Defining Mental Health and Mental Illness
Mental health is defined as successful performance of mental functions, resulting in the ability to engage in productive activities, enjoy fulfilling relationships, and change or cope with adversity.
Mental illness is considered a clinically significant behavioral or psychological syndrome experienced by a person and marked by distress, disability, or the risk of suffering disability or loss of freedom (APA,2008).
Mental health and mental illness can be viewed as ends points on a continuum, with movement back and forth throughout life. You will be studying the continuum from several levels :
- Physical level, in the structure and function of the brain.
- Personal level, in caring for and about the self.
- Interpersonal level, in interactions with others.
- Societal level, in social conditions and the cultural context.
Mental health nursing divided to acute care setting and community setting.
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 problem solving 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. 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.
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.
Examples of Objective Data
• Physical exam
• Behavior
• Mood and affect
• Awareness
• Thought processes
• Appearance
• Activity
• Judgment
• Response to environment
• Perceptual ability
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. It is most important to note both verbal communication and nonverbal mannerisms, expressions, and emotions. Look for congruency between what the client is saying and what is displayed in the accompanying behavior. It is also important to recognize if the client poses any immediate threat or danger to self or others, in which case safety becomes a priority and must be secured.
Components of Mental Status Assessment
• Appearance (grooming, dress, hygiene, eye contact, skin markings, posture, facial expression)
• Motor activity (pacing, slow, rigid, relaxed, restless, combative, bizarre, gait, hyperactive, retarded, aggressive)
• Attitude (cooperative or uncooperative, friendly, hostile, apathetic, suspicious)
• Speech pattern (speed, volume, articulation, congruence, confabulation, slurring, dysphasia)
• Mood (intensity, depth, duration, anxious, sad, euphoric, labile, fearful, irritable, depressed)
• Affect (flat or absence of emotional expression, blunted, congruence with mood, appropriate or inappropriate)
• Level of awareness (level of consciousness, attention span, comprehension, processing)
• Orientation (time, place, person)
• Memory (recent and remote)
• Understanding of illness/insight (ability to perceive and understand illness—symptoms as related to illness)
• Ability to describe stressors (internal or psychologic/physical in nature, and external or actual loss)
• Thought processes (speed, content, organization, logical or illogical, delusions, abstract or concrete)
• Perceptual disturbances (hallucinations, illusions, depersonalization, distortions)
• Judgment (problem-solving and decision-making ability)
• Adaptive or maladaptive defense mechanisms
• Relationships (attainment and maintenance of satisfying interpersonal relationships)
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.
Formulating a nursing diagnosis consists of three parts: (1) the actual or potential problem related to the client’s condition, (2) the 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. To illustrate this concept, a client who has begun to identify strengths and display positive self-talk (self esteem level need) is told by another client that she is stupid and ugly. The client has now refused to eat for two meals. At this point the nutritional needs of the client become the priority.
It is also important to give priority to the problem that the client is currently experiencing
(actual) over a problem that may happen (potential). An actual problem has priority over one that could possibly occur during the course of the illness. Acute withdrawal symptoms in the client with multiple substance abuse would have priority over the potential for social isolation in that individual.
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 short-term and 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 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.
Nursing interventions that focus on mental health care do not involve intensive physical care nursing skills. Rather, the nurse focuses on observing behaviors and symptoms, improving communication strategies, and assisting the client in problem-solving with improved overall functioning. Nursing interventions are implemented according to the nurse’s level of practice. Achievement of the anticipated outcomes is difficult for psychiatric clients. Many require extensive reinforcement and reassurance to change behaviors and understand the underlying emotional issues.
This step of the nursing process should focus on helping clients rechannel their energies in a constructive manner. The nursing interventions should be based on scientific principles for resolution of the identified problem and should be safe for the client and others involved. Other chapters in this text will include appropriate nursing actions for clients with the various categories of mental disorders. As strategies are implemented and documented, a picture of client progress evolves.
Data collection is continuous during the implementation phase. Client response to interventions provides valuable information that assists the nurse in determining whether the client is making progress toward the defined outcome criteria. Additional data also aid in the planning of ongoing nursing care.
Evaluation
During the evaluation phase of the nursing process, 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 reviewed by the entire mental health care team to determine the overall success of the treatment plan. If a goal has been partially met, there may be supporting data to indicate continuance of the current plan of care. This approach recognizes that the client may need more time to make changes and adjust to them. A distinction 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 for 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.
Application of the
Nursing Process
As you study the various mental disorders and situations in this textbook, you will find a section in most chapters that reinforces the application of the nursing process. However, to facilitate your understanding of this process as it relates to the mental health setting, we need to apply this concept to an actual client situation. The following situation will demonstrate the application of the process for three applicable nursing diagnoses.
Sample Client Situation: End of the Road
Freda is a 47-year-old public school teacher who received word several days ago that her only child, 23-year-old Benjamin, was arrested for armed robbery. Benjamin is married and the father of two small children. Two months ago, Freda discovered that her husband of 26 years is having an affair. Freda blames herself for his indiscretion, stating that she is overweight and unattractive. She says that he would be better off without her anyway. She feels that she is a failure as both a mother and a wife. She is unable to concentrate in the classroom and has considered a leave of absence from her job. Last night Freda’s husband told her he was leaving her and wanted a divorce. Freda is brought to the emergency room this morning after being found unresponsive by her daughter-in-law, Andrea. Andrea gives the nurse an empty bottle of Xanax (alprazolam). She also tells the nurse that Freda has been drinking a lot of wine in the past few months. After initial treatment, Freda is admitted to the psychiatric unit with a diagnosis of depressive episode: situational crisis with suicide attempt.
Nursing Assessment
The mental health nurse obtains the following data.
Objective Data
• Suicide attempt with Xanax and alcohol
• Was found unresponsive by daughter-in-law
• Is overweight and has unkempt appearance
• Son has been arrested for armed robbery
• Has two small grandchildren she loves
• Husband has asked for divorce after several months of infidelity
• Has been drinking more in past few months
Subjective Data
• “I don’t blame him for finding someone else. I am so fat and ugly.”
• “He would be better off without me anyway. I’m such a mess.”
• “I must have done something wrong for my son to be in so much trouble. I can’t do anything right.”
• “I can’t even think clearly enough to teach my kids what I’m supposed to. I might as well quit.”
• “The only good thing in my life are my little grandkids. They deserve better than me.”
CARE PLAN
| Nursing Diagnoses | Expected Outcomes | Nursing Interventions | Evaluation |
| Risk for self-injury, related to suicide attempt, evidenced by suicide overdose with use of alcohol Coping, ineffective individual, related to life events, as evidenced by drinking more and inability to meet role expectations. Self-esteem, situational low, related inability to handle life events, evidenced by feelings of self-blame and inadequacy. | -Does not engage in self destructive behavior while hospitalized. -Begins to explore reasons for substance abuse by 48 hours. -Expresses feelings of sadness and despair in 48 hours. -Signs contract that she will not harm herself in 24 hours. -Performs activities of daily living in next 2 days. -Communicates feelings about current situation in next 2 days. -Participates in determining goals for improvement in 2 days. -Identifies at least two adaptive coping strategies in 2 days. -Implements one adaptive coping strategy by the end of 1 week. -Identifies support systems available to her by the end of 1 week. -Refrains from self-blame and negative self-talk by end of 1 week. -Participates in self-care with interest in self improvement in 2 days. -Identifies positive life accomplishments And personal strengths in 3 days. -Identifies internal factors that harm self-esteem in 1 week. -Participates in unit activities in 2 days. -Discusses realistic goals for self-improvement by discharge. | -Monitor frequently for signs of over sedation. -Monitor vital signs every half-hour. -Assess for social withdrawal or isolation. -Assess for self destructive thoughts. -Remove potentially dangerous items from Room. -Provide quiet, soothing environment. -Monitor mood, affect, and behavior. -Help to perform activities of daily living. -Encourage to make decisions about self-care. -Encourage expression of feelings. -Help to identify internal factors of self-blame. -Teach and model adaptive coping strategies. -Encourage to use adaptive coping skills. -Praise efforts and successes in coping. -Establish trusting relationship. -Provide safe and supportive environment. -Encourage to discuss life events. -Assist to distinguish between life situations over which she does and does not have control. -Help to recognize negative self-talk and self defeating statements. -Encourage to keep journal of negative and defeating thoughts. -Encourage social interaction with others. -Assist to identify personal strengths and accomplishments. -Provide positive reinforcement for expression of positive feelings and thoughts. | -Recovers from overdose without complications. -Expresses feelings about substance abuse. -Discusses harmful effects of substance use. -Participates in goal planning sessions. -Identifies self-talk that is destructive. -Has not harmed self during hospitalization. -Develops supportive network of family, friends, and support group. -Independently performs activities of daily living. -Makes independent decisions about self-care. -Openly discusses feelings and emotional response to life situations. -Identifies self-defeating thoughts and behaviors. -Demonstrates use of adaptive coping strategies. -Demonstrates trust in mental health team. -Identifies realistic views of life events. -Demonstrates ability to recognize negative thought patterns. -Reframes negative self talk with more realistic perspective. -Uses positive statements to describe self. -Identifies strengths and acknowledges accomplishments. -Interacts with others using positive approach. |
Summary
The nursing process is a scientific, organized, problem-solving method of addressing those situations for which nursing can legally intervene. Nursing problems are often the result of medical conditions. The physician who treats psychiatric disorders is a psychiatrist. The psychiatrist is responsible for treating the medical or psychiatric disorder. As a member of the mental health team, the nurse is responsible for assessing and communicating information concerning the current status of the client to the physician and other members of the team.
Nursing problems or nursing diagnoses are formulated so that they are related to the cause or contributing factor for the symptoms. They are defined after relevant subjective and objective data from the client assessment have been reviewed. The nursing diagnosis statement is taken from a standardized list approved by the North American Nursing Diagnosis Association (NANDA). This statement includes the actual or potential nursing problem, the causative factor, and the supporting symptoms or behavior. Nursing diagnoses are prioritized according to the severity and immediacy of the problem. Basic physiologic needs such as oxygen, food, warmth, and sleep will obviously be met first. Maslow’s hierarchy of needs is often used to provide a general guide for nurses in determining priorities for problem resolution.
Definition of the problem allows the nurse to determine what evidence will demonstrate the client’s progress toward resolving the situation. This information is stated in an expected outcome with realistic and measurable criteria to decide when the goal has been accomplished. A description of the objective and subjective data provides evidence of whether the client is making progress and gives the nurse a blueprint to guide observation and contact with the client. Nursing interventions are planned and implemented to facilitate the effectiveness of the entire treatment process. Information is also shared with other team members to ensure the continuity and consistency of the approach that is being used to achieve client improvement.
Interventions are evaluated by determining whether the outcome criteria have been accomplished within the expected timeframe. If a goal is only partially achieved or has not been met, it is important to reevaluate the plan and develop new or additional actions to address the deficit. The nursing process is an ongoing continuum from admission to discharge and outpatient status. The problem solving method used to approach client care can also be taught to clients as a way of dealing with the problems and situations of life in general. In this way, nurses have modeled one of the most effective and adaptive coping strategies available for clients with mental health disorders.
Daftar Pustaka
Barry, Patricia D. 1998. Mental Health And Mental Illness Sixth Edition. Philadelphia: Lippincott.
Doenges, M. E., Townsend, M. C., & Moorhouse, M. F. (1995). Psychiatric Care Plans Third Edition.
Holoday, Fottinash Worret. 2007. Psychiatric Nursing Care Plans Fifth Edition. St.Louis Missouri: Mosby Elsevier.
Lee, Karen Fontaine J., Sue Fletcher.1999. Mental Health Nursing.California: Addison Wesley.
Varcarolis, Elizabeth M., Verna Benner Carson, Nancy Christine Shoemaker.2006.Foundations of Psychiatric Mental Health Nursing: A Clinical Approach Fifth Edition.USA: Saunders Elsevier.
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