Term
- Assessment
- Diagnosis
- Outcome Identification
- Planning
- Implementation
- Evaluation
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Definition
| Steps of the nursing process that can be remembered using the mnemonic "Ado pie" |
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Term
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Definition
- Foundation of psych MH nsg.
- integral part of psych MH nsg. standards as defined by ANA
- 6 step prob-solving approach that facilitates safe, quality care for pts.
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Term
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Definition
| formal, thorough collection of pt. data that begins upon entry into Tx. and continues throughout |
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Term
| Issues that need to be addressed in the Assessment |
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Definition
| Psychological, social, physcial, and cultural |
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Term
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Definition
| Data collected directly from the pt. is considered _______ while data collected from someone/something other than the pt. is termed _______ |
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Term
- Development level
- Data may have to be obtained through play or special interviewing
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Definition
| Considerations for assessment of a child |
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Term
- records are confidential
- risk factors (HEADSSS)
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Definition
| Considerations for adolescents during assessment |
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Term
| Home environment, Education/employment, Activities, Drug/alcohol/tobacco use, sexuality, suicide risk/signs of depression/MH disorder, Savagery (violence/abuse) ; Used in the assessment of adolescents |
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Definition
| What does HEADSSS stand for? What is it used for? |
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Term
| Identify physical illness/defecits |
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Definition
| Considerations for older adults during assessment |
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Term
| physical systems, lab data, MSE, psychosocial Hx., spiritual/religious beliefs, cultural/social issues, standardized rating for specific psych prob. |
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Definition
| Aspects of Psych Assessment |
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Term
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Definition
| This evaluates an individual's current cognitive process (obj. data). Important to make sure pt. understands all terms used |
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Term
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Definition
| This evaluates the systems in which a person operates (sub. data) - Education, occupation, sexuality, previous hospitalizations, etc. |
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Term
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Definition
| Clinical judgment about pt's actual/potential problems and the basis for selecting therapeutic outcomes/interventions |
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Term
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Definition
| When selecting a diagnosis for a pt, use this. |
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Term
| Problem, Etiology, Supporting Data |
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Definition
| Three components to a Diagnosis |
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Term
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Definition
| reflect maximal level of pt health achievable through nsg intervention. Stated in attainable/measurable terms w/ time frame |
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Term
| Nursing Outcomes Classification (NOC) |
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Definition
| Standardized list of 385 outcomes. Each outcome has associated group of indicators |
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Term
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Definition
| In this stage, the nurse looks for interventions that are: safe, appropriate, individualized, evidence based. |
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Term
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Definition
| Use of standardized care plans/ clinical pathways which allow for inclusion of EB practice. |
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Term
| Nursing Interventions Classification (NIC) |
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Definition
| research based list of 542 nursing interventions |
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Term
| Psychiatric-MH Nsg: Scope and Standards of Practice (ANA, 2007) |
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Definition
| This differentiates bw basic and AP psych nurses |
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Term
| Coordinate care, health teaching/promotion, milieu therapy, pharmacology, biological/integrative therapy |
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Definition
| Basic level psych nurse duties |
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Term
| prescriptive authority, psychotherapy, consultation |
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Definition
| Advanced level psych nurses interventions |
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Term
| Systematic, Ongoing, Criterion based |
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Definition
| The evaluation process in described as this. . . |
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Term
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Definition
| The purpose of this is to modify/revise care according to pt's ongoing needs |
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Term
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Definition
| Descriptive, chronological statement of significant pt. events throughout the shift |
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Term
| Problem-Oriented Charting: SOAPIE |
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Definition
| This type of charting is accompanied by a problem list and organizes info around: Subjective data, Objective data, Assessment, Plan, Interventions, Evaluation |
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Term
| Subjective data, Objective data, assessment, plan, interventions, evaluation |
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Definition
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Term
| Focused, organized, pertinent, and conforming to legal standards |
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Definition
| Documentation should be. . . |
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Term
| Informed consent, evaluation of stated outcomes, changes in pt. condition, specific concerns of pt, any untoward incidents in health care setting |
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Definition
| Information in Documentation |
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