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Flashcards in MODULE 4 - Nursing Process Deck (5)
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What are the 6 steps of the nursing process?

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


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


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 Psychosocial assessment
o Spiritual or religious assessment
o Cultural and social assessment


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)


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