The Nursing The Nursing Process: Process:

Assessment of Assessment of Psychiatric Psychiatric Nursing Nursing

INTRODUCTIONINTRODUCTIONThe nursing process is five-step The nursing process is five-step

problem-solving approach that problem-solving approach that serves as an organizational frame serves as an organizational frame work for the practice of nursing. It work for the practice of nursing. It sets the practice of nursing in sets the practice of nursing in motion and serves as a monitor of motion and serves as a monitor of quality nursing care.quality nursing care.

ASSESSMENTASSESSMENTThe assessment phase of the nursing process The assessment phase of the nursing process

includes the includes the collection of data about the collection of data about the person, family, or group by the methods person, family, or group by the methods of observation, examination and of observation, examination and interviewing.interviewing.

Two types of data are collected:Two types of data are collected: objective objective and and subjectivsubjectivee. . Objective dataObjective data include information obtained include information obtained verbally from the patient, as well as the result verbally from the patient, as well as the result of inspection, palpation, percussions, and of inspection, palpation, percussions, and auscultation during an examination. auscultation during an examination. Subjective dataSubjective data are obtained as the patient, are obtained as the patient, family members, or significant others provide family members, or significant others provide information spontaneously, during direct information spontaneously, during direct questioning, or during the health history.questioning, or during the health history.

The psychiatric-mental health nurse The psychiatric-mental health nurse utilizes the nursing assessment utilizes the nursing assessment tools:tools:

to obtain factual information to obtain factual information observe appearance and behaviorobserve appearance and behavior evaluate the patient’s mental or evaluate the patient’s mental or

cognitive status.cognitive status.

APPEARANCEAPPEARANCEGeneral appearance includes:General appearance includes:physical characteristics, apparent age, physical characteristics, apparent age,

peculiarity of dress, cleanliness, and use of peculiarity of dress, cleanliness, and use of cosmeticcosmetic. .

A person general appearance, including facial A person general appearance, including facial expressions, is a manner of nonverbal expressions, is a manner of nonverbal communication in which emotions, feelings, and communication in which emotions, feelings, and mood are related. mood are related.

For example, depressed people often neglect their For example, depressed people often neglect their personal appearance, appear disheveled, and wear personal appearance, appear disheveled, and wear drab-looking clothes that are generally dark in drab-looking clothes that are generally dark in color, reflecting a depressed mood.color, reflecting a depressed mood.

The facial expression may appear sad, worried, The facial expression may appear sad, worried, tense, frightened, or distraught. tense, frightened, or distraught.

Manic patients may dress in bizarre or overly Manic patients may dress in bizarre or overly colorful outfits, wear heavy layers of cosmetics, colorful outfits, wear heavy layers of cosmetics, and several pieces of jewelry.and several pieces of jewelry.

BEHAVIOR, ATTITUDE, AND NORMAL COPING PATTERNS:BEHAVIOR, ATTITUDE, AND NORMAL COPING PATTERNS:

The interviewer assesses patients’ actions or behavior by The interviewer assesses patients’ actions or behavior by considering the following factors:considering the following factors:

1.1. Do they exhibit strange, threatening, or violent behavior? Do they exhibit strange, threatening, or violent behavior? Are they making an effort to control their emotions?Are they making an effort to control their emotions?

2.2. Is there evidence of any unusual mannerisms or motor Is there evidence of any unusual mannerisms or motor activity, such as grimacing, tremors, tics, impaired gait, activity, such as grimacing, tremors, tics, impaired gait, psychomotor retardation, agitation? Do they pace psychomotor retardation, agitation? Do they pace excessively?excessively?

3.3. Do they appear friendly, embarrassed, evasive, fearful, Do they appear friendly, embarrassed, evasive, fearful, resentful, angry, negativistic, or impulsive? Their attitude resentful, angry, negativistic, or impulsive? Their attitude toward the interviewer or helping persons can facilitate or toward the interviewer or helping persons can facilitate or impair the assessment process.impair the assessment process.

4.4. Is behavior overactive or underactive? Is it purposeful, Is behavior overactive or underactive? Is it purposeful, disorganized, or stereotyped? Are reactions fairly disorganized, or stereotyped? Are reactions fairly consistent?consistent?

PERSONALITY STYLE AND PERSONALITY STYLE AND COMMUNICATION ABILITYCOMMUNICATION ABILITY

““The manner in which the patient The manner in which the patient talks enables us to appreciate talks enables us to appreciate difficulties with his thought difficulties with his thought processes. It is desirable to obtain a processes. It is desirable to obtain a verbatim sample of the stream of verbatim sample of the stream of speech to illustrate psychopathologic speech to illustrate psychopathologic disturbances” (Small, 1980, p. 8).disturbances” (Small, 1980, p. 8).

Factors to be considered while one is assessing patients’ ability to communicate Factors to be considered while one is assessing patients’ ability to communicate and interact socially include the following:and interact socially include the following:

1.1. Do they speak coherently? Does the flow of speech seem natural or logical, or is Do they speak coherently? Does the flow of speech seem natural or logical, or is it illogical, vague, and loosely organized? Do they enunciate clearly?it illogical, vague, and loosely organized? Do they enunciate clearly?

2.2. Is the rate of speech slow, retarded, or rapid? Do they fail to speak at all or Is the rate of speech slow, retarded, or rapid? Do they fail to speak at all or respond only when questioned?respond only when questioned?

3.3. Do patient whisper or speak softly, or do they speak loudly or shout?Do patient whisper or speak softly, or do they speak loudly or shout?

4.4. Is there a delay in answer or responses, or do patients break off their Is there a delay in answer or responses, or do patients break off their conversation in the middle of a sentence and refuse to talk further?conversation in the middle of a sentence and refuse to talk further?

5.5. Do they repeat certain words and phrases over and over?Do they repeat certain words and phrases over and over?

6.6. Do they make up new words that have no meaning to others?Do they make up new words that have no meaning to others?

7.7. Is their language obscene?Is their language obscene?

8.8. Does their conversation jump from one topic to another?Does their conversation jump from one topic to another?

9.9. Do they stutter, lisp, or regress in their speech?Do they stutter, lisp, or regress in their speech?

10.10. Do they exhibit any unusual personality traits or characteristics that may Do they exhibit any unusual personality traits or characteristics that may interfere with their ability to socialize with others or adapt to hospitalization? interfere with their ability to socialize with others or adapt to hospitalization? -For example, do they associate freely with other or do they consider themselves -For example, do they associate freely with other or do they consider themselves “loners”? Do they appear aggressive or domineering during the interview? “loners”? Do they appear aggressive or domineering during the interview? -Do they feel that people like them or reject them? How do they spend their -Do they feel that people like them or reject them? How do they spend their personal time?personal time?

The following terminologies are generally The following terminologies are generally used to describe impaired communication used to describe impaired communication observed during the assessment process:observed during the assessment process:

1.1. BLOCKINGBLOCKING2.2. CIRCUMSTANTIALITYCIRCUMSTANTIALITY3.3. FLIGHTOF IDEASFLIGHTOF IDEAS4.4. PERSEVERATIONPERSEVERATION5.5. VERBIGERATIONVERBIGERATION6.6. NEOLOGISMNEOLOGISM7.7. MUTISMMUTISM

BLOCKINGBLOCKINGThis impairment is a sudden stoppage in This impairment is a sudden stoppage in the spontaneous flow or stream of the spontaneous flow or stream of thinking or speaking for no apparent thinking or speaking for no apparent external or environmental reason.external or environmental reason.Blocking may be due to preoccupation, Blocking may be due to preoccupation, delusional thoughts, or hallucinations; for delusional thoughts, or hallucinations; for example, while talking to the nurse, a example, while talking to the nurse, a patient stated, “My favorite restaurant is patient stated, “My favorite restaurant is Chi-Chi’s. I like it because the Chi-Chi’s. I like it because the atmosphere is so nice and the food is . . .” atmosphere is so nice and the food is . . .” Most often found in schizophrenics during Most often found in schizophrenics during audio hallucinations.audio hallucinations.

CIRCUMSTANTIALITYCIRCUMSTANTIALITYIn this pattern of speech the person In this pattern of speech the person gives much unnecessary details that gives much unnecessary details that delays meeting a goal or stating a delays meeting a goal or stating a point. For example, hen asked to point. For example, hen asked to state his occupation, a patient gave a state his occupation, a patient gave a very description of the type of work very description of the type of work he did. Commonly found in manic he did. Commonly found in manic disorder and some organic mental disorder and some organic mental disorders.disorders.

FLIGHT OF IDEASFLIGHT OF IDEASThis impairment is characterized by over This impairment is characterized by over

productivity of talk and verbal skipping productivity of talk and verbal skipping from one idea to another. The ideas are from one idea to another. The ideas are fragmentary, although talk is continuous. fragmentary, although talk is continuous. Connections between the part of speech Connections between the part of speech often are determined by change of often are determined by change of associations; for example: “I like the color associations; for example: “I like the color blue. Do you ever feel blue? Feelings can blue. Do you ever feel blue? Feelings can change from the day to day. The days are change from the day to day. The days are getting longer.” Most commonly observed getting longer.” Most commonly observed in manic disorders.in manic disorders.

PERSEVERATIONPERSEVERATIONPerseveration is the persistent, repetitive Perseveration is the persistent, repetitive expression of a single idea in response to various expression of a single idea in response to various questions. Found in some organic mental questions. Found in some organic mental disorders and catatonia.disorders and catatonia.

VERBIGERATIONVERBIGERATIONThis term describes meaningless repetition of This term describes meaningless repetition of incoherent words or sentences. Observed in incoherent words or sentences. Observed in certain psychotic reactions and mental disorders.certain psychotic reactions and mental disorders.

NEOLOGISMNEOLOGISMA neologism is a new word or combination of A neologism is a new word or combination of several words coined or self-invented by a person several words coined or self-invented by a person and not readily understood by others; for and not readily understood by others; for examples: “His phenologs are in the dryer.” examples: “His phenologs are in the dryer.” Found in certain schizophrenic disorders.Found in certain schizophrenic disorders.

MUTISMMUTISMThis impairment is refusal to speak even This impairment is refusal to speak even though the person may give indications or though the person may give indications or being aware of the environment. Mutism being aware of the environment. Mutism may occur from conscious or unconscious may occur from conscious or unconscious reason. Observed in catatonic schizophrenic reason. Observed in catatonic schizophrenic disorders, profound depressive disorders, disorders, profound depressive disorders, and stupors of organic or psychogenic origin.and stupors of organic or psychogenic origin.Other terminology such as loose association, Other terminology such as loose association, echolalia, and clang association is described echolalia, and clang association is described in the chapter discussing schizophrenic in the chapter discussing schizophrenic disorders.disorders.

EMOTIONAL STATE OR AFFECT:EMOTIONAL STATE OR AFFECT:AffectAffect is defined as “the outward manifestation of a person’s feelings, tones, or mood. is defined as “the outward manifestation of a person’s feelings, tones, or mood. Affects and emotion are commonly used interchangeably” (American psychiatric association, 1980, p. 3). Affects and emotion are commonly used interchangeably” (American psychiatric association, 1980, p. 3). ““The relationship between mood and the content of thought is of particular significance. The relationship between mood and the content of thought is of particular significance. There may be a wide divergence between what the patient says or does on the one hand and his emotional state as expressed objectively in his face or attitudes.” (Small 1980, p. 10).There may be a wide divergence between what the patient says or does on the one hand and his emotional state as expressed objectively in his face or attitudes.” (Small 1980, p. 10).

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    Nursing Process in Psychiatric NursingNursing Process in Psychiatric Nursing Mrs. Jyoti Beck, RN, RM,DPN RINPAS, Ranchi, India Mrs. Jyoti Beck, RN, RM,DPN RINPAS, Ranchi, India This page was last updated on March 8, 2011This page was last updated on March 8, 2011 OutlineOutline Introduction Assessment Nursing Diagnosis Outcome Identification Planning Implementation Evaluation Components of Assessment Sample of Nursing Care Plan References Introduction Introduction The nursing process is an interactive, problem-solving process. It is systematic and individualized way to achieve outcome of nursing care. The nursing process is an interactive, problem-solving process. It is systematic and individualized way to achieve outcome of nursing care. The nursing process respects the individual’s autonomy and freedom to make decisions and be involved in nursing care.The nursing process respects the individual’s autonomy and freedom to make decisions and be involved in nursing care. The nursing process is accepted by the nursing profession as a standardThe nursing process is accepted by the nursing profession as a standard

for providing ongoing nursing care that is adapted to individual client needs.for providing ongoing nursing care that is adapted to individual client needs. The nurse and the patient emerge as partner in a relationship built on trust and directed toward maximising the patient’s strengths, maintaining integrity, and promoting adaptive response to stress.The nurse and the patient emerge as partner in a relationship built on trust and directed toward maximising the patient’s strengths, maintaining integrity, and promoting adaptive response to stress. In dealing with psychiatric patients, the nursing process can present unique challenges.In dealing with psychiatric patients, the nursing process can present unique challenges. Emotional problems may be vague, not visible like many physiological disruptions. Emotional problems may be vague, not visible like many physiological disruptions. Emotional problems can also show different symptoms and arise from a number of causes. Similarly, past events may lead to very different form of present behaviours. Many psychiatric patients are unable to describe their problems. Emotional problems can also show different symptoms and arise from a number of causes. Similarly, past events may lead to very different form of present behaviours. Many psychiatric patients are unable to describe their problems. They may be highly withdrawn, highly anxious, ,or out of touch with reality. They may be highly withdrawn, highly anxious, ,or out of touch with reality. Their ability to participate in the problem solving process may also be limited if they see themselves as powerless.Their ability to participate in the problem solving process may also be limited if they see themselves as powerless. Nursing process aims at individualized care to the patient and the care is adapted to patient’s unique needs. Nursing process the following steps;Nursing process aims at individualized care to the patient and the care is adapted to patient’s unique needs. Nursing process the following steps; Assessment Assessment Nursing Diagnosis Nursing Diagnosis Outcome Identification Outcome Identification Planning Planning Implementation  and Implementation  and Evaluation Evaluation AssessmentAssessment Individualized care begins with a detailed assessment as soon as the patient is admitted. In the Assessment phase, information is obtained the patient in a direct and structured manner through observation, interviews and examination. Initial interview includes an evaluation of mental status. In such cases, where the patient is too ill to participate in or complete the interview, the behaviour the patient exhibits to be recorded and reports from  family members if possible, can obtained. Even when the initial assessment is complete, each encounter with the patient involves a continuing assessment .The ongoing assessment involves what patient is saying or doing at that moment.Individualized care begins with a detailed assessment as soon as the patient is admitted. In the Assessment phase, information is obtained the patient in a direct and structured manner through observation, interviews and examination. Initial interview includes an evaluation of mental status. In such cases, where the patient is too ill to participate in or complete the interview, the behaviour the patient exhibits to be recorded and reports from  family members if possible, can obtained. Even when the initial assessment is complete, each encounter with the patient involves a continuing assessment .The ongoing assessment involves what patient is saying or doing at that moment. HEALTH HISTORY AND PHYSICAL ASSESSMENTHEALTH HISTORY AND PHYSICAL ASSESSMENT Client’s complaint, present symptom and focus of concernClient’s complaint, present symptom and focus of concern

Perceptions and expectationsPerceptions and expectations

Previous hospitalizations and   mental health treatmentPrevious hospitalizations and   mental health treatment

Family historyFamily history

Health beliefs and practicesHealth beliefs and practices

Substance useSubstance use

Sexual historySexual history

AbuseAbuse

SpiritualSpiritual

Basic needs (diet, exercise, sleep, elimination)Basic needs (diet, exercise, sleep, elimination)

SocioculturalSociocultural

Coping patternsCoping patterns

Self-esteemSelf-esteem

Medical ExaminationMedical Examination Diagnostic Investigations Diagnostic Investigations Mental Status Examination Mental Status Examination Subjective Data Objective Data Name and general information about theSubjective Data Objective Data Name and general information about the

clientclient Client’s perception of current stressor orClient’s perception of current stressor or

problemproblem Current occupational or work situationCurrent occupational or work situation Any recent difficulty in relationshipsAny recent difficulty in relationships Any somatic complaintsAny somatic complaints Current or past substance useCurrent or past substance use Interests or activities previously enjoyedInterests or activities previously enjoyed Sexual activity or difficultiesSexual activity or difficulties Physical examPhysical exam BehaviorBehavior Mood and affectMood and affect

AwarenessAwareness

Thought processesThought processes

AppearanceAppearance

ActivityActivity

JudgmentJudgment

Response to environmentResponse to environment

Perceptual abilityPerceptual ability When the nurse investigates a patient’s specific behaviour, it is valuable to explore the following,When the nurse investigates a patient’s specific behaviour, it is valuable to explore the following, Situation that precipitated that behaviour Situation that precipitated that behaviour What the patient was thinking at that moment? What the patient was thinking at that moment? Whether that behaviour makes any sense in that context? Whether that behaviour makes any sense in that context? Whether the behaviour was adaptive or dysfunctional? Whether the behaviour was adaptive or dysfunctional? Whether a change is needed? Whether a change is needed? If the nurse has to interview the patient she should select a private place, free from noise and distraction and interview should be goal directed. Although the patient is a  regarded as a source of validation , the nurse should also be prepared to consult with family members or other people  knowledgeable about the patient. This is particularly important when the patient is unable to provide reliable information because the symptoms of the psychiatric illness. She should gather Information from other information sources, including health care records, nursing rounds, change- of shifts, nursing care plans and evaluation of other health care professionals.If the nurse has to interview the patient she should select a private place, free from noise and distraction and interview should be goal directed. Although the patient is a  regarded as a source of validation , the nurse should also be prepared to consult with family members or other people  knowledgeable about the patient. This is particularly important when the patient is unable to provide reliable information because the symptoms of the psychiatric illness. She should gather Information from other information sources, including health care records, nursing rounds, change- of shifts, nursing care plans and evaluation of other health care professionals. Nursing DiagnosisNursing Diagnosis After collecting all data, the nurse compares the information and then analyses the data and derives a nursing diagnosis.After collecting all data, the nurse compares the information and then analyses the data and derives a nursing diagnosis. A nursing diagnosis is a statement of the patient’s nursing problem that includes both the adaptive and maladaptive health responses and contributing stressors. A nursing diagnosis is a statement of the patient’s nursing problem that includes both the adaptive and maladaptive health responses and contributing stressors. These nursing problems concern patient’s health aspects that may need to be promoted or with which the patient needs help.These nursing problems concern patient’s health aspects that may need to be promoted or with which the patient needs help. A nursing diagnosis may be an actual or potential health problem, depending on the situation.A nursing diagnosis may be an actual or potential health problem, depending on the situation. The most commonly used standard is that of the North American Nursing Diagnosis Association (NANDA).The most commonly used standard is that of the North American Nursing Diagnosis Association (NANDA). A nursing diagnostic statement consists of three parts:A nursing diagnostic statement consists of three parts: Health problem Health problem Contributing factors Contributing factors Defining characteristics Defining characteristics The defining characteristics are helpful because they reflect the behaviour that are the target of nursing intervention .They also provide specific indicators for evaluating the outcome of psychiatric nursing interventions and for determining whether the expected goals  of the nursing care were met.The defining characteristics are helpful because they reflect the behaviour that are the target of nursing intervention .They also provide specific indicators for evaluating the outcome of psychiatric nursing interventions and for determining whether the expected goals  of the nursing care were met. Example:Example: If a patient is making statements about dying, he is isolative, anorexic, cannot sleep and wants to die. Then the nursing diagnosis can be- If a patient is making statements about dying, he is isolative, anorexic, cannot sleep and wants to die. Then the nursing diagnosis can be- Helplessness, related to physical complaints, as evidenced by decreased appetite and verbal cues indicating despondency. Helplessness, related to physical complaints, as evidenced by decreased appetite and verbal cues indicating despondency. Fatigue related to insomnia, as evidenced by  an increases in physical complaints and disinterest in surroundings. Fatigue related to insomnia, as evidenced by  an increases in physical complaints and disinterest in surroundings. Social isolation , related to anxiety, as evidenced by withdrawal  and  uncommunicative behaviour. Social isolation , related to anxiety, as evidenced by withdrawal  and  uncommunicative behaviour. Outcome IdentificationOutcome Identification The psychiatric mental health nurse identifies expected outcomes individualised to the patient.  Within the context of providing nursing care, the ultimate goal is to influence health outcomes and improve the patient’s health status. Outcomes should be mutually identified with the patient, and should be identified as clearly as clearly and determine the effectiveness and efficiency of their interventions.The psychiatric mental health nurse identifies expected outcomes individualised to the patient.  Within the context of providing nursing care, the ultimate goal is to influence health outcomes and improve the patient’s health status. Outcomes should be mutually identified with the patient, and should be identified as clearly as clearly and determine the effectiveness and efficiency of their interventions. Before defining expected outcomes, the nurse must realize that patient often seek treatment with goals of their own. These goals may be expressed as relieving symptoms or improving functional ability. The nurse must understand the patient’s coping response and the factors that influence them. Some of these difficulties in defining goals are as follows-Before defining expected outcomes, the nurse must realize that patient often seek treatment with goals of their own. These goals may be expressed as relieving symptoms or improving functional ability. The nurse must understand the patient’s coping response and the factors that influence them. Some of these difficulties in defining goals are as follows- The patient may view a personal problem as someone else’s behaviour. The patient may view a personal problem as someone else’s behaviour. The patient may express a problem as feeling, such as “I am lonely” or “I am so unhappy”. The patient may express a problem as feeling, such as “I am lonely” or “I am so unhappy”. Clarifying goals is an essential step in the therapeutic process. Therefore the patient nurse relationship should be based upon mutually agreed goals. Once the goals are a greed on they must be stated in writing .Goals should be written in behavioural terms, and should be realistically described what the nurse wishes to accomplish within a specific time span. Expected outcomes and short term goals should be developed with short tem objectives contributing to the  long term expected outcomes.Clarifying goals is an essential step in the therapeutic process. Therefore the patient nurse relationship should be based upon mutually agreed goals. Once the goals are a greed on they must be stated in writing .Goals should be written in behavioural terms, and should be realistically described what the nurse wishes to accomplish within a specific time span. Expected outcomes and short term goals should be developed with short tem objectives contributing to the  long term expected outcomes. Example of short term goals:Example of short term goals: At the end of the two weeks patients will stay out of bed and participate in activities At the end of the two weeks patients will stay out of bed and participate in activities At the end of the one week patient will sleep well at night. At the end of the one week patient will sleep well at night. At the end of the one week patient will eat properly and maintain weight. At the end of the one week patient will eat properly and maintain weight. PlanningPlanning As soon as the patient‘s problems are identified, nursing diagnosis made, planning nursing care begins. As soon as the patient‘s problems are identified, nursing diagnosis made, planning nursing care begins. The planning consists of:The planning consists of: Determining priorities Determining priorities Setting goals Setting goals Selecting nursing actions Selecting nursing actions Developing /writing nursing care plan Developing /writing nursing care plan In planning the care the nurse can involve the patient, family, members of the health team. Once the goals are chosen    the next task is to outline the plan achieving them. On the basis of an analysis, the nurse decides which problem requires priority attention or immediate attention. Goals stated indicates as to what is to be achieved if the identified problem is taken care of. These can be immediate short-term and long- term goals. The nursing action technique chosen will enable the nurse to meet the goals or desired objectives. For example, the short-terms for a depressed patient is  "to pursue him or her take bath”. The nursing action may be  “The nurse firmly direct the patient  to get   up and finish her/his bath before 8 O’ clock. On persuasion the patient takes bath . This is an example of selection of the nursing action. Writing or recording of the problems, goals, and nursing actions is a nursing care plan.In planning the care the nurse can involve the patient, family, members of the health team. Once the goals are chosen    the next task is to outline the plan achieving them. On the basis of an analysis, the nurse decides which problem requires priority attention or immediate attention. Goals stated indicates as to what is to be achieved if the identified problem is taken care of. These can be immediate short-term and long- term goals. The nursing action technique chosen will enable the nurse to meet the goals or desired objectives. For example, the short-terms for a depressed patient is  "to pursue him or her take bath”. The nursing action may be  “The nurse firmly direct the patient  to get   up and finish her/his bath before 8 O’ clock. On persuasion the patient takes bath . This is an example of selection of the nursing action. Writing or recording of the problems, goals, and nursing actions is a nursing care plan. ImplementationImplementation The implementation phase of the nursing process is the actual initiation of the nursing care plan. Patient outcome/goals are achieved by he performance of the nursing interventions. During the phase the nurse continues to assess the patient  to determine  whether interventions are effective. An important part of th is phase is documentation. Documentation is necessary for legal reasons because in legal dispute “if it wasn’t charted, it wasn’t done". The nursing interventions are designed to prevent mental and physical illness and promote, maintain, and restore mental and physical health. The nurse may select interventions according to their level of practice. She may select counselling, milieu therapy, self-care activities, psychological interventions, health teaching, case management, health promotion and health maintenance and other approaches to meet the mental health care needs of the patient.The implementation phase of the nursing process is the actual initiation of the nursing care plan. Patient outcome/goals are achieved by he performance of the nursing interventions. During the phase the nurse continues to assess the patient  to determine  whether interventions are effective. An important part of th is phase is documentation. Documentation is necessary for legal reasons because in legal dispute “if it wasn’t charted, it wasn’t done". The nursing interventions are designed to prevent mental and physical illness and promote, maintain, and restore mental and physical health. The nurse may select interventions according to their level of practice. She may select counselling, milieu therapy, self-care activities, psychological interventions, health teaching, case management, health promotion and health maintenance and other approaches to meet the mental health care needs of the patient. To implement the actions, nurses need to have intellectual, interpersonal and technical skills.To implement the actions, nurses need to have intellectual, interpersonal and technical skills. Nursing actions are of two types-Nursing actions are of two types- Dependent nursing action: Action derived from the advice from the psychiatrist. For example, giving medicines.Dependent nursing action: Action derived from the advice from the psychiatrist. For example, giving medicines. Independent nursing actions: This is based on nursing diagnosis and plan of care, pursuing the patient to attend to personal hygiene.Independent nursing actions: This is based on nursing diagnosis and plan of care, pursuing the patient to attend to personal hygiene. EvaluationEvaluation The continuous or ongoing phase of nursing process is evaluation. Nursing care is a dynamic process involving change in the patient’s health status over time, giving rise to the need of new data, different diagnosis, and modifications in the plan of care.The continuous or ongoing phase of nursing process is evaluation. Nursing care is a dynamic process involving change in the patient’s health status over time, giving rise to the need of new data, different diagnosis, and modifications in the plan of care. When evaluating care the nurse should review all previous phases of the nursing process and determine whether expected outcome for the patient have been met. This can be done checking –have I done everything for my patient? Is my patient better after the planned care? .Evaluation is a feed back mechanism for judging the quality of care given. Evaluation of the patient’s progress indicates what problems of the patient have been solved , which need to be assessed  again, replanted, implemented and re-evaluated.When evaluating care the nurse should review all previous phases of the nursing process and determine whether expected outcome for the patient have been met. This can be done checking –have I done everything for my patient? Is my patient better after the planned care? .Evaluation is a feed back mechanism for judging the quality of care given. Evaluation of the patient’s progress indicates what problems of the patient have been solved , which need to be assessed  again, replanted, implemented and re-evaluated. Components of AssessmentComponents of Assessment Mental Status ExaminationMental Status Examination AppearanceAppearance Dress, grooming, hygiene, cosmetics, apparent age, posture, facial expression. Dress, grooming, hygiene, cosmetics, apparent age, posture, facial expression. Behaviour/activityBehaviour/activity  Hyperactivity or hyperactivity, rigid, relaxed, restless, or agitated motor movements, gait and coordination, facial grimacing, gestures, mannerisms,, passive , combative, bizarre.  Hyperactivity or hyperactivity, rigid, relaxed, restless, or agitated motor movements, gait and coordination, facial grimacing, gestures, mannerisms,, passive , combative, bizarre. AttitudeAttitude Interactions with interviewer: - Cooperative, resistive, friendly, hostile, ingratiating Interactions with interviewer: - Cooperative, resistive, friendly, hostile, ingratiating Speech-Quantity: - poverty of speech, poverty of content, volume.Speech-Quantity: - poverty of speech, poverty of content, volume. Quality: - articulate, congruent, monotonous, talkative, repetitious,  spontaneous, circumstantial, confabulation,  tangential and pressuredQuality: - articulate, congruent, monotonous, talkative, repetitious,  spontaneous, circumstantial, confabulation,  tangential and pressured Rate:-slowed, rapidRate:-slowed, rapid Mood and affectMood and affect Mood (Intensity depth duration):- sad, fearful, depressed, angry, anxious,  ambivalent, happy, ecstatic, grandiose. Mood (Intensity depth duration):- sad, fearful, depressed, angry, anxious,  ambivalent, happy, ecstatic, grandiose. Affect (Intensity depth duration) :- appropriate, apathetic, constricted, blunted, flat, labile, euphoric.Affect (Intensity depth duration) :- appropriate, apathetic, constricted, blunted, flat, labile, euphoric. PerceptionPerception Hallucination, illusions, depersonalization, derealization, distortions Hallucination, illusions, depersonalization, derealization, distortions ThoughtsThoughts Form and content-logical vs. illogical, loose associations,  flight of ideas, autistic, blocking., broadcasting,  neologisms,  word salad, obsessions, ruminations, delusions, abstract  vs. concrete Form and content-logical vs. illogical, loose associations,  flight of ideas, autistic, blocking., broadcasting,  neologisms,  word salad, obsessions, ruminations, delusions, abstract  vs. concrete Sensorium and CognitionSensorium and Cognition Level of consciousness, orientation, attention span, , recent and remote memory, concentration, , ability to comprehend and process information, intelligence Level of consciousness, orientation, attention span, , recent and remote memory, concentration, , ability to comprehend and process information, intelligence JudgmentJudgment Ability to assess and evaluate situations makes rational decisions, understand consequence of behaviour, and take responsibly for actions Ability to assess and evaluate situations makes rational decisions, understand consequence of behaviour, and take responsibly for actions InsightInsight Ability to perceive and understand the cause and nature of own and other’s situatio Ability to perceive and understand the cause and nature of own and other’s situatio ReliabilityReliability Interviewer’s impression that individual reported  information accurately and completely Interviewer’s impression that individual reported  information accurately and completely Psychosocial CriteriaPsychosocial Criteria Internal:-Psychiatric or medical illness, perceived loss such as loss of self concept/self-esteem Internal:-Psychiatric or medical illness, perceived loss such as loss of self concept/self-esteem External:-Actual loss, e.g. death of loved ones, diverse, lack of support systems, job or financial loss, retirement of dysfunctional family systemExternal:-Actual loss, e.g. death of loved ones, diverse, lack of support systems, job or financial loss, retirement of dysfunctional family system Coping skillsCoping skills Adaptation to internal and external stressors, use of functional, adaptive coping mechanisms,  and techniques, management of activities of daily living Adaptation to internal and external stressors, use of functional, adaptive coping mechanisms,  and techniques, management of activities of daily living RelationshipsRelationships Attainment and maintenance of satisfying, interpersonal relationships congruent with developmental stages, including sexual relationship as appropriate for age and status Attainment and maintenance of satisfying, interpersonal relationships congruent with developmental stages, including sexual relationship as appropriate for age and status CulturalCultural Ability to adapt and conform to present norms, rules, ethics. Ability to adapt and conform to present norms, rules, ethics. Spiritual (Value-belief)Spiritual (Value-belief) Presence of self-satisfying value-belief system that the individual regards as right, desirable, worthwhile, and comforting Presence of self-satisfying value-belief system that the individual regards as right, desirable, worthwhile, and comforting OccupationalOccupational Engagement is useful, rewarding activity, congruent with developmental stages and societal standards (work, school and recreation) Engagement is useful, rewarding activity, congruent with developmental stages and societal standards (work, school and recreation) Sample of Nursing Care PlanSample of Nursing Care Plan Sample of Nursing Diagnoses (As per NANDA- North American Nursing Diagnosis Association)Sample of Nursing Diagnoses (As per NANDA- North American Nursing Diagnosis Association)     Nursing DiagnosisNursing Diagnosis AnalysisAnalysis 1 1 Risk for injury related to accelerated motor activityRisk for injury related to accelerated motor activity Accelerated motor activity or impulsive actionsAccelerated motor activity or impulsive actions 22 Disturbed thought process related to impaired judgement associated with manic behaviourDisturbed thought process related to impaired judgement associated with manic behaviour Judgement impaired , mood of elation (patient is using inappropriate dress and bizarre dressing)Judgement impaired , mood of elation (patient is using inappropriate dress and bizarre dressing) 33 Self-care deficit (unkempt appearance)  related to hyperactivitySelf-care deficit (unkempt appearance)  related to hyperactivity Unable to take time for self-care  is, dishevelled and unkemptUnable to take time for self-care  is, dishevelled and unkempt 44 Impaired  verbal communication –flight of ideas related to accelerated th inkingImpaired  verbal communication –flight of ideas related to accelerated th inking Accelerated speech with flight of ideas (thought speeded up causing rapid speech and flight of ideas, excessive  planning  for activitiesAccelerated speech with flight of ideas (thought speeded up causing rapid speech and flight of ideas, excessive  planning  for activities 55 Ineffective  coping related to  elated expressive moodIneffective  coping related to  elated expressive mood Euphoria, elation, cheerfulness( an exaggerated sense of well being)Euphoria, elation, cheerfulness( an exaggerated sense of well being) 66 Disturbed thought process –grandiosity related to  elevated moodDisturbed thought process –grandiosity related to  elevated mood Grandiosity-inflation self-esteemGrandiosity-inflation self-esteem 77 Ineffective coping related to emotional liability  associated with manic behaviourIneffective coping related to emotional liability  associated with manic behaviour Emotional  labiality (unstable mood moves from cheerfulness to irritation easily with little irritationEmotional  labiality (unstable mood moves from cheerfulness to irritation easily with little irritation 88 Disturbed thought process –related to delusion of  grandeurDisturbed thought process –related to delusion of  grandeur Grandiose delusions (Belief that well known political religious, or entertainment leader)Grandiose delusions (Belief that well known political religious, or entertainment leader) 99 Disturbed thought process decreased attention span and difficulty in concentration  related to accelerated thinkingDisturbed thought process decreased attention span and difficulty in concentration  related to accelerated thinking Short attention  span, difficulty in concentrating , easily disturbedShort attention  span, difficulty in concentrating , easily disturbed 1010 Risk for violence related to hostile and angry behaviourRisk for violence related to hostile and angry behaviour Hostile comment and complaintsHostile comment and complaints 1111 Impaired verbal communication related to pressure of speechImpaired verbal communication related to pressure of speech Accelerated thinking, highly responsive to environmental stimuli, accompanying flight of ideasAccelerated thinking, highly responsive to environmental stimuli, accompanying flight of ideas 1212 Nutrition: less than body requirements, imbalancedNutrition: less than body requirements, imbalanced

Nutrition: more than body requirements, imbalancedNutrition: more than body requirements, imbalanced

Nutrition: risk for more than body requirements, imbalancedNutrition: risk for more than body requirements, imbalanced Weight loss (less food intake associated with depression which contributes to loss of appetite with weight loss/weight gain following pharmacological management/possible wieght gain Weight loss (less food intake associated with depression which contributes to loss of appetite with weight loss/weight gain following pharmacological management/possible wieght gain 1313 Self-care deficit-neglect of personal hygiene  related to depression Self-care deficit-neglect of personal hygiene  related to depression Neglect of personal hygiene (feeling of worthlessness  associated with depression which contribute to lack of interest in personal hygiene Neglect of personal hygiene (feeling of worthlessness  associated with depression which contribute to lack of interest in personal hygiene 1414 Health Maintenance, ineffective –psychomotor retardation related to depression Health Maintenance, ineffective –psychomotor retardation related to depression Extreme slowness in performing activity Extreme slowness in performing activity 1515 Risk for violence- self-directed, related  to depression Risk for violence- self-directed, related  to depression Bruises, cuts, scars, (possible destructive  behaviour or abuse by others)Bruises, cuts, scars, (possible destructive  behaviour or abuse by others) 1616 Anxiety –neurological symptoms related to depressionAnxiety –neurological symptoms related to depression Extreme nervousness (possible response to loss with symptoms to those of anxiety)Extreme nervousness (possible response to loss with symptoms to those of anxiety) 1717 Risk for violencermRisk for violencerm Suicidal feeling  (Hopelessness contributes to total despairSuicidal feeling  (Hopelessness contributes to total despair 1818 Sensory perceptual alteration –disorientation about time, place, and person  related to increased anxietySensory perceptual alteration –disorientation about time, place, and person  related to increased anxiety Confusion or disorientationConfusion or disorientation 1919 Ineffective coping –obsessive thinking related to  anxietyIneffective coping –obsessive thinking related to  anxiety Anxiety (Increased anxiety unapparent and discharge  through  obsessive thinking)Anxiety (Increased anxiety unapparent and discharge  through  obsessive thinking) 2020 Impaired Social interactions –inability to form warm, meaningful relationships, related to compulsive behaviourImpaired Social interactions –inability to form warm, meaningful relationships, related to compulsive behaviour Lacks ability to develop warm  relationship ( has limited ability to express emotion)Lacks ability to develop warm  relationship ( has limited ability to express emotion) 2121 Ineffective coping –compulsion related to need for excessive cleanliness)Ineffective coping –compulsion related to need for excessive cleanliness) Excessive cleanliness (Over  emphasis for cleanliness and neatness)Excessive cleanliness (Over  emphasis for cleanliness and neatness) 2222 Potential for self harm related to poor impulse control associated with substance abuse)Potential for self harm related to poor impulse control associated with substance abuse) Poor impulse controlPoor impulse control 2323 Potential for self-harm related to marked disorientation , disorganization, and confusionPotential for self-harm related to marked disorientation , disorganization, and confusion Disorientation, disorganization  and confusion (If marked , patient is at high suicidal risk)Disorientation, disorganization  and confusion (If marked , patient is at high suicidal risk) 2424 Distarbance of self-concept-insecurity related to suspiciousnessDistarbance of self-concept-insecurity related to suspiciousness Insecurity, oversensitive, Failure to meet needs results in mistrust and  insecurityInsecurity, oversensitive, Failure to meet needs results in mistrust and  insecurity 2525 Potential for violence  directed towards others related t perceived  threat or injustice to himselfPotential for violence  directed towards others related t perceived  threat or injustice to himself Anger and hostility –may become physically violent (Overly concerned with protecting himself from environment : overly sensitive)Anger and hostility –may become physically violent (Overly concerned with protecting himself from environment : overly sensitive) 2525 Ineffective individual coping persecutory feeling related to mistrustIneffective individual coping persecutory feeling related to mistrust Feeling of being misjudged , conspired against, spied upon , followed , poisoned, dragged, obstructed in achieving long term goals.Feeling of being misjudged , conspired against, spied upon , followed , poisoned, dragged, obstructed in achieving long term goals. Nursing Diagnosis: Risk for violence, self directed.Nursing Diagnosis: Risk for violence, self directed. Risk factors-Chronic illness, retirement, change in marital statusRisk factors-Chronic illness, retirement, change in marital status Patient OutcomePatient Outcome Nursing Intervention with RationaleNursing Intervention with Rationale EvaluationEvaluation Patient will not harm himself Patient will not harm himself    Patient will refrain from suicidal threats or behaviour gestures.Patient will refrain from suicidal threats or behaviour gestures. He will deny any plans for suicideHe will deny any plans for suicide Observe patient’s behaviour during routine patient care. Close observation is necessary to protect from self harm.Observe patient’s behaviour during routine patient care. Close observation is necessary to protect from self harm. Listen carefully suicidal statements and observe for non-verbal indications of suicidal intent. Such behaviours are critical clues regarding risk for self harm.Listen carefully suicidal statements and observe for non-verbal indications of suicidal intent. Such behaviours are critical clues regarding risk for self harm.    Ask direct questions to determine suicidal intent , plans for suicide, and means to commit suicide .Suicide risk increases when  plans and means exists Ask direct questions to determine suicidal intent , plans for suicide, and means to commit suicide .Suicide risk increases when  plans and means exists Patient remained safe, unharmed.Patient remained safe, unharmed.       Absence of verbalized or behavioural indications of suicidal intent by the patient.Absence of verbalized or behavioural indications of suicidal intent by the patient.    Patient denies active suicide plansPatient denies active suicide plans Nursing DiagnosisNursing Diagnosis : Ineffective individual coping, related to response crisis (retirement), as evidence by isolative behaviour, changes in mood, and decreased sense of well-being.: Ineffective individual coping, related to response crisis (retirement), as evidence by isolative behaviour, changes in mood, and decreased sense of well-being. Patient OutcomePatient Outcome Nursing Intervention with RationaleNursing Intervention with Rationale EvaluationEvaluation Patient will identify positive coping strategies, such as structuring leisure time.Patient will identify positive coping strategies, such as structuring leisure time.    Patient will combine past effective coping methods with newly acquired coping strategiesPatient will combine past effective coping methods with newly acquired coping strategies Develop trusting relationship with patient to demonstrate caring and, encourage patient to practice new skills in a safe therapeutic setting.Develop trusting relationship with patient to demonstrate caring and, encourage patient to practice new skills in a safe therapeutic setting.                                                             Praise patient for adaptive coping. Positive feedback encourages repetition of effective coping by patientPraise patient for adaptive coping. Positive feedback encourages repetition of effective coping by patient Patient expresses trust in nurse-patient relationship.Patient expresses trust in nurse-patient relationship.       Patient discusses plans for use of past and newly learned coping methods. Patient discusses plans for use of past and newly learned coping methods. Nursing DiagnosisNursing Diagnosis : Self-care deficit (grooming, dressing, and feeding) related to manic hyperactivity, difficulty in concentrating and making decisions: as evidenced by inappropriate dress, and dysfunctional eating habits.: Self-care deficit (grooming, dressing, and feeding) related to manic hyperactivity, difficulty in concentrating and making decisions: as evidenced by inappropriate dress, and dysfunctional eating habits. Patient OutcomePatient Outcome Nursing Intervention with RationaleNursing Intervention with Rationale EvaluationEvaluation Patient will dress appropriately for age and status.Patient will dress appropriately for age and status.           Patient will eat and drink adequately to sustain fluid balance and  proper nutrition.Patient will eat and drink adequately to sustain fluid balance and  proper nutrition. Offer assistance for selecting clothing and grooming to provide input and direction for appropriateness of dress and hygiene to preserve self-esteem and avoid embracement. Offer assistance for selecting clothing and grooming to provide input and direction for appropriateness of dress and hygiene to preserve self-esteem and avoid embracement.  Encourage and remind patient to drink fluid and to eat food to focus the patient on necessary feeding activities , to prevent dehydration and starvation.Encourage and remind patient to drink fluid and to eat food to focus the patient on necessary feeding activities , to prevent dehydration and starvation. Provide recognition and positive reinforcement for feeding/dressing accomplishments to reinforce appropriate behaviours and enhance self-esteem.Provide recognition and positive reinforcement for feeding/dressing accomplishments to reinforce appropriate behaviours and enhance self-esteem. Patient dresses self appropriately and maintains hygiene.Patient dresses self appropriately and maintains hygiene.          Patient eats and drinks fluids necessarily to maintain physical health.Patient eats and drinks fluids necessarily to maintain physical health.   ReferencesReferences: : Ladwig, A.(1999).Nursing Diagnosis Handbook, A Guide for Planning Care. Section 1:5Ladwig, A.(1999).Nursing Diagnosis Handbook, A Guide for Planning Care. Section 1:5 Kapoor, B. (1994). A Text Book for Psychiatric Nursing: Chapter5, Page 223-224.Kapoor, B. (1994). A Text Book for Psychiatric Nursing: Chapter5, Page 223-224. Foortinash, Hoolodey-Warrant. Psychiatric Mental Health Nursing, 1996: Chapter 20, page 279, 482.Foortinash, Hoolodey-Warrant. Psychiatric Mental Health Nursing, 1996: Chapter 20, page 279, 482. Gail.W.Stuart, Michal T. Laraiya. Principles and Practice of Psychiatric Nursing 1998: Chapter 10, Page 178.Gail.W.Stuart, Michal T. Laraiya. Principles and Practice of Psychiatric Nursing 1998: Chapter 10, Page 178. Katherine N Fortinash, Patrica N Hooliday-Worret. Psychiatric Nursing Care Plans 1991: Chapter 1, Page 1.Katherine N Fortinash, Patrica N Hooliday-Worret. Psychiatric Nursing Care Plans 1991: Chapter 1, Page 1.           

    Mental Health Quiz Mental Health Quiz ECT Quiz-I ECT Quiz-II EEG Quiz Antipsychotics Quiz Antidepressants Quiz Psychopharmacology Quiz-I Psychopharmacology Quiz-II Psychopharmacology Quiz-III Psychopharmacology Quiz-IV Psychopathology Quiz -I Psychopathology Quiz -II Psychopathology Quiz III Psychopathology Quiz -IV Psychopathology Quiz-V Psychopathology Quiz-VII Psychopathology Quiz-VII Psychopathology Quiz-VIII Psychopathology Quiz-IX Psychopathology Quiz -XPsychopathology Quiz -X Psychiatric Nursing History Quiz-IPsychiatric Nursing History Quiz-I Psychiatric Nursing History Quiz-IIPsychiatric Nursing History Quiz-II                                         About Us About Us ll Privacy Policy  Privacy Policy ll Ad Policy Ad Policy ll Disclaimer Disclaimer Hosted with support from AIPPGHosted with support from AIPPG Copyright 2011@CurrentCopyright 2011@Current     A lead question such as A lead question such as “What are you feeling?”“What are you feeling?” may elicit such responses as may elicit such responses as “nervous,” “ angry,” “frustrated,” “depressed,” “nervous,” “ angry,” “frustrated,” “depressed,” or or “confused.” “confused.”

The person should be asked to describe the nervousness, frustration, or confusion. Is the person’s emotional response constant or does it fluctuates during the assessment? The person should be asked to describe the nervousness, frustration, or confusion. Is the person’s emotional response constant or does it fluctuates during the assessment? The interviewer should record a verbatim reply to question concerning the patient’s mood and note whether an intense emotional response accompanies the discussion of specific topics. The interviewer should record a verbatim reply to question concerning the patient’s mood and note whether an intense emotional response accompanies the discussion of specific topics. Affective responses may be Affective responses may be appropriate, inappropriate, flat appropriate, inappropriate, flat oror blunted blunted . An emotional response out of proportion to a situation is considered inappropriate.. An emotional response out of proportion to a situation is considered inappropriate.

CONTENT OF THOUGHTCONTENT OF THOUGHTThe American psychiatric association defines The American psychiatric association defines thought disorder thought disorder as as “a disturbance of speech, “a disturbance of speech, communication, or content of thought, such communication, or content of thought, such as delusions, ideas of referenceas delusions, ideas of reference. . . . . . . . A thought disorder can be caused by a functional A thought disorder can be caused by a functional emotional disorder or an organic condition” emotional disorder or an organic condition” (1980, p. 131). (1980, p. 131).

Small (1980) and Rowe (1989) describe those Small (1980) and Rowe (1989) describe those thought contents more commonly exhibited thought contents more commonly exhibited during the psychiatric examination: during the psychiatric examination:

1.1. DelusionsDelusions2.2. HallucinationsHallucinations3.3. DepersonalizationDepersonalization4.4. ObsessionsObsessions5.5. Compulsions.Compulsions.

DELUSION:DELUSION:A delusion is a fixed false belief not true A delusion is a fixed false belief not true to fact and not ordinary accepted by other to fact and not ordinary accepted by other members of the person’s culture. members of the person’s culture.

It cannot be corrected by an appeal to the It cannot be corrected by an appeal to the reason of the person experiencing it. reason of the person experiencing it.

Delusions occur in various types of Delusions occur in various types of psychotic disorders, such as organic psychotic disorders, such as organic mental disorder and schizophrenic mental disorder and schizophrenic disorder, and in some affective disorders. disorder, and in some affective disorders.

One believes that he or she is the object of environmental attention or is being singled out for harassment.“The police are watching my every move. They’re out to get me.”

The person believes his or her feelings, thoughts, impulses, or actions are controlled by an external source. “A spaceman sends me to do”.

The person denies the reality or existence of self, part of the self, or some external object. “I have no head”.

The individual feels unworthy, ugly, or sinful. “I don’t deserve to live. I’m so unworthy of your love.”

A person experiences exaggerated ideas of her or his importance or identify. “I am Napoleon!”

The person entertains false beliefs pertaining to body image or body function. The person actually believes that she or he has cancer, leprosy, or some other terminal illness.

Delusion of reference or persecution

Delusions of alien control

Nihilistic delusions

Delusion of self-deprecation

Delusion of grandeur

Somatic delusions

DESCRIPTIONTYPES OF DELUSIONS

HALLUCINATIONSHALLUCINATIONSHallucinations Hallucinations are sensory perceptions are sensory perceptions that occur in the absence of an actual that occur in the absence of an actual external stimulus. external stimulus.

They may be They may be auditory, visual, olfactory, auditory, visual, olfactory, gustatory, gustatory, oror tactile tactile in nature. in nature.

Hallucinations occur in substance-Hallucinations occur in substance-use disorders, schizophrenia, and use disorders, schizophrenia, and manic disorders. manic disorders.

Auditory hallucinations

Visual hallucinations

Olfactory hallucinations

Gustatory (taste) hallucination

Tactile hallucinations

Asie tells you that he hears voices frequently while he sits quietly in his long chair. He states, “The voices tell me when to eat, dress, and go to bed each night!”

Ninety-years-old EK describes seeing spiders and snakes on the ceiling of his room late one evening as you make rounds.

AJ, a 65-year-old psychotic patient, states that she smells “rotten garbage” in her bedroom, although there is no evidence of any foul-smelling material.

MY, a young patient with organic brain syndrome complains of a constant metallic taste in her mouth.

NX, a middle-aged woman undergoing symptoms of alcohol withdrawal and delirium tremens, complains of feeling “worms crawling all over (her) body.”

EXAMPLESEXAMPLESTYPES OF HALLUCINATIONS

DEPERSONALIZATION:DEPERSONALIZATION:

Depersonalization Depersonalization is described as a feeling of is described as a feeling of unreality or strangeness concerning self, the unreality or strangeness concerning self, the environment, or both: environment, or both: For example, patients have described out-of-body For example, patients have described out-of-body sensations in which they view themselves from a sensations in which they view themselves from a few feet overhead. few feet overhead.

These people may feel they are These people may feel they are “going crazy.”“going crazy.”

Cause of depersonalization includes prolonged Cause of depersonalization includes prolonged stress and psychological fatigue, as well as stress and psychological fatigue, as well as substance abuse. This feeling has been described substance abuse. This feeling has been described in schizophrenia, bipolar disorders, and in schizophrenia, bipolar disorders, and depersonalization disorders.depersonalization disorders.

OBSESSIONSOBSESSIONS

““Obsessions Obsessions are insistent thoughts, recognized are insistent thoughts, recognized as arising from the self, usually regarded by the as arising from the self, usually regarded by the patient as absurd and relatively meaningless, yet patient as absurd and relatively meaningless, yet they persist despites his endeavors to rid himself they persist despites his endeavors to rid himself of them” (Small, 1980,p. 13). of them” (Small, 1980,p. 13).

Person who experience obsessions generally Person who experience obsessions generally described their thoughts as “thoughts I can’t get described their thoughts as “thoughts I can’t get rid of” or “I can’t stop thinking of things . . . they rid of” or “I can’t stop thinking of things . . . they keep going on in mu mind over and over again.” keep going on in mu mind over and over again.”

Obsessions are typically seen in obsessive-Obsessions are typically seen in obsessive-compulsive disorders.compulsive disorders.

COMPULSIONSCOMPULSIONS

““An inconsistent, repetitive, intrusive and An inconsistent, repetitive, intrusive and unwanted urge to perform an act contrary to unwanted urge to perform an act contrary to one’s ordinary wishes or standards” one’s ordinary wishes or standards” (American psychiatric association, 1980, p. (American psychiatric association, 1980, p. 21). 21).

If one does not engage in the repetitive act If one does not engage in the repetitive act due to an inner need or drive, one generally due to an inner need or drive, one generally experiences feelings of tension and anxiety. experiences feelings of tension and anxiety.

Compulsions are frequently seen in obsessive-Compulsions are frequently seen in obsessive-compulsive disorders.compulsive disorders.

ORIENTATION:ORIENTATION:

During the assessment, patients are asked During the assessment, patients are asked questions regarding their ability to grasp the questions regarding their ability to grasp the significance of their environment, an existing significance of their environment, an existing situation, or the clearness of conscious processes. situation, or the clearness of conscious processes. In other words, are they In other words, are they oriented to person, oriented to person, place, time place, time andand events. events. Do they know who they are, where they are, or what Do they know who they are, where they are, or what the date is? Are they aware of the past and current the date is? Are they aware of the past and current events?events?

Levels of orientation and consciousness are Levels of orientation and consciousness are subdivided as follows:subdivided as follows: confusion, clouding of confusion, clouding of consciousness, stupor, delirium, dream state, consciousness, stupor, delirium, dream state, andand coma. coma.

Confusion

Clouding of consciousness

Stupor

Delirium or acute brain syndrome

Dream state

Coma

Disorientation to person, place or time characterized by bewilderment and complexity.

Disturbance in perception or thought that is slight to moderate in degree, usually owing to physical or chemical factors producing functional impairment of the cerebrum.

A state in which the person does not react to or is unaware of the surrounding. The person maybe motionless and mute but conscious.

Confusion accompanied by altered or fluctuating consciousness. Disturbance in emotion, thought, and perception is moderate to severe. Usually associated with infections, toxic states, head trauma, and so forth.

Disturbed, clouded, or confused consciousness in which the person may not be aware to surroundings. Visual or auditory hallucinations may occur. May last several minutes to a few days

Loss of consciousness.

LEVELS OF ORIENTATION AMD CONSCIOUSNESSLEVELS OF ORIENTATION AMD CONSCIOUSNESS

LEVELLEVEL DESCRIPTIONDESCRIPTION

MEMORYMEMORYMemoryMemory, or the ability to recall past experiences, is , or the ability to recall past experiences, is divided into recent and long-term. divided into recent and long-term.

Recent memoryRecent memory is the ability to recall events in the immediate is the ability to recall events in the immediate past and up to two weeks previouslypast and up to two weeks previously. .

Long-term memoryLong-term memory is the ability to recall remote past is the ability to recall remote past experience such as the date and place of birth, names of experience such as the date and place of birth, names of schools attended, occupational history and chronological schools attended, occupational history and chronological data relating to previous illness. data relating to previous illness.

Small (1980) states that memory defects maybe because of Small (1980) states that memory defects maybe because of lack of attention, difficulty with retention, difficulty with lack of attention, difficulty with retention, difficulty with recall, or any combination of these factors. Loss of recent recall, or any combination of these factors. Loss of recent memory maybe seen in patients which chronic organic memory maybe seen in patients which chronic organic brain dysfunction. brain dysfunction.

Three disorders of memory are: Three disorders of memory are: (1)(1) HypermnesiaHypermnesia or an abnormally pronounced memory or an abnormally pronounced memory(2)(2) AmnesiaAmnesia or loss of memory or loss of memory (3)(3) ParamnesiaParamnesia or falsification of memory or falsification of memory

INTELLECTUAL ABILITYINTELLECTUAL ABILITY

The persons ability to use facts comprehensively is an The persons ability to use facts comprehensively is an indication of intellectual ability. indication of intellectual ability.

During the assessment the person may be asked general During the assessment the person may be asked general information such as: information such as:

(1)(1) name the last three presidentsname the last three presidents(2)(2) to calculate simple arithmetical problemsto calculate simple arithmetical problems(3)(3) ““to correctly estimate and form opinions concerning to correctly estimate and form opinions concerning

objective matters” (Small, 1980, p. 16). objective matters” (Small, 1980, p. 16).

The person maybe ask a question such as “What would The person maybe ask a question such as “What would you do if you found a wallet in front of your house?”you do if you found a wallet in front of your house?”The examiner is able to evaluate reasoning ability and The examiner is able to evaluate reasoning ability and judgments by the response given. judgments by the response given. Abstract and concrete thinking abilities are evaluated by Abstract and concrete thinking abilities are evaluated by responses to proverbs such as “an eye for an eye and a responses to proverbs such as “an eye for an eye and a tooth for a tooth.”tooth for a tooth.”

INSIGHT REGARDING ILLNESS OR INSIGHT REGARDING ILLNESS OR CONDITIONCONDITION

Does the person consider him/her well or ill? Does the person consider him/her well or ill? Does the patient understand what is Does the patient understand what is happening? happening? Is the illness treating to the patients? Is the illness treating to the patients?

Insight is defined as self-understanding, or Insight is defined as self-understanding, or the extent of the one understands of the the extent of the one understands of the origin, nature, and behavior. origin, nature, and behavior.

Patient’s insight into their illness or condition Patient’s insight into their illness or condition range from range from poor to goodpoor to good, , depending on depending on the degree of psychopathology presentthe degree of psychopathology present..

NEUROVEGETATIVE CHANGESNEUROVEGETATIVE CHANGES

Does the patients exhibit change in Does the patients exhibit change in psychophysiologic functionspsychophysiologic functions suck as sleep suck as sleep patterns, eating patterns, energy levels, sexual patterns, eating patterns, energy levels, sexual functioning, or vowel functioning? functioning, or vowel functioning?

Depressed persons usually complain of insomnia or Depressed persons usually complain of insomnia or hypersomnia, loss of appetite or increased appetite, hypersomnia, loss of appetite or increased appetite, loss of energy, decreased libido, and constipation, loss of energy, decreased libido, and constipation, which are all sign of neurovegetative changes. which are all sign of neurovegetative changes.

Persons who are diagnosed as psychotic may neglect Persons who are diagnosed as psychotic may neglect their nutritional intake, appear fatigue, sleep their nutritional intake, appear fatigue, sleep excessively, and ignore elimination habits excessively, and ignore elimination habits (sometimes to the point of developing a fecal (sometimes to the point of developing a fecal impaction.)impaction.)

RECORDING OF ASSESSMENTSRECORDING OF ASSESSMENTS

Information obtained during the assessment process is relayed to the Information obtained during the assessment process is relayed to the members of the health care team in the form of the summary of the members of the health care team in the form of the summary of the history and physical examination, a summary of the social history, a history and physical examination, a summary of the social history, a summary of the psychological testing, and multidisciplinary progress summary of the psychological testing, and multidisciplinary progress notes. notes. Nurse can provide invaluable pertinent information if they follow the Nurse can provide invaluable pertinent information if they follow the criteria of a good recording. Such information is significant to the criteria of a good recording. Such information is significant to the members of the interdisciplinary team, who use these note as an aid members of the interdisciplinary team, who use these note as an aid in planning treatment and disposition of patients. in planning treatment and disposition of patients.

Thorough charting shows progress, lack of progress, or Thorough charting shows progress, lack of progress, or regression on the part of the patient. The detail of the patients regression on the part of the patient. The detail of the patients conduct, appearance and attitude are significant. Increased conduct, appearance and attitude are significant. Increased skill in observation and recording will result in more consist skill in observation and recording will result in more consist charting.charting.

Charting is also important in research because it is an accurate Charting is also important in research because it is an accurate record of the symptoms, behavior, treatment, and reactions of the record of the symptoms, behavior, treatment, and reactions of the patient.patient.

Charting is recognized by legal authorities, who frequently use the Charting is recognized by legal authorities, who frequently use the notes for testimony in court.notes for testimony in court.

The basic criteria for charting psychiatric nursing progress notes should The basic criteria for charting psychiatric nursing progress notes should bebe::

1.1. Objective: the nurse records what the patient says and does by stating facts Objective: the nurse records what the patient says and does by stating facts and quoting the patients conversation.and quoting the patients conversation.

2.2. Descriptive: the nurse describes the patient’s appearance, behavior and Descriptive: the nurse describes the patient’s appearance, behavior and conversation as seen and heard.conversation as seen and heard.

3.3. Complete: a record as of examinations, treatments, medications, therapies, Complete: a record as of examinations, treatments, medications, therapies, nursing interventions, and the patient’s reaction to each should be made ob nursing interventions, and the patient’s reaction to each should be made ob the patients chart. Samples of their patients writing or drawing should be the patients chart. Samples of their patients writing or drawing should be preserved.preserved.

4.4. Legible: psychiatric nursing notes should be written legibly, with the use of Legible: psychiatric nursing notes should be written legibly, with the use of acceptable abbreviations only, and no erasures. Correct grammar and acceptable abbreviations only, and no erasures. Correct grammar and spelling are important, and complete sentences should be used.spelling are important, and complete sentences should be used.

5.5. Dated: It is very important to note the time of entry. For the example, MS Dated: It is very important to note the time of entry. For the example, MS has been quiet and withdrawn all days; however, later in the evening she has been quiet and withdrawn all days; however, later in the evening she becomes agitated. The nurse needs to states the tome at which MS’s becomes agitated. The nurse needs to states the tome at which MS’s behavior changed, as well as described any pertinent situation that might be behavior changed, as well as described any pertinent situation that might be identified as the cause of her behavioral change.identified as the cause of her behavioral change.

6.6. Logical: Presented in logical sequence.Logical: Presented in logical sequence.

7.7. Signed: by the person making the entry.Signed: by the person making the entry.

EXAMPLE OF NURSING PROGRESS NOTESEXAMPLE OF NURSING PROGRESS NOTES

Various forms of documentation are utilized to Various forms of documentation are utilized to record nursing progress notes, including SOAP record nursing progress notes, including SOAP (subjective data, objective data, Assessment (subjective data, objective data, Assessment data, and plan of care) Progress notes should data, and plan of care) Progress notes should reflect the effectiveness of treatment plans. reflect the effectiveness of treatment plans.

Multidisciplinary progress notes have become Multidisciplinary progress notes have become more prevalent as they depict a chronological more prevalent as they depict a chronological picture of the patient’s response to various picture of the patient’s response to various therapeutic interventions.therapeutic interventions.

An example of DAP nursing notes utilizing the multidisciplinary progress note format :An example of DAP nursing notes utilizing the multidisciplinary progress note format :

DateAndTime

ProblemNumber

MultidisciplinaryProgressNotes

07 – 06 - 099:00am

#1D:

A:

P:

RK was eating breakfast at 8:00am when she began to perspire profusely and stated, “I don’t know what’s wrong with me, but I feel jittery inside. I feel like something terrible is going to happen.”When ask to describe her feelings, RK replied,”I can’t. I just have an awful feeling inside.” Affect blunted. Pallor noted. Tearful during interaction. Minimal eye contact.Voice tremulous. P = 120, R = 38, BP = 130/80. No sign of acute physical distress noted at this time.

Expressing fear of the unknown and inability to maintain control of her emotions. Recognized she is experiencing symptoms of anxiety but unable to utilize effective coping skills.

Encourage verbalization of feelings when able to interact/communicate needs. Explore presence of positive coping skills.Administer prescribed anti anxiety agent. Monitors response to medication.

Ineffective Individual Coping

Ineffective Individual Coping

Note:Note: problem #1 refers to *ineffective individual Coping problem #1 refers to *ineffective individual Coping *NANDA approved nursing diagnosis.*NANDA approved nursing diagnosis.

REFERENCES:REFERENCES:

AMERICAN Psychiatric Association. (1980). A AMERICAN Psychiatric Association. (1980). A psychiatric glossary (5psychiatric glossary (5thth ed.). Washington ed.). Washington DC: American Psychiatric Press.DC: American Psychiatric Press.

Barry, P.D (1989). Psychosocial nursing Barry, P.D (1989). Psychosocial nursing assessment and Intervention (2assessment and Intervention (2ndnd ed.). ed.). Philadelphia: J.B. Lippincott.Philadelphia: J.B. Lippincott.

Kolb, L. (1977). Modern Clinical Psychiatry. Kolb, L. (1977). Modern Clinical Psychiatry. Philadelphia: W.B Saunders.Philadelphia: W.B Saunders.

Rowe, C.J. (1989). An outline of Psychiatry (9Rowe, C.J. (1989). An outline of Psychiatry (9thth ed.) Dubuque, 1A: Brown Publishing.ed.) Dubuque, 1A: Brown Publishing.

Examples of Nursing Diagnosis:Examples of Nursing Diagnosis:

-Body image disturbance -Body image disturbance -Potential for violence, or self harm-Potential for violence, or self harm-Social Isolation -Social Isolation -Ineffective Family Coping -Ineffective Family Coping -Impaired Grooming-Impaired Grooming-Self Care Deficit-Self Care Deficit-Knowledge Deficit -Knowledge Deficit -Sensory Deficit-Sensory Deficit-Spiritual Deficit-Spiritual Deficit-Sleep Pattern Disturbance-Sleep Pattern Disturbance

I.I. Clinical ActivitiesClinical ActivitiesA. Assess the following areas of your assigned patient:A. Assess the following areas of your assigned patient:

1. Appearance1. Appearance2. Behavior2. Behavior3. Attitude3. Attitude4. Ability to communicate4. Ability to communicate5. Emotional state or affect5. Emotional state or affect6. Content of thought6. Content of thought7. Orientation7. Orientation8. Memory8. Memory9. Intellectual Ability 9. Intellectual Ability 10. Insight regarding illness10. Insight regarding illness

B. Summarize the data obtained to give an informative B. Summarize the data obtained to give an informative report about the patient’s mental health status.report about the patient’s mental health status.C. Chart pertinent information using descriptive, C. Chart pertinent information using descriptive, noninterpretive data.noninterpretive data.

Related Learning Related Learning ActivitiesActivities

II.II. Independent ActivitiesIndependent ActivitiesA. Use the following nonverbal behavior A. Use the following nonverbal behavior assessment guide while communicating assessment guide while communicating with fellow students or friends:with fellow students or friends:1. State any significant nonverbal 1. State any significant nonverbal behavior, such as finger tapping, tics, or behavior, such as finger tapping, tics, or poor eye contact.poor eye contact.2. State the possible reason for or 2. State the possible reason for or meaning of the behavior, such as fear, meaning of the behavior, such as fear, anxiety, boredom, or impatience.anxiety, boredom, or impatience.B. List nursing interventions for the B. List nursing interventions for the identified behavior.identified behavior.

III. Case Study Behavioral AssessmentIII. Case Study Behavioral AssessmentA. WJ, 45-year-old patient admitted for emergency surgery for a bleeding A. WJ, 45-year-old patient admitted for emergency surgery for a bleeding ulcer, is referred to the psychiatric unit for a consultation because of ulcer, is referred to the psychiatric unit for a consultation because of symptoms of depression of anxiety. This married man has four children, symptoms of depression of anxiety. This married man has four children, two of whom are still living at home while attending college. He runs his two of whom are still living at home while attending college. He runs his own business and often works 10 to 12 hours each day. He had one own business and often works 10 to 12 hours each day. He had one previous hospitalization two years ago, when he had surgery for cancer of previous hospitalization two years ago, when he had surgery for cancer of the colon.the colon.

WJ is alert and oriented in ICU but gets little sleep at night. WJ is alert and oriented in ICU but gets little sleep at night. While awake, he watches the nurses carefully and is very pleasant when While awake, he watches the nurses carefully and is very pleasant when he converses with them. When he calls for a nurse and one does not he converses with them. When he calls for a nurse and one does not respond immediately, WJ begins to shout until someone arrives. His respond immediately, WJ begins to shout until someone arrives. His requests are often minor and he could have waited.requests are often minor and he could have waited.

The staff is not certain how much WJ knows about his latest The staff is not certain how much WJ knows about his latest surgery, but his response is “I’m glad it wasn’t cancer. Maybe this surgery, but his response is “I’m glad it wasn’t cancer. Maybe this happened to slow me down.” He usually terminates such discussions by happened to slow me down.” He usually terminates such discussions by stating that he has to rest and suggests that the attending staff care for stating that he has to rest and suggests that the attending staff care for other patients “who are sicker” than he is.other patients “who are sicker” than he is.B. From the information given:B. From the information given:

1. List the possible stressors before and during hospitalization.1. List the possible stressors before and during hospitalization.2. Describe WJ present coping mechanisms.2. Describe WJ present coping mechanisms.3. While providing nursing care for WJ, identify stressors that the 3. While providing nursing care for WJ, identify stressors that the

staff may experience.staff may experience.4. Write informative nursing progress notes regarding WJ’s 4. Write informative nursing progress notes regarding WJ’s

behavior.behavior.

Orientation

Registration

Attention and Calculation

Recall

Language

1. Ask the patient to name the year, season, date, day, and month. (1point each)

2. Ask the patient to give her/his whereabouts: state, country, town, street, floor.(1 point each)

3. Ask the patient to repeat three unrelated objects that you name. Repeat them and continue to repeat them until all three are learned .(1 point each)

4. Ask the patient to subtract 7 from 100, stopping after five subtractions, or to spell the word “world” backwards. .(1 point for each correct calculation or letter)

5. Ask the patient to repeat the three objects previously named .(1 point each)6. Display a wrist watch and ask the patient to name it. Repeat this for a

pencil .(1 point each)7. Ask the patient to repeat this phrase: “No ifs, ands, or buts!” .(1 point)8. Have the patient follow a three-point command such as, “Take a paper in

your night hand, fold it in half, and put it on the floor.” .(1 point each)9. On a blank piece of paper write, “Close your eyes!” ask the patient to read

it and do what it says. .(1 point)10. Ask the patient to write a sentence on a blank piece of paper. It must be

written spontaneously. Score correctly if it contains a subject and a verb and is sensible (correct grammar and punctuation are not necessary)(1 point)

11. Ask the patient to copy a design you have drawn on a piece of paper (two intersecting pentagons with sides about one inch) .(1 point)

Question MAXIMUM

ScoreScore

( )

( )

( )

( )

( )( )

( )( )

( )

( )

( )

5

5

3

5

32

13

1

1

1

THE FOLSTEIN MINI-MENTAL STATETHE FOLSTEIN MINI-MENTAL STATE