Interventions

The LPN’s role is to assist with identifying and carrying out the specific steps that will help the patient reach the goals. Nurses are able to provide input about new interven- tions that may be helpful, and the LPN/LVN is often the person who begins to help adapt certain procedures to assist the patient. A nurse may use this opportunity to conduct some new patient teaching or to reinforce

prior teaching. Relaying information about implementation(putting the care plan into action) and patient progress to the RN will provide the information the team needs to offer the best possible care for the patient.

Nurses also need to understand and specify the rationale (reason) for the implementa- tions that are selected and be prepared to ex- plain them to patients and families provided the patient consents to their involvement.

Table 6-2 provides information about the nursing process.

States differ in the role the LPN plays in outcome statements or performing an evalu- ation of interventions. In much the same way NANDA developed problem or nursing diagnostic standards, work is being done to standardize outcome statements. Nursing Interventions Classification (NIC)is a com- prehensive standardized language. It provides a number of direct and indirect intervention labels with definitions and possible nursing actions. The interventions address general practice and specialty areas (Doenges and Moorhouse, 2003).

■■■ Clinical Activity

If your clinical affiliates will allow, arrange to shadow a nurse from the mental health unit. Write a sum- mary of the following experience:

• Observations of the nurse-patient relationship

• Communication style

• Understanding

• Patient responses

l

^{Table 6-2} The Nursing Process Nursing

Diagnosis Implementation/

Assessment (NANDA) Planning Intervention Evaluation Subjective/

Objective

Relates to the assess- ment data to deter- mine how the nurse will plan for the care needed.

Planning the patient’s outcome:

Short-term goals

Long-term goals Must be:

Measurable and realistic with target dates.

Defines what actions the nurse/health-care provider will provide.

The nurse/health-care provider should be able to provide a rationale for each action/treatment provided.

Patient’s outcome.

The nurse/health-care provider can deter- mine if the plan and the interventions provide the expected outcome. Determine which interventions can be terminated.

legal ramifications to teaching as well. Even with standardized teaching tools, nurses still need to be aware of some principles of teach- ing and learning. Nurses have an advantage in teaching because, with the exception of nursing diagnosis, the same format they learned for nursing process can be used for setting up a teaching plan.

Teaching in any form is most effective when it is started as soon as possible after admission. Nurses teach patients in different ways. Teaching falls under the categories of either formal teachingor informal teaching.

Formal teaching is any situation in which a class is scheduled or a specific objective must be met. The instructor is often a staff nurse who has worked in the specific area being taught. Formal teaching involves a nurse instructor and one or more patients.

Usually a preset curriculum is used in these classes. The time to teach in the formal set- ting will most likely be limited by the facility according to staffing needs, because the nurse instructor probably also has a patient assign- ment. Examples of formal teaching include diabetic teaching and back-care classes.

C H A P T E R 6 | Nursing Process in Mental Health 97

Patient Teaching

Many implementations or interventions that are helpful to the patient involve patient teaching. Frequently, facilities have special teams or departments to carry out certain teaching (e.g., diabetes education), but teaching is becoming a bigger part of a nurse’s respon- sibility. This is true at all levels of nursing preparation. The doctor is still responsible for the initial information given, but the nurse does the “fine-tuning” required to send pa- tients home safely. Nurses teach about medica- tions, coping strategies, adaptive equipment, and anything else the patient requires, not only for the period of hospitalization, but also for the time when the patient leaves the facility.

Individual states and facilities set the guidelines regarding teaching responsibilities for doctors and nurses.

Everyone needs a little help to get started with teaching, regardless of what sort of teaching will be done. Like the forms used for the patient interviews, the facility may use standardized classes or teaching sheets. This practice helps ensure that continuity exists in teaching and that the critical information has been given to the patient. There are some

Tool Box |The nursing process is a system- atic approach in providing care.

http://nursingworld.org/E speciallyF orY ou/

W hat-is-N ursing/Tools-Y ou-N eed/

Thenursing process.html

■■■ Critical Thinking Question

Your state Nurse Practice Act allows you, the LPN/

LVN, to oversee care and function as a charge nurse, as long as a registered nurse is on call. Your medical patient has gone out on a 3-hour pass with relatives and returns to your agency refusing to perform the guidelines as stated in the care plan. Your patient is argumentative but answers questions appropriately. Your data collection includes fruity odor on breath, mood swings, and hunger. You need to re-evaluate and revise the care plan but are unable to make contact with the RN on call. What would you consider to be appro- priate nursing diagnoses? What interventions can you perform and still remain within your state’s scope of nursing practice?

■■ ■ Classroom Activity

• Divide the class into groups of five. Each group should provide a presentation of the steps in the nursing process using different learning styles.

Informal teaching, or adjunctive teaching, happens anytime, anywhere, whenever the patient needs information. The patient may see the nurse in the hall, or the nurse may no- tice that the patient is working with the colostomy bag in his room or reading the ex- ercise pamphlet. These are excellent times to reinforce what the patient has learned or to make gentle suggestions for improving his or her technique.

■■■ Clinical Activity

Review the medication chart of your assigned patient and provide an informal teaching about one of the medications. Write the outcome of the informal teaching.

Principles of Learning

Nurse-teachers need a basic understanding of the principles of learning and teaching. Some of these principles are listed here:

1. Each person learns differently. Some people process information visually, others by hearing, and still others by hands-on (tactile) learning.

2. Each person learns at his or her own pace.

The larger the class, the more levels of ability the nurse will have to work with.

Some patients catch on more quickly than others.

3. People learn best when the information is meaningfulto them. Nurses should think of their own education: The things they are interested in are the things they work harder at. Subjects that they do not like seem to be hard or boring, yet they are required for graduation. Patients may not see the importance of the class that they may be required to attend as a crite- rion for discharge.

4. Learning is most effective when the in- formation is presented in small segments.

This may be dictated by the facility, but when the nurse can be flexible, it is best to present only as much as the patient can absorb.

5. Success breeds success:Positive reinforce- ment will help the patient succeed at learning the required task. The stronger the positive reinforcement, the greater the learning. Once patients have been successful, they will want to continue to learn.

nurse-teacher will need to adapt the care plan to meet a particular patient’s need.

A nurse-teacher who is not comfortable with the material will be less helpful to the patient than one who can individual- ize the curriculum to the various needs of the class.

3. Have a teaching plan:A good teaching plan will improve a nurse’s confidence and delivery of the material. A teaching plan is constructed in much the same way as the nursing process. A very simple format, such as APIE for the nursing process, may be easily transformed into a teaching format. An example of the APIE format follows.

• A = Assessment. What is the need for the teaching? Who are the patients?

How much time is available? Assessing the need to teach can be as simple as one or two statements. For example,

“Good afternoon, everyone. My name is Sandy. This is the class about bipolar care, and it is open to anyone diagnosed with bipolar disease.” Assessment can also be enhanced by the use of a pre-test or questions to the class to determine their past knowledge in this area.

• P = Plan. In true nursing process, this is often called the goal. Nurse- teachers need to ask themselves a few questions, such as: What do you plan to accomplish in the session?

How do you think you will do it?

Again, this can be accomplished in one or two statements. For example,

“This is the first in a series of three classes, and the task for today is to learn about the different types of appliances and equipment you have available to you.” What is accom- plished in the first session is consid- ered as a short-term goal and the accomplishments in the third session will be the long-term goal.

• I = Implementation. This is the step- by-step method nurse-teachers use to accomplish the plan. It is similar to the implementation portion of the nursing process. The nurse-teacher will have as many or as few steps as Active listening enables the nurse to

focus on the patient’s strengths.

Neeb’s

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Tip

Principles of Teaching

1. Know the patients:What are their abili- ties? What is their prior level of knowl- edge? What are the cultural or language differences of the patients in the class?

2. Know the material:It is not as important to give a perfect lecture or demonstration as it is to be able to interpret the ques- tions patients may have. Sometimes the

needed. In prepared curricula, the steps are written out, but it may or may not be necessary to perform each step. This will depend on the patient group. Chances are good that a class or skill will never be taught exactly the same way twice. There will, however, be critical items that nurses need to cover with all patients to meet legal and safety issues.

• E = Evaluation. In a teaching plan, nurses evaluate the patient’s learning as well as the teaching performance.

Some questions that nurse-teachers need to reflect on for this part of the teaching plan are: How do you know the patient has grasped the concepts and skills from the class? What do you look for? Do you need to ask for a return demonstration? Does it need to be perfect? How did you do? Did you achieve the plan? Did you have enough time? Too much time? What will you do differently next time? How did your students evaluate the session?

Evaluation criteria may change from time to time as well.

4. Be flexible:To the extent that the facility’s program allows, be familiar enough with the material to be able to build in extra practice time for the tactile learn- ers, extra videos for the visual learners, or time to review verbally for the audi- tory learners. Be able to teach in several different styles.

5. Be able to evaluate the learning:In health teaching in the facility, evaluation can be in the form of a question-answer session, a short quiz, or a return demonstration.

6. Plan to allow a few minutes after the class for questions:Even though the nurse may ask for and welcome questions during the session, there are always people who are not comfortable asking questions in a group. These people will want your time in private, so allow some time to clarify their concerns at the time or to set up a time to help individuals later in the day.

Once the plan has been developed, the nurse needs to think about how to implement

the teaching. This requires familiarity with some commonly used methods of teaching.

Teachers tend to teach according to the method of learning they prefer. For instance, if nursing students prefer lecture classes, they probably feel most comfortable teaching in a lecture format. If a specific nursing instructor was particularly helpful to a nurse as a stu- dent, the nurse may prefer to role-model that teacher’s methods when teaching patients. No teaching method is better or worse than any other method. What makes the difference is the learning style of the patients and the rapport that nurses build with them. Because classes in facilities generally have more than one “pupil,” the nurse-teacher will need to be able to use different methods of presenting.

Because people’s personalities are different, each group will have a different dynamic and each class will be different.

The typical methods used in health teach- ing are lecture and demonstration.

1. Lecture:This is a method designed for information giving. It is unilateral; the nurse talks, and the patients listen. It is interactive only when there is some form of question-answer period or brainstorm- ing. Lecturing is an excellent method of introducing a topic to patients and giving them some theory. It is a way to explain the significance so the material becomes meaningful.

In preset programs, the lectures are usually prepared in either text or outline form, so the nurse-teacher has to invest minimal time researching, writing, or setting up for the lectures. Lecture classes may include videos, slides, or charts. Learning from the lecture method is traditionally evaluated through quizzes or question-and-answer sessions. Be- cause not all patient participants are comfort- able answering in a group, it may be difficult to assess how much learning each individual achieves.

C H A P T E R 6 | Nursing Process in Mental Health 99

Not everyone has the same learning style.

Neeb’s

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Tip

2. Demonstration:Demonstration is an excellent technique to follow in an

introductory lecture. For visual and tac- tile learners, it is a preferred method of learning.

In prepared programs, the demonstration outline will be provided. The nurse-teacher is responsible for having the equipment ready for each patient. In diabetic teaching, for example, the nurse needs to have ready the syringes, sterile saline for injection, gloves, injection pad, and any other equipment that the agency uses.

Demonstrations are effective because, after the initial demonstration, the nurse-teacher can have the individual perform a return demonstration. One-on-one help can be pro- vided if needed. This allows the nurse to make more objective assessments of the patient’s learning and therefore predict the patient’s ability to safely perform the technique after discharge. It also allows the nurse to individ- ualize the technique or provide options to the patient.

Evaluation for this method of teaching is usually the return demonstration. The nurse watches each patient perform the technique at a level that is safe for the patient to perform when at home and not under the guidance of the health-care professional. If a home care nurse is assigned to the patient, patient teach- ing continues; the nurse also teaches the family or significant others.

Additional Patient Teaching Tips

• It is customary to assess eye contact and to equate eye contact with interest and attentiveness. It is important for the nurse-teacher to remember that this is a cultural behavior. Not all cultures believe that eye contact is a positive thing; in- deed, many cultures consider direct meet- ing of eyes a sign of blatant disrespect for people who are older or in a position of respect or authority. Nurses and teachers are respected in those cultural groups, and it would be a mistake on the part of the nurse to assume that the lack of direct eye contact is a sign of disinterest in or disrespect for the material.

• Be honest:Nobody said a nurse must have all the answers. If a nurse-teacher does not

know something, he or she should admit it. The nurse should look up the informa- tion and either bring it to the individual who asked or bring it to the next session of the class.

• Have fun!Teaching can be a very reward- ing part of nursing. There is no better way to reinforce nursing knowledge than to teach it to someone else. It is one way of being generative, and it is one way in which nurses can keep the nursing culture alive.

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Step 5: Evaluating Interventions

In this final step of the nursing process, the LPN/LVN plays an assisting role. The LPN/

LVN’s observations and documentation about the effect of the interventions on the patient and progress in attaining the goal are of great importance. Accuracy in verbal and written reporting of the patient’s progress will help determine whether the interventions are helpful or whether they need to be re-evaluated and changed. In some instances, some of the interventions can be terminated, depending on the patient’s progress (DeWit, 2009)

Nursing Outcomes Classification (NOC) is also a standardized language, which provides outcome statements; a set of indicators de- scribing specific patient, caregiver, family, or community states related to the outcome; and a five-point measurement scale to facilitate tracking patients across care settings. It can help demonstrate patient progress even when outcomes are not fully met. NOC also is applicable in all care settings and specialties (Doenges and Moorhouse, 2003).

■■■ Critical Thinking Question

Select a topic to teach the class. This can be any topic with which you are comfortable. You have 10 minutes (classroom instructor may choose own time limit) to teach your topic. Develop a teaching plan. Teach your topic. Evaluate your teaching. What would you do differently the next time?

C H A P T E R 6 | Nursing Process in Mental Health 101

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Key Concepts

1. Nursing process is an example of collabo- rative nursing practice. RNs are primarily responsible for the steps of the nursing process; LPN/LVN-prepared nurses assist in data collection, planning, imple- menting, and evaluating the nursing process.

2. The nursing process format can be used by other health-care disciplines to create a care plan.

3. Nurses are conducting more interviewing and teaching on a daily basis. Entry-level

CASE STUDY

1. How would you start the nursing process for this patient?

2. Describe some questions you would ask as part of the mental status exam Mark is a 15-year-old student who has

recently quit attending his high school classes. Mark has always been a straight-A student who participated in many social and athletic activities at his school.

Today, Mark’s friend Tony brings Mark to the clinic that is part of your commu- nity’s hospital. Tony tells you, “Mark got in with a bad group. He’s been doing’

the stuff real bad. He’s been doing the needles and the smoking. He’s been with me for two days, man, and he’s real sick.

Help him.”

You and the physician undertake an as- sessment of Mark and find that he has yel- lowing of his sclera. He has a fruity odor on his breath and is vomiting copiously.

Mark’s level of consciousness is guarded;

he is in and out of coherence and is not a

reliable source of information about himself at this time.

The physician notifies Mark’s parents and explains that Mark may have several conditions, including but not limited to serum hepatitis.

Meanwhile, you continue to admit Mark to the hospital for further testing and medical care. He is placed in enteric isolation as a precaution. An IV is started and you begin to explain the hospital routines to Mark. After you tell him that he must remain in his room for now and that his visitors will be limited during the time of the isolation precautions, he becomes angry. He conveys to you that this is “an invasion of his privacy”

and that “you nurses are all part of the conspiracy.”

nurses need a basic knowledge of both skills. Individual states and facilities set the guidelines for teaching within the scope of the nurse’s practice.

4. Nursing process is a helpful tool for preparing a teaching plan.

5. The ANA has set guidelines that dic- tate the roles of the RN and the LPN/

LVN in collaborating in the nursing process.

6. New models for collaborative nursing and nursing outcome statements are being developed.