nursing process

1. Nursing Process in Mental
Health Nursing

2. • 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

4. 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.

5. • 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.

8. A quick and brief mental status
evaluation is the follwing:

9. 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

10. • 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).

11. • 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.

12. 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.

13. 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.

14. Several specific interventions are included among the
standards 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, and
Integrative Therapies to restore the patient’s health

15. Standard 6. Evaluation
• The Psychiatric-Mental Health Registered
Nurse evaluates progress toward attainment
of expected outcomes.
• The client’s response to treatment is
documented,

16. 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.

17. 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.

18. • Types of clients who benefit from case management
include (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 problems
that require multifaceted, costly care (e.g., highrisk
infants, those with human immunodeficiency virus
[HIV] or

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

20. APPLYING THE NURSING PROCESS
IN 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:

21. • 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.

23. DOCUMENTATION OF THE NURSING
PROCESS
1. Problem-Oriented Recording: follows the
subjective, objective, assessment, plan,
implementation, and evaluation format.

24. 2. Focus Charting: The documentation
is 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
client
A = Action: Immediate or future nursing actions
R = Response: Description of client’s responses to
any
part of the medical or nursing care.

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

27. 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

28. 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:

29. 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.

30. Thank You