PSYCHIATRIC NURSING

CRITICAL THINKING/CAREPLAN BASICS FOR FINAL

NURSING DIAGNOSIS to be used in Critical Thinking/ Care Plan exercises:

• Risk For Self-Directed Violence (=Risk for Suicide)

• Risk For Violence directed toward self and others
• Risk for Injury towards self and others
• Disturbed thought Process

GUIDELINES FOR CRITICAL THINKING EXERCISES

Use this table to help you identify the problems from the scenario:

1. Identify EGO FUNCTIONS

• Reality Testing 3. Identify STAGE OF DEVELOPMENT
• Judgment • Trust vs. Mistrust
• Sense of Reality of the world and Self (=Self • Autonomy vs. Shame and Doubt
Esteem) • Initiative vs. Guilt
• Impulse Control • Industry vs. Inferiority
• Thought Processes • Identity vs. Role Confusion
• Object Relations • Intimacy vs. Isolation
• A.R.I.S.E (Creativity) • Generativity vs. Stagnation
• Defensive Functioning • Integrity vs. Despair
• Stimulus Barrier
• Autonomous Functioning 4. Identify ANXIETY LEVELS
• Mastery-Competence • Mild
• Moderate
2. Identify DEFENSE MECHANISMS • Severe
• Sublimation
• Rationalization 5. Identify PSYCHOPATHOLOGY (S&S OF
• Intellectualization DISEASE)
• Suppression
• Repression • Refers to signs and symptoms of specific mental
• Displacement illnesses (e.g. Schizophrenia, Depression, Anxiety
• Reaction Formation Disorders, Personality Disorders, etc) (See the list
• Somatization (=Conversion) that follows next page)
• Undoing
• Passive-Aggression
• Acting-Out Behavior
• Idealization
• Splitting
• Devaluation
• Projection
• Denial
• Introjection
• Compensation
PSYCHOPATHOLOGY OF THE DISEASE: (These terms must be used –in addition to the previous table terms)
when referring to identified signs and symptoms. For example, instead of writing “Risk for violence towards self
or others AEB pt throwing objects at staff, and verbalizes “I think you want to kill me” it should say “AEB Poor
Impulse control, Poor judgment, and aggressive behavior toward staff”)

• Type of Crisis (Maturational/Developmental, • Disorganized speech –specify the presence

Situational, Adventitious) of: (associative looseness, neologisms,
• Phobia (specify type) echolalia, clang association, word salad)
• Obsessions • Hypervigilance (instead of saying
• Compulsions “paranoia”)
• Persistent intrusive thoughts • Alterations in perception
• Restlessness • Disorganized thinking
• Sleep Disturbances • Labile mood
• Fatigue • Anergia
• Amnesia • Avolition
• Dissociative Amnesia • Alogia
• Depersonalization • Apathy
• Derealization • Anhedonia
• Suicidal Ideations/Thoughts • Non adherence to medication regimen
• Hopelessness (=Non-compliance)
• Helplessness • Withdrawal symptoms
• Inability to perform ADLs • Substance abuse (if obvious, specify)
• Poor Self-Care (=Poor grooming and Hygiene) • Altered level of conscience (LOC)
• Increased/Decreased/Inadequate Appetite • Altered mental status
• Increased/Decrease/Inadequate Fluid Intake • Decreased LOC (=Acute confusion)
• Inappropriate Affect Blunted/Flat) • Dysphasia
• Hallucinations (specify: auditory, visual…) • Aphasia
• Delusions (specify: of persecution, of • Apraxia
reference…) • Agnosia
• Bizarre behavior (=Inappropriate behavior) • Comorbidities (Identify any current medical
(extreme motor agitation, stereotyped problems: Hyper/Hypoglycemia, High BP
movements, automatic obedience, waxy etc)
flexibility, stupor)
• Aggressive behavior
• Impulsive behavior
NURSING DIAGNOSIS: Lets assume pt is depressed or schizophrenic, and expresses will to kill himself (or
makes overt statement)

1. Risk for Suicide (Self-directed violence) R/T Biochemical/ Neurological imbalance in the brain AEB
(use available data from problem list)
2. Disturbed Thought Process R/T Biochemical/Neurological Imbalance in the brain AEB

POSSIBLE EXPECTED OUTCOMES

• Patient will not harm his/herself during hospitalization and will demonstrate absence of suicidal
ideations/plans AEB no suicidal intent, pt signs “no suicide” contract every shift, makes no overt/covert
statements and verbalizes will to live
• Pt will state that “I will not harm myself now and throughout hospitalization” and will verbalize a will to
live

ASSESS:
1. Vital Signs
2. Safety of patient and in the
environment
3. Suicidal Risk (SAD PERSONS scale,
overt/covert statements)
4. Previous history of Suicide attempts
(patient) or Suicide (family)
5. Psychiatric assessment
6. Past and present psychiatric history
7. Past and present medical history
8. Past and current medication regimen
and compliance
9. Past and present history of substance
abuse
10. Mental status
11. Level of anxiety
12. Pt’s perception of the event and Coping
mechanisms
13. Support system
14. Ego functions (Reality testing, thought
process, Impulse control, sense of
reality of the world and self, Judgment)
15. Stage of development
16. Psychopathology of specific current
disease process
17. Assess any comorbid (medical)
condition if present
Rationale:
1. To establish a baseline for future treatment and evaluation of
pt’s progress
2. To prevent pt from harming self
3. To determine potential for suicide, presence of a plan, and
its lethality, and adjust interventions accordingly
4. B/C a history of previous suicide attempts and/or successful
family Hx of suicide is an important risk factor
5. To obtain significant data on which to base plan of care
6. To determine risk factors
7. To determine comorbid conditions that may impact outcome
and mental health
8. B/C medications play a role at adjusting (or failing to adjust)
any present chemical imbalance that may be causing the
problems
9. To rule out abuse as the cause of the mental disorder, and
adjust treatment accordingly
10. To monitor thought process, cognition, and changes toward
expected outcome
11. B/C anxiety level strongly influences behavior
12. B/C pt’s perception may influence pt’s decisions
13. B/C a structured environment and support system is
important to mental balance, especially after discharge
14. B/C Ego integrity constitutes the pillar of mental health
15. B/C successful achievement of each developmental stage is
essential to mental health
16. B/C identifying specific disease traits may aid in the
formulation of a treatment plan
17. To identify current conditions that may need interventions
INTERVENTIONS:
1. Provide Safety for patient and in the
environment by: removing unsafe
objects, place pt in semiprivate room
2. Implement one-to-one constant
observation. Stay with client at all
times.
3. Have patient sign “No suicide” contract
every shift
4. Maintain MD informed of pt’s
condition and progress during
hospitalization and obtain orders as
needed
5. Decrease anxiety by: firm, calm,
consistent approach, use of breathing
exercises and relaxation techniques
6. Develop a therapeutic, trusting nurse-
client relationship
7. Provide consistent, nurturing
environment
8. Set limits
9. Increase Reality Testing by: presenting
reality and reorienting patient as needed
10. Increase self-esteem by: giving positive
feedback and have pt explore positive
features and previous achievements
11. Instill hope
12. Administer medications as prescribed
13. Ensure all basic needs are met
(includes: physiological needs, attend
to any medical problem if present)
14. Assist pt with ADLs as needed
15. Encourage patient to participate in
group therapy
16. Ensure adequate sleep/rest periods
17. Decrease environmental stimuli
18. Educate patient on:
a. Disease Process
b. Medication Regimen/Side
Effects, Interactions, therapeutic
effects and importance of
compliance
c. Adaptive coping skills
d. Breathing exercises and
relaxation techniques
1. To minimize access to potential objects to inflict harm
2. To prevent client from acting on suicide behavior
3. To have pt make commitment and take responsibility
4. B/C implementation of treatment requires ongoing
teamwork
5. B/C high levels of anxiety may cause impairment of
thought process and increase violent behavior
6. B/C this is essential to have pt express feelings and
reduce anxiety
7. To reduce anxiety, develop trust, and discourage pt from
acting on violent thoughts
8. To establish boundaries and thus prevent violent
behavior
9. B/C Reality Testing is paramount to ego integrity
10. B/C self-esteem is also an important part of Ego
integrity
11. To increase pt’s motivation to comply with treatment
plan
12. To correct any biochemical imbalances in the brain
13. To meet Maslow’s hierarchy of needs
14. To facilitate healing process
15. To help pt develop insight, and improve social
interactions
16. To maintain physiological integrity
17. To reduce anxiety
18. B/C an informed pt is more compliant, more motivated,
and less likely to relapse