Assessment Strategies and the Nursing Process Chapter 9 Assessment Strategies and the Nursing Process Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

Standards of Professional Performance 1. Quality of care 2. Performance appraisal 3. Continuing education 4. Collegiality 5. Ethics 6. Interdisciplinary collaboration 7. Research 8. Resource utilization Standards of Care for psychiatric mental health nursing form the basis for specialty certification, the states’ nurse practice acts, and the National Council of State Boards of Nursing Licensure Exam (NCLEX-RN). See the Standards of Care for Psychiatric Mental Health Nursing Practice developed by the American Nurses Association (ANA) on the back cover of your textbook. Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

The Nursing Process in Psychiatric Mental Health Nursing 1. Assessment 2. Nursing diagnosis 3. Outcome identification Evaluation 4. Planning Implementation Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

1. Assessment Construct database Verifying the data Mental status examination (MSE) Psychosocial assessment Physical examination History taking Interviews Standardized rating scales Verifying the data The mental status exam is comprised of eight major assessment areas (See page 142 of your text): 1. Personal information 2. Appearance 3. Behavior 4. Speech 5. Affect and mood 6. Thinking 7. Perceptual disturbances 8. Cognition Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

Assessment - Continued Data collection Primary source Secondary source Personal consideration Countertransference Age considerations Children Adolescents Elderly Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

Purposes of Psychiatric Assessment Establish rapport Obtain understanding of problem Assess psychological functioning Identify goals Perform mental status examination Identify behaviors/beliefs/areas to be modified to effect positive change Formulate a plan of care Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

2. Nursing Diagnosis Identify problem and etiology Construct nursing diagnosis and problem list Prioritize nursing diagnoses Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

Formulating a Nursing Diagnosis Three structural components 1. Problem: unmet need 2. Etiology: probable cause 3. Supporting data: signs and symptoms Review Appendix C on page 780 of your text for NANDA-approved nursing diagnoses. Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

3. Outcome Identification Identify outcomes Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

Determining Outcomes Outcomes versus goals Short-term goals and long-term goals Nursing Outcomes Classification (NOC) “Outcomes” are used instead of “goals” in current nursing practice to reflect their basis in clinical practice and research. The Nursing Outcomes Classification (NOC) consists of standardized outcome statements that all nurses can use and understand. They are linked to the NANDA-approved nursing diagnoses and the Nursing Interventions Classification (NIC). Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

4. Planning Identify safe, pertinent, evidence-based actions Strive to use interventions that are culturally relevant and compatible with health beliefs and practices Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

Planning - Continued Nursing Interventions Classification (NIC) Principles for planning care Safe Appropriate Individualized Evidence based The NIC is research-based and reflects current clinical practice; there are 514 interventions available to nurses. Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

5. Implementation Basic Level Nursing Counseling Milieu therapy Self-care activities Psychobiological intervention Heath teaching Case management Health promotion and maintenance Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

Implementation - Continued Advanced Practice Nursing All basic level interventions, plus Psychotherapy Prescription of pharmacological agents Consultation Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

6. Evaluation If outcomes have not been achieved at desired level Additional data gathering Reassessment Revised plan Evaluation is “systematic and ongoing” (text, p.149). The Evolve website provides you with an opportunity to follow a nurse as she completes the nursing process and applies the Standards of Care with a client. Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.

Documentation of Client Progress The chart is a legal document that should accurately record the client's Documentation of symptoms Changes in condition Informed consent Reaction to medications Treatments and tests Responses treatments and tests Any untoward incidents Nursing documentation ought to be “focused, organized, and pertinent” (text, p.151). Please review “Legal Considerations for Documentation of Care” on page 151 of your textbook. Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.