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Foundations of Psychiatric Mental Health Nursing Chapter 7
The Nursing Process and Standards of Care
18
Nursing
Undergraduate 2
11/25/2013

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Term
The Nursing Process
Definition
Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation
Term
Quality and Safety Education for Nurses (QSEN) Competencies
Definition
Patient Centered Care
Quality Improvement
Safety
Informatics
Teamwork and Collaboration
Evidenced Based Practice
Term
The HEADSSS Psychosocial Interview Technique
Definition
H-Home environment
E-Education and employment
A-Activities
D-Drug, alcohol, or tobacco use
S-Sexuality
S-Suicide risk
S-Savagery
Term
Mental Status Examination (MSE)
Definition
To evaluate an individuals current cognitive processes.
-Appearance
-Behavior
-Speech
-Mood
-Disorders of the form of thought
-Perceptual disturbances
-Cognition
-Ideas of harming self or others
Term
Psychosocial Assessment
Definition
Chief complaint
History of violent or suicidal behaviors
Alcohol or substance abuse
Family psychiatric history
Personal psychiatric treatment
Stressors and coping methods
Quality of ADLs
Personal background
Social background
Weaknesses, strengths and goals
Racial, ethnic, and cultural beliefs
Spiritual beliefs
Term
Assessment of Children
Definition
It is important to gather data from a variety of sources, such as the child themselves as well as caregivers. Children tend to feel more comfortable being assessed by someone of the same gender.
Term
Assessment of Adolescents
Definition
Adolescents are especially concerned with confidentiality and they need to know that their records are private.
Any threats of suicide, homicide, or any sexual abuse must be reported.
Term
Assessment of Older Adults
Definition
The nurse should be aware of any physical limitations that could increase anxiety, stress, or physical discomfort for the patient during the assessment. Make any accommodations to help the patient feel comfortable.
Term
Purpose of the psychiatric mental health nursing assessment
Definition
Establish rapport
Obtain an understanding of the current problem
Review physical status, baseline vitals
Assess for risk factors affecting safety
Perform a mental status examination
Assess psychosocial status
Identify mutual goals for treatment
Formulating a plan of care
Term
Spiritual/Religious Assessment
Definition
Spirituality - internal phenomenon and is often understood as addressing universal human questions and needs
Religion - external system that includes beliefs, patterns of worship, and symbols
Term
Cultural Assessment
Definition
Primary language
Cultural background
Living situation
Social situation
Medical beliefs/providers
Attitude toward mental illness
Specific diet
Term
Outcome criteria
Definition
Hoped for outcomes that reflect the maximal level of patient health that can realistically be achieved through nursing interventions
Term
Nursing Outcomes Classification
Definition
Includes standardized outcomes that provide a mechanism for communicating the effect of nursing interventions on the well being of patients, families and communities
Term
Evidenced Based Practice
Definition
Combination of clinical skill and the use of clinically relevant research in the delivery of effective patient centered care.
Term
Nursing Interventions Classification
Definition
Research based standardized listing of interventions reflective of current clinical practices the nurse can use to plan care
Term
Health teaching
Definition
Includes identifying the health education needs of the patient and teaching basic principles of physical and mental health.
Term
Milieu Therapy
Definition
Orienting patients to their rights and responsibilities, selecting specific activities that meet patients physical and mental health needs, and ensuring that patients are maintained in the least restrictive environment safety permits.
Term
Self-care Activities
Definition
Assists the patient in assuming personal responsibility for activities of daily living.
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