Chapter 4 Application of the Nursing Process to Mental Health Care

Open Resources for Nursing (Open RN); Kimberly Ernstmeyer; Elizabeth Christman

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing: Mental Health and Community Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

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Nursing: Mental Health and Community Concepts [Internet].

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Chapter 4 Application of the Nursing Process to Mental Health Care

4.1. INTRODUCTION

Learning Objectives

Apply the nursing process to mental health care
Describe nursing assessments when providing mental health care
Incorporate respectful and equitable practice
Consider developmental levels when providing care
Identify common nursing diagnoses/problems related to mental health conditions
Promote a therapeutic environment
Apply the subcategories of the Implementation standard of care to mental health care
Create effective nursing care plans for clients with various mental health disorders
Compare NCLEX Next Generation terminology to the nursing process

Psychiatric-mental health nursing is, “The nursing practice specialty committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the life span. Psychiatric-mental health nursing intervention is an art and a science, employing a purposeful use of self and a wide range of nursing, psychosocial, and neurobiological evidence to produce effective outcomes.” [1]

In 2014 the American Psychiatric Nurses Association (APNA) and the International Society of Psychiatric-Mental Health Nurses (ISPN) published the Psychiatric-Mental Health Nursing: Scope and Standards of Practice resource in alignment with the second edition of the ANA’s Nursing: Scope and Standard of Practice Nursing. The Psychiatric-Mental Health Nursing: Scope and Standards of Practice resource guides psychiatric-mental health nurses in the application of their professional skills and responsibilities and should be reviewed in conjunction with state Board of Nursing policies and practices that govern the practice of nursing. [2] The Standards of Practice for Psychiatric-Mental Health Nursing mirror the ANA Standards of Professional Nursing Practice of Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation, but also have additional competencies for Psychiatric-Mental Health Registered Nurse Specialists (PMH-RNs) and Advanced Practice Registered Nurse Specialists (PMH-APRNs) and additional components for the Implementation standard of care.

This chapter will review how nurse generalists apply the nursing process and the ANA Standards of Professional Nursing Practice to clients experiencing a mental health condition. Assessments, nursing diagnoses, expected outcomes, and interventions pertaining to mental health will be reviewed while incorporating life span and cultural considerations. For specific assessments, nursing diagnoses, expected outcomes, and interventions related to specific mental health conditions, see each corresponding “disorder” chapter.

References

1.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
2.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.

4.2. APPLYING THE NURSING PROCESS

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [1]

The mnemonic ADOPIE is an easy way to remember the six ANA standards regarding the nursing process. Each letter refers to one of the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation. The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.1 [2] for an illustration of the nursing process.

Figure 4.1

The Nursing Process

Review using the nursing process in the “Nursing Process” chapter in Open RN Nursing Fundamentals.

References

1.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
2.: “The Nursing Process” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0.

4.3. ASSESSMENT

The Assessment Standard of Practice established by the American Nurses Association (ANA) states, “The registered nurse collects pertinent data to the health care and information relative to the health care consumer’s health or the situation.” [1] Review the competencies for the Assessment Standard of Practice for registered nurses in the following box.

ANA’s Assessment Competencies [2]

The registered nurse:

Creates the safest environment possible for conducting assessments.
Collects pertinent data related to health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, the inherent dignity, worth, and unique attributes of every person, including, but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.
Utilizes a health and wellness model of assessment that incorporates integrative approaches to data collection and honors the whole person.
Recognizes the health care consumer or designated person as the decision-maker regarding their own health.
Explores the health care consumer’s culture, values, preferences, expressed and unexpressed needs, and knowledge of the heath care situation.
Assesses the impact of family dynamics on the health care consumer’s health and wellness.
Identifies enhancements and barriers to effective communication based on personal, cognitive, physiological, psychosocial, literacy, financial, and cultural considerations.
Engages the health care consumer, family, significant others, and interprofessional team members in holistic, culturally sensitive data collection.
Integrates knowledge from current local, regional, national, and global health initiatives and environmental factors into the assessment process.
State and local departments of health
Prioritizes data collection based on the health care consumer’s immediate condition, the anticipated needs of the health care consumer or situation, or both.
Uses evidence-based assessment techniques and available data and information to identify patterns and variances in the consumer’s health.
Remains knowledgeable about constantly changing technologies that impact the assessment process (e.g., telehealth, artificial intelligence).
Analyzes assessment data to identify patterns, trends, and situations that impact the person’s health and wellness.
Validates the analysis with the health care consumer.
Documents data accurately and makes accessible to the interprofessional team in a timely manner.
Communicates changes in a person’s condition to the interprofessional team.
Applies the provisions of the ANA Code of Ethics, legal guidelines, and policies to the collection, maintenance, use, and dissemination of data and information.
Recognizes the impact of one’s own personal attitudes, values, beliefs, and biases on the assessment process.

Review the components of a nursing assessment in the “Nursing Process” chapter of Open RN Nursing Fundamentals.

Nursing assessments related to mental health disorders differ from physiological assessments with a greater focus on collecting subjective data. For example, prior to administering a cardiac medication to a client with a heart condition, a nurse will assess objective data such as blood pressure and an apical heart rate to determine the effectiveness of the medication treatment. However, prior to administering an antidepressant, a nurse uses therapeutic communication to ask questions and gather subjective data about how the patient is feeling to determine the effectiveness of the medication. The nurse will also observe client behaviors, speech, mood, and thought processes as part of the assessment.

As a nurse, you cannot directly measure a neurotransmitter to determine the effects of the medication, but you can ask questions to determine how your patient is feeling emotionally and perceiving the world, which are influenced by neurotransmitter levels. An example of a nurse using therapeutic communication to perform subjective assessment is, “Tell me more about how you are feeling today.” The nurse may also use general survey techniques such as simply observing the patient to assess for cues of behavior. Examples of objective data collected by a general survey could be assessing the patient’s mood, hygiene, appearance, or movement.

Recall the mental health continuum introduced in the “Foundational Mental Health Concepts” chapter (see Figure 4.2 [3]). Nurses in any setting holistically assess their clients’ physical, emotional, and mental health, as well as any impairments impacting their functioning. They must recognize subtle cues of undiagnosed or poorly managed physical and mental disorders and follow up appropriately with other members of the interprofessional health care team.

Figure 4.2

Mental Health Continuum (Used with permission.)

When assessing a client’s mental health, the nurse incorporates a variety of assessments, in addition to the traditional physical examination. Assessments may include the following:

Performing a mental status examination
Completing a psychosocial assessment
Reviewing the client’s use of psychotropic medications (drugs that treat psychiatric symptoms) and/or other medications that can cause psychiatric symptoms as side effects
Screening for suicidal ideation, exposure to trauma or violence, and substance misuse
Incorporating a spiritual assessment while assessing the client’s coping status
Incorporating life span, developmental, and cultural considerations
Reviewing specific laboratory results related to the client’s use of psychotropic and other medications

Mental Status Examination

Registered nurses must use effective clinical interviewing skills while performing a mental status assessment and developing a therapeutic nurse-client relationship. [4] Read more about establishing a therapeutic nurse-client relationship in the “Therapeutic Communication and the Nurse-Client Relationship” chapter. Assessing a client with a suspected or previously diagnosed mental health disorder focuses on both verbal and nonverbal assessments. New assessment findings are compared to the baseline admission findings to determine if the client’s condition is improving, worsening, or remaining the same.

When conducting a focused assessment on a client’s mental health, the mental status examination is a priority component of the overall assessment. A successful nurse develops a style in which the bulk of the mental status examination is performed through unstructured observations made during the routine physical examination, also referred to as the “general survey.” When the nurse recognizes cues of possible mental health disorders, such as aberrant behavior or difficulties in day-to-day functioning, then a focused mental status examination should be completed.

A mental status examination assesses a client’s level of consciousness and orientation, appearance and general behavior, speech, motor activity, affect and mood, thought and perception, attitude and insight, and cognitive abilities. The examiner should also monitor their personal reaction to a client when performing a mental status examination. The structured components of a mental status examination are outlined in Table 4.3 and further described in the following subsections.

Table 4.3

Mental Status Examination [5]

Read about the components of a general survey in the “General Survey” chapter of Open RN Nursing Skills.

Signs of Distress

If a client is exhibiting signs of distress during an examination, the nurse must quickly obtain focused assessment data and obtain additional assistance based on the level of emergency care required and agency policy. For example, if a client is found unresponsive, a “code” is typically called during inpatient care, or 911 is called in an outpatient setting as the nurse begins cardiopulmonary resuscitation (CPR). If a client is demonstrating difficulty breathing, new onset confusion, or other signs of a deteriorating condition, the rapid response team may be called, or other emergency assistance may be obtained per agency policy. Keep in mind that the emergency administration of naloxone may be required in cases of a suspected opioid overdose.

Level of Consciousness and Orientation

A normal level of consciousness is when the client is alert (i.e., the ability to respond to stimuli at the same level as most people) and oriented to person, place, and time. Clouded consciousness refers to a state of reduced awareness to stimuli. Delirium is an acute onset of an abnormal mental state, often with fluctuating levels of consciousness, disorientation, irritability, and hallucinations. Delirium is often associated with infection, metabolic disorders, or toxins in the central nervous system. Obtundation refers to a moderate reduction in the client’s level of awareness so that mild to moderate stimuli do not awaken the client. When arousal does occur, the patient is slow to respond. Stupor refers to unresponsiveness unless a vigorous stimulus is applied, such as a sternal rub. The client quickly drifts back into a deep sleep-like state on cessation of the stimulation. Coma refers to unarousable unresponsiveness, where vigorous noxious stimuli may not elicit reflex motor responses. For example, a client in a coma may not pull their foot away from a painful prick of their toe with a needle. When documenting reduced levels of consciousness, note the type of stimulus required to arouse the patient and the degree to which the patient can respond when aroused. [6]

Appearance and General Behavior

This component refers to an overall impression of the client, including their physical appearance regarding their age, grooming, dressing, posture, eye contact, ability to socialize with others, and general behaviors. There are several terms used to describe a client’s appearance and behavior. For example, the appearance of one’s age can be altered due to chronic illness and pain. Providers may document that a client “appears their stated age” or “appears older than their stated age.” Clients may be described as well-groomed (i.e., exhibit good hygiene) or disheveled (i.e., their hair, clothes, or hygiene appears untidy, disordered, unkempt, or messy). Their dress may be described as “appropriate” or “inappropriate” according to the weather and situation. A client’s posture may be described as “erect” or “slumped.” Clients may be described as having “good eye contact” (i.e., they maintain a direct gaze into the examiner’s eyes) or “poor eye contact” (i.e., they avoid direct eye contact). [7] Life span and cultural considerations must always be kept in mind when assessing a client’s appearance and general behavior. For example, some cultures consider direct eye contact disrespectful.

Speech

Evaluating speech as the client answers open-ended questions provides useful information. A client demonstrates normal speech when responding to verbal questions appropriately with an even rate, rhythm, and tone. Their speech is clear and understandable, and the client follows instructions appropriately.

Characteristics of speech can be described as normal, rapid, slow (i.e., delayed rhythm of conversation), loud, or soft. Stuttering and aphasia may occur. Examples of speech difficulties include lack of appropriate responses to verbal questions, rapid and/or pressured speech of a client experiencing mania or amphetamine intoxication, or halting speech of a client experiencing word-finding difficulties due to a previous stroke. [8]

Other terms used to describe speech include circumstantial (i.e., speaking with many unnecessary or tedious details without getting to the point of the conversation) and poverty of content (i.e., a conversation in which the client talks without stating anything related to the question, or their speech in general is vague and meaningless).

Motor Activity

Overall motor activity should be noted, including any tics or unusual mannerisms. Normal motor activity refers to the client having good balance, moving all extremities equally bilaterally, and walking with a smooth gait. Slow movements or lack of spontaneity in movement can occur due to depression or dementia. Dyskinesia (uncontrolled, involuntary movement) and akathisia (i.e., motor restlessness) may occur if the client is experiencing extrapyramidal syndrome related to psychotropic medication use. [9]

Terminology used to describe motor activity includes psychomotor agitation (i.e., a condition of purposeless, non goal-directed activity) and psychomotor retardation (i.e., a condition of extremely slow physical movements, slumped posture, or slow speech patterns).

Affect and Mood

Affect refers to the client’s expression of emotion, and mood refers to the predominant emotion expressed by an individual. [10] Sustained emotions influence a person’s behavior, personality, and perceptions. Mood can be described using various terms such as neutral, elevated, or labile (i.e., a rapid change in emotional responses, mood, or affect that are inappropriate for the moment or the situation). It can also be described as anxious, angry, sad, irritable, dysphoric (i.e., exhibiting depression), or euphoric (i.e., a pathologically elevated sense of well-being). People may express feelings of emptiness, impaired self-esteem, indecisiveness, or crying spells. [11]

Normal affect and mood are described as euthymic (i.e., displays a wide range of emotion that is appropriate for the situation). Abnormal findings related to affect include inappropriateness for the situation (e.g., laughing at the recent death of a loved one) or incongruent. Congruence refers to the consistency of verbal and nonverbal communication. Affect may also be described as subdued, tearful, labile, blunted (i.e., diminished range and intensity), or flat (no emotional expression).

Other terminology related to documenting a client’s mood includes alexithymia (i.e., the inability to describe emotions with how one is feeling), anhedonia (i.e, the lack of experiencing pleasure in activities normally found enjoyable), and apathy (i.e., a lack of feelings, emotions, interests, or concerns).

Thoughts and Perceptions

The manner in which a client perceives and responds to stimuli is a critical psychiatric assessment. The inability to process information accurately is a component of the definition of psychotic thinking. For example, does the client harbor realistic concerns or are their concerns elevated to the level of irrational fear? Is the client responding in an exaggerated fashion to actual events? Is there no discernible basis in reality for the patient’s beliefs or behavior? [12]

Clients with mental health disorders may experience intrusive thoughts, delusions, and/or obsessions. Delusions are a fixed, false belief not held by cultural peers and persisting in the face of objective contradictory evidence. For example, a client may have the delusion that the CIA is listening to their conversations via satellites. Grandiose delusions refer to a state of false attribution to the self of great ability, knowledge, importance or worth, identity, prestige, power, or accomplishment. [13] Clients may withdraw into an inner fantasy world that’s not equivalent to reality, where they have inflated importance, powers, or a specialness that is opposite of what their actual life is like. [14] Paranoia is a condition characterized by delusions of persecution. [15] Clients often experience extreme suspiciousness or mistrust or express fear. For example, a resident of a long-term care facility may have delusions that the staff is trying to poison them.

Obsessions are persistent thoughts, ideas, images, or impulses that are experienced as intrusive or inappropriate and result in anxiety, distress, or discomfort. Common obsessions include repeated thoughts about contamination, a need to have things in a particular order or sequence, repeated doubts, aggressive impulses, and sexual imagery. Obsessions are distinguished from excessive worries about everyday occurrences because they are not concerned with real-life problems. [16] Rumination is obsessional thinking involving excessive, repetitive thoughts that interfere with other forms of mental activity. [17]

Clients may also experience altered perceptions such as hallucinations and illusions. Hallucinations are false sensory perceptions not associated with real external stimuli and can include any of the five senses (auditory, visual, gustatory, olfactory, and tactile). For example, a client may see spiders climbing on the wall or hear voices telling them to do things. These are referred to as “visual hallucinations” or “auditory hallucinations.”

Illusions are misperceptions of real stimuli. For example, a client may misperceive tree branches blowing in the wind at night to be the arms of monsters trying to grab them.

It is important for nurses to remember that delusions, hallucinations, and illusions feel very real to clients and cause internal emotional reactions, even when a caregiver reassures them they are not based in reality. Because clients often conceal these experiences, it is helpful to ask leading questions, such as, “Have you ever seen or heard things that other people could not see or hear? Have you ever seen or heard things that later turned out not to be there?” [18]

Other terms used to document clients’ thought processes include racing thoughts, flight of ideas, loose associations, and clang associations. Racing thoughts are fast moving and often repetitive thought patterns that can be overwhelming. They may focus on a single topic, or they may represent multiple different lines of thought. For example, a client may have racing thoughts about a financial issue or an embarrassing moment.

Flight of ideas indicates the client frequently shifts from one topic to another with rapid speech, making it seem fragmented. The examiner may feel the client is rambling and changing topics faster than they can keep track, and they probably can’t get a word in edgewise. [19] An example of client exhibiting a flight of ideas is, “My father sent me here. He drove me in a car. The car is yellow in color. Yellow color looks good on me.” [20]

Loose associations refers to jumping from one idea to an unrelated idea in the same sentence. For example, the client might state, “I like to dance, and my feet are wet.” [21] The term word salad refers to severely disorganized and virtually incomprehensible speech or writing, marked by severe loosening of associations. [22]

Clang associations refers to stringing words together that rhyme without logical association and do not convey rational meaning. For example, a client exhibiting clang associations may state, “Here she comes with a cat catch a rat match.”

Clients with altered perceptions, especially when experiencing hallucinations and delusions, may have violent thoughts regarding themselves or others. If a client is having auditory hallucinations, it is vital for the nurse to determine if the voices are encouraging the client to hurt themselves or others. Homicidal ideation refers to threats or acts of life-threatening harm toward another person. Suicidal ideation is used to describe an individual who has been thinking about suicide but does not necessarily have an intention to act on that idea. Suicide attempt is a term used to describe an individual who harms themselves with intent to end their life but does not die as a result of their actions. Suicide plan refers to an individual who has a plan for suicide, has the means to injure oneself, and has the intent to die.

Of all portions of the mental status examination, the evaluation of thought disorders is the most difficult and requires a thorough assessment. [23] Psychiatric-mental health nurse specialists receive additional training in assessing thought disorders. These types of thought disorders are associated with mental illnesses like bipolar disorder and schizophrenia and may precede an episode of psychosis, so it is important to obtain further assistance if you notice a client is newly exhibiting these types of behaviors. [24]

Read more information about how to help individuals experiencing hallucinations and delusions in the “Applying the Nursing Process to Schizophrenia” section of the “Psychosis and Schizophrenia” chapter.

Attitude and Insight

The client’s attitude is the emotional tone displayed toward the examiner, other individuals, or their illness. It may convey a sense of hostility, anger, helplessness, pessimism, overdramatization, self-centeredness, or passivity. It is important to determine the client’s attitude toward emotional problems or diagnosed mental health disorders. Does the client look forward to improvement and recovery or are they resigned to suffer? [25]

Insight is the client’s ability to identify the existence of a problem and to have an understanding of its nature.

Nurses must also be aware of transference. Transference occurs when the client projects (i.e., transfers) their feelings onto the nurse. For example, a client is feeling angry at a family member related to a previous disagreement and displaces the anger onto the nurse during the interview.

Cognitive Abilities

Cognition is the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. It includes thinking, knowing, remembering, judging, and problem-solving. When performing focused assessments on cognition, the examiner assesses attention and memory. [26] A term related to assessing attention is distractibility, referring to the client’s attention being easily drawn to unimportant or irrelevant external stimuli.

Memory disturbance is a common complaint and is often a presenting symptom in the elderly. Memory can be grouped into three categories: immediate recall, short-term memory, and long-term storage. Short-term memory is the most clinically pertinent, and the most important to be tested. Short-term retention requires that the patient process and store information so that they can move on to a second intellectual task and then call up the remembrance after completion of the second task. For example, short-term memory may be tested by having the patient repeat the names of four unrelated objects and then asking the patient to recall the information in 3 to 5 minutes after performing a second, unrelated mental task. [27]

Examiner’s Reaction to the Client

Assessing a client sometimes results in the nurse developing subtle and easily overlooked feelings toward the client. For example, it can be difficult to repeatedly address a client’s negative state. Examiners may experience feelings of frustration, which can be taken by patients to mean there’s something wrong with them. In such cases, nurses should examine their reactions to the client and be alert to feelings of distraction, boredom, or frustration. They should also be aware that clients perceive a nurse’s feelings through their nonverbal communication, such as facial expressions, posture, tone of voice, and lack of eye contact. [28]

Nurses should also be aware of countertransference. Countertransference refers to a tendency for the examiner to displace (transfer) their own feelings onto the client and then these feelings may influence the client. For example, a nurse finds themself providing advice about how to raise children to a client. Upon self-reflection, they realize it is a countertransference reaction related to their previous parenting experience. [29]

Review a brief mental status examination PDF form from TherapistAid.

Psychosocial Assessment

A psychosocial assessment (also referred to as a health history) is a component of the nursing assessment process that obtains additional subjective data to detect risks and identify treatment opportunities and resources. Agencies have specific forms used for psychosocial assessments/health histories that typically consist of several components [30],[31]:

Cultural assessment
Reason for seeking health care (i.e., “chief complaint”)
Thoughts of self-harm or suicide
Current and past medical history
Current medications
History of previously diagnosed mental health disorders
Previous hospitalizations
Educational background
Occupational background
Family dynamics
History of exposure to psychological trauma, violence, and domestic abuse
Substance use (tobacco, alcohol, recreational drugs, misused prescription drugs)
Family history of mental illness
Coping mechanisms
Functional ability/Activities of daily living
Spiritual assessment

Review specific questions used during a psychosocial assessment/health history in the “Health History” chapter in Open RN Nursing Skills.

Cultural Formulation Interview Questions

While performing a psychosocial assessment, it is important to begin by performing a cultural assessment. We all bring our own cultural beliefs, values, and expectations to the clinical encounter, which influences how we approach specific aspects of care. The American Psychiatric Association developed evidence-based Cultural Formulation Interview (CFI) questions as a way to incorporate cultural assessment into the care of all clients that enhances clinical understanding and decision-making. [32] The CFI questions are used to clarify key aspects of the presenting clinical problem from the point of view of the individual and other members of the individual’s social network (e.g., family, friends, or others involved in the current problem). This includes the problem’s meaning, potential sources of help, and expectations for health care services.

CFI questions used with all clients include the following [33]:

1.: What brings you here today?
2.: What troubles you most about this problem?
3.: Why do you think this is happening to you? What do you think is the cause of this problem?
4.: Are there any kinds of support that make this problem better, such as support from family, friends, or others?
5.: Are there any kinds of stresses that make this problem worse, such as difficulties with money or family problems?
6.: Sometimes aspects of people’s background or identity can make their problem better or worse, such as the communities they belong to, the languages they speak, where they or their family are from, their race or ethnic background, their gender or sexual orientation, or their faith or religion. Are there any aspects of your background or identity that make a difference to this problem?
7.: Sometimes people have various ways of dealing with problems. What have you done on your own to cope with this problem?
8.: Often, people look for help from many different sources, including different kinds of doctors, helpers, or healers. In the past, what kinds of treatment, help, advice, or healing have you sought for this problem?
9.: Has anything prevented you from getting the help you need?
10.: What kinds of help do you think would be most useful to you at this time for this problem?
11.: Are there other kinds of help that your family, friends, or other people have suggested that would be helpful for you now?
12.: Sometimes health care professionals and patients misunderstand each other because they come from different backgrounds or have different expectations. Have you been concerned about misaligned care expectations and is there anything that we can do to provide you with the care you need?

Findings from the cultural formulation interview are used to individualize a client’s plan of care to their preferences, values, beliefs, and goals.

Reason for Seeking Health Care

It is helpful to begin the psychosocial assessment by obtaining the reason why the patient is seeking health care in their own words. During a visit to a clinic or emergency department or on admission to a health care agency, the patient’s primary reasons for seeking care are referred to as the chief complaint. Assessing a client’s chief complaint recognizes that clients are complex beings, with potentially multiple coexisting health needs, but there is often a pressing issue that requires most immediate care. Questions used to evaluate a client’s chief complaint are as follows:

What brought you in today?
How long has this been going on?
How is this affecting you?

After identifying the reason the patient is seeking health care, additional focused questions are used to obtain detailed information about priority concerns, such as pain or other symptoms causing discomfort. The mnemonic PQRSTU is used to ask the patient questions in an organized fashion. See Table 4.3b for examples of questions used to assess a client’s report of pain.

Table 4.3b

Sample PQRSTU Questions

Thoughts of Suicide

As discussed in Chapter 1, all clients aged 12 and older presenting for acute care should be screened for suicidal ideation. Clients being evaluated or treated for mental health conditions often have suicidal ideation, and up to 10 percent of emergency department clients presenting with medical issues have a hidden risk for suicide, such as recent suicidal ideation or previous suicide attempts. [34] Universal screening allows for the detection of suicide risk and implementation of early interventions before a person attempts suicide.

It is important to introduce suicide screening in a way that helps the patient understand its purpose and normalize questions that might otherwise seem intrusive. A nurse might introduce the topic in the following way: “Now I’m going to ask you some questions that we ask everyone treated here, no matter what problem they are here for. It is part of the hospital’s policy, and it helps us to make sure we are not missing anything important.” [35]

The Patient Safety Screener (PSS-3) is an example of a brief screening tool to detect suicide risk in all patients presenting to acute care settings. [36] See Figure 4.3 [37] for an image of the PSS-3.

Figure 4.3

Patient Safety Screener for Suicide Risk. Used under Fair Use.

The PSS-3 consists of assessing for three items: depression, active suicidal ideation, and lifetime suicide attempt. Each of these items taps a different aspect of suicide risk [38]:

Depression is a common precipitant of suicidal ideation and behavior and is the most common diagnosis among those who die by suicide.
Suicidal ideation (i.e., thoughts about killing oneself) is a precondition for suicidal behavior.
A previous suicide attempt is one of the most consistent risk factors for suicide.

Self-Injury

Non-suicidal self-injury (NSSI) refers to intentional self-inflicted destruction of body tissue without suicidal intention and for purposes not socially sanctioned. Common forms of NSSI include behaviors such as cutting, burning, scratching, and self-hitting. It is considered a maladaptive coping strategy without the desire to die. NSSI is a common finding among adolescents and young adults in psychiatric inpatient settings. [39]

Family Dynamics

Family dynamics are included in a psychosocial assessment, especially for children, adolescents, and older adults. Family dynamics refers to the patterns of interactions among relatives, their roles and relationships, and the various factors that shape their interactions. Because family members rely on each other for emotional, physical, and economic support, they are primary sources of relationship security or stress. Family dynamics and the quality of family relationships can have either a positive or negative impact on an individual’s health. For example, secure and supportive family relationships can provide love, advice, and care, whereas stressful family relationships can be burdened with arguments and constant critical feedback. [40]

Unhealthy family dynamics can cause children to experience trauma and stress as they grow up. This type of exposure, known as adverse childhood experiences (ACEs), is linked to an increased risk of developing physical and mental health problems such as heart, lung, and liver disease; depression; and anxiety. Unhealthy family dynamics also correlate with an increased risk of substance use and addiction among adolescents. [41]

Review information about adverse childhood experiences (ACEs) in the “Mental Health and Mental Illness” section of Chapter 1.

Effectively assessing and addressing a client’s family dynamic and its role in health and disease require an interprofessional team of health professionals, including nurses, physicians, social workers, and therapists. Nurses are in a unique position to observe and document interaction patterns, assess family relationships, and tend to family concerns in the clinical setting because they are in frequent contact with family members. [42]

Spiritual Assessment

Spiritual assessment is included in a psychosocial assessment. It is common for people in the process of recovery from mental health disorders and substance use to search for spiritual support. [43] Spirituality includes a sense of connection to something larger than oneself and typically involves a search for meaning and purpose in life. Basic questions used to assess spirituality include the following:

Who or what provides you with strength or hope?
How do you express your spirituality?
What spiritual needs can we advocate for you during this health care experience?

Over the past decade, research has demonstrated the importance of spirituality in health care. [44],[45] Spiritual distress is very common for clients experiencing serious illness, injury, or the dying process, and nurses are on the front lines as they assist these individuals to cope with these life events. Addressing a patient’s spirituality and advocating spiritual care have been shown to improve patients’ health and quality of life, including how they experience pain, cope with stress and suffering associated with serious illness, and approach end of life. [46],[47]

The FICA Spiritual History Tool© is a common tool used to gather information about a patient’s spiritual history and preferences. [48] FICA© is a mnemonic for Faith, Importance, Community, and Address in Care. Read more about the FICA© tool in the following box.

The FICA© Spiritual History Tool [49]

F – Faith and Belief: Determine if the patient identifies with a particular belief system or spirituality.

I – Importance: Ask, “Is this belief important to you? Does it influence how you think about health and illness? Does it influence your health care decisions?”

C – Community: Determine if the client belongs to a spiritual community (e.g., a church, temple, mosque, or other group). If not, ask, “Would it be helpful to you to find a spiritual community?”

A – Address in Care: Evaluate what should be addressed during the client’s care. Ask, “What should be included in your treatment plan? Are there spiritual practices you want to develop? Would you like to see a chaplain, spiritual director, or pastoral counselor while you are here?”

Based on the assessment findings, nurses may refer clients to agency chaplains or to the client’s religious leaders for spiritual support to enhance coping.

Screening Tools

Screening tools are evidence-based methods to assess specific information related to mental health disorders. These tools may be used on admission to the hospital or treatment facility, as well as at different times throughout the client’s stay. Findings may be used to compare client progress during the hospital stay or from a previous admission. The registered nurse often conducts these screening tools as part of the interprofessional health care treatment team. Read more about specific screening tools in each “disorder” chapter.

Laboratory and Diagnostic Testing

Nurses review laboratory and diagnostic testing results as part of the assessment process.

Nurses monitor electrolytes and medication levels as they evaluate the need for medication adjustment. For example, serum sodium levels may be out of range due to conditions such as polydipsia, and poor nutritional or hydration status related to mental health disorders may require additional interventions by the nurse. Specific laboratory and diagnostic tests will be discussed in each “disorder” chapter, as well as in the “Psychotropic Medications” chapter.

Life Span Considerations

Life span considerations influence nursing assessments, care planning, and interventions. Mental health disorders occur across the life span, from the very young to the very old, and developmental stages must be considered when identifying impairments. Assessments and interventions must be individualized to the age and developmental level of the client. Development encompasses physical, social, and cognitive changes that occur continuously throughout one’s life. See Figure 4.4 [50] for an image of the human life cycle.

Figure 4.4

Human Life Cycle

There are multiple factors that affect human development with expected milestones along the way. Cognitive development encompasses several different skills that develop at different rates. Each human has their own individual experience that influences development of intelligence and reasoning as they interact with one another. With these unique experiences, everyone has a memory of feelings and events that is exclusive to them. [51]

There are many theories regarding how infants and children grow and develop into happy, healthy adults. Three major theories that have historically impacted nursing care are Freud’s Psychosexual Theory of Development, Erikson’s Psychosocial Stages of Development, and Piaget’s Cognitive Theory of Development.

Freud’s Psychosexual Theory of Development

Sigmund Freud (1856–1939) believed that personality develops during early childhood, and childhood experiences shape our personalities and behavior as adults. Freud believed that each individual must pass through a series of stages during childhood, and if we lack proper nurturance and parenting during a stage, we may become stuck, or fixated, in that stage. According to Freud, children’s pleasure-seeking urges are focused on different areas of the body, called erogenous zones, at each of the five stages of development: oral, anal, phallic, latency, and genital. [52]

While most of Freud’s ideas are not supported by research and modern psychologists dispute Freud’s psychosexual stages as a legitimate explanation for how one’s personality develops, Freud’s original theory supported that one’s personality is shaped, in some part, by childhood experiences. [53]

Erikson’s Psychosocial Stages of Development

Erik Erikson (1902–1994) took Freud’s theory and modified it as psychosocial theory. Erikson’s psychosocial development theory emphasizes the social nature of our development rather than its sexual nature. It describes eight sequential stages of individual human development influenced by biological, psychological, and social factors throughout the life span that contribute to an individual’s personality. Erikson’s stages of development are trust versus mistrust, autonomy versus shame, initiative versus guilt, industry versus inferiority, identity versus identity confusion, intimacy versus isolation, generativity versus stagnation, and integrity versus despair. [54],[55]

Trust vs. Mistrust

The first stage that develops is trust (or mistrust) that basic needs, such as nourishment and affection, will be met. Trust is the basis of our development during infancy (birth to 12 months). Infants are dependent upon their caregivers for their needs. Caregivers who are responsive and sensitive to their infant’s needs help their baby to develop a sense of trust, and the infant will perceive the world as a safe, predictable place. Unresponsive caregivers who do not meet their baby’s needs can engender feelings of anxiety, fear, and mistrust, and the infant will perceive the world as unpredictable. [56]

Autonomy vs. Shame

Toddlers begin to explore their world and learn that they can control their actions and act on the environment to get results. They begin to show clear preferences for certain elements of the environment, such as food, toys, and clothing. A toddler’s main task is to resolve the issue of autonomy versus shame and doubt by working to establish independence. For example, we might observe a budding sense of autonomy in a two-year-old child who wishes to choose their own clothes and dress themselves. Although the outfits might not be appropriate for the situation, the input in basic decisions has an effect on the toddler’s sense of independence. If denied the opportunity to act on their environment, they may begin to doubt their abilities, which could lead to low self-esteem and feelings of shame. [57]

Initiative vs. Guilt

After children reach the preschool stage (ages 3–6 years), they are capable of initiating activities and asserting control over their world through social interactions and play. By learning to plan and achieve goals while interacting with others, preschool children can master a feeling of initiative and develop self-confidence and a sense of purpose. Those who are unsuccessful at this stage may develop feelings of guilt. [58]

Industry vs. Inferiority

During the elementary school stage (ages 7–11), children begin to compare themselves to their peers to see how they measure up. They either develop a sense of pride and accomplishment in their schoolwork, sports, social activities, and family life, or they may feel inferior and inadequate if they feel they don’t measure up to their peers. [59]

Identity vs. Identity Confusion

In adolescence (ages 12–18), children develop a sense of self. Adolescents struggle with questions such as, “Who am I?” and “What do I want to do with my life?” Along the way, adolescents try on many different selves to see which ones fit. Adolescents who are successful at this stage have a strong sense of identity and are able to remain true to their beliefs and values in the face of problems and other people’s perspectives. Teens who do not make a conscious search for identity, or those who are pressured to conform to their parents’ ideas for the future, may have a weak sense of self and experience role confusion as they are unsure of their identity and confused about the future. [60]

Intimacy vs. Isolation

People in early adulthood (i.e., 20s through early 40s) are ready to share their lives and become intimate with others after they have developed a sense of self. Adults who do not develop a positive self-concept in adolescence may experience feelings of loneliness and emotional isolation. [61]

Generativity vs. Stagnation

When people reach their 40s, they enter a time period known as middle adulthood that extends to the mid-60s. The developmental task of middle adulthood is generativity versus stagnation. Generativity involves finding your life’s work and contributing to the development of others through activities such as volunteering, mentoring, and raising children. Adults who do not master this developmental task may experience stagnation with little connection to others and little interest in productivity and self-improvement. [62]

Integrity vs. Despair

The mid-60s to the end of life is a period of development known as late adulthood. People in late adulthood reflect on their lives and feel either a sense of satisfaction or a sense of failure. People who feel proud of their accomplishments feel a sense of integrity and often look back on their lives with few regrets. However, people who are not successful at this stage may feel as if their life has been wasted. They focus on what “would have,” “should have,” or “could have” been. They face the end of their lives with feelings of bitterness, depression, and despair. [63]

Piaget’s Cognitive Theory of Development

Jean Piaget (1896–1980) studied childhood development by focusing on children’s cognitive growth. He believed that thinking is a central aspect of development and that children are naturally inquisitive but do not think and reason like adults. Children explore the world as they attempt to make sense of their experiences. His theory explains that humans move from one stage to another as they seek cognitive equilibrium and mental balance. There are four stages in Piaget’s theory of development that occur in children from all cultures [64],[65]:

Sensorimotor period. The first stage extends from birth to approximately two years and is a period of rapid cognitive growth. During this period, infants develop an understanding of the world by coordinating sensory experiences (seeing, hearing) with motor actions (reaching, touching). The main development during the sensorimotor stage is the understanding that objects exist, and events occur in the world independently of one’s own actions. Infants develop an understanding of what they want and what they must do to have their needs met. They begin to understand language used by those around them to make needs met.
Preoperational period. The second stage begins in the toddler years. This continues through early school-age years. This is the time frame when children learn to think in images and symbols. Play is an important part of cognitive development during this period.
Concrete Operations period. Older school-age children (age 7 years to 11 years) learn to think in terms of processes and can understand that there is more than one perspective when discussing a concept. This stage is considered a major turning point in the child’s cognitive development because it marks the beginning of logical or operational thought.
Formal Operations period. Children enter this stage around age 12 as they become self-conscious and egocentric. Adolescents gain the ability to think in an abstract manner by manipulating ideas in their head. Moving toward adulthood, this further develops into the ability to critically reason.

Cognitive Impairment

Cognitive impairment is a term used to describe impairment in mental processes that drive how an individual understands and acts in the world, affecting the acquisition of information and knowledge. Cognitive impairments can range from mild impairments, such as impairments in cognitive operations, to profound intellectual impairments causing minimal independent functioning. Components of cognitive functioning include attention, decision-making, general knowledge, judgment, language, memory, perception, planning, and reasoning. [66]

Review information about cognitive impairments associated with dementia and Alzheimer’s disease in the “Cognitive Impairments” chapter of Open RN Nursing Fundamentals.

Intellectual disability (formerly referred to as mental retardation) is a diagnostic term that describes intellectual and adaptive functioning deficits identified during the developmental period. In the United States, the developmental period refers to the span of time prior to the age of 18 years. Children with intellectual disabilities may demonstrate a delay in developmental milestones (e.g., sitting, speaking, walking) or demonstrate mild cognitive impairments that may not be identified until school-age. Intellectual disability is typically nonprogressive and lifelong. It is diagnosed by multidisciplinary clinical assessments and standardized testing and is treated with a multidisciplinary treatment plan that maximizes quality of life. [67]

Resilience

When assessing an individual’s developmental level, it is important to consider possible effects of adverse childhood events (ACEs) on their development. Science tells us that some children develop resilience, the ability to overcome serious hardship or traumatic experiences, while others do not. One way to understand the development of resilience is to visualize a seesaw. Protective experiences and coping skills on one side counterbalance significant adversity on the other. Resilience is evident when a child’s health and development tip toward positive outcomes – even when a heavy load of factors is stacked on the negative outcome side. [68]

The most common factor for children who develop resilience is at least one stable and committed relationship with a supportive parent, caregiver, or other adult. These relationships provide the personalized responsiveness and protection that buffer children from developmental disruption. They also build their ability to plan, monitor, and regulate behavior that enables children to respond adaptively to adversity and thrive. This combination of supportive relationships, adaptive skill-building, and positive experiences is the foundation of resilience. [69]

The capabilities that underlie resilience can be strengthened at any age. It is never too late to build resilience. Age-appropriate, health-promoting activities can significantly improve the chances that an individual will recover from stress-inducing experiences. For example, regular physical exercise, stress management activities, and programs that actively promote self-regulation skills can improve the abilities of children and adults to cope with adversity in their lives. [70]

Cultural Considerations

Cultures and communities exhibit and explain symptoms of mental illness and manifest stress in various ways. Nurses should be aware of relevant contextual information stemming from a patient’s culture, race, ethnicity, religion, or geographical origin. For example, uncontrollable crying and headaches are symptoms of panic attacks in some cultures, whereas difficulty breathing may be the primary symptom in another culture. Understanding such distinctions will help nurses effectively treat them. [71]

At the center of patient-centered care is practicing with cultural humility and inclusiveness. In the 2021 edition of Nursing: Scope and Standards of Practice, the American Nurses Association (ANA) established a Standard of Professional Performance called Respectful and Equitable Practice. This standard is defined as, “The registered nurse practices with cultural humility and inclusiveness.” Cultural humility is “a humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a life-long goal and process.” [72] Inclusiveness is defined as “the practice of providing equal access to opportunities and resources for people who might otherwise be excluded or marginalized, such as those having physical or mental disabilities or belonging to other minority groups.” [73] Read the ANA competencies for the Respectful and Equitable Practice standard in the following box.

ANA’s Respectful and Equitable Practice Competencies [74]

The registered nurse:

Demonstrates respect, equity, and empathy in actions and interactions with all health care consumers.
Respects consumer decisions without bias.
Participates in life-long learning to understand cultural preferences, worldviews, choices, and decision-making processes of diverse consumers.
Reflects upon personal and cultural values, beliefs, biases, and heritage.
Applies knowledge of differences in health beliefs, practices, and communication patterns without assigning values to the differences.
Addresses the effects and impact of discrimination and oppression on practice within and among diverse groups.
Uses appropriate skills and tools for the culture, literacy, and language of the individuals and population served.
Communicates with appropriate language and behaviors, including the use of qualified health care interpreters and translators in accordance with consumer needs and preferences.
Serves as a role model and educator for the cultural humility and the recognition and appreciation of diversity and inclusivity.
Identifies the cultural-specific meaning of interactions, terms, and content.
Advocates for policies that promote health and prevent harm among diverse health care consumers and groups.
Promotes equity in all aspects of health and heatlh care.
Advances organizational policies, programs, services, and practices that reflect respect, equity, and values for diversity and inclusion.

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4.4. DIAGNOSIS

The Diagnosis Standard of Practice by the American Nurses Association states, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” [1] Review the competencies for the Diagnosis Standard of Practice for registered nurses in the following box.

ANA’s Diagnosis Competencies [2]

The registered nurse:

Identifies actual or potential risks to the health care consumer’s health and safety or barriers to health, which may include, but are not limited to, interpersonal, systematic, cultural, socioeconomic, or environmental circumstances.
Uses assessment data, standardized classification systems, technology, and clinical decision support tools to articulate actual or potential diagnoses, problems, and issues.
Identifies the health care consumer’s strengths and abilities, including, but not limited to, support systems, health literacy, and engagement in self-care.
Verifies the diagnoses, problems, and issues with the health care consumer and interprofessional colleagues.
Prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health-illness continuum and the care continuum.
Documents diagnoses, problems, strengths, and issues in a manner that facilitates the development of the expected outcomes and collaborative plan.

Review how to analyze assessment data, make hypotheses, and create nursing diagnoses statements in the “Diagnosis” section of the “Nursing Process” chapter in Open RN Nursing Fundamentals.

Nursing Diagnoses

A nursing diagnosis is “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group, or community.” [3] Nursing diagnoses are customized to each patient and drive the development of the nursing care plan. The nurse should refer to an evidence-based care planning resource and review the definitions and defining characteristics of the hypothesized nursing diagnoses.

Recall that nursing diagnoses are different from medical diagnoses and mental health diagnoses. Medical diagnoses focus on medical problems that have been identified by the physician, physician’s assistant, or advanced nurse practitioner. Mental health diagnoses are established by mental health experts, such as psychiatrists, psychologists, and advanced practice psychiatric-mental health nurses, using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). See Figure 4.5 [4] for an illustration of several mental health diagnoses.

Figure 4.5

Mental Health Diagnoses

Nursing diagnoses focus on the human response to health conditions and life processes and are established by registered nurses. Patients with the same mental health diagnosis will often respond differently and thus have different nursing diagnoses. For example, two clients may have the same diagnosis of Major Depressive Disorder. However, one client may demonstrate a high risk for suicide whereas another patient may experience impaired nutrition due to lack of appetite. The nurse must consider these different responses when creating an individualized nursing care plan.

Prioritization

After identifying nursing diagnoses, the next step is prioritizing specific needs of the patient. Prioritization is the process of identifying the most significant problems and the most important interventions to implement based on a client’s current status.

It is essential that life-threatening concerns and crises are quickly identified and addressed immediately. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds for life-threatening concerns. Nurses must recognize cues signaling a change in patient condition, apply evidence-based practices in a crisis, and communicate effectively with interprofessional team members. Most client care situations fall somewhere between a crisis and routine care.

Maslow’s Hierarchy of Needs is commonly used to prioritize the most urgent patient needs. It is based on the theory that people are motivated by five levels of needs: physiological, safety, love, esteem, and self-actualization. The bottom levels of the pyramid represent the priority physiological needs intertwined with safety, whereas the upper levels focus on belonging, esteem, and self-actualization. Physiological needs must be met before focusing on higher level needs. [5] For example, priorities for a client experiencing mania are the need for food, fluid, and sleep, as well as controlling the agitation and impulsivity to ensure safety. These needs would need to be met before focusing on strategies to improve relationships with family and friends, build respect and acceptance for self and others, and engage in activities promoting personal growth. It is important to note that although safety is not described as a top priority in this theory, nurses must always prioritize safety needs in addition to physiological needs. See Figure 4.6 [6] for an image of Maslow’s Hierarchy of Needs.

Figure 4.6

Maslow’s Hierarchy of Needs

Common Nursing Diagnosis for Mental Health Conditions

Commonly used nursing diagnoses related to caring for clients with mental health conditions are included in Table 4.4. As always, when providing client care, refer to a current, evidence-based nursing care planning resource.

Table 4.4

Common Nursing Diagnoses Related to Mental Health [7]

Sample Case A

During an interview with a 32-year-old client diagnosed with Major Depressive Disorder, Mr. J. exhibited signs of a sad affect and hopelessness. He expressed desire to die and reported difficulty sleeping and a lack of appetite with weight loss. He reports he has not showered in over a week, and his clothes have a strong body odor. The nurse analyzed this data and created four nursing diagnoses using a nurse care plan reference [8]:

Hopelessness related to social isolation
Risk for Suicide as manifested by reported desire to die
Imbalanced Nutrition: Less than Body Requirements related to insufficient dietary intake
Self-Neglect related to insufficient personal hygiene

The nurse established the top priority nursing diagnosis of Risk for Suicide and immediately screened for suicidal ideation and a plan using the Patient Safety Screener.

References

1.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
2.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
3.: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
4.: “Mental_Disorder_Silhouette.png” by Paget Michael Creelman is licensed under CC BY-SA 4.0.
5.: Maslow A. H. A theory of human motivation. Psychological Review. 1943;50(4):370–396. [CrossRef]
6.: “Maslow's hierarchy of needs.svg” by J. Finkelstein is licensed under CC BY-SA 3.0.
7.: McLeod, S. (2020, December 7). Piaget’s theory and stages of development. SimplyPsychology. https://www.simplypsychology.org/piaget.html.
8.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.

4.5. OUTCOME IDENTIFICATION

The Outcomes Identification Standard of Practice by the American Nurses Association states, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [1] Review the competencies for the Outcomes Identification Standard of Practice for registered nurses in the following box.

ANA’s Outcomes Identification Competencies [2]

The registered nurse:

Engages with the health care consumer, interprofessional team, and others to identify expected outcomes.
Collaborates with the health care consumer to define expected outcomes integrating the health care consumer’s culture, values, and ethical considerations.
Formulates expected outcomes derived from assessments and diagnoses.
Integrates evidence and best practices to identify expected outcomes.
Develops expected outcomes that facilitate coordination of care.
Identifies a time frame for the attainment of expected outcomes.
Documents expected outcomes as measurable goals.
Identifies the actual outcomes in relation to expected outcomes, safety, and quality standards.
Modifies expected outcomes based on the evaluation of the status of the health care consumer and situation.

An outcome is a “measurable behavior demonstrated by the patient who is responsive to nursing interventions.” [3] After nursing interventions are implemented, the nurse evaluates if the outcomes were met in the time frame indicated for that patient.

Outcome identification includes setting short-term and long-term goals and then creating specific expected outcome statements for each nursing diagnosis. Outcome statements are always patient-centered. They should be developed collaboratively with the client and individualized to meet the client’s unique needs, values, and cultural beliefs. They should start with the phrase “The client will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving.

Review how to create “SMART” expected outcomes in the “Nursing Process” chapter of Open RN Nursing Fundamentals.

Unfolding Case A

Recall Sample Case A in the “Diagnosis” section regarding the 32-year-old male diagnosed with Major Depressive Disorder. The nurse created these four nursing diagnoses:

Hopelessness related to social isolation
Risk for Suicide as manifested by reported desire to die
Imbalanced Nutrition: Less than Body Requirements related to insufficient dietary intake
Self-Neglect related to insufficient personal hygiene

The nurse established the top priority nursing diagnosis of Risk for Suicide and immediately screened for suicidal ideation and a plan using the Patient Safety Screener.

The nurse then identified the following SMART expected outcome for the nursing diagnosis Risk for Suicide related to reported desire to die: The client will remain free from self-harm self during the hospitalization stay.

References

1.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
2.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
3.: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
4.: “SMART-goals.png” by Dungdm93 is licensed under CC BY-SA 4.0.

4.6. PLANNING

The Planning Standard of Practice by the American Nurses Association states, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [1]

Review the competencies for the Planning Standard of Practice for registered nurses in the following box.

ANA’s Planning Competencies [2]

The registered nurse:

Develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team.
Designs innovative nursing practices that can be incorporated into the plan.
Prioritizes elements of the plan based on the assessment of the health care consumer’s level of safety needs to include risks, benefits, and alternatives.
Establishes the plan priorities with the health care consumer, family, significant others, and interprofessional team.
Advocates for compassionate, responsible, and appropriate use of interventions to minimize unwarranted or unwanted treatment, health care consumer suffering, or both.
Includes strategies designed to address each of the identified diagnoses, health challenges, issues, or opportunities. These strategies may include, but are not limited to, maintaining health and wellness; promotion of comfort; promotion of wholeness, growth, and development; promotion and restoration of health and wellness; prevention of illness, injury, disease, complications, and trauma; facilitation of healing; alleviation of suffering; supportive care; and mitigation of environmental or occupational risks.
Incorporates an implementation pathway that describes an overall timeline, steps, and milestones.
Provides for the coordination and continuity of care.
Identifies cost and economic implications of the plan.
Develops a plan that reflects compliance with current statutes, rules, regulations, and standards.
Modifies the plan according to the ongoing assessment of the health care consumer’s response and other outcome indicators.
Documents the plan using standardized language or recognized terminology.
Actively contributes at all levels in the development and continuous improvement of systems that support the planning process.

As always, consult a current, evidence-based nursing care planning resource when planning nursing interventions individualized to each client’s needs. You might be asking yourself, “How do I know what evidence-based nursing interventions to include in the nursing care plan regarding mental health care?” There are several sources that can be used to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the patient chart. Additionally, the Substance Abuse and Mental Health Services Administration (SAMHSA) maintains an evidence-based resource center. [3]

Access the Evidence-Based Resource Center maintained by the Substance Abuse and Mental Services Administration (SAMHSA).

See sample planned nursing interventions for a client who has been diagnosed with Risk for Suicide in Table 4.6.

Review the “Establishing Safety” section for clients at risk for suicide in Chapter 1.

References

1.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
2.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
3.: Substance Abuse and Mental Health Services Administration. (n.d.). Evidence-based practices resource center. https://www.samhsa.gov/resource-search/ebp.
4.: DeAngelis T. Better relationships with patients lead to better outcomes. Monitor on Psychology. 2019;50(10):38. https://www.apa.org/monitor/2019/11/ce-corner-relationships
5.: DeAngelis T. Better relationships with patients lead to better outcomes. Monitor on Psychology. 2019;50(10):38. https://www.apa.org/monitor/2019/11/ce-corner-relationships
6.: DeAngelis T. Better relationships with patients lead to better outcomes. Monitor on Psychology. 2019;50(10):38. https://www.apa.org/monitor/2019/11/ce-corner-relationships
7.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
8.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
9.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
10.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
11.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
12.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
13.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
14.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
15.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
16.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
17.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
18.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
19.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
20.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
21.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
22.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
23.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
24.: Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.

Table 4.6

Sample Nursing Interventions for Risk for Suicide

4.7. IMPLEMENTATION

The Implementation Standard of Practice by the American Nurses Association (ANA) states, “The registered nurse implements the identified plan.” [1] Review the competencies for the Implementation Standard of Practice for registered nurses in the following box.

ANA’s Implementation Competencies [2]

The registered nurse:

Demonstrates caring behaviors to develop therapeutic relationships.
Provides care that focuses on the health care consumer.
Advocates for the needs of diverse populations across the life span.
Uses critical thinking and technology solutions to implement the nursing process to collect, measure, record, retrieve, trend, and analyze data and information to enhance health care consumer outcomes and nursing practice.
Partners with the health care consumer to implement the plan in a safe, effective, efficient, timely, and equitable manner.
Engages interprofessional team partners with implementation of the plan through collaboration and communication across the continuum of care.
Uses evidence-based interventions and strategies to achieve mutually identified goals and outcomes specific to the problem or needs.
Delegates according to the health, safety, and welfare of the health care consumer.
Delegates after considering the circumstance, person, task, direction or communication, supervision, and evaluation.
Considers the state’s Nurse Practice Act regulations, institution, and regulatory entities while maintaining accountability for the care.
Documents implementation and any modifications, including changes or omissions, of the identified nursing care plan.

In addition to these competencies, the American Nurses Association established two additional subcategories for the Implementation standard: Coordination of Care and Health Teaching and Health Promotion. In addition to these basic subcategories, the American Psychiatric established additional subcategories for registered nurses working in psychiatric/mental health settings: Pharmacological, Biological, and Integrative Therapies; Milieu Therapy; and Therapeutic Relationship and Counseling. Each of these additional subcategories of Implementation is discussed in the following subsections.

Coordination of Care

Review the competencies for the Coordination of Care Standard of Care in the following box.

ANA’s Coordination of Care Competencies [3]

The registered nurse:

Collaborates with the health care consumer and the interprofessional team to help manage health care based on mutually agreed-upon outcomes.
Organizes the components of the plan with input from the health care consumer and other stakeholders.
Manages the health care consumer’s care to reach mutually agreed-upon outcomes.
Engages health care consumers in self-care to achieve preferred goals for quality of life.
Assists the health care consumer to identify options for care and navigate the health care system and its services.
Communicates with the health care consumer, interprofessional team, and community-based resources to effect safe transitions in continuity of care.
Advocates for the delivery of dignified and person-centered care by the interprofessional team.
Documents the coordination of care.

Health Teaching and Health Promotion

Review the competencies for Health Teaching and Health Promotion in the following box.

ANA’s Health Teaching and Health Promotion Competencies [4]

The registered nurse:

Provides opportunities for the health care consumer to identify needed health promotion, disease prevention, and self-management topics such as:
- Healthy lifestyles
- Self-care and risk management
- Coping, adaptability, and resiliency
Uses health promotion and health teaching methods in collaboration with the health care consumer’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status.
Uses feedback from the health care consumer and other assessments to determine the effectiveness of the employed strategies.
Uses technologies to communicate health promotion and disease prevention information to the health care consumer.
Provides health care consumers with information and education about intended effects and potential adverse effects of the plan of care.
Engages consumer alliance and advocacy groups in health teaching and health promotion activities for health care consumers.
Provides anticipatory guidance to health care consumers to promote health and prevent or reduce risk.

Pharmacological, Biological, and Integrative Therapies

Biological therapies are “any form of treatment for mental disorders that attempts to alter physiological functioning, including drug therapies, electroconvulsive therapy, and psychosurgery.” [5] Integrative therapies are defined by the American Psychiatric Association (APA) as “psychotherapy that selects theoretical models or techniques from various therapeutic schools to suit the client’s particular problems.” [6] Psychotherapy interventions include “all generally accepted and evidence-based methods of brief or long-term therapy, including individual therapy, group therapy, marital or couple therapy, and family therapy. These interventions use a range of therapy models, including, but not limited to, psychodynamic, cognitive, behavioral, and supportive interpersonal therapies to promote insight, produce behavioral change, maintain function, and promote recovery.” [7] Review the competencies for this Standard of Care in the following box.

APNA’s Pharmacological, Biological, and Integrative Therapies Competencies [8]

“The psychiatric-mental health registered nurse (PMH-RN) incorporates knowledge of pharmacological, biological, and complementary interventions with applied clinical skills to restore the health care consumer’s health and prevent future disability.” [9]

The PMH-RN:

Applies current research findings to guide nursing actions related to pharmacology, other biological therapies, and integrative therapies.
Assesses the health care consumer’s response to biological interventions based on current knowledge of pharmacological agent’s intended actions, interactive effects, potential untoward effects, and therapeutic doses.
Includes health teaching for medication management to support health care consumers in managing their own medications and adhering to a prescribed regimen.
Provides health teaching about mechanism of action, intended effects, potential adverse effects of the proposed prescription, ways to cope with transitional side effects, and other treatment options, including the selection of a no-treatment option.
Directs interventions toward alleviating untoward effects of biological interventions.
Communicates observations about the health care consumer’s response to biological interventions to other health clinicians.

Milieu Therapy

A therapeutic milieu is defined by the American Psychiatric Nursing Association as, “A safe, welcoming, supportive, and functional physical treatment environment.” Milieu therapy includes nursing interventions used to assist health care consumers to make positive change and promote recovery in a therapeutic milieu. Nursing interventions include providing empathy, assisting in problem-solving, acting as a role model, demonstrating leadership, confronting discrepancies, encouraging self-efficacy, decreasing stimuli when necessary, and manipulating the environment so that the above interventions can be effective.” [10] Review the APNA competencies for this Standard of Care in the following box.

APNA’s Milieu Therapy Competencies [11]

“The psychiatric-mental health registered nurse (PMH-RN) provides, structures, and maintains a safe, therapeutic, recovery-oriented environment in collaboration with health care consumers, families, and other health care clinicians.” [12]

The PMH-RN:

Orients the health care consumer and family to the care environment, including the physical environment, the roles of the different health care providers, self-involvement in the treatment and care delivery processes, schedules of events pertinent to their care and treatment, and expectations regarding safe and therapeutic behaviors.
Orients health care consumers to their rights and responsibilities particular to the treatment or care environment.
Establishes a welcome, trauma-sensitive environment using therapeutic interventions, including, but not limited to, sensory or relaxation rooms.
Conducts ongoing assessments of the health care consumer in relation to the environment to guide nursing interventions in maintaining a safe environment.
Selects specific activities (both individual and group) that meet the health care consumer’s physical and mental health needs for meaningful participation in the milieu and promotion of personal growth.
Advocates that the health care consumer is treated in the least restrictive environment necessary to maintain the safety of the individual and others.
Informs the health care consumer in a culturally sensitive manner about the need for limits related to safety and the conditions necessary to remove the restrictions.
Provides support and validation to health care consumers when discussing their illness experience and seeks to prevent complications of illness.

Therapeutic Relationship and Counseling

The American Nurses Association states, “Nursing integrates the art and science of caring… It facilitates healing and alleviates suffering through compassionate presence… The act of caring is the first step in the power to heal.” [13] Jean Watson’s Human Caring Science Theory emphasizes the therapeutic relationship between the patient and nurse and highlights the role of the nurse in defining the patient as a unique human being to be valued, respected, nurtured, understood, and assisted. [14] In a caring, therapeutic relationship, the nurse implements interventions to promote interpersonal connection, such as listening attentively, making eye contact, using verbal reassurances, and using professional touch with permission. [15] Nurses use several therapeutic techniques during a nurse-client relationship. Read more information in the “Therapeutic Communication and the Nurse-Client Relationship” chapter.

Read the APNA competencies regarding therapeutic relationship and counseling in the following box.

APNA’s Therapeutic Relationship and Counseling Competencies [16]

“The psychiatric-mental health registered nurse (PMH-RN) uses the therapeutic relationship and counseling interventions to assist health care consumers in their individual recovery journeys by improving and regaining their previous coping abilities, fostering mental health, and preventing mental disorder and disability.” [17]

The PMH-RN:

Uses therapeutic relationship and counseling techniques to promote the health care consumer’s stabilization of symptoms and personal recovery goals.
Uses the therapeutic relationship and counseling techniques, both in the individual and group setting, to reinforce healthy behaviors and interaction patterns and helps the health care consumer discover individualized health care behaviors to replace unhealthy ones.
Documents counseling interventions, including, but not limited to, communication and interviewing techniques, problem-solving activities, crisis intervention, stress management, supportive skill building and educational groups, relaxation techniques, assertiveness training, and conflict resolution.

Categories of Interventions

Nurses implement several interventions related to each subcategory of the Implementation Standard of Care for clients in mental health settings. See Table 4.7 for common nursing interventions in mental health settings for each subcategory.

Table 4.7

Categories of Nursing Mental Health Interventions

Implementing Interventions

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During the Implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses patient safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed.

Prioritizing implementation of interventions follows a similar method as to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least restrictive interventions are preferred. Read more about methods for prioritization under the “Diagnosis” section of this chapter.

It is essential to consider patient safety when implementing interventions. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a patient states, “The nurse will ambulate the patient 100 feet three times daily.” However, during assessment this morning, the patient reports feeling dizzy today, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned intervention of ambulating the patient and notifies the provider of suspected side effects of the client’s antidepressant medication. This decision, supporting assessment findings, and notification of the provider should be documented in the patient’s chart and also communicated during the shift handoff report.

References

1.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
2.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
3.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
4.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
5.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/
6.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/
7.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
8.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
9.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
10.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
11.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
12.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
13.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
14.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
15.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
16.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
17.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.

4.8. EVALUATION

The Evaluation Standard of Practice by the American Nurses Association states, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [1] Review the competencies for the Evaluation Standard of Practice for registered nurses in the following box.

ANA’s Evaluation Competencies [2]

The registered nurse:

Uses applicable standards and defined criteria (e.g., Quality and Safety Education for Nurses [QSEN], Quadruple Aim, Institute for Healthcare Improvement [IHI]).
Conducts a systematic, ongoing, and criterion-based evaluation of the goals and outcomes in relation to the structure, processes, and timelines prescribed in the plan.
Collaborates with the health care consumer, stakeholders, interprofessional team, and others involved in the care or situation in the evaluation process.
Determines, in partnership with the health care consumer and other stakeholders, the person-centeredness, effectiveness, efficiency, safety, timeliness, and equitability of the strategies in relation to the responses to the plan and attainment of outcomes.
Uses ongoing assessment data, other data and information resources and benchmarks, research, and meta-analyses for the analytic activities to revise the diagnoses, outcomes, plan, implementation, and evaluation strategies as needed.
Documents the results of the evaluation.
Reports evaluation data in a timely fashion.
Shares evaluation data and conclusions with the health care consumer and other stakeholders to promote clarity and transparency in accordance with state, federal, organizational, and professional requirements.

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. Evaluation includes analysis of data from assessments, screening tools, laboratory results, and pharmacologic interventions, as well as the effectiveness of nursing interventions related to thought process and content. During the Evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. If revision is necessary, the nurse should consider which step of the nursing process requires modification. Have additional assessment data been obtained, or have assessment data changed? Has a different nursing diagnosis become a priority? Were the identified goals or expected outcomes unrealistic? Were any interventions not effective?

Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record.

Ideally, when the planned interventions are implemented, the patient will respond positively, and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:

Did anything unanticipated occur?
Has the patient’s condition changed?
Have the patient’s goals and priorities shifted?
Were the expected outcomes and their time frames realistic?
Are the nursing diagnoses accurate for this patient at this time?
Are the planned interventions appropriately focused on supporting outcome attainment?
What barriers were experienced as interventions were implemented?
Do ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
Are different interventions required?

References

1.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
2.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.

4.9. NCLEX NEXT GENERATION TERMINOLOGY

The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is the exam that all nursing graduates must successfully pass to obtain their nursing license and become a registered nurse. The purpose of the NCLEX is to evaluate if a nursing graduate (i.e., candidate) is competent to provide safe, competent, entry-level nursing care. The NCLEX-RN is developed by the National Council of State Board of Nursing (NCSBN), an independent, nonprofit organization composed of the 50 state boards of nursing and other regulatory agencies. [1]

A new edition of NCLEX will be released in 2023 that includes “Next Generation” questions. (If you take the NCLEX before the new edition is released, you may be asked to voluntarily participate in a special research section that tests the accuracy of these new types of questions without your performance counting toward your final score.) The Next Generation NCLEX (Next Gen) uses evolving case studies and other types of test questions based on the new NCSBN Clinical Judgment Measurement Model (NCJMM). The NCJMM assesses how well the candidate can think critically and use clinical judgment when providing safe nursing care. [2]

Five new Next Generation test item types are called extended multiple response, extended drag and drop, cloze (drop-down), extended hot spot (highlighting), and matrix-grid [3]:

Extended Multiple Response: Extended Multiple Response items allow candidates to select one or more answer options at a time. This item type is similar to the current NCLEX multiple response item but has more options and uses partial credit scoring.
Extended Drag and Drop: Extended Drag and Drop items allow candidates to move or place response options into answer spaces. This item type is like the current NCLEX ordered response items but not all of the response options may be required to answer the item. In some items, there may be more response options than answer spaces.
Cloze (Drop – Down): Cloze (Drop – Down) items allow candidates to select one option from a drop-down list. There can be more than one drop-down list in a cloze item. These drop-down lists can be used as words or phrases within a sentence or within tables and charts.
Enhanced Hot Spot (Highlighting): Enhanced Hot Spot items allow candidates to select their answer by highlighting predefined words or phrases. Candidates can select and deselect the highlighted parts by clicking on the words or phrases. These types of items allow an individual to read a portion of a client medical record (e.g., a nursing note, medical history, lab values, medication record, etc.), and then select the words or phrases that answer the item.
Matrix/Grid: Matrix/Grid items allow the candidate to select one or more answer options for each row and/or column. This item type can be useful in measuring multiple aspects of the clinical scenario with a single item.

View the following YouTube video [4] from NCSBN on Next Generation test items: The Right Decisions Come from the Right Questions

The NCJMM complements the nursing process but uses different terminology in exam questions while assessing the candidate’s clinical judgment. This terminology includes recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, and evaluate outcomes. See Table 4.9 for a comparison of these terms and actions to the nursing process. [5], [6], [7]

Table 4.9

Comparison of the NCSBN Clinical Judgment Measurement Model to the Nursing Process

It is important to note that NANDA Nursing Diagnoses are not specifically assessed on the NCLEX. However, the ability of a candidate to cluster client data, make hypotheses, prioritize hypotheses, and plan nursing interventions is based on a nursing knowledge base of potential human responses to health problems and life processes (otherwise known as nursing diagnoses).

Learning activities are incorporated throughout the chapters of this book to assist students in learning how to respond to NCLEX Next Generation-style test questions.

References

1.: NCSBN. https://www.ncsbn.org/nclex.htm.
2.: NCSBN. https://www.ncsbn.org/nclex.htm.
3.: NCSBN. https://www.ncsbn.org/nclex.htm.
5.: NCSBN (n.d.) NCSBN Clinical Judgment Measurement Model. https://www.ncsbn.org/14798.htm.
6.: Ignativicius, V. & Silvestri, L. (2022). Preparing for the Next-Generation NCLEX (NGN): A “how-to” step-by-step faculty resource manual. Elsevier. https://evolve.elsevier.com/education/wp-content/uploads/sites/2/NGN_FacultyGuide_Final.pdf.
7.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.

4.10. SPOTLIGHT APPLICATION

Let’s review how the nursing process can be applied to Sample Case A introduced in the “Diagnosis” section of this chapter regarding caring for a suicidal client:

Assessment

During an interview with a 32-year-old male client diagnosed with Major Depressive Disorder, the client exhibited signs of a sad affect and hopelessness. He expressed desire to die and reported difficulty sleeping and a lack of appetite. He reports he has not showered in over a week and his clothes have a strong body odor.

Diagnosis

The nurse analyzed this data and created four nursing diagnoses:

Hopelessness related to social isolation
Risk for Suicide as manifested by the reported desire to die
Imbalanced Nutrition: Less than Body Requirements related to insufficient dietary intake
Self-Neglect related to insufficient personal hygiene

The nurse established the top priority nursing diagnosis of Risk for Suicide and immediately screened for suicidal ideation and a plan using the Columbia Suicide Severity Rating Scale (C-SSRS).

Outcome Identification

The nurse identified the following SMART expected outcomes:

The client will verbalize feelings by the end of the shift.
The client will remain free from injury during the hospitalization stay.
The client will progressively gain at least one pound per week toward his ideal body weight (180 pounds).
The client will participate in daily bathing.

Planning and Implementation

The nurse implemented planned nursing interventions for Risk for Suicide as previously discussed in Table 4.6.

Evaluation

Day 1: Outcomes partially met. By the end of the shift, the client verbalized feelings related to hopelessness and did not harm himself. He did not agree to participate in taking a bath and only ate 25% of his meal tray. Interventions will be re-attempted on Day 2 and reassessed for effectiveness.

Sample Documentation

0900: 32-year-old male client diagnosed with Major Depressive Disorder admitted for active suicidal ideation with a plan to do so with a gun. He has the means to accomplish this plan at home. He has expressed the desire to die and reports difficulty sleeping and a lack of appetite for the past two weeks. He reports he has not showered in over a week, and his clothes have a strong body odor. Client was placed in a room near the nursing station and assigned a 1:1 sitter. His personal belongings were removed and placed in a secure area. An environmental scan was completed, and all hazards were removed from the room. He agreed to complete a no-harm contract. Dr. Delgado was notified at 0930. She assessed the client at 0945, and new orders for medications were received and administered. —– Zerimiah Alimi, Nursing Student

4.11. LEARNING ACTIVITIES

IV. GLOSSARY

ADOPIE: A mnemonic for the components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.
Affect: A client’s expression of emotion.
Akathisia: Motor restlessness.
Alexithymia: The inability to describe emotions with how one is feeling.
Anhedonia: The lack of experiencing pleasure in activities normally found enjoyable.
Apathy: A lack of feelings, emotions, interests, or concerns.
Biological therapies: Any form of treatment for mental health disorders that attempts to alter physiological functioning, including drug therapies, electroconvulsive therapy, and psychosurgery.” [1]
Blunted: A diminished range and intensity of affect or mood.
Chief complaint: The patient’s primary reasons for seeking care.
Circumstantial: Speaking with many unnecessary or tedious details without getting to the point of the conversation.
Clang associations: Stringing words together that rhyme without logical association and do not convey rational meaning. For example, a client exhibiting clang associations may state, “Here she comes with a cat catch a rat match.”
Clouded consciousness: A state of reduced awareness to stimuli.
Cognition: The mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. It includes thinking, knowing, remembering, judging, and problem-solving.
Cognitive impairment: Impaired mental processes that drive how an individual understands and acts in the world, affecting the acquisition of information and knowledge. Components of cognitive functioning include attention, decision-making, general knowledge, judgment, language, memory, perception, planning, and reasoning. [2]
Coma: A state of unarousable unresponsiveness, where vigorous noxious stimuli may not elicit reflex motor responses.
Congruence: Consistency of verbal and nonverbal communication.
Countertransference: A tendency for the examiner to displace (transfer) their own feelings onto the client, and these feelings may influence the client.
Cultural humility: A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a life-long goal and process. [3]
Delirium: An onset of an abnormal mental state, often with fluctuating levels of consciousness, disorientation, irritability, and hallucinations. Delirium is often associated with infection, metabolic disorders, or toxins in the central nervous system.
Delusions: A fixed, false belief not held by cultural peers and persisting in the face of objective contradictory evidence. For example, a client may have the delusion that the CIA is listening to their conversations via satellites.
Development: Physical, social, and cognitive changes that occur continuously throughout one’s life.
Diagnostic and Statistical Manual of Mental Disorders (DSM-5): The manual used to make mental health diagnoses established by mental health experts.
Disheveled: A client’s hair, clothes, or hygiene appears untidy, disordered, unkempt, or messy.
Distractibility: A state when the client’s attention is easily drawn to unimportant or irrelevant external stimuli.
Dyskinesia: Uncontrolled, involuntary movements.
Dysphoric: A client’s mood or affect exhibiting persistent sadness or depression.
Euphoric: A pathologically elevated sense of well-being.
Euthymic: Normal affect and mood with a wide range of emotion appropriate for the situation.
Family dynamics: Patterns of interactions among relatives, their roles and relationships, and the various factors that shape their interactions. Because family members rely on each other for emotional, physical, and economic support, they are primary sources of relationship security or stress. Family dynamics and the quality of family relationships can have either a positive or negative impact on an individual’s health.
Flat: No emotional expression.
Flight of ideas: A state where the client frequently shifts from one topic to another with rapid speech, making it seem fragmented. The examiner may feel the client is rambling and changing topics faster than they can keep track, and they probably can’t get a word in edgewise. [4] An example of client exhibiting a flight of ideas is, “My father sent me here. He drove me in a car. The car is yellow in color. Yellow color looks good on me.” [5]
Grandiose delusions: A state of false attribution to the self of great ability, knowledge, importance or worth, identity, prestige, power, accomplishment. [6] Clients may withdraw into an inner fantasy world that’s not equivalent to reality, where they have inflated importance, powers, or a specialness that is opposite of what their actual life is like.
Hallucinations: False sensory perceptions not associated with real external stimuli that can include any of the five senses (auditory, visual, gustatory, olfactory and tactile). For example, a client may see spiders climbing on the wall or hear voices telling them to do things. These are referred to as “visual hallucinations” or “auditory hallucinations.”
Homicidal ideation: Threats or acts of life-threatening harm towards another person.
Illusions: Misperceptions of real stimuli. For example, a client may misperceive tree branches blowing in the wind at night to be the arms of monsters trying to grab them.
Inclusiveness: The practice of providing equal access to opportunities and resources for people who might otherwise be excluded or marginalized, such as those having physical or mental disabilities or belonging to other minority groups. [7]
Insight: The client demonstrates awareness of their situation.
Integrative therapies: Psychotherapy that selects theoretical models or techniques from various therapeutic schools to suit the client’s particular problems. [8]
Intellectual disability: A diagnostic term that describes intellectual and adaptive functioning deficits identified during the developmental period prior to the age 18.
Labile: Rapid changes in emotional responses, mood, or affect that are inappropriate for the moment or the situation.
Loose associations: Jumping from one idea to an unrelated idea in the same sentence. For example, the client might state, “I like to danceg; my feet are wet.” [9] The term “word salad” refers to severely disorganized and virtually incomprehensible speech or writing, marked by severe loosening of associations. [10]
Maslow’s Hierarchy of Needs: A theory commonly used to prioritize the most urgent patient needs.
Mental status examination: An assessment of a client’s level of consciousness and orientation, appearance and general behavior, speech, motor activity, affect and mood, thought and perception, attitude and insight, and cognitive abilities.
Milieu therapy: Nursing interventions used to assist health care consumers to make positive change and promote recovery by creating a therapeutic milieu. Milieu therapy includes interventions such as providing empathy, assisting in problem-solving, acting as a role model, demonstrating leadership, confronting discrepancies, encouraging self-efficacy, decreasing stimuli when necessary, and manipulating the environment so that the above interventions can be effective. [11]
Mood: The predominant emotion expressed by an individual. [12]
Non-suicidal self-injury (NSSI): Intentional self-inflicted destruction of body tissue without suicidal intention and for purposes not socially sanctioned. Common forms of NSSI include behaviors such as cutting, burning, scratching, and self-hitting.
Nursing diagnosis: A clinical judgment concerning a human response to health conditions/life processes or a vulnerability for that response, by an individual, family, group, or community.
Nursing process: A critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care.
Obsessions: Persistent thoughts, ideas, images, or impulses that are experienced as intrusive or inappropriate and result in anxiety, distress, or discomfort. Common obsessions include repeated thoughts about contamination, a need to have things in a particular order or sequence, repeated doubts, aggressive impulses, and sexual imagery. Obsessions are distinguished from excessive worries about everyday occurrences because they are not concerned with real-life problems. [13]
Obtundation: A moderate reduction in the client’s level of awareness so that mild to moderate stimuli do not awaken the client. When arousal does occur, the patient is slow to respond.
Outcome: A measurable behavior demonstrated by the patient who is responsive to nursing interventions.
Paranoia: A condition characterized by delusions of persecution. [14] Clients often experience extreme suspiciousness, mistrust, or expression of fear. For example, a resident of a long-term care facility may have delusions that the staff is trying to poison him.
Poverty of content: A conversation in which the client talks without stating anything related to the question, or their speech in general is vague and meaningless.
Prioritization: The process of identifying the most significant problems and the most important interventions to implement based on a client’s current status.
Psychiatric-mental health nursing: The nursing practice specialty committed to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the life span. Psychiatric-mental health nursing intervention is an art and a science, employing a purposeful use of self and a wide range of nursing, psychosocial, and neurobiological evidence to produce effective outcomes. [15]
Psychomotor agitation: A condition of purposeless, non-goal-directed activity.
Psychomotor retardation: A condition of extremely slow physical movements, slumped posture, or slow speech patterns.
Psychosocial assessment: A component of the nursing assessment process that obtains additional subjective data to detect risks and identify treatment opportunities and resources.
Psychotherapy interventions: Generally accepted and evidence-based methods of brief or long-term therapy, including individual therapy, group therapy, marital or couple therapy, and family therapy. These interventions use a range of therapy models including, but not limited to, psychodynamic, cognitive, behavioral, and supportive interpersonal therapies to promote insight, produce behavioral change, maintain function, and promote recovery. [16]
Racing thoughts: Fast-moving and often repetitive thought patterns that can be overwhelming. They may focus on a single topic, or they may represent multiple different lines of thought. For example, a client may have racing thoughts about a financial issue or an embarrassing moment.
Resilience: The ability to overcome serious hardship or traumatic experiences.
Rumination: Obsessional thinking involving excessive, repetitive thoughts that interfere with other forms of mental activity. [17]
Safety plan: A prioritized written list of coping strategies and sources of support that clients can use before or during a suicidal crisis. The plan should be brief, in the client’s own words, and easy to read. After the plan is developed, the nurse should problem solve with the client to identify barriers or obstacles to using the plan. It should be discussed where the client will keep the safety plan and how it will be located during a crisis.
SMART outcomes: Outcome statements should contain five components easily remembered using the “SMART” mnemonic: Specific, Measurable, Attainable/Action-oriented, Relevant/Realistic, with a Time frame.
Spirituality: A sense of connection to something larger than oneself that typically involves a search for meaning and purpose in life.
Stupor: A state of unresponsiveness unless a vigorous stimulus is applied, such as a sternal rub. The client quickly drifts back into a deep sleep-like state on cessation of the stimulation.
Suicide attempt: An action in which there is intent to end one’s life but the individual does not die as a result of their actions.
Suicidal ideation: When an individual has been thinking about suicide but does not necessarily have an intention to act on that idea.
Suicide plan: An individual who has a plan for suicide, has the means to injury oneself, and has the intent to die.
Therapeutic milieu: A safe, welcoming, supportive, and functional physical treatment environment.
Transference: When the client projects (i.e., transfers) their feelings to the nurse. For example, a client is feeling angry at a family member related to a previous disagreement and displaces the anger to the nurse during the interview.

References

1.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/
2.: Schofield, D. W. (2018, December 26). Cognitive deficits. Medscape. https://emedicine.medscape.com/article/917629-overview.
3.: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
4.: Martin, D. C. (1990). The mental status examination. In Walker, H. K., Hall, W. D., Hurst, J. W., (Eds.), Clinical methods: The history, physical, and laboratory examinations. (3rd ed.). Butterworths. https://www.ncbi.nlm.nih.gov/books/NBK320/ [PubMed: 21250045]
5.: PsychologGenie. (n.d.). The true meaning of flight of ideas explained with examples. https://psychologenie.com/flight-of-ideas-meaning-examples.
6.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/
7.: Oxford Learner’s Dictionaries. (n.d.). Inclusion. Oxford University Press. https://www.oxfordlearnersdictionaries.com/us/definition/english/inclusion.
8.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/
9.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/
10.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/
11.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.) Nursebooks.org.
12.: Martin, D. C. (1990). The mental status examination. In Walker, H. K., Hall, W. D., Hurst, J. W., (Eds.), Clinical methods: The history, physical, and laboratory examinations. (3rd ed.). Butterworths. https://www.ncbi.nlm.nih.gov/books/NBK320/ [PubMed: 21250045]
13.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/
14.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/
15.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
16.: American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2nd ed.). Nursebooks.org.
17.: American Psychological Association. (n.d.). APA Dictionary of Psychology. https://dictionary.apa.org/

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Nursing: Mental Health and Community Concepts [Internet].

Chapter 4 Application of the Nursing Process to Mental Health Care

4.1. INTRODUCTION

Learning Objectives

References

4.2. APPLYING THE NURSING PROCESS

Review using the nursing process in the “Nursing Process” chapter in Open RN Nursing Fundamentals.

References

4.3. ASSESSMENT

ANA’s Assessment Competencies [2]

Review the components of a nursing assessment in the “Nursing Process” chapter of Open RN Nursing Fundamentals.

Mental Status Examination

Read about the components of a general survey in the “General Survey” chapter of Open RN Nursing Skills.

Signs of Distress

Level of Consciousness and Orientation

Appearance and General Behavior

Speech

Motor Activity

Affect and Mood

Thoughts and Perceptions

Attitude and Insight

Cognitive Abilities

Examiner’s Reaction to the Client

Review a brief mental status examination PDF form from TherapistAid.

Psychosocial Assessment

Review specific questions used during a psychosocial assessment/health history in the “Health History” chapter in Open RN Nursing Skills.

Cultural Formulation Interview Questions

Reason for Seeking Health Care

Thoughts of Suicide

Self-Injury

Family Dynamics

Review information about adverse childhood experiences (ACEs) in the “Mental Health and Mental Illness” section of Chapter 1.

Spiritual Assessment

The FICA© Spiritual History Tool [49]

Read more about spiritual assessment and providing spiritual care in the “Spirituality” chapter of Open RN Nursing Fundamentals.

Screening Tools

Laboratory and Diagnostic Testing

Life Span Considerations

Freud’s Psychosexual Theory of Development

Erikson’s Psychosocial Stages of Development

Piaget’s Cognitive Theory of Development

Cognitive Impairment

Review information about cognitive impairments associated with dementia and Alzheimer’s disease in the “Cognitive Impairments” chapter of Open RN Nursing Fundamentals.

Resilience

Read more about promoting resilience across the life span at Harvard’s Center on the Developing Child Resilience webpage.

Cultural Considerations

ANA’s Respectful and Equitable Practice Competencies [74]

Read more about cultural humility and advocating for the values, beliefs, and preferences of diverse clients in the “Diverse Clients” chapter of Open RN Nursing Fundamentals.

References

4.4. DIAGNOSIS

ANA’s Diagnosis Competencies [2]

Review how to analyze assessment data, make hypotheses, and create nursing diagnoses statements in the “Diagnosis” section of the “Nursing Process” chapter in Open RN Nursing Fundamentals.

Nursing Diagnoses

Prioritization

Common Nursing Diagnosis for Mental Health Conditions

Sample Case A

References

4.5. OUTCOME IDENTIFICATION

ANA’s Outcomes Identification Competencies [2]

Read more about how to use the “Motivational Interviewing” technique in setting individualized goals and expected outcomes with a client in the “Therapeutic Communication and Nurse-Client Relationship” chapter.

Review how to create “SMART” expected outcomes in the “Nursing Process” chapter of Open RN Nursing Fundamentals.

Unfolding Case A

References

4.6. PLANNING

ANA’s Planning Competencies [2]

Access the Evidence-Based Resource Center maintained by the Substance Abuse and Mental Services Administration (SAMHSA).

See sample planned nursing interventions for a client who has been diagnosed with Risk for Suicide in Table 4.6.

Review the “Establishing Safety” section for clients at risk for suicide in Chapter 1.

References

4.7. IMPLEMENTATION

ANA’s Implementation Competencies [2]

Coordination of Care

ANA’s Coordination of Care Competencies [3]

Health Teaching and Health Promotion

ANA’s Health Teaching and Health Promotion Competencies [4]

Pharmacological, Biological, and Integrative Therapies

APNA’s Pharmacological, Biological, and Integrative Therapies Competencies [8]

Read more details about different types of psychotherapy treatments in Psychology2e by OpenStax and on the National Alliance of Mental Illness (NAMI) website.

Read more about medications in the “Psychotropic Medications” chapter.

Milieu Therapy