Rationale

The assessment interview, which requires linguistically and culturally effective communication skills, interviewing, behavioral observation, record review, and comprehensive assessment of the patient and relevant systems, enables the psychiatric–mental health nurse to make sound clinical judgments and plan appropriate interventions with the patient.

Key Elements

Identify the patient’s reason for seeking help.

Assess for risk factors related to the patient’s safety, including potential for the following:

In the assessment phase, information is obtained from the patient in a direct and structured manner through observations, interviews, and examinations. An assessment tool or nursing history form can provide a systematic format that becomes part of the patient’s written record. It should include the mental status examination (see Chapter 6).

The nurse also should use the most appropriate behavioral rating scales. These can help define current pretreatment aspects of the patient’s problems, increase the patient’s involvement in treatment, document the patient’s progress over time and the efficacy of the treatment plan, and compare the patient’s responses with those of groups of people with the same illness. This information can help formulate diagnoses and treatment plans, as well as document clinical outcomes of care.

The patient data identified in Standard 1 relate to all parts of the Stuart Stress Adaptation Model used in this text: predisposing factors, precipitating stressors, appraisal of stressors, coping resources, coping mechanisms, and coping responses as described in Chapter 3. The baseline data should include both content and process, and the patient is the ideal source of validation. The nurse should select a private place, free from noise and distraction, in which to interview the patient.

Interviewing is a goal-directed method of communication. It is required in a formal admission procedure and should be focused but open ended, progressing from general to specific and allowing spontaneous patient self-expression. The nurse’s role is to maintain the flow of the interview and to listen to the verbal and nonverbal messages conveyed by the patient. Nurses also must be aware of their responses to the patient.

Although the patient should be regarded as the primary source of validation, the nurse should be prepared to talk with family members or other people knowledgeable about the patient. This is particularly important when the patient is unable to provide reliable information because of the symptoms of the psychiatric illness. The nurse also might consider using a variety of other information sources, including the patient’s health care record, nursing rounds, change-of-shift reports, nursing care plan, and evaluation by other health professionals, such as psychologists, social workers, or psychiatrists.

Rationale

The basis for providing psychiatric–mental health nursing care is the recognition and identification of patterns of response to actual or potential psychiatric illnesses, mental health problems, and potential comorbid physical illnesses.

Key Elements

After collecting all data, the nurse compares the information with documented norms of health and adaptation. Because standards of behavior are culturally determined, the nurse should consider both the patient’s individual characteristics and the characteristics of the larger social group to which the patient belongs. The nurse then analyzes the data and derives a nursing diagnosis. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes (NANDA, 2009).

The subject of nursing diagnoses is the patient’s behavioral response to stress. This response may lie anywhere on the coping continuum from adaptive to maladaptive. Phenomena of concern to psychiatric nurses are listed in Box 11-1.

Nursing interventions are based on the nursing assessment as well as the medical evaluation to ensure a coordinated plan of treatment. Therefore, when formulating nursing diagnoses and using the nursing process, nurses also should be familiar with medical diagnoses and treatment plans.

A medical diagnosis is the health problem or disease state of the patient. In the medical model of psychiatry the health problems are mental disorders or mental illnesses that are classified in the DSM-IV-TR, which describes the symptoms of mental disorders (APA, 2000). Specific diagnostic criteria are provided for each mental disorder but causes of the disorders are not discussed.

Rationale

Within the context of providing nursing care, the ultimate goal is to influence mental health outcomes and improve the patient’s health status.

Key Elements

Patient outcomes may include relieving symptoms or improving functional ability. Sometimes a patient cannot identify specific goals or may describe them in general terms. Translating nonspecific concerns into specific goal statements is not easy. The nurse must understand the patient’s coping responses and the factors that influence them.

The patient’s goals may be inappropriate, undesirable, or unclear. However, the solution is not for the nurse to impose goals on the patient. Even if the patient’s desires seem to be against self-interests, the most the nurse can do is reflect the patient’s behavior and its consequences. If the patient then asks for help in setting new goals, the nurse can help. Mutually identifying goals and expected outcomes is an essential step in the therapeutic process.

In this process a well-intentioned nurse sometimes overlooks the patient’s goals and develops a treatment plan leading to an outcome that the nurse thinks is better. However, this is a mistake because the experience of working cooperatively with the nurse to identify mutually acceptable goals is extremely valuable. If the patient does not share the nurse’s goals, it is best to wait until the patient agrees on its importance. If this is not done the patient is not likely to adhere to the treatment plan and will be seen as noncompliant.

Once overall goals are agreed on, the nurse must state them explicitly. Expected outcomes are derived from diagnoses, guide later nursing actions, and enhance the evaluation of care. Each goal is stated as an observable behavior and includes the period of time in which it is to be accomplished and any other conditions. Expected outcomes can be documented using standardized classification systems, such as the Nursing Outcomes Classification (NOC) (Moorhead et al, 2008). Long- and short-term goals should contribute to the expected outcomes. Following is a sample expected outcome and long- and short-term goals:

In writing goals, psychiatric nurses should remember that they can be classified into the “ABCs,” or three domains, of knowledge:

Correctly identifying the domain of the expected outcome is very important in planning nursing interventions. Some psychiatric nurses place all their emphasis on outcomes related to learning new information (cognitive). They forget about the equally important needs of patients to acquire new values (affective) and to master new skills (behavior).

For example, it would be of limited help to teach a patient about medication if the patient did not value taking medications based on a personal belief system or previous life experiences. It would be equally unsuccessful to engage in medication education if the patient did not know how to take public transportation to fill the prescription.

Finally, it is important to explore with the patient the cost/benefit effect of all identified goals, that is, what is being given up (cost) versus what is being gained (benefit) from attaining the goal. This can be thought of as exploring advantages, or positive effects, and disadvantages, or negative effects.

Patients are not likely to commit themselves to a goal or to work toward attaining a goal if the stakes are too high or the payoffs too low. Exploring advantages and disadvantages helps the patient anticipate what price will be paid to achieve the goal and then decide if the change is worth the cost to oneself or significant others. Sometimes it is helpful to write these down in the form of two columns (advantages and disadvantages) that can be added to or changed at any time.

Rationale

A plan of care is used to guide therapeutic interventions systematically, document progress, and achieve the expected patient outcomes.

Key Elements

One of the most important tasks for the nurse and patient is to assign priorities to the goals. Those goals related to protecting the patient from self-destructive impulses always receive top priority. Because the nursing care plan is dynamic, priorities are constantly changing. If the focus is always on the patient’s behavioral responses, priorities can be modified as the patient changes. If the goal answers the question of what, the plan of care answers the questions of how and why. Once again, the patient’s active involvement leads to a more successful care plan.

After writing a tentative care plan, the nurse must validate this plan with the patient. This communicates to the patient a sense of self-responsibility for getting well. The patient can tell the nurse that a proposed plan is unrealistic based on financial status, lifestyle, value system, culture or, perhaps, personal preference. Usually several approaches to a patient’s problem are possible. Choosing the one most acceptable to the patient improves the chances for success. Failure to reach a goal through one plan can lead to the decision to adopt a new approach or re-evaluate the goal.

Rationale

In implementing the plan of care, psychiatric–mental health nurses use a wide range of interventions designed to prevent mental and physical illness and to promote, maintain, and restore mental and physical health. Psychiatric–mental health nurses select interventions according to their level of practice.

At the basic level nurses may select counseling, milieu therapy, promotion of self-care activities, intake screening and evaluation, psychobiological interventions, health teaching, case management, health promotion and health maintenance, crisis intervention, community-based care, psychiatric home health care, telehealth, and a variety of other approaches to meet the mental health needs of patients.

In addition to the intervention options available to the basic-level psychiatric–mental health nurse, at the advanced level the advanced practice registered nurse in psychiatric–mental health (APRN-PMH) may provide consultation, engage in psychotherapy, and prescribe pharmacological agents where permitted by state statutes or regulations.

Key Elements

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