The Nursing Process in Mental Health Nursing

NURSING PROCESS – PROCESS THAT PROMOTES CONTINUITY OF CLIENT CARE Therapeutic Milieu –Safe, secure environment –Client feels free to express feelings and thoughts without fear of rejection Steps of Process –Assessment –Nursing Diagnosis –Expected Outcome –Nursing Interventions –Evaluation

PSYCHOSOCIAL NURSING ASSESSMENT Subjective Data –Describe stressors –Perception of problem –Insight Objective Data Mental Status –Thought processes –Perceptual disturbances –Judgment –Adaptive or maladaptive defense mechanisms –Relationships –Appearance –Motor activity –Speech pattern –Mood Mental Status (cont.) –Affect –Awareness –Orientation –Memory

NURSING DIAGNOSIS – (APPENDIX C – PAGE 374) Identification of a client problem based on conclusions about the collected data Consists of 3 parts: –Actual or potential problem related to client condition (risk for injury) –Causative or contributing factors (related to marital breakup) –Behavior or symptom that supports the problem (evidenced by suicidal ideation and gestures)

EXPECTED OUTCOME Planning measurable and realistic outcomes: –Anticipate improvement or stabilization of problem identified in nursing diagnosis Short-term goals: – Meet immediate unmet needs of client Long-term goals: –Achieve maximal, realistic level of health as a member of society

NURSING INTERVENTIONS Actions taken to assist client in achieving anticipated outcomes Consider what is realistic and appropriate for that client Collaborative team effort to maintain consistency in approach by all disciplines Nursing Focus: –Observing behaviors and symptoms –Improving communication strategies –Assisting the client in problem-solving –Improved overall functioning

EVALUATION & APPLICATION Evaluate the success of nursing interventions in meeting criteria outlined in expected outcome –Has the goal been achieved? –Has any progress been made? –Is the goal realistic for this client? –What is the client’s expectation for outcome? –Do we need to try another approach? –Have any new problems added to the picture?

REVIEW: MENTAL STATUS FUNCTIONING – CHAPTER 3/5 Level of awareness/orientation Appearance and behavior Speech and communication Mood or affect Thinking Perception Memory Judgment Communication/therapeutic relationship

MENTAL STATUS EXAM Mini-Mental Status Exam (Appendix B )- objective nursing assessment Observation Active listening Medication history Family history Current situation/symptoms

THERAPEUTIC MILIEU Helps clients to replace inappropriate behaviors with more effective personal/psychosocial skills Requires certain limit-setting and control Inpatient or supervised setting Standards set by JCAH Encourages safe, secure, supportive surrounding for client

DSM-IV-TR CLASSIFICATION APPENDIX A (PAGE 359) Diagnostic Standard Manual for the American Psychological Association Guidelines for diagnosing mental illness Characteristics of a condition may exist without meeting criteria for a diagnosis Although it is significant for a diagnosis to be established, how might the positive be undermined by the negative?

TREATMENT MODALITIES Therapeutic Milieu – community Treatment team Role of nurse Therapeutic process – inpatient setting Psychopharmacology – Chapter 19

PSYCHOTHERAPY Reduce symptoms of disorder Improve client’s personal and social well-being Types –Individual –Biomedical – ECT –Group –Biofeedback –Recreation, play, occupational