CS 7 The Nursing Process In Psychiatric Nursing PDF

THE NURSING PROCESS in Psychiatric Nursing Class Session 7 REFERENCE: ESSENTIALS OF PSYCHIATRIC MENTAL HEALTH NURSING, 6th Edition, Mary C. Townsend (pp. 131-152)...

THE NURSING PROCESS in Psychiatric Nursing Class Session 7 REFERENCE: ESSENTIALS OF PSYCHIATRIC MENTAL HEALTH NURSING, 6th Edition, Mary C. Townsend (pp. 131-152) MODIFIED BY: MS. RHODORA ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts  Learning Objectives 1. Define related terms. 2. Explain the six steps of the Nursing Process in the care of client in a psychiatric setting. 3. Document client care that validates the use of the nursing process.  A systematic, dynamic process by which the registered nurse, through Assessment interaction with the patient, family, groups, communities, populations, and health-care providers, collects and analyzes data. Clinical judgments about individual, family, or community experiences/ Nursing responses to actual or potential health problems/life processes. It provides the Diagnosis basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.  End results that are measurable, desirable, and Outcomes observable and translate into observable behaviors. The process of determining the progress toward Evaluation attainment of expected outcomes, including the effectiveness of care.  Standards of Practice Describe a competent level of nursing care as demonstrated by the critical thinking model kn own as the nursing process.  Goal Has six steps: ADOPIE Oriented Uses Problem Solving approach SCIENTIFIC METHOD Dynamic; not static Delivery of Quality = Ongoing process CHANGE Nursing Service CORE CONCEPTS ( Re ) Assessment Evaluation Diagnosis Implementation Outcomes Planning  Standard 1. Assessment The psychiatric/mental health registered nurse collects comprehensive health data that is pertinent to the patient’s health or situation.  Standard 2. Diagnosis The psychiatric/mental health registered nurse analyzes the assessment data to determine diagnoses or problems, including level of risk.  Standard 3. Outcomes Identification The psychiatric/mental health registered nurse identifies expected outcomes for a plan individualized to the patient or to the situation. Nursing Outcomes Classification (NOC) is a comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions.  Standard 4. Planning The psychiatric/mental health registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. Nursing Interventions Classification (NIC) is a comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties.  Standard 5. Implementation The psychiatric/mental health registered nurse implements the identified plan.  Standard 5A. Coordination of Care The psychiatric/mental health registered nurse coordinates care delivery.  Standard 5B. Health Teaching and Health Promotion The psychiatric/mental health registered nurse employs strategies to promote health and a safe environment.  Standard 5C. Milieu Therapy The psychiatric/mental health registered nurse provides, structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other health-care clinicians.  Standard 5D. Pharmacological, Biological, and Integrative Therapies The psychiatric/mental health registered nurse incorporates knowledge of pharmacological, biological, and complementary interventions with applied clinical skills to restore the patient’s health and prevent further disability.  Standard 5E. Prescriptive Authority and Treatment The psychiatric/mental health advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.  Standard 5F. Psychotherapy The psychiatric/mental health advanced practice registered nurse conducts individual, couples, group, and family psychotherapy using evidence-based psychotherapeutic frameworks and nurse-patient therapeutic relationships.  Standard 5G. Consultation The psychiatric/mental health advanced practice registered nurse provides consultation to influence the identified plan, enhance the abilities of other clinicians to provide services for patients, and effect change.  Standard 6. Evaluation The psychiatric/mental health registered nurse evaluates progress toward attainment of expected outcomes.  Case management – Is an innovative model of care delivery that can result in improved client care. – Clients are assigned a manager who negotiates with multiple providers to obtain diverse services. – Concept: the start of diagnosis-related groups and shorter hospital stays. Managed care – refers to a strategy employed by purchasers of health services who make determinations about various types of services in order to maintain quality and control costs. Applying Nursing Process MENTAL HEALTH Applying Nursing Process MENTAL HEALTH Therapy should be… Physician INTERDISCIPLINARY/ Nurse MULTIDISCIPLINARY Psychiatrist Physical Therapist Occupational Therapist Social Worker  Case Scenario: A newly admitted mentally ill patient maybe demonstrating the following behaviors: Inability to trust others Verbalizing hearing voices Refusing to interact with staff and peers Expressing a fear of failure Poor personal hygiene  From these assessments, the treatment team may determine that the client has the following problems: Paranoid Delusions Auditory Hallucinations Social Withdrawal Developmental Regressions  Team Goals:  Reducing suspiciousness  Terminating auditory hallucination  Increasing self worth Nursing Diagnoses: 1. Disturbed Sensory Perception: auditory 2. Disturbed thought process 3. Low self esteem 4. Self care Deficit Nursing Dx are prioritized according to life threatening potential.  NURSING DIAGNOSES NURSING RELATED FACTORS DIAGNOSIS Panic level of anxiety Withdrawal into the self Stress sufficiently severe to threaten an already weak ego Disturbed Altered sensory perception; Sensory excessive environmental stimuli; Perception: psychological stress; Auditory altered sensory reception, transmission, and/or integration/insufficient environmental stimuli; biochemical imbalances for sensory distortion (e.g., illusions, hallucinations); electrolyte imbalance; biochemical imbalance  NURSING DIAGNOSES NURSING RELATED FACTORS DIAGNOSIS Inability to trust Disturbed Panic level of anxiety thought Repressed fears process Stress sufficiently severe to threaten an already weak ego Possible hereditary factor Inability to trust Low self-esteem Inadequate support systems Negative role model Underdeveloped ego  NURSING DIAGNOSES NURSING RELATED FACTORS DIAGNOSIS Lack of positive feedback Low Self Unmet dependency needs Esteem Retarded ego development Repeated negative feedback, resulting in diminished self worth Dysfunctional family system Fixation in earlier level of development  NURSING DIAGNOSES NURSING RELATED FACTORS DIAGNOSIS Withdrawal into the self Self care Regression to an earlier Deficit level of development Panic level of anxiety Perceptual or cognitive impairment Inability to trust Expected Outcomes: Demonstrates trust in one staff member within 3 days Verbalizes understanding that the voices are not real within 5 days. Completes one simple craft project within 5 days. Takes responsibility for self care and performs ADLs independently by time of discharge. Documentation of the Nursing Process SOAPIE  THE END. Thank you! ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts