Applying the Nursing Process

1
Applying the Nursing Process

• Holistic
• Psychosocial assessment
• Measurable goals/outcomes
• Applies principles of therapeutic communication
• Evaluation/analysis of goals/interventions

2
Physical Assessment

• Ageappearance in relation to age
• Attireappropriateness to age/situation
• Hygienecleanliness/grooming
• Physical healthwt.,health maintenance/physical
  distress
• Psychomotor posture,movement, activity level
• Sleep/rest patterns

3
Mental Status Examination

• Appearanceappropriateness/grooming
• Behavior cooperative, suspicious,hostile
• Affect sad,tearful, angry, irritable, congruent
  to mood/conversation
• Mood euthymic, dysthymic,sad, angry,
  hostile,labile

4
Cognitive Assessment (MSE)

• Intellectual functioning
• Orientation(time,place,person,situation)
• Attention/concentration
• Knowledge/educational level
• Memoryimmediate,recent,remote
• Insight into illness/problem
• Judgment
• Ability to abstract

5
Evaluation of Speech(MSE)

• Fluency/spontaneity
• Rate/rhythm/tone/pressured
• Specific aberrations I.e. echolalia,neologisms

6
Thought Process (MSE)

• Assess thoughts for
• Content presence of SI/HI
• Clarity presence of delusions(false fixed ideas)
• Presence of hallucinations(sensory I.e.
  auditory/visual)
• Presence of loose associations,ideas of
  reference,thought blocking,flight of ideas,
  ruminations(repetitious thoughts)obsessions/compul
  sions

7
Social/Cultural Considerations

• AGE assess for developmental tasks/crises,age
  related problems(Erikson)
• Family/Community relationships
• Role of client in family
• Family harmony/support/dependency
• Availability of community support groups

8
Social /Cultural/ Spiritual considerations(MSE)

• Socio-economic group /education
• How client perceives present statehow client is
  approached
• Determination of level of teaching/need for
  social services
• Assess behaviors in context of clients culture
• Avoid stereotyping
• Note religious/philosophic beliefs

9
Analysis

• Selection of nursing diagnosis based on data
  collected during assessment
• Goals The client will
• Mutual agreement of client and nurse whenever
  possible
• Short-term goals(immediate problems)
• Need to be realistic/attainable
• Long-term goals r/t discharge planning/tertiary
  prevention(prevention of recurrence or
  exacerbation of symptoms)

10
Interventions

• Nurse uses therapeutic interventions and the
  Nurse-client relationship to achieve client
  goals.
• Interventions are geared to level of client
  capacity/must relate to specific problems of
  client,family,group.

11
Crisis Theory and Intervention

• Crisis temp state of severe emotional
  disorganization caused by failure of coping
  mechanisms lack of support.
• Decision making problem solving inadequate
• Tx immediate,supportive,directly responsive to
  immediate crisis
• Assists client /family through the stressful
  situation

12
Phases of a Crisis

• 1.External precipitating event
• 2. Perception of threat
• Increased anxiety
• client may Cope or Resolve crisis
• 3. Failure of coping
• Increased disorganization
• Emergence of symptoms
• Relationship problems
• 4. Mobilizes internal/external resources
• Resolution return to pre-crisis
  level,higher level or lower lever.

13
Crisis Intervention

• Treatment Immediate/Supportive
• Interventions goal directed
• Acknowledges client feelings
• Encourages expression/validation of feelings
• Makes connection between meaning of event and the
  crisis
• Explores alternative coping mechanisms/tries new
  behaviors

14
Types of Crises

• Maturational r/t developmental stages
• Situationalr/t external source associated with
  life event that upsets psychological equilibrium
• Adventitious r/t crisis of a disaster or an
  event not part of everyday life/unplanned/accident
  al

15
Role of the nurse in Crisis Intervention

• Assess client PERCEPTION of problem
• Determine SITUATIONAL SUPPORTS
• Explore previous COPING METHODS
• Offer support in resolving problem
• Engage help from situational supports
• Assist client to gain new,effective coping
  behaviors
• Convey HOPE/continue to work with client as the
  crisis is resolving.

16

• A client walk into mental health clinic and
  states, Ive had it, I cant go on any longer.
  Youve got to help me. The nurse asks the client
  to be seated in a private interview room. The
  nurse would
• Reassure the client someone will help him.
• Assess clients insurance coverage
• Find out more about what is happening to the
  client
• Call the clients family to come and provide
  support.

17

• M age 19, recently broke off her one year
  engagement. Her mother states ,She does nothing
  but cry,sit and stare into space.I cant get her
  to eat anything! M. feels she cant go on
  without her boyfriend. The nurse should make
  which priority nursing diagnosis?
• Altered nutritionless than body requirements
• Dysfunctional grieving
• Risk for self-directed violence
• Social Isolation

18

• The nurse is working with a client who has sought
  counseling after trying to rescue a neighbor
  involved in house fire. In spite of the clients
  efforts,the neighbor died.Which action does the
  nurse engage in with the client during the
  working phase of the nurse-client relationship?
• Explore the clients potential for self harm
• Explore clients ability to function
• Inquire about clients perception or appraisal of
  neighbors death
• Inquiring about and examining the clients
  feelings that may block adaptive coping

19

• A client comes to the clinic after losing all
  personal belongings in a hurricane. The nurse
  develops the nursing diagnosis of Ineffective
  coping. Which of the following is the least
  realistic goal for this client?
• The client will identify realistic perception of
  the stressors.
• The client will develop adaptive patterns.
• The client will express and share feelings
  regarding the present crisis.
• The client will stop blaming self for lack of
  insurance.

20

• A female victim of sexual assault is being seen
  in the crisis center. The client states that she
  still feels as though the rape just happened
  yesterdayeven though it has been a few months
  since the incident.The most appropriate nurse
  response would be
• What do you think that you can do to alleviate
  some of your fears about being raped again?
• Tell me more about the incident that makes you
  feel like the rape just occurred.
• It will take some time to get over these
  feelings about your rape.
• You need to try to be realistic. The rape did
  not just occur.

21

• The nurse is developing a plan for a client in a
  crisis state. When developing the plan the nurse
  considers which of the following?
• Presenting symptoms in a crisis situation are
  similar for all individual s experiencing a
  crisis.
• A crisis state indicates that the individual is
  suffering from emotional illness.
• A crisis state indicates the individual is
  suffering from mental illness.
• A clients response to a crisis is individualized
  and what constitutes a crisis for one person may
  not constitute a crisis for another.