The nursing process and standards of care

Objectives

MSE- Mental Status Exam

Appearance

Alertness

Speech

Mood

Affect

Thought process

Thought content

Differentiate between the use of an interpreter and a translator during an assessment with a non–English speaking patient.

Conduct a mental status examination (MSE).

Perform a psychosocial assessment, including brief cultural and spiritual components.

Quality and safety education in nursing

uPatient-centered care

uInterdisciplinary teamwork

uUse of evidence-based practice

uApplication of quality improvement

uUse of informatics

Safe

See Box 7.1

Respect the patients values, they are the source that can control the situation.

Team- Fostering open communication is important.

EBP- Integrate best nursing practice, for delivery of care.

Quality Improvement- Use data to monitor outcomes

Safe-Minimize risk or harm

Informatics- Use information technology to communicate and mitigate risk.

Standards of practice

uStandard 1: Assessment

uCollect & synthesize pertinent patient data

uHIPAA guidelines

uAge considerations

uAssessment of children

uAssessment of adolescents

uAssessment of older adults

uLanguage barriers

Interpreter or translator?

Know all the standard phases of each and what they entail!

What are the differences when assessing the age groups?

Wording of questions, patient use of terms different from nurse.

Assessment of children

Consult caregivers (secondary sources—the patient is the primary source); use interview, observation in play- Consider developmental levels as you evaluate.

Psyc disorders include- Regressing to previous level of development for example child sucking thumb (Babbling) (Using baby voice) and they are 3 vs at 16 year old sucking on thumb.

Assessment of adolescnets

Explain the need to share some information with other adults. Risk factors are priority. Stress to teen how information will be shared, and threats of suicide, homicide, sexual abuse or behaviors that put pt or others at risk will be shared. 

Confidentiality may be lead issue with adolescents. Certain privacy areas exist. ( make sure you know legal requirements)

Brief structured interview techniques help (HEADSSS, box 7.2) Ask about home environment, education how is school going, Activities, drug use, S-Sexuality, active, contraception, Suicide risk, Safety at home seat belt etc.

H- Home enviornment - relation w sibli and parent

E-Educat and employment - school performance

A-Activities _ sports

D- Drugs= alcohol, toabacco

S- Sexulality- contraception- safe

S-Suicide risk- depression
S- Safety- how safe do they feel at home- do they wear a seatbelt.

Assessment of older adul

Avoid dismissive stereotyping. Identify and accommodate for physical defects up front.

Do not stereotype older adults and know their education levels! Know their physical deficits and accommodate in the beginning of interview.

Don’t be the cause of increased anxiety, distress or physical discomfort. Observe closely and listen.

How to knoq when to use an interpreter or translator?

Answers are: An interpreter is someone who interprets the spoken words of a foreign language speaking person or someone who uses American Sign Language (ASL). A translator is an individual who speaks one or more languages in addition to English who translates the written word.

Language barriers are not just by nationality. Generational verbiage, Deaf or even dialect.

Mr. R, a patient in the early stages of Alzheimer’s has not been doing well. He is still aware of family members, including his sister, who has moved in with him.

     “I still have to work,” she says, “so the neighbor downstairs checks in on him during the day, and there’s a bell so he knows if Edgar tries to leave by himself.”

     Mr. R’s sister has brought him to the clinic because she’s worried about recent weight loss and some progression in his disease.

What are the goals in an assessment?

uEstablish rapport

uUnderstand current problem

uReview physical baseline status

uIdentify risk factors

uPerform MSE

uAssess psychosocial status

uIdentify mutual treatment goals

uFormulate plan of care

Document data in retrievable format

See Status verbs to help you describe your patient’s assessment.

Gathering data

uReview of systems

uLaboratory data

uMSE

uPsychosocial assessment

Anxiety- GAD 7-

Depression PHQ9-

Bipolar- Lithium levels, TSH, EKG as follow ups. However with the same token hypothyroidism may have symptoms that correlate with someone who is major depressed. In contrast someone who is hyperthyroidism  such as anxiety, weigh loss, insomnia that can easily be confused or pass as manic phase of bipolar disorder.

Illicit drug use will cause unusual psych signs and symptoms. Abnormal liver enzymes can explain irritability, depression and lethargy.  Chronic renal patients who have abnormal urea nitrogen and abnormal electrolyte levels.

MSE-  (Analogous to physical exam in gen med) Objective Data- Mental status examination.  All things nurses observe,  or testing.  VS, HR, BP, tempt Sat, weight, LOC, scales, verbal and non-verbal behavior.

The Psychosocial assessment

 provides help with developing the plan of care. This is the  patient’s chief complaint you document verbatim “I have been completely miserable since__and alone since my husband died _______:

You gather subjective data from patient or whoever may accompany them. The focus is pt’s perceptions and recollections of current life and life in general. You would ask about support systems, beliefs.

What other data would we gather?

uSpiritual/religious assessment

uCultural and social assessment

uValidating the assessment- looking at all records

Using rating scales-

Use scale dengeralized anxiety disorder GAD 7

Patient health questionare PHQ-9

As you begin the assessment process, Mr. R stops you and says, “I don’t know why you need to do an assessment, I am just here to get my medicines adjusted.”

uHow would you respond to Mr. S? What is the purpose of a psychiatric mental health nursing assessment?

Purposes are

•establish rapport.

•obtain an understanding of the current problem or chief complaint.

•review physical status and obtain baseline vital signs.

•assess for risk factors affecting the safety of the patient or others.

•perform a mental status examination.

•assess psychosocial status.

•identify mutual goals for treatment.

•formulate a plan of care.

what term on an assessment form is broader?

A.Spirituality

B.Religion

C.Church/mosque/temple/synagogue

D.None of the above.

ANS: A

 

Spirituality addresses universal human questions and needs. Spirituality is cognitive, experiential, and behavioral. In contrast, religion is an external system that includes beliefs, patterns of worship, and symbols. Although religion is often concerned with spirituality, religious groups are social entities and are often characterized by other nonspiritual goals (cultural, economic, political, social).

REF: 122

You discover that part of Mr. R’s lack of appetite has been due to a urinary tract infection he has been unable to articulate. You ask his sister for more information about the home environment, ADLs, and medications. What type of information source is his sister?

A.Primary

B.Secondary

C.Private

D.Informed

ANS: B

 

Secondary sources are valuable when caring for a client experiencing psychosis, muteness, agitation, or catatonia. Such secondary sources include members of the family, friends, neighbors, police, health care workers, and medical records.

Diagnoses

uAnalyze assessment data to determine diagnoses, problems and areas of care and treatment focus, including level of risk

uDiagnostic Statement Components

uProblem/potential problem (unmet need)

uProbable cause (“due to”)

uSupporting data (signs and symptoms/ “as evidenced by”)

Part of identifying the focus for areas of care and treatment is the level of risk. The dreadful NANDA the Nursing Diagnosis-  Think finding the main problem and deciding if  the problem is a problem or a potential problem, or if the problem is related to a probable cause you would focus on the related to Part _______.  Don’t forget your supportive data objective and subjective.

Problem focused diagnosis- Anxiety related to losing employment and financial burdens as evidence by “ i cant concentrate, crying , restlessness, insomnia.

Types of Nursing Diagnoses

uProblem-focused diagnoses

uProblem + Probable cause + Supporting Data 

uRisk diagnoses

uAlways begins with the phrase “risk for,” followed by the problem

Risk for self mutilation as evidence by impulsivity, inadequate coping, isolation, and unstable self-esteem.

What is outcome criteria?

uIdentify expected outcomes that reflect the maximal level of patient health that can realistically be achieved through planned nursing interventions

uPrinciples

uReflect a measurable desired change

uProvide direction for continuity of care

uWritten in positive terms

Outcomes often provide both short- and long-term goals.  Example patient will remain free from injury through hospital stay. By discharge the patient will experience hope and desire to live, identify two people patient can contact if thoughts of suicide.

Always written in positive terms.

Table 7.3 example

Planning

uPrescribe strategies to assist patient in attaining expected outcomes

uPrinciples to consider when planning care

uSafe

uCompatible and appropriate

uRealistic and individualized

uEvidence-based

Evidence-based interventions and treatments is the gold standard in healthcare. Evidence-based practice (EBP) for nurses is a combination of clinical skill and the use of clinically relevant research in the delivery of effective patient-centered care. Using the best available research, incorporating patient preferences, and making sound clinical judgment and skills provide an optimal patient-centered nurse-patient relationship.

Implementation

˜Registered Nurse Interventions:

uCoordination of care

uHealth teaching and health promotion

uPharmacological, biological, and integrative therapies

uMilieu therapy

Milieu refers to a physical and social environment. Milieu therapy is a psychiatric philosophy that involves a secure environment including people, settings, structure, and emotional climate to support recovery. Milieu therapy takes naturally occurring events in the environment and uses them as learning opportunities for patients.

Theraputic relat and counseling

uTherapeutic Relationship and Counseling

uBasis of nurse-patient interactions

uProviding presence and a sounding board

uReinforce healthy behavior

uHelp the patient to recognize maladaptive behaviors

uHelp patient identify positive coping methods and try out the new coping methods 

Revert back to Therapeutic Boundaries and effective communication techniques.

Documentation

˜Referred to as the seventh step in the nursing process

uCrucial even through evaluation

uInclude: patient condition, informed consents, drug reactions, patient concerns, and adverse incidents

˜Medical record: Legal Document

˜Documentation of Nonadherence

Importance of Terminology: The term noncompliant is invariably judgmental.

A much more useful term is nonadherent. This term encourages healthcare providers to find out what is going on in the patient’s life and explore barriers to taking the medication and participating in treatment.

Documentation is the 7^th step in the nursing process. Always keep in mind that the medical records are legal documents may be used in the court of law. Besides the evaluation of outcomes, the record should reflect changes, reaction to medication, adverse outcomes, adverse incidents.  When documenting non compliant has negative connotations better to document non-adherence to plan   Under the court of law you chart will be under meticulous records that document the reason for your intervention, clarify explanations, teaching you did,  and include patient’s responses will support healthcare workers in case of lawsuit. The biggest problem in malpractice is whether the patient understood the instructions given by the healthcare provider. Even if pt had printed instructions it is still possible patients do not understand them or understand the follow up to their health care.

This is not just important in psych,, but very important in all aspects of nursing. If your pt in hospital vomits, CP, Changes in VS, changes in status, documenting who you notified, and not stopping until you complete the process.

As Mr. R’s sister has suspected, Mr. S sometimes forgets to eat. In which part of the nursing care plan would the nurse expect to find this statement:

“Offer snacks and finger foods frequently.”

A. Assessment

B. Diagnosis

C. Planning and outcomes identification

D. Implementation

 Evaluation

ANS: D

Psychiatric mental health nursing practice includes four basic-level of implementation: coordination of care, health teaching and health promotion, milieu therapy, and pharmacological, biological, and integrative therapies. Encouraging Mr. R to eat small snacks involves both health teaching (for his caregivers) and health promotion (helping Mr. R. recovery better nutritional habits).

You teach Mr. R’s sister about important precautions associated with a new prescription. Afterward, she accurately summarizes major self-management strategies associated with this drug. Which step of the nursing process applies to her summarization?

A.Assessment

B.Analysis

C.Planning/outcomes identification

D.Intervention

Evaluation

ANS: E

 

Evaluation of the individual’s response to treatment should be systematic, ongoing, and criteria based. Supporting data are included to clarify the evaluation—including ability to accurately relay treatment instructions and precautions.