Exam 2 Study Guide
Chapter 7: Nursing process and standard for care
Nursing process = systemic clinical process
Assessment
o Collect subjective and objective data
o Complete a mental status examination
o Psychosocial and physical exam
o Complete a health history
o Primary source = the patient
o Secondary source = family
Diagnosis
o Synthesize assessment data
o Structural components of nursing diagnosis
Problems
Related factors
Defining characteristics
o Identify problem and etiology
o Prioritize nursing diagnosis
Outcome identification
o Identify expected outcomes of situations
o Include time estimates
o Nursing outcomes classification (NOC): tool that can be referred to when writing nursing outcome s
Planning
o Collab with healthcare team
o Identify safe and evidence-based actions
o Plan should be
Safe
Compatible with and appropriate for implementation with other therapies
Realistic and individualized
Evidence based
Implementation
o Carry out interventions in plan of care
Interventions must be safe, evidence based, individualized and realistic
o Coordination of care
o Health teaching
o Milieu therapy
Evaluation
o Document results
o Reassess
o Continual process
Language barriers always provide and interpreter
Age Considerations
o Children
1
, Child is best source for inner feelings
Caregivers can describe the child’s behavior
Assessed through interview & observation
Interview the child alone when they are reluctant to share
o Adolescents
Confidentiality
Give overview of how information sharing will work
Use HEADSSS to identify risk factors
Home environment
Education & employment
Activities
Sexuality
Suicide risk/symptoms of depression
Safety
o Older Adults
Do not stereotype
Evaluate physical limitations and make accommodations
Milieu Therapy
o Psychiatric philosophy that involves a secure environment including people, settings, structure &
emotional climate to support recovery
o Takes naturally occurring events & uses them as learning opportunities
o Milieu management includes:
Orienting patients to rights/responsibilities
Providing culturally sensitive care
Selecting activities that meet pt needs
Using least restrictive environment
Documentation
o Medical records are legal binding documents
o Should include pt condition, informed consents, treatments, symptoms, reaction to medications,
concerns, & any adverse events
o Documentation of non-adherence:
Do not use the term non-compliance
Research as to why the patient is not adhering the medical advice
Chapter 8: Therapeutic relationships
Core of patient centered care
o Dignity and respect
o Info sharing
o Patient and family participation
o Collaboration
Talk therapy
o Based on psychotherapy
Therapeutic use of self: using our personality traits and talents as gifts to promote healing
Goals and functions of the nurse-patient relationship
2
, o Facilitate communication
o Assist patients with problem solving
o Exam self-defeating behaviors
o Promote self-care
o Provide education and promote recovery
Therapeutic encounter: nurse and client meet informally or have an otherwise limited but helpful
relationship
Types of relationships
o Social/personal: initiated for the purpose of a friendship
Mutual needs are met
Communication can be superficial
o Therapeutic: nurse maximizes communication skills and attempts to enhance patient growth
Clear boundaries (purpose of boundaries is to protect the patient)
Identify the needs of the patient
Encourage problem solving
Develop new coping skills
The nurse must address the following goals…
Helping the patient examine self-defeating behaviors and test alternatives
Promoting self-care and independence
Assist patient with problem solving to help facilitate activities if daily living
Facilitating communication of distressing thoughts and feelings
Blurring of boundaries
o Common circumstances when boundaries are blurred
Relationship slips into social context
Nurses’ needs are met at the expense of patient needs
Transference: patient unconsciously transfers feelings/behaviors R/T significant figures from the past onto
the nurse
o Can be positive or negative
Countertransference: nurse unconsciously displaces feelings R/T significant figures of nurse’s past onto the
patient
o Often results from over involvement leads to impairment of therapeutic relationships
Self-awareness helps us accept uniqueness and differences
o This is key to forming a therapeutic relationship
Peplau nurse-patient relationship (framework to structured care)
o 4 phases
Preorientation
begins with preparing for your assignment
Orientation
Formal and informal contract between the nurse and the patient is established
Nurse + patient meet
Initial interview and introductions (develop rapport and explain confidentiality)
Working
Gather more data
Identify problem solving skills
Provide educations
3
Chapter 7: Nursing process and standard for care
Nursing process = systemic clinical process
Assessment
o Collect subjective and objective data
o Complete a mental status examination
o Psychosocial and physical exam
o Complete a health history
o Primary source = the patient
o Secondary source = family
Diagnosis
o Synthesize assessment data
o Structural components of nursing diagnosis
Problems
Related factors
Defining characteristics
o Identify problem and etiology
o Prioritize nursing diagnosis
Outcome identification
o Identify expected outcomes of situations
o Include time estimates
o Nursing outcomes classification (NOC): tool that can be referred to when writing nursing outcome s
Planning
o Collab with healthcare team
o Identify safe and evidence-based actions
o Plan should be
Safe
Compatible with and appropriate for implementation with other therapies
Realistic and individualized
Evidence based
Implementation
o Carry out interventions in plan of care
Interventions must be safe, evidence based, individualized and realistic
o Coordination of care
o Health teaching
o Milieu therapy
Evaluation
o Document results
o Reassess
o Continual process
Language barriers always provide and interpreter
Age Considerations
o Children
1
, Child is best source for inner feelings
Caregivers can describe the child’s behavior
Assessed through interview & observation
Interview the child alone when they are reluctant to share
o Adolescents
Confidentiality
Give overview of how information sharing will work
Use HEADSSS to identify risk factors
Home environment
Education & employment
Activities
Sexuality
Suicide risk/symptoms of depression
Safety
o Older Adults
Do not stereotype
Evaluate physical limitations and make accommodations
Milieu Therapy
o Psychiatric philosophy that involves a secure environment including people, settings, structure &
emotional climate to support recovery
o Takes naturally occurring events & uses them as learning opportunities
o Milieu management includes:
Orienting patients to rights/responsibilities
Providing culturally sensitive care
Selecting activities that meet pt needs
Using least restrictive environment
Documentation
o Medical records are legal binding documents
o Should include pt condition, informed consents, treatments, symptoms, reaction to medications,
concerns, & any adverse events
o Documentation of non-adherence:
Do not use the term non-compliance
Research as to why the patient is not adhering the medical advice
Chapter 8: Therapeutic relationships
Core of patient centered care
o Dignity and respect
o Info sharing
o Patient and family participation
o Collaboration
Talk therapy
o Based on psychotherapy
Therapeutic use of self: using our personality traits and talents as gifts to promote healing
Goals and functions of the nurse-patient relationship
2
, o Facilitate communication
o Assist patients with problem solving
o Exam self-defeating behaviors
o Promote self-care
o Provide education and promote recovery
Therapeutic encounter: nurse and client meet informally or have an otherwise limited but helpful
relationship
Types of relationships
o Social/personal: initiated for the purpose of a friendship
Mutual needs are met
Communication can be superficial
o Therapeutic: nurse maximizes communication skills and attempts to enhance patient growth
Clear boundaries (purpose of boundaries is to protect the patient)
Identify the needs of the patient
Encourage problem solving
Develop new coping skills
The nurse must address the following goals…
Helping the patient examine self-defeating behaviors and test alternatives
Promoting self-care and independence
Assist patient with problem solving to help facilitate activities if daily living
Facilitating communication of distressing thoughts and feelings
Blurring of boundaries
o Common circumstances when boundaries are blurred
Relationship slips into social context
Nurses’ needs are met at the expense of patient needs
Transference: patient unconsciously transfers feelings/behaviors R/T significant figures from the past onto
the nurse
o Can be positive or negative
Countertransference: nurse unconsciously displaces feelings R/T significant figures of nurse’s past onto the
patient
o Often results from over involvement leads to impairment of therapeutic relationships
Self-awareness helps us accept uniqueness and differences
o This is key to forming a therapeutic relationship
Peplau nurse-patient relationship (framework to structured care)
o 4 phases
Preorientation
begins with preparing for your assignment
Orientation
Formal and informal contract between the nurse and the patient is established
Nurse + patient meet
Initial interview and introductions (develop rapport and explain confidentiality)
Working
Gather more data
Identify problem solving skills
Provide educations
3
