AMANUEL MENTAL SPECIALIZED HOSPITAL

CPD CENTER

Nursing Process in psychiatric nursing

Participant Manual

Addis Ababa, Ethiopia

March, 2023
Foreword

This course aims to increase knowledge, attitude and skills of nursesin order to bring quality of
care at all care levels. Nowadays, increased number of patients need quality care that satisfy their
needs and expectations for this instance knowing psychiatry nursing process brings quality care.
The contents of this course are presented in threedays, designed for all nurses whoinclude full
psychiatric nursing assessment, writing nursing diagnosis based on NANDA and also planning
for patients including intervention, and evaluate the care given for patients.Thus, this training
manual is an important step to address the s knowledge gaps identified to prepare our
professionals with the necessary skills to deliver quality care.We are grateful to all members of
the technical working group and others who have collaborated with us to develop this important
training manual.
Approval statement

This [nursingprocess in psychiatric nursing] training package has been developed and submitted
by AMSH for accreditation. Xx has employed a seasoned and independent panel of experts and
reviewed the course as per the national standard. After a robust review by the panel, the course
has been accredited and registered as a CPD Course.

The course is face-to-face having classroom and simulated practical sessions and is awarded 15
Continuing Education Units (CEU).

Course Summary
Course name Nursing process in psychiatric nursing
Course code
Course owner AMSH
CEU 15
Delivery modality Face-to-face

Accreditor
Name of accreditor: ______________________________
Authorized official: ______________________________
Date of accreditation: ____________________________
Signature: _____________________________________
Acknowledgement

Amanuel Mental Specialized Hospital CPD Center would like to acknowledge all individuals
and organizations who have contributed to the preparation of this manual. The shared technical
knowledge, experiences, and perspectives have produced a training manual that will have a
positive impact on the attitudes and capabilities of health care professionals across the country.
Our gratitude also the goes to Ethiopian Midwives Association, the Ethiopian Nursing
Association, Addis Ababa Health Bureau, and Ministry of Health because the preparation of this
manual would not have been possible without their contribution.
List of developers

NAME INSTITUTION and PROFESSION

Bahiru Melese Amanuel Mental Specialized Hospital
Kedire Seid Amanuel Mental Specialized Hospital
Mensur Nesru Amanuel Mental Specialized Hospital
Seifeslassie Wendwosen Amanuel Mental Specialized Hospital
Kalkidan Dawit Amanuel Mental Specialized Hospital
Alemayhu Tadesse Amanuel Mental Specialized Hospital
Anteneh Teshome Amanuel Mental Specialized Hospital
Asnake Fetene Amanuel Mental Specialized Hospital
Tesfaye Mekonen Amanuel Mental Specialized Hospital
Ayantu Tefera Amanuel Mental Specialized Hospital

List of Contributors

Arega Mohammed City Government of Addis Ababa Health Bureau

Tegene Arega Federal Ministry of Health
BiniyamTsegaye Amanuel Mental Specialized Hospital
ZegeyeYohannis Amanuel Mental Specialized Hospital
Tolesa Fanta Amanuel Mental Specialized Hospital
Kibrom Haile Amanuel Mental Specialized Hospital
Ibrahim Yimer Ethiopian Midwives Association
Lulu Bekana Amanuel Mental Specialized Hospital
HabtamuDerajaw Amanuel Mental Specialized Hospital
Zebiba Nassir Amanuel Mental Specialized Hospital
Ayalew Abate Amanuel Mental Specialized Hospital
Mengistu Bekele Amanuel Mental Specialized Hospital
AberaMulatu Amanuel Mental Specialized Hospital
Acronyms

AMSH- Amanuel Mental Specialized Hospital

ANA - American Nursing Association
ADOPIE-Assessment, Diagnosis, Outcome Identification, Planning, Implementation and
Evaluation
APIE – Assessment Planning, Implementation and Evaluation

CEU- Continuing Education Unit

CPD- Continuous Professional Development

CNS- Central Nervous System

DM- Diabetes Mellitus

ECT -Electroconvulsive therapy

HTN- Hypertension

HIV- Human Immune Deficiency Virus

LMP- Last Menstrual Period

NANDA- North American Nursing Diagnosis Association

RN- Registered Nurse

TOT- Training of Trainers

Contents
Foreword..........................................................................................................................................I

Approval statement........................................................................................................................III

Acknowledgement.........................................................................................................................IV

Acronyms......................................................................................................................................VI

Introduction to the manual...............................................................................................................1

Course syllabus................................................................................................................................2

CHAPTER ONE- NURSING PROCESS IN PSYCHIATRIC NURSING....................................7

1.1 Introduction to psychiatric nursing process......................................................................8

1.1.1PSYCHIATRY NURSING ASSESSMENT...........................................................................9

1.1.1.1 History Taking Format in Psychiatric Nursing..............................................................12

1.1.1.2 Mental Status Examination............................................................................................14

1.1.1.3 Gordon function health Pattern Assessment..................................................................15

1.1.2-PSYCHIATRY NURSING DIAGNOSIS............................................................................17

Types of psychiatric nursing diagnosis......................................................................................18

1.1.2.1 Problem-focused or actual diagnosis.............................................................................18

1.1.2.2 Risk psychiatry nursing diagnosis..................................................................................18

1.1.2.3 Wellness Diagnosis........................................................................................................19

1.1.2.4 Syndrome Diagnosis......................................................................................................20

1.1.3 PLANNING..........................................................................................................................20

1.1.4 IMPLEMENTATION...........................................................................................................23

1.1.4.1 Specific Intervention......................................................................................................24

1.1.5 EVALUATION....................................................................................................................26

CHAPTER 2- Sample Psychiatry Nursing Care Plan...................................................................29

2.1 Introduction to Major Psychiatric Disorders........................................................................30

 2.2Psychiatry Nursing Care Plan for individuals with Schizophrenia and other Psychotic
Disorders....................................................................................................................................31

2.3 Nursing Care Plan for Clients with Major Depressive Disorders........................................34

2.4Nursing Care Plan for Clients with Anxiety Disorders.........................................................37

2.5Nursing Care Plan for Clients with Substance use and related Disorders............................40

2.6 Nursing Care Plan for Clients with Catatonic Features.......................................................43

Reference.......................................................................................................................................47
Icon/Symbol What it Refers to Description

Reflection - Reflection is a systematic reviewing process for

all trainers which allow you to make links from
one experience to the next.

Think, pair and - Think-pair-share (TPS) is a collaborative

share activities learning strategy where students work together to
solve a problem or answer a question about an
assigned reading.

Group discussions - Group discussion. In this method of training two

or more participants converse or engage in
meaningful deliberations about a particular topic
that is facilitated by a trainer/discussion leader.

Case Study -In this method of learning a case scenario is

provided in a training manual. The participants read
the case scenario and react to the reflection points

Role Play In this method of learning, Four role players are

needed, one as a patient, one as a physician, one as
an observer and one as a care giver.

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Introduction to the manual
Currently in Ethiopia and also globally psychiatric disorder are highly prevalent. Our country’s
second growth and transformation plan has set ambitious goals to improve quality of care. To
achieve this objective, application of nursing process in psychiatry nursing is fundamental to
health care professionals. Evidence suggested that nursing process in psychiatry nursing has been
associated with improved health outcomes, appropriate interventions, planned care, and
increased patient satisfaction, reduced health care expenditure, none or fewer malpractices and
decrease professionals’ burn out. Nursing process in psychiatry nursing is becoming increasingly
important to psychiatry nurses and nurses who are working in the area of mental health.
However, as per our knowledge, there is no standardized training manual for practice of
complete nursing care planning psychiatry nursing and because of identified gap which is poor
practice of nursing care plan in psychiatric nursing led to focus on nursing process in psychiatric
nursing.

Core competencies:

 Assessing clients using psychiatry history taking and approach of functional health
patterns
 Formulating psychiatry nursing diagnosis by using NANDA-I approach
 Developing holistic nursing care plan that address basic human needs
 Providing individualized, holistic and ethically accepted nursing care
 Evaluating whether the goals are met, partially met or unmet

Course syllabus
Course Description
This is a 3-day training designed to equip participants with the knowledge, Attitude, and skills on
the application of nursing process in psychiatric nursing and to enable them to deliver
scientifically sound, ethically acceptable and holistic quality care for mentally ill patient.
Course Goal

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  To provide the trainees with the knowledge and skills needed to respondappropriately to
patient’s health care needs.
 To influence in a positive way the attitudes of the trainees towards client centered
andethically accepted nursing care.
Objectives
By the end of this course the trainees will be able to:
 Describe five psychiatry nursing process
 Describe psychiatry nursing assessment
 Explain psychiatry nurse diagnosis
 Apply psychiatric nursing intervention
 Discus about planning phase of process
 Determine psychiatric nursing evaluation
Training/Learning methods
 Interactive lecture
 Individual reflection
 Group discussion
 Case study
 Role play

Training materials
 Participant Manual
 Training Hall
 Trainer Guide
 Power Point
 Flip Chart
 Marker
 Note Book And Pen
 LCD
 Laptop
 Facilitator Guide

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  Evaluation Form

Participants Selection Criteria:

 Participants for this training should be health professional who are working in the area
of mental health care (nurse, psychiatry nurse, )
Trainers Selection Criteria:
 Panel of Experts involved in the development of the training material.
 Psychiatry nurse professional and nurse professional who have TOT in mental health
care and nursing process in psychiatric setting.
 basic training on psychiatry nursing process with basic facilitation training
Method of Evaluation
Participant
1. Formative Assessment:
 Pre-training knowledge assessment (Pretest)
 Individual reflection
 Peer evaluation
 Group discussion
 Case study
 Home work

2. Summative Assessment:
 Post training knowledge assessment/post test
Course Evaluation:
 Daily evaluation by participants
 Daily trainers feedback meeting (debriefing)
 End course evaluation

Certification-
 Participants will be certified if they score ≥75 in the Post-test
 100% attendance is mandatory
 Continuing Educational Unit(CEUS) =15 CEU

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Training venue
 Training should be held on Accredited CPD training centers
Training duration
 3days
Course composition
 Trainer to trainee ratio 1:5, total 20 trainee

Activities Time
Day 1
Registration 8:30-9:00 am
Opening ceremony 9:00-9:30 am
Course overview
- Expectation 9:30-10:00 am
- Schedule introduction
- Group norms
- Review of courses
Pre-test 10:00-10:30 am
Tea break 10:30-11:00 am
- Introduction to nursing process
- Standard-1 psychiatry nurse 11:00-12:30 am
assessment
Lunch 12:30-2:00 pm
Standard 2- psychiatry nursing diagnosis
2:00-3:30 pm
Tea break 3:30-3:45 pm
Standard 3- outcome/planning 3:45-5:00 pm
Group discussion
Day 2
Recap 8:30-9:00am
Standard-4 implementation 9:00-10:25 am

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Specific intervention
Tea break 10:25-10:45 am
Standard 5- evaluation 10:45-12:00 am
Group discussion on writing complete
psychiatry nursing care plan
Lunch 12:00-2:00 pm
Nursing care plan for individuals with 2:00-3:00 pm
Schizophrenia and other psychotic disorders
Tea break 3:00-3:20 pm
Nursing care plan for individuals with 3:30-4:00 pm
Depressive disorders
Discussion on applying nursing process in 4:00-5:00 pm
psychiatry
Day 3
Recap 8:30-9:00 am
Nursing care plan for individuals with anxiety 9:00-9:30 am
disorders
Nursing care plan for individuals with 9:30-10:00 am
Substance and related disorders
Nursing care plan for individuals with 10:00-10:30 am
catatonic features
Tea break 10:30-10:45 am
Clinical practice 10:45-12:00 am
Lunch 12:00-2:00 pm
Group discussion on overall psychiatry 2:00-3:00 pm
nursing process
Tea break 3:00-3:20pm
Post test 3:20-4:20pm
Discussion about post test 4:20-5:00 pm

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CHAPTER ONE- NURSING PROCESS IN PSYCHIATRIC NURSING

Time 7 hour and 30 minutes

Chapter description
The purpose of this chapter is to enhance the participants understanding of psychiatry nursing
process, it also elaborates about psychiatry nursing assessment,psychiatric nursing
diagnosis,planning,implementation and evaluation phase
Primaryobjective: At the end of this chapter participants will be able to:
 Describe psychiatry nursing process
Enabling objective
At the end of this chapter the participant will be able to
 Conduct psychiatry nursing assessment in a small group efficiently
 Explain psychiatry nursing diagnosis in a small group perfectly
 Discus about planning phase of process in a small group correctly
 Apply psychiatric nursing intervention in a small group efficiently
 Determine psychiatric nursing evaluation in a small group perfectly

Chapter outline
1.1introduction to nursing process in psychiatric nursing
1.1.1 psychiatric nursing assessment
1.1.2 psychiatric nursing diagnosis
1.1.3 psychiatric nursing planning

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 1.1.4 psychiatric nursing implementation
1.1.5 psychiatric nursing evaluation
Summary

1.1 Introduction to psychiatric nursing process

Activity 1.1 Describe nursing process in psychiatric

nursing?
List five nursing process in psychiatric
nursing?
(10 minute)

The nursing process in psychiatric nursingis a process by which psychiatry nurses deliver
nursing care to the psychiatric patients to improve or solve their health response.

Purposes of psychiatry nursing process

 Providing professional, quality nursing care.

 Directs nursing activities for health promotion, health protection, and disease prevention
and is used by nurses in every practice setting
 Provides the basis for critical thinking in nursing.
 Ensures continuity of care
 Promotes involvement of clients in their own care

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It has five steps,

1.1.1PSYCHIATRY NURSING ASSESSMENT

Psychiatry nursing assessment is a baseline psychiatric mental health record that nurse
practitioners use in order to determine a patient condition and form a health care plan

It is the key to contributing to establishment of a psychiatric diagnosis; proper diagnosis leads to

effective treatment because it helps us develop the correct interventions and outcomes

9
It includes many dimensions: physical, psychological, sociocultural, spiritual, cognitive,
functional abilities, developmental, economic, and lifestyle assessments

Purpose:

 Organize a database regarding a client physical, psychological, and emotional health.

 Identified of health promoting behaviors and actual or potential health problems
 The nurse can ascertain of the clients about functional abilities, absence or the presence
of dysfunction, normal activities of daily living and lifestyle pattern
 Identifying the client strengths gives the nurse information about the abilities, behavior,
and skills the client can use during the treatment and recovery process.
 Provides an opportunity to form a therapeutic interpersonal relationship with clients.
 The client can discuss health care concerns and goals with the nurse.

Sources of Data

 Primary sources: the client should be considered the primary source of data. As much
information as possible should be gathered from the client, using both interview
techniques and physical examination skills.
 Secondary sources: data source from other than the clients are considered secondary
sources (family members, other health care providers, and medical records).

Types of Data collection

 Subjective data- data provided by patients/informants verbally

Example– “I feel happy’’ “I feel sad”
 Objective data- (also called signs): observable and measurable data
Example- aggressiveness, pulse rate 72

Techniques of Data Collection in Psychiatric Nursing

 Patient observation
 patient interview (process recording)
 Family interview

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  Physical examination
 Mental status examination

Interviewing
 Interviewing is a planned communication or a conversation with a purpose of getting
datafrom patient. For interviewing one need to have skill in obtaining history.
 Interview can be directive interview, which is highly structured and elicits specific
 Information or nondirective interview or rapport-building interview, in which the nurse
allowsthe client to control the purpose, subject matter, and pacing.
Phases of interview
Effective interview has four phases:
I. Preparatory phase /pre interaction phase: this phase comes before the nurse meet thepatient
that involves pre collection of some information about the patient.
II. Introductory phase/orientation phase: this phase is a phase of establishing rapport withthe
patient through clarifying your role. This phase helps to alleviate patient anxiety
III. Maintenance phase /working phase: this phase which the planned interview is undertaken
IV. Concluding phase: finalize the interview with concluding the session, for example by
summarizing what have been collected and acknowledging the patient for his/her cooperation
Interview techniques in psychiatry history taking

 introduce yourself
 greet the patient by name
 arrange for a private comfortable setting
 appropriately tell the purpose of the interview
 put the patient at ease
 Be supportive, attentive, non-judgmental and encouraging.
 Avoid excessive note-taking
 Observe the patient’s nonverbal behavior.
 Pay attention to both content & process.
 Open-ended question versus Closed-ended questions.

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 Reflection. In the technique of reflection, a nurse repeats to a patient in a supportive
manner something that the patient has said.
 Facilitation. Nurse’s help patients continue in the interview by providing both verbal and
nonverbal cues.
 Silence. being silent
 Confrontation. The technique of confrontation is meant to point out to a patient
something that the nurse thinks the patient is not paying attention to, is missing, or is in
some way denying.
 Clarification. In clarification, nurses attempt to get details from patients about what they
have already said.
 Interpretation. The technique of interpretation is most often used when a nurse states
something about a patient's behavior or thinking that a patient may not be aware of.
 Summation. Periodically during the interview, a nurse can take a moment and briefly
summarize what a patient has said thus far.
 Explanation. Nurses explain treatment plans to patients in easily understandable language
and allow patients to respond and ask questions
 Transition. The technique of transition allows nurses to convey the idea that enough
information has been obtained on one subject; the nurse’s words encourage patients to
continue on to another subject.
 Positive Reinforcement- this is technique of providing feedback or praise to the patient
for their cooperation, honesty or efforts
 Reassurance- this is a technique of offering comfort or support to the patient who is
experiencing distress, anxiety or fear.
 Advice- this is a technique of giving suggestion or recommendations to the patient based
on the interviewer’s knowledge, experience or expertise.

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1.1.1.1 History Taking Format in Psychiatric Nursing

ACTIVITY 1.2  Listcomponents of history taking?

 What is rational taking psychiatry
history regarding psychiatry nursing care
plan (Time 10 min)

A psychiatric history is the result of a medical process where a clinician working in the field of
mental health systematically records the content of an interview with a patient.

General Principles before history taking

 Agreement as to Process - At the beginning of the interview the clinician

shouldintroduceself why he/ she is speaking with the patient.
 Privacy and Confidentiality - At the beginning, the interviewer should indicate that the
content of the session(s) will remain confidential except for what needs to be shared with
the referring physician or treatment team.
 Respect - The patient must be treated with respect
 Rapport/Empathy
Rapport can be defined as the harmonious responsiveness of the physician and the
patient
Empathyunderstands what the patient is thinking and feeling
 Safety and ComfortBoth the patient and the interviewer must feel safe on occasion,
especially in hospital or emergency

Psychiatric nursing history components

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Identification data-is a process of collecting and verifying relevant information about the
patient’s biographic data.
Presenting chief complaints-a concise statement describing the reason for the encounter it
usually stated in the patient’s own word and reflects their main concern we also collect data from
collateral
History of present illness-is a detailed description of the development and progression of the
patient’s current problem in chronological order and rule out other symptoms. It includes
information about onset, duration, frequency, severity, impact of symptoms, substance use,
suicidal (ideation, plan, attempt), medication history and any factors that makes them better or
worse.
Past psychiatric history-a detailed description of past illness, hospitalizations, substance use
history, and treatments include past problems with suicidal thinking and attempt.
Past medical history- is a process of obtaining and reviews the patients past and current
physical health condition, medications, allergies, surgical procedure and accident.
Family history-it is a description ofpresence of psychiatric and physical illness in family
members and treatment, presence or history of substance abuse and history of suicide attempt
Personal history- this is a detailed account of the patient’s life history from birth to present. It
should include information about their prenatal, perinatal, postnatal development, child hood,
adolescence, education, occupation, forensic history, relationships, sexuality, social network,
hobbies, interests and achievements. It should also include any history of trauma, abuse, neglect,
loss or stressor in their life.
Pre-morbid personality-this is an evaluation of the patient’s personality traits, coping styles,
strengths, and weakness before the onset of their illness
1.1.1.2 Mental Status Examination

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 Activity 1.3. INDIVIDUAL  What do you mean mental status

REFLECTION examination and its components?

 what is the difference between
psychiatric nursing history and
mental status examination? (Time
10 min)

The mental status examination is an assessment that the clinician snapshot of the patient’s
thought, feeling and behavior at the time of the interview
Examination of mental status is done in anyone with an altered mental status or evolving
impairment of cognition whether acute or chronic.
Appearance and Behavior- which includes observing the patient general appearance, hygiene,
clothing, posture, movement, eye contact and attitude towards the examiner
Speech- which includes noting the patient’srate, volume, tone, fluency, and coherence of speech
as well as any abnormalities such as stuttering, slurring and neologisms.
Emotion- which includes asking the patient how they feel and observing their emotional
expression, range, intensity and appropriateness
Thought- which includes assessing the patients thought content such as delusions, obsessions,
suicidal or homicidal ideation and thought process such as logics, coherence and organizations
Perception-which includes asking the patient about any hallucinations, illusion or
depersonalization experience
Cognition- which includes testing the patient’s orientation, attention, memory, language,
calculation and executive function
Insight andJudgment- which includes evaluating the patient awareness and understanding of
their condition, as well as their ability to make reasonable and safe decisions

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 1.1.1.3 Gordon function health Pattern Assessment
Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by
psychiatry nurses in the psychiatry nursing process to provide a more comprehensive
nursingassessment of the patient

activity 1.4  Select three participants (psychiatry nurse,

patient and patient attendant) for role play
about Gordon’s pattern assessment (25 min)

Health-Perception and Health-Management Pattern

Data collection is focused on the person's perceived level of health and well-being, and
onpractices for maintaining health. Habits that may be detrimental to health are also
evaluated,including smoking and alcohol or drug use. It includes the client’s belief, practice and
values related to health promotion and disease prevention
Nutritional-Metabolic Pattern
This pattern focuses on the pattern of food and fluid consumption relative to metabolic need.The
adequacy of local nutrient supplies is evaluated. Actual or potential problems related tofluid
balance, tissue integrity, and host defenses may be identified as well as problems withthe
gastrointestinal system.
Elimination Pattern
This pattern is focused on excretory patterns (bowel, bladder, skin). Excretory problems suchas
incontinence, constipation, diarrhea, and urinary retention may be identified.
Activity-Exercise Pattern
This pattern isfocused on the activities of daily living requiring energy expenditure,including
self-care activities, exercise, and leisure activities. The status of major body systemsinvolved
with activity and exercise are evaluated, including the respiratory, cardiovascular, and
musculoskeletal systems.
Sleep-Rest Pattern

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This pattern is focused on the person's sleep, rest, and relaxation practices. Dysfunctionalsleep
patterns, fatigue, and responses to sleep deprivation may be identified.
Cognitive-Perceptual Pattern
This pattern describes the client’s cognitive and sensory functions, such as memory, learning,
problem-solving, language, vision, hearing, taste, touch, and pain. It includes the client’s mental
status, level of consciousness, orientation, attention, perceptions and coping strategies.
Self-Perception-Self-Concept Pattern
This pattern is focused on the person's attitudes toward self, including identity, body image,and
sense of self-worth. The person's level of self-esteem and response to threats to his or herself-
concept may be identified.
Role-Relationship Pattern
This pattern is focused on the person's roles in the country, community, and work area or
homeand relationships with others. Satisfaction with roles, role strain, or dysfunctional
relationshipsmay be further evaluated.
Sexuality-Reproductive Pattern
This pattern describes the client’s sexual identity, function and behavior as well as the client’s
reproductive health and needs. It includes the client’s sexual orientation, expression, satisfaction,
problems, history and practices, as well as the client’s menstrual cycle, pregnancy,
contraception’s and sexually transmitted infection.
Coping-Stress-Tolerance Pattern
Assessment is focused on the person's perception of stress and on his or her coping
strategies.Support systems are evaluated, and symptoms of stress are noted. The effectiveness of
aperson's coping strategies in terms of stress tolerance may be further evaluated.
VALUE-BELIEF PATTERN
Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on
thegoals that guide his or her choices or decisions. It includes the client’s cultural, religious,
ethical, and moral influences.

1.1.2-PSYCHIATRY NURSING DIAGNOSIS

Activity 1.5 GROUP DISCUSSION  Discus types of psychiatry nursing diagnosis?

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  What are the components of Psychiatry nursing
diagnosis?
3 Groups for 30 min

A psychiatry nursing diagnosis is a clinical judgment concerning human response to health

conditions/life processes, or a vulnerability for that response, by an individual, family, group,
or community. A psychiatry nursing diagnosis provides the basis for the selection of psychiatry
nursing interventions to achieve outcomes for which the psychiatry nurse has accountability.
Types of psychiatric nursing diagnosis
1.1.2.1 Problem-focused or actual diagnosis
A patient problem present during a nursing assessment is known as a problem-focused diagnosis.
Generally, the problem is seen throughout several shifts or a patient’s entire hospitalization. It is
supported by defining characteristics that cluster in patterns of related cues or inferences.
Problem-focused diagnoses have three components

 Psychiatry Nursing diagnosis/problem/ diagnostic level: this is a concise term or phrase

that represents a pattern of related cues and describes the client’s health problem or
response for which nursing therapy is given. The problem should be derived from a
standardized nursing terminology, such as NANDA-I, and should be clear precise and
ambiguous.
 Related factors: this is a condition, circumstance, or event that contributes to or is
associated with the problem. The etiology should be connected to the problem by the
phrase (related to) and should identify one or more probable causes of the health
problem.
 Defining characteristics: these are the observable and verifiable cues or cluster of cues
that support the presence of problem. The defining characteristics should be connected to

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 the etiology by the phrase (as evidenced by) and should include both subjective and
objective data that the nurse has collected during the assessments.

1.1.2.2 Risk psychiatry nursing diagnosis

A risk psychiatry nursing diagnosis a type of nursing diagnosis that describes a clinical
judgment concerning the vulnerability of an individual, family, group, or community for
developing an undesirable human response to health conditions or life process. It is supported by
risk factors that are environmental, physiological, genetic or chemical elements that increase the
vulnerability of a person or group. This type consists of two components which are diagnostic
label and risk factors.

Activity 1.6 think +pair+ shared Discus the difference between actual and
risk nursing diagnosis and share to the
whole group? (Time 10 min)

1.1.2.3 Wellness Diagnosis

Wellness diagnosis is “a clinical judgment concerning motivation and desire to increase well-
being and to actualize human health potential.” These responses are expressed by the patient’s
readiness to enhance specific health behaviors. A health promotion-wellness diagnosis is used
when the patient is willing to improve a lack of knowledge, coping, or other identified
need.Components of a health promotion diagnosis generally include only the diagnostic label or
aone-part-statement.

Examples of health promotion diagnosis:

Readiness for Enhanced Spiritual Well Being
Readiness for Enhanced Family Coping

Activity 1.7  Define wellness nursing diagnosis and

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 syndrome nursing diagnosis ?(5 min)

1.1.2.4 Syndrome Diagnosis

A syndrome diagnosis is a clinical judgment concerning with a cluster of problem or risk
nursing diagnoses that are predicted to present because of a certain situation or event.

Examples of a syndrome nursing diagnosis are:

 Chronic Pain Syndrome

 Post-trauma Syndrome

Activity 1.8 GROUP DISCUSSION  Formulate two actual and two risk nursing
diagnosis?

3 Groups for 20 min

Steps to formulate nursing diagnosis

 Analyze the data collected during assessment to identify the patients’ health problem,
risks, and strengths.
 Choose a standardized nursing terminology to label patients health problem or response.

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  Use formula to write the nursing diagnosis statement, such as PES (problem, etiology,
sign and symptoms) orPE (problem, etiology) for risk diagnosis
 Validate the accuracy and relevance of the nursing diagnosis with the patient and other
member of health care teams.

1.1.3 PLANNING
Activity 1.9 think +pair+ shared Discus what SMART stands for and define
each term(Time 10 min)

The planning stage is where the nurse collaborates with the patient and other member of the
health care team to develop a plan of care that addresses the patient’s mental health needs.It
consists of the total planning of the patient’s overall treatment to achieve quality outcomes in
safe, effective and timely manner

Major activities in planning

 Setting expected out come
 Setting priorities
 Developing intervention

Expected outcomes: are specific objectives related to the goals and are used to evaluate the
nursing interventions. They must be specific, measurable, achievable, and realistic and have a
time limit.

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Specific outcome: are clear, well defined, and unambiguous and they describe what the patient
will be able to do or achieve as a result of the intervention.
Measurable outcome: are observable and verifiable, and they include criteria or indicators that
can be used to assess the patient’s status and response to the intervention.
Achievable outcome: are realistic and attainable, and they consider the patients abilities,
resources and limitations.
Realistic outcome: are relevant and meaningful, and they reflect the patient’s values,
preferences, and expectations.
Timed outcomes: are time bound and have a specific deadlines or frequency for completion or
evaluation
Types of expected outcomes
Goals should be established to meet the immediate, as well as long-term prevention
andrehabilitation, needs of the client.
1. Short-term outcome (STO):- are those that can be met relatively quickly, often in lessthan a
week, or in a short period. It is usually focused on the etiology.
2. Long term outcome (LTO):-are those that are to be achieved over a longer period of time,
often weeks or months requires more time. LTOs usually focused on the problem.
Activity 1.10  Discuss on how to write a SMART outcome?
Group discussion  Discuss on the criteria during prioritization of
nursing outcome?
 Divide in random 3 groups (20 minute)

Setting priorities: a crucial step that helps the nurse t

o focus on the most urgent and important needs of patient. Prioritization is based on several
factors

22
  The severity and potential harm of patient’s problem or risks such as suicidal ideation,
violence, psychosis or substance abuse.
 The patient’s preferences, values and expectations as well as family involvement
 The availability and feasibility of resources
 The standard of care and evidence-based practice as well as legal and ethical implications
of interventions.
 Strategies to prioritize
 Using ABC (airway, breathing, circulations) or SAFETY (suicide, aggression, falls,
elopement, treatments and you) to rank patients’ needs from the most to the least
essential
Developing intervention:is a process of selecting and documenting the appropriate actions that
will help the patient achieve expected outcomes. The intervention should be based on the best
available evidence, the nurse clinical judgment, and the patients input. Intervention should also
be specific, individualized and documented

1.1.4 IMPLEMENTATION

Direction:- read and discus

Sam was team captain of his soccer

team, but an unexpected fight with
another teammate prompted his parents
to meet with a clinical psychologist.
Sam was diagnosed with major
depressive disorder after showing an
ACTIVITY 1.11 increase in symptoms which is
depressed mood, sleepless, loss of
interest over the previous three months.

 as a psychiatric nurse or other health

professional, be in group and discus
about psychiatric nursing

23
 intervention (20 minute)

Evaluation is a critical component of the psychiatry nursing care plan that assesses the
effectiveness of interventions and the patient's progress toward desired outcomes. Through
ongoing assessment, the nurse determines if goals have been met or require modification based
on the patient's response to treatment. Both objective data, such as symptoms, behaviors and
medication side effects, as well as subjective input from the patient are examined. The
multidisciplinary team also evaluates overall treatment effectiveness. If goals have not been
achieved, the plan is revisited and updated with alternative interventions aimed at goal
attainment. Regular evaluation allows nurses to monitor patients closely, make timely
adjustments as needed, and continually optimize care approaches to support recovery and
wellness. Proper evaluation ensures a dynamic, individualized care process centered on meeting
each unique patient's mental health needs.

Main objectives of implementation phase

 ongoing assessment
 establishing priorities
 allocating resource
 initiating interventions
 documenting interventions and patient response

1.1.4.1 Specific Intervention

Effective psychiatric nursing requires the application of diverse treatment modalities tailored to
individual client needs. A well-rounded, holistic approach aims to alleviate symptoms, empower
recovery and prevent future relapse or disability. To facilitate high-quality, comprehensive client
care, the nursing profession has established specific standards to guide intervention practices.
These standards span both direct care activities and broader system-level roles. They encompass
therapeutic techniques targeting mind, body and social dimensions of health, from lifestyle

24
modifications to intensive psychopharmacology. By incorporating biopsychosocial models of
intervention, nurses can work collaboratively alongside clients to achieve optimal mental
wellness. The following nursing intervention standards outline key domains comprising a
recovery-focused approach grounded in evidence-based principles. Their unified implementation
helps clients regain functionality, equip coping strategies and reintegrate as valued members of
society.

Counseling: to assist clients in improving coping skills and preventing mental illness and
disability
Milieu therapy: to provide and maintain therapeutic environment for client
Self-care activities:to foster independence and mental and physical well-being
Psychobiological intervention: To restore the client’s health and prevent further disability
Health teaching: To assist clients in achieving satisfying, productive and healthy pattern of
living
Case management: To coordinate comprehensive health services and ensure continuity of care
Health promotion and health maintenance: Implements strategies with clients to promote and
maintain mental health and prevent mental illness
Psychotherapy: Provides therapy for individuals, groups and families to foster mental health
and prevent disability
Prescriptive authority and treatment: Provides pharmacological intervention, in accordance
with laws and regulation to treat symptoms of psychiatric illness and improve functional health
status
Consultation: Provides consultation to enhance the abilities of other clinicians to provide
service for clients and effect change in the system

1.1.5 EVALUATION
Activity 1.12

Group discussion  Discuss on the measurements of a

resolved nursing care plan?
 Discuss on when to re-evaluate and
determine the indications of when to re-

25
 assess?
Divide random 3 groups (20 minutes)

Main objectives of evaluation

 to determine if interventions are helping clients achieve expected outcome

 to verify the quality of nursing care provided
 to promote accountability
 to analyze current data
 to promote continuity of care

The evaluation phase of the psychiatry nursing care plan involves assessing the effectiveness of
the interventions and determining if the desired outcomes have been achieved. It includes
gathering data, comparing the actual outcomes with the expected outcomes, and identifying any
variances or discrepancies. Based on this evaluation, adjustments can be made to the care plan to
optimize patient care and improve mental health outcomes.
Steps used to objectively evaluate the degree of success in achieving a goal: -
1. Examine the goal statement and identify the client behavior or response
2. Assess the client for the presence of that behavior or response
3. Compare the established expected outcome with the behavior or response
4. Judge the degree of agreement between expected outcome and the behavior orResponse

When evaluating a resolved care plan in psychiatry nursing, measurements play a crucial role in
determining the success of the interventions. Measurements may include objective assessments,
such as standardized scales or tests, to gauge improvements in symptom severity, functional

26
abilities, or quality of life. Subjective feedback from the patient, as well as input from the
interdisciplinary team, can also provide valuable insights into the effectiveness of the care plan
and help validate the achievement of desired outcomes.
a. Goal is Met- if the client ‘s response matches or exceeds the outcome criteria.
b. Goal is partially Met- If the client ‘s behavior begins to show changes, butdoes not yet meet
specified criteria.
c. Goal is Not Met - If there is no progress
5. Ask questions if there is no agreement.
N.B.When goals have been partially met or when goals have not been met, two conclusions
may be drawn:
 The care plan may need to be revised, since the problem is only partially resolved
OR
 The care plan does not need revision, because the client merely needs more time
toachieve the previously established goals. So, the nurse must reassess why the
goals arenot being partially achieved.
Re-evaluation and reassessment are crucial components of the psychiatry nursing process and
should occur at regular intervals or when specific circumstances warrant. Reevaluation is
necessary when there are significant changes in the patient's condition, treatment response, or
overall progress towards goals. It is also important to reassess when there is a shift in the
patient's needs, preferences, or priorities. Additionally, reevaluation should take place when there
are modifications to the treatment plan or interventions. By periodically assessing and
reassessing the patient, the nursing team can ensure that the care plan remains current, effective,
and aligned with the patient's evolving needs, ultimately promoting optimal mental health
outcomes.The criteria for reevaluation and reassessment during the psychiatry nursing process
can vary depending on the specific context and individual patient.

Chapter Summary

 The psychiatry nursing process is a process by which psychiatry nurses deliver care to the
psychiatric patients to improve or solve their mental problems.
 psychiatry nursing process have 5 stages which is
assessment,diagnosis,planning,implementation and evaluation

27
  psychiatry nursing assessment is the key to contributing to establishment of a psychiatric
diagnosis, proper diagnosis leads to effective treatment because it helps us develop the
correct interventions and outcomes
 A psychiatry nursing diagnosis is a clinical judgment concerning human response to
healthconditions/life processes, or vulnerability for that response, by an individual,
family, group,or community.
 There is four types of nursing diagnosis which is actual, potential, wellness and syndrome
 The planning stage is where goals and outcomes are formulated that directly impact
patient care
 Implementation phase is putting planned intervention in to action.
 The psychiatric nurse evaluates the clients progress in attaining expected outcome

CHAPTER 2- Sample Psychiatry Nursing Care Plan

Time7 hour and half an hour

Chapter description
The purpose of this chapter is to enhance the participant’s skill in formulation of psychiatry
nursing care plan
Chapter objective
To enhance the psychiatric nursing skills of participants in formulating competent nursing care
plans for clients with mental health conditions.
Enabling objective
By the end of this chapter the participant will be able to
 Develop a nursing care plan for an individual with schizophrenia or other psychotic
disorder in a small group correctly

28
  Formulate psychiatry nursing care plan for a client with major depressive disorder in a
small group efficiently
 Construct a nursing care plan for an individual with an anxiety disorder in a small group
perfectly
 Devise a psychiatric nursing care plan for a client with a substance use and related
disorder in a small group efficiently
 Develop psychiatric nursing care plan for clients with Catatonic features in a small
group perfectly

Chapter Outline
2.1 Introduction to Major Psychiatric Disorders
2.2 Psychiatry Nursing Care Plan for Individuals with Schizophrenia and Other
Psychotic Disorders
2.3 Psychiatry Nursing Care Plan for individuals with Major Depressive Disorder
2.4 Psychiatry Nursing Care Plan for individuals with Anxiety Disorders
2.5 Psychiatry Nursing Care Plan for individuals with Substance and related Disorders
2.6 Psychiatry Nursing Care Plan for individuals with Catatonic Features

2.1 Introduction to Major Psychiatric Disorders

A mental disorder is characterized by a clinically significant disturbance in an individual’s
cognition, emotional regulation, or behavior. It is usually associated with distress or impairment

29
in important areas of functioning. There are many different types of mental disorders. Mental
disorders may also be referred to as mental health conditions.

In 2019, 1 in every 8 people, or 970 million people around the world were living with a mental
disorder, with anxiety and depressive disorders the most common. In 2020, the number of people
living with anxiety and depressive disorders rose significantly because of the COVID-19
pandemic. Initial estimates show a 26% and 28% increase respectively for anxiety and major
depressive disorders in just one year. While effective prevention and treatment options exist,
most people with mental disorders do not have access to effective care. Many people also
experience stigma, discrimination and violations of human rights. Also, bipolar and
schizophrenia is the most prevalent So the psychiatric nursing input is vital.

2.2 Psychitry Nursing Care Plan for individuals with Schizophrenia and other Psychotic
Disorders
Activity 2.1  list common problems manifested in
psychotic patient and formulate
nursing diagnosis with intervention?
(15 min)

Schizophrenia and other psychotic disorders are a group of complex mental health conditions
that profoundly impact an individual's thoughts, emotions, perceptions, and
behaviors.Schizophrenia, the most well-known and extensively studied psychotic disorder,
30
affects approximately 1% of the global population.The onset of these disorders typically occurs
during late adolescence or early adulthood, and they can have a profound and long-lasting impact
on individuals, their families, and society as a whole. There are commonly five cardinal
symptoms, and are listed below

 Delusions
 Hallucinations
 Disorganized Speech
 Disorganized or Catatonic behavior
 Negative Symptoms

Nursing professionals play a vital role in the care and support of individuals with schizophrenia,
utilizing the NANDA (North American Nursing Diagnosis Association) terminology to identify
and address their specific needs. By recognizing the symptoms and applying appropriate nursing
diagnoses, healthcare providers can develop tailored interventions to improve the overall well-
being and quality of life of individuals with schizophrenia.Here below are common
manifestation in psychotic disorder and manic phase based on NANDA term

Common NANDA terms for manifestations that occur among schizophrenia patients

Common Schizophrenia symptoms (Behaviors) NANDA term

Impaired communication (inappropriate responses), stops Disturbed Sensory Perception
talking in mid-sentence, Tilts head as if listening, Poor
concentration
Delusional thinking; inability to concentrate; impaired Disturbed Thought Process
volition; inability to problem solve; extreme
suspiciousness of others; inaccurate interpretation of the
environment
Risk factors: Aggressive body language (e.g., clenching Risk for violence: Self-directed
fists and jaw, pacing, threatening stance), verbal or other-directed
aggression, catatonic excitement, command
hallucinations, rage reactions, history of violence, overt
and aggressive acts,

31
 Loose association of ideas, neologisms, word salad, clang Impaired Verbal Communication
associations, echolalia, verbalizations that reflect concrete
thinking, inappropriate verbalization
Inability to take responsibility for meeting basic health Ineffective Health Maintenance
practices, history of lack of health-seeking behavior, lack
of expressed interest in improving health behaviors,
demonstrated lack of knowledge regarding basic health
practices
Difficulty carrying out tasks associated with hygiene, Self-Care Deficit
dressing, grooming, eating, and toileting
Withdrawal, sad dull affect, need-fear dilemma, Social Isolation
preoccupation with own thoughts, expression of feelings
of rejection or of aloneness imposed by others,
uncommunicative, seeks to be alone

A nursing care plan for schizophrenia involves a comprehensive approach to address the unique
needs of individuals living with this mental health condition. The primary goal is to promote
stability, symptom management, and overall well-being.Nursing professionals collaborate with
the multidisciplinary team to assess and monitor symptoms, evaluate medication effectiveness,
and provide ongoing emotional support.

EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH SCHIZOPHRENIA

NURSING DIAGNOSIS: DISTURBED SENSORY PERCEPTION: AUDITORY/VISUAL
RELATED TO: Panic anxiety, extreme loneliness, and withdrawal into the self
EVIDENCED BY: Inappropriate responses, disordered thought sequencing, rapid mood swings,
poor concentration, disorientation
OUTCOME CRITERIA NURSING INTERVENTION

32
 Short-Term Goals 1. Observe the client for signs of hallucinations
 Client will discuss content of (listening pose, laughing ortalking to self, stopping
hallucinations with nurse or in midsentence). Ask, “Are you hearing thevoices
therapist within 1 week again?”
Long-Term Goal 2. Avoid touching the client withoutwarning him or
 Client will verbalize understanding her that you areabout to do so.
that the voices are a result of his or 3. An attitude of acceptance will encourage the
her illness and demonstrate ways client to share the content of the hallucination with
to interrupt the hallucination you. Ask, “What do you hear thevoices saying to
 Client will be able to define and you?
test reality, reducing or eliminating 4. Do not reinforce the hallucination. Use “the
the occurrence of hallucinations voices” instead of words like “they” that imply
validation.
5. Help the client understand the connection
between increased anxiety and the presence of
hallucinations
6. Try to distract the client from the Hallucination

2.3 Psychiatry Nursing Care Plan for Clients with Major Depressive Disorders
ACTIVITY 2.2  A 23-year-old male patient comes
with complaints of being unable to
initiatesleep,worthlessness, and
depressed mood with 2 months
duration he also hasa prior suicide
attempt
 Sobein a group and prioritizeproblems
and formulate at least 3 psychiatry
nursing diagnoses with selected
interventions (20 min)

33
Major Depressive Disorder, also known as clinical depression, is a serious mental health
condition characterized by persistent feelings of sadness, loss of interest or pleasure in activities,
changes in appetite and sleep patterns, low energy levels, difficulty concentrating, and thoughts
of self-harm or suicide. It affects millions of people worldwide and can significantly impair daily
functioning and quality of life. Below are most common symptoms of depression

 Feelings of sadness, tearfulness, emptiness or hopelessness

 Angry outbursts, irritability, or frustration, even over small matters
 Loss of interest or pleasure in most or all normal activities
 Sleep disturbances, including insomnia or sleeping too much
 Tiredness and lack of energy, so even small tasks take extra effort
 Reduced appetite and weight loss or increased cravings for food and weight gain
 Anxiety, agitation or restlessness
 Slowed thinking, speaking or body movements
 Feelings of worthlessness or guilt, fixating on past failures or self-blame
 Trouble thinking, concentrating, making decisions and remembering things
 Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide
Here below are problems seen in depression patient based on NANDA term

Assigning common NANDA terms for a client with Depression

Common Depressive Symptoms NANDA term

Depressed mood; feelings of hopelessness and Risk For Suicide

worthlessness; anger turned inward on the self;
misinterpretations of reality; suicidal ideation, plan

Depression, preoccupation with thoughts of loss, self- Complicated Grieving

blame, grief avoidance, inappropriate expression of
anger, decreased functioning in life roles

Expressions of helplessness, uselessness, guilt, and Low self esteem

shame; hypersensitivity to slight or criticism; negative,
pessimistic outlook; lack of eye contact; self-negating

34
verbalizations

Difficulty falling asleep, difficulty staying asleep, lack Disturbed Sleep Pattern
of energy, difficulty concentrating, verbal reports of not
feeling well rested

Withdrawn, uncommunicative, seeks to be alone, Social Isolation/Impaired Social

dysfunctional interaction with others, discomfort in Interaction
social situations

Weight loss, poor muscle tone, poor skin turgor, Imbalanced nutrition less than body
weakness requirement

A psychiatry nursing care plan for clients with depression focuses on providing holistic care to
address the emotional, cognitive, and physical aspects of their well-being. The plan typically
includes medication management, individual and group therapy sessions, psychoeducation, and
regular assessment of symptoms and treatment progress. Below is an example of psychiatry
nursing care plan among clients with depression.

EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH DEPRESSION

NURSING DIAGNOSIS: Complicated Grieving

RELATED TO: Real or perceived loss, bereavement overload

EVIDENCED BY: Denial of loss, inappropriate expression of anger, idealization of or

obsession with lost object, inability
to carry out activities of daily living

OUTCOME CRITERIA NURSING INTERVENTION

Short-Term Goals 1. Determine the stage of grief in whichthe

client is fixed. Identify behaviorsassociated

35
  Client will express anger about the loss. with this stage.

 Client will verbalize behaviors 2. Develop a trusting relationship with

associated with normal grieving
Long-Term Goal
 Client will be able to recognize his or
her position in the grief process, while
progressing at own pace toward
resolution
theclient. Show empathy, concern,
andunconditional positive regard.
3. Convey an accepting attitude, and enablethe
client to express feelings openly.
4. Encourage the client to express anger.Do not
become defensive if the initialexpression of
anger is displaced on thenurse or therapist.

5. Help the client to discharge pent-upanger

through participation in largemotor activities

6. Teach the normal stages of grief

andbehaviors associated with each stage.

7. Encourage the client to review

therelationship with the lost concept.
misrepresentations are expressed

2.4 Psychiatry Nursing Care Plan for Clients with Anxiety Disorders
Activity 2.3
 Discuss common problems manifest in anxiety
Group discussion disorder
 Make psychiatry nursing diagnosis?
 list intervention for patients who have an anxiety
disorder?

Divide random 3 groups (30 minutes)

36
Anxiety disorders are a group of mental health conditions that involve excessive and persistent
feelings of fear, worry, and unease. These disorders can significantly impact an individual's
thoughts, emotions, and behaviors, leading to various physical and psychological symptoms.
Understanding the nature, causes, and treatment approaches for anxiety disorders is essential in
providing effective care and support to those affected by these conditions. Some of the most
common symptoms include

 Feeling nervous, restless or tense.

 Having a sense of impending danger, panic, or doom.
 Having an increased heart rate.
 Fear
 Breathing rapidly (hyperventilation)
 Sweating.
 Trembling.
 Feeling weak or tired.
 Trouble concentrating or thinking about anything other than the present worry.

The following table shows common anxiety manifestations with their ideal NANDA term

Assigning common NANDA terms for clients with manifestations of Anxiety Symptoms

Common Anxiety Symptoms NANDA term

Palpitations, trembling, sweating, chest pain, Anxiety

shortness of breath, fear of going crazy, fear of

dying, Excessive worry
Verbal expressions of having no control over Powerlessness
life situation; nonparticipation in decision-
making related to own care or life situation
Behavior directed toward avoidance of a feared Fear
object or situation
Stays at home alone, afraid to venture out alone Social Isolation

37
 (agoraphobia)
Repetitive and impulsive pulling out of one’s Ineffective Impulse Control
hair (trichotillomania)
Inability to fulfill usual patterns of Ineffective Role Performance
responsibility because of the need to perform
rituals

A psychiatry nursing care plan for clients with anxiety focuses on providing comprehensive
support to alleviate symptoms and promote emotional well-being. The care plan typically
includes a combination of therapeutic interventions, medication management, and
psychoeducation. Nursing professionals work closely with the client to assess anxiety levels,
identify triggers, and develop coping strategies. The plan may involve relaxation techniques,
such as deep breathing exercises or mindfulness practices, as well as cognitive-behavioral
therapy to address negative thought patterns. Additionally, the care plan emphasizes creating a
calm and supportive environment, promoting self-care activities, and encouraging social support
and engagement. The ultimate goal is to help clients manage anxiety, improve their quality of
life, and develop long-term strategies for coping with stress and anxiety-inducing situations.
Below is an example of psychiatry nursing care plan for clients with anxiety manifestations.

EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH ANXIETY

NURSING DIAGNOSIS: PANIC ANXIETY

RELATED TO: A real or perceived threat to biological integrity or self-concept

EVIDENCED BY: Inability to develop satisfying relationships and manipulation of others for
own desires

OUTCOME CRITERIA NURSING INTERVENTION

38
 Short-Term Goals 1. Recognize the purpose manipulative
behaviors serve for the client: to reduce
 The client will verbalize which of his
feelings of insecurity by increasing feelings of
or her interaction behaviors are
power and control.
appropriate and which are inappropriate
2. Set limits on manipulative behaviors.
within 1 week
Explain to the client what is expected and what
Long-Term Goal
the consequences are if the limits are violated.
 The client will demonstrate the use of
3. Do not argue, bargain, or try to
appropriate interaction skills as
reason with the client. Merely state
evidenced by a lack of, or marked
the limits and expectations.
decrease in, manipulation of others to
4. Provide positive reinforcement
fulfill his/herdesires.
for nonmanipulative behaviors

5. Help the client recognize that

he or she must accept the consequences of own
behaviors and refrain from attributing them to
others.

2.5 Psychiatry Nursing Care Plan for Clients with Substance use and related Disorders
Activity 2.4
 two actual nursing diagnosis for
clients with substance related disorder
(10 minute)

39
A substance use disorder (SUD) is a mental disorder that affects a person’s brain and behavior,
leading to a person’s inability to control their use of substances such as legal or illegal drugs,
alcohol, or medications. Symptoms can range from moderate to severe, with addiction being the
most severe form of SUDs.

 Drug addiction symptoms or behaviors include, among others:

 Feeling that you have to use the drug regularly — daily or even several times a day
 Having intense urges for the drug that block out any other thoughts
 Over time, needing more of the drug to get the same effect
 Taking larger amounts of the drug over a longer period than you intended
 Making certain that you maintain a supply of the drug
 Spending money on the drug, even though you can't afford it
 Not meeting obligations and work responsibilities, or cutting back on social or
recreational activities because of drug use
 Continuing to use the drug, even though you know it's causing problems in your life or
causing you physical or psychological harm
 Doing things to get the drug that you normally wouldn't do, such as stealing
 Driving or doing other risky activities when you're under the influence of the drug
 Spending a good deal of time getting the drug, using the drug or recovering from the
effects of the drug
 Failing in your attempts to stop using the drug
 Experiencing withdrawal symptoms when you attempt to stop taking the drug

Assigning NANDA terms for clients with substance use disorder

Makes statements such as, “I don’t have a Ineffective Denial

problem with (substance). I can quit any time I
want to.” Delays seeking assistance; does not
perceive problems related to the use of substances
Abuse of chemical agents; destructive behavior Ineffective coping
toward others and self; inability to meet basic

40
 needs; inability to meet role expectations; risk-
taking
Denies that substance is harmful; continues to use Deficient Volume
substance in light of obvious consequences

Risk factors: Malnutrition, altered immune Risk for infection

condition, failing to avoid exposure to pathogens
Criticizes self and others, self-destructive Chronic low self-esteem
behavior (abuse of substances as a coping
mechanism), dysfunctional family background

A psychiatry nursing care plan for clients with substance use disorder is centered around
addressing the complex challenges associated with addiction and promoting long-term recovery.
The care plan typically includes a combination of interventions such as detoxification,
medication management, individual and group therapy, and psychoeducation The plan may
involve monitoring and managing withdrawal symptoms, providing emotional support, and
facilitating access to support groups or rehabilitation programs

EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH SUBSTANCE USE

NURSING DIAGNOSIS: INEFFECTIVE DENIAL

RELATED TO: Weak, underdeveloped ego

EVIDENCED BY: Statements indicating no problem with substance use

OUTCOME CRITERIA NURSING INTERVENTION

41
Short-Term Goals
 Client will divert attention away from
external issues and focus on
behavioral outcomes associated with
substance use.
Long-Term Goal
 Client will verbalize acceptance of
responsibility for own behavior and
acknowledge association between
substance use and personal problems
42
1. Begin by working to develop a trusting
nurse-client relationship. Be honest. Keep all
promises.
2. Convey an attitude of acceptance to the
client. Ensure that he or she understands “It
is not you but your behavior that is
unacceptable.”
3.Provide information to correct
misconceptions about substance abuse.
4. Identify recent maladaptive behaviors or
situations that have occurred in the client’s
life, and discuss how use of substances may
have been a contributing factor.
5. Use confrontation with caring. Do not
allow client to fantasize about his or her
lifestyle
2.6 Psychiatry Nursing Care Plan for Clients with Catatonic Features
 A 31-year-old woman with an unknown
psychiatric history presented with mutism, stupor,
negativism, refuse to eat, and withdrawn behavior.
She was admitted to the psychiatric unit for what
appeared to be catatonia. Medical records were
not readily available. A comprehensive evaluation
did not uncover any medical etiology. Lorazepam
was ineffective at consistently reversing her
catatonic symptoms. During week three of
hospitalization, she was given olanzapine with
subsequent improvement in her negativism
 to identify problems, prioritize, and formulate
ACTIVITY 2.5 psychiatry nursing diagnosis with intervention.
(30 min)

Catatonia is associated with a range of symptoms that can significantly affect an individual's
behavior and functioning. Some of the common symptoms include stupor, which is a state of
deep unresponsiveness and immobility, and catalepsy, where the individual may maintain rigid
or statue-like postures for extended periods. Mutism, or the absence of speech, and negativism,
which involves opposing or resisting instructions or movements, are also observed. Echolalia,
the repetition of words or phrases, and echopraxia, the involuntary imitation of others' actions,
can occur as well. Stereotypy, characterized by repetitive and purposeless movements, and
agitation, marked by restlessness and excessive motor activity, are also seen. Other symptoms
include grimacing, posturing, mannerism (odd or exaggerated gestures or speech patterns), and
impulsivity, which involves acting without considering consequences. It's important to note that
the combination and severity of symptoms may vary among individuals with catatonia, and a
comprehensive evaluation by a healthcare professional is necessary for accurate diagnosis and
appropriate treatment.

43
 Assigning Common NANDA terms for clients with manifestations of Catatonia

Mutism or limited speech, Incoherent or Impaired Verbal Communication

nonsensical speech, Echolalia (repeating
words or phrases), Speech apraxia (difficulty
forming words)
Inability to move voluntarily or purposefully, Impaired Physical Mobility
Rigidity or stiffness of muscles, Abnormal
posturing or immobility, Difficulty with
coordination or balance
Poor appetite or reduced food intake, Imbalanced Nutrition Less Than Body
Significant weight loss or malnutrition, Requirement
Inability or refusal to eat, Limited variety or
excessive consumption of certain foods
Difficulty initiating or coordinating Impaired Swallowing
swallowing, Choking or coughing during
meals or when drinking liquids, Complaints
of pain or discomfort while swallowing,
Frequent episodes of aspiration or food
getting stuck

A psychiatry nursing care plan for patients with catatonia involves a comprehensive approach to
address their specific needs and promote their overall well-being. The care plan typically
includes careful observation and assessment of the patient's behavior, monitoring vital signs, and
ensuring safety. Nursing professionals collaborate with the multidisciplinary team to determine
appropriate interventions, which may include medication management, therapeutic
communication, and physical care. The care plan focuses on creating a calm and structured
environment, implementing sensory stimulation or relaxation techniques, and promoting
engagement in therapeutic activities. Additionally, nursing professionals provide emotional

44
support, educate the patient and their family about catatonia, and facilitate communication
between the patient and other healthcare providers.

EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH CATATONIA

NURSING DIAGNOSIS: IMPAIRED VERBAL COMMUNICATION

RELATED TO: Severe depression, altered neurotransmitter imbalance

EVIDENCED BY: difficulty of producing speech, mutism

OUTCOME CRITERIA NURSING INTERVENTION

Short-Term Goals 1.Use simple, concise, and concrete language.

2. Allow sufficient time for the client to
 Facilitate effective communication
process information and respond.
between the client and healthcare
3. Use non-verbal cues, such as gestures, facial
providers.
expressions, and written cues, to support
 Enhance the client's ability to express
understanding.
basic needs, wants, and emotions.
4. Encourage the use of yes/no responses or
Long-Term Goal
simple gestures to facilitate basic
 Promote alternative methods of communication.
communication when verbal
communication is not possible.

 Reduce frustration and anxiety related

to impaired verbal communication.

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Chapter Summary

This chapter helps develop nurses' competency in psychiatric care planning by first establishing
the learning objectives. It aims to enhance participants' abilities to recognize common mental
health diagnoses and formulate appropriate nursing interventions. A deeper understanding of
prevalent disorders experienced in clinical settings is a key foundation for these skills.Five
conditions are examined in depth: schizophrenia, major depressive disorder, anxiety disorders,
substance use disorders, and catatonia. For each, a comprehensive overview of characteristic
symptoms is provided. Examples include delusions, hallucinations and disorganized speech for
schizophrenia; depressed mood, insomnia and worthlessness for depression; excessive worries
and fears for anxiety disorders; drug cravings and withdrawal for substance abuse; and mutism,
rigidity and negativism for catatonia.

An essential feature is assigning each set of symptoms to the relevant nursing diagnosis
terminology outlined by NANDA. By linking clinical manifestations to standardized diagnostic
labels, nurses learn to accurately categorize the essence of patients' problems. The planning
section involves selecting individualized interventions targeted to achieve the specified
outcomes. Interventions address not only symptoms but also emphasize strategies to promote
coping, optimal function, and quality of life. This chapter builds nurses' competency in
psychiatric care planning by examining common mental health diagnoses, outlining standardized
nursing diagnosis terminology, and providing illustrative nursing care plans that demonstrate
how to logically connect comprehensive assessments to individualized goal-oriented
interventions for promoting patients' well-being.

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Reference

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