Module 2: Nursing Process and Mental Status Examination (MSE)

Learning Objectives:

Key Focus Areas:

Key Terms:

Nursing Process and Mental Status Examination (MSE) in Mental Health Nursing

Introduction: Psychiatric–mental health nursing involves a holistic approach to care that spans assessment of a patient’s mental status, identification of nursing diagnoses, planning and implementing therapeutic interventions, and evaluating outcomes. This module provides a comprehensive overview of the Mental Status Examination (MSE) and its components (with special pediatric considerations), suicide risk assessment usin​med.libretexts.orgmbia-Suicide Severity Rating Scale (C-SSRS)**, the use of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) in managing alcohol withdrawal (including adolescent adaptations), and the application of the nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation) in mental health settings. We will also review common NANDA nursing diagnoses in psychiatric care, discuss therapeutic communication strategies across the lifespan, and address cultural, ethical, and legal considerations in psychiatric nursing. Case studies are included to illustrate real-world application of these concepts.^(51)

Mental Status Examination (MSE)

The Mental Status Examination (MSE) is a systematic assessment of a patient’s current mental functioning. It is often described as the psychiatric equivalent of the physical exam – a structured way of observing and evaluating a client’s psychological state【4†L133-L142】【4†L156-L164】. The MSE captures both objective observations (the clinician’s findings) and subjective statements (the patient’s own reports) across several domains. A widely accepted set of components for an MSE includes: appearance, behavior, motor activity, speech, mood, affect, thought process, thought content, perceptual disturbances, cognition, insight, and judgment【4†L156-L164】. Each component assesses a specific area of mental functioning, and together they provide a snapshot of the patient’s psychological status at the time of examination.

Components of the MSE (with Pediatric Considerations):

Thought content involves what themes or beliefs occupy the patient’s mind. Key areas to probe or observe include the presence of delusions (fixed​pmc.ncbi.nlm.nih.gov not grounded in reality, e.g. paranoid belief that others are out to harm them, grandiose belief of having superpowers or special identity), obsessions (intrusive repetitive thoughts, e.g. contamination fears in OCD), phobias, preoccupations (such as with guilt, or with physical somatic concerns), suicidal or homicidal ideation, and any violent or sexual thoughts that are abnormal. In children, fantastical stories or imaginary creatures might be a normal content of play, but overt delusional content is rare and would be concerning if present (e.g. a 7-year-old persistently claiming to hear the devil’s voice telling him to do bad things would warrant further evaluation). Magical thinking (e.g. “step on a crack and break your mother’s back”) is developmentally normal in early childhood, but if an older child or adolescent has illogical beliefs of a similar nature, it could be pathological. Always ask about thoughts of self-harm or harm to others as part of content, regardless of age (tailored to the child’s understanding). For example, a depressed teenager might have persistent thoughts of worthlessness and death. A child might not conceptualize “death” fully but could say things like “I wish I could disappear or run away forever,” which could indicate suicidal intent in a child’s terms.

Pediatric Considerations Summary: When performing an MSE on a child or adolescent, the nurse must adjust expectations to the child’s developmental stage and often rely more on collateral information (from parents, teachers, caregivers) to supplement what the child can report. The presence and behavior of the parent during the exam is also informative. A classic pediatric encounter is triadic – involving patient, parent, and nurse【25†L563-L570】 – which poses unique challenges. The clinician should build rapport with the child and the caregiver, and observe the family dynamics. For instance, a parent might describe the child’s mood and behavior over time (since children ma​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Always consider that normal behavior in a toddler (e.g. tantrums, imaginative play) could be abnormal in a teenager, and vice versa (a teenager might appropriately be somewhat guarded or defiant, whereas a very young child should not be). Developmental context is crucial to interpreting the MSE in pediatrics. Moreover, engaging children often requires creativity – using play, drawing, or storytelling can help the child express themselves. The nurse might say, “Can you draw me a picture of how you feel?” or use toys/dolls to act out scenarios, as play is a child’s natural mode of communication【50†L17-L25】. For adolescents, an approach that respects their emerging autonomy and privacy is important: speak to them one-on-one when appropriate (while still involving parents for consent and big decisions), and assure confidentiality within safe limits (e.g. explain that you won’t share what they talk about with friends or teachers unless someone’s safety is at risk). The MSE with an adolescent might feel more like an adult interview, but remember teens are still developing – for example, abstract thinking (and thus testing proverbs or metaphors for cognition) might not fully mature until late adolescence. Always interpret findings (like poor orientation or bizarre thoughts) in light of what is typical for that age, and when in doubt, consult pediatric mental health references or specialists【1†L199-L201】【3†L197-L203】.

In summary, the MSE is a foundational tool that guides the nurse in understanding the patient’s current mental state. It requires keen observation and interviewing skills, and when applied to children, it also demands knowledge of developmental norms. Thorough documentation of the MSE allows the health care team to track changes over time (for example, improvement or deterioration in mental status)【18†L37-L45】 and to plan appropriate interventions.

Suicide Risk Assessment: Columbia-Suicide Severity Rating Scale (C-SSRS)

Suicide risk assessment is a critical part of psychiatric nursing, as early identification of suicidal ideation can be life-saving. One evidence-based tool widely used for this purpose is the Columbia-Suicide Severity Rating Scale (C-SSRS). The C-SSRS is a standardized, plain-language questionnaire designed to systematically assess suicidal ideation and behavior【8†L109-L117】. It can be administered by clinicians or even by trained non-professionals, as it does not require specialized mental health training to ask the questions【8†L133-L140】. The scale’s primary goal is to determine if an individual is at risk for suicide, the severity and immediacy of that risk, and to guide what level of support or intervention is needed【8†L109-L117】【8†L123-L131】.

What the C-SSRS Measures: The C-SSRS evaluates several key aspects of suicidal ideation and behavior through a series of structured questions. In its full form, the scale covers:

These questions are typically structured in a logical flow. A common version (for recent ideation and behavior) might be summarized as:

  1. “Have you wished you were dead or wished you could go to sleep and not wake up?” – (Passive ideation).

  2. “Have you actually had any thoughts of killing yourself?” – If No, skip to question 6; if Yes, proceed to questions 3–5.

  3. “Have you been thinking about how you might do this? Have you thought of methods?” – e.g. “I could shoot myself, I could overdose,” etc.

  4. *“Have you had these thoughts and had *some in​ncbi.nlm.nih.gov​ncbi.nlm.nih.govopposed to ‘I have the thoughts but I definitely will not do anything’?” – This distinguishes ideation with intent from ideation without intent.

  5. “Have you started to work out or actually prepared any details of how to kill yourself? Do you intend to carry out this plan?” – This assesses planning and preparation (e.g. writing a note, collecting pills, buying a weapon).

  6. “Have you ever done anything, started to do anything, or prepared to do anything to end your life?” – This captures behaviors, including actual attempts, aborted attempts, or pr​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov away possessions, rehearsals).【10†L213-L218】

Each of these items can be rated to indicate presence and severity, and the C-SSRS provides criteria for what counts as a “yes” for each. Based on the responses, clinicians gauge the risk level. For example, a “yes” on questions 4 or 5 (indicating acti​ncbi.nlm.nih.gov​ncbi.nlm.nih.govailed plan) indicates high acute risk – especially if the person also has access to means – and typically warrants immediate safety measures (like constant observation and possibly hospitalization)【10†L219-L221】【10†L221-L221】. A “yes” on question 6 (any history of attempts or preparatory actions) also elevates risk. Conversely, someone who only endorses a passive wish for death but denies any active suicidal thought (q​ncbi.nlm.nih.govgh 6 all “no”) is at lower risk, though still in need of support and monitorin​ncbi.nlm.nih.govtures and Benefits:** The C-SSRS was one of the first scales to comprehensively address the full spectrum of suicidal ideation and behavior – from passive thoughts of death to actual attempts【8†L121-L129】. Research supporting the scale shows that it has strong predictive validity; it helps identify individuals who might otherwise “fall through the cracks” by asking about behaviors like aborted attempts or preparations, not just overt suicide attempts【8†L123-L131】. It is designed to be relatively quick and straightforward to administer (in a matter of minutes) and is widely used in clinical and research settings because of its evidence base【8†L131-L139】. By standardizing the language (for example, defining what constitutes an “attempt” versus preparatory behavior), it improves the consistency of suicide risk assessments across different providers and settings.

Use Across Age Groups: An important advantage of the C-SSRS is that it has been adapted for various populations, including children and adolescents. The full form is suitable for individuals age 6 and up, and there are modified versions for younger children【10†L211-L218】. For example, a special “Very Young Children” version is designed for ages 4–5, which rephrases questions in terms a young child can understand【10†L213-L218】. Instead of bluntly asking a five-year-old “Do you want to kill yourself?”, a question might be worded more simply, such as “Have you ever not wanted to be alive or wished you could just go to sleep and not wake up?” or even concepts like “Have you ever thought about doing something that would make you not alive anymore?”【10†L213-L218】. Young children may not grasp the permanence of death, so probes like “Not alive” or “Did you think this is something you might do?” are used to gauge their understanding and any self-harmful thinking at their level【10†L213-L218】. For school-age children and teens, the standard C-SSRS questions can often be used with minimal adjustment, though the interviewer should ensure the language is understood. For instance, a 12-year-old might understand “Have you ever tried to kill yourself?” but if not, the nurse could clarify by saying “hurt yourself in a way that could have killed you.” Adolescents usually can respond to the standard items similarly to adults. In fact, the C-SSRS has been successfully used in youths as young as 6 in research and clinical practice【10†L211-L218】.

Example – Adult vs. Youth: Consider two scenarios:

Inte​pmc.ncbi.nlm.nih.gov-SSRS Outcomes: The C-SSRS does not produce a single “score” like some scales; rather, it yields categories of risk that guide clinical action. Many institutions categorize responses into low, moderate, or high risk. For instance, any “yes” on questions about intent or an actual attempt is often considered a high risk that warrants urgent evaluation by a mental health professional (potentially a psychiatrist) and possibly constant supervision【10†L219-L221】. A patient who only endorses passive thoughts (e.g. question 1 only) might be considered lower risk but still needs a safety plan (e.g. hotline numbers, follow-up appointments, removal of firearms or lethal means from the home as a precaution). The tool often comes with guidelines – for example, one protocol might say: if a patient answers Yes to questions 4, 5, or 6 (which deal with intent, planning, or action), then do not leave them alone and ensure immediate evaluation【10†L219-L221】. The C-SSRS can also be used to monitor changes in suicidality over time (e.g. during a hospitalization, asking these questions daily to see if ideation is intensifying or subsiding).

Integration into the Nursing Process: Nurses frequently are the first to administer suicide screening in many settings (ERs, clinics, inpatient units). Using th​pmc.ncbi.nlm.nih.gov part of the assessment phase ensures that suicidal ideation is not missed. If a patient is positive for suicidal ideation or behavior on the C-SSRS, that finding becomes central to the nursing diagnosis (often “Risk for Suicide” or “Risk for Self-Directed Violence”). The nurse then plans and implements safety interventions (constant observation, environment safety checks, engaging psychiatric services, developing a safety plan, etc.) based on the risk severity【47†L2959-L2961】【47†L2994-L3000】. During evaluation, changes in the C-SSRS responses (for example, a patient who initially had a plan now denies any ideation after treatment) can indicate improvement, or new affirmative answers might indicate worsening and need for escalation of care. The Columbia scale thus provides a structured, repeatable way to track suicidality.

In summary, the Columbia-Suicide Severity Rating Scale is an indispensable tool in modern mental health nursing for suicide risk assessment. It guides nurses to ask the right questions in a sensitive yet direct manner, covering everything from fleeting death wishes to actual attempts【8†L115-L119】. Its use across the lifespan (with appropriate modifications for young children) means nurses can consistently assess suicide risk in both adults and pediatric patients【10†L211-L218】. By identifying those at risk, the C-SSRS enables early intervention – the “first step in effective suicide prevention is to identify everyone who needs help”【8†L121-L129】. Through such thorough assessment, nurses uphold patient safety, one of their primary responsibilities.

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

Alcohol withdrawal is a significant clinical syndrome that can range from mild tremors and anxiety to severe complications like seizures or delirium tremens. The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is a ten-item scale used to objectively quantify the severity of alcohol withdrawal symptoms, guiding treatment decisions such as medication dosing【16†L7-L15】. It is considered the gold standard for withdrawal assessment in many settings and allows for a symptom-triggered treatment approach – meaning medications (usually benzodiazepines) are given based on the patient’s CIWA-Ar score rather than a fixed schedule, which research has shown can prevent over- or under-treating withdrawal【16†L7-L15】. While CIWA-Ar was developed and validated in adults, it has been utilized in adolescent cases of alcohol withdrawal as well【16†L1-L9】. In this section, we describe the CIWA-Ar scale, its use in managing withdrawal (including adaptations or considerations for adolescents), and how it fits into nursing care.

CIWA-Ar Overview: The CIWA-Ar consists of 10 symptom categories, each rated on a scale (generally 0 to 7, except one item which is 0–4) based on how severe the symptom is【41†L117-L125】. The categories are:

  1. Nausea and vomiting – “Do you feel sick to your stomach? Have you vomited?” (0 = no nausea, no vomiting; 7 = constant nausea, frequent dry heaves or vomiting)【42†L1-L9】.

  2. Tremors – usually assessed by having the patient extend their arms and spread fingers (0 = no tremor; 7 = severe tremor even with arms extended).

  3. Paroxysmal sweats – degree of excessive sweating (0 = no sweat visible; 7 = drenching sweats).

  4. Anxiety – the patient’s subjective feeling of nervousness and the observed tension (0 = no anxiety, at ease; 7 = equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions).

  5. Agitation – observed restlessness (0 = normal activity; 7 = paces constantly or is aggressive)【41†L97-L105】.

  6. Tactile disturbances – e.g. pins-and-needles feelings, burning, numbness, or sensations of bugs crawling on skin (formication); (0 = none; 7 = continuous hallucinations of insects or similar on skin).

  7. Auditory disturbances – sensitivity to sound, auditory hallucinations (0 = not present; 7 = continuous auditory hallucinations or extremely disturbing sounds).

  8. Visual disturbances – sensitivity to light, visual hallucinations (0 = not present; 7 = continuous visual hallucinations, e.g. seeing objects that aren’t there).

  9. Headache, fullness in head – severity of head pressure or pain (0 = no headache; 7 = extremely severe headache).

  10. Orientation and clouding of sensorium – basically level of awareness/orientation (0 = fully oriented and can do mental arithmetic; 4 = completely disoriented or cannot participate in conversation)【41†L107-L115】.

Each item’s score is added up for a total maximum possible score of 67 on the CIWA-Ar【41†L115-L122】. In practice, however, most patients in withdrawal score somewhere between mild (scores in single digits or low teens) to severe (upper twenties or more).

​umem.orgCIWA-Ar Scores:* Generally:

Each institution may have its protocol, but many use thresholds like CIWA-Ar ≥8–10 to start medication, and continue dosing (often diazepam, lorazepam, or chlordiazepoxide) until scores fall below that threshold on consecutive assessments. The CIWA-Ar is often repeated at regular intervals (e.g. every 1–2 hours during acute withdrawal) to guide if additional medication is needed or if symptoms are improving.

Nursing Assessment and Use of CIWA-Ar: Nurses are usually the ones performing CIWA-​pmc.ncbi.nlm.nih.govents at the bedside. This involves asking patients about subjective symptoms (nausea, anxiety, sensory disturbances, headache) and observing objective signs (tremor, sweating, agitation, orientation). The nurse must establish a good rapport so the patient feels comfortable reporting symptoms honestly – sometimes patients under-report out of stoicism or over-report hoping to get medication. Using CIWA-Ar, the nurse can document concrete scores that communicate the patient’s status to the team. For example: “CIWA-Ar score = 18 (notable for moderate tremor, blood pressure elevated, patient anxious, reporting intermittent hallucinations).” This quantification helps ensure the patient gets appropriate medication promptly if needed. Research shows that using a symptom-triggered protocol (medicating based on CIWA-Ar scores) often results in lower total benzodiazepine usage and shorter treatment duration compared to fixed schedules【16†L7-L15】, because medication is given only as necessary to alleviate significant symptoms.

Adolescent Considerations: Alcohol use among adolescents is common, and while severe Alcohol Withdrawal Syndrome (AWS) is rare in teens, it does occur – particularly in those with heavy, sustained drinking patterns【15†L156-L164】. A notable challenge is that pediatric healthcare providers may be less experienced in recognizing AWS, since it is traditionally an adult condition【15†L158-L166】. The CIWA-Ar can be used in adolescents similarly to adults【16†L1-L9】. The physiology of withdrawal is comparable – an adolescent dependent on alcohol will exhibit tremors, autonomic instability, anxiety, etc., just like an adult. There is no separate “CIWA-Youth,” so clinicians typically apply the standard CIWA-Ar while being attentive to the adolescent’s possibly smaller body size and other health differences. For example, vital signs in teens might normally run a bit higher or lower than adults;​ncbi.nlm.nih.govuld interpret things like heart rate or blood pressure in context of normal vitals for ag​columbiapsychiatry.org​pmc.ncbi.nlm.nih.govpractice is ensuring dosing of medications is weight-appropriate. Many hospitals have protocols for adolescents that use CIWA-Ar score to indicate when to give meds, but the dose of benzodiazepine might be adjusted (a 45-kg teenager might get a lower dose than an 80-kg adult for the same score, titrated to effect). Additionally, an adolescent in withdrawal should be assessed for polysubstance use (did they also use benzos, opioids, etc. that could confound the picture?). The setting is important: a 16-year-old in severe withdrawal might be managed in a pediatric intensive care or monitored unit with both pediatric and addiction medicine input. Some pediatric protocols (such as one from the Children’s Hospital of Philadelphia) include CIWA-Ar for alcohol withdrawal monitoring in patients ≥12 years old【14†L135-L143】【14†L151-L158】, alongside monitoring for other substances if relevant.

Case Example – Adolescent with Alcohol Withdrawal: A 16-year-old male is admitted for alcohol withdrawal after drinking heavily (daily liquor) for the past year. Initially, he’s anxious, sweating, with a coarse hand tremor. His blood pressure is 150/95 and heart rate 120 – above his normal. The nurse performs a CIWA-Ar assessment. He reports nausea 4/7 (dry heaves but no vomiting yet) and has marked tremors (rated 6/7). He is very anxious (he states “I feel panicky,” nurse rates 5/7) and mildly agitated (can sit still briefly but fidgets a lot, maybe 4/7). He denies hallucinations at first, but two hours later he says “I keep seeing bugs crawling on the wall, and I know they’re not real” (now tactile/visual disturbance present, say 3/7). He is oriented to person and place but momentarily confused abou​ncbi.nlm.nih.gov​rch.org.aution). His initial CIWA-Ar score comes out to 22 – indicating severe withdrawal. Following protocol, the nurse notifie​rch.org.au​rch.org.austers a benzodiazepine (e.g. lorazepam 2 mg IV) for the high score. Over the next several hours, t​columbiapsychiatry.org​mindpeacecincinnati.com every hour. After two doses of lorazepam, the patient’s score comes down to 10 (tremors and anxiety improving, no halluc​umem.orgever, that evening, the score rises to 18 again as the last dose wears off – the patient develops a low-grade fever and more confusion (​pathways.chop.edudelirium tremens**). The team decides to transfer him to ICU for closer monitoring and start a phenobarbital infusion given the refr​wtcs.pressbooks.pub​wtcs.pressbooks.pubtion was similar to a published case where a 16-year-old’s withdrawal was resistant to benzodiazepines but responded to phenobarbital【1​ncbi.nlm.nih.gov​ncbi.nlm.nih.govwith aggressive treatment guided by serial CIWA-Ar assessments, the adolescent gets through withdrawal without a se​ncbi.nlm.nih.gov​ncbi.nlm.nih.govn. This scenario highlights that while uncommon, **severe alcohol withdrawal can occ​ncbi.nlm.nih.gov, and using the same CIWA-Ar tool helps nurses recognize *how fast it’s progressin​openstax.org​ncbi.nlm.nih.gov​pmc.ncbi.nlm.nih.govhe symptom severity【15†L156-L165】【16†L1-L9】.

Nursing Process Integration: Managing a patient through alcohol withdrawal exemplifies the nursing process:

In summary, CIWA-Ar is an invaluable tool for nurses to objectively assess and manage alcohol withdrawal, including in adolescent patients with some adaptations. It operationalizes symptoms into scores that guide interventions, which has been shown to improve outcomes【16†L7-L15】. The nurse’s role is to carefully assess, score, medicate, and monitor – essentially using CIWA-Ar to ensure patient safety and comfort through a potentially life-threatening process. It also facilitates communication across the care team: for example, a night shift nurse can tell the morning nurse “He’s down to CIWA 6, last dose of diazepam was 8 hours ago,” which succinctly indicates the patient is likely out of danger.

Important: The CIWA-Ar is not the only tool for withdrawal (for opioids, there is COWS – Clinical Opiate Withdrawal Scale), but CIWA-Ar specifically addresses alcohol withdrawal signs. It covers both subjective symptoms (like anxiety, nausea) and objective signs (like tremor, sweating) in a comprehensive way, and it’s not copyrighted – freely reproducible【41†L117-L125】, which has aided its widespread adoption. Nurses must be adept at using CIWA-Ar and interpreting its results, as timely intervention can prevent progression to severe complications like seizures or delirium tremens, which carry mortality risk.

The Nursing Process in Psychiatric Nursing (ADPIE)

The nursing process is a systematic, patient-centered approach used by nurses to ensure consistent and thorough care. In psychiatric–mental health nursing, the nursing process is as essential as in any other field, providing a framework to deliver evidence-based care in an organized way【45†L161-L170】【45†L129-L137】. The classic five (or six) steps are remembered by the acronym ADPIE (or ADOPIE, including “Outcomes Identification” as a separate step per ANA standards【45†L169-L175】): Assessment, Diagnosis, (Outcome Identification), Planning, Implementation, and Evaluation. Psychiatric nursing has some unique applications of each step, but it aligns with the universal standards of practice for nursing【45†L129-L137】. Let’s break down each step with an emphasis on mental health care:

Assessment (Psychiatric Assessment)

Assessment is the first and foundational step. In mental health nursing, this means gathering a comprehensive biopsychosocial history and current mental status. The psychiatric assessment includes many components:

Throughout the assessment, therapeutic rapport is crucial. The patient should feel heard, respected, and not judged. Establishing trust during assessment sets the tone for the rest of the care. In mental health, assessment is ongoing – the patient’s mental status can change from moment to moment, so nurses continually observe and note changes (for example, sudden withdrawal or a burst of anger might occur, and that data is added to the assessment).

A thorough initial assessment forms the basis for accurate nursing diagnoses. For instance, consider a patient who, during assessment, reveals they have a plan to end their life, expresses hopelessness, is not eating, and neglecting hygiene. The nurse, having gathered this information, is now equipped to formulate relevant nursing diagnoses (like Risk for Suicide, Hopelessness, Imbalanced Nutrition, Self-Care Deficit). In psychiatric nursing, assessment is 90% of the job – if you uncover the right information, the rest of the process flows from addressing the identified issues.

Nursing Diagnosis (Analysis)

After collecting assessment data, the psychiatric nurse synthesizes the information to identify nursing diagnoses, which are clinical judgments about the patient’s responses to actual or potential health problems. Nursing diagnoses are distinct from medical diagnoses: for example, a patient’s medical diagnosis might be Major Depressive Disorder, but nursing diagnoses might include Hopelessness, Sleep Disturbance, and Self-Neglect. In mental health, common nursing diagnoses revolve around safety, coping, thought processes, mood regulation, and functional abilities. According to NANDA-I (North American Nursing Diagnosis Association International), diagnoses are standardized with specific criteria and related factors. Some common nursing diagnoses in psychiatric settings include:

These are just a few examples – the full list of NANDA nursing diagnoses is extensive, and nurses select those that best match the assessment data. In formulating diagnoses, the nurse identifies not only the problem but often related factors and evidence. For example: “Hopelessness related to chronic illness and social isolation as evidenced by patient statement ‘I have nothing to live for’ and flat affect.” Or “Risk for Self-Directed Violence related to despair secondary to depressive episode, as evidenced by suicidal ideation and access to means (firearm at home).”

In psychiatric nursing, prioritization of diagnoses is paramount. Generally, safety comes first. So even if a patient has multiple issues (and they often do), any diagnosis addressing a life-threatening risk (like suicide or violence potential) is the top priority【20†L467-L475】【20†L481-L488】. For example, a patient might have Disturbed Sleep Pattern and Low Self-Esteem, but if they also have Risk for Suicide, the latter is urgent. Nurses often use Maslow’s Hierarchy of Needs in prioritizing: physiological and safety needs at the base take precedence over psychological needs【20†L475-L484】. In our case study, Mr. J had four nursing diagnoses identified, and the nurse appropriately ranked Risk for Suicide as the highest priority, acting on that immediately【47†L2957-L2961】.

After identifying and prioritizing nursing diagnoses, the nurse proceeds to the next steps, which involve planning interventions and setting goals to address these diagnoses.

Planning (and Outcome Identification)

In the Planning phase, the nurse formulates the care plan, which includes setting measurable goals/outcomes and determining nursing interventions to achieve those outcomes. The American Nurses Association actually separates “Outcome Identification” as its own standard【45†L169-L175】 – emphasizing how critical it is to clearly define what we want to see happen. In practice, we often combine outcome identification within the planning step.

Outcomes (or goals) should be SMART: Specific, Measurable, Achievable, Relevant, and Time-bound. They are patient-centered statements of what the patient will do or experience as a result of our interventions. For mental health, outcomes might relate to symptom reduction, safety maintenance, improved coping, etc. Examples:

In psychiatric settings, planning often involves the multidisciplinary team. Nursing care plans dovetail with the overall treatment plan which may include psychiatric medications, therapy, social work involvement, etc. The nurse ensures nursing interventions complement these. For instance, if the plan is for a patient with schizophrenia to attend group therapy, an outcome might be “Patient will attend at least 2 group sessions by end of week.”

Cultural, age, and individual considerations must shape the plan. For a child, goals might involve family (e.g. “Parents will implement a behavioral chart at home consistently”). For a patient from a particular cultural background, goals and interventions should be culturally sensitive (e.g. incorporating spiritual support if important to the patient, or dietary preferences respected).

Interventions are the actions the nurse (and by extension the health care team) will carry out to help the patient meet the outcomes. In planning, interventions are chosen based on best evidence (research, clinical guidelines), the nurse’s clinical experience, and patient preferences. Interventions in mental health can be:

The plan should be individualized. Two patients with the same diagnosis may have different triggers or supports; one depressed patient might respond well to journaling, another to exercise – plans should reflect these personal differences.

In practice, nurses often use care plan templates or electronic health record systems where they choose appropriate interventions from a list. For example, for “Risk for Suicide,” common interventions populating might include: Suicide Precautions Level I or II, Remove hazardous objects from environment, Contract for safety, Assess suicidal ideation every shift, Encourage expression of feelings, Involve family or sitter for monitoring, etc. The nurse selects and tailors these as needed.

Implementation

Implementation is carrying out the planned interventions. It is the action phase where the nurse applies their therapeutic skills and all the groundwork laid in previous steps. In a psychiatric setting, implementation can be both challenging and rewarding, as nurses often spend the most time with patients and have to respond in real-time to patient needs and behaviors.

Key aspects of implementation in mental health nursing include:

Throughout implementation, the nurse must remain flexible and responsive. Mental health patients can be unpredictable: a calm patient can suddenly become agitated, or a patient who refused all morning can decide to talk at 3 PM. Nurses seize moments to implement care when the patient is ready. For instance, if a previously guarded patient suddenly starts talking about their trauma, the nurse will shift gears and employ therapeutic listening and support right then, even if it wasn’t “scheduled” – that’s effective implementation, being present when the patient needs.

Evaluation

Evaluation is the step where the nurse determines whether the goals established in the planning phase have been met and whether the nursing interventions have been effective. It involves continuous re-assessment and comparison of the patient’s current state to the desired outcomes. In mental health, evaluation can be challenging because outcomes (like improved mood or coping) may be subjective or take time, but it is essential for ensuring progress and guiding any necessary changes to the care plan.

Key points in evaluation:

Example of Evaluation Documentation:

When an evaluation shows that a goal is not met, the nurse and team revisit each prior step: Was the assessment complete, or did we miss something (like an undiagnosed panic disorder making group intolerable)? Is the diagnosis still accurate? Are the interventions appropriate or do we try a different approach? This cyclical process is what improves care quality continuously.

Case Study Reflection: In the earlier Sample Case of Mr. J (with depression and suicidality), by the end of the first day the nurses evaluated his progress: he remained alive (the critical short-term goal), and he started verbalizing feelings (goal of expressing feelings was being met)【47†L2981-L2989】. However, he had not agreed to bathe or eaten more than 25% of his meal (so self-care and nutrition goals were unmet)【47†L2981-L2989】. Thus, the plan was to “re-attempt interventions on Day 2 and reassess”【47†L2983-L2989】 – essentially, continue working on those unmet needs, perhaps with adjustments (maybe offer preferred foods, involve occupational therapy for grooming). This demonstrates how evaluation directs the ongoing care.

In mental health nursing, evaluation is continuous – sometimes even session by session you evaluate the patient’s response and adjust. For instance, during a single shift, a nurse might try talking about coping strategies; if the patient gets irritated and shuts down (evaluation: approach not working), the nurse might switch to a different tactic (like engaging the patient in a non-threatening activity) later that day. This flexibility within the structured process is a hallmark of psychiatric nursing.

Finally, it’s worth noting that if goals are met consistently and the patient’s health improves, evaluation leads to planning for discharge or the next phase of care. That is success – for example, a goal might be “Depression will reduce from severe to moderate as evidenced by PHQ-9 score drop from 20 to <15 in two weeks”; if achieved, one might plan to discharge to outpatient care with continued follow-up.

In summary, the nursing process (ADPIE) in psychiatric nursing ensures that care is systematic, individualized, and goal-oriented【45†L161-L170】. From assessment to evaluation, it allows nurses to use critical thinking and a structured approach while still being creative and compassionate in meeting the complex needs of patients with mental illness. By applying this process, nurses not only address immediate symptoms but also contribute to long-term recovery, working collaboratively with patients to improve their mental health and quality of life.

Common NANDA Nursing Diagnoses in Mental Health

In the context of psychiatric nursing, certain nursing diagnoses are particularly prevalent. These are standardized labels (per NANDA International) that describe patients’ responses to mental health conditions. Below is a list of common nursing diagnoses in mental health settings, along with brief descriptions or defining characteristics:

Each of these diagnoses comes with related factors (etiology) and as evidenced by (symptoms) when writing a care plan. For instance, Impaired Social Interaction related to lack of impulse control as evidenced by interrupting others and inability to maintain friendships. Or Anxiety related to interpersonal stresses (family conflict) as evidenced by pacing, elevated blood pressure, and verbal reports “I feel very nervous and can’t relax.”

It’s not unusual for a single patient to have multiple nursing diagnoses simultaneously. For example, someone with severe depression might have: Risk for Suicide, Hopelessness, Self-Care Deficit, Sleep Pattern Disturbance, and Imbalanced Nutrition: Less than Body Requirements. The nurse addresses each through the care plan, prioritizing risk for suicide first. Another patient, say with schizophrenia, might have Disturbed Thought Processes, Sensory-Perception Disturbance (Auditory), Social Isolation, and Self-Neglect. Over the course of treatment, some diagnoses may resolve or improve (e.g. hallucinations subside with medication, removing the Sensory-Perception Disturbance diagnosis), whereas others might remain longer-term issues to work on in outpatient (e.g. social isolation may take longer to overcome).

Using Nursing Diagnoses Effectively: These diagnoses guide goal-setting and interventions. They provide a common language for nurses – for instance, in a hand-off, a nurse might say, “Our plan addresses Ineffective Coping by teaching journaling and assertiveness skills, and Chronic Low Self-Esteem by daily affirmations and success-oriented activities.” This communicates succinctly what issues are being targeted. They also link to evidence-based interventions; many nursing textbooks or care planning resources list recommended interventions for each diagnosis. For example, for Risk for Violence, recommended interventions include maintaining a safe distance, using a calm approach, short clear statements, having an escape route, etc., which are drawn from de-escalation evidence【28†L31-L39】.

In mental health nursing education, students learn these common diagnoses and how to apply them to patient scenarios. Recognizing the appropriate nursing diagnosis helps ensure that care is holistic. Even though a psychiatrist might label a patient simply “schizophrenic,” a nursing care plan will unpack that into various human responses: anxiety, isolation, self-care deficit, knowledge deficit about medications, etc., each of which we can do something about.

The NANDA-I taxonomy is updated every few years; the diagnoses listed above are among those frequently encountered in current practice (2018–2020 NANDA list and beyond). It’s important to use the exact NANDA wording when documenting formal care plans (for example, NANDA recently revised “Risk for self-directed violence” to “Risk for Suicide” to be more clear). Additionally, NANDA includes positive diagnoses like Readiness for Enhanced Coping or Readiness for Enhanced Self-Health Management that can be applied when a patient is in recovery and showing willingness to learn better strategies – these highlight strengths and promote empowerment.

By utilizing nursing diagnoses, mental health nurses ensure they address the comprehensive needs of the patient – not just the medical illness, but the emotional, behavioral, social, and self-care dimensions of health. These diagnoses form the backbone of the nursing process in psychiatric care, enabling targeted interventions and consistent evaluation of patient progress.

Therapeutic Communication Strategies Across the Lifespan

Effective therapeutic communication is at the heart of mental health nursing. It is through communication that nurses build trust, gather assessment data, provide support, educate, and intervene to help patients cope and heal. Therapeutic communication involves using techniques that encourage patients to express themselves and that convey empathy and understanding, while avoiding nontherapeutic habits (like giving unsolicited advice or false reassurance). Across the lifespan – from children to older adults – the principles of therapeutic communication remain the same (empathy, respect, genuine concern) but the approach and techniques must be tailored to the person’s developmental level and needs【24†L15-L23】. In this section, we discuss core therapeutic communication techniques and how to adapt communication strategies for children, adolescents, adults, and older adults in psychiatric nursing.

General Therapeutic Communication Techniques: Regardless of age, some foundational techniques are universally helpful in mental health interactions【31†L161-L168】:

These techniques, when used sincerely and appropriately, create a therapeutic alliance – a collaborative partnership between nurse and patient. They prioritize the patient’s wellbeing and encourage expression【31†L161-L168】. It’s also important to avoid non-therapeutic communication such as:

Communicating with Children: Therapeutic communication with children requires special consideration of their developmental stage and communication abilities. Here are strategies effective with pediatric patients:

Overall, when communicating with children, the nurse often has to be more creative, playful, and adapt to shorter attention spans. It’s a balance of engaging the child on their level while also obtaining the needed information and providing emotional support. Ensuring the child feels safe and understood is the top priority; a child who trusts the nurse will eventually share more.

Communicating with Adolescents: Teens can be a challenging group to communicate with because they are in-between childhood and adulthood, and issues of privacy, trust, and autonomy are paramount. Strategies for adolescents:

Overall, therapeutic communication across the lifespan requires the nurse to adjust their technique to the developmental and individual needs of the patient. The principles remain constant – empathy, active listening, genuineness, and respect – but the methods of achieving a trusting dialogue differ for a preschooler, a teenager, an adult, and an elder. A skilled psychiatric nurse is like a linguistic and emotional chameleon, able to meet the patient where they are. This fosters a safe space where patients of any age feel heard and valued, which is the cornerstone of healing in mental health care.

Cultural, Ethical, and Legal Considerations in Psychiatric Nursing

Psychiatric nursing does not occur in a vacuum – it takes place within a rich context of cultural diversity, and it is governed by ethical principles and legal regulations. Nurses must be aware of and integrate cultural, ethical, and legal factors into patient care to provide safe, equitable, and professional mental health services.

Cultural Considerations: Culture profoundly influences how patients express mental distress, how they cope, and how they view mental illness and treatment. Culture encompasses not only ethnicity and language, but also religion, gender roles, family structure, and societal norms. Culturally competent care means the nurse is aware of the patient’s cultural background and tailors the assessment and interventions accordingly【38†L554-L561】. For instance, in some cultures, mental health issues might be expressed somatically – a patient from a culture that stigmatizes mental illness may present with only physical complaints like headaches or stomachaches, even though the root issue is depression or anxiety. The nurse should recognize these possible cultural expressions (often called “culture-bound syndromes” or idioms of distress) and not dismiss physical symptoms but gently explore emotional aspects too. Language barriers must be addressed by using interpreters (preferably professional medical interpreters, not just family members) to ensure accurate communication【38†L573-L581】. It’s crucial to show respect for the patient’s cultural beliefs: ask about their perspective on what caused their illness and what kind of healing they trust【38†L579-L587】. For example, some patients may believe their condition is due to spiritual factors or fate; the nurse can acknowledge this belief and, if appropriate, incorporate culturally relevant healing practices (with the patient’s consent and safety in mind) alongside standard treatment. Family roles differ: in some cultures, decisions are made collectively or by the head of family rather than the individual. The nurse should involve the family in planning if that is the patient’s wish (while also honoring the patient’s autonomy as much as possible). Be mindful of cultural stigma – in many communities, a psychiatric diagnosis is deeply shameful. Building trust and assuring confidentiality is vital so that the patient feels safe accepting help. Dietary customs, modesty, and gender-sensitive care are also considerations (e.g. a Muslim woman with psychosis might only be comfortable with female staff for personal care, or a devout Hindu patient may prefer yoga/meditation as a coping strategy – the nurse can facilitate these preferences when possible). In essence, cultural sensitivity in mental health nursing means seeing the patient as a product of their culture and adapting care without stereotyping. It requires asking open-ended questions like, “Is there anything I should know about your background or beliefs that would help me take better care of you?” and being open to the patient’s explanations and needs【38†L579-L587】. By integrating cultural practices and showing respect for diversity, nurses uphold the patient’s dignity and often improve engagement and outcomes【37†L31-L35】.

Ethical Considerations: Psychiatric nursing often presents complex ethical dilemmas because it deals so much with autonomy, safety, and human rights. The ANA Code of Ethics for Nurses provides general guidance – emphasizing compassion, respect, advocacy, accountability, and preserving patients’ rights and dignity【52†L186-L194】【52†L192-L200】. In mental health, key ethical principles frequently in play are:

Some common ethical dilemmas in psych nursing include: whether to force treatment on an unwilling patient for their own good, how to handle truth-telling in situations like a cognitively impaired patient (should you always orient a person with dementia to the painful truth that their spouse died, or sometimes use therapeutic fibbing to avoid distress?), and how to manage confidential information (like an adolescent telling you about sexual activity or drug use in confidence – do you tell the parents or respect the teen’s privacy?). These situations require careful consideration of principles, consultation with colleagues or ethics committees, and knowledge of laws/policies.

Nurses should use resources such as the ANA Code of Ethics, their facility’s ethics consult service, and experienced mentors when in doubt. Importantly, nurses must also be aware of their own values and possible biases – for example, if a nurse has strong religious beliefs about suicide or substance use, they must ensure they do not impose judgment on patients who engage in those behaviors. The ethical stance is to provide nonjudgmental care to all, upholding the patient’s rights and dignity【52†L170-L178】【52†L211-L218】.

Legal Considerations: Mental health care is subject to specific laws that vary by jurisdiction but often share common features. Key legal concepts in psychiatric nursing include:

In summary, legal and ethical considerations in psychiatric nursing are deeply intertwined: laws often codify ethical duties (like duty to warn, or patients’ rights), and ethical practice helps nurses stay within legal bounds. The psychiatric nurse must stay informed about relevant mental health laws (which can change) and always practice with respect for patients’ rights and welfare. Balancing a patient’s civil liberties with the need for treatment and safety is an ongoing challenge – e.g., deciding to invoke involuntary treatment is never taken lightly, and it typically involves adhering strictly to legal criteria and procedures to protect the patient’s rights as much as possible. Nurses serve as patient advocates in this realm: we advocate for the least restrictive, most humane treatment, help patients understand their rights, and ensure those rights are respected by all team members (for instance, if a patient has a right to have visitors or make phone calls, the nurse makes sure those are allowed unless there’s a compelling reason to restrict them, which must be documented).

By integrating cultural sensitivity, adhering to ethical principles, and following legal mandates, psychiatric nurses provide care that is not only effective, but also just and respectful. This creates a therapeutic environment where patients feel safe, knowing their cultural identity is respected, their rights are protected, and their best interests are the driving force behind every decision.

Clinical Case Studies

The following case studies illustrate how the concepts discussed – MSE, suicide assessment (C-SSRS), CIWA-Ar, the nursing process (ADPIE), communication strategies, and ethical/legal considerations – come together in real-world psychiatric nursing scenarios. Each case includes the situation, the nursing approach, and outcomes, demonstrating application across different patient populations.

Case Study 1: Major Depression with Suicide Risk (Adult)
Situation: Mr. J is a 32-year-old male admitted to the acute psychiatric unit for severe depression with suicidal ideation. On admission, he appears unkempt, with a downcast gaze and very little spontaneous speech. He states flatly, “I have no reason to live.” He reports not sleeping or eating much for the past week. During the initial assessment, the nurse conducts a thorough Mental Status Examination. Mr. J’s mood is “very sad,” and his affect is congruently depressed and tearful at times. His thought process is goal-directed but content reveals ruminations of worthlessness and death. He admits to the nurse, “I’ve been thinking about ending it. I even planned how – I was going to use a gun I bought.” This triggers an immediate suicide risk assessment. The nurse uses the C-SSRS questioning: Mr. J answers Yes to having active suicidal thoughts, a specific plan (firearm), and intent. He also reveals he wrote a goodbye letter yesterday. This indicates high acute risk (presence of plan, intent, and preparatory behavior)【47†L2950-L2958】【47†L2959-L2961】. Legally and ethically, the team invokes one-to-one observation for safety (a staff member with him at all times) and removes any personal items that could be used for self-harm. Mr. J is a voluntary admission, and he agrees to stay and accept help (if he wanted to leave, at this point the team would pursue an emergency hold given the clear danger).

Nursing Process in Action: The nurse identifies several nursing diagnoses for Mr. J, the top priority being Risk for Suicide (related to depression and hopelessness, evidenced by explicit suicidal plan)【47†L2950-L2958】【47†L2959-L2961】. Other diagnoses include Hopelessness (related to ongoing depression and unemployment, as evidenced by statements like “I have no future”) and Self-Care Deficit (hygiene and nutrition) (related to lack of motivation and energy, evidenced by not showering for a week and significant weight loss)【47†L2938-L2946】【47†L2948-L2956】.

The nurse collaborates with Mr. J to develop a care plan. For the suicide risk, the immediate goal is “Patient will remain safe and not attempt self-harm while hospitalized.” Short-term goals include “Patient will express suicidal thoughts to staff rather than acting on them” and “Patient will rate his hopefulness at least 4/10 by the end of week.” Interventions implemented: Suicide precautions are maintained【47†L2994-L3000】, a “no-harm contract” is used (he agrees to notify staff if he has urge to act)【47†L2994-L3000】, and the psychiatrist starts an antidepressant and therapy. The nurse provides therapeutic communication daily – using open-ended questions to encourage Mr. J to vent feelings of despair, and using techniques like reflection (“It sounds like you feel you’re a burden to your family”) and instilling hope (“Depression can make it hard to see a way forward, but there are treatments and people who care. We are here to help you find reasons to live”). The nurse also engages him in simple activities to start improving self-care – for example, sitting with him during meals to encourage some intake (nutritional shakes are provided when appetite is low), and assisting with setting small hygiene goals (such as washing up in the morning). As trust builds, Mr. J opens up about the triggers for his depression (he lost his job and is going through a divorce). The nurse arranges a family meeting with Mr. J’s sister, who is supportive – together they discuss a post-discharge plan (sister will stay with him for a while and help remove the gun from his home, which is an important safety measure). The nurse also educates Mr. J about his new antidepressant medication and emphasizes the importance of continuing it after discharge, explaining it takes a few weeks to work (addressing his Knowledge Deficit about treatment).

Ethical/Legal Aspects: Mr. J’s case involved respecting his autonomy by obtaining his consent for treatment and involving him in his care decisions, while also prioritizing safety (beneficence). The nurse had to ensure confidentiality – when Mr. J’s boss called the unit asking about him (having heard he was hospitalized), the nurse could not divulge information without Mr. J’s permission. The nurse simply took a message and later asked Mr. J if he wanted to return the call. When coordinating with the sister, Mr. J agreed to share information – otherwise, the nurse would only be able to listen to the sister’s concerns but not reveal Mr. J’s health details without consent. The duty to protect was invoked by safely storing his firearm (the team facilitated having the sister remove it from the home, aligning with legal responsibilities to reduce imminent risk). Throughout, the nurse maintained a compassionate, nonjudgmental stance, understanding that Mr. J’s hopeless statements were part of his illness (not “giving up on purpose”).

Outcome: Over a week, with antidepressant medication and daily counseling, Mr. J’s mood slowly improves. By discharge, he denies active suicidal ideation and rates his mood as “maybe 4/10, a bit better.” He has begun eating full meals again and has showered with prompting. He even expressed a slight hope: “Maybe I’m not completely alone, my sister really does care.” This met the outcome of him verbalizing a more hopeful statement【47†L2965-L2973】. The Risk for Suicide is still present but reduced; a follow-up appointment with an outpatient therapist is arranged, and Mr. J commits to it. The case demonstrates how the nursing process and therapeutic interventions can effectively reduce suicide risk and address the multifaceted needs of a patient with major depression. The nurse’s detailed assessment (including MSE and C-SSRS) identified the critical risk, and swift, compassionate intervention likely prevented a tragedy【47†L2981-L2989】.

Case Study 2: Adolescent with Alcohol Withdrawal (Dual Diagnosis Teen)
Situation: Erika is a 17-year-old high school student who was brought to the emergency department by her mother due to severe tremors, agitation, and confusion. Further inquiry reveals Erika has been binge drinking heavily for the past year and likely had her last drink two days ago. She is now showing signs of Alcohol Withdrawal Syndrome (AWS) – her hands are shaking, she’s sweaty, anxious, with a heart rate of 130, blood pressure 156/90, and she has had one brief episode of seeing “spiders” on the wall (visual hallucination). Although alcohol withdrawal severe enough to cause hallucinations is uncommon in adolescents, it can occur in those with heavy use【15†L156-L164】【15†L161-L168】. Erika also has a history of depression, for which she has been inconsistently taking sertraline. Upon admission to the adolescent medical-psychiatric unit, the nurse immediately begins CIWA-Ar assessments to quantify Erika’s withdrawal severity. On arrival, Erika’s CIWA-Ar score is 22 (notable for marked tremor, high anxiety, diaphoresis, intermittent hallucinations, and disorientation to date) – indicating severe withdrawal【16†L1-L9】. The nurse notifies the attending, and per protocol, administers a dose of IV diazepam. The nurse also ensures safety: because Erika is confused at moments, they institute seizure precautions (padding the bed rails, suction and oxygen ready) and a staff observer is assigned to check on her frequently.

Nursing Focus: The priority nursing diagnosis is Risk for Injury (related to alcohol withdrawal, as evidenced by tremors, potential seizures, and hallucinations). Another diagnosis is Disturbed Sensory Perception (visual) related to withdrawal neurotoxicity (evidenced by hallucinating spiders). Erika also has Fluid Volume Deficit (she’s mildly dehydrated, a common issue with withdrawal sweating and poor intake) and Anxiety. Planning includes goals like “Erika will not progress to withdrawal seizures or delirium”, “CIWA-Ar score will be below 10 within 48 hours”, and “Erika will verbalize reduced anxiety (rate <4/10) after medication and supportive interventions.” A longer-term goal is “Erika will accept referral for ongoing alcohol treatment to prevent relapse,” addressing the underlying issue.

Interventions and Implementation: The nurse carries out CIWA-Ar assessments every 1-2 hours and administers diazepam doses whenever the score exceeds the protocol threshold【16†L7-L15】. Over the first day, Erika requires diazepam 4 times as scores remain in the teens (moderate withdrawal). The nurse monitors her vital signs and neurological status each time – noting that after medication, her tremors lessen and blood pressure comes down a bit. The nurse also provides a quiet, low-stimulus environment (dim lights, as bright light bothered her – possibly triggering hallucinations). Reality orientation is done each time the nurse enters: “Hi Erika, I’m Kim, a nurse. You’re here at the hospital because your body is reacting to not having alcohol. You’re safe. That crawling feeling you have is a symptom of withdrawal; it will fade as we treat you.” This helps reduce fear from hallucinations. The nurse uses therapeutic communication to allay Erika’s anxiety: speaking calmly, reassuring her that the symptoms are temporary and not a sign of “going crazy.” When Erika says “I feel like I’m dying,” the nurse responds, “It must feel awful, but I promise these symptoms will get better. Your body is healing from the alcohol. I’m right here with you.” The nurse also engages her mother in the process – explaining what is happening in simple terms and how to support (e.g. “She might get very restless or even say strange things; just stay calm with her, we are giving her medicine to help”). This keeps the mother from panicking and in turn helps Erika stay calmer (seeing her mother calm).

During waking periods when withdrawal symptoms are less intense, the nurse carefully starts a conversation about Erika’s substance use and mental health. This is tricky with an adolescent because of trust issues. The nurse assures Erika, “I’m not here to scold you. I want to understand what led you to drink so much, so we can help you feel better without it.” Erika eventually admits she started drinking to self-medicate her depression and social anxiety – it made her feel more outgoing and forget her sadness. This opens the door for dual-diagnosis treatment planning. The nurse communicates this to the team so that her treatment plan will address both the alcohol dependence and the underlying depression (for example, continuing antidepressants, perhaps initiating therapy targeting coping skills). The nurse provides education (in short, non-lecture snippets given her condition) about how suddenly stopping alcohol after heavy use can be dangerous, and how in the future a medically supervised detox is needed. They discuss options like outpatient rehab or adolescent support groups once she’s medically stable – Erika is hesitant but listens.

Ethical/Legal Points: Erika is a minor, so by law her mother had to consent to treatment. However, the nurses and doctors still involve Erika in decisions (respecting her developing autonomy). There’s a delicate confidentiality issue: Erika confided that she’s been sexually active and sometimes uses marijuana as well. She begs the nurse not to tell her mother about the sexual activity. The nurse knows that isn’t immediately relevant to safe withdrawal treatment and there’s no legal mandate to disclose it (no abuse indicated, it was consensual with a peer). Ethically, the nurse decides to honor Erika’s privacy on that matter, focusing discussions with the mother on the alcohol use which is already known. The nurse encourages Erika to consider looping in her mom or another trusted adult on those other issues when she’s ready, but does not violate her trust – this helps strengthen the therapeutic alliance. Legally, the nurse documents Erika’s withdrawal course meticulously. When Erika briefly refused a dose of diazepam (saying she felt better and didn’t want more meds), the nurse respected that decision at first (autonomy) but explained the risks of under-treating withdrawal. An hour later, Erika’s CIWA score spiked again and she then accepted the medication. Throughout, the nurse adheres to the protocol for restraints – fortunately, despite her agitation, verbal de-escalation and medication sufficed, and no physical restraint was needed (thus upholding the least restrictive principle).

The nurse was also mindful of cultural factors: Erika and her family are of Hispanic background, and her mother at one point said, “We don’t really believe in ‘rehab’; we take care of family problems in the family.” The nurse respectfully provided information that addiction is a medical issue and that getting outside help isn’t a betrayal of family, and mentioned there are bilingual treatment resources and family therapy that can include them. Building cultural bridges helped the mother become more open to follow-up care rather than solely relying on willpower or keeping it a family secret (which had been the approach thus far).

Outcome: After 48 hours, Erika’s withdrawal symptoms subside; her CIWA-Ar scores fall below 8 consistently (mild or no withdrawal signs)【41†L119-L125】. She never had a seizure – a safe withdrawal was achieved. With physical detox completed, she is transferred to the psychiatric unit to continue treatment for her depression and address the substance use. In family meetings, she agrees to attend an adolescent substance abuse program after discharge, and her mother, while initially reluctant, concedes that professional help is needed. By discharge, Erika’s Risk for Injury is resolved (she’s no longer in acute withdrawal danger), her Anxiety is reduced, and she’s starting to articulate motivation to stay sober (“That was the scariest thing ever; I never want to go through that again”). The nurse provided a relapse prevention plan: they discussed triggers for drinking and alternative coping (like using exercise or art instead, and reaching out to her therapist when she’s feeling down rather than reaching for alcohol). Erika and her mom are given contacts for Alateen/Al-Anon (family support groups for alcoholism) in their area, which they showed interest in.

This case shows how a nurse manages a complex adolescent patient with both medical and psychiatric needs. The use of CIWA-Ar guided safe medical intervention【16†L1-L9】, while therapeutic communication and a trust-building approach allowed the nurse to engage the teen in her own recovery plan despite her initial resistance. It also highlights legal/ethical balancing: obtaining parental consent but also preserving the teen’s trust on sensitive disclosures, and using the least restrictive measures to ensure safety. In the end, Erika left the hospital medically stable and emotionally supported, with a clear plan that she and her family felt part of – a successful outcome in acute dual-diagnosis care.

Conclusion: These comprehensive explorations of the nursing process, MSE, suicide risk assessment, withdrawal protocols, communication techniques, and ethical-legal issues underscore the multifaceted role of the psychiatric nurse. Mental health nursing requires sharp assessment skills (from conducting a detailed MSE to quantifying withdrawal on CIWA-Ar), swift critical thinking (prioritizing safety risks like suicide and initiating appropriate precautions), and a deep well of empathy and communication finesse to build therapeutic relationships with patients across the lifespan. Nurses translate scientific knowledge (psychopharmacology, psychopathology, evidence-based therapies) into human care, tailored to each individual’s cultural background and personal needs. They advocate for their patients’ rights and dignity while also protecting them (and others) from harm – often a delicate tightrope walk between autonomy and safety.

In practice, a psychiatric nurse might be talking a despondent adult through their darkest hour one moment, and in the next, using a silly game to connect with a troubled child, or calmly diffusing an agitated psychotic crisis. This module has illustrated the core components that guide such care: the structured yet flexible nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation) ensures nothing important is overlooked【45†L161-L170】. Tools like the C-SSRS and CIWA-Ar provide critical data to inform interventions【8†L115-L119】【16†L1-L9】. Therapeutic communication remains the nurse’s most powerful tool, whether it’s active listening with an adult or engaging a teen with honesty or a child with play – it builds the trust needed for any intervention to work.

Cultural competence, ethical practice, and legal literacy form the framework within which psychiatric nurses operate, ensuring care is not only effective but also just and lawful. By upholding principles such as the patient’s right to informed consent and least restrictive care, and by honoring each patient’s cultural values and personal narrative, nurses foster a healing environment.

Psychiatric nursing is often challenging – progress can be slow, and situations can be emotionally charged – but it is also deeply rewarding. Through skilled assessment and compassionate intervention, psychiatric nurses witness patients regain hope, safety, and functionality. A formerly mute, withdrawn patient starts to talk and smile again; a suicidal teenager finds reasons to live; a hallucinating elder feels safe and understood. These outcomes are the result of the intricate interplay of science and empathy that defines mental health nursing. In sum, the nursing process and MSE guide what to do, therapeutic communication and cultural sensitivity guide how to do it, and ethical-legal principles guide why we do it in certain ways. Together, these equip nursing students and instructors – and practicing nurses – to provide high-quality psychiatric care across the lifespan, making a profound difference in the lives of individuals and families facing mental health challenges.

Sources:

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  2. RCH Clinical Practice Guidelines (2024). Mental state examination – Children. Royal Children’s Hospital Melbourne.【3†L120-L128】【3†L197-L203】

  3. Columbia Lighthouse Project (2023). About the Columbia-Suicide Severity Rating Scale (C-SSRS).【8†L113-L120】【10†L211-L218】

  4. Sullivan JT, et al. (1989). Assessment of alcohol withdrawal: the revised CIWA-Ar. Br J Addict, 84(11), 1353-7.【41†L117-L125】

  5. White, K., et al. (2024). Suspected Substance Withdrawal in Adolescents – Clinical Pathway. Children’s Hospital of Philadelphia.【14†L135-L143】

  6. Open RN Nursing: Mental Health (2020). Common Nursing Diagnoses Related to Mental Health. Chippewa Valley Technical College.【20†L500-L508】【22†L599-L607】

  7. Townsend, M. (2018). Psychiatric Mental Health Nursing: Concepts of Care. F.A. Davis (on therapeutic communication techniques).【35†L98-L105】【35†L123-L131】

  8. American Nurses Association (2015). Code of Ethics for Nurses with Interpretive Statements. ANA Publishing.【52†L186-L194】【52†L192-L200】

  9. Gorshkalova, O., & Munakomi, S. (2025). Duty to Warn. StatPearls Publishing.【56†L96-L102】

  10. (Additional references 60-62 on cultural competency and legal standards)【38†L554-L561】【54†L1-L4】【55†L168-L172】