Chapter 7 - RN Process & Standards

What limits HIPPA?

• Threats of

  • suicide

  • homicide

  • SA

• Behaviors that put patients or others at risk

HEADSSS (Teen Interview Technique)

• Home environment

• Education & employment

• Activities

• Drug, alc, tobacco

• Sexuality

• Suicide risk/symptoms

• Safety

Interpreter

Interprets spoken language

Translator

Translates written word

Mental Status Examination (MSE)

• evaluates a pts current cognitive processes

  • uses objective data

How does a psychosocial assessment begin?

By asking pt how treatment became necessary

Sprituality

How we find meaning and peace in our lives

Religion

Patterns of worship and symbols

Outcome Criteria

Reflect maximum level of patient health

• provides direction for continuity of care

Milieu Therapy

Secure environment that supports recovery

• uses environmental events and uses them as learning opportunities

When are secondary sources essential?

• Silent patients

• Psychosis

• Agitated

• Catatonia

Alternative to documenting noncompliance?

Non-adherent!!

Nursing Process in PMH Nursing

• Assessment

• Diagnosis

• Outcome Identification

• Planning

• Implementation

• Evaluation

Affect (in MSE)

How the patient appears to interviewer? (My observation)

• Visible to others!!

Mood (in MSE)

Asking the pt directly how they feel

MSE Score < 23

Dementia

Why MSE?

Helps detect emotional/behavioral changes in brain activity

• Able to detect brain tumors

Insight Component of MSE

The pts awareness & understanding of illness

Limitations of MSE

• Interpretive bias

• Limited to demographics and culture

• Less accurate for cognitive impaired patients