1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

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

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

13. 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.

14. 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:
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

15. 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.

16. 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.