The Nursing Process

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The Nursing Process

• Psychiatric / Mental Health Nursing
• West Coast University
• NURS 204

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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

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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

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Steps of the Nursing Process

1. Assessment
2. Nursing Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation

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Cyclic Nature of the Nursing Process
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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

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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.

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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)

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MSE Categories

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

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General Behavior, Appearance, Attitude

• Physical characteristics
• Apparent age
• Manner of dress
• Use of cosmetics
• Personal hygiene
• Responses to the examiner

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General Behavior, Appearance, Attitude -
continued

• Also included
• Posture, Gait
• Gestures
• Facial expression, Mannerisms
• Clients general activity level
• Hygiene and dress
• Weight
• Skin color

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Characteristics of Speech

• Loudness
• Flow
• Speed
• Quantity
• Level of coherence
• Logic

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Emotional State

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

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Orientation

• Time
• Place
• Person
• Self or purpose

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Memory

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

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General Intellectual Level

• Nonstandardized evaluation of intelligence
• General grasp of information
• Ability to calculate
• Reasoning
• Judgment
• Abstract Thinking

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Insight Assessment

• Recognizing the significance of the present
  situation
• Feeling the need for treatment
• Explaining the symptoms
• Making suggestions for treatment

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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

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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

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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

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Psychological Testing Cognitive Function

• Stanford-Binet Intelligence Test
• Wechsler Adult Intelligence ScaleIII
• Wechsler Intelligence Scale for ChildrenII
• Ravens Progressive Matrices Test

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Special Issues Related to Assessment

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

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Standard II. Nursing Diagnosis

• Requires diagnostic reasoning
• Analysis
• Synthesis
• Explains the health problem
• States the problem etiology
• Provides defining characteristics

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NANDA Nursing Diagnoses

• Research-based diagnoses
• Unique vocabulary
• Serves as a common language for nurses to ensure
  accountability for care

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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

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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.

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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

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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

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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.

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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.

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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

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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.

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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

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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.

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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)

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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

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Types of Plans

• Interdisciplinary treatment team
• Standardized care plans
• Clinical pathways, variances

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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.

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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.

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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

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Concept Mapping
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Documentation

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

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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.