NURSING PROCESS APPLIED TO ● Alzheimer’s Dss.

Rating Scale
PSYCHIATRIC NURSING PRACTICE AND ○ Cognitive disorder
THE STANDARDS OF CARE ● Eating Dso. Inventory/ Body Attitude
Test
Principles & Techniques of Psychiatric ○ Eating Disorder
Nursing Interview ● Brief Drug Abuse ScreenTest
● Establishing Boundaries (B-DAST)
○ Greet ○ Substance abuse
○ State the name of the patient ● Global Assessment of Functioning
○ State your name ○ Level of Overall Function
○ Your background info
○ Your ROLE Assessment Rating Scale that can be
○ Patient’s ROLE applied to patients done by Psychiatrists
○ Schedule of interaction ● Hamilton Anxiety Scale
○ End of interaction ○ Anxiety
● Beck Inventory/ Geriatric Depression
ASSESSMENT Scale (GDS)/ Hamilton Depression
● Presenting problem Scale
● Present Illness ○ Depression
● Family Hx. ● Mania rating scale
● Medical Hx. ○ Mania
● Recent stressors/losses ● Brief Psychiatric Scale/ Overall
● Psychosocial/ Psychiatric Hx. Psyche Scale
○ Coping skills and relationship ○ Schizophrenia
● Education ● Abnormal Involuntary Movement
● Legal Scale/ Mini-mental
● Marital Hx. ○ EPS effects
● Social Hx.
● Support system NURSING DIAGNOSIS
● Insight ● Actual
● Value-belief system ○ Post trauma syndrome r/t
○ Spiritual Values overwhelming anxiety sec.to
● Special needs rape or assault/ illness/ war
● Discharge goals or disaster as evidenced by
● Client participation reexperience (flashbacks),
● Elements of Psychiatric Hx. repetitive nightmares,
● Mental Status Examinations intrusive thoughts about
traumatic events, excessive
Why is Assessment crucial? verbalization of the event.
Assessment > Action Plan
Which will be the PRIORITY? OUTCOME IDENTIFICATION AND
A. Post trauma syndrome r/t PLANNING
overwhelming anxiety sec. to rape or
assault/ illness/ war or disaster as Nursing Diagnosis:
evidenced by reeexperience
(flashbacks), repetitive nightmares, Anxiety
intrusive thoughts about traumatic Incorrect outcome: exhibits decreased
events, excessive verbalization of anxiety
the event Correct outcome: verbalized feeling calm,
B. Risk for suicide r/t history of suicide relaxed, absence of muscle tension &
or through verbal remarks of diaphoresis, practices deep breathing
harming self
Ineffective Coping
Which will be the PRIORITY? Incorrect outcome: demonstrates coping
A. Imbalanced nutritions; less than the abilities
body requirements Correct outcome: makes own decision to
B. Ineffective coping attend group, interacts to staff and
personnels
NURSING DX.
● Potential or risk diagnosis Hopelessness
○ Risk for suicide r/t history of Incorrect outcome: expresses increased
suicide or through verbal feelings of hope
remarks of harming self Correct outcome: makes plans for the
future, states “my kids need to be well”
Which will be the PRIORITY?
A. Post trauma syndrome r/t PLANNING
overwhelming anxiety sec. to rape or ● The PROCESS
assault/ illness/ war or disaster as ○ Meeting & working with
evidenced by reeexperience client, family, and treatment
(flashbacks), repetitive nightmares, team
intrusive thoughts about traumatic ○ Identifying priorities of care
events, excessive verbalization of ○ Coordinating & delegating
the event responsibilities
B. Risk for suicide r/t history of suicide ○ Making clinical decisions
or through verbal remarks of about the use of
harming self psychotherapeutic, scientific
principles using
Which will be the PRIORITY? evidence-based practice.
C. Imbalanced nutritions; less than the ● Developing plan of care that is
body requirements negotiated among the patient, nurse,
D. Ineffective coping family & interdisciplinary team &
prescribes evidence-based
intervention to attain expected
outcome.
Tools used in Planning ● Preventing relapse through effective
● Interdisciplinary standardized care discharge planning
plans (NANDA) diagnosis
● Clinical pathways EVALUATION
● Evaluation of the client’s progress in
OUTCOME IDENTIFICATION attaining expected outcomes.
● Identification of expected client ● Compare the client’s current mental
behaviors resulting from nursing health state/ condition with the
interventions individualized to the outcome statement
client ● Consider all possible reasons why
● Should be SMART the client did not achieve outcomes.

Implementation DOCUMENTATION
● Counseling ● Evaluation of the client’s changing
● Promotion of Self-care activities condition
● Milieu therapy ● Informed consent
● Others: ● Response to medication
○ Psychobiologic interventions ● Ability to engage in treatment
■ Art, dance, music, programs
therapies ● S/S (most critical suicidal/ homicidal
○ Health teachings tendencies)
○ Case management ● Client concerns, other critical
○ Health promotion & health incidents that occur
maintenance

General nursing considerations

● Promoting health & safety
● Monitoring medications schedules &
effects
● Providing adequate nutrition/
hydration
● Creating a nurturing, therapeutic
environment
● Continuing to build, trust,
self-esteem & dignity
● Participating in therapeutic groups &
activities
● Developing client strengths & coping
methods
● Improving communications & social
skills
● Connecting family & community
support systems