The Nursing Process in Mental Health Nursing NURSING

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 – – – Relationships Perceptual disturbances Judgment Adaptive or maladaptive defense mechanisms 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