Lecture 4a: Nursing Process Within PMH Care

mental health notes Lecture 4A: 1/27 Standard 1: Assessment Collect & synthesize pertinent patient data HIPAA guidelines Age considerations: Nursing Process Within PMH Care Quality and Safety Education in Nursing Patient-centered care ONcial ABA Publication Interdisciplinary teamwork Psychiatric-Mental Health Bursing: Scope and Standards of Practice Use of evidence-based practice Assessment of children Application of quality improvement Assessment of adolescents Use of informatics Legal de,nition of psychiatric-mental health nursing Language barriers: Goals Establish rapport Understand current problem Review physical baseline status Identify risk factors Perform MSE Assess psychosocial status Identify mutual treatment goals Formulate plan of care Document data in retrievable format Gathering data: Review of systems BCLE"-RB questions Standard 2: Diagnosis Analyze assessment data to determine diagnosesT problemsT and areas of care/tx focusT including level of risk Diagnostic statement components: Problem/potential problem (unmet need) Probable cause (+due to+) Supporting data (S/S) Wypes of Bursing Diagnoses Problem-focused diagnoses: Problem probable cause supporting data Risk diagnoses: Xegins with +risk for+ followed by the problem Laboratory data Mental status exam (MSE) Psychosocial assessment Spiritual/religious assessment Cultural and social assessment Validating the assessment Using rating scales (ex. mood) Xasis Certi,cation criteria Assessment of older adults Interpreter (spoken) or translator (written) Standard of Practice for Nursing Standard 3: Outcomes Identi-ca6 tion Outcome Criteria Identify expected outcomes that reect the maximal level of pt health that can realistically be achieved through planned nursing interventions Principles Re ect a measurable desired change Provide direction for continuity of care ritten in positive terms Standard 5: Implementation Registered Burse Interventions Coordination of care Health teaching and health promotion PharmacologicalT biologicalT and integrative therapies Standard v: E aluation Evaluate progress toward attainment expected outcomes Must be systematicT ongoingT and criteria-based Milleu therapy Wherapeutic Relationship and Counseling Xasis of nurse-patient interactions Standard 4: Planning Prescribe strategies to assist pt in attaining expected outcomes Principles to consider when planning care: Safe Compatible and appropriate Standard 7: Documentation Providing a presence and a sounding board Crucial even through evaluation Reinforce healthy behavior Include: Pt conditionT informed consents. drug reactionsT pt concernsT and adverse incidents Help the pt to recognize maladaptive behaviors Help pt identify positive coping methods and try out the new coping methods Advanced Practice Interventions Realistic and attainable Consultation Evidence-based Prescriptive authority Medical record: Legal document Documentation of nonadherence