Co-morbid Conditions

• How would you use therapeutic communication and principles of cognitive behavioral therapy with the client?
• Describe your assessment process. What are some likely co-morbid conditions? List one nursing diagnosis and an appropriate nursing intervention.
• What interdisciplinary referrals might be appropriate?

S.is a 48-year-old divorced woman with one adult daughter and three grandchildren. She is currently working as an LPN part-time in a nursing home and works at a convenience store one or two days per week. She has had many jobs over the last 22 years, usually changing every one or two years to a new job. S notes that she has been called less often to work in the convenience store and worries that they don’t like her anymore. She reports being written up several times for arguing with customers. She also reports that she liked her supervisor at; first; she says, “Now I hate her; she’s trying to get me fired.” S. reports that she has tried to get full-time jobs five times in the last four years was hired for three but only lasted one or two weeks at each one.

 

1. reports that she is currently not talking to her daughter because “she is mean to me and she needs to apologize, or I won’t talk to her again.” She is upset that she hasn’t seen her three small grandchildren in about a year. She sends them presents and cards frequently that say “I still love you! Grandma” but hasn’t called them since she stopped talking to her daughter. She is considering reporting to the county that her daughter is keeping her grandchildren from her.

 

1. is very unhappy that she isn’t in a relationship. She was abused by her ex-husband and had a pattern of meeting and dating men who eventually abused her. She states that her last relationship was very good; the man was not abusive, and “I loved him very much.” The relationship ended for reasons that S. doesn’t understand. However, she does report many arguments that ended in “scenes,” such as her throwing chairs, stomping out of the house, making crank phone calls to his family, and calling the police with false reports. But S. also reports that she “couldn’t have loved him more, and I showed it.” She gives examples of going to her boyfriend’s place of work with flowers, buying him expensive presents, surprising him with tickets to Mexico at the last minute – she was very upset that he wasn’t willing to drop everything and go with her. S. reports asking him why he didn’t love her and what she was doing wrong regularly. When the boyfriend asked to break up, S. reported sitting outside his house for weeks, crying; she called his mother, called his boss, and called and texted him until he filed a restraining order. This occurred about four months ago.

 

1. admitted herself to the mental health unit when she felt suicidal. She reports that she had stopped her psychotherapy three months ago and stopped going to DBT. She also stopped her anti-depressant at that time, as she felt it wasn’t working, and missed her last two psychiatrist appointments.

To work with the client effectively, therapeutic communication and principles of cognitive-behavioral therapy (CBT) can be utilized:

1. Therapeutic Communication:

• Active Listening: Demonstrating genuine interest in the client’s concerns, thoughts, and feelings. Reflecting and clarifying their statements to show understanding and empathy.
• Empathy: Showing understanding and compassion towards the client’s struggles and experiences.
• Non-judgmental Attitude: Creating a safe and non-threatening environment for the client to express themselves openly.
• Open-ended Questions: Encouraging the client to elaborate on their experiences and emotions, promoting self-awareness and exploration.
• Validation: Acknowledging the client’s emotions and experiences without dismissing or minimizing them.

2. Cognitive Behavioral Therapy (CBT): CBT focuses on identifying and changing negative thought patterns and behaviors that contribute to emotional distress. It aims to teach the client coping skills to manage difficult emotions and improve their interpersonal relationships.

Assessment Process:

1. History: Gather information about the client’s personal and family history, including relationships, work history, and mental health treatment history.
2. Presenting Problems: Identify the client’s current issues, including difficulties at work, strained relationships, and emotional struggles.
3. Emotional and Cognitive Patterns: Explore the client’s emotional responses, thought processes, and coping strategies in different situations.
4. Safety Assessment: Assess the client’s suicidal ideation and risk of harm to themselves or others.
5. Co-morbid Conditions: Identify any co-existing mental health conditions or potential psychiatric disorders that may be contributing to the client’s difficulties.

Likely Co-morbid Conditions:

• Borderline Personality Disorder (BPD): The client’s pattern of unstable relationships, emotional dysregulation, and self-destructive behaviors could indicate BPD.
• Major Depressive Disorder (MDD): The client’s history of depressive symptoms, suicidal ideation, and stopping anti-depressant medication may suggest MDD.

Nursing Diagnosis: Risk for Self-harm related to impulsive behavior and emotional dysregulation.

Nursing Intervention:

• Establish a Safety Plan: Collaborate with the client to create a detailed safety plan to manage suicidal thoughts or impulses during crisis situations.
• Monitor and Observe: Keep a close eye on the client to ensure their safety and intervene promptly if any concerning behaviors arise.
• Psychoeducation: Educate the client about the risks associated with impulsive behaviors and help them understand the importance of adhering to their treatment plan, including medication and therapy.

Interdisciplinary Referrals:

1. Psychiatrist: For a comprehensive psychiatric evaluation and medication management to address the client’s mental health concerns.
2. Psychotherapist: To provide ongoing psychotherapy, particularly dialectical behavior therapy (DBT) for emotional regulation and interpersonal skills training.
3. Domestic Violence Support Group/Counselor: For clients who have experienced past abusive relationships, support groups or counseling can provide valuable assistance.
4. Social Services: To explore family-related issues, such as the strained relationship with her daughter and the desire to reconnect with her grandchildren, social services can offer guidance and support.

It is essential to approach the client with empathy, compassion, and a focus on safety while helping them explore their thoughts, emotions, and behavior patterns through therapeutic communication and cognitive-behavioral therapy principles. Interdisciplinary collaboration will aid in addressing the client’s complex needs and promoting holistic care.