The Nursing Process in Psychiatric/Mental Health Nursing

Question 1

Assessment & Documentation

Answer 1

 Key to contributing to establishment of psychiatric diagnosis

 Proper diagnosis leads to effective treatment

 Nursing input is more crucial in the diagnostic processin psychiatry than medical and surgical settings

Question 2

Medical-Surgical Diagnosis

Answer 2

 MD physical exam

 Tests such as EKG and X-ray

 Labs – blood and body fluid analysis

 RN assessment minor in diagnosis

 RN use of the nursing process to enhance med-surg treatment via nursing interventions/nursing process

Question 3

Psychiatric Diagnosis

Answer 3

 MD physical exam to rule out medical conditions

 Mental status exam(MSE) by MD and Nursing

• observations of patient behavior in the environment over time
• interactions with patient over time

 Some labs

 Some psychological tests if needed for Differential Diagnosis

 Establishes diagnosis and yields most effective treatment

Question 4

Nursing Observation and Documentation

Answer 4

• Nurses do parts or all of the MSE
• Nurses observe patient behavior and interactions
• Nurses document response to treatment
• MD re-interview also establishes response to treatment
• Nurses also use nursing process to provide independent care
• Psychiatric DX and care is multidisciplinary

Question 5

Holistic -Biopsychosocial

Answer 5

• Hx of present illness, Psychiatric Hx, Substance use Hx, Coping skills – PSYCHOLOGICAL
• Medical Hx – PHYSICAL
• Family Hx and Developmental Hx – PSYCHOLOGICAL, PHYSICAL, SOCIAL
• Social, Occupational/Educational Hx, Culture – SOCIAL
• Spirituality - SPIRITUAL

Question 6

Mental Status Exam - Elements

Answer 6

• Appearance
• Behavior/Activity
• Speech
• Attitude
• Mood & Affect
• Thought Process
• Thought Content
• Perceptual Disturbance
• Memory/Cognition
• Insight & Judgement

Question 7

Appearance

Answer 7

• Grooming /dress___________________
• Hygiene__________________________
• Eye Contact_______________________
• Posture___________________________
• Identifying features (scars,tatoos)______
• Appearance versus stated age__________
• Overall appearance__________________

Question 8

BEHAVIOR/ACTIVITY

Answer 8

Hyperactive___, Agitated___, Psychomotor retardation___, Calm___, Tremors___, Tics___, Unusual movements/gestures___, Catatonia___, Akathisia___, Rigidity___, Facial movements(jaw/lip smacking)___, Other_______

Question 9

SPEECH

Answer 9

Slow/rapid___, Pressured___, Tone___, Volume(loud/soft)___, Fluency(mute, hesitation, latency of response)___

Question 10

Attitude

Answer 10

Cooperative___, Uncooperative____ Warm and friendly____, Distant___ Suspicious___, Guarded___, Aggressive___, Hostile___, Combative___ Apathetic___, Aloof___ Other__________________

Question 11

MOOD AND AFFECT

Answer 11

MOOD – (general feeling ) Observe and listen

• Elated___, Sad___, Depressed___, Irritable___, Anxious___, Fearful___, Guilty___, Worried___, Angry___, Hopeless___, Labile___, Mixed(anxious and Depressed)

AFFECT – facial expression

• Flat___, Blunted or diminished___,
• Full range___,
• Inappropriate/incongruent(sad and smiling laughing) e.g.. Smiling at a funeral of a loved one when time to be serious. Facial expression does not fit with the topic being discussed

Question 12

THOUGHT PROCESS

Answer 12

• Cognition – How the patient thinks, thinking processes
• Concrete thinking___, Circumstantiality___, Tangentiality___, Loose associations___, Flight of ideas___, Perserveration___, Blocking___, Derailment___,
• (Echolalia, Clang associations, Word salad – not seen often)
• Other___________

Question 13

Thought Content

Answer 13

• What the patient says
• Delusions
• (Gradiose / persecutory/reference/ somatic)___,Homocidal - to whom?____, Suicidal – describe____, Obsessions___, Paranoia___, Phobias___, Magical thinking___, Poverty of speech___, Other__________

Question 14

PERCEPTUAL DISTURBANCE

Answer 14

• Visual hallucinations___, Auditory___
• commenting___, discussion___, commanding___, loud___, soft___, other________ Other hallucination (Olfactory / tactile) Illusions___, Depersonalization___, Other_________

Question 15

MEMORY/COGNITION

Answer 15

• Orientation___,
• Memory (Recent/remote/confabulation)____,
• Level of alertness (Level of consciousness)___

Question 16

INSIGHT AND JUDGEMENT

Answer 16

• Insight(awareness of the nature of the illness___,
• Judgment___ “What would you do if you saw a letter on the ground with a stamp on it?” Are discharge plans appropriate to pt’s income, ability to work, current roles and capabilities?
• Impulse control___
• Other______

Question 17

Focus Charting

Answer 17

• 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 patient’s status or behavior
  • a significant event in the patient’s treatment
• The focus cannot be a medical diagnosis

Question 18

Documentation

Answer 18

• BIRP
• Behavior/Assess/What the patient is saying and doing
• Interventions
• Response/What the patient said of did as a result of the intervention
• Plan/Where to go next/What does the patient need next

Question 19

Quality Documentation

Answer 19

• Specific and descriptive
• No assumptions or hunches – just the facts
• Use the patients words at times to highlight and clarify
• No need to say “Pt” or “Client” – the whole chart is about the patient
• Only chart what you see and hear now, as patients change
• Avoid the use of “I”. Instead “This writer”