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The Nursing Process

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The Nursing Process Psychiatric / Mental Health Nursing West Coast University NURS 204 Standard III. Outcome Identification Outcomes are: Specific, measurable ... – PowerPoint PPT presentation

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Title: 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
  1. Assessment
  2. Nursing Diagnosis
  3. Outcome Identification
  4. Planning
  5. Implementation
  6. 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 clients 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
  • Clients 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 Inventory2,
    StateTrait Anxiety Inventory, Millon Clinical
    Multiaxial InventoryII, and Beck Depression
    Inventory

21
Psychological Testing Cognitive Function
  • Stanford-Binet Intelligence Test
  • Wechsler Adult Intelligence ScaleIII
  • Wechsler Intelligence Scale for ChildrenII
  • Ravens 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

26
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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
  • Parentchild 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.

34
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35
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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 clients own words

37
Outcomes
  • Used to evaluate clients 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 clients 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
    clients response to that care
  • Respect for the clients self-disclosures is a
    measure of the nurses trustworthiness.
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