The Nursing Process in Psychiatric/Mental Health Nursing
· Mental Status Exam
o Appearance
o Behavior
o Speech & language
o Mood
o Affect
o Thought process
o Thought content
o Suicidal/homicidal
o Cognition/dementia/I. Q.
o Insight/judgement
· Brief Mental status examination:
o Orientation to time
o Orientation to Place
o Attention and immediate recall
o Recent memory
o Naming Objects
o Ability to follow simple verbal commands
o Ability to follow simply written commands
o Ability to use language correctly
o Ability to concentrate
o Understanding spatial relationships
· Standards of practice
The nursing process is used for critical thinking and integrates professional standards
Counseling interventions are differentiated from psychotherapy (which is performed by advanced practice nurses)
Support use of the recovery model (we assist everyone in their own recovery journey)
· Nursing Case Management
o A model of care delivery that results in improved client care.
o This type of health care delivery process serves to decrease fragmented care while also containing cost of services.
o It can assist individuals in problem solving, improving their work and socialization skills, promotes activates, and enhancing their independence.
o Managed Care
o Case Manager
· Critical Pathways of Care
o Used as a tool for care in the case management system
o An abbreviated care plan that provides guidelines for goal achievement within a designated length of stay
o Improves quality and safety for the patient
· Documentation in mental health nursing
o Documentation is very important in nursing!
ALWAYS document on the patient's behavior
ALWAYS document on notifying the doctor of important information or issues
ALWAYS document signs and symptoms the patient is experiencing (hallucinations, SI/HI, etc.)
ALWAYS document skin assessments/contraband searches
You can document what the patient tells you (Ex. Patient stated he is tired of this life).
“ADOPIE”