By Judith M. Schultz MS RN, Sheila L. Videbeck PhD RN
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Extra info for Lippincott’s Manual of Psychiatric Nursing Care Plans
Evaluation and Revision The final steps in the nursing process are not termination steps but ongoing activities incorporated into the entire process to evaluate and revise all other steps. As new information is discovered throughout the client’s care, it must be added to the original assessment. Evaluation and revision are necessitated as the client reveals additional (or different) information and as the client’s behavior changes over time. Evaluation and revision include the following: • Nursing diagnoses: Are the diagnoses accurate?
What is the client’s primary language? • Does the client read in this primary language? 19 • Is the client able to speak and read English? • Is an interpreter needed for teaching and interactions with the client and significant others? Cultural considerations. (Remember that cultural background extends beyond race or ethnicity; see “Culture”) • What is the client’s cultural background? • In what kind of cultural environment is the client living (or was the client raised)? • What is the client’s group identification?
Included are problems with primary support group, social environment, education, occupation, housing, economics, and access to health care and legal systems. • Axis V reports the clinician’s rating of the person’s overall psychological functioning using the Global Assessment of Functioning (GAF), which rates functioning on a scale from 0 to 100. , highest GAF in the past year, or GAF 6 months ago) when that information is available. Although nursing students or staff nurses do not use the DSM-IV-TR to diagnose clients, it can be a helpful resource to describe the characteristics of the various disorders and to understand other aspects of psychiatric care.