NSG 3450 Mental Health Exam 2
Unit 3
QSEN
❖ Pt centered care: recognize the pt or designee as the source of control and full pattern in
providing compassionate and coordinated case based on respect for the pt’s preference,
values, and needs
❖ Quality improvement: use data to monitor the outcomes of care processes and use
improvement methods to design and test changes to continuously improve the quality and
safety
❖ Safety: Minimize risk of harm to patients and provide optimal healthcare through both
system effectiveness and individual performance
❖ Informatics: use information and technology to communicate, manage knowledge,
mitigate error and support decision making
❖ Teamwork: function effectively within nursing and interprofessional teams
❖ Evidence based practice(EBP): integrate best current evidence with clinical expertise and
patient/family preference and values for delivery of optimal healthcare
MSE
A: Collects and synthesizes health data pertinent to the healthcare consumers health and or situation.
Primary source of data is patient, secondary includes family, friends, etc. (Range of System) → (MSE)
D: Problem (unmet need), Related factors, Defining characteristics (supporting data or signs and
symptoms)
P: Prescribe strategies to assist patients in attaining expected outcomes. Principles to consider when
planning care (safe, compatible & appropriate, realistic and individualized, evidence based)
I: Coordination of care, health teaching and health promotion, pharmacological, biological and integrative
therapies. Milieu therapy. Therapeutic relationship and counseling
E: Evaluate progress towards attainment of expected outcomes. Must be: systemic, ongoing, criteria
based. Safe D/C → MDT
, ● Important terminology of documentation: The term noncompliant is invariably
judgemental. A much more useful term is nonadherent.
● Nurse-Patient relationship: Basis of all psych nursing treatment approaches. To establish
that the nurse is: Safe, confidential, reliable, & consistent. Relationship with clear
boundaries.
● A therapeutic nurse-patient relationship has specific goals and functions
- To promote self care and independence
- To provide education about medications and symptom management
- To promote recovery
- To model and respect boundaries
Phases of Peplau’s Model
❖ Pre- orientation: Patient assignment and review of the medical record
❖ Orientation: Interview, expression of feelings, determine goals
❖ Working: Gather more data, work on problem solving, manage symptoms, education and
evaluation of progress
❖ Termination: Happens at discharge. Review of outcomes of goals and review of the
treatment. Close discharge instructions
Attending Behaviors
● Eye contact
● Body language
● Intimate distance: 0-18 inches
● Personal distance: 18-40 inches
● Social distance: 4-12 feet
● Public distance:12 feet or more
● NEVER put your back to the door
Unit 3
QSEN
❖ Pt centered care: recognize the pt or designee as the source of control and full pattern in
providing compassionate and coordinated case based on respect for the pt’s preference,
values, and needs
❖ Quality improvement: use data to monitor the outcomes of care processes and use
improvement methods to design and test changes to continuously improve the quality and
safety
❖ Safety: Minimize risk of harm to patients and provide optimal healthcare through both
system effectiveness and individual performance
❖ Informatics: use information and technology to communicate, manage knowledge,
mitigate error and support decision making
❖ Teamwork: function effectively within nursing and interprofessional teams
❖ Evidence based practice(EBP): integrate best current evidence with clinical expertise and
patient/family preference and values for delivery of optimal healthcare
MSE
A: Collects and synthesizes health data pertinent to the healthcare consumers health and or situation.
Primary source of data is patient, secondary includes family, friends, etc. (Range of System) → (MSE)
D: Problem (unmet need), Related factors, Defining characteristics (supporting data or signs and
symptoms)
P: Prescribe strategies to assist patients in attaining expected outcomes. Principles to consider when
planning care (safe, compatible & appropriate, realistic and individualized, evidence based)
I: Coordination of care, health teaching and health promotion, pharmacological, biological and integrative
therapies. Milieu therapy. Therapeutic relationship and counseling
E: Evaluate progress towards attainment of expected outcomes. Must be: systemic, ongoing, criteria
based. Safe D/C → MDT
, ● Important terminology of documentation: The term noncompliant is invariably
judgemental. A much more useful term is nonadherent.
● Nurse-Patient relationship: Basis of all psych nursing treatment approaches. To establish
that the nurse is: Safe, confidential, reliable, & consistent. Relationship with clear
boundaries.
● A therapeutic nurse-patient relationship has specific goals and functions
- To promote self care and independence
- To provide education about medications and symptom management
- To promote recovery
- To model and respect boundaries
Phases of Peplau’s Model
❖ Pre- orientation: Patient assignment and review of the medical record
❖ Orientation: Interview, expression of feelings, determine goals
❖ Working: Gather more data, work on problem solving, manage symptoms, education and
evaluation of progress
❖ Termination: Happens at discharge. Review of outcomes of goals and review of the
treatment. Close discharge instructions
Attending Behaviors
● Eye contact
● Body language
● Intimate distance: 0-18 inches
● Personal distance: 18-40 inches
● Social distance: 4-12 feet
● Public distance:12 feet or more
● NEVER put your back to the door
