1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 06The Nursing Process in Mental Health Nursing

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process Scientific and systematic method, accepted as standard Five steps –Assessment –Diagnosis –Planning –Implementation –Evaluation

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychosocial Assessment Collection of data, begins when client is admitted or contact is made Client history Mental or emotional status Subjective data Objective data

4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Subjective Data Provided by the client Perception of problem Allows the nurse to establish baseline The nurse asks direct, focused, leading questions

5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Objective Data Observed and gathered by the nurse or others who are familiar with the client Physical, social, emotional, and cognitive assessments Standardized assessments Medical history, past illness or surgeries, medication history, allergies, vital signs, height and weight, diet, head-to-toe evaluation

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Diagnosis Identification of the client problem based on conclusions about collected data Prioritized Consists of three parts –Actual or potential problem related to client condition –Causative or contributing factors (related to) –Behavior or symptom that supports the problem (evidenced by)

7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Expected Outcomes Planning measurable and realistic outcomes Short-term goals –Meet immediate unmet needs of the client Long-term goals –Achieve maximal, realistic level of health as a member of society

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Interventions Actions taken to assist the client in achieving anticipated outcome Consider what is appropriate and realistic for the client Team effort to maintain consistency

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Interventions (Cont.) Nursing focus –Observing behaviors and symptoms –Improving communication strategies –Assisting the client in problem solving and improved overall functioning

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation Evaluate success of nursing interventions in meeting the criteria outlined in the expected outcomes One of the following –Goal achieved –Some progress has been made –No steps forward have been observed or documented

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sample ApplicationPg. 98 Client situation Assessment –Objective data –Subjective data Diagnoses Expected outcomes Interventions Evaluation

12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Application 6.1 Page 96

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. When gathering subjective data, the nurse typically asks leading questions to collect information about the client’s perception of the problem.

14. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: Subjective data include the client’s history and perception of the current problem. The nurse usually gathers this type of data by asking the client direct, focused, and leading questions.

15. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following terms means the actions taken to assist the client in achieving anticipated outcomes? A. Assessment B. Nursing diagnosis C. Nursing interventions D. Evaluation

16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Nursing interventions Rationale: Nursing interventions are the actions taken to help the client achieve anticipated outcomes. Interventions are a team effort. The nursing focus involves observing symptoms and behaviors, improving communication, and assisting the client in problem solving.

17. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. Formulation of a nursing diagnosis consists of two parts: the contributing factors and the symptoms.

18. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: A nursing diagnosis includes three parts: the problem, the causative or contributing factors, and a behavior or symptom that supports the problem. Example: Problem: risk for injury Related to marital breakup Evidenced by suicidal ideation and gestures

19. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins