Chapter 7 The Nursing Process and Standards of Care in Psychiatric Mental Health Nursing Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Standards of Care Standard 1: Assessment Age considerations Assessment of children Assessment of adolescents Assessment of older adults Language barriers Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Case Study A patient who just arrived on your unit says, “I don’t know why you need to do an assessment, I am just here to get my medicines adjusted.” Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Case Study (Cont.) What is the purpose of a psychiatric mental health nursing assessment? How would you respond to this patient? Purposes are Establish rapport Obtain an understanding of the current problem or chief complaint Review physical status and obtain baseline vital signs Assess for risk factors affecting the safety of the patient or others Perform a mental status examination Assess psychosocial status Identify mutual goals for treatment Formulate a plan of care Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Psychiatric Mental Health Nursing Assessment Gathering data Review of systems Laboratory data Mental status examination Psychosocial assessment Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Psychiatric Mental Health Nursing Assessment (Cont.) Gathering data (cont’d) Spiritual/religious assessment Cultural and social assessment Validating the assessment Using rating scales Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Standard 2: Diagnosis Three components Problem (unmet need) Etiology (probable cause) Supporting data (signs and symptoms) Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Standard 3: Outcomes Identification Outcome criteria – Outcomes that reflect the maximal level of patient health that can realistically be achieved through nursing interventions Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Standard 4: Planning Principles to consider when planning care Safe Compatible and appropriate Realistic and individualized Evidence-based Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Standard 5: Implementation Basic interventions Coordination of care Health teaching and health promotion Milieu therapy Pharmacological, biological, and integrative therapies Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Standard 5: Implementation (Cont.) Advanced practice interventions Prescriptive authority and treatment Psychotherapy Consultation Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Standard 6: Evaluation Systematic Ongoing Criteria-based Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Question 1 In which part of the nursing care plan would the nurse expect to find this statement: Offer snacks and finger foods frequently. Assessment Diagnosis Planning and outcomes identification Intervention Evaluation Answer: D Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Audience Response Questions A nurse assesses a newly admitted client diagnosed with Alzheimer’s disease and a urinary tract infection. The nurse asks the client’s sibling for information about the home environment, ADLs, and medications. What type of information source is the sibling? Primary Secondary Private Informed ANS: B   Secondary sources are valuable when caring for a client experiencing psychosis, muteness, agitation, or catatonia. Such secondary sources include members of the family, friends, neighbors, police, health care workers, and medical records. REF: 117-118 Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Audience Response Questions Which term is broader? Spirituality Religion Not sure ANS: A   Spirituality addresses universal human questions and needs. Spirituality is cognitive, experiential, and behavioral. In contrast, religion is an external system that includes beliefs, patterns of worship, and symbols. Although religion is often concerned with spirituality, religious groups are social entities and are often characterized by other nonspiritual goals (cultural, economic, political, social). REF: 122 Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Audience Response Questions A nurse taught a client about important precautions associated with a new prescription. Afterward, the client accurately summarized major self-management strategies associated with this drug. Which step of the nursing process applies to the client’s summarization? Assessment Analysis Planning/outcomes identification Intervention Evaluation ANS: E   Evaluation of the individual’s response to treatment should be systematic, ongoing, and criteria based. Supporting data are included to clarify the evaluation. REF: 127 Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.