NURSING PROCESS IN PYSCHIATRIC  The ongoing assessment involves what

MENTAL HEALTH CARE 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
NURSING PROCESS
 Substance use
Nursing process aims at individualized care to  Sexual history
the patient and the care is adapted to patient’s  Abuse
unique needs. Nursing process the following  Spiritual
steps;
 Basic needs (diet, exercise, sleep,
 Assessment elimination)
 Nursing Diagnosis  Sociocultural
 Outcome Identification  Coping patterns
 Planning  Self-esteem
 Implementation and  Medical Examination
 Evaluation  Diagnostic Investigations
 Mental Status Examination
Assessment
Subjective Data
 Individualized care begins with a
detailed assessment as soon as the  Name and general information about
patient is admitted. the client
 In the Assessment phase, information is  Client’s perception of current
obtained the patient in a direct and stressor or problem
structured manner through observation,  Current occupational or work situation
interviews and examination.  Any recent difficulty in relationships
 Initial interview includes an evaluation  Any somatic complaints
of mental status.  Current or past substance use
 In such cases, where the patient is too  Interests or activities previously
ill to participate in or complete the enjoyed
interview, the behavior the patient  Sexual activity or difficulties
exhibits to be recorded and reports
from family members if possible, can Objective Data
obtained.  Physical exam
 Even when the initial assessment is  Behavior
complete, each encounter with the  Mood and affect
patient involves a continuing
 Awareness
assessment .
 Thought processes
Darianne Cacayurin BSN4
  Appearance
 Activity
 Judgment
 Response to environment
 Perceptual ability
When the nurse investigates a patient’s
specific behavior, it is valuable to explore
the following,
 Situation that precipitated that behavior
 What the patient was thinking at that
moment?
 Whether that behavior makes any sense
in that context?
 Whether the behavior 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
Darianne Cacayurin BSN4
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
Outcome Identification
 The psychiatric mental health nurse
identifies expected outcomes
individualized 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 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 behavior.
 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 agreed on, they
must be stated in writing .Goals should
be written in behavioral 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
term 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
Darianne Cacayurin BSN4
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.
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  Speech-Quantity: - poverty of speech,
medicines. poverty of content, volume.
 Independent nursing actions: This is  Quality: - articulate,
based on nursing diagnosis and plan of congruent, monotonous,
care, pursuing the patient to attend to talkative, repetitious,
personal hygiene. spontaneous, circumstantial,
confabulation, tangential
Evaluation and pressured Rate:-slowed,
rapid
• The continuous or ongoing phase of nursing
 Mood and affect
process is evaluation. Nursing care is a
dynamic process involving change in the Hallucination, illusions,
patient’s health status over time, giving rise to depersonalization, derealization,
the need of new data, different diagnosis, and distortions
modifications in the plan of care.  Thoughts
• When evaluating care the nurse should
Form and content-logical vs. illogical,
review all previous phases of the nursing loose associations, flight of ideas,
process and determine whether expected autistic, blocking., broadcasting,
outcome for the patient have been met. This neologisms, word salad, obsessions,
can be done checking –have I done everything ruminations, delusions, abstract vs.
for my patient? Is my patient better after the concrete
planned care? .Evaluation is a feed back
 Sensorium and Cognition
mechanism for judging the quality of care
Level of consciousness, orientation,
given. Evaluation of the patient’s progress
attention span, , recent and remote
indicates what problems of the patient have memory, concentration, , ability to
been solved , which need to be assessed again, comprehend and process information,
replanted, implemented and re-evaluated. intelligence
COMPONENTS OF ASSESSMENT  Judgment
MENTAL STATUS EXAMINATION Ability to assess and evaluate situations
makes rational decisions, understand
 APPEARANCE consequence of behavior, and take
responsibly for actions
Dress, grooming hygiene, cosmetics,
 INSIGHT
apparent age, posture, facial expression.
Ability to perceive and understand the
 BEHAVIOR/ACTIVITY cause and nature of own and other’s
situation
Hyperactivity or hyperactivity, rigid,  Reliability
relaxed, restless, or agitated motor Interviewer’s impression that
movements, gait and coordination, facial individual reported information
grimacing, gestures, mannerisms,, passive , accurately and completely
combative, bizarre
 Attitude
Interactions with interviewer: -
Cooperative, resistive, friendly, hostile,
ingratiating

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 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)
RELATED LAWS IN MENTAL HEALTH
 PHILIPPINE MENTAL HEALTH
LAW
REPUBLIC ACT No. 11036
An Act Establishing a National Mental
Health Policy for the Purpose of
- Enhancing the Delivery of Integrated
Mental Health Services, Promoting and
Protecting the Rights of Persons
Utilizing Psychosocial Health Services,
Appropriating Funds Therefor and
Other Purposes
Darianne Cacayurin BSN4
OTHER LAWS AND ETHICAL
CONTEXT OF PSYHIATRIC MENTAL
HEALTH NURSING
 Patients Bill of Rights
 Magna Carta of Women
 Magna Carta of Disabled Person
 Magna Carta of Health Workers
PATIENTS RIGHTS
 Right to Appropriate Medical Care
and Humane Treatment.
-Every person has a right to health and
medical care corresponding to his state of
health, without any discrimination and within
the limits of the resources, manpower and
competence available for health and medical
care at the relevant time.
 Right to Informed Consent.
The patient has a right to a clear, truthful and
substantial explanation, in a manner and
language understandable to the patient, of all
proposed procedures, whether diagnostic,
preventive, curative, rehabilitative or
therapeutic, wherein the person who will
perform the said procedure shall provide his
name and credentials to the patient,
possibilities of any risk of mortality or
serious side effects, problems related to
recuperation, and probability of success and
reasonable risks involved.
 Right to Privacy and Confidentiality
The privacy of the patients must be assured at
all stages of his treatment. The patient has the
right to be free from unwarranted public
exposure, except in the following cases:
a) when his mental or physical condition is
in controversy and the appropriate court, in
its discretion, order him to submit to a
physical or mental examination by a
physician;
b) when the public health and safety so
demand; and
c) when the patient waives this right in
writing.
 Right to Information
In the course of his/her treatment and hospital
care, the patient or his/her legal guardian has a
right to be informed of the result of the
evaluation of the nature and extent of his/her
disease, any other additional or further
contemplated medical treatment on surgical
procedure or procedures, including any other
additional medicines to be administered and
their generic counterpart including the
possible complications and other pertinent
facts, statistics or studies, regarding his/her
illness, any change in the plan of care
before the change is made, the person's
participation in the plan of care and necessary
changes before its implementation, the extent
to which payment maybe expected from
Philhealth or any payor and any charges for
which the patient maybe liable, the disciplines
of health care practitioners who will provide
the care and the frequency of services that are
proposed to be furnished.
 Right to Self-Determination.
The patient has the right to avail
himself/herself of any recommended
diagnostic and treatment procedures. Any
person of legal age and of sound mind may
make an advance written directive for
physicians to administer terminal care when
he/she suffers from the terminal phase of a
terminal illness:
Provided That
a) he is informed of the medical consequences
of his choice;
b) he releases those involved in his care from
any obligation relative to the consequences of
his decision;
c) his decision will not prejudice public health
and safety.
 Right to Religious Belief
The patient has the right to refuse medical
treatment or procedures which may be
contrary to his religious beliefs, subject to the
limitations described in the preceding
subsection: Provided, That such a right shall
not be imposed by parents upon their children
who have not reached the legal age in a life-
threatening situation as determined by the
Darianne Cacayurin BSN4
attending physician or the medical director of
the facility.
 Right to Medical Records.
The patient is entitled to a summary of his
medical history and condition.
 Right to Leave.
The patient has the right to leave
hospital or any other health care institution
regardless of his physical condition:
Provided, that
a) he/she is informed of the medical
consequences of his/her decision
b) he/she releases those involved in
his/her care from any obligation relative to the
consequences of his decision;
c) his/her decision will not prejudice public
health and safety.
 Right to Refuse Participation In
Medical Research.
The patient has the right to be advised if the
health care provider plans to involve him in
medical research, including but not limited to
human experimentation which may be
performed only with the written informed
consent of the patient.
Provided, that, an institutional review board or
ethical review board in accordance with the
guidelines set in the Declaration of Helsinki
be established for research involving human
experimentation:
Provided, further, That the Department of
Health shall safeguard the continuing training
and education of future health care
provider/practitioner to ensure the
development of the health care delivery in the
country:
Provided, furthermore, That the patient
involved in the human experimentation shall
bemade aware of the provisions of the
Declaration of Helsinki and its respective
guidelines.
  RIght to Correspondence and to R.A. 7305
Receive Visitors.
"Magna Carta of Public Health Workers“
The patient has the right to communicate
This Act aims:
with relatives and other persons and to
receive visitors subject to reasonable limits (a) to promote and improve the social and
prescribed by the rules and regulations of the economic well-being of the health workers,
health care institution.? The patient has the their living and working conditions and
right to communicate with relatives and terms of employment;
other persons and to receive visitors subject
(b) to develop their skills and
to reasonable limits prescribed by the rules
capabilities in order that they
and regulations of the health care institution.
will be more responsive and
better equipped to deliver health projects
and programs; and
 Right to Express Grievances. –
(c) to encourage those with proper
The patient has the right to express complaints qualifications and excellent abilities to join
and grievances about the care and services and remain in government service.
received without fear of discrimination or
reprisal and to know about the disposition of
such complaints. Such a system shall afford all
parties concerned with the opportunity to
settle amicably all grievances.

 RIght to be Informed of His Rights

and Obligations as a Patient.
Every person has the right to be informed of
his rights and obligations as a patient.

 REPUBLIC ACT NO. 9710

AN ACT PROVIDING FOR THE MAGNA
CARTA OF WOMEN
 Republic Act No. 7277 otherwise
known as the Magna Carta for
Disabled Persons was enacted for the
primary reason that persons with
disabilities have the same rights as
other people.
 RA 9442 – An Act Amending
Republic Act No. 7277

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BUILDING THE NURSE AND CLIENT
RELATIONSHIP
COMPONENTS OF A THERAPEUTIC
RELATIONSHIP
 Trust
 Behaviors the nurse can exhibit to help
build the client’s trust include:
 Caring
 Interest
 Understanding
 Consistency
 Honesty
 keeping promises
 listening to the client
 Congruence occurs when words and
actions match.
 Trust erodes when a client sees
inconsistency between what the nurse
says and does.
 Genuine Interest
 When the nurse is comfortable with
him or herself, aware of his or her
strengths and limitations, and clearly
focused, the client perceives a genuine
person showing genuine interest.
 Empathy: the ability of the nurse to
perceive the meanings and feelings of
the client and to communicate that
understanding to the client
Therapeutic techniques
 Reflection
 Restatement
 Clarification
Empathy versus Sympathy
Acceptance
 The nurse who does not become upset
or responds negatively to a client’s
outbursts, anger, or acting out conveys
acceptance to the client.
 Avoiding judgments of the person, no
matter what the behavior, is acceptance.
 The nurse must set boundaries for
behavior in the nurse– client
relationship.
Darianne Cacayurin BSN4
Positive Regard
 The nurse appreciates the client as a
unique worthwhile human being can
respect the client regardless of his or
her behavior, background, or lifestyle.
 measures by which the nurse conveys
respect and positive regard to the client:
 Calling the client by name
 spending time with the client
 listening and responding openly
 considering the client’s ideas and
preferences when planning care
Self-Awareness and Therapeutic Use of Self
 Self-awareness is the process of
developing an understanding of one’s
own values, beliefs, thoughts, feelings,
attitudes, motivations, prejudices,
strengths, and limitations and how
these qualities affect others.
Values
 Abstract standards that give a person a
sense of right and wrong and establish
a code of conduct for living.
 The values clarification process has
three steps: choosing, prizing, and
acting.
 Choosing is when the person considers
a range of possibilities and freely
chooses the value that feels right.
 Prizing is when the person considers
the value, cherishes it, and publicly
attaches it to him or herself.
 Acting is when the person puts the
value into action.
Beliefs
 Ideas that one holds to be true, for
example, “All old people are hard of
hearing,” “If the sun is shining, it will
be a good day,” or “Peas should be
planted on St. Patrick’s Day.”
 Some beliefs have objective evidence
to substantiate them. For example,
people who believe in evolution have
accepted the evidence that supports this
explanation for the origins of life.
  Other beliefs are irrational and may
persist, despite these beliefs having no
supportive evidence or the existence of
contradictory empirical evidence. For
example, many people harbor irrational
beliefs about cultures different from
their own that they developed simply
from others’ comments or fear of the
unknown, not from any evidence to
support such beliefs.
Values clarification process
 Attitudes are general feelings or a
frame of reference around which a
person organizes knowledge about the
world.
 Attitudes, such as hopeful, optimistic,
pessimistic, positive, and negative,
color how we look at the world and
people.
Therapeutic Use of Self
 Nurses use themselves as a therapeutic
tool to establish therapeutic
relationships with clients and help
clients grow, change, and heal.
Johari Window Patterns of Knowing
 Carper (1978) identified four patterns
of knowing in nursing: empirical
knowing (derived from the science of
nursing), personal knowing (derived
from life experiences), ethical knowing
(derived from moral knowledge of
nursing), and aesthetic knowing
(derived from the art of nursing).
TYPES OF RELATIONSHIPS
 Social Relationship
 primarily initiated for the purpose of
friendship, socialization,
companionship, or accomplishment of
a task.
 Intimate Relationship
 A healthy intimate relationship
involves two people who are
emotionally committed to each other.
 Therapeutic Relationship
Darianne Cacayurin BSN4
 focuses on the needs, experiences,
feelings, and ideas of the client only
ESTABLISHING THE
THERAPEUTIC RELATIONSHIP
? Phases of the nurse–client relationship
? Orientation
? Working
? Termination
Orientation
? The orientation phase begins when the
nurse and client meet and ends when the
client begins to identify problems to
examine.
? During the orientation phase, the nurse
establishes roles, the purpose of meeting,
and the parameters of subsequent
meetings; identifies the client’s problems;
and clarifies expectations.
? Before meeting the client, the nurse has
important work to do. The nurse reads
background materials available on the
client, becomes familiar with any
medications the client is taking, gathers
necessary paperwork, and arranges for a
quiet, private, and comfortable setting.
? This is the time for self assessment.
Nurse–Client Contracts.
? The contract should state the following:
? Time, place, and length of sessions
? When sessions will terminate
? Who will be involved in the treatment
plan (family members or health team
members)
? Client responsibilities (arrive on time and
end on time)
? Nurse’s responsibilities (arrive on time,
end on time, maintain confidentiality at all
times, evaluate progress with client, and
document sessions)
Confidentiality.
 ??respecting the client’s right to keep
private any information about his or her
mental and physical health and related
care.
Working
? Two Subphases:
? Problem Identification - the client
identifies the issues or concerns causing
problems
? Exploitation - the nurse guides the client
to examine feelings and responses and
develop better coping skills and a more
positive self-image; this encourages
behavior change and develops
independence
? The specific tasks of the working phase
include the following:
• Maintaining the relationship
•Gathering more data
•Exploring perceptions of reality
• Developing positive coping mechanisms
•Promoting a positive self-concept
• Encouraging verbalization of feelings
• Facilitating behavior change
• Working through resistance
• Evaluating progress and redefining goals
as appropriate
• Providing opportunities for the client to
practice new behaviors
• Promoting independence
Transference versus
Countertransference
? Transference - the client unconsciously
transfer to the nurse feelings he or she has
for significant others
? Countertransference - nurse responds to
the client based on personal unconscious
needs and conflicts
Termination
Darianne Cacayurin BSN4
? final stage in the nurse–client
relationship
? the client especially may feel the
termination as an impending loss
AVOIDING BEHAVIORS THAT
DIMINISH THE THERAPEUTIC
RELATIONSHIP
Inappropriate Boundaries
 Self-awareness is extremely
important; the nurse who is in touch
with his or her feelings and aware of
his or her influence over others can
help maintain the boundaries of the
professional relationship.
Feelings of Sympathy and Encouraging
Client Dependency
 This discourages the client from
exploring his or her problems,
thoughts, and feelings; discourages
client growth; and often leads to
client dependency.
Nonacceptance and Avoidance
 The nurse should be aware of the
client’s behavior and background
before beginning the relationship; if
the nurse believes there may be
conflict, he or she must explore this
possibility with a colleague.
ROLES OF THE NURSE IN A
THERAPEUTIC RELATIONSHIP
Teacher
? During the working phase of the nurse–
client relationship, the nurse may teach the
client new methods of coping and solving
problems.
? He or she may instruct the client about the
medication regimen and available community
resources.
Caregiver
 implementation of the therapeutic
relationship to build trust, explore
feelings, assist the client in
 problem-solving, and help the client
meet psychosocial needs.
 If the client also requires physical
nursing care, the nurse may need to
explain to the client the need for
touch while performing physical
care.
Advocate
 the nurse informs the client and then
supports him or her in whatever
decision he or she makes
 In psychiatric–mental health
nursing, advocacy is a bit different
from medical– surgical settings
because of the nature of the client’s
illness. Advocacy is the process of
acting on the client’s behalf when
he or she cannot do so.
Parent Surrogate
 the nurse must be clear and firm and
set limits or reiterate the previously set
limits
 The nurse must ensure the relationship
remains therapeutic and does not
become social or intimate

Darianne Cacayurin BSN4

Darianne Cacayurin BSN4