Applying Nursing Process: A Tool for Critical Thinking

by Alfaro-Lefevre, Rosalinda

• ISBN13: 9780781774086
• ISBN10: 078177408X
• Edition: 7th
• Format: Paperback
• Copyright: 2009-01-28
• Publisher: LWW

Summary

This trusted resource combines the practical guidance students need to understand each phase of the nursing process with an emphasis on critical thinking, focusing on both independent and collaborative responsibilities facing today's nurses. Using straightforward language, abundant examples, and real case scenarios, the book addresses the nurse's role as a caregiver and decision-maker in a range of settings--from clinic to the home, community, research, and acute care arenas. "Doody's Core Titles 2009."

Table of Contents

Nursing Process Overview
What Is the Nursing Process and Why Learn About It?	p. 5
What Is It?	p. 5
Why Learn About It?	p. 6
Steps of the Nursing Process	p. 7
Relationships Among the Steps of the Nursing Process	p. 9
Assessment and Diagnosis	p. 10
Diagnosis and Planning	p. 10
Planning and Implementation	p. 11
Implementation and Evaluation	p. 11
Evaluation and the Other Nursing Process Steps	p. 11
What Are the Benefits of Using the Nursing Process?	p. 13
Nursing Process in Context of Today's Clinical Setting	p. 15
Patient Safety Is Top Priority	p. 25
Ethics: Advocating for Patients' Rights	p. 26
Seven Ethical Principles	p. 26
Following Ana Ethics Code	p. 27
Including Patient Partners While Following Hipaa Rules	p. 27
What's the Difference Between Nursing Process and Critical Thinking?	p. 32
How to Become a Critical Thinker	p. 32
Using the Four-Circle CT Model	p. 35
Willingness and Ability to Care	p. 38
Willingness to Care	p. 38
Being Able to Care	p. 38
Assessment
Assessment: The First Step to Determining Health Status	p. 47
Characteristics of an Assessment That Promotes Critical Thinking	p. 47
Standard Assessment Tools and Evidence-Based Practice	p. 48
Six Phases of Assessment	p. 48
Collecting Data	p. 50
What Resources Do You Use?	p. 50
How to Ensure Comprehensive Data Collection	p. 51
Data Base, Focus, and Quick Priority Assessments	p. 51
Data Base (Start of Care) Assessment	p. 57
Focus Assessment	p. 57
Quick Priority Assessments (QPAs)	p. 60
Assessing Disease and Disability Management	p. 61
Health Promotion: Screening for Risk Management and Early Diagnosis	p. 62
Partnering With Patients to Make Informed Decisions	p. 63
The Interview and Physical Assessment	p. 63
Ethical, Cultural, and Spiritual Concerns	p. 63
Developing Your Interviewing Skills	p. 64
Guidelines: Promoting a Caring Interview	p. 64
How to Establish Rapport	p. 64
How to Listen	p. 65
How to Ask Questions	p. 66
How to Observe	p. 66
How to Terminate the Interview	p. 68
Developing Your Physical Assessment Skills	p. 68
Guidelines: Performing a Physical Assessment	p. 70
Checking Diagnostic Studies	p. 70
Identifying Subjective and Objective Data	p. 73
Identifying Cues and Making Inferences	p. 74
Validating (Verifying) Data	p. 74
Guidelines: Validating (Verifying) Data	p. 75
Clustering Related Data	p. 77
Clustering Data According to Purpose	p. 77
Identifying Patterns/Testing First Impressions	p. 81
Reporting and Recording	p. 82
Reporting Abnormal Findings	p. 82
Deciding What's Abnormal	p. 82
Guidelines: Reporting and Recording	p. 83
General Guidelines	p. 83
Guidelines: Verbal and Phone Communications	p. 84
Guidelines: Recording the Nursing Data Base	p. 84
Guidelines: Charting on Electronic Records	p. 85
Diagnosis
From Assessment to Diagnosis: A Pivotal Point	p. 93
Diagnosis: What ANA Standards Say	p. 94
Nurses' Growing Responsibilities as Diagnosticians	p. 94
Diagnose and Treat (DT) Versus Predict, Prevent, Manage, and Promote (PPMP)	p. 96
Multidisciplinary Practice	p. 97
Disease and Disability Management	p. 97
Point-of-Care Testing	p. 97
Critical Pathways (Care Maps)	p. 98
Advantages of Critical Paths	p. 98
Disadvantages of Critical Paths	p. 98
Informatics and Computer-Assisted Diagnosis	p. 99
Using Standard or Recognized Terms	p. 99
How to Use Standard Languages	p. 101
Computer-Assisted Diagnosis	p. 102
Limitations of Computer-Assisted Diagnosis	p. 103
Becoming a Competent Diagnostician	p. 103
Key Terms Related to Diagnosis	p. 104
Recognizing Risk Factors: The Key to Proactive Approaches	p. 110
Critical Thinking Indicators (CTIs) Related to Diagnosis	p. 110
Learning How to Make Definitive Diagnoses	p. 114
Fundamental Principles and Rules of Diagnostic Reasoning	p. 114
Patients as Partners in Diagnosis	p. 118
Clarifying Causes and Contributing (Risk) Factors	p. 123
Identifying Nursing Diagnoses	p. 124
Guidelines: Identifying Nursing Diagnoses	p. 125
Mapping Diagnoses	p. 127
Writing Diagnostic Summary Statements Using the PES or PRS Format	p. 128
Identifying Potential Complications	p. 134
Guidelines: Identifying Potential Complications	p. 134
Identifying Problems Requiring Multidisciplinary Approaches	p. 135
Planning
Thinking Critically During Planning	p. 143
Four Main Purposes of the Plan of Care	p. 143
Initial Versus Ongoing Planning	p. 143
Applying Standards	p. 144
Clinical Decision Making	p. 145
Pain Management, Restraint Management, and Patient Safety Standards	p. 146
Standard and Electronic Plans	p. 146
Attending to Urgent Priorities	p. 146
Clarifying Expected Outcomes (Results)	p. 147
Outcomes Versus Indicators	p. 148
Principles of Patient-Centered Outcomes	p. 151
Guidelines: Determining Patient-Centered Outcomes	p. 153
Relationship of Outcomes to Accountability	p. 154
Clinical, Functional, and Quality-of-Life Outcomes	p. 154
Discharge Outcomes and Discharge Planning	p. 155
Case Management	p. 157
Deciding Which Problems Must Be Recorded	p. 157
Determining Nursing Interventions	p. 160
Assessment-Monitoring Health Status and Responses to Care	p. 160
Teaching-Empowering Patients and Families	p. 161
Guidelines: Planning Teaching	p. 161
Counseling and Coaching: Helping People Make Informed Choices	p. 162
Consulting and Referring: Key to Multidisciplinary Care	p. 162
Individualizing Interventions	p. 163
Evidence-Based Practice: Weigh Risks and Benefits-Be Proactive	p. 164
Guidelines: Individualizing Nursing Orders	p. 165
Making Sure the Plan Is Adequately Recorded	p. 167
Multidisciplinary Plans	p. 168
Implementation
Implementation: Putting the Plan into Action	p. 183
Critical Thinking Indicators (CTIs) Related to Implementation	p. 184
Preparing for Report and Getting Report (Shift Hand-off)	p. 184
Preparing for Report (Shift Hand-off)	p. 184
Getting Report (Shift Hand-off)	p. 184
Setting Daily Priorities	p. 185
Strategies: Prioritizing Care for Several Patients	p. 185
Delegating Care, Not Accountability	p. 188
Coordinating Care	p. 190
Monitoring Responses: Assessing and Reassessing	p. 190
Performing Nursing Interventions	p. 191
Be Proactive-Promote Safety, Comfort, and Efficiency	p. 191
Implementation and Evidence-Based Practice	p. 191
Guidelines: Preparing to Act	p. 192
Thinking Critically: What to Do If Things Go Wrong	p. 192
Case Management: Critical Paths and Care Variances	p. 193
Ethical/Legal Concerns	p. 194
Charting	p. 195
Six Purposes of Charting	p. 195
Various Ways of Charting	p. 196
Principles of Effective Charting	p. 197
Avoiding Dumping Syndrome With Electronic Charting	p. 198
Learning to Chart Effectively	p. 198
Guidelines: Charting During Implementation	p. 198
Memory-Jogs for Charting	p. 199
Giving Report (Shift Hand-Off)	p. 200
Guidelines: Giving Report (Shift Hand-off)	p. 201
Keeping the Plan Up-to-Data and Evaluating Your Day	p. 201
Evaluation
Critical Evaluation: Key to Excellence in Nursing	p. 212
Evaluation and the Other Steps in the Nursing Process	p. 212
Evaluating an Individual Plan of Care	p. 212
Guidelines: Determining Outcome Achievement	p. 213
Identifying Variables (Factors) Affecting Outcome Achievement	p. 213
Deciding Whether to Discharge the Patient	p. 214
Quality Improvement (QI)	p. 215
Evidence-Based Practice	p. 215
Consumer Satisfaction: Maximizing Value	p. 216
Health Care Systems Interest and Affect Outcomes	p. 216
Three Types of Evaluation: Outcome, Process, and Structure	p. 217
Staff Nurses' Responsibilities	p. 217
Preventing Mistakes and Infection Transmission	p. 219
Quick Reference To Nursing Diagnoses	p. 223
Example Responses To Critical Thinking Exercises	p. 241
Four Roles Of Advanced Practice Nurses (Apns)	p. 247
Dead On!! A Game To Promote Critical Thinking	p. 249
Commonly Used Nanda Diagnoses Organized According To Gordon's Functional Health Patterns	p. 250
Good Learning Environments, Healthy Workplace Standards, And Establishing A Culture of Safety	p. 252
Nursing Interventions Classification (NIC) And Nursing Outcomes Classification (NOC) Examples	p. 253
Glossary	p. 254
Index	p. 257
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