Firelands Regional Medical Center School of Nursing

Psychiatric Nursing 2012

Nursing Process: Samantha Paris	7/1/12: Date

1. How does the nursing process serve psychiatric nursing practice?

Nursing process assists psych nursing in that it allows a breakdown of the nursing care for psych patients that includes the nursing diagnosis, outcomes, planning and implementation, and reassessment. This continually allows for the nurse provide comprehensive care to fill all the clients needs.

2. Identify the components of the assessment used by psychiatric nurses.

The components of assessment that are used are divided into topics such as physical, sociocultural, psychological, spiritual, cognitive, functional abilities, developmental, economic, lifestyle. This core concepts allow the nurse to be able to gather data in all fields that allows the care to be patient directed, and allows the nurse and health care provider to better understand the needs of the client, as well as how their lifestyle affected their current illness, or psychological state.

3. What is the purpose of the mental status evaluation? What are the components of the mental status exam?

The mental status evaluation allows the nurses to have a baseline of the client’s mental state and activity to compare for how the patient progresses during their care. The main purpose is to assess the presence and extent of a person’s mental impairment. Also to get a measure of biological, psychological and social factors that predisposed, precipitated, and perpetuate the client's current functioning, and establish a client’s capacity to function. This exam is done through verbal and nonverbal communication. The components are observations of appearance, activity level, behavior, speech, and attitude toward the interviewer, level of consciousness, thought content, affect and mood, cognition, reality contact, memory, confidence in information given, and intoxication.

4.	List and describe the Standards of Psychiatric/mental health Clinical Nursing Practice.

Standard 1 Assessment: The RN collects comprehensive heath data that is relevant to the patients health or situation

Standard 2 Diagnosis: The RN analyzes the health data to determine diagnosis, problems, or risk level

Standard 3 Outcomes Identification: The RN identifies expected outcomes for the clients plan of care that are relevant to the clients health or situation

Standard 4 Planning: The RN develops a plan that prescribes strategies and alternatives to attain the outcomes of the plan of care

Standard 5 Implementation: The RN implements the plan of care

Standard 5a Coordination of care: The RN coordinates the delivery of the care

Standard 5b Health teaching and health promotion: The RN employs strategies to promote safety and health

Standard 5c Milieu therapy: The RN provides structures and maintains a safe therapeutic environment in collaboration with the family and other of interdisciplinary team

Standard 5d Pharmacological, Biological, and Integrative therapies: The RN uses their knowledge of Pharmacology, biology, and integrative therapies with clinical skills to improve the patients health and prevent further disability

Standard 5e Prescriptive authority and treatment: The CNP uses her prescriptive authority for procedures, referrals, treatments and therapies in accordance with laws and regulations

Standard 5f psychotherapy: the advanced practice nurse conducts individual, couples, group and family psychotherapy using evidence based practice techniques and frameworks and nurse patient relationships

Standard 5g consultation: The advanced practice RN provides consultation to promote the identified plan, increase the other clinicians ability to provide services for other patient services and effect change

Standard 6 Evaluation: The RN evaluates the progress toward the attainment of expected outcomes

5. Define the core concept of “nursing diagnosis”.

Nursing diagnoses are clinical judgments about individual, family, or community responses, to actual or potential health problems, and life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (Pg. 137)

6. Nursing outcomes (goals) are derived from the “nursing diagnosis”. Identify the aspects of a good outcome.

A good outcome has measurable, expected, patient focused goals that are applicable to observable behaviors by the client. The goals have to be realistic for the patient. The outcomes are better generally when the interdisciplinary team writes them up so all bases are covered so to speak. The goals are also supposed to be attainable.

7. During the evaluation phase of the nursing process, what items are evaluated?

The evaluation phase is the process of determining both the client’s progress toward the attainment of expected outcomes and the effectiveness of nursing care (pg. 140). During this phase the success of interventions in meeting the outcomes is measured in response to the client. The response is documented so that all parts of the care can be evaluated and adjusted according to the clients increased or decreased progress. Then it is revised. The level of nursing, the treatment regimen, the client’s activity, and health status are evaluated.

8. What is meant by case management?

Case management is where clients are assigned to a specific case manager who works with multiple health care providers, and other members of the interdisciplinary team to obtain a multitude of services to help improve the client’s quality of life. It works to see that the time of stay is as short as possible and remains in a certain financial budget. Also it organizes the client’s care so that specific clinical goals and financial outcomes are met. This works for both short term and long term care. They work to maintain quality and control costs while using a multitude of services.

9. What is the nurse’s role in case management?

According to Bower, nurses are suited to case management because clients with multiple health problems need care that has a health related component. Nursing incorporates biological, psychological, and sociocultural aspects that are related to patient and human functioning. Due to all the aspects that incorporated in nursing care it makes them fit case managers because they are able to assist and coordinate all parts of a clients care that they may need because they understand it as well as being able to assess all of these aspects. So nurses are able to manage any aspect of care a client may need due to their training and knowledge base.

10. Using all the components for writing a nursing diagnosis, write a nursing diagnosis for the following individual:

Mr. Smith is admitted through the emergency department of a major health care center. He is accompanied by his wife who states, “My husband has just been fired from his job of 10 years, he speaks negatively of himself to me and friends, he has no desire to go out socially, and secludes himself in his bedroom”.

Sam’s appearance is unkempt. His clothes are dirty and wrinkled, his hair is oily and uncombed, and there is an obvious body odor about him.

The physician has diagnosed Sam with Depression and orders an antidepressant on a scheduled basis and prn.

What components of the assessment data would be significant to nursing?

The important components are the direct view of the husband’s appearance, which are the apparent lack of hygiene, lack of care for appearance, the disheveled appearance. Also his wife’s statements about his behavior need to be taken into consideration. Her statements include the following: loss of job, seclusion, antisocial behavior, and a negative self-image. When talking to the patient I would want to assess his own views on himself especially attitudes and behavior.

Write a nursing diagnosis with defining characteristics, for each identified component selected from the assessment data.

Ineffective coping R/T major lifestyle change (Career loss) AEB:

Lack of hygiene

Unkempt appearance

Social isolation

Seclusion from close friends and family

Negative self image

Impaired Social interaction R/T major lifestyle change AEB:

Social isolation

Seclusion from close friends and family

Negative self image

Hygiene self care deficit R/T major lifestyle change AEB:

Disheveled appearance

Dirty and wrinkly clothes

Oily and uncombed hair

Distinct body odor

Provide outcome criteria for each nursing diagnosis.

Patient will display effective coping AEB:

Performance of hygienic activities

Clean appearance

Denies social isolation

Denies seclusion from friends and family

Denies negative self image

Patient will display improved social interaction AEB:

Denies social isolation

Denies seclusion from close friends and family

Denies negative self image

Patient will display increased self care R/T hygiene AEB:

Clean appearance

Clean and neat clothing

Clean and combed hair

Lack of apparent body odor

Describe appropriate nursing interventions to achieve the outcome criteria.

Ineffective coping:

Assess LOC Q AAT: Rationale: monitor improvement or change in mental status

Assess neuro status/ VS Q 4 hrs. Rationale: monitor improvement or change in client health status

Encourage, assist with ADL’s q AAT: Rationale: help improve patients adherence to ADL’s, improve patient hygiene

Education regarding personal hygiene q until patient can demonstrate understanding of need to perform this: Rationale: promote understanding of need to perform personal hygiene

Promote self image Q AAT: Rationale: help patient to improve view on personal self

Encourage social interaction Q AAT or when pt. is comfortable: Rationale: improve social ability so patient will interact and return to normal social behavior

Educate family regarding encouragement of patient in steps toward improving mental health.

Impaired social interaction:

Assess LOC Q AAT: Rationale: monitor improvement or change in mental status

Assess neuro status/ VS Q 4 hrs. Rationale: monitor improvement or change in client health status

Promote positive self image Q AAT: Rationale: help patient to improve view on personal self

Encourage social interaction Q AAT or when pt. is comfortable: Rationale: improve social ability so patient will interact and return to normal social behavior

Educate family regarding encouragement of patient in steps toward improving mental health

Discuss/ Encourage patient to discuss feelings regarding their current lifestyle: Rationale: help assist patient to explore feelings and openly discuss behavior to improve social and personal feelings

Self care deficit (Hygiene)

Assess LOC Q AAT: Rationale: monitor improvement or change in mental status

Assess neuro status/ VS Q 4 hrs. Rationale: monitor improvement or change in client health status

Encourage, assist with ADL’s q AAT: Rationale: help improve patients adherence to ADL’s, improve patient hygiene

Education regarding personal hygiene q until patient can demonstrate understanding of need to perform this: Rationale: promote understanding of need to perform personal hygiene

Promote self image Q AAT: Rationale: help patient to improve view on personal self

Encourage social interaction Q AAT or when pt. is comfortable: Rationale: improve social ability so patient will interact and return to normal social behavior

Educate family regarding encouragement of patient in steps toward improving mental health

At what point in Sam’s care would you as the nurse evaluate the nursing plan of care?

I would evaluate the plan of care after each assessment of the client oto ensure that all the goals are being met or at least attainable related to the clients health status. I would evaluate the effectiveness of the plan of care if there is improvement or decline in the clients ability to perform interventions or a change from the clients base line.

Firelands Regional Medical Center School of Nursing

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2012-06-28

samantha paris

Firelands Regional Medical Center