5 Nursing Process

THE NURSING PROCESS Care of the Mentally ILL

NURSING PROCESS  Utilized in a unique manner for psychosocial assessment  Set goals with client that can be measured in behavioral terms  Uses principles of therapeutic communication for interventions

ASSESSMENT  Referred to as psychosocial assessment – Includes mental status examination

Purpose – Construct a picture of the client’s current emotional state, mental capacity, & behavioral function – Basis for developing plan of care – A clinical baseline to measure client’s progress

Factors Influencing Assessment 1. Client participation/feedback 2. Client’s health status 3. Previous experiences  Misconceptions about health care

4. Ability to understand 5. Nurse’s attitude and approach

The Interview  Environment – Comfortable, private and safe for both client and nurse

 Input from family and friends  Phrasing of questions – Start with open-ended questions – Use direct questions: focused or closed-ended questions • Clear, simple & focused on specific symptom or behavior

– Use non-judgmental language and matter-offact tone

PHYSICAL ASSESSMENT Subject reporting of health history Objective date: • CHRONOLOGICAL AGE vs DEVELOPMENTAL STAGE • ATTIRE • HYGIENE • PHYSICAL HEALTH • PSYCHOMOTOR • SLEEP and REST

Neurological assessment / level of consciousness

PHYSICAL ASSESSMENT General Appearance and Motor Behavior – Automatism – repeated purposeless behaviors ~ anxiety: drumming of fingers – Psychomotor retardation – overall slowed movements – Waxy flexibility – maintenance of posture or position over time even when awkward or uncomfortable

MENTAL STATUS ASSESSMENT

 Observation of Mood (pervasive and enduring emotional state) and affect (physical manifestations of mood). – APPROPRIATENESS & CONSISTENCY – DESCRIPTION: flat, sad, smiling, serious, happy, euphoric, anxious, angry • LABILE – rapidly changing mood

– STABILITY – SPECIFIC FEELINGS and MOOD – INTENSITY

MENTAL STATUS ASSESSMENT AFFECT – Blunted affect – little or slow-to-respond facial expression – Broad affect – displaying full range of emotional expressions – Flat affect - no facial expression – Inappropriate affect – facial expression incongruent with mood or situation – Restricted affect - one type of expression ~ serious or somber

– Unstable unhappy affect of borderline personality disorder

COGNITIVE ASSESSMENT  Evaluation of thought, sensorium and intelligence 2. INTELLECTUAL PERFORMANCE A. Orientation to person, place and time •

Disorientation vs confusion

B. Attention and concentration • •

Ask client to perform certain tasks spell the word “world” backward

C. Memory: short and long term •

Ask direct questions with verifiable answers

D. Judgment E. Insight to illness F. Abstract thinking & intellectual abilities

COGNITIVE ASSESSMENT 1.

SPEECH A. Amount, Volume, Clarity B. Characteristics: pressured, slow or fast, dull or lively C. Specific aberrations

2. THOUGHTS A. Thought process (how) vs thought content (what) B. Content and clarity C. Characteristics: spontaneity, speed, loose associations, blocked, flight of ideas, repetitions

COGNITIVE ASSESSMENT  Common Terms: – Circumstantial thinking – client answers question only after giving excessive unnecessary detail. – Delusion – fixed false belief not based in reality – Flight of ideas – excessive amount and rate of speech of fragmented unrelated ideas – Ideas of reference – inaccurate interpretation that general events are personally directed to him

COGNITIVE ASSESSMENT – Loose associations – disorganized thinking from one idea to another with little or no evident relation between them – Tangential thinking – wandering off the topic and never providing info requested – Thought blocking – stopping abruptly in middle of sentence or train of thought & unable to continue the idea – Thought broadcasting – delusional belief that others can hear or know what he is thinking

Thought broadcasting

COGNITIVE ASSESSMENT – Thought insertion – delusional belief that others are putting ideas or thoughts into his head – Thought withdrawal – delusional belief that others are taking his thoughts away and he is powerless to stop it – Word salad – flow of unconnected words that convey no meaning to the listener

 Assessment of suicide or harm toward others • •

Ask direct questions Legal duty to warn

COGNITIVE ASSESSMENT 1.

SENSORY-PERCEPTUAL ALTERATIONS A. Hallucinations – false sensory perceptions or perceptual experiences that do not really exist B. Can involve the 5 senses and bodily sensations –

Auditory hallucinations most common

2. SELF-CONCEPT A. Personal view of self B. Description of physical self –

Body image of client

C. Personal qualities or attributes –

Emotions and coping strategies

SOCIAL / CULTURAL CONSIDERATIONS  DEVELOPMENTAL TASKS  FAMILY / COMMUNITY RELATIONSHIPS – Role of client family – Family harmony, family support for or dependency on client – Client’s perception of family – Availability of community support groups to client

SOCIOECONOMIC GROUP / EDUCATION Factors that relate to how client is approached and how client perceives own present state. Determination of level of teaching and need for social services / institutionalization.

CULTURAL / SPIRITUAL BACKGROUND Assess behaviors in context of client’s culture Avoid stereotyping persons as having attributes of their culture/subculture Religious and philosophic beliefs

Physiologic/self-care Considerations Eating habits Sleep patterns Health problems Compliance with medications ADLs

ANALYSIS Anxiety Ineffective family coping Ineffective individual coping Decisional conflict Fatigue Fear Hopelessness

ANALYSIS Knowledge deficit Powerlessness Sleep pattern disturbances Altered thought processes Risk for violence Impaired verbal communication Impaired social interaction

ANALYSIS Altered role performance Spiritual distress Self-esteem disturbance Social isolation Altered family processes Defensive coping Ineffective denial

ANALYSIS Ineffective denial Noncompliance Body Image disturbance Risk for self mutilation Rape-trauma syndrome Impaired adjustment

ANALYSIS Psychological tests – Intelligence tests » Evaluate cognitive abilities, intellectual functioning

– Personality tests » Reflect self-concept, impulse control, reality testing, major defenses

Psychiatric diagnoses – Diagnostic and Statistical Manual of Mental Disorders, Text Revision, 4th edition (DSM-IV-TR) • Classifies mental disorders into categories

PLANNING The psychiatric/mental health nurse identifies expected outcomes individualized to the client. Plan of care is negotiated among the client, nurse, family, and healthcare team and prescribes evidence-based interventions to attain expected outcomes

GOALS – Client will participate in treatment program – Be oriented to time, place , and person and exhibit reality based behavior – Recognize reasons for behavior and develop alternative coping mechanisms – Maintain or improve self-care activities – Be protected from harmful behaviors – Develop mutual agreement between nurse and client whenever possible

GOALS SHORT TERM GOALS – Immediate problems – Feasible – Within client’s capabilities

LONG-TERM GOALS – Relates to discharge planning – Prevention of recurrence – Prevention of exacerbation

IMPLEMENTATION  Implements the interventions identified in the plan of care  Specific interventions: – Counseling: to assist clients in improving coping skills and preventing mental illness and disability. One-on-one listening – Milieu therapy: to provide and maintain a therapeutic environment for client- RN designs unit activities based on client needs – Self-care activities: to foster independence and mental and physical well-being: Bathing, eating, working, paying bills

IMPLEMENTATION – Psychobiological interventions: to restore the client’s health and prevent further disability: medications – Health teaching: to assist clients in achieving satisfying, productive, and healthy patterns of living: Stress management, anger management – Case management: to coordinate comprehensive health services and ensure continuity of care- refer to programs, community support groups

IMPLEMENTATION – Health promotion and health maintenance: implements strategies with clients to promote and maintain mental health and prevent mental illness: Teach – Psychotherapy: provides therapy for individuals, groups, families, & children – Group therapy involves a therapist or leader and a group of clients sharing a common purpose; members contribute to the group and expect to benefit from it. »

Types of groups

Group Therapy Stages of group development – Pregroup stage – Initial stage – Working stage – Termination stage

Group Therapy The therapeutic results of group therapy (Yalom, 1995) include the following: – Gaining new information or learning – Gaining inspiration or hope – Interacting with others – Feeling acceptance and belonging – Becoming aware that one is not alone and that others share the same problems – Gaining insight into one’s problems and behaviors and how they affect others – Giving of oneself for the benefit of others (altruism)

EVALUATION Evaluates the client’s progress in attaining expected outcomes. Collaborates with others on the team including patient and family.