PSYCHIATRIC NURSING

Nursing Process: Planning & Intervention

Nursing Care Plans

 Standardized care plans which are developed with expected outcomes for certain
types of patients
 Standardized care plans are also called clinical pathways or critical pathways or
multidisciplinary care plan
 Might focus on psychiatric diagnoses (e.g. major depression) or more specific
problems (e.g. self mutilation)
 The initial care plan might be updated at any time but begins with one or two
behavior-oriented problems to be addressed immediately (for example: suicide,
aggression, arson, escape, withdrawal or isolation, delusion, hallucination,
impulsive, compulsive acts, suspiciousness, uncooperativeness, altered thought
processes)
 Example: patient who has suicidal ideation would be expected to sign a no-harm
agreement within 24 hours and to verbalize a plan for dealing with suicidal
ideation by day 3 of admission
 Related interventions could be an agreement with the patient for safety and
removal of dangerous objects from the patient, assess for suicidal ideation during
every shift
 Even if the patient tells you that she’s feels okay and she is more hopeful than
before, it is appropriate to still assess for suicidal ideation, especially that the
patient has had suicidal ideation before
 The goal of standardized care plans is to expedite treatment activities to achieve
patient outcomes in a cost-effective manner
 Nursing interventions focus particularly on safety, structure, support and symptom
management
 Each patient is an individual. Even when some of the patients problems may fit
into a standardized plan, take note that a patient’s unique problems and needs
must be address when formulating a plan of care.
  The focus of psychiatric nursing is often on the verbal strategies that are used to
guide patients in solving problems for themselves and achieving desired
outcomes
 Psychiatric nurses are primarily facilitators and educators
 Patients might need developing specific and concrete plans for reaching the goal.

Psychotherapeutic Management: Me, Medication, and Milieu

 What do psychiatric nurses do that are different from other mental health
professionals such as social workers, psychiatrists and psychologist?
1. Me is the therapeutic use of self; Self awareness is important in psychiatric
nursing. Be aware of our strengths and weaknesses. It represents the interpersonal
skills of the nurse, we use the Nurse-Patient Relationship.
2. Medication- anybody can administer medication but a competent nurse
understands the many dimensions of the drug that he or she gives.
3. Milieu represents the least restrictive environment, modifying an environment to
make it both safe and therapeutic.

Principles of Therapeutic Communication

 the patient should be the primary purpose
 we are there to assist the client, not to give the possible solutions. Help the clients
make an option and to choose the best option for himself based on the options
that he also created.
 a professional attitude sets the tone of a therapeutic relationship
 use of self-disclosure cautiously, only when it has a therapeutic purpose
 avoid social relationship with patients
 maintain confidentiality and non-judgmental attitude
 avoid giving an advice
 giving advise is non-therapeutic, it doesn’t not mean that if it works best in you it
will also work best to other people.

Elements of a Therapeutic Relationship: contract, boundaries, confidentiality

  In contract: we establish time, place and the purpose of meetings between the
nurse and the patient. The nurse is defined as professional helper; the client’s
needs and problems are the focus of interaction.
 In boundaries: we establish the roles which are therapeutic; the roles of the
participants are also clearly defined
 In confidentiality: we disclose the information to those who are directly involved
with the patient’s case. It helps build trust and must be maintained by the nurse
through out the relationship. Truthfulness is the foundation of trust.

Dynamics of Therapeutic Communication

 Therapeutic communication requires attention to multiple, interacting factors
 At the core of the therapeutic communication are the words and the non verbal
behaviors that relate to the patient health needs and are exchanged between the
patient and the nurse. Communication does not only in colt the words, it involves
the gestures and etc.
 Carl Rogers one of the leaders in psycho therapy of 20th century viewed patients
with unconditional positive and nonjudgmental acceptance.
 Therapeutic Communication is influenced by the following factors:
1. the individual’s personal experiences, gender, culture, values, beliefs, coping
ability.
2. purpose of the interaction
3. physical and emotional context
4. the nurse must communicate on the patient’s level, according to the
individual patient’s vocabulary, educational background and affects of his or her
illnesses. Without using a patronizing, condescending, or stigmatizing attitude.

A. Interpretation of Communication
 interpretation of message is filtered through an individual’s knowledge,
experience, and biases
  some aspects of communication are more commonly understood than others,
words are more understood more precisely than behaviors unless there is a
barrier in communication like language barrier.
 both nurse and patient bring their own experiences to the relationship
 the nurse and patient is looking at one situation from different lens or angles
because both of you have different beliefs, different culture, as long as you
remember that the interaction is about the patient.
 having a broad knowledge of the effects of cultures is important if the nurse is to
interpret accurately and respond appropriately to patient communications
 when the nurse is unclear of the meaning of a statement, it is acceptable to state,
“Can you help me understand what you mean? I do not comprehend your
meaning when you say...”
 clarification may help express meaning that may not be explicit

B. Themes in Patient Communication

 themes are reflected in patient’s thoughts, which engender feelings and produce
behaviors
 content themes go beyond the words that a patient is saying and examine
underlying messages about patient’s perceptions of themselves and their
problems over time
 mood themes relate to affect and the feelings conveyed while patients discuss
their issues and concerns
 interaction themes involve examining the ways in which patients relate to family,
friends, other patients, and staff

C. Environmental Considerations
 the environment can facilitate or impede therapeutic communication
 consider the following: privacy, decrease background noise, proxemics, type of
illness, the genders of the two parties

D. Physical Considerations
  patients with certain physical problems might experience communication
difficulties
 developmental disabilities might seriously limit the ability of patients to
comprehend and remember
 speech impediments or other problems might interfere with the nurse’s ability to
understand the patient’s needs

E. Kinesics Considerations
 the study of body movements as a form of nonverbal communication
 culturally based body language is another means by which individuals express
their emotional state
 the nurse must be sensitive to the cues and interpret them in a global context of
therapeutic communication
 body language might communicate feelings or emotions, or merely reflect a habit

Therapeutic Use of Self

 in psychiatric nursing, the nurse, using verbal and nonverbal communication, is
the primary therapeutic agent with psychiatric patients
 the nurse’s communication is a major vehicle that helps patients achieve
productive thinking, emotional, and behavioral outcomes
 the use of silence and therapeutic listening are important components of the
therapeutic use of self with patients
 therapeutic listening has been described as being composed of the following
attributes: being actively alert, “hearing” with all the senses; using eye contact,
exhibiting an attending posture; ensuring concentration; being patient; displaying
an openness to receive information; offering empathy and support; asking
questions; assimilating verbal and nonverbal information; organizing, synthesizing,
and interpreting information; validating emotional experiences; clarifying
information; responding verbally and non-verbally to encourage patients to
continue; summarizing important points; giving appropriate feedback
 requires sensitivity to recognize important cues and make decisions about the
priority of these cues
 communicating empathy is an essential skill of the psychiatric nurse
 being therapeutic includes being genuine and sincere
 patients must feel respected, valued and accepted by the nurse*
 touch is a complex issue when working with patients who have underlying
psychiatric issues