Chapter 3:
The Nursing Process and
Standards of Practice
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Standards of Practice and the
Steps of the Nursing Process
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Standard I: Assessment
Standard II: Nursing diagnosis
Standard III: Outcome identification
Standard IV: Implementation
Standard V: Evaluation
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Characteristics of the
Nursing Process
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Six-step, organized, problem solving method
unique to nursing
Designed to meet the needs of the patient,
family, community, and the environment
A universal language that acts as a common
thread to nursing
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Characteristics of the
Nursing Process, cont’d
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Not linear: steps may not be sequential
Research methods that promote evidence
based standards of practice
Common language and body of knowledge
universally accepted by medical, nursing, and
other health care professionals
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Steps of the Nursing Process
1.
2.
3.
4.
5.
6.
Assessment
Nursing diagnosis
Outcome identification
Planning
Implementation (interventions)
Evaluation
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Figure 3-1 Cyclic nature of the nursing process and standards of care.
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Standards of Practice in Mental
Health Nursing
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Developed by the American Nurses Association
(ANA), the American Psychiatric Nurses
Association, and the International Society of
Psychiatric-Mental Health Nurses (American
Nurses Association 2007)
Describes professional activities the nurse
performs during the steps of the nursing
process as they apply to mental health nursing
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Standard I. Assessment
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The nurses assesses the patient’s mental
status, psychosocial state, physical health,
pain level, and nonverbal behaviors with the
use of various methods of data collection
Mental status examination (MSE) and
psychosocial assessment
Subjective: what the patient states
Objective: what is observed
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Nurse as Primary Communicator
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Nurse is primary “tool”
Identifies patient strengths and problems
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Requires knowledge of:
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Psychodynamics
Psychopathology
Communication skills for rapport and support
Patient uniqueness
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Special Issues Related to
Assessment
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Managed care
HIPAA privacy protection
Intuitive reasoning
Expertise
Critical thinking
Assessment settings
Assessment sources
Assessment rating scales
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Standard II. Nursing Diagnosis
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Subjective
Objective
Actual
Potential
Reflects biologic, psychologic, sociocultural,
developmental, religious, spiritual, or sexual
process
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Mental Disorders: Diagnostic and
Statistic Manual of Mental
Disorders
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Axis I: Psychiatric diagnosis
Axis II: Personality disorder or mental
retardation
Axis III: Medical diagnosis
Axis IV: Psychosocial stressors
Axis V: Global assessment of functioning
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Actual and Potential
Nursing Diagnoses
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An actual problem nursing diagnosis consists
of:
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Problem or need
Etiology
Defining characteristics
A potential problem (risk) nursing diagnosis
consists of:
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Risk diagnosis
Risk factors as supporting factors; no etiology
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Figure 3-2 Nursing process depicting an actual diagnosis and a risk diagnosis
format of the six-step process.
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Standard III. Outcome
Identification
Outcomes are:
 Specific, measurable indicators
 Derived from nursing diagnoses
 Projections of expected influence of nursing
interventions
 Opposite of defining characteristics
 Often put in patient’s own words
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Outcomes/Behavioral Goals
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Observable
Measureable
Realistic
Ensure quality care
Justify reimbursement
Nursing Outcomes Classification (NOC) identifies outcomes most influenced by
nursing actions.
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Nursing Outcomes Classification
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First standardized language describing
patient outcomes that are most responsive to
nursing care or most influenced by the
actions and interventions of nurses
Rated on a 5-point continuum (1 to 5)
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Standard IV. Planning
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Collaboration with the patient, physician,
significant others, and interdisciplinary team
Identification of priorities of care
Coordination and delegation of
responsibilities of treatment team based on
expertise as related to patient ‘s needs
Critical decisions regarding interventions
related to evidence based practice (EBP)
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Evidenced Based Practice
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Clinical pathways
Pathway variances
Concept mapping
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Concept Mapping
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A type of algorithm or critical problem-solving plan
Means to organize all elements of care
Breaks down complex, relevant data into
manageable pieces to clarify the situation as a
whole
Helps to make connections between concepts
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Standard V. Implementation
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Perform prescribed interventions
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Nursing Orders/Nursing
Prescriptions
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Select to:
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Achieve client outcomes
Prevent/reduce problems
Prescribe a course of action
Focus on modifying etiology
Rationales are rarely written but are often
discussed in multidisciplinary team meetings.
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Nursing Interventions
Classification
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Facilitates the capture of certain nursing
activities and analysis of their impact on client
outcomes.
NIC interventions are linked to NOC
outcomes.
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Standard VI. Evaluation
Compare client current state/condition with
outcome criteria.
2. Consider all possible reasons why outcomes
are not achieved, should that be the case.
3. Make specific recommendations based on
conclusions drawn.
1.
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Documentation
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“7th Standard of Care”
Problem-oriented SOAP or DAR charting
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Subjective, Objective, Assessment, Planning,
Data, Analysis, Response
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