Nursing Process & Nurse Patient Relationship

Front 1

Assessment in psychiatric environment

Back 1

mental status assessment helps nurse develop treatment plan
collect info from outside sources
history of any previous MH issues

Front 2

Diagnosis in psychiatric environment

Back 2

Clients reaction to stressor R/T actual stressor/biochem imbalance AMB symptoms

Front 3

Planning in psychiatric environment

Back 3

individualized
identifies goals

Front 4

Identification of goals in psychiatric environment

Back 4

ex pt will identify 3 side effects of Paxil medication prior to discharge

Front 5

Implementation in psychiatric environment

Back 5

counseling, education/teaching, somatic therapies (meds or ECT), promote self care activities, music/OT/RT therapies, promote therapeutic milieu, behavior modification, group therapy

Front 6

Evaluation in psychiatric environment

Back 6

continuous process of effectiveness of interventions
share w/pt plan of action post discharge

Front 7

ABCD of documentation

Back 7

A = Appearance document objectively, dressed in a gown, hair combed, etc
B = Behavior – borrowed from mental health assessment (calm, agitated, slow movements, isolating themselves, out interacting w/peers
C = Conversation – client concerns, what did you meet w/pt about – for brief assessment, anxiety, specific stressor, health/med teaching, any significant event mentioned
D = Diagnoses – continued suicide thoughts, problems eating, sleeping

Front 8

6 roles of the psychiatric nurse according to Peplau include:

Back 8

Stranger
Resource person
Teacher
Leader
Surrogate
Counselor

Front 9

4 phases of nurse-patient relationship include:

Back 9

Preinteraction
Orientation or Introductory
Working
Termination

Front 10

Preinteraction phase of nurse-patient relationship

Back 10

preparation before encounter w/patient (chart, signficant others, staff)

Front 11

Orientation or introductory phase of nurse-patient relationship

Back 11

nurse & patient become acquainted, trust started to be built and rapport. Establish treatment contract – what will be done together, expectations & responsibilities of both. Nurse gathers further assessment data, identifies strengths/weakness/limits. Nursing diagnoses formed, goals set, plan of action begun. Explore feelings of anxiety.

Front 12

working phase of nurse-patient relationship

Back 12

trust & rapport maintained. Promote insight and perception of reality. Problem solving “the do part of it”, education, continuous evaluations on how goals are met or addressed. Confrontation to overcome resistance may be used in this phase.

Front 13

termination phase of nurse-patient relationship

Back 13

pt discharged, shift ends, goals are met and task in termination is to bring therapeutic relationship to a close, plan for continuous care or care after discharge, review progress made, address feelings about relationship terminating, review plans for discharge

Front 14

essential component of nurse-client relationship

Back 14

empathy

Front 15

4 parts to mental health assessment

Back 15

identifying data
general description
emotions
thought processes

Front 16

examples of information to gather for identifying data part

Back 16

1.Name, gender
2.Age – how old are you or when were you born
3.Race/culture
4.Occupational/financial status
5.Educational level
6.Significant other
7.Living arrangements
8.Religious preference
9.Allergies
10.Special diet considerations
11.Chief complaint
12.Medical diagnosis

Front 17

examples of information to gather for general description part

Back 17

1. Appearance
2. Grooming & appropriate dress
3. Hygiene
4. Distinguishing marks
5. Bruising
6. Tattoos (count)
7. Piercings (count)
8. Eye contact (not looking at all or staring constantly)
9. Motor activity – tremors, mannerisms, nail biting, hyperactivity, restlessness or agitation, aggressiveness, rigidity, gait patterns, echopraxia (mimicking actions of others), psychomotor retardation (slow movements, speech, thought), freedom of movement
10. Speech patterns – slowness or rapidity of speech, pressure of speech, intonation, volume, stuttering or other impairments, aphasia
11. General attitude – cooperative/uncooperative, friendly/hostile/defensive, uninterested/apathetic, attentive/interested, guarded/suspicious

Front 18

examples of information to gather for emotions part

Back 18

1. Mood – depressed, irritable, anxious, elated, euphoric, fearful, guilty, labile
2. Affect – outward emotional expression is consistent with mood, constricted/blunted, flat, appropriate/inappropriate

Front 19

examples of information to gather for thought processes part

Back 19

form of thought
contents of thought - delusions, suicidal, obsessions
hallucinations
LOC & memory
judgment

Front 20

how to handle suicidal/homicidal question

Back 20

• suicide/homicide thoughts – start by saying I know you’ve been dealing with this ___ for awhile now, have you ever thought about hurting yourself or others? If so, see if they have a plan