Lecture 3
The Nursing Process in
Psychiatric/Mental Health
Nursing
Assessment
Evaluation
Implementation
Diagnosis
Planning
Applying Nursing Process
Role of the nurse in psychiatry
 The nurse assists the client’s successful
adaptation to stressors within the environment.
 Goals are directed toward change in thoughts,
feelings, and behaviors that are age-appropriate
and congruent with local and cultural norms.
Diagnosis
Diagnosis
The Nursing Process
 The standards of care for psychiatric nursing are
written around the five steps of the nursing
process.
 It is a systematic framework for the delivery of
nursing care.
 It uses a problem-solving approach.
 It is goal-directed, its objective being the delivery
of quality client care.
The Nursing Process
 It is dynamic, not static.
 Within the legal scope of nursing
 Client-centered
 Prioritized
 It is accepted for clinical practice established by
the American Nurses Association
Standard I. Assessment
 Standard I. Assessment
The psychiatric/mental health nurse collects client
health data.
 Types of Data
-Objective data-observable and measurable facts (Signs)
-Subjective data-information that only the client feels and
can describe (Symptoms)
Standard I. Assessment
 Sources of Data
-Primary source: Client
-Secondary source: Client’s family, reports, test
results, information in current and past medical
records, and discussions with other health care
workers
Standard I. Assessment
The data will collect through:
 Nursing health history (Demographic data, Chief
complain, History of present illness, Past psychiatric
history, Family history, Life style, Social data,
psychological data)
 Physical examination
 Mental status examination (Appearance, behavior,
speech, mood, affect, intelligence, sensorium, thought)
 Lab results
 Review records and literature
Nursing health history
1. Demographic data:

Client name, address, age, sex, marital
status, occupation, religious.
2. Chief complain:

The answer given to question "what brought
you to the hospital?
Nursing health history
3. History of present illness:
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Basic needs (diet, exercise, sleep, elimination)
Eye contact
Appearance.
Speech
Coping patterns
Self-esteem
Orientation.
Nursing health history
4. Past psychiatric history.
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Childhood illness ,head injury, seizures, and
major illnesses.
Surgeries
Hospitalization.
any previous episodes of the presenting
complaint
The past substance (drug) history.
history of abuse
sexual history
Nursing health history
5. Family history:

Genetic component and the biological family
history
6. Life style:
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Personal habits: tobacco, alcohol, coffee, tea.
Diet description: high fat diet. High salt.
sleep pattern.
recreation, hoppies.
Nursing health history
7. Social data
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Family relation ship, friends, support system.
Level of education.
Occupation history (occupied hazard).
Economic status.
Home (safety measurement)
8. psychological data:

Major stressor, usual coping pattern,
communication style.
Subjective Data
 Name and general information about the
client
 Client’s perception of current stressor or
problem
 Current occupational or work situation
 Any recent difficulty in relationships
 Any somatic complaints
 Current or past substance use
 Interests or activities previously enjoyed
 Sexual activity or difficulties
Objective Data
1. Physical exam
2. Behaviour
3. Mood and affect
4. Awareness
5. Thought processes
6. Appearance
7. Activity
8. Judgment
9. Response to environment
10. Perceptual ability
Components of Assessment
1. Appearance
 Dress, grooming, hygiene, cosmetics, apparent age,
posture, facial expression (sad, worried, tense).
2. Behaviour/activity
 Hyperactivity or hypoactivity, rigid, relaxed, restless,
gait and coordination, facial grimacing, mannerisms,
passive, combative, bizarre.
Components of Assessment
3. Mood and affect
 Mood (Intensity depth duration):- sad, fearful,
depressed, angry, anxious, happy, grandiose,
nervous, confusion.
 Affect (Intensity depth duration) :- appropriate,
apathetic, constricted, flat, euphoric.
4. Perception
 Hallucination, illusions, derealization
Components of Assessment
5. Attitude
 Interactions with interviewer: - Cooperative, resistive,
friendly, hostile
 Speech-Quantity: - poverty of speech, poverty of
content, volume.
 Quality: - articulate, congruent, talkative,
repetitious, spontaneous, circumstantial
 Rate:-slowed, rapid
Components of Assessment
6. Thoughts
 Form and content-logical vs. illogical, loose
associations, flight of ideas, blocking,
neologisms, obsessions, delusions
 Hallucinations: sensory perception that occur in the
absence of an actual external stimulai.
 Delusion: fixed falls belief.
Components of Assessment
7. Cognition
 Level of consciousness, orientation, attention span, ,
recent and remote memory, concentration, ability to
comprehend and process information, intelligence
8. Judgment
 Ability to assess and evaluate situations, makes
rational decisions, understand consequence of
behaviour, and take responsibly for actions
Components of Assessment
9. Insight
 Ability to perceive and understand the cause and
nature of own and other’s situation
10. Psychosocial Criteria
 Internal:-Psychiatric or medical illness, perceived loss
such as loss of self concept/self-esteem
 External:-Actual loss, e.g. death of loved ones,
diverse, job or financial loss, retirement
Components of Assessment
11. Coping skills
 Adaptation to internal and external stressors, use of
functional, adaptive coping mechanisms, and
techniques, management of activities of daily living
12. Relationships
 Attainment and maintenance of satisfying,
interpersonal relationships congruent with
developmental stages, including sexual relationship
as appropriate for age and status
Components of Assessment
13. Cultural
 Ability to adapt and conform to present norms, rules,
ethics.
14. Spiritual (Value-belief)
 Presence of self-satisfying value-belief system that
the individual regards as right, desirable, and
comforting
15. Occupational
 Congruent with developmental stages and societal
standards (work, school and recreation)
Standard II. Diagnosis
 Standard II. Diagnosis
 The psychiatric/mental health nurse analyzes
the assessment data in determining diagnosis
 The purpose of this stage is to identify the
patient's nursing problem
Standard II. Diagnosis
 Nursing diagnosis: actual or potential health
problems that can be managed by independent
nursing interventions .
 Prioritize the problems
 Not a medical diagnosis
 Nursing Diagnosis Categories:
-Actual
-Potential
Standard II. Diagnosis
 It contains three parts:
 Problem: Name of the health-related issue or problem as
identified in the NANDA list
 Etiology: (its cause)
 Sign and symptom
 It called PES system.
 The name of the nursing diagnosis is linked to the etiology
with the phrase “related to,” and the signs and symptoms are
identified with the phrase “as manifested (or evidenced) by”
Standard II. Diagnosis
Writing Diagnostic Statements
Problem
Related
Diagnostic
Label
To
Etiology
As
Signs &
manifested
Symptoms
By
Standard II. Diagnosis
Difference Between Nursing and
Medical Diagnosis
 Nursing Diagnosis- statement used to describe
the client's actual or potential response to a
health problem that a nurse is licensed and
competent to treat
 Medical Diagnosis- physician "clinical judgment
of the disease- i.e. diabetes mellitus.
Standard II. Diagnosis
Example:
If a patient is making statements about dying, he is
isolative, anorexic, cannot sleep and wants to die.
Then the nursing diagnosis can be:
1. Helplessness, related to physical complaints, as
evidenced by decreased appetite and verbal cues
indicating despondency.
2. Fatigue related to insomnia, as evidenced by an
increases in physical complaints and disinterest in
surroundings.
Standard III. Planning
 The psychiatric/mental health nurse develops a
plan of care that is negotiated among the client,
nurse, family, and healthcare team and
prescribes evidence-based interventions to
attain expected outcomes.
 Determine problems that require immediate
action
Standard III. Planning
Short-Term Goals
 Outcomes achievable in a few days or 1 week
 Developed form the problem portion of the
diagnostic statement
 Client-centered
 Measurable
 Realistic
 Accompanied by a target date
Standard III. Planning
Long-Term Goals
 Desirable outcomes that take weeks or months
to accomplish for client’s with chronic health
problems
Standard III. Planning
 Formula for Writing Goals:
Goal statement (long or short term) = patient behavior +
criteria + time + conditions (if needed)
 1. Subject -patient
 2. Verb -action/behavior which pt performs
 3. Criteria -acceptable performance
 4. Within specified time period
 5. Condition (if needed) circumstances under which
behavior performed
Example:
 The patient (1) will walk (2) the length of the hall (3) with
a walker (5) by the end of the shift (4).
Standard III. Planning
 Priorities are classified:
 High: nursing diagnosis that if untreated, could result in
harm to the client or others have the highest priority
 Intermediate: nursing diagnosis involves the nonemergency, non-life threatening needs of the clients
 Low: nursing diagnosis are client’s needs that may not
be directly to a specific illness or prognosis
Standard IV. Implementation
 The psychiatric/mental health nurse implements the
interventions identified in the plan of care.
 Nursing interventions are directed at eliminating the
etiologies.
 Carrying out the plan of care
Standard IV. Implementation
 Nursing interventions must be safe, within the legal
scope of nursing practice, and compatible with medical
orders.
 The nurse implements medical orders and nursing
orders
 Nurses are accountable for carrying out nursing orders
and physician orders.
Standard IV. Implementation
 Direct interventions :
Actions performed through interaction with clients.
 Indirect interventions :
Actions performed away from the client, on behalf of a
client or group of clients.
Standard IV. Implementation
Specific interventions:
 Standard IVa. Counseling: to assist
clients in improving coping skills and
preventing mental illness and disability
 Standard IVb. Milieu therapy: to provide
and maintain a therapeutic environment for
client
Standard IV. Implementation
 Standard IVc. Self-care activities:
To foster independence and mental and physical
well-being
 Standard IVd. Psychobiological interventions:
To restore the client’s health and prevent further disability
 Standard IVe. Health teaching:
To assist clients in achieving satisfying, productive,
and healthy patterns of living
Standard IV. Implementation
 Standard IVf. Case management:
To coordinate comprehensive health services and
ensure continuity of care
 Standard IVg. Health promotion and health
maintenance:
Implements strategies with clients to promote and
maintain mental health and prevent mental illness
Standard IV. Implementation
 Standard IVh. Psychotherapy:
provides therapy for individuals, groups and families to
foster mental health and prevent disability
 Standard IVi. Prescriptive authority and
treatment:
provides pharmacological intervention, in accordance
with laws and regulations, to treat symptoms of
psychiatric illness and improve functional health status
Standard IV. Implementation
 Standard IVj. Consultation:
provides consultation to enhance the abilities of other
clinicians to provide services for clients and effect
change in the system
Standard V. Evaluation
 The psychiatric/mental health nurse evaluates
the client’s progress in attaining expected
outcomes.
 The way nurses determine whether a client has
reached a goal.
Standard V. Evaluation
 It is the analysis of the client’s response,
evaluation helps to determine the effectiveness
of nursing care.
Examples:
 The goal met.
 The goal not met.
 The goal partially met.
Example
 Nursing Diagnosis: Self-care deficit (grooming,
dressing, and feeding) related to hyperactivity, difficulty
in concentrating and making decisions, as evidenced by
inappropriate dress, and dysfunctional eating habits.
 Goal: Patient will dress appropriately for age and status
 Nursing intervention: Offer assistance for selecting
clothing and grooming to provide input and direction for
appropriateness of dress and hygiene to preserve selfesteem and avoid embracement.
 Evaluation: Patient dresses self appropriately and
maintains hygiene.
Documentation of the Nursing Process
 Documentation of the steps of the nursing process is
often considered as evidence in determining certain
cases of negligence by nurses.
Documentation of the Nursing Process (cont.)
Examples of documentation that reflect use
of the nursing process
 Problem-Oriented Recording (POR)
 Has a list of problems as its basis
 Uses subjective, objective,
assessment, plan, intervention,
and evaluation (SOAPIE) format
Documentation of the Nursing Process (cont.)
 Focus Charting
 Main perspective is to choose a
“focus” for documentation. A focus may be
 a nursing diagnosis
 a current client concern or behavior
 a significant change in the client’s status or
behavior
 a significant event in the client’s therapy
 The focus cannot be a medical diagnosis.
 It uses data, action, and response (DAR) format.
Documentation of the Nursing Process (cont.)
 APIE method
 Utilizes flow sheets as accompanying documentation
 Uses assessment, problem, intervention,
and evaluation (APIE) format