The Nursing Process in Psychiatric/Mental Health Nursing Flashcards

1
Q

Assessment & Documentation

A

 Key to contributing to establishment of psychiatric diagnosis

 Proper diagnosis leads to effective treatment

 Nursing input is more crucial in the diagnostic processin psychiatry than medical and surgical settings

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2
Q

Medical-Surgical Diagnosis

A

 MD physical exam

 Tests such as EKG and X-ray

 Labs – blood and body fluid analysis

 RN assessment minor in diagnosis

 RN use of the nursing process to enhance med-surg treatment via nursing interventions/nursing process

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3
Q

Psychiatric Diagnosis

A

 MD physical exam to rule out medical conditions

 Mental status exam(MSE) by MD and Nursing

  • observations of patient behavior in the environment over time
  • interactions with patient over time

 Some labs

 Some psychological tests if needed for Differential Diagnosis

 Establishes diagnosis and yields most effective treatment

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4
Q

Nursing Observation and Documentation

A
  • Nurses do parts or all of the MSE
  • Nurses observe patient behavior and interactions
  • Nurses document response to treatment
  • MD re-interview also establishes response to treatment
  • Nurses also use nursing process to provide independent care
  • Psychiatric DX and care is multidisciplinary
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5
Q

Holistic -Biopsychosocial

A
  • Hx of present illness, Psychiatric Hx, Substance use Hx, Coping skills – PSYCHOLOGICAL
  • Medical Hx – PHYSICAL
  • Family Hx and Developmental Hx – PSYCHOLOGICAL, PHYSICAL, SOCIAL
  • Social, Occupational/Educational Hx, Culture – SOCIAL
  • Spirituality - SPIRITUAL
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6
Q

Mental Status Exam - Elements

A
  • Appearance
  • Behavior/Activity
  • Speech
  • Attitude
  • Mood & Affect
  • Thought Process
  • Thought Content
  • Perceptual Disturbance
  • Memory/Cognition
  • Insight & Judgement
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7
Q

Appearance

A
  • Grooming /dress___________________
  • Hygiene__________________________
  • Eye Contact_______________________
  • Posture___________________________
  • Identifying features (scars,tatoos)______
  • Appearance versus stated age__________
  • Overall appearance__________________
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8
Q

BEHAVIOR/ACTIVITY

A

Hyperactive___, Agitated___, Psychomotor retardation___, Calm___, Tremors___, Tics___, Unusual movements/gestures___, Catatonia___, Akathisia___, Rigidity___, Facial movements(jaw/lip smacking)___, Other_______

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9
Q

SPEECH

A

Slow/rapid___, Pressured___, Tone___, Volume(loud/soft)___, Fluency(mute, hesitation, latency of response)___

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10
Q

Attitude

A

Cooperative___, Uncooperative____ Warm and friendly____, Distant___ Suspicious___, Guarded___, Aggressive___, Hostile___, Combative___ Apathetic___, Aloof___ Other__________________

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11
Q

MOOD AND AFFECT

A

MOOD – (general feeling ) Observe and listen

  • Elated___, Sad___, Depressed___, Irritable___, Anxious___, Fearful___, Guilty___, Worried___, Angry___, Hopeless___, Labile___, Mixed(anxious and Depressed)

AFFECT – facial expression

  • Flat___, Blunted or diminished___,
  • Full range___,
  • Inappropriate/incongruent(sad and smiling laughing) e.g.. Smiling at a funeral of a loved one when time to be serious. Facial expression does not fit with the topic being discussed
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12
Q

THOUGHT PROCESS

A
  • Cognition – How the patient thinks, thinking processes
  • Concrete thinking___, Circumstantiality___, Tangentiality___, Loose associations___, Flight of ideas___, Perserveration___, Blocking___, Derailment___,
  • (Echolalia, Clang associations, Word salad – not seen often)
  • Other___________
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13
Q

Thought Content

A
  • What the patient says
  • Delusions
  • (Gradiose / persecutory/reference/ somatic)___,Homocidal - to whom?____, Suicidal – describe____, Obsessions___, Paranoia___, Phobias___, Magical thinking___, Poverty of speech___, Other__________
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14
Q

PERCEPTUAL DISTURBANCE

A
  • Visual hallucinations___, Auditory___
  • commenting___, discussion___, commanding___, loud___, soft___, other________ Other hallucination (Olfactory / tactile) Illusions___, Depersonalization___, Other_________
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15
Q

MEMORY/COGNITION

A
  • Orientation___,
  • Memory (Recent/remote/confabulation)____,
  • Level of alertness (Level of consciousness)___
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16
Q

INSIGHT AND JUDGEMENT

A
  • Insight(awareness of the nature of the illness___,
  • Judgment___ “What would you do if you saw a letter on the ground with a stamp on it?” Are discharge plans appropriate to pt’s income, ability to work, current roles and capabilities?
  • Impulse control___
  • Other______
17
Q

Focus Charting

A
  • Main perspective is to choose a “focus” for documentation. A focus may be
    • a nursing diagnosis
    • a current client concern or behavior
    • a significant change in the patient’s status or behavior
    • a significant event in the patient’s treatment
  • The focus cannot be a medical diagnosis
18
Q

Documentation

A
  • BIRP
  • Behavior/Assess/What the patient is saying and doing
  • Interventions
  • Response/What the patient said of did as a result of the intervention
  • Plan/Where to go next/What does the patient need next
19
Q

Quality Documentation

A
  • Specific and descriptive
  • No assumptions or hunches – just the facts
  • Use the patients words at times to highlight and clarify
  • No need to say “Pt” or “Client” – the whole chart is about the patient
  • Only chart what you see and hear now, as patients change
  • Avoid the use of “I”. Instead “This writer”