NURS 3554 Lecture Notes - Lecture 4: Nanda, Mental Status Examination, Nursing Process
Document Summary
Standard 1: assessment: age considerations, assessment of children, assessment of adolescents, assessment of older adults, language barriers, gathering data, review of systems. She is cooperative with the interviewer and is judged to be an adequate historian. Her mood and affect are depressed and anxious. Her flow of thought is coherent and her thought content reveals feelings of low self-esteem as well as auditory hallucinations that are self-demeaning. She admits to suicidal ideas but denies active plan or intent. She knows the current date, place, and person. The client shows some insight and judgment regarding her illness and need for help: mini mental status exam is to look for cognitive deficits, count backwards, remember words. Never slight moderate substantial extensive (1: describes prescribed, medications, describes reason for, support groups, describes importance, of self care activities (5) (4) Standard 4: planning: principles to consider when planning care, safe, compatible and appropriate, realistic and individualized, evidence-based interventions.
