1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

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

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.