Nursing Process: Foundation for Safe and Effective Care

1. Chapter 5 Nursing Process: The Foundation for Safe and Effective Care

2. Nursing process Basic framework for all significant action taken by nurses in providing developmentally and culturally relevant psychiatric mental health care for all patients • Psychiatric mental health standards of practice -Criteria for certification -Legal definition of nursing, as reflected in many states nurse practice acts -National Council of State Boards of Nursing Licensure Examination • 6 step problem solving approach -Intended to facilitate and identify appropriate and safe and quality care

3. Standard 1: Assessment • Holistic approach to care -A view of the individual as complex blend of many parts -Age considerations (child, adolescent and elderly) • Psychiatric nursing assessment -Gathering Data: Review of Systems, lab data, mental status exam, psychosocial, spiritual, cultural and social assessment -Validating the assessment

4. Standard 2: nursing diagnosis • Formulating a Nursing Diagnosis -A clinical judgment about a pt’s response, needs, actual and potential psychiatric disorders, mental health problems, and potential comorbid physical illness -3 Structural Components • Problem (unmet need) • Etiology (probable cause) • Supporting data (signs and symptoms)

5. Standard 3: Outcomes identification • Determining Outcomes -Outcomes Criteria • Outcomes that reflect maximal level of pt health that can be achieved through nursing interventions • Nursing Outcomes Classification (NOC) -Includes list of 385 standardized outcomes that provide a mechanism for communicating the effect of nursing interventions on the well being of pts, families, and communities -Each outcome has associated group of indicators that is used to determine pt status in relation to the outcome

6. Standard 4: Planning • Standardized Care Plans or Clinical Pathways for specific diagnosis -Safe -Appropriate -Individualized -Evidence-based • Evidence Based Practice -Combination of clinical skill and use of clinically relevant research in the delivery of effective patient centered care • Nursing Interventions Classification (NIC) -Research based standardized listing of 542 interventions that nurse uses to plan care and reflects current clinical practice

7. Standard 5: Implementation • Psychiatric Mental Health Nursing: Scope and Standards of Practice • Identifies 7 areas for intervention • Basic Level and Advance Practice Interventions • Coordination of Care • Health Teaching and Promotion • Milieu Therapy • Pharmacological, Biological, and Integrative Therapies • Prescriptive Authority and Treatment • Psychopharmacology • Consultations

8. Standard 6: Evaluation • Should be systematic, ongoing, and criterion based • Include supporting data • Ongoing assessment of data allows for revisions of nursing diagnosis, changes to more realistic outcomes or identification of more appropriate interventions when outcomes are not met • Documentation -Patient records are legal documents -Record evaluation, changes in patient condition, informed consents (medication and treatment), reaction to medicine, documentation of symptoms, concerns of pt and any untoward incidents in health care setting