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Psyc Exam 1
Nursing Process
Question | Answer |
---|---|
Standard I | Assessment |
Standard II | Diagnosis |
Standard III | Outcome Identification |
Standard IV | Planning |
Standard V | Implementation |
Standard VI | Evaluation |
ESTABLISH RAPPORT Contains: Subj/Obj data, MSE, HEADSSS, Physical Assess, History, Validation of data | Assessment |
DESCRIBE CLIENTS CONDITION & provide basis for selection on nursing interventions3 components (prob, cause, signs/symp) | Diagnosis |
MSE = Assessment Phase I | Mental Status Exam |
HEADSSS (Assessment Phase I) | Psychosocial Interview |
H=E=A=D=S=S=S= | H=home environment E=education/employment A=Activities D=drug/alcohol/tobacco S=sexuality S=Suicide risk S="Savagery" (violence or abuse in home environment) |
3 components of "Diagnosis" Phase II1. States what should be changed2. Tells what needs to be done to affect the change "related to"3. Characteristics that validate the diagnosis & tells what the condition is like at present | "Diagnosis" Phase IIProblem / Etiology / Supporting Data |
SOAPIE | S=subjective data O=objective data A=assessment P=plan I=interventions E=evaluation |