WEEK 3 Flashcards
nursing process
The steps of the nursing process for registered nurses (RNs) include
assessment
analysis
planning
implementation
evaluation
environmental factors
Setting, situation, and the physical environment: Consider the safety and surroundings.
Observations of client: Consider clinical manifestations, appearance, and age.
Resources: Does the nurse have the tools, staff, or equipment required for client care?
Health record: Review the medical records, client history, labs, and diagnostic tests.
Is there a time limitation? Such as STAT or change in client condition?
cultural considerations
Task requirements: skills needed, number of staff required, complexity of tasks
Risk assessment: identifying, finding, and removing any risks for harm and promoting safety and well-being
individual nurse factors
Nurse Specific: Consider needed knowledge, skill, or specialized training to address the client’s needs.
Nurse Characteristics: Consider self, including attitude, thoughts, bias in caring for this client, as well as level of experience.
Nurse Cognitive Load: Consider stress level, ability to problem-solve, and memory.
The scope of practice differs between
practical nurses (PNs) and registered nurses (RNs)
PN nursing process
collection
planning
implementation
evaluation
data collection for PN
The registered nurse is responsible for assessing the client, and the PN contributes by collecting data. This is not a complete assessment on the part of the PN, but data collection assists the RN in completing an assessment of the client.
how does data collection align with the RN nursing process
goes with the same steps as assessment and analysis
A client has been referred to a behavioral health partial hospitalization program as part of their inpatient hospitalization discharge plan. Which of the following team members should be assigned to admit the client and perform the initial assessment?
the staff registered nurse (RN)
milieu
Environment for which the nurse is responsible. The environment should be safe for each client.
while conducting the assessment, the nurse is to observe the client and consider not only the content of their responses but must also note the
affect (feeling and tone expressed by the client such as angry, sad, flat)
mood (subjective description of their emotions)
orientation (name, DOB)
speech
thought process
cognition
A co-occurring disorder is when
a client has two or more mental health disorders or medical illnesses.
assessment: client’s history
name, age, gender, race/ethnicity
history of present illness
health history and current health status
allergies
coping abilities
cultural, spiritual, and religious beliefs
assessment: physical assessment
assessment of all body systems (potential areas of concern for the client with mental illness)
dental health
vision/eye health
sexual and reproductive health
substance use disorders
metabolic syndrome
The following THINC-MED offers a way to consider what may mimic mental illness
T – Tumors
H – Hormones
I – Infection or infectious diseases such as uremia or sepsis
N – Nutritional deficits
C – Central nervous system disturbances such as neurological conditions or head injury
M – Miscellaneous medical conditions
E – Electrolyte disturbances or environmental toxins
D – Drugs and substances use or polypharmacy
assessment: physical health
Clients with a mental illness may have oral health issues due to
fears regarding dental visits, greater incidence of gum disease, inadequate nutrition, drug or alcohol use, tobacco use, and medication side effects
assessment: physical assessment
vision can be impacted by
some psychotropic medications, while others are contraindicated if the client has been diagnosed with visual disorders like glaucoma
assessment: physical assessment
sexual function
Clients who have a mental illness are at a greater risk for developing sexually transmitted diseases and becoming a victim of sexual violence
assessment: physical assessment
For clients with mental illness, tobacco use has been associated with an increased risk for other mental health conditions such as
Alzheimer’s disease, dementia, or psychosis
assessment: physical assessment
Alcohol use disorder has been associated as a potential cause of
cancer, diseases of the liver, heart disease, gastrointestinal tract health issues, and nutrition-related issues
assesment: physical assessment
Substance use disorder is more prevalent in clients who have mental illness and increases risks for
liver disease, heart disease, and GI disorders
assessment: MSE
what are the 12 domains of the mental status exam?
apperance
alterness
behaviors
motor
speech
mood
affect
thought process
thought content
perception
cognition
judgement
assessment: psychosocial
age/gender/etc
provide mental and physical health history
employment
relationships and social patterns
family med history and mental health conditions
current or past substance use/abuse
health habits
spiritual preferences and practices
safety and risk assessment
assessment: funnel approach to quesitoning
open-ended questions
clarifying questions
close-ended questions
assessment: family assessment
the main component assessed is family functioning.
Family functioning involves the ability of the family unit to manage life, deal with disagreements, and live within a determined set of boundaries effectively
assessment: family assessment
assessment tools (FAD)
family assessment device
also known as the McMaster Family Assessment Device with a Likert scale (scoring 1 to 5) responses for about 60 questions
assessment: family assessment
FAD (six domains)
problem solving
communication
behavior control
affect-involvement
responsiveness
roles within the family
assessment: community assessment
Needs of a community or population
Resources available
Questionnaires/surveys
Community-based participatory research
Staff are part of the community
Information shared with all stake holders
assessment: spiritual assessment
done on assessment
One assessment tool that guides the nurse in collecting data for this area is the FICA (faith, importance/influence, community, address) spirituality tool
assessment: situational assessment
occurs when first entering rooms
note patient behavior
indefinity safety concerns
use de-escalation techniques as needed
analysis (aka what are you looking for)
These clinical manifestations become the cues for determining the plan of care for the client.
analysis: NCSBN model
Recognizing and analyzing cues is part of forming a hypothesis.
Prioritizing hypotheses and generating solutions is part of refining a hypothesis.
analyzing cues
Recognize patterns
Link cues
Determine what is concerning
Determine if additional information is needed
analysis: example of observation (cue) and potential meaning
Client is pacing, unable to sit still, and constantly watching the door.
potential meaning: the client may have anxiety or paranoia
analysis: priotization of problems
Cluster information.
Narrow possibilities.
Determine the order of priorities.
Determine risk for action or inaction.
Provide evidence for the hypothesis.
PLANNING NOW
