Chapter 7 The Nursing Process in PsychiatricMental Health Nursing Nursing Process Six-step, problem-solving care approach Facilitates care that is: Ø Appropriate Ø Safe Ø Culturally competent Ø Developmentally relevant Ø High-quality Foundation for the Standards of Practice Standards of Practice (1 of 9) Provide: Ø Criteria for certification Ø Legal definition of nursing Ø National Council of State Boards of Nursing Licensure Examination (NCLEX-RN®) Ø The Six Standards of Practice • Defining the critical thinking model known as the nursing process Standards of Practice (2 of 9) STANDARD 1: Assessment Ø “The psychiatric mental health registered nurse collects and synthesizes comprehensive health data that are pertinent to the health care consumer’s health and/or situation.” Ø Use holistic, evidence-based assessment technique Ø Primary source = patient; secondary sources (others) Ø Health Insurance Portability and Accountability Act (HIPAA) Ø Document relevant data in retrievable format Assessment considerations Ø Age Ø Language barriers Psychiatric Nursing Assessment Goals (1 of 2) Establish rapport. Obtain an understanding of the current problem or chief complaint. Review physical status and obtain baseline vital signs. Assess for risk factors affecting the safety of the patient or others. (Suicide/homicide) Psychiatric Nursing Assessment Goals (2 of 2) Perform a mental status examination (MSE). Assess psychosocial status. Identify mutual goals for treatment. Formulate a plan of care that prioritizes the patient’s immediate condition and needs. Document data in a retrievable format Gathering Data Review of systems Laboratory data Mental status examination (MSE) Psychosocial assessment Spiritual and/or religious assessment Cultural and social assessment Self-awareness assessment Validating assessment Objective 1: Conduct a mental status examination (MSE). MSE—Is fundamental to overall patient assessment. Purpose of the MSE—To evaluate the current cognitive processes. Aids in collecting and organizing objective data. The nurse observes the person’s: Ø Physical behavior, verbal and nonverbal communications, appearance, speech, thought content and cognitive ability as well as observations centering on the presenting problem(s), current lifestyle, and strength of resources such as family, friends, education and work experiences. Mental Status Examination Personal information Appearance Behavior Speech Affect and mood Thought Perceptual disturbances Cognition Objective 2: Perform a psychosocial assessment including cultural and spiritual components. (1 of 4) Psychosocial assessment provides additional information to develop a plan of care beyond the MSE. Spiritual and/or religious assessment Ø Spirituality and religious beliefs • Are often overlooked. • Influence how people solve problems in their lives (e.g., illness). Objective 2: Perform a psychosocial assessment including cultural and spiritual components. (2 of 4) Cultural and social assessment Ø Cultural and social factors • Influence health and illness. • Awareness can help decrease stereotyping, stigmatizing, and labeling. Objective 2: Perform a psychosocial assessment including cultural and spiritual components. (3 of 4) Psychosocial Assessment Ø Helps in obtaining the following information: • Central or chief complaint (in the patient’s own words) • History of violent, suicidal, or self-mutilating behaviors • Alcohol and/or substance abuse • Family psychiatric history • Personal psychiatric treatment including medications and complementary therapies • Current stressors and coping methods • Quality of activities of daily living Objective 2: Perform a psychosocial assessment including cultural and spiritual components. (4 of 4) Psychosocial Assessment Ø Helps in obtaining the following information: • Personal background • Social background including support system • Weaknesses, strengths, and goals for treatment • Racial, ethnic, and cultural beliefs and practices • Spiritual beliefs or religious practices HEADSSS: Psychosocial Interview Technique—Adolescents H E A D S S Home environment Education and employment Activities Drugs, alcohol, and tobacco Sexuality Suicide risk Ø Symptoms of depression and other mental disorders S “Savagery” Standards of Practice (3 of 9) STANDARD 2: Diagnosis Ø Formulating a nursing Diagnosis Standard nursing diagnosis Ø The problem (unmet need) Ø The etiology (probable cause) Ø The supporting data (signs and symptoms) Risk diagnoses Ø High probability of a future negative event for a vulnerable individual Health promotion diagnoses Ø Willingness to enhance specific health behaviors Standards of Practice (4 of 9) STANDARD 3: Outcomes Identification Ø “The psychiatric mental health registered nurse identifies expected outcomes and the health care consumer’s goals were planned individualized to the health care consumer or to the situation” Outcomes criteria Ø Goal outcomes reflect maximal patient health that can be realistically achieved through evidence-based interventions Ø Provide direction for continuity of care Ø Patient-centered and culturally appropriate Objective 3: Explain three principles a nurse follows in planning actions to reach approved outcome criteria. Outcomes: Ø Are variable and measurable Ø Are a reflection of patient’s actual state Goals: Ø Are measurable Ø Indicate the desired patient behavior(s) Ø Include a set time for achievement Ø Are short and specific Summary of three (3) principles: Therefore outcomes criteria are patient centered, geared to each individual, and documented as obtainable goals. Outcome Criteria Planning interventions to achieve outcomes includes the use of specific principles. The plan should be: (1) Safe (2) Evidence-based whenever possible (3) Realistic (4) Compatible with other therapies Nursing Interventions Classification (NIC) provides nurses with standardized interventions. Nursing Outcomes Classification (NOC) provides standardized outcomes. Standards of Practice (5 of 9) STANDARD 4: Planning Ø “The psychiatric–mental health registered nurse develops a plan that prescribes strategies and alternatives to assist the health care consumer in attainment of expected outcomes.” (ANA, APNA, ISPN, 2014) Care Plans Care plans should always follow these principles: Ø Safe Ø Appropriate Ø Individualized Ø Evidenced Based Objective 4: Construct a plan of care for a patient with a mental or emotional health problem. Scenario: Hal, a high-school science teacher, 38 years of age, has severe depression with suicidal ideation. He is admitted to the hospital psychiatric unit. He has recently experienced a divorce and job loss. His appetite is poor, and he has done little but sleep for the past 2 weeks. He is very withdrawn and is not leaving his room. He tells the nurse manager that he does not want to interact with the other patients on the unit. Standards of Practice (6 of 9) STANDARD 5: Implementation Ø “The psychiatric–mental health registered nurse implements the identified plan.” Basic Level: PMH-RN Role Ø Standard 5A-Coordination of Care Ø Standard 5B-Health Teaching and Health Promotion Ø Standard 5E-Phamacological, Biological, and Integrative Therapies Ø Standard 5F- Milieu therapy Ø Standard 5G-Therapeutic relationship and counseling Standards of Practice (7 of 9) STANDARD 5: Implementation Ø “The psychiatric–mental health registered nurse implements the identified plan.” Advanced Practice Level: PMH-APRN Role Ø Prescriptive Authority and Treatment Ø Psychotherapy Ø Consultation Objective 5: Identify three advanced practice psychiatric nursing interventions. Advanced practice interventions only Prescriptive authority and treatment Psychotherapy Consultation Audience Response Question 1 (1 of 2) Which is a responsibility that only an APRN-PMH can perform? A. Conducting psychotherapy B. Administering prescription medications C. Integrating biological and complementary therapies D. Adapting health instruction to a patient’s specific needs Audience Response Question 1 (2 of 2) Answer: A. Conducting psychotherapy Objective 6: Demonstrate basic nursing interventions and evaluation of care using the Standards of Practice (ANA, APNA, ISPN, 2014). (1 of 2) A theoretical framework has been supported by Psychiatric–Mental Health Nursing: Scope and Standards of Practice (ANA, 2007). The Psychiatric Mental Health Nursing Standards of Practice is the basis for the following: Ø Criteria for certification Ø Legal definition of nursing as reflected in many states’ nurse practice acts Objective 6: Demonstrate basic nursing interventions and evaluation of care using the Standards of Practice (ANA, APNA, ISPN, 2014). (2 of 2) Ø The National Council Licensure Examination for Registered Nurses (NCLEX-RN) Psychiatric–mental health nursing practice bases its nursing judgments and behaviors on an accepted theoretical framework. Standards of Practice (8 of 9) STANDARD 6: Evaluation Ø “The psychiatric–mental health registered nurse enhances progress toward attainment of expected outcomes.” Systematic, ongoing, criterion-based Include supporting data Enables revisions to diagnoses, outcomes, and interventions Standards of Practice (9 of 9) Documentation Ø Considered 7th step in nursing process Ø Patient records are legal documents Contents Ø Evaluation of stated outcomes Ø All changes in patient condition Ø Record of informed consents Ø Medication reactions Ø Symptoms/concerns Ø Untoward incidents Ø Patient progress Ø “Nonadherence” APNA Standards Objective 7: Compare and contrast the Nursing Interventions Classification, Nursing Outcomes Classification, and evidence-based nursing practice. (1 of 2) Nursing Interventions Classification (NIC) Ø Is a research-based standardized listing of interventions that the nurse can use to plan care Nursing Outcomes Classification (NOC) Ø Includes standardized outcomes that provide a mechanism for communicating the effect of nursing interventions Objective 7: Compare and contrast the Nursing Interventions Classification, Nursing Outcomes Classification, and evidence-based nursing practice. (2 of 2) Evidence-based practice (EBP) Ø Is a combination of clinical skills; EBP uses clinically relevant research in the delivery of effective patientcentered care Audience Response Question 2 (1 of 2) Which step in SOAPIE involves interpretation of two kinds of data in identifying a problem or a nursing diagnosis? A. “S” B. “A” C. “P” D. “I” Audience Response Question 2 (2 of 2) Answer: B. “A”
