nursing process in mental health

Nursing Process in Mental Health Nursing

• The nursing process consists of six steps and uses a problem-solving approach. It is goal-directed, with the objective being delivery of quality client care.

• The nursing process is dynamic, not static. It is an ongoing process

Standards of Practice

• The six Standards of Practice describe a component level of nursing care as demonstrated by the critical thinking model known as the nursing process.

• Standard 1. Assessment: The Psychiatric-Mental Health Registered Nurse collects comprehensive health data that is pertinent to the patient’s health or situation.

• information for this database is gathered from a variety of sources including:

• interviews with the client or family, • observation of the client and his or her

environment, • consultation with other health team members, • review of the client’s records, • and a nursing physical examination.

A quick and brief mental status evaluation is the follwing:

Standard 2. Diagnosis

• The Psychiatric-Mental Health Registered Nurse analyzes the assessment data to determine diagnoses or problems, including level of risk.

• Diagnoses and potential problem statements are formulated and prioritized. Diagnoses conform to accepted classification systems, such as the NANDA

• Standard 3. Outcomes Identification• The Psychiatric-Mental Health Registered

Nurse identifies expected outcomes for a plan individualized to the patient

• Outcomes are: Measurable, expected, patient-focused goals that translate into observable behaviors (ANA, 2004).

• Expected outcomes are derived from the diagnosis.

• They must be realistic for the client’s capabilities, and are most effective when formulated cooperatively by the interdisciplinary team members, the client, and significant others.

Standard 4. Planning

• The Psychiatric-Mental Health Registered Nurse develops a plan that prescribes strategies and alternatives to attain expected

outcomes.• For each diagnosis identified, the most appropriate

interventions, based on current psychiatric/mental health nursing practice and research, are selected.

• Client education and necessary referrals are included.

Standard 5. Implementation

• The Psychiatric-Mental Health Registered Nurse implements the identified plan.

• The care plan serves as a blueprint for delivery of safe, ethical, and appropriate interventions.

• Documentation of interventions• also occurs at this step in the nursing process.

Several specific interventions are included among thestandards of psychiatric/mental health clinical nursing

practice :

1. Standard 5A. Coordination of Care with other team members

2. Standard 5B. Health Teaching and Health Promotion to promote safe environment.

3. Standard 5C. Milieu Therapy which is maintaining therapeutic environment with all

4. Standard 5D. Pharmacological, Biological, andIntegrative Therapies to restore the patient’s health

Standard 6. Evaluation

• The Psychiatric-Mental Health Registered Nurse evaluates progress toward attainment of expected outcomes.

• The client’s response to treatment is documented,

WHY NURSING DIAGNOSIS?

• it is the legal duty of the nurse to show that nursing process and nursing diagnosis were accurately implemented in the delivery of nursing care (part of nursing act).

• to maintain a common language within nursing

• The use of nursing diagnosis affords a degree of autonomy for nursing practice.

Nursing case management

• Within this model, clients are assigned a manager who negotiates with multiple providers to obtain diverse services.

• This type of healthcare delivery process serves to decrease fragmentation of care while striving to contain cost of services.

• Types of clients who benefit from case managementinclude (but are not limited to) the following:● The weak elderly● The developmentally disabled● The physically handicapped● The mentally handicapped● Individuals with long-term medically complex problemsthat require multifaceted, costly care (e.g., highriskinfants, those with human immunodeficiency virus[HIV] or

• Nurses are very well qualified to serve as case managers.

APPLYING THE NURSING PROCESSIN THE PSYCHIATRIC SETTING

• Therapy within the psychiatric setting is very often team, or interdisciplinary, oriented.

• The team will use nursing process steps to deal the patient: e.g pp145 for diagnosis of schizophrenia:

• Concept mapping is a diagrammatic teaching and learning strategy that allows students and faculty to visualize interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments.

• The concept map care plan is an innovative approach to planning and organizing nursing care.

DOCUMENTATION OF THE NURSINGPROCESS

1. Problem-Oriented Recording: follows the subjective, objective, assessment, plan, implementation, and evaluation format.

2. Focus Charting: The documentationis organized in the format of DAR. • These categories are defined as follows:D = Data: Information that supports the stated focus or describes relevant observations about the clientA = Action: Immediate or future nursing actionsR = Response: Description of client’s responses to anypart of the medical or nursing care.

The PIE Method

• PIE, or more specifically “APIE” (assessment, problem, intervention, evaluation), is a systematic method of documenting to nursing process and nursing diagnosis

The PIE Method

• A = Assessment: A complete client assessment is conducted at the beginning of each shift.

• P = Problem: A problem list, or list of nursing diagnoses,

• I = Intervention: Nursing actions are performed, directed at resolution of the problem.

• E = Evaluation: Outcomes of the implemented interventions are documented, including an evaluation of client responses to determine the effectiveness of nursing interventions

Electronic Documentation

• Most healthcare facilities have implemented—or are in the process of implementing—some type of electronic health records (EHR) or electronic documentation system.

• There are a set of eight core functions that electronic health records (EHR) systems should perform in the delivery of safer, higher quality, and more efficient health care. These eight core capabilities for example:

For example:

• more rapid access• laboratory test results, radiology procedure

result reports) can be accessed more easily by at any time and place

• Eliminating lost orders• Improved communication among care associates,

such as medicine, nursing, laboratory, pharmacy, and radiology, can enhance client safety and quality of care.

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