The nursing process is the six- step problem-solving approach intended to facilitate and identify appropriate, safe, culturally competent, developmetally relevant, and quality care for individuals, families, groups, or communities.
The nursing process is also foundation of the Standards of practice as presented in Psychiatric-Mental Health Nursing: Scope and Standards of practice (ANA et al., 2007).
The nursing process in psychiatric mental health nursing are includes:
Ø Construct database
– Mental status examination
– Psychosocial assessment
– Physical examination
– History taking
– Standardized rating scale
Ø Verify the data
Ø Identify problem and etiology
Ø Construct nursing diagnosis and problem list
Ø Prioritize nursing diagnosis
3. Outcomes identification
Ø Identify attainable and culturally expected outcomes
Ø Document expected outcomes as measurable goals
Ø Include time estimate for expected outcomes
Ø Identify safe, pertinent, evidence-based actions
Ø Strive to use interventions that are culturally relevant and compatible with health beliefs and practices
Ø Documents plans using recognized terminology
Ø Basic Level and Advanced Practice Interventions
– Coordinations of care
– Helath teaching and health promotion
– Milieu therapy
– Pharmacological, biological, and integratives therapies
Ø Advanced Practice Interventions
– Prescriptive authority and treatment
Ø Documents results of evaluation
Ø If outcomes have not been achieved at desired level
– Additional data gathering
– Revision of plan
Nurses who works in the physchiatric mental health field need to assess or have access to past and present medical history, a recent physical examination, and any physical complaints, as well as document any observable physical conditios of behaviours (e.g., unstead gait, abnormal brething patterns, wincing if in pain, doubling over to relieve discomfort).
The process begins with the initial patient encounter and continues throghout the care of the patient. To develop a basis for the plan of care and in preparation for discharge, every patient should have a thorough, formal nursing assessment on entering treatment. Subsequent, to the formal assessment, data is collected continually and sistematically as the patients condition changes and- hopefully-improves. In emergency situations, immediate interventions is often based on a minimal amount of data. . In all situations, however legal consent must be given by the patient, who must also receive a copy of The Health Insurance Portability andAccountability Act (HIPAA) that have the purpose is to private the individuals health information. The nurses primary source for data collection is the patient; however, there may be times when it necessary to suplement or rely completelyt on another for the assessment information. These secondary sources can be invaluable when caring for a patient experiencing psychosis, muteness, agitation, or catatonia. Such secondary sources include members of the family, friends, neighbours, police, health care workers, and medical records. The best atmosphere in which to conduct an assessment is one of minimal anxiety. Therfore, if and individual becomes upset, defensive, or embarassed regarding any topic the topic should be abandoned. The nurse can acknowledge that subject makes the patient uncomportable and suggest within the medie cal record thatt the topic be discussed when the patient feel more comfortable. It is important that the nurse not probe, pry, or push for information that is difficult for the patient to discuss. When we assess the patient, we must consider:
a. Age consideration
There must be a different assess between assess the children and others. When assessing the children, it is important to gather data from a variety of sources. Developmental level shoild be considered in the evaluation of children. One of the hallmarks of psychiatric disorders in children is the tendency to regress (i.e., return to aprevious level of development). Assessment of children should be accomplished by a combination of interview and observation. Watching children at play provides important clues to their functioning. From a physchodinamic view, play a safe area for the child to act out thoughts and emotions and can serve as a safe way in which children can release pent up emotions. Asking the child to tell the story, tell a story of their family using a family of dolls.
Adolescents are especially concerned with cofidentiality and may fear that anything they say to the nurse will be repeat to their arents. Lack of confidentially can become a barrier of care with this population. Addoescent need to know that their records are private, they should receive an explanation how information will be shared among the treatment team.
Assessment of older adults, our five sense is begin to diminish ( taste, touch, sight, hearing, and smell) and also brain function. And its wise to identify any physical defecits at the onset of the assessment and make acomodations for them.
The HEADSSS Psychosocial interview technique is:
H. Home environment, realtion with parents and siblings
E. Education and employment
A. Activities, sports participations, after school activities, peer relations.
D. Drug, alcohol, and tobacco use
S. Sexuality, practice safe sex, or uses contraception
S. Suicide risk or symptms of depression or other mental disorders.
S. Savagery, violence or abuse in home environment or in neighbour.
b. Language bariers
Its becoming more and more apparent that psychiatric mental health nurses can best serve their patients if they have a thorough understanding of the complex cultural and social factors that influence health and illness.
The purpose of the psychiatric mental health nursing assessment is to
Ø Established raport
Ø Obtain anunderstanding of the current problem or chief complaint.
Ø Review physical status and obtain baseline vital signs
Ø Perform a mental status examination
Ø Identify mutual goals for treatment
Ø Formulate a plan of care
A. Review of systems.
The mind-body connection is significant in the understanding and treaatment of physichiatric disorders. Likewise, most nursing assessment include a baseline swet of vital statistics, a historical and current review of body systems, and a documents of allergics responses. Poole andf Higgo (2006) point out that several medical conditions and physical illness includes:
– Neurological disorders
– Endocrine disorders
– Gastriintestinal disorders
– Cardiovascular disorders
– Respiratory disoreders
– Nutritional disorders
– Collagen vascular diseases
– + drug effects
– Lead, mrcury poisoning
– Medical conditions
– Drug effects
B. Laboratory data
Hypothyroidism may have the clinical appearence of depression, and hyperthyroidism may appear to be a manic phase of bipolar disorder. Blood test can ussualy differentiate between depression and thyroid problems.
C. Mental Status Examination
e. Disorders of the form of the thought
f. Perceptual disturbances
h. Ideas of harming self or others
D. Psychosocial Assessment
Provides additional information from which to develop a plan of care. It includes the following information about the patient:
a. Central or chief complaint
b. History of violent, suicidal, or self mutilating be treatment, including medictions, and behaviours
c. Alcohol ar substance abuse
d. Family psychiatric history
e. Personal phsychiatric treatment
f. Stressors andf coping methods
g. Quality of activities
h. Personal background
i. Social background, including support system
j. Weakness, strength, and goals of treatment
k. Racial, ethnic, and cultural beliefs and practice
l. Spiritual beliefs or religius practice
E. Cultural and Social Assessment
There is a need for nursing assesments, diagnosis and subsequent care to be planned arround the unique cultural health care beliefs, values, and practices of each individual patient.
After cultural and social assessment, it is useful to summarize pertinent data with the patient. This summary provides patients with reassurance that they have been heard ang gives them the opportunity to clarify and missinformation.
F. Validating the Assessment
To gain an even clearer undersanding of yourpatient, it is helpful to look to outside sources. Emergency departement records can be a valuable resource in understanding an individuals presenting behaviour and problems. Police reports, old medical records. If tehe patients was admitted to a psychiatric unit in the past, information about the patients previous level function and behaviour gives you a baseline for making clinical judgements. Ocassionally,, consent forms may have to be signed by the patient or an appropriate relative to obtain access to records.
G. Using Rating Scale
A Number of standardized rating scales are useful for psychitric eveluation and monitoring. Rating scales are often administered by a clinician.
A nuirsing dignosis is a clinical judgement about a patients response, needs, actual and potential psychiatric disorders, mental helath problems, and potential comorbid physical illness. NANDA approved nursing diagnosis.
A nursing diagnosis has three structural components
1. Problem (unmet need)
It describes the state of the patients present. Problems that are within the nurses domain to treat are termed nursing diagnosis. The nursing diagnostic title states what should change. For example Hopelessness.
2. Etiology (probable cause)
It is linked to the diagnostic title with the words related to. Stating th the etiology or probable cause tells what needs to be addressed to effect the change and identifies causes the nurse can threat through nursing intervention. For example hopelessness related to multiple losses.
3. Supporting data ( signs and symptoms)
It is state what the condition is like a present. It may be linked to the diagnosis and etiology with the words as evidcence by. Supporting data (defining characteristics) that validate the diagnosis include:
– The patients statement, for example “ it is no Use; nothing wil change”
– Lack of involvement with family and friends
– Lack of motivation to care for sf the ope oelf or environmnent
The complete nursing diagnosis might be “ Hopelessness related to multiple losse, as evidence by lack of motivation to care for self”.
3. Outcomes Identification
Outcome criteria are the hope-for outcomes that reflect the maximal level of patients health that can relistically be achieved through nursing interventions. Whereas nursing diagnoses identify nursing problems, outcomes, reflect the desired change. The expected outcomes orovide direction for continuity of care (ANA et al., 2007). Outcomes should take in to account the patients culture, values, and ethical beliefs.
Moorhead and collegues (2008) have complied a standardized list of nursing outcomes in Nursing Outcomes Classification ( NOC ) that includes a total of 385 standardized outcomes that provide a mechanism for communicating the effect of nursing interventions on the well being of patients, families, and communities. Each outcomes has an associated group indicators used to determine patients status in relaition to the outcome.
The example of NOC indicators for suicide self-restraint:
1. Never demonstrated…….1
2. Rarely demonmstrated….2
3. Sometimes demonstrated…3
4. Often demonstrated…………..4
5. Consistenly demonstrated…….5
Standardizing pathways or plans of care allows for inclusion of evidence-based practice and newly tested intervention as they become available. Whatever, the care planning procedures in a spesifc institution, the nurse considers the following spesific principles when planning care
– Safe- interventions must be safe for the patient, as well as for other patient, staff, and family
– Compatible and appropriate-Interventions must be compatible with other therapies and with the patients personal goals and cultural values, as well as with institutional rules.
– Relistic and individualized-Interventions should be (1) within the patients capabilities, given the patients age, physical strength, condition, and willingness to change;(2) based on the number of the staff available;(3) reflective of the actual available community resources; (4) within the students or nurses capabilities
– Evidence based-Interventions should be based on scientifif and principles when available.
Evidence Based Practice for nurses is a combination of clinical skill and the use of the clinically relevant research in the delivery of effective patients-centered care.
Psychiatric-Mental Health Nursing: Scope and Standards of practice (ANA et al., 2007) identifies seven area for intervention. Recent graduates and practioners new to the psychiatric setting will participate in many of these activities with the guidance and support of more experienced health care professionals. The following four interventions are performed by both the psychiatric mental health registered nurse (RN-PMH) and the psychiatric mental health advanced practice registered nurse (APRN-PMH).
The basic implementation skills are accomplished through the nurse-patient relationship and terapeutic interventions. The nurse implements the plan using evidence-based practice whenever possible, uses community resources, and collaborates with nursing collegues.
Ø Basic Level Interventions
– Standars 5a : Coordination of Care
The psychiatric mental health nurse coordinates the implementation of the plan and provides documentation.
– Standard 5b : Health Teaching and Health promotion
Psychiatric mentl health nurses use a variety of health teaching methods adaptoive to the patients needs (e.g., age, culture, ability to learn, readiness, etc), integrating current knowledge and research and seeking opportunities for feedback and effectiveness of care. Health teaching includes identifying health education needs of the patients and teaching basic principles of physical and mental health, such as giving information about coping, interpersonal relationships, social skills, mental disorders, the treatments for such illness and their effects of daily living, relapse prevention, problem-solving skills, stress management, crisis intervention, and self care activities. The last of these, self care activities, assist the patient in assuming personal responsibility for activities of daily living (ADL) and focuses on improving the patients mental and physical well-being.
– Standard 5c : Milieu Therapy
Milieu therapy is an extremely important cosideration in nhelping patients feel comfortable and safe. Milieu management includes orienting patients to their rights and responsibilities, selecting spesific activities that meet patientss physical and mental health needs, and ensuring that patients are maintained in the least restrictive environment safety permits. It also includes informing patients about the need for limit and the condition necessary to remove them in a cultural competent manner.
– Standard 5d : Pharmacological Biological and Integrative Therapies
Nurses need to know the intended action, therapeutic dosage, adverse reaction, and safe blood levels of medications being administered and must monitor them when appropriate. The nurse s expected to discuss and provide medication teaching tools to the patient and family regarding drug action, adverse side effects, dietary
Ø Advanced Practice Interventions
– Standard 5E: Prescriptive Authority and treatment
The APRN-PMH is educated and clinically prepared to prescribe psychopharmacological agents for patients with mental health or psychiatric disorders in accordance with state and federal laws and regulations. Prescription take into account individuals variables such as culture, ethnicity, gender, religious beliefs, age, and physical health.
– Standard 5F: Psychotherapy
The ARPN-PMH is educationallyand clinically prepared to conduct individual, couples, group, and family psychotherapy, using evidence-based psychoterapeutic frameworks and nurse-patient therapeutic relationships (ANA, 2007)
– Standard 5G: Consultation
The APRN-PMH works with other clinicians to provide consultation, influence the identified plan, enhance the ability of other clinicians, provide services for patients, and effect change.
Unfortunately, evaluation of Patient outcomes is often the most neglected part of the nursing process. Evaluation of the individuals response to treatment should be systematic, ongoing, and criteria based. Supporting data are included to clarify the evaluation. Ongoing assessment of data allows for revisionof nursing diagnoses, changes to more realistic outcomes, or identification of more appropriate interventions when outcomes are not met.
Documentation could be considered the seventh step in the nursing process. Keep in mind that medical records are legal documents and may be used in a court of law.
Information also must be in format that is retrievable for quality assurance monitoring, utilization management, peer review and research. Documentation_using the nursing process as a guide_is reflected in two of the formats commonly use in health care settings. Electronic medical recirds are increasingly used in both patient and out patient settings. Whatever format is used, documentation must be focused, organized, pertinent, and conforrm to certain legal and other generally accepted principles.
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