Nursing Processes

Question 1

Triage

Answer 1

• 1 - immediate - definite danger to self or others
  
  • need to be dealt with immediately
  • violent behaviour, possession of weapon, self destruction in ED, extreme agitation or restlessness, bizarre / disorientated behaviour, verbal commands to do harm to self or others, recent violent behaviour
  • requires constant supervision, staff need to be alerted immediately, security may be required
• 2 - emergency - probable risk of danger to self or others, client is physically restrained in ED, severe behavioural disturbance
  
  • within 10 minutes
  • unable to wait safely, agitation, restlessness, physically / verbally abusive, confused / unable to cooperate, hallucinations, delusions, paranoia, requires restraint, high risk of absconding and not waiting for treatment
• 3 - urgent - possible danger to self or others
  
  • within 30 minutes
  • very distressed, risk of self harm, agitated / restless, intrusive behaviour, confused, ambivalence about treatment, not likely to wait for treatment, reporting crisis or suicidal idealation, presence of psychotic symptoms
  • close supervision (10 minute intervals), do not leave patient in waiting room without support person, alter mental health triage, ensure safe environment for patient and others
• 4 - semi-urgent - moderate distress
  
  • within 60 minutes
  • semi urgent mental health problem, no immediate risk to self or others, no agitation / restlessness, irritable without aggression, cooperative, gives coherent history, reported pre existing condition, symptoms of anxiety or depression without suicidal idealation, willing to wait
  • intermittent observation (maximum of 30 minutes between), discuss action with mental health triage nurse
• 5 - non-urgent - no danger to self or others
  
  • within 120 minutes
  • no acute distress, no behavioural disturbance, observed to be cooperative, communicating and able to engage in developing management plan, able to discuss concerns, compliant with instructions, reported known patient with known condition, pre existing non-acute condition, request for medication, minor A/E of medication, financial, social, accommodation or relationship problem
  • general observation (maximum of 1 hour between), discuss with mental health triage, refer to treating team

Question 2

Admission

Answer 2

• identify self & role
• orientate client to ward, expectations of what they can & can’t do
• explain patient rights
• explain different routes to admission - car, ambulance, police
• reassurance
• stay calm in communication
• explain what will happen when they get to hospital, what may occur on the ward
• if from community, ward staff need to receive treatment plan, if involuntary or voluntary, history of presenting complaint, signs, symptoms, duration, current mental health act status, current risks, physical health issues, co-morbid conditions, allergies, any previous hosptialisations, appropriate treatments
• family need to be told where they have been admitted, cannot be told why due to confidentiality, if voluntary needs to give permission to liaise with family, if involuntary next of kin contacted and only given required information, if any plans need to be made for dependent children or pets

Question 3

Documentation

Answer 3

• history of presenting complaint
  
  • who, what, where, why, when, how
  • brief, less information, dot points of important words
• formulation
  
  • expected to be 4 short paragraphs, expected to give important information in a brief way
  • predisposing factors, precipitating factors (what’s brought them to services), presenting complaint, why now, what their issues are, why they are there, diagnosis, symptoms, duration and severity, psychosocial issues, perpetuating factors, overview - what they’re there for, intended to be brief

Question 4

Behaviour management - Documentation

Answer 4

• specify behaviours
• document previous occurrence of behaviours
• any inappropriate behaviours observed
• identify what is happening & what staff response will be
• note down challenging behaviours
• if require gender specific interactions
• educate about inappropriate choices / behaviours
• clarify in notes exactly what has been said to client
• positive reinforcement, have consequences
• ensure everyone is clarifying same information / goals to client each shift, reiterate consequences
• behaviour charts
• frequent visual observations
• risk assessments
• incident report forms if anything occurs
• incidents need to be reported to charge nurse
• any tests ordered post incidents

Question 5

Discharge - encouraging successful discharge

Answer 5

• linking in with community services
• educating family & client - relapse prevention, triggers, symptoms to be aware of, medication administration
• social support groups, family support groups
• financial supports / services
• home help, strategies to help at home
• care plan for home
• making sure GP is aware of discharge & arrange follow up, GP handovers
• ensuring support for family members
• test ability to cope with external environment during admission, leading up to discharge

Question 6

Clinical supervision

Answer 6

• supervision - reflection on practice, formalised arrangement, skill development, guidance in decision making & provision of care, supportive
• preceptorship - relationship between professional and student, designed to teach / educate
• mentorship - guidance, communication, relationship base
• peer support - informal discussion

Question 7

Line supervision vs clinical supervision

Answer 7

• line supervision
  
  • higher ranking position, senior, feedback more directed and reflective, direct teaching rather than supportive, disciplined senior, can put through appraisals, fire, hire, etc, can send for retraining if educational gaps
• clinical supervision
  
  • supportive, peer, contracts about time frames, when evaluated, explore difficulties that may be occurring with clients, explore successes, talk about what works, what doesn’t, add to toolkit of skills, from someone with larger skill base, more knowledge, use reflective framework, cycle to improve skills, can request change of supervisor - processes within organisation when this is required