Nursing Process

Question 1

Assessment

Answer 1

• Psychiatric history
• Medical History
• Social History
• Family health history
• Major life events (eg. losses) ; and response, coping, recovery and resilience factors
• Developmental history
• Substance use behaviours
• Risk potential
• Mental state exam (MSE)

Question 2

Planning for treatment

Answer 2

Treatment planning can help set goals, monitor progress, lead to better treatment, and provide life-saving information.

• Perform an assessment of the patient’s needs
• Identify risk factors
• Generate a problems & goals list with the patient and/or guardian
• Include other clinicians (Multi-team)

Question 3

Interventions for care

Answer 3

The treatment plan is a point of reference for treatment interventions.

• As soon as the plan is complete, ensure the client receives a copy.
• People with an agreed role should be involved in the planning stage and receive a copy
• Documentation in patient’s medical file
• Person-centred care

Question 4

Evaluation

Answer 4

• Treatment planning is an ongoing, dynamic process. It involves the treating team, the client and their personal support team.
• Plans should be regularly revised and reviewed.