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