Psychiatric Nursing Diagnosis Care Plans: A DSM-IV 1997 Guide

Psychiatric nursing is a specialized field that focuses on the mental health needs of individuals, families, groups, and communities. At the heart of psychiatric nursing practice lies the ability to accurately assess, diagnose, and plan care for patients experiencing mental health challenges. In 1997, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), was the prevailing diagnostic tool. Understanding how to utilize the DSM-IV within the framework of psychiatric nursing diagnosis and care planning is crucial for providing effective and patient-centered care. This guide will delve into the principles of developing psychiatric nursing diagnosis care plans using the DSM-IV (1997), offering a comprehensive overview for healthcare professionals.

Understanding DSM-IV in Psychiatric Nursing Practice

The DSM-IV, published in 1994 with text revisions in 2000 (DSM-IV-TR), provided a multiaxial system for diagnosing mental disorders. This system was designed to ensure a comprehensive evaluation, considering various aspects of a patient’s condition. For psychiatric nurses in 1997 and the years following, the DSM-IV was an essential resource for understanding the clinical criteria for mental disorders and formulating appropriate nursing diagnoses.

The Multiaxial System of DSM-IV

The DSM-IV’s multiaxial system consisted of five axes, each addressing a different dimension of the patient’s presentation:

Axis I: Clinical Disorders: This axis encompassed the major clinical syndromes that are typically the focus of clinical attention, such as mood disorders, anxiety disorders, psychotic disorders, and substance-related disorders.
Axis II: Personality Disorders and Mental Retardation: This axis included personality disorders and mental retardation (intellectual disability). These conditions are considered more chronic and pervasive aspects of an individual’s functioning.
Axis III: General Medical Conditions: This axis allowed clinicians to list any current general medical conditions that were potentially relevant to the understanding or management of the individual’s mental disorder.
Axis IV: Psychosocial and Environmental Problems: This axis was used to report psychosocial and environmental problems that might affect the diagnosis, treatment, and prognosis of mental disorders (e.g., problems with primary support group, occupational problems, housing problems).
Axis V: Global Assessment of Functioning (GAF) Scale: This axis provided a numerical rating of the individual’s overall level of psychological, social, and occupational functioning. The GAF scale ranged from 0 to 100, with higher scores indicating better functioning.

For psychiatric nurses, understanding each axis was vital in developing holistic care plans. While Axis I provided the primary clinical diagnosis, Axes II, III, and IV offered crucial contextual information that could significantly impact the patient’s mental health and response to treatment. Axis V provided a baseline and a way to track progress over time.

Key Diagnostic Categories Relevant to Nursing Care Plans

Within Axis I, several diagnostic categories were particularly relevant to psychiatric nursing care planning. These included, but were not limited to:

Mood Disorders: Encompassing major depressive disorder, bipolar disorder, and dysthymic disorder. Nursing care plans for mood disorders often focus on managing symptoms like sadness, hopelessness, and suicidal ideation, as well as promoting medication adherence and coping skills.
Anxiety Disorders: Including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobias. Nursing interventions for anxiety disorders are often geared towards reducing anxiety symptoms, teaching relaxation techniques, and facilitating exposure therapies when appropriate.
Psychotic Disorders: Primarily schizophrenia and schizoaffective disorder. Care plans for psychotic disorders address managing positive symptoms (hallucinations, delusions) and negative symptoms (flat affect, social withdrawal), as well as promoting medication adherence and social skills.
Substance-Related Disorders: Covering substance dependence and substance abuse related to alcohol, opioids, stimulants, and other substances. Nursing care in this area focuses on detoxification, managing withdrawal symptoms, preventing relapse, and promoting healthy coping mechanisms.
Cognitive Disorders: Such as delirium, dementia, and amnestic disorders. For patients with cognitive disorders, nursing care plans often emphasize safety, maintaining functional abilities for as long as possible, and providing support to caregivers.

Understanding the specific diagnostic criteria for each disorder within these categories, as outlined in the DSM-IV, was the first step in developing targeted and effective nursing interventions.

The Psychiatric Nursing Diagnosis Process

The nursing diagnosis process in psychiatric settings is a systematic approach to identifying, understanding, and addressing the health needs of individuals with mental health conditions. It is a cyclical process that involves assessment, diagnosis, planning, implementation, and evaluation. Using the DSM-IV (1997) as a foundation, psychiatric nurses would integrate this diagnostic framework into their broader nursing process.

Assessment: Gathering Comprehensive Data

The initial step in developing a psychiatric nursing diagnosis care plan is a thorough assessment. This involves collecting data from various sources to gain a holistic understanding of the patient’s mental health status. Key components of a psychiatric nursing assessment include:

Mental Status Examination (MSE): A structured assessment of the patient’s current mental state, including appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment.
Psychosocial History: Gathering information about the patient’s background, including family history, developmental history, educational and occupational history, relationship history, substance use history, and coping mechanisms.
Medical History and Physical Examination: Identifying any co-existing medical conditions that may impact mental health or treatment.
Review of Records: Examining past psychiatric and medical records, if available, to understand the patient’s history of mental illness, previous treatments, and responses.
Collateral Information: When appropriate and with patient consent, gathering information from family members, caregivers, or other healthcare providers to obtain a broader perspective.

The assessment process is crucial for identifying patterns of behavior, thought, and emotion that align with DSM-IV diagnostic criteria and for uncovering the patient’s strengths and resources.

Nursing Diagnosis: Bridging DSM-IV and Nursing Frameworks

Once the assessment data is collected and analyzed, the next step is to formulate nursing diagnoses. Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems and life processes. In psychiatric nursing, these diagnoses often relate to the symptoms and functional impairments associated with DSM-IV diagnoses, but are framed within a nursing perspective.

While the DSM-IV provides medical diagnoses, nursing diagnoses focus on the patient’s response to their health condition. For example, a DSM-IV diagnosis might be “Major Depressive Disorder,” while related nursing diagnoses could include “Hopelessness,” “Risk for Suicide,” “Social Isolation,” or “Self-Care Deficit.”

Common categories of psychiatric nursing diagnoses include:

Disturbed Thought Processes: Related to disorganized thinking, delusions, or hallucinations.
Disturbed Sensory Perception: Related to hallucinations or illusions.
Risk for Self-Directed Violence/Risk for Suicide: Related to suicidal ideation, intent, or plan.
Ineffective Coping: Related to maladaptive coping mechanisms in response to stress or mental health symptoms.
Social Isolation: Related to withdrawal from social interactions and lack of social support.
Self-Care Deficit: Related to difficulties with activities of daily living due to mental health symptoms.
Anxiety/Fear: Related to excessive worry, panic attacks, or phobias.
Impaired Sleep Pattern: Related to insomnia or other sleep disturbances associated with mental disorders.

The process of formulating nursing diagnoses involves analyzing the assessment data, identifying significant patterns and defining characteristics, and then selecting the most appropriate nursing diagnoses from a recognized taxonomy, such as NANDA-I (North American Nursing Diagnosis Association International). It is essential that the nursing diagnoses are congruent with and supported by the assessment data and the DSM-IV diagnosis.

Planning: Setting Goals and Outcomes

The planning phase of the nursing process involves developing a care plan that is individualized, patient-centered, and based on the identified nursing diagnoses. This includes setting goals and expected outcomes, and selecting appropriate nursing interventions.

Goal Setting: Goals should be specific, measurable, achievable, relevant, and time-bound (SMART). They should reflect what the nurse and patient hope to achieve through nursing interventions. For example, for the nursing diagnosis “Risk for Suicide,” a goal might be: “The patient will verbalize feelings of hope for the future by day 3 of hospitalization.”
Outcome Criteria: Outcome criteria are specific, measurable indicators that demonstrate progress towards achieving the goals. They provide a way to evaluate the effectiveness of the care plan. For the same “Risk for Suicide” diagnosis, an outcome criterion could be: “The patient reports a decrease in suicidal ideation on a scale of 0-10 from 8 to 3 by day 3 of hospitalization.”

Care planning should be collaborative, involving the patient and, when appropriate, family members or caregivers in the process. The care plan should also consider the patient’s strengths, resources, cultural background, and preferences.

Implementation: Putting the Care Plan into Action

Implementation involves carrying out the nursing interventions outlined in the care plan. Psychiatric nursing interventions are diverse and can include:

Therapeutic Communication: Using verbal and nonverbal communication techniques to build rapport, understand the patient’s perspective, and facilitate therapeutic change.
Medication Management: Administering and monitoring psychotropic medications, providing patient education about medications, and assessing for side effects and effectiveness.
Milieu Therapy: Creating and maintaining a safe, therapeutic environment that promotes healing and recovery.
Cognitive Behavioral Therapy (CBT) Techniques: Utilizing CBT principles to help patients identify and change maladaptive thought patterns and behaviors.
Dialectical Behavior Therapy (DBT) Techniques: Employing DBT strategies to help patients manage intense emotions, improve interpersonal skills, and tolerate distress.
Group Therapy: Facilitating therapeutic groups to provide support, education, and opportunities for social learning.
Psychoeducation: Providing patients and families with information about mental illness, treatment options, and coping strategies.
Crisis Intervention: Responding to acute psychiatric emergencies to ensure patient safety and stabilize the situation.
Health Teaching: Educating patients about self-care, stress management, relapse prevention, and healthy lifestyle choices.
Case Management: Coordinating care, connecting patients with community resources, and advocating for their needs.

The selection of interventions should be based on the nursing diagnoses, patient goals, and evidence-based practices. Interventions should be implemented in a manner that is respectful, ethical, and culturally sensitive.

Evaluation: Assessing Effectiveness and Revising the Plan

Evaluation is the final step of the nursing process and is ongoing throughout the care continuum. It involves assessing the effectiveness of the nursing interventions in achieving the stated goals and outcomes. Evaluation includes:

Monitoring Patient Progress: Regularly assessing the patient’s mental and emotional status, symptom severity, and functional abilities.
Reviewing Outcome Criteria: Determining whether the outcome criteria have been met within the established timeframe.
Gathering Patient Feedback: Seeking input from the patient about their experience of care and their perception of progress.
Consulting with the Treatment Team: Discussing the patient’s progress and the effectiveness of the care plan with other members of the interdisciplinary team.

Based on the evaluation data, the care plan may need to be revised. If goals are not being met or if new nursing diagnoses emerge, adjustments to the interventions, goals, or outcome criteria may be necessary. The nursing process is dynamic, and care plans should be continuously adapted to meet the evolving needs of the patient.

Example Care Plan: Major Depressive Disorder (DSM-IV 1997)

To illustrate the application of the psychiatric nursing diagnosis process with DSM-IV (1997), consider an example of a patient diagnosed with Major Depressive Disorder, Single Episode (DSM-IV Axis I).

DSM-IV Diagnosis (Axis I): Major Depressive Disorder, Single Episode

Relevant Assessment Data:

Patient reports persistent feelings of sadness, hopelessness, and worthlessness for the past 6 weeks.
Anhedonia (loss of interest or pleasure in activities).
Significant weight loss due to decreased appetite.
Insomnia (difficulty sleeping).
Fatigue and low energy.
Difficulty concentrating and making decisions.
Thoughts of death and suicide, without a specific plan.
GAF score of 45 (Axis V), indicating serious symptoms and impairment in social and occupational functioning.
No Axis II or Axis III diagnoses reported.
Axis IV: Recent job loss and financial difficulties.

Nursing Diagnoses:

Hopelessness related to feelings of despair and perceived lack of control over the current situation, as evidenced by verbalizations of worthlessness and negative outlook on the future.
Risk for Suicide related to depressed mood, suicidal ideation, and feelings of hopelessness.
Impaired Sleep Pattern related to depressive symptoms, as evidenced by reports of insomnia.
Imbalanced Nutrition: Less Than Body Requirements related to decreased appetite and depressed mood, as evidenced by significant weight loss.
Social Isolation related to depressed mood and anhedonia, as evidenced by withdrawal from social activities and decreased social interaction.

Goals:

The patient will verbalize feelings of hope for the future by day 5 of hospitalization.
The patient will remain safe and free from self-harm throughout hospitalization.
The patient will report improved sleep pattern (at least 6 hours of sleep per night) by day 7 of hospitalization.
The patient will demonstrate adequate nutritional intake (consuming at least 75% of meals) by day 7 of hospitalization.
The patient will participate in at least one social activity per day by day 7 of hospitalization.

Nursing Interventions:

For Hopelessness:
- Engage in therapeutic communication to explore feelings of hopelessness and identify strengths and coping mechanisms.
- Help the patient identify positive aspects of their life and past successes.
- Provide positive reinforcement and encouragement.
- Collaborate with the treatment team to initiate antidepressant medication as prescribed.
For Risk for Suicide:
- Conduct ongoing suicide risk assessments.
- Maintain close observation and monitoring of the patient.
- Establish a safety contract with the patient.
- Provide a safe environment, removing any potentially harmful objects.
- Encourage the patient to express feelings and thoughts, particularly suicidal ideation.
For Impaired Sleep Pattern:
- Promote a relaxing bedtime routine (e.g., warm milk, quiet activities).
- Ensure a comfortable and quiet sleep environment.
- Limit caffeine and stimulants in the evening.
- Administer prescribed sleep medication if ordered.
For Imbalanced Nutrition:
- Offer small, frequent meals and snacks that are appealing to the patient.
- Provide nutritional supplements as needed.
- Monitor weight and nutritional intake.
- Create a pleasant and supportive mealtime environment.
For Social Isolation:
- Encourage participation in group therapy and social activities.
- Facilitate one-on-one interactions with staff and other patients.
- Explore interests and hobbies to identify potential social engagement opportunities.
- Provide positive reinforcement for social interaction.

Evaluation Criteria:

Hopelessness: Patient verbalizes at least two future-oriented goals and expresses a more positive outlook by day 5.
Risk for Suicide: Patient reports no suicidal ideation or intent and demonstrates engagement in safety plan strategies throughout hospitalization.
Impaired Sleep Pattern: Patient reports averaging 6-7 hours of sleep per night for 3 consecutive nights by day 7.
Imbalanced Nutrition: Patient consumes at least 75% of meals for 3 consecutive days by day 7 and weight stabilizes.
Social Isolation: Patient participates in at least one group therapy session and one other social activity (e.g., game, conversation with another patient) per day by day 7.

This example demonstrates how DSM-IV (1997) diagnoses inform the development of specific nursing diagnoses, goals, interventions, and evaluation criteria in a psychiatric care plan.

Best Practices and Considerations

Developing effective psychiatric nursing diagnosis care plans requires adherence to best practices and careful consideration of several factors.

Person-Centered Care

Care plans must be individualized and person-centered. This means focusing on the patient’s unique needs, strengths, preferences, and goals, rather than solely on the diagnosis. Engaging the patient in the care planning process is essential to ensure that the plan is relevant, acceptable, and likely to promote recovery.

Ethical Considerations

Psychiatric nursing care inherently involves ethical considerations, including patient autonomy, beneficence, non-maleficence, and justice. Care plans should respect patient rights, promote well-being, minimize harm, and ensure equitable access to care. Confidentiality, informed consent, and the least restrictive environment principles are paramount in psychiatric nursing practice.

Documentation

Thorough and accurate documentation of the nursing process is crucial. This includes documenting assessments, nursing diagnoses, care plans, interventions implemented, and evaluation findings. Documentation serves as a record of care, facilitates communication among the treatment team, and provides evidence for quality improvement and legal purposes.

Interdisciplinary Collaboration

Psychiatric nursing care is typically delivered within an interdisciplinary team, which may include psychiatrists, psychologists, social workers, occupational therapists, and other professionals. Effective care planning requires collaboration and communication among team members to ensure a coordinated and comprehensive approach to patient care.

Cultural Competence

Mental health is influenced by cultural factors, and psychiatric nurses must provide culturally competent care. This involves understanding the patient’s cultural background, beliefs, values, and practices, and tailoring care plans to be culturally sensitive and appropriate.

Continuous Professional Development

The field of psychiatric nursing is constantly evolving, with new research, treatments, and best practices emerging. Psychiatric nurses must engage in continuous professional development to maintain their knowledge and skills, and to provide the most up-to-date and effective care. While DSM-IV (1997) is now outdated, understanding its principles provides a historical foundation for current diagnostic and care planning approaches using more recent DSM editions.

Conclusion

Psychiatric nursing diagnosis care plans, informed by the DSM-IV (1997), provide a structured and systematic approach to addressing the mental health needs of patients. By understanding the DSM-IV multiaxial system, utilizing the nursing process, and adhering to best practices, psychiatric nurses can develop individualized, patient-centered care plans that promote recovery, improve functioning, and enhance the well-being of individuals experiencing mental health challenges. While the DSM has evolved beyond the 1997 version, the foundational principles of comprehensive assessment, accurate diagnosis, thoughtful planning, effective implementation, and thorough evaluation remain central to excellent psychiatric nursing care. Understanding the historical context of DSM-IV within psychiatric nursing practice provides valuable insight into the evolution of mental health care and the enduring role of the psychiatric nurse in patient-centered recovery.