CLINICAL ASSESSMENT, PROBLEMS, AND TREATMENT

This module aligns with APNA’s “Clinical Decision Making” specific core nursing content (American Psychiatric Nurses Association Education Council, Undergraduate Branch, 2022).

Module Outline

• Using the nursing process to guide mental health nursing care

Module Learning Outcomes

• Describe the nursing process
• Discuss various treatment options

The Nursing Process

Traditionally, the nursing process involves assessment, diagnosis, planning outcomes, implementation, and evaluation (ADPIE). However, you may remember from the Introduction, this text will focus on Problems (see the Introduction for explanation). An interview with the patient will allow the nurse to gather crucial information for the assessment. When interacting with patients, it is imperative to be aware of the potential for transference and countertransference. Transference is the process through which patients transfer attitudes to the nurse. They may be positive and include friendly, affectionate feelings, or negative, and include hostile and angry feelings. Countertransference is a similar attitude transfer, but from the nurse to the patient.

Read more about the nursing process here: https://www.ncbi.nlm.nih.gov/books/NBK499937/  (Toney-Butler & Thayer, 2022).

Assessment

The nursing process is used to guide mental health nursing care. The first step of the nursing process is an assessment. In general, the nurse is gathering data, including:

• allergies and code status
• list of current medications (dose, frequency, route)
• current assessment of presenting signs/symptoms, any effects on daily functioning
• pertinent physical, surgical, and psychosocial history
• cultural, spiritual, sexual, and gender identity

An initial assessment serves as a baseline to inform future needs. The assessment involves the collection of subjective data (i.e., information from the patient or caregiver) and objective data (i.e., measurable data such as vital signs, intake and output, height and weight, and nurse’s assessment). This collection of information involves critical thinking about the client’s skills, abilities, personality characteristics, cognitive and emotional functioning, the social context in terms of environmental stressors that are faced, and cultural factors particular to them such as their language or ethnicity. Lastly, it is important to note that clinical assessment is ongoing.

Mental Health  Assessment

Specific to a mental health assessment, a nurse would also incorporate additional attention to a mental status examination.  A mental status examination is used to organize the information collected during the interview and systematically evaluate the patient through a series of questions assessing appearance and behavior. The latter includes grooming and body posture, thought processes and content to include disorganized speech or thought and false beliefs, mood and affect such that whether the person feels hopeless or elated, intellectual functioning to include speech and memory, and awareness of surroundings to include where the person is and what the day and time are. The exam covers areas not normally part of the interview and allows the mental health professional to determine which areas need to be examined further. See Voss and Das’s (2021) resource for further explanation of the mental status examination.

Additional Assessment Resources

• Nurses can utilize Dr. Leininger’s Sunrise Enabler (Transcultural Nursing Society, 2022) as a tool to help guide assessment.
• For a new admission, students might find Toney-Butler and Unison-Pace’s (2021) resource helpful.

Problems 

Nursing students will notice patients’ medical records may often contain several diagnoses (e.g., medical and psychological). Diagnoses serve as a communication tool to members of the healthcare team and relay the patient’s health needs as well as to insurance providers. Specific to mental health needs, the American Psychiatric Association (APA) publishes the most widely used classification system in the United States (i.e., Diagnostic and Statistical Manual of Mental Disorders (DSM) (APA, 2022).  The DSM is currently in its 5th edition Text-Revision (DSM-5-TR) and is produced by the American Psychiatric Association (APA, 2022). The DSM-5-TR is used to formally document the presence of a mental health diagnosis.

Nurses can use nursing diagnoses to document patient health needs. Nursing diagnoses are apart from medical diagnoses. The North American Nursing Diagnosis Association (NANDA) provides an official list of nursing diagnoses.  Nursing diagnoses are used to describe actual or potential health problems related to a patient, family, or community (Toney-Butler & Thayer, 2022). Remember from Maslow’s Hierarchy of Needs that basic needs should be met before higher level needs (Toney-Butler & Thayer, 2022). Nursing students can typically find NANDA’s nursing diagnoses within a fundamental or medical surgical nursing text.

This text will focus on the problem statement of the nursing diagnosis. For example, in the nursing diagnosis statement: Anxiety related to situational crisis as evidenced by statement of “I feel overwhelmed by the loss of my job!” Anxiety is the identified problem.

Watch “How to write a diagnosis.mov” (hawknurse, 2010) for further explanation of nursing diagnoses.

Planning Outcomes

Planning outcomes, sometimes seen written as “goals”, are created to establish a positive health outcome. The patient’s outcomes should be formed with the patient to ensure patient-centered care (Quality and Safety Education for Nurses, 2020).

Outcomes/goals should be S.M.A.R.T.:

• Specific
• Measurable or Meaningful
• Attainable or Action-Oriented
• Realistic or Results-Oriented
• Timely or Time-Oriented

Implementation

• Explore the Dimensions of Wellness Wheel above to gather ideas patients can help create mental health wellness throughout many aspects of their lives.

Cognitive therapy/CBT

Complementary Alternative Medicine (CAM)

Transcranial Magnetic Stimulation 

Transcranial magnetic stimulation (TMS) is a non-invasive procedure that uses low or high-intensity magnetic fields to stimulate brain tissue (Mann & Malhi, 2022). Repetitive transcranial magnetic stimulation (rTMS) refers to utilizing repetitive TMS pulses to a specific region of the brain (Mann & Malhi, 2022). TMS can be performed outpatient. The patient is alert and will feel a tapping sensation. Possible side effects include headache, neck pain, local pain, and transient tinnitus (Mann & Malhi, 2022). These side effects are typically mild and resolve in a short period of time (Mann & Malhi, 2022). Seizures are rare with higher incidence for those having epilepsy (Mann & Malhi, 2022).

Psychopharmacology

Evaluation

The final step in the nursing process is evaluation of interventions towards achievement of the outcomes ( Toney-Butler & Thayer, 2022). Evaluation is imperative as it provides information to maintain, modify, add additional, and/or stop current interventions.

Adapted from Fundamentals of Psychological Disorders 2nd Edition- Module 3 by Alexis Bridley, Ph.D. and Lee W. Daffin Jr., Ph.D. licensed under a Creative Commons Attribution 4.0 International License. Modifications: revised for clarity and flow .