The Nursing Process in Mental

Health Nursing
By : Eko Mulyadi
nursing major
Faculty of health science
wiraraja university
 Learning outcome
1. Identify the five steps of delivering nursing care using
the nursing process.
2. Describe types of information obtained in a
psychosocial assessment.
3. Determine applicable nursing diagnoses for identified
client problems.
4. Plan realistic expected outcomes for resolution of
identified problems.
5. Evaluate client outcome of anticipated improvement in
functioning and well-being.
6. Apply the nursing process to the care of the client in
the psychiatric setting.
 Nursing process
• The nursing process is a scientific and
systematic method for providing effective
individualized nursing care and serves as an
aid in resolving client problems

Nursing process Client

problem
 Steps of the Nursing Process
Integral to the nursing process approach to
nursing care is an organized method of problem
solving called the care plan, which is developed
from the data that are gathered during
the initial phase. It consists of five steps
that provide planned actions for resolving the
problem:

Nursing Nursing Expected Nursing

Evaluation
assessment diagnosis outcome interventions
 Nursing
assessment Nursing assessment
• Assessment begins when the client is
admitted or contact is made for the first time
• continues new information or changes
occur in reference to the client
• A standard assessment tool helps categorize
the information received by the nurse.
 Nursing
assessment Subjective Data
• Subjective Data. Subjective
information is provided by the
need to be validated
client.
• This information may need to
be validated by other sources
such as family, friends, law information may be supported or
enforcement officers, or contradicted
others who are involved.
• The client’s information may
be supported or contradicted
by others. history ,perception ,feelings,
• The data include the client’s thoughts, symptoms, or emotions
history and perception of the
present situation or problem
in addition to feelings,
thoughts, symptoms, or Citing a direct quote of a client
emotions he or she may be statement
experiencing
 Nursing
assessment Subjective Data
 Nursing
assessment Objective data
physical • Objective Data.
Objective
information is
emotional observed by the
nurse or provided
intellectual by others who are
familiar with the
client or
social additional
members of the
health care team.
 Nursing
assessment objective data

• A standard
mental
status
examination
tool is used
to assess
cognitive,
emotional,
and
behavioral
information.
 Nursing
assessment Objective data
 Nursing
diagnosis Nursing Diagnosis
• The nurse analyzes all data
gathered and compares it to normal
functioning or values to find out if a
problem or a potential problem
exists.
• A nursing diagnosis is not a medical
diagnosis but an identification of a
client problem based on
conclusions about the collected
data.
• A nursing diagnosis may be an
actual or potential health problem,
depending on the situation. The
most commonly used standard is
that of the North American Nursing
Diagnosis Association (NANDA).
 Nursing
diagnosis Nursing Diagnosis

• Any health condition that endangers

life will receive a high priority. 1. Mengancam jiwa
• A client with suicidal ideation or
intent, for example, would have an
immediate risk for self-injury. This 2. Mengancam
problem would require the nurse’s kesehatan
attention first.
• Situations that are recurrent or
chronic may be given a lower 3. Aktual baru
priority and will be addressed at a potensial
later time.
Expected
outcome Expected Outcomes
• Expected Outcomes
• The next phase of the nursing process involves
planning measurable and realistic outcomes
 Expected
outcome Expected outcome
Short-Term Outcomes
• Client symptoms of auditory hallucinations will decrease within 48 hours.
• Client does not harm self or others in next 48 hours.
• Client identifies feelings associated with hallucinations with each episode.
• Client reports decrease in anxiety level within 24 hours.
Long-Term Outcomes
• Client demonstrates understanding of need for continued compliance with
medication therapy by discharge.
• Client demonstrates awareness that hallucinations are the result of internal conflict
within 1 week.
• Client identifies and demonstrates ways to maintain contact with reality at onset of
symptoms by discharge.
• Client identifies environmental factors that precipitate the hallucinations by
discharge.
• Client participates in activities that reinforce reality during hospitalization within
1 week.
 Nursing
interventions Nursing interventions
• Nursing interventions are actions
taken by
• the nurse to assist the client in
achieving the anticipated outcomes
• Nursing interventions that focus on
mental health care do not involve
intensive physical care nursing skills.
Rather, the nurse focuses on
observing behaviors and symptoms,
improving communication strategies,
and assisting the client in problem-
solving with improved overall
functioning. Nursing interventions are
implemented according to the nurse’s
level of practice (see Chapter 21,
Mental Health Care in Nonpsychiatric
Settings).
Evaluation
Evaluation

• During the evaluation

phase of the nursing
process, the nurse
evaluates the success
of the nursing
interventions in
meeting the criteria
outlined in the
expected outcomes.
Congratulation...that’s end of slides