Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. Chapter 8 The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 2 Standards of Care Standard 1: AssessmentStandard 1: Assessment –Age considerations Assessment of childrenAssessment of children Assessment of adolescentsAssessment of adolescents Assessment of older adultsAssessment of older adults –Language barriers

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 3 Psychiatric Mental Health Nursing Assessment Gathering dataGathering data –Review of systems –Laboratory data –Mental status examination –Psychosocial assessment

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4 Psychiatric Mental Health Nursing Assessment Continued Gathering data, continuedGathering data, continued –Spiritual/religious assessment –Cultural and social assessment –Validating the assessment –Using rating scales

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5 Standard 2: Diagnosis Three componentsThree components –Problem (unmet need) –Etiology (probable cause) –Supporting data (signs and symptoms)

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6 Standard 3: Outcomes Identification Outcome criteria – outcomes that reflect the maximal level of patient health that can realistically be achieved through nursing interventionsOutcome criteria – outcomes that reflect the maximal level of patient health that can realistically be achieved through nursing interventions

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7 Standard 4: Planning Principles to consider when planning carePrinciples to consider when planning care –Safe –Compatible and appropriate –Realistic and individualized –Evidence-based

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8 Standard 5: Implementation Basic level interventionsBasic level interventions –Coordination of care –Health teaching and health promotion –Milieu therapy –Pharmacological, biological, and integrative therapies

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 9 Standard 5: Implementation Continued Advanced practice interventionsAdvanced practice interventions –Prescriptive authority and treatment –Psychotherapy –Consultation

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 10 Standard 6: Evaluation SystematicSystematic OngoingOngoing Criteria-basedCriteria-based

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11 In which part of the nursing care plan would the nurse expect to find this statement?In which part of the nursing care plan would the nurse expect to find this statement? Offer snacks and finger foods frequently. Offer snacks and finger foods frequently.

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12 a.Assessment b.Diagnosis c.Planning and outcomes identification d.Intervention e.Evaluation