2. Learning Objectives:
At the end of this session the Students will be able to:
• Define the most important terms in the nursing process
• List and demonstrates the steps of the nursing process.
• Illustrate each step of nursing process
• Explain nursing care plan with examples
3. Nursing Assessment
The assessment interview requires culturally effective
communication skills and encompasses a large database (e.g.,
significant support system; family; cultural and community
system; spiritual and philosophical values, strengths, and health
beliefs and practices; as well as many other factors).
4. QUALITY AND SAFETY EDUCATION FOR NURSES (QSEN) COMPETENCIES
prepare future nurses with the knowledge, skills, and attitudes (KSAs)
required to enhance quality, care, and safety in the health care settings in
which they are employed
7. ASSESSMENT
The assessment process begins with the initial patient encounter
and continues throughout the care of the patient.
To develop a basis for the plan of care and in preparation for
discharge, every patient should have a thorough, formal nursing
assessment on entering treatment.
8. • Age Consideration
• Language Barriers
• Gathering Data ( Review of systems )
• Spiritual/Religious Assessment
• Cultural and Social Assessment
10. A psychosocial assessment provides additional information from which
to develop a plan of care.
• Central or chief complaint (in the patient’s own words)
• History of violent, suicidal, or self-mutilating behaviors
• Alcohol and/or substance abuse
• Family psychiatric history
• Personal psychiatric treatment, including medications and complementary therapies
• Stressors and coping methods
• Quality of activities of daily living
• Personal background
• Social background, including support system
• Weaknesses, strengths, and goals for treatment
• Racial, ethnic, and cultural beliefs and practices
• Spiritual beliefs or religious practices
11. Using Rating Scales A number of
standardized rating scales are useful
for psychiatric evaluation and
monitoring.
12. DIAGNOSIS
a clinical judgment about a patient’s response, needs, actual and
potential psychiatric disorders, mental health problems, and
potential comorbid physical illnesses.
NANDA
(NANDA-I) provides evidence-based diagnoses for nursing care.
13. Diagnostic Statements
Nursing diagnostic statements are made up of the following
structural components:
1. Problem/potential problem
2. Related factors
3. Defining characteristics
14. Types of Nursing Diagnoses
Actual diagnoses are problems that currently exist.
” (Formula: Problem 1 Related Factors 1 Defining Characteristics)
Health promotion diagnoses refer to the desire or motivation to improve
health standing. (Formula: Problem 1 Defining Characteristics)
Risk diagnoses pertain to vulnerability that carries a high
probability of developing problematic experiences or responses.
15. OUTCOMES IDENTIFICATION
are the hoped-for outcomes that reflect the maximal level of patient
health that can realistically be achieved through nursing
interventions.
Nursing Outcomes Classification (NOC)
NOC includes standardized outcomes that provide a mechanism for
communicating the effect of nursing interventions on the well-
being of patients, families, and communities.
16.
17. PLANNING
Standardizing pathways or plans of care allows for inclusion of evidence-
based practice and newly tested interventions as they become available
18. the nurse considers the following specific principles when planning
care:
• Safe
• Compatible and appropriate
• Realistic and individualized
• Evidence-based
19. IMPLEMENTATION
• skills are accomplished through the nurse-patient relationship
and therapeutic interventions.
• the plan using evidence-based practice whenever possible, uses
community resources, and collaborates with nursing colleagues.
20. Basic Level Interventions
• Standard 5a: Coordination of Care
• Standard 5b: Health Teaching and Health Promotion
• Standard 5c: Milieu Therapy
• Standard 5d: Pharmacological, Biological, and Integrative Therapies
21. Advanced Practice Interventions The following three interventions can be
carried out by the APRN-PMH or the psychiatric mental health advanced
practice registered nurse only.
• Standard 5e: Prescriptive Authority and Treatment
• Standard 5f: Psychotherapy
• Standard 5g: Consultation
22. EVALUATION
the individual’s response to treatment should be systematic, ongoing, and
criteria-based. Supporting data are included to clarify the evaluation.
DOCUMENTATION
Patient progress is the responsibility of the entire mental health team
