Vous êtes sur la page 1sur 76

The Nursing Process

in Psychiatric/Mental Health
Nursing
Ns. Heni Dwi Windarwati, M.Kep.Sp. Kep.J
Objectives
After reading this chapter, the student will be
able to
Define nursing process
Identify six steps of the nursing process and
describe nursing action associated with each
Describe the benefits of using nursing process

The Nursing Process
It is a systematic framework for the delivery of
nursing care.
It uses a problem-solving approach.
It is goal-directed, its objective being the
delivery of quality client care.
It makes use of the nurse/Patient relationship
The Nurse/Client Relationship
What is it?
The process by which
the nurse provides care
for the client in need of
psychosocial
intervention.
We use ourselves.


The Goal of the Nurse Client
Relationship
The relationship focuses
on the needs of the
client, has goals which
are specific, is theory
based, and is open to
supervision.


ASSESSMENT
Definition of Asessment
A systematic, dynamic process by which the
nurse , through interaction with the client,
significant others, and healthcare providers,
collects and analyzes data about client.

Include (ANA)
Physical
Psychological
Sociocultural
Spiritual
Cognitive
Functional abilities
Developmental
Economic
Life-style
Biopsychosocial Components:
The Stuart Stress Adaptation Model of psychiatric
nursing care views human behavior from a holistic
perspective that integrates biological, psychological,
and sociocultural aspects of care.

The holistic nature of psychiatric nursing practice
examines all aspects of the individual and the
environment.
Faktor Predisposisi
Biologi Psikologi Sosialkultural
Stresor presipitasi
Nature Origin Timing Number
Penilaian terhadap stresor
Kognitif Afektif Fisiologis Perilaku Sosial
Sumber koping
Kemampuan personal Dukungan sosial Aset material Keyakinan positif
Mekanisme koping
Konstruktif Destruktif
Rentang respon koping
Respon adaptif Respon Maladaptif
DIAGNOSA KEPERAWATAN
Predisposing Factors:
Predisposing factors are risk factors that
influence both the type and amount of
resources the person can use to handle stress
and are biological, psychological, and
sociocultural in nature.
Biological predisposing factors include genetic background,
nutritional status, biological sensitive, general health, and
exposure to toxins.

Psychological predisposing factors include intelligence, verbal
skills; morale; personality; past experiences; self-concept,
motivation; psychological defenses; and locus of control, or a
sense of control over one's own fate
.
Sociocultural predisposing factors include age, gender,
education, income, occupation, social position, cultural
background, religious upbringing and beliefs, political affiliation,
socialization experiences, and level of social integration or
relatedness.
Precipitation Stressors:
Precipitating stressors are stimuli that are challenging,
threatening or demanding to the individual. They require
excess energy, and produce a state of tension and stress. They
may be biological , psychological, or sociocultural in nature,
and they may originate either in the person's internal or
external environment.

Besides describing the nature and origin of a stressor, it is
important to assess the timing of the stressor. A final factor to
be considered is the number of stressors an individual
experiences.
Appraisal of Stressor
Appraisal of a stressor involves determining the meaning
of and understanding the impact of the stressful situation
for the individual. It includes cognitive, affective,
physiological, behavioral, and social responses.

Appraisal is an evaluation of the significance of an event
in relation to a person's well-being. The stressor
assumes its meaning, intensity, and importance as a
consequence of the unique interpretation and
significance given to it by the person at risk.


Coping Resources:
Coping resources are options or strategies that help
determine what can be done as well as what is at
stake.
Coping resources include economic assets, abilities
and skills, defensive techniques, social supports,
and motivation. Other coping resources include
health and energy, spiritual supports , positive
beliefs, problem-solving and social skills, social and
material resources, and physical well-being.
Coping Mechanisms:
Coping mechanisms are any efforts directed at stress
management. The three main types of coping
mechanisms are as follows:
Problem-focused coping mechanisms, which involve tasks and direct
efforts to cope with the treat itself. Examples include negotiation,
confrontation, and seeking advice.
Cognitively focused coping mechanisms, by which the person
attempts to control the meaning of the problem and thus neutralize it.
Examples include positive comparison, selective ignorance,
substitution of rewards, and the devaluation of desired objects.
Emotion-focused coping mechanisms by which the patient is oriented
to moderating emotional distress. Examples include the use of ego
defense mechanisms, such as denial, suppression, or projection. A
detailed discussion of coping and defense mechanisms.

Coping mechanisms can be constructive or
destructive.
Continuum of Care
sehat sakit
Psikososial
Components of Assessment

Health History and Physical Assessment
Mental Status Examination
Psychosocial Criteria
Coping skills
Relationships
Spiritual (Value-belief) and cultural
Occupational



Health History and Physical Assessment

Clients complaint, present symptom and focus of
concern
Perceptions and expectations
Previous hospitalizations and mental health
treatment
Family history
Health beliefs and practices
Substance use
Sexual history
Abuse

Mental Status Examination

Appearance
Dress, grooming, hygiene, cosmetics, apparent age,
posture, facial expression.

Behaviour/activity
Hyperactivity or hyperactivity, rigid, relaxed, restless,
or agitated motor movements, gait and coordination,
facial grimacing, gestures, mannerisms,, passive ,
combative, bizarre.


Attitude
Interactions with interviewer: - Cooperative, resistive,
friendly, hostile, ingratiating
Speech-Quantity: - poverty of speech, poverty of content,
volume.
Quality: - articulate, congruent, monotonous, talkative,
repetitious, spontaneous, circumstantial,
confabulation, tangential and pressured
Rate:-slowed, rapid
Mood and affect
Mood (Intensity depth duration):- sad, fearful, depressed,
angry, anxious, ambivalent, happy, ecstatic, grandiose.
Affect (Intensity depth duration) :- appropriate, apathetic,
constricted, blunted, flat, labile, euphoric.

Perception
Hallucination, illusions, depersonalization, derealization,
distortions


Thoughts
Form and content-logical vs. illogical, loose
associations, flight of ideas, autistic, blocking.,
broadcasting, neologisms, word salad, obsessions,
ruminations, delusions, abstract vs. Concrete

Sensorium and Cognition
Level of consciousness, orientation, attention span, ,
recent and remote memory, concentration, , ability to
comprehend and process information, intelligence

Judgment
Ability to assess and evaluate situations makes
rational decisions, understand consequence of
behaviour, and take responsibly for actions
Insight
Ability to perceive and understand the cause and
nature of own and others situatio
Reliability
Interviewers impression that individual
reported information accurately and completely

Psychosocial Criteria

Internal:-Psychiatric or medical illness,
perceived loss such as loss of self
concept/self-esteem
External:-Actual loss, e.g. death of loved ones,
diverse, lack of support systems, job or
financial loss, retirement of dysfunctional
family system
Coping skills
Adaptation to internal and external stressors,
use of functional, adaptive coping
mechanisms, and techniques, management of
activities of daily living
Relationships
Attainment and maintenance of satisfying,
interpersonal relationships congruent with
developmental stages, including sexual
relationship as appropriate for age and status
Spiritual (Value-belief) and cultural

Presence of self-satisfying value-belief system
that the individual regards as right, desirable,
worthwhile, and comforting

Ability to adapt and conform to present
norms, rules, ethics
Occupational
Engagement is useful, rewarding activity,
congruent with developmental stages and
societal standards (work, school and
recreation)

DIAGNOSIS
Nursing Diagnosis
Terminology used by professional nurses that
identifies actual, risk or wellness responses to a
health state, problem or condition

Terminology used by professional nurses that
identifies a persons, familys, or communitys
motivation and desire to increase wellbeing and
actualize human health potential

After collecting all data, the nurse compares the
information and then analyses the data and derives
a nursing diagnosis.
A nursing diagnosis is a statement of the patients
nursing problem that includes both the adaptive and
maladaptive health responses and contributing
stressors.
These nursing problems concern patients health
aspects that may need to be promoted or with which
the patient needs help.
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)
Nursing Diagnosis: Definition
The NANDA definition of a nursing diagnosis was
adapted from a national, Delphi study by Dr. Joyce
Shoemaker (1984)
Nursing diagnosis is a clinical judgment about
individual, family, or community responses to
actual or potential health problems/life
processes. Nursing diagnoses provide the basis for
selection of nursing interventions to achieve
outcomes for which the nurse is accountable
(NANDA, 1997).

Medical Diagnosis
Describes a disease or
pathology
Conditions MD treats
MD cares for a pt with
Congestive Heart
Failure (CHF) treats
pathology with meds,
oxygen, diet & fluid
restriction
Nursing Diagnosis
Describes pts response
to a health problem
Situations RNs can treat
Nursing dx describe pts
response to CHF: such
as: Anxiety; Activity
Intolerance, Impaired
Peripheral Tissue
Perfusion,
Powerlessness
Types of Nursing Diagnoses
Actual nursing diagnoses: patient has problem
Risk diagnoses: patient is at risk for developing
the problem (Either begins with Risk for or the
definition will include is at risk for)
Wellness diagnoses: patient functioning
effectively but desires higher level of wellness
Others that you do not need to know:
Possible diagnoses
Syndrome diagnoses
Collaborative problems

Parts of a Nursing Diagnosis:
Defining Characteristics
Related Factors or Risk Factors
Formulating the Diagnostic
Statement

After identifying the best NANDA to describe
your patients problem...
You need to formulate a diagnostic
statement
An actual diagnosis has a three-part statement
A risk diagnosis has a two part statement
A wellness diagnosis has a one part statement
Actual Diagnostic Statement
Three-Part Format
Three parts:
NANDA label
Related factors (follows NANDA & linked by the
words related to)
Defining characteristics (follows related factors &
linked by the words as manifested by)
Actual Diagnostic Statement Example

Impaired Physical Mobility
related to (r/t) decreased motor agility and
muscle weakness
as manifested by (AMB) limited ROM

Impaired Physical Mobility r/t muscle
weakness AMB limited ROM
Risk Diagnostic Statement
Two-Part Format

Two parts:
NANDA label
Risk factors (follows NANDA label and is linked by
the words related to)
Risk Diagnostic Statement
Example
Risk for Impaired Physical Mobility
related to (r/t) full leg cast

Risk for Impaired Physical Mobility r/t full leg
cast
Wellness Diagnostic Statement
Used when pt doesnt have a health problem
but can attain higher level of health
Is a one part statement consisting only of the
NANDA:
Readiness for Enhanced Parenting
Readiness for Enhanced Family Processes
Readiness for Enhanced Spiritual Well- Being
Problem Tree
STEP 1
List all possible problems

STEP 2
Identify a starter problem

STEP 3
Identify the causes of a starter
problem

STEP 4
Identify the effects of a starter
problem
STEP 5
Review the diagram as a whole
and verify its validity
andcompleteness
OUTCOME
NANDA label describes human responses that are
problems. Usually, the healthy alternative is goal that
patient wants to achieve

To identify a goal, ask yourself:
If the problem were solved (actual nsg dx) or prevented
(risk nsg dx), how will patient look or behave?
What will I see, hear, palpate or observe?

Establish goals with patient if possible
Types of Goals
Goals can be:
Long term goal: objective expected to be
achieved over weeks or months
Short-term goal: a stepping stone on the way to
reaching long-term goal
Long Term Goal Characteristics
Is a broad statement that reflects:
Resolution of a problem
Progress towards resolution of a problem
Prevention of a problem
Should be attainable and realistic for the
patient
Is expected to be achieved during length of
stay in facility
Short Term Goal Characteristics
Must describe a measurable behavior that nurse can
validate by seeing or hearing or that patient can
measure subjectively and describe
Only one action verb allowed per goal
Short term goal should be:
Attainable & realistic during your time with pt
Specific in time - when is it to have occurred?
Specific as to who or what is to achieve goal
Specific in content - what is to occur?
Example
NURSI NG DI AGNOSI S:
Disturbed Sleep Pattern

GOAL:
Client will sleep uninterrupted for 6 hours.

EXPECTED OUTCOMES
Client will request back massage for relaxation.
Client will set limits to family and significant other visits.


planning
Nursing interventions are treatment, based
upon clinical judgment and knowledge that a
nurse performs to enhance patient / client
outcomes.

Writing a client plan of care
Two important concepts guide a client plan of care:
1- The plan of care is client centered.
2- The plan of care is a step by step process.
Sufficient data are collected to substantiate
nursing diagnoses.
At least one goal must be stated for each nursing
diagnosis
Outcome criteria must be identified for each goal


Nursing interventions must be specifically
designed to meet the identified goal.
Each intervention should be supported by a
scientific rationale.
Evaluation must address whether each goal
was completely met, partially met, or
completely unmet.

Format Rencana Intervensi
Diagnosa
Keperawatan
Tujuan
Keperawatan
Tindakan
Keperawatan
Rasional









Umum:


Khusus:
Laporan Pendahuluan
Masalah Keperawatan
Definisi
Karakteristik/ Tanda dan Gejala
Proses terjadinya masalah
Data yang perlu dikaji/ ditambahkan
Pohon Masalah
Diagnosa Keperawatan
Intervensi Keperawatan
Referensi


implementation
Consists of doing and documenting the activities that are
the specific nursing actions needed to carry out the
interventions or nursing orders.

To implement the care plan successfully, nurses need
cognitive, interpersonal, and technical skills. These skills
are distinct from one another. The cognitive skills
(intellectual skills) include problem solving, decision
making, critical thinking, and creativity
I nterpersonal skills are all of the activities, verbal and
nonverbal, people use when interacting directly with one
another, this depends on the ability of the nurse to
communicate effectively with others. It is necessary for all
nursing activities, caring, comforting, advocating,
referring, counseling, and supporting others.

Technical skills are hands-on skills such as manipulating
equipments, giving injections and bandaging, moving
lifting, and repositioning clients. These are called
procedures, tasks, or psychomotor skills.

Process of I mplementing
Reassessing the client
Determining the nurses need for assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities
Strategi Pelaksanaan
A. Proses Keperawatan
Kondisi klien
Diagnosa
Keperawatan
Tujuan keperawatan
Tindakan keperawatan

B. Strategi Pelaksanaan
Orientasi
Salam
Evaluasi/ validasi
Kontrak (topik, waktu
dan tempat)
Kerja
Terminasi
Evaluasi (subjektif dan
objektif)
Rencana tindak lanjut
Kontrak (topik, waktu
dan tempat)

evaluation
The last phase of the nursing process, follows
implementation of the plan of care, its the
judgment of the effectiveness of nursing care
to meet client goals based on the clients
behavioral responses.

Collecting data related to the desired
outcomes
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the
nursing care plan.




Relationship of Evaluation to Nursing Process


When goals have been partially met or when goals have
not been met, two conclusions may be drawn:
The care plan may need to be revised, since the
problem is only partially resolved
OR
The care plan does not need revision, because
the client merely needs more time to achieve
the previously established goals. So the nurse
must reassess why the goals are not being
partially achieved.

Format Catatan
Implementasi dan Evaluasi
Diagnosa
Keperawatan
Waktu
(hari, tgl, jam)
Implementasi Evaluasi
S: subjektif

O: objektif

A: analisa

P: Perencanaan
Klien:

Peawat:


Ttd
Nama jelas
References
Nanda. (2009). Nursing Diagnoses : Definitions &
Clacification 2005-2006. Philadelphia USA : NANDA
International

Stuart,G.W. (2009). Principles and Practice of psychiatric
nursing. (7
th
edition). St Louis: Mosby

Townsend, M.C. (2009). Apsychiatric Mental Health Nursing:
Concepts of care in evidence-based practice. (6
th
ed.).
Philadelphia: F.A.Davis Company.