NURSING PROCESS & MENTAL HEALTH CONDITIONS
NURSING PROCESS & MENTAL HEALTH CONDITIONS
### 1. **Assessment**
- **Objective:** Gather comprehensive data about the patient's mental and physical health, including their history, symptoms, behavior, thoughts, and feelings.
- **Methods:** Interviewing the patient and family, conducting mental status examinations, observing behavior, and reviewing medical records.
- **Common Findings:** Hallucinations, delusions, mood swings, anxiety, disorganized thoughts, impaired social interactions, and risk of self-harm.
### 2. **Diagnosis**
Based on the assessment, the following nursing problems may be identified for common psychiatric conditions:
#### **1. Schizophrenia:**
- **Nursing Problems:**
- Impaired sensory perception (e.g., auditory or visual hallucinations)
- Disturbed thought processes (e.g., delusions, paranoia)
- Social isolation
- Self-care deficit
- Risk for violence (self-directed or directed at others)
#### **2. Major Depressive Disorder (MDD):**
- **Nursing Problems:**
- Risk for suicide
- Ineffective coping
- Chronic low self-esteem
- Imbalanced nutrition (less than body requirements)
- Sleep pattern disturbance
#### **3. Bipolar Disorder:**
- **Nursing Problems:**
- Risk for injury (due to impulsivity during manic episodes)
- Disturbed sleep pattern
- Impaired social interaction
- Ineffective health maintenance
- Risk for imbalanced nutrition (during manic or depressive phases)
#### **4. Anxiety Disorders:**
- **Nursing Problems:**
- Anxiety (acute or chronic)
- Ineffective coping
- Social isolation
- Disturbed sleep pattern
- Impaired role performance
#### **5. Obsessive-Compulsive Disorder (OCD):**
- **Nursing Problems:**
- Anxiety
- Ineffective coping
- Risk for injury (due to compulsive behaviors)
- Impaired social interaction
- Disturbed thought processes
#### **6. Post-Traumatic Stress Disorder (PTSD):**
- **Nursing Problems:**
- Anxiety
- Flashbacks or intrusive thoughts
- Sleep disturbances (e.g., nightmares)
- Risk for self-harm
- Impaired social interaction
#### **7. Substance Use Disorders:**
- **Nursing Problems:**
- Risk for withdrawal symptoms
- Ineffective coping
- Impaired social interaction
- Risk for injury
- Disturbed thought processes
#### **8. Personality Disorders (e.g., Borderline Personality Disorder):**
- **Nursing Problems:**
- Risk for self-mutilation
- Impaired social interaction
- Chronic low self-esteem
- Ineffective coping
- Risk for suicide
### 3. **Planning**
- **Objective:** Develop a care plan with specific goals and outcomes based on the identified nursing problems.
- **Examples of Goals:**
- The patient will verbalize a reduction in hallucinations within one week.
- The patient will demonstrate effective coping mechanisms during anxiety episodes.
- The patient will maintain a safe environment, minimizing the risk of self-harm.
### 4. **Implementation**
- **Objective:** Execute the care plan using nursing interventions to achieve the identified goals.
- **Interventions Include:**
- **For Schizophrenia:** Reality orientation, administering antipsychotic medications, creating a safe environment.
- **For MDD:** Providing support for expressing emotions, medication management (e.g., antidepressants), monitoring for suicidal ideation.
- **For Bipolar Disorder:** Ensuring medication adherence (e.g., mood stabilizers), providing structured environments, and educating on recognizing triggers.
- **For Anxiety Disorders:** Teaching relaxation techniques, cognitive-behavioral strategies, and gradual exposure to anxiety-provoking stimuli.
- **For OCD:** Encouraging the use of anxiety-reduction techniques, supporting gradual exposure and response prevention.
- **For PTSD:** Providing a safe space to discuss trauma, teaching grounding techniques, and connecting with support groups.
- **For Substance Use Disorders:** Offering detoxification support, educating about relapse prevention, and referring to support programs.
- **For Personality Disorders:** Establishing therapeutic boundaries, offering consistent support, and encouraging positive self-esteem practices.
### 5. **Evaluation**
- **Objective:** Assess the effectiveness of the nursing interventions in achieving the desired outcomes.
- **Questions for Evaluation:**
- Has the patient shown a reduction in anxiety or hallucinations?
- Are coping strategies being used effectively?
- Is there an improvement in social interactions and self-care?
- Has the risk of self-harm or suicide decreased?
**Note:** The nursing process is iterative, meaning if the goals still need to be met, the process must be revisited with new assessments, diagnoses, and plans. This ensures that care remains patient-centered and adaptive to changing needs.
Interventions for each identified nursing problem associated with common psychiatric conditions, following the nursing process.
1. Schizophrenia
Nursing Problem: Impaired Sensory Perception (e.g., Hallucinations)
- Interventions:
- Reality Orientation: Engage the patient in reality-based conversations and activities. Gently remind the patient of what is real and what is not.
- Medication Management: Administer antipsychotic medications as prescribed and monitor for side effects. Educate the patient on the importance of adherence to medication.
- Environmental Control: Reduce stimuli that may exacerbate hallucinations, such as noise or bright lights.
Nursing Problem: Disturbed Thought Processes (e.g., Delusions, Paranoia)
- Interventions:
- Therapeutic Communication: Avoid arguing with the patient about their delusions. Instead, focus on the feelings expressed and offer reassurance.
- Build Trust: Establish a trusting relationship by being consistent and reliable in care, which can help reduce paranoia.
- Cognitive-Behavioral Therapy (CBT): If appropriate, involve the patient in CBT to challenge and modify distorted thoughts.
Nursing Problem: Social Isolation
- Interventions:
- Encourage Social Interaction: Gradually introduce the patient to group activities or social situations where they can interact with others.
- Support Groups: Encourage participation in support groups for individuals with schizophrenia to promote socialization in a safe environment.
- One-on-One Interaction: Spend time with the patient to reduce feelings of isolation and build rapport.
Nursing Problem: Self-Care Deficit
- Interventions:
- Assist with Activities of Daily Living (ADLs): Help the patient with grooming, hygiene, and dressing as needed, while encouraging independence.
- Teach Self-Care Skills: Provide education and support in developing routines for personal care.
- Regular Monitoring: Check regularly on the patient’s ability to perform self-care activities and intervene when necessary.
Nursing Problem: Risk for Violence
- Interventions:
- Create a Safe Environment: Remove potentially harmful objects from the patient’s surroundings.
- Monitor Behavior: Observe for signs of increasing agitation or aggression, and intervene early to de-escalate the situation.
- De-Escalation Techniques: Use calm, non-threatening communication to defuse potential violence. Employ restraint only if necessary and as a last resort.
2. Major Depressive Disorder (MDD)
Nursing Problem: Risk for Suicide
- Interventions:
- Suicide Risk Assessment: Perform regular and thorough assessments of suicidal ideation, including specific plans or intentions.
- Safety Measures: Implement suicide precautions, such as removing harmful objects and close monitoring, especially during high-risk times.
- Therapeutic Communication: Provide a nonjudgmental and empathetic environment where the patient feels safe expressing thoughts and emotions.
Nursing Problem: Ineffective Coping
- Interventions:
- Teach Coping Strategies: Educate the patient on healthy coping mechanisms, such as problem-solving skills, relaxation techniques, and journaling.
- Support Systems: Encourage the patient to utilize available support systems, including family, friends, and community resources.
- Cognitive-Behavioral Therapy (CBT): Collaborate with mental health professionals to provide CBT, which can help the patient reframe negative thoughts.
Nursing Problem: Chronic Low Self-Esteem
- Interventions:
- Positive Reinforcement: Acknowledge and praise the patient’s strengths and accomplishments, no matter how small.
- Support Identity Formation: Help the patient identify positive aspects of themselves and set achievable goals.
- Therapeutic Relationship: Build a trusting relationship to provide a foundation for improving self-esteem.
Nursing Problem: Imbalanced Nutrition (Less than Body Requirements)
- Interventions:
- Nutritional Assessment: Regularly assess the patient’s nutritional status, including weight, dietary intake, and laboratory values.
- Meal Planning: Work with a dietitian to develop a meal plan that meets the patient’s nutritional needs and preferences.
- Monitor Eating Habits: Observe the patient’s eating patterns and provide assistance or encouragement as needed.
Nursing Problem: Sleep Pattern Disturbance
- Interventions:
- Promote Sleep Hygiene: Educate the patient on good sleep practices, such as maintaining a regular sleep schedule and creating a restful environment.
- Medications: Administer prescribed sleep aids or other medications that promote restful sleep, and monitor their effectiveness.
- Relaxation Techniques: Teach relaxation exercises, such as deep breathing or progressive muscle relaxation, to help the patient wind down before bedtime.
3. Bipolar Disorder
Nursing Problem: Risk for Injury (Due to Impulsivity During Manic Episodes)
- Interventions:
- Monitor Activity Levels: Supervise the patient’s activities to prevent accidental injury or risky behavior.
- Set Limits: Establish clear, firm limits on behavior that could lead to harm, and communicate these to the patient.
- Medication Management: Ensure the patient receives mood stabilizers as prescribed and monitor for signs of hyperactivity or impulsivity.
Nursing Problem: Disturbed Sleep Pattern
- Interventions:
- Structured Routine: Encourage the patient to maintain a consistent daily routine, including regular sleep times.
- Environment Control: Create a calm, quiet environment that is conducive to sleep, especially during manic phases.
- Medication: Administer sleep medications or mood stabilizers as prescribed to help regulate the sleep-wake cycle.
Nursing Problem: Impaired Social Interaction
- Interventions:
- Social Skills Training: Teach the patient effective communication and social skills to improve interactions with others.
- Encourage Appropriate Behavior: Reinforce appropriate social behaviors and provide feedback on interactions.
- Group Therapy: Involve the patient in group therapy sessions where they can practice social skills in a supportive setting.
Nursing Problem: Ineffective Health Maintenance
- Interventions:
- Health Education: Educate the patient about the importance of medication adherence, regular health check-ups, and self-care practices.
- Monitor for Relapse: Watch for signs of relapse or noncompliance with treatment, and intervene early.
- Support System: Encourage the involvement of family or caregivers in the patient’s care to help maintain health routines.
Nursing Problem: Risk for Imbalanced Nutrition
- Interventions:
- Dietary Monitoring: Monitor the patient’s dietary intake, especially during manic phases when they may neglect nutrition.
- Nutritional Counseling: Work with a dietitian to develop a balanced meal plan that addresses the patient’s specific needs.
- Supplemental Nutrition: Provide nutritional supplements if the patient is unable to meet dietary needs through food alone.
4. Anxiety Disorders
Nursing Problem: Anxiety (Acute or Chronic)
- Interventions:
- Anxiety Reduction Techniques: Teach and practice relaxation techniques such as deep breathing, meditation, or progressive muscle relaxation.
- Cognitive Behavioral Therapy (CBT): Collaborate with mental health professionals to engage the patient in CBT to address and manage anxiety.
- Create a Calming Environment: Modify the patient’s environment to reduce stressors and triggers that may exacerbate anxiety.
Nursing Problem: Ineffective Coping
- Interventions:
- Teach Coping Strategies: Educate the patient on positive coping mechanisms such as mindfulness, exercise, and journaling.
- Problem-Solving Skills: Assist the patient in developing problem-solving skills to effectively manage stressors.
- Referral to Support Services: Refer the patient to support groups or therapy where coping strategies can be further developed.
Nursing Problem: Social Isolation
- Interventions:
- Gradual Exposure: Encourage gradual exposure to social situations, beginning with less anxiety-provoking interactions.
- Supportive Interaction: Provide a supportive environment where the patient feels comfortable discussing fears and social anxieties.
- Group Therapy: Recommend participation in group therapy to practice social skills in a safe, controlled setting.
Nursing Problem: Disturbed Sleep Pattern
- Interventions:
- Promote Sleep Hygiene: Provide education on good sleep practices, such as a consistent sleep routine and reducing caffeine intake.
- Relaxation Exercises: Teach the patient relaxation exercises to perform before bedtime to help reduce anxiety and promote sleep.
- Monitor Medication: Administer anxiolytics or other prescribed medications that may aid in sleep, and monitor their effectiveness.
Nursing Problem: Impaired Role Performance
- Interventions:
- Support Role Adaptation: Help the patient identify and adapt to new or modified roles that accommodate their current capabilities.
- Reinforce Strengths: Highlight and reinforce the patient’s strengths and successes in their roles, no matter how small.
- Goal Setting: Work with the patient to set realistic and achievable goals related to role performance.
5. Obsessive-Compulsive Disorder (OCD)
Nursing Problem: Anxiety
- Interventions:
- Exposure and Response Prevention (ERP): Collaborate with mental health professionals to engage the patient in ERP therapy to reduce compulsions.
- Relaxation Techniques: Teach and practice anxiety reduction techniques, such as deep breathing and guided imagery.
- Supportive Environment: Provide a calm and supportive environment where the patient feels safe discussing
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.
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.
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.
Mental Status
Examination
Registered nurses must use effective clinical interviewing skills while
performing a mental status assessment and developing a therapeutic nurse-client
relationship.
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.
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). 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.
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.
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. 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.
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?
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. 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. Paranoia is a condition
characterized by delusions of persecution. 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. Rumination is obsessional thinking involving
excessive, repetitive thoughts that interfere with other forms of mental
activity.
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?”
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. 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.”
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.” The term word salad refers
to severely disorganized and virtually incomprehensible speech or writing,
marked by severe loosening of associations.
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. 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.
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, over dramatization, 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?
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. 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.
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.
Nurses should
also be aware of counter transference. Counter transference 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 counter transference reaction
related to their previous parenting experience.
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
- 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
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.
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.
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.
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. 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. . 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.
The FICA
Spiritual History Tool© is a common tool used to gather information about a
patient’s spiritual history and preferences. FICA is a mnemonic for
Faith, Importance, Community, and Address in Care. Read more about the FICA
tool in the following box.
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.
Sample PQRSTU
Questions
|
PQRSTU |
Sample
Questions |
|
Provocation/Palliation |
What makes
your pain worse? |
|
Quality |
What does the
pain feel like? |
|
Region |
Where exactly
do you feel the pain? Does it move around or radiate elsewhere? |
|
Severity |
How would you
rate your pain on a scale of 0 to 10, with “0” being no pain and “10” being
the worst pain you’ve ever experienced? |
|
Timing/Treatment |
When did the
pain start? |
|
Understanding |
What do you
think is causing the pain? |
The FICA
Spiritual History Tool
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?”
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.
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.
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.
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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 :
- 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.
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.
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.
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.
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.
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