Chapter 7: Nursing Process & Standards of Care Outline PDF

**Chapter 7: The Nursing Process and Standards of Care** Psychiatric Nursing Care - A.D.P.I.E. (Assessment, Diagnosis, Planning, Implementation, Evaluation) - Assessment - Subjective information - What the patient states - HPI- history of prese...

**Chapter 7: The Nursing Process and Standards of Care** Psychiatric Nursing Care - A.D.P.I.E. (Assessment, Diagnosis, Planning, Implementation, Evaluation) - Assessment - Subjective information - What the patient states - HPI- history of present illness - What the patient tells you regarding their reason for seeking treatment - includes all of the following: - statements regarding their reason for treatment - voluntary or involuntary - thought content and perception - suicide risk assessment - subjective information regarding suicidal ideations - homicidal risk assessment - subjective information regarding homicidal ideations - hallucinations, delusions, illusions - obsessions, ruminations - insight - understanding their own condition - judgment - problem solving ability - psychiatric history - age of onset of symptoms - age when sought treatment - age received diagnosis and what diagnosis - medication history - psychiatric hospitalization - suicide attempt or self harm history - homicidal ideation history - legal history - trauma history - substance use history - caffeine - nicotine - controlled substances - illicit substances - social history - developmental information - relationship history - as a child and adult - do they have children? - Education - Occupation - current living situation - support - medical history - surgical history - current medications - allergies - review of systems - subjective information related to disease or illness in any of the body systems outside of the reason for seeking treatment - Objective information - What you observe or assess - does not include any subjective information - vital signs - physical assessment - diagnostic tests - labs - scans - results of screening tools - Mental Status Exam (MSE) - Structured assessment used by healthcare professionals, particularly in mental health settings, to evaluate a patient\'s cognitive, emotional, and psychological functioning. - Provides a snapshot of the patient\'s current mental state and is crucial for diagnosis, treatment planning, and monitoring progress. - Diagnosis - analyze assessment data to determine diagnosis, problems and areas of care and treatment focus, including level of risk - diagnostic statement components - problem / potential problem (unmet need) - probable cause ("due to") - supporting data (signs and symptoms/ "as evidenced by") - Example: - disturbed mood regulation r/t emotional dysregulation a.e.b. Prolonged periods of mood irritability - outcomes identification - outcome criteria - identify expected outcomes that reflect the maximal level of patient health that can realistically be achieved through planning nursing interventions - principles - reflect a measurable desired change - provide direction for continuity of care - written in positive terms - Outcomes identification criteria - Specific - goals should be clearly defined and focused on a particular outcome. For example, instead of saying "improve mobility", state "patient will ambulate 50 feet using a Walker". - Measurable - established criteria for measuring progress. For instance, include quantifiable metrics (e.g., "will report pain level of three or less on a scale of 0-10"). - Achievable - Goals must be realistic and attainable based on the patient\'s condition, resources, and support systems. Consider the patients baseline abilities and limitations. - Relevant - goals should align with the patient\'s overall care plan and address their specific health issues or conditions. - Time-bound - assign a time frame for achieving the goals to provide urgency and allow for evaluation. For instance, "within 3 days". - Patient-driven - involve the patient in goal setting to ensure that their priorities, motivations, and preferences guide the objective set. - Flexible - bulls should allow for modifications based on ongoing assessments and changes in the patient\'s condition or situation. - Planning - Prescribe strategies to assist patient in attaining expected outcomes. - Principles to consider when planning care: - Safe - Compatible and appropriate - Realistic and individualized - Evidence based - Nursing Interventions - Evidence based - Intervention should be supported by current research and best practices within the nursing profession. - Individualized - Intervention should be tailored to meet the specific needs, preferences, and circumstances for each patient. Consider cultural, ethical, and personal factors. - Safe - Interventions must prioritize patient safety and minimize risks. Assess for any contraindications or potential side effects. - Feasible - The availability of resources, time, and support must be considered. Interventions should be practical and manageable within the healthcare setting. - Holistic - Interventions should address the physical, emotional, psychological, and social aspects of the patient\'s well-being. - Collaborative - When necessary, involve other healthcare professionals to implement comprehensive care plans that may include interdisciplinary approaches. - Patient-Centered - Engage the patient in the care planning process and ensure that their values and preferences are considered. - Measurable - Interventions should have defined outcomes that can be evaluated for effectiveness, allowing for adjustments as needed. - Outcome identification and implementation - Goal - Example: - Utilize 3 coping mechanisms to help with mood regulation by the end of hospital stay - Interventions to meet goal - Examples: - Provide written and verbal education to patient and dysregulated mood by end of first day of admission - Discuss possible competing mechanisms to help with dysregulated mood by end of day 2 - Have patient identify 3 coping mechanisms they would like to use for dysregulated mood by end of day three - Have patient demonstrate identified coping mechanisms throughout hospital stay when experiencing dysregulated mood - Evaluation - Criteria for evaluation: - specificity: - evaluate whether the patient outcomes are specific and clearly defined as outlined in the nursing goals. - Each objective should provide clarity on what is expected. - Measurability: - Outcomes should be measurable to determine the degree of success. Use quantitative methods and qualitative observations for assessment. - Quantitative - lab values, vital signs - Qualitative - patient self-reports - Achievability: - assess whether the goals set were realistic given the patient\'s conditions, lifestyle, and available resources. Consider the time frame in which goals were set to determine if they were feasible. - Relevance: - Evaluate the relevance of the goals and outcomes in relation to the patient\'s current health condition and overall treatment plan. - Ensure that they align with the patient\'s priorities. - Timeliness: - Consider the time frame for achieving goals. Were the timeliness appropriate, and were the evaluations conducted at the designated intervals? - Documentation: - Document the evaluation findings thoroughly, including any modifications needed to the care plan based on outcomes. - Proper documentation ensures continuity of care. - Patient engagement: - Involve the patient in the evaluation process by soliciting their feedback on the perceived effectiveness of the interventions and their own progress toward goals. - Comparison against standards: - Compare the patients outcomes against established clinical standards or norms. This helps to determine the effectiveness of interventions in relation to best practices. - Analysis of factors influencing outcomes: - Analyze any external factors that may have affected the outcomes, such as support systems, psychosocial factors, or adherence to the treatment plan.