychiatric
history.”
Reassuring—indicating there is no reason for “I wouldn’t worry about that.” “Everything will
anxiety or other feelings of discomfort be all right.” “You’re coming along just fine.”
Rejecting—refusing to consider or showing “Let’s not discuss….”
contempt for the client’s ideas or behaviors “I don’t want to hear about….”
Requesting an explanation—asking the client “Why do you think that?”
to provide reasons for thoughts, feelings, “Why do you feel that way?”
behaviors, event
Testing—appraising the client’s degree of “Do you know what kind of hospital this is?”
insight “Do you still have the idea that…?”
Using denial—refusing to admit that a Client: “I’m nothing.”
problem exists Nurse: “Of course you’re something—
everybody’s something.”
Client: “I’m dead.”
Nurse: “Don’t be silly.”
Assessment in Psychiatric Patient
1. assess the appearance and motor behaviour of the patient
-how the pt dress, hygiene and grooming
-in psychiatric patient, damit nya is appropriate ba sa weather?
-hair is nakasabog or di sinusuklay?
-balbas is napakahaba
-yung suot nya noong nakaraang araw yun padin
2. Check the eye contact, facial expressions -nakakaiyak pero tumatawa sya
3. check if there’s tremor,biglang tumataas yung kamay nya
Terms being used in making assessment in physical
1. automatism-repeated purposeless behavior often indicative anxiety ex. tapping of
foot pag ninenerbyos, ginagalaw yung buhok ganern
2. psychomotor retardation- overall slow movement ex. pagkukuha ng bagay ang
bagal kumilos -makikita sa pt na kapag matagal ng umiinom ng psychotropic drugs
3. waxy flexibility- maintenance of posture or position overtime even when it is
awkward or uncomfortable ex. isang kilos nakataas, tapos 3hrs nakataas yung
kamay or long period of time

Assess the quality and quantity of the abnormal speech

- if the pt may neologism means invented word that have meaning only for the client
Assess the mood and affect-
mood- refers to the client’s pervasive enduring emotional state (happy)
affect-outward expression of the client emotional state (ex. nagpatawa ka how the
client react)
Terms in assesing affect
1. blunted affect-showing little or slow to respond facial expression (nakakatawa
pero nakangiti lang sya
2. broad affect- displaying full range of emotional expression( di nakakatawa pero
tawang tawa)
3. flat affect- showing no facial expression
4. inappropriate affect- displaying a facial expression that is congruent with mood or
situation (hal nakakatawa pero iiyak sya)
5. restricted affect- displaying one type of expression usually serious
6. labile- biglang tatawa,iiyak mood swings

Thought process and content

Thought Process -refers how the clients thinks
- ginagamit usually shows hallucinations and delusion of grandeur
Thouht content- what the client usually says ex. may nakikita na di naman natin
nakikita
Terms:
1. Delusion- fixed false belief that not base in reality ex. delusion of grandeur(ako si
president) ex. feeling nya nasa katawan nya si Jesus Christ
2. delusion Persecution ex. hinahabol ka ng mga authority , or lalasunin ka kaya di
mo kinakain
3. flight of ideas-excessive amount and rate of speech composed of fragmented or
unrelated ideas ex. mabilis magsalita at unrelated
4. ideas of reference- clients inaccurate interpretation the general events are
personally directed to him or her ex. nagbasa ka ng dyaryo feeling mo ikaw yung
tinutukoy dun
5. loose association- disorganised thinking that jumps from one idea to another with
little or no evident relation between the thoughts
6. thought blocking- stopping abruptly in the middle of a sentence
7. word salad- flow of unconnected words that convey no meaning to the listener ex
ALWAYS aknowledge the behaviour but present the reality
Assessment of suicide or harm toward other
-as a nurse determine weather the client is depressed or hopeless
-always ask the pt directly (may binabalak ka bang magpakamatay?) if yes tanggalin
yung mga matatalim na bagay or do the safety precautions
-what’s your plan?
-what do you want to do?
- if depressed, do the suicide precautions but if the pt biglang sumaya at kumain ng
madami means thats the time that you need to do the suicide precautions

Illusion- may stimuli ex. ballpen tingin mo ahas

Delusion- false belief feeling mo ikaw yung superhere
Hallucinations-it can be auditory, patient who has schizophrenia
Tactile -may nararamdaman pero wala naman
visual hallucinations- may nakikita wala naman
bcos of imbalance neurotransmitter
in a patient that has mental problems, it is very important to encourage or
verbalization of feelings to relieve their feeling use the therapeutic communication