Professional Documents
Culture Documents
Nursing Process Psychiatric
Nursing Process Psychiatric
Nursing Process Psychiatric
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation
Characteristics of the nursing process
• Prevention of duplication
• Individualized care
• Standards of care
• Interview:
– Types of questions
– Environment (physical and emotional) and
spiritual considerations
• Examination
*Types of Data to Collect:
• Objective data-observable and measurable facts
(Signs)
• Subjective data-information that only the client
feels and can describe (Symptoms)
*Sources of Data:
• Primary source: Client
• Secondary source: Client’s family, reports, test
results, information in current and past medical
records, and discussions with other health care
workers
* Assessment:
• Data base assessment – comprehensive
information you gather on initial contact with
the person to assess all aspects of health
status.
• Focus assessment – the data you gather to
determine the status of a specific condition.
* Nursing Diagnosis: Health issue that can be prevented,
reduced, resolved, or enhanced through independent
nursing measures by:
• Sorting, clustering, analyzing information
• Identifying potential problems and strengths
• Writing statement of problem or strength
• Prioritizing the problems
• Not a medical diagnosis
*Setting Priorities:
• Determine problems that require immediate action
• Maslow’s Hierarchy of Human Needs
Nurse Identified Priorities
• Composite of all patient’s strengths and health
concerns.
• Moral and ethical issues.
• Time, resources, and setting.
• Hierarchy of needs.
• Interdisciplinary planning.
• Identifying Client-centered outcomes
• State what the patient will do or experience at the
completion of care.
• Give direction to the patient’s overall care.
• Patient behaviors not nurse behaviors!!
*Outcome:
-Components of Outcomes
• Subject: who is the person expected to achieve the
outcome?
• Verb: what actions must the person take to achieve
the outcome?
• Condition: under what circumstances is the person to
perform the actions?
• Performance criteria: how well is the person to
perform the actions?
• Target time: by when is the person expected to be
able to perform the actions?
*Steps for deriving outcomes from Nursing
Diagnosis:
• Look at the first clause of the nursing dx and
restate in a statement that describes improvement,
control or absence of the problem.
*Long-Term Goals:
• Desirable outcomes that take weeks or months to
accomplish for client’s with chronic health problems
*Selecting Nursing Interventions:
• Planning the measures that the client and nurse will
use to accomplish identified goals involves critical
thinking.
• Nursing interventions are directed at eliminating the
etiologies.
*Selecting an intervention:
• The nurse selects strategies based on the knowledge
that certain nursing actions produce desired effects.
• Nursing interventions must be safe, within the legal
scope of nursing practice, and compatible with
medical orders.
*Nursing Interventions:
• Monitor health status.
• Minimize risks.
• Resolve or control a problem.
• Assist with ADLs.
• Promote optimum health and independence.
• Either:
• Direct interventions: actions performed through
interaction with clients.
• Indirect interventions: actions performed away from
the client, on behalf of a client or group of clients.
*Evaluation:
• The way nurses determine whether a client has reached a goal.
• It is the analysis of the client’s response, evaluation helps to
determine the effectiveness of nursing care.
• Ongoing part of the nursing process
• Monitoring the patient’s response to drug therapy
• Identifying the variables affecting outcome achievement
• Deciding whether to continue, modify, or terminate the plan
-Determining Outcome Achievement:
• Must be aware of outcomes set for the client.
• Must be sure patient is ready for evaluation.
• Is patient able to meet outcome criteria?
• Is it: (Completely met? ,Partially met?, Not met at all?)
• Record in progress in notes.
• Update care plan.
*Identifying Variable Affecting Outcome Achievement
• Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for this particular client?
3. Were changes made in the plan when needed?
4. How does the client feel about the plan?
Activity Intolerance
Impaired Gas Exchange in effective Airway Clearance
Ineffective Breathing Pattern
Decreased Adaptive Intracranial Capacity
Decreased Cardiac Output
Disuse syndrome
Diversional Activity Deficit
Impaired Home Maintenance Management
Impaired Physical Mobility
Dysfunctional Ventilatory Weaning Response
Inability to Sustain Spontaneous Ventilation
Self-Care Deficit: (Feeding, Bathing/Hygiene, Dressing/Grooming,
Toileting)
Altered Tissue Perfusion: (Specify type: Cardiac, Cerebral, and Cardiopulmonary.
Renal, Gastrointestinal, Peripheral)
Disorganized Infant Behavior
Risk for Disorganized Infant Behavior
Risk for Peripheral Neurovascular Dysfunction
Risk for altered respiratory function
Sexuality-Reproduction Pattern
Risk- Diagnoses
Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns
Sleep-Rest Pattern
Wellness Diagnoses:
Opportunity to enhance sleep
Risk Diagnoses:
Risk for sleep pattern disturbance
Actual Diagnosis:
Sleeps Pattern Disturbance
Sensory-Perceptual Pattern
Wellness Diagnosis:
Opportunity to enhance comfort level
Risk Diagnoses:
Risk for pain, Risk for Aspiration
Actual Diagnoses:
Pain, Chronic Pain and Dysreflexia.
Cognitive Pattern
*Actual diagnosis
Acute confusion
Chronic Confusion
Decisional Conflict
Impaired Environmental Interpretation Syndrome
Knowledge Deficit (Specify)
Altered Thought Processes
Impaired Memory
*Wellness Diagnosis:
Opportunity to enhance cognition
*Risk Diagnoses:
Risk for altered thought processes
Role-Relationship Pattern
*Actual Diagnoses
Impaired Verbal Communication
Altered Family Processes: Alcoholism
Anticipatory Grieving
Dysfunctional Grieving?
Altered Parenting
Parental Role Conflict
Altered Role Performance
Impaired Social Interaction: Social Isolation
*Risk Diagnoses
Risk for dysfunctional grieving, High risk for Loneliness.
Risk for Altered Parent/Infant/Child Attachment
Self-Perception-Self-Concept Pattern
*Actual Diagnoses
Anxiety fatigue - Fear - Hopelessness- Powerlessness-
Personal Identity.
Disturbance - Body Image
Disturbance- self Esteem
Disturbance.
Risk Diagnoses
Risk for hopelessness
Risk for body image disturbance
Risk for low self esteem
Coping-Stress Tolerance Pattern
*Actual Diagnoses
Impaired Adjustment
Ineffective Individual Coping
Ineffective Family Coping: Disabling
Ineffective Family Coping: Compromised
Ineffective Community Coping: Post-Trauma Response,
Rape-Trauma Syndrome Relocation and Stress Syndrome.
*Risk Diagnoses
Risk for ineffective coping (individual, family, or community)
Risk for self-harm
Risk for self- abuse.
Risk for Self-Mutilation
Risk for suicide
Risk for Violence; Self- directed or directed at others
Value-Belief Pattern
*Actual Diagnosis
Spiritual disturbance (distress of the human spirit).
*Risk diagnosis
Risk for spiritual distress
*Wellness Diagnosis
Potential for enhanced spiritual Well- Being
**PRACTICAL STEPS
• Perform assessment
• Look at the NANDA list
• Look for the defining characteristics or symptoms
from your assessment
• Look for the related factors - things that cause the
symptoms
• Make the sentence read: NANDA Diagnosis…RT…
AEB…
• Develop SMART patient goals or the "patient will"
statements
– Specific & Individualized
– Measurable
– Attainable
– Reasonable Timed, and a date
• Write nursing interventions
• Write rationale that match the intent of the
interventions and goals
• Evaluate the outcome or result of goal interventions.
• More specifically...as you begin to write the care
plan, refer to your assessment findings. What is the
priority problem? Are there clues to the need for
patient teaching? What symptoms is the patient
experiencing?
• Often it helps to look at the NANDA list first, and see
if there is one particular diagnosis that seems to fit
the situation. Then look up that diagnosis in the
Nursing Diagnosis book. Look at their definition, to
see if it fits your patient.
Then look for the defining characteristics or
evidence: These are the signs and symptoms you
have seen in the patient. They will be the "as
evidenced by" or AEB of the diagnosis statement.
• Next, look for the related factors:
These are the "related to" or R/T part of the
statement. Remember, avoid using the medical
diagnosis as a "related to" part. However, it may be
used as a "secondary to" statement. Then change it
around to make the sentence read: NANDA
Diagnosis…RT…AEB…
• For example, if my patient has sores on his legs, and
he also has Diabetes Mellitus, you might use the
statement:
Decreased blood flow and nutrients to tissues of the
lower extremities, secondary to Diabetes
Mellitus AEB a 2 cm skin lesion on the left great toe,
and a 4 cm lesion on the inner aspect of the right
ankle."
• Nursing diagnoses that are in the "risk for"
categories do not need the AEB portion of the
statement, since there is no actual evidence.
However, you should avoid using too many "risk
for" diagnosis. One or two, out of eight to ten, is
acceptable.
• Assessment abnormalities should always be
reflected in the nursing diagnosis, and subjective
and objective data. If the assessment data is not
there, you have no evidence.
• Gradually, with practice, you will find that nursing
diagnoses are easier and easier to develop.
*GOALS or OUTCOMES:
• Next you'll want to develop patient goals or the
"patient will" statements. These must be specific,
measurable, attainable, realistic, timed, and dated.
Collaborate with the patient, to gain cooperation
with the planned goals. They should also be
measurable, and include a time frame, and a date.
Goals should conform to the nursing diagnosis. Make
them specific to your patient's problem.
• They should be individualized to your patient, not
just "canned" from the book.
• They should be attainable for your patient.
• Then look in the Nursing Diagnosis book for nursing
interventions that could be used to assist the patient
to attain the goal (s), you have established.
• Next, find the rationale that match the intent of the
interventions and goals.
• And finally, evaluate the outcome of the
interventions. These statements should match the
wording used in the goal column, and be followed by
the statement as to whether the goal was "met,
partially met, or not met.
Nursing Care Plan 1
**Long-Term Goal
• Patient will experience no delusional or distorted
thinking by discharge.
*Interventions with Selected Rationales
• Convey your acceptance of patient’s need for the
false belief, while letting him or her know that you
don’t share the delusion. A positive response would
convey to the patient that you accept the delusion as
reality.
• Do not argue to deny the belief. Use REASONABLE
DOUBT as a therapeutic technique: “I find that hard
to believe.” An arguing with the patient or denying
the belief serves no useful purpose; delusional ideas
are not eliminated by this approach, and the
development of a trusting relationship may be
impeded.
• Use the technique of CONSENSUAL VALIDATION and
SEEKING CLARIFICATION when communication
reflects alteration in thinking. (Examples: “Is it that
you mean? “or“ I don’t understand what you mean
by that. Would you please explain?”) These
techniques reveal to the patient how he or she is
being perceived by others, while the responsibility for
not understanding is accepted by the nurse.
• Reinforce and focus on reality. Talk about real events
and real people. Use real situations and events to
divert patient away from long, purposeless, repetitive
verbalizations of false ideas.
• Give positive reinforcement, as patient is able to
differentiate between reality- and nonreality-based
thinking. Positive reinforcement enhances self-esteem
and encourages repetition of desirable behaviors.
• Teach patient to intervene, using thought-stopping
techniques, when irrational or negative thoughts
prevail. Thought stopping involves using the
command slop!” or a loud noise (such as hand
clapping) to interrupt unwanted thoughts. This noise
or command distracts the individual from the
undesirable thinking that often precedes undesirable
emotions or behaviors.
• Use touch cautiously, particularly if thoughts reveal
ideas of persecution. Patients who are suspicious
may perceive touch as threatening and may respond
with aggression.
*Desired Patient Outcomes/Discharge Criteria
1.Patient’s thinking processes reflect accurate
interpretation of the environment.
**Long-Term Goal
• Patient will exhibit no signs or symptoms of
malnutrition by discharge (e.g.; electrolytes and
blood counts will be within normal limits; a steady
weight gain will be demonstrated; constipation will
be corrected; patient will exhibit increased energy in
participation of activities).
*Interventions with Selected Rationales
• In collaboration with dietitian, determine number
of calories required to provide adequate nutrition
and realistic (according to body structure and
height) weight gain.
• Ensure that diet includes foods high in fiber content
to prevent constipation. Encourage patient to
increase fluid consumption and physical exercise to
promote normal bowel functioning. Depressed
patients are particularly vulnerable to constipation
due to psychomotor retardation. Constipation is
also a common side effect of many antidepressant
medications.
• Keep strict documentation of intake, output, and
calorie count. This information is necessary to make
an accurate nutritional assessment and maintain
patient’s safety.
• Weigh patient daily. Weight loss or gain is important
assessment information.
• Determine patient’s likes and dislikes and collaborate
with dietitian to provide favorite foods. Patient is
more likely to eat foods that he or she particularly
enjoys.
• Ensure that patient receives small, frequent feedings,
including a bedtime snack, rather than three larger
meals. Large amounts of food may be objectionable,
or even intolerable, to the patient.
• Administer vitamin and mineral supplements and
stool softeners or bulk extenders, as ordered by
physician.
• If appropriate, ask family members or significant
others to bring in special foods that patient
particularly enjoys.
• Stay with patient during meals to assist as needed
and to offer support and encouragement.
• Monitor laboratory values, and report significant
changes to physician. Laboratory values provide
objective data regarding nutritional status.
• Explain the importance of adequate nutrition and
fluid intake. Patient may have inadequate or
inaccurate knowledge regarding the contribution of
good nutrition to overall wellness.
*Desired Patient Outcomes/Discharge Criteria
1.Patient has shown a slow, progressive weight gain dur
ing hospitalization.
**Long-Terms Goal
• Patient will be able to fall asleep within 30 minutes of
retiring, and obtain 6 to 8 hours of uninterrupted
sleep each night without medication by discharge.
*Interventions with Selected Rationales
• Keep strict records of sleeping patterns. Accurate
base line data are important in planning care to assist
patient with this problem.
• Discourage sleep during the day to promote restful
sleep at night.
• Administer antidepressant medication at bedtime so
patient does not become drowsy during the day.
• Assist with measures that may promote sleep, such
as warm, non-stimulating drinks, light snacks, warm
baths, backrubs.
• Performing relaxation exercises to soft music (or
other technique) may be helpful before sleep.
• Limit intake of caffeinated drinks, such as tea, coffee,
and coals. Caffeine is a CNS stimulant that may
interfere with the patient’s ability to rest and sleep.
• Administer sedative medications, as ordered, to
assist patient achieve sleep until normal sleep
pattern is restored.
• For patient experiencing hypersomnia, set limits on
time spent in room. Plan stimulating diversionary
activities on a structured, daily schedule. Explore
fears and feelings that sleep is helping to suppress.
*Desired Patient Outcomes/Discharge Criteria
1.Patient is sleeping 6 to 8 hours per night without med
ication.