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| 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 |
| ... MORE | 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 |
| Table of Contents provided by Ingram. All Rights Reserved. |