unit 3: nursing process in mental health

University of Babylon/ College of Nursing

Unit 3: Nursing Process in Mental Health:

Learning Objectives1. Define the role of the LPN/LVN in the five steps of the nursing

process.

2. Identify the components of a mental health status assessment.

3. Explain the abbreviation of NANDA

4. Prepare a patient interview.

5. Explain the Key Concepts of Nursing Process in Mental Health.

Guidelines for Nurse-Patient Helping Interview

1. Be honest:

2. Be assertive:

3. Be sensitive:

4. Use empathy:

5. Use open-ended questions:

The nursing process is a tool used throughout all areas and levels of nursing.

• Scope of practice determines that the

registered nurse (RN) and the licensed

practical nurse/licensed vocational nurse(LPN/LVN) play different roles in the nursingprocess.

▪ In the early 1950s, Hildegard Peplau hypothesized that

nurses are a tool best utilized in relation to the patient and

the environment and in collaboration with other nurses and

health-care professionals. She stressed the phases of a

working relationship that included a termination phase

where nurses prepare both themselves and their patients for

termination of the relationship.

Step 1: Assessing the Patient’s Mental Health• Assessment is the first step in the nursing process. The

role of the LPN/LVN in Step 1 is to assist with the

assessment. The registered nurse is responsible for the

initial assessment when the patient is admitted or

transferred to a facility.

• Nurses also use nonverbal communication skills to

assess the patient’s attitude, tone of voice, facial

expression, and so on.

APIE format

• It is during the data collection/assessment part of the

nursing process that the mental status exam is

performed. The mental status exam is a series of

questions and activities that check eight areas: the

patient’s (1) level of awareness and orientation, (2)

appearance and behavior, (3) speech and

communication, (4) mood and affect, (5) memory, (6)

thinking/cognition, (7) perception, and (8) judgment.

Mental Health Status Examination

Area of

Assessment

Type of Assessment Suggested Methods of

Assessment and Normal

Parameters

Alterations to Normal

Assessment

• Appearance Objective observations such

as dress, hygiene,

posture; and

about the

patient’s actions

and reactions to

health-care

personnel.

Clean, hair combed; clothing intact and

appropriate to weather or

situation.

Posture erect.

Cooperates with health-care personnel.

Displays either

unusualapathy or

concernabout

appearance.


Area of

Assessment

Type of Assessment Suggested Methods of Assessment

and Normal ParametersAlterations to

Normal

Assessment

• Memory Subjective assessment

of the mind’s ability to

recall previously known

recent and remote

(long-term)

information.

Recent memory: Recall of events

that are immediately past or up to

within 2 weeks before theassessment. One measurement

technique is to verbally list five

items. After 1 minute, patient

should be able to recall 4–5 of

those items. Continue with

assessment and at 5 minutes,

patient should be able to recall 3–

4 of the items.

Remote memory: Recall of events

of the past beyond 2 weeks prior

to assessment. Patients are often

asked questions pertaining to

where they were born, where they

went to grade school, and so on.

Inability toaccurately

perform recent or

remote recallexercises; may

indicate

symptoms ofdelirium or

dementia.


Area of

Assessm

ent



Parameters


Assessment

• Mood and

Affect

Subjective and

objective assessmentof the patient’s stated

feelings and emotions.

Affect measures the

outward expression of

those feelings.

Mood is the stated emotional condition of the

patient and should fluctuate

to reflect situations as they

occur.

Facial expression and body language (affect) should

match (be congruent with)

stated mood. Affect should

change to fluctuate with the

changes in mood.

Mood andaffect do not

match (e.g.,facial

expressiondoes not

change whenstating

opposite

feelings)..


Area of

Assessment



Parameters


Assessment

• Perception Assesses the way a person

experiences reality.

Assessment is based on

the patient’s statements

about his or her

environment and the

behaviors associated with

those statements.

Nurses and health-team

members must document

this often-subjective

information in objective

terms.

All five senses are monitoredfor interaction with the

patient’s reality.

Patient’s insight into his or her

condition is also assessed.

Presence of

hallucinations and

illusions. Individuals

who are not within

normal boundaries of

judgment or insight

will not be able to

state understanding

of the origin of the

illness and the

behaviors associated

with it.

Step 2: Nursing Diagnosis: Defining Patient Problems• Processing the collected data is a function of the registered nurse,

according to the ANA (American Nurses Association). Once datais collected, nursing diagnoses are identified.

• There are different models or theories of nursing diagnosis thatmay be used and recommended by your work setting. Theseinclude nursing diagnoses published by the North AmericanNursing Diagnosis Association (NANDA).

• An emerging format for writing a diagnostic statement for apatient’s plan of care is the P.E.S. Model. The components of thismodel are P, the problem or need; E, the etiology or cause; and S,the signs, symptoms, or risk factors.

Step 3: Planning (Short and Long-Term Goals)

• The LPN/LVN role is again as a partner in care

planning.

• Planning care involves setting short-term and long-

term goals from the patient’s perspective, not

from the nurse’s perspective. It is for this reason

that the patient and significant others must be

involved in the plan of care.

• The aim of selecting goals that will improve mental

health status is to keep the mind-body connection

intact. It is estimated that about 95% of physical

healing is related to a positive mental attitude

(PMA).

• Both goals should be realistic and measurable with

a target date for them to be completed.

Step 4: Implementations/ Interventions

• The LPN’s role is to assist with identifying and carrying

out the specific steps that will help the patient reach the

goals. A nurse may use this opportunity to conduct some

new patient teaching.

• Nurses also need to understand and specify the rationale

(reason) for the implementations that are selected and be

prepared to explain them to patients and families provided

the patient consents to their involvement.

Step 5: Evaluating Interventions

• In this final step of the nursing process, the LPN/LVN

plays an assisting role. The LPN/ LVN’s observations and

documentation about the effect of the interventions on the

patient and progress in attaining the goal are of great

importance.

• Accuracy in verbal and written reporting of the patient’s

progress will help determine whether the interventions are

helpful or whether they need to be re-evaluated and

changed.

Key Concepts of Nursing Process in Mental Health1. Nursing process is an example of collaborative nursing practice. RNs areprimarily responsible for the steps of the nursing process; LPN/LVN-preparednurses assist in data collection, planning, implementing, and evaluating thenursing process.2. The nursing process format can be used by other health-care disciplines tocreate a care plan.3. Nurses are conducting more interviewing and teaching on a daily basis. Entry-level nurses need a basic knowledge of both skills. Individual states and facilitiesset the guidelines for teaching within the scope of the nurse’s practice.4. Nursing process is a helpful tool for preparing a teaching plan.5. The ANA has set guidelines that dictate the roles of the RN and the LPN/ LVNin collaborating in the nursing process.6. New models for collaborative nursing and nursing outcome statements arebeing developed.

EXAMPLE TO APPLYING NURSING PROCESS

❖ Nursing Care plan• Nursing Diagnosis: Suicide attempt

- Risk for Self-Harm or other - related to history of prior suicide attempt,

depressed mood, feelings of hopelessness and worthlessness, misinterpretations

of reality.

▪ Long-term, client centered goals for nursing diagnosis.

- Patient will:

1. Demonstrate alternative ways of dealing with negative feeling and emotional stress.

2. Identify supports and support groups with whom he is in contact within 1 month.

3. State that he wants to live.

4. Start working on constructive plans for the future.

5. Demonstrate adherence with any medication or treatment plan with 2 weeks.

▪ Short-term, client centered goals for nursing diagnosis.

- Patient will:

✓ Not harm self or other.

✓ Have links to self-help group in the community.

✓ Stay with friend or family if person still has potential for

suicide.

N Nursing intervention Rationales

1. 1. Ask client directly: “Have

you thought about killing

yourself?” or “Have you

thought about harming

yourself in any way? If so,

what do you plan to do?

Do you have the means to

carry out this plan?”

1. The risk of

suicide is greatly

increased if the

client has

developed a plan

and particularly if

means exist for

the client to

execute the plan.


2. Create a safe environment for

the client. Remove all

potentially harmful objects

from client’s access (sharp

objects, straps, belts, ties, glass

items, alcohol). Supervise

closely during meals and

medication administration.

Perform room searches as

deemed necessary.

Client safety is a

nursing priority.

3. Formulate a short-term

verbal or written contract

that the client will not harm

self during a specific time

period. When the contract

expires, make another.

Repeat this process for as

long as required.

Discussion of suicidal feelings

with a trusted individual

provides some relief to the

client. A contract gets the

subject out in the open and

some of the responsibility for

his or her safety is given to the

client.

4. Maintain close observation of the

client.

Depending on level of suicide

precaution, provide one-to-one

contact, constant visual

observation, or every- 15-minute

checks. Place in room close to

nurse’s station; do not assign to

private room. Accompany to off-

unit activities if attendance is

indicated. May need to

accompany to bathroom.

Close observation is necessary to

ensure that client does not harm

self in any way. Being alert for

suicidal and escape attempts

facilitates being able to prevent or

interrupt harmful behavior.

5. Maintain special care in

administration of

medications.

Prevents saving up to

overdose or discarding and

not taking.

6. Make rounds at frequent,

irregular intervals (especially

at night, toward early

morning, at change of shift,

or other predictably busy

times for staff).

Prevents staff surveillance

from becoming predictable.

To be aware of client’s

location is important,

especially when staff is busy,

unavailable, or less

observable.

7. Encourage client to express

honest feelings, including

anger. Provide hostility

release if needed. Help the

client to identify the true

source of anger and to work

on adaptive coping skills for

use outside the treatment

setting.

Depression and suicidal

behaviors may be viewed as

anger turned inward on the

self. If this anger can be

verbalized in a

nonthreatening environment,

the client may eventually be

able to resolve these

feelings.

• Nursing Diagnosis: Auditory hallucination.

- Disturbed sensory perception (Auditory hallucination) related

to Panic anxiety, extreme loneliness and chemical alteration

(e.g. electrolyte imbalances).

- EVIDENCED BY: Inappropriate responses, disordered thought

sequencing, rapid mood swings, poor concentration,

disorientation

▪ Long term goals

- Patient will:

- Client will be able to define and test reality, reducing or

eliminating the occurrence of hallucinations. (This goal may

not be realistic for the individual with severe and persistent

illness who has experienced auditory hallucinations for many

years).

- Client will verbalize understanding that the voices are a result

of his or her illness and demonstrate ways to interrupt the

hallucination.

▪ Short-term, client centered goals for nursing diagnosis.

- Patient will:

✓ •Client will discuss content of hallucinations with nurse or therapist within 1

week.


1. If voices are telling the patient to harm self or

others, take necessary environmental

precautions.

a. Notify others and police, physician, and

administration according to unit protocol.

b. If in the hospital, use unit protocols for

threats of suicide or violence if patient plans

to act on commands.

c. If in the community, evaluate need for

hospitalization.

d. Clear document what patient says; if he is

1. People often obey

hallucinatory commands

to kill self or others. Early

assessment and

intervention might save

lives.

2. Decrease environmental

stimuli when possible (low

noise, minimal activity).

2. Decrease potential for

anxiety that might trigger

hallucinations. Help calm

patient.

3. Accept the fact that the

voices are real to the

patient, but explain that

you do not hear the voices.

3. Validating that your reality

does not include voices can

help patient cast "doubt" on

the validity of his voices.

4. Stay with patients when they

are starting to hallucinate,

and direct them to tell the

voices they hear" to go

away. Repeat often a

matter-of-fact manner.

4. Patients can sometimes

learn to push voices aside

when given repeated

instruction, especially within

the framework of a trusting

relationship.

5. Keep to simple, basic, reality

based topics of

conversation. Help patient

to focus on one idea at a

time.

5. Patient's thinking might be

confused and disorganized;

this intervention helps patient

focus and comprehend

reality based issues.

6. Explore how the

hallucinations are

experienced by the patient.

6. Exploring the hallucination

and sharing the experience

can help give the person a

sense of power that he might

be able to manage the

hallucinatory voices.

7. Help patient identify the

needs that might underlie

the hallucination. What

other ways can these needs

be met?

7. Hallucination might reflect

needs for.

a. Power.

b. Self esteem

c. Anger.

d. Sexuality.

8. Help patient identify times

the hallucinations are most

prevalent and frightening.

8. Help both nurse and

patient identify situation and

times that might be most

anxiety producing and

threatening the patient.

9. Be alert for signs of

increasing fear, anxiety, or

agitation.

9. Might herald hallucinatory

activity, which can be very

frightening to patient, and

patient might act on

command hallucinations

(harm self or other).

• Nursing Diagnosis: Persecutory delusion.

- Disturbed Thought processes related to inability to trust, panic

anxiety or biochemical factors

- EVIDENCED BY: Delusional thinking; inability to concentrate;

impaired volition; inability to problem solve, abstract, or extreme

suspiciousness of others.

▪ Long term goals

- Patient will:

- By time of discharge from treatment, client’s verbalizations

will reflect reality- based thinking with no evidence of

delusional ideation.

- By time of discharge from treatment, the client will be able to

differentiate between delusional thinking and reality.

▪ Short term goals

- Patient will:

- By the end of 2 weeks, client will recognize and verbalize that false ideas

occur at times of increased anxiety.


1. Utilize safety measures to

protect patients if he

believes they need to

protect themselves against

specific person.

1. During acute phase,

patient's delusional thinking

might dictate to them that

they might have to hurt others

or self to be safe. External

controls might be needed.

2. Attempt to understand the

significance of these

beliefs to the patient at

the time of their

presentation.

2. Important clues to

underlying fears and

issues can be found in

the patient's seemingly

illogical fantasies.

3. Be aware that patient's

delusions represent the

way that he experiences

reality.

3. Identifying the

patient's experience

allows the nurse to

understand the patient's

feelings.

4. Identify feelings related to

delusions. For example:

a. If patient believes someone is

going to harm him, patient is

experiencing fear.

b. If patient believes someone or

something is controlling his

thoughts, patient is experiencing

helplessness.

4. When people believe that they

are understood, anxiety might

lessen.

5. Do not touch the patient; use

gesture carefully.

5. Arguing will only increase

patient's defensive position,

thereby reinforcing false beliefs.

This will result in the patient

feeling even more isolated and

misunderstood.

6. Do not touch the patient's use

gestures carefully?

6. A psychotic person might

misinterpret touch as either

aggressive or sexual in nature

and might interpret gestures as

aggressive moves. People who

are psychotic need a lot of

personal space.

7. Interact with patients on the basis

of things in the environment. Try to

distract patient from their delusions

by engaging in cards, simple

board games, simple arts and

craft projects, cooking with

another person, and so forth.

7. When thinking is focused on

reality-based activities, the

patient is free of delusional

thinking during that time. Help

focus attention externally.

8. Teach patient coping skills that minimize

"worrying" thoughts.

Coping skill include:

a. Talking to a trusted person.

b. Phoning a helpline.

c. Singing (When auditory hallucinations

start).

d. Going to a gym.

e. Thought-stopping techniques.

8. When patient is

ready, teach strategies

patient can do alone.

9. Encouraging healthy habits to optimize

functioning:

A. Maintain regular sleep pattern.

b. Reduce alcohol and drug intake.

c. Maintain self-care.

d. Maintain medication regimen.

9. All are vital to help

keep patient in

remission.

unit 3: nursing process in mental health

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