Post on 16-Jan-2016
The Nursing Process
Psychiatric / Mental Health Nursing
West Coast University
NURS 204
Standards of Care in Mental Health Nursing
Developed by the American Nurses Association (ANA), the American Psychiatric Nurses Association, and the International Society of Psychiatric-Mental Health Nurses
Delineates what professional activities the nurse performs during the steps of the nursing process as they relate to mental health nursing
Characteristics of the Nursing Process
Reliable, long-standing framework Cyclic/ongoing/interactive Multidimensional Adapts to client responses to health and
illness Make sound clinical judgments Plan appropriate care and intervention
Steps of the Nursing Process
1. Assessment
2. Nursing Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Cyclic Nature of the Nursing Process
Nurse as Primary Communicator
Nurse is primary “tool” Identifies client strengths and problems Requires knowledge of:
Psychodynamics Psychopathology Communication skills for rapport and support Client uniqueness
Collecting the Data The interview:
Gather information. Establish rapport. Structure the interview. Keep the pace comfortable.
Interviewing Basics Do not rush the client in gathering the data. Respect the client’s need for minimal
distractions.
Standard I. Assessment
Mental status examination (MSE) and psychosocial assessment (Objective Data)
Subjective: what the client states Objective: what is observed Findings related to:
Physical, sexual, psychiatric/mental status Psychosocial, developmental, cultural/spiritual factors History, Family History and physical examination
(Previous diagnosis, interventions and treatments)
MSE Categories General behavior, appearance, attitude Characteristics of speech Emotional state Content of thought Orientation Memory General intellectual level Abstract thinking Insight
General Behavior, Appearance, Attitude Physical characteristics Apparent age Manner of dress Use of cosmetics Personal hygiene Responses to the examiner
General Behavior, Appearance, Attitude - continued
Also included: Posture, Gait Gestures Facial expression, Mannerisms Client’s general activity level Hygiene and dress Weight Skin color
Characteristics of Speech Loudness Flow Speed Quantity Level of coherence Logic
Emotional State Evaluate pervasive or dominant mood
or affective reaction. Pay attention to:
Constancy. Change.
Use descriptive terms.
Orientation Time Place Person Self or purpose
Memory Attention span Ability to retain or recall past
experiences Includes both recent and remote past
General Intellectual Level Nonstandardized evaluation of
intelligence General grasp of information Ability to calculate Reasoning Judgment Abstract Thinking
Insight Assessment Recognizing the significance of the
present situation Feeling the need for treatment Explaining the symptoms Making suggestions for treatment
Biologic History Facts about known physical diseases and
dysfunction Information about specific physical
complaints General health history
Occupational assessment Potential exposure to toxic substances Medications the client is taking
Biologic and Neurologic Assessment Objectives
Detection of underlying/unsuspected organic disease
Understanding of disease as a factor in the overall psychiatric disability
Appreciation of somatic symptoms that reflect psychological rather than physiologic problems
Psychological Testing: Personality Projective personality tests
Rorschach Test, Thematic Apperception Test, Sentence Completion Test
Objective personality tests Minnesota Multiphasic Personality
Inventory–2, State–Trait Anxiety Inventory, Millon Clinical Multiaxial Inventory–II, and Beck Depression Inventory
Psychological Testing: Cognitive Function Stanford-Binet Intelligence Test Wechsler Adult Intelligence Scale–III Wechsler Intelligence Scale for
Children–II Raven’s Progressive Matrices Test
Special Issues Related to Assessment
Managed care HIPAA privacy protection Expertise Critical thinking Settings Sources Assessment tools (e.g., GAF scale)
Standard II. Nursing Diagnosis
Requires diagnostic reasoning Analysis Synthesis
Explains the health problem States the problem etiology Provides defining characteristics
NANDA Nursing Diagnoses
Research-based diagnoses Unique vocabulary Serves as a common language for nurses to
ensure accountability for care
Actual and Potential Nursing Diagnoses
An actual problem nursing diagnosis consists of: Problem or need Etiology Defining characteristics
A potential problem (risk) nursing diagnosis consists of: Risk diagnosis Risk factors as supporting factors; no etiology
DSM-IV-TR Multiaxial System It is evaluated on five axes, each dealing
with a different class of information about the client.
Multiaxial assessment is congruent with holistic views of people.
It recognizes the role of environmental stress in influencing behavior.
Data addresses adaptive strengths as well as symptoms or problems.
DSM-IV-TR Multiaxial System Axis I: Clinical disorders Axis II: Personality disorders/mental
retardation Axis III: Present medical conditions Axis IV: Psychosocial/environmental
factors affecting client Axis V: Global Assessment of
Functioning
Axis I: Clinical Disorders Includes psychological factors that would
affect a physical condition: Medication-induced movement disorders,
relational problems, and others Includes conditions which may be a focus but
may not constitute a clinical syndrome: Marital problems Occupational problems Parent–child problems
Axis II: Personality Disorders Contains:
Personality disorders diagnosed in adults Developmental disorders diagnosed in
children and adolescents It is also used to report maladaptive
personality traits.
Axis III: General Medical Conditions Physical disorders and medical
conditions that must be taken into account in planning treatment
They are relevant to understanding the etiology or worsening of the mental disorder.
Axis IV: Psychosocial/Environmental Factors Affecting Client
Problems with primary support group Problems related to the social environment Educational problems Occupational problems Housing problems Economic problems Problems with access to health care services Problems related to interaction with the legal
system/crime
Axis V: Global Assessment of Functioning – continued Information is used to plan treatment.
Develop nursing diagnosis. Predict outcomes
Set goals for client behavior. Measure impact of treatment
Evaluate client response to goal/treatment.
Standard III. Outcome Identification
Outcomes are: Specific, measurable indicators Derived from nursing diagnoses Projections of expected influence of nursing
interventions Opposite of defining characteristics Often use client’s own words
Outcomes
Used to evaluate client’s progress May have target dates Ensure quality care Justify reimbursement
Nursing Outcomes Classification (NOC) identifies outcomes most influenced by nursing actions.
Nursing Outcomes Classification
First standardized language describing client outcomes that are most responsive to nursing care or most influenced by the actions and interventions of nurses
Rated on a Likert scale (1 to 5)
Standard IV. Planning
Collaboration with clients, significant others, and treatment team
Identification of priorities of care Critical decisions regarding interventions to
use Coordination and delegation of
responsibilities of treatment team based on expertise as related to client’s needs
Types of Plans
Interdisciplinary treatment team Standardized care plans Clinical pathways, variances
Nursing Orders
Select to: Achieve client outcomes Prevent/reduce problems Prescribe a course of action Focus on modifying etiology
Rationales are rarely written but are often discussed in multidisciplinary team meetings.
Standard V. Implementation
Perform nursing interventions Captures certain nursing activities and
analysis of their impact on client outcomes. Promote, maintain, and restore mental and
physical health NIC interventions are linked to NOC
outcomes.
Standard VI. Evaluation
1. Compare client current state/condition with outcome criteria.
2. Consider all possible reasons why outcomes are not achieved, if this is the case.
3. Make specific recommendations based on conclusions drawn.
4. Continuous process of appraising the effect of nursing and the treatment regimen
Concept Mapping
Documentation
“7th Standard of Care” Problem-oriented documentation:
Subjective, Objective, Assessment, Planning (SOAP)
Data, Analysis, Response (DAR) Behavior, Intervention, Response (BIR)
Documentation: Nursing Responsibility Maintain confidentiality. Documentation: legal and clinically
relevant expression of care given to the client and the client’s response to that care
Respect for the client’s self-disclosures is a measure of the nurse’s trustworthiness.