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Flashcards in MODULE 4 - Nursing Process Deck (5)
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1

What are the 6 steps of the nursing process?

Assessment, Nursing diagnosis, outcome identification, planning, implementation, evaluation, (documentation considered 7th)

2

Describe the mental status assessment process

purpose is to evaluate an individual’s current cognitive, affective (emotional), and behavioural functioning.
- Key assessment tool used by members of the mental health team for ongoing assessment of the client and to establish treatment effectiveness, as well as certain aspects of recovery
- Also key assessment tool used to communicate assessment data across the interpersonal team

3

Discuss the different techniques of data collection

Nurses Primary source for data collection is the patient -may be times when it is necessary to supplement or rely completely on another for assessment information
- Several med conditions and physical illnesses may mimic psychiatric illnesses. so physical cause of symptoms must be ruled out.
o Review of systems
o Laboratory data
o MSE
o Psychosocial assessment
o Spiritual or religious assessment
o Cultural and social assessment

4

Describe Biopsychosocial Nursing Assessment

- Key elements of this assessment are strongly related to the probability that the patient will experience successful outcomes in the community
(The biopsychosocial model is a system that can guide the nursing assessment and interventions in a holistic manner, viewing clients comprehensively, including their biology, social environment and skills, and psychological characteristics)

5

Describe what nursing diagnosis and patient outcomes entail

Nursing diagnosis is the basis for selecting therapeutic outcomes and interventions
- it has three structural components:
o Problem (unmet need)
o Etiology (probable cause)
o Supporting data (signs and symptoms)
Outcome criteria are the hoped-for outcomes that reflect the maximal level of patient health that can realistically be achieved through nursing interventions
o The expected outcomes provide direction for continuity of care