- Instructor/ faculty on Talkative Patient
This is one of the most troublesome patients for me. It can be very difficult to keep the patient focused on the chief complaint. Listening to the patient is important and the patient needs to feel that the provider has heard what the patient has to say. In a busy office, however, it is equally important for the provider to address the problems and move on to the next patient. I make it a habit to always sit down as I am interviewing the patient and I hope that gives the impression that I am not hurrying through the visit.Jessica
1b. Peer on talkative patient Talkative client
S.M. is a 62-year-old female being seen for right knee pain at her primary care office. The NP is discussing with the patient that the next step for management would be surgery. The patient becomes visibly upset and starts to talk about her friend who had her knee replaced and had some complications. The patient then starts to state her fears and then go on to tell another story about her neighbor’s knee replacement experience. The NP is unable to educate the patient or communicate anything at this time. This can impact the client-provider relationship poorly if the provider cannot direct the patient back to her health and what would be the best options for her to have the highest quality of life. It is important that the NP utilizes basic interviewing techniques to make sure the patient feels heard and understood. According to Ward, good communication is vital to the patient trusting their provider (2018). Good communication is the foundation to building a solid client-provider relationship, which ultimately leads to patient satisfaction and increased adherence to healthcare recommendations. In this type of situation, the NP should allow the patient to speak freely for about five to ten minutes and during this time the NP should listen carefully (Bickley et al., 2021). Once this time has surpassed and the NP feels it is appropriate, the use of summarization of the patient’s concerns could be beneficial. Summarization helps to let the patient know that the provider was listening carefully and to make the plan of care collaborative between the patient and provider (Bickley et al., 2021). It could also be beneficial to use validation, allowing the patient to know her feelings are valid and understood (Bickley et al., 2021). If the NP is competent in good communication and interviewing techniques, then the rapport between the patient and provider should be good, and from there the patient will be more at ease. Once the patient feels at ease, the provider can provide more information to the patient to better understand her options for managing her health and live at the highest quality of life.
Sample documentation for the encounter:
Subjective
HPI: S.M. is a 62-year-old female being seen for chronic right knee pain with a history of arthritis. She has had increasing pain with decreased mobility after exhausting all conservative treatment options.
Pertinent past medical history:
Arthritis.
Pertinent review of systems:
Patient reports increased pain and decreased mobility of her right knee.
Current medications:
Meloxicam 15mg once daily for joint pain
Tylenol 1000mg TID PRN for joint pain
NKDA
Objective
Decreased ROM to right knee.
Assessment
62-year old female with right knee pain who has exhausted all conservative pain management options.
Plan
Patient to make appointment with orthopedic surgeon to discuss scheduling procedure.
Patient educated on previous treatments and plan for surgery.
Surgery explained and patient verbalizes understanding.
Continue current medication regimen as the patient states it helps temporarily relieve symptoms.
Patient to follow-up one week post-operatively.
Reference
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Ward, P. (2018). Trust and communication in a doctor-patient relationship: a literature review. Arch Med, 3(3), 36
- Instructor/ faculty on adolescent reluctant to answer
I have experienced all types of adolescent interactions over the years. There are the quiet ones who are reluctant to share any information. Sometimes this overlaps the “grumpy” type. They are reticent to answer any questions and would obviously rather be somewhere else. One must be careful, however, not to just pass this off as a “typical teenager”. This behavior may also be indicative of an undiagnosed depressive disorder (Redlich et al, 2018).
Redlich, R., Opel, N., Bürger, C. et al. The Limbic System in Youth Depression: Brain Structural and Functional Alterations in Adolescent In-patients with Severe Depression. Neuropsychopharmacol. 43, 546–554 (2018). https://doi.org/10.1038/npp.2017.246
2b. Peer on adolescence reluctant to answer
Adolescent client who is reluctant to answer questions.
- Create a scenario depicting an interaction between an NP and a client. Describe the setting and type of encounter.
Samamtha a 16-year-old female comes into the office with her mother for a behavioral assessment. The mother has concerns about recent abnormal behaviors since her parents split up 6 months ago. Father has been in and out mostly absent from all the patient’s life activities since the split. She has been getting in trouble at school, her grades are slipping, giving her mother attitude, and sneaking out at night. Upon arrival at the office, the nurse practitioner asks the patient “How can I help you today?” The patient just looks at the nurse, grins, and goes back to her phone to watch Tick Tock. The provider asks the patient if the mother could tell the patient what has been going on, and she states, “nothing is going on, but whatever.” The mother begins to tell the provider that the patient has been skipping school with her friends, her grades have gone from A’s & B’s to failing, and she is also sneaking out at night to her boyfriend’s house. She has been defiant at home, not talking to her mother and keeping in her room most of the time and she has been drinking and smoking marijuana. This all seems to have begun when her father left 6 months ago. He calls every so often and he gets her every other weekend but other than that there isn’t much contact between the two of them. They fight because of his new girlfriend and her children because he seems to spend more time with them.
While attempting to speak to the patient, she is reluctant to speak to the provider. She states she is fine her mother is just annoying and she doesn’t need any help. She also states she doesn’t care about her father and his new girlfriend. She just wants to be left alone and for her mom to stop telling her what to do, she’s grown. All while speaking to the provider she is playing on her phone, not looking at the provider avoiding eye contact. It is clear the patient has some animosity towards the fact her parents are slipping, and her dad is living separately with another woman and her children. SAMANTHA
Describe the client’s challenging behaviors related to the topic assigned.
The client’s challenging behavior consists of challenges communicating feelings and actions. The patient isn’t expressing any thoughts or feelings just playing on her phone, ignoring the provider, and saying she is fine. She is blaming her mother for being annoying and saying she is grown up.
- Examine the potential impact of the client’s behavior on the client-provider relationship.
When assessing the adolescent, it is important for the provider to have time with the patient and the parent together, along with time alone with the adolescent patient (The royal children’s hospital Melbourne, n.d.). If the patient will not speak to you, it would be difficult to assess the patient causing a challenging client-patient relationship. If there is a challenge in the client-patient relationship, it will almost be impossible to help the patient.
- Analyze techniques to enhance communication with the client and address the client’s behavior.
One technique that can be used is compassion-focused therapy. Compassion is a sensitivity to someone suffering or distress with a sense to try to alleviate and prevent it (Carona et al., 2017). This type of therapy can provide an evolutionary-based perspective on interpersonal issues. The goal is to help the maturing brain that helps target therapeutic parts that cause shame, and self-criticism to alleviate psychological distress and enhance cognitive-behavioral interventions (Carona et al., 2017).
Another way to enhance communication is to offer a safe and comfortable setting for the patient to speak with the provider. Maybe the patient doesn’t want to talk in front of the parent. Try to understand the patient’s behavior and reluctance to speak. Never criticize them or judge them. Find perspectives they have, yet to have and have the opportunity to appreciate different ways to explain things to them (Webmaster, 2022).
- Create sample documentation for the encounter.
The Situation-Background-Assessment-Recommendation (SBAR) tool will be used to document.
S- Situation-
Ashley a 16-year-old female with no known past medical history comes to the clinic with her mother for concerns about abnormal behavior. The patient is reluctant to speak to the provider and stares at the phone, so the historian is the mother at the bedside. The mother states patients had increasing behaviors in the past 6 months that consist of a decrease in grades, skipping school, alcohol, and drug use, and sneaking out of the house.
B- Background-
No past medical history or psychiatric history
no known allergies
the patient’s a junior in high school, plays volleyball and softball.
parents separated 6 months ago.
A-Assessment-
Unable to do a physical assessment, the patient is uncooperative.
A urine drug screen was ordered, but the patient refused.
The patient was slightly more adaptable to speak to the provider once her mother left, showing signs of depression and anxiety surrounding her parent’s divorce and the new girlfriend.
The patient did admit to trying marijuana and alcohol, states do not regularly participate in these activities though.
R- Recommendation
Feel as if depression and anxiety are situational recommend family and individual therapy.
Follow up next week to access the situation again. Weekly visit until able to get into family consular then follow up as needed.
If therapy is unsuccessful follow up and assess the patient for an SSRI for depression and anxiety.
References
Carona, C., Rijo, D., Salvador, C., Castilho, P., & Gilbert, P. (2017). Compassion-focused therapy with children and adolescents. BJPsych Advances, 23(4), 240–252. https://doi.org/10.1192/apt.bp.115.015420
The Royal Children’s Hospital Melbourne (n.d). The royal children’s hospital melbourne. Retrieved from: https://www.rch.org.au/clinicalguide/guideline_index/Engaging_ with_and_assessing_the_adolescent_patient/
Webmaster, C. (2022, July 18). Engaging avoidant teens. Counseling today. Retrieved from https://ct.counseling.org/2020/05/engaging-avoidant-teens/
