MH 3

Nursing Process in Mental Health

Overview of the Nursing Process

  • The nursing process is a systematic, step-by-step method utilized to provide patient-centered care.
      1. Assessment
      2. Diagnosis
      3. Planning
      4. Implementation
      5. Evaluation
      6. Critical Thinking (often incorporated throughout all steps)

  • The nursing process is employed daily in nursing practice and applicable in everyday life.

  • It facilitates organized, safe, and effective care.

What is Different in Mental Health Nursing?

  • Although the same nursing process is employed, mental health nursing includes additional components, particularly during the assessment phase.

Phase 1: Assessment (MOST IMPORTANT IN MENTAL HEALTH)

Additional Mental Health Assessment Components:

  • Psychosocial History

  • Cultural Beliefs & Practices

  • Spiritual/Religious Beliefs

  • Mental Status Examination (MSE):
      - Level of Consciousness
      - Appearance
      - Behavior
      - Cognitive Abilities
      - Intellectual Functioning

Standardized Screening Tools:

  • Mini-Mental State Exam (MMSE)

  • Glasgow Coma Scale (GCS)

Lifespan Considerations:

Children & Adolescents:
  • Temperament

  • Social/Environmental Influences

  • Developmental Level

  • Cultural/Religious Factors

Older Adults:
  • Functional Ability

  • Economic/Social Status

  • Geriatric Assessment Tools

  • Pain Assessment

Environment for Assessment:

  • Choosing an appropriate setting, including:
      - Quiet, private space
      - Adequate lighting
      - Sitting or standing at patient’s level
      - Introducing oneself to the patient
      - Asking for name preference
      - Utilizing therapeutic touch (if appropriate)

Key Questions to Ask:

  • Sleep Patterns

  • Incontinence

  • Falls

  • Depression

  • Dizziness

  • Energy Levels

Include:
  • Family/Significant Others (when appropriate)

  • Summarizing findings

  • Asking for patient feedback

Phase 2: Nursing Diagnosis

  • Nursing diagnoses are established based on assessment data.

  • Utilizes DSM-5 (Diagnostic and Statistical Manual of Mental Disorders).

Purpose of DSM-5:

  • To identify mental health disorders

  • To guide assessment

  • To assist in planning care

  • To support nursing diagnoses

Phase 3: Planning

  • Development of patient-centered goals takes place in this phase.

  • Prioritization based on:
      - Safety
      - Patient Needs
      - Severity of Condition

Phase 4: Implementation

Common Mental Health Interventions:

  • Counseling/Therapeutic Communication

  • Promotion of Self-Care

  • Psychological Interventions

  • Psychobiological Treatments (Medications)

  • Cognitive & Behavioral Therapies

  • Health Promotion & Maintenance

Phase 5: Evaluation

  • Evaluation phase involves determination of whether established goals were met.

  • Modify the care plan if needed.

  • Continuous reassessment is essential.

Critical Thinking in Nursing

  • Critical thinking is employed throughout all phases of the nursing process.

  • It helps to:
      - Prioritize care
      - Make clinical decisions
      - Adapt interventions

Patient Problem Statement Components

  • A complete problem statement consists of:
      - Problem (nursing diagnosis)
      - Etiology (cause)
      - Signs/Symptoms (evidence)

NCLEX-Style Priority Question Concept

Key Strategy:

  • Look for “PRIORITY” in patient scenarios.

Example Question Focus:
  • First action during the initial interview?

Correct Priority:

  • Identify the client’s perception of their mental health status.

Not Priority Initially:

  • Coordinating services

  • Teaching

  • Including family (unless necessary)

Always assess the patient's perspective FIRST.