MENTAL HEALTH NURSING PROCESS

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MENTAL HEALTH NURSING PROCESS

• JO ANN NORRIS, RN, MN, CORLN

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ASSESSMENT

• INTERVIEW WITH THE CLIENT AND HIS OR HER FAMILY
  OR SIGNIFICANT OTHER
  
• SPEAKING WITH THE CLIENT ALONE AND WITH FAMILY

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ASSESSMENT

• HEALTH HISTORY AND PHYSICAL
• 1. CLIENTS COMPLAINT, PRESENT SYMPTOM AND
  FOCUS OF CONCERN
  
• 2. PERCEPTIONS AND EXPECTATIONS
• 3. PREVIOUS HOSPITALIZATIONS AND MENTAL
  HEALTH TREATMENT
  
• 4. FAMILY HISTORY
• 5. HEALTH BELIEFS AND PRACTICES
• 6. SUBSTANCE USE

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ASSESSMENT

• 7. SEXUAL HISTORY
• 8. ABUSE
• 9. SPIRITUAL
• 10.BASIC NEEDS (DIET, EXERCISE, SLEEP,
  ELIMINATION)
  
• 11.SOCIOCULTURAL
• 12.COPING PATTERNS
• 13.SELF-ESTEEM
• 14.MEDICAL CONCERNS OR ASSESSMENT

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ASSESSMENT

• MENTAL STATUS EXAMINATION
• GENERAL APPEARANCE OBJECTIVE DATA
• A. FACIAL EXPRESSION
• B. GESTURES POSTURE
• C. DRESS
• D. PHYSICAL CHARACTERISTICS

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MENTAL STATUS EXAM

• PSYCHOMOTOR ACTIVITY
• APRAXIA UNABLE TO CARRY OUT MOVEMENT
• AKATHISIA EXTREME RESTLESSNESS
• AKINESIA COMPLETE OR PARTIAL LOSS OF
  MUSCLE MOVEMENT
  
• DYSKINESIA EXCESSIVE MOVEMENT OF THE
  MOUTH, TONGUE, FACIAL GRIMACING

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MENTAL STATUS EXAM

• PSYCHOMOTOR ACTIVITY
• PSEUDOPARKINSONISM FINE TREMORS WITH
  MUSCULAR RIGIDITY
  
• REACTION TO CARE GIVER FRIENDLY, HOSTILE,
  SUSPICIOUS

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MENTAL STATUS EXAM

• AFFECT OBSERVABLE EMOTION
• 1. GIVE A DESCRIPTIVE LABEL
• EUPHORIC ANXIOUS
• ANGRY SUSPICIOUS
• DYSPHORIC
• 2. DESCRIBE THE RANGE AFFECT
• NORMAL BLUNTED
• CONSTRICTED FLAT

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MENTAL STATUS EXAM

• 3. CONGRUENCY
• 4. LABILE AFFECT
• RAPID, ABRUPT, SHIFTING OF AFFECTS

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MENTAL STATUS EXAM

• MOOD USE CLIENTS OWN WORDS

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MENTAL STATUS EXAM

• CHANGE IN BIOLOGICAL FUNCTIONS
• 1. APPETITE
• 2. SLEEP
• 3. ENERGY LEVEL
• 4. INTERESTS HOBBIES, ADLS
• 5. WEIGHT
• 6. LIBIDO
• 7. ANHEDONIA LOSS OF ALL PRESURABLE ACTIVITIES

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MENTAL STATUS EXAM

• SUICIDAL IDEATIONS
• HOMICIDAL IDEATIONS

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MENTAL STATUS EXAM

• ORIENTATION
• 1. PERSON WHO YOU ARE
• 2. PLACE WHERE THE CLIENT IS
• 3. SELF WHO THE CLIENT IS
• 4. SITUATION WHAT IS HAPPENING
• 5. TIME TIME OF DAY, DAY OF WEEK
• DO NOT SAY ORIENTED X4

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MENTAL STATUS EXAM

• CONTENT OF THOUGHT
• 1. DELUSION FALSE FIXED BELIEF
• 2. HALLUCINATION SENSORY PERCEPTION WITHOUT
  EXTERNAL STIMULATION.
  
• 3. ILLUSION MISPERCEPTION OF A REAL EXTERNAL
  STIMULUS
  
• 4. OBSESSION RECURRENT AND PERSISTENT
  THOUGHTS, IMAGES OR IMPULSES

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MENTAL STATUS EXAM

• 5. DEPERSONALIZATION ALTERED SENSE OF ONES OWN
  REALITY
  
• 6. ILLOGICAL THINKING THINKING WITH CLEARLY
  ERRONEOUS CONCLUSIONS

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MENTAL STATUS EXAM

• STREAM OF THOUGHT FORM OF THOUGHT
• 1. CIRCUMSTANTIALLY SPEECH THAT IS
  UNNECESSARY, TEDIOUS, INDRIECT
  
• 2. LOOSENING OF ASSOCIATION SUBJECTS SHIFT,
  NOT UNDERSTANDABLE
  
• 3. FLIGHT OF IDEAS ABRUPT TOPIC CHANGES BUT
  WITH UNDERSTANDABLE
  
• ASSOCIATIONS.

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MENTAL STATUS EXAM

• 4. THOUGHT BLOCKING INTERRUPTION IN A TRAIN OF
  SPEECH BEFORE THE THOUGHT IS COMPLETED
  
• 5. INCOHERENCE SPEECH NOT UNDERSTANDALBE
• 6. PERSERVERATION PERSISTENT REPETITION OF
  WORDS OR IDEAS
  
• 7. POVERTY OF AMOUNT OF SPEECH
• 8. POVERTY OF CONTENT OF SPEECH
• 9. PRESSURED SPEECH LOUD, EMPHATIC

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MENTAL STATUS EXAM

• MEMORY REMOTE
• 1. RECENT PAST 3-10DAYS
• 2. RECENT LAST 24 HOURS
• 3. IMMIDIATE RETENTION 7 DIGITS IS NORMAL
• 4. IMMEDIATE RECALL 4 OBJECTS AFTER 5 MINUTES

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MENTAL STATUS EXAM

• GOGNITIVE, INTELLECTUAL, AND CONCENTRATING
  ABILITIES
  
• 1. CALCULATIONS
• 2. REVERSING DIGITS (7 DIGITS IS NORMAL)
• 3. SERIAL 7S (COUNTING BACK WARDS FROM 100 BY
  7S)

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MENTAL STATUS EXAM

• ABSTRACTING ABILITY 9 INTERPRETING SAYINGS.
• 1 PEOPLE IN GLASS HOUSES SHOULD NOT THROW STONES
• 2. ROLLING STONE GATHERS NO MOSS

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MENTAL STATUS EXAM

• JUDGEMENT FORM VALID CONCLUSIONS
• 1. WHAT WOULD YOU DO IF YOU WERE LOST IN A CITY.
• 2. WHAT WOULD YOU DO IF YOU RECEIVED A 10,000.00
  CHECK JUST FOR YOU TO USE.

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MENTAL STATUS EXAM

• GENERAL INFORMATION
• 1. WHO IS THE PRESIDENT
• 2. WHO IS THE GOVERNOR
• 3. RECENT WORLD EVENTS

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DEVELOPING THE NURSING DIAGNOSIS

• Many diagnoses are not medical or psychiatric
  diagnoses.
  
• Spiritual Distress related to inability to
  practice faith as a result of hospitalization, as
  evidenced by the comment I feel so lost
  
• NANDA has developed nursing diagnosis based on
  clinical judgment about the client, family or
  community responses to health problems/life
  processes

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NURSING DIAGNOSIS

• GORDONS FUNCTIONAL HEALTH PATTERNS AND THE NANDA
  ARE COMBINED TO FORM CLASSES
  
• THESE CLASSES ALLOW FOR GROUPING OF CLINICALLY
  RELATED DIAGNOSIS.
  
• SEVEN CONCEPTS ARE CONSIDERED WHEN MAKING THE
  DIAGNOSIS

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SEVEN CONCEPTS

• 1. DIAGNOSTIC CONCEPT DENIAL, HOPELESSNESS,
  BODY IMAGE
  
• 2. TIME ACUTE, CHRONIC, INTERMITTENT
• 3. UNIT OF CARE INDIVIDUAL, FAMILY
• 4. AGE FETUS TO OLDER ADULT
• 5. HEALTH STATUS POSITION OF THE ILLNESS
  WELLNESS CONTINUUM
  
• 6. DESCRIPTOR DYSFUNCTIONAL, INEFFECTIVE,
  DELAYED
  
• 7. TOPOLOGY AREA OF THE BODY

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DEVELOPING THE DIAGNOSIS

• 1. CHOOSE THE APPROPRIATE DIAGNOSIS FROM THE
  NANDA LIST BY
  
• EXAMINING DEFINITIONS
• CONSIDER RELATED AND RISK FACTORS
• CHOOSE A DIAGNOSTIC CONCEPT THAT FITS THE
  ASSESSMENT DATA
  
• ADD THE ETIOLOGY RELATED TO WHICH GIVES A
  PERCISE IDEA OF THE CLIENTS NEEDS

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DEVELOPING THE DIAGNOSIS

• DEFINING CHARACTERISTICS SUBJECTIVE AND
  OBJECTIVE DATA THAT MUST BE PRESENT TO
  SUBSTANTIATE THE USE OF THE DIAGNOSIS

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DSM IV-TR

• APA TEXT
• SPECIFIC DIAGNOSING CHARACTERISTICS FOR THE
  VARIOUS PSYCHIATRIC DIAGNOSES

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IMPLEMENTATION

• 1. COUNSELING
• 2. MILIEU THERAPY
• 3. SELF-CARE ACTIVITIES
• 4. PSYCHOBIOLOGICAL INTERVENTIONS
• 5. HEALTH TEACHING
• 6. CASE MANAGEMENT
• 7. PSYCHOTHERAPY
• 8. ADMINISTRATION OF PHARMACOLOGIC AGENTS
• 9. CONSULTATION

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5 AXIS FORMAT

• AXIS I PRIMARY DIAGNOSIS CLINICAL DISORDER
• AXIS II PERSONALITY DISORDER MENTAL
  RETARDATION
  
• AXIS III PHYSICAL DISABILITY MEDICAL
  CONDITIONS
  
• AXIS IV SEVERITY OF THE STRESSOR PSYCHOSOCIAL
  ENVIRONMENTAL PROBLEMS
  
• AXIS V SERIOUS SYMPTOMS GLOBAL ASSESSMENT OF
  FUNCTIONING GAF SCALE