Chapter 6: nursing process in mental health Flashcards
1
Q
the nursing process is a tool…
A
- used by all nurses to care for their patients
- to determine priority in providing care
- to provide care in a systematic manner
- all nursing personnel need to be aware of their state’s nursing practice standards and apply the nursing process accordingly
- the RN is responsible to do the initial assessment, the LPN can assist. the RN is responsible for the “nursing diagnosis”
2
Q
nursing process comnents
A
- assessment (data collection)
- nursing diagnosis (not a medical dx)
- planning (goals)
- implementation/intervention (action)
- evaluation (outcome)
3
Q
assessment
A
- data collection
- collect data about their pts physical, mental, and emotional health at every interaction
- information is subjective and objective
- report an document according to NPA and agency policy
4
Q
mental status exam (assessment tool)
A
- usually done by RN, social worker, or mental health professional
5
Q
areas generally assessed in mental status exam
A
- appearance and behavior
- awareness and orientation
- thinking and content of thought
- mood and affect
- speech and ability to communicate
- memory
- judgment
- perception
6
Q
patient interviewing
A
- intake admission interview
- helping interview
7
Q
intake/admission interview
A
- primary method of data collection
- usually on a facility generated form
- questions often close ended
- may be helpful to learn to ask the questions in open ended format if pt is having diffculty answering them in close ended format
8
Q
helping interview
A
- used to determine or isolate a particular concern of the patient
9
Q
guidelines for nurse-patient interviewing
A
- be honest
- be assertive
- be sensitive
- use empathy (not sympathy)
- use open ended questions
10
Q
nursing diagnosis
A
- the RN determines the appropriate nursing diagnosis in most states
- the LPN can assist the RN
- the nursing diagnosis is a 2 or 3 part statement that identifies the patient’s needs
11
Q
planning (goals)
A
- LPN serves as a partner in planning care collaboratively w/ the RN and the pt
- pt is to be included in the planning, in some cases family can also be involved
- planning care will include short term and long term goals
- realistic and measurable in time
12
Q
Implementations/interventions
A
- LPNs will be active in assisting patients with the interventions chosen and in reporting the success of those interventions
- pt teaching is often a big part of assisting the pt in learning new behaviors that will lead to healing & a healthier mental outlook
- be aware of scope of practice with LPN and patient “teaching”
13
Q
evaluating interventions
A
- evaluating is a form of assessment and may not be allowed in the LPN scope of practice
- all nurses are responsible for collecting data on the interventions and reporting them according to NPA and facility policies
14
Q
nursing process classifications
A
- NIC/NOC model to identify nursing interventions and patient outcomes
15
Q
nursing interventions classifications (NIC)
A
- comprehensive standardized language
- provides direct and indirect intervention labels w/ definitions and possible nursing actions
