Applying Nursing Process The Foundation for Clinical Reasoning

ISBN-10: 1609136977
ISBN-13: 9781609136970
Edition: 8th 2014 (Revised)
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Description: Because principles of nursing process are the building blocks for all care models, the nursing process is the first model nurses need to learn to “think like a nurse.” This trusted resource provides the practical guidance needed to understand and  More...

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Book details

List price: $38.95
Edition: 8th
Copyright year: 2014
Publisher: Lippincott Williams & Wilkins
Publication date: 1/23/2013
Binding: Paperback
Pages: 264
Size: 7.00" wide x 9.00" long x 0.40" tall
Weight: 1.342
Language: English

Because principles of nursing process are the building blocks for all care models, the nursing process is the first model nurses need to learn to “think like a nurse.” This trusted resource provides the practical guidance needed to understand and apply each phase of the nursing process, with an increased emphasis on developing both critical thinking and clinical reasoning skills.  With an easy-to-follow and engaging writing style, the author provides strategies, tools, and abundant examples to help nurses develop the skills they need to thrive in today’s complex health care setting.

Overview of Nursing Process, Clinical Reasoning, and Nursing Practice Today
Nursing Process: The Foundation for Clinical Reasoning
Goals of Nursing
Critical Thinking Versus Clinical Reasoning
How the Nursing Process Promotes Safe, Effective Reasoning
Nursing Process Phases
Five Phases
Relationships Among the Phases
Benefits of Using the Nursing Process
Nursing Process in Context of Today's Clinical Setting
Patient Safety and Welfare Is Top Priority
Quality and Safety Education for Nurses Competencies
Legal and Scope of Practice Concerns
Giving Ethical Patient-Centered Care
Additional Clinical Issues Impacting Reasoning
Developing Critical Thinking and Clinical Reasoning Skills
Critical Thinking Indicators
The 4-Circle CT Model
Using Simulation and Debriefing
Willingness and Ability to Care
Willingness to Care
Being Able to Care
Assessment
Assessment: The Key to Safety, Accuracy, and Efficiency
Assessments that Promote Sound Clinical Reasoning
Six Phases of Assessment
Collecting Data
What Resources Do You Use?
Ensuring Comprehensive Data Collection
Data Base, Focus, and Quick Priority Assessments
Data Base (Start of Care) Assessment
Focus Assessment
Quick Priority Assessments (QPA)
Standard Tools, Evidence-Based Practice, and Electronic Health Records
Assessing Disease and Disability Management
Health Promotion: Screening for Risk Management and Early Diagnosis
Partnering With Patients to Make Informed Decisions
Ethical, Cultural, and Spiritual Concerns
The Interview and Physical Assessment
Developing Your Interviewing Skills
Guidelines: Promoting a Caring Interview
Developing Your Physical Assessment Skills
Guidelines: Performing a Physical Assessment
Checking Diagnostic Studies
Identifying Subjective and Objective Data
Identifying Cues and Making Inferences
Validating (Verifying) Data
Guidelines: Validating (Verifying) Data
Clustering Related Data
Clustering Data According to Your Purpose
Identifying Patterns/Testing First Impressions
Reporting and Recording
Reporting and Recording Abnormal Findings
Deciding What's Abnormal
Guidelines: Reporting and Recording
Diagnosis
Diagnosis: Identifying Actual and Potential Problems
What ANA Standards Say
Diagnosis and Accountability
Increased Responsibilities Related to Diagnosis
Shifting to a Predictive Care Model (Predict, Prevent, Manage, Promote)
Failure to Rescue and Rapid Response Teams
Provider-Preventable Conditions and Health Care-Acquired Conditions
Clinical Pathways (Care Maps)
Point-of-Care Testing
Disease and Disability Management
Informatics and Electronics Decision Support
Nursing Versus Medical Diagnoses
Using Standard Terminology
ANA-Recognized Terminologies
Standard Medical Terms
How Do You Know What Terms to Use?
Becoming a Competent Diagnostician
Key Terms Related to Diagnosis
Fundamental Principles of Diagnostic Reasoning
Mapping Diagnoses/Problems
Be on Your Patients' S.I.D.E.
Recording Summary Statements Using the PES or PRS Format
Identifying Potential Complications
Guidelines: Identifying PCs
Identifying Problems Requiring Multidisciplinary Care
Planning
Clinical Reasoning During Planning
Four Main Purposes of the Plan of Care
Standard and Electronic Plans
Patient Safety, Infection Prevention, and Pain and Restraint Management
Attending to Urgent Priorities
Clarifying Expected Outcomes (Results)
Goals, Objectives, Outcomes, and Indicators
Principles of Patient-Centered Outcomes
Guidelines: Determining Patient-Centered Outcomes
Relationship of Outcomes to Accountability
Clinical, Functional, and Quality-of-Life Outcomes
Discharge Outcomes and Discharge Planning
Case Management
Deciding Which Problems Must be Recorded
Determining Nursing Interventions
Assessment-Monitoring Health Status and Responses to Care (Surveillance)
Patient Education-Empowering Patients and Families
Guidelines: Planning Patient Education
Counseling and Coaching: Helping People Make Informed Choices
Consulting and Referring: Key to Multidisciplinary Care
Individualizing Interventions
Evidence-Based Practice: Weigh Risks and Benefits
Individualizing Nursing Orders
Making Sure the Plan is Adequately Recorded
Addressing Patient Needs on Multidisciplinary Plans
Implementation
Implementation: Putting the Plan into Action
Giving and Taking Reports (Hand-Offs)
Guidelines: Giving Reports (Hand-Offs)
Setting Daily Priorities
Guidelines: Prioritizing Care for Several Patients
When and How to Delegate
Coordinating Care
Surveillance-Preventing Errors and Omissions-Creating Safety Nets
How to Identify, Interrupt, and Correct Errors
Keeping an Open Mind
Performing Nursing Interventions
Be Proactive-Promote Safety, Comfort, and Efficiency
Implementation and Evidence-Based Practice
Guidelines: Preparing to Perform Interventions
Clinical Reasoning-What to Do When Things Go Wrong
Standard Plans and Care Variances
Ethical and Legal Concerns
Charting
Six Purposes of Charting
Various Ways of Charting
Principles of Effective Charting
Avoiding Dumping Syndrome With Electronic Charting
Learning to Chart Effectively
Guidelines: Charting During Implementation
Charting Memory-Jogs
Keeping the Plan Up-to-Date and Evaluating Your Day
Evaluation
Evaluation: Key to Excellence in Nursing
Evaluation and the Other Phases of Nursing Process
Evaluating an Individual Plan of Care
Guidelines: Determining Outcome Achievement
Identifying Variables (Factors) Affecting Outcome Achievement
Deciding Whether to Discharge the Patient
Quality Improvement
Research and Evidence-Based Practice
Reflective Practice
Consumer Satisfaction-Maximizing Value
Examining How Health Care Systems Affect Outcomes
Three Types of Evaluation: Outcome, Process, and Structure
Staff Nurses' Responsibilities
Examining Mistakes, Infections, and Injuries
Example Responses to Critical Thinking and Clinical Reasoning Exercises
Appendices
Example Critical Pathway
Building Healthy Workplaces and Safety and Learning Cultures
Key Elements of Critical Thinking in Context of ANA Standards and QSEN and IOM Competencies
DEAD ON!! A Critical Thinking and Clinical Reasoning Game
Glossary
Index

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