THE NURSING PROCESS

Care of the Mentally ILL

 NURSING PROCESS
 Utilized in a unique manner for
psychosocial assessment
 Set goals with client that can be
measured in behavioral terms
 Uses principles of therapeutic
communication for interventions
 ASSESSMENT
 Referred to as psychosocial
assessment
– Includes mental status
examination
Purpose
– Construct a picture of the client’s
current emotional state, mental
capacity, & behavioral function
– Basis for developing plan of care
– A clinical baseline to measure
client’s progress
 Factors Influencing
Assessment
1. Client participation/feedback
2. Client’s health status
3. Previous experiences
 Misconceptions about health care
4. Ability to understand
5. Nurse’s attitude and approach
 The Interview
 Environment
– Comfortable, private and safe for both client
and nurse
 Input from family and friends
 Phrasing of questions
– Start with open-ended questions
– Use direct questions: focused or closed-ended
questions
• Clear, simple & focused on specific symptom or
behavior
– Use non-judgmental language and matter-of-
fact tone
 PHYSICAL ASSESSMENT
Subject reporting of health history
Objective date:
• CHRONOLOGICAL AGE vs
DEVELOPMENTAL STAGE
• ATTIRE
• HYGIENE
• PHYSICAL HEALTH
• PSYCHOMOTOR
• SLEEP and REST
Neurological assessment /
level of consciousness
 PHYSICAL ASSESSMENT

General Appearance and Motor

Behavior
– Automatism – repeated purposeless
behaviors ~ anxiety: drumming of fingers
– Psychomotor retardation – overall slowed
movements
– Waxy flexibility – maintenance of posture
or position over time even when awkward
or uncomfortable
 MENTAL STATUS
ASSESSMENT
 Observation of Mood (pervasive and enduring
emotional state) and affect (physical manifestations
of mood).
– APPROPRIATENESS & CONSISTENCY

– DESCRIPTION: flat, sad, smiling, serious, happy,

euphoric, anxious, angry
• LABILE – rapidly changing mood

– STABILITY
– SPECIFIC FEELINGS and MOOD
– INTENSITY
 MENTAL STATUS
ASSESSMENT
AFFECT
– Blunted affect – little or slow-to-respond
facial expression
– Broad affect – displaying full range of
emotional expressions
– Flat affect - no facial expression
– Inappropriate affect – facial expression
incongruent with mood or situation
– Restricted affect - one type of expression ~
serious or somber
– Unstable
unhappy affect
of borderline
personality
disorder
 COGNITIVE ASSESSMENT
 Evaluation of thought, sensorium and
intelligence
2. INTELLECTUAL PERFORMANCE
A. Orientation to person, place and time
• Disorientation vs confusion
B. Attention and concentration
• Ask client to perform certain tasks
• spell the word “world” backward
C. Memory: short and long term
• Ask direct questions with verifiable answers
D. Judgment
E. Insight to illness
F. Abstract thinking & intellectual abilities
 COGNITIVE ASSESSMENT

1. SPEECH
A. Amount, Volume, Clarity
B. Characteristics: pressured, slow or fast, dull or
lively
C. Specific aberrations
2. THOUGHTS
A. Thought process (how) vs thought content
(what)
B. Content and clarity
C. Characteristics: spontaneity, speed, loose
associations, blocked, flight of ideas, repetitions
 COGNITIVE ASSESSMENT
 Common Terms:
– Circumstantial thinking – client answers
question only after giving excessive
unnecessary detail.
– Delusion – fixed false belief not based in
reality
– Flight of ideas – excessive amount and
rate of speech of fragmented unrelated
ideas
– Ideas of reference – inaccurate
interpretation that general events are
personally directed to him
COGNITIVE ASSESSMENT

– Loose associations – disorganized

thinking from one idea to another with
little or no evident relation between them
– Tangential thinking – wandering off the
topic and never providing info requested
– Thought blocking – stopping abruptly in
middle of sentence or train of thought &
unable to continue the idea
– Thought broadcasting – delusional belief
that others can hear or know what he is
thinking
Thought
broadcasting
 COGNITIVE ASSESSMENT
– Thought insertion – delusional belief that
others are putting ideas or thoughts into
his head
– Thought withdrawal – delusional belief
that others are taking his thoughts away
and he is powerless to stop it
– Word salad – flow of unconnected words
that convey no meaning to the listener
 Assessment of suicide or harm toward
others
• Ask direct questions
• Legal duty to warn
 COGNITIVE ASSESSMENT
1. SENSORY-PERCEPTUAL ALTERATIONS
A. Hallucinations – false sensory perceptions or
perceptual experiences that do not really exist
B. Can involve the 5 senses and bodily sensations
– Auditory hallucinations most common

2. SELF-CONCEPT
A. Personal view of self
B. Description of physical self
– Body image of client
C. Personal qualities or attributes
– Emotions and coping strategies
 SOCIAL / CULTURAL
CONSIDERATIONS
 DEVELOPMENTAL TASKS
 FAMILY / COMMUNITY RELATIONSHIPS
– Role of client family
– Family harmony, family support for or
dependency on client
– Client’s perception of family
– Availability of community support groups to
client
 SOCIOECONOMIC GROUP /
EDUCATION
Factors that relate to how client is
approached and how client perceives own
present state.

Determination of level of teaching and

need for social services /
institutionalization.
 CULTURAL / SPIRITUAL
BACKGROUND
Assess behaviors in context of client’s
culture

Avoid stereotyping persons as having

attributes of their culture/subculture

Religious and philosophic beliefs

 Physiologic/self-care
Considerations
Eating habits
Sleep patterns
Health problems
Compliance with medications
ADLs
 ANALYSIS
Anxiety
Ineffective family coping
Ineffective individual coping
Decisional conflict
Fatigue
Fear
Hopelessness
 ANALYSIS
Knowledge deficit
Powerlessness
Sleep pattern disturbances
Altered thought processes
Risk for violence
Impaired verbal communication
Impaired social interaction
 ANALYSIS
Altered role performance
Spiritual distress
Self-esteem disturbance
Social isolation
Altered family processes
Defensive coping
Ineffective denial
 ANALYSIS
Ineffective denial
Noncompliance
Body Image disturbance
Risk for self mutilation
Rape-trauma syndrome
Impaired adjustment
 ANALYSIS
Psychological tests
– Intelligence tests
» Evaluate cognitive abilities, intellectual functioning
– Personality tests
» Reflect self-concept, impulse control, reality testing,
major defenses

Psychiatric diagnoses
– Diagnostic and Statistical Manual of Mental
Disorders, Text Revision, 4th edition
(DSM-IV-TR)
• Classifies mental disorders into categories
 PLANNING
The psychiatric/mental health nurse
identifies expected outcomes
individualized to the client.

Plan of care is negotiated among the

client, nurse, family, and healthcare team
and prescribes evidence-based
interventions to attain expected outcomes
 GOALS
– Client will participate in treatment
program
– Be oriented to time, place , and person
and exhibit reality based behavior
– Recognize reasons for behavior and
develop alternative coping mechanisms
– Maintain or improve self-care activities
– Be protected from harmful behaviors
– Develop mutual agreement
between nurse and client
whenever possible
 GOALS
SHORT TERM GOALS
– Immediate problems
– Feasible
– Within client’s capabilities
LONG-TERM GOALS
– Relates to discharge planning
– Prevention of recurrence
– Prevention of exacerbation
 IMPLEMENTATION
 Implements the interventions identified in the
plan of care

 Specific interventions:
– Counseling: to assist clients in improving coping
skills and preventing mental illness and disability.
One-on-one listening
– Milieu therapy: to provide and maintain a
therapeutic environment for client- RN designs unit
activities based on client needs
– Self-care activities: to foster independence and
mental and physical well-being: Bathing, eating,
working, paying bills
 IMPLEMENTATION
– Psychobiological interventions: to
restore the client’s health and prevent
further disability: medications
– Health teaching: to assist clients in
achieving satisfying, productive, and healthy
patterns of living: Stress management,
anger management
– Case management: to coordinate
comprehensive health services and ensure
continuity of care- refer to programs,
community support groups
 IMPLEMENTATION
– Health promotion and health
maintenance: implements strategies with
clients to promote and maintain mental
health and prevent mental illness: Teach
– Psychotherapy: provides therapy for
individuals, groups, families, & children

– Group therapy involves a therapist or

leader and a group of clients sharing a
common purpose; members contribute to
the group and expect to benefit from it.
» Types of groups
 Group Therapy
Stages of group development
– Pregroup stage
– Initial stage
– Working stage
– Termination stage
 Group Therapy
The therapeutic results of group therapy (Yalom,
1995) include the following:

– Gaining new information or learning

– Gaining inspiration or hope
– Interacting with others
– Feeling acceptance and belonging
– Becoming aware that one is not alone and that
others share the same problems
– Gaining insight into one’s problems and
behaviors and how they affect others
– Giving of oneself for the benefit of others
(altruism)
 EVALUATION
Evaluates the client’s progress in attaining
expected outcomes.

Collaborates with others on the team

including patient and family.