Module 4: Nursing Process in Mental Health Nursing

Question 1

Describe the nursing process steps used in psychiatric mental health nursing

Answer 1

1. assessment
   - construct data base:
   
   • > mental status examination
   • > psychosocial assessment
   • > physical examination
   • > history taking
   • > interviews
   • > standardized rating scales
     - verify data
2. diagnosis
   - identify problem and ethology
   - construct nursing diagnoses and problem list
   - prioritize nursing diagnoses
3. outcome identification
   - identify attainable and culturally expected outcomes
   - document expected outcomes as measurable goals
   - include time estimate for expected outcomes
4. planning
   - identify safe, pertinent evidence-informed actions
   - strive to use interventions that are culturally relevant and compatible with health beliefs and practices
   - document plan using recognized terminology
5. implementation
   - basic-level and advanced-practice interventions:
   
   • > coordination of care
   • > health teaching and health promotion
   • > milieu therapy
   • > pharmacological, biological, and integrative therapies
     - Advanced-Practice interventions:
   • > prescriptive authority and treatment
   • > psychotherapy
   • > consultation
6. evaluation
   - document results of evaluation
   - if outcomes have not been achieved at desired level:
   
   • > additional data gathering
   • > reassessment
   • > revision of plan

Question 2

HEADSSS Psychosocial interview technique

Answer 2

H- home environment (e.g. relationships with parents and siblings)
E - equation and employment
A - Activities (e.g. sports, after-school activities, peer relations)
D - Drug, alcohol and tobacco use
S- Sexuality
S - Suicide risk or symptoms of depression
S - Savagery (e.g. violence or abuse in the home environment or in the neighbourhood)

Question 3

Describe the mental status assessment process

Answer 3

• page 86 Box 6-3
• the purpose is to evaluate an individuals current cognitive, affective (emotional) and behavioural function
• aids in collecting and organizing objective data of the here and now experience of the patient
• the nurse observes and asks directly about the patients physical behaviour, nonverbal communication, appearance, speech patterns, mood and affect, thought content, perceptions, cognitive ability and insight and judgement

Question 4

Describe Biopsychosocial Nursing Assessment

Answer 4

a system that can guide the nursing assessment and interventions in a holistic manner, viewing clients comprehensively, including their biology, social environment and skills and psychological characteristics.