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.