Chapter 09

Psychiatric Mental Health Nursing,
6th Edition

Chapter 9
The Nursing Process in
Psychiatric/Mental Health Nursing

Copyright © 2009. F.A. Davis Company

6th Edition

The Nursing Process
 It is a systematic framework for the delivery of
nursing care.
 It uses a problem-solving approach.
 It is goal-directed, its objective being the delivery
of quality client care.
 It is dynamic, not static.


6th Edition

Standards of Practice
 The standards of practice for psychiatric nursing
are written around the six steps of the nursing
process.
 Assessment—information is gathered from which
to establish a client database. Box 9 - 1
 Interviews
 Observation
 Health team members
 Medical records

6th Edition

 Diagnosis—data from the assessment are
analyzed. Diagnoses and potential problem
statements are formulated and prioritized.
 It includes level of risks assessed in your
Psychosocial assessment
 Problems identified
 See Appendix D and E


6th Edition

 Outcome identification—
 Expected outcomes of care are identified.
 They must be measurable and estimate a time for attainment.
 Realistic for client’s capabilities
 Effective when written by the health care team and client/significant
others
 Nursing Outcomes Classification (NOC)—
 a comprehensive, standardized classification of patient outcomes
developed to evaluate the effects of nursing interventions.
 Linked to NANDA and NIC (nursing interventions classifications)


6th Edition

 Planning—
 evidence-based interventions for achieving the outcome criteria are
selected.
 Individualized to the client’s mental health problems, condition, or needs
 Developed collaboratively with the mental health team
 The nursing interventions should occur independently but in concert with
overall treatment
 Nursing Interventions Classification (NIC)—
 a comprehensive, standardized language describing treatments that
nurses perform
in all settings and in all specialties.
 NIC interventions are based on research and reflect current clinical
practice.


6th Edition

 Implementation—interventions selected during
the planning stage are executed. Specific
interventions include
 Coordination of care
 Health teaching and
health promotion
 Milieu therapy


6th Edition

Coordination of Care
 Role of the Nurse
 As a Case Manager the nurse acts to negotiate with multiple providers to
obtain diverse services.
 Helps achieve health care goals within a prescribed period of time and
finances
 Mental health case managers provide:
 Improve functioning through problem solving
 Improve social skills to be able to work in the community
 Promote leisure time activities
 Enhance overall productiveness


6th Edition

Health Teaching and Promotion
 The role of the nurse as teacher:
 Patients learn in three domains:
 Cognitive domain – storing and recalling of new knowledge
 Intellectual behaviors – acquisition of knowledge, comprehension, application,
analysis, synthesis, and evaluation
 Psychomotor domain
 Physical skills – the integration of mental and muscular activity
 Ex: patient demonstrates how to change a dressing
 Affective domain
 Includes changes in attitude, values, and feelings
 Ex: patient expresses renewed self confidence after physical therapy


6th Edition

Milieu therapy
 The Nurse as the milieu therapists acts to:
 The goal is to manipulate the environment so that all aspects of the client’s
hospital experience are considered therapeutic.
 The purpose is to affect behavioral changes and improve the psychological
health and functioning of the individual
 The therapeutic environment maintained by the healthcare team can
provide:
 Aid in promoting adaptive coping
 Increased interactions
 Improved social skills
 Build relationships to improve quality of life


6th Edition

 Pharmacological, biological, and integrative
therapies.
 Incorporating knowledge of pharmacological,
biological, and complementary intervention with
applied clinical skills to restore
the patient’s health and
prevent further disability.


6th Edition

 Advanced Practice Interventions
 Prescriptive authority and treatment

 Psychotherapy

 Consultation


6th Edition

 Evaluation—measures progress toward
attainment of expected outcomes


6th Edition

Why Nursing Diagnosis?
 Identification and classification of nursing
phenomena began in 1973 with the First National
Conference on Nursing Diagnosis.
 Both general and specialty standards are written
around the six steps of the nursing process, of
which nursing diagnosis is an inherent part.
 It is defined in most state nursing
practice acts as a legal responsibility
of nursing.
 It promotes research in nursing.

6th Edition

Nursing Case Management
 Case management—A health
delivery process whose goals
are to provide quality health care,
decrease fragmentation, enhance
the client’s quality of life, and
contain costs.
 Managed care—A concept designed to control
the balance between cost and quality of care.
Individuals receive care based on need, which is
determined by coordinators of the providership.


6th Edition

 Case manager—The individual responsible for
negotiating with multiple health care providers to obtain a
variety of services for the client.
 Critical Pathways of Care (CPCs)—The tools for
provision of care in a case management system. CPCs
are abbreviated plans of care on
which outcome-based guidelines
for goal achievement within a
designated length of time
have been established.


6th Edition

 CPCs are used by the entire interdisciplinary team. They determine
which categories of care will be provided, by what date, and by
whom.
 Nurses may be identified as case managers and are ultimately
responsible for ensuring that goals on the CPC are achieved within
the designated time dimension.
 CPCs may be standardized
because they are intended to
be used with uncomplicated cases.
A CPC can be viewed as a protocol
for clients with problems for which a
designated outcome can be predicted.


6th Edition

Applying Nursing Process
Role of the nurse in psychiatry
 To assist the client’s successful adaptation to stressors
within the environment.
 Goals are directed toward change in thoughts, feelings,
and behaviors that are age-appropriate and congruent
with local and cultural norms.
 The nurse is a valuable
member of the interdisciplinary
team, providing a service that is
unique and based on sound
knowledge of psychopathology,
scope of practice, and legal implications of the role.


6th Edition

Concept Mapping
 A diagrammatic teaching
and learning strategy
 Shows interrelationships
among medical and nursing
diagnoses, assessment data
and treatments
 They are practical, realistic,
and time-saving
 They enhance critical thinking skills


6th Edition

Concept Mapping (cont.)
 Based on the components of the nursing process
 Helps students develop a
holistic view of their clients


6th Edition

Documentation of the Nursing
Process
 Documentation of the steps of the nursing
process is often considered as evidence in
determining certain cases of negligence by
nurses.
 It is also required by
some agencies that
accredit health care
organizations.


6th Edition

Process
Examples of documentation that reflect
use of the nursing process
 Problem-Oriented Recording (POR)
 Has a list of problems as its
basis
 Uses subjective, objective,
assessment, plan, intervention,
and evaluation (SOAPIE) format


6th Edition

Documentation of the Nursing Process
 Focus Charting
 Main perspective is to choose a
“focus” for documentation. A focus may be
 a nursing diagnosis
 a current client concern or behavior
 a significant change in the client’s status or behavior
 a significant event in the client’s therapy
 The focus cannot be a medical diagnosis.
 It uses data, action, and response (DAR) format.


6th Edition

Process
 APIE method
 A problem-oriented system
 Uses flow sheets as accompanying
documentation
 Uses assessment, problem,
intervention, and evaluation
(APIE) format


6th Edition

Electronic Documentation
 Most health care facilities have implemented—or
are in the process of implementing—some type of
electronic health records (EHRs) or electronic
documentation system.
 EHRs have been shown to
improve both the quality of
client care and the efficiency
of the health care system.


6th Edition

Electronic Documentation (cont.)
 Eight Core Functions of EHRs:
 Health information and data
 Results management
 Order entry/order management
 Decision support
 Electronic communication
and connectivity


6th Edition

Electronic Documentation (cont.)
 Eight Core Functions of EHRs (cont.):
 Patient support
 Administrative processes
 Reporting and population health management


6th Edition

Advantages and Disadvantages of Paper
and EHR charting
Paper EHRs
Advantages Advantages
Fast Accessed by many
Portable Facilitates research
and billing
People know it Reduces errors
Disadvantages Disadvantages
Can be lost Expensive
Hard to read Large learning curve for
Hard to store new users
Difficult to research Technical difficulties


Chapter 09

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