Defining the Nursing Process
The nursing process is a scientific and systematic method for providing effective individualized
nursing care and serves as an aid in resolving client problems. This problemsolving approach allows the nurse to help the client achieve a maximal level of functioning and well-being. The nursing process is accepted by the nursing profession as a standard for providing ongoing nursing care that is adapted to individual client needs. Accountability to the client and communication between members of the mental health care team is enhanced by the process (see Chapter 21, The Treatment Team). The use of the nursing process also allows nurses to share information that is important to the continuity of client care and treatment. The nurse can reevaluate each step of the nursing process to adjust, revise, or terminate the plan of care based on new or added information. It is important to remember that each client’s response to therapy and treatment may be different. Adjustments can and will be made as the level of illness and dysfunction affects the independence and well-being of the client. Vital to this process is the therapeutic climate of the interaction between the client and members of the mental health team. The nurse is often the first member of the team that is in contact with the client. It is at this point that a therapeutic milieu is established. The milieu is an environment or surroundings that are modified to create a setting in which the client feels safe, secure, and free to express feelings and thoughts without fear of rejection, retaliation, or punishment. The nurse can initiate this atmosphere and establish a sense of trust by approaching the client in an accepting and nonjudgmental manner. This trusting relationship is vital to the successful outcome of improved functioning and well-being of the client (see Chapter 5, The Therapeutic Relationship).
Steps of the Nursing Process
Integral to the nursing process approach to nursing care is an organized method of problem solving called the care plan, which is developed from the data that are gathered during the initial phase. It consists of five steps that provide planned actions for resolving the problem:
· Nursing assessment
· Nursing diagnosis
· Expected outcome
· Nursing interventions
· Evaluation
Nursing Assessment
Assessment begins when the client is admitted or contact is made for the first time. Assessment continues as the cycle of the nursing process progresses and new information or changes occur in reference to the client. An assessment interview is usually conducted within the psychiatric setting; however, the psychosocial needs of a client are part of any nursing assessment, regardless of the setting, because symptoms seen in the mental health setting can also be seen in any area of health care. A standard assessment tool helps categorize the information received by the nurse. A basic psychosocial nursing assessment usually includes the client’s history and mental or emotional status and encompasses both subjective and objective data.
Subjective Data.
Subjective information is provided by the client. This information may need to be validated by other sources such as family, friends, law enforcement officers, or others who are involved. The client’s information may be supported or contradicted by others. The data include the client’s history and perception of the present situation or problem in addition to feelings, thoughts, symptoms, or emotions he or she may be experiencing. When collecting subjective data it is important for the nurse to be as accurate and descriptive as possible. Citing a direct quote of a
client statement is a way of describing what the client is saying without attempting to interpret
the intended meaning. Using the client’s own words to describe feelings or thoughts often provides insight into perceptual distortions or illogical thought processes. The subjective information gathered during the initial assessment will allow the nurse to establish a baseline used to formulate the care plan. By asking direct leading questions, the nurse gets a clear picture of certain problems or issues concerning the client. Successful gathering of data is based on the ability of the nurse to listen to the client. When the nurse selects a climate that ensures privacy and confidentiality, the client feels free to openly communicate personal feelings. Following are examples of leading questions that can be used to obtain data from the client during the assessment interview:
• Tell me what brought you to the hospital today.
• Was there any situation that caused you to feel this way?
• How did you react to the situation?
• Tell me how you are feeling about being here.
• Where do you live?
• Who lives with you?
• What type of work do you do?
• Have you been able to work prior to admission?
• What causes the most stress in your life?
• What do you do to alleviate the stress?
• Do you blame yourself for bad things that happen to you?
• Tell me about things that overwhelm you each day.
• Are you currently taking medication to help you through the stressful times?
Objective Data.
Objective information is observed by the nurse or provided by others who are familiar with the client or additional members of the health care team. The assessment includes the physical, emotional, intellectual, and social aspects of the client. A physical assessment includes medical history, past illnesses or surgeries, medication history, allergies, vital signs, height and weight, diet, and head-to-toe systems evaluation. Social issues may include relationships, family history of mental illness, religious and cultural beliefs, and specific health practices. The client’s emotional state, behavior, and thinking processes are all part of the mental assessment.
A standard mental status examination tool is used to assess cognitive, emotional, and behavioral information. At a Glance 3-3 provides a summary of a basic mental exam. (The
Mini-Mental Status Exam is found in Appendix B). It is most important to note both verbal
communication and nonverbal mannerisms, expressions, and emotions.
Nursing Diagnosis
Establishing a nursing diagnosis from collected data is the second step in the nursing process. The nurse analyzes all data gathered and compares it to normal functioning or values to find out if a problem or a potential problem exists. A nursing diagnosis is not a medical diagnosis but an identification of a client problem based on conclusions about the collected data. A nursing diagnosis may be an actual or potential health problem, depending on the situation. The most commonly used standard is that of the North American Nursing Diagnosis Association (NANDA). This is an approved list of problems that the nurse can legally address toward a measurable outcome. A list of nursing diagnoses approved by NANDA is found in Appendix C. Formulating a nursing diagnosis consists of three parts: (1) the actual or potential problem related to the client’s condition, (2) theb causative or contributing factors, and (3) a behavior or symptom that supports the problem. A nursing diagnosis is correctly written as follows: (problem) risk for injury, related to (contributing factor) marital breakup, evidenced by (behavior) suicidal ideation and gestures. Although a medical diagnosis is not used as the etiology of a nursing problem, signs and symptoms of the condition may be reflected in the cause. This is illustrated by a client who has sensory-perceptual alteration, related to auditory hallucinations, evidenced by talking to people who are not physically present. Determining the problem provides the groundwork for planning nursing interventions to meet the needs of the client for which
the nurse is responsible. Once applicable nursing diagnoses have been determined, they are prioritized according to the intensity and immediate urgency of the problem. Any health condition that endangers life will receive a high priority. Situations that are recurrent or chronic may be given a lower priority and will be addressed at a later time. A client with suicidal ideation or intent, for example, would have an immediate risk for self-injury. This problem would require the nurse’s attention first. Based on Maslow’s hierarchy of needs, basic physiologic needs such as oxygen, food, water, warmth, elimination, and sleep must be met before other needs of safety and security, love and belonging, self-esteem, and self-actualization can be achieved. This model can be seen as a staircase in which a client may vacillate between steps. Given that the client can move up and then back down, the nurse should understand that the priority given to a problem can change at any time during the treatment process.
Expected Outcomes
The next phase of the nursing process involves planning measurable and realistic outcomes that will anticipate the improvement or stabilization of the problem identified in the nursing diagnosis. These outcomes are defined in terms of short-term goals that address the immediate unmet needs of the client and long-term goals that achieve the maximal level of health that is realistic for the individual client at the time of discharge and as a member of society. These goals should be determined in collaboration with the client, so as to increase cooperation and compliance with therapeutic interventions. Listed below are examples of both shortterm
nd long-term outcome criteria for the nursing diagnosis, sensory/perceptual alteration, related to auditory hallucinations.
Short-Term Outcomes
• Client symptoms of auditory hallucinations will decrease within 48 hours.
• Client does not harm self or others in next 48 hours.
• Client identifies feelings associated with hallucinations with each episode.
• Client reports decrease in anxiety level within 24 hours.
Long-Term Outcomes
• Client demonstrates understanding of need for continued compliance with medication therapy by discharge.
• Client demonstrates awareness that hallucinations are the result of internal conflict within 1 week.
• Client identifies and demonstrates ways to maintain contact with reality at onset of symptoms by discharge.
• Client identifies environmental factors that precipitate the hallucinations by discharge.
• Client participates in activities that reinforce reality during hospitalization within 1 week.
Nursing Interventions
Nursing interventions are actions taken by the nurse to assist the client in achieving the anticipated outcomes. It is important to plan actions that are appropriate for the individual client and take into consideration the level of functioning that is realistic for that person. What may be realistic for one person may be unattainable for another. The written plan is a collaborative effort between all members of the health care team and is communicated to each health care worker. This helps to ensure the continuity of care and consistency in the implementation of interventions by all personnel. Consistency is a vital component of the therapeutic milieu. There are many clinical units that use standardized or computer-generated care plans or clinical pathways. In the current managed-care concept, these are designed to be cost-effective and improve the efficiency with which treatment is carried out. Regardless of the method used, the care plan identifies the outcomes and interventions that are to be addressed by each discipline of the care team. Specifically, the nursing care plan identifies those interventions for which the nurse has responsibility. It is imperative that the unique needs and problems of each client are retained as central to that person’s plan of care.
Evaluation
During the evaluation phase of the nursing rocess, the nurse evaluates the success of the nursing interventions in meeting the criteria outlined in the expected outcomes. Either the goal has been achieved, some progress has been made toward the intended outcome, or no steps forward have been observed or documented. Specific client behaviors may be revieweby the entire mental health care team to determine the overall success of the treat ment plan. If a goal has been partially met, there may be supporting data to indicate continuance of the current recognizes that the client may need more time to make changes and adjust to them. A istinction must be made between a lack of client motivation and the need for continuance of the current plan to help the client achieve the outcomes. Some interventions may have been ineffective, and thus new strategies may be needed to help meet the needs of the client. It is also important to reevaluate the outcome criteria; the expected outcome may not actually be achievable for this client. The evaluation phase is a form of validation or the entire nursing process in the delivery of care to the client. Continued data collection may indicate new problems or alterations in the original nursing diagnoses. Criteria are reevaluated to clarify realistic and measurable terms for the individual client. Nursing strategies are reevaluated for effectiveness. This persistence in maintaining a therapeutic approach toward resolution of client problems provides the continuity needed to expedite the treatment process.
Refferensi
Alfaro, R.(1990).Applying nursing diagnosis and nursing process. Philadelpia:J.B Lippincot
American Nurses’Association.(1991). Standart of clinical nursing practice. Washington, DC : American nurses publishing.
Doenges, M. E., Townsend, M. C., & Moorhouse, M. F. (1995). Psychiatric care plans (3rd ed.). Philadelphia, PA: F. A. Davis.
Hickey,P.(1990).Nursing process handbook. St. Louis: C. V. Mosby
Redman, B. (1993). The process of patient education. (7th ed). St. Louis: C. V. Mosby.
Wilkinson,J.(1992). Nursing process in action: A critical thingking approach. Menlo park, CA : Addison-wesley.
