Week 5 Flashcards
What is the purpose of the psychiatric MH nursing assessment?
- establish rapport
- understand current problem and chief complaint
- review physical status and find baseline VS
- Assess for risk factors affecting safety
- assess psychosocial status
- mutual goals
- formulate care plan
Nursing process and standard of care comes from?
- Code of Ethics and Standards of Psychiatric Nursing Practice (Registered Psychiatric Nurses of Canada, 2010).
- Canadian Standards for Psychiatric-Mental Health Nursing (Canadian Federation of Mental Health Nurses, 2006).
Nursing process includes?
Problem solving method Translate values into practice 1 Assessment 2 Nursing Diagnosis 3 Outcomes Identification Short and long-term goals 4 Planning 5 Implementation 6 Evaluation
Define assessment for MH nursing.
- purposeful, systematic and dynamic process that is ongoing throughout the nurse/client rel’n
- Involves collection, validation, analysis, synthesis, organization, and documentation of client health- illness information
Considerations for children.
- info on emotions
- ask parents or other adults about behaviour and performance
- developmental level
- same sex HCP
- use observation (instead of interview)
- usually specially trained clinicians
- concerns about confidentiality
- use brief structured interview for RF
Considerations for older adults.
- stereotypes
- identify physical deficit and accommodate
- language barrier
What is included in the general MH nursing assessment?
GENERAL ASSESSMENT
- review of body systems, allergies, baseline VS
- physical exam
- hx
- lab data
- MSE
What is included in the psychosocial MH assessment?
PSYCHOSOCIAL ASSESSMENT
- chief complaint in clients words
- hx of violent, suicidal or elf-mutilating behaviours
- alcohol or substance abuse
- family psychiatric hx
- personal psychiatric treatment, medications, complementary therapies
- stressors and coping methods
- quality ADL’s
- personal background
- social background, support system
- weaknesses, strengths, goals for treatment
- Racial, ethnic, cultural beliefs and practices.
- Spiritual beliefs or religious practices.
Components of spiritual assessment.
- positive influence on pt’s views of themselves
- how they interact and respond to others
- spiritual addresses universal human questions and needs; 3 dimensions are cognitive, experiential and behaviour
- can increase healthy behaviour, social support, sense of meaning
- Religion external system that comprises beliefs, patterns of worship, symbols, requirements of membership
Religious involvement can lead to better physical health, better mental health, longer survival, prayer can be a source of hope, comfort and support in healing
What do we need to know about cultural and social assessment?
- cultural safety (beyond understanding and toward peer differential)
- nurses need to seek and consider the personal meanings that individuals ascribe to their own ethnicity
- be aware of own views, understand inequalities and engage in advocacy
How do we validate assessment?
check other records with written/verbal consent
What are the 3 components of nursing diagnosis?
- Problem (unmet need)
- Etiology (probable cause; ‘related to’)
- Supporting data (signs and symptoms; ‘as evidence by’)
What is the outcome criteria?
reflect the maximal level of pt health that can realistically be achieved through nursing intervention (direction for continuit of care, long and short term outcomes, written goals, positive terms)
What is considered in planning?
- Safety
- Compatible and appropriate
- Realistic and individualized
- Evidence- based
(NIC can be used to plan care)
What is NIC?
Nursing Interventions Classification (NIC) can be used to plan of care
