2.3 The Nursing Process in Psychiatric Mental Health Nursing Flashcards
The Nursing Process
- Objective is to deliver quality care
- Nursing process is dynamic NOT static
- Process continues as long as nurse and client have interactions directed towards change
The Nursing Process
Assessment - Interact with patient and healthcare provider to collect and analyze data. Information is used to establish a database to determine best possible care for the patient
Diagnosis - Nursing diagnosis (clinical judgement) and potential problems are formulated and prioritized
Outcome Identification - Desired results of nursing interventions that are collaboratively agreed upon. Derived from nursing diagnosis and must be measurable and include a time frame or attainment.
NOC (Nursing Outcomes Classification) - Standardized classification of outcomes
Planning - Plan care individualized to patient and family members. EBP interventions to achieve outcomes.
NIC (Nursing Interventions Classification) - Standardized language describing treatments that nurses preform in all settings and specialties
Implementation - Execution of interventions (nursing actions). Documentation of interventions also happen here.
Evaluation - Process of determining progress towards attainment of expected outcomes and effectiveness of nurses care/interventions
Use of Nursing Diagnosis
- Gives a degree of autonomy that has been lacking in nursing
- Diagnosis describes the clients condition, interventions, and outcome.
Case Management
- Used to improve client care
- Case managers negotiate with multiple providers to obtain diverse services. This helps lowers fragmentation of care and contain cost of services.
Managed Care
- Strategy used by patients to determine various types of services to maintain quality and control costs.
- INDIVIDUALS RECIEVE HEALTHCARE BASED ON NEED
- Case management helps achieve this goal
Critical Pathways of Care
- Tools for care in case management
- It’s a plan of care that provides outcome-based guidelines for goal achievement
- USED BY ALL MEMBERS OF INTERDISCIPLINARY TEAM (nurse, social worker, psychiatrist, dietician, etc)
- Team decides what categories of care should be preformed, when it should be preformed, and by who.
- Nurse (case manager) is ultimately responsible for each assignment being done.
- Intended for use of uncomplicated cases where designated outcomes can be predicted
Goals of Nursing Process in Psychiatric Care
- Change in thoughts, feelings, behaviors that are age-appropriate and congruent with social and cultural norms
- Nurses role is to establish trust in a one-on-one basis, providing positive feedback for small accomplishments to build self-esteem, and encouraging independent self-care.
Concept-Mapping
- Diagram that shows the relationships between medical diagnosis, nursing diagnosis, assessment data, and treatments.
- Used to plan and organize nursing care
- Starts with signs and symptoms, then nursing diagnosis, then nursing actions, then outcomes
SOAPIE Documentation Format
Subjective - Information gathered from the client
Objective - Information gathered through observation (BP, patient responses)
Assessment - Interpretation of objective/subjective data
Plan - Action/treatment to be carried out. (Can be omitted in daily charting if the plan is clearly explained in the written nursing care plan and no changes are expected)
Intervention - Nursing actions that were actually carried out
Evaluation - Optional section, evaluation of the nursing intervention
Focus Charting
- Uses DAR “Data Action Response” Format
- Focus of documentation can include nursing diagnosis, current client behavior, significant change in client behavior, significant event in client therapy.
- FOCUS IS NOT A MEDICAL DIAGNOSIS
Data - Data that supports the “focus” or describes pertinent observations about the client
Action - Immediate/Future nursing actions that address the focus and evaluation of present care
Response - Description of clients response to any part of the medical/nursing care
APIE Format
Assessment - Complete client assessment at the beginning of each shift
Problem - List of problems or nursing diagnosis
Intervention - Nursing actions that are preformed and directed at resolution of a problem
Evaluation - Documented outcomes of the implemented intervention including effectiveness and presence or absence of progress towards a problem
EHR
- Required by institutions in order to receive Medicare/Medicaid reimbursement
FUNCTIONS OF EHR
- Health information and Data (rapid access to patient information improving providers ability to make sound decisions in a timely manner)
- Results management (Results are accessed more easily at the time and place they are needed)
- Order Entry/Management (Eliminates issues of lost orders and removes illegible orders. Monitors for duplicate orders.)
- Decision Support (Uses reminders and prompts, improves regular screenings and preventative practices)
- Electronic Communication (Improves communication between different medical disciplinaries)
- Patient Support (Interactive client education, self-monitoring can help control illness)
- Administrative Processes (Scheduling systems increases efficiency of hospital)
- Reporting and Population Health Management (Organizations can easily report healthcare data to the government and private sectors for patient safety and public health)
