Chapter 11: Diagnosis, interventions and outcomes in psychiatric and mental health nursing Flashcards
Overview
Interventions are nursing activities that promote mental health and physical mental health, assess dysfunction, assist clients to regain or improve their coping abilities and prevent further disabilities. Interventions include any treatment a nurse performs to enhance client outcomes. They can be direct performed through interaction with the client or indirect performed away from but on behalf of the client. They can be nurse initiated or physician initiated.
A commitment to collaboration in person centredness
Practice is moving towards a person and family centred approach recognizing that individuals are unique and should participate in all aspects of their care. This means that plans of care are created and provided with respect for the preference values and particular needs of the person and implemented as much as possible in partnership with the person. To enhance mental health services in primary care the CCMH I was formed in 2001 (Canadian collaborative mental health initiative). This group of 12 national organization represents community services, consumer, family and self-help groups, dietitians, family physicians, nurses, occupational therapists, pharmacist, psychologist, psychiatrist and social workers. The Canadian collaborative mental health care charter was developed by national organizations of consumers. It identifies seven principles of collaborative clinical decisions and interventions: health promotion and prevention of mental health problems, holistic promotion, collaboration, partnership, respect for diversity, information exchange and resources.
A person family centred approach to care places the person and their family at the centre of healthcare it’s practises in services in such a way that individuals are genuine partners with healthcare providers for their health.
Collaboration is the process of working together towards a common goals. Sharing knowledge and information can be an important aspect of this process
Evolution of nursing diagnosis and individual outcomes
Florence Nightingale identified client patient problems and analyzed patient outcomes during the Crimean war. Aydelotte Published first study involving patient outcomes. Laying in Clinton proposed nursing outcomes to include physical health status mental health status social and physical functioning health attitudes, knowledge and behavior, use of professional health resources and client patient perception of the quality of nursing care. Marek identified 15 nursing outcome categories: physiologic measures, symptom control, frequency of service, home maintenance, psychosocial measures, well-being, functional status, goal attainment, person patient behavior, client patient satisfaction, client patient knowledge, rehospitalization, safety costs and resolution of nursing diagnosis. In the 1990s focussed on developing outcomes that could be used to evaluate nursing effectiveness. In 1998 the nursing outcomes classification taxonomy was made. Escalating healthcare costs forced the demonstration of measurable outcomes. In the early 2000s theRNAO was funded to develop implement evaluate and revise best practice guidelines that would inform nursing practice in a number of areas and ensure outcomes thereby reducing costs. BPG‘s are meant to deliver care that is effective and based on current evidence, to aid in seeking resolutions to clinical problems, to meet or exceed current quality standards and providing excellent care, to initiate use of innovations, To illuminate interventions that are not meeting best practice standards, and to foster clinical excellence through supporting work environments. Critiques for BPGSR that ready-made guidelines conserve to impede nurses critical thinking and less diminish the social political and ethical responsibilities of the discipline. BPG’s can also facilitate the control and regulation
Deriving a nursing diagnosis
A nursing diagnosis is a clinical judgement about individual, family or community responses to actual or potential problems/life processes and involves selecting provides nursing interventions to achieve desired outcomes.
Clusters of data lead the nurse to choose certain diagnosis over others. Nonverbal and verbal information are used to identify defining characteristics. Defining characteristics are key signs and symptoms clues that relate to each other and that validate a nursing diagnosis. The nurse analyze these clues to formulate a cluster of data which helps in making a diagnosis or diagnosis is that reflects the actual or potential health status or problems of the individual. Related factors are those that influence or change the individuals health status and are grouped into four categories: pathophysiologic, biologic or physiological (eg cognitve problems); Treatment related (eg Medication’s, diagnostic studies and surgeries); Situational (eg Environmental, Home, community and person); Maturational (egAge related influences on health).
Developing individual of comes
Outcomes are the individuals response to nursing care at a given point in time. An outcome is concise, stated in few words and in neutral terms. Outcomes describe an individual state, behaviour or perception that is variable and can be measured.
Outcomes should be individualized and linked to nursing diagnosis. Should be monitored and documented overtime. Diagnosis specific outcomes show that intervention resolve the problem or diagnosis. The outcome can be non-specific abstract or general. They can be used to evaluate interventions by other healthcare disciplines.
Example diagnosis of risk for self harm would lead to an outcome of identify personal triggers for self harm.
The centre for addictions and mental health identified a number of protest called integrated pathways to eight individuals in receiving treatment and support. These have three characteristics: the focus is on clients overall journey, ensure clients receive right care and treatment at right time, involves care decisions based on evidence, effective teamwork among care providers, empower and inform clients and caregivers.
Indicators answer how close is the individual moving towards the outcome. Represents the dimensions of the outcome. Outcome indicators represent or describe individual statuses behaviours or perceptions of valuated during an individual’s assessment. Indicators are a measurement of individuals progress in relation to the individuals outcomes and conserve as intermediate outcomes in a clinical pathway. Initial outcomes are those written after the initial individual interview and assessment. Revised incomes are written after Each evaluation. Discharge outcomes are those outcomes to be met before discharge.
Documentation of outcomes
Nurses must document individual outcomes, nursing interventions and any changes in diagnosis or care plan. Individuals responses to care are documented as changes in behaviour or knowledge. Outcomes can be expressed in terms of individuals actual response such as no longer reports hearing voices or the status of a nursing diagnosis at the time of the implementation of nursing interventions such as caregiver role strain resolved.
Purpose of individual outcomes
Primary purpose is to ensure quality care and that the needs of the individual are being met. Provides guidelines for what’s expected of the individual and direction for continuity of care that reflects current knowledge. Measurement of outcomes can be used to determine quality of care during a single episode of illness and across the continuum of care and can assist in discharge planning. Can you help validate nursing interventions by identifying which are affective. Can be communication tool between nurses and case managers, caregivers and policymakers.
Nursing interventions
Nursing interventions are treatments or activities, based upon clinical judgement and knowledge, that are used by nurses to enhance patient or client outcomes.
Nursing interventions classification and I see is an extensive system of specific interventions with discrete activities for each. And I see taxonomy include classes or groups of interventions categorized according to seven domains: physiologic basis, physiologic complex, behavioral, safety, family, health system and community. Represents both basic and specialty advanced nursing practice.
Interventions for the biologic domain
Focus on physical functioning. Directed towards clients self-care, activities and exercise, sleep, nutrition, relaxation, hydration, thermal regulation, pain management and medication management
Promotion of self-care activities
Self-care is the ability to perform activities of daily living successfully. Some can manage activities such as bathing dressing appropriately, selecting adequate nutrition and sleeping regularly. Others cannot manage either because of their symptoms or as a result of the side effects of medication. Orem’s 1991 nursing model is based on concept of self-care deficit. Deficit may be related to attitude motivation, knowledge, or skill. The model identifies five nursing approaches: acting or doing for, guiding, teaching, supporting and providing an environment to promote the clients ability to meet current or future demands. Emphasis is on helping the individual develop independence. During acute phases, The inability to attend to basic self-care tasks is very common.
Activity and exercise interventions
Encouraging regular activity and exercise can improve general well-being and physical health. Can help clients deal with weight gain, type two diabetes. Some psychiatric disorders people become set a Terry, this lack of motivation is part of the disorder. Side effects of medication that include sedation and lethargy can compound the problem. The nurse can help client identify realistic activities and goals.
Sleep interventions
Many disorders and medications are associated with sleep disturbances. Sleep is disturbed and clients with dementia. Clients may have difficulty falling asleep, may frequently awakens during the night. May reverse their sleeping patterns by napping during the day and staying awake at night. Increased concern regarding the use of electronic devices prior to bedtime. Nonpharmacological interventions are always used first because of the side effect risks associated with sedatives and Hypnotics. Sleep interventions include: going to bed only when tired or sleepy, establish a consistent bedtime routine, avoid stimulating foods and beverages, avoid naps in the late afternoon, eat lightly before retiring, used to bed only for sleep, avoid emotional stimulation before bed, use behaviour and relaxation techniques, limit distractions, reduce exposure to electronic devices.
Nutrition interventions
Disorders and medication side effects can affect eating behaviors. Some eat a little some too much. Substance-abuse interferes with maintaining adequate nutrition through stimulation or suppression of appetite or by neglecting nutrition due to drug seeking behavior. Nutritional interventions need to be specific to the client. Some psychiatric symptoms involve changes in perceptions of food, appetite and eating habits. Example believing that food is poisonous. It may be necessary to allow clients to examine foods, participate in preparation and test the meal safety by eating slowly or after everyone else. Obesity can be a problem when treating a mental disorder. Antipsychotics, antidepressants and mood stabilizers are associated with weight gain due to changes in metabolism and appetite. Hypoglycaemia can exacerbate a depressed mood and lead to suicidal thoughts
Relaxation interventions
Relaxation promotes comfort, reduces anxiety, alleviate stress, ease his pain and prevents aggression. Can diminish the effects of hallucinations and delusions. Interventions range from simple deep breathing, biofeedback, Hipnosis.Simple relaxation techniques encourage and elicit relaxation to decrease undesirable signs and symptoms. Distraction is the purposeful focussing of attention away from undesired sensations. This includes counting it, exercising, reading, listening to music, watching television or playing. Based on energy level, H, developmental level and literacy. Guided imagery is the purposeful use of imagination to achieve relaxation or to direct attention away from undeserved sensations. Clients imagine themselves doing something pleasurable and relaxing such as lying on a beach. They are encouraged to slowly experience the scene and express how they feel and think about it. Slow deep breathing is encouraged. Clients may experience unexpected therapeutic reactions like crying so students should not attempt this technique. The nurse may teach the client relaxation exercises. Relaxation techniques involving physical touch such as back rubs must be used particularly carefully since they are often not appropriate for clients with a history of physical or sexual abuse
Hydration interventions
Over hydration or under hydration can be a symptom of a psychiatric disorder. Some clients with psychotic disorders experience chronic fluid in balance. Many psychiatric meds affect fluid and electrolyte balance. Example lithium carbonate clients must have adequate fluid intake with special attention paid to serum sodium levels. Psychiatric meds can cause dry mouth which can make individuals drink fluids excessively
Thermo regulation interventions
Psychiatric disorders can disturb the bodies normal temperature regulation. Clients might not be able to sense the temperature increase or does decrease and therefore can’t protect him selves from extremes. Some psychiatric meds have Affect the ability to regulate body temperature. Interventions include education, identifying potential extremes in temperature and developing strategies to protect the client
Pain management
Emotional reactions are often manifested as pain. Chronic pain is particularly problematic when no cause for it is identified. A single intervention is seldom successful for relieving chronic pain. It can involve medication, non-Pharmacological techniques such as relaxation, distraction or imagery. Psychoeducation stress management I biofeedback are also used. The key to managing pain is engaging client in identifying how it is disrupting their personal social professional and family life. Increased stress levels lead to increased pain.
Medication management
Medication management involves more than the actual administration of medications. Nurses assess medication effectiveness, side effects, consider interactions with other drugs, herbal remedies or homeopathic preparation’s, SS factors that may affect the clients adherence to medication regimen such as concerns regarding weight gain, reproductive ability, attitude towards taking medications for cost. Clients must be educated on recognition and reporting of side effects. Medication follow ups me include home visits and telephone calls. Many clients remain on medication regimens for years never become medication free
Interventions for the psychological domain
Emphasis on emotion and behaviour and cognition. Nurse client relationship serves as the basis for interventions. Include counseling, conflict resolution, recovery orientation, reminiscence, behaviour therapy, cognitive interventions, psychoeducation, health teaching and spiritual interventions.
Counselling interventions
Counselling interventions are specific time limited Interactions between a nurse and client family or group experiencing immediate or ongoing difficulties related to their health or well-being. Short term and focusses on improving coping abilities, reinforcing healthy behaviors, fostering positive interactions or preventing illnesses.
Conflict resolution
BIn a conflict a person believes that their own needs interests once our values are in compatible with someone else’s. They experience fear sadness bitterness anger hopelesslness in response to the perceived threat. Conflict resolution is when the nurse helps clients resolve disagreements or disputes with family, friends or individuals. Conflicts can be positive individual sees the problem is solvable and providing an opportunity for growth. The nurse may help teach family members how to resolve their own conflicts positively
Conflict resolution process
Calmness and objectivity are important to resolve conflict. Each party must resolve with a positive outcome. The nurse takes the following steps: identify conflict issues, no nurses on response to the conflict, separate the problem from the people involved, stay focussed on the issue and underlying motivations, identify available options, try to identify established standards to guide the decision making process. It’s important to be aware of what’s causing the conflict.
Cultural brokering in client system complex
Differences in cultural values and language between client and healthcare organizations can contribute to clients feeling powerless. Cultural brokering is the use of culturally appropriate strategies that aid in bridging or mediating between the clients culture and the healthcare system. For the nurse to be an effective broker they must establish and maintain a sense of connection Ness or relationship with a client. Cultural sensitivity and competence is necessary
Recovery orientation
Recovery orientation means helping the person regain functioning or get on with life despite having ongoing symptoms of the psychiatric illness. Recovery may refer to what the client does, how the nurse functions or how the mental health system is organized. The Cure is not necessary for sense of recovery. Guidelines for utilizing this approach are: creating a culture of language and hope, recovery is personal, recovery occurs in the context of one’s life, responding to diverse needs, working with first Nations, recovery is about transforming systems and services. The title model in emphasizes the importance of a collaborative relationship between the nurse and the client. The clients perspectives and experiences are excepted and valued. Recovery is contingent on the health professional having a genuine interest in the client and their experiences. Open and transparent process based on mutual establishment of goals.
Reminiscence
Reminiscence The thinking about or relating of past experiences is used to enhance life review particularly for older adults. Individuals can identify past coping strategies that can support them in the current situation. Clients use reminiscence to maintain self-esteem, stimulate thinking and support the natural healing process of life review. Writing an account of past lives, making a tape-recording and clean it back, explaining pictures and family albums, drawing a family tree and writing to old friends.
Behavioural Therapy
Behavioural therapy interventions focus on reinforcing or promoting desirable behaviours or altering undesirable ones. New functional behaviours can be learned.
Behavioural modification
Behavioural modification is a specific systemized behaviour therapy technique that can be applied to individuals groups are systems. Came to reinforce desired behaviours and extinguish undesired ones. Desired behaviour is rewarded so that client will repeat it and overtime replace the problematic behaviour with it. Behaviour modification is used for dysfunctional eating an addiction and in the care of children and adolescents
Token economy
A token economy applies behaviour modification techniques to multiple behaviors. Clients are rewarded with points or tokens for demonstrating selective desired behaviors. They can use ease to purchase meals, leave the unit, watch TV, wear street clothes. Can be helpful in creating a structured therapeutic environment for children with developmental delays or autism. There has been a decline in the use of token economies since 1980s. Concern In forensic psychiatry that behaviour modification program do not respect the autonomy of the clients being served
Cognitive interventions
Cognitive interventions are verbally structured interventions that reinforce and promote desirable or alter undesirable cognitive functioning. Thoughts guide emotional reactions motivations and behaviors. Cognitive interventions help clients develop new ways of viewing situations so that they can problem solve themselves. Emotional changes will follow the cognitive changes and ultimately behaviours will change. Automatic thinking is often subject to errors or tangible distortions of reality that contradict objective appraisals. Example a client with depression may be convinced that no one cares about them when in fact family and friends are deeply concerned. Illogical thinking occurs when a person draws a faulty conclusion. Example college student devastated by failing an exam that they perceive it as Catastrophic and that college career is over. To engage in cognitive treatment the client must be capable of introspection and reflection about thoughts and fantasies. Cognitive interventions include thought stopping, contracting and cognitive reconstructing.
Psycho education
Psycho education uses educational strategies to teach clients the skills they lack because of a psychiatric disorder. Goal is to change knowledge and behavior. Specific psycho education techniques are based on adult learning principles. Is a continuous process of assessing, setting goals, developing learning activities and evaluating for changes in knowledge and behavior.
Health teaching
Health teaching involves collaborating with the client to determine learning needs and transmitting new information, while considering the context of the clients life experiences. The nurse considers readiness, culture, literacy, language, preferred learning style and resources available. All interactions between the nurse and client are potentially learning/teaching situations. In health teaching the nurse attends holistically to potential healthcare problems. Example if a person has diabetes they may want the nurse to provide teaching related to diabetes and the interaction with the mental disorder they went may want a family member or friend to be taught ways to assist and support them. Nurses help clients identify appropriate resources and identified the credibility and cost, accessibility and ease-of-use to determine the effectiveness of the learning aid or tool. Evaluation is a necessary aspect of teaching it is an ongoing process where some knowledge may need more time or teaching. Nurses must be diligent so that they do not conflate the clients learning style with their own preferred way to learn. They must be aware of their own feelings when providing client About sensitive or culturally taboo topics such as sexual side effects that significantly contribute to medication noncompliance.
Interventions for the social domain
Includes individuals environment and its affect on their response to mental disorders in distress. Interventions are geared towards couples, families, French, large and small social groups with specific attention given to ethnicity and community interactions. The nurse can modify the environment to promote positive behaviours through providing opportunities for clients to interact with others. Can be accomplished through group or recreational activities for holidays or other special events which clients can attend
Milieu Therapy
Milieu therapy provide a stable and coherent social organization to facilitate an individual’s treatment. The design of the physical surroundings, structure of client activities and promotion of a stable social structure and cultural setting in Hanst the settings therapeutic potential. A therapeutic Milieu facilities client interactions and promotes personal growth. Milieu Can create potential for destruction as well as healing. Clients could feel afraid and abandoned or connected and affirmed. Milieu therapy is the responsibility of the nurse in collaboration with a client and other healthcare providers. The basis includes safety and security, validation, open communication and structured interaction.
Safety and security
The milieu Should be a healing place where clients feel safe and secure. Physical shape surroundings should be clean and comfortable and promote a non-institutionalized environment. Pictures on walls comfortable Furniture and soothing colors. Nursing staff wear street clothes.
Validation
Validation firms of clients individuality. Clients should feel validated as persons of worth and deserving of respect. Interactions should reaffirm clients humanity and rates.
Open communication
In open communication, health and treatment information is shared with clients and families. Confidential Aliti is Kat. The environment is shaped facilitate optimal interaction and re-socialization. Support, attention, praise and reassurance gives clients improved self-esteem and increase confidence.
Structured interaction
Structured interaction is a purposeful interaction that is intended to help clients cope with particular behaviours or to learn better ways of interaction. Specific attitudes or approaches are sealed with individual clients. Approaches include indulgence, flexibility, passive or active friendliness, matter-of-fact attitude, casualness, watchfulness or kind firmness. Milieu Treatments are based on the individual needs and include relaxation groups, discussion groups and medication groups.
Promotion of client safety on psychiatric units
Clients may be so severely ill but they engage in behaviour is harmful to themselves or others. They can react with fear or in self-defence Q dangers they perceive such as hallucinations or delusions. Sensitivity to the clients world is used to keep the client safe. Interventions begin with observation and De-escalation and me evolve to the use of containment strategies such as seclusion or physical or chemical restraints for the clients with an involuntary status. Risks include client aggression, self harm, medication refusal and suicide attempts. Key influences on these incidents Are the patient community (Discord among patients such as property damage), patient characteristics (Symptoms and their severity), the regulatory framework(legal status such as involuntary admission), the staff team(levels of stuff anxiety and frustration), the physical environment (clean tidy respectful atmosphere)and outside hospital (Tension in family loss of accommodation or relationship)
Observation
Observation is the ongoing assessment of the client status to identifies and subvert any potential problem. Judgment and cognitive impairment or symptoms of many psychiatric disorders. Observation involves thoughtful, knowledgeable regard of the persons and consistent, responsible monitoring for any potential harm to themselves or others. Intensity of observation depends on assessed risk level. Clients may be asked to simply check in at different times Whereas others may be observed every 15 minutes Or constantly observed if at high risk for suicide
De-escalation
De-escalation is an interactive process of calming and redirecting a client who has an immediate potential for violence directed towards self or others. Involves assessing the situation and preventing it from escalating to one in which injury occurs to the client or others. Once the nurse SS the situation, they respond matter-of-factly to it using various interventions that can include a request for the client to leave the situation, distraction and conflict resolution And cognitive interventions.
Seclusion
Seclusion is the involuntary supervised isolation of a patient in a locked non-stimulating room. A client is placed in seclusion for safety or behavioural management. The room has no furniture except a mattress and a blanket, walls may be padded, room must be environmentally safe with no hanging devices outlets or windows. Once placed in seclusion the client is observed at all times. Can be an extremely negative client experience. It’s use is seriously questioned and many facilities completely abandoned this practice. Clients can perceive it as an instrument of power and control and their outcomes may actually worsen. Find me a report feeling safe and protected in seclusion rooms.
Restraint
Restraint is the most restrictive safety intervention and it’s only used in the most extreme circumstances as a last resort. Alternatives include reducing stimulation, increasing decreasing social interaction, coping strategies, reviewing prescribed meds, distraction or relaxation techniques and access to comfort. Each province has their own laws for restricting freedom of clients against Will. Chemical restraint is the use of medication to control clients or manage their behavior. Physical restraint is any human or mechanical methods that restrict the freedom of movement or normal access to one’s body, material or equipment and cannot be easily removed. Wrist restraints restrict arm movement, four-point restraints are applied to wrists and ankles in bed, five point restraints are used all extremities are secured and another restraint is placed across the chest. Physicians order is necessary for restraints and nurses should document all the previous tried de-escalation interventions before the restraint was applied. Restraints should only be used if individual is judged to be a danger to themselves or others and should only be used until the client has gained control over their behavior. The client should be observed and protected from self harm when restricted.
Home visits
The goal of home visits, the delivery of nursing care in the clients living environment, is to maximize the clients functional ability within the nurse client relationship and with the family or partner as appropriate. The nurse works independently administers and monitored meds and uses community resources for the client. They can help reluctant clients to enter therapy conduct a comprehensive assessment, strengthen a support network and maintain clients in the community when their condition deteriorates. They help individuals adhere to their medication regimen. They provide family members with information and education and engage them in planning and interventions. Allows the nurse to develop cultural sensitivity. The home visit process consists of three steps the pre-visit fees, the home visit and the post visit fees. Pre-visit: the nurse sets goals for the home visit based on data received from other healthcare providers with a client, safety precautions are taken time of visit is agreed-upon in general assessment can be made of the neighbourhood for access to services social economic factors safety. The home visit: divided into four parts the greeting fees, usually brief in which the nurse begins to connect with the client and family members this sets the atmosphere for the visit, the nurse should be friendly but professional. The second phase establishes the focus of the visit: medication administration, health teaching or counseling. The client and family must be clear regarding the purpose. Phase 3 the implementation of the service: Should use most of the visit time. Phase 4 is closure: this time to summarize and clarify important parts schedule additional visits and reiterate client expectations. Post visit fees: includes documentation, reporting and follow up planning, also when the nurse may meet with supervisors and colleagues and present data from home visit at a team meeting
Community action
Nurses can be an advisor to support groups, participate in political processes through lobbying efforts and serve on community mental health boards. These are normally unpaid activities outside of a job. An important role of professionals is to provide community service in addition to services through income generating positions
Interventions for the spiritual domain
Spiritual care involves giving attention to all aspects of the individuals life and takes direction from the reality. The nurse identify spiritual needs and strives to help the individual meet them. The integrative nature of spirituality can make it difficult to isolate and identify spiritual needs, document spiritual interventions and stipulate outcomes. Spiritual nursing care is about developing caring relationships through fostering connections to promote spiritual comfort and well-being. An attitude of respect and concern for the clients comfort, dignity and well-being and recognition of the client as a person with a past present and future are seen as core to connection. For critical qualities for spiritual care: receptive it he, humanity, competency and positivity. Receptive it he involves being open to clients as a person and being genuinely present to them. Humanity is about being human or put another way being real it can be offering the little things such as knocking before entering the clients room. Competency is enabling the client to know that here she is in good hands it reflects the integrative aspects of spiritual care and includes good biopsychosocial care. Positivity describes the positive approach necessary to spiritual care. The nurses attitude is one of hope and determination encouragement and good humour it’s not about smiling all the time but about fostering a Positive spirit in others through one’s own hopeful energy. The person may seek to connect or reconnect with others, with nature, with a greater power than themselves or with some aspect of the sacred. Nurses can support clients by listening to them as they described are seeking, responding to any requests for meeting with a religious leader, or by facilitating the use of religious ritual such as a smudging ceremony.
Evaluations of outcomes
What were the benefits for the individual? What was the individuals level of satisfaction? Was the outcome diagnosis specific or non-specific? What was the cost effectiveness of the intervention? Nurses must consider the time frame. Must identify the intermediate outcome indicators that may be achieved in one setting versus the indicators that may be achieved in a second setting provides a measurement of progress and enhances continuity of care. Outcomes can be measured immediately after the nursing intervention or after Time passes.
