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Description Contents Features Description
For Fundamentals of Nursing, Introduction to Nursing and Critical Thinking. Can be used in all clinical courses. This innovative text uses concrete examples and hands-on exercises to help students clearly understand and apply the five steps of the nursing process to today's rapidly changing healthcare environment. Instead of giving step-by-step instructions on how to use the nursing process in practice, it encourages students to critically think about each step of the nursing process and use critical thinking to make better clinical decisions. Wellness concepts and independent critical thinking, major emphases of this text, are incorporated into each step of the nursing process. Case studies and exercises provide students opportunities to apply the concepts presented to real world situations. topContents
Contents 1 Overview of Nursing Process 1 INTRODUCTION 1 WHAT IS NURSING? 1 Nursing Theory 3 Human Responses 4 Nursing,Medicine, and Multidisciplinary Practice 5 Nursing in Wellness and Illness 6 WHY IS THE NURSING PROCESS IMPORTANT? 7 WHAT IS NURSING PROCESS? 10 Relationship to Nursing and Caring 10 Background 10 Purpose and Characteristics 12 Organization: Phases of the Nursing Process 13 Relationship to Problem-Solving Process 18 QUALITIES NEEDED BY THE NURSE 20 Cognitive (Intellectual) Skills 20 Creativity and Curiosity 20 Interpersonal Skills 21 Cultural Competence 21 Psychomotor Skills 21 Technological Skills 22 NURSING PROCESS AND WELLNESS 22 NURSING PROCESS AND COMMUNITY HEALTH 23 ETHICAL AND CULTURAL CONSIDERATIONS 24 SUMMARY 26 Nursing Process Practice 27 Critical Thinking Practice: Self-Knowledge 29 Case Study: Applying Critical Thinking and Nursing Process 30 SELECTED REFERENCES 31 2 Critical Thinking 35 WHY DO NURSES NEED TO THINK CRITICALLY? 35 Nursing Is an Applied Discipline 36 Nursing Draws on Knowledge from Other Fields 37 Nurses Deal with Change in Stressful Environments 37 Nurses Make Frequent,Varied, and Important Decisions 38 WHAT IS CRITICAL THINKING? 38 Some Definitions of Critical Thinking 39 Characteristics of Critical Thinking 39 Types of Nursing Knowledge 41 CRITICAL THINKING ATTITUDES 43 Independent Thinking 44 Intellectual Humility 44 Intellectual Courage 45 Intellectual Empathy 45 Intellectual Integrity 46 Intellectual Perseverance 46 Intellectual Curiosity 46 Faith in Reason 47 Fair-mindedness 47 Interest in Exploring Thoughts and Feelings 47 CRITICAL THINKING SKILLS 48 Using Language 49 Perceiving 51 Believing and Knowing 52 Clarifying 53 Comparing 54 Judging and Evaluating 57 Reasoning 58 COMPLEX INTELLECTUAL ACTIVITIES 62 STANDARDS OF REASONING 66 CRITICAL THINKING AND NURSING PROCESS 66 CRITICAL THINKING AND NURSING ETHICS 69 DEVELOPING CRITICAL THINKING 70 SUMMARY 71 Nursing Process Practice 72 Critical Thinking Practice:Using Language 74 Case Study: Applying Critical Thinking and Nursing Process 76 SELECTED REFERENCES 77 3 Assessment ASSESSMENT:THE FIRST PHASE OF THE NURSING PROCESS 79 Purpose of Nursing Assessment 80 Relationship to Other Phases of the Nursing Process 81 Critical Thinking in Assessment 81 COLLECTING DATA 83 Subjective and Objective Data 83 Primary and Secondary Data Sources 87 Initial Versus Ongoing Assessment 88 Comprehensive Versus Focus Assessment 89 Use of Computers in Assessment 94 Data Collection Methods 95 VALIDATING THE DATA 105 ORGANIZING DATA 105 Nursing Models 107 NONNURSING MODELS 109 RECORDING DATA 115 SPECIAL-PURPOSE ASSESSMENTS 116 Home Care and Functional Assessment 116 Cultural Assessment 117 Spiritual Assessment 121 Wellness Assessment 123 Family Assessment 123 Community Assessment 123 ETHICAL AND LEGAL CONSIDERATIONS 129 Honesty 132 Confidentiality 132 Malpractice Suits 132 SUMMARY 133 Nursing Process Practice 134 Critical Thinking Practice: Believing and Knowing 139 Case Study: Applying Critical Thinking and Nursing Process 147 SELECTED REFERENCES 147 4 Diagnostic Reasoning INTRODUCTION 151 DIAGNOSIS: SECOND PHASE OF NURSING PROCESS 153 History of Nursing Diagnosis 154 Importance of Nursing Diagnosis 155 HUMAN RESPONSES 157 DIAGNOSING HEALTH STATUS 158 Patient Strengths 160 Wellness Diagnoses 160 Recognizing Nursing Diagnoses 160 Recognizing Collaborative Problems 163 Recognizing Medical Diagnoses 164 Computer-Assisted Diagnosis 167 Using Nursing Diagnoses With Critical Pathways 168 DIAGNOSTIC REASONING 171 Use of Nursing Models 171 Interpreting Data 171 Verifying Diagnoses 183 Labeling and Recording Diagnoses 184 Health Promotion: Diagnosing Wellness 184 CRITICAL THINKING AND DIAGNOSIS 185 Reflective Practice 185 Avoiding Diagnostic Errors 185 ETHICAL CONSIDERATIONS 190 SUMMARY 190 Nursing Process Practice 191 Critical Thinking Practice: Analysis and Synthesis 197 Case Study: Applying Nursing Process and Critical Thinking 202 SELECTED REFERENCES 203 5 Diagnostic Language INTRODUCTION 205 STANDARDIZED NURSING LANGUAGES 206 Classification Systems 206 The Need for Uniform Nursing Language 207 Existing Nursing Taxonomies 208 NANDA INTERNATIONAL 208 The NANDA Taxonomy 210 NANDA Review Process 210 CHOOSING A PROBLEM LABEL 210 Components of a NANDA Diagnosis 211 How to Choose a Label 215 Learning to Recognize the NANDA Labels 218 FORMAT FOR WRITING DIAGNOSTIC STATEMENTS 219 Actual Nursing Diagnoses 220 Potential (Risk) Nursing Diagnoses 225 Possible Nursing Diagnoses 226 Wellness Diagnoses (Format) 226 Collaborative Problems 226 RELATIONSHIP OF NURSING DIAGNOSES TO OUTCOMES AND NURSING ORDERS 227 THINKING CRITICALLY ABOUT THE CONTENT OF DIAGNOSTIC STATEMENTS 228 WELLNESS DIAGNOSES 232 SPIRITUAL DIAGNOSES 234 FAMILY AND HOME HEALTH DIAGNOSES 235 COMMUNITY HEALTH DIAGNOSES 236 ISSUES ASSOCIATED WITH THE NANDA CLASSIFICATIONS 237 Unrealistic Expectations 238 Effect on Holistic Perspective 238 Ethical Considerations 238 Cultural Considerations 240 RECORDING NURSING DIAGNOSES 240 PRIORITIZING DIAGNOSES 241 SUMMARY 243 Nursing Process Practice 244 Critical Thinking Practice: Clarifying, Comparing and Contrasting 251 Case Study: Applying Nursing Process and Critical Thinking 254 SELECTED REFERENCES 256 6 Planning: Overview and Outcomes Learning Outcomes 259 INTRODUCTION 259 PLANNING:THIRD PHASE OF NURSING PROCESS 260 Initial Versus Ongoing Planning 262 Discharge Planning 263 PATIENT CARE PLANS 266 Computerized Care Plans 267 Comprehensive Nursing Care Plans 267 Multidisciplinary Care Plans (Critical Pathways) 271 PLANNING OUTCOMES 271 Purpose of the Outcome Statement 273 Writing Outcome Statements 273 The Nursing Outcomes Classification (NOC) 283 Family and Home Health Outcomes 285 Community Outcomes 286 Outcomes for Wellness Diagnoses 287 Patient Teaching Outcomes 289 CRITICAL THINKING: REFLECTING ON PLANNING 290 Guidelines for Judging the Quality of Outcome Statements 291 Ethical Considerations in Planning 296 Legal Issues in Planning 297 Spiritual Planning and Outcomes 298 Cultural Considerations in Planning 299 SUMMARY 299 Nursing Process Practice 300 Critical Thinking Practice: Classifying 306 Case Study: Applying Nursing Process and Critical Thinking 310 SELECTED REFERENCES 312 7 Planning: Interventions INTRODUCTION 315 NURSING INTERVENTIONS 316 Types of Interventions 316 Theory-Based Planning 319 Nursing Interventions and Problem Status 319 How to Generate and Select Nursing Activities/Interventions 322 Computerized Planning 327 WRITING NURSING ORDERS 327 Purpose 328 Components of a Nursing Order 328 STANDARDIZED LANGUAGE FOR NURSING INTERVENTIONS 329 The Nursing Interventions Classification (NIC) 330 Community Nursing Interventions 332 Family and Home Health Interventions 335 FORMAL TEACHING PLANS 336 WELLNESS INTERVENTIONS 338 Standardized Wellness Interventions 338 SPIRITUAL INTERVENTIONS 339 THINKING CRITICALLY ABOUT PLANNING 341 Reflecting on Interventions 341 Reflecting on Ethical Factors 342 Reflecting on Cultural Factors 343 SUMMARY 344 Nursing Process Practice 346 Critical Thinking Practice: Recognizing Relevant Information 350 Case Study: Applying Nursing Process and Critical Thinking 353 SELECTED REFERENCES 353 8 Implementation LEARNING OUTCOMES 357 INTRODUCTION 357 Relationship of Implementation to Other Nursing Process Phases 360 Healthcare Delivery Systems 360 PREPARING TO ACT 361 Preparing the Nurse 363 Preparing the Patient 363 Preparing Supplies and Equipment 364 ACTION:DOING OR DELEGATING 365 Teaching for Self-Care 366 Delegation and Supervision 367 THINKING CRITICALLY ABOUT IMPLEMENTATION 370 RECORDING 370 Functions of Client Records 372 Documenting Nursing Process 373 Documentation Methods 378 Computerized Documentation 381 Documenting with Standardized Language 386 Guidelines for Charting 386 Home Healthcare Documentation 388 Long-Term Care Documentation 390 ORAL REPORTS 391 ETHICAL ISSUES IN IMPLEMENTATION 392 Respect for Dignity 393 Privacy and Confidentiality 393 LEGAL CONSIDERATIONS 394 Falls 394 Restraints 395 Questioning Medical Orders 395 Patient Behaviors That May Contribute to an Injury 395 CULTURAL AND SPIRITUAL CONSIDERATIONS 396 Cultural Care 397 Spiritual Care 397 SUMMARY Nursing Process Practice Critical Thinking Practice: Reasoning Case Study: Applying Nursing Process and Critical ThinkingSELECTED REFERENCES 9 Evaluation LEARNING OUTCOMES 411 INTRODUCTION 411 GENERAL CHARACTERISTICS OF EVALUATION 412 Standards and Criteria 413 EVALUATION IN NURSING PROCESS 414 Relationship to Other Phases 415 Evaluating Patient Progress 416 Evaluating/Revising the Plan of Care 421 REFLECTING CRITICALLY ABOUT EVALUATION 428 Evaluation Errors 428 Ethical Considerations 429 Cultural and Spiritual Considerations 430 QUALITY ASSURANCE/IMPROVEMENT 431 Computerized Records and Standardized Language 431 Types of Quality-Assurance Evaluation 432 A Procedure for Quality-Assurance Evaluation 434 SUMMARY Nursing Process Practice Critical Thinking Practice: Judging and Evaluating Case Study: Applying Nursing Process and Critical Thinking SELECTED REFERENCES 10 Creating a Care Plan LEARNING OUTCOMES 449 INTRODUCTION 449 COMPREHENSIVE CARE PLANS 450 Components of a Comprehensive Care Plan 451 Standardized Approaches to Care Planning 455 COMPUTERIZED CARE PLANS AND STANDARDIZED LANGUAGE 465 CARE-PLANNING GUIDE 465 CREATING A COMPREHENSIVE CARE PLAN 466 Case Study: Luisa Sanchez 468 Assessment 470 Diagnosis 470 Planning 473 Implementation 480 Evaluation 480 HOW TO MIND-MAP A CARE PLAN 182 WELLNESS IN THE ACUTE-CARE SETTING 483 ETHICAL CONSIDERATIONS 485 SUMMARY Nursing Process Practice Instructions for Preparing the Nursing Plan of Care Critical Thinking Practice: Similarities and Differences Appendix A: ANA Code of Ethics for Nurses with Interpretive Statements 494 Appendix B: Multidisciplinary (Collaborative) Problems Associated with Diseases and other Physiological Disorders 495 Appendix C: Multidisciplinary (Collaborative) Problems Associated with Surgical Treatments 504 Answer Keys 508 Index 533 topFeatures
TEACHING/LEARNING FEATURES Interactive Format Students need to practice applying the concepts; they need to “work problems”. This text provides many practice problems. Learning Aids Each chapter begins with Learning Outcomes and a figure that serves as a visual guide to chapter content. “Key Point” boxes summarize selected content in easily remembered lists. Each chapter ends with a summary of chapter content. Case Studies Each chapter also contains a case study (“Applying Critical Thinking”) to allow students to use critical thinking within the framework of the nursing process. These cases focus on critical thinking and nursing process. Detailed Answer Keys For the “Nursing Process Practices,” the answer keys give the rationale for both correct and incorrect answers and frequently demonstrate the thinking process used to arrive at the answers. The answer key discussions are vital for easing this frustration and modeling the thinking inherent in the process. Because answers can vary widely, the answer keys for “Critical Thinking Practices” and the “Applying Critical Thinking” case studies provide suggested, not comprehensive, answers. Versatility This text is suitable for nursing students as an introduction to nursing process, or for use in the continuing education of professionals who may need refresher information and practice. The text is organized to accommodate the instructor’s professional judgment—that is, it can be used in whole or in part, and for students of different levels, depending on what the instructor chooses to assign or emphasize. Independent Study This text can be used for independent study and for distance learning, but it is in no way limited to that approach. It can be used as a text to supplement lectures, either in a separate course or when the nursing process is integrated in the curriculum. Care Plans–or not This text makes clear that nursing process and a written plan of care are not one and the same. Terminology The terms client and patient are used throughout the book. Either can be appropriate, depending on the context. top
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