Professional Documents
Culture Documents
Status Assessment
(Psychiatric Nursing)
Process Recording
(Parts)
I. Personal Data:
a. Name of Patient
b. Address
c. Age
d. Gender
e. Date/ Place of Birth
f. Religion
g. Place where the patient spent the last 15 yrs. of life
II. Objectives
a. Client Centered Objectives- focus on client’s benefits
b. Nurse Centered Objectives- focus on nurse’s benefits
1. Offering Self
2. Active listening
• paying close attention to what the patient is saying by observing both verbal and
non-verbal cues.
• Maintaining eye contact and making verbal remarks to clarify and encourage
further communication.
3. Exploring
5. Silence
• Planned absence of verbal remarks to allow patient and nurse to think over what is
being discussed and to say more.
6. Stating the observed
• verbalizing what is observed in the patient to, for validation and to encourage
discussion
• “You sound angry”
7. Encouraging comparisons
8. Identifying themes
9. Summarizing
• asking the patients to describe feelings, perceptions and views of their situations.
• “What are these voices telling you to do?”
• stating what is real and what is not without arguing with the patient.
• “I know you hear these voices but I do not hear them”.
• “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.
16. Reflecting
• throwing back the patient’s statement in a form of question helps the patient
identify feelings.
• Patient: I think I should leave now.
• Nurse: Do you think you should leave now?
17. Restating
• repeating the exact words of patients to remind them of what they said and to let
them know they are heard.
• Patient: I can’t sleep. I stay awake all night.
• Nurse: You can’t sleep at night?
20. Empathy
21. Focusing
22. Interpreting
• practicing behaviors for specific situations, both the nurse and patient play
particular role.
• “I’ll play your mother, tell me exactly what would you say when we meet on
Sunday”.
33. Rehearsing
• asking the patient for a verbal description of what will be said or done in a
particular situation.
• “Supposing you meet these people again, how would you respond to them when
they ask you to join them for a drink?”.
34. Feedback
36. Reinforcement
Avoid pitfalls:
1. Giving advise
2. Talking about your self
3. Telling client is wrong
4. Entering into hallucinations and delusions of client
5. False reassurance
6. Cliché
7. Giving approval
8. Asking WHY?
9. Changing subject
10. Defending doctors and other health team members.
1. Overloading
• talking rapidly, changing subjects too often, and asking for more information than
can be absorbed at one time.
• “What’s your name? I see you like sports. Where do you live?”
2. Value Judgments
3. Incongruence
• remaining silent and unresponsive, not picking up cues, and failing to give
feedback.
• The patient ask the nurse, simply walks away.
6. Invalidation
7. Focusing on self
• responding in a way that focuses attention to the nurse instead of the client.
• “This sunshine is good for my roses. I have beautiful rose garden”.
9. Giving advice
• telling the client what to do, giving opinions or making decisions for the client,
implies client cannot handle his or her own life decisions and that the nurse is
accepting responsibility.
• “If I were you… Or it would be better if you do it this way…”
• making an assumption about the meaning of someone else’s behavior that is not
validated by the other person (jumping into conclusion).
• The nurse sees a suicidal clients smiling and tells another nurse the patient is in
good mood.
• Defined Nursing: “The act of utilizing the environment of the patient to assist
him in his recovery.”
• Focuses on changing and manipulating the environment in order to put the patient
in the best possible conditions for nature to act.
• Identified 5 environmental factors: fresh air, pure water, efficient drainage,
cleanliness/sanitation and light/direct sunlight.
• Considered a clean, well-ventilated, quiet environment essential for recovery.
• Deficiencies in these 5 factors produce illness or lack of health, but with a
nurturing environment, the body could repair itself.
• Defined Nursing: “The act of assisting others in the provision and management
of self-care to maintain/improve human functioning at home level of
effectiveness.”
• Focuses on activities that adult individuals perform on their own behalf to
maintain life, health and well-being.
• Has a strong health promotion and maintenance focus.
• Identified 3 related concepts:
1. Self-care – activities an Individual performs independently throughout life
to promote and maintain personal well-being.
2. Self-care deficit – results when self-care agency (Individual’s ability) is
not adequate to meet the known self-care needs.
3. Nursing System – nursing interventions needed when Individual is unable
to perform the necessary self-care activities:
1. Wholly compensatory – nurse provides entire self-care for the
client.
Example: care of a new born, care of client recovering from
surgery in a post-anesthesia care unit
2. Partial compensatory – nurse and client perform care, client can
perform selected self-care activities, but also accepts care done by
the nurse for needs the client cannot meet independently.
Example: Nurse can assist post operative client to
ambulate, Nurse can bring a meal tray for client who can
feed himself
3. Supportive-educative – nurse’s actions are to help the client
develop/learn their own self-care abilities through knowledge,
support and encouragement.
Example: Nurse guides a mother how to breastfeed her
baby, Counseling a psychiatric client on more adaptive
coping strategies.
1.
1. The human being is a unified whole, possessing individual integrity and
manifesting characteristics that are more than and different from the sum
of parts.
2. The individual and the environment are continuously exchanging matter
and energy with each other
3. The life processes of human beings evolve irreversibly and
unidirectionally along a space-time continuum
4. Patterns identify human being and reflect their innovative wholeness
5. The individual is characterized by the capacity for abstraction and
imagery, language and thought, sensation and emotion
• Nursing is participation in care, core and cure aspects of patient care, where
CARE is the sole function of nurses, whereas the CORE and CURE are shared
with other members of the health team.
• The major purpose of care is to achieve an interpersonal relationship with the
individual that will facilitate the development of the core.
• Nursing is broadly grouped into 21 problem areas to guide care and promote the
use of nursing judgement.
• Nursing is a comprehensive service that is based on the art and science and aims
to help people, sick or well, cope with their health needs.
21 Nursing Problems
• Nursing is a process of action, reaction, and interaction whereby nurse and client
share information about their perception in the nursing situation
• Nursing is concerned with promotion health, preventing illness, caring for the
sick, and restoring health.
• Nursing is a human science of persons and human health-illness experiences that
are mediated by professional, personal, scientific, esthetic and ethical human care
transactions
• She defined caring as a nurturant way or responding to a valued client towards
whom the nurse feels a personal sense of commitment and responsibility. It is
only demonstrated interpersonally that results in the satisfaction of certain human
needs. Caring accepts the person as what he/she may become in a caring
environment
• Carative Factors:
1.
1. The promotion of a humanistic-altruistic system of values
2. Instillation of faith-hope
3. The cultivation of sensitivity to one’s self and others
4. The development and acceptance of the expression of positive and
negative feelings.
5. The systemic use of the scientific problem-solving method for decision
making
6. The promotion of interpersonal teaching-learning
7. The provision for supportive, protective and corrective mental, physical,
socio-cultural and spiritual environment
8. Assistance with the gratification of human needs
9. The allowance for existential phenomenological forces
1. Novice
2. Advanced beginner
3. Competent
4. Proficient
5. Expert
• Levels reflect:
o movement from reliance on past abstract principles to the use of past
concrete experience as paradigms
o change in perception of situation as a complete whole in which certain
parts are relevant
Orientation: Person
Place
Date
Time
Situation
*All pages of this MSA have its own interpretation and analysis*
Level 1 - Pathological
The mechanisms on this level, when predominating, almost always are severely
pathological. These four defences, in conjunction, permit one to effectively rearrange
external experiences to eliminate the need to cope with reality. The pathological users of
these mechanisms frequently appear irrational or insane to others. These are the
"psychotic" defences, common in overt psychosis. However, they are found in dreams
and throughout childhood as well.
They include:
Level 2 - Immature
These mechanisms are often present in adults and more commonly present in adolescents.
These mechanisms lessen distress and anxiety provoked by threatening people or by
uncomfortable reality. People who excessively use such defences are seen as socially
undesirable in that they are immature, difficult to deal with and seriously out of touch
with reality. These are the so-called "immature" defences and overuse almost always
leads to serious problems in a person's ability to cope effectively. These defences are
often seen in severe depression and personality disorders. In adolescence, the occurrence
of all of these defences is normal.
They include:
Level 3 - Neurotic
These mechanisms are considered neurotic, but fairly common in adults. Such defences
have short-term advantages in coping, but can often cause long-term problems in
relationships, work and in enjoying life when used as one's primary style of coping with
the world.
They include:
Level 4 - Mature
These are commonly found among emotionally healthy adults and are considered mature,
even though many have their origins in an immature stage of development. They have
been adapted through the years in order to optimize success in life and relationships. The
use of these defences enhances pleasure and feelings of control. These defences help us
integrate conflicting emotions and thoughts, while still remaining effective. Those who
use these mechanisms are usually considered virtuous.
They include:
-Akathisia
1. Restlessness
2. Tenseness
3. Inability to sit still
4. Rocking back and forth on feet
5. Crossing leg frequently
6. Inability to relax
- Tardive Dyskinesia
1. Involuntary movements of mouth, face, may extend to fingers, arms and trunk.
-Loose of association
1. Neologism- is a newly coined word or phrase that may be in the process of
entering common use, but has not yet been accepted into mainstream language.
2. Work Salad- Speech that is unintelligible because, though the individual words
are real words, the manner in which they are strung together results in incoherent
gibberish, e.g. the question "Why do people comb their hair?" elicits a response like
"Because it makes a twirl in life, my box is broken help me blue elephant. Isn't lettuce
brave? I like electrons. Hello, beautiful."
3. Echolalia- the automatic repetition of vocalizations made by another person.
4. Echopraxia- the automatic repetition of movements made by another person.
5. Clang association- the mental connection between dissociated ideas made
because of similarity in the sounds of the words used to describe the ideas. The
phenomenon occurs frequently in schizophrenia.
E.g. "I'm not trying to make noise. I'm trying to make sense. If you can't make sense out
of nonsense, well, have fun." "I heard the bell. Well, hell, I heard the bell."
6. Illogical thinking- Conclusions are reached that do not follow logically (non-
sequiturs or faulty inferences). e.g. "Do you think this will fit in the box?" draws a reply
like "Well duh; it's brown isn't it?"
- Alogia- Complete lack of speech, as in profound mental retardation or advanced
dementia. Alogia is synonymous in this sense with aphasia.
- Concrete thinking
- Lack of insight
- Aphasia- is an acquired language disorder in which there is an impairment of any
language modality. This may include difficulty in producing or comprehending spoken or
written language.
- Apraxia- is a disorder caused by damage to specific areas of the cerebrum,
characterized by loss of the ability to execute or carry out learned purposeful movements
despite having the desire and the physical ability to perform the movements.
- Agnosia- is a loss of ability to recognize objects, persons, sounds, shapes, or smells
while the specific sense is not defective nor is there any significant memory loss.
- Flight of Ideas- A sequence of loose associations or extreme tangentiality where the
speaker goes quickly from one idea to another seemingly unrelated idea. To the listener,
the ideas seem unrelated and do not seem to repeat. Often pressured speech is also
present. e.g. "I own is five cigars. I've been to Havana. She rose out of the water, in a
bikini."
• Derailment (also Loose Association and Knight's Move thinking) - Ideas slip off
the topic's track on to another which is obliquely related or unrelated. e.g. "The
next day when I'd be going out you know, I took control, like uh, I put bleach on
my hair in California."
• Loss of goal - Failure to show a train of thought to a natural conclusion. e.g. "Why
does my computer keep crashing?", "Well, you live in a stucco house, so the pair
of scissors needs to be in another drawer."
• Neologisms - New word formations. These may also involve elisions of two
words that are similar in meaning or in sound. e.g. "I got so angry I picked up a
dish and threw it at the geshinker."
• Stilted speech - Speech excessively stilted and formal. e.g. "The attorney
comported himself indecorously."
• Tangentiality - Replying to questions in an oblique, tangential or irrelevant
manner. e.g.:
• Word approximations - Old words used in a new and unconventional way. e.g.
"His boss was a seeover."
- Delusions
1. Reference- The person falsely believes that insignificant remarks, events, or
objects in one's environment have personal meaning or significance. For instance, a
person may believe they are receiving special messages from newspaper headlines.
2. Prosecution- These are the most common type of delusions and involve the
theme of being followed, harassed, cheated, poisoned or drugged, conspired against,
spied on, attacked, or obstructed in the pursuit of goals. Sometimes the delusion is
isolated and fragmented (such as the false belief that co-workers are harassing), but
sometimes are well-organized belief systems involving a complex set of delusions
("systematized delusions"). People with a set of persecutory delusions may believe, for
example, they are being followed by government organizations because the "persecuted"
person has been falsely identified as a spy. These systems of beliefs can be so broad and
complex that they can explain everything that happens to the person.
3. External influence
4. Somatic- A delusion whose content pertains to bodily functioning, bodily
sensations, or physical appearance. Usually the false belief is that the body is somehow
diseased, abnormal, or changed—for example, infested with parasites.
5. Grandiose- An individual is convinced they have special powers, talents, or
abilities. Sometimes, the individual may actually believe they are a famous person or
character (for example, a rock star). More commonly, a person with this delusion may
believe they have accomplished some great achievement for which they have not
received sufficient recognition (for example, the discovery of a new scientific theory).
Often, this type of person believes they have uncovered an obvious "truth" that has
escaped the entire history of humankind.
Other types:
• Delusion of control: This is a false belief that another person, group of people, or
external force controls one's thoughts, feelings, impulses, or behavior. A person
may describe, for instance, the experience that aliens actually make him or her
move in certain ways and that the person affected has no control over the bodily
movements. Thought broadcasting (the false belief that the affected person's
thoughts are heard aloud), thought insertion, and thought withdrawal (the belief
that an outside force, person, or group of people is removing or extracting a
person's thoughts) are also examples of delusions of control.
• Nihilistic delusion: A delusion whose theme centres on the nonexistence of self
or parts of self, others, or the world. A person with this type of delusion may have
the false belief that the world is ending.
• Delusional jealousy (or delusion of infidelity): A person with this delusion
falsely believes their spouse or lover is having an affair. This delusion stems from
pathological jealousy, and the person often gathers "evidence" and confronts the
spouse about the nonexistent affair.
• Delusion of guilt or sin (or delusion of self-accusation): This is a false feeling
of remorse or guilt of delusional intensity. A person may, for example, believe he
has committed some horrible crime and should be punished severely. Another
example is a person who is convinced he is responsible for some disaster (such as
fire, flood, or earthquake) with which there can be no possible connection.
• Delusion of mind being read: The false belief that other people can know one's
thoughts. This is different from thought broadcasting in that the person does not
believe that his or her thoughts are heard aloud.
• Delusion of reference: The person falsely believes that insignificant remarks,
events, or objects in one's environment have personal meaning or significance.
For instance, a person may believe they are receiving special messages from
newspaper headlines.
• Erotomania is a delusion in which one believes that another person is in love
with him or her. They believe that this other person was the first to declare his or
her affection, often by special glances, signals, telepathy, or messages through the
media.
• Grandiose delusion: An individual is convinced they have special powers,
talents, or abilities. Sometimes, the individual may actually believe they are a
famous person or character (for example, a rock star). More commonly, a person
with this delusion may believe they have accomplished some great achievement
for which they have not received sufficient recognition (for example, the
discovery of a new scientific theory). Often, this type of person believes they have
uncovered an obvious "truth" that has escaped the entire history of humankind.
• Persecutory delusion: These are the most common type of delusions and involve
the theme of being followed, harassed, cheated, poisoned or drugged, conspired
against, spied on, attacked, or obstructed in the pursuit of goals. Sometimes the
delusion is isolated and fragmented (such as the false belief that co-workers are
harassing), but sometimes are well-organized belief systems involving a complex
set of delusions ("systematized delusions"). People with a set of persecutory
delusions may believe, for example, they are being followed by government
organizations because the "persecuted" person has been falsely identified as a spy.
These systems of beliefs can be so broad and complex that they can explain
everything that happens to the person.
• Religious delusion: Any delusion with a religious or spiritual content. These may
be combined with other delusions, such as grandiose delusions (the belief that the
affected person is God, or chosen to act as a God, for example).
• Somatic delusion: A delusion whose content pertains to bodily functioning,
bodily sensations, or physical appearance. Usually the false belief is that the body
is somehow diseased, abnormal, or changed—for example, infested with
parasites.
• Delusions of parasitosis (DOP) or delusional parasitosis: The person believes
that they are infested with an insect, bacteria, mite, spiders, lice, fleas, worms, or
other organisms. They may also report being repeatedly bitten. In some cases,
entomologists are asked to investigate cases of mysterious bites. Sometimes
physical manifestations may occur including skin lesions
- Illusions
- Depersonalization
- Attending to irrelevant stimuli
- Poor reality testing
Page 9: Others
- Amnesia
- Fugue
- Depersonalization
- Phobias
- Memory
1. Remote (long term)
2. Recent (early am)
3. Recent part (current events)
4. Immediate memory (short term)
5. Immediate recall
Prepared by:
Leomar Gonzales
BPSU Nursing Student (2007-2011)