The Nursing Process and Standards of Care in Psychiatric-Mental Health Nursing

Flashcards covering the history, steps, and standards of the nursing process as applied to psychiatric-mental health nursing.

Nursing Process

A six-step problem-solving approach to patient care used to identify and facilitate appropriate, safe, culturally competent, and quality care.

Lydia Hall

The nursing theorist who first used the term nursing process in a speech to describe a three-stage process of observation, ministration of care, and validation.

Yura and Walsh

Nurse leaders who identified four steps of the nursing process in $1967$: Assessing, Planning, Implementing, and Evaluating.

Assessment

The first step of the nursing process involving the collection and synthesis of comprehensive health data from primary sources (patient) and secondary sources (family, records).

Diagnosis

The second step of the nursing process; a clinical judgment about a patient's response to actual and potential health problems.

Outcomes identification

The third step of the nursing process where the nurse identifies expected, attainable, and culturally expected outcomes documented as measurable goals.

Planning

The fourth step of the nursing process consisting of identifying safe, pertinent, and evidence-based actions that are compatible with health beliefs.

Implementation

The fifth step of the nursing process where the identified plan is executed using basic level or advanced practice interventions.

Evaluation

The sixth step of the nursing process involving a systematic, ongoing review of progress toward outcomes and revision of the plan if necessary.

Evidence-based practice (EBP)

A combination of clinical skill and the use of clinically relevant research to provide optimal, patient-centered healthcare.

Scope

A title component in standards publications answering what, where, when, why, and how psychiatric nursing is performed.

QSEN

Quality and Safety Education for Nurses; an initiative defining competencies in patient-centered care, teamwork, EBP, quality improvement, safety, and informatics.

Mental status examination (MSE)

A fundamental psychiatric assessment tool analogous to the physical exam, used to evaluate an individual’s current cognitive processes.

Objective data

Information observable by the nurse or verified through tests, such as vital signs, behavior, nonverbal communication, and physical appearance.

Subjective data

Information gathered from the patient's perceptions and recollections of their lifestyle, support systems, and coping styles.

Psychosocial assessment

An assessment covering the chief complaint, history, social patterns, substance use, and coping abilities to develop a plan of care.

Spirituality

A personal, inner phenomenon involving how individuals find meaning, hope, purpose, and a sense of peace in their lives.

Religion

An external system of beliefs, symbols, and patterns of worship where individuals connect personal beliefs to an organized group.

Interpreter

A professional required by law to handle spoken words of a foreign language or American Sign Language (ASL) for limited English proficient patients.

Translator

An individual who translates the written word from one language to another.

HEADSSS

A structured interview technique for adolescents assessing Home, Education, Activities, Drug use, Sexuality, Suicide risk, and Safety.

Problem-focused diagnosis

A type of nursing diagnosis consisting of a problem, probable cause linked by 'related to,' and supporting data linked by 'as evidenced by.'

Risk diagnosis

A judgment regarding vulnerability for developing problematic responses, beginning with 'risk for' and followed by supporting data.

Outcome criteria

Hoped-for outcomes reflecting the maximum level of health a patient can realistically achieve, written in positive, measurable terms.

Milieu therapy

A psychiatric philosophy providing a secure, therapeutic environment including people, setting, and structure to support recovery.

Advanced Practice Interventions

Specific therapeutic roles only for PMH-APRNs: Consultation, Prescriptive authority and treatment, and Psychotherapy.

SOAPIE

A problem-oriented charting format standing for Subjective, Objective, Assessment, Plan, Interventions, and Evaluation.

Nonadherent

A non-judgmental term replacing 'noncompliant' to encourage providers to explore barriers to a patient's participation in treatment.