Term
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Definition
| Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation |
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Term
| Quality and Safety Education for Nurses (QSEN) Competencies |
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Definition
Patient Centered Care
Quality Improvement
Safety
Informatics
Teamwork and Collaboration
Evidenced Based Practice |
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Term
| The HEADSSS Psychosocial Interview Technique |
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Definition
H-Home environment
E-Education and employment
A-Activities
D-Drug, alcohol, or tobacco use
S-Sexuality
S-Suicide risk
S-Savagery |
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Term
| Mental Status Examination (MSE) |
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Definition
To evaluate an individuals current cognitive processes.
-Appearance
-Behavior
-Speech
-Mood
-Disorders of the form of thought
-Perceptual disturbances
-Cognition
-Ideas of harming self or others |
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Term
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Definition
Chief complaint
History of violent or suicidal behaviors
Alcohol or substance abuse
Family psychiatric history
Personal psychiatric treatment
Stressors and coping methods
Quality of ADLs
Personal background
Social background
Weaknesses, strengths and goals
Racial, ethnic, and cultural beliefs
Spiritual beliefs |
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Term
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Definition
| It is important to gather data from a variety of sources, such as the child themselves as well as caregivers. Children tend to feel more comfortable being assessed by someone of the same gender. |
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Term
| Assessment of Adolescents |
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Definition
Adolescents are especially concerned with confidentiality and they need to know that their records are private.
Any threats of suicide, homicide, or any sexual abuse must be reported. |
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Term
| Assessment of Older Adults |
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Definition
| The nurse should be aware of any physical limitations that could increase anxiety, stress, or physical discomfort for the patient during the assessment. Make any accommodations to help the patient feel comfortable. |
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Term
| Purpose of the psychiatric mental health nursing assessment |
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Definition
Establish rapport
Obtain an understanding of the current problem
Review physical status, baseline vitals
Assess for risk factors affecting safety
Perform a mental status examination
Assess psychosocial status
Identify mutual goals for treatment
Formulating a plan of care |
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Term
| Spiritual/Religious Assessment |
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Definition
Spirituality - internal phenomenon and is often understood as addressing universal human questions and needs
Religion - external system that includes beliefs, patterns of worship, and symbols |
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Term
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Definition
Primary language
Cultural background
Living situation
Social situation
Medical beliefs/providers
Attitude toward mental illness
Specific diet |
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Term
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Definition
| Hoped for outcomes that reflect the maximal level of patient health that can realistically be achieved through nursing interventions |
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Term
| Nursing Outcomes Classification |
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Definition
| Includes standardized outcomes that provide a mechanism for communicating the effect of nursing interventions on the well being of patients, families and communities |
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Term
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Definition
| Combination of clinical skill and the use of clinically relevant research in the delivery of effective patient centered care. |
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Term
| Nursing Interventions Classification |
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Definition
| Research based standardized listing of interventions reflective of current clinical practices the nurse can use to plan care |
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Term
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Definition
| Includes identifying the health education needs of the patient and teaching basic principles of physical and mental health. |
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Term
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Definition
| Orienting patients to their rights and responsibilities, selecting specific activities that meet patients physical and mental health needs, and ensuring that patients are maintained in the least restrictive environment safety permits. |
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Term
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Definition
| Assists the patient in assuming personal responsibility for activities of daily living. |
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