PROSES KEPERAWATAN JIWA

Nursing Process in Psychiatric Nursing

Mrs. Jyoti Beck, RN, RM,DPN RINPAS, Ranchi, India

This page was last updated on 28/7/2010

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 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 standard 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. 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 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 They may be highly withdrawn, highly anxious, ,or out of touch with reality. 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; Assessment Nursing Diagnosis Outcome Identification Planning Implementation and Evaluation Assessment 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 ASSESSMENT Client’s complaint, present symptom and focus of concern Perceptions and expectations Previous hospitalizations and mental health treatment Family history Health beliefs and practices Substance use Sexual history Abuse Spiritual Basic needs (diet, exercise, sleep, elimination) Sociocultural Coping patterns Self-esteem Medical Examination Diagnostic Investigations Mental Status Examination Subjective Data Objective Data Name and general information about the client Client’s perception of current stressor or problem Current occupational or work situation Any recent difficulty in relationships Any somatic complaints Current or past substance use Interests or activities previously enjoyed Sexual activity or difficulties Physical exam Behavior Mood and affect Awareness Thought processes Appearance Activity Judgment Response to environment Perceptual ability When the nurse investigates a patient’s specific behaviour, it is valuable to explore the following, Situation that precipitated that behaviour What the patient was thinking at that moment? Whether that behaviour makes any sense in that context? Whether the behaviour was adaptive or dysfunctional? 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. 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. 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. The most commonly used standard is that of the North American Nursing Diagnosis Association (NANDA). A nursing diagnostic statement consists of three parts: Health problem Contributing factors 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. 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- 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. Social isolation , related to anxiety, as evidenced by withdrawal and uncommunicative behaviour. Outcome 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. 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 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. 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 one week patient will sleep well at night. At the end of the one week patient will eat properly and maintain weight. Planning As soon as the patient‘s problems are identified, nursing diagnosis made, planning nursing care begins. The planning consists of: Determining priorities Setting goals Selecting nursing actions 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. Implementation 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 this 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. Nursing actions are of two types- 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. Evaluation 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. Components of Assessment Mental Status Examination Appearance Dress, grooming, hygiene, cosmetics, apparent age, posture, facial expression. Behaviour/activity Hyperactivity or hyperactivity, rigid, relaxed, restless, or agitated motor movements, gait and coordination, facial grimacing, gestures, mannerisms,, passive , combative, bizarre. Attitude Interactions with interviewer: - Cooperative, resistive, friendly, hostile, ingratiating Speech-Quantity: - poverty of speech, poverty of content, volume. Quality: - articulate, congruent, monotonous, talkative, repetitious, spontaneous, circumstantial, confabulation, tangential and pressured Rate:-slowed, rapid Mood and affect Mood (Intensity depth duration):- sad, fearful, depressed, angry, anxious, ambivalent, happy, ecstatic, grandiose. Affect (Intensity depth duration) :- appropriate, apathetic, constricted, blunted, flat, labile, euphoric. Perception Hallucination, illusions, depersonalization, derealization, distortions Thoughts 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 Cognition Level of consciousness, orientation, attention span, , recent and remote memory, concentration, , ability to comprehend and process information, intelligence Judgment Ability to assess and evaluate situations makes rational decisions, understand consequence of behaviour, and take responsibly for actions Insight Ability to perceive and understand the cause and nature of own and other’s situatio Reliability Interviewer’s impression that individual reported information accurately and completely Psychosocial Criteria 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 system Coping skills Adaptation to internal and external stressors, use of functional, adaptive coping mechanisms, and techniques, management of activities of daily living Relationships Attainment and maintenance of satisfying, interpersonal relationships congruent with developmental stages, including sexual relationship as appropriate for age and status Cultural Ability to adapt and conform to present norms, rules, ethics. Spiritual (Value-belief) Presence of self-satisfying value-belief system that the individual regards as right, desirable, worthwhile, and comforting Occupational Engagement is useful, rewarding activity, congruent with developmental stages and societal standards (work, school and recreation) Sample of Nursing Care Plan Sample of Nursing Diagnoses (As per NANDA- North American Nursing Diagnosis Association) Nursing Diagnosis Analysis 1 Risk for injury related to accelerated motor activity Accelerated motor activity or impulsive actions 2 Disturbed thought process related to impaired judgement associated with manic behaviour Judgement impaired , mood of elation (patient is using inappropriate dress and bizarre dressing) 3 Self-care deficit (unkempt appearance) related to hyperactivity Unable to take time for self-care is, dishevelled and unkempt 4 Impaired verbal communication –flight of ideas related to accelerated thinking Accelerated speech with flight of ideas (thought speeded up causing rapid speech and flight of ideas, excessive planning for activities 5 Ineffective coping related to elated expressive mood Euphoria, elation, cheerfulness( an exaggerated sense of well being) 6 Disturbed thought process –grandiosity related to elevated mood Grandiosity-inflation self-esteem 7 Ineffective coping related to emotional liability associated with manic behaviour Emotional labiality (unstable mood moves from cheerfulness to irritation easily with little irritation 8 Disturbed thought process –related to delusion of grandeur Grandiose delusions (Belief that well known political religious, or entertainment leader) 9 Disturbed thought process decreased attention span and difficulty in concentration related to accelerated thinking Short attention span, difficulty in concentrating , easily disturbed 10 Risk for violence related to hostile and angry behaviour Hostile comment and complaints 11 Impaired verbal communication related to pressure of speech Accelerated thinking, highly responsive to environmental stimuli, accompanying flight of ideas 12 Nutrition: less than body requirements, imbalanced Nutrition: more than body requirements, imbalanced Nutrition: 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 13 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 14 Health Maintenance, ineffective –psychomotor retardation related to depression Extreme slowness in performing activity 15 Risk for violence- self-directed, related to depression Bruises, cuts, scars, (possible destructive behaviour or abuse by others) 16 Anxiety –neurological symptoms related to depression Extreme nervousness (possible response to loss with symptoms to those of anxiety) 17 Risk for violencerm Suicidal feeling (Hopelessness contributes to total despair 18 Sensory perceptual alteration –disorientation about time, place, and person related to increased anxiety Confusion or disorientation 19 Ineffective coping –obsessive thinking related to anxiety Anxiety (Increased anxiety unapparent and discharge through obsessive thinking) 20 Impaired Social interactions –inability to form warm, meaningful relationships, related to compulsive behaviour Lacks ability to develop warm relationship ( has limited ability to express emotion) 21 Ineffective coping –compulsion related to need for excessive cleanliness) Excessive cleanliness (Over emphasis for cleanliness and neatness) 22 Potential for self harm related to poor impulse control associated with substance abuse) Poor impulse control 23 Potential for self-harm related to marked disorientation , disorganization, and confusion Disorientation, disorganization and confusion (If marked , patient is at high suicidal risk) 24 Distarbance of self-concept-insecurity related to suspiciousness Insecurity, oversensitive, Failure to meet needs results in mistrust and insecurity 25 Potential 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) 25 Ineffective individual coping persecutory feeling related to mistrust Feeling of being misjudged , conspired against, spied upon , followed , poisoned, dragged, obstructed in achieving long term goals. Nursing Diagnosis: Risk for violence, self directed. Risk factors-Chronic illness, retirement, change in marital status Patient Outcome Nursing Intervention with Rationale Evaluation Patient will not harm himself Patient will refrain from suicidal threats or behaviour gestures. He will deny any plans for suicide 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. 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. Absence of verbalized or behavioural indications of suicidal intent by the patient. Patient denies active suicide plans Nursing Diagnosis: Ineffective individual coping, related to response crisis (retirement), as evidence by isolative behaviour, changes in mood, and decreased sense of well-being. Patient Outcome Nursing Intervention with Rationale Evaluation Patient will identify positive coping strategies, such as structuring leisure time. Patient 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. Praise patient for adaptive coping. Positive feedback encourages repetition of effective coping by patient Patient expresses trust in nurse-patient relationship. Patient discusses plans for use of past and newly learned coping methods. Nursing 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. Patient Outcome Nursing Intervention with Rationale Evaluation Patient will dress appropriately for age and status. 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. 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. Patient dresses self appropriately and maintains hygiene. Patient eats and drinks fluids necessarily to maintain physical health. References: Ladwig, 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. 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. Katherine N Fortinash, Patrica N Hooliday-Worret. Psychiatric Nursing Care Plans 1991: Chapter 1, Page 1.

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