Week 2: CH 8

Question 1

What does the nursing process include?

Answer 1

Comprehensive Assessment
Nursing Diagnosis
Outcome Identification
Planning and intervention
Evaluation (referrals)

Question 2

What does the initial patient assessment include?

Answer 2

Demographic data
Admission data
Reason for admission
Previous psychiatric history
Current medical problems and medications
Drug and alcohol use, abuse
Disturbances in patterns of daily living
Culture and spirituality
Support systems

Question 3

What does the Mental Status Examination look for?

Answer 3

General appearance
Behaviors during interview
-Cooperation-resistance
Social Skills
Motor activity
Speech patterns
Concentration-attention
Orientation
Memory
-Immediate recall
-Recent
-Remote
Intellectual functioning
Affect
Mood
Thought clarity
Thought content
Thought processes
Insight
Judgment
Motivation for treatment

Question 4

What is the ongiong assessment?

Answer 4

Focuses on patient actions, statements
Considerations
-Context that precipitated behavior
-Patient’s thoughts at the time
-Patient’s feelings, then and now
-Behavior makes sense in the context?
-Behavior adaptive or dysfunctional?
-How episode fits with total patient picture
-Is change needed?

Question 5

What is the Nursing Diagnosis?

Answer 5

Identifies patient problems
NANDA diagnoses widely accepted
Format
-(Problem) related to (contributing factor) as evidenced by (behavioral outcome)
-Do not include medical diagnoses in any part

Question 6

What is the Outcome Identification?

Answer 6

Specifies an adaptive behavior
Must be realistic, achievable
Written in measurable, behavioral terms
Short-term outcomes—attainable in 4 to 6 days
Long-term outcomes—require follow-up after discharge

Question 7

What is the Planning and Intervention?

Answer 7

Nursing care plans
-Often standardized (clinical pathways, critical pathways)
-Goal: Expedite treatment activities to achieve outcomes in a cost-effective manner
Nursing focus: Facilitation and education
-Verbal strategies to guide problem solving

Question 8

What is the evaluation?

Answer 8

Considers patient progress
Might lead to:  
-Reassessment
-Reformulated nursing diagnoses
-More realistic outcomes
Determines need for patient referral
Considers quality and effectiveness of nursing interventions

Question 9

What are the discharge summaries?

Answer 9

Outcomes achieved
Outcomes still to be addressed
Patient instructions
Medication information
Follow-up appointments
Referrals