Chapter 7 - notes PDF

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CHAPTER 7 – QSEN Standards of practice – criteria for certification & legal definition of nursing QSEN competencies: -

Patient centered care Teamwork and collaboration EBP Quality improvement Safety Information

Gathering data 1. Review of systems 2. Laboratory data 3. Mental status examination o objective data o fundamental to overall patient assessment o current cognitive processes 4. Psychosocial assessment – o additional info beyond MSE o central or chief complaint o family history o HEADASS: home environment, education & employment, activities, drugs, sexuality, suicide risk, savagery 5. Spiritual or religious assessment 6. Cultural and social assessment 7. Self awareness assessment Validating the assessment -

Using rating scales

Diagnoses: A standard nursing diagnosis has 3 components: problem, etiology, supporting data Outcomes criteria – optimal goal outcomes -

Variable and measurable Reflection of patient’s actual state Nursing interventions classification (NIC): provides nurses with standardized interventions Nursing outcomes classification (NOC): provides standardized outcomes

Implementation Standard level – PMH-RN role (coordination of care, teaching, therapies, counseling) Advanced practice level – PMH-APRN role (prescriptive authority, psychotherapy, consultation)

Documentation formats: SOAPIE -

Subjective data Objective data Assessment: interpreting S&O Plan Interventions Evaluation...