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Welcome back to the Deep Dive.
Our mission today is pretty clear, actually.
We're looking at the essential framework for really high -quality psychiatric nursing.
Right, the systematic approach.
Exactly.
It's the blueprint, you know, how you turn just observing into care that's measurable and, importantly, safe.
It really is the architecture of safe practice.
And we're digging into Chapter 7, which lays out the six steps of the nursing process.
And the standards of care that go with them?
Yes.
For anyone starting out, these six steps basically govern everything you do.
It's fundamental.
Okay, let's maybe set the stage a bit.
This isn't brand new, right?
It has evolved.
Oh, absolutely.
It started smaller.
Lydia Hall had a three -stage idea.
Observation, administration, validation.
Pretty straightforward back then.
But it grew from there.
It did.
Over decades, it expanded and eventually became the standard six -step process we use now.
The ANA, the American Nurses Association, they formalized the nursing diagnosis idea first back in 73.
And then added another piece later.
Yeah, outcomes identification came in 1991.
So that gives us the current lineup.
Assessment, diagnosis, outcomes identification,
planning,
implementation,
and finally, evaluation.
That's the one.
And these steps are all directly backed up by the psychiatric mental health nursing.
Scope and standards of practice.
That sounds like a key document.
It's your professional backbone, really.
It answers all those basic questions.
What do psych nurses do?
Where?
When?
Why?
How?
It lays it all out.
And we should probably mention this whole process isn't happening in a vacuum.
It's shaped by things like the QSEN competencies.
Quality and safety education for nurses.
Definitely.
You know, things like patient -centered care, using evidence -based practice, focusing on safety.
These aren't just buzzwords.
They actually influence how you do the steps.
Exactly.
Like the need for evidence -based practice directly tells you what needs to go into your planning.
These competencies really shape how we apply those six standards.
OK, good context.
So let's jump into the first standard, the foundation.
Assessment, standard one.
Right.
Assessment, it's continuous.
It starts the second you meet the patient.
And honestly, it never really stops.
You're always gathering information.
Always collecting, synthesizing.
And the key in psych nursing is that holistic view.
You can't just focus on the mind.
You need the physical clues, too.
Absolutely.
An unsteady gait, maybe poor hygiene, someone wincing in pain.
You observe that right alongside their mood or thought process, it's all data.
And we always emphasize patient -centered care.
So the patient is the main source of info.
They're the primary source, yes.
But what if the patient is nonverbal or catatonic or maybe actively psychotic?
Then relying only on them is impossible.
Right.
That's when secondary sources become crucial.
Family,
maybe police if they were involved, old medical records.
But that brings its own challenges, I imagine.
Bias.
Huge challenge.
You have to evaluate that secondary data really critically.
Understand that it might be biased or incomplete.
It's part of the skill.
And this mind -body connection you mentioned, it seems like a major hurdle clinically.
Ruling out physical causes first.
It's non -negotiable.
You have to rule out physical causes.
Think about it.
Hypothyroidism can look exactly like major depression.
Low energy, weight gain, fatigue,
classic symptoms.
And the flip side.
Hypothyroidism.
That can present just like mania or hypomania.
Agitation.
Can't sleep.
Super anxious.
Wow.
So it's not just thyroid issues.
Oh no.
Severe B12 deficiency can cause dementia symptoms, even psychosis, liver problems, substance use.
They can cause acute confusion that looks purely psychiatric at first glance.
So that initial lab work is absolutely critical.
It's the physical baseline.
Didn't practice safely without it.
Once you have that, then you move to the specific tools for assessing the mental state.
The big one is the mental status examination.
The MSE.
The MSE.
That's like the psychiatric version of a physical exam.
That's a great way to put it is how you gather objective data.
Things you can actually observe.
Facts.
Okay.
So what does it cover?
It's systematic.
You look at their appearance, their behavior, their speech, the rate, volume, quality,
then mood and effect what they say they feel versus what you observe.
And their thinking.
Right.
Thought process and content.
Are there delusions?
Odd word usage like neologisms.
Flight of ideas.
You also assess perceptions, hallucinations, illusions,
and cognition.
Are they oriented?
How is their memory?
Insight and judgment too.
It's thorough.
So that's the objective side.
Then you need the patient's perspective.
Exactly.
That's the psychosocial assessment.
This is where you gather this objective data, their perceptions, their story.
And it starts with the chief complaint.
Yes.
And you document that verbatim.
Exactly what they said.
Then you explore their life context, support systems, coping mechanisms, past hospitalizations,
sexual history, spiritual beliefs, and definitely substance use history.
Box 7 .5 in the text lays this out well.
Makes sense.
Now, does assessment change much based on age?
Kids versus adults.
Oh, significantly.
With younger kids, a lot is observation and play.
You need a safe space where they can act out feelings and watch for regression that's often a big red flag in childhood disorders.
Returning to earlier behaviors.
Exactly.
Now, adolescence.
Confidentiality is huge for building trust.
But you have to be upfront.
Threats of harm, suicide, homicide, abuse, those have to be shared.
No exceptions.
Is there a tool for talking to teens?
It can be tricky.
There is.
The head's interview technique is really useful.
It's an acronym.
Okay, what's it stand for?
Home, education, employment, activities, drugs, sexuality, suicide, depression, and safety.
It gives you a structure to cover those high -risk areas in a more natural way.
That sounds practical.
What about older adults?
Need to accommodate potential changes.
Diminish senses, maybe slower processing, speak clearly, maybe a bit slower, slightly louder, often a lower pitch can help, and avoid stereotypes, ageism is real.
Good point.
Okay, one more assessment hurdle, language barriers.
Interpreter versus translator, what's the key difference nurses need to know?
Crucial distinction.
An interpreter handles a spoken word, including sign language like ASL, in real time.
A translator deals with written materials.
And you can't just use a family member.
Absolutely not.
Legally, providers must supply trained interpreters.
Using family is risky.
They might filter information, gather their own bias.
It's a huge malpractice risk for everyone involved.
Okay, that's vital.
So you've done this massive, careful assessment, gathered all this data.
Right.
Then you synthesize it.
Yeah.
And that leads you directly into standard two diagnosis.
Now, this isn't the DSM -5 medical diagnosis, right?
This is the nursing diagnosis.
Correct.
It's a clinical judgment about the patient's response to their health problems, actual or potential.
We use standardized systems like Nanda Eye or the ICMP, which is more global and used in the textbook.
And there's a specific way to write these diagnoses, like a formula?
There is.
Usually a three -part statement.
First, the problem or unmet need.
That's the Nanda label, like hopelessness.
Okay.
Second, the probable cause or etiology linked with the phrase related to what's contributing to the problem.
Got it.
And third?
Third is the supporting data, signs and symptoms you observed, or the patient reported.
This is linked by as evidenced by.
Can you give us an example?
Sure.
Hopelessness related to perceived abandonment as evidenced by the patient stating nothing will change, lack of involvement with peers, and poor hygiene.
See how it links the problem, cause, and evidence.
Yeah, that's clear.
Is it always three parts?
Not always.
There are also risk diagnoses, like risk for self -mutilation.
Because the harm hasn't happened yet, there's no related to cause.
Ah, okay.
So it's just the potential problem and the factors suggesting that risk.
Exactly.
Just the problem and the supporting risk factors.
Okay.
So diagnosis is set.
Next is standard three.
Outcomes, identification, defining the goal.
Right.
What do we want to achieve?
Outcomes are the maximum level of health the patient can realistically reach.
They have to be measurable.
Measurable and positive.
Yes.
Say it positively.
What the patient will do or achieve.
And you often have short -term goals and long -term outcomes.
Like for someone suicidal.
Yeah, a short -term goal might be.
Patient will identify one reason for living by end of shift.
Or patient will speak with staff when feeling overwhelmed.
The long -term outcome could be broader.
Patient will remain free from self -inflicted injury throughout hospitalization.
See table 7 .2 for more examples.
Measurable, achievable, time -limited sometimes.
Makes sense.
Which brings us to standard four, planning.
You have the diagnosis.
You have the goal.
Now the roadmap.
Exactly.
How do we get there?
And priority is key.
Maslow's hierarchy is your guide here.
Kisiological needs first.
Safety next.
Always.
Breathing, food, water, shelter.
Then feeling safe.
Higher level needs come after.
Then every intervention you plan must meet four criteria.
Okay, what are they?
It has to be safe.
Obvious but essential.
It must be compatible and appropriate fits the patient's goals, their culture, their values.
Individualized.
Right.
Realistic and individualized.
Crucially, it must be evidence -based.
Use interventions supported by research.
EBP is the gold standard.
Don't just do things because that's how we've always done it.
Followed principles.
That sets us up for actually doing something, standard five.
Implementation.
Putting the plan into action.
And here we see a difference between the basic RN role and the advanced practice RN, the APRN.
Let's cover the basic RN interventions first.
What are the main categories?
The text breaks it down into five key areas.
First is coordination of care.
The RN is often the central point person, the advocate.
Okay.
Second, health teaching.
This is huge in psych.
Teaching coping skills, medication, education, relapse prevention strategies.
Remember three?
Monitoring pharmacological, biological, and integrative therapies.
Watching for effects, side effects, interactions.
Making sure the patient understands their meds.
Right, what else?
Fourth is milieu therapy.
Using the environment itself as a therapeutic tool.
How does that work?
It's about creating a safe, structured, predictable environment.
Physical and social.
Consistent routines.
Clear expectations.
Group interactions.
It's all part of the therapy aimed at recovery.
Okay.
And the fifth basic RN role?
The therapeutic relationship and counseling.
This is foundational.
Building rapport.
Using communication skills.
Reinforcing healthy behaviors.
Basic problem solving.
It underlies everything else.
So those are the core RN functions.
What can the APRN do beyond that?
APRNs have advanced training so they have three additional exclusive roles.
Consultation is one providing expertise to other team members.
Like advising on a complex case.
Exactly.
Second is prescriptive authority and treatment.
They can diagnose and prescribe psychotropic medications and other treatments.
And the third?
Psychotherapy.
APRNs are trained to deliver various forms of talk therapy, individual, group, or family.
Using established therapeutic models.
Clear distinction.
Okay, we've planned, we've implemented now standard six.
Evaluation.
Checking if it worked.
Yes.
And this step is sometimes, unfortunately, given short shrift.
But it's critical.
You have to systematically evaluate.
Did the patient meet the outcomes we set?
And it has to be based on the criteria you set earlier.
Precisely.
Criterion based.
If the outcomes weren't met, you don't just keep doing the same thing.
You have to revise the plan.
Which means going back.
Back to assessment.
Reassess the situation.
Maybe refine the diagnosis.
Identify different outcomes.
Try new interventions.
It's a continuous cycle.
Makes sense.
Now, holding this entire process together legally and practically is documentation.
The seventh step.
You could call it that.
The medical record is a legal document.
We'll stop.
How you document matters immensely.
The book contrasts narrative charting with problem -oriented charting.
SOAPI.
Right.
Narrative can be useful, but it's often less structured.
Problem -oriented charting, especially SOAPI, is often preferred because it's systematic.
Break down SOAPI for us.
Sure.
Subjective data.
What the patient says.
Objective data.
What you observe.
MSE findings.
Vital signs.
Assessment.
Your interpretation including the nursing diagnosis.
Plan.
What you intend to do.
Intervention.
What you actually did.
And evaluation.
The patient's response to the intervention.
So it directly mirrors the nursing process steps.
Exactly.
It forces you to include all the elements.
Makes it consistent and much more legally sound.
Speaking of legal soundness, what are the absolute must do's and must don'ts in charting?
Do chart facts.
Be objective.
Be timely chart as close to the event as possible.
Do chart every intervention and the patient's response or lack thereof.
Do not chart opinions.
No judgmental language.
No calling patients manipulative or lazy.
Stick to behavior.
Okay.
And critically.
Do not mention in the patient's chart that an incident report was completed.
Why not?
Incident reports are often considered internal privileged communication for quality improvement or legal review.
Charting that one exists can sometimes make it discoverable in a lawsuit when it might otherwise not be.
Keep them separate.
That's a really important legal point.
Okay.
One last documentation point.
There's a language shift happening away from non -compliant.
Yes.
This is crucial.
We need to use non -adherent instead.
Why the change?
What's the difference?
Non -compliant sounds judgmental.
It blames the patient entirely.
Non -adherent prompts us, the providers, to ask why.
Like what are the barriers?
Exactly.
Is it the cost of the medication?
Do they not understand the instructions?
Is there a cultural reason?
A side effect they didn't mention.
So using non -adherent encourages a more thorough patient -centered approach.
It does.
And documenting that exploration,
patient non -adherent with medication states unable to afford copay.
Educated on pharmacy assistance programs.
That protects you legally too.
How so?
It shows you didn't just label a patient and give up.
You investigated the barrier.
You provided education.
You fulfilled your duty of care.
It demonstrates due diligence.
It's much safer documentation than just writing patient non -compliant.
That makes perfect sense.
Okay.
Let's try to pull this all together.
What's the main takeaway for you, our listeners?
Well, the six -step nursing process assessment, diagnosis, outcomes, planning,
implementation, evaluation.
It's not just bureaucracy.
It's the framework for safe, effective, individualized psychiatric nursing care.
Anchored by those professional standards, driven by continuous assessment, and reliant on a really careful, objective, non -judgmental documentation.
Absolutely.
And the success of that whole cycle really hinges on getting that initial assessment right, especially ruling out the physical mimics.
Which leads us to our final thought for you to ponder.
We talked about that long list of physical problems that can look exactly like serious mental illness, thyroid issues,
vitamin deficiencies, liver problems, substance effects, and more.
A really long list.
So considering how vital it is to rule out a medical cause first, what do you think is the single most essential category of lab test a psychiatric nurse should always advocate for before settling on a purely mental health diagnosis?
Something to think about.
Always check the physical first.
It's foundational.
Thank you so much for joining us for this deep dive into the nursing process and standards of care.
Hope it was helpful.
We'll see you next time.