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Psychiatric-Mental Health Nursing

13.3 Nursing Assessment and Care Plans

Psychiatric-Mental Health Nursing13.3 Nursing Assessment and Care Plans

Learning Objectives

By the end of this section, you will be able to:

  • Explain the importance of the nursing assessment and care planning in mental health
  • Outline the nursing assessment process in mental health
  • Explain problem identification and other issues involved in PMH nursing care planning
  • Describe implementation of a nursing care plan in a mental health setting
  • Outline the issues involved in evaluating a nursing care plan for a client with a mental health problem

The nursing process is a systematic framework used by nurses to deliver client-centered care. It consists of six essential steps: recognize cues from assessment data, analyze cues to identify problems, hypothesize priority problems, generate solutions, take action, and evaluate client care outcomes. This is commonly described as ADPIE: Assessment, Diagnosis, Planning, Intervention, and Evaluation.

The Nursing Process in Mental Health

The nurse collects comprehensive data about the client’s mental health status. This involves conducting interviews, observing, and utilizing assessment tools to gather information about the client’s mental health history, current symptoms, cognitive abilities, emotional state, and social functioning.

A nursing care plan in mental health begins the same as all care plans, with the assessment process. The nurse gathers comprehensive information, and in mental health, the mental status exam, to evaluate the client’s needs. Problem identification is based on the assessment findings, prioritizing which needs or problems require immediate attention.

Assessment and Data Collection

The nurse utilizes the skills of observation and a structured interview to obtain information regarding the client’s mental health status. There are several tools available, based on the client’s symptoms, the nurse may employ. Examples include the Patient Health Questionnaire (PHQ-9), which evaluates symptoms of depression. The General Anxiety Disorder (GAD-7) looks at symptoms of anxiety. There are many tools to choose from based on the judgment of the nurse and the needs of the client.

Mental Status Exam

The mental status exam (MSE) is an assessment tool used by mental health professionals to analyze an individual’s cognitive, emotional, and behavioral functioning. It provides an overview of a person’s mental state at a specific point in time and helps clinicians form a treatment plan. The MSE evaluates appearance and behavior, mood (as stated by the client) as well as affect, or emotional expressions observed by the nurse. The MSE also looks at speech and language, including rate and volume, and observes any abnormalities, such as pressured or rapid speech. It also includes observation of thought process, including logic and how thoughts are organized through the client’s expression. The examiner assesses thought content for delusions, hallucinations, or suicidal/homicidal thoughts. Orientation and cognition assessment determines cognitive functions, such as attention or memory. Insight and judgment assessment determines a client’s ability to understand their own condition and make appropriate decisions.

Risk Assessments

Nurses must assess the level of risk clients have for self-harm or harm to others due to their mental health condition. This is an essential part of mental health care, especially when dealing with individuals who may be at risk of self-harm, suicide, or violent behavior. Nurses can utilize the nursing process to gather information, including the client’s mental health history, current symptoms, any social support, and any previous incidents of self-harm or violence, as well as any protective factors in their life such as family support. Nurses can perform an evaluation of the individual’s current thoughts, feelings, and intentions utilizing validated assessment tools, such as the Columbia-Suicide Severity Rating Scale (C-SSRS) (Posner et al., 2010). In order to determine if the client has access to lethal weapons or means to end their life, the nurse may want to ask specific and important assessment questions such as: Are there guns in the home? Are there any medications that may be life-threatening if taken in excess? Utilizing a collaborative approach, involve the individual in the risk assessment process, fostering open communication, and ensure their participation in safety planning. Include other health-care providers, family members, and caregivers in the plan to promote safety.

Cultural Considerations

It is important for nurses to approach each client with an open mind, respect, and sensitivity to cultural differences. Culture plays a significant role in shaping a person’s beliefs, values, attitudes, and behaviors, including their understanding and experience of mental health. Cultural competence involves acquiring knowledge about different cultures, understanding their beliefs and practices, and being sensitive to the impact of culture on mental health. Moreover, language barriers can hinder effective communication and accurate assessment of the client. Nurses must be aware of cultural communication styles and nonverbal cues. Different cultures have varying beliefs and explanations for mental health issues and the nurse must acknowledge these beliefs, including the stigma that many cultures hold regarding mental illness.

The DSM-5-TR and Nursing Care Planning

While the DSM provides classification of mental health disorders, client-care problems are identified based on the assessment findings noted by the nurse. The nurse identifies actual or potential problems related to the client’s mental health condition and helps the client to identify their priority problems as well. Problem identification in mental health nursing may include such stressors or situations as impaired social interaction for those with social anxiety, or risk for self-harm/suicide for those expressing suicidal thoughts. The nurse collaborates with the client, their family, and other health professionals to establish accurate problem identification and prioritization.

Psychosocial Considerations

Mental Health Assessment

Thomas et al. (2020) found that consideration of psychosocial factors in client assessment and planning of care contributed positively to health outcomes, especially involving lifestyle changes.

High-risk health behaviors, such as smoking, high alcohol consumption, inactivity, and poor diet, were shown to exist in multiple in certain individuals in the study. While economic factors were recognized, also identified were psychosocial factors such as depression, hostility, and ineffective coping. Of note is that healthy psychosocial factors (such as positive outlook, hope, and trust) could be protective and contribute to the ability to change risky lifestyles.

Nurses should sharpen their focus on client empowerment for those who live with the burden of chronic disease, with less emphasis on clients’ personal responsibility for behavior change and more direction toward building coping ability.

(Thomas et al., 2020)

Nursing Problem Identification in Mental Health Care

The steps in the Clinical Judgment Measurement Model allow the nurse to assess subjective and objective data and synthesize the data to determine which of the problems or symptoms could be contributing to the client’s presentation or expressed need. The PMH nurse collects this data through observation, interviewing the client and or support persons, and obtaining information from medical records, tests, and other outside sources.

Once the PMH nurse has analyzed the information or assessment data, and connected it to the client’s presenting problem, the nurse then prioritizes which of the problems to address first, hypothesizing which of the problems would be contributing most to the presenting problem. Then, the PMH nurse determines what steps, actions, or interventions would improve or prevent the priority problems, and identifies solutions that focus on improving the outcome for the client. Finally, the PMH nurse must evaluate, reassess, and link the information to the presenting problem and the client’s presentation to determine if the plan of care was effective. These steps allow the nurse to identify the client’s needs and develop appropriate interventions.

Some common client problems that may present in a psychiatric-mental health nursing assessment process are ineffective coping, impaired social interaction, or disturbed thought process. Here are three examples:

  1. Client reports impending eviction from housing and lack of employment.
    • Recognize cues from collected data: Nurse notes psychological distress and impaired functioning.
    • Analyze cues/determine the meaning: Cues supporting client’s experience—client is exposed to multiple stressors.
    • Prioritize hypotheses/what to address first: What is the most likely explanation? Ineffective coping.
    • Generate solutions/formulate what to do: Teach stress reduction, stress management, connect to resources, teach goal-setting, assist to identify personal strengths.
  2. Social history in the health record details repeat admissions.
    • Recognize cues from collected data: Client difficulties in establishing or maintaining stable relationships with others.
    • Analyze cues/determine the meaning: Of concern: client in conflict with roommate, which may sabotage discharge plans.
    • Prioritize hypotheses/what to address first: What is the most likely explanation? Impairment in social interactions.
    • Generate solutions/formulate what to do: Teach conflict resolution, discuss client’s feelings and perceptions, role-play interaction skills.
  3. Client’s speech contains fearful remarks.
    • Recognize cues from collected data: Client preoccupied during interview as if attending to internal stimuli (hallucinating).
    • Analyze cues/determine the meaning: Conditions consistent with cues—delusions and hallucinations.
    • Prioritize hypotheses/what to address first: What is the most likely explanation? Disturbed thought process.
    • Generate solutions/formulate what to do: Nursing management of medications, present reality, provide safety.

Identification of Priority Problems in Mental Health

Nurses must prioritize the issues identified by their evaluation of the client. Safety is a priority for all clients and especially those with mental health disorders at risk for self-harm or harm to others. The nurse is responsible for not only prioritizing, but also individualizing a client’s plan of care. The nurse uses all steps in the nursing process and collaborates with the client to individualize their care.

Generating Solutions and Defining Interventions

In collaboration with the client and considering their individual needs and preferences, the nurse should establish goals and expected outcomes. Outcomes are derived from potential solutions, which are based on hypotheses and interventions. This is a crucial step in the nursing process, involving communication and collaboration among medical providers, nurses, social workers, counselors, and therapists in order to provide safe and effective care for the client.

The American Psychiatric Nurses Association (APNA) Scope and Standards of Practice (2022) reports that outcomes are based on the client’s goals and are individualized per each client’s circumstances. Outcomes should consider age and culture, risks and benefits, as well as costs to the client. The outcomes should provide direction for care and these outcomes should be in language developed by or understandable to the client. The APNA identifies the importance of incorporating clinical guidelines linked to positive clinical outcomes.

The APNA encourages development of a client-centered plan that prescribes strategies and alternatives to attain expected outcomes. Specific to the psychiatric-mental health registered nurse (PMH RN), the APNA identifies assessment and diagnostic strategies and therapeutic interventions that reflect current evidence. These plans aim to minimize complications, promote individualized recovery, and optimize the client’s quality of life through various treatment modalities, including psychodynamic, cognitive behavioral therapy, supportive interpersonal therapies, and psychopharmacology. The APNA stresses the importance of client education on self-regulation skills to promote resilience as well.

Taking Action in Mental Health Care

Competencies for the PMH RN in the implementation of the nursing process include partnering with the client, family, support system, and other health-care providers to provide safe, realistic care (APNA, 2022). This includes utilizing evidence-based care, the principles of recovery and trauma-sensitive care, and cultural humility. Incorporating community resources may further enhance the care needed by the client as might supervision of ancillary staff in the implementation of the plan of care.

Nursing Interventions

Nursing interventions may include strategies to prevent illness, injury, or disease; provide immediate safety and stabilization; or promote recovery. The nurse will prioritize the interventions based on safety needs of each client and the level of risk for harm to themselves or others. Defining nursing interventions includes recognition of actions to be avoided, such as making personal judgments about clients’ preferences or confronting a client about a lifestyle change before the client is stable. Additional data collection is another form of intervention, as are requests for consults and making referrals.

Complex and Challenging Situations

The PMH RN may encounter many challenges in the mental health-care arena. This may include the status of the client. Particularly difficult challenges may include delirium or delusions that make it difficult to maintain orientation. For the client who may be suicidal, safety is of primary importance. This may mean closely monitoring the client in the safest yet least restrictive environment possible. For the client who is angry and aggressive, the importance lies in not only client safety, but also in safety of the health-care team.

Documenting Interventions

The PMH RN must document client progress toward the goals previously developed and any changes made in the plan of care. Documentation is an important step in the nursing process and allows the PMH RN to share information with the health-care team. Documentation should be objective, free of interpretation and judgment, and assist in the communication of the client’s assessment and plan of care to the members of the interdisciplinary team. Documentation should include the progress the client is making toward their goals.

Evaluation of Expected Outcomes in Mental Health Care

An evaluation of the outcomes and goals previously agreed upon and response to interventions should be ongoing. Observed outcomes should be compared with expected outcomes to determine the client’s status as result of the interventions. The APNA (2022) identifies the importance of evaluating intervention outcomes to include optimizing wellness and quality of life as well as minimizing unwarranted or unwanted treatment. Further, the nurse should consider what alternative interventions may have been effective. Continual reassessment and evaluation of the plan of care helps to determine if the nurse should continue or change the plan of care.


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