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Psyc Exam 1

Nursing Process

QuestionAnswer
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
Created by: dbrust
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