AMANUEL MENTAL SPECIALIZED HOSPITAL

CPD CENTER

Nursing Process in psychiatric

nursing

Participant Manual

Addis Ababa, Ethiopia

March, 2023
Foreword

This course aims to increase knowledge, attitude and skills of nurse’s in order to bring quality of
care at all care levels. Nowadays, increased number of patients need quality care that satisfy their
needs and expectations for this instance knowing psychiatry nursing process bring quality care.
The contents of this course are presented in three days, designed for all nurses who include full
psychiatric nursing assessment, writing nursing diagnosis based on NANDA and also planning
for patients including intervention, and evaluate the care given for patients. Thus, this training
manual is an important step to address knowledge gaps identified to prepare our professionals
with necessary skills to deliver quality care. We are grateful to all members of the technical
working group and others who have collaborated with us to develop this important training
manual.
Approval statement

This [nursing process in psychiatric nursing] training package has been developed and submitted
by AMSH for accreditation. Xx has employed a seasoned and independent panel of experts and
reviewed the course as per the national standard. After a robust review by the panel, the course
has been accredited and registered as a CPD Course.

The course is face-to-face having classroom and simulated practical sessions and is awarded 15
Continuing Education Units (CEU).

Course summary
Course name Nursing process in psychiatric nursing
Course code
Course owner AMSH
CEU 15
Delivery modality Face-to-face

Accreditor
Name of accreditor: ______________________________
Authorized official: ______________________________
Date of accreditation: ____________________________
Signature: _____________________________________
Acknowledgement

Amanuel Mental Specialized Hospital CPD Center would like to acknowledge all individuals
and organizations who have contributed to the preparation of this manual. The shared technical
knowledge, experiences, and perspectives have produced a training manual that will have a
positive impact on the attitudes and capabilities of health care professionals across the country.
Our gratitude also goes to Ethiopian Midwives Association, Ethiopian Nursing Association,
Addis Ababa Health Bureau and Ministry of health because the preparation of this manual would
not have been possible without their contribution.
List of Contributors

NAME INSTITUTION and PROFESSION

BahiruMelese Amanuel Mental Specialized Hospital
Kedire Seid Amanuel Mental Specialized Hospital
Mensur Nesru Amanuel Mental Specialized Hospital
Tegene Arega Federal Ministry of Health
Anteneh Teshome Amanuel Mental Specialized Hospital
Asnake Fetene Amanuel Mental Specialized Hospital
Tesfaye Mekonen Amanuel Mental Specialized Hospital
Ayantu Tefera Amanuel Mental Specialized Hospital
Arega Mohammed City Government of Addis Ababa Health Bureau
Biniyam Tsegaye Amanuel Mental Specialized Hospital
Zegeye Yohannis Amanuel Mental Specialized Hospital
Tolesa Fanta Amanuel Mental Specialized Hospital
Kibrom Haile Amanuel Mental Specialized Hospital
Ibrahim Yimer Ethiopian Midwives Association
Lulu Bekana Amanuel Mental Specialized Hospital
Habtamu Derajaw Amanuel Mental Specialized Hospital
Zebiba Nassir Amanuel Mental Specialized Hospital
Ayalew Abate Amanuel Mental Specialized Hospital
Mengistu Bekele Amanuel Mental Specialized Hospital
Abera Mulatu Amanuel Mental Specialized Hospital
Acronyms

AMSH- Amanuel Mental Specialized Hospital

ANA - American Nursing Association
ADOPIE-Assessment, Diagnosis, Outcome Identification, Planning, Implementation and
Evaluation
APIE – Assessment Planning, Implementation and Evaluation

CEU- Continuing Education Unit

CPD- Continuous Professional Development

CNS- Central Nervous System

DM- Diabetes Mellitus

ECT -Electroconvulsive therapy

HTN- Hypertension

HIV- Human Immune Deficiency Virus

LMP- Last Menstrual Period

NANDA- North American Nursing Diagnosis Association

RN- Registered Nurse

TOT- Training of Trainers

Contents
Acknowledgement.....................................................................................................................................IV
Acronyms....................................................................................................................................................V
Introduction to the manual.........................................................................................................................1
Course syllabus............................................................................................................................................2
CHAPTER ONE- NURSING PROCESS IN PSYCHIATRIC NURSING...................................................................7
1.1 Introduction to psychiatric nursing process.................................................................................8
1.1.1PSYCHIATRY NURSING ASSESSMENT...................................................................................................9
1.1.1.1 History Taking Format In Psychiatric Nursing............................................................................13
1.1.1.2 Mental Status Examination........................................................................................................19
1.1.1.3 Gordonsfunction health Pattern Assesment..............................................................................24
1.1.2-PSYCHIATRY NURSING DIAGNOSIS...................................................................................................29
Types of psychiatric nursing diagnosis...................................................................................................29
1.1.2.1 Problem-focused or actual diagnosis.........................................................................................29
1.1.2.2 Risk psychiatry nursing diagnosis...............................................................................................30
1.1.2.3 Wellness Diagnosis....................................................................................................................30
1.1.2.4 Syndromic Diagnosis..................................................................................................................31
1.1.3 PLANNING.........................................................................................................................................34
1.1.4 IMPLEMENTATION............................................................................................................................36
1.1.4.1 Specific Intervention..................................................................................................................37
1.1.5 EVALUATION....................................................................................................................................39
CHAPTER 2- MAJOR PSYCHIATRY NURSING CARE PLAN...........................................................................42
2.1 introduction to major psychiatric disorder......................................................................................43
2.2 Major Nursing Diagnoses and Interventions for Individuals with Schizophrenia,mania and Other
Psychotic Disorders...............................................................................................................................44
2.3 Major Nursing Diagnoses and Interventions for Depression...........................................................55
2.4Major Nursing Diagnoses and Interventions for anxiety disorder.....................................................62
2.5Common Nursing Diagnoses and Interventions for Clients with Substance-Related Disorders........67
2.6 Major nursing diagnosis in clients with catatonic features..............................................................74
Reference..................................................................................................................................................80
Introduction to the manual

Currently in Ethiopia and also globally psychiatric disorder are highly prevalent. Our country’s
second growth and transformation plan has set ambitious goals to improve quality of care. To
achieve this objective, application of nursing process in psychiatry nursing is fundamental to
health care professionals. Evidence suggested that nursing process in psychiatry nursing has been
associated with improved health outcomes, appropriate interventions, planned care, and
increased patient satisfaction, reduced health care expenditure, none or fewer malpractices and
decrease professionals’ burn out. Nursing process in psychiatry nursing is becoming increasingly
important to psychiatry nurses and nurses who are working in the area of mental health.
However, as per our knowledge, there is no standardized training manual for practice of
complete nursing care planning psychiatry nursing and because of identified gap which is poor
practice of nursing care plan in psychiatric nursing led to focus on nursing process in psychiatric
nursing.

Core competencies:

 Assessing clients using psychiatry history taking and approach of functional health
patterns
 Formulating psychiatry nursing diagnosis by using NANDA-I approach
 Developing holistic nursing care plan that address basic human needs
 Providing individualized, holistic and ethically accepted nursing care
 Evaluating whether the goals are met, partially met or unmet

1
Course syllabus
Course Description
This is a 3-day training designed to equip participants with the knowledge, Attitude, and skills on
the application of nursing process in psychiatric nursing and to enable them to deliver
scientifically sound, ethically acceptable and holistic quality care for mentally ill patient.
Course Goal
 To provide the trainees with the knowledge and skills needed to respond appropriately to
patient’s health care needs.
 To influence in a positive way the attitudes of the trainees towards client centered and
ethically accepted nursing care.
Objectives
By the end of this course the trainer will be able to:

 Describe five nursing process in psychiatric nursing

 Describe psychiatry nursing assessment
 Explain psychiatry nursing diagnosis
 Apply psychiatric nursing intervention
 Discus about nursing plan and outcome identification
 Determine psychiatric nursing evaluation

Training/Learning methods
 Interactive lecture
 Individual reflection
 Group discussion
 Case study
 Role play

2
Training materials

3
  Participant Manual
 Training Hall
 Trainer Guide
 Power Point
 Flip Chart
 Marker
 Note Book And Pen
 LCD
 Laptop
 Facilitator Guide
 Evaluation Form

Participants Selection Criteria:

 Participants for this training should be health professional who are working in the area of
mental health care (nurse, psychiatry nurse, mental health professional specialist)
Trainers Selection Criteria:
 Panel of Experts involved in the development of the training material.
 Psychiatry nurse professional and nurse professional who have TOT in mental health care
and nursing process in psychiatric setting.
 basic training on psychiatry nursing process with basic facilitation training
Method of Evaluation
Participant
1. Formative Assessment:
 Pre-training knowledge assessment(Pretest)
 Individual reflection
 Peer evaluation
 Group discussion
 Case study
 Home work

2. Summative Assessment:

4
  Post training knowledge assessment/post test
Course Evaluation:
 Daily evaluation by participants
 Daily trainers feedback meeting (debriefing)
 End course evaluation

Certification-
 Participants will be certified if they score ≥75 in the Post-test
 100% attendance is mandatory
 Can perform required skills with steps and their sequence
 Continuing Educational Unit(CEUS) =15 CEU
Training venue
 Training should be held on Accredited CPD training centers
Training duration
 3days
Course composition
 Trainer to trainee ratio 1:5, total 20 trainee

Activities Time
Day 1

5
Registration 8:30-9:00 am
Opening ceremony/speech 9:00-9:30 am
Course overview
- Expectation 9:30-10:00 am
- Schedule introduction
- Group norms
- Review of courses
Pre-test 10:00-10:30 am
Tea break 10:30-11:00am
- Introduction to nursing process in
psychiatric nursing 11:00-12:30am
- Standard-1 psychiatry nurse
assessment
Lunch 12:30-2:00 pm
Standard 2- psychiatry nursing diagnosis
2:00-3:30 pm
Tea break 3:30-3:45 pm
Standard 3- outcome/planning 3:45-5:00 pm
Group discussion
Day 2
Recap 8:30-9:00am
Standard-4 implementation 9:00-10:25 am
Specific intervention
Tea break 10:25-10:45 am
Standard 5- evaluation 10:45-12:00 am
Group discussion on writing complete
psychiatry nursing care plan
Lunch 12:00-2:00 pm
Common nursing diagnosis in schizophrenia 2:00-3:00 pm
and other psychotic disorders
Tea break 3:00-3:20 pm

6
Common nursing diagnosis in depressive 3:30-4:00 pm
patients
Discussion on applying nursing process in 4:00-5:00 pm
psychiatric nursing
Day 3
Recap 8:30-9:00 am
Common nursing diagnosis in anxiety disorder 9:00-9:30 am
Common nursing diagnosis in substance 9:30-10:00 am
related and addictive disorders
Common nursing diagnosis in catatonic 4:00-4:30 am
patients
Tea break 10:30-10:45 am
Clinical practice 10:45-12:00 am
Lunch 12:00-2:00 pm
Group discussion on overall psychiatry nursing 2:00-3:00 pm
process
Tea break 3:00-3:20pm
Post test 3:20-4:20pm
Discussion about post test 4:20-5:00 pm

CHAPTER ONE- NURSING PROCESS IN PSYCHIATRIC NURSING

Time 6 hour and 30 minutes

7
Chapter description
The purpose of this chapter is to enhance the participants understanding of psychiatry nursing
process, it also elaborates about psychiatry nursing assessment, psychiatric nursing diagnosis,
planning, implementation and evaluation phase
Primary objective: At the end of this chapter participants will be able to:
 Describe psychiatry nursing process
Enabling objective
At the end of this chapter the participant will be able to
Describe five nursing process in psychiatric nursing
Conduct psychiatry nursing assessment
Explain psychiatry nursing diagnosis
Discus about nursing plan and outcome identification
Apply psychiatric nursing intervention
Determine psychiatric nursing evaluation

Chapter outline
1.1introduction to nursing process in psychiatric nursing
1.1.1 psychiatric nursing assessment
1.1.2 psychiatric nursing diagnosis
1.1.3 psychiatric nursing planning
1.1.4 psychiatric nursing implementation
1.1.5 psychiatric nursing evaluation
Summary

1.1 Introduction to psychiatric nursing process

Activity 1.1 Describe nursing process in psychiatric

8
 nursing?
List five nursing process in psychiatric
nursing?
(10 minute)

The nursing process in psychiatric nursing is a process by which psychiatry nurses deliver
nursing care to the psychiatric patients to improve or solve their health response.

Purposes of psychiatry nursing process

 Providing professional, quality nursing care.

 Directs nursing activities for health promotion, health protection, and disease prevention
and is used by nurses in every practice setting
 Provides the basis for critical thinking in nursing.
 Ensures continuity of care
 Promotes involvement of clients in their own care

It has five steps,

9
 psychiatry
nursing
assesment

Psychiatry psychiatry
nursing nursing
evaluation diagnosis

Psychiatry Psychiatry
nursing nursing
implementation planning

1.1.1PSYCHIATRY NURSING ASSESSMENT

Psychiatry nursing assessment is a baseline psychiatric mental health record that nurse
practitioners use in order to determine a patient condition and form a health care plan

It is the key to contributing to establishment of a psychiatric diagnosis; proper diagnosis leads to

effective treatment because it helps us develop the correct interventions and outcomes

It includes many dimensions: physical, psychological, socio cultural, spiritual, cognitive,

functional abilities, developmental, economic, and lifestyle assessments

Purpose:

10
  Organize a database regarding a client physical, psychological, and emotional health.
 Identified of health promoting behaviors and actual or potential health problems
 The nurse can ascertain of the clients about functional abilities, absence or the presence
of dysfunction, normal activities of daily living and lifestyle pattern
 Identifying the client strengths gives the nurse information about the abilities, behavior,
and skills the client can use during the treatment and recovery process.
 Provides an opportunity to form a therapeutic interpersonal relationship with clients.
 The client can discuss health care concerns and goals with the nurse.

Sources of Data

 Primary sources: the client should be considered the primary source of data. As much
information as possible should be gathered from the client, using both interview
techniques and physical examination skills.
 Secondary sources: data source from other than the clients are considered secondary
sources (family members, other health care providers, and medical records).

Types of Data collection

 Subjective data- data provided by patients/informants verbally

Example– “I feel happy’’ “I feel sad”
 Objective data- (also called signs): observable and measurable data
Example- aggressiveness, pulse rate 72

Techniques of Data Collection in Psychiatric Nursing

 Patient observation
 patient interview (process recording)
 Family interview
 Physical examination
 Mental status examination

Interviewing

11
  Interviewing is a planned communication or a conversation with a purpose of getting
data from patient. For interviewing one need to have skill in obtaining history.
 Interview can be directive interview, which is highly structured and elicits specific
 Information or nondirective interview or rapport-building interview, in which the nurse
allows the client to control the purpose, subject matter, and pacing.
Phases of interview
Effective interview has four phases:
I. Preparatory phase /pre interaction phase: this phase comes before the nurse meet the
patient that involves pre collection of some information about the patient.
II. Introductory phase/orientation phase: this phase is a phase of establishing rapport with the
patient through clarifying your role. This phase helps to alleviate patient anxiety
III. Maintenance phase /working phase: this phase which the planned interview is undertaken
IV. Concluding phase: finalize the interview with concluding the session, for example by
summarizing what have been collected and acknowledging the patient for his/her cooperation
Interview techniques in psychiatry history taking

 introduce yourself
 greet the patient by name
 arrange for a private comfortable setting
 appropriately tell the purpose of the interview
 put the patient at ease
 Be supportive, attentive, non-judgmental and encouraging.
 Avoid excessive note-taking
 Observe the patient’s nonverbal behavior.
 Pay attention to both content & process.
 Open-ended question versus Closed-ended questions.
 Reflection. In the technique of reflection, a nurse repeats to a patient in a supportive
manner something that the patient has said.
 Facilitation. Nurse’s help patients continue in the interview by providing both verbal and
nonverbal cues.
 Silence. being silent

12
  Confrontation. The technique of confrontation is meant to point out to a patient
something that the nurse thinks the patient is not paying attention to, is missing, or is in
some way denying.
 Clarification. In clarification, nurses attempt to get details from patients about what they
have already said.
 Interpretation. The technique of interpretation is most often used when a nurse states
something about a patient's behavior or thinking that a patient may not be aware of.
 Summation. Periodically during the interview, a nurse can take a moment and briefly
summarize what a patient has said thus far.
 Explanation. Nurses explain treatment plans to patients in easily understandable language
and allow patients to respond and ask questions
 Transition. The technique of transition allows nurses to convey the idea that enough
information has been obtained on one subject; the nurse’s words encourage patients to
continue on to another subject.
 Positive Reinforcement- this is technique of providing feedback or praise to the patient
for their cooperation, honesty or efforts
 Reassurance- this is a technique of offering comfort or support to the patient who is
experiencing distress, anxiety or fear.
 Advice- this is a technique of giving suggestion or recommendations to the patient based
on the interviewers knowledge, experience or expertise.

1.1.1.1 History Taking Format in Psychiatric Nursing

ACTIVITY 1.2  List components of history taking?

 What is rational taking psychiatry
history regarding psychiatry nursing care plan
(Time 10 min)

A psychiatric history is the result of a medical process where a clinician working in the field of
mental health systematically records the content of an interview with a patient.

13
General Principles before history taking

 Agreement as to Process - At the beginning of the interview the clinician should

introduce self why he/ she is speaking with the patient.
 Privacy and Confidentiality - At the beginning, the interviewer should indicate that the
content of the session(s) will remain confidential except for what needs to be shared with
the referring physician or treatment team.
 Respect - The patient must be treated with respect
 Rapport/Empathy
Rapport can be defined as the harmonious responsiveness of the physician and the patient
Empathy understands what the patient is thinking and feeling
 Safety and Comfort Both the patient and the interviewer must feel safe on occasion,
especially in hospital or emergency

Psychiatric nursing history components

Identification data- is a process of collecting and verifying relevant information about the
patient’s biographic data.
Presenting chief complaints- a concise statement describing the reason for the encounter it
usually stated in the patient’s own word and reflects their main concern we also collect data from
collateral
History of present illness- is a detailed description of the development and progression of the
patient’s current problem in chronological order and rule out other symptoms. It includes
information about onset, duration, frequency, severity, impact of symptoms, substance use,
suicidal (ideation, plan, attempt), medication history and any factors that makes them better or
worse.

Past psychiatric history-a detailed description of past illness, hospitalizations, substance use
history, and treatments include past problems with suicidal thinking and attempt.

Past medical history- is a process of obtaining and reviews the patients past and current
physical health condition, medications, allergies, surgical procedure and accident.

14
Family history- it is a description of presence of psychiatric and physical illness in family
members and treatment, presence or history of substance abuse and history of suicide attempt
Personal history- this is a detailed account of the patient’s life history from birth to present. It
should include information about their prenatal, perinatal, postnatal development, child hood,
adolescence, education, occupation, forensic history, relationships, sexuality, social network,
hobbies, interests and achievements. It should also include any history of trauma, abuse, neglect,
loss or stressor in their life.
Pre-morbid personality- this is an evaluation of the patient’s personality traits, coping styles,
strengths, and weakness before the onset of their illness

1.1.1.2 Mental Status Examination

Activity 1.3. INDIVIDUAL  What do you mean mental status

REFLECTION examination and its components

 what is the difference between
psychiatric nursing history and
mental status examination?(Time
10 min)

The mental status examination is an assessment that the clinician snapshot of the patient’s
thought, feeling and behavior at the time of the interview
Examination of mental status is done in anyone with an altered mental status or evolving
impairment of cognition whether acute or chronic.

Appearance and Behavior- which includes observing the patient general appearance, hygiene,
clothing, posture, movement, eye contact and attitude towards the examiner

15
 Speech- which includes noting the patients rate , volume, tone, fluency, and coherence of speech
as well as any abnormalities such as stuttering, slurring and neologisms.
Emotion- which includes asking the patient how they feel and observing their emotional
expression, range, intensity and appropriateness
Thought- which includes assessing the patients thought content such as delusions, obsessions,
suicidal or homicidal ideation and thought process such as logics, coherence and organizations
Perception-which includes asking the patient about any hallucinations, illusion or
depersonalization experience
Cognition- which includes testing the patient’s orientation, attention, memory, language,
calculation and executive function
Insight and Judgment- which includes evaluating the patient awareness and understanding of
their condition, as well as their ability to make reasonable and safe decisions

1.1.1.3 Gordon function health Pattern Assessment

Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by
psychiatry nurses in the psychiatry nursing process to provide a more comprehensive nursing
assessment of the patient

activity 1.4  Select three participants(psychiatry nurse,

patient and patient attendant) for role play
about Gordon’s pattern assessment(25 min)

Health-Perception and Health-Management Pattern

16
Data collection is focused on the person's perceived level of health and well-being, and on
practices for maintaining health. Habits that may be detrimental to health are also evaluated,
including smoking and alcohol or drug use. It includes the client’s belief, practice and values
related to health promotion and disease prevention
Nutritional-Metabolic Pattern
This pattern focuses on the pattern of food and fluid consumption relative to metabolic need. The
adequacy of local nutrient supplies is evaluated. Actual or potential problems related to fluid
balance, tissue integrity, and host defenses may be identified as well as problems with the
gastrointestinal system.
Elimination Pattern
This pattern is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as
incontinence, constipation, diarrhea, and urinary retention may be identified.
Activity-Exercise Pattern
This pattern is focused on the activities of daily living requiring energy expenditure, including
self-care activities, exercise, and leisure activities. The status of major body systems involved
with activity and exercise are evaluated, including the respiratory, cardiovascular, and
musculoskeletal systems.
Sleep-Rest Pattern
This pattern is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep
patterns, fatigue, and responses to sleep deprivation may be identified.
Cognitive-Perceptual Pattern
This pattern describes the client’s cognitive and sensory functions, such as memory, learning,
problem-solving, language, vision, hearing, taste, touch, and pain. It includes the clients mental
status, level of consciousness, orientation, attention, perceptions and coping stratagies.
Self-Perception-Self-Concept Pattern
This pattern is focused on the person's attitudes toward self, including identity, body image, and
sense of self-worth. The person's level of self-esteem and response to threats to his or her self-
concept may be identified.

Role-Relationship Pattern

17
This pattern is focused on the person's roles in the country, community, and work area or home
and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships
may be further evaluated.
Sexuality-Reproductive Pattern
This pattern describes the client’s sexual identity, function and behavior as well as the client’s
reproductive health and needs. It includes the client’s sexual orientation, expression, satisfaction,
problems, history and practices, as well as the client’s menstrual cycle, pregnancy,
contraception’s and sexually transmitted infection.
Coping-Stress-Tolerance Pattern
Assessment is focused on the person's perception of stress and on his or her coping strategies.
Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a person's
coping strategies in terms of stress tolerance may be further evaluated.
VALUE-BELIEF PATTERN
Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the
goals that guide his or her choices or decisions. It includes the client’s cultural, religious, ethical,
and moral influences.

18
1.1.2-PSYCHIATRY NURSING DIAGNOSIS

Activity 1.5 GROUP DISCUSSION  Discus types of psychiatry nursing diagnosis?

 What are the components of Psychiatry nursing
diagnosis?
3 Groups for 20 min

A psychiatry nursing diagnosis is a clinical judgment concerning human response to health

conditions/life processes, or a vulnerability for that response, by an individual, family, group,
or community. A psychiatry nursing diagnosis provides the basis for the selection of psychiatry
nursing interventions to achieve outcomes for which the psychiatry nurse has accountability.

Types of psychiatric nursing diagnosis

1.1.2.1 Problem-focused or actual diagnosis

A patient problem present during a nursing assessment is known as a problem-focused diagnosis.

Generally, the problem is seen throughout several shifts or a patient’s entire hospitalization. It is
supported by defining characteristics that cluster in patterns of related cues or inferences.
Problem-focused diagnoses have three components

Psychiatry Nursing diagnosis/problem/ diagnostic level: this is a concise term or phrase

that represents a pattern of related cues and describes the client’s health problem or
response for which nursing therapy is given. The problem should be derived from a
standardized nursing terminology, such as NANDA-I, and should be clear precise and
ambiguous.
Related factors: this is a condition, circumstance, or event that contributes to or is
associated with the problem. The etiology should be connected to the problem by the
phrase (related to) and should identify one or more probable causes of the health
problem.
19
 Defining characteristics: these are the observable and verifiable cues or cluster of cues
that support the presence of problem. The defining characteristics’ should be connected
to the etiology by the phrase (as evidenced by) and should include both subjective and
objective data that the nurse has collected during the assessments.

1.1.2.2 Risk psychiatry nursing diagnosis

A risk psychiatry nursing diagnosis a type of nursing diagnosis that describes a clinical
judgment concerning the vulnerability of an individual, family, group, or community for
developing an undesirable human response to health conditions or life process. It is supported by
risk factors that are environmental, physiological, genetic or chemical elements that increase the
vulnerability of a person or group. This type consists of two components which are diagnostic
label and risk factors.

Activity 1.7 think +pair+ shared Discus the difference between actual and
risk nursing diagnosis and share to the
whole group ?(Time 10 min)

1.1.2.3 Wellness Diagnosis

Wellness diagnosis is “a clinical judgment concerning motivation and desire to increase well-
being and to actualize human health potential.” These responses are expressed by the patient’s
readiness to enhance specific health behaviors. A health promotion-wellness diagnosis is used
when the patient is willing to improve a lack of knowledge, coping, or other identified need.
Components of a health promotion diagnosis generally include only the diagnostic label or a one-
part-statement.

Examples of health promotion diagnosis:

Readiness for Enhanced Spiritual Well Being
Readiness for Enhanced Family Coping

20
 Activity 1.8  Define wellness nursing diagnosis and
syndrome nursing diagnosis ?(5 min)

1.1.2.4 Syndrome Diagnosis

A syndrome diagnosis is a clinical judgment concerning with a cluster of problem or risk
nursing diagnoses that are predicted to present because of a certain situation or event.

Examples of a syndrome nursing diagnosis are:

Chronic Pain Syndrome

Post-trauma Syndrome
Steps to formulate nursing diagnosis
Analyze the data collected during assessment to identify the patients health problem,
risks, and strengths.
Choose a standardized nursing terminology to label patients health problem or response.
Use formula to write the nursing diagnosis statement, such as PES( problem, etiology,
sign and symptoms) or PE( problem, etiology) for risk diagnosis
Validate the accuracy and relevance of the nursing diagnosis with the patient and other
member of health care teams.

Activity 1.9 GROUP DISCUSSION  Formulate two actual and two risk nursing
diagnosis?

3 Groups for 20 min

21
1.1.3 PLANNING

Activity 1.10 think +pair+ shared Discus what SMART stands for and define
each term (Time 10 min)

The planning stage is where the nurse collaborates with the patient and other member of the
health care team to develop a plan of care that addresses the patients mental health needs. It
consists of the total planning of the patient’s overall treatment to achieve quality outcomes in
safe, effective and timely manner

Major activities in planning

Setting expected out come
Setting priorities
Developing intervention

Expected outcomes: are specific objectives related to the goals and are used to evaluate the
nursing interventions. They must be specific, measurable, achievable, and realistic and have a
time limit.
Specific outcome: are clear, well defined, and unambiguous and they describe what the patient
will be able to do or achieve as a result of the intervention.
Measurable outcome: are observable and verifiable, and they include criteria or indicators that
can be used to assess the patient’s status and response to the intervention.
Achievable outcome: are realistic and attainable, and they consider the patients abilities,
resources and limitations.
Realistic outcome: are relevant and meaningful, and they reflect the patient’s values,
preferences, and expectations.

22
Timed outcomes: are time bound and have a specific deadlines or frequency for completion or
evaluation
Types of expected outcomes
Goals should be established to meet the immediate, as well as long-term prevention and
rehabilitation, needs of the client.
1. Short-term outcome (STO):- are those that can be met relatively quickly, often in less than a
week, or in a short period. It is usually focused on the etiology.
2. Long term outcome (LTO):- are those that are to be achieved over a longer period of time,
often weeks or months requires more time. LTOs usually focused on the problem.
Setting priorities: a crucial step that helps the nurse to focus on the most urgent and important
needs of patient. Prioritization is based on several factors
The severity and potential harm of patient’s problem or risks such as suicidal ideation,
violence, psychosis or substance abuse.
The patients preferences, values and expectations as well as family involvement
The availability and feasibility of resources
The standard of care and evidence based practice as well as legal and ethical implications
of interventions.
Strategies to prioritize
Using ABC ( airway, breathing, circulations) or SAFETY( suicide, aggression, falls,
elopement, treatments and you) to rank patients needs from the most to the least essential
Developing intervention: is a process of selecting and documenting the appropriate actions that
will help the patient achieve expected outcomes. The intervention should be based on the best
available evidence, the nurse clinical judgment, and the patients input. Intervention should also
be specific, individualized and documented

23
1.1.4 IMPLEMENTATION

Direction:- read and discus

Sam was team captain of his soccer

team, but an unexpected fight with
another teammate prompted his parents
to meet with a clinical psychologist.
Sam was diagnosed with major
depressive disorder after showing an
ACTIVITY 1.11 increase in symptoms which is
depressed mood, sleepless, loss of
interest over the previous three months.

 as a psychiatric nurse or other health

professional, be in group and discus
about psychiatric nursing
intervention(20 minute)

 The psychiatric nurse implements the intervention identified in the plan of care
 Nursing intervention are directed at eliminating the etiologies
 Carrying out the plan of care
 Nursing intervention must be safe, within the legal scope of nursing practice, and
compatible with medical orders
 The nurse implements medical order and nursing order

24
 main objectives of implementation phase

 ongoing assessment
 establishing priorities
 allocating resource
 initiating interventions
 documenting interventions and patient response


1.1.4.1 Specific Intervention

Standard 4a counseling:

 to assist clients in improving coping skills and preventing mental illness and disability

Standard 4b milieu therapy:

 to provide and maintain therapeutic environment for client

Standard 4c self-care activities:

 to foster independence and mental and physical well-being

Standard 4d psychobiological intervention

 To restore the client’s health and prevent further disability

Standard 4e health teaching

 To assist clients in achieving satisfying, productive and healthy pattern of living

25
Standard 4f case management

 To coordinate comprehensive health services and ensure continuity of care

Standard 4g health promotion and health maintenance

 Implements strategies with clients to promote and maintain mental health and prevent
mental illness

Standard 4h psychotherapy

 Provides therapy for individuals, groups and families to foster mental health and prevent
disability

Standard 4i prescriptive authority and treatment

 Provides pharmacological intervention, in accordance with laws and regulation to treat

symptoms of psychiatric illness and improve functional health status

Standard 4j consultation

 Provides consultation to enhance the abilities of other clinicians to provide service for
clients and effect change in the system

26
1.1.5 EVALUATION

 The psychiatric nurse evaluates the clients progress in attaining expected outcome
 The way nurses determine whether clients has reached goal
 It is analysis of the client’s response also it helps determine the effectiveness of nursing
care

main objectives of evaluation

 to determine if interventions are helping clients achieve expected outcome

 to verify the quality of nursing care provided

 to promote accountability

 to analyze current data

 to promote continuity of care

Steps used to objectively evaluate the degree of success in achieving a goal:-

1. Examine the goal statement and identify the client behavior or response
2. Assess the client for the presence of that behavior or response
3. Compare the established expected outcome with the behavior or response

27
4. Judge the degree of agreement between expected outcome and the behavior or
response
a. Goal is Met- if the client‘s response matches or exceeds the outcome criteria.
b. Goal is partially Met- If the client‘s behavior begins to show changes, but
does not yet meet specified criteria.
c. Goal is Not Met - If there is no progress
5. Ask questions if there is no agreement.
N.B.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.
 During evaluation, the following questions should be considered:
Have the goals of the nursing care plan been achieved, If not, why not
Were the goals realistic
Was the patient committed to the goals
Was there enough time to achieve the goals
Did other problems arise that impeded progress
Were interventions consistently performed as prescribed
Have any new problems developed that have not been addressed

28
Chapter Summary

 The psychiatry nursing processis a process by which psychiatry nurses deliver care to the
psychiatric patients to improve or solve their mental problems.
 psychiatry nursing process have 5 stages which is assessment, diagnosis, planning,
implementation and evaluation
 psychiatry nursing assessment is the key to contributing to establishment of a psychiatric
diagnosis, proper diagnosis leads to effective treatment because it helps us develop the
correct interventions and outcomes
 A psychiatry nursing diagnosis is a clinical judgment concerning human response to
health
conditions/life processes, or a vulnerability for that response, by an individual, family,
group,
or community.
 The planning stage is where goals and outcomes are formulated that directly impact
patient care
 four types of nursing diagnosis
 Nursing intervention are directed at eliminating the etiologies
 The psychiatric nurse evaluates the clients progress in attaining expected outcome

29
Better to say sample Psychiatric Nursing care plan and concise it

CHAPTER 2- MAJOR PSYCHIATRY NURSING CARE PLAN

Time 6 hour

Chapter description
The purpose of this chapter is to enhance the participants skill in formulation of psychiatry
nursing diagnosis
Chapter objective
 describe common psychiatric nursing diagnosis

Enabling objective
by the end of this chapter the participant will be able to
 describe major psychiatry nursing diagnosis and intervention for psychotic patients
 elaborate major psychiatry nursing diagnosis and intervention for depressive patients
 describe major psychiatry nursing diagnosis and intervention for anxiety patients
 explain major psychiatry nursing diagnosis and intervention for substance related and
addictive disorder
 apply major nursing diagnosis and intervention incatatonic features patients

30
 Chapter outline
2.1 introduction to major psychiatric disorder
2.2 major Nursing Diagnoses and Interventions for Individuals with Schizophrenia and
Other Psychotic Disorders
2.3 major nursing diagnosis and intervention in depressive patients
2.4 major nursing diagnosis and intervention in anxiety disorder
2.5 major nursing diagnosis and intervention in substance related disorder
2.6 major nursing diagnosis and intervention in catatonic features

2.1 introduction to major psychiatric disorder

A mental disorder is characterized by a clinically significant disturbance in an individual’s

cognition, emotional regulation, or behaviour. It is usually associated with distress or
impairment in important areas of functioning. There are many different types of mental
disorders. Mental disorders may also be referred to as mental health conditions.

In 2019, 1 in every 8 people, or 970 million people around the world were living with a mental
disorder, with anxiety and depressive disorders the most common. In 2020, the number of people
living with anxiety and depressive disorders rose significantly because of the COVID-19
pandemic. Initial estimates show a 26% and 28% increase respectively for anxiety and major
depressive disorders in just one year. While effective prevention and treatment options exist,
most people with mental disorders do not have access to effective care. Many people also
experience stigma, discrimination and violations of human rights. Aalso bipolar and
schizophrenia is the most prevalent Sso, the psychiatric nursing input is vital.

31
2.2 Major Nursing Diagnoses and Interventions for Individuals with Schizophrenia,mania and
Other Psychotic Disorders

Activity 2.1  list common problems manifested in

psychotic patient and formulate nursing
diagnosis with intervention?(15 min)

Five cardinal symptoms (delusions, hallucinations, disorganized speech, grossly disorganized

or catatonic behavior, and negative symptoms) are all still recognized in criterion.However,
two of the first three (delusions, hallucinations, and disorganized speech) are now required to
make the diagnosis

The manic phase of bipolar disorder may include:

 feeling very happy, elated or overjoyed.

32
  talking very quickly.
 feeling full of energy.
 feeling self-important.
 feeling full of great new ideas and having important plans.
 being easily distracted.
 being easily irritated or agitated

here below are commmoncommon maniefstation in psychotic disorder and manic phase based on
NANDA term

RISK FOR SELF DIRECTED OR OTHERDIRECTED VIOLENCE

Definition: At risk for behaviors in which an individual demonstrates that he or she can be
physically, emotionally, and/or sexually harmful [either to self or to others.]

Related/Risk Factors (“related to”)

 Lack of trust (suspiciousness of others)
 Panic level of anxiety
 Catatonic excitement
 Negative role modeling
 Rage reactions
 Command hallucinations
 Delusional thinking
 Body language—rigid posture, clenching of fists and jaw,

33
 Goals/Objectives
Short-term Goals
Within [a specified time], client will recognize signs of increasing anxiety and agitation and
report to staff for assistance with intervention.
Long-term Goal
Client will not harm self or others.

Interventions

 Maintain low level of stimuli in client’s environment

 Observe client’s behavior frequently (every 15 minutes).
 Remove all dangerous objects from client’s environment
 Try to redirect the violent behavior with physical outlets for the client’s anxiety
(e.g., punching bag). Physical exercise is a safe and effective way of relieving
pent-up tension.
 Staff should maintain and convey a calm attitude toward client.
 Have sufficient staff available to indicate a show of strength to client if it becomes
necessary.
 Administer tranquilizing medications as ordered by physician. Monitor
medication for its effectiveness and for any adverse side effects.
 If client is not calmed by “talking down” or by medication, use of mechanical
restraints may be necessary.

34
 SOCIAL ISOLATION

Definition: Aloneness experienced by the individual and perceived as imposed by others and as a
negative or threatening state.

Possible Etiologies (“related to”)

 Lack of trust
 Panic level of anxiety
 Regression to earlier level of development
 Delusional thinking
 Past experiences of difficulty in interactions with others
 Repressed fears
 Unaccepted social behavior
Defining Characteristics (“evidenced by”)
 Staying alone in room
 Sad, dull affect
 Lying on bed in fetal position with back to door
 Inappropriate or immature interests and activities for developmental age or stage
 Preoccupation with own thoughts; repetitive, meaningless actions
 Approaching staff for interaction, then refusing to respond to staff’s acknowledgment

Goals/Objectives
Short-term Goal
Client will willingly attend therapy activities accompanied by trusted staff member within 1
week.
Long-term Goal
Client will voluntarily spend time with other clients and staff members in group activities.

35
Interventions

 Convey an accepting attitude by making brief, frequent contacts.

 Show unconditional positive regard.
 Be with the client to offer support during group activities that may be frightening
or difficult for him or her.
 Be honest and keep all promises. Honesty and dependability promote a trusting
relationship.
 Orient client to time, person, and place, as necessary.
 Be cautious with touch.
 Administer tranquilizing medications as ordered by physician.
 Discuss with client the signs of increasing anxiety and techniques to interrupt the
response (e.g., relaxation exercises, thought stopping).

DISTURBED SENSORY PERCEPTION: AUDITORY/VISUAL

Definition: Change in the amount or patterning of incoming stimuli [either internally or

externally initiated] accompanied by a diminished, exaggerated, distorted, or impaired response
to such stimuli.

Possible Etiologies (“related to”)

 Panic level of anxiety
 Withdrawal into the self
 Stress sufficiently severe to threaten an already weak ego
Defining Characteristics (“evidenced by”)

36
  Talking and laughing to self
 Listening pose (tilting head to one side as if listening)
 Stops talking in middle of sentence to listen
 Rapid mood swings
 Disordered thought sequencing
 Inappropriate responses
 Disorientation
 Poor concentration
 Sensory distortions

Goals/Objectives
Short-term Goal
Client will discuss content of hallucinations with nurse or therapist within 1 week.
Long-term Goal
Client will verbalize understanding that the voices are a result of his or her illness and
demonstrate ways to interrupt the hallucination.

Interventions

 Observe client for signs of hallucinations (listening pose, laughing or talking to

self, stopping in mid-sentence).
 Avoid touching the client before warning him or her that you are about to do so.
 An attitude of acceptance will encourage the client to share the content of the
hallucination with you.
 Do not reinforce the hallucination.
 Try to distract the client away from the hallucination.

37
  Listening to the radio or watching television helps distract some clients from
attention to the voices.

DISTURBED THOUGHT PROCESSES

Definition: Disruption in cognitive operations and activities.

Possible Etiologies (“related to”)

 Inability to trust
 Panic level of anxiety
 Repressed fears
 Stress sufficiently severe to threaten an already weak ego
 Possible hereditary factor
Defining Characteristics (“evidenced by”)
 Delusional thinking (false ideas)
 Inability to concentrate
 Hypervigilance
 Altered attention span—distractibility
 Inaccurate interpretation of the environment

38
 Goals/Objectives
Short-term Goal
[By specified time deemed appropriate], client will recognize and verbalize that false ideas occur
at times of increased anxiety.
Long-term Goal
By time of discharge from treatment, client will be able to differentiate between delusional
thinking and reality.

Interventions

 Convey your acceptance of client’s need for the false belief, while letting him or
her know that you do not share the belief.
 Do not argue or deny the belief
 Help client trye to connect the false beliefs to times of increased anxiety
 Reinforce and focus on reality
 Assist and support client in his or her attempt to verbalize feelings of anxiety,
fear, or insecurity.

39
 SELF CARE DEFICIT

Definition: Impaired ability to perform or complete [activities of daily living (ADLs)].

Possible Etiologies (“related to”)

 Withdrawal into the self
 Regression to an earlier level of development
 Panic level of anxiety
 Perceptual or cognitive impairment
 Inability to trust
Defining Characteristics (“evidenced by”)
 Difficulty in bringing or inability to bring food from receptacle to mouth
 Inability [or refusal] to wash body or body parts
 Impaired ability or lack of interest in selecting appropriate clothing to wear, dressing,
grooming, or maintaining appearance at a satisfactory level

Goals/Objectives
Short-term Goal
Client will verbalize a desire to perform ADLs by end of 1 week.
Long-term Goal
By time of discharge from treatment, client will be able to perform ADLs in an independent
manner and demonstrate a willingness to do so.

Interventions

 Encourage client to perform normal ADLs to his or her level of ability.

 Encourage independence, but intervene when client is unable to perform. Client
comfort and safety are nursing priorities.
 Offer recognition and positive reinforcement for independent accomplishments.

40
  Show client, on concrete level, how to perform activities with which he or she is
having difficulty
 Keep strict records of food and fluid intake.
 Offer nutritious snacks and fluids between meals.
 If client is not eating because of suspiciousness and fears of being poisoned,
provide canned foods and allow client to open them; or, if possible, suggest that
food be served family- style so that client may see everyone eating from the same
servings.
 If client is soiling self, establish routine schedule for toilet-ing needs.

DISTURBED SLEEP PATERN

Definition: A disruption in amount and quality of sleep that impairs functioning.

Possible Etiologies (“related to”)

 Panic level of anxiety
 Repressed fears
 Hallucinations
 Delusional thinking
Defining Characteristics (“evidenced by”)
 Difficulty falling asleep
 Awakening very early in the morning
 Pacing; other signs of increasing irritability caused by lack of sleep

Goals/Objectives

41
 Short-term Goal
Within first week of treatment, client will fall asleep within 30 minutes of retiring and sleep 5
hours without awakening, with use of sedative if needed.
Long-term Goal
By time of discharge from treatment, client will be able to fall asleep within 30 minutes of
retiring and sleep 6 to 8 hours with-out a sleeping aid.

Interventions

 Keep strict records of sleeping patterns.

 Discourage sleep during the day to promote more restful sleep at night.
 Administer antipsychotic medication at bedtime so client does not become drowsy
during the day.
 Assist with measures that promote sleep, such as warm, non-stimulating drinks;
light snacks; warm baths; and back rubs.
 Performing relaxation exercises to soft music may be helpful prior to sleep.
 Limit intake of caffeinated drinks such as tea, coffee, and colas. Caffeine is a
CNS stimulant and may interfere with the client’s achievement of rest and sleep.

42
2.3 Major Nursing Diagnoses and Interventions for Depression

 A 23 years old male patient come

with complaints of unable to
initiatesleep,worthlessness,depress
ed mood with 2 months duration
he also havehas prior suicide
attempt
 Sobein a group and prioritize
problems and formulate at leaste 3
psychiatry nursing diagnosis with
ACTIVITY 2.2
selected interventions(20 min)

symptoms of depression

 Feelings of sadness, tearfulness, emptiness or hopelessness

 Angry outbursts, irritability or frustration, even over small matters
 Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or
sports
 Sleep disturbances, including insomnia or sleeping too much
 Tiredness and lack of energy, so even small tasks take extra effort

43
  Reduced appetite and weight loss or increased cravings for food and weight gain
 Anxiety, agitation or restlessness
 Slowed thinking, speaking or body movements
 Feelings of worthlessness or guilt, fixating on past failures or self-blame
 Trouble thinking, concentrating, making decisions and remembering things
 Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide

 here below are problems seen in depression patient based on NANDA term

RISK FOR SUICIDE

Definition: At risk for self-inflicted, life-threatening injury.

Related/Risk Factors (“related to”)

 Depressed mood
 Grief; hopelessness; social isolation
 History of prior suicide attempt
 Has a suicide plan and means to carry it out
 Widowed or divorced
 Chronic or terminal illness
 Psychiatric illness or substance abuse
 States desire to die Threats of killing self

Goals/Objectives

44
 Short-term Goals
1. Client will seek out staff when feeling urge to harm self.
2. Client will make short-term verbal (or written) contract with nurse not to harm self.
Long-term Goal
Client will not harm self.

Interventions

 Ask client directly: “Have you thought about harming yourself in any way? If so,
what do you plan to do? Do you have the means to carry out this plan?”
 Create a safe environment for the client. Remove all potentially harmful objects
from client’s access (sharp objects, straps, belts, ties, glass items).
 Formulate a short-term verbal or written contract with the client that he or she will
not harm self during specific time period. When that contract expires, make
another, and so forth.
 Secure promise from client that he or she will seek out a staff member or support
person if thoughts of suicide emerge.
 Maintain close observation of client
 Maintain special care in administration of medications.Prevents saving up to
overdose or discarding and not taking.
 Make rounds at frequent, irregular intervals (especially at night, toward early
morning, at change of shift, or other predictably busy times for staff).
 Encourage verbalizations of honest feelings
 Encourage client to express angry feelings within appropriate limits.

45
 COMPLICATED GRIEVING

Definition: A disorder that occurs after the death of a significant other [or any other loss of
significance to the individual], in which the experience of distress accompanying bereavement
fails to follow normative expectations and manifests in functional impairment.

Possible Etiologies (“related to”)

 Real or perceived loss of any concept of value to the individual
 Bereavement overload (cumulative grief from multiple unresolved losses)
 Thwarted grieving response to a loss
 Absence of anticipatory grieving
 Feelings of guilt generated by ambivalent relationship with lost entity
Defining Characteristics (“evidenced by”)
 Idealization of lost entity
 Denial of loss
 Excessive anger, expressed inappropriately
 Obsessions with past experiences
 Developmental regression
 Difficulty in expressing loss
 Prolonged difficulty coping following a loss
 Reliving of past experiences with little or no reduction of intensity of the grief
 Labile affect
 Alterations in eating habits, sleep patterns, dream patterns, activity level, libido

Goals/Objectives

46
 Short-term Goal
Client will express anger toward lost entity.
Long-term Goals
1. Client will be able to verbalize behaviors associated with the normal stages of grief.
2. Client will be able to recognize own position in grief process as he or she progresses at own
pace toward resolution.

Interventions

 Determine stage of grief in which client is fixed.

 Develop trusting relationship with client. Show empathy and caring. Be honest
and keep all promises.
 Convey an accepting attitude, and enable the client to express feelings openly
 Encourage client to express anger.
 Assist client to discharge pent-up anger through participation in large motor
activities (e.g., brisk walks, jogging, physical exercises, volleyball, punching bag,
exercise bike).
 Teach the normal stages of grief and behaviors associated with each stage.

SOCIAL ISOLATION/IMPAIRED SOCIAL INTERACTION

Definition: Social isolation is the condition of aloneness experienced by the individual and
perceived as imposed by others and as a negative or threatened state; impaired social interaction
is an insufficient or excessive quantity or ineffective quality of social exchange.

Possible Etiologies (“related to”)

47
  Developmental regression
 Egocentric behaviors (which offend others and discourage relationships)
 Disturbed thought processes [delusional thinking]
 Fear of rejection or failure of the interaction
 Impaired cognition fostering negative view of self
 Unresolved grief
 Absence of significant others
Defining Characteristics (“evidenced by”)
 Sad, dull affect
 Being uncommunicative, withdrawn; lacking eye contact
 Preoccupation with own thoughts; performance of repetitive,
 meaningless actions
 Seeking to be alone
 Assuming fetal position
 Expression of feelings of aloneness or rejection
 Discomfort in social situations

Goals/Objectives

48
 Short-term Goal
Client will develop trusting relationship with nurse or counselor within time period to be
individually determined.
Long-term Goals
1. Client will voluntarily spend time with other clients and nurse or therapist in group activities
by time of discharge from treatment.

Interventions

 Spend time with client. This may mean just sitting in silence for a while.
 Develop a therapeutic nurse-client relationship through frequent, brief contacts
and an accepting attitude.
 After client feels comfortable in a one-to-one relationship, encourage attendance
in group activities.
 Verbally acknowledge client’s absence from any group activities.

49
2.4Major Nursing Diagnoses and Interventions for anxiety disorder

Activity 2.3
 Discus about common problem manifests in
Group discussion anxiety disorder
 Make psychiatry nursing diagnosis?
 list intervention for patients who have anxiety
disorder?

Divide random 3 groups (30 minute)

Common anxiety signs and symptoms include:

 Feeling nervous, restless or tense.

 Having a sense of impending danger, panic or doom.
 Having an increased heart rate.
 fear
 Breathing rapidly (hyperventilation)
 Sweating.

50
  Trembling.
 Feeling weak or tired.
 Trouble concentrating or thinking about anything other than the present worry.

ANXIETY (PANIC)

Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response

(the source often nonspecific or unknown to the individual); a feeling of apprehension caused by
anticipation of danger. It is an alerting signal that warns of impending danger and enables the
individual to take measures to deal with threat.

Possible Etiologies (“related to”)

 Unconscious conflict about essential values and goals of life
 Situational and maturational crises
 Real or perceived] threat to self-concept
 Real or perceived threat of death
 Unmet needs
 Being exposed to a phobic stimulus
 Attempts at interference with ritualistic behaviors
 Traumatic experience

Defining Characteristics (“evidenced by”)

51
  Increased respiration
 Increased pulse
 Decreased or increased blood pressure
 Nausea
 Confusion
 Faintness
 Trembling or shaking
 Restlessness
 Insomnia
 [Nightmares or visual perceptions of traumatic event]
 [Fear of dying, going crazy, or doing something uncontrolled during an attack

Goals/Objectives
Short-term Goal
Client will verbalize ways to intervene in escalating anxiety within 1 week.
Long-term Goal
Client will be able to recognize symptoms of onset of anxiety and intervene before reaching
panic stage by time of discharge from treatment.

52
Interventions

 Maintain a calm, nonthreatening manner while working with client

 Reassure client of his or her safety and security.
 Use simple words and brief messages, spoken calmly and clearly, to explain
hospital experiences to client
 Keep immediate surroundings low in stimuli (dim lighting, few people, simple
decor).
 Administer tranquilizing medication, as ordered by physician. Assess medication
for effectiveness and for adverse side effects.
 When level of anxiety has been reduced, explore with client possible reasons for
occurrence.
 Encourage client to talk about traumatic experience under nonthreatening
conditions.

FEAR

Definition: Response to perceived threat that is consciously recognized as a danger.

Possible Etiologies (“related to”)

 Phobic stimulus
 Being in place or situation from which escape might be difficult
 Causing embarrassment to self in front of others
Defining Characteristics (“evidenced by”)

53
  Refuses to leave own home alone
 Refuses to eat in public
 Refuses to speak or perform in public
 Refuses to expose self to (specify phobic object or situation)
 Identifies object of fear
 Symptoms of apprehension or sympathetic stimulation in
 presence of phobic object or situation]

Goals/Objectives
Short-term Goal
Client will discuss phobic object or situation with nurse or therapist within 5 days.
Long-term Goal
Client will be able to function in presence of phobic object or situation without experiencing
panic anxiety by time of discharge from treatment.

Interventions

 Reassure client of his or her safety and security. At panic level of anxiety, client
may fear for own life.
 Explore client’s perception of threat to physical integrity or threat to self-concept
 Discuss reality of the situation with client in order to recognize aspects that can be
changed and those that cannot
 Include client in making decisions related to selection of alternative coping
strategies.
 Encourage client to explore underlying feelings that may be contributing to
irrational fears.

54
2.5Common Nursing Diagnoses and Interventions for Clients with Substance-
Related Disorders

Activity 2.4
 two actual nursing diagnosis for clients
with substance related disorder(10
minute)

55
A substance use disorder (SUD) is a mental disorder that affects a person’s brain and behavior,
leading to a person’s inability to control their use of substances such as legal or illegal drugs,
alcohol, or medications. Symptoms can range from moderate to severe, with addiction being the
most severe form of SUDs.

 Drug addiction symptoms or behaviors include, among others:

 Feeling that you have to use the drug regularly — daily or even several times a day
 Having intense urges for the drug that block out any other thoughts
 Over time, needing more of the drug to get the same effect
 Taking larger amounts of the drug over a longer period of time than you intended
 Making certain that you maintain a supply of the drug
 Spending money on the drug, even though you can't afford it
 Not meeting obligations and work responsibilities, or cutting back on social or
recreational activities because of drug use
 Continuing to use the drug, even though you know it's causing problems in your life or
causing you physical or psychological harm
 Doing things to get the drug that you normally wouldn't do, such as stealing
 Driving or doing other risky activities when you're under the influence of the drug
 Spending a good deal of time getting the drug, using the drug or recovering from the
effects of the drug
 Failing in your attempts to stop using the drug
 Experiencing withdrawal symptoms when you attempt to stop taking the drug

Risk For Injury

Definition: At risk for injury as a result of [internal or external] environmental conditions

interacting with the individual’s adaptive and defensive resources.
Related/Risk Factors (“related to”)

56
  Substance intoxication
 Substance withdrawal
 Disorientation
 Seizures
 Hallucinations
 Psychomotor agitation
 Unstable vital signs
 Delirium
 Flashbacks
 Panic level of anxiety

Goals/Objectives
Short-term Goal
Client’s condition will stabilize within 72 hours.
Long-term Goal
Client will not experience physical injury.

Interventions

 Assess client’s level of disorientation to determine specific requirements for

safety.
 Obtain a drug history
 Obtain urine sample for laboratory analysis of substance content.
 Place client in quiet, private room. Excessive stimuliincreaseclient agitation.
 Institute necessary safety precautions (CLIENT safety is a nursing priority.):
 Ensure that smoking materials and other potentially harmful objects are stored
away from client’s access.
 Frequently orient client to reality and surroundings.

57
  Monitor client’s vital signs every 15 minutes initially and less frequently as acute
symptoms subside..

INEFFECTIVE COPING

Definition: Inability to form a valid appraisal of the stressors, inadequate choices of practiced
responses, and/or inability to use available resources.

Possible Etiologies (“related to”)

 Inadequate support systems
 Inadequate coping skills
 Underdeveloped ego
 Possible hereditary factor
 Dysfunctional family system
 Negative role modeling
 Personal vulnerability
Defining Characteristics (“evidenced by”)

58
  Low self-esteem
 Chronic anxiety
 Chronic depression
 Inability to meet role expectations
 Alteration in societal participation
 Inability to meet basic needs
 Inappropriate use of defense mechanisms
 Abuse of chemical agents
 Low frustration tolerance
 Need for immediate gratification

Goals/Objectives
Short-term Goal
Client will express true feelings associated with use of substances as a method of coping with
stress.
Long-term Goal
Client will be able to verbalize adaptive coping mechanisms to use, instead of substance abuse,
in response to stress.

Interventions

 Establish trusting relationship with client (be honest; keep appointments; be

available to spend time).
 Set limits on manipulative behavior
 Encourage client to verbalize feelings, fears, and anxieties.
 Explain the effects of substance abuse on the body.

59
  Explore with client the options available to assist with stressful situations rather
than resorting to substance abuse (e.g., contacting various members of Alcoholics
Anonymous or Narcotics Anonymous; physical exercise; relaxation techniques;
meditation).
 Provide positive reinforcement for evidence of gratification delayed
appropriately.
 Encourage client to be as independent as possible in own self-care.

CHRONIC LOW SELFESTEEM

Definition: Long-standing negative self-evaluating/feelings about self or self-capabilities.

Possible Etiologies (“related to”)

 Retarded ego development
 Dysfunctional family system
 Lack of positive feedback
 Perceived failures
Defining Characteristics (“evidenced by”)

60
  Difficulty accepting positive reinforcement
 Failure to take responsibility for self-care
 Self-destructive behavior (substance abuse)
 Lack of eye contact
 Withdraws into social isolation
 Highly critical and judgmental of self and others
 Sense of worthlessness
 Fear of failure
 Unable to recognize own accomplishments

Goals/Objectives
Short-term Goal
Client will accept responsibility for personal failures and verbalize the role substances played in
those failures.
Long-term Goal
By time of discharge, client will exhibit increased feelings of self-worth as evidenced by verbal
expression of positive aspects about self, past accomplishments, and future prospects.

Interventions

 Be accepting of client and his or her negativism

 Spend time with client to convey acceptance and contribute toward
feelings of self-worth.
 Help client to recognize and focus on strengths and accomplishments

61
  Encourage participation in group activities from which client may receive
positive feedback and support from peers.
 Help client identify areas he or she would like to change about self and
assist with problem solving toward this effort.
 Ensure that client is not becoming increasingly dependent and that he or
she is accepting responsibility for own behaviors.
 Ensure that therapy groups offer client simple methods of achievement.
 Provide instruction in assertiveness techniques: the ability to recognize the
difference among passive, assertive, and aggressive behaviors and the
importance of respecting the human rights of others while protecting one’s
own basic human rights.
 Teach effective communication techniques, such as the use of “I”
messages and placing emphasis on ways to avoid making judgmental
statements

2.6 Major nursing diagnosis in clients withcatatonic features

62
  A 31-year-old woman with an unknown psychiatric
history presented with mutism, stupor,
negativism,refuse to eat and withdrawn behavior.
She was admitted to the psychiatric unit for what
appeared to be catatonia. Medical records were not
readily available. A comprehensive evaluation did
not uncover any medical etiology. Lorazepam was
ineffective at consistently reversing her catatonic
symptoms. During week three of hospitalization, she
was given olanzapine with subsequent improvement
in her negativism
 identify problems,prioritize and formulate
ACTIVITY 2.5 psychiatry nursing diagnosis with intervention?(30
min)

Symptoms

 Not responding to other people or their environment

 Not speaking
 Holding their body in an unusual position
 Resisting people who try to adjust their body
 Agitation
 refuse to eat
 Repetitive, seemingly meaningless movement
 Mimicking someone else’s speech
 Mimicking someone else’s movements

IMPAIRED VERBAL COMMUNICATION

63
Definition: Decreased, delayed, or absent ability to receive, process, transmit, and use a system
of symbols [to communicate].

Possible Etiologies (“related to”)

 Altered perceptions
 Inability to trust
 Panic level of anxiety
 Regression to earlier level of development
 Withdrawal into the self
 Disordered, unrealistic thinking
Defining Characteristics (“evidenced by”)
 Loose association of ideas
 Use of words that are symbolic to the individual (neologisms)
 Use of words in a meaningless, disconnected manner (word salad)
 Use of words that rhyme in a nonsensical fashion (clang association)
 Repetition of words that are heard (echolalia)
 Does not speak (mutism)

Goals/Objectives

64
Short-term Goal
Client will demonstrate ability to remain on one topic, using appropriate, intermittent eye contact
for 5 minutes with nurse or therapist.
Long-term Goal
By time of discharge from treatment, client will demonstrate ability to carry on a verbal
communication in a socially acceptable manner with staff and peers.

Interventions

 Spend time with the patient even if he’s mute and unresponsive, to promote reassurance
and support.
 Remember that, despite appearances, the patient is acutely aware of his environment,
assume the patient can hear – speak to him directly and don’t talk about him in his
presence.
 Emphasize reality during all patient contacts, to reduce distorted perceptions (for
example, say, “The leaves on the trees are turning colors and the air is cooler, It’s fall”)
 Verbalize for the patient the message that his behavior seems to convey, encourage him
to do the same.
 Tell the patient directly, specifically, and concisely what needs to be done; don’t give him
choice (for example, say, “It’s time to go for a walk, lets go.”)
 Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he
won’t complain of pain or physical symptoms.
 Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or
decreased circulation.
 Provide range-of-motion exercises.
 Encourage to ambulate every 2 hours.
 During periods of hyperactivity, try to prevent him from experiencing physical
exhaustion and injury.

65
  As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow
orders with respect to nutrition, urinary catheterization, and enema use.
 Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for
yourself, the patient, and others.

 IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS

Definition: Intake of nutrients insufficient to meet metabolic needs.

Possible Etiologies (“related to”)

 possible neurotransmitter imbalance
 Eating nothing (or very little)
 No interest
 Problems with malabsorptioncaused by chronic alcohol abuse

Defining Characteristics (“evidenced by”)

 Loss of weight
 Poor muscle tone
 Pale conjunctiva and mucous membranes
 Poor skin turgor
 Edema of extremities
 Electrolyte imbalances
 Cheilosis (cracks at corners of mouth)
 Scaly dermatitis
 Weakness
 Neuropathies

Goals/Objectives

66
 Short-term Goals
1. Client will gain 2 lb during next 7 days.
2. Client’s electrolytes will be restored to normal within 1 week.
Long-term Goal
Client will exhibit no signs or symptoms of malnutrition by discharge.

Interventions

 In collaboration with dietitian, determine number of calories required to provide

adequate nutrition and realistic (according to body structure and height) weight
gain.
 Strict documentation of intake, output, and calorie count.
 Weigh daily. Weight loss or gain is important assessment information.
 Determine client’s likes and dislikes and collaborate with dietitian to provide
favorite foods. 5. Ensure that client receives small, frequent feedings, including a
bedtime snack, rather than three larger meals
 Administer vitamin and mineral supplements, as ordered by physician, to improve
nutritional state.

Chapter Summary

67
 A mental disorder is characterized by a clinically significant disturbance in an
individual’s cognition, emotional regulation, or behaviour.
 The most common psychiatric disorders are schizophrenia, depression, substance ,
anxiety and catatonic features
 Most common nursing diagnosis in patient with manic phase and schizophrenia is risk for
violence self directed/other directed, disturbed sensory perception, disturbed thought
process, social isolation , self care deficit and disturbed sleep pattern.
 Most common nursing diagnosis in patient with depression is disturbed sleep pattern,
complicated grieving , risk for suicide and impaired social interaction
 Most common nursing diagnosis in patients with anxiety disorder is fear and
anxiety/panic.
 Most common nursing diagnosis in patints with substance use disorder is ineffective
coping, risk for injury, disturbed sleep pattern and chronic low self steem.
 Most common nursing diagnosis in patients with catatonic feature is imbalanced nutrition
lessthan body requirement and impaired verbal communication

i
Reference

68
i

1. American Nurse association, psychiatric-mental health nursing, published by

nursebooks.org,2014

2. BNS-101 Nursing Foundation, Published By -IGNOU; 2017 [cited 2018 Feb 25].

3. “Birpuri” S Sharma. Principles and practice of nursing, Published By -Jaypee Publication, 2012

4. Burton M, Ludwig LJM. Fundamentals of nursing care: concepts, connections & skills. Second
edition. Philadelphia, PA: F.A. Davis Company; 2014.

5. Kozier B, Berman A, editors. Kozier&Erb’s fundamentals of nursing: concepts, process, and

practice. 9th ed. Boston: Pearson; 2012.

6. Sheila L. Videbeck , Judith M. Schulth. lipincott’s manual of psychiatric nursing care plan.
9thed, 2013

7. Mary C. Townsend. nursing diagnosis in psychiatric nursing. 8th ed. F.A davis company , 2011

8. Nugent PM, Vitale BA. Fundamentals of nursing: content review plus practice questions. 2014.

9. Perry AG, Potter PA, Ostendorf W. Clinical nursing skills & techniques. 8th edition. St. Louis,
Missouri: Elsevier; 2014.

10. Potter PA, Perry AG, Hall A, Stockert PA. Fundamentals of nursing. Eighth edition. St. Louis,
Mo: Mosby Elsevier; 2013.

11. Treas LS, Wilkinson JM. Basic nursing: concepts, skills, & reasoning. Philadelphia, PA: F.A.
Davis Company; 2014.

12. Matt smith , what is catatonia, webmd, 2021

13. Sadock, B. J., &Sadock, V. A.(2007).Kaplan &Sadock's synopsis of psychiatry: Behavioral

sciences/clinical psychiatry (10th ed.).

14. NANDA. Nursing diagnoses. Definitions and classification , 2015-2017