Introduction
- The nursing process is an interactive, problem-solving process. It is systematic and individualized way to achieve outcome of nursing care.
- The nursing process respects the individual’s autonomy and freedom to make decisions and be involved in nursing care.
- The nursing process is accepted
by the nursing profession as a standard
for providing ongoing nursing care that is adapted to individual client needs. - The nurse and the patient emerge as partner in a relationship built on trust and directed toward maximising the patient’s strengths, maintaining integrity, and promoting adaptive response to stress.
- In dealing with psychiatric patients, the nursing process can present unique challenges.
- Emotional problems may be vague, not visible like many physiological disruptions.
- Emotional problems can also show different symptoms and arise from a number of causes. Similarly, past events may lead to very different form of present behaviours. Many psychiatric patients are unable to describe their problems.
- They may be highly withdrawn, highly anxious, ,or out of touch with reality.
- Their ability to participate in the problem solving process may also be limited if they see themselves as powerless.
Nursing
process aims at individualized care to the patient and the care is
adapted to patient’s unique needs. Nursing process the following
steps;
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Assessment
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Nursing Diagnosis
-
Outcome Identification
-
Planning
-
Implementation and
-
Evaluation
Assessment
Individualized
care begins with a detailed assessment as soon as the patient is
admitted. In the Assessment phase, information is obtained the patient
in a direct and structured manner through observation, interviews and
examination. Initial interview includes an evaluation of mental status.
In such cases, where the patient is too ill to participate in or
complete the interview, the behaviour the patient exhibits to be
recorded and reports from family members if possible, can obtained.
Even when the initial assessment is complete, each encounter with the
patient involves a continuing assessment .The ongoing assessment
involves what patient is saying or doing at that moment.
HEALTH HISTORY AND PHYSICAL ASSESSMENT
- Client’s complaint, present symptom and focus of concern
- Perceptions and expectations
- Previous hospitalizations and mental health treatment
- Family history
- Health beliefs and practices
- Substance use
- Sexual history
- Abuse
- Spiritual
- Basic needs (diet, exercise, sleep, elimination)
- Sociocultural
- Coping patterns
- Self-esteem
- Medical Examination
- Diagnostic Investigations
- Mental Status Examination
| Subjective Data | Objective Data |
|---|---|
|
|
When the nurse investigates a patient’s specific behaviour, it is valuable to explore the following,
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Situation that precipitated that behaviour
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What the patient was thinking at that moment?
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Whether that behaviour makes any sense in that context?
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Whether the behaviour was adaptive or dysfunctional?
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Whether a change is needed?
If
the nurse has to interview the patient she should select a private
place, free from noise and distraction and interview should be goal
directed. Although the patient is a regarded as a source of
validation , the nurse should also be prepared to consult with family
members or other people knowledgeable about the patient. This is
particularly important when the patient is unable to provide reliable
information because the symptoms of the psychiatric illness. She should
gather Information from other information sources, including health
care records, nursing rounds, change- of shifts, nursing care plans
and evaluation of other health care professionals.
Nursing Diagnosis
- After collecting all data, the nurse compares the information and then analyses the data and derives a nursing diagnosis.
- A nursing diagnosis is a statement of the patient’s nursing problem that includes both the adaptive and maladaptive health responses and contributing stressors.
- These nursing problems concern patient’s health aspects that may need to be promoted or with which the patient needs help.
- A nursing diagnosis may be an actual or potential health problem, depending on the situation.
- The most commonly used standard is that of the North American Nursing Diagnosis Association (NANDA).
A nursing diagnostic statement consists of three parts:
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Health problem
-
Contributing factors
-
Defining characteristics
The
defining characteristics are helpful because they reflect the behaviour
that are the target of nursing intervention .They also provide
specific indicators for evaluating the outcome of psychiatric nursing
interventions and for determining whether the expected goals of the
nursing care were met.
Example:
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If a patient is making statements about dying, he is isolative, anorexic, cannot sleep and wants to die. Then the nursing diagnosis can be-
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Helplessness, related to physical complaints, as evidenced by decreased appetite and verbal cues indicating despondency.
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Fatigue related to insomnia, as evidenced by an increases in physical complaints and disinterest in surroundings.
-
Social isolation , related to anxiety, as evidenced by withdrawal and uncommunicative behaviour.
Outcome Identification
The
psychiatric mental health nurse identifies expected outcomes
individualised to the patient. Within the context of providing
nursing care, the ultimate goal is to influence health outcomes and
improve the patient’s health status. Outcomes should be mutually
identified with the patient, and should be identified as clearly as
clearly and determine the effectiveness and efficiency of their
interventions.
Before
defining expected outcomes, the nurse must realize that patient often
seek treatment with goals of their own. These goals may be expressed
as relieving symptoms or improving functional ability. The nurse must
understand the patient’s coping response and the factors that influence
them. Some of these difficulties in defining goals are as follows-
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The patient may view a personal problem as someone else’s behaviour.
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The patient may express a problem as feeling, such as “I am lonely” or “I am so unhappy”.
Clarifying
goals is an essential step in the therapeutic process. Therefore the
patient nurse relationship should be based upon mutually agreed goals. Once
the goals are a greed on they must be stated in writing .Goals should
be written in behavioural terms, and should be realistically
described what the nurse wishes to accomplish within a specific time
span. Expected outcomes and short term goals should be developed with
short tem objectives contributing to the long term expected
outcomes.
Example of short term goals:
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At the end of the two weeks patients will stay out of bed and participate in activities
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At the end of the one week patient will sleep well at night.
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At the end of the one week patient will eat properly and maintain weight.
Planning
As soon as the patient‘s problems are identified, nursing diagnosis made, planning nursing care begins.
The planning consists of:
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Determining priorities
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Setting goals
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Selecting nursing actions
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Developing /writing nursing care plan
In
planning the care the nurse can involve the patient, family, members
of the health team. Once the goals are chosen the next task is to
outline the plan achieving them. On the basis of an analysis, the
nurse decides which problem requires priority attention or immediate
attention. Goals stated indicates as to what is to be achieved if the
identified problem is taken care of. These can be immediate short-term
and long- term goals. The nursing action technique chosen will enable
the nurse to meet the goals or desired objectives. For example, the
short-terms for a depressed patient is "to
pursue him or her take bath”. The nursing action may be “The nurse
firmly direct the patient to get up and finish her/his bath before 8
O’ clock. On persuasion the patient takes bath. This is an example of
selection of the nursing action. Writing or recording of the
problems, goals, and nursing actions is a nursing care plan.
Implementation
The
implementation phase of the nursing process is the actual initiation of
the nursing care plan. Patient outcome/goals are achieved by he
performance of the nursing interventions. During the phase the nurse
continues to assess the patient to determine whether interventions
are effective. An important part of this phase is documentation.
Documentation is necessary for legal reasons because in legal dispute
“if it wasn’t charted, it wasn’t done". The nursing interventions are
designed to prevent mental and physical illness and promote, maintain,
and restore mental and physical health. The nurse may select
interventions according to their level of practice. She may select
counselling, milieu therapy, self-care activities, psychological
interventions, health teaching, case management, health promotion and
health maintenance and other approaches to meet the mental health care
needs of the patient.
To implement the actions, nurses need to have intellectual, interpersonal and technical skills.
Nursing actions are of two types-
- Dependent nursing action: Action derived from the advice from the psychiatrist. For example, giving medicines.
- Independent nursing actions: This is based on nursing diagnosis and plan of care, pursuing the patient to attend to personal hygiene.
Evaluation
The
continuous or ongoing phase of nursing process is evaluation. Nursing
care is a dynamic process involving change in the patient’s health
status over time, giving rise to the need of new data, different
diagnosis, and modifications in the plan of care.
When
evaluating care the nurse should review all previous phases of the
nursing process and determine whether expected outcome for the patient
have been met. This can be done checking –have I done everything for
my patient? Is my patient better after the planned care? .Evaluation
is a feed back mechanism for judging the quality of care given.
Evaluation of the patient’s progress indicates what problems of the
patient have been solved , which need to be assessed again,
replanted, implemented and re-evaluated.
Components of Assessment
Mental Status Examination
AppearanceReliability
Behaviour/activity
Attitude
Mood and affect
Perception
Thoughts
Sensorium and Cognition
Judgment
Insight
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Interviewer’s impression that individual reported information accurately and completely
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Internal:-Psychiatric or medical illness, perceived loss such as loss of self concept/self-esteem
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External:-Actual loss, e.g. death of loved ones, diverse, lack of support systems, job or financial loss, retirement of dysfunctional family system
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Adaptation to internal and external stressors, use of functional, adaptive coping mechanisms, and techniques, management of activities of daily living
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Attainment and maintenance of satisfying, interpersonal relationships congruent with developmental stages, including sexual relationship as appropriate for age and status
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Ability to adapt and conform to present norms, rules, ethics.
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Presence of self-satisfying value-belief system that the individual regards as right, desirable, worthwhile, and comforting
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Engagement is useful, rewarding activity, congruent with developmental stages and societal standards (work, school and recreation)
| Sample of Nursing Diagnoses (As per NANDA- North American Nursing Diagnosis Association) | ||
| Nursing Diagnosis | Analysis | |
| 1 | Risk for injury related to accelerated motor activity | Accelerated motor activity or impulsive actions |
| 2 | Disturbed thought process related to impaired judgement associated with manic behaviour | Judgement impaired , mood of elation (patient is using inappropriate dress and bizarre dressing) |
| 3 | Self-care deficit (unkempt appearance) related to hyperactivity | Unable to take time for self-care is, dishevelled and unkempt |
| 4 | Impaired verbal communication –flight of ideas related to accelerated thinking | Accelerated speech with flight of ideas (thought speeded up causing rapid speech and flight of ideas, excessive planning for activities |
| 5 | Ineffective coping related to elated expressive mood | Euphoria, elation, cheerfulness( an exaggerated sense of well being) |
| 6 | Disturbed thought process –grandiosity related to elevated mood | Grandiosity-inflation self-esteem |
| 7 | Ineffective coping related to emotional liability associated with manic behaviour | Emotional labiality (unstable mood moves from cheerfulness to irritation easily with little irritation |
| 8 | Disturbed thought process –related to delusion of grandeur | Grandiose delusions (Belief that well known political religious, or entertainment leader) |
| 9 | Disturbed thought process decreased attention span and difficulty in concentration related to accelerated thinking | Short attention span, difficulty in concentrating , easily disturbed |
| 10 | Risk for violence related to hostile and angry behaviour | Hostile comment and complaints |
| 11 | Impaired verbal communication related to pressure of speech | Accelerated thinking, highly responsive to environmental stimuli, accompanying flight of ideas |
| 12 |
|
Weight loss (less food intake associated with depression which contributes to loss of appetite with weight loss/weight gain following pharmacological management/possible wieght gain |
| 13 | Self-care deficit-neglect of personal hygiene related to depression | Neglect of personal hygiene (feeling of worthlessness associated with depression which contribute to lack of interest in personal hygiene |
| 14 | Health Maintenance, ineffective –psychomotor retardation related to depression | Extreme slowness in performing activity |
| 15 | Risk for violence- self-directed, related to depression | Bruises, cuts, scars, (possible destructive behaviour or abuse by others) |
| 16 | Anxiety –neurological symptoms related to depression | Extreme nervousness (possible response to loss with symptoms to those of anxiety) |
| 17 | Risk for violencerm | Suicidal feeling (Hopelessness contributes to total despair |
| 18 | Sensory perceptual alteration –disorientation about time, place, and person related to increased anxiety | Confusion or disorientation |
| 19 | Ineffective coping –obsessive thinking related to anxiety | Anxiety (Increased anxiety unapparent and discharge through obsessive thinking) |
| 20 | Impaired Social interactions –inability to form warm, meaningful relationships, related to compulsive behaviour | Lacks ability to develop warm relationship ( has limited ability to express emotion) |
| 21 | Ineffective coping –compulsion related to need for excessive cleanliness) | Excessive cleanliness (Over emphasis for cleanliness and neatness) |
| 22 | Potential for self harm related to poor impulse control associated with substance abuse) | Poor impulse control |
| 23 | Potential for self-harm related to marked disorientation , disorganization, and confusion | Disorientation, disorganization and confusion (If marked , patient is at high suicidal risk) |
| 24 | Distarbance of self-concept-insecurity related to suspiciousness | Insecurity, oversensitive, Failure to meet needs results in mistrust and insecurity |
| 25 | Potential for violence directed towards others related t perceived threat or injustice to himself | Anger and hostility –may become physically violent (Overly concerned with protecting himself from environment : overly sensitive) |
| 25 | Ineffective individual coping persecutory feeling related to mistrust | Feeling of being misjudged , conspired against, spied upon , followed , poisoned, dragged, obstructed in achieving long term goals. |
Nursing Diagnosis: Risk for violence, self directed.
Risk factors-Chronic illness, retirement, change in marital status
| Patient Outcome | Nursing Intervention with Rationale | Evaluation |
| Patient will not harm himself Patient will refrain from suicidal threats or behaviour gestures. He will deny any plans for suicide |
Observe patient’s behaviour during routine patient care. Close observation is necessary to protect from self harm. Listen carefully suicidal statements and observe for non-verbal indications of suicidal intent. Such behaviours are critical clues regarding risk for self harm. Ask direct questions to determine suicidal intent , plans for suicide, and means to commit suicide .Suicide risk increases when plans and means exists |
Patient remained safe, unharmed. Absence of verbalized or behavioural indications of suicidal intent by the patient. Patient denies active suicide plans |
Nursing Diagnosis:
Ineffective individual coping, related to response crisis
(retirement), as evidence by isolative behaviour, changes in mood, and
decreased sense of well-being.
| Patient Outcome | Nursing Intervention with Rationale | Evaluation |
| Patient will identify positive coping strategies, such as structuring leisure time. Patient will combine past effective coping methods with newly acquired coping strategies |
Develop
trusting relationship with patient to demonstrate caring and,
encourage patient to practice new skills in a safe therapeutic
setting. Praise patient for adaptive coping. Positive feedback encourages repetition of effective coping by patient |
Patient expresses trust in nurse-patient relationship. Patient discusses plans for use of past and newly learned coping methods. |
Nursing Diagnosis:
Self-care deficit (grooming, dressing, and feeding) related to manic
hyperactivity, difficulty in concentrating and making decisions: as
evidenced by inappropriate dress, and dysfunctional eating habits.
Patient Outcome
|
Nursing Intervention with Rationale
|
Evaluation
|
Patient will dress appropriately for age and status.
|
Offer
assistance for selecting clothing and grooming to provide input and
direction for appropriateness of dress and hygiene to preserve
self-esteem and avoid embracement.
Encourage and remind patient to drink fluid and to eat food to focus the patient on necessary feeding activities , to prevent dehydration and starvation.
Provide
recognition and positive reinforcement for feeding/dressing
accomplishments to reinforce appropriate behaviours and enhance
self-esteem.
|
Patient dresses self appropriately and maintains hygiene.
|
References:
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Ladwig, A.(1999).Nursing Diagnosis Handbook, A Guide for Planning Care. Section 1:5
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Kapoor, B. (1994). A Text Book for Psychiatric Nursing: Chapter5, Page 223-224.
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Foortinash, Hoolodey-Warrant. Psychiatric Mental Health Nursing, 1996: Chapter 20, page 279, 482.
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Gail.W.Stuart, Michal T. Laraiya. Principles and Practice of Psychiatric Nursing 1998: Chapter 10, Page 178.
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Katherine N Fortinash, Patrica N Hooliday-Worret. Psychiatric Nursing Care Plans 1991: Chapter 1, Page 1.
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