The Nursing Process

1. The Nursing Process Psychiatric / Mental Health Nursing West Coast University NURS 204

2. 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

3. 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

4. Steps of the Nursing Process • Assessment • Nursing Diagnosis • Outcome Identification • Planning • Implementation • Evaluation

5. Cyclic Nature of the Nursing Process

6. 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

7. 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.

8. 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)

9. MSE Categories • General behavior, appearance, attitude • Characteristics of speech • Emotional state • Content of thought • Orientation • Memory • General intellectual level • Abstract thinking • Insight

10. General Behavior, Appearance, Attitude • Physical characteristics • Apparent age • Manner of dress • Use of cosmetics • Personal hygiene • Responses to the examiner

11. General Behavior, Appearance, Attitude - continued • Also included: • Posture, Gait • Gestures • Facial expression, Mannerisms • Client’s general activity level • Hygiene and dress • Weight • Skin color

12. Characteristics of Speech • Loudness • Flow • Speed • Quantity • Level of coherence • Logic

13. Emotional State • Evaluate pervasive or dominant mood or affective reaction. • Pay attention to: • Constancy. • Change. • Use descriptive terms.

14. Orientation • Time • Place • Person • Self or purpose

15. Memory • Attention span • Ability to retain or recall past experiences • Includes both recent and remote past

16. General Intellectual Level • Nonstandardized evaluation of intelligence • General grasp of information • Ability to calculate • Reasoning • Judgment • Abstract Thinking

17. Insight Assessment • Recognizing the significance of the present situation • Feeling the need for treatment • Explaining the symptoms • Making suggestions for treatment

18. 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

19. 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

20. 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

21. Psychological Testing: Cognitive Function • Stanford-Binet Intelligence Test • Wechsler Adult Intelligence Scale–III • Wechsler Intelligence Scale for Children–II • Raven’s Progressive Matrices Test

22. Special Issues Related to Assessment • Managed care • HIPAA privacy protection • Expertise • Critical thinking • Settings • Sources • Assessment tools (e.g., GAF scale)

23. Standard II. Nursing Diagnosis • Requires diagnostic reasoning • Analysis • Synthesis • Explains the health problem • States the problem etiology • Provides defining characteristics

24. NANDA Nursing Diagnoses • Research-based diagnoses • Unique vocabulary • Serves as a common language for nurses to ensure accountability for care

25. 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

27. 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.

28. 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

29. 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

30. 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.

31. 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.

32. 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

33. 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.

36. 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

37. 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.

38. 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)

39. 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

40. Types of Plans • Interdisciplinary treatment team • Standardized care plans • Clinical pathways, variances

41. 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.

42. 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.

43. Standard VI. Evaluation • Compare client current state/condition with outcome criteria. • Consider all possible reasons why outcomes are not achieved, if this is the case. • Make specific recommendations based on conclusions drawn. • Continuous process of appraising the effect of nursing and the treatment regimen

44. Concept Mapping

45. Documentation • “7th Standard of Care” • Problem-oriented documentation: • Subjective, Objective, Assessment, Planning (SOAP) • Data, Analysis, Response (DAR) • Behavior, Intervention, Response (BIR)

46. 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.