for nursing students

1. The Nursing Process in
Psychiatric-Mental Health
Care
mk
Gary D. Patricio, RN

2. A. Assessment: Gathering the Big Picture
Subjective Data
This includes what the patient tells you, their own
experiences, feelings, and perspectives. It's like piecing
together their story. We use a variety of tools like the
nursing history and Gordon's Functional Health Patterns to
gather this information.
Objective Data
This is information we observe directly. It could include
things like their appearance, behavior, and responses to
questions. We'll also use tools like the mental status
assessment and psychosocial assessment to gather this
data.

3. Assessment: Exploring the
Patient's World
1 Mental Status
Assessment
This examines the patient's
thought processes, mood, and
behavior. It helps us
understand their current
mental state.
2 Psychosocial
Assessment
We delve into their social
support, coping skills, and
family history to understand
the factors influencing their
well-being.
3 Ethno-Cultural and Spiritual Assessment
We acknowledge the unique cultural and spiritual backgrounds that
shape each patient's experience.

4. Assessment: Utilizing the Tools
Other Assessment Tools
Tools like scales and questionnaires can help us measure specific aspects of
mental health, such as anxiety or depression.
Psychological Tests
These delve deeper into the patient's personality and cognitive abilities.
Personality Tests
These assess traits and patterns of behavior, giving us a better understanding of
their personality.
Intelligence Tests
These gauge cognitive abilities, such as memory and problem-solving skills.

5. Assessment: Completing the
Picture
Diagnostic and
Laboratory
Examinations
Sometimes, physical
health factors can
contribute to mental
health issues, so we
may need to order tests
to rule out medical
conditions.
Brain Imaging
Imaging techniques like
MRI or CT scans can
provide visual
information about the
brain, helpful for
understanding certain
conditions.
Review of Past
Medical History
We carefully review their
medical history to
understand any relevant
past experiences and
treatments.

6. B. Nursing Diagnosis:
Identifying the Needs
1 NANDA Taxonomy
We use the North American Nursing Diagnosis
Association (NANDA) to identify and label specific nursing
diagnoses related to mental health issues.
2 NOC (Nursing Outcomes Classification)
This helps us predict and measure the expected
outcomes of our care. We want to know what changes we
can realistically hope for.

7. Nursing Diagnosis: Examples
Risk for Self-Harm
This identifies patients who are at risk
of harming themselves, often due to
suicidal thoughts or behaviors.
Impaired Social Interaction
This refers to difficulty forming and
maintaining healthy relationships,
which can impact a person's overall
well-being.
Anxiety
This diagnosis addresses excessive
worry and fear, which can manifest in
various ways.

8. C. Planning: Setting Goals and Actions
After identifying a nursing
diagnosis, we work with the
patient to develop individualized
care plans. These plans outline
specific goals and actions to
address their needs.
It's a collaborative process. We
listen to their concerns and
preferences, and work together to
make sure the plan feels realistic
and achievable.
These plans are designed to
promote safety, improve coping
skills, enhance their well-being,
and ultimately help them reach
their goals.

9. Planning: Examples
Reduce self-harm risk
This might involve creating a
safety plan, identifying
triggers, and developing
coping mechanisms to
manage stressful situations.
Improve social
interaction
We might use strategies to
help the patient develop
communication skills, build
rapport, and participate in
social activities.
Reduce anxiety
We could explore relaxation techniques, mindfulness exercises, and
medication to help manage their anxiety symptoms.

10. D. Implementation: Taking Action
Therapeutic Communication
This is the foundation of our care. We
create a safe, supportive space where
the patient feels heard and
understood.
Medication Administration
We ensure safe and accurate
medication administration, monitoring
for side effects and adjusting dosages
as needed.
Psychotherapy
We may refer patients to therapists
who can provide specialized treatment
for their mental health concerns.

11. Implementation: Promoting
Well-being
1 Individualized Care
We tailor care plans to meet each patient's specific needs,
recognizing that everyone's journey is unique.
2 Group Therapy
This can provide a sense of belonging, offer peer support, and
help patients learn from each other's experiences.
3 Milieu Therapy
We create a therapeutic environment that fosters healing and
promotes positive interaction.

12. E. Evaluation: Assessing
Progress
1 Monitor Patient
Progress
We regularly check in with
the patient to see how
they're doing and if the care
plan is making a difference.
2 Assess Goal
Achievement
We track their progress
towards their goals, noting
any significant changes in
their behavior, symptoms,
or well-being.
3 Evaluate Plan Effectiveness
We analyze whether the care plan is achieving its desired
outcomes, and if not, we work together to adjust it.

13. Evaluation: Tools and
Techniques
Patient Feedback
We actively encourage
patients to share their
experiences and perspectives,
making sure they feel
comfortable expressing their
thoughts.
Symptom Monitoring
We may use scales or
questionnaires to assess
changes in their symptoms,
such as anxiety, depression,
or pain.
Behavioral Observations
We observe their behavior and interaction with others to identify
patterns and measure progress.

14. Evaluation: Adjusting as Needed
Reassess and Adjust
If the care plan isn't working as well as we hoped, we
reassess their needs and adjust the plan to better meet
them.
Patient-Centered Care
We remember that each patient's journey is unique, and
we're committed to providing individualized care that
promotes their well-being.

15. The Nursing Process: A Dynamic Framework
Assessment
Gathering the big picture
1
Nursing Diagnosis
Identifying the needs
2
Planning
Setting goals and actions
3
Implementation
Taking action
4
Evaluation
Assessing progress
5

16. Collaboration: A Team Approach
1
Doctors
Provide medical diagnosis and prescribe medications.
2
Nurses
Provide direct patient care, administer medications, and monitor for side effects.
3
Therapists
Offer specialized therapeutic interventions, such as cognitive-behavioral
therapy or group therapy.
4
Social Workers
Help patients navigate social and practical challenges, such as
housing, employment, and legal issues.

17. Challenges in Psychiatric-Mental Health Care
1
Stigma
Mental health stigma is still prevalent, leading some patients to avoid seeking help.
2
Resource Limitations
Access to mental health care can be limited, particularly in underserved
communities.
3
Complexity of Conditions
Mental health conditions can be complex and challenging
to treat, requiring a comprehensive and personalized
approach.

18. Clinical Pathways:
Psychiatric-Mental Health
Care
Depression
Clinical pathways for depression might outline specific treatments, such
as psychotherapy, medication, and lifestyle interventions.
Anxiety Disorders
They could address specific anxiety disorders like generalized anxiety
disorder or panic disorder, outlining appropriate treatments and
strategies.
Schizophrenia
Clinical pathways for schizophrenia might outline medication
management, psychosocial interventions, and strategies to
manage symptoms.

19. Stages of Development of
Therapeutic Relationship
mk
Gary D. Patricio, RN

20. Phases of Therapeutic Nurse-
Patient Relationship
1 Pre-Interaction
Preparing for the relationship.
2 Orientation
Establishing trust and rapport.
3 Working
Collaborating on care goals.
4 Termination
Ending the relationship professionally.

21. Pre-Orientation Stage
Self Awareness – a primary requirement of Therapeutic Nurse-Patient Relationship

22. JOHARI’s WINDOW
1. PUBLIC
Known to SELF and OTHERS
2. BLIND
Known only to OTHERS
3. HIDDEN
Known only to SELF
4. UNKNOWN/CLOSE
NOT Known to SELF nor OTHERS

23. Nurse’s Tasks
• Explore own: (know, experience and feel)
F – feeling
F – Fantasies
F – Fears
• Analyze own professional strength and
limitations
• Gather data about patient when possible

24. Orientation Phase – introductory phase
Can be summarized by acronym (A T N G)

25. Assessment
• Determine why patient sought help (chief complaints)
-Environmental change
- Nurturance (aruga)
- Control
- Problem Solving
- Psychiatric symptoms
- Advise to seek health/help
• Explore patient’s thoughts, feelings, & actions
- Document everything of what the patient has to say

26. Trust
1. Consistently make patient feel important
2. Establish trust, acceptance and open communication
3. Mutually formulate a contract
• Elements of contract
a) Names of individuals
b) Roles
c) Responsibilities
d) Expectation of the nurse and patient
e) Purpose of the relationship (professional)
f) Time of meetings (how long & 8am is 8am)
g) Meeting location
h) Conditions for termination

27. Nursing Diagnosis
Identify patients problem depends on the assessment
Nursing Goals
Define goals with the patient

28. Working Phase – most productive phase
• All starts with CATHARSIS ( allowing of feelings in free judgement environment)
• Coping mechanisms are used and resulting to Appropriate Behavior
• Insight is developed ( pt awareness or recognition that he/she has a problem
• Stressors are explored
• Independence is achieved. Thus,
• Making patient PREPARED for TERMINATION
• (note: prepare for termination = working phase
• Introduction of termination = orientation phase
• Goal evaluated & modified if needed
• Overcome resistance behaviors (absenteeism, tardiness, superficial talks)

29. Working phase- acronym (AEIOU)
• Assess continuously
• Evaluate further/ explore relevant stressors
• Independence increase and insight developed and use
of coping mechanism
• Overcome resistance behaviors
• Use prepare termination phase

30. Termination Phase – can occur anytime
• Establish reality of separation
• Evaluate accomplished goals
• Mutually explore feelings of rejection, loss, sadness and anger and other related behaviors
• Evaluate general progress of therapy
• Maintain initially defined boundaries
• Anticipate problems of this phase: (expect)
• Denial
• Regression
• anger

31. Criteria for Determining Patient’s Readiness for Termin
• 20% - experience relief from the presenting problem
• 20% - social function has improved/ isolation decreased
• 20% - goals are accomplished
• 20% - employs coping mechanism
• 20% - ego functions has been strengthen
• 100% - an impasse has been reached in NPR because of
resistance or countertransference that cannot be worked
through

32. Communication is
NOT ALL THE TIME
Talking

33. Factors Influencing
Communication
1 Environment: Noise,
privacy, temperature.
2 Physical limitations: Pain,
fatigue, sensory
impairments.
3 Kinesics: Body language, facial expressions.

34. Challenges in
Communication
Language barriers
Difficulty understanding
spoken or written language.
Cultural differences
Variations in communication
styles and beliefs.
Emotional distress
Client's emotional state affecting communication.

35. What are 5 elements of
COMMUNICATION
Sender
Message
Receiver/ Recipient
Feedback
Context – where & why the communication is taking place

36. Nonverbal Communication
70%
Nonverbal
30%
Verbal

37. Types of Nonverbal
Communication
1 Kinesics: Body language, facial expressions, posture and mannerisms.
2 Proxemics: Use of space and distance between two communicators.
3 Haptics: Touch.
4 SILENCE.
5 Paralanguage – Pitch/Volume of voice
Intimate – 0 to 18 inches
Personal – 18in to 4 feet
Social – 9 to 12 feet
Public – more than 12 feet

38. Therapeutic Communication
Techniques
Listening
An active processing
of receiving &
examining reaction to
message
Broad Opening
Encouraging the
patient to select
topics for discussion
Restating
Repeating the main
thought the patient
expressed
Example
Maintaining good eye
contact
Example
Where would you like to
begin?
How are you feeling right
Example
P. I’m awake most of the
night
N. You have difficulty of

39. Therapeutic Communication
Techniques
Clarification
Attempting to put
into words vague
ideas or unclear
thoughts of pt.
Reflection
Directing back the
patients ideas,
feelings, questions &
content
Silence
Lack of verbal
communication for
therapeutic reason
Example
I don’t understand of
what you have just said,
could you repeat it for
Example
P. I relied on the wrong guy
N. The wrong guy
Example
Allowing patient a time to
think and gain insight

40. Therapeutic Communication
Techniques
Focusing
Questions or
statement help the
patient expand on a
topic of importance
Sharing perception
Asking pt to verify
nurse’s understanding
of what the pt is
thinking or feeling
Theme identification
Underlying issues or
problems exp by the pt
that emerge repeatedly
during the course of NPR
Example
I think we should talk more
about your relationship
with your father
Example
Nurse share its own
interpretation of what
patient does
Example
I have noticed that in 5days
talking, you’ve been hurt by
your men in you

41. Therapeutic Communication
Techniques
Giving information
Making available to
the patient facts that
he/she needs
Showing acceptance
Indicates that nurse
has heard & is following
the communication
trend
Offering self
Unconditional willingness
to be available
Example
I am nurse Gary assigned
to you (honesty)
Example
Nodding your head
(yes.! Okay.!)
Example
I will stay with you for a
while

42. Therapeutic Communication
Techniques
Offering general leads
Encourages the
individual to continue in
the direction of
conversation already
begun
Encouraging description of
perception & feelings
Learn how the patient
perceives a feeling or
interpret events
Encouraging comparison
Patient is asked to
compare experiences and
ideas
Example
Go on!, and then?, and
next?
Example
P. They don’t love me
anymore
N. they? Who are they?
Note: avoid altered thought
Example
Your mother…. Etc…
How about your father??

43. Therapeutic Communication
Techniques
Seeking validation
Process if verifying
accuracy of massage
sent
Placing events in
sequence or time
Seeing events in
perspective in relation
to tome and their order
Voicing doubts
Lets individual know that
others do not perceive in
the same way
Example
Same with clarification but
with choices
Example
When did it happen?
Before you enter college or
after your college
Example
Really?, is that so?, it is
quite hard to believe.
Presenting reality.

44. Goals of the Therapeutic Relationship
Promote client's well-being.
Facilitate client's self-care.
Improve client's coping skills.
Establish a safe and trusting environment.

45. Thank you..!!